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González-Muñoz A, Pruimboom L, Navarro-Ledesma S. The Relationship between Abdominal Diastasis and Lumbar Pain Pressure Threshold in Women Who Have Given Birth between the Ages of 30 and 45 Years-An Observational Pilot Study. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:591. [PMID: 38674236 PMCID: PMC11052353 DOI: 10.3390/medicina60040591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 03/22/2024] [Accepted: 04/01/2024] [Indexed: 04/28/2024]
Abstract
Background and Objectives: Current evidence confirms that the magnitude of the inter-rectus distance (IRD) is associated with the severity of abdominal pain. Furthermore, evidence exists in the literature about the impact abdominal muscles have on low back pain, lumbopelvic pain, breathing and lumbar abdominal strength; however, no studies analysing the level of association between abdominal diastasis and lumbar pain pressure threshold (PPT) exist. The aim of this study was to analyse the level of association between the rectus abdominis distance and pain pressure threshold in the lumbar spinous processes in women who have given birth between the ages of 30 and 45 years. Secondly, it was to study the level of association between the time elapsed since the last delivery and low back pain in women who have given birth between 30 and 45 years of age. Material and Methods: This was a pilot observational study in which 21 females participated. The abdominal diastasis was measured by ultrasound, the pain pressure threshold was assessed by an algometer and the pain perception by the Mc Gill questionnaire. Results: There was no significant relationship between increased abdominal distance and increased lumbopelvic pain in women who gave birth between the ages of 30 and 45 years. However, there was a correlation between the time that had elapsed since the last delivery and low back pain. Conclusions: there was a correlation between the time that had elapsed since the last delivery and low back pain. Further studies analysing factors that may perpetuate the chronicity of symptoms, such as lifestyle and intrinsic factors, are needed.
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Affiliation(s)
- Ana González-Muñoz
- Clinical Medicine and Public Health PhD Program, Faculty of Health Sciences, University of Granada, Av. de la Ilustración, 60, 18071 Granada, Spain
- Clinica Ana Gonzalez, Avenida Hernan Nuñez de Toledo 6, 29018 Malaga, Spain
| | - Leo Pruimboom
- Chair in Clinical Psychoneuroimmunology, Faculty of Health Sciences, Campus of Melilla, University of Granada and PNI Europe, 2518 JP The Hague, The Netherlands; (L.P.); (S.N.-L.)
| | - Santiago Navarro-Ledesma
- Chair in Clinical Psychoneuroimmunology, Faculty of Health Sciences, Campus of Melilla, University of Granada and PNI Europe, 2518 JP The Hague, The Netherlands; (L.P.); (S.N.-L.)
- Department of Physiotherapy, Faculty of Health Sciences, Campus of Melilla, University of Granada, Querol Street, 5, 52004 Melilla, Spain
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Ceulemans D, Moens M, Reneman M, Callens J, De Smedt A, Godderis L, Goudman L, Lavreysen O, Putman K, Van de Velde D. Biopsychosocial rehabilitation in the working population with chronic low back pain: a concept analysis. J Rehabil Med 2024; 56:jrm13454. [PMID: 38226563 PMCID: PMC10802789 DOI: 10.2340/jrm.v56.13454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 11/29/2023] [Indexed: 01/17/2024] Open
Abstract
OBJECTIVE To identify the essential attributes of biopsychosocial rehabilitation for chronic low back pain in the working population. DESIGN A concept analysis was conducted according to the 8-step method of Walker and Avant. This framework provides a clear concept and theoretical and operational definitions. METHODS Five databases were searched, followed by a systematic screening. Subsequently, attributes, illustrative cases, antecedents, consequences and empirical referents were formulated. RESULTS Of the 3793 studies identified, 42 unique references were included. Eleven attributes were identified: therapeutic exercise, psychological support, education, personalization, self-management, participation, follow-up, practice standard, goal-setting, social support, and dietary advice. Subsequently, illustrative cases were described. Antecedents, such as motivation, preparedness and a multidisciplinary team, were found, together with consequences such as decreased pain, less sick-leave and increased function and work status. Finally, examples of empirical referents were given. CONCLUSION This study identified the attributes that are necessary to develop biopsychosocial rehabilitation intervention programmes for chronic low back pain. The defined concept of biopsychosocial rehabilitation for chronic low back pain may serve as a solid base to further develop and apply interventions. Future research should focus on the objectification of biopsychosocial rehabilitation and conceptualization regarding how personalization is done.
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Affiliation(s)
- Dries Ceulemans
- Faculty of Medicine and Healthcare Sciences, Department of Rehabilitation Sciences, Occupational Therapy Research Group, Ghent University, Ghent, Belgium; STIMULUS Research Group, Vrije Universiteit Brussel, Jette, Belgium.
| | - Maarten Moens
- STIMULUS Research Group, Vrije Universiteit Brussel, Jette, Belgium; Center for Neurosciences (C4N), Vrije Universiteit Brussel, Jette, Belgium; Pain in Motion Research Group (PAIN), Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Jette, Belgium; Department of Neurosurgery, Universitair Ziekenhuis Brussel, Jette, Belgium; Department of Radiology, Universitair Ziekenhuis Brussel, Jette, Belgium
| | - Michiel Reneman
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Groningen, the Netherlands
| | - Jonas Callens
- STIMULUS Research Group, Vrije Universiteit Brussel, Jette, Belgium; Interuniversity Centre for Health Economics Research (I-CHER), Department of Public Health (GEWE), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Jette, Belgium
| | - Ann De Smedt
- STIMULUS Research Group, Vrije Universiteit Brussel, Jette, Belgium; Center for Neurosciences (C4N), Vrije Universiteit Brussel, Jette, Belgium; Department of Physical Medicine and Rehabilitation, Universitair Ziekenhuis Brussel, Jette, Belgium
| | - Lode Godderis
- Centre for Environment and Health, Department of Public Health and Primary Care, KU Leuven (University of Leuven), Leuven, Belgium; IDEWE, External Service for Prevention and Protection at Work, Heverlee, Belgium
| | - Lisa Goudman
- STIMULUS Research Group, Vrije Universiteit Brussel, Jette, Belgium; Center for Neurosciences (C4N), Vrije Universiteit Brussel, Jette, Belgium; Pain in Motion Research Group (PAIN), Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Jette, Belgium; Department of Neurosurgery, Universitair Ziekenhuis Brussel, Jette, Belgium; Research Foundation Flanders (FWO), Brussels, Belgium
| | - Olivia Lavreysen
- STIMULUS Research Group, Vrije Universiteit Brussel, Jette, Belgium; Centre for Environment and Health, Department of Public Health and Primary Care, KU Leuven (University of Leuven), Leuven, Belgium
| | - Koen Putman
- Interuniversity Centre for Health Economics Research (I-CHER), Department of Public Health (GEWE), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Jette, Belgium
| | - Dominique Van de Velde
- Faculty of Medicine and Healthcare Sciences, Department of Rehabilitation Sciences, Occupational Therapy Research Group, Ghent University, Ghent, Belgium
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Bemani S, Sarrafzadeh J, Dehkordi SN, Talebian S, Salehi R, Zarei J. Effect of multidimensional physiotherapy on non-specific chronic low back pain: a randomized controlled trial. Adv Rheumatol 2023; 63:57. [PMID: 38049905 DOI: 10.1186/s42358-023-00329-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 09/27/2023] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND Many people with non-specific chronic low back pain (NSCLBP) do not recover with current conventional management. Systematic reviews show multidimensional treatment improves pain better than usual active interventions. It is unclear whether multidimensional physiotherapy improves pain better than usual physiotherapy. This study determines the effectiveness of this treatment to reduce pain and disability and improve quality of life, pain cognitions, and electroencephalographic pattern in individuals with NSCLBP. METHODS 70 eligible participants aged 18 to 50 years with NSCLBP were randomized into either the experimental group (multidimensional physiotherapy) or the active control group (usual physiotherapy). Pain intensity was measured as the primary outcome. Disability, quality of life, pain Catastrophizing, kinesiophobia, fear Avoidance Beliefs, active lumbar range of motion, and brain function were measured as secondary outcomes. The outcomes were measured at pre-treatment, post-treatment, 10, and 22 weeks. Data were analyzed using intention-to-treat approaches. RESULTS There were 17 men and 18 women in the experimental group (mean [SD] age, 34.57 [6.98] years) and 18 men and 17 women in the active control group (mean [SD] age, 35.94 [7.51] years). Multidimensional physiotherapy was not more effective than usual physiotherapy at reducing pain intensity at the end of treatment. At the 10 weeks and 22 weeks follow-up, there were statistically significant differences between multidimensional physiotherapy and usual physiotherapy (mean difference at 10 weeks, -1.54; 95% CI, -2.59 to -0.49 and mean difference at 22 weeks, -2.20; 95% CI, - 3.25 to - 1.15). The standardized mean difference and their 95% confidence intervals (Cohen's d) revealed a large effect of pain at 22 weeks: (Cohen's d, -0.89; 95% CI (-1.38 to-0.39)). There were no statistically significant differences in secondary outcomes. CONCLUSIONS In this randomized controlled trial, multidimensional physiotherapy resulted in statistically and clinically significant improvements in pain compared to usual physiotherapy in individuals with NSCLBP at 10 and 22 weeks. TRIAL REGISTRATION ClinicalTrials.gov NCT04270422; IRCT IRCT20140810018754N11.
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Affiliation(s)
- Sanaz Bemani
- Department of Physiotherapy, Iranian Center of Excellence in Physiotherapy, Rehabilitation Research Center, School of Rehabilitation Sciences, Iran University of Medical Sciences, Madadkaran St, Shahnazari St, Madar Sq. Mirdamad Blvd., Tehran, Iran
| | - Javad Sarrafzadeh
- Department of Physiotherapy, Iranian Center of Excellence in Physiotherapy, Rehabilitation Research Center, School of Rehabilitation Sciences, Iran University of Medical Sciences, Madadkaran St, Shahnazari St, Madar Sq. Mirdamad Blvd., Tehran, Iran.
| | - Shohreh Noorizadeh Dehkordi
- Department of Physiotherapy, Iranian Center of Excellence in Physiotherapy, Rehabilitation Research Center, School of Rehabilitation Sciences, Iran University of Medical Sciences, Madadkaran St, Shahnazari St, Madar Sq. Mirdamad Blvd., Tehran, Iran
| | - Saeed Talebian
- Department of Physiotherapy, School of Rehabilitation Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Salehi
- Department of Physiotherapy, Iranian Center of Excellence in Physiotherapy, Rehabilitation Research Center, School of Rehabilitation Sciences, Iran University of Medical Sciences, Madadkaran St, Shahnazari St, Madar Sq. Mirdamad Blvd., Tehran, Iran
- Department of Rehabilitation Management, Rehabilitation Research Center, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
- Geriatric Mental Health Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Jamileh Zarei
- Department of Health Psychology, School of Behavioral Sciences and Mental Health, Iran University of Medical Sciences, Tehran, Iran
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Kolu P, Suni JH, Tokola K, Raitanen J, Rinne M, Taulaniemi A, Husu P, Kankaanpää M, Parkkari J. Neuromuscular exercise and counseling for treating recurrent low back pain in female healthcare workers-Findings from a 24-month follow-up study of a randomized controlled trial. Scand J Med Sci Sports 2023; 33:2239-2249. [PMID: 37466018 DOI: 10.1111/sms.14451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 06/26/2023] [Accepted: 07/10/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Female healthcare workers have a high prevalence of low back pain (LBP)-related sickness absence. Here, we report findings of a 24-month follow-up of a previously published 6-month randomized controlled trial (RCT). METHODS By adopting an RCT with 6 months of intervention and follow-up at 6, 12, and 24 months, we assessed the maintenance of changes in the effectiveness (LBP and fear of pain) of the interventions (neuromuscular exercise [NME], back-care counseling, both combined) using a generalized linear mixed model adjusted for baseline covariates. The incremental cost-effectiveness ratio was calculated in terms of quality-adjusted life years (QALY). A bootstrap technique was used to estimate the uncertainty around a cost-effectiveness acceptability curve. RESULTS Of the 219 females, 71% had data at 24 months. Between 6 and 24 months, LBP intensity (primary outcome) remained low in all intervention arms (-20% to -48%) compared to the control (-10% to -16%). Pain interfering with work remained low in the combined and exercise arms for up to 24 months. At 24 months, the total costs were lowest in the combined arm (€484 vs. €613-948, p < 0.001), as were the number of back-related sickness absence days (0.16 vs. 1.14-3.26, p = 0.003). The analysis indicated a 95% probability of the combined arm to be cost-effective per QALY gained at €1120. CONCLUSIONS Six months of weekly NME combined with four counseling sessions was cost-effective for treating LBP and the effect was maintained over 24 months. TRIAL REGISTRATION ClinicalTrials.gov, NCT01465698, 7/11/2011, prospective.
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Grants
- 9K127 Pirkanmaa Hospital District, Tampere, Finland
- 9M099 Pirkanmaa Hospital District, Tampere, Finland
- 9R015 Pirkanmaa Hospital District, Tampere, Finland
- 9S017 Pirkanmaa Hospital District, Tampere, Finland
- 9V014 Pirkanmaa Hospital District, Tampere, Finland
- 9X013 Pirkanmaa Hospital District, Tampere, Finland
- 37/26/2011 The Social Insurance Institution of Finland
- 31/26/2015 The Social Insurance Institution of Finland
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Affiliation(s)
- Päivi Kolu
- UKK Institute for Health Promotion Research, Tampere, Finland
| | - Jaana H Suni
- UKK Institute for Health Promotion Research, Tampere, Finland
| | - Kari Tokola
- UKK Institute for Health Promotion Research, Tampere, Finland
| | - Jani Raitanen
- UKK Institute for Health Promotion Research, Tampere, Finland
- Faculty of Social Sciences (Health Sciences), Tampere University, Tampere, Finland
- Special Services Unit, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Marjo Rinne
- UKK Institute for Health Promotion Research, Tampere, Finland
| | | | - Pauliina Husu
- UKK Institute for Health Promotion Research, Tampere, Finland
| | - Markku Kankaanpää
- Physical and Rehabilitation Medicine Outpatient Clinic, Pirkanmaa Hospital District, Tampere, Finland
| | - Jari Parkkari
- UKK Institute for Health Promotion Research, Tampere, Finland
- Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland
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Bernaers L, Cnockaert E, Braeckman L, Mairiaux P, Willems TM. Disability and return to work after a multidisciplinary intervention for (sub)acute low back pain: A systematic review. Clin Rehabil 2022; 37:964-974. [DOI: 10.1177/02692155221146447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Objective This systematic review aimed to examine pain, functional status and return to work after a multidisciplinary intervention, with or without additional workplace intervention, for (sub)acute low back pain among adults. Data sources A comprehensive search was completed (November 2022) in six electronic databases (Embase, MEDLINE, Web of Science, Cochrane, CENTRAL and Scopus) and in the reference list of all identified studies. Review methods The search results were screened against predefined eligibility criteria by two independent researchers. Included articles were systematic reviews or randomized controlled trials examining the effect of a multidisciplinary intervention, with or without workplace intervention, in working adults with (sub)acute low back pain. Relevant information was summarized and clustered, and the methodological quality and certainty of evidence were assessed respectively using the RoB 2-tool, the ROBIS tool and the GRADE criteria. Results The search resulted in a total of 3020 articles. After the screening process, 12 studies remained (11 randomized controlled trials and 1 systematic review), which studied overall 2751 patients, with a follow-up period of at least 12 months. Conclusions A multidisciplinary intervention is favorable compared to usual care for pain intensity and functional status but this is less clear for return to work. Comparable work-related effects were found when comparing a multidisciplinary intervention with a less extensive intervention, whereas uncertainties exist regarding outcomes of pain intensity and functional status. Furthermore, adding a workplace intervention to usual care and subdividing patients based on work-related characteristics seems beneficial for return to work.
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Affiliation(s)
- Lisa Bernaers
- Faculty of Medicine and Health Sciences, Department of Rehabilitation Sciences, Ghent University, Ghent, Belgium
- Faculty of Medicine and Health Sciences, Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Elise Cnockaert
- Faculty of Medicine and Health Sciences, Department of Rehabilitation Sciences, Ghent University, Ghent, Belgium
- Pain in Motion International Research Group, Ghent, Belgium
| | - Lutgart Braeckman
- Faculty of Medicine and Health Sciences, Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Philippe Mairiaux
- Faculty of Medicine, Department of Public Health Sciences, Liège University, Liège, Belgium
- Federal Agency for Occupational Risks, Brussels, Belgium
| | - Tine Marieke Willems
- Faculty of Medicine and Health Sciences, Department of Rehabilitation Sciences, Ghent University, Ghent, Belgium
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The Efficacy and Effectiveness of Education for Preventing and Treating Non-Specific Low Back Pain in the Hispanic Cultural Setting: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19020825. [PMID: 35055646 PMCID: PMC8776076 DOI: 10.3390/ijerph19020825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 12/31/2021] [Accepted: 01/10/2022] [Indexed: 02/04/2023]
Abstract
A systematic review was conducted to assess the efficacy and effectiveness of education programs to prevent and treat low back pain (LBP) in the Hispanic cultural setting. Electronic and manual searches identified 1148 unique references. Nine randomized clinical trials (RCTs) were included in this review. Methodological quality assessment and data extraction followed the recommendations from the Cochrane Back Pain Review Group. Education programs which were assessed focused on active management (3 studies), postural hygiene (7), exercise (4) and pain neurophysiology (1). Comparators were no intervention, usual care, exercise, other types of education, and different combinations of these procedures. Five RCTs had a low risk of bias. Results show that: (a) education programs in the school setting can transmit potentially useful knowledge for LBP prevention and (b) education programs for patients with LBP improve the outcomes of usual care, especially in terms of disability. Education on pain neurophysiology improves the results of education on exercise, and education on active management is more effective than “sham” education and education on postural hygiene. Future studies should assess the comparative or summatory effects of education on exercise, education on pain neurophysiology and education on active management, as well as explore their efficiency.
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Williams ACDC, Fisher E, Hearn L, Eccleston C. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev 2020; 8:CD007407. [PMID: 32794606 PMCID: PMC7437545 DOI: 10.1002/14651858.cd007407.pub4] [Citation(s) in RCA: 134] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Chronic non-cancer pain, a disabling and distressing condition, is common in adults. It is a global public health problem and economic burden on health and social care systems and on people with chronic pain. Psychological treatments aim to reduce pain, disability and distress. This review updates and extends its previous version, published in 2012. OBJECTIVES To determine the clinical efficacy and safety of psychological interventions for chronic pain in adults (age > 18 years) compared with active controls, or waiting list/treatment as usual (TAU). SEARCH METHODS We identified randomised controlled trials (RCTs) of psychological therapies by searching CENTRAL, MEDLINE, Embase and PsycINFO to 16 April 2020. We also examined reference lists and trial registries, and searched for studies citing retrieved trials. SELECTION CRITERIA RCTs of psychological treatments compared with active control or TAU of face-to-face therapies for adults with chronic pain. We excluded studies of headache or malignant disease, and those with fewer than 20 participants in any arm at treatment end. DATA COLLECTION AND ANALYSIS Two or more authors rated risk of bias, extracted data, and judged quality of evidence (GRADE). We compared cognitive behavioural therapy (CBT), behavioural therapy (BT), and acceptance and commitment therapy (ACT) with active control or TAU at treatment end, and at six month to 12 month follow-up. We did not analyse the few trials of other psychological treatments. We assessed treatment effectiveness for pain intensity, disability, and distress. We extracted data on adverse events (AEs) associated with treatment. MAIN RESULTS We added 41 studies (6255 participants) to 34 of the previous review's 42 studies, and now have 75 studies in total (9401 participants at treatment end). Most participants had fibromyalgia, chronic low back pain, rheumatoid arthritis, or mixed chronic pain. Most risk of bias domains were at high or unclear risk of bias, with selective reporting and treatment expectations mostly at unclear risk of bias. AEs were inadequately recorded and/or reported across studies. CBT The largest evidence base was for CBT (59 studies). CBT versus active control showed very small benefit at treatment end for pain (standardised mean difference (SMD) -0.09, 95% confidence interval (CI) -0.17 to -0.01; 3235 participants; 23 studies; moderate-quality evidence), disability (SMD -0.12, 95% CI -0.20 to -0.04; 2543 participants; 19 studies; moderate-quality evidence), and distress (SMD -0.09, 95% CI -0.18 to -0.00; 3297 participants; 24 studies; moderate-quality evidence). We found small benefits for CBT over TAU at treatment end for pain (SMD -0.22, 95% CI -0.33 to -0.10; 2572 participants; 29 studies; moderate-quality evidence), disability (SMD -0.32, 95% CI -0.45 to -0.19; 2524 participants; 28 studies; low-quality evidence), and distress (SMD -0.34, 95% CI -0.44 to -0.24; 2559 participants; 27 studies; moderate-quality evidence). Effects were largely maintained at follow-up for CBT versus TAU, but not for CBT versus active control. Evidence quality for CBT outcomes ranged from moderate to low. We rated evidence for AEs as very low quality for both comparisons. BT We analysed eight studies (647 participants). We found no evidence of difference between BT and active control at treatment end (pain SMD -0.67, 95% CI -2.54 to 1.20, very low-quality evidence; disability SMD -0.65, 95% CI -1.85 to 0.54, very low-quality evidence; or distress SMD -0.73, 95% CI -1.47 to 0.01, very low-quality evidence). At follow-up, effects were similar. We found no evidence of difference between BT and TAU (pain SMD -0.08, 95% CI -0.33 to 0.17, low-quality evidence; disability SMD -0.02, 95% CI -0.24 to 0.19, moderate-quality evidence; distress SMD 0.22, 95% CI -0.10 to 0.54, low-quality evidence) at treatment end. At follow-up, we found one to three studies with no evidence of difference between BT and TAU. We rated evidence for all BT versus active control outcomes as very low quality; for BT versus TAU. Evidence quality ranged from moderate to very low. We rated evidence for AEs as very low quality for BT versus active control. No studies of BT versus TAU reported AEs. ACT We analysed five studies (443 participants). There was no evidence of difference between ACT and active control for pain (SMD -0.54, 95% CI -1.20 to 0.11, very low-quality evidence), disability (SMD -1.51, 95% CI -3.05 to 0.03, very low-quality evidence) or distress (SMD -0.61, 95% CI -1.30 to 0.07, very low-quality evidence) at treatment end. At follow-up, there was no evidence of effect for pain or distress (both very low-quality evidence), but two studies showed a large benefit for reducing disability (SMD -2.56, 95% CI -4.22 to -0.89, very low-quality evidence). Two studies compared ACT to TAU at treatment end. Results should be interpreted with caution. We found large benefits of ACT for pain (SMD -0.83, 95% CI -1.57 to -0.09, very low-quality evidence), but none for disability (SMD -1.39, 95% CI -3.20 to 0.41, very low-quality evidence), or distress (SMD -1.16, 95% CI -2.51 to 0.20, very low-quality evidence). Lack of data precluded analysis at follow-up. We rated evidence quality for AEs to be very low. We encourage caution when interpreting very low-quality evidence because the estimates are uncertain and could be easily overturned. AUTHORS' CONCLUSIONS We found sufficient evidence across a large evidence base (59 studies, over 5000 participants) that CBT has small or very small beneficial effects for reducing pain, disability, and distress in chronic pain, but we found insufficient evidence to assess AEs. Quality of evidence for CBT was mostly moderate, except for disability, which we rated as low quality. Further trials may provide more precise estimates of treatment effects, but to inform improvements, research should explore sources of variation in treatment effects. Evidence from trials of BT and ACT was of moderate to very low quality, so we are very uncertain about benefits or lack of benefits of these treatments for adults with chronic pain; other treatments were not analysed. These conclusions are similar to our 2012 review, apart from the separate analysis of ACT.
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Affiliation(s)
- Amanda C de C Williams
- Research Department of Clinical, Educational & Health Psychology, University College London, London, UK
| | - Emma Fisher
- Cochrane Pain, Palliative and Supportive Care Group, Pain Research Unit, Churchill Hospital, Oxford, UK
- Centre for Pain Research, University of Bath, Bath, UK
| | - Leslie Hearn
- Cochrane Pain, Palliative and Supportive Care Group, Pain Research Unit, Churchill Hospital, Oxford, UK
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