The effects of cognitive-behavioural therapy in chronic pain

Complex regional pain syndrome in children and adolescents

Complex regional pain syndrome (CRPS) is a disorder characterised by pain, sensory and motor disturbances and represents a significant medical entity. This report discusses two cases of CRPS in children and adolescents, highlighting several critical issues for clinicians in the diagnosis and management of CRPS in these populations. Early diagnosis, referral and appropriate intervention are essential in decreasing pain, suffering and resorting function for children and adolescents with CRPS.

Behavioural treatment for chronic low-back pain

BACKGROUND

Behavioural treatment, commonly used in the treatment of chronic low-back pain (CLBP), is primarily focused at reducing disability through the modification of environmental contingencies and cognitive processes. In general, three behavioural treatment approaches are distinguished: operant, cognitive and respondent.

OBJECTIVES

To determine if behavioural therapy is more effective than reference treatments for CLBP, and which type of behavioural treatment is most effective.

SEARCH STRATEGY

We searched the CENTRAL, MEDLINE, EMBASE, and PsycLIT databases up to October 2003. References of identified randomised trials and relevant systematic reviews were screened.

SELECTION CRITERIA

Only randomised trials on behavioural treatment for non-specific CLBP were included.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the methodological quality and extracted the data. The magnitude of effect was assessed by computing a pooled effect size for post-treatment and long-term results for each comparison, for each domain (i.e., behavioural outcomes, overall improvement, back pain specific and generic functional status, return to work, and pain intensity) using the random effects model.

MAIN RESULTS

Seven studies (33%) were considered high quality. Comparing behavioural treatment to waiting list control (WLC) revealed strong evidence (4 trials, 134 people) in favour of a combined respondent-cognitive therapy for a medium positive effect on pain, and moderate evidence (2 trials, 39 people) in favour of progressive relaxation for a large positive effect on pain and behavioural outcomes (short-term only). When comparing operant treatment to WLC no significant differences could be detected on general functional status (strong evidence: 2 trials, 87 people) or on behavioural outcomes (moderate evidence; 3 trials, 153 people) (short-term only). There is limited evidence (1 trial, 98 people) that a graded activity program in an industrial setting is more effective than usual care for early return to work and reduced long-term sick leave. There is limited evidence (1 trail, 39 people) that there are no differences between behavioural treatment and exercises. Finally, there is moderate evidence (6 trials, 210 people) that there are no significant differences in short-term and long-term effectiveness when behavioural components are added to usual treatment programs for CLBP (i.e. physiotherapy, back education) on pain, generic functional status and behavioural outcomes.

AUTHORS' CONCLUSIONS

Combined respondent-cognitive therapy and progressive relaxation therapy are more effective than WLC on short-term pain relief. However, it is unknown whether these results sustain in the long term. No significant differences could be detected between behavioural treatment and exercise therapy. Whether clinicians should refer patients with CLBP to behavioural treatment programs or to active conservative treatment cannot be concluded from this review.

Behavioral treatment for chronic low back pain: a systematic review within the framework of the Cochrane Back Review Group

STUDY DESIGN

A systematic review of randomized controlled trials.

SUMMARY OF BACKGROUND DATA

The treatment of chronic low back pain is not primarily focused on removing an underlying organic disease but at the reduction of disability through the modification of environmental contingencies and cognitive processes. Behavioral interventions are commonly used in the treatment of chronic (disabling) low back pain.

OBJECTIVES

To determine whether behavioral therapy is more effective than reference treatments for chronic nonspecific low back pain and which type of behavioral treatment is most effective.

METHODS

The authors searched the Medline and PsychLit databases and the Cochrane Controlled Trials Register up to April 1999, and Embase up to September 1999. Also screened were references of identified randomized trials and relevant systematic reviews. Methodologic quality assessment and data extraction were performed independently by two reviewers. The magnitude of effect was assessed by computing a pooled effect size for each domain (i.e., behavioral outcomes, overall improvement, back pain-specific and generic functional status, return to work, and pain intensity) using the random effects model.

RESULTS

Only six (25%) studies were high quality. There is strong evidence (level 1) that behavioral treatment has a moderate positive effect on pain intensity (pooled effect size 0.62; 95% confidence interval [CI] 0.25, 0.98), and small positive effects on generic functional status (pooled effect size 0.35; 95% CI: -0.04, 0.74) and behavioral outcomes (pooled effect size 0.40; 95% CI: 0.10, 0.70) of patients with chronic low back pain when compared with waiting-list controls or no treatment. There is moderate evidence (level 2) that a addition of behavioral component to a usual treatment program for chronic low backpain has no positive short-term effect on generic functional status (pooled effect size 0.31; 95% CI: -0.01, 0.64), pain intensity (pooled effect size 0.03; 95% CI:-0.30, 0.36), and behavioral outcomes (pooled effect size 0.19; 95% CI: -0.08, 0.45).

CONCLUSIONS

Behavioral treatment seems to be an effective treatment for patients with chronic low back pain,but it is still unknown what type of patients benefit most from what type of behavioral treatment.

Behavioral treatment for chronic low back pain: a systematic review within the framework of the Cochrane Back Review Group

STUDY DESIGN

A systematic review of randomized controlled trials.

SUMMARY OF BACKGROUND DATA

The treatment of chronic low back pain is not primarily focused on removing an underlying organic disease but at the reduction of disability through the modification of environmental contingencies and cognitive processes. Behavioral interventions are commonly used in the treatment of chronic (disabling) low back pain.

OBJECTIVES

To determine whether behavioral therapy is more effective than reference treatments for chronic nonspecific low back pain and which type of behavioral treatment is most effective.

METHODS

The authors searched the Medline and PsychLit databases and the Cochrane Controlled Trials Register up to April 1999, and Embase up to September 1999. Also screened were references of identified randomized trials and relevant systematic reviews. Methodologic quality assessment and data extraction were performed independently by two reviewers. The magnitude of effect was assessed by computing a pooled effect size for each domain (i.e., behavioral outcomes, overall improvement, back pain-specific and generic functional status, return to work, and pain intensity) using the random effects model.

RESULTS

Only six (25%) studies were high quality. There is strong evidence (level 1) that behavioral treatment has a moderate positive effect on pain intensity (pooled effect size 0.62; 95% confidence interval [CI] 0. 25, 0.98), and small positive effects on generic functional status (pooled effect size 0.35; 95% CI: 0.04, 0.74) and behavioral outcomes (pooled effect size 0.40; 95% CI: 0.10, 0.70) of patients with chronic low back pain when compared with waiting-list controls or no treatment. There is moderate evidence (level 2) that a addition of behavioral component to a usual treatment program for chronic low backpain has no positive short-term effect on generic functional status (pooled effect size 0.31; 95% CI: 0.01, 0.64), pain intensity (pooled effect size 0.03; 95% CI: 0.30,0.36), and behavioral outcomes (pooled effect size 0.19; 95% CI: 0.08, 0.45).

CONCLUSIONS

Behavioral treatment seems to be an effective treatment for patients with chronic low back pain,but it is still unknown what type of patients benefit most from what type of behavioral treatment.

Behavioural treatment for chronic low back pain

BACKGROUND

The treatment of chronic low back pain is not primarily focused on removing an underlying organic pathology, but at the reduction of disability through the modification of environmental contingencies and cognitive processes. Behavioural interventions are commonly used in the treatment of chronic (disabling) low back pain.

OBJECTIVES

The objective of this systematic review was to determine if behavioural therapy is more effective than reference treatments for chronic non-specific low back pain, and which type of behavioural treatment is most effective.

SEARCH STRATEGY

We searched the Medline, PsycLit databases, and the Cochrane Controlled Trials Register up to April 1999, Embase up to September 1999. We also screened references of identified randomised trials and relevant systematic reviews.

SELECTION CRITERIA

Only randomised trials on any type of behavioural treatment for non-specific chronic low back pain were included.

DATA COLLECTION AND ANALYSIS

Methodological quality assessment and data extraction was done by two reviewers independently. The magnitude of effect was assessed by computing a pooled effect size for each domain (i.e., behavioural outcomes, overall improvement, back pain specific and generic functional status, return to work, and pain intensity) using the random effects model.

MAIN RESULTS

Only 6 studies (25%) were high quality. There is strong evidence (level 1) that behavioural treatment has a moderate positive effect on pain intensity (pooled effect size 0.62; 95% CI 0.25, 0.98), and small positive effects on generic functional status (pooled effect size 0.35; 95% CI -0.04, 0.74) and behavioural outcomes (pooled effect size 0.40; 95% CI 0.10, 0.70) of chronic low back pain patients when compared to waiting list controls or no treatment. There is moderate evidence (level 2) that an additional behavioural component to a usual treatment program for chronic low back pain has no positive short-term effect on generic functional status (pooled effect size 0.31; 95% CI - 0.01, 0.64), pain intensity (pooled effect size 0.03; 95% CI - 0.30, 0. 36) and behavioural outcomes (pooled effect size 0.19; 95% CI - 0.08, 0.45).

REVIEWER'S CONCLUSIONS

Behavioural treatment seems to be an effective treatment for chronic low back pain patients, but it is still unknown what type of patients benefit most from what type of behavioural treatment.