Psychological treatments for non-specific chronic pain
Systematic review
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The purpose of this systematic review is to provide an overview of the effect of psychological treatment on pain and function for people with chronic pain conditions.
Key message
The purpose of this systematic review is to provide an overview of the effect of psychological treatment on pain and function for people with chronic pain conditions.
We identified six systematic reviews of psychological treatment of people with chronic pain. Based on our synthesis of the results and assessment of the quality of the evidence, we can draw the following conclusions:
- Psychological treatment showed small to moderate effect on pain.
- Psychological treatment showed small effect on function.
- Psychological treatment in combination with other treatment showed small effect on pain
- The evidence of psychological treatment on return-to-work is inconclusive.
- Psychological treatment showed greater effect for persons with chronic low back pain, other chronic pain than for persons with fibromyaligia.
The quality of the evidence was moderate to low after assessment. There is a need to conduct well-designed studies on return-to-work. Furthermore research should identify the effect for other chronic pain populations that may benefit from psychological treatment.
Summary
Background
Chronic pain has high prevalence in Norway. About 30 % of the adult population experience pain compared to 16-19 % in our neighboring countries.
Compared to other OECD- countries; the proportion of the working population in Norway which receives benefits is relatively large. About one in ten of the population of working age receives disability benefit in Norway. Chronic pain and psychological disorders are one of the most important reasons for men and women being excluded from working life before retirement age.
Results from a 2005 survey of living conditions suggest that one half of disability benefit cases in Norway are related to chronic pain. Musculoskeletal complaints constitute about 40 % of sick leave days supported by National Insurance. In addition to higher social security costs, chronic pain can have consequences for the individual such as reduced functioning and poorer mental health.
Non-specific pain is defined as an unpleasant sensory and emotional experience of pain, which cannot be classified by any defined physical cause. If pain becomes chronic pain it may cause reduced mental health, anxiety, depression and sleeplessness. Psychosomatic symptoms could be chronic pain, dizziness, stomach pains and headache.
Psychological treatment aims to give a person motivation to change, to develop coping skills and interpersonal skills, and to reduce negative psychological effects of pain such as anxiety, depression, passivity and sleeping problems. Cognitive therapy is a common treatment, but other psychological treatments are also expected to help.
Objective
We aimed to answer the following questions;
1) What is the effect of psychological treatment on pain and function for patients with chronic pain?
2) What is the effect of multidisciplinary treatment on pain for patients with chronic pain?
3) What is the effect of psychological treatment on return-to-work?
Method
We conducted an overview of systematic reviews in accordance with the Norwegian Knowledge Centre for the Health Services’ handbook. We searched for systematic reviews in Cochrane library, Pub MED, MEDLINE, EMBASE, CINAHL, SVEMED and PsycINFO.
Two authors assessed independently the relevance of titles and abstracts of systematic reviews according to inclusion criteria. Potentially relevant publications were ordered in full-text and further assessed for inclusion. Selection criteria were systematic reviews with comparisons of psychological treatments versus control conditions on adults with chronic pain for more than 3 months. The quality of the included systematic reviews was assessed with a checklist and we included only systematic reviews of high and moderate methodological quality. We classified risk of bias and used GRADE 3.6 for quality assessments. Two review authors extracted data, which were pooled and re-analyzed in Rev Man 5.1.
Results
We identified 4 300 articles. 33 systematic reviews in full-text were considered relevant and sorted according to population, intervention, comparison and outcome (PICO). Because of overlap of studies between included reviews we decided to conduct our own meta-analysis.
We identified six systematic reviews of psychological treatment of people with chronic pain. Based on our synthesis of the results and assessment of the quality of the documentation, we can draw the following conclusions:
- Psychological treatment showed small to moderate positive effect on pain.
- Psychological treatment showed small effect on function.
- Psychological treatment in combination with other treatment showed small effect on pain.
- The evidence of the effect of psychological treatment on return-to-work is inconclusive.
- Psychological treatment showed greater effect for persons with chronic low back pain, other chronic pain than for persons with fibromyalgia.
Discussion
For the comparisons of psychological treatment on function with pain we found smaller studies and with fewer participants, and therefore less statistical power to reveal effect sizes or whether these are significant. This is relevant for the ability to generalize findings to other comparable populations. However, our re-analyzed data showed significant results for five of the eleven comparisons.
People with long term chronic pain are a diverse population. This increases the probability of statistical heterogeneity. It is therefore important to analyse which populations show the best response to treatment. This is done to evaluate what factors can lead to bias when different groups are taken together (i.e. in cases of “lumping” of studies).
Conclusion
This overview of reviews of psychological treatment for patients with non-specific chronic pain showed small to moderate effect on pain, thus new studies may alter our conclusions. Subgroup analyses may facilitate the exploration of data, and confirm results to comparable populations. Decision makers faced with implementing psychological treatment to reduce pain may use this overview to inform these decisions and consider the range of treatments available.
Future research should focus 1) on what kind of specific treatment component in psychological treatment work and 2) to identify client populations that may benefit from that specific treatment. It is difficult to distinguish what element may cause the effect for multidisciplinary treatment. Furthermore, there is also a need to conduct well-designed studies on return-to-work and to identify subpopulations that may benefit from that specific treatment is needed.