Cochrane Review: Psychological therapies for the management of chronic pain (excluding headache) in adults, 2020, C De C Williams et al

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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Open access, https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007407.pub4/full


Managing chronic pain in adults: the latest evidence on psychological therapies
In this blog for people affected by chronic pain and those who support and work with them, Dr. Amanda C de C Williams discusses the findings of her team’s latest Cochrane Review on psychological therapies.

Many people with chronic pain (or persistent pain, a term some prefer) feel misunderstood and offended when their GP or pain specialist suggest that they need ‘psychological treatment’: “The pain is real – it’s not in my head”. But psychological methods of treating chronic pain or, rather, treating the problems associated with chronic pain have been used for over 50 years. They are based on understanding the importance of the individual’s beliefs about what is causing the pain, fears about pain worsening over time, conflicting advice from clinicians, friends and family, and disappointment with successive failures of medical attempts to resolve the pain.

Psychological methods are not about ‘thinking positive’ or ‘mind over matter’, but about achieving a deeper understanding of pain and what affects it, about changing habits of thinking and of lifestyle: becoming (ideally) a person who, despite pain, lives a full life with confidence in managing that pain.

We recently updated our Cochrane systematic review ‘psychological therapies for the management of chronic pain (except headache) in adults’. Given how long these treatments have been around, this is not our first version of this review, but it is by far the biggest. This has 75 studies while our last version, in 2012, had 42. Since we started, NICE (National Institute for Health and Care Excellence) has developed guidelines for chronic pain in the UK, to be published early next year, which review some of the same evidence. The question of what works, and what doesn’t work, is important, given the size of the problem. A systematic review and meta-analysis of UK studies (Fayaz et al. 2016) provided an estimate that 10-14% of the adult population has moderately to severely disabling chronic pain.
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https://www.evidentlycochrane.net/chronic-pain-psychological-therapies/


PwME certainly suffer #CochranePain...
In this @CochraneUK blog for people affected by chronic pain and those who support and work with them, Dr. Amanda C de C Williams discusses the findings of her team’s latest Cochrane Review on psychological therapies: buff.ly/32BuGzb #CochranePain @CochranePaPaS
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Code: 
https://twitter.com/CochraneLibrary/status/1313808055134564360

 
Psychological methods are not about ‘thinking positive’ or ‘mind over matter’, but about achieving a deeper understanding of pain and what affects it, about changing habits of thinking and of lifestyle: becoming (ideally) a person who, despite pain, lives a full life with confidence in managing that pain.
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I think CBT for pain is exactly that: thinking positive and mind over matter. When I read a description of CBT for pain, like for example here https://www.webmd.com/pain-management/features/cognitive-behavioral#1 what is described is positive thinking (reaching toxic positivity levels at some points) and some mind over matter claims (change your disease with your mind).
 
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Jonathan Edwards said:
What I wonder is whether reviews ever take note of strong evidence for NO EFFECT. We always hear of weak or moderate evidence for an effect but PACE provides strong evidence for NO EFFECT at least for some outcomes and at least moderate evidence for NO EFFECT as a whole.
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Definitely.
'No difference/no effect' was claimed in the abstracts of 36 (7.8%) of 460 Cochrane reviews and in the abstracts of 13 (6.0%) of 218 other systematic reviews.​
However
Incorrect claims of no difference/no effect of treatments were substantially less common in Cochrane reviews published in in 2017 than they were in abstracts of reviews published in 2001/2002. We hope that this reflects greater efforts to reduce biases and inconsistent judgements in the later survey as well as more careful wording of review abstracts. There are numerous other ways of wording treatment claims incorrectly. These must be addressed because they can have adverse effects on healthcare and health research.​
https://ebm.bmj.com/content/early/2020/03/10/bmjebm-2019-111257
 
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Mike Dean said:
Definitely.
'No difference/no effect' was claimed in the abstracts of 36 (7.8%) of 460 Cochrane reviews and in the abstracts of 13 (6.0%) of 218 other systematic reviews.
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That is something a bit different. Sure, there will be reviews that conclude no effect. But what if a range of studies provide some weak evidence of effect, some moderate evidence of effect and some strong evidence of no effect. What I have not seen is evidence for no effect being graded in the way that evidence for effect is. Maybe it's there but it doesn't come up in the discussions here as far as I know.

Mike Dean said:
However
Incorrect claims of no difference/no effect of treatments were substantially less common in Cochrane reviews published in in 2017 than they were in abstracts of reviews published in 2001/2002.
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How do we know if claims are incorrect or how many there are if it seems that recent reviews make such a hash of grading evidence. I wouldn't take the GRADE system as any indication of quality of evidence of effect. It seems to me a completely bogus system that deliberately replaces direct rational argument with pseudo arithmetical tricks.
 
strategist said:
I think CBT for pain is exactly that: thinking positive and mind over matter. When I read a description of CBT for pain, like for example here https://www.webmd.com/pain-management/features/cognitive-behavioral#1 what is described is positive thinking (reaching toxic positivity levels at some points) and some mind over matter claims (change your disease with your mind).
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I assume someone has pointed this out before i.e. the driver, promoting CBT, is that it is a relativelt cheap intervention and Governments like that!

The alternatives cost more and Governments try to reduce taxes i.e. to get elected --- forget efficacy this is about getting elected!
 
Jonathan Edwards said:
That is something a bit different. Sure, there will be reviews that conclude no effect. But what if a range of studies provide some weak evidence of effect, some moderate evidence of effect and some strong evidence of no effect. What I have not seen is evidence for no effect being graded in the way that evidence for effect is. Maybe it's there but it doesn't come up in the discussions here as far as I know.
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They seem to be moving slowly towards that. From the discussion section in the paper:
It remains important to recognise the uncertainties inherent in statistical estimates of treatment differences, and the need to distinguish between ‘no evidence of a difference/effect’ and ‘evidence of no difference/effect’. In practical terms, this implies using CIs to assess how confidently important treatment differences can be ruled out and using wording that reflects the probabilistic approach entailed.​

Even more concerning than "no effect" is the evaluation of "worse than" in reviews, when primary studies have been fixed to make recording harms harder. PACE widened the goal for success midtrial, but narrowed it for adverse events at the other end of the pitch.
 
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When doctors talk about chronic pain are they assuming that the pain has no cause that can be found?

What would happen if someone had some severe genetic condition that distorted their spine and caused them lots of pain, for example? Would they be told that CBT is all they need or will they actually be given real help?

These are hypothetical questions, by the way...
 
Arnie Pye said:
What would happen if someone had some severe genetic condition that distorted their spine and caused them lots of pain, for example? Would they be told that CBT is all they need or will they actually be given real help?
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My spinal abnormality is congenital rather than genetic, and the GP and pain consultant do take it seriously. After a significant worsening about 4 or 5 years ago, the consultant prescribed low dose opiate patches which have been pretty life-changing.

I did a pain management course 20+ yrs ago, run by a couple of physios and it was helpful at the time, suggesting relevant exercises as well as ways of managing the pain. No CBT suggesting that all you had to do was think differently and all your pain and resulting disabiltieswould vanish.
As ever good to talk to others with similar pain levels.
 
MEMarge said:
My spinal abnormality is congenital rather than genetic, and the GP and pain consultant do take it seriously. After a significant worsening about 4 or 5 years ago, the consultant prescribed low dose opiate patches which have been pretty life-changing.

I did a pain management course 20+ yrs ago, run by a couple of physios and it was helpful at the time, suggesting relevant exercises as well as ways of managing the pain. No CBT suggesting that all you had to do was think differently and all your pain and resulting disabiltieswould vanish.
As ever good to talk to others with similar pain levels.
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My problems with pain are caused by delayed and botched gynaecological surgery for a life-threatening condition in my teens. The damage caused by the delay and the poor surgery has been mentioned in some of my later medical records but the original cause has been obfuscated and I am always treated as if I'm lying no matter what condition or problem I'm complaining about. But of course, the damage I have is invisible. I now take copies of the relevant records with me when I see doctors of any kind. Because my records are so poorly written, when I've had gynae problems that became obvious to a surgeon when I was opened up they have insinuated that I must be in the condition I'm in because of immoral behaviour, so I must have only myself to blame. :banghead:

I asked my question because I was just wondering if anyone with a visible problem was told they needed CBT, or were actually taken seriously and treated for their pain. I knew my mention of "genetic" didn't sound right but I couldn't think of the word "congenital". :)

At least people with visible problems do get treated with some compassion. The problem for me is the invisibility of my condition.

I'm glad you are getting treatment for your pain. :hug:
 
By the very definition of how those services operate, this case was a resounding success: the patient did not come back. Perverse incentives lead to perverse outcomes.

I don't know how the people who run those services do it, though. I could never debase myself this much, because I have a minimum of integrity and self-respect. Zero ethical difference between this and scamming retirees out of their life savings.
 
Arnie Pye said:
I asked my question because I was just wondering if anyone with a visible problem was told they needed CBT, or were actually taken seriously and treated for their pain. I knew my mention of "genetic" didn't sound right but I couldn't think of the word "congenital". :)

At least people with visible problems do get treated with some compassion. The problem for me is the invisibility of my condition.
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So sorry for the way you are treated @Arnie Pye.

I do think the fact that it is so visible has helped me. Even before it was so obvious from the outside, the X-rays showed it was a mess, so doctors have generally been understanding. Even those lacking any empathy, have acknowledged that it looked horrendous on X-rays, would just get worse with age and was I sure i hadn't been in a car crash!
 
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