The quality of evidence is downgraded by study limitations (lack of allocation concealment and blinding).
A Cochrane review [Abstract] 1 included 75 studies with a total of 9 401 subjects. Most participants had fibromyalgia, chronic low back pain, rheumatoid arthritis, or mixed chronic pain. Trials studying headache or malignant disease were excluded. Cognitive behavioural therapy (CBT), behavioural therapy (BT), and acceptance and commitment therapy (ACT) were compared with active control or waiting list/treatment as usual (TAU) at treatment end, and at 6 month to 12 month follow-up. Control conditions were classified as active control when there was a protocolised treatment that engaged the patient, such as an exercise programme, a medical procedure, an education programme, a support group or a self‐instruction booklet.
CBT(59 studies): CBT showed very small benefit at treatment end for pain (SMD -0.09, 95% CI -0.17 to -0.01; 23 studies, n=3 235), disability (SMD -0.12, 95% CI -0.20 to -0.04; 19 studies, n=2 543), and distress (SMD -0.09, 95% CI -0.18 to -0.00; 24 studies, n=3 297) compared to active control. Small benefits for CBT over TAU at treatment end were observed for pain (SMD -0.22, 95% CI -0.33 to -0.10; 29 studies, n=2 572), disability (SMD -0.32, 95% CI -0.45 to -0.19; 28 studies, n=2 524), and distress (SMD -0.34, 95% CI -0.44 to -0.24; 27 studies, n=2 559). Effects were largely maintained at follow-up for CBT versus TAU, but not for CBT versus active control.There was insufficient evidence to assess adverse events.
Behavioural therapy(BT; 8 studies, n=647) and acceptance and commitment therapy (ACT; 5 studies, n=443): There was no evidence of a difference between BT and control, or ACT and control, for most outcomes, and the quality of the evidence for these treatments was mostly low or very low.
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