Authors |
N |
Study |
Treatment Type |
Treatment Components |
Duration |
Outcome Measures |
Results |
Limitations |
Follow up (f/u) |
Thorn et al.18 |
290 with mixed chronic pain |
RCT |
Literacy-adapted CBT (n = 95) vs EDU (education) (n = 97) vs. treatment as usual (TAU) (n = 98) |
CBT: psychoeducation, cognitive restructuring, activity pacing, relaxation, motivational reinforcement
EDU: pain-related information provided, no specific skills-building exercises |
Ten 1.5-h weekly sessions |
Brief Pain Inventory intensity and interference, Patient Health Questionnaire-9 |
CBT = EDU at posttreatment, both > TAU on pain intensity and physical function; gains in intensity maintained at f/u for EDU but not CBT, gains in physical function maintained for both CBT and EDU. No significant changes in depression. |
Participants were recruited from a single health care system, so a self-selection bias was possible. |
6 mo |
Helminen et al.19 |
111 with knee osteoarthritis, aged 35-75 y |
RCT |
CBT (n = 55) vs. medical TAU (n = 56) |
CBT: psychoeducation on pain, problemsolving skills, relaxation, scheduling activities, cognitive appraisals and beliefs, assertiveness training |
Six 2-h weekly sessions |
Western Ontario and McMaster Universities Osteoarthritis Index Pain Scale, Pain Self-Efficacy Questionnaire, RAND-36 emotional well-being, Pain Catastrophizing Scale, Tampa Scale for Kinesiophobia (TSK), Beck Depression Inventory (BDI) |
CBT = TAU on pain and function; CBT > TAU on well-being, TAU > CBT on self-efficacy. No significant differences at f/u. |
Lack of fidelity monitoring, low recruitment to enrollment rate; baseline self-efficacy was high at baseline for both groups. |
3 mo 12 mo |
Linden et al.20 |
103 with chronic low back pain |
RCT |
CBT (n = 53) vs. unspecified occupational therapy (OT; n = 50) |
All participants treated for 21 d in an inpatient interdisciplinary rehabilitation unit. In addition:
CBT group: gate control theory, stress reduction, problem solving, self-monitoring, cognitive restructuring, reducing avoidance, increasing activities, relaxation
OT: additional OT sessions, playing games, motivated to engage in activities |
Six 90-min sessions (3/wk) |
Symptom Checklist-90, Rating of Health Locus of Control Attributions, Fear Avoidance Belief Questionnaire, VAS pain |
All outcomes significantly improved in both groups; CBT > OT on pain and fear avoidance beliefs. |
Lack of fidelity monitoring; effect of CBT in isolation from other interdisciplinary treatments not established; no f/u |
— |
Seminowicz et al.21 |
13 with mixed chronic pain vs. 13 healthy and age-matched controls (baseline only) |
Nonrandomized trial |
CBT (n = 13) |
Self-regulatory skills such as relaxation, cognitive coping strategies such as cognitive restructuring, attention diversion methods, activity pacing, scheduling pleasant events, exercise, methods for enhancing social support |
Eleven 1.5-h weekly sessions |
Structural neuroplasticity (i.e., gray matter, GM), McGill Pain Questionnaire-Short-Form, Treatment Outcomes in Pain Survey, Short-Form Health Survey (SF-36), BDI, Coping Strategies Questionnaire |
Increased GM post-CBT in the bilateral dorsolateral prefrontal, posterior parietal, subgenual anterior cingulate/orbitofrontal, and sensorimotor cortices as well as hippocampus; reduced GM in supplementary motor area. Most increases in GM became significantly greater than GM in controls. CBT-related reductions in pain catastrophizing and increases in pain control were correlated with several of these regional GM changes. |
Small sample size; no comparison or randomization; lack of f/u |
— |
Slavin-Spenny et al.22 |
147 with mixed headaches |
RCT |
Anger awareness and expression training (AAET; n = 50) vs. relaxation (n = 48) vs. WL (n = 49) |
AAET: psychoeducation on stress-headache connection, experiential exercises for emotional awareness, assertive communication
Relaxation: psychoeducation on stress-headache connection, progressive muscle relaxation, deep breathing, brief relaxation |
Three 1-h weekly sessions |
Self-Assessment Manikin, Headache Management Self-Efficacy Scale, Toronto Alexithymia Scale, Rathus Assertiveness Schedule, Emotional Approach Coping Scales, Migraine Disability Assessment Scale, headache frequency, severity and duration, Brief Symptom Inventory |
AAET = relaxation on self-efficacy and headache outcomes, both > control. AAET significantly improved alexithymia, emotional processing, and assertiveness, compared to the other two conditions. |
Lack of f/u; lack of fidelity monitoring; use of a college sample limits generalizability; no headache diagnostic information obtained; no daily diaries of headache outcomes |
— |
Heutink et al.23 |
61 with neuropathic pain after SCI |
RCT |
CBT (n = 31) vs. WL (n = 30) |
CBT: psychoeducation, ABC model, stress, movement and pain, assertiveness, relaxation, goals, social aspects; significant other attended first 2 sessions |
Ten 3-h sessions over 10 wk and booster session 3 wk posttreatment |
Chronic Pain Grade Questionnaire, Hospital Anxiety and Depression Scale, Utrecht Activities List, Life Satisfaction Questionnaire |
CBT = WL on intensity and disability; CBT > WL on anxiety and participation in activities |
Small sample size |
3 and 6 mo |
Thorn et al.24 |
83 with mixed chronic pain |
RCT |
Literacy-adapted CBT (n = 49) vs. EDU (n = 34) |
CBT: stress-pain connection, automatic thoughts, challenging automatic thoughts and beliefs, relaxation, coping statements, expressive writing, assertive communication
EDU: psychoeducation on chronic pain treatment, gate control theory, costs of pain, acute vs. chronic pain, sleep, mood changes, pain behaviors, communication, working with health providers |
Ten 1.5-h sessions over 10 wk |
Brief Pain Inventory, Roland-Morris Disability Questionnaire (RMDQ), Pain Catastrophizing Scale, Center for Epidemiologic Studies Depression Scale, Quality of Life Scale |
CBT = EDU; completer analysis showed CBT > EDU on catastrophizing and depression. Gains maintained at 6-mo f/u |
Higher dropout rate in CBT; underpowered to detect effects of CBT compared to active treatment |
6 mo |
Lamb et al.25 |
701 with subacute or chronic low back pain |
RCT + costeffectiveness |
Active management consultation + CBT (n = 468) vs. active management consultation only |
Active management: active advice on remaining active, avoiding bed rest, medication/symptom management, also provided with The Back Book
CBT: challenging negative thoughts and beliefs, pacing, graded activity, relaxation, activity, and avoidance |
Active management: 15 min
CBT: an individual 1.5-h assessment, six 1.5-h CBT sessions |
Change in RMDQ and modified Von Korff scores at 12 mo |
Consultation + CBT > consultation only on both primary outcomes; inclusion of CBT > cost-effectiveness |
CBT delivered by a range of professionals with a 2-d training (physiotherapists, nurses, occupational therapists, psychologists) |
12 mo |
Van Koulil et al.26 |
158 with fibromyalgia (FM) |
RCT |
Tailored CBT + exercise training vs. wait-list control |
Pain avoidance or pain persistence treatment based on baseline cognitivebehavioral pattern
Patient’s significant other attended 3rd, 9th, and 15th sessions |
16 sessions of CBT (2 h) + exercise training (2 h) over 10 wk and 1 booster session at 3 mo |
Pain, fatigue, functional disability, negative mood, and anxiety scales of the Impact of Rheumatic Diseases on General Health and Lifestyle (IRGL), Pain Coping Inventory |
CBT + exercise > WL on all primary outcomes, with large effect sizes |
Did not compare “tailored” to nontailored treatment; inert comparison |
6 mo |
Falcão et al.27 |
60 females aged 18-65 y with FM |
RCT |
CBT (n = 30) vs. TAU (n = 30) |
CBT: relaxation training, cognitive restructuring, stress management |
CBT: 10 weekly 3-h sessions |
VAS for pain, SF-36, State-Trait Anxiety Inventory, BDI, Fibromyalgia Impact Questionnaire, paracetamol |
CBT > TAU on improved depression, mental health, and paracetamol. Both groups showed significant improvements on all indicators over time. |
Dropouts were excluded from the analyses; limited f/u; participants had not received any prior treatment. |
3 mo |
Ersek et al.28 |
256 with noncancer pain, ≥65 y |
RCT |
Pain selfmanagement (n = 133) vs. EDU (n = 123) |
Self-management: education about persistent pain, problem solving, exercise for pain, relaxation training, pacing and activity scheduling, challenging negative thoughts, medication management, hot/cold packs
EDU: read an assigned book, The Chronic Pain Workbook or Managing Your Pain Before It Manages You |
Self-management, 7 weekly 90-min group sessions |
Primary: RMDQ. Secondary: Geriatric Depression Scale, Brief Pain Inventory (intensity and interference) |
Pain self-management = EDU at posttreatment and 6- and 12-mo f/u. Use of relaxation and exercise/stretching significantly increased in self-management |
The number of strategies covered in selfmanagement may have limited effectiveness. |
6, 12 mo |
Thorn et al.29 |
34 with headache |
RCT compared order of treatment modules |
CBT (N = 22) vs. WLC (N = 11) |
Cognitive restructuring, cognitive coping, relaxation, assertiveness, behavioral pacing, homework |
Ten 90-min group sessions |
Pain Catastrophizing Scale (PCS), Pain Anxiety Symptoms Scale (PASS), Beck Depression Inventory-II (BDI-II), Headache Management Self-Efficacy Scale (HMSE), pain and medication via pain diaries; no difference in outcome based on order of treatment |
CBT > WLC for improvements in catastrophizing, anxiety, headache management self-efficacy. 50% treated patients showed clinically significant reductions in headache frequency, medication use. |
Small sample size rendered limited power to detect potential differences in order of treatment modules. |
6, 12 mo |
Li et al.30 |
64 with work-related injuries |
RCT |
Training on work readiness (T) (N = 34) vs. control (C) (N = 30) |
T: individual vocational counseling (3 sessions), CBT, pain and stress management, relaxation, stages of change assessment, job acquisition, preemployment training |
T: 3 weekly group sessions at 2-3 h, three 1-h individual sessions |
Spinal Function Sort (SFS), Loma Linda University Medical Centre Activity Sort (LLUMC), Chinese Lam Assessment of Stages of Employment Readiness (C-LASER), Chinese State Trait and Anxiety Inventory (C-STAI), SF-36 |
T > C for improvements in anxiety, work readiness, readiness to change, and perceived health status
T: within-group improvements from baseline for most SF-36 subscales and physical capacity |
Lack of f/u, stages of change may require longer time period for assessment |
None specified |
Linton et al.31 |
185 workers with back/neck pain |
RCT |
CBT (N = 69) vs. CBT and physical therapy (CBT 1 PT) (N = 69) vs. minimal treatment (N = 47) |
CBT: problem solving, homework, skills training, stress management, relaxation
CBT + PT: CBT plus personalized exercise program
Minimal: medical visit and advice, educational booklet |
6 weekly 2-h sessions |
Sick absenteeism, health care visits, Outcome Evaluation Questionnaire, VAS pain ratings, HAD, PCS, TSK, activities of daily living (ADLs), RMDQ |
CBT + PT = CBT for most measures. CBT + PT > Minimal for reductions in health care visits. At f/u: CBT + PT fewest sick days, followed by CBT and Minimal. Both treatment groups 5 times less likely to be on long-term sick leave than Minimal. |
Different intervention lengths |
1 y |
Gold et al.32 |
185 with vertebral fracture |
RCT |
Part 1: Intervention (I) (N = 94) vs. education control (EC) (N = 91)
Part 2: Crossover: EC becomes I group after 6 mo. Initial I group selfmaintenance |
I: exercise, coping skills (relaxation, stress reduction)
EC: education of health issues for women |
Part 1:
I: 5 weekly exercise and coping sessions (225 min)
EC: 1 weekly session at 45 min
Part 2: I: self-maintain EC = I group |
Trunk extension strength, Functional Status Index (FSI), Global Severity Index of Hopkins Symptom Checklist-Revised |
Part 1: I > EC for improvement in trunk extension and psychological symptoms
EC: worse for all three outcomes
Part 2: EC showed withingroup improvements in trunk extension and psychological symptoms after intervention
I: decrease in back strength from posttreatment, improvement in psychological state maintained |
Different session lengths for I and EC, no control group at f/u. I group did not receive education in cross-over design. |
6 mo |
van Lankveld et al.33 |
59 with rheumatoid arthritis (RA) |
RCT compared couples to patient-only group |
Couples (C) (N = 31) vs. patient-only (P) (N = 28) |
Education, cognitive restructuring, encouragement to use active coping skills |
C: 2 weekly 1.5-h sessions for 4 wk |
Disease Activity Score (DAS): swollen joint count
IRGL, Coping with Rheumatoid Stressors Questionnaire (CORS), Maudsley Marital Questionnaire (MMQ) |
Sample improvements in disease activity, cognitions, coping, physical and psychological function (C = P). At f/u: C > P for improvements in diseaserelated communication with spouse. |
Possible selection bias of highly invested couples because of study design |
6 mo |
Ersek et al.34 |
45 elderly with chronic pain |
RCT |
Self-management (SM) (N = 17) vs. educational booklet (control) (EB) (N = 23) |
SM: education, self-monitoring, communication, relaxation, individualized goals, homework
EB: booklet with information about pain, medications, instructions for self-management, and pain resources |
SM: 7 group sessions at 90 min |
SF-36, Graded Chronic Pain Scale, Geriatric Depression Scale, Survey of Pain Attitudes (SOPA), survey assessing use of pain management strategies, treatment usefulness scales |
SM > EB for improvements in pain intensity and physical role function (pre- to postchange); clinically significant improvement in 43% SM and 13% EB; SM = EB at f/u. |
Brief f/u |
3 mo |
Tkachuk et al.35 |
28 with irritable bowel syndrome (IBS) |
RCT |
CBT (n = 14) vs. home-based symptom monitoring with weekly telephone contact (SMTC) (n = 14) |
CBT: education, relaxation, cognitive restructuring, assertiveness training
SMTC: daily symptom monitoring, discussion of symptom patterns |
Ten 90-min sessions for 9 wk |
Daily monitoring IBS scores, BDI-II, cognitive emotional distress (CSFBD), trait anxiety (STAI-T), discomfort with assertion (AQ), quality of life (SF-36) |
CBT > SMTC for pain relief ratings, improvement in GI symptoms, quality of life. Maintained at f/u.
One-third treated patients experienced clinically significant improvement. |
Brief f/u |
3 mo |
Mishra et al.36 |
94 with chronic TMD |
Urn method of assignment |
CBT (n = 22), biofeedback (n = 23), CBT + biofeedback (n = 24), no treatment (n = 25) |
CBT: self-change plain; relaxation training; distraction; pleasant activity scheduling; cognitive restructuring; social skills and assertive communication.
Biofeedback: 15 min of temperature feedback and 15 min of electromyography (EMG) biofeedback
Combined: include components of both of the above |
12 sessions of 1.5 h, except for combined treatment which was 2 h; 2/wk for first 4 wk, 1/wk for other 4-wk |
Characteristic Pain Intensity (CPI), Graded Chronic Pain Score (GCPS), Profile of Mood States (POMS) |
CBT = biofeedback = combined and all 3 greater than no treatment on CPI and POMS. No significant pre- to posttreatment change was observed for GCPS across any group. Biofeedback improved the most compared to the no treatment control on CPI. |
Combined treatment was a higher dose.
Lack of f/u |
— |
Leibing et al.37 |
55 with RA |
RCT |
CBT (N = 19) vs. TAU (N = 36), change in medication-matched control group (CN) (N = 20) |
CBT: education, relaxation, cognitive restructuring, pain management, pleasant activity scheduling |
CBT: 12 weekly sessions at 90 min |
C-reactive protein (CRP), blood sedimentation rate (Westergren), swollen joint count, Hannover Functional Ability Questionnaire (HFAQ), medication types, VAS pain intensity, affective pain score, pain diary, STAI, Depression Scale (DS), Arthritis Helplessness Scale (AHI), Bernese Coping Modes |
Overall increase in disease activity across sample
CBT less progressive inflammation than TAU. CBT > CN for pain reduction, improvements in depression, anxiety, helplessness; CBT: improved depression, helplessness, positive coping from baseline |
Potential type I error from multiple significance tests; lack of f/u |
None specified |
Potts et al.38 |
60 with noncardiac chest pain |
RCT |
CBT (N = 34) vs. WLC (N = 26) |
CBT: education, relaxation, biofeedback, graded exercise, challenging automatic thoughts, homework
WLC: delayed treatment |
6 sessions at 2 h |
HADS, Nijmegen hyperventilation scale, Sickness Impact Profile (SIP), Nottingham Health Profile (NHP), chest pain diaries, hyperventilation: portable carbon dioxide monitor, exercise electrocardiography (ECG) |
CBT > C for improvements in chest pain frequency, pain-free days, anxiety, and depression, disability, and exercise tolerance. Similar results for delayed treatment group once treated. Overall, 76% had improvements in chest pain. Maintained at f/u. |
Lack of control group at f/u |
6 mo |
Cole39 |
113 with mixed chronic pain |
Non-RCT |
CBT (N = 88) vs. TAU (N = 25) |
Coping skills, pain self-management, adjustment, stress management, relaxation, self-esteem, positive thinking |
75 min, 1 per week for 16 wk |
Multidimensional Pain Inventory (MPI), Minnesota Multiphasic Personality Inventory-2 (MMPI-2), BDI
Reported narcotic medication usage, health care visits, work status |
CBT: decreases in BDI and MPI scores, and health care visits from baseline, increase in return to work
f/u: medication decreased from 75% at baseline to 44%, health care visits decreased from 5/mo to 1/mo. Work status increased from 10% to 31%. |
Patients not randomly assigned. No direct comparison between CBT and control groups. |
1 y |
Keel et al.40 |
27 with FM |
RCT |
CBT (N = 14) vs. autogenic (N = 13) |
CBT: stress inoculation, cognitive restructuring, activities for pain diversion, information, relaxation, group discussion, stretching, aerobic exercise
Autogenic: practice relaxation |
15 weekly sessions lasting 1-2 h |
Freiburg Personality Inventory, Locus of Control Scale, Rosenzweig Picture-Frustration Diary (of active hours, resting hours, sleep index, pain intensity, and medication consumption), General Symptom Checklist |
2 CBT clients vs. 1 autogenic had clinically significant improvement in medication consumption, physical therapies, sleep, pain scores, general symptoms
At f/u, CBT > autogenic for improvement in pain ratings. 4 CBT vs. 0 autogenic had clinically significant improvements at f/u. |
Small sample size; statistical analyses not described |
3 mo |
Keel et al.41 |
411 with low back pain |
Non-RCT |
Experimental (E) (N = 243) vs. standard physiotherapy (S) (N = 168) |
E: coping strategies, stress management, relaxation, simulated work situations fitness training, education and group activity, individual physiotherapy or psychotherapy for acute pain
S: mostly individual physiotherapy |
E: 4-wk (27 d) inpatient program
S: 3-wk (20 d) inpatient program |
Work situation, physical activities, pain history, VAS pain rating, pain drawing, RMDQ, Psychological General Well-Being Index (PGWB), health costs, quality of life, impairment |
E = S for improvements in functional ability, limitations in daily life, health care visits
E: higher proportion of individuals in work rehabilitation (23% work incapacity decrease), E > S daily hours worked, decrease in professional handicaps; at f/u, larger proportion of S worsened |
Preexisting differences between groups on demographic variables; different predominant treatment modalities in each condition (E = group, S = individual) |
3 mo, 1 y |
Basler et al.42 |
94 with low back pain |
RCT |
CBT (N = 36) vs. TAU (N = 40) |
Education, relaxation, modifying thoughts and feelings, pleasant activity scheduling, postural training |
12 weekly sessions at 150 min |
Pain diary (pain intensity, control over pain, medication consumption), Heidelberg Coping Scale (HCS), Dusseldorf Disability Scale (DDS) |
CBT: decreases in pain intensity, improvements in coping with pain, mental performance, and disability
Gains maintained at 6-mo f/u
TAU: little or no change |
High attrition rate at f/u |
6 mo |
van Dulmen et al.43 |
45 with IBS |
Non-RCT |
CBT (N = 25) vs. WLC (N = 20) |
Patient education (e.g., roles of cognitions, behaviors, in IBS), homework, discussion, progressive muscle relaxation |
8 weekly sessions lasting for 2 h |
Diary (duration of pain, daily avoidance behavior, GI complaints), Abdominal Complaint Inventory, Symptom Checklist 90
(SCL-90) |
CBT > WLC for improvement in Daily Abdominal Complaint Score (DAC), duration, avoidance, and number of successful coping strategies delayed treatment group: decreases in DAC; improvements maintained at f/u |
No WLC at f/u, wide range of f/u assessment times (6 mo-4 y) |
Mean = 2.25 y |
Vlaeyen et al.44 |
131 with FM |
RCT |
Cognitive educational intervention (ECO; N = 47) vs. attention control condition of education and discussion (EDI; N = 39) vs. WLC (N = 40) |
ECO: imaginative transformation of pain, relaxation and biofeedback, homework
EDI: education, sharing thoughts with group members, listening to music, homework |
ECO and EDI = 12 90-min sessions conducted in 6 wk |
Pain cognition list, Coping Strategies Questionnaire (CSQ), Behavioral Approach Test, Pain Behavior Scale, McGill Pain Questionnaire (MPQ), Multidimensional Pain Locus of Control Scale, Checklist for Interpersonal Pain Behavior, Fear Survey Schedule, BDI |
ECO = EDI for improvements in pain coping and knowledge
EDI > WLC on knowledge and pain control. At 12-mo f/u, ECO = EDI, although ECO had an increase in pain intensity. |
Potential confounding of treatment (EDI group shared thoughts, completed homework). Low education level of participants may have made ECO difficult. |
12 mo |
Newton-John et al.45 |
44 with chronic back pain |
RCT |
CBT (N = 16) vs. electromyographic biofeedback (EMGBF; N = 16) vs. WLC (N = 12) |
CBT: education, goal setting, relaxation, cognitive restructuring, homework
EMGBF: education, diaphragmatic breathing, adaptation, homework |
8 sessions at 1 h (2 sessions per week) |
BDI, STAI, CSQ, Pain Disability Index, Pain Beliefs Questionnaire (PBQ) |
CBT and EMGBF > WLC for improvements in intensity, disability, adaptive beliefs, and depression. Improvements maintained at f/u, along with improvements in anxiety and active coping |
Small sample size per group |
6 mo |
James et al.46 |
33 with headache |
RCT |
CBT with goals (goal group) (N = 13) vs. CBT with no goals (open group) (N = 13) vs. WLC (N = 7) |
Both CBT groups: education, coping, developing appropriate self-talk, generalization of skills, relaxation
Goal: specific time goals for coping with pain/stress
Open: instructions to cope as long as possible |
6 weekly sessions at 90 min |
Goal specificity: coping with daily stressors and pain, daily self-monitoring, pain index, medication intake, downtime, Pain Behavior Questionnaire, SCL-90, SIP, BDI, STAI, Cognitive Coping Index |
Goal and open groups > WLC for improvements in pain coping skills, goal group > open and WLC group for reduction of headache and nonnarcotic medication use |
Lack of f/u period |
None specified |
Turner and Jensen47 |
102 with low back pain |
RCT |
Relaxation (R) (N = 17) vs. cognitive therapy (C) (N = 21) vs. cognitive therapy and relaxation (CR) (N = 16) vs. WLC (N = 18) |
R: imagery, progressive muscle relaxation (PMR)
C: identify negative thoughts, counter negative automatic thoughts
CR: combined treatment |
6 weekly sessions at 2 h |
VAS pain ratings, SIP, BDI, Observed Pain Behaviors, Cognitive Errors Questionnaire, BDI |
R, C, and CR > WLC for improvements in pain ratings and disability.
At f/u: all three patient groups improved. At both f/u, patients in all groups improved R = C = CR. |
No comparison to control group at f/u, attrition rates for control condition |
6, 12 mo |
Kneebone and Martin48 |
35 with headache |
Non-RCT
Compared couples to standard noncouple and control groups |
Partners involved (PI) (N = 12) vs. no partners (NPI) (N = 10) vs. no treatment control (NTC) (N = 13) |
PI and NPI: selfmonitoring, relaxation, cognitive restructuring, assertiveness, group process (e.g., support), homework
PI: partners educated in reinforcement principles |
10 weekly sessions at 1.5-2 h |
Headache activity, intensity, medication usage, relaxation practice, Partner Involvement Questionnaire, Dyadic Adjustment Scale (DAS), self-monitoring forms |
PI = NPI for relaxation time, PI > NPI for partner involvement: spouse assisted with relaxation
PI: decrease headache activity from baseline
NPI: decreased medication usage from baseline. NTC increased medication usage. At f/u: NPI > NTC for reductions in medication. Other measures: PI = NPI at f/u. |
Potential for type 1 inflation; low motivation across treatment groups to practice relaxation |
2, 12 mo |
Nicholas et al.49 |
58 with low back pain |
RCT |
Cognitive therapy (CT) + relaxation (N = 8) or CT (N = 10) vs. behavior therapy + relaxation (N = 9) or BT (N = 10) vs. attention (ATC; N = 10) and no attention control (N = 11) |
All groups: physiotherapy, education, exercise
CT: cognitive restructuring, distraction, imagery, self-monitoring
BT: activity pacing, medication reduction, reinforcement
Relaxation: PMR
ATC: group discussion about back pain |
Five 1.5- to 2-h sessions twice per week |
Pain Rating Chart
STAI, PBQ, CSQ, SIP, SIP-Others (SIP-O), medication intake, report of alternative treatments, visits to health care facilities |
Sample improved on affective distress, functional impairment, medication use, and active coping. Both CBT groups and both BT groups > ATC and control for improvements in pain intensity, self-reported disability, pain beliefs, and active coping. BT > CBT for improvements in impairment. Improvements somewhat maintained at f/u. |
Physiotherapy included as part of all treatments
Small sample size |
6, 12 mo |
Subramanian50,51 |
39 with mixed chronic pain
Long-term f/u = 22 |
RCT |
Structured group therapy (N = 19) vs. WLC (N = 20) |
Therapy: stress management, relaxation cognitive restructuring (coping thoughts, self-defeating, selfenhancing thoughts), assertiveness training |
8 weekly 2-h sessions |
SIP, Pain level (0-10 scale) used a control variable
Profile of Mood States (POMS), Social Support Questionnaire |
Therapy > WLC for improvements in physical and psychosocial dysfunction, negative mood states. Within-group improvements also apparent.
Long-term f/u: improvements maintained, improvement in pain severity observed, 77% improved from posttreatment to f/u, 36% reduction in prescription medication usage |
No comparison group at longterm f/u |
6 mo
Long-term: 18-22 mo |
Peters and Large52 |
68 with chronic pain |
RCT |
Group inpatient program (IPMP) (N = 29) vs. Group outpatient program (OPMP) (N = 23) vs. control (C) (N = 16) |
IPMP: education, pain management, relaxation, cognitive restructuring, exercise, vocational counseling, reinforcement
OPMP: education, activity goal setting, exercise, medication and stress management, relaxation |
Inpatient: 4 wk
Outpatient: 9 weekly sessions at 2 h |
BDI, MPQ, General Health Questionnaire (GHQ), SIP, Pain Behaviour Checklist, pain drawings, VAS ratings, VAS stair climbing test, physiologic measures, physical endurance |
Sample improvements in disability, GHQ scores, BDI, and MPQ scores
IPMP and OPMP > control for improvements in disability, VAS pain ratings, and pain behavior |
Results may have been influenced by timing of the assessments; lack of f/u |
None specified |
Turner et al.53 |
96 chronic low back pain patients |
RCT |
Group behavioral and aerobic exercise (BE) (N = 18) vs. behavioral therapy only (B) (N = 18)
Aerobic exercise only (E) (N = 21) vs. WLC (N = 23) |
BE: behavioral intervention followed by exercise in each session
B: reinforcement role-playing, discussion, homework, communication
E: Exercises 5 times per week |
BE and B: 8 weekly 2-h sessions
E: 5 weekly sessions |
MPQ, SIP, Pain Behavior Checklist (PBC), PBCspouse ratings, Physical Work Capacity (PWC), Center for Epidemiologic Studies—Depression Scale (CES-D), recorded pain behaviors |
All three groups improved more than the WLC from pre- to posttreatment,
BE > WLC from preto posttreatment on self-report and observer rated pain behavior measures, BE > E on PBC Spouse ratings
F/u: all treatment groups improved over time |
Interaction with therapists varied by condition |
6, 12 mo |
Linton et al.54 |
66 nurses with back pain |
RCT |
Physical and behavioral preventive intervention (PBI) (N = 36) vs. WLC (N = 30) |
PBI: physical therapy, “low back school,” relaxation, pain control instruction, goal setting, problem solving, coping, identifying high-risk situations |
PBI: 8 h/d for 5 wk |
Daily pain diaries, VAS intensity, fatigue, anxiety, sleep, pain behavior, ADLs, BDI, AHI, marital satisfaction, absenteeism, medication intake |
PBI > WLC for improvements in pain intensity, fatigue, pain behavior, sleep, ADLs, helplessness
Most differences maintained at f/u |
Use of nonstandardized measures of sleep quality, ADLs, marital satisfaction |
6 mo |
Puder55 |
69 with mixed chronic pain |
RCT |
Stress inoculation training (SIT) (N = 31) vs. WLC (N = 38) |
SIT: explaining treatment, reviewing progress, problem solving |
10 weekly 2-h group sessions |
Daily pain diary, nontreatment technique usage: psychological support, exercise, heat/cold, massage, TENS, injections |
SIT > WLC for improvements in pain interference, coping, decreased analgesic intake, discontinuation of heat/cold, and home traction technique. No difference according to age. Improvements maintained at f/u. |
Use of nonstandardized measures |
1, 6 mo |
Bradley et al.56 |
53 with RA |
RCT |
Biofeedbackassisted CBT (N = 17) vs. structured group social support therapy (SGT) (N = 18), no adjunct treatment (NAT) (N = 18) |
CBT: thermal biofeedback, education, relaxation, behavioral goal setting, self-rewards
SGT: education, discussion of coping strategies, encouragement to develop improved strategies |
CBT: 5 thermal sessions, 10 family/friend meetings
SGT: 15 sessions family/friends |
STAI, Depression Adjective Checklist (DACL), Health Locus of Control Scale (HLCS), AHI, pain behaviors, rheumatologist ratings of disease activity level, rheumatoid factor titers, sedimentation rate (Westergren) |
CBT > SGT and NAT for decreases in pain behavior, pain ratings, rheumatoid activity (RAI), NAT: lower RAI scores than SGT
SGT and NAT increased in depression and rheumatoid factor titer across assessments
CBT and SGT > NAT for improvement in anxiety
CBT maintained improvement at f/u |
Session duration not specified |
6 mo |
Larsson et al.57 |
36 high school students with tension/migraine headaches |
RCT |
Self Help Relaxation (SHR) (N = 12) vs. Problem Discussion Condition (PDC) (N = 10) vs. Untreated Self-Monitoring Condition (SM) (N = 12) |
SHR: relaxation programs, rapid cue-controlled strategy, homework, help solving problems during relaxation
PDC: discussion of conflicts in everyday life, role-play, identifying stressors, assertiveness |
5 weekly sessions
SHR = 3 h
PDC = 7 h |
Headache diary: frequency, duration headache free days, peak intensity, modified Depression Scale for Female adolescents, Children’s Manifest Anxiety Scale, Social Relationship-Competence Questionnaire (SRCQ) |
Headache activity:
Greatest reductions for SHR group, SHR > SM and PDC
Headache sum and peak intensity: SHR > PDC during pre-f/u interval
Headache duration and headache-free days:
SHR > SM and PDC |
Small sample size, different therapist interaction for two interventions |
5 mo |
Bradley et al.58 |
33 with RA |
RCT |
Thermal biofeedback and group cognitive behavioral (CB = 11) vs. social support (SS = 10) vs. NAT (N = 12) |
CB: thermal biofeedback, education, skills acquisition, self-instructional training, application
SS: education, support, encouragement to develop own coping strategies
NAT = control |
CB: 5 individual thermal sessions, 10 family meetings
SS: 15 family meetings |
STAI, DACL, VAS ratings of pain intensity, unpleasantness, severity of morning stiffness, pain behaviors, HLCS, rheumatoid factor titers, Westergren, rheumatologist ratings of disease activity |
CB > NAT group for significant decreases in pain intensity, pre- to posttreatment: CB less pain behavior from preto posttreatment, less rheumatoid activity, and rheumatoid factor titer. CB and SS less anxiety and depression. SS increase in sedimentation rate NAT: significant reduction in morning stiffness. |
Small sample size, lack of f/u |
None specified |
Linton et al.59 and Melin and Linton60 |
28 with heterogeneous chronic pain
26 with heterogeneous chronic pain |
RCT
Long-term f/u |
Regular treatment (RT) vs. applied relaxation and operant activities (RT + BT) vs. WLC |
RT: prescribed treatment plan
RT + BT: plan and relaxation training, operant training, reinforcement of well behaviors, decrease in medication |
12 sessions |
BDI, Activities of Daily Living questionnaire, self-monitoring of pain, medication consumption, sleep f/u measures also included pain, health, activity, level, sleep, occupation |
RT + BT > RT and WLC for improvements in pain level and leisure activity
Improvements maintained at f/u |
Small sample size
Long-term f/u: WLC group received individual treatment prior to assessment |
14-16 mo |
Moore and Chaney61 |
43 with mixed chronic pain |
RCT |
Couples group therapy (CBT) (N = 17) vs. patient-only group therapy (N = 14) vs. WLC (N = 12) |
Couples and patient only: education, goal setting, problem solving, relaxation and controlled breathing, direct pain reduction method, coping strategies, homework |
16-h program, couples: 8 biweekly 2-h sessions |
VAS pain severity (patient and spouse)
MMPI Hs, D, and Hy scales only, SIP, PARS IV Community Adjustment Scale (spouses), Locke-Wallace Marital Adjustment Test (LMAT), utilization of medical resources medication usage |
Couples and patient-only groups > WLC for improvements in VAS ratings, pain severity and pain behavior ratings, somatization, and PARS (spouse rating)
Patient-only groups > controls on LMAT and SIP scores
Treatment gains maintained at f/u
Couples = patient-only therapy |
Small sample sizes for each condition |
3, 7 mo |
Cohen et al.62 |
25 with chronic low back pain |
RCT |
Behavioral intervention (BT) (N = 13) vs. physical therapy (PT) (N = 12) |
PT: pain control strategies, relaxation, exercise, pool therapy, use of body mechanics
BT: goal setting, activity pacing, problem solving, assertiveness |
10 weekly 2-h sessions |
Physical Abilities and Walking Abilities testing, Knowledge and Functional Measure of Body Mechanics, CES-D, Psychological Adjustment to Role Scale (PARS-V) |
PT: greater low back control and decreases in CES-D score. BT and PT: lower anxiety and depression per patients and significant others on PARS-V, others.
Decreases in physical and activity limitations for both groups |
Small sample size, validity data for some instruments not provided |
None specified |
Figueroa63 |
15 tension headache patients |
RCT |
Behavior therapy (BT) (N = 5) vs. psychotherapy (P) (N = 5) vs. self-monitoring (SM; N = 5) |
BT: problem solving, relaxation, anxiety management training, stress inoculation
P: discussion, conflict resolution, discussion of stressful events |
BT: seven 90-min sessions
P: seven 90-min sessions (twice weekly) |
Headache questionnaire, headache checklist (e.g., level of relaxation, number of headaches, duration, severity, medication usage, disability), self-monitoring forms |
Pre to f/u: B > P and SM for improvements in perceived disability
BT > SM for reductions in headache frequency and duration, medication usage, level of relaxation, and pain severity |
Small sample size, use of nonstandardized measures |
Time not specified |
Turner64 |
36 chronic low back pain patients |
RCT |
CBT (N = 13), vs. relaxation (N = 14) training, WLC/attention conditions (N = 9) |
CBT: stress inoculation, behavioral goals, cognitive and affective responses to pain, coping self-statements, relaxation
Wait-list/attention: gave daily pain ratings to therapist in weekly phone calls |
5 weekly 90-min sessions |
SIP, SIP Significant Other (SIP-O), VAS ratings, self-ratings of improvement, BDI, work hours, health care usage |
CBT and relaxation groups > WLC for improvements in pain, depression, disability, and spousal ratings of physical and psychosocial function
At f/u: CBT improved on SIP, SIP-O, pain severity, relaxation: worse pain severity
1.5- to 2-y f/u: both groups retain improvements, CBT > in hours worked per week |
Small sample size |
1 mo, 1.5-2 y |
AQ, Assertiveness Questionnaire; CBT, cognitive-behavioral therapy; CSFBD, Cognitive Scale for Functional Bowel Disorders; GI, gastrointestinal; HADS, Hospital Anxiety and Depression Scale; IPMP, inpatient pain management program; OPMP, outpatient pain management program; RAI, Rheumatoid Activity Index; RCT, randomized controlled trial; SCI, spinal cord injury; STAI-T, State-Trait Anxiety Inventory-Trait Scale; TMD, temporomandibular disorder; VAS, Visual Analog Scale; WL, wait-list; WLC, wait-list control. |