Psychological therapies for the management of chronic pain (excluding headache) in adults.
Psychological therapies for the management of chronic pain (excluding headache) in adults.
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DOI：
10.1002/14651858.cd007407.pub4
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发表时间：
2020-08-12
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影响因子：
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通讯作者：
Eccleston, Christopher
中科院分区：
文献类型：
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作者：
Williams, Amanda C de C;Fisher, Emma;Eccleston, Christopher
背景：慢性非癌性疼痛是一种致残和痛苦的状况，在成人中很常见。这是一个全球性的公共卫生问题，也是卫生和社会保健系统以及慢性疼痛患者的经济负担。心理治疗的目的是减轻疼痛、残疾和痛苦。这篇综述更新并扩展了2012年出版的上一个版本。目的：确定心理干预治疗成人慢性疼痛（年龄在bb0 ~ 18岁）的临床疗效和安全性，并与积极对照组或等候名单/照例治疗（TAU）进行比较。检索方法：我们通过检索CENTRAL、MEDLINE、Embase和PsycINFO至2020年4月16日，确定了心理治疗的随机对照试验（rct）。我们还检查了参考文献列表和试验注册表，并检索了引用检索试验的研究。选择标准：心理治疗与主动对照或面对面治疗的TAU对照随机对照试验治疗成人慢性疼痛。我们排除了头痛或恶性疾病的研究，以及在治疗结束时任何组参与者少于20人的研究。数据收集和分析：两个或两个以上的作者评估偏倚风险，提取数据，并判断证据质量（GRADE）。我们比较了认知行为疗法（CBT）、行为疗法（BT）和接受和承诺疗法（ACT）在治疗结束时和6个月至12个月的随访期间采用主动控制或TAU。我们没有分析其他心理治疗的少数试验。我们评估了疼痛强度、残疾和痛苦的治疗效果。我们提取了与治疗相关的不良事件（ae）数据。主要结果：我们在先前综述的42项研究中的34项研究的基础上增加了41项研究（6255名受试者），目前总共有75项研究（治疗结束时9401名受试者）。大多数参与者患有纤维肌痛、慢性腰痛、类风湿关节炎或混合性慢性疼痛。大多数偏倚风险域具有高偏倚风险或不明确的偏倚风险，选择性报告和治疗预期大多具有不明确的偏倚风险。研究中不良事件的记录和/或报告不充分。最大的证据基础是CBT（59项研究）。CBT与主动对照相比，在治疗结束时疼痛的益处非常小(标准化平均差(SMD) -0.09, 95%可信区间(CI) -0.17至-0.01；3235名参与者;23个研究;中等质量证据)、残疾（SMD -0.12, 95% CI -0.20至-0.04；2543名受试者；19项研究；中等质量证据）和痛苦（SMD -0.09, 95% CI -0.18至-0.00；3297名受试者；24项研究；中等质量证据）。我们发现CBT在治疗结束时比TAU在疼痛（SMD -0.22, 95% CI -0.33至-0.10；2572名受试者；29项研究；中等质量证据）、残疾（SMD -0.32, 95% CI -0.45至-0.19；2524名受试者；28项研究；低质量证据）和痛苦（SMD -0.34, 95% CI -0.44至-0.24；2559名受试者；27项研究；中等质量证据）方面有较小的益处。CBT与TAU的效果在随访中基本保持，但CBT与主动控制的效果则没有。CBT结果的证据质量从中等到低不等。在两种比较中，我们都将ae的证据质量评为非常低。我们分析了8项研究（647名参与者）。在治疗结束时，我们没有发现BT和主动对照之间存在差异的证据（疼痛SMD -0.67, 95% CI -2.54至1.20，极低质量证据；残疾SMD -0.65, 95% CI -1.85至0.54，极低质量证据；或痛苦SMD -0.73, 95% CI -1.47至0.01，极低质量证据）。在随访中，效果相似。在治疗结束时，我们发现BT和TAU之间没有差异的证据（疼痛SMD -0.08, 95% CI -0.33至0.17，低质量证据；残疾SMD -0.02, 95% CI -0.24至0.19，中等质量证据；痛苦SMD 0.22, 95% CI -0.10至0.54，低质量证据）。在随访中，我们发现一到三项研究没有证据表明BT和TAU之间存在差异。我们将所有BT与主动对照结果的证据质量评为非常低；BT和TAU的对比。证据质量从中等到极低。我们认为与主动对照相比，BT的ae证据质量非常低。没有研究报道BT与TAU的ae。我们分析了5项研究（443名参与者）。在治疗结束时，ACT和主动对照组在疼痛（SMD -0.54, 95% CI -1.20至0.11，极低质量证据）、残疾（SMD -1.51, 95% CI -3.05至0.03，极低质量证据）或痛苦（SMD -0.61, 95% CI -1.30至0.07，极低质量证据）方面没有差异。在随访中，没有证据表明对疼痛或焦虑有效果（都是非常低质量的证据），但有两项研究显示对减少残疾有很大的好处（SMD -2.56, 95% CI -4.22至-0.89，非常低质量的证据）。两项研究比较了治疗结束时ACT和TAU的差异。结果应谨慎解释。我们发现ACT对疼痛（SMD -0.83, 95% CI -1.57至-0.09，极低质量证据）有很大的益处，但对残疾（SMD -1.39, 95% CI -3.20至0.41，极低质量证据）或痛苦（SMD -1.16, 95% CI -2.51至0.20，极低质量证据）没有益处。缺乏数据妨碍了随访时的分析。我们认为ae的证据质量非常低。我们鼓励在解释非常低质量的证据时保持谨慎，因为这些估计是不确定的，很容易被推翻。作者结论：我们在一个大的证据基础（59项研究，超过5000名参与者）中发现了足够的证据，表明CBT在减轻慢性疼痛、残疾和痛苦方面有很小或非常小的有益效果，但我们发现的证据不足以评估ae。除了残疾证据外，CBT的证据质量一般，我们将其评为低质量。进一步的试验可能会对治疗效果提供更精确的估计，但为了提供改进信息，研究应该探索治疗效果变化的来源。来自BT和ACT试验的证据质量中等到非常低，因此我们非常不确定这些治疗对成人慢性疼痛的益处或缺乏益处；其他治疗方法未进行分析。除了对ACT的单独分析外，这些结论与我们2012年的综述相似。
BACKGROUND: Chronic non-cancer pain, a disabling and distressing condition, is common in adults. It is a global public health problem and economic burden on health and social care systems and on people with chronic pain. Psychological treatments aim to reduce pain, disability and distress. This review updates and extends its previous version, published in 2012.OBJECTIVES: To determine the clinical efficacy and safety of psychological interventions for chronic pain in adults (age > 18 years) compared with active controls, or waiting list/treatment as usual (TAU).SEARCH METHODS: We identified randomised controlled trials (RCTs) of psychological therapies by searching CENTRAL, MEDLINE, Embase and PsycINFO to 16 April 2020. We also examined reference lists and trial registries, and searched for studies citing retrieved trials.SELECTION CRITERIA: RCTs of psychological treatments compared with active control or TAU of face-to-face therapies for adults with chronic pain. We excluded studies of headache or malignant disease, and those with fewer than 20 participants in any arm at treatment end.DATA COLLECTION AND ANALYSIS: Two or more authors rated risk of bias, extracted data, and judged quality of evidence (GRADE). We compared cognitive behavioural therapy (CBT), behavioural therapy (BT), and acceptance and commitment therapy (ACT) with active control or TAU at treatment end, and at six month to 12 month follow-up. We did not analyse the few trials of other psychological treatments. We assessed treatment effectiveness for pain intensity, disability, and distress. We extracted data on adverse events (AEs) associated with treatment.MAIN RESULTS: We added 41 studies (6255 participants) to 34 of the previous review's 42 studies, and now have 75 studies in total (9401 participants at treatment end). Most participants had fibromyalgia, chronic low back pain, rheumatoid arthritis, or mixed chronic pain. Most risk of bias domains were at high or unclear risk of bias, with selective reporting and treatment expectations mostly at unclear risk of bias. AEs were inadequately recorded and/or reported across studies. CBT The largest evidence base was for CBT (59 studies). CBT versus active control showed very small benefit at treatment end for pain (standardised mean difference (SMD) -0.09, 95% confidence interval (CI) -0.17 to -0.01; 3235 participants; 23 studies; moderate-quality evidence), disability (SMD -0.12, 95% CI -0.20 to -0.04; 2543 participants; 19 studies; moderate-quality evidence), and distress (SMD -0.09, 95% CI -0.18 to -0.00; 3297 participants; 24 studies; moderate-quality evidence). We found small benefits for CBT over TAU at treatment end for pain (SMD -0.22, 95% CI -0.33 to -0.10; 2572 participants; 29 studies; moderate-quality evidence), disability (SMD -0.32, 95% CI -0.45 to -0.19; 2524 participants; 28 studies; low-quality evidence), and distress (SMD -0.34, 95% CI -0.44 to -0.24; 2559 participants; 27 studies; moderate-quality evidence). Effects were largely maintained at follow-up for CBT versus TAU, but not for CBT versus active control. Evidence quality for CBT outcomes ranged from moderate to low. We rated evidence for AEs as very low quality for both comparisons. BT We analysed eight studies (647 participants). We found no evidence of difference between BT and active control at treatment end (pain SMD -0.67, 95% CI -2.54 to 1.20, very low-quality evidence; disability SMD -0.65, 95% CI -1.85 to 0.54, very low-quality evidence; or distress SMD -0.73, 95% CI -1.47 to 0.01, very low-quality evidence). At follow-up, effects were similar. We found no evidence of difference between BT and TAU (pain SMD -0.08, 95% CI -0.33 to 0.17, low-quality evidence; disability SMD -0.02, 95% CI -0.24 to 0.19, moderate-quality evidence; distress SMD 0.22, 95% CI -0.10 to 0.54, low-quality evidence) at treatment end. At follow-up, we found one to three studies with no evidence of difference between BT and TAU. We rated evidence for all BT versus active control outcomes as very low quality; for BT versus TAU. Evidence quality ranged from moderate to very low. We rated evidence for AEs as very low quality for BT versus active control. No studies of BT versus TAU reported AEs. ACT We analysed five studies (443 participants). There was no evidence of difference between ACT and active control for pain (SMD -0.54, 95% CI -1.20 to 0.11, very low-quality evidence), disability (SMD -1.51, 95% CI -3.05 to 0.03, very low-quality evidence) or distress (SMD -0.61, 95% CI -1.30 to 0.07, very low-quality evidence) at treatment end. At follow-up, there was no evidence of effect for pain or distress (both very low-quality evidence), but two studies showed a large benefit for reducing disability (SMD -2.56, 95% CI -4.22 to -0.89, very low-quality evidence). Two studies compared ACT to TAU at treatment end. Results should be interpreted with caution. We found large benefits of ACT for pain (SMD -0.83, 95% CI -1.57 to -0.09, very low-quality evidence), but none for disability (SMD -1.39, 95% CI -3.20 to 0.41, very low-quality evidence), or distress (SMD -1.16, 95% CI -2.51 to 0.20, very low-quality evidence). Lack of data precluded analysis at follow-up. We rated evidence quality for AEs to be very low. We encourage caution when interpreting very low-quality evidence because the estimates are uncertain and could be easily overturned.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.