Table 2.
Grading of the evidence for the meta-analyses of RCTs investigating the effectiveness of various psychological interventions for pain reduction
| Author, Year | Intervention Group | Control group | Type of pain | Total N | Largest Studya, b | Summary random effects (95% CI)a, c | Random P-value d | 95% Prediction interval | Egger’s P-valuea |
I2 (%) | Studies | Excess significancee | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| O/Eg | P-valueh | ||||||||||||
| Associations supported by strong evidence | |||||||||||||
| None of the associations studied was supported by strong evidence | |||||||||||||
| Associations supported by highly suggestive evidence | |||||||||||||
| None of the associations studied was supported by highly suggestive evidence | |||||||||||||
| Associations supported by suggestive evidence | |||||||||||||
| Bernardy K, 2013 | CBT | AC/AtC/EDU/TAU/Support | Fibromyalgia, end of treatment | 1150 | −0.62 (−0.89, −0.34) | −0.30 (−0.45, −0.15) | 7.4E-05 | −0.69, 0.09 | 0.37 | 30 | 18 | 4/17.17 | NP |
| Birnie K, 2014 | Distraction | NR | Needle-related (children, adolescents), self-reported | 2472 | 0.09 (−0.08, 0.27) | −0.44 (−0.67, −0.21) | 2.0E-04 | −1.53, 0.65 | 0.13 | 86 | 24 | 7/3.4 | 0.07 |
| Dixon K, 2007 | CBT/Stress management/HYP | NR | Arthritis | 2303 | −0.15 (−0.28, −0.02) | −0.20 (−0.30, −0.10) | 8.5E-05 | −0.37, −0.02 | 0.02 | 9 | 20 | 5/5.03 | NP |
| Du S, 2011 | ASMP/Self-management | WL/ UC/ Conventional/No treatment | Chronic musculoskeletal, 6 m | 1018 | −0.27 (−0.42, −0.12) | −0.29 (−0.42, −0.16) | 6.0E-06 | −1.11, 0.53 | 0.25 | 0 | 3 | 3/2.78 | 1.00 |
| Du S, 2011 | ASMP/Self-management | WL/ UC/ Conventional/No treatment | Chronic musculoskeletal, 4 m | 2968 | −0.35 (−0.49, −0.20) | −0.23 (−0.36, −0.11) | 2.9E-04 | −0.59, 0.13 | 0.73 | 59 | 8 | 4/7.94 | NP |
| Eccleston C, 2014 | Psychological therapies (Internet-delivered) | AC/TAU/WL | Chronic (Non-HA), post-treatment | 1785 | −0.20 (−0.36, −0.05) | −0.37 (−0.59, −0.15) | 9.9E-04 | −1.12, 0.38 | 0.42 | 77 | 11 | 5/5.96 | NP |
| Henrich J, 2015 | Psychological therapies | Control | Irritable bowel syndrome | 2245 | 0.05 (−0.19, 0.28) | 0.40 (0.30, 0.51) | 3.3E-14 | 0.09, 0.72 | 0.01 | 26 | 32 | 9/2.22 | <0.001 |
| Johannsen M, 2013 | EDU/RIMH/SGT | WL/ St. Care/ NR | Breast cancer patients/survivors | 1500 | 0.09 (−0.14, 0.31) | 0.34 (0.18, 0.50) | 3.3E-05 | −0.15, 0.82 | 0.06 | 50 | 15 | 6/2.24 | 0.02 |
| Knittle K, 2010 | Self-regulation | WL/St. Care/No Intervention | Rheumatoid Arthritis | 1316 | 0.13 (−0.16, 0.41) | 0.18 (0.07, 0.29) | 8.9E-04 | 0.07, 0.30 | 0.53 | 0 | 22 | 1/3.73 | NP |
| Kroon FP, 2014 | SMP | UC/WL/No treatment | Osteoarthritis, IT | 2271 | −0.29 (−0.51, −0.07) | −0.17 (−0.26, −0.08) | 1.6E-04 | −0.27, −0.07 | 0.12 | 0 | 13 | 2/10.85 | NP |
| Macea DD, 2010 | Web-based CBT interventions | Control | Chronic pain | 2958 | 0.28 (0.13, 0.42) | 0.29 (0.15, 0.43) | 6.3E-05 | −0.07, 0.64 | 0.11 | 45 | 11 | 3/6.99 | NP |
| Sheinfeld Gorin S, 2012 | Psychological intervention | Control | Cancer Pain severity | 4270 | 0.14 (−0.08, 0.36) | 0.34 (0.23, 0.46) | 7.2E-09 | −0.21, 0.89 | 0.67 | 60 | 38 | 17/9.63 | 0.01 |
| Associations supported by weak evidence | |||||||||||||
| Adachi T, 2013 | Hypnosis | St. Care | Chronic, post-intervention | 46 | 0.64 (−0.27, 1.55) | 1.10 (0.17, 2.02) | 0.020 | NA | NA | 48 | 2 | 1/1.52 | NP |
| Aqqarwal VR, 2011 | Any psychosocial intervention | Usual treatment | Muscle palpation, >3 m | 143 | −1.11 (−1.63, −0.59) i | −1.09 (−1.56, −0.61)i | 7.0E-06 | −4.15, 1.98 | 0.61 | 0 | 3 | 1/2.05 | NP |
| Aqqarwal VR, 2011 | CBT | Usual treatment | Orofacial, >3 m | 383 | −0.32 (−0.66, 0.01) | −0.25 (−0.46, −0.05) | 0.014 | −0.70, 0.19 | 0.91 | 0 | 4 | 1/3.11 | NP |
| Aqqarwal VR, 2011 | CBT + BFB | Usual treatment | Orofacial, >3 m | 196 | −0.82 (−1.23, −0.41) | −0.46 (−0.92, 0.00) | 0.049 | −5.22, 4.30 | 0.47 | 53 | 3 | 1/3 | NP |
| Aqqarwal VR, 2011 | Hypnosis | REL | Orofacial, ≤3 m | 81 | −1.90 (−3.37, −0.43) i | −1.84 (−3.26, −0.42)i | 0.011 | NA | NA | 0 | 2 | 1/1.26 | NP |
| Bernardy K, 2013 | CBT | AC/AtC/EDU/TAU/Support | Fibromyalgia (self-efficacy), end of treatment | 589 | −0.93 (−1.32, −0.54) | −0.39 (−0.73, −0.06) | 0.022 | −1.50, 0.71 | 0.88 | 74 | 9 | 5/8.99 | NP |
| Bernardy K, 2013 | CBT | AC/AtC/EDU/TAU/Support | Fibromyalgia (self-efficacy), LT | 494 | −1.01 (−1.40, −0.61) | −0.52 (−1.04, 0.00) | 0.049 | −2.32, 1.28 | 0.82 | 86 | 8 | 3/8 | NP |
| Bernardy K, 2013 | Operant therapy | AC/EDU/TAU | Fibromyalgia (self-efficacy), LT | 123 | −1.16 (−1.73, −0.59) | −1.69 (−2.76, −0.62) | 0.002 | NA | NA | 83 | 2 | 2/2 | 1.00 |
| Bernardy K, 2013 | CBT | AC/AtC/EDU/TAU/Support | Fibromyalgia, LT | 770 | −0.37 (−0.74, 0.00) | −0.28 (−0.43, −0.14) | 1.3E-04 | −0.47, −0.10 | 0.64 | 2 | 13 | 3/9.36 | NP |
| Bernardy K, 2013 | Operant therapy | AC/EDU/TAU | Fibromyalgia, LT | 123 | −0.76 (−1.31, −0.21) | −1.27 (−2.30, −0.24) | 0.015 | NA | NA | 83 | 2 | 2/2 | 1.00 |
| Damen L, 2006 | REL + CBT | Attention placebo | HA Post-treatment | 69 | 0.33 (−0.14, 0.79) | 0.39 (0.01, 0.77) | 0.045 | NA | NA | 0 | 2 | 0/1.21 | NP |
| Du S, 2011 | ASMP/Self-management | WL/ UC/ Conventional/No treatment | Chronic musculoskeletal, 12 m | 1570 | −0.05 (−0.19, 0.08) | −0.13 (−0.24, −0.03) | 0.008 | −0.30, 0.03 | 0.17 | 0 | 5 | 1/0.71 | 0.53 |
| Eccleston C, 2014 | Psychological therapies | Control | Chronic and recurrent HA (children, adolescents), follow-up | 251 | 0.12 (0.02, 0.23) | 0.49 (0.08, 0.90) | 0.019 | −0.76, 1.75 | 0.00 | 60 | 5 | 2/1.4 | 0.62 |
| Eccleston C, 2014 | Psychological therapies | Control | Chronic and recurrent HA (children, adolescents), post-treatment | 714 | 0.32 (0.13, 0.52) | 0.44 (0.28, 0.60) | 1.2E-07 | 0.08, 0.80 | 0.00 | 25 | 15 | 7/7.46 | NP |
| Eccleston C, 2014 | Psychological therapies | Control | Chronic and recurrent non-HA (children, adolescents), post-treatment | 852 | 0.21 (−0.10, 0.51) | −0.57 (−0.86, −0.27) | 2.0E-04 | −1.63, 0.50 | 0.00 | 75 | 13 | 5/4.58 | 0.78 |
| Eccleston C, 2014 | Psychological therapies (Internet-delivered) | AC/TAU/WL | Chronic HA, post-treatment | 131 | 0.99 (0.35, 1.64) | 1.10 (0.54, 1.65) | 1.0E-04 | NA | NA | 0 | 2 | 2/1.94 | 1.00 |
| Fisher E, 2014 | CBT/BFB/REL/HYP | WL/EDU/St. Care/Self-monitoring | Chronic (excluding HA) | 672 | 0.21 (−0.10, 0.51) | −0.60 (−0.91, −0.29) | 1.7E-04 | −1.63, 0.44 | 0.00 | 71 | 11 | 4/3.65 | 0.76 |
| Fisher E, 2014 | CBT/BFB/REL/HYP | WL/EDU/St. Care/Self-monitoring | Headache | 748 | 0.25 (−0.03, 0.54) | 0.50 (0.34, 0.66) | 3.9E-10 | 0.18, 0.83 | 0.00 | 16 | 18 | 7/6.65 | 1.00 |
| Guzman J, 2002 | Intensive (>100 h) daily MBPSR with functional restoration | NR | Low back, 3-4 m | 165 | −0.45 (−0.86, −0.04) | −0.57 (−0.88, −0.26) | 3.5E-04 | NA | NA | 0 | 2 | 2/1.94 | 1.00 |
| Henschke N, 2011 | CBT | WL | Chronic low back, ST | 239 | −0.54 (−0.93, −0.15) | −0.60 (−0.97, −0.23) | 0.002 | −1.66, 0.46 | 0.34 | 43 | 5 | 2/4.12 | NP |
| Henschke N, 2011 | Operant therapy | WL | Chronic low back, ST | 153 | −0.63 (−1.12, −0.13) | −0.43 (−0.75, −0.11) | 0.009 | −2.52, 1.66 | 0.32 | 0 | 3 | 1/2.95 | NP |
| Henschke N, 2011 | Respondent therapy (EMG BFB) | WL | Chronic low back, ST | 64 | −1.19 (−2.01, −0.37) | −0.80 (−1.32, −0.28) | 0.002 | −4.17, 2.56 | 0.76 | 0 | 3 | 1/2.99 | NP |
| Henschke N, 2011 | Respondent therapy (progressive REL) | WL | Chronic low back, ST | 74 | −10.20 (−23.95, 3.55) i | −19.77 (−34.34, −5.20)i | 0.008 | −175.53, 135.98 | 0.53 | 57 | 3 | 1/1.94 | NP |
| Kamper SJ, 2014 | MBR | UC | Chronic low back, IT | 740 | −0.24 (−0.50, 0.03) | −0.60 (−0.85, −0.34) | 5.1E-06 | −1.37, 0.18 | 0.01 | 63 | 6 | 5/3.95 | 0.67 |
| Kamper SJ, 2014 | MBR | Physical treatment | Chronic low back, IT | 531 | −0.04 (−0.40, 0.32) | −0.28 (−0.54, −0.01) | 0.039 | −1.01, 0.45 | 0.17 | 51 | 9 | 2/0.54 | 0.10 |
| Kamper SJ, 2014 | MBR | UC | Chronic low back, LT | 821 | −0.32 (−0.60, −0.04) | −0.21 (−0.37, −0.04) | 0.013 | −0.57, 0.15 | 0.68 | 26 | 7 | 2/5.94 | NP |
| Kamper SJ, 2014 | MBR | UC | Chronic low back, ST | 879 | −0.20 (−0.46, 0.05) | −0.55 (−0.83, −0.27) | 1.0E-04 | −1.44, 0.33 | 0.29 | 72 | 9 | 5/3.94 | 0.52 |
| Kamper SJ, 2014 | MBR | WL | Chronic low back, ST | 213 | −0.45 (−0.84, −0.06) | −0.73 (−1.22, −0.24) | 0.003 | −6.10, 4.64 | 0.78 | 63 | 3 | 2/2.66 | NP |
| Kamper SJ, 2014 | MBR | Physical treatment | Chronic low back, ST | 1661 | −0.15 (−0.36, 0.05) | −0.30 (−0.54, −0.06) | 0.015 | −1.15, 0.55 | 0.62 | 80 | 12 | 3/4.53 | NP |
| Kisely SR, 2015 | Psychological intervention | No psychological intervention | Chest (frequency), ≤3 m | 294 | −0.09 (−0.57, 0.39) i | −2.26 (−4.41, −0.11)i | 0.039 | −8.95, 4.42 | 0.29 | 94 | 7 | 4/0.45 | <0.001 |
| Kisely SR, 2015 | Psychological intervention | No psychological intervention | Chest, ≤3 m | 172 | −0.21 (−0.34, −0.06) | −0.20 (−0.35, −0.05) | 0.008 | −1.78, 1.38 | 0.75 | 58 | 3 | 2/2.98 | NP |
| Kisely SR, 2015 | Psychological intervention | No psychological intervention | Chest, 3-12 m | 111 | −0.29 (−0.49, −0.09) | −0.30 (−0.44, −0.15) | 6.1E-05 | NA | NA | 0 | 2 | 2/2 | 1.00 |
| Kroon FP, 2014 | SMP | UC/WL/No treatment | Osteoarthritis, ST | 755 | −0.32 (−0.61, −0.03) | −0.26 (−0.41, −0.11) | 8.2E-04 | −0.47, −0.04 | 0.89 | 0 | 6 | 2/5.09 | NP |
| Kroon FP, 2014 | SMP | Control | Osteoarthritis, IT | 574 | −0.22 (−0.45, 0.01) | −0.26 (−0.43, −0.09) | 0.003 | −1.38, 0.86 | 0.27 | 0 | 3 | 0/2.16 | NP |
| Lakhan S, 2013 | MBT/MBCT | EDU/WL/Support | Irritable bowel syndrome | 160 | −0.64 (−1.08, −0.20) | −0.59 (−0.91, −0.27) | 2.6E-04 | NA | NA | 0 | 2 | 2/2 | 1.00 |
| Mustafa M, 2013 | Supportive/expressive group therapy | Usual treatment | Metastatic breast cancer | 279 | −0.75 (−1.36, −0.14) i | −0.58 (−0.99, −0.17)i | 0.005 | −3.21, 2.05 | 0.90 | 0 | 3 | 1/2.94 | NP |
| Peerdeman K, 2016 | Imagery | Control/No treatment | Pain relief | 301 | 0.20 (−0.17, 0.56) | 0.24 (0.01, 0.46) | 0.039 | −0.26, 0.73 | 0.28 | 0 | 4 | 0/1.6 | NP |
| Peerdeman K, 2016 | Verbal suggestion | Control/No treatment | Pain relief | 383 | 0.24 (0.06, 0.41) | 0.31 (0.16, 0.46) | 6.4E-05 | −0.02, 0.64 | 0.08 | 0 | 4 | 2/2.3 | NP |
| Peerdeman K, 2016 | Verbal suggestion/Imagery | Control/No treatment | Affective pain | 169 | 0.16 (−0.27, 0.60) | 0.34 (0.07, 0.61) | 0.013 | −1.41, 2.09 | 0.70 | 0 | 3 | 1/0.78 | 1.00 |
| Roldan-Barraza C, 2014 | Psychosocial Intervention/Psychosocial Intervention + Usual Treatment | Tailored Usual Treatment | MTMD (self-reported), LT | 403 | 0.80 (0.14, 1.46) | 0.66 (0.23, 1.09) | 0.003 | −2.13, 3.45 | 0.54 | 0 | 3 | 2/2.94 | NP |
| Theadom A, 2015 | Psychological therapies | UC | Fibromyalgia, 6 m | 371 | −0.38 (−0.75, −0.02) | −0.52 (−0.76, −0.29) | 1.5E-05 | −1.06, 0.02 | 0.15 | 20 | 5 | 2/4.12 | NP |
| Theadom A, 2015 | Psychological therapies | UC | Fibromyalgia, post-intervention | 453 | −0.23 (−0.60, 0.15) | −0.33 (−0.52, −0.15) | 4.8E-04 | −0.56, −0.11 | 0.90 | 0 | 9 | 2/3.1 | NP |
| Uman LS, 2013 | Hypnosis | Control | Needle-related (children, adolescents), self-reported | 176 | 0.09 (−0.57, 0.74) | −1.4 (−2.32, −0.47) | 0.003 | −4.81, 2.01 | 0.41 | 85 | 5 | 4/0.37 | <0.001 |
| Williams AC, 2012 | Cognitive behavioural | TAU | Chronic (excl. HA), post-treatment | 1148 | −0.53 (−0.87, −0.19) | −0.21 (−0.37, −0.05) | 0.010 | −0.72, 0.29 | 0.02 | 45 | 16 | 4/15.61 | NP |
Abbreviations: AC Active control, AtC Attention control, ASMP Arthritis Self-Management Program, BFB Biofeedback, CBT Cognitive behavioural therapy, EDU Education, EMG BFB Electromyographic biofeedback, HA Headache, HYP Hypnotherapy, IM Imagination, IT Intermediate term, LT Long term, m Months, MBT Mindfulness-based therapy, MBCT Mindfulness-based cognitive therapy, MBPSR Multidisciplinary bio-psychosocial rehabilitation programs, MTMD Myofascial Temporomandibular Disorder, MBR Multidisciplinary biopsychological rehabilitation, NA Not applicable, because only two studies were available, NP Not pertinent, because the expected number of statistically significant studies is larger than the observed, NR Not reported, REL Relaxation, RIMH Relaxation, guided imagery, meditation or hypnosis, SGT Supportive group therapy, SMP Self-management education programmes, ST Short term, St. Care Standard care, TAU Treated as usual, UC Usual Care, WL Waiting list
aAll summary point estimates on this table were indicative of pain reduction comparing the intervention to the control group. However, the original meta-analyses reported both positive and negative effects as observed on this table because they used different outcome metrics (e.g., pain reduction or difference in pain levels)
bOn these comparisons MD is reported, instead of SMD
cSummary effect and 95% confidence interval of largest study (smallest standard error) in each meta-analysis
dRandom effects refer to summary effect (95% CI) using the random-effects model
e P value of summary random effects estimate
f P-value from the Egger’s regression asymmetry test
gExpected number of statistically significant studies using the point estimate of the largest study (smallest standard error) as the plausible effect size
hObserved/Expected number of statistically significant studies
i P value of the excess statistical significance test. All statistical tests were two-sided