Expression of concern
Professor Marco Monticone has acted as the first author of this Cochrane review. Readers should be informed that multiple randomized controlled trials authored by Professor Monticone have been scrutinized because of potential research integrity issues, including irregularities in the data (doi:10.1097/j.pain.0000000000002659). One of the trials suspected of research integrity issues is included in this Cochrane review (doi:10.1007/s00586-012-2287-y). The Cochrane editorial team has concerns about the trustworthiness of the trial data and is applying Cochrane's policy on managing potentially problematic studies (https://www.cochranelibrary.com/cdsr/editorial-policies#problematic-studies). No major differences to the conclusions of this review were found after performing a sensitivity analysis on the main outcomes, whether the potentially problematic trial was included or excluded. Cochrane will take further action as needed on this review once additional investigations into the potentially problematic trial are concluded.
In the meantime, a new version of this review topic is underway with a new author team. The new review will supersede this review.
Background
Neck pain (NP) is defined as pain, muscle tension, or stiffness localized in the neck and may originate from many structures, including the spine or soft tissues. Risk factors include age, gender, a history of pain, poor posture, repetitive strain, and social and psychological factors.
NP is experienced by people of all ages and both genders and is an important cause of medical expenses, work absenteeism, and disability. Current management of NP includes a range of different treatments such as reassurance, education, promotion of a timely return to normal activities, appropriate use of painkillers, and exercises.
There remains uncertainty about the efficacy of cognitive-behavioural therapy (CBT) for these patients. CBT is a psychological technique that encompasses a wide set of interventions conducted by health professionals. It includes cognitive and behavioural modifications of specific activities to reduce the impact of pain as well as physical and psychosocial disability and to overcome dangerous barriers to physical and psychosocial recovery.
Review Question
We therefore reviewed the evidence about the effect of CBT on pain, disability, psychological factors, and quality of life among patients with subacute and chronic NP. Specifically, we compared CBT versus no treatment, CBT versus other types of interventions, and CBT in addition to another intervention (e.g. physiotherapy) versus the other intervention alone.
Study Characteristics
We examined the research published up to November 2014. We included 10 randomised trials (836 participants). Two studies included subjects with subacute NP (337 participants), while the other eight studies included participants with chronic NP (499 participants). CBTwas compared to no treatment (225 participants) or to other types of treatments (506 participants), or combined with another intervention (e.g. physiotherapy) and compared to the other intervention alone (200 participants). The interventions were carried out at primary and secondary health care centres.
Key Results
With regard to chronic NP, CBT was statistically significantly better than no treatment at improving pain, disability, and quality of life, but these effects could not be considered clinically meaningful. No differences between CBT and other types of interventions (e.g. medication, education, physiotherapy, manual therapy, and exercises) were found in terms of pain and disability; there was moderate quality evidence that CBT was better than other interventions in improving fear of movement. Also, there was very low quality evidence that CBT added to another intervention was no better at improving pain and disability than the other intervention alone .
For subacute NP, there was low quality evidence that CBT was statistically significantly better than other types of interventions (e.g. manual therapy or education) for improving pain, but this effect was not clinically relevant. No difference was found in terms of disability and fear of movement.
None of the included studies reported on whether any adverse effects related to cognitive-behavioural therapy were observed.
Quality of the Evidence
The quality of evidence in this review ranged between “very low” and “moderate”. Therefore, the review results should be interpreted with caution. More high quality randomised trials are needed to address short and long term benefits of cognitive-behavioural therapy in subacute and chronic neck pain, and its effectiveness compared with other treatments, and to better understand which patients may benefit most from this type of intervention.
With regard to chronic neck pain, CBT was found to be statistically significantly more effective for short-term pain reduction only when compared to no treatment, but these effects could not be considered clinically meaningful. When comparing both CBT to other types of interventions and CBT in addition to another intervention to the other intervention alone, no differences were found. For patients with subacute NP, CBT was significantly better than other types of interventions at reducing pain at short-term follow-up, while no difference was found for disability and kinesiophobia. Further research is recommended to investigate the long-term benefits and risks of CBT including for the different subgroups of subjects with NP.
Although research on non-surgical treatments for neck pain (NP) is progressing, there remains uncertainty about the efficacy of cognitive-behavioural therapy (CBT) for this population. Addressing cognitive and behavioural factors might reduce the clinical burden and the costs of NP in society.
To assess the effects of CBT among individuals with subacute and chronic NP. Specifically, the following comparisons were investigated: (1) cognitive-behavioural therapy versus placebo, no treatment, or waiting list controls; (2) cognitive-behavioural therapy versus other types of interventions; (3) cognitive-behavioural therapy in addition to another intervention (e.g. physiotherapy) versus the other intervention alone.
We searched CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, SCOPUS, Web of Science, and PubMed, as well as ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform up to November 2014. Reference lists and citations of identified trials and relevant systematic reviews were screened.
We included randomised controlled trials that assessed the use of CBT in adults with subacute and chronic NP.
Two review authors independently assessed the risk of bias in each study and extracted the data. If sufficient homogeneity existed among studies in the pre-defined comparisons, a meta-analysis was performed. We determined the quality of the evidence for each comparison with the GRADE approach.
We included 10 randomised trials (836 participants) in this review. Four trials (40%) had low risk of bias, the remaining 60% of trials had a high risk of bias.
The quality of the evidence for the effects of CBT on patients with chronic NP was from very low to moderate. There was low quality evidence that CBT was better than no treatment for improving pain (standard mean difference (SMD) -0.58, 95% confidence interval (CI) -1.01 to -0.16), disability (SMD -0.61, 95% CI -1.21 to -0.01), and quality of life (SMD -0.93, 95% CI -1.54 to -0.31) at short-term follow-up, while there was from very low to low quality evidence of no effect on various psychological indicators at short-term follow-up. Both at short- and intermediate-term follow-up, CBT did not affect pain (SMD -0.06, 95% CI -0.33 to 0.21, low quality, at short-term follow-up; MD -0.89, 95% CI -2.73 to 0.94, low quality, at intermediate-term follow-up) or disability (SMD -0.10, 95% CI -0.40 to 0.20, moderate quality, at short-term follow-up; SMD -0.24, 95% CI-0.54 to 0.07, moderate quality, at intermediate-term follow-up) compared to other types of interventions. There was moderate quality evidence that CBT was better than other interventions for improving kinesiophobia at intermediate-term follow-up (SMD -0.39, 95% CI -0.69 to -0.08, I2 = 0%). Finally, there was very low quality evidence that CBT in addition to another intervention did not differ from the other intervention alone in terms of effect on pain (SMD -0.36, 95% CI -0.73 to 0.02) and disability (SMD -0.10, 95% CI -0.56 to 0.36) at short-term follow-up.
For patients with subacute NP, there was low quality evidence that CBT was better than other interventions at reducing pain at short-term follow-up (SMD -0.24, 95% CI -0.48 to 0.00), while no difference was found in terms of effect on disability (SMD -0.12, 95% CI -0.36 to 0.12) and kinesiophobia.
None of the included studies reported on adverse effects.