Recently, I had the opportunity to complete a Cochrane systematic review on the effects of cognitive-behavioural therapy on pain, disability, psychological factors, and the quality of life among individuals with subacute and chronic neck pain. This review is the result of a fruitful two year collaboration , between my research team at the Scientific Institute of Lissone, the Fondazione Salvatore Maugeri, the Multidisciplinary Pain Centre of the Geneva University Hospitals, the Department of Electronics, Information and Bioengineering of Politecnico di Milano, the Clinical Epidemiology Unit of the Galeazzi Orthopaedic Institute, the University of Ferrara, and the Department of Biomedical Sciences for Health of the University of Milan.
Neck pain is common and has become an important cause of work absenteeism and disability. One suggested intervention when symptoms persist and cause disruption to daily life is cognitive-behavioural therapy.
Cognitive-behavioural therapy is a psychological technique that includes cognitive and behavioural modifications of specific activities to reduce the impact of pain as well as physical and psychosocial disability and to overcome perceived barriers to physical and psychosocial recovery. It is increasingly used in subjects with low back pain, but there remains uncertainty about its efficacy when neck complaints are addressed.
This Cochrane systematic review sought to fill this knowledge gap.
Ten randomised controlled trials that assessed the use of cognitive-behavioural therapy in adults with subacute and chronic neck pain were included in the review.
But…what were our main findings?
For subacute neck pain, there was low quality evidence that cognitive-behavioural therapy was more effective than other types of interventions (e.g. manual therapy or education) for improving pain (Mean Difference (MD) [95% confidence interval (CI)] of -0.62 [-1.23; 0.00] on a 10-point Numerical Rating Scale), but this effect was deemed not clinically (it is considered a clinically important treatment effect on 0-10 pain scale a change of 2.5 points).
With regard to chronic neck pain, cognitive-behavioural therapy was better than no treatment at improving pain (MD [95% CI] = -0.78 [-1.35; -0.21] on a 0-10 scale), disability (MD [95% CI] = -7.77 [-15.40; -0.13] on a 0-100 scale), and the quality of life (MD [95% CI] = -20.21 [-33.46; -6.74] on a 0-100 scale), but these effects could not be considered clinically meaningful (a 25% relative improvement is generally considered as a clinically important treatment effect). There was moderate quality evidence that cognitive-behavioural therapy was better than other interventions in improving fear of movement, evaluated in terms of Tampa Scale for Kinesiophobia. No differences between cognitive-behavioural therapy and other types of interventions (e.g. medication, education, physiotherapy, manual therapy, and exercises) were otherwise found in terms of pain and disability. Finally, there was very low quality evidence to suggest that there was no additional benefit of cognitive-behavioural therapy when it was added to another intervention
In general, the quality of the evidence ranged from “very low” to “moderate”; very few studies met our inclusion criteria, and the majority of them were characterised by small sample sizes and many methodological biases. Therefore, the results should be interpreted with caution and, as happens in many systematic reviews, a strong, unequivocal conclusion about the usefulness of cognitive-behavioural therapy for patients with neck pain cannot be derived from our findings.
We concluded that more high quality randomised trials are still 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, as well as to better understand which patients (for example, those suffering from whiplash injuries) may benefit most from this type of intervention. Also, it would be of interest to identify which psychological factors (e.g. fear of movement, catastrophising, anxiety, depression, …) might have the strongest influence on a patients’ experience of neck pain and which of these factors can be utilised as appropriate outcome measures. More specifically targeted interventions which might have the potential to achieve stronger treatment effects and the involvement of clinical psychologists and health professionals specifically trained in cognitive-behavioural therapy should be also promoted.
About Marco Monticone
Marco Monticone is the Director of the Operative Unit of Physical Medicine and Rehabilitation at the Scientific Institute of Lissone (Monza Brianza, Italy) of the Salvatore Maugeri Foundation IRCCS.
His main clinical interests are conservative treatments of orthopaedic and neurological disabilities. His main research topics are the evaluation of outcome measures in the field of physical and rehabilitative medicine as well as multidisciplinary conservative approaches to chronic spinal disorders.
Monticone M1, Ambrosini E, Cedraschi C, Rocca B, Fiorentini R, Restelli M, Gianola S, Ferrante S, Zanoli G, Moja L. (2015). Cognitive-behavioral Treatment for Subacute and Chronic Neck Pain: A Cochrane Review. Spine 1;40(19):1495-504