Effectiveness of physical and cognitive-behavioural intervention programmes for chronic musculoskeletal pain in adults: A systematic review and meta-analysis of randomised controlled trials

Autoři: Joyce Oi Suet Cheng aff001;  Sheung-Tak Cheng aff002
Působiště autorů: Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, United Kingdom aff001;  Department of Health and Physical Education, The Education University of Hong Kong, Hong Kong, China aff002;  Department of Clinical Psychology, Norwich Medical School, University of East Anglia, Norwich, United Kingdom aff003
Vyšlo v časopise: PLoS ONE 14(10)
Kategorie: Research Article
doi: 10.1371/journal.pone.0223367


This systematic review and meta-analysis aimed to examine the effects of physical exercise cum cognitive-behavioural therapy (CBT) on alleviating pain intensity, functional disabilities, and mood/mental symptoms in those suffering with chronic musculoskeletal pain. MEDLINE, EMBASE, PubMEd, PsycINFO and CINAHL were searched to identify relevant randomised controlled trials from inception to 31 December 2018. The inclusion criteria were: (a) adults ≥18 years old with chronic musculoskeletal pain ≥3 months, (b) randomised controlled design, (c) a treatment arm consisting of physical intervention and CBT combined, (d) the comparison arm being waitlist, usual care or other non-pharmacological interventions such as physical exercise or CBT alone, and (e) outcomes including pain intensity, pain-related functional disabilities (primary outcomes), or mood/mental symptoms (secondary outcome). The exclusion criteria were: (a) the presence of comorbid mental illnesses other than depression and anxiety and (b) non-English publication. The search resulted in 1696 records and 18 articles were selected for review. Results varied greatly across studies, with most studies reporting null or small effects but a few studies reporting very large effects up to 2-year follow-up. Pooled effect sizes (Hedges’ g) were ~1.00 for pain intensity and functional disability, but no effect was found for mood/mental symptoms. The effects were mainly driven by several studies reporting unusually large differences between the exercise cum CBT intervention and exercise alone. When these outliers were removed, the effect on pain intensity disappeared at post-intervention while a weak effect (g = 0.21) favouring the combined intervention remained at follow-up assessment. More consistent effects were observed for functional disability, though the effects were small (g = 0.26 and 0.37 at post-intervention and follow-up respectively). More importantly, the value of adding CBT to exercise interventions is questionable, as consistent benefits were not seen. The clinical implications and directions for future research are discussed.

Klíčová slova:

Depression – Disabilities – Exercise – Lower back pain – Metaanalysis – Myalgia – Psychometrics – Questionnaires


1. Dieppe P. Chronic musculoskeletal pain. BMJ 2013;346:f3146–f3146. doi: 10.1136/bmj.f3146 23709528

2. Gerdle B, Ghafouri B, Ernberg M, Larsson B. Chronic musculoskeletal pain: review of mechanisms and biochemical biomarkers as assessed by the microdialysis technique. J Pain Res 2014;7:313–326. doi: 10.2147/JPR.S59144 24966693

3. Treede R, Rief W, Barke A, Aziz Q, Bennett MI, Benoliel R, et al. A classification of chronic pain for ICD-11. Pain 2015;156(6):1003–1007. doi: 10.1097/j.pain.0000000000000160 25844555

4. The British Pain Society. Guidelines for pain management programmes for adults: an evidence-based review prepared on behalf of the British Pain Society. London: The British Pain Society; 2013.

5. Aleksiev AR. Ten-year follow-up of strengthening versus flexibility exercises with or without abdominal bracing in recurrent low back pain. Spine 2014;39(13):997–1003. doi: 10.1097/BRS.0000000000000338 24732860

6. Searle A, Spink M, Ho A, Chuter V. Exercise interventions for the treatment of chronic low back pain: a systematic review and meta-analysis of randomised controlled trials. Clin Rehabil 2015;29(12):1155–1167. doi: 10.1177/0269215515570379 25681408

7. Bertozzi L, Gardenghi I, Turoni F, Villafañe JH, Capra F, Guccione AA, et al. Effect of therapeutic exercise on pain and disability in the management of chronic nonspecific neck pain: systematic review and meta-analysis of randomized trials. Phys Ther 2013;93(8):1026. doi: 10.2522/ptj.20120412 23559524

8. Cheng S-T, Leung CMC, Chan KL, Chen PP, Chow YF, Chung JWY, et al. The relationship of self-efficacy to catastrophizing and depressive symptoms in community-dwelling older adults with chronic pain: a moderated mediation model. PLoS One 2018;13(9):e0203964. doi: 10.1371/journal.pone.0203964 30226892

9. Darnall BD. Pain-specific psychological factors. In: Darnall BD, editor. Psychological treatment for patients with chronic pain Washington, DC: American Psychological Association; 2019, p. 63–75.

10. Cooper RG, Booker CK, Spanswick CC. What is pain management, and what is its relevance to the rheumatologist? Rheumatology 2003;42(10):1133–1137. doi: 10.1093/rheumatology/keg313 12777643

11. Richmond H, Hall AM, Copsey B, Hansen Z, Williamson E, Hoxey-Thomas N, et al. The effectiveness of cognitive behavioural treatment for non-specific low back pain: a systematic review and meta-analysis. PLoS One 2015;10(8): e0134192. doi: 10.1371/journal.pone.0134192 26244668

12. Knoerl R, Lavoie Smith E,M., Weisberg J. Chronic pain and cognitive behavioral therapy: an integrative review. West J Nurs Res 2016;38(5):596–628. doi: 10.1177/0193945915615869 26604219

13. Macea DD, Gajos K, Daglia Calil YA, Fregni F. The efficacy of web-based cognitive behavioral interventions for chronic pain: a systematic review and meta-analysis. J Pain 2010;11(10):917–929. doi: 10.1016/j.jpain.2010.06.005 20650691

14. Hozo SP, Djulbegovic B, Hozo I. Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol 2005;5:13–13. doi: 10.1186/1471-2288-5-13 15840177

15. Higgins JPT, Altman DG, Gøtzsche P,C., Jüni P, Moher D, Oxman AD, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ 2011;343:d5928. doi: 10.1136/bmj.d5928 22008217

16. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials 1986 09;7(3):177–188. 3802833

17. Higgins JPT, Green S. Cochrane handbook for systematic reviews of interventions version 5.1.0 [updated March, 2011]. Available at: www.handbook.cochrane.org. Accessed August 1, 2019.

18. Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ 1997 09/13;315(7109):629–634. doi: 10.1136/bmj.315.7109.629 9310563

19. Devasahayam AJ, Siang Lim CK, Goh MR, Lim You JP, Pua PY. Delivering a back school programme with a cognitive behavioural modification: a randomised pilot trial on patients with chronic nonspecific low back pain and functional disability. Proceedings of Singapore Healthcare 2014;23(3):218–225.

20. Monticone M, Baiardi P, Vanti C, Ferrari S, Nava T, Montironi C, et al. Chronic neck pain and treatment of cognitive and behavioural factors: results of a randomised controlled clinical trial. Eur Spine J 2012;21(8):1558–1566. doi: 10.1007/s00586-012-2287-y 22466021

21. Monticone M, Ferrante S, Rocca B, Baiardi P, Farra FD, Foti C. Effect of a long-lasting multidisciplinary program on disability and fear-avoidance behaviors in patients with chronic low back pain: results of a randomized controlled trial. Clin J Pain 2013;29(11):929–938. doi: 10.1097/AJP.0b013e31827fef7e 23328343

22. Monticone M, Ambrosini E, Rocca B, Magni S, Brivio F, Ferrante S. A multidisciplinary rehabilitation programme improves disability, kinesiophobia and walking ability in subjects with chronic low back pain: results of a randomised controlled pilot study. Eur Spine J 2014;23(10):2105–2113. doi: 10.1007/s00586-014-3478-5 25064093

23. Monticone M, Ambrosini E, Rocca B, Cazzaniga D, Liquori V, Foti C. Group-based task-oriented exercises aimed at managing kinesiophobia improved disability in chronic low back pain. Eur J Pain 2016;20(4):541–551. doi: 10.1002/ejp.756 26198386

24. Monticone M, Ambrosini E, Rocca B, Cazzaniga D, Liquori V, Pedrocchi A, et al. Group-based multimodal exercises integrated with cognitive-behavioural therapy improve disability, pain and quality of life of subjects with chronic neck pain: a randomized controlled trial with one-year follow-up. Clin Rehabil 2017;31(6):742–752. doi: 10.1177/0269215516651979 27246516

25. Bennell KL, Ahamed Y, Jull G, Bryant C, Hunt MA, Forbes AB, et al. Physical Therapist-Delivered pain coping skills training and exercise for knee osteoarthritis: randomized controlled trial. Arthritis Care Res 2016;68(5):590–602.

26. Johansson C, Dahl J, Jannert M, Melin L, Andersson G. Effects of a cognitive-behavioral pain-management program. Behav Res Ther 1998;36(10):915–930. doi: 10.1016/s0005-7967(98)00079-5 9714943

27. Kääpä EH, Frantsi K, Sarna S, Malmivaara A. Multidisciplinary group rehabilitation versus individual physiotherapy for chronic nonspecific low back pain: a randomized trial. Spine 2006;31(4):371–376. doi: 10.1097/01.brs.0000200104.90759.8c 16481945

28. Khan M, Akhter S, Soomro RR, Ali SS. The effectiveness of cognitive behavioral therapy (CBT) with general exercises versus general exercises alone in the management of chronic low back pain. Pak J Pharm Sci 2014;27(4):1113–1116.

29. Lambeek LC, van Mechelen W, Knol DL, Loisel P, Anema JR. Randomised controlled trial of integrated care to reduce disability from chronic low back pain in working and private life. BMJ 2010;340:c1035. doi: 10.1136/bmj.c1035 20234040

30. Lee WA, Lee WE, Law S, Lau WA, Leung S, Sieh K, et al. Managing psychosocial contributors in low back pain patients—a randomised controlled trial. Journal of Orthopaedics, Trauma and Rehabilitation 2013;17(1):46–51.

31. Macedo LG, Latimer J, Maher CG, Hodges PW, McAuley JH, Nicholas MK, et al. Effect of motor control exercises versus graded activity in patients with chronic nonspecific low back pain: a randomized controlled trial. Phys Ther 2012;92(3):363–377. doi: 10.2522/ptj.20110290 22135712

32. Martín J, Torre F, Padierna A, Aguirre U, González N, Matellanes B, et al. Impact of interdisciplinary treatment on physical and psychosocial parameters in patients with fibromyalgia: results of a randomised trial. Int J Clin Pract 2014;68(5):618–627. 24868587

33. McBeth J, Prescott G, Scotland G, Lovell K, Keeley P, Hannaford P, et al. Cognitive behavior therapy, exercise, or both for treating chronic widespread pain. Arch Intern Med 2012;172(1):48–57. doi: 10.1001/archinternmed.2011.555 22082706

34. Moffett JK, Torgerson D, Bell-Syer S, Jackson D, Llewlyn-Phillips H, Farrin A, et al. Randomised controlled trial of exercise for low back pain: clinical outcomes, costs, and preferences. BMJ 1999;319(7205):279–283. doi: 10.1136/bmj.319.7205.279 10426734

35. Smeets RJEM Vlaeyen JWS, Hidding A Kester ADM, van der Heijden G,J.M.G., van Geel A,C.M., et al. Active rehabilitation for chronic low back pain: cognitive-behavioral, physical, or both? First direct post-treatment results from a randomized controlled trial [ISRCTN22714229]. BMC Musculoskelet Disord 2006;7:5. doi: 10.1186/1471-2474-7-5 16426449

36. Thompson DP, Oldham JA, Woby SR. Does adding cognitive-behavioural physiotherapy to exercise improve outcome in patients with chronic neck pain? A randomised controlled trial. Physiotherapy 2016;102(2):170–177. doi: 10.1016/j.physio.2015.04.008 26383695

37. Huskisson EC. Measurement of pain. J Rheumatol 1982;9(5):768–769. 6184474

38. Carlsson AM. Assessment of chronic pain. I: aspects of the reliability and validity of the visual analogue scale. Pain 1983;16(1):87–101. doi: 10.1016/0304-3959(83)90088-x 6602967

39. Hjermstad MJ, Fayers PM, Haugen DF, Caraceni A, Hanks GW, Loge JH, et al. Studies comparing numerical rating scales, verbal rating scales, and visual analogue scales for assessment of pain intensity in adults: a systematic literature review. J Pain Symptom Manage 2011;41(6):1073–1093. doi: 10.1016/j.jpainsymman.2010.08.016 21621130

40. Burckhardt CS, Clark SR, Bennett RM. The Fibromyalgia Impact Questionnaire: development and validation. J Rheumatol 1991;18(5):728–733. 1865419

41. Melzack R, Katz J. The McGill Pain Questionnaire: appraisal and current status. In: Turk DC, Melzack R, editors. Handbook of pain assessment (2nd ed.) New York: The Guilford Press; 2001, p. 35–52.

42. Roland M, Morris R. A study of the natural history of back pain. Part I: development of a reliable and sensitive measure of disability in low-back pain. Spine 1983;8(2):141–144. doi: 10.1097/00007632-198303000-00004 6222486

43. Fairbank J. Use of Oswestry Disability Index (ODI). Spine 1995;20(13):1535–1537. 8623078

44. Vernon H, Mior S. The Neck Disability Index: a study of reliability and validity. J Manipulative Physiol Ther 1991;14(7):409–415. 1834753

45. Goolkasian H, P., Wheeler S, A., Gretz S, S. The Neck Pain and Disability Scale: test–retest reliability and construct validity. Clin J Pain 2002;18(4):245–250. 12131066

46. Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW. Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol 1988;15(12):1833–1840. 3068365

47. Kerns RD, Turk DC, Rudy TE. The West Haven-Yale Multidimensional Pain Inventory (WHYMPI). Pain 1985;23(4):345–356. doi: 10.1016/0304-3959(85)90004-1 4088697

48. Chalder T, Berelowitz G, Pawlikowska T, Watts L, Wessely S, Wright D, et al. Development of a fatigue scale. J Psychosom Res 1993;37(2):147–153. doi: 10.1016/0022-3999(93)90081-p 8463991

49. Leak AM, Cooper J, Dyer S, Williams KA, Turner-Stokes L, Frank AO. The Northwick Park Neck Pain Questionnaire, devised to measure neck pain and disability. Br J Rheumatol 1994;33(5):469–474. doi: 10.1093/rheumatology/33.5.469 8173853

50. Von Korff M, Ormel J, Keefe FJ, Dworkin SF. Grading the severity of chronic pain. Pain 1992;50(2):133–149. doi: 10.1016/0304-3959(92)90154-4 1408309

51. Ng F, Trauer T, Dodd S, Callaly T, Campbell S, Berk M. The validity of the 21-item version of the Depression Anxiety Stress Scales as a routine clinical outcome measure. Acta Neuropsychiatr 2007;19(5):304–310. doi: 10.1111/j.1601-5215.2007.00217.x 26952943

52. Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand 1983;67(6):361–370. doi: 10.1111/j.1600-0447.1983.tb09716.x 6880820

53. Goldberg D. A user’s guide to the General Health Questionnaire. Windsor, Berkshire: NFER-Nelson; 1988.

54. Ware JE., Sherbourne CD. The MOS 36-Item Short-Form Health Survey (SF-36), I: conceptual framework and item selection. Med Care 1992;30(6):473–483. 1593914

55. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry 1961;4:561–571. doi: 10.1001/archpsyc.1961.01710120031004 13688369

56. Salokangas RKR, Poutanen O, Stengård E. Screening for depression in primary care: development and validation of the Depression Scale, a screening instrument for depression. Acta Psychiatr Scand 1995;92(1):10–16. doi: 10.1111/j.1600-0447.1995.tb09536.x 7572242

57. Morley S, Eccleston C, Williams A. Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain 1999;80(1):1–13.

58. Smeets RJ, Vlaeyen JW, Kester AD, Knottnerus JA. Reduction of pain catastrophizing mediates the outcome of both physical and cognitive-behavioral treatment in chronic low back pain. J Pain 2006;7(4):261–271. doi: 10.1016/j.jpain.2005.10.011 16618470

Článek vyšel v časopise


2019 Číslo 10

Nejčtenější v tomto čísle

Tomuto tématu se dále věnují…


Zvyšte si kvalifikaci online z pohodlí domova

Léčba bolesti v ordinaci praktického lékaře
nový kurz
Autoři: MUDr. PhDr. Zdeňka Nováková, Ph.D.

Revmatoidní artritida: včas a k cíli
Autoři: MUDr. Heřman Mann

Jistoty a nástrahy antikoagulační léčby aneb kardiolog - neurolog - farmakolog - nefrolog - právník diskutují
Autoři: doc. MUDr. Štěpán Havránek, Ph.D., prof. MUDr. Roman Herzig, Ph.D., doc. MUDr. Karel Urbánek, Ph.D., prim. MUDr. Jan Vachek, MUDr. et Mgr. Jolana Těšínová, Ph.D.

Léčba akutní pooperační bolesti
Autoři: doc. MUDr. Jiří Málek, CSc.

Nové antipsychotikum kariprazin v léčbě schizofrenie
Autoři: prof. MUDr. Cyril Höschl, DrSc., FRCPsych.

Všechny kurzy
Kurzy Doporučená témata Časopisy
Zapomenuté heslo

Nemáte účet?  Registrujte se

Zapomenuté heslo

Zadejte e-mailovou adresu se kterou jste vytvářel(a) účet, budou Vám na ni zaslány informace k nastavení nového hesla.


Nemáte účet?  Registrujte se