Terapias psicológicas para el tratamiento del dolor crónico y recurrente en niños y adolescentes
Appendices
Appendix 1. Previous search results
Four separate searches were undertaken. The first search was undertaken from inception of the abstracting services to the end of 1999 (Eccleston 2003). This yielded 3715 abstracts, of which 123 were read in full, identifying 18 RCTs.
The second search, which updated the original review, was undertaken focusing on the 10 years since the previous search, overlapping by one year (from 1999 to 2008) and was later published (Eccleston 2009). This yielded 1319 abstracts, of which 45 papers were read in full, identifying a further 16 RCTs, giving a total set of 34. However, five studies were later excluded because they did not meet the minimum criteria of 10 participants in each arm, therefore, leaving 29 studies.
The third search, which searched databases from 2008 to March 2012, yielded 851 abstracts, of which 25 papers were read in full, and eight further RCTs were included in the review (Eccleston 2012).
The fourth search, which searched databases from March 2012 to January 2014, yielded 443 abstracts, of which 19 were read in full, and seven papers were included (Grob 2013; Gulewitsch 2013; Hechler 2014; Kashikar‐Zuck 2012; Levy 2010; Powers 2013; Van der Veek 2013). Kashikar‐Zuck 2012 and Levy 2010 provided additional data for studies previously included in this review. Five studies that were previously included, were excluded from this review since treatment was delivered remotely (Connelly 2006; Hicks 2006; Palermo 2009; Stinson 2010; Trautmann 2010). Therefore, a total of 37 RCTs were included (39 papers; Eccleston 2014).
Appendix 2. Model over‐fitting
We used AIC to mitigate the risk of overfitting due to repeated sensitivity analyses. The AIC scores indicate that all meta‐analyses are more parsimonious than meta‐regressions/subgroup analyses except pain intensity in children with mixed pain conditions at post‐treatment. Here, sample size explained enough variation to be worth including in the model based on change in AIC score. The model had very high inconsistency, partly explained by publication bias, but there was further heterogeneity not explained by our subgroup and sensitivity analyses. This reduced our confidence in the estimate of effect which is reflected in the GRADE assessment and 'summary of findings' tables.
Appendix 3. 2017 Search strategies
CENTRAL (CRSO)
#1 MeSH descriptor: [Child] explode all trees
#2 MeSH descriptor: [Infant] explode all trees
#3 MeSH descriptor: [Adolescent] explode all trees
#4 (child* or adolescent* or infant*or juvenil* or pediatric* or paediatric* or "young person*" or "young people" or youth* or "young adult*"):it,ab,kw (Word variations have been searched)
#5 #1 or #2 or #3 or #4
#6 MeSH descriptor: [Psychology] explode all trees
#7 MeSH descriptor: [Psychotherapy] explode all trees
#8 MeSH descriptor: [Behavior Therapy] explode all trees
#9 (psycholog* or (behavio?r and therapy) or hypnos* or relaxation* or ((family or color or colour or music or play) next therap*) or imagery or cogniti* or psychotherap*):it,ab,kw (Word variations have been searched)
#10 #6 or #7 or #8 or #9
#11 (pain* or headache* or "head ache*" or head‐ache* or migraine* or cephalalgi* or "stomach ache*" or "tummy ache*" or "abdominal ache*" or "belly ache*" or earache* or ear‐ache* or toothache* or tooth‐ache* or odontalgi* or dysmenorrh* or neuralgi*):it,ab,kw (Word variations have been searched)
#12 MeSH descriptor: [Pain] explode all trees
#13 MeSH descriptor: [Headache Disorders] explode all trees
#14 #11 or #12 or #13
#15 #5 and #10 and #14
MEDLINE via Ovid search strategy
1. exp child/
2. Infant/
3. Adolescent/
4. (child$ or adolescent$ or infant$ or juvenil$ or pediatric$ or paediatric$ or "young person$" or "young people" or youth$ or "young adult$").ab,it,kf.
5. 1 or 2 or 3 or 4
6. exp Psychology/
7. exp Psychotherapy/
8. exp Behavior Therapy/
9. (psycholog$ or (behavio?r and therapy) or hypnos$ or relaxation$ or ((family or color or colour or music or play) adj therap$) or imagery or cogniti$ or psychotherap$).ab,it,kf.
10. 6 or 7 or 8 or 9
11. (pain$ or headache$ or "head ache$" or head‐ache$ or migraine$ or cephalalgi$ or "stomach ache$" or "tummy ache$" or "abdominal ache$" or "belly ache$" or earache$ or ear‐ache$ or toothache$ or tooth‐ache$ or odontalgi$ or dysmenorrh$ or neuralgi$).ab,it,kf.
12. exp Pain/
13. exp Headache Disorders/
14. 11 or 12 or 13
15. 5 and 10 and 14
16 randomized controlled trial.pt.
17 controlled clinical trial.pt.
18 randomized.ab.
19 placebo.ab.
20 drug therapy.fs.
21 randomly.ab.
22 trial.ab.
23 or/16‐22
24 exp animals/ not humans.sh.
25 23 not 24
26 25 and 15
Embase via Ovid search strategy
1. Child/
2. Infant/
3. Adolescent/
4. (child$ or adolescent$ or infant$ or juvenil$ or pediatric$ or paediatric$ or "young person$" or "young people" or youth$ or "young adult$").ab,it.
5. 1 or 2 or 3 or 4
6. exp PSYCHOLOGY/
7. exp PSYCHOTHERAPY/
8. behavior therapy/
9. (psycholog$ or (behavio?r and therapy) or hypnos$ or relaxation$ or ((family or color or colour or music or play) adj therap$) or imagery or cogniti$ or psychotherap$).ab,it.
10. 6 or 7 or 8 or 9
11. (pain$ or headache$ or "head ache$" or head‐ache$ or migraine$ or cephalalgi$ or "stomach ache$" or "tummy ache$" or "abdominal ache$" or "belly ache$" or earache$ or ear‐ache$ or toothache$ or tooth‐ache$ or odontalgi$ or dysmenorrh$ or neuralgi$).ab,it.
12. exp Pain/
13. exp "Headache and Facial Pain"/
14. 11 or 12 or 13
15. 5 and 10 and 14
16 random$.tw.
17 factorial$.tw.
18 crossover$.tw.
19 cross over$.tw.
20 cross‐over$.tw.
21 placebo$.tw.
22 (doubl$ adj blind$).tw.
23 (singl$ adj blind$).tw.
24 assign$.tw.
25 allocat$.tw.
26 volunteer$.tw.
27 Crossover Procedure/
28 double‐blind procedure.tw.
29 Randomized Controlled Trial/
30 Single Blind Procedure/
31 or/16‐30
32 (animal/ or nonhuman/) not human/
33 31 not 32
34 15 and 33
PsycINFO via OVID
1. (child$ or adolescent$ or infant$ or juvenil$ or pediatric$ or paediatric$ or "young person$" or "young people" or youth$ or "young adult$").ab,it.
2. exp PSYCHOLOGY/
3. exp PSYCHOTHERAPY/
4. behavior therapy/
5. (psycholog$ or (behavio?r and therapy) or hypnos$ or relaxation$ or ((family or color or colour or music or play) adj therap$) or imagery or cogniti$ or psychotherap$).ab,it.
6. 2 or 3 or 4 or 5
7. (pain$ or headache$ or "head ache$" or head‐ache$ or migraine$ or cephalalgi$ or "stomach ache$" or "tummy ache$" or "abdominal ache$" or "belly ache$" or earache$ or ear‐ache$ or toothache$ or tooth‐ache$ or odontalgi$ or dysmenorrh$ or neuralgi$).ab,it.
8. exp Pain/
9. Headache/
10. Migraine Headache/
11. Muscle Contraction Headache/
12. 7 or 8 or 9 or 10 or 11
13. 1 and 6 and 12
14 clinical trials/
15 (randomis* or randomiz*).tw.
16 (random$ adj3 (allocat$ or assign$)).tw.
17 ((clinic$ or control$) adj trial$).tw.
18 ((singl$ or doubl$ or trebl$ or tripl$) adj3 (blind$ or mask$)).tw.
19 (crossover$ or "cross over$").tw.
20 random sampling/
21 Experiment Controls/
22 Placebo/
23 placebo$.tw.
24 exp program evaluation/
25 treatment effectiveness evaluation/
26 ((effectiveness or evaluat$) adj3 (stud$ or research$)).tw.
27 or/14‐26
28 13 and 27
Study flow diagram.
Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
Forest plot of comparison: 1 Treatment versus control (headache) post‐treatment, outcome: 1.1 Pain.
Forest plot of comparison: 3 Treatment versus control (mixed chronic pain conditions) post‐treatment, outcome: 3.1 Pain.
Comparison 1: Treatment versus control (headache) post‐treatment, Outcome 1: Pain
Comparison 1: Treatment versus control (headache) post‐treatment, Outcome 2: Disability
Comparison 1: Treatment versus control (headache) post‐treatment, Outcome 3: Depression
Comparison 1: Treatment versus control (headache) post‐treatment, Outcome 4: Anxiety
Comparison 2: Treatment versus control (headache) follow‐up, Outcome 1: Pain
Comparison 2: Treatment versus control (headache) follow‐up, Outcome 2: Disability
Comparison 2: Treatment versus control (headache) follow‐up, Outcome 3: Depression
Comparison 2: Treatment versus control (headache) follow‐up, Outcome 4: Anxiety
Comparison 3: Treatment versus control (mixed pain) post‐treatment, Outcome 1: Pain
Comparison 3: Treatment versus control (mixed pain) post‐treatment, Outcome 2: Disability
Comparison 3: Treatment versus control (mixed pain) post‐treatment, Outcome 3: Depression
Comparison 3: Treatment versus control (mixed pain) post‐treatment, Outcome 4: Anxiety
Comparison 4: Treatment versus control (mixed pain) follow‐up, Outcome 1: Pain
Comparison 4: Treatment versus control (mixed pain) follow‐up, Outcome 2: Disability
Comparison 4: Treatment versus control (mixed pain) follow‐up, Outcome 3: Depression
Comparison 4: Treatment versus control (mixed pain) follow‐up, Outcome 4: Anxiety
| Psychological therapies compared with any control for children and adolescents with frequent headaches | ||||||
| Patient or population: Children and adolescents with chronic pain Settings: Community and hospitals Intervention: Psychological therapies (cognitive behavioural therapy or behavioural therapy) Comparison: Any control (active, treatment‐as‐usual, wait‐list) | ||||||
| Outcomes | Probable outcome with control | Probable outcome with intervention | NNTB and/or relative effect | No of Participants | Quality of the evidence | Comments |
|---|---|---|---|---|---|---|
| Pain: 50% reduction in headache frequency Post‐treatment Lower scores = fewer headaches | 10 per 1000 | 24 per 1000 | NNTB = 2.86; RR 2.35 (1.67 to 3.30) | 644 participants | ⊕⊝⊝⊝ | |
| Pain: 50% reduction in headache frequency Follow‐up (up to 12 months) Lower scores = fewer headaches | 10 per 1000 | 27 per 1000 | NNTB = 3.16; RR 2.73 (0.98 to 7.63) | 223 participants (5 studies) | ⊕⊝⊝⊝ | |
| Disability Post‐treatment Lower scores = lower reported disability | The mean disability in the intervention groups was 0.26 lower (95% CI ‐0.56 to 0.03) | 446 participants (6 studies) | ⊕⊝⊝⊝ | |||
| Disability Follow‐up Lower scores = lower reported disability | The mean disability in the intervention groups was 0.37 lower (95% CI ‐0.65 to ‐0.10) | 209 participants (3 studies) | ⊕⊝⊝⊝ | |||
| Anxiety Post‐treatment Lower scores = lower reported anxiety | The mean anxiety in the intervention groups was 0.11 lower (95% CI ‐0.39 to 0.17) | 439 participants (7 studies) | ⊕⊝⊝⊝ | |||
| Anxiety Follow‐up Lower scores = lower reported anxiety | The mean anxiety in the intervention groups was 0.12 lower (95% CI ‐0.46 to 0.21) | 271 participants (4 studies) | ⊕⊝⊝⊝ | |||
| Depression Post‐treatment Lower scores = lower reported depression | The mean depression in the intervention groups was 0.08 lower (95% CI ‐0.28 to 0.11) | 400 participants (6 studies) | ⊕⊝⊝⊝ | |||
| CI: Confidence interval; RR: Risk Ratio; NNTB; Number needed to treat to benefit. | ||||||
| GRADE Working Group grades of evidence | ||||||
| a50 to 75% risk of bias ratings were unclear/high. b> 75% of risk of bias ratings were unclear or high. cConfidence intervals were wide. dHeterogeneity (I2) was 46 to 65%. eHeterogeneity (I2) was 66 to 100%. f75 to 100% of studies eligible to be included in the analysis were not included in the analysis. gSmall number of participants contributing to the outcome. hAsymmetrical funnel plots suggesting publication bias. iThere was mostly unclear/high risk of bias in the selective reporting category. | ||||||
| Psychological therapies compared with any control for children and adolescents with chronic pain conditions (mixed) | |||||
| Patient or population: Children and adolescents with chronic pain Settings: Community and hospitals Intervention: Psychological therapies (cognitive behavioural therapy or behavioural therapy) Comparison: Any control (active, treatment‐as‐usual, wait‐list) | |||||
| Outcomes | Probable outcome with control | Probable outcome with intervention | No of Participants | Quality of the evidence | Comments |
|---|---|---|---|---|---|
| Pain Post‐treatment Lower scores = lower reported pain intensity | The mean pain intensity in the intervention group was 0.43 lower (95% CI ‐0.67 to ‐0.19) | 1210 participants (16 studies) | ⊕⊝⊝⊝ | ||
| Pain Follow‐up Lower scores = lower reported pain intensity | The mean pain intensity in the intervention group was 0.08 lower (95% CI ‐0.30 to 0.13) | 763 participants (9 studies) | ⊕⊝⊝⊝ | ||
| Disability Post‐treatment Lower scores = lower reported disability | The mean disability in the intervention group was 0.34 lower (95% CI ‐0.54 to ‐0.15) | 1226 participants (14 studies) | ⊕⊕⊝⊝ | ||
| Disability Follow‐up Lower scores = lower reported disability | The mean disability in the intervention group was 0.27 lower (95% CI ‐0.49 to ‐0.06) | 866 participants (9 studies) | ⊕⊕⊝⊝ | ||
| Anxiety Post‐treatment Lower scores = lower reported anxiety | The mean anxiety in the intervention group was 0.16 lower (95% CI ‐0.29 to ‐0.03) | 883 participants (8 studies) | ⊕⊕⊝⊝ | ||
| Anxiety Follow‐up Lower scores = lower reported anxiety | The mean anxiety in the intervention group was 0.01 lower (95% CI ‐0.20 to 0.18) | 805 participants (8 studies) | ⊕⊕⊝⊝ | ||
| Depression Post‐treatment Lower scores = lower reported depression | The mean disability in the intervention group was 0.05 lower (95% CI ‐0.23 to 0.12) | 757 participants (8 studies) | ⊕⊝⊝⊝ | ||
| CI: Confidence interval. | |||||
| GRADE Working Group grades of evidence | |||||
| a50 to 75% risk of bias ratings were unclear/high. bConfidence intervals were wide. cHeterogeneity (I2) was 46 to 65%. dHeterogeneity (I2) was 66 to 100%. e50 to 75% of studies eligible to be included in the analysis were not included in the analysis. fAsymmetrical funnel plots suggesting publication bias. | |||||
| Headache Studies | |||
|---|---|---|---|
| Author | Illness | Treatment duration (hours) | Setting |
| Headache | 1.5 | Clinic | |
| Headache | 3 | Unknown | |
| Headache | 7 | Clinic | |
| Headache | Unknown | Unknown | |
| Headache | 4 hours plus tasks | Home | |
| Headache | 6.75 | Clinic | |
| Headache | 12 | Home/clinic | |
| Headache | 2.8 | Home/clinic | |
| Mixed | 136.5 (3‐week intensive therapy) | Clinic | |
| Headache | 12 | Clinic | |
| Headache | 6.7 | Clinic | |
| Headache | 7.5 | Clinic | |
| Headache | 6.75 | School | |
| Headache | 5 | School | |
| Headache | Unknown | Home | |
| Headache | 3.3 | Clinic | |
| Headache | 6 | Unknown | |
| Headache | 8 | Home/clinic | |
| Headache | 9.3 | Clinic | |
| Headache | 2.5 | School | |
| Mixed | 5 | Home/clinic | |
| Headache | 13 | Clinic | |
| Headache | 9 | Unknown | |
| Headache | Unknown | Clinic | |
| Headache | 4 | Clinic | |
| Mixed | 10 | Clinic | |
| Mixed Chronic Pain Studies | |||
| Author | Illness | Treatment duration hours) | Setting |
| RAP | Unknown | Clinic | |
| SCD | 6 | Home | |
| SCD | 9.5 | Home/clinic | |
| RAP | 3.3 | Unknown | |
| SCD | 0.75 | Clinic | |
| IBD | 4 | Home | |
| RAP | 9 | Clinic | |
| RAP/IBS | 2 | Clinic | |
| Mixed | 136.5 (3‐week intensive therapy) | Clinic | |
| RAP | Unknown | Clinic | |
| Fibromyalgia | 6 | Clinic | |
| Fibromyalgia | 7.5 | Unknown | |
| RAP | 4 | Home/clinic | |
| IBD | 3.5 | Home/clinic | |
| RAP | 3 | Home/clinic | |
| Mixed | 5 | Home/clinic | |
| RAP | 3.5 | Clinic | |
| RAP | 6 | Clinic | |
| RAP | 4.5 | Clinic | |
| RAP | 1.8 | Home | |
| RAP/IBS | 5 | Clinic | |
| TMD | Unknown | Unknown | |
| TMD | 6 | Clinic | |
| Mixed | 10 | Clinic | |
| *Headache and mixed chronic pain studies were entered twice. | |||
| Psychological treatments for children and adolescents with headache pain | ||||
| Pain | Disability | Depression | Anxiety | |
| Post‐treatment | Effect (15) | No effect (6) | No effect (6) | No effect (7) |
| < 20/arm | Effect (13) | No effect (2) | No effect (3) | No effect (4) |
| > 20/arm | Effect (2) | Effect (4) | No effect (3) | No effect (3) |
| Follow‐up | No effect (5) | Effect (3) | No effect (3) | No effect (4) |
| < 20/arm | Effect (4) | Unknown* | Unknown* | No effect (2) |
| > 20/arm | Unknown* | Effect (2) | No effect (2) | No effect (2) |
| Psychological treatments for children and adolescents with mixed pain conditions | ||||
| Pain | Disability | Depression | Anxiety | |
| Post‐treatment | Effect (16) | Effect (14) | No effect (8) | Effect (8) |
| < 20/arm | Effect (7) | Effect (6) | No effect (2) | Unknown* |
| > 20/arm | No effect (9) | Effect (8) | No effect (6) | Effect (7) |
| Follow‐up | No effect (9) | Effect (9) | No effect (7) | No effect (8) |
| < 20/arm | Effect (2) | No effect (2) | Unknown* | Unknown* |
| > 20/arm | No effect (7) | Effect (7) | No effect (6) | No effect (7) |
| Unknown (no data); Unknown* (only one study); Number in brackets denotes number of studies in analysis. | ||||
| Outcome | Sensitivity analysis |
| Pain, children with headache, post‐treatment | RR 2.79, 95% CI 2.01 to 3.89; participants = 325; studies = 15; I2 = 56% |
| N < 20 | RR 2.79, 95% CI 2.01 to 3.89; participants = 325; studies = 15; I2 = 56% |
| N > 20 | No studies could be included in the analysis |
| Pain, children with mixed pain conditions, post‐treatment | SMD ‐0.57, 95% CI ‐0.90 to ‐0.24; participants = 671; studies = 16; I2 = 74% |
| N < 20 | SMD ‐0.84, 95% CI ‐1.27 to ‐0.41; participants = 221; studies = 7; I2 = 54% |
| N > 20 | SMD ‐0.31, 95% CI ‐0.73 to 0.12; participants = 450; studies = 9; I2 = 79% |
| Disability, children with mixed pain conditions, post‐treatment | SMD ‐0.37, 95% CI ‐0.64 to ‐0.11; participants = 687; studies = 14; I2 = 60% |
| N < 20 | SMD ‐0.67, 95% CI ‐1.21 to ‐0.13; participants = 184; studies = 6; I2 = 64% |
| N > 20 | SMD ‐0.21, 95% CI ‐0.41 to ‐0.00; participants = 503; studies = 8; I2 = 25% |
| CI: confidence intervals | |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1.1 Pain Show forest plot | 15 | 644 | Risk Ratio (M‐H, Random, 95% CI) | 2.35 [1.67, 3.30] |
| 1.1.1 N < 20 | 13 | 437 | Risk Ratio (M‐H, Random, 95% CI) | 2.86 [1.73, 4.72] |
| 1.1.2 N > 20 | 2 | 207 | Risk Ratio (M‐H, Random, 95% CI) | 1.88 [1.36, 2.58] |
| 1.2 Disability Show forest plot | 6 | 446 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.26 [‐0.56, 0.03] |
| 1.2.1 N < 20 | 2 | 61 | Std. Mean Difference (IV, Random, 95% CI) | 0.04 [‐0.47, 0.54] |
| 1.2.2 N > 20 | 4 | 385 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.35 [‐0.69, ‐0.00] |
| 1.3 Depression Show forest plot | 6 | 400 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.08 [‐0.28, 0.11] |
| 1.3.1 N < 20 | 3 | 103 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.16 [‐0.68, 0.35] |
| 1.3.2 N > 20 | 3 | 297 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.06 [‐0.29, 0.17] |
| 1.4 Anxiety Show forest plot | 7 | 439 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.11 [‐0.39, 0.17] |
| 1.4.1 N < 20 | 4 | 136 | Std. Mean Difference (IV, Random, 95% CI) | 0.01 [‐0.54, 0.57] |
| 1.4.2 N > 20 | 3 | 303 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.19 [‐0.49, 0.11] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 2.1 Pain Show forest plot | 5 | 223 | Risk Ratio (M‐H, Random, 95% CI) | 2.73 [0.98, 7.63] |
| 2.1.1 N < 20 | 4 | 99 | Risk Ratio (M‐H, Random, 95% CI) | 3.49 [1.31, 9.26] |
| 2.1.2 N > 20 | 1 | 124 | Risk Ratio (M‐H, Random, 95% CI) | 1.25 [1.03, 1.52] |
| 2.2 Disability Show forest plot | 3 | 209 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.37 [‐0.65, ‐0.10] |
| 2.2.1 N < 20 | 1 | 24 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.45 [‐1.27, 0.36] |
| 2.2.2 N > 20 | 2 | 185 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.36 [‐0.65, ‐0.07] |
| 2.3 Depression Show forest plot | 3 | 228 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.05 [‐0.62, 0.52] |
| 2.3.1 N < 20 | 1 | 24 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.54 [‐1.36, 0.28] |
| 2.3.2 N > 20 | 2 | 204 | Std. Mean Difference (IV, Random, 95% CI) | 0.11 [‐0.61, 0.83] |
| 2.4 Anxiety Show forest plot | 4 | 271 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.12 [‐0.46, 0.21] |
| 2.4.1 N < 20 | 2 | 67 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.28 [‐1.00, 0.45] |
| 2.4.2 N > 20 | 2 | 204 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.04 [‐0.48, 0.41] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 3.1 Pain Show forest plot | 16 | 1210 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.43 [‐0.67, ‐0.19] |
| 3.1.1 N < 20 | 7 | 250 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.83 [‐1.19, ‐0.46] |
| 3.1.2 N > 20 | 9 | 960 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.20 [‐0.45, 0.05] |
| 3.2 Disability Show forest plot | 14 | 1226 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.34 [‐0.54, ‐0.15] |
| 3.2.1 N < 20 | 6 | 213 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.72 [‐1.17, ‐0.26] |
| 3.2.2 N > 20 | 8 | 1013 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.20 [‐0.37, ‐0.04] |
| 3.3 Depression Show forest plot | 8 | 757 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.05 [‐0.23, 0.12] |
| 3.3.1 N < 20 | 2 | 59 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.27 [‐0.95, 0.41] |
| 3.3.2 N > 20 | 6 | 698 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.03 [‐0.21, 0.15] |
| 3.4 Anxiety Show forest plot | 8 | 957 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.16 [‐0.29, ‐0.03] |
| 3.4.1 N < 20 | 1 | 32 | Std. Mean Difference (IV, Random, 95% CI) | 0.12 [‐0.57, 0.82] |
| 3.4.2 N > 20 | 7 | 925 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.17 [‐0.30, ‐0.04] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 4.1 Pain Show forest plot | 9 | 833 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.08 [‐0.30, 0.13] |
| 4.1.1 N < 20 | 2 | 53 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.94 [‐1.75, ‐0.13] |
| 4.1.2 N > 20 | 7 | 780 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.00 [‐0.15, 0.14] |
| 4.2 Disability Show forest plot | 9 | 935 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.27 [‐0.49, ‐0.06] |
| 4.2.1 N < 20 | 2 | 53 | Std. Mean Difference (IV, Random, 95% CI) | ‐1.17 [‐2.60, 0.26] |
| 4.2.2 N > 20 | 7 | 882 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.20 [‐0.34, ‐0.07] |
| 4.3 Depression Show forest plot | 7 | 667 | Std. Mean Difference (IV, Random, 95% CI) | 0.09 [‐0.10, 0.28] |
| 4.3.1 N < 20 | 1 | 24 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.53 [‐1.35, 0.29] |
| 4.3.2 N > 20 | 6 | 643 | Std. Mean Difference (IV, Random, 95% CI) | 0.12 [‐0.06, 0.30] |
| 4.4 Anxiety Show forest plot | 8 | 875 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.01 [‐0.20, 0.18] |
| 4.4.1 N < 20 | 1 | 32 | Std. Mean Difference (IV, Random, 95% CI) | 0.09 [‐0.60, 0.79] |
| 4.4.2 N > 20 | 7 | 843 | Std. Mean Difference (IV, Random, 95% CI) | ‐0.01 [‐0.22, 0.19] |
