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Terapi psikologi bagi pengurusan sakit kronik (tidak termasuk sakit kepala) dalam kalangan dewasa

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Abstract

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Background

Psychological treatments are designed to treat pain, distress and disability, and are in common practice. This review updates and extends the 2009 version of this systematic review.

Objectives

To evaluate the effectiveness of psychological therapies for chronic pain (excluding headache) in adults, compared with treatment as usual, waiting list control, or placebo control, for pain, disability, mood and catastrophic thinking.

Search methods

We identified randomised controlled trials (RCTs) of psychological therapy by searching CENTRAL, MEDLINE, EMBASE and Psychlit from the beginning of each abstracting service until September 2011. We identified additional studies from the reference lists of retrieved papers and from discussion with investigators.

Selection criteria

Full publications of RCTs of psychological treatments compared with an active treatment, waiting list or treatment as usual. We excluded studies if the pain was primarily headache, or was associated with a malignant disease. We also excluded studies if the number of patients in any treatment arm was less than 20.

Data collection and analysis

Forty‐two studies met our criteria and 35 (4788 participants) provided data. Two authors rated all studies. We coded risk of bias as well as both the quality of the treatments and the methods using a scale designed for the purpose. We compared two main classes of treatment (cognitive behavioural therapy(CBT) and behaviour therapy) with two control conditions (treatment as usual; active control) at two assessment points (immediately following treatment and six months or more following treatment), giving eight comparisons. For each comparison, we assessed treatment effectiveness on four outcomes: pain, disability, mood and catastrophic thinking, giving a total of 32 possible analyses, of which there were data for 25.

Main results

Overall there is an absence of evidence for behaviour therapy, except a small improvement in mood immediately following treatment when compared with an active control. CBT has small positive effects on disability and catastrophising, but not on pain or mood, when compared with active controls. CBT has small to moderate effects on pain, disability, mood and catastrophising immediately post‐treatment when compared with treatment as usual/waiting list, but all except a small effect on mood had disappeared at follow‐up. At present there are insufficient data on the quality or content of treatment to investigate their influence on outcome. The quality of the trial design has improved over time but the quality of treatments has not.

Authors' conclusions

Benefits of CBT emerged almost entirely from comparisons with treatment as usual/waiting list, not with active controls. CBT but not behaviour therapy has weak effects in improving pain, but only immediately post‐treatment and when compared with treatment as usual/waiting list. CBT but not behaviour therapy has small effects on disability associated with chronic pain, with some maintenance at six months. CBT is effective in altering mood and catastrophising outcomes, when compared with treatment as usual/waiting list, with some evidence that this is maintained at six months. Behaviour therapy has no effects on mood, but showed an effect on catastrophising immediately post‐treatment. CBT is a useful approach to the management of chronic pain. There is no need for more general RCTs reporting group means: rather, different types of studies and analyses are needed to identify which components of CBT work for which type of patient on which outcome/s, and to try to understand why.

PICO

Population
Intervention
Comparison
Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

Plain language summary

Terapi psikologi dalam kalangan dewasa yang menderita sakit dan ketakupayaan berlarutan

Ramai orang menderita sakit yang berlarutan, yang tidak lega oleh ubat‐ubatan, surgeri atau terapi fizikal. Pencarian untuk suatu diagnosis dan melegakan sakit sering lama, tidak menggalakkan dan memudaratkan. Bagi sesetengah orang, sakit boleh membawa kepada ketakupayaan, kemurungan, kebimbangan dan pemencilan sosial. Ia juga dikaitkan dengan kecenderungan untuk mengalami kebanyakan atau semua hal kehidupan dirosakkan oleh kesakitan, ibarat malapetaka yang mustahil untuk dikawal. Perubahan besar kehidupan ini bukanlah tidak boleh dielakkan dan dilihat sekurang‐kurangnya boleh berbalik menggunakan rawatan yang bertujuan mengurangkan ketakupayaan dan penderitaan walaupun sakit berlarutan. Rawatan adalah berdasarkan prinsip psikologi teguh yang dibangunkan sepanjang 40 tahun penggunaan klinikal.

Carian kami menemui 42 kajian rawatan yang memenuhi kriteria kami, tetapi hanya 35 kajian menyediakan data dalam bentuk yang boleh diguna. Dua jenis rawatan psikologi utama dinamakan terapi tingkah laku kognitif (CBT) dan terapi tingkah laku. Kedua‐duanya memfokus untuk membantu orang mengubah tingkah laku yang mengekalkan atau menerukkan sakit, ketakupayaan, penderitaan dan fikiran katastrofik; CBT juga secara terus menangani masalah pemikiran dan perasaan orang yang sakit berterusan. Kesan kedua‐dua rawatan ini terhadap sakit, ketakupayaan, mood dan fikiran katastrofik diuji sejurus selepas rawatan dan enam bulan kemudian.

Kajian‐kajian yang membandingkan CBT dengan tiada rawatan mendapati manfaat kecil hingga sederhana, lebih kepada ketakupayaan, mood dan fikiran katastrofik . Sesetengah kajian masih positif selepas enam bulan. Rawatan tingkah laku menunjukkan manfaat yang sedikit dan singkat. Terapi psikologi boleh membantu orang dengan sakit kronik untuk mengurangkan mood negatif (kemurungan dan kebimbangan), ketakupayaan, fikiran katastrofik, dan dalam sesetengah kes, rasa sakit. Walaupun kesan keseluruhan adalah positif, kami tidak tahu secara tepat jenis rawatan manakah yang terbaik untuk seseorang.