Cognitive behavioural therapies for fibromyalgia

Kathrin Bernardy; Petra Klose; Angela J Busch; Ernest HS Choy; Winfried Häuser

doi:10.1002/14651858.CD009796.pub2

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Figure 1

Study flow diagram.

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Figure 4

Forest plot of comparison: 1 Cognitive behavioural therapies versus controls at end of treatment, outcome: 1.1 Pain.

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Figure 5

Forest plot of comparison: 1 Cognitive behavioural therapies versus controls at end of treatment, outcome: 1.2 Negative mood.

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Figure 6

Forest plot of comparison: 1 Cognitive behavioural therapies versus controls at end of treatment, outcome: 1.3 Disability.

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Analysis 1.1

Comparison 1 Cognitive behavioural therapies versus controls at end of treatment, Outcome 1 Pain.

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Analysis 1.2

Comparison 1 Cognitive behavioural therapies versus controls at end of treatment, Outcome 2 Negative mood.

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Analysis 1.3

Comparison 1 Cognitive behavioural therapies versus controls at end of treatment, Outcome 3 Disability.

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Analysis 1.4

Comparison 1 Cognitive behavioural therapies versus controls at end of treatment, Outcome 4 Self‐efficacy pain.

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Analysis 1.5

Comparison 1 Cognitive behavioural therapies versus controls at end of treatment, Outcome 5 Acceptability.

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Analysis 1.6

Comparison 1 Cognitive behavioural therapies versus controls at end of treatment, Outcome 6 Fatigue.

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Analysis 1.7

Comparison 1 Cognitive behavioural therapies versus controls at end of treatment, Outcome 7 Sleep problems.

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Analysis 1.8

Comparison 1 Cognitive behavioural therapies versus controls at end of treatment, Outcome 8 Health‐related quality of life.

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Analysis 2.1

Comparison 2 Cognitive behavioural therapies versus controls at long‐term follow‐up, Outcome 1 Pain.

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Analysis 2.2

Comparison 2 Cognitive behavioural therapies versus controls at long‐term follow‐up, Outcome 2 Negative mood.

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Analysis 2.3

Comparison 2 Cognitive behavioural therapies versus controls at long‐term follow‐up, Outcome 3 Disability.

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Analysis 2.4

Comparison 2 Cognitive behavioural therapies versus controls at long‐term follow‐up, Outcome 4 Self‐efficacy pain.

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Analysis 2.5

Comparison 2 Cognitive behavioural therapies versus controls at long‐term follow‐up, Outcome 5 Fatigue.

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Analysis 2.6

Comparison 2 Cognitive behavioural therapies versus controls at long‐term follow‐up, Outcome 6 Sleep problems.

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Analysis 2.7

Comparison 2 Cognitive behavioural therapies versus controls at long‐term follow‐up, Outcome 7 Health‐related quality of life.

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Cognitive behavioural therapies compared to controls for fibromyalgia
Patient or population: Patients with fibromyalgia Settings: In‐ and outpatient Intervention: Cognitive behavioural therapies Comparison: Controls (attention control, treatment as usual, waiting list, other active therapy)
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	controls	Cognitive behavioural therapies
Pain end of treatment (0‐10 scale) Higher scores indicate higher pain levels	Mean pain baseline 7.37 (SD 2.10) ³	The mean pain in the intervention groups was 0.29 standard deviations lower (0.49 to 0.11 lower)		1382 (20)	⊕⊕⊝⊝ low^1,2	SMD ‐0.29 (95% CI ‐0.47 to ‐0.11) 8.5% (95% CI 3.1% to 14.0%) relative improvement 6.3 % (95% 2.3% to 10.3%) CI) fewer points on the scale (absolute change) NNTB 7 (95% CI 5 to19)
Pain follow‐up median 6 months (0‐10 scale) Higher scores indicate higher pain levels	Mean pain baseline 64.72 (SD 10.44) ⁴	The mean pain in the intervention groups was 0.40 standard deviations lower (0.64 to 0.16 lower)		822 (14)	⊕⊕⊝⊝ low^1,2	SMD ‐0.40 (95% CI ‐0.62 to ‐0.17) 6.4% (95% CI 2.7% to 9.9%) relative improvement 4.2% (95% CI 1.8% to 6.5%) fewer points on the scale (absolute change) NNTB 10 (95% CI 6 to 24)
Negative mood end of treatment (0‐10 scale) Higher scores indicate higher negative mood levels	Mean depression baseline 6.82 (SD 3.11) ⁵	The mean negative mood in the intervention groups was 0.33 standard deviations lower (0.49 to 0.17 lower)		1578 (18)	⊕⊕⊝⊝ low^1,2	SMD ‐0.33 (95% CI ‐0.49 to ‐0.17) 15.0% (95% CI 7.7% to 22.3%) relative improvement 10.2% (95% CI 5.2% to 15.2%) fewer points on the scale (absolute change) NNTB 6 (95% CI 4 to12)
Negative mood follow‐up median 6 months (0‐50 scale) Higher scores indicate higher negative mood levels	Mean depression baseline 14.94 (SD 3.11) ⁶	The mean negative mood in the intervention groups was 0.43 standard deviations lower (0.75 to 0.11 lower)		721 (11)	⊕⊕⊝⊝ low^1,2	SMD ‐0.43 (95% CI ‐0.75 to ‐0.11) 8.9% (95% CI 2.3% to 15.8%) relative improvement 2.7% (95% CI 0.1% to 4.7%) fewer points on the scale (absolute change) NNTB 11 (95% CI 6 to 43)
Disability end of treatment (0‐10 scale) Higher scores indicate disability levels	Mean physical impairment baseline 2.80 (SD 2.40) ⁷	The mean disability in the intervention groups was 0.30 standard deviations lower (0.51 to 0.08 lower)		1163 (15)	⊕⊕⊝⊝ low^1,2	SMD ‐0.30 (95% CI ‐0.51 to ‐0.08) 25.8 % (95% CI 6.9% to 43.7% relative improvement 7.2% (95% CI 1.9% to 12.2%) fewer points on the scale (absolute change) NNTB 7 (95% CI 4 to 26)
Disability follow‐up median 6 months (0‐10 scale) Higher scores indicate disability levels	Mean physical impairment baseline 3.24 (SD 2.26) ⁸	The mean disability in the intervention groups was 0.52 standard deviations lower (0.86 to 0.18 lower)		664 (9)	⊕⊕⊝⊝ low^1,2	SMD ‐0.52 (95% CI ‐0.86 to ‐0.18) 36.4% (95% CI 1.3% to 60.2%) relative improvement 11.7% (95% CI 4.1% to 19.4%) fewer points on the scale (absolute change) NNTB 4 (95% CI 3 to12)
Acceptability end of treatment (dropouts from study due to any reasons)	136 (94 to 195) per 1000	127 (88 to 182)	RR 0.94 (0.65 to 1.35)	1914 (21)	⊕⊕⊝⊝ low¹	Absolute risk difference 0% (95% CI ‐1 to 0) Relative per cent change 6% (95% CI 15% improvement to 35% worsening) Not statistically significant
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹ Some studies with lack of reported allocation concealment, without intention‐to‐treat analysis and with selective outcome reporting ² High heterogeneity of treatment effect ³ Luciano 2011: N=216 patients; Pain VAS 0‐10 scale ⁴ Alda 2011: N=113 patients; Pain VAS 0‐100 scale ⁵ Luciano 2011: N=216 patients; Depression VAS 0‐10 scale ⁶ Alda 2011; N=113 patients; Hamilton Rating Scale for Depression (0‐50) ⁷ Luciano 2011: N=216 patients; Physical impairment VAS 0‐10 scale ⁸ Alda 2011; N=113 patients; Physical impairment VAS 0‐10 scale

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Summary of findings 2. Cognitive behavioural therapies versus controls for fibromyalgia

Cognitive behavioural therapies versus controls for fibromyalgia
Patient or population: Patients with fibromyalgia Settings: In‐ and outpatients Intervention: Cognitive behavioural therapies Comparison: Controls (attention control, treatment as usual, waiting list, other active therapy)
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Control	Cognitive behavioural therapies versus controls final treatment
Fatigue end of treatment (0‐10 scale) Higher scores indicate higher fatigue levels	Mean fatigue score 8.13 (SD 1.89) ³	The mean fatigue in the intervention groups was 0.25 standard deviations lower (0.49 to 0.02 lower)		910 (11 studies)	⊕⊕⊝⊝ low¹	SMD ‐0.25 (95% CI ‐0.49 to ‐0.02) 5.8% (95% CI 0.05% to 11.3%) relative improvement 4.7% (95% CI 0.4% to 9.3%) fewer points on the scale (absolute change) NNTB 9 (95% CI 5 to109)
Sleep problems end of treatment (0‐50 scale) Higher scores indicate more sleep problems	Mean sleep problems score 27.9 (SD 8.8) ⁴	The mean sleep problems in the intervention groups was 0.4 standard deviations lower (0.85 lower to 0.05 higher)		422 (8 studies)	⊕⊕⊝⊝ low²	SMD ‐0.40 (95% CI ‐0.85 to 0.05) 0.3% (95% CI ‐0.03% to 1.7%) relative improvement 7.0% (95% CI ‐0.90% to 15.0%) fewer points on the scale (absolute change) NNTB 5 (95% CI ‐45 to 3)
Health‐related quality of life end of treatment (0‐80 scale) Higher scores indicate lower health‐related quality of life	Mean health‐related quality of life score 55.97 (SD 15.95) ⁵	The mean health‐related quality of life in the intervention groups was 0.23 standard deviations lower (0.38 to 0.08 lower)		1238 (13 studies)	⊕⊕⊝⊝ low^1,2	SMD ‐0.23 (95% CI ‐0.38 to ‐0.08) 0.08% (95% CI 0.03% to 0.13%) relative improvement 4.6% (95% CI 1.6% to 7.6%) fewer points on the scale (absolute change) NNTB 9 (95% CI 6 to 27)
Fatigue Follow‐up median 6 months (0‐10 scale) Higher scores indicate higher fatigue levels	Mean fatigue score Mean 8.32 (SD 2.17)⁶	The mean fatigue in the intervention groups was 0.46 standard deviations lower (0.77 to 0.15 lower)		429 (6 studies)	⊕⊕⊝⊝ low^1,2	SMD ‐0.46 (95% CI ‐0.77 to ‐0.15) 1.2% (95% CI 0.4% to 2.0%) relative improvement 10.0% (95% CI 3.2% to 16.7%) fewer points on the scale (absolute change) NNTB 5 (95% CI 3 to 14)
Sleep problems Follow‐up median 6 months (0‐50 scale) Higher scores indicate more sleep problems	Mean sleep problems score 27.9 (SD 8.8) ⁴	The mean sleep problems in the intervention groups was 0.64 standard deviations lower (1.31 lower to 0.03 higher)		378 (7 studies)	⊕⊕⊝⊝ low^1,2	SMD ‐0.64 (95% CI ‐1.31 to 0.03) 0.4% (95% CI ‐0.02% to 0.8%) relative improvement 11.2% (95% CI ‐0.53% to 23.1%) fewer points on the scale (absolute change) NNTB 4 (95% CI ‐74 to 2)
Health‐related quality of life Follow‐up median 6 months (0‐80 scale) Higher scores indicate lower health‐related quality of life	Mean health‐related quality if life score 64.48 (SD 10.50) ⁷	The mean health‐related quality of life in the intervention groups was 0.19 standard deviations lower (0.58 lower to 0.21 higher)		425 (6 studies)	⊕⊕⊝⊝ low¹	SMD ‐0.19 (95% CI ‐0.58 to 0.21) 0.03% (95% CI ‐0.03% to 0.15%) relative improvement 2.0% (95% CI ‐2.2% to 6.1%) fewer points on the scale (absolute change) NNTB 12 (95% CI ‐17 to 6)
Acceptability Follow‐up: median 6 months	See comment	See comment	Not estimable	‐	See comment	Not assessed
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹ Some studies with lack of reported allocation concealment, without intention‐to‐treat analysis and with selective reporting ² High heterogeneity of treatment effect ³ Luciano 2011: N=216 patients; VAS 0‐10 scale ⁴ Castel 2012; N=60 patients; NRS 0‐50 scale ⁵ Luciano 2011: N=216 patients; VAS 0‐80 scale ⁶ Alda 2010; N= 113; VAS 0‐10 scale ⁷ Alda 2010; N= 113; VAS 0‐100 scale

Summary of findings 2. Cognitive behavioural therapies versus controls for fibromyalgia

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Table 1. Main characteristics of included studies

Author	Country	Type of CBT	Type of control group	Duration CBT (weeks)	Number of CBT sessions Total treatment time CBT (hours)	Number of patients in CBT group % women	Number of patients in control group % women
Alda 2011 *	Spain	CBT	TAU	12	6 15	57 95	56 96
Ang 2010 *	USA	CBT	TAU	12	6 3	17 100	15 100
Burckhardt 1994 *	Sweden	CBT	Delayed treatment	6	6 9	28 100	30 100
Castel 2009 *	Spain	CBT	TAU	11	12 18	18 94	12 86
Castel 2012 *	Spain	CBT	TAU	14	14 28	34 94	30 100
Edinger 2005 *	USA	CBT	TAU	6	6 6	16 94	12 100
Falcao 2008 *	Brazil	CBT	TAU	10	20 30	30 100	30 100
Kashikar‐Zuck 2005 **	USA	CBT	Active control	8	8 12	14 100	14 100
Kashikar‐Zuck 2012 **	USA	CBT	Active control	8	8 6	57 95	57 90
King 2002 *	USA	CBT	Delayed treatment	12	12 18	48 100	39 100
Luciano 2011 *	Spain	CBT	TAU	8	8 16	108 95	108 98
Miro 2011 *	Spain	CBT	Active control	6	6 9	20 100	20 100
Nicassio 1997 *	USA	CBT	Active control	10	10 15	36 89	35 89
Oliver 2002 *	USA	Self‐management	TAU	52	10 20	207 96	193 94
Redondo 2004 *	Spain	CBT	Active control	8	8 20	21 100	19 100
Rooks 2007 *	USA	Self‐management	Active control	16	8 16	51 100	50 100
Soares 2002 *	Sweden	CBT	Attention control	10	10 120	18 100	18 100
Thieme 2003 *	Germany	Operant therapy	Active control	5	25 75	42 100	21 100
Thieme 2006a *	Germany	Operant therapy	Attention control	15	15 30	42 100	20 100
Thieme 2006b *	Germany	CBT	Attention control	15	15 30	43 100	20 100
Vlayen 1996 *	Netherlands	CBT	Active control	6	12 18	49 93	43 82
Wigers 1996 *	Norway	CBT	TAU	14	15 30	20 90	20 95
Williams 2010 *	USA	Self‐management	TAU	26	NR	59 95	59 95
Woolfolk 2012 *	USA	CBT	TAU	NR	NR	38 89	38 87
* Studies included only adults ** Studies included only children and adolescents NR = Not reported and not provided on request TAU = Treatment as usual

Table 1. Main characteristics of included studies

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Table 2. Reported treatment quality

	Treatment content and setting	Treatment duration	Manualisation	Adherence to manual	Therapist training	Client engagement	Sum
Alda 2011	2	1	2	1	1	0	7
Ang 2010	2	1	2	1	2	0	8
Burckhardt 1994	1	1	0	0	1	0	3
Castel 2009	1	1	0	0	0	0	2
Castel 2012	1	1	2	1	0	1	6
Edinger 2005	1	1	2	0	1	0	5
Falcao 2008	1	1	0	0	1	1	4
Kashikar‐Zuck 2005	2	1	2	1	2	1	9
Kashikar‐Zuck 2012	2	1	2	1	2	1	9
King 2002	1	1	0	0	0	1	3
Luciano 2011	2	1	1	0	1	0	5
Miro 2011	2	1	2	0	1	0	6
Nicassio 1997	1	1	0	0	0	0	2
Oliver 2002	2	1	0	0	0	0	3
Redondo 2004	2	1	0	0	0	0	3
Rooks 2007	2	1	0	0	0	0	3
Soares 2002	1	1	0	0	1	0	3
Thieme 2003	2	1	2	0	0	0	5
Thieme 2006	2	1	1	0	2	0	6
Vlayen 1996	1	1	0	0	0	0	2
Wigers 1996	1	1	0	0	1	1	4
Williams 2010	2	1	1	0	1	1	6
Woolfolk 2012	1	1	2	0	0	0	4
Items and scores of treatment quality scale (Yates 2005) 1. Treatment content and setting: 2 ‐ Adequate: a clear rationale for the treatment has been reported along with an adequate description of its content; 1 ‐ Partial: either a clear rationale or a description of the content of the treatment is reported; 0 ‐ Inadequate:neither the rationale for treatment or the treatment content are adequately reported. 2. Treatment duration: 1 – Reported; 0 ‐ Unknown. 3. Manualistion of treatment: 2 ‐ Adequate: there is reference to use of a manual that describes the active components of the treatment of study. If more than one treatment arm, manuals were used for all the appropriate treatments; 1 ‐ Partial:in trials with more than one treatment arm, the use of a manual is described but not for all the treatments that would be expected to be manualised; 0 ‐ Inadequate: no evidence that a manual has been used, but reference is made to various principles. 4. Adherence to the manual: 1 ‐ Adequate: there is evidence that the investigators have checked adherence to the manual during the period of study via direct observations, tape recording or supervisory processes that explicitly state adherence to the manual; 0 ‐ Inadequate: no evidence of adherence checks reported. 5. Therapist training: 2 ‐ Adequate: there is documentation of explicit training for the treatment of the trial; 1 ‐ Partial: the general level of therapist training is reported and is adequate (professionally qualified) but there is no mention of explicit training for the trial; 0 ‐ Inadequate: there is no convincing evidence that the therapists have an adequate level of training (e.g. graduate level) or explicit training for the trial. 6. Client Engagement: 1 ‐ Adequate: documented that evidence of engagement was sought e.g. checks on homework were made, skills practice in sessions; 0 – inadequate: no evidence that checks were made on level of engagement.

Table 2. Reported treatment quality

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Comparison 1. Cognitive behavioural therapies versus controls at end of treatment

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain Show forest plot	21	1453	Std. Mean Difference (IV, Random, 95% CI)	‐0.29 [‐0.47, ‐0.11]

1.1 Traditional cognitive behavioural therapy	18	1150	Std. Mean Difference (IV, Random, 95% CI)	‐0.30 [‐0.44, ‐0.15]
1.2 Operant therapy	2	123	Std. Mean Difference (IV, Random, 95% CI)	‐0.67 [‐2.56, 1.23]
1.3 Self‐management	2	180	Std. Mean Difference (IV, Random, 95% CI)	0.02 [‐0.81, 0.84]
2 Negative mood Show forest plot	19	1649	Std. Mean Difference (IV, Random, 95% CI)	‐0.33 [‐0.49, ‐0.17]

2.1 Traditional cognitive‐behavioural therapy	15	1010	Std. Mean Difference (IV, Random, 95% CI)	‐0.34 [‐0.48, ‐0.19]
2.2 Operant therapy	2	124	Std. Mean Difference (IV, Random, 95% CI)	‐0.90 [‐2.21, 0.42]
2.3 Self‐management education	3	515	Std. Mean Difference (IV, Random, 95% CI)	‐0.10 [‐0.27, 0.07]
3 Disability Show forest plot	16	1234	Std. Mean Difference (IV, Random, 95% CI)	‐0.30 [‐0.51, ‐0.08]

3.1 Traditional cognitive‐behavioural therapy	13	931	Std. Mean Difference (IV, Random, 95% CI)	‐0.31 [‐0.45, ‐0.18]
3.2 Operant therapy	2	123	Std. Mean Difference (IV, Random, 95% CI)	‐0.88 [‐3.10, 1.33]
3.3 Self‐management education	2	180	Std. Mean Difference (IV, Random, 95% CI)	0.07 [‐0.60, 0.74]
4 Self‐efficacy pain Show forest plot	11	1047	Std. Mean Difference (IV, Random, 95% CI)	‐0.49 [‐0.80, ‐0.17]

4.1 Traditional cognitive‐behavioural therapy	9	589	Std. Mean Difference (IV, Random, 95% CI)	‐0.39 [‐0.72, ‐0.05]
4.2 Operant therapy	2	123	Std. Mean Difference (IV, Random, 95% CI)	‐1.18 [‐3.01, 0.64]
4.3 Self‐management education	1	335	Std. Mean Difference (IV, Random, 95% CI)	‐0.18 [‐0.39, 0.04]
5 Acceptability Show forest plot	21	1914	Risk Ratio (M‐H, Random, 95% CI)	0.94 [0.65, 1.35]

5.1 Traditional cognitive‐behavioural therapy	17	1169	Risk Ratio (M‐H, Random, 95% CI)	0.98 [0.65, 1.46]
5.2 Operant therapy	2	126	Risk Ratio (M‐H, Random, 95% CI)	0.43 [0.03, 7.34]
5.3 Self‐management education	3	619	Risk Ratio (M‐H, Random, 95% CI)	1.33 [0.81, 2.19]
6 Fatigue Show forest plot	11	910	Std. Mean Difference (IV, Random, 95% CI)	‐0.25 [‐0.49, ‐0.02]

6.1 Traditional cognitive‐behavioural therapy	9	667	Std. Mean Difference (IV, Random, 95% CI)	‐0.38 [‐0.65, ‐0.10]
6.2 Operant therapy	1	63	Std. Mean Difference (IV, Random, 95% CI)	0.09 [‐0.44, 0.62]
6.3 Self‐management education	2	180	Std. Mean Difference (IV, Random, 95% CI)	0.04 [‐0.33, 0.40]
7 Sleep problems Show forest plot	8	422	Std. Mean Difference (IV, Random, 95% CI)	‐0.40 [‐0.85, 0.05]

7.1 Traditional cognitive‐behavioural therapy	6	244	Std. Mean Difference (IV, Random, 95% CI)	‐0.50 [‐1.11, 0.11]
7.2 Operant therapy	1	60	Std. Mean Difference (IV, Random, 95% CI)	‐0.37 [‐0.91, 0.17]
7.3 Self‐management education	1	118	Std. Mean Difference (IV, Random, 95% CI)	0.09 [‐0.27, 0.45]
8 Health‐related quality of life Show forest plot	13	1238	Std. Mean Difference (IV, Random, 95% CI)	‐0.23 [‐0.38, ‐0.08]

8.1 Traditional cognitive‐behavioural therapy	11	778	Std. Mean Difference (IV, Random, 95% CI)	‐0.34 [‐0.49, ‐0.18]
8.2 Operant therapy	1	63	Std. Mean Difference (IV, Random, 95% CI)	0.19 [‐0.34, 0.72]
8.3 Self‐management education	2	397	Std. Mean Difference (IV, Random, 95% CI)	‐0.01 [‐0.36, 0.33]

Comparison 1. Cognitive behavioural therapies versus controls at end of treatment

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Comparison 2. Cognitive behavioural therapies versus controls at long‐term follow‐up

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain Show forest plot	14	893	Std. Mean Difference (IV, Random, 95% CI)	‐0.40 [‐0.62, ‐0.17]

1.1 Traditional cognitive‐behavioural therapy	13	770	Std. Mean Difference (IV, Random, 95% CI)	‐0.28 [‐0.43, ‐0.14]
1.2 Operant therapy	2	123	Std. Mean Difference (IV, Random, 95% CI)	‐1.27 [‐2.30, ‐0.24]
1.3 Self‐management education	0	0	Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2 Negative mood Show forest plot	12	792	Std. Mean Difference (IV, Random, 95% CI)	‐0.43 [‐0.75, ‐0.11]

2.1 Traditional cognitive‐behavioural therapy	11	669	Std. Mean Difference (IV, Random, 95% CI)	‐0.28 [‐0.58, 0.02]
2.2 Operant therapy	2	123	Std. Mean Difference (IV, Random, 95% CI)	‐1.28 [‐1.97, ‐0.59]
2.3 Self‐management education	0	0	Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
3 Disability Show forest plot	10	735	Std. Mean Difference (IV, Random, 95% CI)	‐0.52 [‐0.86, ‐0.18]

3.1 Traditional cognitive‐behavioural therapy	9	612	Std. Mean Difference (IV, Random, 95% CI)	‐0.32 [‐0.55, ‐0.09]
3.2 Operant therapy	2	123	Std. Mean Difference (IV, Random, 95% CI)	‐1.68 [‐2.40, ‐0.96]
3.3 Self‐management education	0	0	Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
4 Self‐efficacy pain Show forest plot	9	617	Std. Mean Difference (IV, Random, 95% CI)	‐0.75 [‐1.27, ‐0.24]

4.1 Traditional cognitive‐behavioural therapy	8	494	Std. Mean Difference (IV, Random, 95% CI)	‐0.52 [‐1.04, ‐0.00]
4.2 Operant therapy	2	123	Std. Mean Difference (IV, Random, 95% CI)	‐1.69 [‐2.76, ‐0.62]
4.3 Self‐management education	0	0	Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
5 Fatigue Show forest plot	6	429	Std. Mean Difference (IV, Random, 95% CI)	‐0.46 [‐0.77, ‐0.15]

5.1 Traditional cognitive‐behavioural therapy	6	366	Std. Mean Difference (IV, Random, 95% CI)	‐0.38 [‐0.69, ‐0.07]
5.2 Operant therapy	1	63	Std. Mean Difference (IV, Random, 95% CI)	‐1.02 [‐1.59, ‐0.46]
5.3 Self‐management education	0	0	Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
6 Sleep problems Show forest plot	7	378	Std. Mean Difference (IV, Random, 95% CI)	‐0.64 [‐1.31, 0.03]

6.1 Traditional cognitive‐behavioural therapy	6	318	Std. Mean Difference (IV, Random, 95% CI)	‐0.46 [‐1.11, 0.19]
6.2 Operant therapy	1	60	Std. Mean Difference (IV, Random, 95% CI)	‐1.68 [‐2.30, ‐1.06]
6.3 Self‐management education	0	0	Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
7 Health‐related quality of life Show forest plot	6	425	Std. Mean Difference (IV, Random, 95% CI)	‐0.19 [‐0.58, 0.21]

7.1 Traditional cognitive‐behavioural therapy	6	362	Std. Mean Difference (IV, Random, 95% CI)	‐0.28 [‐0.68, 0.11]
7.2 Operant therapy	1	63	Std. Mean Difference (IV, Random, 95% CI)	0.39 [‐0.15, 0.92]
7.3 Self‐management education	0	0	Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]

Comparison 2. Cognitive behavioural therapies versus controls at long‐term follow‐up

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