Psychological treatments for the management of postsurgical pain: a systematic review of randomized controlled trials

Figures & data

Table 1 Risk-of-bias assessment

Study	Selection bias: random-sequence generation	Selection bias: allocation concealment	Performance and detection bias: blinding	Attrition bias: incomplete data	Reporting bias: selective reporting
Abbott et al^Citation22	Low	Low	High	Low	Low
Archer et al^Citation24	Low	Low	Low	Low	Low
Doering et al^Citation25	Low	Unclear	Low	High	Low
Monticone et al^Citation23	Low	Low	Low	Low	Low
Rolving et al^Citation27	Low	Low	High	Low	Low
Rolving et al^Citation26	Low	Low	High	Low	Low

Note: Used Cochrane risk-of-bias assessment tool.

Table 2 Characteristics of trials included in systematic review

Paper	Study	Country	Surgical population	Participants (completed), n	Age (years)	Male	Intervention	Comparison	Outcomes
T1	Abbott et al^Citation22	Sweden	Adult (age 18–65 years) lumbar fusion patients	107 (3 months, n=101; 6 months, n=101; 1 year, n=99, 2–3 years, n=87)	Mean PMT 50.3 (SD 10) Mean UC 51 (SD 10.9)	38.3%	PMT Description: UC supplemented with CBT-informed physiotherapy intervention (ie, PMT) including behavioral self-management, cognitive restructuring, relaxation training, and motivational interviewing Timing: 90-minute PMT sessions delivered by physiotherapists at 3, 6, and 9 weeks PO	UC Description: physiotherapist-instructed inpatient exercise-therapy program and 20-minute exercise instruction at discharge Timing: daily exercises with physiotherapist PO, days 1–5 20-minute physiotherapist instruction of 12-week exercise plan at discharge	Primary: disability Secondary: back-pain intensity over past week Outcomes assessed as change in scores from baseline
T2	Archer et al^Citation24	USA	Adult (age ≥21 years) laminectomy patients	86 (80)	Mean 57.6 (SD 12.2)	44.2%	CBPT Description: six weekly 30-minute telephone-based CBPT sessions Consisted of behavioral self-management, problem-solving, cognitive restructuring, and relaxation training + education program (see comparison) Timing: started 6 weeks PO	Education Description: education program consisting of physical therapy, stress management, sleep hygiene, energy management, communication with health providers, injury prevention Timing: started 6 weeks PO	Primary: pain intensity and interference (BPI), disability (ODI) Secondary: mobility (five-chair-stand test, timed up- and-go test, 10 m walk test Outcomes assessed as change in scores from baseline
T3	Doering et al^Citation25	USA	Adult cardiac surgery patients with major or minor depression at discharge (on SCID-I)	53 (limited to completers) CBT, n=33; UC, n=20	Mean 67.8 (SD 9.2)	83.1%	CBT Description: eight weekly 1-hour manualized, nurse-delivered CBT sessions Timing: median time from surgery (in ITT sample) to CBT or UC 45.5 days (IQR 26.25 days)	UC Description: (included patients from secondary analysis comparing UC followed by CBT to early-CBT group) Timing: median time from surgery (in ITT sample) to CBT or UC 45.5 days (IQR 26.25 days)	Secondary (primary reported in 2013 paper): pain severity and interference (BPI-SF)
T4	Monticone et al^Citation23	Italy	Adult (age ≥18 years) patients recovering from lumbar spinal fusion	130 (117)	Mean CBT/exercise 58.9 (SD 11.8) Mean exercise 55.9 (SD 14.2)	39.2%	CBT + exercise Description: two 1-hour psychologist-delivered individual CBT sessions per week over 4 weeks (total of eight CBT sessions) targeting catastrophizing and kinesophobia, in addition to exercise program Timing: two 1-hour sessions per week for 4 weeks Start date of intervention (ie, duration since surgery) not listed	Exercise Description: five 90-minute physiotherapist-led exercise sessions per week for 4 weeks (total of 20 exercise sessions)	Primary: disability (ODI) Secondary: pain severity (0–10 NRS), SF-36-BP Outcomes assessed as change in scores from baseline
T5	Rolving et al^Citation27	Denmark	Adult (age 18–64 years) lumbar spinal fusion patients	96 (90) CBT, n=59 UC, n=31	Range 18–64 Mean CBT 51.4 (SD 9.2) Mean UC 47.7 (SD 8.9)	43.3%	CBT Description: four 3-hour group-CBT sessions in addition to UC Timing: CBT and information delivered preoperatively	UC Description: information on operation, anesthesia, medication, PO rehab, physical restrictions after surgery Timing: information delivered preoperatively	Secondary (primary reported in 2015 paper): median severity of back pain during first PO week (measured daily on 0–10 NRS); consumption of rescue analgesics during first PO week; PO mobility (first 3 days measured on CAS)
T6	Rolving et al^Citation26	Denmark	Adult (age 18–64 years) lumbar spinal fusion patients	96 (90 baseline, 87 at 3- and 6-month FU, 83 at 1-year FU)	Mean CBT 51.4 (SD 9.2) Mean UC 47.7 (SD 8.9)	43.3%	CBT Description: six 3-hour group-CBT sessions in addition to UC protocol Timing: four sessions preoperatively, two PO	UC Description: information and rehab Timing: information delivered preoperatively, rehabilitation programming delivered 12 weeks PO and included 8 weeks of supervised exercise	Primary: disability (ODI) Secondary: low-back PRS; all outcomes measured at baseline, 3 months, 6 months, and 1 year PO Outcomes assessed as change in scores from baseline

Abbreviations: BPI, Brief Pain Inventory; BPI-SF, Brief Pain Inventory-Short Form; CAS, cumulated ambulation score; CBPT, cognitive behavior-based physical therapy; CBT, cognitive behavioral therapy; ITT, intent to treat; NRS, numeric rating scale; ODI, Oswestry Disability Index; PMT, psychomotor therapy; PO, postoperative(ly); PRS, Pain Rating Scale; SCID-I, Structured Clinical Interview for DSM-IV – Axis I; SF-36-BP, Short Form 36 – body pain; UC, usual care.

Table 3 Details of analyses, confounders, and results of included trials

Paper	Study	ITT vs completed	Statistical analyses	Adjusted covariates	Assessment time points	Main results (95% CI)
T1	Abbott et al^Citation22	ITT	ANCOVA for each assessment time point	Baseline score, age, sex	Preoperative 3 months, 6 months, 1 year, and 2–3 years PO	Between-group differences in score reduction + effect sizes for psychomotor therapy from baseline
			RM ANCOVA for entire follow-up			ANCOVA Disability (ODI): 3 months, −9.7 (−15.8 to −3.6, P=0.002), d=1.2; 6 months, −10.7 (−16.8 to −4.6, P=0.001), d=1.32; 1 year, −11.1 (−17.3 to −4.9, P=0.001), d=1.39; 2−3 years, −9.8 (−17.4 to −2.3, P=0.011), d=1.43 Back pain (VAS): 3 months, −11.7 (−19 to −4.3, P=0.002), d=1.45; 6 months, −9.9 (−17.6 to −2.2, P=0.012), d=−1.7; 1 year, −5.4 (−14.8 to 3.9, P=0.25), d=1.67; 2−3 years, −9.8 (20.7 to 1.2, P=0.08), d=1.34
						RM ANCOVA Disability (ODI), P=0.003 Back pain (VAS), P=0.006
T2	Archer et al^Citation24	ITT	RM ANOVA Multivariable linear regression	Pretreatment outcome score, age, education, comorbidity presence, physical therapy visits since baseline	Preoperative (predictor), PO, 3 months (outcome)	RM ANOVA Between-group differences in score reduction + effect sizes for CBPT group from baseline BPI back pain: −0.88 (−1.5 to −0.25, P=0.007), d=0.62 BPI leg pain: −1.2 (−2.1 to 0.34, P=0.007), d=0.62 BPI interference: −1.5 (−2.4 to −0.57, P=0.002), d=0.72 ODI: −9.8 (−15.3 to −4.4, P<0.001), d=0.79 Five-chair-stand test: −7 (−13.7 to −0.37, P=0.04), d=0.49 TUG test: −1.6 (−3.3 to 0.19, P=0.08); d=0.41 10 m walk test: 0.1 (−0.14 to 0.21, P=0.08), d=0.41−0.49
						Multivariable linear regression Between-group differences in score reduction BPI back pain: −0.85 (−1.4 to −0.25, P=0.006, R^2=0.64) BPI leg pain: −1.1 (−1.9 to −0.2, P=0.009, R^2=0.447) BPI pain interference: −1.3 (−2.1 to −1.4, P=0.005, R^2=0.49) ODI: −9.4 (−14.9 to −4, P=0.001, R^2=0.59) Five-chair-stand test: −4.3 seconds (−7.7 to −0.82, P=0.02, R^2=0.52) TUG test: −1.8 seconds (−3.2 to −0.16, P=0.02, R^2=0.62) 10 m walk test: m/s (0.008 to 0.18, P=0.07, R^2=0.33)
T3	Doering et al^Citation25	Completer	RM ANOVA Forward stepwise multivariable linear regression (outcome change in score)	Age, sex, marital status, minority status, BMI, antidepressant use, history of depression, major depression, BDI, BPI-I, BPI-S, CAS-R, PSQI, anxiety scores, statins, employment, PO complications	Baseline (after surgery and before hospital discharge), 8 weeks (conclusion of therapy)	RM ANOVA Group × follow-up interaction favoring CBT Pain interference: (F1,45=5.4, P=0.02) Pain severity: (F1,46=5.1, P=0.03) Multivariable linear regression Pain Interference: CBT β=−2.7, SE=1.06; t=−2.56, P=0.01 (95% CI −4.84, −0.58), d=0.83‡ Pain severity: trend observed (P<0.1)
T4	Monticone et al^Citation23	ITT	Linear mixed models for repeated measures (group and time as fixed effects, outcomes as dependent measures)	Unadjusted	Pretreatment (baseline), 4 weeks follow-up (PO), and 1 year postdischarge	All group effects and time effects significant at P<0.001 level Group × time effects Effect size corresponds to difference between groups ODI: F=20.37, P<0.001, d=0.8‡ NRS back: F=40.87, P<0.001, d=1.13‡ NRS leg: F=12.32, P<0.001, d=0.62‡ SF-36-BP: F=12.25, P<0.001, d=0.62‡
T5	Rolving et al^Citation27	ITT	Wilcoxon rank-sum test χ^2 test	Unadjusted	PO days 1–7	Median pain rating (0−10 NRS): NS Rescue analgesic use: NS PO mobility on day 3 Walk, P=0.02 Rise and sit from chair, P=0.0017 Get in and out of bed, P=0.0017
T6	Rolving et al^Citation26	ITT	Wilcoxon rank-sum test assessed between-group differences score changes during follow-up	Unadjusted	Baseline (mean 42.5 days preoperative), 3 months, 6 months, and 1 year PO	Disability (ODI): 3 months, P=0.003; 6 months, P=0.056; 1 year, P=0.082 Back pain: all time points, NS Leg pain: all time points, NS

Note:

‡ Effect size calculated by authors of this review.

Abbreviations: BDI, Beck Depression Inventory; BMI, body-mass index; BPI, Brief Pain Inventory; BPI-I, BPI – interference; BPI-S, BPI – severity; CAS-R, Control Attitudes Scale – revised; DOS, date of surgery; CBT, cognitive behavioral therapy; CBPT, cognitive behavior-based physical therapy; ITT, intent to treat; NS, not significant; NRS, numeric rating scale; ODI, Oswestry Disability Index; PO, postoperative(ly); PSQI, Pittsburgh Sleep Quality Index; RM, repeated measures; SF-36-BP, Short Form 36 – body pain; TUG, timed up-and-go; VAS, visual analog scale.

Figure 1 Flow diagram of study selection.

Note: Flowchart showing numbers of studies screened, assessed for eligibility, and included in the present review. Also shown are reasons for exclusions at each stage and numbers of articles excluded.
Abbreviation: RCTs, randomized controlled trials.

Table S1 Mapped search strategy

Construct	MeSH terms	Keywords
Psychological Interventions (ACT, CBT, or mindfulness)	cognitive therapy; meditation; mindfulness; acceptance and commitment therapy	cognitive therap*; acceptance and commitment therap*; mindful*; meditation*; meditative*; ACT; CBT
Pain (acute or chronic)	chronic pain; pain (exp) and chronic diseases (exp); arthralgia (exp); back pain (exp); central nervous system in[injuries]; central nervous system and pain (exp); glossalgia; headache disorders (exp); hyperalgesia (exp); mastodynia; metatarsalgia; palliative care (exp); pelvic pain (exp); complex regional pain syndrome (exp); causalgia; reflex sympathetic dystrophy; diabetic neuropathies; neuralgia (exp); neurons, afferent; nociceptors (exp); back pain; headache;	migraine*; chronic pain*; damage* nerve; deafferentation pain*; nerve injur*; neuro* pain*; multiple scleros* pain; pain* syndrom*; pelvic pain*; allodynia*; arthralgi*; causalgia*; cephalagi*; cephalgi*; chronic noncancer* pain; chronic non-cancer* pain; chronic nonmalignan* pain; chronic non-malignan* pain; colic; coccydyni*; dysaesthesia*; dysesthesia*; dysmenorrhea*; dysmenorrhea*; dysmenorrhoea*; earache; ear-ache; failed back; glossalgi*; hyperalges*; hyperpathia*; mastodyni*; metatarsalgi*; migraine*; neuralgi*; neuroma*; neuropath*; nocicept*; palliat*; paraesthesia*; paresthesia*; phantom limb; polymyalgi*; polyneuropath*; reflex sympathetic dystroph*; sciatic; shingles; sympathetically maintained pain; toothache; tooth-ache
Postsurgical period	Pain, postoperative (exp)	postop*; post-op*; poastamput*; post-amput*; postincision*; post-incision; postprocedur*; post-procedur*; postsurg*; post-surg*; postresect*; post-resect*; postintervention*; post-intervention*; postlapar*; post-lapar*; postmastectom*; post-mastectom*; follow* surg*; follow* intervention*; follow* procedur*; follow* resect*; after incision; after laparo*; after operati*; after procedur*; after resect*; after surger*; after surgical*

Note:

* Wildcard character.

Abbreviations: ACT, acceptance and commitment therapy; CBT, cognitive behavioral therapy; exp, “exploded” search term; MeSH, medical subject headings.

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