Cochrane Review: Psychological therapies for the management of chronic pain (excluding headache) in adults, 2020, C De C Williams et al

Moderation note: A number of posts have been moved from
New draft NICE guidelines for chronic pain emphasises exercise, CBT and acupuncture over medication
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Things are horribly broken here. Here is a discussion of Cochrane's evaluation of the evidence: https://www.evidentlycochrane.net/chronic-pain-psychological-therapies/.

Here's my takeaway:

• "But psychological methods of treating chronic pain or, rather, treating the problems associated with chronic pain have been used for over 50 years" (quote from the article)
  
• The evidence is very poor, largely biased and suffers from many very poorly-executed studies
• It could possibly offer small benefits for some, maybe, in the future if someone figures this out

So it's been used in practice for 50 years. And there is no evidence. And it's still recommended because maybe someone could possibly work out how to make something that's been used for over 50 years seem to work. It even plainly states the obvious, which is one of the main points of criticism by the patient community, that it relies on completely unrealistic assumptions about reality:

The evidence was very poor to start using it. The evidence has been very poor throughout decades of use in practice. The evidence is still so very poor that no one can actually tell if it's of any use but let's keep doing it anyway because, let's be honest here, too much has been committed to it and admitting failure would have to acknowledge that something largely useless has been used for decades, prohibiting serious research because somehow the allure that something made out of magical psychology could possibly work in the future is more important than doing actual work.

I have no idea what purpose Cochrane serves at all if this is the stuff they put out. And it seems that NICE basically just takes whatever Cochrane says, mixes it up a bit and runs with the same aspirational delusions that it's OK to do something useless since it's been done this way for so long.

This is a sign of a system broken beyond repair. The introduction of psychology to medicine may have been one of the most misguided efforts in the history of science. People want it to work and that's good enough to actually use it in practice for decades despite being unable to show any reliable evidence that it should be used at all.

What an incredible failure. "Evidence you can trust". I do not trust Cochrane one bit and they seem to work overtime making the point that they deserve no credibility whatsoever.

 

@Hilda Bastian
Appreciate your thoughts on this

 

I hope you don't think this is a cop-out, but although I looked, I'm not going to comment (except to say that I agree that for something this important, it's terrible that there still aren't high quality studies). That's because it would take me a while, given how many studies are in that review. Just now, I don't want to divert away from the things I'm working on because I'm already not making progress quickly enough.

 

Dear @Hilda Bastian ,

I do not think you need to look at any studies to judge this piece of Cochrane output. It displays a complete lack of understanding of the problem. The writer clearly thinks that the fact that psychological therapies have been used for years gives them legitimacy. They also think that restricting studies to those that make use of 'trained' people who 'understand' the basis' (when everything suggests that nobody understands) is legitimate. This is pure phoney science. Transparently so. It could have been written by a homeopath. Science does not allow you to limit yourself to people with 'the right sort of theories'.

All I think people are asking here is for you to agree that transparently phoney talk like this is what it is.
There is then grounds for mutual respect. The members here understand what proper scientific method involves. They see that this piece lies outside that - without looking at any studies. Can you not agree?

 

I'm not going to express an opinion on a review I haven't read, or on a categorization of a review I haven't read.

 

There is the usual reliance on subjective outcomes in unblindable trials. Because psychological therapies are delivered and usually also evaluated by psychologists, there seems to be an acceptance that outcomes can all be subjectively measured using self-report questionnaires.

I didn't have to read the whole review to find that this was the approach of these reviewers too, just the outcomes section. I also read in the Implications for research section that "... there remains a plethora of heterogeneous measurement tools for subjective experiences, with varied content within domains, and few behavioural measures supplementing self-report" And then later in that section "Assessment of treatment benefits in terms of reduced costs, in health and social care, and incurred by patients, is generally lacking".

Presumably, the results of the mostly low quality trials included in the review would not be supported by objective measures. If they weren't measured, we'll never know. What about measuring outcomes such as return to work, education, caring, recreational and social activities, which may have been previously impossible because of chronic pain?

As with the Cochrane CFS reviews, this "general lack" of objective outcomes in unblindable trials is not flagged up by Cochrane as the huge problem it really is.

 

HAve now posted a Comment on the blog https://www.evidentlycochrane.net/chronic-pain-psychological-therapies/

 

I wonder which research group this was?

Additionally, why are Cochrane more concerned with 'research waste' than with the effects of poor and outright misleading research causing harm to patients, for example when medical practitioners take the abstracts and summaries at face value?

 

Thank you

 

I had a look at the review, and this surprise finding about four of the CBT trials which were excluded is not reported - at least not that I could find. Why do they report it in the blog, but not in the review? To save the blushes of the author group maybe? How kind. Why on earth would they do that? They should write to the (presumably public) funders of this research group and tell them that they didn't reply to Cochrane's enquiries about their dodgy looking results. Do they think that a cryptic reference about being excluded from a Cochrane review is punishment enough? They should be named and shamed surely? I will have another look at the review just in case they have mentioned it after all...and if I can't find it, I will write to Amanda Williams and ask.

 

Actually, it was easy to find this information in the review by searching on the word "excluded". I will have a closer look at the three Monticone studies when I get the chance.

 

I commented on the blog, Prof Williams responded, and I responded to that. https://www.evidentlycochrane.net/chronic-pain-psychological-therapies/

It seems that any attempt to point out the obvious problem with relying on subjective outcomes in unblindable trials is deliberately misinterpreted as me advocating for ignoring the "patient voice".

Also, Cochrane seems to confuse patient-reported outcomes with patient-important outcomes - ie. patient-reported outcomes are always good and reflect reality better than objective measures. Therefore it's a great idea to prioritise them even if a treatment is designed to affect the way you feel about and respond to physical symptoms which stop you living your life fully, such as chronic pain and fatigue. Is it so difficult to grasp that trials need to measure as objectively as possible whether people can live their lives more fully as a result of the treatment, not just report they have less pain or fatigue in a questionnaire?

Is this not obvious because it's wrong?? I am beginning to doubt myself to be honest.

Someone whose opinion I trust(ed!) said that they thought Prof Williams response was "largely right". But I am not sure this person understood what I was saying. I think my 2nd comment helped. Why is it so difficult to get the point across?

 

It is difficult to get a man to understand something, when his salary depends on his not understanding it.

That may be the reason. I suspect a lot of people also don't understand how patients are susceptible to wishful thinking and pressure by healthcare providers and therapists. It only takes a few minutes to manipulate a patient into rating their illness as less severe than they did before.

This is really bad news for people invested into things like CBT for unexplained bodily symptoms. They have to accept that they might not be successfully treating a mysterious psychosomatic disease but just manipulating patients into pretending they're better.

 

All I've ever seen from the bPs cabal is questionnaire's designed to elicit the information they want for their own benefit. Your trusted person's opinion has failed you.

The people who make these questionnaire's IMO have always considered their conceptual / theoretical models as pre-eminent and above any patient concerns. This is made very clear by the fact that there is no room in that model for any negative feed-back about the Q's themselves or any concern to follow-up people who drop out or any true long-term follow-up.

The bPs and those who have listened to them all still believe that ME is much more trivial than it truly is. This is why so many coming down with long-covid think it is not all that similar to ME.

 

It is difficult to get the point across because a surprisingly high proportion of people in academia do not understand what makes one theory more valid than another. Most academics are satisfied if everyone agrees an idea is good and make no demands on it actually standing up to rigorous test.

Professor Williams makes it completely transparent that she does not understand how you judge theories from the way she presents things. I have never found it possible to get people like this to understand. In essence a branch of science is a religion for such people. Trying to argue with religious belief is not very productive.

 

They genuinely seem to consider cherry-picked and selectively-reported patient-reported outcomes as the same as patient engagement. I have seen nothing showing otherwise, their idea of patient involvement requires it to be tokenism, ultimately only serves as a process to launder their own opinion. Basically: they do not want patient involvement. At all. None. Only the appearance of, using only the appearance of it as equivalent to the real thing. All the apparent benefits, none of the obligations.

They explicitly reject any and all patient-reported complaints, making that point as clear as possible. This method allows to easily produce any evidence for any opinion they hold and they simply don't want to let go of it. EBM has become an easy way to work as little as possible, produce any kind of evidence to fit their opinion with barely more effort than copy-pasting and there is no oversight or accountability to it. It's self-serving, they couldn't care less about the patient voice, they constantly talk over us and never listen to a damn thing.

They insult us by saying such nonsense. Of course that's one patient voice they'll never hear, because they make it so on purpose. They understand all of this because they would make the exact points if it were about pseudoscience they don't like, never seeing any hypocrisy.

Maybe they're partially right, but on the point of listening to patient voices, they are 100% wrong.

 

In a classic case of "our study doesn't actually support my claim", Beale 2011 found that clinician-researchers outcome choice differed from that of patients...

https://pubmed.ncbi.nlm.nih.gov/21741768/

As for Turk 2008, table 5 shows that pain was not one of the "important" items and emotional well being (the only measure similar to "distress" was just one of 19 items.

 

Watching Derren Brown's 'Miracle' really brought this home for me.

 

From the above: " Only 2 outcomes, physical activities and emotional well-being, were assigned comparable importance by survey respondents and clinician-researchers. Five of the 19 outcomes important to survey respondents were not measured at all, and 8 rarely."

SO, how can they keep ignoring Physical Outcomes?

 

Oh wow! Thank you for this. I think a comment on the review might be in order ;-)