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

Open access, https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007407.pub4/full


Managing chronic pain in adults: the latest evidence on psychological therapies

https://www.evidentlycochrane.net/chronic-pain-psychological-therapies/


PwME certainly suffer #CochranePain...

Code:

https://twitter.com/CochraneLibrary/status/1313808055134564360

https://twitter.com/user/status/1313808055134564360

 

I think CBT for pain is exactly that: thinking positive and mind over matter. When I read a description of CBT for pain, like for example here https://www.webmd.com/pain-management/features/cognitive-behavioral#1 what is described is positive thinking (reaching toxic positivity levels at some points) and some mind over matter claims (change your disease with your mind).

 

What I wonder is whether reviews ever take note of strong evidence for NO EFFECT. We always hear of weak or moderate evidence for an effect but PACE provides strong evidence for NO EFFECT at least for some outcomes and at least moderate evidence for NO EFFECT as a whole.

 

Definitely.

'No difference/no effect' was claimed in the abstracts of 36 (7.8%) of 460 Cochrane reviews and in the abstracts of 13 (6.0%) of 218 other systematic reviews.​

However

Incorrect claims of no difference/no effect of treatments were substantially less common in Cochrane reviews published in in 2017 than they were in abstracts of reviews published in 2001/2002. We hope that this reflects greater efforts to reduce biases and inconsistent judgements in the later survey as well as more careful wording of review abstracts. There are numerous other ways of wording treatment claims incorrectly. These must be addressed because they can have adverse effects on healthcare and health research.​

https://ebm.bmj.com/content/early/2020/03/10/bmjebm-2019-111257

 

https://twitter.com/user/status/1311762673810448408


https://twitter.com/user/status/1311763350070734849

Code:

https://twitter.com/Healthy_Control/status/1311762673810448408

See also forum thread: https://www.s4me.info/threads/new-d...ture-over-medication.16182/page-6#post-288998

And: https://www.s4me.info/threads/new-d...ture-over-medication.16182/page-8#post-292505

Discussion on the 'Risk of Bias Tool' https://www.s4me.info/threads/rob-2...in-randomised-trials-2019-sterne-et-al.11025/

 

That is something a bit different. Sure, there will be reviews that conclude no effect. But what if a range of studies provide some weak evidence of effect, some moderate evidence of effect and some strong evidence of no effect. What I have not seen is evidence for no effect being graded in the way that evidence for effect is. Maybe it's there but it doesn't come up in the discussions here as far as I know.

How do we know if claims are incorrect or how many there are if it seems that recent reviews make such a hash of grading evidence. I wouldn't take the GRADE system as any indication of quality of evidence of effect. It seems to me a completely bogus system that deliberately replaces direct rational argument with pseudo arithmetical tricks.

 

How many Cochrane reviews of CBT for any condition find no effect?

 

I assume someone has pointed this out before i.e. the driver, promoting CBT, is that it is a relativelt cheap intervention and Governments like that!

The alternatives cost more and Governments try to reduce taxes i.e. to get elected --- forget efficacy this is about getting elected!

 

They seem to be moving slowly towards that. From the discussion section in the paper:

It remains important to recognise the uncertainties inherent in statistical estimates of treatment differences, and the need to distinguish between ‘no evidence of a difference/effect’ and ‘evidence of no difference/effect’. In practical terms, this implies using CIs to assess how confidently important treatment differences can be ruled out and using wording that reflects the probabilistic approach entailed.​

Even more concerning than "no effect" is the evaluation of "worse than" in reviews, when primary studies have been fixed to make recording harms harder. PACE widened the goal for success midtrial, but narrowed it for adverse events at the other end of the pitch.

 

And the reality
https://twitter.com/user/status/1344016707069878274

 

The 'patient centred approach' no less.

 

When doctors talk about chronic pain are they assuming that the pain has no cause that can be found?

What would happen if someone had some severe genetic condition that distorted their spine and caused them lots of pain, for example? Would they be told that CBT is all they need or will they actually be given real help?

These are hypothetical questions, by the way...

 

My spinal abnormality is congenital rather than genetic, and the GP and pain consultant do take it seriously. After a significant worsening about 4 or 5 years ago, the consultant prescribed low dose opiate patches which have been pretty life-changing.

I did a pain management course 20+ yrs ago, run by a couple of physios and it was helpful at the time, suggesting relevant exercises as well as ways of managing the pain. No CBT suggesting that all you had to do was think differently and all your pain and resulting disabiltieswould vanish.
As ever good to talk to others with similar pain levels.

 

My problems with pain are caused by delayed and botched gynaecological surgery for a life-threatening condition in my teens. The damage caused by the delay and the poor surgery has been mentioned in some of my later medical records but the original cause has been obfuscated and I am always treated as if I'm lying no matter what condition or problem I'm complaining about. But of course, the damage I have is invisible. I now take copies of the relevant records with me when I see doctors of any kind. Because my records are so poorly written, when I've had gynae problems that became obvious to a surgeon when I was opened up they have insinuated that I must be in the condition I'm in because of immoral behaviour, so I must have only myself to blame.

I asked my question because I was just wondering if anyone with a visible problem was told they needed CBT, or were actually taken seriously and treated for their pain. I knew my mention of "genetic" didn't sound right but I couldn't think of the word "congenital".

At least people with visible problems do get treated with some compassion. The problem for me is the invisibility of my condition.

I'm glad you are getting treatment for your pain.

 

By the very definition of how those services operate, this case was a resounding success: the patient did not come back. Perverse incentives lead to perverse outcomes.

I don't know how the people who run those services do it, though. I could never debase myself this much, because I have a minimum of integrity and self-respect. Zero ethical difference between this and scamming retirees out of their life savings.

 

So sorry for the way you are treated @Arnie Pye.

I do think the fact that it is so visible has helped me. Even before it was so obvious from the outside, the X-rays showed it was a mess, so doctors have generally been understanding. Even those lacking any empathy, have acknowledged that it looked horrendous on X-rays, would just get worse with age and was I sure i hadn't been in a car crash!