The effectiveness of cognitive behavioural therapy in chronic neck pain: A systematic review with meta-analysis

Chronic neck pain (CNP) is one of the most common musculoskeletal disorders as it is the second leading cause of musculoskeletal pain and the 21st leading cause of disability worldwide (Safiri et al., 2020). According to epidemiological studies CNP occurs mainly in women with a female/male ration 3:1, mainly in the fifth decade of their life (Hoy et al., 2014). Neck pain can affect physical, social and psychological condition of a person, neck pain has as a result an increase in economic and social cost (Geneber et al., 2017). The official definition of CNP is “a (Raja et al., 2020). 

Cognitive behavioural therapy (CBT) encloses a wide range of cognitive and behavioural interventions which aim to modify and reduce the impact of physical and psychological disability, as well as the lived experience of people with chronic pain (Hofmann et al 2012; Kazantzis et al., 2018). CBT focuses on “cognitive change” and more specially to make the patient understand about their musculoskeletal pain condition and aim to: a) promote the understanding of pain and the role that patient cognition and behave play in controlling their symptoms, b) explain and teach behavioural coping skills, c) apply these coping skills in daily life, d) graded exposure to their fearful conditions and symptoms (Kern et al. 2011). To summarize, CBT aims to progressively reactive the individual and improve compliance and participation in rehabilitation (Akerblom et al., 2015; Javdeneh et al., 2019). 

Regarding our study, we to evaluated the effectiveness of CBT in people with CNP primary outcomes were pain, disability and kinesiophobia while secondary were anxiety, stress, depression, quality of life and catastrophizing. The most important parts of our study are the subgroup categorization that we make to find out what is the effectiveness of CBT in the two categories of CNP, whiplash associated disorders (WAD) and non-traumatic associated pain. Additionally, two strong aspects of our study were a) minimal clinically important difference of the results and b) the certainty of evidence method. Nineteen studies met the eligibility criteria with a total of 1640 participants of which 1035 were women around 43 years old (28-67 years). Eleven studies evaluated the effect of CBT in CNP, and eight studies in CNP related to WAD. In 84% of the included studies CBT delivered by physiotherapist alone. The mean duration of CBT was 8.2 weeks and the mean number of sessions was 13.5. 

In mixed population results clinically significant difference in favour of CBT were founded in a) pain short term (compared with no intervention), b) kinesiophobia, depression and anxiety at very short term (combined with multimodal intervention compared to other intervention) and c) in kinesiophobia at short term (combined with multimodal intervention compared to other intervention), certainty of evidence were very low to low. Additionally, we found some interesting statistically significant difference in favour of CBT and it was a long-term reduction in disability and a midterm reduction in kinesiophobia, anxiety and catastrophizing certainty of evidence were very low to low. These results didn’t match with the subgroup analysis including only patients with chronic WAD, we found a statistically significant difference only in long term results at disability and clinically significant difference in depression, anxiety and stress.  However, statistically significant difference at disability long term in WAD patients became clinically significant in patients with CNP and the certainty of evidence moves from very low to low. It is important to highlight that the most valuable results were when CBT was part of a multimodal intervention and especially when it combined with exercise intervention. CBT from a clinical perspective, where does this latest review leave chronic pain researchers and clinicians who are open to using CBT in people with CNP and WAD.

Read the full paper here: Ploutarchou, G., Savva, C., Karagiannis, C., Pavlou, K., O’Sullivan, K., & Korakakis, V. (2023). The effectiveness of cognitive behavioural therapy in chronic neck pain: A systematic review with meta-analysis. Cognitive Behaviour Therapy52(5), 523-563.

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