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Evidence of benefit for therapeutics

Updated: Feb 22, 2021


We analysed five studies (443 participants). There was no evidence of difference between ACT and active control for pain (SMD ‐0.54, 95% CI ‐1.20 to 0.11, very low‐quality evidence), disability (SMD ‐1.51, 95% CI ‐3.05 to 0.03, very low‐quality evidence) or distress (SMD ‐0.61, 95% CI ‐1.30 to 0.07, very low‐quality evidence) at treatment end. At follow‐up, there was no evidence of effect for pain or distress (both very low‐quality evidence), but two studies showed a large benefit for reducing disability (SMD ‐2.56, 95% CI ‐4.22 to ‐0.89, very low‐quality evidence). Two studies compared ACT to TAU at treatment end. Results should be interpreted with caution. We found large benefits of ACT for pain (SMD ‐0.83, 95% CI ‐1.57 to ‐0.09, very low‐quality evidence), but none for disability (SMD ‐1.39, 95% CI ‐3.20 to 0.41, very low‐quality evidence), or distress (SMD ‐1.16, 95% CI ‐2.51 to 0.20, very low‐quality evidence). Lack of data precluded analysis at follow‐up.

The largest evidence base was for CBT (59 studies). CBT versus active control showed very small benefit at treatment end for pain (standardised mean difference (SMD) ‐0.09, 95% confidence interval (CI) ‐0.17 to ‐0.01; 3235 participants; 23 studies; moderate‐quality evidence), disability (SMD ‐0.12, 95% CI ‐0.20 to ‐0.04; 2543 participants; 19 studies; moderate‐quality evidence), and distress (SMD ‐0.09, 95% CI ‐0.18 to ‐0.00; 3297 participants; 24 studies; moderate‐quality evidence). We found small benefits for CBT over TAU at treatment end for pain (SMD ‐0.22, 95% CI ‐0.33 to ‐0.10; 2572 participants; 29 studies; moderate‐quality evidence), disability (SMD ‐0.32, 95% CI ‐0.45 to ‐0.19; 2524 participants; 28 studies; low‐quality evidence), and distress (SMD ‐0.34, 95% CI ‐0.44 to ‐0.24; 2559 participants; 27 studies; moderate‐quality evidence). Effects were largely maintained at follow‐up for CBT versus TAU, but not for CBT versus active control.

Evidence quality for CBT outcomes ranged from moderate to low. We rated evidence for AEs as very low quality for both comparisons.


For people with chronic pain, this overview of Cochrane Reviews found it was not possible to confidently state whether TENS is effective in relieving pain compared to sham TENS, usual care/no treatment or when TENS is combined with another active treatment versus the active treatment alone. We were unable to find any reliable evidence that the effectiveness of TENS varies when using different delivery modes (e.g. different frequency, intensity or electrode placement).

Physical activity/physio therapy

Authors' conclusions:

The quality of the evidence examining physical activity and exercise for chronic pain is low. This is largely due to small sample sizes and potentially underpowered studies. A number of studies had adequately long interventions, but planned follow-up was limited to less than one year in all but six reviews. There were some favourable effects in reduction in pain severity and improved physical function, though these were mostly of small-to-moderate effect, and were not consistent across the reviews. There were variable effects for psychological function and quality of life. The available evidence suggests physical activity and exercise is an intervention with few adverse events that may improve pain severity and physical function, and consequent quality of life. However, further research is required and should focus on increasing participant numbers, including participants with a broader spectrum of pain severity, and lengthening both the intervention itself, and the follow-up period.


The findings suggest very low to moderate certainty of evidence that exercise therapy may result in little or no important difference in pain or disability, compared with other interventions, in adult patients with acute low back pain


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