What Are the Mechanisms of Action of Cognitive-Behavioral, Mind-Body, and Exercise-based Interventions for Pain and Disability in People With Chronic Primary Musculoskeletal Pain? A Systematic Review of Mediation Studies From Randomized Controlled Trials

Rafael K Alaiti*, Julia Castro, Hopin Lee, J P Caneiro, Johan W.S. Vlaeyen, Steven J Kamper, Marcelo F da Costa

*Corresponding author for this work

Research output: Contribution to journal(Systematic) Review article peer-review

4 Citations (Web of Science)


OBJECTIVES: This systematic review examined studies that used mediation analysis to investigate the mechanisms of action of cognitive-behavioral, mind-body, and exercise-based interventions for pain and disability in people with chronic primary musculoskeletal pain.

MATERIALS AND METHODS: We searched 5 electronic databases for articles that conducted mediation analyses of randomized controlled trials to either test or estimate indirect effects.

RESULTS: We found 17 studies (n=4423), including 90 mediation models examining the role of 22 putative mediators on pain or disability, of which 4 had partially mediated treatment effect; 8 had mixed results, and 10 did not mediate treatment effect. The conditions studied were chronic whiplash-associated pain, chronic low back pain, chronic knee pain, and mixed group of chronic primary musculoskeletal pain.

DISCUSSION: We observed that several of the studies included in our systematic review identified similar mechanisms of action, even between different interventions and conditions. However, methodological limitations were common. In conclusion, there are still substantial gaps with respect to understanding how cognitive-behavioral, mind-body, and exercise-based interventions work to reduce pain and disability in people with chronic primary musculoskeletal pain.

Original languageEnglish
Pages (from-to)502-509
Number of pages8
JournalClinical Journal of Pain
Issue number7
Publication statusPublished - 1 Jul 2022


  • Chronic Pain/therapy
  • Cognition
  • Exercise Therapy/methods
  • Humans
  • Musculoskeletal Pain/therapy
  • RISK
  • Randomized Controlled Trials as Topic
  • WORK
  • chronic pain
  • cognitive-behavioral
  • exercise
  • mechanisms of action
  • mediation

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