Background: Greater unhelpful thinking is associated with greater musculoskeletal discomfort and incapability. Cognitive-behavioral therapy (CBT) fosters healthy thinking to help alleviate symptoms.

Questions: In a meta-analysis of randomized control trials (RCT) of CBT for unhelpful thinking among people with musculoskeletal symptoms, we asked: 1) Does CBT reduce unhelpful thinking and feelings of distress, and improve capability, in individuals with musculoskeletal symptoms? 2) Are outcomes affected by CBT delivery methods?

Methods: Following QUOROM guidelines, we searched databases using keywords of pain catastrophizing, kinesiophobia, cognitive-behavioral therapy, musculoskeletal and variations. Inclusion criteria were RCT's testing CBT among people with musculoskeletal symptoms. Study quality was assessed with Cochrane Review of Bias 2. Meta-analysis of means and standard deviations was performed.

Results: CBT led to modest reductions in catastrophic thinking (-0.44 CI: -0.76 to -0.12; P = .01, kinesiophobia (-0.60 CI: -1.07 to -0.14; P = .01) and anxiety symptoms (-0.23 CI: -0.36 to -0.09; P < .01) over six months compared to usual care. There were no improvements in levels capability (-0.28 CI: -0.56 to 0.01; P = .05). CBT led by mental health professionals reduced catastrophic thinking more than CBT led by other clinicians (QB Test = 4.73 P = .03). There were no differences between online and in-person sessions, group versus individual therapy, or surgical versus non-surgical interventions.

Conclusion: The evidence that CBT delivered by various clinicians in various settings fosters healthier thinking in people presenting for care of musculoskeletal symptoms, supports comprehensive care of musculoskeletal illness. More research is needed to develop indications and interventions that also improve levels of capability. Level-I, meta-analysis of RCT's.

Keywords: anxiety symptoms; cognitive-behavioral therapy (CBT); fear avoidance; kinesiophobia; mental health interventions; pain catastrophizing; pain management; patient capability; recovery; unhelpful thinking.

© The Author(s) 2024.