scholarly journals Treatment of Pectoralis Major Tendon Tears: A Systematic Review and Meta-Analysis of Operative and Nonoperative Treatment

2020 ◽  
Vol 8 (7_suppl6) ◽  
pp. 2325967120S0041
Author(s):  
Blake Bodendorfer ◽  
Brian McCormick ◽  
David Wang ◽  
Christine Conroy ◽  
Caroline Fryar ◽  
...  
Keyword(s):  
Systematic Review ◽  
Operative Treatment ◽  
Mixed Model ◽  
Meta Analysis ◽  
Random Effect ◽  
Nonoperative Treatment ◽  
Pectoralis Major ◽  
Isokinetic Strength ◽  
Tendon Tears

Objectives: The incidence of pectoralis major tendon tears is rising, and repair is generally considered, but there is a paucity of comparative data to demonstrate the superiority of operative treatment. We sought to compare the outcomes of operative and nonoperative treatment of pectoralis major tendon tears. We hypothesized that repair would result in superior outcomes compared to nonoperative treatment. Methods: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic review of the literature was completed using MEDLINE, SPORTDiscus, CINAHL, Cochrane, Embase and Web of Science databases. English-language studies were included with a minimum of 6 months average follow-up and 5 cases per study. Methodological Index for Nonrandomized Studies was utilized to assess the quality of the existing literature. Meta-analysis of pooled mechanisms of injury and outcomes was completed. Pooled effect-sizes were calculated from random effects models. Continuous variables were assessed using mixed model analysis with the individual study designated as a random effect and the desired treatment for comparison as a fixed effect. Bivariate frequency data was transformed using the Freeman-Tukey log-linear transformation for variance stabilization and then assessed using a mixed model with a study-level random effect and subsequently back-transformed. Significance was set at P<.05. Results: Twenty-three articles with 664 injuries met the inclusion criteria for comparison (Figure 1). All patients were male with 63.2% of injuries occurring during weight training, with an average age of 31.48 years and follow-up of 37.02 months. Included studies had moderately high methodological quality. Operative treatment was significantly superior to nonoperative treatment with a relative improvement of functional outcome by 0.70 (P=.027), full isometric strength by 77.07% (P<.001), isokinetic strength by 28.86% (P<.001) compared to the uninjured arm, cosmesis satisfaction by 13.79% (P=.037), and resting deformity by 98.85% (P<.001) (Table 1). There was an overall complication rate of 14.21%, including a 3.08% rate of rerupture, for operative treatment. Conclusion: Pectoralis major tendon repair resulted in significantly superior outcomes as compared to nonoperative treatment with an associated 14.21% complication rate. There was a statistically significant improvement in functional outcome, isokinetic strength, isometric strength, cosmesis, and resting deformity. [Figure: see text][Table: see text]

scholarly journals Treatment of Pectoralis Major Tendon Tears: A Systematic Review and Meta-analysis of Operative and Nonoperative Treatment

2020 ◽  
Vol 8 (2) ◽  
pp. 232596711990081
Author(s):  
Blake M. Bodendorfer ◽  
Brian P. McCormick ◽  
David X. Wang ◽  
Austin M. Looney ◽  
Christine M. Conroy ◽  
...  
Keyword(s):  
Systematic Review ◽  
Operative Treatment ◽  
Mixed Model ◽  
Meta Analysis ◽  
Random Effect ◽  
Nonoperative Treatment ◽  
Pectoralis Major ◽  
Isokinetic Strength ◽  
Tendon Tears

Background: The incidence of pectoralis major tendon tears is increasing, and repair is generally considered; however, a paucity of comparative data are available to demonstrate the superiority of operative treatment. Purpose/Hypothesis: The purpose of this study is to compare the outcomes of operative and nonoperative treatment of pectoralis major tendon tears. We hypothesized that repair would result in superior outcomes compared with nonoperative treatment. Methods: In accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic review of the literature was completed by use of MEDLINE, SPORTDiscus, CINAHL, Cochrane, EMBASE, and Web of Science databases. We included English-language studies that had a minimum of 6 months of average follow-up and 5 cases per study. The MINORS (Methodological Index for Non-Randomized Studies) was used to assess the quality of the existing literature. Meta-analysis of pooled mechanisms of injury and outcomes was completed. Pooled effect sizes were calculated from random-effects models. Continuous variables were assessed by use of mixed-model analysis, with the individual study designated as a random effect and the desired treatment for comparison as a fixed effect. Bivariate frequency data were transformed via the Freeman-Tukey log-linear transformation for variance stabilization and then assessed through use of a mixed model with a study level random effect and subsequently back-transformed. Significance was set at P < .05. Results: A total of 23 articles with 664 injuries met the inclusion criteria for comparison. All patients were male, with an average age of 31.48 years; 63.2% of injuries occurred during weight training, and the average follow-up was 37.02 months. Included studies had moderately high methodological quality. Operative treatment was significantly superior to nonoperative treatment, with relative improvements of functional outcome by 23.33% (0.70 improvement by Bak criteria which is scored 1-4; P = .027), full isometric strength 77.07% ( P < .001), isokinetic strength 28.86% ( P < .001) compared with the uninjured arm, cosmesis satisfaction 13.79% ( P = .037), and resting deformity 98.85% ( P < .001). The overall complication rate for operative treatment was 14.21%, including a 3.08% rate of rerupture. Conclusion: Pectoralis major tendon repair resulted in significantly superior outcomes compared with nonoperative treatment, with an associated 14.21% complication rate. Statistically significant improvements were noted in functional outcome, isokinetic strength, isometric strength, cosmesis, and resting deformity.

Treatment of Pectoralis Major Tendon Tears: A Systematic Review and Meta-analysis of Repair Timing and Fixation Methods

2020 ◽  
Vol 48 (13) ◽  
pp. 3376-3385 ◽  
Author(s):  
Blake M. Bodendorfer ◽  
David X. Wang ◽  
Brian P. McCormick ◽  
Austin M. Looney ◽  
Christine M. Conroy ◽  
...  
Keyword(s):  
Systematic Review ◽  
Mixed Model ◽  
Meta Analysis ◽  
Random Effect ◽  
Pectoralis Major ◽  
Continuous Variables ◽  
Mixed Model Analysis ◽  
Fixation Methods ◽  
Tendon Tears

Background: Repair of torn pectoralis major tendons is generally considered superior to nonoperative management, but there is a paucity of comparative data to demonstrate ideal repair timing and fixation methods. Purpose/Hypothesis: The purpose was to compare the outcomes between acute and chronic repair and among the various methods of fixation (transosseous tunnels, cortical buttons, suture anchors, screws with washers, and direct repair). It was hypothesized that acute repair would have superior outcomes and there would be similar outcomes among the various methods of fixation. Study Design: Meta-analysis. Methods: In accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic review of the literature was completed through MEDLINE, SPORTDiscus, CINAHL, Cochrane, Embase, and Web of Science databases. English-language studies were included with a minimum of 6 months’ mean follow-up and 5 cases per study. MINORS (Methodological Index for Nonrandomized Studies) was utilized to assess the quality of the existing literature. Analysis of mechanisms of injury and meta-analysis of pooled outcomes were completed. Pooled effect sizes were calculated from random effects models. Continuous variables were assessed via mixed model analysis, with the individual study designated as a random effect and the desired treatment for comparison as a fixed effect. Bivariate frequency data were transformed through Freeman-Tukey log-linear transformation for variance stabilization and then assessed through a mixed model with a study-level random effect and subsequently back-transformed. Significance was set at P < .05. Results: Twenty articles with 384 injuries met the inclusion criteria for comparison. All patients were male, with 61.9% of injuries occurring during weight training, at a mean age of 31.53 years, and with a mean follow-up of 30.12 months. Included studies scored a mean (SD) 15.53 ± 4.26 (range, 7.0-23.3) by MINORS criteria. Acute repair was significantly superior to chronic repair, with a relative improvement of functional outcome by 0.85 ( P = .004) and satisfaction with cosmesis by 20.50% ( P = .003). There was a trend toward acute repair having a higher proportion of patients who were pain-free (34.47%, P = .064). There were no significant differences among the methods of fixation for repair. Conclusion: Acute repair of pectoralis major tendon tears resulted in significantly superior functional outcomes and cosmesis satisfaction with a trend toward a higher proportion of patients who were pain-free. There were no significant differences among the methods of fixation for repair.

scholarly journals Operative Treatment of Isolated Meniscus Injuries in Adolescent Patients: A Meta-Analysis and Review

2018 ◽  
Vol 10 (4) ◽  
pp. 311-316 ◽  
Author(s):  
Gina M. Mosich ◽  
Virginia Lieu ◽  
Edward Ebramzadeh ◽  
Jennifer J. Beck
Keyword(s):  
Systematic Review ◽  
Operative Treatment ◽  
Meta Analysis ◽  
Meniscus Repair ◽  
Meniscal Tears ◽  
Level Of Evidence ◽  
Adolescent Population ◽  
Meniscus Tears ◽  
Adolescent Patients

Context: With the rise in sports participation and increased athleticism in the adolescent population, there is an ever-growing need to better understand adolescent meniscus pathology and treatment. Objective: To better understand the operative management of meniscus tears in the adolescent population. Data Sources: A systematic review of PubMed (MEDLINE) and Google Scholar was performed for all archived years. Study Selection: Studies that reported on isolated meniscus tears in adolescent patients (age, 10-19 years) were included. Study Design: Systematic review and meta-analysis. Level of Evidence: Level 4. Data Extraction: Two authors reviewed and extracted data from studies that fulfilled all inclusion criteria. Results: Nine studies on isolated meniscus tears in adolescent patients were found, with level of evidence ranging from 3 to 4. These studies evaluated a total of 373 patients (248 males, 125 females) and 390 knees. Seven studies were published between 1979 and 2000, all of which discuss meniscectomy as the primary treatment. Two studies were published after 2000 and report on meniscus repair surgery. The mean patient age was 14.4 years. A total of 308 meniscectomies and 64 meniscus repairs were performed. Follow-up ranged from 1.8 to 30 years (mean, 10.8 years). A 37% retear rate was reported for patients undergoing meniscus repair. Different outcome measures were used for meniscectomy versus meniscus repair. Three studies evaluating meniscectomy reported Tapper-Hoover scores, showing 54 patients with an excellent result, 58 with good, 57 with fair, and 23 with poor results. Conclusion: A shift in the management of isolated adolescent meniscal tears is reflected in the literature, with a recent increase in operative repair. This is likely secondary to poor outcomes after meniscectomy reflected in long-term follow-up studies. The current literature highlights the need for improved description of tear patterns, standardized reporting of outcome measures, and improved study methodologies to help guide orthopaedic surgeons on operative treatment of meniscal tears in adolescent patients.

scholarly journals MANAGEMENT OF ENDOCRINE DISEASE: Recurrence or new tumors after complete resection of pheochromocytomas and paragangliomas: a systematic review and meta-analysis

2016 ◽  
Vol 175 (4) ◽  
pp. R135-R145 ◽  
Author(s):  
Laurence Amar ◽  
Charlotte Lussey-Lepoutre ◽  
Jacques W M Lenders ◽  
Juliette Djadi-Prat ◽  
Pierre-Francois Plouin ◽  
...  
Keyword(s):  
Systematic Review ◽  
Recurrent Disease ◽  
Meta Analysis ◽  
Random Effect ◽  
Tumor Resection ◽  
Complete Resection ◽  
Sufficient Information ◽  
Curative Surgery ◽  
Multicenter Studies

Objectives To systematically review the incidence and factors associated with recurrences or new tumors after apparent complete resection of pheochromocytoma or thoraco–abdomino–pelvic paraganglioma. Design A systematic review and meta-analysis of published literature was performed. Methods Pubmed and Embase from 1980 to 2012 were searched for studies published in English on patients with non-metastatic pheochromocytoma or thoraco–abdomino–pelvic paraganglioma, complete tumor resection, postoperative follow-up exceeding 1 month, and recurrence or new tumor documented by pathology, hormonal dosages, or imaging tests. Incidence rates of new events after curative surgery were calculated for each study that had sufficient information and pooled using random-effect meta-analysis. Results In total, 38 studies were selected from 3518 references, of which 36 reported retrospective cohorts from the USA, Europe, and Asia. Patient follow-up was neither standardized nor exhaustive in the included studies. A clear description of patient retrieval methods was available for nine studies and the follow-up protocol and patient flow for four studies. Only two studies used multivariable methods to assess potential predictors of postoperative events. The overall rate of recurrent disease from 34 studies was 0.98 events/100 person-years (95% confidence interval 0.71, 1.25). Syndromic diseases and paragangliomas were consistently associated with a higher risk of a new event in individual studies and in meta-regression analysis. Conclusions The risk of recurrent disease after complete resection of pheochromocytoma may be lower than that previously estimated, corresponding to five events for 100 patients followed up for 5 years after complete resection. Risk stratification is required to tailor the follow-up protocol after complete resection of a pheochromocytoma or paraganglioma. Large multicenter studies are needed to this end.

scholarly journals Ventilator-Associated Pneumonia in Patients with COVID-19: A Systematic Review and Meta-Analysis

Antibiotics ◽  
2021 ◽  
Vol 10 (5) ◽  
pp. 545
Author(s):  
Mariachiara Ippolito ◽  
Giovanni Misseri ◽  
Giulia Catalisano ◽  
Claudia Marino ◽  
Giulia Ingoglia ◽  
...  
Keyword(s):  
Systematic Review ◽  
Primary Outcome ◽  
Web Of Science ◽  
Comparison Group ◽  
Meta Analysis ◽  
Random Effect ◽  
Ventilator Associated Pneumonia ◽  
Icu Length Of Stay ◽  
Reporting Data

The aim of this systematic review and meta-analysis was to estimate the pooled occurrence of ventilator-associated pneumonia (VAP) among patients admitted to an intensive care unit with COVID-19 and mortality of those who developed VAP. We performed a systematic search on PubMed, EMBASE and Web of Science from inception to 2nd March 2021 for nonrandomized studies specifically addressing VAP in adult patients with COVID-19 and reporting data on at least one primary outcome of interest. Random effect single-arm meta-analysis was performed for the occurrence of VAP and mortality (at the longest follow up) and ICU length of stay. Twenty studies were included in the systematic review and meta-analysis, for a total of 2611 patients with at least one episode of VAP. The pooled estimated occurrence of VAP was of 45.4% (95% C.I. 37.8–53.2%; 2611/5593 patients; I2 = 96%). The pooled estimated occurrence of mortality was 42.7% (95% C.I. 34–51.7%; 371/946 patients; I2 = 82%). The estimated summary estimated metric mean ICU LOS was 28.58 days (95% C.I. 21.4–35.8; I2 = 98%). Sensitivity analysis showed that patients with COVID-19 may have a higher risk of developing VAP than patients without COVID-19 (OR 3.24; 95% C.I. 2.2–4.7; P = 0.015; I2 = 67.7%; five studies with a comparison group).

scholarly journals Weight Gain After Thyroidectomy: A Systematic Review and Meta-Analysis

2020 ◽  
Vol 106 (1) ◽  
pp. 282-291 ◽  
Author(s):  
Christine N Huynh ◽  
Janina V Pearce ◽  
Le Kang ◽  
Francesco S Celi
Keyword(s):  
Systematic Review ◽  
Weight Gain ◽  
Weight Change ◽  
Meta Analysis ◽  
Random Effect ◽  
Treatment Modalities ◽  
Weight Changes ◽  
Indication For Surgery ◽  
Subgroup Analyses

Abstract Context Weight gain is a major driver of dissatisfaction and decreased quality of life in patients with hypothyroidism. Data on the changes in body weight following thyroidectomy are conflicting. Objective To perform a systematic review of the literature and a meta-analysis of weight changes following total thyroidectomy. Data Sources Literature search on PubMed. Study Selection Studies in English published between September 1998 and May 2018 reporting post-thyroidectomy weight changes. Data extraction Data were reviewed and compared by 3 investigators; discrepancies were resolved by consensus. Meta-analyses were performed using fixed and random effect models. Univariable and multivariable meta-regression models for weight change were implemented against study follow-up, gender, and age. Exploratory subgroup analyses were performed for indication for surgery. Data Synthesis Seventeen studies (3164 patients) with 23.8 ± 23.6 months follow-up were included. Severe heterogeneity across studies was observed. Using a random effect model, the estimated overall weight change was a gain of 2.13 kg, 95% confidence interval (CI; 0.95, 3.30). Age was negatively associated with weight change (β = -0.238, P &lt; 0.001). In subgroup analyses, weight gain was more evident in patients undergoing thyroidectomy for hyperthyroidism: 5.19 kg, 95% CI (3.21, 7.17) vs goiter or malignancy 1.55 kg, 95% CI (0.82, 2.27) and 1.30 kg, 95% CI (0.45, 2.15), respectively. Conclusions Patients undergoing thyroidectomy experience possible mild weight gain, particularly younger individuals and those with hyperthyroidism as the indication for surgery. Prospective studies directed to assess the pathophysiology of weight gain post-thyroidectomy, and to test novel treatment modalities, are needed to better characterize post-thyroidectomy weight changes.

Mechanical thrombectomy in pediatric stroke: systematic review, individual patient data meta-analysis, and case series

2019 ◽  
Vol 24 (5) ◽  
pp. 558-571 ◽  
Author(s):  
Kartik Bhatia ◽  
Hans Kortman ◽  
Christopher Blair ◽  
Geoffrey Parker ◽  
David Brunacci ◽  
...  
Keyword(s):  
Systematic Review ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Case Reports ◽  
Meta Analysis ◽  
Case Series ◽  
Neurological Outcomes

OBJECTIVEThe role of mechanical thrombectomy in pediatric acute ischemic stroke is uncertain, despite extensive evidence of benefit in adults. The existing literature consists of several recent small single-arm cohort studies, as well as multiple prior small case series and case reports. Published reports of pediatric cases have increased markedly since 2015, after the publication of the positive trials in adults. The recent AHA/ASA Scientific Statement on this issue was informed predominantly by pre-2015 case reports and identified several knowledge gaps, including how young a child may undergo thrombectomy. A repeat systematic review and meta-analysis is warranted to help guide therapeutic decisions and address gaps in knowledge.METHODSUsing PRISMA-IPD guidelines, the authors performed a systematic review of the literature from 1999 to April 2019 and individual patient data meta-analysis, with 2 independent reviewers. An additional series of 3 cases in adolescent males from one of the authors’ centers was also included. The primary outcomes were the rate of good long-term (mRS score 0–2 at final follow-up) and short-term (reduction in NIHSS score by ≥ 8 points or NIHSS score 0–1 at up to 24 hours post-thrombectomy) neurological outcomes following mechanical thrombectomy for acute ischemic stroke in patients < 18 years of age. The secondary outcome was the rate of successful angiographic recanalization (mTICI score 2b/3).RESULTSThe authors’ review yielded 113 cases of mechanical thrombectomy in 110 pediatric patients. Although complete follow-up data are not available for all patients, 87 of 96 (90.6%) had good long-term neurological outcomes (mRS score 0–2), 55 of 79 (69.6%) had good short-term neurological outcomes, and 86 of 98 (87.8%) had successful angiographic recanalization (mTICI score 2b/3). Death occurred in 2 patients and symptomatic intracranial hemorrhage in 1 patient. Sixteen published thrombectomy cases were identified in children < 5 years of age.CONCLUSIONSMechanical thrombectomy may be considered for acute ischemic stroke due to large vessel occlusion (ICA terminus, M1, basilar artery) in patients aged 1–18 years (Level C evidence; Class IIb recommendation). The existing evidence base is likely affected by selection and publication bias. A prospective multinational registry is recommended as the next investigative step.

Exercise interventions in lateral elbow tendinopathy have better outcomes than passive interventions, but the effects are small: a systematic review and meta-analysis of 2123 subjects in 30 trials

2020 ◽  
pp. bjsports-2020-102525
Author(s):  
Stefanos Karanasios ◽  
Vasileios Korakakis ◽  
Rod Whiteley ◽  
Ioannis Vasilogeorgis ◽  
Sarah Woodbridge ◽  
...  
Keyword(s):  
Systematic Review ◽  
Meta Analysis ◽  
Risk Of Bias ◽  
Short Term ◽  
Lateral Elbow ◽  
Long Term Follow Up ◽  
Wait And See ◽  
Lateral Elbow Tendinopathy

ObjectiveTo evaluate the effectiveness of exercise compared with other conservative interventions in the management of lateral elbow tendinopathy (LET) on pain and function.DesignSystematic review and meta-analysis.MethodsWe used the Cochrane risk-of-bias tool 2 for randomised controlled trials (RCTs) to assess risk of bias and the Grading of Recommendations Assessment, Development and Evaluation methodology to grade the certainty of evidence. Self-perceived improvement, pain intensity, pain-free grip strength (PFGS) and elbow disability were used as primary outcome measures.Eligibility criteriaRCTs assessing the effectiveness of exercise alone or as an additive intervention compared with passive interventions, wait-and-see or injections in patients with LET.Results30 RCTs (2123 participants, 5 comparator interventions) were identified. Exercise outperformed (low certainty) corticosteroid injections in all outcomes at all time points except short-term pain reduction. Clinically significant differences were found in PFGS at short-term (mean difference (MD): 12.15, (95% CI) 1.69 to 22.6), mid-term (MD: 22.45, 95% CI 3.63 to 41.3) and long-term follow-up (MD: 18, 95% CI 11.17 to 24.84). Statistically significant differences (very low certainty) for exercise compared with wait-and-see were found only in self-perceived improvement at short-term, pain reduction and elbow disability at short-term and long-term follow-up. Substantial heterogeneity in descriptions of equipment, load, duration and frequency of exercise programmes were evident.ConclusionsLow and very low certainty evidence suggests exercise is effective compared with passive interventions with or without invasive treatment in LET, but the effect is small.PROSPERO registration numberCRD42018082703.

349 Cognitive Behavioral Therapy for Insomnia in Patients with Chronic Pain - A Systematic Review and Meta-Analysis

SLEEP ◽  
2021 ◽  
Vol 44 (Supplement_2) ◽  
pp. A139-A140
Author(s):  
Janannii Selvanathan ◽  
Chi Pham ◽  
Mahesh Nagappa ◽  
Philip Peng ◽  
Marina Englesakis ◽  
...  
Keyword(s):  
Systematic Review ◽  
Cognitive Behavioral Therapy ◽  
Cancer Pain ◽  
Behavioral Therapy ◽  
Meta Analysis ◽  
Post Treatment ◽  
Cognitive Behavioral ◽  
Comorbid Insomnia ◽  
Patient Reported

Abstract Introduction Patients with chronic non-cancer pain often report insomnia as a significant comorbidity. Cognitive behavioral therapy for insomnia (CBT-I) is recommended as the first line of treatment for insomnia, and several randomized controlled trials (RCTs) have examined the efficacy of CBT-I on various health outcomes in patients with comorbid insomnia and chronic non-cancer pain. We conducted a systematic review and meta-analysis on the effectiveness of CBT-I on sleep, pain, depression, anxiety and fatigue in adults with comorbid insomnia and chronic non-cancer pain. Methods A systematic search was conducted using ten electronic databases. The duration of the search was set between database inception to April 2020. Included studies must be RCTs assessing the effects of CBT-I on at least patient-reported sleep outcomes in adults with chronic non-cancer pain. Quality of the studies was assessed using the Cochrane risk of bias assessment and Yates quality rating scale. Continuous data were extracted and summarized using standard mean difference (SMD) with 95% confidence intervals (CIs). Results The literature search resulted in 7,772 articles, of which 14 RCTs met the inclusion criteria. Twelve of these articles were included in the meta-analysis. The meta-analysis comprised 762 participants. CBT-I demonstrated a large significant effect on patient-reported sleep (SMD = 0.87, 95% CI [0.55–1.20], p &lt; 0.00001) at post-treatment and final follow-up (up to 9 months) (0.59 [0.31–0.86], p &lt; 0.0001); and moderate effects on pain (SMD = 0.20 [0.06, 0.34], p = 0.006) and depression (0.44 [0.09–0.79], p= 0.01) at post-treatment. The probability of improving sleep and pain following CBT-I at post-treatment was 81% and 58%, respectively. The probability of improving sleep and pain at final follow-up was 73% and 57%, respectively. There were no statistically significant effects on anxiety and fatigue. Conclusion This systematic review and meta-analysis showed that CBT-I is effective for improving sleep in adults with comorbid insomnia and chronic non-cancer pain. Further, CBT-I may lead to short-term moderate improvements in pain and depression. However, there is a need for further RCTs with adequate power, longer follow-up periods, CBT for both insomnia and pain, and consistent scoring systems for assessing patient outcomes. Support (if any):

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