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Abstract

Introduction: It has been hypothesized that certain persistent physical symptoms (PPS) may be linked to unresolved traumatic or distressing somatic-symptom related memories. EMDR intervention targets and reintegrates distressing memories, thus reducing the re-experiencing of physical sensations. The primary aim of this review was to examine effectiveness of EMDR for PPS. Secondary aims were to investigate effectiveness of EMDR on secondary outcomes (post-traumatic stress, anxiety, and depression), and to evaluate the acceptability of EMDR for this client group. Method: Six electronic databases (PsycInfo, PsycArticles, CINAHL, MEDLINE, Web of Science and SCOPUS) were searched for peer-reviewed literature, with no restrictions on publication dates. Twenty-eight studies met inclusion criteria. Studies were included if the primary aim of EMDR intervention was to reduce intensity, frequency or reported distress associated with PPS. Studies were quality appraised using the MMAT tool prior to narrative synthesis of key findings. Results: Studies varied in design and included RCT, UCT, case study and case series. EMDR treatment length varied between studies; 1–20 sessions. All studies reported significant improvement in PPS at post-test. Effect sizes were available to report in five studies and ranged from moderate to large. Improvement in secondary outcomes were reported in all repeated measure studies. Where available, large effect sizes were reported for reduction in anxiety and depression. Overall drop-out rates in studies with representative samples was low (10.6%). Quality of research varied; low (42.8%), medium (21.4%), and high (35.7%). Conclusions: There is promising emerging evidence for effectiveness and acceptability of EMDR for a range of PPS. However, firm conclusions on efficacy cannot be made. While comparisons between PPS presentations cannot be drawn due to methodological differences, the findings for pain and tinnitus are the most compelling due to methodological quality. High-quality sufficiently powered RCTs are recommended to determine efficacy.

Figures

Figure 1.
PRISMA flowchart of study selection process.
sgremdr_16_4_174View in Context

Tables

DatabaseCoverage
PsycINFO1806 to present
PsycArticles1935 to present
CINAHL1982 to present
MEDLINE1946 to present
Web of Science1900 to present
SCOPUS1788 to present
View in Context
Inclusion criterionRationale
All empirical studiesDue to limited studies published in this area, inclusion of all studies widens the scope of the review
Primary aim of EMDR intervention to reduce intensity, frequency, or reported distress associated with “medically unexplained symptom”Primary focus of review
Adult participant sample characterized by persistent physical symptoms in which onset or maintenance is not better explained by biological factorsPrimary focus of review and theoretically consistent with adaptive information processing (AIP) model that underpins hypothesized mechanisms of EMDR
Peer-reviewedTo provide a measure of quality control
All studies available in English languageTranslation resources not available
View in Context
Critical Appraisal of the Included Studies Based on the MMAT Tool
StudyQualitative MMAT item
1.1. Is the qualitative approach appropriate to answer the research question?1.2. Are the qualitative data collection methods adequate to address the research question?1.3. Are the findings adequately derived from the data?1.4. Is the interpretation of results sufficiently substantiated by data?1.5. Is there coherence between qualitative data sources, collection, analysis and interpretation?
Kelley and Benbadis (2007)

Gupta and Gupta (2002)

Grant (2000)

Hughes (2014)

Proudlock (2015)

Royle (2008)		 Unclear

Unclear

Unclear

Unclear

Unclear

Unclear		 No

No

No

No

No

No		 Unclear

Unclear

Unclear

Unclear

Unclear

Unclear		 Unclear

Unclear

Unclear

Unclear

Unclear

Unclear		 No

No

No

No

No

No
StudyQuantitative randomized controlled MMAT item
2.1. Is randomization appropriately performed?2.2. Are the groups comparable at baseline?2.3. Are there complete outcome data?2.4. Are outcome assessors blinded to the intervention provided?2.5 Did the participants adhere to the assigned intervention?
Demirci et al. (2017)UnclearYesUnclearUnclearYes
Gerhardt et al. (2016)

Luyten et al. (2020)

Marcus (2008)		 Yes

Yes

Unclear		 Yes

Yes

Yes		 Yes

Yes

Yes		 Yes

Yes

No		 Yes

Yes

Yes
Rostaminejad et al. (2017)

Suárez et al. (2020)		 Yes

Yes		 Yes

Yes		 Yes

Yes		 Unclear

Unclear		 Yes

Yes
StudyQuantitative non-randomized MMAT item
3.1. Are the participants representative of the target population?3.2. Are measurements appropriate regarding both the outcome and intervention (or exposure)?3.3. Are there complete outcome data?3.4. Are the confounders accounted for in the design and analysis?3.5. During the study period, is the intervention administered (or exposure occurred) as intended?
De Roos et al. (2010)

Konuk et al. (2011)

Phillips et al. (2019)

Mazzola et al. (2009)

Ray and Page (2002)

Rikkert et al. (2018)		 Yes

No

Yes

Yes

Unclear

Yes		 Yes

Yes

Yes

Yes

Unclear

Yes		 Yes

Yes

Yes

Yes

Yes

Yes		 Unclear

No

Unclear

Unclear

Unclear

Unclear		 Yes

Yes

Yes

Yes

Yes

Yes
StudyQuantitative descriptive MMAT item
4.1. Is the sampling strategy relevant to address the research question?4.2. Is the sample representative of the target population?4.3. Are the measurements appropriate?4.4. Is the data complete?4.5. Is the statistical analysis appropriate to answer the research question?
Altunbaş (2018)

Brennstuhl et al. (2015)

Chemali and Meadows (2004)

Cope (2020)

Grant and Threlfo (2002)

Russell (2008)

Schneider et al. (2008)

Silver et al. (2008)

Wilensky (2006)		 Unclear

Yes

Unclear

Unclear

No

Unclear

Unclear

Unclear

Yes		 Unclear

Yes

Unclear

Unclear

No

Yes

Unclear

Unclear

Unclear		 Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes		 Unclear

Yes

No

Yes

Unclear

Yes

Yes

Yes

No		 Unclear

Unclear

Unclear

Unclear

Yes

No

Yes

No

Unclear
View in Context
Characteristics and Key Findings of Studies
NAuthor (year), countryDesignSampleMedically unexplained symptomComorbiditiesTreatment (protocol, number of sessions)Outcome measures (primary and secondary)Follow upKey findingsMMAT quality rating
1Altunbaş (2018),

Turkey		 Case report

Peer-reviewed		 N = 1

Age: 35

Gender: Female

White Turkish		Daytime blindness (hemeralopia)PTSDEMDR, 9 sessions BAI; BDI; CAPS, IES-R3-month

  • Client reported improvement in vision clarity compared to pre-treatment.

  • Clinically significant and reliable change measured in IES-R, BAI, BDI at post-test.

  • Maintained at 3-month follow up.

 Low
2D’Andrea et al. (2021), FranceUncontrolled Clinical Trial N = 38

Age: Not reported

Gender: Female (n = 17), Male (n = 21)		TinnitusNot reported5 sessionsTHI, VASNo follow up

  • Statistically significant reduction in tinnitus symptoms in 78.9% patients.

  • Significant improvement in reported quality of life and daily functioning.

  • 86.8% participant completed EMDR.

High
3Brennstuhl et al. (2015),

France		Case study N = 2

Age range: 48–56

Gender: Female		Phantom Breast SyndromeChronic pain9–12 sessions (standard and pain protocol)STAI, CES-D, Pain and Sensation Intensity3–6 months

  • Significant decrease in phantom breast sensation and pain at post-test and maintained at follow-up.

  • Significant decrease in depression and anxiety scores at post-test and maintained at follow up.

High
4Chemali and Meadows (2004)

North America		 Case report

Peer-reviewed		 N = 1

Age: 48

Gender: Female

Not specified		Psychogenic seizuresPTSD, Borderline Personality DisorderEMDR, 18 months (session number not specified) N of seizures,

DES, BDI, QUOLIE-31		3-month

  • Client seizure free following 18 months of EMDR.

  • Clonazepam (prescribed for seizures) reduced (dosage information not provided).

  • Maintained at 3-month follow up.

Low
5Cope (2020)

UK		 Case report

Peer-reviewed		 N = 2

Age range: 20–50

Gender: Female (n = 1), Male (n = 1)

Not specified		 Functional non-epileptic attack

Functional sensory symptoms		 Complex trauma

Health Anxiety		EMDR, 20 sessionsBES, BIPQ, GAD-7, HAI, IES-R, MDI, PHQ-93-month

  • Reduction in frequency of FNEA and dissociative episodes.

  • Reduction in severity of functional sensory symptoms and associated distress.

  • Post-treatment scores in subclinical range for PHQ-9, GAD-7, IES-R.

  • Post treatment scores in subclinical range for all subtypes of dissociation (n = 1 remained in clinical range for “emotional constriction” subtype).

Low
6Demirci et al. (2017), Turkey Randomised Clinical Trial

Peer-reviewed		 N = 31 (EMDR arm)

Mean age: 27.65

Gender: Female (n = 31)

Not specified		 Somatic Symptom Disorder

General pain		Psychological TraumaEMDR, 6 sessions (90 mins each)SCL-90, BAI, BDI, SF-36No follow up

  • Significant improvement in somatic symptoms at post-test (n2 = 0.94).

  • Both EMDR and TAU (Duloxetine) resulted in significant decreases in SF-36, BAI, BDI at post-test.

  • EMDR group reported larger effect size (n2 = 0.94) compared to TAU (n2 = 0.68).

Moderate
7De Roos et al. (2010),

Netherlands		 Uncontrolled clinical trial (pre-test/post-test design)

Peer-reviewed		 N = 10

Mean age: 50.1

Gender: Female (n = 4), Male (n = 6)

Not specified		Phantom limb pain Psychological trauma, Obsessive Compulsive Disorder, Substance UseEMDR, 3–10 sessions (90 mins each)Pain rating, SCL-90, CIS-20R, IES, SIL, SF-3626–40 month

  • 80% of patients reported clinically significant reduction in pain at post-test (medium effect size; n2 = 0.63). Maintained at follow up.

  • Four participants reported to be “pain free” at post-test and discontinued pain medication.

  • Significant reduction in trauma measures (IES, SIL) to subclinical range at post-test.

High
8Gerhardt et al. (2016),

Germany		 Randomized controlled pilot study

Peer-reviewed		 N = 20 (EMDR arm)

Mean age: 56.6

Gender: Female (n = 14), Male (n = 6)

White German		Non-specific chronic back pain“Experience of psychological trauma” (assessed by Structured Clinical Interview DSM-5)EMDR standard procedure and pain protocols, 10 sessions (90 mins each)N days with pain, NRS pain intensity, MPI-D, PGIC6-month

  • 45% of participants who received EMDR experienced significant reduction in pain intensity (d = 0.79) and disability (0.39) versus 0% in TAU control group. Follow up (d = 0.50).

  • 50% of participants who received EMDR rated their condition as “much improved” (n = 8) or “very much improved” (n = 2) compared to 0% in control group (d = 1.69).

High
9Grant (2000),

Australia		Case series N = 2

Age range: 28–40

Gender: Female		Chronic painDepression, PTSDChronic pain protocol—no. sessions not specifiedQualitative self-reportNot specified

  • Both clients reported marked improvement in pain symptoms, functioning and associated distress.

Low
10Grant and Threlfo (2002),

Australia		Case series N = 3*

Age range: 27–54

Gender: Female		Chronic painDepression, FatigueChronic pain protocol—9 weekly sessions SFMPQ, CSQ, VOC, Qualitative self-report2 months

  • Significant decrease in pain and distress for all participants.

  • Marked increase in perceived ability to cope with pain and reported daily functioning.

Low
11Gupta & Gupta (2002),

Canada		Case series N = 4

Age range: 22–43

Gender: Female (n = 3), Male (n = 1)		 Dermatologic DisordersAnxiety, Complex Trauma3–6 sessionsVOC, Qualitative self-report6–12 months

  • All patients reported significant improvement in symptoms. Maintained at follow-up.

Low
12Hughes (2014), CanadaCase study N = 1

Age: 35 years

Gender: Female		Complex regional painDepression, Fatigue, Trauma16 sessionsQualitative Self-Report8 months

  • Client reported decreased pain, decreased substance use and improved mood at post-test. Maintained at follow up.

  • Client reported improvement in daily functioning and perceived ability to cope with chronic pain.

Low
13Kelley and Benbadis (2007)

North America		 Case series

Peer-reviewed		 N = 8

Mean age: 37.1

Gender: Female (n = 4), Male (n = 4)

White American		Psychogenic non-epileptic seizures PTSD, Complex Trauma, Depression, Obsessive Compulsive Disorder, Dissociative Disorder, Anxiety, Substance Use, Psychosis, Traumatic Brain InjuryCounselling sessions followed by EMDR, 0–7 sessions EMDR protocolVOC, N of psychogenic seizures18-month

  • Two out of three participants who received EMDR were seizure free following 6–7 sessions of intervention. Maintained at follow up.

  • 12.5% reported being seizure free after consult only (n = 1)

  • 12.5% declined treatment after consult (n = 1)

  • 25% dropped out after 2–3 counselling sessions prior to receiving EMDR (n = 2)

Low
14Konuk et al. (2011), TurkeyUncontrolled clinical trial N = 11

Age range: 18–50

Gender: Female (n = 9), Male (n = 2)		MigrainesTrauma related to headaches8 sessionsNRS, SA-45, WHQ3 months

  • Statistically significant decreases in frequency and duration of headaches. Frequency of headaches increased during intervention but decreased post-treatment.

  • No reductions in reported pain intensity.

  • Significant decrease in pain medication and number of medical visits.

  • Maintained at follow up.

Moderate
15Luyten et al. (2020), BelgiumRCT N = 46 (EMDR arm)

Mean age: 47.87

Gender: Female (n = 26), Male (n = 63)		Chronic Subjective TinnitusAnxiety, Depression5 sessions EMDR (plus Tinnitus Retraining Therapy)TFI, VAS, TQ, HADS, HQ3 months

  • TRT/EMDR showed clinically significant reduction in tinnitus symptoms compared to TRT/CBT.

  • Both TRT/EMDR and TRT/CBT showed significant decrease in tinnitus complaints, hyperacusis, anxiety and depression.

  • Maintained at follow up.

High
16Marcus (2008), North AmericaRCT N = 21 (Integrated EMDR arm)

Mean age: 38.33

Gender: Female (n = 41), Male (n = 2)		MigraineNot reported 1 session (60 minutes)

EMDR with diaphragmatic breathing and cranial compression		SPL, MIDAS, HDI1, 2, 7 days

  • Both the integrated EMDR and TAU (pain medication) groups reported reduced migraine pain posttreatment. Integrated EMDR group showed significantly greater improvements in rapidity of pain reduction.

  • Maintained at follow up.

Moderate
17Mazzola et al (2009), ArgentinaUncontrolled clinical trial N = 38

Age: Not specified

Gender: Female (n = 32), Male (n = 6)		Chronic pain 30 (79%) headaches; 4 (10.5%) fibromyalgia; 4 (10.5%) neuropathic painPersonality disorder, Depression, Anxiety12 weekly sessionsSF-36, STAI, BDI, SCID-II, VASNo follow-up

  • Significant reduction in pain levels resulting in reduction of medication (e.g., benzodiazepines, opioids).

  • EMDR resulted in significant decrease in BDI and STAI at post-test.

  • Statistically significant positive change in perceptions of quality of life (SF-36).

High
18Phillips et al. (2019), UKUncontrolled clinical trial N = 14

Mean age: 57.2

Gender: Female (n = 7), Male (n = 7)		TinnitusAnxiety, Depression3–10 sessionsTHI, BDI, BAI6 months

  • Statistically significant improvement in tinnitus symptoms in “majority of participants.”

  • Marked decrease in depression and anxiety at post-test.

  • Results maintained at 6 month follow up.

High
19Proudlock (2015)

England		 Case report,

Peer-reviewed		 N = 1

Age: “Late 50s”

Gender: Male

White British		Abdomen painPsychological trauma, AnxietyEMDR plus “principles of SLT and CBT,” 20 sessionsIES6-month

  • Client reported reduction in frequency and severity of pain.

  • Client reported improvement in depressed mood.

  • At 6 month follow up, client required 6 additional sessions to manage pain associated with recurrent bladder infections.

Low
20Ray and Page (2002),

Australia		Non-randomized Trial N = 17

Mean age: 36.8

Gender: Female (n = 7), Male (n = 10)		Chronic painPTSD, Depression1 session of EMDR followed by 1 session hypnosis or 1 session hypnosis followed by EMDR (randomly assigned)MPQ<1 month

  • Non-significant reduction in self-reported pain in EMDR condition.

  • Statistically significant pain reduction reported in hypnosis condition.

  • 86.7% reported preference for hypnosis over EMDR post-treatment.

Low
21Rikkert et al. (2018), NetherlandsWithin-groups design N = 35

Mean age: 49.2

Gender: Female (n = 16), Male (n = 19)		TinnitusSleeping difficulties, pain, trauma, other somatic complaint not otherwise specified6 sessionsTFI, Mini TQ, SCL-90, SRIP3 months

  • Significant reduction in tinnitus distress at post-test compared to passive control condition. Medium effect size observed (d = .72).

  • Almost 1 in 2 participants reported benefiting from EMDR.

  • Results maintained at follow up.

High
22Rostaminejad et al. (2017)

Iran		 Randomized controlled trial,

Peer-reviewed		 N = 30 (EMDR arm)

Mean age: 42.8

Gender: Female (n = 9), Male (n = 21)

Not specified		Phantom limb painPsychological trauma related to amputationEMDR, 12 sessions (60 mins each)VOC, Pain rating scale24-month

  • At post-test, 86% of participants who had received EMDR reported being “almost or completely pain free.” Maintained at follow up.

  • Statistically significant reduction in pain intensity and associated distress at post-test (P < .001). Effect size calculated for purpose of review (d = 3.23).

  • In comparison, 96.3% of control group (allocated to routine care) reported no reduction in pain in same period.

High
23Royle (2008),

UK		 Case report,

Peer reviewed		 N = 1

Age: 49

Gender: Male

Not specified		Chronic fatigueAnxiety, depression, work related stressEMDR, 9 sessionsVOC, Qualitative self-report6, 12-month

  • Significant decrease in fatigue which allowed client to return to employment and other daily activities.

  • Reduction in symptom-perpetuating maladaptive cognitions.

  • Maintained at 12 month follow up.

Low
24Russell (2008),

Japan		 Case report,

Peer-reviewed		 N = 1

Age: 40

Gender: Male

Not specified		 Exaggerated startle response, chronic pain, somatic symptomsCombat related traumaEMDR, 5 sessionsIES, BDI, Health Status1, 3, 6-month

  • Marked improvement in health status self-report at post-test. Maintained at 6 month follow up.

  • Clinically significant and reliable change in IES and BDI scores at post-test. Scores in non-clinical range. Maintained at follow up.

Low
25Schneider et al., (2008),

Germany		 Case series,

Peer-reviewed		 N = 5

Mean age: 49.2

Gender: Female (n = 1), Male (n = 4)

Not specified		Phantom limb painPTSDEMDR, 3–15 sessionsIES, BDI, Faces pain scale12–24 month

  • Complete elimination of phantom limb pain in two cases. Maintained at follow up.

  • Reduction in pain in three cases. At follow up, one case (who did not complete full protocol due to relocation) reported “rebound in pain frequency.”

  • At post-test and follow up, two clients reduced pain medication (e.g., morphine) and discontinued Diazepam.

  • Average IES and BDI scores in subclinical range at post-test and follow up.

Moderate
26Silver,et al. (2008),

North America & Japan		 Case report,

Peer-reviewed		 N = 1

Age: 73

Gender: Male

Not specified		Myoclonic movements (upper body shaking & jerking)Combat related PTSDEMDR, 2 sessionsIES, BDI, BHS1, 6-month

  • Clinically significant and reliable change in IES, BDI and BHS scores at post-test. No longer in clinical ranges. Maintained at follow up.

  • Client reported complete elimination of myoclonic movements. Maintained at 6 month follow up.

Moderate
27Suárez et al. (2020), SpainRCT Pilot N = 14 (EMDR arm)

Age range: 49–60

Gender: Female (n = 22), Male (n = 6)		Chronic PainDepression, Anxiety12 sessionsVAS, PDI, EDQ-5D-5L, HADS3 months

  • EMDR+TAU group reported significant improvement in pain intensity, anxiety and depression scores at post-test when compared to TAU.

  • Results from EMDR maintained at follow up.

High
28Wilensky (2006),

Canada		 Case series,

Peer-reviewed		 N = 5

Mean age: 45.6

Gender: Female (n = 1), Male (n = 4)

Not specified		Phantom limb painPsychological traumaEMDR, 3–9 sessions IES, BDI, PDI, TSI1, 3-year (two clients only)

  • Four of the five clients completed planned protocol and reported complete elimination or marked reduction in pain.

  • One client stopped treatment after reducing reported pain by 50%.

  • Significant reduction in BDI and PDI scores at post-test.

  • Significant reduction in IES scores at post-test. One client no longer scoring in clinical range.

  • Three clients lost to follow up.

Moderate

[i] BAI = Beck Anxiety Inventory; BDI = Beck Depression Inventory; CAPS = Clinician-Administered Post-traumatic stress disorder Scale; IES-R = Impact of Events Scale Revised; BES = Beliefs About Emotions Scale; BIPQ = Brief Illness Perception Questionnaire; GAD-7 = Generalized Anxiety Disorder Scale; HAI = Health Anxiety Inventory; IMDI = Multiscale Dissociation Inventory; PHQ-9 = Patient Health Questionnaire; CIS-R = Checklist Individual Strength Revised; SCL-90 = Symptom Checklist; SIL = Self-Inventory List; SF-36 = Short Form Health Survey; NRS Pain = Numeric Pain Rating Scale; MPI-D = Multi-dimensional Pain Inventory (Dutch Version); PGIC = Patient Global Impressions of Change; VOC = Validity of Cognition; BHS = Beck’s Hopelessness Scale; PDI = Peters’ Delusions Inventory; TSI = Trauma Symptom Inventory; SFMPQ = Short-Form McGill Melzack Pain Questionnaire; CSQ = Coping Skills Questionnaire; VAS = Visual Analog Score; WHQ = Weekly Headache Questionnaire; SA-45 = Symptom Assessment 45 Questionnaire; SCID = Structured Clinical Interview for DSM; STAI = State Trait Anxiety Inventory; CES-D = Centre for Epidemiologic Studies—Depression; EQ-5D-5L = EuroQol 5 Dimensions Quality of Life; TFI = Tinnitus Functional Index; Mini TQ = Mini Tinnitus Questionnaire; SRIP = Self-Rating Inventory List for Post-Traumatic Stress Disorder; THI = Tinnitus Handicap Inventory; HQ—Hyperacusis Questionnaire; CTQ = Childhood Trauma Questionnaire; ADES = Adolescent Dissociative Experiences Scale; SPL = Subjective Pain Level; HDI = Headache Disability Inventory; MDAS = Migraine Disability Assessment Scale.

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