Psychological therapies for the management of chronic and recurrent pain in children and adolescents Edited (no change to conclusions)

Abstract

Abstract
Background

This is an update of the original Cochrane review first published in Issue 1, 2003, and previously updated in 2009, 2012 and 2014. Chronic pain, defined as pain that recurs or persists for more than three months, is common in childhood. Chronic pain can affect nearly every aspect of daily life and is associated with disability, anxiety, and depressive symptoms.

Objectives

The aim of this review was to update the published evidence on the efficacy of psychological treatments for chronic and recurrent pain in children and adolescents.

The primary objective of this updated review was to determine any effect of psychological therapy on the clinical outcomes of pain intensity and disability for chronic and recurrent pain in children and adolescents compared with active treatment, waiting‐list, or treatment‐as‐usual care.

The secondary objective was to examine the impact of psychological therapies on children's depressive symptoms and anxiety symptoms, and determine adverse events.

Search methods

Searches were undertaken of CENTRAL, MEDLINE, MEDLINE in Process, Embase, and PsycINFO databases. We searched for further RCTs in the references of all identified studies, meta‐analyses, and reviews, and trial registry databases. The most recent search was conducted in May 2018.

Selection criteria

RCTs with at least 10 participants in each arm post‐treatment comparing psychological therapies with active treatment, treatment‐as‐usual, or waiting‐list control for children or adolescents with recurrent or chronic pain were eligible for inclusion. We excluded trials conducted remotely via the Internet.

Data collection and analysis

We analysed included studies and we assessed quality of outcomes. We combined all treatments into one class named 'psychological treatments'. We separated the trials by the number of participants that were included in each arm; trials with > 20 participants per arm versus trials with < 20 participants per arm. We split pain conditions into headache and mixed chronic pain conditions. We assessed the impact of both conditions on four outcomes: pain, disability, depression, and anxiety. We extracted data at two time points; post‐treatment (immediately or the earliest data available following end of treatment) and at follow‐up (between three and 12 months post‐treatment).

Main results

We identified 10 new studies (an additional 869 participants) in the updated search. The review thus included a total of 47 studies, with 2884 children and adolescents completing treatment (mean age 12.65 years, SD 2.21 years). Twenty‐three studies addressed treatments for headache (including migraine); 10 for abdominal pain; two studies treated participants with either a primary diagnosis of abdominal pain or irritable bowel syndrome, two studies treated adolescents with fibromyalgia, two studies included adolescents with temporomandibular disorders, three were for the treatment of pain associated with sickle cell disease, and two studies treated adolescents with inflammatory bowel disease. Finally, three studies included adolescents with mixed pain conditions. Overall, we judged the included studies to be at unclear or high risk of bias.

 Children with headache pain 

We found that psychological therapies reduced pain frequency post‐treatment for children and adolescents with headaches (risk ratio (RR) 2.35, 95% confidence interval (CI) 1.67 to 3.30, P < 0.01, number needed to treat for an additional beneficial outcome (NNTB) = 2.86), but these effects were not maintained at follow‐up. We did not find a beneficial effect of psychological therapies on reducing disability in young people post‐treatment (SMD ‐0.26, 95% CI ‐0.56 to 0.03), but we did find a beneficial effect in a small number of studies at follow‐up (SMD ‐0.34, 95% CI ‐0.54 to ‐0.15). We found no beneficial effect of psychological interventions on depression or anxiety symptoms.

 Children with mixed pain conditions 

We found that psychological therapies reduced pain intensity post‐treatment for children and adolescents with mixed pain conditions (SMD ‐0.43, 95% CI ‐0.67 to ‐0.19, P < 0.01), but these effects were not maintained at follow‐up. We did find beneficial effects of psychological therapies on reducing disability for young people with mixed pain conditions post‐treatment (SMD ‐0.34, 95% CI ‐0.54 to ‐0.15) and at follow‐up (SMD ‐0.27, 95% CI ‐0.49 to ‐0.06). We found no beneficial effect of psychological interventions on depression symptoms. In contrast, we found a beneficial effect on anxiety at post‐treatment in children with mixed pain conditions (SMD ‐0.16, 95% CI ‐0.29 to ‐0.03), but this was not maintained at follow‐up.

Across all pain conditions, we found that adverse events were reported in seven trials, of which two studies reported adverse events that were study‐related.

 Quality of evidence 

We found the quality of evidence for all outcomes to be low or very low, mostly downgraded for unexplained heterogeneity, limitations in study design, imprecise and sparse data, or suspicion of publication bias. This means our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect, or we have very little confidence in the effect estimate; or the true effect is likely to be substantially different from the estimate of effect.

Authors' conclusions

Psychological treatments delivered predominantly face‐to‐face might be effective for reducing pain outcomes for children and adolescents with headache or other chronic pain conditions post‐treatment. However, there were no effects at follow‐up. Psychological therapies were also beneficial for reducing disability in children with mixed chronic pain conditions at post‐treatment and follow‐up, and for children with headache at follow‐up. We found no beneficial effect of therapies for improving depression or anxiety. The conclusions of this update replicate and add to those of a previous version of the review which found that psychological therapies were effective in reducing pain frequency/intensity for children with headache and mixed chronic pain conditions post‐treatment.

Author(s)

Emma Fisher, Emily Law, Joanne Dudeney, Tonya M Palermo, Gavin Stewart, Christopher Eccleston

Abstract

Plain language summary

 Psychological therapies for the management of chronic and recurrent pain in children and adolescents 

 Bottom line 

Psychological therapies reduce pain frequency immediately following treatment for children and adolescents with chronic headache and reduce pain intensity for children and adolescents with mixed chronic pain conditions. Psychological therapies also reduce disability for children and adolescents with mixed chronic pain conditions immediately following treatment and up to 12 months later, and for children with headache conditions up to 12 months later.

 Background 

Chronic pain or pain that lasts for longer than three months is common in young people. Psychological therapies (e.g. relaxation, hypnosis, coping skills training, biofeedback, and cognitive behavioural therapy) may help people manage pain and its disabling consequences. Therapies can be delivered face‐to‐face by a therapist, via the Internet, by telephone call, or by computer programme. This review focused on treatments that are delivered face‐to‐face by a therapist, which includes therapies delivered by telephone or via a book with exercise instructions. For children and adolescents, there is evidence that relaxation by itself and cognitive behavioural therapy (treatment that helps people test and revise their thoughts and actions) are effective in reducing the intensity of pain in chronic headache, recurrent abdominal pain, fibromyalgia, and sickle cell disease immediately after treatment.

 Study Characteristics 

This review included 47 studies with 2884 participants. The average age of the children and adolescents was 12.6 years. Most studies included young people with headache (23 studies) or stomach pain (10 studies), The remaining studies investigated children with irritable bowel syndrome, fibromyalgia, temporomandibular disorders, sickle cell disease, inflammatory bowel disease, or included samples with various chronic pain conditions.

 Key results 

Psychological therapies reduced pain frequency immediately following treatment for children and adolescents with chronic headache, and pain intensity and anxiety for children and adolescents with other chronic pain conditions. Psychological therapies also reduced disability for children and adolescents with non‐headache chronic pain conditions immediately following treatment and for children with headache and mixed chronic pain conditions up to 12 months later. We did not find any benefit of psychological treatments on reducing anxiety for children with headache or for depression in children with headache or mixed chronic pain conditions.

 Quality of evidence 

We judged all outcomes to be low or very low‐quality, meaning our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect or we have very little confidence in the effect estimate; or the true effect is likely to be substantially different from the estimate of effect.

Author(s)

Emma Fisher, Emily Law, Joanne Dudeney, Tonya M Palermo, Gavin Stewart, Christopher Eccleston

Reviewer's Conclusions

Authors' conclusions

Implications for practice
For children and adolescents with chronic pain

Most therapies that have been delivered to children and adolescents with chronic pain, their parents, or both, are cognitive behavioural therapy or behavioural therapy. We found that these psychological therapies are effective for reducing pain for children with headaches, and reducing pain intensity and disability in children with mixed chronic pain conditions. However, most effects were not maintained at follow‐up, with the exception of disability for children with mixed chronic pain conditions. The treatments had no positive effect on anxiety or depression immediately after treatment or at follow‐up. Quality issues in these trials reduced our confidence in the effect estimates, meaning that new studies could substantially alter the findings.

For clinicians

Taken together, these findings suggested that behavioural and cognitive‐behavioural treatment should be considered as part of standard care for children and adolescents with chronic pain conditions to improve pain and reduce disability. We did not find any beneficial effects for the outcomes of depression at any time point, and only for anxiety in mixed pain conditions post‐treatment. This lack of effect may be due to the fact that anxiety and depression are typically not a specific intervention target of cognitive and behavioural pain management interventions, and enrolled youth had varying levels of anxiety and depression (including many youth with nonclinical levels of anxiety and depression). We also found two trials (n = 277 participants across both trials) that delivered therapy to parents of children with chronic pain, but these should be interpreted with caution. Further data are needed to understand possible downstream effects for children.

For policy makers

The quality of evidence for psychological therapies to reduce pain, disability, anxiety, and depression was mostly low or very low, meaning our confidence in the effect estimate is limited, open to change with future study, and, therefore, should be interpreted with caution. A sister review (Eccleston 2015) included an analysis investigating parent interventions for children with chronic pain and found beneficial effects on parent mental health and behaviour as well as child outcomes. However, the downstream effects for children with chronic pain in trials that only included parents are unknown. More studies will determine this, but this type of treatment could be beneficial for both parent and child.

Implications for research
General

Since the original version of this review, there has been an improvement in the evidence base by the addition of new studies, including additional studies of youth with a variety of chronic pain conditions and the development of treatments that target parents as well as children. We also conducted new subanalyses to evaluate outcomes in larger versus smaller trials. The author team will continue to consider the following changes in the next version of the review.

  • Splitting the title into two: one for headache only and one for mixed pain conditions.
  • Exploring the possibility of subgroup analyses to try to identify variance attributable to nonspecific factors which can affect treatment outcome, such as type of therapy.
  • Exploring the possibility of subgroup analyses by pain condition (e.g. recurrent abdominal pain versus musculoskeletal pain versus headache).
  • Exploring the possibility of subgroup analyses to try to identify whether effects differ by type of comparator (e.g. wait‐list versus active comparators).

Design

Methodologically, there were challenges in this review with trial designs. The majority of included studies were relatively small randomised controlled trials, recruiting fewer than 100 participants. Most trials have evaluated the efficacy of treatment for children with headache, while few trials have been conducted in young people with other chronic pain conditions (e.g. complex regional pain syndrome, sickle cell disease, arthritis). Indeed, it was unclear whether children had different treatment needs, depending on the characteristics of their pain problem, or if a one‐size‐fits‐all approach is appropriate. Treatments tailored to children and adolescents to treat distress before working to reduce pain and disability might find larger effect sizes. Finally, we still do not know the active ingredient of psychological therapies. More detailed description of treatments and inclusion of process measures would help to identify active components of therapies, and allow the development of more targeted interventions for this population. In this update, one trial used problem‐solving therapy delivered to parents of children with chronic pain (Palermo 2016). Divergence from traditional cognitive behavioural therapy and from models where the child is the treatment target may be beneficial, and we encourage further exploration of these alternatives in future trials.

Measurement

Although guidelines for measurement in clinical trials for young people with chronic pain have been published (McGrath 2008), consensus between researchers and clinicians is still needed with regards to gold standard measures of disability, depression, and anxiety. This would reduce the heterogeneity of analyses. Sensitivity to change should be a core psychometric property for measures used in randomised controlled trials (Fisher 2017). Further, clinically meaningful change should be established for outcomes used in trials to help interpret whether therapies are achieving meaningful change for participants. Researchers and clinicians have previously agreed on headache outcomes for young people. There is consensus amongst headache researchers and clinicians that 50% reduction in headache frequency is clinically meaningful and should be used as a primary outcome in headache trials. However, such consensus has not been reached for other pain characteristics and for other pain conditions. Finally, adverse events should be reported in every trial. Although more trials reported adverse events in this update, this was not universal. Development of a common measure of adverse events might encourage more widespread use and reporting of this outcome.

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