Psychological therapies (remotely delivered) for the management of chronic and recurrent pain in children and adolescents Stable (no update expected for reasons given in 'What's new')
This is the first update of a review published in 2015, Issue 1. Chronic pain is common during childhood and adolescence and is associated with negative outcomes, such as increased severity of pain, reduced function, and low mood. Psychological therapies, traditionally delivered face‐to‐face with a therapist, are efficacious at reducing pain intensity and disability. To address barriers to treatment access, such as distance and cost of treatment, technology is being used to deliver these psychological therapies remotely. Therapies delivered remotely, such as via the Internet, computer‐based programmes, and smartphone applications, can be used to deliver treatment to children and adolescents with chronic pain.
To determine the efficacy of psychological therapies delivered remotely compared to waiting list, treatment as usual, or active control treatments, for the management of chronic pain in children and adolescents.
We searched four databases (CENTRAL, MEDLINE, Embase, and PsycINFO) from inception to May 2018 for randomised controlled trials (RCTs) of remotely‐delivered psychological interventions for children and adolescents with chronic pain. We searched for chronic pain conditions including, but not exclusive to, headache, recurrent abdominal pain, musculoskeletal pain, and neuropathic pain. We also searched online trial registries, reference sections, and citations of included studies for potential trials.
We included RCTs that investigated the efficacy of a psychological therapy delivered remotely via technology in comparison to an active, treatment as usual, or waiting‐list control. We considered blended treatments, which used a combination of technology and up to 30% face‐to‐face interaction. Interventions had to be delivered primarily via technology to be included, and we excluded interventions delivered via telephone. We included studies that delivered interventions to children and adolescents (up to 18 years of age) with a chronic pain condition or where chronic pain was a primary symptom of their condition (e.g. juvenile arthritis). We included studies that reported 10 or more participants in each comparator arm, at each extraction point.
Data collection and analysis
We combined all psychological therapies in the analyses. We split pain conditions into headache and mixed (non‐headache) pain and analysed them separately. We extracted pain severity/intensity, disability, depression, anxiety, and adverse events as primary outcomes, and satisfaction with treatment as a secondary outcome. We considered outcomes at two time points: first immediately following the end of treatment (known as 'post‐treatment'), and second, any follow‐up time point post‐treatment between three and 12 months (known as 'follow‐up'). We assessed risk of bias and all outcomes for quality using the GRADE assessment.
We found 10 studies with 697 participants (an additional 4 studies with 326 participants since the previous review) that delivered treatment remotely; four studies investigated children with headache conditions, one study was with children with juvenile idiopathic arthritis, one included children with sickle cell disease, one included children with irritable bowel syndrome, and three studies included children with different chronic pain conditions (i.e. headache, recurrent abdominal pain, musculoskeletal pain). The average age of children receiving treatment was 13.17 years.
We judged selection, detection, and reporting biases to be mostly low risk. However, we judged performance and attrition biases to be mostly unclear. Out of the 16 planned analyses, we were able to conduct 13 meta‐analyses. We downgraded outcomes for imprecision, indirectness of evidence, inconsistency of results, or because the analysis only included one study.
For headache pain conditions, we found headache severity was reduced post‐treatment (risk ratio (RR) 2.02, 95% confidence interval (CI) 1.35 to 3.01); P < 0.001, number needed to treat to benefit (NNTB) = 5.36, 7 studies, 379 participants; very low‐quality evidence). No effect was found at follow‐up (very low‐quality evidence). There were no effects of psychological therapies delivered remotely for disability post‐treatment (standardised mean difference (SMD) ‐0.16, 95% CI ‐0.46 to 0.13; P = 0.28, 5 studies, 440 participants) or follow‐up (both very low‐quality evidence). Similarly, no effect was found for the outcomes of depression (SMD ‐0.04, 95% CI ‐0.15 to 0.23, P = 0.69, 4 studies, 422 participants) or anxiety (SMD ‐0.08, 95% CI ‐0.28 to 0.12; P = 0.45, 3 studies, 380 participants) at post‐treatment, or follow‐up (both very low‐quality evidence).
Mixed chronic pain conditions
We did not find any beneficial effects of psychological therapies for reducing pain intensity post‐treatment for mixed chronic pain conditions (SMD ‐0.90, 95% CI ‐1.95 to 0.16; P = 0.10, 5 studies, 501 participants) or at follow‐up. There were no beneficial effects of psychological therapies delivered remotely for disability post‐treatment (SMD ‐0.28, 95% CI ‐0.74 to 0.18; P = 0.24, 3 studies, 363 participants) and a lack of data at follow‐up meant no analysis could be run. We found no beneficial effects for the outcomes of depression (SMD 0.04, 95% CI ‐0.18 to 0.26; P = 0.73, 2 studies, 317 participants) and anxiety (SMD 0.53, 95% CI ‐0.63 to 1.68; P = 0.37, 2 studies, 370 participants) post‐treatment, however, we are cautious of our findings as we could only include two studies in the analyses. We could not conduct analyses at follow‐up. We judged the evidence for all outcomes to be very low quality.
Across all chronic pain conditions, six studies reported minor adverse events which were not attributed to the psychological therapies. Satisfaction with treatment is described qualitatively and was overall positive. However, we judged both these outcomes as very low quality.
There are currently a small number of trials investigating psychological therapies delivered remotely, primarily via the Internet. We are cautious in our interpretations of analyses. We found one beneficial effect of therapies to reduce headache severity post‐treatment. For the remaining outcomes there was either no beneficial effect at post‐treatment or follow‐up, or lack of evidence to determine an effect. Overall, participant satisfaction with treatment was positive. We judged the quality of the evidence to be very low, meaning we are very uncertain about the estimate. Further studies are needed to increase our confidence in this potentially promising field.
Emma Fisher, Emily Law, Joanne Dudeney, Christopher Eccleston, Tonya M Palermo
Plain language summary
Psychological therapies (remotely‐delivered) for the management of chronic and recurrent pain in children and adolescents
Experiencing long‐term pain during childhood is common. Children and adolescents (< 18 years of age) with long‐term pain often report intense pain which negatively impacts their lives. The pain can affect their ability to function physically, can limit their ability to go to school, and can leave them feeling anxious or depressed. The most common types of chronic pain in children and adolescents are headaches, recurrent abdominal pain, musculoskeletal pain, and back pain. Normally, a therapist, physically together with a patient or family (a method often called face‐to‐face) delivers psychological therapies, such as cognitive behavioural therapy (e.g. coping skills, activity pacing) or behavioural therapy (e.g. relaxation exercises). We know that face‐to‐face therapies can reduce pain intensity and improve physical functioning in children. Technology (e.g. the Internet, computer programmes, and smartphone applications) now allows therapy to be delivered without needing to be face‐to‐face with a therapist. Therapies delivered remotely promise to make treatments easier to access because they remove the need for travel. They may also be less expensive.
We set out to understand if psychological therapies, delivered remotely using technology, can help children and adolescents with long‐term pain to have less pain, to improve physical functioning, and to have fewer symptoms of depression and anxiety, compared to children who are waiting to be treated (waiting‐list control), or being treated in other ways (active control, e.g. receiving education about long‐term pain).
For this update, we conducted the search through to May 2018. We found 10 studies including 697 children and adolescents; four of these studies (326 participants) were new for this update. Four studies treated children with headache, one study treated children with juvenile idiopathic arthritis, one treated children with sickle cell disease, one included children with irritable bowel syndrome, and three studies included mixed samples of children, some who had headache and some with other chronic pain conditions. All studies delivered cognitive behavioural therapy. The average age of children receiving the interventions was 13 years. We looked at six outcomes: pain, physical functioning, depression, anxiety, side effects, and satisfaction with treatment.
We split the painful conditions into two groups and looked at them separately. The first group included children with headache. The second group included children with other painful conditions (e.g. frequent stomach pain, musculoskeletal pain), known as 'mixed chronic pain'. Psychological therapies delivered remotely (primarily via the Internet) were helpful at reducing pain for children and adolescents with headache when assessed immediately following treatment. However, we did not find a beneficial effect for these children at follow‐up. We found no beneficial effect of therapies for reducing pain intensity for children with other types of pain. Further, we did not find beneficial effects of remotely‐delivered therapies on physical functioning, depression, or anxiety post‐treatment for headache and mixed chronic pain conditions. However, there were limited data for mixed chronic pain conditions to draw conclusions from these outcomes, particularly at follow‐up. Satisfaction with treatment was described in the trials and was generally positive. Six trials described side effects which were not linked to receiving psychological therapies.
Currently, there are very few studies investigating this treatment. Caution should be taken when interpreting these results as they are based on a small number of studies with few children. Further studies in this area are likely to change our findings and may show this to be a useful treatment for reducing pain and improving functioning in children with long‐term pain.
Quality of the evidence
We rated the quality of the evidence from studies using four levels: very low, low, moderate, or high. Very low‐quality evidence means that we are very uncertain about the results. High‐quality evidence means that we are very confident in the results. We judged the quality of evidence as very low, downgraded due to differences between studies and assessments for the same outcomes, as well as differences identified in the statistical tests. However, this is a growing field and more trials with more participants using cognitive behavioural therapy and other psychological therapies are needed to determine if remotely‐delivered therapies are helpful for young people with long‐term pain.
Emma Fisher, Emily Law, Joanne Dudeney, Christopher Eccleston, Tonya M Palermo
Implications for practice
For children and adolescents with chronic pain
There is insufficient evidence to confidently say whether psychological therapies delivered via technology can reduce pain intensity/severity, or other symptoms associated with chronic pain. Preliminary evidence suggests that these treatments may reduce pain severity immediately following treatment for children with headache, but these effects are not maintained after at least three months. The overall quality of the evidence is very low, meaning we are very uncertain of the estimates of effects and more trials are needed. We found that there are relatively few adverse events associated with these treatments. However, the studies included here all delivered cognitive behavioural therapy (CBT) and therefore, we are uncertain about whether other forms of psychological therapy could be more effective across more outcomes.
Remotely‐delivered therapies may be useful for some children and adolescents with chronic pain, particularly those who have poor access to face‐to‐face treatment. However, none of the interventions included in this review are available to the public. Many of the trials in this review delivered active control, and therefore receiving an active control (e.g. psychoeducation) may also be beneficial for this population. Receiving some form of CBT remotely may reduce pain in the short term, but there is insufficient evidence to show long‐term effects. We did not find any other effects, and there was a distinct lack of evidence for mood outcomes. We judged the quality of evidence as very low, meaning we are very uncertain about the estimates of effects.
For policy makers
We judged the quality of evidence as very low, meaning we are very uncertain about the estimate of effects and there is currently insufficient evidence. However, waiting lists to access chronic pain clinics are typically long (28 to 140 days (Fashler 2016); 197.5 days (Palermo 2019)), and there is an opportunity to deliver psychological therapies at low cost to a wide range of children whilst they wait to see a clinician. The preliminary evidence suggests that these interventions may decrease headache pain in the short term, although more evidence is needed before we can be confident about the estimate of effects for outcomes included in this review. Further, parents may also benefit from psychological interventions, as shown in Fisher 2018 and Eccleston 2015. Funding in this area should be channeled into the stakeholder advised and iterative development of technology‐delivered psychological therapies, and for large, high quality trials that investigate remotely‐delivered therapies via technology. This would increase our confidence of the effects of these interventions.
For funders for the intervention
Currently, the quality of evidence for remote interventions delivered to children with chronic pain is very low. This is due to the small and fairly heterogeneous field, and therefore we need more randomised controlled trials (RCTs) to increase our confidence in the efficacy of these treatments. This modality of intervention is potentially very powerful at reaching and treating large numbers of children and adolescents with chronic pain (i.e. > 160 participants), and should be considered in funding agendas. We encourage further exploration of CBT interventions in this area, but also alternative therapies to reduce the negative impact of chronic pain on children and their families.
Implications for research
Many of our suggestions from the previous version of this review remain relevant. This field is still small but growing. Preliminary findings presented in this review are promising but future studies should build on this base of knowledge and the proposals outlined here. This field has been heavily dominated by CBTs. Other types of therapies delivered remotely should be tested to investigate whether they can produce equivalent or increased effects for children with chronic pain. Remotely‐delivered therapies are likely, eventually, to be provided as the first choice of treatment for many and it would be helpful to investigate whether particular therapies are more relevant for particular patients (Morley 2013).
We encourage multicentre RCTs of remotely‐delivered psychological interventions for children with chronic pain. We propose that future RCTs should include the following components.
- At least two arms, including (at minimum) a treatment group and a placebo comparator. Placebo comparators that control for technology use (e.g. online education) will strengthen the study designs.
- The optimal information size for headache trials should be 80 participants or more per arm and 117 participants or more per arm for mixed chronic pain conditions.
- Trialling of fully automated interventions (without any human support) would provide a more scalable option by lessening the burden on therapists and other healthcare professionals.
- Including full descriptions of technology components (e.g. interactive elements, human support, etc.) to allow for better understanding of potentially effective features of remotely‐delivered interventions.
- Trialling of other psychological therapies (beyond CBT) for children and adolescents with chronic pain.
With regard to measurement, we encourage trials with the following measurement elements.
- Trials should assess the outcome domains recommended by McGrath 2008 for inclusion in clinical trials of children and adolescents with chronic pain. At minimum, trials should measure and report pain intensity, disability, depression, and anxiety outcomes. Assessment of adverse events should be mandatory and reported in published manuscripts.
- Trials should report a 50% reduction in pain frequency, intensity, and duration for headache trials and intensity for mixed chronic pain conditions between baseline and post‐treatment/follow‐up for intervention and control groups. For mixed conditions, a consensus should be met so that pain measures are standardised within pain conditions.
- Trials should also report satisfaction with treatment in both treatment and control arms of trials, so that we are able to assess whether adolescents are more satisfied with psychological therapies compared to control arms.
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