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Meta-Analysis
. 2018 Sep 29;9(9):CD003968.
doi: 10.1002/14651858.CD003968.pub5.

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

Emma Fisher  1 , Emily Law, Joanne Dudeney, Tonya M Palermo, Gavin Stewart, Christopher Eccleston
Affiliations
Meta-Analysis

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

Emma Fisher et al. Cochrane Database Syst Rev. .

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 painWe 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 conditionsWe 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 evidenceWe 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.

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Conflict of interest statement

EF: None known.

EL: None known; EL is a paediatric psychologist and provides clinical service to children and adolescents with chronic pain. EL is an author on one study included in this review (Palermo 2016) and was not involved in data extraction or assessments of this study. During the completion of this work, EL received salary support from the National Institutes of Health/National Institute of Neurological Disorders and Stroke (Grant number K23NS089966, PI: Law).

JD: None known.

TP: None known; TP is an author on one study included in this review (Palermo 2016) and was not involved in data extraction or assessments of this study. During the completion of this work, TP received salary support from the National Institutes of Health/National Institute of Child Health, behaviour and Development (K24HD060068, PI: Palermo).

CE: None known; CE is an author on one study included in this review (Palermo 2016) and was not involved in data extraction or assessments of this study. Since CE is an author as well as the PaPaS Co‐ordinating Editor at the time of writing, we acknowledge the input of Amanda C de C Williams who acted as Sign Off Editor for this review. CE had no input into the editorial decisions or processes for this review.

Figures

1
1
Study flow diagram.
2
2
Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
3
3
Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
4
4
Forest plot of comparison: 1 Treatment versus control (headache) post‐treatment, outcome: 1.1 Pain.
5
5
Forest plot of comparison: 3 Treatment versus control (mixed chronic pain conditions) post‐treatment, outcome: 3.1 Pain.
1.1
1.1. Analysis
Comparison 1: Treatment versus control (headache) post‐treatment, Outcome 1: Pain
1.2
1.2. Analysis
Comparison 1: Treatment versus control (headache) post‐treatment, Outcome 2: Disability
1.3
1.3. Analysis
Comparison 1: Treatment versus control (headache) post‐treatment, Outcome 3: Depression
1.4
1.4. Analysis
Comparison 1: Treatment versus control (headache) post‐treatment, Outcome 4: Anxiety
2.1
2.1. Analysis
Comparison 2: Treatment versus control (headache) follow‐up, Outcome 1: Pain
2.2
2.2. Analysis
Comparison 2: Treatment versus control (headache) follow‐up, Outcome 2: Disability
2.3
2.3. Analysis
Comparison 2: Treatment versus control (headache) follow‐up, Outcome 3: Depression
2.4
2.4. Analysis
Comparison 2: Treatment versus control (headache) follow‐up, Outcome 4: Anxiety
3.1
3.1. Analysis
Comparison 3: Treatment versus control (mixed pain) post‐treatment, Outcome 1: Pain
3.2
3.2. Analysis
Comparison 3: Treatment versus control (mixed pain) post‐treatment, Outcome 2: Disability
3.3
3.3. Analysis
Comparison 3: Treatment versus control (mixed pain) post‐treatment, Outcome 3: Depression
3.4
3.4. Analysis
Comparison 3: Treatment versus control (mixed pain) post‐treatment, Outcome 4: Anxiety
4.1
4.1. Analysis
Comparison 4: Treatment versus control (mixed pain) follow‐up, Outcome 1: Pain
4.2
4.2. Analysis
Comparison 4: Treatment versus control (mixed pain) follow‐up, Outcome 2: Disability
4.3
4.3. Analysis
Comparison 4: Treatment versus control (mixed pain) follow‐up, Outcome 3: Depression
4.4
4.4. Analysis
Comparison 4: Treatment versus control (mixed pain) follow‐up, Outcome 4: Anxiety
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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Chen 2014 {published data only}
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Kroener‐Herwig 2002 {published data only}
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Labbe 1995 {published data only}
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Larsson 1987a {published data only}
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Larsson 1987b {published data only}
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Larsson 1990 {published data only}
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Larsson 1996 {published data only}
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Levy 2010 {published data only}
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Levy 2017 {published data only}
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McGrath 1988 {published data only}
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McGrath 1992 {published data only}
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Powers 2013 {published data only}
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Robins 2005 {published data only}
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Sanders 1994 {published data only}
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Sartory 1998 {published data only}
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Scharff 2002 {published data only}
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Van der Veek 2013 {published data only}
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Van Tilburg 2009 {published data only}
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Vlieger 2007 {published data only}
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Wahlund 2003 {published data only}
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Wahlund 2015 {published data only}
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References to studies excluded from this review

Connelly 2006 {published data only}
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Fentress 1986 {published data only}
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Jastrowski Mano 2013 {published data only}
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Korterink 2016 {published data only}
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