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

  • Review
  • Intervention

Authors


Abstract

Background

Headache, recurrent abdominal pain, and musculoskeletal pain affect many children, who report severe pain, distressed mood, and disability. Psychological therapies are emerging as effective interventions to treat children with chronic or recurrent pain. This is a substantially updated and expanded version of the Cochrane review published in 2003.

Objectives

To assess the effectiveness of psychological therapies for reducing pain, disability, and improving mood in children and adolescents with recurrent, episodic, or persistent pain.

Search methods

Searches were undertaken of MEDLINE, PsycLIT, EMBASE and CONSORT. RCTs were sought in references of all identified studies, meta-analyses and reviews. Date of most recent search: August 2008.

Selection criteria

Randomised Controlled Trials (RCTs) with at least ten participants in each arm post-treatment comparing psychological therapies with placebo, waiting list or standard medical care for children or adolescents with episodic, recurrent or persistent pain, were eligible for inclusion.

Data collection and analysis

All included studies were analysed and the quality of the studies recorded. All treatments were combined into one class: psychological treatments; headache and non-headache outcomes were separately analysed on three outcomes: pain, disability, and mood.

Main results

Thirty-four RCT studies were recovered; 29 met the inclusion criteria. The total number of participants completing treatments was 1432. Twenty studies addressed treatments for headache (including migraine); six for abdominal pain; one for both headache and abdominal pain, one study was for fibromyalgia, and one was for pain associated with sickle cell disease. The analysis of headache treatment versus control differences immediately post-treatment for pain gave an odds ratio (OR) of 5.51 (95% CI 3.28 to 9.24; z = 6.46, P < 0.05); NNT = 2.57 (CI 2.2 to 3.13). At follow-up, the OR was 9.91 (95% CI 3.73 to 26.33); z = 9.91, P < 0.05); NNT = 1.99 (CI 1.63 to 2.72). Analysis of non-headache treatment versus control differences immediately post-treatment for pain found a large effect size of -0.94 (95% CI -1.43 to -0.44) Z = 3.71, P < 0.05. At follow-up, a large effect size was found of -1.08 (95%CI -1.84 to -0.33); Z = 2.82, P < 0.05). There were no other significant effects.

Authors' conclusions

Psychological treatments are effective in pain control for children with headache and benefits appear to be maintained. Psychological treatments may also improve pain control for children with musculoskeletal and recurrent abdominal pain. There is little evidence available to estimate effects on disability or mood.

摘要

背景

以心理療法處理兒童與青少年慢性與經常性的疼痛

頭痛、經常性的腹痛,以及肌肉骨骼疼痛影響著許多的兒童,他們會反映有嚴重的疼痛、苦惱的情緒,以及失能。對於治療患有慢性或是經常性之疼痛的兒童們而言,心理療法是新興而且具有功效的介入行為。本文是2003年the Cochrane回顧版本的大幅更新與擴充。

目標

對於患有經常性、陣發性,或是持續性疼痛之兒童與青少年而言,評估心理療法對減輕疼痛、失能,以及改善情緒的療效。

搜尋策略

搜尋MEDLINE、PsycLIT、EMBASE以及CONSORT。並透過搜尋所找到的研究、統合分析以及文獻回顧的參考文獻找出相關的RCTs。最近一次搜尋日期為2008年8月。

選擇標準

隨機對照試驗(RTCs),對於患有陣發性、經常性,或是持續性疼痛之兒童與青少年比較心理療法與安慰劑、等候治療者,或是以標準的醫療來進行治療,在每1個組別當中至少有10名以上的參與者,。

資料收集與分析

所有被收集在內的研究都經過了分析,而且這些研究的品質都被記錄了下來。所有的治療方法都被合併到1種類別當中:心理療法;關於頭痛與非頭痛方面的結果,都會針對3種結果而進行個別的分析,而這3種結果為:疼痛、失能,以及情緒。

主要結論

其中涵蓋了34項隨機對照的研究;有29項符合了收集的標準。就進行完治療的參與者來看,總數為1432人。有20項研究針對頭痛的治療方法來進行探討(包括了偏頭痛);有6項研究則是針對腹部疼痛;有1項研究則是同時針對頭痛與腹部疼痛這2種,有1項研究是針對纖維肌痛,還有1項則是針對伴隨著鐮狀細胞病的疼痛。治療之後,在針對頭痛治療相較於對照差異所作的立即性止痛分析中,顯示了某種達到5.51的勝算比(OR)(95% CI 3.28到9.24;z = 6.46,P < 0.05);NNT = 2.57(CI 2.2到3.13)。在後續的追蹤期之中,勝算比為9.91(95% CI 3.73到26.33);z = 9.91,P < 0.05);NNT = 1.99(CI 1.63到2.72)。治療之後,在針對疼痛而對非頭痛治療相較於對照差異所作的立即性分析中,顯示了某種達到−0.94的大型效果規模(95% CI −1.43到−0.44)Z = 3.71,P < 0.05)。在後續的追蹤期之中,我們發現了某種達到−1.08的大型效果規模(95% CI −1.84到−0.33);Z = 2.82,P < 0.05)。其他項目並無顯著效果。

作者結論

對於患有頭痛的兒童們而言,心理療法可有效控制疼痛,而且療效可以持續。對於患有肌肉骨骼與經常性腹部疼痛的兒童們來說,心理療法或許可以改善疼痛控制。至於失能或是情緒方面的影響僅有少量的證據可供評估。

翻譯人

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

心理療法(放鬆、催眠、應對技巧的訓練、生物的回饋作用、認知行為方面的療法)可能可以幫助人們處理疼痛以及它造成的失能後果。針對兒童們與青少年們而言,有1項良好的證據顯示,放鬆與認知行為方面的療法(可以幫助人們測試並修正他們的想法與行為之治療方法)均可以有效地降低慢性疼痛、經常性腹部疼痛,以及纖維肌痛等項目的嚴重性與頻率。這些治療方法顯然會有某種持續性的功效。然而,對於減少失能以及幫助年輕人能夠更獨立積極,並沒有足夠的研究可以測量這些治療方法的效果,而且也沒辦法充分地測量對於情緒方面的效應。

Plain language summary

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

Psychological therapies (relaxation, hypnosis, coping skills training, biofeedback, cognitive behavioural therapy) are treatments which may help people manage pain and its disabling consequences. For children and youths there is good evidence that both relaxation and cognitive behavioural therapy (treatment which helps people test and revise their thoughts and actions) are effective in reducing the severity and frequency of chronic headache, recurrent abdominal pain, and fibromyalgia. These treatments appear to have a lasting effect. Not enough studies, however, measure the effects of these treatments on reducing disability and helping young people to be more independently active, and not enough measure the effects on mood.