Intervention Review

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

  1. Christopher Eccleston1,*,
  2. Tonya M Palermo2,
  3. Amanda C de C Williams3,
  4. Amy Lewandowski Holley4,
  5. Stephen Morley5,
  6. Emma Fisher1,
  7. Emily Law2

Editorial Group: Cochrane Pain, Palliative and Supportive Care Group

Published Online: 5 MAY 2014

Assessed as up-to-date: 22 JAN 2014

DOI: 10.1002/14651858.CD003968.pub4

How to Cite

Eccleston C, Palermo TM, Williams ACDC, Lewandowski Holley A, Morley S, Fisher E, Law E. Psychological therapies for the management of chronic and recurrent pain in children and adolescents. Cochrane Database of Systematic Reviews 2014, Issue 5. Art. No.: CD003968. DOI: 10.1002/14651858.CD003968.pub4.

Author Information

  1. 1

    University of Bath, Centre for Pain Research, Bath, UK

  2. 2

    University of Washington, Anesthesiology and Pain Medicine, Seattle, Washington, USA

  3. 3

    University College London, Research Department of Clinical, Educational & Health Psychology, London, UK

  4. 4

    Department of Pediatrics Oregon Health & Science University, Institute on Development & Disability, Portland, Oregon, USA

  5. 5

    University of Leeds, Leeds Institute of Health Sciences, Leeds, UK

*Christopher Eccleston, Centre for Pain Research, University of Bath, Claverton Down, Bath, BA2 7AY, UK. papas@bath.ac.uk. c.eccleston@bath.ac.uk.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 5 MAY 2014

SEARCH

 

Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary

Background

This is an update of the original Cochrane review first published in Issue 1, 2003, and previously updated in 2009 and 2012. Chronic pain affects many children, who report severe pain, disability, and distressed mood. Psychological therapies are emerging as effective interventions to treat children with chronic or recurrent pain. This update focuses specifically on psychological therapies delivered face-to-face, adds new randomised controlled trials (RCTs), and additional data from previously included trials.

Objectives

There were three objectives to this review. First, to determine the effectiveness on clinical outcomes of pain severity, disability, depression, and anxiety of psychological therapy delivered face-to-face for chronic and recurrent pain in children and adolescents compared with active treatment, waiting-list, or standard medical care. Second, to evaluate the impact of psychological therapies on depression and anxiety, which were previously combined as 'mood'. Third, we assessed the risk of bias of the included studies and the quality of outcomes using the GRADE criteria.

Search methods

Searches were undertaken of CENTRAL, MEDLINE, EMBASE, and PsycINFO. We searched for further RCTs in the references of all identified studies, meta-analyses, and reviews. Trial registry databases were also searched. The date of most recent search was January 2014.

Selection criteria

RCTs with at least 10 participants in each arm post-treatment comparing psychological therapies with active treatment, standard medical care, or waiting-list control for children or adolescents with episodic, recurrent or persistent pain were eligible for inclusion. Only trials conducted in person (face-to-face) were considered. Studies that delivered treatment remotely were excluded from this update.

Data collection and analysis

All included studies were analysed and the quality of outcomes were assessed. All treatments were combined into one class, psychological treatments. Pain conditions were split into headache and non-headache. Both conditions were assessed on four outcomes: pain, disability, depression, and anxiety. Data were extracted 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

Seven papers were identified in the updated search. Of these papers, five presented new trials and two presented follow-up data for previously included trials. Five studies that were previously included in this review were excluded as therapy was delivered remotely. The review thus included a total of 37 studies. The total number of participants completing treatments was 2111. Twenty studies addressed treatments for headache (including migraine); nine for abdominal pain; two for mixed pain conditions including headache pain, two for fibromyalgia, two for recurrent abdominal pain or irritable bowel syndrome, and two for pain associated with sickle cell disease.

Analyses revealed psychological therapies to be beneficial for children with chronic pain on seven outcomes. For headache pain, psychological therapies reduced pain post-treatment and at follow-up respectively (risk ratio (RR) 2.47, 95% confidence interval (CI) 1.97 to 3.09, z = 7.87, p < 0.01, number needed to treat to benefit (NNTB) = 2.94; RR 2.89, 95% CI 1.03 to 8.07, z = 2.02, p < 0.05, NNTB = 3.67). Psychological therapies also had a small beneficial effect at reducing disability in headache conditions post-treatment and at follow-up respectively (standardised mean difference (SMD) -0.49, 95% CI -0.74 to -0.24, z = 3.90, p < 0.01; SMD -0.46, 95% CI -0.78 to -0.13, z = 2.72, p < 0.01). No beneficial effect was found on depression post-treatment (SMD -0.18, 95% CI -0.49 to 0.14, z = 1.11, p > 0.05). At follow-up, only one study was eligible, therefore no analysis was possible and no conclusions can be drawn. Analyses revealed a small beneficial effect for anxiety post-treatment (SMD -0.33, 95% CI -0.61 to -0.04, z = 2.25, p < 0.05). However, this was not maintained at follow-up (SMD -0.28, 95% CI -1.00 to 0.45; z = 0.75, p > 0.05).

Analyses revealed two beneficial effects of psychological treatment for children with non-headache pain. Pain was found to improve post-treatment (SMD -0.57, 95% CI -0.86 to -0.27, z = 3.74, p < 0.01), but not at follow-up (SMD -0.11, 95% CI -0.41 to 0.19, z = 0.73, p > 0.05). Psychological therapies also had a beneficial effect for disability post-treatment (SMD -0.45, 95% CI -0.71 to -0.19, z = 3.40, p < 0.01), but this was not maintained at follow-up (SMD -0.35, 95% CI -0.71 to 0.02, z = 1.87, p > 0.05). No effect was found for depression or anxiety post-treatment (SMD -0.07, 95% CI -0.30 to 0.17, z = 0.54, p > 0.05; SMD -0.15, 95% CI -0.36 to 0.07, z = 1.33, p > 0.05) or at follow-up (SMD 0.06, 95% CI -0.16 to 0.28, z = 0.53, p > 0.05; SMD 0.05, 95% CI -0.24 to 0.33, z = 0.32, p > 0.05).

Authors' conclusions

Psychological treatments delivered face-to-face are effective in reducing pain intensity and disability for children and adolescents (<18 years) with headache, and therapeutic gains appear to be maintained, although this should be treated with caution for the disability outcome as only two studies could be included in the follow-up analysis. Psychological therapies are also beneficial at reducing anxiety post-treatment for headache. For non-headache conditions, psychological treatments were found to be beneficial for pain and disability post-treatment but these effects were not maintained at follow-up. There is limited evidence available to estimate the effects of psychological therapies on depression and anxiety for children and adolescents with headache and non-headache pain. The conclusions of this update replicate and add to those of the previous review which found that psychological therapies were effective in reducing pain intensity for children with headache and non-headache pain conditions, and these effects were maintained at follow-up for children with headache conditions.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary

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

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 focuses on treatments that are delivered face-to-face by a therapist. For children and adolescents there is evidence that both relaxation 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.

Psychological therapies also have a lasting effect in reducing pain and disability for chronic headache. Fifty-six per cent of children who were treated with psychological therapies reported less pain compared with 22% of children who did not receive a psychological therapy. Anxiety was also reduced for children with headaches immediately following treatment. Psychological therapies also reduce pain and disability for children with mixed pain conditions (excluding headache) immediately following treatment. However, we did not find that any treatment effects were maintained at follow-up (between 3-12 months after the end of treatment) for children with mixed pain conditions. Psychological therapies did not produce changes in depression in children with either headache or non-headache conditions, and anxiety did not change in children with non-headache conditions receiving psychological therapies.

More studies are needed to understand whether psychological therapies can improve depression and anxiety and have more lasting effects on pain and disability in other groups of young people who have chronic pain.