Description of the condition
Chronic pain is prevalent during childhood and adolescence (Perquin 2000). Epidemiological studies report that girls experience more pain in comparison to boys, and that pain increases during early adolescence (King 2011). Further, risk of developing a pain condition is higher for children of a lower socioeconomic status (King 2011). The most commonly reported pain problems are headache, recurrent abdominal pain, musculoskeletal pain, and back pain (King 2011). Some children with chronic pain report high levels of pain as well as depression and anxiety (Gauntlett-Gilbert 2007; Kaczynski 2011). Children can also suffer impairments in their physical and social functioning, such as attending school (Cohen 2011). The detrimental effects of chronic pain can also impact their parents who report significant distress and anxiety (Jordan 2007; Maciver 2010).
Description of the intervention
Psychological therapies, delivered individually or in groups to children and families, significantly reduce pain and disability in youths with chronic pain (Eccleston 2014). However, many young people do not receive psychological treatments for chronic pain due to barriers such as a shortage of providers, expense, and geographic distance from treatment centres (Palermo 2013; Peng 2007). This has led to consideration of innovative methods of delivery and calls to assess whether psychological interventions can be effectively delivered remotely using technology such as the Internet (Palermo 2009). The Internet is widely available to a large number of children and adolescents. For example in the UK 83% of households had Internet access in 2013 (ONS 2013), in the US 72% (USDC 2013) and in Australia 79 % (ABS 2012) meaning that access to health information or treatments is potentially more easily available.
Different terms are used within this growing field, broadly described as e-health, telemedicine, telecare, minimal therapist contact, and distance treatment. Here, we adopt "remotely delivered therapies" to define psychological therapies delivered without, or with limited face-to-face contact with the therapist. Therapies will typically be delivered via technology, principally the Internet, but could also be delivered via telephone, written materials, or stand-alone computer programmes. Therapies may also be combined or blended by including both face-to-face and remote components. These interventions can be delivered in the home or community (outside the clinic or hospital setting) without the physical presence of a therapist.
How the intervention might work
Psychological therapies (as discussed in Eccleston 2014) are used in paediatric pain practice to reduce pain symptoms, disability, and negative mood associated with pain conditions, and to modify social-environmental factors to enhance the child’s adaptive functioning. This field is currently dominated by cognitive and behavioural therapies that incorporate components such as relaxation, biofeedback, imagery, parent operant strategies, and coping skills training.
Recognising the advantages of reaching more children in their homes with remotely delivered interventions, earlier studies relied on low levels of technology, including written self-help manuals, portable biofeedback monitors, and relaxation audiotapes (e.g. Burke 1989; McGrath 1992). As technological advances became available to the masses, intervention delivery options expanded to personal computers via CD-ROM applications and then via Internet interventions. The delivery of psychological therapies over the Internet is becoming more common (March 2008; Richardson 2010; Tait 2010). The potential benefits to a successful programme include improved access, improved scale of coverage, and lower cost (Marks 2009; Palermo 2009). However, the change of a delivery mechanism from face-to face delivery to remote delivery solely by, or augmented with technology, arguably changes the content, intensity, and force of a treatment. The move away from delivery is not simply to change the route of intervention delivery to a remote method. Instead, the transformation of a treatment to a reliance on communication technology (instead of face-to-face interaction with a therapist) may involve critical changes in aspects of the treatment thought crucial to its success. For example, treatment where a therapist is not present may influence treatment participation and impact treatment outcomes (Fry 2009).
There may also be different therapeutic opportunities available using interactive and communication technologies. As described in the behavioural change model for Internet interventions (Ritterband 2009), user characteristics interact with website characteristics to produce behaviour change. For example, internet-delivered therapies may work by better matching and designing technology to maximise the therapeutic benefits (e.g. 24 hour access to skills training), or there may be a blend to these solutions that function differently dependent upon user characteristics. Typically, authors are not explicit about how the technology may have changed the intervention itself, but earlier remotely delivered therapies were informed by the question of equivalence: can an remotely delivered therapy perform as well as a face-to-face therapy? More recent trials treat the remotely delivered therapy as a package and ask: can a remotely delivered therapy achieve better outcomes than a comparison group or can remotely delivered therapy be efficacious in achieving positive change in meaningful treatment outcomes?
Why it is important to do this review
Psychological therapies delivered remotely (principally but not exclusively via the Internet) have now developed into stand alone treatments, and are investigated as stand alone treatments. A Cochrane review has previously summarised evidence of psychological therapies for the management of chronic pain in children and adolescents (Eccleston 2014). This was first authored in 2003, and updated in 2009, 2012, and most recently in 2014. Earlier updates combined remote and face-to-face office-based treatment delivery. However, we believe it is important to separate them so that evidence can be separately evaluated. This review should be considered a sister review to the Eccleston 2014 update which excludes treatments delivered remotely. A similar distinction has also been made in the Cochrane reviews on psychological therapies for the management of chronic pain in adults: face-to-face (Williams 2012) and Internet delivered (Eccleston 2012).