Psychological therapies (remotely delivered) for the management of chronic and recurrent pain in children and adolescents

Background

Children and adolescents with chronic pain often report their pain as hurting too much (intense) and happening too often (frequent). The pain can affect their ability to function physically and that can leave them feeling anxious or depressed. The most common types of chronic pain in children and adolescents are headaches and recurrent abdominal pain. A therapist, physically together with a patient or family (a method often called face-to-face) traditionally delivers psychological therapies, such as cognitive behavioural therapy or behavioural therapy. These therapies can include components such as relaxation techniques, coping strategies, and behavioural strategies, all of which have been found to benefit children by reducing pain and improving physical functioning. However, new technologies now allow 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. By technology we mean the Internet, computer-based programmes, smartphone applications, and the telephone.

Review questions

Can psychological therapies, delivered remotely using technology, help children and adolescents with chronic pain to have less pain, to improve physical functioning, and to have fewer symptoms of depression and anxiety? Are any improvements greater than those reported by children who are waiting to be treated (waiting-list control), or being treated in other ways (active control)?

Study characteristics

We conducted the search through to June 2014. We found eight studies including 371 children and adolescents. Five studies treated children with headache, one study treated children with juvenile idiopathic arthritis, and two studies included mixed samples of children, some who had headache and some with other chronic pain conditions. The average age of children receiving the interventions was 12.6 years. Four trials delivered therapy via the internet, two trials used CD-ROMs, one trial delivered therapy via audiotapes, and one trial delivered therapy via the telephone. All therapies delivered were either cognitive behavioural therapy or behavioural therapy. We looked at six outcomes; pain, physical functioning, depression, anxiety, adverse events, and satisfaction with treatment.

Key results

We split the painful conditions into two groups and analysed them separately. The first group included children with headache pain. The second group included children with other painful conditions (e.g. recurrent abdominal pain, musculoskeletal pain), known as 'mixed pain'. Psychological therapies delivered remotely (primarily via the Internet) were beneficial at reducing pain for children and adolescents with headache pain and mixed pain when assessed immediately following treatment. However, we found no effects of treatment on physical functioning post-treatment for headache and mixed pain conditions. There was also no effect on depression for headache conditions post-treatment. Satisfaction was described qualitatively in the trials and was generally positive. However, we could not assess this outcome using any numbers. For all other outcomes, no data were available for analysis. There was no description of adverse events reported in the included studies.

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. However, this is a growing field and more trials using cognitive behavioural therapy and other psychological therapies are needed to determine the efficacy of remotely delivered therapies.

Authors' conclusions: 

Psychological therapies delivered remotely, primarily via the Internet, confer benefit in reducing the intensity or severity of pain after treatment across conditions. There is considerable uncertainty around these estimates of effect and only eight studies with 371 children contribute to the conclusions. Future studies are likely to change the conclusions reported here. All included trials used either behavioural or cognitive behavioural therapies for children with chronic pain, therefore we cannot generalise our findings to other therapies. However, satisfaction with these treatments was generally positive. Larger trials are needed to increase our confidence in all conclusions regarding the efficacy of remotely delivered psychological therapies. Implications for practice and research are discussed.

Read the full abstract...
Background: 

Chronic pain is common during childhood and adolescence and is associated with negative outcomes such as increased severity of pain, reduced function (e.g. missing school), and low mood (e.g. high levels of depression and anxiety). Psychological therapies, traditionally delivered face-to-face with a therapist, are efficacious at reducing pain intensity and disability. However, new and innovative technology is being used to deliver these psychological therapies remotely, meaning barriers to access to treatment such as distance and cost can be removed or reduced. Therapies delivered with technological devices, such as the Internet, computer-based programmes, smartphone applications, or via the telephone, can be used to deliver treatment to children and adolescents with chronic pain.

Objectives: 

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.

Search strategy: 

We searched four databases (CENTRAL, MEDLINE, EMBASE, and PsycINFO) from inception to June 2014 for randomised controlled trials of remotely delivered psychological interventions for children and adolescents (0 to 18 years of age) 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 for potential trials. A citation and reference search for all included studies was conducted.

Selection criteria: 

All included studies were randomised controlled trials that investigated the efficacy of a psychological therapy delivered remotely via the Internet, smartphone device, computer-based programme, audiotapes, or over the phone in comparison to an active, treatment-as-usual, or waiting-list control. We considered blended treatments, which used a combination of technology and face-to-face interaction. We excluded interventions solely delivered face-to-face between therapist and patient from this review. Children and adolescents (0 to 18 years of age) with a primary chronic pain condition were the target of the interventions. Each comparator arm, at each extraction point had to include 10 or more participants.

Data collection and analysis: 

For the analyses, we combined all psychological therapies. We split pain conditions into headache and mixed (non-headache) pain and analysed them separately. Pain, disability, depression, anxiety, and adverse events were extracted as primary outcomes. We also extracted 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 3 and 12 months (known as 'follow-up'). We assessed all included studies for risk of bias.

Main results: 

Eight studies (N = 371) that delivered treatment remotely were identified from our search; five studies investigated children with headache conditions, one study was with children with juvenile idiopathic arthritis, and two studies included mixed samples of children with headache and mixed (i.e. recurrent abdominal pain, musculoskeletal pain) chronic pain conditions. The average age of children receiving treatment was 12.57 years.

For headache pain conditions, we found one beneficial effect of remotely delivered psychological therapy. Headache severity was reduced post-treatment (risk ratio (RR) = 2.65, 95% confidence interval (CI) 1.56 to 4.50, z = 3.62, p < 0.01, number needed to treat to benefit (NNTB) = 2.88). For mixed pain conditions, we found only one beneficial effect: psychological therapies reduced pain intensity post-treatment (standardised mean difference (SMD) = -0.61, 95% CI -0.96 to -0.25, z = 3.38, p < 0.01). No effects were found for reducing pain at follow-up in either analysis. For headache and mixed conditions, there were no beneficial effects of psychological therapies delivered remotely for disability post-treatment and a lack of data at follow-up meant no analyses could be run. Only one analysis could be conducted for depression outcomes. We found no beneficial effect of psychological therapies in reducing depression post-treatment for headache conditions. Only one study presented data in children with mixed pain conditions for depressive outcomes and no data were available for either condition at follow-up. Only one study presented anxiety data post-treatment and no studies reported follow-up data, therefore no analyses could be run. Further, there were no data available for adverse events, meaning that we are unsure whether psychological therapies are harmful to children who receive them. Satisfaction with treatment is described qualitatively.

'Risk of bias' assessments were low or unclear. We judged selection, detection, and reporting biases to be mostly low risk for included studies. However, judgements made on performance and attrition biases were mostly unclear.

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