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

Background

Experiencing long-term pain during childhood is common. Children and adolescents (< 18 years of age) with long-term pain often report intense pain which negatively impacts their lives. The pain can affect their ability to function physically, can limit their ability to go to school, and can leave them feeling anxious or depressed. The most common types of chronic pain in children and adolescents are headaches, recurrent abdominal pain, musculoskeletal pain, and back pain. Normally, a therapist, physically together with a patient or family (a method often called face-to-face) delivers psychological therapies, such as cognitive behavioural therapy (e.g. coping skills, activity pacing) or behavioural therapy (e.g. relaxation exercises). We know that face-to-face therapies can reduce pain intensity and improve physical functioning in children. Technology (e.g. the Internet, computer programmes, and smartphone applications) now allows 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.

We set out to understand if psychological therapies, delivered remotely using technology, can help children and adolescents with long-term pain to have less pain, to improve physical functioning, and to have fewer symptoms of depression and anxiety, compared to children who are waiting to be treated (waiting-list control), or being treated in other ways (active control, e.g. receiving education about long-term pain).

Study characteristics

For this update, we conducted the search through to May 2018. We found 10 studies including 697 children and adolescents; four of these studies (326 participants) were new for this update. Four studies treated children with headache, one study treated children with juvenile idiopathic arthritis, one treated children with sickle cell disease, one included children with irritable bowel syndrome, and three studies included mixed samples of children, some who had headache and some with other chronic pain conditions. All studies delivered cognitive behavioural therapy. The average age of children receiving the interventions was 13 years. We looked at six outcomes: pain, physical functioning, depression, anxiety, side effects, and satisfaction with treatment.

Key results

We split the painful conditions into two groups and looked at them separately. The first group included children with headache. The second group included children with other painful conditions (e.g. frequent stomach pain, musculoskeletal pain), known as 'mixed chronic pain'. Psychological therapies delivered remotely (primarily via the Internet) were helpful at reducing pain for children and adolescents with headache when assessed immediately following treatment. However, we did not find a beneficial effect for these children at follow-up. We found no beneficial effect of therapies for reducing pain intensity for children with other types of pain. Further, we did not find beneficial effects of remotely-delivered therapies on physical functioning, depression, or anxiety post-treatment for headache and mixed chronic pain conditions. However, there were limited data for mixed chronic pain conditions to draw conclusions from these outcomes, particularly at follow-up. Satisfaction with treatment was described in the trials and was generally positive. Six trials described side effects which were not linked to receiving psychological therapies.

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. Further studies in this area are likely to change our findings and may show this to be a useful treatment for reducing pain and improving functioning in children with long-term pain.

Quality of the evidence

We rated the quality of the evidence from studies using four levels: very low, low, moderate, or high. Very low-quality evidence means that we are very uncertain about the results. High-quality evidence means that we are very confident in the results. We judged the quality of evidence as very low, downgraded due to differences between studies and assessments for the same outcomes, as well as differences identified in the statistical tests. However, this is a growing field and more trials with more participants using cognitive behavioural therapy and other psychological therapies are needed to determine if remotely-delivered therapies are helpful for young people with long-term pain.

Authors' conclusions: 

There are currently a small number of trials investigating psychological therapies delivered remotely, primarily via the Internet. We are cautious in our interpretations of analyses. We found one beneficial effect of therapies to reduce headache severity post-treatment. For the remaining outcomes there was either no beneficial effect at post-treatment or follow-up, or lack of evidence to determine an effect. Overall, participant satisfaction with treatment was positive. We judged the quality of the evidence to be very low, meaning we are very uncertain about the estimate. Further studies are needed to increase our confidence in this potentially promising field.

Read the full abstract...
Background: 

This is the first update of a review published in 2015, Issue 1. Chronic pain is common during childhood and adolescence and is associated with negative outcomes, such as increased severity of pain, reduced function, and low mood. Psychological therapies, traditionally delivered face-to-face with a therapist, are efficacious at reducing pain intensity and disability. To address barriers to treatment access, such as distance and cost of treatment, technology is being used to deliver these psychological therapies remotely. Therapies delivered remotely, such as via the Internet, computer-based programmes, and smartphone applications, 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 May 2018 for randomised controlled trials (RCTs) of remotely-delivered psychological interventions for children and adolescents 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, reference sections, and citations of included studies for potential trials.

Selection criteria: 

We included RCTs that investigated the efficacy of a psychological therapy delivered remotely via technology in comparison to an active, treatment as usual, or waiting-list control. We considered blended treatments, which used a combination of technology and up to 30% face-to-face interaction. Interventions had to be delivered primarily via technology to be included, and we excluded interventions delivered via telephone. We included studies that delivered interventions to children and adolescents (up to 18 years of age) with a chronic pain condition or where chronic pain was a primary symptom of their condition (e.g. juvenile arthritis). We included studies that reported 10 or more participants in each comparator arm, at each extraction point.

Data collection and analysis: 

We combined all psychological therapies in the analyses. We split pain conditions into headache and mixed (non-headache) pain and analysed them separately. We extracted pain severity/intensity, disability, depression, anxiety, and adverse events as primary outcomes, and 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 three and 12 months (known as 'follow-up'). We assessed risk of bias and all outcomes for quality using the GRADE assessment.

Main results: 

We found 10 studies with 697 participants (an additional 4 studies with 326 participants since the previous review) that delivered treatment remotely; four studies investigated children with headache conditions, one study was with children with juvenile idiopathic arthritis, one included children with sickle cell disease, one included children with irritable bowel syndrome, and three studies included children with different chronic pain conditions (i.e. headache, recurrent abdominal pain, musculoskeletal pain). The average age of children receiving treatment was 13.17 years.

We judged selection, detection, and reporting biases to be mostly low risk. However, we judged performance and attrition biases to be mostly unclear. Out of the 16 planned analyses, we were able to conduct 13 meta-analyses. We downgraded outcomes for imprecision, indirectness of evidence, inconsistency of results, or because the analysis only included one study.

Headache conditions

For headache pain conditions, we found headache severity was reduced post-treatment (risk ratio (RR) 2.02, 95% confidence interval (CI) 1.35 to 3.01); P < 0.001, number needed to treat to benefit (NNTB) = 5.36, 7 studies, 379 participants; very low-quality evidence). No effect was found at follow-up (very low-quality evidence). There were no effects of psychological therapies delivered remotely for disability post-treatment (standardised mean difference (SMD) -0.16, 95% CI -0.46 to 0.13; P = 0.28, 5 studies, 440 participants) or follow-up (both very low-quality evidence). Similarly, no effect was found for the outcomes of depression (SMD -0.04, 95% CI -0.15 to 0.23, P = 0.69, 4 studies, 422 participants) or anxiety (SMD -0.08, 95% CI -0.28 to 0.12; P = 0.45, 3 studies, 380 participants) at post-treatment, or follow-up (both very low-quality evidence).

Mixed chronic pain conditions

We did not find any beneficial effects of psychological therapies for reducing pain intensity post-treatment for mixed chronic pain conditions (SMD -0.90, 95% CI -1.95 to 0.16; P = 0.10, 5 studies, 501 participants) or at follow-up. There were no beneficial effects of psychological therapies delivered remotely for disability post-treatment (SMD -0.28, 95% CI -0.74 to 0.18; P = 0.24, 3 studies, 363 participants) and a lack of data at follow-up meant no analysis could be run. We found no beneficial effects for the outcomes of depression (SMD 0.04, 95% CI -0.18 to 0.26; P = 0.73, 2 studies, 317 participants) and anxiety (SMD 0.53, 95% CI -0.63 to 1.68; P = 0.37, 2 studies, 370 participants) post-treatment, however, we are cautious of our findings as we could only include two studies in the analyses. We could not conduct analyses at follow-up. We judged the evidence for all outcomes to be very low quality.

All conditions

Across all chronic pain conditions, six studies reported minor adverse events which were not attributed to the psychological therapies. Satisfaction with treatment is described qualitatively and was overall positive. However, we judged both these outcomes as very low quality.

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