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

In this issue of the Journal, we feature the Cochrane Review on psychological therapies for chronic and recurrent pain in children and adolescents. We asked Drs Sara Ahola Kohut and Jennifer Stinson to comment on and put the review in context.

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 randomized controlled trials (RCTs), and additional data from previously included trials.

Methods

Search methods: Searches were undertaken of CENTRAL, MEDLINE, EMBASE and PsycINFO. The references of all identified studies were searched for additional RCTs, meta-analyses and reviews; trial registry databases were also searched. The date of the 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 wait-list control for children or adolescents with episodic, recurrent or persistent pain were eligible for inclusion. Only trials conducted in person (ie, face-to-face) were considered. Studies that delivered treatment remotely were excluded from this update.

Data analysis

All included studies were analyzed and the quality of outcomes were assessed. All treatments were combined into one class: psychological treatments. Pain conditions were split into headache and nonheadache. 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 followup (between three and 12 months post-treatment).

Results

Seven articles were identified in the updated search. Of these articles, 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 because therapy was delivered remotely; thus, the review 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 followup, respectively (risk ratio [RR] 2.47 [95% 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 (standardized 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).

Conclusions

Psychological treatments delivered face-to-face are effective in reducing pain intensity and disability for children and adolescents (<18 years of age) with headache, and therapeutic gains appear to be maintained, although this should be interpreted with caution for the disability outcome because only two studies could be included in the follow-up analysis. Psychological therapies were also beneficial at reducing anxiety post-treatment for headache. For nonheadache conditions, psychological treatments were found to be beneficial for pain and disability post-treatment; however, 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 nonheadache 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.

The full text of the Cochrane Review is available in The Cochrane Library: 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.

EXPERT COMMENTARY

Chronic and recurrent pain is a common complaint in children and adolescents. The most common types of pain include headaches, abdominal pain and musculoskeletal pain. King et al (1) conducted a systematic review of the prevalence of chronic pain in children from 41 studies between 1999 and 2009. They found median prevalence rates ranging from 11% to 38%. Psychological therapies (eg, relaxation, hypnosis, coping skills training, biofeedback and cognitive behavioural therapy) are an essential component of multimodal interventions, comprising pharmacological, physical and psychological treatments, geared at reducing a child’s pain as well as disability (2). Research has made great strides in demonstrating the efficacy of in-person psychological therapies for pain intensity. However, more work is needed to determine immediate and long-term maintenance of improvements in functional disability, anxiety and depression.

Many children and adolescents with chronic and recurrent pain have difficulty accessing appropriate in-person psychological therapies due to limited services (eg, limited availability of trained professionals, specialized clinics are limited to larger metropolitan centres, wait times are long) (3–5). To improve accessibility, numerous research studies are now capitalizing on the Internet to deliver psychological therapies at a distance including online self-management interventions, smartphone applications, and peer mentoring using telephone or online video calling (6–11). An advantage of these therapies is that, if successful, they could enable nonpsychologists and peers to be trained to provide psychological therapies; thus, further improving reach, particularly to children and adolescents living in remote or rural locations.

While new psychological therapies are being developed and investigated, there are strategies that can be currently implemented in office settings without extensive training which are appropriate for all ages. As a part of promoting a multimodal approach to treating pain (ie, pharmacological, physical and psychological therapies), health care providers can:

• –Encourage patients to continue to participate in their daily activities despite pain (eg, encourage continued attendance at school, social engagements, as well as extra-curricular activities and hobbies).
• –Encourage relaxation and stress management strategies such as diaphragmatic breathing, taking breaks, massage, hot or cold packs, and progressive muscle relaxation.
• –Encourage positive coping thoughts, distraction and imagery.
• –Recommend the following books and websites to patients and their families:

Online Resources for children, adolescents and families:

• AboutKidsHealth Pain Resource Centre www.aboutkidshealth.ca/En/ResourceCentres/Pain/

• Pain, Pain, Go Away: Helping Children with Pain http://pediatric-pain.ca/wp-content/uploads/2013/04/PPGA2003.pdf

• PainBytes for Youth: http://www.aci.health.nsw.gov.au/chronic-pain/painbytes/introduction-to-pain

Books for children:

• Managing Your Child’s Chronic Pain, by Tonya M Palermo and Emily F Law

• Be the Boss of Your Pain: Self-Care for Kids, by Cathryn Morgan

• GrrrOUCH!: Pain is Like a Grouchy Bear, by Timothy Culbert and Rebecca Kajander

• Imagine a Rainbow: A Child’s Guide for Soothing Pain, by Brenda S Miles

Books for parents:

• A Child in Pain: How to Help, What to do, by Leora Kuttner

• Me and my Child in Pain, by Sue Beals

• Conquering Your Child’s Chronic Pain: A Pediatrician’s Guide for Reclaiming a Normal Childhood, by Lonnie K Zeltzer and Christina Blackett Schlank

• Relieve Your Child’s Chronic Pain, by Elliot J Krane

• How to Stop Chronic Pain in Children: A Practical Guide, by Michael Dobe and Boris Zernikow, translated by Beverley Stewart

The goal in the office setting is to ensure that patients understand that, although pain may not go away, there are things they can do to manage their pain and ensure it does not interfere with what is important to them. If the above treatments are not successful in reducing pain and disability, a referral to a tertiary care centre that has an interdisciplinary paediatric chronic pain program may be warranted. A list of Canadian and American interdisciplinary paediatric chronic pain clinics can be found at <http://prc.can-adianpaincoalition.ca/en/multidisciplinary_pain_treatment_clinics.html> and <http://www.americanpainsociety.org/membership/content/sharedinterestgroupspainininfantchildandadolescents.html>, respectively.