Psychological Therapies for Children With Chronic Pain
Psychological Therapies for Children With Chronic Pain
Objectives This systematic review and meta-analysis examined the effects of psychological therapies for management of chronic pain in children.
Methods Randomized controlled trials of psychological interventions treating children (<18 years) with chronic pain conditions including headache, abdominal, musculoskeletal, or neuropathic pain were searched for. Pain symptoms, disability, depression, anxiety, and sleep outcomes were extracted. Risk of bias was assessed and quality of the evidence was rated using GRADE.
Results 35 included studies revealed that across all chronic pain conditions, psychological interventions reduced pain symptoms and disability posttreatment. Individual pain conditions were analyzed separately. Sleep outcomes were not reported in any trials. Optimal dose of treatment was explored. For headache pain, higher treatment dose led to greater reductions in pain. No effect of dosage was found for other chronic pain conditions.
Conclusions Evidence for psychological therapies treating chronic pain is promising. Recommendations for clinical practice and research are presented.
Chronic or recurrent pain (lasting longer than 3 months) is a common complaint of childhood (Perquin et al., 2000), although in most cases, it is self-limiting and clinically uncomplicated. However, a minority of children and adolescents report pain that interferes with their daily lives (Huguet & Miro, 2008), is associated with functional disability and distress, and has wider impact on social and physical functioning, family life, and parenting (Hunfeld et al., 2002; Jordan, Eccleston, & Osborn, 2007; Logan, Simons, Stein, & Chastain, 2008; Walker, Guite, Duke, Barnard, & Greene, 1998). Many of these children present health care facilities seeking both pain relief and help with disability, depression, anxiety, and social functioning.
Chronic pain problems can arise from many physical health conditions or emerge idiopathically. The most common pain conditions in children are headache, abdominal pain, back pain, complex regional pain syndrome Type 1, pain from disease such as rheumatoid arthritis, and nonspecific complaints such as "growing pain." Also common are widespread musculoskeletal pain complaints, including fibromyalgia syndrome (FMS) (King et al., 2011). Although pain is commonly defined as chronic after 3 months, patients presenting to specialized pain centers typically have had pain for much longer (Eccleston, Malleson, Clinch, Connell, & Sourbut, 2003; Logan et al., 2012).
Psychological treatments, principally but not exclusively cognitive and behavioral treatments, have been developed with a focus on the self-management of pain and disability (Palermo, 2012). Psychological treatments are well established in the treatment of adult chronic pain (Williams, Eccleston, & Morley, 2012). Typically, cognitive-behavioral treatments focus on the client/patient being actively involved in treatment, which often consists of behavioral strategies for engagement with normal daily activities, an increased awareness and challenge of the role of cognition in exacerbating suffering, a focus on the self-regulation of emotion, and the use of techniques for reducing aversive arousal (e.g., relaxation). This is all delivered within a psychoeducational frame. Treatments that focus specifically on pediatric chronic pain may provide skills training both to children and their parents (Eccleston, Palermo, Fisher, & Law, 2012b). Typically, when parents are included in treatment, the focus of treatment strategies is on operant skills training.
There have been periodic summaries of the evidence base for psychological therapies in children with chronic pain, and this review follows in that tradition. In the previous 1999 Journal of Pediatric Psychology special issue, three reviews focused explicitly on headache (Holden, Deichmann, & Levy, 1999), recurrent abdominal pain (RAP) (Janicke & Finney, 1999), and on disease related pain (including studies with FMS) (Walco, Sterling, Conte, & Engel, 1999). Interestingly, systematic reviews have also been reported outside the psychological press, often with psychological treatments being included in a compound review of treatments for a single condition such as abdominal pain (Weydert, Ball, & Davis, 2003). All of these reviews return either positive or promising conclusions for the effectiveness of psychological treatments, even when data are sparse. However, these earlier reviews were undertaken without any methodological concern for bias and included trials conducted before consensus statements on methodological quality were reported (McGrath et al., 2008). Modern systematic review practices are incorporated in Cochrane Systematic Reviews, which have focused on RAP within the context of irritable bowel syndrome (Huertas-Ceballos, Logan, Bennett, & Macarthur, 2014), and chronic pain in children (Eccleston et al., 2012c). The latter review reports data from a broad range of trials that investigated the effectiveness of psychological therapies in both headache and nonheadache populations. This Cochrane Review was first published in 2003, substantially updated in 2009, and most recently updated in 2012 (Eccleston et al., 2012c). Palermo, Eccleston, Lewandowski, Williams, and Morley (2010) extended the 2009 version of this review to include studies on Internet-delivered treatments. The analyses of 37 included studies showed that psychological therapies were effective in improving pain symptoms for both headache and nonheadache pain conditions posttreatment compared with control conditions, and at follow-up for the headache group. Disability also significantly improved in the nonheadache group posttreatment. Finally, mood (including depression and anxiety) significantly improved in the headache group at follow-up.
In this systematic review, we take the Cochrane Review last updated in 2012 as our starting point. We enhance and extend former reviews in three specific ways:
The aims of the review were as follows:
Abstract and Introduction
Abstract
Objectives This systematic review and meta-analysis examined the effects of psychological therapies for management of chronic pain in children.
Methods Randomized controlled trials of psychological interventions treating children (<18 years) with chronic pain conditions including headache, abdominal, musculoskeletal, or neuropathic pain were searched for. Pain symptoms, disability, depression, anxiety, and sleep outcomes were extracted. Risk of bias was assessed and quality of the evidence was rated using GRADE.
Results 35 included studies revealed that across all chronic pain conditions, psychological interventions reduced pain symptoms and disability posttreatment. Individual pain conditions were analyzed separately. Sleep outcomes were not reported in any trials. Optimal dose of treatment was explored. For headache pain, higher treatment dose led to greater reductions in pain. No effect of dosage was found for other chronic pain conditions.
Conclusions Evidence for psychological therapies treating chronic pain is promising. Recommendations for clinical practice and research are presented.
Introduction
Chronic or recurrent pain (lasting longer than 3 months) is a common complaint of childhood (Perquin et al., 2000), although in most cases, it is self-limiting and clinically uncomplicated. However, a minority of children and adolescents report pain that interferes with their daily lives (Huguet & Miro, 2008), is associated with functional disability and distress, and has wider impact on social and physical functioning, family life, and parenting (Hunfeld et al., 2002; Jordan, Eccleston, & Osborn, 2007; Logan, Simons, Stein, & Chastain, 2008; Walker, Guite, Duke, Barnard, & Greene, 1998). Many of these children present health care facilities seeking both pain relief and help with disability, depression, anxiety, and social functioning.
Chronic pain problems can arise from many physical health conditions or emerge idiopathically. The most common pain conditions in children are headache, abdominal pain, back pain, complex regional pain syndrome Type 1, pain from disease such as rheumatoid arthritis, and nonspecific complaints such as "growing pain." Also common are widespread musculoskeletal pain complaints, including fibromyalgia syndrome (FMS) (King et al., 2011). Although pain is commonly defined as chronic after 3 months, patients presenting to specialized pain centers typically have had pain for much longer (Eccleston, Malleson, Clinch, Connell, & Sourbut, 2003; Logan et al., 2012).
Psychological treatments, principally but not exclusively cognitive and behavioral treatments, have been developed with a focus on the self-management of pain and disability (Palermo, 2012). Psychological treatments are well established in the treatment of adult chronic pain (Williams, Eccleston, & Morley, 2012). Typically, cognitive-behavioral treatments focus on the client/patient being actively involved in treatment, which often consists of behavioral strategies for engagement with normal daily activities, an increased awareness and challenge of the role of cognition in exacerbating suffering, a focus on the self-regulation of emotion, and the use of techniques for reducing aversive arousal (e.g., relaxation). This is all delivered within a psychoeducational frame. Treatments that focus specifically on pediatric chronic pain may provide skills training both to children and their parents (Eccleston, Palermo, Fisher, & Law, 2012b). Typically, when parents are included in treatment, the focus of treatment strategies is on operant skills training.
There have been periodic summaries of the evidence base for psychological therapies in children with chronic pain, and this review follows in that tradition. In the previous 1999 Journal of Pediatric Psychology special issue, three reviews focused explicitly on headache (Holden, Deichmann, & Levy, 1999), recurrent abdominal pain (RAP) (Janicke & Finney, 1999), and on disease related pain (including studies with FMS) (Walco, Sterling, Conte, & Engel, 1999). Interestingly, systematic reviews have also been reported outside the psychological press, often with psychological treatments being included in a compound review of treatments for a single condition such as abdominal pain (Weydert, Ball, & Davis, 2003). All of these reviews return either positive or promising conclusions for the effectiveness of psychological treatments, even when data are sparse. However, these earlier reviews were undertaken without any methodological concern for bias and included trials conducted before consensus statements on methodological quality were reported (McGrath et al., 2008). Modern systematic review practices are incorporated in Cochrane Systematic Reviews, which have focused on RAP within the context of irritable bowel syndrome (Huertas-Ceballos, Logan, Bennett, & Macarthur, 2014), and chronic pain in children (Eccleston et al., 2012c). The latter review reports data from a broad range of trials that investigated the effectiveness of psychological therapies in both headache and nonheadache populations. This Cochrane Review was first published in 2003, substantially updated in 2009, and most recently updated in 2012 (Eccleston et al., 2012c). Palermo, Eccleston, Lewandowski, Williams, and Morley (2010) extended the 2009 version of this review to include studies on Internet-delivered treatments. The analyses of 37 included studies showed that psychological therapies were effective in improving pain symptoms for both headache and nonheadache pain conditions posttreatment compared with control conditions, and at follow-up for the headache group. Disability also significantly improved in the nonheadache group posttreatment. Finally, mood (including depression and anxiety) significantly improved in the headache group at follow-up.
In this systematic review, we take the Cochrane Review last updated in 2012 as our starting point. We enhance and extend former reviews in three specific ways:
First, we separate trials into discrete clinical conditions offering evidence summaries of the quantitative effects of psychological treatment in the areas of headache (including migraine), abdominal pain, neuropathic pain (including complex regional pain syndrome Type 1), and musculoskeletal pain (including FMS).
Second, we expand the outcome assessment in several ways. We separate the compound category of "mood" into two separate outcomes: depression and anxiety (including catastrophizing), as they are distinct concepts that may have differential effects from psychological treatments for chronic pain. Furthermore, rumination about possible extreme negative outcomes due to pain, known variously as catastrophizing, awfulizing, or worry, has been identified as a key anxious cognitive construct in adapting to pain (Eccleston, Fisher, Vervoort, & Crombez, 2012a) and has been identified as a possible therapeutic mechanism that is influential to the effectiveness of cognitive-behavioral therapy (CBT) (Burns, Day, & Thorn, 2012). This addition of an anxiety outcome matches that undertaken in the recent Cochrane Review for psychological interventions with adults suffering chronic pain (Williams et al., 2012). We also include sleep as an outcome, for the first time. There is evidence that sleep disturbances are related to mood disturbances and increased functional disability outcomes of chronic pain in children (Palermo & Kiska, 2004), and that insufficient sleep can negatively impact pain management (Lewin & Dahl, 1999).
Third, we examine the relationship of treatment dose (hours of delivered treatment) on effect sizes related to treatment outcomes to understand the optimal dose of therapy for children with chronic pain.
The aims of the review were as follows:
To quantify the effects of psychological interventions and any adverse outcomes from psychological interventions for the management of chronic pain (including all conditions) in children and adolescents.
To summarize the evidence for the efficacy of psychological interventions for four chronic pain conditions: headache, abdominal pain, neuropathic pain, and musculoskeletal pain. Evidence is reported according to each condition, in five outcome domains (pain, functional disability, depression, anxiety, and sleep). Where possible, outcomes are explored both immediately following treatment and at longer-term follow-up (3–12 months).
To examine the relationship of treatment dose (i.e., total minutes of exposure to treatment) on effect sizes related to treatment outcomes to explore the optimal treatment dose for the reduction of pain symptoms for headache and chronic pain (excluding headache) conditions.
