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Evidence summaries

Psychological Therapies for the Management of Chronic and Recurrent Pain in Children and Adolescents

Psychological treatments delivered predominantly face-to-face may be effective for reducing pain for children and adolescents with headache or other chronic pain conditions post-treatment. Level of evidence: "C"

The quality of evidence is downgraded by study limitations (unclear allocation concealment and blinding), and by imprecise results (wide cofidence intervals).

Summary

A Cochrane review (abstract , review [Abstract]) included 47 studies with a total of 2 884 children and adolescents (<18 years). 23 studies examined treatments for headache (including migraine), 10 for abdominal pain, 2 for fibromyalgia, 2 for temporomandibular disorders, 2 for recurrent abdominal pain or irritable bowel syndrome, 3 for pain associated with sickle cell disease, 2 for inflammatory bowel disease, and 3 for mixed pain conditions.

Psychological therapies reduced headache pain frequency post-treatment but the effects were not maintained at follow-up (table T1).

Psychological therapies compared with any control for children and adolescents with frequent headache

OutcomeRelative effect (95% CI)Probable outcome with controlProbable outcome with interventionNNTParticipants (studies)
50% reduction in headache frequency post-treatmentRR 2.35 (1.67 to 3.30)10 per 100024 per 10002.86644 (15 studies)
50% reduction in headache frequency (at up to 12 months follow-up)RR 2.73 (0.98 to 7.63)*10 per 100027 per 10003.16223 (5 studies)
*statistical heterogeneity, I2 =77%
Psychological therapies also had a small beneficial effect at reducing disability in headache conditions at follow-up (table T2) but not post treatment. No beneficial effects were found on depression or anxiety symptoms.

Psychological therapies compared with any control for children and adolescents with frequent headache

OutcomeStandardized mean difference (95% CI)Participants (studies)
DisabilityThe mean disability in the intervention groups was 0.26 lower (-0.56 to 0.03)*446 (6 studies)
Disability at follow-upThe mean disability (at follow-up) in the intervention groups was 0.37 lower (-0.65 to -0.10)209 (3 studies)
DepressionThe mean depression in the intervention groups was 0.08 lower (-0.28 to 0.11)400 (6 studies)
Depression at follow-upThe mean depression (at follow-up) in the intervention groups was 0.05 lower (-0.62 to 0.52)**
AnxietyThe mean anxiety in the intervention groups was 0.11 lower (-0.39 to 0.17)439 (7 studies)
Anxiety at follow-upThe mean anxiety (at follow-up) in the intervention groups was 0.12 lower (-0.46 to 0.21)271 (4 studies)
*statistical heterogeneity, I2 =55%, ** I2 =72%
Psychological therapies reduced pain intensity post-treatment, but not at follow-up for children and adolescents with mixed pain conditions (table T3). Psychological therapies also had a beneficial effect for disability post-treatment, and at follow-up. No effect was found for depression, but a beneficial effect on anxiety was found post-treatment although this was not maintained at follow-up.

Across all pain conditions, adverse events were reported in 7 studies, of which 2 studies reported adverse events that were study-related.

Psychological therapies compared with any control for children and adolescents with mixed chronic pain

OutcomeStandardized mean difference (95% CI)Participants (studies)
PainThe mean pain in the intervention groups was 0.43 lower (-0.67 to -0.19); I2 =73%1 210 (16 studies)
Pain at follow-upThe mean pain in the intervention groups was 0.08 lower (-0.30 to 0.13); I2 =51%763 (9 studies)
DisabilityThe mean disability in the intervention groups was 0.34 lower (-0.54 to -0.15); I2 =59%1 226 (14 studies)
Disability at follow-upThe mean disability in the intervention groups was 0.27 lower (-0.49 to -0.06); I2 =59%866 (9 studies)
DepressionThe mean depression in the intervention groups was 0.05 lower (-0.23 to 0.12)757 (8 studies)
Depression at follow-upThe mean depression in the intervention groups was 0.09 higher(-0.10 to 0.28)667 (7 studies)
AnxietyThe mean anxiety in the intervention groups was 0.16 lower (-0.29 to -0.03)883 (8 studies)
Anxiety at follow-upThe mean anxiety in the intervention groups was 0.01 lower (-0.20 to 0.18)805 (85 studies)
References
Fisher E, Law E, Dudeney J et al. Psychological therapies for the management of chronic and recurrent pain in children and adolescents. Cochrane Database Syst Rev 2018;(9):CD003968. [PubMed].

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