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

Christopher Eccleston; Tonya M Palermo; Amanda C de C Williams; Amy Lewandowski; Stephen Morley; Emma Fisher; Emily Law

doi:10.1002/14651858.CD003968.pub3

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Figure 1

Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.

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Figure 2

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.

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Figure 3

Forest plot of comparison: 1 Treatment vs control (headache) post‐treatment, outcome: 1.1 Pain.

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Figure 4

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Figure 5

Forest plot of comparison: 3 Treatment vs control (non‐headache) post‐treatment, outcome: 3.1 Pain.

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Analysis 1.1

Comparison 1 Treatment versus control (headache) post‐treatment., Outcome 1 Pain.

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Analysis 1.2

Comparison 1 Treatment versus control (headache) post‐treatment., Outcome 2 Disability.

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Analysis 1.3

Comparison 1 Treatment versus control (headache) post‐treatment., Outcome 3 Mood.

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Analysis 2.1

Comparison 2 Treatment versus control (headache) follow‐up, Outcome 1 Pain.

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Analysis 2.2

Comparison 2 Treatment versus control (headache) follow‐up, Outcome 2 Disability.

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Analysis 2.3

Comparison 2 Treatment versus control (headache) follow‐up, Outcome 3 Mood.

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Analysis 3.1

Comparison 3 Treatment versus control (non‐headache) post‐treatment, Outcome 1 Pain.

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Analysis 3.2

Comparison 3 Treatment versus control (non‐headache) post‐treatment, Outcome 2 Disability.

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Analysis 3.3

Comparison 3 Treatment versus control (non‐headache) post‐treatment, Outcome 3 Mood.

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Analysis 4.1

Comparison 4 Treatment versus control (non‐headache) follow‐up, Outcome 1 Pain.

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Analysis 4.2

Comparison 4 Treatment versus control (non‐headache) follow‐up, Outcome 2 Disability.

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Analysis 4.3

Comparison 4 Treatment versus control (non‐headache) follow‐up, Outcome 3 Mood.

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Summary of findings for the main comparison. Psychological therapies for the management of chronic pain (headache) in children and adolescents

Psychological therapies for the management of chronic pain (headache) in children and adolescents
Patient or population: patients with the management of chronic and recurrent pain in children and adolescents Settings: Community and secondary care Intervention: Psychological therapies
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Control	Psychological therapies
Pain	170 per 1000	492 per 1000 (381 to 632)	RR 2.9 (2.25 to 3.73)	748 (18 studies)	⊕⊕⊕⊝ moderate^1,2	Results were statistically significant
Pain (at follow‐up)	167 per 1000	557 per 1000 (335 to 922)	RR 3.34 (2.01 to 5.53)	196 (6 studies)	⊕⊕⊝⊝ low^1,3,4	Results were statistically significant
Disability		The mean disability in the intervention groups was 0.3 standard deviations lower (0.85 lower to 0.24 higher)		108 (3 studies)	⊕⊕⊕⊝ moderate⁵	SMD ‐0.3 (‐0.85 to 0.24) Results were not significant
Disability (at follow‐up)		The mean disability (at follow‐up) in the intervention groups was 0.45 standard deviations lower (1.27 lower to 0.36 higher)		24 (1 study)	⊕⊕⊝⊝ low^3,6	SMD ‐0.45 (‐1.27 to 0.36) Insufficient evidence to draw conclusions
Mood		The mean mood in the intervention groups was 0.16 standard deviations lower (0.45 lower to 0.13 higher)		204 (5 studies)	⊕⊕⊕⊕ high	SMD ‐0.16 (‐0.45 to 0.13) Results were not significant
Mood (at follow‐up)		The mean mood (at follow‐up) in the intervention groups was 0.6 standard deviations lower (1.13 to 0.07 lower)		59 (2 studies)	⊕⊕⊕⊝ moderate³	SMD ‐0.6 (‐1.13 to ‐0.07) Insufficient evidence to draw conclusions
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio;
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹ A proportion of studies had poor descriptions of randomisation ² A proportion of studies did not report follow‐up data. Unclear whether earlier studies usedITT analyses ³ Small sample sizes ⁴ Wide confidence intervals ⁵ I squared is high >45%, Heterogeneity Tau = P>0.05, variation can be explained ⁶ Only one study in this comparison

Summary of findings for the main comparison. Psychological therapies for the management of chronic pain (headache) in children and adolescents

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Summary of findings 2. Psychological therapies for the management of chronic (non‐headache) in children and adolescents

Psychological therapies for the management of chronic (non‐headache) in children and adolescents
Patient or population: Children and adolescents with chronic pain (non‐headache) Settings: Community and secondary care Intervention: Psychological therapies
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Control	Psychological therapies
Pain		The mean pain in the intervention groups was 0.55 standard deviations lower (0.84 to 0.26 lower)		709 (12 studies)	⊕⊕⊕⊝ moderate¹	SMD ‐0.55 (‐0.84 to ‐0.26) Results were statistically significant
Pain (at follow‐up)		The mean pain (at follow‐up) in the intervention groups was 0.17 standard deviations lower (0.6 lower to 0.26 higher)		357 (5 studies)	⊕⊕⊕⊝ moderate¹	SMD ‐0.17 (‐0.6 to 0.26) Results were not statistically significant
Disability		The mean disability in the intervention groups was 0.29 standard deviations lower (0.49 to 0.1 lower)		588 (9 studies)	⊕⊕⊕⊕ high	SMD ‐0.29 (‐0.49 to ‐0.1) Results were statistically significant
Disability (at follow‐up)		The mean disability (at follow‐up) in the intervention groups was 0.19 standard deviations lower (0.51 lower to 0.13 higher)		292 (3 studies)	⊕⊕⊕⊕ high	SMD ‐0.19 (‐0.51 to 0.13) Results were not statistically significant
Mood		The mean mood in the intervention groups was 0.14 standard deviations lower (0.42 lower to 0.15 higher)		435 (6 studies)	⊕⊕⊕⊝ moderate¹	SMD ‐0.14 (‐0.42 to 0.15) Results were not statistically significant
Mood (at follow‐up)		The mean mood (at follow‐up) in the intervention groups was 0.09 standard deviations lower (0.32 lower to 0.14 higher)		292 (3 studies)	⊕⊕⊕⊕ high	SMD ‐0.09 (‐0.32 to 0.14) Results were not statistically significant
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval;
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹ I squared = > 45%, Heterogeniety Tau = P > 0.05, variance can be explained

Summary of findings 2. Psychological therapies for the management of chronic (non‐headache) in children and adolescents

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Table 1. Duration of treatment and setting by condition

Headache studies
Author	Illness	Treatment duration (Hrs)	Setting
Abram 2007	Headache	1.5	Clinic
Barry 1997	Headache	3	Unknown
Bussone 1998	Headache	7	Clinic
Connelly 2006	Headache	Unknown	Home ‐ CDROM
Fichtel 2001	Headache	6.75	Clinic
Griffiths 1996	Headache	12	Clinic/Home
Hicks 2006*	Mixed	Unknown	Home ‐ Internet
Kroener‐Herwig 2002	Headache	12	Clinic
Labbe 1984	Headache	6.7	Clinic
Labbe 1995	Headache	7.5	Clinic
Larsson 1987a	Headache	6.75	School
Larsson 1987b	Headache	5	School
Larsson 1990	Headache	1.7	Home
Larsson 1996	Headache	3.3	Clinic
McGrath 1988	Headache	6	Unknown
McGrath 1992	Headache	8	Home/Clinic
Osterhaus 1997	Headache	9.3	Clinic
Palermo 2009*	Mixed	4	Home ‐ Internet
Passchier 1990	Headache	2.5	School
Richter 1986	Headache	9	Unknown
Sartory 1998	Headache	Unknown	Clinic
Scharff 2002	Headache	4	Clinic
Trautmann 2010	Headache	Unknown	Home ‐ Internet
Wicksell 2009*	Mixed	10	Clinic
Non‐headache studies
Author	Illness	Treatment duration (Hrs)	Setting
Alfven 2007	RAP	Unknown	Clinic
Barakat 2010	SCD	6	Home
Duarte 2006	RAP	3.3	Unknown
Gil 1997	SCD	0.75	Clinic
Hicks 2006*	Headache + RAP	Unknown	Home ‐ Internet
Humphreys 2000	RAP	Unknown	Clinic
Kashikar‐Zuck 2005	Fibromyalgia	Unknown	Clinic
Kashikar‐Zuck 2012	Fibromyalgia	6	Unknown
Levy 2010	RAP	4	Home/Clinic
Palermo 2009*	Mixed	4	Home ‐ Internet
Robins 2005	RAP	3.5	Clinic
Sanders 1994	RAP	6	Clinic
Stinson 2010	JIA	5	Home ‐ Internet
van Tilburg 2009	RAP	1.8	Home
Vlieger 2007	RAP/IBS	5	Clinic
Wicksell 2009*	Mixed	10	Clinic
*Mixed headache and non‐headache studies are entered twice. Recurrent abdominal pain (RAP), Sickle cell disease (SCD), Juvenile idiopathic arthritis (JIA), Irritable bowel syndrome (IBS).

Table 1. Duration of treatment and setting by condition

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Comparison 1. Treatment versus control (headache) post‐treatment.

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain Show forest plot	18	748	Risk Ratio (M‐H, Fixed, 95% CI)	2.90 [2.25, 3.73]

2 Disability Show forest plot	3	108	Std. Mean Difference (IV, Random, 95% CI)	‐0.30 [‐0.85, 0.24]

3 Mood Show forest plot	5	204	Std. Mean Difference (IV, Random, 95% CI)	‐0.16 [‐0.45, 0.13]

Comparison 1. Treatment versus control (headache) post‐treatment.

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Comparison 2. Treatment versus control (headache) follow‐up

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain Show forest plot	6	196	Risk Ratio (M‐H, Random, 95% CI)	3.34 [2.01, 5.53]

2 Disability Show forest plot	1	24	Std. Mean Difference (IV, Random, 95% CI)	‐0.45 [‐1.27, 0.36]

3 Mood Show forest plot	2	59	Std. Mean Difference (IV, Random, 95% CI)	‐0.60 [‐1.13, ‐0.07]

Comparison 2. Treatment versus control (headache) follow‐up

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Comparison 3. Treatment versus control (non‐headache) post‐treatment

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain Show forest plot	12	709	Std. Mean Difference (IV, Random, 95% CI)	‐0.55 [‐0.84, ‐0.26]

2 Disability Show forest plot	9	588	Std. Mean Difference (IV, Random, 95% CI)	‐0.29 [‐0.49, ‐0.10]

3 Mood Show forest plot	6	435	Std. Mean Difference (IV, Random, 95% CI)	‐0.14 [‐0.42, 0.15]

Comparison 3. Treatment versus control (non‐headache) post‐treatment

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Comparison 4. Treatment versus control (non‐headache) follow‐up

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain Show forest plot	5	357	Std. Mean Difference (IV, Random, 95% CI)	‐0.17 [‐0.60, 0.26]

2 Disability Show forest plot	3	292	Std. Mean Difference (IV, Random, 95% CI)	‐0.19 [‐0.51, 0.13]

3 Mood Show forest plot	3	292	Std. Mean Difference (IV, Random, 95% CI)	‐0.09 [‐0.32, 0.14]

Comparison 4. Treatment versus control (non‐headache) follow‐up

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