Psychological therapies (remotely delivered) for the management of chronic and recurrent pain in children and adolescents.
Psychological therapies (remotely delivered) for the management of chronic and recurrent pain in children and adolescents.
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DOI：
10.1002/14651858.cd011118.pub2
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发表时间：
2015-03-23
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影响因子：
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通讯作者：
Eccleston, Christopher
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文献类型：
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作者：
Fisher, Emma;Law, Emily;Eccleston, Christopher
背景技术背景：慢性疼痛在儿童和青少年时期很常见，并且与负面结果相关，例如疼痛严重程度增加，功能降低（例如缺课）和情绪低落（例如高度抑郁和焦虑）。传统上与治疗师面对面进行的心理治疗在减轻疼痛强度和残疾方面是有效的。然而，新的和创新的技术正在被用来远程提供这些心理治疗，这意味着可以消除或减少获得治疗的障碍，如距离和费用。通过互联网、基于计算机的程序、智能手机应用程序或通过电话等技术设备提供的治疗可用于为患有慢性疼痛的儿童和青少年提供治疗。方法：确定远程心理治疗与等待列表、常规治疗或主动控制治疗相比在儿童和青少年慢性疼痛管理中的疗效。我们检索了从成立到2014年6月的四个数据库（CENTRAL，MEDLINE，EMBASE和PsycINFO），以获得针对患有慢性疼痛的儿童和青少年（0至18岁）的远程心理干预的随机对照试验。我们搜索慢性疼痛疾病，包括但不限于头痛、复发性腹痛、肌肉骨骼疼痛和神经性疼痛。我们还搜索了在线试验注册以寻找潜在的试验。选择标准：所有纳入的研究均为随机对照试验，旨在比较通过互联网、智能手机、计算机程序、录音带或电话远程提供的心理治疗与主动、常规治疗或等待列表对照的疗效。我们考虑了混合治疗，它结合了技术和面对面的互动。我们排除了治疗师和患者之间面对面的干预。患有原发性慢性疼痛疾病的儿童和青少年（0至18岁）是干预的目标。每个对照组，在每个提取点必须包括10个或更多的参与者。数据收集和分析：对于分析，我们结合了所有的心理治疗。我们将疼痛分为头痛和混合（非头痛）疼痛，并分别进行分析。疼痛、残疾、抑郁、焦虑和不良事件被提取为主要结局。我们还提取了对治疗的满意度作为次要结局。我们考虑了两个时间点的结果：第一个是治疗结束后立即（称为“治疗后”），第二个是治疗后3至12个月的任何随访时间点（称为“随访”）。我们评估了所有纳入研究的偏倚风险。主要结果：8项研究（N = 371），提供远程治疗，从我们的搜索确定; 5项研究调查儿童头痛的条件，一项研究是与儿童青少年特发性关节炎，两项研究包括混合样本的儿童头痛和混合（即复发性腹痛，肌肉骨骼疼痛）慢性疼痛条件。接受治疗的儿童平均年龄为12.57岁。对于头痛症状，我们发现远程心理治疗的一个有益效果。治疗后头痛严重程度降低（风险比（RR）= 2.65，95%可信区间（CI）1.56 - 4.50，z = 3.62，p < 0.01，需要治疗获益人数（NNTB）= 2.88）。对于混合性疼痛，我们只发现了一个有益的效果：心理治疗降低了治疗后的疼痛强度（标准化平均差异（SMD）=-0.61，95% CI -0.96至-0.25，z = 3.38，p < 0.01）。两项分析均未发现随访时疼痛减轻的效果。对于头痛和混合性疾病，远程提供的心理治疗对残疾治疗后没有任何有益的影响，随访时缺乏数据意味着无法进行分析。只有一个分析可以进行抑郁症的结果。我们没有发现心理治疗在减少头痛治疗后抑郁方面的有益效果。只有一项研究提供了患有混合性疼痛疾病的儿童的抑郁结局数据，并且在随访时没有任何数据可供使用。只有一项研究提供了治疗后的焦虑数据，没有研究报告随访数据，因此无法进行分析。此外，没有不良事件的数据，这意味着我们不确定心理治疗是否对接受这些治疗的儿童有害。对治疗的满意度是定性描述的。“偏倚风险”评估为低或不明确。我们判断入选研究的选择、检测和报告偏倚大多为低风险。然而，对表现和损耗偏见的判断大多是不清楚的。咨询师的结论：远程提供的心理治疗，主要是通过互联网，赋予在不同条件下治疗后减轻疼痛的强度或严重程度的好处。这些效果估计存在相当大的不确定性，只有8项研究（371名儿童）得出了结论。未来的研究可能会改变这里报道的结论。所有纳入的试验都使用行为或认知行为疗法治疗慢性疼痛儿童，因此我们不能将我们的发现推广到其他疗法。然而，对这些治疗的满意度总体上是积极的。需要更大规模的试验来增加我们对远程心理治疗效果的所有结论的信心。实践和研究的影响进行了讨论。
BACKGROUND: Chronic pain is common during childhood and adolescence and is associated with negative outcomes such as increased severity of pain, reduced function (e.g. missing school), and low mood (e.g. high levels of depression and anxiety). Psychological therapies, traditionally delivered face-to-face with a therapist, are efficacious at reducing pain intensity and disability. However, new and innovative technology is being used to deliver these psychological therapies remotely, meaning barriers to access to treatment such as distance and cost can be removed or reduced. Therapies delivered with technological devices, such as the Internet, computer-based programmes, smartphone applications, or via the telephone, 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 METHODS: We searched four databases (CENTRAL, MEDLINE, EMBASE, and PsycINFO) from inception to June 2014 for randomised controlled trials of remotely delivered psychological interventions for children and adolescents (0 to 18 years of age) 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 for potential trials. A citation and reference search for all included studies was conducted.SELECTION CRITERIA: All included studies were randomised controlled trials that investigated the efficacy of a psychological therapy delivered remotely via the Internet, smartphone device, computer-based programme, audiotapes, or over the phone in comparison to an active, treatment-as-usual, or waiting-list control. We considered blended treatments, which used a combination of technology and face-to-face interaction. We excluded interventions solely delivered face-to-face between therapist and patient from this review. Children and adolescents (0 to 18 years of age) with a primary chronic pain condition were the target of the interventions. Each comparator arm, at each extraction point had to include 10 or more participants.DATA COLLECTION AND ANALYSIS: For the analyses, we combined all psychological therapies. We split pain conditions into headache and mixed (non-headache) pain and analysed them separately. Pain, disability, depression, anxiety, and adverse events were extracted as primary outcomes. We also extracted 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 3 and 12 months (known as 'follow-up'). We assessed all included studies for risk of bias.MAIN RESULTS: Eight studies (N = 371) that delivered treatment remotely were identified from our search; five studies investigated children with headache conditions, one study was with children with juvenile idiopathic arthritis, and two studies included mixed samples of children with headache and mixed (i.e. recurrent abdominal pain, musculoskeletal pain) chronic pain conditions. The average age of children receiving treatment was 12.57 years.For headache pain conditions, we found one beneficial effect of remotely delivered psychological therapy. Headache severity was reduced post-treatment (risk ratio (RR) = 2.65, 95% confidence interval (CI) 1.56 to 4.50, z = 3.62,p < 0.01, number needed to treat to benefit (NNTB) = 2.88). For mixed pain conditions, we found only one beneficial effect: psychological therapies reduced pain intensity post-treatment (standardised mean difference (SMD) = -0.61, 95% CI -0.96 to -0.25, z = 3.38, p < 0.01). No effects were found for reducing pain at follow-up in either analysis. For headache and mixed conditions, there were no beneficial effects of psychological therapies delivered remotely for disability post-treatment and a lack of data at follow-up meant no analyses could be run. Only one analysis could be conducted for depression outcomes. We found no beneficial effect of psychological therapies in reducing depression post-treatment for headache conditions. Only one study presented data in children with mixed pain conditions for depressive outcomes and no data were available for either condition at follow-up. Only one study presented anxiety data post-treatment and no studies reported follow-up data, therefore no analyses could be run. Further, there were no data available for adverse events, meaning that we are unsure whether psychological therapies are harmful to children who receive them. Satisfaction with treatment is described qualitatively.'Risk of bias' assessments were low or unclear. We judged selection, detection, and reporting biases to be mostly low risk for included studies. However, judgements made on performance and attrition biases were mostly unclear.AUTHORS' CONCLUSIONS: Psychological therapies delivered remotely, primarily via the Internet, confer benefit in reducing the intensity or severity of pain after treatment across conditions. There is considerable uncertainty around these estimates of effect and only eight studies with 371 children contribute to the conclusions. Future studies are likely to change the conclusions reported here. All included trials used either behavioural or cognitive behavioural therapies for children with chronic pain, therefore we cannot generalise our findings to other therapies. However, satisfaction with these treatments was generally positive. Larger trials are needed to increase our confidence in all conclusions regarding the efficacy of remotely delivered psychological therapies. Implications for practice and research are discussed.