Psychological therapies (remotely delivered) for the management of chronic and recurrent pain in children and adolescents

Emma Fisher, Emily Law, Joanne Dudeney, Christopher Eccleston, Tonya M. Palermo

Research output: Contribution to journalArticleResearchpeer-review

Abstract

Background: This is the first update of a review published in 2015, Issue 1. Chronic pain is common during childhood and adolescence and is associated with negative outcomes, such as increased severity of pain, reduced function, and low mood. Psychological therapies, traditionally delivered face-to-face with a therapist, are efficacious at reducing pain intensity and disability. To address barriers to treatment access, such as distance and cost of treatment, technology is being used to deliver these psychological therapies remotely. Therapies delivered remotely, such as via the Internet, computer-based programmes, and smartphone applications, 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) frominception toMay 2018 for randomised controlled trials (RCTs) of remotely-delivered psychological interventions for children and adolescents 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, reference sections, and citations of included studies for potential trials.

Background

This is the first update of a review published in 2015, Issue 1. Chronic pain is common during childhood and adolescence and is associated with negative outcomes, such as increased severity of pain, reduced function, and low mood. Psychological therapies, traditionally delivered face‐to‐face with a therapist, are efficacious at reducing pain intensity and disability. To address barriers to treatment access, such as distance and cost of treatment, technology is being used to deliver these psychological therapies remotely. Therapies delivered remotely, such as via the Internet, computer‐based programmes, and smartphone applications, 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 May 2018 for randomised controlled trials (RCTs) of remotely‐delivered psychological interventions for children and adolescents 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, reference sections, and citations of included studies for potential trials.

Selection criteria

We included RCTs that investigated the efficacy of a psychological therapy delivered remotely via technology in comparison to an active, treatment as usual, or waiting‐list control. We considered blended treatments, which used a combination of technology and up to 30% face‐to‐face interaction. Interventions had to be delivered primarily via technology to be included, and we excluded interventions delivered via telephone. We included studies that delivered interventions to children and adolescents (up to 18 years of age) with a chronic pain condition or where chronic pain was a primary symptom of their condition (e.g. juvenile arthritis). We included studies that reported 10 or more participants in each comparator arm, at each extraction point.

Data collection and analysis

We combined all psychological therapies in the analyses. We split pain conditions into headache and mixed (non‐headache) pain and analysed them separately. We extracted pain severity/intensity, disability, depression, anxiety, and adverse events as primary outcomes, and 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 three and 12 months (known as 'follow‐up'). We assessed risk of bias and all outcomes for quality using the GRADE assessment.

Main results

We found 10 studies with 697 participants (an additional 4 studies with 326 participants since the previous review) that delivered treatment remotely; four studies investigated children with headache conditions, one study was with children with juvenile idiopathic arthritis, one included children with sickle cell disease, one included children with irritable bowel syndrome, and three studies included children with different chronic pain conditions (i.e. headache, recurrent abdominal pain, musculoskeletal pain). The average age of children receiving treatment was 13.17 years.

We judged selection, detection, and reporting biases to be mostly low risk. However, we judged performance and attrition biases to be mostly unclear. Out of the 16 planned analyses, we were able to conduct 13 meta‐analyses. We downgraded outcomes for imprecision, indirectness of evidence, inconsistency of results, or because the analysis only included one study.

Headache conditions

For headache pain conditions, we found headache severity was reduced post‐treatment (risk ratio (RR) 2.02, 95% confidence interval (CI) 1.35 to 3.01); P < 0.001, number needed to treat to benefit (NNTB) = 5.36, 7 studies, 379 participants; very low‐quality evidence). No effect was found at follow‐up (very low‐quality evidence). There were no effects of psychological therapies delivered remotely for disability post‐treatment (standardised mean difference (SMD) ‐0.16, 95% CI ‐0.46 to 0.13; P = 0.28, 5 studies, 440 participants) or follow‐up (both very low‐quality evidence). Similarly, no effect was found for the outcomes of depression (SMD ‐0.04, 95% CI ‐0.15 to 0.23, P = 0.69, 4 studies, 422 participants) or anxiety (SMD ‐0.08, 95% CI ‐0.28 to 0.12; P = 0.45, 3 studies, 380 participants) at post‐treatment, or follow‐up (both very low‐quality evidence).

Mixed chronic pain conditions

We did not find any beneficial effects of psychological therapies for reducing pain intensity post‐treatment for mixed chronic pain conditions (SMD ‐0.90, 95% CI ‐1.95 to 0.16; P = 0.10, 5 studies, 501 participants) or at follow‐up. There were no beneficial effects of psychological therapies delivered remotely for disability post‐treatment (SMD ‐0.28, 95% CI ‐0.74 to 0.18; P = 0.24, 3 studies, 363 participants) and a lack of data at follow‐up meant no analysis could be run. We found no beneficial effects for the outcomes of depression (SMD 0.04, 95% CI ‐0.18 to 0.26; P = 0.73, 2 studies, 317 participants) and anxiety (SMD 0.53, 95% CI ‐0.63 to 1.68; P = 0.37, 2 studies, 370 participants) post‐treatment, however, we are cautious of our findings as we could only include two studies in the analyses. We could not conduct analyses at follow‐up. We judged the evidence for all outcomes to be very low quality.

All conditions

Across all chronic pain conditions, six studies reported minor adverse events which were not attributed to the psychological therapies. Satisfaction with treatment is described qualitatively and was overall positive. However, we judged both these outcomes as very low quality.

Authors' conclusions

There are currently a small number of trials investigating psychological therapies delivered remotely, primarily via the Internet. We are cautious in our interpretations of analyses. We found one beneficial effect of therapies to reduce headache severity post‐treatment. For the remaining outcomes there was either no beneficial effect at post‐treatment or follow‐up, or lack of evidence to determine an effect. Overall, participant satisfaction with treatment was positive. We judged the quality of the evidence to be very low, meaning we are very uncertain about the estimate. Further studies are needed to increase our confidence in this potentially promising field.

LanguageEnglish
Article numberCD011118
Pages1-57
Number of pages57
JournalCochrane Database of Systematic Reviews
Volume2019
Issue number4
DOIs
Publication statusPublished - 2 Apr 2019
Externally publishedYes

Fingerprint

Chronic Pain
Psychology
Therapeutics
Headache
Pain
Confidence Intervals
Musculoskeletal Pain
Waiting Lists
Technology
Internet
Abdominal Pain
Juvenile Arthritis
Anxiety
Randomized Controlled Trials
Neuralgia
Depression

Bibliographical note

Copyright © 2019 The Cochrane Collaboration. Version archived for private and non-commercial use with the permission of the author/s and according to publisher conditions. For further rights please contact the publisher.

Cite this

@article{5273cdd20ee742829d1b020fcdfe50b6,
title = "Psychological therapies (remotely delivered) for the management of chronic and recurrent pain in children and adolescents",
abstract = "Background: This is the first update of a review published in 2015, Issue 1. Chronic pain is common during childhood and adolescence and is associated with negative outcomes, such as increased severity of pain, reduced function, and low mood. Psychological therapies, traditionally delivered face-to-face with a therapist, are efficacious at reducing pain intensity and disability. To address barriers to treatment access, such as distance and cost of treatment, technology is being used to deliver these psychological therapies remotely. Therapies delivered remotely, such as via the Internet, computer-based programmes, and smartphone applications, 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) frominception toMay 2018 for randomised controlled trials (RCTs) of remotely-delivered psychological interventions for children and adolescents 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, reference sections, and citations of included studies for potential trials.BackgroundThis is the first update of a review published in 2015, Issue 1. Chronic pain is common during childhood and adolescence and is associated with negative outcomes, such as increased severity of pain, reduced function, and low mood. Psychological therapies, traditionally delivered face‐to‐face with a therapist, are efficacious at reducing pain intensity and disability. To address barriers to treatment access, such as distance and cost of treatment, technology is being used to deliver these psychological therapies remotely. Therapies delivered remotely, such as via the Internet, computer‐based programmes, and smartphone applications, can be used to deliver treatment to children and adolescents with chronic pain.ObjectivesTo 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 methodsWe searched four databases (CENTRAL, MEDLINE, Embase, and PsycINFO) from inception to May 2018 for randomised controlled trials (RCTs) of remotely‐delivered psychological interventions for children and adolescents 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, reference sections, and citations of included studies for potential trials.Selection criteriaWe included RCTs that investigated the efficacy of a psychological therapy delivered remotely via technology in comparison to an active, treatment as usual, or waiting‐list control. We considered blended treatments, which used a combination of technology and up to 30{\%} face‐to‐face interaction. Interventions had to be delivered primarily via technology to be included, and we excluded interventions delivered via telephone. We included studies that delivered interventions to children and adolescents (up to 18 years of age) with a chronic pain condition or where chronic pain was a primary symptom of their condition (e.g. juvenile arthritis). We included studies that reported 10 or more participants in each comparator arm, at each extraction point.Data collection and analysisWe combined all psychological therapies in the analyses. We split pain conditions into headache and mixed (non‐headache) pain and analysed them separately. We extracted pain severity/intensity, disability, depression, anxiety, and adverse events as primary outcomes, and 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 three and 12 months (known as 'follow‐up'). We assessed risk of bias and all outcomes for quality using the GRADE assessment.Main resultsWe found 10 studies with 697 participants (an additional 4 studies with 326 participants since the previous review) that delivered treatment remotely; four studies investigated children with headache conditions, one study was with children with juvenile idiopathic arthritis, one included children with sickle cell disease, one included children with irritable bowel syndrome, and three studies included children with different chronic pain conditions (i.e. headache, recurrent abdominal pain, musculoskeletal pain). The average age of children receiving treatment was 13.17 years.We judged selection, detection, and reporting biases to be mostly low risk. However, we judged performance and attrition biases to be mostly unclear. Out of the 16 planned analyses, we were able to conduct 13 meta‐analyses. We downgraded outcomes for imprecision, indirectness of evidence, inconsistency of results, or because the analysis only included one study.Headache conditionsFor headache pain conditions, we found headache severity was reduced post‐treatment (risk ratio (RR) 2.02, 95{\%} confidence interval (CI) 1.35 to 3.01); P < 0.001, number needed to treat to benefit (NNTB) = 5.36, 7 studies, 379 participants; very low‐quality evidence). No effect was found at follow‐up (very low‐quality evidence). There were no effects of psychological therapies delivered remotely for disability post‐treatment (standardised mean difference (SMD) ‐0.16, 95{\%} CI ‐0.46 to 0.13; P = 0.28, 5 studies, 440 participants) or follow‐up (both very low‐quality evidence). Similarly, no effect was found for the outcomes of depression (SMD ‐0.04, 95{\%} CI ‐0.15 to 0.23, P = 0.69, 4 studies, 422 participants) or anxiety (SMD ‐0.08, 95{\%} CI ‐0.28 to 0.12; P = 0.45, 3 studies, 380 participants) at post‐treatment, or follow‐up (both very low‐quality evidence).Mixed chronic pain conditionsWe did not find any beneficial effects of psychological therapies for reducing pain intensity post‐treatment for mixed chronic pain conditions (SMD ‐0.90, 95{\%} CI ‐1.95 to 0.16; P = 0.10, 5 studies, 501 participants) or at follow‐up. There were no beneficial effects of psychological therapies delivered remotely for disability post‐treatment (SMD ‐0.28, 95{\%} CI ‐0.74 to 0.18; P = 0.24, 3 studies, 363 participants) and a lack of data at follow‐up meant no analysis could be run. We found no beneficial effects for the outcomes of depression (SMD 0.04, 95{\%} CI ‐0.18 to 0.26; P = 0.73, 2 studies, 317 participants) and anxiety (SMD 0.53, 95{\%} CI ‐0.63 to 1.68; P = 0.37, 2 studies, 370 participants) post‐treatment, however, we are cautious of our findings as we could only include two studies in the analyses. We could not conduct analyses at follow‐up. We judged the evidence for all outcomes to be very low quality.All conditionsAcross all chronic pain conditions, six studies reported minor adverse events which were not attributed to the psychological therapies. Satisfaction with treatment is described qualitatively and was overall positive. However, we judged both these outcomes as very low quality.Authors' conclusionsThere are currently a small number of trials investigating psychological therapies delivered remotely, primarily via the Internet. We are cautious in our interpretations of analyses. We found one beneficial effect of therapies to reduce headache severity post‐treatment. For the remaining outcomes there was either no beneficial effect at post‐treatment or follow‐up, or lack of evidence to determine an effect. Overall, participant satisfaction with treatment was positive. We judged the quality of the evidence to be very low, meaning we are very uncertain about the estimate. Further studies are needed to increase our confidence in this potentially promising field.",
author = "Emma Fisher and Emily Law and Joanne Dudeney and Christopher Eccleston and Palermo, {Tonya M.}",
note = "Copyright {\circledC} 2019 The Cochrane Collaboration. Version archived for private and non-commercial use with the permission of the author/s and according to publisher conditions. For further rights please contact the publisher.",
year = "2019",
month = "4",
day = "2",
doi = "10.1002/14651858.CD011118.pub3",
language = "English",
volume = "2019",
pages = "1--57",
journal = "The Cochrane database of systematic reviews",
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}

Psychological therapies (remotely delivered) for the management of chronic and recurrent pain in children and adolescents. / Fisher, Emma; Law, Emily; Dudeney, Joanne; Eccleston, Christopher; Palermo, Tonya M.

In: Cochrane Database of Systematic Reviews, Vol. 2019, No. 4, CD011118, 02.04.2019, p. 1-57.

Research output: Contribution to journalArticleResearchpeer-review

TY - JOUR

T1 - Psychological therapies (remotely delivered) for the management of chronic and recurrent pain in children and adolescents

AU - Fisher, Emma

AU - Law, Emily

AU - Dudeney, Joanne

AU - Eccleston, Christopher

AU - Palermo, Tonya M.

N1 - Copyright © 2019 The Cochrane Collaboration. Version archived for private and non-commercial use with the permission of the author/s and according to publisher conditions. For further rights please contact the publisher.

PY - 2019/4/2

Y1 - 2019/4/2

N2 - Background: This is the first update of a review published in 2015, Issue 1. Chronic pain is common during childhood and adolescence and is associated with negative outcomes, such as increased severity of pain, reduced function, and low mood. Psychological therapies, traditionally delivered face-to-face with a therapist, are efficacious at reducing pain intensity and disability. To address barriers to treatment access, such as distance and cost of treatment, technology is being used to deliver these psychological therapies remotely. Therapies delivered remotely, such as via the Internet, computer-based programmes, and smartphone applications, 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) frominception toMay 2018 for randomised controlled trials (RCTs) of remotely-delivered psychological interventions for children and adolescents 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, reference sections, and citations of included studies for potential trials.BackgroundThis is the first update of a review published in 2015, Issue 1. Chronic pain is common during childhood and adolescence and is associated with negative outcomes, such as increased severity of pain, reduced function, and low mood. Psychological therapies, traditionally delivered face‐to‐face with a therapist, are efficacious at reducing pain intensity and disability. To address barriers to treatment access, such as distance and cost of treatment, technology is being used to deliver these psychological therapies remotely. Therapies delivered remotely, such as via the Internet, computer‐based programmes, and smartphone applications, can be used to deliver treatment to children and adolescents with chronic pain.ObjectivesTo 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 methodsWe searched four databases (CENTRAL, MEDLINE, Embase, and PsycINFO) from inception to May 2018 for randomised controlled trials (RCTs) of remotely‐delivered psychological interventions for children and adolescents 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, reference sections, and citations of included studies for potential trials.Selection criteriaWe included RCTs that investigated the efficacy of a psychological therapy delivered remotely via technology in comparison to an active, treatment as usual, or waiting‐list control. We considered blended treatments, which used a combination of technology and up to 30% face‐to‐face interaction. Interventions had to be delivered primarily via technology to be included, and we excluded interventions delivered via telephone. We included studies that delivered interventions to children and adolescents (up to 18 years of age) with a chronic pain condition or where chronic pain was a primary symptom of their condition (e.g. juvenile arthritis). We included studies that reported 10 or more participants in each comparator arm, at each extraction point.Data collection and analysisWe combined all psychological therapies in the analyses. We split pain conditions into headache and mixed (non‐headache) pain and analysed them separately. We extracted pain severity/intensity, disability, depression, anxiety, and adverse events as primary outcomes, and 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 three and 12 months (known as 'follow‐up'). We assessed risk of bias and all outcomes for quality using the GRADE assessment.Main resultsWe found 10 studies with 697 participants (an additional 4 studies with 326 participants since the previous review) that delivered treatment remotely; four studies investigated children with headache conditions, one study was with children with juvenile idiopathic arthritis, one included children with sickle cell disease, one included children with irritable bowel syndrome, and three studies included children with different chronic pain conditions (i.e. headache, recurrent abdominal pain, musculoskeletal pain). The average age of children receiving treatment was 13.17 years.We judged selection, detection, and reporting biases to be mostly low risk. However, we judged performance and attrition biases to be mostly unclear. Out of the 16 planned analyses, we were able to conduct 13 meta‐analyses. We downgraded outcomes for imprecision, indirectness of evidence, inconsistency of results, or because the analysis only included one study.Headache conditionsFor headache pain conditions, we found headache severity was reduced post‐treatment (risk ratio (RR) 2.02, 95% confidence interval (CI) 1.35 to 3.01); P < 0.001, number needed to treat to benefit (NNTB) = 5.36, 7 studies, 379 participants; very low‐quality evidence). No effect was found at follow‐up (very low‐quality evidence). There were no effects of psychological therapies delivered remotely for disability post‐treatment (standardised mean difference (SMD) ‐0.16, 95% CI ‐0.46 to 0.13; P = 0.28, 5 studies, 440 participants) or follow‐up (both very low‐quality evidence). Similarly, no effect was found for the outcomes of depression (SMD ‐0.04, 95% CI ‐0.15 to 0.23, P = 0.69, 4 studies, 422 participants) or anxiety (SMD ‐0.08, 95% CI ‐0.28 to 0.12; P = 0.45, 3 studies, 380 participants) at post‐treatment, or follow‐up (both very low‐quality evidence).Mixed chronic pain conditionsWe did not find any beneficial effects of psychological therapies for reducing pain intensity post‐treatment for mixed chronic pain conditions (SMD ‐0.90, 95% CI ‐1.95 to 0.16; P = 0.10, 5 studies, 501 participants) or at follow‐up. There were no beneficial effects of psychological therapies delivered remotely for disability post‐treatment (SMD ‐0.28, 95% CI ‐0.74 to 0.18; P = 0.24, 3 studies, 363 participants) and a lack of data at follow‐up meant no analysis could be run. We found no beneficial effects for the outcomes of depression (SMD 0.04, 95% CI ‐0.18 to 0.26; P = 0.73, 2 studies, 317 participants) and anxiety (SMD 0.53, 95% CI ‐0.63 to 1.68; P = 0.37, 2 studies, 370 participants) post‐treatment, however, we are cautious of our findings as we could only include two studies in the analyses. We could not conduct analyses at follow‐up. We judged the evidence for all outcomes to be very low quality.All conditionsAcross all chronic pain conditions, six studies reported minor adverse events which were not attributed to the psychological therapies. Satisfaction with treatment is described qualitatively and was overall positive. However, we judged both these outcomes as very low quality.Authors' conclusionsThere are currently a small number of trials investigating psychological therapies delivered remotely, primarily via the Internet. We are cautious in our interpretations of analyses. We found one beneficial effect of therapies to reduce headache severity post‐treatment. For the remaining outcomes there was either no beneficial effect at post‐treatment or follow‐up, or lack of evidence to determine an effect. Overall, participant satisfaction with treatment was positive. We judged the quality of the evidence to be very low, meaning we are very uncertain about the estimate. Further studies are needed to increase our confidence in this potentially promising field.

AB - Background: This is the first update of a review published in 2015, Issue 1. Chronic pain is common during childhood and adolescence and is associated with negative outcomes, such as increased severity of pain, reduced function, and low mood. Psychological therapies, traditionally delivered face-to-face with a therapist, are efficacious at reducing pain intensity and disability. To address barriers to treatment access, such as distance and cost of treatment, technology is being used to deliver these psychological therapies remotely. Therapies delivered remotely, such as via the Internet, computer-based programmes, and smartphone applications, 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) frominception toMay 2018 for randomised controlled trials (RCTs) of remotely-delivered psychological interventions for children and adolescents 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, reference sections, and citations of included studies for potential trials.BackgroundThis is the first update of a review published in 2015, Issue 1. Chronic pain is common during childhood and adolescence and is associated with negative outcomes, such as increased severity of pain, reduced function, and low mood. Psychological therapies, traditionally delivered face‐to‐face with a therapist, are efficacious at reducing pain intensity and disability. To address barriers to treatment access, such as distance and cost of treatment, technology is being used to deliver these psychological therapies remotely. Therapies delivered remotely, such as via the Internet, computer‐based programmes, and smartphone applications, can be used to deliver treatment to children and adolescents with chronic pain.ObjectivesTo 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 methodsWe searched four databases (CENTRAL, MEDLINE, Embase, and PsycINFO) from inception to May 2018 for randomised controlled trials (RCTs) of remotely‐delivered psychological interventions for children and adolescents 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, reference sections, and citations of included studies for potential trials.Selection criteriaWe included RCTs that investigated the efficacy of a psychological therapy delivered remotely via technology in comparison to an active, treatment as usual, or waiting‐list control. We considered blended treatments, which used a combination of technology and up to 30% face‐to‐face interaction. Interventions had to be delivered primarily via technology to be included, and we excluded interventions delivered via telephone. We included studies that delivered interventions to children and adolescents (up to 18 years of age) with a chronic pain condition or where chronic pain was a primary symptom of their condition (e.g. juvenile arthritis). We included studies that reported 10 or more participants in each comparator arm, at each extraction point.Data collection and analysisWe combined all psychological therapies in the analyses. We split pain conditions into headache and mixed (non‐headache) pain and analysed them separately. We extracted pain severity/intensity, disability, depression, anxiety, and adverse events as primary outcomes, and 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 three and 12 months (known as 'follow‐up'). We assessed risk of bias and all outcomes for quality using the GRADE assessment.Main resultsWe found 10 studies with 697 participants (an additional 4 studies with 326 participants since the previous review) that delivered treatment remotely; four studies investigated children with headache conditions, one study was with children with juvenile idiopathic arthritis, one included children with sickle cell disease, one included children with irritable bowel syndrome, and three studies included children with different chronic pain conditions (i.e. headache, recurrent abdominal pain, musculoskeletal pain). The average age of children receiving treatment was 13.17 years.We judged selection, detection, and reporting biases to be mostly low risk. However, we judged performance and attrition biases to be mostly unclear. Out of the 16 planned analyses, we were able to conduct 13 meta‐analyses. We downgraded outcomes for imprecision, indirectness of evidence, inconsistency of results, or because the analysis only included one study.Headache conditionsFor headache pain conditions, we found headache severity was reduced post‐treatment (risk ratio (RR) 2.02, 95% confidence interval (CI) 1.35 to 3.01); P < 0.001, number needed to treat to benefit (NNTB) = 5.36, 7 studies, 379 participants; very low‐quality evidence). No effect was found at follow‐up (very low‐quality evidence). There were no effects of psychological therapies delivered remotely for disability post‐treatment (standardised mean difference (SMD) ‐0.16, 95% CI ‐0.46 to 0.13; P = 0.28, 5 studies, 440 participants) or follow‐up (both very low‐quality evidence). Similarly, no effect was found for the outcomes of depression (SMD ‐0.04, 95% CI ‐0.15 to 0.23, P = 0.69, 4 studies, 422 participants) or anxiety (SMD ‐0.08, 95% CI ‐0.28 to 0.12; P = 0.45, 3 studies, 380 participants) at post‐treatment, or follow‐up (both very low‐quality evidence).Mixed chronic pain conditionsWe did not find any beneficial effects of psychological therapies for reducing pain intensity post‐treatment for mixed chronic pain conditions (SMD ‐0.90, 95% CI ‐1.95 to 0.16; P = 0.10, 5 studies, 501 participants) or at follow‐up. There were no beneficial effects of psychological therapies delivered remotely for disability post‐treatment (SMD ‐0.28, 95% CI ‐0.74 to 0.18; P = 0.24, 3 studies, 363 participants) and a lack of data at follow‐up meant no analysis could be run. We found no beneficial effects for the outcomes of depression (SMD 0.04, 95% CI ‐0.18 to 0.26; P = 0.73, 2 studies, 317 participants) and anxiety (SMD 0.53, 95% CI ‐0.63 to 1.68; P = 0.37, 2 studies, 370 participants) post‐treatment, however, we are cautious of our findings as we could only include two studies in the analyses. We could not conduct analyses at follow‐up. We judged the evidence for all outcomes to be very low quality.All conditionsAcross all chronic pain conditions, six studies reported minor adverse events which were not attributed to the psychological therapies. Satisfaction with treatment is described qualitatively and was overall positive. However, we judged both these outcomes as very low quality.Authors' conclusionsThere are currently a small number of trials investigating psychological therapies delivered remotely, primarily via the Internet. We are cautious in our interpretations of analyses. We found one beneficial effect of therapies to reduce headache severity post‐treatment. For the remaining outcomes there was either no beneficial effect at post‐treatment or follow‐up, or lack of evidence to determine an effect. Overall, participant satisfaction with treatment was positive. We judged the quality of the evidence to be very low, meaning we are very uncertain about the estimate. Further studies are needed to increase our confidence in this potentially promising field.

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