Pei-Fan Mu, RN., Ph.D. Professor and Deputy Academic Dean, School of Nursing, National Yang-Ming University, Taipei, Taiwan R. O.C. Yann-Fen C. Chao, RN, DNSc. Dean and Professor, School of Nursing, National Yang-Ming University, Taipei, Taiwan, R. O. C.
The International Association for the Study of Pain1definition of pain is an unpleasant sensory and emotional experience with actual or potential tissue damage, or described in terms of such damage. Chronic pain is a significant problem in the pediatric population, conservatively estimated to affect 15% to 20% of children2. Perquin, et. al.3 analyzed a large representative sample of school children's pain experiences and found that 25% of the children reported chronic and recurrent pain of 3 months or longer. Children and adolescents who suffer from ongoing pain have negative outcomes not only to their physical health, but also to their emotional and spiritual health. Besides the discomfort of the pain itself, recurrent pain in children may also cause a number of other negative consequences to the child, the family and society. Thus, there is accumulating evidence that recurrent pain symptoms in children are becoming a serious health concern.
Chronic pain includes persistent and recurrent pain with possible fluctuations in severity, quality, regularity and predictability. Chronic pain can occur in single or multiple body regions and can involve single or multiple organ systems. Ongoing pain is associated with neurosensory changes, and persistent nociception can result in a sensitization of the peripheral and central nervous systems to produce neuroanatomical, neurochemical, and neurophysiological change. Chronic pain may include varying amounts of disability, from none to severe, independent of the amount of tissue damage. Biological, psychological, sociocultural factors are in the developmental context of pain in children.4 Thus, a non-pharmacological approach to reduce the pain is vital to help children having better quality of life. The IASP characterized chronic pain as time periods of less than 1 month, 1 to 6 months, and greater than 6 months.1 Early intervention is very important and essential if it is suspected a child may be developing chronic pain, and it is inappropriate to delay the treatment of chronic pain for longer than one month. Thus, in this study, chronic pain will be defined as pain experienced for equal to or greater than one month.
There are a number of conditions that lead to children and adolescents experiencing chronic pain including chronic abdominal pain, recurrent headache, stomach-ache, backache, vasocclusive pain and cancer pain.
Chronic pain combined with the emotional state and cognitive capacity of an individual can alter the normal sensory and perceptive components of pain. The individuals’ perception of pain is influenced by the interaction of physiologic, psychological and social factors, resulting in prolonged perception of pain. Chronic pain develops when the normal impulse associated with noxious stimuli are altered. Chronic pain in children and adolescents affects their own coping strategies and of their entire family.5–8 The persistence of pain may become the central focus for the patient and family, distracting from normal daily activities. Unrelieved pain in children may lead to a state of fear that the pain or illness may never resolve, resulting in anxiety that is as debilitating as the pain itself.
The gate control theory of pain emphasis on the modulation of inputs in the spinal dorsal horns and the dynamic role of the brain in pain processes had a clinical as well as a scientific impact. Psychological factors are an integral part of pain processing and new avenues for pain control were open.9
Besides the systemic and regional pharmacological interventions, a multi-model approach of treating chronic pain in children is often seen as being effective. Based on the gate control theory, chronic pain tends to move a C-fiber pathway. Once the slow pain message reaches the brain, it takes a pathway to the hypothalamus and limbic system. The hypothalamus is responsible for the release of certain stress hormones in the body, while the limbic system is responsible for processing emotions. The brain also controls pain messages by attaching meaning to the personal and social context in which the pain is experienced. The brain can send signals down the spinal cord to open and close the nerve gates. In times of anxiety or stress, descending messages from the brain may actually amplify the pain signal at the nerve gate as it moves up the spinal cord.
Alternatively, impulses from the brain can “close” the nerve gate, preventing the pain signal from reaching the brain and being experienced as pain. Furthermore, there are some other factors that can open or close the pain gates as messages move up and down the spinal cord. These can be roughly divided into sensory (physical being and activities), cognitive (thoughts), or emotional (feelings) areas. Most of the techniques in developing non-pharmacological treatments were based on these principles. Some of the non-pharmacological interventions that have been commonly used in the treatment of chronic pain is children and adolescents include: increasing activities, relaxation training, message, mind-body therapy (individual psychological therapy, group therapy, art and expression therapy, support therapy), hypnosis therapy, breathing technique, guided imagery, progressive muscle relaxation, biofeedback, cognitive-behavioral training, and music therapy and cognitive behavioral interventions.
A recent Cochrane systematic review identified 18 randomized controlled trails, of which 13 (12 trials of headache and one on the management of abdominal pain in children) provided data suitable for meta-analysis.10 The main findings of this review was that the number of patients needing to be treated to show benefit for psychological therapies producing more than 50% pain relief compared with control treatments. From the pooled data set the NNT was 2.32 (95% CI 1.96 to 2.88). This compares favorably with numbers needed to treat for other published treatments in chronic pain. A striking finding is the evidence was that psychological therapy for headache can be delivered with good effect at low cost, in community settings, and by trained non-psychologists. Unfortunately these trails reported only analyzable data for non-pharmacological pain relief. It remains unclear whether these treatments are also effective for other outcomes.
The context of pain experience is multidimensional. When we are discussing the parental factors and family factors affects on chronic pain experience of children, there are two dominant theoretical models in which such parent and family factors may be considered: operant-behavioral theories and family systems theories. Operant-behavioral theories are centered on the role of social reinforcement in maintaining maladaptive pain behaviors. Treatments based on operant theories attempt to shift social contingencies through operant conditioning to reinforce well behaviors.
Family systems theories emphasize individuals’ behavior within the context of their family situations, such as the child's response to pain under the conditions of the family's overall functioning and role assignment. Treatments stemming from family systems theories attempt to change dysfunctional patterns of relating and communicating using more traditional family therapy approaches to achieve change.8, 11–12 Some research investigating the effectiveness of nonpharmacological interventions to relieve children's and adolescent's pain include parental factors and dyad factors.13
This systematic review will examine the effectiveness of the non-pharmacological pain management for children and adolescents with chronic pain and associated distress and disability. The systematic literature review for study will include children and adolescents with cancer pain, Juvenile chronic arthritis, Sickle cell disease, burn pain, chronic or recurrent abdominal pain, and headache.
The overall objective of this review is to examine the clinical effectiveness of nonpharmacological interventions for chronic pain in children and adolescents. The specific review questions to be addressed are:
- What is the effectiveness of non-pharmacological interventions on behavior variables in children and adolescents?
- What is the effectiveness of non-pharmacological interventions on quality of life in children and adolescents?
- What is the effectiveness of non-pharmacological interventions on pain scores in children and adolescents?
Inclusion Criteria for this review
1. Types of studies:
This review will include any randomized controlled trials and quasi-experimental designs that explore the effectiveness of non-pharmacological interventions for chronic pain in children and adolescents.
2. Types of participants:
Children and adolescents aged 18 years old or less, with pain of at least one months’ duration. The types of pain to be included in this systematic review will be cancer pain, Juvenile chronic arthritis, sickle cell disease, burn pain, chronic or recurrent abdominal pain, and headache.
3. Types of interventions:
This component of the review will consider studies that examine non-pharmacological interventions in relieving chronic pain for children and adolescents including: heat wrap therapy, massage, chiropractic spinal manipulative therapy, cognitive-behavioral therapy (distraction & guided imagery), meditation, progressive muscle relaxation, self-hypnosis, biofeedback, music therapy, and dance training.
4. Types of outcome measures:
- Behavioral variables, such as pain behavior, cognitive coping and appraisal, psychiatric reaction (anxiety and depression), and social activities.
- Quality of life.
- Pain scores.
5. Types of setting:
6. Types of languages:
Exclusion Criteria for this review
1 Types of participants:
1.1 child's age is younger than or equal to newborn
1.2 acute pain (such as procedural pain, postoperative pain, child abuse, dental pain, chemotherapy, low back pain, wrist pain) in children and adolescents
2 Types of interventions: pharmacological interventions,
3 Types of outcome measures: pain assessment
Table 1 below represents the summary of inclusion and exclusion criteria for this review.
The following databases will be searched to identify keywords contained in the title and abstract, and relevant MeSH headings and descriptor terms.
_The Cochrane Library
_PsycINFO 1872 - 2004
_Ovid MEDLINE 1966 -
_Ovid CINAHL 1960 -
_Index to Chinese periodical literature 1997-
Key word search terms will be:
1. Types of studies: Experimental study, random, quasi-experimental study, systematic review
2. Types of participants: child, adolescents, chronic pain, headache, cancer, backache, shoulder pain.
3. Types of interventions: non-pharmacological interventions, massage, sensory stimulation, imagination, sensory and procedural information, mind-body therapy, psychological therapy, group therapy, art therapy, expression therapy, hypnosis, breathing technique, biofeedback, cognitive-behavioral training, music therapy, coping strategies, cognitive therapy, emotional therapy, distraction, relaxation training, complimentary/alternative therapy.
4. Types of outcome measures: pain behavior, cognitive coping, appraisal, psychiatric reaction, anxiety, depression, stress, and social activities, quality of life, pain instrument, pain score, pain questionnaire, behavior observation, physical parameters.
Studies identified during the database search will be assessed for relevance to the review based on the information contained in the title, abstract and MeSH heading. Abstracts identified from the search of the databases will firstly be assessed independently by two reviewers for inclusion criteria. And then, the 2 reviewers compare and resolve differences. A detail report will be provided for all studies that meet the inclusion criteria.
Methods of review
1. Critical appraisal
Studies that meet the inclusion criteria will be assessed for methodological quality. Full text and all potential studies will be retrieved and assessed independently by two reviewers. Disagreements between the 2 reviewers will be resolved by discussion or if necessary by a third reviewer. Assessment of evidence includes strength of evidence, effectiveness, effect size and relevance of evidence to clinical practice. All studies will be assessed using the critical appraisal tool developed by Joanna Briggs Institute (JBI). (See appendix 1)
2. Data Extraction
Data will be extracted from included studies independently by the two reviewers using standardized data extraction tools from the Joanna Briggs Institute (see appendix 2). Any disagreements that arise will be resolved by a third reviewer.
3. Data synthesis
Meta-analysis will be used to pool the data from studies to determine the effectiveness of the intervention. Review manager will be used to manage the data. Intervention studies will be pooled in a meta-analysis and tested for heterogeneity using the standard Chi-square test. Where possible, these binary outcomes will be analyzed by calculation of the Odds Ratio with the 95% CI. The weighted mean difference will be calculated if the pooled studies have used the same scale for continuous data. The standardized mean difference will be calculated for continuous data measuring the same outcome on a different scale. In studies where statistical pooling of results is inappropriate, the findings will be considered for inclusion as a narrative summary.
Potential conflicts of interest
There is no potential conflict of interest.
We are grateful to our research assistant, Shu-Chen Cheng RN., PhD candidate, for participating into the whole process of our study.
1. Task Force on Taxonomy. Classification of chronic pain: Descriptions of chronic pain syndromes and definitions of pain terms
. Seattle: IASP Press, 1994.
2. Goodman JE, McGrath PJ. The epidemiology of pain in children and adolescents: A review. Pain,
1991; 46, 247-264.
3. Perquin CW, Hazebroek-Kampscheur AAJM., Hunfeld JAM, Bohnene AM, van Suijlekom-Smit LWA, Passchier J, van der Wouden JC. Chronic pain among children and adolescents: physician consultation and medication use. Clinical Journal of Pain,
2001; 16, 229-235.
4. Bursh B, Walco GA, Zeltzer L. Clinical assessment and management of chronic pain and painassociated disability syndrome. Journal of Developmental and Behavioral Pediatrics,
1998; 19, 45-53.
5. Harel Z, Gascon G, Riggs S, Vaz R, Brown W, Exil G. Supplementation with Omega-3 Polyunsaturated Fatty Acids in the Management of Recurrent Migraines in Adolescents. Journal of Adolescent Health,
2002; 31, 154-161.
6. Cheng SF, Foster RL, Huang CY. Concept Analysis of Pain. Tzu Chi Nursing Journal,
2003; 2, 20-30.
7. Gerik SM. Pain Management in Children: Developmental Considerations and Mind-body Therapies. Southern Medical Journal,
2005; 98, 295-302.
8. Palermo TM, Chambers CT. Parent and family factors in pediatric chronic pain and disability: An integrative approach. Pain,
2005; 119, 1-4.
9. MelZack R. Pain: an overview. Acta anaeshesiologica Scandinavia,
1999; 43, 880-884.
10. Eccleston C, Morley S, Williams A, Yorke L, Mastroyannopoulou A. Psychological therapies for the management of chronic and recurrent pain in children and adolescents. Cochrane Database Systematic Review,
2003; 1, CD003968.
11. Boughton K, Blower C, Chartrand C, Dircks P et al. Impact of research on pediatric pain assessment and outcomes. Pediatric Nursing,
1998; 24, 31-36.
12. Eccleston C, Malleson PN, Clinch J, Connell H, Sourbut C. Chronic pain in adolescents: evaluation of a programme of interdisciplinary cognitive behavior therapy. Arch. Dis. Child,
2003; 88, 881-885.
13. Allen KD, Elliott AJ, Arndorfer RE. Behavioral Pain Management for Pediatric Headache in Primary Care. Children's Health Care,
2002; 31, 175-189.
Appendix 2: Data Extraction