Psychosocial treatments for chronic pain

1
Psychosocial treatments for chronic pain

• Enabling people to reduce the impact of pain on
  their lives and influencing societys attitude to
  pain

2
What is the size of the problem?

• Perquin et al (2000) Pain, 87, 51-58.
• N 5424 (6636) 0-3 Parents 4-18 children
• Most common pain limb, headache, abdominal
• 54 significant pain episode in the last 3 months
• 26 recurrent or chronic pain
• 8 or 1/3rd had severe disabling chronic pain
• High number of adolescent Girls (12-14 years)

Perquin CW, Hazebroek-Kampscheur AAJM, Hunfeld
JAM, Bohnene, AM, van Suijlekom-Smit LWA,
Passchier J, van der Wouden JC. Pain in children
and adolescents a common experience. Pain
20008751-58.
3
Pain Associated Disability PADS Bursch, Walco
Zeltzer (1998)
School
Family
Mood
Social Life
PAIN
Activity
Fitness
Sleep
Independence
Eating
Bursch, B, Walco, G A and Zeltzer L (1998).
Clinical assessment and management of chronic
pain and Pain-Associated Disability Syndrome,
Developmental Behavioral Pediatrics,19,45-53.
4
MAG Sprangers et al. Which chronic conditions are
associated with a better or poorer quality of
life? Journal of Clinical Epidemiology 2000 53
895-907.

• High scores show greater negative effects on the
  quality of life

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Eccleston, C. Morley, S. Williams, A. Yorke, L.,
Mastroyannopoulou, A. (2002) Systematic review
and a subset meta-analysis of randomised
controlled trials of psychological therapy for
children and adolescents with chronic pain. Pain,
99, 157-165.
To determine the current state of the
evidence To inform future trials To inform
clinical practice
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Results

• 28 studies, 18 RCTs, 13 with data.
• No evidence for non-pain outcomes
• No evidence for non-headache outcomes
• 13 studies with pain diary
• Treatment efficacy (50 pain relief)
• OR 10.22
• NNT 2.14
• ES 0.47

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Promising therapies 1

• CBT with Parent training (RAP).
• RCT of Family intervention vs SC
• improvements in
• pain
• pain behaviour
• life interference
• relapse
• Child coping maternal caregiving

Sanders MR, Shepherd RW, Cleghorn G. Woolford H.
The treatment of recurrent abdominal pain in
children a controlled comparison of cognitive
behavioral family intervention and standard
pediatric care. J Consul Clin Psychol
199462306-314.
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Promising therapies 2

• CBT low dose PT vs CBT high dose PT
• Early identification of CRPS 1
• Combination therapy
• Dose
• disability status
• home compliance.

Lee, B H, Scharff, L, Sethna, N F, McCarthy, C F,
Scott-Sutherland, J, Shea A M, Sullivan, P,
Meier, P, Zurakowski, D, Masek, B J and Berde, C
B (2002). Physical therapy and
cognitive- behavioral treatment for complex
regional pain syndromes, Journal of Pediatrics,
141, 135-140.
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Promising therapies 3

• General chronic pain population (4 years)
• Full interdisciplinary team
• 3 week residential programme
• parent involvement
• parent improvement at post treatment
• child improvement at 3 months
• Significant return to school rates

Eccleston, C., Malleson, PM., Clinch, J.,
Connell, H. Sourbut, C. (2003) Chronic pain in
adolescents Evaluation of a programme of
Inter-disciplinary Cognitive Behaviour Therapy
(ICBT). Archives of Disease in Childhood, 88,
881-885.
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New developments 1. Psychosocial Assessment
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Self Report

• 43 separate measures identified
• 30 developed for adolescents
• 12 had psychometric data on use with pain
  patients
• Median use was twice

• Eccleston, Jordan Crombez (in press) Journal of
  Pediatric Psychology. The impact of
• chronic pain on adolescents A review of
  previously used measures.

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BAPQ

• 222 adolescents completed battery
• 61 item measure
• 7 subscales social functioning, physical
  functioning, depression, general anxiety, pain
  specific anxiety, family functioning, development
• Good comparative validity
• Good temporal reliability

Eccleston C, Jordan A, McCracken L, Sleed, M,
Connell, H, Clinch, J (2005) The Bath Adolescent
Pain Questionnaire (BAPQ) Development and
preliminary psychometric evaluation of an
instrument to assess the impact of chronic pain
on adolescents. Pain, 118, 263-270 .
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New developments 2. physical Assessment
Eccleston, Z Eccleston, C. (2004)
Interdisciplinary management of adolescent
chronic pain developing the role of the
physiotherapist. Physiotherapy, 90, 77-81.
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Examples of walking here
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New developments 3. Conceptual parental distress
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Parental burden/stress/strain 1

• Adolescence as change for parents
• Parenting stress
• I find myself giving up more of my life to meet
  my childrens need than I ever expected
• Predictors of parental stress
• adolescent depression,
• young age
• the long duration of pain

Eccleston, et al (2004) Adolescent chronic pain
patterns and predictors of emotional distress in
adolescents with chronic pain and their parents.
Pain, 108, 221-229.
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Parental burden/stress/strain 2

• 18 parents interviewed
• Qualitative analysis
• Themes
• Struggle for control and coherence
• A different life than expected
• Search for a cure
• Suspension in early parenting pattern

Jordan A, Eccleston, C Osborn M. (in press) Being
a parent of an adolescent with chronic pain An
Interpretative Phenomenological Analysis.
European Journal of Pain.
18
New developments 4. Economic considerations
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Cost of pain study

• 52 families completed comprehensive survey
  (CRSI-pain) 12 months
• Costs (pain)
• DIRECT 7947
• INDIRECT 6213
• Total annual cost 14160
• Annual UK cost of untreated chronic pain
• 6797 Million pounds
• Without long term costs (e.g., reduced employment)

Sleed, Eccleston, et al (2005) The economic
impact of chronic pain in adolescence
Methodological considerations and preliminary
cost-of-illness study. Pain, 119, 183-190. .
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Conclusions

• Chronic pain is under-recognised, undertreated
  and expensive
• Patients and parents present with widespread
  psychsocial problems
• CBT and PT can be effective for complex chronic
  pain
• Parental distress is a key treatment issue
• To advance the science we need to work on
  measurement technology

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New Avenues

• Measure of the impact of pain on parents (Van).
• What predicts disability (underway)
• Social development (Van)
• Longer term treatment outcome (underway)
• Updating systematic review (underway)
• Intergenerational transmission (in mind)
• Sub-group analyses (in mind

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Thank you

• Professor Christopher Eccleston
• Pain Management Unit
• University of Bath
• RNHRD NHS Trust
• Bath, BA1 1RL, UK.
• www.bath.ac.uk/pain-management/