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      Efficacy of Internet-delivered cognitive-behavioral therapy for the management of chronic pain in children and adolescents : A systematic review and meta-analysis

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          Pediatric chronic pain is relatively common in the world. Although cognitive behavior therapy (CBT) has been shown to be efficacious in children and adolescents, it is generally recognized that availability and accessibility of CBT are limited. While Internet-delivered cognitive-behavioral therapy (ICBT) performs better in these areas.


          This systematic review aims to evaluate the clinical effects of ICBT for chronic pain in youth when compared with the control treatments.


          We searched electronic databases to identify randomized controlled trials that compared ICBT with the control therapy for pediatric chronic pain. The primary outcomes were 95% confidence intervals and mean difference or standardized mean difference in change of pain intensity and activity limitations.


          Four trials met the inclusion criteria with a total of 404 participants of whom 208 received ICBT. Compared with pretreatment, children reported significant, medium to large benefits on pain intensity, activity limitations, and parental protective behaviors after receiving ICBT immediately. Significant small to medium effects were found for outcomes of depressive symptoms, anxiety, and sleep quality from baseline to post-treatment in the ICBT group. But most measures of ICBT did not show statistically significant superiority to those of the control conditions, except parental protective behaviors. Generally children and their parents were highly acceptable and satisfied with ICBT.


          ICBT for physical and psychological conditions in youth with chronic pain is a full potential therapy; it can be successful on clinically effects and socioeconomic benefits. However, only limited data supported the conclusion, we require further methodologically robust trials.

          Systematic review registration:

          PROSPERO CRD42017069811.

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          Most cited references 30

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          Cognitive behavior therapy via the Internet: a systematic review of applications, clinical efficacy and cost-effectiveness.

          Internet-based cognitive behavior therapy (ICBT) is a promising treatment that may increase availability of cognitive behavior therapy (CBT) for psychiatric disorders and other clinical problems. The main objective of this study was to determine the applications, clinical efficacy and cost-effectiveness of ICBT. The authors conducted a systematic review to identify randomized controlled trials investigating CBT delivered via the internet for adult patient populations. Searches to identify studies investigating cost-effectiveness of ICBT were also conducted. Evidence status for each clinical application was determined using the American Psychologist Association criteria for empirically supported treatments. Of 1104 studies reviewed, 108 met criteria for inclusion, of which 103 reported on clinical efficacy and eight on cost-effectiveness. Results showed that ICBT has been tested for 25 different clinical disorders, whereas most randomized controlled trials have been aimed at depression, anxiety disorders and chronic pain. Internet-based treatments for depression, social phobia and panic disorder were classified as well-established, that is, meeting the highest level of criteria for evidence. Effect sizes were large in the treatment of depression, anxiety disorders, severe health anxiety, irritable bowel syndrome, female sexual dysfunction, eating disorders, cannabis use and pathological gambling. For other clinical problems, effect sizes were small to moderate. Comparison to conventional CBT showed that ICBT produces equivalent effects. Cost-effectiveness data were relatively scarce but suggested that ICBT has more than 50% probability of being cost effective compared with no treatment or to conventional CBT when willingness to pay for an additional improvement is zero. Although ICBT is a promising treatment option for several disorders, it can only be regarded as a well-established treatment for depression, panic disorder and social phobia. It seems that ICBT is as effective as conventional CBT for respective clinical disorder, that is, if conventional CBT works then ICBT works. The large effects and the limited therapist time required suggest that the treatment is highly cost effective for well-established indications.
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            The frequency, trajectories and predictors of adolescent recurrent pain: a population-based approach.

            Recurrent pains are a complex set of conditions that cause great discomfort and impairment in children and adults. The objectives of this study were to (a) describe the frequency of headache, stomachache, and backache in a representative Canadian adolescent sample and (b) determine whether a set of psychosocial factors, including background factors (i.e., sex, pubertal status, parent chronic pain), external events (i.e., injury, illness/hospitalization, stressful-life events), and emotional factors (i.e., anxiety/depression, self-esteem) were predictive of these types of recurrent pain. Statistics Canada's National Longitudinal Survey of Children and Youth was used to assess a cohort of 2488 10- to 11-year-old adolescents up to five times, every 2 years. Results showed that, across 12-19 years of age, weekly or more frequent rates ranged from 26.1%-31.8% for headache, 13.5-22.2% for stomachache, and 17.6-25.8% for backache. Chi-square tests indicated that girls had higher rates of pain than boys for all types of pain, at all time points. Structural equation modeling using latent growth curves showed that sex and anxiety/depression at age 10-11 years was predictive of the start- and end-point intercepts (i.e., trajectories that indicated high levels of pain across time) and/or slopes (i.e., trajectories of pain that increased over time) for all three types of pain. Although there were also other factors that predicted only certain pain types or certain trajectory types, overall the results of this study suggest that adolescent recurrent pain is very common and that psychosocial factors can predict trajectories of recurrent pain over time across adolescence.
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              The economic costs of chronic pain among a cohort of treatment-seeking adolescents in the United States.

              The aim of this study was to assess the economic cost of chronic pain among adolescents receiving interdisciplinary pain treatment. Information was gathered from 149 adolescents (ages 10-17) presenting for evaluation and treatment at interdisciplinary pain clinics in the United States. Parents completed a validated measure of family economic attributes, the Client Service Receipt Inventory, to report on health service use and productivity losses due to their child's chronic pain retrospectively over 12 months. Health care costs were calculated by multiplying reported utilization estimates by unit visit costs from the 2010 Medical Expenditure Panel Survey. The estimated mean and median costs per participant were $11,787 and $6,770, respectively. Costs were concentrated in a small group of participants; the top 5% of those patients incurring the highest costs accounted for 30% of total costs, whereas the lower 75% of participants accounted for only 34% of costs. Total costs to society for adolescents with moderate to severe chronic pain were extrapolated to $19.5 billion annually in the United States. The cost of adolescent chronic pain presents a substantial economic burden to families and society. Future research should focus on predictors of increased health services use and costs in adolescents with chronic pain.

                Author and article information

                Medicine (Baltimore)
                Medicine (Baltimore)
                Wolters Kluwer Health
                September 2018
                07 September 2018
                : 97
                : 36
                Department of Anaesthesiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
                Author notes
                []Correspondence: Zhi-Song Li, Department of Anaesthesiology, The First Affiliated Hospital of Zhengzhou University, Longhu Road and Longxiang Seven Street Intersection, Zhengdong New District, Zhengzhou 450000, China (e-mail: lzszzu@ 123456163.com ).
                MD-D-17-08068 12061
                Copyright © 2018 the Author(s). Published by Wolters Kluwer Health, Inc.

                This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc/4.0

                Research Article
                Systematic Review and Meta-Analysis
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