Chronic Pain
Chronic pain is recognised as a public health problem. It is the leading cause of years lived with disability globally, producing a significant economic and social burden (1,2). Chronic pain can lead to limitations in daily activities, feelings of low mood and anxiety, and a negative impact on family life.
National Institute and Health Care Excellence (3) recognises chronic pain as pain that persists for more than 3 months. Chronic pain can exist as “chronic primary pain” which can sometimes present without clear underlying condition (3). The mechanisms underlying chronic primary pain are only partially understood. Chronic pain can also exist as “chronic secondary pain”, caused by an underlying condition (e.g., osteoarthritis, rheumatoid arthritis, ulcerative colitis, endometriosis) (4). Chronic primary pain and chronic secondary pain can coexist, and present as persistent, long-term pain (4). The terms chronic primary and secondary pain are new definitions. Given this, it is important to consider evidence as it pertains to a range of chronic pain conditions as previously defined and diagnosed. All forms of pain can cause distress and disability.
While definitions of primary and secondary pain have some value for researchers, clinically there is a great deal of overlap between the two. Receiving a clear cause for their pain may be a key goal for many people using services, but often this will have limited or no effect on treatment approaches. After all treatments aimed at an identified underlying cause have been attempted, the presentations become largely indistinguishable from those who never had a clear cause of their pain as services move towards addressing the suffering and struggling connected with the individual's pain experience.
Beyond diagnosis, a range of biological, social and psychological factors can develop and interact to contribute to the distress and suffering seen as a result of ongoing pain. Known physiological changes such as central and peripheral sensitisation may play a part in explaining persistence of pain even in the absence of clear medical diagnoses. Other factors may include healthcare experiences themselves, the person’s unique understanding of the pain which may include a range of beliefs about what is going on for them, behavioural responses to pain such as avoidance or overactivity, physical deconditioning, low mood and anxiety, and family responses to the pain. Issues of physical and mental health prior to the development of chronic pain may also contribute to levels of disability and distress (see other Matrix topics e.g., depression, PTSD, substance use).
People with pain symptoms often have a long journey through health services prior to accessing services related specifically for their pain symptoms. Health and social care staff/service providers should be involved in coproduction of a care and support plan by setting out a comprehensive person‑centred assessment of the causes and effects of pain, and agreeing possible management strategies, including self‑management (3). Management of chronic pain involves multidisciplinary health care team which can include psychologists, nursing, physiotherapists, occupational therapy, medical and administrative staff. The British pain society recommends multidisciplinary care as outlined in the clinical standards for pain management services (5). For children and young people, the UCL Competency framework for Psychological Interventions in Paediatric Settings (6) and British Psychological Society guidance on delivering psychology in paediatric settings (34) outline appropriate service pathways for young people and their families. Health care providers helping people with chronic pain should be sensitive to the person's socioeconomic, cultural, and ethnic background, and faith group (3). Consideration should also be given to how these might influence symptoms, understanding and choice of treatment (3).
Children and Young People: The current literature indicates that chronic and recurrent pain in children and adolescents is common, with median global prevalence rates ranging from 11% to 38% (7). The most recent systematic review on the epidemiology of chronic pain in children and young people (7) found that prevalence rates ranged substantially across a variety of medical presentations and a lack of consistency in pain definitions was found. Overall headaches are the most commonly researched and a median prevalence rate of 23% is reported. Additionally, female gender and lower socioeconomic status are both related to a higher prevalence of chronic pain (7,8). Prevalence rates increase with age for all medical presentations, other than abdominal pain (7). Although more recent population-based studies have provided estimates of the prevalence of chronic pain in children and adolescents across countries, the reported proportions have continued to vary across studies. Due to the wide variability in the reported estimates and lack of studies in the UK, an accurate epidemiology of chronic pain in children and adolescents in the UK is unclear. An updated systematic review has been recommended (9).
Adult: In the United Kingdom, an estimated 8 million people live with chronic pain (10), with prevalence rates ranging from 20 –34% across the UK (10,11). Age, gender and ethnicity influence the prevalence of chronic pain, with rates reportedly higher in older populations, in women, and in black and minority ethnic groups (11). Prevalence of chronic pain is also associated with area-level deprivation, with rates of 41% reported in more deprived areas. One third of respondents with chronic pain reported high impact upon usual daily activities (11) with such impact associated with greater use of specialist pain services.
This information is relevant to health care practitioners, commissioners, managers, and trainers to consider the evidence base for the delivery of psychological interventions for people with chronic pain. This information is also relevant to adults, children and young people who have primary and secondary chronic pain, and to healthcare professionals (in primary, community, secondary, tertiary settings) who have direct contact with them and make decisions concerning their care.
This topic introduction page covers evidence-based psychological interventions used to treat chronic pain in children, young people, and adults, and the psychological practice/settings in which these interventions can be delivered. This information is relevant only to non-malignant chronic pain. It does not cover pharmacological or other interventions. Full guidance on identifying, assessing and managing chronic pain can be found in the NICE guidance (3) (https://www.nice.org.uk/guidance/ng193) and SIGN guidance for children and young people (12) https://www.sign.ac.uk/media/1538/chronic_pain_in_childrenpdf.pdf and adults (13) https://www.sign.ac.uk/media/1108/sign136_2019.pdf. Recommendations for interventions are listed per chronic pain condition. These include Osteo and Rheumatoid Arthritis, Chronic low back pain (CLBP), Fibromyalgia, Neuropathic pain following spinal cord injury, Non-specific musculoskeletal pain and widespread chronic pain. A large proportion of the evidence base pertains to people with CLBP or Fibromyalgia.
Overview of evidence for Children and Young People
The evidence review supports the use of psychological therapies in children and young people (CYP) with chronic pain, and their families (14,15). The evidence base for interventions and treatments is limited when compared to adult populations. There are fewer RCT level studies, and low quality of studies is reported across reviews. Additionally, reviews include historical evidence with some areas having little to no updated evidence. Clinicians should note that suitable interventions missing from this table may be absent due to a still emerging evidence base. Clinicians should therefore also draw on expert clinical opinion, current adult population evidence, and existing frameworks in paediatric psychology (6), when deciding on suitable treatment pathways.
A review of previous (12) guidance shows that CYP with chronic pain have been recommended a range of psychological therapies. Cognitive behavioural therapy is the most researched area, and the recommended first line of treatment (12). This recommendation is supported by the updated reviews of CBT evidence in CYP experiencing chronic pain (14-16). High level evidence of small to large efficacy on a range of outcomes such as pain, disability, and distress is demonstrated. Emerging evidence indicates that remote delivery may be a viable alternative, especially where access to face to face CBT is limited (15,17). It is recognised that this is an area that is changing rapidly, and reviews included in this guidance have largely been carried out prior to the COVID-19 pandemic. Further information on supporting technology enabled delivery of psychological therapies is available https://www.nes.scot.nhs.uk/media/ud0ijhyo/digital-delivery-guidance-report-final_09-04.pdf.
Previous matrix guidance (2015) included Acceptance and Commitment Therapy (ACT) as part of a range of interventions available to young people, although noted the overall low quality of studies in this field. An updated systematic review confirms that the evidence base for this therapy is still emerging, however notes smaller studies when taken together show some promising directions for ACT in CYP with chronic pain (21).
There are a number of reviews that look at interdisciplinary group interventions with CYP and their parents (40, 41, 42). The evidence base points to large effect improvements in child disability, and medium effect improvements in mood and pain experience (40, 41). Additionally interdisciplinary interventions were found to have a large effect on parenting and parent psychological flexibility, as well as small to moderate improvements in parental mental health and coping (42). The evidence base overall recommends interdisciplinary group working such as pain management programmes (PMPs) as a first line treatment.
Biofeedback and relaxation approaches are often included with CBT analyses and recommendations, however there is very little recent evidence regarding this as a standalone intervention. One recent meta-analysis evidence shows a large and sustained effect for these used together for CYP with headache pain (18).
The current evidence base highlights the importance of a systemic approach to chronic pain work with CYP. A recent Cochrane review (19) shows the impact of psychological therapy with parents of CYP with chronic pain. CBT and Problem Solving therapies (PST) for parents are highlighted as promising. Results show a small to medium beneficial effect for parent mental health and parent behaviour, a small beneficial effect on child disability, and a medium beneficial effect on child pain symptoms. An updated systematic review additionally recommends ACT for direct work with parents, with medium to large effects reported in both parent and child outcomes (20).
Overview of Evidence for Adults
A range of non-pharmacological self-management and psychological interventions are evidenced for people with chronic pain, however, the quality of the evidence in these studies have ranged from low to high. In order to be consistent our focus has been on interventions with the highest levels of efficacy and the strongest levels of evidence where these exist. The evidence tables below include interventions with high and moderate levels of evidence (“A” and “B” respectively) and small to large levels of efficacy. The evidence is obtained from systematic reviews/meta-analyses of Randomised Control Trials (RCTs) and studies of psychological interventions compared to control group (e.g. placebo, treatment as usual, waiting list control or other active treatment).
As highlighted in the table, the following psychological interventions are recommended in the treatment of chronic pain; CBT, ACT, Pain Management Programmes, Self-management Programmes and Mindfulness based interventions. A review of evidence from SIGN, NICE, and other sources recommends consideration of Acceptance and Commitment Therapy (ACT) and/or Cognitive Behavioural Therapy (CBT) for the management of chronic pain in people aged 16 years and over (3,13). This recommendation is supported by high level evidence of small to medium efficacy on psychological, functioning and pain associated outcomes, however, there is insufficient evidence to support superiority of either intervention over the other. A comparative meta-analysis (29) found interdisciplinary ACT had a greater effect size for physical disability, psychosocial impact, and depression compared to unidisciplinary ACT. ACT and CBT should be delivered by healthcare professionals with appropriate training.
There is some evidence from systematic reviews for mindfulness-based interventions in chronic pain (22,32,33). There is also a recommendation for continued research to understand the role of mindfulness in treating pain (3). A small effect size for primary pain outcomes (migraines) was however reported in one meta-analytic study for mindfulness-based interventions. Mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MCBT) have shown more effectiveness compared to eclectic/unspecified Mindfulness-based interventions (MBI) (32).
The evidence for biofeedback has been considered and there is evidence for large effect sizes in some situations (37), however, NICE discourages Biofeedback as a management option for people with chronic primary pain (3). It is included in the table as an alternative or adjunct to other recommendations.
Overview of Evidence for Older People
A review of psychological interventions for the treatment of chronic pain in older adults indicates small benefits, including reducing pain and catastrophizing beliefs and improving pain self-efficacy for managing pain (40). The results were strongest when delivered using group-based approaches. Further research is needed to enhance the efficacy of psychological approaches and sustainability of treatment effects among older people with chronic pain. Clinicians are advised that there are differences in presentation of psychological problems in later life and to consult Delivering Effective Psychological Therapies and Interventions to Older People for further information on factors relevant to practice.
Overview of Evidence of Harms and Adverse Effects
Psychological therapies have the potential to have adverse effects. Until recently, information on potential harms and rates of adverse effects have not been gathered systematically. Although reports of adverse effects are increasingly included in research trials and gathered as part of service provision we do not know if psychological interventions cause more, fewer or similar numbers of adverse effects than no treatment or another treatment, because the evidence in this area is of very low quality at present.
|
Recommendation |
Who For? | What Intervention? | Type of Psychological Practice | Level of Evidence | Level of Efficacy |
| First line recommendation | Children and adolescents with chronic pain |
CBT (14-17)
|
Enhanced / specialist | A | Low - High |
| First line recommendation | Children and adolescents with chronic pain |
Interdisciplinary working (40, 41)
|
Enhanced / specialist | A | Low - High |
|
Alternative |
Children and adolescents with chronic pain |
Remotely Delivered CBT (17) |
Enhanced / specialist |
A |
Low - Medium |
|
Alternative |
Children and adolescents with chronic pain
|
Biofeedback and Relaxation for headache (18) |
Enhanced / specialist |
A |
High |
|
Alternative |
Children and adolescents with chronic pain |
Enhanced / specialist |
B |
Low - Medium |
|
|
First line recommendation
|
Parents of children with chronic pain
|
CBT (19) Problem solving therapy (19) Acceptance and Commitment Therapy (20) |
Enhanced / specialist |
A
|
Low - High
|
|
Recommendation |
Who For? |
What Intervention? |
Type of Psychological Practice |
Level of Evidence |
Level of Efficacy |
|
First line intervention (where psychological treatment is indicated) |
Adults with a range of pain conditions |
CBT for pain management and a range of outcomes (1, 23-28, 36, 39) Specific conditions: Chronic primary pain (1) Cognitive-behavioural treatment for chronic neck pain (25) CBT for migraine or tension-type headaches (24) CBT for treatment of Long-Term Painful Conditions CBT for Rheumatoid Arthritis (36) CBT for Chronic low back pain delivered in combination with physiotherapy care (38) |
Enhanced /specialist |
A |
Low - High on outcomes for pain intensity, mental health, disability
|
|
First line intervention (where psychological treatment is indicated) |
Adults with a range of pain conditions |
Acceptance and commitment therapy (ACT) provided in an interdisciplinary format, mixed pain conditions (3,29)
|
Enhanced/ specialist |
A |
Medium-High on outcomes for physical disability, psychosocial impact and depression. Small for pain intensity, large for pain acceptance.
|
|
First line intervention
|
Adults with a range of pain conditions |
Pain Management Programmes Group-based, multi-disciplinary programmes using a range of interventions focused upon improvement in QOL, function, mental well being and pain intensity. Both in- and out-patient settings (30,31) Consider structure of groups to include 6/7 sessions as optimal for disability/functional improvement, 12/13 sessions for psychological health, and 10 sessions for pain intensity. Consider 8/10 participants per group for more favourable outcomes. |
Enhanced/ specialist |
A |
Medium - High outcomes for QOL, medium for Physical functioning, low to medium for mental health and medium for pain intensity
|
|
Alternative |
|
ACT (individual/unidisciplinary format) (39) (29) |
Enhanced/specialist |
A |
Low - Medium outcomes for pain intensity and psychosocial impact; medium outcomes for depression and anxiety; large outcomes for acceptance |
|
Alternative |
Adults with Chronic Primary Pain / Adults with FM |
Mindfulness based interventions – MBSR and MBCT (22,32,33) |
|
A |
Low - Medium
|
|
Alternative (or as an adjunct to other interventions) |
Adults with Chronic pain (not chronic primary pain) |
Biofeedback (37) |
Skilled/enhanced |
A |
Low -Medium for pain intensity, depression, disability and cognitive coping. |
|
Condition specific recommendations |
Adults with Rheumatoid Arthritis (RA) |
Psychological interventions focusing on adjustment to RA and self management (should include relaxation, stress management and cognitive coping skills (such as managing negative thinking. May include a joint protection focus) (35)
|
Skilled/enhanced |
A |
N/A |
Technical group members: Dr David Craig, Dr Rachel Griffiths, Dr Leeanne Nicklas, Dr Jonathan Todman, Dr Shreena Unadkat
With thanks to the physical health advisory group members and the Pain Psychology network.
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