Cognitive behaviour therapy for chronic pain

Cognitive behaviour therapy is provided by registered practitioners with relevant training and experience. To find a psychologist in your area see: Australian Psychological Association

Cerebral Palsy Alliance offers a service to children and adults with cerebral palsy experiencing chronic pain to help decide if this intervention is a good choice.

Find a Cerebral Palsy Alliance service

Fees will apply for assessment and cognitive behaviour therapy with a trained practitioner and will depend on the provider and the number of sessions needed. Check with the practitioner whether fees will also apply for development of a home program, report writing or practitioner travel.

Ask health care providers if you are eligible for funding to assist with fees. People with a disability living in Australia may be eligible for a health care rebate through Medicare or funding from the National Disability Insurance Scheme.

Cognitive behaviour therapy can be undertaken on a short, medium or long-term basis depending on the needs of the child and the nature of the problems addressed. Some children require one to three sessions, but most require from six to 12 sessions.

Up to 75 per cent of children with cerebral palsy experience pain¹, compared to around 33 per cent of typically developing children of similar ages². Pain can have multiple causes, including dystonia, spasticity and contractures, partial dislocation of the hip, scoliosis and gastroesophageal reflux.³ Pain impacts on emotions and behaviour as well as mobility, sleep and other daily activities, including self-care and school work.

Cognitive behaviour therapy can be used to help reduce the intensity and emotional distress of ongoing pain. It involves learning strategies to alter thinking (cognitive strategies) and behaviour (behavioural strategies). These strategies can influence children’s thoughts and beliefs about themselves and their health, to help them change their feelings and behaviours in response to pain. The strategies will vary according to the child, family and nature of the problem.

Commonly used cognitive behavioural therapy strategies include:

• Activity scheduling - planning and pacing pleasurable activities to increase the range and level of children’s activities
• Stress management - managing stress by using breathing techniques, social connection and pleasant activities to reduce stress and improve overall wellbeing
• Challenging unhelpful thoughts – children learning to identify thoughts and beliefs about pain and themselves that increase their fear and sense of powerlessness, and to replace them with ones that promote confidence and resilience
• Coping skills training - learning to use relaxation and breathing techniques, distraction, counting and other strategies to cope with pain
• Assertiveness training – children learn skills in communicating about their pain levels and the strategies that they would like to use to assist with pain management

Cognitive behaviour therapy can be:

• Completed individually, or in groups
• With a therapist in person, or online
• Using a computerised package with content delivered by email, a website or a DVD.

Parents or carers are often involved in the therapy sessions as it is important for everyone in the family to learn ways to respond to the pain and support the child to use their new techniques at home.

Other pain management interventions to complement cognitive behaviour therapy include:

• Medication
• Exercise
• Specialised equipment or environmental aids
• Massage
• Heat and cold application

Cognitive behaviour therapy is often completed as part of a more comprehensive “package” which involves other health professionals such as physiotherapists, medical staff and exercise physiologists. It is important for children and adolescents with chronic pain and their families to talk about the issue with all of their treating health professionals, and for professionals to communicate with each other on a regular basis.

• A practitioner may recommend that a child and their parents read brochures and other resources on cognitive behaviour therapy to complement their therapy
• A child may be asked to complete homework tasks between sessions to learn new coping skills and practice managing the pain. The strategies can then be practiced after therapy finishes.

• Agency for Clinical Innovation – Pain Management Network
• Australian Pain Society

The decision to use cognitive behaviour therapy should follow a comprehensive assessment to understand the nature of the pain, its impact on daily life and the contributing factors. Goals are established for treatment and a time frame set to achieve them.

Routine assessment to measure if therapy is working is necessary. During or after therapy, practitioners may ask children and families to fill in questionnaires and pain assessments to measure the effect of their therapy on the pain, their daily life, and their behaviour and emotional distress.

We searched the medical, allied health and psychological literature to find research evaluating the outcomes of cognitive behaviour therapy for children and adolescents with cerebral palsy experiencing chronic pain.

The search aimed to find the best available evidence of whether this intervention reduces pain, depression and anxiety, as well as increases children’s ability to participate in everyday activities. Research about cognitive behaviour therapy used with children with acute pain such as post-surgical pain or pain experienced as part of a medical procedure was not included, as acute pain is managed with other forms of intervention. No research was located evaluating the outcomes of cognitive behaviour therapy for children with cerebral palsy with chronic pain. As a consequence, the literature was then searched for high-level evidence (that is, systematic reviews and randomised controlled trials (RCTs)) evaluating cognitive behaviour therapy used with other groups of children and adolescents with chronic pain. The high-level evidence about other groups of children informed the potential for this intervention to be effective for children with cerebral palsy.

The best available evidence was a systematic review⁴ and three more recently published RCTs^5-7 evaluating cognitive behaviour therapy used with children and adolescents with headache and migraine, abdominal pain or fibromyalgia. A relatively new way of offering cognitive behaviour therapy to children and adolescents with pain is using computerised resources. An additional systematic review⁸ and a more recently published RCT⁹ were considered the best available evidence specifically evaluating whether computerised delivery of this intervention was effective.

Although good quality systematic reviews and RCTs are the best available evidence, the quality of this evidence is considered to be moderate quality^4-9 for informing about cognitive behaviour therapy for children with cerebral palsy. This is because the research has been completed with children with diagnoses other than cerebral palsy and, therefore, the results are expected, rather than proven, to apply to children with cerebral palsy.

Cognitive behaviour therapy is more effective than no intervention

Whether face-to-face or computerised, cognitive behaviour therapy is more effective than no intervention for reducing chronic pain in children with headache, abdominal pain and fibromyalgia. It is just as effective as intensive interventions including medical care and education.

Cognitive behaviour therapy, in person, with a therapist is more effective than medical care or education in reducing depression

Completed in-person with a therapist, cognitive behaviour therapy is more effective than equally intensive medical care or education for reducing depressive symptoms in children with chronic pain when measured immediately after treatment and at six months follow up^5-7.

The research is less clear for the effects of computerised cognitive behaviour therapy on depression. One study evaluated depressive symptoms of children with chronic pain participating in computerised therapy⁹. Overall level of depressive symptoms did not change following intervention but these children did not present with elevated levels at the start of the study.

It is unclear whether cognitive behaviour therapy improves daily activities

Evidence of the ability of cognitive behaviour therapy to improve functional ability in children with chronic pain was not clear, as results were inconsistent. Two RCTs^6-7 concluded there was no difference in functional disability between children who had this intervention and those who had no intervention or an alternative intensive intervention such as education or medical care. A third RCT⁵ reported an improvement in functional disability in the group of children who had cognitive behaviour therapy compared with education.

Overall, cognitive behaviour therapy, whether delivered in person or computerised, is effective for reducing pain in children and adolescents with headaches, abdominal pain and fibromyalgia. The children and adolescents in the studies reviewed were mostly aged 10 years and above, and did not have an intellectual disability. Although there were no studies which included children with cerebral palsy, cognitive behaviour therapy is considered a promising intervention and would be worthwhile trialling with children with cerebral palsy who are aged 10 years and older and do not have an intellectual disability. No research has evaluated the effectiveness of cognitive behaviour therapy with younger children or children and adolescents with a developmental or intellectual disability. The decision to trial cognitive behaviour therapy with these groups should be made after carefully considering the unique characteristics of each individual.