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Chronic pain in childhood is an international public health problem. We conducted a systematic review and meta-analysis to provide a summary of the published evidence of pharmacological, physical, and psychological therapies for children with chronic pain conditions. We searched CENTRAL, MEDLINE, EMBASE, and PsycINFO from inception to April 2020; clinical trial registries; and other sources for randomised controlled trials or comparative observational trials. We extracted critical outcomes of pain intensity, quality of life, physical functioning, role functioning, emotional functioning, sleep, and adverse events. We assessed studies for risk of bias and certainty of the evidence using GRADE. We included 34 pharmacological (4091 participants), 25 physical therapy (1470 participants), and 63 psychological trials (5025 participants). Participants reported a range of chronic pain conditions. Most studies were assessed to have unclear or high risk of bias across multiple domains. Pharmacological, physical, and psychological therapies showed some benefit for reducing pain, posttreatment, but only physical and psychological therapies improved physical functioning. We found no benefit of any treatment modality for health-related quality of life, role functioning, emotional functioning, or sleep. Adverse events were poorly reported, particularly for psychological and physical interventions. The largest evidence base for the management of chronic pain in children supports the use of psychological therapies, followed by pharmacological and physical therapies. However, we rated most outcomes as low or very low certainty, meaning further evidence is likely to change our confidence in the estimates of effects. This protocol was registered on PROSPERO (CRD42020172451).

Objective:To identify predictors of prognosis and trial outcomes in prospective studies of people with chronic headache.Methods:This was a systematic review of published literature in peer-reviewed journals. We included (1) randomized controlled trials (RCTs) of interventions for chronic headache that reported subgroup analyses and (2) prospective cohort studies, published in English, since 1980. Participants included adults with chronic headache (including chronic headache, chronic migraine, and chronic tension-type headache with or without medication overuse headache). We searched key databases using free text and MeSH terms. Two reviewers independently extracted data and assessed the methodologic quality of studies and overall quality of evidence identified using appropriate published checklists.Results:We identified 16,556 titles, removed 663 duplicates, and reviewed 199 articles, of which 27 were included in the review—17 prospective cohorts and 10 RCTs with subgroup analyses reported. There was moderate-quality evidence indicating that depression, anxiety, poor sleep and stress, medication overuse, and poor self-efficacy for managing headaches are potential prognostic factors for poor prognosis and unfavorable outcomes from preventive treatment in chronic headache. There was inconclusive evidence about treatment expectations, age, age at onset, body mass index, employment, and several headache features.Conclusions:This review identified several potential predictors of poor prognosis and worse outcome postinterventions in people with chronic headache. The majority of these are modifiable. The findings also highlight the need for more longitudinal high-quality research of prognostic factors in chronic headache.

Background There is a lack of research available that examines the diverse population of frequent users of Urgent and Emergency Healthcare services throughout England. The motivations and decision-making processes which frequent users take into consideration when selecting episodic treatment from: Out of Hours GPs; NHS111; Ambulance Services and Emergency Departments are not full examined. Most research explores this population by focusing on the patient’s demographics or preliminary diagnosis, rather than their unmet needs that has instigated the urgent and emergency contact. Subjective terminology and arbitrary thresholds are employed across these services to identify these individuals, with little standardisation or clinical justification to the reasons why they have been selected. Through understanding the unmet needs of this heterogenous population, improved individualised patient centred support and management options should be achieved. Aims The aim was to analyse the underlying reasons why frequent users of Urgent and Emergency Healthcare Services in England, select and request episodic instances of care, rather than the consistent approach provided within primary care. Methods A systematic mapping exercise was undertaken to create a comprehensive understanding of how these services are currently working with regard to frequent users. The search produced 5094 articles which were screened against the inclusion criteria, leaving 156 articles to be analysed. Data was extracted and a thematic synthesis was used to analyse this diverse population. From this analysis, a taxonomy of sub-groups of frequent users was formed and their underlying needs identified. Thirty-two clinical semi-structured interviews throughout these services were undertaken, to gain critical feedback on the robustness and viability of the taxonomy. A purposeful sampling method ensured that clinical practitioners that had substantial experience in supporting and managing these complex and vulnerable individuals participated within the research. The qualitative data received from clinicians with knowledge and skills of working with this population prompted adjustments to the original taxonomy. Results The taxonomy sub-divided the main heterogeneous group into 5 main groups: Elderly and Frail; Mental Health; Substance Misuse; Chronic Conditions; and Homeless and Vulnerably Housed. Within each sub-group, unmet needs were identified and further categorised. A hidden population of patients that were accessing urgent and emergency healthcare services due to unresolved pain emerged. This population was categorised into: persistent or chronic pain; acute episodes of severe pain (crisis) and addiction, opioid-induced hyperalgesia or tolerance factors. The reasons attributed to the patients’ frequent contacts were due to the breakdown of their relationship with their GP, polypharmacy issues, access to primary care treatments, perceptions and judgements from clinicians and lack of adequate clinical training around pain management both in primary and acute settings. These high intensity users of urgent and emergency healthcare services are often the most vulnerable and complex members of our society. Conclusion Repeated episodic instances of care, which are often given in urgent and emergency healthcare settings relating to pain management are not proactively allowing individuals to manage their long-term outcomes. Understanding the patients’ unmet needs and what has instigated their frequent contacts to services, could enable clinicians to signpost into other specialised services which will improve the patients’ quality of care. Furthermore, Improved pain management training in both the primary and acute services relating to high intensity users could diminish the negative experiences faced by these individuals and frustrations felt within day to day practice.

ObjectiveTo systematically review the qualitative literature of the lived experience of people with a chronic headache disorder.BackgroundChronic headaches affect 3%–4% of the population. The most common chronic headache disorders are chronic migraine, chronic tension-type headache and medication overuse headache. We present a systematic review and meta-ethnographic synthesis of the lived experience of people with chronic headache.MethodsWe searched seven electronic databases, hand-searched nine journals and used a modified Critical Appraisal Skills Programme checklist to appraise study quality. Following thematic analysis we synthesised the data using a meta-ethnographic approach.ResultsWe identified 3586 unique citations; full texts were examined for 86 studies and 4 were included in the review. Included studies differed in their foci: exploring, patient-centred outcomes, chronic headache as a socially invisible disease, psychological processes mediating impaired quality of life, and the process of medication overuse. Initial thematic analysis and subsequent synthesis gave three overarching themes: ‘headache as a driver of behaviour’ (directly and indirectly), ‘the spectre of headache’ and ‘strained relationships’.ConclusionThis meta-synthesis of published qualitative evidence demonstrates that chronic headaches have a profound effect on people’s lives, showing similarities with other pain conditions. There were insufficient data to explore the similarities and differences between different chronic headache disorders.

ObjectivesTo assess the effect of non-pharmacological self-management interventions against usual care, and to explore different components and delivery methods within those interventionsParticipantsPeople living with migraine and/or tension-type headacheInterventionsNon-pharmacological educational or psychological self-management interventions; excluding biofeedback and physical therapy.We assessed the overall effectiveness against usual care on headache frequency, pain intensity, mood, headache-related disability, quality of life and medication consumption in meta-analysis.We also provide preliminary evidence on the effectiveness of intervention components and delivery methods.ResultsWe found a small overall effect for the superiority of self-management interventions over usual care, with a standardised mean difference (SMD) of −0.36 (−0.45 to −0.26) for pain intensity; −0.32 (−0.42 to −0.22) for headache-related disability, 0.32 (0.20 to 0.45) for quality of life and a moderate effect on mood (SMD=0.53 (−0.66 to −0.40)). We did not find an effect on headache frequency (SMD=−0.07 (−0.22 to 0.08)).Assessment of components and characteristics suggests a larger effect on pain intensity in interventions that included explicit educational components (−0.51 (−0.68 to −0.34) vs −0.28 (−0.40 to −0.16)); mindfulness components (−0.50 (−0.82 to −0.18) vs 0.34 (−0.44 to −0.24)) and in interventions delivered in groups vs one-to-one delivery (0.56 (−0.72 to −0.40) vs −0.39 (−0.52 to −0.27)) and larger effects on mood in interventions including a cognitive–behavioural therapy (CBT) component with an SMD of −0.72 (−0.93 to −0.51) compared with those without CBT −0.41 (−0.58 to −0.24).ConclusionOverall we found that self-management interventions for migraine and tension-type headache are more effective than usual care in reducing pain intensity, mood and headache-related disability, but have no effect on headache frequency. Preliminary findings also suggest that including CBT, mindfulness and educational components in interventions, and delivery in groups may increase effectiveness.Trial registration numberPROSPERO 2016:CRD42016041291

Study Design\ud A systematic review of randomised controlled trials (RCTs) \ud Objective\ud To determine the effects of active rehabilitation on functional outcome following lumbar spinal stenosis surgery when compared with 'usual postoperative care'.\ud Summary of background data\ud Surgery rates for lumbar spinal stenosis have risen, yet outcomes remain suboptimal. Post-operative rehabilitation has been suggested as a tool to improve post-operative function but, to date, there is limited evidence to support its use.\ud Methods\ud CENTRAL (The Cochrane Library), the Cochrane Back Review Group Trials Register, MEDLINE, EMBASE, CINAHL and PEDro electronic databases were searched. Randomised controlled trials (RCTs) comparing the effectiveness of active rehabilitation with usual care in adults with lumbar spinal stenosis who had undergone primary spinal decompression surgery were included. Two authors independently selected studies, assessed the risk of bias, and extracted the data in line with the recommendations of the Cochrane Back Review Group. Study results were pooled in a meta-analysis when appropriate using functional status as the primary outcome, with secondary outcomes including measures of leg pain, low back pain, and global improvement/general health. The GRADE approach was used to assess the quality of the evidence.\ud Results\ud Our searches yielded 1,726 articles, of which three studies (N = 373 participants) were suitable for inclusion in meta-analysis. All included studies were deemed to have low risk of bias; no study had unacceptably high dropout rates. There was moderate evidence suggesting that active rehabilitation was more effective than usual care in improving both short- and long-term functional status following surgery. Similar findings were noted for secondary outcomes, including short-term improvement in low back pain and long-term improvement in both low back pain and leg pain. \ud Conclusions\ud We obtained moderate-quality evidence indicating that postoperative active rehabilitation after decompression surgery for lumbar spinal stenosis is more effective than usual care. Further work is required particularly with respect to the cost effectiveness of such interventions.

Background Lumbar spinal stenosis is a common cause of back pain among older people that can also give rise to pain in the buttock, thigh or leg, particularly when walking. There are several possible treatments, of which surgery appears to be best at restoring function and reducing pain. The outcome of surgery however falls well short of ideal and a sizeable proportion of patients do not regain good function. Importantly, there is no accepted evidence-based approach to post-operative care, which is what has prompted this review. Objectives This Cochrane Review was designed, to establish whether the outcome of surgery for lumbar stenosis can be improved by active rehabilitation programmes and if such programmes are superior to usual post-operative care. Active rehabilitation includes any group or therapist led intervention to improve functional status through a programme of exercises or educational material encouraging activity. Search methods A comprehensive search of CENTRAL (The Cochrane Library, most recent issue), the Cochrane Back Review Group Trials Register, MEDLINE, EMBASE, CINAHL, and PEDRO since their first issues was conducted on 12 January 2012. Selection criteria Only RCTs that compared the effectiveness of active rehabilitation with usual care in adults (>18 year olds) with confirmed lumbar spinal stenosis, who had undergone spinal decompressive surgery (with or without fusion) for the first time, were considered in this review. Data collection and analysis Two review authors independently extracted data for the included trials using a pre-developed form. Where necessary the authors of the original trials were contacted to request additional unpublished data. The outcome measures and interventions of the trials were assessed to ensure the baseline characteristics of participants were clinically homogeneous. The clinical relevance of each study was independently assessed, using the five questions recommended by the Cochrane Back Review Group (CBRG), and the risk of bias within the studies was assessed using the CBRG criteria. The results of the individual studies were pooled in a meta-analysis where appropriate. For continuous outcomes, the mean difference (MD) was calculated when the same measurement scales were used in all studies and the standardised mean difference (SMD) when different measurement scales were used. Where the outcome data were skewed meta-analysis was performed on the log-scale and results were converted back to the original scale. A fixed-effect model was used to measure the treatment effect where there was no substantial evidence of statistical heterogeneity. If substantial statistical heterogeneity was detected, a random-effects model was used. The primary outcome measure was functional status measured by a back-specific functional scale. Secondary outcomes included measures of leg pain and low back pain, and global improvement / general health. These were reported and analysed separately for short- and long-term outcomes. Statistical significance as well as clinical relevance of outcomes was considered. The GRADE approach was used to determine the overall quality of evidence for each outcome using five criteria, where evidence is ranked from high to very low quality, depending on the number of criteria met. Results The searches yielded 1726 results, and in total three studies were included in the review and meta-analysis. Outcomes in the short-term (within 6 months post-operative): In the short-term there is moderate quality evidence from three RCTs (N= 340) that active rehabilitation is more effective than usual care for functional status and low quality evidence that rehabilitation is more effective for reported low back pain. In contrast, low quality evidence suggests rehabilitation is no more effective than usual care for leg pain (N=340). Low quality evidence from two RCTs (N=238) indicates that rehabilitation is no more effective than usual care for general health. Outcomes in the long-term (at 12 months post-operative): In the long-term there is moderate quality evidence from three RCTs (N= 373 that rehabilitation is more effective than usual care for functional status and reported low back pain. Moderate quality evidence suggests that rehabilitation is more effective than usual care for leg pain (N=373). In contrast low quality evidence suggests that rehabilitation is no more effective than usual care for general health (evidence from two studies, N=273). Authors' conclusions The evidence suggests that active rehabilitation is more effective than usual care for improving both short and long term (back-related) functional status. Similar findings were noted for other secondary outcomes including; short-term improvements in low back pain and long-term improvement in both low back pain and leg pain. The clinical relevance of these statistically significant effects is medium to small. Our evaluation is limited by the small number of relevant studies identified. Further research is required to provide higher quality evidence, and to consider other relevant outcomes such as work participation. Plain language summary Can active rehabilitation improve the outcome of surgery for spinal stenosis? Spinal stenosis is a common age-related condition of the spine (back) that leads to back and leg pain. Surgery is the treatment of choice for many patients, but we know that their ability to carry out everyday tasks (functional recovery) following surgery is not ideal, although leg pain does improve for most patients. This review wished to find out whether active rehabilitation after surgery could improve the ability of patients to carry out everyday tasks when compared to the usual post-operative care. We found that very little work had been done in this area; only 3 studies were suitable for inclusion. Each involved a rehabilitation programme between 30 to 90 minutes long, either once or twice weekly, starting 6 to 12 weeks after surgery. We found that active rehabilitation is helpful following surgery, providing modest improvements in both function and low back pain in both the short-term (within 6 months of surgery), and long-term (at 12 months).