The World Health Organization has revised its 2012 guidelines for chronic or long-term pain management in children. The new version was expanded to include physical therapy and psychological interventions in acknowledgement of the “complex, multidimensional” nature of chronic pain.

The evidence-based guidelines focus on physical, psychological, and pharmacological interventions for the management of primary and secondary chronic pain in children ages 0 to 19.

According to WHO, “chronic pain or pain that persists or recurs for longer than three months in children is a significant public health problem and a leading cause of morbidity in children globally,” resulting in “higher levels of physical disability, anxiety, depression, sleep problems, and poor academic performance.” Pain, they write, should be treated in a multidisciplinary model of care, from a biopsychosocial perspective that takes into account each child’s culture, health conditions, and specific needs.

Among the recommendations:

• Chronic pain management for children may include physical therapy alone or in combination with other treatments.
• Psychological management, including cognitive behavioral therapy and related interventions, may be used to treat pain either in person or remotely.
• Pharmacological management may be used if tailored to specific indications and conditions.
• Pharmacological interventions may include opioids for end-of-life care or for children with life-limiting conditions — but only in concert with other therapeutic interventions such as physical therapy.

While the guidelines include a recommendation for the use of physical therapy, the recommendation is based on "very low certainty" evidence, according to authors, who also describe "mixed views" of physical therapy among caregivers, parents, and children. "Children reported concerns with these interventions, including boredom with exercises and reluctance to practice new skills in front of peers," they add.

The guidelines also include a caveat that "the costs of physical therapy are likely to vary across countries," with the possibility that in some instances, costs could be "substantial" both in terms of utilization and parents' lost work time.

Authors also suggest that graduate and postgraduate education on pain management should be more comprehensive so that health care providers fully understand the biopsychosocial model of pain management.

The guideline development group noted significant gaps in research evidence for all three categories of pediatric pain management interventions. Authors advocate for increased study of specific interventions alone and as part of a comprehensive plan of care, measurement of standardized outcomes data for better comparison of treatment efficacy, and collection of observational data from clinical registries.

Future research in physical therapy for pain management, say authors, should include large multicenter trials, studies of tailored interventions, and research on interventions integrated into children’s daily activities.