The relationship of daily mood and stressful events to symptoms in juvenile rheumatic disease

Relationship of Fatigue, Pain Interference, and Physical Disability in Children Newly Diagnosed With Juvenile Idiopathic Arthritis

OBJECTIVE

Our objectives were to quantify the relationships among fatigue, pain interference, and physical disability in children with juvenile idiopathic arthritis (JIA) and to test whether fatigue mediates the relationship between pain interference and physical disability in JIA.

METHODS

Patients enrolled within three months of JIA diagnosis in the Canadian Alliance of Pediatric Rheumatology Investigators (CAPRI) Registry between February 2017 and May 2023 were included. Their parents completed the Patient-Reported Outcomes Measurement Information System fatigue and pain interference short proxy questionnaires and the Childhood Health Assessment Questionnaire disability index at registry enrollment. Associations were assessed using Pearson correlations and multiple linear regression. Structural equation modeling (SEM) was used to test if fatigue mediates the relationship between pain interference and physical disability.

RESULTS

Among 855 patients (61.4% female, 44.1% with oligoarthritis), most reported fatigue and pain interference scores similar to those in the reference population, but 15.6% reported severe fatigue and 7.3% reported severe pain interference, with wide variation across JIA categories. Fatigue was strongly correlated with pain interference (r = 0.72, P < 0.001) and with physical disability (r = 0.60, P < 0.001). Pain interference (β = 0.027, P < 0.001) and fatigue (β = 0.013, P < 0.001) were both associated with physical disability after controlling for each other and potential confounders. SEM supported our hypothesis that fatigue partially mediates the relationship between pain interference and physical disability.

CONCLUSION

Our findings suggest both fatigue and pain interference are independently associated with physical disability in children newly diagnosed with JIA, and the effect of pain interference may be partly mediated by fatigue.

Instrumental Substance Use Among Youth with Rheumatic Disease-A Biopsychosocial Model

Youth with chronic medical conditions (YCMC) including rheumatic disease use substances and may experience harms from doing so. The chronic illness experience may amplify substance use risks for some YCMC who may use to ameliorate symptoms of disease activity and negative side effects of medications, so-called "instrumental use." This article provides a brief overview of adolescent substance use, its intersection with chronic illness, and pediatric-onset rheumatic disease (PRD). A biopsychosocial model of substance use vulnerability for youth with PRD is presented along with emerging evidence about instrumental use of substances. Implications for PRD clinical practice are discussed.

Positive Psychological Factors and Impairment in Rheumatic and Musculoskeletal Disease: Do Psychopathology and Sleep Quality Explain the Linkage?

OBJECTIVE

Little is known about potential mechanisms of action linking protective positive psychological variables and functional disability in patients with rheumatic and musculoskeletal disease. The present study was undertaken to examine symptoms of psychopathology, including stress, depression, anxiety, and sleep quality, as serial mediators of the association between gratitude, self-compassion, self-forgiveness, and functional impairment.

METHODS

We assessed risk and protective factors for functional disability in patients with fibromyalgia (FM), osteoarthritis (OA), rheumatoid arthritis (RA), and ankylosing spondylitis (AS) who were recruited from an Austrian health care facility. Respondents completed online surveys, including the Gratitude Questionnaire 6-item form, the Self-Compassion Scale short form, the Self-Forgiveness and Forgiveness of Others Index, the Perceived Stress Scale 4, the Patient Health Questionnaire 2, the 2-item Generalized Anxiety Disorder Scale, the Sleep Condition Indicator, and the Health Assessment Questionnaire. Bivariate and serial mediation analyses were conducted.

RESULTS

For our sample of 1,218 patients (52% female, n = 632; AS [37%], OA [34%], RA [14%], and FM [24%]), stress, depression, and anxiety, in parallel as first-order mediators, and sleep quality as a second-order mediator, explained the association between positive psychological variables and functional disability.

CONCLUSION

Positive psychological factors exert a beneficial downstream effect on mental well-being, sleep health, and health-related functional impairment. Therapeutic promotion of gratitude, self-compassion, and self-forgiveness may improve mental and physical health in patients with rheumatic and musculoskeletal disease.

Vagus nerve stimulation and Neurotrophins: a biological psychiatric perspective

Since 2004, vagus nerve stimulation (VNS) has been used in treatment-resistant or treatment-intolerant depressive episodes. Today, VNS is suggested as possible therapy for a larger spectrum of psychiatric disorders, including schizophrenia, obsessive compulsive disorders, and panic disorders. Despite a large body of literature supports the application of VNS in patients' treatment, the exact mechanism of action of VNS remains not fully understood. In the present study, the major knowledges on the brain areas and neuronal pathways regulating neuroimmune and autonomic response subserving VNS effects are reviewed. Furthermore, the involvement of the neurotrophins (NTs) Nerve Growth Factor (NGF) and Brain Derived Neurotrophic Factor (BDNF) in vagus nerve (VN) physiology and stimulation is revised. The data on brain NGF/BDNF synthesis and in turn on the activity-dependent plasticity, connectivity rearrangement and neurogenesis, are presented and discussed as potential biomarkers for optimizing stimulatory parameters for VNS. A vagus nerve-neurotrophin interaction model in the brain is finally proposed as a working hypothesis for future studies addressed to understand pathophysiology of psychiatric disturbance.

Depression And Anxiety In Patients With Juvenile Idiopathic Arthritis: Current Insights And Impact On Quality Of Life, A Systematic Review

Depression and anxiety are prevalent in children with rheumatologic diseases, including juvenile idiopathic arthritis (JIA). However, prevalence rates and the relationship with disease outcomes, including quality of life are conflicting in the early literature. To review the current literature, determine gaps in our knowledge, and identify areas in need of further investigation, we conducted a systematic review of studies examining depression and anxiety symptoms among children with JIA and the impact these symptoms may have on disease outcomes and quality of life. Six electronic databases were searched up until January 2019. Of 799 potential articles, 60 articles were included with the main focus on 28 articles from 2009 to 2019, to concentrate on the most current evidence. We found that JIA patients experience symptoms of depression and anxiety similar to other childhood chronic diseases and at higher rates than in healthy children. Patients who experience these symptoms have worse quality of life, with some evidence pointing to depression and anxiety symptoms having a greater impact on quality of life than other disease features, such as active joint count. Family members of JIA patients experience high rates of anxiety and depression symptoms which may impact their child's mental health and pain symptoms related to JIA. Conflicting reports of associations between depression/anxiety symptoms and disease features/disease outcomes and a paucity of longitudinal studies investigating the impact of treatment on mental health symptoms indicate areas in need of further research to effectively identify patients at greatest risk of depression and anxiety and to better understand how to treat and prevent these symptoms in youth with JIA. Family mental health should also be considered in investigations concerning mental health and disease outcomes of children with JIA.

Motivational Non-directive Resonance Breathing as a Treatment for Chronic Widespread Pain

Chronic widespread pain (CWP) is one of the most difficult pain conditions to treat due to an unknown etiology and a lack of innovative treatment design and effectiveness. Based upon preliminary findings within the fields of motivational psychology, integrative neuroscience, diaphragmatic breathing, and vagal nerve stimulation, we propose a new treatment intervention, motivational non-directive (ND) resonance breathing, as a means of reducing pain and suffering in patients with CWP. Motivational ND resonance breathing provides patients with a noninvasive means of potentially modulating five psychophysiological mechanisms imperative for endogenously treating pain and increasing overall quality of life.

The role of psychological factors in pediatric functional abdominal pain disorders

BACKGROUND

Pediatric functional abdominal pain disorders (FAPDs) are disorders of brain-gut dysregulation. Psychological factors are known to be related to etiology, maintenance, and exacerbation of pediatric FAPDs. With the evolving literature in the past two decades, a better understanding has emerged of precisely which psychological factors are associated with childhood FAPDs.

PURPOSE

This narrative literature review summarizes the literature of both child and parent psychological factors in pediatric FAPD. Where anxiety and depression were major targets in the older literature, present-day focus is increasingly on pain-specific cognitions and coping strategies including disease threat and catastrophizing. In addition, parental reaction to a child's pain is increasingly recognized as an important moderator of a child's outcomes and has become an area for clinical intervention. Screening for these factors and integrative treatment approaches are recommended in childhood FAPD.

Trajectories of pain severity in juvenile idiopathic arthritis: results from the Research in Arthritis in Canadian Children Emphasizing Outcomes cohort

We studied children enrolled within 90 days of juvenile idiopathic arthritis diagnosis in the Research in Arthritis in Canadian Children Emphasizing Outcomes (ReACCh-Out) prospective inception cohort to identify longitudinal trajectories of pain severity and features that may predict pain trajectory at diagnosis. A total of 1062 participants were followed a median of 24.3 months (interquartile range = 16.0-37.1 months). Latent trajectory analysis of pain severity, measured in a 100-mm visual analogue scale, identified 5 distinct trajectories: (1) mild-decreasing pain (56.2% of the cohort); (2) moderate-decreasing pain (28.6%); (3) chronically moderate pain (7.4%); (4) minimal pain (4.0%); and (5) mild-increasing pain (3.7%). Mean disability and quality of life scores roughly paralleled the pain severity trajectories. At baseline, children with chronically moderate pain, compared to those with moderate-decreasing pain, were older (mean 10.0 vs 8.5 years, P = 0.01) and had higher active joint counts (mean 10.0 vs 7.2 joints, P = 0.06). Children with mild-increasing pain had lower joint counts than children with mild-decreasing pain (2.3 vs 5.2 joints, P < 0.001). Although most children with juvenile idiopathic arthritis in this cohort had mild or moderate initial levels of pain that decreased quickly, about 1 in 10 children had concerning pain trajectories (chronically moderate pain and mild-increasing pain). Systematic periodic assessment of pain severity in the months after diagnosis may help identify these concerning pain trajectories early and lay out appropriate pain management plans. Focused research into the factors leading to these concerning trajectories may help prevent them.

Do the psychological effects of vagus nerve stimulation partially mediate vagal pain modulation?

There is preclinical and clinical evidence that vagus nerve stimulation modulates both pain and mood state. Mechanistic studies show brainstem circuitry involved in pain modulation by vagus nerve stimulation, but little is known about possible indirect descending effects of altered mood state on pain perception. This possibility is important, since previous studies have shown that mood state affects pain, particularly the affective dimension (pain unpleasantness). To date, human studies investigating the effects of vagus nerve stimulation on pain perception have not reliably measured psychological factors to determine their role in altered pain perception elicited by vagus nerve stimulation. Thus, it remains unclear how much of a role psychological factors play in vagal pain modulation. Here, we present a rationale for including psychological measures in future vagus nerve stimulation studies on pain.

Psychosocial interventions for recurrent abdominal pain in childhood

BACKGROUND

This review supersedes the original Cochrane review first published in 2008 (Huertas-Ceballos 2008).Between 4% and 25% of school-aged children complain of recurrent abdominal pain (RAP) severe enough to interfere with their daily activities. No organic cause for this pain can be found on physical examination or investigation for the majority of such children. Although many children are managed by reassurance and simple measures, a large range of psychosocial interventions involving cognitive and behavioural components have been recommended.

OBJECTIVES

To determine the effectiveness of psychosocial interventions for reducing pain in school-aged children with RAP.

SEARCH METHODS

In June 2016 we searched CENTRAL, MEDLINE, Embase, eight other databases, and two trials registers. We also searched the references of identified studies and relevant reviews.

SELECTION CRITERIA

Randomised controlled trials comparing psychosocial therapies with usual care, active control, or wait-list control for children and adolescents (aged 5 to 18 years) with RAP or an abdominal pain-related functional gastrointestinal disorder defined by the Rome III criteria were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Five review authors independently selected studies, assessed them for risk of bias, and extracted relevant data. We also assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

This review includes 18 randomised controlled trials (14 new to this version), reported in 26 papers, involving 928 children and adolescents with RAP between the ages of 6 and 18 years. The interventions were classified into four types of psychosocial therapy: cognitive behavioural therapy (CBT), hypnotherapy (including guided imagery), yoga, and written self-disclosure. The studies were carried out in the USA, Australia, Canada, the Netherlands, Germany, and Brazil. The majority of the studies were small and short term; only two studies included more than 100 participants, and only five studies had follow-up assessments beyond six months. Small sample sizes and the degree of assessed risk of performance and detection bias in many studies led to the overall quality of the evidence being rated as low to very low for all outcomes.For CBT compared to control, we found evidence of treatment success postintervention (odds ratio (OR) 5.67, 95% confidence interval (CI) 1.18 to 27.32; Z = 2.16; P = 0.03; 4 studies; 175 children; very low-quality evidence), but no evidence of treatment success at medium-term follow-up (OR 3.08, 95% CI 0.93 to 10.16; Z = 1.85; P = 0.06; 3 studies; 139 children; low-quality evidence) or long-term follow-up (OR 1.29, 95% CI 0.50 to 3.33; Z = 0.53; P = 0.60; 2 studies; 120 children; low-quality evidence). We found no evidence of effects of intervention on pain intensity scores measured postintervention (standardised mean difference (SMD) -0.33, 95% CI -0.74 to 0.08; 7 studies; 405 children; low-quality evidence), or at medium-term follow-up (SMD -0.32, 95% CI -0.85 to 0.20; 4 studies; 301 children; low-quality evidence).For hypnotherapy (including studies of guided imagery) compared to control, we found evidence of greater treatment success postintervention (OR 6.78, 95% CI 2.41 to 19.07; Z = 3.63; P = 0.0003; 4 studies; 146 children; low-quality evidence) as well as reductions in pain intensity (SMD -1.01, 95% CI -1.41 to -0.61; Z = 4.97; P < 0.00001; 4 studies; 146 children; low-quality evidence) and pain frequency (SMD -1.28, 95% CI -1.84 to -0.72; Z = 4.48; P < 0.00001; 4 studies; 146 children; low-quality evidence). The only study of long-term effect reported continued benefit of hypnotherapy compared to usual care after five years, with 68% reporting treatment success compared to 20% of controls (P = 0.005).For yoga therapy compared to control, we found no evidence of effectiveness on pain intensity reduction postintervention (SMD -0.31, 95% CI -0.67 to 0.05; Z = 1.69; P = 0.09; 3 studies; 122 children; low-quality evidence).The single study of written self-disclosure therapy reported no benefit for pain.There was no evidence of effect from the pooled analyses for any type of intervention on the secondary outcomes of school performance, social or psychological functioning, and quality of daily life.There were no adverse effects for any of the interventions reported.

AUTHORS' CONCLUSIONS

The data from trials to date provide some evidence for beneficial effects of CBT and hypnotherapy in reducing pain in the short term in children and adolescents presenting with RAP. There was no evidence for the effectiveness of yoga therapy or written self-disclosure therapy. There were insufficient data to explore effects of treatment by RAP subtype.Higher-quality, longer-duration trials are needed to fully investigate the effectiveness of psychosocial interventions. Identifying the active components of the interventions and establishing whether benefits are sustained in the long term are areas of priority. Future research studies would benefit from employing active control groups to help minimise potential bias from wait-list control designs and to help account for therapist and intervention time.

Perceptions of Play and Leisure in Junior School Aged Children with Juvenile Idiopathic Arthritis: What are the Implications for Occupational Therapy?

Play is the dominant occupation in childhood and is recognised as having an important role in wellbeing. Past research suggests that children with a disability experience a variety of barriers to engagement in play. Despite this, play is often not assessed as a specific area of occupational performance. This qualitative study aimed to explore the perceptions of play and leisure in junior school aged children with juvenile idiopathic arthritis. Twelve children between the ages of 7 years and 11 years were interviewed in order to uncover the barriers to engagement in play and leisure and to consider the implications, if any, for occupational therapy.

The results showed that all children, regardless of disease activity, reported difficulty in engaging in play and leisure activities. The symptoms of the disease, the treatment regimes and their side-effects, and psychosocial factors were all reported to affect play and leisure experiences. The children also reported that play behaviours were often restricted by parents, friends and school personnel. Fear of damage and unclear communication about the effects of activity also resulted in self-imposed restrictions, which further limited play experiences. Although the children reported a number of coping strategies to deal with these difficulties, they reported more indoor play and engagement in sedentary activities which often gave rise to feelings of being different, sadness and loneliness.

These findings may have important consequences for occupational therapy and provide a timely reminder about the significance of assessing play and leisure as distinct areas of occupational performance in children.

The iPeer2Peer Program: a pilot randomized controlled trial in adolescents with Juvenile Idiopathic Arthritis

BACKGROUND

Adolescents with Juvenile Idiopathic Arthritis (JIA) are at risk for physical, emotional, social and role challenges that negatively impact quality of life. Peer mentoring has been shown to improve positive health behaviours in adolescents with chronic disease while simultaneously providing social support. The objectives of this paper are to examine the feasibility and acceptability of an online peer mentoring program (iPeer2Peer Program) for adolescents with JIA.

METHODS

The iPeer2Peer program was examined using a waitlist pilot randomized control trial (RCT). Participants were randomly allocated to the intervention or wait-list control group via a secure, web-based randomization service. Health care providers and investigators were blinded to participant group allocation. Trained peer mentors (16-25 years; successfully managing their JIA) were matched to participants (12-18 years; diagnosed with JIA) randomized to the intervention group to provide peer support and education for effective self-management of JIA. Participant-mentor pairings connected ten times over 8 weeks using Skype video calls. Primary outcomes focused on implementation (i.e. measures of feasibility and acceptability). Secondary outcomes focused on effectiveness (i.e. measures of self-management, self-efficacy, pain, social support and quality of life).

RESULTS

Thirty adolescents (mean age 14.3 ± 1.7 years, 97 % female) completed the RCT (intervention n = 16, control n = 14).

PRIMARY OUTCOMES

One third (32 %) of adolescents approached agreed to participate, completed baseline measures and were randomized. Half of pairings completed ten calls within 8 weeks. Average call length was twice the required amount with call lengths of 44.72 ± 15.76 min. Participants reported satisfaction with the program and all reported that they would recommend it to their peers. Participants' mean engagement level with the program was 8.53/10 (range = 7-10).

SECONDARY OUTCOMES

Participants who completed the iPeer2Peer Program demonstrated improvements in their perceived ability to manage JIA (p < 0.04), compared to controls. No adverse events were reported.

CONCLUSION

The iPeer2Peer Program is a promising intervention that improves acceptability of self-management and peer support treatments for adolescents with JIA. By using the Internet to connect mentors to adolescents with JIA it may also improve accessibility to these resources. Findings will be used to adapt the program and refine the methodology for a full-scale RCT.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01986400 . Registered November 11, 2013.

Pain buddy: A novel use of m-health in the management of children's cancer pain

BACKGROUND

Over 12,000 children are diagnosed with cancer every year in the United States. In addition to symptoms associated with their disease, children undergoing chemotherapy frequently experience significant pain, which is unfortunately often undertreated. The field of m-Health offers an innovative avenue for pain assessment and intervention in the home setting. The current study describes the development and initial evaluation of a tablet-based program, Pain Buddy, aimed to enhance pain management and foster improved quality of life in children ages 8-18 years undergoing cancer treatment.

METHODS

An animated avatar-based tablet application was developed using state-of-the-art software. Key aspects of Pain Buddy include daily pain and symptom diaries completed by children, remote monitoring of symptoms by uploading patient's data through internet to a cloud server, cognitive and behavioral skills training, interactive three-dimensional avatars that guide children through the program, and an incentive system to motivate engagement. Twelve children between the ages of 8 and 18 participated in a pilot study of Pain Buddy.

RESULTS

Children were highly satisfied with the program. Pain and appetite disturbances were most frequently endorsed. Symptom trigger alerts to outside providers were largely related to clinically significant pain. Children infrequently used analgesics, and reported using some non-pharmacological pain management strategies.

CONCLUSION

Pain Buddy appears to be a promising tool to improve pain and symptom management in children undergoing cancer treatment. Results from the current study will inform future improvements to Pain Buddy, in preparation for a randomized controlled trial to assess the efficacy of this innovative treatment.

Using Patient-Reported Outcome Measures to Capture the Patient's Voice in Research and Care of Juvenile Idiopathic Arthritis

Patient-reported outcome (PRO) measures provide a valuable window into how patients with juvenile idiopathic arthritis and their parents perceive their functioning, quality of life, and medication side effects in the context of their disease and treatment. Momentum behind adoption of PRO measures is increasing as these patient-relevant tools capture information pertinent to taking a patient-centered approach to health care and research. This article reviews the clinical and research utility of obtaining PROs across domains applicable to the experience of juvenile idiopathic arthritis and summarizes available self-report and parent-proxy PRO measures. Current challenges and limitations of PRO usage are discussed.

Fatigue in patients with juvenile idiopathic arthritis: A systematic review of the literature

OBJECTIVE

To perform a systematic review of the current literature on studies related to fatigue in children with JIA. We studied the measurements that were used to assess fatigue and we focused on three outcome measurements, namely, (1) the prevalence of fatigue in JIA patients, (2) the determinants of and associations with fatigue in JIA patients, and (3) the impact of fatigue in JIA patients on daily life.

METHODS

A search was conducted in the electronic databases Pubmed and Embase from January 1, 2000 until August 27, 2015. The quality in prognostic factors (QUIPS) tool was used to assess the risk of bias (ROB) in the selected studies, focused on the outcome fatigue. Of all, two authors independently judged the ROB.

RESULTS

A total of 15 studies were included in this review. To assess fatigue, two unidimensional and three multidimensional scales were used, which hampered comparison. Fatigue was reported to be present in 60-76% of the patients with JIA and was related to time of day, disease activity, pain, psychosocial factors, and sleep. Minor consequences for daily life were found, though this was not studied extensively.

CONCLUSION

Fatigue is common in patients with JIA. The cause reflects a complex interplay of different factors. Based on results from this review and its body of knowledge, a conceptual model for fatigue in patients with JIA is proposed. Consensus is needed for future studies on how to assess fatigue. We promote the use of a combination of unidimensional and validated multidimensional measurements.

The Assessment of Fatigue in Children With Chronic Pain

The purpose of this study was to review the options that are available for assessing fatigue in children and adolescents with chronic pain problems, analyze the psychometric properties of all the instruments and provide health professionals with key information on which to base decisions about their use. A literature search was conducted using PsycINFO, MEDLINE, CINAHL, ERIC, and Scopus databases and the Cochrane Library between 1934 and January 2013 in order to identify all the studies that have evaluated fatigue in these populations. A total of 936 articles were retrieved, of which 24 were relevant. Of these 10 fatigue-related questionnaires were subject to specific content analysis. Only five of them evaluated fatigue in children with chronic pain, and just two had made a specific analysis of their psychometric characteristics. Most measures have been developed with a multidimensional approach of fatigue in mind. Psychometric information is missing for many questionnaires. On the basis of evidence-based assessment (EBA) criteria none of the questionnaires retrieved can be considered to be well-established measures that can be used in children with chronic pain.

Pain management at home in children with cancer: a daily diary study

BACKGROUND

With the transition of care of cancer patients from the hospital to the home setting, parents are largely responsible for children's pain management. Children's cancer pain is undermanaged, yet, there is little empirical data on the occurrence and management of cancer pain in the home setting. The purpose of the present study, therefore, was to employ a daily diary protocol to examine barriers to pain management of children's cancer pain by parents at home.

PROCEDURE

Parent-child dyads were recruited from the Cancer Institute at a major children's hospital in Southern California. A total of 45 patient/parent pairs completed baseline data on demographic and personality characteristics, children's quality of life, and parental beliefs regarding analgesic use for children and then completed daily diaries of pain and analgesic administration for 14 consecutive days.

RESULTS

Most children were reported to experience chronic pain while undergoing treatment for cancer, yet overall analgesic administration at home was low. Parents who reported misconceptions regarding analgesic use for children were less likely to administer pain medication to children. Children who were less shy, more social, or had lower quality of life were more likely to receive analgesics.

CONCLUSIONS

A significant proportion of children receiving outpatient treatment for cancer were rated as experiencing chronic pain and pain was not optimally managed in the home setting. Further understanding and addressing barriers to children's cancer pain management in the home setting will aid in alleviating unnecessary pain in this vulnerable patient population.

Using an electronic pain diary to better understand pain in children and adolescents with arthritis

Summary 

AIM

To explore the pain experience of youths (9-18 years old) with juvenile idiopathic arthritis, using a real-time data capture electronic pain diary.

MATERIALS & METHODS

A descriptive study design with repeated measures was used. A total of 76 youths, aged 9-18 years old with juvenile idiopathic arthritis were recruited from a Canadian pediatric tertiary care center and asked to record their pain three times a day for 2 weeks using the e-Ouch(©) pain diary.

RESULTS

On average, participants reported mild levels of pain intensity, unpleasantness and interference, as well as stiffness and mild-to-moderate levels of fatigue. Interference of stiffness and pain with activities of daily living were significantly higher in the morning versus the afternoon and evening; while fatigue was significantly higher in the morning and evening compared with the afternoon.

CONCLUSION

Real-time data capture approaches can be used enable a better understanding of how pain and other symptoms in youths with juvenile idiopathic arthritis change within and across days, and how best to treat them. Valuable next steps include incorporating the e-Ouch pain diary into an everyday clinical setting to measure patient outcomes.

How stable are diurnal cortisol activity indices in healthy individuals? Evidence from three multi-wave studies

BACKGROUND

Indices of cortisol activity, including the cortisol awakening response (CAR), diurnal slope, and cortisol output across the day (total daily output), are often studied as mechanistic indicators that could link stress with health. Yet there is a paucity of data speaking to their temporal features, particularly whether they behave in a more state- or trait-like manner across time.

METHODS

To address this issue, data from 3 studies were used to assess CAR, diurnal slope and total daily output stability over different age groups and time spans: 130 healthy children and adolescents collected salivary cortisol samples 5 times/day (1, 4, 9 and 11h after wake) over 2 days at 5 visits spaced 6 months apart (Study 1); 147 adolescent girls collected saliva 6 times/day (wake, 1, 4, 9 and 14 h after wake) for 2 days at 3 visits, each a year apart (Study 2); and 47 healthy, primarily middle age adults collected saliva 6 times/day (wake, 1, 4, 9 and 14 h after wake) for 3 days at 4 visits spaced 2-3 months apart (Study 3). Stability was estimated by multilevel model-derived intraclass correlation coefficients (ICCs).

RESULTS

Across studies, approximately 50% of the variance in cortisol indices was attributable to day-to-day fluctuations, suggesting state-like properties. Of the indices, total daily output emerged as the most stable over time, followed by diurnal slope and CAR, but stability estimates were generally quite modest regardless of index and sample. Over time spans of >1 year, ICCs were ≤ .13.

CONCLUSIONS

Most of the variance in CAR, diurnal slope and total daily output reflects day-to-day fluctuation; there was little evidence for more stable trait-like influences. These findings suggest that future research should focus on short-term fluctuations in stress, cortisol and health, as opposed to lengthy disease processes.

Relationship between daily mood and migraine in children

BACKGROUND

Retrospective and cross-sectional studies have suggested a bidirectional relationship between migraine and mood disturbance.

OBJECTIVE

The present prospective daily diary study examined the prevalence and temporal associations between migraine and daily mood, mood and next-day headache, and headache and next-day mood.

METHODS

Sixty-nine children (50 females, 19 males) between the ages of 7 and 12 years and their parents attending neurology clinic appointments and having a diagnosis of migraine as defined by International Headache Classification 2nd edition criteria completed measures on the quality of life, headache disability, child emotions, and child behaviors. Children and parents then recorded children's headache occurrence, headache duration, headache severity, mood, daily hassles, and medication use on paper diaries once a day for 2 consecutive weeks. "Mood" was defined using the Facial Affective Scale, which is a visual representation of negative and positive affect. Data were analyzed using multilevel models.

RESULTS

Controlling for age, sex, quality of life, headache disability, and medication use, worse mood was associated with same-day occurrence, longer duration, and more severe headache in both child and parent report. Today's mood was not consistently associated with next-day headache, and today's headache was not associated with next-day mood in either child or parent report.

CONCLUSIONS

Results of this study lend support to a complex relationship between mood and headache in children with migraine. More research is needed to further elucidate the temporal nature of this relationship within a given day and over an extended period of time.

Illness uncertainty and quality of life in children with cancer

BACKGROUND

Illness uncertainty is prevalent in children with cancer and has been associated with increased psychological distress. The relationship between illness uncertainty and quality of life in pediatric cancer patients remains unclear. The aim of the present study was to examine illness uncertainty as a predictor of health-related quality of life in children diagnosed with cancer. It was hypothesized that child-reported illness uncertainty would be negatively associated with child health-related quality of life.

PROCEDURE

Children aged 8 to 18 years old and receiving treatment for cancer were recruited to participate in this study. One hundred twenty children and their parent(s) completed measures of illness uncertainty, pain, anxiety, and quality of life during a routine visit to the Cancer Center at Children's Hospital of Orange County.

RESULTS

Illness uncertainty was significantly associated with child age (P=0.02), overall health-related (P<0.001) and cancer-related (P<0.001) quality of life, but not with treatment status (on/off chemotherapy) or demographic variables including sex and household income. Regression analyses statistically controlling for age, anxiety, and pain revealed that illness uncertainty significantly predicted child-reported cancer-related and health-related quality of life (P<0.01) as well as parent-reported cancer-specific quality of life (P<0.01).

CONCLUSIONS

Illness uncertainty is prevalent and associated with lower quality of life in children diagnosed with cancer. Improved communication with children regarding disease state, treatment expectations, and prognosis may alleviate uncertainty and improve functioning in this vulnerable patient population.

Pain intensity variability and its relationship with quality of life in youths with juvenile idiopathic arthritis

OBJECTIVE

To describe variability of pain intensity experienced by youths with juvenile idiopathic arthritis (JIA) and examine factors related to within-day patterns of pain and the relationship between magnitude of pain variability and quality of life.

METHODS

Pain intensity was self-reported on a visual analog scale (VAS; range 0-100) by 112 youths with JIA ages 8-18 years using electronic diaries 3 times per day for 7 days. Average absolute change in pain (AAC) was computed as a measure of the magnitude of pain variability for each participant. Logistic regression was used to examine the relationship between demographic and disease characteristics and the probability of having high pain variability (AAC ≥10 VAS units). Linear regression was used to examine the relationship between quality of life (assessed by the Pediatric Quality of Life Inventory) and AAC. The generalized estimating equations approach was used to examine the relationship between the time of day and pain intensity.

RESULTS

The mean ± SD AAC was 15.6 ± 10.5. The majority of youths (65%) had high AAC (≥10 VAS units). Disease severity predicted high pain variability (β = 0.02, P = 0.044). Higher AAC predicted lower quality of life (adjusted R(2) = 0.194, β = -0.59, P = 0.003). Within-day patterns of pain intensity varied by JIA subtype and sex.

CONCLUSION

This study characterized the pain intensity variability experienced by youths with JIA. Pain variability throughout the day was common, varied by JIA subtype and sex, and was related to quality of life. These findings have implications for future pain research, patient education, and development of clinical interventions for this population.

Physical and social functioning in adolescents with rheumatological conditions: a study of predictors

AIM

This study examines possible predictors of physical and social functioning in adolescents with rheumatological conditions. Condition-related variables and psychosocial variables were studied, and their relative contribution as predictors was examined.

METHODS

The study population was one hundred and twelve adolescents (11-18 years) attending secondary and tertiary paediatric rheumatology outpatient clinics in south-west England. These adolescents completed validated self-report accounts of disease history, pain and functioning (condition-related variables) and the Bath Adolescent Pain Questionnaire (psychosocial variables). Correlation and regression analyses were used to establish influences on physical and social functioning, examining condition-related variables and psychosocial variables as separate blocks.

RESULTS

Physical functioning was independently associated with age at onset, intensity of pain, presence of depression and pain-specific anxiety. Social functioning was only associated with general anxiety. The presence of an inflammatory diagnosis had no bearing on optimal functioning in this study.

CONCLUSION

Condition-related variables (age at onset, pain intensity) and psychosocial variables (depression, pain-specific anxiety) were equally important for physical functioning, whereas psychosocial variables (general anxiety) were more influential for social functioning. Understanding the impact of disease and associated variables in the adolescent rheumatology population should optimize targeted multidisciplinary rehabilitation for the young person and their family.

Self-compassion in patients with persistent musculoskeletal pain: relationship of self-compassion to adjustment to persistent pain

CONTEXT

Self-compassion entails qualities such as kindness and understanding toward oneself in difficult circumstances and may influence adjustment to persistent pain. Self-compassion may be a particularly influential factor in pain adjustment for obese individuals who suffer from persistent pain, as they often experience heightened levels of pain and lower levels of psychological functioning.

OBJECTIVES

The purpose of the present study was to examine the relationship of self-compassion to pain, psychological functioning, pain coping, and disability among patients who have persistent musculoskeletal pain and who are obese.

METHODS

Eighty-eight obese patients with persistent pain completed a paper-and-pencil self-report assessment measure before or after their appointment with their anesthesiologist.

RESULTS

Hierarchical linear regression analyses demonstrated that even after controlling for important demographic variables, self-compassion was a significant predictor of negative affect (β=-0.48, P<0.001), positive affect (β=0.29, P=0.01), pain catastrophizing (β=-0.32, P=0.003), and pain disability (β=-0.24, P<0.05).

CONCLUSION

The results of this study indicate that self-compassion may be important in explaining the variability in pain adjustment among patients who have persistent musculoskeletal pain and are obese.

Acute to chronic postoperative pain in children: preliminary findings

BACKGROUND/PURPOSE

Chronic postoperative pain is a well-established clinical phenomenon that is associated with adverse outcomes. The incidence of this clinical phenomenon in children, however, is not well established. The purpose of this study was to identify the incidence of chronic pain in children after surgery.

METHODS

Following a screening process, a total of 113 children and their parents were enrolled in this cross-sectional study. Data regarding persistence and characteristics of pain after surgery were obtained.

RESULTS

Approximately 13% of the children, most of whom underwent orthopedic procedures, reported the existence of symptoms of chronic postoperative pain. Most of the children indicated that the pain started immediately after surgery, was localized to the surgery site, and was intermittent. Children reported a median duration of pain of 4.1 months, and approximately half of the children experienced pain most days of the week. Up to 30% of the children reported interference of pain in functioning in areas such as extracurricular activities and sleep.

DISCUSSION

Given the large number of children at risk for experiencing chronic postoperative pain, preventative efforts are necessary. Large-scale cohort prospective studies are needed to confirm the results of this cross-sectional study.

Daily sleep quality and mood as predictors of pain in children with juvenile polyarticular arthritis

OBJECTIVE

Children with arthritis experience frequent pain, but the predictors of daily pain variations are largely unidentified. The goal of this study was to examine sleep quality as a predictor of pain in children with arthritis and to determine whether mood moderates this relationship.

METHOD

In this prospective, longitudinal study children with polyarticular arthritis (n = 51, ages 8-16 years) tracked daily symptoms, including sleep quality over 2 months. Self-reported daily pain intensity, as indicated on a visual analog scale, was used as the primary outcome measure in multilevel models.

RESULTS

Poorer sleep quality was associated with higher next-day pain ratings (p < .01). Mood moderated this relationship such that as positive mood increased, the relationship between poor sleep quality and high pain weakened (p < .01). Daily pain did not predict nightly sleep quality (p > .05).

CONCLUSIONS

Sleep quality is an important predictor of pain in children with arthritis. These findings add to the growing body of literature on the use of daily diaries for analyzing patterns of pain, sleep, and mood in children with chronic painful conditions.

Daily patterns of symptom reporting in families with adolescent children

OBJECTIVES

This study was designed to investigate how symptom reporting varies by time of day, day of the week, gender and generation.

DESIGN

Concurrent symptom reporting was assessed prospectively using a computer-assisted self-report method.

METHODS

A computer-assisted self-observation method was used to assess concurrent somatic complaints six times a day for 7 consecutive days. Parents and adolescents from 173 families (568 individuals) filled in questionnaires during a normal workweek. A generalized linear model approach for multi-level models was used to analyse the multiple daily observations.

RESULTS

Results show a curvilinear within-day pattern for the reporting of somatic complaints, such that complaints were reported most in the morning and evening and least in the middle of the day. On weekends, participants reported fewer complaints in the evening. Women reported more symptoms throughout the day. Adolescents show an earlier and more pronounced increase in symptom reporting towards the evening. In addition, a slight decline in symptom reporting over the observation period was observed.

CONCLUSIONS

Symptom reporting changes throughout the day, and is influenced by gender, generation and day of the week.

An internet-based self-management program with telephone support for adolescents with arthritis: a pilot randomized controlled trial

OBJECTIVE

To determine the feasibility of a 12-week Internet-based self-management program of disease-specific information, self-management strategies, and social support with telephone support for youth with juvenile idiopathic arthritis (JIA) and their parents, aimed at reducing physical and emotional symptoms and improving health-related quality of life (HRQOL).

METHODS

A nonblind pilot randomized controlled trial (NCT01011179) was conducted to test the feasibility of the "Teens Taking Charge: Managing Arthritis Online" Internet intervention across 4 tertiary-level centers in Canada. Participants were 46 adolescents with JIA, ages 12 to 18 years, and 1 parent for each participant, who were randomized to the control arm (n = 24) or the Internet intervention (n = 22).

RESULTS

The 2 groups were comparable on demographic and disease-related variables and treatment expectation at baseline. Attrition rates were 18.1% and 20.8%, respectively, from experimental and control groups. Ninety-one percent of participants randomized to the experimental group completed all 12 online modules and weekly phone calls with a coach in an average of 14.7 weeks (SD 2.1). The control group completed 90% of weekly attention-control phone calls. The Internet treatment was rated as acceptable by all youth and their parents. In posttreatment the experimental group had significantly higher knowledge (p < 0.001, effect size 1.32) and lower average weekly pain intensity (p = 0.03, effect size 0.78). There were no significant group differences in HRQOL, self-efficacy, adherence, and stress posttreatment.

CONCLUSION

Findings support the feasibility (acceptability, compliance, and user satisfaction) and initial efficacy of Internet delivery of a self-management program for improving disease-specific knowledge and reducing pain in youth with JIA.

Psychological and sensory predictors of experimental thermal pain: a multifactorial model

Although large interindividual differences in pain exist, the underlying factors that contribute to these variations remain poorly understood. Consequently, being able to accurately explain variability in pain ratings in terms of its contributing factors could provide insights into developing a better understanding of individual differences in pain experience. In the present investigation, we show that a significant portion of the variability in experimental heat pain ratings may be predicted using simple quantitative sensory testing and a series of psychological questionnaires including State Trait and Anxiety Inventory (STAI), Center for Epidemiologic Studies - Depression Scale (CES-D), and Positive and Negative Affect Schedule - Expanded form (PANAS-X). A factor analysis was used to reduce individual predictors into sets of composite predictive factors. A multifactorial model that was generated from these factors can reliably predict a significant amount of the variability in heat pain sensitivity ratings (r² = .537, P = .027). Moreover, individual variables including heat pain thresholds and self-assessment of pain sensitivity were found to be poor predictors of heat pain sensitivity. Taken together, these results suggest that a variety of factors underlie individual differences in pain experience and that a reliable model for predicting pain should be constructed from a combination of these factors.

PERSPECTIVE

The present study provides a way to predict subjects' experimental heat pain sensitivity using a multifactorial model generated from a combination of sensory and psychological factors. Future application of such a model in the studies of clinical pain could potentially improve the quality of care provided for patients in pain.

Sex differences in the relations of positive and negative daily events and fatigue in adults with rheumatoid arthritis

Fatigue is a common, disabling symptom for individuals with rheumatoid arthritis (RA). This study 1) examined sex differences in the relations between daily changes in positive and negative interpersonal events and same-day and next-day fatigue and 2) tested positive affect and negative affect as mediators of the associations between changes in interpersonal events and fatigue. Reports of fatigue, number of positive and negative interpersonal events, and positive and negative affect were assessed daily for 30 days via diaries in 228 men and women diagnosed with RA. Days of higher than average daily positive events were associated with both decreased same-day fatigue and increased next-day fatigue, but only among women. Sex differences in same-day relations between positive events and fatigue were mediated by increases in positive affect. For both sexes, days of higher than average daily negative events related to increased same-day and next-day fatigue, and the same-day relations between negative events and fatigue were mediated by increases in negative affect. A more nuanced understanding of similarities and differences between men and women in the associations between changes in interpersonal events and fatigue may inform future interventions for RA fatigue.

PERSPECTIVE

This article presents an examination of sex differences in the links between changes in daily interpersonal events and fatigue in chronic pain patients. The findings can help clinicians target the psychosocial factors that potentially can ameliorate their patients' experience of fatigue.

The role of positive and negative interpersonal events on daily fatigue in women with fibromyalgia, rheumatoid arthritis, and osteoarthritis

OBJECTIVE

The current study tested whether daily interpersonal events predicted fatigue from one day to the next among female chronic pain patients.

DESIGN

Self-reported fatigue, daily events, pain, sleep quality, depressive symptoms, and functional health across 30 days were assessed in women with rheumatoid arthritis (RA: n = 89), Osteoarthritis (OA: n = 76), and Fibromyalgia syndrome (FM: n = 90).

MAIN OUTCOME MEASURES

Self-report fatigue measured on a 0 to 100 scale and fatigue affect from PANAS-X (Watson & Clark, 1994).

RESULTS

Multilevel analyses showed that both higher average levels of and daily increases in negative events predicted more fatigue, whereas daily increases in positive events predicted less fatigue. Across all pain conditions, increases in negative events continued to predict higher fatigue on the following day. Moreover, for participants with FM or RA, increases in positive events also predicted increased fatigue the following day. Daily increases in fatigue, in turn, predicted poorer functional health on both the same day and the next day.

CONCLUSION

These results indicate that both on average and on a daily basis, interpersonal events influence levels of fatigue beyond common physical and psychological correlates of chronic pain and highlight differences between chronic pain groups.

Coping With Daily Stressors

Using daily diary methodology, 67 Mexican American adolescents completed measures assessing daily stressors experienced, specific coping strategies employed with reference to these stressors, and indices of psychological health over 5 consecutive days. With respect to coping usage, adolescents reported they most often used planning and least often used humor to cope with stress. Significant intraindividual and interindividual variability was found for each coping strategy and psychological health. When this variability was modeled, adolescents who reported using more direct problem solving, positive thinking, acceptance, and humor reported more positive affect. Adolescents who reported using more religious coping, distancing, and acceptance reported more negative affect. These findings indicate that intraethnic variability exists at the daily stressor level in Mexican American adolescents and that this variability in coping is predictive of daily psychological health. Discussion focuses on the developmental importance of flexible coping repertories in Mexican American adolescents and the (mal)adaptive nature of specific coping strategies.

Assessment and management of pain syndromes and arthritis pain in children and adolescents

Chronic musculoskeletal pain, whether it is idiopathic or disease-related, is common in childhood. Pediatric rheumatologists and other pediatric health care providers must understand the epidemiology of musculoskeletal pain as part of childhood, diagnose pain syndromes in children and rule out rheumatic disease, and be willing to initiate treatment of pain in children and adolescents. Practitioners' ability to carry out these tasks is enhanced by an awareness of the biopsychosocial model of pain, which integrates biologic, environmental, and cognitive behavioral mechanisms in describing the causes and maintenance of children's pain. A growing body of research in rheumatic diseases, such as JIA, and idiopathic musculoskeletal pain syndromes, such as JPFS, highlights the importance of environmental and cognitive behavioral influences in the pain experience of children in addition to the contribution of disease activity. These influences include factors innate in the child, such as emotional distress, daily stress, coping, and mood, and familial factors, such as parental psychologic health, parental pain history, and the nature of family interactions. Addressing these issues, while providing aggressive traditional medical management, optimizes pain treatment and improves overall quality of life for children who have musculoskeletal pain.

Influence of pharmacologically-induced experimental anxiety on nociception and antinociception in rats

Animal studies reveal that diverse environmental stimuli that generate anxiety-like behaviors also induce antinociception; conversely, clinical data show that pain perception is reduced under anxiolysis. This study was conducted to investigate the influence of pharmacologically induced-anxiety on nociception and antinociception. Experimental anxiety levels were measured using the rat burying behavior test. Diazepam (0, 0.5, 1.0 and 2.0 mg/kg, i.p.) or yohimbine (0, 0.5 and 1.0 mg/kg, i.p.) were used as anxiolytic or anxiogenic drugs, respectively. To evaluate the influence of different experimental anxiety levels on nociception, the pain-induced functional impairment in the rat (PIFIR model) was used. Nociception was induced by an intra-articular injection of 15% uric acid into the knee joint of the right hind limb. Diazepam or yohimbine were administered 15 min before uric acid and the ability of the rat to use the injured hind limb was recorded. To analyze the influence of different levels of anxiety on the antinociceptive effects produced by acetylsalicylic acid (0, 31, 100 and 310 mg/kg, p.o.); this analgesic was administered 3.5 h after uric acid. Fifteen min before diazepam (2.0 mg/kg) or yohimbine (1.0 mg/kg) were administered. We found that, in the burying behavior test, diazepam and yohimbine produced a dose-dependent decrease or augment in the cumulative time of burying, effects denoting reduced or increased experimental anxiety, respectively. Diazepam or yohimbine, administered alone, was unable to produce nociception. The results showed an influence of anxiety on nociception since a decreased (by diazepam) or increased (by yohimbine) experimental anxiety prevented nociception. Control experiments showed that acetylsalicylic acid did not modify experimental anxiety in the burying behavior test, but effectively reversed the nociception induced by uric acid (15%) in the PIFIR model. Such antinociceptive effect was unmodified by the anxiolytic or anxiogenic actions of diazepam or yohimbine. Data are discussed on the bases of clinical- and animal-studies revealing interactions between anxiety and nociception.

e-Ouch: Usability Testing of an Electronic Chronic Pain Diary for Adolescents With Arthritis

OBJECTIVES

The aim of this study was to evaluate the usability of the e-Ouch electronic chronic pain diary in adolescents with juvenile idiopathic arthritis.

METHODS

A qualitative usability testing approach with semistructured, audiotaped interviews with two iterative cycles was used. A purposive sample of 10 adolescents per cycle was drawn from a rheumatology clinic in a university-affiliated pediatric tertiary care center. Participants were provided with a brief demonstration of the diary and then asked to use the diary "thinking aloud" to record the pain they experienced: (1) when they woke up that morning, (2) during that afternoon, and (3) from the previous evening. Adolescents were then asked a series of open-ended questions addressing ease of use of the diary. Qualitative thematic analysis was used to generate categories and emerging themes from interview data.

RESULTS

All of the adolescents stated the e-Ouch diary was very easy to learn, use, and understand and was satisfying to complete. Participants took less than 9 minutes to complete all three of the diary entries with minimal errors. The usability evaluation revealed aspects of the interface that were suboptimal (eg, VAS slider) and impeded the performance of certain tasks. Adolescents generated ideas on how the diary interface could be improved.

CONCLUSIONS

A multifaceted usability approach provided important insight regarding the use of technology by adolescents with arthritis and, more specifically, for understanding how adolescents can more effectively use an electronic chronic pain diary.

Health-related quality of life in adolescents with juvenile idiopathic arthritis

OBJECTIVE

To describe the health-related quality of life (HRQOL) of adolescents with juvenile idiopathic arthritis (JIA), and to examine the usefulness of the Juvenile Arthritis Quality of Life Questionnaire (JAQQ) in a UK context. It was hypothesized that HRQOL would decrease with worsening disease and disability.

METHODS

Patients with JIA ages 11, 14, and 17 years were recruited from 10 major rheumatology centers. HRQOL was measured using the JAQQ. Other data were core outcome variables including the Childhood Health Assessment Questionnaire, demographic characteristics, arthritis-related knowledge, and satisfaction with health care.

RESULTS

Questionnaires were completed by 308 adolescents. One-fifth had persistent oligoarthritis. Median disease duration was 5.7 years (range <1-16 years). The JAQQ was shown to have good psychometric properties when used in the UK, but was not without limitations. HRQOL of adolescents with JIA was less than optimal, particularly in the domains of gross motor and systemic functioning. Items most frequently rated as adolescents' biggest psychological problems were "felt frustrated" and "felt depressed," rated by 30.2% and 23.4%, respectively. These were particularly problematic for the 17-year-olds, with 39% reporting frustration as one of their biggest problems and 63.6% reporting depression. Variation in the adolescent JAQQ scores was explained by functional disability, pain, and disease activity.

CONCLUSION

JIA can have a significant adverse effect on the HRQOL of adolescents. The JAQQ is a useful tool to assess the HRQOL of UK adolescents with JIA, but there is need for improved measures that incorporate developmentally appropriate issues.

Longitudinal relationships of depressive symptoms to pain intensity and functional disability among children with disease-related pain

OBJECTIVE

To examine the longitudinal relationship between depressive symptoms at study entry (T1) on pain intensity (PI) and functional disability over a 1-year period among children with either sickle cell disease (SCD) or juvenile idiopathic arthritis (JIA).

METHODS

119 children, ages 8-17 years, completed measures of depression at T1 as well as pain and functional disability at T1, 6-month (T2), and 12-month (T3) follow-ups. Caregivers also rated their child's pain and disability at each time point. General linear mixed modeling was employed to examine longitudinal relationships between study variables.

RESULTS

For children with JIA, T1 pain significantly moderated the effects of T1-depressive symptoms on T2 and T3 pain where T1-depressive symptoms predicted future child-reported pain only when T1 pain was relatively mild. Similarly, T1-depressive symptoms predicted future child-reported disability only when initial reports of disability were relatively low. Only family income significantly predicted T2 and T3 pain in children with SCD.

CONCLUSIONS

Study findings suggest that T1-depressive symptoms play a role in the longitudinal course of pain symptoms in children with JIA but not in children with SCD.

Pediatric pain syndromes and management of pain in children and adolescents with rheumatic disease

This article introduces important issues related to pain in children with musculoskeletal pain syndromes and rheumatic disease, using juvenile primary fibromyalgia syndrome (JPFS) and juvenile idiopathic arthritis (JIA) as models. A brief summary of the prevalence of pain in healthy children is followed by a summary of existing pain-assessment techniques. The remainder of the article describes the pain experience of children with JPFS and JIA and discusses issues related to pain management.

Pain, stiffness, and fatigue in juvenile polyarticular arthritis: Contemporaneous stressful events and mood as predictors

OBJECTIVE

To analyze patterns of stress, mood, disease symptoms, and activity reduction in children with polyarticular arthritis, using a prospective daily diary method.

METHODS

For a 2-month period, 51 children with polyarticular arthritis (mean age 12.4 years, 65% female) completed daily diaries that included measures of symptoms of pain, stiffness, and fatigue, as well as stress, mood, and activity reduction. Functional status and disease activity were assessed at the initial and followup evaluations with use of the Childhood Health Assessment Questionnaire, physician global assessment, joint count, and laboratory testing.

RESULTS

Children reported having pain, stiffness, and fatigue on >70% of days, with significant variability in symptom levels. Results revealed significant same-day relationships between stress, mood, and disease symptoms, after controlling for covariates. Specifically, daily fluctuations in both stress and mood were predictive of increased pain, stiffness, and fatigue. Increases in daily stress, mood, and disease symptoms were also significantly related to decreased participation in social activities on a day-to-day basis. Only mood and stiffness were predictors of a cutback in school attendance.

CONCLUSION

Stress and mood are important predictors of daily disease symptoms in children with polyarticular arthritis. Moreover, daily fluctuations in stress, mood, and disease symptoms are predictive of aspects of daily function, including participation in school and social activities. Thus, health care providers should solicit daily symptom reports when making decisions regarding clinical management. Nonpharmacologic interventions such as cognitive-behavioral therapy and stress management may be useful adjuvant therapy when treating the disease symptoms of children with polyarticular arthritis.

Effects of stress on inflammatory autoimmune disease: destructive or protective?

We have summarised evidence in the literature for modulatory effects of stress on inflammatory autoimmune disease. We find that overall there is strong evidence for such an interrelationship. Apparent discrepancies between groups and studies are probably due to differences in experimental design, whether longitudinal or retrospective. Other important variables are the specific effects of different types of stress and the intensity and timing of the stressor relative to onset of inflammation. We conclude that there is much of benefit to be learned from scientific study of stress, such as harnessing and rationalising of stressful experiences through self-expression in patients, or the identification of novel anti-inflammatory compounds activated by stress.

Odors and sounds as triggers for medically unexplained symptoms: A fixed-occasion diary study of gulf war veterans

BACKGROUND

Both laboratory studies on healthy volunteers and epidemiological evidence from patient samples indicate that odor can act as a trigger for the reporting of medically unexplained symptoms (MUSs).

PURPOSE

The relationship between concurrent experiences of odor and MUSs has not been explored in a patient sample.

METHODS

This study used an 8-day fixed-occasion diary study, in which 17 veterans of the Persian Gulf War completed diary assessments of (a) the intensity and duration of odor and sound and (b) MUS severity.

RESULTS

The results showed that the intensity of odor was positively associated with the severity on the same day and subsequent days' symptoms, whereas the duration of odor was negatively related to the severity of MUS reporting on the same day.

CONCLUSIONS

These results are consistent with an associative mechanism underlying symptom reporting in veterans. By contrast, the duration, but not the intensity, of sound was related to the severity of MUS reporting on the same day.

Predictors of pain in children with established juvenile rheumatoid arthritis

OBJECTIVE

To examine demographic and disease-related variables that affect pain in a large cohort of patients with juvenile rheumatoid arthritis (JRA).

METHODS

Selection criteria were an onset of JRA >/=5 years prior to study and age >/=8 years at the time of the study. Pain was measured by a self-administered 10-cm visual analog scale. Possible explanatory variables studied included age at study, sex, race, onset subtype, active disease duration, active joint count, and physician's global assessment (PGA).

RESULTS

In a multiple regression model, active disease duration, PGA, and age at study were independent predictors explaining 22% of the variation in pain scores. Stratified analyses showed an effect of age in the 8-15-year group, but not in older patients.

CONCLUSION

Disease-related factors explain only a small proportion of the variation in pain scores. Age has an effect on pain scores only in younger patients. The role of other factors, including psychosocial factors, needs further study.