The role of fatigue in functional outcomes for youth with chronic pain

A systematic review of the biopsychosocial dimensions affected by chronic pain in children and adolescents: identifying reliable and valid pediatric multidimensional chronic pain assessment tools

Pediatric chronic pain is a complex experience that is often challenging to describe and measure. Multidimensional tools that evaluate the biopsychosocial impact of chronic pain in pediatric patients can help clinicians to prioritize and tailor interdisciplinary pain care; yet, the psychometric value and clinical utility of such tools has not yet been systematically studied in the literature. The purpose of this review was to identify multidimensional biopsychosocial tools used in pediatric chronic pain, synthesize their reliability and validity evidence, and draw on this evidence to describe the relationships between chronic pain and biopsychosocial domains. The search involved 2 phases to (1) identify eligible tools and (2) conduct a measured forward citation search of tool development articles. Tool eligibility was guided by the Multidimensional Biobehavioral Model of Pediatric Pain and study eligibility was focused on primary chronic pain diagnoses unrelated to disease. Data extraction was focused on reliability and validity evidence of eligible tools, guided by the Standards for Educational and Psychological Testing. Results yielded 6 tools that included 64 eligible studies, highlighting 84 significant relationships between pain and functional interference across 11 biopsychosocial variables. All tools were shown to have good internal consistency and evidence of validity, primarily through relationships to other variables. Of the 6 tools, the most brief and easy to use were the most under studied. Further psychometric research is warranted for these tools to investigate their clinical utility and psychometric properties in guiding and prioritizing pain care for children and adolescents.

Prevalence and associations of fatigue in childhood atopic dermatitis: A cross-sectional study

BACKGROUND

Fatigue is a symptom that can negatively impact patients' quality of life. However, the relationship of AD with fatigue has not been fully studied, especially in children.

OBJECTIVE

To determine the prevalence of fatigue in AD patients, and whether AD severity, demographics and comorbidities are associated with increased fatigue in children.

METHODS

A cross-sectional observational study was performed among 248 children with AD. Paediatric patients (ages 8-17 years) and parents (of children ages 0-17 years) completed a questionnaire, including demographics, history of atopic comorbidities and validated severity measures of AD, itch, pain, sleep disturbance, sleep-related impairment and fatigue. AD severity was also assessed by clinician-reported Eczema Area and Severity Index (EASI), Scoring AD (SCORAD) and Investigator's Global Assessment (IGA). Fatigue was assessed using Patient Reported Outcome Measurement Information System (PROMIS) Pediatric Fatigue T-score.

RESULTS

Most children with AD had no (38.6%) or mild (32.1%) fatigue, with fewer having moderate (27.2%) or severe (2%) fatigue. Moderate/severe PROMIS Pediatric fatigue T-scores were increased with moderate (25.7%/1.4%) and severe (39.3%/5.4%) IGA vs. mild IGA (18.0%/0.0%) and those with 5-6 (44.4%/0.0%) and 7 (44.2%/5.2%) nights of SD from eczema. Moderate-severe PROMIS Pediatric Fatigue T-scores were associated with history of hay fever (adjusted OR [95% Cl]: 2.803 [1.395-5.632]) and family income (<$100,000: 3.049 [1.294-7.181]), but inversely with Black (0.40 [0.168-0.969]) and AAPI (0.285 [0.094-0.859]) race. In multivariable regression models controlling for demographic factors, PROMIS Pediatric Fatigue T-score was significant with more severe scores for IGA, POEM, EASI, SCORAD, NRS-itch, SCORAD-itch, average itch in the past 7 days, PROMIS Pediatric Pain severity, PROMIS Pediatric SD, PROMIS Pediatric SRI, SCORAD-sleep and more frequent SD from AD.

CONCLUSIONS

Fatigue is a common yet underappreciated symptom in children with AD, particularly those with moderate-severe AD, and warrants more attention in clinical practice and trials.

Baseline Sleep Disturbances Modify Outcome Trajectories in Adolescents With Chronic Pain Receiving Internet-Delivered Psychological Treatment

Over 50% of adolescents with chronic pain report comorbid sleep disturbances (eg, difficulties with falling asleep), which is associated with increased pain-related disability and poorer quality of life. However, limited longitudinal data are available to understand how sleep disturbance may impact response to psychological treatment. Our primary hypothesis was that baseline sleep disturbances would significantly modify how adolescents responded to an internet-delivered psychological intervention for chronic pain in terms of outcome trajectories. The sample included 85 adolescents, 12 to 17 years, with chronic pain recruited from a multidisciplinary pain clinic and headache clinic who received access to an internet-delivered psychological intervention for chronic pain. Baseline sleep assessment included actigraphy monitoring for 7 days and survey measures. Outcomes were assessed at baseline, 8 weeks, and 3 months including core pain-related outcomes, executive functioning, fatigue, positive and negative affect. Results demonstrated that greater baseline insomnia and poorer sleep quality was associated with worse outcome trajectories for pain-related disability, depression, anxiety, fatigue, negative affect, and executive functioning. Findings extend the limited studies that examine how sleep disturbance may modify effectiveness of psychological treatments for adolescent chronic pain and emphasize the importance of treating comorbid sleep disturbance. This trial was registered at clinicaltrials.gov (NCT04043962). PERSPECTIVE: Our study suggests that sleep deficiency, in particular insomnia and poor sleep quality, may modify the effectiveness of psychological treatments for chronic pain, highlighting the urgent need to screen youth for sleep problems prior to initiating treatment, and to consider implementation of sleep-specific treatments such as cognitive-behavioral therapy for insomnia.

Characterizing Fatigue Subtypes in Adolescents with Chronic Musculoskeletal Pain and Pain-Free Controls

Context

General fatigue, sleep-related fatigue, and cognitive fatigue are prevalent and disruptive in adults with chronic musculoskeletal (MSK) pain, but little is known about these fatigue subtypes in pediatric musculoskeletal pain.

Objective

To compare fatigue and its subtypes between adolescents with chronic MSK pain and pain-free controls and to test if fatigue subtypes were associated with concurrent pain and its impact (pain intensity, number of pain sites, pain interference, and functional disability) or experimental pain (intensity and tolerance) in adolescents with chronic MSK pain. Finally, we sought to explore adolescents’ qualitative characterizations of their fatigue.

Methods

Adolescents with chronic MSK pain (12–17 y.o., n = 26) and pain-free controls (n = 26) completed validated self-report measures of fatigue, pain, and functional disability, underwent an experimental pain tolerance task (cold water immersion of the hand), and provided qualitative descriptions of their fatigue (pain group only).

Results

Adolescents with chronic MSK pain reported significantly greater general, sleep-related, and cognitive fatigue than pain-free controls (all p’s < 0.001). In adolescents with chronic MSK pain, fatigue subtypes were associated with clinical pain and pain impact (r’s = 0.43–0.84) but not experimental pain measures (p’s > 0.05). Adolescents with chronic MSK pain qualitatively described the negative implications of the different fatigue subtypes, particularly when perceived as long-lasting.

Conclusion

This preliminary study suggests that fatigue subtypes are prevalent and impactful in pediatric patients with chronic MSK pain. When planning multi-disciplinary treatment for pediatric MSK pain, providers should recognize fatigue as another disabling symptom.

Comparison of pain and psychosocial correlates among Hispanic and Non-Hispanic White youth with chronic pain

Introduction:

Despite well-documented pain disparities among adults from non-White and Hispanic groups, less is known about pain disparities in non-White and Hispanic pediatric populations.

Objectives:

We compare pain and related psychosocial factors at the individual (pain intensity, pain interference, pain catastrophizing, co-occurring symptoms), social (peer relations), and systemic (health insurance) levels among Hispanic and Non-Hispanic White (NHW) youth with chronic pain.

Methods:

Eight hundred thirty-seven (71.4% female) Hispanic (n = 268, 32%) and NHW (n = 569, 68%) youth ages 8 to 17 years (M = 14.00; SD = 2.54) completed a survey at their initial visit to a pain clinic. Independent sample t tests investigated mean differences in psychosocial factors at the individual and social levels. Chi-squared tests investigated differences at the systemic level. Bivariate correlations for each group were compared using Fisher r-to-z transformations.

Results:.

Hispanic youth reported higher levels of pain intensity (t[811] = −2.75, P = 0.006). Groups did not differ in reports of other individual or social factors. Non-Hispanic White youth were more likely to have private insurance (OR, 5.66). All examined variables were significantly correlated among NHW youth. Correlations were weaker or nonsignificant among Hispanic youth. Fisher r-to-z transformations revealed these group differences to be significant.

Conclusion:

Hispanic youth report higher pain levels than NHW counterparts and lower likelihood of having private insurance. Pain and psychosocial factors correlate differently among the 2 groups highlighting a need to better understand the chronic pain experiences of diverse youth because models derived primarily from NHW populations may not generalize across ethnic and racial groups.

Clinical Utility of CAT Administered PROMIS Measures to Track Change for Pediatric Chronic Pain

Patient Reported Outcomes (PROs) are utilized in clinical registries and trials, necessitating development of benchmarks to enhance interpretability. This study aimed to 1) examine if PROMIS measures administered via computer adaptive testing (CAT) were responsive to change, and 2) highlight one method of assessing clinically significant change for youth seen in a tertiary pain clinic. Clinically significant change was achieved if patients had significantly reliable pre-to-post-changes greater than Reliable Change Index (RCI) value and reported decreased symptoms by at least one severity level (e.g., moderate to mild). Participants were 328 youth (8-17 years old) seen in a tertiary pediatric pain management clinic. Small to moderate effect sizes were noted across PROMIS measures (except Peer Relations). Reliable magnitudes of change were estimated for this sample as approximately 6 point reduction for Pain Interference and Mobility, 9 for Fatigue, and 11 for Anxiety and Depression. Depending on the measure, 10 to 24% were categorized as improved, 3 to 6% as deteriorated, and 68 to 81% were either not clinically elevated at baseline or remained unchanged at 3 months. Overall, PROMIS CAT measures demonstrated responsiveness to change over time. Estimation of clinically significant change offers preliminary yet rigorous benchmarks for evaluating treatment response and sets the stage for understanding treatment effects. PERSPECTIVE: This study assesses responsiveness of CAT administered PROMIS measures and highlights one methodological approach of presenting clinical significance for assessing treatment outcomes in pediatric chronic pain. These benchmarks will allow clinicians and researchers to evaluate treatment response utilizing PROs while allowing for a deeper understanding of treatment effects.

Assessing fatigue in children and adolescents: Psychometric validation of the German version of the PROMIS® Pediatric Short Form v2.0 - Fatigue 10a in school children and pediatric chronic pain patients

Purpose

Fatigue is a common symptom in children and adolescents. Its negative impact on health outcomes is even more pronounced in those with chronic pain. There is currently no fatigue measurement tool in German that is validated for both children and adolescents with and without chronic pain. Therefore, this study aimed to gather quantitative validity evidence to support the use of the German version of the PROMIS^® Pediatric Short Form v2.0 - Fatigue 10a (PROMIS^® F-SF) in the German pediatric general population as well as in German pediatric chronic pain patients.

Methods

The 10-item self-assessment questionnaire was validated in a sample of N = 1348 school children (9–18 years; 52.4% female) and N = 114 pediatric chronic pain patients (8–17 years; 63.3% female). Construct and convergent validity, reliability, and item and scale characteristics were examined.

Results

Confirmatory factor analyses showed sufficient model fit for the 1-factor model of the questionnaire (school sample: CFI = 0.94, RMSEA = 0.10, SRMR = 0.04; patient sample: CFI = 0.90, RMSEA = 0.14, SRMR = 0.05). Convergent validity was supported by weak-to-large significant correlations with sleep quality, health-related quality of life (HRQoL), and pain characteristics. The questionnaire had excellent internal consistency in both samples (α = 0.92 and α = 0.93). Sex differences and age distributions of the PROMIS^® F-SF showed that girls reported significantly higher fatigue than boys and that fatigue increased with age.

Conclusion

The PROMIS^® F-SF is a reliable instrument with good psychometric properties. Preliminary evidence is provided that the questionnaire validly measures fatigue in children and adolescents with and without chronic pain.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11136-021-03032-8.

The prevalence of fatigue among Chinese nursing students in post-COVID-19 era

BACKGROUND

Due to the COVID-19 outbreak, all teaching activities in nursing schools were suspended in China, and many nursing students were summoned to work in hospitals to compensate for the shortage of manpower. This study examined the prevalence of fatigue and its association with quality of life (QOL) among nursing students during the post-COVID-19 era in China.

METHODS

This was a multicenter, cross-sectional study. Nursing students in five Chinese universities were invited to participate. Fatigue, depressive and anxiety symptoms, pain and QOL were measured using standardized instruments.

RESULTS

A total of 1,070 nursing students participated. The prevalence of fatigue was 67.3% (95% CI [64.4-70.0]). Multiple logistic regression analysis revealed that male gender (P = 0.003, OR = 1.73, 95% CI [1.20-2.49]), and being a senior nursing student (second year: OR = 2.20, 95% CI [1.46-3.33], P < 0.001; third year: OR = 3.53, 95% CI [2.31-5.41], P < 0.001; and fourth year OR = 3.59, 95% CI [2.39-5.40], P < 0.001) were significantly associated with more severe fatigue. In addition, moderate economic loss during the COVID-19 pandemic (OR = 1.48, 95% CI [1.08-3.33], P < 0.015; compared to low loss), participants with more severe depressive (OR = 1.48, 95% CI [1.22-1.78], P < 0.001) and anxiety symptoms (OR = 1.12, 95% CI [1.05-1.20], P = 0.001), and more severe pain (OR = 1.67, 95%CI [1.46-1.91], P < 0.001) were significantly associated with reported more severe fatigue. After controlling for covariates, nursing students with fatigue had a lower overall QOL score compared to those without (F (1, 1070) = 31.4, P < 0.001).

CONCLUSION

Fatigue was common among nursing students in the post-COVID-19 era. Considering the negative impact of fatigue on QOL and daily functioning, routine physical and mental health screening should be conducted for nursing students. Effective stress-reduction measures should be enforced to assist this subpopulation to combat fatigue and restore optimal health.

A High Psychological and Somatic Symptom Profile and Family Health Factors Predict New or Persistent Pain During Early Adolescence

OBJECTIVES

Persistent or recurrent pain is common among adolescents and is associated with poor functioning. The purpose of this study was to determine whether preteens who present with pain, and higher, co-occurring psychological and somatic symptoms (PSS) are at higher risk for persistent pain than other children.

MATERIALS AND METHODS

We conducted a secondary analysis of the longitudinal Adolescent Brain and Cognitive Development database (version 2.0.1) that includes 11,863 children aged 9 to 12 years. We differentiated children into baseline Pain/PSS profiles using the Child Behavior Checklist assessments of pain, cognitive-fogginess, somatic symptoms, depression, and anxiety and the Sleep Disorder Survey-Children somnolence subscale. We examined whether Pain/PSS profile predicted 1-year new/persistent pain when controlled for child characteristics and intergenerational mental health factors.

RESULTS

Four profiles were differentiated: No Pain/Low PSS, No Pain/High PSS, Pain/Low PSS, Pain/High PSS. Trauma exposure and family symptoms were associated with increased odds of being in the higher PSS groups. Baseline symptom profile predicted 14% of the variance in new/persistent pain at 1-year. Compared with the No Pain/Low PSS group, an increased odds of 1-year new or persistent pain was found in children with No Pain/High PSS (adjusted odds ratio [OR]: 1.44; [95% confidence interval: 1.14, 1.82]), Pain/Low PSS (adjusted OR: 4.69 [4.01, 5.48]) and Pain/High PSS (adjusted OR: 5.48 [4.35, 6.91]).

DISCUSSION

Preteen children with higher comorbid Pain/PSS symptomology were at higher risk for new or persistent pain at 1 year when controlled for important child and family characteristics. Findings support the importance of considering co-occurring symptoms when evaluating children with pain.

Chronic Pain and Mental Health Co-Morbidity in Adolescents: An Urgent Call for Assessment and Evidence-Based Intervention

BACKGROUND

Nearly 30% of children are affected by chronic pain which puts a significant burden on the child's family and society with estimated cost of over $19.5 billion each year. Children and adolescent's quality of life is often impacted leading to physical disability, low self-esteem, depression, anxiety, school stress or decreased performance, insomnia, and fatigue. The purposes of this paper are to: 1) provide an overview of chronic pain in children and adolescents; 2) describe findings from a quality improvement project that assessed the prevalence of negative mood, quality of life, functional disability, and coping with pain in teens with chronic pain, and 3) discuss screening, assessment and evidence-based management of co-morbid chronic pain and mental health problems in children and teens.

FINDINGS

Findings for a quality improvement project indicated that 16.8% of the adolescents scored high risk for depression, which was higher than the national average. Approximately 57% of adolescents were screened as high risk on the Pediatric Quality of Life inventory (PedsQL™). One in four adolescents showed poor functioning on the Functional Disability Inventory and nearly one-third of the adolescents reported poor coping with pain on the Pain Coping Questionnaire. This project indicates that adolescents with chronic pain are at high risk for mental health problems. The outcomes suggest the mental health needs of adolescents with chronic pain need to be identified and addressed to help improve outcomes.

DISCUSSION

Children and youth with chronic pain need to be routinely screened and assessed for mental health problems, especially anxiety and depression. The use of Cognitive Behavioral Therapy (CBT) or CBT-skills building for children and youth with anxiety and depressive disorders has been widely studied and are helpful for children with chronic pain include psychoeducation, which helps the child to learn age and developmental specific information on chronic pain. Evidence-based manualized and internet-based CBT programs should be scaled rapidly to decrease depression and anxiety in children and youth with chronic pain.

Depression, anxiety, and loneliness among adolescents and young adults with IBD in the UK: the role of disease severity, age of onset, and embarrassment of the condition

Purpose

Adolescents and young adults (AYA) with Inflammatory Bowel Disease (IBD) report higher depressive symptoms and anxiety compared to healthy controls, with disease severity and abdominal pain being important factors. In the current study, building on what young people had told us in our previous work, we examined whether embarrassment of the condition, social self-efficacy, and friendship quality mediated the relationship between abdominal pain and disease severity, and mental health/well-being. We also included loneliness as a component of well-being.

Methods

Data on depression, anxiety, loneliness, friendship quality, social self-efficacy, and disease embarrassment were collected from 130 AYA with IBD ages 14–25 years; data on disease severity and abdominal pain were taken from their medical records. Structural Equation Modeling (SEM) was used to test the relationships between the variables.

Results

Using SEM, we established that higher IBD disease activity negatively impacted how AYA felt about their friendships and how embarrassed they were about their condition; embarrassment then influenced reports of mental health, including loneliness. Abdominal pain, disease onset, and social self-efficacy directly predicted internalising problems.

Conclusion

In this sample of 14–25-year-old patients with IBD, specifics about the disease (severity and pain) predicted poorer mental health, suggesting discussion of mental health should be part of the clinical dialogue between patient and consultant. In addition, embarrassment about their condition increased depression, anxiety, and loneliness, mediating the relationship between disease severity and well-being. Thus, it is important to consider how perceived stigma affects those with chronic illness, and those issues should be explored in clinic.

Cross-Sectional Associations of Fatigue Subtypes with Pain Interference in Younger, Middle-Aged, and Older Adults with Chronic Orofacial Pain

Objective

Mental, emotional, physical, and general fatigue, as well as vigor, have each been associated with pain interference—defined as pain-related disruption of social, recreational, and work-related activities—in patients with chronic orofacial pain (COFP). The objectives of the current study were to compare levels of these fatigue subtypes across younger, middle-aged, and older patients with COFP and test the associations between fatigue subtypes and pain interference in these age groups.

Design

A cross-sectional cohort design was used.

Setting

Participants self-reported fatigue subtypes (Multidimensional Fatigue Symptom Inventory–Short Form), pain interference (West Haven–Yale Multidimensional Pain Inventory), pain intensity (visual analog scale), pain duration (months), depression (Symptom Checklist 90–Revised), and sleep quality (Pittsburgh Sleep Quality Index) at their initial appointment at a tertiary orofacial pain clinic.

Subjects

Sixty younger (age 18–39), 134 middle-aged (age 40–59), and 51 older (age 60–79) COFP patients provided data for the study.

Methods

Analysis of variance was used to compare levels of fatigue subtypes between the age groups. Regression with dummy-coding was used to test if the relationship between fatigue subtypes and pain interference varied by age.

Results

Older COFP patients reported less general fatigue and more vigor than younger or middle-aged adults. Fatigue subtypes were each associated with greater pain interference, but associations became nonsignificant after controlling for depression, sleep, and pain intensity/duration. Age group–by–fatigue subtype interactions were not observed.

Conclusions

Managing fatigue may be important to reduce pain interference in COFP populations and may be accomplished in part by improving depression and sleep.