[Three-week multimodal inpatient treatment of children with chronic pain. First results of the long-term follow-up]

[Pediatric inpatient interdisciplinary multimodal pain treatment in Germany]

BACKGROUND

Severely disabling chronic pain affects approximately half a million children in Germany. If there is a lack of response to unimodal treatment, an inpatient interdisciplinary multimodal pain treatment (IMPT) can be considered.

OBJECTIVE

This review article describes the supply situation of pediatric inpatient IMPT in Germany and presents the current evidence on the effectiveness.

MATERIAL AND METHODS

Based on a systematic literature search, studies addressing the effectiveness of pediatric inpatient IMPT in Germany were identified. In addition, further sources were used to extract information on pediatric IMPT treatment centers in Germany in order to describe the treatment approaches, the qualification of personnel and characteristics of patients.

RESULTS

There are four pediatric pain centers in Germany that are specialized in inpatient IMPT for children and adolescents. Treatment duration ranges between 3 and 4 weeks. The multimodal treatment is carried out by a multiprofessional team and is generally available for patients up to 18 years. The majority of patients are female. The effectiveness of pediatric IMPT in Germany was investigated up to 4 years after treatment. Positive effects were shown for pain characteristics and also for the emotional burden. Additional treatment modules can facilitate further optimization of treatment effects.

CONCLUSION

Further research on the effectiveness of IMPT in Germany is important in order to refine and optimize the available treatment programs.

Intensive interdisciplinary pain treatment for children and adolescents with chronic noncancer pain: a preregistered systematic review and individual patient data meta-analysis

ABSTRACT

Chronic noncancer pain in children and adolescents can be impairing and results in substantial health care costs. Intensive interdisciplinary pain treatment (IIPT), an inpatient or day hospital treatment delivered by a team of 3 or more health professionals, may be an effective intervention for these children and adolescents. Based on previous reviews and meta-analyses, we updated findings regarding the description of available treatments and estimated the effectiveness of IIPT, overcoming methodological shortcomings of previous work by requesting and analyzing individual participant data. On June 26, 2021, we searched 5 literature databases (PubMed, PsycINFO, Web of Science, Cochrane Library, and PubPsych) for studies examining the effectiveness of IIPT. Included studies used a pre-post design, assessed patients younger than 22 years, and presented their results in English, German, French, or Spanish. We used standard methodological procedures expected by Cochrane to pool treatment effects and assess risk of bias. We identified 13 different treatment sites with similar treatment inclusion criteria and treatment components, but the descriptions of those treatments varied widely. Regarding treatment effectiveness, IIPT may result in large improvements in the mean pain intensity ( g = -1.28), disability ( g = -1.91), and number of missed school days at the 12-month follow-up ( g = -0.99), as well as moderate improvements in anxiety ( g = -0.77) and depression ( g = -0.76). The certainty of the evidence, however, was graded from very low to low. We recommend that future researchers use more scientific rigor to increase the certainty of the evidence for IIPT and standardize treatment outcomes for children and adolescents with chronic pain.

[Medical pain care for children and adolescents with chronic pain in Germany : An inventory]

Chronic pain in children and adolescents is increasing in prevalence, affects the quality of life, predisposes to pain in adulthood and causes numerous contacts to the healthcare system. In contrast, the number of therapeutic offers tailored to the special needs of this age group is insufficient and confusing. The working group on pain in children and adolescents of the German Pain Society therefore documented appropriate facilities in a questionnaire survey carried out using a snowball system. The response rate of 27/109 questionnaires was low. Thus, the results may not be entirely representative. Nevertheless, the heterogeneity of the offers and in total an undersupply became very clear. In order to improve the care situation, joint efforts by the various pediatric subdisciplines dealing with pain, an increase in the number of child pain treatment centers and a better networking are necessary.

Pain Rehabilitation During Adolescence; Work in Adulthood? A Long-Term Follow-Up Study to Explore the Facilitators and Barriers for Work

BACKGROUND

Adolescents with chronic musculoskeletal pain face different impairments in daily life. After an inpatient pain rehabilitation program, adolescents function better on several domains. The aim of this study was to explore the long-term work participation of adults who followed inpatient pain rehabilitation during adolescence because of chronic musculoskeletal pain and to identify potential facilitators and barriers regarding work in later life.

METHODS

A mixed-methods study with standardized questionnaires and semi-structured interviews. The questionnaires measured pain, disability, work status, and the quality and quantity of the work. The interviews contained questions about work participation. Potential participants were all patients who had participated in an inpatient pain rehabilitation program 15 to 20 years previously. Analyses were performed by thematic analysis. Using the Sherbrooke model as guidance, themes were classified into 4 systems: healthcare, workplace, legislative/insurance, and personal.

RESULTS

Fourteen patients consented to participate (12 females). Seventy-one percent of them had paid work. The mean self-reported quality of the work delivered was 9.6 (standard deviation = 0.5). Eighteen facilitators and 12 barriers regarding work participation later on in life were mentioned. The inpatient pain rehabilitation program was the most frequently mentioned facilitator (n = 5), while the personal system and coping-related factors were the most frequently mentioned barriers (n = 5).

CONCLUSIONS

Ten out of 14 participants are currently working, most of them despite experiencing pain. Several factors based on the 4 systems of the Sherbrooke model contribute as facilitators or barriers regarding current work participation. Pain rehabilitation is mostly regarded as a facilitator for work participation later on in life.

Getting Back to Living: Further Evidence for the Efficacy of an Interdisciplinary Pediatric Pain Treatment Program

OBJECTIVE

This study examined key functional outcomes following a 3-week interdisciplinary pediatric pain rehabilitation program for adolescents with chronic pain. Maintenance of gains was evaluated at 3-month follow-up.

METHODS

Participants included 171 adolescents (12 to 18 y of age) with chronic pain who completed a hospital-based outpatient pediatric pain rehabilitation program. Participants completed measures of functional disability, depressive symptoms, pain catastrophizing, opioid use, school attendance, and pain severity at admission, discharge, and at 3-month follow-up.

RESULTS

Similar to other interdisciplinary pediatric pain rehabilitation program outcome studies, significant improvements were observed at the end of the program. These improvements appeared to be maintained or further improved at 3-month follow-up. Nearly 14% of the patients were taking daily opioid medication at admission to the program. All adolescents were completely tapered off of these medications at the end of the 3-week program and remained abstinent at 3-month follow-up.

DISCUSSION

This study adds to the available data supporting interdisciplinary pediatric pain rehabilitation as effective in improving functioning and psychological distress even when discontinuing opioids. Implications for future research and limitations of the study are discussed.

[Therapy recommendations in a pediatric outpatient pain clinic : Adherence and effectiveness of implementation]

BACKGROUND

Supplementary pain-related recommendations for the treatment of chronic pain in children and adolescents are an essential component of multimodal pain treatment. Studies are scarce regarding adherence to these recommendations and their effectiveness.

OBJECTIVE

The aim of this study was to evaluate patient adherence to pain-related recommendations and their effectiveness 12 months after initial presentation of children and adolescents with chronic pain to a pediatric outpatient pain clinic.

MATERIALS AND METHODS

A total of 413 patients were assessed using a structured telephone interview. The assessment included pain characteristics during the last 4 weeks as well as information regarding the implementation of the pain-related recommendations and the effectiveness. Due to different recommendations given to migraine patients this subgroup was dealt with separately.

RESULTS

Patients reported significant improvements 12 months after the initial presentation and 29.5 % of the patients were pain free. Adherence levels and estimated effectiveness regarding recommendations, such as change of lifestyle, multimodal inpatient treatment and use of medication were high. Other recommendations, such as active relaxation and outpatient psychotherapy had low adherence levels and low estimated effectiveness. Migraine patients had a significantly higher adherence rate and estimated effectiveness regarding the recommendation use of medication than non-migraine patients.

CONCLUSION

The adherence level as well as the estimated effectiveness regarding the majority of pain-related recommendations was high. Some recommendations had low adherence rates and low estimated effectiveness. These results can help to further improve the performance of outpatient clinics for children and adolescents with chronic pain.

[Pain syndrome of the musculoskeletal system in children and adolescents]

Chronic pain syndromes in children and adolescents are defined as continuous or recurrent pain without an underlying causative diagnosis and lasting for more than 3 months. It is estimated that every fourth child in Germany suffers from chronic pain with every twentieth suffering from extreme recurrent pain. The incidence of chronic pain in children and adolescents is increasing with headache, abdominal pain and musculoskeletal pain being the most frequent. The quality of life declines not only due to the pain but to relieving postural and psychological factors, such as fear and sadness. School attendance, social activities and hobbies are mostly affected. This review summarizes the background of chronic pain syndromes and introduces a multimodal therapeutic approach.

Spontaneous recurrent episodes of wrist pain in a 16-year-old girl: a case of complex regional pain syndrome

CRPS in children may imitate rheumatologic diseases, but should be considered if typical signs are present. Diagnosis can be supported by three-phase bone scintigraphy.

Introduction: Complex regional pain syndromes (CRPS) are disabling pain syndromes that can develop after minor tissue injury or trauma and are characterized by sensory, motor, and autonomic abnormalities distributed in a glove-like or stocking-like manner. Complex regional pain syndrome is well known in adults, but is relatively rare in children. Most of the reported cases of CRPS in children are clinical diagnoses that are not supported by examinations such as three-phase bone scintigraphy. Furthermore, different centres often use different diagnostic criteria for CRPS, which sometimes questions the diagnosis of CRPS.

Objective/Methods: Although, recurrences and in particular relapses of CRPS have been observed, a periodically, nearly self-limiting course of disease without any residues in pain-free episodes and without any new obvious injury in CRPS is rather unusual. We present the case of a 16-year-old girl who reported recurrent spontaneous pain which lasted for 2 to 3 weeks and occurred approximately 2 times a year after the patient had experienced a mild trauma 3 years ago.

Results: The pain was accompanied by swelling, temperature asymmetry, and decreased range of motion of the right hand without any complains in pain-free episodes. Recurrent symptoms occurred without any obvious trauma. Diagnosis of CRPS was made from clinical findings including quantitative sensory testing, increased periarticular radioisotope uptake in the delayed phase of three-phase bone scintigraphy and examination during anaesthesia. Multimodal inpatient pain treatment resolved her symptoms substantially.

Conclusion: Complex regional pain syndrome in children may imitate rheumatologic diseases, and the course is different from adults despite similar clinical findings.

Specialized Rehabilitation Programs for Children and Adolescents with Severe Disabling Chronic Pain: Indications, Treatment and Outcomes

Children and adolescents with highly disabling chronic pain of high intensity and frequency are admitted to specialized pain rehabilitation programs. Some barriers to obtaining this specialized care include a lack of availability of treatment centers, a perceived social stigma and individual barriers such as socioeconomic status. Specialized rehabilitation programs for severe disabling chronic pain worldwide have similarities regarding admission criteria, structure and therapeutic orientation. They differ, however, regarding their exclusion criteria and program descriptions. The short- and long-term effectiveness of some rehabilitation programs is well documented. All countries should promote the establishment of future pediatric pain centers to improve the health care of children and adolescents suffering from severe chronic pain. Standardized reporting guidelines should be developed to describe treatments and outcomes to enable comparability across treatment centers.

Household income determines access to specialized pediatric chronic pain treatment in Germany

BACKGROUND

Families with lower socioeconomic status (SES) often face problems with gaining access to health care services. Information is scarce on the relationship between SES and health care delivery for children suffering from chronic pain.

METHODS

Families presenting to a specialized pain center (N = 1,001) provided information on 'household income, 'parental education' and 'occupation' to aid the evaluation of their SES. To assess whether the SES of the clinical sample is representative of the general population, it was compared to data from a community sample (N = 14,558). For the clinical sample, travel distance to the clinic was described in relation to the 75% catchment area. Multiple logistic regression was used to analyze the association between SES and the journey from outside the catchment area.

RESULTS

The SES was significantly higher in the clinical sample than in the community sample. Within the clinical sample, the distance traveled to the pain center increased with increasing SES. The 75% catchment area was 143 miles for families with the highest SES and 78 miles for the lowest SES. 'Household income' predicted travel distance (OR 1.32 (1.12-1.56)). Education and occupational status were not significant predictors of travel from outside the catchment area.

CONCLUSIONS

In Germany, specialized care for children with chronic pain is subject to disparities in access. Future activities should focus on identifying barriers to access and seeking to prevent inequalities in specialized pediatric health care delivery. Increasing the number of specialized treatment facilities could improve access to specialized pediatric pain treatment, regardless of socioeconomic determinants.

Chronic pain treatment in children and adolescents: less is good, more is sometimes better

Background

In children with chronic pain, interdisciplinary outpatient and intensive inpatient treatment has been shown to improve pain intensity and disability. However, there are few systematic comparisons of outcomes of the two treatments. The present naturalistic study aimed to compare the clinical presentation and achieved changes at return in three outcome domains (pain intensity, disability, school absence) between a) outpatients vs. inpatients and b) patients who declined intensive inpatient treatment and completed outpatient treatment instead (decliners) vs. those who completed inpatient treatment (completers).

Methods

The study compared treatment outcomes between n = 992 outpatients vs. n = 320 inpatients (Analysis A) who were treated at a tertiary treatment centre and returned for a return visit within a one-year interval. In Analysis B, treatment outcomes were compared between n = 67 decliners vs. n = 309 completers of inpatient treatment. The three outcome domains were compared by calculating standardized change scores and clinically significant changes.

Results

In analysis A, outpatients and inpatients reported comparably low levels of pain intensity (NRS 0–10; mean = 4, SD = 2.7) and disability (Paediatric Pain Disability Index (PPDI: 12–60; mean = 24; SD = 10) at the return visit. Compared to outpatients, more inpatients achieved clinically significant changes in pain intensity (52% vs. 45%) and disability (46% vs. 31%). There were also significantly greater changes in disability in the inpatient group (change score _outpatients = 1.0; change score _inpatients = 1.4; F_(1,1138) = 12.6, p = .011). School absence was substantially reduced, with approximately 80% in each group attending school regularly. Analysis B showed that even though inpatient decliners achieved improvements in the outcome domains, they reported greater disability at the return visit (PPDI mean _decliners = 27, SD = 9.9; PPDI mean _completers = 24, SD = 10) because they had achieved fewer changes in disability (change score _decliners = 0.9; change score _completers = 1.4; F_(1.334) = 5.7, p = .017). In addition, less decliners than completers achieved clinically significant changes in disability (25% vs. 47%).

Conclusions

Inpatient and outpatient treatments are able to elicit substantial changes in pain intensity, disability and school absence. The results highlight the necessity of intensive inpatient pain treatment for highly affected children, as children who declined inpatient treatment and were treated as outpatients did less well.

[Definition, diagnosis and therapy of chronic widespread pain and so-called fibromyalgia syndrome in children and adolescents. Systematic literature review and guideline]

BACKGROUND

The scheduled update to the German S3 guidelines on fibromyalgia syndrome (FMS) by the Association of the Scientific Medical Societies ("Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften", AWMF; registration number 041/004) was planned starting in March 2011.

MATERIALS AND METHODS

The development of the guidelines was coordinated by the German Interdisciplinary Association for Pain Therapy ("Deutsche Interdisziplinären Vereinigung für Schmerztherapie", DIVS), 9 scientific medical societies and 2 patient self-help organizations. Eight working groups with a total of 50 members were evenly balanced in terms of gender, medical field, potential conflicts of interest and hierarchical position in the medical and scientific fields. Literature searches were performed using the Medline, PsycInfo, Scopus and Cochrane Library databases (until December 2010). The grading of the strength of the evidence followed the scheme of the Oxford Centre for Evidence-Based Medicine. The formulation and grading of recommendations was accomplished using a multi-step, formal consensus process. The guidelines were reviewed by the boards of the participating scientific medical societies.

RESULTS AND CONCLUSION

The diagnosis FMS in children and adolescents is not established. In so-called juvenile FMS (JFMS) multidimensional diagnostics with validated measures should be performed. Multimodal therapy is warranted. In the case of severe pain-related disability, therapy should be primarily performed on an inpatient basis. The English full-text version of this article is available at SpringerLink (under "Supplemental").

Characteristics of highly impaired children with severe chronic pain: a 5-year retrospective study on 2249 pediatric pain patients

BACKGROUND

Prevalence of pain as a recurrent symptom in children is known to be high, but little is known about children with high impairment from chronic pain seeking specialized treatment. The purpose of this study was the precise description of children with high impairment from chronic pain referred to the German Paediatric Pain Centre over a 5-year period.

METHODS

Demographic variables, pain characteristics and psychometric measures were assessed at the first evaluation. Subgroup analysis for sex, age and pain location was conducted and multivariate logistic regression applied to identify parameters associated with extremely high impairment.

RESULTS

The retrospective study consisted of 2249 children assessed at the first evaluation. Tension type headache (48%), migraine (43%) and functional abdominal pain (11%) were the most common diagnoses with a high rate of co-occurrence; 18% had some form of musculoskeletal pain disease. Irrespective of pain location, chronic pain disorder with somatic and psychological factors was diagnosed frequently (43%). 55% of the children suffered from more than one distinct pain diagnosis. Clinically significant depression and general anxiety scores were expressed by 24% and 19% of the patients, respectively. Girls over the age of 13 were more likely to seek tertiary treatment compared to boys. Nearly half of children suffered from daily or constant pain with a mean pain value of 6/10. Extremely high pain-related impairment, operationalized as a comprehensive measure of pain duration, frequency, intensity, pain-related school absence and disability, was associated with older age, multiple locations of pain, increased depression and prior hospital stays. 43% of the children taking analgesics had no indication for pharmacological treatment.

CONCLUSION

Children with chronic pain are a diagnostic and therapeutic challenge as they often have two or more different pain diagnoses, are prone to misuse of analgesics and are severely impaired. They are at increased risk for developmental stagnation. Adequate treatment and referral are essential to interrupt progression of the chronic pain process into adulthood.

Adolescent chronic pain and disability: A review of the current evidence in assessment and treatment

Adolescents who suffer from chronic pain also report complex syndrome-associated disability and distress that can detrimentally affect the quality of their lives and the lives of their family members. Over the past 10 years, there have been significant developments in both methods of assessment and in treatment programs. There have also been good developments in clinical assessment tools, although many need further study. However, the evidence base of available treatments remains small, and there is an urgent need for new trials in both pharmacological and nonpharmacological treatments. The greatest challenges are organizational, and the concern is how to bring patients in contact with available treatments. Many patients who could benefit from evidence-supported treatments are not currently able to access treatment. Theoretical developments aimed at explaining chronic pain within the context of the family, as well as family attempts at coping with complex disability, are underway.

[Pain perception of adolescents with chronic functional pain : adaptation and psychometric validation of the Pain Perception Scale (SES) by Geissner]

BACKGROUND

Pain perception is a central aspect of the multidimensional model of chronic pain. Up to now, validated measurement tools are lacking in the German language for measuring pain perception in adolescents. The aim of this study was to examine and adapt the well-established Pain Perception Scale for Adults by Geissner (SES) for use in adolescents with chronic pain to provide a measure for clinical diagnosis and evaluation of treatment effects.

MATERIAL AND METHODS

Principal component, reliability and item analyses were conducted on a sample with 139 adolescents. To test validity, age and sex effects, correlations with pain-related constructs, differences between treatment groups (inpatients vs outpatients) and concordance between adolescents and their parents were analysed.

RESULTS

Findings support a two-factor solution with one affective and one sensory factor; three additional sensory items were included in the final version. The scales show good internal consistency. Consistent with hypotheses, we found significant correlations with pain characteristics, emotional and cognitive variables as well as pain-related disability. Inpatients and outpatients show a significant difference in affective pain perception. Concordance between parents and adolescents was high.

CONCLUSION

With this questionnaire there is now a validated German assessment tool to measure pain perception in adolescents with chronic pain (Pain Perception Scale for Adolescents, SES-J). Due to its practicability it is suitable for clinical application.

The pain provocation technique for adolescents with chronic pain: preliminary evidence for its effectiveness

OBJECTIVE

This study aims to investigate the effectiveness of the "pain provocation technique" (PPT)--a focused treatment strategy incorporating interoceptive exposure (i.e., imagining increases in pain intensity), bilateral stimulation (tactile stimulation), and implementation of pain-related coping to decrease pain intensity--for adolescents suffering from chronic pain.

DESIGN

Prospective observational comparative study.

METHODS

Adolescents utilizing PPT (19 boys and 21 girls) within multimodal inpatient treatment were compared with adolescents in standard multimodal inpatient treatment matched for age, gender, and diagnosis. Core outcome variables (pain intensity, disability, emotional distress) were assessed at admission and 3 months posttreatment.

RESULTS

Adolescents in the PPT group demonstrated a sharper decrease in pain intensity and school aversion. Both groups demonstrated significant reductions in disability and emotional distress.

CONCLUSIONS

Results are discussed in terms of the importance of focused treatment strategies such as interoceptive exposure for adolescents suffering from disabling chronic pain. Future studies are warranted to carefully investigate the effectiveness and possible process of change during the PPT such as sensory, cognitive, emotional, and memory aspects.

Effectiveness of a 3-week multimodal inpatient pain treatment for adolescents suffering from chronic pain: statistical and clinical significance

OBJECTIVE

The present study aimed to investigate the effectiveness of a 3-week multimodal inpatient pain program for children and adolescents with chronic pain.

METHODS

Effectiveness was investigated for pain-related variables (pain intensity, pain-related disability) and emotional distress in 3 ways: (1) in terms of statistically significant changes; (2) in terms of the clinical significance of these changes by creating post-hoc outcome groups for pain-related variables and emotional distress; and (3) in terms of the clinically significant overall amelioration generalizing the outcome over 3 variables (ie, pain intensity, pain-related disability, and school absence). One hundred sixty-seven adolescents (aged between 11 and 18 y) with various pain disorders (50% with headache) who met inpatient criteria were evaluated at baseline and 3 months posttreatment.

RESULTS

Patients demonstrated statistically significant changes in all variables with large to medium effect sizes. Seventy-two percent and 45% of the patients demonstrated clinically significant changes in pain intensity and pain-related disability, respectively. The percentages of patients demonstrating clinically significant change in emotional distress ranged from 13% to 26%. Seventy-seven adolescents demonstrated overall amelioration.

DISCUSSION

Results of the study are promising in at least 2 ways: (1) a multimodal inpatient program might stop the negative effects of chronic pain, disability, and emotional distress in children and adolescents, and (2) the exploration of clinical significance testing has demonstrated utility and can be applied to future effectiveness studies in pediatric pain.

Pain therapy in children and adolescents

INTRODUCTION

In children, acute pain occurs predominantly during infectious illnesses or after surgery. Chronic pain, especially headache and abdominal pain, is becoming increasingly common among children and adolescents.

METHODS

Selective literature review, also including evidence-based guidelines and recommendations.

RESULTS

Simple self-reporting and behavioral pain scales are easy to use to assess the intensity of acute pain. To evaluate chronic pain, on the other hand, more complicated, multi-dimensional instruments are necessary (e.g., semi-structured interviews). The most commonly used analgesics are ibuprofen and paracetamol (acetaminophen). When paracetamol is used, its narrow therapeutic window should be kept in mind. Perioperative pain should be treated with balanced analgesia involving a combination of non-pharmacological treatment strategies, non-opioid drugs, opioids, and regional anesthesia. Chronic pain in children can only be treated successfully over the long term with multidisciplinary team intervention based on this biopsychosocial model.

DISCUSSION

Pain not only causes children momentary suffering but also threatens to impair their normal development. Therefore, every effort should be made to prevent pain and to treat it effectively once it arises.