Children and Adolescents with Chronic Pain and Functional Disability: Use of a Behavioral Rehabilitation Approach

Improved pain acceptance and interference following outpatient interdisciplinary pediatric chronic pain treatment

OBJECTIVES

Intensive interdisciplinary chronic pain treatment programs have demonstrated that pain acceptance predicts positive treatment outcomes, but limited research has focused on less-intensive programs. This study aimed to examine associations between changes in pain acceptance and pain interference among youth participating in an outpatient interdisciplinary chronic pain treatment program.

DESIGN

Youth presenting to an evaluation within an interdisciplinary outpatient pediatric chronic pain program completed questionnaires at initial program evaluation (T1) and three months later (T2).

MAIN OUTCOME MEASURES

Youth (N = 94, Mage = 14.59 years, 74% female) completed the Chronic Pain Acceptance Questionnaire, Adolescent Version (CPAQ-A) and PROMIS Pediatric Pain Interference scale.

RESULTS

Pain acceptance increased significantly from T1 to T2 (p=.001), driven primarily by activity engagement (p=.001). Pain interference decreased from T1 to T2 (p<.001). Improvements in acceptance were strongly associated with reductions in interference (p<.001). An exploratory cross-lagged structural equation model revealed a number of direct and indirect effects between pain acceptance and pain interference at T1 and T2.

CONCLUSION

Pain acceptance and interference improved after three months in an outpatient chronic pain treatment program. Improvements in acceptance were strongly related to reductions in interference. Future research should examine these relationships over longer periods, in larger samples.

Pain Catastrophizing and Functional Disability in Youth with Chronic Pain: An Examination of Indirect Effects

Pediatric pain conditions are not uncommon and may lead to functional disability. The purpose of this study is to examine indirect effects of pain catastrophizing on functional disability through anxiety, depression, and pain in youth with chronic pain. Participants included 197 youth (144 females, Mage = 14.67 years) with chronic pain conditions. Youth completed self-report measures of pain catastrophizing, depression, anxiety, pain intensity, and functional disability. Caregivers also completed a measure of youth functional disability. Using a cross-sectional design, a multiple mediator model was estimated with pain catastrophizing as the predictor, functional disability as the outcome, and depression, anxiety, and pain intensity as mediators. Results supported a mediation model in which depression (B = 0.1145, SE = 0.0528, Z = 2.1686; B = 0.1512, SE = 0.0585, Z = 2.5846) and pain intensity (B = 0.1015, SE = 0.0422, Z = 2.4052; B = 0.0634, SE = 0.0343, Z = 1.8484) significantly mediated the effects of catastrophizing on child self-report and parent-report functional disability, respectively, while anxiety (B = - 0.0260, SE = 0.0439501, Z = - 0.5923; B = - 0.0637, SE = 0.0552, Z = - 1.1540) did not. Theoretical and clinical applications are discussed.

Exploring the concept of pain of Australian children with and without pain: qualitative study

OBJECTIVE

A person's concept of pain can be defined as how they understand what pain actually is, what function it serves and what biological processes are thought to underpin it. This study aimed to explore the concept of pain in children with and without persistent pain.

DESIGN

In-depth, face-to-face interviews with drawing tasks were conducted with 16 children (aged 8-12 years) in New South Wales, Australia. Thematic analysis was used to analyse and synthesise the data.

SETTING

Children with persistent pain were identified from a pain clinic waiting list in Australia, and children without pain were identified through advertising flyers and email bulletins at a university and hospital.

PARTICIPANTS

Eight children had persistent pain and eight children were pain free.

RESULTS

Four themes emerged from the data: 'my pain-related knowledge', 'pain in the world around me', 'pain in me' and 'communicating my concept of pain'. A conceptual framework of the potential interactions between the themes resulting from the analysis is proposed. The concept of pain of Australian children aged 8-12 years varied depending on their knowledge, experiences and literacy levels. For example, when undertaking a drawing task, children with persistent pain tended to draw emotional elements to describe pain, whereas children who were pain free did not.

CONCLUSIONS

Gaining an in-depth understanding of a child's previous pain-related experiences and knowledge is important to facilitate clear and meaningful pain science education. The use of age-appropriate language, in combination with appropriate assessment and education tasks such as drawing and discussing vignettes, allowed children to communicate their individual concept of pain.

European Portuguese version of the functional disability inventory: translation and cultural adaptation, validity, and reliability in adolescents with chronic spinal pain

BACKGROUND

Functional disability affects a large percentage of adolescents with chronic pain. The functional disability inventory (FDI) has been widely described in the literature to assess functional disability, with good psychometric properties.

PURPOSE

To translate and adapt the FDI to European Portuguese language and assess the validity, reliability, and measurement error of this version in adolescents with chronic musculoskeletal pain and, specifically, with neck and low back pain.

METHOD

The translation and cross-cultural adaptation of the FDI was conducted according to international guidelines. After that, 1730 adolescents completed the following scales and questionnaires: FDI, Nordic Musculoskeletal Questionnaire, Numeric Pain Rating Scale, Pain Catastrophizing Scale, Depression, Anxiety and Stress Scale, Tampa Scale of Kinesiophobia, and Basic Scale on Insomnia complaints and Quality of Sleep. Sixty-three of these adolescents, with at least one painful body site, completed the questionnaire twice to assess reliability and measurement error. Exploratory factor analysis and hypothesis testing was used to assess construct validity.

RESULTS

Cronbach's alpha ranged from 0.81 and 0.88, ICC was 0.86 (95%CI:0.77; 0.92), the SEM and the SDC were 2.50 and 6.93 (total score of 60 points), respectively. Fair to moderate correlations were obtained between FDI and pain intensity (r_s = 0.33 to 0.43), catastrophizing (r_s = 0.41 to 0.44) depression, anxiety, and stress (r_s = 0.48 to 0.53), fear of movement (r_s = 0.32 to 0.42), and sleep impairments (r_s = 0.34 to 0.38). The factor analysis suggested a two-factor solution.

CONCLUSION

The European Portuguese version of the FDI has very good internal consistency, good test-retest reliability, and construct validity when used in a sample of community adolescents with chronic pain.Implications for rehabilitationOne of the most widely instruments used to assess functional disability is the Functional Disability Inventory (FDI), which in its original version has good psychometric properties and is recommended by the Pediatric Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials;However, the FDI has not been translated yet into European Portuguese language and its psychometric properties have not been assessed in adolescents with chronic spinal pain;This study suggests that the European Portuguese version of the FDI has very good internal consistency, good test-retest reliability as well as construct validity when used in a sample of community adolescents with chronic spinal pain;Therefore, these findings suggest the use of the European Portuguese version of the FDI to assess the functional disability in adolescents with chronic spinal pain.

Best-Evidence for the Rehabilitation of Chronic Pain Part 1: Pediatric Pain

Chronic pain is a prevalent and persistent problem in middle childhood and adolescence. The biopsychosocial model of pain, which accounts for the complex interplay of the biological, psychological, social, and environmental factors that contribute to and maintain pain symptoms and related disability has guided our understanding and treatment of pediatric pain. Consequently, many interventions for chronic pain are within the realm of rehabilitation, based on the premise that behavior has a broad and central role in pain management. These treatments are typically delivered by one or more providers in medicine, nursing, psychology, physical therapy, and/or occupational therapy. Current data suggest that multidisciplinary treatment is important, with intensive interdisciplinary pain rehabilitation (IIPT) being effective at reducing disability for patients with high levels of functional disability. The following review describes the current state of the art of rehabilitation approaches to treat persistent pain in children and adolescents. Several emerging areas of interventions are also highlighted to guide future research and clinical practice.

The effectiveness of cognitive behavioural therapy for pain in childhood and adolescence: a meta-analytic review

OBJECTIVES

A variety of chronic painful conditions are present in the paediatric population. Patients with chronic pain often experience considerable scepticism and avoidance by health care providers. This meta-analytic review aimed to utilise well-designed studies, in examining the effectiveness of cognitive behavioural therapy (CBT) in the treatment of chronic pain in children and adolescents.

METHODS

Nine randomized controlled trial studies examining CBT for chronic pain were reviewed. Outcome measures were child reported pain intensity, pain duration and functional disability.

RESULTS

CBT had a large effect on pain intensity for recurrent abdominal pain (RAP), a small effect on headaches, and a medium effect on fibromyalgia. CBT had a medium effect on pain duration across pain types. CBT had a large effect on functional disability for RAP, a small effect on fibromyalgia and a moderate effect on headaches. Findings are limited by the small number of studies and varied control conditions.

CONCLUSIONS

CBT may be effective in reducing child reported pain symptomology. Future studies using a larger sample and examining the differential impact of varied control conditions are needed.