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Kashikar-Zuck S, Thomas S, Bonnette S, Gibler RC, DiCesare C, Schille A, Hulburt T, Briggs MS, Ounpuu S, Myer GD. Comparison of Pain Characteristics, Strength, and Movement Patterns in Adolescents With Juvenile Fibromyalgia and High Versus Low Fear of Movement. THE JOURNAL OF PAIN 2024:104586. [PMID: 38823603 DOI: 10.1016/j.jpain.2024.104586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 04/30/2024] [Accepted: 05/27/2024] [Indexed: 06/03/2024]
Abstract
Physical activity avoidance and fear of movement (FOM) is often observed in individuals with chronic musculoskeletal pain, along with difficulties coping with pain. There is little research regarding how FOM may also relate to reduced physical strength and altered movement patterns that may perpetuate a cycle of pain, FOM, and disability. The objective of this observational study was to compare how adolescents with juvenile fibromyalgia (JFM) exhibiting high versus low FOM (Tampa Scale of Kinesiophobia-11) differed on patient-reported measures of pain, fatigue, catastrophizing and pain interference, and performance-based measures of strength, postural control, and biomechanical function. Participants were youth with JFM (N = 135, Meanage = 15.6 years, 88.9% female) enrolled in an ongoing clinical trial who completed self-report questionnaires and standardized tests, including knee and hip strength, the Star Excursion Balance Test, and the Drop Vertical Jump (with 3 dimensional motion capture). Participants were categorized into Low, Medium, and High FOM groups based on Tampa Scale of Kinesiophobia-11 tertile scores. Relative to the Low FOM group, the High FOM group reported significantly greater fatigue, pain interference and catastrophizing, as well as reduced dominant leg knee strength. Additionally, those with high FOM showed altered lower-extremity movement patterns. This preliminary study highlights the importance of combining self-reported measures of symptoms and functioning with physical assessments to gain a more comprehensive view of the impact of FOM in patients with chronic musculoskeletal pain. The results could inform the development of more precise interventions to reduce FOM using a combination of behavioral and exercise-based interventions. PERSPECTIVE The results of this study demonstrate the association between FOM, fatigue and pain interference in adolescents with JFM, as well as preliminary evidence for altered movement patterns in that may predispose them to further pain/injury and activity avoidance. CLINICAL TRIALS GOV REGISTRATION NCT03268421.
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Affiliation(s)
- Susmita Kashikar-Zuck
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital, Cincinnati, Ohio.
| | - Staci Thomas
- Division of Sports Medicine, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Scott Bonnette
- Division of Sports Medicine, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Robert C Gibler
- Department of Pediatrics, University of Kansas Medical Center, Kansas City, Kansas
| | | | - Andrew Schille
- Sports Performance and Research Center, Emory University School of Medicine, Atlanta, Georgia
| | - Tessa Hulburt
- Sports Performance and Research Center, Emory University School of Medicine, Atlanta, Georgia
| | - Matthew S Briggs
- Sports Medicine Research Institute, Department of Orthopaedics, and Rehabilitation Services The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Sylvia Ounpuu
- Center for Motion Analysis, Division of Orthopedics, Connecticut Children's Medical Center, Farmington, Connecticut
| | - Greg D Myer
- Sports Performance and Research Center, Emory University School of Medicine, Atlanta, Georgia
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Gibler RC, Peugh JL, Pfeiffer M, Thomas S, Williams SE, Beasley K, Bonnette S, Collins S, Beals-Erickson SE, Ounpuu S, Briggs M, Stinson JN, Myer GD, Kashikar-Zuck S. Associations between patient-reported functional disability and measures of physical ability in juvenile fibromyalgia. Pain 2024; 165:589-595. [PMID: 37624912 PMCID: PMC10894309 DOI: 10.1097/j.pain.0000000000003040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 06/23/2023] [Indexed: 08/27/2023]
Abstract
ABSTRACT Juvenile fibromyalgia (JFM) is a chronic condition characterized by symptoms of pain and fatigue and is associated with sedentary behavior and functional disability. Adults with fibromyalgia exhibit deficits in physical fitness as evidenced by lower aerobic capacity and physical endurance, but it is unknown whether these impairments are apparent in adolescents with JFM. Furthermore, the extent to which functional disability and pain interference relate to measures of physical fitness has not been investigated in a pediatric pain population. During a baseline assessment for a clinical trial, 321 adolescents with juvenile fibromyalgia (M age = 15.14, 85.2% female) completed measures of pain intensity, fatigue, JFM symptom severity, functional disability, and pain interference. They also completed 2 validated fitness tasks: (1) the Harvard step test, which assesses aerobic fitness, and (2) the 6-minute walk test, a simple submaximal test of endurance. We examined associations among self-report measures and fitness assessments using bivariate correlations. We then employed hierarchical regression analyses to determine the unique contributions of physical fitness assessments to self-reported functional disability and pain interference. Results indicated that youth with JFM exhibited deficits in aerobic capacity and physical endurance. However, physical fitness explained negligible variance in functional disability and pain interference beyond that accounted for by pain, fatigue, and JFM symptom severity. Scores on available functional disability measures may reflect perceived difficulties in coping with symptoms during physical tasks rather than actual physical capability. Rigorous and sensitive assessments of physical fitness and endurance are needed to determine whether rehabilitation interventions for pediatric pain improve physical functioning.
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Affiliation(s)
- Robert C. Gibler
- Division of Behavioral Medicine & Clinical Psychology, Cincinnati Children’s Hospital Medical Center
| | - James L. Peugh
- Division of Behavioral Medicine & Clinical Psychology, Cincinnati Children’s Hospital Medical Center
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center
| | - Megan Pfeiffer
- Division of Behavioral Medicine & Clinical Psychology, Cincinnati Children’s Hospital Medical Center
| | - Staci Thomas
- Division of Sports Medicine, Cincinnati Children’s Hospital Medical Center
| | - Sara E. Williams
- Division of Behavioral Medicine & Clinical Psychology, Cincinnati Children’s Hospital Medical Center
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center
| | - Katie Beasley
- Division of Sports Medicine, Cincinnati Children’s Hospital Medical Center
| | - Scott Bonnette
- Division of Sports Medicine, Cincinnati Children’s Hospital Medical Center
| | - Sara Collins
- The Micheli Center for Sports Injury Prevention, Boston Children’s Hospital
| | | | - Sylvia Ounpuu
- Department of Pediatrics, Connecticut Children’s Hospital Medical Center
| | - Matthew Briggs
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center
- Department of Orthopaedics, The Ohio State University Wexner Medical Center
| | - Jennifer N. Stinson
- Child Health Evaluative Sciences (CHES), Research Institute, The Hospital for Sick Children
| | - Gregory D. Myer
- Department of Orthopaedics, Emory University School of Medicine
| | - Susmita Kashikar-Zuck
- Division of Behavioral Medicine & Clinical Psychology, Cincinnati Children’s Hospital Medical Center
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center
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Simons LE, Harrison LE, Boothroyd DB, Parvathinathan G, Van Orden AR, O’Brien SF, Schofield D, Kraindler J, Shrestha R, Vlaeyen JW, Wicksell RK. A randomized controlled trial of graded exposure treatment (GET living) for adolescents with chronic pain. Pain 2024; 165:177-191. [PMID: 37624900 PMCID: PMC10840960 DOI: 10.1097/j.pain.0000000000003010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 06/16/2023] [Indexed: 08/27/2023]
Abstract
ABSTRACT Graded exposure treatment (GET) is a theory-driven pain treatment that aims to improve functioning by exposing patients to activities previously feared and avoided. Combining key elements of GET with acceptance-based exposure, GET Living (GL) was developed for adolescents with chronic pain (GL). Based on robust treatment effects observed in our single-case experimental design pilot trial of GL (NCT01974791), we conducted a 2-arm randomized clinical trial comparing GL with multidisciplinary pain management (MPM) comprised of cognitive behavioral therapy and physical therapy for pain management (NCT03699007). A cohort of 68 youth with chronic musculoskeletal pain (M age 14.2 years; 81% female) were randomized to GL or MPM. Owing to COVID-19 restrictions, 54% of participants received zoom video delivered care. Assessments were collected at baseline, discharge, as well as at 3-month and 6-month follow-up. Primary outcomes were self-reported pain-related fear and avoidance. Secondary outcomes were child functional disability and parent protective responses to child pain. As hypothesized, GL improved in primary and secondary outcomes at 3-month follow-up. Contrary to our superiority hypothesis, there was no significant difference between GL and MPM. Patients reported both GL and MPM (in person and video) as credible and were highly satisfied with the treatment experience. Next steps will involve examining the single-case experimental design data embedded in this trial to facilitate an understanding of individual differences in treatment responses (eg, when effects occurred, what processes changed during treatment within the treatment arm). The current findings support GET Living and MPM for youth with chronic pain.
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Affiliation(s)
- Laura E. Simons
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Lauren E. Harrison
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Derek B. Boothroyd
- Quantitative Statistical Unit, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Gomathy Parvathinathan
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Amanda R. Van Orden
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Shannon F. O’Brien
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Deborah Schofield
- Center for Economic Impacts of Genomic Medicine, Department of Economics, Macquarie University, Sydney, Australia
| | - Joshua Kraindler
- Center for Economic Impacts of Genomic Medicine, Department of Economics, Macquarie University, Sydney, Australia
| | - Rupendra Shrestha
- Center for Economic Impacts of Genomic Medicine, Department of Economics, Macquarie University, Sydney, Australia
| | - Johan W.S. Vlaeyen
- Center for Economic Impacts of Genomic Medicine, Department of Economics, Macquarie University, Sydney, Australia
| | - Rikard K. Wicksell
- Research group Behavior Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden & Pain Clinic, Capio St Goran Hospital, Stockholm, Sweden
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Themelis K, Tang NKY. The Management of Chronic Pain: Re-Centring Person-Centred Care. J Clin Med 2023; 12:6957. [PMID: 38002572 PMCID: PMC10672376 DOI: 10.3390/jcm12226957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/03/2023] [Accepted: 11/05/2023] [Indexed: 11/26/2023] Open
Abstract
The drive for a more person-centred approach in the broader field of clinical medicine is also gaining traction in chronic pain treatment. Despite current advances, a further departure from 'business as usual' is required to ensure that the care offered or received is not only effective but also considers personal values, goals, abilities, and day-to-day realities. Existing work typically focuses on explaining pain symptoms and the development of standardised interventions, at the risk of overlooking the broader consequences of pain in individuals' lives and individual differences in pain responses. This review underscores the importance of considering additional factors, such as the influence of chronic pain on an individual's sense of self. It explores innovative approaches to chronic pain management that have the potential to optimise effectiveness and offer person-centred care. Furthermore, it delves into research applying hybrid and individual formulations, along with self-monitoring technologies, to enhance pain assessment and the tailoring of management strategies. In conclusion, this review advocates for chronic pain management approaches that align with an individual's priorities and realities while fostering their active involvement in self-monitoring and self-management.
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Affiliation(s)
- Kristy Themelis
- Department of Psychology, University of Warwick, Coventry CV4 7AL, UK
| | - Nicole K. Y. Tang
- Department of Psychology, University of Warwick, Coventry CV4 7AL, UK
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Darnall BD, Edwards KA, Courtney RE, Ziadni MS, Simons LE, Harrison LE. Innovative treatment formats, technologies, and clinician trainings that improve access to behavioral pain treatment for youth and adults. FRONTIERS IN PAIN RESEARCH 2023; 4:1223172. [PMID: 37547824 PMCID: PMC10397413 DOI: 10.3389/fpain.2023.1223172] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 07/04/2023] [Indexed: 08/08/2023] Open
Abstract
Chronic pain is prevalent across the life span and associated with significant individual and societal costs. Behavioral interventions are recommended as the gold-standard, evidence-based interventions for chronic pain, but barriers, such as lack of pain-trained clinicians, poor insurance coverage, and high treatment burden, limit patients' ability to access evidenced-based pain education and treatment resources. Recent advances in technology offer new opportunities to leverage innovative digital formats to overcome these barriers and dramatically increase access to high-quality, evidenced-based pain treatments for youth and adults. This scoping review highlights new advances. First, we describe system-level barriers to the broad dissemination of behavioral pain treatment. Next, we review several promising new pediatric and adult pain education and treatment technology innovations to improve access and scalability of evidence-based behavioral pain treatments. Current challenges and future research and clinical recommendations are offered.
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Affiliation(s)
- Beth D. Darnall
- Stanford Pain Relief Innovations Lab, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Karlyn A. Edwards
- Stanford Pain Relief Innovations Lab, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Rena E. Courtney
- Salem VA Health Care System, PREVAIL Center for Chronic Pain, Salem, VA, United States
- Virginia Tech Carilion School of Medicine, Department of Psychiatry and Behavioral Medicine, Roanoke, VA, United States
| | - Maisa S. Ziadni
- Systems Neuroscience and Pain Lab, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Laura E. Simons
- Biobehavioral Pediatric Pain Lab, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Lauren E. Harrison
- Biobehavioral Pediatric Pain Lab, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
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Hess CW, Rosen MA, Simons LE. Looking inward to improve pediatric chronic pain outcomes: a call for team science research. Pain 2023; 164:690-697. [PMID: 36637136 PMCID: PMC10879964 DOI: 10.1097/j.pain.0000000000002836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 11/22/2022] [Indexed: 01/14/2023]
Affiliation(s)
- Courtney W. Hess
- Stanford University School of Medicine; Department of Anesthesiology, Perioperative, & Pain Medicine
| | - Michael A. Rosen
- Johns Hopkins University School of Medicine; Department of Anesthesiology and Critical Care Medicine
| | - Laura E. Simons
- Stanford University School of Medicine; Department of Anesthesiology, Perioperative, & Pain Medicine
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Caru M, Alberts NM, Freeman MC, Dandekar SC, Rao P, McKeone DJ, Brown VI, McGregor LM, Schmitz KH. Chronic pain in children and adolescents diagnosed with cancer: the challenge of mitigating the pain and the potential of integrating exercise into pain management. Support Care Cancer 2023; 31:228. [PMID: 36952029 DOI: 10.1007/s00520-023-07695-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 03/16/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND Pain is one of the most common and distressing symptoms experienced by children and adolescents diagnosed with cancer. It is vital that children and adolescents receive adequate pain management early on in their cancer treatments to mitigate pain and cancer-related symptoms. Exercise training shows particular promise in the management of acute and chronic pain among children and adolescents diagnosed with cancer. METHODS This position paper comes to outline the challenge of mitigating pain in children and adolescents diagnosed with cancer, and the potential benefits of integrating exercise training to the management of chronic pain in this population in need. RESULTS Integrating exercise training into the care and pain management of children and adolescents diagnosed with cancer who have chronic pain would have the advantage of addressing several shortcomings of pain medication. Pain medication aims to temporarily manage or reduce pain; it does not have the potential to directly improve a patient's physical condition in the way that exercise training can. The current paucity of data available on the use of exercise training as a complementary treatment to pain medications to reduce chronic pain in children and adolescents diagnosed with cancer allows only for hypotheses on the effectiveness of this pain management modality. CONCLUSION More research on this important topic is necessary and mitigating pain effectively while also reducing the use of opioid pain medication is an important goal shared by patients, their families, clinicians, and researchers alike. Future research in this area has great potential to inform clinical care, clinical care guidelines, and policy-making decisions for pain management in children and adolescents diagnosed with cancer who experience chronic pain.
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Affiliation(s)
- Maxime Caru
- Division of Hematology and Oncology, Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA.
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA.
| | - Nicole M Alberts
- Department of Psychology, Concordia University, Montréal, QC, Canada
| | - Michelle C Freeman
- Division of Complex and Palliative Care, Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| | - Smita C Dandekar
- Division of Hematology and Oncology, Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| | - Pooja Rao
- Division of Hematology and Oncology, Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| | - Daniel J McKeone
- Division of Hematology and Oncology, Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| | - Valerie I Brown
- Division of Hematology and Oncology, Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| | - Lisa M McGregor
- Division of Hematology and Oncology, Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| | - Kathryn H Schmitz
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
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Schemer L, Hess CW, Van Orden AR, Birnie KA, Harrison LE, Glombiewski JA, Simons LE. Enhancing Exposure Treatment for Youths With Chronic Pain: Co-design and Qualitative Approach. J Particip Med 2023; 15:e41292. [PMID: 36892929 PMCID: PMC10037174 DOI: 10.2196/41292] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 12/19/2022] [Accepted: 01/23/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Increasing the access to and improving the impact of pain treatments is of utmost importance, especially among youths with chronic pain. The engagement of patients as research partners (in contrast to research participants) provides valuable expertise to collaboratively improve treatment delivery. OBJECTIVE This study looked at a multidisciplinary exposure treatment for youths with chronic pain through the lens of patients and caregivers with the aim to explore and validate treatment change processes, prioritize and develop ideas for improvement, and identify particularly helpful treatment elements. METHODS Qualitative exit interviews were conducted with patients and caregivers at their discharge from 2 clinical trials (ClinicalTrials.gov NCT01974791 and NCT03699007). Six independent co-design meetings were held with patients and caregivers as research partners to establish a consensus within and between groups. The results were validated in a wrap-up meeting. RESULTS Patients and caregivers described that exposure treatment helped them better process pain-related emotions, feel empowered, and improve their relationship with each other. The research partners developed and agreed upon 12 ideas for improvement. Major recommendations include that pain exposure treatment should be disseminated more not only among patients and caregivers but also among primary care providers and the general public to facilitate an early referral for treatment. Exposure treatment should allow flexibility in terms of duration, frequency, and delivery mode. The research partners prioritized 13 helpful treatment elements. Most of the research partners agreed that future exposure treatments should continue to empower patients to choose meaningful exposure activities, break long-term goals into smaller steps, and discuss realistic expectations at discharge. CONCLUSIONS The results of this study have the potential to contribute to the refinement of pain treatments more broadly. At their core, they suggest that pain treatments should be disseminated more, flexible, and transparent.
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Affiliation(s)
- Lea Schemer
- Department of Clinical Psychology and Psychotherapy, University of Kaiserslautern-Landau, Landau, Germany
| | - Courtney W Hess
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Amanda R Van Orden
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Kathryn A Birnie
- Department of Anesthesiology, Perioperative, and Pain Medicine, Department of Community Health Sciences, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Lauren E Harrison
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Julia A Glombiewski
- Department of Clinical Psychology and Psychotherapy, University of Kaiserslautern-Landau, Landau, Germany
| | - Laura E Simons
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
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Thielen H, Tuts N, Welkenhuyzen L, Huenges Wajer IMC, Lafosse C, Gillebert CR. Sensory sensitivity after acquired brain injury: A systematic review. J Neuropsychol 2023; 17:1-31. [PMID: 35773750 DOI: 10.1111/jnp.12284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 06/01/2022] [Accepted: 06/07/2022] [Indexed: 11/30/2022]
Abstract
Patients with acquired brain injury frequently report experiencing sensory stimuli as abnormally under- (sensory hyposensitivity) or overwhelming (sensory hypersensitivity). Although they can negatively impact daily functioning, these symptoms are poorly understood. To provide an overview of the current evidence on atypical sensory sensitivity after acquired brain injury, we conducted a systematic literature review. The primary aim of the review was to investigate the behavioural and neural mechanisms that are associated with self-reported sensory sensitivity. Studies were included when they studied sensory sensitivity in acquired brain injury populations, and excluded when they were not written in English, consisted of non-empirical research, did not study human subjects, studied pain, related sensory sensitivity to peripheral injury or studied patients with a neurodegenerative disorder, meningitis, encephalitis or a brain tumour. The Web of Science, PubMed and Scopus databases were searched for appropriate studies. A qualitative synthesis of the results of the 81 studies that were included suggests that abnormal sensory thresholds and a reduced information processing speed are candidate behavioural mechanisms of atypical subjective sensory sensitivity after acquired brain injury. Furthermore, there was evidence for an association between subjective sensory sensitivity and structural grey or white matter abnormalities, and to functional abnormalities in sensory cortices. However, further research is needed to explore the causation of atypical sensory sensitivity. In addition, there is a need for the development of adequate diagnostic tools. This can significantly advance the quantity and quality of research on the prevalence, aetiology, prognosis and treatment of these symptoms.
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Affiliation(s)
- Hella Thielen
- Department Brain and Cognition, Leuven Brain Institute (LBI), KU Leuven, Leuven, Belgium
| | - Nora Tuts
- Department Brain and Cognition, Leuven Brain Institute (LBI), KU Leuven, Leuven, Belgium
| | - Lies Welkenhuyzen
- Department Brain and Cognition, Leuven Brain Institute (LBI), KU Leuven, Leuven, Belgium.,Department Psychology, Hospital East-Limbourgh, Genk, Belgium.,TRACE, Centre for Translational Psychological Research, KU Leuven - Hospital East-Limbourgh, Genk, Belgium
| | - Irene M C Huenges Wajer
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands.,Experimental Psychology, Utrecht University, Utrecht, The Netherlands
| | | | - Céline R Gillebert
- Department Brain and Cognition, Leuven Brain Institute (LBI), KU Leuven, Leuven, Belgium.,TRACE, Centre for Translational Psychological Research, KU Leuven - Hospital East-Limbourgh, Genk, Belgium
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Harrison LE, Webster SN, Van Orden AR, Choate E, Jehl N, Stinson J, Wicksell RK, Darnall BD, Simons LE. Agile development of a digital exposure treatment for youth with chronic musculoskeletal pain: protocol of a user-centred design approach and examination of feasibility and preliminary efficacy. BMJ Open 2022; 12:e065997. [PMID: 36109029 PMCID: PMC9478845 DOI: 10.1136/bmjopen-2022-065997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 08/23/2022] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Chronic pain affects a significant number of children and impacts multiple domains including social, emotional and behavioural functioning, and negatively impacts family functioning. Roughly 5% of youth with chronic pain experience moderate to severe pain-related disability, with pain-related fear and avoidance of activities being identified as substantial barriers to treatment engagement. Evidence supports targeted psychological and physical interventions to address these barriers (eg, graded-exposure treatment), but accessibility to intervention is undermined by a shortage of services outside of urban areas, high treatment-related costs, and long provider waitlists; highlighting the need to develop digitally delivered behavioural intervention, using agile and iterative study designs that support rapid development and timely dissemination. METHODS AND ANALYSIS This study seeks to develop an effective and scalable intervention for youth with chronic pain and their caregivers. This paper presents a user-centred protocol for the development and refinement of a digital exposure treatment for youth and caregivers, as well as the study design to examine feasibility and preliminary efficacy of the treatment using single-case experimental design (SCED). Assessments include daily diaries, completed from baseline and daily throughout the intervention (~6 weeks), and at 3-month follow-up, as well as self-report measures completed at baseline, end of intervention and 3-month follow-up. Primary outcomes include treatment satisfaction, treatment expectancy, adherence to daily dairies and functional disability. Secondary outcomes are pain-related fear and avoidance of activities, pain catastrophising and pain acceptance. We will present descriptive and model-based inference analyses, based on SCED reporting guidelines. We will calculate effect sizes for each individual on each outcome. We will examine mean treatment expectancy, credibility and satisfaction scores, and patient drop-out percentage. ETHICS AND DISSEMINATION This study is approved by the Institutional Review Board at Stanford University (protocol #53323). Findings will be actively disseminated through peer-reviewed journals, conference presentations and social media. TRIAL REGISTRATION NUMBER NCT05079984.
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Affiliation(s)
- Lauren E Harrison
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Sarah N Webster
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Amanda R Van Orden
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ellison Choate
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Nicole Jehl
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Jennifer Stinson
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Rikard K Wicksell
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
- Pain Clinic, Capio St. Goran Hospital, Stockholm, Sweden
| | - Beth D Darnall
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Laura E Simons
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, USA
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11
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Shear D, Harrison LE, O'Brien S, Khazendar Z, Lyons S, Morgan JJ, Chan SK, Feinstein AB, Simons LE. Rapid Transition to Virtual Assessment and Treatment in an Interdisciplinary Randomized Clinical Trial for Youth With Chronic Pain: Adaptations and Implications for Future Trials. Clin J Pain 2022; 38:459-469. [PMID: 35686576 PMCID: PMC9199594 DOI: 10.1097/ajp.0000000000001040] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 12/15/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES COVID-19 abruptly halted in-person clinical care and research requiring a shift to virtual assessment and treatment. This unexpected transition of a 2-arm randomized controlled trial (RCT) examining interdisciplinary graded exposure treatment (GET Living) compared with multidisciplinary pain management for youth with chronic pain provided an opportunity to implement the first remotely delivered exposure treatment and remotely delivered biomechanical assessment for pediatric chronic pain. Here we describe these new approaches and provide lessons learned to inform future efforts in digital health care. METHODS A total of 68 youth (M=14.2 y; 80.9% female) were enrolled in the RCT (n=31 in-person, n=5 hybrid, n=32 virtual, n=9 withdrew). Of those withdrawn, n=3 withdrew due to COVID-19 related reasons. Some RCT elements required slight modification (eg, e-consent, actigraphy deployment, recruitment, and screening), while others were significantly altered (eg, session format and lab-based biomechanical assessment). Data from exit interviews were also examined to assess perspectives on the virtual format transition. RESULTS Results showed an increased enrollment rate when virtual care was an option (70.7%) compared with in-person (44.3%). Equivalent rates of completion for daily assessment (in-person, 72.8%; virtual, 73.3) were also observed, and participants described enhanced experience when able to complete exercises and exposures in their home environment during session (vs. a rehabilitation gym) allowing for genuine in vivo exposures (eg, household chores, riding bicycles). DISCUSSION Overall, our data demonstrate acceptability, feasibility, and equivalent patient engagement to virtual treatment. Novel methods implemented in this RCT can inform trial design and measures of clinical endpoints for future digital health interventions.
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Affiliation(s)
- Deborah Shear
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto
| | - Lauren E Harrison
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto
| | - Shannon O'Brien
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto
| | - Zeena Khazendar
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto
| | - Samuel Lyons
- Motion and Sports Performance Lab, Department of Orthopedic Sports Medicine, Lucile Packard Children's Hospital, Sunnyvale, CA
| | - Jeffery J Morgan
- Motion and Sports Performance Lab, Department of Orthopedic Sports Medicine, Lucile Packard Children's Hospital, Sunnyvale, CA
| | - Salinda K Chan
- Motion and Sports Performance Lab, Department of Orthopedic Sports Medicine, Lucile Packard Children's Hospital, Sunnyvale, CA
| | - Amanda B Feinstein
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto
| | - Laura E Simons
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto
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12
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Bartels SL, Johnsson SI, Boersma K, Flink I, McCracken LM, Petersson S, Christie HL, Feldman I, Simons LE, Onghena P, Vlaeyen JWS, Wicksell RK. Development, evaluation and implementation of a digital behavioural health treatment for chronic pain: study protocol of the multiphase DAHLIA project. BMJ Open 2022; 12:e059152. [PMID: 35428645 PMCID: PMC9014062 DOI: 10.1136/bmjopen-2021-059152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Chronic pain affects about 20%-40% of the population and is linked to mental health outcomes and impaired daily functioning. Pharmacological interventions are commonly insufficient for producing relief and recovery of functioning. Behavioural health treatment is key to generate lasting benefits across outcome domains. However, most people with chronic pain cannot easily access evidence-based behavioural interventions. The overall aim of the DAHLIA project is to develop, evaluate and implement a widely accessible digital behavioural health treatment to improve well-being in individuals with chronic pain. METHODS AND ANALYSIS The project follows the four phases of the mHealth Agile Development and Evaluation Lifecycle: (1) development and pre-implementation surveillance using focus groups, stakeholder interviews and a business model; (2) iterative optimisation studies applying single case experimental design (SCED) method in 4-6 iterations with n=10 patients and their healthcare professionals per iteration; (3) a two-armed clinical randomised controlled trial enhanced with SCED (n=180 patients per arm) and (4) interview-based post-market surveillance. Data analyses include multilevel modelling, cost-utility and indicative analyses.In October 2021, inter-sectorial partners are engaged and funding is secured for four years. The treatment content is compiled and the first treatment prototype is in preparation. Clinical sites in three Swedish regions are informed and recruitment for phase 1 will start in autumn 2021. To facilitate long-term impact and accessibility, the treatment will be integrated into a Swedish health platform (www.1177.se), which is used on a national level as a hub for advice, information, guidance and e-services for health and healthcare. ETHICS AND DISSEMINATION The study plan has been reviewed and approved by Swedish ethical review authorities. Findings will be actively disseminated through peer-reviewed journals, conference presentations, social media and outreach activities for the wider public. TRIAL REGISTRATION NUMBER NCT05066087.
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Affiliation(s)
| | - Sophie I Johnsson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Katja Boersma
- Center for Health and Medical Psychology (CHAMP), School of Law, Psychology, and Social Work, Örebro University, Orebro, Sweden
| | - Ida Flink
- Center for Health and Medical Psychology (CHAMP), School of Law, Psychology, and Social Work, Örebro University, Orebro, Sweden
| | - Lance M McCracken
- Division of Clinical Psychology, Department of Psychology, Uppsala University, Uppsala, Sweden
| | - Suzanne Petersson
- Department of Medicine and Optometry, Linnaeus University, Kalmar, Sweden
| | - Hannah L Christie
- Department of Psychiatry and Neuropsychology and Alzheimer Centre Limburg, School for Mental Health and Neurosciences, Maastricht University, Maastricht, Netherlands
| | - Inna Feldman
- Department of Public Health and Caring Science, Uppsala Universitet, Uppsala, Sweden
| | - Laura E Simons
- Department of Anaesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Patrick Onghena
- Research Group on Methods, Individual and Cultural Differences, Affect and Social Behavior, KU Leuven, Leuven, Belgium
| | - Johan W S Vlaeyen
- Research Group Health Psychology, KU Leuven, Leuven, Belgium
- Research Group Experimental Health Psychology, Maastricht University, Maastricht, The Netherlands
| | - Rikard K Wicksell
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
- Pain Clinic, Capio St. Göran Hospital, Stockholm, Sweden
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Harrison LE, Heathcote LC, Khazendar Z, Richardson PA, Simons LE. Measuring Clinically Meaningful Change in Outcomes for Youth With Chronic Pain Following Graded Exposure Treatment. Clin J Pain 2022; 38:334-342. [PMID: 35276700 PMCID: PMC9012214 DOI: 10.1097/ajp.0000000000001031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 02/11/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Functional improvement is a critical outcome for individuals living with chronic pain. Graded exposure treatment (GET) has been associated with statistically significant improvements in functional outcomes for youth with chronic pain by targeting pain-related fear and avoidance. OBJECTIVE The aim of the present study was to explore clinically meaningful change in outcomes in adolescents with chronic pain following participation in a GET, and to then classify patients as treatment responders versus nonresponders. MATERIALS AND METHODS Participants included 27 youth (Mage=13.5) with chronic pain enrolled in a recently published single-arm randomized baseline trial of GET Living. Reliable change at the individual level was assessed using the Reliable Change Index (RCI). Adolescents were classified as treatment responders if they achieved a reliable change in outcomes across time points and also demonstrated a change in clinical severity range in the expected direction (ie, from severe to moderate). RESULTS Reliable and clinically significant improvements in pain-related fear and avoidance, functional disability, and school functioning were demonstrated at discharge, with improvements maintained at 3-month and 6-month follow-up. Among core outcomes, 48% (n=13) of patients were classified as treatment responders in one or more outcomes at discharge, with this increasing to 76% (n=19) at 3-month follow-up. DISCUSSION Examining reliable and clinically meaningful change (vs. statistical significance alone) provides a way to examine treatment response to an intervention and to enhance the interpretability of findings, helping to bridge the gap between clinical trials and clinical practice by providing guidelines for interpretation.
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Affiliation(s)
- Lauren E. Harrison
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Lauren C. Heathcote
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA
- Health Psychology Section, Institute of Psychiatry Psychology and Neuroscience, King’s College London, London
| | - Zeena Khazendar
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Patricia A. Richardson
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA
- Departments of Pediatric Psychology and Pediatric Pain and Palliative Medicine, Helen DeVos Children’s Hospital, Grand Rapids
- Department of Pediatrics and Human Development, Michigan State University College of Human Medicine, East Lansing, MI
| | - Laura E. Simons
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA
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14
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Leake HB, Moseley GL. Clinimetrics: Assessing functional disability in children and adolescents. J Physiother 2021; 67:145. [PMID: 32861612 DOI: 10.1016/j.jphys.2020.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 06/29/2020] [Accepted: 07/22/2020] [Indexed: 11/25/2022] Open
Affiliation(s)
- Hayley B Leake
- IIMPACT in Health, University of South Australia, Adelaide, Australia, Australia; Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia
| | - G Lorimer Moseley
- IIMPACT in Health, University of South Australia, Adelaide, Australia, Australia
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15
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Griffin A, Wilson L, Feinstein AB, Bortz A, Heirich MS, Gilkerson R, Wagner JF, Menendez M, Caruso TJ, Rodriguez S, Naidu S, Golianu B, Simons LE. Virtual Reality in Pain Rehabilitation for Youth With Chronic Pain: Pilot Feasibility Study. JMIR Rehabil Assist Technol 2020; 7:e22620. [PMID: 33226346 PMCID: PMC7721555 DOI: 10.2196/22620] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 09/02/2020] [Accepted: 10/29/2020] [Indexed: 12/16/2022] Open
Abstract
Background In the field of pain, virtual reality (VR) technology has been increasingly common in the context of procedural pain management. As an interactive technology tool, VR has the potential to be extended beyond acute pain management to chronic pain rehabilitation with a focus on increasing engagement with painful or avoided movements. Objective We outline the development and initial implementation of a VR program in pain rehabilitation intervention to enhance function in youth with chronic pain. Methods We present the development, acceptability, feasibility, and utility of an innovative VR program (Fruity Feet) for pediatric pain rehabilitation to facilitate increased upper and lower extremity engagement. The development team was an interdisciplinary group of pediatric experts, including physical therapists, occupational therapists, pain psychologists, anesthesiologists, pain researchers, and a VR software developer. We used a 4-phase iterative development process that engaged clinicians, parents, and patients via interviews and standardized questionnaires. Results This study included 17 pediatric patients (13 female, 4 male) enrolled in an intensive interdisciplinary pain treatment (IIPT) program, with mean age of 13.24 (range 7-17) years, completing a total of 63 VR sessions. Overall reports of presence were high (mean 28.98; max 40; SD 4.02), suggestive of a high level of immersion. Among those with multisession data (n=8), reports of pain (P<.001), fear (P=.003), avoidance (P=.004), and functional limitations (P=.01) significantly decreased. Qualitative analysis revealed (1) a positive experience with VR (eg, enjoyed VR, would like to utilize the VR program again, felt VR was a helpful tool); (2) feeling distracted from pain while engaged in VR; (3) greater perceived mobility; and (4) fewer clinician-observed pain behaviors during VR. Movement data support the targeted impact of the Fruity Feet compared to other available VR programs. Conclusions The iterative development process yielded a highly engaging and feasible VR program based on qualitative feedback, questionnaires, and movement data. We discuss next steps for the refinement, implementation, and assessment of impact of VR on chronic pain rehabilitation. VR holds great promise as a tool to facilitate therapeutic gains in chronic pain rehabilitation in a manner that is highly reinforcing and fun.
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Affiliation(s)
- Anya Griffin
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Luke Wilson
- Mighty Immersion, Inc., New York, NY, United States
| | - Amanda B Feinstein
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Adeline Bortz
- PGSP-Stanford University Psy.D. Consortium, Stanford, CA, United States
| | - Marissa S Heirich
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | | | - Jenny Fm Wagner
- Lucile Packard Children's Hospital, Stanford, CA, United States
| | - Maria Menendez
- Lucile Packard Children's Hospital, Stanford, CA, United States
| | - Thomas J Caruso
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Samuel Rodriguez
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Srinivas Naidu
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Brenda Golianu
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Laura E Simons
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, United States
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16
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Richardson PA, Harrison LE, Heathcote LC, Rush G, Shear D, Lalloo C, Hood K, Wicksell RK, Stinson J, Simons LE. mHealth for pediatric chronic pain: state of the art and future directions. Expert Rev Neurother 2020; 20:1177-1187. [PMID: 32881587 PMCID: PMC7657989 DOI: 10.1080/14737175.2020.1819792] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 09/02/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Chronic pain conditions are common among children and engender cascading effects across social, emotional, and behavioral domains for the child and family. Mobile health (mHealth) describes the practice of delivering healthcare via mobile devices and may be an ideal solution to increase access and reach of evidence-based behavioral health interventions. AREAS COVERED The aim of this narrative review is to present a state-of-the-art overview of evidence-based mHealth efforts within the field of pediatric chronic pain and consider new and promising directions for study. Given the nascent nature of the field, published mHealth interventions in all stages of development are discussed. Literature was identified through a non-systematic search in PubMed and Google Scholar, and a review of reference lists of papers that were identified as particularly relevant or foundational (within and outside of the chronic pain literature). EXPERT OPINION mHealth is a promising interventional modality with early evidence suggesting it is primed to enhance behavioral health delivery and patient outcomes. There are many exciting future directions to be explored including drawing inspiration from digital health technology to generate new ways of thinking about the optimal treatment of pediatric chronic pain.
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Affiliation(s)
- Patricia A. Richardson
- Departments of Pediatric Psychology and Pediatric Pain and Palliative Medicine, Helen DeVos Children’s Hospital, Grand Rapids, MI, USA
- Department of Pediatrics and Human Development, Michigan State University College of Human Medicine, East Lansing, MI, USA
| | - Lauren E. Harrison
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Lauren C. Heathcote
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Gillian Rush
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Deborah Shear
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Chitra Lalloo
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Canada
- Institute for Health Policy, Management & Evaluation, University of Toronto, Toronto, Canada
| | - Korey Hood
- Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Rikard K. Wicksell
- Department of Clinical Neuroscience, Division for Psychology, Karolinska Institutet, Stockholm, Sweden
| | - Jennifer Stinson
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Canada
- Lawrence S. Bloomberg, Faculty of Nursing, The University of Toronto, Toronto, Canada
| | - Laura E. Simons
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
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