Treatment expectations for CAM interventions in pediatric chronic pain patients and their parents

A cognitive-behavioral digital health intervention for sickle cell disease pain in adolescents: a randomized, controlled, multicenter trial

ABSTRACT

Severe acute and chronic pain are the most common complications of sickle cell disease (SCD). Pain results in disability, psychosocial distress, repeated clinic visits/hospitalizations, and significant healthcare costs. Psychosocial pain interventions that teach cognitive and behavioral strategies for managing pain have been effective in other adolescent populations when delivered in person or through digital technologies. Our aim was to conduct a multisite, randomized, controlled trial to improve pain and coping in youth aged 12 to 18 years with SCD using a digital cognitive-behavioral therapy program (iCanCope with Sickle Cell Disease; iCC-SCD) vs Education control. We enrolled 137 participants (ages 12-18 years, 59% female) and analyzed 111 adolescents (107 caregivers), 54 randomized to Education control and 57 randomized to iCC-SCD. Ninety-two percent of youth completed posttreatment assessments and 88% completed 6-month follow-up. There was a significant effect of treatment group (iCC-SCD vs Education) on reduction in average pain intensity from baseline to 6-month follow-up (b = -1.32, P = 0.009, 95% CI [-2.29, -0.34], d = 0.50), and for the number of days with pain, adolescents in the iCC-SCD group demonstrated fewer pain days compared with the Education group at 6-month follow-up (incident rate ratio = 0.63, P = 0.006, 95% CI [0.30, 0.95], d = 0.53). Treatment effects were also found for coping attempts, momentary mood, and fatigue. Several secondary outcomes did not change with intervention, including anxiety, depression, pain interference, and global impression of change. Future studies are needed to identify effective implementation strategies to bring evidence-based cognitive-behavioral therapy for sickle cell pain to SCD clinics and communities.

Internet-delivered cognitive behavioral therapy for youth with functional abdominal pain: a randomized clinical trial testing differential efficacy by patient subgroup

ABSTRACT

Inconsistent results of psychological treatments for pediatric functional abdominal pain (FAP) may be due to heterogeneity of patients' pain-related psychological characteristics. This randomized controlled trial tested whether statistically derived patient subgroups (high pain dysfunctional [HPD], high pain adaptive [HPA], and low pain adaptive [LPA]) moderated response to cognitive behavior therapy (CBT) for adolescents with FAP and their parents (n = 278 dyads; patients were 66% female, mean [SD] age was 14.62 [1.88] years, and parents were 95% female). Randomization to Internet-delivered CBT vs Internet-delivered pain education (EDU) was stratified by patient subgroup. Follow-up assessments of gastrointestinal (GI) symptoms (primary outcome), abdominal pain, and pain interference were at midtreatment, posttreatment, 6 months, and 12 months. Data were analysed using linear mixed effects models. Significant treatment × subgroup × time interaction effects showed that patient subgroup significantly moderated the effect of treatment on GI symptoms (t[853 = -2.93, P = 0.003) and abdominal pain (t(844) = -2.14, P = 0.03) across the treatment period. Among HPD youth, those in CBT had significantly greater GI symptom reduction than those in EDU through posttreatment. By contrast, among HPA and LPA youth, symptom improvement did not differ by treatment condition. Furthermore, among all patients assigned to CBT, HPD youth demonstrated significantly greater reductions in GI symptoms compared with HPA and LPA youth and greater reductions in abdominal pain compared with LPA youth. All subgroups maintained symptom reductions throughout the follow-up period. Results suggest that subgrouping FAP patients may inform treatment allocation and optimize treatment response.

The Use of Yoga as a Group Intervention for Pediatric Chronic Pain Rehabilitation: Exploring Qualitative and Quantitative Outcomes

Purpose:

With the increase in opioid use over the last decade, mind–body approaches to pediatric pain management have been trending. To date, there is limited research regarding the use of yoga with pediatric chronic pain. This study aims to gauge the effectiveness of group yoga as part of chronic pain rehabilitation and one's ability to continue practicing independently by exploring qualitative and quantitative information.

Methods:

A single therapist used yoga as a group physical therapy intervention once a week for 60 minutes. Yoga education, iyengar yoga components, relaxation, and stretching were incorporated into the therapeutic yoga session. Qualitative and quantitative information was collected.

Results:

Qualitative outcomes provided valuable data about distractions and benefits. Quantitative outcomes showed that there were significant improvements in areas such as mental tension, emotional tension, muscle tension, and pain (all P < 0.001 significant).

Conclusion:

Pediatric chronic pain patients can identify many benefits after a single group yoga session. It combines the physical and cognitive aspects of interdisciplinary pain rehabilitation for continued use after discharge. The use of yoga is an economical means of physical activity after discharge to promote long-term benefits.

Web-based cognitive-behavioral intervention for pain in pediatric acute recurrent and chronic pancreatitis: Protocol of a multicenter randomized controlled trial from the study of chronic pancreatitis, diabetes and pancreatic cancer (CPDPC)

INTRODUCTION

Abdominal pain is common and is associated with high disease burden and health care costs in pediatric acute recurrent and chronic pancreatitis (ARP/CP). Despite the strong central component of pain in ARP/CP and the efficacy of psychological therapies for other centralized pain syndromes, no studies have evaluated psychological pain interventions in children with ARP/CP. The current trial seeks to 1) evaluate the efficacy of a psychological pain intervention for pediatric ARP/CP, and 2) examine baseline patient-specific genetic, clinical, and psychosocial characteristics that may predict or moderate treatment response.

METHODS

This single-blinded randomized placebo-controlled multicenter trial aims to enroll 260 youth (ages 10-18) with ARP/CP and their parents from twenty-one INSPPIRE (INternational Study Group of Pediatric Pancreatitis: In search for a cuRE) centers. Participants will be randomly assigned to either a web-based cognitive behavioral pain management intervention (Web-based Management of Adolescent Pain Chronic Pancreatitis; WebMAP; N = 130) or to a web-based pain education program (WebED; N = 130). Assessments will be completed at baseline (T1), immediately after completion of the intervention (T2) and at 6 months post-intervention (T3). The primary study outcome is abdominal pain severity. Secondary outcomes include pain-related disability, pain interference, health-related quality of life, emotional distress, impact of pain, opioid use, and healthcare utilization.

CONCLUSIONS

This is the first clinical trial to evaluate the efficacy of a psychological pain intervention for children with CP for reduction of abdominal pain and improvement of health-related quality of life. Findings will inform delivery of web-based pain management and potentially identify patient-specific biological and psychosocial factors associated with favorable response to therapy. Clinical Trial Registration #: NCT03707431.

iCanCope with Sickle Cell Pain: Design of a randomized controlled trial of a smartphone and web-based pain self-management program for youth with sickle cell disease

Many adolescents with sickle cell disease (SCD) experience recurrent and chronic pain, which has a negative impact on their health-related quality of life (HRQL). Cognitive-behavioral therapy (CBT) interventions can lead to improvement in pain and HRQL, yet due to barriers to care, most youth with SCD will not receive these interventions. To address this need for innovative programs targeting youth with SCD pain, we developed iCanCope, a tailored smartphone and web-based program that delivers a pain self-management intervention to youth with SCD. We describe the rationale, design, and implementation of a three-site parallel group randomized controlled trial with a sample of 160 adolescents with SCD and their parent caregivers. The iCanCope program includes pain self-management skills training (personalized CBT-based coping skills such as deep breathing, relaxation, and cognitive skills), goal setting, and social support. The attention control group is provided with access to a self-guided website with education about SCD. Assessments will occur at baseline (T1), immediately after completion of the intervention (12 weeks; T2) and at 6 months post-intervention (T3). Primary outcomes include coping strategies and pain intensity; secondary outcomes include physical, social, and emotional functioning, treatment satisfaction, health service use and caregiver response to youth pain behavior. Potential mediators (goal setting, self-management, and perceptions of social support) and moderators (e.g., demographic factors) will also be tested. The objective is to offer an effective, convenient, and low-cost psychosocial intervention to youth with SCD to enhance their self-management of pain.

Efficacy of Self-hypnosis on Quality of Life For Children with Chronic Pain Syndrome

The aim of this study was to assess the efficacy of self-hypnosis in a therapeutic education program (TEP) for the management of chronic pain in 26 children aged 7 to 17 years. Outcomes of the study were a total or a partial (at least 1) achievement of the therapeutic goals (pain, quality of sleeping, schooling, and functional activity). Sixteen patients decreased their pain intensity, 10 reached all of their therapeutic goals, and 9 reached them partially. Self-hypnosis was the only component of the TEP associated with these improvements. The current study supports the efficacy of self-hypnosis in our TEP program for chronic pain management in children.

Chronic Pain in Children: A Look at the Referral Process to a Pediatric Pain Clinic

We reviewed the referral pattern of children with chronic pain to a specialized pediatric pain clinic. Data were obtained from referring physicians and medical records and during an interview with patients and their parents by physicians and a psychologist. We analyzed the following: referral diagnosis, demographics, duration of symptoms, number of physicians previously consulted, school attendance, sports activities, presence of psychological disorders, final team diagnosis, and outcomes. Children had been experiencing pain for 34 ± 55 months. Patients had consulted on average 3 physicians in addition to their pediatrician. 32% of the patients had missed at least 10 days of school in a calendar year, and 47% had stopped playing sports. 15% had an operation because of pain that had been unsuccessful. The most common missed diagnosis was anxiety (25%) and depression (13%). 69% of the patients were back to school and/or playing sports within 4 months from our initial consultation. 32% of the patients did not make any progress during the follow-up period. The most common reasons for failure to improve were no compliance with the recommended treatments and poorly controlled major mood disorder. The time to refer children with chronic pain for specialized care could be extremely long causing significant social and psychological consequence.

Internet-delivered cognitive-behavioral treatment for adolescents with chronic pain and their parents: a randomized controlled multicenter trial

Internet-delivered interventions are emerging as a strategy to address barriers to care for individuals with chronic pain. This is the first large multicenter randomized controlled trial of Internet-delivered cognitive-behavioral therapy (CBT) for pediatric chronic pain. Participants included were 273 adolescents (205 females and 68 males), aged 11 to 17 years with mixed chronic pain conditions and their parents, who were randomly assigned in a parallel-group design to Internet-delivered CBT (n = 138) or Internet-delivered Education (n = 135). Assessments were completed before treatment, immediately after treatment, and at 6-month follow-up. All data collection and procedures took place online. The primary analysis used linear growth models. Results demonstrated significantly greater reduction on the primary outcome of activity limitations from baseline to 6-month follow-up for Internet CBT compared with Internet education (b = -1.13, P = 0.03). On secondary outcomes, significant beneficial effects of Internet CBT were found on sleep quality (b = 0.14, P = 0.04), on reducing parent miscarried helping (b = -2.66, P = 0.007) and protective behaviors (b = -0.19, P = 0.001), and on treatment satisfaction (P values < 0.05). On exploratory outcomes, benefits of Internet CBT were found for parent-perceived impact (ie, reductions in depression, anxiety, self-blame about their adolescent's pain, and improvement in parent behavioral responses to pain). In conclusion, our Internet-delivered CBT intervention produced a number of beneficial effects on adolescent and parent outcomes, and could ultimately lead to wide dissemination of evidence-based psychological pain treatment for youth and their families.

Patients' expectations of osteopathic care: a qualitative study

BACKGROUND

Research has shown that patients' expectations of health care and health-care practitioners are complex and may have a significant impact on outcomes of care. Little is known about the expectations of osteopathic patients.

OBJECTIVES

To explore osteopathic patients' expectations of private sector care.

DESIGN

Focus groups and individual interviews with purposively selected patients; this was the qualitative phase of a mixed methods study, the final phase being a patient survey.

SETTING AND PARTICIPANTS

A total of 34 adult patients currently attending for treatment at private osteopathic practices across the United Kingdom.

INTERVENTION

Focus group discussions and individual interviews around expectations before, during and after osteopathic care.

OUTCOME MEASURES

Thematic analysis of text data to identify topics raised by patients and to group these into broad themes.

RESULTS

Many components of expectation were identified. A preliminary conceptual framework describing the way the therapeutic encounter is approached in osteopathy comprised five themes: individual agency, professional expertise, customer experience, therapeutic process and interpersonal relationship.

DISCUSSION AND CONCLUSION

The components of expectation identified in this phase of the study provided potential question topics for the survey questionnaire in the subsequent phase of the investigation. The model developed in this study may add a new perspective to existing evidence on expectations. Further research is recommended to test the findings both within private practice and the National Health Service.

Integrative Therapy Use for Management of Side Effects and Toxicities Experienced by Pediatric Oncology Patients

Integrative Therapies (IT), otherwise known as Complementary and Alternative Medicine, are widely used among pediatric oncology patients, despite a paucity of available evidence. This review summarizes surveys that describe the prevalence of IT use by pediatric oncology patients, both during therapy and in survivorship, as well as the modalities being used. Additionally, the evidence that exists for specific treatments that appear to be efficacious in controlling specific symptoms is described. Finally, there are recommendations for practitioners on how to best counsel patients about IT use.

Treatment expectations among adolescents with chronic musculoskeletal pain and their parents before an initial pain clinic evaluation

OBJECTIVES

To understand expectations regarding treatment recommendations among treatment-seeking adolescents with chronic musculoskeletal pain and their parents.

METHODS

A total of 102 adolescent-parent dyads were recruited at the time of initial contact with a multidisciplinary pain management clinic. Each participant completed reports of adolescent pain intensity and disability, biopsychosocial perspective of pain, and treatment expectations related to recommendations and feedback for a vignette description of an adolescent presenting at an initial multidisciplinary pain clinic evaluation.

RESULTS

Descriptive findings for individual treatment expectations and adolescent-parent dyad agreement statistics were examined. Slight to fair levels of agreement occurred for 50% of the expectations assessed. The strongest shared expectations were for recommendations to return to school, pursue psychological counseling, and pursue PT/OT treatment. Stronger agreement occurred for items reflecting alternative, emotional, behavioral, and activity recommendations with weaker agreement for medical interventions (eg, medication and surgery). Correlations emerged between individual expectations and adolescent pain intensity, disability, with the greatest number of significant relationships found for adolescent and parent expectations and biopsychosocial perspectives of pain.

DISCUSSION

Our results document that adolescents and parents show modest levels of agreement on expectations for treatment at the time of an initial pain clinic evaluation. This may relate to expectations being internal perspectives not clearly expressed within families; thus, the initial treatment consultation may provide an important opportunity to create and align appropriate expectations. Implications of our findings are considered with respect to education, treatment, and future research to understand factors that contribute to treatment adherence and outcomes.

Iyengar yoga and the use of props for pediatric chronic pain: a case study

Iyengar yoga uses postures and props to support the body so that practitioners can engage in poses that would otherwise be more difficult. This type of yoga may be useful in treating children and adolescents who have chronic pain and disability. In this case study, the authors discuss a 14-y-old girl who had two surgeries for gastro-esophageal reflux disease (GERD) and who had continued chest and abdominal pain, as well as vomiting, difficulty eating, weight loss, and anxiety. Having significantly impaired functioning, she was unable to attend school, sleep, socialize, or eat, and she had become wheelchair-bound. Despite evaluations and treatments by specialists over an extended period of time, her symptoms had not improved. This case history describes how the authors used a 4-mo treatment of Iyengar yoga to help the adolescent resume activities and re-engage with her environment. The authors intend this report to stimulate scientific study of this form of treatment for children and adolescents with chronic pain.

Patients' expectations of private osteopathic care in the UK: a national survey of patients

Background

Patients’ expectations of osteopathic care have been little researched. The aim of this study was to quantify the most important expectations of patients in private UK osteopathic practices, and the extent to which those expectations were met or unmet.

Methods

The study involved development and application of a questionnaire about patients’ expectations of osteopathic care. The questionnaire drew on an extensive review of the literature and the findings of a prior qualitative study involving focus groups exploring the expectations of osteopathic patients. A questionnaire survey of osteopathic patients in the UK was then conducted. Patients were recruited from a random sample of 800 registered osteopaths in private practice across the UK. Patients were asked to complete the questionnaire which asked about 51 aspects of expectation, and post it to the researchers for analysis.

The main outcome measures were the patients-perceived level of expectation as assessed by the percentage of positive responses for each aspect of expectation, and unmet expectation as computed from the proportion responding that their expectation “did not happen”.

Results

1649 sets of patient data were included in the analysis. Thirty five (69%) of the 51 aspects of expectation were prevalent, with listening, respect and information-giving ranking highest. Only 11 expectations were unmet, the most often unmet were to be made aware that there was a complaints procedure, to find it difficult to pay for osteopathic treatment, and perceiving a lack of communication between the osteopath and their GP.

Conclusions

The findings reflected the complexity of providing osteopathic care and meeting patients’ expectations. The results provided a generally positive message about private osteopathic practice. The study identified certain gaps between expectations and delivery of care, which can be used to improve the quality of care. The questionnaire is a resource for future research.

Yoga for youth in pain: the UCLA pediatric pain program model

Children, adolescents, and young adults do not typically feature in clinics, studies, and mainstream notions of chronic pain. Yet many young people experience debilitating pain for extended periods of time. Chronic pain in these formative years may be especially important to treat in order for young patients to maintain life tasks and to prevent protracted disability. The Pediatric Pain Program at the University of California, Los Angeles, is a multidisciplinary treatment program designed for young people with chronic pain and their families. We offer both conventional and complementary medicine to treat the whole individual. This article describes the work undertaken in the clinic and our newly developed Yoga for Youth Research Program. The clinical and research programs fill a critical need to provide service to youth with chronic pain and to scientifically study one of the more popular complementary treatments we offer, Iyengar yoga.

The efficacy of acupuncture and decompression splints in the treatment of temporomandibular joint pain-dysfunction syndrome

OBJECTIVES

The goal of the present study was to evaluate the results of applying acupuncture or occlusal decompression splints in the treatment of patients diagnosed with the temporomandibular joint pain-dysfunction syndrome.

DESIGN OF THE STUDY

We conducted a randomized clinical trial including 20 patients to whom the mentioned treatments were applied. Results were evaluated through an analogue pain scale, measurements of mouth opening and jaw lateral deviation in millimetres, and assessment of sensitivity to pressure on different points: preauricular, masseter muscle, temporal muscle and trapezius. Parameters were evaluated before and 30 days after the treatment. For standardized pressure, we used a pressure algometer.

RESULTS

Patients treated with decompression splints showed reductions in subjective pain and pain upon pressure on temporal, masseter and trapezius muscles, as well as increased mouth opening after the treatment. Patients treated with acupuncture showed pain reduction in the short term and improvements in all of the evaluated para-meters (stronger pressure was required to produce pain; mouth opening was improved).

CONCLUSION

Acupuncture was an effective complement and/or an acceptable alternative to decompression splints in the treatment of myofascial pain and temporomandibular joint pain-dysfunction syndrome.

Parents' initial perceptions of multidisciplinary care for pediatric chronic pain

Chronic and recurrent pain is experienced by many children and adolescents. Treatment of chronic pain using a multidisciplinary approach has been found to be effective for treatment of chronic pain. Parent satisfaction with treatment and treatment providers highly correlates to children's treatment adherence. Parents of children treated at a multidisciplinary chronic pain clinic were interviewed following their initial appointment. Parents reported high satisfaction with treatment team members and with the treatment plan. Parents also reported appreciation of multidisciplinary structure, the high level of expertise of the team members, and the team members' genuine interest in treating their children. This increase in satisfaction when compared to previous treatment is important since increases in satisfaction may correlate with a reduction in experiences of chronic pain. Parents reported high satisfaction with interactions with treatment team members and with the treatment plan provided for their children. Parents had appreciation of multidisciplinary team structure and the high level of expertise of the team members. This increase in satisfaction when compared to treatment from previous providers is important since increases in satisfaction may correlate with an increase in children's treatment adherence and a reduction in experiences of chronic pain.

Measurement properties of questionnaires assessing complementary and alternative medicine use in pediatrics: a systematic review

Objective

Complementary and alternative medicine (CAM) is commonly used by children, but estimates of that use vary widely partly due to the range of questionnaires used to assess CAM use. However, no studies have attempted to appraise measurement properties of these questionnaires. The aim of this systematic review was to critically appraise and summarize measurement properties of questionnaires of CAM use in pediatrics.

Study design

A search strategy was implemented in major electronic databases in March 2011 and conference websites, scientific journals and experts were consulted. Studies were included if they mentioned a questionnaire assessing the prevalence of CAM use in pediatrics. Members of the team independently rated the methodological quality of the studies (using the COSMIN checklist) and measurement properties of the questionnaires (using the Terwee and Cohen criteria).

Results

A total of 96 CAM questionnaires were found in 104 publications. The COSMIN checklist showed that no studies reported adequate methodological quality. The Terwee criteria showed that all included CAM questionnaires had indeterminate measurement properties. According to the Cohen score, none were considered to be a well-established assessment, two approached the level of a well-established assessment, seven were promising assessments and the remainder (n = 87) did not reach the score’s minimum standards.

Conclusion

None of the identified CAM questionnaires have been thoroughly validated. This systematic review highlights the need for proper validation of CAM questionnaires in pediatrics, which may in turn lead to improved research and knowledge translation about CAM in clinical practice.

Thermographical measuring of the skin temperature using laser needle acupuncture in preterm neonates

In children, laser acupuncture is used more often than needle acupuncture in Western countries, due to their aversion to needles. When applying laser acupuncture to premature babies and neonates, firstly the degree of the thermal increase to the skin has to be evaluated so as to guarantee safe application. The patients were premature neonates before their discharge from hospital. The measurements were carried out by means of a polygraphy while they were asleep shortly. The large intestine 4 acupoint (LI4, Hegu) was stimulated by a microlaser needle (10 mW, 685 nm) twice (5 and 10 min). Local thermographic pictures were taken with a thermal camera (Flir i5, Flir Systems Inc., Portland, USA), and the warmest point was determined and subsequently compared. The study included 10 premature neonates (7 male, 3 female). The measurements were carried out on the 33rd day of life (weight 2030 g, gestational age 36 + 3 weeks of pregnancy). In comparison to the initial temperature (32.9°C), after 5 minutes of stimulation (33.9°C) (P = 0.025) and also after 10 minutes of stimulation (34.0°C) (P = 0.01), there was found to be a significant increase in the skin temperature. The singular maximum value of 37.9°C bears a potential danger; however, compared to the local temperatures reached in transcutaneous blood gas measurements it appears not to entail any risks.

Adolescents' pain coping profiles: expectations for treatment, functional outcomes and adherence to psychological treatment recommendations

OBJECTIVES

To explore how adolescents' pain coping profiles relate to their expectations regarding psychological treatment recommendations, and to examine patients' functioning and engagement in psychological treatment three months following a multidisciplinary pain clinic evaluation.

METHODS

Adolescents and their parents completed measures of pain coping strategies, treatment expectations, pain ratings, somatic symptoms, school absences and functional disability. Parents also reported whether patients followed through with psychological treatment recommendations.

RESULTS

Adaptive copers and their parents were more likely to expect psychological treatments to be helpful; however, at follow-up, there were no significant group differences in patients' participation in psychological treatment. Patients in both groups experienced significantly lower levels of somatic symptoms and functional disability, and had fewer school absences from the initial evaluation to the follow-up.

DISCUSSION

The results of the present study identify preliminary clinical implications for the way in which practitioners in multidisciplinary pain clinics present recommendations for psychological treatment to patients and their families.

Treatment Preferences for CAM in children with chronic pain

CAM therapies have become increasingly popular in pediatric populations. Yet, little is known about children's preferences for CAM. This study examined treatment preferences in chronic pediatric pain patients offered a choice of CAM therapies for their pain. Participants were 129 children (94 girls) (mean age = 14.5 years ± 2.4; range = 8–18 years) presenting at a multidisciplinary, tertiary clinic specializing in pediatric chronic pain. Bivariate and multivariate analyses were used to examine the relationships between CAM treatment preferences and patient's sociodemographic and clinical characteristics, as well as their self-reported level of functioning. Over 60% of patients elected to try at least one CAM approach for pain. The most popular CAM therapies were biofeedback, yoga and hypnosis; the least popular were art therapy and energy healing, with craniosacral, acupuncture and massage being intermediate. Patients with a diagnosis of fibromyalgia (80%) were the most likely to try CAM versus those with other pain diagnoses. In multivariate analyses, pain duration emerged as a significant predictor of CAM preferences. For mind-based approaches (i.e. hypnosis, biofeedback and art therapy), pain duration and limitations in family activities were both significant predictors. When given a choice of CAM therapies, this sample of children with chronic pain, irrespective of pain diagnosis, preferred non-invasive approaches that enhanced relaxation and increased somatic control. Longer duration of pain and greater impairment in functioning, particularly during family activities increased the likelihood that such patients agreed to engage in CAM treatments, especially those that were categorized as mind-based modalities.

Patterns and predictors of health service utilization in adolescents with pain: comparison between a community and a clinical pain sample

There is limited research describing the patterns of healthcare utilization in adolescents with chronic pain. This study describes healthcare utilization in a clinical chronic pain sample, and compares the patterns of service use of this group to a community sample with intermittent pain complaints. We also investigated demographic and clinical factors that predicted healthcare visits and medication use in the clinical sample. Data on 117 adolescents (aged 12-18; n = 59 clinical pain sample, n = 58 community) were collected. Caregivers and adolescents reported on sociodemographics, medical visits, current medications, pain, activity limitations, and depression. As hypothesized, the clinical pain sample had higher rates of healthcare consultation on all types of medical visits (general, specialty care, complementary medicine, mental health, OT/PT), and higher medication use compared to the community sample. Regression analyses revealed that higher annual income, greater pain frequency, and higher levels of caregiver-reported activity limitations were associated with a greater number of healthcare visits for the total sample. Within the clinical pain sample, higher pain frequency and greater activity limitations (caregiver report) predicted more specialty care visits. Additionally, higher income and greater levels of depressive symptoms predicted a higher number of prescribed medications.

PERSPECTIVE

This study contributes to the limited available data on health service and medication use in a clinical chronic pain sample versus a community sample of adolescents. We also identify clinical factors (pain frequency, parent-reported activity limitations, depressive symptoms) and demographic factors (gender, income) associated with healthcare utilization.

Associations between parent and child pain and functioning in a pediatric chronic pain sample: A mixed methods approach

This study employed a mixed-method design to test sex-specific parent-child pain associations. Subjects were 179 chronic pain patients aged 11-19 years (mean = 14.34; 72% female) presenting for treatment at a multidisciplinary, tertiary clinic. Mothers and children completed questionnaires prior to their clinic visit, including measures of children's pain, functioning and psychological characteristics. Mothers also reported on their own pain and psychological functioning. Interviews were conducted with a sub-sample of 34 mothers and children prior to the clinic visit and analyzed using a grounded theory approach. The quantitative data suggest stronger mother-daughter than mother-son pain relationships. The qualitative data suggest that girls' pain and pain-related disability is related to an overly enmeshed mother-daughter relationship and the presence of maternal models of pain, while boys' pain and disability is linked to male pain models and criticism and to maternal worry and solicitousness. Boys and girls appear to have developmentally incongruous levels of autonomy and conformity to maternal expectations. The mixed-method data suggest distinct trajectories through which mother and father involvement may be linked to chronic pain in adolescent boys and girls.

What do the parents of children who have chronic pain expect from their first visit to a pediatric chronic pain clinic?

BACKGROUND

Chronic pain in childhood is increasingly recognized as a significant clinical problem. Best-practice management of pediatric chronic pain in a multidisciplinary pain clinic involves a variety of treatment modalities. It is important that parents of children treated in these settings understand the different treatment options available for their children. By involving parents more effectively, care providers may more efficiently address unmet treatment needs and improve tailoring of treatment programs aimed at increasing function, reducing pain-related disability and improving quality of life.

OBJECTIVES

To explore the expectations held by parents for their first visit to a pediatric multidisciplinary pain clinic.

METHODS

Fourteen parents completed a paper-based survey exploring their expectations immediately before their first visit to a multidisciplinary pediatric pain clinic in a tertiary care children's hospital.

RESULTS

Responses from parents suggest a clear desire for information about the causes of their child's pain, treatment options available at the pain clinic, effective strategies to enhance children's ability to cope with pain, and the effects of pain on both body and mood. Most parents rated the various treatment options as important for their child. All parents indicated it was very important to have the pain team 'be there' for them.

CONCLUSIONS

These findings indicate that parents want more information about chronic pain and treatment options. Pediatric chronic pain clinics have the ability to assist children with chronic pain and their families considerably by providing information about chronic pain and the various treatment options available to them.

Yoga as a complementary therapy for children and adolescents: a guide for clinicians

Yoga is being used by a growing number of youth and adults as a means of improving overall health and fitness. There is also a progressive trend toward use of yoga as a mind-body complementary and alternative medicine intervention to improve specific physical and mental health conditions. To provide clinicians with therapeutically useful information about yoga, the evidence evaluating yoga as an effective intervention for children and adolescents with health problems is reviewed and summarized. A brief overview of yoga and yoga therapy is presented along with yoga resources and practical strategies for clinical practitioners to use with their patients. The majority of available studies with children and adolescents suggest benefits to using yoga as a therapeutic intervention and show very few adverse effects. These results must be interpreted as preliminary findings because many of the studies have methodological limitations that prevent strong conclusions from being drawn. Yoga appears promising as a complementary therapy for children and adolescents. Further information about how to apply it most effectively and more coordinated research efforts are needed.

Engagement in multidisciplinary interventions for pediatric chronic pain: parental expectations, barriers, and child outcomes

OBJECTIVES

To examine the adherence to the recommendations of pain treatment among children and adolescents evaluated for a variety of chronic and recurrent pain conditions.

METHODS

Several measures during initial evaluation and after 3 months were collected to assess satisfaction with initial evaluation, adherence to multidisciplinary recommendations, pain ratings, somatic symptoms, functional limitations, and school attendance.

RESULTS

Of the 120 patients who initially enrolled in the study, 70 parents and 57 children participated in 3-month follow-up interviews and reported significantly fewer doctor visits, decreased somatic symptoms, fewer functional limitations, and decreased pain compared with their initial evaluation. Adherence to multidisciplinary recommendations ranged from 46.7% to 100% with the highest level of overall adherence to physical therapy. Factors associated with adherence varied across type of recommendation. For medical recommendations, higher parent-reported patient satisfaction and expectations that medical tests would be beneficial were associated with engagement in medical treatment, whereas parent reports of negative attitude-type barriers and experience with surgery were associated with less frequent engagement in recommended treatment. With regard to physical therapy recommendations, only earlier experience with exercise was associated with better adherence. For psychologic recommendations, familiarity with hypnosis and biofeedback in addition to positive expectations regarding psychologic treatment and biofeedback were all associated with subsequent engagement in psychologic treatment. Lastly, we identified modest associations between functional improvements and adherence to specific recommendations.

DISCUSSION

Results of this study support the importance of examining adherence to multidisciplinary interventions among children and adolescents with chronic pain.

Pediatric acupuncture: a review of clinical research

Practiced in China for more than 2000 years, acupuncture has recently gained increased attention in the United States as an alternative treatment approach for a variety of medical conditions. Despite its growing prevalence and anecdotal reports of success among pediatric populations, few empirically based studies have assessed the efficacy of acupuncture for children and adolescents. This article presents a review of the current literature, including a systematic appraisal of the methodological value of each study and a discussion of potential benefits and adverse effects of acupuncture. While acupuncture holds great promise as a treatment modality for diverse pediatric conditions, a significant amount of additional research is necessary to establish an empirical basis for the incorporation of acupuncture into standard care.

Audio-recorded guided imagery treatment reduces functional abdominal pain in children: a pilot study

OBJECTIVE

This study was designed to develop and to test a home-based, guided imagery treatment protocol, using audio and video recordings, that is easy for health care professionals and patients to use, is inexpensive, and is applicable to a wide range of health care settings.

METHODS

Thirty-four children, 6 to 15 years of age, with a physician diagnosis of functional abdominal pain were assigned randomly to receive 2 months of standard medical care with or without home-based, guided imagery treatment. Children who received only standard medical care initially received guided imagery treatment after 2 months. Children were monitored for 6 months after completion of guided imagery treatment.

RESULTS

All treatment materials were reported to be self-explanatory, enjoyable, and easy to understand and to use. The compliance rate was 98.5%. In an intention-to-treat analysis, 63.1% of children in the guided imagery treatment group were treatment responders, compared with 26.7% in the standard medical care-only group (P = .03; number needed to treat: 3). Per-protocol analysis showed similar results (73.3% vs 28.6% responders). When the children in the standard medical care group also received guided imagery treatment, 61.5% became treatment responders. Treatment effects were maintained for 6 months (62.5% responders).

CONCLUSION

Guided imagery treatment plus medical care was superior to standard medical care only for the treatment of abdominal pain, and treatment effects were sustained over a long period.

Parental attitudes toward acupuncture in a community sample

OBJECTIVES

The primary objective of this study was to investigate parental attitudes toward acupuncture for their child. No known research has explored how medical providers discuss acupuncture with families or specific concerns parents have about acupuncture. This study examined whether acupuncture attitudes were influenced by (1) the way acupuncture is explained to parents by a physician and (2) parental experience with acupuncture.

DESIGN

Parents (N = 240) read vignettes that varied in a 2 (Physician Description of Acupuncture: Traditional Chinese Medicine versus biomedical) x 2 (Gender: male versus female) design and responded to questions assessing their attitudes toward acupuncture.

RESULTS

A factor analysis of the vignette questions resulted in two factors: acupuncture acceptability (alpha = 0.88) and information seeking (alpha = 0.70). Previous experience with acupuncture significantly increased acupuncture acceptability and reduced interest in information seeking. Parents with experience were more likely to report wanting to pursue acupuncture for their child. A biomedical explanation led to increased acceptability and interest in pursuing information among parents with experience (d = 0.36), and significantly predicted parental agreement with the vignette item, "I would have my child receive acupuncture treatment." Common acupuncture concerns included fear of needles and acupuncture ineffectiveness.

CONCLUSIONS

Parents' experience with acupuncture, regardless of its perceived helpfulness, appears to play an important role in their consideration of acupuncture for their child. Additional research is needed to fully understand the importance of the way acupuncture is presented to families, as it appears to impact parental attitudes in subtle ways. Parents have numerous concerns regarding acupuncture. Our findings suggest that providers would benefit from increased awareness of families' interest in and use of complementary and alternative medicine so as to better monitor safety, provide advice, and discuss treatment expectations and misconceptions.

"I can't be what I want to be": children's narratives of chronic pain experiences and treatment outcomes

BACKGROUND

Chronic or recurrent nonmalignant pain is a significant problem for many children and adolescents and often limits the child's participation in normal physical, academic, and social activities.

OBJECTIVE

To better understand the impact of chronic or recurrent pain on children within the context of their own lives and experiences, using qualitative analysis, and to suggest the applications of the narrative method to clinical practice.

DESIGN

Grounded theory and narrative analysis of in-depth semi-structured interviews conducted at baseline and 6-12 months following clinic intake.

SETTING

Subject homes.

PATIENTS

Fifty-three children ages 10-17 presenting with recurrent pain to a university-based pain clinic. This sample did not differ significantly from the overall clinic population during the study period.

RESULTS

Five common themes were identified; these suggested that isolation, changed self-perception, activity limitations, concerns about barriers to future goals, and lack of medical validation were important to the children's perceived impact of pain on their lives. Five narratives were identified, each of which provided a coherent, integrated description of the factors and perspectives presented by a specific subset of children at baseline. These narratives were then compared against the children's reports of improvement in pain and functioning at 6-12 months; from this comparison, a sixth narrative of therapeutic change emerged for some of the children.

CONCLUSIONS

The authors suggest that physicians and parents who take the initiative to elicit the child's narrative can help the child to rewrite the story to promote therapeutic change, a better outcome, and higher satisfaction.

Sex differences in anxiety sensitivity among children with chronic pain and non-clinical children

Although sex differences in anxiety sensitivity or the specific tendency to fear anxiety-related sensations have been reported in adults with clinical pain, there is a dearth of relevant research among children. This study examined sex differences in anxiety sensitivity across unselected samples of 187 children with chronic pain (71.7% girls; mean age = 14.5) and 202 non-clinical children (52% girls; mean age = 13.6). Girls in the chronic pain and non-clinical samples reported elevated anxiety sensitivity relative to boys irrespective of clinical status. Girls with chronic pain also reported heightened fears of the physical consequences of anxiety compared to non-clinical girls but there were no such differences for psychological or social concerns. Among boys, anxiety sensitivity did not differ between the chronic pain and non-clinical groups. Future longitudinal research may examine whether specific fears of anxiety-related somatic sensations constitutes a sex-based vulnerability factor in the development of chronic pain.

"Just be in pain and just move on": Functioning limitations and strategies in the lives of children with chronic pain

This paper uses a mixed-methods approach to examine the impact of pain-associated functioning limitations on children's lives and the strategies they develop to try to continue functioning. Forty-five children ages 10-18 completed standardized questionnaires and participated in semistructured interviews prior to intake at a university-based tertiary clinic specializing in the treatment of pediatric chronic pain. All the children reported that pain limited their functioning in everyday activities and that these limitations caused them frustration and distress. Qualitative analysis identified three distinct functioning patterns or groups, which were designated as Adaptive, Passive, and Stressed. The groups did not differ significantly in demographics or clinical pain characteristics. Adaptive children continued to participate in many activities and were more likely to realize that focusing on pain would heighten their perception of pain. Children in this group reported more effective use of distraction and of other independently developed strategies to continue functioning. Passive children had given up most activities, tended to use passive distraction when in pain, and were more likely to feel isolated and different from peers. Stressed children described themselves as continuing to function, but were highly focused on their pain and the difficulties of living with it. The qualitative groupings were supported by quantitative findings that Stressed children reported a higher degree of social anxiety than did Passive children and were more likely than the other groups to report experiencing pain throughout the day. Finally, Adaptive children were rated by their parents as having better overall health compared to Passive children.

Therapeutic effects of yoga for children: a systematic review of the literature

PURPOSE

We completed a systematic review of the literature on the effect of yoga on quality of life and physical outcome measures in the pediatric population. We explored various databases and included case-control and pilot studies, cohort and randomized controlled trials that examined yoga as an exercise intervention for children.

SUMMARY OF KEY POINTS

Using the Sackett levels of evidence, this article reviews the literature on yoga as a complementary mind-body movement therapy. We address the research through three practice patterns according to the Guide to Physical Therapist Practice and provide considerations for the inclusion of yoga into clinical practice.

STATEMENT OF CONCLUSIONS AND RECOMMENDATIONS FOR CLINICAL PRACTICE

The evidence shows physiological benefits of yoga for the pediatric population that may benefit children through the rehabilitation process, but larger clinical trials, including specific measures of quality of life are necessary to provide definitive evidence.

Acupuncture for chronic pain in Japan: a review

Many Japanese reports of acupuncture and moxibustion for chronic pain are not listed in medical databases such as Medline. Therefore, they are not easily accessible to researchers outside of Japan. To complement existing reviews of acupuncture and moxibustion for chronic pain and to provide more detailed discussion and analysis, we did a literature search using 'Igaku Chuo Zasshi Wed' (Japana Centra Revuo Medicina) and 'Citation Information by National Institute of Information' covering the period 1978-2006. Original articles and case reports of acupuncture and moxibustion treatment of chronic pain were included. Animal studies, surveys, and news articles were excluded. Two independent reviewers extracted data from located articles in a pre-defined structured way, and assessed the likelihood of causality in each case. We located 57 papers written in Japanese (20 full papers, 37 case reports). Conditions examined were headache (12 trials), chronic low back pain (9 trials), rheumatoid arthritis (8 trials), temporomandibular dysfunction (8 trials), katakori (8 trials) and others (12 trials). While 23 were described as clinical control trials (CCTs), 11 employed a quasi-random method. Applying the 5-point Jadad quality assessment scoring system, the mean score was 1.5 +/- 1.3 (SD). Eleven (52%) of the CCTs were conducted to determine a more effective procedure for acupuncture; these compared a certain type of acupuncture with another type of acupuncture or specific additional points. In particular, the trigger point acupuncture was widely used to treat chronic low back pain in Japan. Many reports of chronic pain treatment by acupuncture and moxibustion are listed in Japanese databases. From the data, we conclude that there is limited evidence that acupuncture is more effective than no treatment, and inconclusive evidence that trigger point acupuncture is more effective than placebo, sham acupuncture or standard care.

The management of pain in children with life-limiting illnesses

The management of pain in children with life-limiting illnesses is complex and unfortunately not often done effectively. Pain is a multidimensional symptom that can overshadow all other experiences of both the child and family. This article focuses on topics common to practitioners caring for children with lifelimiting illnesses, including a review of myths and obstacles to achieving adequate pain control, a review of the pathophysiology of pain, an overview of the use of opioids in children, an approach to the management of neuropathic pain, and a brief discussion of nonpharmacologic pain management strategies.

Practitioner review: clinical applications of pediatric hypnosis

BACKGROUND

Over the past quarter century, hypnosis has been employed in a broad range of pediatric clinical settings; however, its efficacy and feasibility as a treatment approach for children and adolescents remain in question.

METHOD

Published studies on the role of clinical hypnosis in the management of specific pediatric medical and psychological conditions were identified and reviewed.

RESULTS

Pediatric clinical hypnosis has been employed in diverse medical settings to treat primary conditions (e.g., enuresis), as well as to address factors related to management of the condition (e.g., skills training for asthma) or its treatment (e.g., burn dressing changes). Despite great breadth to the possible applications of pediatric hypnosis and many reported successes, much of the present research comprises case histories and small, uncontrolled group studies.

CONCLUSION

To date, research in pediatrics views clinical hypnosis as a promising tool with the potential to help manage a variety of conditions. However, additional research, particularly utilizing randomized, controlled methodologies and adequate sample sizes, is required.

Anxiety sensitivity and health-related quality of life in children with chronic pain

Anxiety sensitivity (AS), or the fear of anxiety sensations, has been shown to independently predict poorer health-related quality of life (HRQOL) in adults with chronic pain. Specifically, AS was found to contribute to decrements in psychological well-being and social functioning but not to decrements in physical functioning. Existing studies have not examined the relationship between AS and HRQOL in children with chronic pain. The present study used multivariate regression analysis to test the association between AS and self-reported HRQOL in 87 children (62 girls; mean age = 14.4 years +/-2.3) presenting for treatment at a tertiary, multidisciplinary clinic specializing in pediatric chronic pain. After controlling for key sociodemographic and pain-related characteristics, higher AS was associated with poorer perceived general and mental health, greater impairment in family activities, lower self-esteem, increased behavior problems, and more social/academic limitations due to emotional problems. AS accounted for 4% to 28% of incremental variance in these HRQOL domains above and beyond the demographic and pain-related variables. However, AS was not significantly associated with physical functioning or with academic/social limitations due to physical health. Additional research is required to delineate possible mechanisms by which AS may influence certain aspects of children's HRQOL but not others.

PERSPECTIVE

The present findings support the evaluation of AS in pediatric chronic pain patients as part of a comprehensive assessment battery. The links between AS and multiple HRQOL domains suggest that treatment components aimed at reducing AS may lead to enhanced psychosocial well-being in children with chronic pain.

CAM for pediatric pain: what is state-of-the-research?

Previously, we reviewed the evidence for the efficacy of CAM approaches for pediatric pain (volume 2; issue 2; 2005) using criteria developed by the American Psychological Association Division 12 Task Force. Our review focused on CAM modalities that had been tested with at least one controlled trial or multiple baseline study. In addition, only those trials in which children comprised the study sample were included. Thus, several CAM modalities were not included in our review. Key ethical and other reasons for the limited literature on CAM for pediatric pain as well as directions for future studies are discussed.