Chronic pain in adolescents: evaluation of a programme of interdisciplinary cognitive behaviour therapy

Meaningful Clinical Outcomes for Young People and Parents When Treated for Chronic Musculoskeletal Pain in the UK: Q Set Development

Previous studies have established a core outcome set for pediatric chronic pain clinical trials. The aim of this research was to establish which outcomes young people and parents considered important to measure during treatment for chronic musculoskeletal pain. To the best of our knowledge, this is the first study to explore which outcomes could be used to tailor interventions within a clinical setting. Twenty-one young people (aged 11-18 years) and 21 parents were recruited from 2 UK hospital sites and took part in semi-structured interviews that incorporated drawing a timeline of their treatment. They identified positive and negative outcomes showing the perceived effectiveness of treatment. Informed by Q methodology, the words and phases of young people and parents were developed into 101 statements that were mapped onto the core outcome set and represented wide-ranging opinions regarding the outcomes they considered important (Q set). This approach helped identify additional statements related to "parent and family functioning" not routinely considered. Outcomes related to the treatment experience and adverse effects were highlighted as important, yet are not routinely prioritized in clinical research. Parents prioritized outcomes related to the treatment experience, whereas young people prioritized their overall well-being. Over the course of treatment, outcome focus changed, with some outcomes only deemed relevant at a specific time point. Overall, the research highlighted the need for clinical guidance on which outcome domains to measure during the treatment course to gauge treatment effectiveness and optimally tailor interventions. PERSPECTIVE: This study established the range of outcomes that were important to young people and their parents during treatment for chronic musculoskeletal pain. The findings show how young people and parents have different outcome preferences and how their outcome focus changes during the treatment course.

Co-design and evaluation of pain science messages on social media with adolescents with a history of chronic pain

Pain science education is an important component of paediatric pain care; however, access to services is limited. To disseminate pain science concepts on social media, we partnered with adolescents with chronic pain to co-design content. We engaged seven adolescent co-designers (aged 13-18 years) with lived experience of chronic pain to take part in four co-design workshops. Co-designers actively contributed to the social media campaign by selecting the social media platform, dictating design principles, generating metaphors and language, and recommending changes of mock designs. Co-designers suggested expanding the intended audience of the campaign to include people without a lived experience of chronic pain, such as friends, family, and teachers, alongside targeting adolescents with chronic pain. We published 30 posts and 102 stories over an 18-week period on Instagram, that reached over 40,000 individuals. We evaluated co-designers experience, where they reported having clear communication and necessary supports and information to participate; were able to share their ideas and felt they were heard; and felt their input was making a difference. The outputs of this campaign could be useful to guide the tailoring of other pain science education content delivered by clinicians as part of clinical care. Future testing of the content generated in this co-design process could evaluate if it leads to meaningful changes to the lives of people with chronic pain. PERSPECTIVE: Researchers partnered with adolescents with chronic pain to co-design content for a social media campaign on pain science education. Adolescent co-designers actively shaped the campaign direction, broadening its scope to reach diverse audiences. Our Instagram initiative reached over 40,000 individuals, indicating the potential for innovative educational approaches.

Feasibility of wearable activity tracking devices to measure physical activity and sleep change among adolescents with chronic pain-a pilot nonrandomized treatment study

Purpose

Personal informatics devices are being used to measure engagement in health behaviors in adults with chronic pain and may be appropriate for adolescent use. The aim of this study was to evaluate the utilization of a wearable activity tracking device to measure physical activity and sleep among adolescents attending a three-week, intensive interdisciplinary pain treatment (IIPT) program. We also assessed changes in physical activity and sleep from baseline to the treatment phase.

Methods

Participants (57.1% female, average age 15.88, SD = 1.27) wore an activity tracking device three weeks prior to starting and during the treatment program.

Results

Of 129 participants contacted, 47 (36.4%) agreed to participate. However, only 30 (64%) complied with the instructions for using the device prior to programming and during program participation. Preliminary analyses comparing averages from 3-weeks pre-treatment to 3-weeks during treatment indicated increases in daily overall activity minutes, daily step counts, and minutes of moderate to vigorous physical activity (by 353%), as well as a corresponding decrease in sedentary minutes. There was more missing data for sleep than anticipated.

Conclusions

Wearable activity tracking devices can be successfully used to measure adolescent physical activity in-person, with more difficulty obtaining this information remotely. Adolescents with chronic pain experience improvements in objective measurements of physical activity over the course of a 3-week IIPT program. Future studies may want to spend more time working with pediatric patients on their understanding of how to use trackers for sleep and physical activity.

Pain Neuroscience Education in Elementary and Middle Schools

PURPOSE

The purpose of this study was to deliver pain neuroscience education (PNE) to participants in grades 3 to 8 to determine whether participants in these grades had positive shifts in pain knowledge and beliefs.

METHODS

Three hundred twenty participants, grades 3 to 8, received a 1-time, 30-minute PNE lecture. The Neurophysiology of Pain Questionnaire and the Health Care Provider's Pain and Impairment Relationship Scale were administered before and after the PNE lecture.

RESULTS

All grades improved in pain knowledge and beliefs. Higher-grade school participants (sixth to eighth grades) experienced larger shifts in pain knowledge and attitudes and beliefs than lower-grade (third to fifth grades) participants.

CONCLUSION

PNE results in changes in pain knowledge and beliefs in school participants in grades 3 to 8.

The effect domains, measures, and methods reported in pediatric-specialized multidisciplinary outpatient rehabilitation programs: An integrated review

OBJECTIVES

Specialized pain rehabilitation is recognized as the treatment of choice for youth with pain-related disability. Appropriate outcomes for program evaluation are critical. This study aimed to summarize the effect domains and methods used to evaluate pediatric-specialized outpatient pain rehabilition programs, map them to the PedIMMPACT statement, and highlight future directions.

METHODS

An integrated review framework, incorporating stakeholders, was used. Academic Search Complete, CINAHL, ERIC, MEDLINE, PsycINFO, and Google Scholar were searched for studies published in 1999-2021 featuring the treatment effects of specialized outpatient pain rehabilitation on youth with pain-related disability and their parents. Selected studies were critically appraised using the Quality Assessment Tool for Studies of Diverse Design, organized by study characteristics, and analyzed using constant comparison.

RESULTS

From the 1951 potentially relevant titles, 37 studies were selected. Twenty-five effects targeted youth and 24 focused on parents, with a maximum of 15 youth and 11 parent effect domains (median = 5 domains per study). Although most studies measured a combination of effect domains and were inclusive of some recommended in the PedIMMPACT statement, no effect was measured consistently across studies. Youth physical functioning and parent emotional functioning were measured most often. Eighty-five instruments were used to assess youth outcomes and 59 for parents, with self-report questionnaires dominating.

DISCUSSION

A lack of standardization exists associated with the domains and methods used to evaluate the effects of pediatric-specialized outpatient pain rehabilitation programs, hindering comparisons. Future program evaluations should be founded on their theory, aim, and anticipated outcomes.

Functionally relevant physical exercises as an objective measure of clinical improvement in pediatric chronic pain

PURPOSE

This exploratory study demonstrates the application of functionally relevant physical exercises (FRPE) to objectively assess physical functioning among children with chronic pain. Intensive interdisciplinary pain treatment (IIPT) focuses on functional improvements as a primary outcome. FRPEs aim to enhance clinical assessments and monitoring by providing relevant data for physical and occupational therapies.

METHODS

Children enrolled in three weeks of IIPT provided data for study. They completed two self-report measures of functioning (Lower Extremity Functioning Scale [LEFS] and Upper Extremity Functioning Index [UEFI]), measure of pain intensity, and six separate FRPEs (box carry, box lifts, floor to stand, sit to stand, step ups, and modified six-minute walk test). Data from 207 participants aged 8-20 years old were analyzed.

RESULTS

Upon admission, over 91% of children could perform each FRPE at some level to provide clinicians with a baseline assessment of functional strength. Following IIPT, all children were able to complete FRPEs. Overall, children reported statistically significant gains in functioning on all subjective reports and FRPEs (p's < 0.001). Spearman correlations demonstrated that LEFS and UEFI were weakly to moderately correlated to all FRPEs at admission (r's between.43-.64, p's < 0.001 and.36-.50, p's < 0.01 respectively). Correlations between all subjective and objective measures were comparatively lower at discharge.

CONCLUSION

FRPEs appear to serve as good objective measures of strength and mobility for children with chronic pain, measuring variability across patients and change over time, which is unique from subjective data gathered via self-report. Due to face validity and objective measurement of functioning, from a clinical practice perspective, FRPEs provide meaningful information to support initial assessment, treatment planning, and patient monitoring. This study offers initial support for a novel measurement method that is easily administered and replicated to effectively measure functional improvement in children with chronic pain.

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

ABSTRACT

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

A randomized controlled trial on long-term effectiveness of a psychosocial aftercare program following pediatric chronic pain treatment: Who benefits the most?

BACKGROUND

For pediatric chronic pain patients, intensive interdisciplinary pain treatment (IIPT) is a well-established treatment. The treatment's short-term effectiveness can be improved by an additive psychosocial aftercare (PAC). However, neither the program's long-term effectiveness nor the patients in particular need have been investigated yet.

METHODS

This study aimed at determining the long-term effects of PAC and detecting predictors of treatment outcome within a multicenter randomized controlled trial measured at five time points up to twelve months after discharge. At inpatient admission to IIPT, patients (N=419, 14.3 years of age, 72.3% female) were randomly assigned to intervention or control group. After IIPT discharge, the intervention group received PAC, whereas the control group received treatment as usual (TAU). Patient-reported outcomes included pain and emotional characteristics. Clinicians assessed potential psychosocial risk factors and their prognosis of treatment outcome. Statistical analyses included mixed-models and univariable logistic regressions.

RESULTS

Data at the 12-month follow-up (n=288) showed a significant benefit of PAC compared with TAU; the majority (59.0%) of patients in the PAC-group reported no chronic pain compared to 29.2% of TAU-patients (p<.001). Patients with a single parent specifically benefited from PAC compared to TAU. Clinicians were able to make a reliable prognosis of treatment outcome, but did not successfully predict which patients would benefit the most from PAC.

CONCLUSIONS

Study results suggest that PAC is highly effective irrespective of patient characteristics, but particularly for patients with single parents. Its broad implementation could help to improve the long-term outcomes of youth with severely disabling chronic pain.

What about parents? A systematic review of paediatric intensive interdisciplinary pain treatment on parent outcomes

BACKGROUND AND OBJECTIVE

Intensive interdisciplinary pain treatment (IIPT) for youth with high impact chronic pain has been found to be effective in improving child symptoms and functioning. However, it remains unclear how these interventions impact the parents' own well-being, as well as cognitions and behaviours which are known to influence child pain and functioning. Thus, the current study sought to determine the effect of IIPT on parent mental health, cognitions and behaviours in parents of youth attending IIPT with their child.

DATABASES AND DATA TREATMENT

A search of the electronic databases CINAHL, Ovid EBM Reviews, Embase, Medline, APA PsychINFO, Scopus and web of Science was conducted. Studies were included if they comprised at least 10 parents of patients aged 9-22 with nonmalignant chronic pain attending an IIPT and were written in English.

RESULTS

A random-effects model was used to pool the standardized mean change (SMC) across seven prepost studies. At discharge, IIPT participation was associated with small to moderate improvements in direct parental outcomes (general mental health, anxiety, depression and parenting stress), a moderate improvement in pain catastrophizing and large improvements in psychological flexibility and parenting behaviours. Most improvements were maintained at follow-up. The risk of bias of all studies was rated as serious and the certainty of the evidence as low, suggesting limited confidence in the estimates.

CONCLUSIONS

Although parents appear to benefit from attending an IIPT with their child, RCTs are needed to substantiate the effect of these interventions on important aspects of parent well-being and functioning.

Psychological Interventions for Parents of Youth With Chronic Pain: A Scoping Review

OBJECTIVE

Parents are integral to their youth's chronic pain experiences, and intervening with parents may improve parent and youth functioning. Existing systematic reviews are not specific to pain or do not systematically report critical aspects to facilitate implementation of parent interventions in diverse settings. Thus, this scoping review aimed to map published parent interventions for pediatric chronic pain to summarize the participant and intervention characteristics, treatment components, methods, outcomes, feasibility, and acceptability, as well as identify gaps for future research.

METHODS

Four databases were searched (PubMed, PsycINFO, CINAHL, and Google Scholar). Studies of any design reporting psychological interventions including parents of youth (0 to 18 y) with chronic pain were included. Data on study characteristics, treatment components, effectiveness, and feasibility/acceptability were extracted.

RESULTS

Fifty-four studies met inclusion criteria from 9312 unique titles. The majority were nonrandomized cognitive-behavioral therapy interventions delivered individually. The degree of parent participation ranged from 17% to 100%; the average enrollment rate was 68%. Reported parent and youth outcomes were variable; 26% of studies did not include any parent-related outcomes.

DISCUSSION

Parent interventions may be a helpful and feasible way to support parents and youth with chronic pain. There is variability across study characteristics, treatment content/aims, parent participation, and parent/youth outcomes.

Is It Worth It? A Comparison of an Intensive Interdisciplinary Pain Treatment and a Multimodal Treatment for Youths With Pain-related Disability

OBJECTIVE

The objective of this study was to evaluate the effectiveness of an intensive interdisciplinary pain treatment (IIPT) day-hospital program as compared with an outpatient multimodal treatment (MMT) for youth with chronic pain.

MATERIALS AND METHODS

A nonrandomized pretest posttest with control group design was used. A battery of patient-oriented measures assessing pain interference, quality of life, and depressive symptoms were completed at treatment commencement and at 3, 6, and 12 months after treatment by 44 youths enrolled in the IIPT and 138 youths engaged in the MMT, with various chronic pain conditions. Data were analyzed using longitudinal mixed-effects models.

RESULTS

The main outcomes were the score difference from baseline of patient-oriented measures across 3 timepoints within 12 months of intervention initiation for both treatment groups. IIPT participants demonstrated greater improvement in pain interference, as compared with MMT at 3 and 12 months. Initially, health-related quality of life scores improved similarly in both groups, but greater improvement was seen in the MMT group at 12 months. Depressive symptom scores did not improve with either intervention. Only pain interference scores reached statistically and clinically significant difference levels.

DISCUSSION

This study supports the benefits of specialized rehabilitation interventions, including both MMT and IIPT programs, for youths with chronic pain. The findings also suggest that IIPT might have a greater long-term effect for helping youths, in particular those with high pain interference scores.

The Parent Version of the Sensitivity to Pain Traumatization Scale (SPTS-P): A Preliminary Validation

Sensitivity to pain traumatization (SPT) is defined as the propensity to develop responses to pain that resemble a traumatic stress reaction. To date, SPT has been assessed in adults with a self-report measure (Sensitivity to Pain Traumatization Scale (SPTS-12)). SPT may also be relevant in the context of parenting a child with chronic pain, as many of these parents report clinically elevated posttraumatic stress symptoms (PTSS). This study aimed to develop and validate a measure of parent SPT by adapting the SPTS-12 and evaluating its psychometric properties in a sample of parents whose children have chronic pain. In total, 170 parents (90.6% female) and children (aged 10–18 years, 71.2% female) were recruited from a tertiary chronic pain program. Parents completed the parent version of the SPTS-12 (SPTS-P) and measures of PTSS, depression, anxiety and anxiety-related constructs, and parenting behaviors. Youth completed measures of pain. Consistent with the SPTS-12, the SPTS-P demonstrated a one-factor structure that accounted for 45% of the variance, adequate to good reliability and moderate construct validity. Parent SPT was positively related to their protective and monitoring behaviors but was unrelated to youth pain intensity, unpleasantness, and interference. These results provide preliminary evidence for the psychometric properties of the SPTS-P and highlight the interaction between parent distress about child pain and parent responses to child pain.

A lateralized model of the pain-depression dyad

Chronic pain and depression are two frequently co-occurring and debilitating conditions. Even though the former is treated as a physical affliction, and the latter as a mental illness, both disorders closely share neural substrates. Here, we review the association of pain with depression, especially when symptoms are lateralized on either side of the body. We also explore the overlapping regions in the forebrain implicated in these conditions. Finally, we synthesize these findings into a model, which addresses gaps in our understanding of comorbid pain and depression. Our lateralized pain-depression dyad model suggests that individuals diagnosed with depression should be closely monitored for pain symptoms in the left hemibody. Conversely, for patients in pain, with the exception of acute pain with a known source, referrals in today's pain centers for psychological evaluation should be part of standard practice, within the framework of an interdisciplinary approach to pain treatment.

Understanding How Perfectionism Impacts Intensive Interdisciplinary Pain Treatment Outcomes: A Nonrandomized Trial

OBJECTIVE

Several factors are known to impact response to the intensive interdisciplinary pain treatment (IIPT) program described in this study, yet no research has explored the role of perfectionism. This secondary data analysis explored direct and indirect relations between perfectionism and functional disability (primary outcome) and pain severity (secondary outcome) after IIPT, with pain catastrophizing and fear of pain as mediators.

METHODS

Youth (N = 253) aged 8-21 with chronic pain and associated disability completed pre- and post-IIPT measures of self-oriented perfectionism (SOP), socially prescribed perfectionism (SPP), pain catastrophizing, fear of pain, functional disability, and pain characteristics for routine clinical care and this nonrandomized trial. Eight mediated models were run for the two predictors, two mediators, and two outcomes.

RESULTS

Pretreatment perfectionism (SOP and SPP) led to greater reductions in pain catastrophizing over the course of IIPT, which resulted in lower pain severity (β = -.02 [CI = -0.07, -0.01] for SOP and β = -.02 [CI = -0.06, -0.003] for SPP) and less functional disability (β = -.06 [CI = -0.13, -0.01] for SOP and β = -.06 [CI = -0.14, -0.01] for SPP). Independent of pain catastrophizing, pretreatment SPP was directly associated with more posttreatment functional disability (β = .16 [CI = 0.05, 0.27]). Fear of pain was not a mediator.

CONCLUSIONS

Findings suggest perfectionism has the potential to negatively impact IIPT outcomes. However, when perfectionistic youth with chronic pain learn to manage pain-related distress, they benefit. Results highlight the importance of assessing for and treating perfectionism and pain-related distress in youth with chronic pain.

Sleep among Youth with Severely Disabling Chronic Pain: Before, during, and after Inpatient Intensive Interdisciplinary Pain Treatment

Poor sleep is commonly reported in pediatric chronic pain. There are signals that intensive interdisciplinary pain treatments (IIPT) may inadvertently improve objective sleep, but this claim cannot be substantiated without baseline sleep data prior to IIPT. This study followed the objective sleep/wake patterns (e.g., duration, quality, timing, consistency) of pediatric patients with severely functionally disabling chronic pain before, during, and after inpatient IIPT (the Functional Independence Restoration Program-"FIRST Program"), alongside a similarly-disabled chronic pain Comparison Group. The final sample included N = 10 FIRST Patients and N = 9 Comparison Group patients. At baseline, the whole sample showed healthy sleep duration (~9 h), average sleep efficiency <90%, late sleep onset and offset (mean = 11:56 p.m.-8:50 a.m.), and highly inconsistent sleep schedules night to night. During IIPT, FIRST Patients maintained healthy sleep durations, moved sleep schedules 2 h earlier, and decreased timing and duration variability by >60 min while the Comparison Group maintained similar sleep to baseline. At follow up (1-2 months later), FIRST Patients' sleep schedules shifted later but were still less variable than at baseline. Results point to the malleability of sleep/wake patterns within treatment contexts with strict environmental control but suggest that these gains may be difficult for youth with chronic pain to maintain in the home environment.

[Pediatric pain treatment and prevention for hospitalized children]

INTRODUCTION

Prevention and treatment of pain in pediatric patients compared with adults is often not only inadequate but also less often implemented the younger the children are. Children 0 to 17 years are a vulnerable population.

OBJECTIVES

To address the prevention and treatment of acute and chronic pain in children, including pain caused by needles, with recommended analgesic starting doses.

METHODS

This Clinical Update elaborates on the 2019 IASP Global Year Against Pain in the Vulnerable "Factsheet Pain in Children: Management" and reviews best evidence and practice.

RESULTS

Multimodal analgesia may include pharmacology (eg, basic analgesics, opioids, and adjuvant analgesia), regional anesthesia, rehabilitation, psychological approaches, spirituality, and integrative modalities, which act synergistically for more effective acute pediatric pain control with fewer side effects than any single analgesic or modality. For chronic pain, an interdisciplinary rehabilitative approach, including physical therapy, psychological treatment, integrative mind-body techniques, and normalizing life, has been shown most effective. For elective needle procedures, such as blood draws, intravenous access, injections, or vaccination, overwhelming evidence now mandates that a bundle of 4 modalities to eliminate or decrease pain should be offered to every child every time: (1) topical anesthesia, eg, lidocaine 4% cream, (2) comfort positioning, eg, skin-to-skin contact for infants, not restraining children, (3) sucrose or breastfeeding for infants, and (4) age-appropriate distraction. A deferral process (Plan B) may include nitrous gas analgesia and sedation.

CONCLUSION

Failure to implement evidence-based pain prevention and treatment for children in medical facilities is now considered inadmissible and poor standard of care.

Functional Disability in Adolescents with Chronic Pain: Comparing an Interdisciplinary Exposure Program to Usual Care

(1) Background: Chronic musculoskeletal pain (CMP) in adolescents can negatively affect physical, psychological, and social functioning, resulting in functional disability. This randomized controlled trial (RCT) aimed to evaluate the effectiveness of an outpatient rehabilitation program based on graded exposure in vivo (EP) compared with care as usual (CAU: interdisciplinary outpatient rehabilitation care). Both EP and CAU aim to improve functional ability in adolescents with CMP. (2) Methods: Pragmatic multicenter RCT with 12-month follow-up. Adolescents (12-21 years) with CMP were invited to participate. Primary outcome: functional disability; secondary outcomes: perceived harmfulness; pain catastrophizing; pain intensity. Data analysis: intention-to-treat linear mixed model. (3) Results: Sixty adolescents (mean 16 years) were randomized; data for 53 were analyzed. Adolescents in EP showed relevant and significant decreases in functional disability (estimated mean difference at least -8.81, p ≤ 0.01) compared with CAU at all times. Significant differences in favor of EP were found for perceived harmfulness at all times (p ≤ 0.002), for pain catastrophizing at 2 months (p = 0.039) and for pain intensity at 4 and 10 months (p ≤ 0.028). (4) Conclusion: EP leads to a significant and clinically relevant decrease in functional disability compared with usual care.

Barriers to Outpatient Pediatric Chronic Pain Clinic Participation Among Referred Patients

Initial clinic evaluation among referred patients and factors limiting treatment initiation are not well characterized. We conducted a retrospective review of referrals to our outpatient pain clinic to identify intake visits and factors associated with treatment initiation among adolescents with chronic pain. We identified adolescents aged 13 to 18 years at the time of referral to clinic (2010-2016). Factors associated with completion of visits were evaluated using logistic regression. Patients who completed visits more frequently had private insurance than public or no insurance (P = .053). The most common reasons for caregiver decision not to attend the pain clinic included use of another pain clinic, that services were not wanted or no longer needed, and that their child was undergoing further testing. The current study demonstrated that patients with head pain were more likely to complete an intake visit, while there was a trend showing that lack of private insurance decreased this likelihood.

Behavior Change Following Pain Neuroscience Education in Middle Schools: A Public Health Trial

Chronic pain and the opioid epidemic need early, upstream interventions to aim at meaningful downstream behavioral changes. A recent pain neuroscience education (PNE) program was developed and tested for middle-school students to increase pain knowledge and promote healthier beliefs regarding pain. In this study, 668 seventh-grade middle-school students either received a PNE lecture (n = 220); usual curriculum school pain education (UC) (n = 198) or PNE followed by two booster (PNEBoost) sessions (n = 250). Prior to, immediately after and at six-month follow-up, pain knowledge and fear of physical activity was measured. Six months after the initial intervention school, physical education, recess and sports attendance/participation as well as healthcare choices for pain (doctor visits, rehabilitation visits and pain medication use) were measured. Students receiving PNEBoost used 30.6% less pain medication in the last 6 months compared to UC (p = 0.024). PNEBoost was superior to PNE for rehabilitation visits in students experiencing pain (p = 0.01) and UC for attending school in students who have experienced pain > 3 months (p = 0.004). In conclusion, PNEBoost yielded more positive behavioral results in middle school children at six-month follow-up than PNE and UC, including significant reduction in pain medication use.

A Secondary Analysis of Integrated Pediatric Chronic Pain Services Related to Cost Savings

Youth with chronic pain have high healthcare utilization and associated costs. Research supports integrated treatment; though, it's unclear which treatments are used and cost-effective. This study expands on work that found reduced service use and cost savings following participation in an outpatient integrated pediatric pain clinic. We explored which services were commonly used and which individual (psychotherapy, medication management, acupuncture, massage, biofeedback) and/or combinations of services were associated with service use reduction and cost savings. Medication management and psychotherapy were more common than complementary integrative medicine (CIM) services. Massage services were associated with reduced inpatient costs. There were trends of fewer emergency department visits for participants who received CIM services in addition to medication management and psychotherapy, and more visits for those with biofeedback. Findings suggest that a more detailed examination of service utilization is needed to better understand cost outcomes related to the integrated treatment of pediatric chronic pain.

Feasibility of a Randomized Controlled Trial of Paediatric Interdisciplinary Pain Management Using Home-Based Telehealth

Purpose

Chronic pain is common in adolescents. Evidence-based guidelines recommend interdisciplinary treatment, but access is limited by geography. The development of hybrid programs utilizing both face-to-face and videoconference treatment may help overcome this. We developed a 7-week hybrid pediatric interdisciplinary pain program (Hybrid-PIPP) and wished to compare it to individual face-to-face sessions (Standard Care). Our objective was to test the feasibility of a protocol that used a matched pair un-blinded randomized controlled design to investigate the efficacy and cost-effectiveness of the Hybrid-PIPP compared to Standard Care.

Patients and Methods

Parent-adolescent dyads were recruited from tertiary pediatric clinics and matched by disability before randomization to minimize allocation bias. The adolescents (aged 11-17) had experienced primary pain for >3 months. Hybrid-PIPP involved 11 hrs of group therapy and 4 individual videoconference sessions. Standard care was provided by the same clinical team, using the same treatment model and similar intensity as the Hybrid-PIPP. The intention was to recruit participants for 3 Hybrid-PIPP groups with a comparison stream. Recruitment was ceased after 2 groups due to the high participant disability requiring more intensive intervention.

Results

Eighteen dyads were screened and 13 randomized (7 Hybrid-PIPP, 6 Standard Care, 2 unsuitable, 3 unallocated when the study was stopped). The study met a priori feasibility criteria for staff availability; recruitment rate; treatment completion; and data collection. Global satisfaction ratings were similar in both streams (SC median 7, range 5-9 and Hybrid-PIPP median 8.5, range 5-10). Challenges were identified in both streams. A future modified Hybrid-PIPP was considered acceptable if the intensity is increased to manage the high level of disability. Standard care was considered inefficient. No adverse events were reported.

Conclusion

The study determined that the protocol met a priori feasibility criteria, but to be practicable in a real world, health environment requires significant modifications.

Registration

ANZTR(ACTRN2614000489695).

Using collaborative logic analysis evaluation to test the program theory of an intensive interdisciplinary pain treatment for youth with pain‐related disability

Intensive interdisciplinary pain treatment (IIPT) involves multiple stakeholders. Mapping the program components to its anticipated outcomes (ie, its theory) can be difficult and requires stakeholder engagement. Evidence is lacking, however, on how best to engage them. Logic analysis, a theory‐based evaluation, that tests the coherence of a program theory using scientific evidence and experiential knowledge may hold some promise. Its use is rare in pediatric pain interventions, and few methodological details are available. This article provides a description of a collaborative logic analysis methodology used to test the theoretical plausibility of an IIPT designed for youth with pain‐related disability. A 3‐step direct logic analysis process was used. A 13‐member expert panel, composed of clinicians, teachers, managers, youth with pain‐related disability, and their parents, were engaged in each step. First, a logic model was constructed through document analysis, expert panel surveys, and focus‐group discussions. Then, a scoping review, focused on pediatric self‐management, building self‐efficacy, and fostering participation, helped create a conceptual framework. An examination of the logic model against the conceptual framework by the expert panel followed, and recommendations were formulated. Overall, the collaborative logic analysis process helped raiseawareness of clinicians’ assumptions about the program causal mechanisms, identified program components most valued by youth and their parents, recognized the program features supported by scientific and experiential knowledge, detected gaps, and highlighted emerging trends. In addition to providing a consumer‐focused program evaluation option, collaborative logic analysis methodology holds promise as a strategy to engage stakeholders and to translate pediatric pain rehabilitation evaluation research knowledge to key stakeholders.

Pediatric pain treatment and prevention for hospitalized children

Introduction:

Prevention and treatment of pain in pediatric patients compared with adults is often not only inadequate but also less often implemented the younger the children are. Children 0 to 17 years are a vulnerable population.

Objectives:

To address the prevention and treatment of acute and chronic pain in children, including pain caused by needles, with recommended analgesic starting doses.

Methods:

This Clinical Update elaborates on the 2019 IASP Global Year Against Pain in the Vulnerable “Factsheet Pain in Children: Management” and reviews best evidence and practice.

Results:

Multimodal analgesia may include pharmacology (eg, basic analgesics, opioids, and adjuvant analgesia), regional anesthesia, rehabilitation, psychological approaches, spirituality, and integrative modalities, which act synergistically for more effective acute pediatric pain control with fewer side effects than any single analgesic or modality. For chronic pain, an interdisciplinary rehabilitative approach, including physical therapy, psychological treatment, integrative mind–body techniques, and normalizing life, has been shown most effective. For elective needle procedures, such as blood draws, intravenous access, injections, or vaccination, overwhelming evidence now mandates that a bundle of 4 modalities to eliminate or decrease pain should be offered to every child every time: (1) topical anesthesia, eg, lidocaine 4% cream, (2) comfort positioning, eg, skin-to-skin contact for infants, not restraining children, (3) sucrose or breastfeeding for infants, and (4) age-appropriate distraction. A deferral process (Plan B) may include nitrous gas analgesia and sedation.

Conclusion:

Failure to implement evidence-based pain prevention and treatment for children in medical facilities is now considered inadmissible and poor standard of care.

Recent advances in pain treatment for children with serious illness

Pain is a common distressing symptom in children receiving pediatric palliative care. Both in children with cancer, but especially in children with progressive neurodegenerative and chromosomal conditions with CNS impairment pain is common, and often under-recognized and undertreated. Multimodal analgesia for children with serious illness acts synergistically for more effective pediatric pain and symptom control with fewer side effects than a single analgesic or modality. Successful pain treatment and prevention usually include integrative 'nonpharmacological' therapies, rehabilitation, psychology and spirituality in addition to pharmacology and regional anesthesia. This review article will address these effective components of multimodal pediatric analgesia and present starting doses of basic analgesia, opioids and adjuvants analgesia in infants, children and adolescents with serious illness.

Evaluation of an Intensive Interdisciplinary Pain Treatment Based on Acceptance and Commitment Therapy for Adolescents With Chronic Pain and Their Parents: A Nonrandomized Clinical Trial

Objective

Parental factors are central in the development and maintenance of chronic pain in youths. Only a handful of studies have investigated the impact of psychological treatments for pediatric chronic pain on parental factors, and the relationships between changes in parental and adolescent factors. In the current study, we evaluated the effects of an intensive interdisciplinary pain treatment (IIPT) program based on Acceptance and Commitment Therapy (ACT) for adolescents with chronic pain, on adolescent and parental variables, and the relationship between parental psychological flexibility and adolescent pain acceptance.

Methods

Adolescents (N = 164) with chronic pain were included, with a mean age of 15.5 years, and completed the 3-week treatment with an accompanying parent (N = 164). Linear mixed-effects models were used to analyze change over time (from pretreatment to 3-month follow-up) on parent (depression, health-related quality of life and parent psychological flexibility) and adolescent (physical, social and emotional functioning, and adolescent pain acceptance) variables. Additionally, linear mixed-effects models were used to analyze the relationship between parent psychological flexibility and adolescent pain acceptance.

Results

Results illustrated significant improvements over time in depressive symptoms and levels of psychological flexibility in parents. Excluding social development, adolescents improved significantly in all assessed aspects of functioning and pain acceptance. Additionally, changes in parent psychological flexibility were significantly associated with changes in adolescent pain acceptance.

Conclusions

Results indicated that treatment had positive effects for parents and adolescents, and a significant positive relationship between changes in parent psychological flexibility and adolescent pain acceptance was found.

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

BACKGROUND

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

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Back to Living: Long-term Functional Status of Pediatric Patients Who Completed Intensive Interdisciplinary Pain Treatment

OBJECTIVES

To provide a descriptive account of long-term functioning (≥5 y posttreatment) among youth who completed intensive interdisciplinary pain treatment (IIPT) for pediatric chronic pain conditions.

MATERIALS AND METHODS

A total of 95 patients (mean age at follow-up=20.0 y) treated at least 5 years previously at a single IIPT program completed questionnaires assessing pain, functional disability, health care utilization, academic/career achievement, and quality of life. Data analyses focused on pain, functioning, and progress toward developmental goals at long-term follow-up.

RESULTS

The majority of respondents report significant reduction in pain compared with preadmission (P<0.001). Five years posttreatment, average functional disability scores were in the minimal range, with statistically significant decrease in functional disability from time of admission (P<0.001). Nearly 80% of respondents characterized themselves as having no functional difficulties at follow-up. Clinically significant improvement was established for both pain and function. Respondents generally reported developmentally appropriate status, with 89% graduating high school on schedule.

DISCUSSION

Results show long-term positive functioning among individuals who underwent intensive rehabilitation treatment for chronic pain as children or adolescents. Despite experiencing one or more pain flares at some point after treatment, most former IIPT patients report minimal to no ongoing functional disability, complete or partial resolution of pain symptoms, and developmentally appropriate progress toward goals (eg, school completion, independent living).

Pain, Physical, and Psychosocial Functioning in Adolescents at Risk for Developing Chronic Pain: A Longitudinal Case-Control Stusdy

This longitudinal case-control study aims to 1) compare symptoms and functioning in otherwise healthy adolescents with versus without a parent with chronic pain (Parent CP+/Parent CP-) 2) test adolescent sex as a moderator of the relation between parent CP group and child functioning, and 3) determine changes in adolescent pain over 1 year. Adolescents (n = 140; ages 11-15) completed tests of pain responsivity and physical function, as well as self-report measures assessing pain characteristics, somatic symptoms, and physical and psychosocial functioning. Self-reported pain and somatic symptoms were reassessed 1 year later. Adolescents in the Parent CP+ group reported greater pain, somatic symptoms, and worse physical health than Parent CP- youth. Parent CP+ youth performed worse on all tests of physical function. Some observed effects were stronger for girls than boys. There were no differences between groups on pain responsivity. Both groups reported increased pain and somatic symptoms from baseline to 1-year follow-up, with the Parent CP+ group reporting the highest level of symptoms at both time points. This study highlights the potential impact of parental pain status on children, particularly daughters, and is the first to document objective physical functioning differences in youth at risk for developing chronic pain. PERSPECTIVE: Adolescents who have a parent with chronic pain demonstrate higher pain and lower physical function than adolescents who have a parent without chronic pain. Group differences in pain and somatic symptoms persist over 1 year. Family based interventions are needed for comprehensive pain prevention and treatment.

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

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

Pain is Associated With Increased Physical and Psychosocial Impairment in Youth With a History of Burn Injuries

Burn injuries are significantly painful and associated with physical and psychological impairment. However, little research to-date has examined the potential role of the subjective experience of pain in either physical or psychological impairment in this population. This may be particularly important to examine, given that the pain experience can often be a significant barrier to recovery in other pediatric populations. The current study examined the cross-sectional and predictive relationships between patient-reported experience of pain (operationalized as PROMIS pain interference and self-reported pain intensity) and physical and psychosocial outcomes. Data were gathered as part of the Burn Model System National Database (1994-2018) with the data request inclusive of pediatric self-report PROMIS measures, child PTSD, and post-traumatic growth symptoms assessed at 6- and 12-month postdischarge following initial injury. A total of 65 youth between the ages of 6 and 16 years at the time of their injury were included in the dataset. Correlational and regression analyses indicated that pain interference was cross-sectionally and longitudinally associated with decreased physical functioning, depressive symptoms, and peer relationships. Pain intensity was significantly associated with and predictive of physical functioning and pain interference. Results of the current study are an important first step in understanding the pain experience and associated outcomes in youth with a history of burn injuries. Future research is needed to further examine these relationships. PERSPECTIVE: This study presents preliminary findings from a national database on pain-related outcomes both cross-sectionally and longitudinally in youth with a history of burn injury. To-date, pain-related outcomes are poorly understood in this population and the results of this study serve to inform future research and treatment-related efforts.

Effectiveness of interdisciplinary interventions in paediatric chronic pain management: a systematic review and subset meta-analysis

BACKGROUND

Paediatric chronic pain is a significant problem that can have devastating impacts on quality of life. Multimodal interdisciplinary interventions are the mainstay of paediatric treatment. The aim of this article is to provide a comprehensive review of the effectiveness of interdisciplinary interventions in the management of paediatric chronic pain.

METHODS

Studies were identified via a search of nine databases. The search strategy included concept blocks pertaining to type of pain, study population, and type of intervention. Eligible studies reported the effects of an intervention co-ordinated by two or more healthcare professionals of different disciplines, and recruited a sample aged 22 yr or below with chronic pain. Twenty-eight studies were included, and 21 provided data for inclusion in between- and within-groups meta-analyses.

RESULTS

Patients randomised to interdisciplinary interventions reported significantly lower pain intensity 0-1 month post-intervention compared with patients randomised to the control groups. Within-groups analysis of patients receiving interdisciplinary interventions showed significant improvements pre- to post-intervention in pain intensity, functional disability, anxiety, depression, catastrophising, school attendance, school functioning, and pain acceptance. Few differences were found between interventions delivered in inpatient vs outpatient settings. Significant heterogeneity due mainly to differing outcome variables and intervention content was found in most analyses.

CONCLUSIONS

Overall, interdisciplinary interventions show promise in providing a range of clinical benefits for children with chronic pain. Methodologically robust randomised controlled trials using standardised outcome measures are needed, however, to guide clinical care.

Special considerations in conducting clinical trials of chronic pain management interventions in children and adolescents and their families

INTRODUCTION

Disabling chronic pain is a common experience for children and adolescents. However, the evidence base for chronic pain interventions for youth is extremely limited, which has hindered the development of evidence-based practice guidelines for most pediatric chronic pain conditions.

OBJECTIVES

To review and provide recommendations on clinical trial design and evaluation in children and adolescents with chronic pain.

METHODS

In this article, we summarize key issues and provide recommendations for addressing them in clinical trials of chronic pain interventions in children and adolescents and their families.

RESULTS

To stimulate high-quality trials of pediatric chronic pain management interventions, attention to key issues including sample characterization, trial design and treatment administration, outcome measurement, and the ethics of intervening with children and adolescents, as opposed to adults with chronic pain, is needed.

CONCLUSION

Future research to develop interventions to reduce or prevent childhood chronic pain is an important priority area, and requires special considerations in implementation and evaluation in clinical trials.

Parenting in the Context of Children's Chronic Pain: Balancing Care and Burden

Parents of youth with chronic health conditions encounter numerous challenges in supporting their children across pediatric treatment contexts. Structural barriers to care, such as access issues and coordinating care across school, health, and family settings, can exacerbate challenges to daily functioning. Parents are often concomitantly managing their child’s chronic condition, their own health care needs, work and family demands. For these parents, accomplishing a manageable “work-life balance” feels elusive, if not impossible, when a chronic health condition is part of family life. Based on a recent symposium presentation, combined perspectives from the disciplines of pediatric psychology, parenting, and human development and family studies consider key challenges and opportunities to assist parent coping with stress associated with caregiving amidst pervasive changes in healthcare service delivery. Two innovative interventions to support parents in both an outpatient (“Parents as Coping Coaches”) and an inpatient (“Putting Parents FIRST”) context are described, with commonalities and unique aspects highlighted for each. These programs are considered in reference to a rapidly changing healthcare landscape, growing focus on the family as a core context for care, and importance of parent/caregiver self-care and crucial role in supporting children’s long-term health and resiliency.

Efficacy of Internet-delivered cognitive-behavioral therapy for the management of chronic pain in children and adolescents: A systematic review and meta-analysis

BACKGROUND

Pediatric chronic pain is relatively common in the world. Although cognitive behavior therapy (CBT) has been shown to be efficacious in children and adolescents, it is generally recognized that availability and accessibility of CBT are limited. While Internet-delivered cognitive-behavioral therapy (ICBT) performs better in these areas.

OBJECTIVES

This systematic review aims to evaluate the clinical effects of ICBT for chronic pain in youth when compared with the control treatments.

METHODS

We searched electronic databases to identify randomized controlled trials that compared ICBT with the control therapy for pediatric chronic pain. The primary outcomes were 95% confidence intervals and mean difference or standardized mean difference in change of pain intensity and activity limitations.

RESULTS

Four trials met the inclusion criteria with a total of 404 participants of whom 208 received ICBT. Compared with pretreatment, children reported significant, medium to large benefits on pain intensity, activity limitations, and parental protective behaviors after receiving ICBT immediately. Significant small to medium effects were found for outcomes of depressive symptoms, anxiety, and sleep quality from baseline to post-treatment in the ICBT group. But most measures of ICBT did not show statistically significant superiority to those of the control conditions, except parental protective behaviors. Generally children and their parents were highly acceptable and satisfied with ICBT.

CONCLUSION

ICBT for physical and psychological conditions in youth with chronic pain is a full potential therapy; it can be successful on clinically effects and socioeconomic benefits. However, only limited data supported the conclusion, we require further methodologically robust trials.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017069811.

Somatic symptom and related disorders in children and adolescents: evaluation of a naturalistic inpatient multidisciplinary treatment

BACKGROUND

This naturalistic study assesses the effectiveness of inpatient multidisciplinary treatment of children and adolescents with somatic symptom disorders (SSD) and investigates the role of pain coping strategies and psychiatric comorbidity (anxiety, depression).

METHODS

Sixty children and adolescents (mean age 14.4 years) with SSD who underwent inpatient multidisciplinary treatment were assessed regarding their school attendance, levels of discomfort, coping strategies and psychiatric comorbidity (depression, anxiety) at pretreatment, discharge and 6 months following treatment.

RESULTS

At discharge, the children and adolescents reported improvements in their level of discomfort, psychiatric comorbidities (anxiety, depression) and pain coping strategies, with medium to large effect sizes. Six months following treatment, the improvements remained stable, including significantly higher school attendance rates (d = 1.6; p < 0.01). Improvement in pain coping was associated with increased school attendance.

CONCLUSION

Inpatient multidisciplinary treatment is effective in reducing levels of discomfort, psychiatric comorbidity (anxiety, depression), and school absence and in improving coping strategies.

Changes in Maternal and Paternal Pain-Related Attitudes, Behaviors, and Perceptions across Pediatric Pain Rehabilitation Treatment: A Multilevel Modeling Approach

Objectives

This prospective study compared paternal versus maternal factors and their impact on child outcomes in the context of an intensive pediatric pain rehabilitation program.

Methods

One hundred four youth with treatment refractory chronic pain and their parents enrolled in an intensive pediatric pain rehabilitation program completed measures of pain, functional disability, and parent pain-related attitudes, perceptions, and behaviors at admission and discharge.

Results

Linear mixed models were used. Controlling for significant demographic and clinical characteristics, mothers and fathers who were present for the program typically demonstrated significantly better improvement from admission to discharge compared with nonpresent fathers. Mothers made the most significant gains in protective parent responses. Children also had significant decreases in pain and improvements in functioning over time.

Conclusions

Results indicate the efficacy of this treatment model for both children with chronic pain and their parents and highlights the importance of parental presence in treatment.

Chronic non-cancer pain in children: we have a problem, but also solutions

Chronic non-cancer pain in children and adolescents has been described as "a modern public health disaster" that has generated significant medical and economic burdens within society. Seen as a disease in its own right, chronic pain has short and long-term consequences that impact not only the patient's health but also that of friends and families, due to significant parenting stress and disruptions in family life and structure. The evidence supporting pharmacological treatments and interventional procedures is limited, and no single strategy has been shown to be completely effective in children with chronic non-cancer pain. Therefore, considering the multifactorial nature of chronic pain, these patients should be treated with a multidisciplinary, balanced approach that seeks a primary outcome of improved functioning rather than of pain reduction. Using a bio-psycho-social approach, a multidisciplinary team, including a physiotherapist, nurse, social worker, psychologist, and physician, has been effective in achieving this outcome of improved functioning in children and adolescents with chronic pain. In this review, we discuss the impact, associated conditions, and evolution of chronic pain, along with the crucial role of every member of a multidisciplinary chronic pain clinic involved in the care of the children and adolescents with chronic non-cancer pain.

Pain and its Impact on the Functional Ability in Children Treated at the Children's Cancer Center of Lebanon

PURPOSE

The purpose of this study was to describe the characteristics of pain in children under treatment at the Children Cancer Centre of Lebanon at the American University of Beirut Medical Centre. Design and Methods A cross-sectional correlational survey was used. The Adolescent Pediatric Pain Tool and the Functional Disability Inventory were used to examine the characteristics of pain experienced in a consecutive sample of children treated at the CCCL and its impact on their functional abilities.

RESULTS

The mean age of the 62 participants was 12.3 (SD 2.9). The overall mean pain intensity rating for the sample was 5.06 (SD 1.87) on a 10 cm Word Graphic Rating Scale. More than one-half of the children in the sample (57.4%) reported having pain "sometimes" with a median duration of two hours per pain episode. The most frequently reported locations of pain were the forehead, the abdomen, and the lower back. For the most part, the children used sensory words to describe their pain experience. The children reported moderate levels of functional disability (mean FDI score 25.04, SD 13.81). Multivariable linear regression analysis identified frequency, duration, location, use of affective descriptors, and treatments as statistically significant predictors of pain intensity.

CONCLUSION

Regrettably, the findings reported attest once again to unrelieved pain in a pediatric oncology population.

PRACTICE IMPLICATIONS

Policy makers can contribute to pain control by introducing legislation and national policies to ensure adequate pain management for children with cancer in Lebanon.

Connecting the Mind-Body Split: Understanding the Relationship between Symptoms and Emotional Well-Being in Chronic Pain and Functional Gastrointestinal Disorders

Paediatric chronic conditions, e.g., chronic pain and functional gastrointestinal disorders, are commonly diagnosed, with fatigue, pain and abdominal discomfort the most frequently reported symptoms across conditions. Regardless of whether symptoms are connected to an underlying medical diagnosis or not, they are often associated with an increased experience of psychological distress by both the ill child and their parents. While pain and embarrassing symptoms can induce increased distress, evidence is also accumulating in support of a reciprocal relationship between pain and distress. This reciprocal relationship is nicely illustrated in the fear avoidance model of pain, which has recently been found to be applicable to childhood pain experiences. The purpose of this article is to illustrate how mind (i.e., emotions) and body (i.e., physical symptoms) interact using chronic pain and gastrointestinal disorders as key examples. Despite the evidence for the connection between mind and body, the mind-body split is still a dominant position for families and health care systems, as evidenced by the artificial split between physical and mental health care. In a mission to overcome this gap, this article will conclude by providing tools on how the highlighted evidence can help to close this gap between mind and body.

Physical and occupational therapy outcomes: Adolescents' change in functional abilities using objective measures and self-report

PURPOSE

This study evaluates the clinical usefulness of patient-rated and objective measures to identify physically-oriented functional changes after an intensive chronic pain program in a pediatric setting. Past studies have demonstrated the importance of adolescents' perception of their abilities and measurement tools used for rehabilitation outcomes within physical and occupational therapy; however, these tools used are not often easily utilized or have not been examined with a pediatric chronic pain population. In chronic pain rehabilitation, it is important to have a primary focus on functional improvement not on pain reduction as a leading outcome. This study examines how both self-report and objective physical activity measures can be meaningful constructs and can be used as reliable outcome measures. It was hypothesized that adolescents completing an interdisciplinary pain rehabilitation program would report functional gains from admission to discharge, and that perceived gains in physical ability would be associated with objective physical activities. Further, it was hypothesized that gains in functioning would be associated with mild pain reduction.

METHODS

Data from 78 children and adolescents with chronic pain that participated in an intensive multidisciplinary treatment program completed self-report measures including the Lower Extremity Functional Scale (LEFS), Upper Extremity Functional Index (UEFI). In addition, adolescents were objectively monitored for repetitions of selected physical activities for 1min intervals.

RESULTS

Data demonstrated significant gains in all measures of functioning during the program. Correlations between self-report and objective outcomes suggest they are measuring similar yet distinct factors.

CONCLUSIONS

The LEFS, UEFI, and objective exercises provide a meaningful way to track progress in pediatric chronic pain rehabilitation. Despite similarities, they appear to track separate but related aspects of rehabilitation and capture important short-term response to rehabilitation. Both measures appear distinct from pain as an outcome. These findings increase our understanding of rehabilitation practices provide opportunities to promote clinical improvement in pediatric pain.

IMPLICATIONS

The use of self-report measures along with objective measures can help therapists gain understanding in regards to a patient's insight and how that may impact their overall outcome compared to the use of a single outcome measure. Viewing these rated measures at any point in the rehabilitation process can be useful to facilitate discussion about challenges they can identify and how therapies can facilitate improvement and functional gains.

Pediatric chronic pain programs: current and ideal practice

This report may be useful for health care professionals and policy makers concerned with improving the care of children with chronic pain and their families.

Introduction:

The treatment of youth with chronic pain has improved in recent years. However, because pediatric chronic pain programs are not governed by international standards, the development and implementation of new initiatives may be limited.

Objectives:

The objectives of this study were to identify the features of programs as they exist at present and to determine what features they should have in an ideal state.

Methods:

A web-based international survey was used to collect information. The survey contained 86 questions seeking respondent professional demographic data and information about the pain program with which the respondent was affiliated at the time (program organization, types of pain problem treated, professionals involved, services provided, size of the program, research, professional training, public education and advocacy, and funding sources).

Results:

Respondents were 136 pediatric pain experts representing different specialties located in 12 countries. Most respondents indicated that ideal programs would have a multidisciplinary staff; provide a wide range of treatments for different chronic pain problems; integrate research, formal clinical training of specialists, and public education and advocacy into their activities; and be an accredited part of the public health system.

Conclusions:

The results of this survey may be useful for health care professionals interested in treating chronic pain in children and adolescents and for policy makers concerned with improving the care given to these children and their families.