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Mirzaie S, Oberoi MK, Huang KX, Caprini RM, Malapati SH, Dejam D, Bedar M, Cronin BJ, Khetpal S, Lee JC. Association of Patient-Reported Anxiety and Pain After Alveolar Bone Grafting. Cleft Palate Craniofac J 2024; 61:1336-1343. [PMID: 37077147 PMCID: PMC11308277 DOI: 10.1177/10556656231169483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023] Open
Abstract
OBJECTIVE To evaluate the role of psychosocial well-being on perioperative pain and opioid use among patients with cleft lip and palate (CLP) undergoing alveolar bone grafting (ABG). DESIGN Retrospective review. SETTING Tertiary level craniofacial clinic. PARTICIPANTS 34 patients with CLP (median age: 11.7 years), including 25 (73.5%) unilateral CLP and 9 (26.5%) bilateral CLP, who underwent ABG from 2015 to 2022. INTERVENTIONS ABG using iliac crest bone graft. Patients were prospectively administered four patient-reported psychosocial instruments from the Patient-Reported Outcomes Measurement Information System. MAIN OUTCOME MEASURES Perioperative opioid use in morphine equivalent dosage/kilogram, patient-reported pain scores, and length of hospital stay after ABG. RESULTS Patient-reported anxiety (r = 0.41, p = 0.02) and depressive symptoms (r = 0.35, p = 0.04) correlated to higher perioperative opioid usage. Multivariable regression models including psychosocial scores, total acetaminophen usage, length of surgery, and other simultaneous surgeries were developed for total opioid usage, patient-reported pain, and length of hospital stay. Patient-reported anxiety was independently predictive of higher perioperative opioid use (β=0.36, p = 0.01) and higher pain scores (β=0.39, p = 0.02), but not length of hospital stay. CONCLUSIONS We identified an association for patient-reported anxiety and perioperative opioid use and pain in a CLP cohort undergoing ABG. Future considerations in preoperative patient and family consultation may be indicated in patients self-reporting higher anxiety in an effort to minimize perioperative opioid usage.
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Affiliation(s)
- Sarah Mirzaie
- Division of Plastic and Reconstructive Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Michelle K. Oberoi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Kelly X. Huang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Rachel M. Caprini
- Division of Plastic and Reconstructive Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Sri Harshini Malapati
- Division of Plastic and Reconstructive Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Dillon Dejam
- Division of Plastic and Reconstructive Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Meiwand Bedar
- Division of Plastic and Reconstructive Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Brendan J. Cronin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Sumun Khetpal
- Division of Plastic and Reconstructive Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Justine C. Lee
- Division of Plastic and Reconstructive Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California, USA
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Kammerer E, Linkiewich D, Ali S. Healthcare professionals' perspectives on optimizing pain care-related education at a Canadian children's hospital: A qualitative study. Paediatr Child Health 2024; 29:163-167. [PMID: 38827367 PMCID: PMC11141606 DOI: 10.1093/pch/pxad071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 10/06/2023] [Indexed: 06/04/2024] Open
Abstract
Objectives Pain affects all children and youth, yet acute and procedural pain remains undertreated in Canadian hospitals. To improve pain management practices in paediatric hospitals, it is necessary to understand how healthcare professionals (HCPs) wish for educational interventions to be designed to improve their pain management practice. Methods Semi-structured interviews were conducted with 18 HCPs between October and December 2020. Snowball sampling was used to first recruit interested members from the hospital's Pediatric Pain Management Committee. Interviews were conducted per participant preference and included Zoom, telephone, and in-person interviews. Recruitment ceased when data were determined sufficiently rich. A thematic analysis of verbatim transcripts and reflexive field notes were used to create a data set focused on knowledge mobilization and clinical education. Results Three core themes were identified: (a) the necessity for just-in-time education for HCPs; (b) the availability of clinical pain champions to educate staff; and (c) the provision of resources to educate children and their families about available pain management interventions. Just-in-time education included suggestions for in-service training, hands-on training, and regular updates on the latest research. Pain champions, including clinical nurse educators, were stressed as being important in motivating staff to improve their pain management practices. Participants noted the lack of resources for patient and family education on pain management and suggested providing more multimodal resources and educational opportunities. Conclusion Having local champions introduce pain management initiatives and just-in-time education positively impacts the implementation climate, which also helps HCPs provide evidence-based education and resources to patients and families.
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Affiliation(s)
- Elise Kammerer
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- Faculty of Medicine and Dentistry, Women and Children’s Health Research Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Delane Linkiewich
- Department of Psychology, University of Guelph, Guelph, Ontario, Canada
| | - Samina Ali
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- Faculty of Medicine and Dentistry, Women and Children’s Health Research Institute, University of Alberta, Edmonton, Alberta, Canada
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Thorsell Cederberg J, Bartels SL, Thulin M, Beeckman M, Wicksell RK, Goubert L. Child and Parent Risk and Resilience Factors as Predictors of Long-term Recovery in Youth Undergoing Spinal Fusion Surgery. Clin J Pain 2024; 40:278-287. [PMID: 38287774 PMCID: PMC11005675 DOI: 10.1097/ajp.0000000000001200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 01/16/2024] [Accepted: 01/16/2024] [Indexed: 01/31/2024]
Abstract
OBJECTIVES Undertreated pediatric postsurgical pain negatively affects health-related quality of life (HRQOL) and functioning and may lead to chronic postsurgical pain (CPSP). Predictors of recovery have been identified but more research is needed, particularly regarding resilience, social factors, and long-term effects. The aim of the present study was to investigate child and parent risk and resilience factors as predictors of long-term postsurgical recovery for adolescents. METHODS Participants were patients with Adolescent Idiopathic Scoliosis (AIS), 12 to 18 years old, undergoing spinal fusion, and their parents. Recruitment occurred at the orthopedic units at 4 hospitals in Belgium. Data were collected before surgery (T0), at 3 (T1) and 6 weeks (T2), 6 months (T3), and 1 year (T4) post surgery. Multiple regression models were used to evaluate the predictive effect of pain intensity, pain catastrophizing, psychological flexibility, and pain acceptance on long-term functioning, HRQOL, and pain. RESULTS The sample comprised 100 adolescents and 61 parents. Pain at T0, T1, and T3 and adolescent pain catastrophizing (T0) predicted health-related quality of life, functioning, and pain at T4 (while pain at T2 predicted HRQOL and pain). Parent pain catastrophizing predicted pain at T4. Adolescent and parental psychological flexibility predicted HRQOL, and parent psychological flexibility also predicted pain at T4. Adolescent acceptance at T1 predicted pain, and acceptance at T2 predicted HRQOL, at T4. DISCUSSION The study identified pain and adolescent pain catastrophizing as risk factors, and adolescent and parental psychological flexibility and adolescent pain acceptance as resilience factors, for long-term recovery in youths undergoing spinal fusion. Postsurgical pain management targeting these factors may therefore promote recovery for these adolescents.
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Affiliation(s)
| | | | - Måns Thulin
- Mathematics, Uppsala University, Uppsala, Sweden
| | | | | | - Liesbet Goubert
- Experimental-Clinical and Health Psychology, Ghent University, Ghent, Belgium
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Kammerer E, Elliott SA, Hartling L, Basi C, Dennett L, Khangura JK, Scott SD, Candelaria P, Ruzycki S, Ali S. Pain experiences of marginalized children in the emergency department: A scoping review protocol. PLoS One 2024; 19:e0296518. [PMID: 38635744 PMCID: PMC11025926 DOI: 10.1371/journal.pone.0296518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 12/14/2023] [Indexed: 04/20/2024] Open
Abstract
INTRODUCTION Pain affects all children, and in hospitals across North America, this pain is often undertreated. Children who visit the emergency department (ED) experience similar undertreatment, and they will often experience a painful procedure as part of their diagnostic journey. Further, children and their caregivers who experience social injustices through marginalization are more likely to experience healthcare disparities in their pain management. Still, most of our knowledge about children's pain management comes from research focused on well-educated, white children and caregivers from a middle- or upper-class background. The aim of this scoping review is to identify, map, and describe existing research on (a) how aspects of marginalization are documented in randomized controlled trials related to children's pain and (b) to understand the pain treatment and experiences of marginalized children and their caregivers in the ED setting. METHODS AND ANALYSIS The review will follow Joanna Briggs Institute methodology for scoping reviews using the Participant, Concept, Context (PCC) framework and key terms related to children, youth, pain, ED, and aspects of marginalization. We will search Medline, Embase, PsychInfo, CINAHL, Web of Science, Cochrane Library Trials, iPortal, and Native Health Database for articles published in the last 10 years to identify records that meet our inclusion criteria. We will screen articles in a two-step process using two reviewers during the abstract and full-text screening stages. Data will be extracted using Covidence for data management and we will use a narrative approach to synthesize the data. ETHICS AND DISSEMINATION Ethical approval is not required for this review. Findings will be disseminated in academic manuscripts, at academic conferences, and with partners and knowledge users including funders of pain research and healthcare professionals. Results of this scoping review will inform subsequent quantitative and qualitative studies regarding pain experiences and treatment of marginalized children in the ED.
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Affiliation(s)
- Elise Kammerer
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Sarah A. Elliott
- Alberta Research Centre for Health Evidence, Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
- Department of Pediatrics, Cochrane Child Health, University of Alberta, Edmonton, AB, Canada
| | - Lisa Hartling
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
- Alberta Research Centre for Health Evidence, Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
- Department of Pediatrics, Cochrane Child Health, University of Alberta, Edmonton, AB, Canada
- Women and Children’s Health Research Institute, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Calveen Basi
- Departments of Chemistry and Psychology, Faculty of Science, University of Alberta, Edmonton, AB, Canada
| | - Liz Dennett
- Geoffrey and Robyn Sperber Health Sciences Library, University of Alberta, Edmonton, AB, Canada
| | - Jaspreet K. Khangura
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | | | - Patricia Candelaria
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Shannon Ruzycki
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Samina Ali
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
- Women and Children’s Health Research Institute, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
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Nair AA, Placencia JL, Farber HJ, Aparasu RR, Johnson M, Chen H. Pain-related hospitalization and emergency room visit following initial analgesic prescription after outpatient surgery. Pharmacoepidemiol Drug Saf 2024; 33:e5759. [PMID: 38357824 DOI: 10.1002/pds.5759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 10/31/2023] [Accepted: 01/15/2024] [Indexed: 02/16/2024]
Abstract
PURPOSE Our study examined the association between outpatient postsurgical analgesic prescription and risk of insufficiently managed pain characterized by pain-associated hospital admission and emergency room (ER) visit. METHODS Eligible individuals were children 1-17 years of age who filled an incident analgesic following an outpatient surgery during 2013-2018. Pain-associated hospital admission or ER visit were measured within 30 days following the outpatient surgical procedure. A hierarchical multivariable logistic regression model with patients nested under prescribers was fitted to test the association between incident analgesic prescription and risk of having pain-associated hospital admission or ER visit. RESULTS Of 14 277 children meeting the inclusion criteria, 6224 (43.6%) received an incident opioid and 8053 (56.4%) received an incident non-opioid analgesic prescription respectively. There were a total of 523 (3.7%) children undergoing surgical procedures that had pain-related hospital admissions or ER visits with 5.1% initiated on non-opioid analgesics and 1.8% on opioid analgesics. The multilevel model indicated that initial opioid analgesic recipients were 32% less likely of having a pain-associated hospital admission or ER visit [aOR: 0.68 (95% CI: 0.3-0.8)]. CONCLUSION Majority of postsurgical patients do not require additional pain management strategies. In the 3.7% of patients requiring additional pain management strategies, those initiated on non-opioid analgesics are more likely to have a pain-associated hospital admission or ER visit compared with their opioid recipient counterparts.
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Affiliation(s)
- Abhishek A Nair
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas, USA
| | | | - Harold J Farber
- Department of Pediatrics, Section of Pulmonology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Rajender R Aparasu
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas, USA
| | - Michael Johnson
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas, USA
| | - Hua Chen
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, Texas, USA
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Pope N, Jones S, Crellin D, Palmer G, South M, Harrison D. "Seeing the light in the shade of it": primary caregiver and youth perspectives on using an inpatient portal for pain care during hospitalization. Pain 2024; 165:450-460. [PMID: 37638836 DOI: 10.1097/j.pain.0000000000003039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 06/30/2023] [Indexed: 08/29/2023]
Abstract
ABSTRACT Studies from multiple countries report that most hospitalized children, especially the youngest and sickest, experience pain that is often severe yet inadequately treated. Evidence suggests this can lead to immediate and lifelong consequences affecting children, families, and communities. Partnership and shared decision-making by children, families, and clinicians is the ideal pediatric healthcare model and can improve care quality and safety, including pain care. A growing evidence base demonstrates that inpatient portals (electronic personal health record applications linked to hospital electronic medical or health records) can improve child and family engagement, outcomes, and satisfaction during hospitalization. This study examined the perspectives of caregivers of hospitalized children and of hospitalized youth about using an inpatient portal to support their engagement in pain care while in hospital. A qualitative descriptive study design was used and 20 participants (15 caregivers and 5 youth) with various painful conditions in one pediatric hospital participated in semistructured interviews. The authors applied a reflexive content analysis to the data and developed 3 broad categories: (1) connecting and sharing knowledge about pain, (2) user-centred designs, and (3) preserving roles. These findings outlined caregiver and youth recommendations for portal configurations that deeply engage and empower children and families in pain care through multidirectional knowledge sharing, supporting caregiver and clinicians' roles without burdening, or replacing human interaction implicit in family-centered pain care. Further research should measure the impact of portals on pain-related outcomes and explore the perspectives of clinicians.
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Affiliation(s)
- Nicole Pope
- The Royal Children's Hospital, Melbourne, Australia
- The University of Melbourne, Australia, Faculty of Medicine, Dentistry and Health Sciences, Department of Nursing
- The Murdoch Children's Research Institute, Melbourne, Australia
| | - Sophie Jones
- The Royal Children's Hospital, Melbourne, Australia
- The University of Melbourne, Australia, Faculty of Medicine, Dentistry and Health Sciences, Department of Nursing
- The Murdoch Children's Research Institute, Melbourne, Australia
| | - Dianne Crellin
- The Royal Children's Hospital, Melbourne, Australia
- The University of Melbourne, Australia, Faculty of Medicine, Dentistry and Health Sciences, Department of Nursing
- The Murdoch Children's Research Institute, Melbourne, Australia
| | - Greta Palmer
- The Royal Children's Hospital, Melbourne, Australia
- The University of Melbourne, Australia, Faculty of Medicine, Dentistry and Health Sciences, Department of Nursing
- The Murdoch Children's Research Institute, Melbourne, Australia
| | - Mike South
- The Royal Children's Hospital, Melbourne, Australia
- The University of Melbourne, Australia, Faculty of Medicine, Dentistry and Health Sciences, Department of Nursing
- The Murdoch Children's Research Institute, Melbourne, Australia
| | - Denise Harrison
- The Royal Children's Hospital, Melbourne, Australia
- The University of Melbourne, Australia, Faculty of Medicine, Dentistry and Health Sciences, Department of Nursing
- The Murdoch Children's Research Institute, Melbourne, Australia
- The University of Melbourne, Australia. Faculty of Medicine, Dentistry and Health Sciences, Department Paediatrics
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Pope N, Korki de Candido L, Crellin D, Palmer G, South M, Harrison D. Call to focus on digital health technologies in hospitalized children's pain care: clinician experts' qualitative insights on optimizing electronic medical records to improve care. Pain 2023; 164:1608-1615. [PMID: 36722464 DOI: 10.1097/j.pain.0000000000002863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 11/29/2022] [Indexed: 02/02/2023]
Abstract
ABSTRACT Most hospitalized children experience pain that is often inadequately assessed and undertreated. Exposure to undertreated childhood pain is associated with negative short-term and long-term outcomes and can detrimentally affect families, health services, and communities. Adopting electronic medical records (EMRs) in pediatric hospitals is a promising mechanism to transform care. As part of a larger program of research, this study examined the perspectives of pediatric clinical pain experts about how to capitalize on EMR designs to drive optimal family-centered pain care. A qualitative descriptive study design was used and 14 nursing and medical experts from 5 countries (United States, Canada, United Kingdom, Australia, and Qatar) were interviewed online using Zoom for Healthcare. We applied a reflexive content analysis to the data and constructed 4 broad categories: "capturing the pain story," "working with user-friendly systems," "patient and family engagement and shared decision making," and "augmenting pain knowledge and awareness." These findings outline expert recommendations for EMR designs that facilitate broad biopsychosocial pain assessments and multimodal treatments, and customized functionality that safeguards high-risk practices without overwhelming clinicians. Future research should study the use of patient-controlled and family-controlled interactive bedside technology to and their potential to promote shared decision making and optimize pain care outcomes.
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Affiliation(s)
- Nicole Pope
- The Royal Children's Hospital, Melbourne, Australia
- The University of Melbourne, Melbourne, Australia
- The Murdoch Children's Research Institute, Melbourne, Australia
| | | | - Dianne Crellin
- The Royal Children's Hospital, Melbourne, Australia
- The University of Melbourne, Melbourne, Australia
- The Murdoch Children's Research Institute, Melbourne, Australia
| | - Greta Palmer
- The Royal Children's Hospital, Melbourne, Australia
- The University of Melbourne, Melbourne, Australia
- The Murdoch Children's Research Institute, Melbourne, Australia
| | - Mike South
- The Royal Children's Hospital, Melbourne, Australia
- The University of Melbourne, Melbourne, Australia
- The Murdoch Children's Research Institute, Melbourne, Australia
| | - Denise Harrison
- The Royal Children's Hospital, Melbourne, Australia
- The University of Melbourne, Melbourne, Australia
- The Murdoch Children's Research Institute, Melbourne, Australia
- The University of Ottawa, Ottawa, ON, Canada
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Agoston AM. Expanding Neuroprotective Care: A Trauma-Informed Approach to Delivery of Services within Pediatric Inpatient Units. Clin Pediatr (Phila) 2023; 62:234-240. [PMID: 36039787 DOI: 10.1177/00099228221120290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Children with a history of trauma or adverse childhood experiences may be at higher risk for poor psychological and physical responses to medical experiences aimed at enhancing their well-being. Health care institutions are aware of the need for integration of trauma-informed care (TIC) practices yet struggle to find frameworks that promote resiliency to medical stress. An approach called neuroprotective care buffers the effects of toxic stress negatively affecting child health and well-being. Although often used in neonatal and cardiac intensive care units, the development and broad implementation of universal neuroprotective care measures across age groups and hospital settings has not been previously explored. An expanded neuroprotective care protocol takes a prevention approach to TIC. It fits a TIC framework, accounts for children's ecological, biological, and developmental needs, protects them against medical traumatic stress and retraumatization, and provides a tailored, measurable approach that systematically preserves child well-being within hospital settings.
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Affiliation(s)
- A Monica Agoston
- Children's Healthcare of Atlanta, Atlanta, GA, USA.,Division of Pediatric Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
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Sieberg CB, Lunde CE, Wong C, Manganella J, Starkweather AR, Sethna N, Perry-Eaddy MA. Pilot Investigation of Somatosensory Functioning and Pain Catastrophizing in Pediatric Spinal Fusion Surgery. Pain Manag Nurs 2023; 24:27-34. [PMID: 36564325 PMCID: PMC9925410 DOI: 10.1016/j.pmn.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 11/11/2022] [Accepted: 11/13/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE Chronic post-surgical pain (CPSP) is a significant concern and contributes to the opioid epidemic; however, little is known about CPSP in young people. DESIGN This prospective study aimed to identify sensory, psychological, and demographic factors that may increase the risk of CPSP after spinal fusion surgery for children and adolescents with idiopathic scoliosis. METHODS 32 children and adolescents from two children's hospitals completed quantitative sensory testing (QST) and the Pain Catastrophizing Scale Child (PCS-C) pre-and 4-6 months post spinal fusion surgery. Between-group differences were assessed using an independent samples t-test. Pearson's correlations and stepwise linear regression were used to assess the relationship between variables at both time points. RESULTS 56% of patients endorsed pain post-surgery. They were more sensitive tomechanical detection on both a control non-pain site (r = -2.87, p = .004) and the back (r = -1.83, p = .04), as well as pressure pain (r=-2.37, p = .01) on the back. This group also reported worse pain scores pre-surgery. Pre-surgery helplessness positively correlated with preoperative pain (r = .67 p < .001), and age was negatively correlated with the post-surgical catastrophizing total score (r =-.39, p = .05), suggesting that younger patients endorsed more pain-related worry after surgery. CONCLUSIONS Patients who present with pain during their preoperative appointment may need to be monitored with increased vigilance throughout the perioperative period, possibly with bedside QST and psychological questionnaires, which nurses could administer. Biobehavioral interventions targeting pain intensity and feelings of helplessness and anxiety during the preoperative period may alleviate the transition to CPSP.
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Affiliation(s)
- Christine B Sieberg
- Biobehavioral Pain Innovations Lab, Department of Psychiatry and Behavioral Sciences, Boston Children's Hospital, Boston, Massachusetts; Pain and Affective Neuroscience Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts; Department of Psychiatry, Harvard Medical School, Boston, Massachusetts.
| | - Claire E Lunde
- Biobehavioral Pain Innovations Lab, Department of Psychiatry and Behavioral Sciences, Boston Children's Hospital, Boston, Massachusetts; Pain and Affective Neuroscience Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts; Nuffield Department of Women's and Reproductive Health, Medical Sciences Division, University of Oxford, Oxford, England
| | - Cindy Wong
- Biobehavioral Pain Innovations Lab, Department of Psychiatry and Behavioral Sciences, Boston Children's Hospital, Boston, Massachusetts
| | - Juliana Manganella
- Biobehavioral Pain Innovations Lab, Department of Psychiatry and Behavioral Sciences, Boston Children's Hospital, Boston, Massachusetts
| | | | - Navil Sethna
- Biobehavioral Pain Innovations Lab, Department of Psychiatry and Behavioral Sciences, Boston Children's Hospital, Boston, Massachusetts; Pain and Affective Neuroscience Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts; Mayo Family Pediatric Pain Rehabilitation Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts; Department of Anesthesiology, Harvard Medical School, Boston, Massachusetts
| | - Mallory A Perry-Eaddy
- University of Connecticut, School of Nursing, Storrs, Connecticut; University of Connecticut, School of Medicine, Department of Pediatrics, Storrs, Connecticut; University of Connecticut, Institute for Collaboration on Health, Intervention, and Policy (InCHIP), Storrs, Connecticut; Pediatric Intensive Care Unit, Connecticut Children's, Hartford, CT
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10
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Holley AL, Gaultney W, Wilson AC. Using the Parent Risk Screening Measure (PRISM) to Assess Pain-Related Risk Factors in Parents of Youth Seeking Treatment for Acute Musculoskeletal Pain. Clin J Pain 2022; 38:520-527. [PMID: 35696711 PMCID: PMC9283372 DOI: 10.1097/ajp.0000000000001053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 05/26/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The Parent Risk Screening Measure (PRISM) rapidly assesses parent distress, psychosocial function, and behaviors associated with child pain-related dysfunction in parents of youth with chronic pain. Recognizing the importance of parent pain-related cognitions and responses to pain during the acute pain period, the current study examined the utility of the PRISM in screening parents of youth with acute pain. METHODS Participants were 175 parent-youth dyads taking part in a larger study examining risk and resilience in youth with acute musculoskeletal pain. Parents completed the PRISM and a battery of measures reporting on their child's pain-related disability and cognitions and behaviors in response to their child's pain. Youth reported on their pain, pain-related disability, pain-related fear, catastrophizing, and pain self-efficacy. RESULTS PRISM total scores ( M =2.55, SD=2.77) were correlated with many parent and child report measures (eg, protectiveness, catastrophizing, and pain-related fear), with higher scores associated with greater symptoms. Using published PRISM cutoffs, 86.9% of parents were classified as low and 13.13% as elevated risk. t tests revealed significant differences between elevated and low-risk groups on several measures. Moreover, youth of parents in the elevated risk group were more likely to meet clinical cutoffs on pain catastrophizing and fear avoidance measures. DISCUSSION Findings suggest the PRISM is useful in screening for parent distress and behaviors associated with elevated pain symptomatology in a pediatric acute musculoskeletal pain sample. The important next steps are to identify the ideal time for administering the PRISM and to examine the associations among PRISM scores and pain outcomes over time.
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Affiliation(s)
- Amy L Holley
- Division of Psychology, Department of Pediatrics, Oregon Health and Science University (OHSU), Portland, OR
| | | | - Anna C Wilson
- Division of Psychology, Department of Pediatrics, Oregon Health and Science University (OHSU), Portland, OR
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Ellyson AM, Gordon G, Zhou C, Rabbitts JA. Trajectories, Risk Factors, and Impact of Persistent Pain After Major Musculoskeletal Surgery in Adolescents: A Replication Study. THE JOURNAL OF PAIN 2022; 23:995-1005. [PMID: 34974171 PMCID: PMC9232895 DOI: 10.1016/j.jpain.2021.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 12/20/2021] [Accepted: 12/20/2021] [Indexed: 06/03/2023]
Abstract
Studies have identified high rates of chronic postsurgical pain in adolescents. Characterizing patterns of pain in the transition from acute to chronic following major surgery may pinpoint critical periods of recovery. This observational study modelled pain trajectories over 1-year following surgery to attempt replication of prior work and evaluate baseline psychosocial factors and 12-month health outcomes. Adolescents 10 to 18 years completed electronic daily pain reporting for 7 days and self-reported health outcomes, at 5 assessment timepoints. Group-based trajectory modelling identified two trajectories with similar starting points in-hospital but distinct recovery courses at home. Pain declined steadily in one group across the study period ("Declining Pain"; estimated probability,18.9%), but pain increased after hospital discharge and remained high through 12-months in the other group ("High and Persistent Pain"; estimated probability,81.1%). Pre-surgery pain (Aor = 1.86, P = .001) and sleep quality (Aor = 0.49, P = .029) were associated with the High and Persistent pain trajectory in multivariate regressions. This trajectory was associated with lower total quality of life (B=-9.79, P = .002), physical health (B = -15.93, P < .001), psychosocial health (B = -6.73, P = .06), and greater fatigue (B = -13.61, P = .001). This study replicated prior findings identifying two post-surgical pain trajectories with diverging pain in the first two weeks. Clinical detection of those with increasing pain and early intervention may interrupt persistence of pain. PERSPECTIVE: This article replicates a prior study identifying distinct post-surgical pain trajectories, Declining Pain and High and Persistent Pain. The High and Persistent pain trajectory is associated with pre-surgery pain, pre-surgery sleep quality, and lower quality of life (total, physical, and psychosocial health as well as fatigue) at 12-month follow-up.
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Affiliation(s)
- Alice M Ellyson
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington
| | - Grace Gordon
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington; University of Washington College of Arts and Sciences, Seattle, Washington
| | - Chuan Zhou
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington
| | - Jennifer A Rabbitts
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington; Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington.
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Birnie KA, Stinson J, Isaac L, Tyrrell J, Campbell F, Jordan IP, Marianayagam J, Richards D, Rosenbloom BN, Clement F, Hubley P. Mapping the current state of pediatric surgical pain care across Canada and assessing readiness for change. Can J Pain 2022; 6:108-120. [PMID: 35692556 PMCID: PMC9176261 DOI: 10.1080/24740527.2022.2038031] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background Preventing pediatric chronic postsurgical pain is a patient, parent/caregiver, health care professional, and policymaker priority. Poorly managed presurgical and acute postsurgical pain are established risk factors for pediatric chronic postsurgical pain. Effective perioperative pain management is essential to prevent the transition from acute to chronic pain after surgery. Aims The aim of this study was to identify current pediatric surgical pain management practices and assess health system readiness for change at health care institutions conducting pediatric surgery in Canada. Methods An online survey was completed by 85 multidisciplinary health care professionals (nurses, surgeons, anesthesiologists, allied health) from 20 health institutions in Canada regarding institutional pre- and postsurgical pediatric pain care, specialty pain services, and Organizational Readiness for Implementing Change (ORIC). Results Of all specialty pain services, acute and chronic/complex pain services were most common, primarily with physician and nursing involvement. Alignment to recommended practices for pediatric pre- and postsurgical pain care varied (38.1%–79.8% reported “yes, for every child”), with tertiary/quaternary children’s hospitals reporting less alignment than other institutions (community/regional or rehabilitation hospitals, community treatment centers). No significant differences were reported between health care institutions serving pediatric populations only versus those also serving adults. Health care professional experience/practice was the most reported strength in pediatric surgical pain care, with inconsistent standard of care the most common gap. Participants “somewhat agreed” that their institutions were committed and capable of change in pediatric surgical pain care. Conclusions There is a continued need to improve pediatric pain care during the perioperative period at Canadian health care institutions to effectively prevent the development of pediatric postsurgical pain.
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Affiliation(s)
- Kathryn A. Birnie
- Department of Anesthesiology, Perioperative, and Pain Medicine, University of Calgary, 2500 University Dr NW, Calgary, AB T2N 1N4
- Department of Community Health Sciences, University of Calgary, 2500 University Dr NW, Calgary, AB T2N 1N4
- Alberta Children’s Hospital Research Institute, 3330 Hospital Dr NW, Calgary, AB T2N 4N1
| | - Jennifer Stinson
- Child Health Evaluative Sciences, The Hospital for Sick Children, 686 Bay St., Toronto, ON M5G 0A4
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College St, Toronto, ON M5T 1P8
| | - Lisa Isaac
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children555 University Ave, Toronto, ON M5G 1X8
- Department of Anesthesiology and Pain Medicine, University of Toronto, 123 Edward St., Toronto, ON M5G 1E2
| | - Jennifer Tyrrell
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College St, Toronto, ON M5T 1P8
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children555 University Ave, Toronto, ON M5G 1X8
| | - Fiona Campbell
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children555 University Ave, Toronto, ON M5G 1X8
- Department of Anesthesiology and Pain Medicine, University of Toronto, 123 Edward St., Toronto, ON M5G 1E2
| | | | | | - Dawn Richards
- Five02Labs, Inc., #502 – 25 Ritchie Ave, Toronto, ON M6R 2J6
| | - Brittany N. Rosenbloom
- Child Health Evaluative Sciences, The Hospital for Sick Children, 686 Bay St., Toronto, ON M5G 0A4
| | - Fiona Clement
- Department of Community Health Sciences, University of Calgary, 2500 University Dr NW, Calgary, AB T2N 1N4
| | - Pam Hubley
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College St, Toronto, ON M5T 1P8
- The Hospital for Sick Children, 555 University Ave, Toronto, ON M5G 1X8
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Murray CB, Bartlett A, Meyyappan A, Palermo TM, Aaron R, Rabbitts J. A pilot feasibility and acceptability study of an internet-delivered psychosocial intervention to reduce postoperative pain in adolescents undergoing spinal fusion. Can J Pain 2021; 6:12-23. [PMID: 35434455 PMCID: PMC9009921 DOI: 10.1080/24740527.2021.2009334] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background Spinal fusion surgery is a common and painful musculoskeletal surgery performed in the adolescent population. Despite the known risk for developing chronic postsurgical pain, few perioperative psychosocial interventions have been evaluated in this population, and none have been delivered remotely (via the Internet) to improve accessibility. Aims The aim of this single-arm pilot study was to evaluate the feasibility and acceptability of the first Internet-based psychological intervention delivered during the perioperative period to adolescents undergoing major spinal fusion surgery and their parents. Methods Thirteen adolescents (M age = 14.3; 69.2% female) scheduled for spine fusion surgery and their parents were provided access to the online psychosocial intervention program. The program included six lessons delivering cognitive-behavioral therapy skills targeting anxiety, sleep, and acute pain management during the month prior to and the month following surgery. Feasibility indicators included recruitment rate, intervention engagement, and measure completion. Acceptability was assessed via quantitative ratings and qualitative interviews. Results Our recruitment rate was 81.2% of families approached for screening. Among participating adolescent–parent dyads, high levels of engagement were demonstrated (100% completed all six lessons). All participants completed outcome measures. High treatment acceptability was demonstrated via survey ratings and qualitative feedback, with families highlighting numerous strengths of the program as well as areas for improvement. Conclusions These findings suggest that this online psychosocial intervention delivered during the perioperative period is feasible and acceptable to adolescents and their parents. Given favorable feasibility outcomes, an important next step is to evaluate the intervention in a full-scale randomized controlled trial.
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Affiliation(s)
- Caitlin B. Murray
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA
- Center for Child Health, Behavior and Development, Seattle Children’s Hospital, Seattle, WA, USA
| | - Anthea Bartlett
- School of Social and Political Science, The University of Edinburgh, Edinburgh, UK
| | | | - Tonya M. Palermo
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA
- Center for Child Health, Behavior and Development, Seattle Children’s Hospital, Seattle, WA, USA
| | - Rachel Aaron
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jennifer Rabbitts
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA
- Center for Clinical and Translational Research
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Beeckman M, Hughes S, Van der Kaap-Deeder J, Plasschaert F, Michielsen J, Moens P, Schelfaut S, Goubert L. Risk and Resilience Predictors of Recovery After Spinal Fusion Surgery in Adolescents. Clin J Pain 2021; 37:789-802. [PMID: 34419974 DOI: 10.1097/ajp.0000000000000971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 07/20/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This prospective study examined risk and resilience predictors of pain and functional recovery in the first 6 months after spinal fusion surgery in adolescents. METHODS Adolescents with adolescent idiopathic scoliosis undergoing spinal fusion surgery (n=100, aged 12 to 18 y, 77% girls) completed assessments before surgery and at 3 weeks, 6 weeks, and 6 months after surgery. Recovery trajectories in pain, health-related quality of life (HRQOL), and objectively registered physical activity were identified. Presurgical pain catastrophizing and pain intensity (risk), and psychological flexibility, and postsurgical pain acceptance (resilience) were examined as predictors of recovery. RESULTS Latent growth class analyses revealed 4 distinct pain recovery trajectories (ie, Severe-Moderate [11%, n=9], Mild-No [58%, n=49], Moderate-Mild [24%, n=20], and Moderate-Severe [7%, n=6] pain trajectory), 2 HRQOL recovery trajectories; 2 trajectories characterizing recovery in average daily physical activity at moderate-to-vigorous intensity (MVPA); and 3 trajectories characterizing recovery in total physical activity volume characterized by the average daily number of steps. Subsequent multivariate analyses of variance revealed that presurgical pain intensity (partial η2=0.21, P<0.001) and pain catastrophizing (partial η2=0.13, P<0.01) were both predictive of poorer recovery in HRQOL, and pain catastrophizing additionally predicted poorer pain recovery (partial η2=0.15, P<0.05). Psychological flexibility (partial η2=0.25, P<0.001) and postsurgical pain acceptance (partial η2=0.07, P<0.05) were predictive of more favorable recovery trajectories in HRQOL, and psychological flexibility additionally predicted more favorable recovery trajectories in postsurgical pain (partial η2=0.15, P<0.05). Daily MVPA trajectories were not significantly predicted by any of the hypothesized factors, while presurgical pain catastrophizing levels were predictive of a delayed recovery trajectory in the daily amount of steps (partial η2=0.17 P<0.01). CONCLUSIONS Presurgical screening could include assessment of pain intensity, pain catastrophizing, psychological flexibility, and pain acceptance to identify adolescents who are at risk for poorer recovery. These are potentially modifiable factors that can be targeted in presurgical interventions to prevent poor and foster adaptive outcomes after major surgery in adolescents.
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Affiliation(s)
| | - Sean Hughes
- Experimental-Clinical and Health Psychology, Ghent University
| | | | - Frank Plasschaert
- Department of Orthopedics and Traumatology, Ghent University Hospital, Ghent
| | | | - Pierre Moens
- Department of Orthopedics, Leuven University Hospital, Leuven, Belgium
| | | | - Liesbet Goubert
- Experimental-Clinical and Health Psychology, Ghent University
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Tirotta CF, de Armendi AJ, Horn ND, Hammer GB, Szczodry M, Matuszczak M, Wang NQ, Scranton R, Ballock RT. A multicenter study to evaluate the pharmacokinetics and safety of liposomal bupivacaine for postsurgical analgesia in pediatric patients aged 6 to less than 17 years (PLAY). J Clin Anesth 2021; 75:110503. [PMID: 34534923 DOI: 10.1016/j.jclinane.2021.110503] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 08/12/2021] [Accepted: 09/03/2021] [Indexed: 10/20/2022]
Abstract
STUDY OBJECTIVE To evaluate the pharmacokinetics and safety of liposomal bupivacaine in pediatric patients undergoing spine or cardiac surgery. DESIGN Multicenter, open-label, phase 3, randomized trial (PLAY; NCT03682302). SETTING Operating room. PATIENTS Two separate age groups were evaluated (age group 1: patients 12 to <17 years undergoing spine surgery; age group 2: patients 6 to <12 years undergoing spine or cardiac surgery). INTERVENTION Randomized allocation of liposomal bupivacaine 4 mg/kg or bupivacaine hydrochloride (HCl) 2 mg/kg via local infiltration at the end of spine surgery (age group 1); liposomal bupivacaine 4 mg/kg via local infiltration at the end of spine or cardiac surgery (age group 2). MEASUREMENTS The primary and secondary objectives were to evaluate the pharmacokinetics (eg, maximum plasma bupivacaine concentrations [Cmax], time to Cmax) and safety of liposomal bupivacaine, respectively. MAIN RESULTS Baseline characteristics were comparable across groups. Mean Cmax after liposomal bupivacaine administration was lower versus bupivacaine HCl in age group 1 (357 vs 564 ng/mL); mean Cmax in age group 2 was 320 and 447 ng/mL for spine and cardiac surgery, respectively. Median time to Cmax of liposomal bupivacaine occurred later with cardiac surgery versus spine surgery (22.7 vs 7.4 h). In age group 1, the incidence of adverse events (AEs) was comparable between liposomal bupivacaine (61% [19/31]) and bupivacaine HCl (73% [22/30]). In age group 2, 100% (5/5) and 31% (9/29) of patients undergoing spine and cardiac surgery experienced AEs, respectively. AEs were generally mild or moderate, with no discontinuations due to AEs or deaths. CONCLUSIONS Plasma bupivacaine levels following local infiltration with liposomal bupivacaine remained below the toxic threshold in adults (~2000-4000 ng/mL) across age groups and procedures. AEs were mild to moderate, supporting the safety of liposomal bupivacaine in pediatric patients undergoing spine or cardiac surgery. Clinical trial number and registry URL: ClinicalTrials.gov identifier: NCT03682302.
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Affiliation(s)
| | - Alberto J de Armendi
- University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States of America
| | - Nicole D Horn
- Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Gregory B Hammer
- Stanford University School of Medicine, Stanford, CA, United States of America
| | - Michal Szczodry
- Shriners Hospital for Children, Chicago, IL, United States of America
| | - Maria Matuszczak
- University of Texas, McGovern Medical School, Houston, TX, United States of America
| | - Natalie Q Wang
- Pacira BioSciences, Inc., Parsippany, NJ, United States of America
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Rabbitts JA, Zhou C, de la Vega R, Aalfs H, Murray CB, Palermo TM. A digital health peri-operative cognitive-behavioral intervention to prevent transition from acute to chronic postsurgical pain in adolescents undergoing spinal fusion (SurgeryPal TM): study protocol for a multisite randomized controlled trial. Trials 2021; 22:506. [PMID: 34330321 PMCID: PMC8325315 DOI: 10.1186/s13063-021-05421-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 07/03/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Spinal fusion surgery is associated with severe acute postsurgical pain and high rates of chronic postsurgical pain in adolescents. Psychological distress, sleep disturbance, and low pain self-efficacy predict higher acute pain and likelihood of developing chronic postsurgical pain. Interventions targeting baseline psychosocial risk factors have potential to interrupt a negative trajectory of continued pain and poor health-related quality of life (HRQL) over time but have not yet been developed and evaluated. This randomized controlled trial will test effectiveness of a digital peri-operative cognitive-behavioral intervention (SurgeryPalTM) vs. education-control delivered to adolescents and their parents to improve acute and chronic pain and health outcomes in adolescents undergoing spine surgery. METHODS Adolescents 12-18 years of age undergoing spinal fusion for idiopathic conditions, and their parent, will be recruited from pediatric centers across the USA, for a target complete sample of 400 dyads. Adolescents will be randomized into 4 study arms using a factorial design to SurgeryPalTM or education control during 2 phases of treatment: (1) pre-operative phase (one-month before surgery) and (2) post-operative phase (1 month after surgery). Acute pain severity and interference (primary acute outcomes) and opioid use will be assessed daily for 14 days following hospital discharge. Chronic pain severity and interference (primary acute outcomes), as well as HRQL, parent and adolescent distress, sleep quality, and opioid use/misuse (secondary outcomes), will be assessed at 3 months and 6 months post-surgery. DISCUSSION Demonstration of effectiveness and understanding optimal timing of perioperative intervention will enable implementation of this scalable psychosocial intervention into perioperative care. Ultimately, the goal is to improve pain outcomes and reduce reliance on opioids in adolescents after spine surgery. TRIAL REGISTRATION NCT04637802 ClinicalTrials.gov. Registered on November 20, 2020.
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Affiliation(s)
- Jennifer A. Rabbitts
- Center for Clinical and Translational Research (CCTR), Seattle Children’s Hospital, 4800 Sand Point Way NE MB.11.500.3, Seattle, WA 98105 USA
- Department of Anesthesiology and Pain Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA 98195 USA
| | - Chuan Zhou
- Center for Child Health Behavior and Development (CHBD), Seattle Children’s Hospital, 1920 Terry Avenue, Seattle, WA USA
- Department of Pediatrics, University of Washington, 4800 Sand Point Way NE, Seattle, WA 98105 USA
| | - Rocio de la Vega
- Department of Psychology, University of Málaga, Campus de Teatinos, s/n, 29071 Málaga, Spain
| | - Homer Aalfs
- Center for Child Health Behavior and Development (CHBD), Seattle Children’s Hospital, 1920 Terry Avenue, Seattle, WA USA
| | - Caitlin B. Murray
- Department of Anesthesiology and Pain Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA 98195 USA
- Center for Child Health Behavior and Development (CHBD), Seattle Children’s Hospital, 1920 Terry Avenue, Seattle, WA USA
| | - Tonya M. Palermo
- Department of Anesthesiology and Pain Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA 98195 USA
- Center for Child Health Behavior and Development (CHBD), Seattle Children’s Hospital, 1920 Terry Avenue, Seattle, WA USA
- Department of Pediatrics, University of Washington, 4800 Sand Point Way NE, Seattle, WA 98105 USA
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Kaplan SH, Fortier MA, Shaughnessy M, Maurer E, Vivero-Montemayor M, Masague SG, Hayes D, Stern HS, Dai M, Kain ZN. Development and initial validation of self-report measures of general health, preoperative anxiety, and postoperative pain in young children using computer-administered animation. Paediatr Anaesth 2021; 31:150-159. [PMID: 33174313 DOI: 10.1111/pan.14068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 10/06/2020] [Accepted: 10/26/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND For young children, existing measures of children's health-related quality of life must be parent-reported or interviewer-administered for those who cannot read or complete measures independently. Parents' and childrens' reports about the child's health have been shown to disagree. AIMS (a) To test the reliability and validity of an animated, computer-administered Child Health Rating Inventories (CHRIS2.0) among children aged 4-12 undergoing surgery; and (b) to develop and test two CHRIS measures of preoperative anxiety and postoperative pain management. METHODS We conducted a longitudinal cohort study of a diverse group of 542 children aged 4-12 undergoing surgery. We compared the CHRIS measures to Pediatric Quality of Life Inventory (PedsQL), the Functional Disabilities Inventory (FDI), State-Trait Anxiety Inventory for children (STAI-CH), and the Parent Postoperative Pain Measure (PPPM). RESULTS Factor analyses supported the construct validity of the 12-item general physical health and the 8-item mental health CHRIS scales, as well as a composite 20-item scale, and the CHRIS preoperative anxiety and postoperative pain scales. Internal consistency reliability for all CHRIS scales exceeded the standard for group comparisons (Cronbach's α ≥0.70). The CHRIS general health composite was significantly correlated with composite PedsQL and FDI (r = 0.28, P < .001 and r = 0.43, P < .001, respectively). The CHRIS peri-operative anxiety measure was significantly correlated with the STAI-CH (r = 0.44, P < .001), as was the CHRIS postoperative pain scale with the PPPM (r = 0.52, P < .001). CONCLUSIONS The CHRIS measures were reliable and valid in this diverse sample of young children (4-12). Because CHRIS measures are self-administered, scored in real time, and run on multiple different platforms, this approach provides a feasible method for the collection of health-related quality of life in young children and those with limited literacy. Our data indicate that this approach is psychometrically sound and has the potential for adding the child's voice to pediatric outcomes.
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Affiliation(s)
- Sherrie H Kaplan
- Health Policy Research Institute, University of California, Irvine, CA, USA
| | - Michelle A Fortier
- Sue & Bill Gross School of Nursing, University of California, Irvine, CA, USA
| | | | - Eva Maurer
- Health Policy Research Institute, University of California, Irvine, CA, USA
| | | | - Sergio Gago Masague
- Donald Bren School of Information and Computer Sciences, University of California, Irvine, CA, USA
| | - Dylan Hayes
- Independent animation consultant, Providence, RI, USA
| | - Hal S Stern
- Donald Bren School of Information and Computer Sciences, University of California, Irvine, CA, USA
| | - Maozhu Dai
- Donald Bren School of Information and Computer Sciences, University of California, Irvine, CA, USA
| | - Zeev N Kain
- Health Policy Research Institute, University of California, Irvine, CA, USA.,Department of Anesthesiology & Perioperative Care, University of California, Irvine, CA, USA
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Chow CHT, Schmidt LA, Buckley DN. The role of anxiety and related states in pediatric postsurgical pain. Can J Pain 2020; 4:26-36. [PMID: 33987517 PMCID: PMC7942768 DOI: 10.1080/24740527.2020.1847600] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 10/25/2020] [Accepted: 11/04/2020] [Indexed: 11/22/2022]
Abstract
Background: Nearly 20% of children and adolescents have pain with disability 1 year after surgery, and they experience poor sleep, school absence, and decreased activities. Negative clinical, psychological, and developmental effects include greater pain medication use, longer recovery, and fear of future medical care. Research has found psychological and family influences (i.e., child and parental anxiety) on pediatric chronic postsurgical pain (CPSP), but a better understanding of the role of perioperative anxiety and its related states in predicting pediatric postsurgical pain is needed. The poor understanding of the causes of child CPSP can lead to misdiagnosis and inadequate treatment, with significant short- and long-term effects. Objectives: The aim of this review was to summarize the literature on children's perioperative anxiety and parental anxiety in relation to acute postsurgical pain, CPSP, and pain trajectories. We also examined other related psychological factors (i.e., anxiety sensitivity, catastrophizing, pain anxiety, and fear of pain) in relation to pediatric acute and chronic postsurgical pain. Lastly, we discuss the interventions that may be effective in reducing children's and parents' preoperative anxiety. Conclusions: Our findings may improve the understanding of the causes of CPSP and highlight the gaps in research and need for further study.
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Affiliation(s)
- Cheryl H. T. Chow
- Department of Psychology, Neuroscience & Behavior, McMaster University, Hamilton, Ontario, Canada
| | - Louis A. Schmidt
- Department of Psychology, Neuroscience & Behavior, McMaster University, Hamilton, Ontario, Canada
| | - D. Norman Buckley
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
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Rabbitts JA, Palermo TM, Lang EA. A Conceptual Model of Biopsychosocial Mechanisms of Transition from Acute to Chronic Postsurgical Pain in Children and Adolescents. J Pain Res 2020; 13:3071-3080. [PMID: 33262642 PMCID: PMC7699440 DOI: 10.2147/jpr.s239320] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 10/21/2020] [Indexed: 12/20/2022] Open
Abstract
Acute and chronic pain are highly prevalent and impactful consequences of surgery across the lifespan, yet a comprehensive conceptual model encompassing biopsychosocial factors underlying acute to chronic pain transition is lacking, particularly in youth. Building on prior chronic postsurgical pain models, we propose a new conceptual model of biopsychosocial mechanisms of transition from acute to chronic postsurgical pain. This review aims to summarize existing research examining key factors underlying acute to chronic postsurgical pain transition in order to guide prevention and intervention efforts aimed at addressing this health issue in children. As pain transitions from acute nociceptive pain to chronic pain, changes in the peripheral and central nervous system contribute to the chronification of pain after surgery. These changes include alterations in sensory pain processing and psychosocial processes (psychological, behavioral, and social components), which promote the development of chronic pain. Patient-related premorbid factors (eg, demographic factors, genetic profile, and medical factors such as premorbid pain) may further modulate these changes. Factors related to acute injury and recovery (eg, surgical and treatment factors), as well as biological response to surgery (eg, epigenetic, inflammatory, and endocrine factors), may also influence this process. Overall, longitudinal studies examining temporal pathways of biopsychosocial processes including both risk and resiliency factors will be essential to identify the mechanisms involved in the transition from acute to chronic pain. Research is also needed to unravel connections between the acute pain experience, opioid exposure, and sensory pain processing during acute to chronic pain transition. Furthermore, future studies should include larger and more diverse samples to more fully explore risk factors in a broader range of pediatric surgeries. The use of conceptual models to guide intervention approaches targeting mechanisms of transition from acute to chronic pain will significantly advance this field and improve outcomes for children and adolescents undergoing surgery.
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Affiliation(s)
- Jennifer A Rabbitts
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA, USA
- Center for Clinical and Translational Research, Seattle Children’s Hospital, Seattle, WA, USA
| | - Tonya M Palermo
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA, USA
- Center for Child Health, Behavior and Development, Seattle Children’s Hospital, Seattle, WA, USA
- Department of Pediatrics, University of Washington, Seattle, WA, USA
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The Potential Role of Preoperative Pain, Catastrophizing, and Differential Gene Expression on Pain Outcomes after Pediatric Spinal Fusion. Pain Manag Nurs 2020; 22:44-49. [PMID: 32771349 DOI: 10.1016/j.pmn.2020.05.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 04/29/2020] [Accepted: 05/28/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Adolescent idiopathic scoliosis is one of the most common spinal deformities in children and adolescents requiring extensive surgical intervention. Due to the nature of surgery, spinal fusion increases their risk of experiencing persistent postsurgical pain. Up to 20% of adolescents report pain for months or years after corrective spinal fusion surgery. AIMS To examine the influence of preoperative psychosocial factors and mRNA expression profiles on persistent postoperative pain in adolescents undergoing corrective spinal fusion surgery. DESIGN Prospective, longitudinal cohort study. SETTING Two freestanding academic children's hospitals. METHODS Utilizing a longitudinal approach, adolescents were evaluated at baseline (preoperatively) and postoperatively at ±1 month and ±4-6 months. Self-report of pain scores, the Pain Catastrophizing Scale-Child, and whole blood for RNA sequencing analysis were obtained at each time point. RESULTS Of the adolescents enrolled in the study, 36% experienced persistent pain at final postoperative follow-up. The most significant predictors of persistent pain included preoperative pain severity and helplessness. Gene expression analysis identified HLA-DRB3 as having increased expression in children who experienced persistent pain postoperatively, as opposed to those whose pain resolved. A prospective validation study with a larger sample size is needed to confirm these findings. CONCLUSIONS While adolescent idiopathic scoliosis is not often classified as a painful condition, providers must be cognizant of pre-existing pain and anxiety that may precipitate a negative recovery trajectory. Policy and practice change are essential for early identification and subsequent intervention.
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Rabbitts JA, Palermo TM, Zhou C, Meyyappan A, Chen L. Psychosocial Predictors of Acute and Chronic Pain in Adolescents Undergoing Major Musculoskeletal Surgery. THE JOURNAL OF PAIN 2020; 21:1236-1246. [PMID: 32553622 DOI: 10.1016/j.jpain.2020.02.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 01/27/2020] [Accepted: 02/08/2020] [Indexed: 02/07/2023]
Abstract
Acute and chronic pain delay recovery and impair outcomes after major pediatric surgery. Understanding unique risk factors for acute and chronic pain is critical to developing effective treatments for youth at risk. We aimed to identify adolescent and family psychosocial predictors of acute and chronic postsurgical pain after major surgery in adolescents. Participants included 119 youth age 10 to 18 years (Mage = 14.9; 78.2% white) undergoing major musculoskeletal surgery and their parents. Participants completed presurgery baseline questionnaires, with youth reporting on baseline pain, anxiety, depression, insomnia and sleep quality, and parents reporting on parental catastrophizing and family functioning. At baseline, 2-week, and 4-month postsurgery, youth completed 7 days of daily pain diaries and reported on health-related quality of life. Sequential logistic regression models examined presurgery predictors of acute and chronic postsurgical pain, defined as significant pain with impairment in health-related quality of life. Acute pain was experienced by 27.2% of youth at 2 weeks, while 19.8% of youth met criteria for chronic pain at 4 months. Baseline pain predicted acute pain (odds ratio [OR] = 1.96; 95% confidence interval [CI] = 1.32-2.90), while depressive symptoms (OR = 1.22; 95%CI = 1.01-1.47), and sleep quality (OR = 0.26; 95%CI = 0.08-0.83) predicted chronic pain. Tailored interventions need to be developed and incorporated into perioperative care to address risk factors for acute and chronic pain. PERSPECTIVE: Longitudinal results demonstrate adolescents' presurgery pain severity predicts acute postsurgical pain, while depressive symptoms and poor sleep quality predict chronic postsurgical pain. Tailored interventions should address separate risk factors for acute and chronic pain after adolescent surgery.
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Affiliation(s)
- Jennifer A Rabbitts
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington; Center for Clinical and Translational Research, Seattle Children's Hospital, Seattle, Washington.
| | - Tonya M Palermo
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington; Center for Child Health, Behavior and Development, Seattle Children's Hospital, Seattle, Washington
| | - Chuan Zhou
- Department of Pediatrics, University of Washington, Seattle, Washington; Center for Child Health, Behavior and Development, Seattle Children's Hospital, Seattle, Washington
| | - Alagumeena Meyyappan
- Center for Clinical and Translational Research, Seattle Children's Hospital, Seattle, Washington; University of Washington College of Arts and Sciences, Seattle, Washington
| | - Lucas Chen
- Center for Clinical and Translational Research, Seattle Children's Hospital, Seattle, Washington; University of Washington College of Arts and Sciences, Seattle, Washington
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Rosenbloom BN, Pagé MG, Isaac L, Campbell F, Stinson JN, Wright JG, Katz J. Pediatric Chronic Postsurgical Pain And Functional Disability: A Prospective Study Of Risk Factors Up To One Year After Major Surgery. J Pain Res 2019; 12:3079-3098. [PMID: 31814752 PMCID: PMC6858804 DOI: 10.2147/jpr.s210594] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Accepted: 10/07/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Chronic postsurgical pain (CPSP) is a surgical complication associated with increased functional disability, psychological distress, and economic costs. The aims of this paper were to prospectively: (1) examine the incidence of CPSP 6 and 12 months after pediatric major surgery; (2) identify pain intensity and pain unpleasantness trajectories before, and up to 12 months after, surgery; (3) identify pre-operative factors that predict pain trajectory group membership; and (4) identify predictors of 12-month functional disability. METHODS This study followed 265 children aged 8-17 years at four time points (pre-surgical [T0], in-hospital [T1], 6 [T2] and 12 [T3] months after surgery). Children and parents completed pain and psychological questionnaires. In-hospital physical activity was monitored using actigraphy. RESULTS AND DISCUSSION The incidence of moderate-to-severe CPSP at 6 and 12 months was 35% (95% CI 29.1% to 41.9%) and 38% (95% CI 32.4% to 45.1%), respectively. Three percent (95% CI 1.17% to 6.23%) and 4% (95% CI 1.45% to 6.55%) of children reported using opioids to manage pain at 6 and 12 months, respectively. Growth mixture modeling revealed a two-class trajectory model with a quadratic slope best fit the data for both pain intensity (Bayesian information criterion [BIC] = 3977.03) and pain unpleasantness (BIC = 3644.45) over the 12 months. Preoperative functional disability and cumulative in-hospital opioid consumption predicted pain intensity trajectories. Preoperative functional disability predicted pain unpleasantness trajectories. Preoperative functional disability (OR: 1.05, 95% CI: 1.01 to 1.09) and pain unpleasantness trajectories (OR: 2.59, 95% CI: 1.05 to 6.37) predicted 12-month moderate-to-severe functional disability. CONCLUSION Pre-surgical functional disability is the only factor that predicts both 12-month functional disability and the course of pain intensity and pain unpleasantness ratings over the 12-month period.
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Affiliation(s)
| | - M Gabrielle Pagé
- Centre de recherche du Centre hospitalier de l’Université de Montréal and Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Lisa Isaac
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - Fiona Campbell
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - Jennifer N Stinson
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, and Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - James G Wright
- Department of Surgery, University of Toronto and the Hospital for Sick Children, Toronto, ON, Canada
| | - Joel Katz
- Department of Psychology, York University, Toronto, ON, Canada
- Department of Psychology, The Hospital for Sick Children, Toronto, ON, Canada
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23
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Rabbitts JA, Kain Z. Perioperative Care for Adolescents Undergoing Major Surgery: A Biopsychosocial Conceptual Framework. Anesth Analg 2019; 129:1181-1184. [PMID: 30720491 PMCID: PMC6867702 DOI: 10.1213/ane.0000000000004048] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/26/2018] [Indexed: 11/05/2022]
Affiliation(s)
- Jennifer A. Rabbitts
- From the Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, Washington
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Zeev Kain
- Center on Stress & Health, University of California Irvine, Irvine, California
- Children's Hospital of Orange County, Orange, California
- Department of Anesthesiology and Perioperative Medicine, University of California, Irvine, California
- Yale Child Study Center, Yale University, New Haven, Connecticut
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24
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Kamel Escalante MC, Abdennour A, Farah A, Rivera-Richardson E, Burgos F, Forero I, Murrieta-Aguttes M, El Laboudy M, Diagne-Gueye NR, Barragan Padilla S. Prescription patterns of analgesics, antipyretics, and non steroidal anti-inflammatory drugs for the management of fever and pain in pediatric patients: a cross-sectional, multicenter study in Latin America, Africa, and the Middle East. Pragmat Obs Res 2019; 10:41-51. [PMID: 31616200 PMCID: PMC6699589 DOI: 10.2147/por.s168140] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 06/24/2019] [Indexed: 11/23/2022] Open
Abstract
Objective To evaluate the daily practice of pediatricians, physician-perceived reasons for unsatisfactory effects of treatment, and unmet needs in the management of acute pain and/or fever. Methods This was a multinational (n=13), multicenter, non interventional, cross-sectional study conducted in Latin America, Africa, and the Middle East in children under 16 years of age with fever (defined as a central body temperature ≥38°C) and/or acute pain (defined as pain lasting ≤6 weeks). Data were collected during a single visit using a structured physician-administered questionnaire and case report forms. Results A total of 2125 patients were recruited by 178 physicians between September 2010 and September 2011. From the 2117 analyzed patients, 1856 (87.7%) had fever, 705 (33.3%) had acute pain, and 446 (21.1%) had both. Of 1843 analyzed patients with fever, 1516 (82.3%) were previously prescribed a pharmacological treatment for the management of fever concomitantly with a non pharmacological approach, while 1817/1856 patients (97.9%) were currently receiving a prescribed pharmacological treatment for fever. Paracetamol/acetaminophen was the most commonly prescribed antipyretic medication during both previous (70.8%) and current (64.1%) consultations. With regard to acute pain management, 67.2% of the patients received previous and 93.9% received current treatment for pain. The most frequently prescribed analgesic during previous consultations was paracetamol/acetaminophen (53.7%), and the current most commonly prescribed analgesics were non steroidal anti-inflammatory drugs (55.2%). Treatment patterns for patients with both fever and acute pain were similar. Overall, 53.4% of the physicians reported poor treatment compliance as a reason for the unsatisfactory effect of the pain/fever treatment, and the most common unmet need was the availability of new drugs (according to 63.5% of the physicians). Conclusions Adequate management of fever was observed; however, due to the complex etiology of pediatric pain, better evaluation and management of pain in pediatrics is necessary.
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Affiliation(s)
| | - Abbas Abdennour
- Department of Pediatrics, Santé Publique Baraki, Algiers, Algeria
| | - Antoine Farah
- Department of Pediatrics, Saint-Georges Hospital, Ajaltoun, Lebanon
| | | | - Fernando Burgos
- Maternal and Child Department, Hospital Universitario Austral, Buenos Aires, Argentina
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25
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Cravero JP, Agarwal R, Berde C, Birmingham P, Coté CJ, Galinkin J, Isaac L, Kost‐Byerly S, Krodel D, Maxwell L, Voepel‐Lewis T, Sethna N, Wilder R. The Society for Pediatric Anesthesia recommendations for the use of opioids in children during the perioperative period. Paediatr Anaesth 2019; 29:547-571. [PMID: 30929307 PMCID: PMC6851566 DOI: 10.1111/pan.13639] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 03/25/2019] [Accepted: 03/27/2019] [Indexed: 12/13/2022]
Abstract
Opioids have long held a prominent role in the management of perioperative pain in adults and children. Published reports concerning the appropriate, and inappropriate, use of these medications in pediatric patients have appeared in various publications over the last 50 years. For this document, the Society for Pediatric Anesthesia appointed a taskforce to evaluate the available literature and formulate recommendations with respect to the most salient aspects of perioperative opioid administration in children. The recommendations are graded based on the strength of the available evidence, with consensus of the experts applied for those issues where evidence is not available. The goal of the recommendations was to address the most important issues concerning opioid administration to children after surgery, including appropriate assessment of pain, monitoring of patients on opioid therapy, opioid dosing considerations, side effects of opioid treatment, strategies for opioid delivery, and assessment of analgesic efficacy. Regular updates are planned with a re-release of guidelines every 2 years.
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Affiliation(s)
- Joseph P. Cravero
- Department of Anesthesiology, Critical Care, and Pain MedicineBoston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Rita Agarwal
- Pediatric Anesthesiology DepartmentLucille Packard Children's Hospital, Stanford University Medical SchoolStanfordCalifornia
| | - Charles Berde
- Department of Anesthesiology, Critical Care, and Pain MedicineBoston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Patrick Birmingham
- Department of AnesthesiologyAnn and Robert H. Lurie Children's Hospital Northwestern University Feinberg School of MedicineEvanstonIllinois
| | - Charles J. Coté
- Department of AnesthesiologyMass General Hospital for Children, Harvard UniversityBostonMassachusetts
| | - Jeffrey Galinkin
- Anesthesiology DepartmentChildren's Hospital of Colorado, University of ColoradoAuroraColorado
| | - Lisa Isaac
- Department of Anesthesia and Pain MedicineHospital for Sick Children, University of TorontoTorontoOntarioCanada
| | - Sabine Kost‐Byerly
- Pediatric Anesthesiology and Critical Care MedicineJohns Hopkins University HospitalBaltimoreMaryland
| | - David Krodel
- Department of AnesthesiologyAnn and Robert H. Lurie Children's Hospital Northwestern University Feinberg School of MedicineEvanstonIllinois
| | - Lynne Maxwell
- Department of Aneshtesiology and Critical Care MedicineChildren's Hospital of Philadelphia, Perelman School of Medicine at the University of PennsylvaniaPhiladelphia
| | - Terri Voepel‐Lewis
- Department of AneshteiologyC. S. Mott Children's Hospital, University of Michigan Medical SchoolAnn ArborMichigan
| | - Navil Sethna
- Department of Anesthesiology, Critical Care, and Pain MedicineBoston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Robert Wilder
- Department of Anesthesiology and Perioperative MedicineMayo ClinicRochesterMinnesota
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Birnie KA, Campbell F, Nguyen C, Lalloo C, Tsimicalis A, Matava C, Cafazzo J, Stinson J. iCanCope PostOp: User-Centered Design of a Smartphone-Based App for Self-Management of Postoperative Pain in Children and Adolescents. JMIR Form Res 2019; 3:e12028. [PMID: 31008704 PMCID: PMC6658275 DOI: 10.2196/12028] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 01/15/2019] [Accepted: 02/24/2019] [Indexed: 12/15/2022] Open
Abstract
Background Moderate to severe postoperative pain in children is common. Increased pediatric day surgeries have shifted postoperative pain management predominantly to the home setting. Mobile health technology has the potential to overcome barriers to pain care by improving access to self-management resources. However, pain apps generally lack scientific evidence and are highly underutilized due to lack of involvement of end users in their development. Thus, an evidence-based pain self-management smartphone app that incorporates the needs and perspective of children and adolescents (end users) has potential to improve postoperative pain management. Objective This paper aimed to describe how the principles of user-centered design were applied to the development of iCanCope PostOp, a smartphone-based pain self-management app for children and adolescents after surgery. Specifically, it presents 2 completed phases of the user-centered design process (concept generation and ideation) for the iCanCope PostOp app. Methods Phase 1 was a multisite needs assessment from the perspective of 19 children and adolescents who had undergone various day surgeries, 19 parents, and 32 multidisciplinary health care providers. Children, adolescents, and parents completed individual semistructured interviews, and health care providers participated in focus groups. Data were summarized using qualitative content analysis. Phase 2 developed a pain care algorithm for the app using Delphi surveys and a 2-day in-person design workshop with 11 multidisciplinary pediatric postoperative pain experts and 2 people with lived experience with postoperative pain. Results Phase 1 identified self-management challenges to postoperative pain management and recovery; limited available resources and reliance on medications as a predominant postoperative pain management strategy; and shared responsibility of postoperative pain care by children and adolescents, parents, and health care providers. Key app functions of tracking pain, pain self-management strategies, and goal setting were identified as priorities. Phase 2 led to the successful and efficient generation of a complete preliminary pain care algorithm for the iCanCope PostOp app, including clinically relevant inputs for feasible assessment and reassessment of pain and function (rest or sleep, movement or play, and mood or worry), as well as a catalog of pain management advice to be pushed to end users (psychological, physical, pharmacological, and education). Conclusions The concept ideation and generation phases of the user-centered design approach were successfully completed for the iCanCope PostOp app. Next steps will include design finalization, app development (iOS or Android), evaluation through a randomized controlled trial, and subsequent implementation of the iCanCope PostOp app in clinical care.
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Affiliation(s)
- Kathryn A Birnie
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada.,Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Fiona Campbell
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Cynthia Nguyen
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada
| | - Chitra Lalloo
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada
| | - Argerie Tsimicalis
- Ingram School of Nursing, Faculty of Medicine, McGill University, Montreal, QC, Canada.,Shriners Hospitals for Children - Canada, Montreal, QC, Canada
| | - Clyde Matava
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Joseph Cafazzo
- Centre for Global eHealth Innovations, Techna Institute, University Health Network, Toronto, ON, Canada.,Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, ON, Canada
| | - Jennifer Stinson
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada.,Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
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Birnie KA, Chorney J, El-Hawary R. Child and parent pain catastrophizing and pain from presurgery to 6 weeks postsurgery: examination of cross-sectional and longitudinal actor-partner effects. Pain 2018; 158:1886-1892. [PMID: 28598902 DOI: 10.1097/j.pain.0000000000000976] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Child and parent pain catastrophizing are reported preoperative risk factors for children's acute and persistent postsurgical pain. This study examined dyadic relations between child and parent pain catastrophizing and child and parent ratings of child pain prior to (M = 4.01 days; "baseline") and following surgery (M = 6.5 weeks; "acute follow-up"), as well changes in pain catastrophizing during this time in 167 youth (86% female; Mage = 14.55 years) undergoing spinal fusion surgery and 1 parent (89% mothers). Actor-partner interdependence models assessed cross-sectional and longitudinal intra- and interpersonal effects. Cross-sectionally, child pain catastrophizing was positively associated with child pain at baseline and acute follow-up (actor effects: βbaseline = 0.288 and βfollow-up = 0.262; P < 0.01), and parents' ratings of child pain at baseline (partner effect: βbaseline = 0.212; P < 0.01). Parent pain catastrophizing was not cross-sectionally associated with ratings of child pain. Longitudinally, higher pain catastrophizing at baseline predicted higher pain catastrophizing at acute follow-up for children (actor effect: β = 0.337; P < 0.01) and parents (actor effect: β = 0.579; P < 0.01) with a significantly smaller effect for children (respondent × actor interaction: β = 0.121; P < 0.05). No longitudinal partner effects for catastrophizing were observed. Baseline child and parent pain catastrophizing did not predict child pain at acute follow-up. In conclusion, child, not parent, pain catastrophizing was associated with children's pre- and postsurgical pain, and showed significantly less stability over time. There is a need to better understand contributors to the stability or changeability of pain catastrophizing, the prospective relation of catastrophizing to pain, and contexts in which child vs parent pain catastrophizing is most influential for pediatric postsurgical pain.
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Affiliation(s)
- Kathryn A Birnie
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada.,Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada
| | - Jill Chorney
- Department of Anesthesia, Pain, and Perioperative Medicine, Dalhousie University, Halifax, NS, Canada.,Centre for Pediatric Pain Research, IWK Health Centre, Halifax, NS, Canada
| | - Ron El-Hawary
- Department of Surgery, Dalhousie University, Halifax, NS, Canada
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Noel M, Rabbitts JA, Fales J, Chorney J, Palermo TM. The influence of pain memories on children's and adolescents' post-surgical pain experience: A longitudinal dyadic analysis. Health Psychol 2017; 36:987-995. [PMID: 28726472 DOI: 10.1037/hea0000530] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Although children's pain memories have been shown to be a powerful predictor of subsequent pain experiences in acute procedural and experimental pain settings, little is known about the influence of children's and parents' pain memories on children's future pain experiences in other painful contexts. This study used a dyadic approach to examine the roles of children's and parents' memories of pain on their subsequent reporting of postsurgical pain several months after the child underwent a major surgical procedure. METHOD The sample included 66 parent-child dyads (Mage youth = 14.73 years, SD = 2.01) recruited from 2 tertiary level pediatric hospitals. At baseline, children and parents reported on their catastrophic thinking about the child's pain. Parent and child reports of child pain were collected at approximately 1 month and 5 months postsurgery. At 2-4 months postsurgery, children's and parents' memories for postsurgical pain were assessed. RESULTS Results revealed that children's, but not parents', pain memories were a strong predictor of subsequent pain experienced at 5 months postsurgery. Children's and parents' memories for pain did not influence each others' subsequent pain reporting. CONCLUSIONS Findings suggest that children's pain memories influence their continued recovery from postsurgical pain and may contribute to pain persistence. Implications for intervention and prevention are discussed. (PsycINFO Database Record
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Affiliation(s)
| | - Jennifer A Rabbitts
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute
| | - Jessica Fales
- Department of Psychology, Washington State University
| | - Jill Chorney
- Department of Anesthesiology and Psychology, Dalhousie University
| | - Tonya M Palermo
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute
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29
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Barnes A, Tollefson A, Hickey P, Bares J, Zhang L. Pain Control and Parent Mental Health Among Pediatric Inpatients. Hosp Pediatr 2017; 7:149-155. [PMID: 28174215 DOI: 10.1542/hpeds.2016-0142] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Pain control remains a problem for hospitalized children, with more than half experiencing ongoing pain. Pain in turn negatively affects child quality of life. To clarify the relationship between inpatient pain control and parent and child psychological factors, we tested the hypotheses that pain control is worse in the context of higher child executive function problems, lower parent mindfulness, and higher parent mental health symptoms. METHODS We conducted an observational study of stable pediatric inpatients' (n = 81; mean age = 10.5 [SD 4.7]; 55% male) nurse-recorded pain scores; physical health and executive function; and parental cognitive-affective mindfulness and mental health. Linear mixed models examined associations between these variables and changes in pain scores over time, adjusting for covariates. RESULTS After adjusting for child age, child gender, and parent educational status, both time (β = -.23, P = .003) and baseline pain (β = .43, P < .001) were related to pain control. After adjusting for demographics, time, and baseline pain, both parental anxiety (β = .11, P < .001) and depression (β = .12, P < .001) were significantly related to pain control. CONCLUSIONS Child pain control worsened with higher parent anxiety and depression. The results highlight the importance of offering mental health resources to distressed parents of hospitalized children in pain.
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Affiliation(s)
| | | | | | - Jennifer Bares
- University of Minnesota Medical School, Minneapolis, Minnesota
| | - Lei Zhang
- Clinical and Translational Science Institute, University of Minnesota Medical School, Minneapolis, Minnesota; and
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30
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Liaqat N, Dar SH. Comparison of single-dose nalbuphine versus tramadol for postoperative pain management in children: a randomized, controlled trial. Korean J Anesthesiol 2016; 70:184-187. [PMID: 28367289 PMCID: PMC5370303 DOI: 10.4097/kjae.2017.70.2.184] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 04/26/2015] [Accepted: 04/27/2015] [Indexed: 12/03/2022] Open
Abstract
Background Acute postoperative pain control in children is an essential component of postoperative care, particularly in daycare procedures. Giving patients continuous narcotic analgesics can be risky; however, a single dose may be sufficient. Methods This study used a prospective, randomized controlled design and was conducted at the Pediatric Surgery Unit, Services Hospital, Lahore. In total, 150 patients who underwent inguinal herniotomy (age range: 1–12 years) were randomly assigned to two groups: group A (nalbuphine) and group B (tramadol). Patients were given a single dose of either nalbuphine (0.2 mg/kg) or tramadol (2 mg/kg) immediately after surgery and pain was measured at 0, 1, 2, 4, and 8 h. Results The demographic characteristics were similar between the two groups. The mean pain score was lower in group A than in group B at 0 and 1 h (P < 0.05). However, at 4 h and 8 h, the pain scores in group A were still lower, but not significantly. In all, 9 patients (12.0%) required rescue analgesics in group A compared to 16 patients (21.3%) in group B (P = 0.051). The mean time for requirement of rescue analgesics was 6.5 ± 0.5 h in group A and 5.3 ± 1.7 h in group B (P = 0.06). Conclusions A single dose of nalbuphine is sufficient, and superior to tramadol, for postoperative pain management in children who have undergone daycare procedures.
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Affiliation(s)
- Naeem Liaqat
- Department of Pediatric Surgery, Services Institute of Medical Sciences/Services Hospital, Lahore, Pakistan
| | - Sajid Hameed Dar
- Department of Pediatric Surgery, Services Institute of Medical Sciences/Services Hospital, Lahore, Pakistan
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31
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Brooks MR, Golianu B. Perioperative management in children with chronic pain. Paediatr Anaesth 2016; 26:794-806. [PMID: 27370517 DOI: 10.1111/pan.12948] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/27/2016] [Indexed: 12/28/2022]
Abstract
Children with chronic pain often undergo surgery and effective perioperative management of their pain can be challenging. Identification of the pediatric chronic pain patient preoperatively and development of a perioperative pain plan may help ensure a safer and more comfortable perioperative course. Successful management usually requires multiple different classes of analgesics, regional anesthesia, and adjunctive nonpharmacological therapies. Neuropathic and oncological pain can be especially difficult to treat and usually requires an individualized approach.
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Affiliation(s)
- Meredith R Brooks
- Department of Anesthesiology, Cook Children's Hospital, Fort Worth, TX, USA
| | - Brenda Golianu
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
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32
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Trajectories of postsurgical pain in children: risk factors and impact of late pain recovery on long-term health outcomes after major surgery. Pain 2016; 156:2383-2389. [PMID: 26381701 DOI: 10.1097/j.pain.0000000000000281] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Over 1 million children undergo inpatient surgery annually in the United States. Emerging research indicates that many children have longer-term problems with pain. However, limited data exist on the course of pain over time and the impact of pain recovery on long-term health outcomes. We sought to prospectively characterize children's postsurgical pain trajectories using repeated assessments over 12 months. In addition, we identified presurgical child and parent psychological risk factors associated with persistent pain and examined relationships between pain trajectories and long-term health outcomes. Sixty children aged 10 to 18 years undergoing major surgery and their parent/guardian were enrolled. Participants completed assessments at 5 time points: presurgery, inhospital, 2 weeks, 4 months, and 1 year postsurgery. Child and parent pain catastrophizing was assessed during the week before surgery. Children completed daily monitoring with an electronic pain diary and reported on pain characteristics, health-related quality of life, and activity limitations. Group-based longitudinal modeling revealed 2 distinct trajectories of postsurgical pain: early recovery (n = 49, 82%) and late recovery (n = 11, 18%). In a logistic regression model controlling for age and sex, parental pain catastrophizing before surgery significantly predicted membership in the late recovery group (odds ratio = 1.11, P = 0.03), whereas child catastrophizing and baseline pain did not (Ps < 0.05). In a multivariate regression controlling for age and sex, late pain recovery was significantly associated with poorer health-related quality of life (β = -10.7, P = 0.02) and greater activity limitations (β = 3.6, P = 0.04) at 1 year. Our findings suggest that preoperative interventions that modify parent behaviors and cognitions might be beneficial in this population.
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Avian A, Messerer B, Wünsch G, Weinberg A, Kiesling AS, Berghold A. Postoperative paediatric pain prevalence: A retrospective analysis in a university teaching hospital. Int J Nurs Stud 2016; 62:36-43. [PMID: 27450664 DOI: 10.1016/j.ijnurstu.2016.07.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 07/12/2016] [Accepted: 07/12/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Overall pain prevalence in paediatric patients is well documented, but relatively little attention has been paid to pain prevalence and intensity on specific postoperative days within the first week following an operation. OBJECTIVES To evaluate reported pain prevalence on the day of surgery and each day during the following week and to analyse pain trajectories. DESIGN Retrospective study. SETTING Single centre university hospital. PARTICIPANTS 815 postoperative children and adolescents (age≤18 years) were included (female: 36%, age 9.8±5.8). Children with ear, nose, throat (e.g. tonsillectomy), eye (e.g. strabismus repair) or dental surgery (e.g. dental extraction) were treated at other departments and therefore were not included in this study. METHODS Retrospective analysis of the overall and clinically relevant (pain score ≥4/10) postoperative pain prevalence in children and adolescents during the first week after surgery. Possible influencing factors (age, sex, body mass index, type of anaesthesia, type of surgery and duration of surgery) on pain trajectories are analysed using mixed model techniques. RESULTS Overall, 36% of 815 analysed children and adolescents suffered from pain ≥4 during their entire hospital stay. Compared to the day of surgery, the number of patients with pain ≥4 was slightly higher on day 1 after surgery (21% vs. 25%, respectively). In self-reported pain intensity rating (done for patients age≥4 years) the type of surgery (p<.001) was the only significant variable influencing pain intensity. In observational pain assessment (age<4 years) pain scores increased with patient's age (p=.004). In this patient group, pain intensity ratings did not differ between types of surgery (p=.278). CONCLUSION Type of surgery is an important predictor for self-reported pain intensity ratings in children but not for observational pain assessment in younger children. In younger children observational pain assessment ratings increase with age.
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Affiliation(s)
- Alexander Avian
- Institute for Medical Informatics, Statistics and Documentation, Medical University Graz, Auenbruggerplatz 2, 8036 Graz, Austria.
| | - Brigitte Messerer
- Department of Anesthesiology and Intensive Care Medicine, Medical University Graz, University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria.
| | - Gerit Wünsch
- Institute for Medical Informatics, Statistics and Documentation, Medical University Graz, Auenbruggerplatz 2, 8036 Graz, Austria.
| | - Annelie Weinberg
- Department of Orthopedics and Orthopedic Surgery, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria; Mathias-Hospital Rheine, Frankenburgstr. 31, 48431 Rheine, Germany.
| | - Andreas Sandner Kiesling
- Department of Anesthesiology and Intensive Care Medicine, Medical University Graz, University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria.
| | - Andrea Berghold
- Institute for Medical Informatics, Statistics and Documentation, Medical University Graz, Auenbruggerplatz 2, 8036 Graz, Austria.
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Situational but Not Dispositional Pain Catastrophizing Correlates With Early Postoperative Pain in Pain-Free Patients Before Surgery. THE JOURNAL OF PAIN 2016; 17:549-60. [DOI: 10.1016/j.jpain.2015.12.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 11/05/2015] [Accepted: 12/28/2015] [Indexed: 12/12/2022]
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George E, Elman I, Becerra L, Berg S, Borsook D. Pain in an era of armed conflicts: Prevention and treatment for warfighters and civilian casualties. Prog Neurobiol 2016; 141:25-44. [PMID: 27084355 DOI: 10.1016/j.pneurobio.2016.04.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 03/23/2016] [Accepted: 04/08/2016] [Indexed: 12/13/2022]
Abstract
Chronic pain is a common squealae of military- and terror-related injuries. While its pathophysiology has not yet been fully elucidated, it may be potentially related to premorbid neuropsychobiological status, as well as to the type of injury and to the neural alterations that it may evoke. Accordingly, optimized approaches for wounded individuals should integrate primary, secondary and tertiary prevention in the form of thorough evaluation of risk factors along with specific interventions to contravene and mitigate the ensuing chronicity. Thus, Premorbid Events phase may encompass assessments of psychological and neurobiological vulnerability factors in conjunction with fostering preparedness and resilience in both military and civilian populations at risk. Injuries per se phase calls for immediate treatment of acute pain in the field by pharmacological agents that spare and even enhance coping and adaptive capabilities. The key objective of the Post Injury Events is to prevent and/or reverse maladaptive peripheral- and central neural system's processes that mediate transformation of acute to chronic pain and to incorporate timely interventions for concomitant mental health problems including post-traumatic stress disorder and addiction We suggest that the proposed continuum of care may avert more disability and suffering than the currently employed less integrated strategies. While the requirements of the armed forces present a pressing need for this integrated continuum and a framework in which it can be most readily implemented, this approach may be also instrumental for the care of civilian casualties.
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Affiliation(s)
- E George
- Center for Pain and the Brain, Harvard Medical School (HMS), United States; Department of Anesthesia, Critical Care and Pain Medicine, MGH, HMS, Boston, MA, United States; Commander, MC, USN (Ret), United States
| | - I Elman
- Center for Pain and the Brain, Harvard Medical School (HMS), United States; Department of Psychiatry, Boonshoft School of Medicine and Dayton VA Medical Center, United States; Veterans Administration Medical Center, Dayton, OH, United States
| | - L Becerra
- Center for Pain and the Brain, Harvard Medical School (HMS), United States; Department of Anesthesia, Critical Care and Pain Medicine, BCH, HMS, Boston, MA, United States; Departments of Psychiatry and Radiology, MGH, Boston, MA, United States
| | - Sheri Berg
- Center for Pain and the Brain, Harvard Medical School (HMS), United States; Department of Anesthesia, Critical Care and Pain Medicine, MGH, HMS, Boston, MA, United States
| | - D Borsook
- Center for Pain and the Brain, Harvard Medical School (HMS), United States; Department of Anesthesia, Critical Care and Pain Medicine, BCH, HMS, Boston, MA, United States; Departments of Psychiatry and Radiology, MGH, Boston, MA, United States.
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Remembering pain after surgery: a longitudinal examination of the role of pain catastrophizing in children's and parents' recall. Pain 2016; 156:800-808. [PMID: 25630028 DOI: 10.1097/j.pain.0000000000000102] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Children's memories for pain play a powerful role in their pain experiences. Parents' memories may also influence children's pain experiences, by influencing parent-child interactions about pain and children's cognitions and behaviors. Pain catastrophizing of children and parents has been implicated as a factor underlying memory biases; however, this has not been empirically examined. The current longitudinal study is the first to examine the role of pain catastrophizing of children and parents in the development of their pain memories after surgery. Participants were 49 youth (32 girls) aged 10 to 18 years undergoing major surgery and their parents. One week before surgery, children and parents completed measures of pain catastrophizing. Two weeks after surgery (the acute recovery period), children and parents completed measures of child pain intensity and affect. Two to 4 months after surgery, children's and parents' memories of child pain intensity and affect were elicited. Hierarchical linear regression models revealed that over and above covariates, parent catastrophizing about their child's pain (magnification, rumination) accounted for a significant portion of variance in children's affective and parents' sensory pain memories. Although parent catastrophizing had a direct effect on pain memories, mediation analyses revealed that child catastrophizing (helplessness) indirectly influenced children's and parents' pain memories through the child's postoperative pain experience. Findings highlight that aspects of catastrophic thinking about child pain before surgery are linked to distressing pain memories several months later. Although both child and parent catastrophizing influence pain memory development, parent catastrophizing is most influential to both children's and parents' evolving cognitions about child pain.
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Katz J, Weinrib A, Fashler SR, Katznelzon R, Shah BR, Ladak SS, Jiang J, Li Q, McMillan K, Santa Mina D, Wentlandt K, McRae K, Tamir D, Lyn S, de Perrot M, Rao V, Grant D, Roche-Nagle G, Cleary SP, Hofer SO, Gilbert R, Wijeysundera D, Ritvo P, Janmohamed T, O'Leary G, Clarke H. The Toronto General Hospital Transitional Pain Service: development and implementation of a multidisciplinary program to prevent chronic postsurgical pain. J Pain Res 2015; 8:695-702. [PMID: 26508886 PMCID: PMC4610888 DOI: 10.2147/jpr.s91924] [Citation(s) in RCA: 178] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Chronic postsurgical pain (CPSP), an often unanticipated result of necessary and even life-saving procedures, develops in 5-10% of patients one-year after major surgery. Substantial advances have been made in identifying patients at elevated risk of developing CPSP based on perioperative pain, opioid use, and negative affect, including depression, anxiety, pain catastrophizing, and posttraumatic stress disorder-like symptoms. The Transitional Pain Service (TPS) at Toronto General Hospital (TGH) is the first to comprehensively address the problem of CPSP at three stages: 1) preoperatively, 2) postoperatively in hospital, and 3) postoperatively in an outpatient setting for up to 6 months after surgery. Patients at high risk for CPSP are identified early and offered coordinated and comprehensive care by the multidisciplinary team consisting of pain physicians, advanced practice nurses, psychologists, and physiotherapists. Access to expert intervention through the Transitional Pain Service bypasses typically long wait times for surgical patients to be referred and seen in chronic pain clinics. This affords the opportunity to impact patients' pain trajectories, preventing the transition from acute to chronic pain, and reducing suffering, disability, and health care costs. In this report, we describe the workings of the Transitional Pain Service at Toronto General Hospital, including the clinical algorithm used to identify patients, and clinical services offered to patients as they transition through the stages of surgical recovery. We describe the role of the psychological treatment, which draws on innovations in Acceptance and Commitment Therapy that allow for brief and effective behavioral interventions to be applied transdiagnostically and preventatively. Finally, we describe our vision for future growth.
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Affiliation(s)
- Joel Katz
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada ; Department of Psychology, York University, Toronto, ON, Canada ; Department of Anesthesia, University of Toronto, Toronto, ON, Canada
| | - Aliza Weinrib
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada ; Department of Psychology, York University, Toronto, ON, Canada
| | | | - Rita Katznelzon
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada ; Department of Anesthesia, University of Toronto, Toronto, ON, Canada
| | - Bansi R Shah
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Salima Sj Ladak
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Jiao Jiang
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Qing Li
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Kayla McMillan
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Daniel Santa Mina
- Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada ; Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
| | - Kirsten Wentlandt
- Palliative Care, University Health Network, University of Toronto, Toronto, ON, Canada ; Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Karen McRae
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada ; Department of Anesthesia, University of Toronto, Toronto, ON, Canada
| | - Diana Tamir
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada ; Department of Anesthesia, University of Toronto, Toronto, ON, Canada
| | - Sheldon Lyn
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada ; Department of Anesthesia, University of Toronto, Toronto, ON, Canada
| | - Marc de Perrot
- Division of Thoracic Surgery, Toronto General Hospital, York University, Toronto, ON, Canada
| | - Vivek Rao
- Division of Cardiovascular Surgery, Toronto General Hospital, York University, Toronto, ON, Canada
| | - David Grant
- Multiorgan Transplant Program, Toronto General Hospital, York University, Toronto, ON, Canada
| | - Graham Roche-Nagle
- Division of Vascular Surgery, Toronto General Hospital, York University, Toronto, ON, Canada
| | - Sean P Cleary
- Division of General Surgery, Toronto General Hospital, York University, Toronto, ON, Canada
| | - Stefan Op Hofer
- Division of Plastic Surgery, Toronto General Hospital, York University, Toronto, ON, Canada
| | - Ralph Gilbert
- Division of Otolaryngology - Head and Neck Surgery, Toronto General Hospital, York University, Toronto, ON, Canada
| | - Duminda Wijeysundera
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada ; Department of Anesthesia, University of Toronto, Toronto, ON, Canada
| | - Paul Ritvo
- Department of Kinesiology and Health Science, York University, Toronto, ON, Canada
| | | | - Gerald O'Leary
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada ; Department of Anesthesia, University of Toronto, Toronto, ON, Canada
| | - Hance Clarke
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada ; Department of Anesthesia, University of Toronto, Toronto, ON, Canada
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Rabbitts JA, Palermo TM, Zhou C, Mangione-Smith R. Pain and Health-Related Quality of Life After Pediatric Inpatient Surgery. THE JOURNAL OF PAIN 2015; 16:1334-1341. [PMID: 26416163 DOI: 10.1016/j.jpain.2015.09.005] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 08/11/2015] [Accepted: 09/12/2015] [Indexed: 11/27/2022]
Abstract
UNLABELLED Around 4 million children undergo inpatient surgery in the United States each year, however little is known about the impact of surgery and postoperative pain on children's health-related quality of life (HRQOL) during the weeks and months after surgery. We measured pain and HRQOL in a large, heterogeneous pediatric postsurgical population from baseline to 1-month follow-up. Over a 20-month period, parents of 915 children age 2 to 18 years (mean = 9.6 years), 50% male, 56% white, admitted to surgical services at a children's hospital enrolled in the study. Parent participants reported on sociodemographics, child HRQOL, and pain characteristics at baseline and 1 month after discharge. Although most of the children recovered to baseline by 1 month after hospital discharge, 23% of children had a significant decline in HRQOL. Logistic regression analyses found that increasing child age (odds ratio = 2.1 for age 13-18 years) and the presence of moderate-severe postsurgical pain at 1 month (odds ratio = 5.7) were significantly associated with deterioration in HRQOL from baseline to 1-month follow-up (P < .05 for each variable). Although HRQOL returns to the baseline level for most children, a sizeable proportion have significant deterioration in HRQOL associated with continued postsurgical pain at 1 month after hospital discharge from surgery. PERSPECTIVE This study addresses an important gap in the literature, examining pain and health-related quality of life in a broad population of children undergoing a wide range of inpatient surgeries. Evaluation of inpatient health services from a patient and family perspective is essential in evaluating outcomes of surgical care.
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Affiliation(s)
- Jennifer A Rabbitts
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington; Seattle Children's Research Institute, Seattle, Washington.
| | - Tonya M Palermo
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington; Seattle Children's Research Institute, Seattle, Washington
| | - Chuan Zhou
- Department of Pediatrics, University of Washington, Seattle, Washington; Seattle Children's Research Institute, Seattle, Washington
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington, Seattle, Washington; Seattle Children's Research Institute, Seattle, Washington
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Rabbitts JA, Groenewald CB, Tai GG, Palermo TM. Presurgical psychosocial predictors of acute postsurgical pain and quality of life in children undergoing major surgery. THE JOURNAL OF PAIN 2014; 16:226-34. [PMID: 25540939 DOI: 10.1016/j.jpain.2014.11.015] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 11/19/2014] [Accepted: 11/22/2014] [Indexed: 11/26/2022]
Abstract
UNLABELLED Limited research has examined presurgical risk factors for poor outcomes in children after major surgery. This longitudinal study examined presurgical psychosocial and behavioral factors as predictors of acute postsurgical pain intensity and health-related quality of life (HRQOL) in children 2 weeks after major surgery. Sixty children aged 10 to 18 years, 66.7% female, and their parent/guardian participated in the study. Children underwent baseline assessment of pain (daily electronic diary), HRQOL, sleep (actigraphy), and psychosocial factors (anxiety, pain catastrophizing). Caregivers reported on parental pain catastrophizing. Longitudinal follow-up assessment of pain and HRQOL was conducted at home 2 weeks after surgery. Regression analyses adjusting for baseline pain revealed that presurgery sleep duration (β = -.26, P < .05) and parental pain catastrophizing (β = .28, P < .05) were significantly associated with mean pain intensity reported by children 2 weeks after surgery, with shorter presurgery sleep duration and greater parental catastrophizing about child pain predicting greater pain intensity. Adjusting for baseline HRQOL, presurgery child state anxiety (β = -.29, P < .05) was significantly associated with HRQOL at 2 weeks, with greater anxiety predicting poorer HRQOL after surgery. In conclusion, child anxiety, parental pain catastrophizing, and sleep patterns are potentially modifiable factors that predict poor outcomes in children after major surgery. PERSPECTIVE This study addresses an important gap in literature, examining presurgical risk factors for poorer acute postsurgical outcomes in children undergoing major surgery. Knowledge of these factors will enable presurgical identification of children at risk for poorer outcomes and guide further research developing prevention and intervention strategies for these children.
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Affiliation(s)
- Jennifer A Rabbitts
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington; Seattle Children's Research Institute, Seattle, Washington.
| | - Cornelius B Groenewald
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington; Seattle Children's Research Institute, Seattle, Washington
| | | | - Tonya M Palermo
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington; Seattle Children's Research Institute, Seattle, Washington
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Lombar B, Reiter F. Place des stratégies non médicamenteuses en postopératoire Focus sur la distraction et Fhypno-analgésie. Arch Pediatr 2014. [DOI: 10.1016/s0929-693x(14)71568-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Grosen K, Vase L, Pilegaard HK, Pfeiffer-Jensen M, Drewes AM. Conditioned pain modulation and situational pain catastrophizing as preoperative predictors of pain following chest wall surgery: a prospective observational cohort study. PLoS One 2014; 9:e90185. [PMID: 24587268 PMCID: PMC3935997 DOI: 10.1371/journal.pone.0090185] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Accepted: 01/30/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Variability in patients' postoperative pain experience and response to treatment challenges effective pain management. Variability in pain reflects individual differences in inhibitory pain modulation and psychological sensitivity, which in turn may be clinically relevant for the disposition to acquire pain. The aim of this study was to investigate the effects of conditioned pain modulation and situational pain catastrophizing on postoperative pain and pain persistency. METHODS Preoperatively, 42 healthy males undergoing funnel chest surgery completed the Spielberger's State-Trait Anxiety Inventory and Beck's Depression Inventory before undergoing a sequential conditioned pain modulation paradigm. Subsequently, the Pain Catastrophizing Scale was introduced and patients were instructed to reference the conditioning pain while answering. Ratings of movement-evoked pain and consumption of morphine equivalents were obtained during postoperative days 2-5. Pain was reevaluated at six months postoperatively. RESULTS Patients reporting persistent pain at six months follow-up (n = 15) were not significantly different from pain-free patients (n = 16) concerning preoperative conditioned pain modulation response (Z = 1.0, P = 0.3) or level of catastrophizing (Z = 0.4, P = 1.0). In the acute postoperative phase, situational pain catastrophizing predicted movement-evoked pain, independently of anxiety and depression (β = 1.0, P = 0.007) whereas conditioned pain modulation predicted morphine consumption (β = -0.005, P = 0.001). CONCLUSIONS Preoperative conditioned pain modulation and situational pain catastrophizing were not associated with the development of persistent postoperative pain following funnel chest repair. Secondary outcome analyses indicated that conditioned pain modulation predicted morphine consumption and situational pain catastrophizing predicted movement-evoked pain intensity in the acute postoperative phase. These findings may have important implications for developing strategies to treat or prevent acute postoperative pain in selected patients. Pain may be predicted and the malfunctioning pain inhibition mechanism as tested with CPM may be treated with suitable drugs augmenting descending inhibition.
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Affiliation(s)
- Kasper Grosen
- The Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
- * E-mail:
| | - Lene Vase
- The Department of Psychology and Behavioral Sciences, Aarhus University, Aarhus, Denmark
- The Danish Pain Research Center, Aarhus University, Aarhus, Denmark
| | - Hans K. Pilegaard
- The Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | | | - Asbjørn M. Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Center for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
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Esteve R, Marquina-Aponte V, Ramírez-Maestre C. Postoperative Pain in Children: Association Between Anxiety Sensitivity, Pain Catastrophizing, and Female Caregivers' Responses to Children's Pain. THE JOURNAL OF PAIN 2014; 15:157-68.e1. [DOI: 10.1016/j.jpain.2013.10.007] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Revised: 08/12/2013] [Accepted: 10/06/2013] [Indexed: 01/27/2023]
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Simons LE, Elman I, Borsook D. Psychological processing in chronic pain: a neural systems approach. Neurosci Biobehav Rev 2013; 39:61-78. [PMID: 24374383 DOI: 10.1016/j.neubiorev.2013.12.006] [Citation(s) in RCA: 246] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2013] [Revised: 12/17/2013] [Accepted: 12/19/2013] [Indexed: 12/22/2022]
Abstract
Our understanding of chronic pain involves complex brain circuits that include sensory, emotional, cognitive and interoceptive processing. The feed-forward interactions between physical (e.g., trauma) and emotional pain and the consequences of altered psychological status on the expression of pain have made the evaluation and treatment of chronic pain a challenge in the clinic. By understanding the neural circuits involved in psychological processes, a mechanistic approach to the implementation of psychology-based treatments may be better understood. In this review we evaluate some of the principle processes that may be altered as a consequence of chronic pain in the context of localized and integrated neural networks. These changes are ongoing, vary in their magnitude, and their hierarchical manifestations, and may be temporally and sequentially altered by treatments, and all contribute to an overall pain phenotype. Furthermore, we link altered psychological processes to specific evidence-based treatments to put forth a model of pain neuroscience psychology.
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Affiliation(s)
- Laura E Simons
- Center for Pain and the Brain, P.A.I.N. Group, Boston Children's Hospital, United States; Department of Psychiatry, United States; Harvard Medical School, United States.
| | | | - David Borsook
- Center for Pain and the Brain, P.A.I.N. Group, Boston Children's Hospital, United States; Harvard Medical School, United States
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Pagé MG, Campbell F, Isaac L, Stinson J, Katz J. Parental risk factors for the development of pediatric acute and chronic postsurgical pain: a longitudinal study. J Pain Res 2013; 6:727-41. [PMID: 24109194 PMCID: PMC3792832 DOI: 10.2147/jpr.s51055] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background The goal of this longitudinal study was to examine the associations among psychological factors and pain reports of children and their parents over the 12 month period after pediatric surgery. Materials and methods Included in the study were 83 children aged 8–18 years undergoing major surgery. In each case, the child and one of their parents completed measures of pain intensity and unpleasantness, psychological function, and functional disability at 48–72 hours, 2 weeks (child only), 6 months, and 12 months after surgery. Results The strength of the correlation coefficients between the psychological measures of the parent and their child increased significantly over time. There was a fair level of agreement between parent ratings of child acute and chronic pain (6 months after surgery) and the child’s actual ratings. Parent and child pain anxiety scores 48–72 hours after surgery interacted significantly to predict pain intensity, pain unpleasantness, and functional disability levels 2 weeks after discharge from hospital. Parent pain catastrophizing scores 48–72 hours after surgery predicted child pain intensity reports 12 months later. Conclusion These results raise the possibility that as time from surgery increases, parents exert greater and greater influence over the pain response of their children, so that by 12 months postsurgery mark, parent pain catastrophizing (measured in the days after surgery) is the main risk factor for the development of postsurgical pain chronicity.
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Affiliation(s)
- M Gabrielle Pagé
- Department of Psychology, Faculty of Health, York University, Toronto, ON, Canada
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