Talking to Children and Families about Chronic Pain: The Importance of Pain Education-An Introduction for Pediatricians and Other Health Care Providers

Terminology for discussing chronic pain: Using metaphors to educate families on chronic pediatric pain

To educate families about chronic pain requires a holistic discussion on the nature of pain, multidisciplinary treatment, and empowering families with tools to support their child's recovery.

Acceptability of a Pain History Assessment and Education Chatbot (Dolores) Across Age Groups in Populations With Chronic Pain: Development and Pilot Testing

BACKGROUND

The delivery of education on pain neuroscience and the evidence for different treatment approaches has become a key component of contemporary persistent pain management. Chatbots, or more formally conversation agents, are increasingly being used in health care settings due to their versatility in providing interactive and individualized approaches to both capture and deliver information. Research focused on the acceptability of diverse chatbot formats can assist in developing a better understanding of the educational needs of target populations.

OBJECTIVE

This study aims to detail the development and initial pilot testing of a multimodality pain education chatbot (Dolores) that can be used across different age groups and investigate whether acceptability and feedback were comparable across age groups following pilot testing.

METHODS

Following an initial design phase involving software engineers (n=2) and expert clinicians (n=6), a total of 60 individuals with chronic pain who attended an outpatient clinic at 1 of 2 pain centers in Australia were recruited for pilot testing. The 60 individuals consisted of 20 (33%) adolescents (aged 10-18 years), 20 (33%) young adults (aged 19-35 years), and 20 (33%) adults (aged >35 years) with persistent pain. Participants spent 20 to 30 minutes completing interactive chatbot activities that enabled the Dolores app to gather a pain history and provide education about pain and pain treatments. After the chatbot activities, participants completed a custom-made feedback questionnaire measuring the acceptability constructs pertaining to health education chatbots. To determine the effect of age group on the acceptability ratings and feedback provided, a series of binomial logistic regression models and cumulative odds ordinal logistic regression models with proportional odds were generated.

RESULTS

Overall, acceptability was high for the following constructs: engagement, perceived value, usability, accuracy, responsiveness, adoption intention, esthetics, and overall quality. The effect of age group on all acceptability ratings was small and not statistically significant. An analysis of open-ended question responses revealed that major frustrations with the app were related to Dolores' speech, which was explored further through a comparative analysis. With respect to providing negative feedback about Dolores' speech, a logistic regression model showed that the effect of age group was statistically significant (χ22=11.7; P=.003) and explained 27.1% of the variance (Nagelkerke R2). Adults and young adults were less likely to comment on Dolores' speech compared with adolescent participants (odds ratio 0.20, 95% CI 0.05-0.84 and odds ratio 0.05, 95% CI 0.01-0.43, respectively). Comments were related to both speech rate (too slow) and quality (unpleasant and robotic).

CONCLUSIONS

This study provides support for the acceptability of pain history and education chatbots across different age groups. Chatbot acceptability for adolescent cohorts may be improved by enabling the self-selection of speech characteristics such as rate and personable tone.

Pediatrician Explanations of Pediatric Pain in Clinical Settings: A Delicate Craft

Explaining chronic pain to children and families can be challenging, particularly in the absence of an obvious physiologically identifiable cause for the child's pain. In addition to medical intervention, children and families may expect clinicians to provide clarity around the cause of pain. Such explanations are often provided by clinicians who have not received formal pain training. This qualitative study sought to explore the following question: What do pediatricians consider to be important when providing pain explanations to children and their parents? Using semistructured interview methods, 16 UK pediatricians were interviewed regarding their perceptions of explaining chronic pain to children and families in clinical settings. Data were analyzed using inductive reflexive thematic analysis. Analyses generated 3 themes: 1) timing of the explanation, 2) casting a wider net, and 3) tailoring of the narrative. Study findings demonstrated the need for pediatricians to skilfully interpret where children and families are in their pain journey and deliver an appropriate and adaptable explanation relating to individual needs. Analyses identified the importance of providing a pain explanation that could be repeated and understood by others outside the consultation room, to enable children and families to accept the explanation. PERSPECTIVE: Study findings identify the importance of language in addition to familial and broader factors that may influence the provision and adoption of chronic pain explanations provided by pediatricians to children and families. Improving pain explanation provision may influence treatment engagement for children and their parents, subsequently impacting pain related outcomes.

Healthcare Professionals’ Knowledge about Pediatric Chronic Pain: A Systematic Review

Pediatric chronic pain is a common public health problem with a high prevalence among children and adolescents. The aim of this study was to review the current knowledge of health professionals on pediatric chronic pain between 15–30% among children and adolescents. However, since this is an underdiagnosed condition, it is inadequately treated by health professionals. To this aim, a systematic review was carried out based on a search of the electronic literature databases (PubMed and Web of Science), resulting in 14 articles that met the inclusion criteria. The analysis of these articles seems to show a certain degree of heterogeneity in the surveyed professionals about the awareness of this concept, especially regarding its etiology, assessment, and management. In addition, the extent of knowledge of the health professionals seems to be insufficient regarding these aspects of pediatric chronic pain. Hence, the knowledge of the health professionals is unrelated to recent research that identifies central hyperexcitability as the primary factor affecting the onset, persistence, and management of pediatric chronic pain.

How does pain work? A qualitative analysis of how young adults with chronic pain conceptualize the biology of pain

BACKGROUND

Pain science education (PSE) is commonly integrated into treatments for childhood-onset chronic pain. A core component of PSE is learning about, and often reconceptualizing, the biology of chronic pain. Yet, few interventions have been developed specifically for young adults and little is known about how young adults conceptualize the biology of pain. This study used a qualitative methodology to examine how young adults with childhood-onset chronic pain understand the biology of pain, and the language they use in this meaning-making process, which may inform future interventions tailored to this age group.

METHODS

We identified a cohort of young adults with childhood onset chronic pain, and a subset of 17 young adults with continuing chronic pain completed individual, semi-structured interviews. Telephone interviews were audio-recorded, transcribed verbatim and analysed using reflexive thematic analysis.

RESULTS

We generated four themes that capture participants' conceptualizations of the biology of pain: (1) Something is wrong with the body, (2) An injury has not healed, (3) Nerves fire when they should not, (4) An overactive stress system.

CONCLUSION

These conceptualizations, and the language used by young adults with childhood-onset chronic pain to describe them are discussed. Recommendations are provided for how PSE interventions can be tailored for young adults.

SIGNIFICANCE

This study provides new qualitative insights reflecting a variety of ways that young adults with childhood-onset chronic pain conceptualize pain. Some conceptualizations of pain align with modern pain science principles (altered function of nervous and endocrine systems) while others conflict (unhealed injury). Health professionals can use these findings to tailor their pain education interventions by leveraging concepts that 'stick' for youth, being aware of, and interrogating, common misconceptions, and offering language and metaphors familiar to youth.

Overview of radiotherapy-induced chronic pain in childhood cancer survivors: A narrative review

Radiotherapy is an important aspect of oncological treatment in several childhood cancers. However, radiotherapy is known to have numerous side effects, including detrimental effects on growth, neurocognitive impairment, and the development of secondary malignancies. One less studied long-term side effect of pediatric radiotherapy treatment is chronic pain. While the short-term toxicities of radiotherapy resolve over a few weeks to months, the chronic pain caused by radiotherapy-induced tissue damage can significantly affect children's quality of life. As long-term childhood cancer survivors age into adulthood, they are typically followed up by a wide variety of doctors, not all of whom may be familiar with radiotherapy-induced chronic pain and its management. The aim of this review is to discuss the various common manifestations of radiotherapy-related pain in children, as well as ways to identify and manage these. Common radiotherapy-related side effects leading to chronic pain symptoms include radiation fibrosis, enteritis, dermatitis, lymphedema, neuropathic pain, and effects on bone development. The pathophysiology, evaluation and management of these are briefly summarized in this review. This is followed by an overview of radiotherapy techniques that allow greater sparing of normal tissue, minimizing future painful side effects. Finally, the assessment of pain in children is described, as well as strategies for management, and red flag symptoms that should prompt urgent specialist referral. In conclusion, a good understanding of the long-term side effects of radiotherapy treatment in children is essential for the various medical professionals that follow-up the child in the years after treatment. For young children, the evaluation of pain is in itself a challenge, and effects on growth, development, and learning are crucial. For older children, social and psychological factors become increasingly important. As radiation therapy techniques continue to advance, the spectrum and incidence of chronic pain syndromes may change over time.

The concept of pain inventory for children: The reliability and validity study of the Turkish version

BACKGROUND AND PURPOSE

Pain experiences in childhood are very likely to be reflected in adulthood. The early evaluation of the concept of pain in children may eventually lead to. better patient outcomes in the future. Therefore, we aimed to culturally and developmentally adapt the Concept of Pain Inventory for Children (COPI) for Turkish children.

METHODS

This descriptive, correlational study was conducted with 239 post-operative children aged 8-12 years between June and December 2021. The research adhered to COSMIN guidelines. The data were collected using a descriptive information form and the COPI. Factor analysis, Cronbach's alpha, and item-total score analysis were used for the data analysis.

RESULTS

The resulting unidimensional scale consists of 12 items in Turkish. The scale explained 65% of the total variance. The exploratory factor analysis showed that the factor loadings of items ranged from 0.64 to 0.91. The confirmatory factor analysis showed that the factor loadings of items ranged from 0.66 to 0.92. Goodness of fit indexes were found to be as follows: Normed Fit Index >0.90; Incremental Fit Index >0.90; Comparative Fit Index >0.90; and the Root Mean Square Error of Approximation <0.08. The total Cronbach's alpha coefficient of the scale was 0.78 (reliable).

CONCLUSIONS

The 12-item Turkish translation of the COPI was deemed valid and reliable in 8-12-year-old children in a post-operative setting.

PRACTICE IMPLICATIONS

Evaluation of children's pain concepts during childhood may contribute to the identification of conceptual gaps for pain science education.

General practitioners' experiences with children and adolescents with functional gastro-intestinal disorders: a qualitative study in Norway

Objective: Functional gastrointestinal disorders (FGIDs) are common in children and adolescents. During 2016 and 2019, we investigated the experiences among parents of children with FGIDs and interviewed their children and adolescents during 2020. The aim of the present study was to explore the experiences among general practitioners (GPs) who treat this patient group.Design: Individual interviews with open-ended questions were audio recorded and transcribed, and subsequently analysed using descriptive content analysis.Setting: Urban and rural areas in two municipalities in Southern Norway. Participants: Twelve GPs practicing in the region were interviewed.Results: GPs generally feel competent treating these patients without referring them to hospital or specialists. Having known the patients and their families over time is important. Providing psycho-educational resources to the patients and parents is essential for their understanding that the pain is not dangerous. The importance of attending school was emphasised.Conclusions: The GPs' biopsychosocial focus and long-term follow-up care are essential in treating children and adolescents with FGIDs and their parents.KEY POINTSCurrent awarenessAbdominal pain is a common symptom in children and adolescents, for which an organic cause is seldom found.Main statementsGPs feel competent to treat children and adolescents who have functional gastro-intestinal disorders (FGIDs) without referring them to hospital or specialists. • A main task for GPs is to inform children, adolescents, and their parents that FGIDs are not a serious organic disease and that everyday life should continue.

Musculoskeletal disorders in basketball players and associated factors: a systematic review protocol with meta-analysis

Introduction: Musculoskeletal disorders play an important role in athletes’ health and success in sports; they are the main contributors to disability, and back pain is a common problem in athletes. Back pain and spinal injuries occur in players because of the repetitive and unilateral body overload during sports practice. Reviews focused on musculoskeletal disorders in basketball players are scarce in the literature. We describe a systematic review protocol for assessing the prevalence of musculoskeletal disorders and the associated factors in basketball players. Methods and analysis: The protocol will be based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) items and articles will be searches in the databases EMBASE, PubMed, and Scopus. Studies will be included if they are written in English and without restriction regarding the search period. All research stages will be performed by two independent reviewers and will be conducted using Rayyan. Potential disagreements will be analyzed by a third reviewer. The inter-rater reliability will be determined through the Cohen's kappa coefficient. Evidence quality will be ascertained by using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system, while the Downs and Black checklist will be used for assessing the risk of bias. A descriptive summary and presentation of the characteristics and findings of all included studies will be provided in a table. Regarding these data, if there are sufficient high-quality studies, we plan to perform a meta-analysis. Discussion: The obtained results might possibly relate back pain to postural changes in this population. In addition, the data will be compared based on gender and different age groups. It is expected that the results can support the implementation of programs and actions for prevention, ultimately aiming at improving health, quality of life, and sports performance. Registration: PROSPERO CRD42020201653 on August, 31, 2020.

Recommendations for a Pediatric Pain Education Curriculum for Physical and Occupational Therapists: Scoping Review and Survey

Specialization training for physiotherapists, occupational therapists, and sports therapists involved in pediatric pain is scarce and curricula are rarely published. The objectives of this study are twofold: firstly, to perform a scoping review to derive important contents for a pediatric pain education curriculum for specialized pain therapists. Secondly, to conduct a survey on specific contents in curricula currently used by pain experts and to obtain their evaluation regarding the importance of such contents for a specialized curriculum. The review substantiated the importance of a specific curriculum in pediatric pain education, but provided little information on adequate contents. In the survey, 45 experts in pediatric pain education confirmed that specific curricula and specialized contents for pediatric pain education are missing. Their answers give a well-defined picture of the specifics needed in the interaction with a pediatric population. The most important items they classified were e.g., the biopsychosocial framework and the impact of pediatric pain on daily life. Those expert ratings were in line with the recommendations of pediatric pain management guidelines. Further curriculum work in an interdisciplinary, international network is highly recommended.

Advancing the Field of Pain Medicine-Special Issue on Pediatric Pain Management

Pediatric pain management has made great strides over the past 50 years [...].