Comparative benefits and harms of perioperative interventions to prevent chronic pain after orthopedic surgery: a systematic review and network meta-analysis of randomized trials

BACKGROUND

Chronic postsurgical pain (CPSP) is common following musculoskeletal and orthopedic surgeries and is associated with impairment and reduced quality of life. Several interventions have been proposed to reduce CPSP; however, there remains uncertainty regarding which, if any, are most effective. We will perform a systematic review and network meta-analysis of randomised trials to assess the comparative benefits and harms of perioperative pharmacological and psychological interventions directed at preventing chronic pain after musculoskeletal and orthopedic surgeries.

METHODS

We will search MEDLINE, Embase, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials from inception to present, without language restrictions. We will include randomised controlled trials that as follows: (1) enrolled adult patients undergoing musculoskeletal or orthopedic surgeries; (2) randomized them to any pharmacological or psychological interventions, or their combination directed at reducing CPSP, placebo, or usual care; and (3) assessed pain at 3 months or more after surgery. Screening for eligible trials, data extraction, and risk-of-bias assessment using revised Cochrane risk-of-bias tool (RoB 2.0) will be performed in duplicate and independently. Our main outcome of interest will be the proportion of surgical patients reporting any pain at ≥ 3 months after surgery. We will also collect data on other patient important outcomes, including pain severity, physical functioning, emotional functioning, dropout rate due to treatment-related adverse event, and overall dropout rate. We will perform a frequentist random-effects network meta-analysis to determine the relative treatment effects. When possible, the modifying effect of sex, surgery type and duration, anesthesia type, and veteran status on the effectiveness of interventions will be investigated using network meta-regression. We will use the GRADE approach to assess the certainty evidence and categorize interventions from most to least beneficial using GRADE minimally contextualised approach.

DISCUSSION

This network meta-analysis will assess the comparative effectiveness of pharmacological and psychological interventions directed at preventing CPSP after orthopedic surgery. Our findings will inform clinical decision-making and identify promising interventions for future research.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42023432503.

Effects of perioperative clinical hypnosis on heart rate variability in patients undergoing oncologic surgery: secondary outcomes of a randomized controlled trial

Introduction

Clinical hypnosis has been proposed for post-surgical pain management for its potential vagal-mediated anti-inflammatory properties. Evidence is needed to understand its effectiveness for post-surgical recovery. Iin this secondary outcome study, it was hypothesized that surgical oncology patients randomized to receive perioperative clinical hypnosis (CH) would demonstrate greater heart-rate variability (HRV) during rest and relaxation at a 1-month post-surgery assessment compared to a treatment-as-usual group (TAU).

Methods

After REB approval, trial registration and informed consent, 92 participants were randomized to receive CH (n = 45) or TAU (n = 47). CH participants received a CH session before surgery and during post-surgical in-hospital stay HRV was assessed during rest (5 min) and relaxation (10 min) before and 1-month after surgery. Pain intensity was obtained using a 0-10 numeric rating scale pre and post 1-week and 1-month post surgery.

Results

One month after surgery, HRV was significantly higher in CH group (n = 29) during rest and relaxation (both p < 0.05, d = 0.73) than TAU group (n = 28). By contrast, rest and relaxation HRV decreased from pre- to 1-month post-surgery for the TAU (both p < 0.001, d > 0.48) but not the CH group. Pain intensity increased from pre-surgery to 1-week post-surgery (p < 0.001, d = 0.50), and decreased from 1-week to 1-month post-surgery (p = 0.005, d = 0.21) for all participants.

Discussion

The results suggest that hypnosis prevents the deleterious effects of surgery on HRV by preserving pre-operative vagal activity. These findings underscore the potential of clinical hypnosis in mitigating the adverse effects of surgery on autonomic function and may have significant implications for enhancing post-surgical recovery and pain management strategies.

Clinical Trial Registration

ClinicalTrials.gov, identifier (NCT03730350).

A Randomized Controlled Trial of Clinical Hypnosis as an Opioid-Sparing Adjunct Treatment for Pain Relief in Adults Undergoing Major Oncologic Surgery

Clinical hypnosis is an effective strategy for managing acute pain in the surgical setting. However, the opioid sparing effects of clinical hypnosis are not as well understood. This pre-registered (NCT03730350) randomized, controlled trial (RCT) examined the impact of clinical hypnosis, pre- and post-surgery, on opioid consumption during hospitalization as well as on measures of pain intensity, pain interference, depressed mood, anxiety, sleep, and pain catastrophizing. Participants (M = 57.6 years; SD = 10.9) awaiting oncologic surgery were randomized to treatment-as-usual (n = 47) or hypnosis (n = 45). Intent-to-treat analyses were conducted using linear mixed effects modeling. A significant Group × Time interaction, F(6, 323.34) = 3.32, p = 0.003, indicated an opioid sparing effect of clinical hypnosis during the acute postoperative period. Hypnosis also protected against increases in pain catastrophizing at one-week after surgery, F (1, 75.26) = 4.04, p = 0.048. A perioperative clinical hypnosis intervention had a sparing effect on opioid consumption in-hospital after major oncologic surgery. These findings extend the efficacy of clinical hypnosis as an adjunct tool for perioperative pain management.

The Impact of Preoperative Patient Education on Postoperative Pain, Opioid Use, and Psychological Outcomes: A Narrative Review

Background

Recent studies have shown that preoperative education can positively impact postoperative recovery, improving postoperative pain management and patient satisfaction. Gaps in preoperative education regarding postoperative pain and opioid use may lead to increased patient anxiety and persistent postoperative opioid use.

Objectives

The objective of this narrative review was to identify, examine, and summarize the available evidence on the use and effectiveness of preoperative educational interventions with respect to postoperative outcomes.

Method

The current narrative review focused on studies that assessed the impact of preoperative educational interventions on postoperative pain, opioid use, and psychological outcomes. The search strategy used concept blocks including "preoperative" AND "patient education" AND "elective surgery," limited to the English language, humans, and adults, using the MEDLINE ALL database. Studies reporting on preoperative educational interventions that included postoperative outcomes were included. Studies reporting on enhanced recovery after surgery protocols were excluded.

Results

From a total of 761 retrieved articles, 721 were screened in full and 34 met criteria for inclusion. Of 12 studies that assessed the impact of preoperative educational interventions on postoperative pain, 5 reported a benefit for pain reduction. Eight studies examined postoperative opioid use, and all found a significant reduction in opioid consumption after preoperative education. Twenty-four studies reported on postoperative psychological outcomes, and 20 of these showed benefits of preoperative education, especially on postoperative anxiety.

Conclusion

Preoperative patient education interventions demonstrate promise for improving postoperative outcomes. Preoperative education programs should become a prerequisite and an available resource for all patients undergoing elective surgery.

Development and expansion of a pediatric transitional pain service to prevent complex chronic pain

The prevention of chronic pain is a key priority in North America and around the world. A novel pediatric Transitional Pain Service (pTPS) at the Hospital for Sick Children was established to address four main areas of need, which the authors will describe in more detail: (1) provide comprehensive multi-modal pain management and prevention techniques to children at-risk for the development of chronic pain, (2) provide opioid stewardship for children at-risk for chronic pain and their families at home after discharge, (3) facilitate continuity of pain care for children across transitions between inpatient and outpatient care settings, and (4) support caregivers to manage their child's pain at home. The pTPS works with healthcare providers, patients, and their families to address these areas of need and improve quality of life. Furthermore the service fills the gap between inpatient acute pain services and outpatient chronic pain services (accessible only once pain has persisted for >3 months). In pediatric patients who experience pain in hospital and who have been prescribed opioids, discharge to home or rehabilitation may represent a vulnerable time in which pain may persist and during which analgesic requirements may change. This offers an important opportunity to address and prevent the development of chronic pain, and to monitor opioids while ensuring alternative pain therapy is available. The authors will outline risk factors for persistent postsurgical pain, the development and implementation of a pTPS, present initial clinical outcomes andsuggest areas for future research in this evolving area of care.

Virtual multidisciplinary pain treatment: Experiences and feedback from children with chronic pain and their caregivers

BACKGROUND

The onset of the coronavirus disease 2019 (COVID-19) necessitated a rapid transition to virtual care for chronic pain treatment.

OBJECTIVE

This study examined experiences of patients and caregivers who received virtual multidisciplinary pain treatment (MDT) for pediatric chronic pain between March 2020 and August 2021.

METHODS

A mixed methods design was implemented using qualitative interviews and quantitative satisfaction surveys. Satisfaction surveys were administered to a convenience sample of patients (aged 8 to 18; N = 20) and their caregivers (N = 20) who received MDT through an outpatient hospital pediatric chronic pain program. Interviews were conducted with a subset of these patients and their caregivers (n = 6).

RESULTS

Analysis of interviews revealed four themes: 1) benefits of virtual care; 2) challenges of virtual care; 3) recommendations and evaluation of virtual care; and 4) patient preferences. Analysis of the satisfaction survey data revealed that while patients and caregivers were satisfied with many aspects of virtual care, 65% (n = 13) of patients reported a preference for in-person appointments, with caregivers showing equal preference for in-person and virtual appointments, though this was a non-significant difference (p = .37). Overall, both patients and caregivers stated a stronger preference for in-person physiotherapy sessions but were willing to have psychology sessions provided virtually. Finally, the most reported preference was for a hybrid model of care incorporating at least some in-person contact with providers.

CONCLUSION

This study provides a rich exploration of virtual care for multidisciplinary pediatric chronic pain treatment. The current results may inform the future development of guidelines for virtual care delivery with pediatric chronic pain populations.

Sensibility and measurement properties of the Tampa Scale of Kinesiophobia to measure fear of movement in children and adults in surgical settings

Purpose: Fear of movement, or kinesiophobia, is a risk factor for developing chronic post-surgical pain (CPSP) and may impede recovery. Identifying people with kinesiophobia peri-operatively is potentially valuable to intervene to optimize rehabilitation and prevent CPSP. This narrative review aims to describe and critically appraise the sensibility and measurement properties of the Tampa Scale of Kinesiophobia (TSK) in the surgical setting in both pediatric and adult populations.Material and methods: PubMed was searched for relevant articles using search terms related to the TSK and measurement properties; the search was restricted to articles published in English. COSMIN guidelines were used to rate measurement property sufficiency and study quality.Results: Four articles examined the measurement properties of the TSK-17 in the surgical setting. Included studies demonstrated sufficient internal consistency, structural validity, construct validity, but insufficient predictive validity. Study quality was variable. Although the TSK was not originally intended for the surgical setting, with minor modification, it appears sensible to use in this population.Conclusions: The TSK is a sensible tool to measure fear of movement in children and adults undergoing, or who underwent, surgery. Future studies are needed to test content validity, test-retest reliability, measurement error, and responsiveness in the surgical setting.IMPLICATIONS FOR REHABILITATIONFear of movement is a predictor of developing chronic post-surgical pain in children and adults.Rehabilitation interventions can address fear of movement in hopes to optimize surgical outcomes and prevent chronic post-surgical pain.The Tampa Scale of Kinesiophobia (TSK), with minor modification, is a sensible tool to measure fear of movement in surgical settings.There is some evidence that the TSK is reliable and valid to use with older children, adolescents, and adults who are undergoing or underwent surgery.

Modeling the transition from acute to chronic postsurgical pain in youth: A narrative review of epidemiologic, perioperative and psychosocial factors

A growing number of studies have identified high rates of pediatric chronic postsurgical pain (CPSP) after major surgery. Pediatric CPSP is associated with pain-related distress and comorbid mental health outcomes, such as anxiety and depression. From a biopsychosocial perspective, youth factors, such as genetics, epigenetics, sex, presurgical pain, sleep, anxiety, and pain catastrophizing, as well as parent factors, such as cognitive appraisals of their child’s pain expression and pain catastrophizing, converge and lead to chronic pain disability. A comprehensive and testable psychosocial model of the transition from acute to chronic pediatric postsurgical pain has not been developed. This narrative review begins by evaluating the epidemiology and trajectories of pediatric CPSP and moves on to examine the more influential psychosocial models that have been proposed to understand the development of pediatric CPSP. Much of the literature to date has been conducted on adolescents undergoing spinal fusion. To conceptualize the transition from acute to chronic pain in youth, a combined diathesis-stress and interpersonal fear avoidance model is presented. Novel areas of future research include the potential influence that siblings and peers have on a youth’s development of CPSP as well as the influence of gender.

Mapping the current state of pediatric surgical pain care across Canada and assessing readiness for change

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.

Differential Risk Factor Profiles in the Prediction of General and Pain-Specific Functional Limitations 12 Months after Major Pediatric Surgery

Pediatric chronic post-surgical pain is a surgical complication associated with various levels of functional limitation. Two commonly used measures of functional limitations in youth are the Functional Disability Inventory (FDI) and the PROMIS Pediatric Pain Interference Scale (PPIS), where the former is general, and the latter, pain specific. The aim of the present study was to prospectively compare pre-surgical youth and parent risk factors for youth functional limitations, assessed by the FDI and PPIS, 12 months after major pediatric surgery. Risk factors for the FDI and PPIS were compared in 79 dyads consisting of youth (58% female, M = 14.56 years; SD = 2.31) undergoing major surgery and one of their parents. The FDI and PPIS were highly correlated prior to surgery (r = 0.698, p < 0.001) and even more so 12 months after surgery (r = 0.807, p < 0.001). Parent pre-surgical anxiety sensitivity and youth pre-surgical functional disability significantly predicted 12-month FDI (F(6,56) = 4.443, p = 0.001, Adjusted R² = 0.25), whereas parent pre-surgical anxiety sensitivity, trait anxiety, pain anxiety, as well as youth pain-related anxiety and worry significantly predicted 12-month PPIS (F(6,45) = 4.104, p = 0.002, Adjusted R² = 0.27). Risk factors for 12-month general and pain-specific functional limitations differ by dyad member and type. Functional limitations in youth after surgery are predicted by youth and parent factors, however the risk factors differ between the FDI and the PPIS.

Fear of movement in children and adolescents undergoing major surgery: A psychometric evaluation of the Tampa Scale for Kinesiophobia

BACKGROUND

The objective of this study was to evaluate the psychometric properties of the 17-item Tampa Scale for Kinesiophobia (TSK) in youth.

METHODS

Participants were 264 children and adolescents (58.7% female, M_age  = 14.1 years, SD_age  = 2.51) scheduled for major surgery who were assessed before surgery, while in hospital postoperatively, and at 6 and 12 months after surgery. Exploratory factor analyses (EFA) were conducted to determine the factor structure of pre-operative TSK scores. Reliability, and convergent, discriminant, and predictive validity were examined.

RESULTS

EFA on the 17-item TSK revealed a two-factor model distinguishing the 13 positively scored items from the 4 reverse scored items, but the fit was poor. A second EFA was conducted on the 13 positively scored items (TSK-13) revealing a three-factor model: Fear of injury, bodily vulnerability, and activity avoidance. The TSK-13 showed adequate internal consistency (Ω = 0.82) and weak convergent validity. The TSK-13 was not correlated with postoperative, in-hospital physical activity (actigraphy; r (179) = -0.10, p = 0.18) and showed adequate discriminant validity, that is correlations less than 0.70, with measures of depression (r (225) = 0.41, p < 0.001) and general anxiety (r (224)=0.35, p < 0.001). Predictive validity for pain-related disability at 12 months (r (70) = 0.34, p < 0.001) was adequate.

CONCLUSIONS

The original TSK-17 does not appear to be a meaningful measure of kinesiophobia in youth after surgery possibly because of the syntactic structure of the reverse scored items. In contrast, a modified TSK-13, comprised of only the positively scored items, revealed a 3-factor structure that is reliable and demonstrates adequate convergent, discriminant, and predictive validity.

SIGNIFICANCE

Kinesiophobia is an important construct to evaluate in the transition from acute to chronic pain among children and adolescents. The 17 item Tampa Scale for Kinesiophobia (TSK) does not show adequate validity or reliability in youth undergoing major surgery, however, the psychometric properties of a 13-item modified scale (TSK-13) are promising.

Pediatric Chronic Postsurgical Pain And Functional Disability: A Prospective Study Of Risk Factors Up To One Year After Major Surgery

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.

Prevalence and Predictors of Chronic Postsurgical Pain in Children: A Systematic Review and Meta-Analysis

Emerging research suggests that pain may persist longer-term for many children after major surgery, with significant effects on their health outcomes. This systematic review identified the prevalence of chronic postsurgical pain (CPSP) in children after surgery, and determined presurgical biomedical and psychosocial risk factors associated with CPSP prevalence or severity. Prospective studies assessing CPSP 3 to 12 months after surgery in children 6 to 18 years of age published in English in MedLine, EMBASE, PsycINFO, and Cochrane Database of Systematic Reviews since 1996 were eligible for inclusion. Of 16,084 abstracts yielded by the search, 123 full articles were assessed for eligibility, and 12 studies were included in the review. Overall quality of included studies assessed using the Quality in Prognostic Studies tool was low. On the basis of 4 studies with a total of 628 participants across all surgery types, median prevalence of CPSP across studies was 20% (25th percentile = 14.5%, 75th percentile = 38%) at 12 months after surgery. Presurgical pain intensity, child anxiety, child pain coping efficacy, and parental pain catastrophizing were the only presurgical factors identified as predictive of CPSP. Biological and medical factors assessed were not associated with CPSP in any study. Well designed studies examining prevalence and predictors of CPSP are critically needed in children.

PERSPECTIVE

In this systematic review, the median prevalence of CPSP in children was 20% across studies. Presurgical pain intensity, and child and parent psychosocial factors predicted CPSP. Additional resources and interventions are needed for youth who report persistent pain after surgery.

Predictors of Prescription Opioid Use 4 Months After Traumatic Musculoskeletal Injury and Corrective Surgery: A Prospective Study

The aim of the present study was to examine the incidence and predictors of persistent prescription opioid use 4 months after traumatic injury. Adults who sustained a traumatic musculoskeletal injury were recruited to participate in this observational prospective, longitudinal study within 14 days of injury (T1) and followed for 4 months (T2). Measures included questionnaires on pain, opioid consumption, pain disability, anxiety, depression, and posttraumatic stress symptoms as well as a chart review for injury related information. The sample consisted of 122 patients (66.4% male; mean age = 44.8 years, SD = 17.1), of whom 94.3% (n = 115) were using prescription opioids. At T2, 35.3% (n = 43) patients were using prescription opioids. After controlling for age, sex, injury severity, T1 pain severity, and T2 symptoms of depression, 2 factors emerged as significantly related to T2 prescription opioid use; namely, T2 pain severity (odds ratio = 1.248, 95% confidence interval, 1.071-1.742) and T2 pain self-efficacy (odds ratio = .943, 95% confidence interval, .903-.984). These results suggest that opioid use after traumatic musculoskeletal injury is related to pain severity and how well patients cope specifically with their pain, over and above other psychological factors, such as depression and anxiety.

PERSPECTIVE

This article identifies predictive factors for prescription opioid use after traumatic musculoskeletal injury, namely severe pain and a poor sense of control over the pain. These results highlight the importance of using prospective longitudinal study designs to understand why patients continue to use prescription opioids after major tissue-damaging events.

Chronic Pain, Psychopathology, and DSM-5 Somatic Symptom Disorder

Unlike acute pain that warns us of injury or disease, chronic or persistent pain serves no adaptive purpose. Though there is no agreed on definition of chronic pain, it is commonly referred to as pain that is without biological value, lasting longer than the typical healing time, not responsive to treatments based on specific remedies, and of a duration greater than 6 months. Chronic pain that is severe and intractable has detrimental consequences, including psychological distress, job loss, social isolation, and, not surprisingly, it is highly comorbid with depression and anxiety. Historically, pain without an apparent anatomical or neurophysiological origin was labelled as psychopathological. This approach is damaging to the patient and provider alike. It pollutes the therapeutic relationship by introducing an element of mutual distrust as well as implicit, if not explicit, blame. It is demoralizing to the patient who feels at fault, disbelieved, and alone. Moreover, many medically unexplained pains are now understood to involve an interplay between peripheral and central neurophysiological mechanisms that have gone awry. The new Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, somatic symptom disorder overpsychologizes people with chronic pain; it has low sensitivity and specificity, and it contributes to misdiagnosis, as well as unnecessary stigma. Adjustment disorder remains the most appropriate, accurate, and acceptable diagnosis for people who are overly concerned about their pain.

Comparison of child-parent and parent-only cognitive-behavioral therapy programs for anxious children aged 5 to 7 years: short- and long-term outcomes

OBJECTIVE

Childhood anxiety disorders (AD) are prevalent, debilitating disorders. The most effective treatment approach for children less than 8 years old requires further investigation. The study's primary objective was to compare 2 cognitive-behavioral therapy (CBT) group programs. CBT was delivered to children 5 to 7 years old and their parents (child-parent) or only to parents (parent-only), whereas children attended group sessions but did not receive CBT.

METHOD

Using a prospective, repeated measures, longitudinal study design, 77 children (29 male, mean age = 6.8 years; SD = 0.8 year) with AD and their parents participated in either a 12-week child-parent or parent-only CBT group treatment after a 3-month no-treatment wait-time. Well-validated treatment outcome measures were completed at 5 assessment time points: initial assessment, pretreatment, immediately posttreatment, 6 months, and 12 months posttreatment. A mixed models analysis was used to assess change in AD severity and global functioning improvements from baseline within each treatment and between treatments.

RESULTS

No significant changes were noted in child-parent or parent-only treatment during the 3-month no-treatment wait time. Both treatments saw significant improvements posttreatment and at longer-term follow-up with significant reductions in AD severity measured by clinician and parent report and increases in global functioning. Significantly greater improvements were observed in the child-parent compared to the parent-only treatment.

CONCLUSION

This study suggests that both parent-only and child-parent group CBT improves AD severity in children 5 to 7 years old. Study results suggest that involvement of both children and parents in treatment is more efficacious than working with parents alone.

Systematic review of persistent pain and psychological outcomes following traumatic musculoskeletal injury

Background

Persistent pain and psychological distress are common after traumatic musculoskeletal injury (TMsI). Individuals sustaining a TMsI are often young, do not recover quickly, and place a large economic burden on society.

Objectives

The aim of this systematic review is to determine (1) the incidence of persistent pain following TMsI, (2) the characteristics of pain, characterized by injury severity and type, and (3) risk and protective factors associated with persistent pain following TMsI.

Methods

A systematic search of electronic databases (MEDLINE^®, PubMed^®, Embase, and PsycINFO^®) was conducted for prospective, interventional, or noninterventional studies measuring the incidence of pain associated with TMsI.

Results

The search revealed 4388 studies. Eleven studies examined persistent pain and met inclusion criteria. Pain was assessed using a validated measure of pain intensity or pain presence in six studies. Persistent pain was reported by all studies at variable time points up to 84 months postinjury, with wide variation among studies in pain intensity (ie, from mild to very severe) and pain incidence at each time point. The incidence of pain decreased over time within each study. Two studies found significant relationships between injury severity and persistent pain. Frequently cited predictive factors for persistent pain included: symptoms of anxiety and depression, patient perception that the injury was attributable to external sources (ie, they were not at fault), cognitive avoidance of distressing thoughts, alcohol consumption prior to trauma, lower educational status, being injured at work, eligibility for compensation, pain at initial assessment, and older age.

Conclusion and implications

The evidence from the eleven studies included in this review indicates that persistent pain is prevalent up to 84 months following traumatic injury. Further research is needed to better evaluate persistent pain and other long-term posttraumatic outcomes.