Effectiveness of a multimodal inpatient treatment for pediatric chronic pain: A comparison between children and adolescents

Objectives To evaluate short and long‐term treatment outcome of children (7–10 years) in comparison to adolescents (11–18 years) with disabling chronic pain following multimodal inpatient pain treatment. Patients and methods: Thirty‐three children and 167 adolescents underwent multimodal inpatient pain treatment. Standardized assessment of pain‐related variables, disability, coping, and use of analgesics was performed at admission, 3‐ and 12‐month follow‐up. Results: Children and adolescents displayed similar pain‐characteristics at admission. Adolescents demonstrated significantly higher disability and passive pain coping. Children relied more on others when in pain. All core variables (i.e., pain intensity, pain‐related disability, school absence and pain‐related coping) decreased significantly in both children and adolescents after 3 months. Both groups maintained this decline 12 months later. More than half of the children and adolescents demonstrated a 50%‐reduction in pain intensity after 3 months, and almost 60% after 12 months. Use of analgesics was significantly reduced at 3‐month follow‐up with no additional changes after 12 months. While age did not exert any impact on results, there were significant gender differences in pain intensity and school absence. Girls demonstrated higher pain intensity and higher school absence 1 year following treatment. Conclusions: Children display similar pain‐characteristics to adolescents when entering inpatient treatment. A multimodal inpatient program appears to stop the the long‐term vicious cycle of disability and pain for both children and adolescents. The demonstrated gender differences raise issues for further research and the possiblity of additional pain management strategies for girls.     

Predicting work status following interdisciplinary treatment for chronic pain.

The effectiveness of interdisciplinary treatments for chronic pain is well established. In general, these treatments decrease psychosocial distress and increase physical abilities. Further, return to work rates following interdisciplinary treatment tend to be quite high. Previous studies have highlighted a number of factors that individually influence return to work rates; however, there is a need for more comprehensive and unified models that allow an evaluation of the inter-relations among these factors. The present investigation examined how demographic and treatment outcome variables interacted to influence post-treatment return to work rates in a sample of individuals with chronic pain following interdisciplinary treatment. Results indicated that patient age, lifting ability, pain duration, depression level, and reported disability were individually related to return to work; however, when these variables were evaluated relative to one another, level of depression and patient age had the best ability to predict post-treatment work status. These results add to the literature by specifically highlighting post-treatment factors that best discriminate patients who had returned to work from those that had not. Furthermore, they provide evidence that general emotional distress is perhaps the most important predictor of work status following treatment.     

Higher levels of pain readiness to change and more positive affect reduce pain reports--a weekly assessment study on arthritis patients

The objective of the study was to analyze the relationships between Pain Readiness to Change, weekly measures of positive and negative affect and pain over eight subsequent weeks in patients with rheumatoid arthritis (RA). Factor analysis based on data from three different samples of patients with rheumatic diseases and other chronic pain conditions suggested a three factor solution for the Norwegian version of the Pain Stages of Change questionnaire (PSOCQ) representing Precontemplation, Contemplation, and Action/Maintenance (ACT) stages from the original Transtheoretical Model. Multilevel analyses on the weekly assessed data from a sub sample of 40 patients with RA revealed that higher levels of Pain Readiness to Change represented by high ACT scores were associated with more positive affect from week to week while no association was found between Readiness to Change and weekly pain. However, there was an interaction effect between Pain Readiness to Change and weekly positive affect on weekly pain, indicating that those persons having a higher level of Readiness to Change reported less pain in weeks when they also experienced increased positive affect. This may imply that a combination of cognitive factors and positive affect is most effective in relation to pain reduction. Results encourage continued investigation of apparent interactions between chronic pain, affect, and pain self-management.     

Inpatient-based intensive interdisciplinary pain treatment for highly impaired children with severe chronic pain: Randomized controlled trial of efficacy and economic effects

Pediatric chronic pain, which can result in deleterious effects for the child, bears the risk of aggravation into adulthood. Intensive interdisciplinary pain treatment (IIPT) might be an effective treatment, given the advantage of consulting with multiple professionals on a daily basis. Evidence for the effectiveness of IIPT is scarce. We investigated the efficacy of an IIPT within a randomized controlled trial by comparing an intervention group (IG) (n = 52) to a waiting-list control group (WCG) (n = 52). We made assessments before treatment (PRE), immediately after treatment (POST), as well as at short-term (POST6MONTHS) and long-term (POST12MONTHS) follow-up. We determined a combined endpoint, improvement (pain intensity, disability, school absence), and investigated 3 additional outcome domains (anxiety, depression, catastrophizing). We also investigated changes in economic parameters (health care use, parental work absenteeism, subjective financial burden) and their relationship to the child’s improvement. Results at POST showed that significantly more children in the IG than in the WCG were assigned to improvement (55% compared to 14%; Fisher P < .001; 95% confidence interval for incidence difference: 0.21% to 0.60%). Although immediate effects were achieved for disability, school absence, depression, and catastrophizing, pain intensity and anxiety did not change until short-term follow-up. More than 60% of the children in both groups were improved long-term. The parents reported significant reductions in all economic parameters. The results from the present study support the efficacy of the IIPT. Future research is warranted to investigate differences in treatment response and to understand the changes in economic parameters in nonimproved children.     

Preliminary evaluation of a multidisciplinary pain management program for children and adolescents with chronic musculoskeletal pain

Purpose. To describe the outcome of a multidisciplinary pain management program for children and adolescents with chronic musculoskeletal pain.

Methods. Study design: exploratory retrospective cohort study. The study sample consisted of a cohort of 70 children and adolescents (age: 8 - 21 years) with chronic musculoskeletal pain who completed a 3-month inpatient multidisciplinary pain management program. The program consisted of graded physical exercises, graded activities and counseling of the children and their parents. Assessed were motor and social activities, pain intensity, global assessment of physical functioning and psychosocial well-being (by patient and physician), understanding of the pain process and reduction of medical consumption. Assessments were performed at pre-admission, day of admission, day of discharge and at three months after discharge. Data collection took place over a 10-year period.

Results. Compared to admission, at discharge there were significant improvements in motor performances, school attendance, reduction of pain scores, understanding of the chronic pain process and reduction of medical consumption. Results remained stable at follow-up after three months.

Conclusion. The results of this study indicate that a multidisciplinary pain management program for children and adolescents with chronic musculoskeletal pain may be effective.     

The lived experience of parents of children admitted to the pediatric intensive care unit in Lebanon

Background

Family caregivers have a significant responsibility in the care of their child in the Pediatric Intensive Care Unit (PICU). Parents staying with their child in the PICU have particular needs that should be acknowledged and responded to by clinicians. Several studies have been conducted in the USA and Europe to try to understand the experience of family caregivers of children admitted to the Pediatric Intensive Care Unit. There are no such studies in Lebanon or the Middle East where the culture and support systems differ from other countries.

Objective

To understand the lived experience of Lebanese parents of children admitted to the PICU in a tertiary hospital in Beirut.

Design

Phenomenological study.

Methods

The study followed purposeful sampling in which 10 parents (mother or father) of children admitted to PICU were interviewed. Data were analyzed following the hermeneutical process as described by Diekelmann and Ironside (1998).

Results

A constitutive pattern “Journey into the unknown” which constitutes an overarching theme and four major themes with subthemes emerged from the data. These were: We are human beings with dignity “; “looking for a healthier environment”; Dependence on God and “The need to be in the loop” reveal the parents’ journey into the unknown.

Conclusion

This qualitative study adds to the knowledge that would help health care workers understand the experience of Lebanese parents with a child in PICU and to highlight the significance of this experience to them. The findings could be used to inform the development of a PICU parental satisfaction instrument for the sample group.     

Development and feasibility testing of a Pain Neuroscience Education program for children with chronic pain: treatment protocol

Background

Current treatment for adults with chronic pain often includes Pain Neuroscience Education (PNE) to make people understand the nature underlying their pain and thus provides a clear rational for a biopsychosocial approach. Despite recommendations to use Pain Neuroscience Education as well in children with chronic pain, a specific program, tailored to children aged 6–12 years is lacking.

Return to work after comparing outpatient multidisciplinary treatment programs versus treatment in general practice for patients with chronic widespread pain.

Former studies have questioned the quality and effectiveness of multidisciplinary rehabilitation for working-age adults with fibromyalgia and chronic widespread pain (CWP). High-quality trials are needed, and return to work should also be included as an outcome variable. This randomized study evaluated the return-to-work outcome of an extensive and a light multidisciplinary treatment program combining cognitive strategies and exercise versus treatment-as-usual initiated by a general practitioner, for CWP patients. The patients (n=208), on sick leave for 3 months on average, were randomized to the extensive program including group sessions, a light and more individual program, and to treatment-as-usual. The number of days absent from work and full return to work were used as an outcome, and follow-up lasted 54 months after the programs ended. The regression analysis showed that the extensive program was associated with significantly fewer days absent from work among women. For women, the mean effect of extensive treatment versus treatment-as-usual on total number of days absent from work was estimated to -206.95 days. Among men, the light program was associated with significantly more days absent from work compared to treatment-as-usual. Both among men and women, independent of type of treatment, patients with poorer health (poor prognosis) were absent from work more days than patients with good prognosis. In our sample, higher age significantly increased the number of days absent from work, but only for women. The extensive outpatient multidisciplinary treatment program was effective in returning women to work.     

Hypoalgesia related to elevated resting blood pressure is absent in adolescents and young adults with a history of functional abdominal pain

Elevated resting blood pressure (BP) is hypoalgesic in healthy individuals, but this effect is absent in adults with chronic somatic pain. This study tested whether BP-related hypoalgesia is similarly altered in individuals with a history of chronic visceral pain in childhood. Resting BP was assessed in 94 adolescents and young adults with a known history of childhood functional abdominal pain (FAP) and 55 comparable healthy controls. Responses to an acute heat pain stimulus were then evaluated following exposure to two laboratory stressors. A significant participant type × systolic BP (SBP) interaction (p < .005) revealed that elevated resting SBP was associated with significantly higher heat pain threshold (p < .001) in healthy controls, but was unrelated to pain threshold in the FAP group. A similar pattern was observed for heat pain tolerance, with elevated SBP linked to significantly higher pain tolerance (p < .05) in healthy controls, but unrelated to tolerance in the FAP group. Dysfunction in BP-related hypoalgesia associated with FAP was evident regardless of whether childhood FAP had resolved or still persisted at the time of laboratory testing. Subgroup analyses indicated that BP-related hypoalgesia (in healthy controls) and FAP-linked absence of this hypoalgesia was observed only among females. Result suggest that childhood visceral chronic pain may be associated with relatively long-lasting dysfunction in overlapping systems modulating pain and BP that persists even after FAP resolves. Potential implications for later hypertension risk are discussed.     

Catastrophizing and internal pain control as mediators of outcome in the multidisciplinary treatment of chronic low back pain.

The aim of the present study was to examine (a) whether a cognitive-behavioral treatment (differentially) affects pain coping and cognition; and (b) whether changes in pain coping and cognition during treatment mediate treatment outcome. Participants in this randomized clinical trial were 148 patients with chronic low back pain attending a multidisciplinary treatment program consisting of operant-behavioral treatment plus cognitive coping skills training (N = 59) or group discussion (N = 58) or allocated to a waiting list control condition (N = 31). Patients improved with respect to level of depression, pain behavior and activity tolerance at posttreatment and 12-month follow-up. Treatment also resulted in a short- and long-term decrease in catastrophizing and an enhancement of internal pain control. Changes in catastrophizing and to a lesser degree in internal pain control mediated the reduction in level of depression and pain behavior following treatment. The use of behavioral and cognitive interventions aimed at decreasing catastrophizing thoughts about the consequences of pain and promoting internal expectations of pain control possibly constitute an important avenue of change irrespective of the type of treatment.     

Social modulation of facial pain display in high-catastrophizing children: an observational study in schoolchildren and their parents

The present study examined existing communal and operant accounts of children’s pain behavior by looking at the impact of parental presence and parental attention upon children’s pain expression as a function of child pain catastrophizing. Participants were 38 school children and 1 of their parents. Children completed a cold pressor pain task (CPT) twice, first when told that no one was observing (alone condition) and subsequently when told that they were being observed by their parent (parent-present condition). A 3-minute parent-child interaction occurred between the 2 CPT immersions, allowing measurement of parental attention to their child’s pain (ie, parental pain-attending talk vs non-pain-attending talk). Findings showed that child pain catastrophizing moderated the impact of parental presence upon facial displays of pain. Specifically, low-catastrophizing children expressed more pain in the presence of their parent, whereas high-catastrophizing children showed equally pronounced pain expression when alone or in the presence of a parent. Furthermore, children’s catastrophizing moderated the impact of parental attention upon facial displays and self-reports of pain; higher levels of parental nonpain talk were associated with increased facial expression and self-reports of pain among high-catastrophizing children; for low-catastrophizing children, facial and self-report of pain was independent of parental attention to pain. The findings are discussed in terms of possible mechanisms that may drive and maintain pain expression in high-catastrophizing children, as well as potential limitations of traditional theories in explaining pediatric pain expression.     

Role of psychological flexibility in parents of adolescents with chronic pain: development of a measure and preliminary correlation analyses

Parent responses to the experiences of adolescents with chronic pain are deemed important. At the same time the best ways to conceptualize, measure, and intervene with these are unclear. The purpose of the present study was to develop a measure of parent responses based on the approach proposed in Acceptance and Commitment Therapy (ACT), an approach that focuses on psychological flexibility. A total of 183 adolescents attending a specialty treatment center for chronic pain, and adults attending with them, provided the data examined in this study. Standard measures of adolescent functioning and parent responses were obtained. In addition, the attending adults, who were mostly mothers, also completed a pool of items for an instrument called the Parent Psychological Flexibility Questionnaire (PPFQ). Preliminary analyses of these items showed an internal consistency of α = 0.91. The total score for parent psychological flexibility was negatively correlated with protective and encouraging parent responses to pain, as predicted. It was also positively correlated with adolescent acceptance of pain and negatively correlated with measures of pain-related impact on their social, emotional, family, and developmental functioning. Additional analyses showed that the PPFQ yields significant unique information about adolescent functioning independent of age and gender and beyond that provided by another well-established measure of parent responses. There is increasing evidence for the effectiveness of ACT in the treatment of a range of behavior problems in adults and young people and in training for persons without identified “disorders.” It seems potentially applicable for parent training in the context of adolescent chronic pain.     

Lived experiences with unmet supportive care needs in pediatric cancer: Perspective of Chinese children and their parents

ObjectiveUnmet supportive care needs(SCNs) impact pediatric cancer patients and their parents. This study aimed to explore the unmet SCNs from the perspective of Chinese children with cancer and their parents through lived experiences.MethodsThe data of this study was collected using face-to-face semi-structured interviews. The participants were recruited from the oncology units of three children’s hospitals in China’s cities (Shanghai, Guangzhou, and Hefei) from October 2020 to December 2021. Data were analyzed using Colaizzi’s seven-step phenomenological analysis method.ResultsEight pediatric cancer patients and twenty-four parents were enrolled in the study. Four main themes and eight subthemes (both children’s and parent’s perspectives) were generated: 1) meeting the ongoing needs along the cancer trajectory (can you tell me what comes next; our needs are growing); 2) communicating with a family focus (they only talk to my parents; let each family member have a voice); 3) providing care beyond the treatment (I am bigger than my body [the children’s needs for emotional consolidation and information about their prognosis]; there are things beyond treatment); 4) getting support from the community (I am not a monster [the children were unhappy about being treated differently]; we want to connect with the resources near us).ConclusionThis study revealed multiple unmet SCNs from the perspective of Chinese children with cancer and their parents. The findings call for comprehensive and in-depth supportive care beyond treatment, integration of the family member voice in pediatric cancer care, and a coordinated pediatric cancer support mechanism in the Chinese healthcare system.     

Specialized multimodal outpatient treatment for children with chronic pain: Treatment pathways and long‐term outcome

Objective: Despite the increased recognition of paediatric chronic pain, centres for providing appropriate treatment are scarce, and much remains unknown about optimal treatment approaches. The purpose of this study was to investigate effectiveness of multimodal outpatient treatment (MOT) through the examination of treatment pathways and long‐term outcomes. Methods: Within an observational longitudinal study, 275 children (4–18 years) formed the study group and received MOT. Over a 12‐month period, we followed the progress of the study group to identify how many children completed treatment, how many continued treatment and how many were stepped‐up to more intensive treatment. To investigate significant and clinically relevant changes in primary and secondary outcomes the study group was assessed at three consecutive treatment sessions (initial session, 3‐, 6‐month visit) and 12 months following the initial session. Results: Analysis of treatment pathways showed that 1/3 of the children did not attend the prescribed second and third visit to the clinic. Cessation of treatment correlated with significant improvement. Only a small number of children were still in treatment at 12‐month follow‐up (12%) or needed more intensive treatment (11%). At 12‐month follow‐up, almost 70% of children in the study group were able to attend school regularly. Pain intensity, pain‐related disability and inappropriate coping strategies were significantly reduced at 3‐month visit and remained stable at the subsequent time points. Conclusions: MOT appears to be beneficial for children with chronic pain. A short intensive intervention (comprising of a total of 2.5‐h) can lead to substantial improvements even for severely affected children.     

Differential changes in functional disability and pain intensity over the course of psychological treatment for children with chronic pain

Patients presenting for treatment of chronic pain often believe that pain reduction must be achieved before returning to normal functioning. However, treatment programs for chronic pain typically take a rehabilitative approach, emphasizing decreasing pain-related disability first with the expectation that pain reduction will follow. This information is routinely provided to patients, yet no studies have systematically examined the actual trajectories of pain and disability in a clinical care setting. In this study of youth with chronic pain (N = 94, 8 to 18 years), it was hypothesized that 1) functional disability and pain would decrease over the course of psychological treatment for chronic pain and 2) functional disability would decrease more quickly than pain intensity. Participants received cognitive behavioral therapy (CBT) for pain management (M = 5.6 sessions) plus standard medical care. The Functional Disability Inventory and a Numeric Rating Scale of average pain intensity were completed by the child at every CBT session. Hierarchical linear modeling was conducted to examine the longitudinal trajectories of disability and pain. Standardized estimates of the slopes of change were obtained to test differences in rates of change between pain and disability. Results showed an overall significant decline in functional disability over time. Although pain scores reduced slightly from pretreatment to posttreatment, the longitudinal decline over treatment was not statistically significant. As expected, the rate of change of disability was significantly more rapid than pain. Evidence for variability in treatment response was noted, suggesting the need for additional research into individual trajectories of change in pediatric pain treatment.     

Acceptance of pain in adolescents with chronic pain: Validation of an adapted assessment instrument and preliminary correlation analyses

It is important to understand the processes that contribute to disability and distress in adolescents with chronic pain. For example, research has identified that when adolescents can positively adapt to the consequences of health condition, rather than attempt to change the condition itself, they also function better and experience less distress. This pattern of behavior is similar to what is referred to as “acceptance” of pain in the adult literature. Although acceptance is consistently associated with positive outcomes in adult studies, there has been less investigation of acceptance in adolescents. This study aimed to examine the reliability and validity of an adolescent‐adapted version of the Chronic Pain Acceptance Questionnaire (CPAQ‐A), and, using this instrument, to carry out a preliminary investigation of acceptance in adolescents with chronic pain. A sample of 122 highly disabled adolescents with chronic pain attending a specialty service completed the adapted CPAQ‐A. They also completed standardized measures of their pain and daily functioning. Results supported the reliability and validity of the CPAQ‐A. Correlation analyses showed that higher levels of acceptance were associated with lower levels of distress and disability, but not with lower pain intensity. Regression analyses were carried out to assess the independent contribution of acceptance after pain intensity and demographic variables were taken into account. In these analyses acceptance accounted for significant variance in disability, psychological distress, and developmental and family functioning. We discuss developmental aspects of acceptance in adolescents and clinical implications of these findings.     

疼痛教育对射频治疗小关节源性下腰痛患者的效果

目的探讨疼痛教育对射频治疗小关节源性下腰痛患者疗效的影响,评估患者疼痛缓解程度及满意度。方法选择2010年10月—2011年10月在上海交通大学附属第六人民医院接受射频治疗的小关节源性下腰痛患者60例,随机分为实验组和对照组各30例。实验组在常规护理的基础上加强疼痛教育,对照组采用常规护理,分别观察两组患者治疗前后视觉模拟评分(VAS)、临床疗效和对疼痛控制满意度。结果实验组治疗后VAS评分低于对照组,疼痛缓解效果及满意度明显优于对照组,两组比较差异有统计学意义(P<0.05)。结论有效的疼痛教育能提高患者对疾病的认知程度,使患者能积极配合治疗,有助于提高射频治疗小关节源性下腰痛患者的疗效。     

Pain catastrophizing in children with chronic pain and their parents: Proposed clinical reference points and reexamination of the Pain Catastrophizing Scale measure

The current study aimed to validate the child and parent pain catastrophizing scale in a large chronic pain sample and to identify child pain catastrophizing clinical reference points. Patients and parents (n = 697) evaluated at a pediatric pain program completed the Pain Catastrophizing Scale, child (PCS-C) and parent (PCS-P) reports, along with additional measures of psychological functioning. The measure’s psychometric properties were examined, as were relations across demographic, pain, and psychological characteristics and pain catastrophizing. Clinical reference points were identified for the PCS-C from differences in pain catastrophizing across levels of disability, depressive symptoms, and anxiety. Overall, we did not find support for the hypothesized 3-dimension structure, and we recommend potentially removing items 7 and 8 for both the PCS-P and PCS-C as a result of floor/ceiling effects. The 11-item PCS-C is most parsimonious as a unitary construct, while the 11-item PCS-P comprises 2 factors. Although parent catastrophizing was significantly associated with child outcomes after controlling for pain level, it was no longer significant when accounting for child catastrophizing. When comparing PCS-C scores based on child outcomes, significant differences emerged for low, moderate, and high catastrophizing levels. It appears that the influence of parent catastrophizing on outcomes can be explained through its impact on child catastrophizing levels. PCS-C reference points derived from this large sample can aid clinicians in assessment and treatment planning, in turn increasing the utility of the PCS-C for both clinical and research purposes.