The multidimensional assessment and management of recurrent pain syndromes in children

Multidimensional Self-report Assessment of Children's Acute Pain in an Inpatient Setting

OBJECTIVE

This study assessed the feasibility of administering a multidimensional, self-report pain assessment protocol to children in an inpatient, acute pain context, and sought insight into the interrelationships between sensory, affective, and evaluative pain dimensions.

METHODS

A total of 132 children (5 to 16 y) experiencing acute pain were recruited from acute pain ward rounds or the short-stay surgical unit. A multidimensional self-report assessment protocol was administered, assessing pain intensity, pain-related affect, bother, perceived unfairness, and pain expectations (for tomorrow and in 1 wk). Duration of protocol administration was assessed and ease of administration was rated. Pain-related behaviors were rated using the Face, Legs, Activity, Cry, and Consolability (FLACC) Scale.

RESULTS

The duration of protocol administration was <2.5 minutes, on average, for all age groups. Median ease of protocol administration was 7/10 for 5- to 7-year-olds and 8/10 for older age groups. Pain-related bother was higher for 14- to 16-year-olds, relative to younger age groups, and significantly correlated with perceived unfairness (r=0.59, P<0.01), intensity (r=0.76, P<0.01), and affect (r=0.33, P<0.05). For younger age groups, bother was significantly positively correlated only with pain intensity (rs=0.59 to 0.79, Ps<0.01) and affect (rs=0.4 to 0.71, Ps <0.05). A stepwise multiple regression analysis found multidimensional self-reported information (especially pain intensity and perceived unfairness), accounted for significant additional amount of variance, beyond that explained by age, pain duration, and observed pain behavior.

DISCUSSION

Sensory, affective, and evaluative aspects of children's clinical, acute pain experience may be assessed using self-report tools, which provide unique and valuable information about their pain experience.

Effect of magnesium supplementation on emergence delirium and postoperative pain in children undergoing strabismus surgery: a prospective randomised controlled study

Background

The benefits of intraoperative magnesium supplementation have been reported. In this prospective, randomized study, the effects of magnesium supplementation during general anaesthesia on emergence delirium and postoperative pain in children were evaluated.

Methods

A total of 66 children aged 2 to 5 years who underwent strabismus surgery were assigned to the magnesium or to the control group. Preoperative anxiety was assessed using the modified Yale Preoperative Anxiety Scale. After anaesthesia induction, the magnesium group received an initial loading dose of 30 mg/kg magnesium sulphate over 10 min and, then, continuous infusion of 10 mg/kg per h until 10 min before the end of the surgery. The control group received an equal volume of normal saline via the same regimen. The Paediatric Anaesthesia Emergence Delirium (PAED) score, pain score, and respiratory events were assessed at the postanaesthetic care unit.

Results

Data obtained from 65 children were analyzed. The PAED and pain scores of the two groups did not differ significantly. There were 26 of 33 (78.8%) and 27 of 32 (84.4%) children with emergence delirium in the control and the magnesium groups, respectively (odds ratio 0.69, 95% CI 0.19–2.44; p = 0.561). The preoperative anxiety score was not significantly correlated with the PAED score. The incidence of respiratory events during the emergence period did not differ significantly between the two groups.

Conclusions

Magnesium supplementation during anaesthesia had no significant effects on the incidence of emergence delirium or postoperative pain in children undergoing strabismus surgery.

Trial registration

ClinicalTrials.gov (NCT03132701). Prospectively registered May 8, 2017.

The Dutch version of the self-report Child Activity and Limitations Interview in adolescents with chronic pain

PURPOSE

To assess the factor structure, related constructs and internal consistency of the Child Activity Limitation Interview 21-Child version for use in Dutch-language countries.

METHODS

Cross-sectional validation study: After forward and back translation of the Dutch version of the Child Activity Limitation Interview 21-Child adolescents (11-21 years old) with chronic musculoskeletal pain completed an assessment. The assessment contained the Dutch Child Activity Limitation Interview, and questionnaires about demographics, pain intensity, functional disability, anxiety and depression. Internal consistency and construct validity were evaluated through exploratory factor analysis (principal axis factoring with oblique rotation) and hypotheses testing using pain intensity, activity limitations, anxiety and depression as comparative constructs.

RESULTS

Seventy-four adolescents completed the assessment. Exploratory factor analysis resulted in a two-factor structure, explaining 50% of the variance. Internal consistency was good (Cronbach's α = 0.91 total scale, α = 0.90 Factor 1, α = 0.80 Factor 2). All nine hypotheses were confirmed.

CONCLUSION

The Dutch version can be used to assess pain-related disability in Dutch-speaking adolescents comparable to the study sample. Scores on both subscales provide insight into the severity of the pain-related disability in both daily routine and more physically vigorous activities. Implications for Rehabilitation Chronic pain is a disabling disorder which not only impacts physically but restricts quality of life. This study provides clinicians a questionnaire to measure pain-related disability and quantify the impact of pain on the daily living of adolescents. The advantage of the Dutch version of the Child Activity and Limitations Interview over other measurements is that it can distinguish limitations in daily activities from more physically vigorous activities.

A comprehensive review of randomized placebo-controlled pharmacological clinical trials in children with functional abdominal pain disorders

OBJECTIVES

Abdominal pain-predominant functional gastrointestinal disorders (AP-FGIDs) are the most common cause of consultation to pediatric gastroenterology; however, no medications have been approved to treat this group of disorders in children. The Food and Drug Administration have published recommendations for clinical trials on AP-FGIDs in adults but not in children. The lack of methodological guidelines and accepted primary endpoints for clinical trials in children hampers the progress of the field, making the approval of new medications difficult. A necessary first step to determine the feasibility of clinical trials in children and provide recommendations on the best design for future trials is to review the methods, ability to recruit, attrition rate, and results of previous clinical trials. We designed a comprehensive review of pharmacological clinical trials in AP-FGIDs in children focused on study design.

METHODS

Study eligibility was randomized controlled trials (RCTs) evaluating the efficacy of pharmacological interventions compared with that of placebo in children and adolescents with AP-FGIDs.

RESULTS

There is no evidence to support the use of most commonly used drugs in children. Only 7 pharmacological RCTs on AP-FGIDs in children were found. Most studies were single center based and had a small sample size. The methods and outcomes were heterogeneous. Primary endpoints varied widely among studies. Many of the RCTs did not show a consistently significant benefit of the drug over placebo in some or all of the outcomes. We found a considerable risk of bias in most studies. None of the studies have considered minimal clinically important differences in their selection of primary endpoints.

CONCLUSIONS

Few randomized clinical trials have been conducted. Most studies have methodological limitations and small sample size. There is an urgent need for well-designed randomized clinical trials using age-appropriate validated outcome measures.

The psychometric characteristics of an assessment instrument for perceived harmfulness in adolescents with musculoskeletal pain (PHODA-youth)

BACKGROUND

Cognitive-behavioural models of chronic pain predict that dysfunctional assumptions about harmfulness of activities may maintain pain-related fear and disability. To assess perceived harmfulness in adolescents, the Photograph Series of Daily Activities for youth (PHODA-youth) was developed. Information concerning its methodological quality is currently lacking.

OBJECTIVE

To investigate psychometric characteristics (factor structure, test-retest reliability, construct validity) and feasibility of the PHODA-youth in adolescents with chronic musculoskeletal pain.

STUDY DESIGN

Test-retest design.

STUDY POPULATION

Adolescents aged 13-21 years with chronic nonspecific musculoskeletal pain.

METHODS

Participants filled in an electronic version of the PHODA-youth including 89 items twice with a 4-week interval. The instrument's factor structure was determined by a factor analysis. Construct validity was studied with criterion variables: catastrophizing (Pain Catastrophizing Scale for Children), pain intensity (visual analogue scale), depression (Children's Depression Inventory) and pain-related disability (Functional Disability Inventory) using regression analysis. Test-retest reliability was evaluated based on the Pearson correlation coefficient. Feasibility was studied with self-constructed questions.

RESULTS

Seventy-one adolescents participated. Results show a three-factor structure for the PHODA-youth including 51 items with subscales labelled as: 'activities of daily life', 'intensive physical activities' and 'social activities'. Total and subscale scores showed a high internal consistency. Its test-retest reliability was good (r = 0.94) and its construct validity is supported by the finding that both catastrophizing (β = 0.25; p = 0.02) and disability (β = 0.71; p < 0.001) were uniquely related to the PHODA-youth. In addition, feasibility appeared adequate.

CONCLUSION

The findings support the PHODA-youth as a valid and reliable measure of the perceived harmfulness of activities in adolescents with musculoskeletal pain.

Psychological interventions for headache in children and adolescents

Headache in children and adolescents represents a number of complex and multifaceted pain syndromes that can benefit from psychological intervention. There is good evidence for the efficacy of cognitive behavioral therapy, relaxation training, and biofeedback. The choice of intervention is influenced by patients' age, sex, family and cultural background, as well as the nature of stressors and comorbid psychiatric symptoms. Management must always be family-centered. Psychological treatments are essential elements of the multidisciplinary, biopsychosocial management of primary headache disorders, particularly for those with frequent or chronic headache, a high level of headache-related disability, medication overuse, or comorbid psychiatric symptoms. Future studies of efficacy and effectiveness of psychological treatment should use the International Headache Society's definition and classification of headache disorders, and stratify results by headache type, associated conditions, and treatment modality.

Neck pain in adolescence. A 4-year follow-up of pain-free preadolescents

The main aim of this study was to explore the occurrence and changes of neck pain in pain-free preadolescents. The evaluation was performed at 1- and 4-year follow-ups. Of the pain-free preadolescents, 366 (71.9%) completed structured pain questionnaires at 1 and 4 years. The occurrence of neck pain at least once a month was 21.3 and 43.4% and at least once a week was 6.3 and 19.4%. Sex difference was found only at the 4-year follow-up, when subjects were 13-16-year-old. Neck pain was then more common among girls than boys (P < 0.001). The intensity of pain increased with the frequency of pain (P < 0.001). Of those with neck pain, 28% had used painkillers. The proportion increased with the frequency of neck pain (P = 0.054). Neck pain occurred more often with some other musculoskeletal pain than as a single pain. The frequency of neck pain correlated with the frequency of headache (r = 0.39 [95% confidence interval (CI), 0.30-0.47]) and with the disability (r = 0.26 [95% CI, 0.16-0.35]). This study strengthens the results of the previous cross-sectional studies that occurrence of neck pain increases with age, and that neck pain becomes more common among girls than boys in adolescence. Among preadolescents who were originally pain-free, there was only a small proportion who reported frequent neck pain at both 1 and 4 years. It also showed that the frequency of neck pain reflects the intensity of pain fairly well.

Extending the efficacy of a thermal biofeedback treatment package to the management of tension-type headaches in children

This study explored the efficacy of a thermal biofeedback treatment package as an intervention with children with tension-type headaches. In a within-subject, time-lagged, multiple baseline design, five children, aged 8 to 14 years, were assigned to baselines of varying lengths prior to receiving treatment. Treatment was introduced sequentially across subjects and involved six thermal biofeedback treatment visits. Parents were also given guidelines for how best to encourage children to independently use the biofeedback skills. Data confirm that the participants learned the handwarming skill, practiced the skill on a regular basis during treatment, and independently used the skills to manage their pain. All participants demonstrated clinically significant reductions in one or more headache parameters (frequency, duration, intensity) following treatment. At 6-month follow-up, four of the five participants were headache-free. Although the thermal biofeedback treatment package was generally effective for these children with tension-type headaches, the specific type of headache experienced by each child appeared to influence the specific response to treatment. In addition, no single measure of headache activity was the best indicator of response to treatment. The efficacy of the thermal biofeedback treatment package is supported as an alternative treatment for children suffering from tension-type headaches.

Widespread pain among 11-year-old Finnish twin pairs

OBJECTIVE

To examine the prevalence of widespread musculoskeletal pain (WSP) symptoms in 11-year-old Finnish twins and to determine the relative role of genetic and environmental factors in the etiology of WSP.

METHODS

Data on current pain items were collected from 1995 to 1998 from a national sample of Finnish families with 11-year-old twins born between 1984 and 1987. The presence of WSP was determined using a validated questionnaire method. Pairwise similarity was computed for 583 monozygotic (MZ) pairs, 588 same-sex dizygotic (DZ) pairs, and 618 opposite-sex DZ twin pairs. Variance components for genetic and environmental factors were estimated using biometric structural equation modeling techniques.

RESULTS

The prevalence of WSP was 9.9%, with no sex difference. The majority of twin pairs with WSP were discordant. The tetrachoric correlations for male MZ (r = 0.38), male DZ (r = 0.37), female MZ (r = 0.59), female DZ (r = 0.54), and opposite-sex pairs (r = 0.43) showed little difference by zygosity. Female pairs were more concordant than male pairs among both MZ and DZ twins. Biometric model-fitting indicated that genetic factors did not account for the pattern of twin similarity. Among boys 35%, and among girls 56%, of the variation in liability to WSP could be attributed to shared familial environmental effects. The remainder was attributed to unshared environmental effects.

CONCLUSION

Genetic factors seem to play at most a minor role in WSP in 11-year-old twins, and environmental factors shared by family members account for a substantial proportion of the variability in WSP.

Brief cognitive-behavioral group treatment for children's headache

OBJECTIVE AND DESIGN

Using a randomized design with a waiting list control condition, we assessed the effectiveness of an abbreviated cognitive therapy group program for headaches in children 7 to 12 years of age. In the treatment condition, small groups of five to eight children were taught relaxation, distraction, visualization, and stress management skills in two 90-minute sessions. Parent groups, seen concurrently, reviewed the children's program and addressed parenting strategies. The waiting list control groups were treated 5 weeks later. Thirty-six children meeting inclusion criteria were included in the study; complete data were available for 29 participants (mean age, 9.4 years; 66% female).

DEPENDENT MEASURES

We obtained children's ratings of headache frequency, intensity, duration, and five other variables in a diary kept for 3 weeks before and 3 weeks after treatment. Parent measures were collected once before treatment and once at 3-month follow-up.

RESULTS

CHILD RATINGS: The control condition showed a significant reduction in children's self-rated headache frequency, while the treatment condition did not. On all other self-reported variables, there were no significant differences between the control and treatment conditions. Two participants in each condition achieved a 50% or greater reduction in a self-rating headache index.

RESULTS

PARENT RATINGS: Follow-up ratings, obtained over the telephone from parents after the children in both conditions had been treated, indicated that the children in both conditions had experienced reduced intensity, frequency, and duration of headaches and that 82% of the children were using the techniques taught in the program. Fourteen children achieved a 50% or greater reduction in a headache index based on parent ratings.

CONCLUSIONS

Although parents were very positive about the effectiveness of the program, the results for children's self-ratings do not support the use of this highly abbreviated treatment method.

Quantitative and qualitative assessments of pain in children with juvenile chronic arthritis based on the Norwegian version of the Pediatric Pain Questionnaire

Quantitative and qualitative aspects of pain were studied using a standardized questionnaire (the Varni/Thompson Pediatric Pain Questionnaire--PPQ). Fifty-seven of 64 consecutive in- and out-patients (6-18 yrs) with juvenile chronic arthritis (pauciart. n = 27, polyart. n = 30) and 52 parents participated. The patients were examined by the same rheumatologist and randomly interviewed by either a disabled or a non-disabled person. Present pain, worst pain intensity and disease severity were scored (on visual analogue scales [10 cm. VAS]) by patients, parents and rheumatologist. Eighty-two percent of the children reported pain lasting from 30 min up to 24 h daily (mean 4.3 h). No significant differences were found between median pain scores of children, parents and the physician, but the correlations found between children's and parent's assessment of pain and assessment of disease severity were low, indicating that the two sets of raters did not agree to an acceptable level. Two-thirds of the adolescents reported that they would become more physically active if pain disappeared. Should the pain suddenly vanish, a positive change in family relationships was anticipated by one out of four patients. Forty-two percent of the patients thought it valuable to be interviewed by a disabled physician. The Norwegian Varni/Thompson PPQ is easy to administer to children down to six years and makes it possible to compare results internationally. Lack of agreement on the assessment of pain by a child and his/her parent indicates the need to interview both parties.

Chronic nonprogressive headaches in children and adolescents

Chronic nonprogressive headaches are common in adolescents. The features of this syndrome are distinct from those of migraine. Chronic nonprogressive headaches have received less attention and study than migraine headaches. The prevalence of this syndrome is not clear. A structured psychological interview with the patient and the parents of the patient coupled with psychological testing of the patient will usually identify factors playing a role in the continuing headache. Counseling, biofeedback, and cognitive training, combined with judicious use of medication, will frequently lead to resolution of the headache.

A bio-psychosocial evaluation of ten adolescents with fibromyalgia

A comprehensive assessment of 10 adolescents (mean age 15.7 years) fulfilling the ACR criteria for fibromyalgia, disclosed that 3 patients also had juvenile chronic arthritis. Based on semi-structured psychiatric interviews, testing and family assessments, 6 of the patients had a psychiatric diagnosis (over anxious and/or depressive disorders). The pain scores for the group (mean 5.0, SD 1.5) were significantly higher than for a comparison group of patients with juvenile chronic arthritis (mean 2.5, SD 1.7), (p < 0.01). Average IQ was normal (mean 102.3, SD 13.9), but striving for achievement and high parental expectations were evident in 8 families. Seven of the mothers and 3 of the fathers had chronic diseases. The frequency of individual and family stress indicates a need for psychosocial assessment and counselling soon after onset of symptoms. This study also serves as a reminder that the diagnosis of juvenile chronic arthritis does not exclude fibromyalgia.

The Children's Headache Assessment Scale (CHAS): factor structure and psychometric properties

This study investigated the content validity, factor structure, and psychometric properties of the Children's Headache Assessment Scale (CHAS), a parent rating scale for identifying environmental variables associated with pediatric headache. In Study 1, input from physicians and psychologists was obtained to develop a revised set of 44 items receiving high endorsement. In Study 2, the questionnaire was administered to parents of 92 child headache sufferers, ages 6-16, and readministered 2 weeks later. An exploratory factor analysis revealed five factors (Disruptive Impact, Social Consequences, Stress Antecedents, Physical Antecedents and Quiet Coping, and Prescription Medication Use) that reflect distinct environmental concomitants of childhood headache. Scale reliabilities (alpha, .64-.82) indicate acceptable internal consistency, and test-retest reliabilities indicate relatively stable factors and items. High scores on the Disruptive Impact factor were associated with more severe, lengthy, and infrequent headache occurrence, lending initial support for the validity of this factor. Overall, the findings support the clinical and research utility of the CHAS in behavioral treatment of childhood headache.

Pain in the pediatric oncology patient

Pediatric oncology nurses face many challenges in treating the pain associated with childhood cancer. The type and severity of pain children with cancer experience varies from acute, short-term, procedure-related pain to the progressive chronic pain associated with terminal illness. In addition, the unfounded fears of using strong narcotic analgesics and the underutilization of psychological techniques to treat pain in children limit the effectiveness of pain management. Armed with objective data, pediatric oncology nurses can work with other members of the cancer treatment team to provide relief from the pain associated with the diagnosis and treatment of childhood cancer.

A holistic approach to vaso-occlusive pain crisis in children with sickle cell disease

A significant number of children with sickle cell disease suffer from episodes of acute recurrent vaso-occlusive pain crisis. Unfortunately, very limited published information is available about specific pain management practices used for these patients. There is even less information available on the use of an interdisciplinary approach for management of sickle cell crisis pain. The purpose of this article is to review the genetic cellular pathophysiology, the sickling process, vaso-occlusive crisis, and management of pain associated with sickle cell disease in children. The article further examines an interdisciplinary approach for the management of vaso-occlusive pain crisis.

Recurrent abdominal pain in children: psychiatric diagnoses and parental psychopathology

Approximately 12% of children report recurrent episodes of abdominal pain. In only about 10% of these cases, however, can an organic etiology be identified, and therefore it often is assumed that these children have emotional problems. To test this hypothesis, children with recurrent abdominal pain (RAP) with no identifiable organic cause were compared to children with an organic diagnosis for their abdominal pain, children with psychiatric disorders, and healthy controls. Both groups of children with abdominal pain had significantly more psychiatric disorders (predominantly anxiety and depression) than did the healthy group. Both RAP and psychiatric children had significantly higher Child Behavior Checklist internalizing scores; psychiatric children were rated as significantly more maladjusted on the Children's Global Assessment Scale. Mothers of RAP children were significantly more anxious than mothers of organic pain and healthy children. Psychiatric children were significantly more likely than the other three groups to underreport their psychiatric symptoms relative to their mothers.

Relationship between pain, disease severity and psychosocial function in patients with juvenile chronic arthritis (JCA)

At their first admission to hospital, 57 children (7-16 yrs) with definite or suspected rheumatic disease were interviewed regarding their perceptions of quality and intensity of pain and disease severity. All children reported pain. This was most often described as 'aching' (74%). The assessments of quality and quantity of pain by the children did not differ between diagnostic, age, or gender groups, or between children with or without previous exposure to other persons with rheumatic diseases. Actual pain intensity was correlated with disease severity assessed by the child and the parent. However, pain intensity was not correlated with a global assessment of disease severity by the physician or the child's psychosocial functioning. These findings may indicate a need for more generally accepted criteria of disease severity and pain assessment in patients with JCA.

Evaluating a child's pain

Much recent attention has focused on the development and refinement of pain measures, as well as on the use of more effective pain control methods for infants, children, and adolescents. This article reviews the primary categories of pediatric pain measures, with a specific focus on the selection of the most appropriate behavioral, physiologic, or subjective method for assessing a child's pain. The optimum pain measure depends on the age and cognitive level of a child, the type of pain experienced, and the situation in which the pain occurs. While no single measure is adequate for all children for all types of acute, recurrent, and chronic pain, it is possible to choose practical, valid, and reliable methods for evaluating any child's pain experience.