Fear of pain in children and adolescents with neuropathic pain and complex regional pain syndrome

Pediatric Neural Changes to Physical and Emotional Pain After Intensive Interdisciplinary Pain Treatment: A Pilot Study

OBJECTIVE

Brain areas activated during pain can contribute to enhancing or reducing the pain experience, showing a potential connection between chronic pain and the neural response to pain in adolescents and youth.

METHODS

This study examined changes in brain activation associated with experiencing physical pain and observing physical and emotional pain in others by using functional magnetic resonance imaging (fMRI) before and after intensive interdisciplinary pain treatment (IIPT). Eighteen youths (age 14 to 18) with widespread chronic pain completed fMRI testing before and after IIPT to assess changes in brain activation in response to physical and emotional pain.

RESULTS

Broadly, brain activation changes were observed in frontal, somatosensory, and limbic regions. These changes may suggest improvements in descending pain modulation via thalamus and caudate, and the different pattern of brain activation after treatment suggests potentially better discrimination between physical and emotional pain. Brain activation changes were also correlated with improvements in clinical outcomes of catastrophizing (reduced activation in right caudate, right mid-cingulate, and postcentral gyrus) and pain-related disability (increased activation in precentral gyrus, left hippocampus, right middle occipital cortex, and left superior frontal gyrus).

DISCUSSION

These changes could indicate that reduced brain protective responses to pain were associated with treatment-related improvements. This pilot study highlights the need for larger trials designed to better understand the brain mechanisms involved in pediatric widespread pain treatment.

Treating Anxiety-Based Cognitive Distortions Pertaining to Somatic Perception for Better Chronic Pain Outcomes: A Recommendation for Better Practice in the Present Day and the Cyber Age of Medicine

Anxiety-based cognitive distortions pertaining to somatic perception (ABCD-SPs)-primarily catastrophizing, fear avoidance, and kinesiophobia-have been repeatedly linked to worsening chronic, non-cancer pain (CNCP) outcomes of increased disability, amplified pain, ineffective opioid use, and opioid misuse. Several studies have suggested that treating ABCD-SPs can improve pain outcomes, yet identification and targeting of ABCD-SPs are not part of the standard medical pain assessment and treatment plan. Utilizing a narrative review of proposed mechanisms, published patient perspectives, and study correlations connecting these cognitive distortions with CNCP outcomes, an approach for better practice in the delivery of standard medical CNCP care can be deduced and formulated into a Belief and Behavior Action Plan (BBAP) for medical clinicians treating CNCP to implement into initial and maintenance care planning. These recommendations require relatively few resources to implement and have the potential to disseminate more effective CNCP treatment on a large scale now and in the future with the new frontier of cognitive computing in medicine.

Comparison of Pain Characteristics, Strength, and Movement Patterns in Adolescents With Juvenile Fibromyalgia and High Versus Low Fear of Movement

Physical activity avoidance and fear of movement (FOM) is often observed in individuals with chronic musculoskeletal pain, along with difficulties coping with pain. There is little research regarding how FOM may also relate to reduced physical strength and altered movement patterns that may perpetuate a cycle of pain, FOM, and disability. The objective of this observational study was to compare how adolescents with juvenile fibromyalgia (JFM) exhibiting high versus low FOM (Tampa Scale of Kinesiophobia-11) differed on patient-reported measures of pain, fatigue, catastrophizing and pain interference, and performance-based measures of strength, postural control, and biomechanical function. Participants were youth with JFM (N = 135, Meanage = 15.6 years, 88.9% female) enrolled in an ongoing clinical trial who completed self-report questionnaires and standardized tests, including knee and hip strength, the Star Excursion Balance Test, and the Drop Vertical Jump (with 3 dimensional motion capture). Participants were categorized into Low, Medium, and High FOM groups based on Tampa Scale of Kinesiophobia-11 tertile scores. Relative to the Low FOM group, the High FOM group reported significantly greater fatigue, pain interference and catastrophizing, as well as reduced dominant leg knee strength. Additionally, those with high FOM showed altered lower-extremity movement patterns. This preliminary study highlights the importance of combining self-reported measures of symptoms and functioning with physical assessments to gain a more comprehensive view of the impact of FOM in patients with chronic musculoskeletal pain. The results could inform the development of more precise interventions to reduce FOM using a combination of behavioral and exercise-based interventions.

PERSPECTIVE

The results of this study demonstrate the association between FOM, fatigue and pain interference in adolescents with JFM, as well as preliminary evidence for altered movement patterns in that may predispose them to further pain/injury and activity avoidance.

CLINICAL TRIALS

GOV REGISTRATION

NCT03268421.

The impact of foot orthoses on gait in children with Osteogenesis Imperfecta type I, III and IV - a cross-sectional study

BACKGROUND

For children with Osteogenesis Imperfecta (OI), a rare genetic bone disease, walking can be difficult to carry out due to a combination of bone fragility and deformity, muscle weakness, joint hypermobility, and pain. Bisphosphonate treatment has facilitated more children being able to walk, but for many, foot and ankle hypermobility is a limiting factor. Current evidence on foot orthoses in children with OI is sparse. This study aimed to evaluate gait characteristics in children with OI walking barefoot as compared to walking with foot orthoses.

METHODS

Twenty-three children with OI and hypermobility (mean age 8.3 ± 3.0 years) were included in this cross-sectional study. Children conducted three-dimensional gait analysis barefoot, and with foot orthoses and appropriate foot wear (stable yet light-weight), respectively. Walking speed, step length, lower limb kinematics and kinetics were collected. Differences in gait characteristics between test conditions were evaluated using paired sample t-tests.

RESULTS

When walking with foot orthoses, the external foot progression angle was reduced, peak ankle dorsiflexion angle increased, and peak plantarflexion moment increased as compared to barefoot. No difference was found in walking speed between test conditions, however, children with OI walked with longer steps with foot orthoses as compared to barefoot.

CONCLUSION

The observed gait alterations suggest that foot orthoses, aiming to support the foot and ankle joint, contributed to reduced overall foot rotation as measured by external foot progression, increased peak plantarflexion moment, and increased step length. In a wider perspective, the ability to walk provides the opportunity to be physically active, and thereby increase skeletal loading and prevent fractures, thus, foot orthoses may be an important treatment option to consider in children with OI.

LEVEL OF EVIDENCE

III.

Longitudinal Pain Outcomes Following an Intensive Pediatric Pain Rehabilitation Program: Testing Potential Treatment Mechanisms

OBJECTIVES

This study tested performance measures of physical functioning and pain-related psychosocial measures as potential mechanisms of improvements in outcomes following intensive outpatient interdisciplinary pain rehabilitation for adolescents. We hypothesized that improvements in performance measures of physical functioning, fear of pain, pain catastrophizing, and self-efficacy during treatment would be related to improvements in pain, functional disability, and depressive symptoms.

METHODS

Seventy-seven adolescents, 10 to 18 years old, completed self-report measures before treatment, after the first week, at discharge, and at the 3-month follow-up. Participants completed physical performance measures of physical and exercise capacity and core strength on day 1, after the first week, and at discharge. Linear mixed models were used to examine the association between changes in potential mechanisms and changes in outcomes, adjusting for age, sex, pain duration, and baseline functional disability.

RESULTS

Statistically significant improvement in functional disability, pain, and depressive symptoms was demonstrated across the 4 time points. Improvements were also demonstrated in physical performance measures, fear of pain, pain catastrophizing, and self-efficacy. Improvements in pain catastrophizing predicted improvements in functional disability, pain, and depressive symptoms. Improvements in self-efficacy predicted improvements in all outcome variables except depression. Improvements in physical performance measures predicted improvements in some aspects of functional disability and pain, but not depressive symptoms.

DISCUSSION

This study contributes to the growing literature on the effectiveness of pediatric intensive interdisciplinary pain rehabilitation programs and mechanisms that influence improvements in outcomes, an area that is currently underexplored. Results are important to guide future research and inform clinical practice.

Sensitivity and Specificity of a Neuropathic Screening Tool (Self-Report Leeds Assessment of Neuropathic Symptoms and Signs, S-LANSS) in Adolescents With Moderate-Severe Chronic Pain

Neuropathic screening tools improve recognition of neuropathic pain in adults. Although utilized in pediatric populations, the sensitivity, specificity and methodology of screening tool delivery have not been compared in children. We evaluated the Self-Report Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) in adolescents (10-18 years) referred to a tertiary pediatric pain clinic. History and examination by specialist clinicians and multidisciplinary assessment informed classification of the primary pain type. In a prospective cohort, scores were obtained at interview (S-LANSS interview; n = 161, 70% female), and following substitution of self-reported signs with examination findings in the primary pain region (Leeds Assessment of Neuropathic Symptoms and Signs, LANSS examination). Secondly, we retrospectively retrieved questionnaires self-completed by adolescents at their initial clinic appointment (S-LANSS self-completed; n = 456, 73% female). Thirdly, we explored relationships between patient-reported outcomes and S-LANSS scores. S-LANSS interview scores varied with pain classification, and S-LANSS self-completed scores were similarly highest with neuropathic pain (median [interquartile range]: 18 [11, 21]) and complex regional pain syndrome (21 [14, 24]), variable with musculoskeletal pain (13 [7, 19]) and lowest with visceral pain (6.5 [2, 11.5]) and headache (8.5 [4, 14]). As in adults, the cutpoint score of 12/24 was optimal. Sensitivity was highest with inclusion of examination findings and lowest with self-completion (LANSS examination vs S-LANSS interview vs S-LANSS self-completed: 86.3% vs 80.8% vs 74.7%), but specificity was relatively low (37.8% vs 36.7% vs 48%). High S-LANSS scores in non-neuropathic groups were associated with female sex and high pain catastrophizing. The S-LANSS is a sensitive screening tool for pain with neuropathic features in adolescents, but needs to be interpreted in the context of clinical evaluation (clinicaltrials.gov NCT03312881). PERSPECTIVE: This article reports high sensitivity of the S-LANSS screening tool for identifying pain with neuropathic features in adolescents with moderate-severe chronic pain. However, as sensitivity is lower than in adult populations, further interdisciplinary evaluation is necessary to inform diagnosis and management.

Regional anesthesia for pain control in children with solid tumors-a review of case reports

Introduction

Around seventy percent of all childhood cancer patients suffer from severe pain. This pain can arise from various sources, including tumors themselves, pain caused by metastasizing tumor cells or as the outcome of therapy meant to deal with tumors. If managed inadequately, such pain can lead to many hazardous sequelae. However, there are extreme cases when pain does not respond to standard treatment. For such cases, regional anesthesia or nerve blocks are utilized as the utmost pain control measure. Blocks are used to treat pain in patients who no longer respond to conventional opioid-based treatment or whose worsened condition makes it impossible to receive any other therapy. The data regarding the use of regional anesthesia for such cases in the children population is limited.

Methods

For this review we searched for case reports in Scopus and PubMed from inception to 2023. The descriptive search items included terms related to childhood cancer and the description of each block. The inclusion criteria for review include children (0-18 years old) receiving oncology-related surgical procedures or palliative care. The data collection was limited to solid tumor-related cases only. We analyzed a total of 38 studies that included case reports and one retrospective study.

Results and discussion

It was concluded that nerve blocks, although rarely performed, are a safe and efficient way of pain control in children with solid tumors. The major settings for block performance are postoperative pain control and palliative care. We observed that block indication and its outcomes depend on unique health circumstances in which they should be performed. Patients with similar diagnoses had differing outcomes while receiving the same block treatment.

Virtual reality facilitated exercise improves pain perception: A crossover study

STUDY OBJECTIVE

Both virtual reality (VR) and exercise are recognized for their analgesic and anxiolytic properties. The purpose of this study is to evaluate the ability of VR-facilitated exercise to modulate pain.

DESIGN

Within-subject cross-over clinical trial.

SETTING

The Stanford Chariot Program conducted this study at Lucile Packard Children's Hospital Stanford (LCPHS).

PATIENTS

Healthy participants meeting inclusion criteria were recruited by volunteer solicitation from LCPHS.

INTERVENTIONS

Participants were randomized by hand dominance and subjected to a standardized cold pressor test with no VR or exercise. After a 5-min wash-out period, participants repeated the test on their other hand while experiencing a VR-facilitated exercise condition. Pain sensitivity, pain tolerance, and sympathetic activation data were collected during both conditions.

MEASUREMENTS

Pain sensitivity was scored 0-10 and collected every 30 s. Pain tolerance was recorded as the duration a participant could endure the painful stimuli. Sympathetic activation was measured by skin conductance response density (SCRD) and recorded in 30 s epochs by a biosensor. In all analyses, data were nested by participant.

MAIN RESULTS

Forty-one participants completed both interventions. Pain sensitivity was reduced in the VR-facilitated exercise condition (p < 0.0001). There was no difference in pain tolerance between conditions. While both conditions resulted in an increase in sympathetic activity, SCRD was higher at all time points in the VR-facilitated exercise condition.

CONCLUSIONS

The reduction in pain sensitivity indicates VR-facilitated exercise results in improved pain perception. VR-facilitated exercise may be especially useful for patients with chronic pain or other conditions requiring physical therapy, where pain may be exacerbated by exercise.

Application of PainDETECT in pediatric chronic pain: how well does it identify neuropathic pain and its characteristics?

Introduction

Neuropathic pain (NP) arises from nerve damage or disease, and when not defined, it can impair function and quality of life. Early detection allows for interventions that can enhance outcomes. Diagnosis of NP can be difficult if not properly evaluated. PainDETECT is a NP screening tool developed and successfully used in adults.

Objectives

We evaluated the validity of painDETECT in a pediatric population.

Methods

Adolescents and young adults (10-19 years old) completed painDETECT and quantitative sensory testing (QST), which assessed mechanical allodynia and hyperalgesia, common symptoms of NP. Pain diagnoses, including neuropathic pain (n = 10), were collected through documentation in the medical chart. Descriptive statistics were used to examine age, gender, pain diagnoses, and painDETECT scores. Kruskal-Wallis H tests were conducted to examine differences in QST results across painDETECT categorizations.

Results

Youth with chronic pain (N = 110, Mage = 15.08 ± 2.4 years, Nfemale = 88) and peers without pain (N = 55, Mage = 15.84 ± 3.9 years, Nfemale = 39) completed the painDETECT. The painDETECT scores for youth with pain (M = 12.7 ± 6.76) were significantly higher than those for peers without pain (M = 2.05 ± 2.41). PainDETECT demonstrated 80% sensitivity and 33% specificity in a pediatric population. Individuals who screened positively on the PainDETECT had significantly higher mechanical allodynia (M = 0.640 ± 0.994) compared with those who screened negatively (M = 0.186 ± 0.499; P = 0.016).

Conclusion

PainDETECT demonstrated the ability to screen for NP, and QST mechanical allodynia results were consistent with a positive NP screen. Results of the study offer preliminary support for the ongoing assessment of the painDETECT as a brief, inexpensive, and simple-to-use screening tool for pediatric patients with primary pain complaints.

Pediatric Neural Changes to Physical and Emotional Pain After Intensive Interdisciplinary Pain Treatment: A Pilot Study

Brain areas activated during pain can contribute to enhancing or reducing the pain experience, showing a potential connection between chronic pain and the neural response to pain in adolescents and youth. This study examined changes in brain activation associated with experiencing physical pain, and the observation of physical and emotional pain in others, by using functional magnetic resonance imaging (fMRI) before and after intensive interdisciplinary pain treatment (IIPT). Eighteen youth (age 14 to 18) with widespread chronic pain completed fMRI testing before and after IIPT to assess changes in brain activation in response to physical and emotional pain. Broadly, brain activation changes were observed in frontal, somatosensory, and limbic regions. These changes suggest improvements in descending pain modulation via thalamus and caudate, and the different pattern of brain activation after treatment suggests better discrimination between physical and emotional pain. Brain activation changes were also correlated with improvements in clinical outcomes of catastrophizing (reduced activation in right caudate, right mid-cingulate, and postcentral gyrus) and pain-related disability (increased activation in precentral gyrus, left hippocampus, right middle occipital cortex, and left superior frontal gyrus). These changes support interpretation that reduced brain protective responses to pain were associated with treatment-related improvements. This pilot study highlights the need for larger trials designed to better understand the brain mechanisms involved in pediatric widespread pain treatment.

Tension-Type Headache in Children and Adolescents

In pediatric neurology, tension-type headache (TTH) represents a very common type of primary headache during the pediatric age. Despite the high prevalence of TTH, this diagnosis is often underestimated in childhood, with relevant difficulties in the differential diagnosis of TTH from secondary and primary headache manifestations. Even among primary headaches, a clinical overlap is not so infrequent in children: migraine attacks could present tension headache-like features while tension-type headaches may display migraine-like symptoms as well. Several variables play a role in the complex trajectory of headache evolution, such as hormonal changes during adolescence, triggers and genetic and epigenetic factors. The trajectories and outcomes of juvenile migraine and TTH, as well as the transition of one form to the other, have been investigated in several long-term prospective studies. Thus, the aim of this paper is to review the current literature on the differential diagnosis workout of TTH in pediatrics, the possible outcomes during the developmental age and the appropriate therapeutic strategies. Indeed, TTH represents a challenging diagnostic entity in pediatrics, both from a clinical and a therapeutic point of view, in which early diagnosis and appropriate treatment are recommended.

Predicting the Need for Transition from Pediatric to Adult Pain Services: A Retrospective, Longitudinal Study Using the Electronic Persistent Pain Outcome Collaboration (ePPOC) Databases

A proportion of youth with chronic pain do not respond to interdisciplinary pain management and may require transition to adult pain services. This study sought to characterize a cohort of patients referred to pediatric pain services who subsequently required referral to an adult pain service. We compared this transition group with pediatric patients eligible by age to transition but who did not transition to adult services. We sought to identify factors predicting the need to transition to adult pain services. This retrospective study utilized linkage data from the adult electronic Persistent Pain Outcomes Collaboration (ePPOC) and the pediatric (PaedePPOC) data repositories. The transition group experienced significantly higher pain intensity and disability, lower quality of life, and higher health care utilization relative to the comparison group. Parents of the transition group reported greater distress, catastrophizing, and helplessness relative to parents in the comparison group. Three factors significantly predicted transition: compensation status (OR = 4.21 (1.185-15)), daily anti-inflammatory medication use (OR = 2 (1.028-3.9)), and older age at referral (OR = 1.6 (1.3-2.17)). This study demonstrated that patients referred to pediatric pain services who subsequently need transition to adult services are a uniquely disabled and vulnerable group beyond comparative peers. Clinical applications for transition-specific care are discussed.

Exploring pain interference and self-perceived health status in children with osteogenesis imperfecta - a cross-sectional study

Background

Chronic pain may affect and interfere in children’s everyday life and can be present in children with Osteogenesis Imperfecta (OI). However, the knowledge is still sparse to what extent pain is present, how pain interfere in children’s everyday life and affect their self-perceived health status. The purpose of the study was therefore to explore presence of chronic pain, pain interference in daily life, and self-perceived health status in children with OI.

Methods

Children with OI, aged 6–18 years, were recruited consecutively to this cross-sectional study. Participants answered a standardised interview including five pre-structured questions, and the Numeric Pain Rating Scale (NPRS), the Pain Interference Index, and a questionnaire concerning self-perceived health status the Patient Reported Outcomes Measurement Information System Pediatric-25 Profile v1.1 (PROMIS-25).

Results

Twenty-eight children (median: 11 years, IQR 6) with OI type I, III, or IV participated. Pain was present in 27 of 28 children and interfered in their everyday life regardless of OI-type, sex, and age. The median NPRS for average pain intensity was 4 (IQR 2), the median for pain frequency was 2–3 times/week, and the median frequency of school absence due to pain was 2–3 times per month. The most common pain locations were back and feet. Pain in the feet was more frequently reported in children with type I (p = 0.032), and pain in the hip was more often reported in children ≥13 years (p = 0.011). The children were asked what they thought to be the cause of pain and the most frequent response was “walking long distances”. Self-perceived health status for mobility was lower than the general population, and lowest for children with type III (p = 0.016). Pain interference was associated with children’s self-perceived health status (r_s = 0.84, p < 0.001).

Conclusion

Almost all children experienced pain, which interfered in children’s everyday lives, affected participation in various activities and was associated with reduced self-perceived health status. If children avoid physical activities because of pain, it might cause a vicious circle of inactivity, which further decreases bone density and increase the risk of fractures. The results emphasize the importance to offer adequate pain reducing interventions.

Amygdalar Functional Connectivity Differences Associated With Reduced Pain Intensity in Pediatric Peripheral Neuropathic Pain

Background

There is evidence of altered corticolimbic circuitry in adults with chronic pain, but relatively little is known of functional brain mechanisms in adolescents with neuropathic pain (NeuP). Pediatric NeuP is etiologically and phenotypically different from NeuP in adults, highlighting the need for pediatric-focused research. The amygdala is a key limbic region with important roles in the emotional-affective dimension of pain and in pain modulation.

Objective

To investigate amygdalar resting state functional connectivity (rsFC) in adolescents with NeuP.

Methods

This cross-sectional observational cohort study compared resting state functional MRI scans in adolescents aged 11–18 years with clinical features of chronic peripheral NeuP (n = 17), recruited from a tertiary clinic, relative to healthy adolescents (n = 17). We performed seed-to-voxel whole-brain rsFC analysis of the bilateral amygdalae. Next, we performed post hoc exploratory correlations with clinical variables to further explain rsFC differences.

Results

Adolescents with NeuP had stronger negative rsFC between right amygdala and right dorsolateral prefrontal cortex (dlPFC) and stronger positive rsFC between right amygdala and left angular gyrus (AG), compared to controls (P_FDR<0.025). Furthermore, lower pain intensity correlated with stronger negative amygdala-dlPFC rsFC in males (r = 0.67, P = 0.034, n = 10), and with stronger positive amygdala-AG rsFC in females (r = −0.90, P = 0.006, n = 7). These amygdalar rsFC differences may thus be pain inhibitory.

Conclusions

Consistent with the considerable affective and cognitive factors reported in a larger cohort, there are rsFC differences in limbic pain modulatory circuits in adolescents with NeuP. Findings also highlight the need for assessing sex-dependent brain mechanisms in future studies, where possible.

The Pediatric Pain Screening Tool (PPST) can Rapidly Identify Elevated Pain and Psychosocial Symptomatology in Treatment-Seeking Youth with Acute Musculoskeletal Pain

This cross-sectional study examines the utility of the Pediatric Pain Screening Tool (PPST) for rapidly assessing pain and psychosocial symptomatology in treatment-seeking youth with acute musculoskeletal pain. Participants were 166 youth (10-18 years, 53.6% female) participating in one of two larger cohort studies of youth with acute musculoskeletal pain. Youth completed the PPST and measures of pain, pain-related fear, pain catastrophizing, pain-related disability, and sleep quality. Participants were categorized into PPST risk groups using published cut-offs. ANOVA and chi-square examined associations between PPST risk groups and self-report measures; receiver operating characteristic (ROC) analyses examined associations among PPST scores and clinical reference cut-offs. The PPST classified 28.3% of youth as high, 23.5% as moderate, and 48.2% as low-risk. Females were more likely to be high-risk. ANOVAs revealed differences in clinical factors by PPST risk group particularly differences among youth labeled high versus low-risk. ROC analyses showed the PPST is effective in discriminating "cases" versus "non-cases" on pain-related disability, pain-fear and catastrophizing. Results reveal the PPST is effective for rapidly screening youth with acute pain for pain and psychosocial symptomatology. An important next step will be to examine the validity of the PPST in predicting recovery outcomes of acute pain samples. PERSPECTIVE: This article presents the Pediatric Pain Screening Tool (PPST) as a measure for rapidly screening youth with acute pain for pain and psychosocial symptomatology. The tool categorizes youth into low, moderate or high-risk groups and discriminates among those with versus without clinically significant levels of disability, pain-related fear and catastrophizing.

Developmental Mechanisms of CPSP: Clinical Observations and Translational Laboratory Evaluations

Understanding mechanisms that underly the transition from acute to chronic pain and identifying potential targets for preventing or minimizing this progression have specific relevance for chronic postsurgical pain (CPSP). Though it is clear that multiple psychosocial, family, and environmental factors may influence CPSP, this review will focus on parallels between clinical observations and translational laboratory studies investigating the acute and long-term effects of surgical injury on nociceptive pathways. This includes data related to alterations in sensitivity at different points along nociceptive pathways from the periphery to the brain; age- and sex-dependent mechanisms underlying the transition from acute to persistent pain; potential targets for preventive interventions; and the impact of prior surgical injury. Ongoing preclinical studies evaluating age- and sex-dependent mechanisms will also inform comparative efficacy and preclinical safety assessments of potential preventive pharmacological interventions aimed at reducing the risk of CPSP. In future clinical studies, more detailed and longitudinal peri-operative phenotyping with patient- and parent-reported chronic pain core outcomes, alongside more specialized evaluations of somatosensory function, modulation, and circuitry, may enhance understanding of individual variability in postsurgical pain trajectories and improve recognition and management of CPSP.

What is pain: Are cognitive and social features core components?

Pain is a universal experience, but it has been challenging to adequately define. The revised definition of pain recently published by the International Association for the Study of Pain addressed important shortcomings of the previous version; however, it remains narrow in its focus on sensory and emotional features of pain, failing to capture the substantial roles of cognitive and social core components of the experience and their importance to advances in pain management. This paper reviews evidence and theoretical models for the significant role social and cognitive factors play in pain experience and we argue that without explicit recognition of these core components in the definition, significant nuances are lost at a cost to understanding and clinical management of pain. A focus on sensory and emotional features perpetuates biomedical interventions and research, whereas recognition of cognitive and social features supports a multidimensional model of pain, advances in interdisciplinary care, and the benefits of cognitive behavioral therapy and self‐management interventions. We also explore the six Key Notes that accompany the new definition of pain, discuss their application to the understanding of pain in childhood, and, in doing so, further explore social and cognitive implications. Considerations are also described for assessment and treatment of pain in pediatric populations.

Comparing Three Music Therapy Interventions for Anxiety and Relaxation in Youth With Amplified Pain

Research in pediatric hospitals has shown that active music engagement, preferred music listening, and music-assisted relaxation can decrease anxiety and increase relaxation responses. However, there is little research on the use of music therapy with pediatric chronic pain conditions such as amplified pain syndromes. The purpose of the current study was to examine the effects of 3 specific music therapy interventions (active music engagement, live patient-selected music, and music-assisted relaxation) on anxiety and relaxation levels in youth (ages 10-18) participating in a 40 hr per week hospital-based intensive interdisciplinary pain treatment program. A sample of 48 patients participated in this study which utilized a 3-period, 3-treatment cross-over design with 3 interventions delivered in a quasi-randomized order determined by when the patients started the treatment program. State anxiety was measured via the state form of the State-Trait Inventory for Cognitive and Somatic Anxiety for Children and relaxation scores were assessed with a Visual Analog Scale. Statistically significant changes were found in anxiety and relaxation outcomes across all interventions provided. Results suggest that music therapy services (using active music engagement, live patient-selected music, and music-assisted relaxation) may be an effective modality to decrease anxiety and increase relaxation levels in pediatric patients with amplified pain syndromes.

Phenotyping peripheral neuropathic pain in male and female adolescents: pain descriptors, somatosensory profiles, conditioned pain modulation, and child-parent reported disability

ABSTRACT

Neuropathic pain (NeuP) can be difficult to diagnose and manage in children. Data regarding prevalence and sex-dependent differences are limited, and more detailed phenotyping is needed. This observational cohort study recruited adolescents (10-17 years) with NeuP or complex regional pain syndrome (CRPS). After pain history and NeuP questionnaires, quantitative sensory testing was performed. Individual z-score plots were calculated with body-region control measures and matched to mechanism-related sensory profiles (sensory loss, thermal hyperalgesia, and mechanical hyperalgesia). Conditioned pain modulation was assessed with pressure pain threshold and a contralateral cold conditioning stimulus, and meaningful conditioned pain modulation defined as twice the standard error of measurement. Patients and parents completed validated questionnaires for child quality of life (QoL), pain catastrophizing, and self-reported anxiety/depression. Males (n = 23) and females (n = 43) with NeuP (n = 52) or CRPS (n = 14) reported moderate-severe pain with neuropathic sensory descriptors. Mixed patterns of sensory gain/loss at pain sites were not sex-dependent. Thermal hyperalgesia was common in both NeuP and CRPS, whereas sensory loss occurred only with NeuP and in a smaller proportion than adult cohorts. Conditioned pain modulation was inhibitory in 54%, facilitatory in 14%, and nonresponders had variable cold conditioning sensitivity. Males and females reported marked impairment of QoL, increased emotional distress, and pain catastrophising. Child-parent QoL scores correlated, but catastrophizing scores were discordant when parents or adolescents reported higher anxiety/depression. NeuP in adolescents is associated with significant pain, physical impairment, and psychosocial impairment. Quantifying alterations in somatosensory profiles, descending modulation, child and parent psychological function will inform individualized therapy and stratification for future clinical trials.

Clinical overlap of functional neurologic symptom disorder and complex regional pain syndrome in pediatrics: A case report

This case study documents a 13-year-old female who presented to our intensive inpatient chronic pain rehabilitation program with complex regional pain syndrome (CRPS) of her left leg, which was significantly interfering with her normal daily functioning. She participated in a full day of traditional interdisciplinary therapies, including physical and occupational therapy for 3 hours daily. As assistive equipment was altered or weaned her physical mobility, balance, and tremors worsened and/or increased. As she began advancing her legs more independently (versus requiring physical assist), she demonstrated more variable functional strength and stability, inconsistent balance reactions, and a more unsteady gait pattern. The team was treating her according to her incoming CRPS diagnosis; however, as treatment progressed, her physical and psychological presentation seemed more aligned with diagnostic criteria of functional neurologic symptom disorder (FND). Staff then treated according to the FND diagnosis resulting in successful long-term outcomes. The clinical impact from this case study includes highlighting the commonalities between CPRS and FND clinically, discussing treatment suggestions depending on the diagnosis, and emphasizing key components of family/patient education.

Neuropathic pain in children: Steps towards improved recognition and management

Neuropathic pain in children can be severe and persistent, difficult to recognise and manage, and associated with significant pain-related disability. Recognition based on clinical history and sensory descriptors is challenging in young children, and screening tools require further validation at older ages. Confirmatory tests can identify the disease or lesion of the somatosensory nervous system resulting in neuropathic pain, but feasibility and interpretation may be influenced by age- and sex-dependent changes throughout development. Quantitative sensory testing identifies specific mechanism-related sensory profiles; brain imaging is a potential biomarker of alterations in central processing and modulation of both sensory and affective components of pain; and genetic analysis can reveal known and new causes of neuropathic pain. Alongside existing patient- and parent-reported outcome measures, somatosensory system research methodologies and validation of mechanism-based standardised end-points may inform individualised therapy and stratification for clinical trials that will improve evidence-based management of neuropathic pain in children.

Loss-adjusting: Young People's Constructions of a Future Living With Complex Regional Pain Syndrome

OBJECTIVES

Complex Regional Pain Syndrome (CRPS) is a chronic pain condition that can present specific difficulties when occurring in adolescence. There is limited work exploring future narratives of healthy adolescents, and how these may differ for those who have chronic health conditions, but there is no research on the future narratives of adolescents who have CRPS.

MATERIALS AND METHODS

In this study, 50 adolescents (44 females, 5 males, 1 preferred not to say) aged 14 to 25 years (mean=19.8, SD=3.68), completed an online story completion task, with a further sample of 10 completing a follow-up telephone interview.

RESULTS

Story completion data were initially analyzed deductively based on the work of Morley and colleagues using hoped-for and feared-for future codes, revealing higher instances of hope (291 over 48 stories) than fear (99 over 27 stories). These codes were subsequently analyzed alongside the in-depth interview data using inductive thematic analysis, generating 2 themes that represent distinct, yet related, approaches of how adolescents incorporate CRPS into their future narratives: (1) the centrality of loss theme identifies the ways some adolescents described how CRPS brings loss, with narratives focused on how these adolescents imagine such losses continuing into the future, and (2) the adjusting to loss theme illustrates the ways other adolescents were able to imagine a future in which they were able to adjust to the losses which CRPS may bring.

DISCUSSION

CRPS may damage the future plans of adolescents. However, being or learning how to be flexible about these goals, may help them to build more positive future narratives.

Predicting trait-like individual differences in fear of pain in the healthy state using gray matter volume

Fear of pain (FOP) can be considered as a product of evolution from overstated negative interpretations of pain and sometimes may cause more damage than the actual pain itself. While trait-like measures of FOP have emerged as predictors for the inception and development of chronic pain, its neural underpinnings are not well understood. To investigate the relationship between gray matter volumes (GMV) and trait-like individual differences in FOP, we analyzed structural magnetic resonance imaging data in a sample of healthy young adults. Regression analysis results showed that individuals with higher FOP scores displayed higher GMV in brain regions important for the regulation of pain and fear. These brain areas include the pregenual anterior cingulate cortex (ACC), the anterior part of the dorsal ACC, the dorsomedial prefrontal cortex, and the adjacent pre-supplementary motor area. Furthermore, cross-validation analysis confirmed that the identified regional GMV offered a reliable neural signature of trait-like FOP. Our findings shed more light on the neuroanatomical architecture of FOP in currently pain-free people, which may be helpful to guide early interventions to prevent FOP from becoming chronic.

Stress-system activation in children with chronic pain: A focus for clinical intervention

Accumulating evidence indicates that psychological and neurophysiological processes interconnect and interact to activate the body's stress system and to trigger and maintain functional somatic symptoms. This study used the Early Life Stress Questionnaire, Depression Anxiety Stress Scales and biological markers (heart rate, heart rate variability, skin conductance, C-reactive protein (CRP) titre, respiratory rate, and accuracy and reaction time in an emotion-face identification task), to examine childhood adversity, psychological distress and stress-system activation in 35 children and adolescents (23 girls and 12 boys, 9-17 years old) disabled by chronic pain (vs two groups of age- and sex-matched healthy controls). Patients reported more early-life stress (U = 798.5, p = .026) and more psychological distress (U = 978, p < .001). They showed activation of the autonomic system: elevated heart rate (U = 862.5, p = .003), elevated electrodermal activity (U = 804.5, p = .024) and lower heart rate variability in the time domain (U = 380.5, p = .007) and frequency domain (U = 409.5, p = .017). The group showed an upward shift of CRP titres (with 75th and 90th CRP percentiles of 4.5 and 10.5 mg/L, respectively), suggesting the activation of the immune-inflammatory system. Elevated CRP titres were associated with elevated heart rate (p = .028). There were no differences in respiratory rate or in accuracy and reaction time in the emotion-face identification task. The results indicate that interventions for children and adolescents with chronic pain need a multidisciplinary mind-body approach that concurrently addresses psychological distress, physical impairment and stress-system dysregulation.

Biological and behavioral markers of pain following nerve injury in humans

The evolution of peripheral and central changes following a peripheral nerve injury imply the onset of afferent signals that affect the brain. Changes to inflammatory processes may contribute to peripheral and central alterations such as altered psychological state and are not well characterized in humans. We focused on four elements that change peripheral and central nervous systems following ankle injury in 24 adolescent patients and 12 age-sex matched controls. Findings include (a) Changes in tibial, fibular, and sciatic nerve divisions consistent with neurodegeneration; (b) Changes within the primary motor and somatosensory areas as well as higher order brain regions implicated in pain processing; (c) Increased expression of fear of pain and pain reporting; and (d) Significant changes in cytokine profiles relating to neuroinflammatory signaling pathways. Findings address how changes resulting from peripheral nerve injury may develop into chronic neuropathic pain through changes in the peripheral and central nervous system.

Learning to fear pain after observing another's pain: An experimental study in schoolchildren

BACKGROUND

Children of individuals with chronic pain have an increased vulnerability to experience pain problems, possibly through observation of pain in their parents. As pain-related fear (PRF) is a critical factor in the development and maintenance of chronic pain, the current experimental study examined the acquisition of PRF through observational learning and subsequent extinction after first-hand experience of the feared stimulus.

METHODS

Healthy children (8-16 years) observed either their mother or a stranger performing two cold pressor tasks (CPT) filled with coloured water. In a differential conditioning procedure, one colour (CS+) was combined with genuine painful facial expressions and the other colour (CS-) with neutral facial expressions. Following this observation phase, children performed both CPTs (10°C) themselves.

RESULTS

Children expected the CS+ to be more painful than the CS- and they reported being more afraid and hesitant to immerse in the CS+ compared to the CS-. Moreover, this fear was reflected in children's level of arousal in anticipation of CPT performance. This learned association extinguished after performing both CPTs. Effects were not moderated by whether the child observed their mother or a stranger, by the child's pain catastrophizing, trait PRF or trait anxiety. Remarkably, learning effects increased when the child perceived a larger difference between the model's painful and neutral facial expressions.

CONCLUSIONS

This study provides evidence for observational learning of PRF and subsequent extinction in schoolchildren. This acquisition of PRF by observing parental pain may contribute to vulnerabilities in children of parents with chronic pain.

SIGNIFICANCE

Children may acquire pain-related fear by observing pain in others and this learned fear can diminish after first-hand experience. Remarkably, observational learning did not depend on the children's relationship with the model, but it did depend on the intensity of pain that is perceived. A better understanding of the impact of observing (parental) pain may help clarify the intergenerational transmission of risk for pain and inform the development of preventive programs.

Graded exposure treatment for adolescents with chronic pain (GET Living): Protocol for a randomized controlled trial enhanced with single case experimental design

Chronic musculoskeletal pain in adolescence is a significant public health concern with 3-5% of adolescents suffering from significant pain-related disability. Pain-related fear and avoidance of activities has been found to have a significant influence on pain outcomes in children and adolescents and is a risk factor for less favorable response to treatment. To address this need, we developed graded exposure treatment for youth with chronic pain (GET Living). We describe the rationale, design, and implementation of a two-group randomized controlled trial (RCT) enhanced with single-case experimental design (SCED) methodology with a sample of 74 adolescents with chronic musculosketal pain and their parent caregivers. GET Living includes education, behavioral exposures, and parent intervention jointly delivered by pain psychology and physical therapy providers. The multidisciplinary pain management control group includes pain psychology delivered education and pain self-management skills training (e.g., relaxation, cognitive skills) and separate physical therapy. Assessments include brief daily diaries (baseline to discharge, 7-days at 3-month and 6-month follow-up), comprehensive in-person evaluations at baseline and discharge, and questionnaire across all time points (baseline, discharge, 3-month and 6-month follow-up). Primary outcome is pain-related fear avoidance. Secondary outcome is functional disability. We also outline all additional outcomes, exploratory outcomes, covariates, and implementation measures. The objective is to offer a mechanism-based, targeted intervention to youth with musculoskeletal pain to enhance likelihood of return to function.

Pilot Randomized Controlled Trial of an Exercise Program Requiring Minimal In-person Visits for Youth With Persistent Sport-Related Concussion

Objective: To evaluate feasibility and acceptability of a sub-threshold exercise program with minimal in-person visits to treat youth with persistent sport-related concussion, and explore efficacy for improving concussive symptoms, health-related quality of life, and fear-avoidance. Study design: We conducted a pilot randomized controlled trial comparing a 6 week sub-threshold exercise program requiring only two in-person visits to active control (stretching) for 12-18 year old youth with persistent sport-related concussion. We measured moderate-to-vigorous physical activity pre- and post-intervention using accelerometry, and increased goals weekly via phone contact. We examined feasibility and acceptability using qualitative interviews. We used exponential regression to model differences in trajectory of concussive symptoms by experimental group, and linear regression to model differences in trajectory of health-related quality of life and fear-avoidance of pain by experimental group. Results: Thirty-two subjects randomized, 30 completed the study (n = 11 control, n = 19 intervention), 57% female. Youth and parents reported enjoying participating in the study and appreciated the structure and support, as well as the minimal in-person visits. Exponential regression modeling indicated that concussive symptoms declined more rapidly in intervention youth than control (p = 0.02). Health-related quality of life and fear-avoidance of pain improved over time, but were not significantly different by group. Conclusions: This study indicates feasibility and potential benefit of a 6 week subthreshold exercise program with minimal in-person visits for youth with persistent concussion. Potential factors that may play a role in improvement such as fear-avoidance deserve further study.

Topical Review: Basic Psychological Needs in Adolescents with Chronic Pain-A Self-Determination Perspective

This topical review outlines the resilience pathway to adaptive functioning in pediatric pain within a developmental perspective. Self-Determination Theory proposes that the satisfaction of one's basic psychological needs (for autonomy, relatedness, and competence) is crucial for understanding human flourishing and healthy development. However, the role of the basic psychological needs received little attention in a pediatric-pain population. Yet, we propose that need satisfaction may be a resilience factor and need frustration a risk factor, for living with chronic pain. In this topical review, we first discuss two major models that have been developed to understand pain-related disability: the fear-avoidance model of pain and the ecological resilience-risk model in pediatric chronic pain. Both models have been used with children and adolescents but do not include a developmental perspective. Therefore, we introduce Self-Determination Theory and highlight the potentially moderating and mediating role of the basic needs on pain-related disability in children and adolescents. Taken together, we believe that Self-Determination Theory is compatible with the fear-avoidance model of pain and the ecological resilience-risk model in pediatric chronic pain and may deepen our understanding of why some adolescents are able to live adaptively in spite of chronic pain.

When pain gets stuck: the evolution of pain chronification and treatment resistance

It is well-recognized that, despite similar pain characteristics, some people with chronic pain recover, whereas others do not. In this review, we discuss possible contributions and interactions of biological, social, and psychological perturbations that underlie the evolution of treatment-resistant chronic pain. Behavior and brain are intimately implicated in the production and maintenance of perception. Our understandings of potential mechanisms that produce or exacerbate persistent pain remain relatively unclear. We provide an overview of these interactions and how differences in relative contribution of dimensions such as stress, age, genetics, environment, and immune responsivity may produce different risk profiles for disease development, pain severity, and chronicity. We propose the concept of "stickiness" as a soubriquet for capturing the multiple influences on the persistence of pain and pain behavior, and their stubborn resistance to therapeutic intervention. We then focus on the neurobiology of reward and aversion to address how alterations in synaptic complexity, neural networks, and systems (eg, opioidergic and dopaminergic) may contribute to pain stickiness. Finally, we propose an integration of the neurobiological with what is known about environmental and social demands on pain behavior and explore treatment approaches based on the nature of the individual's vulnerability to or protection from allostatic load.

Recovery from acute pediatric complex regional pain syndrome type I after ankle sprain by early pharmacological and physical therapies in primary care: a case report

Background

Complex regional pain syndrome type I (CRPS I) in children is a serious condition disrupting the family and school life of patients with the condition after it fully develops. It has been emphasized that early diagnosis is closely associated with earlier reduction of pain leading to preferable outcomes.

Objectives

To report a case of acute CRPS I in a boy who was found to develop this condition by a routine visual analog scale (VAS) pain monitoring and who recovered from CRPS I at an early phase by prompt pharmacological, physical, and educational therapies.

Study design

Case report.

Case report

A 12-year-old boy sprained his left ankle while playing soccer and was referred to our clinic 4 days after the injury. At the first visit, he could walk, reporting motion pain with a VAS scale of 80 mm. On day 5, pain intensity increased to 100 mm, and a diagnosis of acute CRPS I was made. On day 7, he could not move the injured ankle; therefore celecoxib and pregabalin were administered, and physical and educational therapies started. On day 35, pain intensity was 0 mm and he could walk and run normally.

Conclusion

Routine monitoring of VAS for every patient in pain is useful to discover an abnormal transition of VAS, enabling the early diagnosis of CRPS I. Inflammation and peripheral or central sensitization are postulated for early development of CRPS I. The present case suggested a combination of physical therapy and pharmacological intervention with celecoxib and pregabalin reduced peripheral and central sensitization.

Evidence-Based Psychological Interventions for the Management of Pediatric Chronic Pain: New Directions in Research and Clinical Practice

Over the past 20 years our knowledge about evidence-based psychological interventions for pediatric chronic pain has dramatically increased. Overall, the evidence in support of psychological interventions for pediatric chronic pain is strong, demonstrating positive psychological and behavioral effects for a variety of children with a range of pain conditions. However, wide scale access to effective psychologically-based pain management treatments remains a challenge for many children who suffer with pain. Increasing access to care and reducing persistent biomedical biases that inhibit attainment of psychological services are a central focus of current pain treatment interventions. Additionally, as the number of evidence-based treatments increase, tailoring treatments to a child or family’s particular needs is increasingly possible. This article will (1) discuss the theoretical frameworks as well as the specific psychological skills and strategies that currently hold promise as effective agents of change; (2) review and summarize trends in the development of well-researched outpatient interventions over the past ten years; and (3) discuss future directions for intervention research on pediatric chronic pain.