Development and validation of the self-reported PROMIS pediatric pain behavior item bank and short form scale

Positive effects of tactile massage for adolescents with Attention Deficit/Hyperactivity Disorder (ADHD) - A small scale study

BACKGROUND AND PURPOSE

Epidemiological studies show the prevalence of attention deficit hyperactivity disorder (ADHD) in adolescents is around 5 %. There is strong evidence for psychosocial interventions and medication for treatment of ADHD core symptoms, but these alone do not always reach a satisfactory outcome. The aim of this small-scale study was to evaluate the impact of tactile massage on ADHD core symptoms in adolescents in a clinical setting. Secondary outcome measures addressed pain perception, ability to fall asleep, and stress levels before, during, and after the intervention.

MATERIALS AND METHODS

Fourteen adolescents aged 15-17 and previously diagnosed with ADHD received tactile massage sessions in an experimental, single-subject ABA study combined with a group-based evaluation using descriptive statistics. The adolescents and their parents answered questionnaires to follow up on the primary and secondary outcomes.

RESULTS

The results showed a statistically significant reduction in hyperactivity/impulsivity and inattention, as well as oppositional defiant disorder (ODD). Participants reported that it was significantly easier to fall asleep. There was also a tendency to perceive less pain, but these results were not statistically significant. The compliance in this study was excellent.

CONCLUSION

In this study, tactile massage appears to have had a significantly positive impact on ADHD core symptoms and the ability to fall asleep. The absence of adverse physiological changes and the excellent compliance, coupled with positive results, supports the idea that tactile massage may be considered safe and beneficial for adolescents with ADHD. Our findings need to be further investigated in future research.

Who develops chronic pain after an acute lower limb injury? A longitudinal study of children and adolescents

ABSTRACT

Prevention of chronic pain is a major challenge in this area of clinical practice. To do this, we must be able to understand who is most at risk of developing chronic pain after an injury. In this study, we aimed to identify risk factors of chronic pain onset, disability, and pain interference after a lower limb musculoskeletal injury in children and adolescents between 8 to 16 years of age. We assessed biopsychosocial factors including age, sex, pubertal status, anxiety, depression, fear of pain, pain worry, adverse life events, and sleep in children. We also assessed risk factors in parents including parent anxiety, depression, parent pain catastrophising, and protective behaviours. Logistic and hierarchical linear regressions identified risk factors assessed immediately postinjury for outcomes assessed at 3 months postinjury. Fourteen percent (17/118 children) reported chronic pain 3 months after injury. There were significant between-group differences in children with and without chronic pain at baseline. Children with chronic pain reported higher pain intensity, disability, pain interference, child depression, fear of pain, and catastrophic thinking about their pain. Regressions showed child depression and fear of pain at baseline independently predicted chronic pain onset at 3 months, parent protectiveness predicted child pain interference at 3 months, and child depression, poor sleep, parent anxiety and pain catastrophising predicted disability. Most children recover after a lower limb injury, but a minority develop chronic pain predicted by important psychosocial risk factors, which could be addressed to prevent the onset of treatment-resistant chronic pain and disability.

Longitudinal Associations Between Pain, Risk for Posttraumatic Stress Disorder, Posttraumatic Stress Symptoms, and Pain Characteristics in Children After Unintentional Injury

OBJECTIVES

Approximately 20% of children demonstrate persistent posttraumatic stress symptoms (PTSS) after unintentional injury, with more severe pain intensity predicting concurrent and later PTSS. Examining additional pain characteristics like pain behaviors, impairment related to pain, and subjective experiences of pain might provide additional insight into the mechanisms that reinforce relationships between risk for posttraumatic stress disorder (PTSD), PTSS, and pain.

METHODS

During hospitalization for unintentional injury, the Screening Tool for Predictors of PTSD (STEPP) was administered and the highest pain score was collected. One month later, the Child PTSD Symptom Scale and PROMIS questionnaires assessed PTSS and pain characteristics respectively, including intensity, interference, behaviors, and quality.

RESULTS

Correlations between PTSS and PROMIS questionnaires were significant. STEPP predicted future PTSS and all PROMIS questionnaires. The highest pain score predicted future PTSS, as well as pain interference and pain behavior, and did not predict pain intensity and pain quality. When STEPP and highest pain score were combined into a single regression, STEPP and highest pain score predicted future PTSS but only STEPP continued to predict all PROMIS questionnaires.

DISCUSSION

PTSD risk significantly predicted PTSS and pain characteristics 1 month later. The highest pain score predicted future PTSS and several pain characteristics but no longer had predictive value for pain-related outcomes when combined with PTSD risk. These results indicate that risk factors for PTSD are stronger predictors than pain-related risk factors in predicting pain outcomes. Addressing PTSD risk, as well as pain intensity during hospitalization, may result in improved outcomes for children with unintentional injury.

Understanding how children and young people with chronic non-cancer pain and their families experience living with pain, pain management and services: a meta-ethnography

Background

Childhood chronic pain is a widespread public health issue. We need to understand how children with chronic pain and their families experience chronic pain and its management.

Objectives

To conduct a meta-ethnography on the experiences and perceptions of children with chronic pain and their families of chronic pain, treatments and services. We investigated how children and their families conceptualise and live with chronic pain; what they think of and want from health and social care services; and what they conceptualise as 'good' pain management.

Design

Meta-ethnography with stakeholder and patient and public involvement in the design, search and sampling strategies, analysis and dissemination. Review strategy: comprehensive searches of 12 bibliographic databases and supplementary searches in September 2022, to identify qualitative studies with children aged 3 months to 18 years with chronic non-cancer pain and their families. We included studies with rich explanatory data; appraised methodological limitations using the Critical Appraisal Skills Programme tool; and extracted, analysed and synthesised studies' findings. We used Grading of Recommendations Assessment, Development and Evaluation-confidence in the evidence from reviews of qualitative research to assess confidence in review findings. We integrated findings with 14 Cochrane treatment effectiveness reviews on children's chronic non-cancer pain.

Results

We synthesised 43 studies sampled from 170 eligible studies reported in 182 publications. Studies had minor (n = 24) or moderate (n = 19) methodological limitations. Grading of Recommendations Assessment, Development and Evaluation-confidence in the evidence from reviews of qualitative research assessments of review findings were high (n = 22), moderate (n = 13) or very low confidence (n = 1). Moderate and severe chronic pain had profound adverse impacts on family members' well-being, autonomy and self-identity; family dynamics; parenting approaches; friendships and socialising; children's education and parental paid employment. Most children and families sought a biomedical cure for pain. They experienced difficulties seeking and receiving support from health services to manage pain and its impacts. Consequently, some families repeatedly visited health services. Cochrane reviews of intervention effects and trials did not measure some outcomes important to children and families, for example effects of pain on the family and resolution of pain. Reviews have mainly neglected a biopsychosocial approach when considering how interventions work.

Limitations

There were limited data on common pain conditions like migraine/headache, abdominal pain; some rarer conditions; children with learning disabilities and under-fives; siblings; fathers and experiences of treatments/services. We excluded studies on cancer, end-of-life pain and experiences of healthcare professionals.

Conclusions

We developed the family-centred theory of children's chronic pain management, integrating health and social care with community support.

Future work

Future research should explore families' experiences of services and treatments, including opioids, and social care services; experiences of children with autism and learning disabilities, under 5 years old and with certain common pain conditions. We need development and testing of family-centred interventions and services.

Study registration

This study is registered as PROSPERO (CRD42019161455) and Cochrane Pain, Palliative and Supportive Care (623).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR128671) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 17. See the NIHR Funding and Awards website for further award information.

PROMIS-29 in rheumatoid arthritis patients who screen positive or negative for fibromyalgia on MDHAQ FAST4 (fibromyalgia assessment screening tool) or 2011 fibromyalgia criteria

BACKGROUND

PROMIS-29 T-scores query health-related quality of life (HRQL) in 7 domains, physical function, pain, fatigue, anxiety, depression, sleep quality, and social participation, to establish population norms. An MDHAQ (multidimensional health assessment questionnaire) scores these 7 domains and includes medical information such as a FAST4 (fibromyalgia assessment screening tool) index. We analyzed PROMIS-29 T-scores in rheumatoid arthritis (RA) patients vs population norms and for positive vs negative fibromyalgia (FM) screens and compared PROMIS-29 T-scores to MDHAQ scores to assess HRQL.

METHODS

A cross-sectional study was performed at one routine visit of 213 RA patients, who completed MDHAQ, PROMIS-29, and reference 2011 FM Criteria. PROMIS-29 T-scores were compared in RA vs population norms and in FM+ vs FM- RA patients, based on MDHAQ/FAST4 and reference criteria. Possible associations between PROMIS-29 T-scores and corresponding MDHAQ scores were analyzed using Spearman correlations and multiple regressions.

RESULTS

Median PROMIS-29 T-scores indicated clinically and statistically significantly poorer status in 26-29% FM+ vs FM- RA patients, with larger differences than in RA patients vs population norms for 6/7 domains. MDHAQ scores were correlated significantly with each of 7 corresponding PROMIS-29 domains (|rho|≥0.62, p<0.001). Linear regressions explained 55-73% of PROMIS-29 T-score variation by MDHAQ scores and 56%-70% of MDHAQ score variation by PROMIS-29 T-scores.

CONCLUSIONS

Scores for 7 PROMIS-29 domains and MDHAQ were highly correlated. The MDHAQ is effective to assess HRQL and offers incremental medical information, including FAST4 screening. The results indicate the importance of assessing comorbidities such as fibromyalgia screening in interpreting PROMIS-29 T-scores.

Cerebral palsy pain instruments: Recommended tools for clinical research studies by the National Institute of Neurological Disorders and Stroke Cerebral Palsy Common Data Elements project

AIM

This study describes the process of updating the cerebral palsy (CP) common data elements (CDEs), specifically identifying tools that capture the impact of chronic pain on children's functioning.

METHOD

Through a partnership between the American Academy for Cerebral Palsy and Developmental Medicine and the National Institute of Neurological Disorders and Stroke (NINDS), the CP CDEs were developed as data standards for clinical research in neuroscience. Chronic pain was underrepresented in the NINDS CP CDEs version 1.0. A multi-step methodology was applied by an interdisciplinary professional team. Following an adapted CP chronic pain tools' rating system, and a review of psychometric properties, clinical utility, and compliance with inclusion/exclusion criteria, a set of recommended pain tools was posted online for external public comment in May 2022.

RESULTS

Fifteen chronic pain tools met inclusion criteria, representing constructs across all components of the International Classification of Functioning, Disability and Health.

INTERPRETATION

This paper describes the first condition-specific pain CDEs for a pediatric population. The proposed set of chronic pain tools complement and enhance the applicability of the existing pediatric CP CDEs. The novel CP CDE pain tools harmonize the assessment of chronic pain, addressing not only intensity of chronic pain, but also the functional impact of experiencing it in everyday activities.

Agreement between youth and caregiver report of pain and functioning in pediatric sickle cell disease: PedsQL sickle cell disease module

ABSTRACT

Pain is a primary symptom of sickle cell disease (SCD) and is often severe and chronic. To treat SCD-related pain, proper assessment of SCD pain among youth, including the degree of concordance or agreement between youth and caregiver reports of pain, is essential but has not yet been adequately evaluated. In this study, 525 youth with SCD and their parents were evaluated as part of the Sickle Cell Clinical Research and Intervention Program (SCCRIP) to examine pain rating concordance and predictors of concordance. Youth and parents completed the Pediatric Quality of Life Inventory Sickle Cell Disease module (PedsQL-SCD) to measure pain, pain interference, and pain-related constructs. Disease, clinical, and demographic variables were obtained from the SCCRIP database. Intraclass correlations demonstrated moderate-to-poor consistency between youth and caregiver reports of pain and pain interference (ICCs range from 0.17 to 0.54). Analysis of covariance and regression models found that patient age, frequency of hospitalizations and emergency department (ED) visits, economic hardship, and fetal hemoglobin levels were significantly associated with varying pain-rating agreement levels among parent proxy and child self-report pain. Concordance of pain assessments among youth with SCD and their caregivers using the PedsQL-SCD Module was moderate at best, corroborating prior research. Youth factors predicting discordance among pain-related factors included increased ED visits, older age, and female sex. Collectively, these results bolster the use of integrated pain assessments to reduce parent-child discrepancies, thereby improving the adequacy of SCD-related pain assessment and treatment.

Recommendations for Patient-Reported Outcomes Measurement Information System pediatric measures in youth with chronic pain: a COnsensus-based Standards for the selection of health Measurement INstruments systematic review of measurement properties

ABSTRACT

The Patient-Reported Outcome Measurement Information System (PROMIS) pediatric measures assess physical, emotional, and social health among children and adolescents. However, their measurement properties have not been systematically examined in youth with chronic pain. A systematic review applying the COnsensus based Standards for the selection of health Measurement INstruments (COSMIN) methodology was conducted to evaluate self-reported PROMIS pediatric measures in youth with chronic pain, assessing 8 measurement properties across all versions (item bank, short form, and computer adaptive testing) from 63 studies covering 25 measures. Moderate or high-quality evidence was most available for content validity, structural validity, internal consistency (measurement precision), and construct validity. Four short-form PROMIS pediatric measures-mobility, anxiety, depressive symptoms, and physical stress experiences-achieved recommendation for the use in chronic pain clinical trials; 7 approached recommendation and 14, including the commonly used PROMIS Pediatric Pain Interference Scale, would be recommended with further evidence. Recommendations were also provided for the use of each measure in observational studies. Overall, based on the existing evidence, a total of 11 self-reported PROMIS pediatric short-form measures, including pain intensity, pain behavior, mobility, sleep disturbance, sleep-related impairment, anxiety, depressive symptoms, psychological stress experiences, physical stress experiences, family relationships, and positive effect, are recommended or approaching recommendation for use in youth ages 8 to 19 years with chronic pain. Research is needed to further establish test-retest reliability, measurement errors, cross-cultural validity, and responsiveness. Future work should expand the evaluation of PROMIS pediatric measures in subpopulations of youth with chronic pain, particularly young children and those with neurodevelopmental disabilities.

Impact of Musculoskeletal Pain on Functioning and Disability in Children with Juvenile Idiopathic Arthritis in Iceland

AIMS

1) to map questions of pain from a survey to the International Classification of Functioning, Disability and Health (ICF) 2) to compare the impact of musculoskeletal pain on functioning based on the different components of the ICF in children with juvenile idiopathic arthritis (JIA) and age-matched peers.

METHOD

A cross-sectional case-control survey. A total of 28 children with JIA and 36 age-matched children participated. The survey included questions on the child's sex and age, about pain experienced, number of painful body areas, pain frequency and three short forms of Patient-Reported Outcome Measurement Information System (PROMIS) pain questionnaires. Sixteen children with JIA (57%) and 10 peers (28%) reported pain during past seven days. Their responses were used in the description of impact of pain.

RESULTS

After the mapping of the questions to ICF, a comparison between the two groups indicated that a higher number of children with JIA described effects of pain on mental function, mobility, general tasks and demands, than their peers. More children with JIA expressed to others that they had pain, non-verbally and verbally.

CONCLUSION

The findings provide important information about the impacts of pain on daily life in children with JIA and about their intervention needs.

Feasibility and preliminary efficacy of the Balance Program to reduce pain-related disability in pediatric sickle cell disease

BACKGROUND

Sickle cell disease (SCD) pain is associated with functional impairment, and treatment is often limited to pharmacological approaches with unwanted side effects. Although behavioral interventions exist for non-SCD pain populations, interventions designed to address pain-related impairment in SCD are lacking.

METHODS

Twenty youth (9-17 years) with SCD completed a four-week telemedicine pain intervention (NCT04388241). Participants and caregivers completed baseline and post-intervention PROMIS pain measures and the Treatment Evaluation Inventory-Short Form (TEI-SF). Descriptive analyses assessed feasibility and acceptability. Reliable Change Index analyses assessed for significant post-intervention changes in pain functioning. Paired t test analyses compared baseline and post-intervention opioid prescription fills.

RESULTS

All participants completed at least one treatment session. Eighteen (90%) youth completed all sessions. Youth (100%) and caregivers (94%) rated the intervention as moderately or highly acceptable on the TEI-SF. Forty-seven percent of caregivers and 44% of youth reported reliably significant improvements in pain interference after the intervention (median T-score differences: 24.8 and 23.5, respectively). Sixty-five percent of caregivers (T-score improvement difference: 19.3) and 31% of youth (T-score improvement difference: 32) reported improvements in pain behaviors. There was no significant difference in opioid prescription fills pre- and post-intervention (P > 0.05).

CONCLUSIONS

The Balance Program is feasible, highly acceptable, and can be delivered remotely to reduce barriers to care. Approximately half of youth and caregivers reported significant declines in pain interference following the intervention, with substantial improvements in functioning for treatment responders. Behavioral pain interventions are important adjunctive treatments to uniquely address functional impairment associated with acute and chronic pain in SCD.

Theory, Measurement, and Psychometric Properties of Risk and Protective Factors for Drug Misuse Among Adolescents Living on or near the Cherokee Nation Reservation

A team of tribe-based behavioral health specialists and university-based researchers partnered to implement a cluster randomized trial for the prevention of drug misuse among adolescents attending public high schools on or near the Cherokee Nation Reservation in northeastern Oklahoma. The conceptual framework, which guided intervention and measurement design for the trial, incorporates indigenous knowledge and worldviews with empirically-based frameworks and evidence-based practices. Our goal is to serve multicultural youth, families, and schools and to provide a model of effective strategies for wide dissemination. This paper presents the conceptual model, survey design, and psychometric properties of scales to measure risk and protective factors for substance misuse. The survey includes common measures drawn from the PhenX Toolkit on substance use patterns-adolescent module, measured with standard items from the Monitoring the Future (MTF) study and items harmonized across ten NIH-funded research projects with diverse samples of youth. In our trial, brief (20-minute) self-report questionnaires were administered to 10th grade students in fall 2021 (n = 919, 87% response rate) and spring 2022 (n = 929, 89% response rate) in 20 participating high schools on or near the Cherokee Nation Reservation. The sample primarily fell into the following three categories of race/ethnicity identification: only American Indian (AI-only, 29%), AI and another race/ethnicity (AI+, 27%), and only White (35%). Results indicate that risk and protective factor scales were reliably and validly measured with 10 scales and 10 subscales. There were minimal differences between youth who identified as AI only, AI+, and White only, especially for the main scales, which provide confidence in the interpretation of trial outcomes across demographic groups. Study results may not be generalizable to AI/AN youth who live and attend school in more homogenous reservation lands, or alternatively, live in large diverse metropolitan areas.

A meta-ethnography of how children and young people with chronic non-cancer pain and their families experience and understand their condition, pain services, and treatments

BACKGROUND

Chronic non-cancer pain in childhood is widespread, affecting 20% to 35% of children and young people worldwide. For a sizeable number of children, chronic non-cancer pain has considerable negative impacts on their lives and quality of life, and leads to increased use of healthcare services and medication. In many countries, there are few services for managing children's chronic non-cancer pain, with many services being inadequate. Fourteen Cochrane Reviews assessing the effects of pharmacological, psychological, psychosocial, dietary or physical activity interventions for managing children's chronic non-cancer pain identified a lack of high-quality evidence to inform pain management. To design and deliver services and interventions that meet the needs of patients and their families, we need to understand how children with chronic non-cancer pain and their families experience pain, their views of services and treatments for chronic pain, and which outcomes are important to them.

OBJECTIVES

1. To synthesise qualitative studies that examine the experiences and perceptions of children with chronic non-cancer pain and their families regarding chronic non-cancer pain, treatments and services to inform the design and delivery of health and social care services, interventions and future research. 2. To explore whether our review findings help to explain the results of Cochrane Reviews of intervention effects of treatments for children's chronic non-cancer pain. 3. To determine if programme theories and outcomes of interventions match children and their families' views of desired treatments and outcomes. 4. To use our findings to inform the selection and design of patient-reported outcome measures for use in chronic non-cancer pain studies and interventions and care provision to children and their families. The review questions are: 1. How do children with chronic non-cancer pain and their families conceptualise chronic pain? 2. How do children with chronic non-cancer pain and their families live with chronic pain? 3. What do children with chronic non-cancer pain and their families think of how health and social care services respond to and manage their child's chronic pain? 4. What do children with chronic non-cancer pain and their families conceptualise as 'good' chronic pain management and what do they want to achieve from chronic pain management interventions and services?

SEARCH METHODS

Review strategy: we comprehensively searched 12 bibliographic databases including MEDLINE, CINAHL, PsycInfo and grey literature sources, and conducted supplementary searches in 2020. We updated the database searches in September 2022.

SELECTION CRITERIA

To identify published and unpublished qualitative research with children aged 3 months to 18 years with chronic non-cancer pain and their families focusing on their perceptions, experiences and views of chronic pain, services and treatments. The final inclusion criteria were agreed with a patient and public involvement group of children and young people with chronic non-cancer pain and their families.

DATA COLLECTION AND ANALYSIS

We conducted a qualitative evidence synthesis using meta-ethnography, a seven-phase, systematic, interpretive, inductive methodology that takes into account the contexts and meanings of the original studies. We assessed the richness of eligible studies and purposively sampled rich studies ensuring they addressed the review questions. Cochrane Qualitative Methods Implementation Group guidance guided sampling. We assessed the methodological limitations of studies using the Critical Appraisal Skills Programme tool. We extracted data on study aims, focus, characteristics and conceptual findings from study reports using NVivo software. We compared these study data to determine how the studies related to one another and grouped studies by pain conditions for synthesis. We used meta-ethnography to synthesise each group of studies separately before synthesising them all together. Analysis and interpretation of studies involved children with chronic non-cancer pain and their families and has resulted in theory to inform service design and delivery. Sampling, organising studies for synthesis, and analysis and interpretation involved our patient and public involvement group who contributed throughout the conduct of the review. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each review finding. We used a matrix approach to integrate our findings with existing Cochrane Reviews on treatment effectiveness for children's chronic non-cancer pain.

MAIN RESULTS

We synthesised 43 studies sampled from 170 eligible studies reported in 182 publications. Included studies involved 633 participants. GRADE-CERQual assessments of findings were mostly high (n = 21, 58%) or moderate (n = 12, 33%) confidence with three (8%) low or very low confidence. Poorly managed, moderate or severe chronic non-cancer pain had profound adverse impacts on family dynamics and relationships; family members' emotions, well-being, autonomy and sense of self-identity; parenting strategies; friendships and socialising; children's education and future employment prospects; and parental employment. Most children and parents understood chronic non-cancer pain as having an underlying biological cause and wanted curative treatment. However, families had difficulties seeking and obtaining support from health services to manage their child's pain and its impacts. Children and parents felt that healthcare professionals did not always listen to their experiences and expertise, or believe the child's pain. Some families repeatedly visited health services seeking a diagnosis and cure. Over time, some children and families gave up hope of effective treatment. Outcomes measured within trials and Cochrane Reviews of intervention effects did not include some outcomes of importance to children and families, including impacts of pain on the whole family and absence of pain. Cochrane Reviews have mainly neglected a holistic biopsychosocial approach, which specifies the interrelatedness of biological, psychological and social aspects of illness, when selecting outcome measures and considering how chronic pain management interventions work.

AUTHORS' CONCLUSIONS

We had high or moderate confidence in the evidence contributing to most review findings. Further research, especially into families' experiences of treatments and services, could strengthen the evidence for low or very low confidence findings. Future research should also explore families' experiences in low- to middle-income contexts; of pain treatments including opioid use in children, which remains controversial; and of social care services. We need development and testing of family-centred interventions and services acceptable to families. Future trials of children's chronic non-cancer pain interventions should include family-centred outcomes.

A digital health game to prevent opioid misuse and promote mental health in adolescents in school-based health settings: Protocol for the PlaySmart game randomized controlled trial

Adolescents who engage in non-opioid substance misuse and/or experience mental health symptoms are at greater risk of misusing opioids and/or developing opioid use disorder. Adolescence is a critical developmental period to both prevent the initiation of opioid misuse and target mental health. To date, there are no digital health games targeting both conditions. We describe the protocol for a randomized controlled trial designed to assess the efficacy of an original digital health game, PlaySmart. Five hundred and thirty-two adolescents aged 16-19 years old, who are at greater risk for initiating opioid misuse are recruited from 10 Connecticut school-based health sites. Participants are randomized to PlaySmart or a set of time/attention control videogames. Randomization was stratified by sex at birth and school grade. Participants play their assigned game or games for up to six weeks (300 minutes) and complete assessment questions over a 12-month period (baseline, post-gameplay, 3, 6, and 12 months). The primary outcome is perception of risk of harm of opioid misuse at 3 months. Secondary outcome measures specific to opioid misuse include intentions, self-efficacy, attitudes, knowledge, and perceived norms. Mental health outcomes include measures of depression (Patient Health Questionnaire-8), anxiety (Generalized Anxiety Disorder-7), help-seeking behaviors, stigma, measures of self-regulation, self-efficacy to seek professional help for mental health, and knowledge around coping skills. PlaySmart has the potential to significantly reduce the risk of initiation of opioid misuse, improve mental health outcomes, and given its high levels of engagement and accessibility, holds the promise for extensive reach, scale, and impact for adolescents. Trial registration: ClinicalTrials.gov: NCT04941950. Registered on 23 June 2021.

Pediatric pain rehabilitation during the COVID-19 pandemic: exploring the effectiveness of a hybrid intensive interdisciplinary pain treatment model

PURPOSE

This study aimed to (1) examine improvements in rehabilitation outcomes after participation in a pediatric hybrid intensive interdisciplinary pain treatment model (50% in-person and 50% video-based telehealth) and (2) compare magnitude of hybrid model improvements to patients treated in a traditional, 100% in-person model prior to the pandemic.

MATERIALS AND METHODS

Rehabilitation outcomes for 33 youth with chronic pain from the model were compared to 33 youth with chronic pain who completed a traditional, in-person model. Improvements between admission and discharge in both models were examined using paired student t-tests. Independent samples t-tests compared change scores for the hybrid and traditional models.

RESULTS

Participants in both models experienced significant improvements on all rehabilitation outcomes, including cardiovascular endurance, pain interference, functional disability, and occupational performance (p < 0.001), except for pain intensity (p = 0.15). Change scores for rehabilitation outcomes did not significantly differ between models.

CONCLUSIONS

Quantitatively, hybrid model rehabilitation outcomes appeared clinically equivalent to the traditional, in-person model. Qualitative and psychosocial outcome comparisons of each model are warranted to better understand challenges and barriers associated with hybrid pain treatment models. The feasibility and impact of tools to enhance telehealth, such as actigraphy or virtual reality, should also be explored.IMPLICATIONS FOR REHABILITATIONThis study supports the efficacy of video-based telehealth interventions for children and adolescents with chronic pain syndromes.Disability outcomes for a hybrid (50% in-person, 50% video-based telehealth) intensive interdisciplinary pain treatment program appear to be equivalent to patients treated within a fully in-person program.

Collaborating with a Youth Council to Improve Chronic Pain Resources

Background

There is a recognized need to involve people with lived experience of chronic pain when developing chronic pain resources.

Aims

The aim of this study was to develop, implement, and evaluate a short-term youth council focused on eliciting youths' recommendations for key features of chronic pain informational resources.

Methods

In this mixed methods instrumental case study, demographic data were collected via Survey Monkey®. Select Patient-Reported Outcomes Measurement Information System® brief measures were used to provide context regarding pain impact within this group. Participants completed an initial interview, which informed youth council workshop delivery. Over two youth council workshops, participants reviewed select informational resources and identified key features of chronic pain resources. Participants evaluated their involvement experience during a second interview. Qualitative data were transcribed and analyzed using directed content analysis. Member-checking occurred during a third workshop, held virtually.

Results

Seven youth self-identifying as girl/woman or demi-girl participated. The youth were satisfied with the youth council experience, highlighting the importance of meeting others, a relaxed environment, and participating in valuable work. A list of youth-identified key features for informational resources was created through the workshops, which includes considerations for audience groups, content, and presentation.

Conclusion

Participants' input into youth council development and meeting others with lived experience contributed to a safe and supportive involvement experience. Youth council involvement supported the development of preliminary recommendations for chronic pain informational resources.

Percutaneous electrical nerve field stimulation improves comorbidities in children with cyclic vomiting syndrome

Introduction

Children with cyclic vomiting syndrome (CVS) frequently suffer from disabling abdominal pain and comorbidities that impair quality of life. A noninvasive, auricular percutaneous electrical nerve field stimulation (PENFS) device is shown to be effective for abdominal pain in children with disorders of gut-brain interaction. We aimed to determine the effects of PENFS on pain, common comorbidities, and quality of life in pediatric CVS.

Methods

Children aged 8-18 years with drug-refractory CVS were enrolled in a prospective, open-label study receiving 6 consecutive weeks of PENFS. Subjects completed the following surveys at baseline, during/after therapy (week 6), and at extended follow-up approximately 4-6 months later: Abdominal Pain Index (API), State-Trait Anxiety Inventory for Children (STAI-C), Pittsburgh Sleep Quality Index (PSQI), and Patient Reported Outcome Measurement Information System (PROMIS) Pediatric Profile-37.

Results

Thirty subjects were included. Median (interquartile range, IQR) age was 10.5 (8.5-15.5) years; 60% were female. Median API scores decreased from baseline to week 6 (p = 0.003) and to extended follow-up (p < 0.0001). State anxiety scores decreased from baseline to week 6 (p < 0.0001) and to extended follow-up (p < 0.0001). There were short-term improvements in sleep at 6 weeks (p = 0.031) but not at extended follow-up (p = 0.22). Quality of life measures of physical function, anxiety, fatigue, and pain interference improved short-term, while there were long-term benefits for anxiety. No serious side effects were reported.

Conclusions

This is the first study to demonstrate the efficacy of auricular neurostimulation using PENFS for pain and several disabling comorbidities in pediatric CVS. PENFS improves anxiety, sleep, and several aspects of quality of life with long-term benefits for anxiety.Clinical trial registration: ClinicalTrials.gov, identifier NCT03434652.

Development and evaluation of the patient-reported outcomes measurement information system (PROMIS) pediatric pain quality item bank and short form

ABSTRACT

Pain is a common problem among children, particularly those with pediatric chronic diseases. Multifaceted assessment of pain can improve communication about pain and help clinicians characterize, differentiate, and treat a patient's unique experience of pain. Pain quality is an important domain of pain, describing the subjective sensory experiences associated with pain as well as the affective experiences of pain. The aim of the current study was to quantitatively evaluate the measurement properties of the 59 Patient-Reported Outcomes Measurement Information System pediatric pain quality candidate items developed as part of the National Institutes of Health's Patient-Reported Outcomes Measurement Information System initiative with input from children and adolescents with chronic pain. Participants included N = 448 pediatric patients between 8 and 18 years of age with chronic health conditions with a prominent component of chronic or recurrent pain, including juvenile fibromyalgia, juvenile idiopathic arthritis, and sickle cell disease. A confirmatory factor analysis revealed a unidimensional model fit the data best, with 56 of the 59 items demonstrating good psychometric properties for inclusion in the final measure. In addition, a consensus-building method was used to establish 2 versions of a short form measure-one with 8 items focused primarily on the sensory pain qualities and one with 8 items focused on affective pain qualities. The final measure shows good reliability and validity, and is recommended for use in research and clinical care with pediatric populations.

German translation of the PROMIS® pediatric anxiety, anger, depressive symptoms, fatigue, pain interference and peer relationships item banks

BACKGROUND

The present study aimed at the translation and cross-cultural adaptation of six PROMIS^® pediatric self- and proxy- item banks and short forms to universal German: anxiety (ANX), anger (ANG), depressive symptoms (DEP), Fatigue (FAT), pain interference (P) and peer relationships (PR).

METHODS

Using standardized methodology approved by the PROMIS Statistical Center and in line with recommendations of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) PRO Translation Task Force, two translators for each German-speaking country (Germany, Austria, and Switzerland) commented on and rated the translation difficulty and provided forward translations, followed by a review and reconciliation phase. An independent translator performed back translations, which were reviewed and harmonized. The items were tested in cognitive interviews with 58 children and adolescents from Germany (16), Austria (22), and Switzerland (20) for the self-report and 42 parents and other caregivers (Germany (12), Austria (17), and Switzerland (13)) for the proxy-report.

RESULTS

Translators rated the translation difficulty of most items (95%) as easy or feasible. Pretesting showed that items of the universal German version were understood as they were intended, as only 14 out of 82 items of the self-report and 15 out of 82 items of the proxy-report versions required minor rewording. However, on average German translators rated the items more difficult to translate (M = 1.5, SD = 0.20) than the Austrian (M = 1.3, SD = 0.16) and the Swiss translators (M = 1.2, SD = 0.14) on a three-point Likert scale.

CONCLUSIONS

The translated German short forms are ready for use by researchers and clinicians ( https://www.healthmeasures.net/search-view-measures ).

Comparison of CAT and short forms for PROMIS pain and physical health domains in children with sickle cell disease

BACKGROUND

Pain and physical health domains included in Patient-Reported Outcomes Measurement Information System® (PROMIS®) can be administered as short forms (SF) or as computer adaptive tests (CAT). CAT is ideal in many settings but cannot be administered without specialized technology. We compared SF and CAT to identify items for customized SFs to improve the SF performance for children with sickle cell disease (SCD).

METHODS

Eligible children 8-17 years old were administered CATs for 5 domains of physical health and 2 domains of pain, followed by any items on the corresponding SF that were not included in the CAT assessments. We describe the range of scores on the CAT and SFs, including the percentage of participants with floor or ceiling effects using the SF. The agreement and correlation between CAT and SF scores were assessed using Bland-Altman plots. Items frequently offered on CAT that had variable responses and were not already present on SF are recommended as additional items for customized SFs.

RESULTS

Among 90 children with SCD, there were strong correlations between CAT and SF scores (Concordance Correlation Coefficient > 0.8) however, the SFs for fatigue, mobility, strength impact, pain behavior, and pain interference had substantial floor/ceiling effects. Fatigue, mobility, physical stress experience, and pain behavior domains had items that were frequently offered on CAT, variable responses, and were not present on the SF.

CONCLUSIONS

Adding items to the SFs for the fatigue, mobility, physical stress experience, and pain behavior domains may improve these domains' SFs performance for children with SCD.

A Diagnostic Prediction Model for Separating Juvenile Idiopathic Arthritis and Chronic Musculoskeletal Pain Syndrome

OBJECTIVE

To develop and validate a diagnostic prediction model that can distinguish between juvenile idiopathic arthritis (JIA) and chronic musculoskeletal pain syndrome (CMPS) based on patient-reported outcomes.

STUDY DESIGN

This retrospective cohort study evaluated whether the Juvenile Arthritis Multidimensional Assessment Report (JAMAR) performs well in distinguishing JIA from CMPS. We analyzed JAMARs completed by 287 patients at their first visit to the pediatric rheumatology department of Wilhelmina Children's Hospital in Utrecht, The Netherlands. Relevant JAMAR items for predicting a diagnosis of JIA were selected in a penalized multivariable model suitable for clinical application. The model was subsequently validated with new data from the same center.

RESULTS

A total of 196 JAMARs (97 JIA, 99 CMPS) were collected in the model development data, and 91 JAMARs (48 JIA, 43 CMPS) were collected in the validation data. Variables in the prediction model that were strongest associated with a diagnosis of JIA instead of CMPS were asymmetric pain/swelling in the shoulder (OR, 2.34), difficulty with self-care (OR, 2.41), skin rash (OR, 2.07), and asymmetric/pain swelling in the knee (OR, 2.29). Calibration and discrimination (area under the receiver operating characteristic curve, 0.83; 95% CI, 0.74-0.92) of the model in the validation data were good.

CONCLUSIONS

Several items from the JAMAR questionnaire can potentially distinguish JIA from CMPS in patients with corresponding symptoms. We present an easy-to-use, adjusted, and validated model to separate these 2 diagnoses early at presentation based on patient-reported outcomes to facilitate proper referral and treatment.

The "STOP Pain" Questionnaire: using the Plan-Do-Study-Act model to implement a patient-family preferences-informed questionnaire into a pediatric transitional pain clinic

BACKGROUND

Patient engagement is an important tool for quality improvement (QI) and optimizing the uptake of research findings. The Plan-Do-Study-Act (PDSA) model is a QI tool that encourages ongoing evaluation of clinical care, thus improving various aspects of patient care. Ascertaining pediatric patient priorities for a pain questionnaire in the post-acute, or transitional pain, setting is important to guide clinical care since active engagement with the population of interest can optimize uptake. We used the PDSA model to adapt a chronic pain questionnaire for the pediatric transitional pain setting to reflect pediatric patient and parent/guardian preferences and to form an example of how the PDSA model can be used to improve clinical care through patient engagement.

METHODS

This project employed the PDSA model to adapt the pediatric Ontario Chronic Pain Questionnaire for use in the pediatric Transitional Pain Service (pedTPS) setting. Plan: Following reviewing the Ontario Chronic Pain Questionnaire and literature on pain questionnaire development, goal-based questions, questions on pain location, relevant Patient-Reported Outcomes Measurement Information System (PROMIS^®) measures and the Pain Catastrophizing Scale, child (PCS-C) and parent (PCS-P), informed the questionnaire. Do: The questionnaire and a satisfaction survey were sent to patients and families through Research Electronic Data Capture (REDCap™).

STUDY

Results from the satisfaction survey were analyzed. Act: Using descriptive statistics employing ordinal mixed-models with random effects, ANOVA, and double-blinded qualitative thematic coding, questionnaire preferences were analyzed and the questionnaire was adapted accordingly before implementation into the (pedTPS).

RESULTS

Eighty-eight questionnaires and satisfaction surveys were analyzed from 69 respondents (32 patients; 37 parents/guardians). Sixty-six (75.00%) surveys indicated satisfaction with the questionnaire. A combined 77 (87.50%) "strongly agreed" (25/88) or "agreed" (52/88) that the questionnaire language was clear. The application of suggested changes to the questionnaire resulted in four versions across the project timeline, which reflected patient and parent/guardian preferences for questions that reflect the themes, "Story"; "Time-Optimal"; and "Pertinent" ("STOP"). There were no statistically significant differences in satisfaction across the versions due to sample size.

CONCLUSION

Most respondents were satisfied with the questionnaire and prefer "STOP" questions. Future studies will focus on testing the questionnaire for validity and reliability across pedTPS populations.

Data visualization as an intervention for pediatric chronic pain: a pilot feasibility study protocol for a randomized controlled crossover trial

BACKGROUND

Chronic pain is a common and costly condition in youth, associated with negative implications that reach far beyond the pain experience itself (e.g., interference with recreational, social, and academic activities, mental health sequelae). As a self-appraised condition, pain experience is influenced by patient's biases and meaning-making in relation to their symptoms and triggers. We propose that interacting with self-reported data will impact the experience of pain by altering understanding and expectations of symptom experience and how pain interacts with other factors (e.g., sleep, emotions, social interactions). In this study, we aim to establish the feasibility and acceptability of using a data visualization platform to track and monitor symptoms and their relationship with other factors, versus simply daily reporting of symptoms using a smartphone-based Ecological Momentary Assessment (EMA).

METHODS

This protocol is for a randomized, single-center, open-label crossover trial. We aim to recruit 50 typically developing youth aged 12-18 years with chronic pain to take part in two phases of data collection. The trial will utilize an A-B counterbalanced design in which participants will be randomly assigned to receive either Part A (EMA alone for 7 days) or Part B (EMA plus visualization platform for 7 days) first and then receive the opposite phase after a 7-day break (washout period). Key outcomes will be participant reports of acceptability and feasibility, EMA completion rates, barriers, and perceptions of the benefits or risks of participation. Secondary exploratory analyses will examine the relationship between EMA-reported symptoms over time and in relation to baseline measures, as well as pilot data on any improvements in symptoms related to engaging with the data visualization platform.

DISCUSSION

This protocol describes the feasibility and pilot testing of a novel approach to promoting self-management and facilitating symptom appraisal using visualized data. We aim to determine whether there is a sufficient rationale, both from the perspective of feasibility and patient satisfaction/acceptability, to conduct a larger randomized controlled trial of this intervention. This intervention has the potential to support clinical care for youth with chronic pain and other conditions where self-appraisal and understanding of symptom patterns are a critical component of functional recovery.

TRIAL REGISTRATION

Open Science Framework doi: https://doi.org/10.17605/OSF.IO/HQX7C . Registered on October 25, 2021, osf.io/hqx7c.

Validity and reliability of Spanish PROMIS pediatric pain interference short form

BACKGROUND

The goal of this study was to analyze psychometric properties of the Spanish PROMIS Pediatric Pain Interference short form (PROMIS-PPI) in a sample of Spanish children and adolescents.

METHODS

In a hospital pediatric sample it was studied the structure scale (exploratory and confirmatory analysis), construct validity, convergent validity, and reliability (internal consistency).

FINDINGS

163 children and adolescents (mean age 13.3 years; SD 2.01; 39.26% female) with and without chronic pain completed measures pertaining to their pain experience. Psychometric analysis showed the PROMIS-PPI Spanish version maintains the original one-factor model of the scale, excellent internal consistency (Cronbach's α coefficient 0.90 (95% CI 0.88-0.92)), and convergent validity (showed a positive, significant, and moderate magnitude correlation [r from 0.330 to 0.604] with pediatric quality of life, child and parent pain intensity, and showed a low correlation with the number of medical consultations in the last year).

DISCUSSION

The Spanish PROMIS-PPI scale is a valid and reliable tool. It is recommended for research and clinical care in pediatric populations.

APPLICATION TO PRACTICE

The results provide evidence that the Spanish version of PROMIS-PPI is valid and reliable tool. Health professionals who work with children in risk to develop persistent pain, will have access to short tool with highest evidence, for assess pain interference.

Musculoskeletal pain and its effect on daily activity and behaviour in Icelandic children and youths with juvenile idiopathic arthritis: a cross-sectional case-control study

BACKGROUND

Juvenile idiopathic arthritis is characterised by recurring episodes of acute inflammation, with joint swelling in one or more joints, often accompanied by pain. These episodes can now be controlled better than in the past because of a new category of medications. However, despite more stable disease activity, pain may continue to cause problems in the children with juvenile idiopathic arthritis and can reduce their performance of routine physical activities and participation in social or school activities.

AIM

To evaluate the prevalence of pain, pain intensity, pain behaviour, and pain interference in Icelandic children with juvenile idiopathic arthritis compared with healthy peers.

METHODS

A cross-sectional, case-control study including 8-18 years old children; 28 with juvenile idiopathic arthritis and 36 in a control group. The children answered questions on pain experienced during the last 7 days, painful areas of the body and pain frequency. They completed short form versions of the Patient-Reported Outcome Measurement Information System (PROMIS) questionnaires on pain intensity, pain behaviour, and pain interference.

RESULTS

Significantly more children with juvenile idiopathic arthritis had pain compared with the control group (p = 0.02). Children with JIA also had a greater number of painful body areas (p = 0.03), more pain intensity (p = 0.009), and showed more pain behaviour (p = 0.006), and pain interference (p = 0.002). Children with juvenile idiopathic arthritis who had pain, experienced more pain interference (p = 0.023) than their peers who had pain. However, the groups did not differ in terms of pain intensity (p = 0.102) and pain behaviour (p = 0.058).

CONCLUSION

The research results indicate that pain experience was different between children with juvenile idiopathic arthritis and the control group. The results suggest that further research of the role of pain management on functional outcomes in children with juvenile idiopathic arthritis is needed.

Pediatric chronic post-surgical pain prevalence, pain scores, and quality-of-life: results of an exploratory patient survey at a single-center tertiary care children's hospital

PURPOSE

Twenty percent of children may develop chronic post-surgical pain (CPSP), but studies investigating pediatric CPSP are limited in scope. In an exploratory patient survey, we sought to assess CPSP prevalence among children of all ages, across a wide range of surgeries, and over an extended period of time after surgery.

METHODS

We conducted a survey study, including patients < 19 years of age at the time of their surgery at a single-center, quaternary care academic pediatric hospital. Pediatric patients who underwent surgery from May 2014 to August 2019 were included. Via electronic survey, patients/caregivers were asked whether the child had any pain related to their last surgery at the pediatric hospital. Patients/caregivers who answered yes were asked 11 additional questions about the child's pain and pain-related quality of life. The primary outcome was CPSP prevalence; secondary outcomes were pain scores, quality-of-life scores, and the associations of CPSP with time since surgery, preoperative pain, and patient age.

RESULTS

The response rate of completed surveys was 4.0%. 30% of respondents reported CPSP; the median pain score was 4.0 on an 11 point scale (0 to 10). Responses to quality of life questions indicated CPSP negatively impacted many children's lives. Preoperative pain was associated with an odds ratio for CPSP of 1.09 [95% confidence interval (CI): 0.58, 2.04], each year after surgery with an odds ratio of 0.94 (95% CI 0.80, 1.10), and each year of age at surgery with an odds ratio of 1.07 (95% CI 1.02, 1.12).

CONCLUSION

While limited by a low response rate, results from this exploratory survey suggest that CPSP is a considerable problem for children who undergo surgery across many specialties, with marked effects on patient well-being even years after surgery.

Post-Intensive Care Syndrome in a Cohort of School-Aged Children and Adolescent ICU Survivors: The Importance of Follow-up in the Acute Recovery Phase

Pediatric intensive care unit (PICU) survivors experience a collection of physical, cognitive, emotional, and social symptoms named post-intensive care syndrome (PICS). We aimed to quantify PICS morbidities from multiple stakeholder perspectives across domains. Using physician, neuropsychologist, and parent/caregiver-completed outcome measures across domains in a cross-sectional analysis of 186 children between the ages of 8 and 19 years with data from a PICU follow-up clinic 1 to 3 months after PICU discharge, we quantified PICS morbidities and used Spearman correlation to evaluate interdependence of PICS domains. Compared with pre-hospitalization functioning, new PICS-related morbidities were observed and significant correlations were identified between the PICS domains. Results highlight the need to identify and support patients and families for multiple morbidities simultaneously across all relevant PICS domains; moreover, an important divergence between caregiver report, physician, and neuropsychologist assessment was also found, showcasing the importance of multiple assessments and perspectives. New PICS morbidities across domains are common after discharge from the PICU, and timely follow-up care is needed that involves collaboration/integration of physicians, neuropsychologists, youth, and families to effectively identify and treat PICS-related issues.

Neurofeedback-Augmented Mindfulness Training Elicits Distinct Responses in the Subregions of the Insular Cortex in Healthy Adolescents

Mindfulness training (MT) reduces self-referential processing and promotes interoception, the perception of sensations from inside the body, by increasing one’s awareness of and regulating responses to them. The posterior cingulate cortex (PCC) and the insular cortex (INS) are considered hubs for self-referential processing and interoception, respectively. Although MT has been consistently found to decrease PCC, little is known about how MT relates to INS activity. Understanding links between mindfulness and interoception may be particularly important for informing mental health in adolescence, when neuroplasticity and emergence of psychopathology are heightened. We examined INS activity during real-time functional magnetic resonance imaging neurofeedback-augmented mindfulness training (NAMT) targeting the PCC. Healthy adolescents (N = 37; 16 female) completed the NAMT task, including Focus-on-Breath (MT), Describe (self-referential processing), and Rest conditions, across three neurofeedback runs and two non-neurofeedback runs (Observe, Transfer). Regression coefficients estimated from the generalized linear model were extracted from three INS subregions: anterior (aINS), mid (mINS), and posterior (pINS). Mixed model analyses revealed the main effect of run for Focus-on-Breath vs. Describe contrast in aINS [R2 = 0.39] and pINS [R2 = 0.33], but not mINS [R2 = 0.34]. Post hoc analyses revealed greater aINS activity and reduced pINS activity during neurofeedback runs, and such activities were related to lower self-reported life satisfaction and less pain behavior, respectively. These findings revealed the specific involvement of insula subregions in rtfMRI-nf MT.

Pediatric Pain Screening Tool: A Simple 9-Item Questionnaire Predicts Functional and Chronic Postsurgical Pain Outcomes After Major Musculoskeletal Surgeries

Reliable, clinic-friendly screening for Chronic postsurgical pain (CPSP) risk is unavailable. Within a prospective, observational study, we evaluated Pediatric Pain Screening Tool (PPST), a concise 9-item questionnaire, as a preoperative screening tool to identify those at higher risk for CPSP (Numerical Rating Scale > 3/10 beyond 3 months post-surgery) and poor function (disability/Functional Disability Inventory [FDI]/quality of life/ Pediatric Quality of Life) after spine fusion and Nuss procedures. Incidence of CPSP was 34.86% (38/109). We confirmed PPST scale stability, test re-test reliability (ICC = 0.68; P< .001); PPST measures were positively correlated with known CPSP risk factors (P< .001) preoperative pain (Pearson or Spearman Correlation Coefficient [SCC]:0.672), Child anxiety sensitivity index (SCC:0.357), Patient Related Outcome Measures Information System pain interference (SCC:0.569), Patient Related Outcome Measures Information System depression (SCC:0.501), Pediatric Quality of Life (SCC:-0.460) and insomnia severity index (SCC0.567). Preoperative PPST and PPST physical sub-scores (median(IQR) were higher in CPSP (2[0.5,4], 1[0,2]) compared to non-CPSP (1[0,3], 0[0,1.5]) groups (P= .026, P= .029) respectively. PPST scores/sub-scores positively correlated with higher FDI at 6 months but only PPST total and PPST psychosocial subscore correlated with higher FDI at 12 months. Based on ROC, optimal PPST cutoff for CPSP was 2 (63.9% sensitivity, 64.7% specificity). CPSP risk was high (48.94% risk) if PPST ≥ 2 (n = 47) and medium (22.81%) if PPST < 2 (n = 57) after spine/pectus surgery. General and risk-strata specific, targeted psychosocial non-pharmacological interventions, need to be studied. Findings need validation in diverse, larger cohorts. CLINICALTRIALS.GOV IDENTIFIER: NCT02998138. PERSPECTIVE: The article supports Pediatric Pain Screening Tool, a simple 9-item questionnaire, as a preoperative screening tool for CPSP and function 6-12 months after spine/pectus surgeries. PPST measures correlate with known risk factors for CPSP. Risk stratification and targeted preventive interventions in high-risk subjects are proposed.

Poorly Controlled Pediatric Fracture Pain Requiring Unplanned Medical Assistance or Advice

OBJECTIVES

This study aimed to define the proportion of children who seek assistance for poorly controlled fracture pain, identify factors associated with requesting help, and explore caregivers' opioid preferences.

METHODS

We enrolled 251 children and their caregivers in the orthopedic surgery clinic of a tertiary care children's hospital. Children 5 to 17 years old presenting within 10 days of injury for follow-up for a single-extremity, nonoperative long bone fracture(s) were eligible. The primary outcome was seeking unscheduled evaluation or advice for poorly controlled pain before the first routine follow-up appointment by telephone call, medical visit, or rescheduling to an earlier appointment. Factors associated with the outcome were assessed using bivariable analysis.

RESULTS

Overall, 7.3% (95% confidence interval, 4.1%-10.6%) of participants sought unscheduled evaluation or advice for poorly controlled pain. The 2 most common reasons were to obtain over-the-counter analgesic dosage information (64.7%) and a stronger analgesic (29.4%). These children were more likely to have a leg fracture, have an overriding or translated fracture, or require manual reduction under procedural sedation. These children had higher Patient-Reported Outcomes Measurement Information System Pain Behavior and Pain Interference scores and more anxious caregivers. One-third of caregivers expressed hesitancy or refusal to use opioids to treat severe pain, and 45.7% reported potential addiction or abuse as the rationale.

CONCLUSIONS

A notable proportion of children seek assistance for poorly controlled fracture-related pain. Medical providers should target discharge instructions to the identified risk factors and engage caregivers in shared decision making if opioids are recommended.

5-Year Activity and Participation Outcomes of the First Successful Pediatric Bilateral Hand Transplantation: A Case Report

AIMS

Describe the 5-year outcomes of the first successful pediatric bilateral hand transplantation.

METHODS

The child underwent quadrimembral amputation at age two and received bilateral hand allografts at age eight. Rehabilitation included biomechanical, neurorehabilitation, and occupational approaches in acute and outpatient settings. Therapist observed outcomes, patient-reported measures, and parent-reported measures were repeated over a 5-year period.

RESULTS

Observation assessments revealed functional dexterity skills and modified independence to full independence with self-care activities. The parent reported the child had moderate difficulty with upper extremity functioning 25-, 41-, and 48-months post-transplantation, and mild difficulty at 60-months; the child reported no difficulties in this domain at 41 months. Five years post-transplantation the child reported enjoying many age-appropriate activities, and high-quality peer relations were endorsed by both parent and child.

CONCLUSION

The child developed hand movements for daily activities and was completing daily activities with improved efficiency. Health-related quality of life outcomes were favorable.

Using the Electronic Health Record to Enhance Care in Pediatric Rheumatology

The electronic health record (EHR) ecosystem is undergoing rapid evolution in response to new rules and regulations promulgated by the US HITECH Act (2009) and the 21st Century Cures Act (2016), which together promote and support enhanced information use, access, exchange, as well as vendor-agnostic application development. By leveraging emerging new standards and technology for EHR data interchange, for example, FHIR and SMART, pediatric rheumatology clinical care, research, and quality improvement communities will have the opportunity to streamline documentation workflows, integrate patient-reported outcomes into clinical care, reuse clinical data for research purposes, and embed implementation science approaches within the EHR.

Pain Management for Pediatric Burns in the Outpatient Setting: A Changing Paradigm?

Childhood burns are common and distressing for children and their parents. Pain is the most common complaint and often thought to be undertreated, which can negatively influence the child's care and increase the risk of posttraumatic stress disorder. There is limited literature on the role of opioids and multimodal therapy in the treatment of pediatric outpatient burns. We sought to evaluate the current use of opioids (including the use of multimodal therapies), storage, and disposal of opioids in this patient population. Parents of burn-injured children 8 months to 18 years old, who were seen in an outpatient setting within 2 weeks of their burn injury, were queried from April to December 2019 regarding their child's pain control, opioid medication use, over-the-counter pain medication use, opioid storage, and disposal. A total of 142 parents of burn-injured children and their parents were surveyed. The median age of the burn-injured children was 2.7 years old and the majority (54.2%; 77/142) were male. The mean total body surface area (TBSA) was 1.8% and half sustained burn injuries to one or both hands. The most frequently used regimens for constant and/or breakthrough pain control were acetaminophen (62.7%) and nonsteroidal anti-inflammatory drugs (NSAIDs; 68.3%). Less than one fifth (26/142;18%) of patients were prescribed opioids and 88% filled their prescription. The median number of doses of opioids prescribed was eight doses, with a median of four doses of opioids unused. Only three patients used all of their prescribed opioids and no patient ≥12 years old used their entire prescription. Burns greater than 3% TBSA, irrespective of burn injury location, were associated with opioid prescription (P = .003). Approximately 40% (10/26) of parents who filled their child's opioid prescription stored the opioid in a locked area. Fewer than one third (7/26) of patients were educated on how to dispose of excess opioid pain medication. Overall, most pediatric outpatient burn injuries can be successfully managed with over-the-counter medications. Providers, who care for burn-injured children ≤ 12 years old with burns that cover ≥3% TBSA in the outpatient setting, should consider no more than four opioid doses for initial pain control. This guideline, coupled with family and provider-centered education on multimodal therapy at the time of initial presentation and safe use of opioids, are important first steps to minimizing the use of opioids in the management of small area burns in children.

Identifying pain trajectories in children and youth with cerebral palsy: a pilot study

Background

Although chronic pain is common in children with cerebral palsy (CP), little is known about short-term pain fluctuations and their impact on children’s well-being. High-quality cohort studies are needed to understand the clinical course of pain in this population. We aimed to determine the feasibility of conducting a multicentre cohort study. In this pilot study we assessed: 1) study processes, 2) resource and 3) management indicators including recruitment and follow-up rates, data completeness, participant characteristics, and successes and barriers in the study conduct.

Methods

A multi-centre pilot cohort study was conducted with 10 Canadian children/youth with CP attending one of two children’s rehabilitation centers. We collected self-reported pain intensity (Faces Pain Scale-Revised [FPS-R], Numeric Rating Scale [NRS]); pain interference (PROMIS PI); pain location (pain diagram); physical and psychological well-being (KIDSCREEN-27), sleep characteristics, preceding months’ interventions, and some clinical characteristics at baseline. Average pain intensity was reported weekly for five weeks. Well-being, sleep and interventions were measured at baseline and again at five weeks. We used feasibility indicators to evaluate:1) study processes (e.g. recruitment, attrition rates); 2) resources (e.g. data completion, budgetary challenges); and 3) management (e.g. data optimization, variability of participants and pain scores).

Results

Between March and May 2019, 24 children and their parents/guardians were contacted and 20 met eligibility criteria. Of those, 10 agreed to in-person screening (50%) and were subsequently enrolled. The follow-up rate was 90% and self-reported missing data was minimal. Ninety percent of participants chose e-questionnaire follow-ups versus mailed paper questionnaires. Sixty percent required reminders to complete e-follow-ups. Participants were aged 8-17 years, five were female, GMFCS levels I-IV (none with level V), 90% had spastic CP and 80% reported having pain in the preceding week. Pain intensity (FPS-R) between participants ranged from 0-8/10 at baseline and 0-6/10 across all four weekly follow-ups.

Conclusions

This pilot study demonstrates the feasibility of conducting a multicentre cohort study to identify short-term pain trajectories and measure their association with well-being in children and youth with CP. Additional strategies to improve recruitment and accessibility for those with GMFCS levels V should be implemented in future studies.

Perceived Injustice Is Associated With Pain-related Function and Mood in Youth With Acute Musculoskeletal Pain

OBJECTIVES

Perceived injustice (PI), which is one's appraisal of justice or fairness regarding the pain experience, is an emerging area of interest in pediatric pain research. No previous studies have investigated PI in youth with acute pain. To fill this gap, this study examined (1) associations among PI, pain-related function, and psychological function in treatment-seeking youth with acute musculoskeletal (MSK) pain, and (2) the impact of parent-child PI discordance on children's pain and psychosocial function.

MATERIALS AND METHODS

Participants were youth (aged 11 to 17, 55% male) with acute pain (onset <1 mo) recruited from emergency departments or outpatient clinics and participating parents (102 parent-child dyads). Dyads completed study questionnaires within 1 month of the child's pain onset.

RESULTS

Youth-reported PI was significantly correlated with poorer physical and psychosocial quality of life, higher pain catastrophizing, higher fear of pain, increased pain-related disability, and greater depression and anxiety. Furthermore, PI was significantly associated with the physical quality of life, psychosocial quality of life, and pain-related disability. Moreover, discordance in youth and parent ratings of PI was associated with children's psychological and pain-related function. Specifically, compared with Concordant dyads, youth in the Discordant dyads (youth high PI/parent low PI) reported significantly poorer physical quality of life, psychosocial quality of life, higher pain-related disability, depression, anxiety, and pain catastrophizing.

DISCUSSION

These findings reveal that PI in youth with acute MSK pain is associated with quality of life and pain-related disability. Furthermore, results highlight the importance of discordance between youth and parent reports of PI on pain-related functioning.

The Clinical Utility of a Brief Psychological Stress Measure (Patient-Reported Outcomes Measurement Information System) in Youth with Chronic Pain

OBJECTIVE

To preliminarily examine the psychometric properties (i.e., internal consistency reliability, construct validity) and clinical utility of the Patient-Reported Outcomes Measurement Information System (PROMIS) psychological stress experiences scale in a sample of youth with chronic pain.

METHODS

Participant data were gathered from an institutional review board (IRB) approved clinical data registry. One hundred sixty-eight children and adolescents (age: mean = 14.97, SD = 2.78) with chronic pain presenting to a tertiary pain treatment clinic were included in the data set. Internal consistency estimates (i.e., Cronbach's alpha), bivariate correlations, and confirmatory factor analyses were performed to preliminarily examine reliability and validity. Multivariate regression analyses were performed to examine the associations between PROMIS psychological stress and pain-related and psychosocial outcomes.

RESULTS

Confirmatory factor analysis and correlational results indicated that the PROMIS psychological stress experiences scale shows promising reliability and validity in the current sample of youth with chronic pain. Additionally, the results indicated that almost 50% of youth with chronic pain report "high" or "very high" stress (T ≥ 60) and significantly higher rates of stress when compared with national validation samples (P < 0.001). The results also indicated that the PROMIS psychological stress experiences scale was significantly associated with both pain-related and psychosocial outcomes (all P <0.01).

CONCLUSIONS

The PROMIS psychological stress experiences scale shows promising psychometric properties in youth with pediatric pain and may be useful in assessing for psychological impairment. Future research should further examine the use of this brief measure to assess psychological stress in medical clinics as a way to enhance intervention and prevention efforts in these youth.

Patient-Reported Outcomes from a Randomized, Active-Controlled, Open-Label, Phase 3 Trial of Burosumab Versus Conventional Therapy in Children with X-Linked Hypophosphatemia

Changing to burosumab, a monoclonal antibody targeting fibroblast growth factor 23, significantly improved phosphorus homeostasis, rickets, lower-extremity deformities, mobility, and growth versus continuing oral phosphate and active vitamin D (conventional therapy) in a randomized, open-label, phase 3 trial involving children aged 1-12 years with X-linked hypophosphatemia. Patients were randomized (1:1) to subcutaneous burosumab or to continue conventional therapy. We present patient-reported outcomes (PROs) from this trial for children aged ≥ 5 years at screening (n = 35), using a Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaire and SF-10 Health Survey for Children. PROMIS pain interference, physical function mobility, and fatigue scores improved from baseline with burosumab at weeks 40 and 64, but changed little with continued conventional therapy. Pain interference scores differed significantly between groups at week 40 (- 5.02, 95% CI - 9.29 to - 0.75; p = 0.0212) but not at week 64. Between-group differences were not significant at either week for physical function mobility or fatigue. Reductions in PROMIS pain interference and fatigue scores from baseline were clinically meaningful with burosumab at weeks 40 and 64 but not with conventional therapy. SF-10 physical health scores (PHS-10) improved significantly with burosumab at week 40 (least-squares mean [standard error] + 5.98 [1.79]; p = 0.0008) and week 64 (+ 5.93 [1.88]; p = 0.0016) but not with conventional therapy (between-treatment differences were nonsignificant). In conclusion, changing to burosumab improved PRO measures, with statistically significant differences in PROMIS pain interference at week 40 versus continuing with conventional therapy and in PHS-10 at weeks 40 and 64 versus baseline.Trial registration: ClinicalTrials.gov NCT02915705.

Patient-reported Outcome Measures in Pediatric Non-Malignant Hematology: A Systematic Review

Patient-reported outcome measures (PROMs) are questionnaires completed by patients or caregivers without influence by health care professionals. As such, PROMs show subjective health experiences, enhance the clinical information available to providers, and inform clinical action. The objective of this systematic review is to identify and list which validated PROMs have been used to monitor health-related quality of life in pediatric patients with nonmalignant hematology (hemophilia, immune thrombocytopenia, sickle cell disease, and thalassemia). Databases (MEDLINE, Embase, HaPI, CINAHL, and PsycTESTS) were searched to identify publications that validated or used PROMs as an outcome measure in the 4 disease groups. Overall, 209 articles met the inclusion criteria, identifying 113 PROMs. Of the 113 identified PROMs, 95 are generic and can be used in multiple disease groups. The Pediatric Quality of Life Generic Core Scales was the most frequently used generic PROM (68 studies). The 18 remaining PROMs were disease specific. The results of this review, together with the COSMIN tool for selecting outcome measures, will allow clinicians to evaluate the PROMs that are best suited to their patient population. In addition, the focus groups are currently being conducted with patients, parents, and clinicians to determine the optimal use of PROMs in the clinical environment.

Do Obese Children Have Poor Patient-reported Outcomes After Closed Reduction and Percutaneous Pin Fixation of Supracondylar Humerus Fractures?

BACKGROUND

Nearly 1 in 5 American children are obese. The primary purpose of this study is to evaluate the relationship between childhood obesity and perioperative complications, patient-reported outcomes (PRO), and functional recovery after closed reduction and percutaneous pinning (CRPP) of type II and III supracondylar humerus fractures.

METHODS

Retrospective review of patients treated operatively with CRPP of Wilkins modification of the Gartland classification type II and III supracondylar humerus fractures was performed over a 1-year timeframe (July 1, 2016 to July 1, 2017). One hundred forty-four patients under the age of 16 treated were identified. Obesity was defined as body mass index (BMI) at or above the 95th percentile for age. Obesity as a risk factor for poor outcomes was assessed. The primary outcome measure was postoperative PRO [quick-DASH, Patient Reported Outcomes Measurement Information System (PROMIS)-UE, PROMIS Global Health, and PROMIS Pain scores].

RESULTS

Mean age at surgery was 5.9 years (SD=2.1, 1.07 to 12.2) and mean age at final follow-up (3.3 y) was 8.8 (SD=2.14, 4 to 16). Mean patient BMI was 17.2 (SD=4.48, 12.4 to 56.2). Sixty-six patients were female (45.8%) and 78 patients were male (54.2%). In all, 31 of 144 patients (21.5%) met criteria for obesity. Obesity (95th percentile for BMI or above) was not associated with a higher rate of complications overall (χ2=1.29, P=0.256), range of motion loss (χ2=0.2, P=0.655) or requirement of postoperative physical therapy (χ2=0.17, P=0.678). Seventy-five patients were available and willing to participate in the outcomes score assessments. Mean follow-up for this cohort of 75 patients was 3.3 years (SD=0.31, 2.85 to 3.88). There were no differences in PROMIS pain, PROMIS upper extremity function, PROMIS general health, or quick-DASH scores when comparing obese with nonobese patients.

CONCLUSIONS

Obesity is a growing concern in the United States and its effect on long-term outcomes after CRPP of supracondylar humerus fractures is unknown. The present study demonstrates no difference in complications or PRO among obese patients compared with nonobese patients.

LEVEL OF EVIDENCE

Level IV-retrospective cohort study.

Social Deprivation and Congenital Upper Extremity Differences-An Assessment Using PROMIS

PURPOSE

Social deprivation, a measure of socioeconomic status, has been shown to negatively affect perceptions of orthopedic conditions and outcomes of treatment. The objective of this study was to assess whether social deprivation correlates with subjective assessment of function in pediatric patients with congenital hand differences.

METHODS

Patients enrolled in the Congenital Upper Limb Differences (CoULD) registry were assessed using the Patient-Reported Outcomes Measurement Information System (PROMIS). The PROMIS scores for Pain Interference, Peer Relations, Anxiety, Depression, and Upper Extremity (UE) function were obtained for all patients 5 years and older at initial presentation. Social deprivation was determined by the Area Deprivation Index (ADI); the index ranges from 0 to 100 with higher scores being the most deprived. The PROMIS scores were correlated with the ADI for all patients.

RESULTS

Three hundred seventy-five pediatric patients with congenital UE differences were evaluated. Average age was 11 years, 56% were female, and 55% had bilateral involvement. Overall, PROMIS scores were within 1 SD of normal for Peer Relations, Pain, Depression, and Anxiety. However, child-reported scores for UE function (39) were more than 1 SD below the national average (50). The mean ADI for the cohort was lower than the national average, indicative of less deprivation, with 14% of patients in the most deprived national quartile. Children in the highest ADI quartile reported PROMIS scores that reflected higher Pain Interference (41 vs 45), lower Peer Relations (55 vs 50), higher Anxiety (44 vs 49), and higher Depression (43 vs 47) than children in the lowest ADI quartile.

CONCLUSIONS

The PROMIS scores were normal for psychosocial measures in children with congenital hand differences when evaluated as an entire cohort. However, child self-reported PROMIS scores for Pain Interference, Peer Relations, Anxiety, and Depression were worse in more socially deprived areas, suggesting more psychosocial challenges in these children.

CLINICAL RELEVANCE

Pediatric patients with congenital upper extremity differences in areas of higher social deprivation report lower psychosocial well-being. The care of these individuals must be considered within the context of their environment because they may be more at risk for negative outcomes secondary to environmental and societal stressors.

Development and Psychometric Evaluation of the PROMIS Pediatric Pain Intensity Measure in Children and Adolescents with Chronic Pain

The goal of the current study was to enhance the measurement of the pediatric chronic pain experience through a methodologically rigorous approach. This paper outlines the development and initial validation of a pain intensity measure for pediatric patients with chronic pain using Patient-Reported Outcomes Measurement Information System methodology. Measure development incorporated feedback from children with painful conditions. Based on input from pediatric participants and content experts, 4 candidate items assessing pain intensity were included for large scale testing. Children completed self-report items pertaining to their pain experience that were developed as part of a larger pool of new candidate Patient-Reported Outcomes Measurement Information System pediatric pain domain items as well as measures of pain interference, depressive symptoms, fatigue, pain behavior, pain intensity, and pain catastrophizing. The final sample for the large scale testing included N = 442 pediatric patients between the ages 8 to 18 years (Mean age = 13.54, Standard Deviation = 2.78; 71.27% female) experiencing chronic pain. Psychometric analysis resulted in a final measure that included 3 items with evidence of reliability (Cronbach alpha = .82) and convergent validity. The Likert format of the response options may be preferable to the traditional numeric rating scale for use in pediatric populations who experience chronic pain based on patients' feedback, which was directly utilized in designing the scale. Further, the inclusion of fewer and clinically meaningful response options should reduce ambiguity for young respondents. PERSPECTIVE: We have developed and evaluated a clinically sensitive and psychometrically precise 3-item pain intensity measure with Likert-type responses for self-report use among children and adolescents ages 8 to 18 years with chronic pain. Development of the item content and response options included input from children and adolescents with chronic pain. The development of pain intensity items with pediatric appropriate language, and labeled, fewer response options to yield maximal clinically meaningful information improves the precision of pain intensity measurement in children.

Using nationally representative percentiles to interpret PROMIS pediatric measures

PURPOSE

This study's aim was to use a representative sample of the US pediatric population to estimate percentiles for several PROMIS pediatric measures: Anger, Anxiety, Depressive Symptoms, Family Relationships, Fatigue, Global Health, Life Satisfaction, Meaning and Purpose, Pain Behavior, Pain Interference, Physical Activity, Physical Function Mobility, Physical Function Upper Extremity, Physical Stress Experiences, Positive Affect, Psychological Stress Experiences, Sleep Disturbance, Sleep Impairment, and Peer Relationships.

METHODS

We used two separate, nationally representative samples of parents and children aged 5-17 years drawn in different years from the GfK Knowledge Panel, a dual-frame online probability panel.

RESULTS

All measures that were developed using a representative sample had a median at or near the expected value of 50. For the other measures, the 50th percentile was often 10 points or more from 50. Several domains had high floors or low ceilings. No domain's percentiles completely corresponded to the percentiles associated with a normal distribution with a mean of 50 and standard deviation of 10.

CONCLUSIONS

This work allows users to interpret a child's self-reported quality of life relative to children in the US general population. When attempting to evaluate whether a child falls above or below other children in the US, one should use the values presented in this study. In addition, we recommend that users should focus on whether a child's score falls into one of a few broad severity groups rather than on specific percentile scores.

Clinical meaning of PROMIS pain domains for children with sickle cell disease

The Patient Reported Outcomes Measurement Information System (PROMIS) pain interference and pain behavior domains are valid and reliable for children with sickle cell disease (SCD). However, clinical interpretation of the scores is unknown. The objective of this study was to determine the clinical meaning of PROMIS pain scores for children with SCD. We used 2 approaches to determine clinical meaning: dichotomization of item responses and T-score ranges. T-score ranges determined thresholds for no/mild, moderate, and severe pain. We compared the proportion of patients who needed pain medications among pain severity groups using χ²/Fisher's exact tests. The study included 117 children (mean age, 11.5 years [standard deviation, 2.9 years]). Using the dichotomization approach, 43 children had pain interference T-scores ≤48 reflecting minimal pain, and 30 children had T-scores >60 reflecting substantial pain. For pain behavior, 34 children had T-scores ≤41 reflecting minimal problems, and 23 patients had T-scores >57 reflecting substantial problems with pain. Using T-score ranges, clinical thresholds of no/mild and severe pain interference were determined as ≤48.3 and >63.6, respectively. The thresholds for no/mild and severe pain behavior were ≤41.3 and >57.3, respectively. Overall, the proportion of patients who took pain medications was significantly different among those with no/mild, moderate, and severe pain as identified by pain interference (P = .002) and pain behavior domains (P = .0113). We identified T-scores for PROMIS pain domains that facilitate clinical interpretation and provide necessary information for PROMIS users in a clinical setting.

Post-intensive care syndrome in a cohort of infants & young children receiving integrated care via a pediatric critical care & neurotrauma recovery program: A pilot investigation

OBJECTIVE

Children treated in the pediatric intensive care unit (PICU) often face difficulties with long-term morbidities associated with neurologic injuries and lifesaving PICU interventions termed Post-Intensive Care Syndrome (PICS). In an effort to identify and address critical issues related to PICS, we developed an integrated model of care whereby children and families participate in follow-up clinics with a neuropsychologist and a critical care physician. To demonstrate preliminary impact, we present pilot findings on the early identification and treatment of PICS in a cohort of infants and young children in our program through a combination of multi-professional direct assessment and parent proxy questionnaires.

METHOD

Thirty-three infants and children, ages 3-72 months, participated in our initial follow-up clinic where issues related to physical health/recovery, development/cognition, mood/behavior, and quality of life were screened 1-3 months after discharge from the PICU.

RESULTS

In comparison to pre-hospitalization functioning, direct assessment revealed new neurological concerns identified by the critical care physician in 33.3% of participants and new neurocognitive concerns identified by the neuropsychologist in 36.4% of participants. Caregiver reported measures showed significant issues with patient cognitive functioning, emotional functioning, sleep, and impact on the family. Participants and families experienced significant difficulties related to changes in functioning and disability. Parents/caregivers and clinicians demonstrated agreement on functioning across a variety of indicators; however, important divergence in assessments were also found highlighting the importance of multiple assessments and perspectives.

CONCLUSIONS

New PICS morbidities are common in the early phase of recovery after discharge in infants, young children and their families. Results demonstrate the benefits and need for timely PICU follow-up care that involves collaboration/integration of physicians, neuropsychologists, and families to identify and treat PICS issues.

Incorporating integrative medicine and patient preferences into a pilot interdisciplinary sickle cell wellness clinic

OBJECTIVE

Sickle Cell Disease (SCD) is an inherited blood disorder that includes acute pain episodes and chronic pain that can dramatically impact quality of life and goal-achievement. Our staff had limited success in connecting families with the Pain, Palliative Care and Integrative Medicine Clinic (PPCIM) to receive specialized skills for pain management. We created a partnership between Hematology and PPCIM to provide SCD patients/families with needed resources.

DESIGN/SETTING

In 2016, key stakeholders collaborated to create a Sickle Cell Wellness Clinic (SCWC) clinic to provide families access to integrative medicine and wellness strategies. Design/structure, based on family focus group data and staff expertise, included a half-day, 7-discipline clinic housed in the PPCIM space. Patients with SCD, ages 8-20, learned strategies in an effort to improve health care utilization and increase overall quality of life.

MAIN OUTCOME MEASURES/RESULTS

Feedback from two successful pilot clinics in 2017 was incorporated into the formal roll-out of SCWC in 2018. SCWCs continued monthly for one year, serving a total of 20 families post-pilot. SCD patients increased follow-up appointment engagement in the PPCIM clinic following SCWC and reported high levels of satisfaction with their healthcare experience.

CONCLUSIONS

It is feasible to run a multidisciplinary clinic focused on pain management, coping skills, and healthy living with SCD. Providers benefited from the opportunity to collaborate with other disciplines. Patient and family feedback was positive, highlighted benefits of being introduced to new modalities, and reported advantages of meeting other patients/families in a new setting.

Performance of Pediatric PROMIS CATs in Children With Upper Extremity Fractures

Background: This study was designed to quantify the performance of the pediatric Patient-Reported Outcome Measurement Information System (PROMIS) when delivered as part of routine care to children with upper extremity (UE) fractures. Methods: This cross-sectional study analyzed 964 new pediatric patients presenting with an UE fracture. All patients completed PROMIS computer adaptive tests for pain interference, peer relationships, UE function, and mobility domains at clinic registration. PROMIS was completed by parent-proxy (n = 418) for 5- to 7-year-olds and self-reported by 8- to 10-year-olds (n = 546). PROMIS score distributions were defined, and Pearson correlations assessed the interrelation between PROMIS domains. Student's t tests compared mean PROMIS scores between parent-proxy and self-completion groups. Results: UE scores indicated the greatest average impairment of all PROMIS domains. However, 13% of patients reached the UE score ceiling indicating maximal UE function. UE scores and mobility scores had a strong positive correlation while UE scores had a moderate negative correlation with pain interference. In all patients, peer relationships were, at most, very weakly correlated with any other PROMIS domain. After grouping by fracture type, parent-proxy completion estimated worse UE function, more pain interference, and worse peer relationship. Conclusions: Pediatric PROMIS UE function scores capture impairment from UE fractures but do have a strong positive correlation with pediatric PROMIS Mobility, which assesses lower extremity function. Among children with UE fractures, parent-proxy completion of pediatric PROMIS appears associated with worse scores on most PROMIS domains.

End points for sickle cell disease clinical trials: patient-reported outcomes, pain, and the brain

To address the global burden of sickle cell disease (SCD) and the need for novel therapies, the American Society of Hematology partnered with the US Food and Drug Administration to engage the work of 7 panels of clinicians, investigators, and patients to develop consensus recommendations for clinical trial end points. The panels conducted their work through literature reviews, assessment of available evidence, and expert judgment focusing on end points related to: patient-reported outcomes (PROs), pain (non-PROs), the brain, end-organ considerations, biomarkers, measurement of cure, and low-resource settings. This article presents the findings and recommendations of the PROs, pain, and brain panels, as well as relevant findings and recommendations from the biomarkers panel. The panels identify end points, where there were supporting data, to use in clinical trials of SCD. In addition, the panels discuss where further research is needed to support the development and validation of additional clinical trial end points.

Maternal Protective Parenting Accounts for the Relationship Between Pain Behaviors and Functional Disability in Adolescents

INTRODUCTION

A variety of factors influence parent responses to pain behaviors they observe in their adolescents with chronic pain. Certain parental responses to pain, such as attention or overprotection, can adversely impact adolescent adaptive functioning and correspond to poor clinical outcomes.

OBJECTIVES

It was hypothesized that the relationship between adolescent pain behaviors and functional disability was mediated by maladaptive parenting (protective, monitoring, solicitousness) responses.

MATERIALS AND METHODS

Participants were 303 adolescents and their mothers presenting to a pain clinic. Adolescents completed measures of functional disability and pain intensity; mothers completed measures assessing adolescent pain behaviors, their own catastrophizing about their adolescent's pain, and responses to pain. A path model tested the direct and indirect associations between pain behaviors and disability via 3 parenting responses, controlling for average pain intensity and parent pain catastrophizing.

RESULTS

Greater pain behavior was associated with increased protective responses (α path, P<0.001); greater protective behavior was associated with increased disability (β path, P=0.002). Including parenting responses in the model, the path between pain behaviors and disability remained significant (c' path, P<0.001). The indirect path between pain behaviors and disability via parenting responses was significant for protective responses (P<0.02), controlling for pain intensity and parent pain catastrophizing. The indirect effect of protective responses explained 18% of the variance between pain behaviors and disability.

DISCUSSION

Observing adolescent pain behaviors may prompt parents to engage in increased protective behavior that negatively impacts adolescents' functioning, even after controlling for the effects of parental pain catastrophizing.

Parental Proxy PROMIS Pain Interference Scores are Only Modestly Concordant With Their Child's Scores: An Effect of Child Catastrophizing

OBJECTIVES

Pediatric patients with chronic musculoskeletal conditions such as idiopathic scoliosis awaiting surgical correction can experience pain that interferes with their daily functioning. Reports of this interference are commonly gathered from patients through the Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference Scale and through parent-proxy scores. However, the child and parent/caregiver reports vary. To provide appropriate treatment for young patients with pain, the nature of the discrepancies and under which circumstances the reports differ needs to be understood. This report offers new information on the level of concordance among parent and child report of pain interference within this patient population, and which parent and child characteristics may influence concordance rates.

METHODS

Youth (age=10 to 17 y) with a history of musculoskeletal disorders, including idiopathic scoliosis, under consideration for surgical correction of that scoliosis and parent/caregiver dyads (n=103) completed the PROMIS Pain Interference Scale during an orthopedic presurgical visit. The current data was taken from a larger study examining postsurgical pain among patients undergoing orthopedic surgical procedures to correct scoliosis. The purpose of the current study was to measure the degree of agreement between parent and child reports of pain interference and discovery of relationships among predictors of pain interference score correspondence among dyads.

RESULTS

Correspondence between parent/caregiver and child reports of pain interference was modest (intraclass correlation coefficient=0.530). In total, 46% of dyads had similar pain interference scores, whereas 24% of parents reported higher pain interference in comparison to their child, the remaining 30% reported lower pain interference in relation to their child's report. Among children where discrepancies appeared, using logistic regression models, only child catastrophizing scores were associated with differences in parent and child estimation of child's pain interference scores. No parental characteristics predicted discrepancies between dyad pain interference reports.

DISCUSSION

Parent-proxy and child reports generally correspond, but when discrepant, 24% of parents reported higher pain interference in relationship to the child report of pain interference and 31% noted less intense pain interference than their child's pain interference. Given these results, care should be taken when interpreting parent reports of child pain interference, especially when a child reports higher degrees of pain interference.