Remembering the pain of surgery 1 year later: a longitudinal examination of anxiety in children's pain memory development

Efficacy of Virtual Reality vs. Tablet Games for Pain and Anxiety in Children Undergoing Bone Pins Removal: Randomised Clinical Trial

AIMS

To verify the efficacy of virtual reality compared to tablet games for pain and anxiety management in children undergoing percutaneous bone pin and/or suture removal procedures.

DESIGN

Randomised clinical trial using two parallel groups: (1) virtual reality or (2) tablet game.

METHODS

Three-center, randomised pragmatic clinical trial, using a parallel design with two groups (experimental group: immersive virtual reality; active comparator: tablet games). Children aged 6-17 requiring percutaneous pins and/or sutures were recruited between 2020 and 2022 from three outpatient orthopaedic clinics in paediatric hospitals. Pain was measured with the Numerical Rating Scale and anxiety with the Child Fear Scale before and immediately after the procedure.

RESULTS

A total of 188 participants were assigned to either the virtual reality group (96 participants) or the tablet group (92 participants). At the first assessment, there was no noticeable difference between the two groups in terms of pain or anxiety levels. However, further analysis revealed that participants aged 13 and older in the virtual reality group experienced significantly lower anxiety.

CONCLUSION

Virtual reality was not more efficacious than games on a tablet for pain and anxiety of children undergoing removal of bone pins or sutures. However, virtual reality demonstrated a benefit in reducing anxiety for teenagers, particularly those aged 13-older.

IMPLICATION FOR THE PROFESSIONAL AND/OR PATIENT CARE

Virtual reality games provide an immersive, non-pharmacological alternative of for anxiety management of teenagers during pins and/or sutures removal.

IMPACT

This study showed that a virtual reality game may help reduce anxiety during pins and/or sutures removal procedures in patients aged 13 years and older.

REPORTING METHOD

We adhered to the CONSORT checklist for reporting results.

PATIENT OR PUBLIC CONTRIBUTION

A patient partner reviewed the study design, methods and final manuscript.

TRIAL REGISTRATION

NCT03680625.

Health Benefits in a Cohort of Children 6 Months After Tonsil Surgery in Relation to the Perioperative Period: An Observational Prospective Cohort Study

Background and Aim

Tonsil-surgery is a common treatment for tonsillitis and upper-airway obstruction. Health benefits are a key point of clinical concern. Aim: To evaluate health benefits 6-months after pediatric tonsil-surgery and to examine the influence of the perioperative period on health-related quality of life (HRQoL).

Method

Participants, 198 children (4-17 years) who underwent tonsillectomy ± adenoidectomy on infection-related indications (TE ± A infec , n = 46), tonsillectomy ± adenoidectomy due to upper-airway-obstruction (TE ± A obstr , n = 44), or tonsillotomy ± adenoidectomy due to upper-airway-obstruction (TT ± A obstr , n = 108). Data were collected via a postoperative pain-diary, and 6-month-questionnaires. The Glasgow Children's Benefit Inventory (GCBI) evaluated HRQoL. An additional questionnaire assessed disease-specific benefits, including open-ended-questions to capture what the children wanted to convey to other children scheduled for surgery.

Results

QoL-score after surgery was positive in all indication/surgical-method groups. The highest GCBI-scores were seen in the subscale-scores for physical health and vitality. Comparing TE ± A obstr and TT ± A obstr , no significant differences were noted in the total-score or in the subscores. No differences in GCBI-scores were seen between subgroups of patients divided by postoperative pain intensity and duration. No differences in frequency or loudness of snoring or ENT-infections were seen between the groups, and satisfaction rates were high. The information that the children considered essential to share with others covered details of the day of surgery, including the anesthesia, nutrition, pain and pain relief, and well-being after surgery.

Conclusions

All indication/surgical-method groups reported improvements regarding the health benefits of surgery, with the most pronounced effect being seen for physical health and vitality. TE ± A and TT ± A showed similar benefits in cases of obstructive and infection problems. Postoperative pain had no impact on QoL at the 6-month follow-up. Children's memories of the surgery can provide direction for management and improvements in children's care. Pain management needs to be optimized to improve recovery.

Prevalence, pain trajectories, and presurgical predictors for chronic postsurgical pain in a pediatric sample in Spain with a 24-month follow-up

ABSTRACT

Pediatric chronic pain, particularly chronic postsurgical pain (CPSP), poses a significant public health challenge, impacting 20% of pediatric populations. While several presurgical predictors have been identified, there is a scarcity of data on long-term outcomes, especially beyond 1 to 2 years postsurgery. Previous research primarily focuses on North American children, creating gaps in understanding CPSP outcomes in diverse health systems, such as in Spain. This study, registered as NCT04735211, investigates CPSP in 159 children and adolescents (mean age = 12.4 years, 37.1% girls, retention rate = 65%) undergoing various surgeries in Spain. The objectives include examining CPSP prevalence (Numerical Rating Scale ≥ 4) at 3, 6, 12, and 24 months, exploring postsurgical pain trajectories through group-based trajectory modeling, and identifying potential presurgical predictors for CPSP (pain intensity, pain catastrophizing, pain anxiety, fear of pain, kinesiophobia, health-related quality of life, pain interference, and physical activity), using multiple logistic regressions. Results show a CPSP prevalence of 41% at 3 months, decreasing to 14% at 24 months. Presurgical factors including pain intensity (adjusted odds ratio [aOR] = 1.25, 95% confidence interval [CI] = 1.02-1.53), pain catastrophizing (aOR = 1.06, 95% CI = 1.00-1.13), and pain anxiety (aOR = 1.06, 95% CI = 1.02-1.11) were associated with CPSP at 3 months. Group-based trajectory modeling revealed 3 postsurgical pain trajectories: Low Pain with Rapid Recovery Group (30.2%), Moderate Pain with Recovery Group (53.5%), and High Pain with Slow Recovery Group (16.3%), with group differences in presurgical predictors, excluding physical activity. This study contributes valuable insights into CPSP, emphasizing the need for long-term follow-up. The findings could inform the implementation of preventive programs for CPSP into diverse health systems.

When thinking about pain contributes to suffering: the example of pain catastrophizing

ABSTRACT

The extensive literature on the potent role negative thoughts about pain have on the experience of pain and pain-related suffering has documented associations with important neurobiological processes involved in amplifying nociceptive signals. We focus this review on pain catastrophizing (pCAT)- appraisals of pain as threatening, overwhelming, and unmanageable- and review the evidence that these thoughts are learned in childhood through experience and observation of others, particularly caretakers and parents. For children who have learned pCAT, repeated exposures to pain over time activate pCAT and likely contribute to further amplification of pain through changes in the neurobiological pain regulatory systems, which overlap with those regulating the stress response. We propose that repeated pain and stress exposures throughout childhood, adolescence, and into adulthood alter the neurobiology of pain via a repetitive positive feedback loop that increases risk for heightened pain sensitivity over time with repeated exposures. At some point, often precipitated by an acute episode of pain and possibly influenced by allostatic load, pCAT contributes to persistence of episodic or acute pain and exacerbates pain-related suffering. This developmental trajectory is not inevitable, as the impact of pCAT on pain and pain-related suffering can be influenced by various factors. We also present future directions for work in this area.

Risk of Unfavorable Trajectories of Chronic Pain Severity-Results of a Longitudinal Study in School Children

Chronic pain is a common burden among children and adolescents associated with impairments in many aspects of life. Higher pain severity increases this burden. Subsequently, it is important to identify factors predicting the course of pain severity, classified by the chronic pain grading (CPG). In a 1-year longitudinal assessment of a general school-age population (N = 2,280), we aimed to identify biopsychosocial factors associated with CPG trajectories. We focused on children and adolescents who reported chronic pain at the start of the year (N = 689). Using longitudinal latent class analysis, we identified 3 classes of CPG trajectories over 1 year: 1) the "pain recovery group" exhibited initially moderate CPG scores that rapidly and consistently declined to a pain-free level, 2) the "continuously moderate pain severity group" displayed initially high CPG levels with a mild decline over time, and 3) the "continuously low pain severity group" had initially moderate CPG levels, which only slightly declined. In comparison to the pain recovery group, the continuously moderate pain severity group presented with heightened levels of anxiety (odds ratio [OR] = 1.12, 95% confidence interval [CI] [1.02, 1.24], P = .023), depression (OR = 1.10, 95% CI [1.01, 1.19], P = .029), and affective pain perception (OR = 1.10, 95% CI [1.02, 1.18], P = .010) and were more likely to be female (OR = 2.14, 95% CI [1.05, 4.35], P = .036). The continuously low pain severity group was predominantly female (OR = 1.65, 95% CI [1.10, 2.49], P = .016) compared to the pain recovery group. In conclusion, girls and individuals with impaired psychological well-being more often exhibit unfavorable trajectories of chronic pain severity. PERSPECTIVE: Pediatric chronic pain patients, particularly females and those exhibiting elevated anxiety or depression scores or heightened affective pain perception warrant special attention in health care. These individuals have a greater risk of an unfavorable trajectory of chronic pain severity and might need more urgent and specialized treatment.

A systematic review of the prevalence of chronic postsurgical pain in children

Two prior reviews highlight the scarcity and conflicting nature of available data on chronic postsurgical pain in children, reporting a wide prevalence range of 3.2% to 64% (at ≥3 months). This updated systematic review aimed to consolidate information on the prevalence of pediatric chronic postsurgical pain. A thorough literature search of full English-text publications from April 2014 to August 2021 was conducted using Ovid MEDLINE, PubMed, and Cochrane Database of Systematic Reviews, with search terms: postoperative pain, child, preschool, pediatrics, adolescent, chronic pain. Seventeen relevant studies were identified. Most assessed chronicity once greater than 3 months duration postoperatively (82%), were predominantly prospective (71%) and conducted in inpatient settings (88%). The surgeries examined included orthopedic (scoliosis and limb), urological, laparotomy, inguinal, and cardiothoracic procedures, involving numbers ranging from 36 to 750, totaling 3137 participants/2792 completers. The studies had wide variations in median age at surgery (6 days to 16 years), the percentage of female participants (unspecified or 12.5% to 90%), and follow-up duration (2.5 months to 9 years). Various pain, functional, psychosocial, and health-related quality of life outcomes were documented. Chronic postsurgical pain prevalence varied widely from 2% to 100%. Despite increased data, challenges persist due to heterogeneity in definitions, patient demographics, mixed versus single surgical populations, diverse perioperative analgesic interventions, follow-up durations and reported outcomes. Interpretation is further complicated by limited information on impact, long-term analgesia and healthcare utilization, and relatively small sample sizes, hindering the assessment of reported associations. In some cases, preoperative pain and deformity may not have been addressed by surgery and persisting pain postoperatively may then be inappropriately termed chronic postsurgical pain. Larger-scale, procedure-specific data to better assess current prevalence, impact, and whether modifiable factors link to negative long-term outcomes, would be more useful and allow targeted perioperative interventions for at-risk pediatric surgical patients.

Photos Sculpt the Stories of Youth: Using Photovoice to Holistically Capture the Lived Experiences and Pain of Youth Who Underwent Spinal Fusion Surgery

Spinal fusion surgery is one of the most common major surgical procedures in youth. Adolescent idiopathic scoliosis (AIS) is the most frequent reason for corrective spinal fusion. AIS (∼25%-47% of cases) and spinal fusion surgeries are associated with pain, including the development of new onset chronic pain for up to 15% of youth. This research used photovoice approaches to explore the journeys of youth from before, during, and after spinal fusion surgery, to demonstrate their experiences both of and beyond pain. Twenty participants were recruited from a previous study conducted by the senior author's lab. Participants captured photos/videos in their daily life (Phase 1); collected previously taken photos/videos from before/during/after their surgery (Phase 2); and participated in individual interviews to reflexively discuss the meaning behind photos/videos (Phase 3). Before interviews, a questionnaire was administered to assess pain characteristics. Nineteen girls/women with scoliosis and one boy/man with kyphosis (12-19 years old, Mage = 16 years) participated; they identified as white (80%), other (15%), and Southeast Asian (5%). The researchers used a reflexive thematic analysis approach, which generated five themes: (1) body aesthetic versus machine; (2) expectations and anticipation of surgery/outcomes; (3) desire of normalcy and freedom; (4) navigating a hoped-for positive surgery experience; and (5) the journey sculpts identity formation and sense of self. Findings support youth advocacy, underscoring the need to validate youth concerns and inform healthcare professionals of the importance of individualized care. Youth perspectives highlighted opportunities for optimizing surgery/healthcare experiences and the psychosocial impacts of scoliosis on body image and appearance.

The autobiographical memory system and chronic pain: A neurocognitive framework for the initiation and maintenance of chronic pain

Chronic pain affects approximately 20% of the world's population, exerting a substantial burden on the affected individual, their families, and healthcare systems globally. Deficits in autobiographical memory have been identified among individuals living with chronic pain, and even found to pose a risk for the transition to chronicity. Recent neuroimaging studies have simultaneously implicated common brain regions central to autobiographical memory processing in the maintenance of and susceptibility to chronic pain. The present review proposes a novel neurocognitive framework for chronic pain explained by mechanisms underlying the autobiographical memory system. Here, we 1) summarize the current literature on autobiographical memory in pain, 2) discuss the role of the hippocampus and cortical brain regions including the ventromedial prefrontal cortex, anterior temporal lobe, and amygdala in relation to autobiographical memory, memory schemas, emotional processing, and pain, 3) synthesize these findings in a neurocognitive framework that explains these relationships and their implications for patients' pain outcomes, and 4) propose translational directions for the prevention, management, and treatment of chronic pain.

Pain memory in children: a systematic review and meta-analysis with a meta-regression

ABSTRACT

The aim of this systematic review and meta-analysis was to analyze the accuracy of memory of pain and the variables that may influence it in children with acute, experimental, and chronic pain. We conducted a search in electronic databases from inception to February 11, 2022. Twelve observational studies and 3 randomized controlled studies were included in the study. The main outcome measure was the accuracy of the memory of the pain intensity (experienced/recalled). To compare the outcomes reported by the studies, we calculated the standardized mean difference (SMD) over time for the continuous variables. The overall meta-analysis showed a small effect size in favor of an overestimation of experienced pain intensity (SMD = 0.28). Subanalyzing per pain context, there was a small effect size in favor of overestimation in the clinical context (SMD = 0.33), but there was no evidence of any change in the accuracy of memory of pain in the experimental context (SMD = 0.07). The mean age of the participants and the proportion of girls significantly predicted the accuracy of the memory of pain. The period since the experienced pain measurement, the intensity of expected and recalled fear, trait anxiety, and anxiety sensitivity did not significantly predict the accuracy of the memory of pain. Children showed an overestimation in pain memory between the experienced and recalled intensity of acute pain, especially in a clinical context. Furthermore, only gender and age were predictors of the accuracy of pain memory. These results highlight the relevance of pain memory to medical practice and future research.

Chronic Postsurgical Pain in Children and Adolescents: A Call for Action

Chronic postsurgical pain (CPSP) affects a significant proportion of children and adolescents after major surgery and is a detriment to both short- and long-term recovery outcomes. While clinical characteristics and psychosocial risk factors for developing CPSP in children and adults are well established in the literature, there has been little progress on the prevention and management of CPSP after pediatric surgery. Limited evidence to support current pharmacologic approaches suggests a fundamentally new paradigm must be considered by clinicians to both conceptualize and address this adverse complication. This narrative review provides a comprehensive evaluation of both the known and emerging mechanisms that support our current understanding of CPSP. Additionally, we discuss the importance of optimizing perioperative analgesic strategies to mitigate CPSP based on individual patient risks. We highlight the importance of postoperative pain trajectories to identify those most at risk for developing CPSP, the early referral to multi-disciplinary pain clinics for comprehensive evaluation and treatment of CPSP, and additional work needed to differentiate CPSP characteristics from other chronic pain syndromes in children. Finally, we recognize ongoing challenges associated with the universal implementation of available knowledge about pediatric CPSP into practically useful care plans for clinicians.

The Influence of Children's Pain-Related Attention Shifting Ability and Pain Catastrophizing Upon Negatively Biased Pain Memories in Healthy School Children

The current study investigated the influence of children's ability to flexibly shift attention toward and away from pain information on the development of negatively biased pain memories, thereby employing a direct measure of attention control reliant on behavioral responses in the context of pain (ie, an attention switching task). The direct influence of children's attention-shifting ability and pain catastrophizing as well as the moderating role of this shifting ability in the relationship between pain catastrophizing and the development of negatively biased pain memories was examined. Healthy school children (N = 41; 9-15 years old) received painful heat stimuli and completed measures of state and trait pain catastrophizing. They then performed an attention-switching task wherein they had to shift attention between personally relevant pain-related and neutral cues. Two weeks after the painful task, children's pain-related memories were elicited via telephone. Findings indicated that children's reduced ability to disengage attention away from pain information predicted more fear memory bias 2 weeks later. Children's pain-related attention-shifting ability did not moderate the relationship between children's pain catastrophizing and negatively biased pain memories. Findings highlight the contribution of children's attention control skills in the development of negatively biased pain memories. PERSPECTIVE: Results of the current study indicate that children with a reduced ability to shift attention away from pain information are at risk for developing negatively biased pain memories. Findings can inform interventions to minimize the development of these maladaptive negatively biased pain memories by targeting pain-relevant attention control skills in children.

Distress and Resilience Narratives within Pain Memories of Adolescents and Young Adults with Complex Regional Pain Syndrome: A Multi-Method Study

A comprehensive understanding of pain memories requires consideration of risk and resilience factors across biopsychosocial domains. Previous research has typically focused on pain-related outcomes, largely ignoring the nature and context of pain memories. Using a multiple-method approach, this study explores the content and context of pain memories in adolescents and young adults with complex regional pain syndrome (CRPS). Recruited via social media and pain-related organizations, participants completed an autobiographical pain memory task. Two-step cluster analysis was conducted on the pain memory narratives of adolescents and young adults with CRPS (n=50) using a modified version of the Pain Narrative Coding Scheme. Narrative profiles generated from the cluster analysis subsequently guided a deductive thematic analysis. Cluster analysis identified two narrative profiles of Distress and Resilience, with the role of coping and positive affect emerging as important profile predictors across pain memories. Subsequent deductive thematic analysis, utilizing Distress and Resilience codes, demonstrated the complex interplay between affect, social, and coping domains. Findings highlight the importance of applying a biopsychosocial framework to pain memory research, accounting for both risk and resilience perspectives and encourage the use of multiple method approaches to improve understanding of autobiographic pain memories. Clinical implications of reframing and recontextualizing pain memories and narratives are discussed, and the importance of exploring the origins of pain and possible application to developing resilience-based, preventative interventions is highlighted. PERSPECTIVE: Using multiple methods, this paper presents a comprehensive account of pain memories in adolescents and young adults with CRPS. Study findings promote the importance of adopting a biopsychosocial approach to examining both risk and resilience factors in understanding autobiographical pain memories in the context of pediatric pain.

Electric toy car to reduce anxiety before a cardiac catherisation: randomised controlled trial

BACKGROUND

Anxiety before an invasive intervention is associated in children with persistent psychological disorders. We studied the effect of the transfer to the catheterisation room by an electric toy car on the anxiety of children and their parents before a cardiac catheterisation.

METHODS

Forty-eight children with a median age of 5.6 years [4.2-7.0] were randomised to either riding on an electric car to go to the catheterisation laboratory or being transported lying supine on a gurney. Anxiety assessments were performed by a physician blinded to group allocation on the day before the procedure (T0) and at anaesthesia induction (T1). The modified Yale Preoperative Anxiety Scale Short Form (mYPAS-SF) and visual analogue scale for anxiety (VAS-A) were used in the children and the VAS-A in the parents.

RESULTS

The mYPAS-SF, VAS-A-child, and the VAS-A-parent scores were significantly higher at T1 than at T0 (p < 0.001, p < 0.001, and p = 0.005, respectively). The primary outcome (the median mYPAS-SF score at T1) was not significantly different in the two groups when males and females were combined. At T1, the VAS-A-child score, however, was significantly lower in the intervention than the control group (22 versus 55, p < 0.001). In the boys, the median mYPAS-SF score at T1 was significantly lower in the intervention group (25.0 versus 51.0, p = 0.024). No difference was observed in girls. The VAS-A parent score was lower at T1 in the intervention group (60 versus 87, p = 0.05).

CONCLUSION

Riding to the catheterisation laboratory on an electric toy car decreased anxiety in boys and decreased parental anxiety.

Autobiographical memory predicts postsurgical pain up to 12 months after major surgery

ABSTRACT

Recent cross-sectional studies have identified differences in autobiographical memory (AM) among individuals with chronic pain, but the temporal relationship between the 2 is unknown. Moreover, AM has yet to be studied in patients undergoing major surgery. This study addressed these gaps by conducting a prospective, longitudinal study of memory performance, postsurgical pain, and psychosocial factors in 97 adult participants scheduled for major surgery. Memories were evaluated using the Autobiographical Memory Test before and one month after surgery when participants were asked to recall personal events related to positive and pain-related word cues. Responses were coded for level of specificity, emotional valence, and surgery-related content. Questionnaires assessing presence/absence of pain and psychological functioning were administered before and at 1-, 3-, 6-, and 12-month follow-ups. Generalized estimating equations modelled pain at each postsurgical time point with memory variables as predictors. As hypothesized, higher numbers of specific pain memories recalled before surgery predicted lower odds of pain across all time points (OR = 0.58, 95% CI [0.37-0.91]). Participants who took longer to recall pain memories before surgery (OR = 2.65, 95% CI [1.31-5.37]) and those who produced more surgery-related content at the one-month assessment (OR = 1.31, 95% CI [1.02-1.68]) had greater odds of reporting postsurgical pain up to 12 months later. These findings indicate that presurgical AM biases are risk factors for development and maintenance of postsurgical pain. To the extent that these biases are causal, presurgical interventions that modify the quality and content of patients' memories may prove to be promising strategies in the prevention of chronic postsurgical pain.

Virtual reality mobility for burn patients (VR-MOBILE): A within-subject-controlled trial protocol

In the acute phase, burn patients undergo several painful procedures. Pediatric burn care procedures conducted in hydrotherapy have been known to generate severe pain intensity and moderate to high levels of anxiety. Hydrotherapy treatments are done with the use of opioids and benzodiazepines for pain and anxiety. Unfortunately, nonpharmacological methods are rarely combined with pharmacological treatments despite evidence showing that distraction can serve as an effective method for pain management and can potentially decrease analgesic requirements in other painful medical procedures. Virtual reality (VR) is a method that uses distraction to interact within a virtual environment. The use of VR is promising for pain reduction in varying settings. Considering the lack of optimal pain and anxiety management during burn wound care and the positive effect of an immersive distraction for painful procedures, using VR for burn wound care procedures may show promising results. This is a within-subject randomized controlled trial design in which each participant will serve as his/her own control. A minimum of 20 participants, aged 7 to 17 years old undergoing a burn care session, will receive both standard and experimental treatments during the same session in a randomized order. The experimental treatment will consist of combining VR distraction using the video game Dreamland® to the current standard pharmacological care as per unit protocol. The control group will only receive the unit's standard pharmacological care. The mean difference in both pain intensity scores and in anxiety between the two different sequences will be the primary outcomes of this study. This study evaluates the effect of VR on burn wound care. If results from this study show a positive effect of VR compared to standard care, this protocol may provide guidance on how to implement this type of immersive care as part of the tools available for distraction of painful procedures for acute burn victims.

A Qualitative Study of the Pain Experiences of Children and Their Parents at a Canadian Children's Hospital

Current literature is lacking in describing families' experiences in being involved in children's pain management. This study sought to understand children and their parents' experiences with pain management at a tertiary care children's hospital. Twelve child-parent dyads were recruited to participate in the study from January to August 2022. Children and their parents chose whether to be interviewed together or separately. Transcripts were analyzed using inductive, data-driven codes. Codes and themes were developed using a codebook and member-checking. Three main themes were identified: a. Painful experiences can have a significant positive or negative effect on families' lives and healthcare trajectories; b. There can be a mismatch between families' expectations of pain management and how they perceive the pain was managed; c. Families feel that they must advocate for better pain care, but often feel too intimidated to do so, or worry that their concerns will be dismissed by healthcare professionals. Families want healthcare professionals to proactively manage their children's pain, supporting the shaping of early positive memories of the child's healthcare interactions. Healthcare providers must further recognize that poorly treated pain can significantly impact families' lives and should both seek and be receptive to child and parent input for better pain care.

Painful reminders: Involvement of the autobiographical memory system in pediatric postsurgical pain and the transition to chronicity

Memory biases for previous pain experiences are known to be strong predictors of postsurgical pain outcomes in children. Until recently, much research on the subject in youth has assessed the sensory and affective components of recall using single-item self-report pain ratings. However, a newly emerging focus in the field has been on the episodic specificity of autobiographical pain memories. Still in its infancy, cross-sectional work has identified the presence of various memory biases in adults living with chronic pain, one of which concerns the lack of spatiotemporal specificity. Moreover, a recent prospective longitudinal study found that adults scheduled for major surgery who produced fewer specific pain memories before surgery were at greater risk of developing chronic postsurgical pain up to 12 months later. The present review draws on this research to highlight the timely need for a similar line of investigation into autobiographical pain memories in pediatric surgical populations. We (1) provide an overview of the literature on children's pain memories and underscore the need for further research pertaining to memory specificity and related neurobiological factors in chronic pain and an overview of the (2) important role of parent (and sibling) psychosocial characteristics in influencing children's pain development, (3) cognitive mechanisms underlying overgeneral memory, and (4) interplay between memory and other psychological factors in its contributions to chronic pain and (5) conclude with a discussion of the implications this research has for novel interventions that target memory biases to attenuate, and possibly eliminate, the risk that acute pain after pediatric surgery becomes chronic.

Extending the Biopsychosocial Conceptualisation of Chronic Post Surgical Pain in Children and Adolescents: The Family Systems Perspective

A substantial number of children and adolescents undergoing surgical procedures, as many as 40% in some estimates, will go on to develop chronic postsurgical pain (CPSP). Because of the significant negative impact of CPSP on social and emotional milestones, as well as the child's quality of life, it is important to identify modifiable factors that are associated with the onset and maintenance of the condition. Research has demonstrated that parent factors can play a role in pediatric chronic pain; however, there has been little examination of parent and family influences on the transition to CPSP. Family systems theories, which consider the influence of the family unit overall on the behavior of individuals members, have been applied to the eating disorders literature for decades. This narrative review proposes a novel application of family systems theory to pediatric CPSP and, in particular, highlights the role that parental dyadic factors may play in the development and maintenance of persistent pain following surgery in children and adolescents.

A Memory-Reframing Intervention to Reduce Pain in Youth Undergoing Major Surgery: Pilot Randomized, Controlled Trial of Feasibility and Acceptability

Background

Three to 22% of youth undergoing surgery develop chronic postsurgical pain (CPSP). Negative biases in pain memories (i.e., recalling higher levels of pain as compared to initial reports) are a risk factor for CPSP development. Children’s memories for pain are modifiable. Existing memory-reframing interventions reduced negatively biased memories associated with procedural pain and pain after minor surgery. However, not one study has tested the feasibility and acceptability of the memory-reframing intervention in youth undergoing major surgery.

Aims

The current pilot randomized clinical trial (RCT; NCT03110367; clinicaltrials.gov) examined the feasibility and acceptability of, as well as adherence to, a memory reframing intervention.

Methods

Youth undergoing a major surgery reported their baseline and postsurgery pain levels. Four weeks postsurgery, youth and one of their parents were randomized to receive control or memory-reframing instructions. Following the instructions, parents and youth reminisced about the surgery either as they normally would (control) or using the memory-reframing strategies (intervention). Six weeks postsurgery, youth completed a pain memory interview; parents reported intervention acceptability. Four months postsurgery, youth reported their pain.

Results

Seventeen youth (76% girls, M_age = 14.1 years) completed the study. The intervention was feasible and acceptable. Parents, but not youth, adhered to the intervention principles. The effect sizes of the intervention on youth pain memories (η_p² = 0.22) and pain outcomes (η_p² = 0.23) were used to inform a larger RCT sample size.

Conclusions

Memory reframing is a promising avenue in pediatric pain research. Larger RCTs are needed to determine intervention efficacy to improve pain outcomes.

The Effects of Pain Expectancy and Desire for Pain Relief on the Memory of Pain in Half Trail Marathon Runners

Purpose

It has been shown that the memory of pain induced by running might be underestimated. Our previous study showed the contribution of emotional factors to this process. This study aimed to investigate the cognitive factors that might influence the memory of this type of pain, ie expectancy of pain intensity, expectancy of pain unpleasantness, and desire for pain relief.

Participants and Methods

A total of 49 half-marathon runners rated the intensity and unpleasantness of pain immediately after completing a run and one month later. Participants rated the expected intensity and unpleasantness of the upcoming pain before starting the run, as well as the desire for pain relief after its completion. Those who also participated in the previous edition of the half marathon were asked to recall the pain experienced due to that run.

Results

Participants underestimated remembered pain intensity and unpleasantness. The desire for pain relief mediated the memory of pain intensity (p < 0.05), while expectancy of pain intensity influenced memory of pain intensity (a × b) through its effect on the experienced pain (bootstrapped point estimate = 0.08; 95% CI: 0.02–0.32). The remembered intensity of pain experienced during the previous half marathon affected the current pain experience directly (p < 0.05) or indirectly (a × b) by generating pain-related expectancy (bootstrapped point estimate = 0.11; 95% CI: 0.01–0.46). The cognitive variables did not influence the memory of pain unpleasantness.

Conclusion

The memory of pain induced by sports activity may change due to cognitive factors; however, further research is needed to investigate their role in shaping the memory of the sensory and affective dimensions of pain.

Developmental Mechanisms of CPSP: Clinical Observations and Translational Laboratory Evaluations

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

Use of intravenous lidocaine for dose reduction of propofol in paediatric colonoscopy patients: a randomised placebo-controlled study

BACKGROUND

Propofol, a widely used sedative in endoscopic procedures, sometimes causes cardiopulmonary complications. Intravenous lidocaine can diminish visceral pain and decrease the dose of propofol. The purpose of this study was to assess the efficacy and safety of intravenous lidocaine in reducing propofol dosage during paediatric colonoscopy.

METHODS

Forty children who underwent colonoscopy were divided into two groups. Lidocaine hydrochloride (1.5 mg/kg induction and 2 mg/kg/h maintenance) was given intravenously to the lidocaine group, and the same amount of saline was given to the control group after they received lidocaine induction. Propofol initial plasma concentration of 5 μg/mL was targeted, and the procedure was performed after the bispectral index value reached 55. The primary outcome was propofol requirement.

RESULTS

The propofol requirement in the lidocaine group was decreased by 35.5% (128.6 ± 30.4 mg vs. 199.4 ± 57.6 mg; p < 0.001; 95%CI: - 100.60, - 41.02). The incidence of involuntary body movements was significantly lower in the lidocaine group (p = 0.028; OR = 0.17; 95%CI: 0.03, 0.92). The awakening time (p < 0.001; 95%CI: - 7.67, - 5.13) and recovery times (p < 0.001; 95%CI: - 7.45, - 4.35) were significantly lower in the lidocaine group. Pain was significantly less at 30 min and 60 min after the procedure in the lidocaine group (0 [0-4] vs. 3 [0-5], p < 0. 001; 0 [0-2] vs. 1 [0-3], p = 0.001). There was no difference in the incidence of bradycardia, hypotension, or hypoxia between the two groups.

CONCLUSIONS

For colonoscopy procedures in paediatric patients, intravenous lidocaine reduces the amount of propofol needed, provides better sedation and postprocedural pain management, as well as a reduction in recovery time.

TRIAL REGISTRATION

The trial was registered on November 6, 2020 at China Clinical Trials Registration Center ( www.chictr.org.cn ) ref.: ChiCTR 2,000,039,706.

The Moderating Role of Attention Control in the Relationship Between Pain Catastrophizing and Negatively-Biased Pain Memories in Youth With Chronic Pain

The present study examined the role of attention control in understanding the development of negatively-biased pain memories as well as its moderating role in the relationship between pain catastrophizing and negatively-biased pain memories. Youth with chronic pain (N = 105) performed a cold pressor task (CPT) and completed self-report measures of state/trait pain catastrophizing and attention control, with the latter comprising both attention focusing and attention shifting. Two weeks after the CPT, youth's pain-related memories were elicited via telephone allowing to compute pain and anxiety memory bias indices (ie, recalling pain intensity or pain-related anxiety, respectively, as higher than initially reported). Results indicated no main effects of attention control and pain catastrophizing on pain memories. However, both components of attention control (ie, attention focusing and attention shifting) moderated the impact of pain catastrophizing on youth's memory bias, with opposite interaction effects. Specifically, whereas high levels of attention shifting buffered the influence of high pain catastrophizing on the development of pain memory bias, high levels of attention focusing strengthened the influence of high pain catastrophizing on the development of anxiety memory bias. Interaction effects were confined to trait catastrophizing (ie, not state catastrophizing). Theoretical and clinical implications are discussed. PERSPECTIVE: This article investigates the role of attention control in the development of negatively-biased pain memories in children with chronic pain. Findings underscore the importance of targeting differential components of attention control and can inform intervention efforts to minimize the development of negatively biased pain memories in youth with chronic pain.

Reframe the Pain: A Randomized Controlled Trial of a Parent-Led Memory-Reframing Intervention

Negatively-biased pain memories (ie, recalling more pain as compared to earlier reports) are a robust predictor of future pain experiences. This randomized controlled trial examined the efficacy of a memory-reframing intervention to reframe children's pain memories. Sixty-five children (54% girls, M_age=5.35 years) underwent a tonsillectomy and reported their levels of post-surgical pain intensity and pain-related fear. 2 weeks post-surgery, children and 1 of their parents were randomized to the memory-reframing intervention or control group. Following control/intervention instructions, parents and children reminisced about the past surgery as they normally would (control) or using the memory-reframing strategies (intervention). Children recalled their post-surgical pain intensity and pain-related fear one week later. Parents reported the intervention's acceptability. Recruitment statistics were used to assess feasibility. Controlling for initial pain intensity ratings and using the Faces Pain Scale Revised, children in the intervention group reported more accurate/positively-biased memories for day 1 post-surgery pain intensity (M = 2.60/10; 95% CI, 1.62 to 3.68), compared to children in the control group (M = 4.11/10; 95% CI, 3.12 to 5.03), η_p² = .07, p = .040. The intervention was acceptable and feasible. Optimal parent-child reminiscing about a past pain experience resulted in children remembering their pain more accurately/positively. Clinicaltrials.gov:NCT03538730. PERSPECTIVE: This article presents results of the first randomized controlled trial examining the efficacy of parent-led memory-reframing intervention to change children's memories for pain. Children of parents who were taught and engaged in optimal reminiscing about a past surgery experience remembered their pain intensity more accurately/positively.

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

ABSTRACT

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

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

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

Immersive virtual reality vs. non-immersive distraction for pain management of children during bone pins and sutures removal: A randomized clinical trial protocol

AIMS

To examine the efficacy of an immersive virtual reality distraction compared with an active non-immersive distraction, such as video games on a tablet, for pain and anxiety management and memory of pain and anxiety in children requiring percutaneous bone pins and/or suture removal procedures.

DESIGN

Three-centre randomized clinical trial using a parallel design with two groups: experimental and control.

METHODS

Study to take place in the orthopaedic department of three children hospital of the Montreal region starting in 2019. Children, from 7-17 years old, requiring bone pins and/or suture removal procedures will be recruited. The intervention group (N = 94) will receive a virtual reality game (Dreamland), whereas the control group (N = 94) will receive a tablet with video games. The primary outcomes will be both the mean self-reported pain score measured by the Numerical Rating Scale and mean anxiety score, measured by the Child Fear Scale. Recalls of pain and anxiety will be measured 1 week after the procedure using the same scales. We aim to recruit 188 children to achieve a power of 80% with a significance level (alpha) of 5%.

DISCUSSION

While multiple pharmacological methods have previously been tested for children, no studies have evaluated the impact of immersive virtual reality distraction for pain and anxiety management in the orthopaedic setting.

IMPACT

Improved pain management can be achieved using virtual reality during medical procedures for children. This method is innovative, non-pharmacological, adapted to the hospital setting, and user-friendly.

TRIAL REGISTRATION

NCT03680625, registered on clinicaltrials.gov.

Parent-Child Reminiscing about Past Pain as a Preparatory Technique in the Context of Children's Pain: A Narrative Review and Call for Future Research

Pain permeates childhood and remains inadequately and/or inconsistently managed. Existing research and clinical practice guidelines have largely focused on factors influencing the immediate experience of pain. The need for and benefits of preparing children for future pain (e.g., painful procedures) has been well established. Despite being a robust predictor of future pain and distress, memories of past painful experiences remain overlooked in pediatric pain management. Just as autobiographical memories prepare us for the future, children’s memories for past pain can be harnessed to prepare children for future painful experiences. Children’s pain memories are malleable and can be reframed to be less distressing, thus reducing anticipatory distress and promoting self-efficacy. Parents are powerful agents of change in the context of pediatric pain and valuable historians of children’s past painful experiences. They can alter children’s pain memories to be less distressing simply by talking, or reminiscing, about past pain. This narrative review summarizes existing research on parent–child reminiscing in the context of acute and chronic pediatric pain and argues for incorporation of parent–child reminiscing elements into preparatory interventions for painful procedures.

Efficacy and adverse events of 4% articaine compared with 2% lidocaine on primary molar extraction: A randomised controlled trial

BACKGROUND

There is no consensus regarding the most effective anaesthetic solution for children; nerve block, especially mandibular, can be difficult for general dentists. Therefore, the study aims to compare the efficacy and the adverse events of articaine 4% with epinephrine 1:100 000 with lidocaine 2% with epinephrine 1:100 000 for primary molar extraction using buccal infiltration.

METHODS

These are data from a parallel triple-blind randomised controlled trial with a computer-generated allocation treatment. Forty-three children aged 6-10 years with a clinical and radiographic indication of primary molar extraction were enrolled. The intervention was local buccal infiltration with articaine 4% compared with lidocaine 2%. The main outcome was pain during anaesthetic injection and tooth extraction. Adverse events were examined as secondary outcomes. Children were treated in a University setting from April to June 2019.

RESULTS

Both solutions had similar anaesthetic efficacy in primary molar extraction when applied by the infiltrative technique (β -0.47; 95% CI -3.19 to 2.24; P = .76); however, children reported higher mean pain during articaine deposition (β 2.43; 95% CI 0.28-4.57; P = .02). The measured lidocaine pH was 3.19 (0.15) and articaine was 2.43 (0.00) (P = .04). Post-operative pain, oedema and nausea were observed without differences between the groups.

CONCLUSIONS

There was no difference in the efficacy of articaine compared to lidocaine for primary molar extraction. Articaine was more painful during the injection.

PRACTICAL IMPLICATIONS

Primary molar extractions can be performed with both articaine and lidocaine buccal infiltration.

Why Unidimensional Pain Measurement Prevails in the Pediatric Acute Pain Context and What Multidimensional Self-Report Methods Can Offer

Although pain is widely recognized to be a multidimensional experience and defined as such, unidimensional pain measurement focusing on pain intensity prevails in the pediatric acute pain context. Unidimensional assessments fail to provide a comprehensive picture of a child's pain experience and commonly do little to shape clinical interventions. The current review paper overviews the theoretical and empirical literature supporting the multidimensional nature of pediatric acute pain. Literature reporting concordance data for children's self-reported sensory, affective and evaluative pain scores in the acute pain context has been reviewed and supports the distinct nature of these dimensions. Multidimensional acute pain measurement holds particular promise for identifying predictive markers of chronicity and may provide the basis for tailoring clinical management. The current paper has described key reasons contributing to the widespread use of unidimensional, rather than multidimensional, acute pediatric pain assessment protocols. Implications for clinical practice, education and future research are considered.