Rapid identification and clinical indices of fear-avoidance in youth with chronic pain

The comprehensibility and feasibility of the modified brief pain inventory and fear of pain questionnaire adapted for children and young people with cerebral palsy

PURPOSE

To test the comprehensibility and feasibility of the modified brief pain inventory (mBPI) and Fear of Pain Questionnaire for Children short-form (FOPQ-C-SF) adapted for children and young people with cerebral palsy (CP), with diverse cognitive and communication abilities. Improving assessment of pain interference (mBPI) and pain-related fear (FOPQ-C-SF) in CP can enhance quality of life by increasing access to under-utilised interventions targeting pain-related physical disability and mental health.

METHODS

A convergent mixed methods approach was used. Twenty-two people (5-30 years) with CP completed the adapted mBPI and FOPQ-C-SF in a cognitive interview, administered by pen/paper or TalkingMats®, an evidence-based visual communication framework. Cognitive interviewing approaches were adapted to optimise participation and expression for diverse cognitive and communication abilities. Quantitative data were analysed to report tool administration times, overall completion rates and communication effectiveness. Qualitative data were analysed by content analysis to determine further changes required to the tools.

RESULTS

Median administration times were 6.2 min (IQR = 5.3-7.6) for mBPI and 4.1 min (IQR = 2.7-4.9) for FOPQ-C-SF. All completed the mBPI. Three did not complete the FOPQ-C-SF due to fatigue, challenging behaviour and parent recommendation. Ten minor changes were identified.

CONCLUSION

The adapted mBPI and FOPQ-C-SF are likely comprehensible and feasible for children and young people with CP, including those with diverse cognitive and communication abilities. It is likely most children and young people with CP can effectively communicate responses to both tools. The adapted tools will now undergo further psychometric testing, prior to becoming freely available for clinical and research use.

A core outcome set to assess chronic pain interference and impact on emotional functioning for children and young people with cerebral palsy

AIM

To: (1) develop a core outcome set (COS) to assess chronic pain interference and impact on emotional functioning for children and young people with cerebral palsy (CP) with varying communication, cognitive, and functional abilities; (2) categorize the assessment tools according to reporting method or observer-reported outcome measures; and (3) categorize the content of tools in the COS according to the International Classification of Functioning, Disability and Health (ICF).

METHOD

A two-stage multi-stakeholder consensus process was used: stage 1 consisted of a workshop where 42 valid and reliable assessment tools were presented to 12 clinicians and six individuals with lived experience of CP to exclude tools considered not feasible; stage 2 consisted of a 2-round Delphi survey of 85 clinicians, researchers, and individuals with lived experience of CP to gain consensus on which tools to include. Included tools were mapped to the framework of the ICF.

RESULTS

Twenty of 29 chronic pain assessment tools considered feasible reached 75% or greater consensus for inclusion in the COS. The tools were categorized according to reporting type: patient-reported or observer-reported; and their purpose: to identify the presence of chronic pain, to assess pain interference on activities of daily living, or to assess the impact on emotional functioning.

INTERPRETATION

The developed COS guided the assessment of pain interference and impact on emotional functioning for children and young people with CP with a range of communication and cognitive abilities; the COS can be used to facilitate patient-centred care.

Measurement properties and feasibility of chronic pain assessment tools for use with children and young people with cerebral palsy

PURPOSE

Chronic pain assessment tools exist for children, but may not be valid, reliable, and feasible for populations with functional, cognitive or communication limitations, for example, cerebral palsy (CP). This study aimed to (i) identify chronic pain assessment tools used with children and young people and rate their measurement properties; (ii) develop a CP specific feasibility rating tool to assess the feasibility of tools in CP; and (iii) categorise tools according to reporting method.

MATERIALS AND METHODS

Assessment tools were identified by literature review. Their measurement properties were rated using the COnsensus based standards for the Selection of health Measurement INstruments. The CP specific Feasibility Rating Tool was developed and used to rate the tools.

RESULTS

Fifty-seven chronic pain assessment tools were identified. Six have content validity for CP, four of these use proxy-report. Forty-two tools were considered feasible for people with CP; 24 self report and 18 observational/proxy-report. Only the Paediatric Pain Profile has content validity and feasibility for people with CP unable to self-report.

CONCLUSIONS

There are few valid, reliable and feasible tools to assess chronic pain in CP. Further research is required to modify tools to enable people with cognitive limitations and/or complex communication to self-report pain.

Understanding the role of perfectionism in contributing to internalizing symptoms in youth with juvenile idiopathic arthritis

OBJECTIVE

Youth with juvenile idiopathic arthritis (JIA) experience elevated rates of internalizing symptoms, although more research is required to understand this phenomenon. Perfectionism, a multidimensional personality trait that involves dimensions such as striving for flawlessness (self-oriented perfectionism) and feeling that others demand perfection (socially-prescribed perfectionism), is a well-known risk factor for internalizing symptoms that has received minimal attention in pediatric populations. Preregistered hypotheses explored the relationships between youth and parent perfectionism and symptoms of depression and anxiety in youth with JIA, as mediated by (a) youth/parent negative self-evaluations and (b) youth self-concealment.

METHODS

One hundred fifty-six dyads comprised of youth (13-18 years) with JIA and a caregiver completed online questionnaires about trait perfectionism, negative self-evaluations (i.e., pain catastrophizing and fear of pain), self-concealment, and internalizing symptoms.

RESULTS

Positive relationships were observed between parent/youth self-oriented perfectionism and negative self-evaluations, youth self-oriented perfectionism and internalizing symptoms, and youth negative self-evaluations and internalizing symptoms. Parent self-oriented perfectionism was negatively related to youth depression symptoms. Indirect effects were observed for youth self-oriented perfectionism predicting anxiety and depression symptoms through pain catastrophizing (a1b1 = 0.13 and 0.12, 95% CI [.03, .24 and .03, .22], respectively). Exploratory mediations suggested youth socially-prescribed perfectionism might predict internalizing symptoms directly and indirectly through self-concealment.

CONCLUSION

Youth and parent perfectionism are implicated in the internalizing symptoms of youth with JIA and may manifest through youth negative self-evaluations (e.g., catastrophic thoughts) and self-concealment. While future research is needed, screening for perfectionistic tendencies in this population may help guide assessment, prevention, and treatment efforts.

The Relationship Between Fatigue, Pain Interference, Pain-Related Distress, and Avoidance in Pediatric Hypermobile Ehlers-Danlos Syndrome

BACKGROUND/OBJECTIVES

Fatigue is a known predictor of disability and reduced quality of life in youth with hypermobility and chronic pain in general. Given the added relationship between chronic fatigue and connective tissue disorders, including hypermobile Ehlers-Danlos Syndrome (hEDS), this study aims to investigate the comparative role of fatigue on important predictors of outcomes for youth with and without hEDS who have chronic pain.

METHODS

In this retrospective study, pediatric patients with chronic pain diagnosed with hEDS (n = 100) were compared to an age- and sex-matched group of youth with chronic pain without diagnosed hypermobility (n = 100). Participants completed measures of pain-related distress (PCS-C), avoidance (FOPQ-A), and pediatric PROMIS measures for fatigue, anxiety, and pain interference. Data were analyzed using chi-square tests, t-tests, and ANCOVAs in RStudio.

RESULTS

Fatigue scores were higher and clinically elevated fatigue was more prevalent in those with hEDS than in matched chronic pain peers. Fatigue was significantly positively related to pain interference, avoidance, and pain-related distress in youth with and without hEDS.

CONCLUSIONS

The current study supports the need for multidisciplinary treatment and rehabilitation for pediatric chronic pain and hypermobility and suggests that fatigue may be an important factor to consider when treating youth with hypermobility.

The validity and reliability of the Turkish version of the Fear of Pain Questionnaire for Children-Short Form (FOPQC-SF) in children and adolescents with juvenile idiopathic arthritis

OBJECTIVE

The aim of this study was to investigate the validity and reliability of the Turkish version of the Fear of Pain Questionnaire for Children-Short Form (FOPQC-SF) in children/adolescents with juvenile idiopathic arthritis (JIA).

METHODS

To evaluate validity of FOPQC-SF, 70 children/adolescents with JIA were included. Data were collected using Pediatric Quality Of Life Inventory 3.0. Module Arthritis (PedsQL), Childhood Health Assessment Questionnaire (CHAQ) and Juvenile Arthritis Disease Activity Score (JADAS).To determine the reliability of the FOPQC-SF, test-retest was performed at one-week intervals on participants who had not made any changes to their pharmacological treatment and had not received any additional treatment.

RESULTS

With factor restrictions, items of Turkish version of FOPQC-SF were found acceptable for a 2-factor structure (fear:4 items; avoidance:6 items)(RMSEA = 0.058, GFI = 0.890, X2 = 40.667 X2/df = 1.196). With no restrictions, items of Turkish version of FOPQC-SF were found to be excellent for a 3-factor structure (fear:3 items; avoidance:4 items; other:3 items) (RMSEA = 0.036, GFI = 0.909, X2 = 34.465, X2/df = 1.077).The Cronbach's alpha value of Turkish version of FOPQC-SF total was 0.865 (good). The intraclass correlation coefficient (ICC2,1) was 0.865 (very high). Fear and avoidance subscales and total score of Turkish version of FOPQC-SF had low to moderate correlation with CHAQ-disability index, CHAQ-pain, CHAQ-global evaluation, JADAS, PedsQL-child total, PedsQL-parent total (r:-0.283/-0.452)(p < 0.05). Other subscale of Turkish version of FOPQC-SF had low to moderate correlation with CHAQ-disability index, CHAQ-pain, PedsQL-parent total (r:0.286/0.318) (p < 0.05).

CONCLUSION

The Turkish version of FOPQC-SF was found to be clinically valid and reliable in children and adolescents with JIA.

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.

The Photo- and Phonosensitivity Avoidance Behavior Scales: Evaluating Clinical Utility in Pediatric Primary Chronic Headache

Background/Objectives: Pediatric primary chronic headache disorders are often associated with sensitivities to light (photosensitivity) and sound (phonosensitivity) that may trigger or worsen headache pain. These sensory sensitivities may result in changes to activity participation or environmental modifications to avoid visual and auditory stimuli. Over time, avoidance behaviors can inadvertently increase functional disability, suggesting the importance of their thorough consideration. The PhotoSensitivity and PhonoSensitivity Avoidance Behavior Scales (PHOTO-SABS and PHONO-SABS, respectively) were recently developed and preliminarily validated to assist clinicians in evaluating such behaviors. This study aimed to confirm each of their factor structures in a new sample and enhance their clinical utility. Methods: A sample of 176 youth (aged 8-17) with a primary chronic headache diagnosis completed the PHOTO-SABS and PHONO-SABS as part of their multidisciplinary evaluation in a pediatric headache clinic. Results: Consistent with the previous validation, confirmatory factor analyses supported a two-factor model for the PHOTO-SABS and a single-factor model for the PHONO-SABS. Tertile groupings (low, moderate, high) provided the most appropriate clinical reference points. The relative change criterion (RCCrit) was established at 6.4 points for both measures. Conclusions: These findings confirm that the PHOTO- and PHONO-SABS are psychometrically robust tools for clinicians to evaluate sensitivity-related avoidance behavior and to monitor response to interventions in youth with primary chronic headaches.

Examining tools for assessing the impact of chronic pain on emotional functioning in children and young people with cerebral palsy: stakeholder preference and recommendations for modification

PURPOSE

To firstly identify tools for assessing the impact of chronic pain on emotional functioning in children and young people with cerebral palsy (CP), and secondly identify suggestions to improve their relevance, comprehensiveness, comprehensibility and feasibility for the CP population. Improving assessment of the impact of pain on emotional functioning can enhance quality of life by improving access to interventions for pain-related physical disability, anxiety and depression.

METHODS

Ethics approval was granted through the Women's and Children's Health Network Human Research Ethics Committee (2022/HRE00154). A mixed methods study with people with lived experience and clinicians, and guided by the Consensus-based Standards for Measurement Instruments (COSMIN), was undertaken. An online survey identified the highest rated tools for validation and/or modification for young people with CP and chronic pain. Focus groups and interviews investigated content validity and feasibility of the tools identified as highest rated.

RESULTS

The Fear of Pain Questionnaire for Children-SF (FOPQ-C-SF) and Modified Brief Pain Inventory (mBPI) were the highest rated for pain coping and multidimensional assessment (respectively) from the online survey (n = 61) of eight tools presented. Focus group and interview data (n = 30), including 58 unique modification suggestions, were coded to six categories: accessibility, comprehensibility, feasibility, relevance, presentation and comprehensiveness.

CONCLUSION

Potential modifications have been identified to improve the appropriateness and feasibility of the FOPQ-C-SF and mBPI for children and young people with CP. Future research should implement and test these modifications, prioritising the involvement of people with lived experience to ensure their needs are met alongside clinicians.

Chronic pain in children and young people with cerebral palsy: a narrative review of challenges, advances, and future directions

BACKGROUND

Cerebral palsy (CP), the most common physical disability of childhood, is often accompanied by a range of comorbidities including pain. Pain is highly prevalent in children and young people with CP, yet has been poorly understood, inaccurately assessed, and inadequately managed in this vulnerable population. This narrative review presents recent research advances for understanding and managing pain in children and young people with CP, focusing on chronic pain, and highlights future research directions.

MAIN BODY

Pain prevalence rates in CP vary due to different methodologies of studies. Recent systematic reviews report up to 85% of children experience pain; higher in older children, females, and those with dyskinesia and greater motor impairment. Research examining the lived experience perspectives of children and their families demonstrate that even those with mild motor impairments have pain, children want to self-report pain where possible to feel heard and believed, and management approaches should be individualized. Notably, many children with cognitive and communication impairments can self-report their pain if adjustments are provided and they are given a chance. Past inadequacies of pain assessment in CP relate to a focus on pain intensity and frequency with little focus on pain interference and coping, a lack of tools appropriate for the CP population, and an assumption that many children with cognitive and/or communication limitations are unable to self-report. Recent systematic reviews have identified the most reliable and valid assessment tools for assessing chronic pain. Many were not developed for people with CP and, in their current form, are not appropriate for the spectrum of physical, communication, and cognitive limitations seen. Recently, consensus and co-design in partnership with people with lived experience and clinicians have identified tools appropriate for use in CP considering the biopsychosocial framework. Modifications to tools are underway to ensure feasibility and applicability for the spectrum of abilities seen.

CONCLUSION

Recent research advances have improved our understanding of the prevalence, characteristics and lived experience of chronic pain, and refined assessment methods in children and young people with CP. However, the very limited evidence for effective and novel management of chronic pain in this population is where research should now focus.

Racial Differences in Movement-Related Appraisals and Pain Behaviors Among Adults With Chronic Low Back Pain

Research documents racial disparities in chronic low back pain (CLBP). Few studies have examined racial disparities in movement-related appraisals and no studies have examined anticipatory appraisals prior to or pain behaviors during functional activities among individuals with CLBP. This cross-sectional study examined racial differences in anticipatory appraisals of pain, concerns about harm, and anxiety, appraisals of pain and anxiety during movement, and observed pain behaviors during 3 activities of daily living (supine-to-standing bed task, sitting-to-standing chair task, floor-to-waist lifting task) in a sample (N = 126) of non-Hispanic Black (31.0%), Hispanic (30.2%), and non-Hispanic White (38.9%) individuals with CLBP. Hispanic participants reported more expected pain, concerns about harm, and pre-movement anxiety prior to the bed and chair tasks compared to non-Hispanic White participants. Hispanic participants reported more pain during the bed task and more anxiety during the bed and chair tasks compared to non-Hispanic White participants. Non-Hispanic Black participants reported more expected pain, concerns about harm, and pre-movement anxiety prior to the bed task and more pre-movement anxiety prior to the chair task compared to non-Hispanic White participants. Non-Hispanic Black participants reported more anxiety during the bed and chair tasks compared to non-Hispanic White participants. Non-Hispanic Black participants were observed to have significantly more verbalizations of pain during the bed task compared to non-Hispanic White participants. Current findings identify racial disparities in important cognitive-behavioral and fear-avoidance mechanisms of pain. Results indicate a need to revisit traditional theoretical and treatment models in CLBP, ensuring racial disparities in pain cognitions are considered. PERSPECTIVE: This study examined racial disparities in anticipatory and movement-related appraisals, and pain behaviors during activities of daily living among Non-Hispanic Black, Non-Hispanic White, and Hispanic individuals with CLBP. Racial disparities identified in the current study have potentially important theoretical implications surrounding cognitive-behavioral and fear-avoidance mechanisms of pain.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

DISCUSSION

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

Translation, cross-cultural adaptation and psychometric properties of the Urdu version of the avoidance endurance behavior questionnaire in patients with chronic musculoskeletal pain

BACKGROUND

The Avoidance Endurance Questionnaire (AEQ) successfully measures the fear-avoidance and endurance-related responses to chronic pain.

OBJECTIVE

The objective of this study was to translate, cross-culturally adapt AEQ into Urdu and assess the reliability and validity of the Urdu version.

METHOD

For the translation and cross-cultural adaptation process, the Beaton Guidelines were followed. A total of 103 participants responded to the Urdu version of the AEQ SF-12, Pain Catastrophizing Scale (PCS) and Numeric Pain Rating Scale (NPRS) at baseline and after 48 hours. The test-retest reliability was assessed using the intraclass correlation coefficient (ICC). Cronbach's alpha was used to measure internal consistency. To measure validity, Pearson's correlation between the subscales of AEQ-Urdu and other outcome measures (SF-12, PCS and NPRS scores) were used (p< 0.05).

RESULTS

The mean age of the total 103 participants was 32.7 ± 10.90 among which 45 (43.6%) were male and 58 (56.3%) were female. The pre-final version of the translated AEQ was tested on 40 Urdu speaking participants and no major changes were made. The Cronbach's alpha for all subscales of the AEQ-Urdu ranged from 0.848-0.990. AEQ-U showed an excellent test-retest reliability with the ICC ranging from 0.775-0.996. The majority of the subscales of AEQ showed significant (p< 0.05) positive correlation with pain scales (PCS and NPRS) and negative correlation with the domains of SF-12.

CONCLUSION

The AEQ-U has reliable and valid construct validity, good internal consistency, and test-retest reliability, indicating that it has adequate psychometric features and can be a useful tool for evaluating pain responses in patients with chronic musculoskeletal pain.

Pain coping tools for children and young adults with a neurodevelopmental disability: A systematic review of measurement properties

AIM

To systematically identify and evaluate the measurement properties of patient-reported outcome measures (PROMs) and observer-reported outcome measures (parent proxy report) of pain coping tools that have been used with children and young adults (aged 0-24 years) with a neurodevelopmental disability.

METHOD

A two-stage search using MEDLINE, Embase, CINAHL, Web of Science, and PsycInfo was conducted. Search 1 in August 2021 identified pain coping tools used in neurodevelopmental disability and search 2 in September 2021 located additional studies evaluating the measurement properties of these tools. Methodological quality was assessed using the COnsensus-based Standards for the Selection of Health Measurement INstruments (COSMIN) guidelines (PROSPERO protocol registration no. CRD42021273031).

RESULTS

Sixteen studies identified seven pain coping tools, all PROMs and observer-reported outcome measures (parent proxy report) versions. The measurement properties of the seven tools were appraised in 44 studies. No tool had high-quality evidence for any measurement property or evidence for all nine measurement properties as outlined by COSMIN. Only one tool had content validity for individuals with neurodevelopmental disability: the Cerebral Palsy Quality of Life tool.

INTERPRETATION

Pain coping assessment tools with self-report and parent proxy versions are available; however, measurement invariance has not been tested in young adults with a neurodevelopmental disability. This is an area for future research.

Targeting Pain Science Education in Youth With Chronic Pain: What Are the Sticking Points for Youth and Their Parents?

OBJECTIVES

An important part of providing pain science education is to first assess baseline knowledge and beliefs about pain, thereby identifying misconceptions and establishing individually-tailored learning objectives. The Concept of Pain Inventory (COPI) was developed to support this need. This study aimed to characterize the concept of pain in care-seeking youth and their parents, to examine its clinical and demographic correlates, and to identify conceptual gaps.

MATERIALS AND METHODS

Following an initial interdisciplinary evaluation, a cohort of 127 youth aged 8 to 18 years, and their parents, completed a series of questionnaires.

RESULTS

Parents had slightly higher COPI scores than youth did, reflecting parents' greater alignment with contemporary pain science. The moderate positive association with older age among youth ( r =.32) suggests that COPI is sensitive to cognitive development and life experiences. Youth and parent COPI responses were weakly associated ( r =0.24), highlighting the importance of targeting the concept of pain in both groups. For both parents and youth, 'Learning about pain can help you feel less pain' was the least endorsed concept. This conceptual 'gap' is a key point of intervention that could potentially lead to greater engagement with multidisciplinary pain treatment.

DISCUSSION

The COPI appears useful for identifying conceptual gaps or 'sticking points'; this may be an important step to pre-emptively address misconceptions about pain through pain science education. Future research should determine the utility of COPI in assessing and treating youth seeking care for pain. The COPI may be a useful tool for tailoring pain science education to youth and their parents.

Virtual Reality-Augmented Physiotherapy for Chronic Pain in Youth: Protocol for a Randomized Controlled Trial Enhanced With a Single-Case Experimental Design

BACKGROUND

Chronic musculoskeletal (MSK) pain is a prominent health concern, resulting in pain-related disability, loss of functioning, and high health care costs. Physiotherapy rehabilitation is a gold-standard treatment for improving functioning in youth with chronic MSK pain. However, increasing physical activity can feel unattainable for many adolescents because of pain-related fear and movement avoidance. Virtual reality (VR) offers an immersive experience that can interrupt the fear-avoidance cycle and improve engagement in physiotherapy. Despite promising initial findings, data are limited and often lack the rigor required to establish VR as an evidence-based treatment for MSK pain.

OBJECTIVE

This trial evaluates physiorehabilitation with VR in adolescents with MSK pain. This protocol outlines the rationale, design, and implementation of a randomized controlled trial enhanced with a single-case experimental design.

METHODS

This study is a 2-group randomized controlled trial assessing the use of physiorehabilitation with VR in adolescents with MSK pain. The authors will collaborate with physical therapists to integrate VR into their standard clinical care. For participants enrolled in standard physiotherapy, there will be no VR integrated into their physical therapy program. Primary outcomes include physical function and engagement in VR. Secondary outcomes include pain-related fear and treatment adherence. Moreover, we will obtain clinician perspectives regarding the feasibility of integrating the intervention into the flow of clinical practice.

RESULTS

The pilot study implementing physiorehabilitation with VR demonstrated that high engagement and use of physiorehabilitation with VR were associated with improvements in pain, fear, avoidance, and function. Coupled with qualitative feedback from patients, families, and clinicians, the pilot study results provide support for this trial to evaluate physiorehabilitation with VR for youth with chronic MSK pain. Analysis of results from the main clinical trial will begin as recruitment progresses, and results are expected in early 2024.

CONCLUSIONS

Significant breakthroughs for treating MSK pain require mechanistically informed innovative approaches. Physiorehabilitation with VR provides exposure to progressive challenges, real-time feedback, and reinforcement for movement and can include activities that are difficult to achieve in the real world. It has the added benefit of sustaining patient motivation and adherence while enabling clinicians to use objective benchmarks to influence progression. These findings will inform the decision of whether to proceed with a hybrid effectiveness-dissemination trial of physiorehabilitation with VR, serving as the basis for potential large-scale implementation of physiorehabilitation with VR.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04636177; https://clinicaltrials.gov/ct2/show/NCT04636177.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/40705.

Agile development of a digital exposure treatment for youth with chronic musculoskeletal pain: protocol of a user-centred design approach and examination of feasibility and preliminary efficacy

INTRODUCTION

Chronic pain affects a significant number of children and impacts multiple domains including social, emotional and behavioural functioning, and negatively impacts family functioning. Roughly 5% of youth with chronic pain experience moderate to severe pain-related disability, with pain-related fear and avoidance of activities being identified as substantial barriers to treatment engagement. Evidence supports targeted psychological and physical interventions to address these barriers (eg, graded-exposure treatment), but accessibility to intervention is undermined by a shortage of services outside of urban areas, high treatment-related costs, and long provider waitlists; highlighting the need to develop digitally delivered behavioural intervention, using agile and iterative study designs that support rapid development and timely dissemination.

METHODS AND ANALYSIS

This study seeks to develop an effective and scalable intervention for youth with chronic pain and their caregivers. This paper presents a user-centred protocol for the development and refinement of a digital exposure treatment for youth and caregivers, as well as the study design to examine feasibility and preliminary efficacy of the treatment using single-case experimental design (SCED). Assessments include daily diaries, completed from baseline and daily throughout the intervention (~6 weeks), and at 3-month follow-up, as well as self-report measures completed at baseline, end of intervention and 3-month follow-up. Primary outcomes include treatment satisfaction, treatment expectancy, adherence to daily dairies and functional disability. Secondary outcomes are pain-related fear and avoidance of activities, pain catastrophising and pain acceptance. We will present descriptive and model-based inference analyses, based on SCED reporting guidelines. We will calculate effect sizes for each individual on each outcome. We will examine mean treatment expectancy, credibility and satisfaction scores, and patient drop-out percentage.

ETHICS AND DISSEMINATION

This study is approved by the Institutional Review Board at Stanford University (protocol #53323). Findings will be actively disseminated through peer-reviewed journals, conference presentations and social media.

TRIAL REGISTRATION NUMBER

NCT05079984.

Leveraging Virtual Reality and Augmented Reality to Combat Chronic Pain in Youth: Position Paper From the Interdisciplinary Network on Virtual and Augmented Technologies for Pain Management

BACKGROUND

Virtual reality (VR) and augmented reality (AR) interventions are emerging as promising tools in the treatment of pediatric chronic pain conditions. However, in this young field, there is little consensus to guide the process of engaging in the development and evaluation of targeted VR-based interventions.

OBJECTIVE

The INOVATE-Pain (Interdisciplinary Network on Virtual and Augmented Technologies for Pain management) consortium aims to advance the field of VR for pediatric chronic pain rehabilitation by providing guidance for best practices in the design, evaluation, and dissemination of VR-based interventions targeting this population.

METHODS

An interdisciplinary meeting of 16 academics, clinicians, industry partners, and philanthropy partners was held in January 2020.

RESULTS

Reviewing the state of the field, the consortium identified important directions for research-driven innovation in VR and AR clinical care, highlighted key opportunities and challenges facing the field, and established a consensus on best methodological practices to adopt in future efforts to advance the research and practice of VR and AR in pediatric pain. The consortium also identified important next steps to undertake to continue to advance the work in this promising new area of digital health pain interventions.

CONCLUSIONS

To realize the promise of this realm of innovation, key ingredients for success include productive partnerships among industry, academic, and clinical stakeholders; a uniform set of outcome domains and measures for standardized evaluation; and widespread access to the latest opportunities, tools, and resources. The INOVATE-Pain collaborative hopes to promote the creation, rigorous yet efficient evaluation, and dissemination of innovative VR-based interventions to reduce pain and improve quality of life for children.

Something Else Going On? Diagnostic Uncertainty in Children with Chronic Pain and Their Parents

Diagnostic uncertainty, the perceived lack of an accurate explanation of the patient's health problem, remains relatively unstudied in children. This study examined the prevalence, familial concordance, and correlates of diagnostic uncertainty in children and their parents presenting to a multidisciplinary pain clinic in the United States. One hundred and twenty-six parents and 91 of their children (Mage = 13.93 years, range = 8-18 years) completed a brief three-item measure of diagnostic uncertainty, as well as measures of pain-related distress and functioning. Forty-eight percent of children and 37% of parents believed something else was going on with the child's pain that doctors had not found out about yet. Across the three items, 66%-77% of children and their parents agreed in their endorsement of diagnostic uncertainty. Parents who believed that something else was going on with their child's pain had children with higher avoidance of pain-related activities (F = 5.601, p = 0.020) and lower pain willingness (F = 4.782, p = 0.032). Neither parent nor child diagnostic uncertainty was significantly related to the child's pain-related functioning. Diagnostic uncertainty, particularly in parents, is relevant in the experience of pediatric chronic pain and warrants further investigation as both a risk factor and therapeutic target.

Stuck on pain? Assessing children's vigilance and awareness of pain sensations

BACKGROUND

Attending towards pain is proposed as a key mechanism influencing the experience and chronification of pain. Persistent attention towards pain is proposed to drive poor outcomes in both adults and children with chronic pain. However, there are no validated self-report measures of pain-related attention for children.

METHODS

The goals of this study were to adapt the Pain Vigilance and Awareness Questionnaire (PVAQ) for use in a child sample, to preliminary examine its psychometric properties, and to assess its utility over and above a measure of general attentional capacities. We adapted the language of the PVAQ to be more easily understood by children as young as 8 years. In a sample of 160 children (8-18 years) with chronic pain, we examined the factor structure, internal consistency and criterion validity of the PVAQ-C.

RESULTS

The PVAQ-C demonstrated excellent internal consistency (α = 0.92) and moderate-to-strong criterion validity. A one-factor structure best fit the data. Children who reported greater attention to pain also reported greater pain catastrophizing, fear of pain, avoidance of activities and poorer physical functioning. Pain-related attention remained a significant predictor of functioning while controlling for demographics, catastrophizing and fear-avoidance. Pain-related attention also significantly predicted child outcomes independent of the child's general attention control capacities, indicating added value of a pain-specific measure of attention.

CONCLUSIONS

The PVAQ-C shows strong indices of internal reliability and criterion validity, and indicates unique predictive utility. It will be important to study the role of pain-related attention in youth within developmental and functional-motivational frameworks.

SIGNIFICANCE

Pain-related attention is proposed as a key factor influencing fear-avoidance outcomes in both adults and youth with chronic pain, yet no self-report measures of pain-related attention have been validated for children. This paper presents a child version of the Pain Vigilance and Awareness Questionnaire (PVAQ-C), which indicates strong internal consistency, criterion validity and unique predictive validity, and provides evidence to support the Fear-Avoidance Model in youth with chronic pain.