The prioritization of symptom beliefs over illness beliefs: The development and validation of the Pain Perception Questionnaire for Young People

Assessment of self-rated pain perception and whole salivary cortisol levels among adolescents with and without temporomandibular disorders

OBJECTIVE

To assess the self-perceived pain perception (PP) and whole salivary cortisol levels (CL) among adolescents with and without temporomandibular disorders (TMD).

METHODS

Adolescents between 15 and 17 years were included. Participants were categorized into three groups: Group 1: patients with TMD; Group 2: nocturnalbruxers without TMD; and Group 3: controls. Demographic data CL and self-rated PP were assessed. A p-value < 0.05 was proposed as statistically significant.

RESULTS

Fifty-four patients (18 per group) were included. Scores of self-rated PP in the affected TMJ were higher in Group 1 than Group 2 (p < 0.001). Whole salivary CL were higher in groups 1 and 2 (p < 0.01) than in Group 3. Whole salivary CL were higher in Group 2 than Group 3 (p < 0.05).

CONCLUSION

Whole salivary CL are higher in adolescents with TMD, and there is a direct relationship between self-rated PP in the TMJ area and salivary CL.

Beliefs About Pain in Pediatric Inflammatory and Noninflammatory Chronic Musculoskeletal Conditions: A Scoping Review

OBJECTIVE

The Common Sense Self-Regulatory Model posits that beliefs about pain influence coping behaviors and subsequent physical and mental health outcomes in children/young people with chronic musculoskeletal conditions. It was unclear how and what beliefs had been investigated in this population, and whether there were similarities and differences in beliefs held about pain by those experiencing inflammatory versus noninflammatory musculoskeletal conditions. This scoping review addressed this gap.

METHODS

A systematic search was conducted using four databases (MEDLINE, PsycINFO, Embase, and CINAHL) in November 2021. Primary studies exploring key stakeholders' (including children, parents, and/or healthcare professionals) beliefs about pain underlying pediatric chronic musculoskeletal conditions were synthesized.

RESULTS

Eighteen articles were identified. Cross-sectional designs were predominantly used to explore beliefs (n = 6). The majority used questionnaires to assess beliefs (n = 12). Beliefs common across musculoskeletal conditions were that children/young people felt their pain was not understood by others, and pain affected their physical functioning. Differences included children/young people and parents thinking they had some ability to control pain, and causal beliefs relating to underlying disease activity. These pain beliefs were more likely to be held in relation to inflammatory diagnoses. In contrast, children/young people and parents were more likely to view pain as uncontrollable, with more uncertainty regarding underlying causes, relating to noninflammatory diagnoses.

CONCLUSIONS

Methods used to explore pain beliefs were inconsistent. Studies identified similarities and differences which appear to be closely related to the underlying diagnosis. Findings justify further exploration to identify potentially modifiable targets to improve pain outcomes in this population.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Know Pain, No Pain? Preliminary Testing and Application of a New Tool to Assess Biopsychosocial Pain Concepts in Children

To deliver tailored pain science education, assessing children's biopsychosocial pain concepts is necessary. As validated tools are lacking, a new tool is presented, the biopsychosocial pain concept matrix (BiPS matrix), which assesses children's biological, psychological, and social pain concepts in five domains according to the Common-Sense Model of Self-Regulation (Hagger and Orbell, 2003): (1) illness identity, (2) causes, (3) consequences, (4) duration, and (5) treatment. The present preliminary study aims to (1) assess the items' readability and understandability in cognitive interviews with N = 9 healthy children (9 to 19 years, M = 13.78 years, SD = 3.05; 44% female) and (2) pre-test the BiPS matrix within an online survey of N = 27 healthy children (9 to 19 years, M = 13.76 years, SD = 3.03; 56% female). Results revealed difficulties in understanding some items. Children's understanding increased with age. Age, chronic pain status, and pain in the social environment were positively associated with the BiPS total score, whereas the latter explained the most variance in pain concepts of children. Patient-focused methods such as cognitive interviews proved essential in testing the readability and understanding of items in children. Future studies are warranted to further validate the BiPS matrix.

Glimpsing the raging seas that stop swans: A qualitative look at living with multimorbidity and pain in patients from a tertiary care service

Multimorbidity requires complex and ongoing care. Understanding the subjective illness experience is critical to effective care. Literature isn't clear about illness perception in patients with multimorbidity followed in services of high complexity. This study aims to investigate the illness experience based on narratives about daily living and symptoms of patients with multimorbidity and pain in a tertiary health care service.

Methods

Qualitative narrative inquiry design with framework analysis from semi-structured interviews at a tertiary internal medicine outpatient clinic. Patients with Elixhauser comorbidity index ≧3 or and pain during the last week were included. Framework analysis was performed using 3 main patterns of illness experience from a previous study: "Gliding swan" (Resilience); "Stormy Seas" (Vulnerability); and "Stuck adrift" (Disruption); and identifying subthemes. One case study was selected from each main category. 43 patients, 14 classified as "gliding swan," 12 as "stormy seas" and 17 as "stuck adrift." Within the "gliding swan" group, positive examples of how to navigate through physical and emotional factors to sustain their wellbeing based on comprehension; In the "stormy seas" group, themes revolved around vulnerability, burden and ambiguity in relation to the health team. In the "stuck adrift" group the main content was about overwhelmed feelings and limitations.

Conclusions

Narratives brought the content about lacking personalized understanding of diseases, with great emotional repercussion. Some meaningful anchors were highlighted. This study reinforces multimorbidity and pain interact and that healthcare professional should be aware of the turbulences that can disturb navigation in the raging seas of long-term multimorbid conditions.

Adolescents' experiences of fluctuating pain in musculoskeletal disorders: a qualitative systematic review and thematic synthesis

BACKGROUND

Adolescents with chronic musculoskeletal pain experience daily fluctuations in pain. Although not all fluctuations are bothersome, pain flares are a distinct type of symptom fluctuation with greater impact. Since literature on the experience of pain flares is non-existent, the aim of this review was to (i) synthesise the qualitative literature on adolescents' experiences of fluctuating pain in musculoskeletal disorders in order to (ii) identify knowledge gaps to inform future research on pain flares.

METHODS

Electronic databases (CINAHL, MEDLINE, EMBASE, PsycINFO), grey literature and reference lists were searched from inception to June 2018 for qualitative studies reporting adolescents' experiences of pain. Comprehensiveness of reporting was assessed using the Consolidated Criteria for Reporting Qualitative Health Research. Studies were analysed using thematic synthesis.

RESULTS

Of the 3787 records identified, 32 studies (n = 536) were included. Principal findings were synthesised under three key themes: 1) symptom experience, 2) disruption and loss, and 3) regaining control. The first theme (symptom experience) describes adolescent's perception and interpretation of pain fluctuations. The second theme (disruption and loss) describes the physical, social and emotional constraints faced as a result of changes in pain. The third theme (regaining control) describes coping strategies used to resist and accommodate unpredictable phases of pain. Each theme was experienced differently depending on adolescents' characteristics such as their developmental status, pain condition, and the duration of the pain experience.

CONCLUSIONS

Adolescents with chronic musculoskeletal pain live with a daily background level of symptoms which frequently fluctuate and are associated with functional and emotional difficulties. It was not clear whether these symptoms and challenges were experienced as part of 'typical' fluctuations in pain, or whether they reflect symptom exacerbations classified as 'flares'. Further research is needed to explore the frequency and characteristics of pain flares, and how they differ from their typical fluctuations in pain. The review also highlights areas relating to the pain experience, symptom management and health service provision that require further exploration to support more personalised, tailored care for adolescents with chronic musculoskeletal pain.

The Role of Prediagnosis Audiovestibular Dysfunction Versus Distress, Illness-Related Cognitions, and Behaviors in Predicted Ongoing Dizziness Handicap

OBJECTIVE

People with chronic vestibular diseases experience variable degrees of self-perceived disability. However, longitudinal data examining the predictive validity of relevant clinical variables alongside psychological variables are limited. The present study examined whether these factors predict self-reported dizziness handicap 3 months after assessment and diagnosis.

METHODS

Patients were recruited from a waiting list of a tertiary neuro-otology clinic and completed standardized mood, cognitive, behavioral, and dizziness handicap questionnaires before and 3 months after their initial consultation and diagnosis. All patients were clinically assessed and underwent comprehensive audiovestibular investigations.

RESULTS

Seventy-three percent of participants responded at follow-up (n = 135, 73% female, mean [standard deviation] age = 54.23 [17.53] years), of whom 88% were diagnosed with a neurotological condition. There were significant improvements in handicap, depression, and anxiety at 3 months. Thirty (22%) of 135 showed clinically meaningful improvement in handicap. The percentage of case-level depression and anxiety remained the same. Negative illness perceptions and symptom responses reduced, although participants still tended to view their condition negatively. Vestibular tests and type of diagnosis were not associated with self-reported handicap. Most baseline psychological variables significantly correlated with handicap at 3 months. When adjusting for baseline handicap and demographics, the baseline psychological variables only explained a significant ~3% of the variance in dizziness handicap at follow-up, with baseline handicap explaining most of the variance. All-or-nothing behavior was the most significant predictor.

CONCLUSIONS

Tertiary patients with vertigo and dizziness report negative illness perceptions and cognitive and behavioral responses to symptoms that are associated with self-reported handicap over time. Future studies are needed to investigate whether targeting these factors alongside traditional treatment approaches improves handicap in patients with chronic dizziness.

"Asking Too Much?": Randomized N-of-1 Trial Exploring Patient Preferences and Measurement Reactivity to Frequent Use of Remote Multidimensional Pain Assessments in Children and Young People With Juvenile Idiopathic Arthritis

Background

Remote monitoring of pain using multidimensional mobile health (mHealth) assessment tools is increasingly being adopted in research and care. This assessment method is valuable because it is challenging to capture pain histories, particularly in children and young people in diseases where pain patterns can be complex, such as juvenile idiopathic arthritis (JIA). With the growth of mHealth measures and more frequent assessment, it is important to explore patient preferences for the timing and frequency of administration of such tools and consider whether certain administrative patterns can directly impact on children’s pain experiences.

Objective

This study aimed to explore the feasibility and influence (in terms of objective and subjective measurement reactivity) of several time sampling strategies in remote multidimensional pain reporting.

Methods

An N-of-1 trial was conducted in a subset of children and young people with JIA and their parents recruited to a UK cohort study. Children were allocated to 1 of 4 groups. Each group followed a different schedule of completion of MPT for 8 consecutive weeks. Each schedule included 2 blocks, each comprising 4 different randomized time sampling strategies, with each strategy occurring once within each 4-week block. Children completed MPT according to time sampling strategies: once-a-day, twice-a-day, once-a-week, and as-and-when pain was experienced. Adherence to each strategy was calculated. Participants completed the Patient-Reported Outcomes Measurement Information System Pain Interference Scale at the end of each week to explore objective reactivity. Differences in pain interference scores between time sampling strategies were assessed graphically and using Friedman tests. Children and young people and their parents took part in a semistructured interview about their preferences for different time sampling strategies and to explore subjective reactivity.

Results

A total of 14 children and young people (aged 7-16 years) and their parents participated. Adherence to pain reporting was higher in less intense time sampling strategies (once-a-week=63% [15/24]) compared with more intense time sampling strategies (twice-a-day=37.8% [127/336]). There were no statistically significant differences in pain interference scores between sampling strategies. Qualitative findings from interviews suggested that children preferred once-a-day (6/14, 43%) and as-and-when pain reporting (6/14, 43%). Creating routine was one of the most important factors for successful reporting, while still ensuring that comprehensive information about recent pain was captured.

Conclusions

Once-a-day pain reporting provides rich contextual information. Although patients were less adherent to this preferred sampling strategy, once-a-day reporting still provides more frequent assessment opportunities compared with other less intense or overburdensome schedules. Important issues for the design of studies and care incorporating momentary assessment techniques were identified. We demonstrate that patient reporting preferences are key to accommodate and are important where data capture quality is key. Our findings support frequent administration of such tools, using daily reporting methods where possible.

Optimism and the Experience of Pain: A Systematic Review

A growing body of literature provides evidence of the health-promoting effects of optimism, including its protective role in acute and chronic pain. Optimists are characterized by positive expectations concerning the future. These positive outcome expectancies lead to more and longer goal-directed efforts and the use of approach coping strategies. No systematic review on the effects of optimism on the experience of pain has so far been conducted. A search in the databases PubMed, Web of Science and PsycInfo, and the scanning of reference lists identified 69 eligible studies. These were categorized according to sample size, participants' age and sex, design, optimism-pain relation as primary vs. secondary study objective, and level of study/publication quality. Overall percentages of positive, zero, and negative associations between optimism and pain as well as relative frequencies of these associations in the different categories were analyzed. About 70% of the studies showed a positive, i.e., beneficial association between optimism and at least one pain outcome. A larger percentage of beneficial associations was found in studies with experimental designs, in studies with the optimism-pain relation as primary objective, in high-quality studies/publications, and in studies including participants with a higher average age. The review suggests that optimism is associated with less acute and chronic pain, especially since a higher percentage of beneficial associations was found with high study/publication quality and with the primary focus on this relationship. For the moderating role of age, different explanations are proposed. Further research on causal relationships and on optimism-fostering clinical interventions is needed.

Comparison of Pain Perception in Patients Affected by Cleft and Cranio Facial Anomalies Treated With Traditional Fixed Appliances or Invisalign

Introduction:

The objective of this prospective study was to compare the difference in pain perception between treatment with aligners (AL) and fixed appliances (FA) in patients affected by cleft and craniofacial anomalies (CFA).

Methods:

The sample consisted of 100 syndromic caucasian patients affected by various CFA from 2 different hospitals. Fifty patients treated with AL were matched for sex, age, and CFA with a control sample of 50 patients treated with FA. A modification of the Mc Gill Pain Questionnaire was adapted to our needs.

Results:

Statistical differences were found. Aligners induced more tightness and tension than FA, while FA induced more pain descriptors and patients reported a higher intake of painkillers.

Conclusions:

The results of this study documented a higher pain perception with FA than with AL in patients affected by CFA. The higher sensitivity to pain in cleft and craniofacial patients with fixed treatment could be related to their higher prior sensitization, given the past surgeries and orthodontic treatments. Thus, this study might suggest that Invisalign treatment might be a further interesting treatment option for patients with cleft in order to reduce their burden of orthodontic pain.

Psychometric evaluation of the Chinese version of the revised illness perception questionnaire for breast cancer-related lymphedema

The aim of this study was to modify and test the Chinese version of the Revised Illness Perception Questionnaire to measure the illness perception of breast cancer-related lymphedema among breast cancer survivors. Before the investigation, identity and causal subscales were modified and the wording of the remaining scales was also adjusted. The psychometric properties of this instrument was evaluated using the technique of explore and confirmatory factor analysis. Data from 203 breast cancer survivors was entered into factor analysis. Five causal factors were extracted after removing one item, accounting for 68.02% of the variance in total. An acceptable fit with the data for the proposed seven-factor model was obtained after eliminating three items and resetting seven error covariances. The Cronbach's α values and composite reliability coefficients were acceptable. This measurement is reliable and valid for measuring illness perceptions of breast cancer-related lymphedema in Chinese breast cancer survivors. It could be helpful for further studies that examine the effect of illness perceptions on health-related behaviours, such as lymphedema risk-reduction behaviours in the Chinese cultural context.