Assessment of chronic pain in children: current status and emerging topics

Nurses' knowledge and attitude towards children pain management: a multi-site survey study

Background

Adequate children's pain management is universally considered an ethical obligation. In evaluating and treating children's pain, nurses invest more time and take a leading role. This study aims to evaluate the knowledge and attitudes of nurses towards the treatment of pediatric pain.

Materials and Methods

A total of 292 nurses working at four South Gondar Zone hospitals of Ethiopia was surveyed. To gather information from study participants, the Pediatric Nurses' -Knowledge and Attitudes- Survey Regarding Pain (PNKAS) was employed. Frequency, percentage, mean, and standard deviation of the data were used for descriptive analysis, while Pearson correlation, one-way between-groups analysis of variance, and independent-samples t-test were used for inferential analysis.

Results

A large percentage of nurses (74.7%) lacked adequate knowledge and attitudes (PNKAS score <50%) for pediatric pain treatment. The mean ± SD accurate response score of 43.1% ± 8.6% was achieved by nurses. An increase in pediatrics nursing experience was significantly correlated with nurses' PNKAS score (p < 0.001). The mean PNKAS scores of nurses who had official pain management training differed in a statistically significant way as compared to its counterpart (p < 0.001).

Conclusion

Nurses who are working South Gondar Zone of Ethiopia have insufficient knowledge and attitudes towards treatment of pediatric pain. Therefore, pediatric pain treatment in-service training is urgently needed.

Knowledge and attitude towards pediatric pain management among nurses at Ethiopian tertiary hospitals; a multi-center study

Background

Pain is the most disturbing and annoying symptom experienced by children. However, it obtains poor attention in low- and middle-income countries particularly. The objective of this study was to assess knowledge, attitude and factors associated with pediatric pain management among nurses in tertiary hospitals in Northwest Ethiopia.

Methodology

: A multi-center cross-sectional study was conducted from March 1 to April 30, 2021. The knowledge and attitude of nurses were measured by using Nurses’ Knowledge and Attitudes Survey regarding Pain (P-NKAS). Descriptive and binary logistic regression analyses were performed to determine factors associated with knowledge and attitude. The strength of the association was presented by using adjusted odds ratio with 95% confidence interval and p-value < 0.05 was considered as statistically significant.

Result

A total of 234 (86.03% response rate) nurses were included and 67.1% of nurses had good knowledge and 89.3% had favorable attitudes towards pediatric pain management. The factors associated with good knowledge were having Bachelor’s Degree and above [AOR = 2.1, P = 0.015], having in-service training [AOR = 2.4, P = 0.008] and favorable attitude [AOR = 3.3, CI = 0.008]. The nurses who demonstrated good knowledge [AOR = 3.3, P = 0.003] and those who had Bachelor’s Degree and above [AOR = 2.8, P = 0.03] were found to have favorable attitude.

Conclusion

The nurses who were working in pediatrics care areas had good knowledge and favorable attitude towards pediatrics pain management. However, improvements are needed to eradicate misconceptions; particularly, on pediatrics pain perception, opioid analgesia, multimodal analgesia, and non-pharmacologic pain therapies. Nurses who had higher level of education, in-service training, favorable attitude were found to be knowledgeable. Furthermore, nurses who had higher levels of education and knowledge were found to have favorable attitude.

Les pratiques exemplaires pour l’évaluation et le traitement de la douleur chez les enfants

L’évaluation et le traitement de la douleur sont des aspects essentiels des soins pédiatriques. L’évaluation de la douleur adaptée au développement représente une première étape importante pour en optimiser la prise en charge. L’autoévaluation de la douleur est à prioriser. Si c’est impossible, des outils appropriés d’évaluation du comportement, adaptés au développement, doivent être utilisés. Des directives et stratégies de prise en charge et de prévention de la douleur aiguë, qui combinent des approches physiques, psychologiques et pharmacologiques, doivent être accessibles dans tous les milieux de soins. Le meilleur traitement de la douleur chronique fait appel à une combinaison de modalités thérapeutiques et de counseling, dans l’objectif premier d’obtenir une amélioration fonctionnelle. La planification et la mise en œuvre de stratégies de prise en charge de la douleur chez les enfants doivent toujours être personnalisées et axées sur la famille.

Best practices in pain assessment and management for children

Pain assessment and management are essential components of paediatric care. Developmentally appropriate pain assessment is an important first step in optimizing pain management. Self-reported pain should be prioritized. Alternatively, developmentally appropriate behavioural tools should be used. Acute pain management and prevention guidelines and strategies that combine physical, psychological, and pharmacological approaches should be accessible in all health care settings. Chronic pain is best managed using combined treatment modalities and counselling, with the primary goal of attaining functional improvement. The planning and implementation of pain management strategies for children should always be personalized and family-centred.

Phenotyping Chronic Musculoskeletal Pain in Male and Female Adolescents: Psychosocial Profiles, Somatosensory Profiles and Pain Modulatory Profiles

Purpose

A major limitation in treatment outcomes for chronic pain is the heterogeneity of the population. Therefore, a personalized approach to the assessment and treatment of children and adolescents with chronic pain conditions is needed. The objective of the study was to subgroup pediatric patients with chronic MSK pain that will be phenotypically different from each other based on their psychosocial profile, somatosensory function, and pain modulation.

Patients and Methods

This observational cohort study recruited 302 adolescents (10–18 years) with chronic musculoskeletal pain and 80 age-matched controls. After validated self-report questionnaires on psychosocial factors were completed, quantitative sensory tests (QST) and conditioned pain modulation (CPM) were performed.

Results

Three psychosocial subgroups were identified: adaptive pain (n=125), high pain dysfunctional (n=115), high somatic symptoms (n=62). Based on QST, four somatosensory profiles were observed: normal QST (n=155), thermal hyperalgesia (n=98), mechanical hyperalgesia (n=34) and sensory loss (n=15). Based on CPM and temporal summation of pain (TSP), four distinct groups were formed, dysfunctional central processing group (n=27) had suboptimal CPM and present TSP, dysfunctional inhibition group (n=136) had suboptimal CPM and absent TSP, facilitation group (n=18) had optimal CPM and present TSP, and functional central processing (n=112) had optimal CPM and absent TSP. A significant association between the psychosocial and somatosensory profiles. However, no association was observed between the psychosocial or somatosensory profiles and pain modulatory profiles.

Conclusion

Our results provide evidence that adolescents with chronic musculoskeletal pain are a heterogenous population comprising subgroups that may reflect distinct mechanisms and may benefit from different treatment approaches. The combination of screening self-reported questionnaires, QST, and CPM facilitate subgrouping of adolescents with chronic MSK pain in the clinical context and may ultimately contribute to personalized therapy.

Psychosocial and psychophysical assessment in pediatric patients and young adults with chronic back pain: a cluster analysis

Background

Identifying subgroups with different clinical profiles may inform tailored management and improve outcomes. The objective of this study was to identify psychosocial and psychophysical profiles of children and adolescents with chronic back pain.

Methods

One hundred and ninety‐eight patients with chronic back pain were recruited for the study. Pain assessment was mainly conducted in the form of an interview and with the use of validated pain‐related questionnaires assessing their psychosocial factors and disability. All patients underwent mechanical and thermal quantitative sensory tests assessing detection and pain thresholds, and conditioned pain modulation efficacy.

Results

Hierarchal clustering partitioned our patients into three clusters accounting for 34.73% of the total variation of the data. The adaptive cluster represented 45.5% of the patients and was characterized to display high thermal and pressure pain thresholds. The high somatic symptoms cluster, representing 19.2% of patients, was characterized to use more sensory, affective, evaluative and temporal descriptors of pain, more likely to report their pain as neuropathic of nature, report a more functional disability, report symptoms of anxiety and depression and report poor sleep quality. The pain‐sensitive cluster, representing 35.4% of the cohort, displayed deep tissue sensitivity and thermal hyperalgesia.

Conclusions

This study identified clinical profiles of children and adolescents experiencing chronic back pain based on specific psychophysical and psychosocial characteristics highlighting that chronic pain treatment should address underlying nociceptive and non‐nociceptive mechanisms.

Significance

To our current knowledge, this study is the first to conduct cluster analysis with youth experiencing chronic back pain and displays clinical profiles based on specific physical and psychosocial characteristics. This study highlights that in a clinical context, chronic pain assessment should include multiple elements contributing to pain which can be assessed in a clinical context and addressed when pathoanatomical symptoms are unidentifiable.

The Critical Role of Parents in Pediatric Cancer-Related Pain Management: a Review and Call to Action

PURPOSE OF REVIEW

Even with optimized medical management, pain remains an inevitable part of pediatric cancer care. The most effective interventions for nonpharmacologic pain management within pediatric psychology include parent skills training. This review specifically explored the role of parents in cancer-related pain management with the goal of defining a set of evidence-based skills that could translate to improved pediatric cancer pain management.

RECENT FINDINGS

Pain is now widely understood to be both a sensory and emotional experience. As a result, within pediatric non-cancer pain management there is increasing application of the biopsychosocial model for pain management, inclusive of evidence-based psychological intervention. This review, specifically focusing on the role of parent training in cancer-related pain management, finds few interventions that systematically included parents. There is a need for continued evidence-based innovation and knowledge dissemination in this area of care. This paper highlights a critical gap in translational science within pediatric cancer pain management, namely, that parents who have a child with cancer are not reliably gaining access to well-established, evidence-based psychological skills training that can help to mitigate pain and pain-related stress. Based on the literature, the authors provide recommendations for generating adaptable, evidence-informed interventions that support and empower parents to help their child with pain management through all phases of cancer treatment.

Investigating How Parental Instructions and Protective Responses Mediate the Relationship Between Parental Psychological Flexibility and Pain-Related Behavior in Adolescents With Chronic Pain: A Daily Diary Study

BACKGROUND

Parental behavior can influence how well adolescents cope with chronic pain. Previous research has largely focused on how parents negatively impact adolescent functioning. Yet more recent work suggests that parents - and particularly parental psychological flexibility - can foster better adolescent pain-related functioning. In this study we examined if parental protective responses and instructions to engage in activities in the presence of pain mediate the impact of parental psychological flexibility and acceptance of adolescent pain on adolescents' daily pain-related behavior.

METHOD

Fifty-six adolescents with chronic pain (M age = 14.5 years, 86% girls) and one of their parents (93% mothers) were recruited at initial evaluation at two pediatric pain clinics in the US. Parents completed baseline questionnaires assessing psychologically flexible parenting and acceptance of adolescent pain. Next, parents and adolescents completed a 14-day self-report diary assessing adolescent activity-avoidance and activity-engagement in the presence of pain (adolescent report), and parental protective responses and instructions for their adolescent to engage in activities (parent report).

RESULTS

Psychologically flexible parenting and acceptance of adolescent pain in parents were indirectly related to lower daily adolescent activity-avoidance, via their negative association with daily parental protective responses. Positive associations also emerged between baseline psychologically flexible parenting and overall levels of adolescent activity-engagement via its negative association with overall levels of parental protectiveness across the 14-day period. Psychologically flexible parenting and parental acceptance of adolescent pain were also indirectly related to daily decreases in adolescent activity-avoidance via their association with daily increases in parental activity-engagement instructions. These baseline parental resilience factors were also positively related to overall levels of parental engagement instructions, a route via which an indirect association with both higher overall activity-engagement as well as higher overall activity-avoidance in the adolescent was observed.

CONCLUSION

Our findings suggest an (indirect) adaptive role of parental psychological flexibility on adolescent daily pain-related behavior via its impact on parental protective behavior. If our findings replicate, they would suggest that these parental behaviors could be targeted in pain treatments that include both adolescents and their parents. Future research could further examine the impact of parental instructions on pain-related behavior in adolescents with chronic pain.

The CALI-9: A brief measure for assessing activity limitations in children and adolescents with chronic pain

Pain-related functional limitations represent an important outcome domain to assess in children and adolescents with chronic pain. The aim of this study was to extend the empirical support of the 21-item Child Activity Limitations Interview (CALI-21), a well-validated measure of activity limitations, using a large, multisite sample and to develop a brief form of the measure with more interpretable scoring. A sample of 1616 youth and 1614 parents completed the CALI-21 at an initial appointment in 1 of 3 pain specialty clinics in the Midwest or Northwest United States, or as part of a research study after this initial visit. All youth also reported on usual pain intensity. The CALI-21 data from 1236 youth and parents were used in analyses. Results of the exploratory and confirmatory factor analyses supported a common 2-factor structure (Active and Routine factors) for both child- and parent-report versions. Using item reduction, the 9-item measure (CALI-9) was developed with both child and parent versions showing good internal consistency and high cross-informant reliability. Initial validity was shown by the ability of the CALI-9 to distinguish by level of pain intensity. Findings suggest that the CALI-9 is a promising brief tool for the evaluation of pain-related activity limitations in youth with chronic pain and for proxy report by parents. Advantages of the shortened scale include the revised 0 to 100-point scale, which increases interpretability, and further validation of the subscale scoring to assess specific limitations in Active and Routine physical functioning domains.

The research gap in chronic paediatric pain: A systematic review of randomised controlled trials

BACKGROUND AND OBJECTIVE

Chronic pain is associated with significant functional and social impairment. The objective of this review was to assess the characteristics and quality of randomized controlled trials (RCTs) evaluating pain management interventions in children and adolescents with chronic pain.

METHODS

We performed a systematic search of PubMed, Embase and the Cochrane Library up to July 2017. We included RCTs that involved children and adolescents (3 months-18 years) and evaluated the use of pharmacological or non-pharmacological intervention(s) in the context of pain persisting or re-occurring for more than 3 months. Methodological quality was evaluated using the Cochrane Risk of Bias (ROB) Tool.

RESULTS

A total of 58 RCTs were identified and numbers steadily increased over time. The majority were conducted in single hospital institutions, with no information on study funding. Median sample size was 47.5 participants (Q1,Q3: 32, 70). Forty-five percent of RCTs included both adults and children and the median of the mean ages at inclusion was 12.9 years (Q1,Q3: 11, 15). Testing of non-pharmacological interventions was predominant and only 5 RCTs evaluated analgesics or co-analgesics. Abdominal pain, headache/migraine and musculoskeletal pain were the most common types of chronic pain among participants. Methodological quality was poor with 90% of RCTs presenting a high or unclear ROB.

CONCLUSIONS

Evaluation of analgesics targeting chronic pain relief in children and adolescents through RCTs is marginal. Infants and children with long-lasting painful conditions are insufficiently represented in RCTs. We discuss possible research constraints and challenges as well as methodologies to circumvent them.

SIGNIFICANCE

There is a substantial research gap regarding analgesic interventions for children and adolescents with chronic pain. Most clinical trials in the field focus on the evaluation of non-pharmacological interventions and are of low methodological quality. There is also a specific lack of trials involving infants and children and adolescents with long-lasting diseases.

Development and Testing of an Intelligent Pain Management System (IPMS) on Mobile Phones Through a Randomized Trial Among Chinese Cancer Patients: A New Approach in Cancer Pain Management

Background

Cancer has become increasingly prevalent in China over the past few decades. Among the factors that determine the quality of life of cancer patients, pain has commonly been recognized as a most critical one; it could also lead to the ineffective treatment of the cancer. Driven by the need for better pain management for cancer patients, our research team developed a mobile-based Intelligent Pain Management System (IPMS).

Objective

Our objective was to design, develop, and test the IPMS to facilitate real-time pain recording and timely intervention among cancer patients with pain. The system’s usability, feasibility, compliance, and satisfaction were also assessed.

Methods

A sample of 46 patients with cancer pain symptoms were recruited at the Oncology Center of Xinhua Hospital affiliated to Shanghai Jiao Tong University School of Medicine, Chongming Branch (hereinafter referred to as “the Oncology Center”). In a pretest, participants completed a pain management knowledge questionnaire and were evaluated using the baseline cancer pain assessment and Karnofsky Performance Status (KPS) evaluation. The participants were then randomly assigned into two groups (the trial group and the control group). After a 14-day trial period, another round of cancer pain assessment, KPS evaluation and pain management knowledge assessment were repeated. In the trial group, the data were fully automatically collected by the IPMS. In the control group, the data were collected using conventional methods, such as phone interviews or door-to-door visits by physicians. The participants were also asked to complete a satisfaction questionnaire on the use of the IPMS.

Results

All participants successfully completed the trial. First, the feasibility of IPMS by observing the number of daily pain assessments recorded among patients was assessed. Second, the users’ satisfaction, effectiveness of pain management, and changes in the quality of their lives were evaluated. All the participants gave high satisfaction score after they used IMPS. Both groups reported similar pain scores and KPS scores at the baseline. At the end of the trial, the mean pain score of the trial group was significantly lower than of the control group (P<.001). The ending KPS score of the trial group was significantly higher than of the control group (P<.001). The improvement of pain management knowledge score in the trial group was more pronounced than that in the control group (P<.001).

Conclusions

This study provided preliminary data to support the potentials of using IPMS in cancer pain communication between patients and doctors and to provide real-time supportive intervention on a convenient basis at a low cost. Overall, the IPMS can serve as a reliable and effective approach to control cancer pain and improve quality of life for patients with cancer pain.

Trial Registration

Clinicaltrials.gov NCT02765269; http://clinicaltrials.gov/ct2/show/NCT02765269 (Archived by WebCite at http://www.webcitation.org/6rnwsgDgv)

Pediatric-Collaborative Health Outcomes Information Registry (Peds-CHOIR): a learning health system to guide pediatric pain research and treatment

The pediatric adaptation of the Collaborative Health Outcomes Information Registry (Peds-CHOIR) is a free, open-source, flexible learning health care system (LHS) that meets the call by the Institute of Medicine for the development of national registries to guide research and precision pain medicine. This report is a technical account of the first application of Peds-CHOIR with 3 aims: (1) to describe the design and implementation process of the LHS; (2) to highlight how the clinical system concurrently cultivates a research platform rich in breadth (eg, clinic characteristics) and depth (eg, unique patient- and caregiver-reporting patterns); and (3) to demonstrate the utility of capturing patient-caregiver dyad data in real time, with dynamic outcomes tracking that informs clinical decisions and delivery of treatments. Technical, financial, and systems-based considerations of Peds-CHOIR are discussed. Cross-sectional retrospective data from patients with chronic pain (N = 352; range, 8-17 years; mean, 13.9 years) and their caregivers are reported, including National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS) domains (mobility, pain interference, fatigue, peer relations, anxiety, and depression) and the Pain Catastrophizing Scale. Consistent with the literature, analyses of initial visits revealed impairments across physical, psychological, and social domains. Patients and caregivers evidenced agreement in observable variables (mobility); however, caregivers consistently endorsed greater impairment regarding internal experiences (pain interference, fatigue, peer relations, anxiety, and depression) than patients' self-report. A platform like Peds-CHOIR highlights predictors of chronic pain outcomes on a group level and facilitates individually tailored treatment(s). Challenges of implementation and future directions are discussed.

Pain Measurement in Children with Functional Abdominal Pain

Functional abdominal pain (FAP) occurs frequently in pediatric patients. Lacking clear biomarkers, clinicians and researchers must rely on patient reports of pain intensity. Presently, there are challenges affecting our ability to use existing measures of self-reported pediatric pain intensity. This report discusses those challenges, finding that: (a) inter-rater agreement of children's pain intensity is generally low; (b) typically used approaches to measuring outcomes may yield high levels of unreliable reports of improvement;

Acceptance and commitment therapy in youth with neurofibromatosis type 1 (NF1) and chronic pain and their parents: A pilot study of feasibility and preliminary efficacy

Neurofibromatosis type 1 (NF1) is an autosomal dominant genetic disorder affecting about 1 in 3,500 individuals. Chronic pain is commonly reported among individuals with NF1 and plexiform neurofibroma tumors (PNs). Acceptance and Commitment Therapy (ACT), an empirically supported method for addressing chronic pain, helps individuals re-focus on valued relationships and activities. This pilot study investigated the feasibility and preliminary efficacy of a brief ACT workshop in the NF1 population. Eligible participants included adolescents and young adults (AYA; 12-21 years) with NF1 and chronic pain that interfered with daily functioning and their parents. Patients and parents completed baseline measures of pain interference, pain intensity, functional disability, pain acceptance, depression, and anxiety. Then, AYA and parents participated separately in a 2-day small-group ACT workshop. A telephone booster session occurred 1 month post-intervention. Three-month post-treatment measures were completed by mail. Ten adolescents (4 males; M age = 16.9 years) and seven parents provided baseline and 3-month data. Mean satisfaction with the study was moderate to high (3.9 for patients and 4.6 for parents on a 1-5 scales). Patients and parents reported significant declines in patients' pain interference at 3 months post-treatment. Patient-reported pain intensity significantly declined from baseline to 3 months. Parents reported marginally greater acceptance of their child's pain. No changes emerged in functional ability or mood. Preliminary findings suggest that a brief ACT group intervention is feasible and may help AYA with NF1 and PNs cope with their chronic pain, although larger randomized studies are needed to confirm treatment efficacy. © 2016 Wiley Periodicals, Inc.

Physical activity in adolescents with psychiatric disorders and in the general population

BACKGROUND

Adults who suffer from psychiatric disorders report low levels of physical activity and the activity levels differ between disorders. Less is known regarding physical activity across psychiatric disorders in adolescence. We investigate the frequency and type of physical activity in adolescent psychiatric patients, compared with adolescents in the general population.

METHODS

A total of 566 adolescent psychiatric patients aged 13-18 years who participated in the CAP survey, Norway, were compared to 8173 adolescents aged 13-19 years who participated in the Nord-Trøndelag Health Study, Young-HUNT 3, Norway. All adolescents completed a questionnaire, including questions about physical activity and participation in team and individual sports.

RESULTS

Approximately 50% of adolescents with psychiatric disorders and 25% of the population sample reported low levels of physical activity. Within the clinical sample, those with mood disorders (62%) and autism spectrum disorders (56%) were the most inactive and those with eating disorders (36%) the most active. This pattern was the same in individual and team sports. After multivariable adjustment, adolescents with a psychiatric disorder had a three-fold increased risk of lower levels of physical activity, and a corresponding risk of not participating in team and individual sports compared with adolescents in the general population.

CONCLUSIONS

Levels of physical activity were low in adolescent psychiatric patients compared with the general population, yet activity levels differed considerably between various disorders. The findings underscore the importance of assessing physical activity in adolescents with psychiatric disorders and providing early intervention to promote mental as well as physical health in this early stage of life.

Chronic pain and pain-related disability across psychiatric disorders in a clinical adolescent sample

BACKGROUND

People who suffer from psychiatric disorders are burdened with a high prevalence of chronic illnesses and pain, but evidence on pain prevalence among adolescents with psychiatric disorders is scarce. The aim of this study was to investigate the frequency and location of self-reported chronic pain and pain-related disability in adolescent psychiatric patients.

METHODS

This study was part of the larger Health Survey administered at the Department of Child and Adolescent Psychiatry (CAP) at St. Olav's University Hospital, in Trondheim, Norway. All patients aged 13-18 years who visited the CAP clinic at least once between February 15, 2009 and February 15, 2011 were invited to participate. A total of 717 (43.5% of eligible/invited patients) participated; of these, 566 were diagnosed with one or more psychiatric disorders. The adolescents completed a questionnaire, which included questions about pain and pain-related disability. Clinical diagnoses were classified by a clinician according to International Statistical Classification of Diseases and Related Health Problems, 10th revision criteria.

RESULTS

In adolescents with psychiatric disorders, 70.4% reported chronic pain, and 37.3% experienced chronic pain in three or more locations (multisite pain). Chronic musculoskeletal pain was the most prevalent type of pain (57.7%). Pain-related disability was found in 22.2% of the sample. The frequency of chronic pain and multisite pain increased with age, and girls reported a higher frequency of chronic pain, multisite pain and pain-related disability than boys did. There was an increased risk of chronic pain among adolescents with mood or anxiety disorders versus those with hyperkinetic disorders, yet this was not present after adjusting for sex. Comorbidity between hyperkinetic and mood or anxiety disorders involved an increased risk of pain-related disability.

CONCLUSIONS

In this study, seven out of 10 adolescents with psychiatric disorders reported chronic pain. These findings indicate the importance of early detection of chronic pain in adolescents with psychiatric disorders, to provide targeted treatment and reduce poor long-term outcomes.

Development and testing of a multidimensional iPhone pain assessment application for adolescents with cancer

Background

Pain is one of the most common and distressing symptoms reported by adolescents with cancer. Despite advancements in pain assessment and management research, pain due to cancer and/or its treatments continues to be poorly managed. Our research group has developed a native iPhone application (app) called Pain Squad to tackle the problem of poorly managed pain in the adolescent with cancer group. The app functions as an electronic pain diary and is unique in its ability to collect data on pain intensity, duration, location, and the impact pain has on an adolescent’s life (ie, relationships, school work, sleep, mood). It also evaluates medications and other physical and psychological pain management strategies used. Users are prompted twice daily at configurable times to complete 20 questions characterizing their pain and the app transmits results to a database for aggregate reporting through a Web interface. Each diary entry represents a pain case filed by an adolescent with cancer and a reward system (ie, moving up through law-enforcement team ranks, built-in videotaped acknowledgements from fictitious officers) encourages consistent use of the diary.

Objective

Our objective was to design, develop, and test the usability, feasibility, compliance, and satisfaction of a game-based smartphone pain assessment tool for adolescents with cancer.

Methods

We used both low- and high-fidelity qualitative usability testing with qualitative semi-structured, audio-taped interviews and iterative cycles to design and refine the iPhone based Pain Squad app. Qualitative thematic analysis of interviews using constant comparative methodology captured emergent themes related to app usability. Content validity was assessed using question importance-rating surveys completed by participants. Compliance and satisfaction data were collected following a 2-week feasibility trial where users were alarmed to record their pain twice daily on the app.

Results

Thematic analysis of usability interviews showed the app to be appealing overall to adolescents. Analyses of both low- and high-fidelity testing resulted in minor revisions to the app to refine the theme and improve its usability. Adolescents resoundingly endorsed the game-based nature of the app and its virtual reward system. The importance of app pain diary questions was established by content validity analysis. Compliance with the app, assessed during feasibility testing, was high (mean 81%, SD 22%) and adolescents from this phase of the study found the app likeable, easy to use, and not bothersome to complete.

Conclusions

A multifaceted usability approach demonstrated how the Pain Squad app could be made more appealing to children and adolescents with cancer. The game-based nature and built-in reward system of the app was appealing to adolescents and may have resulted in the high compliance rates and satisfaction ratings observed during clinical feasibility testing.

The ripple effect: systems-level interventions to ameliorate pediatric pain

The focus of this brief review is to highlight to the reader some of the 'ripple effects' of broader systems-level healthcare issues and the implications they may have for effective treatment of pediatric chronic pain. Many healthcare providers focus almost exclusively on the patient, but lack the knowledge of how to intervene effectively at systems levels with families, schools and healthcare institutions surrounding the pediatric patient with pain. We provide a case example and consider this issue across three systems that are particularly relevant to pediatric pain management: the outpatient pain clinic, school and inpatient settings. The information presented will improve the healthcare provider's ability to effectively treat pediatric pain through an enhanced understanding of the multiple systems of care that surround children with pain.

Clinical utility and validity of the Functional Disability Inventory among a multicenter sample of youth with chronic pain

The Functional Disability Inventory (FDI) is a well-established and commonly used measure of physical functioning and disability in youth with chronic pain. Further validation of the measure has been called for, in particular, examination of the clinical utility and factor structure of the measure. To address this need, we utilized a large multicenter dataset of pediatric patients with chronic pain who had completed the FDI and other measures assessing pain and emotional functioning. Clinical reference points to allow for interpretation of raw scores were developed to enhance clinical utility of the measure, and exploratory factor analysis was performed to examine its factor structure. Participants included 1300 youth ages 8 to 18 years (mean=14.2 years; 76% female) with chronic pain. Examination of the distribution of FDI scores and validation with measures of depressive symptoms and pain intensity yielded 3 distinct categories of disability: No/Minimal Disability, Moderate Disability, and Severe Disability. Factor analysis of FDI scores revealed a 2-factor solution representing vigorous Physical Activities and non-physically strenuous Daily Activities. The 3-level classification system and factor structure were further explored via comparison across the 4 most commonly encountered pain conditions in clinical settings (head, back, abdominal, and widespread pain). Our findings provide important new information regarding the clinical utility and validity of the FDI. This will greatly enhance the interpretability of scores for research and clinical use in a wide range of pediatric pain conditions. In particular, these findings will facilitate use of the FDI as an outcome measure in future clinical trials.

PROMIS Pediatric Pain Interference Scale: an item response theory analysis of the pediatric pain item bank

An aim of the National Institutes of Health (NIH) Patient Reported Outcomes Measurement Information System (PROMIS) initiative is to develop item banks and computerized adaptive tests (CAT) that are applicable across a wide variety of chronic disorders. The PROMIS Pediatric Cooperative Group has concentrated on the development of pediatric self-report item banks for ages 8 through 17 years. The objective of the present study is to describe the Item Response Theory (IRT) analysis of the NIH PROMIS pediatric pain item bank and the measurement properties of the new unidimensional PROMIS Pediatric Pain Interference Scale. Test forms containing pediatric pain items were completed by a total of 3048 respondents. IRT analyses regarding scale dimensionality, item local dependence, and differential item functioning were conducted. A pain item pool was developed to yield scores on a T-score scale with a mean of 50 and standard deviation of 10. The recommended 8-item unidimensional short form for the PROMIS Pediatric Pain Interference Scale contains the item set which provides the maximum test information at the mean (50) on the T-score metric. A simulated CAT was computed that provides the most information at 5 possible score locations (30, 40, 50, 60, and 70 on the T-score metric).

PERSPECTIVE

The present study provides initial calibrations of the NIH PROMIS pediatric pain item bank and the creation of the PROMIS Pediatric Pain Interference Scale. It is anticipated that this new scale will have application in pediatric chronic and recurrent pain.

Development and preliminary validation of the Child Pain Anxiety Symptoms Scale in a community sample

OBJECTIVE

To develop, and provide initial validation of, a 20-item Child Pain Anxiety Symptoms Scale (CPASS), a modified version of the adult 20-item Pain Anxiety Symptoms Scale.

METHODS

A community sample of children and adolescents (N = 959) aged 8-18 years completed the CPASS and measures of pain catastrophizing, anxiety sensitivity, and general anxiety. Factor structure was assessed using exploratory and confirmatory factor analyses (EFA and CFA).

RESULTS

EFA yielded a one- and a three-factor solution using 17 items of the CPASS. CFA supported a hierarchical model for both a 20-item four-factor solution (based on the adult literature) and a 20-item slightly modified four-factor solution. The CPASS showed excellent internal consistency (Cronbach's alpha = .903) and good construct, discriminant, and concurrent validity.

CONCLUSIONS

This study provides support for the relevance of pain anxiety in a community sample of children and adolescents and offers preliminary validity and reliability for the CPASS.

Randomized controlled trials of psychological therapies for management of chronic pain in children and adolescents: an updated meta-analytic review

The purpose of this meta-analytic review was to quantify the effects of psychological therapies for the management of chronic pain in youth. Specifically, in this review we updated previous systematic reviews of randomized controlled trials by including new trials, and by adding disability and emotional functioning to pain as treatment outcomes. Electronic searches of the Cochrane Register of Randomised Controlled Trials, MEDLINE, PsycLIT, EMBASE, and the Social Sciences Citation Index were conducted from inception through August 2008. Methodological quality of the studies was assessed, and data extracted on the three primary outcomes of interest. Twenty-five trials including 1247 young people met inclusion criteria and were included in the meta-analysis. Meta-analytic findings demonstrated a large positive effect of psychological intervention on pain reduction at immediate post-treatment and follow-up in youth with headache, abdominal pain, and fibromyalgia. Small and non-significant effects were found for improvements in disability and emotional functioning, although there were limited data on these outcomes available in the included studies. Omnibus cognitive-behavioral therapy, relaxation therapy, and biofeedback all produced significant and positive effects on pain reduction. Studies directly comparing the effects of self-administered versus therapist-administered interventions found similar effects on pain reduction. Psychological therapies result in improvement in pain relief across several different pain conditions in children. Future trials are needed that incorporate non-pain outcome domains, that focus significant therapeutic content on reductions in disability, and that include extended follow-up to better understand maintenance of treatment effects.

Randomized controlled trial of an Internet-delivered family cognitive-behavioral therapy intervention for children and adolescents with chronic pain

Cognitive-behavioral therapy (CBT) interventions show promise for decreasing chronic pain in youth. However, the availability of CBT is limited by many factors including distance to major treatment centers and expense. This study evaluates a more accessible treatment approach for chronic pediatric pain using an Internet-delivered family CBT intervention. Participants included 48 children, aged 11-17 years, with chronic headache, abdominal, or musculoskeletal pain and associated functional disability, and their parents. Children were randomly assigned to a wait-list control group or an Internet treatment group. Primary treatment outcomes were pain intensity ratings (0-10 NRS) and activity limitations on the Child Activity Limitations Interview, both completed via an online daily diary. In addition to their medical care, the Internet treatment group completed 8 weeks of online modules including relaxation training, cognitive strategies, parent operant techniques, communication strategies, and sleep and activity interventions. Youth randomized to the wait-list control group continued with the current medical care only. Findings demonstrated significantly greater reduction in activity limitations and pain intensity at post-treatment for the Internet treatment group and these effects were maintained at the three-month follow-up. Rate of clinically significant improvement in pain was also greater for the Internet treatment group than for the wait-list control group. There were no significant group differences in parental protectiveness or child depressive symptoms post-treatment. Internet treatment was rated as acceptable by all children and parents. Findings support the efficacy and acceptability of Internet delivery of family CBT for reducing pain and improving function among children and adolescents with chronic pain.