Sleep Health Assessment and Treatment in Children and Adolescents with Chronic Pain: State of the Art and Future Directions

5HT1AR agonist alleviates presurgical prolonged sleep deprivationinduced postsurgical pain in adolescent mice

OBJECTIVES

Sleep deprivation (SD) is a risk factor for the development of chronic pain in adolescents, significantly affecting pain management and prognosis; however, the mechanisms by which SD influences postoperative pain outcomes remain unclear. This study aims to investigate the molecular mechanism through which the spinal 5-hydroxytryptamine 1A receptor (5-HT1AR) regulates the excitation/inhibition (E/I) balance in the dorsal horn to modulate postoperative chronic pain induced by SD in adolescent mice.

METHODS

A pain model combining 4.5 days of SD and a plantar incision was established in adolescent C57BL/6J mice, which were randomly assigned to 4 groups: control (C), SD, hind toe incision (I), and SD combined with hind toe incision (SI). The effects of a single intrathecal injection of the 5-HT1AR agonist 8-hydroxy-2-dipropylamino-tetralin (8-OH-DPAT) and both single and continuous intrathecal injections of the extracellular signal-regulated kinase (ERK) inhibitor U0126 on SD-induced postoperative chronic in mice (SI+8-OH-DPAT group, SI+U0126 group, and SI+Vehicle group) were observed. Paw withdrawal mechanical threshold (PWMT) was measured on the 1st, 3rd, 5th, 7th, 10th, and 14th day before and after model induction. On the 7th day after surgery, immunofluorescence was used to assess 5-HT1AR expression in the spinal dorsal horn, and Western blotting was employed to measure protein expression levels of 5-HT1AR, postsynaptic density protein-95 (PSD95), N-methyl-D-aspartic acid receptor 1 (NR1), phosphorylated NR1 (p-NR1), vesicular glutamate transporter 1 (VGLUT1), gephyrin, glutamic acid decarboxylase 67 (GAD67), vesicular gamma-aminobutyric acid transporter (VGAT), ERK, p-ERK, calmodulin-dependent protein kinase II (CaMKⅡ), phosphorylated CaMKⅡ (p-CaMKⅡ), cAMP- response element-binding protein (CREB), and phosphorylated CREB (p-CREB) in the dorsal horn.

RESULTS

1) Behavioral pain analysis. Compared with group C, the PWMT in groups I and SD decreased significantly on the 1st, 3rd, 5th and 7th day after surgery (all P<0.05), and returned to baseline on the 10th day. Compared with group I, the PWMT in group SI was significantly lower on the 5th, 7th and 10th day (all P<0.05). The SI+8-OH-DPAT group exhibited higher PWMT values at the 1st, 2nd, and 4th hour postoperatively, as well as on the 3rd, 5th, 7th,10th and 14th day compared to the solvent control group (all P<0.05). Similarly, both single and continuous intrathecal injections of U0126 resulted in higher PWMT values at 1, 2, and 4 hours after surgery postoperatively and on the 3rd, 5th and 7th day compared to the SI+Vehicle group (all P<0.05). 2) Immunofluorescence. On the 7th day after surgery, group SI showed decreased 5-HT1AR expression in the spinal dorsal horn, while a single intrathecal injection of 8-OH-DPAT upregulated 5-HT1AR expression (all P<0.05). 3) Western blotting. On the 7th day after surgery, group SI exhibited decreased 5-HT1AR expression and increased ratios of p-CaMKⅡ/CaMKⅡ, p-CREB/CREB, and p-ERK/ERK (all P<0.05). Compared with group C, group SI showed increased expression of PSD95, VGLUT1, and the p-NR1/NR1 ratio, and decreased expression of 5-HT1AR, gephyrin, and VGAT in the dorsal horn (all P<0.05). Compared with group I, group SI demonstrated upregulated 5-HT1AR and PSD95 expression and downregulated gephyrin, GAD67, and VGAT expression (all P<0.05). In the SI+8-OH-DPAT group, the levels of PSD95, VGLUT1, p-NR1/NR1, p-CaMKⅡ/CaMKⅡ, p-CREB/CREB, and p-ERK/ERK on the 7th day after surgery were lower than those in the SI+Vehicle group, while the expression levels of 5-HT1AR, GAD67, and VGAT were upregulated (all P<0.05). Additionally, 2 hours after a single intrathecal injection of U0126, the SI+U0126 group exhibited significantly lower levels of p-CaMKⅡ/CaMKⅡ, p-CREB/CREB, and p-ERK/ERK compared with the SI+Vehicle group (all P<0.05).

CONCLUSIONS

The 5-HT1AR agonist alleviates postoperative chronic pain induced by SD in adolescent mice by inhibiting the CaMKⅡ-ERK-CREB signaling pathway, thereby correcting the E/I imbalance in the spinal dorsal horn.

Temporal Daily Relationships Between Sleep and Pain in Adolescents With Systemic Lupus Erythematosus

INTRODUCTION

Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder characterized by recurrent episodes of pain. This study aimed to describe the temporal daily relationships between sleep and pain in adolescents with SLE.

METHOD

Twenty-three adolescents with SLE recruited from a pediatric hospital wore actigraphy and completed diaries. Generalized estimating equation models were used.

RESULTS

On average, evening pain negatively predicted subsequent sleep quality that night, and, on average, sleep quality negatively predicted morning pain. Shorter total sleep time significantly predicted higher morning pain (95% confidence intervals [CI], -0.38 to -0.03, p = .02), whereas sleep efficiency and sleep quality were not significantly associated with morning pain (95% CI, -0.03 to 0.03; 95% CI, -0.08 to 0.06, respectively). Subsequent evening pain did not predict daily nighttime sleep DISCUSSION: Our findings suggest that sleep is a target for pain interventions to include among adolescents with SLE.

Association of Neighborhood Characteristics and Chronic Pain in Children and Adolescents in the United States

OBJECTIVE

To determine the associations between neighborhood characteristics and chronic pain during childhood and adolescence in the United States, 2020-2021.

METHODS

Cross-sectional analysis of the 2020 and 2021 National Survey of Children's Health. National Survey of Children's Health grouped parents' responses to questions about neighborhood characteristics into 5 categories: neighborhood support, neighborhood safety, school support, neighborhood amenities, and the presence of detracting neighborhood elements. Chronic pain was defined as parents reporting their children had "frequent or chronic difficulty with repeated or chronic physical pain, including headache or other back or body pain during the past 12 months." Multivariable Poisson regression analyses estimated associations between neighborhood characteristics and chronic pain, adjusted for sociodemographic characteristics.

RESULTS

The sample contained 55,387 children (6 to 17 years), weighted to represent 44 million nationally. Children had significantly increased rates of chronic pain if they lived in neighborhoods that were unsupportive, unsafe, had unsafe schools, fewer amenities, and greater numbers of detracting elements ( P <0.0001). After adjusting for covariates, children had significantly increased chronic pain if they lived in neighborhoods that were not supportive (adjusted prevalence rate ratio=1.7 (95% CI: 1.5-1.9, P <0.0001), with similar patterns observed for living in neighborhoods characterized as not safe, that did not have safe schools, with fewer amenities, and/or more detracting elements.

DISCUSSION

Disadvantageous neighborhood characteristics are associated with pediatric chronic pain prevalence. Future research should investigate the underlying mechanisms of this association and guide neighborhood interventions aimed at preventing and decreasing childhood chronic pain and its associated burdens.

Personalized Multimodal Lifestyle Intervention as the Best-Evidenced Treatment for Chronic Pain: State-of-the-Art Clinical Perspective

Chronic pain is the most prevalent disease worldwide, leading to substantial disability and socioeconomic burden. Therefore, it can be regarded as a public health disease and major challenge to scientists, clinicians and affected individuals. Behavioral lifestyle factors, such as, physical (in)activity, stress, poor sleep and an unhealthy diet are increasingly recognized as perpetuating factors for chronic pain. Yet, current management options for patients with chronic pain often do not address lifestyle factors in a personalized multimodal fashion. This state-of-the-art clinical perspective aims to address this gap by discussing how clinicians can simultaneously incorporate various lifestyle factors into a personalized multimodal lifestyle intervention for individuals with chronic pain. To do so the available evidence on (multimodal) lifestyle interventions targeting physical (in)activity, stress, sleep and nutritional factors, specifically, was reviewed and synthetized from a clinical point of view. First, advise is provided on how to design a personalized multimodal lifestyle approach for a specific patient. Subsequently, best-evidence recommendations on how to integrate physical (in)activity, stress, sleep and nutritional factors as treatment targets into a personalized multimodal lifestyle approach are outlined. Evidence supporting such a personalized multimodal lifestyle approach is growing, but further studies are needed.

Help overcoming pain early, a brief person-centred intervention for adolescents with chronic pain in a school setting, may improve symptoms of insomnia

Introduction and aims

Chronic pain and symptoms of insomnia affect large numbers of adolescents and early interventions are prioritized. The aim of the current study was to evaluate potential secondary effects of the intervention, Help Overcoming Pain Early (HOPE), on symptoms of insomnia and self-rated health.

Methods

The study included non-randomized aggregated data from the active and control conditions in a previously conducted randomized controlled trial evaluating the efficacy of HOPE, after the participants in the control condition also had received the intervention. Symptoms of insomnia were assessed with the Minimal Insomnia Symptom Scale and self-rated health was assessed with one item, at the start of the intervention, post intervention, and at a six-month follow-up. Baseline variables included age, gender, pain localization, pain impact, school absence and symptoms of depression (assessed with the Center for Epidemiological Studies Depression Scale for Children). Inferential analyzes were performed using Linear Mixed Models (LMM). Effect sizes were evaluated by calculating Cohen's d.

Results

There were statistically significant improvements in symptoms of insomnia at the six-month follow-up, and statistically significant improvements in self-rated health at the end of the intervention and at the six-month follow-up. Effect sizes were small across outcomes and assessments.

Discussion and conclusion

Results illustrated significant but small improvements in symptoms of insomnia and self-rated health in adolescents with chronic pain following the HOPE intervention. Although caution is needed when assessing the findings, results illustrate the potential utility of an accessible brief early intervention in a school context.

Risk Factors for the Development of Multisite Pain in Children

OBJECTIVE

Chronic pain has economic costs on par with cardiovascular disease, diabetes, and cancer. Despite this impact on the health care system and increasing awareness of the relationship between pain and mortality, efforts to identify simple symptom-based risk factors for the development of pain, particularly in children, have fallen short. This is critically important as pain that manifests during childhood often persists into adulthood. To date, no longitudinal studies have examined symptoms in pain-free children that presage a new, multisite manifestation of pain in the future. We hypothesized that female sex, sleep problems, and heightened somatic symptoms complaints at baseline would be associated with the risk of developing new multisite pain 1 year later.

METHODS

Symptom assessments were completed by parents of youth (ages 9 to 10) enrolled in the Adolescent Brain Cognitive Development study. Multivariate logistic regression models focused on children who developed multisite pain 1 year later (n=331) and children who remained pain free (n=3335).

RESULTS

Female sex (odds ratio [OR]=1.35; 95% CI, 1.07, 1.71; P =0.01), elevated nonpainful somatic symptoms (OR=1.17; 95% CI, 1.06, 1.29; P <0.01), total sleep problems (OR=1.20; 95% CI, 1.07, 1.34; P <0.01), and attentional issues (OR=1.22; 95% CI, 1.10, 1.35; P <0.001) at baseline were associated with new multisite pain 1 year later. Baseline negative affect was not associated with new multisite pain.

DISCUSSION

Identifying symptom-based risk factors for multisite pain in children is critical for early prevention. Somatic awareness, sleep and attention problems represent actionable targets for early detection, treatment, and possible prevention of multisite pain in youth.

Assessment of postoperative pain in children with computer assisted facial expression analysis

PURPOSE

The present study was conducted to evaluate the use of computer-aided facial expression analysis to assess postoperative pain in children.

DESIGN AND METHODS

This was a methodological observational study. The study population consisted of patients in the age group of 7-18 years who underwent surgery in the pediatric surgery clinic of a university hospital. The study sample consisted of 83 children who agreed to participate and met the sample selection criteria. Data were collected by the researcher using the Wong Baker Faces pain rating scale and Visual Analog Scale. Data were collected from the child, mother, nurse, and one external observer. Facial action units associated with pain were used for machine estimation. OpenFace was used to analyze the child's facial action units and Python was used for machine learning algorithms. The intraclass correlation coefficient was used for statistical analysis of the data.

RESULTS

The pain score predicted by the machine and the pain score assessments of the child, mother, nurse, and observer were compared. The pain assessment closest to the self-reported pain score by the child was in the order of machine prediction, mother, and nurse.

CONCLUSIONS

The machine learning method used in pain assessment in children performed well in estimating pain severity.It can code facial expressions of children's pain and reliably measure pain-related facial action units from video recordings.

APPLICATION TO PRACTICE

The machine learning method for facial expression analysis assessed in this study can potentially be used as a scalable, standard, and valid pain assessment method for nurses in clinical practice.

The Key Role of Lifestyle Factors in Perpetuating Chronic Pain: Towards Precision Pain Medicine

Chronic pain has a massive personal and socioeconomic impact and remains a challenge for many clinicians around the world [...].