Intensive Interdisciplinary Pain Treatment Research Articles

Using collaborative logic analysis evaluation to test the program theory of an intensive interdisciplinary pain treatment for youth with pain‐related disability

Intensive interdisciplinary pain treatment (IIPT) involves multiple stakeholders. Mapping the program components to its anticipated outcomes (ie, its theory) can be difficult and requires stakeholder engagement. Evidence is lacking, however, on how best to engage them. Logic analysis, a theory‐based evaluation, that tests the coherence of a program theory using scientific evidence and experiential knowledge may hold some promise. Its use is rare in pediatric pain interventions, and few methodological details are available. This article provides a description of a collaborative logic analysis methodology used to test the theoretical plausibility of an IIPT designed for youth with pain‐related disability. A 3‐step direct logic analysis process was used. A 13‐member expert panel, composed of clinicians, teachers, managers, youth with pain‐related disability, and their parents, were engaged in each step. First, a logic model was constructed through document analysis, expert panel surveys, and focus‐group discussions. Then, a scoping review, focused on pediatric self‐management, building self‐efficacy, and fostering participation, helped create a conceptual framework. An examination of the logic model against the conceptual framework by the expert panel followed, and recommendations were formulated. Overall, the collaborative logic analysis process helped raiseawareness of clinicians’ assumptions about the program causal mechanisms, identified program components most valued by youth and their parents, recognized the program features supported by scientific and experiential knowledge, detected gaps, and highlighted emerging trends. In addition to providing a consumer‐focused program evaluation option, collaborative logic analysis methodology holds promise as a strategy to engage stakeholders and to translate pediatric pain rehabilitation evaluation research knowledge to key stakeholders.

Complementary Parent Components for Pediatric Pain Families: Innovations in Treatment.

For families with a child with chronic pain, the home environment is the context in which adaptive or maladaptive illness behaviors are developed. Supporting families to effectively cope with their child’s chronic pain is a critical need. This work analyzes intervention approaches from emerging treatment programs to support families coping with pediatric pain that diverge from traditional treatment models by specifically targeting parents. Two novel parent intervention programs are presented that consider caregiver needs in both outpatient and inpatient pain treatment settings: Parents as Coping Coaches and Putting Parents FIRST. These programs are evaluated through comparing parental training components across different stages of treatment. Additionally, the efficacy of Putting Parents FIRST in promoting maintenance of children’s functional gains achieved in intensive interdisciplinary pain treatment is presented, and compared to previous results of the efficacy of Putting Parents FIRST. Specifically, outcomes of 36 children whose parents received the intervention in Putting Parents FIRST were compared to a matched control sample of children whose parents did not receive the parent intervention. Similar to the findings from Parents as Coping Coaches, results indicated that patients whose parents received the intervention maintained/improved program gains in disability, coping, and pain significantly more than patients whose parents did not receive the intervention. Implications for parent-focused intervention development efforts targeting parent and youth functioning in the context of pediatric chronic pain are considered.

The Impact of Spatial Distribution of Pain on Long-Term Trajectories for Chronic Pain Outcomes After Intensive Interdisciplinary Pain Treatment.

Evidence for the effectiveness of intensive interdisciplinary pain treatment (IIPT) for pediatric chronic pain is growing; however, little research has considered factors that contribute to differences in patients' treatment response. The present study utilized multilevel modeling to examine trajectory of change over time in functional disability from clinic assessment to 6-month follow-up in pediatric patients participating in IIPT, considering spatial distribution of pain, coping efficacy, and pain intensity. Participants included 110 pediatric patients (Mage=14.65, SD=2.37; localized pain, 27.3%; widespread pain, 72.7%) consecutively admitted into IIPT. Patients completed self-report measures of functional disability, pain intensity, and coping efficacy at pretreatment assessment, admission, weekly during IIPT, discharge, and several follow-ups. Analysis identified a model with 3 three-way interactions, including time, time squared, pain intensity, coping efficacy, and pain distribution, on functional disability. The spatial distribution of pain had the greatest impact on treatment trajectory in patients with widespread pain, high pain intensity, and poor coping efficacy; these patients demonstrated greater functional disability compared with patients with localized pain. In addition, patients with widespread pain and poor coping efficacy had the most functional disability across all levels of pain intensity. Patients with localized pain and poor coping efficacy demonstrated initial treatment gains, but evidenced an increase in functional disability at follow-up. Overall, spatial distribution of pain, coping efficacy, and pain intensity played an important role in patients' response to treatment. Better understanding of these variables could improve treatment response, particularly for the most severely disabled chronic pain patients.

(315) Pain and Somatic Symptoms at 2-5 Year Follow-Up after Intensive Interdisciplinary Pain Treatment

There is a paucity of literature regarding long-term follow up of pediatric patients who have participated in intensive interdisciplinary pain treatment (IIPT) programs. Evidence suggests that pain and somatic symptoms in childhood often lead to increased pain and somatic in adulthood, but data is lacking in this population. To better understand the long-term outcomes of individuals who completed IIPT as youth, we surveyed 139 participants who had completed IIPT at least two years prior to the survey. We received 58 responses (42% response rate), all 2-5 years after program completion. Participants (age 18.9±2.0, 86% female) completed measures of pain and health status (including the Widespread Pain Index), medical utilization, and emotional functioning. They were also asked to characterize if their pain was “better” than before IIPT, if they considered it “resolved,” and if they had any new pain or other medical diagnoses. Contrary to results of adolescents who have not received intensive treatment, half (50%) of the current sample did not have fibromyalgia symptoms at follow up, and only 31% met criteria for fibromyalgia.1 Most (79%) rated their pain as better, and 45% described their pain as resolved, though 22% indicated new areas of pain and 9% reported a new pain-related diagnosis. Consistent with other studies of this population, these participants continued to have higher than typical medical utilization and reported elevated anxiety and depressive symptoms. Overall, the results show that while pain often improves into adulthood for patients who completed IIPT, other somatic symptoms, anxiety, and depression often persist or increase in this population. These results suggest the need for further study, particularly in light of the increased medical utilization, as ongoing medical focus and intervention could be a causal factor in maintaining or increasing disability into adulthood. (1. Kashikar-Zuck et al., Pediatrics, 2014) There is a paucity of literature regarding long-term follow up of pediatric patients who have participated in intensive interdisciplinary pain treatment (IIPT) programs. Evidence suggests that pain and somatic symptoms in childhood often lead to increased pain and somatic in adulthood, but data is lacking in this population. To better understand the long-term outcomes of individuals who completed IIPT as youth, we surveyed 139 participants who had completed IIPT at least two years prior to the survey. We received 58 responses (42% response rate), all 2-5 years after program completion. Participants (age 18.9±2.0, 86% female) completed measures of pain and health status (including the Widespread Pain Index), medical utilization, and emotional functioning. They were also asked to characterize if their pain was “better” than before IIPT, if they considered it “resolved,” and if they had any new pain or other medical diagnoses. Contrary to results of adolescents who have not received intensive treatment, half (50%) of the current sample did not have fibromyalgia symptoms at follow up, and only 31% met criteria for fibromyalgia.1 Most (79%) rated their pain as better, and 45% described their pain as resolved, though 22% indicated new areas of pain and 9% reported a new pain-related diagnosis. Consistent with other studies of this population, these participants continued to have higher than typical medical utilization and reported elevated anxiety and depressive symptoms. Overall, the results show that while pain often improves into adulthood for patients who completed IIPT, other somatic symptoms, anxiety, and depression often persist or increase in this population. These results suggest the need for further study, particularly in light of the increased medical utilization, as ongoing medical focus and intervention could be a causal factor in maintaining or increasing disability into adulthood. (1. Kashikar-Zuck et al., Pediatrics, 2014)

(129) Sleep Changes in Adolescents with Chronic Pain Enrolled in Intensive Interdisciplinary Pain Treatment

Research demonstrates bi-directional associations between sleep difficulty and chronic pain, as well as relationships between sleep, daily function, and mental health. Adolescents with chronic pain frequently report difficulty falling and staying asleep, associated daytime fatigue, and decreased energy levels. However, few studies track both objective and subjective sleep changes in adolescents with chronic pain, and how these changes impact measures of daily functioning and mental health. This prospective longitudinal study followed 62 adolescents (53 female, age 13-17) through an intensive interdisciplinary pain treatment (IIPT) program consisting of daily intensive exercise, creative and relaxation-based coping, and psychological intervention. Prior to entering the program, all sleep medications besides melatonin were discontinued. Participants were assessed prior to the program, weekly throughout the program, and approximately one month after completion using actigraphy and self-report measures of sleep, fatigue, anxiety, depression, daily functioning, and pain. Paired samples t-tests were performed and accompanied by hierarchical linear modeling for longitudinal analyses. At baseline, patients were dissatisfied with their sleep (mean score 1.13, range 0-4) and reported difficulty falling asleep (mean 2.69, range 0-4), low energy (46/100) and high fatigue (T-score=63). Objective measures suggested adequate sleep efficiency (92%), but a 58-minute latency to persistent sleep. Statistically-significant improvements were observed at program end for sleep satisfaction, as well as difficulty falling asleep, energy level, and daytime fatigue, with continued improvement at the 2-week follow up (all P's

Chronic Pediatric Pain Management: a Review of Multidisciplinary Care and Emerging Topics

Chronic pain is a prevalent, disabling, and expensive pediatric condition. Specific treatment options have limited evidence and are often extrapolated from adult care. This review evaluates pain outcome measures, psychological treatment, pharmacologic management, multidisciplinary treatment models, and emerging topics in pediatric pain medicine. Multimodal cognitive behavioral therapy and intensive interdisciplinary pain treatment have the strongest evidence for improving pain and function while decreasing healthcare utilization. There is emerging evidence that parental involvement in care is an important factor in pediatric outcomes. While there is increased interest in emerging topics such as use of marijuana-derived products, acupuncture, and virtual reality, the evidence behind such interventions remains limited. Pediatric chronic pain treatment centers on the biopsychosocial model of pain and multidisciplinary treatment. Recent research shows that intensive interdisciplinary pain treatment can improve pain, function, and healthcare utilization. Long-term benefits and risks of emerging treatments in pediatric chronic pain remain poorly understood.

Back to Living: Long-term Functional Status of Pediatric Patients Who Completed Intensive Interdisciplinary Pain Treatment.

To provide a descriptive account of long-term functioning (≥5 y posttreatment) among youth who completed intensive interdisciplinary pain treatment (IIPT) for pediatric chronic pain conditions. A total of 95 patients (mean age at follow-up=20.0 y) treated at least 5 years previously at a single IIPT program completed questionnaires assessing pain, functional disability, health care utilization, academic/career achievement, and quality of life. Data analyses focused on pain, functioning, and progress toward developmental goals at long-term follow-up. The majority of respondents report significant reduction in pain compared with preadmission (P<0.001). Five years posttreatment, average functional disability scores were in the minimal range, with statistically significant decrease in functional disability from time of admission (P<0.001). Nearly 80% of respondents characterized themselves as having no functional difficulties at follow-up. Clinically significant improvement was established for both pain and function. Respondents generally reported developmentally appropriate status, with 89% graduating high school on schedule. Results show long-term positive functioning among individuals who underwent intensive rehabilitation treatment for chronic pain as children or adolescents. Despite experiencing one or more pain flares at some point after treatment, most former IIPT patients report minimal to no ongoing functional disability, complete or partial resolution of pain symptoms, and developmentally appropriate progress toward goals (eg, school completion, independent living).

Satisfaction With an Intensive Interdisciplinary Pain Treatment for Children and Adolescents: An Independent Outcome Measure?

Although treatment satisfaction is recommended in the Pediatric Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (PedIMMPACT) as a core outcome measure in pediatric chronic pain clinical trials, no results regarding this outcome measure have been reported to date for intensive interdisciplinary pain treatment in children and adolescents. The aim of the present study was to close this gap and investigate the treatment satisfaction of pediatric patients with different chronic pain disorders who received intensive interdisciplinary pain treatment and who were followed up over 4 years. Treatment satisfaction and treatment outcome were assessed immediately after and 6, 12, and 48 months after intensive interdisciplinary pain treatment for N=104 patients (Mage=13.5; SD=2.2). Patients and their parents were highly satisfied with the treatment and strongly agreed in their ratings. Emotional distress before treatment and younger age increased the risk of being dissatisfied. Analyses revealed that treatment satisfaction was independent of treatment outcome. Taken together, the results show that treatment satisfaction is not associated with treatment outcome. A global judgment of satisfaction seems to be an independent outcome measure but may be inappropriate for measuring the multifaceted construct of satisfaction. Instead, separate satisfaction ratings in specific areas, for example, treatment methods or outcome, may be more suitable.

Efficacy of adding interoceptive exposure to intensive interdisciplinary treatment for adolescents with chronic pain: a randomized controlled trial

Fear of pain plays an important role in the maintenance of chronic pain. It may be reduced through exposure therapy. This 2-arm parallel samples randomized controlled trial aimed to investigate whether interoceptive exposure (IE) therapy enhances reductions in fear of pain (primary outcome), pain (pain intensity, pain-related disability, and school absence), and emotional characteristics (anxiety and catastrophizing) when implemented as an adjunctive treatment in the context of intensive interdisciplinary pain treatment for pediatric chronic pain patients. N = 126 adolescents, aged 11 to 17 years, who were receiving standard intensive interdisciplinary pain treatment were randomly assigned to either receive additional IE (n = 64) or additional relaxation therapy (RT) (n = 62). All patients were assessed at admission, discharge, and 3 months after discharge. The data of N = 104 patients were analyzed. Significant large reductions were found in the total score and subscale scores of the Fear of Pain Questionnaire for Children in both study groups (eg, total score [range 0-60; IE/RT]: admission M = 23.5/24.9; discharge M = 16.0/19.7; P < 0.001, (Equation is included in full-text article.)= 0.27) and mainly large reductions in pain characteristics. There were no greater decreases in the IE group (P > 0.1). The exploratory analyses revealed that the patients with high fear of pain before treatment (P < 0.05, (Equation is included in full-text article.)> 0.03) and the patients with abdominal pain (P < 0.04, (Equation is included in full-text article.)> 0.25) showed greater decreases in their fear of pain (total and subscale score) in the IE group than in the RT group. In conclusion, the results suggest that IE is not particularly effective for all the pediatric chronic pain patients, but the patients with high fear of pain before treatment and with abdominal pain strongly benefit from this intervention.

Neuropsychological Functioning of Youth Receiving Intensive Interdisciplinary Pain Treatment.

Chronic pain is associated with school difficulties; however, there is limited published evidence on the cognitive or neuropsychological functioning of youth with chronic pain. When beginning intensive interdisciplinary pain treatment, 94 youth (age = 10-18) with chronic pain completed neuropsychological assessment (e.g., intelligence, academic skills, learning and recall, and attention) and clinical questionnaires (e.g., pain and physical and psychological functioning). We compared neuropsychological scores with test norms and with clinical questionnaires. Youth with chronic pain had higher verbal comprehension and full scale IQ scores than expected, below-average nondominant hand dexterity, and difficulty with visual recall. Self-reported difficulties with executive functioning were associated with small-to-moderate difficulties with objectively measured attention. Performance on neuropsychological measures was generally not associated with pain, impairment, anxiety, or depression, though catastrophizing was negatively correlated with perceptual reasoning. An expected number of these youth had learning disorders (14%); however, more than expected had an autism spectrum disorder (9%) or attention deficit hyperactivity disorder (18%), and nearly a quarter demonstrated characteristics of nonverbal learning disability (22%). Some of these cognitive findings may be a consequence of chronic pain, and others may reflect subtle neurodevelopmental differences that may predate or be comorbid with pain. Regardless of etiology, with more than half the current sample experiencing some type of learning challenge, often undiagnosed, pediatric psychologists evaluating youth with chronic pain may wish to screen for comorbid learning difficulties.

Parent Responses to Child Pain During Intensive Interdisciplinary Pain Treatment and 1-Year Follow-Up

Targeting parents’ responses to their child's pain during intensive interdisciplinary pain treatment (IIPT) could influence child functioning. This longitudinal, observational study investigated changes in these responses and concurrent relationships between parent responses and changes in levels of child functioning and pain. Parents of youths 10 to 19 years of age (mean = 15 years, SD = 1.98 years) participated in twice weekly, parent-only groups while their teens were enrolled in IIPT (mean length of treatment = 3.93 weeks, SD = 1.16 weeks). Parent responses to child symptoms, as well as child pain and functional disability, were assessed weekly during treatment (n = 114) and at 3 follow-up visits: 1 month (n = 96), 6 months (n = 68), and 12 months (n = 45). Longitudinal multilevel modeling analyses indicated statistically significant decreases during treatment in parents’ protective, monitoring, and minimizing responses and further improvement in all responses during follow-up. These changes were associated with concurrent changes in child disability. However, changes in parent behaviors occurred independently from changes in child pain levels. Baseline child characteristics affected neither baseline parent responses to pain nor changes over time. Results indicate that, in the context of IIPT, parental responses are amenable to change and that these changes may impact child pain-related functioning, providing further support for the role of parent-specific programming within IIPT. PerspectiveDuring intensive IIPT, parents made statistically significant changes in responses to their child's pain, which was associated with improvements in child disability, but not child pain. Changes were sustained through 1-year follow-up. Targeting parental responses to child pain is feasible and may relate to improved child functioning.

Evaluation of an Intensive Interdisciplinary Pain Treatment Based on Acceptance and Commitment Therapy for Adolescents With Chronic Pain and Their Parents: A Nonrandomized Clinical Trial.

Parental factors are central in the development and maintenance of chronic pain in youths. Only a handful of studies have investigated the impact of psychological treatments for pediatric chronic pain on parental factors, and the relationships between changes in parental and adolescent factors. In the current study, we evaluated the effects of an intensive interdisciplinary pain treatment (IIPT) program based on Acceptance and Commitment Therapy (ACT) for adolescents with chronic pain, on adolescent and parental variables, and the relationship between parental psychological flexibility and adolescent pain acceptance. Adolescents (N = 164) with chronic pain were included, with a mean age of 15.5 years, and completed the 3-week treatment with an accompanying parent (N = 164). Linear mixed-effects models were used to analyze change over time (from pretreatment to 3-month follow-up) on parent (depression, health-related quality of life and parent psychological flexibility) and adolescent (physical, social and emotional functioning, and adolescent pain acceptance) variables. Additionally, linear mixed-effects models were used to analyze the relationship between parent psychological flexibility and adolescent pain acceptance. Results illustrated significant improvements over time in depressive symptoms and levels of psychological flexibility in parents. Excluding social development, adolescents improved significantly in all assessed aspects of functioning and pain acceptance. Additionally, changes in parent psychological flexibility were significantly associated with changes in adolescent pain acceptance. Results indicated that treatment had positive effects for parents and adolescents, and a significant positive relationship between changes in parent psychological flexibility and adolescent pain acceptance was found.

Health Care Utilization and Cost in Children and Adolescents With Chronic Pain: Analysis of Health Care Claims Data 1 Year Before and After Intensive Interdisciplinary Pain Treatment.

The aim of this study was to analyze changes in health care utilization and cost among a sample of highly impaired children and adolescents who sought a 3-week intensive interdisciplinary pain treatment (IIPT). Claims data from 7 statutory health insurance companies were analyzed for 65 children and adolescents who sought IIPT at the German Paediatric Pain Centre. The annual health care utilization and cost were determined for the following 4 areas: outpatient care, inpatient care, medications, and remedies and aids. We analyzed the changes in resource utilization in the year before (pre_1 y) IIPT and in the subsequent year (post_1 y). Within the first year after IIPT, overall health care costs did not decrease significantly. However, the pattern of health care utilization changed. First, significantly more children and adolescents started outpatient psychotherapy (P=0.001). Second, the number of hospitalized children decreased significantly from 1-year pre to 1-year post (P=0.001). Accordingly, there were significantly fewer hospitalizations for primary chronic pain disorders at 1-year post (P<0.001). The prescription of nonopioids, co-analgesics and opioids was significantly reduced from 1-year pre to 1-year post (all P<0.013). The present results indicate that the health care costs of children and adolescents with severe chronic pain disorders do not significantly decrease 1 year after IIPT; however, the treatment becomes more goal-focused. Differential diagnosis measures and nonindicated therapeutic interventions decreased, and more indicated interventions, such as psychotherapy, were used. Future research is needed to investigate the economic long-term changes after IIPT.

Clinical and Economic Long-Term Treatment Outcome of Children and Adolescents with Disabling Chronic Pain.

Disabling pediatric chronic pain is accompanied by a significant burden to those affected and by high societal costs. Furthermore, it bears the risk of aggravation into adulthood. Studies have shown intensive interdisciplinary pain treatment to result in short-term positive effects on pain-related and psychological outcomes. In this study, we aimed to prove the stability of the long-term effects of intensive interdisciplinary pain treatment four years after treatment. This longitudinal observational study followed adolescents who had received intensive interdisciplinary pain treatment over four years. We defined a combined end point, overall improvement (pain intensity, pain-related disability, and school/work absence), and investigated three additional psychological outcome domains (anxiety, depression, pain catastrophizing). We also examined changes to economic parameters (health care utilization, subjective financial burden) and their relationship to patient improvement. Similar patterns were observed for pain-related and psychological outcome domains, with data showing statistically and clinically significant reductions from admission to four-year follow-up. These positive effects were stable from one- to four-year follow-up. Approximately 60% of the adolescents showed an overall long-term improvement. Older age was found to be a risk factor for treatment failure. Economic parameters decreased statistically significantly, particularly for those with an overall improvement of the chronic pain disorder. The results of this study support the long-term effectiveness of intensive interdisciplinary pain treatment and indicate that it can interrupt pain chronification. Future research is warranted to investigate why some of the adolescents did not show improvement and to allow for a more individualized treatment.

Fear of pain in children and adolescents with neuropathic pain and complex regional pain syndrome.

A significant proportion of children and adolescents with chronic pain endorse elevated pain-related fear. Pain-related fear is associated with high levels of disability, depressive symptoms, and school impairment. Because of faulty nerve signaling, individuals with neuropathic pain and complex regional pain syndrome may be more prone to develop pain-related fear as they avoid use of and neglect the affected body area(s), resulting in exacerbated symptoms, muscle atrophy, maintenance of pain signaling, and ongoing pain-related disability. Not surprisingly, effective treatments for elevated pain-related fears involve exposure to previously avoided activities to downregulate incorrect pain signaling. In the context of intensive interdisciplinary pain treatment of youth with neuropathic pain, decreasing pain-related fear is associated with improved physical and psychological functioning, whereas high initial pain-related fear is a risk factor for less treatment responsiveness. An innovative approach to targeting pain-related fear and evidence of a neural response to treatment involving decoupling of the amygdala with key fear circuits in youth with complex regional pain syndrome suggest breakthroughs in our ability to ameliorate these issues.

Systematic Review on Intensive Interdisciplinary Pain Treatment of Children With Chronic Pain.

Pediatric debilitating chronic pain is a severe health problem, often requiring complex interventions such as intensive interdisciplinary pain treatment (IIPT). Research is lacking regarding the effectiveness of IIPT for children. The objective was to systematically review studies evaluating the effects of IIPT. Cochrane, Medline/Ovid, PsycInfo/OVID, PubMed, PubPsych, and Web of Science were searched. Studies were included if (1) treatment was coordinated by ≥3 health professionals, (2) treatment occurred within an inpatient/day hospital setting, (3) patients were <22 years, (4) patients experienced debilitating chronic pain, (5) the study was published in English, and (6) the study had ≥10 participants at posttreatment. The child's pain condition, characteristics of the IIPT, and 5 outcome domains (pain intensity, disability, school functioning, anxiety, depressive symptoms) were extracted at baseline, posttreatment, and follow-up. One randomized controlled trial and 9 nonrandomized treatment studies were identified and a meta-analysis was conducted separately on pain intensity, disability, and depressive symptoms revealing positive treatment effects. At posttreatment, there were large improvements for disability, and small to moderate improvements for pain intensity and depressive symptoms. The positive effects were maintained at short-term follow-up. Findings demonstrated extreme heterogeneity. Effects in nonrandomized treatment studies cannot be attributed to IIPT alone. Because of substantial heterogeneity in measures for school functioning and anxiety, meta-analyses could not be computed. There is preliminary evidence for positive treatment effects of IIPT, but the small number of studies and their methodological weaknesses suggest a need for more research on IIPTs for children.

Rapid treatment-induced brain changes in pediatric CRPS.

To date, brain structure and function changes in children with complex regional pain syndrome (CRPS) as a result of disease and treatment remain unknown. Here, we investigated (a) gray matter (GM) differences between patients with CRPS and healthy controls and (b) GM and functional connectivity (FC) changes in patients following intensive interdisciplinary psychophysical pain treatment. Twenty-three patients (13 females, 9 males; average age±SD=13.3±2.5years) and 21 healthy sex- and age-matched controls underwent magnetic resonance imaging. Compared to controls, patients had reduced GM in the primary motor cortex, premotor cortex, supplementary motor area, midcingulate cortex, orbitofrontal cortex, dorsolateral prefrontal cortex (dlPFC), posterior cingulate cortex, precuneus, basal ganglia, thalamus, and hippocampus. Following treatment, patients had increased GM in the dlPFC, thalamus, basal ganglia, amygdala, and hippocampus, and enhanced FC between the dlPFC and the periaqueductal gray, two regions involved in descending pain modulation. Accordingly, our results provide novel evidence for GM abnormalities in sensory, motor, emotional, cognitive, and pain modulatory regions in children with CRPS. Furthermore, this is the first study to demonstrate rapid treatment-induced GM and FC changes in areas implicated in sensation, emotion, cognition, and pain modulation.

Inpatient-based intensive interdisciplinary pain treatment for highly impaired children with severe chronic pain: Randomized controlled trial of efficacy and economic effects

Pediatric chronic pain, which can result in deleterious effects for the child, bears the risk of aggravation into adulthood. Intensive interdisciplinary pain treatment (IIPT) might be an effective treatment, given the advantage of consulting with multiple professionals on a daily basis. Evidence for the effectiveness of IIPT is scarce. We investigated the efficacy of an IIPT within a randomized controlled trial by comparing an intervention group (IG) (n=52) to a waiting-list control group (WCG) (n=52). We made assessments before treatment (PRE), immediately after treatment (POST), as well as at short-term (POST6MONTHS) and long-term (POST12MONTHS) follow-up. We determined a combined endpoint, improvement (pain intensity, disability, school absence), and investigated 3 additional outcome domains (anxiety, depression, catastrophizing). We also investigated changes in economic parameters (health care use, parental work absenteeism, subjective financial burden) and their relationship to the child’s improvement. Results at POST showed that significantly more children in the IG than in the WCG were assigned to improvement (55% compared to 14%; Fisher P<.001; 95% confidence interval for incidence difference: 0.21% to 0.60%). Although immediate effects were achieved for disability, school absence, depression, and catastrophizing, pain intensity and anxiety did not change until short-term follow-up. More than 60% of the children in both groups were improved long-term. The parents reported significant reductions in all economic parameters. The results from the present study support the efficacy of the IIPT. Future research is warranted to investigate differences in treatment response and to understand the changes in economic parameters in nonimproved children.

PC-FACS

PC-FACS

Changes in willingness to self-manage pain among children and adolescents and their parents enrolled in an intensive interdisciplinary pediatric pain treatment program

The importance of willingness to adopt a self-management approach to chronic pain has been demonstrated in the context of cognitive-behaviorally oriented interdisciplinary pain treatment programs for adults, both as a treatment outcome and as a process that facilitates functional improvements. Willingness to self-manage pain has not been studied in pediatric interdisciplinary pain treatment settings. Study aims were (1) to investigate willingness to self-manage pain among children and parents undergoing intensive interdisciplinary pain treatment and (2) to determine whether increased willingness to self-manage pain influenced functional treatment outcomes. A total of 157 children ages 10 to 18 and their parents enrolled in a pediatric pain rehabilitation program completed the Pain Stages of Change Questionnaire (PSOCQ youth and parent versions) at pretreatment, posttreatment, and short-term follow-up. They also reported on pain, functional disability, depressive symptoms, fear of pain, and use of passive and accommodative coping strategies. Results show that willingness to self-manage pain increased during treatment among both children and parents, with gains maintained at follow-up. Increases in children’s readiness to self-manage pain from pretreatment to posttreatment were associated with decreases in functional disability, depressive symptoms, fear of pain, and use of adaptive coping strategies. Increases in parents’ readiness to adopt a pain self-management approach were associated with changes in parent-reported fear of pain but not with other child outcomes. Few associations emerged between pretreatment willingness to self-manage pain and posttreatment outcomes. Findings suggest that interdisciplinary pediatric pain rehabilitation may facilitate increased willingness to self-manage pain, which is associated with improvements in function and psychological well-being.