Amy Lewandowski Holley

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

BACKGROUND AND OBJECTIVE: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Bidirectional associations between pain and physical activity in adolescents

Objectives:The objectives were to: (1) examine temporal relationships between pain and activity in youth, specifically, whether physical activity affects pain intensity and whether intensity of pain affects subsequent physical activity levels on a daily basis, and (2) examine clinical predictors of this relationship. Methods:Participants were 119 adolescents (59 with chronic pain and 60 healthy) aged 12 to 18 years, 71% female. Adolescents completed 10 days of actigraphic monitoring of physical activity and daily electronic diary recordings of pain intensity, medication use, sleep quality, and mood. Linear mixed models assessed daily associations among physical activity and pain. Daily mean (average count/min) and peak (highest daily level) activity were used for analyses. Medication use, sleep quality, and mood ratings were included as covariates, and age, sex, and body mass index percentile were adjusted for. Results:Higher pain intensity was associated with lower peak physical activity levels on the next day (t641=−2.25, P=0.03) and greater medication use predicted lower mean physical activity levels the same day (t641=−2.10, P=0.04). Higher mean physical activity levels predicted lower pain intensity ratings at the end of the day (t705=−2.92, P=0.004), but only in adolescents with chronic pain. Discussion:Youth experiencing high pain intensity limit their physical activity level on a day-to-day basis. Activity was related to subsequent pain intensity, and may represent an important focus in chronic pain treatment. Further study of the effect of medications on subsequent activity is needed.

Current Smoking as a Predictor of Chronic Musculoskeletal Pain in Young Adult Twins

UNLABELLED Chronic pain is common during adolescence and young adulthood and is associated with poor quality of life, depression, and functional disability. Recognizing that chronic pain has significant consequences, it is important to identify modifiable health behaviors that may place young adults at risk for chronic pain. This study examines associations between chronic musculoskeletal pain and smoking in young adult twins (n = 1,588, ages 18-30) participating in a statewide twin registry. Twins completed questionnaires assessing smoking, mood (anxiety, depressive symptoms, and stress), and chronic musculoskeletal pain. Analyses examined associations between chronic pain and smoking, particularly the role of genetics/shared familial factors and psychological symptoms. As predicted, results revealed a near-2-fold increased risk for chronic musculoskeletal pain in twins who currently smoked compared to nonsmokers, even when accounting for psychological factors. Results of within-pair analyses were only minimally attenuated, suggesting that associations between smoking and chronic musculoskeletal pain are better accounted for by nonshared factors than by shared familial factors/genetic effects. Future twin research is needed to identify what nonshared factors (eg, attitudes, direct effects of smoking on pain) contribute to these associations to further understand comorbidity. Longitudinal studies and recruitment of participants prior to smoking initiation and chronic pain onset will better identify causal associations. PERSPECTIVE This article describes associations between musculoskeletal pain and smoking in young adult twins, taking into account psychological symptoms. Findings highlight the importance of nonshared factors in associations between pain and smoking and the need to explore the roles of lifestyle, individual attitudes, and direct effects of smoking on pain.

The importance of the family environment in pediatric chronic pain.

The impact of chronic pain during childhood and adolescence has been well described (e.g.,1). A subset of youth with chronic pain has high levels of anxiety and depressive symptoms, poor quality of life, and impairment in school and activity participation (2–4). Moreover, pain impacts the entire family. Parents of children with chronic pain report increased parenting stress, anxiety and depressive symptoms, financial strain, and family dysfunction (5–6). Parents also play a critical role in their child’s ability to adapt to living with chronic pain, both in terms of their child’s emotional functioning as well as their child’s ability to participate in activities of daily life. For example increased parent psychological distress is recognized as a risk factor for poorer outcomes in youth with chronic pain (5,7). A bidirectional relationship between parent and family factors (e.g., parental responses to pain behavior; family environment) and children’s pain experience has been described where parent and family factors may increase risk for pain and disability, and in turn, pain and disability may impact parent and family life (8). Contemporary research in pediatric pain has focused on the identification of risk factors associated with presence and development of chronic pain as well as longitudinal risk. Such investigations have explored a range of biological, social, and psychological risk factors (e.g.,9–10). Findings from the study by Hoftun and colleagues published in this issue of Archives contribute to this body of literature. Using an innovative family linkage study design, their findings revealed that maternal and paternal chronic pain increased the odds of chronic pain in adolescents. Associations were even stronger when both parents reported chronic pain. Several family and psychosocial correlates were examined including the structure of the family living situation. Associations in chronic pain status were strongest among adolescents living exclusively with their mother, or their mother and her new partner. These findings raise important questions about the role of the family environment in pediatric pain. The family environment encompasses a range of variables including individual parent behaviors, dyadic interactions between family members, and the broader family system including socioeconomic conditions, family structure, family functioning, and culture. In their integrative model describing parent and family factors in pediatric pain, Palermo and Chambers8 highlight the association between different levels of the family system and child pain and disability. For example, at the level of the individual parent, parental emotions, behaviors, and health may play a role in the child’s pain experience with overly protective behaviors, increased distress, and history of chronic pain being important parent-level influences. A distinction is made in the model between factors that are predictive of pain versus factors that are predictive of the child’s level of disability. Pertinent to the study published in this issue by Hoftun and colleagues, a key question not addressed concerns the level of pain-related functional impairment experienced by adolescents (and parents) in the sample. Pain and disability can vary considerably among children with pain, and therefore, the assessment of functional impairment is important in order to define severity and impact of pediatric chronic pain. Prior research indicates that only a small subset of youth with chronic pain (approximately 5%) experience moderate-severe disability11. While the assessment of pain severity is important in the context of the family environment, different predictors have been associated with pain presence versus pain-related disability. For example, in a systematic review of studies of family functioning in youth with chronic pain, much stronger associations were found between family dysfunction and disability in contrast to more limited associations between family dysfunction and pain6. Future research incorporating measurement of patterns of disability in both parents and adolescents will be important to understanding how the family environment is associated with youth functioning across different domains (e.g., school attendance, activity participation). Hoftun and colleagues’ research also suggests that family structure may play a role in either development or maintenance of chronic pain. In their study, associations between parent and adolescent pain were strongest in adolescents living primarily with their mothers. Was family structure a proxy for additional variables not captured in the current study? While Hoftun and colleagues collected data on education, socioeconomic status, and family structure, the study did not include measurement of other elements of the family, such as overall level of family functioning or dyadic interactions between parents and adolescents. It is unknown why adolescents living with both parents had lower rates of chronic pain, while adolescents living primarily with their mothers had higher rates of chronic pain and stronger associations with maternal pain. Perhaps mothers in these living situations had higher levels of parenting stress or family functioning was poorer overall. Additional research is needed to provide a more comprehensive assessment of the family in order to understand how family structure may relate to other key aspects of family function (such as level of organization, cohesion, communication, affective environment, and problem solving)12. Well-validated self-report and observational tools are available for measuring family variables (see review12) in other pediatric populations that could be applied to families of youth with chronic pain. One strength of the study by Hoftun and colleagues is the inclusion of maternal, paternal, and adolescent report. There has been a general lack of inclusion of fathers in research on chronic pain in children. Further inclusion of fathers in pediatric pain research will allow for the examination of potential differences in how mothers and fathers respond to adolescent pain complaints, and how dyad-partner interactions impact both the marital relationship and broader family functioning. The study of family environment in adolescence could also be strengthened through consideration of the developmental context. Rates of pain and pain-related disability are higher during adolescence compared to any other developmental stage of childhood (e.g.,13). Moreover, many social changes occur during adolescence including achieving autonomy or independence from parents, and may be associated with parent and adolescent reported stress as well as psychological symptoms. Balancing parental involvement and autonomy is a complex issue for adolescents with medical conditions. In our own work in adolescents with chronic headache, we found that higher levels of family conflict and lower levels of adolescent autonomy were associated with increased functional impairment and increased symptoms of depression (7) in youth. Developmental considerations will be important to furthering the study of family environment in pediatric chronic pain, and in examining longitudinal associations among pain in parents and children to understand potential changes over time and across developmental stages. Last, the family environment is critical to consider in behavioral interventions to address pain and disability in adolescents. In general, cognitive-behavioral pain interventions have included parent strategies focused on operant techniques (e.g., minimizing response to pain complaints, encouraging adaptive behavior) taught to parents in brief individual or group sessions. For example, seven of 25 randomized controlled trials (RCTs) included in a recent meta-analysis of psychological therapies for the treatment of pediatric chronic pain incorporated operant intervention strategies directed to parents14. Results revealed that including parent-focused interventions had positive effects on pain reduction in children and adolescents. In contrast, existing behavioral interventions for children with chronic pain have no effect on parent outcomes such as psychological distress15. A focus on the development of family and parent interventions for youth with chronic pain should be a research priority. To date, there has been limited development of intervention content directed at other aspects of the family environment such as parent modeling or family conflict. Based on the findings of Hoftun and colleagues, development and testing of interventions that provide instruction to parents in modifying their own response to their chronic pain (e.g., modeling) will be an important next step.

Post-traumatic stress symptoms in children and adolescents with chronic pain: A topical review of the literature and a proposed framework for future research

The co‐occurrence of chronic pain and post‐traumatic stress symptoms (PTSS) and post‐traumatic stress disorder (PTSD) has gained increasing research attention. Studies on associations among pain and PTSS or PTSD in youth have largely been conducted in the context of acute injury or trauma. Less is known about the risk for co‐occurrence with paediatric chronic pain. In this review, we (1) propose a conceptual framework to outline factors salient during childhood that may be associated with symptom severity, co‐occurrence and mutual maintenance, (2) present relevant literature on PTSS in youth with acute and chronic pain and identify research gaps and (3) provide recommendations to guide paediatric research examining shared symptomatology.

Posttraumatic stress disorder symptoms in youth with vs without chronic pain

Abstract Chronic pain and posttraumatic stress disorder (PTSD) symptoms have been found to co-occur in adults; however, research has not examined this co-occurrence in adolescence, when pediatric chronic pain often first emerges. The aims of this study were to compare the frequency and intensity of PTSD symptoms and stressful life events in cohorts of youth with (n = 95) and without (n = 100) chronic pain and their parents and to determine the association between PTSD symptoms, health-related quality of life, and pain symptoms within the chronic pain sample. All participants completed questionnaire measures through an online survey. Findings revealed that youth with chronic pain and their parents had significantly higher levels of PTSD symptoms as compared with pain-free peers. More youth with chronic pain (32%) and their parents (20%) reported clinically significant elevations in PTSD symptoms than youth without chronic pain (8%) and their parents (1%). Youth with chronic pain also reported a greater number of stressful life events than those without chronic pain, and this was associated with higher PTSD symptoms. Among the chronic pain cohort, higher levels of PTSD symptoms were predictive of worse health-related quality of life and were associated with higher pain intensity, unpleasantness, and interference. Results suggest that elevated PTSD symptoms are common and linked to reduced functioning among youth with chronic pain. Future research is needed to examine PTSD at the diagnostic level and the underlying mechanisms that may explain why this co-occurrence exists.

Clinical Phenotyping of Youth With New-Onset Musculoskeletal Pain: A Controlled Cohort Study.

Objectives: The course of pediatric musculoskeletal pain from acute to chronic has not been well described and there is limited understanding of how to identify individuals with new-onset pain who may be predisposed to developing persisting symptoms. Thus, the purpose of this study was to describe the clinical phonotype of treatment-seeking youth with new-onset musculoskeletal pain compared with youth with and without chronic pain. Further, we tested predictors of pain-related disability and pain sensitivity in the new-onset pain sample. Methods: Participants were 191 youth, ages 10 to 17 years, representing 3 cohorts (new-onset musculoskeletal pain, chronic musculoskeletal pain, and a comparison group without chronic pain). Participants completed questionnaire measures of pain characteristics, psychological functioning, sleep, and pain-related disability. They also attended a laboratory visit to complete an experimental pain assessment using heat and cold stimuli to assess pain sensitivity and conditioned pain modulation. Results: Findings revealed youth with new-onset musculoskeletal pain had a distinct clinical phenotype where symptoms of pain and disability were in the mid-range between those of youth with diagnosed chronic musculoskeletal pain and youth in the community without chronic pain. Linear regressions within the new-onset pain sample demonstrated poorer sleep quality and higher pain fear predicted greater pain-related disability, and pain catastrophizing predicted cold pressor sensitivity. Discussion: Clinical phenotyping of youth with new-onset musculoskeletal pain highlights factors relevant to the pain experience. Future research can examine the roles of these variables in predicting longitudinal risk for chronic pain and disability.

Applications of laboratory pain methodologies in research with children and adolescents: Emerging research trends

Historically, laboratory pain research with children and adolescents has largely been conducted with healthy samples using the cold pressor task (CPT). Additional laboratory methodologies, commonly referred to as Quantitative Sensory Testing (QST), include a variety of psychophysical tests assessing sensory perception (e.g., pressure and heat tolerance) and sensory abnormalities. There is significant variation in QST protocols in terms of methodology (e.g., number and type of measurement modalities) and data gleaned (e.g., pain threshold versus central sensitization). Generally speaking, QST laboratory assessment methodologies yield measures of pain tolerance, pain threshold, or self-report of pain intensity. Studies utilizing these methods have greatly expanded knowledge of individual and social factors contributing to acute pain responses, including: parental behavior (e.g., [8]), child sex differences, coping, distraction, catastrophizing, and anxiety (e.g., [26]). CPT guidelines and reviews of use in pediatric pain research are available [34,4]. Additionally, researchers have begun to identify reference values and validate other QST protocols in healthy children and adolescents [23,5,30]. Despite the plethora of laboratory research examining pain responses in healthy children, much less is known about pain responses in pediatric clinical samples. In adult populations, laboratory pain research has proven useful for characterizing the neurobiology of chronic pain disorders [15,27]. The underlying biological, psychological, and motoric domains that contribute to the pain experience [31] change and become more complex as children move through childhood into adolescence and adulthood. Because youth are at risk for pain to persist into adulthood [6], a more complete understanding of factors that influence the onset and development of alterations in pain processing systems is critical. This information can be used to both inform lifespan models of pain conditions and to help identify potential targets for preventative interventions. This topical review aims to: 1) outline current knowledge of laboratory pain responses in clinical pediatric pain populations, 2) review emerging research methodologies, and 3) provide recommendations for future research that addresses gaps in the current literature.

Predictors of the transition from acute to persistent musculoskeletal pain in children and adolescents: a prospective study

Abstract Strategies directed at the prevention of disabling pain have been suggested as a public health priority, making early identification of youth at risk for poor outcomes critical. At present, limited information is available to predict which youth presenting with acute pain are at risk for persistence. The aims of this prospective longitudinal study were to identify biopsychosocial factors in the acute period that predict the transition to persistent pain in youth with new-onset musculoskeletal (MSK) pain complaints. Participants were 88 children and adolescents (age 10-17 years) presenting to the emergency department (n = 47) or orthopedic clinic (n = 41) for evaluation of a new MSK pain complaint (<1 month duration). Youth presented for 2 study visits (T1 ⩽1 month post pain onset; T2 = 4-month follow-up) during which they completed questionnaires (assessing pain characteristics, psychological factors, sleep quality) and participated in a laboratory task assessing conditioned pain modulation. Regression analyses tested T1 predictors of longitudinal pain outcomes (pain persistence, pain-related disability, quality of life [QOL]). Results revealed approximately 35% of youth had persistent pain at 4-month follow-up, with persistent pain predicted by poorer conditioned pain modulation and female sex. Higher depressive symptoms at T1 were associated with higher pain-related disability and poorer QOL at T2. Findings highlight the roles of depressive symptoms and pain modulation in longitudinally predicting pain persistence in treatment-seeking youth with acute MSK pain and suggest potential mechanisms in the transition from acute to chronic MSK pain in children and adolescents.

A population-based study of quantitative sensory testing in adolescents with and without chronic pain.

Abstract Quantitative sensory testing (QST) has been used to characterize pain sensitivity in individuals with and without pain conditions. Research remains limited in pediatric populations, hindering the ability to expand the utility of QST toward its potential application in clinical settings and clinical predictive value. The aims of this study were to examine pain sensitivity using QST in adolescents with chronic pain compared to adolescents without chronic pain and identify predictors of pain sensitivity. A population-based study conducted from 2010 to 2011 provided data on 941 adolescents, 197 were classified as having chronic pain and 744 were classified without chronic pain. Self-reported data on pain characteristics, psychological functioning, and QST responses were examined. The findings revealed lower pressure pain threshold and tolerance on the trapezius (Ps = 0.03) in adolescents with chronic pain compared to adolescents without chronic pain, but no differences on heat or cold-pressor pain tasks. Female sex (Ps = 0.02) and poorer psychological functioning (Ps = 0.02) emerged as significant predictors of greater pain sensitivity across all pain modalities. Exploratory analyses revealed several associations between clinical pain characteristics and QST responses within the chronic pain cohort. Findings from this large pediatric sample provide comprehensive data that could serve as normative data on QST responses in adolescents with and without chronic pain. These findings lay the groundwork toward developing future QST research and study protocols in pediatric populations, taking into consideration sex and psychological distress.