Cynthia Harbeck-Weber

Pediatric Pain Measurement Using a Visual Analogue Scale: A Comparison of Two Teaching Methods

The goals of this study were to evaluate the validity of the visual analogue scale (VAS) for young children and to compare a newly developed method of teaching children to use a VAS with one used in our previous studies. It was hypothesized that the new method would increase the number of children who understand the VAS and correctly mark their responses on the VAS line. The association between childs age and ability to understand the VAS was also evaluated. One hundred-six children with a laceration requiring sutures and receiving a lidocaine injection for local anesthesia participated in the study. They ranged in age from 5 to 14 years. Two outcome measures were used to assess the baseline and lidocaine injection pain: a 5-point Likert scale and a VAS. A calibration study was used to determine whether the subjects were able to use the VAS to make proportional judgments about their perceptions. Teaching method had no effect on the number of subjects who could correctly mark their responses on the VAS line, nor did it significantly increase the number of subjects who could understand the concept of the VAS. Subjects who were able to understand the VAS were significantly older (mean = 9.8 years, SD = 2.8) than those who did not (mean = 8.2 years, SD = 2.5). Overall, only about one third of the subjects were able to correctly mark the VAS and understand the concept of the VAS. Other measures of pain that are better understood by young children may be more valid indicators of pain than the VAS.

Adolescent Fatigue, POTS, and Recovery: A Guide for Clinicians

Many teenagers who struggle with chronic fatigue have symptoms suggestive of autonomic dysfunction that may include lightheadedness, headaches, palpitations, nausea, and abdominal pain. Inadequate sleep habits and psychological conditions can contribute to fatigue, as can concurrent medical conditions. One type of autonomic dysfunction, postural orthostatic tachycardia syndrome, is increasingly being identified in adolescents with its constellation of fatigue, orthostatic intolerance, and excessive postural tachycardia (more than 40 beats/min). A family-based approach to care with support from a multidisciplinary team can diagnose, treat, educate, and encourage patients. Full recovery is possible with multi-faceted treatment. The daily treatment plan should consist of increased fluid and salt intake, aerobic exercise, and regular sleep and meal schedules; some medications can be helpful. Psychological support is critical and often includes biobehavioral strategies and cognitive-behavioral therapy to help with symptom management. More intensive recovery plans can be implemented when necessary.

Adolescent Acceptance of Pain: Confirmatory Factor Analysis and Further Validation of the Chronic Pain Acceptance Questionnaire, Adolescent Version

UNLABELLED Preliminary reports suggest that acceptance of pain is an important construct when assessing and treating adolescents with chronic pain. Although the Chronic Pain Acceptance Questionnaire, Adolescent version (CPAQ-A) appears to be a promising tool, it has been evaluated in only 1 study. The current results present a confirmatory analysis of the CPAQ-A and validity data collected independently from the developers of the scale. A sample of 109 adolescents with chronic pain completed the CPAQ-A, as well as measures of pain characteristics, functional impairment, depression, anxiety, and pain self-efficacy. Results of the confirmatory factor analysis indicate the previously reported 2-factor solution provides a good fit to the data, and has acceptable internal consistency. The CPAQ-A correlated strongly with disability, depression, anxiety, and self-efficacy. It correlated only moderately with pain intensity and was not correlated with pain frequency or duration of pain. When entered last into a hierarchical regression model predicting disability, acceptance accounted for more variance than pain intensity, depression, anxiety, and self-efficacy. Results supported the internal consistency and validity of the CPAQ-A as a measure of pain acceptance in this sample of adolescents with chronic pain. Use of the CPAQ-A may provide valuable insight into the manner in which adolescents adapt to chronic pain and can guide acceptance-based treatment. PERSPECTIVE This article strengthens the psychometric support for a measure of chronic pain acceptance in adolescents. Acceptance-based treatment has been shown to reduce disability in preliminary research targeting adolescents with chronic pain; the CPAQ-A may be useful for assessing the degree to which acceptance-based approaches may be indicated for a given patient.

Prilocaine-phenylephrine topical anesthesia for repair of mucous membrane lacerations.

Objective: To compare the effectiveness of prilocaine‐phenylephrine (Prilophen), a new topical anesthetic that does not contain cocaine, to that of lidocaine infiltration during repair of lacerations on or near mucous membranes in children. Design: A prospective, randomized, blinded trial. Setting: The emergency department of a large academic childrens hospital. Patients: Children one year of age or older with a laceration 5 cm or less in length on or near a mucous membrane. Interventions: Forty patients were randomly assigned one of the two local anesthetics, with 20 patients in each treatment group. Outcome measures: Pain felt during suturing was scored by suture technicians, research assistants, a videotape reviewer, parents, and patients five years of age and older using a visual analog scale (VAS). Results: There was no statistically significant difference in performance between topical Prilophen and lidocaine infiltration when VAS pain scores of research assistants, parents, and patients were compared. However, lidocaine infiltration performed significantly better than topical Prilophen when comparing VAS scores of suture technicians (P = 0.003) and the videotape reviewer (P = 0.02). When power analyses were performed using &agr; = 0.05 and &bgr; = 0.20, it was possible to detect a difference of 2 units for VAS scores of suture technicians, 2 VAS units for research assistants, 3 VAS units for the videotape reviewer and parents, and 7 VAS units for patients. There were no wound healing or other complications. Conclusions: Prilophen is a new topical anesthetic alternative to lidocaine infiltration for closure of lacerations on or near mucous membranes, where use of tetracaine‐adrenaline‐cocaine is contraindicated. The performance of Prilophen was rated by two of the observer groups as statistically inferior to that of lidocaine infiltration; however, the differences in pain scores were small and may not be clinically significant. Further investigation of this new topical anesthetic is warranted.

Managing Chronic Pain in Children and Adolescents: A Clinical Review

Chronic pain in children and adolescents can be difficult for a single provider to manage in a busy clinical setting. Part of this difficulty is that pediatric chronic pain not only impacts the child but also the families of these children. In this review article, we discuss etiology and pathophysiology of chronic pain, along with variables that impact the severity of chronic pain and functional loss. We review diagnosis and management of selected chronic pain conditions in pediatric patients, including headache, low back pain, hypermobility, chronic fatigue, postural orthostatic tachycardia syndrome, abdominal pain, fibromyalgia, and complex regional pain syndrome. For each condition, we create a road map that contains therapy prescriptions, exercise recommendations, and variables that may influence pain severity. Potential medications for these pain conditions and associated symptoms are reviewed. A multidisciplinary approach for managing children with these conditions, including pediatric pain rehabilitation programs, is emphasized. Lastly, we discuss psychological factors and interventions for pediatric chronic pain and potential complementary and alternative natural products and interventions.

Parental Perceptions of Pediatric Pain and POTS-Related Disability.

Adolescents with postural orthostatic tachycardia syndrome (POTS) often have pain and functional impairment. This study evaluated how parental attributions of children’s symptoms relate to child functional impairment. Adolescents with chronic pain and clinical symptoms suggestive of autonomic dysfunction (fatigue, dizziness, nausea) that attended a multidisciplinary chronic pain clinic completed measures of depression, anxiety, and functioning (n = 141). Parents of 114 of these patients completed the Parent Pain Attribution Questionnaire (PPAQ), a measure indicating the extent they believe physical and psychosocial factors account for their child’s health condition. Patients were retrospectively grouped as to whether or not they had significant POTS on tilt table testing (n = 37). Greater parental attribution to physical causes was associated with increased levels of functional disability whether patients had POTS (r = 0.45, P = .006) or not (r = 0.25, P = .03). These results suggest that providers should advocate a more comprehensive family-oriented rehabilitative approach to treatment.

Executive Functioning in Pediatric Chronic Pain: Do Deficits Exist?

Objective Despite ample research documenting deficits in executive functioning for adults with chronic pain, the literature on pediatric patients with chronic pain is limited and provides mixed results. The current study sought to further investigate the nature of executive dysfunction in this population and also examine the relationships between pain intensity, duration, and catastrophizing with sustained attention, working memory, and self- and parent-report of executive functioning. Settings Pediatric pain clinic and rehabilitation program. Participants Forty adolescents with chronic pain and their parents participated in this study. Methods Participants completed neuropsychological measures and standardized self-report questionnaires during a 45- to 60-minute testing session. Results Fifty percent of this sample of adolescents with chronic pain demonstrated significant difficulties on at least one measure, with nine participants indicating difficulties on multiple measures. Pain significantly increased during the testing session. Pain variables of intensity, duration, and catastrophizing are related to sustained attention and working memory. Conclusions This study adds support to previous findings suggesting subclinical struggles with executive functioning for adolescents with chronic pain. One-half of the sample indicated difficulties in either sustained attention and/or working memory. Future studies that would more thoroughly examine more complex executive functioning skills in this population would be helpful to further guide multidisciplinary treatment of these patients, particularly regarding whether or not school accommodations are warranted.

Youth with Chronic Pain and Postural Orthostatic Tachycardia Syndrome (POTS): Treatment Mediators of Improvement in Functional Disability

Intensive pain rehabilitation programs are effective in increasing functioning for youth with chronic pain (CP). However, the utility of such programs for youth with CP and co-morbid postural orthostatic tachycardia syndrome (POTS) is rarely examined. In addition, studies examining mediators of treatment for CP are sparse. This paper compares treatment outcomes for youth with CP (n = 117) and youth with CP + POTS (n = 118). Additionally, depression and pain catastrophizing were tested as potential mediators of treatment effects. Significant treatment improvements were found for functional disability, depression, pain catastrophizing, and perceived pain intensity but with no differences between groups. Improvements in depressed mood, pain catastrophizing (helplessness subscale), and pain severity partially mediated functioning improvement. Pain severity was not a significant mediator in the CP + POTS group. We concluded that depression and pain catastrophizing, especially the helplessness domain, can impact functioning improvement in adolescents with CP and POTS and are particularly important to target in treatment.

Pain assessment methods and interventions used by pediatric psychologists: A survey by the Pain Special Interest Group of the Society of Pediatric Psychology.

Although many valid pain-related assessment instruments and interventions exist, little is known about which are actually utilized in practice and the factors that contribute to pediatric psychologist’s decisions about their use. The aim of this survey study was to present a summary of current clinical practice among pediatric psychologists in the area of pediatric pain and to identify the needs and possible resources that would enable practitioners to better implement evidence-based assessments and interventions. To accomplish this aim, the Pain Special Interest Group of the Society of Pediatric Psychology (SPP) constructed an online survey that was sent electronically to current members of the SPP list serve. Results indicated the majority of participants are guided by a theoretical model and are using evidence-based assessments and interventions, although they are not always familiar with the literature supporting their use. Providers noted evidence-based pain intervention is facilitated by assessment tools, intervention resources, and appreciation of pain interventions by multidisciplinary team members. Barriers are both logistical (clinic space and time constraints) and knowledge-based (lack of familiarity with assessments/interventions). Thus, while pediatric psychologists are progressing toward better translation of research to practice, continued educational efforts and communication among practitioners about available resources are warranted.

(493) Pediatric pain assessment methods and interventions used by mental health providers: a survey by the Pain Special Interest Group of the Society of Pediatric Psychology

catastrophizing was a significant predictor of pain intensity (b = .386, p < .001) and pain interference (b = .336, p < .001); and depressive symptoms (b = -.415, p < .001) was a significant predictor for perceived disability based on physical functioning. Consistent with previous research, our results confirm the strong influences of psychosocial factors on pain and disability, even in a unique multiply disadvantaged population.