Karen E. Weiss

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.

A Single-Arm Feasibility Trial of Problem-Solving Skills Training for Parents of Children with Idiopathic Chronic Pain Conditions Receiving Intensive Pain Rehabilitation

Objective To adapt problem-solving skills training (PSST) for parents of children receiving intensive pain rehabilitation and evaluate treatment feasibility, acceptability, and satisfaction. Methods Using a prospective single-arm case series design, we evaluated the feasibility of delivering PSST to 26 parents (84.6% female) from one of three pediatric pain rehabilitation programs. Results Parents completed four to six sessions of PSST delivered during a 2-4-week period. A mixed-methods approach was used to assess treatment acceptability and satisfaction. We also assessed changes in parent mental health and behavior outcomes from pretreatment to immediate posttreatment and 3-month follow-up. Parents demonstrated excellent treatment adherence and rated the intervention as highly acceptable and satisfactory. Preliminary analyses indicated improvements in domains of mental health, parenting behaviors, health status, and problem-solving skills. Conclusions Findings demonstrate the potential role of psychological interventions directed at reducing parent distress in the context of intensive pediatric pain rehabilitation.

Interdisciplinary Treatment of Maladaptive Behaviors Associated with Postural Orthostatic Tachycardia Syndrome (POTS): A Case Report

Abstract The prevalence of postural orthostatic tachycardia syndrome (POTS) in adolescents and young adults has been increasing during the past decade. Despite this increase, documentation regarding treatment of these patients is just beginning to emerge. In addition, despite a call for a multidisciplinary or interdisciplinary approach, no studies have examined the efficacy of such an approach to treatment. This paper describes a case study of a 19-year-old male with debilitating POTS seen at a tertiary clinic for evaluation and subsequent intensive interdisciplinary treatment. The treatment approach is described and outcomes are presented.

Improvement in Functioning and Psychological Distress in Adolescents With Postural Orthostatic Tachycardia Syndrome Following Interdisciplinary Treatment

Significant functional impairment and psychological distress have been observed in adolescent patients with postural orthostatic tachycardia syndrome (POTS). Interdisciplinary rehabilitation programs have been shown to be beneficial in the treatment of chronic pain in adults and adolescents. Only preliminary data have examined interdisciplinary rehabilitation efforts in patients with POTS. This study evaluated the impact of an interdisciplinary rehabilitation program on the functional impairment and psychological distress in 33 adolescents diagnosed with POTS. Patients included in the study were adolescents ages 11 to 18 diagnosed with POTS. Measures completed at admission and discharge from the program included the Functional Disability Index, Center for Epidemiological Studies–Depression–Child scale, and the Pain Catastrophizing Scale for Children. After participation in the 3-week program, adolescents with POTS demonstrated a significant increase in overall functional ability and significant reductions in depression and catastrophizing.

Psychosocial Dimensions and Functioning in Youth With Postural Orthostatic Tachycardia Syndrome

Postural orthostatic tachycardia syndrome (POTS) is characterized by symptoms of lightheadedness, dizziness, actual or near syncope, leg weakness, altered vision, headache, nausea, poor concentration, chest pain, palpitations, feeling warm, and/or tremulousness. These symptoms occur on standing and are relieved when an individual reclines. While initially POTS was more recognized in adults, more recently, it is increasingly being diagnosed in adolescents. Symptoms of POTS can be debilitating and have significant impact on many areas of functioning (eg, academic, peer and familial relationships, extracurricular activities). Furthermore, as these impairments in functioning are occurring within key developmental periods, the impact of the symptoms can result in missed opportunities to develop typical social and emotional skills. Clinical presentation of POTS is heterogeneous, with many patients who do well with medication management and standard nonpharmacological approaches such as increased exercise and increased salt and water intake. However, a portion of pediatric patients with POTS experience significant impairment in functioning and disability similar to pediatric patients experiencing chronic pain. Relationships between psychosocial dimensions and functioning have been clearly demonstrated in pediatric pain populations. Furthermore, a multidimensional biobehavioral model is widely accepted as appropriate for conceptualizing and treating chronic pain in pediatric populations with a focus on increasing the patients’ functioning. A similarly multifaceted approach has been recommended in the treatment of pediatric POTS patients. However, little research has been done on the relationship between psychological factors and overall functioning in this population. The aim of this study is to determine relationships between functioning and symptoms of anxiety, perfectionism, catastrophizing, and/or depression in adolescents diagnosed with POTS who were being treated in an intensive pediatric pain rehabilitation program. Methods

Marijuana and Chronic Nonmalignant Pain in Adolescents

C hronic nonmalignant pain in children and adolescents occurs worldwide and can be associated with a lower selfreported quality of life. Headache, abdominal pain, or musculoskeletal pain is the most common complaint. Comorbid symptoms such as fatigue, sleep disturbance, depression, and anxietymay exacerbate pain andcontribute tonotable disability, psychological distress, and impaired functioning. Patients may find it difficult to attend school, concentrate on homework, socialize with friends, or engage in physical activityd ie, activities at the core of being a normal adolescent (patients 13-17 years of age)ddue to ongoing pain. In affected adolescents, evaluations and medical tests may be undertaken over months or longer, with protracted investigations often failing to determine the etiology. Many patients have had unsuccessful medication trials and procedures engendering frustration that “something is being missed.” Patients expect a “quick fix” that, when not forthcoming, may cause them to turn to alternative treatments. Marijuana is one such treatment. Given its widespread availability throughout the United States and expanded use for medical conditions, it is reasonable to anticipate increasing numbers of adolescents turning to marijuana to treat chronic pain. There is a paucity of original research data regarding risks and benefits of marijuana use for treating chronic pain in adults, and there is even less data for treating adolescents. Although benefits may accrue in specific conditions, adverse effects influencing daily functioning (eg, impaired concentration or lengthened reaction time when performing tasks) often limit treatment. More studies are needed in all ages of patients to determine if marijuana effectively reduces chronic nonmalignant pain, withoutmajor adverse effects worsening debility. We could find only one study describing marijuana use to manage pain, mood, and sleep disturbances in an adolescent population. A limitation of this study was its failure to describe participants’ ability to function daily while using marijuana. In this commentary, we describe how marijuana use in 3 adolescent patients presenting to a pediatric chronic pain clinic may have contributed to their functional difficulties. We offer speculative synthesis about the consequences of marijuana consumption and appropriate methods for patient management. During their evaluations, the described patients volunteered that they used marijuana regularly. Urine drug screens are not routinely performed in our clinic and were not used to evaluate these 3 patients. Institutional review board approval was obtained before reporting.

Development of an Interdisciplinary Pediatric Pain Rehabilitation Program: The First 1000 Consecutive Patients

Objective To describe the development of a clinically and financially successful interdisciplinary pediatric pain rehabilitation program at a large tertiary academic medical center and present demographic and clinical information on the first 1000 patients. Patients and Methods All patients who were consecutively admitted to this program between October 1, 2008, and March 31, 2015 were included in this review. The patients ranged in age from 9 to 24 years. The program is a 3-week, hospital-based outpatient treatment program that requires substantial parental involvement. At admission and discharge, patients completed the Center for Epidemiologic Studies of Depression Scale for Children, the Functional Disability Inventory, and the Pain Catastrophizing Scale for Children. Opioid use was also assessed. Results At admission, patients reported substantial pain-associated disability and depressive symptoms; they had elevated pain catastrophizing scores, and 16% were taking opioids. Primary sites/types of pain included head, abdomen, and generalized. Functional disability scores decreased significantly, from 27 to 9 after the program (P<.001). Depression scale scores improved from 27 to 14 (P<.001). Pain catastrophizing scores decreased significantly, from 26 to 14 (P<.001), at discharge from the program. All but 4 patients successfully tapered off of all opioid use by the conclusion of the program. Conclusion Participation in a multidisciplinary pediatric pain rehabilitation program can be successful, with significant decreases in disability, depression symptoms, and pain catastrophizing, as well as discontinuation of opioid use.