Kenneth R. Goldschneider

Depression and functional disability in chronic pediatric pain.

ObjectivesThe primary aim of this study was to describe pain characteristics, coping strategies, depression, and functional disability in children and adolescents with chronic pain and to examine potential factors that are associated with functional disability in a pediatric pain population. The secondary aim of this study was to compare functional disability in two chronic pain conditions: localized musculoskeletal pain and chronic daily headaches. SubjectsThe participants in this study were 73 pediatric pain patients with a variety of chronic pain conditions. Subjects in the second part of the study were a subset of patients (N = 44) from the pain clinic sample with chronic localized musculoskeletal pain and a subset of patients (N = 38) from the headache center of the same hospital who had chronic daily headaches. DesignPatients completed self-report measures of pain intensity, depression, coping strategies, coping efficacy, and functional disability. ResultsResults indicated that chronic pain had a substantial impact on the childrens lives and that depression was strongly associated with functional disability. Maladaptive coping was correlated with depression and disability; however, maladaptive coping was not independently associated with functional disability. A comparison between the two groups found significant differences in pain intensity and functional disability. The localized musculoskeletal pain group reported higher levels of disability and more difficulty coping than the chronic daily headache group. ConclusionsThe implications for treatment of chronic pain in children are discussed with an emphasis on greater attention to developmental issues and their relation to coping, emotional functioning, and disability in pediatric pain. Further research examining differences in coping and disability between different pediatric pain groups is also warranted.

Neurological Complications Associated with Epidural Analgesia in Children: A Report of 4 Cases of Ambiguous Etiologies

The safety and utility of pediatric epidural analgesia is well established, but the risk of permanent neurological injury is unknown and largely must be extrapolated from adult literature. In this article we present a series of 4 cases of longterm or permanent neurologic complications associated with epidural analgesia. Possible mechanisms of injury and implications for practice are discussed.

The interplay of parent and adolescent catastrophizing and its impact on adolescents' pain, functioning, and pain behavior.

Objectives:Catastrophizing is a coping style linked to poorer patient outcomes. Little attention has focused on the parent-adolescent dyad and catastrophizing as a shared coping style. The purpose of this study was to: (1) examine the effects of adolescent and parent pain catastrophizing on adolescent functioning and (2) explore concordance in catastrophizing in parent-adolescent dyads, with equal interest in outcomes of dyads with discordant coping styles. Methods:Pain intensity, catastrophizing, depressive symptoms, quality of life, and pain behaviors were assessed in adolescents (ages 11 to 17) presenting to a pediatric chronic pain clinic (N=240). Results:Significant correlations between (1) parent and adolescent catastrophizing; (2) catastrophizing and pain behaviors; and (3) catastrophizing and adolescent outcomes were found. Parents and adolescents were classified into concordant or discordant dyads based on catastrophizing with a majority of dyads (>70%) showing concordant coping styles. Among discordant dyads, functional disability and depressive symptoms were significantly higher in a dyad with a high catastrophizing adolescent and low catastrophizing parent. Discussion:Results provide further support for catastrophizing being a maladaptive coping strategy for adolescents with pain and their parents. Greater adolescent catastrophizing was related to increased pain behaviors and poorer adolescent functioning. Parent catastrophizing also seems related to poorer adolescent outcomes, and most parent-adolescent dyads showed concordance in use of catastrophizing, which may suggest a shared tendency for adaptive or maladaptive styles of coping with pain. Future research should investigate pain coping at a dyadic or family level to explore how family coping styles magnify distress and disability or buffer adolescents from such problems.

Healthcare Utilization and Indirect Burden among Families of Pediatric Patients with Chronic Pain

Objectives: Chronic pain is associated with substantial direct and indirect costs in adulthood. Chronic pain problems are also common in childhood, but little is known about the costs of pediatric chronic pain and its treatment. The objectives of this study were to examine and describe healthcare utilization and indirect burden among pediatric chronic pain patients and their families. Methods: Participants were parents of 75 pediatric patients with daily or almost daily pain for at least three months, seen at a multidisciplinary pediatric pain outpatient clinic. Information about healthcare use and indirect familial burden was obtained during a semi-structured interview at the patients* first visit to the pain clinic. A financial analyst extracted cost data regarding hospital charges. To assess change over time, the same information was gathered from parents and the hospital financial analyst six months after their initial visit. Results: Parents reported numerous healthcare visits related to their childs pain condition [e.g., visits to specialists, physical therapy visits], high financial costs [e.g., charges for outpatient visits], and substantial indirect burden [e.g., time spent in medical appointments and missed workdays]. Parents reported lower healthcare utilization and decreased burden on families at the six-month follow-up assessment. Conclusions: Our results suggest that pediatric chronic pain is associated with considerable direct financial costs and indirect familial costs. Preliminary evidence suggests that involvement in a multidisciplinary program may be associated with decreased health care use and indirect burden.

Pain Management in Epidermolysis Bullosa

Pain is an unfortunate constant in the lives of most patients with epidermolysis bullosa (EB), especially for those with the more severe types of EB. Patients with EB have a broad spectrum of need for pain treatment, varying with the type of EB, the severity within that type, and the particular physical, emotional, and psychological milieu of each individual. Prevention of situations that precipitate trauma to the skin or exacerbate other pain-inducing complications of this multifaceted disorder is the primary goal of the treating physician. The approach to pain management is different in daily life, during intermittent exacerbations or injuries, or when hospitalizations or operative procedures occur.

Differential changes in functional disability and pain intensity over the course of psychological treatment for children with chronic pain

&NA; Children with chronic pain completing cognitive behavioral therapy show significant reductions in functional disability and faster rates of change in disability compared to pain intensity. &NA; Patients presenting for treatment of chronic pain often believe that pain reduction must be achieved before returning to normal functioning. However, treatment programs for chronic pain typically take a rehabilitative approach, emphasizing decreasing pain‐related disability first with the expectation that pain reduction will follow. This information is routinely provided to patients, yet no studies have systematically examined the actual trajectories of pain and disability in a clinical care setting. In this study of youth with chronic pain (N = 94, 8 to 18 years), it was hypothesized that 1) functional disability and pain would decrease over the course of psychological treatment for chronic pain and 2) functional disability would decrease more quickly than pain intensity. Participants received cognitive behavioral therapy (CBT) for pain management (M = 5.6 sessions) plus standard medical care. The Functional Disability Inventory and a Numeric Rating Scale of average pain intensity were completed by the child at every CBT session. Hierarchical linear modeling was conducted to examine the longitudinal trajectories of disability and pain. Standardized estimates of the slopes of change were obtained to test differences in rates of change between pain and disability. Results showed an overall significant decline in functional disability over time. Although pain scores reduced slightly from pretreatment to posttreatment, the longitudinal decline over treatment was not statistically significant. As expected, the rate of change of disability was significantly more rapid than pain. Evidence for variability in treatment response was noted, suggesting the need for additional research into individual trajectories of change in pediatric pain treatment.

Parent perceptions of adolescent pain expression: The adolescent pain behavior questionnaire

&NA; Pain behaviors provide meaningful information about adolescents in chronic pain, enhancing their verbal report of pain intensity with information about the global pain experience. Caregivers likely consider these expressions when making judgments about their adolescents’ medical or emotional needs. Current validated measures of pain behavior target acute or procedural pain and young or non‐verbal children, while observation systems may be too cumbersome for clinical practice. The objective of this research was to design and evaluate the Adolescent Pain Behavior Questionnaire (APBQ), a parent‐report measure of adolescent (11–19 years) pain expressions. This paper provides preliminary results on reliability and validity of the APBQ. Parent‐adolescent dyads (N = 138) seen in a multidisciplinary pain management clinic completed the APBQ and questionnaires assessing pain characteristics, quality of life, functional disability, depressive symptoms, and pain catastrophizing. Principal components analysis of the APBQ supported a single component structure. The final APBQ scale contained 23 items with high internal consistency (&agr; = 0.93). No relationship was found between parent‐reported pain behaviors and adolescent‐reported pain intensity. However, significant correlations were found between parent‐reported pain behaviors and parent‐ and adolescent‐reported functional disability, pain catastrophizing, depressive symptoms, and poorer quality of life. The assessment of pain behaviors provides qualitatively different information than solely recording pain intensity and disability. It has clinical utility for use in behavioral treatments seeking to reduce disability, poor coping, and distress.

Pain care for patients with epidermolysis bullosa: best care practice guidelines

BackgroundInherited epidermolysis bullosa (EB) comprises a group of rare disorders that have multi-system effects and patients present with a number of both acute and chronic pain care needs. Effects on quality of life are substantial. Pain and itching are burdensome daily problems. Experience with, and knowledge of, the best pain and itch care for these patients is minimal. Evidence-based best care practice guidelines are needed to establish a base of knowledge and practice for practitioners of many disciplines to improve the quality of life for both adult and pediatric patients with EB.MethodsThe process was begun at the request of Dystrophic Epidermolysis Bullosa Research Association International (DEBRA International), an organization dedicated to improvement of care, research and dissemination of knowledge for EB patients worldwide. An international panel of experts in pain and palliative care who have extensive experience caring for patients with EB was assembled. Literature was reviewed and systematically evaluated. For areas of care without direct evidence, clinically relevant literature was assessed, and rounds of consensus building were conducted. The process involved a face-to-face consensus meeting that involved a family representative and methodologist, as well as the panel of clinical experts. During development, EB family input was obtained and the document was reviewed by a wide variety of experts representing several disciplines related to the care of patients with EB.ResultsThe first evidence-based care guidelines for the care of pain in EB were produced. The guidelines are clinically relevant for care of patients of all subtypes and ages, and apply to practitioners of all disciplines involved in the care of patients with EB. When the evidence suggests that the diagnosis or treatment of painful conditions differs between adults and children, it will be so noted.ConclusionsEvidence-based care guidelines are a means of standardizing optimal care for EB patients, whose disease is often times horrific in its effects on quality of life, and whose care is resource-intensive and difficult. The guideline development process also highlighted areas for research in order to improve further the evidence base for future care.

Review article: Perioperative care of patients with epidermolysis bullosa: proceedings of the 5th international symposium on epidermolysis bullosa, Santiago Chile, December 4–6, 2008

Epidermolysis bullosa (EB) has become recognized as a multisystem disorder that poses a number of pre‐, intra‐, and postoperative challenges. While anesthesiologists have long appreciated the potential difficult intubation in patients with EB, other systems can be affected by this disorder. Hematologic, cardiac, skeletal, gastrointestinal, nutritional, and metabolic deficiencies are foci of preoperative medical care, in addition to the airway concerns. Therefore, multidisciplinary planning for operative care is imperative. A multinational, interdisciplinary panel of experts assembled in Santiagio, Chile to review the best practices for perioperative care of patients with EB. This paper presents guidelines that represent a synthesis of evidence‐based approaches and the expert consensus of this panel and are intended to aid physicians new to caring for patients with EB when operative management is indicated. With proper medical optimization and attention to detail in the operating room, patients with EB can have an uneventful perioperative course.

Anxiety Adversely Impacts Response to Cognitive Behavioral Therapy in Children with Chronic Pain.

OBJECTIVE To evaluate whether clinical anxiety in children presenting to a pediatric pain management center is associated with a poorer treatment response for those who completed pain-focused cognitive behavioral therapy (CBT). STUDY DESIGN The total sample consisted of 175 children, 40 of whom completed CBT for chronic pain. The Screen for Child Anxiety Related Emotional Disorders was completed at initial evaluation and outcome measures (average pain intensity and the Functional Disability Inventory) were collected during the initial evaluation and at the end of CBT. Group differences in outcomes were examined following CBT. The role of anxiety in CBT initiation and completion was also explored. RESULTS Presence of clinical anxiety was associated with greater initiation and/or completion of pain-focused CBT but also a poorer treatment response. Specifically, the group with subclinical anxiety exhibited a substantial reduction in pain intensity, and the group with clinical anxiety exhibited a more limited response to treatment (F [1, 36] = 13.68 P < .01). A similar effect was observed for Functional Disability Inventory, such that the group with clinical anxiety had a significantly smaller response to treatment (F [1, 38] = 4.33 P < .05). The difference in pain and disability between groups following CBT suggest moderate effects (Cohen d = 0.77 and 0.78, respectively). CONCLUSIONS Although youths with clinical anxiety are more likely to start and/or complete pain-focused CBT, anxiety has an adverse impact on CBT treatment response in children with chronic pain. Identification of patients with anxiety and use of tailored behavioral interventions may improve clinical outcomes.