Marie Kanstrup

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.

Insomnia in paediatric chronic pain and its impact on depression and functional disability

Children and adolescents attending health care due to chronic pain commonly presents with insomnia. Previous research suggests that problems with sleep are associated with depression and functional disability. However, more research is needed to clarify the relationship between pain, insomnia and disability.

A Clinical Pilot Study of Individual and Group Treatment for Adolescents with Chronic Pain and Their Parents: Effects of Acceptance and Commitment Therapy on Functioning.

Pediatric chronic pain is common and can result in substantial long-term disability. Previous studies on acceptance and commitment therapy (ACT) have shown promising results in improving functioning in affected children, but more research is still urgently needed. In the current clinical pilot study, we evaluated an ACT-based interdisciplinary outpatient intervention (14 sessions), including a parent support program (four sessions). Adolescents were referred to the clinic if they experienced disabling chronic pain. They were then randomized, along with their parents, to receive group (n = 12) or individual (n = 18) treatment. Adolescent pain interference, pain reactivity, depression, functional disability, pain intensity and psychological flexibility, along with parent anxiety, depression, pain reactivity and psychological flexibility were assessed using self-reported questionnaires. There were no significant differences in outcomes between individual and group treatment. Analyses illustrated significant (p < 0.01) improvements (medium to large effects) in pain interference, depression, pain reactivity and psychological flexibility post-treatment. Additionally, analyses showed significant (p < 0.01) improvements (large effects) in parent pain reactivity and psychological flexibility post-treatment. On all significant outcomes, clinically-significant changes were observed for 21%–63% of the adolescents across the different outcome measures and in 54%–76% of the parents. These results support previous findings and thus warrant the need for larger, randomized clinical trials evaluating the relative utility of individual and group treatment and the effects of parental interventions.

Low-grade inflammation may moderate the effect of behavioral treatment for chronic pain in adults

The purpose of the present pilot study was to explore the moderating role of basal inflammation on the effects of behavioral pain treatment in 41 patients with long-standing pain. Baseline pro-inflammatory status moderated behavioral treatment outcomes: higher pre-treatment levels of Tumor Necrosis Factor (TNF)-α and Interleukin (IL)-6 were related to less improvement in pain intensity, psychological inflexibility and in mental health-related quality of life. The treatment outcomes improved in the subgroup that had low levels of pro-inflammatory cytokines at baseline, while the subjects with higher pro-inflammatory status did not. Altogether, results indicate that low-grade inflammation may influence the behavioral treatment outcomes and provide a possible explanation of the heterogeneity in treatment response.

Evaluating the Statistical Properties of the Pain Interference Index in Children and Adolescents with Chronic Pain.

&NA; The high prevalence of chronic debilitating pain in pediatric populations calls for more knowledge regarding the impact of pain on functioning or pain interference. This in turn requires valid and reliable instruments to adequately assess the impact of pain on functioning. Also, adequate measures of pain interference are important in evaluations of behavioral interventions aimed at improving functioning. Objective: The objectives of this study were to evaluate the statistical properties of the Pain Interference Index (PII), including the factor structure, internal consistency, and concurrent criteria validity of the instrument. Method: Data were collected from a consecutive sample of children and adolescents referred to a tertiary pain clinic due to chronic pain (n = 163). A principal component analysis was used to investigate the latent factor structure of items. The internal consistency was assessed by Cronbachs alpha. A set of hierarchical regression analyses was conducted to evaluate the ability of instruments to predict levels of depression and functional disability. Results: Analyses indicated the adequacy of a 1-factor solution with a total of 6 items. The intercorrelation between items and the scales reliability was satisfactory. Furthermore, bivariate correlations and hierarchical regression analyses illustrate the concurrent criteria validity of the instrument. Conclusion: Results support the use of PII as an adequate instrument to assess pain interference in children and adolescents with chronic pain.

The Parent Psychological Flexibility Questionnaire (PPFQ): Item Reduction and Validation in a Clinical Sample of Swedish Parents of Children with Chronic Pain

In pediatric chronic pain, research indicates a positive relation between parental psychological flexibility (i.e., the parent’s willingness to experience distress related to the child’s pain in the service of valued behavior) and level of functioning in the child. This points to the utility of targeting parental psychological flexibility in pediatric chronic pain. The Parent Psychological Flexibility Questionnaire (PPFQ) is currently the only instrument developed for this purpose, and two previous studies have indicated its reliability and validity. The current study sought to validate the Swedish version of the 17-item PPFQ (PPFQ-17) in a sample of parents (n = 263) of children with chronic pain. Factor structure and internal reliability were evaluated by means of principal component analysis (PCA) and Cronbach’s alpha. Concurrent criterion validity was examined by hierarchical multiple regression analyses with parental anxiety and depression as outcomes. The PCA supported a three-factor solution with 10 items explaining 69.5% of the total variance. Cronbach’s alpha (0.86) indicated good internal consistency. The 10-item PPFQ (PPFQ-10) further explained a significant amount of variance in anxiety (29%), and depression (35.6%), confirming concurrent validity. In conclusion, results support the reliability and validity of the PPFQ-10, and suggest its usefulness in assessing psychological flexibility in parents of children with chronic pain.

Pain Interference Mediates the Relationship between Pain and Functioning in Pediatric Chronic Pain

Pediatric chronic pain is a major health problem commonly associated with impaired functioning. There is a great need for more knowledge regarding the complex interplay between demographic variables such as age and gender, pain, and functioning in pediatric chronic pain. Objective: The objective of the study was to investigate if; (1) pediatric chronic pain patients with high and low levels of functioning differ in demographic variables, pain, and pain interference; (2) explore the mediating function of pain interference in the relationship between pain and functioning (i.e., depression and functional disability). Method: The study includes a consecutive sample of children and adolescents referred to a tertiary pain clinic due to chronic pain (n = 163). Cross-sectional data was analyzed to investigate the interrelationships between variables. Analyses of indirect effects were used to assess the impact of pain interference on the relation between pain and depression. Results: Findings illustrate high levels of depression, school absence and pain interference in this sample. Furthermore, pain interference mediated the relationship between pain and depression. Conclusion: Thus, this study adds to the growing support of findings suggesting that functioning and pain interference should be routinely assessed in pediatric chronic pain and a central target in treatment. Particularly, these findings imply a need for interventions specifically aimed at improved functioning for patients with chronic debilitating pain.

Evaluation of an intensive interdisciplinary pain treatment based on Acceptance and Commitment Therapy for adolescents with chronic pain and their parents: A non-randomized clinical trial

Objective 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. Methods 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 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. Conclusions 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.