Michael Dobe

Characteristics of highly impaired children with severe chronic pain: a 5-year retrospective study on 2249 pediatric pain patients

BackgroundPrevalence of pain as a recurrent symptom in children is known to be high, but little is known about children with high impairment from chronic pain seeking specialized treatment. The purpose of this study was the precise description of children with high impairment from chronic pain referred to the German Paediatric Pain Centre over a 5-year period.MethodsDemographic variables, pain characteristics and psychometric measures were assessed at the first evaluation. Subgroup analysis for sex, age and pain location was conducted and multivariate logistic regression applied to identify parameters associated with extremely high impairment.ResultsThe retrospective study consisted of 2249 children assessed at the first evaluation. Tension type headache (48%), migraine (43%) and functional abdominal pain (11%) were the most common diagnoses with a high rate of co-occurrence; 18% had some form of musculoskeletal pain disease. Irrespective of pain location, chronic pain disorder with somatic and psychological factors was diagnosed frequently (43%). 55% of the children suffered from more than one distinct pain diagnosis. Clinically significant depression and general anxiety scores were expressed by 24% and 19% of the patients, respectively. Girls over the age of 13 were more likely to seek tertiary treatment compared to boys. Nearly half of children suffered from daily or constant pain with a mean pain value of 6/10. Extremely high pain-related impairment, operationalized as a comprehensive measure of pain duration, frequency, intensity, pain-related school absence and disability, was associated with older age, multiple locations of pain, increased depression and prior hospital stays. 43% of the children taking analgesics had no indication for pharmacological treatment.ConclusionChildren with chronic pain are a diagnostic and therapeutic challenge as they often have two or more different pain diagnoses, are prone to misuse of analgesics and are severely impaired. They are at increased risk for developmental stagnation. Adequate treatment and referral are essential to interrupt progression of the chronic pain process into adulthood.

Effectiveness of a 3-week Multimodal Inpatient Pain Treatment for Adolescents Suffering From Chronic Pain : Statistical and Clinical Significance

ObjectiveThe present study aimed to investigate the effectiveness of a 3-week multimodal inpatient pain program for children and adolescents with chronic pain. MethodsEffectiveness was investigated for pain-related variables (pain intensity, pain-related disability) and emotional distress in 3 ways: (1) in terms of statistically significant changes; (2) in terms of the clinical significance of these changes by creating post-hoc outcome groups for pain-related variables and emotional distress; and (3) in terms of the clinically significant overall amelioration generalizing the outcome over 3 variables (ie, pain intensity, pain-related disability, and school absence). One hundred sixty-seven adolescents (aged between 11 and 18 y) with various pain disorders (50% with headache) who met inpatient criteria were evaluated at baseline and 3 months posttreatment. ResultsPatients demonstrated statistically significant changes in all variables with large to medium effect sizes. Seventy-two percent and 45% of the patients demonstrated clinically significant changes in pain intensity and pain-related disability, respectively. The percentages of patients demonstrating clinically significant change in emotional distress ranged from 13% to 26%. Seventy-seven adolescents demonstrated overall amelioration. DiscussionResults of the study are promising in at least 2 ways: (1) a multimodal inpatient program might stop the negative effects of chronic pain, disability, and emotional distress in children and adolescents, and (2) the exploration of clinical significance testing has demonstrated utility and can be applied to future effectiveness studies in pediatric pain.

Inpatient-based intensive interdisciplinary pain treatment for highly impaired children with severe chronic pain: Randomized controlled trial of efficacy and economic effects

Summary Intensive interdisciplinary pain treatment is effective for highly impaired children with chronic pain in terms of the childs well‐being and the economic effects. ABSTRACT Pediatric chronic pain, which can result in deleterious effects for the child, bears the risk of aggravation into adulthood. Intensive interdisciplinary pain treatment (IIPT) might be an effective treatment, given the advantage of consulting with multiple professionals on a daily basis. Evidence for the effectiveness of IIPT is scarce. We investigated the efficacy of an IIPT within a randomized controlled trial by comparing an intervention group (IG) (n = 52) to a waiting‐list control group (WCG) (n = 52). We made assessments before treatment (PRE), immediately after treatment (POST), as well as at short‐term (POST6MONTHS) and long‐term (POST12MONTHS) follow‐up. We determined a combined endpoint, improvement (pain intensity, disability, school absence), and investigated 3 additional outcome domains (anxiety, depression, catastrophizing). We also investigated changes in economic parameters (health care use, parental work absenteeism, subjective financial burden) and their relationship to the childs improvement. Results at POST showed that significantly more children in the IG than in the WCG were assigned to improvement (55% compared to 14%; Fisher P < .001; 95% confidence interval for incidence difference: 0.21% to 0.60%). Although immediate effects were achieved for disability, school absence, depression, and catastrophizing, pain intensity and anxiety did not change until short‐term follow‐up. More than 60% of the children in both groups were improved long‐term. The parents reported significant reductions in all economic parameters. The results from the present study support the efficacy of the IIPT. Future research is warranted to investigate differences in treatment response and to understand the changes in economic parameters in nonimproved children.

Effectiveness of a multimodal inpatient treatment for pediatric chronic pain: A comparison between children and adolescents

Objectives To evaluate short and long‐term treatment outcome of children (7–10 years) in comparison to adolescents (11–18 years) with disabling chronic pain following multimodal inpatient pain treatment.

Schmerzbezogene Beeinträchtigung bei Jugendlichen mit chronischen Schmerzen

ZusammenfassungHintergrundAls Folge chronischer Schmerzen leiden viele Kinder und Jugendliche unter schmerzbedingten Beeinträchtigungen, die sich auf alle Lebensbereiche auswirken können. Ein zentrales Ziel der Kinderschmerztherapie ist die Reduktion dieser schmerzbedingten Beeinträchtigungen, allerdings fehlen bisher geeignete validierte Messinstrumente. Ziel dieser Untersuchung ist die Übersetzung des Pediatric Pain Disability Index (P-PDI) von Varni und die Überprüfung seiner psychometrischen Eigenschaften.MethodenBei 163 ambulant und 167 stationär behandelten Jugendlichen mit chronischen Schmerzen (vorwiegend Kopfschmerzen) wurden Hauptkomponenten- und Itemanalysen durchgeführt. Zur Überprüfung der Stabilität wurde die Veränderung der schmerzbedingten Beeinträchtigung 3 Monate nach Beginn der ambulanten Therapie bei 110 Jugendlichen untersucht. Zudem wurden der Zusammenhang der schmerzbedingten Beeinträchtigung mit Schmerzvariablen, emotionaler Beeinträchtigung und Schulfehltagen und die Übereinstimmung zwischen Selbst- und Elterneinschätzung überprüft.ErgebnisseDer P-PDI zeigt sich als eindimensionales Messinstrument mit zufrieden stellender Reliabilität. Signifikante Zusammenhänge konnten zwischen der schmerzbedingten Beeinträchtigung und Schmerzintensität sowie Schulfehltagen aufgezeigt werden; kein Zusammenhang fand sich zu Schmerzdauer, Angst und Depression. Eltern- und Selbsteinschätzung korrelieren signifikant, jedoch schätzen 57% der Eltern die schmerzbedingte Beeinträchtigung ihrer Kinder niedriger ein als diese selbst.SchlussfolgerungMit dem P-PDI liegt erstmals ein validiertes deutschsprachiges Instrument zur Einschätzung der schmerzbedingten Beeinträchtigung bei Jugendlichen mit chronischen Schmerzen vor, das gut zur Überprüfung von Therapieeffekten genutzt werden kann.AbstractBackgroundPain-related disability affects many children and adolescents suffering from chronic pain and may exert an impact on all areas of their lives. Reduction of pain-related disability is, therefore, a fundamental aim of treatment; however, no validated means exist to assess pain-related disability in children and adolescents. The aim of this study was to translate the Pediatric Pain Disability Index (P-PDI) of Varni into German and to investigate its psychometric qualities.MethodsPrincipal component and item analyses were conducted on outpatient (n=163) and inpatient samples (n=167) of adolescents suffering from chronic pain. Changes in pain-related disability 3 months after starting treatment were analysed in an outpatient sample of 110 adolescents. Correlations between pain-related disability, emotional variables and school absence as well as concordance with parents’ ratings were investigated.ResultsThe P-PDI is a one-dimensional assessment tool with sufficient reliability. There were significant correlations between pain-related disability and pain intensity and school absence but not with pain duration, fear and depression. Parents and adolescents ratings correlated significantly, but 57% of parents underestimated the pain-related disability of their children.ConclusionThere is now a validated German version of the P-PDI to measure pain-related disability in adolescents suffering from chronic pain, which can be used in studies investigating treatment effectiveness.

Changes in pain-related coping strategies and their importance for treatment outcome following multimodal inpatient treatment: does sex matter?

UNLABELLED While sex differences in pain-related coping have been widely reported, little is known on sex differences in changes in coping following multimodal pain treatment and how these changes relate to treatment outcome. The present prospective study therefore aimed to investigate sex differences in coping strategies between boys and girls with chronic pain prior to multimodal inpatient treatment and at 3-month follow-up. Sixty-four boys and 103 girls with various pain disorders were evaluated. Core outcomes (pain intensity and pain-related disability) and coping were assessed via validated questionnaires. At admission, boys and girls used similar coping strategies. Three months following treatment, boys and girls decreased passive pain coping and seeking social support while they maintained the degree of positive self-instruction. Girls displayed higher seeking social support than boys and of importance, only for girls, a reduction in seeking social support was related to decreases in pain intensity. In both groups, the changes in coping were related to positive treatment outcome. Results suggest that both groups may benefit from reductions in passive pain coping and seeking social support. The causal quality of this relationship remains to be determined in future studies. Gender-role expectations and family interactions may account for the sex differences demonstrated for seeking social support. PERSPECTIVE Boys and girls with chronic pain show profound similarities in pain-related coping strategies prior and after multimodal pain treatment. The changes in coping are related to positive treatment outcomes. Sex-specific treatment strategies for changing seeking social support may need to be developed and tested for their differential efficacy in boys and girls.

Maintaining Lasting Improvements: One-Year Follow-Up of Children With Severe Chronic Pain Undergoing Multimodal Inpatient Treatment

OBJECTIVE To investigate the long-term effectiveness of a 3-week multimodal inpatient program for children and adolescents with chronic pain. METHODS 167 adolescents were evaluated at pretreatment baseline, 3-, and 12-month follow-up. Long-term effectiveness was investigated for pain-related variables (pain-related disability, school absence, pain intensity) and emotional distress. RESULTS We found statistically and clinically significant changes in all variables. After 1 year, the majority (56%) showed overall improvement as indexed by decreased pain-related disability or school absence. 22% had an unsuccessful treatment outcome. Those showing only short-term improvements had higher levels of emotional distress at baseline. CONCLUSIONS 1 year after completing a multimodal inpatient program adolescents report less chronic pain, disability, and emotional distress. Clinically significant changes remain stable. Adolescents with high levels of emotional distress at admission may require special attention to maintain positive treatment outcomes. Specialized inpatient therapy is effective for children with chronic pain.

Commentary: A Worldwide Call for Multimodal Inpatient Treatment for Children and Adolescents Suffering from Chronic Pain and Pain-related Disability

Children and adolescents presenting to clinicians with chronic pain and severe interferences in their daily life, such as school absence, reduced contact to peers, and emotional, sleep, and eating problems (Palermo, 2000) are not very well cared for worldwide. In contrast to children, a recent review illustrated the therapeutic network for affected adults in Germany with 18 centers in Bavaria alone providing multidisciplinary treatment programs (Arnold et al., 2009). For children, there are only four multimodal inpatient programs worldwide that have been described and evaluated in terms of their effectiveness, despite the fact that a noteworthy number of children and their families are severely affected by chronic pain and in need of multimodal inpatient treatment. Across studies from the USA (Perquin et al., 2000), Europe (Huguet & Miro, 2008; Kröner-Herwig, Heinrich, & Morris, 2007), and Canada (Shiff et al., 2009), 3% of children and adolescents suffering from chronic pain demonstrate significant pain-related disability leading to widespread negative consequences for the adolescent and family that may be difficult to treat in an outpatient setting. These children are faced with a desert of centers offering multimodal inpatient treatment which in turn, may aggravate the child’s situation. A recent Dolphi Poll on predictive factors of chronic pediatric pain and disability (Miro, Huguet, & Nieto, 2007) identified the excessive use of health care services as one factor with great influence on the chronicity of the pain experience. In accordance, Shiff et al. (2009) have recently shown that a median of three healthcare providers were seen for a median of five visits prior to treatment in a specialized pain clinic of Canadian children. In a German sample, >70% had consulted more than three physicians prior to specialized inpatient treatment (Hechler, Blankenburg, Dobe, Kosfelder, Hübner, & Zernikow, 2009). The study of Maynard, Amari, Wieczorek, Christensen, & Slifer (2009), therefore, adds to our knowledge on the effectiveness of urgently needed multimodal inpatient programs for this specific group of children and adolescents. However, some issues need clarification to carefully interpret the results presented by Maynard et al. (2009): In light of the previous studies, some of which were conducted prospectively over a period of 1–2 years (e.g. Dobe, Damschen, Reiffer-Wiesel, Sauer, & Zernikow, 2006; Sherry, Wallace, Kelley, Kidder, & Sapp, 1999), the retrospective chart analysis conducted by Maynard et al. (2009) seems to be a drawback. In line with that, the number of children included in previous studies range from 103 (Sherry et al., 1999) to 200 (Hechler, Blankenburg, et al., 2009). Hence, the sample size of 41 (of which 19 were reassessed at 3 month follow-up (Maynard et al., 2009) seems rather small. Until recently, the definition of core outcomes in clinical trials remained a matter of discussion. However, with the publication of the PedIMMPACT recommendation for assessment of core outcomes in clinical trials (McGrath et al., 2008), guidelines were established and have already been included in previous studies (Dobe et al., 2006; Eccleston, Malleson, Clinch, Connell, & Sourbut, 2003; Hechler, Blankenburg, et al., 2009; Hechler, Dobe, et al., 2009). Maynard et al. (2009) chose not to assess pain intensity in their study. However, their argument against its assessment—such as defocusing patients from the pain experience and little variability in patients’ pain scores— can be critically discussed given the recent findings. We

[Pain-related disability in adolescents suffering from chronic pain. Preliminary examination of the Pediatric Pain Disability Index (P-PDI)].

ZusammenfassungHintergrundAls Folge chronischer Schmerzen leiden viele Kinder und Jugendliche unter schmerzbedingten Beeinträchtigungen, die sich auf alle Lebensbereiche auswirken können. Ein zentrales Ziel der Kinderschmerztherapie ist die Reduktion dieser schmerzbedingten Beeinträchtigungen, allerdings fehlen bisher geeignete validierte Messinstrumente. Ziel dieser Untersuchung ist die Übersetzung des Pediatric Pain Disability Index (P-PDI) von Varni und die Überprüfung seiner psychometrischen Eigenschaften.MethodenBei 163 ambulant und 167 stationär behandelten Jugendlichen mit chronischen Schmerzen (vorwiegend Kopfschmerzen) wurden Hauptkomponenten- und Itemanalysen durchgeführt. Zur Überprüfung der Stabilität wurde die Veränderung der schmerzbedingten Beeinträchtigung 3 Monate nach Beginn der ambulanten Therapie bei 110 Jugendlichen untersucht. Zudem wurden der Zusammenhang der schmerzbedingten Beeinträchtigung mit Schmerzvariablen, emotionaler Beeinträchtigung und Schulfehltagen und die Übereinstimmung zwischen Selbst- und Elterneinschätzung überprüft.ErgebnisseDer P-PDI zeigt sich als eindimensionales Messinstrument mit zufrieden stellender Reliabilität. Signifikante Zusammenhänge konnten zwischen der schmerzbedingten Beeinträchtigung und Schmerzintensität sowie Schulfehltagen aufgezeigt werden; kein Zusammenhang fand sich zu Schmerzdauer, Angst und Depression. Eltern- und Selbsteinschätzung korrelieren signifikant, jedoch schätzen 57% der Eltern die schmerzbedingte Beeinträchtigung ihrer Kinder niedriger ein als diese selbst.SchlussfolgerungMit dem P-PDI liegt erstmals ein validiertes deutschsprachiges Instrument zur Einschätzung der schmerzbedingten Beeinträchtigung bei Jugendlichen mit chronischen Schmerzen vor, das gut zur Überprüfung von Therapieeffekten genutzt werden kann.AbstractBackgroundPain-related disability affects many children and adolescents suffering from chronic pain and may exert an impact on all areas of their lives. Reduction of pain-related disability is, therefore, a fundamental aim of treatment; however, no validated means exist to assess pain-related disability in children and adolescents. The aim of this study was to translate the Pediatric Pain Disability Index (P-PDI) of Varni into German and to investigate its psychometric qualities.MethodsPrincipal component and item analyses were conducted on outpatient (n=163) and inpatient samples (n=167) of adolescents suffering from chronic pain. Changes in pain-related disability 3 months after starting treatment were analysed in an outpatient sample of 110 adolescents. Correlations between pain-related disability, emotional variables and school absence as well as concordance with parents’ ratings were investigated.ResultsThe P-PDI is a one-dimensional assessment tool with sufficient reliability. There were significant correlations between pain-related disability and pain intensity and school absence but not with pain duration, fear and depression. Parents and adolescents ratings correlated significantly, but 57% of parents underestimated the pain-related disability of their children.ConclusionThere is now a validated German version of the P-PDI to measure pain-related disability in adolescents suffering from chronic pain, which can be used in studies investigating treatment effectiveness.

Schmerzbezogene Copingstrategien von Kindern und Jugendlichen mit chronischen Schmerzen

Validated intruments for measuring coping in children and adolescents with chronic pain are rare in Germany. Using a sample of 180 out-patient children with chronic pain, a main component analysis was performed as well as cross-validations with out-patient and in-patient treated children. The scales of the PPCI-R showed significant relationships to pain characteristics and emotional stress. Different alterations were found in the PPCI-R scales in children with migraine and those with tension-type headache. The PPCI revised is therefore a validated instrument for measuring coping an can be implemented e.g. in treatment studies for children suffering from chronic pain.