Soumitri Sil

Long-Term Outcomes of Adolescents With Juvenile-Onset Fibromyalgia in Early Adulthood

OBJECTIVE: This prospective longitudinal study examined the long-term physical and psychosocial outcomes of adolescents with juvenile-onset fibromyalgia (JFM), compared with healthy control subjects, into early adulthood. METHODS: Adolescent patients with JFM initially seen at a pediatric rheumatology clinic (n = 94) and age- and gender-matched healthy control subjects (n = 33) completed online measures of demographic characteristics, pain, physical functioning, mood symptoms, and health care utilization at ∼6 years’ follow-up (mean age: 21 years). A standard in-person tender-point examination was conducted. RESULTS: Patients with JFM had significantly higher pain (P < .001), poorer physical function (P < .001), greater anxiety (P < .001) and depressive symptoms (P < .001), and more medical visits (P < .001)than control subjects. The majority (>80%) of JFM patients continued to experience fibromyalgia symptoms into early adulthood, and 51.1% of the JFM sample met American College of Rheumatology criteria for adult fibromyalgia at follow-up. Patients with JFM were more likely than control subjects to be married and less likely to obtain a college education. CONCLUSIONS: Adolescent patients with JFM have a high likelihood of continued fibromyalgia symptoms into young adulthood. Those who met criteria for fibromyalgia in adulthood exhibited the highest levels of physical and emotional impairment. Emerging differences in educational attainment and marital status were also found in the JFM group. JFM is likely to be a long-term condition for many patients, and this study for the first time describes the wide-ranging impact of JFM on a variety of physical and psychosocial outcomes that seem to diverge from their same-age peers.

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.

Identifying Treatment Responders and Predictors of Improvement after Cognitive-Behavioral Therapy for Juvenile Fibromyalgia

Summary A clinically significant change in functional disability for adolescents with fibromyalgia comprised an approximate 8‐point reduction in disability scores and a reduction in disability grade after cognitive‐behavioral treatment (CBT). ABSTRACT The primary objective of this study was to estimate a clinically significant and quantifiable change in functional disability to identify treatment responders in a clinical trial of cognitive‐behavioral therapy (CBT) for youth with juvenile fibromyalgia (JFM). The second objective was to examine whether baseline functional disability (Functional Disability Inventory), pain intensity, depressive symptoms (Childrens Depression Inventory), coping self‐efficacy (Pain Coping Questionnaire), and parental pain history predicted treatment response in disability at 6‐month follow‐up. Participants were 100 adolescents (11–18 years of age) with JFM enrolled in a recently published clinical trial comparing CBT to a fibromyalgia education (FE) intervention. Patients were identified as achieving a clinically significant change in disability (ie, were considered treatment responders) if they achieved both a reliable magnitude of change (estimated as a ≥7.8‐point reduction on the FDI) using the Reliable Change Index, and a reduction in FDI disability grade based on established clinical reference points. Using this rigorous standard, 40% of patients who received CBT (20 of 50) were identified as treatment responders, compared to 28% who received FE (14 of 50). For CBT, patients with greater initial disability and higher coping efficacy were significantly more likely to achieve a clinically significant improvement in functioning. Pain intensity, depressive symptoms, and parent pain history did not significantly predict treatment response. Estimating clinically significant change for outcome measures in behavioral trials sets a high bar but is a potentially valuable approach to improve the quality of clinical trials, to enhance interpretability of treatment effects, and to challenge researchers to develop more potent and tailored interventions.

Preliminary Evidence of Altered Biomechanics in Adolescents With Juvenile Fibromyalgia

Juvenile fibromyalgia (FM) is characterized by chronic musculoskeletal pain and marked reduction in physical activity. Despite recommendations for exercise to manage juvenile FM pain, exercise adherence is poor. Because of pain and activity avoidance, adolescents with juvenile FM are at risk for altered joint mechanics that may make them susceptible to increased pain and reduced tolerance for exercise. The primary aim of this study was to assess functional deficits in patients with juvenile FM compared to healthy controls using objective biomechanical assessment.

Child pain catastrophizing mediates the relation between parent responses to pain and disability in youth with functional abdominal pain.

Objectives: Functional abdominal pain (FAP) in youth is associated with substantial impairment in functioning, and prior research has shown that overprotective parent responses can heighten impairment. Little is known about how a range of parental behaviors (overprotection, minimizing, and/or encouragement) in response to their childs pain interact with child coping characteristics (eg, catastrophizing) to influence functioning in youth with FAP. In this study, it was hypothesized that the relation between parenting factors and child disability would be mediated by childrens levels of maladaptive coping (ie, pain catastrophizing). Methods: Seventy-five patients with FAP presenting to a pediatric pain clinic and their caregivers participated in the study. Youth completed measures of pain intensity (Numeric Rating Scale), pain catastrophizing (Pain Catastrophizing Scale), and disability (Functional Disability Inventory). Caregivers completed measures of parent pain catastrophizing (Pain Catastrophizing Scale), and parent responses to child pain behaviors (Adult Responses to Child Symptoms: Protection, Minimizing, and Encouragement/Monitoring subscales). Results: Increased functional disability was significantly related to higher child pain intensity, increased child and parent pain catastrophizing, and higher levels of encouragement/monitoring and protection. Parent minimization was not related to disability. Child pain catastrophizing fully mediated the relation between parent encouragement/monitoring and disability and partially mediated the relation between parent protectiveness and disability. Conclusions: The impact of parenting behaviors in response to FAP on child disability is determined, in part, by the childs coping style. Findings highlight a more nuanced understanding of the parent–child interaction in determining pain-related disability levels, which should be taken into consideration in assessing and treating youth with FAP.

A Qualitative Examination of a New Combined Cognitive-Behavioral and Neuromuscular Training Intervention for Juvenile Fibromyalgia.

Objectives:Adolescents with juvenile fibromyalgia (JFM) are typically sedentary despite recommendations for physical exercise, a key component of pain management. Interventions such as cognitive-behavior therapy (CBT) are beneficial but do not improve exercise participation. The objective of this study was to obtain preliminary information about the feasibility, safety, and acceptability of a new intervention—Fibromyalgia Integrative Training for Teens (FIT Teens), which combines CBT with specialized neuromuscular exercise training modified from evidence-based injury prevention protocols. Materials and Methods:Participants were 17 adolescent females (aged 12 to 18 y) with JFM. Of these, 11 completed the 8-week (16 sessions) FIT Teens program in a small-group format with 3 to 4 patients per group. Patients provided detailed qualitative feedback via individual semistructured interviews after treatment. Interview content was coded using thematic analysis. Interventionist feedback about treatment implementation was also obtained. Results:The intervention was found to be feasible, well tolerated, and safe for JFM patients. Barriers to enrollment (50% of those approached) included difficulties with transportation or time conflicts. Treatment completers enjoyed the group format and reported increased self-efficacy, strength, and motivation to exercise. Participants also reported decreased pain and increased energy levels. Feedback from participants and interventionists was incorporated into a final treatment manual to be used in a future trial. Discussion:Results of this study provided initial support for the new FIT Teens program. An integrative strategy of combining pain coping skills via CBT enhanced with tailored exercise specifically designed to improve confidence in movement and improving activity participation holds promise in the management of JFM.

Psychosocial and Functional Outcomes in Youth With Chronic Sickle Cell Pain.

Objective:To describe chronic pain—pain that is present most days per month over the past 3 months—in youth with sickle cell disease (SCD). This study characterized differences in functional outcomes, psychosocial characteristics, and health care utilization for youth with SCD across 3 groups based on pain frequency: chronic pain, episodic pain, and no SCD pain in the past month. Materials and Methods:Children and adolescents (aged 8 to 18 y) with SCD and their parents (n=100) completed measures of functional disability, health-related quality of life, depressive symptoms, pain catastrophizing, pain beliefs, and health care utilization during an outpatient comprehensive sickle cell clinic appointment. On the basis of pain frequency and duration, patients were categorized as follows: (1) chronic (≥3 d of pain per week in the past month lasting ≥3 mo; range, 12 to 31 d/mo), (2) episodic (<3 d of pain per week for the past month; range, 1 to 10 d/mo), and (3) no SCD pain in the past month. Results:Consistent with other pediatric chronic pain conditions, youth characterized as having chronic sickle pain (n=40) reported significantly greater functional disability, depressive symptoms, and inpatient admissions for pain relative to patients characterized with having episodic SCD pain (n=40) or no SCD pain (n=20). The chronic and episodic pain groups had comparable levels of pain intensity, pain catastrophizing, and quality of life. Discussion:Specific definitions and criteria for chronic sickle pain in youth are needed. Identifying risk and protective factors related to the transition from acute to chronic pain is important to facilitate improved psychosocial functioning.

Psychiatric Disorders in Young Adults Diagnosed with Juvenile Fibromyalgia in Adolescence.

Objective. Adolescents with juvenile-onset fibromyalgia (JFM) have increased rates of psychiatric disorders, but to our knowledge no studies have examined psychiatric disorders in adolescents with JFM when they enter young adulthood. This study examined the prevalence of psychiatric disorders in young adults diagnosed with JFM during adolescence and the relationship between mental health diagnoses and physical functioning. Methods. Ninety-one young adults (mean age 21.60, SD 1.96) with a history of JFM being followed as part of a prospective longitudinal study and 30 matched healthy controls (mean age 21.57, SD 1.55) completed a structured interview of psychiatric diagnoses and a self-report measure of physical impairment. Results. Young adults with a history of JFM were more likely to have current and lifetime histories of anxiety disorders (70.3% and 76.9%, respectively) compared with controls (33.3% for both, both p < 0.001). Individuals with JFM were also more likely to have current and lifetime histories of major mood disorders (29.7% and 76.9%, respectively) compared with controls (10% and 40%, p < 0.05). The presence of a current major mood disorder was significantly related to impairment in physical functioning [F (1, 89) = 8.30, p < 0.01] and role limitations attributable to a physical condition [F (1, 89) = 7.09, p < 0.01]. Conclusion. Psychiatric disorders are prevalent in young adulthood for individuals with a history of JFM, and a current major mood disorder is associated with greater physical impairment. Greater attention to early identification and treatment of mood disorders in patients with JFM is warranted.

Preliminary outcomes of a cross‐site cognitive‐behavioral and neuromuscular integrative training intervention for juvenile fibromyalgia

Cognitive–behavioral therapy (CBT) is effective in reducing disability among youth with juvenile fibromyalgia (FM); however, engagement in moderate to vigorous physical activity remains poor, even after CBT. The purpose of this study was to evaluate the feasibility and preliminary outcomes of an innovative program combining CBT with specialized neuromuscular exercise: the Fibromyalgia Integrative Training for Teens (FIT Teens) program.

A pilot study of biomechanical assessment before and after an integrative training program for adolescents with juvenile fibromyalgia.

BackgroundAdolescents with juvenile fibromyalgia (JFM) tend to be very sedentary and avoid participation in physical activity. A prior study suggested that JFM patients show altered biomechanics compared to healthy adolescents which may make them more prone to pain/injury during exercise. A new intervention combining well established cognitive behavioral therapy (CBT) techniques with specialized neuromuscular exercise —Fibromyalgia Integrative Training for Teens (FIT Teens) was developed and shown to be promising in improving functioning in adolescents with JFM. In contrast to traditional exercise programs such as aerobic or resistance training, neuromuscular training is a tailored approach which targets gait, posture, balance and movement mechanics which form the foundation for safe exercise participation with reduced risk for injury or pain (and hence more tolerable by JFM patients). The aim of this pilot feasibility study was to establish whether objective biomechanical assessment including sophisticated 3-D motion analysis would be useful in measuring improvements in strength, balance, gait, and functional performance after participation in the 8-week FIT Teens program.MethodsEleven female participants with JFM (ages 12–18 years) completed pre- and post-treatment assessments of biomechanics, including walking gait analysis, lower extremity strength assessment, functional performance, and dynamic postural stability.ResultsDescriptive data indicated that mechanics of walking gait and functional performance appeared to improve after treatment. Hip abduction strength and dynamic postural control also demonstrated improvements bilaterally.ConclusionsOverall, the results of this pilot study offer initial evidence for the utility of biomechanical assessment to objectively demonstrate observable changes in biomechanical performance after an integrated training intervention for youth with JFM. If replicated in larger controlled studies, findings would suggest that through the FIT Teens intervention, adolescents with JFM can progress towards normalized strength and biomechanics, which may enhance their ability to engage in physical exercise.