Tasha Murphy

Pain complaint-exercise performance relationship in chronic pain☆

Abstract Chronic pain patients typically display reduced activity level attributed to pain and implying a positive correlation between exercise or activity and pain complaints. This study correlated observed pain complaints with amount of prescribed exercise performed by chronic pain patients when exercising to tolerance. Patients were in evaluation of earliest stages of multi‐modal treatment. Exercises were physician prescribed to assess use of involved body parts and to promote general activity level. Patients were instructed to do exercise repetitions until pain, weakness of fatigue caused them to stop. Patients decided when to stop. Observations of amount of exercise performed were correlated with observed visible or audible indications of pain or suffering (pain behaviors). Results indicate a consistent negative relationship, i.e., the more exercise performed, the fewer the pain behaviors. This finding is contrary to the frequently observed physician prescription with chronic pain to limit exercise when pain increases.

Biopsychosocial Aspects of Functional Gastrointestinal Disorders: How Central and Environmental Processes Contribute to the Development and Expression of Functional Gastrointestinal Disorders

In this paper, we provide a general framework for understanding the functional gastrointestinal disorders (FGID) from a biopsychosocial perspective. More specifically, we provide an overview of the recent research on how the complex interactions of environmental, psychological, and biological factors contribute to the development and maintenance of the FGID. We emphasize that considering and addressing all these factors is a conditio sine qua non for appropriate treatment of these conditions. First, we provide an overview of what is currently known about how each of these factors - the environment, including the influence of those in an individuals family, the individuals own psychological states and traits, and the individuals (neuro)physiological make-up - interact to ultimately result in the generation of FGID symptoms. Second, we provide an overview of commonly used assessment tools which can assist clinicians in obtaining a more comprehensive assessment of these factors in their patients. Finally, the broader perspective outlined earlier is applied to provide an overview of centrally acting treatment strategies, both psychological and pharmacological, which have been shown to be efficacious to treat FGID.

Cognitive Mediators of Treatment Outcomes in Pediatric Functional Abdominal Pain

Objectives:Cognitive-behavioral (CB) interventions improve outcomes for many pediatric health conditions, but little is known about which mechanisms mediate these outcomes. The goal of this study was to identify whether changes in targeted process variables from baseline to 1 week posttreatment mediate improvement in outcomes in a randomized controlled trial of a brief CB intervention for idiopathic childhood abdominal pain. Materials and Methods:Two hundred children with persistent functional abdominal pain and their parents were randomly assigned to 1 of 2 conditions: a 3-session social learning and CB treatment (N=100), or a 3-session educational intervention controlling for time and attention (N=100). Outcomes were assessed at 3-, 6-, and 12-month follow-ups. The intervention focused on altering parental responses to pain and on increasing adaptive cognitions and coping strategies related to pain in both parents and children. Results:Multiple mediation analyses were applied to examine the extent to which the effects of the social learning and CB treatment condition on child gastrointestinal (GI) symptom severity and pain as reported by children and their parents were mediated by changes in targeted cognitive process variables and parents’ solicitous responses to their child’s pain symptoms. Reductions in parents’ perceived threat regarding their child’s pain mediated reductions in both parent-reported and child-reported GI symptom severity and pain. Reductions in children’s catastrophic cognitions mediated reductions in child-reported GI symptom severity but no other outcomes. Reductions in parental solicitousness did not mediate outcomes. Discussion:Results suggest that reductions in reports of children’s pain and GI symptoms after a social learning and CB intervention were mediated at least in part by decreasing maladaptive parent and child cognitions.

Brief telephone-delivered cognitive behavioral therapy targeted to parents of children with functional abdominal pain: A randomized controlled trial

Pediatric functional abdominal pain disorders (FAPD) are associated with increased healthcare utilization, school absences, and poor quality of life (QoL). Cost-effective and accessible interventions are needed. This multi-site study tested the effects of a 3-session cognitive-behavioral intervention delivered to parents, in person or remotely, on the primary outcome of pain severity and secondary outcomes (process measures) of parental solicitousness, pain beliefs, catastrophizing, and child-reported coping. Additional outcomes hypothesized a priori and assessed included functional disability, quality of life, pain behavior, school absences, healthcare utilization, and gastrointestinal symptoms. The study was prospective and longitudinal (baseline, 3 and 6 months follow-up) with three randomized conditions: social learning and cognitive-behavioral therapy in-person (SLCBT) or by phone (SLCBT-R) and education/support condition by phone (ES-R). Participants were children aged 7-12 with FAPD and their parents (N = 316 dyads). While no significant treatment effect for pain severity was found, the SLCBT groups showed significantly greater improvements compared to controls on process measures of parental solicitousness, pain beliefs and catastrophizing, and additional outcomes of parent-reported functional disability, pain behaviors, child healthcare visits for abdominal pain, and (remote condition only) quality of life and missed school days. No effects were found for parent and child- reported gastrointestinal symptoms, or child- reported quality of life or coping. These findings suggest that for children with FAPD, a brief phone SLCBT for parents can be similarly effective as in-person SLCBT in changing parent responses and improving outcomes, if not reported pain and symptom report, compared to a control condition.

Comparative Estimates of Crude and Effective Coverage of Measles Immunization in Low-Resource Settings: Findings from Salud Mesoamérica 2015.

Timely and accurate measurement of population protection against measles is critical for decision-making and prevention of outbreaks. However, little is known about how survey-based estimates of immunization (crude coverage) compare to the seroprevalence of antibodies (effective coverage), particularly in low-resource settings. In poor areas of Mexico and Nicaragua, we used household surveys to gather information on measles immunization from child health cards and caregiver recall. We also collected dried blood spots (DBS) from children aged 12 to 23 months to compare crude and effective coverage of measles immunization. We used survey-weighted logistic regression to identify individual, maternal, household, community, and health facility characteristics that predict gaps between crude coverage and effective coverage. We found that crude coverage was significantly higher than effective coverage (83% versus 68% in Mexico; 85% versus 50% in Nicaragua). A large proportion of children (19% in Mexico; 43% in Nicaragua) had health card documentation of measles immunization but lacked antibodies. These discrepancies varied from 0% to 100% across municipalities in each country. In multivariate analyses, card-positive children in Mexico were more likely to lack antibodies if they resided in urban areas or the jurisdiction of De Los Llanos. In contrast, card-positive children in Nicaragua were more likely to lack antibodies if they resided in rural areas or the North Atlantic region, had low weight-for-age, or attended health facilities with a greater number of refrigerators. Findings highlight that reliance on child health cards to measure population protection against measles is unwise. We call for the evaluation of immunization programs using serological methods, especially in poor areas where the cold chain is likely to be compromised. Identification of within-country variation in effective coverage of measles immunization will allow researchers and public health professionals to address challenges in current immunization programs.

Selective screening for atrial fibrillation using multivariable risk models

Objective Atrial fibrillation can lead to stroke if untreated, and identifying those at higher risk is necessary for cost-effective screening for asymptomatic, paroxysmal atrial fibrillation. Age has been proposed to identify those at risk, but risk models may provide better discrimination. This study compares atrial fibrillation risk models with age for screening for atrial fibrillation. Methods Nine atrial fibrillation risk models were compared using the Atherosclerosis Risk in Communities study (11 373 subjects, 60.0±5.7 years old). A new risk model (Screening for Asymptomatic Atrial Fibrillation Events—SAAFE) was created using data collected in the Monitoring Disparities in Chronic Conditions study (3790 subjects, 58.9±15.3 years old). The primary measure was the fraction of incident atrial fibrillation subjects who should receive treatment due to a high CHA2DS2-VASc score identified when screening a fixed number equivalent to the age criterion. Secondary measures were the C statistic and net benefit. Results Five risk models were significantly better than age. Age identified 71 (61%) of the subjects at risk for stroke who subsequently developed atrial fibrillation, while the best risk model identified 96 (82%). The newly developed SAAFE model identified 95 (81%), primarily based on age, congestive heart failure and coronary artery disease. Conclusions Use of a risk model increases identification of subjects at risk for atrial fibrillation. One of the best performing models (SAAFE) does not require an ECG for its application, so that it could be used instead of age as a screening criterion without adding to the cost.

Eating behaviors and quality of life in preadolescents at risk for obesity with and without abdominal pain

Objectives: We evaluated eating behaviors and quality of life (QOL) in preadolescent children at risk for obesity, with and without abdominal pain (AP). Methods: Participants were parent–child dyads enrolled in a randomized, controlled obesity prevention trial. The children were between 5 and 10 years of age and at risk for obesity (70th–95th percentile of body mass index, n = 420). Parents completed measures of their childs eating behaviors, QOL, AP, and bowel function and their own depression status, concern about child weight, and feeding practices. Childrens height and weight were also measured. Results: Children with frequent AP (≥2/month, n = 103) were compared with children reporting infrequent AP (<2/month, n = 312). Age and body mass index did not differ between groups, but AP was more prevalent in girls. Child emotional overeating and parental depression scores were higher in the frequent AP group (P < 0.01), and child QOL was lower (P < 0.01). In multivariable analysis, female gender (odds ratio [OR] 2.18, 95% confidence interval [CI] 1.20–3.97), emotional overeating (OR 2.28, 95% CI 1.37–3.81), and parental depression (OR 1.23, 95% CI 1.12–1.35) were associated with more frequent AP. Secondary analyses were completed for children who met Rome III criteria for irritable bowel syndrome. Conclusions: Clinicians working with children with AP at risk for obesity should consider assessing for and, when appropriate, addressing parent and child factors that could exacerbate AP.

Health and wealth in Mesoamerica: findings from Salud Mesomérica 2015.

BackgroundIndividual income and poverty are associated with poor health outcomes. The poor face unique challenges related to access, education, financial capacity, environmental effects, and other factors that threaten their health outcomes.MethodsWe examined the variation in the health outcomes and health behaviors among the poorest quintile in eight countries of Mesoamerica using data from the Salud Mesomérica 2015 baseline household surveys. We used multivariable logistic regression to measure the association between delivering a child in a health facility and select household and maternal characteristics, including education and measures of wealth.ResultsHealth indicators varied greatly between geographic segments. Controlling for other demographic characteristics, women with at least secondary education were more likely to have an in-facility delivery compared to women who had not attended school (OR: 3.20, 95 % confidence interval [CI]: 2.56-3.99, respectively). Similarly, women from households with the highest expenditure were more likely to deliver in a health facility compared to those from the lowest expenditure households (OR 3.06, 95 % CI: 2.43-3.85). Household assets did not impact these associations. Moreover, we found that commonly-used definitions of poverty do not align with the disparities in health outcomes observed in these communities.ConclusionsAlthough poverty measured by expenditure or wealth is associated with health disparities or health outcomes, a composite indicator of health poverty based on coverage is more likely to focus attention on health problems and solutions. Our findings call for the public health community to define poverty by health coverage measures rather than income or wealth. Such a health-poverty metric is more likely to generate attention and mobilize targeted action by the health communities than our current definition of poverty.

Maladaptive Coping and Depressive Symptoms Partially Explain the Association Between Family Stress and Pain-Related Distress in Youth With IBD

Objective To extend existing research on the pain burden experienced by youth with inflammatory bowel disease (IBD) by examining the complexity of psychosocial factors involved in pain-related distress. Methods Parents completed measures of family stress and their childs pain-related expressions of distress and coping. Youth with IBD rated their depressive symptoms (n = 183 dyads). Mediation analyses were performed using regression-based techniques and bootstrapping. Results Greater family stress was positively related to childrens pain-related expressions of distress and passive coping. Significant indirect effects were found in the relationship between family stress and expressed pain-related distress through parent-reported passive coping, depressive symptoms, and both passive coping and depressive symptoms sequentially. Conclusions Results suggest that family stress can place children at risk for greater expressed pain-related distress through effects on coping and depressive symptoms. Addressing psychosocial difficulties is important for closing the gap between disability and health in youth with IBD.

Comparative estimates of immunisation coverage from three different sources: results from the SM2015 evaluation

Abstract Background Estimating vaccination coverage is challenging in resource-poor settings where accurate records are sparse. Household surveys, a key source of coverage information, typically capture data from child health cards and rely on maternal recall when cards are unavailable. As a result, little is known about how coverage estimates based on maternal recall differ from those based on health cards for the same children. Furthermore, little is known about how these measures compare with actual rates of seroconversion, which could be used to estimate effective coverage of immunisations. This study compares the accuracy of maternal recall, health card documentation, and antibody presence in vaccination coverage estimates in the state of Chiapas, Mexico. Methods Data for this study were collected as part of the Mesoamerican Health Initiative 2015 baseline survey. A random sample of 4700 households with children under-5 and women of reproductive age were surveyed. A pre-survey census was carried out within segments that had been randomly selected with probability proportional to size. Standardised multilingual household surveys were implemented using netbooks. Anthropometric measurements were collected for all children under-5 and dry blood spot samples for the detection of measles antibodies were collected from children aged 12–23 months. Findings Preliminary results suggest that maternal recall, child health cards, and antibody tests generate differing estimates of immunisation coverage. Recall differs from card-based estimates of vaccination coverage by up to 40 percentage points. There are potentially considerable differences in measles immunisation coverage as assessed by the presence of measles antibodies versus other survey sources, highlighting weaknesses in card accuracy, card coverage, and vaccine administration. Interpretation Current national estimates of immunisation coverage based on the combination of maternal recall and childrens health cards may be overestimating actual protection against vaccine-preventable diseases. Correcting for biases in recall and card coverage may produce more accurate estimates of intervention coverage. Funding Salud Mesoamerica 2015 is funded by the Bill & Melinda Gates Foundation, the Carlos Slim Health Institute, and the Government of Spain and is administered by the Inter-American Development Bank. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funders or the Inter-American Development Bank.