Graded exposure treatment for adolescents with chronic pain (GET Living): Protocol for a randomized controlled trial enhanced with single case experimental design.
Contemporary clinical trials communications
Simons, L. E., Harrison, L. E., O'Brien, S. F., Heirich, M. S., Loecher, N., Boothroyd, D. B., Vlaeyen, J. W., Wicksell, R. K., Schofield, D., Hood, K. K., Orendurff, M., Chan, S., Lyons, S.
2019; 16: 100448
Abstract
Chronic musculoskeletal pain in adolescence is a significant public health concern with 3-5% of adolescents suffering from significant pain-related disability. Pain-related fear and avoidance of activities has been found to have a significant influence on pain outcomes in children and adolescents and is a risk factor for less favorable response to treatment. To address this need, we developed graded exposure treatment for youth with chronic pain (GET Living). We describe the rationale, design, and implementation of a two-group randomized controlled trial (RCT) enhanced with single-case experimental design (SCED) methodology with a sample of 74 adolescents with chronic musculosketal pain and their parent caregivers. GET Living includes education, behavioral exposures, and parent intervention jointly delivered by pain psychology and physical therapy providers. The multidisciplinary pain management control group includes pain psychology delivered education and pain self-management skills training (e.g., relaxation, cognitive skills) and separate physical therapy. Assessments include brief daily diaries (baseline to discharge, 7-days at 3-month and 6-month follow-up), comprehensive in-person evaluations at baseline and discharge, and questionnaire across all time points (baseline, discharge, 3-month and 6-month follow-up). Primary outcome is pain-related fear avoidance. Secondary outcome is functional disability. We also outline all additional outcomes, exploratory outcomes, covariates, and implementation measures. The objective is to offer a mechanism-based, targeted intervention to youth with musculoskeletal pain to enhance likelihood of return to function.
View details for DOI 10.1016/j.conctc.2019.100448
View details for PubMedID 31650069
Abstract
Headache is a common presenting complaint in emergency departments (EDs), with the goal of improving acute pain. However, youth with chronic headaches may demonstrate broad functional impairment in their lives due to headaches. Our objective was to determine if degree of functional impairment predicts ED course for patients with headache as part of a clinical protocol. One hundred and thirty-seven pediatric patients presenting to an ED with headache were included. Patients and parents were administered the Functional Disability Index (FDI) and ED charts were reviewed to evaluate outcomes. Higher child-reported FDI scores were associated with more medications, longer ED stay, and admission. High parent-proxy FDI score was associated with longer ED stay. Both pain score and parent-proxy FDI score were associated with imaging. The FDI was a more useful predictor of visit resources than pain score. FDI scores could be used to help anticipate patients who may require greater time and resources.
View details for DOI 10.1177/0009922819884585
View details for PubMedID 31690099
Abstract
Pain-related fear and avoidance are increasingly demonstrated to play an important role in adult and childhood chronic pain. The Fear of Pain Questionnaire for Children (FOPQC) is a 24-item measure of pain-related fear-avoidance in youth that has demonstrated good indices of reliability and validity, treatment responsiveness, and associations with brain circuitry alterations. This study describes the development and psychometric examination of the FOPQC-SF, a short form of the original measure. We selected 10 items for the short form that best represented the content and two-factor (Fear and Avoidance) structure of the original measure from a cohort of 613 youth (Mage = 14.7 years) with chronic pain. Next, confirmatory factor analyses from a second sample of 526 youth (Mage = 14.7 years) with chronic pain who completed the FOPQC-SF supported the original two-factor model but indicated that one item should be moved to the avoidance subscale. The FOPQC-SF demonstrates strong internal consistency and moderate-to-strong construct and criterion validity. Three-month test-retest reliability estimates (N=94) were strong and there was preliminary evidence of responsivity to change. To aid integration into intervention trials and clinical practice, we provide clinical reference points and a criterion to assess reliable change. The short form could be used for rapid identification of pain-related fear and avoidance in youth during clinic evaluations, and is optimized for clinical registries.
View details for DOI 10.1097/j.pain.0000000000001742
View details for PubMedID 31688496
Abstract
Targeting individually based psychosocial profiles when treating children with chronic pain and their families is key to effective behavioral health intervention and in line with tenants of precision medicine. Extant research is primarily driven by variable-centered models that focus on broad, group-level differences. The current study adopts a person-centered approach, latent profile analysis (LPA), to identify patient subgroups. Cross-sectional data are presented from 366 children (8-17 years; M=14.48; SD=2.36) with chronic pain and a primary caregiver (94% mothers). LPA indicator variables were, self-reported: fatigue, internalizing symptoms, pain catastrophizing, and pain acceptance; parent-reported: pain catastrophizing and responses to child pain. One-way ANOVAs examined the effect of profiles on child age, pain, and function. LPA identified a four-profile solution. Class 1 (12%) demonstrated the lowest scores (conveying least risk) across 5 of 6 factors. Class 4 (37%) had the highest scores (conveying greatest risk) across all factors. Classes 2 (12%) and 3 (39%) demonstrated more variability across domains. Results revealed significant effects of profile based on child age, pain, and function. This study highlights differential presentation of treatment-modifiable domains within a large sample. LPA methodology is showcased to potentially facilitate clinical conceptualizations and tailored approaches to intervention in pediatric chronic pain. Perspective: This article presents a methodological and statistical approach that may be beneficial to better assess individual profiles of pediatric pain functioning. Tools that allow providers to better match patient presentation and intervention are in line with the tenants of precision medicine and may ultimately serve to improve child outcomes.
View details for DOI 10.1016/j.jpain.2019.08.015
View details for PubMedID 31521795
Abstract
Chronic pain is a prevalent and persistent problem in middle childhood and adolescence. The biopsychosocial model of pain, which accounts for the complex interplay of the biological, psychological, social, and environmental factors that contribute to and maintain pain symptoms and related disability has guided our understanding and treatment of pediatric pain. Consequently, many interventions for chronic pain are within the realm of rehabilitation, based on the premise that behavior has a broad and central role in pain management. These treatments are typically delivered by one or more providers in medicine, nursing, psychology, physical therapy, and/or occupational therapy. Current data suggest that multidisciplinary treatment is important, with intensive interdisciplinary pain rehabilitation (IIPT) being effective at reducing disability for patients with high levels of functional disability. The following review describes the current state of the art of rehabilitation approaches to treat persistent pain in children and adolescents. Several emerging areas of interventions are also highlighted to guide future research and clinical practice.
View details for DOI 10.3390/jcm8091267
View details for PubMedID 31438483
