[Cross-sectoral interdisciplinary multimodal pain therapy : Recommendations on structural and process parameters of the ad hoc commission "Interdisciplinary Multimodal Pain Therapy" of the German Pain Society (Deutsche Schmerzgesellschaft e.  V.)]. / Sektorenübergreifende interdisziplinäre multimodale Schmerztherapie : Empfehlungen zu Struktur- und Prozessparametern der Ad-hoc-Kommission "Interdisziplinäre Multimodale Schmerztherapie" der Deutschen Schmerzgesellschaft e. V.

Based on the fundamental concept of the biopsychosocial model, interdisciplinary multimodal pain therapy (IMPT) has developed to one of the most important components in the treatment of patients suffering from chronic pain. The process criteria for IMPT in Germany are described in the German OPS catalogue and IMPT is mainly offered as an inpatient treatment only. This article updates some of the fundamental criteria for IMPT for adult inpatient treatment and the task force defines basic structural and process criteria for the implementation of IMPT for outpatients.

[Therapy outcome one year after pediatric outpatient chronic pain evaluation : Chronic Pain Grading (CPG) for adolescent pain patients]. / Therapie-Outcome ein Jahr nach Erstvorstellung in einer pädiatrischen Schmerzambulanz : Das Chronic Pain Grading (CPG) für jugendliche Schmerzpatienten.

BACKGROUND: Interdisciplinary pain treatment has been shown to be effective for children and adolescents with chronic pain, both in an outpatient and inpatient setting. Until now, the effectiveness has been analyzed with various outcome measures. Although it has only rarely been used for adolescents so far, Chronic Pain Grading (CPG) developed by Von Korff could be an appropriate general outcome measure. OBJECTIVE: The study aims at prospectively investigating and comparing the therapy outcome one year after initial presentation for both outpatients and inpatients using the CPG. MATERIALS AND METHODS: Data of 258 adolescents were gathered at initial presentation and one year later and analyzed using the CPG. Changes from pretreatment to follow-up and predictors of good therapy outcome were investigated for the whole sample and separately for outpatients and inpatients. RESULTS: Compared to inpatients, outpatients were characterized by a lower CPG both before and one year after initial presentation. Large effects were found both for outpatient and inpatient therapy regarding the improvement of the CPG. In outpatient therapy, boys were two times more likely to display therapy success. CONCLUSION: The study shows that the CPG is an appropriate outcome measure to display the long-term effectiveness of an inpatient and outpatient interdisciplinary pain treatment. The interdisciplinary pain treatment needs to be better tailored to girls to improve its effectiveness.

[Pain-related parental behavior : Maternal and paternal responses to chronic pain of their child and modifications following inpatient interdisciplinary pain treatment]. / Schmerzbezogenes Elternverhalten : Mütterliche und väterliche Reaktionen auf die chronischen Schmerzen ihres Kindes und deren Veränderung nach stationärer interdisziplinärer Schmerztherapie.

BACKGROUND: There is a dearth of research studies regarding the pain-related behavior of parents with children suffering from chronic pain. This study examined the pain-related reactions of mothers and fathers, analyzed changes in these reactions following the child's inpatient interdisciplinary pain treatment and identified predictors for these changes. METHOD: Using validated questionnaires 40 mothers and 40 fathers of children suffering from chronic pain reported their pain-related responses and cognitive distortions at treatment commencement, immediately following therapy as well as at follow-up after 6 and 12 months. RESULTS: At treatment commencement there were neither differences between maternal and paternal behavior nor in their reactions towards the sons and daughters. Immediately after treatment both parents showed increased distracting behavior and decreased solicitous behavior. Only the change in solicitous behavior showed long-term stability. The study identified the extent of parental catastrophizing at treatment commencement as well as changes in this reaction during treatment as predictors for reduction in solicitous behavior. The more parents reported catastrophizing thoughts at treatment commencement, the less they changed their solicitous behavior and strong changes in catastrophizing during treatment correlated with strong changes in solicitous reactions. CONCLUSION: Pain-related solicitous behavior can be modified by the interdisciplinary inpatient treatment of chronic pain in children and changes in solicitous behavior seem to be closely related to parental catastrophizing. This association should be considered when dealing with parents of children with chronic pain and also within the framework of future research projects.

[Therapy recommendations in a pediatric outpatient pain clinic : Adherence and effectiveness of implementation]. / Therapeutische Empfehlungen in einer pädiatrischen Schmerzambulanz : Adhärenz und Wirksamkeit der Umsetzung.

BACKGROUND: Supplementary pain-related recommendations for the treatment of chronic pain in children and adolescents are an essential component of multimodal pain treatment. Studies are scarce regarding adherence to these recommendations and their effectiveness. OBJECTIVE: The aim of this study was to evaluate patient adherence to pain-related recommendations and their effectiveness 12 months after initial presentation of children and adolescents with chronic pain to a pediatric outpatient pain clinic. MATERIALS AND METHODS: A total of 413 patients were assessed using a structured telephone interview. The assessment included pain characteristics during the last 4 weeks as well as information regarding the implementation of the pain-related recommendations and the effectiveness. Due to different recommendations given to migraine patients this subgroup was dealt with separately. RESULTS: Patients reported significant improvements 12 months after the initial presentation and 29.5 % of the patients were pain free. Adherence levels and estimated effectiveness regarding recommendations, such as change of lifestyle, multimodal inpatient treatment and use of medication were high. Other recommendations, such as active relaxation and outpatient psychotherapy had low adherence levels and low estimated effectiveness. Migraine patients had a significantly higher adherence rate and estimated effectiveness regarding the recommendation use of medication than non-migraine patients. CONCLUSION: The adherence level as well as the estimated effectiveness regarding the majority of pain-related recommendations was high. Some recommendations had low adherence rates and low estimated effectiveness. These results can help to further improve the performance of outpatient clinics for children and adolescents with chronic pain.

Difficulties in screening for peripheral neuropathies in children with diabetes.

AIMS: To assess the diagnostic utility of a novel abbreviated monofilament test in comparison with the tuning fork test to detect diabetic peripheral neuropathy in children. METHODS: A total of 88 children with Type 1 diabetes mellitus were screened for diabetic peripheral neuropathy using the monofilament test and the tuning fork. Nerve conduction studies were performed according to the 'gold standard' for neuropathy. We assessed the diagnostic utility and inter-rater agreement of the two screening methods. RESULTS: A total of 43 (49%) children (aged 6-18 years) had at least one abnormal nerve conduction study result. Diagnostic utility and inter-rater agreement were very low for both screening methods. The monofilament test yielded a sensitivity of 18% and a specificity of 80%. The tuning fork yielded a sensitivity of 0% and a specificity of 98%. CONCLUSION: The present study found that an abbreviated monofilament test has low diagnostic utility for the detection of early diabetic peripheral neuropathy because of its low reliability. The problem of reliability needs to be more thoroughly addressed in order to improve the screening procedures in diabetes management in childhood and adolescence.

[Chronic primary pain disorders in children and adolescents]. / Chronische primäre Schmerzen bei Kindern und Jugendlichen.

AIM: Chronic and debilitating pediatric pain has a prevalence of 5% and as such constitutes a considerable health problem. The aim of this article is to provide an overview of current research activities on pediatric pain, available health care for children with chronic pain and education and training programs for health professionals. METHOD: This overview is based on the authors' personal experience, information available from medical, research and professional associations, as well as a PubMed literature search for the time period 2012-2015 using "children";"pain" and "Germany" as search terms. RESULTS: There are numerous research activities in Germany focusing on the epidemiology, the underlying psychobiological mechanisms and on the multimodal treatment of chronic pediatric pain. This research is internationally widely acknowledged and makes a significant contribution to current developments in pediatric pain research. By contrast, health services and basic science research is clearly lacking in Germany. Moreover, specialized health care for youth with chronic pain is far less institutionalized when compared to adults suffering from chronic pain. Indeed, primary and secondary care services have rarely been studied or even evaluated. CONCLUSION: Similar to international trends, research on chronic pediatric pain has also grown and advanced in Germany. Indeed, not only the amount of research has increased but also its scope. Nonetheless, there is clearly a need for more research efforts with regard to the understanding of (pediatric) pain mechanisms, clinical studies and, especially, investigations on health care services. It is particularly important to focus on the implementation, improvement and systematic evaluation of specialized health care services which would be available and accessible for children and adolescents with chronic pain and not be restricted to tertiary care.

[Pediatric general practitioners and tertiary care structures for pain therapy. A qualitative study on the need for networking]. / Niedergelassene Pädiater und tertiäre Versorgungsstrukturen der Schmerztherapie. Eine qualitative Studie zum Bedarf an Vernetzung.

BACKGROUND: Despite the urgency of the problem of chronic pediatric pain and the importance of early interventions, many children experience intermittent episodes of pain over a long period of time. One aim of this study was to investigate the need of structured diagnostic tools and therapies of chronic pediatric pain in pediatric general practices. Another aim was to describe the aims, services and challenges of a network between pediatric practices and a tertiary pediatric pain centre, from the perspective of general pediatric practitioners. MATERIAL AND METHODS: A qualitative research design was selected and 20 general pediatric practitioners were interviewed using a semistructured interview guide. Interviews were analyzed by use of qualitative content analysis according to Mayring. RESULTS: Generally, the idea of a network between pediatric practices and the German Pediatric Pain Centre was rated positively by pediatric general practitioners. From the results of the analysis three categories were identified: (i) expectations from the network (ii) desire for cooperation in the network and (iii) recommendations for improved patient care. CONCLUSION: A network with a centre for tertiary care was preferred by the general pediatric practitioners. To optimize the care of children with chronic pain further education for general pediatric practitioners as well as structured diagnostic tools and therapies of frequent pediatric chronic pain diseases are warranted.

[Economic effects of chronic pain in childhood and adolescence: self-assessment of health care costs for affected families before and after a multidisciplinary inpatient pain therapy]. / Familiäre finanzielle Belastung durch chronische Schmerzen im Kindes- und Jugendalter : Selbsteinschätzung der Krankheitskosten für betroffene Familien vor und nach einer stationären interdisziplinären Schmerztherapie.

BACKGROUND: Chronic pain in children and adolescents causes a high utilization of the health care system and thereby significant costs. The aim of the present study is to describe the economic effects of pediatric chronic pain from the family's perspective. MATERIAL AND METHODS: Six months before and 6 and 12 months after a 3-week inpatient-based intensive interdisciplinary pain treatment, the parents of 101 children with chronic pain filled in a standardized cost questionnaire containing the following parameters: (1) child's utilization of medical and social services, (2) subjective financial burden, and (3) type and extent of direct costs. RESULTS: During the 6 months before inpatient-based intensive interdisciplinary pain treatment, children used a median of four different services. After inpatient pain treatment, service utilization has been reduced significantly (p < 0.001). One fifth of the families report a high or very high financial burden before treatment. Family's direct costs are most often caused by travelling (86 %) and drugs (60 %). After inpatient pain treatment, family's financial burden decreased significantly (p < 0.001). The frequency of additional expenditures is also reduced after treatment: parents report less additional costs due to travelling and drugs (p < 0.001, respectively). CONCLUSION: The present study emphasizes the pronounced utilization of health and social care due to pediatric chronic pain. In the future, the use of appropriate diagnostic and therapeutic standards that contribute to avoiding unnecessary and expensive interventions is preferred.

Influence of parental occupation on access to specialised treatment for paediatric chronic pain: a retrospective study.

BACKGROUND: The purpose of this study was to determine patients' travel distances to a tertiary paediatric pain clinic and to analyse the association between travel distance and the parents' occupational skill level and the patients' pain characteristics. PATIENTS AND METHODS: The retrospective study consisted of 2,248 children assessed at the first evaluation. All children (0-20 years) who visited the clinic during a 5-year period (2005-2010) were enrolled in this study. RESULTS: The mean travel distance was 81 km, and the 80 % catchment area was 109 km. Children of parents with a high occupational skill level had a 1.5-fold higher probability of travelling from outside the catchment area. The 80 % catchment area increased constantly with increasing occupational skill level. Additional significant factors for greater distance travelled were high impairment, musculoskeletal pain, long pain duration and a high number of previous physician contacts. CONCLUSION: The association between travel distance and parental occupational skill level suggests that there is social injustice due to access barriers based on socioeconomic deprivation and education. An increase in the number of health care facilities for chronic pain in children would be a first step in rectifying this injustice.

Childhood diabetic neuropathy: functional impairment and non-invasive screening assessment.

AIM: Sensory diabetic neuropathy, determined by nerve conduction studies, is common in children with Type 1 diabetes. Diabetic neuropathy diagnoses are rarely made in paediatric daily care because they are asymptomatic, vibration detection is mostly normal and nerve-conduction testing is impractical. The present study aims to: (1) describe somatosensory dysfunction in children with diabetes, (2) test whether diabetes duration and HbA(1c) are related to somatosensory dysfunction and (3) identify the best screening test for large-fibre dysfunction, as indicated by nerve conduction studies. METHODS: Forty-five children (age 13.2 ± 2.5 years) with Type 1 diabetes for 6.7 ± 2.5 years and matched control subjects were assessed by neurological examinations, nerve conduction tests and quantitative sensory testing on the feet using the protocol of the German Research Network on Neuropathic Pain. Abnormal nerve conduction was used as gold standard to define neuropathies. RESULTS: We found a high prevalence of mechanical (38%) and thermal (24%) hypoesthesia often associated with hyperalgesia (47%). Tactile hypoesthesia (33%) was more frequent than pallhypaesthesia (11%). Only cold detection and mechanical pain thresholds were related to HbA(1c). Tactile hypoesthesia had the highest sensitivity (75%), specificity (89%) and positive (75%) and negative (89%) predictive values for neuropathies defined by nerve conduction tests (31% abnormal). CONCLUSIONS: Almost half of the children with diabetes have subclinical large- and small-fibre neuropathies. Tactile detection was better than vibration for neuropathy assessment. Quantitative sensory testing is a valuable tool for assessment of neuropathy as well as a target of interventional studies in children with diabetes.

[Please don't hurt me!: a plea against invasive procedures in children and adolescents with complex regional pain syndrome (CRPS)]. / Bitte nicht noch mehr verletzen! : Plädoyer gegen eine invasive Schmerztherapie bei Kindern mit komplexem regionalem Schmerzsyndrom (CRPS).

BACKGROUND: Complex regional pain syndrome (CRPS; formerly known as Morbus Sudeck/reflex dystrophy) is diagnosed in children and adolescents, but the clinical presentation is often atypical. Unfortunately, potentially harmful, invasive treatments are used in pediatric patients. PATIENTS AND METHODS: A retrospective chart study of pediatric chronic pain patients with CRPS was performed. RESULTS: Over the course of 6 years, 37 (35 girls) children and adolescents took part in a multidisciplinary chronic pain inpatient program. At admission, patients took on average 4.4 (range 1-10) different medications and 29 different pharmaceuticals were used overall. Prior to admission, invasive pain treatments were performed without success in 16 of the children (43%). At least 13 children received two or more invasive treatments. Although sympathetic blocks were most prevalent, operations and regional anesthesia were also used. CONCLUSION: Despite a lack of evidence for invasive procedures, these continue to be used in children and adolescents with CRPS, who later respond positively to conventional treatment. The English full-text version of this article is available at SpringerLink (under "Supplemental").

[Definition, diagnosis and therapy of chronic widespread pain and so-called fibromyalgia syndrome in children and adolescents. Systematic literature review and guideline]. / Definition, Diagnostik und Therapie von chronischen Schmerzen in mehreren Körperregionen und des sogenannten Fibromyalgiesyndroms bei Kindern und Jugendlichen. Systematische Literaturübersicht und Leitlinie.

BACKGROUND: The scheduled update to the German S3 guidelines on fibromyalgia syndrome (FMS) by the Association of the Scientific Medical Societies ("Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften", AWMF; registration number 041/004) was planned starting in March 2011. MATERIALS AND METHODS: The development of the guidelines was coordinated by the German Interdisciplinary Association for Pain Therapy ("Deutsche Interdisziplinären Vereinigung für Schmerztherapie", DIVS), 9 scientific medical societies and 2 patient self-help organizations. Eight working groups with a total of 50 members were evenly balanced in terms of gender, medical field, potential conflicts of interest and hierarchical position in the medical and scientific fields. Literature searches were performed using the Medline, PsycInfo, Scopus and Cochrane Library databases (until December 2010). The grading of the strength of the evidence followed the scheme of the Oxford Centre for Evidence-Based Medicine. The formulation and grading of recommendations was accomplished using a multi-step, formal consensus process. The guidelines were reviewed by the boards of the participating scientific medical societies. RESULTS AND CONCLUSION: The diagnosis FMS in children and adolescents is not established. In so-called juvenile FMS (JFMS) multidimensional diagnostics with validated measures should be performed. Multimodal therapy is warranted. In the case of severe pain-related disability, therapy should be primarily performed on an inpatient basis. The English full-text version of this article is available at SpringerLink (under "Supplemental").

[Pain therapy with children and adolescents severely disabled due to chronic pain: long-term outcome after inpatient pain therapy]. / Schmerztherapie bei Chronisch Schmerzkranken, Schwer Beeinträchtigten Kindern und Jugendlichen: Langzeiterfolge einer 3-Wöchigen Stationären Schmerztherapie.

BACKGROUND: A prospective study controlled for sex and age was conducted evaluating the success of a 3-week inpatient pain therapy after 3, 6 and 12 months for 200 children and adolescents severely disabled due to chronic pain. METHODS: The following validated German questionnaires were used: pain questionnaire (DSF-K/J/E), pain coping inventory (PPCI-R), anxiety questionnaire (AFS) and depression questionnaire (DIKJ). After an intention-to-treat analysis unifactorial und multifactorial variance analyses were conducted. A significance level of p<0.01 was used. RESULTS: Durable improvements were observed for average pain intensity, pain disability, days absent from school, depression and for passive and interaction-based pain coping strategies 3 months after finishing inpatient pain therapy. On the other hand general anxiety and school aversion were only reduced at 6 and 12 months, respectively. Girls reported more pain in general and during follow-up. Younger children relied in general more on others when dealing with their pain. CONCLUSION: An inpatient pain therapy can help children and adolescents severely disabled due to chronic pain not only in the short term but also in the long term.

[Pediatric pain management: what do German nurses know?]. / Pädiatrische Schmerztherapie: Wie ist der Wissensstand von Pflegenden?

BACKGROUND: In order to provide efficient pain treatment clinicians need to know the latest developments in pain management and to implement this knowledge into clinical practice. The knowledge of pediatric nursing staff with regards to pediatric pain management has not yet been investigated. In this study we therefore investigated nurses' knowledge of pediatric pain management strategies. METHODS: Nursing staff knowledge was analyzed using the German version of the PNKAS-Sr2002. This questionnaire was distributed to 310 pediatric nurses and the response rate was 51.3% (n=159). Analyses of variance (ANOVA) were conducted to examine whether educational level and work experience had an influence on knowledge. Independent from work experience the educational level of nurses is important for their knowledge in pediatric pain management. RESULTS: On average nurses obtained a mean individual test score of 69.3%. Nurses with advanced qualification and nurses with 6-10 years work experience obtained the highest scores. CONCLUSION: Pediatric nurses must be trained more efficiently in pediatric pain management so that an adequate pain management is available for children and adolescents.

[Pain perception of adolescents with chronic functional pain : adaptation and psychometric validation of the Pain Perception Scale (SES) by Geissner]. / Schmerzempfindung bei Jugendlichen mit chronischen funktionellen Schmerzen : Adaptation und psychometrische Uberprüfung der Schmerzempfindungsskala (SES) nach Geissner.

BACKGROUND: Pain perception is a central aspect of the multidimensional model of chronic pain. Up to now, validated measurement tools are lacking in the German language for measuring pain perception in adolescents. The aim of this study was to examine and adapt the well-established Pain Perception Scale for Adults by Geissner (SES) for use in adolescents with chronic pain to provide a measure for clinical diagnosis and evaluation of treatment effects. MATERIAL AND METHODS: Principal component, reliability and item analyses were conducted on a sample with 139 adolescents. To test validity, age and sex effects, correlations with pain-related constructs, differences between treatment groups (inpatients vs outpatients) and concordance between adolescents and their parents were analysed. RESULTS: Findings support a two-factor solution with one affective and one sensory factor; three additional sensory items were included in the final version. The scales show good internal consistency. Consistent with hypotheses, we found significant correlations with pain characteristics, emotional and cognitive variables as well as pain-related disability. Inpatients and outpatients show a significant difference in affective pain perception. Concordance between parents and adolescents was high. CONCLUSION: With this questionnaire there is now a validated German assessment tool to measure pain perception in adolescents with chronic pain (Pain Perception Scale for Adolescents, SES-J). Due to its practicability it is suitable for clinical application.

[German Pain Questionnaire for Children, Adolescents and Parents (DSF-KJ). A multimodal questionnaire for diagnosis and treatment of children and adolescents suffering from chronic pain]. / Deutscher Schmerzfragebogen für Kinder, Jugendliche und deren Eltern (DSF-KJ). Entwicklung und Anwendung eines multimodalen Fragebogens zur Diagnostik und Therapie chronischer Schmerzen im Kindes- und Jugendalter.

BACKGROUND: A multidimensional assessment of chronic pain is the most important tool for diagnosis and treatment. While the German Pain Questionnaire is routinely implemented in the treatment of adults with chronic pain, similar questionnaires are scarce for children and adolescents. It was the aim of the present study to report on the development and quality of a multimodal questionnaire assessing all relevant aspects of chronic pain in children and adolescents. The quality of the questionnaire was assessed (1) by implementing the questionnaire in a sample of children and adolescents suffering from chronic pain (aged 4-18 years), (2) by analysing missing items in the child, adolescent and parent version and (3) by analysing experts' ratings of the questionnaire. MATERIAL AND METHODS: The German Pain Questionnaire for Children, Adolescents and Parents (DSF-KJ) was developed on the basis of the biopsychosocial model of chronic pain in experts' meetings. The DSF-KJ entails an assessment of sociodemographic variables, pain characteristics, triggering factors, previous pain treatment, pain-related disability and cognitive and emotional factors related to the pain experience. A total of 284 children and adolescents who presented for pain treatment in our tertiary institute completed the DSF-KJ. Eleven pain experts rated the questionnaire regarding its utility for diagnosis and treatment. RESULTS: With the use of the DSF-KJ, a detailed sample description was derived on the basis of the biopsychosocial model. More adolescent girls than boys presented to the institute. The majority of the children and adolescents suffered from headache and were severely affected by their chronic pain. Children and adolescents displayed similar pain characteristics. However, adolescents were more disabled due to chronic pain and had already undergone a variety of pain treatments. These differences may reflect an ongoing chronification in adolescents. Children, adolescents and their parents filled in the questionnaire thoroughly with very few missing items. The experts rated the questionnaire as very useful for diagnosis and treatment. CONCLUSION: The DSF-KJ provides a standardized assessment and comprehensive description of paediatric chronic pain problems and facilitates medical and psychological diagnostic and therapeutic decisions. The preliminary results suggest that the questionnaire is a clinically useful and practical assessment tool for children and adolescents with chronic pain.

Paroxysmal hemicrania in children--symptoms, diagnostic criteria, therapy and outcome.

Whereas paroxysmal hemicrania (PH) is studied extensively in adults, even case reports of PH in children are rare. We present the first prospective follow-up study on PH in children. Our aim was to investigate whether differences exist between paediatric and adult patients. We assessed all children with chronic headache who were referred to our paediatric out-patient pain clinic within 3 years based on interviews and validated questionnaires. Among 628 patients we found five children with PH (0.8%) and three with probable PH (0.5%), in total 1.3%. Pain characteristics, autonomic symptoms and treatment response to indomethacin were similar to adult PH patients. Our results demonstrate that the International Headache Society classification of PH is also applicable to children. We suspect that PH has been underdiagnosed in children and therefore suboptimally treated thus far.