Psychometric Properties of the Multidimensional Impression of Change in a Cohort of Pediatric Patients With Pain.

OBJECTIVES: This study assessed the utility of the Multidimensional Patient Impression of Change (MPIC) questionnaire in a pediatric pain population after interdisciplinary treatment. DESIGN: Observational study with retrospective chart review. The observed treatment program included psychological counseling, relaxation training, physical therapy, occupational therapy, and physician management. SETTING: Outpatient pain management center affiliated with an academic rehabilitation hospital. PARTICIPANTS: A heterogeneous group of pediatric patients with chronic pain (N=202) who completed an interdisciplinary pain management program. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Measures assessing pain, mood, development, social functioning, physical functioning, and family functioning were administered pre- and posttreatment, and the MPIC was administered posttreatment. RESULTS: Statistically significant improvements were observed in all outcomes (P<.05). The majority of patients perceived themselves to be improved (minimally to very much) in all clinical domains of the MPIC, ranging from 60% (medication efficacy) to 96% (coping with pain). The MPIC ratings were significantly correlated with improvements in most of the outcome measures. The MPIC domains accounted for more than half of the unique variance in predictive models when added to the Patient Global Impression of Change, and most of the variance when added to the models first. CONCLUSIONS: The MPIC was found to be an effective screening tool for assessing patient perceived progress in a pediatric chronic pain population.

Does diagnosis matter? Evaluating impact of pediatric chronic pain diagnosis on pain and function.

PURPOSE: This study aimed to A) evaluate changes in pain and function following an outpatient interdisciplinary pain management program (IPMP) for children with different chronic pain conditions and B) explore differences in pain and function at baseline and discharge for different diagnoses. METHODS: A retrospective chart review was performed for 488 children who participated in an outpatient IPMP. Children's pain and physical, social, and emotional functioning were assessed at initial evaluation, discharge, and one-to-two-month follow-up. Patients were stratified by diagnosis (complex regional pain syndrome [CRPS], headache, musculoskeletal pain, visceral pain, and widespread pain) to evaluate differences in pain and functioning at baseline and discharge. RESULTS: Children's pain and function improved from initial evaluation to discharge. Those with headache and musculoskeletal pain exhibited better baseline physical and emotional functioning than other diagnostic groups (p = 0.03; p = 0.005; p = 0.002; p = 0.04). Children with CRPS displayed the worst baseline physical functioning (p = 0.003). Those with widespread pain exhibited the worst baseline emotional functioning at both initial evaluation and discharge (p = 0.009; p = 0.007). CONCLUSION: Children with CRPS, visceral pain, and widespread pain undergoing treatment in an IPMP exhibited the most impaired baseline functioning, while those with musculoskeletal pain and headache were least impaired. All exhibited improvements in pain and function following the IPMP.

Pneumorrhachis: A rare cause of headache in a patient with a traumatic spinal cord injury due to gunshot wound.

CONTEXT: A pneumorrhachis (PR) is a rare phenomenon in which air is found in the spinal canal. There are multiple etiologies, including iatrogenic, nontraumatic, and traumatic. Most traumatic PR are asymptomatic and resolve on their own, but a subset are symptomatic and require urgent surgical intervention. This case describes a traumatic PR in which a headache was the primary symptom. FINDINGS: A 17-year-old male sustained a gunshot wound to the left flank with associated bilateral pulmonary lacerations, multiple rib fractures, and T5-7 vertebral body fractures with displaced bony fragments causing spinal cord injury with resultant paraplegia (T3 AIS-A) was admitted to inpatient rehabilitation. Three weeks into his course of rehabilitation, he developed throbbing headaches that were found to be caused by a subarachnoid PR. He underwent a T4-7 laminectomy with repair of dural tear and theco-pleural-bronch-fistula closure, and his headaches subsequently resolved. DISCUSSION/CLINICAL RELEVANCE: This case demonstrated that a headache can be a presenting symptom of a subarachnoid PR.

Home-based aerobic conditioning for management of symptoms of fibromyalgia: a pilot study.

OBJECTIVE: This pilot study was designed to evaluate the impact of a home-based aerobic conditioning program on symptoms of fibromyalgia and determine if changes in symptoms were related to quantitative changes in aerobic conditioning (VO(2) max). METHODS: Twenty-six sedentary individuals diagnosed with fibromyalgia syndrome participated in an individualized 12-week home-based aerobic exercise program with the goal of daily aerobic exercise of 30 minutes at 80% of estimated maximum heart rate. The aerobic conditioning took place in the participants' homes, outdoors, or at local fitness clubs at the discretion of the individual under the supervision of a physical therapist. Patients were evaluated at baseline and completion for physiological level of aerobic conditioning (VO(2) max), pain ratings, pain disability, depression, and stress. RESULTS: In this pilot study subjects who successfully completed the 12-week exercise program demonstrated an increase in aerobic conditioning, a trend toward decrease in pain measured by the McGill Pain Questionnaire-Short Form and a weak trend toward improvements in visual analog scale, depression, and perceived stress. Patients who were unable or unwilling to complete this aerobic conditioning program reported significantly greater pain and perceived disability (and a trend toward more depression) at baseline than those who completed the program. CONCLUSIONS: Patients suffering from fibromyalgia who can participate in an aerobic conditioning program may experience physiological and psychological benefits, perhaps with improvement in symptoms of fibromyalgia, specifically pain ratings. More definitive trials are needed, and this pilot demonstrates the feasibility of the quantitative VO2 max method. Subjects who experience significant perceived disability and negative affective symptoms are not likely to maintain a home-based conditioning program, and may need a more comprehensive interdisciplinary program offering greater psychological and social support.

Interdisciplinary Pain Management Improves Pain and Function in Pediatric Patients with Chronic Pain Associated with Joint Hypermobility Syndrome.

BACKGROUND: The relation between chronic musculoskeletal pain and joint hypermobility in a small percentage of the pediatric population is well described. However, literature discussing the treatment of chronic pain associated with joint hypermobility in pediatrics is limited. The present study examines the impact of interdisciplinary treatment on chronic pain in pediatrics with joint hypermobility syndrome. OBJECTIVE: To determine if pediatric patients with chronic pain related to joint hypermobility can be effectively treated with an intensive, interdisciplinary pain management program, as measured by changes in pain, psychosocial and physical functioning, as well as parental coping. DESIGN: Retrospective cohort study. SETTING: Urban academic tertiary intensive outpatient interdisciplinary pain management clinic. PARTICIPANTS: The study involved 30 patients who met the criteria for a diagnosis of joint hypermobility and chronic pain and completed an interdisciplinary pain management program. INTERVENTION: All patients were treated in an intensive pediatric interdisciplinary pain management program for a duration of 6 to 8 weeks. The program provided physical therapy, occupational therapy, psychological counseling, and weekly pediatric rehabilitation medicine follow-up. MAIN OUTCOME MEASURES: Outcome measures included numeric rating scale pain scores, the Bath Adolescent Pain Questionnaire, and the Bath Adolescent Pain-Parent Impact Questionnaire. Changes from pre- to post-treatment were analyzed using paired-samples t tests. RESULTS: Patients endorsed pre- to post-treatment improvements in pain, depression, general anxiety, pain-related anxiety, social functioning, and physical functioning (P < .05). The patients' parents showed significant improvements in depression, anxiety, catastrophic thinking, self-blame and helplessness, leisure functioning, and parental behavior (P < .05). CONCLUSION: The present findings suggest that an intensive interdisciplinary rehabilitation pain management program yields short-term improvements in pain, emotional and physical function, and daily activity in a pediatric population diagnosed with joint hypermobility. Parents also experienced benefits from the program. A larger prospective study with longer-term follow-up is needed. LEVEL OF EVIDENCE: III.

Effects of an Off-Axis Pivoting Elliptical Training Program on Gait Function in Persons With Spastic Cerebral Palsy: A Preliminary Study.

This preliminary study examined the effects of off-axis elliptical training on reducing transverse-plane gait deviations and improving gait function in 8 individuals with cerebral palsy (CP) (15.5 ± 4.1 years) who completed an training program using a custom-made elliptical trainer that allows transverse-plane pivoting of the footplates during exercise. Lower-extremity off-axis control during elliptical exercise was evaluated by quantifying the root-mean-square and maximal angular displacement of the footplate pivoting angle. Lower-extremity pivoting strength was assessed. Gait function and balance were evaluated using 10-m walk test, 6-minute-walk test, and Pediatric Balance Scale. Toe-in angles during gait were quantified. Participants with CP demonstrated a significant decrease in the pivoting angle (root mean square and maximal angular displacement; effect size, 1.00-2.00) and increase in the lower-extremity pivoting strength (effect size = 0.91-1.09) after training. Reduced 10-m walk test time (11.9 ± 3.7 seconds vs. 10.8 ± 3.0 seconds; P = 0.004; effect size = 1.46), increased Pediatric Balance Scale score (43.6 ± 12.9 vs. 45.6 ± 10.8; P = 0.042; effect size = 0.79), and decreased toe-in angle (3.7 ± 10.5 degrees vs. 0.7 ± 11.7 degrees; P = 0.011; effect size = 1.22) were observed after training. We present an intervention to challenge lower-extremity off-axis control during a weight-bearing and functional activity for individuals with CP. Our preliminary findings suggest that this intervention was effective in enhancing off-axis control, gait function, and balance and reducing in-toeing gait in persons with CP.

West Nile virus encephalitis with thalamic involvement in an immunocompromised child.

West Nile virus has been an increasingly important pathogen in the United States since it was first reported in 1999. Neuroinvasive West Nile virus has been infrequently reported in the pediatric population. We report a case of severe West Nile virus encephalitis with cranial magnetic resonance imaging findings not yet described in children.

The use of botulinum toxin in pediatric disorders.

Botulinum toxins have an exciting and important role in treating the child with hypertonia. The guidelines presented in this article are those that have been published representing the safe use of botulinum toxins in children. Experience and a decade of research have provided the framework for using botulinum toxins in decreasing deformity and promoting function. In children, a window of opportunity exists with botulinum toxin that allows improved motor control and elongation of shortened muscles. Although 3 to 4 months in an adult life is short, for a child it is a relatively greater proportion of their life experience and may be long enough for skill development. The improvement noted in function after botulinum toxin use is facilitated by comprehensive rehabilitation. The pediatric physiatrist has a unique role in the management of children with cerebral palsy and other conditions with hypertonia. Their knowledge and training reflect an understanding of anatomy and development that allows accurate evaluation of specific functional problems in children related to hypertonia. The pediatric physiatrist has experience in localization of muscles by EMG, nerve stimulation, and surface anatomy. Although many other physicians inject botulinum toxins, goal-directed management is the cornerstone to the physiatrist's thinking and treatment plan. Orthopedic surgery ultimately may be the intervention of choice if persistent contracture or progression of contractures occurs. Working in collaboration with an orthopedist identifies the timing of optimal surgical intervention for alignment. For persistent and severe hypertonia, the treatment team includes a neurosurgeon. All options for spasticity, such as selective posterior rhizotomy and intrathecal baclofen, should be considered. Re-evaluation of the child after selective dorsal rhizotomy or intrathecal baclofen is appropriate and should be discussed with therapists for focal intervention. Communication between members of the team and the family is desirable and frequently is one of the major contributions of the pediatric physiatrist. For children with focal hypertonia, botulinum toxins offer a dramatic but temporary repeatable change that affects rehabilitation. Research rapidly has captured the positive effect of the toxins on impairment and functional limitations. Not to be overlooked are outcomes related to quality of life. The long-term use of botulinum toxins and the role the toxins play throughout the life span of the person with a childhood hypertonic disorder are yet to be determined.

Building a pediatric neurocritical care program: a multidisciplinary approach to clinical practice and education from the intensive care unit to the outpatient clinic.

We describe our 10-year experience developing the Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program at Northwestern University Feinberg School of Medicine. The neurocritical care team includes intensivists, neurologists, and an advanced practice nurse who have expertise in critical care neurology and who continue care in long-term follow-up of intensive care unit patients in a dedicated neurocritical care outpatient clinic. Brain-directed critical care requires collaboration between intensivists and neurologists with specific expertise in neurocritical care, using protocol-directed consistent care, and physiological measures to protect brain function. The heterogeneity of neurologic disorders in the pediatric intensive care unit requires a background in the relevant basic science and pathophysiology that is beyond the scope of standard neurology or critical care fellowships. To address this need, we also created a fellowship in neurocritical care for intensivists, neurologists, and advanced practice nurses. Last, we discuss the implications for pediatric neurocritical care from the experience of management of pediatric stroke and the development of stroke centers.

A critical analysis of the tender points in fibromyalgia.

OBJECTIVE: To pilot methodologies designed to critically assess the American College of Rheumatology's (ACR) diagnostic criteria for fibromyalgia. DESIGN: Prospective, psychophysical testing. SETTING: An urban teaching hospital. SUBJECTS: Twenty-five patients with fibromyalgia and 31 healthy controls (convenience sample). INTERVENTIONS: Pressure pain threshold was determined at the 18 ACR tender points and five sham points using an algometer (dolorimeter). OUTCOME MEASURES: The patients "algometric total scores" (sums of the patients' average pain thresholds at the 18 tender points) were derived, as well as pain thresholds across sham points. RESULTS: The "algometric total score" could differentiate patients with fibromyalgia from normals with an accuracy of 85.7% (P < 0.001). Even a single tender point had a diagnostic accuracy between 75% and 89%. Although fibromyalgics had less pain across sham points than across ACR tender points, sham points also could be used for diagnosis (85.7%; Ps < 0.001). Hierarchical cluster analysis showed that three points could be used for a classification accuracy equivalent to the use of all 18 points. CONCLUSIONS: There was a significant difference in the "algometric total score" between patients with fibromyalgia and controls, and we suggest this quantified (although subjective) approach may represent a significant improvement over the current diagnostic scheme, but this must be tested vs other painful conditions. The points specified by the ACR were only modestly superior to sham points in making the diagnosis. Most importantly, this pilot suggests single points, smaller groups of points, or sham points may be as effective in diagnosing fibromyalgia as the use of all 18 points, and suggests methodologies to definitively test that hypothesis.