Young Adult Pain Rehabilitation: Interdisciplinary Development and Preliminary Outcomes of a Novel Treatment Program.

BACKGROUND: Young adults with chronic pain and symptoms experience disruptions to their social, emotional, physical, and vocational functioning. Interdisciplinary pain rehabilitation programs for pediatric and adult populations are not designed specifically to address the developmental needs of young adults. METHODS: This article describes the development of a novel intensive interdisciplinary outpatient rehabilitation program tailored to the unique needs of young adults with chronic pain and symptoms. Tailored content included vocational assessment and consultation, financial literacy education, and sexual health education. RESULTS: Outcome data demonstrate treatment gains, with reductions in pain interference, pain severity, pain catastrophizing, and depressive symptoms, as well as improvements in mental and physical quality of life, perceived performance, perceived satisfaction with performance, and objective measures of physical functioning. CONCLUSIONS: The article concludes with clinical recommendations for the management of chronic pain and symptoms in young adults, applicable across multiple treatment settings.

Executive Functioning in Pediatric Chronic Pain: Do Deficits Exist?

Objective: Despite ample research documenting deficits in executive functioning for adults with chronic pain, the literature on pediatric patients with chronic pain is limited and provides mixed results. The current study sought to further investigate the nature of executive dysfunction in this population and also examine the relationships between pain intensity, duration, and catastrophizing with sustained attention, working memory, and self- and parent-report of executive functioning. Settings: Pediatric pain clinic and rehabilitation program. Participants: Forty adolescents with chronic pain and their parents participated in this study. Methods: Participants completed neuropsychological measures and standardized self-report questionnaires during a 45- to 60-minute testing session. Results: Fifty percent of this sample of adolescents with chronic pain demonstrated significant difficulties on at least one measure, with nine participants indicating difficulties on multiple measures. Pain significantly increased during the testing session. Pain variables of intensity, duration, and catastrophizing are related to sustained attention and working memory. Conclusions: This study adds support to previous findings suggesting subclinical struggles with executive functioning for adolescents with chronic pain. One-half of the sample indicated difficulties in either sustained attention and/or working memory. Future studies that would more thoroughly examine more complex executive functioning skills in this population would be helpful to further guide multidisciplinary treatment of these patients, particularly regarding whether or not school accommodations are warranted.

Development of an Interdisciplinary Pediatric Pain Rehabilitation Program: The First 1000 Consecutive Patients.

OBJECTIVE: To describe the development of a clinically and financially successful interdisciplinary pediatric pain rehabilitation program at a large tertiary academic medical center and present demographic and clinical information on the first 1000 patients. PATIENTS AND METHODS: All patients who were consecutively admitted to this program between October 1, 2008, and March 31, 2015 were included in this review. The patients ranged in age from 9 to 24 years. The program is a 3-week, hospital-based outpatient treatment program that requires substantial parental involvement. At admission and discharge, patients completed the Center for Epidemiologic Studies of Depression Scale for Children, the Functional Disability Inventory, and the Pain Catastrophizing Scale for Children. Opioid use was also assessed. RESULTS: At admission, patients reported substantial pain-associated disability and depressive symptoms; they had elevated pain catastrophizing scores, and 16% were taking opioids. Primary sites/types of pain included head, abdomen, and generalized. Functional disability scores decreased significantly, from 27 to 9 after the program (P<.001). Depression scale scores improved from 27 to 14 (P<.001). Pain catastrophizing scores decreased significantly, from 26 to 14 (P<.001), at discharge from the program. All but 4 patients successfully tapered off of all opioid use by the conclusion of the program. CONCLUSION: Participation in a multidisciplinary pediatric pain rehabilitation program can be successful, with significant decreases in disability, depression symptoms, and pain catastrophizing, as well as discontinuation of opioid use.

Getting Back to Living: Further Evidence for the Efficacy of an Interdisciplinary Pediatric Pain Treatment Program.

OBJECTIVE: This study examined key functional outcomes following a 3-week interdisciplinary pediatric pain rehabilitation program for adolescents with chronic pain. Maintenance of gains was evaluated at 3-month follow-up. METHODS: Participants included 171 adolescents (12 to 18 y of age) with chronic pain who completed a hospital-based outpatient pediatric pain rehabilitation program. Participants completed measures of functional disability, depressive symptoms, pain catastrophizing, opioid use, school attendance, and pain severity at admission, discharge, and at 3-month follow-up. RESULTS: Similar to other interdisciplinary pediatric pain rehabilitation program outcome studies, significant improvements were observed at the end of the program. These improvements appeared to be maintained or further improved at 3-month follow-up. Nearly 14% of the patients were taking daily opioid medication at admission to the program. All adolescents were completely tapered off of these medications at the end of the 3-week program and remained abstinent at 3-month follow-up. DISCUSSION: This study adds to the available data supporting interdisciplinary pediatric pain rehabilitation as effective in improving functioning and psychological distress even when discontinuing opioids. Implications for future research and limitations of the study are discussed.

Improvement in Functioning and Psychological Distress in Adolescents With Postural Orthostatic Tachycardia Syndrome Following Interdisciplinary Treatment.

Significant functional impairment and psychological distress have been observed in adolescent patients with postural orthostatic tachycardia syndrome (POTS). Interdisciplinary rehabilitation programs have been shown to be beneficial in the treatment of chronic pain in adults and adolescents. Only preliminary data have examined interdisciplinary rehabilitation efforts in patients with POTS. This study evaluated the impact of an interdisciplinary rehabilitation program on the functional impairment and psychological distress in 33 adolescents diagnosed with POTS. Patients included in the study were adolescents ages 11 to 18 diagnosed with POTS. Measures completed at admission and discharge from the program included the Functional Disability Index, Center for Epidemiological Studies-Depression-Child scale, and the Pain Catastrophizing Scale for Children. After participation in the 3-week program, adolescents with POTS demonstrated a significant increase in overall functional ability and significant reductions in depression and catastrophizing.

Interdisciplinary Treatment of Maladaptive Behaviors Associated with Postural Orthostatic Tachycardia Syndrome (POTS): A Case Report.

The prevalence of postural orthostatic tachycardia syndrome (POTS) in adolescents and young adults has been increasing during the past decade. Despite this increase, documentation regarding treatment of these patients is just beginning to emerge. In addition, despite a call for a multidisciplinary or interdisciplinary approach, no studies have examined the efficacy of such an approach to treatment. This paper describes a case study of a 19-year-old male with debilitating POTS seen at a tertiary clinic for evaluation and subsequent intensive interdisciplinary treatment. The treatment approach is described and outcomes are presented.

Management of neonatal abstinence syndrome from opioids.

Most infants at risk for neonatal abstinence syndrome have opioid plus another drug exposure; polypharmacy is the rule rather than the exception. Scales for evaluation of neonatal abstinence syndrome are primarily based for opioid withdrawal. A standard protocol to treat neonatal abstinence syndrome has not been developed. Institute nonpharmacologic strategies for all neonates at risk. The American Academy of Pediatrics recommends mechanism-directed therapy (treat opioid withdrawal with an opioid) as the first-line therapy. Second-line medications are currently under evaluation.

Acceptance of pain: associations with depression, catastrophizing, and functional disability among children and adolescents in an interdisciplinary chronic pain rehabilitation program.

OBJECTIVES: The aims of this study were: (1) investigate relations between pain acceptance, depressive symptoms, catastrophizing, and functional disability in pediatric patients in an interdisciplinary chronic pain rehabilitation program, (2) examine changes in acceptance from pre- to posttreatment, and (3) test if changes in acceptance predict changes in depressive symptoms, catastrophizing, and functional disability from pre- to posttreatment. METHODS: 112 participants, ages 11-18 years, completed the Chronic Pain Acceptance Questionnaire, Adolescent Version, Center for Epidemiological Studies-Depression-Children's Scale, Pain Catastrophizing Scale for Children, and Functional Disability Inventory on admission to and completion of the program. RESULTS: Significant and strong relations between acceptance, depression, catastrophizing, and functional disability were demonstrated. Participants demonstrated significant increases in acceptance and decreases in depression, catastrophizing, and functional disability. Finally, changes in acceptance significantly predicted changes in depressive symptoms, catastrophizing, and functional disability. CONCLUSIONS: Pain acceptance is an important variable in the treatment of pediatric chronic pain.

Covert video monitoring in the assessment of medically unexplained symptoms in children.

OBJECTIVE: Diagnosis of medically unexplained symptoms (MUS) occurs after thorough evaluations have failed to identify a physiological cause for symptoms. However, families and providers may wonder if something has been missed, leading to reduced confidence in behavioral treatment. Confidence may be improved through the use of technology such as covert video monitoring to better assess functioning across settings. METHODS: A 12-year-old male presented with progressive neurological decline, precipitated by chronic pain. After thorough evaluation and the failure of standard treatments (medical, rehabilitative, and psychological) covert video monitoring revealed that the patient demonstrated greater abilities when alone in his room. Negative reinforcement was used to initiate recovery, accompanied by positive reinforcement and a rehabilitative approach. Covert video monitoring assisted in three subsequent cases over the following 3 years. RESULTS AND CONCLUSIONS: In certain complex cases, video monitoring can inform the assessment and treatment of MUS. Discussion includes ethical and practical considerations.

Prevalence of moderate-severe pain in hospitalized children.

BACKGROUND: Acute pain management in children is often inadequate. The prevalence of pain in hospitalized children in the US is unknown. METHODS: We reviewed clinical characteristics of all pediatric patients admitted to Mayo Eugenio Litta Children's hospital during July 2009. Patients with moderate-severe pain were identified. For patients identified as having moderate-severe pain risk factors, analgesia regimens, and pain outcomes were reviewed. RESULTS: The prevalence of moderate-severe in-hospital pain was 27% (95% C.I. 23% to 32%). Teenagers and infants experienced higher prevalence rates of moderate-severe pain (38% and 32% respectively) than children (17%, P < 0.001). In addition, patients admitted to medical services had much lower rates of moderate-severe pain (13%) than those admitted to surgical services (44%, P < 0.001). Regional anesthesia was used in eleven (7.2%) of the patients on surgical services. Acetaminophen was administered to 75% of patients with moderate-severe pain. Only 21% of these patients had nonsteroidal anti-inflammatory drugs (NSAIDS) available. Opioids were given scheduled to 36% of patients with moderate-severe pain and as needed to another 40%. Fifty-five percent of patients still had one or more episode of moderate-severe pain on the day following an initial diagnosis; however, this number decreased steadily over subsequent days. Eleven patients (13% of those diagnosed with moderate-severe pain) still had one or more episodes of daily moderate-severe pain by day four. CONCLUSIONS: The prevalence of moderate-severe pain in hospitalized children remains high. Analgesia regimens may not be optimal. Underutilization of regional anesthesia techniques may have contributed to increased pain scores. A large proportion of children diagnosed with moderate-severe pain may have persistent clinically significant pain in subsequent days.

Adolescent acceptance of pain: confirmatory factor analysis and further validation of the chronic pain acceptance questionnaire, adolescent version.

UNLABELLED: Preliminary reports suggest that acceptance of pain is an important construct when assessing and treating adolescents with chronic pain. Although the Chronic Pain Acceptance Questionnaire, Adolescent version (CPAQ-A) appears to be a promising tool, it has been evaluated in only 1 study. The current results present a confirmatory analysis of the CPAQ-A and validity data collected independently from the developers of the scale. A sample of 109 adolescents with chronic pain completed the CPAQ-A, as well as measures of pain characteristics, functional impairment, depression, anxiety, and pain self-efficacy. Results of the confirmatory factor analysis indicate the previously reported 2-factor solution provides a good fit to the data, and has acceptable internal consistency. The CPAQ-A correlated strongly with disability, depression, anxiety, and self-efficacy. It correlated only moderately with pain intensity and was not correlated with pain frequency or duration of pain. When entered last into a hierarchical regression model predicting disability, acceptance accounted for more variance than pain intensity, depression, anxiety, and self-efficacy. Results supported the internal consistency and validity of the CPAQ-A as a measure of pain acceptance in this sample of adolescents with chronic pain. Use of the CPAQ-A may provide valuable insight into the manner in which adolescents adapt to chronic pain and can guide acceptance-based treatment. PERSPECTIVE: This article strengthens the psychometric support for a measure of chronic pain acceptance in adolescents. Acceptance-based treatment has been shown to reduce disability in preliminary research targeting adolescents with chronic pain; the CPAQ-A may be useful for assessing the degree to which acceptance-based approaches may be indicated for a given patient.

Perioperative cardiac arrests in children between 1988 and 2005 at a tertiary referral center: a study of 92,881 patients.

BACKGROUND: The objective of this study was to determine the incidence and outcome of perioperative cardiac arrest (CA) in children younger than 18 yr undergoing anesthesia for noncardiac and cardiac procedures at a tertiary care center. METHODS: After institutional review board approval (Mayo Clinic, Rochester, Minnesota), all patients younger than 18 yr who had perioperative CA between November 1, 1988, and June 30, 2005, were identified. Perioperative CA was defined as a need for cardiopulmonary resuscitation or death during anesthesia care. A cardiac procedure was defined as a surgical procedure involving the heart or great vessels requiring an incision. RESULTS: A total of 92,881 anesthetics were administered during the study period, of which 4,242 (5%) were for the repair of congenital heart malformations. The incidence of perioperative CA during noncardiac procedures was 2.9 per 10,000, and the incidence during cardiac procedures was 127 per 10,000. The incidence of perioperative CA attributable to anesthesia was 0.65 per 10,000 anesthetics, representing 7.5% of the 80 perioperative CAs. Both CA incidence and mortality were highest among neonates (0-30 days of life) undergoing cardiac procedures (incidence: 435 per 10,000; mortality: 389 per 10,000). Regardless of procedure type, most patients who experienced perioperative CA (88%) had congenital heart disease. CONCLUSION: The majority of perioperative CAs were caused by factors not attributed to anesthesia, in distinction to some recent reports. The incidence of perioperative CA is many-fold higher in children undergoing cardiac procedures, suggesting that definition of case mix is necessary to accurately interpret epidemiologic studies of perioperative CA in children.