The Telehealth Tradeoff: A Multimethod Study of the Benefits and Challenges Associated With Maintaining Treatment Outcomes Using a Hybrid Model of Pediatric Intensive Interdisciplinary Pain Treatment.

OBJECTIVES: The COVID-19 pandemic required intensive interdisciplinary pain treatment (IIPT) programs to shift to virtual models of care. This study used a multimethod approach to examine outcomes of a pediatric hybrid IIPT program (50% in-person treatment and 50% synchronous video-based telehealth) and assessed staff experiences while treating within this model. MATERIALS AND METHODS: Patients (M=14.73, SD=2.04; 79% female) reported pain intensity, functional disability, and psychological factors (anxiety, depressive symptoms, fear of pain, pain catastrophizing, social functioning) at admission, discharge, and short-term follow-up. Differences in treatment outcomes at discharge and short-term follow-up between patients who participated in the hybrid IIPT model (n=42) during the pandemic and those who participated in the traditional in-person model before the pandemic (n=42) were examined. Quantitative assessments of staff burnout and perceived effort and qualitative assessments exploring staff perspectives about the challenges and advantages of the hybrid IIPT model were gathered. RESULTS: Youth in both groups made significant improvements across the majority of treatment outcomes; however, the hybrid group reported higher levels of pain at discharge and anxiety at follow-up. The majority of IIPT staff reported moderate to high levels of overall burnout, and almost half reported high levels of emotional exhaustion. Staff highlighted various challenges and benefits associated with treating within the hybrid model. DISCUSSION: When considering telehealth as a treatment tool for youth with complex chronic pain, it is crucial to leverage its benefits while addressing its challenges for patients and providers.

Pediatric pain rehabilitation during the COVID-19 pandemic: exploring the effectiveness of a hybrid intensive interdisciplinary pain treatment model.

PURPOSE: This study aimed to (1) examine improvements in rehabilitation outcomes after participation in a pediatric hybrid intensive interdisciplinary pain treatment model (50% in-person and 50% video-based telehealth) and (2) compare magnitude of hybrid model improvements to patients treated in a traditional, 100% in-person model prior to the pandemic. MATERIALS AND METHODS: Rehabilitation outcomes for 33 youth with chronic pain from the model were compared to 33 youth with chronic pain who completed a traditional, in-person model. Improvements between admission and discharge in both models were examined using paired student t-tests. Independent samples t-tests compared change scores for the hybrid and traditional models. RESULTS: Participants in both models experienced significant improvements on all rehabilitation outcomes, including cardiovascular endurance, pain interference, functional disability, and occupational performance (p < 0.001), except for pain intensity (p = 0.15). Change scores for rehabilitation outcomes did not significantly differ between models. CONCLUSIONS: Quantitatively, hybrid model rehabilitation outcomes appeared clinically equivalent to the traditional, in-person model. Qualitative and psychosocial outcome comparisons of each model are warranted to better understand challenges and barriers associated with hybrid pain treatment models. The feasibility and impact of tools to enhance telehealth, such as actigraphy or virtual reality, should also be explored.IMPLICATIONS FOR REHABILITATIONThis study supports the efficacy of video-based telehealth interventions for children and adolescents with chronic pain syndromes.Disability outcomes for a hybrid (50% in-person, 50% video-based telehealth) intensive interdisciplinary pain treatment program appear to be equivalent to patients treated within a fully in-person program.

Does intensive interdisciplinary pain treatment improve pediatric headache-related disability?

PURPOSE: To examine the effectiveness of intensive interdisciplinary pain treatment for improving disability in children with chronic headache using the International Classification of Functioning, Disability and Health model as a conceptual framework for disability assessment. MATERIALS AND METHODS: Children with chronic headache (n = 50; ages 10-19 years; 62% female) attended an intensive interdisciplinary pain treatment program 8 h/day, 5 times/week for 2-7 weeks. Disability measures were administered at admission, discharge, and 6-8 week follow-up. Disability outcomes were analyzed retrospectively. Wilcoxon signed rank tests and Friedman's analyses of variance were used to compare scores across two and three longitudinal time points, respectively. RESULTS: After rehabilitation, disability reduced on the Headache Impact Test-6 from severe impact at admission to some impact at follow-up (p < 0.001). Median time on the modified Bruce protocol increased from 13.1 min (interquartile range = 12.6-14.1) to 14.4 min (interquartile range = 12.9-16.3), p < 0.001, with gains maintained at follow-up. Improvements in pain and disability were associated with improvements in school participation. CONCLUSIONS: Findings of this study support the effectiveness of intensive interdisciplinary pain treatment for improving disability in children with chronic headache.Implication for rehabilitationIntensive interdisciplinary pain treatment is effective for improving pain and disability in children with chronic headaches.Application of the ICF model to disability assessment suggests that children with chronic headaches may experience significant disability, even when standardized assessments of physical capacity are normal.The modified Bruce protocol, Pediatric Evaluation of Disability Inventory - Computerized Adaptive Tests, and Headache Impact Test-6 appear particularly valuable in understanding the nature of disability in children with chronic headaches.

The biopsychosocial model of pain in the context of pediatric burn injuries.

BACKGROUND: Burns are a common and traumatic source of childhood injury in the United States. The treatment and recovery from burn injuries can be significantly painful and may lead to chronic or persistent pain for years following the initial incident. Further, burn injuries in youth have been found to increase the potential for significant psychosocial (e.g., anxiety, depression, PTSD) and physical (e.g., decreased mobility) impairment. Relatedly, the general experience and processing of pain in youth can also be associated with greater psychosocial (e.g., anxiety, depression) impairment and functional disability over time. However, the phenomenology and associated characteristics of the pain experience following burn injury and, in particular, the potential for combined impact on physical and psychosocial outcomes in youth with severe and/or prolonged pain and a history of burn injury is poorly understood. METHODS: A review of the literature was performed in the areas of burn injuries and outcomes associated with both acute and chronic pain with youth and adult populations. RESULTS: The current review highlights current gaps in the literature in important areas of function in youth with a history of burn injuries using the biopsychosocial model of pain. Future research and considerations for practice are also outlined. CONCLUSIONS: Gaining a greater understanding of the relationship between pain, physical impairment, and psychosocial functioning in these youth is significantly important in order to provide greater preventative and treatment-related intervention going forward. SIGNIFICANCE: Using a biopsychosocial framework, this review highlights the need for a greater understanding of pain processing and the long-term potential for persistent pain and pain-related impairment (e.g., functional disability) in youth with a history of burn injuries.

Back to Living: Long-term Functional Status of Pediatric Patients Who Completed Intensive Interdisciplinary Pain Treatment.

OBJECTIVES: To provide a descriptive account of long-term functioning (≥5 y posttreatment) among youth who completed intensive interdisciplinary pain treatment (IIPT) for pediatric chronic pain conditions. MATERIALS AND METHODS: A total of 95 patients (mean age at follow-up=20.0 y) treated at least 5 years previously at a single IIPT program completed questionnaires assessing pain, functional disability, health care utilization, academic/career achievement, and quality of life. Data analyses focused on pain, functioning, and progress toward developmental goals at long-term follow-up. RESULTS: The majority of respondents report significant reduction in pain compared with preadmission (P<0.001). Five years posttreatment, average functional disability scores were in the minimal range, with statistically significant decrease in functional disability from time of admission (P<0.001). Nearly 80% of respondents characterized themselves as having no functional difficulties at follow-up. Clinically significant improvement was established for both pain and function. Respondents generally reported developmentally appropriate status, with 89% graduating high school on schedule. DISCUSSION: Results show long-term positive functioning among individuals who underwent intensive rehabilitation treatment for chronic pain as children or adolescents. Despite experiencing one or more pain flares at some point after treatment, most former IIPT patients report minimal to no ongoing functional disability, complete or partial resolution of pain symptoms, and developmentally appropriate progress toward goals (eg, school completion, independent living).

Children With Chronic Pain: Response Trajectories After Intensive Pain Rehabilitation Treatment.

Intensive pain rehabilitation programs for children with chronic pain are effective for many patients. However, characteristics associated with treatment response have not been well documented. In this article we report trajectories of pain and functional impairment in patients with chronic pain up to 1 year after intensive pain rehabilitation and examine baseline factors associated with treatment response. Patients (n = 253) with chronic pain and functional disability were assessed at 5 time points (admission, discharge, 1-month, 4-month, and 12-month follow-ups). Individual trajectories were empirically grouped using SAS PROC TRAJ. For functional disability, 2 groups emerged: treatment responders (88%) and nonresponders (12%). Using a binomial logistic regression model to predict disability trajectory group, no baseline variables were significant predictors for the disability trajectory group. For pain, 3 groups emerged: early treatment responders (35%), late treatment responders (38%), and nonresponders (27%). Using multinomial regression analyses to predict pain trajectory group, older age, higher pain scores, fewer social difficulties, higher anxiety levels, and lower readiness to change were characteristics that distinguished nonresponders from responders; no significant predictors distinguished the late responders from the early responders. These results provide key information on the baseline factors that influence intensive pain rehabilitation outcomes, including risk factors that predict treatment nonresponse. Our findings have implications for developing more targeted treatment interventions. PERSPECTIVE: Deriving groups of individuals with differing treatment response trajectories stimulates new thinking regarding potential mechanisms that may be driving these outcomes.

Feeling the Pressure to Be Perfect: Effect on Pain-Related Distress and Dysfunction in Youth With Chronic Pain.

Despite clinical observation of perfectionistic tendencies among youth with chronic pain and their parents as well as established relationships between perfectionism and functional somatic symptoms in adults and youth, no research in the pediatric pain literature has examined perfectionism. This study explored the role of various types of youth and parent perfectionism on youth and parent pain-related distress and behavior and youth pain-related dysfunction. At admission, 239 parent-child pairs from outpatient and day-treatment rehabilitation settings completed several questionnaires assessing perfectionism, pain-related distress, and pain-related dysfunction. Bivariate correlations indicated that socially prescribed perfectionism in youth and parents was linked to youth pain duration, parent and youth pain-related distress and behavior, and youth somatization. Indirect relations showed that youth socially prescribed perfectionism was the only form of perfectionism directly associated with youth somatization whereas all forms of youth perfectionism were indirectly associated with somatization and functional disability through increases in youth pain-related fear and catastrophizing. Additionally, socially prescribed perfectionism was the only type of parent perfectionism linked to youth pain-related dysfunction (somatization, functional disability) through its association with youth pain-related fear. Findings support clinical observations that parent and youth perfectionism is a psychosocial factor that should be targeted in pediatric chronic pain treatment. PERSPECTIVE: Perfectionism in youth with chronic pain and their parents was indirectly linked to youth pain-related dysfunction through its effect on youth pain-related catastrophizing and fear. Findings support clinical observations that parent and youth perfectionism is a psychosocial factor that should be targeted in pediatric chronic pain treatment.

Photographs of Daily Activities-Youth English: validating a targeted assessment of worry and anticipated pain.

PHODA is an electronic measure that individualizes and guides treatment for individuals with chronic pain. Implicit in its design is recognition that pain-related fear is a driving force that impedes treatment progress. With this tool, patients visually rate their expectations about the harmful consequences of specific movements. This study aimed to (1) develop and validate PHODA-Youth English (PHODA-YE) and (2) evaluate the potential impact of PHODA-YE assessment on treatment outcomes. Participants were 195 youth, age 8 to 20 years, who presented to an outpatient pain clinic for evaluation (n = 99), or enrolled at the Pediatric Pain Rehabilitation Center (PPRC) intensive program (PPRC; n = 96). All patients completed the PHODA-YE along with measures of emotional functioning and disability. Patients in the PPRC completed the measure at both admission and discharge. After eliminating infrequently endorsed and poorly loading items, factor analytic procedures yielded a 4-subscale, 50-item measure with strong internal consistency (from 0.92 to 0.97 across subscales). Fear, avoidance, and functional disability were strongly associated with PHODA-YE scores, supporting construct validity. Within the PPRC sample, PHODA-YE was sensitive to changes over time in relation to functional improvements. Across the PPRC sample, patients found it helpful to complete the PHODA and target feared activities. Altogether, the PHODA-YE is a valid and concrete assessment tool that rapidly identifies specific activities and movements that elicit fearful responses from patients.

Changes in sleep habits in adolescents during intensive interdisciplinary pediatric pain rehabilitation.

Sleep behaviors play an important role in the experience of chronic pain in adolescence; less well known is the effect of improved sleep in the context of pain rehabilitation. This study examined changes in sleep habits and their association with pain and functioning following day-hospital interdisciplinary pediatric pain rehabilitation. Participants (84% female) were a cohort of 274 youth (ages 10-18, mean age 14.6 years) with neuropathic or musculoskeletal pain and associated disability who completed measures at admission, discharge, and short term (1-3 month) follow-up. Parents reported on the child's sleep habits; participants reported on pain, functional disability, and school functioning. Results show that sleep habits improved over the course of intensive pain rehabilitation treatment, with continued improvements at follow-up. Sleep habits at discharge correlated with concurrent measures of functional disability and mood symptoms, with healthier sleep habits being associated with less disability and fewer mood symptoms. Furthermore, greater sleep duration, less sleep onset delay, and fewer night wakings correlated with lower pain intensity ratings at discharge. Controlling for change in pain with treatment, baseline sleep habits, age, and concurrent depressive symptoms, sleep habits at discharge predicted global functioning and school functioning measured at follow-up. There was modest support for changes in sleep habits over the course of treatment predicting pain reduction at follow-up, with decreased night wakings significantly predicting reduced pain intensity at follow-up. Improvements in sleep habits may be one mechanism of efficacy for intensive pediatric pain rehabilitation.

What does it take? Comparing intensive rehabilitation to outpatient treatment for children with significant pain-related disability.

OBJECTIVES: This study compared outcomes between day hospital pain rehabilitation patients and patients engaged in outpatient multidisciplinary pain treatment. METHODS: This study included 100 children who presented for an initial tertiary care pain clinic evaluation. 50 patients enrolled in intensive day hospital pain rehabilitation and 50 patients pursued outpatient multidisciplinary treatment. Across 2 time points, children completed measures of functional disability, pain-related fear, and readiness to change and parents completed measures of pain-related fear and readiness to change. RESULTS: Across both treatment modalities, patients and parents reported improvements. Patients enrolled in intensive pain rehabilitation had significantly larger improvements in functional disability, pain-related fear, and readiness to change. Parents of day hospital patients reported larger declines in child pain-related fear and increased readiness to change compared with their outpatient counterparts. Discussion For patients with high levels of pain-related disability and distress, intensive pain rehabilitation provides rapid, dramatic improvements in functioning.

Ecological system influences in the treatment of pediatric chronic pain.

Family, school and the peer network each shape the chronic pain experience of the individual child, and each of these contexts also represents a domain of functioning often impaired by chronic pain. The goal of the present article is to summarize what is known about these bidirectional influences between children with pain and the social systems that surround them. Case reports that illustrate these complex, transactional forces and their ultimate impact on the child's pain-related functioning are included. A case involving siblings participating in an intensive interdisciplinary program for functional restoration and pain rehabilitation highlights how parents change through this treatment approach and how this change is vital to the child's outcomes. Another case involving a child undergoing intensive interdisciplinary treatment illustrates how school avoidance can be treated in the context of pain rehabilitation, resulting in successful return to the regular school environment. Finally, an acceptance and commitment therapy-focused group intervention for children with sickle cell disease and their parents demonstrates the benefits of peer contact as an element of the therapeutic intervention.

Fear of pain in the context of intensive pain rehabilitation among children and adolescents with neuropathic pain: associations with treatment response.

UNLABELLED: Recent research has implicated pain-related fear in relation to functional outcomes in children with chronic pain. The current study examined fear of pain, disability, and depression within the context of an intensive pain rehabilitation program. One hundred forty-five children and adolescents who participated in an intensive interdisciplinary pediatric pain rehabilitation day program were assessed in this study. Patients completed measures of pain intensity, pain-related fears, functional disability, and depressive symptoms at admission, discharge, and on average, 2 months postdischarge. After controlling for pain intensity, pain-related fear was significantly related to disability and depressive symptoms at all time points. As predicted, a decline in pain-related fear was significantly associated with a decrease in disability and depressive symptoms. Interestingly, high levels of pain-related fears at admission predicted less reduction in functional disability and depression at discharge, suggesting that high levels of pain-related fear may be a risk factor in relation to treatment outcomes. Overall, results indicate that the relationship between fear of pain and changes in disability and depressive symptoms are closely linked, with fear of pain playing an important role in treatment. PERSPECTIVE: This paper presents results underscoring the importance of pain-related fear in relation to treatment response for children and adolescents with chronic pain. These findings support the need to develop and implement interventions that target reductions in pain-related fear.

Changes in willingness to self-manage pain among children and adolescents and their parents enrolled in an intensive interdisciplinary pediatric pain treatment program.

The importance of willingness to adopt a self-management approach to chronic pain has been demonstrated in the context of cognitive-behaviorally oriented interdisciplinary pain treatment programs for adults, both as a treatment outcome and as a process that facilitates functional improvements. Willingness to self-manage pain has not been studied in pediatric interdisciplinary pain treatment settings. Study aims were (1) to investigate willingness to self-manage pain among children and parents undergoing intensive interdisciplinary pain treatment and (2) to determine whether increased willingness to self-manage pain influenced functional treatment outcomes. A total of 157 children ages 10 to 18 and their parents enrolled in a pediatric pain rehabilitation program completed the Pain Stages of Change Questionnaire (PSOCQ youth and parent versions) at pretreatment, posttreatment, and short-term follow-up. They also reported on pain, functional disability, depressive symptoms, fear of pain, and use of passive and accommodative coping strategies. Results show that willingness to self-manage pain increased during treatment among both children and parents, with gains maintained at follow-up. Increases in children's readiness to self-manage pain from pretreatment to posttreatment were associated with decreases in functional disability, depressive symptoms, fear of pain, and use of adaptive coping strategies. Increases in parents' readiness to adopt a pain self-management approach were associated with changes in parent-reported fear of pain but not with other child outcomes. Few associations emerged between pretreatment willingness to self-manage pain and posttreatment outcomes. Findings suggest that interdisciplinary pediatric pain rehabilitation may facilitate increased willingness to self-manage pain, which is associated with improvements in function and psychological well-being.