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Children’s Chronic Pain Trajectories May Predict Their Response to Intensive Rehab

While rehabilitation programs are effective, new research sheds light on baseline factors

With Laura E. Simons, PhD, and Tala Dajani, MD, MPH

Intensive pain rehabilitation programs have been demonstrated to be effective in helping children with chronic pain return to their levels of function before their pain onset. However, these programs are costly and require substantial time commitments from both patients and their families. According to a study1 by Simons et al, researchers have now identified pain trajectories for children with chronic pain who participate in these programs from up to 1 year following treatment. These findings have allowed researchers to assess baseline factors that appear to be associated with treatment response with regards to improvements in functional ability and pain reduction.

As pain rehabilitation programs may cost upwards of $30,000, clinicians need to “make sure the family is ready for the commitment of time, energy, and openness to learning strategies to live life in the presence of pain,” lead author Laura E. Simons, PhD, associate professor of anesthesiology, perioperative and pain medicine (pediatric) at the Stanford University Medical Center, told Practical Pain Management.

Regaining Functional Ability

The study included 253 patients aged 8 to 18 years (mean age of 14.5 years) with complex regional pain syndrome (CRPS). Patients were considered eligible for the program if they had not progressed through other outpatient physical and cognitive behavioral therapies. Rehabilitation programs included physical, occupational and psychological therapies for 8 hours a day, 5 days a week, with the typical stay lasting between three to four weeks. Patients attended follow-up appointments at 1, 4 and 12 months post-discharge.

Pain intensity was assessed using an 11-point scale (0 to 10). Functional disability was assessed using the 15-item Functional Disability Inventory. The researchers used “disability and pain as primary markers of treatment gains, [but] examined a number of other factors over time,” said Dr. Simons. Other useful markers can include missed schools days; quality of life; depression measures; frequency, potency and accumulated doses of pain medications; and effects on daily routines, Tala Dajani, MD, assistant professor of clinical science education at the ATSU School of Osteopathic Medicine in Arizona, told Practical Pain Management.

Dr. Simons and her co-authors reported that 88% of the children studied were able to regain day-to-day functional ability. Almost three-quarters (73%) reported mild to no pain at one-month follow-up, and these improvements were maintained at one year. Most importantly, they found that older age, higher pain scores, fewer social difficulties, higher anxiety levels and lower readiness to change differentiated the children who responded well to intensive programs from those who did not, with regards to pain. With regard to functional ability, researchers did not find any baseline characteristics to distinguish between responders and non-responders.

Mapping Out Three Trajectories

Two trajectories were identified for functional disability (N = 194)—responders and non-responders. The researchers theorized that no baseline factors were identified to distinguish the two groups because the group of non-responders was so small (12%). Three trajectories were identified for pain intensity—early responders (35%), late responders (38%) and non-responders (27%). Early responders saw reductions in pain at discharge and had virtually no pain at 1-month follow-up. In contrast, late responders saw little improvement at discharge, but by 1-month follow-up, reported considerable improvement that was maintained at one year.

The group of non-responders was large enough in the analysis of pain intensity to identify risk factors, two of which may be modifiable—readiness to change and anxiety. Those considered to be pre-contemplative or contemplative-based on scores from the Pain Stages of Change Questionnaires for Adolescents and Parents—were at a nine-fold greater risk of not responding to the program compared with those considered to be at an action/maintenance stage. The researchers suggested that “patients should be screened on readiness to change before enrollment” in this type of intensive treatment. Higher levels of anxiety were also associated with lower likelihood of pain response.

Conclusion

Study findings are consistent with previous research.2 “Addressing more generalized anxiety symptoms via interoceptive exposure may yield enhanced outcomes,” wrote the researchers. Dr. Simons added that the real potential of these findings is "in shifting perspective to one where a patient is open to taking a self-management approach. Pain actually improves when they feel that they have some agency in making it happen, rather than relying on treating clinicians to provide that relief."

Last updated on: May 2, 2018
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Chronic Pain in Children
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