Social learning pathways in the relation between parental chronic pain and daily pain severity and functional impairment in adolescents with functional abdominal pain.

Having a parent with chronic pain (CP) may confer greater risk of persistence of CP from childhood into young adulthood. Social learning, such as parental modeling and reinforcement, represents one plausible mechanism for the transmission of risk of CP from parents to offspring. Based on a 7-day pain diary in 154 pediatric patients with functional abdominal CP, we tested a model in which parental CP predicted adolescents' daily average CP severity and functional impairment (distal outcomes) via parental modeling of pain behaviors and parental reinforcement of adolescent's pain behaviors (mediators) and adolescents' cognitive appraisals of pain threat (proximal outcome representing adolescents' encoding of parents' behaviors). Results indicated significant indirect pathways from parental CP status to adolescent average daily pain severity (b = 0.18, SE = 0.08, 95% confidence interval: 0.04-0.31, P = 0.03) and functional impairment (b = 0.08, SE = 0.04, 95% confidence interval: 0.02-0.15, P = 0.03) over the 7-day diary period via adolescents' observations of parent pain behaviors and adolescent pain threat appraisal. The indirect pathway through parental reinforcing responses to adolescents' pain did not reach significance for either adolescent pain severity or functional impairment. Identifying mechanisms of increased risk of pain and functional impairment in children of parents with CP ultimately could lead to targeted interventions aimed at improving functioning and quality of life in families with CP. Parental modeling of pain behaviors represents a potentially promising target for family-based interventions to ameliorate pediatric CP.

Congenital vaginal atresia: A report of 39 cases in a regional Obstetrics and Gynecology Hospital.

To investigate the clinical course and management of congenital vaginal atresia. This retro-spective analysis included patients with congenital vaginal atresia treated from March 2004 to August 2014 at the Obstetrics and Gynecology Hospital of Fudan University. Thirty-nine patients were included in this study. Their average age was 16.87±2.2 years when they came to our hospital. Totally, 51% of the patients had isolated congenital vaginal atresia with a normal cervix, whereas the others had either cervical atresia or imperforate hymen. The primary presenting signs and symptoms included primary amenorrhea (71.8%), periodic abdominalgia (41.0%), abdominal pain (36.0%), dyspareunia (10.3%), menstrual disorders (5.1%), and pelvic mass (5.1%). Ultrasound and magnetic resonance imaging (MRI) were effective inspection methods for the screening of urogenital tract-associated anomalies. Vagi-noplasty mainly included simple vagina reconstruction with insertion of a mold (n=22) and split-thickness skin grafting (n=4). In 64% of surgical patients, normal menstrual bleeding was achieved. Four of the patients subsequently became pregnant and delivered at term. Primary amenorrhea, periodic abdominalgia and abdominal pain are the main reasons for the post pubertal patients to visit doctors. Surgical methods can successfully provide these patients an opportunity for subsequent conservative management, can result in normal menstrual bleeding, resolve cyclic pelvic pain, and provide some po-tential for fertility.

Brief telephone-delivered cognitive behavioral therapy targeted to parents of children with functional abdominal pain: a randomized controlled trial.

Pediatric functional abdominal pain disorders (FAPDs) are associated with increased health care utilization, school absences, and poor quality of life (QoL). Cost-effective and accessible interventions are needed. This multisite study tested the effects of a 3-session cognitive behavioral intervention delivered to parents, in-person or remotely, on the primary outcome of pain severity and secondary outcomes (process measures) of parental solicitousness, pain beliefs, catastrophizing, and child-reported coping. Additional outcomes hypothesized a priori and assessed included functional disability, QoL, pain behavior, school absences, health care utilization, and gastrointestinal symptoms. The study was prospective and longitudinal (baseline and 3 and 6 months' follow-up) with 3 randomized conditions: social learning and cognitive behavioral therapy in-person (SLCBT) or by phone (SLCBT-R) and education and support condition by phone (ES-R). Participants were children aged 7 to 12 years with FAPD and their parents (N = 316 dyads). Although no significant treatment effect for pain severity was found, the SLCBT groups showed significantly greater improvements compared with controls on process measures of parental solicitousness, pain beliefs, and catastrophizing, and additional outcomes of parent-reported functional disability, pain behaviors, child health care visits for abdominal pain, and (remote condition only) QoL and missed school days. No effects were found for parent and child-reported gastrointestinal symptoms, or child-reported QoL or coping. These findings suggest that for children with FAPD, a brief phone SLCBT for parents can be similarly effective as in-person SLCBT in changing parent responses and improving outcomes, if not reported pain and symptom report, compared with a control condition.

Abdominal Trigger Points and Psychological Function.

Myofascial trigger points (TPs) are a poorly understood phenomenon involving the myofascial system and its related neural, lymphatic, and circulatory elements. Compression or massage of a TP causes localized pain and may cause referred pain and autonomic phenomena. The authors describe a 58-year-old woman who experienced precipitation of substantial psychological symptoms directly related to her treatment for a lower abdominal TP. Her symptoms resolved after 2 weeks of receiving high-velocity, low-amplitude manipulation and soft tissue massage. Particularly in the abdomen, TPs may be associated with psychological reactions as well as physical aspects of bodily function.

Athletic groin pain: a systematic review and meta-analysis of surgical versus physical therapy rehabilitation outcomes.

BACKGROUND: Athletic groin pain (AGP) is an encompassing term for the multitude of chronic conditions presenting as pain in the inguinal region. The purpose of this review was to compare the return to play rates (RTPrate) and return to play times (RTPtime) between surgical and rehabilitation interventions in the treatment of AGP. METHODS: A systematic review of English language peer review journals was carried out between 1980 to June 2013 using PubMed, Embase, CINHAL and Google Scholar searching for all papers relating to AGP (and its various pseudonyms) and all surgical and rehabilitative interventions which reported RTPrate and/or RTPtime. AGP literature has been subdivided by many eponymous diagnoses but anatomical diagnostic groupings of (1) abdominal wall, (2) adductor and (3) pubic related pain were used in this review. Meta-analysis was then carried out on the data to compare results between the surgical and rehabilitation groups. RESULTS: Fifty-six papers out of the 561 discovered in the initial search were included in the review with 3332 athletes included. Evidence was mostly level IV. Using the Black and Downs checklist we found poor study quality overall with a high risk of bias especially among surgical studies. The results showed comparable RTPrate between surgical and rehabilitative interventions within the three diagnostic groups. Rehabilitation had significantly quicker RTPtime for pubic related groin pain compared to surgery (10.5 weeks and 23.1 weeks respectively). The abdominal group had the fastest return of the three groups for the rehabilitation and surgery. CONCLUSIONS: The review suggested better outcomes with rehabilitation for pubic-related groin pain with no difference between the adductor and abdominal groups. The review highlighted the poor quality and risk of bias in the literature making accurate comparison difficult.

Systematic review: laparoscopic treatment of long-standing groin pain in athletes.

OBJECTIVES: No single aetiological factor has been proven to cause long-standing groin pain in athletes and no sole operative technique (either open or laparoscopic) has been shown to be the preferred method of repair. The aim of this systematic review was to determine whether there are any differences in the return to full sporting activity following laparoscopic repair of groin pain in athletes. DATA SOURCES: The minimal access approaches include laparoscopic transabdominal pre-peritoneal (TAPP) or endoscopic total extraperitoneal (TEP) techniques. A systematic literature search was performed in PubMed, SCOPUS, UpToDate and the Cochrane Library databases. Series reporting laparoscopic repair (TAPP/TEP) of groin pain in adult (>18 years) athletes were included. The primary outcome was return to full sporting activity and secondary outcomes included percentage success rates and complications of operations. RESULTS: Only 18 studies fulfilled the search criteria with both laparoscopic and sports hernia repairs. The studies were mainly observational with some reporting comparative data, but no large randomised controlled trials were detected. The median return to sporting activity of 4 weeks (28 days) was the same for the TAPP as well as TEP techniques. No real difference in secondary outcome measures was shown. More reported cases to date in the literature used the TAPP technique compared with TEP repair (n=605 vs n=266). CONCLUSIONS: Laparoscopic surgery for elite athlete groin pain is increasingly becoming more common with almost 1000 patients reported since 1997. No particular laparoscopic technique appears to offer any advantage over the other.

Pubic apophysitis: a previously undescribed clinical entity of groin pain in athletes.

BACKGROUND: Sport-related pubalgia is often a diagnostic challenge in elite athletes. While scientific attention has focused on adults, there is little data on adolescents. Cadaveric and imaging studies identify a secondary ossification centre located along the anteromedial corner of pubis beneath the insertions of symphysial joint capsule and adductor longus tendon. Little is known about this apophysis and its response to chronic stress. AIM: We report pubic apophysitis as a clinically relevant entity in adolescent athletes. METHODS: The clinical and imaging findings in 26 highly trained adolescent football players (15.6 years ± 1.3) who complained of adductor-related groin pain were reviewed. The imaging features (X-ray 26/26, US 9/26, MRI 11/26, CT 7/26) of the pubic apophyses in this symptomatic group were compared against those of a comparison group of 31 male patients (age range 9-30 years) with no known history of groin pain or pelvic trauma, who underwent pelvic CT scans for unrelated medical reasons. RESULTS: All symptomatic subjects presented with similar history and physical findings. The CT scans of these patients demonstrated open pubic apophyses with stress-related physeal changes (widening, asymmetry and small rounded cyst-like expansions) that were not observed in the comparison group. No comparison subject demonstrated apophyseal maturity before 21 years of age, and immaturity was seen up to the age of 26 years. CONCLUSIONS: This retrospective case series identifies pubic apophyseal stress (or 'apophysitis') as an important differential consideration in the adolescent athlete who presents with groin pain.

Pain severity and pain catastrophizing predict functional disability in youth with inflammatory bowel disease.

BACKGROUND: Abdominal pain is commonly reported by youth with IBD. In a significant subset of youth, pain severity and pain catastrophizing (i.e., unhelpful thoughts related to the pain) may contribute to more negative outcomes and greater impairment in functioning. This study aimed to examine relationships of pain severity and pain catastrophizing with functional disability among a sample of youth with inflammatory bowel disease (IBD). METHODS: Seventy-five youth aged 11 to 18 years completed ratings of abdominal pain severity, pain catastrophizing, and functional disability using validated measures. Disease activity was rated by treating physicians. RESULTS: Over half of participants reported abdominal pain in the past two weeks, and pain was present among those with and without clinical disease activity. Nearly one-third of youth reported mild to moderate functional disability. After controlling for gender, pain severity accounted for 15% of the variance in patient functional disability. Moreover, pain catastrophizing contributed significant variance to the prediction of functional disability (approximately 7%) beyond the role of pain severity. CONCLUSIONS: Greater attention to the role of pain catastrophizing in contributing to functional disability in youth with IBD may be important given that pain-related cognitions are modifiable via intervention.

Cognitive mediators of treatment outcomes in pediatric functional abdominal pain.

OBJECTIVES: Cognitive-behavioral (CB) interventions improve outcomes for many pediatric health conditions, but little is known about which mechanisms mediate these outcomes. The goal of this study was to identify whether changes in targeted process variables from baseline to 1 week posttreatment mediate improvement in outcomes in a randomized controlled trial of a brief CB intervention for idiopathic childhood abdominal pain. MATERIALS AND METHODS: Two hundred children with persistent functional abdominal pain and their parents were randomly assigned to 1 of 2 conditions: a 3-session social learning and CB treatment (N=100), or a 3-session educational intervention controlling for time and attention (N=100). Outcomes were assessed at 3-, 6-, and 12-month follow-ups. The intervention focused on altering parental responses to pain and on increasing adaptive cognitions and coping strategies related to pain in both parents and children. RESULTS: Multiple mediation analyses were applied to examine the extent to which the effects of the social learning and CB treatment condition on child gastrointestinal (GI) symptom severity and pain as reported by children and their parents were mediated by changes in targeted cognitive process variables and parents' solicitous responses to their child's pain symptoms. Reductions in parents' perceived threat regarding their child's pain mediated reductions in both parent-reported and child-reported GI symptom severity and pain. Reductions in children's catastrophic cognitions mediated reductions in child-reported GI symptom severity but no other outcomes. Reductions in parental solicitousness did not mediate outcomes. DISCUSSION: Results suggest that reductions in reports of children's pain and GI symptoms after a social learning and CB intervention were mediated at least in part by decreasing maladaptive parent and child cognitions.

'Treatment of the sportsman's groin': British Hernia Society's 2014 position statement based on the Manchester Consensus Conference.

INTRODUCTION: The aim was to produce a multidisciplinary consensus to determine the current position on the nomenclature, definition, diagnosis, imaging modalities and management of Sportsman's groin (SG). METHODS: Experts in the diagnosis and management of SG were invited to participate in a consensus conference held by the British Hernia Society in Manchester, U.K. on 11-12 October 2012. Experts included a physiotherapist, a musculoskeletal radiologist and surgeons with a proven track record of expertise in this field. Presentations detailing scientific as well as outcome data from their own experiences were given. Records were made of the presentations with specific areas debated openly. RESULTS: The term 'inguinal disruption' (ID) was agreed as the preferred nomenclature with the term 'Sportsman's hernia' or 'groin' rejected, as no true hernia exists. There was an overwhelming agreement of opinion that there was abnormal tension in the groin, particularly around the inguinal ligament attachment. Other common findings included the possibility of external oblique disruption with consequent small tears noted as well as some oedema of the tissues. A multidisciplinary approach with tailored physiotherapy as the initial treatment was recommended with any surgery involving releasing the tension in the inguinal canal by various techniques and reinforcing it with a mesh or suture repair. A national registry should be developed for all athletes undergoing surgery. CONCLUSIONS: ID is a common condition where no true hernia exists. It should be managed through a multidisciplinary approach to ensure consistent standards and outcomes are achieved.

Changes in symptoms and lifestyle factors in patients seeking healthcare for gastrointestinal symptoms: an 18-year follow-up study.

BACKGROUND: Gastrointestinal symptoms and lifestyle change over time. The data from this 18-year longitudinal study are intended to further elucidate the long-term natural course of functional gastrointestinal (GI) symptoms and possible influencing factors. AIM: The aim of this study was to evaluate the correlation between lifestyle factors over time by reassessing symptom profiles in patients who presented with GI symptoms in 1990. METHOD: The study population comprises a subset of individuals enrolled in the Swedish Dyspepsia Study, which commenced in 1990. In 1990, each participant in the Swedish Dyspepsia Study underwent physical assessment and completed a computer-based questionnaire on eight GI symptoms and lifestyle factors. An identical questionnaire was completed in 2008. RESULTS: In total, 137 participants, 85 women and 52 men, were included in the follow-up study. None of the symptoms increased in frequency. Four of the symptoms decreased in frequency: abdominal pain [odds ratio (OR) 2.70], flatulence (OR 4.09), nausea (OR 3.05), and acid regurgitation (OR 1.59). Significant lifestyle changes included increased BMI (P<0.0001), decreased tobacco smoking (P<0.0001), and milk drinking (P=0.0080). Increased exercise was correlated with a decrease in acid regurgitation (OR 3.05) and vomiting (OR 7.38), but an increase in diarrhea (OR 0.23) and nausea (OR 0.33). Decreased smoking was correlated with a decrease in acid regurgitation (OR 3.45) and heartburn (OR 2.91). CONCLUSION: The results indicated that the lifestyle changes in the studied population followed the same pattern as seen in the general population, and changes in lifestyle factors may have an impact on GI symptoms and may guide symptom management in the patient, all in order to reduce personal suffering and healthcare costs in the form of fewer visits to the doctor and lower numbers of drug prescriptions.

Treatment of refractory irritable bowel syndrome with visceral osteopathy: short-term and long-term results of a randomized trial.

OBJECTIVE: In light of the low efficiency of available drugs in treating irritable bowel syndrome (IBS), there has been a growing interest in its alternative therapies. The aim of this study was to evaluate the effectiveness of visceral osteopathy for IBS. METHODS: In total, 31 consecutive refractory IBS patients were prospectively included in a randomized, crossover placebo-controlled study. Qualitative evaluation of depression and four symptoms including constipation, diarrhea, abdominal distension and abdominal pain before and after each phase of the study were conducted using visual analog scales, measures of rectal sensitivity and colonic transit time. One year after the study, the assessment of symptoms was performed again in all patients. RESULTS: Visceral osteopathy was associated with a significant amelioration of self-reported diarrhea, abdominal distension and abdominal pain, while constipation did not change significantly after this therapy. It was also associated with decreased rectal sensitivity, presenting as an increase in threshold volume, constant sensation volume and maximum tolerable volume (P < 0.001). However, no significant evolution of rectal sensitivity was observed when patients underwent placebo manipulations. Modifications of depression and total or segmental colonic transit time were not observed. One year after the end of this trial, symptom scores of diarrhea, abdominal distension and abdominal pain were significantly lower than those at enrollment (P < 0.05). CONCLUSION: This study suggests that visceral osteopathy improves short-term and long-term abdominal distension and pain, and also decreases rectal sensitivity in IBS patients.

Cannabinoid hyperemesis: a case series of 98 patients.

OBJECTIVE: To promote wider recognition and further understanding of cannabinoid hyperemesis (CH). PATIENTS AND METHODS: We constructed a case series, the largest to date, of patients diagnosed with CH at our institution. Inclusion criteria were determined by reviewing all PubMed indexed journals with case reports and case series on CH. The institution's electronic medical record was searched from January 1, 2005, through June 15, 2010. Patients were included if there was a history of recurrent vomiting with no other explanation for symptoms and if cannabis use preceded symptom onset. Of 1571 patients identified, 98 patients (6%) met inclusion criteria. RESULTS: All 98 patients were younger than 50 years of age. Among the 37 patients in whom duration of cannabis use was available, most (25 [68%]) reported using cannabis for more than 2 years before symptom onset, and 71 of 75 patients (95%) in whom frequency of use was available used cannabis more than once weekly. Eighty-four patients (86%) reported abdominal pain. The effect of hot water bathing was documented in 57 patients (58%), and 52 (91%) of these patients reported relief of symptoms with hot showers or baths. Follow-up was available in only 10 patients (10%). Of those 10, 7 (70%) stopped using cannabis and 6 of these 7 (86%) noted complete resolution of their symptoms. CONCLUSION: Cannabinoid hyperemesis should be considered in younger patients with long-term cannabis use and recurrent nausea, vomiting, and abdominal pain. On the basis of our findings in this large series of patients, we propose major and supportive criteria for the diagnosis of CH.

Teratoma inmaduro intramedular infantil / Immature childhood intramedullary teratoma

Los teratomas en la infancia son generalmente benignos; siendo los inmaduros los menos frecuentes. Son tumores intradurales; lo que supone el 10% de los tumores raquimedulares en el niño. Presentamos el caso clínico de un paciente varón afecto de lesión medular diagnosticada a los 2 años de edad sin déficit sensoriomotor. Tras extirpar la lesión quedaron secuelas que requirieron tratamiento neurorehabilitador: vejiga neurógena, paresia de extremidades inferiores. El estudio anatomopatológico diagnostica la lesión de teratoma inmaduro grado II/III de localización D11-L3. Existe además una recidiva de las lesiones intradurales; a pesar de lo cual la evolución es satisfactoria. Se realiza búsqueda bibliográfica sin encontrar ningún caso publicado con las características de nuestro paciente. Mediante este caso se demuestra la importancia de un seguimiento y tratamiento multidisciplinar para el tratamiento de estas lesiones; de modo que el papel del médico rehabilitador es actuar de forma precoz para minimizar las secuelas y conseguir el mayor grado de independencia posible(AU)

Teratomas in childhood are usually benign, the immature ones being the least frequent. They are intradural tumors, which account for 10% of all the spinal tumors in children. We present a case of a male whose lesion was detected when he was 2 years old with no sensory-motor deficit. Following the tumor excision, some sequels remained that required rehabilitation treatment: neurogenic bladder and lower limb paresis. The anatomy-pathology diagnosed an immature teratoma grade II/III located in D11-L3. There was also recurrence of the intradural lesions in spite of which the evolution was good. A bibliographic search was performed, without finding any case similar to our patient. The importance of a follow-up and multidisciplinary treatment for those lesions is demonstrated by this case. Thus, the role of the rehabilitation doctor is to act early to minimize the sequels and to the highest independence possible(AU)

Functional abdominal pain in children: new understanding, diagnostic criteria, and treatment approaches.

From the array of articles, one can readily see the clinical and scientific progress made in symptom-based diagnosis and management of functional abdominal pain disorders over the past 5 years. We have provided a series of useful tools to approach these patients. We have provided the symptom-based diagnostic criteria plus the red flags to help you avoid missing an organic diagnosis. We have placed these disorders squarely within the complex biopsychosocial framework by identifying early life stress and many environmental factors that are key factors in the development of pain. We have identified the role of psychological comorbidities of anxiety and depression and the need to address them directly in order to rehabilitate a disabled child. Finally, pharmacologic, psychological, dietary, and complementary approaches are reviewed and recommended as empiric therapy in functional abdominal pain, functional dyspepsia, and irritable bowel syndrome. Use these new tools well.

Celiac plexus block: a new technique using the left lateral approach.

We describe a new celiac plexus block approach in a patient with cholangiocarcinoma who was referred to the Pain Clinic due to uncontrollable abdominal pain. The patient was initially programmed for a neurolytic celiac plexus block using the anterior approach with helical computerized tomography (CT) guidance. The CT scan revealed interposition of the transverse colon in the anterior approach territory, which made the anterior approach technique difficult, and also difficulty to practice the posterior approach without injuring the kidneys. We decided to attempt a left lateral atypical approach because the CT revealed the possibility of using a left lateral window to arrive to the celiac area. The left lateral access allowed us to carry out the neurolytic block using 50% alcohol without injuring any viscera. The patient tolerated the technique and was discharged without pain. No complications regarding either the punction or the block were observed.

Relationships between family and parent characteristics and functional abilities in children with recurrent pain syndromes: an investigation of moderating effects on the pathway from pain to disability.

OBJECTIVE: To identify family characteristics associated with children's ability to function with recurrent pain. METHODS: Seventy-eight children ages 7-17 years with recurrent pain syndromes [migraine headache or recurrent abdominal pain (RAP)] were recruited from clinic settings. Children completed pain diaries and the Functional Disability Inventory (FDI). Mothers and fathers completed self-report measures of psychological distress, and mothers reported on family environment. RESULTS: Controlling for the influence of pain intensity, family environment and parental distress jointly predicted children's ability to function with pain. Among children with migraine, family environment moderated the relationship between pain and functional disability; in this group, greater pain associated with more functional disability in children from disruptive family environments, but not in children from more adaptive family environments. CONCLUSIONS: For some pediatric recurrent pain sufferers, family characteristics associate with the extent of pain-related disability and may help identify children likely to experience more impaired functioning in response to recurrent pain.

Physical and emotional functioning of adult patients with chronic abdominal pain: comparison with patients with chronic back pain.

UNLABELLED: Adults with chronic abdominal pain remain a poorly defined population, despite the debilitation and depression associated with this therapeutically challenging condition. This study compared patients with chronic abdominal pain with an empirically well-known group of patients with chronic pain (back pain) to investigate similarities and differences in their physical and mental functioning. This retrospective, cross-sectional study included 136 patients with abdominal pain and 364 patients with back pain seen in a comprehensive pain rehabilitation center. Patients' functioning was assessed with the Short Form-36 Health Survey, Multidimensional Pain Inventory, Center for Epidemiological Studies-Depression scale, and Coping Strategies Questionnaire-Catastrophizing subscale. Both the abdominal and back pain patients reported long-standing and severe pain, numerous surgery procedures, poor functioning, and high prevalence of depression. When age, education, and marital status were controlled for, analyses showed that although patients with abdominal pain reported significantly better physical functioning than patients with back pain (P < .001), their overall health perception was significantly poorer (P < .001). Although less prevalent, it is clear that patients with chronic abdominal pain exhibit poor functioning and prevalence of depression that are comparable to patients with chronic back pain. This study also suggests distinct characteristics that are vital to consider for effective treatment of this chronic pain population. PERSPECTIVE: As a result of being an overlooked and poorly defined population, adults with chronic abdominal pain might not receive adequate pain management treatment. Learning more about the physical and emotional functioning of patients with long-standing abdominal pain can increase recognition of the needs of and improve treatment for this population.