Gait Variability and Relationships With Fear, Avoidance, and Pain in Adolescents With Chronic Pain.

OBJECTIVE: Some children with chronic pain struggle with fear of pain, avoidance behaviors, and associated disability; however, movement adaptations in the context of chronic pain in childhood is virtually unknown. Variability in adaptive movement responses previously observed between individuals might be largely explained by the presence of problematic psychological drivers (eg, fear, avoidance). The goals of this study were to quantify the variability of gait and examine relationships among pain, fear, avoidance, function (perceived and objective), and gait variability. METHODS: This study used a cross-sectional design. Eligible patients were between 8 and 17 years of age and had musculoskeletal, neuropathic, or headache pain that was not due to acute trauma (eg, active sprain) or any specific or systemic disease. Participants completed the Numeric Pain Rating Scale, Fear of Pain Questionnaire (FOPQ), Functional Disability Inventory, and 6-Minute Walk Test and received kinematic gait analysis. Relationships were analyzed among these measures, and the self-report and functional measures were examined to determine whether they predicted gait variability (GaitSD). RESULTS: The 16 participants who were evaluated (13.8 [SD = 2.2] years of age; 13 female) had high Numeric Pain Rating Scale scores (6.2 [SD = 2.1]), FOPQ-Fear scores (25.9 [SD = 12.1]), FOPQ-Avoidance scores (22.8 [SD = 10.2]), and Functional Disability Inventory scores (28.6 [SD = 9.4]) and low 6-Minute Walk Test distance (437.1 m [SD = 144.6]). Participants had greater GaitSD than age-predicted norms. Fear was related to self-selected GaitSD, and avoidance was related to both self-selected and standardized GaitSD. Avoidance predicted 43% and 47% of the variability in self-selected and standardized GaitSD, respectively. CONCLUSION: GaitSD was significantly related to both fear of pain and avoidance behaviors, suggesting the interplay of these psychological drivers with movement. FOPQ-Avoidance was robust in accounting for GaitSD. IMPACT: This study offers preliminary evidence in understanding movement adaptations associated with adolescents with chronic pain. They may lend to more directed interventions.

Avoid or engage? Outcomes of graded exposure in youth with chronic pain using a sequential replicated single-case randomized design.

Pain-related fear is typically associated with avoidance behavior and pain-related disability in youth with chronic pain. Youth with elevated pain-related fear have attenuated treatment responses; thus, targeted treatment is highly warranted. Evidence supporting graded in vivo exposure treatment (GET) for adults with chronic pain is considerable, but just emerging for youth. The current investigation represents the first sequential replicated and randomized single-case experimental phase design with multiple measures evaluating GET for youth with chronic pain, entitled GET Living. A cohort of 27 youth (81% female) with mixed chronic pain completed GET Living. For each participant, a no-treatment randomized baseline period was compared with GET Living and 3- and 6-month follow-ups. Daily changes in primary outcomes fear and avoidance and secondary outcomes pain catastrophizing, pain intensity, and pain acceptance were assessed using electronic diaries and subjected to descriptive and model-based inference analyses. Based on individual effect size calculations, a third of participants significantly improved by the end of treatment on fear, avoidance, and pain acceptance. By follow-up, over 80% of participants had improved across all primary and secondary outcomes. Model-based inference analysis results to examine the series of replicated cases were generally consistent. Improvements during GET Living was superior to the no-treatment randomized baseline period for avoidance, pain acceptance, and pain intensity, whereas fear and pain catastrophizing did not improve. All 5 outcomes emerged as significantly improved at 3- and 6-month follow-ups. The results of this replicated single-case experimental phase design support the effectiveness of graded exposure for youth with chronic pain and elevated pain-related fear avoidance.

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.

A day-hospital approach to treatment of pediatric complex regional pain syndrome: initial functional outcomes.

OBJECTIVES: To examine clinical outcomes of an interdisciplinary day-hospital treatment program (comprised of physical, occupational, and cognitive-behavioral therapies with medical and nursing services) for pediatric complex regional pain syndrome (CRPS). METHODS: The study is a longitudinal case series of consecutive patients treated in a day-hospital pediatric pain rehabilitation program. Participants were 56 children and adolescents with ages 8 to 18 years (median=14 y) with CRPS spectrum conditions who failed to progress sufficiently with a previous outpatient and/or inpatient treatments. Patients participated in daily physical therapy, occupational therapy, and psychological treatment and received nursing and medical care as necessary. The model places equal emphasis on physical and cognitive-behavioral approaches to pain management. Median duration of stay was 3 weeks. Outcome measures included assessments of physical, occupational, and psychological functioning at program admission, discharge, and at posttreatment follow-up at a median of 10 months after discharge. Scores at discharge and follow-up were compared with measures on admission by Wilcoxon tests, paired t tests, or analysis of variance as appropriate, with corrections for multiple comparisons. RESULTS: Outcomes demonstrate clinically and statistically significant improvements from admission to discharge in pain intensity (P<0.001), functional disability (P<0.001), subjective report of limb function (P<0.001), timed running (P<0.001), occupational performance (P<0.001), medication use (P<0.01), use of assistive devices (P<0.001), and emotional functioning (anxiety, P<0.001; depression, P<0.01). Functional gains were maintained or further improved at follow-up. DISCUSSION: A day-hospital interdisciplinary rehabilitation approach seems effective in reducing disability and improving physical and emotional functioning and occupational performance among children and adolescents with CRPSs that have failed to improve with outpatient treatment.