An examination of referrals declined for chronic pain care: There is increasing mental health complexity within care-seeking patients with chronic pain over time.

Background: Chronic pain is a complex disease that requires interprofessional care for effective management. Despite the need for multidisciplinary care, disease and health care inequities can prevent individuals from attaining adequate treatment. Factors such as mental health, cost, and distance to a health care center can contribute to health care accessibility inequality. The aim of this study is to examine declined referrals at the Toronto Academic Pain Medicine Institute (TAPMI) to determine the reason for declining care and number of declined referrals. Methods: A retrospective chart review of all declined referrals at TAPMI in 2018 and 2022 was conducted. Referral documentation and the intake decision were extracted from the electronic medical charts by the research team and verified by the clinical intake team. Chi-square tests were conducted to determine whether the proportion of declined referrals changed between the years reviewed. Results: The number of declined referrals due to mental health complexities increased significantly from 51 (11%) in 2018 to 180 (18%) in 2022 (χ2 = 10.9, P = 0.0009). A significant rise in the number of declines due to mental health service requests was also observed (χ2 = 24.53, P < 0.00001). Other common reasons for declined referrals in 2018 and 2022 included duplicate service, no primary care provider, and health care service changes. Conclusion: Mental health complexities continue to be a significant barrier to health care service acquisition for individuals living with chronic pain. The increase in patient complexity from 2018 to 2022 highlights the need for integrated health care resources.

Contexte: La douleur chronique est une maladie complexe qui nécessite des soins interprofessionnels pour une prise en charge efficace. Malgré la nécessité de soins multidisciplinaires, les maladies et les iniquités en matière de soins de santé peuvent empêcher les individus d'obtenir un traitement adéquat. Des facteurs tels que la santé mentale, le coût et la distance d'un centre de soins de santé peuvent contribuer aux inégalités en matière d'accessibilité des soins de santé. Le but de cette étude est d'examiner les demandes de consultation refusées à l'Institut universitaire de médecine de la douleur de Toronto (TAPMI) afin de déterminer la raison du refus des soins et le nombre de demandes de consultation refusées.Méthodes: Un examen rétrospectif de toutes les demandes de consultation refusées au TAPMI en 2018 et 2022 a été effectué. La documentation relative à la demande de consultation et la décision d'admission ont été extraites du dossier médical électronique par l'équipe de recherche et vérifiées par l'équipe d'admission clinique. Des tests de chi-carré ont été effectués pour déterminer si la proportion de demandes de consultation refusées avait changé entre les années examinées.Résultats: Le nombre de demandes de consultation refusées en raison des complexités de la santé mentale a considérablement augmenté, passant de 51 (11 %) en 2018 à 180 (18%) en 2022 (χ2 = 10,9, P = 0,0009). Une augmentation significative du nombre de refus attribuables aux demandes de services de santé mentale a également été observée (χ2 = 24,53, P < 0,00001). Parmi les autres raisons courantes pour lesquelles les demandes de consultation ont été refusées en 2018 et 2022, on compte la duplication du service, l'absence de prestataire de soins primaires et les changements dans les services de soins de santé.Conclusion: Les complexités de la santé mentale continuent d'être un obstacle important à l'acquisition de services de soins de santé pour les personnes vivant avec une douleur chronique. L'augmentation de la complexité des patients de 2018 à 2022 souligne la nécessité de ressources de soins de santé intégrées.

Comparative benefits and harms of perioperative interventions to prevent chronic pain after orthopedic surgery: a systematic review and network meta-analysis of randomized trials.

BACKGROUND: Chronic postsurgical pain (CPSP) is common following musculoskeletal and orthopedic surgeries and is associated with impairment and reduced quality of life. Several interventions have been proposed to reduce CPSP; however, there remains uncertainty regarding which, if any, are most effective. We will perform a systematic review and network meta-analysis of randomised trials to assess the comparative benefits and harms of perioperative pharmacological and psychological interventions directed at preventing chronic pain after musculoskeletal and orthopedic surgeries. METHODS: We will search MEDLINE, Embase, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials from inception to present, without language restrictions. We will include randomised controlled trials that as follows: (1) enrolled adult patients undergoing musculoskeletal or orthopedic surgeries; (2) randomized them to any pharmacological or psychological interventions, or their combination directed at reducing CPSP, placebo, or usual care; and (3) assessed pain at 3 months or more after surgery. Screening for eligible trials, data extraction, and risk-of-bias assessment using revised Cochrane risk-of-bias tool (RoB 2.0) will be performed in duplicate and independently. Our main outcome of interest will be the proportion of surgical patients reporting any pain at ≥ 3 months after surgery. We will also collect data on other patient important outcomes, including pain severity, physical functioning, emotional functioning, dropout rate due to treatment-related adverse event, and overall dropout rate. We will perform a frequentist random-effects network meta-analysis to determine the relative treatment effects. When possible, the modifying effect of sex, surgery type and duration, anesthesia type, and veteran status on the effectiveness of interventions will be investigated using network meta-regression. We will use the GRADE approach to assess the certainty evidence and categorize interventions from most to least beneficial using GRADE minimally contextualised approach. DISCUSSION: This network meta-analysis will assess the comparative effectiveness of pharmacological and psychological interventions directed at preventing CPSP after orthopedic surgery. Our findings will inform clinical decision-making and identify promising interventions for future research. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42023432503.

Effects of perioperative clinical hypnosis on heart rate variability in patients undergoing oncologic surgery: secondary outcomes of a randomized controlled trial.

Introduction: Clinical hypnosis has been proposed for post-surgical pain management for its potential vagal-mediated anti-inflammatory properties. Evidence is needed to understand its effectiveness for post-surgical recovery. Iin this secondary outcome study, it was hypothesized that surgical oncology patients randomized to receive perioperative clinical hypnosis (CH) would demonstrate greater heart-rate variability (HRV) during rest and relaxation at a 1-month post-surgery assessment compared to a treatment-as-usual group (TAU). Methods: After REB approval, trial registration and informed consent, 92 participants were randomized to receive CH (n = 45) or TAU (n = 47). CH participants received a CH session before surgery and during post-surgical in-hospital stay HRV was assessed during rest (5 min) and relaxation (10 min) before and 1-month after surgery. Pain intensity was obtained using a 0-10 numeric rating scale pre and post 1-week and 1-month post surgery. Results: One month after surgery, HRV was significantly higher in CH group (n = 29) during rest and relaxation (both p < 0.05, d = 0.73) than TAU group (n = 28). By contrast, rest and relaxation HRV decreased from pre- to 1-month post-surgery for the TAU (both p < 0.001, d > 0.48) but not the CH group. Pain intensity increased from pre-surgery to 1-week post-surgery (p < 0.001, d = 0.50), and decreased from 1-week to 1-month post-surgery (p = 0.005, d = 0.21) for all participants. Discussion: The results suggest that hypnosis prevents the deleterious effects of surgery on HRV by preserving pre-operative vagal activity. These findings underscore the potential of clinical hypnosis in mitigating the adverse effects of surgery on autonomic function and may have significant implications for enhancing post-surgical recovery and pain management strategies. Clinical Trial Registration: ClinicalTrials.gov, identifier (NCT03730350).

A Randomized Controlled Trial of Clinical Hypnosis as an Opioid-Sparing Adjunct Treatment for Pain Relief in Adults Undergoing Major Oncologic Surgery.

Clinical hypnosis is an effective strategy for managing acute pain in the surgical setting. However, the opioid sparing effects of clinical hypnosis are not as well understood. This pre-registered (NCT03730350) randomized, controlled trial (RCT) examined the impact of clinical hypnosis, pre- and post-surgery, on opioid consumption during hospitalization as well as on measures of pain intensity, pain interference, depressed mood, anxiety, sleep, and pain catastrophizing. Participants (M = 57.6 years; SD = 10.9) awaiting oncologic surgery were randomized to treatment-as-usual (n = 47) or hypnosis (n = 45). Intent-to-treat analyses were conducted using linear mixed effects modeling. A significant Group × Time interaction, F(6, 323.34) = 3.32, p = 0.003, indicated an opioid sparing effect of clinical hypnosis during the acute postoperative period. Hypnosis also protected against increases in pain catastrophizing at one-week after surgery, F (1, 75.26) = 4.04, p = 0.048. A perioperative clinical hypnosis intervention had a sparing effect on opioid consumption in-hospital after major oncologic surgery. These findings extend the efficacy of clinical hypnosis as an adjunct tool for perioperative pain management.

The Impact of Preoperative Patient Education on Postoperative Pain, Opioid Use, and Psychological Outcomes: A Narrative Review.

Background: Recent studies have shown that preoperative education can positively impact postoperative recovery, improving postoperative pain management and patient satisfaction. Gaps in preoperative education regarding postoperative pain and opioid use may lead to increased patient anxiety and persistent postoperative opioid use. Objectives: The objective of this narrative review was to identify, examine, and summarize the available evidence on the use and effectiveness of preoperative educational interventions with respect to postoperative outcomes. Method: The current narrative review focused on studies that assessed the impact of preoperative educational interventions on postoperative pain, opioid use, and psychological outcomes. The search strategy used concept blocks including "preoperative" AND "patient education" AND "elective surgery," limited to the English language, humans, and adults, using the MEDLINE ALL database. Studies reporting on preoperative educational interventions that included postoperative outcomes were included. Studies reporting on enhanced recovery after surgery protocols were excluded. Results: From a total of 761 retrieved articles, 721 were screened in full and 34 met criteria for inclusion. Of 12 studies that assessed the impact of preoperative educational interventions on postoperative pain, 5 reported a benefit for pain reduction. Eight studies examined postoperative opioid use, and all found a significant reduction in opioid consumption after preoperative education. Twenty-four studies reported on postoperative psychological outcomes, and 20 of these showed benefits of preoperative education, especially on postoperative anxiety. Conclusion: Preoperative patient education interventions demonstrate promise for improving postoperative outcomes. Preoperative education programs should become a prerequisite and an available resource for all patients undergoing elective surgery.

Contexte: Des études récentes ont démontré que l'éducation préopératoire peut avoir un effet positif sur la récupération postopératoire en améliorant la prise en charge de la douleur postopératoire et la satisfaction des patients. Des lacunes dans l'éducation préopératoire concernant la douleur postopératoire et l'utilisation d'opioïdes peuvent entraîner une augmentation de l'anxiété chez les patients et une utilisation persistante d'opioïdes après l'opération.Objectifs: L'objectif de cette revue narrative était de recenser, d'examiner et de résumer les données probantes disponibles sur l'utilisation et l'efficacité des interventions éducatives préopératoires en ce qui concerne les résultats postopératoires.Méthode: Cette revue narrative s'est concentrée sur des études évaluant l'effet des interventions éducatives préopératoires sur la douleur postopératoire, l'utilisation d'opioïdes et les résultats psychologiques. La stratégie de recherche a eu recours à des blocs de concepts comprenant « préopératoire ¼ ET « éducation des patients ¼ ET « chirurgie élective ¼, limités à la langue anglaise, aux humains et aux adultes, en utilisant la base de données MEDLINE ALL. Les études portant sur des interventions éducatives préopératoires qui comprenaient des résultats postopératoires ont été incluses, tandis que celles qui décrivaient une amélioration de la récupération après des interventions chirurgi ont été exclues.Résultats: Sur un total de 761 articles recensés, 721 ont été examinés en entier et 34 répondaient aux critères d'inclusion. Parmi les 12 études évaluant l'effet des interventions éducatives préopératoires sur la douleur postopératoire, cinq ont rapporté des avantages pour la diminution de la douleur. Huit études ont examiné l'utilisation d'opioïdes postopératoires, et toutes ont constaté une diminution significative de la consommation d'opioïdes suite à une éducation préopératoire. Vingt-quatre études ont rendu compte des résultats psychologiques postopératoires, et vingt d'entre elles ont démontré que l'éducation préopératoire présentait des avantages, en particulier en ce qui concerne l'anxiété postopératoire.Conclusion: Les interventions éducatives préopératoires présentent des perspectives prometteuses pour améliorer les résultats postopératoires. Les programmes d'éducation préopératoire devraient devenir une condition préalable et une ressource disponible pour tous les patients subissant une chirurgie élective.

Development and expansion of a pediatric transitional pain service to prevent complex chronic pain.

The prevention of chronic pain is a key priority in North America and around the world. A novel pediatric Transitional Pain Service (pTPS) at the Hospital for Sick Children was established to address four main areas of need, which the authors will describe in more detail: (1) provide comprehensive multi-modal pain management and prevention techniques to children at-risk for the development of chronic pain, (2) provide opioid stewardship for children at-risk for chronic pain and their families at home after discharge, (3) facilitate continuity of pain care for children across transitions between inpatient and outpatient care settings, and (4) support caregivers to manage their child's pain at home. The pTPS works with healthcare providers, patients, and their families to address these areas of need and improve quality of life. Furthermore the service fills the gap between inpatient acute pain services and outpatient chronic pain services (accessible only once pain has persisted for >3 months). In pediatric patients who experience pain in hospital and who have been prescribed opioids, discharge to home or rehabilitation may represent a vulnerable time in which pain may persist and during which analgesic requirements may change. This offers an important opportunity to address and prevent the development of chronic pain, and to monitor opioids while ensuring alternative pain therapy is available. The authors will outline risk factors for persistent postsurgical pain, the development and implementation of a pTPS, present initial clinical outcomes andsuggest areas for future research in this evolving area of care.

Virtual multidisciplinary pain treatment: Experiences and feedback from children with chronic pain and their caregivers.

BACKGROUND: The onset of the coronavirus disease 2019 (COVID-19) necessitated a rapid transition to virtual care for chronic pain treatment. OBJECTIVE: This study examined experiences of patients and caregivers who received virtual multidisciplinary pain treatment (MDT) for pediatric chronic pain between March 2020 and August 2021. METHODS: A mixed methods design was implemented using qualitative interviews and quantitative satisfaction surveys. Satisfaction surveys were administered to a convenience sample of patients (aged 8 to 18; N = 20) and their caregivers (N = 20) who received MDT through an outpatient hospital pediatric chronic pain program. Interviews were conducted with a subset of these patients and their caregivers (n = 6). RESULTS: Analysis of interviews revealed four themes: 1) benefits of virtual care; 2) challenges of virtual care; 3) recommendations and evaluation of virtual care; and 4) patient preferences. Analysis of the satisfaction survey data revealed that while patients and caregivers were satisfied with many aspects of virtual care, 65% (n = 13) of patients reported a preference for in-person appointments, with caregivers showing equal preference for in-person and virtual appointments, though this was a non-significant difference (p = .37). Overall, both patients and caregivers stated a stronger preference for in-person physiotherapy sessions but were willing to have psychology sessions provided virtually. Finally, the most reported preference was for a hybrid model of care incorporating at least some in-person contact with providers. CONCLUSION: This study provides a rich exploration of virtual care for multidisciplinary pediatric chronic pain treatment. The current results may inform the future development of guidelines for virtual care delivery with pediatric chronic pain populations.

Sensibility and measurement properties of the Tampa Scale of Kinesiophobia to measure fear of movement in children and adults in surgical settings.

Purpose: Fear of movement, or kinesiophobia, is a risk factor for developing chronic post-surgical pain (CPSP) and may impede recovery. Identifying people with kinesiophobia peri-operatively is potentially valuable to intervene to optimize rehabilitation and prevent CPSP. This narrative review aims to describe and critically appraise the sensibility and measurement properties of the Tampa Scale of Kinesiophobia (TSK) in the surgical setting in both pediatric and adult populations.Material and methods: PubMed was searched for relevant articles using search terms related to the TSK and measurement properties; the search was restricted to articles published in English. COSMIN guidelines were used to rate measurement property sufficiency and study quality.Results: Four articles examined the measurement properties of the TSK-17 in the surgical setting. Included studies demonstrated sufficient internal consistency, structural validity, construct validity, but insufficient predictive validity. Study quality was variable. Although the TSK was not originally intended for the surgical setting, with minor modification, it appears sensible to use in this population.Conclusions: The TSK is a sensible tool to measure fear of movement in children and adults undergoing, or who underwent, surgery. Future studies are needed to test content validity, test-retest reliability, measurement error, and responsiveness in the surgical setting.IMPLICATIONS FOR REHABILITATIONFear of movement is a predictor of developing chronic post-surgical pain in children and adults.Rehabilitation interventions can address fear of movement in hopes to optimize surgical outcomes and prevent chronic post-surgical pain.The Tampa Scale of Kinesiophobia (TSK), with minor modification, is a sensible tool to measure fear of movement in surgical settings.There is some evidence that the TSK is reliable and valid to use with older children, adolescents, and adults who are undergoing or underwent surgery.

Mapping the current state of pediatric surgical pain care across Canada and assessing readiness for change.

Background: Preventing pediatric chronic postsurgical pain is a patient, parent/caregiver, health care professional, and policymaker priority. Poorly managed presurgical and acute postsurgical pain are established risk factors for pediatric chronic postsurgical pain. Effective perioperative pain management is essential to prevent the transition from acute to chronic pain after surgery. Aims: The aim of this study was to identify current pediatric surgical pain management practices and assess health system readiness for change at health care institutions conducting pediatric surgery in Canada. Methods: An online survey was completed by 85 multidisciplinary health care professionals (nurses, surgeons, anesthesiologists, allied health) from 20 health institutions in Canada regarding institutional pre- and postsurgical pediatric pain care, specialty pain services, and Organizational Readiness for Implementing Change (ORIC). Results: Of all specialty pain services, acute and chronic/complex pain services were most common, primarily with physician and nursing involvement. Alignment to recommended practices for pediatric pre- and postsurgical pain care varied (38.1%-79.8% reported "yes, for every child"), with tertiary/quaternary children's hospitals reporting less alignment than other institutions (community/regional or rehabilitation hospitals, community treatment centers). No significant differences were reported between health care institutions serving pediatric populations only versus those also serving adults. Health care professional experience/practice was the most reported strength in pediatric surgical pain care, with inconsistent standard of care the most common gap. Participants "somewhat agreed" that their institutions were committed and capable of change in pediatric surgical pain care. Conclusions: There is a continued need to improve pediatric pain care during the perioperative period at Canadian health care institutions to effectively prevent the development of pediatric postsurgical pain.

Contexte: La prévention de la douleur post-chirurgicale chronique pédiatrique est une priorité des patients, des parents/prestataires de soins, des professionnels de la santé et des décideurs. La douleur pré-chirurgicale et post-chirurgicale aiguë mal prises en charge constituent des facteurs de risque connus de la douleur post-chirurgicale chronique pédiatrique. La prise en charge efficace de la douleur périopératoire est essentielle pour prévenir la transition de la douleur aiguë à la douleur chronique aprés une chirurgie.Buts: Le but de cette étude était de recenser les pratiques actuelles en matiére de prise en charge de la douleur chirurgicale pédiatrique et d'évaluer l'état de préparation au changement du systéme de santé dans les établissements de soins de santé menant des chirurgies pédiatriques au Canada.Méthodes: 85 professionnels de la santé multidisciplinaires (infirmiéres, chirurgiens, anesthésistes, auxiliaires médicaux) ont répondu à un sondage en ligne de 20 établissements de santé au Canada concernant les soins pédiatriques pré et post-chirurgicaux en établissement, les services spécialisés de traitement de la douleur, les services de la douleur spécialisés et la préparation organisationnelle à la mise en œuvre du changement.Résultats: De tous les services de la douleur spécialisés, les services de la douleur aiguë et chronique/complexe étaient les plus fréquents, principalement avec la participation d'un médecin et d'une infirmiére. L'adéquation avec les pratiques recommandées pour les soins pédiatriques pré et post-chirurgicaux était variable (38,1 %-79,8 % ont déclaré « oui, pour chaque enfant ¼), alors que les hôpitaux pour enfants tertiaires/quaternaires ont déclaré moins d'adéquation que les autres institutions (hôpitaux communautaires/régionaux ou de réadaptation, centres de traitement communautaires). Aucune différence significative n'a été rapportée entre les établissements de soins de santé desservant uniquement les populations pédiatriques et ceux desservant aussi les adultes. L'expérience professionnelle/la pratique en matière de soins de santé a été la force la plus rapportée dans les soins de la douleur chirurgicale pédiatrique, tandis que les normes de soins incoh'rentes constituaient la lacune la plus courante. Les participants ont « quelque peu convenu ¼ que leurs institutions étaient engagées et capables de changer les soins chirurgicaux pédiatriques.Conclusions: ll y a un besoin continu déaméliorer les soins de la douleur pédiatrique pendant la période périopératoire dans les établissements de soins de santé canadiens afin de prévenir efficacement le développement de la douleur postopératoire.

Modeling the transition from acute to chronic postsurgical pain in youth: A narrative review of epidemiologic, perioperative, and psychosocial factors.

A growing number of studies have identified high rates of pediatric chronic postsurgical pain (CPSP) after major surgery. Pediatric CPSP is associated with pain-related distress and comorbid mental health outcomes, such as anxiety and depression. From a biopsychosocial perspective, youth factors, such as genetics, epigenetics, sex, presurgical pain, sleep, anxiety, and pain catastrophizing, as well as parent factors, such as cognitive appraisals of their child's pain expression and pain catastrophizing, converge and lead to chronic pain disability. A comprehensive and testable psychosocial model of the transition from acute to chronic pediatric postsurgical pain has not been developed. This narrative review begins by evaluating the epidemiology and trajectories of pediatric CPSP and moves on to examine the more influential psychosocial models that have been proposed to understand the development of pediatric CPSP. Much of the literature to date has been conducted on adolescents undergoing spinal fusion. To conceptualize the transition from acute to chronic pain in youth, a combined diathesis-stress and interpersonal fear avoidance model is presented. Novel areas of future research include the potential influence that siblings and peers have on a youth's development of CPSP as well as the influence of gender.

Un nombre croissant d'études ont recensé des taux élevés de douleur post-chirurgicale chronique pédiatrique après une intervention chirurgicale majeure. La douleur post-chirurgicale chronique pédiatrique est associée à de la détresse liée à la douleur et à des problèmes de santé mentale concomitants tels que l'anxiété et la dépression. D'un point de vue biopsychosocial, les facteurs liés aux jeunes tels que la génétique, l'épigénétique, le sexe, la douleur pré-chirurgicale, le sommeil, l'anxiété et la catastrophisation de la douleur, et les facteurs parentaux tels que l'évaluation cognitive de l'expression de la douleur et la catastrophisation de la douleur chez leur enfant, convergent et mènent à une invalidité attribuable à la douleur chronique. Aucun modèle psychosocial complet et vérifiable de la transition de la douleur post-chirurgicale pédiatrique aigue à la douleur post-chirurgicale chronique n'a encore été élaboré. Cette revue narrative commence par l'évaluation de l'épidémiologie et des trajectoires de douleur post-chirurgicale pédiatrique chronique et poursuit en examinant les modèles psychosociaux les plus influents qui ont tenté de comprendre le développement de la douleur post-chirurgicale chronique pédiatrique. Une grande partie de la littérature à ce jour a poré sur les adolescents subissant une fusion vertébrale. Afin de conceptualiser la transition de la douleur aigue à la douleur chronique chez les jeunes, un modèle combinant le diathèse-stress et l'évitement de la peur interpersonnelle est présenté. Parmi les domaines de recherche novateurs, on compte l'influence potentielle que les frères et sœurs et les pairs ont sur le développement de la douleur post-chirurgicale chronique chez les jeunes, ainsi que l'influence du genre.

A Systematic Review of the Prospective Relationship between Child Maltreatment and Chronic Pain.

OBJECTIVE: The present systematic review aimed to evaluate the association between childhood maltreatment and chronic pain, with specific attention to the temporal nature of the relationship and putative moderators, including, the nature (type), timing of occurrence, and magnitude of maltreatment; whether physical harm or injury occurred; and whether post-traumatic stress disorder (PTSD) subsequently developed. METHOD: We included studies that measured the prospective relationship between child maltreatment and pain. Medline, EMBASE, PsycINFO, and CINAHL were searched electronically up to 28 July 2019. We used accepted methodological procedures common to prognosis studies and preregistered our review (PROSPERO record ID 142169) as per Cochrane review recommendations. RESULTS: Nine studies (17,340 participants) were included in the present review. Baseline participant age ranged from 2 years to more than 65 years. Follow-up intervals ranged from one year to 16 years. Of the nine studies included, three were deemed to have a high risk of bias. With the exception of one meta-analysis of three studies, results were combined using narrative synthesis. Results showed low to very low quality and conflicting evidence across the various types of maltreatment, with the higher quality studies pointing to the absence of direct (non-moderated and non-mediated) associations between maltreatment and pain. PTSD was revealed to be a potential mediator and/or moderator. Evidence was not found for other proposed moderators. CONCLUSIONS: Overall, there is an absence of evidence from high quality studies of an association between maltreatment and pain. Our results are limited by the small number of studies reporting the relationship between child maltreatment and pain using a prospective design. High quality studies, including prospective cohort studies and those that assess and report on the moderators described above, are needed to advance the literature.

Differential Risk Factor Profiles in the Prediction of General and Pain-Specific Functional Limitations 12 Months after Major Pediatric Surgery.

Pediatric chronic post-surgical pain is a surgical complication associated with various levels of functional limitation. Two commonly used measures of functional limitations in youth are the Functional Disability Inventory (FDI) and the PROMIS Pediatric Pain Interference Scale (PPIS), where the former is general, and the latter, pain specific. The aim of the present study was to prospectively compare pre-surgical youth and parent risk factors for youth functional limitations, assessed by the FDI and PPIS, 12 months after major pediatric surgery. Risk factors for the FDI and PPIS were compared in 79 dyads consisting of youth (58% female, M = 14.56 years; SD = 2.31) undergoing major surgery and one of their parents. The FDI and PPIS were highly correlated prior to surgery (r = 0.698, p < 0.001) and even more so 12 months after surgery (r = 0.807, p < 0.001). Parent pre-surgical anxiety sensitivity and youth pre-surgical functional disability significantly predicted 12-month FDI (F(6,56) = 4.443, p = 0.001, Adjusted R2 = 0.25), whereas parent pre-surgical anxiety sensitivity, trait anxiety, pain anxiety, as well as youth pain-related anxiety and worry significantly predicted 12-month PPIS (F(6,45) = 4.104, p = 0.002, Adjusted R2 = 0.27). Risk factors for 12-month general and pain-specific functional limitations differ by dyad member and type. Functional limitations in youth after surgery are predicted by youth and parent factors, however the risk factors differ between the FDI and the PPIS.

Fear of movement in children and adolescents undergoing major surgery: A psychometric evaluation of the Tampa Scale for Kinesiophobia.

BACKGROUND: The objective of this study was to evaluate the psychometric properties of the 17-item Tampa Scale for Kinesiophobia (TSK) in youth. METHODS: Participants were 264 children and adolescents (58.7% female, Mage  = 14.1 years, SDage  = 2.51) scheduled for major surgery who were assessed before surgery, while in hospital postoperatively, and at 6 and 12 months after surgery. Exploratory factor analyses (EFA) were conducted to determine the factor structure of pre-operative TSK scores. Reliability, and convergent, discriminant, and predictive validity were examined. RESULTS: EFA on the 17-item TSK revealed a two-factor model distinguishing the 13 positively scored items from the 4 reverse scored items, but the fit was poor. A second EFA was conducted on the 13 positively scored items (TSK-13) revealing a three-factor model: Fear of injury, bodily vulnerability, and activity avoidance. The TSK-13 showed adequate internal consistency (Ω = 0.82) and weak convergent validity. The TSK-13 was not correlated with postoperative, in-hospital physical activity (actigraphy; r (179) = -0.10, p = 0.18) and showed adequate discriminant validity, that is correlations less than 0.70, with measures of depression (r (225) = 0.41, p < 0.001) and general anxiety (r (224)=0.35, p < 0.001). Predictive validity for pain-related disability at 12 months (r (70) = 0.34, p < 0.001) was adequate. CONCLUSIONS: The original TSK-17 does not appear to be a meaningful measure of kinesiophobia in youth after surgery possibly because of the syntactic structure of the reverse scored items. In contrast, a modified TSK-13, comprised of only the positively scored items, revealed a 3-factor structure that is reliable and demonstrates adequate convergent, discriminant, and predictive validity. SIGNIFICANCE: Kinesiophobia is an important construct to evaluate in the transition from acute to chronic pain among children and adolescents. The 17 item Tampa Scale for Kinesiophobia (TSK) does not show adequate validity or reliability in youth undergoing major surgery, however, the psychometric properties of a 13-item modified scale (TSK-13) are promising.

Pediatric Chronic Postsurgical Pain And Functional Disability: A Prospective Study Of Risk Factors Up To One Year After Major Surgery.

BACKGROUND: Chronic postsurgical pain (CPSP) is a surgical complication associated with increased functional disability, psychological distress, and economic costs. The aims of this paper were to prospectively: (1) examine the incidence of CPSP 6 and 12 months after pediatric major surgery; (2) identify pain intensity and pain unpleasantness trajectories before, and up to 12 months after, surgery; (3) identify pre-operative factors that predict pain trajectory group membership; and (4) identify predictors of 12-month functional disability. METHODS: This study followed 265 children aged 8-17 years at four time points (pre-surgical [T0], in-hospital [T1], 6 [T2] and 12 [T3] months after surgery). Children and parents completed pain and psychological questionnaires. In-hospital physical activity was monitored using actigraphy. RESULTS AND DISCUSSION: The incidence of moderate-to-severe CPSP at 6 and 12 months was 35% (95% CI 29.1% to 41.9%) and 38% (95% CI 32.4% to 45.1%), respectively. Three percent (95% CI 1.17% to 6.23%) and 4% (95% CI 1.45% to 6.55%) of children reported using opioids to manage pain at 6 and 12 months, respectively. Growth mixture modeling revealed a two-class trajectory model with a quadratic slope best fit the data for both pain intensity (Bayesian information criterion [BIC] = 3977.03) and pain unpleasantness (BIC = 3644.45) over the 12 months. Preoperative functional disability and cumulative in-hospital opioid consumption predicted pain intensity trajectories. Preoperative functional disability predicted pain unpleasantness trajectories. Preoperative functional disability (OR: 1.05, 95% CI: 1.01 to 1.09) and pain unpleasantness trajectories (OR: 2.59, 95% CI: 1.05 to 6.37) predicted 12-month moderate-to-severe functional disability. CONCLUSION: Pre-surgical functional disability is the only factor that predicts both 12-month functional disability and the course of pain intensity and pain unpleasantness ratings over the 12-month period.

Remembering the pain of surgery 1 year later: a longitudinal examination of anxiety in children's pain memory development.

Children who develop greater negatively-biased recall of pain (ie, recalled pain is higher than the initial pain report) following surgery are at risk for developing chronic pain; therefore, identifying risk factors for the development of biased pain memories is important. Higher anxiety has been implicated in the development of greater negatively-biased recall of pain; however, studies have not examined anxiety at multiple time points before and after a surgery and its relationship to children's postsurgical pain memories after 1 year. This prospective study examined a cohort of 237 children and adolescents undergoing major surgery. Anxiety sensitivity, pain catastrophizing, and pain anxiety were assessed at baseline, 48 to 72 hours after surgery, and at 6- and 12-month follow-ups. Pain intensity at rest, movement-evoked pain intensity, and pain unpleasantness were assessed daily in hospital. Memories for pain were elicited via telephone 1-year post surgery. Findings revealed that children who had higher levels of anxiety at baseline and 48 to 72 hours after surgery developed greater negatively-biased recall of pain intensity 12 months after surgery. Specifically, higher anxiety sensitivity at baseline and greater tendencies to catastrophize about pain at baseline and in the immediate acute recovery phase were most strongly linked to greater negatively-biased recall of pain. Greater negatively-biased recall of pain was related to higher pain intensity at 6 and 12 months post surgery. Findings support conceptual models of anxiety and pain memory biases and can inform intervention efforts to reduce anxiety in the pre- and post-op periods to minimize negative biases in pain memories.

Prevalence and Predictors of Chronic Postsurgical Pain in Children: A Systematic Review and Meta-Analysis.

Emerging research suggests that pain may persist longer-term for many children after major surgery, with significant effects on their health outcomes. This systematic review identified the prevalence of chronic postsurgical pain (CPSP) in children after surgery, and determined presurgical biomedical and psychosocial risk factors associated with CPSP prevalence or severity. Prospective studies assessing CPSP 3 to 12 months after surgery in children 6 to 18 years of age published in English in MedLine, EMBASE, PsycINFO, and Cochrane Database of Systematic Reviews since 1996 were eligible for inclusion. Of 16,084 abstracts yielded by the search, 123 full articles were assessed for eligibility, and 12 studies were included in the review. Overall quality of included studies assessed using the Quality in Prognostic Studies tool was low. On the basis of 4 studies with a total of 628 participants across all surgery types, median prevalence of CPSP across studies was 20% (25th percentile = 14.5%, 75th percentile = 38%) at 12 months after surgery. Presurgical pain intensity, child anxiety, child pain coping efficacy, and parental pain catastrophizing were the only presurgical factors identified as predictive of CPSP. Biological and medical factors assessed were not associated with CPSP in any study. Well designed studies examining prevalence and predictors of CPSP are critically needed in children. PERSPECTIVE: In this systematic review, the median prevalence of CPSP in children was 20% across studies. Presurgical pain intensity, and child and parent psychosocial factors predicted CPSP. Additional resources and interventions are needed for youth who report persistent pain after surgery.

Predictors of Prescription Opioid Use 4 Months After Traumatic Musculoskeletal Injury and Corrective Surgery: A Prospective Study.

The aim of the present study was to examine the incidence and predictors of persistent prescription opioid use 4 months after traumatic injury. Adults who sustained a traumatic musculoskeletal injury were recruited to participate in this observational prospective, longitudinal study within 14 days of injury (T1) and followed for 4 months (T2). Measures included questionnaires on pain, opioid consumption, pain disability, anxiety, depression, and posttraumatic stress symptoms as well as a chart review for injury related information. The sample consisted of 122 patients (66.4% male; mean age = 44.8 years, SD = 17.1), of whom 94.3% (n = 115) were using prescription opioids. At T2, 35.3% (n = 43) patients were using prescription opioids. After controlling for age, sex, injury severity, T1 pain severity, and T2 symptoms of depression, 2 factors emerged as significantly related to T2 prescription opioid use; namely, T2 pain severity (odds ratio = 1.248, 95% confidence interval, 1.071-1.742) and T2 pain self-efficacy (odds ratio = .943, 95% confidence interval, .903-.984). These results suggest that opioid use after traumatic musculoskeletal injury is related to pain severity and how well patients cope specifically with their pain, over and above other psychological factors, such as depression and anxiety. PERSPECTIVE: This article identifies predictive factors for prescription opioid use after traumatic musculoskeletal injury, namely severe pain and a poor sense of control over the pain. These results highlight the importance of using prospective longitudinal study designs to understand why patients continue to use prescription opioids after major tissue-damaging events.

Predicting pain outcomes after traumatic musculoskeletal injury.

Traumatic musculoskeletal injury results in a high incidence of chronic pain; however, there is little evidence about the nature, quality, and severity of the pain. This study uses a prospective, observational, longitudinal design to (1) examine neuropathic pain symptoms, pain severity, pain interference, and pain management at hospital admission and 4 months after traumatic musculoskeletal injury (n = 205), and (2) to identify predictors of group membership for patients with differing moderate-to-severe putative neuropathic pain trajectories. Data were collected on mechanism of injury, injury severity, pain (intensity, interference, neuropathic quality), anxiety (anxiety sensitivity, general anxiety, pain catastrophizing, pain anxiety), depression, and posttraumatic stress while patients were in-hospital and 4 months after injury. A third of patients had chronic moderate-to-severe neuropathic pain 4 months after injury. Specifically, 11% of patients developed moderate-to-severe pain by 4 months and 21% had symptoms immediately after injury that persisted over time. Significant predictors of the development and maintenance of moderate-to-severe neuropathic pain included high levels of general anxiety while in-hospital immediately after injury (P < 0.001) and symptoms of posttraumatic stress 4 months after injury (P < 0.001). Few patients had adequate pharmacological, physical, or psychological pain management in-hospital and at 4 months. Future research is needed among trauma patients to better understand the development of chronic pain and to determine the best treatment approaches.