[Cross-sectoral interdisciplinary multimodal pain therapy : Recommendations on structural and process parameters of the ad hoc commission "Interdisciplinary Multimodal Pain Therapy" of the German Pain Society (Deutsche Schmerzgesellschaft e.  V.)]. / Sektorenübergreifende interdisziplinäre multimodale Schmerztherapie : Empfehlungen zu Struktur- und Prozessparametern der Ad-hoc-Kommission "Interdisziplinäre Multimodale Schmerztherapie" der Deutschen Schmerzgesellschaft e. V.

Based on the fundamental concept of the biopsychosocial model, interdisciplinary multimodal pain therapy (IMPT) has developed to one of the most important components in the treatment of patients suffering from chronic pain. The process criteria for IMPT in Germany are described in the German OPS catalogue and IMPT is mainly offered as an inpatient treatment only. This article updates some of the fundamental criteria for IMPT for adult inpatient treatment and the task force defines basic structural and process criteria for the implementation of IMPT for outpatients.

The impact of a short educational movie on promoting chronic pain health literacy in school: A feasibility study.

BACKGROUND: School-based health education programs on chronic pain providing information about the proper management of recurrent and chronic pain may increase health literacy in terms of pain knowledge, may thereby prevent dysfunctional coping and may decrease the risk of pain chronification. The aim of the present feasibility study was to evaluate the effectiveness of an educational movie on recurrent and chronic pain in increasing pain knowledge among students. METHODS: N = 95 adolescent students provided demographic and pain-related information and completed a pain knowledge questionnaire before and after viewing an educational movie on recurrent and chronic pain. Participants were classified as experiencing frequent pain if they reported pain at least once a week in the last 3 months. RESULTS: One-third of the participants experienced frequent pain. There was a significant increase in pain knowledge for all participants (ηp2 = 0.544). Students with frequent pain had a stronger knowledge increase regarding the management of chronic and recurrent pain than those without frequent pain (ηp2 = 0.087). Sex did not moderate the gain in pain knowledge. CONCLUSIONS: This feasibility study provides first evidence that a short educational movie on recurrent and chronic pain may increase chronic pain health literacy in students. Future studies should investigate the long-term retention of pain knowledge and any associated effects on behaviour change. Due to barriers to the implementation of interventional studies in the school setting, these studies should use a waitlist control group design and online data collection. SIGNIFICANCE: This feasibility study provides first evidence for the effectiveness of an 11-min educational movie on chronic pain in increasing chronic pain knowledge in students. Students with frequent pain benefitted more from the education than students without frequent pain.

Quantitative sensory testing profiles in children, adolescents and young adults (6-20 years) with cerebral palsy: Hints for a neuropathic genesis of pain syndromes.

INTRODUCTION: Many patients with cerebral palsy (CP) suffer chronic pain as one of the most limiting factors in their quality of life. In CP patients, pain mechanisms are not well understood, and pain therapy remains a challenge. Quantitative sensory testing (QST) might provide unique information about the functional status of the somatosensory system and therefore better guide pain treatment. OBJECTIVES: To understand better the underlying pain mechanisms in pediatric CP patients, we aimed to assess clinical and pain parameters, as well as QST profiles, which were matched to the patients' cerebral imaging pathology. PATIENTS AND METHODS: Thirty CP patients aged 6-20 years old (mean age 12 years) without intellectual impairment underwent standardized assessments of QST. Cerebral imaging was reassessed. QST results were compared to age- and sex-matched controls (multiple linear regression; Fisher's exact test; linear correlation analysis). RESULTS: CP patients were less sensitive to all mechanical and thermal stimuli than healthy controls but more sensitive to all mechanical pain stimuli (each p < 0.001). Fifty percent of CP patients showed a combination of mechanical hypoesthesia, thermal hypoesthesia and mechanical hyperalgesia; 67% of CP patients had periventricular leukomalacia (PVL), which was correlated with mechanic (r = 0.661; p < 0.001) and thermal (r = 0.624; p = 0.001) hypoesthesia. CONCLUSION: The combination of mechanical hypoesthesia, thermal hypoesthesia and mechanical hyperalgesia in our CP patients implicates lemniscal and extralemniscal neuron dysfunction in the thalamus region, likely due to PVL. We suspect that extralemniscal tracts are involved in the original of pain in our CP patients, as in adults.

Testing the validity of telephone interviews to assess chronic pain in children and adolescents: A randomized cross-over trial.

BACKGROUND: Telephone surveys are intended to reduce attrition in longitudinal studies. For paediatric chronic pain patients, the comparability of pain-related information gathered using telephone interviews and postal surveys remain unknown. Furthermore, it remains unknown how social desirability may influence answers. METHODS: To compare data from telephone interviews and postal surveys, a randomized cross-over design with two measure points 2 weeks apart and four conditions (combinations of telephone interviews (T) and postal surveys (P): P-T, T-P, P-P, T-T) was conducted in a sample of N = 323 paediatric chronic pain patients. RESULTS: In the inter-group comparison, pain-related information did not differ between telephone interviews and postal surveys except for the information on pain location (back and extremities). Agreement measures of the intra-group comparisons suggest substantial to excellent agreements for all items and did not differ between the groups. The internal consistency of a disability scale was excellent for both assessment modes; the number of missing values did not differ. Participation rate was higher for telephone interviews compared to the postal surveys. Across both time points, attrition was lowest for the groups without a switch in assessment mode compared to the groups with a switch in assessment mode. Except for pain-related school absence, no effect of social desirability occurred. CONCLUSIONS: Telephone interviews are a useful method to achieve a high response rate. Pain locations should be asked for separately and not in an open question when interviewing children and adolescents on the telephone. SIGNIFICANCE: Telephone interviews are a good method to achieve a high response rate and obtain valid data in studies with paediatric chronic pain patients.

Validation of the German fear of pain questionnaire in a sample of children with mixed chronic pain conditions.

BACKGROUND: To date, no German instrument exists to measure pain-related fear in paediatric pain populations. The objective of the current study was to determine the construct validity of the translated German fear of pain questionnaire for children (GFOPQ-C) in a sample of children with mixed chronic pain disorders by testing the underlying factor structure, and its psychometric properties. METHOD: N = 241 children with mixed chronic pain disorders (aged 8-19 years) presenting to a specialized pain clinic completed the GFOPQ-C and several other pain, fear and disability measures. RESULTS: The two-factor structure of the FOPQ-C (fear, avoidance) was replicated. Internal consistency for the shortened German version was good for both subscales (Fear subscale: α = 0.89; avoidance subscale: α = 0.76). As expected, the fear subscale correlated highly with anxiety sensitivity (r = 0.63), pain catastrophizing (r = 0.62) and general anxiety (r = 0.54), while the avoidance subscale was more closely related to disability (r = 0.24) and school functioning (r = 0.28). Pain-related fear differed in children with chronic pain depending on their pain location with higher fear ratings in children with abdominal pain and musculoskeletal pain. CONCLUSION: The GFOPQ-C is a valid instrument that assesses two distinct dimensions of pain-related fear in children: fear and avoidance. Future research is needed to evaluate the impact of increased pain-related fear on outcomes over time as well as to examine pain-related fear among healthy children. This will enhance our knowledge of who might be particularly vulnerable to potentially dysfunctional trajectories, such as ongoing pain or anxiety symptoms. SIGNIFICANCE: The current study validates the first tool to assess pain-related fear in German-speaking children with chronic pain. Findings support two distinct domains: fear and activity avoidance.

[Therapy outcome one year after pediatric outpatient chronic pain evaluation : Chronic Pain Grading (CPG) for adolescent pain patients]. / Therapie-Outcome ein Jahr nach Erstvorstellung in einer pädiatrischen Schmerzambulanz : Das Chronic Pain Grading (CPG) für jugendliche Schmerzpatienten.

BACKGROUND: Interdisciplinary pain treatment has been shown to be effective for children and adolescents with chronic pain, both in an outpatient and inpatient setting. Until now, the effectiveness has been analyzed with various outcome measures. Although it has only rarely been used for adolescents so far, Chronic Pain Grading (CPG) developed by Von Korff could be an appropriate general outcome measure. OBJECTIVE: The study aims at prospectively investigating and comparing the therapy outcome one year after initial presentation for both outpatients and inpatients using the CPG. MATERIALS AND METHODS: Data of 258 adolescents were gathered at initial presentation and one year later and analyzed using the CPG. Changes from pretreatment to follow-up and predictors of good therapy outcome were investigated for the whole sample and separately for outpatients and inpatients. RESULTS: Compared to inpatients, outpatients were characterized by a lower CPG both before and one year after initial presentation. Large effects were found both for outpatient and inpatient therapy regarding the improvement of the CPG. In outpatient therapy, boys were two times more likely to display therapy success. CONCLUSION: The study shows that the CPG is an appropriate outcome measure to display the long-term effectiveness of an inpatient and outpatient interdisciplinary pain treatment. The interdisciplinary pain treatment needs to be better tailored to girls to improve its effectiveness.

[Pain-related parental behavior : Maternal and paternal responses to chronic pain of their child and modifications following inpatient interdisciplinary pain treatment]. / Schmerzbezogenes Elternverhalten : Mütterliche und väterliche Reaktionen auf die chronischen Schmerzen ihres Kindes und deren Veränderung nach stationärer interdisziplinärer Schmerztherapie.

BACKGROUND: There is a dearth of research studies regarding the pain-related behavior of parents with children suffering from chronic pain. This study examined the pain-related reactions of mothers and fathers, analyzed changes in these reactions following the child's inpatient interdisciplinary pain treatment and identified predictors for these changes. METHOD: Using validated questionnaires 40 mothers and 40 fathers of children suffering from chronic pain reported their pain-related responses and cognitive distortions at treatment commencement, immediately following therapy as well as at follow-up after 6 and 12 months. RESULTS: At treatment commencement there were neither differences between maternal and paternal behavior nor in their reactions towards the sons and daughters. Immediately after treatment both parents showed increased distracting behavior and decreased solicitous behavior. Only the change in solicitous behavior showed long-term stability. The study identified the extent of parental catastrophizing at treatment commencement as well as changes in this reaction during treatment as predictors for reduction in solicitous behavior. The more parents reported catastrophizing thoughts at treatment commencement, the less they changed their solicitous behavior and strong changes in catastrophizing during treatment correlated with strong changes in solicitous reactions. CONCLUSION: Pain-related solicitous behavior can be modified by the interdisciplinary inpatient treatment of chronic pain in children and changes in solicitous behavior seem to be closely related to parental catastrophizing. This association should be considered when dealing with parents of children with chronic pain and also within the framework of future research projects.

[Therapy recommendations in a pediatric outpatient pain clinic : Adherence and effectiveness of implementation]. / Therapeutische Empfehlungen in einer pädiatrischen Schmerzambulanz : Adhärenz und Wirksamkeit der Umsetzung.

BACKGROUND: Supplementary pain-related recommendations for the treatment of chronic pain in children and adolescents are an essential component of multimodal pain treatment. Studies are scarce regarding adherence to these recommendations and their effectiveness. OBJECTIVE: The aim of this study was to evaluate patient adherence to pain-related recommendations and their effectiveness 12 months after initial presentation of children and adolescents with chronic pain to a pediatric outpatient pain clinic. MATERIALS AND METHODS: A total of 413 patients were assessed using a structured telephone interview. The assessment included pain characteristics during the last 4 weeks as well as information regarding the implementation of the pain-related recommendations and the effectiveness. Due to different recommendations given to migraine patients this subgroup was dealt with separately. RESULTS: Patients reported significant improvements 12 months after the initial presentation and 29.5 % of the patients were pain free. Adherence levels and estimated effectiveness regarding recommendations, such as change of lifestyle, multimodal inpatient treatment and use of medication were high. Other recommendations, such as active relaxation and outpatient psychotherapy had low adherence levels and low estimated effectiveness. Migraine patients had a significantly higher adherence rate and estimated effectiveness regarding the recommendation use of medication than non-migraine patients. CONCLUSION: The adherence level as well as the estimated effectiveness regarding the majority of pain-related recommendations was high. Some recommendations had low adherence rates and low estimated effectiveness. These results can help to further improve the performance of outpatient clinics for children and adolescents with chronic pain.

[Chronic primary pain disorders in children and adolescents]. / Chronische primäre Schmerzen bei Kindern und Jugendlichen.

AIM: Chronic and debilitating pediatric pain has a prevalence of 5% and as such constitutes a considerable health problem. The aim of this article is to provide an overview of current research activities on pediatric pain, available health care for children with chronic pain and education and training programs for health professionals. METHOD: This overview is based on the authors' personal experience, information available from medical, research and professional associations, as well as a PubMed literature search for the time period 2012-2015 using "children";"pain" and "Germany" as search terms. RESULTS: There are numerous research activities in Germany focusing on the epidemiology, the underlying psychobiological mechanisms and on the multimodal treatment of chronic pediatric pain. This research is internationally widely acknowledged and makes a significant contribution to current developments in pediatric pain research. By contrast, health services and basic science research is clearly lacking in Germany. Moreover, specialized health care for youth with chronic pain is far less institutionalized when compared to adults suffering from chronic pain. Indeed, primary and secondary care services have rarely been studied or even evaluated. CONCLUSION: Similar to international trends, research on chronic pediatric pain has also grown and advanced in Germany. Indeed, not only the amount of research has increased but also its scope. Nonetheless, there is clearly a need for more research efforts with regard to the understanding of (pediatric) pain mechanisms, clinical studies and, especially, investigations on health care services. It is particularly important to focus on the implementation, improvement and systematic evaluation of specialized health care services which would be available and accessible for children and adolescents with chronic pain and not be restricted to tertiary care.

Physician consultation in young children with recurrent pain-a population-based study.

Background. Recurrent pain is a common experience in childhood, but only few children with recurrent pain attend a physician. Previous studies yielded conflicting findings with regard to predictors of health care utilization in children with recurrent pain. Methods. The present study analyzes data from the German Health Interview and Examination Survey for Children and Adolescents (KiGGS) study comprising n = 2,149 children (3-10 years old) with recurrent pain to find robust predictors. We used multiple logistic regressions to investigate age, gender, socio-economic status (SES), migration background, pain intensity, pain frequency, pain-related disability, mental health problems, and health-related quality of life (HRQL) as predictors for visiting a doctor due to pain. Results. Overall, young girls with high pain-related disability, intensity, frequency, and migration background were more likely to attend a physician. Pain-related disability had the largest impact. Socioeconomic status, health-related quality of life and mental health problems were not systematically related to health care utilization. An analysis of the variability of these results indicated that several hundred participants are needed until the results stabilize. Conclusions. Our findings highlight the importance of pain-related disability and frequency in assessing the severity of recurrent pain. Generic predictors and demographic variables are of lesser relevance to children with recurrent pain. On a methodological level, our results show that large-scale studies are need to reliably identify predictors of health care utilization.

Difficulties in screening for peripheral neuropathies in children with diabetes.

AIMS: To assess the diagnostic utility of a novel abbreviated monofilament test in comparison with the tuning fork test to detect diabetic peripheral neuropathy in children. METHODS: A total of 88 children with Type 1 diabetes mellitus were screened for diabetic peripheral neuropathy using the monofilament test and the tuning fork. Nerve conduction studies were performed according to the 'gold standard' for neuropathy. We assessed the diagnostic utility and inter-rater agreement of the two screening methods. RESULTS: A total of 43 (49%) children (aged 6-18 years) had at least one abnormal nerve conduction study result. Diagnostic utility and inter-rater agreement were very low for both screening methods. The monofilament test yielded a sensitivity of 18% and a specificity of 80%. The tuning fork yielded a sensitivity of 0% and a specificity of 98%. CONCLUSION: The present study found that an abbreviated monofilament test has low diagnostic utility for the detection of early diabetic peripheral neuropathy because of its low reliability. The problem of reliability needs to be more thoroughly addressed in order to improve the screening procedures in diabetes management in childhood and adolescence.

[Pediatric general practitioners and tertiary care structures for pain therapy. A qualitative study on the need for networking]. / Niedergelassene Pädiater und tertiäre Versorgungsstrukturen der Schmerztherapie. Eine qualitative Studie zum Bedarf an Vernetzung.

BACKGROUND: Despite the urgency of the problem of chronic pediatric pain and the importance of early interventions, many children experience intermittent episodes of pain over a long period of time. One aim of this study was to investigate the need of structured diagnostic tools and therapies of chronic pediatric pain in pediatric general practices. Another aim was to describe the aims, services and challenges of a network between pediatric practices and a tertiary pediatric pain centre, from the perspective of general pediatric practitioners. MATERIAL AND METHODS: A qualitative research design was selected and 20 general pediatric practitioners were interviewed using a semistructured interview guide. Interviews were analyzed by use of qualitative content analysis according to Mayring. RESULTS: Generally, the idea of a network between pediatric practices and the German Pediatric Pain Centre was rated positively by pediatric general practitioners. From the results of the analysis three categories were identified: (i) expectations from the network (ii) desire for cooperation in the network and (iii) recommendations for improved patient care. CONCLUSION: A network with a centre for tertiary care was preferred by the general pediatric practitioners. To optimize the care of children with chronic pain further education for general pediatric practitioners as well as structured diagnostic tools and therapies of frequent pediatric chronic pain diseases are warranted.

Identifying subgroups of paediatric chronic pain patients: a cluster-analytic approach.

BACKGROUND: Paediatric chronic pain patients are a heterogeneous group. Individuals respond differently to standardized treatment. OBJECTIVES: This study aimed to identify subgroups of adolescent chronic pain patients. METHODS: Subgroups were identified by means of a cluster analysis (Sample A, nA = 266). The stability of clusters was tested in a cross-validation with a second sample (Sample B, nB = 108). In a third sample (Sample C, nC = 83), differences in change scores of the outcome parameters were tested between cluster subgroups 12 months after a standardized treatment. RESULTS: Five distinct cluster subgroups with pain problems differing by pain intensity, school absence, pain-related disability, passive pain coping and affective pain perception were identified. Two groups reported overall moderate pain problems and differed with regard to passive pain coping, which was low in Cluster 1 and moderate in Cluster 2. The patients in Cluster 3 reported severe pain problems, including high pain-related disability and frequent school absences. The patients in Clusters 4 and 5 reported very severe pain problems, with those in Cluster 5 reporting very frequent school absences. Cross-validation was performed to assess the accuracy of our subgrouping and indicated a stable cluster solution (κ = 0.64). The five subgroups displayed distinct patterns in treatment outcome after a standardized multidisciplinary treatment program. The mean change scores were significantly different between subgroups [F(4,78) = 5.88; p = 0.017]. CONCLUSIONS: The patient subgroups that were established proved stable across samples. Depending on the subgroup classification, patients differed in changes of core outcomes. These results offer initial hints for the need for subgroup-specific treatment planning.

[Economic effects of chronic pain in childhood and adolescence: self-assessment of health care costs for affected families before and after a multidisciplinary inpatient pain therapy]. / Familiäre finanzielle Belastung durch chronische Schmerzen im Kindes- und Jugendalter : Selbsteinschätzung der Krankheitskosten für betroffene Familien vor und nach einer stationären interdisziplinären Schmerztherapie.

BACKGROUND: Chronic pain in children and adolescents causes a high utilization of the health care system and thereby significant costs. The aim of the present study is to describe the economic effects of pediatric chronic pain from the family's perspective. MATERIAL AND METHODS: Six months before and 6 and 12 months after a 3-week inpatient-based intensive interdisciplinary pain treatment, the parents of 101 children with chronic pain filled in a standardized cost questionnaire containing the following parameters: (1) child's utilization of medical and social services, (2) subjective financial burden, and (3) type and extent of direct costs. RESULTS: During the 6 months before inpatient-based intensive interdisciplinary pain treatment, children used a median of four different services. After inpatient pain treatment, service utilization has been reduced significantly (p < 0.001). One fifth of the families report a high or very high financial burden before treatment. Family's direct costs are most often caused by travelling (86 %) and drugs (60 %). After inpatient pain treatment, family's financial burden decreased significantly (p < 0.001). The frequency of additional expenditures is also reduced after treatment: parents report less additional costs due to travelling and drugs (p < 0.001, respectively). CONCLUSION: The present study emphasizes the pronounced utilization of health and social care due to pediatric chronic pain. In the future, the use of appropriate diagnostic and therapeutic standards that contribute to avoiding unnecessary and expensive interventions is preferred.

Influence of parental occupation on access to specialised treatment for paediatric chronic pain: a retrospective study.

BACKGROUND: The purpose of this study was to determine patients' travel distances to a tertiary paediatric pain clinic and to analyse the association between travel distance and the parents' occupational skill level and the patients' pain characteristics. PATIENTS AND METHODS: The retrospective study consisted of 2,248 children assessed at the first evaluation. All children (0-20 years) who visited the clinic during a 5-year period (2005-2010) were enrolled in this study. RESULTS: The mean travel distance was 81 km, and the 80 % catchment area was 109 km. Children of parents with a high occupational skill level had a 1.5-fold higher probability of travelling from outside the catchment area. The 80 % catchment area increased constantly with increasing occupational skill level. Additional significant factors for greater distance travelled were high impairment, musculoskeletal pain, long pain duration and a high number of previous physician contacts. CONCLUSION: The association between travel distance and parental occupational skill level suggests that there is social injustice due to access barriers based on socioeconomic deprivation and education. An increase in the number of health care facilities for chronic pain in children would be a first step in rectifying this injustice.

Classifying the severity of paediatric chronic pain - an application of the chronic pain grading.

BACKGROUND: The chronic pain grading (CPG), a standard approach to classify the severity of pain conditions in adults, combines the characteristics of pain intensity and pain-related disability. However, in children and adolescents, the CPG has only been validated in a school sample, but not in the actual target population, i.e., clinical populations with pain. METHODS: In the present study, we applied the CPG to a tertiary sample of adolescents with chronic pain (n=1242). Construct validity, sensitivity to change and prognostic utility were examined. RESULTS: Results indicate that most adolescents were equally classified into the three higher severity grades. Higher CPG classification was associated with more pain locations, higher pain frequency, longer pain duration, extensive use of health care and more depressive symptoms. Adolescents with a high CPG received recommendations for inpatient treatment more often; however, the prognostic utility for therapy recommendation - as operationalized in this study - was low. Sensitivity to change was assessed via reassessment at follow-up for a subsample of 490 adolescents. The majority of adolescents improved to a less severe CPG; changes were more common in the high severity range. CONCLUSION: The CPG may be applied to adolescent tertiary care samples and to assess outcomes in clinical trials. However, in this study it was not appropriate to assign adolescent patients to different treatment options. Future work should focus on developing a comprehensive assessment tool for assigning patients to different treatments.

[Definition, diagnosis and therapy of chronic widespread pain and so-called fibromyalgia syndrome in children and adolescents. Systematic literature review and guideline]. / Definition, Diagnostik und Therapie von chronischen Schmerzen in mehreren Körperregionen und des sogenannten Fibromyalgiesyndroms bei Kindern und Jugendlichen. Systematische Literaturübersicht und Leitlinie.

BACKGROUND: The scheduled update to the German S3 guidelines on fibromyalgia syndrome (FMS) by the Association of the Scientific Medical Societies ("Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften", AWMF; registration number 041/004) was planned starting in March 2011. MATERIALS AND METHODS: The development of the guidelines was coordinated by the German Interdisciplinary Association for Pain Therapy ("Deutsche Interdisziplinären Vereinigung für Schmerztherapie", DIVS), 9 scientific medical societies and 2 patient self-help organizations. Eight working groups with a total of 50 members were evenly balanced in terms of gender, medical field, potential conflicts of interest and hierarchical position in the medical and scientific fields. Literature searches were performed using the Medline, PsycInfo, Scopus and Cochrane Library databases (until December 2010). The grading of the strength of the evidence followed the scheme of the Oxford Centre for Evidence-Based Medicine. The formulation and grading of recommendations was accomplished using a multi-step, formal consensus process. The guidelines were reviewed by the boards of the participating scientific medical societies. RESULTS AND CONCLUSION: The diagnosis FMS in children and adolescents is not established. In so-called juvenile FMS (JFMS) multidimensional diagnostics with validated measures should be performed. Multimodal therapy is warranted. In the case of severe pain-related disability, therapy should be primarily performed on an inpatient basis. The English full-text version of this article is available at SpringerLink (under "Supplemental").