Search

Jordi Miró,1–4 Rocío de la Vega,1,5 Catarina Tomé-Pires,1–3 Elisabet Sánchez-Rodríguez,1–3 Elena Castarlenas,1–3 Mark P Jensen,5 Joyce M Engel,6 1Unit for the Study and Treatment of Pain – ALGOS, Universitat Rovira i Virgili, Catalonia, Spain; 2Research Center for Behavior Assessment (CRAMC), Department of Psychology, Universitat Rovira i Virgili, Catalonia, Spain; 3Institut d’Investigació Sanitària Pere Virgili, Catalonia, Spain; Universitat Rovira i Virgili, Catalonia, Spain; 4Chair in Pediatric Pain, Universitat Rovira i Virgili-Fundación Grünenthal, Catalonia, Spain; 5Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA; 6Department of Occupational Science and Technology, University of Wisconsin-Milwaukee, Milwaukee, WI, USA Background: The aim of this study was to increase our understanding of the role that spatial qualities of pain (location and extent) play in functioning, among youths with disabilities and chronic pain. Methods: One-hundred and fifteen youths (mean age 14.4 years; SD ±3.3 years) with physical disabilities and chronic pain were interviewed and were asked to provide information about pain locations and their average pain intensity in the past week, and to complete measures of pain interference, psychological function and disability. Most of the participants in this sample were males (56%), Caucasian (68%), and had a cerebral palsy (34%) or muscular dystrophy (25%) problem. Most participants did not report high levels of disability ( =12.7, SD ±9.5, range 0–60) or global pain intensity ( =3.2, SD ±2.4, range 0–10).Results: Pain at more than one body site was experienced by 91% of participants. There were positive associations between pain extent with pain interference (r= 0.30) and disability (r = 0.30), and a negative association with psychological function (r= –0.38), over and above average pain intensity. Additionally, pain intensity in the back (as opposed to other locations) was associated with more pain interference (r = 0.29), whereas pain intensity in the shoulders was associated with less psychological function (r= –0.18), and pain intensity in the bottom or hips was associated with more disability (r= 0.29).Conclusion: The findings support the need to take into account pain extent in the assessment and treatment of youths with physical disabilities and chronic pain, call our attention about the need to identify potential risk factors of pain extent, and develop and evaluate the benefits of treatments that could reduce pain extent and target pain at specific sites. Keywords: pain extent, pediatric chronic pain, physical disability, function

Background: There is growing evidence confirming that youths with physical disabilities are at risk for chronic pain. Although many scales for assessing pain intensity exist, it is unclear whether they are all equally suitable for youths. The aim of this study was to address this knowledge gap by comparing the validity of the Numerical Rating Scale (NRS-11), the Wong Baker FACES Pain Rating Scale (FACES), and a 6-point categorical Verbal Rating Scale (VRS-6) for assessing pain intensity among youths (aged 8–20) with physical disabilities. Methods: One hundred and thirteen youths (mean age = 14.19 years; SD = 2.9) were interviewed and asked to rate their current pain intensity and recalled (in the past week) worst, least, and average pain with the NRS-11 and the FACES. Participants were also asked to rate their average pain intensity during the past 4 weeks using a VRS-6, and were administered measures assessing pain interference, disability and psychological functioning. Results: Analyses showed that all of the pain intensity measures were associated positively with each other. Nevertheless, the NRS-11 appeared to out-perform both the VRS-6 and in particular the FACES scale with respect to: (1) the associations with the validity criterion (i.e. pain interference, disability and psychological functioning) and (2) a lack of any moderating effect of age on the association between the measure and the criterion variables. Conclusions: The findings support the validity of the NRS-11 for assessing pain intensity in youths with physical disabilities between the ages of 8 and 20 years.

Family social support and parental solicitous responses have been hypothesised to play an important role in paediatric pain. However, research testing the hypothesised associations between these social domains and measures of adjustment to pain in youths with disabilities and chronic pain is non-existent.About 111 youths with physical disabilities and bothersome pain were interviewed and asked to complete measures of average pain intensity, pain interference, family social support, parent solicitous responding, and catastrophising.Children's perceptions of pain-related solicitous responses from their parent/guardian were associated both with more pain interference and greater pain-related catastrophising; perceived social support was negatively associated with pain interference.The findings provide new information regarding the role that psychosocial factors have in predicting function and adjustment, and have important implications as to how youth with physical disabilities with pain might be most effectively treated. Implications for rehabilitation Little is known about the role of perceived family social support or parental solicitous responses in the adjustment to chronic pain in young people with physical disabilities. This study provides new and important findings that have significant theoretical and practical implications that could help to understand and manage function in these patients. Results show that it matters how parents respond to their children with disabilities who have pain, and raise the possibility that interventions which target these responses may result in significant benefits for the children.

Pain catastrophizing can be defined as excessively negative thoughts related to pain, its impact, and one’s ability to cope with pain (Sullivan et al., 2001). Recent research suggests that catastrophizing in children with chronic pain is associated with pain intensity (Crombez et al., 2003), psychological distress, and physical functioning (Kashikar-Zuck, Goldschneider, Powers, Vaught, & Hershey, 2001). When excessive attention is paid to pain, an individual may avoid activities that could potentially be painful, and therefore experience a decrease in functioning (Vlaeyen & Linton, 2000). However, none of this research has been conducted using samples of children with physical disabilities. Cerebral palsy (CP), spina bifida (SB), and neuromuscular disease (NMD) are distinct conditions; however, they all have, or have the potential for, musculoskeletal, neurological, and cognitive impairments. Furthermore, pain is a common experience among children with CP (Engel, Petrina, Dudgeon, & McKearnan, 2005; Parkinson, Gibson, Dickinson, & Colver, 2010; Tuzun, Guven, & Eker, 2010), SB (Wood, Watts, Hauser, Rouhani, & Frias, 2009), and NMD (Engel, Kartin, Carter, Jensen, & Jaffe, 2009). The experience of pain has also been found to be related to decreased quality of life in children with CP (Tuzun et al., 2010) and SB (Oddson, Clancy, & McGrath, 2006) and severity of physical impairment in children with CP (Parkinson et al., 2010). It is important to consider other variables that are related to functioning in this population. The purpose of this study is to determine whether the significant associations found between catastrophizing and adjustment in samples of youths without physical disabilities replicate in youths with physical disabilities. Lazarus and Folkman’s stress-coping model provides a theoretical framework for understanding how appraisal processes—of which catastrophizing can be a key component—impact coping and emotional responses (Lazarus & Folkman, 1984). In their model, a person’s ongoing evaluations of his or her situation directly influence how one responds to that situation, and explains how different people can respond in many ways to the same situation. They distinguish between primary appraisals (the implications of the situation for one’s well-being), and secondary appraisals (thoughts related to what can be done to address the situation). Catastrophizing cognitions are stress evaluations that have both primary (e.g., “It is terrible and I feel it is never going to get any better.”) and secondary (e.g., “I feel I can’t go on.”) components. The fear-avoidance model of chronic pain states that individuals with these negative expectancies about pain and the consequences of pain are likely to avoid activities in anticipation of pain. Avoiding physical and social activities results in a significant increase in functional disability and deconditioning of one’s body over time, which can lead to further painful experiences (Asmundson, 1999; Vlaeyen & Linton, 2000). Children with chronic pain report higher levels of catastrophizing than children without chronic pain (Hermann, Hohmeister, Zohsel, Ebinger, & Flor, 2007). Moreover, catastrophizing has been found to be positively correlated with pain severity in a number of samples of youths with chronic pain. For example, Schanberg and colleagues found that youths with juvenile chronic arthritis who reported infrequent catastrophizing rated their pain significantly lower than did those who catastrophized frequently (Schanberg, Lefebvre, Keefe, Kredich, & Gil, 1997). Similarly, Thastum and colleagues and Walker and colleagues found that catastrophizing responses were associated with higher pain in a sample of youths with juvenile idiopathic arthritis and abdominal pain, respectively (Thastum, Herlin, & Zachariae, 2005; Walker, Smith, Garber, & Van Slyke, 1997). Catastrophizing predicts pain intensity in children with chronic pain above and beyond the effects of sex, age (Crombez et al., 2003), and negative affectivity (Vervoort, Goubert, Eccleston, Bijttebier, & Crombez, 2006). Furthermore, a longitudinal study found that catastrophizing predicts pain intensity 6 months later, controlling for initial pain intensity and level of disability (Vervoort, Eccleston, Goubert, Buysse, & Crombez, 2010). In addition to pain intensity, Walker et al. (1997) also found that catastrophizing predicted depressive symptoms. Finally, Kashikar-Zuck et al., (2001) found that catastrophizing was related to both depression and functional impairment in youths with a variety of chronic pain conditions, although they did not find that catastrophizing cognitions predicted functional ability over and above the contribution of depression, as has previous research in adults with chronic pain (Keefe et al., 2000). Vervoort et al. (2006), however, found that catastrophizing did predict disability beyond sex, age, and negative affectivity in both community and clinical samples of children. Despite some inconsistency regarding which domains are most useful in predicting future pain, the consistent findings that catastrophizing and important functioning domains are related in both pediatric and adult chronic pain samples (e.g., Severeijns, Vlaeyen, van den Hout, & Picavet, 2004; Sullivan, Stanish, Waite, Sullivan, & Tripp, 1998; Vervoort et al., 2006, 2010), as well as theory hypothesizing strong links between catastrophizing and important outcomes, suggest the possibility that catastrophizing may play a critical role in the extent to which pain impacts functioning in children with physical disabilities and chronic pain. We expected that, consistent with previous research in samples of youths with chronic pain as a primary presenting problem, pain intensity would be positively associated with pain catastrophizing, and psychological adjustment, functional ability, and community participation would be negatively associated with pain catastrophizing regardless of age, sex, and disability type. The aim of the current study was to determine the associations between catastrophizing and pain intensity, psychological adjustment, and functional ability in youths with physical disabilities and chronic pain. The sample comprised youths with CP, NMD, and SB who reported persistent bothersome pain. The primary difference between the current study and previously published studies is the focus on catastrophizing and pain in youths with physical disabilities. We expected that, consistent with previous research in samples of youths with chronic pain as a primary presenting problem, pain intensity would be positively associated with pain catastrophizing, and psychological adjustment, functional ability, and community participation would be negatively associated with pain catastrophizing regardless of age, sex, and disability type.

). ( Background. Older adults with amnestic mild cognitive impairment (aMCI) are at higher risk for developing Alzheimer disease. Physical performance decline on gait and mobility tasks in conjunction with executive dysfunction has implications for accelerated functional decline, disability, and institutionalization in sedentary older adults with aMCI. Objectives. The purpose of this study was to examine whether performance on 2 tests commonly used by physical therapists (usual gait speed and Timed “Up & Go” Test [TUG]) are associated with performance on 2 neuropsychological tests of executive function (Trail Making Test, part B [TMT-B], and Stroop-Interference, calculated from the Stroop Word Color Test) in sedentary older adults with aMCI. Design. The study was a cross-sectional analysis of 201 sedentary older adults with memory impairment participating in a longitudinal intervention study of cognitive function, aging, exercise, and health promotion. Methods. Physical performance speed on gait and mobility tasks was measured via usual gait speed and the TUG (at fast pace). Executive function was measured with the TMT-B and Stroop-Interference measures. Results. Applying multiple linear regression, usual gait speed was associated with executive function on both the TMT-B (0.215, P.003) and Stroop-Interference ( 0.195, P.01) measures, indicating that slower usual gait speed was associated with lower executive function performance. Timed “Up & Go” Test scores (in logarithmic transformation) also were associated with executive function on both the TMT-B (0.256, P.001) and Stroop-Interference (0.228, P.002) measures, indicating that a longer time on the TUG was associated with lower executive function performance. All associations remained statistically significant after adjusting for age, sex, depressive symptoms, medical comorbidity, and body mass index. Limitations. The cross-sectional nature of this study does not allow for inferences of causation. Conclusions. Physical performance speed was associated with executive function after adjusting for age, sex, and age-related factors in sedentary older adults with aMCI. Further research is needed to determine mechanisms and early intervention strategies to slow functional decline.

Data from 26 participants in a case series of hypnotic analgesia for chronic pain were examined to determine the long-term effects of hypnosis treatment. Statistically significant decreases in average daily pain intensity, relative to pre-treatment values, were observed at post-treatment and at 3 and 9 months follow- up but not at 6 or 12 months follow-up. The percent of participants who reported clinically meaningful decreases in pain were 27%, 19%, 19%, and 23%, at 3, 6, 9, and 12 months follow-up points, respectively. Moreover, at 12 months post-treatment, 81% of the sample reported that still used the self-hypnosis skills learned in treatment. Overall the results indicate that about 20% of the sample obtained substantial and lasting long-term reductions in average daily pain following hypnosis treatment and that many more continue to use self-hypnosis up to 12 months following treatment.

Twenty-two patients with multiple sclerosis (MS) and chronic pain we recruited into a quasi-experimental trial comparing the effects of self-hypnosis training (HYP) with progressive muscle relaxation (PMR) on pain intensity and pain interference; 8 received HYP and the remaining 14 participants were randomly assigned to receive either HYP or PMR. HYP-condition participants reported significantly greater pre- to postsession as well as pre- to posttreatment decreases in pain and pain interference than PMR-condition participants, and gains were maintained at 3-month follow-up. Most of the participants in both conditions reported that they continued to use the skills they learned in treatment and experienced pain relief when they did so. General hypnotizability was not significantly related to treatment outcome, but treatment-outcome expectancy assessed before and after the first session was. The results support the efficacy of self-hypnosis training for the management of chronic pain in persons with MS.

Case study research suggests that hypnosis treatment may provide benefits that are not necessarily the target of specific suggestions. To better understand satisfaction with and the beneficial "side effects" of hypnosis treatment, questions inquiring about treatment satisfaction and treatment benefits were administered to a group of 30 patients with chronic pain who had participated in a case series of hypnotic analgesia treatment. The results confirmed the authors' clinical experience and showed that most participants reported satisfaction with hypnosis treatment even when the targeted symptom (in this case, pain intensity) did not decrease substantially. Study participants also reported a variety of both symptom-related and nonsymptom-related benefits from hypnosis treatment, including decreased pain, increased perceived control over pain, increased sense of relaxation and well-being, and decreased perceived stress, although no single benefit was noted by a majority of participants.

The experiences of chronic pain among children and adolescents with cerebral palsy (CP) were examined in this survey-based study. Perspectives of both the individual and the parent were solicited in a preliminary sample of 20 youths with CP, ages 6-to-17 years from a metropolitan area. Selected participants completed in-person, structured interviews that focused on quality of life with attention to pain experiences. Quantitative data were analyzed descriptively. Seventy percent of participants (n = 14) experienced recurrent chronic pain of moderate intensity on a daily or weekly basis. Greater than half of those participants (n = 9) reported that pain presented a problem for them and especially interfered with self-care and with sleep. Pain appears to be a problem for many youths with CP, and may create additional interference with routine activities of daily living and participation. Further exploration regarding pain experiences and the nature of pain interference is warranted in order to address develo...

The experiences of chronic pain among children and adolescents with cerebral palsy (CP) were examined in this survey-based study. Perspectives of both the individual and the parent were solicited in a preliminary sample of 20 youths with CP, ages 6-to-17 years from a metropolitan area. Selected participants completed in-person, structured interviews that focused on quality of life with attention to pain experiences. Quantitative data were analyzed descriptively. Seventy percent of participants (n = 14) experienced recurrent chronic pain of moderate intensity on a daily or weekly basis. Greater than half of those participants (n = 9) reported that pain presented a problem for them and especially interfered with self-care and with sleep. Pain appears to be a problem for many youths with CP, and may create additional interference with routine activities of daily living and participation. Further exploration regarding pain experiences and the nature of pain interference is warranted in order to address develo...

Objective. To examine the association between pain-coping strategies and adjustment to cerebral palsy (CP)-related pain. Design. Longitudinal study of 48 adults with CP-related chronic pain. Study participants were interviewed on two occasions, separated by 6 months, to assess pain-coping strategies used and two domains of adjustment to chronic pain: depression and pain interference. Results. Changes in coping strategy use were associated with changes in functioning. Specifically, decreased use of catastrophizing and rest, and increased use of task persistence were associated with decreases in depression over a 6-month period. Increased use of task persistence was also associated with decreases in pain interference. Conclusion. Changes in pain-coping strategies over time are associated with changes in functioning in persons with CP-related pain, consistent with biopsychosocial models of chronic pain. Some coping strategies (e.g., catastrophizing, task persistence), however, appear to be more closely linked to functioning than others. These results provide preliminary empiric guidance for the coping strategies that may be most fruitfully targeted in the treatment of CP-related pain.

Thirty-three adults with chronic pain and a disability were treated with hypnotic analgesia. Analyses showed significant pre- to posttreatment changes in average pain intensity that was maintained at 3-month follow-up. Significant changes were also found in pain unpleasantness and perceived control over pain but not in pain interference or depressive symptoms. Hypnotizability, concentration of treatment (e.g., daily vs. up to weekly), and initial response to treatment were not significantly associated with treatment outcome. However, treatment-outcome expectancy assessed after the first session showed a moderate association with treatment outcome. The findings support the use of hypnotic analgesia for the treatment of pain in persons with disabilities for some patients but not the use of pretreatment measures of hypnotizability or treatment-outcome expectancy for screening patients for treatment.

Objectives To determine if cerebral palsy-related pain and frequency of use of pain treatments change over time and to examine the association between use of pain treatments and changes in pain intensity. Design Longitudinal study of 50 adults with cerebral palsy-related chronic pain, interviewed five times during the course of 2 yrs (6 mos between each interview). Subjects ranged in age from 18 to 76 yrs old and included 25 women and 25 men. Results Pain intensity did not change significantly during the time period of the study (2 yrs), although there was a substantial increase in the frequency of use of several pain treatments from the initial to the second interview. Participants reported that many pain treatments were at least moderately helpful, but only three of the treatments (whirlpool, ultrasound, and transcutaneous electrical nerve stimulation) seemed to be associated with a decrease in pain among those who started using these treatments during the study. Conclusion Pain does not seem to become systematically better or worse during the course of a 2-yr time period in adults with cerebral palsy-related pain. Although several pain treatments are reported to provide pain relief, many of these were rarely used by (or provided to) the study participants. There is a need for more research to determine which pain treatments are most helpful for cerebral palsy-related pain and to increase patient accessibility to effective pain treatments.

Engel JM, Jensen MP, Hoffman AJ, Kartin D. Pain in persons with cerebral palsy: extension and cross validation. Arch Phys Med Rehabil 2003;84:1125–8. Objective: To cross-validate and extend the assessment of pain in persons with cerebral palsy (CP). Design: Standardized in-person interviews. Setting: University medical clinics and local residential and community housing for persons with developmental disabilities. Participants: One hundred adults with CP. Interventions: Not applicable. Main Outcome Measures: Measures of pain intensity, pain interference in daily activities, psychologic function, significance of pain problem, and satisfaction with pain treatment. Results: Sixty-seven (67%) subjects reported 1 or more chronic pain problem(s). Low back, hip, and leg pain were most common. Twenty-four percent reported constant pain; 19% reported that pain occurred daily. Mean pain intensity ± standard deviation over the previous week on an 11-point scale (0, no pain; 10, pain as bad as could be) was 4.08±2.25. Minor interference (2.55±3.03; scale range, 0–10) from pain with routine daily activities was reported. Responses to the Satisfaction with Life Scale (n=63) indicated only moderate life satisfaction (18.44±8.34; scale range, 5–35) among those with 1 or more pain problem(s). Responses to the Rand Mental Health Inventory (n=65; mean score, 60.65±20.36) revealed relatively high levels of psychologic distress in those with chronic pain. Consumer satisfaction with pain management care varied, with 32.8% of the subjects reporting dissatisfaction. Conclusions: The study findings are consistent with earlier findings concerning pain problems in adults with CP and provide further evidence that pain problems may be overlooked and undertreated in this population.

Pain is a serious secondary problem for many persons with cerebral palsy (CP). Cognitive-behavioral models of pain hypothesize that how patients cope with painful episodes plays an important role in their adjustment to chronic pain. The utility of this model, however, has never been tested in persons with CP-related pain. Fifty adults with CP and chronic pain were interviewed to assess pain experience, the interference of pain on activities (BPI), depressive symptoms (CES-D), and coping strategies used for the pain (CSQ and CPCI). The results indicated that pain-contingent rest and catastrophizing were both significantly associated with pain interference and depressive symptoms even when controlling for pain severity. These findings support a cognitive-behavioral model of chronic pain as it might be applied to persons with CP. The results also support the need for research to determine if, and to what extent, cognitive-behavioral interventions that provide training in specific coping responses reduce depressive symptoms and pain interference in persons with CP.

Objective: To examine the nature and scope of pain in persons with cerebral palsy (CP). Design: Standardized interviews to assess demographics, pain experiences, and the impact of pain on activities. Subjects: Ninety-three adults with CP recruited from medical clinics at the University of Washington and local residential and community housing for persons with developmental disabilities. Main Outcome Measures: Weekly and 3-month pain intensities, chronic pain grade, interference in daily activities caused by pain, and pain-exacerbating and pain-relieving factors. Results: Sixty-two subjects (67%) reported one or more areas of pain of ≥3 months' duration. Lower extremity pain and back pain were the most common complaints. Fifty-six percent of the subjects reporting pain indicated it occurred daily. Mean average pain intensity, graded on a scale of 0 (no pain) to 10 (pain as bad as could be), was 3.16 (SD = 2.45) in the preceding week and 4.45 (SD = 2.34) in the previous 3 months. Approximately 53% of subjects reporting pain indicated their average pain was of moderate to severe intensity (average pain rated as ≥5). Using Von Korff's Chronic Pain Grade classification system, the majority of subjects who reported pain fell into either grade II(low disability, low pain intensity; 51%) or grade II (low disability, high pain intensity; 39%). Subjects reported many factors that exacerbate pain (eg, stress or weather) or decrease it (eg, exercise or rest). Conclusions: The data suggest that pain is common in adults with CP. In many subjects, pain levels were moderate to intense

The role of the occupational therapist in pediatric pain management is emerging. Whatever intervention methods are used, effective management of pain and associated symptoms depends upon accurate assessment. The use of the Sensory Integration and Praxis Tests (SIPT) for identifying vestibular-proprioceptive abilities in children experiencing recurrent migraine or mixed headaches was investigated. Most of the subjects showed significantly high postrotary nystagmus scores and strengths in the areas of sensory processing and praxis. These data suggest the SIPT may be helpful in determining cortical versus brain-stem processing dysfunction in children with recurrent headaches to assist with treatment intervention.

Biopsychosocial models of pain hypothesize patient attitudes, and beliefs about pain play a key role in adjustment to chronic pain. The purpose of this study was to facilitate research testing the utility of biopsychosocial models in youths with physical disabilities by developing and testing the validity of a measure of pain-related beliefs that could be used with younger patients.One hundred four youths with physical disabilities were administered, via interview, a measure of pain-related beliefs developed for youths with chronic pain-the Pediatric Survey of Pain Attitudes (Peds-SOPA)-and a modified Brief Pain Inventory Pain Interference scale.Item analyses yielded a 29-item pain belief attribution that assessed seven belief domains. The internal consistency (Cronbach alpha) of the subscales varied from good to excellent (0.67-0.92). Pearson correlations between Peds-SOPA and the modified Brief Pain Inventory showed moderate associations between pain beliefs and pain interference for the Medical Cure (r = 0.29), Emotion (r = 0.27), and Disability (r = 0.36) scales.The findings indicate the Peds-SOPA scales are reliable and that a subset of the scales is associated with an important pain-related domain (pain interference), providing preliminary support for the validity of the Peds-SOPA scales.

The aims of this study were to identify the types and frequencies of pain treatments used by individuals with cerebral palsy, examine the perceived effectiveness of these treatments, and identify the types of healthcare providers that were accessed for pain-related services.A cross-sectional survey design was used. A total of 83 adults (mean [SD] age, 40.3 [13.6] yrs) with cerebral palsy indicated their pain location and intensity during the past 3 mos. Next, they indicated their use of 24 different pain treatments and the effectiveness of each. Finally, participants indicated the frequency of pain-related healthcare visits to specific providers over the past 6 mos.Of the participants, 63% reported experiencing chronic pain and rated their pain intensity over the past week as 5.1 of 10, on average. The most common pain locations were the lower back, hips, and legs. Physical interventions (e.g., physical therapy, strengthening) were the most common pain treatments reportedly used and were rated as moderately effective. Many other treatments were also used, and participants sought pain-related care from a variety of providers.Although participants reportedly accessed pain care from a variety of providers and perceived that several types of treatments were effective, many of the treatments rated as effective were rarely used or provided. Future research using clinical trial methods would further elucidate the specific pain treatments that are most beneficial for adults with cerebral palsy.

Jensen MP, Moore MR, Bockow TB, Ehde DM, Engel JM. Psychosocial factors and adjustment to chronic pain in persons with physical disabilities: a systematic review. Objective To systematically review the research findings regarding the associations between psychosocial factors and adjustment to chronic pain in persons with physical disabilities. Data Sources A key word literature search was conducted using articles listed in PubMed, PsychInfo, and CINAHL up to March 2010, and manual searches were made of all retrieved articles to identify published articles that met the review inclusion criteria. Study Selection To be included in the review, articles needed to (1) be written in English, (2) include adults with a physical disability who report having pain, (3) include at least 1 measure of a psychosocial predictor domain, (4) include at least 1 criterion measure of pain or patient functioning, and (5) report the results of associations between the psychosocial factors and criterion measures used in the study. Twenty-nine studies met the inclusion criteria. Data Extraction Three reviewers tabulated study details and findings. Data Synthesis The disability groups studied included spinal cord injury (SCI), acquired amputation, cerebral palsy (CP), multiple sclerosis (MS), and muscular dystrophy (MD). Psychosocial factors were shown to be significantly associated with pain and dysfunction in all disability groups. The psychosocial factors most closely associated with pain and dysfunction across the samples included (1) catastrophizing cognitions; (2) task persistence, guarding, and resting coping responses; and (3) perceived social support and solicitous responding social factors. Pain-related beliefs were more strongly associated with pain and dysfunction in the SCI, CP, MS, and MD groups than in the acquired amputation group. Conclusions The findings support the importance of psychosocial factors as significant predictors of pain and functioning in persons with physical disabilities. Clinical trials to test the efficacy of psychosocial treatments for pain and dysfunction are warranted, as are studies to determine whether psychosocial factors have a causal influence on pain and adjustment in these populations.

The current study sought to (1) determine the relative frequency and severity of eight symptoms in adults with cerebral palsy (CP), (2) examine the perceived course of these eight symptoms over time, and (3) determine the associations between the severity of these symptoms and psychosocial functioning. Eighty-three adults with CP completed a measure assessing the frequency, severity, and perceived course of eight symptoms (pain, weakness, fatigue, imbalance, numbness, memory loss, vision loss, and shortness of breath). Respondents also completed measures of community integration and psychological functioning. The results indicated that pain, fatigue, imbalance, and weakness were the most common and severe symptoms reported. All symptoms were reported to have either stayed the same or worsened, rather than resolved, over time. The symptoms were more closely related to social integration than to home integration, productive activity, or psychological functioning. Memory loss was a unique predictor of social integration in the multivariate context. This study highlighted several common and problematic symptoms experienced by adults with CP. Additional research is needed to identify the most effective treatments for those symptoms that affect community integration and psychological functioning as a way to improve the quality of life of individuals with CP.

Thirty-seven adults with spinal-cord injury and chronic pain were randomly assigned to receive 10 sessions of self-hypnosis (HYP) or EMG biofeedback relaxation (BIO) training for pain management. Participants in both treatment conditions reported sub-stantial, but similar, decreases in pain intensity from before to after the treatment sessions. However, participants in the HYP condition, but not the BIO condition, reported statistically significant decreases in daily average pain pre- to posttreatment. These pre- to posttreatment decreases in pain reported by the HYP participants were maintained at 3-month follow-up. Participants in the HYP condition, but not the BIO condition, also reported significant pre- to posttreatment increases in perceived control over pain, but this change was not maintained at the 3-month follow-up.

To examine the prevalence and characteristics of pain in children with neuromuscular disease (NMD), 42 youths with NMD underwent a comprehensive evaluation including a detailed intake interview and structured questionnaire that included demographic and functional data. Youths who reported chronic pain were further queried about pain characteristics, locations, and intensity using an 11-point numerical rating scale and a modified Brief Pain Inventory (BPI). The sample consisted of 24 males (57%) and 18 females (43%), ages ranging from 9 to 20 years (M = 14.8, SD = 2.96). Participants included 14 (37%) with Duchenne muscular dystrophy, 6 (14%) with myotonic dystrophy, 2 (5%) with Becker dystrophy, 2 (5%) with limb-girdle dystrophy, 2 (5%) with congenital muscular dystrophy, 1 (2%) facioscapulohumeral, and 15 (36%) were classified as ‘‘other NMD.’’ Twenty-one (50%) were ambulatory; 26 (62%) used power wheelchairs/scooters, 9 (2%) used manual wheelchairs, 3 (.07%) used crutches/canes, and 1 (2%) used a walker. A total of 23 (55%) of the youths reported having chronic pain. Current pain intensity was 1.30 (range = 0-6), mean pain intensity over the past week was 2.39 (range = 0-7), mean pain duration was 8.75 hours (SD = 12.84). Pain in the legs was most commonly reported and 83% reported using pain medications. This study indicates that chronic pain is a significant problem in youths with NMD. These data strongly support making comprehensive pain assessment and management an integral part of the standard of care for youths with NMD.

Data from 26 participants in a case series of hypnotic analgesia for chronic pain were examined to determine the long-term effects of hypnosis treatment. Statistically significant decreases in average daily pain intensity, relative to pretreatment values, were observed at posttreatment and at 3- and 9-month follow-up but not at 6- or 12-month follow-up. The percent of participants who reported clinically meaningful decreases in pain were 27%, 19%, 19%, and 23%, at the 3-, 6-, 9-, and 12-month follow-up points, respectively. Moreover, at 12-months posttreatment, 81% of the sample reported that they still used the self-hypnosis skills learned in treatment. Overall, the results indicate that about 20% of the sample obtained substantial and lasting long-term reductions in average daily pain following hypnosis treatment and that many more continue to use self-hypnosis up to 12 months following treatment.

Headaches are one of the most common somatic complaints among adults and children. This study investigated the effects of thermal biofeedback-assisted relaxation training on adult and child tension, migraine, and mixed (migraine and tension) headache disorders. A multiple baseline design across three adult and four child participants was used and multiple outcomes were assessed including participants' records of headache duration and severity, medication intake, and downtime because of headaches. To corroborate participants' records of headache activity, family members independently recorded headache occurrences, and medication intake was corroborated by investigators' pill counts of headache medications. After treatment, reductions in headache duration and severity, downtime, and medication intake were noted for all participants, with four of seven participants headache-free at 1-year follow-up. The results are compared with previous studies and methodological issues are discussed, particularly the need to corroborate self-report measures in headache studies.

Recurrent migraine and tension headache is a common somatic complaint which often begins in childhood and continues into adulthood. Until recently, this has been an under-researched area in children and adolescents. Medical and behavioral management approaches for these headaches will be discussed in this paper with the conclusion that relaxation training appears to be a promising treatment intervention. Specific guidelines for relaxation training and the role of the treating physical or occupational therapist are offered.

Fifty-nine adults with cerebral palsy (CP) were administered, via in-person interviews, measures of pain intensity, pain-related disability, and psychological functioning, in addition to a measure of pain coping (Waldron/Varni Pediatric Pain Coping Inventory; PPCI). Regression analyses indicated that the PPCI scales made a nonsignificant contribution to the prediction of pain intensity, but did make a significant contribution to the prediction of psychological functioning when controlling for pain intensity. Only the PPCI Catastrophizing subscale made a significant independent contribution to the prediction of psychological functioning, and only the PPCI Seek Social Support subscale made a significant independent contribution to the prediction of pain-related disability. These findings support a link between coping and functioning among adults with CP, and suggest that catastrophizing responses and some aspects of support seeking may be maladaptive for coping with CP-related pain. Limitations of the study include a correlational design, a reliance on self-report data, and a small subject population. Experimental research is needed to determine if changes in coping lead to changes in psychological and physical functioning.

Chronic pain in children is drawing increasing attention from families, clinicians, and researchers. Its prevalence is conservatively estimated at 15% to 20% of the pediatric population [1]. There remains, however, a paucity of published research on chronic pain in children with neuromuscular disease (NMD) [2]. Neuromuscular disorders constitute a diverse spectrum of conditions that anatomically span the nerve (motor, sensory, or autonomic) and its supporting structures, the neuromuscular junction, and muscledskeletal, smooth, and cardiac. Encompassed are a wide variety of clinical entities including anterior horn cell disorders, neuropathies, neuromuscular junction disorders, and myopathies and muscular dystrophies. Our understanding of chronic pain in this group of disorders is strikingly limited. Gaps in our knowledge include the nature and scope of the associated pain (its frequency, intensity, and quality); areas of the body most affected; the impact of pain on function and quality of life; and pain treatments and their effectiveness. In order to explore the complexities of chronic pain in children with NMD, we will use Duchenne Muscular Dystrophy (DMD), the most common NMD of childhood, as an informative model [3]. The inherent

Dudgeon BJ, Ehde DM, Cardenas DD, Engel JM, Hoffman AJ, Jensen MP. Describing pain with physical disability: narrative interviews and the McGill Pain Questionnaire. Objectives To identify common pain descriptors used by people with physical disability-related pain and to suggest words that are likely to prompt responses in clinical interviews and assessments. Design Open-ended interviews were coded and then contrasted with responses to a pain questionnaire, obtained through mail or interview surveys. Setting Rehabilitation research program. Participants Twenty-eight people with physical disability-related pain in a series (n=54) of in-depth interviews and 1053 participants with disabilities who responded to mailed questionnaires or structured interviews about pain and its impact (459 with acquired lower-limb amputation, 471 with spinal cord injury, 123 with cerebral palsy). Interventions Not applicable. Main outcome measures Pain interview descriptions and McGill Pain Questionnaire (MPQ). Results Different pain experiences were reflected in narrative descriptions and self-report questionnaire responses. We report the common terms, but across diagnoses use of terms does not appear to clearly differentiate distinct pain phenomenon. Narrative interviews support the use of several MPQ pain descriptors. However, discrete descriptors are recommended when assessing adults with physical disability. Conclusions We identified pain descriptors that appear to be most useful in assessing daily life and participation experiences with physical disability-related pain. These may be clinically useful, but caution is advised when doing diagnostic workups based solely on sensory and affective pain descriptions.

Children with cerebral palsy (CP) face many challenges including impaired motor control and coordination, functional impairment, sensory disturbances, and, sometimes, communication difficulties and cognitive deficits. Pain also may be a problem for children with CP due in part to the inherent deficits associated with the disease, as well as the invasive medical and surgical procedures and rehabilitative activities children with CP undergo on a regular basis. A review of current literature indicates pain is a common experience for children with CP and has been understudied in this population. Further emphasis and research on appropriate assessment and management strategies sensitive to the unique characteristics and limitations of children with CP are warranted.

Chronic pain is a common secondary problem associated with cerebral palsy (CP). This pain may be due to the musculoskeletal problems that often accompany CP, including spasticity, scoliosis, and bony deformity. The purpose of this study was to determine the effects of biofeedback-assisted relaxation training on self-reported pain and muscle tension in 3 adults with CP using a multiple baseline design across subjects. Two of 3 participants reported decreases in their pain experiences posttreatment. Their subjective reports, however, did not correspond with physiological changes. Complications in the use of progressive relaxation exercises and EMG biofeedback equipment are described and suggestions for future research provided.

Chronic pain is a common condition in persons with cerebral palsy (CP), although there is a paucity of research studying CP-related pain. One of the barriers to a better understanding of pain in persons with CP is the lack of information concerning the validity of pain measures that may be used with this population. The purpose of this study was to determine the relative validity of several pain measures in a sample of persons with CP-related pain. Six pain rating scales and measures of depression and pain interference were administered to a sample of 45 adults participating in a longitudinal study of pain in persons with CP. An additional 24 persons with CP were administered 5 of the 6 pain intensity scales. The results of factor analyses support the validity of each measure of pain in this sample of persons with CP. However, an examination of the pattern of associations between each of the pain ratings with measures of pain interference and depression suggest that the 7-point Faces Scale may be somewhat less valid than the other measures.

Background: Until recently, very little has been written regarding chronic pain as a secondary problem in persons who already have a physical disability, despite the potential for pain to increase the negative impact of what may already be a very disabling condition. The purpose of this review is to summarize what is currently known concerning the nature and scope of chronic pain as a secondary condition to disability, specifically spinal cord injury, acquired amputations, cerebral palsy, multiple sclerosis, neuromuscular disease, and postpolio syndrome. Method: What is known concerning the frequency, severity, impact, and treatment of pain in these specific conditions is reviewed, as are the factors that contribute to, or are associated with, adjustment to chronic pain in these disability groups. The authors conclude with several research questions that emerge from this knowledge, the answers to which will contribute to the long-term goal of the reduction of pain and suffering in persons with disabilities. Conclusions: The existing literature clearly documents that many persons with disabilities experience chronic pain. Many questions remain unanswered regarding the scope, severity, and treatment of chronic pain in these groups.

Objectives: To identify the interventions currently being used by adults with cerebral palsy (CP) for pain management, examine the perceived helpfulness of these interventions, and determine the extent to which these individuals with cerebral palsy-related pain were accessing the services of healthcare providers for the explicit purpose of addressing pain. Design: Retrospective, descriptive study of 64 adults with cerebral palsy-related chronic pain. Subjects ranged in age from 18 to 76 yr and included 35 women and 29 men. Subjects were evaluated by using a protocol-based interview. Results: The study sample sought and used a variety of pain treatments and healthcare providers and rated many of the interventions as being at least moderately helpful. Despite the reported helpfulness of the pain interventions, however, most are only being used by a small subset of the sample. Conclusion: The majority of the sample with chronic pain did not access healthcare providers for help in managing their pain. Cerebral palsy-related pain is undertreated in the adult population with cerebral palsy.

Tyler EJ, Jensen MP, Engel JM, Schwartz L. The reliability and validity of pain interference measures in persons with cerebral palsy. Arch Phys Med Rehabil 2002;83:236-9. Objective: To evaluate the reliability and validity of 2 measures of pain interference in persons with cerebral palsy (CP). Design: Standardized interviews to assess pain and impact of pain on activities. Setting: University medical center. Participants: Fifty adults with CP. Interventions: Patients asked to rate pain's intensity, interference with general activities, and depression levels. Main Outcome Measures: Pain interference scales: Chronic Pain Grade (CPG) and Brief Pain Inventory (BPI); rating of disability: Craig Handicap Assessment and Reporting Technique (CHART); rating of depression: Center for Epidemiologic Studies Depression (CES-D) Scale. Results: Mean interference of pain on 3 CPG items (pain interference with daily activities, social activities, work) were 1.74 ± 2.45, 1.06 ± 2.05, and.89 ± 1.84 (out of 10), respectively. Mean interference on 10 modified BPI interference items ranged from 2.28 ± 3.01 to 3.67 ± 3.15 (out of 10). The composite CPG interference score did not correlate significantly with pain intensity. However, the composite BPI interference score did correlate significantly with pain intensity ( r =.66, P r = −.21, NS). Pain showed a significant association with CES-D score ( r =.45, P Conclusions: The pain interference items of the BPI serve as a reliable and valid measure of pain's impact on persons with CP-related pain. © 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Recurrent headache, such as migraine and tension headaches, is a common problem which often begins in childhood and extends into adulthood. Until recently, little attention has been devoted in the literature to this common chronic pain problem in children and adolescents. The purpose of this review is to examine the different types of headache, pharmacologic, and behavioral strategies for assessment and management of pediatric headache disorders, and the role of the pediatric nurse in headache management. Specific guidelines are offered to assist nurses in identifying headaches which can signal serious underlying disease. The literature on management of migraine and tension headaches is reviewed with the conclusion that behavioral strategies (such as relaxation training) would appear to be a viable treatment approach for children and adolescents.