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1.  Persistent pain in a community-based sample of children and adolescents: Sex differences in psychological constructs 
The prevalence of persistent and recurrent pain among children and adolescents has important economic, social and psychological repercussions. The impact of chronic pain in children extends beyond the affected individuals – more than one-third of parents of children with pain report clinically significant levels of stress and depression. Although many pain-related psychological factors have been examined in chronic pediatric pain populations, much of that research involved clinical samples. Community-based research, however, is necessary to uncover the way pain is experienced by youth, regardless of whether treatment is sought or is available. This study aimed to ascertain the lifetime prevalence of pediatric pain in a Canadian community-based sample, and to explore age and sex differences in children who report persistent pain and those who do not with respect to several constructs believed to play important roles in the development and maintenance of persistent pain.
Very few studies have investigated the psychological factors associated with the pain experiences of children and adolescents in community samples.
To examine the lifetime prevalence of, and psychological variables associated with, persistent pain in a community sample of children and adolescents, and to explore differences according to sex, age and pain history.
Participants completed the Childhood Anxiety Sensitivity Index (CASI), the Child Pain Anxiety Symptoms Scale (CPASS), the Multidimensional Anxiety Scale for Children-10 (MASC-10), the Pain Catastrophizing Scale for Children (PCS-C) and a pain history questionnaire that assessed chronicity and pain frequency. After research ethics board approval, informed consent/assent was obtained from 1022 individuals recruited to participate in a study conducted at the Ontario Science Centre (Toronto, Ontario).
Of the 1006 participants (54% female, mean [± SD] age 11.6±2.7 years) who provided complete data, 27% reported having experienced pain that lasted for three months or longer. A 2×2×2 (pain history, age and sex) multivariate ANOVA was conducted, with the total scores on the CASI, the CPASS, the MASC-10 and the PCS-C as dependent variables. Girls with a history of persistent pain expressed higher levels of anxiety sensitivity (P<0.001) and pain catastrophizing (P<0.001) than both girls without a pain history and boys regardless of pain history. This same pattern of results was found for anxiety and pain anxiety in the older, but not the younger, age group.
Boys and girls appear to differ in terms of how age and pain history relate to the expression of pain-related psychological variables. Given the prevalence of persistent pain found in the study, more research is needed regarding the developmental implications of persistent pain in childhood and adolescence.
PMCID: PMC3206778  PMID: 22059200
Children; Persistent pain; Psychosocial factors; Sex differences
2.  Hospitalized children continue to report undertreated and preventable pain 
Pain among hospitalized children is known to be common; however, previous research has been lacking with regard to measures of patient self-report and patients’ pain treatment thresholds. Therefore, the authors of this article conducted an interview- and chart review-based study to obtain a more comprehensive viewpoint regarding hospitalized children’s pain experience, taking into consideration pain treatment thresholds.
Published reports of substantial rates of moderate to severe pediatric inpatient pain tend to overlook lower-intensity pain that may be clinically significant.
To document the prevalence of clinically significant pain in pediatric inpatients by considering the pain threshold at which each child desires intervention, and to assess sources of pain, pain assessment and intervention, and relationships among demographic and medical variables to reported pain.
Inpatients or their parents on four hospital units during four nonconsecutive days were eligible for inclusion. Interviews (76 parents; 31 patients) captured experiences of 107 inpatients (three weeks to 18 years of age) including current, worst and usual pain, pain treatment thresholds, sources of pain and help received during the previous 24 h. A chart review provided data regarding demographic and medical variables, and pain assessment and management.
In total, 94% of patients experienced pain. The prevalence of clinically significant pain was 8% (current), 62% (worst) and 24% (usual). Current and worst pain was primarily procedural, and usual pain was primarily disease related. On average, patients had 4.03 documented pain assessments over 24 h. Caregiver responses (eg, reassurance) and nonpharmacological interventions were frequently reported (>90%) but infrequently documented (<50%); 66% of patients received pharmacological interventions. Younger patients received fewer pain assessments and opioids. Patients with clinically significant usual pain were more likely to have undergone surgery, and receive more pain assessments and interventions.
While recent studies suggest reduced pain in pediatric inpatients, the present findings reveal a continued high frequency of undertreated pain. High rates of procedural pain are preventable and should be targeted given the underutilization of pain management strategies.
PMCID: PMC4158935  PMID: 24809068
Epidemiology; Hospital; Pain management; Pediatric pain; Pediatrics
3.  Pain Site Frequency and Location in Sickle Cell Disease: the PiSCES Project 
Pain  2009;145(1-2):246-251.
Treatment options for sickle cell disease (SCD) pain could be tailored to pain locations. But few epidemiologic descriptions of SCD pain location exist; these are based on few subjects over short time periods. We examined whether SCD pain locations vary by disease genotype, gender, age, frequency of pain, depression, pain crisis or healthcare utilization.
We enrolled 308 adults with SCD in 2002–2004. Subjects kept daily pain diaries for up to 6 months, including a body chart. Analyses employed mixed model and generalized estimating equations.
260 subjects completed at least one body chart. An average of 3.3/16 sites (25%) were painful. The number of pain sites varied by age, depression, frequent pain days, crisis and unplanned hospital/ED utilization. Lower back, knee/shin and hip, hurt on average more than a third of pain days, while jaw and pelvis hurt on fewer than 10% of days. Odds of a crisis were increased substantially when pain was in the arm, shoulder, upper back, sternum, clavicle, chest or pelvis (OR>1.5) while the odds of unplanned utilization were substantially increased for the sternum, clavicle and chest (OR>2.0).
Pain in SCD varies considerably both within and between subjects, although it occurs most commonly in the lower back and lower extremities. The number and location of pain sites varies significantly by age, frequent pain, crisis and utilization. Identification and understanding of combinations of pain location and intensity may help to understand the etiology of SCD and improve SCD management.
PMCID: PMC2771372  PMID: 19631468
4.  Comparing Diary and Retrospective Reports of Pain and Activity Restriction in Children and Adolescents with Chronic Pain Conditions 
The Clinical journal of pain  2009;25(4):299-306.
The current study investigated the daily relationship between pain, activity restriction and depression in children and adolescents with chronic pain, and compared participants’ responses on diary and retrospective assessment measures.
Data collection included the administration of diary and retrospective measures of pain, activity restriction, and depression to 93 children with recurrent headache, juvenile chronic arthritis, and sickle cell disease. The study used HLM to examine the relationship between daily pain and activity restriction, and analyses compared participants’ responses on diary and retrospective assessment measures.
Using diary measures, daily pain intensity was related to children’s levels of activity restriction. Diary completion was predicted by age and diary-type, with younger children and children utilizing electronic diaries demonstrating higher compliance. Pain intensity was significantly higher on retrospective compared to diary measures, demonstrating inflation in retrospective reports of pain. No significant differences between measures of activity restriction emerged.
These preliminary results suggest that while retrospective reports of activity restriction may be an acceptable alternative to daily diary assessment for children with chronic pain, retrospective measures of pain intensity may show inflated pain levels. To provide support for the findings, longitudinal research comparing responses to diary versus retrospective measures is recommended.
PMCID: PMC2709738  PMID: 19590478
chronic pain; activity restriction; depression; children; adolescents
5.  Characteristics of Pain and Stooling in Children with Recurrent Abdominal Pain 
To collect symptom data longitudinally from children with recurrent abdominal pain (RAP) and Control (asymptomatic) children.
Children with RAP (n = 77) and Controls (n = 33) ages 7–10 yrs. completed daily diaries for two weeks tracking pain frequency and severity, how often the pain interfered with activities, and stooling pattern.
RAP children reported a greater number of pain episodes and greater pain severity than Control children. Pain commonly was reported to be in the periumbilical area and occurred evenly across the day in both groups. However, the pain interfered with activity more often in the RAP group. There was a positive relation between pain and interference with activities. Both groups reported stool changes but there were no differences between groups in stool character (e.g., hard, mushy, etc.). For both groups the presence of watery stool was related positively to pain. Of children with RAP, 65% could be categorized as having irritable bowel syndrome (IBS) whereas 35% were classifiable as having functional abdominal pain (FAP) according to the pediatric Rome II criteria.
To our knowledge this is the first longitudinal report of symptoms in children with RAP compared with Controls. These data demonstrate that there is considerable overlap between children with RAP and Control children on a number of items commonly obtained in the history (e.g., pain location, timing, and stooling pattern). A majority of children with RAP could be characterized as having IBS. The relationship between pain reports and interference with activities substantiates the need to deal specifically with the abdominal pain to decrease disability. The relationship between pain and watery stools requires further study.
PMCID: PMC2826272  PMID: 17255832
Recurrent abdominal pain; diary; pain; stool pattern; irritable bowel syndrome; functional abdominal pain
6.  Prevalence and management of back pain in adolescent idiopathic scoliosis patients: A retrospective study 
Back pain is significantly more common among adults compared with children; however, it still represents an important issue in the pediatric population, and back pain in childhood is a predictor for back pain in adulthood. One potential predictor of back pain in childhood is adolescent idiopathic scoliosis. The authors of this article conducted a retrospective chart review involving 310 patients with adolescent idiopathic scoliosis. The prevalence of back pain and management of the pain/scoliosis were assessed, as well as the relationship between the severity of scoliosis and intensity of the pain.
Back pain (BP) has often been associated with adolescent idiopathic scoliosis (AIS), which is a three-dimensional deviation of the vertebral column. In adolescents, chronic pain appears to be a predictor of health care utilization and has a negative impact on physical, psychological and family well-being. In this population, BP tends to be persistent and may be a predictor of BP in adulthood.
To document the prevalence and management of BP in AIS patients.
A retrospective chart review of AIS patients who were referred to Sainte-Justine University Teaching Hospital (Montreal, Quebec) from 2006 to 2011 was conducted.
A total of 310 randomly selected charts were reviewed. Nearly one-half of the patients (47.3%) mentioned that they experienced BP, most commonly in the lumbar (19.7%) and thoracic regions (7.7%). The type of BP was documented in only 36% (n=112) of the charts. Pain intensity was specified in only 21% (n=65) of the charts. In approximately 80% (n=248) of the charts, no pain management treatment plan was documented.
The prevalence of BP was moderately high among the present sample of adolescents with AIS. An improved system for documenting BP assessment, type, treatment plan and treatment effectiveness would improve pain management for these patients.
PMCID: PMC4447159  PMID: 25831076
Adolescent idiopathic scoliosis; Back pain; Chronic pain; Pain management; Prevalence
7.  A record review of reported musculoskeletal pain in an Ontario long term care facility 
BMC Geriatrics  2006;6:5.
Musculoskeletal (MSK) pain is one of the leading causes of chronic health problems in people over 65 years of age. Studies suggest that a high prevalence of older adults suffer from MSK pain (65% to 80%) and back pain (36% to 40%). The objectives of this study were:
1. To investigate the period prevalence of MSK pain and associated subgroups in residents of a long-term care (LTC) facility.
2. To describe clinical features associated with back pain in this population.
3. To identify associations between variables such as age, gender, cognitive status, ambulatory status, analgesic use, osteoporosis and osteoarthritis with back pain in a long-term care facility.
A retrospective chart review was conducted using a purposive sampling approach of residents' clinical charts from a LTC home in Toronto, Canada. All medical records for LTC residents from January 2003 until March 2005 were eligible for review. However, facility admissions of less than 6 months were excluded from the study to allow for an adequate time period for patient medical assessments and pain reporting/charting to have been completed. Clinical data was abstracted on a standardized form. Variables were chosen based on the literature and their suggested association with back pain and analyzed via multivariate logistic regression.
140 (56%) charts were selected and reviewed. Sixty-nine percent of the selected residents were female with an average age of 83.7 years (51–101). Residents in the sample had a period pain prevalence of 64% (n = 89) with a 40% prevalence (n = 55) of MSK pain. Of those with a charted report of pain, 6% (n = 5) had head pain, 2% (n = 2) neck pain, 21% (n = 19) back pain, 33% (n = 29) extremity pain and 38% (n = 34) had non-descriptive/unidentified pain complaint. A multivariate logistic regression analysis revealed that osteoporosis was the only significant association with back pain from the variables studied (P = 0.001).
Residents with back pain represent 13.6% (n = 19) of the sample population studied. This is as frequent as other serious conditions commonly found in LTC. Of the variables studied, only osteoporosis and the self-report of back pain were found to be associated. The back pain resident in this facility can typically be described as female, osteoporotic, with mild to moderate dementia, an independent or assisted walker having low levels of depression. Further research using other sites is needed to determine the overall prevalence of this condition and its impact on quality of life issues. The results of this study should inform future research in this area.
PMCID: PMC1435899  PMID: 16556306
8.  A Novel Tool for the Assessment of Pain: Validation in Low Back Pain 
PLoS Medicine  2009;6(4):e1000047.
Joachim Scholz and colleagues develop and validate an assessment tool that distinguishes between radicular and axial low back pain.
Adequate pain assessment is critical for evaluating the efficacy of analgesic treatment in clinical practice and during the development of new therapies. Yet the currently used scores of global pain intensity fail to reflect the diversity of pain manifestations and the complexity of underlying biological mechanisms. We have developed a tool for a standardized assessment of pain-related symptoms and signs that differentiates pain phenotypes independent of etiology.
Methods and Findings
Using a structured interview (16 questions) and a standardized bedside examination (23 tests), we prospectively assessed symptoms and signs in 130 patients with peripheral neuropathic pain caused by diabetic polyneuropathy, postherpetic neuralgia, or radicular low back pain (LBP), and in 57 patients with non-neuropathic (axial) LBP. A hierarchical cluster analysis revealed distinct association patterns of symptoms and signs (pain subtypes) that characterized six subgroups of patients with neuropathic pain and two subgroups of patients with non-neuropathic pain. Using a classification tree analysis, we identified the most discriminatory assessment items for the identification of pain subtypes. We combined these six interview questions and ten physical tests in a pain assessment tool that we named Standardized Evaluation of Pain (StEP). We validated StEP for the distinction between radicular and axial LBP in an independent group of 137 patients. StEP identified patients with radicular pain with high sensitivity (92%; 95% confidence interval [CI] 83%–97%) and specificity (97%; 95% CI 89%–100%). The diagnostic accuracy of StEP exceeded that of a dedicated screening tool for neuropathic pain and spinal magnetic resonance imaging. In addition, we were able to reproduce subtypes of radicular and axial LBP, underscoring the utility of StEP for discerning distinct constellations of symptoms and signs.
We present a novel method of identifying pain subtypes that we believe reflect underlying pain mechanisms. We demonstrate that this new approach to pain assessment helps separate radicular from axial back pain. Beyond diagnostic utility, a standardized differentiation of pain subtypes that is independent of disease etiology may offer a unique opportunity to improve targeted analgesic treatment.
Editors' Summary
Pain, although unpleasant, is essential for survival. Whenever the body is damaged, nerve cells detecting the injury send an electrical message via the spinal cord to the brain and, as a result, action is taken to prevent further damage. Usually pain is short-lived, but sometimes it continues for weeks, months, or years. Long-lasting (chronic) pain can be caused by an ongoing, often inflammatory condition (for example, arthritis) or by damage to the nervous system itself—experts call this “neuropathic” pain. Damage to the brain or spinal cord causes central neuropathic pain; damage to the nerves that convey information from distant parts of the body to the spinal cord causes peripheral neuropathic pain. One example of peripheral neuropathic pain is “radicular” low back pain (also called sciatica). This is pain that radiates from the back into the legs. By contrast, axial back pain (the most common type of low back pain) is confined to the lower back and is non-neuropathic.
Why Was This Study Done?
Chronic pain is very common—nearly 10% of American adults have frequent back pain, for example—and there are many treatments for it, including rest, regulated exercise (physical therapy), pain-killing drugs (analgesics), and surgery. However, the best treatment for any individual depends on the exact nature of their pain, so it is important to assess their pain carefully before starting treatment. This is usually done by scoring overall pain intensity, but this assessment does not reflect the characteristics of the pain (for example, whether it occurs spontaneously or in response to external stimuli) or the complex biological processes involved in pain generation. An assessment designed to take such factors into account might improve treatment outcomes and could be useful in the development of new therapies. In this study, the researchers develop and test a new, standardized tool for the assessment of chronic pain that, by examining many symptoms and signs, aims to distinguish between pain subtypes.
What Did the Researchers Do and Find?
One hundred thirty patients with several types of peripheral neuropathic pain and 57 patients with non-neuropathic (axial) low back pain completed a structured interview of 16 questions and a standardized bedside examination of 23 tests. Patients were asked, for example, to choose words that described their pain from a list provided by the researchers and to grade the intensity of particular aspects of their pain from zero (no pain) to ten (the maximum imaginable pain). Bedside tests included measurements of responses to light touch, pinprick, and vibration—chronic pain often alters responses to harmless stimuli. Using “hierarchical cluster analysis,” the researchers identified six subgroups of patients with neuropathic pain and two subgroups of patients with non-neuropathic pain based on the patterns of symptoms and signs revealed by the interviews and physical tests. They then used “classification tree analysis” to identify the six questions and ten physical tests that discriminated best between pain subtypes and combined these items into a tool for a Standardized Evaluation of Pain (StEP). Finally, the researchers asked whether StEP, which took 10–15 minutes, could identify patients with radicular back pain and discriminate them from those with axial back pain in an independent group of 137 patients with chronic low back pain. StEP, they report, accurately diagnosed these two conditions and was well accepted by the patients.
What Do These Findings Mean?
These findings indicate that a standardized assessment of pain-related signs and symptoms can provide a simple, quick diagnostic procedure that distinguishes between radicular (neuropathic) and axial (non-neuropathic) low back pain. This distinction is crucial because these types of back pain are best treated in different ways. In addition, the findings suggest that it might be possible to identify additional pain subtypes using StEP. Because these subtypes may represent conditions in which different pain mechanisms are acting, classifying patients in this way might eventually enable physicians to tailor treatments for chronic pain to the specific needs of individual patients rather than, as at present, largely guessing which of the available treatments is likely to work best.
Additional Information
Please access these Web sites via the online version of this summary at
This study is further discussed in a PLoS Medicine Perspective by Giorgio Cruccu and and Andrea Truini
The US National Institute of Neurological Disorders and Stroke provides a primer on pain in English and Spanish
In its 2006 report on the health status of the US, the National Center for Health Statistics provides a special feature on the epidemiology of pain, including back pain
The Pain Treatment Topics Web site is a resource, sponsored partly by associations and manufacturers, that provides information on all aspects of pain and its treatment for health care professionals and their patients
Medline Plus provides a brief description of pain and of back pain and links to further information on both topics (in English and Spanish)
The MedlinePlus Medical Encyclopedia also has a page on low back pain (in English and Spanish)
PMCID: PMC2661253  PMID: 19360087
9.  Pain in hospitalized children: A prospective cross-sectional survey of pain prevalence, intensity, assessment and management in a Canadian pediatric teaching hospital 
Pain is under-recognised and undertreated. Although standards now exist for pain management, it is not known if this has improved care of hospitalized children.
To benchmark pain prevalence, pain intensity, pain assessment documentation and pharmacological treatment of pain. The aim was to highlight areas of good practice, identify areas for improvement and inform development of hospital standards, education, future audits and the research agenda.
The present prospective cross-sectional survey of all medical and surgical inpatient units took place on a single day at the Hospital for Sick Children (Toronto, Ontario), a Canadian tertiary and quaternary pediatric hospital. A structured, verbally administered questionnaire was used to obtain information on patient demographics, pain before admission, pain intensity during admission and pain treatment. Charts were reviewed to establish frequency of documented pain assessment, the pain assessment tool used and analgesics given. Subgroup analysis was included for age, sex, visible minority or fluency in English, medical versus surgical services and acute pain service input.
Two hundred forty-one (83%) of the 290 inpatients or their carergivers were interviewed. It was found that 27% of patients usually had pain before admission, and 77% experienced pain during admission. Of these, 23% had moderate or severe pain at interview and 64% had moderate or severe pain sometime in the previous 24 h. Analgesics were largely intermittent and single-agent, although 90% of patients found these helpful. Fifty-eight per cent of those with pain received analgesics in the preceding 24 h but only 25% received regular analgesia. Only 27% of children had any pain score documented in the preceding 24 h. It was concluded that pain was infrequently assessed, yet occurred commonly across all age groups and services and was often moderate or severe. Although effective, analgesic therapy was largely single-agent and intermittent. Widespread dissemination of results to all professional groups has resulted in the development of a continuous quality assurance program for pain at the Hospital for Sick Children. A re-audit is planned to evaluate changes resulting from the new comprehensive pain strategies.
PMCID: PMC2670807  PMID: 18301813
Inpatient pain; Pain assessment; Pain intensity; Pain management; Pain prevalence; Pediatric pain
10.  Inter and intra-rater repeatability of the scoring of foot pain drawings 
Foot pain drawings (manikins) are commonly used to describe foot pain location in self-report health surveys. Respondents shade the manikin where they experience pain. The manikin is then scored via a transparent overlay that divides the drawings into areas. In large population based studies they are often scored by multiple raters. A difference in how different raters score manikins (inter-rater repeatability), or in how an individual rater scores manikins over time (intra-rater repeatability) can therefore affect data quality. This study aimed to assess inter- and intra-rater repeatability of scoring of the foot manikin.
A random sample was generated of 50 respondents to a large population based survey of adults aged 50 years and older who experienced foot pain and completed a foot manikin. Manikins were initially scored by any one of six administrative staff (Rating 1). These manikins were re-scored by a second rater (Rating 2). The second rater then re-scored the manikins one week later (Rating 3). The following scores were compared: Rating 1 versus Rating 2 (inter-rater repeatability), and Rating 2 versus Rating 3 (intra-rater repeatability). A novel set of clinically relevant foot pain regions made up of one or more individual areas on the foot manikin were developed, and assessed for inter- and intra-rater repeatability.
Scoring agreement of 100% (all 50 manikins) was seen in 69% (40 out of 58) of individual areas for inter-rater scoring (range 94 to 100%), and 81% (47 out of 58) of areas for intra-rater scoring (range 96 to 100%). All areas had a kappa value of ≥0.70 for inter- and intra-rater scoring. Scoring agreement of 100% was seen in 50% (10 out of 20) of pain regions for inter-rater scoring (range 96 to 100%), and 95% (19 out of 20) of regions for intra-rater scoring (range 98 to 100%). All regions had a kappa value of >0.70 for inter- and intra-rater scoring.
Individual and multiple raters can reliably score the foot pain manikin. In addition, our proposed regions may be used to reliably classify different patterns of foot pain using the foot manikin.
PMCID: PMC3831824  PMID: 24180324
Foot pain; Pain drawings; Manikins; Reliability; Repeatability; Agreement
11.  COOP-WONCA charts: a suitable functional status screening instrument in acute low back pain? 
BACKGROUND: Functional status is considered an important measure of health status in primary care. The COOP-WONCA charts, which comprise six single-item scales, have mainly been used to determine functional ability in chronically ill patients. AIM: A study was carried out to determine whether the charts are able to measure the degree of functional impairment associated with acute illness and the improvement in functional ability accompanying the process of recovery. METHOD: A total of 95 patients presenting with acute low back pain were recruited from 15 single-handed general practices in northern Germany. At presentation and at two-week follow up, these patients completed self-administered questionnaires which included the COOP-WONCA charts. The charts ask patients to use the timescale of the past two weeks when rating their condition. Baseline and follow-up measurements of the charts were compared and correlations of chart scores with patients' measurements of pain intensity on a visual analogue scale, general practitioners' ratings of impairment and patients' measurements of recovery were analysed. RESULTS: Only the chart measuring change in health revealed a deterioration in functional ability associated with the onset of pain and an improvement in functional status at follow up. Two of the other charts indicated a deterioration at follow up. Only the chart measuring change in health was correlated with ratings of pain and impairment at baseline. At follow up, strong correlations were found between general practitioners' assessments of impairment, patients' ratings of pain and patients' ratings of recovery for all scales except for those measuring social activities and daily activities. The patients interpreted the instructions for using the COOP-WONCA charts differently; some included the period of acute back pain while others did not. CONCLUSION: Of the six charts only the change in health chart proved to be a suitable scale for measuring short-term changes in functional ability among general practice patients with acute low back pain. This may partly be a result of patients misunderstanding the instructions. If the COOP-WONCA charts are used with acutely ill patients, the fixed two-weeks timescale is not appropriate. It is suggested that patients consider their present complaints when rating their condition.
PMCID: PMC1239469  PMID: 8745864
12.  Sociodemographic factors in a pediatric chronic pain clinic: The roles of age, sex and minority status in pain and health characteristics 
Journal of pain management  2010;3(3):273-281.
Little is known about how sociodemographic factors relate to children’s chronic pain. This paper describes the pain, health, and sociodemographic characteristics of a cohort of children presenting to an urban tertiary chronic pain clinic and documents the role of age, sex and minority status on pain-related characteristics. A multidisciplinary, tertiary clinic specializing in pediatric chronic pain. Two hundred and nineteen patients and their parents were given questionnaire packets to fill out prior to their intake appointment which included demographic information, clinical information, Child Health Questionnaire – Parent Report, Functional Disability Index – Parent Report, Child Somatization Index – Parent Report, and a Pain Intensity Scale. Additional clinical information was obtained from patients’ medical records via chart review. This clinical sample exhibited compromised functioning in a number of domains, including school attendance, bodily pain, and health compared to normative data. Patients also exhibited high levels of functional disability. Minority children evidenced decreased sleep, increased somatization, higher levels of functional disability, and increased pain intensity compared to Caucasians. Caucasians were more likely to endorse headaches than minorities, and girls were more likely than boys to present with fibromyalgia. Younger children reported better functioning than did teens. The results indicate that sociodemographic factors are significantly associated with several pain-related characteristics in children with chronic pain. Further research must address potential mechanisms of these relationships and applications for treatment.
PMCID: PMC3113686  PMID: 21686073
Chronic pain; pediatric; clinical cohort; ethnic differences
13.  Pain assessment using the Adolescent Pediatric Pain Tool: A systematic review 
The Adolescent Pediatric Pain Tool (APPT), a pain assessment tool with three separate components, has been well validated among hospitalized patients between eight and 17 years of age. The tool may also be useful among other age groups or clinical settings; accordingly, the authors conducted a systematic review of the APPT to identify situations in which it has been used and to identify strengths and weaknesses of the tool.
The Adolescent Pediatric Pain Tool (APPT) is a multidimensional pain assessment tool designed to assess pain location (body outline diagram), intensity (word graphic rating scale) and quality (list of pain descriptors) in hospitalized children eight to 17 years of age.
To identify the age range, health conditions, settings and purpose for which APPT has been used; the components of the APPT that have been used; and the reported clinical and research utility of the APPT.
A systematic review of published studies using the APPT was performed. Studies were identified through electronic searches in CINAHL, Medline, PubMed, SciELO and PsycInfo.
Twenty-three studies were analyzed. APPT has been used in patients between two and 68 years of age, with various acute and chronic conditions, in and out of hospital. All but six studies used the three components of the APPT. Most of the studies used the total number of sites marked, mean pain intensity and mean number of pain descriptors selected as main outcome measures; however, scoring methods varied. Studies report that the use of the APPT is relevant for clinical practice and for research.
Obtaining self-report of pain using the APPT may help clinicians to tailor pain management interventions. It may also be used in studies to provide a deeper understanding of the pain experience and to examine the effectiveness of pain management interventions. However, outcome measures and methods of scoring the different components of the APPT need to be clearly identified.
PMCID: PMC4158937  PMID: 24950413
Adolescent; Child; Pain; Pain measurement; Review
14.  18D. Yoga Promotes Relaxation in Children and Adolescents With Recurrent Headache 
Focus Areas: Integrative Approaches to Care, Supporting Behavioral Change, Alleviating Pain
Recurrent headaches are prevalent in children and adolescents. Up to 89% of these individuals identify stress as a trigger. Yoga offers a complementary and alternative method for this population who often lacks effective relaxation tools for stress relief. This presentation describes the yoga group offered as part of the Integrative Headache Clinic (IHC) at Children's Hospital Colorado. One of the objectives is to determine the effect of the yoga group for children and adolescents with recurrent headaches on pain and relaxation scores.
Over the course of 18 months (January 2011 to June 2012), a retrospective chart review was conducted of 40 children and adolescents with an average age of 15 years, 62.5% of whom were female. During the first hour of clinic, every individual takes part in a 50-minute group yoga session consisting of 10 asanas that promote relaxation and pain relief. Before and after yoga group, participants rate their level of pain and relaxation on a scale from 0 to 10 (with 0 being no pain or relaxation and 10 being maximum pain or relaxation). The average “before yoga” pain score was 3.7 ( /- 3.0) and “after yoga” pain score was 3.4 ( /-3.1) (P=.0672), representing a decrease in pain. The average “before yoga” relaxation score was 5.2 ( /- 2.3) and “after yoga” relaxation score was 7.5 ( /-1.9) (P<.0001), representing a statistically significant increase in relaxation.
Group yoga is effective in promoting relaxation in children and adolescents with recurrent headache. Yoga may offer an adjunct to common pharmaceutical options for headache management for children and adolescents.
PMCID: PMC3875043
15.  Outcomes of a Simple Treatment for Complex Regional Pain Syndrome Type I in Children 
The Iowa Orthopaedic Journal  2015;35:175-180.
Chronic Regional Pain Syndrome type I (CRPSI) in children is a disorder of unknown etiology. No standard diagnostic criteria or treatment exists. Published treatment protocols are often time and resource intensive. Nonetheless, CRPSI is not rare and can be disabling. This reports the results of a simple and inexpensive treatment protocol involving no medicines, nerve blockades, physical therapy resources or referrals to pain specialists. The patient is instructed in a self-administered massage and mobilization program. The diagnosis required allodynia (pain on light touch of the skin) and signs or the history of signs of autonomic dysfunction.
A chart review of patient coded for “reflex sympathetic dystrophy” or ‘autonomic dysfunction” was performed yielding a cohort of eighty-three patients treated by a common protocol. Most patients were identified in the last 15 years. Most patients with this CRPSI were doubtless coded simply as “foot pain” or “knee pain”, etc and were not identified in this search. Charts were reviewed for patient demographics and outcomes. A subset of patients filled out the Pediatric Outcomes Data Collection Instrument (PODCI) giving a validated pre-treatment disability measure.
The cohort characteristics were similar to prior reports with respect to age, gender, location, and history of trauma. Of the 26 patients who completed the PODCI before treatment the Pain/Comfort Core Scale score mean was 20.81(0–63). The Global Functioning Scale score mean was 52.11(27–83.5). Eighty-nine percent of 51 patients who attended clinic until their outcome was definite had no or minimal residual pain. Treatment averaged 2.2 visits per patient, typically over a six-week period.
A simple, inexpensive protocol can be effective in treating CRPSI in children. The protocol is risk free, inexpensive to families and conservative of physician and physical therapy resources.
Level of Evidence
Therapeutic Level IV.
PMCID: PMC4492150  PMID: 26361462
16.  Pain as a Comorbidity of Pediatric Obesity 
The purpose of this study was to document the prevalence and characteristics of physical pain in a sample of severely obese children and adolescents. In this retrospective chart review, primary measures included current and past pain, pain intensity, and pain characteristics during a 5-minute walk test. Pain assessments for 74 patients (mean age 11.7 years; 53% female; 41% African American) were conducted by a physical therapist. Past pain was reported by 73% of the sample, with 47% reporting pain on the day of program enrollment. Although average pain intensity was moderate (M = 5.5/10), alarmingly, 42% of those with current pain reported severe pain (6/10 to 10/10). Overall, pain occurred primarily in the lower extremities and with physical activity. Patients reporting current pain had a significantly higher body mass index than those reporting no pain. These findings suggest that pain is common in severely obese youth, and furthermore, that pain should be recognized as a comorbidity of pediatric obesity. Routinely screening severely obese children and adolescents for pain presence and intensity is recommended.
PMCID: PMC3979543  PMID: 24723992
obesity; pain; pediatric population; body mass index
17.  Mother-child concordance for pain location in a pediatric chronic pain sample 
Journal of pain management  2013;6(2):135-145.
Body maps have long been used to assess pain location in adult and pediatric chronic pain patients. Assessing agreement between parent and child reports of pain location using such maps may help establish a unified picture of children’s pain experience. However, few studies have examined the extent of agreement between mothers and children on the location of the child’s pain. Using kappa coefficients and other determinants of the magnitude of kappa we assessed mother-child concordance in pain location using body maps with 21 standardized areas in 41 children with chronic pain (65.9% female, mean age = 14.60) and their mothers. The highest level of agreement was found for the abdominal region; agreement for the head region was moderate and not superior to the other body areas. Approximately half of the body map areas yielded poor to fair mother-child agreement, while the other half yielded moderate or better agreement. There was more agreement between mothers and sons than between mothers and daughters on the total number of body areas considered painful, but there were no effects of pubertal status, race, and ethnicity on agreement. Our results are consistent with previous studies indicating that parent assessments of children’s pain do not necessarily mimic their child’s report. Future research should test additional psychosocial factors that may contribute to parent-child discordance regarding the location of the child’s pain.
PMCID: PMC4580285  PMID: 26413192
children; adolescents; parents; pediatric pain; chronic pain
18.  How Well Do Clinical Pain Assessment Tools Reflect Pain in Infants? 
PLoS Medicine  2008;5(6):e129.
Pain in infancy is poorly understood, and medical staff often have difficulty assessing whether an infant is in pain. Current pain assessment tools rely on behavioural and physiological measures, such as change in facial expression, which may not accurately reflect pain experience. Our ability to measure cortical pain responses in young infants gives us the first opportunity to evaluate pain assessment tools with respect to the sensory input and establish whether the resultant pain scores reflect cortical pain processing.
Methods and Findings
Cortical haemodynamic activity was measured in infants, aged 25–43 wk postmenstrual, using near-infrared spectroscopy following a clinically required heel lance and compared to the magnitude of the premature infant pain profile (PIPP) score in the same infant to the same stimulus (n = 12, 33 test occasions). Overall, there was good correlation between the PIPP score and the level of cortical activity (regression coefficient = 0.72, 95% confidence interval [CI] limits 0.32–1.11, p = 0.001; correlation coefficient = 0.57). Of the different PIPP components, facial expression correlated best with cortical activity (regression coefficient = 1.26, 95% CI limits 0.84–1.67, p < 0.0001; correlation coefficient = 0.74) (n = 12, 33 test occasions). Cortical pain responses were still recorded in some infants who did not display a change in facial expression.
While painful stimulation generally evokes parallel cortical and behavioural responses in infants, pain may be processed at the cortical level without producing detectable behavioural changes. As a result, an infant with a low pain score based on behavioural assessment tools alone may not be pain free.
Rebeccah Slater and colleagues show that although painful stimulation generally evokes parallel cortical and behavioral responses in infants, pain may produce cortical responses without detectable behavioral changes.
Editors' Summary
Pain is a sensory and emotional experience. It is normally triggered by messages transmitted from specialized receptors (nociceptors) in the body to integrative centers in the spinal cord and brainstem and on to the brain, where it undergoes higher sensory and cognitive analysis, allowing the body to respond appropriately to the stimuli. While the experience of pain may be considered to be unpleasant, it is a useful tool in communicating to us and to others that there is something wrong with our bodies. Ultimately, these responses help restrict further damage to the body and start the process of healing.
In a clinical setting, the ability to communicate about pain allows an individual to seek strategies to ease the pain, such as taking analgesics. Being unable to effectively communicate one's experience of pain leaves the individual vulnerable to prolonged suffering. One such vulnerable group is infants.
Ignored and untreated pain in infants has been shown to have immediate and long-term effects as a result of structural and physiological changes within the nervous system. For example, the body responds to untreated pain by increased release of stress hormones, which may be associated with increased morbidity and mortality in the short term. Long-term effects of pain may include altered pain perception, chronic pain syndromes, and somatic complaints such as sleep disturbances, feeding problems, and inability to self-regulate in response to internal and external stressors. It has been proposed that attention deficit disorders, learning disorders, and behavioral problems in later childhood may be linked to repetitive pain in the preterm infant.
Why Was This Study Done?
Until as recently as the 1990s, newborns in some clinical centres underwent surgery with minimal anesthesia. Also, newborns received little or no pain management postoperatively or for painful procedures such as lumbar punctures or circumcisions. Since then, there has been growing awareness amongst clinicians that pain may be experienced from the earliest stages of postnatal life and that inadequate analgesia may lead to the type of long-term consequences mentioned above. However, gauging how much pain infants and young children are experiencing remains a substantial challenge. The researchers in this study wanted to assess the association between cortical pain responses in young infants and currently used tools for the assessment of pain in these infants. These current tools are based on behavioral and physiological measures, such as change in facial expression, and it is possible that these tools do not give an adequate measure of pain especially in infants born preterm.
What Did the Researchers Do and Find?
Twelve clinically stable infants were studied on 33 occasions when they required a heel lance to obtain a blood sample for a clinical reason. The researchers examined the relationship between brain activity and a clinical pain score, calculated using the premature infant pain profile (PIPP) in response to a painful event. Activity in the somatosensory cortex was measured noninvasively by near-infrared spectroscopy, which measures brain regional changes in oxygenated and deoxygenated hemoglobin concentration. The PIPP is a well-established pain score that ascribes a value to infant behavior such as change in facial expression.
They found that changes in brain activity in response to a painful stimulus were related to the PIPP scores. These changes were more strongly linked to the behavioral components of the PIPP, e.g., facial expression, than physiological components, e.g., heart rate. They also found that a positive brain response could occur in the absence of any facial expression.
What Do These Findings Mean?
Behaviors to communicate pain require motor responses to sensory and emotional stimuli. The maturity of this complex system in infants is not clearly understood. The results of this study raise further awareness of the ability of infants to experience pain and highlight the possibility that pain assessment based on behavioral tools alone may underestimate the pain response in infants.
Additional Information.
Please access these Web sites via the online version of this summary at
Important papers on pain in human neonates are discussed in the open access Paediatric Pain Letter with links to original articles
The Institute of Child Health in London has a Web site describing a three-year international project on improving the assessment of pain in hospitalized children, with many useful links
The International Association for the Study of Pain (IASP) provides accurate and up-to-date information and links about pain mechanisms and treatment
PMCID: PMC2504041  PMID: 18578562
19.  Spine day 2012: spinal pain in Swiss school children– epidemiology and risk factors 
BMC Pediatrics  2013;13:159.
The key to a better understanding of the immense problem of spinal pain seems to be to investigate its development in adolescents. Based on the data of Spine Day 2012 (an annual action day where Swiss school children were examined by chiropractors on a voluntary basis for back problems), the aim of the present study was to gain systematic epidemiologic data on adolescent spinal pain in Switzerland and to explore risk factors per gender and per spinal area.
Data (questionnaires and physical examinations) of 836 school children were descriptively analyzed for prevalence, recurrence and severity of spinal pain. Of those, 434 data sets were included in risk factor analysis. Using logistic regression analysis, psycho-social parameters (presence of parental back pain, parental smoking, media consumption, type of school bag) and physical parameters (trunk symmetry, posture, mobility, coordination, BMI) were analyzed per gender and per spinal area.
Prevalence of spinal pain was higher for female gender in all areas apart from the neck. With age, a steep increase in prevalence was observed for low back pain (LBP) and for multiple pain sites. The increasing impact of spinal pain on quality of life with age was reflected in an increase in recurrence, but not in severity of spinal pain. Besides age and gender, parental back pain (Odds ratio (OR)=3.26, p=0.011) and trunk asymmetry (OR=3.36, p=0.027) emerged as risk factors for spinal pain in girls. Parental smoking seemed to increase the risk for both genders (boys: OR=2.39, p=0.020; girls: OR=2.19, p=0.051). Risk factor analysis per spinal area resulted in trunk asymmetry as risk factor for LBP (OR=3.15, p=0.015), while parental smoking increased the risk for thoracic spinal pain (TSP) (OR=2.83, p=0.036) and neck pain (OR=2.23, p=0.038). The risk for TSP was further enhanced by a higher BMI (OR=1.15, p=0.027).
This study supports the view of adolescent spinal pain as a bio-psycho-social problem that should be investigated per spinal area, age and gender. The role of trunk asymmetry and passive smoking as risk factors as well as the association between BMI and TSP should be further investigated, preferably in prospective studies.
PMCID: PMC3852258  PMID: 24094041
Adolescence; Risk factor; Spinal pain
20.  Implementation of multidimensional knowledge translation strategies to improve procedural pain in hospitalized children 
Despite extensive research, institutional policies, and practice guidelines, procedural pain remains undertreated in hospitalized children. Knowledge translation (KT) strategies have been employed to bridge the research to practice gap with varying success. The most effective single or combination of KT strategies has not been found. A multifaceted KT intervention, Evidence-based Practice for Improving Quality (EPIQ), that included tailored KT strategies was effective in improving pain practices and clinical outcomes at the unit level in a prospective comparative cohort study in 32 hospital units (16 EPIQ intervention and 16 Standard Care), in eight pediatric hospitals in Canada.
In a study of the 16 EPIQ units (two at each hospital) only, the objectives were to: determine the effectiveness of evidence-based KT strategies implemented to achieve unit aims; describe the KT strategies implemented and their influence on pain assessment and management across unit types; and identify facilitators and barriers to their implementation.
Data were collected from each EPIQ intervention unit on targeted pain practices and KT strategies implemented, through chart review and a process evaluation checklist, following four intervention cycles over a 15-month period.
Following the completion of the four cycle intervention, 78% of 23 targeted pain practice aims across units were achieved within 80% of the stated aims. A statistically significant improvement was found in the proportion of children receiving pain assessment and management, regardless of pre-determined aims (p < 0.001). The median number of KT strategies implemented was 35 and included reminders, educational outreach and materials, and audit and feedback. Units successful in achieving their aims implemented more KT strategies than units that did not. No specific type of single or combination of KT strategies was more effective in improving pain assessment and management outcomes. Tailoring KT strategies to unit context, support from unit leadership, staff engagement, and dedicated time and resources were identified as facilitating effective implementation of the strategies.
Further research is required to better understand implementation outcomes, such as feasibility and fidelity, how context influences the effectiveness of multifaceted KT strategies, and the sustainability of improved pain practices and outcomes over time.
PMCID: PMC4263210  PMID: 25928349
Pediatric procedural pain; Knowledge translation strategies; Tailored interventions; Quality improvement
21.  Health care professionals’ pain narratives in hospitalized children’s medical records. Part 2: Structure and content 
Although clinical narratives – described as free-text notations – have been noted to be a source of patient information, no studies have examined the composition of pain narratives in hospitalized children’s medical records.
To describe the structure and content of health care professionals’ narratives related to hospitalized children’s acute pain.
All pain narratives documented during a 24 h period were collected from the medical records of 3822 children (0 to 18 years of age) hospitalized in 32 inpatient units in eight Canadian pediatric hospitals. A qualitative descriptive exploration using a content analysis approach was performed.
Three major structural elements with their respective categories and subcategories were identified: information sources, including clinician, patient, parent, dual and unknown; compositional archetypes, including baseline pain status, intermittent pain updates, single events, pain summation and pain management plan; and content, including pain declaration, pain assessment, pain intervention and multidimensional elements of care.
The present qualitative analysis revealed the multidimensionality of structure and content that was used to document hospitalized children’s acute pain. The findings have the potential to inform debate on whether the multidimensionality of pain narratives’ composition is a desirable feature of documentation and how narratives can be refined and improved. There is potential for further investigation into how health care professionals’ pain narratives could have a role in generating guidelines for best pain documentation practice beyond numerical representations of pain intensity.
PMCID: PMC3805354  PMID: 24093123
Children; Documentation; Free-text; Notation; Narratives; Pain
22.  Effect of varying the time frame for COOP-WONCA functional health status charts: a nested randomised controlled trial in Bristol, UK 
STUDY OBJECTIVES: To investigate whether changing the stated time frame for COOP-WONCA charts has any effect on responses. Specifically, to assess the effect of attempting to avoid the situation where the time frame crosses the onset of an acute episode. DESIGN: A randomised controlled trial of two time frames, nested within a main trial comparing early discharge with a hospital at home scheme against routine discharge policy. The time frames compared were the standard two weeks (four for the pain chart) and a shorter period of 48 hours for all seven charts. SETTING: Acute hospital wards in Frenchay Healthcare Trust and the Avon Orthopaedic Centre in Bristol. PARTICIPANTS: Patients entered into the main trial, who were medically stable, in need of continued rehabilitative care but suitable for discharge to hospital at home. MAIN RESULTS: A total of 200 patients were randomised, 106 to the shorter time frame, 94 to the standard charts. No clear differences were observed between the two groups for the proportion failing to self complete the charts. For the (seven) chart scores, only pain was statistically significantly different between the time frames (Mann-Whitney p = 0.0085; proportion reporting moderate or severe pain 19% higher in the standard group, 95% confidence intervals 5% to 33%). For both this chart and that for change in health, however, there was evidence of greater differences between the versions of the chart among those admitted more recently (p values for relevant interactions 0.004 and < or = 0.001 respectively). CONCLUSIONS: While the present findings give some support for the wide applicability of the standard version, there is sufficient evidence here to indicate that the time frame may influence the results, particularly for patients with a recent acute episode. In the absence of further data, then, it would seem prudent to consider a shorter time frame for such patients, especially if the aim is to assess current health status or to measure changes over a comparatively short period of time, or both.
PMCID: PMC1756607  PMID: 9604043
23.  A Systematic Review of Sleep in Pediatric Pain Populations 
The primary aim of this systematic review was to examine the evidence for a pain-sleep relationship in children with persistent pain by reviewing studies using single and mixed pediatric persistent pain samples.
Electronic searches of Medline, PubMed, the Cochrane Database of Systematic Reviews, and PsycINFO were conducted to identify all relevant empirical studies. Studies were included in the review if the majority of participants were between 0-17 years and from one of the following pediatric pain populations: juvenile idiopathic arthritis, sickle cell disease, migraine/headache, functional abdominal pain, juvenile fibromyalgia syndrome, chronic musculoskeletal pain, or mixed populations including the aforementioned conditions.
Research from single and mixed sample studies support the hypothesis that children and adolescents with persistent pain suffer from sleep impairment. Literature addressing factors that may influence or mediate the pain-sleep relationship and the functional outcomes of the pain-sleep relationship was reviewed, and a model of the interrelationships with pain and sleep developed.
Findings from this review highlight the need to assess and treat sleep problems in children presenting with persistent pain. Healthcare providers should consider conducting routine sleep screenings, including a comprehensive description of sleep patterns and behaviors obtained through clinical interview, sleep diaries, and/or the use of standardized measures of sleep. Future research focusing on investigating the mechanisms associating sleep and pediatric persistent pain and on functional outcomes of poor sleep in pediatric pain populations is needed.
PMCID: PMC3562475  PMID: 23369958
adolescent; child; persistent pain; sleep
24.  The association of self-injurious behaviour and suicide attempts with recurrent idiopathic pain in adolescents: evidence from a population-based study 
While several population-based studies report that pain is independently associated with higher rates of self-destructive behaviour (suicidal ideation, suicide attempts, and self-injurious behaviour) in adults, studies in adolescents are rare and limited to specific chronic pain conditions. The aim of this study was to investigate the link between self-reported idiopathic pain and the prevalence and frequency of self-injury (SI) and suicide attempts in adolescents.
Data from a cross-sectional, school-based sample was derived to assess SI, suicide attempts, recurrent pain symptoms and various areas of emotional and behavioural problems via a self-report booklet including the Youth Self-Report (YSR). Adolescents were assigned to two groups (presence of pain vs. no pain) for analysis. Data from 5,504 students of 116 schools in a region of South Western Germany was available. A series of unadjusted and adjusted multinomial logistic regression models were performed to address the association of pain, SI, and suicide attempts.
929 (16.88%) respondents reported recurrent pain in one of three areas of pain symptoms assessed (general pain, headache, and abdominal pain). Adolescents who reported pain also reported greater psychopathological distress on all sub-scales of the YSR. The presence of pain was significantly associated with an increased risk ratio (RR) for SI (1–3 incidences in the past year: RR: 2.96; >3 incidences: RR: 6.04) and suicide attempts (one attempt: RR: 3.63; multiple attempts: RR: 5.4) in unadjusted analysis. Similarly, increased RR was observed when adjusting for sociodemographic variables. While controlling for psychopathology attenuated this association, it remained significant (RRs: 1.4–1.8). Sub-sequent sensitivity analysis revealed different RR by location and frequency of pain symptoms.
Adolescents with recurrent idiopathic pain are more likely to report previous incidents of SI and suicide attempts. This association is likely mediated by the presence of psychopathological distress as consequence of recurrent idiopathic pain. However, the observed variance in dependent variables is only partially explained by emotional and behavioural problems. Clinicians should be aware of these associations and interview adolescents with recurrent symptoms of pain for the presence of self-harm, past suicide attempts and current suicidal thoughts. Future studies addressing the neurobiology underpinnings of an increased likelihood for self-injurious behaviour and suicide attempts in adolescents with recurrent idiopathic pain are necessary.
PMCID: PMC4584487  PMID: 26417388
Pain; Adolescents; Self-injury; Suicide attempts
25.  An Experimental Paradigm for the Prediction of Post-Operative Pain (PPOP) 
Many women undergo cesarean delivery without problems, however some experience significant pain after cesarean section. Pain is associated with negative short-term and long-term effects on the mother. Prior to women undergoing surgery, can we predict who is at risk for developing significant postoperative pain and potentially prevent or minimize its negative consequences? These are the fundamental questions that a team from the University of Washington, Stanford University, the Catholic University in Brussels, Belgium, Santa Joana Women's Hospital in São Paulo, Brazil, and Rambam Medical Center in Israel is currently evaluating in an international research collaboration. The ultimate goal of this project is to provide optimal pain relief during and after cesarean section by offering individualized anesthetic care to women who appear to be more 'susceptible' to pain after surgery.
A significant number of women experience moderate or severe acute post-partum pain after vaginal and cesarean deliveries. 1 Furthermore, 10-15% of women suffer chronic persistent pain after cesarean section. 2 With constant increase in cesarean rates in the US 3 and the already high rate in Brazil, this is bound to create a significant public health problem. When questioning women's fears and expectations from cesarean section, pain during and after it is their greatest concern. 4 Individual variability in severity of pain after vaginal or operative delivery is influenced by multiple factors including sensitivity to pain, psychological factors, age, and genetics. The unique birth experience leads to unpredictable requirements for analgesics, from 'none at all' to 'very high' doses of pain medication. Pain after cesarean section is an excellent model to study post-operative pain because it is performed on otherwise young and healthy women. Therefore, it is recommended to attenuate the pain during the acute phase because this may lead to chronic pain disorders. The impact of developing persistent pain is immense, since it may impair not only the ability of women to care for their child in the immediate postpartum period, but also their own well being for a long period of time.
In a series of projects, an international research network is currently investigating the effect of pregnancy on pain modulation and ways to predict who will suffer acute severe pain and potentially chronic pain, by using simple pain tests and questionnaires in combination with genetic analysis. A relatively recent approach to investigate pain modulation is via the psychophysical measure of Diffuse Noxious Inhibitory Control (DNIC). This pain-modulating process is the neurophysiological basis for the well-known phenomenon of 'pain inhibits pain' from remote areas of the body. The DNIC paradigm has evolved recently into a clinical tool and simple test and has been shown to be a predictor of post-operative pain.5 Since pregnancy is associated with decreased pain sensitivity and/or enhanced processes of pain modulation, using tests that investigate pain modulation should provide a better understanding of the pathways involved with pregnancy-induced analgesia and may help predict pain outcomes during labor and delivery. For those women delivering by cesarean section, a DNIC test performed prior to surgery along with psychosocial questionnaires and genetic tests should enable one to identify women prone to suffer severe post-cesarean pain and persistent pain. These clinical tests should allow anesthesiologists to offer not only personalized medicine to women with the promise to improve well-being and satisfaction, but also a reduction in the overall cost of perioperative and long term care due to pain and suffering. On a larger scale, these tests that explore pain modulation may become bedside screening tests to predict the development of pain disorders following surgery.
PMCID: PMC2818706  PMID: 20107427

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