Juvenile idiopathic arthritis (JIA) is a common chronic childhood illness. Pain is the most common and distressing symptom of JIA. Pain has been found to negatively impact all aspects of functioning, including physical, social, emotional and role functions. Children with arthritis continue to experience clinically significant pain despite adequate doses of disease-modifying antirheumatic drugs and anti-inflammatory agents. The present article reviews the prevalence and nature of pain in JIA, the biopsychosocial factors that contribute to the pain experience, current approaches to assessing pain in this population, and ways of managing both acute and persistent pain using pharmacological, physical and psychological therapies. Finally, new approaches to delivering disease self-management treatment for youth with JIA using the Internet will be outlined.
Assessment; Internet; Juvenile idiopathic arthritis; Management; Pain
As adolescents with hemophilia approach adulthood, they are expected to assume responsibility for their disease management. A bilingual (English and French) Internet-based self-management program, “Teens Taking Charge: Managing Hemophilia Online,” was developed to support adolescents with hemophilia in this transition. This study explored the usability of the website and resulted in refinement of the prototype.
A purposive sample (n=18; age 13–18; mean age 15.5 years) was recruited from two tertiary care centers to assess the usability of the program in English and French. Qualitative observations using a “think aloud” usability testing method and semi-structured interviews were conducted in four iterative cycles, with changes to the prototype made as necessary following each cycle. This study was approved by research ethics boards at each site.
Teens responded positively to the content and appearance of the website and felt that it was easy to navigate and understand. The multimedia components (videos, animations, quizzes) were felt to enrich the experience. Changes to the presentation of content and the website user-interface were made after the first, second and third cycles of testing in English. Cycle four did not result in any further changes.
Overall, teens found the website to be easy to use. Usability testing identified end-user concerns that informed improvements to the program. Usability testing is a crucial step in the development of Internet-based self-management programs to ensure information is delivered in a manner that is accessible and understood by users.
Usability testing; Internet; Patient education; Self-management; Adolescent; Hemophilia
The goal of this longitudinal study was to examine the associations among psychological factors and pain reports of children and their parents over the 12 month period after pediatric surgery.
Materials and methods
Included in the study were 83 children aged 8–18 years undergoing major surgery. In each case, the child and one of their parents completed measures of pain intensity and unpleasantness, psychological function, and functional disability at 48–72 hours, 2 weeks (child only), 6 months, and 12 months after surgery.
The strength of the correlation coefficients between the psychological measures of the parent and their child increased significantly over time. There was a fair level of agreement between parent ratings of child acute and chronic pain (6 months after surgery) and the child’s actual ratings. Parent and child pain anxiety scores 48–72 hours after surgery interacted significantly to predict pain intensity, pain unpleasantness, and functional disability levels 2 weeks after discharge from hospital. Parent pain catastrophizing scores 48–72 hours after surgery predicted child pain intensity reports 12 months later.
These results raise the possibility that as time from surgery increases, parents exert greater and greater influence over the pain response of their children, so that by 12 months postsurgery mark, parent pain catastrophizing (measured in the days after surgery) is the main risk factor for the development of postsurgical pain chronicity.
pain anxiety; pain catastrophizing; children; parental risk factors; postsurgical pain
We examined the usability of smartphones for accessing a web-based e-Diary for self-monitoring symptoms in children and adolescents with sickle cell disease (SCD). One group of participants (n=10; mean age 13.1 ± 2.4 years; 5M; 5F) responded to questions using pre-completed paper-based measures. A second group (n=21; mean age 13.4 ± 2.4 years; 10M;11F) responded based on pain and symptoms they experienced over the previous 12 hours. The e-Diary was completed with at least 80% accuracy when compared to paper-based measures. Symptoms experienced over the previous 12 hours included feeling tired (33.3%), headache (28.6%), coughing (23.8%), lack of energy/fatigue (19.0%), yellowing of the eyes (19.0%), pallor (19.0%), irritability (19.0%), stiffness in joints (19.0%), general weakness (14.3%), and pain (14.3%), rating on average as 2.0 ± 1.7 (on 0 to 10 scale). Overall, sleep was good (8.1 ± 1.4 on the 0 to 10 scale). In conclusion, children with SCD were able to use smartphones to access a web-based e-Diary for reporting pain and symptoms. Smartphones may improve self-reporting of symptoms and communication between patients and their health care providers, who may consequently be able to improve pain and symptom management in children and adolescents with SCD in a timely manner.
e-Diary; pain; symptoms; children and adolescents; sickle cell disease
Painful vaso-occlusive crisis (VOC) is the most common reason for hospitalization in children with sickle cell disease.
To benchmark pain outcomes in sickle cell disease, including process outcomes (eg, pain assessment and documentation practices, pain management interventions) and clinical outcomes (eg, pain intensity over hospital stay), to identify areas for improvement.
A retrospective study was conducted on electronic charts of children hospitalized with a primary diagnosis of VOC between July 2007 and August 2008.
A convenience sample of 50 admissions was used. In terms of clinical outcomes, patients presented to the emergency department with an initial median pain intensity of 9/10 (interquartile range 8/10 to 10/10). Forty-three per cent had not used opioids for pain relief at home. The mean (± SD) length of stay was 4.0±2.3 days. For most patients, median scores for highest daily pain intensity remained moderate to high throughout hospitalization, although scores did decrease significantly per day of hospitalization. In terms of process outcomes, pain intensity was assessed according to hospital standards on 25% of days in both the emergency department and the ward. There was no discrepancy between prescribed and administered opioid doses and medication use. In 95% of cases, strong opioid use was in a subtherapeutic or low therapeutic dosage range.
The results showed three areas to target for improvement: improved pain assessment and documentation using valid pain tools; more aggressive multimodal management for peak VOC pain; and better education and support for pain management at home. Further studies are required to evaluate optimal pain treatment practices.
Children; Pain assessment; Pain management; Sickle cell disease
A previous audit performed at a tertiary/quaternary pediatric hospital in Toronto, Ontario, demonstrated suboptimal assessment and treatment of children’s pain. Knowledge translation (KT) initiatives (education, reminders, audit and feedback) were implemented to address identified care gaps; however, the impact is unknown.
To determine the impact of KT initiatives on pain outcomes including process outcomes (eg, pain assessment and management practices) and clinical outcomes (eg, pain prevalence and intensity); and to benchmark additional pain practices, particularly opioid administration and painful procedures.
Medical records at The Hospital for Sick Children (Toronto, Ontario) were reviewed on a single day in September 2007. Pain assessment and management practices, and pain prevalence and intensity in the preceding 24 h were recorded on a standardized data collection form. Where possible, pain outcomes were compared with previous audit results.
Records of 265 inpatients were audited. Sixty-three per cent of children underwent a documented pain assessment compared with 27% in an audit conducted previously (P<0.01). Eighty-three per cent of children with documented pain received at least one pain management intervention. Overall, 51% of children received pharmacological therapy, and 15% received either a psychological or physical pain-relieving intervention. Of those assessed, 44% experienced pain in the previous 24 h versus 66% in the previous audit (P<0.01). Fewer children experienced severe pain compared with the first audit (8.7% versus 26.1%; P<0.01). One-third of children received opioids; 19% of these had no recorded pain assessment. Among 131 children who underwent a painful procedure, 21% had a concurrent pain assessment. Painful procedures were accompanied by a pain-relieving intervention in 12.5% of cases.
Following KT initiatives, significant improvements in pain processes (pain assessment documentation and pain management interventions) and clinical outcomes (pain prevalence, pain intensity) were observed. Further improvements are recommended, specifically with respect to procedural pain practices and opioid utilization patterns.
Knowledge translation; Pain assessment; Pain intensity; Pain management; Pain prevalence; Painful procedures
Pain is one of the most common and distressing symptoms reported by adolescents with cancer. Despite advancements in pain assessment and management research, pain due to cancer and/or its treatments continues to be poorly managed. Our research group has developed a native iPhone application (app) called Pain Squad to tackle the problem of poorly managed pain in the adolescent with cancer group. The app functions as an electronic pain diary and is unique in its ability to collect data on pain intensity, duration, location, and the impact pain has on an adolescent’s life (ie, relationships, school work, sleep, mood). It also evaluates medications and other physical and psychological pain management strategies used. Users are prompted twice daily at configurable times to complete 20 questions characterizing their pain and the app transmits results to a database for aggregate reporting through a Web interface. Each diary entry represents a pain case filed by an adolescent with cancer and a reward system (ie, moving up through law-enforcement team ranks, built-in videotaped acknowledgements from fictitious officers) encourages consistent use of the diary.
Our objective was to design, develop, and test the usability, feasibility, compliance, and satisfaction of a game-based smartphone pain assessment tool for adolescents with cancer.
We used both low- and high-fidelity qualitative usability testing with qualitative semi-structured, audio-taped interviews and iterative cycles to design and refine the iPhone based Pain Squad app. Qualitative thematic analysis of interviews using constant comparative methodology captured emergent themes related to app usability. Content validity was assessed using question importance-rating surveys completed by participants. Compliance and satisfaction data were collected following a 2-week feasibility trial where users were alarmed to record their pain twice daily on the app.
Thematic analysis of usability interviews showed the app to be appealing overall to adolescents. Analyses of both low- and high-fidelity testing resulted in minor revisions to the app to refine the theme and improve its usability. Adolescents resoundingly endorsed the game-based nature of the app and its virtual reward system. The importance of app pain diary questions was established by content validity analysis. Compliance with the app, assessed during feasibility testing, was high (mean 81%, SD 22%) and adolescents from this phase of the study found the app likeable, easy to use, and not bothersome to complete.
A multifaceted usability approach demonstrated how the Pain Squad app could be made more appealing to children and adolescents with cancer. The game-based nature and built-in reward system of the app was appealing to adolescents and may have resulted in the high compliance rates and satisfaction ratings observed during clinical feasibility testing.
neoplasms; pain; child; adolescent; youth; cellular phone; game
The goals of this study were to examine the trajectory of pediatric chronic postsurgical pain (CPSP) over the first year after surgery and to identify acute postsurgical predictors of CPSP.
Eighty-three children aged 8–18 years (mean 13.8, standard deviation 2.4) who underwent major orthopedic or general surgery completed pain and pain-related psychological measures at 48–72 hours, 2 weeks (pain anxiety and pain measures only), and 6 and 12 months after surgery.
Results showed that 1 year after surgery, 22% of children developed moderate to severe CPSP with minimal functional disability. Children who reported a Numeric Rating Scale pain-intensity score ≥ 3 out of 10 two weeks after discharge were more than three times as likely to develop moderate/severe CPSP at 6 months and more than twice as likely to develop moderate/severe CPSP at 12 months than those who reported a Numeric Rating Scale pain score < 3 (6-month relative risk 3.3, 95% confidence interval 1.2–9.0 and 12-month relative risk 2.5, 95% confidence interval 0.9–7.5). Pain unpleasantness predicted the transition from acute to moderate/severe CPSP, whereas anxiety sensitivity predicted the maintenance of moderate/severe CPSP from 6 to 12 months after surgery.
This study highlights the prevalence of pediatric CPSP and the role played by psychological variables in its development/maintenance. Risk factors that are associated with the development of CPSP are different from those that maintain it.
chronic postsurgical pain; children; adolescents; anxiety sensitivity
Post-surgical pain is prevalent in children, yet is significantly understudied. The goals of this study were to examine gender differences in pain outcomes and pain-related psychological constructs postoperatively and to identify pain-related psychological correlates of acute post-surgical pain (APSP) and predictors of functional disability 2 weeks after hospital discharge.
Eighty-three children aged 8–18 (mean 13.8 ± 2.4) years who underwent major orthopedic or general surgery completed pain and pain-related psychological measures 48–72 hours and 2 weeks after surgery.
Girls reported higher levels of acute postoperative anxiety and pain unpleasantness compared with boys. In addition, pain anxiety was significantly associated with APSP intensity and functional disability 2 weeks after discharge, whereas pain catastrophizing was associated with APSP unpleasantness.
These results highlight the important role played by pain-related psychological factors in the experience of pediatric APSP by children and adolescents.
acute post-surgical pain; children; adolescents; pain anxiety; pain catastrophizing
A significant number of patients continue to experience unrelieved, moderate-to-severe postoperative pain, which can have cardiovascular, pulmonary, gastrointestinal and immunological consequences. Poor pain assessment skills and many common misconceptions about pain among health care professionals (HCPs) are among the factors contributing to inadequate postoperative pain assessment and relief. Although standardized patients (SP) have been successfully used as a simulation method to improve HCP’s assessment skills, not all centres have SP programs. Accordingly, this pilot study examined the efficacy of an alternative simulation method – deteriorating patient simulation – for improving HCP’s pain assessment skills.
Pain-related misbeliefs among health care professionals (HCPs) are common and contribute to ineffective postoperative pain assessment. While standardized patients (SPs) have been effectively used to improve HCPs’ assessment skills, not all centres have SP programs. The present equivalence randomized controlled pilot trial examined the efficacy of an alternative simulation method – deteriorating patient-based simulation (DPS) – versus SPs for improving HCPs’ pain knowledge and assessment skills.
Seventy-two HCPs were randomly assigned to a 3 h SP or DPS simulation intervention. Measures were recorded at baseline, immediate postintervention and two months postintervention. The primary outcome was HCPs’ pain assessment performance as measured by the postoperative Pain Assessment Skills Tool (PAST). Secondary outcomes included HCPs knowledge of pain-related misbeliefs, and perceived satisfaction and quality of the simulation. These outcomes were measured by the Pain Beliefs Scale (PBS), the Satisfaction with Simulated Learning Scale (SSLS) and the Simulation Design Scale (SDS), respectively. Student’s t tests were used to test for overall group differences in postintervention PAST, SSLS and SDS scores. One-way analysis of covariance tested for overall group differences in PBS scores.
DPS and SP groups did not differ on post-test PAST, SSLS or SDS scores. Knowledge of pain-related misbeliefs was also similar between groups.
These pilot data suggest that DPS is an effective simulation alternative for HCPs’ education on postoperative pain assessment, with improvements in performance and knowledge comparable with SP-based simulation. An equivalence trial to examine the effectiveness of deteriorating patient-based simulation versus standardized patients is warranted.
Pain assessment; Randomized controlled trial; Simulation
Complementary and alternative medicine (CAM) is commonly used by children, but estimates of that use vary widely partly due to the range of questionnaires used to assess CAM use. However, no studies have attempted to appraise measurement properties of these questionnaires. The aim of this systematic review was to critically appraise and summarize measurement properties of questionnaires of CAM use in pediatrics.
A search strategy was implemented in major electronic databases in March 2011 and conference websites, scientific journals and experts were consulted. Studies were included if they mentioned a questionnaire assessing the prevalence of CAM use in pediatrics. Members of the team independently rated the methodological quality of the studies (using the COSMIN checklist) and measurement properties of the questionnaires (using the Terwee and Cohen criteria).
A total of 96 CAM questionnaires were found in 104 publications. The COSMIN checklist showed that no studies reported adequate methodological quality. The Terwee criteria showed that all included CAM questionnaires had indeterminate measurement properties. According to the Cohen score, none were considered to be a well-established assessment, two approached the level of a well-established assessment, seven were promising assessments and the remainder (n = 87) did not reach the score’s minimum standards.
None of the identified CAM questionnaires have been thoroughly validated. This systematic review highlights the need for proper validation of CAM questionnaires in pediatrics, which may in turn lead to improved research and knowledge translation about CAM in clinical practice.
Pain in children with rheumatic conditions such as arthritis is common. However, there is currently no standardized method for the assessment of this pain in children presenting to pediatric rheumatologists. A more consistent and comprehensive approach is needed to effectively assess, treat and monitor pain outcomes in the pediatric rheumatology population. The objectives of this study were to: (a) develop consensus regarding a standardized pain assessment tool for use in pediatric rheumatology practice and (b) test the feasibility of three mediums (paper, laptop, and handheld-based applications) for administration.
In Phase 1, a 2-stage Delphi technique (pediatric rheumatologists and allied professionals) and consensus meeting (pediatric pain and rheumatology experts) were used to develop the self- and proxy-report pain measures. In Phase 2, 24 children aged 4-7 years (and their parents), and 77 youth, aged 8-18 years, with pain, were recruited during routine rheumatology clinic appointments and completed the pain measure using each medium (order randomly assigned). The participant's rheumatologist received a summary report prior to clinical assessment. Satisfaction surveys were completed by all participants. Descriptive statistics were used to describe the participant characteristics using means and standard deviations (for continuous variables) and frequencies and proportions (for categorical variables)
Completing the measure using the handheld device took significantly longer for youth (M = 5.90 minutes) and parents (M = 7.00 minutes) compared to paper (M = 3.08 and 2.28 minutes respectively p = 0.001) and computer (M = 3.40 and 4.00 minutes respectively; p < 0.001). There was no difference in the number of missed responses between mediums for children or parents. For youth, the number of missed responses varied across mediums (p = 0.047) with the greatest number of missed responses occurring with the handheld device. Most children preferred the computer (65%, p = 0.008) and youth reported no preference between mediums (p = 0.307). Most physicians (60%) would recommend the computer summary over the paper questionnaire to a colleague.
It is clinically feasible to implement a newly developed consensus-driven pain measure in pediatric rheumatology clinics using electronic or paper administration. Computer-based administration was most efficient for most users, but the medium employed in practice may depend on child age and economic and administrative factors.
Pain; Rheumatic diseases; Pediatrics; Feasibility studies; Pain measurement
Disturbances in family functioning have been identified in youth with chronic pain and are associated with worse child physical and psychological functioning. Assessment measures of family functioning used in research and clinical settings vary. This systematic review summarizes studies investigating relationships among family functioning, pain and pain-related disability in youth with chronic pain. Sixteen articles were reviewed. All studies were cross-sectional, seven utilized between-group comparisons (chronic pain versus healthy/control) and twelve examined within-group associations among family functioning, pain and/or pain-related disability. Studies represented youth with various pain conditions (e.g., headache, abdominal pain, fibromyalgia) aged 6 – 20 years. Findings revealed group differences in family functioning between children with chronic pain and healthy controls in five of seven studies. Significant associations emerged among family variables and pain-related disability in six of nine studies with worse family functioning associated with greater child disability; relationships between family functioning and children’s pain were less consistent. Different patterns of results emerged depending on family functioning measure used. Overall, findings showed that families of children with chronic pain generally have poorer family functioning than healthy populations, and that pain-related disability is more consistently related to family functioning than pain intensity.
Child; adolescent; chronic pain; disability; family functioning
Immunization injections are the most common painful medical procedures experienced during childhood, yet there is a discrepancy between recommendations for the effective use of topical anesthetics to reduce vaccine injection pain and actual practice.
To improve our understanding of mothers’ experiences and practices regarding their children’s routine immunizations.
Adopting an interpretive, naturalistic paradigm, semi-structured interviews were conducted with 15 mothers to examine their perceptions and experiences of their children’s immunization pain and pain management.
The findings demonstrated three main themes: attitudes toward immunization pain, immunization pain management and physicians as sources of information. Participants described feeling distressed while their children were being immunized, but most managed these difficulties by focusing on the benefits of immunization and by minimizing or justifying the pain. All of the participants used non-pharmacological techniques to manage immunization injection pain. Few mothers were aware of the availability of topical anesthetics. When participants did use pharmacological analgesic approaches, oral analgesics were most likely to be used for prophylaxis and treatment of fever, and participants were unaware of evidence-based approaches to managing pain. Participants viewed their physicians as trusted sources of information, and the majority said that they would likely use a topical anesthetic in the future if recommended or approved by their physician.
The present findings provide direction for future knowledge translation activities to enhance the knowledge of mothers and clinicians regarding pain during immunization injections and its effective management.
Child; Immunization; Infant; Pain management; Qualitative research; Topical anesthetics
Children being cared for in hospital undergo multiple painful procedures daily. However, little is known about the frequency of these procedures and associated interventions to manage the pain. We undertook this study to determine, for children in Canadian hospitals, the frequency of painful procedures, the types of pain management interventions associated with painful procedures and the influence of the type of hospital unit on procedural pain management.
We reviewed medical charts for infants and children up to 18 years of age who had been admitted to 32 inpatient units at eight Canadian pediatric hospitals between October 2007 and April 2008. We recorded all of the painful procedures performed and the pain management interventions that had been implemented in the 24-hour period preceding data collection. We performed descriptive and comparative (analysis of variance, χ2) analyses.
Of the 3822 children included in the study, 2987 (78.2%) had undergone at least one painful procedure in the 24-hour period preceding data collection, for a total of 18 929 painful procedures (mean 6.3 per child who had any painful procedure). For 2334 (78.1%) of the 2987 children who had a painful procedure, a pain management intervention in the previous 24 hours was documented in the chart: 1980 (84.8%) had a pharmacologic intervention, 609 (26.1%) a physical intervention, 584 (25.0%) a psychologic intervention and 753 (32.3%) a combination of interventions. However, for only 844 (28.3%) of the 2987 children was one or more pain management interventions administered and documented specifically for a painful procedure. Pediatric intensive care units reported the highest proportion of painful procedures and analgesics administered.
For less than one-third of painful procedures was there documentation of one or more specific pain management interventions. Strategies for implementing changes in pain management must be tailored to the type of hospital unit.
Peer relationships during childhood and adolescence are acknowledged to be negatively impacted by chronic pain; however, to date there has been no synthesis of this literature.
To systematically review existing literature describing the social functioning and peer relationships in children and adolescents with recurrent or continuous chronic pain.
Articles on peer relationship factors studied in samples of children and adolescents with chronic pain published in English or French were identified using EMBASE, Medline, CINAHL and PsycINFO. Two independent reviewers performed initial screenings using study titles and abstracts, and reviewed each eligible article in full.
Of 1740 published papers yielded by the search, 42 articles met the inclusion criteria and were included in the present review. Nine studies had peer relationship investigation as the primary purpose of the study; the remaining 33 examined peer relationships as part of a broader study. A range of specific and more general measures was used to examine peer relationships. Across studies, children and adolescents with chronic pain were reported to have fewer friends, be subjected to more peer victimization, and were viewed as more isolated and less likeable than healthy peers.
Children and adolescents with chronic pain have peer relationship deficiencies. However, the majority of studies to date measure peer relationships as part of a broader study and, thus, little attention has been paid specifically to peer relationships in this group. Additional research examining the quality of peer relationships of children and adolescents with chronic pain, as well as development of measures specifically designed to assess these relationships, is needed.
Adolescent; Chronic pain; Pediatric pain; Peer relationships; Systematic review
A new bilingual (English and French) Internet-based self-management program, Teens Taking Charge: Managing Arthritis Online, for adolescents with arthritis and their parents was developed following a needs assessment.
This study explored the usability (user performance and satisfaction) of the self-management program for youth with juvenile idiopathic arthritis (JIA) and their parents to refine the health portal prototype.
A qualitative study design with semi-structured, audio taped interviews and observation by a trained observer was undertaken with two iterative cycles to determine the usability (ease of use, efficiency, errors, and user satisfaction) of the user interface and content areas of the intervention. A purposive sample of English-speaking (n = 11; mean age = 15.4, standard deviation [SD] 1.7) and French-speaking (n = 8; mean age = 16.0, SD 1.2) adolescents with JIA and one of their respective parents/caregivers were recruited from 2 Canadian tertiary care centers. Descriptive statistics and simple content analyses were used to organize data into categories that reflected the emerging usability themes.
All of the participants had access to a computer/Internet at home; however, adolescents were more comfortable using the computer/Internet than their parents. Adolescents and parents provided similar as well as differing suggestions on how the website user interface could be improved in terms of its usability (navigation; presentation and control usage errors; format and layout; as well as areas for further content development). There were no major differences in usability issues between English- and French-speaking participants. Minor changes to the website user interface were made and tested in a second cycle of participants. No further usability problems were identified in the second iterative cycle of testing. Teens and parents responded positively to the appearance and theme of the website (ie, promoting self-management) and felt that it was easy to navigate, use, and understand. Participants felt that the content was appropriate and geared to meet the unique needs of adolescents with JIA and their parents as well as English- and French-speaking families. Many participants responded that the interactive features (discussion board, stories of hope, and video clips of youth with JIA) made them feel supported and “not alone” in their illness.
We describe the usability testing of a self-management health portal designed for English- and French-speaking youth with arthritis and their parents, which uncovered several usability issues. Usability testing is a crucial step in the development of self-management health portals to ensure that the various end users (youth and parents) have the ability to access, understand, and use health-related information and services that are delivered via the Internet and that they are delivered in an efficient, effective, satisfying, and culturally competent manner.
Juvenile idiopathic arthritis; Internet; usability testing; self-management; adolescent
Current methods for evaluating chronic pain in children suffer from methodological problems. Real-time data capture approaches using electronic diaries have been proposed as a new standard for pain measurement. However, there is limited information available regarding the development, feasibility and validity of these approaches in children. The present paper reviews problems with current measures; rationale for developing real-time data capture approaches using electronic diaries; mechanics of developing electronic pain diaries; current evidence regarding their usability, feasibility and validity; and discusses future directions for research in this area.
Child; Electronic diary; Pain; Real-time data capture
To examine the role of health care professionals in multidisciplinary pain treatment facilities (MPTF) for the treatment of chronic pain across Canada.
MPTF were defined as clinics that advertised specialized multidisciplinary services for the diagnosis and management of chronic pain, and had staff from a minimum of three different health care disciplines (including at least one medical specialty) available and integrated within the facility. Administrative leaders at eligible MPTF were asked to complete a detailed questionnaire on their infrastructure as well as clinical, research, teaching and administrative activities.
A total of 102 MPTF returned the questionnaires. General practitioners, anesthesiologists and physiatrists were the most common types of physicians integrated in the MPTF (56%, 51% and 32%, respectively). Physiotherapists, psychologists and nurses were the most common nonphysician professionals working within these MPTF (75%, 68% and 57%, respectively), but 33% to 56% of them were part-time staff. Only 77% of the MPTF held regular interdisciplinary meetings to discuss patient management, and 32% were staffed with either a psychologist or psychiatrist. The three most frequent services provided by physiotherapists were patient assessment, individual physiotherapy or exercise, and transcutaneous electrical nerve stimulation. The three most common services provided by psychologists were individual counselling, cognitive behavioural therapy and psychodynamic therapy. The major roles of nurses were patient assessment, assisting in interventional procedures and patient education.
Different health care professionals play a variety of important roles in MPTF in Canada. However, few of them are involved on a full-time basis and the extent to which pain is assessed and treated in a truly multidisciplinary manner is questionable.
Health care professional; Multidisciplinary pain centre; Nursing; Physicians; Psychologist; Physiotherapist
Hospitalized infants undergo multiple, repeated painful procedures. Despite continued efforts to prevent procedural pain and improve pain management, clinical guidelines and standards frequently do not reflect the highest quality evidence from systematic reviews.
To critically appraise all systematic reviews on the effectiveness of procedural pain interventions in hospitalized infants.
A structured review was conducted on published systematic reviews and meta-analyses of pharmacological and nonpharmacological interventions of acute procedural pain in hospitalized infants. Searches were completed in the Cochrane Database of Systematic Reviews, MEDLINE, EMBASE, CINAHL and PsycINFO. Two reviewers independently selected articles for review and rated the methodological quality of the included reviews using a validated seven-point quality assessment measure. Any discrepancies were resolved by a third reviewer.
Of 1469 potential systematic reviews on interventions for painful procedures in hospitalized infants, 11 high-quality reviews were included in the analysis. Pharmacological interventions supported by research evidence included premedication for intubation, dorsal penile nerve block and EMLA (AstraZeneca Canada, Inc) for circumcision, and sucrose for single painful procedures. Non-nutritive sucking, swaddling, holding, touching, positioning, facilitative tucking, breast feeding and supplemental breast milk were nonpharmacological interventions supported for procedural pain.
There is a growing number of high-quality reviews supporting procedural pain management in infants. Ongoing research of single, repeated and combined pharmacological and nonpharmacological interventions is required to provide the highest quality evidence to clinicians for decision-making on optimal pain management.
Acute pain; Infants; Pain management; Systematic review
Current approaches to evaluating pain in children with chronic arthritis suffer from methodological problems. A real-time data capture approach using electronic diaries has been proposed as a new standard for pain measurement. However, there is limited information available regarding the development and feasibility of this approach in children.
The aim of the present study was to pilot test the e-Ouch electronic pain diary in terms of compliance and acceptability in adolescents with arthritis to further refine the prototype.
A descriptive study design – with two iterative phases of testing, modifying the prototype and retesting – was used. A purposive sample of 13 adolescents with mild to severe pain and disability was drawn from a large rheumatology clinic in a university-affiliated pediatric tertiary care centre in Canada over a four-week period in December 2004. Participants were signalled with an alarm to use the diary three times per day for a two-week period. Adolescents completed an electronic diary acceptability questionnaire.
Overall mean compliance rates for phases 1 and 2 were 72.9% and 70.5%, respectively. Compliance was affected by the timing of data collection and technical difficulties. Children rated the diary as highly acceptable and easy to use. Phase 1 testing revealed aspects of the software program that affected compliance, which were subsequently altered and tested in phase 2. No further technical difficulties arose in phase 2 testing.
Feasibility testing is a crucial first step in the development of electronic pain measures before use in clinical and research practice.
Adolescents; Electronic diary; Juvenile idiopathic arthritis; Pain; Pilot testing
Acute pain is a common experience for hospitalized children. Despite mounting research on treatments for acute procedure-related pain, it remains inadequately treated.
To critically appraise all systematic reviews on the effectiveness of acute procedure-related pain management in hospitalized children.
Published systematic reviews and meta-analyses on pharmacological and nonpharmacological management of acute procedure-related pain in hospitalized children aged one to 18 years were evaluated. Electronic searches were conducted in the Cochrane Database of Systematic Reviews, Medline, EMBASE, the Cumulative Index to Nursing and Allied Health Literature and PsycINFO. Two reviewers independently selected articles for review and assessed their quality using a validated seven-point quality assessment measure. Any disagreements were resolved by a third reviewer.
Of 1469 published articles on interventions for acute pain in hospitalized children, eight systematic reviews met the inclusion criteria and were included in the analysis. However, only five of these reviews were of high quality. Critical appraisal of pharmacological pain interventions indicated that amethocaine was superior to EMLA (AstraZeneca Canada Inc) for reducing needle pain. Distraction and hypnosis were nonpharmacological interventions effective for management of acute procedure-related pain in hospitalized children.
There is growing evidence of rigorous evaluations of both pharmacological and nonpharmacological strategies for acute procedure-related pain in children; however, the evidence underlying some commonly used strategies is limited. The present review will enable the creation of a future research plan to facilitate clinical decision making and to develop clinical policy for managing acute procedure-related pain in children.
Acute pain, Children; Pain management; Systematic review
As medical costs escalate, health care resources must be prioritized. In this context, there is an increasing need for benchmarks and best practices in wait time management. In December 2005, the Canadian Pain Society struck a Task Force to identify benchmarks for acceptable wait times for treatment of chronic pain. The task force mandate included a systematic review and survey to identify national or international wait time benchmarks for chronic pain, proposed or in use, along with a review of the evidence upon which they are based. An extensive systematic review of the literature and a survey of International Association for the Study of Pain Chapter Presidents and key informants has identified that there are no established benchmarks or guidelines for acceptable wait times for the treatment of chronic pain in use in the world. In countries with generic guidelines or wait time standards that apply to all outpatient clinics, there have been significant challenges faced by pain clinics in meeting the established targets. Important next steps are to ensure appropriate additional research and the establishment of international benchmarks or guidelines for acceptable wait times for the treatment of chronic pain. This will facilitate advocacy for improved access to appropriate care for people suffering from chronic pain around the world.
Benchmarks; Chronic pain; Health outcomes; Pain; Pain clinics; Pain management; Waiting times