Publications by authors named "Keri R Hainsworth"

32 Publications

Circulating inflammatory biomarkers in adolescents: evidence of interactions between chronic pain and obesity.

Pain Rep 2021 1;6(1):e916. Epub 2021 Apr 1.

Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA.

Introduction: The negative effects of chronic pain and obesity are compounded in those with both conditions. Despite this, little research has focused on the pathophysiology in pediatric samples.

Objective: To examine the effects of comorbid chronic pain and obesity on the concentration of circulating inflammatory biomarkers.

Methods: We used a multiple-cohort observational design, with 4 groups defined by the presence or absence of obesity and chronic pain: healthy controls, chronic pain alone, obesity alone, as well as chronic pain and obesity. Biomarkers measured were leptin, adiponectin, leptin/adiponectin ratio (primary outcome), tumor necrosis factor-alpha, interleukin 6, and C-reactive protein (CRP).

Results: Data on 125 adolescents (13-17 years) were analyzed. In females, there was an interaction between chronic pain and obesity such that leptin and CRP were higher in the chronic pain and obesity group than in chronic pain or obesity alone. Within the chronic pain and obesity group, biomarkers were correlated with worsened pain attributes, and females reported worse pain than males. The highest levels of interleukin 6 and CRP were found in youth with elevated weight and functional disability. We conclude that in adolescents, chronic pain and obesity interact to cause dysregulation of the inflammatory system, and this effect is more pronounced in females.

Conclusion: The augmented levels of inflammatory biomarkers are associated with pain and functional disability, and may be an early marker of future pain and disability.
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http://dx.doi.org/10.1097/PR9.0000000000000916DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8104468PMC
April 2021

Advancing the Field of Pain Medicine-Special Issue on Pediatric Pain Management.

Children (Basel) 2021 Mar 6;8(3). Epub 2021 Mar 6.

Department of Psychology, University of Cincinnati, Cincinnati, OH 45221, USA.

Pediatric pain management has made great strides over the past 50 years [...].
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http://dx.doi.org/10.3390/children8030197DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8001934PMC
March 2021

Obesity in Youth with Chronic Pain: Giving It the Seriousness It Deserves.

Pain Med 2021 Jun;22(6):1243-1245

Medical College of Wisconsin, Department of Anesthesiology, Milwaukee, Wisconsin, USA.

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http://dx.doi.org/10.1093/pm/pnab101DOI Listing
June 2021

Investigating the Effects of Cuing Medication Availability on Patient-controlled Analgesia Pump Usage in Pediatric Patients: Results of a Randomized Controlled Trial.

Clin J Pain 2021 01;37(1):1-10

Department of Anesthesiology.

Objectives: The study of patient-controlled analgesia (PCA) behaviors has led to a greater understanding of factors that affect the pain experience. Although PCA behaviors can be influenced by cues to medication availability, no studies have examined the effects of such cues in pediatric populations.

Materials And Methods: This randomized controlled trial examined patient satisfaction with pain management, PCA behaviors, opioid consumption, and state anxiety in a sample of 125 postsurgical children and adolescents (7 to 17 y). Patients were randomized to a "light" group (lockout period status cued by light on the PCA button) or control group (no cues to medication availability).

Results: Although cuing did not affect patient satisfaction with pain management (P=0.11), patients in the light group consumed significantly more opioid than those in the control group (adj. P=0.016). This effect was primarily because of children in the light group (median, 0.019; interquartile range, 0.012 to 0.036 mg/kg/h) consuming more opioid than children (12 y or younger) in control group (median, 0.015; interquartile range, 0.006 to 0.025 mg/kg/h) (P=0.007). In contrast to the control group, for patients in the light group, opioid consumption was unrelated to pain and the proportion of patients with a 1:1 injections:attempts ratio was higher (P<0.001) across the study period.

Discussion: The overall pattern of results suggests that patients in the light group used their PCA in response to the light more than in response to their pain, which likely reflects operant influences on PCA behavior by pediatric patients.
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http://dx.doi.org/10.1097/AJP.0000000000000892DOI Listing
January 2021

Serum soluble urokinase plasminogen activator receptor in adolescents: interaction of chronic pain and obesity.

Pain Rep 2020 Jul-Aug;5(4):e836. Epub 2020 Jul 22.

Department of Anesthesiology, Medical College of Wisconsin and the Jane B. Pettit Pain and Headache Center, Children's Wisconsin, Milwaukee, WI, USA.

Introduction: Obesity in adolescents is increasing in frequency and is associated with short-term and long-term negative consequences that include the exacerbation of co-occurring chronic pain.

Objective: To determine whether the interaction between chronic pain and obesity would be reflected in changes in serum soluble urokinase plasminogen activator receptor (suPAR) concentrations, a novel marker of systemic inflammation associated with obesity, insulin resistance, and cardiovascular disease.

Methods: We measured serum suPAR levels in 146 adolescent males and females with no pain or obesity (healthy controls; n = 40), chronic pain with healthy weight (n = 37), obesity alone (n = 41), and the combination of chronic pain and obesity (n = 28).

Results: Serum suPAR (median [interquartile range]) was not increased by chronic pain alone (2.2 [1.8-2.4] ng/mL) or obesity alone (2.2 [2.0-2.4] ng/mL) but was increased significantly with the combination of chronic pain and obesity (2.4 [2.1-2.7] ng/mL; < 0.019). This finding confirms the proposition that pain and obesity are inflammatory states that display a classic augmenting interaction.

Conclusion: We propose that measurement of serum suPAR can be added to the armamentarium of serum biomarkers useful in the evaluation of mechanisms of inflammation in adolescent obesity and chronic pain.
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http://dx.doi.org/10.1097/PR9.0000000000000836DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7382552PMC
July 2020

Quantitative Sensory Testing in Adolescents with Co-occurring Chronic Pain and Obesity: A Pilot Study.

Children (Basel) 2020 Jun 2;7(6). Epub 2020 Jun 2.

Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI 53226, USA.

Factors such as gender, ethnicity, and age affect pain processing in children and adolescents with chronic pain. Although obesity has been shown to affect pain processing in adults, almost nothing is known about pediatric populations. The aim of this pilot study was to explore whether obesity alters sensory processing in adolescents with chronic pain. Participants were recruited from a chronic pain clinic (Chronic Pain (CP), = 12 normal weight; Chronic Pain + Obesity (CPO), = 19 overweight/obesity) and from an obesity clinic (Obesity alone (O), = 14). The quantitative sensory testing protocol included assessments of thermal and mechanical pain thresholds and perceptual sensitization at two sites with little adiposity. The heat pain threshold at the hand was significantly higher in the CPO group than in either the CP or O groups. Mechanical pain threshold (foot) was significantly higher in the CPO group than the CP group. No differences were found on tests of perceptual sensitization. Correlations between experimental pain and clinical pain parameters were found for the CPO group, but not for the CP group. This preliminary study provides important lessons learned for subsequent, larger-scale studies of sensory processing for youth with co-occurring chronic pain and obesity.
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http://dx.doi.org/10.3390/children7060055DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7346135PMC
June 2020

Barriers to Pediatric Pain Management: A Brief Report of Results from a Multisite Study.

Pain Manag Nurs 2019 08 15;20(4):305-308. Epub 2019 May 15.

Jane B. Pettit Pain and Headache Center, Children's Hospital of Wisconsin, Milwaukee, Wisconsin; Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin.

Background: Pain management is essential for the care of hospitalized children. Although multiple barriers have been identified that interfere with nurses' ability to provide optimal pain management, it is not known how pervasive are these barriers across the United States.

Aims: This study is the third in a series of studies examining barriers to pediatric pain management. The aim of this study was to examine barriers in different organizations using the same tool during the same period of time.

Settings/participants: A sample of 808 nurses from three pediatric teaching hospitals responded to a survey addressing barriers to optimal pain management for children.

Results: Barriers unanimously identified as being most significant included inadequate or insufficient physician medication orders, insufficient time allowed to premedicate before procedures, insufficient premedication orders before procedures, and low priority given to pain management by medical staff.

Conclusions: Barriers identified as the most and least significant were similar regardless of hospital location. Revealing similar barriers across multiple pediatric hospitals provides direction for nurses trying to provide solutions to these pain management barriers.
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http://dx.doi.org/10.1016/j.pmn.2019.01.008DOI Listing
August 2019

A Pilot Study of Iyengar Yoga for Pediatric Obesity: Effects on Gait and Emotional Functioning.

Children (Basel) 2018 Jul 4;5(7). Epub 2018 Jul 4.

Jane B. Pettit Pain and Headache Center, Department of Anesthesiology and Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI 53226, USA.

Obesity negatively impacts the kinematics and kinetics of the lower extremities in children and adolescents. Although yoga has the potential to provide several distinct benefits for children with obesity, this is the first study to examine the benefits of yoga for gait (primary outcome) in youths with obesity. Secondary outcomes included health-related quality of life (HRQoL), physical activity, and pain. Feasibility and acceptability were also assessed. Nine youths (11⁻17 years) participated in an eight-week Iyengar yoga intervention (bi-weekly 1-h classes). Gait, HRQOL (self and parent-proxy reports), and physical activity were assessed at baseline and post-yoga. Pain was self-reported at the beginning of each class. Significant improvements were found in multiple gait parameters, including hip, knee, and ankle motion and moments. Self-reported and parent-proxy reports of emotional functioning significantly improved. Time spent in physical activity and weight did not change. This study demonstrates that a relatively brief, non-invasive Iyengar yoga intervention can result in improved malalignment of the lower extremities during ambulation, as well as in clinically meaningful improvements in emotional functioning. This study extends current evidence that supports a role for yoga in pediatric obesity.
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http://dx.doi.org/10.3390/children5070092DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6068554PMC
July 2018

On the Difficulties of Studying Pain Management in Individuals with Developmental Delay-Response.

Pain Med 2018 07;19(7):1504-1505

Division of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin.

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http://dx.doi.org/10.1093/pm/pny061DOI Listing
July 2018

Parent/Nurse-Controlled Analgesia Compared with Intravenous PRN Opioids for Postsurgical Pain Management in Children with Developmental Delay: A Randomized Controlled Trial.

Pain Med 2018 04;19(4):742-752

Jane B. Pettit Pain and Headache Center, Children's Hospital of Wisconsin, Milwaukee, Wisconsin.

Objectives: The aim of this study was to conduct a randomized, controlled comparison of outcomes associated with parent/nurse-controlled analgesia (PNCA), with and without a basal (background) opioid infusion, with intravenous (IV) opioids intermittently administered by a nurse on an "as needed" basis (IV PRN) for postoperative pain management in children with developmental delay (DD).

Methods: Participants included children with DD expected to require IV opioids for at least 24 postoperative hours. Patients were randomized to one of three groups: PNCA with a basal infusion, PNCA without a basal infusion, or IV PRN opioids. Demographics, pain scores, opioid consumption, and frequency of side effects were collected beginning 12 hours after emerging from anesthesia to decrease the impact of anesthetic agents on outcomes.

Results: The 81 participants (median = 12.0, 9.0-15.0 years) were primarily Caucasian (74%) males (58%), with severe DD (69%) having spinal surgery (41%). The proportion of patients in each group with pain scores ≤3 vs ≥ 4 revealed no between-group differences in any epoch (P = 0.09-0.27). Patients in the PNCA with a basal group consumed significantly more opioid (median = 0.03 mg/kg/h morphine equivalents, 0.02-0.03 mg/kg/h) than the PNCA without a basal infusion. No difference was found between the PNCA without a basal (median = 0.01 mg/kg/h morphine equivalents, 0.00-0.02 mg/kg/h) and the PRN groups (median = 0.01 mg/kg/h morphine equivalents, 0.01-0.02 mg/kg/h). There were no statistically significant differences in side effects, with the exception that more children in the PNCA group required supplemental oxygen (P = 0.05).

Conclusions: Results suggest there may be no advantage to PNCA over PRN opioids in this patient population after the first 12 postoperative hours with regard to pain scores, opioid consumption, or side effects.
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http://dx.doi.org/10.1093/pm/pnx257DOI Listing
April 2018

Behavioral Changes in Children After Emergency Department Procedural Sedation.

Acad Emerg Med 2018 03 13;25(3):267-274. Epub 2017 Nov 13.

Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI.

Objective: The purpose of this study was to determine the proportion of children undergoing procedural sedation for fracture reduction in the emergency department (ED) observed to experience negative postdischarge behaviors. Predictors of negative behaviors were evaluated, including anxiety.

Methods: This was a prospective cohort study of children receiving intravenous ketamine sedation for ED fracture reduction. The child's anxiety prior to sedation was measured with the Modified Yale Preoperative Anxiety Scale. Negative behavioral changes were measured with the Post-Hospitalization Behavior Questionnaire 1 to 2 weeks after discharge. Descriptive statistics and odds ratios (ORs) were calculated. Chi-square test was used for comparisons between groups. Multivariable logistic regression models evaluated predictors of negative behavioral change after discharge.

Results: Ninety-seven patients were enrolled; 82 (85%) completed follow-up. Overall, 33 (40%) children were observed to be highly anxious presedation and 18 (22%) had significant negative behavior changes after ED discharge. Independent predictors for negative behaviors were high anxiety (OR = 9.0, 95% confidence interval [CI] = 2.3-35.7) and nonwhite race (OR = 6.5, 95% CI = 1.7-25.0).

Conclusion: For children undergoing procedural sedation in the ED, two in five children have high preprocedure anxiety and almost one in four have significant negative behaviors 1 to 2 weeks after discharge. Highly anxious and nonwhite children have increased risk of negative behavioral changes that have not been previously recognized in the ED setting.
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http://dx.doi.org/10.1111/acem.13332DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5842101PMC
March 2018

Seasonal Variation in Pediatric Chronic Pain Clinic Phone Triage Call Volume.

Pain Manag Nurs 2017 10 1;18(5):288-294. Epub 2017 Aug 1.

Medical College of Wisconsin, Department of Anesthesiology, Milwaukee, Wisconsin.

Chronic pain is highly prevalent in youth and often results in significant health care usage and familial distress. Telephone triage nurses in pediatric pain clinics provide support and consultation to families and engage parents of pediatric pain patients in interdisciplinary intervention efforts. Despite evidence of winter predominance in rates of pain-related and psychiatric complaints, seasonal variations have not been examined in terms of the demand placed on pain clinic triage nurses. The present study investigated seasonal patterns in the frequency and type of phone calls made over the course of 1 year to an interdisciplinary outpatient pediatric chronic pain clinic at a large Midwestern children's hospital. Pain complaints, reasons for phone calls, and call outcomes (e.g., medication changes, consultation with medical or mental health providers) were recorded in patient charts and retrospectively reviewed by the clinic registered nurse. A total of 721 calls regarding 253 patients were made over the course of 1 year. Results indicated that overall call volume across pain conditions was more than two times greater in the winter than in the summer (χ = 64.13, p < .001), and the odds of a call involving headache pain were almost twice as likely in the winter as in the summer. The majority of calls required consultation with physicians and/or mental health providers. Present data may be useful for pediatric chronic pain clinics making staffing decisions throughout the year because the winter season appears to place a significantly greater demand on triage nurses.
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http://dx.doi.org/10.1016/j.pmn.2017.05.002DOI Listing
October 2017

"What Does Weight Have to Do with It?" Parent Perceptions of Weight and Pain in a Pediatric Chronic Pain Population.

Children (Basel) 2016 Nov 14;3(4). Epub 2016 Nov 14.

Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI 53226, USA.

Tailored pain management strategies are urgently needed for youth with co-occurring chronic pain and obesity; however, prior to developing such strategies, we need to understand parent perspectives on weight in the context of pediatric chronic pain. Participants in this study included 233 parents of patients presenting to a multidisciplinary pediatric chronic pain clinic. Parents completed a brief survey prior to their child's initial appointment; questions addressed parents' perceptions of their child's weight, and their perceptions of multiple aspects of the relationship between their child's weight and chronic pain. The majority (64%) of parents of youth with obesity accurately rated their child's weight; this group of parents was also more concerned ( < 0.05) about their child's weight than parents of youth with a healthy weight. However, the majority of parents of youth with obesity did not think their child's weight contributed to his/her pain, or that weight was relevant to their child's pain or pain treatment. Overall, only half of all parents saw discussions of weight, nutrition, and physical activity as important to treating their child's pain. Results support the need for addressing parents' perceptions of their child's weight status, and educating parents about the relationship between excessive weight and chronic pain.
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http://dx.doi.org/10.3390/children3040029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5184804PMC
November 2016

Psychometric Properties of the Pain Stages of Change Questionnaire: New Insights on the Measurement of Readiness to Change in Adolescents, Mothers, and Fathers.

J Pain 2015 Jul 8;16(7):645-56. Epub 2015 Apr 8.

Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, Wisconsin.

Unlabelled: There is increasing interest in the measurement of "readiness to change," or willingness to engage in a self-management approach to pain coping, as a predictor of treatment response in pediatric pain populations. The primary aim of the present study was to provide cross-validation of the Pain Stages of Change Questionnaire-Adolescent and -Parent versions in a new, independent pediatric chronic pain sample by examining aspects of reliability, validity, and generalizability of the factor structures identified in the initial validation study. Secondary aims were to 1) expand upon previously identified differences between the Pain Stages of Change Questionnaire-Adolescent and -Parent versions and 2) examine previously unreported aspects of father data. Although slight differences emerged, the factor structures identified in the initial validation were largely replicated, suggesting that the psychometric properties of the measure are robust across pediatric outpatient chronic pain samples. Variability between parent and adolescent reports suggests that there may be meaningful differences in the interpretation of each measure and that factors other than readiness to change may influence response patterns. Findings highlight the need for more fine-tuned analyses of the way the construct operates in youth with pediatric pain and their parents.

Perspective: Findings provide further validation of the Pain Stages of Change Questionnaire-Adolescent and -Parent versions measures in a new outpatient pediatric chronic pain sample. Previously uninvestigated father data showed good reliability and patterns of findings similar to validated mother reports. Moreover, the study suggests that the adolescent and parent versions may function in meaningfully different ways.
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http://dx.doi.org/10.1016/j.jpain.2015.03.012DOI Listing
July 2015

Distinct Influences of Anxiety and Pain Catastrophizing on Functional Outcomes in Children and Adolescents With Chronic Pain.

J Pediatr Psychol 2015 Sep 2;40(8):744-55. Epub 2015 Apr 2.

University of Wisconsin-Milwaukee.

Objectives: Examine whether anxiety and pain catastrophizing are distinct constructs in relation to functional outcomes in pediatric chronic pain, and whether they differentially predict functional outcomes based on age.

Methods: In all, 725 youth (191 children, 534 adolescents) with chronic pain completed measures of pain characteristics, anxiety, pain catastrophizing, functional disability, and health-related quality of life (HRQOL). Structural equation modeling was used to examine interrelationships.

Results: Anxiety and pain catastrophizing were distinct. For both children and adolescents, pain catastrophizing predicted pain, functional disability, and HRQOL, and was a stronger predictor of pain intensity. For children, anxiety predicted HRQOL, and pain catastrophizing was a stronger predictor of functional disability. For adolescents, anxiety predicted functional disability and HRQOL, and anxiety was a stronger predictor of HRQOL.

Conclusions: There were age-related differences regarding whether anxiety or pain catastrophizing more strongly predicted specific functional outcomes. Assessment and intervention efforts should emphasize both anxiety and pain catastrophizing.
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http://dx.doi.org/10.1093/jpepsy/jsv029DOI Listing
September 2015

Predicting Multiple Facets of School Functioning in Pediatric Chronic Pain: Examining the Direct Impact of Anxiety.

Clin J Pain 2015 Oct;31(10):867-75

*Department of Anesthesiology, Medical College of Wisconsin, Children's Hospital of Wisconsin §Department of Pediatrics and Quantitative Health Sciences ∥Department of Quantitative Health Sciences, Medical College of Wisconsin, Milwaukee, WI †Cincinnati Children's Hospital Medical Center, Division of Behavioral Medicine and Clinical Psychology ‡Department of Psychology, University of Cincinnati, Cincinnati, OH.

Objectives: The relationships among chronic pain, anxiety, and school functioning are complex, and school functioning is often negatively impacted in youth with chronic pain. The objective of this study was to empirically test a model of associations between constructs predicting school functioning in youth with chronic pain to examine the direct effect of anxiety on school attendance and other indicators of school-related disability.

Materials And Methods: Participants included 349 youth and their parents (311 mothers and 162 fathers) who attended a multidisciplinary pain clinic. Youth, mothers, fathers, and clinicians completed assessments of clinical outcomes important to family and clinician perceptions of school functioning; youth, mothers, and fathers completed an assessment of youth anxiety. Structural equation modeling was used to examine interrelations among predictors.

Results: Measurement and structural models for predicting youth school functioning provided a very good fit of the data to the conceptual model. Anxiety was directly related to problems with school attendance and avoidance, concentration, and keeping up with schoolwork.

Discussion: Anxiety was a robust predictor of school functioning across a range of domains. Evaluating anxiety symptoms in pediatric chronic pain will likely facilitate case conceptualization and treatment planning. This study supports a shift in focus from pain to anxiety as the driving force of school impairment in youth with chronic pain.
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http://dx.doi.org/10.1097/AJP.0000000000000181DOI Listing
October 2015

The pain frequency-severity-duration scale as a measure of pain: preliminary validation in a pediatric chronic pain sample.

Pain Res Treat 2014 20;2014:653592. Epub 2014 Jan 20.

Children's Hospital of Wisconsin and Medical College of Wisconsin, 9000 W. Wisconsin Ave, Milwaukee, WI 53226, USA.

Typically, pain is measured by intensity and sensory characteristics. Although intensity is one of the most common dimensions of pain assessment, it has been suggested that measuring pain intensity in isolation is only capturing part of the pain experience and may not lead to an accurate measurement of how pain impacts a child's daily functioning. The current study aimed to develop a measure that would capture pain intensity along with frequency and duration in a clinical sample of youth diagnosed with chronic pain. The pain-frequency-severity-duration (PFSD) scale was developed and data were collected from a multidisciplinary pain clinic at a large, midwestern children's hospital. Validated measures of functional limitations and health related quality of life were also collected. Significant correlations were found between the PFSD composite score, functional limitations, and health related quality of life. Future research should continue to evaluate this questionnaire utilizing other validated pain measures and other areas potentially impacted by chronic pain and with more diverse samples. This initial finding suggests that the PFSD is a convenient self-reported measure and is strongly related to health related quality of life and functional disability.
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http://dx.doi.org/10.1155/2014/653592DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3918349PMC
February 2014

A randomized, controlled pilot study of mindfulness-based stress reduction for pediatric chronic pain.

Altern Ther Health Med 2013 Nov-Dec;19(6):8-14

Context: It is estimated that 1 in 5 children in the United States is affected by chronic pain. Increasing adaptive coping strategies and decreasing stress may be important in treatment. Research has suggested that mindfulness can help alleviate symptoms associated with medical illnesses and increase quality of life. Little is known about the effectiveness of mindfulness-based stress reduction (MBSR) in youth, partly due to insufficient methodological rigor in related studies.

Objective: The primary purpose of the present study was to examine the feasibility, acceptability, and effectiveness of MBSR for a treatment-seeking sample of youth with chronic pain.

Design: The current study was the first randomized, controlled pilot study of MBSR for pediatric chronic pain. The research team had intended to use block randomization involving a total of five recruitment waves, with each wave consisting of one MBSR group and one psychoeducation group. Due to difficulties with recruitment and attrition before the start of either group, however, only MBSR was conducted at each wave after the first wave.

Setting: Participants were recruited from a multidisciplinary pain clinic in a large, Midwestern children's hospital.

Participants: The final sample included six adolescents between the ages of 12 and 17 y, four in the MBSR group and two in the psychoeducation group.

Intervention: Weekly sessions for the MBSR group were 90 min in length and followed a structured protocol. Sessions included a review of homework, an introduction to and practice of meditation, discussion of the session, and a review of the home practice assignment. The psychoeducation group participated in six group sessions, which were based on a cognitive-behavioral model of pain, and discussion topics included the nature of chronic pain and stress management.

Primary Outcome Measures: Health-related quality of life, pain catastrophizing, anxiety, functional disability, mindfulness, and treatment acceptability were all assessed pre- and postintervention as well as at follow-up.

Results: Recruitment and retention difficulties were experienced. Qualitative examination of participants' scores suggested increased mindfulness but inconsistent patterns on other outcome measures.

Conclusions: The research team highlighted critical challenges faced by potential researchers aiming to investigate MBSR for pediatric chronic pain, and the study provides recommendations for research and implications for clinical practice.
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January 2014

Pain reports in children and adolescents with type 1 diabetes mellitus.

J Child Health Care 2015 Mar 12;19(1):43-52. Epub 2013 Aug 12.

Medical College of Wisconsin, USA; Children's Hospital of Wisconsin, USA.

The purpose of this study is to examine prevalence rates of pain reports in youth with type 1 diabetes mellitus (T1DM) and potential predictors of pain. Pain is a common and debilitating symptom of diabetic polyneuropathies. There is currently little research regarding pain in youth with T1DM. It was predicted that self-care and general health factors would predict pain as suggested by the general pain literature. Participants (N = 269) ranged in age from 13 to 17 years; youth had a mean time since diagnosis of 5.8 years. Data collected included diabetes self-management variables, ratings of the patient's current functioning and pain intensity ('current'), and information collected about experiences that occurred in the time preceding each appointment ('interim'). About half of the youth (n = 121, 49.0%) reported any interim pain across both appointments. Female adolescents and those individuals who were physically active and/or utilized health-care system more acutely were more likely to report interim central nervous system pain. Improved diabetes self-management and increased level of physical activity may reduce experiences of pain and increase the quality of life of youth with T1DM. Regular monitoring of both current and interim pain experiences of youth with T1DM is recommended.
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http://dx.doi.org/10.1177/1367493513496908DOI Listing
March 2015

Developing an in-patient acupuncture treatment in a pediatric hospital.

J Complement Integr Med 2013 May 7;10. Epub 2013 May 7.

Children’s Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA.

Little is known about the broad application of acupuncture as adjuvant treatment for in-patient pediatric populations. We review a series of cases involving acupuncture for conditions ranging from insomnia to cyclic vomiting. The details of the protocol for each are included. This case series illustrates the benefits of an in-patient acupuncture treatment service, as well as the subtleties of an acupuncture protocol when treating children and adolescents.
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http://dx.doi.org/10.1515/jcim-2012-0056DOI Listing
May 2013

Do barriers to pediatric pain management as perceived by nurses change over time?

Pain Manag Nurs 2014 Mar 20;15(1):292-305. Epub 2013 Feb 20.

Medical College of Wisconsin, Milwaukee, Wisconsin.

For decades, nurses (RNs) have identified barriers to providing the optimal pain management that children deserve; yet no studies were found in the literature that assessed these barriers over time or across multiple pediatric hospitals. The purpose of this study was to reassess barriers that pediatric RNs perceive, and how they describe optimal pain management, 3 years after our initial assessment, collect quantitative data regarding barriers identified through comments during our initial assessment, and describe any changes over time. The Modified Barriers to Optimal Pain Management survey was used to measure barriers in both studies. RNs were invited via e-mail to complete an electronic survey. Descriptive and inferential statistics were used to compare results over time. Four hundred forty-two RNs responded, representing a 38% response rate. RNs continue to describe optimal pain management most often in terms of patient comfort and level of functioning. While small changes were seen for several of the barriers, the most significant barriers continued to involve delays in the availability of medications, insufficient physician medication orders, and insufficient orders and time allowed to pre-medicate patients before procedures. To our knowledge, this is the first study to reassess RNs' perceptions of barriers to pediatric pain management over time. While little change was seen in RNs' descriptions of optimal pain management or in RNs' perceptions of barriers, no single item was rated as more than a moderate barrier to pain management. The implications of these findings are discussed in the context of improvement strategies.
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http://dx.doi.org/10.1016/j.pmn.2012.12.003DOI Listing
March 2014

A pilot study of yoga for chronic headaches in youth: promise amidst challenges.

Pain Manag Nurs 2014 Jun 19;15(2):490-8. Epub 2013 Feb 19.

Department of Anesthesiology, Medical College of Wisconsin/Children's Hospital of Wisconsin, Jane B. Pettit Pain and Palliative Care Center, Milwaukee, Wisconsin.

The primary aim of the current study was to provide preliminary data on the feasibility, acceptability, and safety of alignment-based yoga for youths with chronic headaches. A secondary aim was to provide preliminary estimates of yoga's ability to improve headache pain, daily functioning, quality of life, and anxiety level in this population. The yoga intervention consisted of 8 weekly, 75-minute classes. Participant flow data revealed challenges to feasibility primarily due to recruitment and retention. Scores on most outcome measures changed in the predicted direction with medium effect sizes found for the functional outcomes. Pain measures did not change significantly. This pilot suggests that yoga for pediatric headaches may be acceptable, as indicated by positive parent and participant ratings of the yoga experience. These preliminary findings suggest that yoga trials for pediatric headaches include both challenges and promise. Recommendations for overcoming challenges include designs that optimize family convenience.
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http://dx.doi.org/10.1016/j.pmn.2012.12.002DOI Listing
June 2014

Physical, cognitive, and psychosocial predictors of functional disability and health-related quality of life in adolescents with neurofibromatosis-1.

Pain Res Treat 2012 26;2012:975364. Epub 2012 Sep 26.

Children's Hospital of Wisconsin Community Services, 620 S. 76th Street, Suite 120, Milwaukee, WI 53214, USA.

Objective. To examine physical, cognitive, and social-emotional predictors of quality of life (HRQOL) and functional disability (FD) in adolescents diagnosed with Neurofibromatosis-1. Methods. Participants were twenty-seven adolescents with a diagnosis of NF-1 who were recruited through an NF-1 specialty clinic at a large Midwestern children's hospital. Measurements of the adolescents' cognitive functioning, pain, FD, HRQOL, and social and emotional functioning were obtained with corresponding parent measures. Results. Emotional functioning significantly predicted youth-reported and parent-reported HRQOL, whereas days of pain significantly predicted youth-reported FD. Conclusions. NF-1 is a complex disease. Measurements of the overall impact of the disease tap into different aspects of the effects of NF-1 on daily life. Global outcomes such as HRQOL appear to be influenced especially by emotional functioning, whereas outcomes such as FD appear to be influenced by the physical/organic aspects of NF-1.
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http://dx.doi.org/10.1155/2012/975364DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3463937PMC
October 2012

Pain as a Comorbidity of Pediatric Obesity.

Infant Child Adolesc Nutr 2012 Oct;4(5):315-320

Jane B. Pettit Pain and Palliative Care Center, Children's Hospital of Wisconsin, Milwaukee, Wisconsin (KRH, SJW); Rogers Partners in Behavioral Health, Roger's Memorial Hospital, Oconomowoc, Wisconsin (LAM); College of Health Sciences, Marquette University, Milwaukee, Wisconsin (SCS); NEW Kids Program, Children's Hospital of Wisconsin, Milwaukee, Wisconsin (BMF); Department of Psychology, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin (WHD); and Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, North Carolina (JAS).

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.
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http://dx.doi.org/10.1177/1941406412458315DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3979543PMC
October 2012

The psychometric properties of the screen for child anxiety related emotional disorders in pediatric chronic pain.

J Pediatr Psychol 2012 Oct 7;37(9):999-1011. Epub 2012 Jun 7.

Alliant International University, 10455 Pomerado Road, San Diego, CA 92131, USA.

Objective: Examine the psychometric properties of the SCARED in pediatric chronic pain.

Methods: Participants were parents (n = 313 mothers, 163 fathers) and youth (n = 349) presenting for treatment of pediatric chronic pain. Participants completed the SCARED and measures of pain catastrophizing, internalizing problems, and health-related quality of life.

Results: Internal consistency (Cronbach's α) of SCARED Total scores ranged from .92 to .93 across sources of report. All subscales except for School Phobia exhibited good internal consistency. SCARED scores were significantly positively related to internalizing symptoms and pain catastrophizing; and negatively related to health-related quality of life. Confirmatory factor analysis revealed acceptable fit of the SCARED measurement model.

Conclusions: The SCARED shows promise as a measure of anxiety in pediatric pain. Important caveats for its usage and areas in need of additional research are discussed. Of importance in pediatric pain is improving current approaches for measuring school anxiety in this population.
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http://dx.doi.org/10.1093/jpepsy/jss069DOI Listing
October 2012

Health-related quality of life in pediatric minor injury: reliability, validity, and responsiveness of the Pediatric Quality of Life Inventory in the emergency department.

Arch Pediatr Adolesc Med 2012 Jan;166(1):74-81

Section of Emergency Medicine, Department of Pediatrics, Children’s Research Institute, Medical College of Wisconsin, Milwaukee, WI 53226, USA.

Objective: To evaluate the feasibility, reliability, validity, and responsiveness of the Pediatric Quality of Life Inventory 4.0 Generic Core Scales (PedsQL) in the first 2 weeks after pediatric emergency department care of minor injury.

Design: Prospective cohort study.

Setting: Pediatric hospital emergency department.

Participants: Children and adolescents with minor injury (n = 334).

Main Outcome Measures: Child- and parent-reported clinical outcomes and PedsQL scale scores.

Results: The PedsQL had good to excellent internal consistency reliability (α range, 0.73-0.93). For each day that the clinical symptoms persisted, there were consistent decreases in mean health-related quality of life (HRQOL) scores (validity testing). There were significantly greater negative changes in mean HRQOL scores for fractures vs soft-tissue injuries and for lower vs upper extremity injuries. Clinical outcomes categorized as poor had large negative changes in HRQOL not seen in good outcome groups. Distribution-based indicators of change supported good responsiveness (effect sizes for the physical summary score, 0.01-2.44; group differences at follow-up exceeded estimates of the minimal importance difference).

Conclusions: The PedsQL is feasible, reliable, and demonstrates good construct and discriminant validity and responsiveness in measuring short-term outcome after minor injury care in the pediatric emergency department. Assessing short-term outcome from the patient perspective with HRQOL measures may greatly enhance our ability to evaluate the effectiveness of emergency department care.
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http://dx.doi.org/10.1001/archpediatrics.2011.694DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3714102PMC
January 2012

School functioning and chronic pain: a review of methods and measures.

J Pediatr Psychol 2011 Oct 10;36(9):991-1002. Epub 2011 Jul 10.

Department of Psychology, University of Wisconsin, Milwaukee, WI 53211, USA.

Objective: School functioning is among the most important life domains impacted by chronic pain. This review provides a summary of the measures currently used by researchers to assess school functioning in children with chronic pain.

Methods: We conducted a systematic review of the literature on school absenteeism and school functioning in children and adolescents with pain. Searches were restricted to a time frame including January 1985 to December 2010.

Results: Fifty-three articles are reviewed: all include some form of assessment of school absenteeism or school functioning as part of the study outcome measures. Of the 53 articles, 26 assessed school absenteeism and 27 assessed an aspect of school functioning; 14 of these 27 articles assessed both.

Conclusions: Understanding the comprehensive impact of pain on school functioning will require improvements in our current assessment methods.
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http://dx.doi.org/10.1093/jpepsy/jsr038DOI Listing
October 2011

Pediatric minor injury outcomes: an initial report.

Pediatr Emerg Care 2011 May;27(5):371-3

Pediatrics, Section of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.

Objectives: The objectives were (1) to present a preliminary evaluation of outcomes after pediatric emergency department (PED) minor injury care (not previously described) and (2) to test the feasibility of study methods and of a HRQOL tool in this acute care setting.

Methods: A prospective observational study of clinical and functional short-term outcomes in PED patients with minor injury was performed.

Results: Thirty-five (80%) of 44 families completed telephone follow-up. Children had a median of 3 days of pain; 24% had pain for more than 7 days. Children returned to normal activity in a median of 3 days, and 37%, in more than 7 days. Fifty percent of families had normal activities disrupted, with median of 5 days and 39% in more than 7 days. Among children with school/scheduled activities, 55% missed more than 3 days, and 20% missed more than 7 days. Among parents who missed work/school, the mean was 1 day, and 22% missed more than 3 days. The acute Pediatric Quality of Life Inventory (PedsQL) was feasible for emergency department/follow-up use and had the expected inverse correlations with poor outcomes.

Conclusions: We found significant morbidity after PED treatment of minor injury. The study methods and PedsQL patient and proxy forms were feasible for emergency department use. The PedsQL had some initial indications of construct validity for this population.
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http://dx.doi.org/10.1097/PEC.0b013e318216b0e7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3714099PMC
May 2011

Initial surgical and pain management outcomes after Nuss procedure.

J Pediatr Surg 2010 Sep;45(9):1767-71

Children's Hospital of Wisconsin, Milwaukee, WI 53226, USA.

Purpose: The purpose of this article was to report surgical and pain management outcomes of the initial Nuss procedure experience at the Children's Hospital of Wisconsin (Milwaukee) and to place this experience in the context of the published literature.

Methods: The initial 118 consecutive Nuss procedures in 117 patients were retrospectively reviewed with approval of the Children's Hospital of Wisconsin human rights review board. Patient, surgical, complication, and pain descriptors were collected for each case. Statistical methods for comparison of pain strategies included the Kolmogorov-Smirnov test for normality, 1-way repeated measures analysis of variance, and paired t tests.

Results: Patient, surgical, and complication descriptors were comparable to other large series. Complication rates were 7% early and 25% late. Epidural success rate was 96.4%. There was 1 episode of recurrence 2 years postbar removal (n = 114).

Conclusions: The institution of the Nuss procedure provides a highly desired result with significant complication rates. The ideal approach would deliver this result with lower risk. A pain service-driven epidural administration of morphine or hydromorphone with local anesthetic provides excellent analgesia for patients after Nuss procedure. The success of epidural analgesia is independent of catheter site and adjunctive medications. Ketorolac was an effective breakthrough medication.
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http://dx.doi.org/10.1016/j.jpedsurg.2010.01.028DOI Listing
September 2010

Gabapentin use in pediatric spinal fusion patients: a randomized, double-blind, controlled trial.

Anesth Analg 2010 May;110(5):1393-8

Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA.

Background: Gabapentin has opioid-sparing effects in adult surgical patients, but no reported studies have involved children and adolescents. In a double-blind, randomized, controlled trial, we examined whether gabapentin decreases postoperative opioid consumption for pediatric spinal fusion patients with idiopathic scoliosis.

Methods: Patients, aged 9 to 18 years, received preoperative gabapentin (15 mg/kg, treatment) or placebo. Anesthesia was standardized. After surgery, all patients received standardized patient-controlled analgesia opioid and continued on either gabapentin (5 mg/kg) or placebo 3 times per day for 5 days. Opioid use was calculated in mg/kg/time intervals. Pain scores and opioid side effects were recorded.

Results: Data from 59 patients (30 placebo and 29 gabapentin) did not differ in demographics. Total morphine consumption (mg/kg/h +/- SD) was significantly lower in the gabapentin group in the recovery room (0.044 +/- 0.017 vs 0.064 +/- 0.031, P = 0.003), postoperative day 1 (0.046 +/- 0.016 vs 0.055 +/- 0.017, P = 0.051), and postoperative day 2 (0.036 +/- 0.016 vs 0.047 +/- 0.019, P = 0.018). In addition, gabapentin significantly reduced first pain scores in the recovery room (2.5 +/- 2.8 vs 6.0 +/- 2.4, P < 0.001) and the morning after surgery (3.2 +/- 2.6 vs 5.0 +/- 2.2, P < 0.05), but otherwise pain scores were not significantly different. There were no differences in opioid-related side effects over the course of the study.

Conclusion: Perioperative oral gabapentin reduced the amount of morphine used for postoperative pain after spinal fusion surgery, but not overall opioid-related side effects. Initial pain scores were lower in the treatment group. Perioperative use of gabapentin seems to be an effective adjunct to improve pain control in the early stages of recovery in children and adolescents undergoing spinal fusion.
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http://dx.doi.org/10.1213/ANE.0b013e3181d41dc2DOI Listing
May 2010