Objectives:This study explored potential resilience factors that facilitate engagement in physical activity (PA) among adolescents with chronic musculoskeletal pain after completing intensive interdisciplinary pain treatment. Methods:Ten adolescents aged 13 to 17 years with a history of chronic musculoskeletal pain from a mid-western pediatric hospital in the United States participated in this qualitative study. Participants provided demographic information and completed semistructured virtual interviews. The interviews focused on their pain experiences, resilience, and engagement in PA. Transcripts were analyzed using primarily directed content analysis based on a pain resilience framework. Results:Participants highlighted several key resilience factors that influenced their PA engagement, including positive affect, motivation, acceptance, and self-efficacy. Positive affect and mood affected their willingness and enjoyment of PA. Motivation was enhanced by focusing on short-term and long-term gains and setting smaller, manageable goals. Acceptance of pain allowed participants to engage in PA even on bad pain days, using psychological flexibility skills. Social support and the ability to pair PA with other valued activities, such as spending time with friends and family, were also crucial in maintaining PA engagement. Conclusion:The study identified resilience factors relevant to PA interventions for pediatric chronic pain. Incorporating strategies that enhance positive affect, motivation, acceptance, and self-efficacy, along with fostering social support, may improve PA engagement and could enhance the effectiveness of PA programs, promoting better outcomes for adolescents with pain. Future research should explore and further validate the importance of these resilience factors in larger, more diverse populations and across different stages of pain treatment.

Background/Objectives: Chronic musculoskeletal pain (CMSKP) affects up to 40% of adolescents and leads to substantial disability, reduced quality of life, and long-term health risks. Physical activity is central to treatment, but adherence to moderate-to-vigorous physical activity (MVPA) is inconsistent. We evaluated higher-resilience constructs—self-efficacy, pain acceptance, motivational stage, and affect—and hypothesized that higher resilience would be associated with greater objectively measured physical activity, better daily functioning, and higher quality of life in adolescents with CMSKP. Methods: Forty-three adolescents (13–18 years) with CMSKP completed measures of physical activity-specific self-efficacy, acceptance (AFQ-Y), motivational stage (PSOCQ-A), and affect (PANAS-C). Participants wore activPAL monitors to assess MVPA, light activity, and sedentary time. Physical function endurance was measured by the six-minute walk test (6MWT) and the Functional Disability Inventory (FDI); quality of life by the Pediatric Quality of Life Inventory (PedsQL). Spearman’s correlations assessed associations among resilience variables, physical activity metrics, 6MWT distance, FDI, and PedsQL. Results: MVPA was correlated positively with 6MWT distance (ρ = 0.48, p = 0.002) and negatively with FDI scores (ρ = −0.56, p < 0.001). Self-efficacy related to higher MVPA (ρ = 0.41, p = 0.009), better endurance (ρ = 0.36, p = 0.017), and lower disability (ρ = −0.38, p = 0.013). Acceptance was correlated with PedsQL total (ρ = 0.45, p = 0.004); motivation (specifically maintenance) scores were correlated with higher quality of life (ρ = 0.33, p = 0.027). Light activity and sedentary time were not significantly linked to functional or psychosocial outcomes. In a step-wise regression, only physical activity self-efficacy for ambulation at school predicted MVPA, B = 1.56, p = 0.008. Conclusions: Resilience constructs—including self-efficacy, acceptance, and readiness to change—were meaningfully associated with MVPA, daily functioning, and quality of life, and may have implications for treatment development.

Intensive interdisciplinary pain treatment (IIPT) effectively treats pediatric patients with highly impairing chronic pain; however, safety and outcomes for patients with comorbid pediatric generalized joint hypermobility (pGJH) have not been rigorously examined. This study assessed the prevalence of injuries and physical and psychosocial outcomes of IIPT for patients with chronic pain with and without pGJH. This study was a retrospective review of patients admitted to an IIPT program providing 40 h of weekly physical and psychological therapies for approximately 4–6 weeks. Joint protective methods were utilized, and all participants had daily assessment by a medical provider, including assessment of injuries. Pain intensity, health-related disability, and social, emotional, and academic functioning were measured via standardized, self- and parent-report measures at baseline, weekly during treatment, and at established follow-up time points of one-, six-, and 12-months post-program completion. Of 304 patients (M age = 15.3 years, SD = 2.1; 83.6

To investigate the experiences of adolescents with chronic pain who participated in an intensive interdisciplinary pain treatment program, this secondary study analyzes the themes that emerged regarding the spontaneous utilization of music in coping strategies for chronic pain. During research interviews focused on coping skills and treatment engagement, participants spontaneously reported using music as an effective coping strategy for managing pain. A deductive thematic analysis revealed key themes related to their usage, including using music as a distractor, motivator and in other ways as coping strategies. Since participants indicated that music is essential to their experiences of coping with pain, incorporating these strategies could improve the effectiveness of treatment protocols. To this end, further investigation is necessary to assess the impact of music on adolescents with chronic pain, focusing on its role in enhancing interdisciplinary treatment.

Chronic pain in children and adolescents is often associated with functional, physical, and psychosocial challenges. Intensive interdisciplinary pain treatment (IIPT) programs are effective at helping these youth regain functioning, but little is known about their perspectives prior to and during IIPT participation. This study sought to better understand how children and adolescents experience the process from evaluation to completion of the IIPT program. Individual interviews (n = 7) were conducted at three time-points; (1) prior to initial evaluation in a pain clinic, (2) after pain clinic evaluation while considering IIPT, and (3) after completion of an IIPT program. Participants ranged in age from 13–17 years. Across these time points, participants demonstrated changes in thoughts and perspectives. While Time 1 was associated with ambivalence, skepticism, and some hope, Time 2 was characterized by processing information about the program and resolution of some of their ambivalence. At Time 3, participants described their experience as “challenging” and “intense” and reported recognition that they had benefited from the program. Participants also wished to pass along lessons learned to future potential patients. This study provides information to help clinicians better approach adolescents with chronic pain who may be considering IIPT. This study, for the first time, characterizes patient experiences as they navigate entry to, beginning, and completion of an intensive interdisciplinary pain treatment program. It highlights adolescents’ thought processes as they weigh whether to engage in and ultimately complete the program, providing insight on changes in their thinking over time.

Objective: Brain areas activated during pain can contribute to enhancing or reducing the pain experience, showing a potential connection between chronic pain and the neural response to pain in adolescents and youth. Methods: This study examined changes in brain activation associated with experiencing physical pain and observing physical and emotional pain in others by using functional magnetic resonance imaging (fMRI) before and after intensive interdisciplinary pain treatment (IIPT). Eighteen youths (age 14 to 18) with widespread chronic pain completed fMRI testing before and after IIPT to assess changes in brain activation in response to physical and emotional pain. Results: Broadly, brain activation changes were observed in frontal, somatosensory, and limbic regions. These changes may suggest improvements in descending pain modulation via thalamus and caudate, and the different pattern of brain activation after treatment suggests potentially better discrimination between physical and emotional pain. Brain activation changes were also correlated with improvements in clinical outcomes of catastrophizing (reduced activation in right caudate, right mid-cingulate, and postcentral gyrus) and pain-related disability (increased activation in precentral gyrus, left hippocampus, right middle occipital cortex, and left superior frontal gyrus). Discussion: These changes could indicate that reduced brain protective responses to pain were associated with treatment-related improvements. This pilot study highlights the need for larger trials designed to better understand the brain mechanisms involved in pediatric widespread pain treatment.

Objective: Parents of youth with chronic pain report psychosocial difficulties, yet treatment often focuses on improving their child's functioning and pain. This study evaluated changes in parents' social and emotional functioning and explored predictors of change, as they completed a parent-focused intervention while their child was enrolled in an intensive interdisciplinary pain treatment (IIPT) program.Methods: Parents (n = 69) completed questionnaires at baseline and weekly (average duration of 4 weeks) during their child's participation in IIPT. Parents engaged in 3 groups per week providing education, therapeutic art, and psychotherapy (3 hr/week total).Results: At baseline, 38% of parents reported scores in the clinically elevated range for at least 1 psychosocial variable. Linear mixed modeling for the full sample indicated reduced parent anxiety (t = -2.72, p <.01) and depression (t = -3.59, p <.001), but not increased emotional support (t = 1.86, p >. 05) or reduced social isolation (t = -1.20, p >.05). For parents with at least moderately elevated psychosocial concerns, statistically significant improvements were observed for all 4 outcomes (all p's<.01). Psychological flexibility, cognitive reappraisal, and emotional suppression were found to be related to changes in parent outcomes (anxiety, depression, isolation, and support).Conclusions: Findings support the benefit of parent-focused interventions in addition to child-focused interventions. Many parents of youth participating in IIPT had elevated scores for at least 1 psychosocial concern at baseline. Brief, parent-focused intervention including psychoeducation, therapeutic art, and psychotherapy targeting mindfulness, acceptance, and values had a significant impact on these parents, particularly those with greater struggles at baseline.

No validated measure for pain self-efficacy in children and adolescents is currently available in the German language, and existing English versions have limitations. This study used a thorough development process to create the Scale for Pain Self-Efficacy (SPaSE) in both German and English languages. Scale development was based on self-efficacy theory, adapting items from existing self-efficacy measures, and review of patients' perspectives. The final version of the 11-item SPaSE was created with expert discussions and testing of content validity, comprehensibility, and construct validity. The validation process consisted of exploratory factor analysis, testing of item characteristics, internal consistency, and sensitivity to change in 2 German samples of children and adolescents with chronic pain (study 1: outpatient sample N = 150, inpatient sample N = 31). Cross-validation in a U.S. sample (study 2: N = 98) confirmed the 1-factor structure, the sound psychometric properties and reliability of the SPaSE. Sum scores of the SPaSE were negatively correlated with pain-related disability, pain intensity, passive pain coping strategies, and emotional distress, in line with previous research. The valid and reliable SPaSE can be used in clinical practice to monitor pain treatment progress, advances the field of pain self-efficacy research in Germany, and opens the door to comparative research in German and English samples. PERSPECTIVE: This article presents psychometric properties of a newly developed measure of pain self-efficacy in children and adolescents that is available in both German and English language. This measure could be used in both research and clinical practice to measure treatment progress and outcome.

Journal Article Diagnosis Does Not Automatically Remove Stigma for Young People with Invisible Illness Get access Cara M Hoffart, DO, Cara M Hoffart, DO Department of Pediatrics, Children’s Mercy Kansas City, USAUniversity of Missouri-Kansas City School of Medicine, USA Search for other works by this author on: Oxford Academic PubMed Google Scholar Dustin P Wallace, PhD Dustin P Wallace, PhD Department of Pediatrics, Children’s Mercy Kansas City, USAUniversity of Missouri-Kansas City School of Medicine, USA All correspondence concerning this article should be addressed to Dustin P. Wallace, PhD, Department of Pediatrics, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA. E-mail: dpwallace@cmh.edu https://orcid.org/0000-0002-1592-9686 Search for other works by this author on: Oxford Academic PubMed Google Scholar Journal of Pediatric Psychology, Volume 48, Issue 4, April 2023, Pages 352–355, https://doi.org/10.1093/jpepsy/jsad010 Published: 08 March 2023 Article history Received: 27 December 2022 Revision received: 31 January 2023 Accepted: 06 February 2023 Published: 08 March 2023

Objective: Interventions for parents are important during intensive interdisciplinary pain treatment (IIPT) for youth. Therapeutic art reinforces parent strengths and promotes healthy coping during their child’s treatment. This study measured the feasibility of implementing a published, parent-only group-based therapeutic art intervention in an IIPT program, delivered by a Certified Child Life Specialist (CCLS) with training in therapeutic art. Method: While their child participated in IIPT, forty-two parents participated in at least one therapeutic art group. Content rotated through four modules designed to promote reflection on interpersonal relationships, cultivate support, identify values, acknowledge personal struggles and barriers, and increase artistic self-expression (Pielech et. al., 2013). Following each group, parents completed measures of perceived satisfaction and helpfulness as well as open-ended questions for qualitative analysis. The mixed method design was used to provide depth to the understanding of these parents’ experiences. Results: Supporting feasibility, the full intervention was replicated in a different setting with different providers. Parents attended 69% of sessions, reported little difficulty attending, and reported a high degree of satisfaction, helpfulness, and support. Following each group, parents completed measures of perceived satisfaction and helpfulness as well as open-ended questions. Conclusion: A mixed method design was used to provide depth to the understanding of these parents’ experiences. Disclosure Statement: No potential conflict of interest was reported by the author(s). Funding Statement: No funding sources were provided by the author(s).

This journal recently published a paper by Wager and colleagues, entitled "Long-term outcomes of children with severe chronic pain: Comparison of former patients with a community sample” (Wager et al. in press). This paper demonstrates the lasting positive effects of intensive interdisciplinary pain treatment (IIPT) in children, and adds confidence in the duration of treatment effects through its unprecedented, controlled, 7-year follow-up design. Youth treated in IIPT are those with the most impairing pain; thus, these results are particularly encouraging, with almost 60% of the clinical sample no longer experiencing chronic pain. It is hard to evaluate the long-term impacts of IIPT in children, as retaining participants into young adulthood is difficult, and as it is obviously unethical to compare IIPT to a long-term control group assigned to not receive treatment. The few previous studies, although valuable, either included no comparison groups or attempted broad comparison with national normative data. Through the innovative use of an age- and sex-matched community sample, Wager and colleagues were able to directly compare IIPT ‘graduates’ and non-clinical peers who did not face the same challenges in childhood. Some results are encouraging, as IIPT graduates reported comparable autonomy to their peers, which suggests better functioning than has been reported for youth with a history of chronic pain who did not receive intensive treatment (e.g. Kashikar-Zuck et al., 2019). At the same time, these results show clearly that when compared to the community sample, those with a history of disabling chronic pain continue to have poorer physical and mental health and greater healthcare usage. These results suggest that IIPT is effective at treating pain, but raise questions about whether treatment programs are failing to promote broader physical and psychological health. The exact implications of the findings are not clear—for example, there was no subgroup analysis, so it is not possible to tell whether the whole group was faring poorly in these domains, or whether it was primarily a subset of young people who were struggling (with or without continued pain). Further analysis of these data could indicate whether there needs to be a more selective focus on non-responders or other specific types of patients. On a related point, multiple (perhaps annual) data points would allow data evaluation from a longitudinal perspective, which has shown utility in revealing trajectories of health symptoms and functioning in other samples (e.g. Kashikar-Zuck, 2019). The control group design used by Wager and colleagues is a genuine innovation and potential example for others to follow. At the same time, we believe this can be improved. Importantly, it would be useful to match the control group for socioeconomic status (SES) as well as age and sex. Low SES is a risk for paediatric pain, and as such the IIPT group may have started with this vulnerability, as well as having parents with increased rates of pain and emotional difficulty. These challenges may not have been represented in this community-based control group, meaning that the findings of broad health and physical problems could potentially be ascribed to this mismatch rather than to specific pain-related vulnerabilities or treatment shortcomings. At the same time, there are many reasons why these youth and young adults may continue to struggle, even after intensive treatment. Children with disabling pain often spend more of their formative years in medical clinics than extracurricular activities, and miss important social, academic and vocational milestones. It may be unrealistic to expect that these young people will ‘catch up’ to complete parity with their peers in young adulthood. Thus, it may make sense to incorporate broader techniques around psychological flexibility that can make intensive treatment more resilient in the face of newer stresses not initially addressed. Incorporating psychological flexibility more directly related to broader health (not just pain) may help preserve functioning as these young people face different physical and emotional challenges in their early adulthood. Even broader, recent work on “multidomain pain resilience” focuses on the contributions of psychological, social, biological and health/lifestyle domains to promote resilience across the lifespan (Palit, Palermo, Fillingim, & Bartley, in press). Integrating these ideas into IIPT and perhaps into aftercare programs could also have significant benefits. Finally, we would like to emphasize the value of this important work. Not many clinical and research groups have the resources to conduct long-term studies like this, and these findings will have broad impacts. Perhaps obviously, these data inform medical providers who are directing their patients towards effective care, and will provide helpful guidance for patients and parents wondering what to expect for the future. We are aware of no comparable long-term follow-up data for the medical and interventional treatments that are routinely used in paediatric pain care. Further, such high quality follow-up data help IIPT programs everywhere to clarify the results that come from investment in such programs.

Research in pediatric hospitals has shown that active music engagement, preferred music listening, and music-assisted relaxation can decrease anxiety and increase relaxation responses. However, there is little research on the use of music therapy with pediatric chronic pain conditions such as amplified pain syndromes. The purpose of the current study was to examine the effects of 3 specific music therapy interventions (active music engagement, live patient-selected music, and music-assisted relaxation) on anxiety and relaxation levels in youth (ages 10-18) participating in a 40 hr per week hospital-based intensive interdisciplinary pain treatment program. A sample of 48 patients participated in this study which utilized a 3-period, 3-treatment cross-over design with 3 interventions delivered in a quasi-randomized order determined by when the patients started the treatment program. State anxiety was measured via the state form of the State-Trait Inventory for Cognitive and Somatic Anxiety for Children and relaxation scores were assessed with a Visual Analog Scale. Statistically significant changes were found in anxiety and relaxation outcomes across all interventions provided. Results suggest that music therapy services (using active music engagement, live patient-selected music, and music-assisted relaxation) may be an effective modality to decrease anxiety and increase relaxation levels in pediatric patients with amplified pain syndromes.

Research demonstrates bi-directional associations between sleep difficulty and chronic pain, as well as relationships between sleep, daily function, and mental health. Adolescents with chronic pain frequently report difficulty falling and staying asleep, associated daytime fatigue, and decreased energy levels. However, few studies track both objective and subjective sleep changes in adolescents with chronic pain, and how these changes impact measures of daily functioning and mental health. This prospective longitudinal study followed 62 adolescents (53 female, age 13-17) through an intensive interdisciplinary pain treatment (IIPT) program consisting of daily intensive exercise, creative and relaxation-based coping, and psychological intervention. Prior to entering the program, all sleep medications besides melatonin were discontinued. Participants were assessed prior to the program, weekly throughout the program, and approximately one month after completion using actigraphy and self-report measures of sleep, fatigue, anxiety, depression, daily functioning, and pain. Paired samples t-tests were performed and accompanied by hierarchical linear modeling for longitudinal analyses. At baseline, patients were dissatisfied with their sleep (mean score 1.13, range 0-4) and reported difficulty falling asleep (mean 2.69, range 0-4), low energy (46/100) and high fatigue (T-score=63). Objective measures suggested adequate sleep efficiency (92%), but a 58-minute latency to persistent sleep. Statistically-significant improvements were observed at program end for sleep satisfaction, as well as difficulty falling asleep, energy level, and daytime fatigue, with continued improvement at the 2-week follow up (all P's<0.01). While objective measures (i.e. actigraphy) of sleep improved, none reached statistical significance. Longitudinal analysis revealed that changes in daily functioning were the strongest predictors of self-reported sleep satisfaction and difficulty falling asleep. However, improvements in both pain and functioning contributed to staying asleep. Importantly, decrease in depression was the strongest predictor for less daytime fatigue. Future studies should examine this relationship further to learn about long-term impacts on pediatric patients. Research demonstrates bi-directional associations between sleep difficulty and chronic pain, as well as relationships between sleep, daily function, and mental health. Adolescents with chronic pain frequently report difficulty falling and staying asleep, associated daytime fatigue, and decreased energy levels. However, few studies track both objective and subjective sleep changes in adolescents with chronic pain, and how these changes impact measures of daily functioning and mental health. This prospective longitudinal study followed 62 adolescents (53 female, age 13-17) through an intensive interdisciplinary pain treatment (IIPT) program consisting of daily intensive exercise, creative and relaxation-based coping, and psychological intervention. Prior to entering the program, all sleep medications besides melatonin were discontinued. Participants were assessed prior to the program, weekly throughout the program, and approximately one month after completion using actigraphy and self-report measures of sleep, fatigue, anxiety, depression, daily functioning, and pain. Paired samples t-tests were performed and accompanied by hierarchical linear modeling for longitudinal analyses. At baseline, patients were dissatisfied with their sleep (mean score 1.13, range 0-4) and reported difficulty falling asleep (mean 2.69, range 0-4), low energy (46/100) and high fatigue (T-score=63). Objective measures suggested adequate sleep efficiency (92%), but a 58-minute latency to persistent sleep. Statistically-significant improvements were observed at program end for sleep satisfaction, as well as difficulty falling asleep, energy level, and daytime fatigue, with continued improvement at the 2-week follow up (all P's<0.01). While objective measures (i.e. actigraphy) of sleep improved, none reached statistical significance. Longitudinal analysis revealed that changes in daily functioning were the strongest predictors of self-reported sleep satisfaction and difficulty falling asleep. However, improvements in both pain and functioning contributed to staying asleep. Importantly, decrease in depression was the strongest predictor for less daytime fatigue. Future studies should examine this relationship further to learn about long-term impacts on pediatric patients.

There is a paucity of literature regarding long-term follow up of pediatric patients who have participated in intensive interdisciplinary pain treatment (IIPT) programs. Evidence suggests that pain and somatic symptoms in childhood often lead to increased pain and somatic in adulthood, but data is lacking in this population. To better understand the long-term outcomes of individuals who completed IIPT as youth, we surveyed 139 participants who had completed IIPT at least two years prior to the survey. We received 58 responses (42% response rate), all 2-5 years after program completion. Participants (age 18.9±2.0, 86% female) completed measures of pain and health status (including the Widespread Pain Index), medical utilization, and emotional functioning. They were also asked to characterize if their pain was “better” than before IIPT, if they considered it “resolved,” and if they had any new pain or other medical diagnoses. Contrary to results of adolescents who have not received intensive treatment, half (50%) of the current sample did not have fibromyalgia symptoms at follow up, and only 31% met criteria for fibromyalgia.1 Most (79%) rated their pain as better, and 45% described their pain as resolved, though 22% indicated new areas of pain and 9% reported a new pain-related diagnosis. Consistent with other studies of this population, these participants continued to have higher than typical medical utilization and reported elevated anxiety and depressive symptoms. Overall, the results show that while pain often improves into adulthood for patients who completed IIPT, other somatic symptoms, anxiety, and depression often persist or increase in this population. These results suggest the need for further study, particularly in light of the increased medical utilization, as ongoing medical focus and intervention could be a causal factor in maintaining or increasing disability into adulthood. (1. Kashikar-Zuck et al., Pediatrics, 2014) There is a paucity of literature regarding long-term follow up of pediatric patients who have participated in intensive interdisciplinary pain treatment (IIPT) programs. Evidence suggests that pain and somatic symptoms in childhood often lead to increased pain and somatic in adulthood, but data is lacking in this population. To better understand the long-term outcomes of individuals who completed IIPT as youth, we surveyed 139 participants who had completed IIPT at least two years prior to the survey. We received 58 responses (42% response rate), all 2-5 years after program completion. Participants (age 18.9±2.0, 86% female) completed measures of pain and health status (including the Widespread Pain Index), medical utilization, and emotional functioning. They were also asked to characterize if their pain was “better” than before IIPT, if they considered it “resolved,” and if they had any new pain or other medical diagnoses. Contrary to results of adolescents who have not received intensive treatment, half (50%) of the current sample did not have fibromyalgia symptoms at follow up, and only 31% met criteria for fibromyalgia.1 Most (79%) rated their pain as better, and 45% described their pain as resolved, though 22% indicated new areas of pain and 9% reported a new pain-related diagnosis. Consistent with other studies of this population, these participants continued to have higher than typical medical utilization and reported elevated anxiety and depressive symptoms. Overall, the results show that while pain often improves into adulthood for patients who completed IIPT, other somatic symptoms, anxiety, and depression often persist or increase in this population. These results suggest the need for further study, particularly in light of the increased medical utilization, as ongoing medical focus and intervention could be a causal factor in maintaining or increasing disability into adulthood. (1. Kashikar-Zuck et al., Pediatrics, 2014)