BACKGROUND:Patients with life-limiting conditions are often cared for at home by family, typically without adequate training to carry out the challenging tasks performed. This systematic review assessed the efficacy of interventions designed to help family caregivers manage pain and other symptoms in adults and children with life-limiting conditions at home. METHODS:A systematic search was performed on seven databases. A narrative synthesis was conducted, along with a meta-analysis comparing outcomes in those who received an intervention to those who did not, or to preintervention scores. RESULTS:84 eligible studies were identified. Significant improvements in pain and fatigue in patients with cancer were found compared with patients in the control group and baseline. Caregivers of patients with cancer receiving an intervention, compared with the control group caregivers, showed significant improvements in self-efficacy and active coping and lower avoidant coping. This group also showed significant improvements in burden, self-efficacy, anxiety and depression, and decreases in avoidant coping pre- to post intervention. Patients with dementia whose caregivers received an intervention showed significantly reduced pain intensity and improvements in quality of life pre- to post intervention. Caregivers of patients with dementia showed significantly reduced distress pre- to post intervention. No beneficial effects were found for caregivers of patients with Parkinson's disease or heart failure, although only limited analyses could be performed. CONCLUSIONS:Interventions targeting family caregivers can improve both patient symptoms and caregiver outcomes, as demonstrated in cancer and dementia care. Future mixed-methods research should collect data from caregiver and patient dyads, identifying key intervention components. There is also need for more studies on caregivers of paediatric patients.

Background: Breakthrough pain is common in life-limiting conditions and at end-of-life. Despite over 30 years of study, there is little consensus regarding the definition and characteristics of breakthrough pain. Objective: This study aims to update and expand a 2010 systematic review by Haugen and colleagues to identify (1) all definitions of breakthrough pain and (2) all descriptions and classifications of breakthrough pain reported by patients, caregivers, clinicians, and experts. Design: This rapid systematic review followed the Cochrane Rapid Review Methods Group guidelines. A protocol is published on PROSPERO (CRD42019155583). Data sources: CINAHL, MEDLINE, PsycINFO, and the Web of Science were searched for breakthrough pain terms from the inception dates of each database to 26th August 2022. Results: We identified 65 studies that included data on breakthrough pain definitions, descriptions, or classifications from patients (n = 30), clinicians (n = 6), and experts (n = 29), but none with data from caregivers. Most experts proposed that breakthrough pain was a sudden, severe, brief pain occurring in patients with adequately controlled mild-moderate background pain. However, definitions varied and there was no consensus. Pain characteristics were broadly similar across studies though temporal factors varied widely. Experts classified breakthrough pain into nociceptive, neuropathic, visceral, somatic, or mixed types. Patients with breakthrough pain commonly experienced depression, anxiety, and interference with daily life. Conclusions: Despite ongoing efforts, there is still no consensus on the definition of breakthrough pain. A compromise is needed on breakthrough pain nomenclature to collect reliable incidence and prevalence data and to inform further refinement of the construct.

Background/Objectives: Conditioned pain modulation (CPM) is a psychophysical experimental measure of the endogenous pain inhibitory pathway in humans, wherein one pain stimulus (the conditioning stimulus) is used to inhibit an individual’s perception of a second painful (test) stimulus. Research provides evidence of impaired endogenous inhibitory pain responses in adults with chronic pain. CPM is now increasingly applied in paediatric research and clinical practice. The primary aim of this systematic review was to examine the efficacy of CPM in paediatric chronic pain populations (6–24-year-olds) compared to pain-free children and young people (CYP). Methods: The protocol was registered on PROSPERO (CRD42020221927). A systematic search of seven databases was conducted from database inception to 20th June 2024. Study inclusion criteria were as follows: (i) recruited a sample of CYP aged 6 to 24 (inclusive) with chronic pain or who were pain-free; and (ii) applied a CPM paradigm comprising both a painful test and conditioning stimuli that were sufficiently detailed to allow for replication,(iii) adhered to a study design of randomised control trial, case control or cohort study, including cross-sectional or longitudinal; (iv) available in the English language. Study exclusion criteria were: (i) The CPM paradigm used a non-painful test or conditioning stimulus only; and (ii) was only available as an abstract, letter, poster, editorial, case report, or review with or without meta-analyses. Risk of bias was assessed using the Appraisal Tool for Cross Sectional Studies (AXIS). Meta-analyses were conducted in Comprehensive Meta Analysis 3.0 using random effects models to compare the overall CPM responses in CYP with chronic pain conditions to healthy control CYP. Results: Thirty-two studies were eligible for inclusion, six of which were included in one or more meta-analysis (n = 407 chronic pain, n = 205 control). Meta-analysis revealed significantly weaker CPM responses in CYP with a variety of chronic pain conditions compared to healthy controls (standardized mean difference (SMD) = 0.352), and significantly weaker CPM responses in CYP with abdominal pain conditions compared to healthy controls (SMD = 0.685). No significant difference in CPM response was found between CYP with migraine and healthy controls (SMD = −0.201). Conclusions: Variable results were found across individual studies, and the meta-analysis of the small number of eligible studies provides tentative evidence for impaired CPM in CYP with chronic pain compared to healthy controls. Further research is clearly needed. In particular, studies should present CPM results separately for different age groups, ethnic groups, and sexes, as these variables shape clinical pain responses.

Editor—Paediatric chronic pain is a significant clinical problem.1Miró J. McGrath P.J. Finley G.A. Walco G.A. Pediatric chronic pain programs: current and ideal practice.Pain Rep. 2017; 2: e613Crossref PubMed Scopus (28) Google Scholar The experience, severity, and impact of chronic pain are shaped by a complex interaction of biological, psychological, and social factors.2Liossi C. Howard R.F. Pediatric chronic pain: biopsychosocial assessment and formulation.Pediatrics. 2016; 138e20160331Crossref PubMed Scopus (116) Google Scholar,3Rajapakse D. Liossi C. Howard R.F. Presentation and management of chronic pain.Arch Dis Child. 2014; 99: 474-480Crossref PubMed Scopus (45) Google Scholar Multimodal interdisciplinary interventions are essential in the management of paediatric chronic pain.4Liossi C. Johnstone L. Lilley S. Caes L. Williams G. Schoth D.E. Interdisciplinary interventions for pediatric chronic pain: a systematic review and meta-analysis.Br J Anaesth. 2019; 123: e359-e371Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar,5Hechler T. Kanstrup M. Holley A.L. et al.Systematic review on intensive interdisciplinary pain treatment of children with chronic pain.Pediatrics. 2015; 136: 115-127Crossref PubMed Scopus (150) Google Scholar To select the best course of treatment, accurate diagnostic methods are needed to precisely differentiate between pain phenotypes.6Bordeleau M. Léonard G. Gauthier L. et al.Classification of qualitative fieldnotes collected during quantitative sensory testing: a step towards the development of a new mixed methods approach in pain research.J Pain Res. 2021; 14: 2501-2511Crossref PubMed Scopus (5) Google Scholar Sensory profiling is useful for differentiating between pain phenotypes, which can be investigated using quantitative sensory testing,7Baron R. Förster M. Binder A. Subgrouping of patients with neuropathic pain according to pain-related sensory abnormalities: a first step to a stratified treatment approach.Lancet Neurol. 2012; 11: 999-1005Abstract Full Text Full Text PDF PubMed Scopus (210) Google Scholar a range of noninvasive techniques for exploring somatosensory processing that relies on the individual’s subjective report to a standardised stimulus.8Yarnitsky D. Quantitative sensory testing.Muscle Nerve. 1997; 20: 198-204Crossref PubMed Scopus (242) Google Scholar Quantitative sensory testing is a feasible technique in children,9Blankenburg M. Boekens H. Hechler T. et al.Reference values for quantitative sensory testing in children and adolescents: developmental and gender differences of somatosensory perception.Pain. 2010; 149: 76-88Abstract Full Text Full Text PDF PubMed Scopus (140) Google Scholar,10van den Bosch G.E. van Dijk M. Tibboel D. Valkenburg A.J. Thermal quantitative sensory testing in healthy Dutch children and adolescents standardized test paradigm and Dutch reference values.BMC Pediatr. 2017; 17: 77Crossref PubMed Scopus (20) Google Scholar although before any test is widely adopted in clinical care evaluation of its psychometric properties is needed to ascertain its meaningfulness, appropriateness, and usefulness. The primary objective of this systematic review was to examine the association between established quantitative sensory testing measures and pain intensity or disability in paediatric chronic pain. Further objectives were to assess whether the strength of these relationships was moderated by variables related to the quantitative sensory testing method and pain condition; examine the use of quantitative sensory testing in paediatric chronic pain (including modalities, outcome measures, and anatomical test sites, differentiating between pain mechanisms (e.g. neuropathic vs nociceptive) and in selecting analgesics); assess the reliability of quantitative sensory testing; evaluate the ability of quantitative sensory testing to differentiate patients with paediatric chronic pain from healthy controls; and consider whether there are differences in the above between anatomical test sites. The protocol was registered on PROSPERO (CRD42019134069) and published.11Schoth D.E. Blankenburg M. Wager J. et al.The association between quantitative sensory testing and pain or disability in paediatric and young adult chronic pain: protocol for a systematic review and meta-analysis.BMJ Open. 2019; 9 (e031861)Crossref Scopus (5) Google Scholar MEDLINE, PsycINFO, CINAHL, Web of Science, SCOPUS, Cochrane Library, and OpenGrey databases were searched from inception until May 25, 2021 (Supplementary material). Studies were eligible for inclusion if they were available in English, recruited a sample aged 6–24 yr old (inclusive) with chronic pain, applied at least one quantitative sensory testing modality, and used a quantitative sensory testing protocol allowing reliable replication. Studies were excluded if they used an invasive form of quantitative sensory testing (e.g. rectal barostat), examined pain modulation only, or only provided correlations between pain intensity or disability and quantitative sensory testing composite scores. Study quality was assessed using the Appraisal Tool for Cross Sectional Studies (AXIS).12Downes M.J. Brennan M.L. Williams H.C. Dean R.S. Development of a critical appraisal tool to assess the quality of cross-sectional studies (AXIS).BMJ Open. 2016; 6 (e011458)Crossref PubMed Scopus (1008) Google Scholar Meta-analyses were performed where data from two or more eligible studies were available, with data grouped into clinically meaningful diagnostic categories (e.g. juvenile arthritis). Full details on meta-analytic methods are provided in Supplementary material. The study selection process is shown in Supplementary Figure S1. Of the 60 studies selected, 27 were included in one or more meta-analysis. A detailed description of each study is provided in Supplementary Table S1. Studies recruited patients with a wide range of diagnoses, with headache the most common. The quantitative sensory testing procedures and parameters performed are reported in Supplementary Table S2. Pressure quantitative sensory testing was the most common. Testing location varied considerably across studies. No study assessed quantitative sensory testing in relation to analgesic treatment. Only five studies commented on the quantitative sensory testing psychometric properties for the samples recruited. Quality assessment and risk of bias ratings for each study are shown in Figure 1. All studies used appropriate quantitative sensory testing methods, although many did not explicitly state that they had used a protocol that had been trialled, piloted, or published previously or if researchers were trained in quantitative sensory testing. Full meta-analytic results are presented in Supplementary material. Few studies explored the relationship between pain intensity, disability, or both and quantitative sensory testing outcomes. Lower pressure pain detection thresholds at the trapezius were associated with higher pain/headache intensity in children with tension-type headache {Analysis 11: n=60, k=2, point estimate=−0.42 (95% confidence interval [CI]: −0.62 to −0.18, z=−3.31, P=0.001, Q=0.008, P=0.930, I2<0.001)}, and poorer functioning was associated with lower pressure pain detection thresholds in children with juvenile arthritis (Analysis 19: n=115, k=2, point estimate=−0.36 [95% CI: −0.60 to −0.07, z=−2.43, P=0.015, Q=2.66, P=0.103, I2=62.40]). Additional meta-analytic results revealed children with tension-type headache (Analysis 7: tension-type n=155, control n=229, k=4, standardized mean difference (SMD)=−2.33 [95% CI: −4.14 to −0.52, z=−2.52, P=0.012, Q=139.90, P<0.001, I2=97.90]), juvenile arthritis (Analysis 12: arthritis n=88, control n=160, k=2, SMD=−0.72 [95% CI: −0.99 to −0.45, z=−5.26, P<0.001, Q=0.49, P=0.49, I2<0.001]), and mixed chronic pain (Analysis 25: chronic pain n=241, control n=790, k=2, SMD=−0.31 [95% CI: −0.62 to −0.01, z=2.02, P=0.044, Q=2.12, P=0.145, I2=52.81]) had significantly lower pressure pain detection thresholds at pain sites than healthy children. Effect sizes are presented in Figure 2. Lower pressure pain detection threshold values were observed at pain test sites across chronic pain samples compared with healthy controls, and were correlated with higher pain/headache intensity and poorer functioning in children with tension-type headaches and juvenile arthritis, respectively. Complex neurobiological and psychosocial processes may account for the differences in pressure pain detection thresholds2Liossi C. Howard R.F. Pediatric chronic pain: biopsychosocial assessment and formulation.Pediatrics. 2016; 138e20160331Crossref PubMed Scopus (116) Google Scholar; further research is needed to describe these processes and to identify the time frames in which these changes occur. Quantitative sensory testing is increasingly used to assess somatosensory functioning in children, predominantly in observational studies. The limited number of studies aiming to understand pain mechanisms or predict response to therapy, in combination with variation in study samples and quantitative sensory testing procedures, precluded us from addressing most of our objectives. Research is needed to establish whether quantitative sensory testing in children offers benefits over and above a comprehensive clinical assessment that includes a standard neurological evaluation. Studies should follow a standardised protocol such as that of the German research network on neuropathic pain (DFNS)9Blankenburg M. Boekens H. Hechler T. et al.Reference values for quantitative sensory testing in children and adolescents: developmental and gender differences of somatosensory perception.Pain. 2010; 149: 76-88Abstract Full Text Full Text PDF PubMed Scopus (140) Google Scholar,13Rolke R. Baron R. Maier C. et al.Quantitative sensory testing in the German research network on neuropathic pain (DFNS): standardized protocol and reference values.Pain. 2006; 123: 231-243Abstract Full Text Full Text PDF PubMed Scopus (1784) Google Scholar or justify protocol modifications, and provide details on the training and experience of quantitative sensory testing assessors. The heterogeneity observed in several of the meta-analyses may be partly attributable to differences in quantitative sensory testing methods and assessor training/experience. Studies should provide details on sample size calculations, and recruit large enough samples to ensure adequate power for the statistical tests used. To achieve mechanism-based personalised pain management, there is a need for large international, multicentre studies to ascertain whether quantitative sensory testing responses are stable and reproducible in the paediatric pain population, and to explore clinical applications in evaluating responses to interventions, along with patient profiling and monitoring of somatosensory dysfunctions over time. The authors declare that they have no conflicts of interest. The following are the Supplementary data to this article: Supplementary material is available at British Journal of Anaesthesia online. Download .docx (.02 MB) Help with docx files Supplementary Material 1 Download .docx (.04 MB) Help with docx files Supplementary Material 2 Download .docx (.14 MB) Help with docx files Supplementary Material 3 Download .docx (.59 MB) Help with docx files Table S1 Download .docx (.04 MB) Help with docx files Table S2 Download .doc (.03 MB) Help with doc files Figure S1

Background: Adolescent chronic pain is prevalent, and interdisciplinary treatment is recommended. Although it is welt known that technology is a key part of adolescents' daily lives, there have not been any online, interdisciplinary interventions developed for adolescents with chronic pain in a UK healthcare context. Little is known about how adolescents currently use online resources to manage chronic pain, or what guidance they seek. Methods: Ninety-five participants from the community answered this mixed-methods, online survey (adolescent n=54, parent n=41), which assessed the needs of UK-based adolescents for a new online chronic pain management resource. Results: Findings indicated that, at the time of the survey, adolescents frequently used social media platforms, such as instagram, for chronic pain management. Desired techniques for a new interdisciplinary resource for adolescents included 'advice on explaining chronic pain to others' (86.7% of adolescents) and sleep hygiene (82.2% of adolescents), though access to a range of pain management techniques was desired. Qualitative results indicated endorsement of a new programme by adolescents and parents. Conclusions: Adolescents and parents had a positive outlook towards the development of a UK-specific online resource to help manage chronic pain. Such an intervention should aim to be made accessible via the National Health Service. Adolescent use of social media platforms to seek support for chronic pain requires further exploration in future research.

This systematic review and meta-analysis aimed to evaluate the evidence pertaining to attentional bias for painful and nonpainful somatosensory stimuli in individuals with chronic pain. Eligible studies were identified through searches of Medline, PsycINFO, CINAHL, Web of Science, Scopus, and Cochrane Library databases. Search terms were words and phrases organised into 3 concept blocks: pain condition, cognitive process, and stimuli/paradigm. The search identified 29 eligible studies (reporting 32 eligible experiments), of which quantitative meta-analysis was possible for 16 studies (19 experiments). The meta-analysis found that chronic pain patients, excluding somatoform pain patients, showed significantly greater attentional bias to stimuli in the somatosensory modality than healthy controls (k = 9, g = 0.34). In addition, meta-analysis of studies that used a temporal order judgement task found that patients with unilateral chronic pain showed a spatial attentional bias away from somatosensory stimuli (k = 7, effect estimate = 22.43 ms) and visual stimuli (k = 2, effect estimate = 13.75 ms) on or near the painful body side. Most studies of attentional bias to the somatosensory modality recruited samples of patients with fibromyalgia, whereas most studies of spatial attentional bias assessed patients with complex regional pain syndrome. The extent to which these results generalise to other pain conditions is therefore unclear. We recommend future research test spatial and modality attentional biases across chronic pain conditions and examine the psychometric properties of attentional bias measurement paradigms for use with chronic pain populations. PROSPERO registration number CRD42019124510.

ABSTRACT Attentional bias to pain-related information may contribute to chronic pain maintenance. It is theoretically predicted that attentional bias to pain-related language derives from attentional bias to painful sensations; however, the complex interconnection between these types of attentional bias has not yet been tested. This study aimed to investigate the association between attentional bias to pain words and attentional bias to the location of pain, as well as the moderating role of pain-related interpretation bias in this association. Fifty-four healthy individuals performed a visual probe task with pain-related and neutral words, during which eye movements were tracked. In a subset of trials, participants were presented with a cold pain stimulus on one hand. Pain-related interpretation and memory biases were also assessed. Attentional bias to pain words and attentional bias to the pain location were not significantly correlated, although the association was significantly moderated by interpretation bias. A combination of pain-related interpretation bias and attentional bias to painful sensations was associated with avoidance of pain words. In addition, first fixation durations on pain words were longer when the pain word and cold pain stimulus were presented on the same side of the body, as compared to on opposite sides. This indicates that congruency between the locations of pain and pain-related information may strengthen attentional bias. Overall, these findings indicate that cognitive biases to pain-related information interact with cognitive biases to somatosensory information. The implications of these findings for attentional bias modification interventions are discussed.

BACKGROUND:Many online interventions for paediatric chronic pain have been developed and evaluated. In accordance with the biopsychosocial model, the recommended treatment approach for chronic pain is multidisciplinary. Despite this, multidisciplinary components within existing online interventions have not been examined. The objective of the present review was to summarise and evaluate the content of existing online interventions for paediatric chronic pain by mapping intervention content to evidence-based guidelines for chronic pain management.METHODS:Interventions were identified using an updated systematic review. Nine chronic pain management strategies that reflect evidence-based guidance for multidisciplinary chronic pain management were defined by the authors, examples of which include 'pain education', 'activity pacing' and 'physiotherapy'. Identified interventions were then coded against the target strategies. These codes were compiled descriptively to provide an overview of how well each chronic pain management strategy was represented across the dataset, and which interventions represented the most strategies.RESULTS:Thirty-five articles, relating to 13 unique interventions for paediatric chronic pain management were identified; few encompassed a complete multidisciplinary approach. Many CBT-based interventions included multidisciplinary elements. Across interventions, physiotherapy and non-pharmacological physical therapies were the least represented chronic pain management strategies.CONCLUSIONS:The content analysis revealed a lack of online interventions encompassing complete multidisciplinary pain management. It is important that new interventions for paediatric chronic pain management are evidence-based and reflect current best practice guidelines. Established intervention development approaches should be utilised and include a process evaluation to help identify which intervention components are effective in which contexts.SIGNIFICANCE:This content analysis of online interventions for paediatric chronic pain highlights the need for multidisciplinary practices in pain management to be translated into online interventions. Improving the availability of pain management resources is essential for many families who cannot attend specialist pain clinics, particularly in the context of the COVID-19 pandemic. There is potential for new resources, as well as for established resources, to be further developed to deliver a broader range of pain management content.

Background: Symptom management for infants, children and young people at end of life is complex and challenging due to the range of conditions and differing care needs of individuals of different ages. A greater understanding of these challenges could inform the development of effective interventions. Aim: To investigate the barriers and facilitators experienced by patients, carers and healthcare professionals managing symptoms in infants, children and young people at end of life. Design: A mixed-methods systematic review and meta-analysis was undertaken (PROSPERO ID: CRD42019124797). Data sources: The Cochrane Library, PROSPERO, CINAHL, MEDLINE, PsycINFO, Web of Science Core Collection, ProQuest Dissertations & Theses Database, Evidence Search and OpenGrey were electronically searched from the inception of each database for qualitative, quantitative or mixed-methods studies that included data from patients, carers or healthcare professionals referring to barriers or facilitators to paediatric end-of-life symptom management. Studies underwent data extraction, quality appraisal, narrative thematic synthesis and meta-analysis. Results: A total of 64 studies were included (32 quantitative, 18 qualitative and 14 mixed-methods) of medium-low quality. Themes were generated encompassing barriers/facilitators experienced by carers (treatment efficacy, treatment side effects, healthcare professionals’ attitudes, hospice care, home care, families’ symptom management strategies) and healthcare professionals (medicine access, treatment efficacy, healthcare professionals’ demographics, treatment side effects, specialist support, healthcare professionals’ training, health services delivery, home care). Only one study included patients’ views. Conclusion: There is a need for effective communication between healthcare professionals and families, more training for healthcare professionals, improved symptom management planning including anticipatory prescribing, and urgent attention paid to the patients’ perspective.

IntroductionChronic musculoskeletal pain is a complex medical condition that can significantly impact quality of life. Patients with chronic pain demonstrate attentional biases towards pain-related information. The therapeutic benefits of modifying attentional biases by implicitly training attention away from pain-related information towards neutral information have been supported in a small number of published studies. Limited research however has explored the efficacy of modifying pain-related biases via the internet. This protocol describes a randomised, double-blind, internet-delivered attentional bias modification intervention, aimed to evaluate the efficacy of the intervention on reducing pain interference. Secondary outcomes are pain intensity, state and trait anxiety, depression, pain-related fear, and sleep impairment. This study will also explore the effects of training intensity on these outcomes, along with participants’ perceptions about the therapy.Methods and analysisThe study is a double-blind, randomised controlled trial with four arms exploring the efficacy of online attentional bias modification training versus placebo training theorised to offer no specific therapeutic benefit. Participants with chronic musculoskeletal pain will be randomised to one of four groups: (1) 10-session attentional modification group; (2) 10-session placebo training group; (3) 18-session attentional modification group; or (4) 18-session placebo training group. In the attentional modification groups, the probe-classification version of the visual-probe task will be used to implicitly train attention away from threatening information towards neutral information. Following the intervention, participants will complete a short interview exploring their perceptions about the online training. In addition, a subgroup analysis for participants aged 16–24 and 25–60 will be undertaken.Ethics and disseminationThis study has been approved by the University of Southampton Research Ethics Committee. Results will be published in peer-reviewed journals, academic conferences, and in lay reports for pain charities and patient support groups.Trial registration numberNCT02232100; Pre-results.

INTRODUCTION:Breakthrough pain is common in children and adults with cancer and other conditions, including those approaching end-of-life, although it is often poorly managed, possibly partly due to a lack of validated assessment tools. This review aims to (1) identify all available instruments measuring breakthrough pain in infants, children, adolescents or adults and (2) critically appraise, compare and summarise the quality of the psychometric properties of the identified instruments using COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) criteria.METHODS AND ANALYSIS:Two searches will be carried out between October 2019 and January 2020, one for each aim of the review. The Cochrane Library, International Prospective Register of Systematic Reviews, Embase, Cumulative Index of Nursing and Allied Health Literature, Medical Literature Analysis and Retrieval System Online (MEDLINE), PsycINFO, Web of Science Core Collection, Google Scholar, the ProQuest Dissertations & Theses Database, Evidence Search and OpenGrey databases will be searched from database inception until the date the search is conducted. Reference lists of eligible articles will be screened and authors in the field contacted. For search 1, articles will be screened by two reviewers by abstract, and full-text where necessary, to identify if a breakthrough pain assessment was used. Search 2 will then be conducted to identify studies evaluating measurement properties of these assessments. Two reviewers will screen articles from search 2 by title and abstract. All potentially relevant studies will be screened by full text by both reviewers. For search 2, data will be extracted in parallel with the quality assessment process, as recommended by COSMIN. Two reviewers will assess methodological quality using the COSMIN Risk of Bias checklist and the COSMIN updated criteria for good measurement properties. Findings will be summarised and, if possible, data will be pooled using meta-analysis. The quality of the evidence will be graded and summarised using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) guidelines.ETHICS AND DISSEMINATION:Results of this review will be submitted for publication in a peer review journal and presented at conferences.PROSPERO REGISTRATION NUMBER:CRD42019155583.

Pain-related memory biases have been frequently explored in individuals with chronic pain, and along with attentional and interpretation biases are hypothesised to contribute to the onset and/or maintenance of chronic pain. The aim of this review is to provide a systematic review and synthesis of studies exploring memory recall biases for pain-related information in individuals with chronic pain relative to healthy controls and the recall of neutral information. Studies were identified through a search of Medline, PsychINFO, Web of Science, CINAHL, Cochrane Library, and Open Grey databases. Search terms were memory, recall, recognition, and bias*, intersected with pain. Eighteen studies meeting the inclusion criteria were included. Subset meta-analyses are also reported from 12 studies with relevant between-groups data (comparing recall in chronic pain vs healthy control groups) and 12 studies with relevant within-groups data (eg, comparing recall of pain-related/emotional vs neutral words). Between-groups analysis revealed significantly weaker recall bias for affective-pain words in individuals with chronic pain relative to healthy controls, but only when nondepressed chronic pain individuals were included. No significant differences were found between groups in the recall of sensory-pain, illness-related, or depression-related words. Within-groups analysis revealed individuals with chronic pain show a significant recall bias favouring sensory-pain words relative to neutral and affective-pain words, and a bias for illness-related words relative to depression-related words. A recall bias favouring neutral words was found in healthy individuals. Evidence for the presence of pain-related memory biases in patients with chronic pain is inconclusive. Further methodologically rigorous research is required.

Background: Paediatric chronic pain is a significant problem that can have devastating impacts on quality of life. Multimodal interdisciplinary interventions are the mainstay of paediatric treatment. The aim of this article is to provide a comprehensive review of the effectiveness of interdisciplinary interventions in the management of paediatric chronic pain. Methods: Studies were identified via a search of nine databases. The search strategy included concept blocks pertaining to type of pain, study population, and type of intervention. Eligible studies reported the effects of an intervention coordinated by two or more healthcare professionals of different disciplines, and recruited a sample aged 22 yr or below with chronic pain. Twenty-eight studies were included, and 21 provided data for inclusion in between- and within-groups meta-analyses. Results: Patients randomised to interdisciplinary interventions reported significantly lower pain intensity 0-1 month post-intervention compared with patients randomised to the control groups. Within-groups analysis of patients receiving interdisciplinary interventions showed significant improvements pre- to post-intervention in pain intensity, functional disability, anxiety, depression, catastrophising, school attendance, school functioning, and pain acceptance. Few differences were found between interventions delivered in inpatient vs outpatient settings. Significant heterogeneity due mainly to differing outcome variables and intervention content was found in most analyses. Conclusions: Overall, interdisciplinary interventions show promise in providing a range of clinical benefits for children with chronic pain. Methodologically robust randomised controlled trials using standardised outcome measures are needed, however, to guide clinical care.

INTRODUCTION:This protocol describes the objective and methods of a systematic review of barriers and facilitators experienced by patients, carers and healthcare professionals when managing symptoms in infants, children and young people (ICYP) at end-of-life.METHODS AND ANALYSIS:The Cochrane Library, PROSPERO, CINAHL, MEDLINE, PsycINFO, Web of Science Core Collection, ProQuest Dissertations & Theses Database, Evidence Search and OpenGrey will be electronically searched. Reference screening of relevant articles and inquiries to researchers in the field will be undertaken. Studies will be selected if they apply qualitative, quantitative or mixed-methods designs to explore barriers and facilitators experienced by patients, carers and healthcare professionals when managing symptoms in ICYP at end-of-life.Articles will be screened by title and abstract by one reviewer with a second reviewer assessing 10% of the articles. Both reviewers will read and screen all remaining potentially relevant articles. For included articles, one reviewer will extract study characteristics and one will check this.Both reviewers will undertake independent quality assessments of included studies using established and appropriate checklists including The Critical Appraisal Skills Programme Qualitative Checklist; The evaluative criteria of credibility, transferability, dependability and confirmability; The Quality Assessment Tool for Quantitative Studies, and The Mixed Methods Appraisal Tool. Data synthesis methods will be decided after data extraction and assessment.ETHICS AND DISSEMINATION:This review will inform our understanding of symptom management in ICYP at end-of-life. The findings will be reported in a peer-reviewed journal and presented at conferences. The study raises no ethical issues.PROSPERO REGISTRATION NUMBER:CRD42019124797.

Introduction This protocol describes the objective and methods of a systematic review of the association between quantitative sensory testing (QST) measures and pain intensity or disability in paediatric chronic pain (PCP). The review will also assess whether the relationship strength is moderated by variables related to the QST method and pain condition; the use of QST in PCP (modalities, outcome measures and anatomical test sites as well as differentiating between pain mechanisms (eg, neuropathic vs nociceptive) and in selecting analgesics); the reliability of QST across the paediatric age range; the ability of QST to differentiate patients with chronic pain from healthy controls; and differences between anatomical test sites. Methods and analysis Medline, PsycINFO, CINHAL, Web of Science, Scopus, Cochrane Library and OpenGrey will be searched. English language studies will be eligible if they recruit a sample aged 6–24 (inclusive) with chronic pain, including primary and secondary pain; apply at least one of the following QST modalities: chemical, electrical, mechanical (subgroups include pressure, punctate/brush and vibratory) or thermal stimulus to measure perception of noxious or innocuous stimuli applied to skin, muscle or joint; use a testing protocol to control for stimulus properties: modality, anatomical site, intensity, duration and sequence. Following title and abstract screening, the full texts of relevant records will be independently assessed by two reviewers. For eligible studies, one reviewer will extract study characteristics and data, and another will check for accuracy. Both will undertake independent quality assessments using the Appraisal Tool for Cross-Sectional Studies. A qualitative synthesis will be presented with discussion centred around different QST modalities. Where eligible data permit, meta-analyses will be performed separately for different QST modalities using comprehensive meta-analysis. Ethics and dissemination Review findings will be reported in a peer-reviewed journal and presented at conferences. The study raises no ethical issues. PROSPERO registration number CRD42019134069.

Background Pain-related cues are evolutionarily primed to capture attention, although evidence of attentional biases towards pain-related information is mixed in healthy individuals. The present study explores whether healthy individuals show significantly different eye-movement behaviours when viewing real-world pain-related scenes compared to neutral scenes. The effect of manipulating via written information the threat value of the pain-related scenes on eye-movement behaviours was also assessed. Methods Participants were randomized to threatening (n = 28) and non-threatening (n = 27) information conditions. All completed a free-viewing task with real-world pain-related and neutral images while their eye movements were recorded. Results Participants made significantly fewer fixations of significantly longer duration when viewing pain-related images compared to neutral images. No significant differences were found between threatening and non-threatening information groups in their pattern of eye movements. Conclusions This study shows that healthy individuals demonstrate attentional biases to pain-related real-world complex images compared to neutral images. Future research is needed to establish the implications of these biases, particularly in the context of acute pain, on the onset and/or subsequent maintenance of chronic pain conditions. Significance Healthy individuals show different eye-movement behaviours when viewing pain-related scenes than neutral scenes, supporting evolutionary accounts of pain. Implications for the onset and/or maintenance of chronic pain need to be explored.

INTRODUCTION:Cognitive biases in attention, interpretation and less consistently memory have been observed in individuals with chronic pain and play a critical role in the onset and maintenance of chronic pain. Despite operating in combination cognitive biases are typically explored in isolation.AIM:The primary aim of this study was to explore attentional, interpretation and memory biases and their interrelationship in individuals with chronic headache.METHODS:Twenty-eight participants with chronic headache and 34 healthy controls completed paradigms assessing attentional, interpretation and memory biases with ambiguous sensory-pain and neutral words.RESULTS:Individuals with chronic pain showed significantly greater pain-related attentional and interpretation biases relative to controls, with no differences in memory bias. No significant correlation was found between any of the three forms of cognitive bias assessed.DISCUSSION AND CONCLUSION:The clinical implications of cognitive biases in individuals with chronic pain remain to be fully explored, although one avenue for future research would be specific investigation of the implications of biased interpretations considering the consistency of results found across the literature for this form of bias.

Abstract Online educational interventions are increasingly developed for health professionals and students, although graduate and undergraduate medical curricula often contain limited information about how to assess and manage pain. This study reviews the literature on the effectiveness of pain-related online educational resources. Studies were identified through a search of Medline, PsychINFO, Web of Science, CINAHL, PubMed, Scopus, Cochrane Library, Google Scholar, and OpenGrey databases. Search terms included 3 concept blocks: (1) type of intervention—online education, computer-based, e-learning, web-based, and internet-based; (2) population—pediatrician, physician, nurse, psychologist, and medical; and (3) outcome—pain*. Thirty-two studies (13 randomised controlled trials, 5 nonrandomised controlled trials, and 14 single-group pre–post studies) were included. Ten provided data for inclusion in a series of between-groups meta-analyses. After intervention, participants receiving online instruction had significantly greater knowledge compared with those receiving training as usual/alternative training (Hedges' g = 0.80, 95% confidence interval [CI]: 0.12-1.49), and students had significantly greater skills compared with students receiving training as usual (g = 1.34, CI: 0.38-2.30). No significant differences were found for confidence/competence (g = 0.02, CI: −0.79 to 0.84) or attitudes/beliefs (g = 0.16, CI: −0.48 to 0.79). Although online educational resources show promise in improving learner knowledge, considerable heterogeneity exists between studies in quality, design, educational content, and outcomes. Furthermore, methodologically robust RCTs are required to establish the effectiveness of online educational interventions and a greater understanding of the key features of successful online resources, including cognitive interactivity. Few studies assessed health outcomes for patients, remaining a major priority for future investigations.

The aim of this review is to synthesise the existing data regarding the content and effectiveness of interdisciplinary interventions for paediatric chronic pain. Specifically, the following questions will be addressed: • How effective are existing interdisciplinary interventions for paediatric chronic pain? • Which outcome measures are used in existing interdisciplinary interventions for paediatric chronic pain?