Emerging research suggests that pain may persist longer-term for many children after major surgery, with significant impact on their health outcomes. This systematic review identified the prevalence of chronic postsurgical pain (CPSP) in children after surgery, and determined presurgical biomedical and psychosocial risk factors associated with CPSP prevalence or severity. Prospective studies assessing CPSP 3–12 months after surgery in children 6–18 years of age published in English in MEDLINE, EMBASE, PsycINFO, and Cochrane Database of Systematic Reviews since 1996 were eligible for inclusion. Of 16,084 abstracts yielded by the search, 123 full manuscripts were assessed for eligibility, and 12 studies were included in the review. Overall quality of included studies assessed using the Quality in Prognostic Studies tool was low. Based on 4 studies with a total of 628 participants across all surgery types, median prevalence of CPSP across studies was 20% (25th percentile=14.5%, 75th percentile=38%) at 12 months after surgery. Presurgical pain intensity, child anxiety, child pain coping efficacy, and parental pain catastrophizing were the only presurgical factors identified as predictive of CPSP. Biological and medical factors assessed were not associated with CPSP in any study. Well-designed studies examining prevalence and predictors of CPSP are critically needed in children.
BackgroundPersistent pain and psychological distress are common after traumatic musculoskeletal injury (TMsI). Individuals sustaining a TMsI are often young, do not recover quickly, and place a large economic burden on society.ObjectivesThe aim of this systematic review is to determine (1) the incidence of persistent pain following TMsI, (2) the characteristics of pain, characterized by injury severity and type, and (3) risk and protective factors associated with persistent pain following TMsI.MethodsA systematic search of electronic databases (MEDLINE®, PubMed®, Embase, and PsycINFO®) was conducted for prospective, interventional, or noninterventional studies measuring the incidence of pain associated with TMsI.ResultsThe search revealed 4388 studies. Eleven studies examined persistent pain and met inclusion criteria. Pain was assessed using a validated measure of pain intensity or pain presence in six studies. Persistent pain was reported by all studies at variable time points up to 84 months postinjury, with wide variation among studies in pain intensity (ie, from mild to very severe) and pain incidence at each time point. The incidence of pain decreased over time within each study. Two studies found significant relationships between injury severity and persistent pain. Frequently cited predictive factors for persistent pain included: symptoms of anxiety and depression, patient perception that the injury was attributable to external sources (ie, they were not at fault), cognitive avoidance of distressing thoughts, alcohol consumption prior to trauma, lower educational status, being injured at work, eligibility for compensation, pain at initial assessment, and older age.Conclusion and implicationsThe evidence from the eleven studies included in this review indicates that persistent pain is prevalent up to 84 months following traumatic injury. Further research is needed to better evaluate persistent pain and other long-term posttraumatic outcomes.
Unlike acute pain that warns us of injury or disease, chronic or persistent pain serves no adaptive purpose. Though there is no agreed on definition of chronic pain, it is commonly referred to as pain that is without biological value, lasting longer than the typical healing time, not responsive to treatments based on specific remedies, and of a duration greater than 6 months. Chronic pain that is severe and intractable has detrimental consequences, including psychological distress, job loss, social isolation, and, not surprisingly, it is highly comorbid with depression and anxiety. Historically, pain without an apparent anatomical or neurophysiological origin was labelled as psychopathological. This approach is damaging to the patient and provider alike. It pollutes the therapeutic relationship by introducing an element of mutual distrust as well as implicit, if not explicit, blame. It is demoralizing to the patient who feels at fault, disbelieved, and alone. Moreover, many medically unexplained pains are now understood to involve an interplay between peripheral and central neurophysiological mechanisms that have gone awry. The new Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, somatic symptom disorder overpsychologizes people with chronic pain; it has low sensitivity and specificity, and it contributes to misdiagnosis, as well as unnecessary stigma. Adjustment disorder remains the most appropriate, accurate, and acceptable diagnosis for people who are overly concerned about their pain.
BackgroundChronic postsurgical pain (CPSP) is a surgical complication associated with increased functional disability, psychological distress, and economic costs. The aims of this paper were to prospectively: (1) examine the incidence of CPSP 6 and 12 months after pediatric major surgery; (2) identify pain intensity and pain unpleasantness trajectories before, and up to 12 months after, surgery; (3) identify pre-operative factors that predict pain trajectory group membership; and (4) identify predictors of 12-month functional disability.MethodsThis study followed 265 children aged 8–17 years at four time points (pre-surgical [T0], in-hospital [T1], 6 [T2] and 12 [T3] months after surgery). Children and parents completed pain and psychological questionnaires. In-hospital physical activity was monitored using actigraphy.Results and discussionThe incidence of moderate-to-severe CPSP at 6 and 12 months was 35% (95% CI 29.1% to 41.9%) and 38% (95% CI 32.4% to 45.1%), respectively. Three percent (95% CI 1.17% to 6.23%) and 4% (95% CI 1.45% to 6.55%) of children reported using opioids to manage pain at 6 and 12 months, respectively. Growth mixture modeling revealed a two-class trajectory model with a quadratic slope best fit the data for both pain intensity (Bayesian information criterion [BIC] = 3977.03) and pain unpleasantness (BIC = 3644.45) over the 12 months. Preoperative functional disability and cumulative in-hospital opioid consumption predicted pain intensity trajectories. Preoperative functional disability predicted pain unpleasantness trajectories. Preoperative functional disability (OR: 1.05, 95% CI: 1.01 to 1.09) and pain unpleasantness trajectories (OR: 2.59, 95% CI: 1.05 to 6.37) predicted 12-month moderate-to-severe functional disability.ConclusionPre-surgical functional disability is the only factor that predicts both 12-month functional disability and the course of pain intensity and pain unpleasantness ratings over the 12-month period.
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