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Bidirectional associations between pain and physical activity in adolescents
Abstracts (228) Can bidirectional changes facilitate pain following nerve injury? A case report and discussion M Kaur, K Donnelly, H Wang, G Bernardini, F Rice, P Albrecht, J Wymer, and C Argoff; Albany Medical Center, Albany, NY
The Journal of Pain
S33
B14 Pain in Children (230) Bidirectional associations between pain and physical activity in adolescents
Central Post Stroke Pain Syndrome (CPSP) is a neuropathic pain syndrome that can occur following a stroke. We present a 65 year old female with no previous pain complaints nor peripheral neuropathy, who developed intractable, unremitting dysesthesia described as burning pain in her left upper and lower extremities following a right basal ganglia hemmorragic stroke confirmed by neuroImaging. She was diagnosed with CPSP and all initial attempts to manage her pharmacologically and non-pharmacologically were suboptimal. A 3mm skin biopsy of her left lower extremity was performed to evaluate for possible peripheral nervous system dysfunction. Results demonstrated reduced epidermal nerve fiber density, consistent with small fiber neuropathy. A subsequent nerve conduction study revealed an axonal peripheral neuropathy. She was also found by magnetic resonance imaging to have multilevel cervical and lumbosacral degenerative disc disease. The concomitant existence of CPSP, peripheral neuropathy, as well as spinal degenerative disease may have collectively contributed to her symptoms. To our knowledge, these three entities have not been previously described to coexist and contribute to this type of clinical presentation. In particular, the skin biopsy findings have not been described in this setting. Recognizing the coexisting peripheral and central nervous system contributions may have significant clinical implications for both diagnosis and treatment as well as to better understand the bidirectional changes (peripheral and central) that may facilitate pain following nerve injury. This patients’ course reinforces the need for a high clinical suspicion for alternative explanations when patients’ complaints do not respond adequately to established treatment.
J Rabbitts, A Lewandowski, G Tai, C Karlson, and T Palermo; Seattle Children’s Hospital, Seattle, WA
(229) Findings and treatment of a rare case presentation of painful neuroborreliosis
(231) Healthcare experiences of at-risk youth with sickle cell disease
S Shah and J Nagda; Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
A Jones, E Jacob, V Wong, C Hodge, M Lewis, and L Zeltzer; UCLA School of Nursing, Los Angeles, CA
The painful component of Neuroborreliosis is potentially a severe and debilitating complication of Lyme disease and is thoroughly underreported in pain literature. Case reports of successful treatment of pain component are also not well described. We describe a rare case of painful Neuroborreliosis successfully treated with neuropathic agent gabapentin. A 68 y male in usual health with 4 weeks history of progressive torso numbness, paresthesias, back pain, and proximal leg weakness. Six weeks prior to admission, noted acute episode of interscapular back pain after golfing in CT, progressive to flanks, groin and lower extremities bilaterally. No documentation of tick bite. PO opioid rotation unsuccessful. Rapid progressive weakness to lower extremity paraplegia upon presentation to hospital. Full diagnostic work-up: positive confirmatory serum IgM and IgG Lyme Ab by Western Blot. Patient diagnosed with Neuroborreliosis; discharged home with 3 weeks IV ceftriaxone with full neurological resolution, however with remanent pain symptoms. Patient presents to Pain Center three weeks post discharge. Intense pins/needles sensation in T8-T12 dermatomal distribution with significant hyperhydrosis on affected dermatomes. Physical exam demonstrates thoracolumbar neuropathy secondary to recent history of Lyme disease with inflammatory radiculopathy. Given neuropathic model of pain, patient prescribed gabapentin. Within three weeks of escalating doses of gabapentin, patient’s painful radiculitis completely resolved with total of 300mg BID dose. There is unclear mechanism of effects of Lyme disease on the nervous system, and particularly on dorsal column neurons. While case reports of neurologic sequelae of Lyme disease is plentiful in neurological literature, the painful syndromes and neuropathies that result are far more rare, and probably unknown to the pain physician. The use of gabapentin, even low dose, in this case shows very impressive result in treating painful Neuroborreliosis. (Halperin JJ. Curr Treat Options Neurol 2007.)
Children with Sickle Cell Disease (SCD) have elevated healthcare needs, frequently using outpatient and inpatient services for chronic pain management and acute vaso-occlusive pain crises. Few studies have examined barriers to care and healthcare experiences among this population. Such findings are needed to target systems interventions and improve the quality of life for children with SCD. The goal of this study was to identify barriers to care and perceptions of care among youth with SCD. Seventy-four youth, age 9-16, were recruited to participate in a wireless pain intervention. Parents (n=38) completed validated measures of healthcare experiences: Barriers to Care Questionnaire (BCQ), Parent’s Perceptions of Primary Care (P3C). Each scale ranges from 0-100 with higher scores indicating more positive experiences. Overall, we found that parents were satisfied with their child’s healthcare experiences: mean BTC = 79.2 (19.7); mean P3C = 78.1 (19.9). Pragmatic barriers such as ‘‘having to take time off work’’ and ‘‘having to wait long in the waiting room’’ were endorsed most frequently. Parents reported favorable experiences with provider communication, while expressing less favorable perceptions of access to care (e.g. ‘‘getting care on the same day’’, ‘‘having access to services on the weekends or evenings’’). There were significant correlations between childrens’ pain ratings and parents’ perceptions of care. Those with worse pain in the past month had less favorable perceptions of care (r = -.39, p < .05). Pain ratings were not associated with BTC (p > .05). Study findings indicate that children with SCD have long-standing relationships with providers and these relationships are often viewed in a positive light. However, providing same-day appointments and extending clinic hours may improve access to care. Future studies should investigate the role of expanded clinic availability for improving pain management and reducing use of costly hospital services.
Enhancing physical activity is an important treatment goal for adolescents with chronic pain, who as a group, demonstrate decreased physical activity compared to healthy youth. Prior retrospective studies found lower physical activity levels overall are associated with greater pain. It is not clear whether high pain levels lead to reduced physical activity or whether physical activity leads to increased or decreased pain. To address this gap we examined temporal daily associations between pain and physical activity to examine (1) activity as a predictor of end of day pain and (2) end of day pain as a predictor of next day activity. Participants were 119 adolescents (59 with chronic pain and 60 healthy) aged 12–18 years, 71% female. Adolescents completed 10 days of continuous actigraphic monitoring of physical activity and daily diary ratings of pain (0–10 NRS) and mood (0–10 NRS). Three actigraphy variables were used for analyses: daily total (summary count), mean (average count/min) and peak activity (highest daily level). Linear mixed models assessed daily associations between activity and pain. Age and daily mood were included as predictors. Mean activity was lower in adolescents with chronic pain compared to healthy adolescents (M= 447 6 168 counts/min vs M = 509 6 113 counts/min, p < 0.05). Results revealed end of day pain predicted next day total, mean and peak physical activity, with greater pain predicting lower activity the next day (p’s < 0.01). Conversely, physical activity was a significant predictor of end of day pain with higher total physical activity predicting less pain (p < 0.001). Age predicted physical activity but not pain. Mood was not a significant predictor of pain or physical activity. Findings support a complex bidirectional association between pain and physical activity, which may have implications for targeting physical activity in treatment of pain in youth.
The Journal of Pain
S33
B14 Pain in Children (230) Bidirectional associations between pain and physical activity in adolescents
Central Post Stroke Pain Syndrome (CPSP) is a neuropathic pain syndrome that can occur following a stroke. We present a 65 year old female with no previous pain complaints nor peripheral neuropathy, who developed intractable, unremitting dysesthesia described as burning pain in her left upper and lower extremities following a right basal ganglia hemmorragic stroke confirmed by neuroImaging. She was diagnosed with CPSP and all initial attempts to manage her pharmacologically and non-pharmacologically were suboptimal. A 3mm skin biopsy of her left lower extremity was performed to evaluate for possible peripheral nervous system dysfunction. Results demonstrated reduced epidermal nerve fiber density, consistent with small fiber neuropathy. A subsequent nerve conduction study revealed an axonal peripheral neuropathy. She was also found by magnetic resonance imaging to have multilevel cervical and lumbosacral degenerative disc disease. The concomitant existence of CPSP, peripheral neuropathy, as well as spinal degenerative disease may have collectively contributed to her symptoms. To our knowledge, these three entities have not been previously described to coexist and contribute to this type of clinical presentation. In particular, the skin biopsy findings have not been described in this setting. Recognizing the coexisting peripheral and central nervous system contributions may have significant clinical implications for both diagnosis and treatment as well as to better understand the bidirectional changes (peripheral and central) that may facilitate pain following nerve injury. This patients’ course reinforces the need for a high clinical suspicion for alternative explanations when patients’ complaints do not respond adequately to established treatment.
J Rabbitts, A Lewandowski, G Tai, C Karlson, and T Palermo; Seattle Children’s Hospital, Seattle, WA
(229) Findings and treatment of a rare case presentation of painful neuroborreliosis
(231) Healthcare experiences of at-risk youth with sickle cell disease
S Shah and J Nagda; Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
A Jones, E Jacob, V Wong, C Hodge, M Lewis, and L Zeltzer; UCLA School of Nursing, Los Angeles, CA
The painful component of Neuroborreliosis is potentially a severe and debilitating complication of Lyme disease and is thoroughly underreported in pain literature. Case reports of successful treatment of pain component are also not well described. We describe a rare case of painful Neuroborreliosis successfully treated with neuropathic agent gabapentin. A 68 y male in usual health with 4 weeks history of progressive torso numbness, paresthesias, back pain, and proximal leg weakness. Six weeks prior to admission, noted acute episode of interscapular back pain after golfing in CT, progressive to flanks, groin and lower extremities bilaterally. No documentation of tick bite. PO opioid rotation unsuccessful. Rapid progressive weakness to lower extremity paraplegia upon presentation to hospital. Full diagnostic work-up: positive confirmatory serum IgM and IgG Lyme Ab by Western Blot. Patient diagnosed with Neuroborreliosis; discharged home with 3 weeks IV ceftriaxone with full neurological resolution, however with remanent pain symptoms. Patient presents to Pain Center three weeks post discharge. Intense pins/needles sensation in T8-T12 dermatomal distribution with significant hyperhydrosis on affected dermatomes. Physical exam demonstrates thoracolumbar neuropathy secondary to recent history of Lyme disease with inflammatory radiculopathy. Given neuropathic model of pain, patient prescribed gabapentin. Within three weeks of escalating doses of gabapentin, patient’s painful radiculitis completely resolved with total of 300mg BID dose. There is unclear mechanism of effects of Lyme disease on the nervous system, and particularly on dorsal column neurons. While case reports of neurologic sequelae of Lyme disease is plentiful in neurological literature, the painful syndromes and neuropathies that result are far more rare, and probably unknown to the pain physician. The use of gabapentin, even low dose, in this case shows very impressive result in treating painful Neuroborreliosis. (Halperin JJ. Curr Treat Options Neurol 2007.)
Children with Sickle Cell Disease (SCD) have elevated healthcare needs, frequently using outpatient and inpatient services for chronic pain management and acute vaso-occlusive pain crises. Few studies have examined barriers to care and healthcare experiences among this population. Such findings are needed to target systems interventions and improve the quality of life for children with SCD. The goal of this study was to identify barriers to care and perceptions of care among youth with SCD. Seventy-four youth, age 9-16, were recruited to participate in a wireless pain intervention. Parents (n=38) completed validated measures of healthcare experiences: Barriers to Care Questionnaire (BCQ), Parent’s Perceptions of Primary Care (P3C). Each scale ranges from 0-100 with higher scores indicating more positive experiences. Overall, we found that parents were satisfied with their child’s healthcare experiences: mean BTC = 79.2 (19.7); mean P3C = 78.1 (19.9). Pragmatic barriers such as ‘‘having to take time off work’’ and ‘‘having to wait long in the waiting room’’ were endorsed most frequently. Parents reported favorable experiences with provider communication, while expressing less favorable perceptions of access to care (e.g. ‘‘getting care on the same day’’, ‘‘having access to services on the weekends or evenings’’). There were significant correlations between childrens’ pain ratings and parents’ perceptions of care. Those with worse pain in the past month had less favorable perceptions of care (r = -.39, p < .05). Pain ratings were not associated with BTC (p > .05). Study findings indicate that children with SCD have long-standing relationships with providers and these relationships are often viewed in a positive light. However, providing same-day appointments and extending clinic hours may improve access to care. Future studies should investigate the role of expanded clinic availability for improving pain management and reducing use of costly hospital services.
Enhancing physical activity is an important treatment goal for adolescents with chronic pain, who as a group, demonstrate decreased physical activity compared to healthy youth. Prior retrospective studies found lower physical activity levels overall are associated with greater pain. It is not clear whether high pain levels lead to reduced physical activity or whether physical activity leads to increased or decreased pain. To address this gap we examined temporal daily associations between pain and physical activity to examine (1) activity as a predictor of end of day pain and (2) end of day pain as a predictor of next day activity. Participants were 119 adolescents (59 with chronic pain and 60 healthy) aged 12–18 years, 71% female. Adolescents completed 10 days of continuous actigraphic monitoring of physical activity and daily diary ratings of pain (0–10 NRS) and mood (0–10 NRS). Three actigraphy variables were used for analyses: daily total (summary count), mean (average count/min) and peak activity (highest daily level). Linear mixed models assessed daily associations between activity and pain. Age and daily mood were included as predictors. Mean activity was lower in adolescents with chronic pain compared to healthy adolescents (M= 447 6 168 counts/min vs M = 509 6 113 counts/min, p < 0.05). Results revealed end of day pain predicted next day total, mean and peak physical activity, with greater pain predicting lower activity the next day (p’s < 0.01). Conversely, physical activity was a significant predictor of end of day pain with higher total physical activity predicting less pain (p < 0.001). Age predicted physical activity but not pain. Mood was not a significant predictor of pain or physical activity. Findings support a complex bidirectional association between pain and physical activity, which may have implications for targeting physical activity in treatment of pain in youth.