Chronic pain treatment in children and adolescents: less is good, more is sometimes better

Abstract

Background: In children with chronic pain, interdisciplinary outpatient and intensive inpatient treatment has been shown to improve pain intensity and disability. However, there are few systematic comparisons of outcomes of the two treatments. The present naturalistic study aimed to compare the clinical presentation and achieved changes at return in three outcome domains (pain intensity, disability, school absence) between a) outpatients vs. inpatients and b) patients who declined intensive inpatient treatment and completed outpatient treatment instead (decliners) vs. those who completed inpatient treatment (completers).

Methods: The study compared treatment outcomes between n = 992 outpatients vs. n = 320 inpatients (Analysis A) who were treated at a tertiary treatment centre and returned for a return visit within a one-year interval. In Analysis B, treatment outcomes were compared between n = 67 decliners vs. n = 309 completers of inpatient treatment. The three outcome domains were compared by calculating standardized change scores and clinically significant changes.

Results: In analysis A, outpatients and inpatients reported comparably low levels of pain intensity (NRS 0-10; mean = 4, SD = 2.7) and disability (Paediatric Pain Disability Index (PPDI: 12-60; mean = 24; SD = 10) at the return visit. Compared to outpatients, more inpatients achieved clinically significant changes in pain intensity (52% vs. 45%) and disability (46% vs. 31%). There were also significantly greater changes in disability in the inpatient group (change score outpatients = 1.0; change score inpatients = 1.4; F(1,1138) = 12.6, p = .011). School absence was substantially reduced, with approximately 80% in each group attending school regularly. Analysis B showed that even though inpatient decliners achieved improvements in the outcome domains, they reported greater disability at the return visit (PPDI mean decliners = 27, SD = 9.9; PPDI mean completers = 24, SD = 10) because they had achieved fewer changes in disability (change score decliners = 0.9; change score completers = 1.4; F(1.334) = 5.7, p = .017). In addition, less decliners than completers achieved clinically significant changes in disability (25% vs. 47%).

Conclusions: Inpatient and outpatient treatments are able to elicit substantial changes in pain intensity, disability and school absence. The results highlight the necessity of intensive inpatient pain treatment for highly affected children, as children who declined inpatient treatment and were treated as outpatients did less well.

Figure 1

Study flowchart and depiction of the two analyses of the study.

Figure 2

Comparison between outpatients vs. inpatients and between decliners vs. completers regarding clinically significant changes in pain intensity and disability. The figure shows the number of children with clinically significant changes in pain intensity and disability. The left part of the figure (a) shows the comparison between outpatients and inpatients. The right part (b) shows the comparison between decliners and completers. Clinically significant changes were defined according to Jacobson and Truax as i) statistical and reliable change between pre- and post-treatment scores, and ii) as patients’ move from a dysfunctional to a functional level. Cut-off for pain intensity was defined as a raw change of -1 on an NRS [21]. Cut-off for disability was defined as a PPDI-score of 23.09 (range: 12–60) based on previous studies [12].

Figure 3

Comparison between outpatients vs. inpatients and between decliners vs. completers regarding improvements, stable or deterioration in school absence for the group of children with initially moderate school absence. The figure shows changes in school absence for children with initially moderate school absence (i.e., 2 to 5 days within four school weeks). The left part of the figure (a) shows the comparison between outpatients vs. inpatients. The right part (b) shows the comparison between decliners vs. completers. Children were assigned to the ‘Improvement-group’ if they reported low school absence (<2 days/week) at the return visit. ‘Stable school absence’ represents children who still reported moderate school absence (2 to 5 days/week) at the return-visit and ‘deterioration’ represents children who reported high school absence (>5 days/week) at the return-visit.