New models of therapy in the treatment of chronic pain conditions such rheumatoid arthritis (RA) and fibromyalgia now target psychosocial function to improve the efficacy of therapeutic interventions in adolescents by reducing negative attitudes toward pain and strengthening engagement in physical and social activity.
Chronic pain syndromes have broadly negative effects on the quality of life in children and adolescents, having a significant impact on psychosocial status and impairing daily function. In recent years, studies in children and adolescents with chronic pain have indicated that they miss a significant number of school days, have greater problems with concentration, lower grades, and perceive their pain to have a negative impact on their grades and social experiences.1-3 They also frequently report sleep problems (53.6%), inability to pursue hobbies (53.3%), eating problems (51.1%), school absence (48.8%), and inability to meet friends (46.7%).2
How Children Cope with Pain
Children’s ability to cope with pain differs from adults and until recently was not studied separately. Anxiety appears to contribute significantly to the distress caused by chronic pain conditions in adolescents, with reported rates of 57.5%.1 A 2015 study by Cunningham, et al4 found that current anxiety in young adults with juvenile fibromyalgia was likely to produce significantly more impairment in physical function.4,5 Symptoms of fibromyalgia were still present in more than 80% of the adolescents at 6-year follow-up, at which time greater than 60% continued to report anxiety symptoms and nearly 27% reported mild-to-moderate depression.6
Catastrophizing involves both negative attitudes toward pain-related outcomes and the magnification and rumination on the pain itself.7 A 2006 review by Edwards et al 7 showed a significant impact from catastrophizing on perceptions of pain severity and sensitivity (measured by tender-point counts) that was associated with particularly high levels of emotional distress in patients with fibromyalgia.8-11 The review found that in patients with RA, high-catastrophizers also showed more attention to their pain in daily diaries than low-catastrophizers.12,13
The consequences of catastrophizing are that pain signals traveling within the central nervous system (CNS) appear to be magnified over time, although the mechanisms of this are not well understood.7 Expressions of catastrophizing also appear to have a negative impact on social function as the person seeks sympathy from others who reflect pain back and are likely to perceive catastrophizers as less able to cope with pain.14-17
Impact of Family Environment on Catastrophizing
A study by Sil et al18 investigated the separate impacts of a negative home environment and highly controlled, protective environment on long-term outcomes in juvenile fibromyalgia. The researchers found that adolescents with fibromyalgia who came from homes with a high degree of family conflict were no more likely than healthy adolescents to show distress, and that this had little effect on the outcomes of their chronic pain syndrome. Of more importance, adolescents with fibromyalgia whose parents showed a high degree of concern and protective parenting had higher levels of both disability and depression associated with their pain, which was consistent with results from earlier studies.19,20
Fear and Avoidance
Acute pain signals normally suggest injury or illness that requires rest and recovery before engaging in full physical activity. Because chronic pain syndromes such as RA and fibromyalgia involve misguided pain signals that are not triggered by normal injuries or illness, treatment approaches require patients to “push through” pain to maintain or increase physical activity levels.
Fear of pain and avoidance in adolescent activities results in sedentary behaviors and withdrawal from social interactions that have a significant negative impact on physical health, family life, and school performance.
Treatment of Juvenile Chronic Pain Syndromes
The study by Sil et al18 concluded that children with fibromyalgia from controlling environments were at a higher risk for poorer emotional function in subsequent years, and that interventions are needed to target both independent coping skills in patients and greater flexibility in their parents in order to effect the most significant improvements.
Work by Fisher and Palermo21 reached a similar conclusion, proposing a new model of chronic pain management in juveniles that focuses on shifting “goal pursuit” within the same contexts of patient and parental coping strategies. This model reflects the notion that “the child’s experience of pain is modified by child factors (eg, goal salience, motivation/energy, pain-related anxiety/fear, and self-efficacy) and parent factors (eg, parent expectations for pain, protectiveness behaviors, and parent anxiety), which lead to specific goal pursuit behaviors.” The model suggests adjustment of goals particularly in the direction of achieving higher levels of activity and function despite pain through direct confrontation of these behaviors.
Cognitive Behavioral Therapy – FIT for Teens Program
A new psychosocial approach to chronic pain management that has demonstrated efficacy in fibromyalgia is cognitive behavioral therapy (CBT), which involves retraining of patient perceptions of pain and focuses on engagement in moderate physical activity to reduce pain.22 In juvenile fibromyalgia, however, exercise retention rates have tended to be poor even after CBT.23 A group of investigators designed a program to combine CBT with special neuromuscular exercise, called the Fibromyalgia Integrative Training for Teens (FIT for Teens) program.
The study involved two 90-minute sessions per day for 8 weeks (16 total), with 45 minutes devoted to CBT techniques for pain management and 45 minutes given to physical resistance training in neuromuscular exercises designed to improve strength, fitness and body mechanics. Parents were asked to participate in 6 CBT sessions to enhance the independence of adolescent patients in taking responsibility for pain management.
The pilot study for FIT Teens demonstrated significant reductions in all psychosocial domains evaluated in 22 female participants (age 12 to 18), including functional disability (P <.05), depression (P <.001), fear of movement (P <.01), and pain catastrophizing (P <.001) with treatment.24 Additionally, the investigators found a substantial decrease in pre-contemplation (P <.01) associated with avoidance.
At the end of 8 weeks, the participants all achieved improvement in physical function in less time than previously recorded with CBT interventions without exercise. They also reported a reduction in general fear of pain and lessened avoidance was marked by an 80% retention to exercise after the trial ended.24
Summary & Clinical Applicability
Overall, psychosocial impact therapies such as CBT are effective in the treatment of chronic pain conditions, including fibromyalgia. In adolescents who tend to demonstrate higher degrees of catastrophizing and avoidance behaviors, however, the addition of a neuromuscular training component significantly enhances adherence and success of the program.
- Logan DE, Simons LE, Stein MJ, et al. School impairment in adolescents with chronic pain. J Pain. 2008;9:407-416.
- Roth-Isigkeit, Thyen U, Stöven H, et al. Pain among children and adolescents: restrictions in daily living and triggering factors. Pediatrics. 2005;115:e152-e162.
- King S, Chambers CT, Huguet A, et al. The epidemiology of chronic pain in children and adolescents revisited: A systematic review. PAIN. 2011;152:27-29.
- Cunningham, NR, Tran ST, Jordan AL, et al. Psychiatric disorders in young adults diagnosed with juvenile fibromyalgia in adolescence. J Rheumatol. 2015;42:2427-2433.
- Kashikar-Zuck S, Parkins IS, Graham TB, et al. Anxiety, mood, and behavioral disorders among pediatric patients with juvenile fibromyalgia syndrome. Clin J Pain. 2008;24:620-626.
- Kashikar-Zuck S, Cunningham N, Sil S, et al. Long-term outcomes of adolescents with juvenile-onset fibromyalgia in early adulthood. Pediatrics. 2014;133:e592-e600.
- Edwards RR, Bingham CO III, Bathon J, et al. Catastrophizing and pain in arthritis, fibromyalgia and other rheumatic diseases. Arthritis Care Res. 2006;55:325-332.
- Gracely RH, Geisser ME, Giesecke T, et al. Pain catastrophizing and neural responses to pain among persons with fibromyalgia. Brain. 2004;127:835-843.
- Viane I, Crombez G, Eccleston C, et al. Acceptance of pain is an independent predictor of mental well-being in patients with chronic pain: empirical evidence and reappraisal. Pain. 2003;106:65-72.
- Hassett AL, Cone JD, Patella SJ. The role of catastrophizing in the pain and depression of women with fibromyalgia syndrome. Arthritis Rheum. 2000;43:2493-2500.
- Schochat T, Raspe H. Elements of fibromyalgia in an open population. Rheumatology. 2003;42:829-835.
- Affleck G, Tennen H, Urrows S, et al. Neuroticism and the pain-mood relation in rheumatoid arthritis: insights from a prospective daily study. J Consult Clin Psychol. 1992;60:119-126.
- Lefebvre JC, Keefe FJ. Memory for pain: the relationship of pain catastrophizing to the recall of daily rheumatoid arthritis pain. Clin J Pain. 2002;18:56-63.
- Sullivan MJ, Thorn B, Haythornthwaite JA, et al. Theoretical perspectives on the relation between catastrophizing and pain. Clin J Pain. 2001;17:52-64.
- Thorn BE, Keefe FJ, Anderson T. The communal coping model and interpersonal context: problems or process? Pain. 2004;110:505-507.
- Keefe FJ, Ahles TA, Porter LS, et al. The self-efficacy of family caregivers for helping cancer patients manage pain at end-of-life. Pain. 2003;103:157-162.
- Keefe FJ, Lipkus I, Lefebvre JC, et al. The social context of gastrointestinal cancer pain: a preliminary study examining the relation of patient pain catastrophizing to patient perceptions of social support and caregiver stress and negative responses. Pain. 2003;103:151-156.
- Sil S, Lynch-Jordan A, Ting TV, et al. Influence of family environment on long-term psychosocial functioning of adolescents with juvenile fibromyalgia. Arthritis Care Res. 2013;65:903-909.
- Claar RL, Guite JW, Kaczynski KJ, et al. Factor structure of the adult responses to children’s symptoms: validation in children and adolescents with diverse chronic pain conditions. Clin J Pain. 2010;26:410-417.
- Peterson CC, Palermo TM. Parental reinforcement of recurrent pain: the moderating impact of child depression and anxiety on functional disability. J Pediatr Psychol. 2004;29:331-441.
- Fisher E, Palermo TM. Goal pursuit in youth with chronic pain. Children. 2016;3:36. doi:10.3390/children3040036
- Lazaridou A, Kim J, Cahalan CM, et al. Effects of cognitive-behavioral therapy (CBT) on brain connectivity supporting catastrophizing in fibromyalgia. Clin J Pain. 2017;33(3):215-221.
- Kashikar‐Zuck S, Flowers SR, Strotman D, et al. Physical activity monitoring in adolescents with juvenile fibromyalgia: Findings from a clinical trial of cognitive–behavioral therapy. Arthritis Care Res. 2013;65:398-405.
- Tran ST, Guite JW, Pantaleao A, et al. Preliminary outcomes of a cross-site cognitive-behavioral and neuromuscular integrative training intervention for juvenile fibromyalgia [published online June 22, 2016]. Arthritis Care Res. doi:10.1002/acr.22946
This article originally appeared on Rheumatology Advisor