Ethics of pain management in infants and older children

Moderate-to-severe pain arising from injuries, diseases, and medical procedures is inevitable during infancy and childhood, yet pain is often unrecognized, ignored, poorly assessed, underestimated, untreated, or poorly treated. Ineffective care for clinically significant acute and chronic pain typically reflects a lack of scientific understanding, inadequate treatments, and insufficient education of healthcare professionals in evidence-based care. Infants and older children warrant special care. Despite a moral responsibility to prevent and ameliorate pain and suffering in children, there is substantial evidence of systemic and individual failures to prevent and control their pain, despite known, evidence-supported, and cost-effective interventions in both the developing and developed world. Instructive perspectives from the philosophy of ethics focus on the consequences of pain, delineating intrinsically bad and destructive features, the intentions of parties responsible for inflicting and relieving pain, specific imperatives addressing human rights concerning inflicting and relieving pain, and characteristics of virtuous people committed to ethical caring. We address ethical implications of the inadequacies of our understanding and control of pediatric pain, as well as barriers preventing important research in the field. Problematic issues concern dominance of biomedical care, rather than care based on a biopsychosocial model of pain, and the human capacity for cognitive biases in interactions with other people. Ethical obligations of healthcare professionals are addressed. Attention is directed to an online training resource for ethical practice in caring for children’s pain. Specific issues are also addressed, including clinician competence, free and informed consent and assent confidentiality, and assessment and treatment choice.

THE ASSOCIATION OF LONELINESS AND CHRONIC CLINICALLY SIGNIFICANT PAIN AMONG AFRICAN AMERICAN AND WHITE OLDER ADULTS

Loneliness and pain are significant public health problems in later life, yet limited research has examined how these factors interact among racially diverse older adults. Guided by the Biopsychosocial Model of Pain, we used data from Waves 2 and 3 of the National Social Life, Health, and Aging Project to investigate the relationship between loneliness and chronic pain among 1,102 African-American and White adults aged 50 and over. Using logistic regression analyses, our final models considered demographics, physical and mental health, functioning, medication, health behaviors and social factors. Approximately 32% of African Americans and 28% of Whites reported chronic loneliness. Compared to Whites African-Americans were 2.5 times more likely to experience chronic pain. Among White participants, loneliness was not associated with chronic pain; however, the interaction of being African-American and lonely was associated with decreased odds of chronic pain in main and gendered analyses. African American women were 4 times more likely than White women to report chronic pain. Our results address the objectives of the National Pain Strategy (2016) to elucidate the experiences of chronic pain among diverse elders in the US. Future work should seek a deeper understanding of loneliness and chronic pain among African Americans elders and how cultural dynamics may help explain our counter intuitive findings (e.g., “Superwoman Schema”).

“Puttin’ on”: Expectations Versus Family Responses, the Lived Experience of Older African Americans With Chronic Pain

The lack of family research documenting the changes that occur and the capacity of families to support individuals with chronic pain effectively is a major limitation in the application of the biopsychosocial model of pain. This study investigated the lived experience of older African Americans ( N = 18) with chronic pain and explored their expectations and perceptions of familial support. A descriptive phenomenology framework revealed an existential theme: “puttin’ on,” a phenomenon that potentiates the power of pain to disrupt roles and relationships and discourages the family from meeting the expected needs of older African Americans. We uncovered new information into the actual support mechanisms that are missing or, when present, are not as positive and strong as would be expected in the African American culture, at least in the context of chronic pain management. Interventions should target family-based education, chronic pain destigmatization, and intergenerational empathy in the African American community.

Best-Evidence for the Rehabilitation of Chronic Pain Part 1: Pediatric Pain

Chronic pain is a prevalent and persistent problem in middle childhood and adolescence. The biopsychosocial model of pain, which accounts for the complex interplay of the biological, psychological, social, and environmental factors that contribute to and maintain pain symptoms and related disability has guided our understanding and treatment of pediatric pain. Consequently, many interventions for chronic pain are within the realm of rehabilitation, based on the premise that behavior has a broad and central role in pain management. These treatments are typically delivered by one or more providers in medicine, nursing, psychology, physical therapy, and/or occupational therapy. Current data suggest that multidisciplinary treatment is important, with intensive interdisciplinary pain rehabilitation (IIPT) being effective at reducing disability for patients with high levels of functional disability. The following review describes the current state of the art of rehabilitation approaches to treat persistent pain in children and adolescents. Several emerging areas of interventions are also highlighted to guide future research and clinical practice.

The Complex Interplay Between Weight, Chronic Pain, and Mood: How Team-Based Care and Personalized Approaches Can Improve Function and Quality of Life

Patients presenting with a desire to lose weight often have underlying factors that complicate recommendations regarding diet and exercise. In this woman’s story, a significant physical injury resulted in chronic pain and a loss in her ability to participate in activities she had previously enjoyed and which played a role in her self-identity. While her previous history of a mood disorder may have increased her risk of developing chronic pain, the impact her injury had on her sense of self was also a likely factor. A multidisciplinary approach that addressed her sense of loss; incorporated innovative adaptations that enabled her to exercise outdoors and led to a renewed sense of hope; helped her find creative outlets and increase her sense of self efficacy; and improve the quality of sleep was instrumental in supporting her ability to incorporate dietary change, lose weight, and improve her mood and well-being. The biopsychosocial model of pain provides a framework of understanding for the complex interplay between mood, pain, and social support, which in turn can impact weight and ability to incorporate lifestyle change. Addressing these underlying factors is a critical part of whole person health.

Physiotherapy pain curricula in Finland: a faculty survey

Background and aims Despite the recognition of pain as a global health problem and advancements achieved in what is known about effective pain management, pain education for undergraduate health care professionals remains insufficient. This study investigated the content of pain curricula and the time allocated to pain education on physiotherapy programs at bachelor’s level at Universities of Applied Sciences (UASs) in Finland. Methods A web-based survey questionnaire was sent to the directors of the physiotherapy programs at all the Finnish UASs (n=15) where physiotherapy is taught at bachelor’s level. The questionnaire consisted of 14 questions covering basic concepts and the science of pain, pain assessment, pain management, and the adequacy of pain curricula. Each UAS completed one questionnaire i.e. returned one official opinion. Results The response rate was 80% (n=12). The mean for the total number of contact hours of pain education was 74 (standard deviation 34.2). All UASs had integrated pain education. In addition to this 42% (n=5) of the UASs had a separate pain course. The UASs offering such a course over and above the integrated pain education had twice the amount of pain content education compared to those UASs that only had integrated pain education (mean 103 h vs. 53 h, p=0.0043). Most of the education was devoted to conditions where pain is commonly a feature, manual therapy, and electrical agents for pain control. The biopsychosocial model of pain, cognitive behavioral methods of pain management, physician management, and multidisciplinary management were the least covered topics. Five UASs (42%) payed attention to the International Association for the Study of Pain curriculum outline and only 33% (n=4) considered their pain education to be sufficient. Conclusions Our results indicate that more contact hours are devoted to pain education on the Finnish UASs’ physiotherapy programs at bachelor’s level, than has previously been reported in faculty surveys. A separate pain course is one way to ensure a sufficient amount of pain education. Overall, despite a sufficient time devoted to pain education, some essential pain contents were inadequately covered. Implications The study contributes information on how pain education can be organized on physiotherapy programs at undergraduate level. Besides a sufficient amount of pain education, which can be ensured by a separate pain course, attention should be paid to pain education content being up-to-date. This could help in estimating the different proportions of pain content needed in educational settings. Efforts should also be made at keeping integrated pain education well-coordinated and purposeful. There is a need for further research estimating the effectiveness of pain education according to the different ways in which it is organized. There is also a need to investigate whether more hours allocated to pain education results in better understanding and professional skills.

Measuring the Quality of Mobile Apps for the Management of Pain: Systematic Search and Evaluation Using the Mobile App Rating Scale (Preprint)

BACKGROUND Chronic pain is a major health issue requiring an approach that not only considers medication, but also many other factors included in the biopsychosocial model of pain. New technologies, such as mobile apps, are tools to address these factors, although in many cases they lack proven quality or are not based on scientific evidence, so it is necessary to review and measure their quality. OBJECTIVE The aim is to evaluate and measure the quality of mobile apps for the management of pain using the Mobile App Rating Scale (MARS). METHODS This study included 18 pain-related mobile apps from the App Store and Play Store. The MARS was administered to measure their quality. We list the scores (of each section and the final score) of every app and we report the mean score (and standard deviation) for an overall vision of the quality of the pain-related apps. We compare the section scores between the groups defined according to the tertiles via analysis of variance (ANOVA) or Kruskal-Wallis test, depending on the normality of the distribution (Shapiro-Wilk test). RESULTS The global quality ranged from 1.74 (worst app) to 4.35 (best app). Overall, the 18 apps obtained a mean score of 3.17 (SD 0.75). The best-rated sections were functionality (mean 3.92, SD 0.72), esthetics (mean 3.29, SD 1.05), and engagement (mean 2.87, SD 1.14), whereas the worst rated were app specific (mean 2.48, SD 1.00), information (mean 2.52, SD 0.82), and app subjective quality (mean 2.68, SD 1.22). The main differences between tertiles were found on app subjective quality, engagement, esthetics, and app specific. CONCLUSIONS Current pain-related apps are of a certain quality mainly regarding their technical aspects, although they fail to offer information and have an impact on the user. Most apps are not based on scientific evidence, have not been rigorously tested, and the confidentiality of the information collected is not guaranteed. Future apps would need to improve these aspects and exploit the capabilities of current devices.