Focusing on Functional Improvement for Children with Chronic Pain

By Ethan Benore, PhD, and Heidi Kempert, PTA

Children with chronic pain often face severe impairment in physical functioning as they withdraw from typical life activities, becoming deconditioned and fearful of more pain. This study demonstrates the utility of both subjective and objective measures to identify changes in physical functioning during an intensive pediatric chronic pain rehabilitation program.

In chronic pain rehabilitation, it is important to have a primary focus on functional improvement as the leading outcome – not pain reduction. While past studies have demonstrated the importance of measuring adolescents’ self-perception of their abilities within physical and occupational therapy, these tools are not often easily utilized or have not been examined with a pediatric chronic pain population. In this study it was hypothesized that adolescents completing an intensive interdisciplinary pain rehabilitation program would report functional gains from admission to discharge, and that perceived gains in physical ability would be associated with objective physical activities. Further, it was hypothesized that gains in functioning would be associated with pain reduction.

Seventy-eight children and adolescents with chronic pain who participated in the three-week intensive interdisciplinary pain rehabilitation program completed self-report measures. These included the Lower Extremity Functional Scale (LEFS) and the Upper Extremity Functional Index (UEFI). In addition, adolescents were objectively monitored for repetitions of selected physical activities for one-minute intervals. Assessments were taken at admission and discharge.

Results indicate significant gains in all measures of functioning during the program (all p’s <0.01). Over half of the children also reported clinical gains (> 9 points) on the LEFS and UEFI. Small but significant correlations between self-report and objective outcomes suggest they are measuring similar yet distinct factors. Further, while children reported a mild reduction in pain over the three weeks, regression statistics do not support that pain reduction was directly related to changes in physical functioning alone. It is likely that cognitive or emotional changes in response to rehabilitation are involved.

Using subjective and objective measures provides both a feasible and meaningful way to track progress in chronic pain rehabilitation. While objective measures target purely physical gains, subjective measures allow for assessment of psychological constructs important to rehabilitation, such as self-efficacy. These functional improvements appear independent of pain ratings and should be valued as a separate outcome in pain rehabilitation.

These findings increase our understanding of rehabilitation practices and provide opportunities to promote clinical improvement in pediatric pain. The use of self-reported measures along with objective measures can help therapists better understand a patient’s level of impairment from chronic pain — and track their improvement over time. In addition, these measures may be used clinically to facilitate patient education and improve patient insight into aspects of rehabilitation therapy. Further research should include evaluation of follow-up data to assess maintenance of functional gains to further inform and improve pain rehabilitation programs.

Dr. Benore (benoree@ccf.org; 216.448.6253) is Head of the Center for Pediatric Behavioral Health at the Cleveland Clinic and fellowship director of the Postdoctoral Fellowship in Pediatric Pain Psychology. Heidi Kempert, PTA (kemperh@ccf.org; 216.448.6253) is a primary treating therapist in the Pediatric Pain Rehabilitation Program.”