Subacute pain trajectories following major musculoskeletal surgery in adolescents: A pilot study

Abstract

Background: Adolescents who undergo major surgery experience high rates of disabling acute and chronic postsurgical pain (CPSP). However, little is known about the subacute period when acute to chronic pain transition occurs. Aims: The aims of this study were to examine feasibility of electronic daily monitoring of pain and opioid use in adolescents during the first 30 days at home following major surgery and identify target features of subacute pain curves associated with CPSP at 4 months. Methods: Twenty-five youth (10-18 years) undergoing major musculoskeletal surgery reported daily pain severity, interference, and opioid use on the Brief Pain Inventory each evening for 30 days after hospital discharge to form short time series trajectories. At 4 months, youth reported on pain intensity and health-related quality of life. Characteristics of subacute pain severity and interference curves were compared by 4-month CPSP status. Results: At 4 months, 20.8% of youth met criteria for CPSP. During the 30-day monitoring period, youth who went on to develop CPSP reported high pain severity on 45.9% of days compared to 2.9% of days in youth who recovered (P = 0.005) and high pain interference on 49.4% of days vs. 9.7% in youth who recovered (P = 0.01). Pain variability and rate of change were not significantly associated with CPSP in our pilot sample. Conclusions: We found it feasible to collect daily pain data in youth recovering at home after major surgery. Pilot findings suggest that daily electronic monitoring may identify early recovery problems at home after surgery. Larger studies are needed to validate subacute pain trajectory features to identify risk for CPSP. RÉSUMÉ Contexte:Les adolescents qui subissent des interventions chirurgicales majeures présentent des taux élevés de douleur chronique postopératoire aiguë et débilitante. Cependant, on sait peu de choses sur la période subaiguë, pendant laquelle la transition de la douleur aiguë à la douleur chronique s'effectue. Objectifs: Cette étude avait pour but d'examiner la faisabilité d'un suivi électronique quotidien de la douleur et de l'utilisation d'opioïdes chez les adolescents au cours des 30 premiers jours à la maison après une opération chirurgicale importante, ainsi que de déterminer les caractéristiques cibles des courbes de douleur subaiguë associées à la douleur postopératoire chronique après quatre mois. Méthodes: Vingt-cinq jeunes (10-18 ans) subissant une chirurgie musculo-squelettique majeure ont déclaré chaque jour l'intensité et l'interférence de leur douleur, ainsi que l'utilisation d'opioïdes à l'aide de l'Inventaire abrégé de la douleur chaque soir pendant 30 jours après leur sortie de l'hôpital, afin de former de courtes trajectoires en série chronologique. Au bout de quatre mois, les jeunes ont déclaré l'intensité de leur douleur et de leur qualité de vie liée à la santé. Les caractéristiques des courbes portant sur l'intensité de la douleur subaiguë et l'interférence ont été comparées en fonction du statut relatif à la douleur postopératoi...

<p>A Conceptual Model of Biopsychosocial Mechanisms of Transition from Acute to Chronic Postsurgical Pain in Children and Adolescents</p>

“…2,3 Continued pain at home during the subacute period has been shown to significantly affect recovery. 4 In a wide range of inpatient surgeries, moderate to severe postsurgical pain at one month was independently associated with greater than three-fold higher odds of experiencing a clinically significant deterioration in both physical and psychosocial health, as well as in overall health-related quality of life after surgery. 5 When acute pain persists after surgery, it can develop into a chronic pain condition.…”

“…9,10,51 Looking beyond hospital discharge, studies examining recovery during the initial weeks at home identified significant relationships between subacute pain with subsequent chronic pain. 4,16,28 In general, studies have relied on self-report measures and data from the electronic medical record to assess acute recovery. Future studies should apply more granular monitoring (such as daily pain diaries) and employ objective measures (eg, actigraphy monitoring of activity, electronic medication monitoring of opioid use) to better capture acute recovery.…”

“…Three studies using nuanced approaches to characterize the acute pain trajectory over multiple postoperative days found that higher levels of pain in the hospital and during the initial days at home were associated with a higher incidence of CPSP. 4 , 38 , 44 Acute pain treatment may impact acute recovery, and is integrally related to the acute pain experience. However, studies examining in-hospital pain treatment have not identified a relationship with subsequent CPSP.…”

“…Future studies should apply more granular monitoring (such as daily pain diaries) and employ objective measures (eg, actigraphy monitoring of activity, electronic medication monitoring of opioid use) to better capture acute recovery. 4 Such studies may help to unravel the connections between the acute pain experience, pain treatment, and opioid exposure that play a role in acute to chronic pain transition. Further, mechanistic studies will be essential in understanding physiological perturbations tied to acute recovery that may contribute to the transition from acute to chronic postsurgical pain.…”

A memory-reframing intervention to reduce pain in youth undergoing major surgery: Pilot randomized controlled trial of feasibility and acceptability

“…A trained researcher blind to group allocation conducted an established telephone interview previously used in pediatric surgical cohorts 14 , 15 to collect the ratings needed to calculate the memory biases 6 weeks postsurgery. Youth recalled both the sensory (i.e., pain intensity) and affective (i.e., pain unpleasantness and anxiety) aspects of their postsurgical pain at two time points when pain is typically most severe 36 : (1) on day 1 postsurgery and (2) during the acute recovery period (i.e., days 1 to 3 postsurgery); thus, acute recovery encompassed the first time point (i.e., day 1 after surgery). These time points have been used in previous postsurgical pain memory research.…”