Commentary: A Worldwide Call for Multimodal Inpatient Treatment for Children and Adolescents Suffering from Chronic Pain and Pain-related Disability

Children and adolescents presenting to clinicians with chronic pain and severe interferences in their daily life, such as school absence, reduced contact to peers, and emotional, sleep, and eating problems (Palermo, 2000) are not very well cared for worldwide. In contrast to children, a recent review illustrated the therapeutic network for affected adults in Germany with 18 centers in Bavaria alone providing multidisciplinary treatment programs (Arnold et al., 2009). For children, there are only four multimodal inpatient programs worldwide that have been described and evaluated in terms of their effectiveness, despite the fact that a noteworthy number of children and their families are severely affected by chronic pain and in need of multimodal inpatient treatment. Across studies from the USA (Perquin et al., 2000), Europe (Huguet & Miro, 2008; Kröner-Herwig, Heinrich, & Morris, 2007), and Canada (Shiff et al., 2009), 3% of children and adolescents suffering from chronic pain demonstrate significant pain-related disability leading to widespread negative consequences for the adolescent and family that may be difficult to treat in an outpatient setting. These children are faced with a desert of centers offering multimodal inpatient treatment which in turn, may aggravate the child’s situation. A recent Dolphi Poll on predictive factors of chronic pediatric pain and disability (Miro, Huguet, & Nieto, 2007) identified the excessive use of health care services as one factor with great influence on the chronicity of the pain experience. In accordance, Shiff et al. (2009) have recently shown that a median of three healthcare providers were seen for a median of five visits prior to treatment in a specialized pain clinic of Canadian children. In a German sample, >70% had consulted more than three physicians prior to specialized inpatient treatment (Hechler, Blankenburg, Dobe, Kosfelder, Hübner, & Zernikow, 2009). The study of Maynard, Amari, Wieczorek, Christensen, & Slifer (2009), therefore, adds to our knowledge on the effectiveness of urgently needed multimodal inpatient programs for this specific group of children and adolescents. However, some issues need clarification to carefully interpret the results presented by Maynard et al. (2009): In light of the previous studies, some of which were conducted prospectively over a period of 1–2 years (e.g. Dobe, Damschen, Reiffer-Wiesel, Sauer, & Zernikow, 2006; Sherry, Wallace, Kelley, Kidder, & Sapp, 1999), the retrospective chart analysis conducted by Maynard et al. (2009) seems to be a drawback. In line with that, the number of children included in previous studies range from 103 (Sherry et al., 1999) to 200 (Hechler, Blankenburg, et al., 2009). Hence, the sample size of 41 (of which 19 were reassessed at 3 month follow-up (Maynard et al., 2009) seems rather small. Until recently, the definition of core outcomes in clinical trials remained a matter of discussion. However, with the publication of the PedIMMPACT recommendation for assessment of core outcomes in clinical trials (McGrath et al., 2008), guidelines were established and have already been included in previous studies (Dobe et al., 2006; Eccleston, Malleson, Clinch, Connell, & Sourbut, 2003; Hechler, Blankenburg, et al., 2009; Hechler, Dobe, et al., 2009). Maynard et al. (2009) chose not to assess pain intensity in their study. However, their argument against its assessment—such as defocusing patients from the pain experience and little variability in patients’ pain scores— can be critically discussed given the recent findings. We