Chronic pain is prevalent in both children and adults and has major negative consequences for their daily life, e.g. reduced participation in activities and depressive and anxious feelings. Therefore, it is important to early signal and treat chronic pain. This thesis aimed to provide answers to two important questions: 1. How to improve early signaling and assessment of chronic pain in adolescents? and 2. How to improve self-management of chronic pain in both adolescents and adults? Psychosocial stress seems to serve as an important risk factor for the occurrence of pain. In chapter 2 we examined if early adversities, e.g. bullying, abuse, and family conflict are risk factors for chronic pain in adolescents. Additionally, we described the pain characteristics of chronic pain in adolescents in a community sample of Dutch adolescents. Participants in the present study were 15,220 adolescents, attending schools (grade 7 and 8) in Rotterdam, the Netherlands. Chronic pain was measured with a newly developed questionnaire; the Pain Barometer. Early adversities were measured using single item questions from the Rotterdam Youth Monitor, a longitudinal youth health surveillance system. Cross-sectional associations between early adversities and chronic pain were investigated using logistic multilevel analysis, adjusted for potential confounding. In school year 2010-2011, 9.2% of the 15,220 adolescents reported chronic pain. Physical abuse by others (OR=1.51, 95% CI=1.07-2.14), sexual abuse (OR=1.46, 95% CI=1.05-2.05), family conflict (OR=1.79, 95% C=1.61-1.99), and being bullied (OR=1.23, 95% CI=1.17-1.29) are more common in adolescents with chronic pain. Physical abuse (OR=1.28, 95% CI=.95-1.71) by parents and parental divorce (OR=1.07, 95% CI=.93-1.22) were not significantly related to chronic pain. The results of the present study suggest that bullying, abuse, and family conflict may be risk factors for chronic pain. Early signaling these stressors might, prevent chronic pain. In chapter 3 we determined whether pain is associated with specific aspects of academic performance, i.e. lower grades, and with factors critical to an adolescent’s academic performance, i.e. decreased emotional well-being and attention problems. We hypothesized that the association between pain and school grades is mediated by emotional well-being and attention problems. In a large cross-sectional study, we collected data from 2215 pupils, aged 12-13 years old. Pain, emotional well-being, and attention problems were reported by a self-rating scale. Dutch, English, and math grades were taken as an index of academic performance. Frequent pain in adolescents was associated with lower grades (Dutch p = .02 and math p = .01). Both occasional and frequent pain were associated with reduced emotional well-being (p =< .01) and reduced self-reported attention (p = <.01). Furthermore, the association between pain and lower grades was partially mediated by both emotional well-being and reduced self-reported attention (p-values = <.01). The results of the present study show that the association between pain and grades can be partially explained by both reduced emotional well-being and attention problems. The results suggest that an intervention targeted at subjective pain in adolescents could have a positive effect on emotional well-being and school performance. Behavioral migraine approaches are effective in reducing headache attacks. Availability of treatment might be increased by using migraine patients as trainers. Therefore, Mérelle and colleagues developed and evaluated a home-based behavioral management training (BMT) by lay trainers. The maintenance of effects at long-term follow-up are reported in chapter 4. Measurements were taken pre-BMT (T0), post-BMT (T1), at six-month follow-up (T2), and at long-term follow-up, i.e. two to four years after BMT (T3). Data of 127 participants were analyzed with longitudinal multi-level analyses. Short-term improvements in attack frequency and self-efficacy post-BMT were maintained at long-term follow-up ( DT0T3  = -.34 and DT0T3  = .69, respectively). The level of internal control that increased during BMT decreased from post-BMT to long-term follow-up ( DT0T3  = .18). Quality of life and migraine-related disability improved gradually over time ( DT0T3  = .45 and DT0T3  = -.26, respectively). Although the results should be interpreted with caution because of the lack of a follow-up control group and the inability to gather information about additional treatments patients may have received during the follow-up period, the findings suggest that lay BMT for migraine may be beneficial over the long term. If so, this could make migraine treatments more widely available. Chapter 5 describes a study protocol to early promote the self-management skills of adolescents with chronic pain, using an internet-based self-management program: Move It Now. This program includes cognitive behavioral techniques, including relaxation exercises and positive thinking. The objective of the intervention was to improve the ability of adolescents to cope with pain. In chapter 6 the effects of Move It Now were evaluated. Because of treatment attrition and loss to follow-up we could not apply the originally proposed between-group design but had to employ a within-group design, comparing the waiting list trajectory with the treatment trajectory. The Internet intervention consisted of seven weekly interactive Internet modules, which adolescents worked through independently. Additionally, a therapist weekly contacted them by e-mail or telephone. Adolescents (N = 69) were assessed on the outcome measures pain, coping, disability, catastrophizing, rewarding of pain behavior by parents, and quality of life. Measures were taken seven weeks before treatment, pre-treatment, post-treatment, and at three months follow-up. Multi-level modelling was used for longitudinal analysis of the data. Pain intensity, rewarding of pain behavior by parents, and sleep problems significantly decreased from pre-treatment to post-treatment in adolescents with chronic pain. Results for quality of life and pain coping were mixed. No significant differences were found for pain-related disability and pain catastrophizing. Contrary to expectations, an Internet-based self-management intervention for chronic pain is difficult to employ in adolescents, as it suffers from treatment attrition and loss to follow-up. We found indications that an Internet intervention has potential in decreasing pain, rewarding of pain behavior by parents, and sleep problems. In conclusion, this thesis shows that early signaling of chronic pain is very important. Chronic pain is highly prevalent among adolescents and not only negatively influences their quality of life, but also their grades. Adolescents who have experienced early adversities seem to be more vulnerable to experience chronic pain. Signaling for these early adversities might prevent chronic pain. Online self-management may reduce pain in adolescent with chronic pain, but is difficult to employ in adolescents. In future, more research should be done to improve adherence to online therapy. Since the patient-therapist relation seems so important, strategies to strengthen this relationship should be studied. In adults, home-based BMT provided by lay trainers seems to improve the self-management skills of migraine patients, even at long-term follow-up. If the cost-effectiveness has been proven, BMT by lay trainers could be implemented at large scale. This would make treatment for migraine patients more available.

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J. Passchier (Jan) , J.J. van Busschbach (Jan)
The work presented in this thesis was performed at the Department of Psychiatry, Section Medical Psychology and Psychotherapy, Erasmus MC, Rotterdam, in close collaboration with Rijndam rehabilitation center and Municipal Health Services Rotterdam-Rijnmond. The studies presented in this thesis were funded by Innovatiefonds Zorgverzekeraars, Pijnkenniscentrum, and Stichting Coolsingel. This thesis was printed with the financial support of the Department of Psychiatry, Section Medical Psychology and Psychotherapy, Erasmus MC, Rotterdam.
Erasmus MC: University Medical Center Rotterdam

Voerman, J. (2015, September 23). Psychosocial assessment and self-management of chronic pain. Retrieved from http://hdl.handle.net/1765/78549