Behavioral Medicine Treatment for Adolescents in Pain
Behavioral Medicine Treatment for Adolescents in Pain
Recurrent pain, such as headache, stomach pain and musculoskeletal pain is common in children
 and adolescents. Children and adolescents are reported to have restrictions in daily life
 activities, social contacts, and school attendance, and to have poorer academic skills and as
 well as an increased utilization of heath care services due to pain problems. The treatment
 approaches available today for teenagers with pain are often biological/physiological and
 little evidence for their effectiveness has been shown. It is urgent to try new interventions
 for pain problems in early ages in order to prevent disability, development of maladaptive
 coping strategies and to avoid negative impact on daily activities.

 The optimal treatment regime for paediatric pain patients has been suggested to be cognitive
 behavioural approach integrated with physical therapy The aim of this project is to develop
 and evaluate in a randomized controlled trial a treatment program with a behavioural medicine
 approach (suitable to use in primary care or school based health care context) compared with
 standard treatment for adolescents with persistent pain problems. The aim is also to compare
 short and long-term costs for patients and for the health care system related to the two
 interventions, in order to determine strategies for future cost-effective care of children
 and adolescents experiencing recurrent pain.
Chronic or recurrent pain symptoms are widely studied and generally regarded as an important
 public health concern in adults. The prevalence of pain symptoms are reported to be as high
 as 25-30 % in children and adolescents. Children and adolescents are reported to have
 restrictions in daily life activities, social contacts, and school attendance, and to have
 poorer academic skills and as well as an increased utilization of heath care services due to
 pain problems. These patients suffer from a wide variety of problems, for example sports
 injuries, persistent postoperative pain, musculoskeletal pains, headaches or multiple
 recurrent pain problems. The treatments given today to adolescents are dealing with symptoms
 in a physical manner.

 In this study participants will be recruited among adolescents referred to paediatric
 physiotherapy. The participants will be randomly allocated to either physiotherapy including
 standard treatment or a behavioural medicine treatment program. Standard treatment includes
 muscle strengthening, stretching, posture training, training of relaxation techniques and
 information about pain according to the best empirical praxis.

 The behavioural medicine treatment program will include the same components as the standard
 treatment with the addition of age appropriate interventions aimed to address the emotional
 and behavioural processes of pain. The treatment is based on earlier intervention programs
 and includes the following phases;

 -  Individual functional behavioural analysis The adolescents lists specific important and
 frequent activities and situations they have problems to master due to pain and target
 activities are then chosen. Individual capabilities (both physical and psychological),
 behavioural responses, and their short and long-term consequences are identified.
 Parental responses and their impact on adolescent's pain behaviours are noted. Target
 activity related treatment goals as well goals for engagement in the treatment are
 defined from the individual functional behavioural analysis.

 -  Basic skill acquisition Physical abilities and cognitive skills required for improvement
 of behaviour in target activities are trained. For example to meet the problem of fear
 of movement, graded activity, or exposure will be provided. When negative thoughts are
 recognized the adolescents are taught and trained on how to replace these thoughts,
 self-efficacy for target activities are increased by carefully selected activities witch
 allows the adolescent to succeed and by repeated feedback from the physiotherapists.
 Adequate coping strategies for restoring and sustaining activities are taught and
 trained. Parents are trained on how to support new behaviours.

 -  Applied skill acquisition The basic capabilities are put together in order to shape the
 more complex skills required when applying in target activities. Self- efficacy is
 reinforced by feedback from both the physiotherapists and parents.

 -  Generalisation This phase includes the generalisation of new, both physical and
 psychological skills to other, for the adolescent important, activities.

 -  Maintenance and relapse prevention This phase includes the identification of "risk
 situations", and recognition of how adolescents and parents can support positive
 behaviours further.

 Patient follow-ups takes place immediately after completed intervention, after 6 months and
 after one year and two years after intervention in order to evaluate the long-term effect.

 • Parents The treatment is based on earlier intervention program and includes; Information on
 pain and pain behaviours and parental impact on adolescent's pain behaviours. An individual
 intervention plan according to each teenager's problems is made. All parents will be trained
 on how to support new positive health behaviours.
Inclusion Criteria:

 -  Adolescents with pain and interference of daily activities due to pain, referred to
 paediatric physiotherapy in a primary health setting will be included.

 -  Participants must understand written and oral Swedish and have had persistent pain for
 more than 6 weeks or recurrent pain more than once a week for over three months.

 -  The adolescents´ parents will be included in a brief intervention.

 Exclusion Criteria:

 -  Subjects with resent trauma, ongoing treatment for any psychiatric illness or
 cognitive problems will be excluded.