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

The commentary by Hechler, Dobe, & Zernikow (2009) that discusses our retrospective review of an inpa- tient protocol for pain-associated disability (Maynard, Amari, Wieczorek, Christensen, & Slifer, 2009) highlights a number of important points for consideration regarding the worldwide need and standards for multimodal inpa- tient treatment of children and adolescents with chron- ic pain and pain-related disability. In their commentary and recent work reporting the results of a similar multimodal inpatient protocol, Hechler, Blankenburg, Dobe, Kosfelder, Hubner, & Zernikowet, (2009) have cogently set forth important standards for future clinical trials of multidisciplinary inpatient treatment for chronic pain and functional disability in chil- dren and adolescents. We acknowledged the considerable limitations of a retrospective study in Maynard et al. (2009). We fully acknowledge the need to interpret the results of our study with caution, given its limitations. We have discussed the need for prospective, randomized controlled clinical trials involving multiple centers, and using both a standard protocol and standardized out- come measures. The prospective studies by Dobe, Damschen, Reiffer-Wiesel, Sauer, & Zernikow (2006) and Hechler, Blankenburg, et al. (2009) should be encouraged, and we commend them for their fine work. Our objective in publishing our limited retrospect- ive clinical results was to focus more attention in the field on the relatively untapped potential for multidiscip- linary inpatient treatment within a rehabilitation setting to interrupt the downward spiral of pain, avoidance behavior and increasing disability in children and adoles- cents. Although we conducted a retrospective study, the clinical outcomes seen using our protocol have been encouraging. This along with the increasing demand for a brief inpatient alternative for patients who are not responsive to more typical outpatient pain clinic services seemed worth presenting to our colleagues in pediatric psychology. As noted in the commentary, we recognize that the sample size of 41 is less than optimal. Again, based upon the available data that we had at our institute, we felt that it was meaningful to present this information despite this relative weakness. We agree with Hechler, Dobe, et al. (2009) that future research studies should obtain larger sample sizes and more complete follow-up data at standard intervals post-discharge. A longer follow-up period beyond our 3-month assessment is critical to evaluating mainten- ance and generalization of treatment effects. The need for reporting pain intensity was also discussed in the commentary. Clearly, these data are important and should be included in future studies. Our clinical objective has been to de-emphasize pain ratings relative to functional outcomes with our patients and families. We agree that this does not obviate the need for obtaining pain intensity data. We recommend that the number of times per day that intensity ratings are obtained should be made standard and time based rather than con- tingent on observed distress. Patients' subjective pain ex- perience should be acknowledged with both empathy and objectivity, but a contingent association between distress behavior and social attention or termination of therapy demands should be carefully avoided. Subjective pain in- tensity ratings are obtained on our inpatient unit by the nursing staff at standard times. However, we did not have the research resources to conduct validity and reliability analyses on these pain intensity ratings from our clinical database. Certainly, it is important to obtain these data systematically in any prospective research study, preferably using the core outcome measures recommended by Hechler, Dobe, et al. (2009) and the PedIMMPACT