Abstract
Objective
Pain-related function is not routinely assessed in the hospital. This prospective cohort study examined whether patients’ daily pain-related function during hospitalization, based on the validated Youth Acute Pain Functional Ability Questionnaire (YAPFAQ), is associated with pain and quality of life.
Design
The YAPFAQ is a 12-item measure assessing functional parameters of recovery related to pain and has been validated in children and adolescents with sickle cell disease and after surgery. Adolescents undergoing major musculoskeletal surgery (n = 93) completed the YAPFAQ daily for up to 3 days after surgery. Adolescents self-reported health-related quality of life on the Pediatric Quality of Life Inventory and pain intensity on a numeric rating scale at home 2 weeks after surgery.
Results
Higher YAPFAQ scores, representing poorer function, were associated with higher pain intensity (β = 0.2, P = 0.04) and poorer health-related quality of life (β = –0.3, P = 0.01) at home 2 weeks after surgery. This functional measure could be clinically relevant to providers to identify adolescents at risk of difficulty with pain and recovery at home after surgery who might need further intervention to minimize functional impairment and delayed recovery.
Perspective
This article provides conceptual validation of a functional score for pediatric pain, the YAPFAQ, to assess pain intensity and health-related quality of life in the subacute period.
Keywords: Health-Related Quality of Life, Youth Acute Pain Functional Ability Questionnaire, Numeric Rating Scale, Pain Intensity, Postoperative Pain, Function, Functional Impairment, Surgery
Introduction
Poorly controlled postoperative pain is a considerable source of distress in adolescent patients undergoing major surgery [1, 2]. Consequences include delayed healing, decreased mobility, poor sleep, and if pain persists after hospital discharge, potential return to the emergency department and readmission to the hospital for pain control [3, 4]. Accurate assessment is essential for effective management of acute postoperative pain, and measuring function is an important component of comprehensive evaluation of acute pain [5]. Nevertheless, acute pain assessment in the hospital typically relies solely on numeric rating scales of pain intensity, a unidimensional measure [5–7], and there has been limited incorporation of measures of acute pain-related function into clinical practice. In addition, recent guidelines for acute pain assessment recommend measuring the trajectory of pain intensity and pain-related function [5, 8]. The ability to predict pain outcomes after hospital discharge is particularly important, as pediatric patients are discharged home earlier in the recovery period, often within 2–3 days after major surgery [9, 10].
The Youth Acute Pain Functional Ability Questionnaire (YAPFAQ) addresses this gap in the assessment of acute pain-related function through measuring self-reported ability to perform activities of daily living and mobility in adolescents. This measure was originally developed in children and adolescents with sickle cell disease hospitalized for painful vasocclusive episodes [11]. It was subsequently evaluated in pediatric patients hospitalized for major surgery [12], demonstrating good reliability and concurrent associations with pain intensity and health-related quality of life (HRQOL). However, the predictive validity of this measure, specifically whether in-hospital functional ability is associated with key patient outcomes such as pain intensity and HRQOL after discharge, has not been determined. In addition, YAPFAQ scores demonstrated responsiveness to expected postsurgical recovery [12], but whether the rate of functional recovery in the hospital predicts postdischarge outcomes is unknown.
Our primary aim was to examine the predictive validity of the YAPFAQ, assessing in-hospital daily acute pain-related function in adolescents, as a predictor of pain and HRQOL at home 2 weeks after major musculoskeletal surgery. We hypothesized that poorer pain-related function during the first 3 postoperative days (higher mean YAPFAQ scores) would be significantly associated with higher pain intensity and lower HRQOL at 2 weeks postoperatively. We also aimed to explore the rate of change in acute in-hospital YAPFAQ scores as a predictor of 2-week outcomes. We hypothesized that slower improvement in pain-related function over the first 3 inpatient days after surgery would be associated with higher pain intensity and lower HRQOL at 2 weeks postoperatively.
Methods
Data were collected prospectively as part of a larger longitudinal study of chronic postsurgical pain in adolescents after major musculoskeletal surgery. The primary outcome data describing psychosocial risk factors for acute and chronic pain were previously published [13]; however, in-hospital data (the YAPFAQ measure) have not been analyzed or reported to date. For the purposes of the present report, we used participant data from the baseline (before surgery), in hospital, and 2-week postsurgery assessments.
Participants
Participants were recruited at a free-standing pediatric specialty hospital in the northwestern United States from October 2014 to June 2018. Potential participants were eligible for inclusion in the larger study if they were 1) 10–18 years of age, 2) scheduled to undergo an eligible major musculoskeletal surgery (surgery for pectus deformity, spinal fusion for idiopathic deformity, or hip/femur osteotomy), and 3) able to read and understand English. Potential participants were excluded if they 1) had an underlying chronic medical condition, 2) had a diagnosed chronic pain condition on treatment, 3) had undergone major surgery in the past, or 4) had significant developmental delay such that they could not complete study measures. For this analysis, we excluded participants with missing data (no YAPFAQ, n = 20; missing baseline or follow-up outcomes measures, n = 2) and those who had undergone hip/femur surgery (because of the direct effects of surgery on mobility, n = 4).
Procedures
This study was approved by the Institutional Review Board at Seattle Children’s Hospital. Electronic health data, filtered by age, diagnosis, and procedure, were used to identify potential participants. Research coordinators mailed to potentially eligible participants packets containing a flyer outlining the purpose of the study, consent documents, and a toll-free number to decline contact by the study team. Participants were approached by study staff by phone or at their preoperative visits. There were 213 potentially eligible families approached for enrollment in the study; 88 declined participation, six were not eligible, and 119 enrolled in the study, of which 93 were included in the present analyses. Adolescents provided assent, and parents provided written consent.
Study data were collected and managed with Research Electronic Data Capture (REDCap) tools hosted at the University of Washington [14]. Participants completed baseline study measures, including a parent-reported demographic questionnaire, and youth self-reported pain intensity and HRQOL at home during the week before surgery. After surgery, adolescents completed the YAPFAQ measure daily for 3 days on their own mobile devices via REDCap. A link to the daily survey was sent by e-mail or text to participants at 14:00 and expired after 12 hours. Adolescents self-reported on pain intensity and HRQOL 2 weeks after their surgery from home via REDCap. Participants received modest honoraria in the form of gift cards for completion of questionnaires. Long-term follow-up data were collected as described in the primary outcomes article [13].
Measures
Pain-Related Function
Adolescents completed the YAPFAQ, assessing self-reported perceived level of difficulty with activities that day (i.e., “Today, how difficult are these things for you?”), including movement (four items, e.g., “Walk around in the room?”) and activities of daily living (seven items, e.g., “Turn over or roll over in bed?”). Responses were indicated on a five-point Likert scale ranging from 0 to 4 (0 =“not difficult” to 4 =“extremely difficult”). Items were summed to yield a total score ranging from 0 to 44, with higher total scores indicating greater difficulty (worse functional ability). As recommended in the postsurgical validation study of this measure, the item concerning homework was removed because of lack of applicability in the acute postsurgical setting.
Pain Intensity
Participants reported pain experienced in the prior 7 days, in response to the question, “When you have aches or pains, how much hurt do you usually have?” Responses were indicated on an 11-point numeric rating scale with anchors 0 =“no pain” and 10 =“worst pain possible.” Numeric rating scales for pain were evaluated in children more than 8 years old for psychometric properties and were found to have good convergent and discriminant validity in children undergoing surgery [15].
Health-Related Quality of Life
Adolescents completed the Pediatric Quality of Life Inventory (PedsQL) short form, acute version, a 15-item self-report measure that evaluates physical, emotional, school, and social HRQOL in the preceding 7 days. This measure has shown strong validity in assessing quality of life in pediatric populations with acute and chronic health conditions [16], and it has been used broadly to assess postoperative outcomes [17, 18]. All items use a five-point Likert scale with anchors 0, indicating “never,” and 4, indicating “almost always a problem.” Items are reverse-scored and linearly transformed and then averaged to produce a total score ranging from 0 to 100, with a higher score indicating a better HRQOL [19].
Demographic and Clinical Characteristics
Parents reported on children’s age, sex, and race and ethnicity; surgery procedure was electronically extracted from the medical record.
Statistical Analysis
Two-sided t tests and χ2 tests were used to compare baseline characteristics (pain intensity, HRQOL, and sex) between adolescents included in the present analyses (n = 93) and those who were excluded (n = 26). No significant differences in baseline characteristics were detected between these groups.
Mean YAPFAQ scores across the 3 postoperative hospital days were calculated for each individual adolescent. We calculated the rate of change for in-hospital YAPFAQ score by subtracting the first day from the last day and dividing by the number of intervening days to obtain the percent relative change per day for each individual adolescent. For this analysis, participants needed at least 2 days of YAPFAQ data (n = 71). This method was chosen because of potential easy application to patients in the clinical setting [20]. Daily YAPFAQ scores for each separate day, mean YAPFAQ score across days, and YAPFAQ rate of change were then collapsed across the sample to calculate summary statistics.
To address our first aim, we used two separate multiple linear regression models to examine the association between the mean in-hospital YAPFAQ score during the first 3 days of postoperative hospitalization (independent variable) and pain intensity and HRQOL at 2 weeks after surgery (dependent variables). Each model included the following a priori selected baseline covariates: surgery type, sex, and baseline pain intensity or HRQOL (corresponding to the model dependent variable). We provided a standardized beta-coefficient for each independent variable and F statistic for each model.
To address our second exploratory aim, we conducted two separate multiple linear regression models evaluating the association between the relative rate of change of in-hospital function (independent variable) and 2-week pain intensity and HRQOL (dependent variables). We examined the association between the YAPFAQ rate of change and the 2-week HRQOL and pain intensity, with covariates surgery type, sex, and baseline pain intensity or quality of life (corresponding to the dependent variable) included in each model. We provided a standardized beta-coefficient for each variable and F statistic for each model. Analyses were performed in Stata Statistical Software, Release 14 (StataCorp LP, College Station, TX, USA).
Results
Descriptive Data
Demographic characteristics of the sample (n = 93) are summarized in Table 1. Participants were 10–18 years old (mean = 14.8 years, standard deviation [SD] = 1.9) and 67% female, and 80% identified as Non-Hispanic White. The majority of patients (74%) had major spine surgery, and 26% underwent a pectus deformity correction.
Table 1.
Demographics and clinical characteristics of participants (n = 93)
| Characteristic | n (%) or Mean (Range) |
|---|---|
| Age, years, mean (range) | 14.8 (10.6–18.9) |
| Sex, n (%) | |
| Female | 62 (67) |
| Male | 31 (33) |
| Race and ethnicity, n (%) | |
| Non-Hispanic White | 75 (80) |
| Hispanic | 3 (4) |
| Black or African American | 4 (4) |
| Native American or Pacific Islander | 1 (1) |
| Asian | 3 (4) |
| Other | 2 (2) |
| No response | 5 (5) |
| Surgery, n (%) | |
| Spinal fusion | 69 (74) |
| Pectus repair | 24 (26) |
| Pain intensity, mean (range) | 4 (2–5) |
| HRQOL, mean (range) | 78.00 (66.7–91.7) |
Continuous data are given as mean with interquartile range. Discrete data are given as absolute numbers and %.
The sample mean for in-hospital YAPFAQ scores was 30.0 (SD = 9.0), and the mean rate of change was 6.8 (SD = 21.9) over the first 3 days after surgery. YAPFAQ data by postoperative day are presented in Table 2. Individual YAPFAQ scores and trajectory over 3 days postoperatively, are shown with overlying sample mean and sample mean trajectory in Figure 1. Clinical outcomes at two weeks post-surgery are visualized in Figure 2.
Table 2.
Daily YAPFAQ scores
| n | Mean | SD | Interquartile Range | |
|---|---|---|---|---|
| Day 1 | 73 | 33.0 | 9.5 | 27.0–41.0 |
| Day 2 | 77 | 30.1 | 10.4 | 25.0–39.0 |
| Day 3 | 68 | 26.3 | 9.6 | 19.5–33.0 |
| Rate of change | 71 | –6.8 | 21.9 | –17.4 – (–2.4) |
Figure 1.
Individual YAPFAQ scores and trajectory over 3 days postoperatively, with overlying sample mean and sample mean trajectory.
Figure 2.
Clinical outcomes at 2 weeks: HRQOL and pain intensity.
Predictive Validity of Mean YAPFAQ
Multivariate linear regression models examining associations of the mean in-hospital YAPFAQ score over the first 3 postoperative days with 2-week pain intensity and HRQOL, with adjustment for baseline covariates, are presented in Table 3. Consistent with hypotheses, we found that mean in-hospital function was significantly associated with 2-week outcomes. Specifically, higher YAQFAQ scores (i.e., poorer function) were associated with higher pain intensity (β = 0.2, P = 0.04) and poorer HRQOL (β = –0.3, P = 0.01) at home 2 weeks after surgery. In terms of covariates, presurgery pain intensity and HRQOL were associated with the corresponding 2-week outcome (β = 0.3, P < 0.001, for pain intensity, and β = 0.4, P < 0.001, for HRQOL). Neither sex nor surgery type was found to be significantly associated with 2-week outcomes in either model.
Table 3.
Multivariate models examining associations between mean in-hospital YAPFAQ score and 2-week pain and quality-of-life outcomes
| β | F | P Value | |
|---|---|---|---|
| Outcome: 2-week pain intensity | 3.39 | 0.01 | |
| Mean in-hospital YAPFAQ score | 0.2* | ||
| Presurgery pain intensity | 0.3* | ||
| Sex | |||
| Male | Ref | ||
| Female | 0.02 | ||
| Surgery | |||
| Pectus repair | 0.1 | ||
| Major spine | Ref | ||
| Outcome: 2-week HRQOL | 3.71 | <0.001 | |
| Mean in-hospital YAPFAQ score | –0.3* | ||
| Presurgery HRQOL | 0.4* | ||
| Sex | |||
| Male | Ref | ||
| Female | –0.1 | ||
| Surgery | |||
| Pectus repair | –0.3 | ||
| Major spine | Ref |
P ≤ 0.05.
Higher YAPFAQ scores indicate poorer function.
Predictive Validity of YAPFAQ Slope
Multivariate linear regression analyses examining the association of the rate of change of in-hospital YAPFAQ scores with 2-week pain intensity and HRQOL are presented in Table 4. Contrary to hypotheses, we did not observe any association between YAPFAQ rate of change and pain intensity or HRQOL at home 2 weeks after surgery (β = –0.2, P = 0.10, for pain intensity, and β = –0.02, P = 0.87, for HRQOL). Baseline pain was associated with 2-week pain (β = 0.2, P < 0.05), and baseline HRQOL was associated with HRQOL 2 weeks after surgery (β = 0.3, P < 0.01 for HRQOL). Sex and type of surgery were not associated with 2-week outcomes in either model (P values >0.05).
Table 4.
Multivariate models examining associations between in-hospital YAPFAQ rate of change and 2-week pain and quality-of-life outcomes
| β | F | P Value | |
|---|---|---|---|
| Outcome: 2-week pain intensity | |||
| YAPFAQ rate of change | –0.2 | ||
| Presurgery pain intensity | 0.2* | ||
| Sex | |||
| Male | Ref | ||
| Female | 0.1 | ||
| Surgery procedure | |||
| Pectus repair | 0.1 | ||
| Spinal fusion | Ref | 2.13 | 0.01 |
| Outcome: 2-week HRQOL | |||
| YAPFAQ rate of change | –0.02 | ||
| Presurgery HRQOL | 0.3* | ||
| Sex | |||
| Male | Ref | ||
| Female | –0.1 | ||
| Surgery procedure | |||
| Pectus repair | –0.2 | ||
| Spinal fusion | Ref | 1.95 | 0.11 |
P < 0.05.
Discussion
This study examined the predictive validity of the YAPFAQ in adolescents in the acute postoperative inpatient setting, finding significant longitudinal associations between acute pain-related function and pain intensity and HRQOL at 2 weeks after major surgery. This study builds on prior work [12] by providing additional evidence that the YAPFAQ can identify decreased function in surgical inpatients, which predicts decreased HRQOL and increased pain intensity, not only in the hospital but also at home.
Evaluation of function during the postoperative period is particularly important for informing treatment, planning for discharge, and informing follow-up planning [21, 22]. Pain intensity, though commonly measured in inpatients, does not capture the functional impact of pain [5], and few studies have looked at the effect of poor function in the acute inpatient setting. The present study shows that as patients recover from surgery in the acute inpatient setting, early mobilization and resumption of activities of daily living, as captured by the YAPFAQ, are indicators of a favorable anticipated course of recovery at home in terms of pain intensity and HRQOL. Early identification of patients with poor functional scores could allow for more effective triage of patients to clinical intervention.
Evaluation of function during the postoperative period is important for informing acute pain treatment. Opioids are a primary treatment for acute postoperative pain in pediatric inpatients. Appropriate use includes short duration of therapy [23] and an optimal balance between benefits and negative effects, such as sedation that could inhibit function. Evaluating function aids with achieving optimal balance between pain control and the facilitation of functional activities. A brief measure assessing function can inform prescribing practices to allow for a more comprehensive and nuanced approach to a patient’s pain treatment. We had previously developed a three-item version of the YAPFAQ that could be easily integrated into standard inpatient postoperative assessments [12]. Given the nationwide opioid epidemic, it is also crucial that we try to curb home-going opioid prescriptions. A recent study identified a lack of consistent prescribing practices among pediatric physicians prescribing postoperative opioids [24]. Standardized assessment of the patients’ functional recovery before discharge could help inform tailored prescribing practices.
On the basis of recent guidelines to incorporate assessment of trajectories of acute pain and function [20], we also explored the rate of change of YAPFAQ scores in the hospital, using a metric of relative change that can easily be calculated for individual patients in a clinical context. Consistent with prior findings [12], YAPFAQ scores improved during the course of hospitalization, but the rate of change was not associated with 2-week outcomes. Although we accounted for surgery procedure type, the rate of change in YAPFAQ scores might need to be stratified by surgery type, which will require larger studies. In addition, longer duration of monitoring after surgery into the postdischarge period could be necessary to identify early pain trajectories [25, 26]. Indeed, larger studies in adult postsurgical populations extending into the subacute period have shown that pain trajectories in the postoperative period can be predictive of pain outcomes at home 3 months to a year postoperatively [26].
Several limitations should be considered in the interpretation of the findings of the present study. Our sample was recruited at a single institution and showed limited sociodemographic diversity. YAPFAQ data were missing for several youth, though there were no systematic differences between youth who completed the YAPFAQ and those who did not. Sample size did not allow us to stratify analyses by surgery type and limited our ability to identify any predictive utility of the YAPFAQ rate of change in the 3 postoperative days. Larger samples could be needed to validate the predictive value of pain recovery trajectories and to examine nonlinear models of change in pain and pain-related function [20].
In conclusion, we provide further support for the construct validity of the YAPFAQ as a daily measure of inpatient pain-related function after pediatric surgery. Findings demonstrated that YAPFAQ scores in the hospital predict pain intensity and HRQOL 2 weeks after discharge. This demonstrates that the YAPFAQ provides a valid way to evaluate postoperative function, which could inform acute pain treatment in the hospital and tailor discharge planning.
Supplementary Data
Supplementary Data may be found online at http://painmedicine.oxfordjournals.org.
Supplementary Material
Contributor Information
Elisabeth B Powelson, Center for Child Health, Behavior and Development, Seattle Children’s Hospital, Seattle, Washington; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington.
Nuria Alina Chandra, Center for Clinical and Translational Research, Seattle Children’s Hospital, Seattle, Washington; Paul G. Allen School of Computer Science and Engineering, University of Washington, Seattle, Washington.
Tricia Jessen-Fiddick, Center for Child Health, Behavior and Development, Seattle Children’s Hospital, Seattle, Washington.
Chuan Zhou, PhD, Center for Child Health, Behavior and Development, Seattle Children’s Hospital, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington, USA.
Jennifer Rabbitts, Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington; Center for Clinical and Translational Research, Seattle Children’s Hospital, Seattle, Washington.
Funding sources: Research reported in this publication was supported by the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health under Award Number K23HD078239 (PI: Rabbitts), as well as the T32 Training Program (T32GM086270 National Institute of General Medical Science) in the Postdoctoral Training Program in Anesthesiology at the University of Washington (Dr. Powelson). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Conflicts of interest: The authors have no conflicts of interest.
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