A pilot feasibility and acceptability study of an Internet-delivered psychosocial intervention to reduce postoperative pain in adolescents undergoing spinal fusion

Figures & data

Table 1. Summary of adolescent and parent intervention timing and content.

Lesson	Delivery/timing	Teen content/skills	Parent content/skills
Preoperative intervention phase
Lesson 1: Preparing for Surgery	4–6 weeks prior to surgery	Information on preparing for surgery Psychoeducation on relaxation strategies and training in deep breathing Information about the role of sleep in recovery and provision of strategies to improve sleep habits	Information on preparing for surgery Psychoeducation on relaxation strategies and training in deep breathing Information about the role of sleep in recovery and provision of strategies to improve teen sleep habits
Lesson 2: Coping with Stress before Surgery	2–4 weeks prior to surgery	Psychoeducation on cognitive strategies Training in cognitive skills (thought replacement, thought stopping) and “54321 mindfulness” (relaxation skill using five senses for grounding)	Psychoeducation on cognitive strategies Training in cognitive skills (thought replacement, thought stopping) and “54321 mindfulness” (relaxation skill using five senses for grounding) Strategies to enhance parent–child communication
Lesson 3: Getting Ready for the Hospital	1–2 weeks prior to surgery	Information on preparing for the hospital including developing a social connection plan Training in additional relaxation (i.e., imagery) and cognitive (i.e., distraction) strategies for managing anxiety and pain	Information on preparing for the hospital including developing a social connection plan Training in additional relaxation (i.e., imagery) and cognitive (i.e., distraction) strategies for managing anxiety and pain Information on preparing for hospital discharge
Postoperative intervention phase
Lesson 4: Coping at Home after Surgery	1 week postsurgery	Introduction to behavioral activation and training in pleasant activity scheduling to improve mood Review of thought restructuring Training in mindful breathing	Introduction to basic principles of self-care Introduction to behavioral activation and training in pleasant activity scheduling to improve teen mood Review of restructuring thoughts Training in mindful breathing
Lesson 5: Return to Activities and School	2–4 weeks postsurgery	Review of strategies to improve sleep habits Information about preparing to make transition back to school Goal setting and training in strategies to gradually increase physical activities (i.e., activity pacing) Training in “mini relaxation” and using relaxation strategies in school	Review of strategies to improve sleep habits Information about preparing to teen to make transition back to school Goal setting and training in strategies to gradually increase teen’s physical activities (i.e., activity pacing) Operant strategies to facilitate teen’s return to activities (praise, reinforcement) Training in “mini relaxation”
Lesson 6: Long-Term Recovery	6–8 weeks postsurgery	Review of skills Relapse prevention	Review of skills Relapse prevention

Table 2. Sample baseline characteristics (n = 13 parent–adolescent dyads).

Adolescent characteristics
Age (years), M (SD)	14.3 (1.4)
Range	12−17
Sex (female), n (%)	9 (69.2)
Race/ethnicity, n (%)
Hispanic/Latinx	1 (7.7)
Black	1 (7.7)
Asian	1 (7.7)
American Indian or Alaska Native	1 (7.7)
White	9 (69.2)
VAS average pain intensity, M (SD)	3.0 (0.4)
PROMIS pain interference, M (SD)*	54.3 (7.8)
PedsQL total, M (SD)	74.1 (18.7)
n, % cutoff <75	5 (38.1)
Parent characteristics
Parent/caregiver relation to adolescent, n (%)
Mother	10 (76.9)
Father	2 (15.4)
Grandparent	1 (7.7)
Race/ethnicity, n (%)
Hispanic/Latinx	0 (0.0)
Black	0 (0.0)
Asian	1 (7.7)
American Indian or Alaska Native	1 (7.7)
White	11 (84.6)
Marital status, n (%)
Married or remarried	9 (69.2)
Divorced	1 (7.7)
Widowed	1 (7.7)
Never married	2 (15.4)
Highest level of education completed, n (%)
High school or less	4 (30.8)
Vocational or trade school	4 (30.8)
College or university	3 (23.1)
Graduate degree/professional school	2 (15.4)
Annual household income, n (%)
≤$29,999	1 (7.7)
$30,000–$49,999	0 (0.0)
$50,000–$69,999	1 (7.7)
$70,000–$100,999	5 (38.5)
More than $100,999	6 (46.2)

*VAS, Visual Analogue Scale, 0–10; PROMIS, Patient-Reported Outcomes Measurement Information Systems, scores based on a population mean of 50 with a SD of 10; PedsQL, Pediatric Quality of Life Inventory (based on the established cut point of 1 standard deviation below the population mean, values below 74.9 indicate impairment in health-related quality of life).

Figure 1. Consort diagram depicting flow through the study from recruitment to analysis.

Table 3. Program evaluation: Quantitative ratings on intervention acceptability.

Questions	Parent presurgery program	Teen presurgery program	Parent postsurgery program	Teen postsurgery program
1. Did the program come at a good or convenient time? (0 = very inconvenient to 5 = very convenient)	4.0 (0.9)	3.8 (1.1)	4.0 (1.0)	3.3 (1.1)
2. How easy or difficult was it to understand the information presented? (0 = very difficult to 5 = very easy)	4.8 (0.4)	4.5 (0.8)	4.6 (0.5)	4.2 (0.8)
3. Did you like accessing the information online? (0 = did not like it at all to 5 = liked it a lot)	4.9 (0.3)	4.0 (1.2)	4.6 (0.9)	3.8. (1.3)
4. How useful or relevant was the program content overall? (0 = not at all useful to 5 = very useful)	4.2 (1.1)	3.6 (0.9)	4.3 (0.7)	3.3 (1.1)
5. If you did at least one, how useful were the telephone coaching calls? (0 = not at all useful to 5 = very useful)	4.2 (1.1)	3.2 (1.6)	3.5 (1.2)	3.0 (1.0)

Table 4. Program evaluation: Qualitative feedback on intervention acceptability.

Topic	Themes	Representative participant quotes
Intervention components (skills/lessons)	Cognitive and relaxation strategies helped adolescents and parents cope with stress	“I had thoughts like, ‘Oh my gosh, this is going to be so overwhelming,’ or, ‘This is going to take forever,’ stuff like that, and I definitely reframed those to, ‘Well, they said it’s going to be better every week, so I’m going to rely on that.’” (ID9, parent) “Sometimes with the picturing you’re in a different place … those [strategies] were like the main things that helped me through surgery.” (ID9, teen)
	Cognitive and relaxation strategies helped adolescents cope with pain during recovery	“I used some distraction techniques when she was in a lot of pain … encouraging her to talk about school or something else outside of the four walls of the hospital room.” (ID1, parent) “Deep breathing, like, calms me down and usually makes my pain feel a whole lot better.” (ID11, teen)
	Strategies for improving sleep were beneficial before surgery and during recovery	“I would usually go to bed at the same time and I would play music usually to go to sleep … and I still kind of do that to just relax.” (ID6, teen) “He got more sleep than he would have in the weeks going up to the surgery because of the lessons … like, I was really worried about how we were going to keep him on a schedule over all those weeks home because the surgery … but he just slept at the normal times and kept a schedule.” (ID9, parent)
	Activity pacing and goal setting used to gradually return to regular activities	“We would do little goals here and there, like one day let’s walk to the mailbox … and then let’s walk around the kitchen. … And then another [goal] was try to walk in the backyard.” (ID6 parent) “After surgery, gradually getting back into the things I did was helpful … instead of just rushing right back into it. For me we started with half days at school, so I’d go to part of my classes and go home instead of trying to do all 6 periods of my classes.” (ID3, child)
	Parents valued strategies to encourage self-care	“Self-care—having that was a good reminder … because you you’re so focused on taking care of your child that you kind of put yourself to the side … having that was a good reminder just to kind of give yourself a chance to recharge a little bit.” (ID3, parent) “Self-care was helpful, especially when it talked about managing your expectations for your recovery and giving yourself some grace.” (ID1, parent)
Program structure	Families found narratives relatable and validating	“It was like we were reading a diary of what we were going through. … ” (ID6, parent) “It helped me to know that there’s other people that got the surgery because it kind of feels like it’s just me … like, everyone around me doesn’t even know what scoliosis is.” (ID9, teen)
	Families appreciated flexibility of online program	“[We liked] the flexibility because the weeks after surgery … we just wouldn’t have been able to participate if it had to be during business hours.” (ID9, parent) “Sometimes I would get really tired, and I could pause it and go back to it later … so I liked doing it when I had nothing else to do.” (ID6, teen)
Suggestions/improvements	Rethink timing and reduce length of first postsurgical lesson	I felt that you guys needed to maybe wait a little longer [to send the first postsurgical lesson] … it was literally like the next day when we were home, and I’m like, “I’ve already got my hands full!” (ID2, parent) “Sometimes [the timing of lessons] was good and sometimes it wasn’t. Like right after the surgery maybe not as long of lessons … it was really hard to do. I was hurting a lot and I didn’t really feel like doing it at the time.” (ID6, teen)
	Reduce repetitive lesson content	“I tended to get a little frustrated because I want to get through the lesson and I wanted to learn, but it felt like I was learning the same things over and over again.” (ID2, parent) “I felt like it was repeating it too much, like if it was saying an example, then it would say, like, kind of the exact same examples in a couple more pages.” (ID9, teen)
	Enhance program accessibility and interactivity	“It would’ve been cool if it worked on a mobile phone or a mobile platform.” (ID1 parent) “One thing that could help is to kind of gamify it a little bit … maybe even sprinkled throughout add some multiple-choice questions and something just to kind of engage people.” (ID3 parent)