Pain in Pediatric Primary Care: Lessons from a Med-Psych Day

Treatment ProgramHeather Chapman, MD1 and Jack Nassau, PhD2

1Clinical Assistant Professor of Pediatrics and Staff Pediatrician,2Clinical Associate Professor of Psychiatry and Human Behavior

and Chief Psychologist

Alpert Medical School of Brown UniversityHasbro Children’s Partial Hospital Program, Rhode Island Hospital

DisclosureDr. Chapman does not have any conflicts of interest

to disclose

Dr. Nassau does not have any conflicts of interest to disclose

got pain?

Objectives

Describe the biopsychosocial model of pain

Understand the benefits of functional pain assessment

Develop strategies for incorporating the biopsychosocial model in primary care pain assessment and management

What is Pain?“An unpleasant sensory and emotional experience

associated with actual or potential tissue damage, or described in terms of such damage.”

Pain is always a psychological state that cannot be reduced to objective signs. In other words, pain is always subjective.

Extensive tissue damage may occur without pain Pain may occur in the total absence of tissue

damage

Pictures of:

Pain is aBiopsychosocial Experience

Biological Site - Pain is absolutely real and is physically experienced

Psychological “Interpretation” – “No brain, no pain”

Social Context – “Pain is felt where you hurt and where you are”

Biological Stress ReponsesAutonomic Nervous System

Sympathetic-Adrenal-Medullary (SAM) System Catecholamines (epinephrine, norepinephrine) released into

blood via sympathetic nerve endings and adrenal medulla Increased blood pressure, heart rate, sweating, and

constriction of peripheral nerve endings “Fight or flight” response

Central Nervous SystemHypothalamic-Pituitary-Adrenocortical (HPA) Axis

Hypothalamus releases corticotropin releasing factor >> pituitary releases adrenocorticotropic hormone >> adrenals release cortisol

Things You Can Change

(Think)

Cognitive Understanding Control Expectations Relevance Pain Control Strategies Tissue Damage Or Pain Source

(Do) Behavior Overt Actions Response of Others Physical Restraint Physical Activities Social Activities Age Gender Cognitive Previous Pains Family History Culture

(Feel) Emotional Anxiety Fear Frustration Anger Depression Pain Sensation Pain Experience

Things You Can’t Change

Adapted from McGrath, P.A, & Miller, L.M. (1996). Controlling children’s pain. In R.J. Gatchel & D.C. Turk (Eds.), Psychological approaches to pain management: A practitioner’s handbook (pp. 331-370). New York: Guilford.

Possible pain “signs” in childrenVerbalEmotionalBehavioralPhysiological

Avoidance, somatic complaints (headache, stomach ache), fatigue, irritability, disrupted appetite/sleep, “clinginess”, regressive behaviors

Traditional Pain AssessmentLocationFrequencyDurationIntensity

What’s missing???

Biopsychosocial Pain AssessmentLocationFrequencyDurationIntensityFunctional Impact

MoodBehaviorFamilySchool

Functional Pain Assessment Tool Functional Assessment ToolHasbro Children’s Partial Hospital Program

Date:

      

    

Time 

Pt reports

Pain (Y/N)

Activity/Behavior at assessment

FACES pain rating

(Pt report)

Functional rating

(Pt report)

FACES pain rating

(RN report)

Coping Strategies/Interventions

RN initials

     

             

     

             

     

             

     

             

  

  

             

[i]

Functional Pain Assessment Tool FACES scale

0 2 4 6 8 10No pain/hurt Very much pain/hurt   Functional Scale: (1) MILD = You know the pain is there, but it doesn’t bother you

much. (2) MODERATE = The pain does bother you, but you can still do things. (3) SEVERE = The pain bothers you a lot, you can’t do very much (4) VERY SEVERE = You can’t do anything but rest.     RN Initials RN Signature/Print Name Date/Time _____ __________________________________ ________ _____ __________________________________ ________

Pain Management StrategiesMedical ProviderPatientFamilyProfessional referral

Pain Management Strategies –Medical Provider

Framework - Holistic approachMedical testing and treatment AND psychosocial

contextEmphasize mind-body connection

Mental and emotional factors are important even when medical findings are positive

The lack of a positive medical finding does not mean the pain is “all in my head”, “unreal”, or “made up”

Possible questionsWhat are you doing to manage the pain?How does the pain affect your mood? How does your

mood affect the pain?

Pain Management Strategies– PatientPain monitoring (clinical implications)Stay active - exercise releases endorphinsSleep schedule

Actively focus/attend to other things – sometimes called distraction

Diaphragmatic breathing

Pain Management Strategies - FamilyValidate pain experience and expectation for pain

managementLimit attention to pain symptom

Limit asking about painRespond to pain complaint with questions/directions

related to managementFocus on functioning rather than pain intensity Encourage pain coping strategiesMaintain normative expectationsMake decisions that empower person, not pain

Pain Management Strategies Professional Referral

Family TherapyFocuses on influencing family stressors, relationships, and behaviors

Cognitive behavioral therapyFocuses on addressing pain related thoughts, emotions and behaviorsIncludes setting specific functional goals

Relaxation TrainingA group of techniques designed to produce physiological,

psychological and behavioral changesSpecific rationale to decrease arousal, muscle tension, and negative

mood statesBiofeedback

Instrumentation that provides data on psychophysiological processes that are not usually consciously available to the person, but can be brought under voluntary control

Family TherapyA child’s pain affects the whole familyHelp family adopt a holistic view that acknowledges

the child’s (and family’s) physical and emotional functioning

Model this same approach – support appropriate medical treatments

Support child, parents, entire family in functioning through pain despite fear of doing so

Address specific family pain responses/behaviorsAddress additional family stressors or relationship

patterns that may be influencing pain expression

Cognitive Behavioral TherapyRecognizes the

interrelationships between thoughts, feelings and actions (behaviors)

Work on changing thoughts, behaviors, and emotions to manage pain experience

Cognitive restructuringGraduated exposure to

increase functioning (goal setting)

Positive reinforcement for task completion

Changing Maladaptive Pain ThoughtsAddressing automatic negative thoughts with

positive coping statements

>>>“I’m always in pain!” “I usually feel good in the afternoon.”

“I can’t do anything because of my pain!”

>>> “I can still ______ even thoughI have pain.

Limit catastrophizing and “all-or-none” thinking

Relaxation TrainingA skill that develops with

repetition over timeAn active and empowering

strategy (not merely “relaxing” in front of the TV)

Attend to environment and body position

Diaphragmatic breathingProgressive Muscle

RelaxationGuided imagery

Diaphragmatic (Belly) BreathingOften recommended, not given adequate trialPacing and mechanics are related and both are

importantThoracic “Chest” breathing is more common

Uses chest muscles; leads to faster, shallower breathsDiaphragmatic “belly” breathing

Uses diaphragm muscle; leads to slower, deeper, and longer breaths

In through nose, out through mouthBelly should rise on in-breath, collapse on out-breath

PMR and Guided ImageryProgressive Muscle Relaxation

Typically done sitting upSeries of tensing and relaxing muscle groupsFocus on noticing the difference between tension

and relaxation so that tension can be a cue to relax

Guided ImageryOften done reclining or laying downUse mental imagery and associate it with relaxing

and pain relieving words, sensations, and suggestions

Purple = Finger temperatureOrange = Skin conductance levelGrey = Skin conductance responseGreen = Forehead muscle tension

Biofeedback

Things You Can Change

(Think)

Cognitive Understanding Control Expectations Relevance Pain Control Strategies Tissue Damage Or Pain Source

(Do) Behavior Overt Actions Response of Others Physical Restraint Physical Activities Social Activities Age Gender Cognitive Previous Pains Family History Culture

(Feel) Emotional Anxiety Fear Frustration Anger Depression Pain Sensation Pain Experience

Things You Can’t Change

Adapted from McGrath, P.A, & Miller, L.M. (1996). Controlling children’s pain. In R.J. Gatchel & D.C. Turk (Eds.), Psychological approaches to pain management: A practitioner’s handbook (pp. 331-370). New York: Guilford.

THANK YOU