Out of the Nurses Office and Back to the Classroom: A

Functional Approach to Chronic Pain

Nancy S. Bright BS, RNCoordinator, Pain Relief Program

Connecticut Children’s May 20, 2010

Objectives

• To understand the multifactorial components of chronic pain

• To learn about a functional approach to treating chronic pain

• To identify challenges for integrating children with chronic pain back into the school setting

Body maps

Sources of Chronic Pain

• Ongoing illness: sickle cell, cancer

• Post infectious myalgias that sensitize the central nervous system

• Non-progressive disorders whose manifestation is pain—chronic daily headache, functional abdominal pain, widespread musculoskeletal pain

Functional Pain Syndromes

• A disorder that after appropriate medical assessment cannot be explained in terms of conventionally defined medical disease based on biochemical or structural abnormalities

• Not typically responsive to conventional medical therapy but responsible for the consumption of enormous medical resources

• Unfortunately, often pejorative implication, i.e. pain is not organic and therefore not real or serious

• As a result, patients often marginalized from meaningful professional care

A new model

• Traditionally, all of these entities were viewed in the medical model

• Assumption was that if pain did not have an identifiable biologic etiology, it was psychological in origin

Central sensitization

• Overall, increased sensitivity to pain both peripherally and centrally

• Hypersensitivity of the peripheral nerves

• Explanatory model of hurt versus harm

Chronic pain

• Recognition that the experience of pain is the result of the interplay of biologic predispositions (genetic tendencies, pain vulnerabilities) and a host of psychosocial factors that either amplify or diminish the pain

Epidemiology

• Marked increase in pain prevalence at 8 years• Incidence peaks at 14 years• Transition years in school: 5th, 7th, 9th grade• Over 50% of children who reported chronic pain

reported pain in multiple sites• Incidence of multiple pain sites increased with age• Girls 2X as likely to have multiple sites of chronic

pain • HA and abdominal pain most common combination

(25% of all cases of multiple pain sites)

Incidence musculoskeletal pain

– Overall prevalence – 22%• Fibromyalgia – 1.25% (7% of pedi rheum referrals)• Knee pain – 18%• Back pain – 7-34%• Limb pain – 4-33%

– Pain persistence - 31% had pain 1 year later and 30% had recurrences of pain 4 years later

Incidence headache

• Overall headache incidence over childhood 37%– Migraine occurrence:

5-15 yrs - 10.6%10-19 yrs – 28%

– Tension – 18.5% – Unclassifiable – 74%

• 22% of neurology referrals for headache

Incidence abdominal pain

• 2-4% of pediatric visits

• 50% of GI consultations

• 21% reported pain severe enough to affect activities

Pain related visits to school nurse

• In a large, urban school district in Milwaukee, WI the most common reason for visit to the school nurse, other than first aid:– Stomach ache 17%– Headache 16% 59% females

» Hainsworth et al, Children’s hospital of WI 2009

Impact on the Child

• 30-40% restrictions in daily living• 90% decreased or no sporting activities• Increased social difficulties

– 68% of large study of chronic pain pts had significant restrictions on daily life

• Sleep – 50% 0f children with chronic pain have sleep difficulties– Sleep initiation– Maintaining sleep– Early morning awakening

• Chronic pain has potential to permanently alter child’s development and future role functioning

Impact on School

• Academic–Often academic deterioration–Frequent school absence–1 in 6 patients with chronic pain had

missed one third of school year–Impaired ability to cope with the

demands of classroom/homework workload

Teachers

• Teacher response to chronic pain may influence the extent to which school functioning is disrupted in children with pain– Over solicitous– Not understanding– Parents approach to school may affect the

schools response to accommodations

» Logan et al, 2007

Impact on Family

• Frustration of finding the diagnosis and understanding it

• Loss time from work

• Flexibility in orchestrating a return to school; negotiating make up work

• Fitting in appointments such as physical therapy, psychology in addition to the activities of other siblings

Psychiatric co morbidity

• Study of 3500 schoolchildren, stress and depressive symptoms associated with chronic pain

• Prospective study of 9000 pain free individuals – depressed individuals were 3x more likely to develop new onset chronic back pain than non depressed

• In sample of 80 adolescents with chronic pain (Eccleston, Pain 2004), anxiety scores 2x as large as general population; depression in 70% of sample

• Increased catastrophizing and lower self esteem

Psychiatric co morbidity

Abdominal pain– More anxiety and depression – In one study 79% of children referred for recurrent abdominal pain

meet criteria for anxiety disorder; 43% depressive disorder

Headache – Psych co-morbidity in children, 46% of chronic daily headache

vs. 17% migraine; anxiety disorders predict headache persistence and poorer treatment response

– 86% of children with Chronic daily headache reported severe school achievement related stress

– WMSP (fibromyalgia)– Children with fibromyalgia more likely to be depressed

Commonalities of chronic pain problems

• Female predominance

• Abnormalities of pain processing

• Frequent psychiatric co-morbidity/stress sensitivity

• Similarities of diagnostic approach and treatment

Treatment plan

• Demystify the problem – hurt vs. harm; labels such as psychosomatic are not helpful and in fact not accurate

• Emphasize the fact that pain no longer has a warning function• State clearly that symptom complex is familiar to the provider;

symptoms are real and not imagined• Reassurance is critical as many families will have had

frustrating experience with medical community and often misdiagnosis or no diagnosis

• Goal of treatment should be return to function; not solely reduction of pain

Treatment plan

• Medications for pain: neuropathic, preventive

• Recognize role of anxiety, depression

• Psychological support/ health psychologist

• Treat sleep problems

• Establish regular exercise or physical therapy program

• Biofeedback, acupuncture, massage

Go to School

• School– Development of modification plan /504 plan

• Frequency of Attendance• Graduated return to school- scripted re-

entry plan• Nurse office sanctuary• Criteria for staying home- fever>102• Work modification• Tutoring support for missed work

Return to school

• An integral part of clinical care

• School attendance is how we measure function, which is a more accurate measure of pain than a pain scale

• School performance indicates adaptive response to pain

Summary

• Chronic pain problems have biological, psychological and social components

• Treatment plan needs to be multidisciplinary

• Return to school is an important part of the clinical care plan

References• Logan D, Scharff L et al. Evaluating Teacher’s Perceptions to Children with Chronic

Pain Syndromes. Children’s Hospital, Boston• Ladwig J, Khan K. School Avoidance: Implications for School Nurses. JSPN Vol 12,

No 3, July 2007. pp 210-212.• Logan D, Coakley R, Scharff L. Teachers’ Perceptions of and Responses to

adolescents with Chronic Pain Syndromes. Journal of Pediatric Psychology 2007 vol32 no 2, pp 139-149.

• Mayer EA, Bushnell MC. Functional Pain Syndromes. Seattle: IASP Press, 2009.• Williams DA, Clauw DJ. Understanding fibromyalgia: Lessons from the Broader Pain

research Community. Journal of Pain 2009:10 pp777-791• Nurko S, DiLorenzo C. Functional Abdominal Pain: Time to Get together and move

Forward. Journal of Pediatric Gastroenterology and Nutrition. 2008: 47,pp 679• Scher AI, Stewart WF, Lipton RB. Co morbidity of Headache with Other Pain

Syndromes. Headache 2006:46,pp 1416-23• Zeltzer L. Conquering Your Child’s Chronic Pain