Schanberg 2010 Ped Grand Rounds Chronic Pain

8/11/2019 Schanberg 2010 Ped Grand Rounds Chronic Pain

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and

Pediatric Rheumatic DiseaseResearch Laboratory

Dr Schanbergs visit is sponsored by

Treating PediatricTreating Pediatric

Chronic Pain:Chronic Pain:Myths and MisconceptionsMyths and Misconceptions

Laura E. Schanberg, M D

Professor of Pediatrics

9/23/2010

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PAIN isPAIN is

An unpleasant sensory and emotional

experience associated with actual orpotential tissue damage, or described in

terms of such damage.International Ass ociation for the Study of Pain

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11Healthy children donHealthy children dontthave pain.have pain.

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Musculoskeletal PainMusculoskeletal Pain 5-20% in healthy children (Goodman 1991, Perquin

2000)

Females and older children (Sherry 1991; Mi kkelso n1998; Perqui n 2000)

gender differences at puberty teenage girls highest risk

Associated with significant impairment(Mikkelson et al., 19 97; Egger et al., 1999)

depression and anx iety social difficulties school absenteeism

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Prevalence Rates ofPrevalence Rates of

Chronic PainChronic Pain

Perquinet al, Pain 2000 6


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Incidence of Growing PainsIncidence of Growing Pains

%

Aple y and Naish (UK 1955) 4Brenning (Sweden, 1960) 14

Oster and Nielson (Denmark, 1972) 18 F, 12 M

Tedford (USA, 1976) 4

Do growing pains predispose to chroni c painsyndromes in adulthood?

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HypermobilityHypermobility SyndromeSyndrome

Up to 10% of normal population

Arthralgias, back pain common Beighton score defines hypermobility

Injuries common dislocations

meniscal tears

tendon injuries

MV prolapse

Geneticallydetermined

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www.arc.org.uk/about_arth/booklets/6019/6019.htm

1 point

1 pointeach side

Beighton Scale

22I can tell if my patientI can tell if my patientis in pain.is in pain.

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Pain AssessmentPain Assessment

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DiagnosisPain Behavior

ProviderProvider

Pain RatingsPain Ratings

Affect

Gender

PhysicalCharacteristics

Ethnicity11

PainPain Behavior

Perception

Suffering

Nociception

Loeser JD, Cousins MJ. 1990

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Child Pain BehaviorChild Pain Behavior

Children cope differently than adults.

Pain behavior and language variesfrom child to child.

Classic pain behavior often not present.

May be subtle changes

sleeping more

sad

change in activity level

decreased appetite

clingy 13

So,

Self report is gold standard

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33Children canChildren cant selft self--report pain.report pain.

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Developmental FactorsDevelopmental Factors

Newborns and small children cant self-report - OBSERVATION

Avoidance behavior observed by 6 months

Consistency of facial and cry response

demonstrated in neonates and infants

Children 3-5 years able to use self-report

measures and localize pain

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Self Report Pain ToolsSelf Report Pain Tools

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44Young children donYoung children donttremember painfulremember painful

experiences.experiences.

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Pain in NeonatesPain in Neonates

By 26 wks, anatomicaland neurochemicalcapabilities for nociceptionpresent.

By 29 wks, cortical andsub-cortical centers forpain perception includingpain modulation present.

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secondinnocence.blogspot.com

Reviewed Grunau, Holsti, Peters 2006

Pain sensitivity i n neonates may be heightened

compared to older indi viduals (less effective at

blocking painful stimuli)!

Neonatal surgery in m ice effects adultresponses to pain stimuli. (Sternberg 2005)

Circumcised infants show stronger painresponse to routine vaccination. (Taddio 1997)

Young children given placebo for previousprocedures had consistently higher painscores than children with proper proceduralanalgesia. (Weisman, Bernstein, Schechter 1998)

Children exposed to repeated painfulprocedures experience increasing pain andanxiety with procedures. (Zeltzer 1990)

Pain MemoryPain Memory

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The pain itself may not be consciously

remembered, but the painful experience impacts

wiring of the pain sensing pathways in age

dependent manner.

55Chronic pain is aChronic pain is apsychiatric disease.psychiatric disease.

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Simple Pain PathwaySimple Pain Pathway

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Pain PathwaysPain Pathways

DeLeo 2006

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BiobehavioralBiobehavioral Model of PainModel of Pain

BehavioralEnvironmental

Biologic

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66Children do notChildren do notdevelop paindevelop pain

syndromes.syndromes.

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Childhood Pain SyndromesChildhood Pain SyndromesChildhood Pain Syndromes 25% of new patients seen by

pediatric rheumatologists 75% female

Average age of onset 12

DIFFICULT TO TREAT !

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Spectrum of DisordersSpectrum of Disorders

Fibromyalgia

Chronic fatigue

syndrome

Migraine

Irritable bowel

syndrome

TMJ disorders

CRPS

Functional

abdominal pain

Chronic pelvicpain

Premenstrual

Syndrome

Myofascial pain

syndromes

Add li ght spectrum

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Juvenile FibromyalgiaJuvenile Fibromyalgia

Widespreadmusculoskeletalpain for 3 months

Well defined tenderpoints

1-6% prevalencedepending on study

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Incidence unknown (under diagnosed)

Girls 6:1

Lower extremities 5:1

Delayed diagnosis (1 yr)

Neuropathic descriptors

Autonomic dysfunction

Childhood CRPS (RSD)Childhood CRPS (RSD)Childhood CRPS (RSD)

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77All pain has to beAll pain has to betreated with medicine.treated with medicine.

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0

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60Pain Coping

Disease Activit y

Disease Dur ation

Age

* p


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Pain Coping StrategiesPain Coping StrategiesPain Coping Strategies Activity/rest

cycling Cognitive

restructuring

Imagery

Relaxation

Distraction

Problem solving

Sleep hygiene Autogenic

training

Pleasant

activities

Life planning

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Pain coping skills

physicalphysical

triggerstriggers

emotionalemotional

triggerstriggers

PAIN

thoughts feelings behavior

Pain coping skills38

55Children canChildren cant effectivelyt effectivelyuse nonuse non--pharmacologicpharmacologic

interventions for pain.interventions for pain.

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NonNon--PharmPharm Rx: InfantsRx: Infants

Positioning

Swaddling

Rocking

Pacifier (sucrose)

Soft music/voice

Touch

Dim light

Reduce noise

Visual distraction

Access to parents

Cuddling

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NonNon--PharmPharm Rx: 1Rx: 1--6 yrs6 yrs

Medical play

Music

Security objects Soothing voice

Bubbles

Holding a hand

Dim light

Reduce noise

Visual distraction

Access to parents Cuddling/rocking

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NonNon--PharmPharm Rx: > 6 yrsRx: > 6 yrs Medical

preparation

Music (headset)

Security objects

Breathing

techniques

Guided imagery

Video games

Holding a hand

Distraction (books,

TV, etc)

Access to parents

Visual focusing

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66Pain medicines are notPain medicines are notsafe in children.safe in children.

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PharmacotherapiesPharmacotherapies

Local anesthetics

Non Steroidal Anti-inflammatoryAgents (NSAIDS)

Opioids

Adjunctive agents

Antiepileptic drugs

Antidepressants

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Treatment ApproachTreatment Approach

By the ladder

By the clock

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By the mouth

By the person

SEDATION

PAIN

ANALGESIA

OpioidsOpioids

Underused

Avoid codeine,propoxyphene, meperidine

Utilize long-actingpreparations as appropriate

Use to maintain function

Use with non-pharmtreatments

Avoid using for depression,

sedation, etc46

AddictionAddiction

DependenceDependenceWithdrawalWithdrawal

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Addictio n is a primary, chronic,

neurobiologic DISEASE with

genetic, psychosocial, and

environmental facto rs influencing

its development and

manifestations.

AAPM, APS, ASAM 2001

Withdrawal is a syndrome often

not a sign of addiction but of

medical mismanagement!

Physical dependence is a state

of adaptation that is manifested

by a drug class specificwithdrawal s yndrome that can be

produced by abru pt cess ation,

rapid dose reduction, dec reasing

blood level of the drug, and /or

administration of an antagonist.

AAPM, APS, ASAM 2001

Addiction and ChildrenAddiction and Children

Less than 1% of children treated with

opioids for PAIN develop addiction (Foley,1996)

Consider diversion!

Use opioid contract

www.Ini.wa.gov

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88I canI cant treat chronict treat chronicpain in childrenpain in children

effectively.effectively.

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But not alone!

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YES, you canYES, you can

Barriers to Success Passive, sick role

Anticipated failure

Poorcommunication

Fear of addiction

Fear of side effects

Noncomplicance

Lack of resources

Anticipated failure

Poorcommunication

Fear of addiction

Knowledge deficits

Opioid underuse

Patient Physician 51

Multidisciplinary TeamMultidisciplinary Team Pain specialist

Local care provider

Social w orker

Teacher

Psychologist

Psychiatrist

Physical

therapist

Pharmacist

Alternative medicine

providers

Par ents

Patient

Nurse Clinician

Other subspecialty

physicians

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NO MAGIC BULLETNO MAGIC BULLET

Patient education and empowerment

Family engagement

Utilize team approach Use pharmacologic and

non-pharmacologictreatments together

Be patient!

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Thanks!Thanks!

Heather van Mater, M D

Stacy Ardoin, M D

Carl von Baeyer, PHD

Karen Gil, PHD

Maggie Bromber g, MA

Mark Connelly, PHD

Kelly Anthony, PHD

Lindsey Franks, BS

Schanberg 2010 Ped Grand Rounds Chronic Pain

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