and

Pediatric Rheumatic Disease

Research Laboratory
Dr Schanberg s vi si t i s sponsored by
Treating Pediatric Treating Pediatric
Chronic Pain: Chronic Pain:
Myths and Misconceptions Myths and Misconceptions
Laura E. Schanberg, MD
Professor of Pedi atrics
9/23/2010
2
PAIN is PAIN is
An unpl easant sensory and emotional
experi ence associated with actual or
potential tissue damage, or described in
terms of such damage.
International Association for the Study of Pain
3
1 1
Healthy children don Healthy children dont t
have pain. have pain.
4
Musculoskeletal Pain Musculoskeletal Pain
5-20% in healt hy children (Goodman 1991, Perquin
2000)
Females and older children (Sherr y 1991; Mi kkelson
1998; Perqui n 2000)
gender dif f erences at puberty
teenage girls highest r isk
Associated with significant impairment
(Mikkelson et al., 1997; Egger et al. , 1999)
depression and anxiety
social dif f icult ies
school absent eeism
5
Prevalence Rates of Prevalence Rates of
Chronic Pain Chronic Pain
Perquin et al, Pain 2000
6
Incidence of Growing Pains Incidence of Growing Pains
%
Apley and Naish (UK 1955) 4
Brenning (Sweden, 1960) 14
Oster and Nielson (Denmark, 1972) 18 F, 12 M
Tedford (USA, 1976) 4
Do growi ng pai ns predi spose to chroni c pai n
syndromes i n adulthood?
7
Hypermobility Hypermobility Syndrome Syndrome
Up to 10% of normal population
Arthral gias, back pain common
Beighton score defines hypermobility
Injuries common
di sl ocati ons
meni scal tears
tendon inj uries
MV prolapse
Genetically
determi ned
8
www.arc.org.uk/about_arth/booklets/6019/6019.htm
1 point
1 point
each side
Bei ghton Scal e
2 2
I can tell if my patient I can tell if my patient
is in pain. is in pain.
9
Pain Assessment Pain Assessment
10
Diagnosis
Pain Behavior
Provider Provider
Pain Ratings Pain Ratings
Affect
Gender
Physical
Characteristics
Ethnicity
11
Pain Pain
Behavior
Perception
Suffering
Nociception
Loeser JD, Cousins MJ. 1990
12
Child Pain Behavior Child Pain Behavior
Children cope di fferently than adults.
Pain behavior and language varies
from child to child.
Classic pain behavior often not present.
May be subtle changes
sleeping more
sad
change in activity level
decreased appet ite
clingy
13
So,
Self report is gold standard
14
3 3
Children can Children cant self t self--
report pain. report pain.
15
Developmental Factors Developmental Factors
Newborns and small children cant self-
report - OBSERVATION
Avoidance behavi or observed by 6 months
Consistency of facial and cry response
demonstrated in neonates and infants
Children 3-5 years abl e to use self-report
measures and localize pain
16
Self Report Pain Tools Self Report Pain Tools
17
4 4
Young children don Young children dont t
remember painful remember painful
experiences. experiences.
18
Pain in Neonates Pain in Neonates
By 26 wks, anatomical
and neurochemical
capabilities for nociception
present.
By 29 wks, cortical and
sub-cortical centers for
pain perception including
pain modulation present.
19
secondinnocence.blogspot.com
Reviewed Grunau, Holsti, Peters 2006
Pain sensiti vity i n neonates may b e heightened
compar ed t o older indi viduals (less eff ective at
blocking painful stimuli)!
Neonatal surgery in mice effects adult
responses to pain stimuli. (Sternberg 2005)
Circumcised infants show stronger pain
response to routine vaccination. (Taddi o 1997)
Young children gi ven placebo for previous
procedures had consistently higher pain
scores than children with proper procedural
analgesia. (Wei sman, Bernstein, Schechter 1998)
Children exposed to repeated painful
procedures experience increasing pain and
anxiety with procedures. (Zel tzer 1990)
Pain Memory Pain Memory
20
The pai n itself may not be consciously
remember ed, but the painf ul experience impacts
wiring of t he pain sensing pat hways in age
dependent manner.
5 5
Chronic pain is a Chronic pain is a
psychiatric disease. psychiatric disease.
21
Simple Pain Pathway Simple Pain Pathway
22
Pain Pathways Pain Pathways
DeLeo 2006
23
Biobehavioral Biobehavioral Model of Pain Model of Pain
Behavioral Environmental
Biologic
24
6 6
Children do not Children do not
develop pain develop pain
syndromes. syndromes.
25
Childhood Pain Syndromes Childhood Pain Syndromes Childhood Pain Syndromes
25% of new patients seen by
pediatric rheumatologists
75% female
Average age of onset 12
DIFFICULT TO TREAT !
26
Spectrum of Disorders Spectrum of Disorders
Fibromyalgia
Chronic fatigue
syndrome
Migraine
Irritable bowel
syndrome
TMJ disorders
CRPS
Functional
abdominal pain
Chronic pelvic
pain
Premenstrual
Syndrome
Myofascial pain
syndromes
Add light spectrum
27
Juvenile Fibromyalgia Juvenile Fibromyalgia
Widespread
musculoskeletal
pain for 3 months
Well defined tender
points
1-6% prevalence
dependi ng on study
28
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)
29
7 7
All pain has to be All pain has to be
treated with medicine. treated with medicine.
30
0
20
40
60
Pain Copi ng
Disease Act ivit y
Disease Duration
Age
* p<0.05
** p<0.01
*** p<0.00
Pain
Thermometer
Oucher Pain
Locat ions
*
*** ***
***
***
**
Pain Variance Accounted for by Coping, Pain Variance Accounted for by Coping,
Age, Disease Duration and Acti vi ty Age, Disease Duration and Acti vi ty
%

V
a
r
i
a
n
c
e
Schanber g 1997 31
Role of Stress and Mood Role of Stress and Mood
Pain () Stiffness () Fati gue ()
Increased
negative mood
20.60** 14.26** 20.84**
Increased daily
stressful events
0.65* 0.35 0.96*
32
* p < .02, ** p < .0001
Increased negati ve dail y mood was associ ated wi th
i ncreased dail y symptoms of dai l y pain, fati gue, &
sti ffness.
Increased dail y stress was al so associ ated wi th
i ncreased dail y pai n & fati gue.
Schanberg 2005
Multidisciplinary Treatment Multidisciplinary Treatment Multidisciplinary Treatment
Education
Graduated
aerobic exercise
Sleep hygiene
Pain coping
skills training
Stress reduction
Counseling
School
Medication
Blocks
Acupuncture
Massage
Other
33
Education Education
Low
mood
Inactivity
Stress
Isolat ion Poor
sleep
Lack of
control
Anxiety
Fatigue
34
Vicious Cycle
Exercise Exercise
Graduated aerobic
program (Ri chards 2002)
Aerobic component
improves symptoms
30 mi nutes dail y
Short bouts (Schachter 2003)
Wal ki ng/home-based
program (Valim 2003)
Effecti vely treats fatigue
(Cochrane review) h
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Sleep Hygiene Sleep Hygiene
No naps
Sleep at night
Regular bedtime and awake time
No distractions
Relaxati on techni ques
Tricyclics if needed
36
Pain Coping Strategies Pain Coping Strategies Pain Coping Strategies
Activity/rest
cycling
Cognitive
restructuring
Imagery
Relaxation
Distraction
Problem solving
Sleep hygiene
Autogenic
training
Pleasant
activities
Life planning
37
Pain coping skills
physical physical
triggers triggers
emotional emotional
triggers triggers
PAIN
thoughts feelings behavior
Pain coping skills
38
5 5
Children can Children cant effectively t effectively
use non use non--pharmacologic pharmacologic
interventions for pain. interventions for pain.
39
Non Non--Pharm Pharm Rx: Infants Rx: Infants
Positioning
Swaddling
Rocking
Pacifier (sucrose)
Soft music/voice
Touch
Dim light
Reduce noise
Visual distraction
Access to parents
Cuddling
40
Non Non--Pharm Pharm Rx: 1 Rx: 1--6 yrs 6 yrs
Medical play
Music
Security objects
Soothing voice
Bubbles
Holding a hand
Dim light
Reduce noise
Visual distraction
Access to parents
Cuddling/rocking
41
Non Non--Pharm Pharm Rx: > 6 yrs Rx: > 6 yrs
Medical
preparation
Music (headset)
Security objects
Breathi ng
techniques
Guided imagery
Video games
Holdi ng a hand
Distraction (books,
TV, etc)
Access to parents
Visual focusing
42
6 6
Pain medicines are not Pain medicines are not
safe in children. safe in children.
43
Pharmacotherapies Pharmacotherapies
Local anesthetics
Non Steroidal Anti-inflammatory
Agents (NSAI DS)
Opioids
Adjunctive agents
Antiepileptic drugs
Antidepressants
44
Treatment Approach Treatment Approach
By the ladder
By the clock
45
By the mouth
By the person
SEDATION
PAIN
ANALGESIA
Opioids Opioids
Underused
Avoid codeine,
propoxyphene, meperidine
Utilize long-acting
preparations as appropriate
Use to maintain function
Use with non-pharm
treatments
Avoid using for depression,
sedation, etc
46
Addiction Addiction
Dependence Dependence
Withdrawal Withdrawal
47
Addicti on is a primary, chronic,
neurobiologic DISEASE with
genetic, psychosocial, and
environmental factors 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 specific
withdrawal syndrome that can be
produced by abrupt cessation,
rapid dose reduction, dec reasing
blood level of t he drug, and/or
administration of an antagonist.
AAPM, APS, ASAM 2001
Addiction and Children Addiction and Children
Less than 1% of chil dren treated with
opioi ds for PAIN devel op addiction (Fol ey,
1996)
Consider di version!
Use opi oid contract
www.Ini.wa.gov
48
8 8
I can I cant treat chronic t treat chronic
pain in children pain in children
effectively. effectively.
49
But not alone!
50
YES, you can YES, you can
Barriers to Success
Passive, sick role
Anticipated failure
Poor
communication
Fear of addiction
Fear of side effects
Noncomplicance
Lack of resources
Anticipated failure
Poor
communication
Fear of addiction
Knowledge deficits
Opioid underuse
Pati ent Physi ci an 51
Multidisciplinary Team Multidisciplinary Team
Pain specialist
Local care provider
Social worker
Teacher
Psychologist
Psychiatr ist
Physical
ther apist
Phar macist
Alter nat ive medicine
providers
Par ents
Patient
Nurse Clinician
Ot her subspecialty
physicians
52
NO MAGIC BULLET NO MAGIC BULLET
Patient education and empowerment
Family engagement
Utilize team approach
Use pharmacologic and
non-pharmacologic
treatments together
Be patient!
53
Thanks! Thanks!
Heat her van Mater, MD
Stacy Ardoin, MD
Carl von Baeyer, PHD
Karen Gil, PHD
Maggie Bromberg, MA
Mark Connelly, PHD
Kell y Anthony, PHD
Lindsey Franks, BS