Post on 02-Jun-2018
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
20
40
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