Chronic pain in childhood Facing an increasing problem using new media

Transcription

1 Chronic pain in childhood Facing an increasing problem using new media Dr. Julia Wager German Paediatric Pain Centre Department of Children s Pain Therapy and Paediatric Palliative Care, Datteln, Witten/Herdecke University, Germany Nordic Pediatric Pain Symposium, Stockholm, Sweden March 31 st, 2017

2 Epidemiology

3 Prevalence of chronic pain in children Legend: first author (year of data collection) Du et al. Eur J Pain. 2012; 16(6): Huguet & Miro. J Pain. 2008; 9(3): Perquin et al. Pain. 2000; 87(1):51-8. Roth-Isigkeit et al. Acta Paediatr. 2004; 93(2): van Dijk et al. Pain Res Manag. 2006; 11(4): month prevalence 1-month prevalence

4 Prevalence Prevalence of chronic pain in children Hirschfeld et al. In prep

5 Causes of chronic pain in children Most of the chronic pain conditions are not explained by a defined medical illness Alp et al. Cephalalgia. 2010;30(7):

6 Causes of chronic pain in children Most of the chronic pain conditions are not explained by a defined medical illness 268,623 children with non-specific abdominal pain Later hospitalization with the following diagnosis N % Bowel pathology 15, % Acute appendicitis 12, % Crohn s disease 1, % Coeliac disease % Ulcerative colitis % Gastro-oedophageal reflux disease 1, % Thornton et al. Arch Dis Child. 2016; 101(4):305-9.

7 Chronic pain in children is

8 Chronic pain in children is What s the Problem

9 Chronic pain in children Spanish school children Age: 8-16 years N=561 Huguet & Miro. J Pain. 2008;9(3):

10 Chronic pain & disability Spanish school children Age: 8-16 years N=561 low disability moderate disability high disability Huguet & Miro. J Pain. 2008;9(3):

11 Huguet & Miro. J Pain. 2008;9(3): Chronic pain & disability

12 Longterm prognosis of pediatric pain Chronic pain in childhood risk factor for chronic pain in adulthood - Back pain: 4-times increased risk - Functional abdominal pain: 25% still report pain 5 years later - Headache: 70% still have headache 20 years later Hestbaek et al. Spine 2006;31(4): Shelby et al. Pediatrics 2013;132(3): Walker et al. Pain 2010;150(3): Brna et al. Arch Pediatrc Adolesc Med 2005;159(12): Fearon et al. BMJ 2001;322:1-6. risk factor for mental disorders in adulthood - Functional abdominal pain: 4-times increased risk for anxiety disorders; 3-times increased risk for depression - Headache: increased risk for mental problems

13 Health care utilization

14 Who becomes a patient? N=2,149 children (3-10 years) 7.4 years 2.25; 54% female disability + intensity frequency migration - age Hirschfeld et al. PeerJ. 2015;28(3):e916.

15 Health care utilization due to chronic pain in the US previous 6 months 20 1 Toliver-Sokol et al. J Pain 2011;12(7):

16 Health care utilization due to chronic pain in the US previous 6 months 20 Within 3 months before specialized pain treatment: 29 hours spent at medical appointments Ho et al. J Musculoskelet Pain 2008;16(3):

17 Health care utilization due to chronic pain in the US previous 6 months 61% 38% 73% 0% Toliver-Sokol et al. J Pain 2011;12(7):

18 Health care utilization due to chronic pain generates costs direct costs - treatment - drugs indirect costs - missed school / workdays - time spent at medical appointments UK: direct and indirect costs due to chronic pain in children and adolescents total approximately 8,000 per child and year (~15.000$) Groenewald et al. J Pain 2014;15: USA: $19.5 billion for health care per year Ho et al. J Musculoskelet Pain 2008;16(3): Sleed et al. Pain 2005;119(1-3):

19 Chronic pain in children is

20 Chronic pain in children is

21 Treatment options for pediatric chronic pain

22 Treatment options for pediatric chronic pain Primary care Specialized care Lisman-van Leeuwen et al., The Annals of Family Medicine 2013;11: outpatient day care inpatient Spee et al., Scandinavian Journal of Primary Health Care 2013;31:

23 Treatment options for pediatric chronic pain Primary care Eccleston et al. The Cochrane Database of Systematic Reviews 2014;5: CD Hechler et al. European Journal of Pain 2011;15: Specialized care outpatient day care inpatient Hechler et al. Pediatrics. 2015;136(1):

24 Challenges of the present and the future Limited access to specialized pain services - Availability of treatment facilities - Distance - Financing - Increasing number of patients Coakley & Wihak. Children (Basel) ;4(2). pii: E9. doi: /children

25 Treatment options for pediatric chronic pain Prevention Primary care Specialized care outpatient day care inpatient

26 Pain Education Education is part of many interventions Neuroscience Education explains the neurobiology and neurophysiology of pain and pain processing in the nervous system Goal: - learn about the basic neuroscience of pain, e.g., nerve hypersensitivity, central sensitization, neuroplasticity - Understand that pain experience does not necessarily represent ongoing harm to the body Well studied in adults with chronic pain Coakley & Wihak. Children (Basel) ;4(2). pii: E9. doi: /children

27 The power of education RCT Sample: N=104 patients with functional abdominal pain; 8-17 years Pediatricians and pediatric gastroenterologists - pain diary - education - gut-brain-axis - necessity of normal daily routine und functional aspects of chronic pain - nutrician - medication, if necessary vs. CBT (without education) 6 sessions during a 6 week period Van der Veek et al. Pediactrics 2013;132: e1163- e1172

28 The power of education Measure points - T2: immediately after treatment - T3: 6 months after treatment - T4: 12 months after treatment Abdominal Pain Index: Pain frequency Pain duration Pain intensity education Van der Veek et al. Pediactrics 2013;132: e1163- e1172

29 The power of education Measure points - T2: immediately after treatment - T3: 6 months after treatment - T4: 12 months after treatment No significant differences for pain measures between the 2 groups Changes in psychological measures (anxiety, depression, health-related quality of life) - Shortterm positive effects for CBT - After 12 months comparable reduction in both groups Van der Veek et al. Pediactrics 2013;132: e1163- e1172

30 How to better reach children?

31 New media internet content available on-demand accessible on digital devices interactive user feedback and creative participation internet today: important source of knowledge regarding health and medical questions

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34 Online treatment #1 MODULES 1) Intro/Education 2) Managing stress 3) Relaxation and distraction 4) School 5) Cognitive skills 6) Sleeping and lifestyle 7) Staying active 8) Maintenance & prevention Palermo et al. Pain 2016;157(1):

35 Online treatment #1 travel themed; 8 different locations includes animations and audio users choose their own treatment goals users can ask questions of therapists via messaging therapists provide personalized feedback for children and their parents 1 session a week (30 minutes) 8 week program Palermo et al. Pain 2016;157(1):

36 Online treatment #1 Randomized controlled multicenter trial Sample: N=273 adolescents with chronic pain, years 3 measure points: baseline, post treatment, 6-months follow up Internet-delivered CBT vs. Internet-delivered education Results: pain intensity (NRS 0-10) Minimal reduction in both groups In CBT: Baseline = 6,28 Follow-up=5,85 no significant differences between groups activity limitation small effect! Palermo et al. Pain 2016;157(1):

37 Online treatment #1 Randomized controlled multicenter trial Sample: N=273 adolescents with chronic pain, years 3 measure points: baseline, post treatment, 6-months follow up Internet-delivered CBT vs. Internet-delivered education Results: - Treatment engagement - 67% - 80% completed all modules - Higher engagement in the education group - Treatment satisfaction - High for both interventions Palermo et al. Pain 2016;157(1):

38 Online treatment #2 MODULES 1) Relaxation 2) Cognitive strategies 3) Education Hicks et al. J Ped Psychol, 2006, 31,

39 Online treatment #2 7 week training Children: 7 chapters Parents: 2 chapters Hicks et al. J Ped Psychol, 2006, 31,

40 Online treatment #2 Randomized controlled trial Sample: N=47 children with recurrent pain, 9-16 years 3 measure points: baseline, 1-month follow up, 6-months follow up Internet-delivered CBT vs. standard medical care (control) Hicks et al. J Ped Psychol, 2006, 31,

41 Online treatment #2 Results: Number of children with 50% pain reduction Hicks et al. J Ped Psychol, 2006, 31,

42 Online treatment #2 Results: Number of children with 50% pain reduction Hicks et al. J Ped Psychol, 2006, 31,

43 Online treatment what else?

44 Online treatment what else? Search on 4 major operating systems: ios (itunes), Android (Google Play), BlackBerry OS (BlackBerry World), Windows Phone (Windows Store) 279 pain apps! Conclusion: Currently available pain self-management apps for patients are simplistic, lack the involvement of health care professionals in their development, and have not been rigorously tested for effectiveness on painrelated health outcomes. Lallo et al. Clin J Pain. 2015;31(6):

45 Lallo et al. Clin J Pain. 2015;31(6): Online treatment what else?

46 Lallo et al. Clin J Pain. 2015;31(6): Online treatment what else?

47 Online treatment what else? internet-delivered CBT intervention for adolescents with chronic pain Age: years Treatment attrition: 52% loss to follow-up after treatment: 65% reasons for treatment attrition - reduction of pain (n = 6) - intervention too time-consuming (n = 2) - crashed computer (n = 1) - worsening psychological complaints (n = 2) - not satisfied with content of intervention (n = 2) - not satisfied with therapeutic support (n = 2) - no reason reported (n=22) Voerman et al. J. Pain 2015, 16,

48 Online treatment what else? internet-delivered CBT intervention for adolescents with chronic pain Age: years Treatment attrition: 52% loss to follow-up after treatment: 65% Contrary to expectations, guided Internet-delivered self-help for chronic pain is difficult to use in adolescents, resulting in treatment attrition and loss to follow-up. Voerman et al. J. Pain 2015, 16,

49 New media for pain treatment a conclusion An online treatment or app is not good just because New media is easily accessible but hard (and cost intensive) to provide and sustain Patient motivation is difficult to maintain BUT It is worth it to use new media, because - kids like it - it has a far reach - it allows new approaches - it generates creative ideas

50 Pain education online

51 Education cartoon: Migraine under control

52 The Future New media especially for psychological interventions Embedded into multimodal programs What we need: - more creativity - more interaction - new formats, e.g., online newspapers, blogs, wikis, video games and social media. New media is grounded on an interactive community interaction has to be utilized