UNDERSTANDING CHRONIC PAIN in CHILDREN. The Problem of Children s Pain 4/14/2009 OVERVIEW

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1 UNDERSTANDING CHRONIC PAIN in CHILDREN LONNIE ZELTZER MD DIRECTOR UCLA PEDIATRIC PAIN PROGRAM PROFESSOR OF PEDIATRICS, ANESTHESIOLOGY, PSYCHIATRY AND BIOBEHAVIORAL SCIENCES OVERVIEW THE PROBLEM OF PAIN IN CHILDREN WHAT IS PAIN WHERE IS PAIN HOW DOES PAIN BECOME CHRONIC FACTORS THAT IMPACT PAIN PAIN TREATMENT The Problem of Children s Pain Increasing survival rates for premature infants Pain in neonates can change developing sensory nervous system: risk for longterm chronic pain Increasing survival of children with genetic diseases Children with complex chronic pain often have co-morbid symptoms Anxiety, depression PDD, learning disabilities Multiple pain problems 15-30% of children in studies from U.S., Canada, Australia, UK, Germany, and Holland report chronic pain: headaches and belly pain are common COMMON PAIN SYNDROMES IN CHILDREN IRRITABLE BOWEL SYNDROME (IBS) & FUNCTIONAL ABDOMINAL PAIN (FAP) CHRONIC DAILY HEADACHE CHRONIC MYOFASCIAL PAIN, SUCH AS NECK, BACK, EXTREMITY PAIN COMPLEX REGIONAL PAIN SYNDROME (CRPS) CHRONIC FATIGUE SYNDROME FIBROMYALGIA How can we prevent the development of adult chronic pain by preventing pain in children and providing good pain treatment when children treatment when children have pain? 1

2 WHAT IS PAIN? A DYNAMIC PROCESS THAT INVOLVES: NOCICEPTION: noxious information traveling from pain site to brain PAIN FACILITORY CIRCUITS (ENHANCING, HYPERALGESIC) PAIN INHIBITORY CIRCUITS (ANALGESIC) PAIN PERCEPTION: the experience of pain as the messages reach consciousness WHERE IN THE BRAIN IS PAIN? PAIN SENSORY PERCEPTION: INTENSITY AND LOCATION SOMATOSENSORY CORTEX (S1) SECONDARY SOMATOSENSORY CORTEX (S2) INSULAR CORTEX PAIN UNPLEASANTNESS: AFFECTIVE ASPECT OF PAIN, SUFFERING ANTERIOR CINGULATE CORTEX Rainville P et al, Science Hofbauer RK et al, J Neurophysiol CHRONIC PAIN: DYSREGULATION IN INTEGRATION OF SYSTEMS DEVELOPMENT OF CHRONIC PAIN We have moved from the more simple GATE THEORY OF PAIN TO Understanding the development of PATHOLOGICAL PAIN PATHWAYS and CENTRAL NEUROMATRICES CENTRAL PAIN NETWORKS LEARNED RESPONSES FROM PARENTS COPING STYLE ANTICIPATION OF PAIN AROUSAL/ANXIETY M E M O R Y A T T G E E N N T E I T O I N C S NOCICEPTION PERCEPTIONS OF CONTROLABILITY OF PAIN FACTORS AFFECTING PAIN PERCEPTION & EXPRESSION SEX AGE ATTENTIONAL FOCUS AROUSAL/ANXIETY COGNITIVE LEVEL EXPOSURE TO OTHERS PAIN PAST PAIN EXPERIENCE 2

3 FACTORS AFFECTING PAIN PERCEPTION & EXPRESSION CULTURAL NORMS EXPECTATIONS CONSEQUENCES PERCEPTION OF CONTROL RELEVANCE OF PAIN COPING ABILITY AND STYLE DO MICE HAVE EMPATHY? IMPLICATIONS FOR PAIN RESPONSES IN HUMANS Mice exposed to a noxious stim showed greater pain responses if they were waiting in a cage with cage-mates for their turn Mice pairs showed greater concordance in pain responses if they were mice from the same cage vs mice from different cages Pain responses in mice given noxious stim of diff intensities were dep on whether they had observed a cage-mate in pain Conclusion: nociceptive mechanisms can be sensitized through observation and empathy Langford et al. Social modulation of pain as evidence for empathy in mice. Science. 2006;312(5782): Pathway for Child with Chronic Pain Child brought to doctor: diagnosis made & medication given/problem solved Pain continues: search for the cause Child gets more tests, sees more doctors, more tests & can develop PTSD Painful procedures contribute to sensory hypersensitivity & more pain As tests come out negative, child feels not believed Child referred to mental health specialist & child believes doctors think he is crazy Chronic pain typically does not have a single cause & evaluation requires a biopsychosocial model KEY POINTS All pain is physical: involving neural pathways, neurotransmitters, hormones, immune factors, and genes All pain is influenced by thoughts, emotions, and social-cultural context: these all connect to form a central neuromatrix that maintains the pain Pain is longer dichotomized as physical vs psychological Assessment and RX need to be aimed at emotions, cognitions, physiology, and environment PAIN-ASSOCIATED DISABILITY SYNDROME PADS CLINICAL EVALUATION DOWNWARD SPIRAL OF INCREASING SYMPTOMS AND DISABILITY 3

4 DOMAINS OF ASSESSMENT PAIN & PAIN HISTORY OTHER PHYSICAL SYMPTOMS PHYSICAL FUNCTIONING SOCIAL FUNCTIONING ACADEMIC FUNCTIONING FAMILY FUNCTIONING DOMAINS OF ASSESSMENT EMOTIONAL & COGNITIVE FUNCTIONING COPING STYLE & PROBLEM- SOLVING CAPACITY PERCEIVED STRESSORS MAJOR LIFE EVENTS PAIN CONSEQUENCES TREATMENT GOALS Instill a new paradigm about the causes & treatment of complex chronic pain Goal: Restore balance in neural signaling How: 1) Reduce focus on child s body; 2) Increase self-efficacy efficacy related to pain ( I can cope ); and 3) address other problems identified in the evaluation Long-term goal: Increase adaptive functioning and active coping style TREATMENT GOALS FOR PTS Goal: Restore balance in neural signaling How: Distract yourself: keep your focus off your body and onto something else Learn methods of coping with the pain Identify stressors that make the pain worse and address those Be as active as you can Work on balancing your mind and body PAIN TREATMENT EDUCATION PHARMACOLOGICAL PHYSICAL BEHAVIORAL PSYCHOLOGICAL COMPLEMENTARY THERAPIES EDUCATION: importance of good restorative sleep PHYSICAL: be active BEHAVIORAL: get support for activity and school attendance PSYCHOLOGICAL: get thelp for anxiety or depression MEDICATION: be specific about use of meds, too much can cause pain, work with your doc COMPLEMENTARY THERAPIES 4

5 EDUCATION: CHILD The pain is real and biological Pain is caused by nerve signals that became out of balance Medical tests were negative because they did d not look at nerve e signaling g Your body is like a car without a tune up for a while: not broken but not running well The nerve signals causing the pain can get back in balance if you help them with some things you can do with your mind and some things with your body EDUCATION: PARENTS Help your child develop good sleep habits Do not ask your child about pain: cause a focus on the pain producing more pain There are risk factors for why your child developed e pain: treatment e t will be focused on treatable factors The mind and body work together to cause pain and a mind-body treatment is the best way to get rid of the pain and increase function PHYSICAL THERAPY Especially for patients who have chronic musculoskeletal pain complex regional pain syndrome become deconditioned due to inactivity Requires specific expertise by PT Exercise has specific benefits related to muscle strengthening/functioning & posture, and generalized benefits related to improved body image, body mechanics, somatic selfefficacy, sleep, and mood BEHAVIORAL INTERVENTIONS To increase independent functioning To facilitate effective problem-solving To decrease pain behaviors in patient and dfamily members To increase restorative sleep & nonimpact aerobic exercise To meet rehab goals incrementally PSYCHOLOGICAL INTERVENTIONS Cognitive-Behavioral Therapy (CBT) Social Skills Training Psychotherapy: child or family or both Academic interventionsi Treatment aimed at PTSD or unresolved grief or trauma MEDICATIONS Neuropathic pain, CRPS-1: TCA, gabapentin, pregabalin (Lyrica) IBS: TCA, peppermint geltabs Comorbid Anxiety/Depression: SSRIs/SSNRI PDD (perseveration e on pain): Neuroleptics ept like Resperidone or Abilify Insomnia: Benadryl, Melatonin, Trazadone Myofascial pain: muscle relaxants, topical anesthetics (e.g. lidoderm patch) Other: alpha-adrenergics (e.g. clonidine patch), Ultram (Ultram-ER), opioids (e.g. methadone) 5

6 REFERENCES Zeltzer LK, Schlank CB. Conquering your child s chronic pain: a pediatrician s guide to reclaiming a normal childhood (HarperCollins, 2005) THE END 6