WHAT IS PAIN? PEDIATRIC PAIN: NOT JUST A FACE ON A SCALE LEARNING OBJECTIVES

Transcription

1 PEDIATRIC PAIN: NOT JUST A FACE ON A SCALE Erin Davis, M.S., OTR/L FOTA Conference November 7, LEARNING OBJECTIVES 2 Recognize the prevalence of pediatric pain and its impact on function Identify the neurological and physiological process of pain response Differentiate typical pain response vs. maladaptive pain patterns Define different kinds of pain/pain disorders Recognize the role of occupational therapists in working with children and adolescents in pain 3 WHAT IS PAIN?

2 4 An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. -International Association for the Study of Pain 5 NOCICEPTORS: AN INTRODUCTION TO PAIN 6 SUPERFICIAL PAIN Cutaneous injury Easily localized/identified by patient Not always accompanied by obvious signs of injury

3 VISCERAL PAIN 7 Stimulation of deeper nociceptors Thoracic, abdominal, pelvic, cranial cavities Often diffuse and reported via referred pain SOMATIC/STRUCTURAL PAIN 8 Arises in muscles, bones, joints, ligaments, tendons, or fascia Can be intermittent or constant Often related to activity or position Can be acute or chronic NEUROPATHIC PAIN 9 Abnormal processing of sensory input due to damaged or changed nervous system Can be centrally or peripherally based Commonly continuous (vs. intermittent)

4 GATE CONTROL THEORY 10 Gate in the dorsal horn inhibits the transition of the pain message to the brain 11 ACUTE PAIN ACUTE PAIN 12 Happens after surgery or injury Caused by damage to tissue or nerves Often resolved within 1 month, but can last up to 3 months

5 13 CHRONIC PAIN 14 ELLIOT KRANE: THE MYSTERY OF CHRONIC PAIN 15 MEET THE PAIN MONSTER

6 CENTRAL SENSITIZATION 16 Increased responsiveness of nociceptive neurons in the central nervous system to their normal or subthreshold afferent input. Clinically, sensitization may only be inferred indirectly from phenomena such as hyperalgesia or allodynia. (International Association for the Study of Pain) CHRONIC PEDIATRIC CONDITIONS 17 Arthritis Headaches/migraines Recurrent abdominal pain Sickle cell disease AMPLIFIED MUSCULOSKELETAL PAIN SYNDROMES 18 Fibromyalgia Chronic regional pain syndrome Neuropathic pain Myofascial pain syndrome Localized or diffuse idiopathic pain

7 19 AMELIA WATT: COMPLEX REGIONAL PAIN SYNDROME 20 IMPACT 21 IMPACT ON PHYSICAL FUNCTION Fatigue Decreased physical activity Decreased endurance

8 IMPACT ON COGNITION & EXECUTIVE FUNCTIONING 22 Attentional interruption Hypervigilance Depression IMPACT ON OCCUPATION 23 given up when aches became worse except when the occupation is so enjoyed that the pain is put out of focus. Persson, D., Andersson, I., & Eklund, M. (2011). Defying aches and revaluating daily doing: Occupational perspectives on adjusting to chronic pain. Scandinavian Journal of Occupational Therapy, 18, IMPACT ON FAMILY 24 Economic burden of multiple medical visits Parent time off work Time and attention for other family members Emotional drain

9 25 ROLE OF O.T. BIOPSYCHOSOCIAL MODEL 26 Organic pathology does not reliably predict impairment and disability. the role of the clinician is to assist the patient in becoming an active participant in their own healthcare. Shultz, I.Z., Crook, J., Fraser, K., & Joy, P.W. (2000). Models of diagnosis and rehabilitation in musculoskeletal pain-related occupational disability. Journal of Occupational Rehabilitation, 10(4), Lynch, M., Craig, K. D., & Phillip, W. H. (2011). Introduction to management (pp.91-96). In Clinical Pain Management. Lynch, M. E., Craig, K. D., & Peng, P. W. H. (eds.). Hoboken, NJ: John Wiley & Sons, Ltd. ASSESSMENT 27 Self-report of pain if at all possible Patient report vs. parent/caregiver report Use age-appropriate tools (see Resources)

10 BIOMECHANICAL GOALS 28 Increase physical activity Return to prior sports/activities Increase muscle strength/ endurance BIOMECHANICAL GOALS CONT D 29 Reduce muscle tension Reduce inflammatory responses Decrease allodynia Reduce dependence on assistive devices BIOMECHANICAL MODALITIES 30 Massage Accupressure Heat/cold TENS Kinesio Tape Fluidotherapy Desensitization Mirror therapy

11 PSYCHOSOCIAL GOALS 31 Facilitate autonomy/role competence Coping strategies PSYCHOSOCIAL MODALITIES 32 Guided relaxation/imagery Biofeedback Distraction Creative arts EDUCATION GOALS 33 Body mechanics Pacing/energy conservation Work simplification Relaxation/stress management Sleep hygiene Nutrition

12 34 BARRIERS TO SUCCESS PROVIDER 35 Poor pain assessment Limited knowledge Pathology Treatment options Limited resources Treatment modalities Referral options (specialists, etc.) PATIENT 36 Inability to describe pain Motivation to participate in therapy/healthcare Minimize emotional concerns in favor of physical symptoms Perceived threats of returning to normal

13 FAMILY 37 Cultural beliefs re: pain, medication use, etc. Personal beliefs re: procedures, addiction, etc. Lack of local options/covered resources Economics Hopelessness 38 You can t always fix the problem by fixing the problem. -Unknown REFERRAL TO A SPECIALIST 39 Inadequate pain control despite use of standard protocols Consideration for specialist interventions Specific patient request Confirmation that all reasonable approaches have been explored Need for access to an interdisciplinary team and/or pain management program

14 INTEGRATED PAIN MANAGEMENT 40 Medicine Behavioral Health Rehabilitation 41 RESOURCES: PAIN ASSESSMENT NEONATAL/INFANT PAIN 42 Combination of behavior + vital sign changes Premature Infant Pain Profile-Revised (PIPP-R) CRIES

15 FLACC 43 2 months - 7 years Face No particular expression or smile Occasional grimace or frown, withdrawn, uninterested Frequent to constant quivering chin, clenched jaw Legs Normal position or relaxed Uneasy, restless, tense Kicking, or legs drawn up Activity Lying quietly, normal position, moves easily Squirming, shifting, back and forth, tense Arched, rigid or jerking Cry No cry (awake or asleep) Moans or whimpers; occasional complaint Crying steadily, screams or sobs, frequent complaints Consolability Content, relaxed Reassured by occasional touching, hugging or being talked to, distractible Difficult to console or comfort Merkel, S. I., Voepel-Lewis, T., Shayevitz, J. R., & Malviya, S. (1997). The FLACC: A behavioral scale for scoring postoperative pain in young children. Pediatric Nursing, 23(3), COMFORT SCALE 44 Unconscious and/or ventilated patients of any age Scoring criteria (0-5 points) for: Alertness Calmness/agitation Respiratory response Physical movement Blood pressure Heart rate Muscle tone Facial tension 45 WONG-BAKER FACES 3 years and older Robertson, J. (1993). Pediatric pain assessment: validation of a multidimensional tool, Pediatric Nursing, 19(3),

16 MANCHESTER PAIN LADDER 46 3 years and older Lyon F, Boyd R, Mackway-Jones K. (2005). The convergent validity of the Manchester Pain Scale. Emergency Nurse, 13(1), VISUAL ANALOG SCALE 47 7 years and older Bijur, P. E., Silver, W. & Gallagher, E. J. (2001). Reliability of the Visual Analog Scale for measurement of acute pain. Academic Emergency Medicine, 8, SLIDE ALGOMETER 48 7 years and older Price, D.D., Long, S., and Harkins, S.W. (1994). A comparison of pain measurement characteristics of mechanical visual analogue and simple numerical rating scales of pain. Pain, 56,

17 ASSESSMENT TOOLS/METHODS 49 Pediatric Quality of Life Inventory (PedsQL) 2-18 years Varni/Thompson Pediatric Pain Questionnaire 3-18 years McGill Pain Questionnaire Designed for adults Pain diary Drawing