Dr. P. Rushatamukayanunt 18/01/2016
Pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage, and lasts beyond the normal time for healing.
What is chronic pain? persists beyond expected healing time (defined as 3 6 months) and develops into a chronic persistent or recurrent pain syndrome Chronic pain in children is the result of a dynamic integration of biological processes, psychological factors, and sociocultural context considered within a developmental trajectory.
Chronic non cancer pain in pediatrics Significance of the Problem affect 20% to 35% of children and adolescents around the world (King et al., 2011; Stanford, Chambers, Biesanz, & Chen,2008).
Prevalence types of chronic pain Headache 8-83% Abdominal pain 4-53% Back pain 14-24% Musculoskeletal/limb pain 4-40% Higher in girls Increase with age (King et al)
central sensitization inadequate pain control Peripheral sensitization 6 Histamine Bradykinin Prostaglandins Nerve growth factor
Learning Principles and the Bio-Psychosocial Model of Illness (Engel G. 1977-1980) In 1977, psychiatrist George Engel postulated a Bio-psychosocial Model of Illness. All three levels, biological, psychological and social must be taken into account in every health task (G. Engel 1980)
Cognitive-Behavioural Model of Fear of Movement/(Re)Injury including Catastrophisation Disability, Disuse, Depression Injury Recovery Avoidance Painful Experiences Confrontation Fear of Movement/(Re)Injury + - CATASTROPHISING No Fear Vlaeyen et al, 1995
Chronic non cancer pain in pediatrics Convincing evidence suggest that childhood chronic pain predisposes both for the continuation of pain and the development of new forms of chronic pain in adulthood Walker, Dengler-Crish, Rippel, & Bruehl,2010
Approach to Pain Recognize Assess Comprehensive assessment Treat
Assessment :clinical evaluation of chronic pain Biological Pain characteristics Site Temporal features Descriptors Intensity Radiation Precipitants Relieving factors Physical functioning Psychological Mood Anxiety Cognitions (eg, beliefs, attitudes) Sleep Social School attendance Social functioning (peer and family relationships) Parental behaviour (solicitous or protective ) Parent characteristics Cognitions (eg, catastrophising, expectancies) Anxiety Mood
Several Pathophysiologies May Contribute to Chronic Pain Fibromyalgia IBS Neck and back pain (no structural pathology) Musculoskeletal pain Headaches CRPS RA Tumor-related NocP Back pain Hereditary or congenital syndromes cerebral palsy muscular dystrophy hypermobility syndromes sickle cell disease Nociceptive Pain Central sensitization/ dysfunctional pain Neuropathic Pain Tumor-related neuropathy Chemotherapy-induced neuropathy traumatic and metabolic neuropathies Persistent postoperative pain Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain. 2011;152(3 Suppl):S2-S15.
Goal of management The primary goal :to improve all domains of functioning and quality of life. Treatment strategies should be based on the findings of the assessment and should address the inciting and contributing factors.
Management of chronic non cancer pain in pediatric Optimal treatment require multidisciplinary approach based upon : biopsychosocial approach. Cognitive behavioral therapies (CBT) physical therapies pharmacological management Pediatr Drugs (2014) 16:457 471
Biopsychosocial Approach to Multimodal Pain Therapy Lifestyle management Sleep hygiene Stress management Physical therapy Pharmacotherapy Occupational therapy Complementary therapies Education Biofeedback Gatchel RJ et al. Psychol Bull 2007; 133(4):581-624; Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research.; National Academies Press; Washington, DC: 2011; Mayo Foundation for Medical Education and Research. Comprehensive Pain Rehabilitation Center Program Guide. Mayo Clinic; Rochester, MN: 2006. 18
Goals for drug therapy Decrease current pain Reduce central sensitization Facilitate physiotherapy and rehabilitation
Anti-convulsants Gabapentin Recommended first-line in neuropathic pain Dangerous side-effects minimal dizziness, fatigue, memory/concentration Renal excretion, not metabolized Start 5 mg/kg/dose TID max 50 mg/kg/day Pregabalin Similar effects,?fewer side-effects Better bioavailability Dose BID based based on 1:6 ratio to gabapentin
Anti-depressants Tricyclics Amitriptyline, Nortriptyline Screening ECG (prolonged QTc) 0.1-0.2 mg/kg evening (12 h before waking) Dose titration Side-effects (may be less with nortript.) anticholinergic, sedation
Management neuropathic pain Medication Options
Musculoskeletal pain Medication Options
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