Clinical and Health Affairs
Pediatric Chronic Pain: There Is Hope
By Tracy Harrison, M.D.
■ Chronic pain is prevalent in children and can limit their ability to attend school, socialize with peers, and participate in physical activity. This article describes the advantages of using a multidisciplinary approach to evaluating and treating children with chronic pain and discusses medications and techniques for managing pain and restoring functionality.
Chronic pain is prevalent in the pediatric population. It has been estimated that between 25% and 46% of patients younger than 18 years of age throughout the world have experienced pain on a daily basis for more than three months.1 Although no specific figure is available regarding the cost associated with treating chronic pain in the pediatric population, it is reasonable to estimate that it is significant because the medical cost for adults with chronic pain is nearly $70 billion per year. When factoring in the lost productivity that results from their inability to work, the annual overall cost for adults with chronic pain climbs to $140 billion per year.2
Research on children who were seen at a pediatric chronic pain clinic suggests headache, abdominal pain, and musculoskeletal pain are the most common complaints.3 In addition, investigators found that adolescents who experienced pain for more than one year also had anxiety and depression.3 The quality of life for children with chronic pain has been compared to that of young people with cancer and other chronic diseases.4
Treating Pediatric Chronic Pain Patients at Mayo Clinic
Children with chronic pain who come to Mayo Clinic are evaluated by providers with a special interest in pediatric pain management. Children whose pain is relatively new and who may not have been exposed to many treatment modalities are usually seen in the Pediatric Chronic Pain Clinic by a team that includes a pediatric anesthesiologist who completed a pain fellowship, an adolescent psychologist, and a physiatrist in an outpatient setting.
Those patients who are more functionally disabled from their pain may be referred to the Pediatric Pain Rehabilitation Program. Staffed by a team that includes a pain physician, clinical psychologist, clinical practice nurses, physical therapists, pharmacists, biofeedback technicians, and occupational therapists, the program primarily serves patients between the ages of 13 and 20 years whose pain has limited their ability to attend school and participate in physical activity and negatively affected their mood and psychological functioning. The three-week hospital-based outpatient program introduces a variety of strategies and activities to restore functionality and minimize the effect of pain on patients’ lives. Of the 150 patients who successfully completed the program during the past three years, virtually all returned to school full time immediately after. They also report improvement in measures of depression, anxiety, and pain catastrophizing, and increased activity.
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Suffering from pain daily can limit a child’s ability to attend school, socialize with peers, and participate in physical activity. In fact, well-meaning health care providers and school personnel often recommend that children not attend school or participate in other activities while they are attempting to manage their pain. Ironically, this can exacerbate the child’s pain. When children don’t attend school, they can feel stress both because they are isolated and because they are worried about keeping up with their schoolwork. The added stress can make their pain worse. In addition, for children who are used to being active, physical inactivity can lead to deconditioning, which may cause a child to feel dizzy and lightheaded when moving from a supine to upright position. This subsequent increase in sympathetic nervous system activity may cause pain to increase as well.
Clearly, chronic pain often starts a vicious cycle of social isolation, avoidance of school and physical activity, and further pain. Thus, it is not surprising that evaluating and treating a patient with chronic pain can be challenging.
Evaluating Chronic Pain
Children with pain usually present first to their primary care physician. If their pain proves to be chronic and is beyond the scope of their primary care provider, they should be seen by a specialist with experience in evaluating and treating particular pain syndromes to rule out life-threatening or readily treatable conditions. For example, children with chronic headaches should be evaluated by a neurologist, those with abdominal pain by a gastroenterologist, and those with musculoskeletal pain by a rheumatologist or neurologist. If pain continues despite a negative workup, patients and providers often may insist on further evaluation with the thought that a treatable condition may have been missed. Thus begins a cycle of extensive workup and more medical treatment that may prolong debility and further convince the patient that he or she is sick.
One of the challenges in dealing with patients who have chronic pain is that the symptoms may not have a specific physical cause. For that reason, they may benefit from being seen at a pediatric chronic pain center, where they can be evaluated by an interdisciplinary team of specialists who view pain and disability as a complex and dynamic interaction among physiologic, psychologic, and social factors.2 At Mayo Clinic, for example, pediatric chronic pain patients may be evaluated and treated by a team that includes pain physicians, clinical psychologists, clinical practice nurses, physical therapists, pharmacists, biofeedback technicians, and occupational therapists (see box).
A Multimodal Approach to Treatment
Medications alone are unlikely to significantly benefit children with chronic pain. For that reason, it is important to take a multidisciplinary approach to treatment early on. A number of modalities from various specialties can benefit patients with chronic pain. These modalities need to be applied concurrently for the greatest effect.
A number of medications can be used to manage chronic pain. A physician initially should try over-the-counter medicines before prescribing more potent drugs. The World Health Organization analgesic ladder recommends starting with over-the-counter analgesics such as acetaminophen and nonsteroidal anti- inflammatory medications for mild pain. It is important to remember that these medications may not eliminate pain. In addition, with some pain syndromes such as headache, continuous use of these medications may contribute to rebound pain and, in effect, perpetuate the problem.
Studies of adults have found opioids such as oxycodone, hydrocodone, ultram, fentanyl, and morphine can lead to a 40% to 50% improvement in chronic pain.5 However, opioid medications may affect the patient’s short-term memory, ability to retain information, and reflexes. Patients also can become physiologically dependent on these medications. There is currently controversy among pain management providers regarding the use of opioids for chronic nonmalignant pain in adults (there is no literature pertaining to opioid use for chronic pain in children). These medications appear to be beneficial for some adult patients. However, few studies have looked at whether their use leads to improvement in functioning (ie, return to gainful employment, ability to perform activities of daily living). Therefore, before prescribing opioids, the benefits and the risks need to be evaluated for each patient—both adult and pediatric.
Medications such as tricyclic antidepressants and anticonvulsants can be safely used for analgesic purposes in the pediatric population under the guidance of an experienced provider. (Their use may be beyond the scope of many providers.) Patients using these medications must be monitored, as these drugs can be associated with side effects such as increased suicidal thinking. A thorough history should be obtained before prescribing them. In addition, these medications take time to work. Usually, a six-month trial is prescribed. During that time, health care providers and family members should be vigilant about watching for development of adverse side effects.
In addition to oral medications, steroid injections may be indicated to minimize suspected inflammation around a nerve that may be responsible for pain. These are usually performed by pain physicians, primarily anesthesiologists, physiatrists, or neurologists. Injections are often used in conjunction with physical therapy to lessen pain so patients can work on gaining mobility and strength. In a subgroup of patients with complex regional pain syndrome, for example, epidural infusions may facilitate more active involvement in physical therapy. For headaches, supraorbital or occipital nerve injections may be considered. Patients with abdominal pain often have a musculoskeletal component to their pain and may benefit from a trigger point injection.
Various nonpharmacologic strategies also can be helpful to children who have chronic pain. Techniques including diaphragmatic breathing, guided imagery, progressive muscle relaxation, and biofeedback have proven helpful for alleviating headache, nausea and vomiting, and other conditions.6 These make use of the patient’s own ability to alter their physiology to minimize their pain and involve bringing the sympathetic and parasympathetic nervous systems into balance. It is recommended that a consultation with a psychologist take place to introduce these strategies and that patients practice them daily.
Finally, returning the patient to physical activity is an important part of treating their chronic pain, as it reverses deconditioning caused by inactivity and results in improved functioning. Activity should be reintroduced gradually under the supervision of a physical therapist so that the patient does not overdo it.
Conclusion
Chronic pain can have a significant impact on a child’s ability to attend school, interact with peers, participate in regular physical activity, and lead the kind of life he or she wishes. It cannot be treated in the same way as acute pain. Waiting for the complete resolution of pain before having a child return to school or regular physical activity can lead to great debility and increased stress, which increases pain.
Chronic pain is best approached by a multidisciplinary team that specializes in treating pediatric pain patients. In all cases, parental involvement is imperative and attention should be paid to other stressors that may affect pain. Pain and disability should be viewed as a complex and dynamic interaction among physiological, psychological, and social factors, and the goal of treatment should be restoring function, rather than alleviating pain. MM
Tracy Harrison is an instructor in the department of anesthesiology, director of the pediatric acute pain and palliative care service, and medical director of the pediatric pain rehabilitation center at Mayo Clinic.
References
1. Perquin CW, Hazebroek-Kampschreur AA, Hunfeld JA, et al. Pain in children and adolescents: a common experience. Pain. 2000;87(1):51-8.
2. Gatchel RJ, Okifuji A. Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic nonmalignant pain. J Pain. 2006;7(11):779-93.
3. Vetter TR. A clinical profile of a cohort of patients referred to an anesthesiology-based pediatric chronic pain medicine program. Anesth Analg. 2008;106(3):786-94.
4. Gold JI. Pediatric chronic pain and health-related quality of life. J Ped Nursing. 2009;24(2):141-50.
5. Turk DC. Clinical effectiveness and cost-effectiveness of treatments for patients with chronic pain. Clin J Pain. 2002;18(6):355-65.
6. Penzien DB. Behavioral management of recurrent headache: three decades of experience and empiricism. Applied Psychophys Biofeed. 2002;27(2): 163-83.