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Chronic pain management
Introduction
Recurrent or persistent chronic pain is common among children and adolescents. Chronic pain can be the result of an underlying medical condition such as cancer or cystic fibrosis, or pain can be a primary disorder such as complex regional pain syndrome (CRPS) or functional abdominal pain. Regardless of underlying causes, chronic pain can result in severe suffering, significant impairments in physical and emotional functioning, and reduced quality of life for many children and adolescents. This chapter aims to provide an understanding and an approach to treating common chronic pain conditions in children and adolescents.
Development of nociception and pain pathways
Over the past 3 decades knowledge about pain perception and pain pathway development in infants and children has greatly expanded ( ). Maturation of the nervous system starts at 6 weeks of gestational age (GA) and continues well past 42 weeks GA. Sensory neurons synapse into the dorsal horn of the spinal cord by 8 weeks GA, and by 20 weeks GA, there is development of ascending nociceptive pathways (reflexive motor withdrawal to noxious stimulus). By 24 weeks GA, thalamo-cortical projections form. At this time, the peripheral nervous system is developmentally mature and functional ( ; ; ). The descending inhibitory pathway is immature at birth; the neonatal cortex has little control over pain processes. The descending pain pathway is mature at 6 to 8 months postnatal.
Pain assessment
Assessment of a child’s pain experience is fundamental when developing a comprehensive treatment plan. Pain assessment involves the use of developmentally appropriate tools to determine pain intensity and descriptive characteristics of pain like duration, distribution, frequency, and quality. Pain assessment scales are validated to determine the intensity of pain ( Table 25.1 ). To qualify chronic pain in children, the multiple dimensions that influence the pain experience such as emotional, cognitive, developmental, behavioral, and cultural factors need to be assessed ( ; ; ). The American Pain Society defines chronic pain in children as the result of a dynamic integration of biological process, psychological factors, and sociocultural factors considered within a developmental trajectory ( ). These types of factors and processes should be considered when assessing chronic pain. This is often best accomplished through a biopsychosocial assessment, allowing clinicians to gather important clinical information regarding the pain history from the patient and family.
TABLE 25.1
Pain Scales: Description and Age-Appropriate Use
From Greffe, B. S., Galinkin, J. L., & King, N. A. (2020). Pain management and pediatric palliative and end-of-life care. In W. W. Hay, M. J. Levin, M. J. Abzug, & M. Bunik (Eds.), Current diagnosis & treatment: Pediatrics (25th ed.). New York: McGraw Hill.)
| Name of Scale | Type | Description | Age Group |
|---|---|---|---|
| Numeric | Self-report | Verbal 0–10 scale; 0 = no pain, 10 = worst pain you could ever imagine | Children who understand the concept of numbers, rank, and order; approximately >8 yr |
| Bieri and Wong-Baker scales | Self-report | 6 faces that range from no pain to the worst pain you can imagine | Younger children who have difficulty with numeric scale; cognitive age 3–7 yr |
| FLACC | Behavioral observer | 5 categories: face, legs, activity, cry, and consolability; range of total score is 0–10; score ≤7 is severe pain | Nonverbal children >1 yr |
| CRIES, NIPS, PIPP | Behavioral observer | Rates a set of standard criteria and gives a score | Nonverbal infant <1 yr |
CRIES, C rying R equires O 2 saturation, I ncreased vital signs, E xpression, and S leeplessness; FLACC, F ace, L egs, A ctivity, C rying, C onsolability; NIPS, N eonatal I nfant P ain S cale; PIPP, P remature I nfant P ain P rofile.
Chronic pain in children has a significant impact on daily function. This impact is demonstrated through school attendance and corresponding work quality, sports, social relationships, sleep, and mood ( ; ; ). Because of the significant impact of chronic pain on daily function, the assessment of function is integral in an ongoing assessment of pain management. It is often helpful to understand the impact of chronic pain on family functioning as well ( ).
Several validated measures exist to assess various domains of functioning. Some of the more common assessment tools are the Functional Disability Inventory (FDI) ( ; ) and the Child Activity Limitations Interview (Palermo and ), which assess illness and relative activity limitation in children and adolescents with chronic medical conditions ( ; ; ; ). The Peds Quality and Life Inventory (PedsQL) is also a well-validated tool for assessing physical, emotional, social, and school function in children 5 to 18 years of age, which also includes parent and child reports in parallel. With a parent proxy instrument for younger children, this assessment tool can obtain accurate results in children as young as 2 years old ( ; ).
For older children, ages 8 to 17, the Patient Reported Outcome Measure Information System (PROMIS) is a self-report questionnaire that assesses general health domains, including depressive symptoms, anxiety, mobility, pain, interference, fatigue, peer relationships, and pain intensity ( ; ).
Catastrophic thinking about pain can also influence coping strategies and can have a significant impact on the pain experience. The Pain Catastrophizing Scale uses the dimensions of rumination, magnification, and helplessness to assess catastrophic thinking ( ).
Many children with chronic pain conditions suffer from significant school impairment. These impairments may present as high absentee rates and delayed academic progress ( ). Complementing school function impairments, poor sleep hygiene often plays a large role in the pain experience. Measures of sleep hygiene in pediatric patients with chronic pain include the Adolescent Sleep-Wake Scale (ASWS) and the Children’s Sleep Habits Questionnaire (CSHQ).
A psychosocial evaluation is an important part of the ongoing assessment of a child with chronic pain, because psychological, social, and family functioning can contribute to pain or pain-related disability, independent of underlying causes of pain. The psychosocial assessment of a patient will often consist of clinical interviews and standardized psychological measures to identify potential stressors, coping strategies, and various challenges faced by the family and patient that can have an impact on pain. Dependent on particular concerns, a psychologist may choose to incorporate other standardized measures as indicated.
Principles in the treatment of chronic pain
A rehabilitative approach to managing pain incorporates the biopsychosocial model, accounting for the complex relationship of biological, psychological, individual, social, and environmental factors that affect the ongoing pain experience and often associated functional disability ( ; ; ). Similar to the assessment of pain, multidisciplinary teams are often necessary to implement a rehabilitative model for managing pain. Typically, providers span various disciplines, which include medicine, psychology, physical therapy, occupational therapy, nutrition, social work, and nursing. Treatment plans also often incorporate alternative medicine practitioners and fields, such as acupuncture and massage therapy.
An important part of the management of chronic pain is education of patients and parents, emphasizing that unlike acute nociceptive pain, chronic pain with no clear etiology often provides no protective benefit. Rather, it results in an ongoing, unpleasant experience without a protective value. The goal is to alleviate familial anxiety and encourage engagement in three main components focused on improving daily function: pharmacotherapy, physical therapy, and psychological therapy ( ). This multimodal biopsychosocial approach to management focuses on improving daily function, with the primary goal to improve physical function while promoting patients’ reengagement in age-appropriate activity, which can be measured through school attendance, participation in social and age-appropriate activities, and sleep hygiene ( ; ; ). Sports, social, sleep, and school are the dimensions of daily function that can be categorized ( ). Improvement in one or more functions may precede a reduction in pain intensity, and there is strong evidence to support the positive impact of a multidisciplinary approach for the treatment of children diagnosed with chronic pain ( ; ; ).
Frequent scheduled follow-up appointments help the child and family build confidence and avoid unnecessary tests. As an approach labeled watchful waiting, it serves to reassure families that nothing has been missed or is contributing to ongoing symptoms ( ).
Multidisciplinary treatment of chronic pain conditions should be individualized with combinations of pharmacologic treatment, physical therapy, and psychological therapy.
Pharmacologic treatment
Medications are often used in the treatment of chronic pain in children and adolescents; however, it should be emphasized to patients and parents that pharmacologic treatment is only one modality in a comprehensive, multidisciplinary treatment approach. Neuromodulating agents include antidepressants and anticonvulsants, irrespective of specific triggers; however, there are limited studies showing efficacy, and use is often extrapolated from adult studies.
Use of analgesics depends on the underlying disease process and specific triggers of pain. As an example, a child with arthritis will often be prescribed nonsteroidal antiinflammatory drugs (NSAIDs) or another form of antiinflammatory agent. This differs from a child with spasticity and myofascial pain, who may benefit more from an antispasmodic. Analgesic agents such as acetaminophen and NSAIDS may be helpful when used in moderation, although they also come with certain risks when used for chronic pain management, such as analgesic rebound headaches or worsened abdominal pain ( ; ). Generally, opioid use for chronic pain from non-life-limiting illnesses in children and adolescents is not supported. Data suggest that the use of opioids for chronic pain conditions is often associated with worse overall clinical outcomes ( ; ). Opioid therapy related to specific disease processes, such as osteogenesis imperfecta or certain neurodegenerative conditions, should be determined on a case-by-case basis ( ).
There are limited data on efficacy to support the use of neuromodulators for the treatment of pediatric chronic pain, particularly as the sole or primary therapy. Some of the more common medications approved for use with children include amitriptyline and gabapentin ( ). Gabapentin is an anticonvulsant that is widely used in the management of adult chronic pain with some evidence for efficacy in the treatment of postherpetic neuralgia. Tricyclic antidepressants, such as amitriptyline, can be considered for patients with chronic pain and disordered sleep. A baseline electrocardiogram (ECG) to screen for prolonged QT is recommended. Some studies show better effect of tricyclic antidepressants than selective serotonin reuptake inhibitors (SSRIs) for the treatment of chronic pain, although there are no large clinical trials in children ( ; ; ; ; ; ; ; ). Neuromodulating medications should be initiated below the anticipated therapeutic dose and titrated slowly to a therapeutic dose to minimize side effects. See Table 25.2 .
TABLE 25.2
Medications for Pediatric Chronic Pain
| Medication | Dosing | Comments |
|---|---|---|
| Tricyclic Antidepressants | ||
| Amitriptyline, nortriptyline | For patients ≥50 kg: Initial dose 5–10 mg PO qhs; titrate over 2–3 weeks to 25–50 mg PO qhs For patients 25–50 kg: Initial dose 0.1 mg/kg PO qpm. Titrate over 2–3 weeks to max dose of 0.5 mg/kg |
Obtain 12-lead ECG for (prolonged) QT interval Side effects are related to anticholinergic effects, including tachycardia, dry mouth, urinary retention, and sedation Use with caution with other antidepressants because of risk of serotonin syndrome Concomitant use with CYP2D6 inhibitors may lead to increased serum concentration |
| Anticonvulsants | ||
| Gabapentin (Neurontin) | For patients ≥50 kg: Initial dose 100 mg PO 1–2 times daily; titrate slowly to max dose of 1800 mg/day divided TID; higher dosing possible in select patients For patients <50 kg: Initial dose 2–5 mg/kg PO daily; titrate slowly to max dose of 35 mg/day divided TID; higher dosing possible in select patients |
Side effects include drowsiness, concentration and memory impairments, and peripheral edema (rare) Dose adjustment necessary with renal impairment |
| Pregabalin (Lyrica) | Patients >12 years of age: Initial dose 25–50 mg PO 1–2 times daily; titrate up to max of 300 mg/day divided BID or TID | Side effects include drowsiness, headaches, peripheral edema (rare), and thrombocytopenia (rare) |
Titrate all medications according to clinical benefit and side effects; use lowest effective dose.
Antidepressants and anticonvulsants may increase the risk of suicidal thinking and behavior in children, adolescents, and young adults. Monitor closely for changes in mood or behavior.
Physical therapy
Of particular value in musculoskeletal pain syndromes, physical therapy can be valuable for many types of chronic pain that has affected a child’s activity level and resulted in a deconditioned state ( ; ; ; ). A comprehensive musculoskeletal examination conducted in the course of a comprehensive physical examination allows for assessment of hypersensitivity, hypermobility, myofascial components, and deconditioning. Physical therapy is premised on offering guided, graded reentry into exercise, allowing for reassurance and confidence in the child’s ability to regain lost function ( ). Additionally, reconditioning modalities such as desensitization, core stabilization, and learned joint-protective strategies may be helpful in allowing for a return to normal function among certain patient populations with chronic pain. ( ; ; ; ).
Physical therapy for the treatment of chronic pain emphasizes active participation in exercises with an incorporated home exercise program for long-term improvement in function. There is less emphasis on passive strategies, such as massage ( ; ; ; ). Transcutaneous electrical nerve stimulation (TENS) is widely incorporated as a physical therapy tool; however, the evidence of utility is limited.
Complementary and alternative medicine (CAM) has become increasingly used in the treatment of chronic pain in pediatrics ( ). CAM refers to interventions such as acupuncture, yoga, and biofeedback, commonly used in conjunction with conventional medical treatment. Evidence suggests that these techniques may be helpful for headaches and chronic abdominal pain ( ; ; ; ; ).
Psychological treatment
Cognitive behavioral interventions allow for learned self-regulation techniques and cognitive strategies to perceive pain as less debilitating ( ; ). Evidence supports psychological interventions as an effective treatment of chronic pain in children. Multiple studies confirm that the effect of a biopsychosocial treatment of chronic pain is strengthened when coping strategies are implemented. Strategies include meditation, hypnosis, and mindfulness ( ; ; ; ). Acceptance and commitment therapy (ACT) uses acceptance and mindfulness strategies to help with ongoing pain ( ).
Education of parents regarding the best way to support their children with ongoing pain symptoms is a fundamental element in the treatment of chronic pain. Supporting a child with chronic pain while facilitating physical functioning and reducing pain behaviors is often challenging for parents. Specific education should be provided about the “helpful but not harmful” aspect of chronic pain and the value of a return to normal daily function, specifically with respect to school attendance and sleep hygiene. This education better equips parents to support their children and to become more confident implementing treatment plans. The Comfort Ability Program (CAP) is a psychological intervention for adolescents with chronic pain and their parents, designed to address several identified knowledge-to-practice gaps in the field of pediatric pain ( ; Fig. 25.1 ).
Children with chronic pain often develop impairments in school and social functioning. Evidence shows that children with chronic pain often have difficulty with completion of academic assignments and consistent school attendance. School participation has been identified as the largest stressor for children with chronic pain ( ). Reports also indicate that children with chronic pain experience problems with social and peer relationships when in a school setting ( ). In order to be successful, reintegration of children and adolescents into these settings in a paced fashion with a graded plan for increasing school and social functioning requires commitment and time from both parents and schools in addition to support from clinicians.
Children and adolescents with chronic pain also often struggle with sleep hygiene ( ; ; ; ). Sleep hygiene refers to the recommended environmental and behavioral practices designed to promote better-quality sleep. Some of the most common sleep difficulties include falling asleep, frequent awakening throughout the night, and excessive daytime fatigue ( ). Sleep interventions may be included as part of cognitive behavioral therapy for chronic pain but can also be independent treatment ( ; ). Interventions targeted at improving sleep hygiene appear to affect function in children with chronic pain.
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