Children and adolescents commonly experience chronic pain problems, such as recurrent abdominal pain, chronic daily headaches, chest pain, and limb pains.1 Although the evaluation and management of such conditions is fundamental to pediatrie practice, often pediatricians feel better equipped to manage complicated acute and chronic illnesses. However, the pediatrician's working knowledge of psychosocial development provides an excellent base to oversee the majority of chronic pain problems.
This review focuses on chronic pain not associated with disease or trauma. However, many of the principles described here also can be applied to chronic pain that is more directly related to an illness.
Chronic pain may be related to underlying disease, such as inflammatory bowel disease, rheumatoid arthritis, sickle cell disease, cancer, or human immunodeficiency virus (HIV) infection. Alternatively, the pain may be related to perturbations in physiology, as in headaches, intestinal motility disorders, fibromyalgia, or reflex sympathetic dystrophy. Alternatively, some pain disorders have no identifiable relationship to disease, trauma, or physiologic alterations.
The subjective nature of pain gives rise to numerous problems. Medical practice's orientation to requiring objective documentation of pathology to validate subjective complaints is so gripping that physicians often have trouble seeing beyond this paradigm. In adults, chronic symptoms unrelated to disease are very common,2 and children with persistent symptoms unrelated to disease often have parents who have experienced chronic symptoms.3,4 Some children with pain unrelated to disease or trauma become debilitated with somatization disorders.5 Even in the absence of identifiable pathology, expeditious treatment is necessary for the child who is very uncomfortable or dysfunctional. Appropriate concern and intervention can prevent "doctor shopping" and potentially dangerous or expensive workups and treatments.
THE PROCESS OF CHRONICITY
When pain starts, although the patient may be overwhelmed by its intensity and the family becomes worried about its cause, all assume that it will stop, and initially hope is maintained. However, as the pain continues, hope often gives way to despair, depression, anger, and apathy. The pain may become a central focus for the patient and the family, displacing energy from other activities and altering plans for the future. Behaviors and social interactions begin to revolve around the pain.
Intercurrent illnesses (eg, viral infections), trauma, or aberrant physiologic processes (eg, altered bowel motility, reflex sympathetic dystrophy and headaches) may initiate the pain. Alternatively, normal bodily sensations such as bloating or muscle tension or overuse become a focus of attention. If the pain lasts longer than expected, anxiety mounts, and focus on the pain builds. The child may try to return to usual activities, only to experience an exacerbation of symptoms. A causative link between activity and pain becomes internalized, and the child, often prompted by the parents, restricts activities. Muscles can become deconditioned and fatigue ensues. Fear of pain may become as debilitating as the pain itself The interruption of normal activities is demoralizing and leads to depression,6 and secondary gains become more prominent.
Pain starting in one area of the body can spread to other areas. Additional nociceptive pathways are neurologically recruited, and neurophysiologic modulation of the nociceptive input is impaired. At the same time, muscles around the painful area become tense, and muscle tension and spasms increase the pain.
Psychological factors are involved in all pain. Unrelieved pain affects emotions, thoughts, and social interactions, and likewise, preexisting emotional or family issues may predispose to focusing on or worrying about symptoms.7 Attempting to establish emotional causality versus effect is unnecessary and may be counterproductive. Psychosocial problems must be addressed either way.
Be patient when working with these children. At times, physicians unwittingly reinforce dysfunction associated with pain. Dismissal, disbelief, and overreaction can transform reasonably adjusted children and families into dysfunctional units. Time is required to sort out complicated pain problems. Although primary care physicians may have the capability to provide effective evaluation and intervention, regrettably, they may be discouraged from doing so because of inadequate time or reimbursement.
Careful assessment is the cornerstone of intervention and may in itself be therapeutic. Careful inquiry about the pain and its effects communicates that the physician takes the complaints seriously and believes the patient.
Evaluation should always include a rating of the intensity of the pain. (See McGrath P.A. "Pain in the Pediatrie Patient," pages 126-138).
A mnemonic for understanding pain is "pqrst," to which "m" is added, "p" stands for provocative and palliative factors, "q" for quality, V for region and radiation, V for severity, and V for temporal factors; "m" refers to the meaning of the pain for the patient and family. IC for example, the family assumes that the pain means that the child has cancer and this belief is not elicited and addressed, reassurance will be futile, and treatment will likely be ineffective.
The initial history generally includes the parents and the patient together, although some practitioners prefer to interview older adolescents alone at the beginning. The group interview establishes an environment where all family members can express concerns and the clinician can note areas of consonance and dissonance. The patient and parents then are interviewed individually. Usually the parents can be interviewed as a team, although in some situations separation is helpful. The clinician's prior knowledge of the family may suggest the optimal structure of the interview. Interviews must respect confidentiality.
The physician inquires about the effects of pain on school, play, friends, family interaction, mood, and sleep. Chronic pain often is associated with sleep dysfunction, and children may be sleeping with their parent or parents because of the pain. Many children with chronic pain have other symptoms, such as fatigue, nausea, dizziness, bloating, sore throats, blurred vision, apathy, and inability to concentrate. Focusing on the pain to the exclusion of other symptoms can lead to pain improvement while other symptoms persist.
Medical information relevant to the diagnosis of underlying or related disease and trauma must be obtained, as well as information about psychosocial function. These questions can be easily incorporated into the history from its start. Because chronic pain is best understood within a biopsychosocial context, the physician models this conceptualization for parents and the patient by exploring all aspects of the pain from the beginning; leaving psychosocial assessment to the end may communicate that these concerns are secondary.8 At the same time, the physician must take care to frame questions in a manner that is not inappropriately intrusive or that causes the patient or a family member to "lose face."
The physical examination is as important as the history. Accompanying the exam with a running commentary usually helps alleviate anxiety. If the parents are not present, the findings from the examination can be detailed on their return. Although in some situations a focused examination is sufficient, when anxiety is present, an examination from head to toe (even when not "medically necessary") can be reassuring.
After the physical examination, the physician discusses his or her impressions and outlines a recommended treatment plan. If the pain appears unlikely to be related to disease or trauma, but further workup is desirable for reassurance, careful explanation can help the family and the patient accept normal results. If instead, the physician orders tests without an explanation, when normal findings are returned, families may logically insist on more tests. The physician can say something such as; "1 am really glad to find that the physical examination is normal. With the way Henry describes his pain, and the normal exam, it looks as if the headaches are the type of headaches that many children and adults get. There certainly are no signs of a brain tumor or a sinus infection or anything else like that. However, just to be absolutely sure, I think we should get a blood test. I am very sure that this test will be normal, but this is so you and I can feel safe in treating the headaches as simple headaches."
A home diary of symptoms aids both evaluation and treatment. The request for the diary validates the physician's concern and desire to understand the symptoms. The diary emphasizes the role of the patient (and of the family if involved) as an active participant in the treatment. The information can help reveal provocative, palliative, and temporal factors. Mood and activity can be charted along with pain. Depending on age, the child may take full or partial responsibility for the diary. In the case of intrusive parents and a child who is able to maintain his or her own diary, the physician can emphasize that this task is best regarded as the child's responsibility or may ask the child and parents to keep separate diaries. Chaotic families and families for whom written communication is difficult may be unable to keep diaries. In such circumstances, requests for diaries are not helpful.
The model for assessment outlined above is a rough schema. When the pain is easily understood and has had minimal effect on function, the assessment can be abbreviated. When time is limited, a rapid evaluation can be performed and instructions for maintaining a diary can be provided, following which a longer follow-up appointment may be scheduled. When the pain is long-standing and significantly affects mood, important activities, or interactions, a more lengthy evaluation is indicated. If appropriate, such an evaluation can be performed in stages. When the situation is complex, asking all of the significant family members to come for an interview may help elicit hidden agendas or concerns.
In recognition of the multifeceted nature of pain, the physician may choose treatments from three major classes: 1) pharmacologie, 2) physical, and 3) psychosocial. The selection must be individualized to the patient and family. For example, children with relatively uncomplicated pain may only require training in coping skills or an analgesic. When problems are complicated and well-established, intense application of all three groups is more often indicated.
Even when emotional problems are significant, acceptance of a somatic basis for distress should underlie all interactions and treatment, since all pain is experienced as bodily complaints. Language must reflect this understanding, or the treatment will not be accepted. At the same time, the mind-body connection can be emphasized. Almost everyone experiences somatic reactions to stress and distress, and thus the association of pain with emotion is not understood as abnormal or pathologic. This approach helps defuse the stigmatization and shame experienced by many patients around physical reactions to emotional stress.
Finding a common language to discuss the meaning and treatment of symptoms is essential. The manner in which emotional issues are addressed will differ for families that are more psychologically or somatically oriented. The same phenomenon can be framed as predominantly physical or mental. When the physician and the family speak different languages, little is accomplished, and an adversarial relationship may develop.9 One of the physician's challenges is to express beliefs honestly, but in a manner that is accepted and understood by the patient.
Maintenance and reinforcement of pain can result inadvertently from medical care. For some children and their parents, chronic pain may comprise part of an unconscious agenda vis-à-vis their physician. In most cultures, physicians are powerful, reassuring, and safe parental figures, and the relationship between the family and the physician can be maintained by persistent or changing symptoms. Commonly, physicians respond to such needs by escalating the medical worltup (colluding), by referring to another physician (displacing), by scheduling visits as infrequently as possible (avoiding), or implying via word or action that the symptoms are not of concern (denying or devaluing). Research and clinical experience demonstrate that taking the distress seriously, scheduling frequent non-crisis visits accompanied by careful examinations, and minimizing laboratory tests decrease distress and overall health-care utilization in patients with chronic symptoms.10 While concurrent psychotherapy and other treatments may be indicated, they often fail without the supportive relationship provided by the primary doctor.
Finally, emphasizing the distinction between comfort and function, even when they are closely related, facilitates the assessment of treatment efficacy. With effective treatment, function, mood, and family/ interactions usually improve first, while decrements in the intensity and frequency of pain and other symptoms accrue more slowly. Explicitly identifying this sequence decreases the potential for the patient and family to become discouraged and frustrated.
The primary medications used to treat chronic pain unrelated to disease or trauma are nonsteroidal antiinflammatory drugs (NSAIDS), acetaminophen, and tricyclic antidepressants (TCAs). Occasionally, selective serotonin reuptake inhibitors, opioids, certain anticonvulsants, and selected other medications are helpful.
In using any medication, efficacy must be assessed from a framework that recognizes the subjectivity of symptoms. If patients report no improvement within an expected interval, the medication should be discontinued, and an alternate drug may be considered. Sometimes a salutary effect is noted only after a drug is discontinued. The use of pain intensity ratings and symptom and function diaries provide a structured means of assessing treatment.
The manner in which a pharmacologie interven' tion is presented and explained influences efficacy. The physician should emphasize that while medica' tions rarely ease the pain entirely, small decreases help patients use coping skills more optimally.
For patients with occasional exacerbations of pain, medication can be used effectively at the start of an exacerbation. For severe or persistent pain, however, medications should be prescribed on a scheduled basis, rather than contingent on symptoms. An as needed schedule is counterproductive if it focuses the patient's attention on the pain.
Tricyclic antideptessants decrease the intensity of chronic pain in adults and are synergistic with psycho' therapy and other treatment modalities.11 Although controlled trials in pediatrics are lacking, many clinicians successfully use these medications, especially for adolescents with chronic pain.12 Their analgesic activity is independent of effects on mood, and thus they may relieve pain even in the absence of clinically evident depression. Parents may be reassured that pain relief can ensue without altering affect. Unless depression is separately identified, treatment with tricyclics should be presented as aimed at pain and not the psyche. Tricyclic antidepressants such as amitriptyline and doxepin are sedating. Prescribed in a single dose at bedtime, they may both relieve pain and restore sleep. Patients with chronic pain commonly experience problems initiating or maintaining sleep. Sleep may be disrupted because of pain, reduced daytime activity, and emotional issues correlated with the pain. Improved sleep may, in turn, reduce pain.
The best studied tricyclic antidepressant for chronic pain in adults is amitriptyline. Nortriptyline, doxepin, imipramine, and desipramine have demonstrated analgesic activity in adults. However, desipramine is not used in children because it is more activating and has been associated with sudden death.13 A careful history and EKG are recommended before starting a tricyclic antidepressant.11 The initial dose should be small, ie, if amitriptyline is selected, recommended starting doses are about 10 to 12.5 mg qhs for patients over 50 kg, or about 0.2 to 0.3 mg per kg for patients under 50 kg. Patients with chronic pain are often sensitive to side effects, and unless starting doses are modest, anticholinergic effects may precipitate premature discontinuation of therapy. Analgesia accrues over time, and the dose is slowly increased every few days as tolerated, while efficacy is assessed. Some patients respond to small doses, while others require doses typically therapeutic for depression. In higher dose ranges, monitoring serum levels may help guide therapy by providing information about compliance, absorption, and impending toxicity. A persistent unfavorable balance between side effects and pain relief should prompt a change to an agent that posesses a different pharmacologie profile.
Opioids are the mainstay of therapy for acute pain and moderate to severe pain associated with chronic illnesses such as cancer, HIV infection, and sickle cell disease. In general opioids are not used to treat chronic pain not associated with disease or trauma. Occasional use of opioids for infrequent and welldefined exacerbations is sometimes indicated, although this is a matter of clinical judgment.
The consideration of psychological treatments in no way implies the presence of psychopathology. These techniques are helpful for many kinds of pain.14 Many approaches under the rubric of "psychological" or "cognitive-behavioral" are used by physicians in day-to-day practice.
Validation, Explanation, and Démystification. Validation of the distressing nature of the pain is the first step in therapy. The physician should then offer a straightforward explanation for the pain that reinforces the absence of a serious underlying cause, but acknowledges how the pain, in and of itself, can create serious problems. This process demystifies the pain. Our atavistic response to pain is to assume that it indicates bodily injury and that further injury will ensue unless medical treatment is prescribed. Although difficult, interrupting the cognitive association between hurt and harm can have powerful therapeutic effects. Tnis also gives patients and families permission to continue activities despite pain. It is essential, though, that explaining the distinction between hurt and harm be accompanied by a discussion of the effects pain can have on function, mood, relationships, and development.
Defining Treatment Goals. After the patient and parents are provided an explanation for the pain, consensually acceptable treatment goals are introduced, and strategies for achieving these are negotiated. NX/hen the patient and parents perceive the symptoms have been regarded seriously, they can focus on recovery rather than trying to prove severity.
Discussion is required so that the treatment goals of the patient, family, and physician are not in conflict. People experiencing pain want treatment that will cause the pain to decrease or abate. Because impaired function typically accompanies chronic pain, treatment strategies often target functional restoration as a primary goal, even though such activities (eg, physical therapy or return to school) may increase pain transiently. It needs to be communicated that improving function initially results in increased reports of pain, and that, conversely, waiting passively for the pain to improve before addressing functional impairments often leads to a cycle of worsening pain and dysfunction.
Pacing and Contingencies. Unaccustomed to normal activity, patients with chronic pain who decide to push themselves on a given day typically experience worse pain, and this strengthens convictions that increased activity will worsen pain. A gradual stepwise approach to rehabilitation is more effective. Thus, the treatment plan for an adolescent who has engaged in little physical activity for months may initially involve walking just 5 minutes daily, with plans for subsequent increases. By focusing on achievable, short-term goals, a paced program can be effective even when the ultimate goal seems unachievable.
Planning paced rehabilitation requires that activity not be contingent on the amount of pain experienced day-to-day, but occur on schedule. This can only be achieved if the program includes achievable goals and rewards persistence over absolute performance. The child is expected to perform to predetermined levels even on days when pain is severe and likewise should be discouraged from over-performing when pain is less.
When function and mood are not seriously affected, planning a return to normal activity is usually relatively simple. Rehabilitation for the seriously impaired patient requires support and guidance. The rehabilitation plan is best formulated by the family and patient in consultation with the physician. The physician functions best as a facilitator and "coach," providing general principles and guidance, but allowing the family to plan details.
Planning for Exacerbations. When pain has been associated with numerous exacerbations, there is a high probability that more will occur once treatment commences. Such exacerbations often are accompanied by emotional crises and urgent calls to the physician. When these events are predicted and a defined plan is outlined to deal with them, their occurrence is less likely to be viewed as a failure, and emotional crises often can be contained.
Distraction, Relaxation, and Sei/-Hypnosis, Various forms of distraction are adopted unconsciously by patients to cope with persistent pain. Often, though, patients do not realize that they are using a coping strategy, and that it works. Calling this to their attention may bring such techniques under conscious control. Patients can benefit further from training that validates their techniques or introduces new approaches.
Relaxation techniques are simply taught and learned. Only a few minutes are required to teach the therapeutic use of deep, slow abdominal breathing. Such techniques are best accepted when accompanied by an explanation of the relationship between muscle tension and pain intensity. Self-hypnosis includes simple and more complex approaches.15
Exploration of Stressors and Problems. Chronic pain is by itself stressful, and Stressors of other kinds may trigger exacerbations of pain. Although the majority of patients with chronic pain do not exhibit major psychopathology, some have major problems or a cluster of minor problems. Maximizing the strengths of a well functioning family can help decrease stres' sors.
Conflict Resolution. Difficulties in resolving con' flict accompany many chronic pain problems. Patients and families may be reluctant to express conflict with or in the presence of their physician. The physician must be aware of subtle indicators of unresolved disagreements such as passive resistance, lack of compliance to negotiated goals, cancelled appoint' ments, crisis-oriented phone calls, and a string of visits to different doctors. These should be addressed directly, but sensitively.
Decreasing Secondary Gain. Secondary gain may assume primary importance when an individual feels overwhelmed by various Stressors. Although a "safe way out," secondary gain is ultimately a dysfunctional way of coping with diversity and stress. The physician can aid the patient and family by considering secondary gains seriously, and devising a management pían that avoids the patient or family members "losing face."
Scheduling Frequent Visits. Ongoing contact is important, and restricting access to the physician often increases anxiety. Return visits should not be contingent on symptoms, as symptoms may increase if appointments only occur when the pain is intense. If crises occur every 4 weeks, scheduling visits every 3 weeks may be helpful.
Referral to Mental Health Professional or Pain Specialist. Although the management of most chronic pain falls within the province of the general pediatri' cían, consultation should be considered for complex or refractory problems. Feeling "out of one's depth" may be a reliable indicator. In general, cases involving severe disturbances of mood, function, or social or family interaction should be referred for mental health consultation.
If psychological and physical issues have been addressed in parallel from the statt, referral is likely to be accepted. To avoid feelings of abandonment, the pediatrician should continue to monitor progress with office visits.
Physical and Rehabilitative Treatments
Physical and rehabilitative treatments are helpful for many patients, especially when symptoms have resulted in functional losses, such as decreased activity, school absenteeism, and alterations in weight. These are aimed at improving function, but often are associated with decreased pain and improvements in emotional status.
Physical Therapy. Physical therapy may include local modalities applied to reduce pain, exercises for flexibility and strengthening, programs for aerobic conditioning, and the use of adjunctive treatments such as transcutaneous electrical nerve stimulation (TENS). Treatment, such as ultrasound, heat, massage, positioning, and TENS usually only relieve pain transiently and may reinforce passivity. These are applicable when relief is a means to participate more fully in active rehabilitation.
Transcutaneous electrical nerve stimulation can be helpful for even school-aged children unless there are multiple sites of pain or when administered without a comprehensive treatment program. If the response is poor over a few days , relief is unlikely to follow prolonged trials.
Anesthesiologic and Neurosurgical Treatments
Anesthetic treatments include nerve blocks and trigger point injections. The value of these modalities is controversial, especially with chronic nonmalignant pain. In general, they are only occasionally indicated, and then only in the context of a more comprehensive treatment program.
COMMON CHRONIC PAIN SYNDROMES OF CHILDHOOD
Recurrent Abdominal Pain
Recurrent abdominal pain is one of the most common pain syndromes of childhood and adolescence.16 It may follow a viral illness or not have an identifiable precipitant. The managements described above are helpful in most cases.
A tripartite approach using pharmacologie, psychologic, and physical modalities is the most accepted method for treating chronic daily headaches.17"19 Depending on their nature, NSAIDS may abort some headaches, and TCAs or propranolol can be used for prophylaxis. Self-hypnosis (or biofeedback) may substitute for medication,20 although pharmacologie management often is required until these skills are learned. Cervical muscle spasm contributes to many headache syndromes and may be aggravated by stress and poor posture, eg, watching TV while lying down with the neck flexed. Nocturnal bruxism or daytime clenching also can contribute to headaches. The patient with a sudden onset of severe headaches not associated with disease or trauma should be assessed for depression and recent losses.21
Myofascial pain occurs in children, but often is not diagnosed. Any muscle may be affected by painful spasm. Generalized pain and tender points help fulfill the criteria for fibromyalgia while trigger points (palpable areas of facial muscle spasm that reproduce the pain, often in adjacent regions) may be found in more regional pain problems. Myofecial pain due to over use may respond to simple physical treatments and redirection of activity; while more chronic problems are likely to require more intensive and prolonged therapy.
Emotional Problems Associated With Pain
Abdominal pain not associated with disease or trauma may be a forme fruste of an eating disorder. The child with recurrent abdominal pain and weight loss or vomiting, who has a normal physical examination and studies, should be questioned about body image, eating patterns, and other issues.
Panic disorder commonly is associated with chest pain.22 Other symptoms of panic include a sense of doom, sudden short-lived unpredictable episodes, hyperventilation, and dizziness.
Although depression and chronic pain are closely associated, it is rarely possible to distinguish whether depression is cause or effect. Regardless, depression must be addressed before improvement can be expected.
Criteria for post-traumatic stress disorder include hypervigilance and physiologic reactivity, features that may be expressed as persistent muscle tension, spasm, and pain. Patients with severe, persistent pain should be questioned about past trauma and assessed for other criteria for post-traumatic stress disorder, which may differ from those seen in adults.23
The evaluation and treatment of chronic pain in children and adolescents is a fundamental aspect of general pediatrics. Successful treatment requires a broad biopsychosocial approach and differs in many aspects from the treatment of acute childhood problems. Access to a referral network is necessary, as complicated pain problems may require a team effort.
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