Chronic Pain in Children
By Jennifer Stinson RN, Ph.D.
Most people believe that chronic pain is an adult issue, but children can also suffer from chronic pain.
What is chronic pain in children?
Chronic pain in children has been defined as any recurrent or persistent pain lasting longer than three months. Headaches, belly aches or leg and arm pain are examples of recurrent pain. Back pain, cancer and arthritis related pain and neuropathic pain such as chronic regional pain syndrome are examples of persistent pain.
Children who suffer from chronic pain may demonstrate various levels of disability, from none to serious. Most children who suffer from chronic pain function very well, they may continue to attend school, interact with friends and take part in social and recreational activities. However, some develop more complex chronic pain issues related to distress and disability. Biological, psychological, social, cultural and developmental factors can be a strong influence in the seriousness of chronic pain and the level of disability that may ensue.
Several children with complex chronic pain issues have nociceptive and neuropathic components. Nociceptive pain is a normal type of pain while neuropathic pain forms at the nerve level. Both types of pain may make treating the issue more complicated. While chronic pain issues in children can be treated by health professionals, such as a family physician, interdisciplinary chronic pain management teams are often required to treat more complex chronic pain issues.
What are interdisciplinary chronic pain management teams?
Chronic pain management teams who treat children usually include specialists such as anaesthesiologists, neurologists and physiatrists, nurses, psychologists and physiotherapists. Team members are specifically engaged according to the needs of the child to be treated and their family.
A child’s first consultation usually involves an interview with the team and a physical exam or perhaps separate interviews with each health professional. Complete physical and psychosocial evaluations may last up to several hours perhaps even one whole day depending on the child’s previous diagnostic tests and the team’s set of evaluation questionnaires. Team members then meet to determine a diagnosis of the child’s pain and the preferred treatment plan:
- The diagnosis: The underlying causes and contributing factors;
- • The reason for a rehabilitation approach that includes a clear description of the options involved in the specific treatment and an opportunity for the family to contribute and adapt the plan.
Some clinics specialised in working with children also offer different treatment programs that can be given during the day or as residential programs either on the clinic’s premises or in an affiliated institution.
What is the goal of interdisciplinary treatment of chronic pain?
Interdisciplinary chronic pain management programs use a re-education approach to treat pain in children. The pain is addressed with the most appropriate treatments such as medication, physical and psychological therapies. The team helps children and their parents recover and improve the children’s mobility. In certain cases, the teams work with the families to help them understand that the child’s pain may not be completely eradicated. Efforts are focused on improving the child’s mobility and quality of life.
The objectives of interdisciplinary treatment include the following:
- Complete physical and psychosocial evaluation of the child suffering from chronic pain and their family to uncover the factors that may be contributing to their pain;
- Design and implement a flexible treatment approach focused on the child that takes into consideration every factor that contributes to their pain;
- A treatment plan that usually includes physical, pharmacological and psychological therapies, and in certain cases, medical interventions such as nerve blocks.
- The specific goals of the treatment may involve:
- Increasing independent mobility to perform daily, school, social and physical activities;
- Facilitating adaptation and communication solutions and improving adaptation skills;
- Address specific issues identified during the evaluation process, such a depression or anxiety;
- Help children and their families understand the nature of the pain, its related issues and its treatment from a holistic perspective.
- Continuous evaluation and re-evaluation of the treatment plan.
Pharmacological methods represent a significant component of a flexible and integrated approach that also involves physical and psychological strategies.
The choice of medication depends on the source of the pain, either nociceptive or neuropathic or both. Pain medications are adapted to each child’s needs based on the outcome of the evaluation. Drug therapies are basically divided into analgesics (pain medication) and adjuvant drugs (additional).
Nociceptive pain medications
Analgesics are given in the context of a progressive approach and are recommended for nociceptive or combination pain. Simple analgesics like acetaminophen and non steroidal anti-inflammatory drugs (NSAID such as ibuprofen), given at adequate dosages, are efficient in certain children. Opiates may be added to analgesics when the latter no longer relievespain.
Neuropathic pain medications
As for neuropathic pain, it is often resistant to pain medication therapies that usually provide relief to nociceptive pain. Consequently, other medications are used and are referred to as adjunctive agents for chronic pain management. Such adjunctive agents include anticonvulsants and tricyclic antidepressants.
In fact, gabapentin is the most commonly used anticonvulsant since it is safe and well tolerated. Meanwhile, amitriptyline is the most commonly used tricyclic antidepressant and is often recommended for use in children who have trouble sleeping. Antidepressants are also quite useful for children who are depressed and suffering from chronic pain.
There are several types of psychological therapies available to treat children suffering from chronic pain. These treatments may include:
- Support therapy
- Relaxation therapy
- Behaviour modification
- Cognitive strategies including hypnosis and psychotherapy.
These therapies are often integrated into a comprehensive program of cognitive behaviour therapy (CBT). The goal of CBT is to identify and improve the factors that influence the child’s pain and disability. A recent study showed the efficacy of CBT in chronic headaches and belly aches in children.
CBT is often part of a therapy program provided by various members of the chronic pain management team (psychologists, nurses and physiotherapists.) The content of such programs varies from clinic to clinic, but usually involves the following:
- Teaching children specific adaptation and pain management skills
- Fostering positive responses from the family to encourage family members to return to their normal lives;
- Rehabilitative gymnastics;
- Education and self-management strategies.
The goal of these psychological therapies is to help children take back control of their lives and manage their pain.
Chronic pain often leads children to avoid physical activity since they are fearful of experiencing another injury or exacerbating their pain. Unused muscles lead to loss of muscle strength, flexibility and endurance, which means that the overall result in muscular deconditionning. Consequently, physical therapies constitute a significant portion, and in some cases, the cornerstone of treatment provided to children who suffer from complex chronic pain.
The most commonly used physical therapies include:
- Rehabilitative gymnastics
- Thermal therapy: Therapy using both cold and heat
- Sensory therapy: Desensitization, transdermal neurostimulation
Physical therapies are often combined for treatment.
Regular exercise (20 minutes 3 times per week for example), should improve sleep, mood, self esteem and energy. However, maintaining daily activities like going to school, engaging in sports and playing is often just as efficient as doing a formal exercise program.
Some children will benefit from intensive physiotherapy. Physiotherapy is usually given on an external patient basis with the ultimate goal being to teach children to perform their own program at home. Children are more likely to enjoy and pursue a program they like and where time spent exercising is gradually increased.
Essentially, children who suffer from complex chronic pain issues experience prolonged pain and disability. Pain has negative consequences on every aspect of their lives, from their physical functions to psychological and social wellbeing. Several sensory, cognitive, behavioural and emotional factors can intensify pain and extend the disability as it relates to pain. Moreover, these complex pain issues tend to present nociceptive and neuropathic components thus making them more difficult to treat.
Considering the complexity of the issue, single disciplinary (only one discipline such as medicine) and unimodal treatments (using only pain medication) are seldom successful. Consequently, children with complex chronic pain issues must be treated within an interdisciplinary and multimodal perspective that includes rehabilitation. Pharmacological, physical and psychological therapies should be incorporated into a flexible program that focuses on the children.
More information on chronic pain in children is available by clicking on the following link.
The AboutKidsHealth Pain Resource Centre at the Hospital for Sick Children : www.aboutkidshealth.ca.