For Children

Children and Chronic Pain

Chronic pain in children has been defined as any recurrent or persistent pain that lasts longer than three months. Headaches, abdominal pain or pain in one’s limbs are just a few examples of recurrent pain. Back pain, cancer-related pain, pain caused by arthritis, or even neuropathic pain such as Complex Regional Pain Syndrome are examples of persistent pain.

Children living with chronic pain may have different levels of disability, from none to severe. Most children who suffer from chronic pain function quite well; they can still go to school, interact with their friends and take part in social and recreational activities. However, some do develop more complex chronic pain issues associated with distress and disability. Different factors, such as biological, psychological, social, cultural and developmental factors may have a strong influence on the severity of chronic pain and the level of disability they may cause.

Several children with complex chronic pain issues have nociceptive and neuropathic components. Nociceptive pain is the usual type of pain, but neuropathic pain occurs at the nerve endings. These conditions may make it harder to treat. Although children with chronic pain can often be treated by healthcare professionals in the community such as family physicians, interdisciplinary teams specialized in chronic pain are often required to care for the more complex issues related to chronic pain.

Interdisciplinary Teams Specialized in Chronic Pain Management

Teams who specialize in chronic pain management usually include specialists (anesthesiologists, neurologists and psychiatrists), nurses, psychologists and physiotherapists. The group who specialize in treating children with chronic pain varies according to each child’s individual needs as well as those of their families.

A child’s first consultation generally involves a team interview and a physical exam or individual interviews with each healthcare professional. Complete physical and psychosocial assessments may last anywhere from a few hours to a full day depending on the child’s previous diagnostic tests and the team’s own battery of assessments (questionnaires). Team members then meet to determine the child’s pain diagnosis and appropriate treatment plan. The most often used physical therapies include:

Diagnosis: underlying causes and contributing factors;
The rationale for a rehabilitation approach includes a clear description of specific treatment options and an opportunity for the family to modify the plan if needed.

Some pediatric clinics also offer on-site treatment programs, either on an outpatient or residential basis (lodging is provided by an establishment associated with the clinic).

The Objectives of an Interdisciplinary Treatment of Chronic Pain

Interdisciplinary chronic pain management programs rely on a rehabilitation approach to treat pain in children. The pain is managed using the most appropriate therapies, such a medication, physical and psychological therapies. The team helps children and their parents improve the child’s mobility in spite of the pain they are experiencing. In some cases, the team works with the family and helps them understand that their child’s pain may not be completely gone. The focus is on improving mobility and quality of life.

Interdisciplinary treatment goals include:

A comprehensive physical and psychosocial evaluation of the child living with pain as well as their family to find which elements could be contributing to the child’s pain.
The development and implementation of a treatment approach that is flexible and concentrated on the child and addresses all of the elements involved in pain.
A treatment plan, usually including physical, pharmacological and psychological therapies, and in some cases, medical interventions such as truncal anesthesia.
Specific treatment goals may include:
- Increasing independent mobility in terms of day-to-day tasks, school and social and physical activities.
- Promoting an adaptive problem-solving, communication and coping skills.
- Addressing specific problems identified during the general assessment, such as depression and anxiety.
- Helping children and their families to better understand the nature of pain, issues related to pain and its treatment from a holistic perspective.

Ongoing assessment and re-evaluation of the treatment plan.

Chronic Pain

Chronic pain is pain that lasts for at least three months. Chronic pain is also any recurrent pain that presents at least three times over a three month period. Chronic pain may be:

Persistent pain: ongoing pain.
Recurrent: frequent episodes of pain, such as headaches.

Unlike acute pain, chronic pain has no useful objective; it’s a prolonged and abnormal response to injury. Consider it to be your body’s alarm malfunctioning, sending danger signals without a valid reason. Chronic pain can be related to diseases such as arthritis and cancer, or it may simply occur without a known reason (idiopathic pain). The difference with acute pain is that chronic pain has no real purpose except to remind the person that their disease is ongoing and requires permanent treatment. It needs to be meticulously managed to improve the body’s overall function. It’s much more difficult to treat then acute pain and requires a multimodal approach. This type of approach uses a combination of medications as well as physiotherapy and psychotherapy. There are teams of professionals specialized in chronic pain that use an interdisciplinary approach (medication, nursing care, physiotherapy, psychology, etc.) There are two types of chronic pain: nociceptive pain and neuropathic pain.

Pharmacological Therapies

Pharmacological approaches are an important part of a flexible and integrated approach, which also includes physical and psychological strategies.

The choice of medication depends on the source of the pain (nociceptive, neuropathic or both). Pain medications are tailored to each child’s individual needs and chosen according to the evaluation’s findings. Pharmacotherapy is basically divided into analgesics (painkillers) and adjuvant medications (indirect and supplemental).

Nociceptive Pain Medications

Analgesics are prescribed within a progressive approach and are recommended for nociceptive and mixed pain treatment. Simple analgesics, such as acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs, such as ibuprofen), when given in appropriate doses are efficacious for some children. Opioids may supplement analgesics when simple analgesics aren’t enough for pain relief.

Neuropathic Pain Medications

In contrast, neuropathic pain is often resistant to medication therapies that usually work well for nociceptive pain. Consequently, other types of medication referred to “adjuvant pain medications” are used. Some examples of adjuvant pain drugs include anticonvulsants and tricyclic antidepressants.

Gabapentin is the most used anticonvulsant; it is safe and well tolerated. Amitriptyline is a tricyclic antidepressant that is most often prescribed and recommended for children with sleep disturbances. Antidepressants are also an efficient treatment option for children with chronic pain and depression.

Psychological Therapies

There are several types of psychological therapies to treat chronic pain in children. These treatments include:

Support therapy;
Relaxation therapy;
Biofeedback;
Behavioural modification;
Cognitive therapies such as hypnosis and psychotherapy.

These therapies are often integrated into a complete program of cognitive behavioural therapy (CBT). The goal is to identify and improve the factors that influence a child’s pain and disability. A recent study demonstrated cognitive behavioural therapy effectiveness for chronic headaches and abdominal pain in children.

Cognitive behavioural therapy is often used as part of a therapy program that is conducted by different members of the pain management team (psychologists, nurses, physiotherapists). The program content varies from clinic to clinic, but it usually includes:

Teaching children specific coping and pain management skills;
Encouraging positive responses from family members to return to their usual activities;
Rehabilitative gymnastics;
Self-management strategies and education.

The goal of psychological therapies is to help children regain control of their lives and manage their pain.

Physical Therapies

Chronic pain often leads children to avoid physical activities out of fear of getting hurt or that the activity itself will aggravate their pain. When muscles are not used they weaken and lose their flexibility and endurance, which as a whole is referred to as muscular deconditioning. Consequently, physical therapies represent an important part, and in some cases, the cornerstone of treating children who suffer from complex issues related to chronic pain.

The most common physical therapies include:

Rehabilitative gymnastics;
Physiotherapy;
Thermal therapy: therapy that uses both cold and warmth;
Sensory therapy: desensitisation, transcutaneous neural stimulation;
Massage.

Physical therapies are frequently used as a complement to other types of therapy.

Regular exercise (for example, 20 minutes, 3 times per week) can improve sleep, mood, self-esteem and energy level. However, maintaining daily activities such as going to school and playing are often just as efficient as performing a proper exercise program.

Some children benefit from intensive physiotherapy. This type of therapy is usually done on an outpatient basis and its goal is to teach children to complete their own program at home. The child is more likely to enjoy and to pursue a program they like; one in which time devoted to activity is increased progressively over time.

Children with complex chronic pain related issues experience pain and extended disability.

Pain negatively influences all aspects of a child’s life: physical, psychological and social. Several sensory, cognitive, behavioural and emotional aspects may intensify their pain and prolong their disability. Moreover, these complex pain issues tend to include nociceptive and neuropathic components which make treating these children more complicated.

Due to the complex nature of pain, unidisciplinary treatments (a single discipline, such as medicine for example) and unimodal (using only pain medications) are rarely successful. Consequently, children with complex chronic pain issues must be treated as part of an interdisciplinary, multimodal and rehabilitation perspective. Pharmacological, physical and psychological therapies should be incorporated into a flexible, child-centered program.

Find out more about chronic pain in children at the following website:

The AboutKidsHealth Pain Resource Centre at the Hospital for Sick Children : www.aboutkidshealth.ca.