Pain in Pediatric Primary Care: Lessons from a Med-Psych Day Treatment Program

1. Pain in Pediatric Primary Care: Lessons from a Med-Psych Day Treatment Program Heather Chapman, MD1 and Jack Nassau, PhD2 1Clinical Assistant Professor of Pediatrics and Staff Pediatrician, 2Clinical Associate Professor of Psychiatry and Human Behavior and Chief Psychologist Alpert Medical School of Brown University Hasbro Children’s Partial Hospital Program, Rhode Island Hospital

2. Disclosure • Dr. Chapman does not have any conflicts of interest to disclose • Dr. Nassau does not have any conflicts of interest to disclose

3. got pain?

5. Objectives • Describe the biopsychosocial model of pain • Understand the benefits of functional pain assessment • Develop strategies for incorporating the biopsychosocial model in primary care pain assessment and management

6. What is Pain? • “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” • Pain is always a psychological state that cannot be reduced to objective signs. In other words, pain is always subjective. • Extensive tissue damage may occur without pain • Pain may occur in the total absence of tissue damage

7. Pictures of:

9. Pain is aBiopsychosocial Experience • Biological Site - Pain is absolutely real and is physically experienced • Psychological “Interpretation” – “No brain, no pain” • Social Context – “Pain is felt where you hurt and where you are”

10. Biological Stress Reponses • Autonomic Nervous System • Sympathetic-Adrenal-Medullary (SAM) System • Catecholamines (epinephrine, norepinephrine) released into blood via sympathetic nerve endings and adrenal medulla • Increased blood pressure, heart rate, sweating, and constriction of peripheral nerve endings • “Fight or flight” response • Central Nervous System • Hypothalamic-Pituitary-Adrenocortical (HPA) Axis • Hypothalamus releases corticotropin releasing factor >> pituitary releases adrenocorticotropic hormone >> adrenals release cortisol

12. Possible pain “signs” in children • Verbal • Emotional • Behavioral • Physiological • Avoidance, somatic complaints (headache, stomach ache), fatigue, irritability, disrupted appetite/sleep, “clinginess”, regressive behaviors

13. Traditional Pain Assessment • Location • Frequency • Duration • Intensity • What’s missing???

14. Biopsychosocial Pain Assessment • Location • Frequency • Duration • Intensity • Functional Impact • Mood • Behavior • Family • School

15. Functional Pain Assessment Tool [i]

16. Functional Pain Assessment Tool • FACES scale • 0 2 4 6 8 10 No pain/hurt Very much pain/hurt • Functional Scale: (1) MILD = You know the pain is there, but it doesn’t bother you much. • (2) MODERATE = The pain does bother you, but you can still do things. • (3) SEVERE = The pain bothers you a lot, you can’t do very much • (4) VERY SEVERE = You can’t do anything but rest. • RN Initials RN Signature/Print Name Date/Time • _____ __________________________________ ________ • _____ __________________________________ ________

18. Pain Management Strategies • Medical Provider • Patient • Family • Professional referral

19. Pain Management Strategies –Medical Provider • Framework - Holistic approach • Medical testing and treatment AND psychosocial context • Emphasize mind-body connection • Mental and emotional factors are important even when medical findings are positive • The lack of a positive medical finding does not mean the pain is “all in my head”, “unreal”, or “made up” • Possible questions • What are you doing to manage the pain? • How does the pain affect your mood? How does your mood affect the pain?

20. Pain Management Strategies– Patient • Pain monitoring (clinical implications) • Stay active - exercise releases endorphins • Sleep schedule • Actively focus/attend to other things – sometimes called distraction • Diaphragmatic breathing

21. Pain Management Strategies - Family • Validate pain experience and expectation for pain management • Limit attention to pain symptom • Limit asking about pain • Respond to pain complaint with questions/directions related to management • Focus on functioning rather than pain intensity • Encourage pain coping strategies • Maintain normative expectations • Make decisions that empower person, not pain

22. Pain Management Strategies Professional Referral • Family Therapy • Focuses on influencing family stressors, relationships, and behaviors • Cognitive behavioral therapy • Focuses on addressing pain related thoughts, emotions and behaviors • Includes setting specific functional goals • Relaxation Training • A group of techniques designed to produce physiological, psychological and behavioral changes • Specific rationale to decrease arousal, muscle tension, and negative mood states • Biofeedback • Instrumentation that provides data on psychophysiological processes that are not usually consciously available to the person, but can be brought under voluntary control

23. Family Therapy • A child’s pain affects the whole family • Help family adopt a holistic view that acknowledges the child’s (and family’s) physical and emotional functioning • Model this same approach – support appropriate medical treatments • Support child, parents, entire family in functioning through pain despite fear of doing so • Address specific family pain responses/behaviors • Address additional family stressors or relationship patterns that may be influencing pain expression

24. Cognitive Behavioral Therapy • Recognizes the interrelationships between thoughts, feelings and actions (behaviors) • Work on changing thoughts, behaviors, and emotions to manage pain experience • Cognitive restructuring • Graduated exposure to increase functioning (goal setting) • Positive reinforcement for task completion

25. Changing Maladaptive Pain Thoughts • Addressing automatic negative thoughts with positive coping statements “I usuallyfeel good in the afternoon.” “I’m always in pain!” >>> “I can’t do anything because of my pain!” >>> “I can still ______ even though I have pain. Limit catastrophizing and “all-or-none” thinking

26. Relaxation Training • A skill that develops with repetition over time • An active and empowering strategy (not merely “relaxing” in front of the TV) • Attend to environment and body position • Diaphragmatic breathing • Progressive Muscle Relaxation • Guided imagery

27. Diaphragmatic (Belly) Breathing • Often recommended, not given adequate trial • Pacing and mechanics are related and both are important • Thoracic “Chest” breathing is more common • Uses chest muscles; leads to faster, shallower breaths • Diaphragmatic “belly” breathing • Uses diaphragm muscle; leads to slower, deeper, and longer breaths • In through nose, out through mouth • Belly should rise on in-breath, collapse on out-breath

28. PMR and Guided Imagery • Progressive Muscle Relaxation • Typically done sitting up • Series of tensing and relaxing muscle groups • Focus on noticing the difference between tension and relaxation so that tension can be a cue to relax • Guided Imagery • Often done reclining or laying down • Use mental imagery and associate it with relaxing and pain relieving words, sensations, and suggestions

29. Biofeedback Purple = Finger temperature Orange = Skin conductance level Grey = Skin conductance response Green = Forehead muscle tension

31. THANK YOU