LONNIE ZELTZER, MD

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UNDERSTANDING CHRONIC PAIN IN CHILDREN

• LONNIE ZELTZER, MD
• PEDIATRIC PAIN PROGRAM
• MATTEL CHILDRENS HOSPITAL AT UCLA

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OVERVIEW

• WHAT IS PAIN?
• WHAT ARE FACTORS THAT IMPACT PAIN?
• WHAT ARE COMPONENTS OF PAIN TREATMENT?
• COMPLEMENTARY AND ALTERNATIVE MEDICINE (CAM)

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WHAT IS PAIN?

• A DYNAMIC PROCESS THAT INVOLVES
• NEURAL SIGNALS FROM PAIN SITE TO BRAIN (CALLED
  PAIN TRANSMISSION)
• NEURAL SIGNALS FROM BRAIN DOWN TO PAIN SITE
  (CALLED PAIN INHIBITION OR PAIN CONTROL)
• MANY FACTORS CAN INCREASE OR DECREASE THE PAIN
  SIGNALS
• PAIN PERCEPTION THE EXPERIENCE OF PAIN AS THE
  MESSAGES REACH CONSCIOUSNESS

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CHRONIC PAIN DYSREGULATION IN INTEGRATION OF
SYSTEMS
BRAIN
PAIN TRANSMISSION
PAIN INHIBITION
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PAIN PERCEPTION BRAIN IS THE LAST STOP
AROUSAL/ANXIETY
ATTENTION
CONTROL
MEMORY
NOCICEPTION
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WHERE IN THE BRAIN IS PAIN?

• PAIN SENSORY PERCEPTION INTENSITY AND LOCATION
• SOMATOSENSORY CORTEX (S1)
• SECONDARY SOMATOSENSORY CORTEX (S2)
• INSULAR CORTEX
• PAIN UNPLEASANTNESS AFFECTIVE ASPECT OF PAIN,
  SUFFERING
• ANTERIOR CINGULATE CORTEX
• Rainville P et al, Science. 1997
• Hofbauer RK et al, J Neurophysiol. 2001

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IS CHRONIC PAIN PHYSICAL OR PSYCHOLOGICAL?

• Answer BOTH!
• all pain perception involves the integration and
  interpretation of sensory input
• sensory input is dampened or enhanced by pain to
  brain up and down systems
• and is effected by other factors (emotions,
  thoughts, environment, culture, learned patterns
  of thought or behavior, etc.)

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IBS example of brain-gut (neuroenteric)
dysregulation
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FACTORS AFFECTING PAIN PERCEPTION EXPRESSION

• SEX
• AGE
• ATTENTIONAL FOCUS
• AROUSAL/ANXIETY
• COGNITIVE LEVEL
• EXPOSURE TO OTHERS PAIN
• PAST PAIN EXPERIENCE

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FACTORS AFFECTING PAIN PERCEPTION EXPRESSION

• CULTURAL NORMS
• EXPECTATIONS
• CONSEQUENCES
• PERCEPTION OF CONTROL
• RELEVANCE OF PAIN
• COPING ABILITY AND STYLE

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MEDICALIZATION THE CONTINUED SEARCH FOR THE
CAUSE

• adds psychological stress (can contribute to
  development of PTSD)
• painful procedures contribute to more
  sensitivity in the neural pain signals
• the more tests that come out negative, the more
  likely children feel that no one believes them

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KEY POINTS

• ALL PAIN IS PHYSICAL
• ALL PAIN IS INFLUENCED BY BIOLOGY, THOUGHTS,
  EMOTIONS, AND SOCIAL-CULTURAL CONTEXT
• DICHOTOMIZING PAIN AS EITHER PHYSICAL OR
  PSYCHOLOGICAL IS UNHELPFUL AND DOES NOT LEAD TO
  GOOD TREATMENT

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PAIN-ASSOCIATED DISABILITY SYNDROMEPADS

• DOWNWARD SPIRAL
• OF INCREASING
• SYMPTOMS AND DISABILITY

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CLINICAL EVALUATION
PAIN
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DOMAINS OF ASSESSMENT

• PAIN PAIN HISTORY
• OTHER PHYSICAL SYMPTOMS
• PHYSICAL FUNCTIONING
• SOCIAL FUNCTIONING
• ACADEMICFUNCTIONING
• FAMILY FUNCTIONING

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DOMAINS OF ASSESSMENT

• EMOTIONAL COGNITIVE FUNCTIONING
• COPING STYLE PROBLEM-SOLVING CAPACITY
• PERCEIVED STRESSORS
• MAJOR LIFE EVENTS
• PAIN CONSEQUENCES

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TREATMENT GOALS

• Instill a new paradigm about the causes
  treatment of complex chronic pain
• Goal Restore balance in neural signaling
• How 1) Reduce focus on childs body
• 2) Increase self-efficacy related to pain (I
  can cope) and 3) address other problems
  identified in the evaluation
• Long-term goal Increase adaptive functioning and
  active coping
• style

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TREATMENT MODALITIES

• EDUCATION
• PHARMACOLOGICAL
• PHYSICAL
• BEHAVIORAL
• PSYCHOLOGICAL
• COMPLEMENTARY THERAPIES

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EDUCATION

• Reassurance pain is real and biological
• Reason for pain dysregulation in pain neural
  signaling system
• Reason for failure of medical tests looking in
  the wrong places
• Avoid mind-body split
• Review how other factors influence pain anxiety,
  depression, beliefs, attention, memory

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PHARMACOLOGICAL GOALS

• Prevention treat acute pain well
• Reduce somatic contributors (inflammation, muscle
  tension, etc)
• Facilitate nighttime sleep
• Treat comorbid disorders, including anxiety
  and/or depression
• Reduce neural transmission
• Consider best routes of drug delivery

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MEDICATIONS

• Neuropathic pain, CRPS-1 TCA, neurontin,
  pregabalin (Lyrica)
• IBS TCA, Zelnorm, peppermint geltabs
• Comorbid Anxiety/Depression SSRIs/SSRI
• PDD (perseveration on pain) Neuroleptics like
  Resperidone
• Insomnia Benadryl, Melatonin, Trazadone
• Myofascial pain muscle relaxants, topical
  anesthetics (e.g. lidoderm patch)
• Other alpha-adrenergics (e.g. clonidine patch),
  Ultram (Ultram-ER), opioids (e.g. methadone)

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PHYSICAL THERAPY

• Especially for patients who have
• chronic musculoskeletal pain
• complex regional pain syndrome
• become deconditioned due to inactivity
• Requires specific expertise by PT
• Exercise has specific benefits related to muscle
  strengthening/functioning posture, and
  generalized benefits related to improved body
  image, body mechanics, somatic self-efficacy,
  sleep, and mood

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BEHAVIORAL INTERVENTIONS

• To increase independent functioning
• To facilitate effective problem-solving
• To decrease pain behaviors in patient and family
  members
• To increase restorative sleep non-impact
  aerobic exercise
• To meet rehab goals incrementally
• Sanders, Scharf, others child CBT and family
• CBT child/family and individual/group what is
  best?

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PSYCHOLOGICAL INTERVENTIONS TYPES

• Cognitive-Behavioral Therapy (CBT)
• Social Skills Training
• Psychotherapy child or family or both
• Academic interventions
• Treatment aimed at PTSD or unresolved grief or
  trauma

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FAMILY THERAPY

• To observe and alter family contributors to pain
  perception
• To participate in development implementation of
  behavioral plan (e.g. how to get child to go to
  school)
• To address family stress problems
• To improve family communication
• To provide support improve family coping
  
  
  

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CAM and OTHER PAIN TREATMENTS

• Acupuncture
• Distraction
• Muscle Relaxation/Breathing
• Meditation
• Hypnotherapy
• Iyengar Yoga
• Biofeedback
• Massage Therapy
• Art Therapy

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ACUPUNCTURE

• Use of needles, heat, pressure,or other
  stimulation at points along the meridian to
  promote flow of Qi
• Research support Efficacy in headaches,
  myofascial pain, primary dysmenorrhea, sickle
  cell crisis pain, and sore throat pain
• Only child migraine study (Pintov)
• FEASIBLE IN CHILDREN WITH CHRONIC PAIN
• Zeltzer, LK et al (2002) A Phase I study on the
  feasibility of an acupuncture and hypnotherapy
  intervention for chronic pediatric pain. Journal
  of Pain and Symptom Management, 24, 437-446.
• Waterhouse, M, Stelling C, Powers M, Levy S, and
  Zeltzer LK Acupuncture and hypnotherapy in the
  treatment of chronic pain in children. Clinical
  Acupuncture and Oriental Medicine, 2000
  1139-150.

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The beginning of acupuncture
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CAM and OTHER PAIN TREATMENTS

• Acupuncture
• Meditation
• Distraction
• Muscle Relaxation/Breathing
• Hypnotherapy
• Iyengar Yoga
• Biofeedback
• Massage Therapy
• Art Therapy

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MINDFULNESS MEDITATION

• Learn how to be present
• Learn to notice thoughts and distressed feelings
  and to let them go
• Dissociate from arousal associated with pain
• Develop a sense of inner control and peacefulness
• Impact of MM on central pain centers and frontal
  asymmetry (Davidson, et al).

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HYPNOTHERAPY

• Capture attentional focus alter sensory
  experience
• Reduce distress
• Reframe situation
• Dissociate from the pain alter time
• Role of suggestion vs formal hypnotherapy power
  of words
• Chen E, Zeltzer LK, Craske MG, Katz ER
  Alteration of memory in the reduction of
  childrens distress during repeated aversive
  medical procedures. Journal of Clinical and
  Consulting Psychology, 1999

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BIOFEEDBACK

• Use of computer or other feedback device to
  assist patient in altering muscle tension, skin
  temperature or other body states
• Increases body awareness, symptom control,
  somatic self-efficacy using concrete data
• Scharf and others (IBS, migraines)

RELAX
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MASSAGE

• Good for myofascial pain and any type of chronic
  pain, except those with hyperalgesia
• Increases restorative sleep
• Research evidence in children (e.g. Fields)
  efficacy in JRA, cancer pain, fibromyalgia,
  anxiety and depression
• What is the neurobiology of touch and what
  changes over time? How much, how long, by whom?

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CAM and OTHER PAIN TREATMENTS

• Acupuncture
• Meditation
• Muscle Relaxation/Breathing
• Distraction
• Hypnotherapy
• Biofeedback
• Massage Therapy
• Iyengar Yoga
• Art Therapy

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YOGA
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IYENGAR YOGA

• Use of body poses (Asanas), breathing techniques,
  and attentional focus to enhance body awareness
  and achieve physical and emotional balance
• Woolery A, Myers H, Sternlieb B, Zeltzer LK A
  yoga intervention for young adults with elevated
  symptoms of depression Alternative Therapies in
  Health and Medicine, 2004 10, 60-63.

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IYENGAR YOGA
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KEY POINTS

• All pain is comprised of a complex interplay of
  biological processes, cognitive psychological
  factors, and social-cultural context.
• Rehab goals and treatment should be developed
  with patient and family participation and follow
  logically from a comprehensive biopsychosocial
  assessment

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• Children with chronic pain need to learn
• CONFIDENCE
• 
  FREEDOM
• MASTERY
• 
  ACCOMPLISHMENT
• 
  
  EFFORTLESS EFFORT

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THEEND
PAIN
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REFERENCES

• Zeltzer LK, Schlank CB. Conquering your childs
  chronic pain a pediatricians guide to
  reclaiming a normal childhood (HarperCollins,
  2005)

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REFERENCES

• Clark MR, Treisman GJ. Neurobiology of pain. Adv
  Psychosom Med. 2578-88 2004.
• Mackey SC, Maeda F. Functional imaging and the
  neural systems of chronic pain. Neurosurg Clin N
  Am. 15(3)269-88 2004.
• Bursch B, Ingman K, Vitti L, Hyman P, Zeltzer LK.
  Chronic pain in individuals with previously
  undiagnosed autistic spectrum disorders. J Pain.
  5(5)290-5 2004.
• Pattinson D, Fitzgerald M. The neurobiology of
  infant pain development of excitatory and
  inhibitory neurotransmission in the spinal dorsal
  horn. Reg Anesth Pain Med. 29(1)36-44 2004.

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REFERENCES

• Yung Chung O, Bruehl SP. Complex Regional Pain
  Syndrome. Curr Treat Options Neurol.
  5(6)499-511 2003.
• Zeltzer LK, Bursch B, Walco G Responsiveness
  and chronic pain a psychobiological
  perspective, Journal of Developmental and
  Behavioral Pediatrics, 1997 18, 402-412.
• Bursch B, Walco G, Zeltzer LK Clinical
  assessment and management of chronic pain and
  pain-associated disability syndrome (PADS).
  Journal of Developmental and Behavioral
  Pediatrics, 1998 19 (1), 44-52.
• Chen, E, Zeltzer, LK, Craske, MG, Katz, ER
  Children's memories for painful cancer treatment
  procedures Implications for distress. Child
  Development, 2000 71933-947.

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REFERENCES

• Bursch, B Zeltzer, LK. Autism spectrum
  disorders presenting as chronic pain syndromes
  Case presentations and discussion. The Journal
  of Developmental and Learning Disorders, 2002 6
  41-48.
• Hyman, PE, Bursch, B, Lopez, E, Schwankovsky, L,
  Cocjin, J, Zeltzer, LK. Visceral
  pain-associated disability syndrome A
  descriptive analysis. Journal of Pediatric
  Gastroenterology and Nutrition, 2002 35 (5),
  663-8.
• Bursch, B, Joseph, M. J. Zeltzer, L K.
  Pain-associated disability syndrome. In
  Schechter, N L, Berde, CB, Yaster, M (Eds.)
  Pain in Infants, Children, and Adolescents, 2nd
  Ed. Lippincott, Williams Wilkins, 2002841-848.

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REFERENCES

• Bursch, B. Zeltzer, LK. Pain management in
  children. In Behrman, R.E., Kliegman, R.M.,
  Jenson, H.B. (Eds) Nelson Textbook of
  Pediatrics, 17th Edition, 2003 358-366.
• Raghavan R, Joseph M, Zeltzer LK The
  development of visceral pain. In Hyman PE (Ed.)
  Pediatric Functional Bowel Disorders. Academy
  Professional Information Services New York,
  1999 6.1-6.17.
• .