7/18/2012

Managing Pain in Kids in the School Setting Dustin P. Wallace, PhD Licensed Psychologist Integrative Pain Management Clinic & Developmental/Behavioral Sciences Children’s Mercy Hospitals and Clinics

Assistant Professor of Pediatrics School of Medicine University of Missouri-Kansas City

August 4, 2012

Disclosures • None pertinent to this talk

Learning Objectives • Pain conditions and biopsychosocial contributions to pain and disability • Common medical treatments, recommendations, and school accommodations • Developing IEPs and 504 plans that emphasize functioning – Responding to pain exacerbations with compassion – Encouraging return-to-class and independent pain management

• Discussion of specific case examples, including your examples and questions

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These conditions are a PAIN • • • • • • •

Juvenile Arthritis / rheumatologic (Crohn’s, lupus, etc) Sickle-Cell disorders Abdominal pain (reflux, eosinophilic, etc) Headache (migraine, tension-type, etc) Chest pain Musculoskeletal pain (back, neck, knees, hips, hands) Amplified musculoskeletal pain (a.k.a. pain amplification) – the term “juvenile fibromyalgia” is also used but controversial

• Complex Regional Pain Syndrome

These conditions are REAL • Sometimes it is easy to see reason for pain (e.g. arthritis) • Sometimes it is not (headache, pain amplification) – These kids are experiencing real pain, regardless of whether it can be seen, and what they can do with pain, and what affects the pain

• All pain is worse with stress

These conditions are COMMON • “Benign” chronic pain occurs in about 1 in 4 teens Age-Specific Prevalence Rates of Chronic Pain 60% 50% 40%

Girls Boys

30% 20%

• Physical maturation • Emotion regulation • Identity development • Autonomy • Responsibilities

10% 0% 0

2

4

6

8

10

12

14

16

18

Age in Years

King et al., 2011; Perquin, et al., 2000

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These conditions are COMMON Prevalence of “Severe” Chronic Pain 18% 16% 14% 12% 10% 8% 6% 4% 2% 0%

17%

15%

14%

7% 3% 3%

0-3

7%

4%

2% 2%

4-7

8-11 years

12-14

16-18 Boys Girls

Perquin et al., 2000

Tied together with “biopsychosocial” model • Pain comes from physiological/medical factors as well as psychological, social, behavioral, historical and environmental contributions

Think Bio-Psycho-Socially! • Physiological / Medical – – – –

Inflammation Autoimmune processes Autonomic dysregulation Nerves get “practiced” at sending and receiving pain signals – Muscles guard and may spasm

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Think Bio-Psycho-Socially! • Psychological / Emotional – Stress affects immune system and muscle tension – Anxiety increases autonomic nervous system – Depression leads to less physical and social activity

Think Bio-Psycho-Socially! • Behavioral / Environmental – Loss of friends reduces options for distraction – People do not listen/believe pain, which increases stress and anxiety

Pain is not merely sensory excitation

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Common Treatments • • • • • •

Medications Physical activity or physical therapy Adequate water and nutrition! Distraction (sensory and cognitive) “Biobehavioral” (usually relaxation-based) Going to school!

Medications • • • • • • •

Pain killers (tylenol, opioids, patches/creams) NSAIDs, steroids Muscle relaxers Serotonin-targeting and anxiolytic Anti-seizure and blood pressure meds Anti-migraine meds or cocktails Antacid and antihistamines

Medications • Medication may not be given for primary use: – Patient may have antiseizure or depression medication specifically for pain

• Meds have side-effects – Sedation, hunger, dizziness

• Some meds may need to be taken at school – Due to tid scheduling, or abortive purpose

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Physical Activity • Why does it help? – Stimulates nerves normally – Strengthens and supports joints

• Strategies – – – – –

Moderation! Stretching Physical therapy Yoga Tai Chi

Adequate water; good nutrition • Why does it help? – Promotes healing through normal body processes – May decrease inflammation – Allows medications to work their best

• Strategies – Aim for 64oz water daily – Variety of fresh foods including colorful fruits and veggies – Reduce processed foods and sugar

Distraction - sensory • Why does it help? – Closes pain gate – May promote relaxation and healing – Releases feel-good neurotransmitters

• Strategies – Self-massage – Heat, cold, movement in water – Petting animals – Vibration – TENS

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Distraction - sensory • TENS example

Picture from: http://www.comforttechnologies.com/?digitaltens

Distraction - cognitive • Why does it help? – Helps close pain gate – Adds fun activities – Releases feel-good neurotransmitters

• Strategies – TV, movies, video games, – Non-video games, books – Music, art, activities – Friends

Biobehavioral strategies • Why does it help? – Regulates autonomic nervous system – Decreases overactive pain nerves – Promotes healing

• Strategies – Relaxed breathing – Progressive muscle relaxation – Imagery/self-hypnosis – Biofeedback – Yoga, acupuncture

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School is IMPORTANT • School provides: – – – –

Distraction (cognitive & sensory) Physical activity Social engagement Oh, and education

Pain + school = HARD School Absenteeism for Adolescents with Chronic Pain (School Report) 50% 45% 44.00%

% of Sample

40% 35% 30% 25% 20%

24.60% 20.40%

15% 14.00%

10% 5% 0% Few days missed

1

Missed >25% of school days1

Missed >50% of school days 1

No school for >3 months 2

Logan et al., 2008 Koninjberg et al., 2004

Pain + school = HARD Change in Grades for Adolescents with Chronic Pain Since Onset of Pain 60 50 40

16.6

30 50.3

20

16

10

5.7

0

2.9 2.9

Grades Improved

1 2 3 4

level levels levels levels

5.7

Grades Unchanged

Grades Declined

Logan et al., 2008

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Again, school is IMPORTANT • Full medical homebound contraindicated for most adolescents with chronic pain – May do more harm than good

• Commitment to regular school attendance despite pain is critical to prevent enduring disability – Avoid pattern of withdrawal

• Students retained in one grade are 50% more likely to drop out

Making school WORK • IEP / 504 set out bidirectional expectations – Help kids succeed, spell out accommodations – Support teachers and staff – Hopefully provide clear guidelines for school nurse

Making school WORK • Accommodations may facilitate regular attendance: – – – – – – –

Rest/relaxation breaks in a quiet area (or classroom) Ability to move around, stretch Have water in classroom, take meds at school? Extra time for tests/assignments Modified PE curriculum Assignments and grading limited to essential learning Gradual reentry plan

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Making school WORK • School nurse expectations – What to do if patient comes to nurse’s office • How long can they stay, what do they do there?

– Respond compassionately, while neutral or “matter-of-fact” – Encourage return-to-class when ready or as specified in plan – Allow independent pain management skills

Discussion • • • •

Questions Clarifications Suggestions Case Examples

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