Pain! Why & What To Do About It
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This document discusses pain in children and adolescents, including musculoskeletal pain, fibromyalgia, and central pain processing disorders. It notes that 25% of new patients seen by pediatric rheumatologists have childhood pain syndromes, with average age of onset being 12 years old. Musculoskeletal pain affects 6% of pediatric primary care visits. The document defines different types of pain including nociceptive, neuropathic, and central pain processing. It discusses how conditions like fibromyalgia, chronic fatigue syndrome, and irritable bowel syndrome may involve central pain processing and sensitization. Treatment options discussed include validation, education, exercise, cognitive behavioral therapy, and various pharmacologic approaches.
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Pain! Why & What To Do About It
- 1. PAINWhy, and What To Do About It…Kenneth N. Schikler, MD, Department of Pediatrics, Division of Pediatric RheumatologyUniversity of Louisville School of Medicine
- 2. Childhood Pain Syndromes25% of all new patients seen by pediatric rheumatologists75% femaleAverage age of onset 12 yearsPediatric Rheumatology Database Group J Rheum 23(11)1968-74, 1996
- 3. Musculoskeletal PainPopulation based survey of >6600 children and adolescents in Netherlands82% response rate25% reported chronic painOf that group 57% consulted MDRef: Perquin,et al. Clin J Pain,2000
- 4. Musculoskeletal Pain (MSP)6% of visits to a pediatric primary clinic of children>3 y/o was for MSP¹Low back pain 1 month prevalence in UK among 1496 students 11-14 years old was 24% (pain for >1 day), 94 % reported disability via a disability questionairre²¹ De Inocencio. Pediatrics, 1998² Watson. Arch Dis Child, 2003
- 5. PAIN is no fun, but…
- 6. Pain isAn unpleasant sensory and/or emotional experience associated with actual or potential tissue damage It is a protective early warning system to alert us to adjust what we are doing in order to assess whether harm or damage might occur
- 8. PainPhysical recognition of unpleasant stimulus, and…The Cerebral/emotional recognition and response to the unpleasant stimulus
- 10. Dealing with the cerebral/emotional
- 11. Dealing with the Cerebral/Emotional Side of PainUntil one is sure that they are safe from harm or damage from an unpleasant stimulus (pain), fear and anxiety complicate and heighten the unpleasant reaction, until someone we trust to have our welfare in mind and is knowledgeable and can reassure us that we are safe, the painful experience and response to it continues at maximal levels
- 12. Dealing with the Cerebral Component of PainThe highly motivated individual even when “unaware” of an unpleasant stimulus may “ignore” it until the motivation diminishesExamples: athletes, First Responders, military personnel in action or friends or family members in emergenciesOften function without conscious recognition of pain until their “need to function” passes
- 14. Pain : typesNociceptiveNeuropathicCentral Pain Processing (Central Sensitization)
- 17. Nociceptive PainWhen nerve endings are stimulated to the point approaching a harmful levelThermal: temperature extremesMechanical: crushing, tearing, piercing of non-nerve tissueChemical: salt in a wound
- 19. Neuropathic PainInsult to portions of a nerve typically with a tingling, burning, “pins and needles” sensation, or a “shooting pain”Obstructive blood flow to a nerve from pressure (hand falling asleep or dysautonomia)Direct trauma (bumping funny bone)Diseases that affect the nerve
- 21. Central Pain ProcessingHeightened sensitivity of the areas within the brain that alert us to potential damage at intensity levels that typically would not provoke those pain centers to “activate”When activated in addition to arousing recognition of pain, the physiologic responses to pain are triggered, altering the Autonomic Nervous System’s behavior
- 23. Inflammatory Arthritis & PainIL-1IL-6TNF-MMP’s
- 24. JIA, Cytokines & PainCytokines in the joint have a direct effect on nerve endings, and also on the joint lining and cartilage causing inflammation and swelling. This puts mechanical pressure on nerve endings in addition to the direct chemical nerve stimulation and promotes other pain inducing substancesWithin the central nervous system these cytokines and other chemicals make the pain centers more “alert” to pain
- 26. Pain & Inflammatory Arthritis: TreatmentNSAID’sAcetaminophenDMARD’sBiologicsModerate exerciseTreatment aimed at minimizing the bradykinin, Substance P, prostaglandins, MMP’s, and pro-inflammatory cytokines
- 31. Chronic MSK/Central Pain Processing & Related DisordersFibromyalgiaChronic FatigueMigraineIrritable Bowel SyndromeTMJ disordersMood DisordersComplex Regional Pain Syndrome (RSD)Chronic Pelvic PainPremenstrual SyndromeMyosfascial Pain syndromesMultiple Chemical SensitivitiesChronic cystitisDysautonomia/ POTS
- 32. History of widespread pain has been present for at least 3 monthsDefinition: Pain is considered widespread when all of the following are present: Pain in both sides of the body
- 33. Pain above and below the waistIn addition, axial skeletal pain (cervical spine, anterior chest, thoracic spine, or low back pain) must be present. Low back pain is considered lower segment pain.Pain in 11 of 18 tender point sites on digital palpationDefinition: Pain, on digital palpation, must be present in at least 11 of the following 18 tender point sitesDigital palpation should be performed with an approximate force of 4 kg. A tender point has to be painful at palpation, not just "tender."The American College of Rheumatology 1990 Criteria for the Classification of FM[13,25]
- 34. Juvenile Fibromyalgia (JFS)Widespread MSP for at least 3 months≥ 5 well-defined tender points3 of 10 minor criteria≤age 16 at onsetIf 5 minor criteria present only 4 tender points neededRef: Yunis & Masi. Arthritis Rheum;28(2):138,1985
- 35. Juvenile Fibromyalgia: Minor CriteriaFatigueSleep problemsAnxiety/ tensionSubjective swellingNumbness/tinglingLightheadedness/ dizzinessChronic headacheIrritable Bowel syndromePain modulated by stressPain modulated by weatherPain modulated by physical activity
- 36. Juvenile Fibromyalgia1756 school-aged (pre-adolescent) Finnish children prospectively studied by questionnaire then PE; 1.3% prevalence338 healthy Israeli 9-15 y/o students studied; 6.2% prevalence1.3% healthy Mexican 9-15 y/o students1 in 6 people with fibromyalgia are less than 18 years old
- 37. New ACR Criteria for Fibromyalgia (preliminary)Remove tender points from criteria as the central elementQuantitate widespread pain with widespread pain index (WPI)Incorporate key symptomsProvide symptom severity scale (SS)Ref: Arthritis Care Res;62(5):600-10,2010
- 38. Fibromyalgia & rCBFFibromyalgia patients and controls detect sensory stimuli at the same levels (electric, thermal, mechanical)Level at which stimuli become noxious is ~twice as high for controlsSimilar stimuli produce significant differences in regional Cerebral Brain Flow; >2x’s in pts vs controls, particularly in the Anterior Cingulate Cortex
- 39. FMS : rCBF
- 40. Central Pain Processing Disorders & CatastrophizingResponses that characterize pain as being “awful” “horrible”, “unbearable”Found to be independent of DepressionMay influence intentional focus on painful or potentially painful eventsIncreases pain-related fear leading to increased attention to stimuli and amplifying perception of painrCBF similar to that found in Fibromyalgia
- 42. Mood Stress & The Brain
- 44. Fibromyalgia & Other Central Pain Syndromes:TreatmentValidationEducationPharmacologicAerobic Exercise Cognitive Behavior TherapyAlternative Therapies
- 45. Validation & EducationAcknowledge the presence of discomforting symptoms of these conditions (not diseases)Provide an explanation for our understanding of how these mechanisms occurPrevent “sick mode” identification
- 46. Sleep HygieneBed is for sleep onlyNo napsRegular bedtimeNo vigorous exercise within 2 hrs of bedtimeNo more than 30 minutes of sleeplessness in bedRelaxation, self-guided imagery techniques
- 47. Cognitive Behavioral TherapyModules of pain management, psycho-education, sleep hygiene & ADL’sInstruction in cognitive restructuring, distraction, relaxation and self-rewardMinimize catastrophizing style of copingFocus on regaining function via developing self-management skills
- 48. Exercise (I)Aerobic nearly universally beneficial; tolerance, compliance, adherence are biggest issuesTo maximize benefits:Both physician and patient should consider this as a “drug”Assure physiologic capability ( eg exclude EIA)Review/instruct in how to measure heart rate/pulseReview availability of access to aerobic exercise equipment in home
- 49. Pharmacologic Treatment of Central PainAntidepressantsMixed norepinephrine/serotonin reuptake inhibitorsAnticonvulsantsAlpha-2-delta (α2δ) ligandsOpioid receptor antagonistsFutureCentral alpha-2-adrenergic agonistDopamine receptor agonistsNMDA receptor antagonistsNK-1 receptor antagonistGABA receptor agonistsVitamin D (??)