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Pediatric Chronic Pain

January 1, 2023January 2, 2023
by Tyler Ambrose

Children 0-17 years old are a vulnerable demographic that need specific care in pain management since they rely on adults for assessment, prevention, and therapy. It is not uncommon for newborns, children, and teenagers to feel pain, both acute and chronic. Statistics gathered from pediatric hospitals show that children’s pain is widespread, frequently misdiagnosed, and inadequately addressed.

According to a recent comprehensive analysis, neonates in intensive care units endure between 7 and 17 painful operations each day, with venipuncture, heel lancing, and peripheral venous catheter placement being the most common.

Most infants do not make use of any analgesic methods. Children with life-threatening illnesses can endure numerous painful diagnostic and painful treatments (e.g., bone marrow aspirations, lumbar punctures).

More so, even perfectly healthy kids have to endure a number of unpleasant medical procedures. Vaccinations are the most prevalent type of needle operation for children, and vaccine reluctance due to pain is a common problem.

Morbidity (e.g., intraventricular hemorrhage) and mortality are both enhanced when severe pain is endured without proper pain management. Premature infants that experience pain have been shown to have impaired cognitive and motor abilities, as well as increased pain self-ratings after venipuncture as they get older.

Studies have indicated that childhood trauma can raise a person’s likelihood of experiencing mental health issues later in life (chronic pain, anxiety and depressive disorders). An effective pain management plan is essential for infants and children.

Prevention and Treatment of Pediatric Needle-related Pain

In the long run, untreated needle discomfort from operations including vaccines, blood draws, injections, venous cannulation, etc. can lead to needle phobia, pre-procedural anxiety, hyperalgesia, and healthcare avoidance, all of which raise the risk of morbidity and mortality.

Four bundled modalities to reduce or eliminate pain experienced by children during elective needle procedures are strongly suggested based on current evidence, supported by guidelines from the Canadian Pediatric Society and HELPinKids, and recently brought forward by science-to-social media campaigns.

Healthcare providers and parents should generally speak in neutral terms and avoid phrases that may be perceived as deceptively soothing but instead serve to heighten anxiety (such as “it will be over soon” or “you will be ok”).

Cognitive behavioral therapy, breathing techniques, distraction, and hypnosis were all found to be useful in lowering children’s pain and/or fear of needles in a recent Cochrane review. Many clinics and hospitals for kids across the globe now use a standardized protocol of four easy steps for all needle procedures involving children.

Needlestick Pain: Prevention and Treatment

Provide a package of four approaches that have been shown to be effective for kids:

First, “Numb the skin” with topical anesthetics (for children 36 weeks corrected gestational age and older). 4% lidocaine cream, EMLA-cream, and the J-tip® (a sterile, single-use, disposable injector that uses pressured gas to drive drug into the skin) are all examples of topical anesthetics.

Infants aged 0-12 months can benefit from either sucrose or breast milk.

Relaxed holding, “Do not put down youngsters.” For any surgery involving a child, restraint is never helpful, always has a bad outcome, and exacerbates discomfort and fear. Swaddling, heat, skin-to-skin contact, and assisted tucking are all good options for babies.

Children aged 6 months and up should be encouraged to sit up straight, with their parents either holding them or sitting nearby.

Distractions suited to the age group such as toys, novels, bubbles, pinwheels, stress balls, applications, films, or games on electronic devices.

Treatment of Severe Pediatric Pain

Tissue injury from disease, trauma, surgery, treatments, and/or disease-directed therapy can all contribute to nociception, or nociceptive pain. If acute pain isn’t addressed, it can cause dread of doctors and even prevent people from seeking care.

The standard method for treating complex acute pain nowadays is multimodal analgesia. Acute pain in children may require more than just pharmacology (including basic analgesia, opioids, and adjuvant analgesia). For more effective (opioid-sparing) pediatric pain control with fewer side effects than single analgesic or modality, the addition, and integration of modalities such as regional anesthesia, rehabilitation, effective psychosocial interventions, psychology, and spirituality is recommended.

Acute Pain: Prevention and Management Using a variety of Pain Relief Techniques

When compared to the use of a single analgesic or modality, the synergistic benefits of multimodal analgesia result in more effective pediatric pain control with fewer adverse effects There are a variety of medications that may be prescribed (based on the specifics of each case):

Analgesics at the most fundamental level (paracetamol/acetaminophen, NSAIDs, COX-2 inhibitors, etc.)
Opioids (e.g. tramadol, morphine, methadone)
Additional pain relievers (e.g. gabapentin, clonidine, amitriptyline)
Intrathecal port/pump, neurolytic block, peripheral/plexus nerve block, and other forms of regional anesthesia
Recuperation, Third (e.g. physical therapy, graded motor imagery [32], occupational therapy) (4) Psychology (e.g. cognitive behavioral treatment) (e.g. cognitive behavioral therapy)
Integrative (“non-pharmacological”) methods (including mind-body techniques like diaphragmatic breathing, bubble blowing, self-hypnosis, progressive muscle relaxation, biofeedback, plus massage, aromatherapy, acupressure, and acupuncture) (5) Spirituality (e.g. chaplain)

Methods for Treating Chronic Pediatric Pain

There is a considerable problem with pediatric chronic pain, with conservative estimates indicating that 20% to 35% of children and adolescents are affected by it worldwide. More than 10% of hospitalized children display signs of chronic pain, and yet this pain is often misdiagnosed and untreated.

About 3% of pediatric chronic pain patients require rigorous rehabilitation, while the majority of children who report chronic pain are not significantly impaired by it.

According to the American Pain Society’s 2012 Position Statement on the Assessment and Management of Children with Chronic Pain, chronic pain in children is the result of a dynamic integration of biological processes, psychological factors, and sociocultural variables within a developmental trajectory.

However, a more functional definition is used to characterize chronic pain in children, such as “pain that extends beyond the expected period of healing” and “hence lacks the acute warning function of physiological nociception”. This is in contrast to the way chronic pain is typically defined in adult medicine, where arbitrary temporal parameters (such as 3 months) are used.

There appears to be success with an interdisciplinary strategy that includes

rehabilitation;
integrative medicine/active mind-body approaches;
psychology; and
regularizing daily school attendance, sports participation, social activities, and sleep.

Pain relief and even complete disappearance are normal outcomes of functional rehabilitation. Main pain syndromes, such as centrally mediated abdominal pain syndrome, primary headaches (tension headaches/migraines), or extensive musculoskeletal pain, are not appropriate for opioids, and other drugs are rarely used as initial treatment.

A recent Cochrane review found that in-person psychosocial interventions for children and adolescents with headache and other chronic pain may be useful in improving pain outcomes.

Both immediately following therapy and at follow-up, psychological interventions have been shown to be beneficial in lowering pain-related impairment in children and adolescents with a variety of chronic pain problems.

Cognitive-Behavioral Therapy and Acceptance and Commitment Therapy are the two main types of psychological treatments studied extensively.

Incorporating parents into the multidisciplinary treatment is recommended because of growing evidence that it is crucial to address parents’ catastrophizing thoughts, parents’ anguish, and parents’ behaviors in relation to their children’s pain (e.g., protective behaviors).

Chronic Pain and Main Pain Disorders: Boxed Treatment

(1) Modalities of rehabilitation (such as physical therapy, graded motor imagery, and occupational therapy)

(2) Modalities of integration (or “non-pharmacological” approaches) (e.g., mind-body techniques such as diaphragmatic breathing, bubble blowing, self-hypnosis, progressive muscle relaxation, biofeedback plus modalities such as massage, aromatherapy, acupressure, acupuncture)

(3) Science of Mind (e.g., cognitive behavioral therapy, acceptance, and commitment therapy)

(4) Getting Back to Normal (usually, life gets back to normal first, then the pain goes down – not the other way around). It may include activities like;

Exercise and sports
Sleep-hygiene
Life in Society
Going to Class

(5) Medications (may or may not be required) (may or may not be required)

First-line pain relievers (such as acetaminophen/paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), and COX-2 inhibitors)

Additional pain relievers (e.g., gabapentin, clonidine, amitriptyline)

Importantly, opiates are typically NOT needed in the absence of new tissue injuries, such as in epidermolysis bullosa or osteogenesis imperfecta.

Finally

For more information on chronic pain management, pain disorders, chronic pain resources, psychogenic pain, effective chronic pain treatment options or other physical therapy, you should book a consultation session with a specialist at Chronic Therapy today, to give you professional advice that will suit your personal experience.

Also, for people with chronic pain who are constantly worried on how to treat chronic pain or get their chronic pain treated, our specialist at Chronic Therapy have made huge success over the year in recommending reliable resources to manage chronic pain from nerve pain or any other developing chronic pain conditions.

Chronic Pain

Using Antidepressants for Treating Chronic Pain

December 22, 2022January 2, 2023
by Tyler Ambrose

You might be startled if your doctor prescribes an antidepressant for persistent pain. Is it because she thinks you’re depressed? Can antidepressants help with pain in persons who don’t have any indications of depression?

Let’s have a look at what the literature says regarding the role of various antidepressant classes in the treatment of chronic pain.

Depression and Chronic Pain: The Connection

People suffering from chronic pain symptoms and conditions such as rheumatoid arthritis, lupus, fibromyalgia, and neuropathic pain are prone to depression. Chronic physical issues are associated with an increased lifetime risk of severe depression. In other words, pain and depression are frequently co-occurring conditions (go hand in hand.)

On the other hand, a considerable number of patients who have been diagnosed with depression also have chronic pain. Depression and chronic pain are linked in both directions.

Having said that, it is not uncommon for people suffer chronic pain to be prescribed antidepressants even if they do not exhibit any indications of depression.

Antidepressants for Chronic Pain in the Absence of Co-Existing Depression

While antidepressants are most commonly used to improve the mood of clinically depressed individuals by changing neurotransmitters in the brain, they can also be used as a primary treatment for chronic pain, anxiety disorders, or sleep difficulties.

When used to treat chronic pain, they are most commonly utilized as adjuvant analgesics. This means that they are administered in conjunction with other pain drugs rather than being used as a standalone pain treatment.

Using Antidepressants for Treating Chronic Pain

The precise method by which antidepressants function to manage pain is uncertain, but it appears that the processes by which they treat chronic pain are unrelated to the mechanisms by which they reduce depression.

Antidepressants are known to have an influence on the neurotransmitter’s serotonin and norepinephrine, particularly along descending spinal pain pathways. Antidepressants can also affect histamine receptors and sodium channels.

Antidepressant Classifications for Chronic Pain

There are various antidepressant classes that have been explored for persons with chronic pain, and the way one antidepressant class works may differ from another. Among the drugs that have been examined are:

Antidepressants tricyclic
Inhibitors of serotonin and norepinephrine reuptake (SNRIs)
Inhibitors of selective serotonin reuptake (SSRIs)
Reuptake inhibitors and receptor blockers in combination
Dopamine and norepinephrine reuptake inhibitors (NDRIs)
Inhibitors of monoamine oxidase (MAO inhibitors)

Antidepressant Clinical Trials for Chronic Pain

Antidepressants, particularly amitriptyline, have been shown in studies to be beneficial in the treatment of chronic pain in adults.

Unfortunately, there is very little information available on the use of antidepressants in children and adolescents for non-cancer-related pain.

Off-Label Use vs. Drugs Approved to Treat Chronic Pain

When discussing the use of antidepressants for chronic pain, it is critical to distinguish between medicines that are approved for this purpose and those that are taken off-label. When the FDA approves a medicine for a certain application, it implies that the FDA analyzed the studies and determined that the drug may be effective and generally safe for that use.

Off-label use, on the other hand, refers to medications that are FDA approved for one ailment (in this case, depression) but may be used for another (for example, chronic pain).

The use of antidepressants comes with some risks. According to the FDA, adults, particularly youngsters, should be monitored for increased depression or suicidal thoughts or behavior during the first few months of treatment or after a change in medication dosage.

People should contact their healthcare provider right away if their depression symptoms worsen or if suicidal thoughts or conduct escalate. It’s also critical for people who take antidepressants to understand the risk factors and warning symptoms of suicide.

Not the First Choice for Managing Chronic Pain

An antidepressant prescription is not normally the first treatment indicated for persons who have chronic low back or neck pain or hip or knee osteoarthritis.

Physical therapy, exercise, weight loss, nonsteroidal anti-inflammatory medications (NSAIDs), or cortisone injections are typically tried initially. If these don’t work, antidepressants like duloxetine or amitriptyline may be a good next step.

When used to treat pain, the initial dose is usually low (often lower than the starting dose for depression). If necessary, it is progressively raised. People should notice a benefit within a few weeks after starting the medicine, and the medication should be continued at the lowest effective dose.

If pain is not effectively controlled, adverse effects arise, or there is a combination with another medication, switching to a different antidepressant may be recommended.

Summary

Antidepressants can benefit patients suffering from chronic pain in a variety of ways. Many persons who have fibromyalgia or other chronic pain problems also have depression. However, some antidepressants may provide relief from persistent pain via several processes.

Tricyclic antidepressants, particularly amitriptyline, have received the most extensive research of any antidepressant class, particularly for the treatment of neuropathic pain.

Coping with chronic pain is challenging and has an impact on all aspects of your life. A combination of drugs (for example, adding an antidepressant) may be most useful, although non-medication therapy and stress management are also crucial.

Finally

Chronic Pain

How Social Security Assesses Chronic Pain for Disability Claims

December 22, 2022January 2, 2023
by Tyler Ambrose

Chronic pain is defined as persistent or recurring pain that lasts longer than expected; that is, longer than the average length of an injury, or more than three to six months.

Chronic pain can manifest itself in any place, causing back pain, headaches, joint pain, or generalized muscle or nerve discomfort. It could be the result of an injury or sickness, or it could have no known cause.

If you have been experiencing pain for more than six months, you may be diagnosed with a pain disorder such as chronic pain syndrome, reflex sympathetic dystrophy, and somatoform pain disorder (RSD).

Or you could be diagnosed with a condition known to produce chronic, difficult-to-treat pain, such as peripheral neuropathy, fibromyalgia, arthritis, or ilioinguinal neuralgia.

Is Chronic Pain Linked to Disability?

Chronic pain might render you disabled, preventing you from engaging in strenuous exercise. Your medical records must prove that you have a serious “medically determinable” impairment (MDI) that causes your chronic pain for the Australian Social Security to pronounce you disabled. This means that your records must contain medical documentation proving your loss of function.

In other words, your impairment must be proved just on the basis of symptoms to be termed a disability. Simply informing the Australian Social Security that you suffer incapacitating chronic pain is insufficient.

Pain, even severe chronic pain that is disabling, will not qualify you for disability payments unless your medical record contains lab testing, x-rays, and/or physical exam results. The claims examiner or disability judge will be searching for proof that you have a physical impairment that is likely to cause your symptoms.

How Social Security Assesses Chronic Pain for Disability Claims

For example, if a doctor analyzes you and discovers that you have broad pain and 11 out of 18 probable tender point sites, you are diagnosed with fibromyalgia. Because everyone feels pain differently, your objective medical findings do not need to support the level of your discomfort, simply that there is a physical disability that is likely to cause pain.

A correctly diagnosed psychological source of pain, such as a somatoform pain condition, can meet Social Security’s requirements for a medically determinable impairment. The most crucial thing is to obtain a diagnosis from a skilled medical practitioner, such as a doctor or a psychiatrist.

What Technical Requirements Are There for Disability Benefits?

You must demonstrate that your impairment has persisted (or is expected to last) for 12 months or more. With chronic pain, it’s beneficial to have not just one, but multiple diagnoses based on examinations by one or more specialists throughout a year.

If you have long-term, chronic pain caused by an MDI, Social Security will determine if your impairment qualifies you for SSDI or SSI disability benefits. There are two methods to qualify for benefits: through a disability “listing” and by demonstrating that your loss of function is so severe that you are unable to work full-time.

How Do You Get Benefits Through a Disability Listing?

Chronic pain is not listed in Social Security’s Blue Book, which is a list of ailments that may automatically qualify you for disability benefits.

You may be eligible if your persistent pain is caused by another diagnosed impairment. Chronic pain can be caused by, for example, back injuries chronic renal illness, or inflammatory bowel disease (IBD).

However, most chronic pain patients do not fulfill a Blue Book classification and must try to qualify for benefits through a “residual functional capacity,” or “RFC,” examination.

How Does an RFC Assessment Help You Qualify for Benefits?

A disability claims examiner from Disability Determination Services (DDS) will evaluate your physical and mental limits during an RFC examination. Your RFC is a paragraph that describes your peak physical and mental talents. Your RFC may specify time limits for sitting, standing, and walking, as well as weight limits for lifting and carrying. The claims examiner will then use your RFC to decide if your impairment prevents you from working full-time. (For additional details, visit our section on how Social Security determines disability based on your RFC.)

Unfortunately, claims examiners do not often take extreme pain claims seriously when creating your RFC. One reason for this is because pain statements from disability applicants are subjective and difficult to substantiate. Another factor is that doctors who actually treat disability applicants (the “treating physicians”) frequently fail to include your pain levels in their treatment notes and describe how your pain affects your ability to engage in everyday activities.

However, federal court decisions have maintained that disability examiners must consider the intensity, persistence, and limiting consequences of your pain symptoms on your ability to do basic employment tasks. They must take the following variables into account:

the location, duration, frequency, and intensity of your pain
how pain affects your daily activities
the factors that trigger your pain and make it worse
the type, dosage, effectiveness, and side effects of medication that you take for pain
other treatments you’ve used to relieve symptoms, such as acupuncture or physical therapy, and
other ways you relieve pain, such as lying down or applying ice.

In order for the following characteristics to appear in your medical record, your doctor should add information about them in their treatment notes. Your doctors’ opinions on the functional limits imposed by your pain and how long your chronic pain is projected to impair your capacity to function should be included.

Informing Australian Social Security How Your Pain Impairs Your Work Ability

Social Security will ask you to complete a disability report as part of your application. You can describe how your chronic pain physically limits you in the remarks area of this form. However, this can be difficult.

For example, you might be able to stand or walk for an hour without stopping if you grit your teeth against the discomfort. Or maybe a long stroll feels good at the time, but you pay for it later with achy muscles or tiredness. How would you put this in terms of Social Security?

When filling out your information, be honest about how your pain would impede your ability to work full-time.

If you can only stand or walk for two hours a day while ignoring severe discomfort, you probably won’t be able to stand or walk for two hours every day to accomplish your job. You might not want to suggest you can stand or walk for two hours in that situation.

Don’t forget to keep track of everything you do to relieve your pain during the day. Do you have to put your feet up on a regular basis? Do you need to sleep or lie down every day? Is it critical that you can stand up and stretch your legs whenever you want? Is it necessary to use heat or cold packs throughout the day?

You must list these physical limitations in your application because they impede your ability to work several full-time jobs. Remember, if you don’t write it down (and your doctor doesn’t either), Social Security won’t know all the ways your pain limits you.

How Chronic Pain’s Mental Effects Can Limit You

Don’t overlook the mental and emotional consequences of chronic pain. In order to prove impairment through the RFC exam, you may need to include information about how your pain impairs your mental capacity.

Even if Social Security determines that the physical effects of your suffering confine you to sedentary labor, there will still be plenty of jobs available to you, unless you can demonstrate that you lack the mental capacity for sedentary work.

Chronic pain frequently causes difficulty with concentration and memory. When you are distracted by discomfort, it might be difficult to acquire and retain new knowledge. Chronic pain might also make you irritated and impatient, making it difficult to get along with coworkers and superiors.

Because chronic pain can be difficult to live with, you should also examine the emotional implications of your suffering. Chronic pain can lead to sadness and anxiety. Furthermore, psychological stress may exacerbate discomfort.

Follow up with your medical doctors if they have ever indicated that you seek counseling or a psychological examination. Include any mental illness diagnosis or treatments in your disability application.