Flashcards in Chapter 57 Chronic Pain Management in Children and Adolescents Deck (41):
assessment of pain in children and adolescents is
a complex clinical endeavor that ideally involves a multidisciplinary
approach specifically tailored to the
biomedical, psychological, and social elements of each patient and family.
the measurement of pediatric pain conventionally falls into three common categories
(1) patient self-report;
(2) healthcare provider or parent observational
(3) physiological parameters
seemed to have greater validity in recording and reporting chronic pain in children.
The FACES Pain Scale-Revised
(FPS-R) and the visual analogue score
The Varni-Thompson Pediatric Pain Questionnaire (PPQ
is a patient self-report instrument that is age specific for a young child (5–7 years), a child (8–12 years), or an adolescent (13–18 years). The PPQ is a valid and reliable tool for measuring pediatric self-reported chronic
pain intensity in children as young as 5 years old.
The Functional Disability Inventory (FDI)
assess illness related
activity limitations in children and adolescents with a variety of chronic medical conditions. The patient self report
FDI consists of 15 items addressing physical and
psychosocial functioning, including common activities, such as playing with friends, during the previous two weeks.
Pediatric Quality of Life Inventory (PedsQL™)
a tool aimed at recognizing clinical
outcomes, including pain intensity, health-related quality of life, impact of the health-related condition on the family, and parents’ satisfaction with the treatment. This has been used successfully for the treatment of childhood
Quantitative sudomotor axon reflex test (QST)
a noninvasive computer-based method to assess transmission of thermal sensation through A-delta fibers and unmyelinated C fibers, as well as vibration sensation transmitted by A-beta fibers
multidisciplinary pain clinics for managing
pain in children
composition includes an anesthesiologist specialized in pain management, child psychologist with a special interest in pain, physical therapist, complementary medicine including massage therapy and acupuncture therapy, as well as biofeedback.
Common chronic pain diagnoses in children include
CRPS type 1, headaches, abdominal pain, chest wall pain, back pain, and Pelvic pain, cancer pain
COMPLEX REGIONAL PAIN SYNDROME (CRPS) type 1, or reflex sympathetic dystrophy
a complex syndrome consisting of pain, allodynia, hyperalgesia, and potential loss of function.
There are three distinct presentations of CRPS based on their time course
(i) an acute phase where the limb may be swollen
(ii) a dystrophic phase where the limb may
have decreased blood supply with potential vasomotor and sudomotor changes including loss of hair and color changes; and
(iii) an atrophic phase where the limb may
atrophy and have loss of muscle mass.
The pain in CRPS
may be sympathetically independent or sympathetically
main focus of the treatment and management of CRPS
to improve function and to get the child back to his or her normal daily activities.
Diagnosis of CRPS
The diagnosis is made by physical examination. The presence of allodynia and hyperalgesia along with other symptoms including weakness and muscle atrophy are similar
to the adult with CRPS type 1
Diagnosis of CRPS
Quantitative sensory testing (QST) is not reliable for the diagnosis of CRPS.
Bone scintigraphy has been used for recognizing and diagnosing CRPS; however, this is not very sensitive and, although performed in several centers, is not a gold
standard for the diagnosis of CRPS. Sympathetic blocks have been used for the diagnosis and management of
CRPS type 1
The management of CRPS
to provide ample physical therapy; Pharmacotherapy is used in addition for pain
relief. Cognitive behavioral therapy is one of the mainstays in the management of CRPS in children. Multiple
psychological interventions have been used for the management of pain including visual guided imagery, hypnosis,
relaxation therapy, and biofeedback therapy
Physical therapy in management of CRPS
Physical therapy is aimed towards adequate functional
ability of the child. Active and passive physical therapy
methods, including the use of magnet and temperature
modulated physical therapy is provided.
used extensively in
children with CRPS as a first modality for providing pain relief following initial injury or diagnosis of CRPS
electric nerve stimulation (TENS)
used initially for the management of pain
Tricyclic antidepressants. A screening ECG is obtained to determine
if there is a prolongation of the QT interval. Amitriptyline may result in sedation but nortriptyline, have less sedative and anticholinergic side effects. It is uncommon to see the use of imipramine or desimipramine in a pain center used solely for the purpose of pain relief
Anticonvulsant drugs for the management of pain
oxcarbazepine have been used extensively for neuropathic pain. the introduction of gabapentin and more recently the introduction of pregabalin have revolutionized
the world of pain medicine
selective serotonin reuptake inhibitors (SSRIs)
no proven efficacy of the use in the management of
pain in children and adolescents, they are used to treat psychological co-morbidities including depression associated
Regional anesthesia in management of CRPS
A central neuraxial block is used especially if the child is in severe pain to facilitate the introduction of physical therapy. An indwelling catheter in the lumbar or cervical
area is used with low concentration local anesthetic solution. Bier block is used for mild to moderate cases of CRPS
as a first modality for the provision of analgesia and a sympathetic blockade. prefer popliteal fossa blocks for the lower extremities and interscalene or infraclavicular brachial plexus blocks for the upper extremities.
utilized in children and adolescents
after exhausting the other techniques in CRPS
Sympathetic blockade.A stellate ganglion block is performed under ultrasound guidance for
upper extremity CRPS and a lumbar sympathetic blockade is performed under fluoroscopic guidance for lower extremity CRPS.
Most headaches in children can be classified into
organic and nonorganic types and can be deemed as acute or chronic based on the duration of the headaches. The classification of headaches is based on the presumed
location of the abnormality, its origin, its pathophysiology or the symptom complex with which the patient presents
should be routinely used
to evaluate headaches in children
A thorough questionnaire. Other specific questions
about neurologic symptoms such as ataxia, lethargy, seizures, or visual impairments are asked. Other important
medical problems such as hypertension, sinusitis,
and other emotional disturbances must be evaluated. A history of a severe headache without a previous history of
headache, pain that awakens a child from sleep, headaches
associated with straining, change in the headache
pattern, or the presence of a headache with associated symptoms such as N/V suggests a more pathological etiology of the headache and must be very carefully evaluated.
information is obtained
at the time of the visit:
l Neurological status including a complete neurological examination.
l Physical status of the patient (i.e., is the patient actively mobile?).
l Does the headache prevent the child from performing his or her normal activities (e.g., interacting with others,
participating in sports)?
l Is there school absenteeism?
l What is the child’s interaction with the parents and siblings at home?
l Are there any relieving factors for the headache?
l Has the child been placed on any medications for pain?
l Has there been any improvement at all in the clinical characteristic of pain?
Managment for persistent
occipital pain have been shown to be effective
A trigeminal nerve block
Tension-type Headaches due to
contraction of the temporalis muscle and the tension on the scalp muscles. Management is the use of relaxation techniques as well as biofeedback. Routine use of nonsteroidal agents
usually helps allay the pain in patients with tension-type headaches
Persistent Neuropathic Headaches
Patients who have had former surgery or have had decompression for Chiari malformation may continue to experience headaches in the postoperative period.
This applies to patients who have ventriculo-peritoneal shunts who have headaches following shunt revisions
Persistent Neuropathic Headaches Management
After cognitive behavioral therapy is utilized, we have attempted to use serial peripheral nerve blocks for these patients. This includes trigeminal nerve blocks for frontal headaches and occipital nerve blocks for occipital headaches. Local anesthetic injection with or without a small dose of steroids is used for providing analgesia.
Abdominal pain diagnosis
Most important, it is imperative that all organic causes are eliminated.
Management of Abdominal pain
Once a diagnosis
of functional abdominal pain is established, cognitive behavioral measures along with family centered therapy
have been shown to be effective. The use of amitriptyline for managing functional abdominal pain has been demonstrated
to be effective in children. The use of ultrasound guided rectus sheath blocks or transversus abdominis plane
(TAP) blocks performed serially has decreased abdominal pain. By blocking the thoracolumbar nerve roots, we are able to provide complete analgesia of the anterior abdominal wall.
occurs following hernia repair. A TENS unit may be helpful for managing
pain, but in most instances the use of peripheral nerve blocks have been demonstrated to be effective. Ultrasound guided ilioinguinal nerve blocks are effective for managing pain
CHEST PAIN that is a common symptom especially in older children and adolescents
tightness of the chest with pain that is usually lateral to the sternum
Management of Chest Pain
After cardiac causes are ruled out with an
ECG and a careful physical examination, other causes for
chest pain should be considered
Differential Diagnosis of Chest Pain
Other causes of chest pain, including, but not limited to, drug toxicity,
functional anxiety, gastrointestinal illness, asthma, and musculoskeletal
problems, should be ruled out. Costochondritis
Trauma, muscle overuse
Precordial catch or Texidor’s twitch
Tietze’s syndrome (after minor trauma)
Slipping rib-cage syndrome
Xiphoid cartilage syndrome
Management of Chest Pain
The management of all chest wall pain is usually with reassurance and NSAIDs. In addition, with severe, recurring
chest wall pain, place intercostal nerve blocks under ultrasound guidance with very good
relief. Serial blocks are performed with adequate resources available for biofeedback and massage therapy to allay the
anxiety associated with recurrent chest wall pain.
Cancer pain in children is due to several reasons:
pain (e.g., solid tumor or bony metastatic tumors);
(ii) pain caused by treatment (e.g., mucositis pain and surgical pain); and (iii) neuropathic pain either secondary to surgery or caused by tumor invasion
Management of Cancer Pain
Management of pain must be individualized, and attempt to accommodate
the family needs in the entire process. Patient controlled analgesia is used extensively with good results.
side effects of opioid administration including
itching and pruritus, and somnolence. There is also a distinct
possibility of developing opioid tolerance, and this
needs to be addressed effectively.