Interdisciplinary Pain Rehabilitation for Children and Adolescents

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Interdisciplinary Pain Rehabilitation for
Children and Adolescents
Gerard Banez, PhD, Douglas Henry, MD, and Ryan
Suder, M.S., OTR/L

• Wednesday, October 9, 2013
• RCPA Conference
• Seven Springs, PA

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Pediatric Interdisciplinary Pain Rehabilitation

• Overview of Pediatric Chronic Pain Conditions
• Rehabilitation Model Cleveland Clinic Pediatric
  Pain Rehabilitation Program
• Behavioral Health Services
• Therapeutic Services for Chronic Pain
• Medical Management
• Q A and Discussion

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Overview of Pediatric Chronic Pain Conditions

• Doug Henry, MD
• Cleveland Clinic Childrens

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Mechanistic Categorization of Pain
Primary Cause Therapeutic Response Psychologicalfactors Examples
Peripheral (nociceptive) Inflammation or mechanical damage in periphery Responds to NSAIDs and opioids Minor Osteoarthritis Soft tissue injury Cancer
Neuropathic Damage or entrapment of peripheral nerves Responds to both peripheral and central pharmacologic therapy Minor Postherpetic neuralgia Nerve trauma
Central (non-nociceptive) Central disturbance in pain processing TCAs, SNRIs, other centrally acting meds Prominent Fibromyalgia IBS Idiopathic low back pain
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Clinical entities currently considered parts of
the spectrum of central sensitivity
syndromes(Ablin Clauw 2009)

• Fibromyalgia
• Chronic fatigue syndrome
• Irritable bowel syndrome and other functional
  gastrointestinal disorders
• Temporomandibular joint disorder
• Restless leg syndrome and periodic limb movements
  in sleep
• Idiopathic low back pain
• Multiple chemical sensitivity
• Primary dysmenorrhea
• Headache (tension greater than migraine, mixed)
• Migraine
• Interstitial cystitis/chronic prostatitis/painful
  bladder syndrome
• Chronic pelvic pain and endometriosis
• Myofascial pain syndrome/regional soft tissue
  pain syndrome

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Complex regional pain syndrome (CRPS) aka Reflex
sympathetic dystrophy (RSD)

• Presence of an initiating noxious event, or a
  cause of immobilization
• Continuing pain, allodynia or hyperalgesia which
  is disproportionate to any inciting event
• Evidence at some time of edema, changes in skin
  blood flow or abnormal sudomotor activity in the
  region of the pain
• This diagnosis is excluded by the existence of
  conditions that would otherwise account for the
  degree of pain and dysfunction

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Pain-Associated Disability Syndrome (PADS)

• Describes chronic pain pts with severe problems
  in functioning for gt three months, regardless of
  location or etiology of pain
• Pain often results from an illness, life event,
  or psychosocial stress that taxes the vulnerable
  child/adolescent
• Pain and symptoms lead to activity restriction
  that is rewarding (eg stress reduction) and
  further debilitating
• Sick role behavior develops
• Secondary effects of pain and decreased activity
  contribute to increasing functional disability

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Pain-Associated Disability SyndromeAdditional
Features

• Multiple associated symptoms, including multiple
  sensory sensitivies
• Stop going to school
• Stop recreational and social activities
• Afraid to do physical activities
• Inconsistent and nonphysiologic motor and sensory
  abnormalities
• Parental enmeshment

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Treatment

• Once you get to the PADS state, medications and
  procedures are unlikely to benefit
• A focus on controlling pain and distress is
  useful when it can be achieved, but problematic
  when it is not successful
• Need an intensive biopsychosocial
  multidisciplinary approach to address the
  multiple contributing factors and variety of
  symptoms.
• Need to identify and interrupt the downward
  spiral of decreased functioning, inactivate the
  fear that improvement is impossible, and reduce
  the vulnerability to somatic and behavioral
  symptoms
• Need to get patient and family to focus on
  functional improvement rather than pain
  resolution and more diagnostic studies.

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Rehabilitation Model

• An understandable and useful alternative to the
  acute pain model of care
• Pain is accepted as a symptom that may or may not
  be eradicated
• Focus is on independent functioning, improved
  coping, and increased self-efficacy
• Increased functioning, enhanced coping, and
  improved self-efficacy are seen as signs of
  progress

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Cleveland Clinic Pediatric Pain Rehabilitation
Program

• Serves children and adolescents with chronic pain
  and related functional disability

• Goals
• To help patients cope better
• To restore normal activity

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Variety of Pain Conditions Treated

• Complex regional pain syndrome (CRPS)
• Headache
• Abdominal Pain
• Fibromyalgia

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Combined Inpatient/Day Hospital Care

• Wks 1-2 Inpatient Treatment
• Controlled environment (eg, activity, sleep,
  diet)
• Shared treatment philosophy
• Interrupt unhelpful parent-child interactions and
  promote healthy behaviors
• Wk 3 Day Hospital
• Patients participate as outpatients but stay with
  parents at night
• Assist with transition to home

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Program Philosophy

• To treat, clinicians must identify and interrupt
  the cycle of decreased functioning, inactivate
  the fear that improvement is impossible, and
  reduce the vulnerability to somatic and
  behavioral symptoms
• A biopsychosocial rehabilitation treatment plan
  that addresses the multiple specific contributors
  is needed

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Treatment Plan

• Individualized but coordinated care
• Blending of pediatric subspecialty care,
  behavioral health, and rehabilitation therapies
• Structured like school days
• Medical/nursing visits
• Psychosocial care
• PT, OT, RT
• School program
• Communication with referral sources is central

Pain Rehabilitation l December 7, 2013 l 18
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Adolescent Pain Severity and BAPQ Composite
Scores at Admission and 1-year Follow-Up
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Pain Ratings and School Work Days
Missed School Days Work Days
Hospitalization Pain Ratings Missed/Wk Missed/Wk
Days/Mo (0-to-10) Admission 3.32 2
.51 2.47 6.76 Two Years Post-Discharge 0.
22 0.16 0.13 3.79 Three
Years Post-Discharge 0.32 0.00 0.31 3.0
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Behavioral Health

• Individual/Family Therapy (3-4x/week)
• Mind-Body Skills Group (3x/wk)
• Cognitive-Behavioral Approaches
• CAM Strategies
• Individualized Functional Plans (IFPs)

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Parent/Family Education

• Individual/Group Parent Education
• Education about physical and psychological
  aspects of childs pain and its treatment
• Importance of encouraging normal activity and
  discouraging pain behaviors
• Assistance on transition to home and regression
  prevention
• Participation in Rehabilitation Therapies

Pain Rehabilitation l December 7, 2013 l 22
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School Re-Entry Process

• Patients receive classroom services throughout
  three-week program
• School re-entry meeting held on final week
• Consultation to school on diagnosis and
  functioning, with a focus on childs abilities
  (not on pain)

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Therapeutic Services for Chronic Pain
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Focus of Rehabilitation

• Accept pain as a symptom and not focus on
  eradication of pain
• Independent functioning with improved coping
• As these improve pain and distress decrease over
  time
• Specifically to our program
• Return to full day of school
• Recognize stressors in life and how they impact
  pain
• Utilize their tools to cope with stressors
• Become a healthy kid and shift out of the sick
  role

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Chronic Pain and Activity

• Regular exercise reduces stress, anxiety, and
  depression
• Physical activity in childhood predicts continued
  active lifestyle into and through adulthood
• Learning to understand your body through
  increased activity and relaxation

(Herring, M., OConnor P., Dishman, R., 2010
Rethorst, C., Wipfli, B., Landers, D, 2009
Landry, B., Driscoll, S., 2002).
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Person-Occupation-Environment Model
Occupational Performance
(Law, M., Cooper, B., Strong, S., Steward, D.,
Rigby, P., Letts, L. 1996)
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Occupational Performance
A dynamic experience of a person engaged in
purposeful activities and tasks within an
environment Successful occupational
performance occurs when a person is able to
complete a task or activity in a manner that
achieves the goal of the task or activity, while
satisfying the person
(Law, Dunn, Baum, 2005, p. 108 Law et al.,
1996, p. 16)
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Occupational Performance

• Return to Work
• Sense of purpose
• Financial benefit
• Lifetime learning
• School performance
• Social interaction
• Different demands from home
• Preparation for life after high school
• Engagement in leisure occupation
• Added protection against suicide and poor mental
  health
• Develops sense of self
• Develops friendships
• Increased health and wellness through activity

(Konijnenberg et al., 2005 Petrenchik, King
Batorowicz, 2011 Hunfeld et al., 2001)
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Understanding Chronic Pain
Understanding Pain What to do about it in less
than five minutes?
Sourcehttp//www.youtube.com/watch?v4b8oB757DKc
listFLP80cMhkXObvAgWV6EiiRpA
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Cleveland Clinic Childrens Pediatric Pain
Rehabilitation Program

• 3 week program (2 inpatient, 1 day hospital)
• Individual and Group Sessions
• Aquatic Therapy
• Occupational Therapy
• Physical Therapy
• Psychology
• Recreational Therapy
• School
• Nutrition

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Evaluation Methods

• Canadian Occupational Performance Measure (COPM)
  (Law, M,
  Baptiste, S, Carswell, A, McColl, M, Polatajko,
  H, Pollock, N., 1998).
• Childs Assessment of Participation and Enjoyment
  (CAPE) and Preferences for Activities of Children
  (PAC)
  (King, G, Law, M, King, S, Hurley, P,
  Hanna, S, Kertoy, M, . . . Young, N., 2004).
• Lower Extremity Functional Scale (LEFS)
  (Binkley JM, Stratford PW, Lott SA, Riddle DL.,
  1999)
• Upper Extremity Functional Index (UEFI) (Gabel,
  Michener, Burkett Neller, 2006)

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Morning Exercise Group

• 800 a.m. every morning
• Groups philosophy Movement is therapeutic
• Focus of group
• Stretching
• Circuit Training (endurance)
• Team building
• Education on book bag safety, body mechanics,
  anatomy and chronic pain

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Aquatic therapy

• Combined effort of OT/PT/RT
• Heated pool water to 92 degrees
• Works to improve
• Core strengthening-noodles
• Endurance-running, swimming, treading
• Strengthening-Step-ups with use of
  stairs/platform
• Team building with use of group games

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Individual Treatment

• Each patient participates in individual OT and PT
  sessions daily
• Focuses on
• Re-gaining life through activity
• Sensory stimulation, weight bearing, and load
  bearing
• Postural alignment/body awareness
• Equipment assessments such as orthotics, arch
  supports, shoes, appropriate clothing
• Kinesiotaping/other types of taping
• Surface electromyography (SEMG)

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Components of Program

• Therapeutic Leave Day (TLD)
• Family interaction and coping
• Goals for adolescent and family
• Community re-entry trips
• Importance of real-world training
• Social pragmatics and living with chronic pain
• School re-entry
• Bridging gap between pain rehab and school
• Collaborative effort to decrease school
  absenteeism

(Schaefer, S., Patterson, C., Lang, C.,
2013)
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Home Exercise Program

• Focus is on functional activities with exercise
  as one component
• Age-appropriate peer activities
• Each patient given ongoing evening exercises to
  perform independent of therapy sessions
• Prior to discharge, individualized HEP developed
  including endurance/strengthening activity
• Individualized pictures and directions included

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Individualized Functioning Plan

• Cognitive-behavioral approach
• Active process for adolescent to work on own
  goals
• Goals evaluated by adolescent and provider
• Goals are revised weekly to update progress

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Treatment for Fibromyalgia

• Mixed Evidence
• Acupuncture
• Mixed reviews Some indications of relieving
  stiffness over standard therapy with some
  indications of no relief of pain over sham
• Multi-disciplinary approach insufficient data
  showing effectiveness
• Some potential of programs with stress
  management, physical and behavioral training
  improving pain and disability levels
• Minimal Evidence
• Cardiovascular exercise Muscle Strengthening
• Flexibility Training

(Busch, A., Barber, K., Overend, T., Peloso, P.,
Schachter , C., 2007 Karjalainen, K.,
Malmivaara, A., van Tulder, M., Roine, R.,
Jauhiainen, M., Hurri, H., Koes, B., 1999
Eccleston, C., Palermo, T., Williams, A.,
Lewandowski, A., Morley, S., Fisher, E., Law,
E., 2012 Deare, J., Zheng, Z., Xue, C., Liu,
J. P., Shang, J., Scott, S., Littlejohn, G.,
2013).
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Traditional Treatment for CRPS

• Minimal Evidence
• Mirror Treatment
• Strong evidence for patients with CVA
• Weak evidence works in CRPS OT and PT
• Graded motor imagery
• Acupuncture rehabilitation
• No Evidence
• Acupuncture vs Sham

(OConnell, N., Wand, B., McAuley, J., Marston,
L., Moseley, L., 2013 Thieme, H., Mehrholz,
J., Pohl, M., Behrens, J., Dohle, C., 2012).
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Treatment Ideas
Whats better than Bowling!
Shaving cream and packaging bubbles
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Cleveland Clinic Childrens Pediatric Pain
Rehabilitation Program
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References

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