Transitioning Into the Next Phase
By Anjana Kundu, MBBS, MD
Dayton Children's Hospital
Greetings everyone! This is my first address to you as I assume the responsibility as the President of the Society, following in the footsteps of an incredible leader, Dr. Sabine Kost-Byerly. I realize it’s a tall order, and I pledge my dedication to fulfilling this role to the best of my capabilities. I can confidently step into this role knowing that a strong foundation has been laid down by a dedicated Board of Directors, very productive committees and by the enthusiastic and engaged members of this Society. The commitment and enthusiasm was apparent from the exceptional attendance at our fourth Annual Meeting in Austin and from the passionate feedback that helps to shape the future direction of our society.
Just as the Society transitions into its next phase, I can’t help but think of another transition that all of us in the field of pediatric pain medicine encounter all too often; the transitions from acute to chronic pain. This area of pain medicine has, yet, much to investigate and I’m heartened to see some good work being brought to light, both in the areas of perioperative pain as well as non-surgical or musculoskeletal pain.
The May 2017 edition of the journal, PAIN, highlights an excellent article by Holley et. al and thoughtful editorial by Rathleff et. al where they discuss the common prevalence of chronic pain during adolescence, its impact, progression into adulthood and most importantly the prognostic factors that may predict transition of acute pain into chronic pain during adolescence. There has been data amongst adults experiencing traumatic injury regarding the factors that predict transition to chronic pain, including older age, high initial pain ratings, psychological factors and lower education levels. However, these factors may not apply to the pediatric population given their unique developmental and interpersonal factors. Holley et al. explore 88 youth between the ages of 10-17 years, with acute musculoskeletal (MSK) pain and describe the longitudinal findings and characteristics that predict the persistence of MSK pain amongst these youths. At 4-month follow up, they report persistence of pain among 35% of youth. The three important predictive factors for transition of acute to chronic or persistent MSK pain include:
- Youth with poor conditioned pain modulation (CPM) or impaired inhibitory pain modulation,
- Female gender, and
- Depressive symptoms during the acute pain period
These findings give us insights into where our future efforts need to directed to both further understanding of the to mechanisms behind these findings, AND how to better address these factors as we manage acute pain win perioperative or non-operative setting. So I urge all our researcher colleagues to take these investigations further and enhance our understanding of mechanisms, factors and interventions to nip pain in the bud.
A proactive approach to addressing psychological factors, especially depressive symptoms, would enhance the efficacy of analgesia we provide for our children. A multimodal approach beyond pharmaceutical agents is paramount in our efforts for improved pain control and quality of life for our patients and families. Female gender and incidence of pain is well established in the literature and this distinction becomes obvious around adolescence/pubertal period. A better understanding of mechanisms that influence this divergence would greatly assist our ability to treat our patients. Mechanisms to better assess and understand the inhibitory mechanisms in pain modulation would be paramount to achieving effective analgesia in the acute period and preventing the development of chronic pain.
It’s a call to action: investigators, both young and seasoned---direct your efforts upstream; clinicians-- implement multimodal analgesia with pharmacological and non-pharmacological techniques. Let’s try to improve management and outcome of the pain experience in our young and vulnerable.
I wish everyone a great summer!