Acute Pediatric Pain Management
Biobehavioral Strategies for Acute Pain Management
Pain has historically and erroneously been treated as a biomedical issue due exclusively to tissue damage, system dysfunction and other biological processes. We now know that pain is biopsychosocial – the combined result of biological, psychological and social factors.1-2 Neuroscience reveals that pain is informed by multiple CNS sites, including the limbic system, and can be amplified or muted by cognitive, emotional, behavioral, and contextual factors.3-6 However, the biological domain of pain continues to receive the most attention, and psychosocial factors in pediatric pain are often ignored.
Psychological factors implicated in pediatric pain processing include thoughts, beliefs, emotions, memories, prior knowledge and experiences, and coping behaviors (e.g. activity avoidance, exercise cessation). Social factors include socioeconomic status, access to care, adverse childhood experiences, familial and parental factors, friends, culture, and environmental context. To overlook these psychosocial factors is to miss two-thirds of the pain problem.
To illustrate the role of psychosocial factors in acute pain, consider this case example: In 1995, the BMJ reported that a construction worker jumped onto a 15cm nail that impaled his boot clear through to the other side.7 In terrible pain, he was rushed to the hospital and given intravenous opioids. When the doctors removed his boot, they discovered that the nail had passed between his toes, missing his foot entirely. There was no tissue damage and he was unharmed. However, the man’s pain was real: his brain – taking into account contextual information such as visual input, awareness of the dangers of his job, prior knowledge and experiences, and the emotional reaction of witnesses – believed his body was in danger, so it made pain to protect him.
Biobehavioral approaches that address biopsychosocial factors such as Cognitive Behavioral Therapy (CBT), biofeedback, and Mindfulness-Based Stress Reduction (MBSR) have a growing research base with evidence of efficacy across various acute and chronic conditions.8-12 As such, The Joint Commission now recommends a multimodal approach to acute pain management, encouraging physicians to adopt an integrative approach to treatment and consider nonpharmacologic interventions such as CBT13. These recommendations are echoed by the CDC,14 Clinical Practice Guidelines for Pain Management in Acute Musculoskeletal Injury,15 and reports from the Institute of Medicine16 and National Pain Strategy.17 Unfortunately, these interventions remain underutilized due to a number of factors, including insufficient pain education in health provider training programs, dearth of pediatric pain therapists, and poor insurance reimbursement.18 Integrative, comprehensive pain programs are similarly insufficiently reimbursed despite demonstrated long-term cost and health care utilization advantages.19-20
Cognitive Behavioral Therapy (CBT) for pediatric pain is a structured, time-limited intervention that can be tailored to meet patients’ unique needs. Ideally, it should include pain education; behavioral strategies such as “pacing” – a graded movement-and-exercise program to increase functionality and strength; relaxation skills and guided imagery; distraction strategies; mindfulness; cognitive techniques targeting catastrophic thoughts about pain and health; emotion regulation skills to reduce the stress, anxiety, and depressed mood that normally and naturally accompany chronic pain; sleep hygiene; coordination of care with physicians and schools, and parent training.21
Due to the lack of available CBT therapists trained in pain, it’s often difficult for physicians and patients to find providers. To bridge this gap between necessity and availability, The Chronic Pain and Illness Workbook for Teens can now be used by any therapist or health professional regardless of discipline or training. Published by New Harbinger in 2019, it is available on Amazon and has been vetted and endorsed by national authorities in pediatric pain.
CBT tips for acute pain management:
- Take a few minutes to explain pain basics. Pain education isn’t appropriate or possible in all acute clinical encounters but may be applicable during a calm moment or follow-up appointment. Research indicates that explaining pain – how pain works in the brain, the role of thoughts and emotions in pain, the difference between “hurt” and “harm”– can improve disability, pain ratings, physical movement, fear-avoidance, pain catastrophization, and healthcare utilization.22-23 For tips on explaining pain to youth and families, see The Chronic Pain and Illness Workbook for Teens Chapter 1: “Pain and the Brain.”24
- Identify and refer to local biobehavioral providers (e.g. pain psychologists, CBT therapists, biofeedback providers). Explain to families that, because pain always has psychological and social components, you recommend incorporating interventions like CBT and biofeedback to more effectively manage pain. Clearly communicate that you don’t believe they’re “crazy” or that the pain is “all in their heads.” Suggest that if it’s okay to get a soccer coach to get better at soccer, it’s okay to get a “pain coach” (aka, pain psychologist) to get better at managing pain.
- Prescribe biobehavioral interventions like CBT as you would medications by writing them on a prescription pad. This conveys to insurance companies that these treatments are medically necessary and may increase likelihood they’ll be reimbursed. It also validates the import of these interventions for families who may not understand a biopsychosocial approach.
- Offer references – books, videos, websites and apps – to empower patients, decrease pain-related anxiety and fear, and let them know that additional information and help are available. For an extensive list of pediatric pain resources, see zoffness.com/resources.
- To prevent the development of a chronic pain cycle, recommend that patients return to school, physical/social activity, and hobbies as soon as possible. Activity reduction and social withdrawal can lead to falling behind academically and socially, loss of fitness and strength, sensitization of brain and body, and the development of anxiety and depressed mood – which can then cycle back around to trigger and amplify pain.26-28
- Increase youth agency and decrease parent worry by establishing a “pain plan.” Help families generate a list of acute pain coping strategies. Suggest that families write out this pain plan at home using markers, glitter, etc, offering an engaging way for them to increase independent pain coping capacities. A copy of the “pain plan” can then go on the fridge, bedroom wall, and in the child’s backpack to be shared with the school nurse or teachers (these plans are easily adaptable for school environments).
A sample acute pain plan might look like this:
- Lay down for 20 minutes
- Apply cold pack
- Take anti-inflammatories and analgesics
- Relax: belly breathe, body scan, use imagery
- Use CBT self-talk strategies: “I’ve had 42 pain flares so far this year, I know I can get through this one.”
- Self-soothe the five senses (listen to music, bake cookies, put on fuzzy pajamas, watch a movie, etc.)
- Turk DC, Gatchel RJ, Eds. Psychological approaches to pain management: A practitioner's handbook. Guilford publications; 2018. New York, NY: Guilford Press.
- Gatchel RJ, Peng YB, Peters ML, Fuchs PN, Turk DC. The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychological bulletin. 2007;133(4):581-624.
- Martucci KT, Mackey SC. Neuroimaging of Pain: Human Evidence and Clinical Relevance of Central Nervous System Processes and Modulation. Anesthesiology: The Journal of the American Society of Anesthesiologists. 2018;128(6):1241-54.
- Melzack R, Wall PD. Pain mechanisms: a new theory. Science. 1965;150(3699):971-9.
- Woo CW, Roy M, Buhle JT, Wager TD. Distinct brain systems mediate the effects of nociceptive input and self-regulation on pain. PLoS biology. 2015;13(1):e1002036.
- Bushnell MC, Ceko M, Low LA. Cognitive and emotional control of pain and its disruption in chronic pain. Nat Rev Neurosci. 2013;14(7):502-11.
- Fisher JP, Hassan DT, O'Connor N. Minerva. BMJ 1995;310:70.
- Coakley R. & Wihak T. Evidence-Based Psychological Interventions for the Management of Pediatric Chronic Pain: New Directions in Research and Clinical Practice. Children 2017;4,9.
- Flor, H. Psychological pain interventions and neurophysiology: Implications for a mechanism-based approach. American Psychologist. 2014;69(2):188.
- Fisher, E., Heathcote, L., Palermo, T. M., de C Williams, A. C., Lau, J., & Eccleston, C. Systematic review and meta-analysis of psychological therapies for children with chronic pain. Journal of pediatric psychology, 2014;39(8):763-782.
- Cunningham, N.R. & Kashikar-Zuck, S. Nonpharmacological Treatment of Pain in Rheumatic Diseases and Other Musculoskeletal Pain Conditions. Curr Rheumatol Rep, 2013;15:306.
- Fein JA, Zempsky WT, Cravero JP. Relief of pain and anxiety in pediatric patients in emergency medical systems. Pediatrics, 2012 130(5): 1391-405.
- The Joint Commission (TJC). Joint Commission enhances pain assessment and management requirements for accredited hospitals. 2017. https://www.jointcommission.org/topics/pain_management.aspx (Accessed Nov 2019)
- Dowell D, Haegerich TM & Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA, 315(15), 1624-1645.
- Hsu JR, Mir H, Wally MK, Seymour RB. Clinical Practice Guidelines for Pain Management in Acute Musculoskeletal Injury. Journal of Orthopaedic Trauma. 2019;33(5):e158
- IOM Committee on Advancing Pain Research and Care. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Available at: http://www.iom.edu/_/media/Files/Report%20Files/2011/Relieving-Pain-in-America-ABlueprint-for-Transforming-Prevention-Care-Education-Research/Pain%20Research%202011%20Report%20Brief.pdf. (Accessed Oct 2019).
- NIH Interagency Pain Research Coordinating Committee. National Pain Strategy. Available at: http://iprcc.nih.gov/National_Pain_Strategy/NPS_Main.htm 2015 (Accessed Nov 2019).
- Darnall BD, Scheman J, Davin S, Burns JW, Murphy JL, Wilson AC, Kerns RD, Mackey SC. Pain psychology: A global needs assessment and national call to action. Pain Medicine. 2016; 17(2): 250-63.
- Gatchel RJ, Okifuji A. Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic nonmalignant pain. The Journal of Pain. 2006;7(11):779-93.
- Gatchel RJ, McGeary DD, McGeary CA, Lippe B. Interdisciplinary chronic pain management: past, present, and future. American Psychologist. 2014;69(2):119.
- Palermo, T. M. (2012). Cognitive-Behavioral Therapy for Chronic Pain in Children and Adolescents. New York, New York: Oxford University Press.
- Louw A, Butler DS, Diener I, Puentedura EJ. Development of a preoperative neuroscience educational program for patients with lumbar radiculopathy. Am J Phys Med Rehabil, 2013;92:00Y00.
- Louw A, Zimney K, Puentedura EJ, Diener I. The efficacy of pain neuroscience education on musculoskeletal pain: a systematic review of the literature. Physiotherapy Theory and Practice, 2016, 32(5):332-55.
- Zoffness, R. (2019). The Chronic Pain and Illness Workbook for Teens. New Harbinger.
- Ernst MM, O'Brien HL, Powers SW. Cognitive‐behavioral therapy: How medical providers can increase patient and family openness and access to evidence‐based multimodal therapy for pediatric migraine. Headache: The Journal of Head and Face Pain. 2015; 55(10):1382-96.
- IsHak WW, et al. Pain and depression: A systematic review. Harvard Review of Psychiatry. 2018;26:352.
- Kashikar-Zuck S, Vaught MH, Goldschneider KR, Graham TB, & Miller JC. Depression, coping, and functional disability in juvenile primary fibromyalgia syndrome. Journal of Pain, 2002; 3(5): 412-419.
- Chu HT, Liang CS, Lee JT, Yeh TC, Lee MS, Sung YF, Yang FC. Associations Between Depression/Anxiety and Headache Frequency in Migraineurs: A Cross-Sectional Study. Headache. 2018; 58(3):407.