Chronic Pediatric Pain Management: a Review of Multidisciplinary Care and Emerging Topics
- 23 Downloads
Purpose of Review
Chronic pain is a prevalent, disabling, and expensive pediatric condition. Specific treatment options have limited evidence and are often extrapolated from adult care. This review evaluates pain outcome measures, psychological treatment, pharmacologic management, multidisciplinary treatment models, and emerging topics in pediatric pain medicine.
Multimodal cognitive behavioral therapy and intensive interdisciplinary pain treatment have the strongest evidence for improving pain and function while decreasing healthcare utilization. There is emerging evidence that parental involvement in care is an important factor in pediatric outcomes. While there is increased interest in emerging topics such as use of marijuana-derived products, acupuncture, and virtual reality, the evidence behind such interventions remains limited.
Pediatric chronic pain treatment centers on the biopsychosocial model of pain and multidisciplinary treatment. Recent research shows that intensive interdisciplinary pain treatment can improve pain, function, and healthcare utilization. Long-term benefits and risks of emerging treatments in pediatric chronic pain remain poorly understood.
KeywordsPediatric chronic pain Pediatric pain psychology Interdisciplinary pain treatment Medical marijuana Acupuncture Virtual reality
Compliance with Ethical Standards
Conflict of Interest
The authors declare no conflicts of interest relevant to this manuscript.
Human and Animal Rights and Informed Consent
All reported studies/experiments with human or animal subjects performed by the authors have been previously published and complied with all applicable ethical standards (including the Helsinki declaration and its amendments, institutional/national research committee standards, and international/national/institutional guidelines).
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 1.Merskey H, Bogduk N. Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms. Seattle: IASP Press; 1994.Google Scholar
- 12.Vetter TR, McGwin G, Bridgewater CL, Madan-Swain A, Ascherman LI. Validation and clinical application of a biopsychosocial model of pain intensity and functional disability in patients with a pediatric chronic pain condition referred to a subspecialty clinic. Pain Res Treat. 2013;143292:1–12. https://doi.org/10.1155/2013/143292.Google Scholar
- 14.• Miro J, McGrath PJ, Finley GA, Walco GA. Pediatric chronic pain programs: current and ideal practice. Pain Rep. 2017;2:e613. https://doi.org/10.1097/PR9.0000000000000613 This article provides survey results from current pediatric pain providers, describing characteristics of current pain programs and an ideal program. These results can help inform providers interested in starting or modifying a pediatric chronic pain program. CrossRefGoogle Scholar
- 15.Tran ST, Jastrowski Mano KE, Hainsworth KR, Medrano GR, Anderson Khan K, Weisman DJ, et al. Distinct influences of anxiety and pain catastrophizing on functional outcomes in children and adolescents with chronic pain. J Pediatr Psychol. 2015;40:744–55. https://doi.org/10.1093/jpepsy/jsv029.CrossRefGoogle Scholar
- 21.•• Mahrer NE, Gold JI, Luu M, Herman PM. A cost-analysis of an interdisciplinary pediatric chronic pain clinic. J Pain. 2018;19:158–65. https://doi.org/10.1016/j.jpain.2017.09.008 This article describes an interdisciplinary outpatient pediatric pain clinic and demonstrates how such a clinic can save costs to hospitals and insurance companies. CrossRefGoogle Scholar
- 26.Jacob E, Puntillo KA. A survey of nursing practice in the assessment and management of pain in children. Pediatr Nurs. 1999;25:178–86.Google Scholar
- 33.•• 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:E9. https://doi.org/10.3390/children4020009 This review article summarizes psychological treatment approaches for pediatric chronic pain, including descriptions and evidence base for different approaches. CrossRefGoogle Scholar
- 35.Lynch-Jordan AM, Sil S, Peugh J, Cunningham N, Kashikar-Zuk S, Goldschneider KR. Differential changes in functional disability and pain intensity over the course of psychological treatment for children with chronic pain. Pain. 2014;155:1955–61. https://doi.org/10.1016/j.pain.2014.06.008.CrossRefGoogle Scholar
- 36.Palermo TM, Law EF, Zou C, Lewandowski A, Logan D, Tai G. Trajectories of change during a randomized controlled trial of Internet-delivered psychological treatment for adolescent chronic pain: how does change in pain and function relate? Pain. 2015;156:626–34. https://doi.org/10.1097/01.j.pain.0000460355.17246.6c.CrossRefGoogle Scholar
- 37.• Cunningham NR, Jagpal A, Tran ST, Kashikar-Zuck S, Goldschneider KR, Coghill RC, et al. Anxiety adversely impacts response to cognitive behavioral therapy in children with chronic pain. J Pediatr. 2016;171:227–33. https://doi.org/10.1016/j.jpeds.2016.01.018 This article shows that patients with untreated anxiety do not respond well to pain-focused cognitive behavioral therapy. This suggests that successful individualized pain treatment for such patients must also include anxiety management. CrossRefGoogle Scholar
- 42.Gmuca S, Xiao R, Weiss PF, Sherry DD, Knight AM, Gerber JS. Opioid prescribing and polypharmacy in children with chronic musculoskeletal pain. Pain Medicine 2018 https://doi.org/10.1093/pm/pny116.
- 43.• Stinson J, Harris L, Garofalo E, Lalloo C, Isaac L, Brown S, et al. Understanding the use of over-the-counter pain treatments in adolescents with chronic pain. Can J Pain. 2017;1:84–93. https://doi.org/10.1080/24740527.2017.1337468 This article provides qualitative information from interviews with adolescents who have chronic pain, including their use of over-the-counter medications, their perception of medications, and their decision-making process. CrossRefGoogle Scholar
- 46.Arnold LM, Schikler KN, Bateman L, Khan T, Pauer L, Bhadra-Brown P, et al. Safety and efficacy of pregabalin in adolescents with fibromyalgia: a randomized, double-blind, placebo- controlled trial and a 6-month open-label extension study. Pediatr Rheumatol. 2016;14:46. https://doi.org/10.1186/s12969-016-0106-4.CrossRefGoogle Scholar
- 51.•• Powers SW, Coffey CS, Chamblerlin LA, Ecklund SJ, Klingner EA, Yankey JW, et al. Trial of amitriptyline, topiramate, and placebo for pediatric migraine. N Eng J Med. 2017;376:115–24. https://doi.org/10.1056/NEJMoa1610384 This randomized placebo-controlled trial of amitriptyline and topiramate for pediatric chronic headache showed no difference between topiramate or amitriptyline and placebo in improving headaches. This study is particularly important as one of few placebo-controlled medication trials in pediatric chronic pain. CrossRefGoogle Scholar
- 54.•• Hechler T, Kanstrup M, Holley AL, Simons LE, Wicksell R, Hirschfeld G, et al. Systematic review on intensive interdisciplinary pain treatment of children with chronic pain. Pediatrics. 2015;136:115–27. https://doi.org/10.1542/peds.2014-3319 This systematic review article describes various intensive interdisciplinary pain treatment programs and demonstrates that such programs can effectively improve function and pain intensity. CrossRefGoogle Scholar
- 55.Logan DE, Conroy C, Sieberg CB, Simons LE. Changes in willingness to self-manage pain among children and adolescents and their parents enrolled in an intensive interdisciplinary pediatric pain treatment program. Pain. 2012;153:1863–70. https://doi.org/10.1016/j.pain.2012.05.027.CrossRefGoogle Scholar
- 57.• Evans JR, Benore E, Banez GA. The cost-effectiveness of intensive interdisciplinary pediatric chronic pain rehabilitation. J Pediatr Psychol. 2016;41:849–56. https://doi.org/10.1093/jpepsy/jsv100 This article shows that intensive interdisciplinary pain treatment can be cost-effective, even after accounting for the cost of the program. CrossRefGoogle Scholar
- 58.Ruhe SK, Frosch M, Wagner J, Linder R, Pfenning I, Sauerland D, et al. Health care utilization and cost in children and adolescents with chronic pain: analysis of health care claims data 1 year before and after intensive interdisciplinary pain treatment. Clin J Pain. 2017;33:767–76. https://doi.org/10.1097/AJP.0000000000000460.CrossRefGoogle Scholar
- 59.Sieberg CB, Smith A, White M, Manganella J, Sethna N, Logan DE. Changes in maternal and paternal pain-related attitudes, behaviors, and perceptions across pediatric pain rehabilitation treatment: a multilevel modeling approach. J Pediatr Psychol. 2017;42:52–64. https://doi.org/10.1093/jpepsy/jsw046.Google Scholar
- 61.Kemani MK, Kanstrup M, Jordan A, Caes L, Gauntlett-Gilber J. Evaluation of an intensive interdisciplinary pain treatment based on acceptance and commitment therapy for adolescents with chronic pain and their parents: a nonrandomized clinical trial. J Pediatr Psychol. 2018;43:1–14. https://doi.org/10.1093/jpepsy/jsy031.CrossRefGoogle Scholar
- 63.Kashikar-Zuck S, Black WR, Pfeiffer M, Peugh J, Williams SE, Ting TV, et al. Pilot randomized trial of integrated cognitive-behavioral therapy and neuromuscular training for juvenile fibromyalgia: The FIT Teens Program. J Pain. 2018;19:1049–62. https://doi.org/10.1016/j.jpain.2018.04.003.CrossRefGoogle Scholar
- 64.National Conference of State Legislatures. State Medical Marijuana Laws [Internet]. 2018 [accessed 2018 November 14]. Available from: http://www.ncsl.org/research/health/state-medical-marijuana-laws.aspx.
- 68.• Wong SS, Wilens TW. Medical cannabinoids in children and adolescents: a systematic review. Pediatrics. 2017;140:e20171818. https://doi.org/10.1542/peds.2017-1818 This review is the most comprehensive review of medical use of marijuana-derived products for children and adolescents. While the review is not primarily about treating pain, it highlights the lack of research on this topic at this time. CrossRefGoogle Scholar
- 71.Allan GM, Finley CR, Ton J, Perry D, Ramji J, Crawford K, et al. Systematic review of systematic reviews for medical cannabinoids: pain, nausea and vomiting, spasticity, and harms. Can Fam Physician. 2018;64:e78–94.Google Scholar
- 77.Meier MH, Caspi A, Ambler A, Harrington H, Houts R, Keefe RS, McDonald K, Ward A, Poulton R, Moffitt TE. Persistent cannabis users show neuropsychological decline from childhood to midlife. Proc Natl Acad Sci U S A 2012:109:e2657–e2664. 0.1073/pnas.1206820109.Google Scholar
- 78.National Center for Complementary and Integrative Health. Complementary, alternative, or integrative health: what’s in a name? [Internet]. 2017 [accessed 2018 November 14]. Available from: https://nccih.nih.gov/health/integrative-health.
- 79.Black LI, Clarke TC, Barnes PM, Stussman BJ, Nahin RL. Use of complementary health approaches among children aged 4-17 years in the United States: National Health Interview Survey, 2007-2012. Natl Health Stat Rep. 2015;78:1–19.Google Scholar
- 80.• McClafferty H, Vohra S, Bailey M, Brown M, Esparham A, Gerstbacher D, et al. Pediatric integrative medicine. Pediatrics. 2017;140:e20171961. https://doi.org/10.1542/peds.2017-1961 This article summarizes attitudes regarding pediatric integrative medicine, as well as the evidence base for various forms of complementary and integrative medicine. CrossRefGoogle Scholar
- 81.Faith J, Thorburn S, Tippens KM. Examining the association between patient-centered communication and provider avoidance, CAM use, and CAM-use disclosure. Altern Ther Health Med. 2015;21:30–5.Google Scholar
- 87.Won AS, Bailey J, Bailenson J, Tataru C, Yoon IA, Golianu B. Immersive virtual reality of pediatric pain. 2017:4:pii:e52. https://doi.org/10.3390/children4070052.