Pain Management: Beyond the Pills and

Procedures

Dustin P. Wallace, PhDLicensed Psychologist, Integrative Pain Management Clinic

Children’s Mercy Hospitals and ClinicsAssistant Professor of Pediatrics, School of Medicine

University of Missouri-Kansas City

JA National ConferenceJuly 21, 2012; St. Louis, MO

Disclosures

• I am not a medical doctor!

• Please check with your doctor before starting any new treatment, including the ones we discuss today

Today’s plan

1. Many things influence pain from JA

2. Pills and procedures can lead to pain relief… but do not always eliminate pain

3. Certain other strategies can be more effective and have fewer side-effects– Strategies for children, teens, and parents

4. Time for questions and discussion – (and feel free to ask at any time!)

JA is a PAIN

• Broad set of autoimmune inflammatory conditions– Joints: JIA (oligo-, poly-, systemic)– Tendon/ligament: Enthesitis (ankylosing

spondylitis, spondyloarthropathies, reactive)– Psoriatic arthritis, dermatomyositis, scleroderma

lupus, HLAB, etc…

• Inflammation -> pain -> more inflammation!

• Impairment varies across individuals

• Severity of symptoms does not fully account for disability• According to most studies, arthritis activity

accounts for less than 10% of the pain that kids report

Pain can be Disabling

Think Bio-Psycho-Socially!

• Pain comes from physiological/medical factors as well as psychological, social, behavioral, historical and environmental contributions

Also…

• Nerves get “practiced” at pain signals– Sending nerves– Listening nerves

• Muscles guard, become tight, and may spasm

Pictures from: https://www.umm.edu/ imagepages/18125.htm & http://www.jvillechiro.com/sciatica.htm

Pills & procedures are important

• Arthritis drugs: Anti-inflammatory & disease-modifying

• Other pain medications• Surgeries & other procedures (injections, soft-

tissue release, joint replacement, etc)• Splints or orthotics

But these have limitations…

• Arthritis medications:– if disease is improving, more may not help pain– side effects can limit dose

• Pain medications:– Hyperalgesia, side-effects

• Surgeries/procedures: invasive, side-effects

• Splints/orthotics: only correct certain issues

What other options do you have?

• Lots!!– Address those overactive nerves– Ease those painful muscles– Take advantage of the pain gate

Pain is not

merely sensory excitatio

n

What other options do you have?

• BIG categories:– Physical activity– Adequate water and nutrition– Distraction (sensory and cognitive)– “Biobehavioral” (usually relaxation-based)– Combination approaches

• Parenting strategies

Physical Activity

• Why does it help?– Stimulates nerves

normally– Stretches and

strengthens muscles– Supports joints

• What you can do– Moderation!– Stretching– Physical therapy

Adequate water; good nutrition

• Why does it help?– Promotes healing

through normal body processes

– May decrease inflammation

– Allows medications to work their best

• What you can do– Aim for 64oz water

daily– Variety of fresh foods

including colorful fruits and veggies

– Reduce processed foods and sugar

** Not specifically endorsing this diet, but it has a number of excellent elements.

Reminder: talk to your doctor before making any large changes.

Picture from:http://www.drweil.com/drw/u/ART02995/Dr-Weil-Anti-Inflammatory-Food-Pyramid.html

Anti-inflammatory diet (as example)

Distraction - sensory

• Why does it help?– Closes pain gate– May promote

relaxation and healing– Releases feel-good

neurotransmitters

• What you can do– Heat, cold, movement

in water– Petting animals– Vibration– TENS– Massage, self-massage

Distraction – sensory (massage)

• Example:– Comfort Hold

• Simply laying warm, full hands on your child can be very calming. Start with forehead and neck, and work down. Hold each place for a few calm breaths.

– Massage:• More than just a shoulder rub!

Distraction – sensory (massage)

• Face: sides of face, forehead, nose, chin

• Stomach: hand over hand, then clockwise

• Legs: hip to foot, foot, then back up

• Arms: same as legs

• Back: down, side to side, circular, neck, head to toe

Ages 4-16!

Distraction – sensory (massage)

Distraction – sensory (massage)

Distraction - cognitive

• Why does it help?– Helps close pain gate– Adds fun activities– Releases feel-good

neurotransmitters

• What you can do– TV, movies, video

games,

Distraction - cognitive

• Why does it help?– Helps close pain gate– Adds fun activities– Releases feel-good

neurotransmitters

• What you can do– TV, movies, video

games,– Non-video games,

books– Music, art, activities– Friends

Biobehavioral strategies

• Why does it help?– Regulates autonomic

nervous system– Decreases overactive

pain nerves– Promotes healing

• What you can do– Relaxed breathing– Progressive muscle

relaxation– Imagery/self-hypnosis– Biofeedback– Meditation

Biobehavioral strategies

• Examples:– Diaphragmatic breathing– Quick muscle relaxation– Imagery

Combine some of these?

• Yoga or Tai Chi– Physical activity, strengthening, stretching,

relaxation, biobehavioral, distraction (sensory & cognitive)

• Massage– Relaxation, nerve stimulation, distraction (sensory)

Combine some of these?

• Acupuncture– Biobehavioral, stimulates nerves

• School!– Distraction (cognitive & sensory), physical

activity, social engagement feels good

Stay in school!

• Full medical homebound contraindicated for most adolescents with chronic pain– May do more harm than good

• Commitment to regular school attendance despite pain is critical to prevent enduring disability– Avoid pattern of withdrawal

• Students retained in one grade are 50% more likely to drop out

Stay in school!

• Accommodations may help facilitate regular attendance:– Rest or stretch breaks– Extra time for tests/assignments– Modified PE curriculum– Assignments/grading limited to essential learning– Gradual reentry plan

• Chronic medical conditions can get kids down– Especially if painful, or limiting activities

• Might also worry about their pain, JA, or what is going to happen

• Completely normal, but might get in the way in addition to pain/JA– If so, therapy can help

Mood or anxiety may get in the way

• Symptom reduction and acceptance:– Education of patient and family– Relaxation and possibly biofeedback– Develop coping and self-efficacy– Build motivation– Skills training and goal setting– Reducing avoidance, engaging with values– Treating adjunctive problems such as anxiety and

depression– Training parents in behavioral strategies

Mood or anxiety may get in the way

• Referral– Ask your doctor if other patients have had good

experience with a certain psychologist or therapist– Meet a couple different therapists before deciding– Find someone experienced at working with kids who

have JA or other painful medical conditions

• Make sure they have a good understanding of what you are coming for, and a plan to help you reach your goals!

Mood or anxiety may get in the way

Parenting pain flexibly

• Many roles:– Protector, advocate, encourager, coach, comforter,

limit setter, role model!

• At the same time…– You have your own worries and struggles about

your child, and other aspects of your life!– Responsible for helping your child’s adherence– Social/family roles disrupted

Parenting pain flexibly

• Some challenges– Parent distress may be modeled for kids– Hard to balance being responsive and supportive,

while encouraging coping and not doing too much

• The good news– Good coping modeled for kids– When disease and pain management are in context

with other values, kids function better!

Parenting pain flexibly

• Role Model:– Understand stress and burden are normal– Have social support; get more help if you need it!– Follow your own values, and encourage this in

your child(ren)• Keep JA treatment and pain avoidance from becoming

sole family focus

– Support and celebrate your child’s development

Let’s talk!

• Questions, Comments, and Discussion!