Pain Management: Pediatric Chronic Illness


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  • A major difference in managing a child with pain is accurately or adequately assessing his or her pain.
  • The five essential concepts in the WHO approach to drug therapy of cancer pain are:•By the mouth.•By the clock.•By the ladder.•For the individual.•With attention to detail.The first step in this approach is the use of acetaminophen, aspirin, or another NSAID for mild to moderate pain. Adjuvant drugs to enhance analgesic efficacy, treat concurrent symptoms that exacerbate pain, and provide independent analgesic activity for specific types of pain may be used at any step.When pain persists or increases, an opioid such as codeine or hydrocodone should be added (not substituted) to the NSAID. Opioids at this step are often administered in fixed dose combinations with acetaminophen or aspirin because this combination provides additive analgesia (Weingart, Sorkness, and Earhart, 1985). Fixed-combination products may be limited by the content of acetaminophen or NSAID, which may produce dose-related toxicity. When higher doses of opioid are necessary, the third step is used. At this step separate dosage forms of the opioid and nonopioid analgesic should be used to avoid exceeding maximally recommended doses of acetaminophen or NSAID.Pain that is persistent, or moderate to severe at the outset, should be treated by increasing opioid potency or using higher dosages. Drugs such as codeine or hydrocodone are replaced with more potent opioids (usually morphine, hydromorphonet methadone, fentanyl, or levorphanol), as described below.Medications for persistent cancer-related pain should be administered on an around-the-clock basis, with additional "as-needed" doses, because regularly scheduled dosing maintains a constant level of drug in the body and helps to prevent a recurrence of pain. Patients who have moderate to severe pain when first seen by the clinician should be started at the second or third step of the ladder.
  • ]): PT Intervention: Therapeutic Exercise  Passive range of motion, active assistive range of motion, active range of motion, progressive resistive exercise, balance training, gait training, postural correction and reeducation, ergonomics 2. PT Intervention: Manual Therapy  Mobilization and manipulation of the joints, craniosacral therapy, myofascial release, massage 3. PT Intervention: Modalities  Electrical stimulation, transcutaneous electrical nerve stimulation (TENS), iontophoresis, ultrasound, diathermy, infrared, hydrotherapy (warm), fluid therapy, cold laser, hot packs, paraffin wax therapy, ice packs 4. OT Intervention for Pain Reduction:  Activity of daily living, adaptive devices to simplify tasks, energy conservation techniques, therapeutic exercises, wheelchair measurement, wheelchair positioning devices, bed positioning devices, cushions for appropriate pressure relief, splinting for stretching tight joints/muscles, reduce pain and prevent pressure sore 5. Both PT and OT upon discharge from the therapy program should provide:  Illustrated home exercise program, in-service to caregiver
  • Pain Management: Pediatric Chronic Illness

    1. 1. Pain Management: Pediatric Chronic Illness Gregory Kirkpatrick, MD Pediatric Hematology/Oncology
    2. 2. Childhood Chronic Pain Position Statement from the American Pain Society Significance of the problem: Affects 15% to 20% of children (Goodman & McGrath, 1991). Creates significant emotional and social consequences. Financial costs, healthcare utilization and indirect costs are high Impact child’s overall health and may predispose for adult chronic pain (Campo et al., 1999; Walker, Garber, Van Slyke, & Greene, 1995).
    3. 3. Defining Pain Pain means an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. Acute pain signals a specific nociceptive event and is self-limited Chronic pain has been defined as pain that lasts longer than 3 (6) months and continues beyond the normal time expected for resolution of the problem or persists or recurs for other reasons.
    4. 4. Defining Pain Acute Pain Classification Somatic Pain: Result of activation of nociceptors (sensory receptors) sensitive to noxious stimuli in cutaneous or deep tissues. Experienced locally and described as constant, aching and gnawing. The most common type in cancer patients. Visceral Pain: Mediated by nociceptors. Described as deep, aching and colicky. Is poorly localized and often is referred to cutaneous sites, which may be tender. In cancer patients, results from stretching of viscera by tumor growth.
    5. 5. Defining Pain Chronic Pain Classification Nociceptive pain: Visceral or somatic. stimulation of pain receptors by tissue inflammation, mechanical deformation, ongoing tissue injury. Responds well to common analgesic medications and nondrug strategies. Neuropathic Pain: Involves the peripheral or central nervous system. Does not respond predictably to conventional analgesics. May respond to adjuvant analgesic drugs. Mixed or undetermined pathophysiology: Treatment is unpredictable; requires various approaches. Psychologically based pain syndromes: Traditional analgesia is not indicated.
    6. 6. Assessing Pain QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
    7. 7. Assessing Pain Age variations in abilty to identify Location Quality Time element Source
    8. 8. Assessing Pain • Wong/Baker FACES Pain Rating Scale • FLACC • Pain Intensity Rating QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
    9. 9. Assessing Pain QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
    10. 10. Assessing Pain QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
    11. 11. Assessing Pain QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
    12. 12. Assessing Pain
    13. 13. Managing Pain General Treatment Principles: Ask about pain regularly. Believe the patient's and family's reports of pain and what relieves it. Choose appropriate pain control options. Deliver interventions in a timely, logical, and coordinated fashion. Empower patients and their families.
    14. 14. Managing Pain Opioid Medications QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
    15. 15. Managing Pain Opioid Medications QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
    16. 16. Managing Pain Opioid Medications QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
    17. 17. Managing Pain Opioid Medications QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
    18. 18. Managing Pain Non-steroidal Anti- inflammatoryQuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.
    19. 19. Managing Pain Adjuvant Medication for Pain Corticosteroids Decadron Prednisone Most specific indication for brain metastasis and spinal cord compression. May add benefit for pain associated with inflammatory process. Side effects common: hunger and weight gain, stretch marks, muscle weakness
    20. 20. Managing Pain Adjuvant Medication for Pain Anticonvulsants Carbamazepime Gabapentin Neuropathic pain: May be helpful as antidepressant
    21. 21. Managing Pain Adjuvant Medication for Pain Antidepressants Amytriptyline Doxepin Trazadone Serotonin re-uptake inhibitors May be helpful as antidepressant Neuropathic pain of peripheral nerve injury
    22. 22. Managing Pain Adjuvant Medication for Pain Diphenhydramine Transdermal clonidine (0.1 to 0.2 mg/day)
    23. 23. Managing Pain Wisconsin Cancer Pain Initiative
    24. 24. Managing Pain Physical Pain Management Exercise regimen Cutaneous stimulation techniques: superficial heat and cold, massage, pressure or vibration Physical therapy: active and passive range- of-motion exercises to prevent joint contracture, muscle atrophy, cardiovascular deconditioning
    25. 25. Managing Pain Rehabilitation Treatment Modalities Physical Therapy Occupational Therapy Alternative Interventions: Acupuncture, reflexology, aroma therapy, music therapy, dance therapy, yoga, hypnosis, relaxation and imagery, distraction and reframing, psychotherapy, peer support group, spiritual, chiropractic, magnet therapy, bio-feedback, meditation, relaxation techniques
    26. 26. Managing Pain Nonpharmacologic Interventions: Invasive Procedures With rare exception, noninvasive treatments should precede invasive palliative approaches Palliative radiation therapy: treatment of symptomatic metastasis where tumor has caused pain, obstruction, or compression. Radiation should be administered in the fewest fractions possible to promote patient comfort during and after treatment. Neurolytic blockade of peripheral nerves should be reserved with rare exception for instances in which other therapies (palliative radiation, TENS, pharmacotherapy) are ineffective, poorly tolerated, or clinically inappropriate. Intraspinal medication (Ommya resevoir)
    27. 27. Managing Pain Psychological Intervention
    28. 28. Managing Pain Painful Procedures
    29. 29. Perceived Pain
    30. 30. Specific Disease States Sickle Cell Anemia Bone Infarction Pneumonia Abdominal Crisis
    31. 31. Specific Disease States Cancer Bone Pain Primary Bone Tumors Bone Metastasis Bone Marrow Metastasis
    32. 32. Specific Disease States Cancer Nerve Pain Spinal Cord Compression Increased Intracranial Pressure Peripheral Nerve Compression/Injury
    33. 33. Specific Disease States