“Psychological Interventions For Pediatric Chronic Pain” by Karen Kaczynski for OPENPediatrics
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“Psychological Interventions For Pediatric Chronic Pain” by Karen Kaczynski for OPENPediatrics

December 3, 2019


Psychological Interventions for Pediatric
Chronic Pain by Dr. Karen Kaczynski. I’m Karen Kaczynski, and I’m a psychologist
at the Pain Treatment Service and the Headache Clinic at Children’s Hospital in Boston. I’m going to start by talking about psychological
interventions for pediatric chronic pain. Just to give a general overview, I’m going
to start by giving some general information about pain and how it works. Then I’ll present some theoretical models
that are relevant to pediatric chronic pain. I’ll next talk about the relationship between
stress and pain and then give some specific information about cognitive behavioral assessment
and treatment of pediatric chronic pain. Lastly, I’ll talk about acceptance and commitment
therapy or ACT, which is a new but promising psychological intervention for pediatric pain. Definitions. According to IASP, pain is defined as an unpleasant
sensory and emotional experience associated with actual or potential tissue damage and
described in terms of such damage. There’s a distinction between pain and nociception. Nociception involves stimulation of nerves
that carry information about tissue damage to the brain. Pain, however, is a much broader experience. It’s considered a subjective experience, possibly
involving nociception, but not necessarily, but also involving the person’s genetics,
temperament, past history with painful experiences, their cognitive and emotional responses to
pain, as well as the responses from important people in their lives and in their environment. All of these factors can modulate the person’s
pain experience. There’s a distinction between acute and chronic
pain, which is important to be aware of. Acute pain is pain which is relatively recent
onset. It often involves a clear precipitant or physiological
etiology such as an injury or acute disease process. And it serves a protective role in the body. What that means is that the pain is there
to signal the brain that there’s something wrong, and the person needs to change their
activity or take certain measures to allow the body to heal or to prevent further injury. In contrast, chronic pain is pain which persists
for three or more months. There may or may not be a clear precipitant
or etiology. At times, chronic pain may onset following
an injury or a surgery, but the pain persists longer than the natural healing process would
take. Other times chronic pain can just onset out
of the blue with no clear physical trauma or precipitant. And in this case, the pain does not serve
a protective purpose because there’s no damage to the tissue in the body that the pain is
serving to protect. The focus of this talk will be on chronic
pain. Several important aspects of the pain experience
that are important to keep in mind are that pain is inconsistent, subjective, and contextual. What that means is that the same pain may
be experienced differently by the same individual on different days, in different contexts,
in different situations. Pain may also be experienced very differently
individual to individual, depending on the circumstances. For example, pediatric patients that I work
with often say that their pain is worse when they’re lying in bed at night because they
don’t have anything to take their mind off of their pain, and they’re just focusing on
their pain a lot. In contrast to when they’re talking to a friend
or doing something they enjoy when they’re a little bit more distracted from their pain. The pain may be the same, but the person’s
experience of it can differ significantly based on the context. Theoretical Models. In understanding pain, many different theoretical
models have been developed, but the most important in terms of this talk are a couple. One is the Sensory Model, which is a very
kind of concrete model that says that the extent of pain is consistent with the extent
of tissue damage in the body. This model is very basic and just made a lot
of intuitive sense. It was developed early in the 20th century. However, the model was inconsistent with clinical
presentations of patients with chronic pain who, at times, may have presented with an
injury, which had healed, although their pain persisted. Other times, there seemed to be a poor correlation
between the pain and any underlying tissue damage at all, and it appeared that the person’s
emotional and cognitive responses to the pain may have been playing a role in the amount
of pain they perceived. This model was discarded and in its replacement,
Melzack and Wall developed the Gate Control Theory in 1965. This model describes or explains why there
is so much variability in the pain experience. In general, the theory states that there are
sensory, cognitive, affective, and behavioral factors which contribute to the pain experience. Physiologically, the model indicates that
there are peripheral pain receptors, which transmit pain signals to the dorsal horn of
the spinal cord via small fiber nerves. There are also descending inhibitory large
fiber nerves, which can modify or stop the pain signals from being transmitted. These inhibitory processes are due to cognitive,
affective, and behavioral factors. The model states that they are actually nerves
which serve the process of inhibiting or modulating the pain signals coming in from the periphery
of the body, and these are the actual pain gate, which can control how much of the pain
signals are going to get through to the brain. Although the underlying physiology in this
model was not ultimately supported, the theory behind it indicating that cognitive and affective
and behavioral factors can modulate the pain experience has been supported. And in fact, there are imaging studies, which
show that, in a painful experience, there is activation in both sensory and affective
regions of the brain. This multi-factorial perspective on how pain
works is what’s resulted in the development of cognitive and behavioral treatments to
address chronic pain. The Biopsychosocial Model was developed as
a framework for understanding the pain experience based on the Multifactorial Model of pain. It states that there are biological, psychological,
and social factors that influence the pain experience. These are all of the factors that we can address
in cognitive and behavioral treatment. The biopsychosocial model is a complex model
which shows that there are multiple factors impacting the person’s subjective pain experience. First, we think about just the physiological
aspect of pain, so this is things like tissue damage, nerve malfunctions, scar tissue, and
acute disease process– that sort of thing. Anything physiological and generally what
people think about when they tell you why they’re in pain. This is something that we acknowledge maybe
underlying their pain, but it’s not something that’s directly addressed in cognitive and
behavioral treatment. Pain sensation is sort of the subjective experience
of pain. As I said, some people might experience pain
differently in different situations. There is also variability in terms of people’s
sensitivity to pain and how high of a threshold they have for being bothered by their pain. So the same pain in different individuals
may be experienced differently just because people have different levels of sensitivity
for pain. Thoughts– how people think about their pain–
can impact that pain experience. Oftentimes, when people have chronic pain,
they may have negative thoughts. They may think things like, “I can’t take
it anymore. It’s never going to get better. This isn’t fair. Why is this happening to me?” Although those thoughts are very normal and
natural in the situation of chronic pain, those thoughts are not very helpful and that
negative cognitive response can actually intensify their pain experience. Additional cognitive factors, such as focusing
attention on pain or having expectations that pain will increase in a certain situation
can also intensify the pain experience. Emotional factors, such as how the person
responds emotionally to their pain, can also play a role. Oftentimes, when people have chronic pain,
their emotions tend to be more negative. They might get stressed, anxious, depressed,
frustrated, angry. And again, while all of these emotional responses
are normal and natural given the circumstances, they aren’t necessarily so helpful and they
may actually intensify or exacerbate the pain experience as well. Behavioral factors may also play a role. Some people, in the context of chronic pain,
may respond as if they are having an acute pain experience. So with acute pain, people tend to rest, discontinue
activities, guard– that sort of thing. And while those responses may be helpful with
acute pain because they allow the body to heal, those responses are not very helpful
with chronic pain because they may perpetuate the pain cycle. They may contribute to increased disability
and deconditioning and generally not help the person recover. In contrast, if people remain physically active
and participate in things like physical or occupational therapy, that can actually help
them improve their functioning and that may help them close the pain gate or decrease
the amount of pain sensation. Lastly, social factors can also play a role. This is how other people in the environment
respond to the person in pain. If friends are dismissive or critical regarding
their pain, that can be stressful and focus the person’s attention more on their pain. And it may increase their negative thoughts
and feelings– intensifying the pain experience as well. In contrast, a lot of times with pediatric
chronic pain, parents may unintentionally reinforce poor coping with pain by allowing
kids to get out of regular responsibilities, not go to school, giving them special attention. While this is a very normal response when
your child is in pain and you want to help them feel better, these types of responses
can actually reinforce the pain experience as well. One thing that all of these factors have in
common is that they can increase stress, and increased stress intensifies current pain
and can contribute to chronic pain. Stress and Pain. When we think about the relation between stress
and pain, we have to start by talking about the flight or fight response. This is an automatic physiological response
to real or threatened harm. When we perceive harm in the environment,
our body has certain changes that occur that allow us to keep ourselves safe, whether that
involves running away to escape from the threat, or preparing to fight off whatever the threat
may be. These changes include increased muscle tension,
changes in the way our breathing rate is, or our heart rate, changes in vasodilation
or constriction, changes in the way our GI tract is functioning. Pain itself is actually perceived as a threat
and results in a stress response. So all of those physiological changes do occur
in the context of pain. With acute pain, there may be persistent increased
muscle tension, altered cardiac and pulmonary function, constriction, contraction, and increased
motility in the gut, as well as vasodilation. While these processes may be protective in
the short – term if there were an immediate threat or injury, they are not so helpful
long – term. In the case of chronic pain, there may be
a prolonged stress reaction, which can actually exacerbate and maintain pain directly. Physiological reactions such as increased
muscle tension, vasodilation, and constriction in the gut can directly increase pain. But also over the long – term, these processes
can contribute to central sensitization. What this means is that if the body is experiencing
a prolonged state of stress or pain, the brain is going to adapt to that state, and there
will be actual changes in the brain, which serve ultimately to maintain the chronic pain,
independently of whatever is going on in the periphery of the body. So the pain sort of takes on a life of its
own in the brain and maintains itself based on these changes in the brain. Research has supported this idea of central
sensitization in chronic pain. There have been found to be alterations in
the HPA immune access, as well as changes in the way neurons communicate with each other. There are increases in excitability and synaptic
efficiency in neurons that process pain signals in the CNS, as well as decreased pain inhibitory
processes that have been shown to be found in patients with prolonged pain, supporting
the idea of central sensitization. So the general idea is that when a person
is in a state of prolonged chronic pain, the brain is going to change and alter itself
based on that experience, and based on those brain changes, the pain will persist. So what does this look like in an actual patient? What we see is that our patients with chronic
pain get stuck in a very vicious cycle. First there’s the pain, and then they often
respond as if there’s an acute pain situation, meaning that they may reduce their activity,
withdraw from school, discontinue sports, spend more time at home resting, hoping that
will allow their body to heal and the pain to go away. However, in the case of chronic pain, that
unfortunately is not the case. So reducing their activities and their engagement
in their lives results in other issues such as stress due to being out of school, increased
physical deconditioning, boredom, emotional distress, anxiety. All of these things can increase their sensitivity
to pain and focus their attention more on pain, resulting in increased pain and continuing
that cycle of pain and disability. Psychological Interventions. So when we think about treating pediatric
chronic pain, we have to look at the larger picture and think about not just treating
the pain itself, but also treating the emotional distress and disability which goes along with
it. So this is where cognitive behavioral therapy
comes in. So cognitive behavioral therapy is a psychological
treatment, which is based on cognitive behavioral theory. This theory generally shows that thoughts,
feelings, and behaviors are interrelated. Therefore, if we change what we do or how
we’re thinking, we can change how we’re feeling. CBT targets the stress response and cognitive,
emotional, and behavioral responses to pain. These are all of the different factors according
to the biopsychosocial model that can open the pain gate and intensify the pain experience. We also teach cognitive and behavioral coping
strategies to help patients manage pain better and increase their functioning. So cognitive behavioral therapy starts with
a very thorough assessment. We evaluate the emotional, behavioral, and
cognitive functioning of the child, as well as any psychosocial stressors which may increase
their general emotional distress and also could potentially exacerbate their pain. We also do a careful assessment of any antecedents
or consequences of pain episodes. So an antecedent may be an event which triggers
or precedes a pain episode. For example, antecedents could include things
like family conflict, a test at school, increased physical activity. Consequences are factors which may serve to
reinforce pain episodes. So these things might be receiving extra parental
attention following a pain episode, being allowed to miss out on school or skip homework,
that sort of thing. And both consequences and antecedents are
good targets for treatment. So cognitive behavioral therapy addresses
both the cognitive and behavioral aspects of a person’s experience. And these are things that we target in treatment
with people with chronic pain. Oftentimes, as I said, people with chronic
pain engage in negative cognitions. But the more they think negatively, that may
intensify the pain that they’re experiencing. So these negative thoughts are identified,
challenged, and modified in treatment. For example, some people with chronic pain
may think, my pain will never go away. Again, although that’s an understandable,
natural response to chronic pain, it’s not the most helpful way to think. And it’s not necessarily the most realistic
way to think, either, because the person doesn’t really know how things are going to go in
the future. It’s not definite that their pain will never
go away. So we try to identify that thought and point
out the flaws in it and think about different ways for the person to think. So for example, in the case of episodic pain,
we may encourage the person to think, well, you know, I survived pain episodes before. And they do not last forever. I can get through this as well. In the case of more persistent pain, which
is not episodic, we might help the patient think, I can live a full life even if pain
is in the picture. And I don’t know if my pain is going to last,
or how long my pain is going to last. By changing the way they’re thinking about
their pain, we decrease the stress reaction and decrease the amount that they’re focusing
negatively on their pain. This also may allow them to reengage in their
life. We also teach behavioral coping strategies,
which are really helpful at addressing some of the negative thoughts, but also the stress
reaction. I’ll talk about those in more detail next. Structured problem solving is also used to
address stressors and improve functioning. So for example, a lot of patients with chronic
pain may have difficulties in the school setting. They may have missed a lot of school. They may be very behind. They may have makeup work which is piling
up and increasing the amount of stress and pain they’re experiencing. So we’ll work closely with parents and school
personnel to set up a school plan to make sure that they are able to be functioning
in school to the extent that they’re capable, and that they’re provided with adequate supports,
so that they’re not overwhelmed. Parental involvement is also a very important
piece of treatment. So we often will teach parents the same coping
strategies that we’re teaching their kids so that parents can support adaptive coping
with pain in their children. We also help parents be better advocates and
reinforce their children for active, positive pain coping rather than avoidance or passive
coping. And in fact, results of a recent Cochrane
Review article show that CBT which involves the parental component in that way has been
found to be really effective for improving pain and functioning in children and adolescents. So the other piece of cognitive behavioral
therapy is the behavioral piece. So behavioral coping skills are taught to
reduce pain and distress and improve functioning. An added benefit of these coping skills is
that they serve as a distraction because you really have to focus on them and pay attention
to what you’re doing in order to do them correctly. And that doesn’t allow you to focus as much
on your pain. So by distracting oneself, it helps kids re-engage
in something that’s positive rather than focusing on their pain. So diaphragmatic is the first coping skill
that we often teach because it’s the easiest for kids to pick up. And it can be immediately very, very helpful. The idea is that normal breathing may be disrupted
by pain or stress. So we teach deep, slow, diaphragmatic breathing
to reduce tension and create focused awareness. So we teach kids to breathe deeply with their
diaphragm all the way into their bellies and to pretend that they have a balloon in their
bellies and they need to fill up the balloon with as much air as possible. We teach them to breathe in slowly through
their nose to a count of four, and then out through their mouth to a count of five or
six about 10 times. This type of slow focused breathing can send
a signal to the brain that everything is OK in the environment and that stress response
is not necessary. And therefore, the stress response will be
reduced or turned off. This is a strategy which can be useful in
any context– at school, at home, with friends– because you don’t need any materials to do
it. You can do it pretty subtly so other people
may not even know that you’re doing it. It can even be effective with younger children. We often use props such as pinwheels or bubbles
to teach younger children to do deep breathing. It can be effective for them as well. Progressive muscle relaxation is another strategy
that we teach. So a common reaction when in pain is to tense
up one’s muscles. And if people are in chronic pain, they may
be chronically tense, and they may not even realize it. But that chronic muscle tension can certainly
exacerbate the pain that they’re feeling. So PMR involves progressively tensing and
relaxing various muscle groups in the body. And it allows people to improve their body
awareness and increase the conscious control of muscle activity. So by gaining more awareness about what’s
going on in their body, they can learn to recognize that muscle tension when it happens
and reduce it on their own. Visual imagery is another strategy that we
use with kids. This can be very effective because kids are
very good at using their imaginations and daydreaming. We just build on those natural skills that
they already have. So visual imagery just involves imagining
a pleasant, relaxing scenario, and imagining all of the sensory components of that scenario,
so what they’re seeing, what they’re hearing, what they’re smelling, what their tactile
experience is, as many of the components of the scenario that they can imagine. With this type of deep focused imagery, the
brain reacts as if the experience is actually happening. This can decrease the stress response and
decrease negative cognitions through distraction. And it also increases subjective feelings
of relaxation and well being, which can be very helpful for people who are living with
chronic pain and don’t have that type of experience very often. Self-hypnosis is another strategy. It’s similar to visual imagery, but it involves
more of a permissive, suggestive language. And there’s also often a specific induction
that’s used. This type of imagery can be used to alter
the sensory or emotional component of pain or both. And fMRI research has actually shown that
you can alter either the sensory or emotional component of pain through self-hypnosis. We also use self-hypnosis to help the person
mentally alter their own pain experience. So we may ask the child to imagine or visualize
what their pain looks like to them. So for example, a child may visualize their
pain as a big, red ball of fire. Once they have an image of the pain in their
heads, we ask them to alter it in some way so it’s not affecting them or so it’s not
as strong anymore. So a child may imagine that they have a bucket
of water that they’re pouring over the fire to put it out so that the pain is not as strong
anymore. This can be very effective at reducing the
person’s subjective pain experience. We also used personal relaxation strategies. So if a child naturally enjoys something like
art, listening to music, taking a bath, reading magazines, anything like that, anything that
they already engage in that they find relaxing or distracting, we use that as well to help
support active coping. Sometimes kids just need to be reminded that
these strategies are already there in their repertoires and that they can be used to help
them manage pain episodes. One very important component of teaching these
relaxation strategies is that practice is key. So these are skills like anything else. Although we feel like we all breathe and use
our muscles naturally day to day, this is a very different type of breathing, muscle
relaxation, and imagery. And so the more kids practice, the better
they’ll get at it, and the more effective these skills will be for them. I generally recommend to patients that they
practice relaxation for 10 minutes once or twice a day, whether they’re in pain or not,
so that by the time they have a pain episode, they’re really good at these strategies and
they will be most effective. Biofeedback is a type of relaxation training,
which is often used in pediatric chronic pain. Biofeedback just involves getting information
about a biological process, and using that information to guide behavior. One form of biofeedback that we are all familiar
with is a scale. If you’re concerned about your weight, you
may step on the scale. And based on the number on the scale, you
can alter your diet or your activity level in order to change the number. The idea behind biofeedback is just using
technology to find out information about our bodies so that we can alter our behavior. In the sense of chronic pain, we use very
simple sensors to evaluate various aspects of the stress response– things like breathing
and heart rate, muscle tension, skin conductance, and peripheral temperature. All of these physiological processes are going
to be altered whether the person is in a relaxed state or a more stressed-out state. We use these sensors to get information about
how the child’s body is doing. And this information is shown on a computer
screen. Based on the information on the computer screen,
the child can use different relaxation strategies– deep breathing, imagery, whatever– in order
to relax their body and reduce those stress responses. This type of treatment has been found to be
really helpful for kids who are opposed to traditional talk therapy and more comfortable
with technology. A lot of adolescent boys find biofeedback
to be more acceptable to them because they don’t necessarily want to talk about feelings. But working with a computer feels more comfortable. It can also be really useful for increasing
buy-in for psychological treatment. A lot of kids with chronic pain may be resistant
to working with a psychologist because they feel like that may imply that their pain is
not real or it’s all in their head. It dismisses the physiological component of
pain, which is what a lot of people like to focus on. So by allowing people to try biofeedback and
showing them concretely that there are changes in their bodies that occur when they’re in
pain or when they’re stressed, and that they can use different relaxation strategies to
reduce those stress responses and help themselves feel better, people may increase their motivation
or acceptance to engaging in additional psychological therapies. Biofeedback can be used as a treatment on
its own independently. Or it may also be used as one component of
cognitive behavioral therapy in conjunction with the other coping strategies, as well
as the cognitive interventions. It’s been found to be really effective at
reducing pain in children and adolescents in a variety of chronic pain conditions, and
is particularly effective in pediatric headache. There’s a lot of really strong empirical evidence
for cognitive behavioral therapy in pediatric chronic pain. It’s been found to be effective at reducing
pain and in improving functioning in youth with chronic abdominal pain. It’s also been shown to be effective immediately
but also at long-term follow-up in children with a variety of chronic pain conditions. And most recently, online cognitive behavioral
interventions have been found to be feasible and effective at reducing pain and improving
functioning in use with chronic headache, abdominal pain, and musculoskeletal pain. The focus on online interventions recently
is very encouraging because it allows us to access a larger number of patients, particularly
those in areas where there are less psychological resources. Lastly, I’ll briefly talk about Acceptance
and Commitment Therapy, or ACT. ACT is an extension of traditional cognitive
behavioral therapy. However, there is a distinction between ACT
and CBT. ACT does not directly focus on changing thoughts
or feelings. Rather, negative thoughts and feelings are
accepted as a natural part of living a full life. It’s the attachment to and belief in these
negative thoughts and feelings that is challenged in ACT. In addition, in ACT, behavioral coping strategies
are not taught. Coping skills are seen as attempts to avoid
pain and distress and therefore, are not encouraged. In contrast, in ACT therapy, the therapist
may use mindfulness techniques and In Vivo Exposure to increase acceptance of pain and
distress. Mindfulness techniques include allowing one’s
thoughts, including uncomfortable and painful thoughts, to come and go in their mind like
leaves on a stream without getting attached to them. ACT also involves using In Viivo Exposure
exercises, supporting the patient in engaging in activities they may have previously avoided
because they were concerned that the activity may result in increasing pain. By allowing the person to engage in activities
they avoided before, despite the presence of pain, we can confront negative thoughts
and feelings about pain and help the person live a fuller life. ACT also involves focus on living a life based
on one’s values. If one’s values are to be a good student,
a helpful friend, a good athlete, but the pain is interfering in all of those domains,
an ACT therapist may help the patient focus on engaging in activities that are consistent
with their values, whether or not pain is in the picture. While ACT does involve addressing thoughts
and behaviors– and certainly the goal is increasing functioning and decreasing the
focus on pain– it’s done in a very different way than it is in traditional CBT. There’s some preliminary evidence for the
effectiveness of ACT in pediatric chronic pain, as well. It’s been shown to improve pain and functioning
in use with chronic musculoskeletal pain. It’s also been found to be more effective
than standard medical treatment at improving pain and functioning in adolescents. In adults with chronic pain, ACT was found
to be as effective as CBT at reducing pain interference, depression, and anxiety. So ACT is a promising new psychological treatment
for chronic pain, but more research is needed to support the use of ACT in pediatrics. Please help us improve the content by providing
us with some feedback.

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