Issues Magazine

Kids Get Chronic Pain Too

By Kathleen Cooke

A holistic plan is essential, including physical, emotional and social support, to manage chronic pain in adolescents and children.

I feel like my foot is on fire and I cannot walk on it. Nothing helps, no one knows why, no one believes me. – TJ, aged 12

TJ rolled her ankle playing netball. Although it was strapped and she rested as recommended, her ankle pain worsened. She had a normal X-ray and MRI scan but her foot changed colour and went cold. She could not sleep, concentrate or go to school. Her Mum was forced to take time off to attend multiple appointments and look after her.

After 12 weeks, TJ was diagnosed with complex regional pain syndrome of her foot. It was only after the hard work and support from a dedicated pain management team, including a physiotherapist, occupational therapist, psychologist and pain specialist, that TJ learnt to manage her pain. She recovered to play netball with her friends again.

Approximately 20% of children and adolescents suffer recurrent or chronic pain. More than 100,000 children and adolescents are estimated to be suffering from persistent pain at any one time in Queensland.

Chronic pain is less obvious than acute pain (which is associated with physical injuries such as a broken leg), but it is equally debilitating, incessant and, too often, suffered in silence.

Chronic pain lasts longer than the expected time for an illness or injury to heal, or is associated with recurrent ongoing illness. Pain in this instance no longer serves as a warning sign to protect the body from harm; it is a disease in itself.

Pain signals stem from interactions between the brain and the rest of the body. If the body has been in pain for a long time, the brain can continue sending pain signals, even if no tissue damage or problems with the body remain. At this point, pain is no longer a symptom of another problem – it is the condition itself.

The most common types of chronic pain in children and adolescents are headaches, recurrent abdominal pain, musculoskeletal pain (back, legs, joints) and other types including complex regional pain syndrome, arthritis-related pain, and pain post-cancer survival or post-surgery.

It is more common in girls than boys, with a peak incidence at 14 years of age. Girls use more health care, medications and non-drug methods of pain control.

The gender bias in the reporting of pain may be associated with greater societal acceptance of girls complaining of pain and seeking help. Boys may resort to alternative approaches such as acting out, school truancy, anxiety and depression.

Headaches increase with age and tend to affect more girls than boys, with 5% of headaches converting to migraines in adulthood, especially with a positive family history. However, tension-type headaches are more common and can be associated with anxiety or depressed mood. Keeping a diary to manage triggers and symptoms can be very helpful.

Recurrent abdominal pain tends to be more common in younger children and decreases with age. Musculoskeletal pain can affect both children and adolescents.

Complex regional pain syndrome can be the result of either a minor injury or nerve injury that results in abnormal pain signals. It can be associated with temperature, hair and colour changes in the affected limb. In children it usually affects the lower limb. Treatment requires a team approach to retrain the brain and pain pathways in the body to control pain signals again. Children with this condition, if treated early and appropriately, largely do well.

If left untreated, chronic pain not only places a physical, emotional and financial strain on the affected children and their families, but also on their support network – their friends and their school. Children and parents often worry that there must be a definitive cause for the pain.

Children and adolescents are often anxious that their pain will worsen or never get better. They are also very conscious of what other kids will think. This leads to a cycle of fear and stress that interferes with their daily lives. Pain stops them going to school, participating in sports or arts that they enjoy, and from just being kids.

Increasingly, children can become isolated from their friends, peers and social network. This can lead to sadness and an increase in pain, as it becomes the sole focus.

About 62% of children diagnosed with chronic pain continue to experience pain for a prolonged period of between 1 and 5 years. More than half of those continue to report pain that is highly frequent, adversely impacting their activities of daily living and necessitating active pain control interventions.

Restrictions on daily activities tend to be related to the intensity of the pain. Children and adolescents with reported pain experience sleep problems (54%), inability to pursue hobbies (53%), eating problems (51%), school absence (49%) and inability to meet friends (47%). Pain frequency and restrictions on daily activities increase with age.

Fifty per cent of children and adolescents with pain seek professional help and 52% report using pain medications. Yet there are significant barriers to the provision of health care in this population, including lack of knowledge, training and education among healthcare providers. Outmoded beliefs, such as “children do not get chronic pain”, and misconceptions about paediatric pain and analgesia continue to prevail. Resources and funding for multidisciplinary pain management services specifically for children are lacking, although they do exist in some paediatric hospitals.

Management of chronic pain is to initially exclude a preventable or fixable cause for the pain. General practitioners are a common referral point to tertiary centres for paediatrics and to pain medicine specialists. We then aim to provide a holistic approach to the pain management involving physical, emotional and social components. Children and adolescents do well in paediatric facilities that provide a team approach to pain management, including physiotherapy, occupational therapy, psychology, music therapy and pain medicine specialists.

Physical treatments include medication, as appropriate, and physiotherapy. Often hydrotherapy is a helpful first step in treatment because this is fun, allows movement without necessarily requiring weight-bearing, and the warmth of the water helps with inflammatory pain. Some regular exercise is good to increase the child’s own natural endorphins and adrenaline to fight the pain. Hot or cold packs can be useful.

Sleep is often interrupted by pain. Sleep is important for restoring chemicals of the body such as adrenaline and natural endorphins that help fight pain through the day. Strategies for sleep, such as reduced stimulation prior to bed, having a set bedtime, warm milk, relaxation and music are worth trying to ensure maintained sleep patterns.

Emotional support is essential because chronic pain is a major challenge, both physically and emotionally. It can be difficult to mobilise with pain and remain positive.

Psychologists and occupational therapists help to encourage positive thinking and set realistic, achievable goals for return to activity, including school. They also provide assessment of factors such as anxiety and sadness, which may hamper return to function and reduction in pain levels.

Relaxation techniques and distraction can change the experience of pain and make it more manageable. These need to be learned and then practised to be effective. Children have good imaginations and can utilise these techniques once learnt.

Social support and a team approach including doctors, therapists and the school is necessary to manage chronic pain because it often disrupts daily function for these children and adolescents. The family dynamics can also be disrupted, especially if there are large amounts of time off school, multiple medical interventions and investigations leading to parental time off work.

It is very difficult for parents to see their children suffer with pain. Being sympathetic, while also setting limits and encouraging healthier responses to pain and maintaining daily functioning, can be hard. Chronic pain can be managed to return function and fun to this important stage of life.

Chronic pain in children and adolescents is a major problem and can affect many aspects of life: physical, emotional and social. However, with the correct approach it can be managed to limit the impact, now and in the future.