SHIFTING THE APPROACH TO CHRONIC PAIN How to validate, educate, reframe, and collaborate on goals
David Becker, MD, MPH, MA, LMFT Clinical Professor, UCSF Department of Pediatrics UCSF Osher Center for Integrative Medicine Co-Medical Director, Pediatric Pain Management Clinic
OBJECTIVES
¡ Develop an approach to pain management that addresses the key components of: ¡ Validation
¡ Education
¡ Reframing
¡ Collaborative goal setting
¡ Define chronic pain
¡ Know how to describe how pain signaling works in developmentally appropriate language
CASE: KENDRA
Kendra is a 12 year old girl who returned to your office 2 weeks after being seen for a mild sprained ankle.
¡ Still tender to palpation
¡ Said she still needed her crutches to get around
¡ Repeat x-ray negative for a SH type I fracture
Orthopedics
¡ CAM boot
¡ After 2 more weeks…
Rheumatology
TAKE HOME POINTS
¡ These patients take time
¡ Assume they think that you think it’s all in their head
¡ There is no quick fix
¡ Engage the family
¡ Hold the hope and confidence in recovery
¡ Progress will happen slower than expected
¡ Functional recovery happens before pain improves
¡ Frame mental health referrals as coping supports
¡ De-medicalize
CASE: KENDRA
She returns a week later (after normal labs) and…
¡ The pain had spread to the knee and hip
¡ The leg remains exquisitely sensitive to light touch
¡ She now has complains of pain of the opposite leg and has intermittent numbness
¡ There is no history of color or temp changes or asymmetry
¡ No skin or vascular findings on exam
¡ Kendra is a perfectionist, is highly accomplished academically, and is a competitive gymnast. She appears anxious in the room. Her parents are frustrated and want help.
¡ Homeopath has diagnosed food allergies and started an elimination diet and several supplements
CASE: DIAGNOSIS?
1) Chronic Regional Pain Syndrome (RSD)
2) Illness Anxiety Disorder (Hypochondriasis)
3) Somatic Symptom Disorder (Somatization)
4) Amplified Pain Syndrome
5) Functional Neurological Symptom Disorder (Conversion Disorder)
CASE EXAMPLE – TREATMENT COURSE
¡ Validation, Reframing, Return to the history ¡ Overhead parent comment
¡ Intensive PT and OT
¡ Brief trial of an SNRI – intolerable side effects, no improvement
¡ Very gradual improvement over 2-3 months
¡ In person or telehealth visits every 1-3 weeks
¡ In 3 months: ¡ Walking around the house, much improved appetite and mood, having friends over
¡ How did we get here?
WHAT IS PAIN?
¡ All pain is a subjective sensory and emotional experience.
¡ Influenced by biologic, psychological, cognitive, and social variables.
¡ Sensory input is ascribed meaning by limbic and cortical brain regions
¡ Patient-specific responses are moderated by fears, hopes, expectations and memories
Zeltzer. Pain in Children &Young Adults. Shilysca Press. 2017
WHAT IS PAIN?
An unpleasant somatic or visceral sensation associated with actual, potential, or perceived tissue damage
UpToDate. 2017
tickling
Light touch sprain
migraine
broken bone
paper cut neuritis
active arthritis
Severe burn
Physical Psychological
Social Spiritual
bump
pinch
Sleep/fatigue
Conditioning
Inflammation
Sympathetic arousal
Peer relationships Academic pressure
Performance pressure
Anxiety
Resilience ACE’s
Depression
Catastrophizing
Past illness experience
Meaning of illness
Values
Religious faith
Experience of Pain
Connection Outside of Oneself
Family dynamics
DISCERNING SUFFERING FROM THE SIGNAL
“The absence of changes in the sensory component of pain perception and the lack of similar modulation within other pain-related cortical structures argue for a significant involvement of the ACC in the affective component of pain.”
WHEN DOES PAIN BECOME “CHRONIC”?
¡ When it persists past the normal time of healing - Bonica, 1953
¡ When it is disproportionate to the nociceptive input
¡ When it becomes a maladaptive response
WHEN DOES PAIN BECOME “CHRONIC”?
¡ Has the underlying injury had adequate time to heal?
¡ Has any underlying condition (inflammatory or otherwise) been shown to be in remission?
¡ Does the pain seem disproportionate to any persistent underlying issues?
AMPLIFIED PAIN SYNDROMES
¡ CRPS I and II
¡ Localized or diffuse idiopathic pain
¡ Chronic fatigue syndrome
¡ Fibromyalgia
¡ Functional abdominal pain
¡ Irritable bowel syndrome
¡ Chronic daily headache Hoffart CM, Wallace DP. Curr Opin Rheum 2014
CRPS: DIAGNOSTIC CRITERIA
1. Continuing pain, disproportionate to any inciting event
2. At least one symptom in three of the following four categories: ¡ Sensory: history of hyperalgesia and/or allodynia
¡ Vasomotor: history of temp asymmetry and/or skin color change and/or color asymmetry
¡ History of edema and/or asymmetric sweating
¡ History of decreased ROM and/or motor dysfunction (weakness, tremor, dystonia), and/or trophic changes (hair, nails, skin)
CRPS: DIAGNOSTIC CRITERIA
3. During the evaluation, at least one sign in two or more of the following four categories: ¡ Sensory: hyperalgesia (to pin prick) and/or allodynia (to light touch or joint movement)
¡ Vasomotor: temp asymmetry and/or color changes
¡ Edema or asymmetric sweating
¡ Motor/trophic: decreased ROM and/or weakness, tremor, dystonia; and/or trophic changes (hair, nails, skin)
4. No other diagnosis better explains the signs and symptoms
CASE EXAMPLE – TREATMENT COURSE
¡ Validation, Reframing, Return to the history ¡ Overhead parent comment
¡ Intensive PT and OT
¡ Brief trial of an SNRI – intolerable side effects, no improvement
¡ Very gradual improvement over 2-3 months
¡ In person or telehealth visits every 1-3 weeks
¡ In 3 months: ¡ Walking around the house, much improved appetite and mood, having friends over
¡ How did we get here?
STEPS IN CHRONIC PAIN ASSESSMENT AND MANAGEMENT ¡ History, History, History…
¡ Rapport, Rapport, Rapport… ¡ Validation and Clarification statements ¡ Summarize and Reframe ¡ Review the good news (negative studies) ¡ Begin to discuss moving forward with uncertainty ¡ Watch for cues to understanding, confusion, frustration… ¡ Discuss treatment options ¡ Engage and re-engage the family ¡ Follow up and adjust plans as needed
NON-PHARM IN U.S. PEDIATRIC PAIN CENTERS
Bodner et al. A cross-sectional review of the prevalence of integrative medicine in pediatric pain clinics across the US. Comp Ther Med, 2018
¡ Improved pain outcomes compared with sham-acupuncture and no-acupuncture control with response rates of: ¡ 30% for no acupuncture
¡ 42.5% for sham acupuncture
¡ 50% for acupuncture
JAMA March 5, 2014 Volume 311, Number 9
¡ Hypothesized to work through neurohumoral mechanisms ¡ Endorphins and other neurochemicals released locally and
centrally by acupuncture
¡ Pain-relieving effects of acupuncture have been reversed by naloxone
¡ Evidence of clinical efficacy in practice in children is limited ¡ Musculoskeletal pain, headaches, dysmenorrhea
¡ Referral success may depend on relative acceptance
MEDITATION AND PAIN
¡ Small study of adults with meditation experience
¡ Significant difference in the anticipation and negative appraisal of pain
¡ Mindfulness meditation may change anticipatory priming
Brown, Jones. Pain, 2010
Hoffart CM, Wallace DP. Curr Opin Rheum 2014
INITIAL TREATMENT APPROACH ¡ Begin reframing during the history and exam ¡ Educate about how the nerves are no longer firing correctly – use
metaphors ¡ Reinforce: this is not ‘in your head’ ¡ Graduated physical activity – PT/OT, other exercise ¡ Sleep support ¡ School attendance – required; use 504 plan ¡ Family support – name and address stressors ¡ Psychotherapy ¡ Medications ¡ Other non-pharm modalities ¡ If things are not improving, it means we need to change the plan
(what am I missing?)
HISTORY, HISTORY, HISTORY
¡ Treatment starts when you walk in the room
¡ How we communicate matters
¡ Leave your cynicism at the door but bring your sense of humor, even in face of severe pain
and always watch for how it lands!
HISTORY
¡ Be certain that they know that you know what their experience is, how bad it’s been, and whether anyone’s listened to them yet.
¡ Watch for non-verbal communication and speak to it.
¡ Take your time and stay curious
HISTORY
¡ Coping strategies ¡ What do you do to help yourself?
¡ How are you getting by?
¡ What does your Dad do when he gets stressed? Your Mom?
¡ Has anyone taught you how to manage your stress?
¡ Complementary or alternative treatments:
¡ What have you tried?
¡ What’s worked? Not worked?
¡ What has been your experience with other doctors? Specialists?
NOCEBO EFFECT
¡ Def: the occurrence of a negative outcome or symptom when the expectation of one is stated or suggested.
¡ Examples: ¡ This medication can cause nausea, headache, rash, glaucoma, etc…
¡ Knowledge of receipt of pain/anxiety medication augments efficacy (placebo)
¡ Knowledge of discontinuation of pain/anxiety medication reduces duration of efficacy (nocebo)
Science. 2017 October 06; 358(6359)
JUST BREATHE NORMALLY…
“This will hurt a bit! There will be a little poke!”
“Little sting here!—Little sting here again!”
“You shouldn’t feel anything sharp”
Can words hurt? Pain 114 (2005) 303–309
“Let us know if you feel pain”
“OK! It’s going to be really hot!” “It will feel like a bee sting”
“Are you uncomfortable? This isn’t ideal, I know. If you’re not comfortable, you let me know.”
NOCEBO EFFECTS: Context Matters
Rossettini et al. BMC Musculoskeletal Disorders (2018) 19:27
METAPHORS AND EXAMPLES
¡ Fire station alarm
¡ Electric guitar amplifier
¡ No ‘noise’ means increase the noticing
¡ Phantom limb pain and mirror box therapy
¡ Tightened net or mesh
¡ Hurt not Harm
¡ Keep the pain until you don’t need it anymore
MIRROR BOX THERAPY
PAIN PREVENTION
¡ Use medications wisely ¡ Drugs are not the only answer
¡ Don’t undertreat acute pain, and…
¡ Always incorporate non-pharm options
¡ Instill confidence in healthy recovery ¡ Model for the parents and teach them to model for their kids
¡ “I wonder which of your tools you going to use to cope until that pain isn’t needed any more?”
¡ Shift from external to internal locus of control
TAKE HOME POINTS
¡ These patients take time
¡ Assume they think that you think it’s all in their head
¡ There is no quick fix
¡ Engage the family
¡ Hold the hope and confidence in recovery
¡ Progress will happen slower than expected
¡ Functional recovery happens before pain improves
¡ Frame mental health referrals as coping supports
¡ De-medicalize
FAP-IBS
¡ H, H, H
¡ R, R, R
¡ Work-up needed?
¡ Two key domains: ¡ Nutrition
¡ Stress management
How we talk reflects how we think, what we believe, how we teach and what we come to expect.
- Dan Kohen
