Pain, Pain Go Away - How Behavioral and Rehabilitation Therapies Helps Kids Manage Chronic Pain
Online Health Chat Transcript with Dr. Gerard Banez June 16, 2009
Cleveland_Clinic_Host: Today's Live Web Chat with Gerard Banez, PhD begins at 12 noon EST. He will be answering a variety of questions regarding chronic pain management in teens and children. Please submit your questions by typing them below and then clicking 'Ask.'
Living in constant pain is difficult for anybody – but for children and adolescents, it can be almost unbearable. As a parent or caregiver, you may feel helpless and frustrated as you watch your child: drop out of sports and outside activities, avoid personal and family responsibilities, miss school and stop doing things with their friends, experience increased stress and/or develop symptoms of depression and anxiety, give up their dreams and goals, and feel increased hopelessness. Your child is not alone...nor are you. The Pediatric Pain Rehabilitation program at Cleveland Clinic Children's Hospital is specifically designed for children and teens whose chronic pain interferes with their normal activities. Our number one goal is to get your child back to doing things they love to do – despite their pain.
Gerard A. Banez, PhD, is a pediatric psychologist at Cleveland Clinic Children's Hospital, where he serves as Program Director for the Pediatric Pain Rehabilitation Program and leads the Behavioral Pediatrics Treatment Service. His clinical/research interests include pain-associated disability syndrome, pediatric functional gastrointestinal disorders, elimination disorders and vocal cord dysfunction.
Cleveland Clinic Children’s Hospital interdisciplinary team of specialists addresses each child's individual needs. Children are examined by the appropriate pediatric specialist(s) to better understand their pain condition. For example, a pediatric neurologist will evaluate a child with headaches. A pediatric rheumatologist will assess a child with fibromyalgia. Children are admitted into the program when there is agreement that an intensive, coordinated team approach is needed. Over the course of the program, our staff will communicate with you on a regular basis regarding the status of your child.
The two-part program consists of inpatient and day hospital components. The program's length is tailored to each child's needs, but children are typically seen for three weeks – two weeks as inpatients, and one week as day hospital patients. As inpatients, children and adolescents are often initially seen and treated apart from their parents. This allows them to concentrate on their care, and gives our team the chance to observe and treat them independently. Parents will have meetings with various team members and can visit with their children in the evenings.
Our Children's Hospital Pediatric Pain Rehabilitation Program is the only one of its kind regionally. Nationally, it is the only program that consists of both an in-patient AND out-patient component.
Today, join us as Dr. Gerard Banez discusses a variety of questions regarding chronic pain management in teens and children. To make an appointment with Dr. Gerard Banez, or our Children's Hospital Pediatric Pain Rehabilitation Program, please call 216.636.KIDS (5437) or visit us online at www.clevelandclinic.org/kids
Welcome to our Online Health Chat with Dr. Gerard Banez. We are thrilled to have him here today for this chat. Let’s begin with some of the numerous questions we have received.
Chronic Pediatric Pain
FRAN007: My daughter has been experiencing foot pain - hot feels cold and cold feels hot to her. Is this normal?
Speaker_-_Dr__Gerard_Banez: Temperature changes like you describe could be symptomatic of certain pain conditions. I would suggest that you discuss this with your primary care physician to begin evaluation of the pain and temperature changes.
Daizee396: Do people have different pain thresholds and is pain tolerance higher in children?
Speaker_-_Dr__Gerard_Banez: Yes, all people, including children, have different pain thresholds. Pain tolerance is not necessarily higher in children.
Pain experience can be affected by a number of factors including the source or cause of the pain itself as well as our thoughts, feelings, the situation, amount of control perceived over the pain. All of these things will vary from individual to individual.
supermon1987: What special considerations should be made when treating pain in children?
Speaker_-_Dr__Gerard_Banez: Treatment options vary between medicines, procedures, psychological and behavioral therapies and physical therapy. The types of medications, procedures, psychological, behavioral therapies and physical therapy appropriate for adults may not be the most helpful for kids. Therefore, it is recommended to pediatric pain specialists.
elderson: What should you do if your child has back/low back pain? Is back pain common in young children?
Speaker_-_Dr__Gerard_Banez: First, go to be evaluated by your pediatrician to determine and assess the cause of the pain and appropriate treatment. Back pain is not one of the most frequently seen problems in children, but it is not uncommon.
Back pain may be associated with a number of different conditions and therefore is important to be evaluated thoroughly.
bobbyb: Since my child suffers with chronic pain will it affect him for the rest of his life?
Speaker_-_Dr__Gerard_Banez: This is difficult to determine. The answer falls into three categories. Some kids with chronic pain will outgrow their pain. Some continue to have the pain for the rest of their life. The third group of kids with chronic pain will have intermittent pain episodes.
Complex Regional Pain Syndrome (CRPS), or RSD
brown_karen: What are the symptoms of RSD? Is RSD connected with Muscular Dystrophy?
Speaker_-_Dr__Gerard_Banez: Symptoms for Complex Regional Pain Syndrome (CRPS), or RSD include:
- Pain in one or more limbs and/or ankles, feet, or hands
- Pain disproportionate to original injury
- Pain that lingers long after trauma has healed
- Pain that appears after a traumatic event, like a broken bone, automobile accident or bad fall
- Pain described as burning or sharp, coldness and swelling in the affected limb(s), and allodynia (intense pain with light stroking or touching of the skin)
- More common among pre- and adolescent girls than boys by about 5:1
- Usually seen in girls who engage in sports, dancing, or gymnastics
- Affects between 200, 000 and 1.2 mil Americans overall
Speaker_-_Dr__Gerard_Banez: The actual cause of CPRS remains unknown.
- Overuse injuries, trauma, psychological stress, nutritional factors, hormones are possible contributors
- Reflects dysfunction (overreaction) of ANS (transmission of pain signals after initial injury)
How is Complex Regional Pain Syndrome (CRPS), or RSD diagnosed?
- No single test for CRPS/RSD
- Clinical diagnosis is made by patient history, thorough examination, and the results of numerous tests (to rule out serious causes – neurological, vascular, breaks, tears, inflammation)
CRPS/RSD not life-threatening, but it can become chronic and even spread to other parts of the body. It can last for years and disrupt lives by interfering with daily activity. It is also noted that children with CRPS miss 25% of school days
Will it go away?
Early diagnosis and treatment offer the highest probability of remission
What can we do about it?
- Physical Therapy (PT) of affected body part (desensitizes and restores function – strength, endurance, range of motion)
- Drug therapy and other techniques such as nerve blocks (injection of nerve numbing substance to block pain), TECs (small catheter placed in epidural space in spinal column, providing small dose of pain killing medication during rehabilitation), SCSs (implantable medical device that sends electrical impulses to spine, affecting pain perception)
- Mind-body approaches, like relaxation, biofeedback, self-hypnosis
- Psychological treatment to assist with coping and emotional responses
- Family therapy to promote adaptive parental/familial responses.
marydb: Since my daughter has been diagnosed with RSD I’ve noticed more frequent mood swings and I’m worried she is becoming depressed. She doesn’t want to talk what can I do to help?
Speaker_-_Dr__Gerard_Banez: Mood swings, depression and other emotional symptoms are not uncommon among children with chronic pain. Living with chronic pain can be stressful and result in various adjustment difficulties.
Be certain that your daughter is receiving appropriate medical care for RSD. Psychologists and other mental health providers familiar with RSD can help her deal with her pain, cope with her stress and improve her quality of life.
Pediatric Chronic Pain and Medications
clintons: Is it okay to take nonprescription pain relievers in addition to regular prescription pain drugs?
Speaker_-_Dr__Gerard_Banez: The best thing to do is to consult with your physician about which type of non-prescription pain relievers would work with the prescribed pain meds.
Sleep and Chronic Pain
newtonm: My son is in so much pain that he is not sleeping which has been keeping me up as well. Now I’m exhausted and having trouble getting through my daily activities. How does sleep affect chronic pain?
Speaker_-_Dr__Gerard_Banez: We know that sleep and chronic pain are affected in a number of ways. Many kids with chronic pain have difficulty falling asleep and staying asleep because of their pain and discomfort. As a result of their fatigue, the pain felt during the day may often feel worse and be more difficult to deal with. What we often find is that kids with chronic pain will have unusual sleep cycles where they go to bed very late and then sleep for long periods of time, not getting up when they are supposed to. Thus getting up and going to school becomes difficult.
We also find that kids not sleeping well during the night are taking naps during the day which makes the cycle worse. It is important to emphasize regular sleep-wake schedule.
Physical Activity and Chronic Pain
newtonm: If physical activity causes my child pain, why is it important to do it anyway? Could my child get hurt?
Speaker_-_Dr__Gerard_Banez: First it is important to distinguish between acute pain (recent onset and directly related to injury or trauma) vs. chronic pain.
For kids who have chronic pain, physical activity is very important. What we have found is that for kids with chronic pain, the less active they are, the more risk of disability related to the pain is seen. Increased physical activity will improve strength and endurance. For those reasons, kids will feel better.
Physical activity also results in release of brain chemicals that provide pain relief. The more active kids are doing things that they like, the less they think of their pain, the better their mood and quality of life becomes.
PFT229: My daughter was very athletic before she was diagnosed with RSD. Now she is concerned she will get out of shape. Should she keep exercising even when she is in pain?
Speaker_-_Dr__Gerard_Banez: For most people with RSD, exercise and physical activity are actually the treatment of choice. Exercise and physical activity are what we do here in our program.
I would advise for you with your physician to seek out a Physical Therapist to design a program specifically for her.
School and Chronic Pain
worriedmom: My daughter’s pain is so bad on some days that she can’t go to school. I know that doesn’t solve anything but our doctor can’t find anything wrong. What else can I do?
Speaker_-_Dr__Gerard_Banez: For kids with pain problems, we encourage daily school attendance as the norm.
It is important that kids maintain structure and normal activity despite their pain problems. When kids miss school, they fall behind in classes, become more socially isolated which in turn may cause stressors that can make their pain worse.
It is also important to seek the assistance of a pediatric psychologist or pediatric pain specialist who will help your daughter maintain age appropriate functioning.
Fibromyalgia and Chronic Pain
happydays: My son was diagnosed with fibromyalgia when he turned 13 years old. Recently, we've been hearing about success with acupuncture. Is there any proof to validate these claims?
Speaker_-_Dr__Gerard_Banez: Acupuncture and other complementary and alternative approaches have become increasingly popular for chronic pain. Clinically, some individuals have reported much benefit from acupuncture treatment because individuals vary in their response to treatments. It is difficult to predict how your child would respond. I would suggest discussion with your pediatrician to determine how this utility would work for your child.
Pediatric Migraine Chronic Pain
silverandgold: My daughter has been getting headaches and migraines starting around age 5. Will this have an impact on her development as she gets older?
Speaker_-_Dr__Gerard_Banez: With appropriate medical care, psychological care and other therapies as indicated, kids with migraines and other pain conditions can maintain normal activity and achieve to their potential. With lifestyle changes, this does not have to have a negative impact.
Summer Camp and Chronic Pain
nystrom: If you are trying to maintain normality for your child - what would you do about summer camp? What kind of information would be important for (sleep-over) camp staff to know when dealing with your child?
Speaker_-_Dr__Gerard_Banez: Make sure that you have in writing from the physician; psychologist or physical therapist what types of activities should be tolerated by your child.
- Encourage Normal Activity:
- Frequent approval for maintaining activity patterns.
- Encourage child to stay calm and practice relaxation where feasible.
- Advocate camp activity attendance or stay with the group doing the activity.
- To Discourage Pain Behavior:
- Ignore excessive complaining, pain gestures, and request for special treatment and assistance. Instruct others to do the same if necessary.
- Dispense medications for symptomatic relief according to directions and follow recommended time sequence.
- Evaluate whether the consequence of the pain behavior is to avoid or escape from an activity or situation. If so, consider maintaining things as they are or alternative (e.g., bed rest) that has little appeal to child.
- Avoid questioning about presence of pain or status of pain.
Pediatric Pain Rehabilitation Programs
samcat13345: How many programs like yours exist?
Speaker_-_Dr__Gerard_Banez: There are only a handful of interdisciplinary pediatric pain rehabilitation programs in the U.S. Most other programs are day treatment programs. The program that we offer at Cleveland Clinic is unique because it provides both an inpatient and outpatient components. We believe that the inpatient component of our program allows us to teach and instill important life style habits and behaviors effectively, while the day hospital (out patient component) helps to facilitate a successful transition from hospital to home.
Lifestyle Changes for Kids with Chronic Pain
Charliesmom: Charlie has been suffering with chronic pain since he was 10. He is now 12 and very self conscious. Is there anything our friends and family can do to help with his pain?
Speaker_-_Dr__Gerard_Banez: Encourage as much normal activity as possible so that he does not view himself entirely defined by his pain. Promote daily school attendance, social interactions with peers, participation in sports and other extra curricular activities.
It is also important maintain open and non-judgmental lines of communication with your child. Again pediatric psychologists and mental health professionals can play a huge role with chronic pain.
babybird213: It sounds like lifestyle changes often help reduce pain symptoms. Are there any other modifications you would recommend?
Speaker_-_Dr__Gerard_Banez: As I just stated in the previous question, there are good care and treatment options available for children who have chronic pain. It is vital for parents to be strong advocates for their child.
Critical to the success of any child experiencing pain is the acceptance and commitment to the fact that he/she can live a normal and valued life despite pain.
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Gerard Banez is now over. Thank you again Dr. Banez, for taking the time to answer our questions about the numerous options for chronic pain management in teens and children.
Speaker_-_Dr__Gerard_Banez: Thank you for having me here today. In closing, it is important to know that “pain is pain and suffering is optional.”
I hope that this chat has given you some direction regarding your pain concerns.
For more information about Children's Hospital Pediatric Pain Rehabilitation Program and our specialists at Cleveland Clinic you may visit clevelandclinic.org/kids.
To make an appointment with Dr. Gerard Banez, or our Children's Hospital Pediatric Pain Rehabilitation Program, please call 216.636.KIDS (5437)
A remote second opinion may also be requested from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, eclevelandclinic.org/myConsult
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