heather chapman, md 1 and jack nassau, phd 2 1 clinical assistant professor of pediatrics and staff...
TRANSCRIPT
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Pain in Pediatric Primary Care: Lessons from a Med-Psych Day
Treatment ProgramHeather Chapman, MD1 and Jack Nassau, PhD2
1Clinical Assistant Professor of Pediatrics and Staff Pediatrician,2Clinical Associate Professor of Psychiatry and Human Behavior
and Chief Psychologist
Alpert Medical School of Brown UniversityHasbro Children’s Partial Hospital Program, Rhode Island Hospital
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DisclosureDr. Chapman does not have any conflicts of interest
to disclose
Dr. Nassau does not have any conflicts of interest to disclose
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got pain?
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Objectives
Describe the biopsychosocial model of pain
Understand the benefits of functional pain assessment
Develop strategies for incorporating the biopsychosocial model in primary care pain assessment and management
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What is Pain?“An unpleasant sensory and emotional experience
associated with actual or potential tissue damage, or described in terms of such damage.”
Pain is always a psychological state that cannot be reduced to objective signs. In other words, pain is always subjective.
Extensive tissue damage may occur without pain Pain may occur in the total absence of tissue
damage
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Pictures of:
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Pain is aBiopsychosocial Experience
Biological Site - Pain is absolutely real and is physically experienced
Psychological “Interpretation” – “No brain, no pain”
Social Context – “Pain is felt where you hurt and where you are”
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Biological Stress ReponsesAutonomic Nervous System
Sympathetic-Adrenal-Medullary (SAM) System Catecholamines (epinephrine, norepinephrine) released into
blood via sympathetic nerve endings and adrenal medulla Increased blood pressure, heart rate, sweating, and
constriction of peripheral nerve endings “Fight or flight” response
Central Nervous SystemHypothalamic-Pituitary-Adrenocortical (HPA) Axis
Hypothalamus releases corticotropin releasing factor >> pituitary releases adrenocorticotropic hormone >> adrenals release cortisol
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Things You Can Change
(Think)
Cognitive Understanding Control Expectations Relevance Pain Control Strategies Tissue Damage Or Pain Source
(Do) Behavior Overt Actions Response of Others Physical Restraint Physical Activities Social Activities Age Gender Cognitive Previous Pains Family History Culture
(Feel) Emotional Anxiety Fear Frustration Anger Depression Pain Sensation Pain Experience
Things You Can’t Change
Adapted from McGrath, P.A, & Miller, L.M. (1996). Controlling children’s pain. In R.J. Gatchel & D.C. Turk (Eds.), Psychological approaches to pain management: A practitioner’s handbook (pp. 331-370). New York: Guilford.
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Possible pain “signs” in childrenVerbalEmotionalBehavioralPhysiological
Avoidance, somatic complaints (headache, stomach ache), fatigue, irritability, disrupted appetite/sleep, “clinginess”, regressive behaviors
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Traditional Pain AssessmentLocationFrequencyDurationIntensity
What’s missing???
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Biopsychosocial Pain AssessmentLocationFrequencyDurationIntensityFunctional Impact
MoodBehaviorFamilySchool
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Functional Pain Assessment Tool Functional Assessment ToolHasbro Children’s Partial Hospital Program
Date:
Time
Pt reports
Pain (Y/N)
Activity/Behavior at assessment
FACES pain rating
(Pt report)
Functional rating
(Pt report)
FACES pain rating
(RN report)
Coping Strategies/Interventions
RN initials
[i]
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Functional Pain Assessment Tool FACES scale
0 2 4 6 8 10No pain/hurt Very much pain/hurt Functional Scale: (1) MILD = You know the pain is there, but it doesn’t bother you
much. (2) MODERATE = The pain does bother you, but you can still do things. (3) SEVERE = The pain bothers you a lot, you can’t do very much (4) VERY SEVERE = You can’t do anything but rest. RN Initials RN Signature/Print Name Date/Time _____ __________________________________ ________ _____ __________________________________ ________
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Pain Management StrategiesMedical ProviderPatientFamilyProfessional referral
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Pain Management Strategies –Medical Provider
Framework - Holistic approachMedical testing and treatment AND psychosocial
contextEmphasize mind-body connection
Mental and emotional factors are important even when medical findings are positive
The lack of a positive medical finding does not mean the pain is “all in my head”, “unreal”, or “made up”
Possible questionsWhat are you doing to manage the pain?How does the pain affect your mood? How does your
mood affect the pain?
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Pain Management Strategies– PatientPain monitoring (clinical implications)Stay active - exercise releases endorphinsSleep schedule
Actively focus/attend to other things – sometimes called distraction
Diaphragmatic breathing
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Pain Management Strategies - FamilyValidate pain experience and expectation for pain
managementLimit attention to pain symptom
Limit asking about painRespond to pain complaint with questions/directions
related to managementFocus on functioning rather than pain intensity Encourage pain coping strategiesMaintain normative expectationsMake decisions that empower person, not pain
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Pain Management Strategies Professional Referral
Family TherapyFocuses on influencing family stressors, relationships, and behaviors
Cognitive behavioral therapyFocuses on addressing pain related thoughts, emotions and behaviorsIncludes setting specific functional goals
Relaxation TrainingA group of techniques designed to produce physiological,
psychological and behavioral changesSpecific rationale to decrease arousal, muscle tension, and negative
mood statesBiofeedback
Instrumentation that provides data on psychophysiological processes that are not usually consciously available to the person, but can be brought under voluntary control
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Family TherapyA child’s pain affects the whole familyHelp family adopt a holistic view that acknowledges
the child’s (and family’s) physical and emotional functioning
Model this same approach – support appropriate medical treatments
Support child, parents, entire family in functioning through pain despite fear of doing so
Address specific family pain responses/behaviorsAddress additional family stressors or relationship
patterns that may be influencing pain expression
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Cognitive Behavioral TherapyRecognizes the
interrelationships between thoughts, feelings and actions (behaviors)
Work on changing thoughts, behaviors, and emotions to manage pain experience
Cognitive restructuringGraduated exposure to
increase functioning (goal setting)
Positive reinforcement for task completion
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Changing Maladaptive Pain ThoughtsAddressing automatic negative thoughts with
positive coping statements
>>>“I’m always in pain!” “I usually feel good in the afternoon.”
“I can’t do anything because of my pain!”
>>> “I can still ______ even thoughI have pain.
Limit catastrophizing and “all-or-none” thinking
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Relaxation TrainingA skill that develops with
repetition over timeAn active and empowering
strategy (not merely “relaxing” in front of the TV)
Attend to environment and body position
Diaphragmatic breathingProgressive Muscle
RelaxationGuided imagery
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Diaphragmatic (Belly) BreathingOften recommended, not given adequate trialPacing and mechanics are related and both are
importantThoracic “Chest” breathing is more common
Uses chest muscles; leads to faster, shallower breathsDiaphragmatic “belly” breathing
Uses diaphragm muscle; leads to slower, deeper, and longer breaths
In through nose, out through mouthBelly should rise on in-breath, collapse on out-breath
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PMR and Guided ImageryProgressive Muscle Relaxation
Typically done sitting upSeries of tensing and relaxing muscle groupsFocus on noticing the difference between tension
and relaxation so that tension can be a cue to relax
Guided ImageryOften done reclining or laying downUse mental imagery and associate it with relaxing
and pain relieving words, sensations, and suggestions
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Purple = Finger temperatureOrange = Skin conductance levelGrey = Skin conductance responseGreen = Forehead muscle tension
Biofeedback
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Things You Can Change
(Think)
Cognitive Understanding Control Expectations Relevance Pain Control Strategies Tissue Damage Or Pain Source
(Do) Behavior Overt Actions Response of Others Physical Restraint Physical Activities Social Activities Age Gender Cognitive Previous Pains Family History Culture
(Feel) Emotional Anxiety Fear Frustration Anger Depression Pain Sensation Pain Experience
Things You Can’t Change
Adapted from McGrath, P.A, & Miller, L.M. (1996). Controlling children’s pain. In R.J. Gatchel & D.C. Turk (Eds.), Psychological approaches to pain management: A practitioner’s handbook (pp. 331-370). New York: Guilford.
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THANK YOU