Reviewing the evidence presented here, a number of issues are apparent. First, that there is a great deal of variation across physically disabling conditions in the extent to which biopsychosocial factors have been investigated. Second, that over all the conditions considered, social factors are relatively less well explored and this remains a significant omission in the literature. Despite this, and the variation in the patterns in each specific physically disabling condition, across the majority of the conditions for which data is available it is clear that there is evidence to suggest that psychological and social factors are broadly related to pain intensity, as well as associated disability and distress. Across all the factors which have been investigated thus far, it appears that the findings related to pain catastrophizing and its association with pain intensity and related disability and distress are the most consistent. This suggests that pain catastrophizing should be explored as part of assessment protocols for people with chronic pain associated with physically disabling conditions. Further research in the area is clearly needed, particularly prospective studies that begin prior to the development of chronic pain, and which are sufficiently large to permit demographic and medical factors to be controlled for in the analyses.

#### **4. Interventions focused on psychological and social factors**

There are two major reasons why psychosocial interventions for pain might be considered for people with chronic pain secondary to physically disabling conditions. The first, that psychosocial variables are important contributors to variance in pain itself, as well as pain related distress or disability, and the second, that existing interventions based on biomedical models of pain are insufficient. The evidence presented in the previous section suggests that, while there are gaps in the literature, there is sufficient reason to think that psychosocial variables do make a significant contribution to pain and associated distress and disability. In addition, there is evidence that people with chronic pain secondary to a range of physically disabling conditions, including cerebral palsy, stroke and multiple sclerosis, are unlikely to be receiving treatment for their pain, are dissatisfied with the pain treatment available to them or report limited improvement in pain despite treatment (Engel, et al., 2003; Hirsh, et al., 2010; Kalia & O'Connor, 2005; Kong, et al., 2004).

Psychosocial interventions for people with chronic pain, predominantly behavioural and cognitive behavioural in origin, are well-established and supported by an extensive evidence base (Meldrum, 2007). A series of systematic reviews and meta-analyses attest to the efficacy of these programs among child and adults with primary chronic pain conditions, as well as early interventions designed to reduce the development of pain-related disability (Eccleston, Morley, Williams, Yorke, & Mastroyannopoulou, 2002; Eccleston, Yorke, Morley, Williams, & Mastroyannopoulou, 2003; Linton & Nordin, 2006; Morley, Eccleston, & Williams, 1999).

#### **4.1 The nature of psychosocial interventions**

A very small number of studies have been published that specifically report on the use of psychosocial interventions among people with physically disabling conditions. The majority

perception of their significant others solicitous responses to their pain behaviours. One study in people with spinal cord injury reported on partner's ratings of their own responses to pain behaviour, and it was notable that these were unrelated to pain intensity, depression

Reviewing the evidence presented here, a number of issues are apparent. First, that there is a great deal of variation across physically disabling conditions in the extent to which biopsychosocial factors have been investigated. Second, that over all the conditions considered, social factors are relatively less well explored and this remains a significant omission in the literature. Despite this, and the variation in the patterns in each specific physically disabling condition, across the majority of the conditions for which data is available it is clear that there is evidence to suggest that psychological and social factors are broadly related to pain intensity, as well as associated disability and distress. Across all the factors which have been investigated thus far, it appears that the findings related to pain catastrophizing and its association with pain intensity and related disability and distress are the most consistent. This suggests that pain catastrophizing should be explored as part of assessment protocols for people with chronic pain associated with physically disabling conditions. Further research in the area is clearly needed, particularly prospective studies that begin prior to the development of chronic pain, and which are sufficiently large to

There are two major reasons why psychosocial interventions for pain might be considered for people with chronic pain secondary to physically disabling conditions. The first, that psychosocial variables are important contributors to variance in pain itself, as well as pain related distress or disability, and the second, that existing interventions based on biomedical models of pain are insufficient. The evidence presented in the previous section suggests that, while there are gaps in the literature, there is sufficient reason to think that psychosocial variables do make a significant contribution to pain and associated distress and disability. In addition, there is evidence that people with chronic pain secondary to a range of physically disabling conditions, including cerebral palsy, stroke and multiple sclerosis, are unlikely to be receiving treatment for their pain, are dissatisfied with the pain treatment available to them or report limited improvement in pain despite treatment (Engel,

Psychosocial interventions for people with chronic pain, predominantly behavioural and cognitive behavioural in origin, are well-established and supported by an extensive evidence base (Meldrum, 2007). A series of systematic reviews and meta-analyses attest to the efficacy of these programs among child and adults with primary chronic pain conditions, as well as early interventions designed to reduce the development of pain-related disability (Eccleston, Morley, Williams, Yorke, & Mastroyannopoulou, 2002; Eccleston, Yorke, Morley, Williams, & Mastroyannopoulou, 2003; Linton & Nordin, 2006; Morley, Eccleston, & Williams, 1999).

A very small number of studies have been published that specifically report on the use of psychosocial interventions among people with physically disabling conditions. The majority

permit demographic and medical factors to be controlled for in the analyses.

**4. Interventions focused on psychological and social factors**

et al., 2003; Hirsh, et al., 2010; Kalia & O'Connor, 2005; Kong, et al., 2004).

**4.1 The nature of psychosocial interventions**

or pain-related disability in their partner (Stroud, et al., 2006).

**3.3 Summary**

of these have involved group-based cognitive behavioural pain management programs, but they also include cognitive restructuring and hypnosis. The potential use of such interventions in people with spinal cord injury was identified in the early 1990's (Umlauf, 1992), but a review of the literature concerning the application and evaluation of these programs among any group with a physically disabling condition reveals a disappointingly small number of studies and little translation into standard practice.

#### **4.2 Feasibility and acceptability of psychosocial interventions**

A study undertaken in the US specifically examined the issue of the feasibility and acceptability of psychosocial interventions, with a mixed sample of individuals with chronic pain of more than six months duration occurring secondary to multiple sclerosis, amputations, spinal cord injury and cerebral palsy (Ehde & Jensen, 2004). The study found that both the cognitive restructuring intervention, and the control condition which was an educational intervention, were both rated positively by the participants. A study of a cognitive behavioural pain management program for people with spinal cord injury neuropathic pain reported that attendance at the group was high and participants reported that they were very satisfied with the program (Norrbrink Budh, Kowalski, & Lundeberg, 2006). Authors of another study, examining the effectiveness of a cognitive behavioural pain management program for people with spinal cord injury, provide an analysis of the issues encountered in the implementation of the program (Nicholson Perry, Nicholas, & Middleton, 2010; Nicholson Perry, Nicholas, & Middleton, 2011). These findings suggest that these interventions are potentially acceptable, at least to people with spinal cord injury related pain.

#### **4.3 Use and effectiveness of psychosocial interventions**

Psychosocial interventions for pain either described for use with or evaluated with people with physically disabling conditions are extremely few. They are mainly cognitive behavioural, group-based pain management programs, but examples of the use of cognitive restructuring alone and hypnosis are also reported.

#### **4.3.1 Cognitive behavioural group-based pain management programs**

Four group-based, cognitive behavioural pain management program of various sorts are described in the literature (Cundiff, Blair, & Puckett, 1995; Gironda, 2004; Nicholson Perry, et al., 2010; Norrbrink Budh, et al., 2006). The main components of such interventions are represented in Table 1. The earliest reports in the literature of cognitive behavioural pain management programs in physically disabling conditions were for spinal cord injury pain and were descriptive. Cundiff and colleagues (1995) described the development of a groupbased cognitive behavioural pain management program for people with spinal cord injury pain of all types. This involved many of the common components of pain management programs for primary pain diagnoses, including: the explanation of the self-management model, relaxation (including diaphragmatic breathing, guided imagery), the role of self-talk, and pain behaviours and their impact. Gironda (2004) reported on an intervention which was characterized as an interdisciplinary pain management program for spinal cord injury shoulder pain. It was described as a functional preservation approach aimed at enabling individuals to maintain and improve functional capacities where injuries had already been sustained. The program was provided during a two week in-patient stay and comprised of:

Chronic Pain in People with Physically Disabling

context of refractive spinal cord injury pain.

**4.3.2 Cognitive restructuring**

Conditions: A Review of the Application of Biopsychosocial Models 385

measures (including pain intensity and unpleasantness, health-related quality of life and life satisfaction). An Australian study compared a cognitive behavioural pain management program with standard care in a tertiary pain management service in Australia. The program was a modification of an existing program, the design and implementation of which is reported in depth elsewhere, which was approximately half of the usual number of contact hours (Nicholson Perry, et al., 2011). The group attending the pain management program showed an overall improved in mood and pain-related disability at the end of the program compared with the controlled group. This was associated with significant decreases in pain catastrophizing and anxiety in the pain management program group. Three-quarters of people completing the pain management program reported a clinically significant improvement, in contrast to less than a third in the usual care comparison group, however long-term follow up data in this group suggested that benefits were not maintained at six months. Both programs were approximately half of the optimal dose (100 hours) recommended for the management of patients with heterogeneous, disabling chronic pain in a pain management program (Guzman, et al., 2001). While it may appear at first sight that there is a degree of inconsistency in providing an intervention incorporating pacing, where other evidence suggests pacing is an unhelpful strategy among those with chronic pain due to physically disabling conditions, this may be a matter of definition; pacing as taught in cognitive behavioural pain management programs takes a systematic approach to continuing to build up quotas of activity which it may be hypothesized is absent in what respondents would endorse as pacing in surveys of pain-related coping strategies. However, the findings from the evaluation of the programs suggested that there was merit in pursuing the use of cognitive behavioural pain management programs in the

A pilot program exploring the use of a cognitive restructuring intervention targeting catastrophizing for a heterogeneous group of people with disability related chronic pain has recently been reported (Ehde & Jensen, 2004). The authors compared eight 90-minute sessions of cognitive restructuring with an education control intervention among 18 people with disability-related chronic pain (including those with amputations, spinal cord injury, cerebral palsy and multiple sclerosis). The cognitive restructuring intervention included: the role of negative cognitions; how to identify maladaptive thinking; thought-stopping and cognitive restructuring techniques; and use of reassuring self-statements. The education control intervention included pain education (underlying mechanisms and theories of pain), sleep problems in pain and common pain treatments. The authors report that nine of those who attended the first session did not return, but of the eighteen who did continue with their treatment all reported benefiting from the intervention regardless of the group attended. The preliminary results reported by the authors, describing mean pain intensity on a range of 0 to 10 before and after attendance, suggested that whereas pain intensity was unchanged in those attending the education group there was a reduction of approximately 0.2 of a standard deviation among those participating in the cognitive intervention. The authors conclude that a properly powered controlled trial would be required to establish the effectiveness of this approach, but that it was certainly feasible to provide and regarded as acceptable by at least half the patients. Although the literature on the use of psychosocial interventions in people with physically disabling conditions is limited, there is some evidence of similar therapeutic mechanisms operating in these populations as in chronic primary pain conditions (Burns,

medication adjustment; an exercise regimen designed to increase range of motion, endurance and stretch in upper limbs; biomechanical education; a psychoeducational component designed to enhance understanding of the self-management approach, promote problem-solving and implementation of strategies at home, raise awareness of compensatory responses that may be impacting upon psychological or physical well-being; and recreation therapy to encourage return to social and leisure interests. Preliminary data from eight participants in the program suggested improvements across a range of domains, including mood, sleep and pain intensity during shoulder range of motion testing.

Table 1. Common components of cognitive behavioural pain management programs

Two controlled studies have been published which have examined the effectiveness of cognitive behavioural group pain management programs for people with physically disabling conditions, both in those with spinal cord injury (Nicholson Perry, et al., 2010; Norrbrink Budh, et al., 2006). The first controlled study in the literature described a cognitive behavioural pain management program for people with neuropathic pain arising from a spinal cord injury (Norrbrink Budh et al., 2006). The program developed was very like the pain management programs described for people with primary pain diagnoses in content, although of shorter duration (totalling 50 hours over ten weeks). Compared with those in the no-treatment control group, those participating in the program showed significant improvements in depression and sense of coherence (a concept comprising comprehensibility, manageability and meaningfulness of the injury) over 12 months. While there were no other significant differences between the groups, the treatment group showed improvements in anxiety symptoms, emotional reaction and sleep from baseline to the 12 month evaluation, but no significant changes over time were observed in the other outcome

medication adjustment; an exercise regimen designed to increase range of motion, endurance and stretch in upper limbs; biomechanical education; a psychoeducational component designed to enhance understanding of the self-management approach, promote problem-solving and implementation of strategies at home, raise awareness of compensatory responses that may be impacting upon psychological or physical well-being; and recreation therapy to encourage return to social and leisure interests. Preliminary data from eight participants in the program suggested improvements across a range of domains,

> Information is presented about the underlying pain mechanisms relevant to chronic pain, including central sensitization, as well as

Collaborative goal-setting related to a variety of goals across a wide spread of domains, including physical activities or mood, emphasizing the identification of short-term goals building towards long-term goals that are challenging but achievable in

Development of a plan to manage temporary increases in pain

(flare ups) or other situations likely to trigger relapse.

the limitations of medical treatment for chronic pain.

including mood, sleep and pain intensity during shoulder range of motion testing.

order to increase a sense of mastery. Activity pacing Adoption of quota or time based activities, systematically upgraded over time and linked to goals. Relaxation Applied relaxation to reduce muscle tension and improve sleep. Functional exercise Whole body reconditioning exercise programme related functional

Cognitive therapy Identification and modification of unhelpful thoughts regarding

Medication reduction Gradual reduction of inappropriate or excessive pain medications

Two controlled studies have been published which have examined the effectiveness of cognitive behavioural group pain management programs for people with physically disabling conditions, both in those with spinal cord injury (Nicholson Perry, et al., 2010; Norrbrink Budh, et al., 2006). The first controlled study in the literature described a cognitive behavioural pain management program for people with neuropathic pain arising from a spinal cord injury (Norrbrink Budh et al., 2006). The program developed was very like the pain management programs described for people with primary pain diagnoses in content, although of shorter duration (totalling 50 hours over ten weeks). Compared with those in the no-treatment control group, those participating in the program showed significant improvements in depression and sense of coherence (a concept comprising comprehensibility, manageability and meaningfulness of the injury) over 12 months. While there were no other significant differences between the groups, the treatment group showed improvements in anxiety symptoms, emotional reaction and sleep from baseline to the 12 month evaluation, but no significant changes over time were observed in the other outcome

Table 1. Common components of cognitive behavioural pain management programs

pain, such as catastrophizing.

using an agreed schedule.

Component Description

physical goals. Stretch Whole body daily stretch programme.

Education regarding

Flare-up management & relapse prevention

pain

Goal-setting

measures (including pain intensity and unpleasantness, health-related quality of life and life satisfaction). An Australian study compared a cognitive behavioural pain management program with standard care in a tertiary pain management service in Australia. The program was a modification of an existing program, the design and implementation of which is reported in depth elsewhere, which was approximately half of the usual number of contact hours (Nicholson Perry, et al., 2011). The group attending the pain management program showed an overall improved in mood and pain-related disability at the end of the program compared with the controlled group. This was associated with significant decreases in pain catastrophizing and anxiety in the pain management program group. Three-quarters of people completing the pain management program reported a clinically significant improvement, in contrast to less than a third in the usual care comparison group, however long-term follow up data in this group suggested that benefits were not maintained at six months. Both programs were approximately half of the optimal dose (100 hours) recommended for the management of patients with heterogeneous, disabling chronic pain in a pain management program (Guzman, et al., 2001). While it may appear at first sight that there is a degree of inconsistency in providing an intervention incorporating pacing, where other evidence suggests pacing is an unhelpful strategy among those with chronic pain due to physically disabling conditions, this may be a matter of definition; pacing as taught in cognitive behavioural pain management programs takes a systematic approach to continuing to build up quotas of activity which it may be hypothesized is absent in what respondents would endorse as pacing in surveys of pain-related coping strategies. However, the findings from the evaluation of the programs suggested that there was merit in pursuing the use of cognitive behavioural pain management programs in the context of refractive spinal cord injury pain.

#### **4.3.2 Cognitive restructuring**

A pilot program exploring the use of a cognitive restructuring intervention targeting catastrophizing for a heterogeneous group of people with disability related chronic pain has recently been reported (Ehde & Jensen, 2004). The authors compared eight 90-minute sessions of cognitive restructuring with an education control intervention among 18 people with disability-related chronic pain (including those with amputations, spinal cord injury, cerebral palsy and multiple sclerosis). The cognitive restructuring intervention included: the role of negative cognitions; how to identify maladaptive thinking; thought-stopping and cognitive restructuring techniques; and use of reassuring self-statements. The education control intervention included pain education (underlying mechanisms and theories of pain), sleep problems in pain and common pain treatments. The authors report that nine of those who attended the first session did not return, but of the eighteen who did continue with their treatment all reported benefiting from the intervention regardless of the group attended. The preliminary results reported by the authors, describing mean pain intensity on a range of 0 to 10 before and after attendance, suggested that whereas pain intensity was unchanged in those attending the education group there was a reduction of approximately 0.2 of a standard deviation among those participating in the cognitive intervention. The authors conclude that a properly powered controlled trial would be required to establish the effectiveness of this approach, but that it was certainly feasible to provide and regarded as acceptable by at least half the patients. Although the literature on the use of psychosocial interventions in people with physically disabling conditions is limited, there is some evidence of similar therapeutic mechanisms operating in these populations as in chronic primary pain conditions (Burns,

Chronic Pain in People with Physically Disabling

physically disabling conditions.

**4.5 Summary**

**5. Conclusion**

psychosocial interventions.

**6. Acknowledgement**

Conditions: A Review of the Application of Biopsychosocial Models 387

Service delivery models which are able to overcome some of these barriers are yet to be designed, and many of the interventions with a research pedigree to support them have not generalized to routine care due to the lack of support to assist with translation into routine clinical practice. The increased availability of high speed internet may permit the use of online interventions to provide at least some access to some of the components of effective psychosocial interventions for chronic pain, either for use alone or with the support of a health professional, and this may be of particular benefit to those with pain secondary to

Despite the limited evidence available about the effective of psychosocial interventions in people with physically disabling conditions, the findings suggest that there is merit in further research to evaluate their usefulness in a broader range of conditions. Intervention studies in this area are notoriously difficult, due to the many barriers to participation and retention in trials. National and international collaborations are likely to be necessary to ensure a sufficient sample size for such studies to be adequately powered. Provision of these services is impeded by a number of practical barriers, some of which might at least partially addressed by making more effective use of information technology (World Health Organisation, 2011). While there is currently insufficient evidence to support a wholesale recommendation to use these interventions in all physically disabling conditions, in light of the dissatisfaction with pain treatment among many with chronic pain secondary to physically disabling conditions they may be considered for use on an individual basis.

It can be concluded based upon the data presented that the application of biopsychosocial models to the understanding, assessment and management of chronic pain associated with physically disabling conditions is at an early stage of development. There is a well-established body of research in some conditions, such as spinal cord injury, whereas almost nothing is known about the application of these models to other conditions, notably Parkinson's Disease. Many of the patterns observed in primary pain conditions are replicated in these conditions, but the exceptions noted underscore the importance of caution in generalising findings from one condition to another. Relatively, research concerning the use of psychosocial interventions is less well-developed that research examining the relationships between psychosocial and pain variables in physically disabling conditions. Despite this, the findings generally are suggestive of an important role of including psychosocial variables in our conceptualization of individual differences in the experience of chronic pain and its consequences in people with physically disabling conditions, and the possibility of improved outcomes through the use of

Much of what I have learned about this area has resulted from the conversations I have been privileged to have with people with physically disabling conditions, and I thank them for their willingness to educate me. I am continually grateful for the opportunity to work with many wise colleagues who have taught me a great deal about pain and some of the physically disabling conditions which have formed the subject of this chapter. In particular, I would like to thank Associate Professor Michael Nicholas, Associate Professor James

Kubilus, Bruehl, Harden, & Lofland, 2003). In particular, the observation of the association between decreased pain catastrophising and improvements in mood and disability in those who participate in the interventions is consistent with findings in other chronic pain populations (Jensen, et al., 2011; Nicholson Perry, et al., 2010). This cognitive restructuring intervention therefore has particular promise as it targets pain catastrophizing, but requires implementation of a smaller range of treatment strategies than traditional cognitive behavioural pain management programs as described above.

#### **4.3.3 Hypnosis**

Hypnosis has also been applied to spinal cord injury related pain in a series of studies (Ehde & Jensen, 2007) using individual hypnosis treatments with 10 sessions over four weeks and daily practice. The suggestions used were reported to include imagery, changing sensations and ignoring pain, with associated post-hypnotic suggestions that a relaxed state and the ability to ignore pain will become increasingly easy. The case studies found that a sub-group of individuals with disability-related pain were able to obtain decreases in pain severity, with associated improvements in mood, sleep and general well-being in individual cases. However, in the absence of randomized controlled trials, no firm conclusions can be drawn about the effectiveness of hypnosis in this context.

In a variation of the more common cognitive behavioural interventions reported in the literature, a cognitive restructuring approach combined with self-hypnosis training was reported in people with multiple sclerosis (Jensen, et al., 2011). This intervention was intended to target pain catastrophising as well as pain intensity. When compared with either cognitive restructuring or hypnosis alone, or the control condition, the combined approach resulted in a decrease in the frequency of pain catastrophising and increase in the frequency of reassuring cognitions, as well as improved average and worst pain intensity.

#### **4.4 Barriers to the use of psychosocial interventions**

While access to specialist pain management services of any type is problematic, there are some additional reasons to think that access to psychosocial pain interventions will be particularly difficult for those with physically disabling conditions. Broadly, these include the demands of providing such services and accessibility of such services. Health professionals specialising in the provision of psychosocial interventions for chronic pain, such as clinical psychologists, tend to be limited in supply and concentrated in specialist services in major cities. The skills and expertise required to provide psychosocial pain management interventions to those with physically disabling conditions requires expertise in both pain and some of the specific aspects of the physically disabling condition which may impact upon the delivery of the intervention. This includes having an understanding of the physically disabling conditions and its associated symptoms, such as motor function or fatigue, and how these may impact upon the relevance or implementation of the strategies taught. The additional challenges to mobility from having a physically disabling conditions, as well as chronic pain, in combination with environmental barriers which must be overcome to attend a specialist pain management service reduces the chances that an individual with a chronic pain problem due to a physically disabling condition will be able to attend. The costs of living with a physically disabling condition may result in limited financial resources available to fund travel or accommodation in locations where specialist pain management services are available.

Service delivery models which are able to overcome some of these barriers are yet to be designed, and many of the interventions with a research pedigree to support them have not generalized to routine care due to the lack of support to assist with translation into routine clinical practice. The increased availability of high speed internet may permit the use of online interventions to provide at least some access to some of the components of effective psychosocial interventions for chronic pain, either for use alone or with the support of a health professional, and this may be of particular benefit to those with pain secondary to physically disabling conditions.

#### **4.5 Summary**

386 Pain Management – Current Issues and Opinions

Kubilus, Bruehl, Harden, & Lofland, 2003). In particular, the observation of the association between decreased pain catastrophising and improvements in mood and disability in those who participate in the interventions is consistent with findings in other chronic pain populations (Jensen, et al., 2011; Nicholson Perry, et al., 2010). This cognitive restructuring intervention therefore has particular promise as it targets pain catastrophizing, but requires implementation of a smaller range of treatment strategies than traditional cognitive

Hypnosis has also been applied to spinal cord injury related pain in a series of studies (Ehde & Jensen, 2007) using individual hypnosis treatments with 10 sessions over four weeks and daily practice. The suggestions used were reported to include imagery, changing sensations and ignoring pain, with associated post-hypnotic suggestions that a relaxed state and the ability to ignore pain will become increasingly easy. The case studies found that a sub-group of individuals with disability-related pain were able to obtain decreases in pain severity, with associated improvements in mood, sleep and general well-being in individual cases. However, in the absence of randomized controlled trials, no firm conclusions can be drawn

In a variation of the more common cognitive behavioural interventions reported in the literature, a cognitive restructuring approach combined with self-hypnosis training was reported in people with multiple sclerosis (Jensen, et al., 2011). This intervention was intended to target pain catastrophising as well as pain intensity. When compared with either cognitive restructuring or hypnosis alone, or the control condition, the combined approach resulted in a decrease in the frequency of pain catastrophising and increase in the frequency of reassuring cognitions, as well as improved average and worst pain

While access to specialist pain management services of any type is problematic, there are some additional reasons to think that access to psychosocial pain interventions will be particularly difficult for those with physically disabling conditions. Broadly, these include the demands of providing such services and accessibility of such services. Health professionals specialising in the provision of psychosocial interventions for chronic pain, such as clinical psychologists, tend to be limited in supply and concentrated in specialist services in major cities. The skills and expertise required to provide psychosocial pain management interventions to those with physically disabling conditions requires expertise in both pain and some of the specific aspects of the physically disabling condition which may impact upon the delivery of the intervention. This includes having an understanding of the physically disabling conditions and its associated symptoms, such as motor function or fatigue, and how these may impact upon the relevance or implementation of the strategies taught. The additional challenges to mobility from having a physically disabling conditions, as well as chronic pain, in combination with environmental barriers which must be overcome to attend a specialist pain management service reduces the chances that an individual with a chronic pain problem due to a physically disabling condition will be able to attend. The costs of living with a physically disabling condition may result in limited financial resources available to fund travel or accommodation in locations where specialist

behavioural pain management programs as described above.

about the effectiveness of hypnosis in this context.

**4.4 Barriers to the use of psychosocial interventions**

pain management services are available.

**4.3.3 Hypnosis**

intensity.

Despite the limited evidence available about the effective of psychosocial interventions in people with physically disabling conditions, the findings suggest that there is merit in further research to evaluate their usefulness in a broader range of conditions. Intervention studies in this area are notoriously difficult, due to the many barriers to participation and retention in trials. National and international collaborations are likely to be necessary to ensure a sufficient sample size for such studies to be adequately powered. Provision of these services is impeded by a number of practical barriers, some of which might at least partially addressed by making more effective use of information technology (World Health Organisation, 2011). While there is currently insufficient evidence to support a wholesale recommendation to use these interventions in all physically disabling conditions, in light of the dissatisfaction with pain treatment among many with chronic pain secondary to physically disabling conditions they may be considered for use on an individual basis.

#### **5. Conclusion**

It can be concluded based upon the data presented that the application of biopsychosocial models to the understanding, assessment and management of chronic pain associated with physically disabling conditions is at an early stage of development. There is a well-established body of research in some conditions, such as spinal cord injury, whereas almost nothing is known about the application of these models to other conditions, notably Parkinson's Disease. Many of the patterns observed in primary pain conditions are replicated in these conditions, but the exceptions noted underscore the importance of caution in generalising findings from one condition to another. Relatively, research concerning the use of psychosocial interventions is less well-developed that research examining the relationships between psychosocial and pain variables in physically disabling conditions. Despite this, the findings generally are suggestive of an important role of including psychosocial variables in our conceptualization of individual differences in the experience of chronic pain and its consequences in people with physically disabling conditions, and the possibility of improved outcomes through the use of psychosocial interventions.

#### **6. Acknowledgement**

Much of what I have learned about this area has resulted from the conversations I have been privileged to have with people with physically disabling conditions, and I thank them for their willingness to educate me. I am continually grateful for the opportunity to work with many wise colleagues who have taught me a great deal about pain and some of the physically disabling conditions which have formed the subject of this chapter. In particular, I would like to thank Associate Professor Michael Nicholas, Associate Professor James

Chronic Pain in People with Physically Disabling

*46*(1), 13-29.

*Pain, 99*(1-2), 157-165.

*Rehabilitation, 81*(8), 1039-1044.

*49*(3), 254-258.

*49*(3), 254-258.

*84*(8), 1125-1128.

*316*(7135), 903.

412.

Conditions: A Review of the Application of Biopsychosocial Models 389

Dickinson, H. O., Parkinson, K. N., Ravens-Sieberer, U., Schirripa, G., Thyen, U., Arnaud, C.,

Dijkstra, P. U., Geertzen, J. H., Stewart, R., van der Schans, C. P., Dijkstra, P. U., Geertzen, J.

Dobscha, S. K., Clark, M. E., Morasco, B. J., Freeman, M., Campbell, R., & Helfand, M. (2009).

Douglas, C., Wollin, J. A., & Windsor, C. (2008). Biopsychosocial correlates of adjustment to pain among people with multiple sclerosis. *Clinical Journal of Pain, 24*(7), 559-567. Eccleston, C., Morley, S., Williams, A., Yorke, L., & Mastroyannopoulou, K. (2002).

Eccleston, C., Yorke, L., Morley, S., Williams, A. C., & Mastroyannopoulou, K. (2003).

Ehde, D. M., & Jensen, M. P. (2004). Feasibility of a cognitive restructuring intervention for

Ehde, D. M., Czerniecki, J. M., Smith, D. G., Campbell, K. M., Edwards, W. T., Jensen, M. P.,

Ehde, D. M., & Jensen, M. P. (2004). Feasibility of a cognitive restructuring intervention for

Ehde, D. M., & Jensen, M. P. (2007). Psychological treatment for pain management in

Engel, J. M., Jensen, M. P., Hoffman, A. J., & Kartin, D. (2003). Pain in persons with cerebral

Engel, J. M., Jensen, M. P., & Schwartz, L. (2006). Coping with chronic pain associated with

Engel, J. M., Kartin, D., Carter, G. T., Jensen, M. P., & Jaffe, K. M. (2009). Pain in youths with

Engel, J. M., Schwartz, L., Jensen, M. P., & Johnson, D. R. (2000). Pain in cerebral palsy: the

Finnerup, N. B., Baastrup, C., & Jensen, T. S. (2009). Neuropathic pain following spinal cord injury pain: mechanisms and treatment. *Scandinavian Journal of Pain, 1*(S1), 3-11. Fisher, K., & Hanspal, R. S. (1998). Phantom pain, anxiety, depression, and their relation in

cerebral palsy. *Occupational Therapy International, 13*(4), 224-233.

relation of coping strategies to adjustment. *Pain, 88*(3), 225-230.

*Topics in Spinal Cord Injury Rehabilitation, 13*(2), 72-80.

children and adolescents. *Cochrane Database of Systematic Reviews, 1*.

palsy: a cross-sectional European study. *Lancet, 369*(9580), 2171-2178. Dijkers, M., Bryce, T., & Zanca, J. (2009). Prevalence of chronic pain after traumatic spinal

*Pain and Symptom Management, 24*(6), 578-585.

traumatic brain injury. *Pain Medicine, 10*(7), 1200-1217.

et al. (2007). Self-reported quality of life of 8-12-year-old children with cerebral

cord injury: a systematic review. *Journal of Rehabilitation Research and Development,*

H. B., et al. (2002). Phantom pain and risk factors: a multivariate analysis. *Journal of*

Systematic review of the literature on pain in patients with polytrauma including

Systematic review of randomised controlled trials of psychological therapy for chronic pain in children and adolescents, with a subset meta-analysis of pain relief.

Psychological therapies for the management of chronic and recurrent pain in

treatment of chronic pain in persons with disabilities. *Rehabilitation Psychology,*

et al. (2000). Chronic phantom sensations, phantom pain, residual limb pain, and other regional pain after lower limb amputation. *Archives of Physical Medicine &*

treatment of chronic pain in persons with disabilities. *Rehabilitation Psychology,*

persons with spinal cord injury: cognitive therapy and self-hypnosis training.

palsy: extension and cross validation. *Archives of Physical Medicine and Rehabilitation,*

neuromuscular disease. *American Journal of Hospice & Palliative Medicine, 26*(5), 405-

consecutive patients with amputated limbs: case reports. *BMJ (Clinical Research Ed.),*

Middleton, Professor Ashley Craig and Associate Professor Philip Siddall. I would also like to express my gratitude to the School of Psychology, University of Western Sydney for the support provided in the writing of this chapter, particularly the continuing support of Professor Jane Ussher, as well as the able assistance of Rio Yamaguchi.

#### **7. References**

Middleton, Professor Ashley Craig and Associate Professor Philip Siddall. I would also like to express my gratitude to the School of Psychology, University of Western Sydney for the support provided in the writing of this chapter, particularly the continuing support of

Appelros, P. (2006). Prevalence and predictors of pain and fatigue after stroke: a populationbased study. *International Journal of Rehabilitation Research, 29*(4), 329-333. Behr, J., Friedly, J., Molton, I., Morgenroth, D., Jensen, M. P., & Smith, D. G. (2009). Pain and

Beiske, A., & Loge, J. (2009). Pain in Parkinson's disease: prevalence and characteristics. *Pain,*

Blyth, F. M., March, L. M., Brnabic, A. J., Jorm, L. R., Williamson, M., & Cousins, M. J. (2001). Chronic pain in Australia: a prevalence study. *Pain, 89*(2-3), 127-134. Borsbo, B., Peolsson, M., & Gerdle, B. (2009). The complex interplay between pain intensity,

Bradbury, C. L., Wodchis, W. P., Mikulis, D. J., Pano, E. G., Hitzig, S. L., McGillivray, C. F.,

Bruce, J. M., Polen, D., & Arnett, P. A. (2007). Pain and affective memory biases interact to predict depressive symptoms in multiple sclerosis. *Multiple Sclerosis, 13*(1), 58-66. Buchanan, R. J., Wang, S., Tai-Seale, M., & Ju, H. (2003). Analyses of nursing home residents

Burns, K., Kubilus, A., Bruehl, S., Harden, R., & Lofland, K. (2003). Do changes in cognitive

Cairns, D. M., Adkins, R. H., & Scott, M. D. (1996). Pain and depression in acute traumatic

Cardenas, D. D., Felix, E. R., Cardenas, D. D., & Felix, E. R. (2009). Pain after spinal cord

Conant, L. L. (1998). Psychological variables associated with pain perceptions among

Cruz-Almeida, Y., Alameda, G., & Widerstrom-Noga, E. G. (2009). Differentiation between

Cundiff, G. W., Blair, K. L., & Puckett, M. J. (1995). Group pain management therapy for persons with spinal cord injury. *SCI Psychosocial Process, 8*(2), 61-66. Desmond, D. M., & Maclachlan, M. (2010). Prevalence and characteristics of phantom limb

pain-related interference in adults with lower-limb amputation: Comparison of knee-disarticulation, transtibial, and transfemoral surgical sites. *Journal of*

depression, anxiety and catastrophising with respect to quality of life and

et al. (2008). Traumatic brain injury in patients with traumatic spinal cord injury: Clinical and economic consequences. *Archives of Physical Medicine and Rehabilitation,*

with multiple sclerosis and depression using the Minimum Data Set. *Multiple*

factors influence outcome following multidisciplinary treatment for chronic pain? A cross-lagged panel analysis. *Journal of Consulting and Clinical Psychology, 71*, 81-91.

spinal cord injury: Origins of chronic problematic pain? *Archives of Physical Medicine*

injury: a review of classification, treatment approaches, and treatment assessment.

individuals with chronic spinal cord injury pain. *Journal of Clinical Psychology in*

pain-related interference and interference caused by the functional impairments of

pain and residual limb pain in the long term after upper limb amputation.

Professor Jane Ussher, as well as the able assistance of Rio Yamaguchi.

*Rehabilitation Research and Development, 46*(7), 963-972.

disability. *Disability and Rehabilitation, 31*(19), 1605-1613.

**7. References**

*141*(1-2), 173-177.

*89*(12, Supplement 12), S77-84.

*& Rehabilitation., 77*(4), 329-335.

*PM and R, 1*(12), 1077-1090.

*Medical Settings, 5*(1), 71-90.

spinal cord injury. *Spinal Cord, 47*(5), 390-395.

*International Journal of Rehabilitation Research, 33*(3), 279-282.

*Sclerosis, 9*(2), 171-188.

Chronic Pain in People with Physically Disabling

*88*(5), 638-645.

*Cord, 44*(2), 95-105.

*Rehabilitation, 85*(1), 35-40.

*Rehabilitation, 88*(12), 1643-1648.

*Palliative Medicine, 26*(4), 308-319.

*55*(2), 126-138.

epidemiological study. *Pain, 87*(1), 33-41.

Conditions: A Review of the Application of Biopsychosocial Models 391

Jensen, M. P., Hoffman, A. J., Stoelb, B. L., Abresch, R. T., Carter, G. T., & McDonald, C. M.

Jonsson, A. C., Lindgren, I., Hallstrom, B., Norrving, B., & Lindgren, A. (2006). Prevalence

Kennedy, P., Lude, P., & Taylor, N. (2006). Quality of life, social participation, appraisals

Kitisomprayoonkul, W., Sungkapo, P., Taveemanoon, S., & Chaiwanichsiri, D. (2010).

Kooijman, C. M., Dijkstra, P. U., Geertzen, J. H. B., Elzinga, A., & van der Schans, C. P.

Kratz, A. L., Williams, R. M., Turner, A. P., Raichle, K. A., Smith, D. G., & Ehde, D. M.

Lahz, S., & Bryant, R. A. (1996). Incidence of chronic pain following traumatic brain injury.

Linton, S. J. P., & Nordin, E. M. A. (2006). A 5-year follow-up evaluation of the health and

Lundstrom, E., Smits, A., Terent, A., & Borg, J. (2009). Risk factors for stroke-related pain 1 year after first-ever stroke. *European Journal of Neurology, 16*(2), 188-193. Meldrum, M. L. (2007). Brief history of multidisciplinary management of chronic pain, 1990-

Middleton, J. W., Tran, Y., & Craig, A. (2007). Relationship between quality of life and self-

Miro, J., Raichle, K. A., Carter, G. T., O'Brien, S. A., Abresch, R. T., McDonald, C. M., et al.

Molton, I. R., Stoelb, B. L., Jensen, M. P., Ehde, D. M., Raichle, K. A., & Cardenas, D. D.

*Archives of Physical Medicine and Rehabilitation, 77*(9), 889-891.

A randomized, controlled trial. *Spine, 31*(8), 853-858.

*multidisciplinary program development*: Informa Healthcare.

of life in multiple sclerosis. *Multiple Sclerosis, 11*(3), 322-327.

dystrophy. *Archives of Physical Medicine and Rehabilitation, 89*(2), 320-328. Jensen, M. P., Kuehn, C. M., Amtmann, D., & Cardenas, D. D. (2007). Symptom burden in

(2008).  *Archives of Physical Medicine and Rehabilitation,*

and intensity of pain after stroke: a population based study focusing on patients' perspectives. *Journal of Neurology, Neurosurgery and Psychiatry, 77*(5), 590-595. Kalia, L. V., & O'Connor, P. W. (2005). Severity of chronic pain and its relationship to quality

and coping post spinal cord injury: a review of four community samples. *Spinal*

Medical complications during inpatient stroke rehabilitation in Thailand: a prospective study. *Journal of the Medical Association of Thailand, 93*(5), 594-600. Klit, H., Finnerup, N. B., Andersen, G., & Jensen, T. S. (2011). Central poststroke pain: A population-based study. *Pain, 152*(4), 818-824. doi: 10.1016/j.pain.2010.12.030 Kong, K.-H., Woon, V.-C., & Yang, S.-Y. (2004). Prevalence of chronic pain and its impact on

health-related quality of life in stroke survivors. *Archives of Physical Medicine and*

(2000). Phantom pain and phantom sensations in upper limb amputees: an

(2010). To lump or to split? Comparing individuals with traumatic and nontraumatic limb loss in the first year after amputation. *Rehabilitation Psychology,*

economic consequences of an early cognitive behavioral intervention for back pain:

2000. In M. Schatman & A. Campbell (Eds.), *Chronic pain management: guidelines for*

efficacy in persons with spinal cord injuries. *Archives of Physical Medicine and*

(2009). Impact of biopsychosocial factors on chronic pain in persons with myotonic and facioscapulohumeral muscular dystrophy. *American Journal of Hospice &*

(2009). Psychosocial factors and adjustment to chronic pain in spinal cord injury:

Ford, B. (2010). Pain in Parkinson's disease. *Movement Disorders, 25*(S1), S98-S103.

Gallien, P., Nicolas, B., Dauvergne, F., Petrilli, S., Houedakor, J., Roy, D., et al. (2007). Pain in

Gatchel, R. J., Peng, Y. B., Peters, M. L., Fuchs, P. N., & Turk, D. C. (2007). The

Gironda, R. J. (2004). An interdisciplinary, cognitive-behavioral shoulder pain treatment

Guzman, J., Esmail, R., Karjalainen, K., Malmivaara, A., Irvin, E., & Bombardier, C. (2001).

Hammarlund, C. S., Carlström, M., Melchior, R., & Persson, B. M. (2011). Prevalence of back

Hanley, M. A., Jensen, M. P., Ehde, D. M., Hoffman, A. J., Patterson, D. R., & Robinson, L. R.

Heneweer, H., Aufdemkampe, G., van Tulder, M. W., Kiers, H., Stappaerts, K. H., &

Henwood, P., & Ellis, J. A. (2004). Chronic neuropathic pain in spinal cord injury: the

Hill, A., Niven, C. A., & Knussen, C. (1995). The role of coping in adjustment to phantom

Hirsh, A. T., Gallegos, J. C., Gertz, K. J., Engel, J. M., & Jensen, M. P. (2010). Symptom

Hoffman, J. M., Pagulayan, K. F., Zawaideh, N., Dikmen, S., Temkin, N., & Bell, K. R. (2007).

Ivanhoe, C. B., & Hartman, E. T. (2004). Clinical caveats on medical assessment and treatment of pain after TBI. *Journal of Head Trauma Rehabilitation, 19*(1), 29-39. Jahnsen, R., Villien, L., Aamodt, G., Stanghelle, J. K., & Holm, I. (2004). Musculoskeletal pain

Jensen, M. P., Abresch, R. T., Carter, G. T., & McDonald, C. M. (2005). Chronic pain in

Jensen, M. P., Ehde, D. M., Gertz, K. J., Stoelb, B. L., Dillworth, T. M., Hirsh, A. T., et al.

pain. *International Journal of Clinical and Experimental Hypnosis, 59*(1), 45-63.

and phantom limb pain. *Disability & Rehabilitation, 26*(14-15), 882-893. Hanley, M. A., Raichle, K., Jensen, M., & Cardenas, D. D. (2008). Pain catastrophizing and

persons with spinal cord injury. *The Journal of Pain, 9*(9), 863-871.

patient's perspective. *Pain Research and Management, 9*(1), 39-45.

amputation. *Prosthetics and Orthotics International, 35*(1), 97-105.

adults with cerebral palsy. *Annales de Readaptation et de Medecine Physique, 50*(7),

biopsychosocial approach to chronic pain: scientific advances and future directions.

Multidisciplinary rehabilitation for chronic low back pain: systematic review.

pain, its effect on functional ability and health-related quality of life in lower limb amputees secondary to trauma or tumour: a comparison across three levels of

(2004). Psychosocial predictors of long-term adjustment to lower-limb amputation

beliefs predict changes in pain interference and psychological functioning in

Vanhees, L. (2007). Psychosocial variables in patients with (sub)acute low back pain: an inception cohort in primary care physical therapy in The Netherlands.

burden in individuals with cerebral palsy. *Journal of Rehabilitation Research and*

Understanding pain after traumatic brain injury: impact on community participation. *American Journal of Physical Medicine and Rehabilitation, 86*(12), 962-969.

in adults with cerebral palsy compared with the general population. *Journal of*

persons with neuromuscular disease. *Archives of Physical Medicine & Rehabilitation,*

(2011). Effects of self-hypnosis training and cognitive restructuring on daily pain intensity and catastrophizing in individuals with multiple sclerosis and chronic

Ford, B. (2010). Pain in Parkinson's disease. *Movement Disorders, 25*(S1), S98-S103.

558-563.

*Spine, 32*(5), 586-592.

limb pain. *Pain, 62*(1), 79-86.

*Development, 47*(9), 863-876.

*Rehabilitation Medicine, 36*(2), 78-84.

*86*(6), 1155-1163.

*Psychological Bulletin, 133*(4), 581-624.

program. *SCI Psychosocial Process, 17*(4), 247-252.

*British Medical Journal, 322*(7301), 1511-1516.

Chronic Pain in People with Physically Disabling

*Psychology, 51*(2), 166-174.

*49*(4), 405-413.

*Pain, 100*(3), 231-242.

*Psychology, 55*(1), 12-22.

*Development, 41*(1), 75-88.

*Pain, 24*(4), 335-342.

*Bulletin, 53*(3), 131-142.

446-451.

Conditions: A Review of the Application of Biopsychosocial Models 393

Osborne, T. L., Turner, A. P., Williams, R. M., Bowen, J. D., Hatzakis, M., Rodriguez, A., et

Osterberg, A., Boivie, J., & Thuomas, K. A. (2005). Central pain in multiple sclerosis- prevalence and clinical characteristics. *European Journal of Pain, 9*(5), 531-542. Parkes, J., White-Koning, M., Dickinson, H. O., Thyen, U., Arnaud, C., Beckung, E., et al.

Parkinson, K. N., Gibson, L., Dickinson, H. O., & Colver, A. F. (2010). Pain in children with

Piwko, C., Desjardins, O. B., Bereza, B. G., Machado, M., Jaszewski, B., Freedman, M. S., et

Pollmann, W., Feneberg, W., & Erasmus, L. P. (2004). Pain in multiple sclerosis--a still

Quale, A. J., & Schanke, A. (2010). Resilience in the face of coping with a severe physical

Rintala, D. H., Hart, K. A., & Priebe, M. M. (2004). Predicting consistency of pain over a 10-

Russo, R. N., Miller, M. D., Haan, E., Cameron, I. D., & Crotty, M. (2008). Pain characteristics

Schley, M. T., Wilms, P., Toepfner, S., Schaller, H.-P., Schmelz, M., Konrad, C. J., et al. (2008).

amputees. *Journal of Trauma-Injury Infection & Critical Care, 65*(4), 858-864. Schwartz, L., Engel, J. M., & Jensen, M. P. (1999). Pain in persons with cerebral palsy.

Siddall, P. J., Yezierski, R. P., & Loeser, J. D. (2000). Pain following spinal cord injury: clinical

Smedema, S. M., Catalano, D., & Ebener, D. J. (2011). The relationship of coping, self-worth,

Stormer, S., Gerner, H. J., Gruninger, W., Metzmacher, K., Follinger, S., Wienke, C., et al.

Stroud, M. W., Turner, J. A., Jensen, M. P., & Cardenas, D. D. (2006). Partner responses to

*Archives of Physical Medicine & Rehabilitation, 80*(10), 1243-1246.

factors in chronic spinal cord injury pain. *Pain, 47*(2), 183-189.

features, prevalence and taxonomy. *IASP Newsletter, 3*.

multicentre study. *Spinal Cord, 35*(7), 446-455.

burden in Canada. *Pain Research and Management, 12*(4), 259-265.

al. (2006). Correlates of pain interference in multiple sclerosis. *Rehabilitation*

(2008). Psychological problems in children with cerebral palsy: a cross-sectional European study. *Journal of Child Psychology and Psychiatry and Allied Disciplines,*

cerebral palsy: a cross-sectional multicentre European study. *Acta Paediatrica, 99*(3),

al. (2007). Pain due to multiple sclerosis: analysis of the prevalence and economic

underestimated problem. The 1 year prevalence of pain syndromes, significance and quality of care of multiple sclerosis inpatients. *Nervenarzt, 75*(2), 135-140. Putzke, J. D., Richards, J. S., Hicken, B. L., & DeVivo, M. J. (2002). Interference due to pain

following spinal cord injury: important predictors and impact on quality of life.

injury: A study of trajectories of adjustment in a rehabilitation setting. *Rehabilitation*

year period in persons with spinal cord injury. *Journal of Rehabilitation Research and*

and their association with quality of life and self-concept in children with hemiplegic cerebral palsy identified from a population register. *Clinical Journal of*

Painful and nonpainful phantom and stump sensations in acute traumatic

and subjective well-being: A structural equation model. *Rehabilitation Counseling*

(1997). Chronic pain/dysaesthesiae in spinal cord injury patients: results of a

pain behaviors are associated with depression and activity interference among persons with chronic pain and spinal cord injury. *The Journal of Pain, 7*(2), 91-99. Summers, J. D., Rapoff, M. A., Varghese, G., Porter, K., & Palmer, R. E. (1991). Psychosocial

replication and cross-validation. *Journal of Rehabilitation Research and Development, 46*(1), 31-42.

Morley, S., Eccleston, C., & Williams, A. (1999). Systematic review and meta-analysis of

Motl, R. W., McAuley, E., Snook, E. M., & Gliottoni, R. C. (2009). Physical activity and

Nampiaparampil, D. E. (2008). Prevalence of chronic pain after traumatic brain injury: A

Newland, P. K., Naismith, R. T., & Ullione, M. (2009). The impact of pain and other

Newland, P. K., Wipke-Tevis, D. D., Williams, D. A., Rantz, M. J., & Petroski, G. F. (2005).

Nicholson Perry, K., Nicholas, M. K., & Middleton, J. W. (2009). Spinal cord injury-related

Nicholson Perry, K., Nicholas, M. K., Middleton, J. W., & Siddall, P. (2009). Psychological

Norrbrink Budh, C., Hultling, C., & Lundeberg, T. (2005). Quality of sleep in individuals

Norrbrink Budh, C., Kowalski, J., & Lundeberg, T. (2006). A comprehensive pain

Norrbrink Budh, C., & Osteraker, A. L. (2007). Life satisfaction in individuals with a spinal

O'Connor, A. B., Schwid, S. R., Herrmann, D. N., Markman, J. D., & Dworkin, R. H. (2008).

O'Sullivan, S. S., Williams, D. R., Gallagher, D. A., Massey, L. A., Silveira-Moriyama, L., &

disease: a clinicopathological study. *Movement Disorders, 23*(1), 101-106. Osborne, T. L., Jensen, M. P., Ehde, D. M., Hanley, M. A., & Kraft, G. (2007). Psychosocial

mood and physical function. *European Journal of Pain: Ejp, 13*(5), 511-517. Nicholson Perry, K., Nicholas, M. K., & Middleton, J. W. (2010). Comparison of a pain

sclerosis. *Journal of the American Geriatrics Society, 53*(9), 1490-1496.

for chronic pain in adults, excluding headache. *Pain, 80*(1-2), 1-13.

*Journal of Neuroscience Nursing, 41*(6), 322-328.

doi:10.3109/09638288.2010.524276

*Rehabilitation Medicine, 38*(3), 172-180.

classification. *Pain, 137*(1), 96-111.

cord injury and pain. *Clinical Rehabilitation, 21*(1), 89-96.

*46*(1), 57-67.

*Spinal Cord, 43*(2), 85-95.

*46*(1), 31-42.

replication and cross-validation. *Journal of Rehabilitation Research and Development,*

randomized controlled trials of cognitive behaviour therapy and behaviour therapy

quality of life in multiple sclerosis: Intermediary roles of disability, fatigue, mood, pain, self-efficacy and social support. *Psychology, Health and Medicine, 14*(1), 111-124.

systematic review. *JAMA: Journal of the American Medical Association, 300*(6), 711-719.

symptoms on quality of life in women with relapsing-remitting multiple sclerosis.

Impact of pain on outcomes in long-term care residents with and without multiple

pain in rehabilitation: a cross-sectional study of relationships with cognitions,

management program with usual care in a pain management center for people with spinal cord injury-related chronic pain. *The Clinical Journal of Pain, 26*(3), 206-216. Nicholson Perry, K., Nicholas, M. K., & Middleton, J. W. (2011). Multidisciplinary cognitive

behavioural pain management programmes for people with a spinal cord injury: design and implementation. *Disability and Rehabilitation, 33*(13-14), 1272-1280. doi:

characteristics of people with spinal cord injury-related persisting pain referred to a tertiary pain management center. *Journal of Rehabilitation Research and Development,*

with spinal cord injury: a comparison between patients with and without pain.

management programme comprising educational, cognitive and behavioural interventions for neuropathic pain following spinal cord injury. *Journal of*

Pain associated with multiple sclerosis: systematic review and proposed

Lees, A. J. (2008). Nonmotor symptoms as presenting complaints in Parkinson's

factors associated with pain intensity, pain-related interference, and psychological functioning in persons with multiple sclerosis and pain. *Pain, 127*(1-2), 52-62.

**19**

 *Canada*

**The Role of Peripheral Nerve Blocks in the Interdisciplinary**

Gillian R. Lauder1 and Nicholas West2

**Care of Children with Chronic Pain:**

**A Case Series and Review of the Literature**

Chronic pain of childhood is an extremely complex condition which can lead to damaging effects on physical and social wellbeing. Some children with severe chronic pain embark on a downward spiral of decreased physical, psychological and social functioning. This includes loss of mobility and inability to participate in physical and sporting activities, poor sleep, difficulty concentrating on school work, school absenteeism, social isolation and family stress. As chronic pain persists the child can experience increased pain intensity, distress, anxiety and depression. When enmeshed in this disordered lifestyle the child and their family require coordinated integrated care. The interdisciplinary team management approach, based on pharmacology, physiotherapy and psychology, is now well established to be the standard of care for children with chronic pain. Treatment goals are targeted to individual children after careful consideration of the history and examination. In appropriately selected children peripheral nerve blocks can provide immediate and effective pain relief. This chapter will present a referenced review of the literature on interdisciplinary paediatric chronic pain management whilst highlighting the role of peripheral nerve blocks. The case histories of eight paediatric patients with chronic pain

who gained significant relief from peripheral nerve blocks will be presented.

The International Association for the Study of Pain (IASP) defines pain as "an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage" (1986). One defining characteristic of pain is its duration. Acute pain is relatively short-term pain that typically lasts until the underlying cause has been identified and treated. On the other hand, chronic pain is understood to mean prolonged pain or "pain that extends beyond the expected period of healing" (Turk & Okifuji, 2001) and while defined time frames that determine a diagnosis of chronic pain vary, the definition adopted by most studies, including those cited here, is pain lasting

Chronic pain can have its roots in one or a combination of types of pain mechanism. Types of pain include nociceptive, inflammatory, neuropathic or psychogenic pain (DSM-IV "Pain Disorder"). Extreme caution is required before labelling a patient with a diagnosis of

**1. Introduction**

longer than three months.

*1Department of Anesthesia, British Columbia Children's Hospital (BCCH), 2Pediatric Anesthesia Research Team, University of British Columbia (UBC),*

### **The Role of Peripheral Nerve Blocks in the Interdisciplinary Care of Children with Chronic Pain: A Case Series and Review of the Literature**

Gillian R. Lauder1 and Nicholas West2

*1Department of Anesthesia, British Columbia Children's Hospital (BCCH), 2Pediatric Anesthesia Research Team, University of British Columbia (UBC), Canada*

#### **1. Introduction**

394 Pain Management – Current Issues and Opinions

Turner, J. A., Jensen, M. P., Warms, C. A., & Cardenas, D. D. (2002). Catastrophizing is

Ullrich, P. M., Jensen, M., Loeser, J. D., & Cardenas, D. D. (2007). Catastrophizing mediates

Umlauf, R. L. (1992). Psychological interventions for chronic pain following spinal cord

Vase, L., Nikolajsen, L., Christensen, B., Egsgaard, L. L., Arendt-Nielsen, L., Svensson, P., et

Vlaeyen, J. W., & Linton, S. J. (2000). Fear-avoidance and its consequences in chronic

Vogtle, L. K. (2009). Pain in adults with cerebral palsy: impact and solutions. *Developmental*

Wartan, S. W., Hamann, W., Wedley, J. R., & McColl, I. (1997). Phantom pain and sensation among British veteran amputees. *British Journal of Anaesthesia, 78*(6), 652-659. Widerstrom-Noga, E. G., & Turk, D. C. (2004). Exacerbation of chronic pain following spinal

Wollaars, M. M., Post, M. W. M., van Asbeck, F. W. A., & Brand, N. (2007). Spinal cord

World Health Organisation. (2011). World report on disability 2011. Geneva: World Health

injury pain: the influence of psychologic factors and impact on quality of life.

*Development, 45*(6), 793-800.

injury. *Clinical Journal of Pain, 8*, 111-118.

*Clinical Journal of Pain, 23*(5), 383-391.

Organisation.

phantom limb pain patients. *Pain, 152*(1), 157-162.

*Medicine and Child Neurology, 51 Suppl 4*, 113-121.

cord injury. *Journal of Neurotrauma, 21*(10), 1384-1395.

musculoskeletal pain: a state of the art. *Pain, 85*(3), 317-332.

associated with pain intensity, psychological distress, and pain-related disability among individuals with chronic pain after spinal cord injury. *Pain, 98*(1-2), 127-134.

associations between pain severity, psychological distress, and functional disability among persons with spinal cord injury. *Rehabilitation Psychology, 52*(4), 390-398. Ullrich, P. M., Jensen, M. P., Loeser, J. D., Cardenas, D. D., & Weaver, F. M. (2008). Pain

among veterans with spinal cord injury. *Journal of Rehabilitation Research and*

al. (2011). Cognitive-emotional sensitization contributes to wind-up-like pain in

Chronic pain of childhood is an extremely complex condition which can lead to damaging effects on physical and social wellbeing. Some children with severe chronic pain embark on a downward spiral of decreased physical, psychological and social functioning. This includes loss of mobility and inability to participate in physical and sporting activities, poor sleep, difficulty concentrating on school work, school absenteeism, social isolation and family stress. As chronic pain persists the child can experience increased pain intensity, distress, anxiety and depression. When enmeshed in this disordered lifestyle the child and their family require coordinated integrated care. The interdisciplinary team management approach, based on pharmacology, physiotherapy and psychology, is now well established to be the standard of care for children with chronic pain. Treatment goals are targeted to individual children after careful consideration of the history and examination. In appropriately selected children peripheral nerve blocks can provide immediate and effective pain relief. This chapter will present a referenced review of the literature on interdisciplinary paediatric chronic pain management whilst highlighting the role of peripheral nerve blocks. The case histories of eight paediatric patients with chronic pain who gained significant relief from peripheral nerve blocks will be presented.

The International Association for the Study of Pain (IASP) defines pain as "an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage" (1986). One defining characteristic of pain is its duration. Acute pain is relatively short-term pain that typically lasts until the underlying cause has been identified and treated. On the other hand, chronic pain is understood to mean prolonged pain or "pain that extends beyond the expected period of healing" (Turk & Okifuji, 2001) and while defined time frames that determine a diagnosis of chronic pain vary, the definition adopted by most studies, including those cited here, is pain lasting longer than three months.

Chronic pain can have its roots in one or a combination of types of pain mechanism. Types of pain include nociceptive, inflammatory, neuropathic or psychogenic pain (DSM-IV "Pain Disorder"). Extreme caution is required before labelling a patient with a diagnosis of

The Role of Peripheral Nerve Blocks in the Interdisciplinary

Gagnon et al, 2007).

conflict.

Care of Children with Chronic Pain: A Case Series and Review of the Literature 397

Previous pain experiences, cognitive, emotional and behavioural factors, family background, environment, peer group and culture have an influence on the impact, perception and biopsychosocial outcomes of chronic pain. Children living in lower educated, lower income families have been found to be at a greater risk of suffering recurrent pain, which is consistent with adult studies (Grøholt et al, 2003). Children suffering chronic pain themselves are quite likely to be living with another chronic pain sufferer, whether parent or sibling, and further investigation suggests that pre-existing chronic pain in the family environment is a predictor of both physical and psychological effects on the child (Lynch et al, 2006). Ethnicity and area of residence also appear to affect prevalence rates. For example, in Canada, the incidence of chronic pain is higher among Aboriginal people and, for males, is higher in rural areas (Ramage-Morin & Gilmour, 2010). There may also be cultural differences in the perception and reporting of pain (Mailis-

While chronic pain is clearly not confined to the developed world, most published studies provide figures for European or North American children, which may not be generalisable to different environments. A US study found that 13% of 12-13 year-olds and 17% of 15-16 year-olds experience abdominal pain every week (Hyams et al, 1996), while Dutta et al (1999) reported a considerably higher incidence (74%) in India. However, with gastrointestinal infections more widespread than the inflammatory bowel disease seen in developing countries, these figures probably represent the outcome of different disease processes (Ganesh et al, 2010). Abu-Saad Huijer (2010) considers the effects of war and traumatic events. Despite an absence of research in this area, he argues that chronic pain has been linked with post-traumatic stress disorders and that, as a consequence, we may expect to see a different profile of chronic pain among children affected by armed

In developed countries, headache, abdominal and musculoskeletal pain form the primary foci of chronic and recurrent pain among the paediatric population. In their study of Canadian 9-13 year olds, van Dijk et al (2006) received reports of recurrent headaches (32%), growing pains (21%), stomach pains (19%) and muscle aches (2%). Perquin et al (2000) had published similar findings from their survey of Dutch schoolchildren, in which they also analysed reports of pain at multiple locations. They found that the single location pain was most often reported. The combination of headache and abdominal pain was the most commonly reported multiple pain, found in 25% of all children. This greater than one pain

Recent figures from a Statistics Canada health report identify chronic pain among 2.4% of males and 5.9% of females aged 12 to 17 years (Ramage-Morin & Gilmour, 2010). It has been reported that girls are as much as three times more likely to report chronic pain than boys (Martin et al, 2007). Perquin et al (2000) also showed a significant increase in the prevalence of chronic pain in girls. These girls were aged between 12 and 14 which may well be linked with the onset of menstruation. In general, abdominal pain is significantly more likely to be reported by girls and limb pain (or growing pains/muscle aches) is significantly more likely to be reported by boys (Perquin et al, 2000; van Dijk et al, 2006). A review on gender and pain suggests potential mechanisms within social and psychological processes, such as coping processes and catastrophising, are likely to contribute to the repeatedly observed sex

Aetiology and predisposition to chronic pain in children is largely unknown and depends on the type of pain. Factors associated with the development of chronic pain include

profile was significantly more prevalent in adolescent girls.

differences in pain (Fillingim et al, 2009).

psychogenic pain, functional pain or somatisation disorder as the true prevalence of these conditions is extremely low. Most patients with chronic pain will have psychosocial elements to their suffering, but this does not mean that the pain is "psychogenic".

Nociceptive pain is felt in response to noxious stimuli, such as the trauma associated with injury, oncological and other disease processes as well as following surgery. This pain functions as a protective and interpretable symptom: 'it hurts here' means 'here is the damage' and can be a straightforward guide to what needs to be treated or allowed to heal. *Inflammatory pain* occurs as a result of inflammatory mediators in many disease processes or associated with healing following acute trauma or surgery. If either nociceptive or inflammatory pains are left unrecognised or undertreated they can lead to ongoing and then chronic pain. *Neuropathic pain* signifies some dysfunction in the nervous system itself and is a major cause of chronic suffering, occurring in about 6-7% of the population (Vinik, 2010).

Neuropathic pain may derive from some identifiable damage to the nerves, resulting from a disease process, inflammation or accidental damage during trauma or surgery, or may result from a failure of integration and function of the peripheral and central nervous systems. Many conditions previously labelled as functional pain are now known to have peripheral and central nervous elements, which would re-class them as neuropathic pain. Complex regional pain syndrome (CRPS) is an immuno-neurological disorder (Fechir et al, 2008). It may be associated with no nerve lesion (type I) or may be related to some identifiable nerve lesion (type II). Chronic conditions like functional abdominal pain syndrome (FAPS) and CRPS have been under-recognised by physicians, but are experienced by a significant number of adolescents (Clouse et al, 2006; Kachko et al, 2008). In summary, a combination of pain mechanisms may be involved in the development of chronic pain conditions.

#### **1.1 The epidemiology of paediatric chronic pain**

The epidemiology of chronic pain in children is less well understood than it is in adults, but some useful studies have been published in the last decade that help us to understand the overall scale of the problem and to elicit some socio-demographic particulars of the affected population. A survey of over 5,000 children aged 0 – 18 years in the Netherlands reported that 25% had experienced some form of chronic or recurrent pain (Perquin et al, 2000). A Spanish study, of 561 schoolchildren aged 8 – 16 years, reported an incidence of 37%, but concluded that only 5% suffer moderate or severe chronic pain (Huguet & Miró, 2008). In a Canadian study of 495 schoolchildren aged 9 - 13, more than half reported having experienced at least one recurrent pain, typically characterised as a headache, stomach pain or 'growing pain'. Although 46% reported a 'long-lasting' pain, the researchers judged that in many cases this represented a recurrent pain condition; nonetheless, 6% of children were classified as having possible, probable or definite chronic pain (van Dijk et al, 2006).

While these studies highlight the methodological difficulties in distinguishing acute, recurrent and chronic pain from children's responses to questionnaire and interview questions, these statistics clearly also demonstrate that childhood chronic pain is a significant problem: slightly more than one child in every twenty is a chronic pain sufferer; that is, at least one child in every average-sized classroom in every school. Perquin et al (2000) conclude that childhood chronic pain is 'a common experience' and that the incidence of severe chronic pain amongst adolescents should provoke both concern and further research from the healthcare community.

psychogenic pain, functional pain or somatisation disorder as the true prevalence of these conditions is extremely low. Most patients with chronic pain will have psychosocial

Nociceptive pain is felt in response to noxious stimuli, such as the trauma associated with injury, oncological and other disease processes as well as following surgery. This pain functions as a protective and interpretable symptom: 'it hurts here' means 'here is the damage' and can be a straightforward guide to what needs to be treated or allowed to heal. *Inflammatory pain* occurs as a result of inflammatory mediators in many disease processes or associated with healing following acute trauma or surgery. If either nociceptive or inflammatory pains are left unrecognised or undertreated they can lead to ongoing and then chronic pain. *Neuropathic pain* signifies some dysfunction in the nervous system itself and is a major cause of chronic suffering, occurring in about 6-7% of the

Neuropathic pain may derive from some identifiable damage to the nerves, resulting from a disease process, inflammation or accidental damage during trauma or surgery, or may result from a failure of integration and function of the peripheral and central nervous systems. Many conditions previously labelled as functional pain are now known to have peripheral and central nervous elements, which would re-class them as neuropathic pain. Complex regional pain syndrome (CRPS) is an immuno-neurological disorder (Fechir et al, 2008). It may be associated with no nerve lesion (type I) or may be related to some identifiable nerve lesion (type II). Chronic conditions like functional abdominal pain syndrome (FAPS) and CRPS have been under-recognised by physicians, but are experienced by a significant number of adolescents (Clouse et al, 2006; Kachko et al, 2008). In summary, a combination of pain

The epidemiology of chronic pain in children is less well understood than it is in adults, but some useful studies have been published in the last decade that help us to understand the overall scale of the problem and to elicit some socio-demographic particulars of the affected population. A survey of over 5,000 children aged 0 – 18 years in the Netherlands reported that 25% had experienced some form of chronic or recurrent pain (Perquin et al, 2000). A Spanish study, of 561 schoolchildren aged 8 – 16 years, reported an incidence of 37%, but concluded that only 5% suffer moderate or severe chronic pain (Huguet & Miró, 2008). In a Canadian study of 495 schoolchildren aged 9 - 13, more than half reported having experienced at least one recurrent pain, typically characterised as a headache, stomach pain or 'growing pain'. Although 46% reported a 'long-lasting' pain, the researchers judged that in many cases this represented a recurrent pain condition; nonetheless, 6% of children were classified as having possible, probable or definite

While these studies highlight the methodological difficulties in distinguishing acute, recurrent and chronic pain from children's responses to questionnaire and interview questions, these statistics clearly also demonstrate that childhood chronic pain is a significant problem: slightly more than one child in every twenty is a chronic pain sufferer; that is, at least one child in every average-sized classroom in every school. Perquin et al (2000) conclude that childhood chronic pain is 'a common experience' and that the incidence of severe chronic pain amongst adolescents should provoke both concern and further

mechanisms may be involved in the development of chronic pain conditions.

**1.1 The epidemiology of paediatric chronic pain**

chronic pain (van Dijk et al, 2006).

research from the healthcare community.

elements to their suffering, but this does not mean that the pain is "psychogenic".

population (Vinik, 2010).

Previous pain experiences, cognitive, emotional and behavioural factors, family background, environment, peer group and culture have an influence on the impact, perception and biopsychosocial outcomes of chronic pain. Children living in lower educated, lower income families have been found to be at a greater risk of suffering recurrent pain, which is consistent with adult studies (Grøholt et al, 2003). Children suffering chronic pain themselves are quite likely to be living with another chronic pain sufferer, whether parent or sibling, and further investigation suggests that pre-existing chronic pain in the family environment is a predictor of both physical and psychological effects on the child (Lynch et al, 2006). Ethnicity and area of residence also appear to affect prevalence rates. For example, in Canada, the incidence of chronic pain is higher among Aboriginal people and, for males, is higher in rural areas (Ramage-Morin & Gilmour, 2010). There may also be cultural differences in the perception and reporting of pain (Mailis-Gagnon et al, 2007).

While chronic pain is clearly not confined to the developed world, most published studies provide figures for European or North American children, which may not be generalisable to different environments. A US study found that 13% of 12-13 year-olds and 17% of 15-16 year-olds experience abdominal pain every week (Hyams et al, 1996), while Dutta et al (1999) reported a considerably higher incidence (74%) in India. However, with gastrointestinal infections more widespread than the inflammatory bowel disease seen in developing countries, these figures probably represent the outcome of different disease processes (Ganesh et al, 2010). Abu-Saad Huijer (2010) considers the effects of war and traumatic events. Despite an absence of research in this area, he argues that chronic pain has been linked with post-traumatic stress disorders and that, as a consequence, we may expect to see a different profile of chronic pain among children affected by armed conflict.

In developed countries, headache, abdominal and musculoskeletal pain form the primary foci of chronic and recurrent pain among the paediatric population. In their study of Canadian 9-13 year olds, van Dijk et al (2006) received reports of recurrent headaches (32%), growing pains (21%), stomach pains (19%) and muscle aches (2%). Perquin et al (2000) had published similar findings from their survey of Dutch schoolchildren, in which they also analysed reports of pain at multiple locations. They found that the single location pain was most often reported. The combination of headache and abdominal pain was the most commonly reported multiple pain, found in 25% of all children. This greater than one pain profile was significantly more prevalent in adolescent girls.

Recent figures from a Statistics Canada health report identify chronic pain among 2.4% of males and 5.9% of females aged 12 to 17 years (Ramage-Morin & Gilmour, 2010). It has been reported that girls are as much as three times more likely to report chronic pain than boys (Martin et al, 2007). Perquin et al (2000) also showed a significant increase in the prevalence of chronic pain in girls. These girls were aged between 12 and 14 which may well be linked with the onset of menstruation. In general, abdominal pain is significantly more likely to be reported by girls and limb pain (or growing pains/muscle aches) is significantly more likely to be reported by boys (Perquin et al, 2000; van Dijk et al, 2006). A review on gender and pain suggests potential mechanisms within social and psychological processes, such as coping processes and catastrophising, are likely to contribute to the repeatedly observed sex differences in pain (Fillingim et al, 2009).

Aetiology and predisposition to chronic pain in children is largely unknown and depends on the type of pain. Factors associated with the development of chronic pain include

The Role of Peripheral Nerve Blocks in the Interdisciplinary

a child's quality of life are wide-ranging and profound.

not properly understood or tolerated.

There are a number of reasons for this difficulty.

prompted poorer function regardless of the level of pain.

amounts of school.

Care of Children with Chronic Pain: A Case Series and Review of the Literature 399

2–21 years, attending a chronic pain clinic found that the HRQoL scores of these patients were not only considerably lower than scores obtained from normal healthy children, but were significantly lower than scores observed in children with rheumatological or cancer disease (Vetter, 2008). Another US study found that the mean PedsQL score for a cohort of 69 children and adolescents (aged 8 – 18 years) seeking outpatient pain management services, fell below the 'at-risk cut-off score' for all dimensions except social functioning, suggesting that the majority of these children were experiencing significant disruption in their day-to-day lives. The message from these studies is clear: the effects of chronic pain on

School functioning has received perhaps the most attention (Palermo, 2000). It demonstrates the most marked detriment of all the psychosocial dimensions of the PedsQL scale (Vetter, 2008; Gold et al, 2009) and clearly illustrates the complex effects of chronic pain on quality of life. A child with chronic pain may experience a range of problems which impact on their schooling: fatigue and/or poor sleep profile prevents early morning waking; pain inhibits physical ability to get to school, to sit in a classroom for long periods or to participate in physical activities; fear of pain by accidentally being knocked during recess times inhibits social interaction and imparts a sense of isolation, difference and not being involved with peers; poor memory and concentration affects schoolwork; as school work becomes missed or incomplete these unfinished projects become a barrier to return to school if workload is not controlled; and the school may represent an environment where their pain condition is

For all these reasons school absences are common. In a survey of adolescent chronic pain sufferers aged 12-17 in Boston USA, 44% missed more than one-quarter of school days and 20% had missed more than half (Logan et al, 2008). Of course, schools typically offer only a limited degree of health-related support. In the Boston study, two-thirds of participants had received some form of accommodation from their school, such as being sent to the nurse's office, being sent home in pain, reduction in workload, extension on an assignment, and so on. Nonetheless, 44.3% of parents reported their child's grades had suffered (Logan et al, 2008) and missing school can clearly have negative consequences that extend beyond academic performance to a child's physical, emotional and social development. Six of the eight cases presented in this chapter had missed significant

Assessing the impact of chronic pain on a child's life is an important but problematic task.

Firstly, the specific effects of chronic pain are not easily isolated from one another. For example, fatigue may be a mediating factor between pain and school functioning (Gold et al, 2009). Anxiety also plays a complex role in moderating the relationship between pain and function. Tsao et al (2007) studied anxiety sensitivity, or the fear of anxiety sensations, in 87 children aged 10-18 presenting at a US chronic pain clinic. Anxiety sensitivity was found to be linked with academic and/or social limitations, where those limitations arose from emotional rather than physical difficulties. Greater anxiety sensitivity was associated with lower self-esteem and perceived general and mental health, and with more behavioural problems and family disruption, but did not appear to affect physical functioning (Tsao et al, 2007). In a similar study of 222 adolescents aged 11 to 19 years attending two chronic pain clinics in the UK, Cohen et al (2010) found that in children with low anxiety, level of pain was a good predictor of physical and social function, but that high levels of anxiety

surgery, trauma, emotional distress and chronic disease. In many cases, a definitive aetiology is difficult to establish. Even chronic post-surgical pain (CPSP) can be difficult to diagnose and consequently remains under-recognised. However, it represents a significant clinical problem. A 2006 review suggests that CPSP occurs after 10-50% of operations and results in severe chronic pain in 2-10% of these patients (Kehlet et al, 2006). This may, in fact, represent a significant portion of chronic pain sufferers. A UK study found that 22.5% of chronic pain patients developed their condition after surgery (Crombie et al, 1998). CPSP will often be neuropathic, resulting from nerve damage during surgery, though it could also be an ongoing inflammatory/nociceptive mechanism. The incidence of CPSP in the adult population is found to depend on a number of perioperative factors which include: genetic predisposition, degree of pre-operative anxiety, depression, pre-operative pain status, the surgical pain model, surgical technique, length of surgery and the quality of acute postoperative pain management (Kehlet et al, 2006; Macrae, 2008). The probability of an adult developing chronic pain after mastectomy or hernia surgery is decreased with increased age (Poleshuck et al, 2006; Poobalan et al, 2003). How this relationship to age translates to children and adolescents is not known as there is no published literature on CPSP in children. Six out of the eight paediatric cases presented in this chapter developed chronic pain following surgery.

Untangling factors to establish clear causality for the development of paediatric chronic pain is a challenge. Whether initiated by surgery or injury or other cause, it is a complex multifactorial process. Understanding this mechanism requires not only a search for a cause, but also a clearer understanding of the effects of chronic pain. It is established that some paediatric chronic pain conditions have been under-diagnosed. Better recognition and early treatment of these conditions requires that healthcare providers understand the effects of chronic pain on a child and their family.

#### **1.2 The impact of chronic pain on children and their families**

Childhood chronic pain has a negative impact on physical, psychological and social function. It can prevent a child participating in sporting activities and other forms of exercise. It can cause sleep disruption and fatigue. It can contribute to depression and anxiety. It can affect school work through fatigue, poor memory and concentration and result in reduced school attendance. Friendships and family relationships are disrupted which may lead to varying degrees of social isolation. An Australian study of 207 children and adolescents attending a paediatric pain management clinic found that 95% had missed school, 90% had been unable to participate in some sporting activity and 71% had suffered some sleep disruption (Chalkiadis, 2001). Roth-Isigkeit et al (2005) found that 30-40% of children/adolescents with pain reported effects of their pain on school attendance, hobbies, social contacts, appetite, sleep, as well as increased utilization of health services because of their pain. An understanding of the range and interaction of all these different effects is crucial to the effective recognition and treatment of chronic pain in children.

These impacts on daily living can be bundled into the notion of Health-Related Quality of Life (HRQoL), which may be defined as *"an individual's subjective assessment of his or her functioning and emotional state"* (Gold et al, 2009) and can be used for comparative purposes. One such measurement instrument is the Pediatric Quality of Life Inventory (PedsQL), which contains items relating specifically to both physical and psychosocial function (the latter comprising emotional, social and school function) and can be completed by self-report or parent-proxy (Varni et al, 2001). Using this instrument, a US study of 100 patients, aged

surgery, trauma, emotional distress and chronic disease. In many cases, a definitive aetiology is difficult to establish. Even chronic post-surgical pain (CPSP) can be difficult to diagnose and consequently remains under-recognised. However, it represents a significant clinical problem. A 2006 review suggests that CPSP occurs after 10-50% of operations and results in severe chronic pain in 2-10% of these patients (Kehlet et al, 2006). This may, in fact, represent a significant portion of chronic pain sufferers. A UK study found that 22.5% of chronic pain patients developed their condition after surgery (Crombie et al, 1998). CPSP will often be neuropathic, resulting from nerve damage during surgery, though it could also be an ongoing inflammatory/nociceptive mechanism. The incidence of CPSP in the adult population is found to depend on a number of perioperative factors which include: genetic predisposition, degree of pre-operative anxiety, depression, pre-operative pain status, the surgical pain model, surgical technique, length of surgery and the quality of acute postoperative pain management (Kehlet et al, 2006; Macrae, 2008). The probability of an adult developing chronic pain after mastectomy or hernia surgery is decreased with increased age (Poleshuck et al, 2006; Poobalan et al, 2003). How this relationship to age translates to children and adolescents is not known as there is no published literature on CPSP in children. Six out of the eight paediatric cases presented in this chapter developed

Untangling factors to establish clear causality for the development of paediatric chronic pain is a challenge. Whether initiated by surgery or injury or other cause, it is a complex multifactorial process. Understanding this mechanism requires not only a search for a cause, but also a clearer understanding of the effects of chronic pain. It is established that some paediatric chronic pain conditions have been under-diagnosed. Better recognition and early treatment of these conditions requires that healthcare providers understand the effects of

Childhood chronic pain has a negative impact on physical, psychological and social function. It can prevent a child participating in sporting activities and other forms of exercise. It can cause sleep disruption and fatigue. It can contribute to depression and anxiety. It can affect school work through fatigue, poor memory and concentration and result in reduced school attendance. Friendships and family relationships are disrupted which may lead to varying degrees of social isolation. An Australian study of 207 children and adolescents attending a paediatric pain management clinic found that 95% had missed school, 90% had been unable to participate in some sporting activity and 71% had suffered some sleep disruption (Chalkiadis, 2001). Roth-Isigkeit et al (2005) found that 30-40% of children/adolescents with pain reported effects of their pain on school attendance, hobbies, social contacts, appetite, sleep, as well as increased utilization of health services because of their pain. An understanding of the range and interaction of all these different effects is

These impacts on daily living can be bundled into the notion of Health-Related Quality of Life (HRQoL), which may be defined as *"an individual's subjective assessment of his or her functioning and emotional state"* (Gold et al, 2009) and can be used for comparative purposes. One such measurement instrument is the Pediatric Quality of Life Inventory (PedsQL), which contains items relating specifically to both physical and psychosocial function (the latter comprising emotional, social and school function) and can be completed by self-report or parent-proxy (Varni et al, 2001). Using this instrument, a US study of 100 patients, aged

chronic pain following surgery.

chronic pain on a child and their family.

**1.2 The impact of chronic pain on children and their families**

crucial to the effective recognition and treatment of chronic pain in children.

2–21 years, attending a chronic pain clinic found that the HRQoL scores of these patients were not only considerably lower than scores obtained from normal healthy children, but were significantly lower than scores observed in children with rheumatological or cancer disease (Vetter, 2008). Another US study found that the mean PedsQL score for a cohort of 69 children and adolescents (aged 8 – 18 years) seeking outpatient pain management services, fell below the 'at-risk cut-off score' for all dimensions except social functioning, suggesting that the majority of these children were experiencing significant disruption in their day-to-day lives. The message from these studies is clear: the effects of chronic pain on a child's quality of life are wide-ranging and profound.

School functioning has received perhaps the most attention (Palermo, 2000). It demonstrates the most marked detriment of all the psychosocial dimensions of the PedsQL scale (Vetter, 2008; Gold et al, 2009) and clearly illustrates the complex effects of chronic pain on quality of life. A child with chronic pain may experience a range of problems which impact on their schooling: fatigue and/or poor sleep profile prevents early morning waking; pain inhibits physical ability to get to school, to sit in a classroom for long periods or to participate in physical activities; fear of pain by accidentally being knocked during recess times inhibits social interaction and imparts a sense of isolation, difference and not being involved with peers; poor memory and concentration affects schoolwork; as school work becomes missed or incomplete these unfinished projects become a barrier to return to school if workload is not controlled; and the school may represent an environment where their pain condition is not properly understood or tolerated.

For all these reasons school absences are common. In a survey of adolescent chronic pain sufferers aged 12-17 in Boston USA, 44% missed more than one-quarter of school days and 20% had missed more than half (Logan et al, 2008). Of course, schools typically offer only a limited degree of health-related support. In the Boston study, two-thirds of participants had received some form of accommodation from their school, such as being sent to the nurse's office, being sent home in pain, reduction in workload, extension on an assignment, and so on. Nonetheless, 44.3% of parents reported their child's grades had suffered (Logan et al, 2008) and missing school can clearly have negative consequences that extend beyond academic performance to a child's physical, emotional and social development. Six of the eight cases presented in this chapter had missed significant amounts of school.

Assessing the impact of chronic pain on a child's life is an important but problematic task. There are a number of reasons for this difficulty.

Firstly, the specific effects of chronic pain are not easily isolated from one another. For example, fatigue may be a mediating factor between pain and school functioning (Gold et al, 2009). Anxiety also plays a complex role in moderating the relationship between pain and function. Tsao et al (2007) studied anxiety sensitivity, or the fear of anxiety sensations, in 87 children aged 10-18 presenting at a US chronic pain clinic. Anxiety sensitivity was found to be linked with academic and/or social limitations, where those limitations arose from emotional rather than physical difficulties. Greater anxiety sensitivity was associated with lower self-esteem and perceived general and mental health, and with more behavioural problems and family disruption, but did not appear to affect physical functioning (Tsao et al, 2007). In a similar study of 222 adolescents aged 11 to 19 years attending two chronic pain clinics in the UK, Cohen et al (2010) found that in children with low anxiety, level of pain was a good predictor of physical and social function, but that high levels of anxiety prompted poorer function regardless of the level of pain.

The Role of Peripheral Nerve Blocks in the Interdisciplinary

treatment strategies for children with chronic pain.

biopsychosocial aspects of the child's life.

pharmacological treatment of paediatric chronic pain.

**Drug Dose Comments**

10-15 mg/kg/dose PO Q4H PRN (max 75 mg/kg/day)

8H (max 40 mg/kg/day)

5-7 mg/kg/dose PO/PR

**>3 months of age to adolescents:**

Ibuprofen 5-10 mg/kg/dose PO Q6-

Naprosyn **Children >2 years:**

Q8-12H

**1.3.1 Pharmacology**

Acetaminophen

Care of Children with Chronic Pain: A Case Series and Review of the Literature 401

clinician should consider including interventions that address these factors in their

Management of children and adolescents with severe suffering and extensive pain-related disability as a result of chronic pain requires an interdisciplinary approach (Eccleston et al, 2003). This includes the treatment modalities of pharmacology, physiotherapy and psychology running in parallel or, more importantly, enmeshed with one another. How these elements are balanced is dependant on each individual child and takes into consideration the type and duration of pain, as well as the impact of pain on particular

The pharmacological approach to management of a child with chronic pain requires consideration of the type of pain, the impact of the pain on the child's biopsychosocial functions and the potential side effects of the medications. Medications need to be individualised to each child and continually re-assessed for efficacy and side effects. If medications are having no impact at therapeutic dosage they need to be discontinued and the child re-evaluated for consideration of other appropriate agents. Close liaison with psychiatry is advised prior to and following up on prescription of mood stabilising medications. It is important to emphasise that pharmacological interventions are only one part of an interdisciplinary approach to improve function in children/adolescents with chronic pain. Table 1 provides a summary of the medications that may be considered in the

mechanism

malnutrition

compromise)

constipation

or renal insufficiency

concomitantly with other NSAIDs

concomitantly with other NSAIDs

Central analgesic action via cannabinoid or prostaglandin

Hepatotoxic in acute overdose or with chronic long term use; risk factors for toxicity include fever, prolonged fasting (>48 hrs), concomitant interacting drugs, obesity, poorly controlled diabetes, liver disease, viral infections and

Doses apply to normal healthy children (i.e. no hepatic or renal

Non steroidal anti-inflammatory agent; should not be used

Use caution in patients with aspirin hypersensitivity, hepatic

Non steroidal anti-inflammatory agent; should not be used

Contraindicated with active GI bleeding and ulcer disease; administer with food or milk to avoid GI upset; common GI side effects include abdominal pain, appetite loss, stomatitis or

May cause photosensitive vesicular rash (pseudoporphyria)

Administer with food or milk to lessen GI upset; contraindicated with active GI bleeding and ulcer disease

**1.3 Interdisciplinary team management of children with chronic pain**

Secondly, the impact of chronic pain on health and quality of life often extends beyond any immediate effects. For example, more than 50% of adolescents with chronic pain report some symptoms of insomnia (compared with less than 20% of healthy adolescents), and while these may initially be related directly to the experience of pain, behavioural patterns can transform this disruption into a primary sleep disorder (Palermo et al, 2010). Furthermore, chronic pain in childhood appears to increase the risk of developing further chronic conditions in adulthood. Adults, who have suffered recurrent headaches as children, are at an increased risk not only of headaches, but other physical and psychiatric symptoms (Fearon & Hotopf, 2001). Similarly, a longitudinal cohort study of paediatric FAPS patients, aged 6 to 18 at enrolment, found that, 15 years later, those with unresolved FAPS experienced higher levels of non-abdominal chronic pain (including migraine, tension-type headaches, and pelvic, back and limb pain) than those with resolved FAPS or normal controls (Walker et al, 2010).

Thirdly, the effects of chronic pain are felt not just by the child, but become a burden for the whole family. The child may no longer participate in shared physical activities, limiting family excursions and fun. Relationships with parents, siblings and other family members are put under strain resulting in anxiety and depression (Eccleston et al, 2004). A number of studies report associations between family functioning and the level of a child's pain-related disability, generally finding that the worse the disability, the greater the family dysfunction (Lewandowski et al, 2010). While it is difficult to interpret the causal relationship underpinning this association with confidence, it is likely that causation runs in both directions: a child's chronic pain has an adverse effect on family life; family problems make it more difficult for the child to cope and so worsen the experience of pain. The impact of chronic pain on the family matches the adverse impact experienced by families caring for children at home with severe cerebral palsy or birth defects (Vetter, 2008).

Daily care arrangements for the child/adolescent with chronic pain require additional support, which may cost money or require a parent to give up a job. The direct and indirect costs of caring for a child with chronic pain have been estimated. A UK study calculated, from a sample of 52 families, that the total annual cost, to a family living with a child in chronic pain, was as much as £14,160 or, approximately, \$25,000 (Sleed et al, 2005). This figure included direct healthcare costs for the child and other family members and indirect costs such as loss of earnings, adaptations to housing, over-the-counter medications and care assistance. This is a potentially ruinous sum for low-income families.

Fourthly, physical and social effects of chronic pain carry another associated economic burden, which may be less easily identified and difficult to quantify. Diminished school function and educational achievement will have potential long-term career and economic cost for both the child and for society.

Finally, the immediate effects of chronic pain have the potential to feed back negatively on the physical and psychosocial health of children and their families. This further reduces their capacity to cope. Unremitting pain can cause sleep disruption and fatigue. Missing school leads to social isolation. The extra burden of stress and financial hardship on families makes them less able to provide the required care. The physical, psychological and social effects of chronic pain can lead the child and their family into a downward spiral, from which it is difficult to emerge without inter-disciplinary support. It is crucial that physicians not only identify the wider psychosocial effects of chronic pain, but recognise that these effects are contributory factors which play an important role in the ongoing pain and functioning of their patient (Jensen, 2011). With the goal of optimal patient care in mind, a clinician should consider including interventions that address these factors in their treatment strategies for children with chronic pain.

#### **1.3 Interdisciplinary team management of children with chronic pain**

Management of children and adolescents with severe suffering and extensive pain-related disability as a result of chronic pain requires an interdisciplinary approach (Eccleston et al, 2003). This includes the treatment modalities of pharmacology, physiotherapy and psychology running in parallel or, more importantly, enmeshed with one another. How these elements are balanced is dependant on each individual child and takes into consideration the type and duration of pain, as well as the impact of pain on particular biopsychosocial aspects of the child's life.

#### **1.3.1 Pharmacology**

400 Pain Management – Current Issues and Opinions

Secondly, the impact of chronic pain on health and quality of life often extends beyond any immediate effects. For example, more than 50% of adolescents with chronic pain report some symptoms of insomnia (compared with less than 20% of healthy adolescents), and while these may initially be related directly to the experience of pain, behavioural patterns can transform this disruption into a primary sleep disorder (Palermo et al, 2010). Furthermore, chronic pain in childhood appears to increase the risk of developing further chronic conditions in adulthood. Adults, who have suffered recurrent headaches as children, are at an increased risk not only of headaches, but other physical and psychiatric symptoms (Fearon & Hotopf, 2001). Similarly, a longitudinal cohort study of paediatric FAPS patients, aged 6 to 18 at enrolment, found that, 15 years later, those with unresolved FAPS experienced higher levels of non-abdominal chronic pain (including migraine, tension-type headaches, and pelvic, back and limb pain) than those with resolved FAPS or

Thirdly, the effects of chronic pain are felt not just by the child, but become a burden for the whole family. The child may no longer participate in shared physical activities, limiting family excursions and fun. Relationships with parents, siblings and other family members are put under strain resulting in anxiety and depression (Eccleston et al, 2004). A number of studies report associations between family functioning and the level of a child's pain-related disability, generally finding that the worse the disability, the greater the family dysfunction (Lewandowski et al, 2010). While it is difficult to interpret the causal relationship underpinning this association with confidence, it is likely that causation runs in both directions: a child's chronic pain has an adverse effect on family life; family problems make it more difficult for the child to cope and so worsen the experience of pain. The impact of chronic pain on the family matches the adverse impact experienced by families caring for

Daily care arrangements for the child/adolescent with chronic pain require additional support, which may cost money or require a parent to give up a job. The direct and indirect costs of caring for a child with chronic pain have been estimated. A UK study calculated, from a sample of 52 families, that the total annual cost, to a family living with a child in chronic pain, was as much as £14,160 or, approximately, \$25,000 (Sleed et al, 2005). This figure included direct healthcare costs for the child and other family members and indirect costs such as loss of earnings, adaptations to housing, over-the-counter medications and

Fourthly, physical and social effects of chronic pain carry another associated economic burden, which may be less easily identified and difficult to quantify. Diminished school function and educational achievement will have potential long-term career and economic

Finally, the immediate effects of chronic pain have the potential to feed back negatively on the physical and psychosocial health of children and their families. This further reduces their capacity to cope. Unremitting pain can cause sleep disruption and fatigue. Missing school leads to social isolation. The extra burden of stress and financial hardship on families makes them less able to provide the required care. The physical, psychological and social effects of chronic pain can lead the child and their family into a downward spiral, from which it is difficult to emerge without inter-disciplinary support. It is crucial that physicians not only identify the wider psychosocial effects of chronic pain, but recognise that these effects are contributory factors which play an important role in the ongoing pain and functioning of their patient (Jensen, 2011). With the goal of optimal patient care in mind, a

children at home with severe cerebral palsy or birth defects (Vetter, 2008).

care assistance. This is a potentially ruinous sum for low-income families.

normal controls (Walker et al, 2010).

cost for both the child and for society.

The pharmacological approach to management of a child with chronic pain requires consideration of the type of pain, the impact of the pain on the child's biopsychosocial functions and the potential side effects of the medications. Medications need to be individualised to each child and continually re-assessed for efficacy and side effects. If medications are having no impact at therapeutic dosage they need to be discontinued and the child re-evaluated for consideration of other appropriate agents. Close liaison with psychiatry is advised prior to and following up on prescription of mood stabilising medications. It is important to emphasise that pharmacological interventions are only one part of an interdisciplinary approach to improve function in children/adolescents with chronic pain. Table 1 provides a summary of the medications that may be considered in the pharmacological treatment of paediatric chronic pain.

The Role of Peripheral Nerve Blocks in the Interdisciplinary

**Drug Dose Comments**

Initial: 25 mg PO daily Titrate upward to effect to 2.5 mg/kg PO BID or max

agents see Compendium of Pharmaceuticals and

37.5 – 75 mg PO Once

37.5-75 mg every 4-7 days **Usual Dose Range:**  75-225 mg/day

Pregabalin **Children > 10 years:**

300 mg/day

Opioids For dosing of different

Specialties

DAILY **Increment:**

**Clonidine** 1-4 micrograms/kg/dose PO Q4-6H

pain management

Venlafaxine **Initial Dose:**

Care of Children with Chronic Pain: A Case Series and Review of the Literature 403

neuron hyperexcited.

behaviour change.

mu-opioid agonist

Similar in mechanism to gabapentin

week.

week.

alcohol

addiction

oral doses are associated with decreased bioavailability; do not administer with antacids; primarily excreted unchanged in the urine, therefore need to adjust dose in renal impairment Maximum dose often not be needed for maximum effect; do not suddenly stop long-term treatment; wean dose by 25% per

Calcium channel α 2-δ ligand; calcium channel blocker when

Gradual dose increase helps to minimize sedation; increased oral doses are associated with increased bioavailability; do not administer with antacids; primarily excreted unchanged in the urine, therefore need to adjust dose in renal impairment. Maximum dose often not be needed for maximum effect; do not suddenly stop long-term treatment; wean dose by 25% per

Side effects may include somnolence, ataxia, fatigue and

Additive sedative effects with other medications and/or

Serotonin/norepinephrine reuptake inhibitor (SNRI) Effective in the treatment of Depression, Generalized Anxiety Disorder, Social Anxiety Disorder, Panic Disorder. Also used to treat ADHD, Post-Traumatic Stress Disorder and

sweating, tremor and impaired sexual function

Side effects include: headache, nausea, increased heart rate and blood pressure (more prominent at higher doses), anorexia/weight loss, drowsiness, dizziness, dry mouth,

Administer with food or milk to decrease GI upset; full beneficial effects may not be seen until 4 weeks of therapy

*Warnings issued by Health Canada regarding use of*

An alpha adrenergic receptor antagonist; metabolism is hepatic and renal (roughly 50:50); drug interactions with beta

Sedative, anxiolytic and analgesic effects; a useful adjunct used to minimise other analgesic drug doses such as opioids Side effects include sedation, dry mouth, hypotension Do not suddenly stop long-term treatment; wean dose by 25%

Obsessive-Compulsive Disorder.

*antidepressants in pediatric patients.*

blockers, tricyclic anti-depressants

per week to prevent rebound hypertension

(adolescents/adults).

completed.

Table 1. Modalities of medications that may be considered in outpatient paediatric chronic

Side effects include sedation, nausea, vomiting, constipation, pruritis, tolerance dependance opioid induced hyperalgesia,

Long-term use rarely indicated in children; addiction potential should be assessed prior to commencement of opioids; opioid prescription should follow national guidelines for safe practice

efficacy

per week

nerves.

serotonergic drugs

improved by gradual dose titration. Caution in renal and/or hepatic impairment

An opioid analgesic with norepinephrine and serotonin effects Side effects include nausea and vomiting; tolerability is

Serotonin syndrome reported with concurrent use of

Seizures reported with concurrent TCAs, SSRIs, and opioids or

Withdrawal symptoms may develop if abruptly discontinued; do not suddenly stop long-term treatment; wean dose by 25%

Blockade of upregulated sodium channel receptors in injured

Tricyclic antidepressant agent (TCA) used in low dose for chronic neuropathic pain; prevents the re-uptake of serotonin

Pretreatment ECG required to exclude arrhythmia potential.

Side effects include: sedation, confusion, weakness, fatigue, tremor, sweating, headache, anticholinergic effects, cardiovascular effects (including orthostatic hypotension, tachycardia, prolonged QTc and arrhythmias at higher plasma

Sedative side effect used to help with improved sleep profile If one TCA not helpful due to intolerable side effects try another with a different SE profile before abandoning this modality of pharmacological therapy (Nortriptyline is less

A withdrawal syndrome is documented for Tricyclics (flu-like symptoms, dizziness, mood changes). Assess patient carefully and limit prescribed quantities to minimum effective dose; do not suddenly stop long-term treatment; wean dose by 25% per

Calcium channel α 2-δ ligand; calcium channel blocker when

Analgesic, anticonvulsant, anxiolytic, and sleep-modulating

Gradual dose increase helps to minimize sedation; increased

Side effects may include somnolence, ataxia, fatigue and

Tramadol is metabolized to active form (i.e. a prodrug) Inter-individual pharmacogenomic variations affect

with conditions that lower seizure threshold

Extended release product given ONCE daily.

Minimal side effects (mild skin reactions)

Drug interactions via cytochrome p450 system; contraindicated if MAO inhibitors used within 14 days; tricyclics have limited efficacy for treatment of depression in

Useful for very localised pain

and norepinephrine.

children and adolescents

commencement.

neuron hyperexcited

behaviour change.

week.

activities.

levels), decreased seizure threshold.

sedating, doxepin less anticholinergic).

Analgesic effect may not occur for 2 weeks from

**Drug Dose Comments**

50-100 mg Q4-6H PRN (max: 400 mg/day)

**Extended-release form: Adolescents:** Initial: 100 mg PO daily; titrate by 100 mg increments every 2-3 days PRN (max: 300

**Adolescents:**

mg/day).

Amitriptyline Initial: 0.1 mg/kg/dose

Gabapentin **Children:** titrate to effect

over a few days, starting at 2 mg/kg once or twice daily, then increase to TID dosing to a maximum of 35 mg/kg/24hr (max 3600 mg/day)

Topical: 5% under occlusive

dressing for 12 hours (once per day)

PO HS; increase as needed and tolerated over 2-3 wks to 0.5-2 mg/kg/dose HS

**Immediate-release form: Children:** 1-2 mg/kg Q4- 6H PRN (max: 400 mg/day or 8 mg/kg/day)

Tramadol (Ultram, Ralivia)

Topical Lidocaine

Table 1. Modalities of medications that may be considered in outpatient paediatric chronic pain management

The Role of Peripheral Nerve Blocks in the Interdisciplinary

of the individual patient.

(Peng & Castano, 2005).

meningitis (Gaul et al, 2005).

benefit from interventional treatments.

**1.3.4 Interventional therapies**

Care of Children with Chronic Pain: A Case Series and Review of the Literature 405

teachers become more aware of the condition and its impact on schoolwork. The psychologist helps to negotiate or advocate for any accommodations needed in order to help the child succeed at school. Psychologists help the child and their family identify and resolve stresses such as anxiety or depression that could be preventing return to function. A Cochrane Review determined that there is strong evidence for psychological therapies being effective in the treatment of headaches in children and some evidence for their efficacy in the treatment of musculoskeletal and recurrent abdominal pain (Eccleston et al, 2009). Psychological interventions are often, and ideally, delivered as part of an interdisciplinary approach and consequently there are few randomized-controlled-trial (RCT) studies providing definite evidence for individual therapies (McGrath & Holahan, 2003).  Nerve blocks are used widely among Canadian anaesthesiologists who specifically practice chronic pain management: of those, 84% perform nerve blocks, compared with 60% who use pharmacotherapy, and a majority of them estimated that more than 40% of their patients require some form of nerve block as part of their treatment programme

However, there is very little evidence to demonstrate that interventions benefit a patient more than would be seen from a placebo response. The literature is comprised of case reports and small case series, along with a few randomized, placebo-controlled trials (RCTs). For example, therapeutic lumbar facet joint nerve blocks can provide effective pain relief and functional improvement (Manchikanti et al, 2010). However, epidural corticosteroid injections for sciatica appear to offer only transient benefit (Arden et al, 2005). Results of RCTs are not always consistent, however. For example, one RCT has shown that radiofrequency lesioning of the dorsal root ganglion for treatment of chronic lumbosacral radicular pain appears not to be more effective than control treatment with local anaesthetic (Geurts et al, 2003); on the the other hand, another RCT has shown that it is both safe and effective (Simopoulos et al, 2008). For some techniques, such as myofascial trigger point injections, it has not even been possible to establish a consensus on methods for diagnosis or treatment (Tough et al, 2007). Furthermore, any RCTs that have been done mainly comprise adult studies. The evidence of efficacy in children/adolescents is even more limited and more research is required. There are also rare but significant iatrogenic risks associated with some of these interventions. Injection therapies for lower back pain carry the risk of paraspinal, spinal end epidural abscesses or

Despite this negative portrayal of interventional medicine for chronic pain "absence of evidence is not evidence of absence" (Altman & Bland, 1995) and there are many pain physicians and patients, including those in this case series, who have derived enormous

#### **1.3.2 Physiotherapy**

Chronic pain sufferers often experience some level of physical incapacity and many adopt activity patterns that can make their pain worse, such as alternating episodes of overactivity and under-activity (Birkholtz et al, 2004). Physiotherapy plays an important role in the interdisciplinary treatment of chronic pain in children and adolescents. Eccleston & Eccleston (2004) divide it into the following four components:

Other reports of physiotherapy interventions in the treatment of chronic pain stress the importance of the interdisciplinary approach. For example, a combination of physical therapy and CBT has been shown to be effective in treating CRPS in children (Lee et al, 2002). Harding et al (1998) also highlight the need to integrate behavioural and cognitive components in activity training to minimise distress and unhelpful beliefs.

#### **1.3.3 Psychology**

There are a number of psychological factors, which are directly involved in the perception, reporting and self-management of pain. These include fear, vigilance to the feeling and threat of pain, catastrophising, avoidance of pain-inducing activity, sadness, depression, anger and self-denigration. Psychological factors are also important in coping mechanisms, taking action, and being able to predict or make sense of pain and its consequences (Eccleston, 2001). Psychologists provide continual education/reassurance on the pathophysiology of the chronic pain condition and teach mind-body techniques like breathing, muscle relaxation exercises, self-hypnosis, imagery, and cognitive strategies. These techniques help reduce the impact of pain on daily living and mood.

Cognitive behaviour therapy (CBT) is central to the notion of interdisciplinary care. CBT refers to an *"integration of treatments aimed at reducing or extinguishing the influence of the factors that maintain patients' maladaptive behaviours, beliefs and patterns of thought... and is delivered by a team of pain therapists, including anaesthetists, clinical psychologists and physiotherapists"* (Eccleston, 2001). Interdisciplinary CBT programmes aimed at adolescents with chronic musculoskeletal pain have been found to improve physical function, reduce emotional distress, increase attendance at school and reduce medicine consumption (Eccleston et al, 2003; de Blécourt et al, 2008). Furthermore, there is evidence to suggest that an interdisciplinary framework is beneficial for the family members involved. Schurman & Friesen (2010) report that an 'integrative care' approach in a paediatric Abdominal Pain Clinic (that is, service delivered by a gastroenterologist and a psychologist) was acceptable to families, produced higher satisfaction scores and, crucially, improved receptivity to treatment recommendations.

Relaxation strategies and plans to improve sleep hygiene are a vital part of the psychologist's role. When schooling has been impacted by pain, the psychologist helps teachers become more aware of the condition and its impact on schoolwork. The psychologist helps to negotiate or advocate for any accommodations needed in order to help the child succeed at school. Psychologists help the child and their family identify and resolve stresses such as anxiety or depression that could be preventing return to function.