Out of the Nurses Office and
Back to the Classroom: A
Functional Approach to Chronic
Pain
Nancy S. Bright BS, RN
Coordinator, Pain Relief Program
Connecticut Children’s
May 20, 2010
Objectives
• To understand the multifactorial
components of chronic pain
• To learn about a functional approach to
treating chronic pain
• To identify challenges for integrating
children with chronic pain back into the
school setting
Body maps
Sources of Chronic Pain
• Ongoing illness: sickle cell, cancer
• Post infectious myalgias that sensitize the
central nervous system
• Non-progressive disorders whose
manifestation is pain—chronic daily
headache, functional abdominal pain,
widespread musculoskeletal pain
Functional Pain Syndromes
• A disorder that after appropriate medical
assessment cannot be explained in terms of
conventionally defined medical disease based on
biochemical or structural abnormalities
• Not typically responsive to conventional medical
therapy but responsible for the consumption of
enormous medical resources
• Unfortunately, often pejorative implication, i.e. pain
is not organic and therefore not real or serious
• As a result, patients often marginalized from
meaningful professional care
A new model
• Traditionally, all of these entities
were viewed in the medical
model
• Assumption was that if pain did
not have an identifiable biologic
etiology, it was psychological in
origin
Central sensitization
• Overall, increased sensitivity to
pain both peripherally and
centrally
• Hypersensitivity of the peripheral
nerves
• Explanatory model of hurt versus
harm
Chronic pain
• Recognition that the experience of
pain is the result of the interplay of
biologic predispositions (genetic
tendencies, pain vulnerabilities) and a
host of psychosocial factors that
either amplify or diminish the pain
Epidemiology
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Marked increase in pain prevalence at 8 years
Incidence peaks at 14 years
Transition years in school: 5th, 7th, 9th grade
Over 50% of children who reported chronic pain
reported pain in multiple sites
• Incidence of multiple pain sites increased with age
• Girls 2X as likely to have multiple sites of chronic
pain
• HA and abdominal pain most common combination
(25% of all cases of multiple pain sites)
Incidence musculoskeletal pain
– Overall prevalence – 22%
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Fibromyalgia – 1.25% (7% of pedi rheum referrals)
Knee pain – 18%
Back pain – 7-34%
Limb pain – 4-33%
– Pain persistence - 31% had pain 1 year later
and 30% had recurrences of pain 4 years
later
Incidence headache
• Overall headache incidence over
childhood 37%
– Migraine occurrence:
5-15 yrs - 10.6%
10-19 yrs – 28%
– Tension – 18.5%
– Unclassifiable – 74%
• 22% of neurology referrals for
headache
Incidence abdominal pain
• 2-4% of pediatric visits
• 50% of GI consultations
• 21% reported pain severe
enough to affect activities
Pain related visits to school nurse
• In a large, urban school district in
Milwaukee, WI the most common reason
for visit to the school nurse, other than
first aid:
– Stomach ache 17%
– Headache 16% 59% females
» Hainsworth et al, Children’s hospital of WI 2009
Impact on the Child
• 30-40% restrictions in daily living
• 90% decreased or no sporting activities
• Increased social difficulties
– 68% of large study of chronic pain pts had significant restrictions
on daily life
• Sleep – 50% 0f children with chronic pain have sleep
difficulties
– Sleep initiation
– Maintaining sleep
– Early morning awakening
• Chronic pain has potential to permanently alter child’s
development and future role functioning
Impact on School
• Academic
–Often academic deterioration
–Frequent school absence
–1 in 6 patients with chronic pain had
missed one third of school year
–Impaired ability to cope with the
demands of classroom/homework
workload
Teachers
• Teacher response to chronic pain may
influence the extent to which school
functioning is disrupted in children with
pain
– Over solicitous
– Not understanding
– Parents approach to school may affect the
schools response to accommodations
» Logan et al, 2007
Impact on Family
• Frustration of finding the diagnosis and
understanding it
• Loss time from work
• Flexibility in orchestrating a return to
school; negotiating make up work
• Fitting in appointments such as physical
therapy, psychology in addition to the
activities of other siblings
Psychiatric co morbidity
• Study of 3500 schoolchildren, stress and
depressive symptoms associated with chronic pain
• Prospective study of 9000 pain free individuals –
depressed individuals were 3x more likely to
develop new onset chronic back pain than non
depressed
• In sample of 80 adolescents with chronic pain
(Eccleston, Pain 2004), anxiety scores 2x as large
as general population; depression in 70% of
sample
• Increased catastrophizing and lower self esteem
Psychiatric co morbidity
Abdominal pain
– More anxiety and depression
– In one study 79% of children referred for recurrent abdominal pain
meet criteria for anxiety disorder; 43% depressive disorder
Headache
– Psych co-morbidity in children, 46% of chronic daily headache
vs. 17% migraine; anxiety disorders predict headache
persistence and poorer treatment response
– 86% of children with Chronic daily headache reported severe
school achievement related stress
– WMSP (fibromyalgia)
– Children with fibromyalgia more likely to be depressed
Commonalities of chronic pain
problems
• Female predominance
• Abnormalities of pain processing
• Frequent psychiatric comorbidity/stress sensitivity
• Similarities of diagnostic approach
and treatment
Treatment plan
• Demystify the problem – hurt vs. harm; labels such as
psychosomatic are not helpful and in fact not accurate
• Emphasize the fact that pain no longer has a warning function
• State clearly that symptom complex is familiar to the provider;
symptoms are real and not imagined
• Reassurance is critical as many families will have had
frustrating experience with medical community and often
misdiagnosis or no diagnosis
• Goal of treatment should be return to function; not solely
reduction of pain
Treatment plan
• Medications for pain: neuropathic,
preventive
• Recognize role of anxiety, depression
• Psychological support/ health psychologist
• Treat sleep problems
• Establish regular exercise or physical
therapy program
• Biofeedback, acupuncture, massage
Go to School
• School
– Development of modification plan /504 plan
• Frequency of Attendance
• Graduated return to school- scripted reentry plan
• Nurse office sanctuary
• Criteria for staying home- fever>102
• Work modification
• Tutoring support for missed work
Return to school
• An integral part of clinical care
• School attendance is how we measure
function, which is a more accurate
measure of pain than a pain scale
• School performance indicates adaptive
response to pain
Summary
• Chronic pain problems have biological,
psychological and social components
• Treatment plan needs to be
multidisciplinary
• Return to school is an important part of the
clinical care plan
References
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Logan D, Scharff L et al. Evaluating Teacher’s Perceptions to Children with Chronic
Pain Syndromes. Children’s Hospital, Boston
Ladwig J, Khan K. School Avoidance: Implications for School Nurses. JSPN Vol 12,
No 3, July 2007. pp 210-212.
Logan D, Coakley R, Scharff L. Teachers’ Perceptions of and Responses to
adolescents with Chronic Pain Syndromes. Journal of Pediatric Psychology 2007
vol32 no 2, pp 139-149.
Mayer EA, Bushnell MC. Functional Pain Syndromes. Seattle: IASP Press, 2009.
Williams DA, Clauw DJ. Understanding fibromyalgia: Lessons from the Broader Pain
research Community. Journal of Pain 2009:10 pp777-791
Nurko S, DiLorenzo C. Functional Abdominal Pain: Time to Get together and move
Forward. Journal of Pediatric Gastroenterology and Nutrition. 2008: 47,pp 679
Scher AI, Stewart WF, Lipton RB. Co morbidity of Headache with Other Pain
Syndromes. Headache 2006:46,pp 1416-23
Zeltzer L. Conquering Your Child’s Chronic Pain