Psychological management of Acute and Chronic Pain

1. Psychological management of Acute and Chronic Pain Dr Janie Donnan RHSC Gastroenterology Team CPD 2/5/07

2. Pain: What is it? �Pain is whatever the experiencing person says it is, existing wherever they say it does� �An unpleasant sensory sensation & emotional experience with actual or potential tissue damage. Pain is always subjective. Each individual learns the application of the word through experiences related to injury in early life� Pain a subjective and individual phenomenonPain a subjective and individual phenomenon

3. Development of a Concept of Pain Children�s development of a concept of pain is affected by both cognitive maturation and the child�s experience of pain (McGrath, 1995) Child�s experience of pain can be affected by direct experiences with hospital or vicariously through the behaviour of others

4. Development of a Concept of Pain 0-18 mths: Crying or simple verbalisations. 18 mths-2 yrs: Verbalise info. about pain, localise it in their own bodies and identify pain in others. Can attribute pain to causes. 3-4yrs: Differentiate between different intensities and qualities of pain. 5-7yrs: Proficient in distinguishing differing levels of pain and fluctuations in pain 18months �2 yrs: understand that their experience of pain can be alleviated by asking for medicine or receiving hugs / kisses from carers. May also try to alleviate pain in others, giving them a hug. 3-4yrs: can ask them how much pain they feel and how it feels e.g. stingy, throbbing etc. 5-7yrs:18months �2 yrs: understand that their experience of pain can be alleviated by asking for medicine or receiving hugs / kisses from carers. May also try to alleviate pain in others, giving them a hug. 3-4yrs: can ask them how much pain they feel and how it feels e.g. stingy, throbbing etc. 5-7yrs:

5. Development of a Concept of Pain 7-10yrs: Children can explain why pain hurts Adolescence: Can explain the adaptive value of pain for protecting people from harm Adaptive value of pain e.g. removing hand from hot pan handle, stopping running when ankle hurts.Adaptive value of pain e.g. removing hand from hot pan handle, stopping running when ankle hurts.

6. Assessing Children�s Pain Preverbal Children: Facial Expression, Grunau & Craig, 1987 Body / Limb Movements Crying Preschool: Faces Rating Scale, Wong & Baker,1988 Faces Pain Scale, Bieri et al, 1990 The Oucher, Beyer & Aradine, 1986 Poker Chip Tool Preverbal Children: Young children, including neonates do experience pain and not managing this appropriately can have a number of negative consequences, such as affects on the parent-child attachment, behaviour changes and other medical complications as a result of the increased distress in the child e.g.intra ventricular haemorrhage. Difficult to assess their level of pain, but are a number of behaviours that have been studied, which have helped professionals to understand preverbal children�s pain. Facial Expression: Grunau & Craig, 1987. Developed the Neonatal Facial Acting Coding System, NFCS. (0-4months) Describes a number of �pain expressions� Eye squeeze Brow contraction Open mouth Taut tongue Body / Limb Movement: For Example: Movement in response to painful stimulus can be used to assess pain e.g reflex withdrawal. Torso squirming and limb movements seen immediately after surgery if analgesia is inadequate. However, it�s important to know that absence of movement does not mean absence of pain � can mean more pain. Crying: Research indicates that there is a typical cry in response to painful stimulus, not considered reliable on it�s own � need to use this info in conjunction with other indicators of pain. No crying does not therefore mean lack of pain. Levine & Gordon, 1982, PIV: Pain-induced Vocalisation � Mothers able to distinguish between PIV and other types of cry. Self report scales Wong & Baker Faces Rating Scale, 1988: 3-18 yrs 6 faces numbered 0-5, depicting smiling through neutral to total misery. Faces Pain Scale, Bieri et al, 1990 3yrs + Similar to Wong and Baker. Series of 7 faces derived from children�s drawings The Oucher, Beyer & Aradine, 1986 3-12yrs 2 Scales: 6 photographs arranged vertically, depicting children in different degrees of distress and along side these � a vertical numerical scale from 0-100. Poker Chip Tool Child given 4 poker chips and these are described as �pieces of hurt� 1 �just a little hurt� 2 �a little more hurt� 3 �more hurt� 4 �the most hurt you can have�Preverbal Children: Young children, including neonates do experience pain and not managing this appropriately can have a number of negative consequences, such as affects on the parent-child attachment, behaviour changes and other medical complications as a result of the increased distress in the child e.g.intra ventricular haemorrhage. Difficult to assess their level of pain, but are a number of behaviours that have been studied, which have helped professionals to understand preverbal children�s pain. Facial Expression: Grunau & Craig, 1987. Developed the Neonatal Facial Acting Coding System, NFCS. (0-4months) Describes a number of �pain expressions� Eye squeeze Brow contraction Open mouth Taut tongue Body / Limb Movement: For Example: Movement in response to painful stimulus can be used to assess pain e.g reflex withdrawal. Torso squirming and limb movements seen immediately after surgery if analgesia is inadequate. However, it�s important to know that absence of movement does not mean absence of pain � can mean more pain. Crying: Research indicates that there is a typical cry in response to painful stimulus, not considered reliable on it�s own � need to use this info in conjunction with other indicators of pain. No crying does not therefore mean lack of pain. Levine & Gordon, 1982, PIV: Pain-induced Vocalisation � Mothers able to distinguish between PIV and other types of cry. Self report scales Wong & Baker Faces Rating Scale, 1988: 3-18 yrs 6 faces numbered 0-5, depicting smiling through neutral to total misery. Faces Pain Scale, Bieri et al, 1990 3yrs + Similar to Wong and Baker. Series of 7 faces derived from children�s drawings The Oucher, Beyer & Aradine, 1986 3-12yrs 2 Scales: 6 photographs arranged vertically, depicting children in different degrees of distress and along side these � a vertical numerical scale from 0-100. Poker Chip Tool Child given 4 poker chips and these are described as �pieces of hurt� 1 �just a little hurt� 2 �a little more hurt� 3 �more hurt� 4 �the most hurt you can have�

7. Assessing Children�s Pain Older Children: Visual Analogue Scales Numerical Rating Scale / Pain thermometer Eland Colour Scale Pain Assessment Tool for Children (PATCh) McGill Pain Questionnaire (Melzack,1987) Varni-Thompson Questionnaire (Varni etal, 1987) Pain Diaries Visual analogue scales: e.g Single line with child�s own words at each end �No pain� / �Worst pain ever� Numerical Rating Scale Pain thermometer Eland Colour Scale: 2 body outlines � front and back of a child Children given a number of coloured pens and colour in 4 boxes labelled no pain, mild pain, moderate pain and severe pain. Then use this coloured key to indicate pain and degree of pain in different areas of their body. Pain Assessment Tool for Children (PATCh) Uses a combination of 5 measures similar to those above including faces, body outline,visual analogue scales. McGill Pain Questionnaire (Melzack,1987) Twycross p69 Varni-Thompson Questionnaire (Varni etal, 1987) Twycross p69 Pain Diaries: Particularly useful in Chronic Pain. Can include faces, numerical or visual analogue scales. Can be adapted to gather information that is salient for that individual and can explore a lot more detail about their experiences by documenting episodes of pain. Can include additional information about timing, environment, thoughts and feelings. Helpful for exploring possible precipitating or maintaining factors and in planning treatment strategies. Visual analogue scales: e.g Single line with child�s own words at each end �No pain� / �Worst pain ever� Numerical Rating Scale Pain thermometer Eland Colour Scale: 2 body outlines � front and back of a child Children given a number of coloured pens and colour in 4 boxes labelled no pain, mild pain, moderate pain and severe pain. Then use this coloured key to indicate pain and degree of pain in different areas of their body. Pain Assessment Tool for Children (PATCh) Uses a combination of 5 measures similar to those above including faces, body outline,visual analogue scales. McGill Pain Questionnaire (Melzack,1987) Twycross p69 Varni-Thompson Questionnaire (Varni etal, 1987) Twycross p69 Pain Diaries: Particularly useful in Chronic Pain. Can include faces, numerical or visual analogue scales. Can be adapted to gather information that is salient for that individual and can explore a lot more detail about their experiences by documenting episodes of pain. Can include additional information about timing, environment, thoughts and feelings. Helpful for exploring possible precipitating or maintaining factors and in planning treatment strategies.

8. Assessment Clinical Interview: Previous experiences, family functioning, other stressors, developmental level. Staff interview Coping Style especially locus of control Observation / video Assessment tools / diaries Coping style: useful to know if they have current coping strategies / styles - are these adaptive or can they be built on . Much better to use interventions that fit with their coping styles or build on their own strategies.Coping style: useful to know if they have current coping strategies / styles - are these adaptive or can they be built on . Much better to use interventions that fit with their coping styles or build on their own strategies.

9. Pain Gate Theory Sets of nerves carrying information to the spinal cord about sensations such as heat, movement, touch or pain. Messages have to pass through gate before brain feels them as painful. (DRAW THIS OUT TO HELP UNDERSTANDING). Feelings like stress or worry make the pain worse as �open gate�. Being relaxed or distracted make pain less bad as �close the gate� � give concrete examples � so we want to find ways to close the gate!! NB Important they understand Pain not in mind but it is felt by a message going to your brain and so psychological techniques can help to close the gate, put up a road block etc�. Use alongside medical treatments e.g. pain medication

10. Pain Gate Theory - cont Car analogies (can use with older children if above information would be too detailed)� messages like cars on a road � the more cars, the more pain is felt. When people have had pain for a long time, one thing that can happen is the road becomes wide, like a motorway and the body gets very used to lots of pain messages. So we need to think of ways to help slow down or stop the pain messages (the cars) getting up to your brain e.g. By learning to put up traffic lights or a road block or a no entry sign. It won�t cure the pain but it will make the road less busy so less messages get through to the brain

11. Psychological Methods of Pain Management Distraction Imagery Relaxation (belly breathing, progressive muscle relaxation) CBT (thoughts, feelings, behaviour, physiological symptoms) Hypnosis Motivational Interviewing (if need to increase motivation or confidence to change) Family / Systems interventions Etc�.. Distraction eg counting, blowing bubbles, music, stories Imagery e.g. preparation of scene, either a script or their own experience such as a holiday or imaginary place Relaxation eg muscular relaxation, younger children � spaghetti dance, floppy bear Biofeedback Hypnosis CBT : using CBT framework to enable the child or young person to understand the factors that increase,precipitate or maintain their pain and planning interventions accordingly Distraction eg counting, blowing bubbles, music, stories Imagery e.g. preparation of scene, either a script or their own experience such as a holiday or imaginary place Relaxation eg muscular relaxation, younger children � spaghetti dance, floppy bear Biofeedback Hypnosis CBT : using CBT framework to enable the child or young person to understand the factors that increase,precipitate or maintain their pain and planning interventions accordingly

12. CBT example Unhelpful� Situation: Needing to have injection Thoughts I don�t want it, It will be painful, Why me? Behaviour Mood/Feelings Not doing injection Frightened Physiological Symptoms Hot flushes, headache, stomach churning