Annual Meeting Reviews

Neuropathic Pain and Associated Challenges

By Ashlee Holman, MD
Clinical Assistant Professor,
Department of Anesthesiology
University of Michigan
Ann Arbor, Michigan

What We Know and What We Don’t Know About Neuropathic Pain
Dr. Amber N. Borucki is an Assistant Professor of Anesthesiology and Pain Medicine and the Director of the Anesthesia Pain Service at UCSF Benioff Children’s Hospital. In her lecture, she discussed both what is known and unknown about neuropathic pain in children.

What is known? Dr. Borucki highlighted pathophysiology, incidence, diagnosis, treatment, and specific pediatric disorders associated with neuropathic pain. In summary, neuropathic pain involves a primary lesion or dysfunction of the peripheral or central nervous system. After a nerve injury, there is a cascade of changes in the peripheral and central nervous system leading to central sensitization. Children have different rates of development and types of neuropathic pain as opposed to adults. Diagnosis is heavily history and physical exam-based; however, there are new diagnostic tools in development. There are several classes of medications used to treat neuropathic pain, graded as 1st-3rd line by the International Association for the Study of Pain.

What is unknown? All unexplained pediatric chronic pain states may not be neuropathic pain as small fiber neuropathy may play a role in unexplained pain. Neuropathic medications are being utilized in pediatric chronic pain; however, good quality evidence for their use is lacking. That being said, the WHO suggests appropriate pharmacological management given low rates of adverse events secondary to these medications.

Evidence Based Interventional Procedures for Management of neuPain in Children
Dr. Ardin S. Berger is an Assistant Professor of Anesthesiology and practices pediatric pain management at Stanford Children’s Hospital. In their lecture, they discussed common interventional pain procedures used in pediatric neuropathic pain management. Dr. Berger highlights indications and contraindications as well as risks of each procedure, anatomy of each block, and updates in technical developments allowing for safer and more precise performance.

Specific procedures discussed include greater and lesser occipital nerve blocks, intercostal nerve blocks, paravertebral blocks, celiac and superior hypogastric plexus blocks, stellate ganglion blocks, and lumbar sympathetic plexus blocks. In summary, multiple, low-risk procedures can be incorporated into pediatric pain management to improve the quality of life for children, adolescents, and young adults with neuropathic pain complaints. As ultrasonic guidance becomes the predominant imaging modality, procedures are becoming increasingly safe and precise, with risk to benefit ratios becoming more favorable. Thorough understanding of anatomy and judicious selection of patient candidates should combine to increase the overall success of interventional pain management procedures in pediatric patients with neuropathic pain.

The Psychology of Chronic Pain: Danger and Stress Systems Conspire to Create Chronicity, and Strategies to Address It
Dr. Dustin P. Wallace is a Psychologist, Associate Professor of Pediatrics, and the Director of the Behavioral Health for the Rehabilitation for Amplified Pain Syndromes Program at Children’s Mercy Kansas City. In his lecture, he discussed how aspects of everyone’s psychological makeup leads to stress and increased impairment due to avoidance of pain. Dr. Wallace also provided a patient-friendly rationale for multimodal non-pharmacological care of chronic pain. He focused on primary chronic pain and suggested that in all cases of pain, a thorough medical evaluation is needed to rule out disease, injury, or other treatable condition.

In summary, many aspects of human physiology and life experiences can lead to the development of chronic pain. Once started, chronic pain is maintained through learning and memory in the body and brain, avoidance and deconditioning, stress and autonomic dysregulation, and pain becoming “overprotective”. Treatment starts with biopsychosocial education of the patient and family followed by medication if indicated, physical activity and exercise, desensitization if needed, proactive stress management with CBT and counseling if necessary, thus making pain less of a decision-maker and less “dangerous” to the brain, and general health promotion.

Treating Persistent Pain with Lifestyle Medicine
Dr. Kim S. Clarno is a Certified Clinical Specialist in Orthopaedic Physical Therapy at Kaiser Permanente and is dual board-certified in Lifestyle Medicine and Othropaedic Physical Therapy. In her lecture, she defines lifestyle medicine and its relevance for pediatric patients, listed the components of lifestyle medicine that are applicable in treating pain, and discussed evidence that supports the use of lifestyle for therapeutic behavior change to enhance the treatment of pain.

Dr. Clarno defined lifestyle medicine as the use of evidence-based lifestyle therapeutic approaches, such as plant-predominant dietary lifestyle, regular physical activity, adequate sleep, stress management, avoidance of risky substances, and use of other non-drug modalities, to treat, reverse, and prevent lifestyle-related chronic disease.

In summary, Dr. Clarno suggests the first step of implementing lifestyle treatment is assessing the patient’s readiness for change followed by prioritizing and offering “prescriptions” to guide healthy behaviors. Overall, positive prescriptions are more effective than negative prescriptions. Additionally, she suggests offering resources for pain management related to exercise, breathing, sleep, relaxation, mindfulness practice, pacing, CBT, and nutrition.

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