Intensive Interdisciplinary Pain Treatment for Children with Chronic Pain
By Eugene Kim, MD
Chief, Division of Pain Medicine
Children’s Hospital Los Angeles
Assistant Professor of Anesthesiology
Keck School of Medicine
University of Southern California
Los Angeles, California
and Sara E. Williams, PhD
Pediatric Psychologist, Clinical
Behavioral Medicine & Clinical Psychology
Cincinnati Children’s Hospital
Associate Professor, UC Department of Pediatrics
University of Cincinnati
Cincinnati, Ohio
Chronic pain is prevalent among pediatric patients, with population studies estimating that one in four children meet criteria for a chronic pain condition at some point during their development.1 Chronic pain is a highly disabling condition in children, resulting in physical limitations, school absence, social problems, and psychological comorbidities.2 Pediatric patients with chronic pain are typically seen across multiple medical outpatient specialties and may be hospitalized on acute care or inpatient rehabilitation units for pain exacerbations. It can be challenging for providers from various disciplines to successfully treat children with chronic pain and its consequences in any setting.
Typically, a multidisciplinary outpatient approach is recommended as a first line treatment to address biopsychosocial factors that contribute to chronic pain. This may include therapeutic approaches such as medication, physical therapy, occupational therapy, and psychological intervention. Research in pediatric chronic pain shows that function improves before pain;3 as such, when children reengage in everyday activities through multidisciplinary intervention, many succeed at managing and overcoming pain as well as related functional deficits.
However, a subset of pediatric patients—those with the highest levels of pain and disability—struggle to make functional or pain-related improvements in standard outpatient care.4 These children require delivery of services in a structured environment where medical, physical, and emotional needs are met simultaneously through coordinated, regular care. Unfortunately, there are few comprehensive pain rehabilitation programs that can address the challenges of chronic pain at this level. As a result, many children and families are required to travel great distances to receive treatment at specialty centers. Worse still, some do not receive the care they need, continue to struggle with pain, and suffer associated losses in education, physical, psychological, and social function.
To meet these challenges, the field of pain medicine has a unique opportunity to enhance treatment of highly disabled pediatric chronic pain patients and expand specialty services. Specifically, Intensive Interdisciplinary Pain Treatment (IIPT), inpatient or day treatment programs, offer the ideal setting with integrated resources that, with the right training and leadership, can provide effective treatment for chronic pain. These models offer increased intensity and frequency of therapies in a specialized setting that provides a “higher dose” of treatment from a coordinated care team who can provide a consistent message of functional restoration. This approach is effective for pediatric patients with complex chronic pain conditions.5 IIPT programs have been shown to decrease short and long-term pain intensity, reduce pain-related disability, improve school attendance, and improve emotional functioning, while being cost-effective.6
In the IIPT model, the primary treatment goal is to normalize activity and increase self-management for children with chronic pain conditions. Typically, children and adolescents ages 10-18 who have chronic pain conditions causing significant functional disability and impairments in activities of daily living, are good candidates for IIPT. Common pain diagnoses include amplified musculoskeletal pain, complex regional pain syndrome, Ehlers-Danlos Syndrome-Hypermobility Type, fibromyalgia, chronic headaches, and chronic abdominal pain. Formal IIPT day treatment or inpatient programs typically deliver services on a structured schedule. Patients receive daily therapies from specialists in a variety of disciplines, such as pain and rehabilitation medicine physicians, nurse practitioners, nurses, dieticians, psychologists, social workers, physical therapists, occupational therapists, recreational therapists, speech pathologists, schoolteachers, massage therapists, acupuncturists, yoga instructors, music therapists, art therapists, or child life specialists. Team meetings are held on a regular basis to coordinate care, discuss clinical goals, and monitor treatment progress, and may include the patient and family. Parents are often included in some aspects of the patients’ treatment so they can receive education and support from the IIPT team to learn the skills necessary to continue the child’s functional success at home.
Children are ready for discharge from IIPT when they demonstrate significant improvements in function, independence in exercise, and positive coping efforts, among other individually set goals (e.g., ability to return to school, improvement in nutrition and hydration, ability to return to sports). Length of stay ranges from a few weeks to a few months, depending on the degree of impairment and progress in treatment. While a majority of children regain their function in IIPT, pain does not always improve. One study found that while 35% of patients reported improvement in pain upon discharge from an IIPT program, and a further 38% reported improvement at one month, 27% of patients never experienced any pain improvement.7 In that sample, older age, high baseline pain scores, anxiety, fewer social difficulties, but most of all, low readiness to change were all factors found to contribute to the lack of pain improvement following IIPT. Addressing these factors are important components of the initial evaluation to determine a patient’s readiness for IIPT.
IIPT programs are an effective treatment modality that has been shown to improve pain and function in a cost-effective manner.8 Nevertheless, the number of these programs fall drastically short in meeting the needs of all of the children who experience high levels of chronic pain resulting in functional disability. A collaborative effort of established IIPT programs is required to increase awareness and advance the body of evidence to improve outcomes. Similarly, these experienced programs may assist in the establishment and growth of new programs which are necessary to help meet the need. The Society for Pediatric Pain Medicine’s newly established IIPT special interest group seeks to help in that effort by providing an interdisciplinary home for professionals with interest in IIPT.
References
- King S, Chambers CT, Huguet A, MacNevin RC, McGrath PJ, Parker L, MacDonald AJ. The epidemiology of chronic pain in children and adolescents revisited: a systematic review. Pain. 2011 Dec 31;152(12):2729-38.
- Palermo TM. Impact of recurrent and chronic pain on child and family daily functioning: a critical review of the literature. Journal of Developmental & Behavioral Pediatrics. 2000 Feb 1;21(1):58-69.
- Lynch-Jordan AM, Sil S, Peugh J, Cunningham N, Kashikar-Zuck S, Goldschneider KR. Differential changes in functional disability and pain intensity over the course of psychological treatment for children with chronic pain. PAIN. 2014 Oct 31;155(10):1955-61.
- Simons LE, Sieberg CB, Pielech M, Conroy C, Logan DE. What does it take? Comparing intensive rehabilitation to outpatient treatment for children with significant pain-related disability. Journal of Pediatric Psychology. 2013 Mar 1;38(2):213-23.
- Hechler T, Kanstrup M, Holley AL, Simons LE, Wicksell R, Hirschfeld G, Zernikow B. Systematic review on intensive interdisciplinary pain treatment of children with chronic pain. Pediatrics. 2015 Jul 1;136(1):115-27.
- Stahlschmidt L, Zernikow B, Wager J. Specialized Rehabilitation Programs from Children and Adolescents with Severe Disabling Chronic Pain: Indications, Treatment and Outcomes. Children. 2016 Nov 21;3(4):33.
- Simons LE, Sieberg CB, Conroy C, Randall ET, Shulman J, Borsook D, Berde C, Sethna NF, Logan DE. Children With Chronic Pain: Response Trajectories After Intensive Pain Rehabilitation Treatment. J Pain. 2018 Feb;19(2):207-18.
- Evans JR, Benore E, Banez GA. The cost-effectiveness of intensive interdisciplinary pediatric chronic pain rehabilitation. J Ped Psych. 2016 Sep 1;41(8):849-56.
