Physical Therapy is an Integral Element of Intensive Interdisciplinary Pediatric Chronic Pain Rehabilitation

By Roxanne DeFabio, PT, DPT and Julie Shulman, PT, DPT, PCS, PhD
Department of Physical Therapy and Occupational Therapy Services
Boston Children’s Hospital
Boston, Massachusetts

Chronic pain occurs in 11-38% of youth and is associated with significant pain-related disability in one in 20 youth affected.1,2 Chronic pain can lead to activity avoidance and secondary deconditioning that perpetuates the cycle of pain and disability.3,4 Youth with chronic pain commonly experience deficits in movement and function of affected regions, atrophy and/or movement disorders that impact participation in valued activities and necessitate physical therapy (PT) intervention. Physical Therapists (PTs) play an integral role in Intensive Interdisciplinary Pain Treatment (IIPT) programs by helping youth with chronic pain regain independence in functioning through exercise and education with an emphasis on self-management in collaboration with several other disciplines (e.g., physicians and nurse practitioners), and the effectiveness of IIPT programs is well established.5

Disability among youth with chronic pain is heterogeneous and can vary widely between individuals or different chronic pain diagnoses. Upon admission to IIPT programs, PTs carefully evaluate factors that contribute to pain and disability using the International Classification of Disability, Functioning and Health, Child, and Youth Version (ICF-CY) model6 as a guide for understanding the complex relationships between biological, personal, and environmental factors that contribute to pain and disability. Both patient-report and performance-based outcome measures are used to capture differences in a child’s perceived limitations versus actual capacity, and the measures are individualized to suit the diagnosis and abilities of the child. Cardiovascular endurance, posture, muscle power and endurance, range of motion and physical ability with gross motor tasks (i.e., stair negotiation, gait, jumping) are common elements of the PT examination. Following the initial evaluation, the physical therapist works with the patient to set personal treatment goals and develop specific plans as well as coping strategies to support them in achieving these goals.

Evidence for specific PT interventions for improving pain and disability in youth with chronic pain is lacking;7 however, there is increasing evidence that aerobic exercise and strength training have analgesic effects in adults, presumably by activating endogenous opioids and descending inhibitory controls.8 PTs facilitate exercise to increase cardiovascular fitness and promote normalized movement, posture, and function in the presence of pain. Interventions emphasize a self-management approach, including stretching, strengthening, balance training, and aerobic exercise. Passive modalities (e.g., massage, manual therapy, transcutaneous electrical nerve stimulation) are avoided in order to facilitate a self-management approach.

Frequently youth with chronic pain experience challenges participating in the intensity of exercise and training involved during IIPT, which can require one-three hours of physical rehabilitation daily. For this reason, a graded exposure approach is often utilized in collaboration with each child’s psychologist and additional team members in order for patients to achieve their physical goals. With guidance from the psychologists, PTs also help patients develop and implement coping strategies during performance of functional tasks and support the patient’s progress by reinforcing behavioral interventions or plans during challenging activities.

In addition to the interventions provided within the clinic, another integral component to PT within an IIPT program is the development and provision of a home exercise program (HEP) for each patient. The HEP helps to promote self-management through continued physical activity and exercise each night after the program as well as on weekends. This affords patients the opportunity to generalize the skills they learn at the program to their home environment. A HEP typically includes an aerobic warm-up, stretching, strengthening and balance exercises; however, each patient’s HEP is individualized to meet their specific needs. Since youth with chronic pain are deconditioned at baseline and have persistent cardiovascular impairments at discharge as compared to age matched peers,9 it is important that patients are provided with a HEP upon discharge from an IIPT program that supports ongoing aerobic exercise. Through the establishment of a comprehensive long-term plan of care, most of the youth with chronic pain who have completed treatment at an IIPT program report significant improvements in pain and functioning during their first-year post discharge.10

In summary, the key elements of PT within an IIPT that are critical in treating youth with chronic pain are the following:

(1) use of exercise to promote normalized movement and function,
(2) an emphasis on self-management rather than passive modalities,
(3) integration of psychological and behavioral interventions as indicated,
(4) and development of an ongoing plan of care after discharge that includes aerobic exercise.

Although there is still a great need for further research regarding how and which specific PT interventions improve pain and disability in youth with chronic pain, the research completed thus far demonstrates promising success for the role of PT in contributing to observed improvements in both pain and functioning after IIPT.

References

  1. King S, Chambers CT, Huguet A, et al. The epidemiology of chronic pain in children and adolescents revisited: a systematic review. Pain. 2011;152(12):2729-2738.
  2. Simons LE, Kaczynski KJ. The Fear Avoidance model of chronic pain: examination for pediatric application. The journal of pain: Official journal of the American Pain Society. 2012;13(9):827-835.
  3. Rabbitts, J., Holley, A., Karlson, C. and Palermo, T. Bidirectional Associations Between Pain and Physical Activity in Adolescents. The Clinical Journal of Pain. 2014;30(3): 251-258.
  4. O'Sullivan, P., Beales, D., Jensen, L., Murray, K. and Myers, T. Characteristics of chronic non-specific musculoskeletal pain in children and adolescents attending a rheumatology outpatients’ clinic: a cross-sectional study. Pediatric Rheumatology. 2011;9(1).
  5. Logan, D. E., Carpino, E. A., Chiang, G., Condon, M., Firn, E., & Gaughan, V. J. A dayhospital approach to treatment of pediatric complex regional pain syndrome: initial functional outcomes. The Clinical journal of pain. 2012;28(9).
  6. World Health Organization. International classification of functioning, disability, and health : ICF. Geneva: World Health Organization; 2001.
  7. Birnie KA, Ouellette C, Do Amaral T, Stinson JN. Mapping the evidence and gaps of interventions for pediatric chronic pain to inform policy, research, and practice: A systematic review and quality assessment of systematic reviews. Canadian Journal of Pain. 2020/01/01 2020;4(1):129-148
  8. Naugle KM, Fillingim RB, Riley JL, 3rd. A meta-analytic review of the hypoalgesic effects of exercise. J Pain. Dec 2012;13(12):1139-1150.
  9. Shulman J, Smith A, Keysor J, et al. Putting fitness to the test: clinical application of the Fitkids Treadmill Test in youth with chronic pain. European Journal of Physiotherapy. 2020 doi: 10.1080/21679169.2020.1779343.
  10. Simons LE, Sieberg CB, Conroy C et al. Children with Chronic Pain: Response Trajectories following Intensive Pain Rehabilitation Treatment. The journal of pain. 2018; 1

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