Managing Chronic Pain – PediaCast 489
- Dr Lindsey Vater and Dr Alex Rospert visit the studio as we explore chronic pain. Nearly one-third of children and teenagers experience pain that lasts more than three months. Discover why it happens and what you can do about it. We hope you can join us!
- Chronic Pain
- Pain Management
- Comprehensive Pain Services at Nationwide Children’s Hospital
- Comprehensive Pain Management Clinic at Nationwide Children’s
- The Intensive Pain Rehabilitation and Education Program (iPREP)
- Understanding Pain in Less Than 5 Minutes And What To Do About It (YouTube)
- Introduction to the Gate Control Theory of Pain (YouTube)
- Applying Cognitive and Behavioral Techniques in the Medical Setting – PediaCast CME 61
Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.
Dr. Mike Patrick: Hello, everyone, and welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike coming to you from Nationwide Children's Hospital. We are in Columbus, Ohio.
It's Episode 489 for May 6th, 2021. We're calling this one "Managing Chronic Pain". I want to welcome all of you to the program.
So, May is Mental Health Month and we typically include an episode this time of year that spotlights a mental health topic in an effort to promote awareness and understanding of common mental health conditions, things like anxiety and depression.
This year, we're going to take a bit of a different twist and talk about a condition that has both a physical and a mental component. And it's one that impacts mental health and can result and heighten levels of anxiety and sometimes depression. That topic is chronic pain which has a simple definition of pain lasting longer than three months.
It's also a common condition in the pediatric population, with one study showing nearly one-third of all kids and teenagers experiencing an episode of pain that last longer than three months. And it turns out that three months is a dividing line and how long pain should last at its maximum, because injuries and inflammatory responses have typically resolved by that time. Meaning, pain signals have largely stopped flowing to the brain but the brain continues to experience pain coming from the affected area.
It's still real pain because it's felt and it interferes with function in daily life. But it's also treatable, especially with regard to managing the pain and returning to an active and functional lifestyle even when the pain is not completely eliminated.
There's lots more to say on this topic, including who is likely to suffer from chronic pain, what exactly is happening inside the body when it occurs, when it's time to seek help, where to seek that help, why all of these matters and how you can best help a family member or friend that is experiencing chronic pain.
To help us explore the topic, we have two terrific guests joining us this week, Dr. Lindsey Vater, she's a pediatric psychologist, and Dr. Alex Rospert is a physical therapist, both with the Comprehensive Pain Management Program at Nationwide Children's Hospital.
Before we get to them, I want to remind you once again, this will be my last time reminding you of a golden opportunity that will present itself in one week, okay? It's a week from tomorrow, actually, on May 14th, 2021. And that is our annual Communicating Medicine Conference at Nationwide Children's Hospital. This year, it's going to be really easy to join us because we are offering a virtual event from the comfort of your home. If you have an interest in providing evidence-based health-related education online, then this is the event for you.
We have a terrific line-up of speakers covering lots of digital communication topics including the role of social media and promoting diversity and inclusion, strategies for overcoming vaccine hesitancy among patients and families, and overcoming cancel culture and online harassment. We'll also have breakout workshops and how to become an interview star, creating an effective medical blog, and maintaining professionalism and compliance while engaging online.
We also have some special presentations including Podcasting 101, 15 Social Medial Perils in 15 Minutes and Addressing Misinformation During the COVID-19 Pandemic.
So, if you would like to take an active role in educating the public online on healthcare matters, then this is the virtual event for you. Communicating Medicine takes place on Friday, May 14th, 2021 on a computer screen near you.
Registration is affordable and really very easy to do. The cost is $25 for most attendees. And if you are affiliated with the Nationwide Children's Hospital or the Ohio State University, we give you a $5 discount, so it's just $20. If you're a student, registration is just $15.
And I guarantee you, you will not find this breadth and depth of content presented by gifted and experienced speakers at such a low cost anywhere on the face of the planet.
Registration is limited. We do still have a handful of openings left. You'll find links in the show notes for this episode to the conference registration page and also an online brochure which outlines the complete rundown of topics and speakers.
Again, those links are going to be there for you at pediacast.org. Just look for the show notes for this episode, 489, and you'll find those links. I will be there and I hope to see many of you as well.
All right, let's move on with our usual very quick reminders today. Don't forget, you can find PediaCast wherever podcasts are found.
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So, let's take a quick break. We'll get our expert guests connected to the studio. And then we will be back to talk about chronic pain. It's coming up right after this.
Dr. Mike Patrick: Dr. Lindsey Vater is a pediatric psychologist and Dr. Alex Rospert is a physical therapist both with Nationwide Children's. They're members of our hospital's comprehensive Pain Management team. That's what they here to talk about, chronic pain and its management.
So let's give a warm PediaCast welcome to Dr. Lindsey Vater and Dr. Alex Rospert. Thank you both so much for being here today.
Dr. Lindsey Vater: Thanks for having us.
Dr. Alex Rospert: Yes, thanks for having us.
Dr. Mike Patrick: Yeah, absolutely. Really appreciate both of you taking time out of your busy schedules.
So, Lindsey, let's start with you. Let's just provide a definition first. What exactly is pain?
Dr. Lindsey Vater: If you want to look at the technical definition of what is pain, it's really any unpleasant sensory or emotional experience. And pain can be associated with actual tissue damage or an injury. But also, we now know that the damage or an injury does not necessarily have to be present for pain to occur.
There's some key characteristics that you like to look at for pain. And my number one message to all patients and family is any pain report is a valid pain report. We don't currently have any tests or measures to look at whether or not that pain is there. So any verbal report is an actual report of pain.
We do know that pain can be present in the first 24 hours of life, so this is a pretty universal experience across all people. And we know that kids as young as age three can communicate pain whether it is through the words that we typically know which is like ache is stabbing or things like that. But we know a three-year old can say that they don't feel good.
Dr. Mike Patrick: Interestingly, pain can be described really having some different characteristics with it. So, pain is sensory, right? I mean, we have receptors in our skin and those take pain messages to the brain. Or if you have inflammation in a muscle, there's going to be input into the brain that says "Hey, there's pain here."
But it's also cognitive, meaning that we experience pain at the brain level, right? So when we feel pain, our brain is telling us that we feel pain. And even if there's not pain messages coming in from the nerves, we can still experience pain because our brain is saying it's there, right?
Dr. Lindsey Vater: Yeah, and we can learn pain. So we know the older we get, certain experiences start to be interpreted as pain, which maybe as younger kids were not interpreted as pain. And I always tell all kids too, pain serves a role. Pain is not necessarily a bad experience. It's a very adaptive and protective experience.
So, we never want to take away all pain because it is there as natural warning or danger sign. But it's when that pain starts to get in the way of our day-to-day functioning or maybe it's not protecting us anymore that it starts to become a problem.
Dr. Mike Patrick: And then that brings in the third aspect of pain. So, we talk about the sensory aspect, the cognitive aspect. But then the affective aspect, meaning that it changes our behavior. So, we change our behavior in response to pain and that's something else that we'll be considering as we move forward with our talk today.
Alex, what then is chronic pain? When would we say that sort of normal pain has become a chronic condition?
Dr. Alex Rospert: Yeah, that's a great question. So, we, in its simplest terms, can identify or define chronic pain as pain that's lasting longer that three months. And that number is not just an arbitrary number. It's a number that's been identified as classifying chronic pain because we know that when there is an injury or an illness, that the pain as the result of those will typically resolve within a three-month timeframe.
And so, when we start to notice that pain is lasting longer than that expected healing timeframe, then we start to look at, well, is the body sending these signals correctly or is there kind of a glitch in the system?
And other characteristics that kind of identifying or defining what chronic pain would be is an individual that maybe experiences pain from an ankle sprain. They experience that pain and then if that pain persists for three, four months, outside of when we would typically expect it to be healed, that's when we start to consider is this more of a chronic pain experience than an acute pain experience?
And in a lot of cases, this pain starts to generalize as well. So with chronic pain, we might notice that the pain initiated in the ankle but now, we're starting to experience pain in the hip, and then maybe some in the back. And now, we're starting to develop some headaches. And so those are some signs and characteristics that would define what chronic pain is.
Dr. Mike Patrick: So, in early stages of the sprained ankle, you really are having pain signals being sent by nerves to the brain. And then the brain is producing the sensation that we experience as pain telling us that that hurt. But then, after three months or so, by that time the sprained ankle really should be healed. And so, now the brain is just still experiencing that pain without necessarily the input. Correct?
Dr. Alex Rospert: Yeah, that's a great example there. And so, it's basically when the brain is sending these pain signals when there's not necessarily an identifiable tissue damage or an identifiable pathology that's causing that.
Lindsey does a great job of explaining that same idea with the gate control theory. So, I don't know, Lindsey, if you wanted to add to that.
Dr. Lindsey Vater: Yeah. I think if you, as a parent, take your kid to the doctor, you're probably going to hear the gate control theory of pain. And put very simply, pain travels up and down the spinal cord, so the brain and the body are constantly talking. And we have this gate that lives in our brain and its purpose, if the gate is closed. is to block any and all those pain receptors from the brain getting to the body. So, if the gates are closed, there are no experiences of pain.
Now, let's say that we do fall and we hurt our ankle, well, the ankle has to send the signal up to the spinal cord. And our gatekeeper's job is to determine, is this serious enough injury that we need to have pain in the body and is now the right time for this pain to occur? And if both of those conditions are met, then those gates will open and the pain signal will be sent to that part of the body alerting us that there's danger.
Now, there are instances where maybe that gate doesn't open. We've all have the paper cut that didn't hurt. And today in the day of COVID, we're using a lot of hand sanitizers. So we might notice, "Oh, wait, tissue damage occurred but I did not experience pain." And that's because that gate's job is to protect us against pain that is maybe not adapted in that moment.
And with chronic pain, what I tell kids is your gate just stop rusty. So for one reason or another, your gates decided to be open a little bit more and what we see is over time, the body starts to learn that certain stressors or emotions or activities are dangerous and therefore should cause pain. So the pain experiences are real, the gates are open but the actual danger is not what is opening those gates.
Dr. Mike Patrick: Now, we do want to point out that there are instances where pain maybe lasting three or four months. And there really is still tissue damage because some folks with the sprained ankle may not rest like they were supposed to rest They may not do proper rehabilitation. And so they get repeated injuries that can make it last longer.
And that sprained ankle may change your walking mechanics. And now, you do have some hip pain because your strained muscle's related to the hip. And so you still certainly want to follow up from a physical aspect and make sure that there's not a physical reason that you're still experiencing the pain. But when you get to that three-month period, it's much more likely, because usually sprained ankles are better in a couple of weeks, not three months. By that three-month period, if things still aren't better, then it's really time to call this chronic pain.
There's a couple of YouTube videos that I think are really helpful in explaining all of this. And I'm going to put links to those in the show notes over at pediacast.org. One is called Understanding Pain in Less Than Five Minutes and What To Do About It. And the other one talks more about that gate control theory of pain, sort of an introduction to it which, Lindsey, you had mentioned. And again, we'll put links in the show notes to both of those.
Alex, so this chronic pain, pain lasting three months or longer, how common is this among kids and teenagers?
Dr. Alex Rospert: I think a lot of times when we look at chronic pain, we often immediately think of adults. And having a longer life experience, you're going to have maybe more pain experiences and it gives get an opportunity to develop that chronic pain experience.
But really, we do see it quite prevalent in children and that's why we're here today with the jobs that we fortunately have. So, when looking at pediatrics or kids or teenagers, 30% of children will experience pain that lasting longer than three months. And taking that a little bit further, we can even identify that 3% to 8% of those individuals that are experiencing this pain lasting longer than three months are now going to start experiencing significant functional deficits as a result.
So, they might not be attending school. They may not be participating in their sporting events. They may not be spending time with friends because now this pain has so much impacted their life that they're starting to withdraw from some of those things.
We see chronic pain in this pediatric population at a young age. And then as it kind of continues into young adulthood and into adulthood, and we start to notice. Research shows there's this increased report of chronic pain and starting around the age of 11 in kids. And once we get to that age of 17, 18, we start to notice a slight decline but still definitely prevalent in things that we see.
And then lastly, I would say in terms of difference between males and females, we do notice research shows that there is more chronic pain identified in females than there is in males.
Dr. Mike Patrick: So, a couple I think really important points to bring out of what you just said, 30% of all kids at some point in their childhood or teenage years experienced pain the last three months or longer. So when we talk about chronic pain, I think it's easy for folks to think, "Well, that's not my kids. That happens to someone else." But really, I mean, a third of kids experience it at some point or another. Does that surprise you, Lindsey?
Dr. Lindsey Vater: Unfortunately, no. In my past days when I would work in the hospital and meet kids in their hospital room, they might be admitted for an acute injury. But when I start talking to them with my kind of pain lens, they are reporting those continued reports of pain. So, I think it is more prevalent than we think it is and I think some of that has to be of how much are we asking about pain.
Dr. Mike Patrick: And you mentioned too that pain then can affect their day-to-day function. And so, it maybe a reason that they're missing school or they're not able to participate in their sport which then causes anxiety. And it can end up leading to depression and it can interfere with relationships between kids.
And so when kids are having other problems, sometimes you do want to go back and ask those pain questions because there are some kids that may not complain about the pain. It's just it's been there for so long that they're just living with it. Or you may live in a family where pain is sort of downplayed like, "We don't make a big deal of pain. We're not complainers." And so that pain can linger without it really being addressed, which then impacts many other areas of their life.
And so I'm sure, as a psychologist, you see that quite a bit. And I think compared to 10 years ago or 20 years ago, there's a lot more than we know about pain now and that we can do to help kids with chronic pain, right?
Dr. Lindsey Vater: Absolutely. So, I identify, as a science nerd myself. And I think the history of pain is really, really important to understand what we know and why we treat it the way we do now. And I always give the example, if you know somebody who had a surgery ten years ago, they were spending days in the hospital and many of those days on bed rest. Whereas now, if you have a surgery, what we know actually helps best for that long-term pain management is getting up and moving.
So, I think our approach and our understanding of pain, unfortunately, the opioid epidemic opened a lot of doors when it comes to research and understanding. And we're just now kind of being able to benefit from the fruits of the labor of all of those intensive research things. So, it depends on the generations when you ask how do you treat pain.
Dr. Mike Patrick: Absolutely. Alex, what are some of the conditions then that are most associated with chronic pain? What are the conditions most likely to have the pain just keep lingering?
Dr. Alex Rospert: So there are some that we commonly see in the pediatric population and even into the adult population. And some of those would be individuals with sickle cell disease, juvenile arthritis. Or even in adult population RA or OA, individuals with hypermobility, or an example of that would be Ehlers-Danlos syndrome, endometriosis in our female population.
And then, it can really go further than those specific diagnosis and looking at just general like orthopedic injuries can contribute then to chronic pain. Or individuals that experience a GI illness or have Crohn's Disease and they start to develop this pain that's present for a long period of time in their abdomen or their belly.
Individuals that have had concussions. We frequently see individuals that come in having a concussion a year ago and they're still experiencing headache pain, neck pain associated with this.
And then, one other would be motor vehicle accidents. Not necessarily a diagnosis but something in a life experience that cause some sort of stress to the body, whether that be physically. There could be psychological stress associated with that accident. And those are some of the examples that we most commonly see associated with chronic pain
Dr. Mike Patrick: One of the first two that you mentioned sickle cell disease and juvenile arthritis. Those are cases where there still may be inflammation and still be a reason for pain. So those aren't necessary the cases where the signals aren't going to the brain anymore, but our brain is still experiencing the pain. Those are some situations where, really, you do have pain input into the brain that's leading to that pain experience.
And that difference between when there's still signals coming in or not signals coming in, that kind of plays into this term functional pain. Lindsey, what exactly is functional pain and why is it important for us to distinguish if that's what's happening or not?
Dr. Lindsey Vater: Functional pain is real pain, but that real pain is not being caused by any bodily damage or a tissue damage or harm. So bodies are really unique in a way that sometimes they glitch just like a computer can glitch.
And what we see is that for one reason or another, those gatekeeps that I talked about earlier, they are now interpreting things that are not tissue damage as pain. So they're opening and closing and responding to things that is not that danger.
So some common diagnosis, you might hear in a world of functional pain is amplified muscular skeletal pain or AMPS. You might hear chronic widespread pain. Every now and then, depending on who gives the diagnosis, some people consider complex regional pain syndrome or functional syndrome. But at the root of all of these, the good news is that the treatment, whether it's functional or whether there is a biological cause for this, is going to be exactly the same. So, the key message here is the pain experiences are real.
Dr. Mike Patrick: So, in functional pain that's where the brain is saying, "Hey, there's pain," but there's not necessarily signals coming to the brain to suggest that there's injury. The brain is just feeling pain. And, of course, that's real pain because you're feeling pain.
So you could take two kids and have them really be in the same situation in terms of the injury and the length of time. And one kid is going to have chronic pain and another one is not going to have chronic pain. Is there a genetic predisposition to this? I mean, is there a genetic basis for the experience of pain?
Dr. Lindsey Vater: When I think of pain, I think of it as the truest definition of what we call a biopsychosocial diagnosis, where there are definitely parts of biology that play into this. But equally as important is how is our psychological wellbeing, as well as what is the environment in the world around us teaching us about how we understand and react to pain. So, I think it's equal parts all of those things.
Dr. Mike Patrick: Okay. So, genetics, environment, individuals can really all impact the experience of pain. What are some of the environmental factors then, Lindsey, that influence chronic pain?
Dr. Lindsey Vater: There's quite a few. Really, one of the biggest things that influences chronic pain is those gates are really receptive to how much we're moving our body. So, we do see that those who have increased physical activity are going to have gates that are closed a little bit more often. We know that psychological stressors have a big impact on whether or not we're experiencing pain. So, if you're more anxious or depressed or your mental abilities are maxed out, it's going to be a lot harder for your body to fight off some of those pain signals.
We know that social interactions are a really big piece of things. So I like to think of it as the brain can only do so many things at once. So the busier the brain, the less power the gates have. So if we're involved in sports and extracurriculars and we're really putting our thought and effort and energy into our homework, we should see less pain.
And then, just how the family response. So when you think of pain, pain and the things we do to avoid pain is what we would call reinforcing. It feels really good to avoid walking on the broken ankle, so we're going to continue to avoid walking on that ankle.
So those things also are really important in terms of chronic pain because some people have better reactive pleasure centers in that brain and the avoidance can feel a little better. So that might extend how long we're dealing with that.
Dr. Mike Patrick: What about sleep? Does sleep have any basis on chronic pain?
Dr. Lindsey Vater: I say sleep and moods when it comes to chronic pain. It's a lot like a chicken-or-an-egg situation, which came first? And the answer is all of the above.
So when your body doesn't get enough sleep, we know that sleep is really important for restorative process with both the brain and the body. So, sleep is a huge thing especially in kids and teenagers, they're already learning how to sleep. And sleep changes a lot throughout those years, so it's really important.
But then diet and exercises and hydration, we know that if we're not getting enough water throughout the day, that's going to set our body up for headaches, belly aches, things like that.
Dr. Mike Patrick: And then those things make it difficult to sleep. So you really just spiral into a cycle that we need to break. And then, of course, chronic pain really impacts lots of areas of our life. And I think we've talked about many of those but just reiterate the importance that how this impacts a child's life altogether.
Dr. Lindsey Vater: I really like when you said spiral because that is exactly what we talked about in our intakes with families. It often starts with an injury and then all of a sudden, it has impacted not only the child living with chronic pain, the entire family unit. We, a lot of times, see changes and how often they're attending school, their school performance. A lot of the times, they are dropping out of preferred activities which is then going to make our moods worst.
We also see just in terms of family members, too. A lot of times we see parents have to make pretty significant job changes to accommodate all the different doctor's appointment, physical therapy treatments. So this is really an impact on the full family.
Dr. Mike Patrick: Yeah, absolutely. And, of course, then there's higher rates of going to the doctor. And so because of the pain that were not getting under control, there's more visits to the doctor's offices, urgent cares, emergency departments. And then, that takes time and there's a financial burden that occurs with that, too.
And so I think we've done a good job of painting the picture that there is a better way that we can really address chronic pain and manage it. How do we start with that? Where do you begin with treating chronic pain?
Dr. Lindsey Vater: The gold standard for treatment of chronic pain is a little backwards than what we would think. So the gold standard of chronic pain is we really focus on how are we functioning? So what our day-to-day look like?
And when I think of chronic pain and I think of the treatment, there is no one answers. It's, unfortunately, not a quick fix. It's not one medication or one doctor's visit. It's a lot like the legs on the table. When it comes to chronic pain, all areas of your life are impacted by it. So we have to treat it from a multidisciplinary approach to make sure the legs on those tables are balanced out.
So really what we're doing is we are working towards getting back to what is normal first. And then, that's when we start to see the pain reduction coming second. So, functioning comes first and then pain reduction will be second.
Dr. Mike Patrick: Yeah, that's really interesting because I feel like 20 years ago, it would be what kind of medicine can we give to make this pain go away? And now what you're saying is, "Okay, we have this chronic pain. It's impacting our life in some way. And how can we get back to our life being the way that it was before?" And then in doing so, that is going to help the pain go away. Is that right?
Dr. Lindsey Vater: Yeah, absolutely right.
Dr. Mike Patrick: So, then what does that look like? So, you said a multidisciplinary approach. From a family standpoint, what exactly does it look like to have my child's chronic pain treated?
Dr. Lindsey Vater: So, as a family member, it is really hard to see your child in pain. And it's a very distressing event and honestly for us providers, I know a lot of the times we feel like we have to take this pain away. We have to do a quick intervention and the treatment for chronic pain takes a little bit of time. And it actually takes a lot of effort and work on the side of the families.
So if you were to make your way to a pain psychologist, we're going to do a lot of fun things. So not only are they skills for chronic pain, they're really good skills for life, too.
So, my job is to teach patients and families how do we learn how to regulate our body systems. So that, a lot of the time, comes by way of coping skills. So controlling our breathing in a way that relaxes the body. There's something called progressive muscle relaxation that helps reduce the tension that sits in those muscles that frequently become tight with chronic pain. We teach guided imagery and mindfulness skills to really calm down the brain.
We do know that there are frontal cortex deficits that happen with chronic pain. A lot of time these kids will complain of feeling foggy. They can't concentrate. Parents will describe their memory as really awful. So, a lot of that is gaining control over those thinking parts of the brain.
We do a lot of cognitive behavioral therapy as well, so we change how we think about pain. I think a lot of us, our first thought when we think of pain is, "This is awful. I can't do anything if I'm in pain." And our goal is to retrain and challenge some of those thoughts and focus on what can we control.
And then there are small piece of it called acceptance-based therapy as well, where we're promoting the functioning and that learning to tolerate the pain while still focusing our thoughts towards the achievement in our life goals. So what can I do versus what I'm not able to do?
Dr. Mike Patrick: You mentioned cognitive behavioral therapy. And in addition to moms and dads listening to this podcast, we also have a lot of pediatricians and other pediatric providers who listen. And, Lindsey, you joined me for a podcast on our sister program, PediaCastCME, Continuing Medical Education for providers, called applying cognitive and behavioral technics in the medical setting.
And so, I think some of the providers in the crowd would be interested in hearing that particular episode. And I'll put a link in the show notes to this show over at pediacast.org, so folks can find it easily.
You mentioned cognitive behavioral therapy, self-regulatory strategies, relaxation techniques, and of course, getting the family on board is all going to be important. What about the role of complimentary or alternative medicine? Things like acupuncture and massage therapy, aroma therapy, yoga, what role do those play in pain management?
Dr. Lindsey Vater: Those play a really important role. So, we, here in our comprehensive pain clinics have all of the above that you just mentioned. So anything that can teach our body to relax and help our body to get to that relaxation state is going to overall do really long-term good for the body.
So we know any kind of changes in our thoughts, our moods, our behaviors, our self-care. Self-care is a big, big piece of these things. So, any of those medicines, we know that there's research to suggest improvements and pain. And if you meet with us here in our pain clinics, our medical doctors are really good in explaining, "Should we do acupuncture versus massage for different types of pain?" because they do target the body's autonomic nervous responses in different ways.
Dr. Mike Patrick: When you talk about this pain program and you say it's a lot of work and it takes some time, this is not something that you fix overnight. There are a lot of programs out there. And I think we have one here at Nationwide Children's Hospital as well that's really an intensive outpatient pain rehab program that really it's like a nine-to-five job, five days a week for I think three weeks. Tell us more about that program.
I think we call it here the Intensive Pain Rehabilitation and Education Program or IPREP and I'll put a link to that in the show notes for our program here at Nationwide Children's. But give us a little background on that and what families can expect when they have a child that's treated in that program.
Dr. Alex Rospert: So, fortunately Lindsey and I get the privilege to be able to work in our Intensive Outpatient Program. And so what that program is, exactly what you said, it's an intensive outpatient program and our kids come for three straight weeks, Monday through Friday from 8 to 4. And they're there all day, every one of those days.
And they're working hard with a lot of different disciplines. So kind of like Lindsey explained, like the legs on the table. Sometimes, I'll explain it to the patients as we basically need all four tires pumped up for a car to be able to run correctly, right? For it to be able to drive correctly.
And a lot of times you may have tried physical therapy and that didn't work. And then maybe you want to try a massage therapist and if that didn't work. And then, you went to psychology and that didn't help as much. And those were all individual and it's like trying to drive car with one tire, right?
So, our program brings all those tires together. And we're going to put all those tires on the car and get you moving. And what that looks like in our program specifically is we have group and individual sessions. So our group sessions are we're focusing on how can we get these kids functioning together in social settings, mimicking things like school, mimicking things like sports, mimicking things like social interaction with peers.
And then, our individual sessions are really honing on our specific needs individually and how can we get them to where they need to be.
And we're really fortunate in IPREP to be able to have a number of different disciplines. So disciplines that we have specifically in our clinic are psychology, physical therapy, occupational therapy. We have music therapy and therapeutic recreation. We have a school teacher. We have massage therapy, acupuncture. We have a medical provider.
And so, really, our goal is how can we take all of these disciplines and put them together in the same place at the same time and facilitate this optimal functional improvement in these kids in a more intensive setting.
Dr. Mike Patrick: And I think that's really an important distinction that the goal of the program is to get kids functioning again like they were functioning before they had the chronic pain, sort of to get their lives back. And in the process of doing that, the pain will likely improve but it doesn't always completely go away, right?
Dr. Alex Rospert: Yeah, that's absolutely correct. And that's something that when we sit down with our patients initially, we talk them about expectations and understanding that this is a process. It was a process to get you to this point. And it's going to be a process to get you where you want to be.
And so I'll often explain that kind of like a mountain. And it kind of feels like a mountain to these patients. They're trying to climb this uphill battle of being and experiencing this pain for so long.
And we have to explain to them that we have to improve this functional side of things. We have to climb the mountain, improve our function. And once we get to that top of the mountain, then we can start to come down, right, the easier side. And that's when we start to see that our pain improves.
But just making sure that patients understand that by coming to an intensive program. Or even if it's a less intensive program and pursuing these disciplines individually, to know that this is going to be a process and it's not going to be a consistent steady straight line. There's going to be some ebbs and flows, some ups and downs, and in function and in the pain that you're experiencing.
But, ultimately, we do see that over a period of months, we can start to identify that patients are experiencing less pain and most importantly experiencing less functional decline or functional impairment because of their pain.
And ultimately, we always say that IPREP is a lifestyle, it's not a place. It's a lifestyle, so we're teaching you how to use these coping skills, how to stay physically active when you're not with the physical therapist, how you can support or how you can be in an environment that supports your lifestyle changes. And when we see kids implementing this, that's when we see, even though they might have some pain still, they're functioning and they're meeting their goals and they're doing the things that they want to do.
Dr. Mike Patrick: So this is really a difficult thing to do for these kids. I mean, there's a lot of work. It takes a lot of time and not only for the children and teenagers who are experiencing the chronic pain but, really, this is a challenge for the entire family.
So, Lindsey, what role does the family take in the treatment of chronic pain? I mean, how can they help their child get better sooner?
Dr. Lindsey Vater: So, if a kid makes their way to us here in IPREP, actually, the answer to that is about 15 hours of education. So our parents are here for an hour a day, every day, and they're also learning the skills. So, what we see and what the research suggest that is going to set a kid and a family out for most success is that the parents themselves know the skills so that they can, one, model the skills. The kids can see the parents using them and using them successfully. And two, encouraging the kids to use some of the skills.
We also know the research calls it misguided support. And I think that's a really beautiful term for this because parents only want the best for their kids, but every now and then, what would come natural or would make the most sense is actually continuing some of that pain disability. So, we teach parents what is appropriate to let the kid rest, when is it appropriate to maybe put down more parental discipline and say, "No, these are the expectations we have."
And I always describe it as we're taking the family out of like survival mode. And we're putting them kind of back in that thriving mode and how do we get back to normal and work together and kind of jump off that tight rope.
Dr. Mike Patrick: From a parent standpoint, you just want the pain to go away, okay? I just want that's not to be an issue anymore and that really seems like it's the path forward to get a child's life back. And honestly, to get the family's life back because, oftentimes, it really makes a huge impact on day-to-day function of the family.
But I think that's really the key message of this podcast today, is that it's really about getting dealing with the function and getting kids back in school, back involved with their sports, back to being physically active. And then, the pain will take care of itself once you do those things.
Alex, what is the long-term outlook following treatments? So once they're on the road to recovery and they really have a lot of the function back, the pain is getting better. We're coming down off that mountain as you put it. Once we get back to flat ground again, is this likely to come back or is this gone for good?
Dr. Alex Rospert: Yeah, that's a great question and it really can vary. So we see some kids that what all it takes is this intensive program or this outpatient treatment. And once they can get that kind of footing underneath of them and they get an understanding of what pain actually is and they understand how they need to manage this, then we see them do really well. And they can really get back to doing what they want without having to come back and see us hopefully.
There are some kids that's a little bit more of a up-and-down type of journey. But we're here to help them through that. And knowing that again, that's not a failure, that's not a failed treatment, it's just your pain experience. And so, we're there to help walk them through that. But it really can vary and we see it in a lot of different ways.
Dr. Mike Patrick: If it does reoccur, hopefully they've learned some tools to be able to deal with the pain again and sort of get their own function back. However, if it does really impact their life again, are folks able to do one of these three-week program, like IPREP, more than once? Maybe a few years down the road if they need it again. Or is it one-and-done sort of thing?
Dr. Lindsey Vater: That's a complicated question and that the answer is going to be it depends on a few different things. So, if you were to come through IPREP and our patients at a time were 10 years old, they're going to be learning a certain set of skills and language and kind of those day-to-day tests. Whereas if pain reoccurs and you're 16, 17, our program is going to be a little bit different.
So, we're really looking at, we continue to follow our patients for a year after they graduate from this program. We're giving them constant reminders of the skills they've learned. We're helping them generalize the skills to what they did here in IPREP too, maybe their outside lifestyle.
And if we have a family that calls and say that they're maybe in one of these downwards spirals, we really do our best to help them problem solve and see what steps they have taken to help get them back on that functioning path.
And if it seems to be that the skills just need a total refresh or maybe we need to mature the skills a little bit, then they could redo our program. But I would say the majority of the time, we're able to talk them through, maybe connect them with one of those legs of the table. Maybe they need a little bit of PT or maybe they need a little more pain psychology. So the answer is there's a few different pathways these kids can take.
Dr. Mike Patrick: It sounds like an expensive treatment if they have eight hours a day, five days a week for three weeks. Is this usually a financial burden for families or does insurance typically take care of it?
Dr. Lindsey Vater: When you look at the research for this, pain in of itself is one of the most expensive healthcare cost. And that is as a nation and that is for our teens, for adolescents, and for adults.
So we are seeing that insurance is normally pretty nice in terms of reimbursement for this programs. Now, it is a very expensive program. But what we see, if you look at the outcome, once people have completed one of these intensive pain rehab program, it's about a $40,000 a year savings on insurance and families alike. Just from the cost that they're saving in medical cost by not going to all of those emergency room visits or specialist appointment.
So, I would say when it comes to this, don't worry. We have folks on our team who help us navigate that. I would say physical therapy, there's often some limits to visits for that. But we can make a case of if we have these many sessions, here is what we expect to save and insurance companies are likely to work with us then.
Dr. Mike Patrick: And it's always helpful when you have a program like yours, that whatever situation a particular family is in, you've seen other families in that situation as well and kind of know the tricks of being able to get them to service that's really going to improve outcome and make their life and their family's life better.
So, we will put links in the show notes again for the IPREP program here at Nationwide Children's Hospital. We'll also put a link to the Comprehensive Pain Management Clinic at Nationwide Children's. So listeners can get connected with those programs pretty easily. Does it require a referral from a primary care doctor to get into the program?
Dr. Lindsey Vater: Anyone can place a referral. So, we do have a lot of self-referrals too, but the important thing to know is Dr. Mike, you said, we do have the Comprehensive Pain Clinic. And then we have the Intensive Pain Program as well.
So all referrals will go through clinic. And clinic is kind of a step-down from this intensive program where you would be treated every other week for about four hours by psychology, physical therapy, one of those complementary alternative medicines. And you will meet with the medical provider.
So, a lot of the time, insurance requires you to do a lesser level of care. And that is where we can kind of get eyes on you, see how the functioning is going, try and treat you with kind of a less invasive form of treatment. And if you need that higher up, that's when you would get referred to IPREP and that would come directly from clinic, usually.
Dr. Mike Patrick: Okay, that make sense. And so the providers in the crowd who may have families that would benefit from this, the Comprehensive Pain Management Clinic is the place to start and make that referral.
One last question for you, Alex. Can chronic pain be prevented? Is there a way to identify who's at risk for chronic pain and maybe hit off at the pass?
Dr. Alex Rospert: This is a great question and I think warrants a lot of continued research in our areas. But when I think the idea of preventing chronic pain, two things come to my mind. The first is making sure that as healthcare providers, as family members, we are helping our kids understand what pain is and knowing that not all pain is bad pain, and knowing that pain serves a role in our lives.
And when we can understand effectively what pain is, then when we do experience pain, we might not go down this rabbit hole of fear avoidance with activities and just starting to withdraw and isolate ourselves. And then developing some anxiety and depression as a result.
And so I really think understanding pain, and knowing that this is a normal life experience and this is going to be okay and there are things that we can do, is really important.
And the second is when we look at the treatment of chronic pain promoting essentially a healthy lifestyle, promoting a healthy mind, a healthy body, and a healthy environment, I think when we can do that in treatment. If we apply that to our kids before they have pain as just a part of their lifestyle, I think those are the keys to helping prevent this chronic pain.
Dr. Mike Patrick: Well, we really appreciate all that you do for kids and families here in Central Ohio and beyond, And again, we'll put all those links in the show notes. And also don't forget those YouTube videos, Introduction to the Gate Control Theory of Pain. If that's something that you have not heard of before, make sure you check that out. And Understanding Pain In Less Than Five Minutes and What To Do About It, and again, I'll put links to both of those in the show notes over at pediacast.org.
So, Dr. Lindsey Vater and Dr. Alex Rospert, both with Nationwide Children's Hospital and the Comprehensive Pain Management Program, thank you both so much for being here today.
Dr. Lindsey Vater: Thank you, Mike.
Dr. Alex Rospert: Thanks for having us. Appreciate it.
We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast a part of it. Really do appreciate that. Also, thanks to our guests this week, Dr. Lindsey Vater and Dr. Alex Rospert, both with The Comprehensive Pain Management Program at Nationwide Children's Hospital.
One last time, I want to remind you about that golden opportunity next week for the medical professionals in the crowd or really anyone in the healthcare industry. Nationwide Children's Annual Communicating Medicine conference takes place on Friday, May 14th, 2021. It is a virtual event this year, so you can attend from the comfort of your home.
Topics include the role of social media and promoting diversity and inclusion, strategies for overcoming vaccine hesitancy among patients and families, overcoming cancel culture and online harassment, how to become an interview star, creating an effective medical blog, maintaining professionalism and compliance while engaging online, podcasting 101, 15 social media perils and 15 minutes in addressing misinformation during the COVID-19 pandemic.
Registration is affordable. It is also limited but we do have a handful of open spaces remaining. Cost is $25 for most attendees. If you're affiliated with Nationwide Children's Hospital or the Ohio State University, it's $20. And for students, registration is just $15. You'll links to the registration page and our conference brochure in the show notes over at pediacast.org. I will be there, and I hope you can too.
Reviews are also helpful wherever you get your podcast. We always appreciate when you share your thoughts about the show, and we love connecting with you on social media. You'll find us on Facebook, Twitter, LinkedIn, and Instagram. Simply search for PediaCast.
Also, don't forget about our sibling podcast PediaCast CME. It's similar to this program. We turn the science up a couple notches and offer free continuing medical education credit for those who listen. And that includes, by the way, physicians, of course, but also nurse practitioners, physician assistants, nurses, pharmacist, psychologist, social workers, and even dentist. And since Nationwide Children's is jointly accredited by many professional organizations, it's likely we offer the exact credits you need to fulfill your states Continuing Medical Education requirements. Shows and details are available at the landing site for that program pediacastcme.org. You can also listen wherever podcasts are found. Simply search for PediaCast CME.
Thanks again for stopping by. And until next time, this is Dr. Mike saying stay safe, stay healthy and stay involved with your kids. So, long, everybody.
Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.