This document summarizes a presentation about managing pain from juvenile arthritis (JA) beyond just pills and procedures. It discusses that while medications and surgeries can provide relief, they do not always eliminate pain and have limitations. Alternative strategies discussed include physical activity, nutrition, distraction techniques, relaxation methods, massage, and combining approaches. It also stresses the importance of regular school attendance and addressing any mood or anxiety issues. Finally, it discusses the role of parents in modeling flexible coping and supporting their child's development beyond just their medical condition.
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Pain Management Beyond the Pills and Procedures
1. Pain Management:
Beyond the Pills and Procedures
JA National Conference
July 21, 2012; St. Louis, MO
Dustin P. Wallace, PhD
Licensed Psychologist, Integrative Pain Management Clinic
Childrenโs Mercy Hospitals and Clinics
Assistant Professor of Pediatrics, School of Medicine
University of Missouri-Kansas City
2. Disclosures
โข I am not a medical doctor!
โข Please check with your doctor before starting
any new treatment, including the ones we
discuss today
3. Todayโs plan
1. Many things influence pain from JA
2. Pills and procedures can lead to pain reliefโฆ but do
not always eliminate pain
3. Certain other strategies can be more effective and
have fewer side-effects
โ Strategies for children, teens, and parents
4. Time for questions and discussion
โ (and feel free to ask at any time!)
4. JA is a PAIN
โข Broad set of autoimmune inflammatory
conditions
โ Joints: JIA (oligo-, poly-, systemic)
โ Tendon/ligament: Enthesitis (ankylosing
spondylitis, spondyloarthropathies, reactive)
โ Psoriatic arthritis, dermatomyositis, scleroderma
lupus, HLAB, etcโฆ
โข Inflammation -> pain -> more inflammation!
5. Pain can be Disabling
โข Impairment varies across
individuals
โข Severity of symptoms does not fully
account for disability
โข According to most studies, arthritis activity
accounts for less than 10% of the pain that kids
report
6. Think Bio-Psycho-
Socially!
โข Pain comes from
physiological/medical
factors as well as
psychological, social,
behavioral, historical and
environmental
contributions
7. Alsoโฆ
โข Muscles guard,
become tight, and
may spasm
โข Nerves get โpracticedโ
at pain signals
โ Sending nerves
โ Listening nerves
Pictures from: https://www.umm.edu/
imagepages/18125.htm &
http://www.jvillechiro.com/sciatica.htm
8. Pills & procedures are important
โข Arthritis drugs: Anti-inflammatory & disease-
modifying
โข Other pain medications
โข Surgeries & other procedures (injections, soft-
tissue release, joint replacement, etc)
โข Splints or orthotics
9. But these have limitationsโฆ
โข Arthritis medications:
โ if disease is improving, more may not help pain
โ side effects can limit dose
โข Pain medications:
โ Hyperalgesia, side-effects
โข Surgeries/procedures: invasive, side-effects
โข Splints/orthotics: only correct certain issues
10. What other options do you have?
โข Lots!!
โ Address those overactive nerves
โ Ease those painful muscles
โ Take advantage of the pain gate
12. What other options do you have?
โข BIG categories:
โ Physical activity
โ Adequate water and nutrition
โ Distraction (sensory and cognitive)
โ โBiobehavioralโ (usually relaxation-based)
โ Combination approaches
โข Parenting strategies
13. Physical Activity
โข Why does it help? โข What you can do
โ Stimulates nerves โ Moderation!
normally โ Stretching
โ Stretches and โ Physical therapy
strengthens muscles
โ Supports joints
14. Adequate water; good nutrition
โข Why does it help? โข What you can do
โ Promotes healing โ Aim for 64oz water
through normal body daily
processes โ Variety of fresh foods
โ May decrease including colorful
inflammation fruits and veggies
โ Allows medications to โ Reduce processed
work their best foods and sugar
15. Anti-inflammatory diet (as example)
** Not specifically
endorsing this diet, but
it has a number of
excellent elements.
Reminder: talk to your
doctor before making
any large changes.
Picture from:
http://www.drweil.com/
drw/u/ART02995/Dr-
Weil-Anti-Inflammatory-
Food-Pyramid.html
16. Distraction - sensory
โข Why does it help? โข What you can do
โ Closes pain gate โ Heat, cold, movement
โ May promote in water
relaxation and healing โ Petting animals
โ Releases feel-good โ Vibration
neurotransmitters โ TENS
โ Massage, self-massage
17. Distraction โ sensory (massage)
โข Example:
โ Comfort Hold
โข Simply laying warm, full hands on your child can be
very calming. Start with forehead and neck, and work
down. Hold each place for a few calm breaths.
โ Massage:
โข More than just a shoulder rub!
18. Distraction โ sensory (massage)
โข Face: sides of face,
forehead, nose, chin
โข Stomach: hand over
hand, then clockwise
โข Legs: hip to foot, foot,
then back up
โข Arms: same as legs
โข Back: down, side to
side, circular, neck, head
to toe
21. Distraction - cognitive
โข Why does it help? โข What you can do
โ Helps close pain gate โ TV, movies, video
โ Adds fun activities games,
โ Releases feel-good
neurotransmitters
22. Distraction - cognitive
โข Why does it help? โข What you can do
โ Helps close pain gate โ TV, movies, video
โ Adds fun activities games,
โ Releases feel-good โ Non-video games,
neurotransmitters books
โ Music, art, activities
โ Friends
23. Biobehavioral strategies
โข Why does it help? โข What you can do
โ Regulates autonomic โ Relaxed breathing
nervous system โ Progressive muscle
โ Decreases overactive relaxation
pain nerves โ Imagery/self-hypnosis
โ Promotes healing โ Biofeedback
โ Meditation
25. Combine some of these?
โข Yoga or Tai Chi
โ Physical activity, strengthening, stretching,
relaxation, biobehavioral, distraction (sensory &
cognitive)
โข Massage
โ Relaxation, nerve stimulation, distraction (sensory)
26. Combine some of these?
โข Acupuncture
โ Biobehavioral, stimulates nerves
โข School!
โ Distraction (cognitive & sensory), physical
activity, social engagement feels good
27. Stay in school!
โข Full medical homebound contraindicated for most
adolescents with chronic pain
โ May do more harm than good
โข Commitment to regular school attendance despite pain
is critical to prevent enduring disability
โ Avoid pattern of withdrawal
โข Students retained in one grade are 50% more likely to
drop out
28. Stay in school!
โข Accommodations may help facilitate regular
attendance:
โ Rest or stretch breaks
โ Extra time for tests/assignments
โ Modified PE curriculum
โ Assignments/grading limited to essential learning
โ Gradual reentry plan
29. Mood or anxiety may get in the way
โข Chronic medical conditions can get kids
down
โ Especially if painful, or limiting activities
โข Might also worry about their pain, JA, or
what is going to happen
โข Completely normal, but might get in the way
in addition to pain/JA
โ If so, therapy can help
30. Mood or anxiety may get in the way
โข Symptom reduction and acceptance:
โ Education of patient and family
โ Relaxation and possibly biofeedback
โ Develop coping and self-efficacy
โ Build motivation
โ Skills training and goal setting
โ Reducing avoidance, engaging with values
โ Treating adjunctive problems such as anxiety and
depression
โ Training parents in behavioral strategies
31. Mood or anxiety may get in the way
โข Referral
โ Ask your doctor if other patients have had good
experience with a certain psychologist or therapist
โ Meet a couple different therapists before deciding
โ Find someone experienced at working with kids who
have JA or other painful medical conditions
โข Make sure they have a good understanding of
what you are coming for, and a plan to help you
reach your goals!
32. Parenting pain flexibly
โข Many roles:
โ Protector, advocate, encourager, coach, comforter,
limit setter, role model!
โข At the same timeโฆ
โ You have your own worries and struggles about
your child, and other aspects of your life!
โ Responsible for helping your childโs adherence
โ Social/family roles disrupted
33. Parenting pain flexibly
โข Some challenges
โ Parent distress may be modeled for kids
โ Hard to balance being responsive and supportive,
while encouraging coping and not doing too much
โข The good news
โ Good coping modeled for kids
โ When disease and pain management are in context
with other values, kids function better!
34. Parenting pain flexibly
โข Role Model:
โ Understand stress and burden are normal
โ Have social support; get more help if you need it!
โ Follow your own values, and encourage this in
your child(ren)
โข Keep JA treatment and pain avoidance from becoming
sole family focus
โ Support and celebrate your childโs development