Chronic non cancer pain in children: we have a problem, but also solutions
12
0
0
Texto completo
(2) ©. This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.. COPYRIGHT 2018 EDIZIONI MINERVA MEDICA VEGA CHRONIC NON-CANCER PAIN IN CHILDREN. tal health care costs. The augmentation in health care expenditures associated with pediatric painrelated conditions was similar to those of attention deficit and hyperactivity disorder, but more than those associated with asthma and obesity.5 More than two-thirds of these additional costs are related to direct medical care and one-third to nonmedical expenses and productivity losses.6. cortical areas as well as subcortical limbic regions.11-13 However, they also have a shift in the sensory processing of pain towards regions encoding emotional and motivational subjective states.14, 15 Finally, a disruption of the balance of descending modulatory circuits to favor facilitation over inhibition may promote and maintain chronic pain.16. The complex underlying processes of chronic pain in children and adolescents. The consequences of chronic pain on everyday life. Chronic pain can be triggered by physical trauma, by medical conditions such as infection, or by surgeries or other medical procedures.2 Nonetheless, in many chronic pain conditions the symptoms cannot be attributed to any particular cause, which leads to discouragement and frustration for patients, their families, and healthcare providers. The most common chronic pain conditions affecting children and adolescents are headaches and visceral and musculoskeletal pain. These are more frequent in girls, with peak prevalence in those 14 years of age. A national registry in the United States from 2004 to 2010, showed an increase of 831% in the admission of patients with non-organic causes of recurrent pain. These patients often had gastrointestinal (65%) and psychiatric (44%) comorbidities, which present new challenges for healthcare providers and highlight the complexity of pain management.4 Most of the time, the original pain worsens while waiting for treatment, with the risk of increasing disability due to pain.7 Uncontrolled ongoing pain in the absence of any external stimulation characterizes chronic pain. Patients with chronic pain present an increase in transduction sensitivity, reduced threshold and amplified nociceptor response (peripheral sensitization) that may persist over time.8, 9 Many of them show signs of allodynia and hyperalgesia to various peripheral stimuli (central sensitization), due to increases in synaptic efficacy and reductions in inhibition. The net results are the central amplification of nociceptive stimulus and an increase in the amplitude, duration and spatial extent of the pain response.8, 10 Patients with chronic pain conditions have preferential activation of medial prefrontal. Adolescents with chronic pain are more prone to passive or dependent coping styles and are more likely to have a parent with chronic illness, unresolved family problems, early pain experiences, learning/developmental difficulties, and perfectionist tendencies. Most adolescents with chronic pain have two or more of these contributing factors.17 Children with chronic pain are at risk of having significant consequences like impairment in physical activity, reduced quality of life, school avoidance, anxiety, depression, decreased social life and poor sleep hygiene among others.18 These psychological, physical and social sequelae have an impact not only on the patient but also friends and families with high parenting stress and dysfunctional family roles.3, 17 Figure 1 summarized the consequences of chronic pain.. 1082. Parental stress and dysfuncional family roles. Physical activity impairment. Sedentary behavior and loss of physical condition. Isolation and social life impairment. Medication side effects Chronic pain. Sleep hygiene disturbance, concentration problems and chronic fatigue. Deterioration in quality of life and functional disability. Stress and anxiety. School avoidance and pressure for catching up. Mood changes and depression. Figure 1.—Impact of chronic pain.. Minerva Anestesiologica September 2018.
(3) ©. This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.. COPYRIGHT 2018 EDIZIONI MINERVA MEDICA CHRONIC NON-CANCER PAIN IN CHILDREN. VEGA. Sleep problems are a major modifiable risk factor for pain and distress After pain, chronic insomnia is the most common symptom reported by children and adolescents in a chronic pain service.19 Pain delays sleep onset latency and results in frequent and prolonged awakenings.20 Further, insomnia causes severe fatigue and difficulties in attention and concentration. Both pain and insomnia lead to school absenteeism, significant anxiety and mood changes. It is not unusual for children to enter into an increasingly complex cycle of school absenteeism, pressure to catch up on missed school material, and increased stress.21 Insomnia correlates with depression, functional disability and reduced quality of life. The frequency and severity of insomnia is a stronger predictor of disability and depression than pain, and it has been suggested that insomnia may mediate the relationship between pain and depression as well as between pain and disability.22. School attendance and academic performance Children with chronic pain tend to experience more school related difficulties than their healthy peers due to frequent absences for medical appointments, pain crises, medication side effects and a lack of adapted environments. Chronic pain has a significant impact on concentration, memory, and cognition that can be associated with an overall decrease in academic performance. School is an integral part of a youth’s social development, friendships and social identity. When youth spend an extended time away from school due to illness, their reintegration can be anxiety provoking. These children and adolescents may feel left out socially and are at risk of more social exclusion than their peers.23. pain conditions among prepubertal children.25 Adolescents who spend much time using the computer and watching TV have an increased prevalence of headache and musculoskeletal pain in multiple sites.26, 27 Most children with chronic pain withdraw from participating in sports activities, or experience reductions in other activities, including gym class, playing, running, and walking.28. Parents’ emotions, behaviors, and health Witnessing the pain and suffering of one’s own child is distressing for parents and for the wider family. Many parents of children with chronic pain report feeling powerless and discouraged and have more worries and fears about their child’s health.29 Protective parent behaviors, increased distress, and history of chronic pain in one of the parents are associated with poorer outcomes on the children evolution.30 In order to show support for their child, many parents will naturally or intuitively engage in protective and solicitous behaviors by demanding less from their children (routine tasks) and will provide them with more attention, privilege, and help than would otherwise be the case. However, overprotective parental behaviors are positively associated with adverse outcomes such as functional disability, low school performance and higher health care utilization.31 A recent study in the adult population, assessing a nested cohort of dyads (only two relatives per family), showed an increase in odds of chronic pain if exposure family member had chronic pain, if both were female, if both were older and if both had low incomes.32 As a result, an exploration of family circumstances and dynamics may guide our efforts towards factors that could be helpfully modified to improve chronic pain outcomes.. The relationship between pain and physical activity. Chronic pain progression into adulthood. Limitations in activity due to pain are related to reduced physical and psychosocial functioning and poor quality of life.24 Low cardiorespiratory fitness and high levels of sedentary behavior are associated with increased likelihood of various. Between 35% to 73% of children and adolescents with chronic pain are at risk for progressing into adulthood with chronic pain.33, 34 For example, headaches persist in approximately 70% of children 30 years after diagnosis.35. Vol. 84 - No. 9. Minerva Anestesiologica. 1083.
(4) ©. This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.. COPYRIGHT 2018 EDIZIONI MINERVA MEDICA VEGA CHRONIC NON-CANCER PAIN IN CHILDREN. The consequences of children not receiving adequate treatment go beyond the continuation of pain into adulthood.36 For example, children with chronic pain may develop pain in areas other than where the initial pain began or present new psychological disorders.33, 37 In adulthood, one in six chronic pain patients report a history of chronic pain during childhood or adolescence. In such patients, pain is more likely to be widespread and neuropathic in nature, and accompanied by psychological comorbidities and decreased functional status.36. Measurable factors and core outcome domains It has now been clearly established that pain is a consequence of the complex interplay between biological, psychological, individual, social, and environmental factors, though are still debates as to the exact roles and relative contributions of different elements of these factors.38 Thus, it follows that the assessment of children with chronic pain conditions has to move beyond evaluating pain parameters (e.g., pain intensity and location) and must encompass sleep patterns, physical and social functioning, and the psychological impact of pain. The Pediatric Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (PedIMMPACT) recommends core outcome domains that should be considered in the design of clinical trials evaluating pharmacological, behavioral, or environmental interventions.39 Such a standardization of domains can also be used in daily clinical practice. These domains include: measures of pain intensity along with physical, emotional, and role functioning; sleep; family impact, quality of life, medication adverse events; and patient’s global satisfaction with treatment at baseline and discharge from the pain clinic could be part of the standard of care of the biopsychosocial program.. Interdisciplinary approach to chronic pain in children Considering the multifactorial nature and farreaching consequences of chronic pain, multiple healthcare providers of different specialties are. 1084. Multidisciplinary pain assessment during the first visit (60-90 minutes). Establish a trusting relationship with patient and family. Structured pain clinic history (e.g. using OPQRST mnemonic; onset, provocation or palliation, quality, region, severity and time), temporal pain patterns and previous diagnostics workup and treatments.. Address the impact of pain in other domains such as sleep, mood, school attendance, academic performance, physical and social functioning and family impact. Assess expectations of the patient and family. Physical examination oriented to find an underlying pain cause.. Multidisciplinary team discussion: Impressons and feedback from every team member. Identification of problems. Additional diagnostic workup. Involvement or referral to another specialist.. Treatment tailored to working hypothesis and oriented to increase function and cure the pain. Meeting with patient and family to discuss the goals, solve doubts and clarify expectations.. Figure 2.—Interdisciplinary pain evaluation and treatment.. needed to assess and treat patients with chronic pain conditions. A group of specialists working together under a fluid structure with flexible collaboration and shared treatment goals represents the preferred approach in helping patients with chronic pain conditions.40 In our institution, the evaluation begins with a chart review and data collection from the patient’s medical and family history. In a pre-assessment evaluation meeting our team reviews the medical history and the results of patient questionnaires regarding physical, psychological, family function, and sleep quality. We also review the results of Quantitative Sensory Testing. Patients come to the first appointment accompanied by their parents and meet with the whole team, including a nurse, psychologist, social worker, physiotherapist, and pain physician. Figure 2 shows the flowchart of an interdisciplinary team evaluation at the Montreal Children’s Hospital. Interdisciplinary chronic pain programs are oriented towards optimizing physical and psychological function, normalizing sleep and social function (i.e. school attendance and age dependent quality of life), and increasing levels of activity, while also assisting with the management of the pain (Figure 3). Considering the important short and long-term consequences of chronic pain, the goal of treatment is not simply to manage the pain but ultimately to “cure” it. A patient who has been cured is a young adult without pain, no longer receiving medications, and with normal physical and adaptive functioning without significant emotional distress. This young adult, and family, will also be equipped. Minerva Anestesiologica September 2018.
(5) ©. This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.. COPYRIGHT 2018 EDIZIONI MINERVA MEDICA CHRONIC NON-CANCER PAIN IN CHILDREN. Patient. Psychologist. VEGA. • Active participant in the multidisciplinary team. • Provides the needed to add/remove treatments.. • Teaches about coping strategies and pain misconceptions. • Management of sleep and mood disturbances. • Assessment of family dynamics.. • Education, empower and excercise. • Improves physical condition and function with no any increase in pain. Physiotherapist • Encourages the patient to take an active role in the treatment. • The link between school and patient. • Provides family education regarding pain beliefs and school attendance. Social worker • Regain social contact with peers.. Nurse. • Monitoring response/adverse effects of the treatments. • Liaison between team members and patient’s family. • Education.. • Pharmacological treatment. • Interventional procedures. Pain physician • Counseling and education.. Figure 3.—Role of the team members on the interdisciplinary team.. with tools and strategies to anticipate the recurrence of pain and related disability. In this case, the cured patient is able to return to developmentally appropriate function within society. Participation in chronic pain treatment programs can vary from a few weeks to several months, and can occasionally last for years, thus the process must be regularly adapted to the patient’s and family’s current situation and the availability of the therapeutic options. Both, interdisciplinary outpatient and intensive inpatient treatment programs have demonstrated long-term improvements in pain intensity, emotional distress, and disability.41, 42 However, highly affected children and adolescents with severe emotional distress may require intensive inpatient treatment programs to maintain positive treatment outcomes.43, 44. The role of the patient The interdisciplinary team (nurses, psychologists, physiotherapists, social workers, physicians, etc.) helps patients and families to develop successful strategies to understand and manage their pain and modulate negative behaviors regarding pain and disability. Children and adolescents who can self-manage their pain demonstrate less functional disability, depressive symptoms, fear of pain, and use of negative coping. Vol. 84 - No. 9. strategies. Improved functioning is the most important outcome in the treatment of chronic pain and, interestingly, patients generally report significant improvement in function before reporting decreases in pain intensity.45 A recent study of pain trajectory after an intensive pain rehabilitation program (median length of treatment of 4 weeks) found that 88% of patients experienced function improvement at the time of discharge while only 35% reported significant pain reduction. Patients who were in precontemplation and contemplation stages of change had a ninefold risk of not having a positive outcome.46 Therefore, is essential that chronic pain patients take an active role in their care otherwise even the best multidisciplinary pain treatment program is at risk of failure.. The physiotherapist as a coach The physiotherapist aims to achieve measurable goals with a focus on three E’s — Educate, Empower and Exercise, providing strategies to help the patients to regain function.47 Fear-avoidance beliefs, including fear of failing, can significantly hinder progress, as well as predict functional capacity and disability. Patients and parents who have a greater understanding of their pathology and pain have shown decreased levels of kinesiophobia and subsequently increased levels of activity.48 For example, an increase in “pacing” daily physical activity is associated with less pain at the end of the day. As a consequence, pain reduction on a given day may enable children to achieve higher levels of physical activity, creating a positive circle of healing.49 Integrating specific exercises into activities that are of interest to the patient optimizes adherence. It is important to link the level of participation in physical education courses, extracurricular activities, as well as events outside of school with friends or family with the physical rehabilitation program.48. Psychological interventions Behavioral therapies such as Cognitive Behavioral Therapy (CBT) and Acceptance and Commitment Therapy (ACT) are validated psychological. Minerva Anestesiologica. 1085.
(6) ©. This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.. COPYRIGHT 2018 EDIZIONI MINERVA MEDICA VEGA CHRONIC NON-CANCER PAIN IN CHILDREN. interventions for treating pediatric chronic pain that include, among others: 1) psychoeducation about the biopsychosocial factors involved in pain perception, expression, and management; 2) pain management through the use of strategies such as relaxation, self-hypnosis, and biofeedback; 3) insomnia management through stimulus control, mindfulness, and ACT-based strategies; and 4) the management of discouragement, helplessness, and depression through the identification and alteration of thoughts, appraisals, attributions, or other obstacles to change and/or acceptance and reframing of the inalterable.50 These treatments were initially developed to be delivered in a face-to-face format in which the patients and therapists work together to implement therapeutic strategies. However, methods of remote delivery (i.e. internet tools, computer/phone applications, etc.) of psychological treatments have been developed, and are now extensively used.51 CBT interventions reduced headaches soon after the treatment and several months after with a number needed to treat to benefit (NNTB) of 2.94 (95% CI: 1.03 to 8.07). Psychological treatment also decreased pain and disability in children with non-headache pain, mostly after therapy with fewer evidence months afterward. Parent interventions have been successfully incorporated into many cognitive-behavioral treatments for children with chronic pain conditions. Clinical interventions may benefit from addressing parental attitudes, especially their confidence in their child’s ability to function.30 Similarly to children’s, increases in parents’ readiness to adopt a pain self-management approach were associated with changes in parentreported fear of pain.52. The social worker as a bridge between the hospital and the school The social worker (along with other members of the team) can provide the necessary education and tools to schools to allow a child who is suffering from chronic pain to attend school regularly. The influence of the social workers in the efficacy of the treatment includes their therapeutic efforts with the parents. Parental pain catastrophizing and overprotective responses to. 1086. child’s pain independently predicts the school attendance rates and overall school impairment. Parental protectiveness mediates the association between parental pain catastrophizing and child school functioning outcomes. These findings underscore the importance of family intervention to help the children to engage and succeed in the school environment despite the pain.53. The nurse as the communication hub of the team The nurse links children and families with other members of the team based on evolving issues, continuously oversees responses to, and side effects of, treatment, collaborates with families and team members to update plans and goals, and builds connections with healthcare workers at primary health centers.54, 55. Medical treatment: the weakest link in the therapeutic chain Most of the information supporting the use of pharmacological treatments comes from the adult population.56 As in the “adult world” the reality of the everyday clinical practice of the pharmacological treatment of chronic pain in children and adolescents is full of uncertainties and in many conditions it remains empirical.57 For example, the treatments used for controlling pain caused by a lesion or disease affecting the somatosensory nervous system (neuropathic pain) is far to be considered optimal. The number needed to treat (NNT) for 50% pain relief was calculated to be 6.4 for serotonin-noradrenaline reuptake inhibitors; 7.7 for pregabalin; 7.2 for gabapentin and enacarbil; and 10.6 for capsaicin high-concentration patches.58 Even when they are included as part of the multidisciplinary pain treatment program, evidence-based treatment of chronic neuropathic pain provides long-term benefit in only about one-quarter of patients seen in tertiary care centers.59 There is little or no evidence supporting the use of pain medications in pediatric population. A recent Cochrane review of antiepileptics, antidepressants, opioids, acetaminophen, and nonsteroidal anti-inflammatories concluded that. Minerva Anestesiologica September 2018.
(7) ©. This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.. COPYRIGHT 2018 EDIZIONI MINERVA MEDICA CHRONIC NON-CANCER PAIN IN CHILDREN. VEGA. “There is no evidence to support or refute the use of them to treat chronic non-cancer pain in children or adolescents.”60-64 Therefore, the information regarding the risk/benefit of medications is almost lacking in this particular population, with an absence of data on potential long-term effects on the central nervous system after exposure during brain development.65 Looking at this situation in a positive light, this is an opportunity for collaboration between pharmacologists, policy makers and pediatric pain clinicians to produce evidence for the treatment of chronic and complex pediatric pain.66 Currently, the decision to start a new pharmacological treatment is mainly based on clinical judgment that: 1) matching the underlying pathophysiology of pain (QST/CPM) with the mechanism of action of a drug; 2) close follow up of potential side effects; and 3) data extrapolation from the adult population or expert opinions. Table I summarizes the most common non-opioid medications used in clinical practice.. Personalized medical pain management Patients with chronic pain conditions often present with peripheral sensitization, central sensitization, and impairment of the efficacy of endogenous pain inhibitory pathways.67 Theoretically, central sensitization can be prevented or treated by reducing the nociceptive input from the periphery, through pharmacological interventions on the spinal cord mechanisms, or with pharmacological and psychological interventions acting at a supraspinal level and the descending modulatory system.68 Quantitative Sensory Testing (QST) is a clinical methodology that identify alterations in the facilitatory pain processes (i.e. peripheral and central sensitization).69 As part of QST, the conditioned pain modulation (CPM) paradigm is used to assess the efficacy of the endogenous pain inhibitory pathways.70 The extent of pain inhibition during conditioning, reflects the efficacy of the diffuse noxious inhibitory control (DNIC) system.71 The assessment of underlying pain mechanisms with the QST and CPM as part of the standard clinical evaluation facilitates decisions concerning pharmacological treatment towards a mechanism-based personalized pain treatment.. Vol. 84 - No. 9. Interventional pain treatments in children and adolescents Interventional procedures (IPs) have been used extensively to treat specific painful conditions in adults. In addition to reducing the intensity of pain, these procedures are also indicated as a diagnostic/prognostic tool to facilitate the physical therapy or to reduce the use of systemic medications.72 Most pediatric interdisciplinary chronic pain teams provide a variety of IPs.73 However, there is no consistent information available regarding the effectiveness of these in the treatment of chronic pain in children.74 The limited evidence of the efficacy of IPs could be explained by the quality of the publications on the use of IPs as part of a multidisciplinary approach and in the lack of a common definition of success. Future research is needed to evaluate the realistic role of IPs in the treatment of children with chronic pain.. Education of primary and secondary care specialists The inadequate education of primary and secondary care providers about chronic pain has been defined as one of the most preeminent crises in pain management.75 General practitioners and specialists are responsible for the diagnosis, treatment and hospital admission of children with chronic pain conditions. However, they have almost no training or resources to deal with these patients. Very often they apply procedures and treatments indicated for acute pain that have no indication or in fact may be contraindicated for children with chronic pain. One efficient way to reverse this situation is to equip primary and secondary care specialists through education. As stated in the “recommendations for pain treatment services” established by the International Association for the Study of Pain (IASP), education is part of the primary mandate of tertiary care centers.76 Multidisciplinary pain centers should “actively engaged in disseminating relevant information to patients, other healthcare providers and organizations, and the public at large, to improve the quality of pain management across the continuum of care.” It is also expected that multidisciplinary pain centers “provide educational activities and. Minerva Anestesiologica. 1087.
(8) ©. This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.. COPYRIGHT 2018 EDIZIONI MINERVA MEDICA VEGA CHRONIC NON-CANCER PAIN IN CHILDREN. Table I.—Non-opioid medications for the treatment of chronic pain in children. Medication class and generic name. ANTIDEPRESSANTS Secondary amine TCAs Amitriptyline Nortriptyline. SSNRIs Duloxetine. ANTICONVULSANTS Calcium channel α2 ligands Gabapentin. Pregabalin. Other anticonvulsants Topiramate. Valproic acid. Route. Mechanism of action. Common pain indications. PO. Blockade of serotonin and norepinephrine reuptake. Functional GI disorders Migraine prophylaxis 1st line in neuropathic pain. PO. Selective serotonin and norepinephrine reuptake inhibitor. Diffuse musculoskeletal pain 1st line in neuropathic pain. PO. Modulation of voltage-gated calcium channels, inhibiting excitatory neurotransmitter release. 1st line in neuropathic pain Diffuse musculoskeletal pain. PO. Modulation of voltage-gated calcium channels inhibiting excitatory neurotransmitter release. 1st line in neuropathic pain Diffuse musculoskeletal pain. PO. Voltage-dependent sodium channels Migraine prophylaxis blockade, GABA activity enhancement, Mixed results in neuropathic pain AMPA/kainite glutamate receptors antagonism and weakly carbonic anhydrase inhibition Migraine prophylaxis Increase availability of GABA or enhancement of its action. PO. LOCAL ANESTHETICS Topical lidocaine. TD. Voltage-gated sodium channel blockade. Peripheral neuropathic pain Musculoskeletal pain. Intravenous lidocaine. IV. Voltage-gated sodium channel blockade. Central and peripheral neuropathic pain. Cyclooxygenase 1 and 2 inhibitors. As a group, they are used to treat: Musculoskeletal pain, migraine, tensional-type headache (abortive treatment) and juvenile idiopathic arthritis. NSAIDS AND ACETAMINOPHEN Ibuprofen (I) PO Ketorolac (K) Diclofenac (D) Celecoxib (C). Diclofenac. Acetaminophen. Selective cyclooxygenase 2 inhibitor. Topical Cyclooxygenase 1 and 2 inhibitor. PO. Central and peripheral actions not fully elucidated. Musculoskeletal pain. Musculoskeletal pain, migraine, tensional-type headache and juvenile idiopathic arthritis. PO: per os; IV: intravenous; GI: gastrointestinal; GABA: gamma-aminobutyric acid; QHS: at bedtime; BID: twice a day; TID: three times a day; QID: four times a day.. 1088. Minerva Anestesiologica September 2018.
(9) ©. This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.. COPYRIGHT 2018 EDIZIONI MINERVA MEDICA CHRONIC NON-CANCER PAIN IN CHILDREN. Starting dosage, titration and maximum dose. VEGA. Major side effects and precautions. Other benefits expected. 0.1-0.2 mg/kg QHS, slow titration by 10 Increase risk of suicidal behavior and ideation mg weekly dry mouth, sedation, weight gain, QT prolongation, constipation, urinary retention, fatigue, weakness Usual dose of 0.5 mg/kg (max 25 mg) Nortriptyline has less anticholinergic effects Caution with concomitant use of tramadol. Improvement in depression and insomnia, low cost. Maximum daily dose 1 mg/kg. Can be started at 20-30 mg daily up to 60 mg QD. Increase risk of suicidal behavior and ideation, nausea, sedation, drowsiness, weight loss, sweating, loss appetite, headache, insomnia, dizziness Caution with concomitant use of Tramadol. Improvement in depression and generalized anxiety disorder. Start at 2-5 mg/kg up to 300 mg QHS, slow titration every 3-7 days to 5 mg/ kg TID up to 10 mg/kg TID (max 1200 TID) Start at 1-1.5 mg/kg PO QHS, slow titration to 1-1.5 mg PO BID up to 6 mg/kg BID (max 300 mg BID). Increase risk of suicidal behavior and thoughts Somnolence, dizziness, sedation, nausea, depression, flatulence, peripheral edema Adjustment by renal function is required Increase risk of suicidal behavior and thoughts, sedation, dizziness, drowsiness, blurred vision, peripheral edema, weight gain, confusion, dementia, fever, lack of coordination Adjustment by renal function is required. Improvement in sleep and generalized anxiety disorder. Start at 0.5 mg/kg daily, slow weekly titration up to 2 mg/kg per day. Children age ≥12, initial dose 25 mg QHS for 1 week, increase the dose 25 mg weekly up to 100-200 mg daily Start at 5-7.5 mg/kg BID, slow titration up to 15 mg/kg BID. Cognitive impairment, somnolence, fatigue Decrease appetite and weight loss, sedation, mood changes, urinary incontinence, nephrolithiasis Adjustment by renal function is required. Weight loss in overweight patients. <50 kg: 1-2 patches for 12 hours daily >50 kg: up to 3 patches for 12 hours daily. No cases of local anesthetic systemic toxicity have been Excellent tolerability profile reported Local reaction such as skin irritation Avoid its use in severe hepatic dysfunction Potential of local anesthetic systemic toxicity in case of inadequate dose or infusion rate administration Flushing and itching skin, nausea, vomiting, hypotension, arrhythmia, cardiovascular collapse, dizziness, drowsiness, tremor, seizures, nystagmus, paresthesias. A total dose of 5 mg/kg. Commonly used a bolus of 1 mg/kg (administered slowly) followed by an infusion of 2-4 mg/kg over a period of 1-6 hours I: 8-10 mg/kg TID up to 600 mg q 4-6 h K: 1 mg/kg dose up to 10 mg q 6 h D: 1mg/kg TID up to 50 mg q 8 h (max 1000 mg daily) 10-25 kg 50 mg BID, >25 kg 100 mg BID Children age <16 1.16% apply 2-4 g TID-QID Children age ≥16 2.32 apply 2 g BID 10-15 mg/kg q 4-6 h, do not exceed 75 mg/kg in 24 h or 3-4 g daily. Vol. 84 - No. 9. Cautiously use in patients <5 years of age because of potential hepatotoxicity. Liver function test, amylase and complete blood count should be measured during initial treatment, weight gain, mood changes, teratogenic Not recommended in adolescents of child-bearing potential. Gastrointestinal injury, flatulence, renal dysfunction, platelet aggregation impairment, thrombocytopenia, edema, hypertension, hypokalemia, hypernatremia, tinnitus, pruritus Lower gastrointestinal toxicity and no impact on coagulation Fever, skin rash, blurred vision, confusion, dry mouth, vomiting, loss appetite Local skin irritation It should be only applied to intact skin. Anti-inflammatory effect. Hepatotoxicity in case of overdose Rash, nausea, vomiting, anemia, insomnia, fatigue, bronchospasm. Minerva Anestesiologica. 1089.
(10) ©. This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.. COPYRIGHT 2018 EDIZIONI MINERVA MEDICA VEGA CHRONIC NON-CANCER PAIN IN CHILDREN. training in multidisciplinary pain management for clinicians from multiple disciplines (e.g., physicians of different specialties, clinical psychologists, nurses, physical therapists).” Education itself is a very useful modality for the treatment of chronic pain as its therapeutically influenced pain perception and provided “a common language between provider and patient.”77 Knowledge transfer and dissemination means producing tools to recognize chronic pain conditions, facilitate the diagnosis, and efficiently use the resources available in the community. Links with community practitioners would facilitate earlier treatment and referrals. A practical approach is to share therapeutic pathways, protocols, and resources for specific conditions with primary and secondary care practitioners. With these tools, primary care professionals may become part of the diagnosis and treatment process; and in many cases, this would be enough to prevent the use of tertiary care services.. Conclusions Pediatric chronic pain continues to challenge all health providers involved in the care of children. Considering the multifactorial nature of chronic pain, optimal management is often complex and requires the involvement of more than one specialist. Chronic pain can be associated with an impairment of many aspects of the child’s life, including sleep disturbances, social isolation, mood changes, deconditioning, and poor academic performance, among others. If these patients are not properly treated, they have a higher chance of becoming an adult with the same or different chronic pain conditions. A bio-psycho-social approach centered in self-care, reconditioning, school attendance, social reintegration, and restoration of the sleep architecture and family roles, currently represents the best therapeutic option for the management of chronic pain in children. There is no “magic pill” or a miraculous interventional procedure that can cure a chronic pain condition in children. The prudent use of both pharmacological treatment and interventional procedures needs to be assessed case-by-case, always weighing risks and benefits as a part of an interdisciplinary treatment program. The patient is the most important member of this interdisciplinary team and. 1090. the goal is to see this child or adolescent living without pain, not receiving medications, without significant emotional distress, and with normal physical and adaptive functioning. A child or adolescent living their own normal, daily life.. Key messages • Chronic pain in children has a significant economic, social and public health impact worldwide. • Among the most common consequences of pediatric chronic pain are; impairment in physical activity, reduced quality of life, school avoidance, anxiety, depression, decreased social life and poor sleep hygiene. • Considering its multifactorial nature and impact, a biopsychosocial approach is essential to achieve positive outcomes. • Considering the risk of having a disabled patient in adulthood, our efforts have to be focused on curing pediatric chronic pain and not only treating it. The concept of “cured pain” means a patient with normal physical and adaptive functioning, not receiving medications and with neither significant emotional distress nor pain.. References 1. Perquin CW, Hazebroek-Kampschreur AA, Hunfeld JA, Bohnen AM, van Suijlekom-Smit LW, Passchier J, et al. Pain in children and adolescents: a common experience. Pain 2000;87:51–8. 2. King S, Chambers CT, Huguet A, MacNevin RC, McGrath PJ, Parker L, et al. The epidemiology of chronic pain in children and adolescents revisited: a systematic review. Pain 2011;152:2729–38. 3. Huguet A, Miró J. The severity of chronic pediatric pain: an epidemiological study. J Pain 2008;9:226–36. 4. Coffelt TA, Bauer BD, Carroll AE. Inpatient characteristics of the child admitted with chronic pain. Pediatrics 2013;132:e422–9. 5. Groenewald CB, Wright DR, Palermo TM. Health care expenditures associated with pediatric pain-related conditions in the United States. Pain 2015;156:951–7. 6. Groenewald CB, Essner BS, Wright D, Fesinmeyer MD, Palermo TM. The economic costs of chronic pain among a cohort of treatment-seeking adolescents in the United States. J Pain 2014;15:925–33. 7. Lynch ME, Campbell F, Clark AJ, Dunbar MJ, Goldstein D, Peng P, et al. A systematic review of the effect of waiting for treatment for chronic pain. Pain 2008;136:97–116.. Minerva Anestesiologica September 2018.
(11) ©. This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.. COPYRIGHT 2018 EDIZIONI MINERVA MEDICA CHRONIC NON-CANCER PAIN IN CHILDREN. VEGA. 8. Latremoliere A, Woolf CJ. Central sensitization: a generator of pain hypersensitivity by central neural plasticity. J Pain 2009;10:895–926. 9. Bolay H, Moskowitz MA. Mechanisms of pain modulation in chronic syndromes. Neurology 2002;59(Suppl 2):S2–7. 10. Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain 2011;152(Suppl):S2–15. 11. Borsook D, Upadhyay J, Chudler EH, Becerra L. A key role of the basal ganglia in pain and analgesia—insights gained through human functional imaging. Mol Pain 2010;6:27. 12. Neugebauer V, Li W, Bird GC, Han JS. The amygdala and persistent pain. Neuroscientist 2004;10:221–34. 13. Apkarian AV. Cortical pathophysiology of chronic pain. Novartis Found Symp 2004;261:239–45. 14. Apkarian AV, Hashmi JA, Baliki MN. Pain and the brain: specificity and plasticity of the brain in clinical chronic pain. Pain 2011;152(Suppl):S49–64. 15. Hashmi JA, Baliki MN, Huang L, Baria AT, Torbey S, Hermann KM, et al. Shape shifting pain: chronification of back pain shifts brain representation from nociceptive to emotional circuits. Brain 2013;136:2751–68. 16. Ossipov MH, Morimura K, Porreca F. Descending pain modulation and chronification of pain. Curr Opin Support Palliat Care 2014;8:143–51. 17. Wojtowicz AA, Banez GA. Adolescents with chronic pain and associated functional disability: A descriptive analysis. J Child Health Care 2015;19:478–84. 18. Rathleff MS, Roos EM, Olesen JL, Rasmussen S. High prevalence of daily and multi-site pain—a cross-sectional population-based study among 3000 Danish adolescents. BMC Pediatr 2013;13:191. 19. Palermo TM, Wilson AC, Lewandowski AS, Toliver-Sokol M, Murray CB. Behavioral and psychosocial factors associated with insomnia in adolescents with chronic pain. Pain 2011;152:89–94. 20. Palermo TM, Fonareva I, Janosy NR. Sleep quality and efficiency in adolescents with chronic pain: relationship with activity limitations and health-related quality of life. Behav Sleep Med 2008;6:234–50. 21. Palermo TM, Kiska R. Subjective sleep disturbances in adolescents with chronic pain: relationship to daily functioning and quality of life. J Pain 2005;6:201–7. 22. Kanstrup M, Holmström L, Ringström R, Wicksell RK. Insomnia in paediatric chronic pain and its impact on depression and functional disability. Eur J Pain 2014;18:1094–102. 23. Chin EP, Betts G. The school functioning of children with chronic and recurrent pain. Pediatric Pain Letter 2005;7:11–6. 24. Hainsworth KR, Davies WH, Khan KA, Weisman SJ. Development and preliminary validation of the child activity limitations questionnaire: flexible and efficient assessment of pain-related functional disability. J Pain 2007;8:746–52. 25. Vierola A, Suominen AL, Lindi V, Viitasalo A, Ikävalko T, Lintu N, et al. Associations of Sedentary Behavior, Physical Activity, Cardiorespiratory Fitness, and Body Fat Content With Pain Conditions in Children: The Physical Activity and Nutrition in Children Study. J Pain 2016;17:845–53. 26. Paananen MV, Auvinen JP, Taimela SP, Tammelin TH, Kantomaa MT, Ebeling HE, et al. Psychosocial, mechanical, and metabolic factors in adolescents’ musculoskeletal pain in multiple locations: a cross-sectional study. Eur J Pain 2010;14:395–401. 27. Hakala PT, Rimpelä AH, Saarni LA, Salminen JJ. Frequent computer-related activities increase the risk of neck-. Vol. 84 - No. 9. shoulder and low back pain in adolescents. Eur J Public Health 2006;16:536–41. 28. Konijnenberg AY, Uiterwaal CS, Kimpen JL, van der Hoeven J, Buitelaar JK, de Graeff-Meeder ER. Children with unexplained chronic pain: substantial impairment in everyday life. Arch Dis Child 2005;90:680–6. 29. Eccleston C, Crombez G, Scotford A, Clinch J, Connell H. Adolescent chronic pain: patterns and predictors of emotional distress in adolescents with chronic pain and their parents. Pain 2004;108:221–9. 30. Palermo TM, Valrie CR, Karlson CW. Family and parent influences on pediatric chronic pain: a developmental perspective. Am Psychol 2014;69:142–52. 31. Jaaniste T, Jia N, Lang T, Goodison-Farnsworth EM, McCormick M, Anderson D. The relationship between parental attitudes and behaviours in the context of paediatric chronic pain. Child Care Health Dev 2016;42:433–8. 32. Campbell P, Jordan KP, Smith BH, Scotland G, Dunn KM. Chronic pain in families: a cross-sectional study of shared social, behavioural, and environmental influences. Pain 2018;159:41-7. 33. Walker LS, Dengler-Crish CM, Rippel S, Bruehl S. Functional abdominal pain in childhood and adolescence increases risk for chronic pain in adulthood. Pain 2010;150:568–72. 34. Fearon P, Hotopf M. Relation between headache in childhood and physical and psychiatric symptoms in adulthood: national birth cohort study. BMJ 2001;322:1145. 35. Dooley JM, Augustine HF, Brna PM, Digby AM. The prognosis of pediatric headaches—a 30-year follow-up study. Pediatr Neurol 2014;51:85–7. 36. Hassett AL, Hilliard PE, Goesling J, Clauw DJ, Harte SE, Brummett CM. Reports of chronic pain in childhood and adolescence among patients at a tertiary care pain clinic. J Pain 2013;14:1390–7. 37. Noel M, Groenewald CB, Beals-Erickson SE, Gebert JT, Palermo TM. Chronic pain in adolescence and internalizing mental health disorders: a nationally representative study. Pain 2016;157:1333–8. 38. Liossi C, Howard RF. Pediatric Chronic Pain: Biopsychosocial Assessment and Formulation. Pediatrics 2016;138:138. 39. McGrath PJ, Walco GA, Turk DC, Dworkin RH, Brown MT, Davidson K, et al.; PedIMMPACT. Core outcome domains and measures for pediatric acute and chronic/recurrent pain clinical trials: PedIMMPACT recommendations. J Pain 2008;9:771–83. 40. Odell S, Logan DE. Pediatric pain management: the multidisciplinary approach. J Pain Res 2013;6:785–90. 41. Hechler T, Blankenburg M, Dobe M, Kosfelder J, Hübner B, Zernikow B. Effectiveness of a multimodal inpatient treatment for pediatric chronic pain: a comparison between children and adolescents. Eur J Pain 2010;14:97.e1–9. 42. Sherry DD, Brake L, Tress JL, Sherker J, Fash K, Ferry K, et al. The Treatment of Juvenile Fibromyalgia with an Intensive Physical and Psychosocial Program. J Pediatr 2015;167:731–7. 43. Hechler T, Wager J, Zernikow B. Chronic pain treatment in children and adolescents: less is good, more is sometimes better. BMC Pediatr 2014;14:262. 44. Hirschfeld G, Hechler T, Dobe M, Wager J, von Lützau P, Blankenburg M, et al. Maintaining lasting improvements: one-year follow-up of children with severe chronic pain undergoing multimodal inpatient treatment. J Pediatr Psychol 2013;38:224–36. 45. Lynch-Jordan AM, Sil S, Peugh J, Cunningham N, Ka-. Minerva Anestesiologica. 1091.
(12) ©. This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.. COPYRIGHT 2018 EDIZIONI MINERVA MEDICA VEGA CHRONIC NON-CANCER PAIN IN CHILDREN. shikar-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;155:1955–61. 46. Simons LE, Sieberg CB, Conroy C, Randall ET, Shulman J, Borsook D, et al. Children With Chronic Pain: Response Trajectories After Intensive Pain Rehabilitation Treatment. J Pain 2018;19:207–18. 47. Semmons J. The role of physiotherapy in the management of chronic pain. Anaesth Intensive Care Med 2016;17:445–7. 48. Ambrose KR, Golightly YM. Physical exercise as nonpharmacological treatment of chronic pain: why and when. Best Pract Res Clin Rheumatol 2015;29:120–30. 49. Rabbitts JA, Holley AL, Karlson CW, Palermo TM. Bidirectional associations between pain and physical activity in adolescents. Clin J Pain 2014;30:251–8. 50. Eccleston C, Malleson PN, Clinch J, Connell H, Sourbut C. Chronic pain in adolescents: evaluation of a programme of interdisciplinary cognitive behaviour therapy. Arch Dis Child 2003;88:881–5. 51. Fisher E, Law E, Palermo TM, Eccleston C. Psychological therapies (remotely delivered) for the management of chronic and recurrent pain in children and adolescents. Cochrane Database Syst Rev 2015;(3):CD011118. 52. Logan DE, Conroy C, Sieberg CB, Simons LE. Changes in willingness to self-manage pain among children and adolescents and their parents enrolled in an intensive interdisciplinary pediatric pain treatment program. Pain 2012;153:1863–70. 53. Logan DE, Simons LE, Carpino EA. Too sick for school? Parent influences on school functioning among children with chronic pain. Pain 2012;153:437–43. 54. Morse JM, Penrod J. Linking concepts of enduring, uncertainty, suffering, and hope. Image J Nurs Sch 1999;31:145–50. 55. Morales-Fernandez A, Morales-Asencio JM, Canca-Sanchez JC, Moreno-Martin G, Vergara-Romero M; Group for pain management Hospital Costa del Sol Members. Impact on quality of life of a nursing intervention programme for patients with chronic non-cancer pain: an open, randomized controlled parallel study protocol. J Adv Nurs 2016;72:1182–90. 56. Kashikar-Zuck S, King C, Ting TV, Arnold LM. Juvenile Fibromyalgia: Different from the Adult Chronic Pain Syndrome? Curr Rheumatol Rep 2016;18:19. 57. Boulkedid R, Abdou AY, Desselas E, Monégat M, de Leeuw TG, Avez-Couturier J, et al.; GAPP Consortium. The research gap in chronic paediatric pain: A systematic review of randomised controlled trials. Eur J Pain 2018;22:261–71. 58. Finnerup NB, Attal N, Haroutounian S, McNicol E, Baron R, Dworkin RH, et al. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurol 2015;14:162–73. 59. Moulin DE, Clark AJ, Gordon A, Lynch M, Morley-Forster PK, Nathan H, et al. Long-Term Outcome of the Management of Chronic Neuropathic Pain: A Prospective Observational Study. J Pain 2015;16:852–61. 60. Cooper TE, Wiffen PJ, Heathcote LC, Clinch J, Howard R, Krane E, et al. Antiepileptic drugs for chronic non-cancer pain in children and adolescents. Cochrane Database Syst Rev 2017;8:CD012536.. 61. Cooper TE, Heathcote LC, Clinch J, Gold JI, Howard R, Lord SM, et al. Antidepressants for chronic non-cancer pain in children and adolescents. Cochrane Database Syst Rev 2017;8:CD012535. 62. Cooper TE, Fisher E, Gray AL, Krane E, Sethna N, van Tilburg MA, et al. Opioids for chronic non-cancer pain in children and adolescents. Cochrane Database Syst Rev 2017;7:CD012538. 63. Cooper TE, Fisher E, Anderson B, Wilkinson NM, Williams DG, Eccleston C. Paracetamol (acetaminophen) for chronic non-cancer pain in children and adolescents. Cochrane Database Syst Rev 2017;8:CD012539. 64. Eccleston C, Cooper TE, Fisher E, Anderson B, Wilkinson NM. Non-steroidal anti-inflammatory drugs (NSAIDs) for chronic non-cancer pain in children and adolescents. Cochrane Database Syst Rev 2017;8:CD012537. 65. Mathew E, Kim E, Zempsky W. Pharmacologic Treatment of Pain. Semin Pediatr Neurol 2016;23:209–19. 66. Grégoire MC, Finley GA. Drugs for chronic pain in children: a commentary on clinical practice and the absence of evidence. Pain Res Manag 2013;18:47–50. 67. Staud R, Weyl EE, Price DD, Robinson ME. Mechanical and heat hyperalgesia highly predict clinical pain intensity in patients with chronic musculoskeletal pain syndromes. J Pain 2012;13:725–35. 68. Curatolo M, Arendt-Nielsen L, Petersen-Felix S. Central hypersensitivity in chronic pain: mechanisms and clinical implications. Phys Med Rehabil Clin N Am 2006;17:287–302. 69. Cruz-Almeida Y, Fillingim RB. Can quantitative sensory testing move us closer to mechanism-based pain management? Pain Med 2014;15:61–72. 70. Yarnitsky D. Role of endogenous pain modulation in chronic pain mechanisms and treatment. Pain 2015;156(Suppl 1):S24–31. 71. Le Bars D, Dickenson AH, Besson JM. Diffuse noxious inhibitory controls (DNIC). II. Lack of effect on non-convergent neurones, supraspinal involvement and theoretical implications. Pain 1979;6:305–27. 72. Smith H, Youn Y, Guay RC, Laufer A, Pilitsis JG. The Role of Invasive Pain Management Modalities in the Treatment of Chronic Pain. Med Clin North Am 2016;100:103–15. 73. Peng P, Stinson JN, Choiniere M, Dion D, Intrater H, Lefort S, et al.; STOPPAIN Investigators Group. Dedicated multidisciplinary pain management centres for children in Canada: the current status. Can J Anaesth 2007;54:985–91. 74. Shah RD, Cappiello D, Suresh S. Interventional Procedures for Chronic Pain in Children and Adolescents: A Review of the Current Evidence. Pain Pract 2016;16:359–69. 75. Loeser JD. Five crises in pain management. Pain Clinical Updates 2012;XX:1–3. 76. International Association for the Study of Pain. Recommendations for pain treatment services; 2009 [Internet]. Available from: www.iasp-pain.org/Education/Content. aspx?ItemNumber=1381 [cited 2018, Jun 26]. 77. Robins H, Perron V, Heathcote LC, Simons LE. Pain Neuroscience Education: State of the Art and Application in Pediatrics. Children (Basel) 2016;3:3.. Conflicts of interest.—Pablo M. Ingelmo is member of the Editorial Board of Pediatric Anesthesia. The rest of the authors have no conflict of interest, financial or otherwise, to disclose. Funding.—The Chronic Pain Service of the Montreal Children’s Hospital is supported by an unrestricted grant from the Montreal Children’s Hospital Foundation and the Louise and Alan Edwards Foundation. Article first published online: May 9, 2018. - Manuscript accepted: May 3, 2018. - Manuscript revised: March 26, 2018. - Manuscript received: August 15, 2017.. 1092. Minerva Anestesiologica September 2018.
(13)
Figure
Documento similar
