Matching children in chronic pain with the right treatment

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(Giovanni Cancemi/Shutterstock)

Chronic pain ranks with ADHD and asthma among the most costly chronic pediatric conditions in the United States. To some extent, the cost—roughly $19.5 billion annually—stems from the large number of children—an estimated 1.9 million—seen for pain every year.

However, in large part the problem may also be one of matching children and adolescents in pain to the appropriate treatments. As psychologist and pain specialist Laura Simons, PhD, and collaborators recently noted in PAIN, pediatrician surveys reveal a lack of consensus when it comes to diagnosing pain, making treatment planning a challenge and potentially putting children at risk for chronic pain problems as adults.

“We’re not catching pain problems early enough,” says Simons, who works in Boston Children’s Hospital’s Department of Anesthesia, Perioperative and Pain Medicine. “Patients may undergo multiple medical procedures, or see several specialists before a diagnosis is given or an appropriate treatment plan is put into place.”

A matter of inquiry

In the experience of Simons and her colleagues in Boston Children’s Chronic Pain Clinic, patients often appear seeking help with chronic pain having never been asked questions that could have helped guide them toward the right treatment approach.

“We review a lot of patient’s records, and you see their journey,” Simons says. “Specific pain-related questions that frontline providers could ask have the potential to facilitate early treatment success and potentially more rapid recovery.

“Patients shouldn’t come to a chronic pain clinic and have that be the first time that they are asked basic questions about their pain,” she adds. “It results in a lot of unnecessary tests and, potentially, overtreatment for those who pose low risk for poor prognostic outcomes.”

What we need is a tool

Simons strongly believes that what’s needed is a stepped approach that matches children in pain to the appropriate level of care based on the complexity of their pain. However, this care model requires a standardized pediatric pain-specific approach to screening and risk stratifying patients—which the field has historically lacked—in order to work.

Examples do exist, though, such the Keele STarT Back Screening Tool (SBST)—a questionnaire developed in the UK to help primary care providers (PCPs) stratify adults with lower back pain based on the patients’ risk for poor psychological outcomes, such as pain catastrophizing or distress and anxiety related to their pain.

“It’s a nine-item screening tool that allows general practitioners to screen for level of risk,” Simons explains. “If you fit into the low risk category, education and reassurance should be sufficient to get you back on track. If you’re medium risk, you’ll probably need some physical therapy, and at high risk you’ll need physical therapy and likely some biobehavioral treatment, such as cognitive behavioral therapy.”

“Patients shouldn’t come to a chronic pain clinic and have that be the first time that they are asked basic questions about their pain.”

When Simons first heard about the SBST in 2011, she was inspired to create a similarly simple, brief tool that could be used in a primary care setting to help route patients with pain complaints to the right level of therapy early.

Working with the Keele University team that developed the SBST, Simons adapted the screen to pediatric care and made it applicable to a wider range of pain complaints (e.g., abdominal pain, neuropathic pain, musculoskeletal pain).

Together, she and her collaborators recently evaluated the resulting Pediatric Pain Screening Tool (PPST) in a cohort of 321 children seen at Boston Children’s Chronic Pain Clinic to see whether this brief screening tool—which still had a total of nine questions—could:

  • predict how patients would do
  • provide useful and actionable information at presentation and at a four-month follow up visit

As they reported in PAIN, the team found that the PPST captured a great deal of information that helped distinguish patients who met clinical criteria for significant pain-related disability from those who didn’t.

“The data show that the nine-item PPST was a valid screening tool, capturing a lot of information about what is happening with our patients,” Simons says. “We were also able to use the information to derive risk categories that were predictive of outcomes four months after our clinic evaluations.”

Small surveys with potentially big impact

Simons notes that she’s already had several colleagues in the pain community approach her asking about using the PPST in their clinics. She hopes to work with several of the specialty care clinics at Boston Children’s to implement the screen with their patients, and also encourage its adoption among pediatric PCPs.

“If a patient comes in with a pain complaint,” Simons explains, “this measure could help the PCP know very quickly whether they should make a referral to a multidisciplinary pain clinic, or whether the patient seems to be at a good status where they could have physical therapy referral or education.”

She’s hopeful that this kind of screening-based, stepped care approach could translate into better care, better outcomes and reductions in health care costs. “It’s pretty powerful if used correctly. It allows clinicians in a very busy clinical setting to be able to implement something rapidly and get some good, meaningful information that can then inform the treatment recommendations they make.”

Learn more about the Pediatric Pain Screening Tool, or download the tool itself, on Boston Children’s Hospital’s Research & Innovation site.