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When should I consider making a referral to the Pain Clinic?Primary care practitioners see the vast majority of pain complaints and manage them quite well. Occasionally, a pain condition presents itself that is perplexing, multifaceted or resistant to standard treatments. We make our services available for this subset of pain conditions. Neuropathic pain (including RSD), cancer pain, pelvic pain and pain behaviors in developmentally disabled children are conditions that would warrant a referral.
How can I provide the best pain care to my patients?As consultants, we recognize and respect the therapeutic bond between primary practitioners and their patients. We strive to forge an alliance with the practitioner to provide the smoothest, most coordinated care for our shared patients.
Communication is of the utmost importance. Therefore, you will receive a letter detailing our comprehensive evaluation after the first visit, as well as brief notes after follow-up visits. We will try to coordinate the initiation of new medications or therapies if there is any risk of interference with an existing plan of treatment.
We ask only that you do not start or stop pain-related medication without contacting us, as several medications have either drug-drug interactions or withdrawal symptoms. We have a physician on-call at all times to respond to any emergency needs that arise.
Finally, we spend a fair amount of time and effort “de-medicalizing” pain. We try to reduce the emphasis on tests and procedures, once life-threatening entities have been ruled out. We ask for your cooperation in not ordering more tests, X-rays or other such things, even at the risk of irritating the patient or parents. Often, the more unnecessary tests are done, the slower the progress is.
How can I ensure a smooth referral process for my patients?As a consulting service, we must receive a physician consultation request to receive reimbursement from most insurance companies. We request that pre-certification numbers for “pain physician, ” “physical therapist” and “psychologist” be sent along with the physician consult. Sending these pre-certification numbers will avoid delays in scheduling appointments.
Any relevant records, tests and radiological studies should accompany the initial letter. Certainly, sending copies along with the patient is helpful. We often receive a consult request that reads, in total: “evaluate and treat chronic (insert body part) pain,” which minimally serves the patient. The more relevant information we have at the time of evaluation, the better we can help the patient and primary physician alike.
Who should treat pain in children?Most common painful conditions of childhood have been and should continue to be managed by pediatricians and family practitioners. Occasionally, a child will develop a pain that does not resolve with time or simple interventions. The pain that results from cancer or other complicated medical problems can also be difficult to control and need special expertise. For those situations, a pediatric pain clinic can provide more comprehensive pain care.
What is a pediatric pain clinic?Pediatric pain clinics have healthcare workers with special training and experience in managing pain in children and young adults. Children differ from adults in many ways. They are not mature yet. They have a more limited understanding of life and why things happen. Their bodies are still growing. Medications may have different effects. And pediatric pain problems often have different prognoses and patterns than similar problems in adults.
A clinic designed for children has specialists in physical therapy, nursing, behavioral medicine and pain medicine that can take these differences into account when treating children with pain. The term “inter-disciplinary” is often used to describe this team of experts, and is an important factor to consider when selecting a pain treatment clinic for your child. We were honored to receive the Clinical Center of Excellence from the American Pain Society for our inter-disciplinary pain program in 2007.
How can I have my child seen by the Pain Team?If your child is coming to the hospital for an operation, or has a painful problem while in the hospital, ask your child’s doctor or surgeon about calling the Pain Service for assistance. Many times, we will automatically see you and your child before a major operation so that we can set up the best plan for your child’s comfort from the beginning.
If your child has an ongoing or long-term pain problem, ask your pediatrician about referring him to the Pain Clinic at Cincinnati Children’s. You can help us help your child by asking your doctor to send information about X-rays and lab tests to us ahead of time. We can use that information to help our diagnosis and treatment planning. If your doctor cannot send information ahead of your visit, please bring it with you. If you live far away, feel free to contact us for help in finding a pain clinic closer to you. If there is no clinic near to you, we will work with you and your child’s primary care physician on the best possible way to help your child.
Who can answer my questions when my child is being treated in the pain clinic?All of our staff are available to answer questions. Our advance practice nurses, however, are the people you are most likely to speak with. They are specially trained and have years of experience working with children and families in the pain clinic. They can help you adjust medications, monitor side effects, answer general questions about pain conditions and advise you about making changes in your child’s treatment plan.
Our administrative assistant will usually be the first person you speak with and will refer you to the proper team member. She will take care of most of your scheduling and medical record keeping needs.
Are nerve blocks used for pediatric pain problems?We use nerve blocks and epidurals most often to help control pain after surgery. Sometimes nerve blocks can help diagnose the cause of pain as well as relieving it. For some pain conditions, epidurals can allow your child to undergo physical therapy that he or she would not otherwise be able to tolerate.
Nerve blocks to treat chronic pain are typically done less frequently in children than adults for three reasons:
Why is a psychologist involved?Pain is not just physical. It causes stress and suffering, and depression and anxiety can result from pain or make it worse. All of our patients have at least an evaluation by our pain psychologist when they first come to the clinic to determine if treatments such as biofeedback, relaxation training, coping skills training or psychotherapy may help with pain management.
The entire family is affected by this stress, and addressing this issue is important to your child’s recovery. Often pain does not go away quickly, and coping skills training can help the entire family manage until the pain resolves.
In addition, there are pathways in the brain and spinal cord whose job it is to suppress pain. Our psychologists can help your child harness these neurologic defenses to reduce and manage his pain.
Why is a physical therapist involved?Pain affects the way the body functions. Whether they know it or not, children may change the way they walk, sit, use their legs or arms, or hold their head due to pain. They may simply become “out of shape.”
Our physical therapist is an expert in assessing these changes and designing a course of therapy to optimize the body’s function. In fact, there are some severe pain conditions that seem to improve because of physical therapy as much as through other therapies.
A TENS unit that you may use is conducted under the supervision of our physical therapist. Keep in mind that the increase in activity that may be recommended often briefly increases the pain before it helps. We can help with this, but it is to be expected and you will need to help your child stick with the program to get long-term benefits.
What is a TENS unit?TENS stands for Transcutaneous Electrical Nerve Stimulation. It is a pain-relief device that uses two small patches that stick to the skin, providing a tapping or tingly sensation to the painful area. The nervous system handles sensation on a “first-come, first-serve” basis. The sensation provided by the TENS unit travels faster than pain sensations and helps the spinal cord block out the pain.
The TENS device can be worn under clothing for use at work or school, and it is very safe. TENS units are provided by our physical therapist, with a prescription from the doctor.
Can children become addicted to pain medications?We use opioid (narcotic) pain medicines for certain pain conditions, especially after surgery and for patients with cancer pain. The number of children who become addicted to these medications is extraordinarily small.
People of any age can become tolerant to opioid medications. They may need more and more to get the same effect, and may have withdrawal if they stop the medicine suddenly (withdrawal can be avoided by following a medication schedule provided by the pain service). This is a physical phenomenon that happens to almost everyone, and is different from addiction.
As a matter of policy, though, we do have patients and parents sign a “controlled substances contract” when these medicines are prescribed through the pain clinic for non-cancer pain. We strictly enforce the rules, and problems are rare.
Isn’t methadone for drug abusers?Methadone is a long-acting opioid medication similar to morphine. Because it does not cause a “high” and is long acting, it is used in drug clinics to keep former users off of heroin.
In our pain practice, methadone is a useful medication because it works well for pain, lasts a long time, comes as a liquid (for those who cannot take pills), and has special properties as a pain medicine that other opioids do not. It often has fewer side effects for patients who have had problems with other medications. We also often use methadone to help prevent withdrawal symptoms in patients who are discontinuing opioid medications after taking them for a long time.
Why are medications used to treat seizures and depression used to treat pain?An interesting feature of pain is that many of the same chemicals the body uses to transmit or block pain signals are the same as those that seem to be out of balance when a person becomes depressed. Other types of pain act a bit like seizures, where nerves fire at inappropriate times and in inappropriate ways.
Antidepressants and anticonvulsants have been shown to help many different pain conditions. They also help with sleep, which is often disturbed by pain, and have a helpful effect on the patient’s mood. They do have side effects, and we monitor their use carefully.
What is Complex Regional Pain Syndrome (formerly Reflex Sympathetic Dystrophy [RSD])? Complex Regional Pain Syndrome (CRPS) is a rare type of neuropathic (relating to nerves) pain that can be severe. There are several differences between CRPS in children and in adults. Most children recover from it. It is most common in active female adolescents (athletes, dancers) from high-achievement oriented families. It tends to occur in the lower legs and feet, and usually does not progress to the withered appearance that can occur in adults with the syndrome. CRPS in children appears to respond well to aggressive physical therapy, medication and behavioral medicine. Sometimes nerve blocks are used to interrupt the pain cycle or to allow physical therapy to be done if it is otherwise too painful. Information available online about CRPS is predominantly related to adults and often paints a picture that does not apply to children with this syndrome.
What causes pelvic pain?Pelvic pain is more common in adolescent girls than once thought. Often, endometriosis is the cause. Endometriosis is a condition in which the clusters of cells that usually form the lining of the uterus become lodged in the pelvis and abdomen and cause pain.
Other causes of pain include menstrual cramps, ovarian cysts, venereal diseases, pelvic floor dysfunction and adhesions from surgery. Sometimes extensive testing reveals no obvious cause.
Treatment involves medications (often including oral contraceptive pills), TENS, physical therapy, behavioral medicine and other non-traditional treatments such has acupuncture.
What can be done for cancer pain in children?Pain is assumed to be a natural part of having cancer; it is one reason why cancer is so feared as a disease. In addition, many of the treatments and tests for cancer are painful.Fortunately, we have many things to offer for controlling cancer pain, as well as the pain and fear from the tests and treatments. We believe strongly that cancer pain should be brought under control to the greatest degree possible for all children, regardless of prognosis.We established the Pediatric Palliative and Comfort Care Team (PACT) to provide consistent, compassionate and up-to-date pain and symptom management for our cancer patients. We use a combination of medications, behavioral medicine techniques to reduce stress and nerve blocks to relieve cancer-related pain. We have the training and experience to utilize advanced procedures and the latest innovations to relieve cancer pain that does not respond to conservative measures.For patients having common but painful tests (such as bone marrow aspirations), we have a Procedural Management service. We provide sedation and anesthesia for patients when they have these procedures. In partnership with the Cancer and Blood Diseases Institute, we established a procedure room and recovery room in the Hematology-Oncology clinic so children feel comfortable in their surroundings and recognize the friendly faces of their clinic nurses when they awake from anesthesia.We make ourselves available around the clock to all our cancer pain patients and are involved in the StarShine Hospice program for children based at Cincinnati Children’s.
What can be done for the pain of surgery in children?We have an active acute pain service that advocates for the children who need special pain care.
We use epidural catheters for a wide range of operations, both in the operating room and during recovery. We also employ peripheral nerve blocks and catheters to provide pain relief for certain operations. For children age 7 and up, Patient Controlled Analgesia (PCA) pumps can be very effective. For children who are either too young to use a PCA or are handicapped and cannot use a PCA, we will sometimes teach parents to use the PCA pump, although this is done on a case-by-case basis.Treatment of pain goes beyond the traditional, morphine-type medications. Medicines such as anti-seizure drugs, anti-depressants and anti-inflammatory medications can all be helpful for pain. Music therapy, physical therapy and psychological treatments can all be helpful to children going through the experience of a big operation.Even with the latest advances on medicine and technology, we cannot promise that there will be no pain after surgery. We do promise to do our best to minimize the pain as much as possible, while managing side effects and following safety standards.
What is a PCA (Patient-Controlled Analgesia) pump?A PCA is a computerized pump that can be set to deliver a specific amount of medication when your child pushes a button. Children as young as 7 years old can use PCAs effectively. For younger children, parents or nurses can help push the button to relieve pain.Safety settings limit how often the pump will deliver the medication, how much is given at a time, and how much can be given over a four-hour period. Several medications can be used this way. Only the patient is allowed to press the button; pressing the button while a patient is asleep is dangerous (no matter how old the patient is) and we prohibit it in a policy we strictly enforce.In specific cases, we may allow a parent or nurse to use the button on behalf of the child. Because this carries extra risk, we reserve the right to limit who receives this treatment. We will discuss the options with you, and decide if your child is a candidate for this treatment. While we are named the Pain Service, our primary focus is safety, and all decisions are based on what is the safest way to care for your child.
What is an epidural?Most people know of epidural analgesia as a way to keep women comfortable during childbirth. The epidural is a long and thin plastic tube that is placed in a space between the bones of the spine and spinal cord. Medications can be given as an infusion to keep children comfortable after surgery.
Children are generally afraid of needles and would move during catheter placement (which could be dangerous), so we typically place the catheter while the child is asleep under general anesthesia. Abdominal, chest, hip and leg surgery are the types of surgery most appropriate for an epidural. Epidurals can be used from the first day of life through adulthood, and can be left in to work for up to a week after surgery, if needed. We check on the catheter every day. If there is any suspicion of infection or another problem, we will remove the catheter. Again, your child’s safety is our primary concern.
What is a peripheral nerve block?Peripheral nerve blocks are a way to give local anesthesia to a specific nerve. We use a needle to inject the numbing medicine close to a nerve, using either an electronic stimulation device or ultrasound to guide the proper placement of the needle. This allows the medicine to work on one specific set of nerves, so only a small area of the body is numbed. This way, a patient can be comfortable, without some of the side effects of numbness in a bigger area. The numbness usually lasts four to 18 hours with a single injection.
The advantage of these blocks is that a person needs less of the other types of pain medicine, and can be comfortable without as much sleepiness, nausea or other side effects. Sometimes, the increase in blood flow can be helpful to healing in some surgeries.
One thing to be aware of with peripheral nerve blocks is that when they wear off, accurate, prompt pain medication is important so that pain does not get out of control. Also, patients and families have to be aware that the area of the child’s body will be numb, and to protect it from things that could do damage; your child would not feel something that would otherwise hurt. Most of the time, nerve blocks are used for surgery on the hand, foot, arm, leg shoulder or hip, but there are many types of blocks for a variety of surgeries.
What is a peripheral nerve catheter? Peripheral nerve catheters are similar to peripheral nerve blocks, but instead of an injection, we place a thin tubing right next to the nerve. The catheter can be left in place for up to three days, providing continuous comfort. Extensive surgery on the arm or leg, or surgeries requiring skin or muscle grafting are common reasons for this technique to be used.
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