The Importance of Pain Management
Children with arthritis shouldn’t have to accept pain
By Linda J. Brown
Pain’s throb, stab and ache can become a serious problem for a child with a chronic disease like juvenile arthritis (JA) and can affect many facets of a child’s life. But do kids with arthritis have to be saddled with pain?
“What I see clinically is that a lot of kids and their families assume that because they have arthritis they need to live with pain and nothing can be done, and that’s not true,” says Lonnie Zeltzer, MD, director of the Pediatric Pain Program at Mattel Children’s Hospital at UCLA in California.
Another reality is that pediatric rheumatologists don’t always think of targeting the pain directly; instead focusing on disease control with the belief that decreased inflammation will be all that is needed to ease discomfort.
While first-line analgesics like acetaminophen, as well as nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen, decrease pain for many kids, they don’t help all children with JA. Powerful new anti-arthritis medications curb inflammation and pain for a lot of kids too, but “we’ve found that many children continue to have significant pain despite the use of these strong medicines,” says Yukiko Kimura, MD, chief of pediatric rheumatology, Joseph M. Sanzari Children’s Hospital, Hackensack University Medical Center in New Jersey.
Research into pain
Why does pain persist for some children? Many questions remain unanswered but researchers in the small, yet growing study of pediatric pain are turning up some intriguing findings. “A fairly new finding is that pain can lead to more inflammation, so by treating pain in somebody with arthritis, you can reduce some of the inflammation,” says Dr. Zeltzer.
There also may be differences in how pain affects girls and boys. Certain pain conditions like fibromyalgia affect girls much more than boys but not until adolescence through adulthood. Researchers are trying to figure out why girls are more vulnerable.
“We also don’t know how pain changes developmentally as children mature through childhood into adolescence and young adulthood,” says Patricia McGrath, PhD, scientific director at the Divisional Center for Pain Management and Pain Research, the Hospital for Sick Children in Toronto, Ontario.
Researchers are sure that the mind-body connection is strong when it comes to pain in adults and kids. “What we think, how we feel, what we believe, how stressed we are and what’s happening to our body in terms of inflammation, for example, are all interconnected,” says Dr. Zeltzer. “We’ve documented with functional magnetic resonance imaging (fMRI) studies that you can change pain systems biologically by what you do with your mind.”
One of the largest growing areas of research is the whole question of the long-term effects of untreated pain in kids. It appears that having a lot of pain as a child that is not well treated is one of a number of risk factors that may make a person more sensitive to pain as an adult.
Curbing the pain
So what options exist for a child with arthritis who is having difficulty with chronic pain? The wide range of drugs that may help include various NSAIDs, corticosteroids and pain relievers that contain acetaminophen, opioids or acetaminophen-and-opioid mixes. The use of opioids in children is controversial due to worries over addiction or side effects. A couple years ago, Dr. Kimura did a study that surveyed pediatric rheumatologists about their use of opioids for their patients. Many did not agree with prescribing opioids for kids and only used opioids at times in the most severe cases.
“In the last five to 10 years, opioid medications have become much more accepted as a treatment for many types of chronic pain in adults including arthritis,” says Dr. Kimura. “Some pediatric rheumatologists who have been using long-acting opioids in children with residual pain have seen beneficial results without a lot of side effects.”
Dr. Kimura is conducting a pilot study on pain treatment for kids with JA using an opioid called methadone. Five-year-old Chandler Leskovar of Plainfield, Ill., who has had JA since he was 16 months old, participated in the study and his mother, Kim, saw great results. “He was happier, more willing to try new things, more mobile, slept better and had more confidence in school because he wasn’t afraid to be around kids for fear of getting bumped.”
Non-medication methods can offer wonderful results too and include physical therapy with a therapist who has experience working with kids and can make therapy fun. Biofeedback and hypnotherapy teach kids to alter pain signals. In biofeedback, a therapist uses a computer or other feedback device to teach the child how to change body functions associated with stress.
Hypnotherapy uses children’s imaginations to teach them to calm their nervous systems and release stress and pain. Massage therapy, which parents can learn to do with their kids, is very helpful in increasing circulation to the joints and in releasing strain and tension that may be in many parts of their bodies. Cognitive behavior therapy teaches kids to reduce feelings of anxiety and to calm themselves.
Dr. Zeltzer recommends a particular type of yoga, called Iyengar yoga that is very beneficial for people with arthritis. These non-medication strategies are not used consistently according to McGrath. “Often people try something then give it up because it didn’t take the pain away immediately. If they gave it a chance they might find it would work.”
Always keep in mind that other factors in your child’s life may exacerbate their pain. “Children are developing and maturing,” says McGrath. “How they handle what gets thrust at them socially, sport-wise and academically is constantly changing and the demands are increasing.” Remain a positive support to your child through it all.
Parents can help
Dr. Zeltzer, author of Conquering Your Child’s Chronic Pain, offers the following suggestions to parents:
- Stay calm if your child is in pain. If you get visibly worried, your child will get anxious and that’s going to make the pain worse.
- Don’t ask how your child’s pain is as you’ll make the child focus on their pain.
- Help your child stay calm by taking 10 slow breaths together. “That can actually change their stress hormones and reduce pain signals,” says Dr. Zeltzer.
- Distract your child from their pain.
- Keep them busy with an activity, board game, TV show, good book or computer game.
- Help your child imagine being some place fun or envisioning protective colors around their joints that soothe and heal.
- Use heat or ice, or give your child a massage.
Source: Kids Get Arthritis Too, Arthritis Foundation. For more articles from this newsletter, visit www.arthritis.org/ja-kgat.
Gary, for My Daughter Kylee
My daughter Kylee was diagnosed with Polyarticular Juvenile Idiopathic Arthritis in December 2009. She is currently on 25 mgs of Methotrexate by injection once a week. Also, 740 mgs of Naproxen (slow release) and 2000 MGs of Tylenol(rappid release) and 2 mgs of Folic Acid each day. She is experiencing a lot of joint pain, and cannot sleep at night. Her Rhuematoligist has just prescribed 20 mgs. of Prednisone daily to help with the pain, but so far we see little or no relief. This is very discouraging. Does anyone out there have any suggestions, and does anyone else have any experience personally or working with family members with JRA??? Any other information would be helpful and useful for use and with her schooling. Thanks