Champions for Children: Meet George and Greta

Everyone experiences pain differently and there are many ways to manage pain. For children living with chronic pain, the cause and effects can vary greatly.  

To learn more about chronic pain and how patients at the RCH are treated, we had a chat with Assoc Professor George Chalkiadis and Assoc Professor Greta Palmer from the RCH’s Children’s Pain Management Service (CPMS).

Tell us a bit about the work you do …

The RCH Children’s Pain Management Service helps children and their carers to improve disability, quality of life (including sleep), engagement with their family and the world beyond (particularly school attendance) and to manage their pain to function to the best of their ability.

The CPMS Team comprises clinicians from medical (George and Greta, a pain fellow and a hypnotherapist), psychology, child and adolescent psychiatry, physiotherapy and occupational therapy backgrounds with a clinic coordinator, secretarial and administration support.

How did you get involved in the pain space?

George: I started my anaesthesia training in the UK. One of the UK units had a strong interest in acute and chronic pain management and I would attend their clinics and was inspired by how they could improve the quality of life of patients with chronic pain.

Greta: I first worked with a multidisciplinary team focusing on holistic patient care as a junior rehabilitation doctor. In my anaesthesia training, I became versed in medications and interventions to relieve pain. I then pursued further training in the pain space doing fellowships in the USA with pain gurus in New York and at Boston Children’s Hospital where I learnt to advocate for the patients in achieving realistic goals.

What does chronic pain look like in children and how is it diagnosed?

Chronic pain has a widely different look for children and adults alike. The diagnoses vary in nature from musculoskeletal to nerve memory (nociplastic) or nerve irritation or damage (neuropathic). Our CPMS patients have significant functional impairment in physical, school, sleep, emotional, family and friendship domains.

Examples of chronic pain conditions in children include sport related injuries, dysplasias, back pain or as a consequence of surgery, amputation or cancer, chronic daily headache, recurrent abdominal pain/irritable bowel syndrome, chronic widespread pain or fibromyalgia, complex regional pain syndrome or other conditions such as pain amplification or somatoform pain disorder.

When does acute pain become chronic pain in children? And are there preventative measures to stop this from occurring?

By definition, acute pain becomes chronic if it persists beyond three months. However, some persistent pain conditions are evident before then. Pain can also be recurrent or relapsing. Preventative measures are a big focus of pain research and the medications used have been summarised in Acute Pain Management Scientific Evidence, a book that Greta has edited. One of the main measures is working out who are the ‘at-risk’ patients and intervening early. Patients who are worriers or catastophisers are at higher risk following surgery, injury or an initial or recurrently painful condition and they may share these traits with their family. There are also certain surgical procedures that are more likely to result in persistent pain.

The focus of wellbeing for all (physical, psychological and emotional), and raising children ‘with resilience and skills to deal with any of life’s challenges in the marathon of life’ are important in prevention, along with learning that chronic pain is sending the body the wrong message in telling it ‘to STOP’.

However, it is not so simple. There are many conditions that result in persistent pain because the underlying condition is progressive and cannot be cured. In those situations, our emphasis is on how to manage pain most effectively and optimise a child’s functioning, whilst acknowledging we might never cure the problem that is contributing to their pain.

The best approach to managing chronic pain is a multidisciplinary approach. What does this look like at the RCH?

The reason why a biopsychosocial multidisciplinary approach works best is because individuals are made up of many parts and chronic pain affects many aspects of their lives. Each discipline in the team helps the child with chronic pain with making little or big changes “to strengthen every spoke in their umbrella so it can be carried and holds up better against the rain of pain”.

The first step is a comprehensive pain biopsychosocial assessment of the child’s persistent pain to determine what aspects need to be addressed to optimise function.

This is achieved with combinations of medication; education; exercise; school liaison; sensory regulation; distraction tools, relaxation, sleep and screen hygiene, meditation and self-hypnosis training; and review of thoughts and beliefs around the meaning of chronic pain.

The child has to do most of the work and they and their carers “need to be ready to change” so that the pain no longer controls the child stopping them from doing what they want in life and they become more in charge and better able to manage their chronic pain.

What surprises people most about pain in children?

The acute, subacute, procedural, recurrent or chronic pain experience is not surprising in that it is different for everyone.

Children can surprise us every day. The best feedback we get as a team is seeing these children employ their acquired skills to do something that was previously impossible for them. This varies from having an IV inserted, getting through post-surgery rehabilitation that they were dreading or a photograph or email from the child with chronic pain who has achieved a bucket list item – like sleeping in their own bed, getting to school full time/achieving an academic goal, attending a school excursion or camp, participating in sport or getting their new bike that they can now ride.

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