Tools to help navigate childhood pain
Physiotherapists have access to a tool that can be used to motivate families despite the overwhelming challenge and distress of childhood chronic pain, writes Rebecca Fechner.
It is well known that the gold standard for chronic pain management for adults and children involves biopsychosocial care in multidisciplinary teams (Harrison et al 2019).
Deconditioning is a common aspect of pain presentations due to withdrawal from participation in activities such as school, sport and leisure. Physiotherapists are vital team members for assessment and treatment of deconditioning, which has been traditionally performed with a focus on reconditioning ﬁtness, strength and endurance, as well as biomechanical factors such as improving range of motion.
However, with young people, this approach overlooks the importance of re-establishing the achievement of motor proﬁciency milestones, which include a complex interplay of sensory processing, body awareness, coordination, agility and ﬁne tuning of the balance system. These represent critical aspects of normal child and adolescent development, which have often gone awry in pain presentations in childhood and interfere with ongoing developmental trajectory.
It has been shown that unresolved pain disorders in childhood and adolescence incur a high risk for pain disorders, physical issues and mental health problems in adulthood (Noel et al 2016). Development is a dynamic process that occurs through engagement in activity and motor function which promotes cognitive and perceptual development (Piek et al 2006). When a child’s attainment of expected motor proﬁciencies is interrupted due to pain, such as through withdrawal from activity, physical delays can become part of the problem. This can lead to clear long-term side-effects in all domains of functioning, including social, cognitive, emotional, sensory and physical domains. It is easy to imagine how this could snowball and affect a young person’s participation in activities that would further influence their development. As such, assessing motor proﬁciency delays either as a consequence or precursor to persistent pain is important to re-establishing normal developmental trajectories and thus reducing the long-term effects of pain disorders.
In order to assess motor proﬁciency in this group of vulnerable young people, I propose the use of a developmental assessment tool with age-norm referenced data. This could allow physiotherapists and their colleagues to positively impact the developmental trajectories of young people who may otherwise be susceptible to the long-term effects of delayed milestone achievement into adulthood. The ﬁrst step in this process is the implementation of an appropriate assessment tool with age-norm referenced data into current models of care. This would form part of a suite of allied health measures that accurately quantify and monitor improvements over time.
The Queensland Interdisciplinary Paediatric Persistent Pain Service has implemented the Bruininks-Oseretsky Test of Motor Proﬁciency, Second Edition (BOT-2) as part of an initial assessment tool for young people engaging in allied health interventions for persistent pain. The BOT-2 is a validated tool with high test–retest and inter-rater reliability (Grifﬁths et al 2018). It measures gross and ﬁne motor performance, including measurements of ﬁne manual control, manual coordination, body coordination and strength and agility for people aged four to 21 years (Bruininks & Bruininks 2005). This tool identiﬁes motor proﬁciency delays at assessment to assist the team in developing an ongoing formulation for the chronic pain experience and hence, guide treatment approaches for the team.
I foresee that the utility of the BOT-2 will be threefold and set the scene for rich research opportunities. Firstly, sharing the results of the BOT-2 with families will increase investment in treatment. Parents can be reluctant to challenge their children to participate in activities if the child is experiencing pain and distress, or if the activities are perceived to exacerbate pain. Given that treatment of chronic pain is counterintuitive, and children must engage in challenging activities to improve their function and pain experience, motivation is critical.
It has been my experience that if delays and their potential long-term impact can be demonstrated tangibly to parents, such as with age- norms, their motivation to participate in therapy increases. Despite the challenge of therapy, parents can be more easily recruited as ‘co-therapists’ working towards the shared goal of resuming the individual’s developmental trajectory, through graded exposure to developmentally appropriate and challenging activities.
Secondly, identiﬁcation of reduced proﬁciency in speciﬁc domains may help to target more speciﬁc interventions. Allied health teams can verify whether interventions are achieving biopsychosocial goals and positively influencing developmental trajectories.
Thirdly, as the BOT-2 is sensitive to developmental conditions such as developmental coordination disorder (DCD), it may assist in identifying common precursors to paediatric pain conditions or comorbidities otherwise potentially dismissed such as DCD, particularly in middle-school-age children. This could allow treating teams to have more speciﬁc data to refer to appropriate paediatric teams if treatment interventions do not make clinical change to BOT- 2 scores.
Finally, I am hopeful that if practitioners use a consistent tool such as the BOT-2 across paediatric pain settings throughout the world, we will have opportunities for collaborations and research drawn from rich objective data.
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Rebecca Fechner, APAM, is a senior physiotherapist with the Queensland Interdisciplinary Paediatric Persistent Pain Service at Queensland Children’s Hospital in South Brisbane. To discuss the ideas raised in this article further, email rebecca.fechner@ health.qld.gov.au.
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