I AM CATHERINE LAW, DIRECTOR OF
COMMUNICATIONS AT THE NATIONAL
CENTER FOR COMPLEMENTARY AND
INTEGRATIVE HEALTH, OR NCCIH, AT
THE NATIONAL INSTITUTES OF
HEALTH.
I WANT TO WELCOME YOU
TO THE LATEST PRESENTATION IN
NCCIH’S INTEGRATIVE MEDICINE
RESEARCH LECTURE SERIES.
TODAY’S LECTURE, "NEW INSIGHTS
INTO PREVENTION AND MANAGEMENT
OF CHRONIC PAIN IN CHILDREN AND
ADOLESCENTS," IS PRESENTED BY
DR. TONYA PALERMO FROM THE
UNIVERSITY OF WASHINGTON.
I AM NOW PLEASED TO INVITE
DR. DAVID SHURTLEFF, DEPUTY
DIRECTOR OF NCCIH, TO INTRODUCE
OUR SPEAKER.
AND I ALSO WANT TO NOTE THAT WE
ARE JOINED TODAY BY DR. HELENE
LANGEVIN, DIRECTOR OF NCCIH, AND
DR. EMILY EDWARDS, DIRECTOR OF
OUR DIVISION OF EXTRAMURAL
RESEARCH HERE AT NCCIH.
WE'RE PLEASED TO HAVE ALL OF
THEM WITH US AS WE HEAR
DR. PALERMO'S LECTURE.
DR. SHURTLEFF, PLEASE TAKE IT
AWAY.
>>WELL, THANK YOU, CATHERINE,
AND WELCOME, EVERYONE, TO THE
SECOND OF TWO LECTURES IN OUR
SPRING 2023 SEASON IN THE
INTEGRATIVE MEDICINE LECTURE
SERIES HERE SPONSORED BY NCCIH.
TODAY WE'RE DELIGHTED TO WELCOME
DR. TONYA PALERMO WHO WILL SPEAK
ON NEW INSIGHTS INTO PREVENTION
AND MANAGEMENT OF CHRONIC PAIN
IN CHILDREN AND ADOLESCENTS.
JUST A NOTE, DR. PALERMO'S TOPIC
REFLECTS AT LEAST A COUPLE
CURRENT AREAS OF INTEREST AT
NCCIH.
THE FIRST INCLUDES OUR INTEREST
IN SYMPTOM MANAGEMENT, INCLUDING
NON-PHARMACOLOGICAL APPROACHES
TO MANAGE AND TREAT OR PREVENT
CHRONIC PAIN.
CLEARLY A PUBLIC HEALTH CRISIS
IN THE UNITED STATES.
IT AFFECTS 18% OF U.S. ADULTS,
HAVE CHRONIC PAIN, ABOUT
40 MILLION U.S. ADULTS IN THE
UNITED STATES.
AND AS WE WILL LEARN FROM
DR. PALERMO, CHRONIC PAIN
AFFECTS UP TO 40% OF CHILDREN
AND ADOLESCENTS WORLDWIDE,
CLEARLY A GLOBAL HEALTH EPIDEMIC
IN SOME RESPECTS.
OPIOIDS AND DRUGS CAN BE
EFFECTIVE IN SOME CASES, BUT AS
WE ALL KNOW, THEY CARRY RISKS
AND CAN HAVE ADVERSE EFFECTS,
INCLUDING OVERDOSE AND DEATH.
OTHER OPTIONS ARE NEEDED,
INCLUDING NON-PHARMACOLOGIC,
BEHAVIORAL INTERVENTIONS THAT
ADDRESS THIS PUBLIC HEALTH
CRISIS, AND I KNOW DR. PALERMO
WILL GIVE US MORE INFORMATION ON
THIS VERY TOPIC.
TODAY'S TOPIC IS ALSO RELATED TO
NCCIH'S INTEREST IN RESILIENCE
IN THE CONTEXT OF THIS LECTURE,
RESILIENCE CAN BE DEFINED AS THE
CAPACITY TO ADAPT, RECOVER,
BOUNCE BACK OR GROW FROM A
PAINFUL INJURY OR DISEASE.
AND WE ALL KNOW RESILIENCE
INVOLVES MANY FACTORS COVERED
UNDER THE NCCIH OVERARCHING
FRAMEWORK OF WHOLE PERSON HEALTH
RESEARCH.
THOSE FACTORS INCLUDED IN THE
FRAMEWORK INCLUDE AN
INDIVIDUAL'S SOCIAL SUPPORT
SYSTEM, COMMUNITY AND
CONNECTION, EMOTIONAL AND
BEHAVIORAL FLEXIBILITY, AND AN
INDIVIDUAL'S MOLECULAR,
CELLULAR, PHYSIOLOGICAL AND
ORGAN SYSTEMS WITHIN THE WHOLE
PERSON.
YOU CAN FIND OUT MORE ABOUT
WHOLE PERSON HEALTH RESEARCH AND
OUR INTERESTS IN INTEGRATING
ACROSS SYSTEMS AND DISCIPLINES
ON OUR WEBSITE, AND IN OUR
STRATEGIC PLAN.
NOW IT'S MY GREAT PLEASURE TO
INTRODUCE AND WELCOME DR. TONYA
PALERMO, PROFESSOR AND VICE
CHAIR OF RESEARCH IN THE
DEPARTMENT OF ANESTHESIOLOGY AND
PAIN MEDICINE.
SHE'S ALSO THE HUGHES M. AND
KATHERINE BLAKE ENDOWED
PROFESSOR IN HEALTH PSYCHOLOGY
AND AN ADJUNCT PROFESSOR OF
PEDIATRICS AND PSYCHIATRY.
DR. PALERMO ALSO HOLDS
APPOINTMENTS AT SEATTLE
CHILDREN'S RESEARCH INSTITUTE,
AS ASSOCIATE DIRECTOR OF THE
CENTER FOR CHILD HEALTH,
BEHAVIORAL AND DEVELOPMENT AND
DIRECTOR OF THE PEDIATRIC PAIN
AND SLEEP INNOVATIONS LAB.
SHE'S EDITOR-IN-CHIEF OF A
JOURNAL WE ALL KNOW WELL, THE
JOURNAL OF PAIN, AND DR. PALERMO
COMPLETED HER UNDERGRADUATE
TRAINING IN PSYCHOLOGY AT THE
UNIVERSITY OF CALIFORNIA
LOS ANGELES, UCLA, AND HER PH.D.
IN CLINICAL PSYCHOLOGY AT CASE
WESTERN RESERVE UNIVERSITY.
IN ADDITION TO OVER 300 ARTICLES
IN PEER REVIEWED JOURNALS,
DR. PALERMO HAS AUTHORED TWO
BOOKS MANAGING YOUR CHILD'S
CHRONIC PAIN, AND COGNITIVE
THERAPY FOR CHRONIC PAIN IN
CHILDREN AND ADOLESCENTS.
MANY NIH INSTITUTES AND CENTERS
HAVE FUNDED HER RESEARCH,
INCLUDING THE EUNICE KENNEDY
SHRIVER NATIONAL INSTITUTE ON
CHILD HEALTH AND HUMAN
DEVELOPMENT, THE NATIONAL
INSTITUTE ON GENERAL MEDICAL
SCIENCES, THE NATIONAL INSTITUTE
OF DIABETES AND DIGESTIVE AND
KIDNEY DISEASES, AND THE
NATIONAL INSTITUTE OF
NEUROLOGICAL DISORDERS AND
STROKE.
SO NOW I WANT TO WELCOME YOU
AGAIN, DR. PALERMO, AND I'LL
TURN THE MIC OVER TO YOU.
THANK YOU.
>>THANK YOU SO MUCH FOR THE
NICE INTRODUCTION, AND FOR THE
INVITATION TO PRESENT TODAY.
IT'S A PLEASURE AND OPPORTUNITY
TO SHARE MY WORK ON PREVENTION
AND MANAGEMENT OF CHRONIC PAIN
IN CHILDREN AND
ADOLESCENTS.
THIS SHOWS MY DISCLOSURES.
AS MENTIONED MY SUPPORT FROM
NATIONAL INSTITUTES OF HEALTH AS
WELL AS ROYALTIES THROUGH OXFORD
UNIVERSITY PRESS.
MY GOAL TODAY IS TO ANSWER THESE
FOUR QUESTIONS: WHY DOES PAIN
IN CHILDREN MATTER?
DO CHILDREN GROW OUT OF PAIN?
CAN WE PREVENT PAIN AND CHRONIC
DISABILITY?
AND, WHAT IS THE ROLE OF
PSYCHOLOGICAL INTERVENTIONS?
TO BEGIN TO ADDRESS WHY PAIN IN
CHILDREN MATTERS, IT'S IMPORTANT
TO UNDERSTAND SOME EPIDEMIOLOGY
OF PEDIATRIC CHRONIC PAIN.
GLOBALLY, A HIGH PREVALENCE OF
ADOLESCENTS DESCRIBE CHRONIC
WEEKLY PAIN, OVER 40%.
IF WE EXAMINE ESTIMATES THAT
INCLUDE A DEFINITION OF HAVING
PAIN THAT'S ACCOMPANIED BY
MODERATE TO SEVERE DISABILITY,
THE ESTIMATES ARE ABOUT 5 TO 8%
OF YOUNG PEOPLE.
WE KNOW THAT THE MOST COMMON
TYPE OF PAIN IN CHILDHOOD IS A
PRIMARY PAIN CONDITION INVOLVING
THESE LOCATIONS HERE, THE HEAD,
THE ABDOMEN AND MUSCULOSKELETAL
LOCATIONS.
BUT CHILDREN ALSO HAVE
DISEASE-RELATED PAIN.
WE KNOW SIMILAR TO ADULTS THAT
MULTIPLE BODILY LOCATIONS OF
PAIN ARE QUITE COMMON.
THIS IS TRUE IN CHILDHOOD, WHERE
MANY CHILDREN HAVE MORE THAN ONE
SITE OR LOCATION OF PAIN.
AND DURING CHILDHOOD, THERE'S A
PEAK RISE POST PUBERTY IN THE
ONSET OF CHRONIC PAIN, WHERE WE
ALSO SEE THAT GIRLS HAVE A
GREATER INCIDENT OF MOST FORMS
OF CHRONIC PAIN, AND THE
MECHANISMS THAT ACCOUNT FOR THE
CHANGES DURING PUBERTY THAT
MIGHT ACCOUNT FOR THIS ARE NOT
WELL UNDERSTOOD, BUT IS AN
IMPORTANT AND ACTIVE AREA OF
RESEARCH.
PAIN IN CHILDREN ALSO MATTERS
BECAUSE PAIN CAN IMPACT MANY
ASPECTS OF EVERYDAY LIVING FOR
CHILDREN, INCLUDING THEIR
ABILITY TO ATTEND SCHOOL, TO
PERFORM AT SCHOOL, THEIR SOCIAL
FUNCTIONING, THEIR PHYSICAL
ACTIVITIES, THEIR ABILITY TO
SLEEP, AS WELL AS PSYCHOLOGICAL
AND BEHAVIORAL FUNCTIONING.
PAIN IN CHILDREN MATTERS BECAUSE
IT ALSO IMPACTS PARENTS AND
FAMILIES.
WE KNOW THAT PARENTS DESCRIBE A
HIGH LEVEL OF BURDEN IN CARING
FOR A CHILD WITH CHRONIC PAIN.
THEY CAN EXPERIENCE THEIR OWN
FEELINGS AND SYMPTOMS OF
DEPRESSION AND ANXIETY, AS WELL
AS ANGER AND HOSTILITY.
PARENTS REPORT FEELINGS OF BEING
BLAMED BY HEALTHCARE
PROFESSIONALS.
AND THEY REPORT A SENSE OF
ISOLATION AND A LACK OF SOCIAL
SUPPORT.
PARENTS ALSO DESCRIBE A
FINANCIAL BURDEN, WHERE THEY
INCUR A HIGH LEVEL OF OUT OF
POCKET COST IN CARING FOR A
CHILD WITH CHRONIC PAIN.
INDEED, ESTIMATES OF PEDIATRIC
CHRONIC PAIN DEMONSTRATE THAT
PAIN IS COSTLY.
THIS IS WORK DONE IN MY LAB WHO
EXPLAINED HEALTHCARE
EXPENDITURES ASSOCIATED WITH
PEDIATRIC PAIN RELATED
CONDITIONS, INCLUDING ADHD,
ASTHMA AND OBESITY.
AS YOU CAN SEE IN THE RED BAR,
EXPENDITURES FOR PAIN-RELATED
CONDITIONS ARE MUCH HIGHER
COMPARED TO OTHER CONDITIONS.
AS I'LL SHOW YOU IN A MOMENT, IF
WE THINK ABOUT THE POTENTIAL FOR
COST TO COMPOUND OVER THE
LIFESPAN, THAT IF CHILDREN
CONTINUE WITH CHRONIC PAIN INTO
ADULTHOOD, THAT THESE COSTS WILL
CONTINUE.
WE ALSO KNOW THAT THERE ARE
DISPARITIES IN THE MANAGEMENT OF
CHILDREN'S PAIN BY RACE,
ETHNICITY AND OTHER FACTORS.
THIS IS A STUDY FROM COLLEAGUES
AT UNIVERSITY OF WASHINGTON
INCLUDING EMILY LAW WHO'S IN MY
LAB, LOOKING SPECIFICALLY AT
MANAGEMENT OF MIGRAINE IN THE
EMERGENCY DEPARTMENT, AND WHAT
THEY FOUND IS THAT CHILDREN FROM
UNDERREPRESENTED RACIAL AND
ETHNIC GROUPS AND THOSE WHOSE
PARENTS HAD NON-ENGLISH LANGUAGE
OF CARE WERE LESS LIKELY TO
RECEIVE BEST PRACTICE MIGRAINE
TREATMENT IN THE EMERGENCY
DEPARTMENT.
UNFORTUNATELY, THIS IS NOT
ISOLATED TO MANAGEMENT OF
MIGRAINE ONLY, BUT WE KNOW THAT
THIS IS PART OF A PATTERN THAT'S
BEEN OBSERVED WITH HAVING
DIFFERENCES IN THE MANAGEMENT OF
PAIN THAT'S BEEN IGNORED FOR
CHILDREN OF COLOR.
SO WE KNOW PAIN IN CHILDREN HAS
NOT MATTERED ENOUGH.
THIS IS SHOWN BY EVIDENCE OF
COMMON FAILINGS IN PROVIDING
ADEQUATE OR APPROPRIATE PAIN
RELIEF IN CLINICAL PRACTICE.
THIS HAS BEEN SEEN AS A REAL
UNDERTROOTMENT OFTREATMENT OF PN
CHILDREN.
THIS MAY BE BECAUSE PAIN IS
EXPECTED TO BE TRANSITORY DURING
CHILDHOOD, OR WE DON'T
APPRECIATE THE IMPACT IT HAS
LONG TERM.
THERE'S ALSO AN ABSENCE OF
CHILDREN'S VOICE.
CHILDREN DON'T HAVE THE SAME
OPPORTUNITY AS ADULTS TO BE
HEARD AROUND THEIR PAIN
MANAGEMENT.
THERE'S BEEN A LACK OF
INVESTMENT IN RESEARCH AND
SERVICES DEVOTED TO CHILDREN'S
PAIN MANAGEMENT, AND INEQUITIES
IN ACCESS TO EVIDENCE-BASED PAIN
CARE FOR ALL CHILDREN.
THIS HAS LED TO SOMEWHAT OF AN
EXCLUSION FROM THE BROADER
NARRATIVE REGARDING THE PUBLIC
HEALTH IMPACT OF PAIN IN WHICH
MOST OF THE FOCUS HAS BEEN ON
ADULT CHRONIC PAIN.
THIS SLIDE SHOWS A GRAPHIC FROM
THE COMMISSION I HAD AN
OPPORTUNITY TO CONTRIBUTE TO LED
BY CHRIS ECCLESTON.
IT ALSO IS ORGANIZED AROUND FOUR
TRANSFORMATIVE GOALS THAT, IF
THEY WERE TO BE ACHIEVED, WOULD
MAKE A TREMENDOUS DIFFERENCE IN
THE MANAGEMENT OF CHILDREN'S
PAIN.
AND THE FOUNDATIONAL GOAL IS
REALLY MAKING PAIN MATTER, AND
THAT IS THE EMPHASIS THAT I WANT
TO PUT ON THE TALK TODAY,
BECAUSE IF WE -- WE REALLY NEED
TO DEMONSTRATE THAT PAIN MATTERS
TO ALL STAKEHOLDERS, TO HEALTH
PROFESSIONALS, TO POLICY MAKERS,
FUNDERS, RESEARCHER, CLINICIANS
AND SOCIETY AT LARGE SO THAT WE
CAN ACHIEVE THESE OTHER GOALS OF
MAKING PAIN UNDERSTOOD, MAKING
PAIN VISIBLE, AND MAKING PAIN
BETTER.
SO ONE ASPECT OF THE MYTH THAT I
THINK HAS LED TO UNDERTREATMENT
OF PAIN IN CHILDREN THAT I WANT
TO DISCUSS TODAY IS THAT
CHILDREN HAD HISTORICALLY BEEN
THOUGHT TO GROW OUT OF PAIN AND
THE IDEA WAS THAT PAIN USUALLY
RESOLVES DURING CHILDHOOD.
THERE HAVE BEEN, OVER THE LAST
10, 15 YEARS, SOME REALLY GOOD
EVIDENCE THAT THIS IS NOT THE
CASE, THAT INDEED, CHILDREN
OFTEN CONTINUE TO HAVE PAIN INTO
ADULTHOOD.
THIS IS ONE OF THE FIRST STUDIES
THAT CAME OUT OF LYNN WALKER'S
GROUP AT VANDERBILT FOCUSED ON
FUNCTIONAL ABDOMINAL PAIN IN
CHILDHOOD AND THE RISK FOR NOT
ONLY CONTINUED ABDOMINAL PAIN
BUT OTHER FORMS OF CHRONIC PAIN
IN ADULTHOOD.
WHAT THEY FOUND IS THAT 35% OF
PATIENTS WITH FUNCTIONAL
ABDOMINAL PAIN HAD A
CONTINUATION OF THESE SAME
SYMPTOMS WHEN THEY WERE ADULTS,
BUT IMPORTANTLY, A LARGE
SUBGROUP ALSO HAD OTHER FORMS OF
CHRONIC PAIN, INCLUDING HEADACHE
AND OTHER SITES OF NON-ABDOMINAL
PAIN.
THERE WAS ALSO AN INCREASED RISK
FOR ANXIETY AND DEPRESSION IN
ADULTHOOD.
SIMILARLY, KASHIKAR-ZUCK AND
COLLEAGUES ALSO EXAMINED LONG
TERM OUTCOMES OF ADOLESCENTS
WITH JUVENILE-ONSET
FIBROMYALGIA.
THEY HAD A VERY HIGH RATE OF
CONTINUATION OF SYMPTOMS INTO
ADULTHOOD WITH ALMOST 60%
CONTINUING TO MEET CRITERIA FOR
FIBROMYALGIA AND THEY ALSO
EXPERIENCED A WORSENING OF
DEPRESSIVE SYMPTOMS FOR A
SUBGROUP OF THE COHORT.
SO PAIN DOES NOT SEEM TO GO AWAY
ON ITS OWN.
WE KNOW THAT IT CONTINUES FOR
MANY ADOLESCENTS AND YOUNG
ADULTS.
ANOTHER WAY OF EXAMINING THIS
EVIDENCE IS TO THINK ABOUT WHAT
IS THE PREVALENCE SPECIFICALLY
IN THE YOUNG ADULT AGE RANGE TO
FILL IN THIS GAP OF KNOWLEDGE
BETWEEN A PEDIATRIC LITERATURE
AND THE ADULT LITERATURE.
CAITLIN MURRAY UNDERTOOK THIS
SYSTEMATIC REVIEW OF
META-ANALYSIS WHERE SHE LOOKED
AT THE PREVALENCE ESTIMATES OF
THE VARIOUS FORMS OF CHRONIC
PAIN IN YOUNG ADULTS, AGES 18 TO
29 YEARS.
AND WHAT SHE FOUND ACROSS 43
STUDIES WAS THAT THE PREVALENCE
OF CHRONIC PAIN IN YOUNG ADULTS
SPECIFICALLY WAS 12%, WHICH IS
SIMILAR TO ADULT ESTIMATES.
AND SHE ALSO FOUND THAT THERE
WERE SOME CONDITIONS FOR WHICH
THERE ARE NO PREVALENCE
ESTIMATES IN YOUNG ADULTS, SO I
IDENTIFIED SOME GAPS IN
KNOWLEDGE.
CAITLIN ALSO ASKED SOME
QUESTIONS ABOUT WHAT ARE THE
ACTUAL LONG-TERM OUTCOMES IN A
POPULATION-BASED SAMPLE WHO HAD
CHRONIC PAIN IN ADOLESCENCE.
AND SHE HAS A HEALTH DATASET TO
HELP ANSWER THE QUESTION WHETHER
OR NOT WHAT HAPPENS DURING THIS
IMPORTANT TRANSITION.
WE KNOW THAT DURING ADOLESCENCE
AND YOUNG ADULTHOOD, MANY
CHANGES OCCUR.
THIS IS WHEN NEXT STEPS IN
EDUCATION AND EMPLOYMENT ARE
TAKEN, THIS IS ALSO IMPORTANT
SOCIALLY IN TERMS OF
RELATIONSHIP DEVELOPMENT.
SO IN THIS DATASET, THERE WAS
3,000 YOUTH WHO HAD CHRONIC PAIN
DURING ADOLESCENCE, WHEN THEY
WERE 11 TO 17 YEARS, AND 11,600
THAT DID NOT HAVE CHRONIC PAIN
IN ADOLESCENCE.
AND IN COMPARING WHAT THEIR
OUTCOMES WERE DURING THE YOUNG
ADULT YEARS FROM AGES 24 TO
32 YEARS, WHAT THEY FOUND WAS
THAT IN TERMS OF EDUCATION, IF
YOU HAD ADOLESCENT CHRONIC PAIN,
YOU WERE LESS LIKELY TO RECEIVE
EITHER A HIGH SCHOOL DIPLOMA OR
A BACHELOR'S DEGREE BY THE TIME
YOU WERE A YOUNG ADULT.
IN TERMS OF VOCATIONAL
FUNCTIONING, THERE WERE ALSO
IMPACTS SHOWING IN TERMS OF
LOWER LIKELIHOOD OF RECEIVING
EMPLOYER-PROVIDED INSURANCE
BENEFITS, INDICATING A LESS
STABLE FORM OF EMPLOYMENT, AND
AN INCREASED LIKELIHOOD OF
RECEIVING PUBLIC ASSISTANCE OR
DISABILITY FOR THOSE WHO HAD
ADOLESCENT CHRONIC PAIN COMPARED
TO THOSE WHO DID NOT.
AND IN TERMS OF SOCIAL OUTCOMES,
THERE WERE ALSO EFFECTS SEEN
WITH EARLIER PREGNANCY AND
PARENTHOOD AS WELL AS LIKELIHOOD
OF HAVING LOWER RELATIONSHIP
SATISFACTION IN THE PRESENCE OF
ADOLESCENT CHRONIC PAIN.
SO TAKEN TOGETHER, WE'RE SEEING
REALLY IMPORTANT RISK OF
NEGATIVE DEVELOPMENTAL OUTCOMES
ACROSS A RANGE OF ASPECTS OF
YOUNG ADULT LIFE.
SO ONE HYPOTHESIS WE HAD WAS
THAT PERHAPS YOUNG ADULTS AREN'T
CONTINUING TO RECEIVE CARE FOR
THEIR CHRONIC PAIN DURING THIS
TRANSITION PERIOD.
WE KNOW THAT IN OTHER
POPULATIONS AS WELL, AND EVEN
AMONG HEALTHY YOUNG ADULTS, THAT
THE RATE OF MEDICAL CARE IS
LOWER IN THIS AGE GROUP.
WE ALSO FOUND IN THIS MIXED
METHODS STUDY THAT 42% OF OUR
SAMPLE WHO HAD RECEIVED
INTERDISCIPLINARY PAIN CARE
DURING CHILDHOOD, DURING THIS
TRANSITION TO YOUNG ADULTHOOD,
42% WERE NOT ENGAGED TO ANY FORM
OF HEALTHCARE FOR THEIR PAIN
MANAGEMENT, SO INDEED THERE DOES
SEEM TO BE A DROPOFF IN
RECEIVING CARE FOR CHRONIC PAIN
DURING THE YOUNG ADULT YEARS.
IN QUALITATIVE INTERVIEWS, YOUNG
ADULTS ALSO IDENTIFIED SEVERAL
BARRIERS TO TRANSITION,
INCLUDING HAVING LOW PREPARATION
FROM THEIR PEDIATRIC PAIN
PROVIDERS, AND ALSO HAVING SOME
NEGATIVE PATIENT-PROVIDER
RELATIONSHIPS IN ADULT CARE.
THEY ALSO IDENTIFIED SOME
FACILITATORS OF HEALTHCARE
TRANSITION, INCLUDING HAVING
INCREASED SELF-EFFICACY AROUND
THEIR PAIN MANAGEMENT DURING
CHILDHOOD, AS WELL AS ACCEPTANCE
OF PAIN.
SO WE KNOW THAT PAIN DURING
CHILDHOOD MATTERS, BUT IT IS
IMPORTANT FOR THE LIFESPAN, AND
THIS WAS A PAPER THAT REFLECTS
ON HOW CAN WE USE CHILDHOOD AS A
POINT OF EARLY IDENTIFICATION
AND TREATMENT TO PREVENT PAIN
AND DISABILITY, AND ALSO THE
CONTINUATION OF PAIN AND
NEGATIVE IMPACTS FROM CHILD TO D
TO ADULTHOOD.
THIS PAPER OF THE DEVELOPMENTAL
LIFESPAN MODEL OF PEDIATRIC
PAIN, WANT TO HIGHLIGHT THAT
THERE ARE A RANGE OF FACTORS,
INCLUDING EMOTIONAL FACTORS SUCH
AS MOOD, PAIN COPING, HEALTH
BEHAVIOR FACTORS SUCH AS SLEEP,
PHYSICAL ACTIVITY, AND SOCIAL
AND FAMILY FACTORS SUCH AS
PARENT BEHAVIOR OR FAMILY
FUNCTIONING IN AND PEER
RELATIONSHIPS.
THERE'S VULNERABILITIES AS WELL
AS RESILIENCY FACTORS WITHIN
EACH OF THESE DOMAINS THAT ARE
NOT ONLY IMPORTANT DURING
CHILDHOOD FOR UNDERSTANDING RISK
AND RESILIENCE AGAINST CHILDHOOD
CHRONIC PAIN, BUT ALSO HAVE
EVIDENCE FOR PREDICTING ADULT
OUTCOMES INCLUDING ADULT PAIN,
AS WELL AS DEVELOPMENTAL AND
HEALTH OUTCOMES.
ONE OF THE ADVANTAGES OF USING
LIFESPAN APPROACHES IS IT REALLY
CAN CONNECT THE PEDIATRIC
RESEARCH TO ADULTERY SEARCH, AND
HOPEFULLY ENCOURAGE THE TYPE OF
COLLABORATIONS THAT HELP US
UNDERSTAND REALLY WHAT CAN WE DO
TO PREVENT PAIN OVER THE
LIFESPAN.
SO MY BACKGROUND IS IN CLINICAL
PSYCHOLOGY AND I'VE USED KIND OF
BEHAVIORAL INTERVENTIONS FOR
CHRONIC PAIN BECAUSE IT REALLY
CAN TARGET THE DOMAINS THAT ARE
IMPORTANT IN CHRONIC PAIN
MANAGEMENT, INCLUDING THESE
EMOTIONAL SOCIAL FAMILY AND
HEALTH BEHAVIOR DOMAINS, AND WE
KNOW THAT THERE'S MANY DIFFERENT
INTERVENTIONS WITHIN COGNITIVE
BEHAVIORAL THERAPY FRAME WORKS.
THESE ARE BASED ON THEORIES OF
BEHAVIOR, COGNITION, EMOTION AND
SOCIAL LEARNING, DIFFERENT
ASPECTS CAN BE EMPHASIZED, AND
I'LL SHOW YOU SOME COMPONENTS
THAT WE'VE USED IN OUR WORK.
PSYCHOLOGICAL THERAPIES AS A
WHOLE HAS A PRETTY ROBUST
EVIDENCE BASE FOR THE MANAGEMENT
OF CHRONIC AND RECURRENT PAIN IN
CHILDREN AND ADOLESCENTS.
THIS WAS OUR COCHRANE REVIEW
THAT WE PUBLISHED ABOUT FIVE
YEARS AGO.
AT THAT TIME, THERE WERE
43 RANDOMIZED CONTROL TRIALS OF
PSYCHOLOGICAL TREATMENT.
MOST OF THESE WERE KIND OF
BEHAVIORAL THERAPY INTERVENTIONS
AND THERE WERE SMALL TO MODERATE
EFFECTS FOR REDUCING PAIN
INTENSITY AND FREQUENCY, AND
DISABILITY AND ANXIETY.
AT THIS TIME MOST OF THE
EVIDENCE WAS AT POST-TREATMENT
ONLY, AND THERE WERE MORE
LIMITED DATA ON THE LONGER TERM
IMPACT ON PSYCHOLOGICAL
THERAPIES FOR CHRONIC PAIN
MANAGEMENT.
SO DESPITE HAVING A ROBUST
EVIDENCE BASE, ONE OF THE
PRIMARY PROBLEMS IS THAT MOST
CHILDREN AND MOST COMMUNITIES
CANNOT RECEIVE ACCESS TO
PSYCHOLOGICAL TREATMENT FOR PAIN
MANAGEMENT.
THERE'S A REAL SHORTAGE OF
INTERDISCIPLINARY PAIN CLINICS
FOR CHILDREN.
THERE'S APPROXIMATELY ONE PER
STATE, SO FOR MANY FAMILIES
THERE'S A GREAT GEOGRAPHIC
DISTANCE TO CARE.
THERE'S ALSO STIGMA ASSOCIATED
WITH RECEIVING PSYCHOLOGICAL
TREATMENT THAT MAY PREVENT
ENGAGEMENT.
BECAUSE OF THE LIMITED NUMBER OF
CLINICS, THERE'S TYPICALLY LONG
WAITING LISTS.
THIS MAY BE THREE TO SIX MONTHS
IN MOST LOCATIONS, AND OUR OWN
GROUP AND OTHERS HAVE STUDIED
PATIENT FUNCTIONING WHILE
WAITING TO BE SEEN FOR PAIN
CLINIC, FINDING THAT PATIENT
FUNCTIONING OFTEN DETERIORATE.
SO THE REAL TAKE-HOME MESSAGE
WAS THAT ACCESSIBLE OPTIONS TO
PROVIDE THIS TYPE OF CARE ARE
URBURGENTLY NEEDED.
A LOT OF MY WORK USES DIGITAL
HEALTH TREATMENTS TO ADDRESS THE
PROBLEM OF ACCESSIBILITY.
THIS CAN BE DELIVERED IN A
VARIETY OF FORMATS.
STARTING WITH TELEHEALTH AND
TELEMEDICINE, WHICH WE SUE A SAA
HUGE INCREASE OF DURING THE
PANDEMIC.
THIS IS THE MOST RESTRICTIVE AND
STILL REQUIRES AN APPOINTMENT
WITH A HEALTHCARE PROFESSIONAL
TO MORE FLEXIBLE FORMS THAT ARE
SELF-GUIDED SUCH AS E-HEALTH OR
INTERNET INTERVENTIONS AND
M-HEALTH SMARTPHONE APPS.
THE PURPOSE IS VARIED.
IT CAN REPLACE IN-PERSON CARE,
IT CAN SUPPLEMENT IN-PERSON CARE
OR SERVE AS A BOOSTER OR
MAINTENANCE AFTER FINISHING AN
IN-PERSON PROGRAM.
I'VE WORKED FOR ABOUT 15 YEARS
ON DIGITAL HEALTH TREATMENTS FOR
PEDIATRIC CHRONIC PAIN.
EARLY ON WE DEVELOPED AN
INTERNET COGNITIVE BEHAVIORAL
THERAPY PROGRAM THAT WE CALLED
WEB-BASED MANAGEMENT OF
ADOLESCENT PAIN OR WEBMAP.
THIS WAS CO-DESIGNED WITH
ADOLESCENTS AND THEIR PARENTS,
AND WAS INTENDED TO PROVIDE BOTH
SKILLS TRAINING FOR THE CHILD
DIRECTLY AROUND SKILLS THAT
INCLUDE BOTH BEHAVIORAL DOMAINS
AS WELL AS COGNITIVE TYPES OF
INTERVENTIONS.
WE ALSO HAVE A BIG FOCUS ON
SLEEP AND PROMOTING PHYSICAL
ACTIVITY IN OUR INTERVENTIONS.
WE FELT IT WAS IMPORTANT FOR
PARENTS TO HAVE THEIR OWN
PROGRAM AND SPENT TIME WORKING
ON DEVELOPING A PROGRAM THAT
COULD FIT THE NEEDS OF PARENTS
AROUND COMMUNICATION, MODELING,
CHANGING BEHAVIORAL RESPONSES
AND SUPPORTING CHILDREN'S
SKILLS.
EARLY ON, WE WERE INTERESTED IN
JUST UNDERSTANDING THE
FEASIBILITY OF ENGAGING CHILDREN
AND FAMILIES IN THIS MODE OF
INTERVENTION DELIVERY AND FOUND
HIGH ACCEPTABILITY AROUND BOTH
PARENT AND CHILD INVOLVEMENT IN
THE INTERVENTIONS.
LATER ON, WE WENT TO STUDY THE
EFFICACY IN A NUMBER OF
DIFFERENT POPULATIONS, AND I'LL
JUST SHOW A FEW HIGHLIGHTS OF
THAT WORK.
THIS WAS A RANDOMIZED CONTROLLED
TRIAL OF YOUTH WITH CHRONIC PAIN
CONDITIONS THAT RECEIVED EITHER
OUR INTERNET CBT VERSUS AN
INTERNET EDUCATION CONDITION,
AND AT SIX-MONTH FOLLOW-UP, WE
FOUND SMALL TO MODERATE EFFECTS
FOR REDUCTIONS IN ADOLESCENT
PAIN-RELATED DISABILITY,
DEPRESSION AND ANXIETY SYMPTOMS,
AND IMPORTANTLY ALSO SHOWED
IMPROVEMENTS IN PARENT BEHAVIORS
AND REDUCTIONS IN THE IMPACT
THAT PARENTS PERCEIVED FROM
CHRONIC PAIN.
THIS SLIDE SHOWS OUR LONG-TERM
EFFECTS UP TO 12 MONTHS AFTER
INTERVENTION.
THESE ARE SMALL EFFECTS I WILL
HIGHLIGHT, BUT AT THE POPULATION
LEVEL, IMPACT OF AN INTERVENTION
IS REALLY THE COMBINATION OF THE
REACH TIMES THE EFFECT, AND
GIVEN THE WIDE REACH THAT THE
INTERVENTION CAN HAVE, WE FEEL
LIKE THIS IS A PROMISING
INTERVENTION FOR DELIVERING AT A
VERY WIDE SCALE LEVEL.
WE'VE ALSO BEEN INTERESTED OVER
THE YEARS IN HOW COMORBIDITIES
MAY INFLUENCE RESPONSE TO
TREATMENT.
A BIG FOCUS IN MY LAB IS ON THE
INTERRELATIONSHIP OF SLEEP AND
PAIN, AND WE'VE LOOKED
SPECIFICALLY AT HOW DOES SLEEP
DEFICIENCY AFFECT AN
ADOLESCENT'S RESPONSE TO
INTERNET CBT.
THIS WAS A STUDY WHERE WE
EXAMINED BOTH ACTIVITY MEASURED
SLEEP DOMAINS AS WELL AS
SELF-REPORTED SLEEP INCLUDING
INSOMNIA SYMPTOMS.
WE DID FIND AT BASELINE, IF
ADOLESCENTS HAD HIGHER RATES OF
SLEEP DEFICIENCY ACROSS THESE
DOMAINS, THAT INDEED THEIR
PAIN-RELATED OUTCOMES WERE
WORSE.
SHOWING REDUCED EFFECTIVENESS OF
OUR CBT TREATMENT.
AND WHAT THIS REALLY SUGGESTS IS
THAT WE MAY NEED TO TREAT SLEEP
DISTURBANCES BEFORE DELIVERING
OTHER COMPONENTS OF CBT FOR PAIN
SELF-MANAGEMENT.
THIS IS EXACTLY WHAT ONE OF MY
COLLEAGUES IS DOING NOW.
THIS IS A STUDY THAT EMILY LAW
IS CARRYING OUT TO TEST THE
OPTIMAL SEQUENCE OF SLEEP
INTERVENTION AND PAIN
INTERVENTION IN YOUTH WHO HAVE
CO-MORBID MIGRAINE AND INSOMNIA.
THIS SLIDE SHOWS AN INTERVENTION
THAT SHE HAS DEVELOPED TO TREAT
INSOMNIA IN ADOLESCENTS THAT IS
BASED ON COGNITIVE BEHAVIORAL
THERAPY FOR INSOMNIA.
SO ONE OF THE PROBLEMS THAT'S
EMERGED OVER THESE YEARS AS
THESE DIGITAL INTERVENTIONS ARE
BEING DEVELOPED IN RESEARCH
STUDIES IS THAT MOST ARE NOT
ACCESSIBLE AT THE END OF THE
STUDY TO THE USERS WHO COULD
BENEFIT FROM THEM.
THIS WAS A SYSTEMATIC REVIEW
CONDUCTED BY HIGGINS AND
COLLEAGUES IN ABOUT 50
INTERVENTIONS THAT WERE
DEVELOPED FOR PEDIATRIC PAIN.
THEY FOUND THAT ONLY 28% WERE
AVAILABLE TO END USERS.
THEY FOUND MANY BARRIERS THAT
WERE CITED FOR NOT MAKING
INTERVENTIONS AVAILABLE AT THE
END OF THE STUDY, MOSTLY AROUND
FUNDING AND CHANGES IN
TECHNOLOGY AND UPKEEP.
AND REALLY, THE CONCLUSION WAS
THAT WE NEED TO USE STUDY
DESIGNS THAT FACILITATE THE
STUDY OF IMPLEMENTATION OUTCOMES
EARLIER IN THE RESEARCH PROCESS.
ONE OF THE MAJOR TECHNOLOGY
CHANGES THAT OCCURRED OVER THE
COURSE OF OUR WORK WITH OUR
DIGITAL HEALTH INTERVENTIONS IS
THAT THERE WAS A HUGE TRANSITION
IN HOW PEOPLE ACCESS THE
INTERNET FROM THE COMPUTER TO A
SMARTPHONE.
THIS IS PARTICULARLY TRUE FOR
YOUNGER AGE GROUPS, SO
ADOLESCENTS IN PARTICULAR HAVE
VERY LOW RATES OF USING A
COMPUTER TO ACCESS THE INTERNET,
AND HAVE AN ALMOST EXCLUSIVE USE
OF THE INTERNET THROUGH MOBILE
DEVICES, SO AT THIS POINT, THIS
IS OUTDATED FROM THE PEW
RESEARCH CENTER, BUT EVEN IN
2018, 95% OF TEENS WERE USING A
MOBILE DEVICE.
SO IT WAS REALLY IMPORTANT TO US
IN THINKING ABOUT HOW TO MAKE
OUR INTERVENTIONS MORE
ACCESSIBLE AND AVAILABLE, SO WE
TRANSFORMED OUR INTERNET-BASED
VERSION OF WEBMAP INTO A MOBILE
APPLICATION AND TOOK THE
OPPORTUNITY TO ALSO STUDY
IMPLEMENTATION USING A HYBRID
EFFECTIVENESS IMPLEMENTATION
RANDOMIZED TRIAL.
THIS SLIDE SHOWS SOME SCREEN
SHOTS FROM OUR WEBMAP MOBILE
INTERVENTION.
WE DESIGNED THIS TO COVER THE
SAME GENERAL TREATMENT
COMPONENTS AS OUR INTERNET-BASED
VERSION, SO REALLY FOCUSING ON
SOME EDUCATION ABOUT PAIN,
STRESS, EMOTIONS AND THOUGHTS,
TEACHING SEVERAL DIFFERENT
RELAXATION METHODS, SOME
LIFESTYLE AND SCHOOL
INTERVENTIONS INCLUDING SLEEP,
STAYING ACTIVE, AND MAINTENANCE
AND RELAPSE PREVENTION.
I WANT TO JUST HIGHLIGHT THAT WE
HAVE A GREAT LOCAL PARTNER,
2MORROW, A COMPANY BASED IN
SEATTLE, WHO DESPI DESIGNS BEHAL
BASED APPS AND THEY'VE BEEN A
WONDERFUL PARTNER IN HELPING US
MAINTAIN AND DESIGN THESE
PROGRAMS.
PART OF HOW WE PERSONALIZE AND
TAILOR THE PROGRAM IS THROUGH A
PROFILE THAT USERS SET UP.
WE HAVE ADDED SOME TAILORING
BASED ON RESPONSES TO SCREENING
QUESTIONS ABOUT INSOMNIA AND LOW
MOOD, AND ARE ABLE TO DELIVER A
FEW ADDITIONAL TAILORED MODULES
BASED ON THEIR RESPONSES.
THIS SHOWS SEVERAL SCREEN SHOTS
OF THE VARIOUS COMPONENTS OF OUR
APP, INCLUDING THE LESSONS.
WE HAVE A LIBRARY WITH SKILLS,
TEENS CAN EARN REWARDS FOR
PROGRESS THROUGH DIFFERENT PARTS
OF THE INTERVENTION.
THERE'S AN OPTION TO DO DAILY
CHECK-INS, AND THERE'S ALSO
OPPORTUNITY TO TRACK SKILLS ONCE
A SKILL IS LEARNED IN THE
PROGRAM.
BECAUSE WE WERE INTERESTED IN
NOT ONLY THE EFFECTIVENESS OF
THE MOBILE APP VERSION OF THE
PROGRAM, WE ALSO WANTED TO STUDY
IMPLEMENTATION DURING THE
MAINTENANCE PERIOD, SO AT THE
END OF OUR RANDOMIZED CONTROL
TRIAL, WE HAD -- ALL CLINICS
HAVE ACCESS TO THE WEBMAP MOBILE
APP AND PROVIDED A REFERRAL
DOCUMENT THAT COULD BE USED, AND
SO PROVIDERS COULD MAKE A
REFERRAL TO THE APP BY GIVING
YOUTH A FLYER WITH PROGRAM
INFORMATION.
SO WE WERE ABLE TO SEE
SPECIFICALLY HOW MANY REFERRALS
WERE MADE PER CLINIC, AND THE
DOWNLOAD RATE BY NEW USERS OF
THE APP.
ALSO PERCEPTIONS ABOUT THE
WEBMAP MOBILE APP.
OUR IMPLEMENTATION RESULTS WERE
POSITIVE.
YOUTH AND PARENTS RATED THE
PROGRAM AS MODERATELY TO HIGHLY
ACCEPTABLE.
PROVIDERS ALSO HAD A POSITIVE
EXPERIENCE WITH MAKING REFERRALS
TO THE INTERVENTION.
WE HAD HIGH RATE OF ADOPTION.
ALL OF THE INVITED CLINICS
AGREED TO PARTICIPATE.
THEY EACH MADE REFERRALS, AND
DURING OUR MAINTENANCE PERIOD,
WE HAD CONTINUED REFERRALS AND
NEW PATIENTS DOWNLOADING THE
APP.
AT THE END OF THE STUDY, WE
PUBLICLY RELEASED WEB MAP MOBILE
IN SEPTEMBER OF 2019 FOR BOTH
ANDROID AND IPHONE.
AND WE HAVE WORKED THROUGH USING
INSTITUTIONAL FUNDS TO MAINTAIN
THESE PROGRAMS OVER THIS TIME
PERIOD.
OUR NEXT STEPS ARE TO MAKE SOME
MODIFICATIONS TO INCREASE
ENGAGEMENT, TECHNOLOGY CONTINUES
TO CHANGE SO WE ALSO ARE WORKING
ON SOME TECHNOLOGY UPDATES, AND
IMPORTANTLY, WE'VE HAD A
RELATIVELY LOW RATE OF DIVERSE
YOUTH IN A NUMBER OF OUR
CLINICAL TRIALS, SO WE REALLY
WANT TO WORK ON MAKING THE
PROGRAM MORE RELEVANT TO DIVERSE
CULTURES, AND DESIGN SOME
STUDIES THAT CAN INCREASE
ENGAGEMENT ACROSS A BROADER
POPULATION.
SO I WANT TO TALK NOW ABOUT HOW
DO WE TAKE THESE ACCESSIBLE
DIGITAL HEALTH INTERVENTIONS TO
PREVENT PAIN AND DISABILITY.
THIS IS THE PREVENTION PIPELINE
THAT REALLY SHOWS OPPORTUNITIES
AT MULTIPLE TIME POINTS, AND WE
CAN THINK ABOUT THIS BOTH ACROSS
THE LIFESPAN AS WELL AS JUST
ACROSS SHORTER PERIODS OF TIME
DURING CHILDHOOD.
SO PRIMARY PREVENTION APPROACHES
HAVE BEEN RELATIVELY UNDERUSED
IN PEDIATRIC PAIN TO DATE, BUT
IN THEORY, WE COULD BE
DELIVERING SCHOOL-BASED
PROGRAMS, OTHER PROGRAMS IN THE
COMMUNITY THAT ARE INTENDED FOR
PAIN-FREE POPULATIONS TO REALLY
TARGET THE PREVENTION OF PAIN.
THESE COULD BE RESILIENCE-BASED
APPROACHES THAT TEACH CHILDREN
AND ADOLESCENTS HOW TO DEAL WITH
EVERYDAY ACHES AND PAINS AND TO
LEARN MORE ABOUT HOW THEY CAN
USE HEALTHY AND POSITIVE PAIN
COPING SKILLS.
SECONDARY PREVENTION APPROACHES
REALLY COULD BE TARGETED TOWARD
ACUTE PAIN AND IN THAT CONTEXT,
THE GOAL IS TO PREVENT THE
TRANSITION TO CHRONIC PAIN, SO
THIS COULD BE APPLIED TO
POPULATIONS THAT HAVE AN ACUTE
INJURY OR ARE UNDERGOING EVENTS
THAT ARE EXPECTED TO CAUSE ACUTE
PAIN SUCH AS SURGERY.
AND LAST, AT THE TERTIARY
PREVENTION LEVEL, THIS IS REALLY
FOCUSING ON POPULATIONS THAT
ALREADY HAVE CHRONIC PAIN, SUCH
AS CHILDREN WHO HAVE PAIN IN THE
CONTEXT OF A CHRONIC DISEASE
WHERE THE GOAL IS TO PREVENT
CHRONIC DISABILITY.
SO I'M GOING TO SHARE SOME
EXAMPLES OF ONGOING WORK IN EACH
OF THESE AREAS TO HIGHLIGHT
TEUBTS TOPPORTUNITIES THAT ARE
AVAILABLE.
SO THE FIRST ONGOING STUDY I
WANT TO TALK ABOUT IS CALLED
REACH.
THIS IS A PRIMARY PREVENTION
FOCUSED TRIAL IN PARENTS WHO
HAVE IRRITABLE BOWEL SYNDROME.
THIS IS WORK I'M UNDERTAKING
WITH RONA LEVY FROM THE SCHOOL
OF SOCIAL WORK.
THIS IS BASED ON THE OBSERVATION
THAT CHILDREN OF PARENTS WITH
IRRITABLE BOWEL SYNDROME ARE AT
FOUR TIMES GREATER RISK FOR
ABDOMINAL PAIN COMPARED TO
PARENTS OF CHILDREN WITHOUT
IRRITABLE BOWEL SYNDROME.
WE KNOW IN SOME OF OUR WORK WITH
YOUTH WITH CHRONIC PAIN
CONDITIONS ALREADY, THERE ARE
ASPECTS OF PARENT MODELING AND
BEHAVIOR THAT CAN BE MODIFIED,
AND THAT IN THE CONTEXT OF
PREVENTION, OUR GOAL IS TO
MODIFY HOW PARENTS REACT TO
EVERYDAY SOMATIC SYMPTOMS SUCH
AS EVERYDAY ACHES AND PAINS.
SO OUR STUDY AIMS ARE TO
DETERMINE THE EFFICACY OF A
PREVENTIVE SOCIAL LEARNING AND
COGNITIVE BEHAVIORAL THERAPY
INTERVENTION IN REDUCING PARENT
SOLICITOUSNESS, ANXIETY, AS WELL
AS CHILD SYMPTOMS.
WE'RE ALSO INTERESTED IN
DETERMINING THE CONTRIBUTION OF
CHANGES IN PARENTAL RISK AND
PROTECTIVE FACTORS IN MEDIATING
TREATMENT EFFECTS.
AND LAST, DETERMINE COST SAVINGS
ON HEALTHCARE EXPENDITURES AND
RESOURCE UTILIZATION FOR
CHILDREN OVER A SUBSEQUENT 18
MONTH PERIOD.
THIS SLIDE SHOWS A FEW SCREEN
SHOTS FROM OUR INTERNET PROGRAM
THAT WE AR ARE CURRENTLY UNDERGG
SOME USER TESTING.
IT GETTING CLOSE TO BEING
FINISHED AND READY TO USE IN OUR
TRIAL.
AND THE GOAL IS TO REALLY TEACH
PARENTS HOW TO FOCUS ON WELLNESS
BEHAVIORS IN THE CONTEXT OF
EVERYDAY ACHES AND PAINS.
SO THIS IS A RANDOMIZED
CONTROLLED TRIAL WITH
460 PARENTS WITH IRRITABLE BOWEL
SYNDROME WHO HAVE YOUNG CHILDREN
WHO ARE AGES 4 TO 7 YEARS, WHO
DO NOT YET HAVE ANY PROBLEMS
WITH ABDOMINAL PAIN.
THEY'RE RANDOMIZED TO EITHER A
SOCIAL LEARNING OR AN EDUCATION
CONTROL WEBSITE, AND WE'RE
UNDERTAKING A MULTIPRONGED
RECRUITMENT APPROACH, WE WILL BE
RECRUITING FROM IBS SUPPORT
GROUPS, FROM SCHOOL DISTRIBUTION
LISTS, AND OTHER LARGE
EMPLOYER-BASED DISTRIBUTION
LISTS THAT CAN GO DIRECTLY TO
PARENTS.
WE'RE ON TARGET TO LAUNCH THE
TRIAL THIS SUMMER, AND WE'LL
HAVE HOPEFULLY SOME RESULTS TO
SHARE WITH YOU IN A FEW YEARS.
SO MOVING ON TO SECONDARY
PREVENTION, I WANT TO JUST
HIGHLIGHT AN ONGOING TRIAL THAT
IS CALLED SURGERYPAL.
THIS IS A MULTI-SITE CLINICAL
TRIAL TESTING THE EFFECTIVENESS
OF A MOBILE APP INTERVENTION
THAT WE CALL SURGERYPAL TO
IMPROVE ACUTE AND CHRONIC PAIN
AND HEALTH OUTCOMES AFTER
ADOLESCENT SPINAL FUSION
SURGERY.
THE GOAL IS TO PREVENT THE
TRANSITION FROM ACUTE TO CHRONIC
POST SURGICAL PAIN.
THIS IS DESIGNED AS A TWO-PHASE
INTERVENTION.
WE'RE INTERESTED IN
UNDERSTANDING WHETHER
INTERVENTION SHOULD BE DELIVERED
DURING A PRE-SURGERY PHASE
AND/OR A POST SURGERY PHASE OR
BOTH.
SO YOU CAN SEE OUR TIMELINE
HERE, WHO ARE RANDOMIZED TO GET
A PRE-SURGERY INTERVENTION WILL
RECEIVE THAT AT 4 TO 8 WEEKS
BEFORE SURGERY, AND YOUTH WHO
ARE RANDOMIZED TO GET A
POST-SURGERY INTERVENTION WILL
RECEIVE THAT AT ABOUT 3 WEEKS
AFTER SURGERY.
WE'RE COLLECTING BOTH ACUTE PAIN
OUTCOMES AND IMMEDIATE PAIN
OUTCOMES IN THE THREE AND SIX
MONTHS POST SURGERY.
THIS IS A HEAL-FUNDED TRIAL WITH
RABBITTS, PAIN, AS WELL AS
OPIOID USE, QUALITY OF LIFE AND
PSYCHOSOCIAL DISTRESS.
THE MOBILE APP IS BASED ON
CONTENT THAT IS TARGETING
SEVERAL AREAS THAT HAVE BEEN
FOUND TO BE ASSOCIATED WITH BOTH
ACUTE AND CHRONIC PAIN AFTER
SURGERY IN CHILDREN.
SO WE'RE TARGETING CHILD
ANXIETY, CHILD SLEEP BEFORE
SURGERY, ACUTE PAIN COPING
SKILLS, AS WELL AS PARENT
DISTRESS.
AND WE HAVE SIMILAR TARGETS
POST-SURGERY.
THIS IS A BRIEF INTERVENTION
WHICH IS THREE WEEKS BEFORE
SURGERY AND THREE WEEKS AFTER
SURGERY.
THIS SLIDE JUST SHOWS THE
ENROLLMENT SITES.
WE ARE ABOUT HALFWAY -- A LITTLE
OVER HALFWAY THROUGH THIS
ENROLLMENT PERIOD WITH 263
ADOLESCENTS RECRUITED TO DATE.
THERE ARE 34 REFERRING SITES
THAT HAVE BEEN HIGHLY ENGAGED IN
REFERRING PARTICIPANTS TO THE
PROJECT.
AND WE'RE EXCITED TO FINISH THIS
STUDY UP OVER THE NEXT YEAR TO
18 MONTHS AND BE ABLE TO ANSWER
SOME OF THESE QUESTIONS.
AND THEN I WANT TO HIGHLIGHT IN
THE CONTEXT OF TERTIARY
PREVENTION A TRIAL THAT WAS
RECENTLY COMPLETED IN A
POPULATION OF ADOLESCENTS WITH
SICKLE CELL DISEASE PAIN THAT WE
CALL I CAN COPE.
THIS WAS A STUDY UNDERTAKEN WITH
CARLTON DAMPIER FROM EMORY AND
JENNIFER STINSON FROM THE
HOSPITAL FOR SICK KIDS.
THE BACKGROUND AND RATIONALE FOR
COMPLETING THIS STUDY WAS THAT
THERE'S LIMITED EVIDENCE TO
SUPPORT TREATMENT
RECOMMENDATIONS FOR SICKLE CELL
DISEASE PAIN IN ADOLESCENTS.
WE KNOW THAT C BT PAIN
INTERVENTIONS ARE USEFUL IN
OTHER POPULATIONS, BUT THERE
REALLY WAS VERY LIMITED EVIDENCE
IN SICKLE CELL DISEASE
POPULATIONS SPECIFICALLY.
WE AIMED TO DETERMINE THE
EFFICACY OF A DIGITAL HEALTH
INTERVENTION THAT WE CALL I CAN
COPE WITH SCD FOR TEACHING CBT
SKILLS FOR PAIN MANAGEMENT FOR
ADOLESCENTS WITH SICKLE CELL
DISEASE.
AND WE HYPOTHESIZED THAT THE
GROUP RECEIVING COGNITIVE
BEHAVIORAL THERAPY INTERVENTION
WOULD HAVE INCREASED ADAPTIVE
COPING STRATEGIES, REDUCED PAIN
SEVERITY AND ACTIVITY
LIMITATIONS COMPARED TO A GROUP
RECEIVING SICKLE CELL EDUCATION
ONLY.
THIS WAS A MULTICENTER
RANDOMIZED CONTROL TRIAL WITH
SEVEN DIFFERENT SITES.
WE ENROLLED YOUTH AGES 12 TO 18
YEARS AND ENDED UP RANDOMIZING
111 YOUTH TO EITHER THE I CAN
COPE OR EDUCATION CONTROL GROUP.
THEY COMPLETED A BASELINE
ASSESSMENT.
OUR TREATMENT WAS ABOUT 8 WEEKS,
AND THEY COMPLETED BOTH A
POST-TREATMENT AS WELL AS A
6-MONTH FOLLOW-UP ASSESSMENT.
WE HAD REALLY EXCELLENT
RETENTION IN THIS TRIAL.
92% OF YOUTH COMPLETED A
POST-TREATMENT ASSESSMENT, AND
88% COMPLETED THE 6-MONTH
FOLLOW-UP.
THIS SLIDE SHOWS SOME SCREEN
SHOTS FROM OUR INTERVENTION.
THIS WAS A TWO-COMPONENT
INTERVENTION.
THERE WAS A MOBILE APP THAT
ALLOWED FOR SOME DAILY
INFORMATION ON HOW TO CHECK IN,
A LIBRARY, AS WELL AS A
COMMUNITY SECTION, AND THEN WE
HAD A WEBSITE THAT ALLOWED FOR
MORE EXTENDED LEARNING AROUND
PARTICULAR SKILLS.
THIS TABLE SHOWS EFFECTS OF OUR
CBT INTERVENTION COMPARED TO
EDUCATION CONTROL ON OUR PAIN
AND COPING OUTCOMES.
AND WE DID FIND SIGNIFICANT
EFFECTS FOR REDUCTIONS IN
AVERAGE DAILY PAIN AND NUMBER OF
DAYS WITH PAIN, AS WELL AS FOR
INCREASES IN COPING ATTEMPTS.
THIS IS A STUDY WE JUST RECENTLY
HAD ACCEPTED IN PAIN SO IT WILL
BE PUBLISHED IN THE COMING
MONTHS.
THIS SLIDE JUST HIGHLIGHTS THE
REDUCTIONS IN PAIN DAYS AND PAIN
INTENSITY.
AND YOU CAN SEE THAT OVER TIME,
THESE EFFECTS INCREASED SO THAT
WE HAD AT 6 MONTHS A SIGNIFICANT
DIFFERENCE BETWEEN OUR TREATMENT
CONDITIONS.
RM I WANT TO TAKE A MOMENT JUST
TO HIGHLIGHT THAT THIS TRIAL WAS
A GOOD OPPORTUNITY TO THINK
ABOUT HOW TO DESIGN STUDIES THAE
MORE INCLUSIVE, THAT ADDRESS
BARRIERS THAT MIGHT PREVENT MORE
DIVERSE INDIVIDUALS FROM
PARTICIPATING.
I WANT TO HIGHLIGHT THIS ARTICLE
FROM MARY JANEVIC THAT WAS
PUBLISHED LAST YEAR IN THE
JOURNAL OF PAIN THAT PROVIDES A
REALLY WONDERFUL OVERVIEW OF HOW
TO PRACTICALLY ADDRESS BARRIERS
TO INCLUSION THROUGH SOME
PRACTICAL STRATEGIES.
FOR EXAMPLE, REFRAMING THE STUDY
DESIGN AND PROCEDURES TO FIT
PARTICIPANTS' LIVES.
FOR EXAMPLE, IN OUR I-CAN-COPE
TRIAL, THIS WAS ENTIRELY REMOTE,
WE HAD NO IN-PERSON PROCEDURES,
AND REALLY FELT THAT THIS MADE
THE TRIAL MUCH MORE ACCESSIBLE
TO ALL.
WE ALSO -- ANOTHER SUGGESTION IS
TO USE APPROACHES TO RECRUITMENT
THAT DO NOT RELY ON CLINIC
CONTACT ONLY.
THIS CAN INCLUDE CONTACTS THAT
OCCUR OUTSIDE OF CLINIC THROUGH
COMMUNITY ORGANIZATIONS AND
COMMUNITY PARTNERSHIPS.
AND THEN LAST, BUILDING
ENGAGEMENT WITH STAKEHOLDER
PARTNERSHIP.
THIS IS SOMETHING WE'VE ALWAYS
DONE IN OUR DIGITAL HEALTH
INTERVENTIONS, BUT THERE ARE
MANY GOOD STRATEGIES AND
SUGGESTIONS IN THIS ARTICLE FOR
HOW TO BUILD ENGAGEMENT.
AND I THOUGHT IT WAS IMPORTANT
TO CLOSE WITH SOME THOUGHTS
ABOUT OUTCOMES.
WHEN WE ARE THINKING ABOUT HOW
TO DEVELOP INTERVENTIONS THAT
CAN HELP CHILDREN WITH CHRONIC
PAIN, AN IMPORTANT COMPONENT OF
THAT IS BEING ABLE TO PRODUCE AN
EVIDENCE BASE THAT SHOWS US
WHICH TREATMENTS WORK.
WE NEED RELIABLE, VALID OUT COME
ASSESSMENT TOOLS IN ORDER TO DO
THIS.
THIS WAS WORK THAT WE'VE
RECENTLY FINISHED THAT REALLY
COMES FROM PRIOR WORK THAT WAS
DONE ALMOST 20 YEARS AGO.
OUR FIRST STEP WAS TO UPDATE
THIS WORK BY CONDUCTING A NEW
DELPHI POLL AND CONSENSUS
MEETING TO DEVELOP A NEW CORE
OUTSOME SET FOR PEDIATRIC
CHRONIC PAIN.
WE DID A DELPHI POLL WITH
ADOLESCENTS AND PARENTS
DIRECTLY, AS WELL AS WITH
HEALTHCARE PROVIDERS.
AND FROM THAT, WE WERE ABLE TO
ACHIEVE CONSENSUS ON MANDATORY
DOMAINS THAT SHOULD BE USED IN
ALL TRIALS OF PEDIATRIC CHRONIC
PAIN, IMPORTANT OPTIONAL DOMAINS
THAT SHOULD BE USED IN SOME BUT
MAYBE NOT ALL TRIALS, AS WELL AS
A RESEARCH AGENDA.
SO THE COMMITTEE USED THE
FRAMEWORK YOU SEE HERE TO FIT
THESE VARIOUS DOMAINS, AND AS
YOU CAN SEE PAIN SEVERITY, PAIN
INTERFERENCE WITH DAILY LIVING,
OVERALL COPLIVING -- OVERALL WED
ADVERSE EVENTS WERE INCLUDED IN
ALL TRIALS.
EMOTIONAL FUNCTIONING, PHYSICAL
FUNCTIONING AND SLEEP WERE
RECOMMENDED IN MANY TRIALS AS
OPTIONAL DOMAINS.
BUILDING FROM THIS, OUR NEXT
PHASE OF WORK WAS TO SELECT
OUTCOME MEASURES THAT COULD FIT
EACH OF THESE DOMAINS.
WE USED A MULTIPHASE APPROACH,
WE DID A DELPHI STUDY OF EXPERTS
TO IDENTIFY CANDIDATE MEASURES
AND THEN DID A REVIEW PHASE TO
GATHER EVIDENCE FOR MEASUREMENT
PROPERTIES OF EACH OF THESE
CANDIDATE MEASURES.
AND THEN LAST, A CONSENSUS
CONFERENCE TO MAKE FINAL
RECOMMENDATIONS.
SO THIS PROCESS REALLY ALLOWED
US TO MAKE INFORMED
RECOMMENDATIONS ON MEASURES FOR
THE NEW CORE OUTCOME SET.
AND THE NEXT STEP OF THIS IS
REALLY TO MAKE THIS ACCESSIBLE,
SO THAT WE CAN, AS A COMMUNITY,
BE ABLE TO ACCESS THESE TOOLS
EASILY.
I WANT TO GIVE A SHOUT OUT TO
RAY LEE, ONE OF MY COLLEAGUES
WHO HAS DONE TREMENDOUS WORK ON
REALLY NOT ONLY REVIEWING THE
EVIDENCE LEVEL FOR THE OUTCOME
MEASURES, BUT ALSO THINKING
THROUGH HOW TO DISSEMINATE THIS
INFORMATION NOW.
OUR GOAL IS TO BE ABLE TO HAVE
ACCESSIBLE ENGLISH AND SPANISH
MEASURES FOR EACH DOMAIN, AS
WELL AS TO HAVE CONTENT THAT
HELPS WITH UNDERSTANDING HOW TO
DO -- HOW TO REACH OTHER
MEASURES THAT ARE RECOMMENDED.
SO QUICK SUMMARY, I HOPE AT THE
END OF THIS LECTURE THAT YOU'VE
UNDERSTOOD THAT PAIN IN CHILDREN
DOES MATTER.
IT'S A COMMON PROBLEM IN
CHILDREN AND ADOLESCENTS, AND WE
KNOW PAIN HAS A SIGNIFICANT
IMPACT DURING CHILDHOOD AND CAN
HAVE A REAL LASTING IMPACT INTO
ADULTHOOD AS WELL.
PSYCHOLOGICAL INTERVENTIONS MAY
HELP TO PREVENT PAIN AND
DISABILITY IN CHILDHOOD AS WELL
AS DURING ADULTHOOD.
THEY COULD BE USED ACROSS THE
PREVENTION PIPELINE AND I SHOWED
SEVERAL EXAMPLES OF HOW THAT CAN
BE DONE, BUT THERE'S LOTS OF
OPPORTUNITIES FOR CONTINUED
APPLICATIONS.
TECHNOLOGY DELIVERED
INTERVENTIONS CAN ADDRESS
BARRIERS TO ACCESS AND MAY
EVENTUALLY BE ABLE TO IMPROVE
EQUITY IN ACCESS TO PAIN CARE.
WE KNOW THAT HARMONIZING
MEASURES IN CLINICAL TRIALS FOR
CHRONIC PAIN CAN HELP US ADVANCE
KNOWLEDGE OF CLINICAL
INTERVENTIONS.
SO SOME FUTURE DIRECTIONS.
AS MENTIONED, DEVELOPMENTAL OR
LIFESPAN MODELS OF CHRONIC PAIN
CAN REALLY HELP US TO CONNECT
CHILDHOOD AND ADULT PAIN AND
HELP BETTER DEFINE INTERVENTION
TARGETS.
IF WE THINK FORWARD OF WHAT ARE
THOSE OUTCOMES IN ADULTHOOD THAT
WE'RE STRIVING FOR, WE MAY
DESIGN PEDIATRIC INTERVENTIONS A
LITTLE DIFFERENTLY.
AS MENTIONED, I THINK WE NEED TO
CONTINUE TO TEST PSYCHOLOGICAL
INTERVENTIONS ACROSS THE
PREVENTION PIPELINE, AND REALLY
UNDERSTAND WHAT ARE THOSE
WINDOWS OF OPPORTUNITY FOR
DELIVERING INTERVENTIONS THAT
CAN BOTH PROMOTE RESILIENCY AS
WELL AS ADDRESS RISK FACTORS.
YOUNG ADULTS IN PARTICULAR HAVE
BEEN LEFT OUT OF SOME OF THE
RESEARCH TO DATE, ESPECIALLY
AROUND DEVELOPMENT OF
TREATMENTS.
WE HAVE A PRETTY GOOD
UNDERSTANDING OF TREATMENTS THAT
CAN BE EFFECTIVE IN THE
PEDIATRIC POPULATION, AS WELL AS
THE ADULT POPULATION, BUT
THERE'S BEEN REAL LIMITED FOCUS
ON TREATMENTS SPECIFICALLY
DESIGNED FOR YOUNG ADULTS.
AND THAT'S AN IMPORTANT FUTURE
OPPORTUNITY.
IT'S ALSO OPPORTUNITIES TO
IDENTIFY THE BEST WAYS TO
DISSEMINATE AND IMPLEMENT
TECHNOLOGY-DELIVERED
INTERVENTIONS.
WE STILL HAVE A LOT TO LEARN
ABOUT HOW TO GET THESE
INTERVENTIONS TO THE PEOPLE WHO
NEED THEM MOST AND CAN BENEFIT
FROM THEM, AS WELL AS LEARNING
HOW CAN WE MAKE PARTNERSHIPS TO
SUSTAIN THESE PROGRAMS OVER
TIME.
AND LAST, THERE ARE MANY
PROMISES OF BEING ABLE TO
PERSONALIZE TREATMENT WITH
TECHNOLOGY, BUT WE REALLY
HAVEN'T REALIZED THAT IN OUR
PAIN INTERVENTIONS TO DATE.
BUT THERE'S MANY WAYS WE CAN
THINK ABOUT HOW TO DELIVER THE
RIGHT TREATMENT AT THE RIGHT
TIME TO THOSE WHO NEED IT.
I WANT TO THANK MY WONDERFUL
COLLEAGUES IN THE PEDIATRIC PAIN
AND SLEEP INNOVATIONS LAB WHO
HAVE MADE ALL OF THE WORK
POSSIBLE THAT I TALKED WITH YOU
TODAY.
AND LAST, HERE'S MY CONTACT
INFORMATION.
I AM HAPPY TO ANSWER QUESTIONS
IN A MOMENT BUT IF I CAN'T GET
TO YOUR QUESTION TODAY, PLEASE
FEEL FREE TO REACH OUT TO ME
DIRECTLY.
THANK YOU.
>>THANK YOU SO MUCH,
DR. PALERMO.
WE REALLY APPRECIATED THAT TALK.
AND HELENE, EMILY AND
DR. SHURTLEFF, I SEE YOU ALL
COMING ON.
I KNOW THAT DR. LANGEVIN HAS TO
JUMP TO ANOTHER MEETING VERY
QUICKLY.
SO I'M GOING TO GIVE HELENE THE
OPPORTUNITY TO ASK YOU A FIRST
QUESTION, DR. PALERMO, AS WE
HEAD INTO OUR Q & A SESSION.
AND RIGHT BEFORE I DO THAT,
REMINDER TO ALL OF OUR VIDEOCAST
VIEWERS, USE THAT LIVE FEEDBACK
FORM TO ASK YOUR QUESTIONS.
THAT LINK IS RIGHT BELOW THE
SCREEN WHERE YOU ARE SEEING
LIVESTREAM.
SO HELENE, DO YOU HAVE A
QUESTION TO KICK US OFF FOR THE
Q & A?
>>YES, SO FIRST OF ALL, BRAVO,
I MEAN, I REALLY SO APPRECIATE
THE FACT THAT YOU'RE FOCUSING ON
EASILY DELIVERABLE, SIMPLE
INTERVENTIONS THAT ARE SO
NEEDED.
I ALSO REALLY LIKE YOUR APPROACH
TO PRIMARY, SECONDARY AND
TERTIARY PREVENTION PIPELINE.
I'M A LITTLE CURIOUS ABOUT THE
SECONDARY PREVENTION, AND I KNOW
THIS IS SOMETHING YOU MUST HAVE
THOUGHT ABOUT A LOT, KIDS WHO
HAVE SPINAL SURGERY MUST -- IT
DEPENDS ON WHY THEY HAD THE
SPINAL SURGERY, BUT DID A LOT OF
THEM ALREADY HAVE PAIN BEFORE
THE SURGERY, IN WHICH CASE IT
WOULD BE MORE LIKE ALREADY A
CHRONIC PAIN SITUATION, OR HOW
DID YOU FACTOR THAT IN?
>>YEAH, NO, IT'S INTERESTING,
AND REALLY A LOT OF THIS WORK IS
INFORMED BY JENNIFER RABBITZ'
OBSERVATIONAL STUDIES.
SPINAL FUSION SURGERY IS DONE
FOR CHILDREN FOR DIFFERENT
REASONS THAN ADULTS AND
PRIMARILY THESE SURGERIES ARE
DONE IN CHILDREN WHO DO NOT HAVE
PAIN.
IT'S NOT DONE FOR PAIN.
AND SO THE POPULATION DOES, IN
GENERAL, START OFF BEING
PAIN-FREE, AND OUR FOCUS IS ON
REALLY WHAT HAPPENS AFTER
SURGERY.
JENNIFER HAS FOUND THAT UP TO
20% OF ADOLESCENTS HAVE CHRONIC
PAIN AFTER SPINAL FUSION
SURGERY, SO IT'S A GROUP THAT WE
KNOW IS AT RISK.
IT'S A PRETTY MAJOR SURGERY, SO
IT'S AN IMPORTANT ONE FOR US TO
START WITH.
I THINK EVENTUALLY, THE GOAL
WOULD BE TO UNDERSTAND WHETHER
THIS MIGHT TRANSLATE TO OTHER
SURGICAL POPULATIONS IN TERMS OF
AN APPROACH TO PREVENT THE ACUTE
TO CHRONIC TRANSITION.
>>WHAT IS IT, IS IT MOSTLY
SCOLIOSIS OR WHERE ARE MOST --
AND THEY DON'T HAVE PAIN?
>>WE DO SCREEN THEM FOR CHRONIC
MUSCULOSKELETAL PAIN, AND THAT
IS AN EXCLUSION CRITERIA.
BUT MOST OF THEM DO NOT.
>>OKAY.
AND WORSE AFTER SURGERY, WHICH
IS SAD.
>>YEAH.
>>THANK YOU.
>>YOU'RE WELCOME.
>>DAVID, DID YOU HAVE A
QUESTION YOU WANTED TO KICK OFF
WITH IN THE Q & A SESSION?
>>SO MANY BUT I'LL JUST TRY TO
LIMIT TO ONE TO START.
VERY INTERESTED IN YOUR PRIMARY
PREVENTION STRATEGY.
HELENE ALLUDED TO THE REACH
PROGRAM.
IT SEEMS AS THOUGH YOU MENTIONED
THE EMPHASIS ON WELLNESS.
I'M JUST WONDERING, IN ADDITION
TO LOOKING AT IBS OUTCOME, THE
PAIN OUTCOMES, IF YOU'RE LOOKING
AT SECONDARY OUTCOMES RELATED TO
OTHER DISORDERS SUCH AS -- WHICH
I'M THINKING ABOUT ADOLESCENTS
AS WE ALL KNOW, EARLY -- LATER
CHILDHOOD, IS SUCH A CRITICAL
STAGE FOR A LOT OF DEVELOPMENTAL
DISORDERS, WHETHER IT'S
DEPRESSION, ANXIETY, MENTAL
HEALTH DISORDERS, PHYSICAL
DISORDERS.
ARE YOU ABLE TO CAPTURE IF THIS
INTERVENTION MAYBE GOES MORE
BROADLY THAN JUST A PAIN
CONDITION?
ARE YOU CAPTURING ANY OF THOSE
MEASURES?
JUST CURIOUS, I THINK IT WOULD
BE A GREAT OPPORTUNITY BECAUSE I
IMAGINE IT WOULD AFFECT A
VARIETY OF CONDITIONS BEYOND
PAIN.
>>ABSOLUTELY, GREAT QUESTION,
AND OUR TEAM HAS TALKED A LOT
ABOUT THIS VERY ISSUE BECAUSE
INDEED, THESE CHILDREN DON'T
HAVE PAIN YET, AND WE DIDN'T
WANT TO EXCLUSIVELY FOCUS ON
PAIN.
SO WE ARE ALL -- ALSO ARE
COLLECTING SOME OTHER
PSYCHOLOGICAL OUTCOMES AS WELL
AS BROADER HEALTH-RELATED
QUALITY OF LIFE OUTCOMES, SO
HOPEFULLY WE'LL HAVE A BETTER
CONTEXT AROUND POSSIBLE BENEFIT
IN OTHER AREAS.
>>OKAY, THANK YOU.
DAVID, ANY FOLLOW-UP TO THAT
OR -- EMILY, MIGHT YOU HAVE A
QUICK QUESTION?
I KNOW YOU TWO HAV TOO HAVE A VY
SCHEDULE TODAY.
>>I JUST WANTED TO COMMENT ON
THE STUDY THAT YOU HAD WITH THE
ADOLESCENTS WITH SICKLE CELL.
ARE YOU PLANNING ON DOING A
STUDY WHERE YOU START EARLIER?
BECAUSE, I MEAN, CHILDREN WITH
SICKLE CELL PAIN, THE IDEA TO
START EARLY MIGHT POTENTIALLY
PREVENT, YOU KNOW, THE
DEVELOPMENT OF CHRONICITY.
SO IS THERE ANY PLANNING ON
THAT?
>>IT'S A GREAT QUESTION, AND
IT'S SIMILAR TO ONE WE'VE
THOUGHT OF IN ANOTHER POPULATION
I WORK WITH, WHICH IS FOR
CHRONIC PAN KREE T PANCREATITISE
THERE'S A BALANCE BETWEEN WILL A
CHILD ENGAGE IF THEY DON'T HAVE
FREQUENT ENOUGH SYMPTOMS, BUT WE
WANT TO PREVENT THE MORE
FREQUENT SYMPTOMS BUT IT'S HARD
TO KNOW IF THAT WINDOW OF
OPPORTUNITY.
WE'VE LEARNED FROM SOME OF OUR
OTHER STUDIES THAT IF PAIN IS
NOT FREQUENT, THE ENGAGEMENT HAS
DECLINED IN THE INTERVENTION
ITSELF, SO I THINK WE NEED TO
LEARN MORE ABOUT WHAT IS THE
OPTIMAL TIME TO DELIVER
SOMETHING, AND MAYBE WE'RE
TRYING TO DELIVER TOO MUCH.
MAYBE THE PREVENTIVE FOCUS NEEDS
TO BE BRIEFER AND -- OR MORE
FLEXIBLE IN ITS DELIVERY.
>>THANK YOU, EMMELINE.
WE WANT TO MOVE TO A QUESTION
FROM THE AUDIENCE.
THE PERSON WATCHING ON VIDEOCAST
SAYS, COULD YOU PLEASE COMMENT
ON HOW YOU'VE RECRUITED AND
RETAINED UNDERREPRESENTED YOUTH
IN YOUR STUDIES OR ANY BARRIERS
YOU MAY HAVE FACED?
>>YEAH, YOU KNOW, IT'S REALLY
POPULATION-SPECIFIC IN THE
STUDIES WHERE WE'VE RECRUITED
FROM PEDIATRIC PAIN CLINICS.
UNFORTUNATELY THERE'S A VERY LOW
REPRESENTATION OF DIVERSE GROUPS
BECAUSE IT REFLECTS THE CLINIC
POPULATION.
FOR MANY REASONS, PEDIATRIC
TERTIARY PAIN CLINICS ARE NOT
REPRESENTATIVE, AND WE KNOW WHEN
WE GO TO THE COMMUNITY, THE
POPULATIONS ARE VERY DIFFERENT.
SO ONE I THINK JUST IMPORTANT
LEARNING IS THAT THERE ARE --
THERE IS A REALLY IMPORTANT NEED
TO GO TO THE COMMUNITY WHEN
WE'RE DELIVERING INTERVENTIONS
SO THAT WE DON'T LEARN ONLY
ABOUT BENEFITS IN THESE CLINIC
POPULATIONS.
BUT I APPRECIATE THE QUESTION
BECAUSE I THINK THERE'S A LOT OF
ROOM FOR OPPORTUNITY IN THAT
AREA, ESPECIALLY IN PEDIATRIC
PAIN.
>>WE HAD A COUPLE OF OTHER
QUESTIONS THAT CAME IN.
WE HAD ONE THAT WAS ABOUT
VIRTUAL REALITY TECHNIQUES.
THE PERSON WAS ASKING, IT SEEMS
THAT VIRTUAL REALITY TECHNIQUES
COULD ENHANCE DIGITAL COGNITIVE
BEHAVIORAL THERAPY OR CBT
EFFECTS.
HAS ANY WORK BEEN DONE IN THAT
AREA?
>>THAT'S A GREAT QUESTION.
I KNOW THERE'S A LOT OF INTEREST
IN VIRTUAL REALITY, THERE'S
DEFINITELY BEEN APPLICATIONS IN
ADOLESCENTS.
IT'S NOT SOMETHING OUR GROUP
DOES DIRECTLY, BUT I THINK THAT
THERE'S CERTAINLY -- IT'S
IMPORTANT TO THINK ABOUT HOW TO
POTENTIALLY OPTIMIZE BOTH
INTERVENTIONS BY DELIVERING THEM
TOGETHER.
I THINK THAT BOTH THERE ARE
BENEFITS FROM SOME OF THE
STRATEGIES WE TEACH IN COGNITIVE
BEHAVIORAL THERAPY THAT CAN'T BE
ACHIEVED AS WELL FROM JUST
VIRTUAL REALITY AND VICE VERSA,
SO THERE MIGHT BE SOME IMPORTANT
SYNERGIES THAT WOULD BE
INTERESTING TO UNDERSTAND.
>>SO ANOTHER QUESTION THAT
WE'VE HAD HAS TO DO WITH THE
WORK THAT YOU'VE DONE IN SICKLE
CELL DISEASE.
THE PERSON ASKS, IN YOUR WORK
WITH SICKLE CELL DISEASE, HAVE
YOU INCORPORATED SPIRITUAL CARE
PRACTICES OR INTERVENTIONS INTO
PAIN COPING STRATEGIES?
THIS TOPIC OFTEN COMES UP IN
DISCUSSIONS OF SICKLE CELL
CAREGIVERS AND WARRIORS AS
IMPORTANT SUPPORT FOR THEM, THAT
THEY STARTED IN CHILDHOOD.
SO ANY THOUGHTS ABOUT THAT?
>>THAT'S A GREAT QUESTION, AND
I AGREE, YOU KNOW, ALTHOUGH THE
FAMILIES I WORK WITH CLINICALLY
ALSO IDENTIFY SPIRITUAL COPING
IS IMPORTANT, I THINK THE COPING
MEASURE WE USE DOES ASSESS THAT.
IN TERMS OF INTERVENTION ITSELF,
ONE OF THE THINGS THAT WE DID
WAS TO RECORD REAL -- IN YOUNG
ADULTS WITH SICKLE CELL THAT
TALK ABOUT THEIR LIVES AND I
THINK THAT GIVES IMPORTANT
CONTEXT AND THAT WAS ONE WAY TO
KIND OF INCREASE RELEVANCY, SO
WE DO HAVE, FOR EXAMPLE, IN ONE
OF THE VIDEOS SOMEONE TALKING
ABOUT SPIRITUAL FORMS OF COPING.
I THINK THOSE ARE SMALL WAYS TO
INTEGRATE KIND OF THE DOMAINS
THAT ARE IMPORTANT TO SPECIFIC
POPULATIONS, IS THROUGH USE OF
PEOPLE WHO HAVE LIVED EXPERIENCE
IN THE INTERVENTIONS AND IN BOTH
THE DESIGN AS WELL AS WHEN YOU
ARE ABLE TO SHOW SNIPPETS OF
REAL LIFE TO TAKE THOSE
OPPORTUNITIES.
WE'VE ALWAYS GOTTEN REAL
POSITIVE FEEDBACK WHEN WE SHOW
PEER MODELS IN OUR
INTERVENTIONS.
I THINK EVERYONE LIKES TO SEE
OTHER PEOPLE WHO ARE COPING WITH
SIMILAR ISSUES.
>>SO WHILE WE'RE -- I THINK WE
HAVE A COUPLE MORE Qs COMING
IN FROM THE AUDIENCE.
DAVID, DID YOU HAVE ANOTHER Q
THAT YOU WANTED TO POSE?
>>I THINK IT'S ALONG SIMILAR
LINES OF SOME OF THE QUESTIONS
ABOUT CBT, IT SEEMS IT'S
EFFECTIVE AND HAS REACH BUT IT,
I GUESS, A MODEST IMPACT MAYBE
IN SOME RESPECTS.
WE JUST HAD A PAIN CONSORTIUM
CONFERENCE AND THEY SPOKE WITH
SOME OF THESE MULTI-COMPONENTS,
CBT WAS A MAJOR COMPONENT, BUT
SHE ALSO ENGAGED WITH SPORTS
MEDICINE SPECIALISTS ON EXERCISE
PROGRAMS TARGETED TOWARDS THIS
POPULATION, TAKING INTO ACCOUNT
KIN ESTHETICS AND OTHER THINGS.
I'M JUST WONDERING, A COUPLE
QUESTIONS AROUND THE CBT.
IT'S THE DEVELOPMENTAL STAGE
THAT MAYBE IMPACTS THE ULTIMATE
EFFECTIVENESS OF THIS
INTERVENTION.
ARE THERE OTHER COMPONENTS SUCH
AS EXERCISE USING, SAY, ADVICE
FROM SPORTS MEDICINE EXPERTS OR
OTHER INTERVENTIONS YOU THINK IN
ADDITION TO CBT COULD BE HELPFUL
IN SORT OF MAYBE INCREASING THE
STIGMA -- OF THE INTERVENTION?
>>IT'S A REALLY GOOD QUESTION,
AND DEFINITELY CBT HAS SOME
PROMISE.
IT DEFINITELY DOESN'T WORK FOR
EVERYONE.
AND ONE OF THE MAIN OBSERVATIONS
I'LL MAKE IS THAT IT'S REALLY
TYPICALLY DELIVERED AS A ONE
SIZE FITS ALL INTERVENTION.
AND CLEARLY THAT'S NOT GOING TO
BE OF BENEFIT TO EVERYONE.
I THINK WE COULD DO A BETTER JOB
OF FIGURING OUT HOW TO TAILOR
AND PERSONALIZE CBT SO THAT
ADOLESCENTS ARE ACTUALLY
RECEIVING THE CONTENT THAT IS
MOST IMPORTANT TO THEIR
PARTICULAR SYMPTOMS, AND SO THAT
MIGHT BE A COMBINATION OF
SEQUENCING AS WELL AS CHANGING
CONTENT, BUT I AGREE THAT THERE
ARE MANY OTHER PROMISING
INTERVENTIONS THAT COULD BE
INCLUDED ALONGSIDE CBT, AND THAT
IS SOMETHING THAT ALSO HAS NOT
BEEN WELL STUDIED AS THESE
COMBINATIONS OF TREATMENTS.
SO I DO THINK THAT'S A REALLY
IMPORTANT AREA FOR UNDERSTANDING
HOW WE CAN MAXIMIZE THE VALUE OF
THIS TREATMENT TO THIS
POPULATION.
>>SO WE HAVE A FEW MORE COMING
IN FROM THE AUDIENCE.
ONE WE'VE HAD COMING IN IS, DID
THE PSYCHOLOGICAL INTERVENTIONS
THAT YOU AND YOUR TEAM TESTED
INCLUDE SOMATIC EXPERIENCING
EXERCISES?
>>HMMM.
THAT'S AN INTERESTING QUESTION.
I'M NOT SURE THAT THE DIGITAL
DELIVERY THAT WE DO OF OUR
INTERVENTIONS WOULD BE THE SAME
AS WHAT I'M IMAGINING THIS
QUESTION IS ABOUT.
THERE ARE, I THINK,
OPPORTUNITIES WHEN YOU HAVE
SOMEONE IN PERSON TO DO A LITTLE
MORE OF THESE TYPES OF
APPROACHES.
SO I WILL SAY THAT'S NOT BEEN A
MAJOR STRATEGY WE'VE USED IN OUR
DIGITAL INTERVENTIONS.
>>THANK YOU.
SO THE NEXT QUESTION, THE PERSON
SAID THANK YOU FOR A GREAT TALK.
I'D BE GLAD TO KNOW ABOUT THE
AVAILABILITY OF THE WEBMAP
MOBILE APP.
THERE ARE SOME OTHER CBT APPS
OUT THERE, CURABLE IS ONE.
DO YOU HAVE ANY THOUGHTS ON
THEIR UTILITY IN ADOLESCENTS
WITH CHRONIC PAIN?
CURABLE WAS DESIGNED FOR ADULTS,
THEY BELIEVE, SO THEY'RE NOT
SURE IF IT'S BEEN VALIDATED IN
ANY SPECIFIC POPULATION.
>>YEAH, IT'S A GREAT QUESTION,
AND THERE'S MANY, MANY MOBILE
APPS OUT THERE THAT ARE SOMEHOW
RELEVANT TO PAIN, WHETHER
THEY'RE FOCUSING ON MONITORING
OF PAIN OR TREATMENT OF PAIN, AS
WELL AS APPS FOR ANXIETY OR
DEPRESSIVE SYMPTOMS.
THERE ARE MANY, MANY
POSSIBILITIES.
ONE OF THE REAL BARRIERS IS
THERE AREN'T -- ISN'T A CLEAR
WAY OF LOOKING AT WHAT IS THE
EVIDENCE FOR THIS APP, WHAT'S
THE QUALITY OF IT, DOES IT --
THEY DON'T HAVE A STAMP OF
APPROVAL THAT WE CAN EASILY SAY
THIS HAS A GOOD EVIDENCE BASE
AND WE KNOW IT'S BEEN USED IN
THIS DEVELOPMENTAL AGE RANGE AND
THIS PARTICULAR POPULATION, SO
THAT'S REALLY LIMITED THE
ABILITY TO SORT OF MAKE
RECOMMENDATIONS TO PATIENTS.
I THINK THAT'S BEEN REALLY HARD.
THERE'S A FEW TOOLS OUT THERE.
THERE'S A TOOL CALLED CYBER
GUIDE THAT IS A WAY OF LOOKING
UP THOSE PRODUCTS THAT HAVE AT
LEAST BEEN PUBLISHED ON AND HAVE
SOME DEM STRAYTIVE EFFECTS.
UNFORTUNATELY IT'S MOSTLY
FOCUSED ON ADULT APPS, BUT THERE
ARE SOME IN THAT GUIDE FOR KIDS
THAT YOU CAN LOOK AT.
SO HOPEFULLY OVER TIME, WE GET
BETTER AT FIGURING OUT HOW TO
GIVE SOME QUALITY RATINGS TO
PRODUCTS THAT COME OUT SO THAT
YOU CAN UNDERSTAND THEIR LEVEL
OF SCIENTIFIC EVIDENCE AND
VALUE.
BUT I THINK IN THE INTERIM, YOU
KNOW, I ALWAYS ENCOURAGE
PROVIDERS WHO WANT TO USE THESE
WITH PATIENTS TO CHECK OUT THE
PRODUCT YOURSELF, MAKE SURE YOU
KNOW WHAT IT DOES, AND ASK
COLLEAGUES ABOUT WHAT THEY'VE
USED IN POPULATIONS AS WELL WHEN
YOU CAN'T FIND PUBLISHED
EVIDENCE.
>>SO WE HAD A PERSON WHO WROTE
IN, IT'S A THREE-PART QUESTION,
SO LET'S SEE WHAT WE CAN DO HERE
FOR THEM.
FIRST THE COMMENT WAS
"INCREDIBLE PRESENTATION," SO
THANKING YOU FOR THAT.
THEN THEY'RE ASKING, CAN YOU
ADDRESS CHRONIC, QUOTE-UNQUOTE,
GROWING PAIN AMONG ADOLESCENTS?
AND THEN HOW IS CHRONIC PAIN
DETERMINED AND ADDRESSED IN
YOUNGER CHILDREN WHO MAY NOT BE
ABLE TO SORT OF ADEQUATELY
DESCRIBE THEIR PAIN EXPERIENCE
OR EXPRESS THE SEVERITY OF THE
PAIN THAT THEY'RE EXPERIENCING?
SO DO YOU WANT TO START WITH
THOSE AND THEN WE CAN CATCH THIS
THIRD ONE.
>>YEAH, AND I THINK, YOU KNOW,
GROWING PAINS IS AN INTERESTING
QUESTION BECAUSE CLEARLY THERE'S
A PHENOMENON OF, YOU KNOW,
GROWTH SPURTS FOR CHILDREN
DESCRIBE JOINT OR BONE-RELATED
PAIN.
I THINK THE PROBLEM I HAVE WITH
THAT TERM IS IT'S BEEN
GENERALIZED ACROSS CHILDHOOD
WITH -- AS MENTIONED WITH THIS
MYTH THAT CHILDREN GROW OUT OF
PAIN, SO I'VE BEEN REALLY
WORRIED ABOUT THAT TERM BECAUSE
IT IMPLIES THAT IT'S TRANSITORY,
AND IT MAY BE GENERALIZED TO
PAIN COMPLAINTS THAT REALLY ARE
NOT.
SO I THINK -- I'VE ALWAYS JUST
BEEN CAUTIOUS OF THAT.
I THINK IT WOULD BE BETTER IF
THERE WAS ANOTHER TERM USED TO
DESCRIBE SOME OF THESE OTHER
MUSCULOSKELETAL COMPLAINTS THAT
ARE COMMON IN CHILDHOOD.
IN TERMS OF YOUNG CHILDREN, IT'S
A GOOD QUESTION.
WE DO HAVE VALID AND RELIABLE
PAIN ASSESSMENT TOOLS ACROSS A
PRETTY BROAD PEDIATRIC AGE
RANGE.
THE AVERAGE AGE OF A CHILD WITH
CHRONIC PAIN IS A LITTLE BIT
OLDER, SO A LOT OF THE TOOLS
HAVE FOCUSED MORE -- THAT ARE
FOR YOUNG CHILDREN -- ON ACUTE
PAIN EXPERIENCES, BUT THERE
CERTAINLY ARE RELIABLE AND VALID
TOOLS THAT CAN BE USED ACROSS
THE WHOLE AGE RANGE.
>>SO THEN THIS PERSON GOES TO A
THIRD PART WHICH I THINK IS
INTERESTING, BECAUSE IT TALKS
ABOUT -- YOU TALK ABOUT TRYING
TO SHY AWAY FROM THINGS THAT
SOUND TRANSITORY, BUT THE PERSON
SAYS THEY'RE CURIOUS ABOUT WHAT
THEY'RE CALLING, QUOTE-UNQUOTE,
GHOST CHRONIC PAIN AMONG
STUDENTS WHO MAY NOT WANT TO
ATTEND SCHOOL FOR VARIOUS
REASONS.
WHICH I THINK IS AN INTERESTING
QUESTION, SO ANY THOUGHTS ON
THAT AS A --
>>I'VE NOT HEARD THE TERM GHOST
CHRONIC PAIN BEFORE BUT I
UNDERSTAND THE QUESTION IS
REALLY ABOUT HOW T DO YOU
UNDERSTAND WHEN THERE ARE
REASONS PERHAPS THAT ARE
REINFORCING TO AVOID CERTAIN
ACTIVITIES AND INDEED FOR SOME
KIDS, SCHOOL IS NOT AN ACTIVITY
THAT BRINGS A LOT OF -- A LOT
OF, YOU KNOW, POSITIVES FOR
THEM.
I WILL SAY COVID WAS INTERESTING
BECAUSE WITH KIDS NOT BEING IN
SCHOOL OR HAVING HOME-BASED
LEARNING, WE LEARNED THAT FOR
SOME KIDS WITH CHRONIC PAIN,
THAT WAS INCREDIBLY POSITIVE
EXPERIENCE TO NOT BE EXPECTED TO
BE AT SCHOOL.
AND IT WAS FOR MANY REASONS, NOT
JUST THAT THAT DIDN'T WANT TO BE
IN THE CLASSROOM, BUT THEY ALSO
DIDN'T EXPERIENCE BULLYING, FOR
EXAMPLE, THAT THEY MIGHT HAVE
EXPERIENCED IN PERSON.
SO THERE'S SOME LEARNINGS, I
THINK, TO BE HAD ABOUT WHAT
REALLY IS HAPPENING IN AN
ENVIRONMENT THAT MAYBE IS NOT
POSITIVE FOR ALL CHILDREN IN OUR
WORK ON INCREASING SCHOOL
ATTENDANCE WHEN THAT'S A GOAL
FOR FAMILIES, WE'RE USUALLY
TRYING TO UNDERSTAND WHAT ARE
THOSE FACTORS THAT ARE LIMITING
A CHILD'S PARTICIPATION IN
SCHOOL AND INDIVIDUALIZING SOME
OF OUR RECOMMENDATIONS AROUND
THAT.
SO I THINK IT'S AN IMPORTANT
TOPIC.
BECAUSE OF THE LATER IMPACT THAT
I SHOWED YOU ON FUTURE
EDUCATIONAL ATTAINMENT, I THINK
IT'S ONE WE REALLY NEED TO MAKE
SURE WE UNDERSTAND.
>>THEN WE MOVE TO A QUESTION
THAT CAME IN ABOUT WHAT ARE YOUR
RECOMMENDATIONS FOR PARENTS
DEALING WITH AN ADOLESCENT WHO'S
EXPERIENCING CHRONIC PAIN AND IS
NOT GETTING THEIR CHILD'S NEEDS
MET BY HEALTHCARE PROVIDERS?
FOR EXAMPLE, THEY'RE CONCERNED
THAT MAYBE THE PROVIDER IS NOT
EXPLORING WHAT WAS REALLY
CAUSING THE PAIN, OR NOT
RECOMMENDING TESTING TO GET TO
THE BOTTOM OF THE PAIN.
SO THOUGHTS THERE FOR THE
FRUSTRATED PARENT?
>>I THINK THAT'S A VERY COMMON
EXPERIENCE OF PARENTS BECAUSE
THERE ARE FEW PROVIDERS TO START
WITH, SO NOT ONLY IS THE
EXPERIENCE OF NOT GETTING THE
RECOMMENDATION, ALSO THE WAIT TO
GET THE LIMITED RECOMMENDATION,
SO I THINK THE COMBINATION OF
FACTORS IS INCREDIBLY
FRUSTRATING FOR MANY FAMILIES.
UNFORTUNATELY, THERE ARE OFTEN
NOT SPECIFIC DIAGNOSTIC TESTS
THAT HELP US UNDERSTAND WHY PAIN
IS OCCURRING WHEN IT CHRONIC,
AND SO THAT CAN ALSO BE A SOURCE
OF FRUSTRATION BECAUSE THERE'S
NOT A SIMPLE WAY OF DETERMINING
A DIAGNOSIS OR THE SPECIFIC
ETIOLOGY OF THE PAIN.
YOU KNOW, WE REALLY ENCOURAGE
PARENTS TO MAKE GOOD USE OF
THEIR PRIMARY CARE PHYSICIAN WHO
KNOWS THEIR CHILD BETTER THAN A
PROVIDER WHO THEY MAYBE HAVE
ONLY SEEN ONCE OR TWICE AND TO
REALLY BE ABLE TO FOLLOW UP WITH
A PERSON WHO KNOWS YOUR FAMILY
WELL AND WHO CAN MAKE CONTINUED
RECOMMENDATIONS.
AND KNOWING THAT ALL CHRONIC
PAIN DOESN'T NEED TO BE TREATED
BY A SPECIALIST, THERE ARE MANY
EFFECTIVE STRATEGIES THAT
PRIMARY CARE PROVIDERS ARE VERY
SKILLED AT BEING ABLE TO ALSO
DELIVER.
>>I THINK WE'RE GOING TO NOW
TAKE OUR LAST QUESTION HERE, AND
THIS IS -- THIS IS SHARED IN THE
CHAT, IN CASE YOU WANT TO TAKE A
LOOK WHILE I'M SUMMARIZING AND
PARAPHRASING A LITTLE BIT.
SO WE'RE HEARING FROM A PROVIDER
WHO SAYS THAT THEY'VE WORKED IN
PEDIATRIC SURGERY AND THEY'VE
SEEN CARE FOR A TEEN POST SPINAL
FUSION AND THE PAIN MANAGEMENT
REGIMEN SEEMED TO BE, TO HER OR
THIS INDIVIDUAL, INEFFECTIVE.
SO THEY'RE COMMENTING THAT IT'S
CRITICAL TO PROPERLY TREAT ACUTE
PAIN TO MINIMIZE ITS TRANSITION
TO CHRONIC PAIN AND
COMPLEMENTARY AND MULTIMODAL
APPROACHES COULD HAVE GREATLY
IMPROVED THIS PATIENT'S
EXPERIENCE.
SO I THINK REALLY THEIR QUESTION
TO YOU IS HOW CAN THEY AS A
PROVIDER PROMOTE CHANGES IN PAIN
MANAGEMENT WITHIN A HEALTHCARE
SYSTEM THAT YOU MIGHT SHARE WITH
PROVIDERS?
>>IT'S A GREAT POINT.
WE TALK A LOT ABOUT THESE
INDIVIDUAL LEVEL INTERVENTIONS,
BUT INDEED, WE NEED TO DO MORE
AT THE SYSTEMS LEVEL IF WE'RE
REALLY GOING TO EFFECT CHANGE
MORE BROADLY SO I APPRECIATE
YOUR QUESTION BECAUSE WE HAVEN'T
EVALUATED VERY MANY SYSTEMS
LEVEL INTERVENTIONS IN PEDIATRIC
PAIN MANAGEMENT.
THERE IS A GREAT ORGANIZATION
CALLED CHILD KIND THAT CAN WORK
WITH HOSPITALS AROUND
PARTNERSHIPS AROUND PROMOTING --
I WON'T SAY A PAIN-FREE
ENVIRONMENT BUT A COMFORT
ENVIRONMENT IN CHILDREN'S
HOSPITALS.
I THINK THAT'S ONE ORGANIZATION
TO THINK ABOUT, AND IF YOU CAN
GET YOUR HOSPITAL INVOLVED IN
WANTING TO BE PART OF THAT, YOU
GET KIND OF A CHILD KIND STAMP
OF APPROVAL AS A HOSPITAL THAT
CARES ABOUT PAIN MANAGEMENT IN
CHILDREN.
BUT THAT'S ONE TYPE OF, I THINK,
THING TO EXPLORE THAT COULD BE
HELPFUL AT A SYSTEMS LEVEL.
>>WELL, THANK YOU SO MUCH.
AND THE ORGANIZATION THAT YOU
MENTIONED WAS CHILD KIND, YOU
SAID?
>>YES.
GREAT.
THANK YOU.
WELL, DR. PALERMO, THANK YOU SO
MUCH.
I THINK THAT BRINGS US TO THE
END OF OUR QUESTION AND ANSWER
PERIOD WITH YOU, AND BRINGS US
TO THE END OF OUR LECTURE TODAY.
SO AGAIN, I WANT TO THANK
DR. PALERMO, I WANT TO THANK DRT
TO THANK THE NCCIH TEAM WHO
HELPED THIS LECTURE COME TO
FRUITION.
BUT ALSO WE REALLY JUST WANT TO
THANK YOU, OUR VIEWERS, FOR
JOINING US TODAY, FOR ASKING
YOUR THOUGHTFUL QUESTIONS.
AGAIN, THIS IS BEING RECORDED,
AND WILL BE AVAILABLE ON THE NIH
VIDEOCAST WEBSITE IN THE PAST
EVENTS SECTION FOR FUTURE
VIEWING, SO IF YOU'D LIKE TO
WATCH AGAIN, TUNE IN AGAIN.
AND ALSO AS YOU KNOW,
DR. PALERMO GRACIOUSLY SHARED
HER CONTACT INFORMATION WITH YOU
IF YOU'D LIKE TO FOLLOW UP WITH
ANY QUESTIONS THAT YOU HAVE.
SO WITH THAT, I WANT TO BRING
OUR TIME TOGETHER TODAY TO A
CONCLUSION, AND I WISH YOU ALL A
WONDERFUL AFTERNOON.
SO TAKE CARE, EVERYONE.
BYE-BYE.