Chronic pain: How to treat and manage in older children

By SickKids staff

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Find out how to use the 3P approach to manage chronic pain in older children.

Key points

The 3P approach to pain management includes psychological, physical and pharmacological methods to treat and manage pain.
Physical approaches include helping your child choose a level of physical activity that will not cause harm and balancing periods of rest with periods of activity.
Psychological approaches include changing thinking patterns to reduce pain-related fears and stress and using techniques such as distraction, guided imagery and relaxation.
Pharmacological approaches include over-the-counter and prescription pain relievers.

Introduction

Treatment

Physical strategies

Physical strategies are activities that help the body to function physically. They include conditioning exercises, stretches, endurance activities and nervous system retraining. They are typically guided by physical and occupational therapists.

"Pacing" is one strategy that can help an older child. It involves learning how to balance activity and rest so that a child can be active in important daily activities (such as participating in school and going outdoors with friends).

Try using the traffic light analogies below for your child's physical activity.

Pacing guidelines for physical activity

Traffic lights to pace physical activity and rest

Red light

Severe pain increases during an activity and stops activity participation
Pain persists for day to weeks
Possible risk of injury

Yellow light

Safe pain
Pain spikes but is tolerable during an activity and will not cause harm
Pain persists for 24-48 hours after an activity before returning to baseline

Green light

Safe pain
Pain spikes but is tolerable during an activity and will not cause harm
Pain is no worse after an activity

Your child should stay in the green light and may edge into the yellow. They should not go in the red light.

Red light

Stop and rest.
Key phrase: “I need to take a break. I can use my coping strategies for relaxation and recovery so I am ready to go again after my rest.”

Yellow light

Be alert.
Key question: “Am I overdoing it or can I use my coping strategies to keep going a bit longer?”

Green light

Be active but save some of your energy.
Key phrase: “I am being active and I am fine.”

Make sure that your child has time in the green and red traffic light areas. Yellow reminds them to stop and take a break.

Psychological strategies

Psychological strategies can be thought of as "mind-body" strategies or "the power of the brain to help the pain".

They can include therapies to:

reduce fearful thoughts about pain
reduce fear of moving a painful area of the body
decrease stress
improve confidence in being able to get back into life in areas that pain has disrupted (such as sports, school, sleep or social activities).

They also include some of the following techniques to support your child and reduce the impact of pain on the family.

Distraction

Distraction can be a particularly helpful psychological strategy when a child is experiencing pain. Distract your child with an activity or item that is of interest to them. Active distraction (such as doing an activity or talking with friends) is better than passive distraction (such as watching TV).

Guided imagery

You can help your child use guided imagery to cope with an episode of pain by asking them to imagine that they are in a calm, peaceful environment or to remember a pleasant experience from their past. Encourage your child to describe what they see, as well as any smells, sounds or other sensations. Older children can also listen to online guided imagery scripts.

Belly breathing

Relaxation

Relaxation is another psychological strategy that can help your child cope with chronic pain.

Belly breathing is one such technique, as it helps your child slow down their breathing and become more relaxed. Encourage your child to take a few slow deep breaths into their belly, breathing in through their nose and out through their mouth.

They can place their hands over their belly to check that it is rising with every in-breath and falling with every out-breath.

Your child's health-care team may teach you other strategies to support your child and reduce the impact of pain on the family. These include helping to distract your child from pain, remaining calm and developing a plan to cope with pain when it arises.

Pharmacological strategies (medications)

Pharmacological strategies are the medications that treat your child's chronic pain. They are rarely used alone; they should nearly always support physical and psychological strategies.

Pain medications are typically divided into:

simple analgesics (pain relievers)
opioids
adjuvants

Simple analgesics include acetaminophen and ibuprofen and are available over the counter. They are helpful for mild to moderate pain (especially resulting from tissue inflammation).

Opioids are among the strongest pain relievers and are often used after surgery or other major painful procedures. If your child is in moderate to severe pain, their health-care team may prescribe opioids such as morphine, oxycodone or hydromorphone, generally for short-term use.

Opioids have risks and side effects, which can be serious. Always talk to your child's health-care provider for advice on taking, storing and disposing of opioids safely.

Adjuvants are medications that are shown to work well for pain but are mainly used for other reasons. Examples include anticonvulsants and cannabinoids.

For all medications, talk to your health-care professional for more information.

What kind of improvements should I see in my child's chronic pain?

Your child's chronic pain will not always improve consistently. There may be good days and bad days, good weeks and harder weeks.

Sometimes things might even get worse before they get better. For example, as your child begins their therapies and their body becomes more active, they may experience muscle soreness and throbbing. This is natural in weak or tight muscles that are not used to exercise or stretching and will ease in time.

To stay focused on managing pain effectively, make weekly goals with your child and remember that improvement can sometimes take time.

Improvements in function

One important area for goal setting is return to function. This means returning to activities that pain has disrupted, for example going to school, taking part in family routines or doing physical or social activities.

A return to function, rather than improvement in pain, is actually the first sign that chronic pain treatment is successful. This is because pain can often take weeks to months to improve while weak muscles gradually become stronger. If your child waits for their pain to go away before getting back into life, there is a risk that their pain will get worse.

Resources

References

Last updated: January 25th 2019

Chronic pain: How to treat and manage in older children

Key points