Chronic pain: How to treat and manage in teens

By SickKids staff

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Find out how the 3P approach to pain management can help your teen manage their chronic pain.

Key points

The 3P approach to pain management is a mix of psychological, physical and pharmacological methods to treat and manage pain.
Physical approaches involve encouraging your teen to use pacing to help them choose the right level of physical activity and balance activity with periods of rest.
Psychological approaches include techniques such as distraction, guided imagery and relaxation and, if needed, therapy to address unwanted thoughts and behaviours related to pain.
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 a teen stick to their routines. It involves learning how to balance activity and rest so that your teen can do important everyday activities (such as participating in school and meeting up with friends) even if they are in pain.

Try using the traffic light analogies below to help your teen follow their routines without making their pain worse.

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 days 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 to 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 teen should stay in the green light and may edge into the yellow. They should not go in the red light.

Pacing guidelines to balance activity and rest

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.”

Your teen should make sure they spend time in the green and red traffic light areas. Yellow reminds them to stop and take a break.

Golden rules of pacing

Understand that it takes time to learn how to pace properly – don’t expect immediate success.

Encourage your teen to try using a timer to know when to stop an activity before their pain or tiredness gets bad.

Encourage your teen to use time as their guide so that they, not their pain, stays in control of their activities.

Remind your teen that they are only pacing themselves, not competing with any of their peers.

Encourage your teen to plan their activities carefully so that they do not squash everything into one day.

Psychological strategies

Psychological 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 routines and activities 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 teen is experiencing pain. Active distraction (such as doing an activity, talking with friends or playing a video game) is better than passive distraction (such as watching TV).

Guided imagery

Your teen can use guided imagery to cope with an episode of pain by imagining that they are in a calm, peaceful environment or remembering a pleasant experience from their past. Guided imagery works best when the scene includes what they see, as well as any smells, sounds or other sensations. There are many online guided imagery scripts that your teen can follow on their smartphone or other mobile device.

Belly breathing

Relaxation

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

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

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

Behavioural therapy

If your teen has become fearful of moving their body and is very distressed about their pain, they may need specialized therapy to help them. Cognitive behavioural therapy (CBT) can help change a person's unhelpful thoughts and behaviour patterns if they are getting in the way of their day-to-day life. Working with a therapist, your teen can develop strategies and tools to understand and change their unhelpful thinking patterns or behaviours. For example, instead of thinking “I won't go out with friends because I will be a burden to them”, CBT can help someone develop more helpful thoughts such as, “I won’t be able to do the same level of activity as my friends right now, but that doesn’t mean we can’t have fun together. I can invite them over to watch a movie or we can meet up for dinner.”

Pharmacological strategies (medications)

Pharmacological strategies are the medications that treat your child's 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. 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 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 teen's chronic pain?

Your teen'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 teen 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 teen 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