The various types of pain and how to assess them
We sat with Dr Amaury Salavert, an authority in pediatric pain management, for a fascinating talk on pain ranging from assessment to treatments and the contribution Alternative and Complementary medicines can make.
This is part 1 of 6, where we discuss the various types of pain and how to assess them.
Dr Amaury, thank you for joining us. What is your experience with treating and managing pediatric pain?
Thank you for having me. I have been working in pediatrics for seven years and have developed a specialty in pain management. I have treated over 800 patients with chronic pain. I am currently the only doctor providing consultation for pediatric pain at the Ambroise Paré hospital.
Can you explain the different types of pain for children?
There are two types of pain for children: short-term pain and long-term pain. Short-term pain is the pain everyone experiences when they have stitches or a bone break. Long-term pain is more insidious and can last for a long time, making it difficult for the patient, family, and doctors to know how to treat it. Mind you, these are slightly different than the usual acute/chronic pain distinction we make for adults as they are of different lengths.
And the second type of pain, long term pain, is what you have a strong expertise in, right?
I specialize in long-term pain yes, but I also help with short-term pain when medications are not working. For instance with sickle cell disease. In this case you need a lot of pain killers, heavy pain killers, and sometimes doctors don't know why they still won't work. That's when they call me too.
When you say doctors reach out because “they don't know”, is it because they lack the training, there isn’t enough research or because the drugs aren’t developed yet?
Most of the time it's because they lack the training. Also it's because these medications are extremely hard to use. There were a lot of misuse of opioids in the past for instance. Now doctors are scared to use them. If used properly though, you can mitigate the risks. That's when and where I can help.
You distinguish between short term pain and long term pain. Do you also distinguish between physical pain and emotional pain?
Yes I do, to be more specific I distinguish between three types: nociceptive, neuropathic and nociplastic pain. Nociceptive pain is the pain of a fracture, neuropathic pain is postoperative pain or when a nerve is reached and nociplastic pain is a combination of physical and emotional pain. This is where I'm truly specialized, as normal pediatricians learn about these types of pain but do not necessarily know the different treatments used for each. For instance, doctors might not know that for nociplastic pain both pharmaceutical and non-pharmaceutical treatments are equally important. In fact non-pharmaceutical treatments are critical
When you meet a child, how do you determine when the child is experiencing pain and what type of tests do you typically use to determine the source and level of pain?
In France, it is mandatory by law to evaluate every child's pain. Depending on the age of the child, different tools can be used to assess the pain, such as the Evindol scale, which is validated from age zero to seven, or the Wong–Baker faces pain rating scale, which can be used starting from four to five years. In addition, the medical history and the parents' input can help determine the source for more nuanced chronic pains.
Are there objective ways to measure pain that you use too?
There are some tools that are designed to control pain objectively, based on heart rate or the blood pressure, but they are not very effective. The reason why Wong-Baker is so effective versus more objective scales is because you can trust your patient’s feedback in pediatrics. Maybe they won't know how to precisely quantify pain but if they experience it they will tell you. Children answer's are free from all social conventions. The exception being psychomotor atony. That's when pain is so intense that a child doesn't cry anymore and doesn't move anymore. Then the only way to measure pain is to stimulate it.
We've talked about the intensity, now how do you assess the gravity of pain in a child?
When assessing the gravity of pain in a child, it is important to consider the intensity as well as the cultural and social factors that can influence its perception. For example, Chinese women are known to feel less feet pain than European or Occidental women. That's because in some parts of China they were wearing tiny shoes for cultural reasons. Because of this, still today, they end up feeling less feet pain. So pain differs from one individual to the next. It also differs for a single individual from one situation to the next. For example, hitting one's toe on furniture can be very painful on a Monday morning when one is in a rush, but not as much on a Saturday afternoon when one is on holiday. This is why it is important to take into account all the factors that can influence the perception of pain.
And so how does that impact the treatment?
That's the thing. For a same cause, depending on the lesion, depending on your emotional state, depending on your cultural background, the pain can be felt differently and so requires a different treatment. That’s why it’s so difficult to do pain management, it’s multifactorial.
What are the most common causes of pain in pediatric patients?
When it comes to the most common causes of pain in pediatric patients, the most common types of short term pain are broken limbs or twisted limbs, abdominal pain (such as appendicitis or constipation or gastroenteritis), and headaches. Long term pain is most often experienced as migraines and headaches, but can also include musculoskeletal pain or abdominal pain.
Hope you've enjoyed this part of the interview. To continue and learn about the different types of treatments available for pediatric pain management, go to part 2.