A new Web tool developed by Dr. Tonya Palermo is improving the outcome for kids with chronic pain by teaching cognitive behavior and pain management skills.

Palermo 220x180When Dr. Tonya Palermo started studying chronic pain in children, little was known about risk factors or effective treatment approaches. “The field of pediatric chronic pain was barely recognized 20 years ago,” says Palermo, who specializes in pain management.

Today, pediatric pain medicine programs like the one at Seattle Children’s treat chronic pain using a variety of integrated methods, including cognitive behavioral strategies that teach children skills to cope with their pain. While it may not be possible to eliminate the pain, treatment can help children manage their condition and live a full life.

The problem is there are only about 30 to 40 hospitals in the country with programs like these.

“Many children have no option in their local community for pain management,” says Palermo, a psychologist who joined Children’s in 2010. “Even children who may be able to come to a pain program for consultation may not have the resources to return and learn effective skills such as behavioral pain management — especially if they live in rural areas.”

Much of her research involves understanding how problem-solving, relaxation techniques and other cognitive behavioral strategies can help children reduce their pain and stay active. Now she is testing whether those strategies can work via the Internet.

Though Palermo isn’t the only one pursuing this approach, she is among the first to go live with an online pain management intervention, notes Dr. Gary Walco, who leads pain medicine at Children’s. “Tonya’s work has already resulted in some very promising findings that ultimately could improve the quality of life for many children.”

Bringing pain management home

A surprisingly large number of children — an estimated 35% to 40% — experience some degree of chronic pain, usually headaches, backaches or abdominal pain. In 5% to 10% of the cases, the pain becomes disabling, causing children to miss school, stop exercising and withdraw from friends. The peak age of chronic pain is around 14 or 15 and it’s most prevalent in girls. “We believe there may be aspects of adolescent biology, physiology and psychology that put youth at risk,” Palermo says. “Understanding risk factors for developing chronic pain is an active area of research.”

Medications play a large role in managing acute pain when the underlying mechanisms causing the pain are clear, but they play a much smaller role in chronic pain management because the mechanisms are often more complex.

The most effective approach combines the expertise of pain physicians, physical therapists and psychologists to develop treatments focused on a child’s specific needs. A comprehensive treatment plan often includes physical/rehabilitative interventions, cognitive behavioral strategies, medical care and complementary approaches like acupuncture — all of which are offered in integrated pediatric pain medicine programs like the one at Children’s.

Palermo’s interest in helping children overcome the geographic barriers to pain management programs began at Oregon Health & Science University. “A lot of families were struggling to find the care they needed,” says Palermo. “I wondered if the Internet could help children cope with chronic pain because of the success of other online health interventions, and the Internet’s availability to many families.”

Dr. Tonya Palermo's online intervention changes the options available for individuals with chronic pain and may ultimately prevent or lessen its negative consequences.

Largest pediatric chronic pain trial ever begins

The online intervention developed by Palermo takes a two-pronged approach: it teaches the child with chronic pain to use cognitive behavioral strategies, and it teaches parents how to support their children.

Palermo led a small trial comparing children who completed the eight-week intervention to a control group and found that the children who completed the intervention reduced their pain and increased their activity (going to school, playing sports, spending time with friends) at a greater rate than the control group.

She recently received a five-year grant from the National Institutes of Health to carry out a larger version of the trial involving over 300 children at a dozen sites across the United States and Canada. It’s the largest randomized controlled trial targeting pediatric chronic pain ever undertaken, and enrollment is expected to begin in spring or summer 2011. In the meantime, patients and families in the pain medicine program at Children’s have access to the online intervention to supplement the care provided at the hospital.

Palermo added more content to her website for the new study, but the intervention’s basic format is the same. Every week, children are introduced to a new cognitive behavioral strategy via an engaging travel scenario where they journey to different destinations to learn new skills. Children then practice the skills, report on their experience and receive encouragement from study staff to continue practicing. They also keep a pain diary.

Interrupting the spiral

Unlike acute pain, which is typically caused by injury or illness and subsides with recovery, chronic pain either lasts beyond the expected period of recovery or persists indefinitely without any obvious cause. It can also get worse over time. As the intensity and frequency of the pain increases, individuals may become less active, experience declines in their mood, develop sleep problems and begin to feel hopeless about their problem with pain. These negative physical and emotional responses can in turn increase pain sensations, contributing to a spiral that can be difficult to interrupt.

“This spiral can continue into adulthood,” says Palermo, who hopes to disseminate her online intervention on the websites of hospitals and community organizations if the larger study confirms her earlier success. She sees her approach as a way to change the options available for individuals with chronic pain and ultimately prevent or lessen its negative consequences.

“We often don’t see children at pain medicine programs until the pain is already disabling,” Palermo says. “Providing broad access to behavioral coping skills over the Internet might lead more children to get help earlier in the course of the pain problem. My next step is to examine whether reaching children earlier in their own communities can interrupt the progression of chronic pain before it spirals into a difficult clinical condition.”