Tag Archives: chronic abdominal pain

Educating Families About Chronic Pain

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AN Borucki et al. JPGN 2024; 78:169–173. Terminology for discussing chronic pain: Using metaphors to educate families on chronic pediatric pain

This article provides a good review and practical advice regarding chronic pain which “affects 25% of all children in U.S.”

Defining pain: “Acute pain is protective pain, which is related to tissue damage that resolves with healing. Acute pain processes often respond to rest and treatments aimed at reducing inflammation. The problem is when acute pain treatments are applied to chronic pain. Chronic pain is not protective; it is due to functional dynamic changes at the level of the brain and spinal cord that are pronociceptive…When pain persists after the expected time for the tissue to be healed or infection to have cleared, the pain is considered chronic.”

Education on chronic pain: “Patients may also have felt their pain dismissed when medical workup returned as normal. When providers explain the neurobiology of pain, families can be validated that the pain IS real and that pain CAN exist without evidence of structural damage.”

Pain treatment:

  • “There is little evidence to support the efficacy of medications within chronic pain treatment. A systematic review including over 1000 children with functional abdominal pain found very low evidence for the efficacy of antihistamines, antiemetics, serotonin agonists, buspirone, melatonin and concluded antispasmodics or antidepressants can be considered given their tolerability.”
  • “Cognitive behavioral therapy has the most support in treatment of functional abdominal pain in children.”
  • “Metaphors used to distinguish acute and chronic pain …[Alarm metaphor] :Pain is an experience with body, mind, and social factors produced by the brain. Pain is supposed to alert us of bodily harm. If this alarm does not shut off, we have chronic pain. Imagine that you’re in a building and the fire alarm goes off because there is afire. Once the fire is extinguished, then the alarm stops, just like as the body heals, pain goes away. This is acute pain. Now imagine that the fire alarm goes off, firefighters arrive, investigate, and then announce that fortunately there is no fire. But unfortunately, they cannot turn off the fire alarm because it’s broken—the alarm continues. This is chronic pain. With chronic pain, the wiring of the alarm system itself is malfunctioning. The system that detects the fire and then signals the danger is not working and, in fact, is sending a false alarm. This is your nervous system with chronic pain. It is detecting danger to your body and signaling pain when it should not be. Now normal everyday experiences, including thoughts, feelings, and sensations are being interpreted as pain.”
  • Three-legged stool for resetting system: 1. Medical treatments, like certain medications, therapies like acupuncture, or procedures 2. Physical/occupational therapy which teaches us how to move more effectively with the pain we are experiencing 3. Psychological interventions like CBT.

My take: This article provides a good approach for addressing chronic pain.

Related blog posts:

Bryce Canyon (using vertical pano)

A (Virtual) Reality Without Pain?

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NY Times Magazine, Helen Ouyang 5/22/22: Can Virtual Reality Help Ease Chronic Pain?

This lengthy article describes the emerging therapy of virtual reality to help with chronic pain. Some of the article focuses on chronic abdominal pain.

Here are some excerpts:

  • Brennan Spiegel, a gastroenterologist and researcher at Cedars-Sinai .. runs one of the largest academic medical initiatives studying virtual reality as a health therapy…
  • As Daniel Clauw, who runs the Chronic Pain and Fatigue Research Center at the University of Michigan, put it in a 2019 lecture, there isn’t “any drug in any chronic-pain state that works in better than one out of three people.” He went on to say that nonpharmacological therapy should instead be “front and center in managing chronic pain — rather than opioids, or for that matter, any of our drugs…”
  • In November, the Food and Drug Administration gave authorization for the first V.R. product to be marketed for the treatment of chronic pain.…
  • [In one] virtual environment … built specifically for patients with chronic gastrointestinal symptoms…[the patient] used hand controls. Inside a virtual clinic, a robot named Maia — short for “mixed-reality artificial-intelligence assistant” — guided her to a young blond woman, who expressed frustration with abdominal symptoms. [The patient] examined the [virtual] patient with her virtual hands, placing a stethoscope on her stomach to listen to the sounds of digestion. Maia explained how the brain and the gut work together. As she spoke, an image of a brain popped up, connected to intestines by a yellow flashing line. When the brain became stressed, it turned fuchsia in color, and the yellow line to the gut metamorphosed into a stream of fire...
  • Scientists knew that the brain has some control over pain, but that insight was mostly confined to the situations described by Patrick Wall’s and Ronald Melzack’s gate-control theory, which helps explain why, say, a person running from a house on fire may not realize that she sprained her ankle until she is a safe distance away. The brain, so intent on escaping the fire, shuts the gate, blocking pain signals coming up the spinal cord from the ankle. “You could close the gate,” says Clifford Woolf, a neurobiology professor at Harvard Medical School who worked in Wall’s lab, but “essentially there was nothing about the opposite possibility — which is that the brain, independent of the periphery, could be a generator of pain.”
  • “Woolf was conducting his own experiment in Wall’s lab, applying painful stimuli to rats’ hind legs. The animals developed large “fields” of pain that could easily be activated months later with a light tap or gentle warmth, even in spots that weren’t being touched directly. “I was changing the function of the nervous system, such that its properties were altered,” Woolf says. “Pain was not simply a measure of some peripheral pathology,” he concluded; it “could also be the consequence of abnormal amplification within the nervous system — this was the phenomenon of central sensitization.”
  • V.R.’s “unique ability to convey a sense of just ‘being there,’ wherever there happens to be,” as he [Spiegel] puts it in his book “VRx: How Virtual Therapeutics Will Revolutionize Medicine.” “All of its revolutionary potential tumbles out of its ability to compel a person’s brain and body to react to a different reality.” 
  • RelieVRx also has modules that prompt patients to redirect their attention through game play or by allowing scenes — waves washing onto a sunny coast, say — to soothe their nervous systems. The average session lasts seven minutes, and patients are directed to do just one a day for eight weeks…
  • A recently published study by researchers affiliated with the company [AppliedVR], for which they recruited subjects during the pandemic through Facebook ads and pain organizations, reported an average drop in chronic back pain by nearly 43 percent for the RelieVRx group compared with 25 percent for the control group. For those who used RelieVRx, pain also interfered less with their activity and sleep. Three months after the last V.R. session, these gains were mostly found to endure…
  • In chronic pain, the body part that hurts may be undamaged and even seem healthy; what’s altered is the area of the brain that corresponds to its anatomical location...
  • If doctors do start prescribing V.R., there’s another hurdle to clear: Who will pay for it? 

My take: I am looking forward to the pediatric studies which will be needed before this technology can be promoted. I would think pediatric patients with chronic pain may respond even more favorably than adults. If this technology were in our clinic, I am certain that are “no show” rate would be lower.

Related blog posts:

This could be me in a virtual reality. Picture taken at Connie’s Photo Park in Madrid, NM.

Disaccharidase Deficiencies in Recurrent Abdominal Pain

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Question for pediatric gastroenterologists (first poll I’ve placed in this blog): Do you think disaccharidases are needed routinely for patients with abdominal pain in the absence of bloating, or diarrhea?

A recent report indicated a high rate of disaccharidase deficiencies among children with recurrent abdominal pain. Here’s the abstract link: Disaccharidase Deficiencies in Children With Chronic Abdominal Pain (K El-Chammas, SE Williams, A Miranda. Published online before print July 9, 2015, doi: 10.1177/0148607115594675JPEN J Parenter Enteral Nutr July 9, 2015 0148607115594675).  Thanks to Kipp Ellsworth for this reference.

Here’s an excerpt:

Data on disaccharidase activity and histology of endoscopic biopsies were collected retrospectively. Only patients with normal histology were included in the study.

Results: A total of 203 pediatric patients with CAP were included. The mean (SD) age was 11.5 (3.1) years, and 32.5% were male. The percentages of abnormally low disaccharidase levels using the standard laboratory cutoffs were lactase, 37%; sucrase, 21%; glucoamylase, 25%; and palatinase, 8%. Thirty-nine percent of the patients with low lactase also had low sucrase, and 67% of the patients with low sucrase had low lactase…Also, no association was found between stool consistency, stool frequency, or location of pain and low disaccharidase activity.

My take: I am highly skeptical regarding these findings–see Twyman’s Law | gutsandgrowth. For sucrase deficiency, for example, this report represents an extraordinarily high rate of deficiency compared with previous reports. In addition, there are numerous errors which can occur in the handling of tissue specimens.  With regard to lactase deficiency, of course, this is common but having lactose intolerance does not prove causality with regard to abdominal pain.  Many physicians encourage families to see if there is a link between milk ingestion and GI symptoms to help determine if lactose intolerance is a likely contributor to stomach pain (before endoscopy). Stomach pain in the absence of milk ingestion is not due to lactose intolerance.

Before accepting these high rates, improved methodology (eg. control group and duplicating results) would be helpful.

Related blog post: Congenital Sucrase Isomaltase Deficiency