Table Of ContentManaging Persistent Pain in Adolescents
Managing Persistent Pain in Adolescents
A handbook for therapists
ROSLYN ROGERS
Occupational Therapist
Royal Children’s Hospital
Victoria, Australia
Foreword by
ANITA UNRUH
PhD RSW OT(C) RegNS
Professor, Health and Human Performance
and Occupational Therapy
Dalhousie University
Halifax, Nova Scotia, Canada
Radcliffe Publishing
Oxford (cid:129) New York
Radcliffe Publishing Ltd
18 Marcham Road
Abingdon
Oxon OX14 1AA
United Kingdom
www.radcliffe-oxford.com
Electronic catalogue and worldwide online ordering facility.
© 2008 Roslyn Rogers
Roslyn Rogers has asserted her right under the Copyright, Designs and Patents Act 1998 to
be identifi ed as the author of this work.
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system
or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording
or otherwise, without the prior permission of the copyright owner.
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library.
ISBN-13: 978 184619 012 4
Typeset by Pindar New Zealand (Egan Reid), Auckland, New Zealand
Printed and bound by TJI Digital, Padstow, Cornwall, UK
Contents
Foreword vii
Preface ix
Acknowledgements xi
Using this book xiii
Introduction 1
CHAPTER 1 The how and why of pain 11
CHAPTER 2 Medical matters 38
CHAPTER 3 Pain and the family 53
CHAPTER 4 Sleep 71
CHAPTER 5 Making changes 82
CHAPTER 6 Dealing with the pain 101
CHAPTER 7 Mindfulness, relaxation and imagery 117
CHAPTER 8 Thought, words and actions 133
CHAPTER 9 Becoming fi t 155
CHAPTER 10 Returning to school 168
Glossary 185
Appendix: The handouts 187
Index 207
Foreword
In the past 30 years our understanding of pain in infants, children and
adolescents has advanced by leaps and bounds. As a result there are many
books now about pain in children, and an excellent book on pain in neonates
which is now in its third edition. But there is, as yet, no book that is specifi cally
concerned with pain in adolescents and their special needs and circumstances.
More importantly, there has been no clinical book that is specifi cally for the
therapists and practitioners who work with adolescents living with pain.
Roslyn Rogers has worked with adolescents in pain for many years in her
capacity as an occupational therapist at the Royal Children’s Hospital in
Victoria, Australia. Rogers has always worked as a member of a multidisciplinary
team using a biopsychosocial approach, and believes that a team approach will
work whereas serial referrals to a single discipline are more likely to fail. This
view is supported by existing pain research; implementing a biopsychosocial
approach enables adolescents who have been unable to function (sometimes
for years) to live a meaningful life – sometimes despite their pain, sometimes
with no pain, sometimes with less pain. Rogers is convinced that therapists
can assist families and adolescents to apply strategies that support optimal
coping and independence.
Rogers has taken the theoretical underpinnings of cognitive behavioural
therapy and contextual cognitive behavioural therapy, and applied them to the
issues of adolescents as they pertain to managing and living with pain. There is
a strong focus in this book on practical, applied strategies – including working
with beliefs and values, mindfulness meditation, relaxation and imagery along
with improving overall physical fi tness and promoting routines for restorative
sleep. Family relationships and the family context are always a signifi cant issue
for parents and adolescents who are struggling with signifi cant health concerns.
Rogers provides a practical discussion about interventions with families that
is thoughtful, compassionate and fi rm in promoting the adolescent’s need to
take responsibility for her or his health towards independence. A signifi cant
aspect of this direction is negotiating return to school and the anxieties and
uncertainties a return will hold for the adolescent and family.
Each chapter has sections that provide practical instructions and suggested
F
ways to deal with potential obstacles. ‘Yellow fl ags ’ are used to identify
vii
viii FOREWORD
key psychosocial factors that may interfere for the child, family or school and
some strategies for managing these factors. Clinicians will appreciate the many
case examples. Many of the cases are success stories but others illustrate the
complexity of situations that do not resolve or improve easily, if at all, and
some of the issues that can limit progress.
This book is a wonderful clinical book for those who are interested in
understanding more about the practical application of contextual cognitive
behavioural therapy for the management of pain in adolescents.
Anita Unruh
Professor, Health and Human Performance and Occupational Therapy
Dalhousie University
Halifax, Nova Scotia, Canada
January 2008
Preface
For the last eight years I have been treating adolescents with persistent pain
who have been referred to a multidisciplinary outpatient pain management
clinic attached to a large paediatric hospital. The multidisciplinary team in the
clinic consists of an occupational therapist, a physiotherapist, a psychologist, an
anaesthetist and a consultant psychiatrist and follows a consistent programme
based on cognitive behaviour therapy. The pain management outpatient
clinic is open to all children up to 18 years of age. Most of our population are
adolescents with a mean age of 14 years. For this reason this book is based on
an adolescent population.
The idea for this book has grown in my mind for some years. The impetus
grew whenever I had students or a health practitioner just starting practice,
or phone calls from solo practitioners, particularly in rural areas, struggling
to understand what to do with an adolescent whose pain and distress was
greater than the original injury: ‘they ‘ought’ to be better’, ‘it’s a mystery’,
‘it’s all psychological’, ‘we’ve tried this, we’ve tried that, nothing works’ being
recurring themes. The impetus also grew whenever our team failed in our
attempts to fi nd a therapist or therapists able to treat persistent pain not as
unimodal but as a complex biopsychosocial problem. We have always needed
a support system of therapists in the community to whom our patients could
be referred following completion of our programme.
Finally, as I worked in a teaching hospital with access to training and
libraries, I dreamt of providing a bridge between the academic arm of
research in the pain-management specialty and the clinical application of
these ideas. Most therapists in the community do not have either time or
access to conferences, journals and books. Additionally, knowledge in chronic
pain mana gem ent is drawn from a very wide fi eld. For this reason, I have
made an attempt to support suggestions for clinical practice with evidence
from a wide fi eld. Sometimes, however, there is no clear evidence for what is
common clinical practice. This does not mean that a practice is inadvisable:
it may refl ect the insuf fi ciency of evidence or the limitations of scientifi c
investigation. Therefore, some suggestions in this book are based on clinical
experience while others are based on evidence presented in the research
literature, and this is indicated in the text. While the book does not critically
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