Speaker: Susmita Kashikar-Zuck


Dr. Kashikar-Zuck will discuss gaps in the evidence-base for biopsychosocial interventions for pediatric chronic pain and the need to increase innovation and rigor in interventions for chronic musculoskeletal pain. Prior work in cognitive-behavioral (CBT) and related therapies have shown great promise in reducing disability and improving pain. However, the effects of these treatments are modest and not optimized for robust effects on pain reduction and physical activity promotion. The Fibromyalgia Integrative Training program for Teens (FIT Teens) was developed in collaboration with Sports Medicine and combines CBT and progressive neuromuscular exercise training. FIT Teens is conducted in a supportive (in-person or remote) group setting and aims to reduce pain and disability and increase confidence in movement. A large multi-center clinical trial of FIT Teens enrolled over 350 adolescents with juvenile fibromyalgia (JFM) and is nearing completion. Dr. Kashikar-Zuck will present highlights of successfully running a behavioral trial with strong clinical trial rigor (in the context of a global pandemic). Clinical characteristics of this large sample of adolescents with JFM including patient-reported and performance-based outcomes will be discussed as well as engagement with the study and social cohesion in the treatment groups. The talk will include a methodologic primer on the implementation of multicenter trials, centralized data management and monitoring of trial metrics including recruitment, retention, fidelity, adverse events and safety. This large study has provided the infrastructure for a number of ancillary studies of pain mechanisms, executive functioning and pain-related stigma in adolescents with chronic pain. Adaptations of FIT Teens are also being developed for multiple medical conditions such as sickle cell disease and juvenile arthritis. Future research should take a mechanistically informed approach to more effectively treat chronic pain in childhood.


Learning Objectives:
1. Describe how the new FIT Teens intervention addresses gaps in current behavioral treatments for chronic musculoskeletal pain in adolescents.
2. Recognize the characteristic features of JFM and the impact of pain on self-reported and performance-based measures of functioning. 
3. Articulate the key elements required for running a rigorous randomized controlled trial in pediatric chronic pain.

Understanding pain processes over the first years of life is an important area of study, as the implications of these processes ripple across not only childhood but other life stages.  Implicit in this ripple effect is that there is a malleability that can support early intervention for more adaptive pain experiences as one ages. While pain is ubiquitous, how pain is experienced and expressed takes shape uniquely for each individual based on an idiosyncratic synthesis of biological, psychological, and social experiences.  Taking a multidisciplinary perspective, this international panel will take a deeper dive into three distinct developmental phases of early childhood and important influences that shape pain responses. Dr. Ranger, an early career nurse scientist, will present original findings on whether early repeated exposure to pain, sucrose, or a combination of the two, affects inflammatory markers and induces brain microgliosis in neonatal mice.  Professor. Pillai Riddell, a basic behavioural scientist and clinical psychologist, will present novel results regarding regulatory patterns of parent-child attunement during vaccinations over the second year of life.  Finally, Dr. Wallwork, a postdoctoral fellow in physiotherapy, will present new findings regarding how parents and other caregivers can build resilience in pre-schoolers through the power of narratives. 

Chronic pain in children is common and associated with increased risk for psychosocial and academic impairment.  While cognitive behavioral therapy with a trained specialist is effective, many youth do not have access to specialized care. Partnerships between researchers and school providers may help address pain in youth in a manner that is equitable and inclusive. This session presents data from experiences of partnering with school providers to develop and implement training in cognitive behavioral approaches for addressing pediatric pain.  This session will discuss experiences from different regions and countries in partnering with school providers to offer training in nonpharmacological strategies to manage pediatric chronic pain.  Dr. Natoshia Cunningham will report on an ongoing project targeting rural underserved areas in Michigan (USA) by partnering with key stakeholders to train school providers (nurses and mental health specialists) in pain-focused CBT.  Dr. Mark Connelly will present on a project in Kansas and Missouri (USA) training school nurses in the evaluation and nonpharmacological management of headache.  Aikaterini Giannakopoulou (junior presenter) will present on a project in Gothenburg (Sweden) involving training school nurses in the use of a mobile app to improve attendance in youth with chronic pain. Controversies and future directions will be addressed.

Pediatric chronic pain is complex, common, costly, and consequential. While many youth with persistent pain benefit from outpatient treatment, those with refractory pain often experience functional impairment requiring a more intensive approach. Such intensive interdisciplinary pain treatment (IIPT) programs use a biopsychosocial framework to restore patient function and reduce pain-related disability, through a self-management approach. Studies of IIPT clinical effectiveness demonstrate significant decreases in pain, functional disability, and psychiatric symptoms at program completion and up to seven years after treatment. Still, not all patients benefit sufficiently from IIPT. As IIPT entails significant time and resources from patients, caregivers, providers, and institutions, there is a fundamental need to simultaneously optimize IIPT effectiveness and efficiency. This symposium will describe three innovative approaches to enhance IIPT engagement and outcomes by partnering with patients and families at various points in their IIPT experience: while preparing for IIPT, while engaging in IIPT, and while generalizing IIPT to the home setting. Each presenter will describe key aspects of the clinical application of their intervention as well as share research findings thus far, using mixed methods of data analysis. Discussion will include additional potential future directions for IIPT, with time for audience questions as well. 

Pain is the most common symptom reported by parents of children with severe neurological impairments (SNI), but when children can’t tell us where it hurts, parents and healthcare providers rely on interpretation of nonspecific pain-like behaviours to detect the presence of pain. These signs are challenging to evaluate and cannot always be attributed to a specific cause. Moreover, in children with complex neurological conditions, pain-like behaviours are not always due to disease or injury (nociceptive-inflammatory, or nociceptive), but instead may be due to generalized irritability of the central nervous system (nociplastic). When we cannot determine the origin of the sensation we call it Pain and Irritability of Unknown Origin (PIUO). This presentation will provide a description of a specific patient population of children with SNI who experience unexplained pain. Our newest research provides answers to common issues in treating these children. What we add in this seminar are timely findings around possible pain sources, a new clinical pathway for treatment and support for parents, and a medication to address neuroirritability if the clinical pathway fails.

In the wake of the COVID-19 pandemic, conventional approaches to healthcare were challenged, and the world saw an unprecedented acceleration in the development and uptake of innovative digital solutions targeting pediatric pain. Hosted by Dr William Zempsky (USA), speakers Dr. Jennifer Stinson (Canada), Nicole Pope (Australia), and Zahra Alidina (Canada) will highlight initiatives and inspire interactive discussions about leveraging digital health interventions as tools to address pediatric pain in acute care and outpatient settings. Dr. Stinson will share insights into creating and co-designing Youth PoP to empower youth with rapid access to early, flexible, and individualized chronic pain interventions to improve quality of life and function. Nicole will discuss leveraging hospital-based digital health technologies to drive biopsychosocial and developmentally targeted care and highlight pain as a priority. The expert panelists will share their visions for interoperable systems that integrate hospital and virtual care solutions for pediatric pain to promote the wide adoption of digital health solutions, support individualized care, and improve outcomes for children and families.

This workshop is designed to build on new advances in the treatment of pediatric functional abdominal pain disorders and contribute both with state of the art-overview of available treatments and their efficacy as well as a deepened presentation of both movement-based and psychological treatment approaches. Special attention will be given to how service providers across disciplines (physicians, mental health providers, etc.) can support youth in psychologically-minded ways. Dance and yoga with focus on enjoyment will be offered in the hands-on part of the workshop, which constitutes an example of a novel and resource-effective intervention that has shown pain-reliving effects for young girls with functional abdominal pain disorders.

While knowledge syntheses and clinical practice guidelines exist about reducing pain, fear, and stress-related responses during needle procedures in children, there are few resources to guide patients and providers about how to systematically integrate this evidence into routine practice. Evidence-based and systems-level approaches are required to help make the research ‘actionable’ to users. We created a framework called the CARD (Comfort-Ask-Relax-Distract) system to address this knowledge-to-care gap. CARD was demonstrated to reduce fear, pain, and stress-related responses in children and adults undergoing vaccinations across settings, including schools, pharmacies, mass vaccination clinics, and hospitals. It was recently adapted for venipunctures undertaken in the hospital setting. This presentation will introduce the CARD framework to attendees and review some of the key tools for promoting practice change. Upon completion, attendees will be able to describe how to integrate evidence-based interventions into practice to improve the quality of care during needle procedures.

 

*Free CARD postcard distributed to all attendees.

Lunch is provided to attendees by the University of Toronto.

The panel includes interdisciplinary professionals working in pediatric chronic pain and co-morbid functional neurologic disorders (FND). We will begin with a brief review of evidence-based diagnosis and treatment of youth with chronic pain and FND. Then, a clinical pathway for FND treatment will be discussed through a case of a child with chronic pain comorbid psychogenic non-epileptic seizures (PNES), including a review of the latest evidence. Finally, we will present 2 pediatric cases with similar presentations – one with successful outcomes and another with refractory symptoms. Evidence-based recommendations and challenges in this population will be discussed. Patient videos will be used to demonstrate symptom presentation and treatment progress. The presentations will be under 10 minutes to allow sufficient time for a Q&A session and audience engagement. During Q&A Ms. Nicholson will serve as a moderator and ask questions to generate discussion among panelists and the audience. Questions will aim to 1) elicit expert opinion, 2) discuss characteristics among individuals with treatment refractory symptoms, 3) discuss treatment options for youth refractory to clinical pathways, and 4) highlight gaps in knowledge requiring future research. The audience will be encouraged to participate throughout and provided opportunities to contribute questions or cases to the discussion. 

Children experience pain and distress in clinical settings every day. The negative consequences of unaddressed pain can be both short-term (e.g., fear, distress, inability to perform procedures) and long-term (e.g., needle phobia, anxiety, healthcare overuse or avoidance). Socially assistive robotics (SARs) is an area of robotics where the goal is for a robot to use speech, facial expressions, and gestures to interact with a human partner for the purpose of providing assistance. The utility of SARs in pediatric settings have shown promise, demonstrating high acceptance among children and efficacy in reducing procedure-related distress. However, existing studies are all hindered by a critical technical limitation: all robots were operated remotely and employed entirely scripted behaviour with very limited real-time responsiveness and complete lack of autonomy. Artificial intelligence (AI), the ability for computer systems to make autonomous decisions and independently select appropriate behaviours, has potential to address these limitations and improve the clinical experience for children and their families.    Our research group brings together a multidisciplinary, international team of experts in healthcare, biomedical sciences, social sciences, humanities, natural sciences and engineering to develop and evaluate a clinically relevant and responsive AI-enhanced social robot. In this symposium, we will share our experiences working an a multi-disciplinary international team using a user centred co-design to create the robot system and the ethical implications of using AI in healthcare.

The development of a tool to rate the feasibility of chronic pain outcome measures in children with cerebral palsy 
Presenter: Nadine Smith

Procedural pain assessments for neonates at risk of neonatal opioid withdrawal syndrome: A scoping review 
Presenter: Julianna Lavergne

Preliminary Evaluation of the Pain-Related Stigma Scale for Adolescents (PReSS-A) with Juvenile Fibromyalgia: Demonstrating the Importance of Internalized Stigma 
Presenter: Emily Wakefield

Community- Directed Needs Assessment for Pediatric Rehabilitation with a First Nations Community 
Presenter: Hailey Dunn

Grading the severity of chronic pain in children and adolescents - a revised Pediatric Chronic Pain Grading (P-CPG) 
Presenter: Lisa-Marie Rau

Youth in Pain and Opioids: Towards Effective, Safe, and Equitable Use 
Presenter: Raad Fadaak

Over the past few years there has been growing evidence that the clinical encounter plays a critical role pain treatment outcomes, for better or worse. Our ability to effectively assess and manage chronic pain in children and youth often rests on effective communication between clinicians, children and their families. While there has been substantial work documenting the nature of the encounter, researchers are now starting to examine developing solutions for clinicians and patients to deal with clinical uncertainty and harness the encounter’s therapeutic benefits. This symposium will cover three elements that should assist in making the clinical encounter therapeutic. These include the role (and words) of the clinician, the clinician’s ability to recognize and manage uncertainty, and an exploration of pain explanations and the ways youth themselves explain their pain.

Millions of children undergo routine and major surgical interventions annually, which confer risk for short and long term impact (i.e. persistent pain, opioid misuse, decreases in mental health). Negative health-related outcomes following surgery are addressable and preventable, yet there remains a dearth of developmentally-tailored psychosocial and educational interventions to optimize pediatric post-surgical outcomes. Understanding perspectives and treatment needs of individuals and systems involved in delivering or receiving perioperative psychosocial interventions is optimal for intervention development to increase the likelihood that the content and format are acceptable and feasible for use in real-world treatment settings.  This symposium focuses on the application of diverse methodologies (qualitative, quantitative, meta-analysis) to assess patient, family, and provider perspectives on improving perioperative pain care and education. Studies consider intervention needs across the continuum of surgical severity and focus on multiple treatment targets identified in biopsychosocial conceptual frameworks of pediatric perioperative care (substance use, mental health, parent education). Additionally, findings from an updated systematic review and meta-analysis evaluating the effectiveness of existing psychosocial interventions for pediatric perioperative pain will be presented for consideration in relation to patient and provider identified treatment needs/preferences. The session will conclude with an interactive discussion of future directions for perioperative intervention development. 

Nerve blocks and the use of ultrasound are important tools in the arsenal of multimodal analgesia for postoperative and post-trauma pain relief in children. They are opioid-sparing and enhance recovery, and hence essential skills for pediatric anesthesia, trauma, critical care, and pain practitioners. In this workshop, sponsored by the Society of Pediatric Pain Medicine, the initial 30 minutes will provide some basic foundations in ultrasound and the advantages of its use for commonly performed nerve/fascia blocks for acute postsurgical pain. We will also discuss the placement of single injection blocks and dosing, nerve catheters, and dosing, as well as the use of management of ambulatory nerve catheters. Indications, contraindications, side effects/complications, and management of potential problems will be discussed.

Following this, we will divide participants to get hands-on experience at 4 work stations (15 minutes each):

At each station, we will discuss the anatomy and ultrasound images and indications of the most common blocks/pitfalls/decision considerations in managing acute pediatric pain from trauma, surgery, or other acute pain.

We will provide practical instruction to maximize the success of the block placement, including sedation and the use of ultrasound for accurate needle placement.  The specific blocks we will discuss are in the presentations below.  
Participants will be able to view only the ultrasound probes used on live models to best understand the relevant anatomy for accurate block placement and will be able to practice on phantoms to practice hand-eye coordination with needle insertion.

Speaker: Adrienne Harvey


Cerebral palsy is one of the most common physical disabilities of childhood, with a global prevalence of 1.6 per 1,000 live births. Children with cerebral palsy experience a range of co-morbidities, including epilepsy, intellectual disability, and pain. Chronic pain is common in children and young people with cerebral palsy, with a reported prevalence of up to 77%; however, it is poorly understood, identified, and managed. Pain prevalence in children and young people with cerebral palsy increases with the severity of gross motor impairment, age, and female gender and has multiple contributing factors.
Pain assessment in children and young people with cerebral palsy presents several challenges due to the complexity of pain within this heterogeneous population and the impact that disability has on pain assessment. Pain assessment is complicated by varying intellectual ability, communication methods, and functional ability across the cerebral palsy population. Inconsistent pain assessment compromises effective pain management, potentially causing poorer quality of life and reduced participation.
This presentation will utilize recent evidence to provide a background to how pain presents in children and young people with cerebral palsy. The challenges associated with assessing and managing pain in this population will be explored. Solutions for accurately assessing pain in children with cerebral palsy will be presented using a biopsychosocial approach with a focus on how pain impacts activities important to children and families. Finally, current evidence for management options, as well as where future research should focus, will be highlighted.


Learning Objectives:
1. Consider the challenges of assessing and managing pain in children and young people with cerebral palsy.
2. Describe the lived experience of chronic pain for children and young people with cerebral palsy and their families.  
3. Consider management options tailored to children and young people with cerebral palsy with chronic pain. 

Speaker: Kathrina Epino

The World Health Organization places burn injuries as the 5th most common cause of non-fatal childhood injuries. A query of the WHO Global Burn Registry in 2021 showed over 8,000 burn injuries recorded from 20 countries. 40% were children, with the most numbers in the 1–5-year age group. More than half of these pediatric burn injuries occurred in middle-income countries. Burn injuries in children carried a 10% mortality rate, while disability on discharge was at 7%. (Jordan et al. 2022)

Children, particularly those under 5, have been established to be the most vulnerable population for contracting burn injuries. Children are most at risk from consequences following a burn. Pain is a significant issue and, if poorly controlled, can affect the delivery of necessary interventions. Children are prone to develop contractures due to their small body size. Burn injuries are also known to cause physical and psychological trauma. (Woolard et al. 2021) Consequently, disability from disfigurement, functional limitation, and ongoing pain can happen even after discharge. Children’s caregivers are similarly met with physical and psychological burdens.

Opportunities for pain management interventions begin at the place of injury, all the way to admission, and even upon discharge. This talk will present the epidemiology and consequent morbidity of burn injuries in children. Current data on managing pain at different stages during the child’s burn injury will be discussed alongside our own local experience and adaptations at the University of the Philippines-Philippine General Hospital Burn Center. The role of economics and culture in pain and its management will also be highlighted.



Learning Objectives:
1. To describe the epidemiology and burden of burn injuries
2. To summarise relevant evidence in burn pain management and procedural analgesia
3. To demonstrate adaptations made in a general hospital to improve burn-associated pain in children