Speaker: Marsha Treadwell

Sickle cell disease (SCD) is the most common inherited blood disorder in the world with over 300,000 affected births annually, primarily in low- and middle-income countries in sub-Saharan Africa and the Caribbean, and in India.  SCD is characterized by serious but preventable acute and chronic complications, including unique pain syndromes, as well as by stigmatization and/or structural racism. Both quantity and quality of life, psychological well-being, educational attainment, and employment are negatively impacted. SCD remains a neglected disease regarding access to comprehensive care, and to disease modifying and curative therapies. In this presentation, I will describe the complexities of SCD healthcare in a global context and I will focus on barriers to pain care including: healthcare providers’ biases and their failure to adhere to available guidelines; health related stigma; challenges with the transition from pediatric to adult care, particularly the emergence of chronic pain syndromes with age; and lack of access to interdisciplinary pain teams. I will describe strategies to establish partnerships to address these barriers - with individuals with SCD and their families, emergency department providers and community-based organizations. I will also discuss the importance of supporting the successful transition from pediatric to adult care for addressing barriers to pain care, as well as the utilization of anti-racism frameworks to improve SCD clinical care.

Learning Objectives:
1. Provide an overview of sickle cell disease and its most common complication, pain
2. Recognize barriers to optimal sickle cell disease pain care within a global context
3. Discuss strategies for achieving equity in pain care for youth with sickle cell disease

Speaker: Mike Salter

Advances in transcriptomics in the dorsal horn of the spinal cord have led to cataloging diverse cellular pathways and transcriptomic alterations in response to peripheral nerve injury, but have focused on phenomenology and classifying transcriptomic changes.  Recently, we took a purposeful approach of exploring the possibility of identifying pain-relieving drugs by simultaneously looking not just between sexes in a single species but between sexes in two species.  Surprisingly, given the massive emphasis on sex differences across biomedical sciences we found that there are many more commonalities than differences between sexes and across species in the gene expression changes produced in the spinal dorsal horn.  The key was then determining whether there was a way to use this information to make testable predictions about drug response.  We used pathway analysis to define the molecular network of proteins encoded by the genes in which transcript expression had changed.  Because of the power of our four-way analysis we not only identified known pathways – which validated our analyses – but we discovered connections and hubs not seen previously.   With this information we developed a workflow through mining the database of FDA-approved drugs and interrogating this with the common nodes and hubs we had identified.  The top hit from this analysis was fostamatinib, the molecular target of which is the non-receptor tyrosine kinase SYK, which our analysis had identified as a key node in the interactome. We found that intrathecally administrating the active metabolite of fostamatinib, R406, and another SYK inhibitor P505-15, reversed pain hypersensitivity and, as our analysis predicted, did this in both sexes.  Thus, we identified and showed the efficacy of agents that could not have been previously predicted to have analgesic properties.


Learning Objectives:
1. Upon completion, the participant will be better able to understand processing, plasticity and transmission of nociceptive information in the central nervous system. 
2. The participant will be better able to appreciate the critical role of glia-neuron interactions in the pathological pain neuroplasticity.
3. The participant will be better able to understand sex differences and sex similarities in mechanisms underlying pain.

This symposium will highlight how cross-disciplinary science can propel novel directions in pediatric pain research and treatment. Specifically, the speakers (Kashikar-Zuck, Myers) will discuss how synergistic collaboration from the fields of behavioral medicine and sports medicine evolved into the creation of the Fibromyalgia Integrative Training (FIT Teens) program for the treatment of juvenile fibromyalgia (JFM) in adolescents. The ongoing multi-center FIT Teens trial infrastructure has facilitated collaborative translational research including sophisticated biomechanical measurement of movement patterns in adolescents and fMRI studies of structural and functional alterations in pain processing in JFM (Lopez-Sola). This cross-disciplinary seminar will highlight how a multi-institutional collaboration between three research disciplines are, for the first time, beginning to 1) elucidate sensory integration and pain processing impairments underlying JFM symptoms, 2) demonstrate the role of altered movement patterns that contribute to physical impairment and fear of movement, and 3) integrate findings to inform more mechanistically-driven, non-pharmacologic treatments for complex chronic pain conditions in children.

Painful experiences (e.g., surgeries, injuries) can be traumatic for individuals of any age, but emerging evidence suggests that adverse experiences and trauma (e.g., emotional and physical abuse and neglect) in early life play a key role in the development of chronic pain problems. Moreover, while research shows that chronic pain can be transmitted across generations, less is known about how and why early adversity and trauma experienced by parents may confer risk for chronic pain in their offspring. Little research has examined the link between exposure to adversity and trauma in early life, how it confers risk for pain within and across generations, and the underlying mechanisms that drive these relationships over time, although it is evident that adverse experiences early in life ‘sets’ the organism to anticipate high levels of threat and mobilize defences, including pain. We are an international, (UK, Canada, Australia), interdisciplinary panel consisting of an epidemiologist (Macfarlane), clinical psychologist (Noel), and developmental neuroscientist (Mychasiuk). From this international collaboration, we will present new, unpublished data from epidemiological, clinical and community cohort, and pre-clinical studies. These studies examine the relationships between physical and emotional adversity and pain across infancy, childhood, and adolescence, how childhood adversity confers risk for chronic pain across generations, as well as the neurobiological, cognitive, behavioural, and interpersonal mechanisms that drive these relationships over time. An interactive discussion will underscore implications of this work, including the need for anti-racist approaches to this research, new categories of adversity to consider (e.g., victimization, discrimination, iatrogenic clinical encounters), adoption of a trauma-informed approach to research and practice, controversies, prevention, the need for application of a structural and systemic lens, and new avenues for community-level interventions beyond traditional CBT approaches. 

Prevalence of Chronic Postsurgical Pain in Spanish Adolescents: A Prospective Study with Long-Term Follow-Up to Evaluate the Impact of Healthcare Systems on Pain Management in Pediatric Surgery 
Presenter: Guillermo Ceniza-Bordallo

Adolescent Psychosocial Predictors of Substance Use Among Young Adults with Childhood-onset Chronic Pain 
Presenter: Andrew Rogers

Pain Dismissal in Adolescents: How Does Weight Fit into This Picture? 
Presenter: Monica Gremillion

Describing pain processing in pediatric erythromelalgia and congenital insensitivity to pain: a case series 
Presenter: Don Daniel Ocay

Adversity Contributes towards Comorbid Pain, Psychological and Sleep Disturbance Symptom Trajectories Across Early Adolescence 
Presenter: Thea Senger-Carpenter

Daily Associations among Pain Intensity, Subjective Activity Limitations, and Objective Physical Activity in Youth with Acute Musculoskeletal Pain 
Presenter: Jacqueline O'Brien

Despite the high prevalence, cost, and impact of chronic pain in children and adolescents, the evidence base for chronic pain interventions is limited. Appropriate outcome measures and high-quality intervention trials are critical to advancing care. The prior PedIMMPACT recommendations published in 2008 have been used to guide outcomes measurement in clinical registries and trials but overall had modest uptake over the past 14 years, potentially due to the limitations in the methodology used. This symposium provides timely updates on a new core outcome set for pediatric chronic pain interventions that involved collecting providers’, patients’, and parents’ perspectives about treatment of pediatric chronic pain to understand clinically meaningful outcomes that should be routinely measured. Youth with neurodevelopmental disabilities have been neglected from previous core outcome sets for pediatric chronic pain. A new systematic review identifies pain and functioning outcome measures and future recommendations to address this research gap. The newly developed Patient-Reported Outcome Measurement Information System (PROMIS®) pediatric measures provide opportunity for inclusion in core outcome sets but need systematic evaluation. Recommendations for their use in children and adolescents with chronic pain are made following a systematic review of their measurement properties.

Chronic post-surgical pain (CPSP) is highly prevalent in children with an incidence of 15-43%. It affects the child’s psychological and physical health, and family well-being and has a large socioeconomic impact on the community. Individual and environmental factors are associated with CPSP,  including preoperative pain, poorly controlled acute postoperative pain, parental pain catastrophizing, psychosocial factors, and social disadvantages.  Understanding the interplay between individual, family, and environmental factors is key to providing patient-centered interventions. We have assembled an international, multidisciplinary panel including an individual with lived experience of CPSP, to provide a comprehensive understanding of the impact of CPSP. We will start with a personal account of lived experience with CPSP by our patient partner followed by an overview of prevalence and risk factors. We will elaborate on various mechanisms based on psychophysical and neuroimaging studies. We will explore genomic, immunologic, and gene-environmental interactions underlying nociceptive priming and pain sensitization. We will also discuss population health and disparities in CPSP and the effect of social determinants of health in pain management.   Finally, panelists will discuss personalization/models of care, offering potential solutions. Format: Introductions and “big-picture” presentations (30 minutes) followed by an interactive moderated discussion between panelists (25 minutes), interspersed with audience polls, and finally audience Q and A session (20 minutes).

 Evidence indicates that disparities exist in pediatric pain care, such that the pain of children with marginalized (e.g., identifying as a person of color, LGBTQIA+) vs. valued (e.g., identifying as a White person, cisgender heterosexual) individual and social identities are treated differently. This symposium will present state of the art empirical research examining antecedents, consequences, and potential mechanisms underlying these disparities, and actionable solutions to addressing inequities. Specifically, Ama Kissi will discuss how observer (i.e., attentional processing of another’s pain, perspective-taking and biases about pain experience) and pain sufferer (i.e., facial expressions of pain) characteristics may account for racial disparities in pediatric pain care. Katelynn Boerner will address how cisnormative and patriarchal biases may contribute to gender differences in pediatric pain care, with specific examples of the experiences of gender-diverse youth. Lauren Harrison will present data collected through semi-structured interviews with LGTBQIA+ youth with chronic pain, with a particular focus on pain-related stigma and the impact of the intersection of identities that are frequently invalidated and their perspectives on what is needed for inclusive pain care. 

Participate in our lunch session on the Global Comfort Promise, which aims to present and discuss a quality improvement project to reduce procedural pain in children with cancer in LMICs. 

The session begins with an overview of the current state of pediatric cancer care in LMICs, highlighting the disparities and gaps in pain management. The Global Comfort Promise seeks to bridge these gaps by implementing evidence-based strategies and best practices for pain reduction during needle procedures, highlighting the results of implementing the Global Comfort Promise in Brazil, Peru, the Philippines, and South Africa.

 

Lunches will be provided to attendees by St. Jude Global Palliative Care

 

Speakers:

Michael McNeil,

Director, Global Palliative Care Program, St. Jude Global

Joliza Patricia Caneba, MD

Consultant, Philippine General Hospital

Erica Boldrini, MD, PhD

OTHR, Barretos Câncer Hospital

 

The advancement of the field of pediatric pain has beckoned for new research approaches to address ongoing and novel issues within how children’s pain is understood and managed. Advances in technology and experimental research methodologies present innovative opportunities to generate modern solutions and understandings in pediatric pain, including the promotion of equity and accessibility in research and care. This symposium, led by an international (i.e., Canada, United States), multidisciplinary panel (i.e., psychology, nursing) will present three innovative approaches to understanding and managing children’s acute and chronic pain. The first speaker will present a choice experiment method to understanding partner priorities when implementing evidence for pediatric pain management. The second speaker will detail a novel mixed methods approach to adapting evidence-based digital health interventions to improve engagement and benefit for vulnerable sub-groups of youth with chronic pain, highlighting the integration of methods including meta-analysis, component profile analysis, qualitative interviews, and validated self-report measurements. The third speaker will present a qualitative approach combining theory and stakeholder perspectives to inform implementation interventions in infant pain. Examples from the speakers’ research will demonstrate applications of these methods and how they can be utilized in support of best practices in pediatric care.  

The session will provide expert advice on best practices for successful grant writing from a number of different perspectives, including clinical trials, human subjects research, and basic science.  Information on how different funding agencies review proposals will also be discussed.  The panel will open up with brief overviews by each of our panelists, followed by a Q&A session with the audience.

Since January 2022, the 11th version of the International Classification of Diseases (ICD-11) came into effect. It includes a new classification system for chronic pain, which could change how chronic pain is perceived, diagnosed, managed, and paid for. We will present and discuss the potential impact of the new classification on pediatric chronic pain in an interactive session with the audience. Dr. Jeremy Gauntlett-Gilbert reviews how chronic primary pain diagnoses may affect the culture of acute medicine, stigma, and help to address parent fears and coping. Dr. See Wan Tham will illustrate the clinical perspective on how application of the ICD-11 diagnoses could influence conceptualization of pain diagnoses from the perspective of patients and families, treatment options, and comparison to other diagnostic classification systems. Dr. Christine Greco will provide insight on the implications of a new diagnostic system on healthcare financial resources and reimbursements on medical institutions and patients and families. She will propose strategies how we can advocate for continued and adequate health care coverage for treatment of chronic pain in children and adolescents in the future. Lisa-Marie Rau will outline a data-informed approach to evaluate chronic pain diagnostic criteria with the goal of enhancing the utility of ICD-11 for the pediatric population.

Approximately 20% of youth undergoing major surgery develop chronic post-surgical pain (CPSP). Rates for pain persistence in youth with acute musculoskeletal injury are 30-40%. Growing evidence from surgical and acute injury populations identify psychosocial factors, such as anxiety and low mood, as driving forces for poor pain outcomes. Psychosocial assessment during pre-surgical or acute pain period can inform early intervention and treatment to improve pain outcomes. This symposium will explore risk factors for elevated symptomatology which impact recovery and the development of screening measures to identify those at risk of developing chronic pain. Patient partner, Gillian Newman, will provide her lived experience with adolescent spinal fusion surgery and the development of CPSP. Dr. Rabbitts (anesthesiologist) will present on dynamic risk factors of the development of CPSP in youth. Dr. Holley (psychologist) will present data on psychosocial screening and predictors of poor pain outcomes after acute musculoskeletal injury. Dr. Rosenbloom (psychologist) will present on the development of a pre-surgical screening measure for CPSP. We will conclude with a panel discussion that includes all presenters around risk factors, potential barriers regarding timing assessment of risk factors in the clinical environment, and the ethical and clinical implications of when risk is identified. 

Pain science has historically failed autistic children and youth. Autistic youth and their families have been systematically excluded from decades of pain research, despite the fact that recent evidence suggests higher rates of chronic pain, pain-inducing accidents, and co-occurring painful illnesses in young people with autism. Differences in social communication and cognition mean that pain measures validated in neurotypical youth may not be appropriate in the context of autism and coupled with increased rates of placebo responses, may together necessitate adaptations to the clinical encounter with the clinician (e.g., physiotherapy, psychological interventions, prescribing of pharmacotherapies). However, current research may not be sufficient to guide effective pain assessment and care to children with autism and their families. This panel discussion will cover a variety of topics relevant to advancing our capacity to develop novel approaches to assessment and treatment of acute and chronic pain in autistic children and youth, including patient-parent-provider communication, appreciating the impact of intellectual impairment, the presence of placebo effects in treatment, and sex/gender influences, sharing findings from qualitative and quantitative research.  We will also engage in a discussion with panelists and audience members around increasing the accessibility of pain research methods for autistic children and youth, including patient partnership. 

The three conferences that will be presented in this symposium will cover different clinical contexts where virtual reality (VR) was used and tested in both hospitalized and ambulatory clinical contexts. This symposium will focus on the use of VR for pain and anxiety management of children hospitalized for treatment of cancer as well as in children visiting the orthopedic clinics for bone pins’ and/or sutures removal following a fracture. Also, we will present a pilot study on the experience related to the implementation of virtual reality within some of the clinical units of an orthopedic pediatric hospital. Participants will have an opportunity, at the end of all presentations, to discuss the results presented as well as provide suggestions or share their own experience using VR with children as a distraction for management of procedural pain and anxiety or initiatives for implementation of VR within their own institution. 

Speaker: Katie Birnie

All are welcome to attend.