A painful feeling starts in your fingertips and spreads through your hand, radiating up your arm until it reaches your brain, prompting an “Ouch!” Pain is most commonly defined as “physical suffering or discomfort caused by illness or injury,” and while this may be true, we also know from first-hand experience that pain is subjective and affects people of all ages  [1]  . But if pain is so subjective, how can healthcare providers treat patients with chronic pain? The most common treatment for chronic pain is currently pharmaceuticals, but this is not optimal because of the adverse side effects, abuse potential, and negative impacts on neurodevelopment. A safer alternative is cognitive behavioral therapies (CBTs), which can provide a means to treat different types of pain holistically by also considering psychological factors.

Pain is classified as either chronic or acute, depending on how long it lasts. Acute pain is shorter in

duration, serves to alert the body to a possible injury, and is driven by external stimulation of the peripheral nervous system. Chronic pain is defined as pain that lasts more than 12 weeks, serves no physiological function, and is driven by the central nervous system with no external stimulation  [2]  . There is limited knowledge on what sort of treatments work for chronic pain because of its centrally driven mechanism  [3]  . Chronic pain most commonly manifests as headaches, abdominal pain or musculoskeletal pain  [5]  . Patients undergoing major surgery are at a higher risk for developing chronic pain post-surgery because of the invasive, pain-inducing nature of surgery, and this risk is specifically heightened in developing children  [5]  . Recovering from surgery can be an arduous process, and children are often plagued with inadequate long-term pain management  [2]  .

The current standard of pain management in large pediatric hospitals consists first of a visit to the pre-anesthesia clinic before surgery to discuss the anesthetic that will be administered to the child. After this visit, the child arrives on site the day of the surgery and meets their anesthesiologist before entering surgery. There is no post-operative pain checkup, but the patient can elect to schedule one if there is persistent pain  [8]  . The current practice lacks structured long-term management of chronic pain after surgical patients leave the hospital. It is difficult to develop such a program because pain is a subjective, psychosomatic condition that can be managed using different methods such as physical therapy, CBT, and occupational therapy based on individual patients. To date, it is not clear what biological mechanisms are responsible for chronic pain.

A study conducted on patients after spinal cord injury concluded that degeneration and inflammation of axons within the spinothalamic tract (nerves carrying pain and temperature information up from the spine to the thalamus) may cause spontaneous activity in intact neurons that act as a ‘central pain generator’  [3]  . However, the role of the spinothalamic tract and pain receptors in chronic pain is still unclear, and researchers have not been able to identify a biological pathway of this development. This lack of biological information is the reason the field of pain medicine has turned to pharmaceuticals. One of the most common reasons that adults seek medical care is chronic pain, but unfortunately, 11-40% of these patients end up becoming dependent on opioids  [4]  . The current opioid crisis has led to a rise in adult chronic pain research, but between 1999 and 2014, over 1.3 million opioid prescriptions were written to children, resulting in an annual incidence of 15%  [6]  . However, the prevalence of pediatric opioid addiction is considerably lower than in adults and therefore less resources have gone into pediatric chronic pain research. Over five million adolescents undergo major surgery in the United States each year, and almost half of them report moderate to severe pain in the hospital, which persists months after surgery  [2]  . Debilitating post-surgical chronic pain can affect the child’s long-term social development, intellectual functioning in an educational environment, and overall mood and self-esteem  [2]  . Seventeen percent of adult chronic pain patients worldwide report a history of chronic pain as adolescents that persisted into adulthood  [5]  .

Pain catastrophizing (the tendency to exaggerate, ruminate on, and feel helpless about one’s pain), sleep patterns, and anxiety have been shown to be risk factors for developing chronic pain  [2]  . Studies conducted at Seattle Children’s Hospital have shown that adolescents undergoing major surgery with poorer quality of life and greater chronic pain intensity exhibit high pain catastrophizing, irregular sleep patterns, and increased anxiety before surgery  [9]  . The correlation of these factors has led to the understanding that these psychological elements play a role in the development of post-surgical chronic pain. In order to present a holistic treatment of pain, the relationship of these psychological factors to pediatric chronic pain must be extensively studied to develop targeted therapies. The development of more CBTs to target psychological causes of chronic pain is the future of chronic pain treatment  [3]  .

Cognitive Behavioral Therapies

CBTs target the psychological and behavioral risk factors of chronic pain in adolescents  [7]  . They specifically emphasize the connections between thoughts, feelings, and behaviors in terms of development and pain maintenance. There are many different components of a successful CBT, including psychoeducation, self-monitoring, coping skills training for children, parent training, and relapse prevention. Some chronic pain CBTs focus specifically on reducing previously identified risk factors for chronic pain development, such as anxiety, pain catastrophizing, and disrupted sleep. Targeting these risk factors before and after surgery can greatly decrease the likelihood of developing post-surgical chronic pain  [4]  . Dr. Jennifer Rabbitts, an anesthesiologist at Seattle Children’s Hospital, is developing an extensive post-surgical chronic pain CBT program to administer to children undergoing major surgeries and their parents  [9]  . These programs consist of different modules that can be accessed by both parents and children online and followed over a period of months before and after surgery. The modules contain informational lessons on chronic pain prevention, coping mechanisms, and information about surgery, including anecdotes from other patients and families. Additionally, they educate patients and families about surgery, pain management techniques, and chronic pain  [9]  . Incorporating tips, references to old modules, and homework into these CBT programs encourages children and parents to practice the skills that they learned in different sessions. They can increase quality of life, teach patients how to ease back into their normal routines after surgery, and change

patients’ thinking about the surgical experience. These CBT programs were initially proven to be effective in reducing pain severity in children with chronic headaches, but recent studies have shown there is a 10% or greater reduction in pain when CBTs were used in post-surgical populations in general  [10]  .

In a nationwide survey administered in 2011, it was found that minority children had significantly more debilitating pain compared to Caucasians, girls had a higher pain intensity than boys, and teenagers had more compromised functioning than younger children  [6]  . These are important factors to consider when assessing the participant population of behavioral therapy studies and the effectiveness of CBT on different demographics. There have been no studies showing the biological mechanism of these relationships or how they impact the application of pain treatments; however, there are other psychological factors that impact post-surgical pain in these demographics that can be more readily targeted for specific groups of people.

Future Work

Future applications for these post-surgical CBT programs could be integrated into phone-based apps for outpatient administration. Dr. Tonya Palermo, a psychologist at Seattle Children’s Hospital, is currently doing this with WEB-MAP, a pain self-management program  [11]  . These phone-based apps are designed to be accessible to increasingly plugged-in youth, enabling them to use cognitive behavioral therapy modules remotely. This encourages increased participation and completion of modules by eliminating the need to be physically located at a laptop or desktop device. CBTs currently exist for anxiety disorders such as PTSD, OCD, panic disorder, generalized anxiety disorder, social anxiety disorder, and specific phobias  [12]  . Other CBTs are available for mood disorders such as depression and even substance use disorders  [13,14]  . Including motivational interviewing of patients in CBT may also improve outcomes and increase patient engagement  [10]  . Pediatric pain-related conditions are associated with 11.8 billion dollars in total health care expenditures  [15]  . With the development of cost-effective, personalized CBTs for pain management, we can hope to reduce the national cost of treating pediatric pain-related conditions and the number of individuals living with persistent chronic pain.

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