The language of pain
Oxford textbook of paediatric pain
McGrath PJ, Stevens, BJ, Walker SM, Zempsky WT, editors (2014). Oxford: Oxford University Press, 704 pp. ISBN 978-0-1996-4265-6 (Hardcover: $275.00 USD). Link
Reviewed by Shalini Shah, Michelle A. Fortier, and Cheryl Deters
A medical/nursing perspective by Shalini Shah and Cheryl Deters
In 1926, Virginia Woolf published an essay in which she lamented the “poverty of the language of pain.” She contrasted the many literary sources available to describe love to the scarcity of literary references to pain, noting, “…Let a sufferer try to describe a pain in his head to a doctor and language at once runs dry.” (As cited by Joanna Bourke, New York Times, July 12, 2014).
Ms. Woolf could take some comfort in Oxford textbook of paediatric pain, edited by Patrick McGrath, Bonnie Stevens, Suellen Walker and William Zempsky and published in its first edition in 2014. This is an impressive editorial team representing the highest expertise in developmental neurobiology of pain, clinical medicine, psychology and nursing. The list of contributors to this text is also exceptional, encompassing many leaders within the field of pediatric pain. Even more impressive is that significant chapters have single author contributions, adding to the depth and flow of the chapter. What I was most struck by in this textbook is its contribution to advancing the language between patients and providers to explain and communicate about pain.
The book is divided into nine sections. The introductory section is very valuable, exploring the history of pain in children, addressing prevalence of pediatric pain and offering a deeper understanding of the long term effects of early pain and injury. Section Two discusses the biological basis of pediatric pain and highlights include the state of the science regarding nociceptive pathways written by Sueellen Walker and Maria Fitzgerald. This is a shining example of the opportunities this textbook offers to read a summation of a career’s worth of understanding of pain as recounted by the foremost experts in the field, and not summarized by other contributors as we often see in other texts.
Section Three delves into the social and psychological basis of pediatric pain, and I am delighted to see this topic covered so early in the text. The importance of the context of the pain experience is prioritized in this book, not relegated to the end of the book as an afterthought. Section Four discusses disease specific pain syndromes and specific populations. Section Five focuses on the measurement of pain. Although the natural flow would be to have this as more of an introductory section, it is a nice change of pace to see this presented later in the text. Too many introductory sections early in a book tend to bring a monotonous presentation of pediatric pain, and it is refreshing to read such a chapter towards the end.
Within this measurement section, Chapters 35, 36, and 37 discuss available tools for the measurement of pain within each chapter’s specific focus. Chapter 41 shifts the focus from measurement of pain itself to assessment of function and quality of life. Table format is utilized well in several of these chapters to keep the information organized. Overall, this section provides a comprehensive overview of available tools for measurement of pain and related constructs. For instance, Chapter 35 list 30 different pain assessment tools related to neonatal and infant pain assessment. The reader can anticipate finding pain assessment tools they have not encountered previously as tools listed are from a variety of countries. Psychometric properties are included for most tools.
Chapters 38, 39 and 40 present methods being used to identify quantitative findings of pain. The content of these chapters addresses the growing recognition of physiological assessments of pain, taking the guess work out of pain assessment for those who work with the unresponsive patient or those patients with severe limitations in their ability to communicate. At times, these chapters are quite technical for the more casual reader and they fail to address the clinical application of these tools in practice. The included references do point the reader toward some additional clinically useful information.
Nurses reading this textbook will gain a greater understanding as to specific use of the assessment tools presented. This reader appreciated the challenges and limitations in pain assessment noted in each of these chapters. The case examples at the end of Chapters 35, 37 and 41 are excellent examples of application and could be utilized by nurses and other clinicians.
Sections Six, Seven and Eight discuss pain interventions—pharmacological, psychosocial, and physical, respectively. Section Nine discusses special topics, such as complementary therapy, drugs, ethics and education in pediatric pain.
In summary, the title does the text justice; this is the authoritative textbook on pediatric pain. This is a very comprehensive, yet not overwhelming textbook of pain medicine. Each chapter is so well edited and cited, with a holistic approach to treating a complex phenomenon in children. It includes a historical perspective of the evolution of pain understanding and treatment and offers a conceptual biopsychosocial model of pain encompassing both the child and their family. The chapters are philosophical as a medical textbook can be, the list of contributors includes many heavy weights in the field, and the editing is excellent. The difficulty of talking about painful sensations and suffering is well tackled by this text.
A pediatric psychology perspective by Michelle Fortier
As a pediatric psychologist with a clinical practice devoted exclusively to children with chronic pain, I am always in search of resources to inform my work. Chronic pain is an area that relies on knowledge of the myriad biopsychosocial components that can contribute to the experience of pain and its impact on functioning. Therefore, I often find myself in search of greater understanding of the medical/physical factors that may underlie a child’s experience in addition to furthering my education on psychosocial components involved in chronic pain and its associated impacts. The Oxford textbook of paediatric pain, edited by McGrath, Stevens, Walker, and Zempsky is an ideal book to keep me up to date with the latest information in the field of pediatric pain.
Historically, children’s pain has been neglected and although tremendous progress has been made in the past several decades in advancements in the assessment and management of pediatric pain, there is much to learn. This text is a wealth of information for clinicians and scientists alike with nine sections covering information about pain prevalence and effects, biological and psychosocial bases of pain, pain associated with specific populations (e.g. children with developmental disabilities) and illnesses (e.g. cancer pain), pain assessment and pharmacological, psychosocial, and physical interventions for pain management. In addition there is a section focused on special topics, which includes chapters on complementary and alternative (CAM) approaches to the treatment of pediatric pain, translational efforts in the treatment of pain, ethics of pain management in children, and disparities in pain management.
By the time patients reach our pain management center, they have been seen by dozens of health care providers, many of which are specialists in a variety of areas, and have been given often confusing information about why they are experiencing chronic pain. Therefore, it is often necessary to spend time educating children and their families about the nature of chronic pain and this requires knowledge about a variety of pain types (e.g. headache pain, neuropathic pain) to adequately convey the biological explanations for the child’s experience of pain. Chapters 6-8 provide detailed explanations of the nociceptive system that are useful in understanding not just how pain is processed by the brain and spinal cord but how the nociceptive system develops and may be impacted by early exposure to pain. In addition, I find patients frequently interested in understanding why certain behavioral interventions, such as relaxation strategies, can reduce pain and therefore the discussion of the descending pathways that modulate pain is particularly helpful in this regard. At times children and their parents, particularly those who adhere strongly to the traditional Western medical approach to treatment of illness may be hesitant to engage in cognitive behavioral therapy (CBT) for pain management. Thus, providing patients with biological explanations for how such an approach can improve pain and functioning is quite useful and necessary.
Section Three, which includes Chapters 9-15, covers the psychosocial bases of chronic pain, with chapters devoted to psychological theories; cognitive processes; environmental components of pain, including culture and family; pain in the context of relationships and school; sex and gender effects on pain; and pain and sleep. Any practitioner working clinically with children in chronic pain knows that pain can impact all aspects of a child’s daily life and interactions and its effects are not limited to the child in pain; chronic pain in children impacts family functioning as well. This section provides conceptual models for understanding pain and its impact in children that can be particularly useful for helping children and families understand the biopsychosocial model of pain. Parents, in particular, often vacillate between frustration and empathy in dealing with a child in pain, simultaneously wanting to comfort and protect their child and wanting the cycle of debilitation to end. Therefore, helping parents to understand the many factors that are contributing to their child’s pain-related disability is often necessary to begin to move toward change. Parents are often desperate for tools and strategies to help their child and such biopsychosocial models are important tools in laying the foundation for addressing parent behaviors that support healthy functioning in children. Chapter 12, families in pain, also includes specific recommendations for parents in managing both acute and chronic pain in children. There is also a growing recognition of the racial/ethnic disparities in the experience of pain; accordingly, Chapter 11, which is devoted to how culture and communication impact pain is particularly relevant. This chapter also highlights how much more work is needed to understand cultural disparities in the experience and management of pediatric pain.
Sections Five through Eight cover assessment and treatment of pediatric pain. Special attention is given to assessment in various populations (e.g. neonates), various modes of assessment (e.g. self-report, observational, physiological), and domains of assessment (e.g. functional ability, quality of life). There is a growing recognition that simple measures of pain severity, such as numeric rating scales, provide quite limited information to inform treatment and guide progress and that measures of functioning and quality of life are necessary as treatment outcomes. Information is provided as to which measures are most appropriate for different developmental stages/age groups and pain types to guide both clinicians and researchers in selection of the most validated and evidence-based assessment tools. As a pediatric psychologist who provides CBT to children with chronic pain and their families as part of a multidisciplinary pain clinic, it is important for me to have an understanding of the most current treatments recommended for children for a variety of pain conditions. Thus, Section Six covers current pharmacological interventions (e.g. opioids, over-the-counter medications, interventional procedures, topical agents, medications for neuropathic pain, and sucrose) that may be used with children. Section Seven has chapters focused on psychosocial interventions, including CBT, operating conditioning, child life, distraction, hypnosis, relaxation, and communication technologies. Finally, Section Eight covers physical therapy, occupational therapy, and maternal care practices for infants (e.g. breastfeeding, kangaroo care, maternal voice recordings). As with all other chapters of this text, these sections each include case examples to put information into specific clinical context and/or specific instructions on the use of the techniques covered (e.g. hypnotic techniques for acute pain management) therefore providing valuable information for the provider to incorporate into the clinical environment.
The last section of the text is devoted to special topics and includes chapters on CAM, ethics, knowledge translation, organizational systems, education, and disparities. As a scientist-practitioner, the chapter on knowledge translation is particularly relevant. As a parent of a young child, it is particularly frustrating for me to attend medical appointments where established guidelines for pediatric pain management are not implemented. Accordingly, Chapter 61 reviews knowledge translation theories, frameworks, and models, and then covers strategies for the incorporation of evidence into practice, including a case example. This is an extremely timely topic in the literature and well covered in this text.
Overall, the Oxford textbook of paediatric pain is an excellent resource for health care providers and researchers in the area of pediatric pain. It covers a wealth of information that is consistent with a biopsychosocial model of pain and includes evidence-based and clinically-relevant information to inform readers about our current knowledge of pediatric pain. In addition, it includes helpful case examples to illustrate the concepts presented, easy-to-read tables and figures, and practical strategies that could be implemented in a clinical setting. This book will appeal to professionals at all levels – from those just starting out in the field who need a foundation in the field of pediatric pain, to seasoned professionals who would like a valuable resource to provide empirically grounded information and recommendations. McGrath and colleagues and the numerous experts who contributed chapters to this book have provided a substantial contribution to the literature on pediatric pain.
Cite as: Shah S, Fortier MA, Deters C. The language of pain. Book review: Oxford textbook of paediatric pain. Pediatric Pain Letter 2015;17(1):9-12. www.childpain.org/ppl