First step to normal: A top-notch roadmap to navigating childhood pain
Pain in children & young adults: the journey back to normal. Two pediatricians’ mind-body guide for parents
Zeltzer LK, Zeltzer PM (2016). Encino, CA: Shilysca Press, 382 pp. ISBN 978-0-9760171-2-7 (ebook: $9.99 USD). Link
Reviewed by R. Blake Windsor
References to a journey are common in the world of health related books. Commonly, a dynamic storyteller tells an inspirational story of long odds faced by one or more patients to help others relate lessons learned to their own struggles. By the end of the story, the reader may experience optimism and hope that they too can be cured, but without any instruction for their own journey. The work put together by Drs. Lonnie and Paul Zeltzer is anything but common. This comprehensive book titled Pain in children & young adults: the journey back to normal is a manual that equips even the most unprepared parent for the arduous process of pain and functional rehabilitation. It is simultaneously inspiring and instructive. Written with the well-educated parent in mind, the Zeltzers demonstrate a healthy respect for the intelligence of their readers and expertly communicate the complexities of central pain sensitization, need and rationale for multidisciplinary care, and the biopsychosocial approach to pediatric pain medicine.
The book is divided into five large sections with a breadth of topics relevant to clinical practice. Interspersed through the text are patient vignettes, expert commentary, and checklists. Section one covers pain physiology and common conditions associated with chronic pain states. As one would expect from a seasoned educator, pain physiology is communicated in accessible language that weaves the intuitive and counterintuitive aspects of pain processing into a scientific, but not overly burdensome read. Direct citations to the scientific literature are sparse throughout the book, instead relying on excerpts from a wide range of regional, national, and internationally renowned experts. The effect is a convincing demonstration to the reader that central pain sensitization is a real neurologic process with international consensus amongst pediatric pain experts.
Following a concise, but thorough discussion of functional pain disorders, section one also contains chapters discussing the role of the pain processing system in common conditions including headaches, dysmenorrhea, and chronic sports injuries. Less common painful conditions are also covered, including inflammatory bowel disease, cancers, and sickle cell disease. Finally, an admirable chapter discusses the link between pain, developmental conditions such as autism, and the challenges of assessing pain when it is communicated differently.
Logistics dominate the second section of the book. It is the most specific section, and most likely to cause disagreement amongst pain clinician readers. The goal of the section is to prepare the parents of a child with chronic pain for their journey. This goal is very clearly met, and the offered advice includes preparing written histories to be given to their pain team, seeking out clinical trials, and instructions on how to maintain a three-ring binder, for example. As a clinician in a tertiary referral pain clinic, my team and I sometimes observe that diaries and extensive record keeping can lead to parental hypervigilance and overfocus on a diagnostic label that can be at the expense of moving onto functional rehabilitation. This can, perhaps, be explained as advice that is most relevant to a US regional audience, as suggested by several paragraphs on how to appeal for a second opinion referral outside of an HMO (health maintenance organization), with specific mention of predominantly US west coast, large HMOs.
Despite the best efforts of parents and clinicians, children with longstanding pain rarely recover quickly. The third section of the book explores the complex interaction of emotions, attention, coping, and the experience of pain. It is in this section that the patient vignettes are the most helpful. While many families struggle to identify how their child’s emotions and coping may contribute to the maintenance of their pain, annotated stories about other people’s children are quite logical and, even, intuitive. For example, the Zeltzers relate a story about a teenager who had a cardiac transplant complicated by a series of traumatic surgeries and catheter displacements. She developed chronic pain in her abdomen near the former site of one of her catheters. The relationship between these factors would not normally be clear to a lay reader, but under the Zeltzers’ guidance, the neurologic effects of psychosocial stressors is quite clear. The story ends well; the girl is almost pain free and off all medications after a course of psychological and pharmacologic interventions targeting both pain and concomitant anxiety.
Clinicians everywhere will enjoy the extremely egalitarian one hundred pages exploring various multidisciplinary treatments. It is probably the strongest section of the book and would improve the general knowledge of non-pain specialist physicians, psychologists, therapists, and even many pain specialists in these fields. Weaving together expert commentary, evidence, and patient narrative, the section covers physical therapies, cognitive behavioral therapies (CBT), mind-body therapies, and medications. Within these approaches, there are discussions about conventional treatments including desensitization, CBT, and common medications, but also explorations of other helpful strategies such as yoga, acupuncture, mirror-box therapy, and herbs for the treatment of pain. At the end, patients and clinicians alike will be amazed at the range of opportunities that exist to help children and teenagers with their chronic pain.
The book concludes with more logistic instruction, including school reintegration, how to use the US Family Medical Leave Act, locations of the various North American pediatric pain centers and the treatments they provide (as of 2015), glossary of pain related terms, and examples of appeal letters to third party health insurers who have denied pain-specialty care. It should be noted here that much of the logistical guidance offered in this chapter is specific to the US healthcare system and that readers from other countries will likely need supplemental guidance on navigating the subtleties of their own health care system.
In writing Pain in children & young adults: the journey back to normal, Drs. Lonnie and Paul Zeltzer created a comprehensive, instructive resource for patients, parents, and clinicians alike. Complex interactions between pain, emotions, environment, and disease states are clearly communicated in a sophisticated yet accessible style. While other books may provide more detailed explanations of particular treatment approaches, such as cognitive behavioral therapy and parenting guidance, Pain in children & young adults excels in the breadth of its coverage. Any family who picks up this book will have already taken their first step on their journey back to normal.
Cite as: Windsor RB. First step to normal: a top-notch roadmap to navigating childhood pain. Book review: Pain in children & young adults: the journey back to normal. Two pediatricians’ mind-body guide for parents. Pediatric Pain Letter 2017;19(2):29-30. www.childpain.org/ppl