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In order to move forward with rehabilitation it is essential that the adolescent and family have an understanding of chronic pain. This is a very difficult concept for many individuals to understand (including professionals) as there is a belief that pain is always a warning sign that a disease process or abnormality is present. There is a need for the young person and family to find a cause, and often skepticism from health professionals that the pains are present at all. During the consultation it is initially important to investigate what thoughts the family and the young person have about the cause of the pains. There are often fears that an undiagnosed condition such as cancer is triggering the discomfort. No family will move forward with pain education or future rehabilitation until these fears are allayed.

Essentially the team need to show and reinforce to the family the fact that many pains are not useful. It is helpful to give common examples of non-useful pain. Headaches are extremely common but very rarely due to conditions such as brain tumors or vascular events. Back pain is one of the most common presentations to general practitioners. But, again, very rarely does this signify malignancy or arthritis.

It is also useful to illustrate to families how complicated pain physiology is and how little is understood. Phantom limb pain is familiar to many—why, after a painful limb is amputated, do the pains remain, as severe as they were when the limb was present? Not only are the pains still present but they are in exactly the same place. This can lead onto an explanation of pain memory and amplification.

The young person will often be experiencing the pain-related symptoms and signs mentioned earlier in this chapter. By explaining that nausea, dizziness, blurred vision, sudden falls etc are all related to the pain effects the health professionals will not only educate but also alleviate some of the fears that other conditions are coexisting.

Analgesics are often unhelpful in chronic pain conditions. The adolescent may have tried a variety of nonsteroidals, codeine preparations, and/ or opioids with no lasting effect. This can be confusing. An explanation that chronic pain conditions (whether directly related to disease, e.g., cancer or not) are notoriously difficult to treat should be given. For reasons that are unclear, the pains may be initially held but then breakthrough. This can be devastating both physically and emotionally.

From this point, one can move on to show how pain and the associated disability can amplify. An example is leg pain. If a young person has pain in an ankle then he/she is reluctant to move it. Over time this stiffens and the pain increases with smaller movements. The skin becomes hypersensitive. Weight bearing is difficult and the leg is held in an awkward position. This puts strain on the upper leg and hip. These in turn become painful and immobilized. The other leg takes more weight and becomes increasingly sore. Lower lumbar pain sets in as the pelvis is tilted. Sitting and standing become uncomfortable. By this stage sleeping is affected and fatigue increases. Other pain associated symptoms may develop. Activities drop off and mood lowers. The young person and their family will identify with this downward spiral.

It is important that they understand that slow, consistent physical and emotional rehabilitation is essential despite the pain—akin to re-educating the whole body. This approach has been shown to be successful. By introducing psychology in this way the family will hopefully understand the importance of emotional rehabilitation in chronic conditions.

In some cases of CRPS early, intensive physiotherapy may be appropriate (15) and this may be discussed.

At this stage, having answered as many questions as appropriate, one should be in a position to plan multidisciplinary rehabilitation.

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Natural Pain Management

Natural Pain Management

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