Dr. Arvind Srinath: From UPMC Children's Hospital of Pittsburgh, welcome to That's Pediatrics. I'm Arvind Srinath from the Division of Pediatric Gastroenterology.
Dr. Amanda Poholek: And I'm Amanda Poholek, Assistant Professor of Pediatrics.
Dr. Srinath: Today we have the opportunity to speak to Dr. Angela Garcia and the topic today is designing rehabilitation programs for children with chronic pain to become more functional or a non-pharmacologic approach to chronic pain management in kids. Dr. Garcia is an Assistant Professor in the Department of Physical Medicine and Rehabilitation and an Assistant Director of the Pediatric Rehabilitation Medicine Fellowship Program. Her clinical specialties include congenital and acquired musculoskeletal disabilities, concussion, and rehabilitation through sports and physical activities in the pediatrics. As well she serves as medical volunteer in Haiti, bringing rehabilitation care to children throughout annual visits. And her clinical interests include pediatric rehabilitation, pediatric musculoskeletal medicine, concussion, spasticity and movement disorders management, pediatric pain management, and acupuncture. She does everything, folks.
So Dr. Garcia, thank you for joining us and can you just start with sharing your path to coming to Children's Hospital of Pittsburgh and the Division of Rehabilitation Medicine?
Dr. Angela Garcia: Thank you so much for inviting me on to the podcast today. I really appreciate it and appreciate the opportunity to talk with everyone. So what drew me to pediatric rehabilitation medicine? Well, first I got interested in physical medicine and rehabilitation in medical school. I really enjoyed working with patients who had acquired brain injuries, spinal cord injuries, and pediatric onset medical conditions that led to changes in the functioning in the home, and school, and community environment. And I really also enjoyed the team aspect.
The physical medicine and rehabilitation team is multidisciplinary involving PT, OT, speech, the rehabilitation physician, rehab nursing, and psychology to help improve a child's functioning. And then when I was in residency I realized I belong in pediatrics and so that led to me applying and staying here at Children's Hospital of Pittsburgh for my pediatric rehabilitation medicine fellowship and stayed on eventually as an attending. And so I've been very happy here. It's been an excellent place to be.
Dr. Srinath: That's amazing. You were clearly pulled to where you ended up being and obviously do a huge, huge service to your patient population. So can you tell us about your pain rehabilitation program just in general first?
Dr. Garcia: The hallmark of our Pain Rehabilitation Program is that we are really focused on trying to improve the functioning of these children who have been suffering from chronic pain, whether it's chronic pain from an amplified pain syndrome, complex regional pain syndrome, or another medical condition that led to having chronic pain. We take a very much a holistic approach to treating the child with a pain condition. The child is assessed by a multidisciplinary team, so it involves a physician. I am part of the pain clinic along with Dr. Scott Brancolini. He's one of our anesthesiologists at Children's and so he also sees children with chronic pain as well. They are also seen by a PT, physical therapist, a pain psychologist, a social worker, and our advanced practice provider as part of a multidisciplinary team evaluation. Altogether, we actually then discuss how we should treat this child and what therapeutic modalities might actually be best for them to help treat their pain and improve their functioning.
And so we do a lot of collaboration. There's a lot of education that goes into this for the child and their family because obviously when the child is not functioning well due to chronic pain, the family unit is also affected by this and so we have to do a lot of counseling of the parents and we even will talk with their siblings during those initial appointments if they happen to be there to help them understand what the child is going through.
Dr. Poholek: So how does a patient get referred to the program and is it something that they have to come, and that's a big number of people to have to meet with, is that something they come in and do a big team visit all in one day or does some of the folks on the team go to the home and try to assess things in the home that can be modified to help with the rehabilitation program that they're going to plan?
Dr. Garcia: Unfortunately we would love to be able to do home visits, but that is not feasible at this point.
Dr. Poholek: Okay, so the patient comes in.
Dr. Garcia: The patient comes in.
Dr: Poholek: So how do they generally get referred to the program to get started?
Dr. Garcia: So any child that has actually been experiencing pain for greater than three months can be actually referred to our program directly by any provider, physician in the system.
Dr. Poholek: Fantastic. Okay, great. And then how long does that process usually take from sort of, okay, we need to refer this patient to the program, what does the next step sort of look like in terms of the time course to get that done? And then at some point, how do you then go in and assess whether it's working, the plan that you've put in place?
Dr. Garcia: Exactly. Great questions. And so it sometimes can take a little bit of time to get into the program because we only do our multidisciplinary evaluations on Mondays and Tuesdays right now. We are looking to potentially expand that in the future. It's just due to availability of all the providers it's been a little bit more challenging to actually put that into place. And so we are hoping to be able to expand that.
And after that, once the child's been seen, they will follow up in clinic, usually just seen by the physician or our APP every two to three months to ensure that they're responding to the program, the program is working, seeing what is going right, what's going wrong, trying to make adjustments in that time period. We're also very responsive to the patient and the families. They are able to get ahold of us very easily through the portal and so we will answer emails during the week to help try to troubleshoot in real time as much as possible.
Dr. Srinath: Nice, nice. And this program, from what I understand is a super comprehensive program with specialists you mentioned. What type of treatment modalities do they use or is it too specific to discuss in the general?
Dr. Garcia: No, actually we have larger modalities we can discuss just in this moment. So when we think about, let's go with behavioral health to begin with, we actually have the Virtual Comfort Ability Program here at Children's. We are one of the pilot programs for the Comfort Ability Program, which was originally started at Boston Children's.
Dr. Srinath: Okay.
Dr. Garcia: And so with the pandemic we actually started the virtual component, which has worked really, really well. We have two groups that typically are ongoing at that time, every other month basically either the preteen group or the teenage group will meet together. This is a group therapy program for children who have chronic pain, so they have to be willing to participate in a group setting. It's run by one of our psychologists here at Children's and during this group they are able to learn about how chronic pain occurs and then talk about different ways that they can use their brain to basically flare down their pain.
The other part of the group that we all like is the fact that the children get to meet other children who are going through a similar circumstance with their chronic pain and we're able to facilitate those relationships in a very therapeutic manner. As we all know, kids are very savvy about being online and so they usually will meet other children who have chronic pain, but depending on how that is occurring, like through what modality, it may not always be a super therapeutic relationship. So this is a way that we can actually have children meet each other and actually gain support in a really therapeutic way.
Dr. Srinath: So do you think it's helpful, for example, if Amanda and I are patients in this Comfort Ability Program and I am mentioning perhaps a maladaptive coping mechanism, are those settings where you use that as an opportunity to help restructure my thoughts as an example for Amanda, and is that therapeutic for Amanda?
Dr. Garcia: Absolutely. I would say that's therapeutic for everybody in that group setting because you're able to educate about that maladaptive coping mechanism and also then correct it and give another coping mechanism that they could use in its place.
Dr. Srinath: Nice. Nice.
Dr. Garcia: So very much so. The Comfort Ability Program does use a lot of cognitive behavioral strategies to help reframe how people think about pain and how that pain is impacting their lives.
Dr. Srinath: Got it.
Dr. Garcia: Basically just to help them be able to function better with the pain.
Dr. Srinath: Got it. Got it.
Dr. Poholek: What would you say are some of the primary challenges that you've encountered in the program? Either implementing the program, or just sort of treating patients, or being consistent across different modalities.
Dr. Garcia: Sometimes uncertainty with the diagnoses can still lead to challenges in terms of accepting having the chronic pain and being willing to move forward in terms of treatment that we recommend. So a lot of times, depending on how a child presents with their physical exam, we will order additional studies and test just to make sure that what we think is happening is really what is happening and to rule out anything else that could be occurring that could actually prevent them from being able to fully participate.
Dr. Poholek: So I'm the non-physician part of this co-hosting team. So I guess maybe you mentioned before amplified pain syndrome. What is amplified pain syndrome? How does that happen and how do you manage that?
Dr. Garcia: Great question. So amplified pain syndrome is now what we call a centralized pain disorder, meaning that due to something going on, whether it was another injury or circumstance, the brain and spine pain pathways become overactive. And when that occurs, they keep firing even when there may not be a structural change in a joint or a limb, say the arm, or the leg, or the knee and the pain signal just keeps going, and going, and going. And then it gets worse if they do an activity, it gets worse if they don't do an activity.
Dr. Poholek: And so how do you treat that?
Dr. Garcia: So we usually have to treat it both with medications. Common medications that we'll use in this situation include tricyclic antidepressants, so amitriptyline, nortriptyline, and we'll use gabapentin. We'll maybe use an antidepressant such as duloxetine, which is a selective norepinephrine reuptake inhibitor, or one of the SSRIs, selective serotonin reuptake inhibitors as well to help treat it depending on what other symptoms may be actually occurring at the same time. In addition, that's only a very small component. The bigger component is actually doing the appropriate physical therapies to help them regain strength. Because a lot of times what will happen is that a child will start to develop pain in an area and then not want to move because it causes pain, which makes a lot of sense in a child's mind because they're like, something hurts, I won't move, it won't hurt as much. But in this situation it actually perpetuates that signal, it doesn't actually alleviate it.
Dr. Poholek: I see.
Dr. Garcia: And so we'll also do... That's where kind of behavioral therapy, we'll sometimes have them do biofeedback in those pain psychology sessions, the Virtual Comfort Ability Program is part of all this. And then we'll also recommend therapies like acupuncture to help out with treating the pain by interrupting that nerve signal that's actually helping perpetuate that pain signal.
Dr. Srinath: So we are talking about pain, we are talking about behavioral health, we are talking about medications such as antidepressants, but I can foresee patients thinking that you're thinking this is psychological. How do you approach that? Because it's clearly not.
Dr. Garcia: Exactly. No, that's actually a major, major part of what we have to address in those initial patient visits. They've gotten the idea that someone's saying that this is all in my head. I've had lots of patients come to tell me that, "I've been told this," and the first thing to say is, "No, this is real. This is a signal that is going from the joint up the nerve to the spine, to the brain being processed by all these different areas of the brain." And what I'll usually do is bring up a diagram of the brain on pain matrix and literally we'll be like, "This area affects how you move. This area affects your mood itself. This area affects how you process the pain. This is how you sense it."
Dr. Srinath: Nice.
Dr. Garcia: And then that way they can understand that this is a real medical condition that is affecting their life.
Dr. Srinath: Then why do, and I'm playing a family role and this is my question that comes up is, how come many of the medications you mentioned are antidepressants, or antianxiety, or those types of classifications of medicines?
Dr. Garcia: Absolutely, because what we're trying to do is we're actually trying to manipulate the nerves themselves. So all of these different medications work on receptors that are on the nerves in our brain and spine. And that can help modulate that pain signal, whether it helps inhibit it, or stop it, or helps enhance something else like another area of the brain that will actually lead to stopping that pain signal.
Dr. Srinath: Got it. That's super helpful.
Dr. Poholek: Yeah, that's really helpful. So I'm curious a little if you know where is the research going in this area? What do we know about... Because actually as Arvind was talking about depression, it's like well, a lot of people who are experiencing depression also feel pain. So what's the difference? How do we unlink these things? Or are they totally linked? Maybe you have actual pain and that drives this feeling that you're always going to have pain, which drives a psychological condition that then actually experiences pain. And what's the difference between real pain that's coming from a condition, a chronic condition, and the perception of pain? Are those even different or is it all just pain?
Dr. Garcia: So great, great question. So we always say that pain is biopsychosocial, meaning that it's biologic, so what's happening in the structures of the body itself and then also what's happening both in the brain, the spine in terms of that pain processing, and also what's happening around the child. Because all that can influence pain. Unfortunately, I call it a cycle because you actually described it really, really nicely. Child starts to experience pain, they're not able to participate in their activities that they really enjoy, and then they get anxious because they don't want to cause more pain or they get depressed. In children, what we have found is that most children pain will drive anxiety and depression. It's not actually the other way around.
Dr. Poholek: Interesting.
Dr. Garcia: But once those conditions, because they all are being processed by very similar areas of the brain, once they exist, they can actually all play off of each other.
Dr. Poholek: Mm-hmm. Yeah, complicated, complicated. And important to I'm sure convey that to the families and to the patients so that they feel like they can really understand this and that it doesn't feel like, oh, it's all in your head, right? Because it's not.
Dr. Garcia: It's not, exactly. This is really happening, this pain is real.
Dr. Poholek: Yeah. Yeah. Yeah. How long does it usually take do you feel like for patients to really start to feel less pain?
Dr. Garcia: So that depends, some patients it will take a long time. Unfortunately, usually by the time they make it into our clinic, they've been experiencing pain for a very long time. I've seen kids, children who are as young three to teenagers and a lot of our teens will actually express that, "Oh, I've been having pain since I was in kindergarten."
Dr. Poholek: Oh wow.
Dr. Garcia: We just didn't necessarily say anything. And so some of the areas, you mentioned what research is ongoing. A lot of researchers are actually trying to figure out this pain matrix and the pain pathways themselves in the brain so that way we can find better therapeutic treatment options for these kids because we have these medications, but they're not perfect. They all have side effects and those side effects can sometimes be really detrimental themselves. So we try to avoid them when we can. I will use them, but I will also try to find other ways to treat their pain if it's possible.
Dr. Poholek: Yeah, especially long term.
Dr. Garcia: Exactly.
Dr. Srinath: So your program is so, so comprehensive and clearly you're really tailoring your nuanced care to each patient here. What has been the reception from a patient standpoint for your programs?
Dr. Garcia: So I would say the patients overall are very receptive. First off, I think they just are relieved to be validated in their pain experience and in what they're actually experiencing. That validation is super important. Once they actually feel like, you understand what’s happening and you understand that this has really affected our life, they're usually more open to trying treatments. Now if I have a child for example, that maybe has done physical therapy in the past and has not had a great experience, we'll try other treatments first before thinking about going back to that. Because when you've had that experience, it's really hard to trust that we're going to do something different and we have to build that trust. And so in terms of actually relieving pain, we have some kids who their pain will get better, but they may always have a little bit of pain just because those pathways are still there.
And so that's why a lot of our goal is also to work on that coping and that functioning with their pain because I would love to see the pain get better, but I also, if they have pain, I don't want that pain to be stopping them from participating in life.
Dr. Srinath: Right. Right.
Dr. Garcia: I want them to be going to school. I want them to be able to do whatever sport they happen to be doing, whatever activity they enjoy, and we'll try to tailor their activities and stuff to what they're able to do without flaring their pain.
Dr. Srinath: Now speaking of life and long-term, so what's the natural history of the folks who do get amplified pain disorders? So is if you get this type of problem at age X, the chances of you being responsive to treatment is higher as opposed to later on versus...
Dr. Garcia: So we find that the earlier we can actually treat it, the better it is.
Dr. Srinath: Okay.
Dr. Garcia: Unfortunately, there is a very strong likelihood that a child who is experiencing chronic pain will end up experiencing chronic pain again at some point in adulthood.
Dr. Srinath: Got it.
Dr. Garcia: Because those pain pathways are there and depending on what is occurring, they can get reactivated. And so they are definitely at more risk to have chronic pain as an adult.
Dr. Srinath: Got it.
Dr. Garcia: Which is again why coping and learning those coping skills is going to be so important when they're younger. Now, can we actually change how they perceive pain and how the body actually reacts to a painful signal? Yes, we can. When they're younger, for example, I'll usually try to screen for more sensory processing disorders because if I find that they have several areas where their nervous system, brain, spine, and the receptors are acting differently with different stimuli, so say like wet grass, not being able to tolerate jeans, not being able to eat certain foods because the texture is just not compatible with how they feel, then we'll work on that as part of it. Because if we can actually change the system when they're younger, it actually changes how their system will react to a pain signal when they're older.
Dr. Srinath: Got it.
Dr. Garcia: And so that is one of the areas that we're really trying to work on and there's actually a lot of research going on in this area for children with chronic pain who are younger.
Dr. Srinath: Interesting.
Dr. Garcia: We're also working on how we treat pain from birth all the way through life. Unfortunately, children who are in the neonatal ICU are more likely to develop chronic pain when they're older just because of the fact that their nervous systems are still developing at that time period. It's actually a very critical period of development and they become more sensitized due to all the necessary and lifesaving interventions we have to have them undertake.
Dr. Srinath: Got it.
Dr. Garcia: But because of that, we also are recognizing that they are more likely or have a greater risk of developing chronic pain when they're older. So there's a lot of research going on, on what we can do even in that neonatal ICU setting to help. If we have to do blood work, how do we make it less painful and being less of what we call a noxious stimuli, which is a stimulus that is just not pleasant.
Dr. Poholek: Yeah. That's really interesting. It almost makes you feel like these are real pathways that get laid down early on that have a long-term impact, which is truly fascinating. So then what do you feel like are the needs of the future? It sounds like maybe one area is being able to even identify patients with pain at the earliest stages of that pain, but are there other areas that you feel really need development for the future for the program?
Dr. Garcia: One of the things that we would like to do is eventually develop an inpatient pain rehabilitation program. We used to have an inpatient pain rehabilitation program here in Pittsburgh, but it closed about five years ago. What the goal of those programs are is for the children whose functioning has just gotten to a point where they're not able to go to school, their pain is really causing problems with living life, that we can actually bring them in and do intensive therapies, both psychological and physical therapies to help treat their pain. We can do, depending on the program, some of the programs nationally will change medications depending on what's going on. They'll do other modalities.
Some of the research that's been completed in pediatric pain medicine has indicated that functioning will improve before pain does. So getting the child back to their normal life and being able to go to school, participate in whatever activities that bring them joy is so important to helping treat their pain in the long run.
Dr. Srinath: Got it. Got it. Well, Dr. Garcia, we really appreciate you taking the time to talk about this really incredible program and the huge, huge, huge population you're reaching in really innovative ways and creative ways too. So we really appreciate that. So thank you.
Dr. Poholek: Thank you so much for being here today.
Dr. Garcia: Oh my God, thank you so much for bringing me. I appreciate it.
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Angela Garcia, MD,
