Sound of Metal

Dominik Ochocinski MD and Rita Agarwal MD, FAAP, FASA

As promised and in keeping with Ron Litman’s vision, we are slowly but surely expanding the number of journals and reviewers for the PAAD.  Rita Agarwal volunteered to join us and she will concentrate on surveying and commenting on issues related to pediatric acute and chronic pain.  Today’s PAAD comes from the J Pain. For those of you who you who don’t know her, Rita has served as the Editor for the Society for Pediatric Anesthesia’s Newsletter and is a member of its Board of Directors. She is immediate past Chair for the American Academy of Pediatric’s Section on Anesthesiology and Pain Management and is the Vice President for the Society of Pediatric Pain Management. She is a clinical professor, anesthesiology, perioperative and pain medicine at Stanford.  This is her maiden PAAD voyage and she invited one of her fellows, Dr. Dominik Ochocinski, to join her.  Myron Yaster MD

Original Article:

Suryakumar Narayanasamy, Fang Yang, Lili Ding, Kristie Geisler, Susan Glynn, Arjunan Ganesh, Madhankumar Sathyamoorthy, Victor Garcia, Peter Sturm, Vidya Chidambaran.  Pediatric Pain Screening Tool: A Simple 9-Item Questionnaire Predicts Functional and Chronic Postsurgical Pain Outcomes After Major Musculoskeletal Surgeries. J Pain. 2021 Jul 17;S1526-5900 (21)00291-1. PMID: 34280572

In the 2019 movie “Sound of Metal”,

the main character, heavy metal drummer Ruben, loses his hearing.  In his ongoing struggle to accept his hearing loss, Ruben decides to undergo cochlear implant surgery. Unfortunately, the results of surgery are far less than the quality of hearing he expected. His struggle with adjusting to his new reality is something that is all too familiar to those of us who treat chronic pain.

Chronic Post-Surgical Pain (CPSP), occurs much more commonly in pediatrics than is widely believed (14-38%).  There is currently no way to identify patients who are at risk.  In today’s PAAD, we review the paper by Narayanasamy et al. who describe the use of the Pediatric Pain Screening Tool (PPST) as a potential tool to predict populations at risk for CPSP.

What is Pediatric Pain Screening Tool (PPST)?

PPST is a nine-item questionnaire evaluating two constructs of pain: physical (function i.e walking, quality of life measures such as attending school, widespread pain and sleep) and psychosocial (pain associated fear and anxiety, depressive symptoms, catastrophizing, pain inconvenience) (see table). All questions on PPST are scored in 0 or 1 per each item. Narayanasamy et al. hypothesized that the PPST could independently predict CPSP in patients undergoing posterior spinal fusion for scoliosis repair or the Nuss procedure for pectus excavatum repair, procedures associated with a high risk of CPSP.

Pediatric Pain Screening Tool1:

Physical Subscale

·        My pain is in more than one body part

·        I can only walk a short distance because of my pain

·        It is difficult for me to be at school all day because of pain

·        It is difficult for me to fall asleep and stay asleep at night

Psychosocial Subscale

·        It is not really safe for me to be physically active

·        I worry about my pain a lot

·        I feel that my pain is terrible and it is never going to get any better

·        In general I do not have as much fun as I used to

·        Overall how much has pain been a problem in the past 2 weeks

What did they find?

Out of 164 patients, 109 patients responded and about 1/3 of patients were lost to follow up. In patients undergoing posterior spinal fusion for scoliosis repair or the Nuss procedure for pectus excavatum repair,

1.       PPST sub scores are predictive for development of CPSP and can be used as screening tool for CPSP in  preoperative evaluation.

2.       The group with CPSP scored higher on psychosocial characteristics of PPST than non-CPSP group.

3.       PPST allows for risk assessment and stratification of patients depending on their risk for CPSP, which permits future targeted interventions.

4.       Even patients with low PPST scores of <2 still had medium risk (10-30%) for developing CPSP (1). 

What’s next?

Narayanasamy et al. suggested the following recommendations for high-risk patients:

1.       Preoperative referral to behavioral medicine for cognitive behavioral therapy

2.       Education around coping strategies, relaxation therapy, hypnosis, biofeedback preoperatively

3.       Pharmacological therapy for anxiety and depression

This study opens the door for further research, because of 70% moderate predictive accuracy of PPST for CPSP indicates that there are other factors contributing. For instance, race, sex, surgical duration, acute postoperative pain, different treatment modalities and other factors can all play a role in development of CPSP and those areas need further investigation. Future studies can expand on different types of pain, for example, visceral pain, genomics of analgesics, various treatment modalities, etc.

Spoiler alert, in the last scene of the movie, Ruben sits down in the park, turns off his implant and enjoys the silence. Using Pediatric Pain Screening Tool to identify population at risk for chronic postsurgical pain can be a way to bring these patients closer to adapting to new postsurgical reality.

References:

1.   LE Simons, A Smith, C Ibagon, R Coakley, DE Logan, N Schechter, D Borsook, JC. Hill Pediatric Pain Screening Tool: rapid identification of risk in youth with pain complaints. Pain, 156 (2015), pp. 1511-1518