everyone. Thanks for joining us for our talk on acute and chronic pain in the pediatric athlete. And thanks to AAPMNR for helping us host this awesome session. And we have a number of speakers from diverse backgrounds. We have Dr. Holly Benjamin. She's a professor of orthopedic surgery, rehab medicine, and pediatrics. She's the director of primary care sports medicine at the University of Chicago. She is the team physician for WNBA, Chicago Sky, UChicago Maroons, U.S. Soccer Federation, USA Triathlon, BOA, Chicago Marathon, and an associate editor for CJS Clinical Journal of Sports Medicine. And then we have Dr. Andy Collins. He's a clinical associate professor of Department of Orthopedic Surgery Division of PMNR at Stanford University. He is also the medical director of rehabilitation services at Stanford Children's Health. And then Dr. Jennifer Cushman. She's an interventional pain fellow PGY5 at St. Elizabeth Hospital Medical Center. She's the delegate New York Society of Physical Medicine and Rehabilitation for the MSSNY House of Delegates. She is also the co-chair for the New York Society of PMNR legislative team and the AAPMNR chair of the pain medicine member community, as well as a reviewer for the Pain Practice Journal. And then there's me. I'm Dr. Ami Hample. I'm a musculoskeletal electrodiagnostic and acute inpatient rehab physician for the Department of PMNR at Advocate Christ Medical Center and Hope Children's Hospital. I'm the executive director for Chicago Youth Foundation, lead physician for Skating Council of Illinois, and AAPMNR pediatric sports medicine community chair. And then we have Dr. Chaitanya Konda. He is an assistant professor, director of the intrathecal pain pump program, and director of the simulation lab curriculum department of PMNR at UT Southwestern Medical Center, as well as an ad hoc reviewer for the Journal of Pain. Then we have Dr. Caitlin Mooney. She is an assistant professor of orthopedics at Vanderbilt University Medical Center and the team physician for Vanderbilt Dance and Cheer. I think I got it right this time, Dr. Mooney. And then Dr. Stephanie Tao. Am I saying that correctly, Dr. Tao? She is the assistant professor, Department of PMNR at University of Colorado, Pediatric Rehab and Sports Medicine. She is on the Department of Pediatric Rehab Medicine, Pain Medicine, and Sports Medicine at Children's Hospital of Colorado. And she's the head team physician for Team USA Paralympics Swimming National Team. And so thanks, everyone, for joining. Next, I'm going to go ahead and start. So the first part of our talk, we're going to talk about acute pain management in the pediatric athlete. And I will hand the microphone to Dr. Jennifer Cushman to begin. Hi, everyone. Thank you so much for attending. So I'm just going to give a brief introduction to pediatric acute and subacute pain in athletes. And from the IASP definition of pain, it's an unpleasant sensory and emotional experience that arises from actual or potential tissue damage. And as we all know, it's subdivided into the time that you feel the pain. So acute pain is anything less than six weeks. A subacute pain is six to 12 weeks. And chronic pain is anything that's over three months. So pain is a result of the interactions between the developmental, physiological, psychological, and as we all know, environmental and social factors. And it's affected also by one's emotion. We all know that depression can affect our pain and how we perceive it. So we definitely know that the pediatric pain is underreported. And research shows that the undertreatment of pain is very common, especially in younger and nonverbal PEDS patients. And we could also see that you can see it up to 70% that's in trauma patients of all ages. And the Emergency Medicine Residents Association accounts that pediatric pain can be up to 70% of ED visits, which is extremely high. And we all know that the musculoskeletal system is the most common organ involved. We also know that kids, you know, go to the ED, they have throat, ear, headaches, et cetera. But definitely MSK injuries are the most common. And, you know, common clinical settings where we have to be mindful for acute and chronic pain are sideline coverage, orthopedic, sports medicine clinics, as well as our inpatient hospital settings. So we can go to the next slide. So we all know that there's a burden with, you know, treating acute and chronic pain in the PEDS population. And there's definitely an increased prescription, and which is alarming, a non-prescription opioid use in adolescents and high school, especially in athletes. And it was sourced that one in eight teens admitted trying opioids in high school recreationally without an actual prescription. And 60% of teens who admitted to using heroin started by misusing prescription opioids and getting it through diversion, et cetera. And some studies show that children and youth use cannabis to self-medicate. So this is something that they're introducing to their lungs and it's causing a lot of long-term effects. So it's very challenging to diagnose and treat, especially in the PEDS population. And, you know, there's resulting persistent or chronic pain and long-term changes in pain perception and pain behaviors, which can lead to complications into their adulthood. And we all know that untreated pain can lead to sleep disturbance, nutrition problems, depression, anxiety, and suicide. So we can go to the next slide. So basically, I'm going to go into some of the pediatric pain scales, and there's quite a few. And basically, the first one is about the CRY scale. So the CRY scale shows that if the score is more than four, then further pain assessment should be undertaken. And anything above six, you should make sure that the CRY scale is met. And then the second one is about the six, you should make sure that the PEDS patient does get some analgesic administration. Then we have the NIPS score, which is, it's a behavioral scale that can be utilized with both full and preterm infants. And then the FLAC scale, which is the face, legs, activity, CRY, consolability scale, is a measurement used to assess pain for children between the ages of two months to seven years, and especially the pediatric population that's unable to communicate their pain. Then we have the VRS, which is a categorical ordinal scale. It has four or five levels of verbal adjectives to describe increasing intensity of pain. We have the CHOPS, which is an observational scale for measuring post-op pain in children one to seven years. And then we also have the poker chip tool or the pieces of heart tool, which is an observational scale for measuring post-op pain in children one to seven. And I also just wanted to go into the nociceptive and, you know, the nociceptive pain, notify the brain about injury with electrical signals sent via the peripheral and central nervous system. So we can go to the next slide. And this is just like an example of the CRY scale. I just wanted to show a picture. And it's used for infants more or less of 38 weeks of gestation. And you just monitor like crying, oxygen requirements, change in vital signs, facial expression, and sleep state, and a maximal score of 10 as possible. And like I said, anything six or higher, they would need some analgesic intervention. Next slide. And here, I'm just going to go through again of some, you know, of the age ranges again. So you have the numeric rating scale, seven years and older. The faces pain scale, which we use for five to 12 years old. The pain word scale, which is three to seven years. Also, the face, legs activity, which is two to seven years. The premature infant pain profile, we use for preterm and term infants. And also the neonatal infant pain scale, which is for full term and preterm infants. And, you know, it is very challenging to assess pain and especially in the preterm infant, you know, population. So there's definitely more research that needs to be completed in order, you know, so, you know, children like, you know, especially preterm and infants, like they don't suffer unnecessarily. So we can go to the next slide. So I'm just going to talk briefly about like the multiple components and mechanisms of the pain system. So we can go to the next slide. So basically, some of the neurobiology behind, you know, the pain perception. So for the peripheral terminals, there's definitely sensitization of the peripheral terminals and it's due to changes in the density distribution and biophysical properties of the channels that are responsible for the sensory transduction. And then you also have the peripheral nerves that, you know, chronic pain, when we see injuries that aren't healed, they can induce changes in the action potential conductions and affect the velocity and activity dependence slowing has been also described. And also nerve injury may also result in the emergence of ectopic activity, which is also seen with chronic pain. So you see this ectopic activity along the nerve with neuroma formation, and that also can become a site of ectopic activity. And then the DRGs, you know, we do see with chronic pain changes within the DRG, and they may also enable the emergence of some ectopic activity. We also see changes and sites of plasticity within the spinal dorsal horn. And that's a primary site of central sensitization that reflects both the pre and post synaptic facilitation and a decrease in inhibitory neurotransmitters like GABA and glycine signaling have also been seen an increase in the intrinsic excitability of the dorsal horn neurons. Going up, we also have the nucleus raffi magnus, and the rostral ventral medulla, and they shift from a descending inhibition to a facilitation. And we have the periductal gray area. And we can also see loss of the descending inhibitory tone from the periductal periaqueductal gray area. Also changes in the synaptic strength and gene expression and structures have been seen in the anterior cingulate, amygdala, and hippocampus region. And changes have been in several of the chronic pain states. The thalamus is also affected with chronic pain. There have been increases in spontaneous and evoked activity following spinal cord injury and other forms of chronic pain. And the cortex, we've seen changes in cortical thickness, and that's also been described in several chronic pain states. So I'm going to pass along the talk to Dr. Amy Hample, and thank you again. And please ask questions at the end if anybody has any concerns or questions. Thanks. Yes. Thank you, Dr. Cushman. So we have a case. We have an 11-year-old, skeletally immature female diver with right ankle pain while in gym class at school. The only pertinent positive review systems was swelling, tenderness to palpation, and a limp. So it's important for the physical exam, obviously, to do a full musculoskeletal exam, especially in the area of the pain, but to check the joint above and below. But also keep in mind that a comprehensive neurologic exam and kinetic chain biomechanical exam can help. Assessing physical maturation and emotional development can also be helpful, especially in regards to pain. And then in regards to back pain in adults and children, the Waddles sign can help differentiate organic versus non-organic causes of back pain. So on physical exam, our 11-year-old female patient, she showed mild swelling and tenderness to palpation at the distal fibular physis and showed an antalgic gait. And there were no deformities, no cuts or scrapes. So does anyone want to put in the chat what they would put in the differential? I'm going to give you only a minute. So go ahead. And if anyone wants to participate, feel free. Okay, so I'm going to keep going. So we know a fracture or bone contusion are some of the differential ankle sprain. I'm going to hide this really fast. All right, so. So there's, it's important to, so there's different types of acute and subacute pain conditions in pediatric athlete. It's important to know that injury is not equivalent to pain. For example, it can have an injury, but not have pain. You can have pain, but not have an injury or like substantive tissue damage that is detectable. And so there's, of course, we have the acute traumatic injury in athletes of where you have a single event that leads to a singular macrotrauma on previously healthy tissue. And this can be accompanied by fear, anxiety and heightened focus on the, in the injury itself. Then you can have, we have the overuse injury exacerbations which can be subcategorized as subacute recurrent injuries where we have, you know, which are defined as, you know repetitive submaximal loading on MSK system where with inadequate recovery. And so what happens is then this, you know the body is unable to dissipate the stress or force that repetitively happens. And so there's either repetitive microtrauma on otherwise healthy tissue or repeated application of lesser forces on already damaged tissue. And so basically the athletes are not training at their optimum to capacity workload to build physical capacity and resilience to the demand of their sport. And then you have, then you can have, you know exacerbations of a chronic degenerative condition. Again, you can have a degeneration from overuse injury repetitive overuse injury. And so then that can be, it can be subcategorized as that. And then there are also conditions related to disabled and wheelchair reliant athletes. For example, Paralympic athletes with spinal cord injuries can have obviously chronic pain but they can have acute pain related to their condition such as spasticity related pain, you know amputees can have stump, has new onset stump pain or recurrent stump pain as well as phantom limb pain. And then MS can also be associated with pain syndrome as well. Most likely chronic though. And then, so in our, in our, in case, in the in regards to our case, we got x-rays and we had we got AP lateral and mortise views of the ankle and then as well as full length tibia views to rule out most new fractures, her x-rays were normal. And so then we prescribed pain control with rice, rest, ice, compression elevation as well as Tylenol and ibuprofen which is a commonly used medications used for pediatric pain control, especially in athletes. She was told to wait there as tolerated with a walking boot and follow up with us in four to six weeks. So there with especially pediatric population and athletes especially, and also helpful for adults non-pharmacologic options for acute and subacute pain should be implemented. For example, you know, starting out with for athletes padding, splinting, bracing, orthotics taping, crutches, equipment adjustments or replacements those can be helpful, especially if there's an injury involved or some equipment malfunction or issue. And then it's important. And then of course, physical therapy exercise and examining the activity rest cycle to see if they're, you know, overdoing it or not getting enough rest or not cross training appropriately. It's important to understand that and it's more for athletes to understand that relative rest and immobilization can be helpful for injuries or, and the pain that often comes with injuries but prolonged total rest and immobilization are usually not helpful for reducing pain or injury healing. It's also important to improve range of motion, strength, endurance, and then correct any biomechanical contributors to the pain along the kinetic chain as soon as possible. And then if there's any joint dislocations, reducing early, reducing them early can usually help with pain for the acute and subacute period. There's obviously the cold treatments, cold therapy has been shown to be effective for pain and inflammation the first one to three days and exercise helps pain by activating the endogenous anti-nociceptive pathways as well as a secondarily by improving mood and sleep. And then we have obviously a lot of modalities for short-term pain relief. Of course, there's not enough studies to like validate any of them. However, some of them can be helpful and depend on the athlete perception as well as the clinician skill level. These modalities include low level laser therapy which is often used for endopathy or acute muscle injury, therapeutic ultrasound, electrical stimulation, massage therapy, myofascial trigger point treatments and acupuncture. And then the bolded ones are the ones used for athletes which are typically older, but you'll see in the non-bolded ones are more for like the babies neonates like pacifies and swell blankets, but that doesn't apply to our talk. And then there's also biofeedback, relaxation, breathing techniques, distractions such as art, music, dance therapy and then role-playing, meditation, video games and virtual reality can also help. And of course, sleep hygiene can be very helpful and then referral to a psychology or psychotherapist can be very helpful, especially when an athlete's transitioning from acute to subacute pain. And then cognitive behavior therapy more for a chronic pain, but the idea is to keep in mind if the patient is going to where it's a subacute pain duration. So the biopsychosocial model is often employed for chronic pain, but important to keep in mind for acute pain, especially in athletes because there's a lot going on. You know, there's a lot of social, biological psychological factors and stressors on athletes. So it's important to first educate athletes about the nervous system and how it's involved in the definitions of different types of pain because it can help them be more receptive to the biopsychosocial model and be more involved in properly healing themselves. And then it's also important to when communicating with the athletes and their coaches and their parents to account for the tension between ignoring or masking pain versus understanding the protective role pain has in the presence of an injury. Like I said before, sleep improves pain in recovering athletes. Stress in athletics is a risk factor for athletic injury and pain. So minimizing stress as much as possible can be helpful. And then mood disorders are not only a risk factor for poor treatment response in the athletes with acute or chronic pain, but they also can the pain, if the pain persists can lead to mood disorders. And then exaggerated negative mental thoughts or perceptions or poor coping skills can, if they are targeted can help with improving healing from pain. And then also important to identify disordered eating because they can often present acutely with pain or, and then untreated pain can lead to disordered eating as well. Then you wanna look from the social aspect as well because it's normal for parents to worry about their children and protect them from pain, but overly protective behaviors can also has been shown to increase pain related disability. And then as well as high amount of family conflict can also has been shown to hinder recovery from pain. And then very helpful for athletes to get and be still remain involved with the team, even if they're in pain or having an injury, even if they're in an administrative or managerial role. And then also keep in mind relationship with coaches, administrators, or other team members, as these can positively or negatively impact the pain experience for the athletes. And then keep in mind cultural aspects because socialization in athletes and male sports, there's a degree of hyper masculinity where it's culturally appropriate to disregard or downplay pain and injury. Also exists in women and girls sports as well. And then often keep in mind that elite athletes may potentially be experiencing pain every single day. And that an abrupt change in their pain experience is what they're more likely to act on. So keeping all that in mind can help with treatment. And then this is, I'm not gonna talk about this, but this is a quality improvement project I did at our acute rehab facility. This is for adults. We employed all the chaplains and did all this non-pharmacologic pain management and saw some very promising results. Of course, it was just a pilot study, helpful, I think, to potentially, hopefully people can model this for the pediatric population inpatient and elsewhere. So here's some pictures of different modalities. There's laser therapy in the upper left corner. And then you can see pet therapy below that, where even putting the dog's paw on the area of pain can be helpful. Then there's a picture of all the different types of biofeedback, EEG, respiratory, heart rate variability, EMG, sweat gland activity and temperature can all be monitored while doing different therapies to see if there's improvement in pain and give the patient also feedback as well on that. And then there's a woman breathing, which breathing is very helpful for pain relief often. So then we go now, now there's pharmacologic options for pain management in athletes. And this is a quick picture of where these, many of these medications act. Of course, there's some chronic medications on here like TCAs, which will be talked about later. But as you can see, there's NSAIDs and acetaminophen and aspirin on here, which I will talk about shortly. And here's a list of the commonly used medications and for acute and subacute pain for pediatric athletes. Sucrose is more for babies, but NSAIDs, acetaminophen and topical and spray analgesics, as well as opioids. This slide is kind of just kind of going over what is commonly used in the emergency room. There's oral, rectal, intranasal, inhaled, intravenous and subcutaneous pain medications that can be used. And then here's a list of all the topical analgesics are commonly used in the emergency setting or for procedural purposes. So for pharmacologic management, NSAIDs are often used and they help, obviously we know they're anti-inflammatory action in the peripheral nervous system, but then because inflammation sensitizes peripheral nociceptors, they also help with pain through that pathway as well. The NSAID choice in the pediatric population, the choice is more based on the differing side effect profiles, not by the differing analgesic outcomes. There is no current data to show that NSAIDs inhibit muscle, bone, tendon or ligament healing in injured athletes. NSAIDs plus acetaminophen combination has been shown to be more effective than either alone and has not shown any increase in adverse effects. And important to remember that never use aspirin in youth less than 12 years old because there's a risk of Ray syndrome. And then for acetaminophen, the max daily dose, as you can see listed here, depends on whether they're less than 50 kgs or greater than 50 kgs. Of course, for neonates and infants, it's much less. In the pediatric athlete population, it's not relevant, but it is thought to act as an anti-inflammatory more in the central nervous system than the peripheral nervous system. And it's also an antipyretic. And then we have topicals. We have limited data on the efficacy and use in the pediatric population, but most topicals appear to act through the nociceptive cutaneous pathway. Topical NSAIDs act at superficial synovial joints and can get absorbed systemically as well. And then we have muscle relaxants that can play a role in acute pain management, but there's poor evidence that they actually have skeletal muscle relaxant effects as a primary effect. They have some sedating effects, which can be helpful for sleep, but then the risk of increasing daytime sedation is there. Cyclobenzaprine is a commonly used one in the pediatric population. It's near identical to TCA, antidepressant drugs pharmacologically, but however, just also keep in mind that kids younger than 12 should not be prescribed any muscle relaxants. And then we have injectables. There's lack of evidence guiding the use of injectable medications for the treatment in pain in youth and adolescent athletes. There's also a lack of evidence for use of injectable NSAIDs for the use of same-day return to play, but local anesthetic injections can sometimes be used for same-day return to play. And then corticosteroid injections can help with pain and inflammation, but not useful for same-day return to play as they kick in a little bit later. But it's been very helpful to combine, if you're gonna do injections, combine it with non-pharmacological options like padding, bracing, to help them get back to return to play on the same day. And then opioids. Opioids, so we want to steer clear of opioids as much as possible, so try to exhaust your non-pharmacologic and non-opioid analgesics first, and then if you cannot treat the pain, then usually a three-day, three to five-day prescription is enough for common athletic injuries, including, and then one to two weeks should be sufficient for those requiring surgery. But very important to do a full screening on misuse risk, and then monitoring closely on the opioid, monitoring databases. And then keep in mind, keep close follow-up on the athletes for signs and symptoms of problematic use, opioid use, such as sedation, apathy, early refill requests, and lost prescriptions. It's also important to know that opioid withdrawal has been reported in patients who have received regular opioids for as brief as five days, but typically not common for those less than seven days, but has been seen as low as five days. Usually you're okay, though, if you do five to seven days. Again, if there is some signs of withdrawal, then that has to be assessed appropriately, and there should be a titration, proper wean implemented. And then if there's any unused opioids, educating family and athletes about any unused opioid medications increase the risk of misuse, abuse, and addiction, and they should be either initially locked up and then disposed of appropriately. And then, again, education is key. When initiating opioid treatment, make sure you make it clear about the taper plan and clarify the patient's expectation and communicate everything to educate the entire team, as this can help with many, many things, including even results from pain relief as well. Avoid long-acting opioids in this population, and keep in mind that combining opioids with sedative hypnotics, it can be lethal. And then keep in mind emerging state and federal laws on opioid use and guidelines. In opioid-naive pediatric patients, morphine and hydromorphone is usually the starting opioid, but the FDA does have a warning about codeine and tramadol use in children, where they noted some ultra-rapid metabolizers were getting severe respiratory depression, so keep that in mind. I just threw this slide in quickly for those who are studying for boards, because I just finished my board exams, and I thought this, I made this mnemonic for memorizing the morphine milligram equivalents. This is just, if anyone needs, this is basically a mnemonic that I made, and then it's just the order, the medications, opioids are in order of low to high morphine milligram equivalents. So it's called, trucks can travel many highways very often or hit many fast-moving mobiles. Hopefully that can help you, it helped me. And then this is more a chronic pain thing, however, because I'm talking about subacute pain, I threw it in here quickly, but they have done epidural steroid injections for radiculopathy or back pain in children and adolescents, and there are not many, much data out there, and not many places do it. However, it is, according to this study, this analysis, it seems to be that it could be safely performed under conscious sedation and reduce more aggressive intervention and should be evaluated. We should study this more in pediatric population. This study in particular studied, the pediatric athletes were involved in basketball, baseball, softball, soccer, lacrosse, football, dance, cheerleading, track and field, and volleyball, and most of these kids were having pain for five to nine months. But again, because of subacute pain, this could be a treatment option, I just threw it in there real fast. And then a couple more guidelines, I put guidelines in quotes because there are not really any specific guidelines, like per se, but prescribers should fully understand the indications, mechanism of action, contraindications, side effect profile for the medication, written documentation, and good communication and education is key. It's very important to keep track of the medication history and past medical history of medications that the athletes are taking. And it's important to also, and I'm not gonna read this entire slide, but it's basically making sure licensed healthcare providers are the prescribers, and an individualized approach for each athlete is very important. The healthcare setting is also important to keep in mind as you can see these athletes with acute pain in the ER, or in your clinic, in the MS skeletal or sports medicine clinic, or at the game sidelines or in training room. And then always start with non-pharmacologic and go to pharmacologic, non-opioids, and then progress to opioids, start with less invasive, less painful medication routes, and it helps to use image guiding, just it seems to reduce injection pain and adverse events and increase accuracy, according to most of the studies that are, the data is showing that this is more the case. And then for dosage and frequency, it's appropriate, you use what is appropriate for the age or weight class and start with the lowest dose for the shortest time period for adequate pain control. Never provide medications through any route for prevention of pain and injury for athletes as they may ask for, what can I take to prevent pain? No, we shouldn't give them any. And then there's limited literature to suggest that analgesics enhance performance. It's important to keep in mind athlete banned substances and therapeutic use exemptions. As some of these opioids and marijuana, which can be used for pain control are banned substances. And then supplement use is important to address as there are none, there are certain many supplements that are not regulated and can have a banned substances in them or harm the athlete in some way in long-term effects. So keeping that open communication with the athlete and the family and coaches and team and communicating appropriately are very important here. And then anytime you do a procedure make sure you obtain informed consent. And then if they're inpatient consulting the pain management team early especially if there's opioids involved, very helpful. But again, education and communication are key here. And then this is just a list of the 2024 WADA banned substances in terms of analgesics. So as you can see, a lot of opioids are listed on here. And then of course, THC is banned, but CBD is not. So just keep that in mind and educating your athletes on that. So I'm gonna go ahead and pass the microphone to Dr. Holly Benjamin to continue the rest of this talk. Thanks, Dr. Hamphill, that was wonderful. And thanks for having me and for organizing this great panel. This is an important topic. So I'm gonna follow up on the case and now we've got our little athlete here who's at six weeks follow-up, comes back to clinic and it has less swelling. However, it's still tender at that distal fibular physis. Next step in the case was an MRI which showed no major findings other than a salter hair swan distal fibular fracture. At that time, a physical therapy was started. So next slide. Still sort of following a reasonably common pathway I think for this type of injury. So I'm gonna cover really briefly just a few things as we morph from acute musculoskeletal injury into more chronic musculoskeletal injury and just hit a few key points. And one of the things that I think super important in my clinic is people always want to know, I take care of primarily pediatric athletes and they always wanna know that expected timeframe for each individual injury that I would expect to get better. So I think it's good to have some familiarity with what really happens when you get injured. So in those early days to weeks following a musculoskeletal injury, there's an inflammation, scarring and remodeling phase. And then what is important is after that first like six to 12 weeks, you're either going to heal or you're going to branch off to the right there into like two sort of common areas. At the top there, it's a development of subacute or chronic pain associated with chronic inflammation, possibly neuropathic pain, possibly just, you know, chronic overuse versus like more important to look at the nociceptive pain due to injury, which resolves as tissue heals as well. So this is a good slide to be familiar with. Next slide. All right, so other circumstances. This is pain and injury are difficult to assess in cognitively impaired children and sometimes physically impaired children as well. When an injury becomes chronic or is not healing, one must really figure out why and look for the red flags. I think the point here, and you'll hear this again later in the talk, is that initial pain is good pain. You're supposed to have pain when you have an acute injury. It slows the athlete down. That's what Amy was talking about where you don't want to overmedicate. You want to manage the pain, but you don't want to overmedicate or premedicate to prevent pain in order to participate when you should be participating. So I think that as you go along into chronic pain, it's perfectly okay. You're going to see lots and lots of injuries that are not going to be better in six to 12 weeks. And you have to figure out when this sort of morphing into chronic condition is okay, not okay to be expected, or just understanding the why and monitoring for red flags. So in general, red flags are always oncologic injury or illness such as the constant pain, nighttime pain, a neurologic problem, rheumatologic problem, or psychiatric issues. Now, this could be alternate diagnoses. These could be confounding diagnoses, which we'll talk about later as well. Occasionally, you'll have something roll in the office that needs the emergency room inpatient hospitalization or surgery. I have admitted three patients directly to the hospital from my clinic, maybe four. Three of them were conversion disorders, where a poor mom was carrying a 10-year-old who weighed like 120 pounds in a fireman's carry all the way up the three flights of stairs because he couldn't put weight on an ankle sprain after he had been off it for about three weeks or so. And he was just getting a lot worse. And then I've admitted an osteomyelitis and a chronic forearm pain who had like banged their arm, but just never got better. And then it seemed to get swollen after a few weeks of red and was just acting sort of weird. And then the other thing is, is when you're just getting a bad history or weird history of patients' family coaches. As far as pain management plans, I think it should fit the type of injury. You don't want to just keep over-medicating and medicating and medicating. If there's a lot of pain, you should understand why that is. However, as I said briefly before, pain control was super important to allow for recovery and progression. And a lot of times I'm using ibuprofen, naproxen, and all the anti-inflammatories or even Tylenol because I need pain control in order for the athlete to be successful at physical therapy. And as their pain is controlled, as they get stronger, then they need less pain medication and rehab is progressing the way you would expect it. I think I said this already as well, but pain out of proportion to the type of injury is always a red flag. Next slide. All right. So I think these are two important concepts when you're talking about chronic pain or a little bit in overuse injury, because those oftentimes will come in with already a several week or several month history of pain. And the way I very simplistically think about overuse injuries in clinic is genetics, biomechanics, and workload. The vast majority of pediatric athletes, people initially default to, oh, they're just doing too much. They're running too much. They're throwing too much. It's a workload problem. But I try to delve a little bit deeper and figure out, well, is it a genetic problem? Do they have Severs disease because they have the super flat feet, the worst flat feet and the tightest Achilles I've ever seen in this 10-year-old and they just grew three inches? Is that the primary problem or is it biomechanics? This person is just horrible form when they throw. So there's no way they can throw a normal amount of pitches in baseball or things like that. So I think understanding the contributing factors to injury also helps you treat these injuries effectively. So keep that in mind. As you get stronger, as you throw with good form, you will not hurt your elbow and little league elbow. You will not get shin splints when you run, things like that. On the right slide, which Amy, I don't know if you could point out that pain threshold dotted line, but if you all take a look, sorry, that's really, really important. This graph here that's led better sort of model of inflammation and overtraining. And that's that here is, you can see my hands, here's where injury starts on the left and here's pain threshold very high. And so that whole period of overuse on the left side where there's failed adaptation that can go on for weeks or months. And as you stop training is when you hit that pain threshold and you can no longer participate. And then as you go down on the right side, you may again, return to training too soon because you're below your pain threshold, but you're not fully recovered. Next slide. All right. So simple sometimes isn't so simple. So I'm going to speed up really quickly, but key factors are also what are the comorbidities, whether they're contributing factors to any type of injury, whether it's acute or chronic, if you're injured, all of a sudden your mood and your effects that your behavior, how you're dealing with this injury, your sleep, your diet, what you do to recover your attitude towards your sport and your general health and your mental health all are important. So these all have to be assessed and that's super difficult in the office. Next slide. I'm going to go, I think you can read these, they'll be there for you to refer, but basically remember anything acute can also become chronic. So sprain, strains, tendonitis, stress fractures, cartilage injuries. So when I look for chronic, simple, it's just lingering and I just want to understand why. Next slide. All right. Does the severity matter? So, you know, this is just a little bit dramatic, but my point is, I think as Dr. Hample also said, and Dr. Cushman did as well, on the left, you know, you can have a severe accident, a severe injury, and you can more or less walk away from that relatively uninsured or have very little pain. Then you can have something like the middle or the right where you could like have a simple ankle sprain, roll your ankle, and like you could be out for an entire season, months. You could turn into impingement syndrome and struggle for an entire year sometimes. So red flags, three important red flags, not so severe injuries should not cause severe pain in general. And if it's a severe injury of a severe pain, it should follow a normal pattern. Constant 24-7 pain is never normal. It's technically rule out cancer or psych in my book if I keep things simple. And worsening pain despite treatment interventions, you know, the kid that you boot, that you cast, that you rest, and it's just getting worse, worse, worse. It's always red flags. Next slide. All right. So the only point I want to make here is that there's a lot of complex musculoskeletal pain conditions as well. That for me gets into nerve, room, kind of the things I mentioned already. And what's I think super important here is just always remembering that concept that not all chronic complex pain is severe, but I make the analogy to this in anxiety. So I tried to put a jazzy slide there because it's Zoom about fire. One of the most interesting, I was on a pain panel for the NCAA, and we wrote a paper about guidelines for pain management. And what was really interesting was we went around the room and said, what was the most painful experience we could envision that would be the worst experience of our life? And people were like drowning, like being, like burning alive, like being on fire, you know, like not being able to breathe, being choked, being strangled, you know, all these crazy things. But it was very, very, very different. The first 10 people all came up with 10 different things. So my point is that pain and anxiety for me are very simple. A little bit of pain can make you realize you're injured. It can make you be compliant with treatment. And that's just like anxiety. Anxiety can motivate you to like get your slides done for a talk or to study for the boards. But a lot of pain can be overwhelming, just like a lot of anxiety can be overwhelming. So Katniss handles fire very, very well. It motivates her, it makes her look strong. But the person on the left whose head's about to explode is overwhelmed by pain, and they're going to be very dysfunctional. So that's super important. All right, next slide. I think it's my last one. I'm going to skip over this because this is just, again, more like medical causes of pain. Basically, the nutshell is anything can give pain, not just musculoskeletal. And musculoskeletal problems can have all kinds of confounders from the medical part of someone's health. Next slide. Last but not least, all right, case follow-up part two. Now we are at 10 to 12 weeks out. And in fact, no improvement and was now unable to bear weight, kind of what I talked about earlier. She was unable to return to diving. At this point, labs were ordered and they were normal. There was a concern about psychosocial component to her injury. And she was noted to be slightly anxious. And at this point, she was referred to the Cleveland Clinic for a CRPS evaluation. So more to follow on that. My red flag here was she got worse with rest and appropriate treatment for what seemed to be a simple musculoskeletal problem. Dr. Hample? Hi, I'm Caitlin Mooney. So I'm going to talk a little bit about post-operative pain. So we're taking a little segue. Can you advance? So let's say this patient actually was my own in fellowship. But let's say instead at the initial visit, she ended up having a displaced salter hair fracture and she ended up having surgery. So now we're going into that post-operative pain. So let's advance. So management and post-operative pain is important. We know that it is common to have pain in the post-operative period in pediatric patients and that pain can prolong recovery and hospitalization. And also as Dr. Benjamin says, can limit our mobilization and lead to complications if we're not able to move early on, especially for orthopedic concerns. It's also been persistent post-surgical pain is increasingly being identified in adolescents, probably due to awareness, high rate in orthopedic problems, probably secondary to including scoliosis, probably not sports injuries being the highest rate of that. But and then increasingly also early life pain is being shown to that it can alter pain perception and neural pathways for later in life. So good pain management in post-operative period is important. Advanced slide. I'm not going to go into pediatric pain assessment tools because we already went into that, but using those are helpful. Also just big principles you can go on for pediatric post-operative pain management would include screening before the patient comes in for any opioid use and risk of misuse and overuse, which will include mental health problems. Use alternate alternatives and multimodal pain management whenever possible to limit opioid exposure. Use the lowest amount of opioid for the shortest amount of time. Use the oral form when possible. Use it regularly so that intervals, at least initially, and then base it on the severity of pain and titrating. And then also making sure that opiates are disposed of in the household is important to be counseled on because we do know that teenagers are using these and that sometimes that can lead to drug use. Interesting. One of my earliest cases I submitted in residency to AMSSM for a case evaluation ended up being a Brody's or subacute abscess. I'm sorry, my dog is scratching at things. And this patient actually ended up becoming addicted to opiates after that hospitalization and ended up passing away from an overdose. So we do know that at the age of about 19, a couple of years later, so we do know that we need to be cognizant of this in the adolescent athlete. Some barriers to pain control for outpatient surgery, since most of our athletes are going to have outpatient surgery, include parental factors such as fear of over medicating, child factors, children can't swallow pills, they might not be able to take what's prescribed, even teenagers sometimes can't swallow pills, not optimizing dosing and type, so scheduling it, any system issues, and then so education can be helpful to address these issues. Next slide. Here are some examples of multimodal pain management, which we already went into quite a bit. So also physical therapy and cognitive behavioral strategies can be helpful as well, as well as using blocks for expected orthopedic pain can be helpful just to decrease opiates. And then using adjuncts, which include antispasmodics, gabapentins, ketamine, non-steroidals, and acetaminophen. Go on. So just another, I know we're running late on time, so opiates do cause a great deal of side effects beyond just, beyond addiction, we have respiratory depression, nausea, vomiting, and pruritus, so being cognizant of limiting those and then paying attention to that FDA warning about codeine and tramadol in peds patients. Some useful tips and tricks is also knowing at your institution that you're working at, whether there's an acute or chronic pain service, whether you have a pain pharmacist, just a regular pharmacist that you can ask these questions to, do you guys have child life at your location, or psychiatric services that deal with pain, we have a psychiatric, or a pain therapist that we can refer to, so that's very helpful. And then also considering psychosocial factors that can prolong pain or cause persistent pain. Next. Now we're going to have Dr. Collins and Dr. Conda come on and talk about chronic pain management. All right, next slide. Yeah, so, you know, for the sake of time, I'll try to speed up some of these slides and kind of hit the main points. We've talked a lot about chronic pain in the previous slide, but we're going to chronic pain in the previous slides, you know, typically it's greater than three months, and what we think of chronic pain, we don't, there isn't an implication of a specific etiology at time. So, next slide. We know that statistically, we don't have any updated statistics, but we know that one in four children experience chronic pain, and one in 20 experience disability from their chronic pain in the pediatric population. Next slide. These are just an example of some of the common pain diagnoses. When we talk about chronic pain type patients, you know, some of this can come from the pediatric athlete population, as you can see, CRPS, amphithymoskeletal pain, you know, some of them in post-concussion syndrome, you know, a lot of them are in the inflammatory, rheumatological, neurological realm of things. Next slide. This is an important concept that's fairly new from the International Association of Society for Pain. They have submitted, and eventually when this does go into play, a classification for pain, chronic primary pain, meaning that, the implication being that pain, the pain system is the primary driver of a patient's experience with chronic pain, and there's no, there's potentially no identified etiology or injury. Chronic secondary pain is what most of us are used to, or kind of have a little bit more familiarity with, meaning, you know, you have an insult, you have a, an injury, and, you know, and the pain has continued past the expected timeframe for, you know, recovery. So that's usually what we would see. I'm trying to block the light as well. That's usually what we would see with patients in the pediatric athlete population that develop chronic pain. Next slide. So diagnostic labels, they can be helpful. It helps us to tie together symptoms, provide education, provide reassurance. You know, a lot of times that when we run into patients in the pediatric population, we're also dealing with the parents. And a lot of times it's not even, it's not just the patient, but it's the parents that are trying to figure out what's going on. You know, when there's nothing to tie around, then that uncertainty can lead to a continued search for what's going on or what's wrong, and that can get in the way of treatment. You know, but there are also aspects where this can be harmful because, you know, a common population as people are running into hypermobility, EDS hypermobility, you know, there can be a tie into that or a, a embracement, for lack of a better word, of a diagnosis and a definer of them. And that can impede your treatment and your, and your goals for functional improvement for the patient. And of course, you know, diagnoses can lead to like, you know, Dr. Google approach where patients will see unnecessary types of information regarding their diagnoses, and that can impede treatment. Next slide. Psychological versus physical. You know, we talk a lot about in chronic pain, you know, the contribute, contribution of the psychosocial factors. The reality is that it is really, truly difficult to tease out and isolate one versus the other. Sometimes it can be straightforward. Other times, it is very much enmeshed into the experience of pain for that patient. And really, there's no isolation of treatment when it comes down to it from a chronic pain perspective. Each one needs to be addressed on some level from a psychological standpoint, physiological, and also if there are resources from a social standpoint for these patients. Next slide. Diagnostic challenges. So, you know, a lot of times what we'll see is when we evaluate these patients, we'll see an incomplete evaluation of the diagnosis. And this goes back to the realm of if things are not resolving as expected, how do you reset yourself to approach and revisit what may be missed, what might need to be ruled out? You know, when we are trying to, it is hard to get a patient to comply with treatment plan if they still feel like something is missed out. And if you can provide any objective data for or against what they're going through, then that helps get them further towards buying into the treatment plan when it comes down to it. So, some of these, you know, you can have primary chronic pain and secondary chronic pain. They can also be together. So, things like, you know, sickle cell disease, you have a primary cause, but then that can, sorry, you can have a secondary cause, which would be like a sickle cell, but then that can turn into like a primary because you have constant, let's, for example, basic occlusive crises that hits the nerves, then patients start to develop chronic joint pain that is out of proportion to what's objectively there. Next slide. So, red flag signs, I think we talked a little bit, we talked plenty about this, pain outside the expected recovery timeline, aledinia, any abnormal signs from a, you know, color changes, swelling, trophic changes, there's any myofascial dysfunction, you know, when you think about like, you know, periscapular pain that doesn't have any objective data behind it. Other symptoms like dizziness, IBS, chronic headaches that are associated with the MSK pain are also things that you have to worry about. Next slide. I think we've kind of gone over all these things as well. Fever, systemic symptoms are always like a red flag sign. You know, weight loss, weight gain, unexplained significant swelling, stiffness, those are all other red flag signs. Next slide. Some examples. Next slide. Some things that you'll see is complex regional pain syndrome, which can occur after like minor injuries. Next slide. There are two types, you know, type 1 and type 2, and these are signs of CRPS. And I'll hand it off to Dr. Collins. Oh, yeah, sorry. So this is not well-researched. It's more common in younger athletes and more common in lower extremities. Next slide. Another example of a chronic pain condition that we see somewhat often in our athlete population is post-concussion syndrome, which is more of a cluster of related physical, cognitive, behavioral, and emotional symptoms that happen after having had a concussion. And they can include some chronic pain symptoms, such as chronic headache, chronic musculoskeletal neck pain, or other areas of chronic musculoskeletal pain. The symptoms in post-concussion syndrome remain prolonged, and there's some data out there that this can be relatively common in children. I am not a sports doctor. I'm a pain doctor. When I see people that have post-concussion symptoms, it's usually been going on for a very long time, and I've probably seen only a subset of this larger subset of patients. So there's people that are getting better before they make it to the Nth referral. Go to the next slide. One of the benefits of a multidisciplinary evaluation for post-concussion syndrome, as with other types of chronic pain, is that we can address any other treatable co-occurring conditions. So in post-concussion syndromes, there's a list of things on here, but if you're checking for all these things, you should treat them as their own symptoms, in addition to treating the post-concussion syndrome through multidisciplinary care. Next slide. The other complication, this has been talked about a little bit, but with chronic pain and athletic identity, having a higher athletic identity, when you have an injury that takes you out of sport, people with higher athletic identity end up with more depressive symptoms. But also, having a higher athletic identity before an injury is associated with less pain-related distress and less pain-related functional disability than non-athletes. That might be actually because people have some continued athletic involvement, and that might be a protective factor. These seem contradictory to each other. They're just comparing different groups, so that first one is all within athletes. If you have an injury, you're more likely to get depressed. If you identify as an athlete, as very athletic and as an athletic part of your identity, but people that have athletic identity do better than other children in general when they have a chronic pain condition. Go to the next slide. We unfortunately don't have a ton of time for treatment of chronic pain conditions. You can go to the next slide, but I will breeze through each aspect of this. It's overall very important for it to be multidisciplinary treatment. The most important part is the discussion about pain and getting people to understand what's going on in their body. You can go to the next slide, because that is where we talk a little bit about that. Oh, sorry. This is just a graphic of that multidisciplinary way of approaching care. This is from some article that I took from other articles. Go ahead. Go to the next slide again. Pain communication is how we address this during the initial time we talk about it. You should talk to patients about the differences between acute and chronic pain and how rest and decreased function is very helpful in acute pain and injury. It's the right thing for the patient to do. It's the right thing for the parents to recommend. But then once pain has been around for a long period of time, you don't want people to rest. And actually, you really don't want people to rest as soon as the most acute phase is over. You want to get people mobilized, get them staying as active as they can be, and continue to live life in a more normalized fashion as much as is possible. People are doing what they think is right by stopping their kids from moving, and it's actually creating more likelihood of chronic pain. So we need to get people to keep moving. Talk a little bit about medicines, which we've gone over before, so I won't rehash, and focus on the idea that we need to keep functionally improving. Next slide. This is just a little bit about the difference between acute and chronic pain, that pain is helpful and necessary when it's acute, but it stops being helpful or necessary over time, and we need to then address the pain as its own symptom. Next slide. Next slide. Pain psychology, which we talked about some of these different aspects before with cognitive behavioral therapy, DBT and ACT are listed down there too, which are kind of like offshoots of cognitive behavioral therapy, and all of these other parts are different skills that can be learned within cognitive behavioral therapy. Next slide. Pain psychology is for people who have chronic pain. Pain psychology is not exclusively for people who have chronic pain and a psychological problem. It is for anyone who has chronic pain. If someone has a very significant other psychological problem, that will interfere with their ability to participate in pain psychology, and that other symptom needs to be either addressed in co-treatment or addressed before they can engage in pain psychology effectively. That is something that I think addresses that false dichotomy that Dr. Kanda talked a little bit about, but pain psychology is a very helpful thing, and if it's introduced as, oh, nothing else has worked, now go see a psychologist, a patient interprets that as, we now think this is all in your head. If you introduce pain psychology as an important part of treating the biological system of the way our nervous system works and changing the way the brain and body communicate early on in someone's course, they can understand that it's effective treatment. You can go to the next slide. Yeah, this is what I was talking about. You can go to the next slide again. Sorry. I'm trying to rush through so that we can go. I mentioned this as well, so you can go through. This is physical therapy, so it's really just helping people continue to move. There's more details about it. We can keep going. Sorry. These are the things that I typically end up recommending to people with chronic pain. Next slide. We talked a lot about medications before. The first two NSAIDs and acetaminophen are for rescue medicines. The next four are chronic pain daily treatments, including naltrexone, which is listed. It's a low-dose naltrexone used for chronic pain. I use muscle relaxers as a rescue. I do not use opioids. as a rescue for chronic pain, except really extenuating circumstances. If it's chronic pain, it should probably be being done by someone who has experience with pediatric chronic pain if they're prescribing opiates on a longer basis. And then NMDA antagonists, I will sometimes use, but that's kind of like a different thing out there. I'm sure the next few slides are more of these medications, but we're gonna skip through all of them. Oh, nope, it's just, oh yeah. This is just a really nice quote about how amitriptyline is a first-line treatment for neuropathic pain, and we don't have any evidence about it, but it's probably really just because we don't know how to narrow down who the right people are for each drug, and we probably aren't gonna ever have a study that really works for chronic pain when we expand it broadly until we understand more about the nuances of what's different about each different drug. So the fact that these studies don't work doesn't mean that these drugs don't work for individual people, and you should still think about using them and think about the way the side effects can help you rather than hurt you. For example, sedating medicines can be used at night for people who have comorbid sleep dysfunction. Sleep dysfunction is a big part of chronic pain. We need to get people sleeping better for their chronic pain to get better. I apologize that this was super rushed, but we are now down to three minutes for our panel. So sorry about that. Please ask some questions. I will stay around for a little bit longer. I'm sure a few other of our panelists will be around for a little bit longer, so you can ask questions. You can absolutely email me if you have a specific question that you want to talk to me about from my super abbreviated talk. I'll leave my email in the chat. All right, yeah, we actually have 13 minutes. So if you want to finish up, Dr. Collins, on this last slide, we can go ahead, or otherwise we can go ahead and put, no? Okay. You can go ahead. That's just what I talked about. We'll go ahead and start the panel discussion. So go ahead and put your questions in the chat, and we'll answer them if anyone has any, or you can raise your hand as well. While we're waiting for people to put questions into the chat, I know, thank you everyone for all those wonderful talks. I think for me, I think I'm one of the few, or maybe the only one on this call that does both sports, pediatric sports medicine and chronic pain, like regularly in my practice. And so, and I purposely did not do that in my training, but it's been very interesting over the past couple of years for me to learn more about the role of chronic pain and acute pain in pediatric athletes. And something I think, you know, there are a lot of things you read in textbooks or in articles, but I think what Andy was saying in his last talk, in his last few slides, I think for us, we oftentimes, yes, we'll reiterate pain psychology and physical therapy with a chronic pain approach is really important for any athletes with chronic pain. But I think the other thing too, is we try different medications. I always explain to my patients that, hey, I need you to meet me halfway. Like, yes, I'm happy to treat you with medications to see what works, but you need to also put in the work of working with PT. And I always delve in to a lot of detail. And if it's just like in my regular sports medicine visits of like, if they're continuing to have pain or any other symptoms, what specifically are you working on in physical therapy or have you seen pain psychology and what have they worked on with you? What are your home exercises? Because if they're truly doing your home exercise program for PT, but also pain psychology, they should be able to spitball that back to you really quickly, right? Ami, I think you had mentioned, one of the articles had mentioned not using muscle relaxants under the age of 12. Andy and I were chatting behind the scenes and I was like, I do that all the time under the age of 12, but I think it's because, you know, we're Peds Rehab Docs too. And we do, you know, we do Baclofen all the time in little itty bitty kids, right? I even have some colleagues who do it under the age of two for Baclofen. And so for us, I use Tizanidine. Baclofen is my kind of second line, but Tizanidine more commonly in my practice. I know Andy does both and then also does some of our Baxin. But I basically tell my patients, I kind of get a sense of like where I feel like their pain is coming from. Like, do I feel like it's more of a nervous system type thing? Because in that case, sometimes I use Gabapentin or Lyrica or sometimes Cybalta to kind of damper down that nervous system response. But then also muscle relaxants may be helpful if they have more myofascial pain. I'll do trigger point injections with a lot of our kids. And so there's, like Dr. Collins was saying, I don't think there's one strategy. And I think the main thing I've learned too from my sports med practice to my chronic pain practice is that looking for those red flags, but looking for risk factors as well, right? Like we see, for instance, I think a lot of my athletes that are in my chronic pain practice, main sports they're doing are cheer, gymnastics, figure skating, those high level type A type sports, right? And we know too, and forgive me if I missed, if someone said this, but if you are a type A personality, research has shown you are at higher risk for having a chronic pain syndrome. So delving into that as well. And then also looking at family dynamics, right? Because a lot of times that can also influence pain. Yeah, I'll say for the medications, the daily chronic medicines, I listed kind of four categories, which are the antiepileptics, gabapentin, pregabalin, oxcarbazepine maybe, though probably if you're not a pediatric pain doctor, you're probably not using it for pain that often. The TCAs, the SNRIs, which is mostly Cymbalta or buloxetine, and then low dose naltrexone. For some patients, I will just tell them what all four of those are and go over the risks and benefits of each and tell them like, look, I don't have a good answer for which one I think is gonna work best for you. Which one do you think will work best for you after I talked about what the benefits and risks are of each? And usually if I have a hint in my mind of like, kind of like this one, they often pick the same one. Maybe that's because I present it in a way that sounds better if I have an idea in my head, but I think there are reasons that like you can let someone pick, they have some ownership over that. And I know Dr. Tao mentioned that I will use muscle relaxers in kids of all sorts of ages. In my spasticity practice, I'm definitely perfectly fine with back with an under two person. I do limit my muscle relaxers for kids who have hypermobility. So I usually start with limiting them to 15 tablets in a month, but I will sometimes go up to 30 tablets a month. It's mostly because I'm even okay with people with hypermobility doing it for a short course of like three time a day treatment. But if you're constantly on three time a day treatment and you're like decreasing the muscle, I don't know, the overly relaxed muscles in the setting of overly relaxed ligaments makes me wary. I have no evidence for that, but that's what I do in my individual practice. Our experience may differ. I'll chime in. You know, as someone who's still UT and kind of took Stephanie Tao's spot, I've actually gone from chronic pain and I've seen a lot more sports in my pediatric clinic. And I think the common theme that I see is the importance of education. You have a soccer player, a girl who has continued ankle pain, hasn't done any basics, doesn't understand what's going on. Mother is like sitting here trying to figure out what's going on. No one's done any basics. And a lot of what I do is spend time explaining, figuring out what happened, what is going on, and why I think they still have continued pain. Whether it's as simple as have not done any physical therapy, have not seen anybody for it, have not gotten any x-ray to like, well, you've done all this, but are there any other underlying conditions that might be leading to like that prolonged pain or like what's their social status? So I think it's a huge for me in both my, and I do adult NPDs, it's a huge education. I think that's the most important part for any kind of chronic pain, but particularly pediatric athletes who have that extra layer of competitiveness. You know, I had a patient recently who had basically had thoracic outlet syndrome, was a competitive softball player and ended up going with a rib removal and had improvement for a good few months. And then they exacerbated it. And now I'm having a conversation with like, well, what does the future look like for you? Softball's probably not in the cards for them. And then, so there's all those like things at play that I feel like we have to, we should be screening for and continue to revisit when it comes down to it. And usually when they feel like they have a better, stronger base of knowledge of their own body, they can usually get involved with the treatment plan and or understand and face that situation. Better, and at least that's from my personal experience. Looks like we have a question. Thanks for all of that input. Thanks all of you. Oh, this isn't a question, sorry. But Dr. Collins wrote in here, he said, I also advise a lot of athletes who have chronic pain that we may need to adjust their physical therapy, move away from intense style of sports recovery to a more paced treatments, focusing on basics to start. And then they can go back to aggressive strengthening skill and training for their sport. And that makes total sense. Anyone have any more questions? We've about five minutes left in the talk. To add to what Dr. Collins commented on too, like for me, when I came to this institution and took on chronic pain, in addition to sports, just like, you know, when peds, like there's different flavors of physical therapy, right? Like you've got some physical therapists that are more focused on developmental disabilities. And certainly I would not send one of my pediatric sports patients to that one that works with cerebral palsy, right? They're not gonna know what to do with this athlete and that athlete is not gonna be happy with me. It's the same thing. I got to know our therapist that I still am constantly getting to know our therapist. And I try to figure out who is a better fit for the chronic pain because not, I think most pediatric physical therapists on the orthopedic side, they get a little bit of pain neuroscience education in their training, but not all of them are equally trained or comfortable working with patients with primary or secondary pain syndromes. And it's really important because if the physical therapist is not comfortable, that patient is gonna sense it and they're not gonna get better. I also try to have, and I came into an institution where I'm still working on repairing some relationships between PT and like our anesthesia side of the program. So as a rehab physician, like it's been really helpful being like a liaison between everyone, but also having a synergistic effect of if you're seeing pain psychology while you're also doing physical therapy, they both will feed off of each other too and have a synergistic effect with helping patients and reiterating the same things over and over again so that they realize, okay, I have pain, so what? This does not mean I have tissue damage, it's okay. And then eventually they modulate the pain perception or experience over time. Yeah, there was something else I wanted to say, but now I'm blanking on what it was. So it'll come to me. I just moved to a new institution as well. So at my old institution, I had really good knowledge of what therapists were good with either some sorts of chronic pain, like pacing them, but also really explaining and educating that sometimes pain is okay. And recently I had an Ehlers-Danlos patient who I think they had an ankle sprain. Now I can't remember the original injury, but they went to PT for about two, three weeks and then the therapists told them that they think that they should have been getting better by now and that they needed to get an MRI. And they came to me with pain in a completely different area, now it was arch pain, which isn't abnormal really for that demographic either. But then the patient feels like they need imaging because something's really wrong with them because they're not getting better in three weeks, which I think was a pretty short timeframe, but especially for a person who already has chronic pain and that can really be a difficult situation that now they're fearing moving again. And you're trying to say, well, we'll get this MRI, probably won't change what we do, but hopefully this will help your therapist be okay with treating you again. So I'm now having to find like maybe my go-to people for those sorts of problems. Yeah, and Caitlin, I'll build on that too. Like I sometimes will order imaging even though I don't expect anything for reassurance for patients, but once in a while I'm surprised and I find like an occult injury or like there was a patient I saw who was referred, she had been seen by one of our sports med docs who's really great with her exam and they sent her over and they're like, I think they have CRPS and I examined them and I was like, they have some CRPS criteria but they didn't fulfill all of it. And I was like, there's something weird going on. The fact that this athlete had injured themselves in lacrosse, had an impact injury, no one ever got an MRI and he had impaired range of motion. I was like, why don't we get an MRI? Turns out he had a stress fracture at the distal femur, but it didn't correlate with like his pain was localized to somewhere else. But once we treated that fracture properly, his secondary pain syndrome also resolved. And so the other thing I would recommend is, I mean, for us in our chronic pain program, in our referral it says, has everything been worked up? And everyone always says, yes, but my job when I'm in my chronic pain program is I'm evaluating our athletes thoroughly and making sure because they're seeing me for like a fifth opinion, right? And I'm like, I'm gonna try not to misdiagnose them with a primary pain syndrome and make sure I don't miss something else, right? Because sometimes they can have a secondary pain syndrome that doesn't get better if something else wasn't treated. I do wanna answer that one question about resources, about supporting children's sleep health. A lot of, well, I'm assuming I'm interpreting this correctly for like behavioral strategies around sleep and pain and other health conditions. There are some self-guided pain and other health CPT resources available. One of them is the chronic pain and illness workbook for teens, which is by Rachel Zoffness. I would definitely recommend that one. And they can do that with any mental health provider who's knowledgeable in CBT or on their own. But if they have some additional needs, if you don't have a pain psychologist, if you have someone else who has skills in the CBT, they can use the chronic pain and illness workbook together with a CBT therapist, social worker, counselor, family therapist, or psychologist. And that can help address some of those symptoms, which includes sleep. And then Webmap Mobile is an app from Seattle Children's. I have no ties to either of these, but these are the things that I give my patients if they don't have access to a pain psychologist. Webmap Mobile is a phone app. Thanks everybody for joining us. And that was amazing. I hope this was useful for everybody. We actually have to wrap up now and we will get the slides out to you through the AAPMNR. So everyone have a good night. Take care. Thanks for all the panelists and for AAPMNR for helping us host this awesome discussion. Bye.

pediatric athletes

acute pain

chronic pain

individualized treatment plans

non-pharmacologic interventions

pharmacologic interventions

pain assessment

pain treatment challenges

overuse injuries

chronic pain management

multidisciplinary approaches

psychological factors