Medication usually comes to mind as the first line of defense for managing pain. Doing so isn’t always desirable, however, particularly with pediatric patients.

To potentially sidestep this problem, orthopedic surgery specialists in the Cincinnati Children’s Division of Orthopaedics have developed the Pediatric Pain Screening Tool (PPST). According to Peter Sturm, MD, director of the Crawford Spine Center, it’s a questionnaire that can help children use the “mind over matter” approach to reducing their discomfort.

“By using a tool like this, we can come up with a plan for how to mitigate a child’s pain issues,” he says. “It’s effective with the procedures that are the most painful, and we’re looking to extend it to other procedures, as well.”

The Impact of Pain

Chronic post-surgical pain (CPSP) is a common problem for children who have orthopaedic surgery. In fact, it appears in roughly 35% of children who have these types of procedures. It isn’t only the physical impacts of surgery that can cause severe pain, however. In many cases, a child’s experience can be intense simply because they anticipate the worst and worry about it.

Consequently, it’s critical to find an approach that speaks to the emotional and mental aspects of pain for both the patient and their parents, says Victor Garcia, MD, founding director of trauma services.

“Historically, in medicine, we have a charge-ahead approach in surgery. We operate on the patient, take care of their problem, and deem ourselves successful if there are no complications related to the procedure,” he says. “We must look beyond the historical or even contemporary approaches to managing pain to improve more than the child’s immediate experience. It’s time to look at using the power of the mind and the mindset to mitigate the pain and create a more positive experience.”

How PPST Works

Controlling a child’s pain starts before the procedure even happens, Sturm says, with a robust pre-operative education program. As part of a pre-surgery class for patients with idiopathic scoliosis, two spine nurses explain the procedure to patients. They also give patients an opportunity to talk with children who have been through the operation.

“Using what we know about pain issues, we are changing the expectations that families have,” Sturm says. “We’re helping them understand how much pain there’s going to be and what to expect.”

Providers go a step further to manage expectations for children and their parents. They use the nine-item PPST tool to determine which children might be at high risk for developing CPSP. With this questionnaire, children self-report, on a scale of one to 10, how they anticipate they will respond in nine different areas, including sleep, anxiety, depression, daily functioning and pain. Children who score at least a four are considered high risk for CPSP.

Once the PPST tool identifies the patient’s greatest concerns, Garcia says, providers work with these children to develop personalized strategies that will help them have a less intense physical reaction to surgery.

“We can actually influence the body’s response for both the patient and the parent. If you go into surgery with the mindset that the pain will be debilitating, your outcomes will be worse,” he says. “Think of it like a long-distance runner who feels pain but has the capability of training their mind to deal with it. We look at these nine factors, acknowledge that surgery is going to be uncomfortable, and help our patients learn to deal with it in a constructive way.”

Throughout the patient’s postoperative recovery in the hospital, he says, providers routinely offer reminders of how children can best handle their discomfort.

The Impact of PPST

To date, using PPST with patients who have idiopathic scoliosis has made a significant positive impact on their outcomes. The ultimate goal, Sturm says, is reducing opioid use.

“What drives us is the concern about opioids because these kids need a lot of pain medication postoperatively. Traditionally, they’ve gotten narcotics after surgery and for a short, defined time period afterward,” he says. “We’re finding other strategies to improve pain control and outcomes without using opioids.”

In fact, he says, efforts with PPST from one of the division’s nurse practitioners, Kelly Falcone, RN, CPNP, have decreased postoperative narcotic use from 10 days to seven days. Alongside that reduction, the PPST tool has also helped providers reduce a patient’s length of stay from 4.7 days to 2.7 days.

While these important outcomes measures show that the PPST is effective, Garcia says, the most significant improvement is perhaps the patient’s overall emotional and mental response to their surgery and pain. 

“It’s gratifying to know that children leave the hospital in a much more positive mindset even after they’ve had this uncomfortable, painful operation,” he says. “They feel more empowered not only for handling the outcomes of their surgery better but also for the long-term course of their lives.”