Pediatric Amplified Pain Rehabilitation Program

Children with amplified pain syndrome have an abnormal neurological response to pain, causing them to feel it more intensely. This can lead to decreased quality of life and chronic disability. These children often have other medical conditions that make their chronic pain more difficult to treat, such as juvenile arthritis, systemic lupus erythematosus or inflammatory bowel disease.

The Pediatric Amplified Pain Rehabilitation (PAPR) Program is an intensive inpatient program for children with severe amplified pain syndrome. While our long-term treatment goal is pain relief, our immediate goal is to help our patients regain functions lost due to pain. For example, the goal could be walking without crutches, returning to school or participating in sports again. We also teach healthy, effective strategies for managing stress.

After discharge, children continue using their regained functions and new coping skills at home. Most continue to see their outpatient mental health providers but do not need outpatient rehabilitative therapy. It is in this second phase — usually one to six months after discharge — that we see significant improvement and often total resolution of pain.

How Pain Rehabilitation Differs From Traditional Rehabilitative Therapy

Traditional rehabilitative therapy limits patients' pain during exercise. This makes sense when a patient is recovering from an injury or healing after surgery, but with amplified pain there is no damaged tissue that needs to heal. Pain rehabilitation requires that these patients work through their pain.

Exercising through pain and using desensitization techniques, in which a light touch stimulates painful areas, can retrain pain-sensing nerves to function normally. This is done safely, under the close supervision of physical and occupational therapists, and in a supportive way to minimize emotional distress. During a PAPR admission, most rehabilitative therapy is done one-on-one with our physical and occupational therapists.

Physical and occupational therapy education does not routinely include pain rehabilitation, so most outpatient clinics are not equipped to treat severe amplified pain.

The PAPR Team

The PAPR team includes physicians, physical and occupational therapists, creative arts therapists, child life specialists, social workers, integrative medicine specialists, schoolteachers and a psychologist.

The program is led by Dr. William Bernal, a pediatric rheumatologist and specialist in pediatric amplified pain syndromes. Before coming to UCSF, Bernal worked with Dr. David Sherry, head of the Center for Amplified Musculoskeletal Pain Syndrome (CAMPS) at the Children's Hospital of Philadelphia. CAMPS has provided intensive pain rehabilitation for more than a thousand pediatric patients with amplified pain syndrome. Our physical and occupational therapists have received specialized training in amplified pain rehabilitation at CAMPS.

Before Admission

Your child may be a candidate for the PAPR program if he or she has not responded to outpatient therapy or if severe disability necessitates intensive therapy. Other criteria include acceptance of the amplified pain diagnosis and willingness to exercise through pain and engage in psychotherapy.

As part of the assessment Bernal and child psychologist Cristina Benki meet with patients to evaluate their readiness for admission. Benki's assessment includes communicating with your child's mental health providers. One of our physicians of physical medicine and rehabilitation may also meet with your child as part of the evaluation.

Children can participate even if they have other medical issues, such as joint hypermobility or bone fragility. We will take those issues into consideration when we develop a personalized treatment plan.

During Admission

The PAPR program aims to empower patients to regain function and learn healthy, effective coping strategies for managing stress. We provide a safe, comfortable space in which our patients can focus on working toward recovery. We do not use medications for amplified pain, and most patients will be weaned off pain medication before admission. The average stay is three to four weeks.

A variety of PAPR providers treat patients over the course of their stay:

  • Our physical and occupational therapists evaluate your child upon admission to develop an individualized rehabilitation program. A typical day consists of two to three hours of physical therapy and two to three hours of occupational therapy.
  • Patients meet with our psychologist three times a week to address psychological factors associated with chronic pain and for help coping with the emotional stresses of pain rehabilitation. Our psychologist also works with patients' parents during the PAPR admission.
  • Art and music therapists work with patients to promote healthy ways to cope with stress. Creative arts therapy can help patients explore their feelings, develop social skills, reduce anxiety and boost self–esteem.
  • Child life specialists support general development and adjustment in the hospital setting. Their work with patients may include strengthening social skills and peer relationships, identifying outlets for expression or providing biofeedback training for pain management with the support of the psychologist.
  • Our integrative medicine specialists offer alternative treatments such as acupressure. The goal is to teach patients techniques they can use on their own to reduce pain and anxiety.
  • Our physician and nurse practitioner teams include a general pediatric hospitalist, physical medicine and rehabilitation physicians as well as providers from Integrated Pediatric Pain and Palliative Care services.
  • Our hospital schoolteacher coordinates with your child's school to prepare for admission. Children don't have much time for schoolwork during the PAPR program, so we request that assignments are kept to a minimum. Most important, our schoolteacher coordinates the transition back to school as part of discharge planning, so your child can catch up without undue stress.

We hold weekly team meetings to assess each child's progress. Patients are ready for discharge when they have met their goals and the PAPR team is confident they will maintain function and can successfully transition back to home and school.

Therapeutic Day Passes

On weekends the PAPR team may give a seven-hour therapeutic day pass to patients who have completed the week's therapies successfully and who can safely leave the hospital without staff supervision. These passes are an important part of the program. Spending time outside of the hospital with family gives children the opportunity to practice new skills in their home environment and supports their emotional health. It also provides both the patient and family greater confidence that the patient is ready for discharge, and helps ensure a successful transition home.

After Discharge

To ensure that the transition has gone well, patients return to the Pediatric Pain Management Clinic one month after discharge. They also have at least one or two more follow-up visits over the next six months to check that they have maintained function and are managing their stress well. We recommend that your child continues to see his or her counselor or psychotherapist after discharge.

Patients who successfully complete the PAPR program will have the skills necessary to successfully manage any future flare-ups of the amplified pain, so they do not cause significant disability or distress.

Related Information

Ways to Give

How to Reach Us

Integrated Pediatric Pain & Palliative Care (IP3)

Pediatric Amplified Pain Rehabilitation Program

UCSF Benioff Children's Hospital
1975 Fourth St.
San Francisco, CA 94158
Phone: (415) 353-1328
Fax: (415) 353-3729

Our Team

William Bernal
Dr. William Bernal,
pediatric rheumatologist
Cristina Benki
Cristina Benki,
pediatric psychologist