REVIEW For reprint orders, please contact: [email protected]

Treatment of chronic pain in children and adolescents

Practice Points

Shahram Yazdani*1,2 & Lonnie Zeltzer1 „„ The biopsychosocial model of chronic pain care in children involves obtaining a thorough history that

includes the onset and pattern of symptoms along with complete psychosocial and developmental history. „„ Complex regional pain syndrome is a neuropathic pain syndrome in which there is a nondermatomal

distribution of pain that is described as sharp, stabbing, stinging and/or burning, and the skin in the affected area is typically hypersensitive to even light touch (allodynia) and pain from a stimulus that typically lasts longer than expected (hyperpathia). „„ Fibromyalgia is a centrally mediated widespread pain syndrome in which multiple parts of the body are

experienced as painful and it is not a psychologiocal or imagined condition. „„ Treatment of chronic pain in children typically requires a biopsychosocial approach that focuses primarily

on regaining function while there is ongoing treatment for pain with medication and behavioral strategies. „„ Clinical analgesic pharmacological and psychological/behavioral treatment trials are needed to optimize

the treatment of pediatric chronic pain, since treatments for adults with chronic pain do not always translate to effective treatment for children. „„ Better understanding of the confounding psychosocial and biological factors that influence a child’s pain

severity, maintenance and pain-related disability can facilitate the planning of effective treatment. „„ Multi-institutional clinical trials are needed to target treatments to specific populations of children based

on age, pubertal status and pain type.

SUMMARY Chronic pain in children is a poorly recognized entity that is challenging to treat and leaves many families frustrated. Often, lack of an identifiable etiology along with the complex biopsychosocial nature of this condition leads to a lengthy diagnostic odyssey and delayed treatment that exacerbates the existing problem. Effective treatment of chronic pain requires a team approach in order to deal with the various aspects of this Pediatric Pain Program & Division of General Pediatrics, David Geffen School of Medicine at University of California, Los Angeles (UCLA), 10833 Le Conte Ave, Los Angeles, CA 90095-1752, USA 2 Mattel Children’s Hospital, University of California, Los Angeles (UCLA), CA, USA *Author for correspondence: Tel.: +1 310 825 9346; [email protected] 1

10.2217/PMT.13.25 © 2013 Future Medicine Ltd

Pain Manage. (2013) 3(4), 303–314

part of

ISSN 1758-1869

303

Review  Yazdani & Zeltzer condition. ­Combinations of medication along with nonpharmacologic treatments, such as physical therapy, psychological interventions and complementary therapies, are often the most effective ways of treating chronic pain rather than medication alone. Further research is needed to understand the complex biobehavioral processes involved in the development and maintenance of chronic pain. Development of targeted novel therapies as well as comparative studies of existing treatments will help to improve treatment for chronic pain in children. Physicians and other healthcare workers are frequently faced with the challenge of diagnosing and treating recurrent or continuous pain in children that lasts beyond the normal healing time for an injury or illness, or a seemingly unidentifiable source. Chronic pain is typically thought of in the adult literature as pain lasting more than 6 months. The position statement from the American Pain Society has eliminated any specific duration of pain for the definition of chronic pain in childhood and rather defines it as “persistent and recurrent pain” [101]. For example, a 2‑month-old baby who has been in continuous pain related to a problem at birth can be said to have chronic pain. Thus, setting a time limit on the definition offers little in the way of assisting with treatment. Chronic pains that have no identifiable metabolic, infectious, mechanical, or inflammatory causes are particularly complicated to treat, since physicians often use the biomedical model to look for ‘the cause’ that fits into a linear model (the ‘rule out other causes’ model) rather than a broader biopsychosocial model that integrates the relationships of biologic, social and psychological contributions to a pain problem. While the biomedical diagnostic approach often works for acute pain, chronic pain, regardless of its initial course, typically picks up ‘baggage’ over time, and is usually accompanied by a vague constellation of symptoms that often leads to a lengthy diagnostic odyssey, recalcitrance to common treatments, and is compounded by a high level of child and family distress (as well as physician distress). This is why chronic pain in children must be evaluated within a biopsychosocial framework, while considering the child’s developmental status, as well as psychological, social and family factors. This article is intended to provide a better general understanding of chronic pediatric pain for primary care physicians and other healthcare workers by providing a broad review of various forms of chronic pain, its impact on children and their families and the spectrum of treatment modalities that are presently in use.

304

Pain Manage. (2013) 3(4)

Terms, definitions & examples Chronic pain serves no protective function and may become a disease in itself, as noted in the Institute of Medicine’s 2011 publication on pain [102]. A more thorough discussion of the definition and description of chronic pain in children is beyond the scope of this review; readers are directed to reference [102] for further information. Pain as a disease typically comes about when pain-signaling systems get perturbed. Such is the case in functional abdominal pain, functional dyspepsia, or irritable bowel syndrome when the neuroenteric system (often called the ‘little brain’) becomes dysregulated causing hypersensitivity anywhere within the GI tract. Chest pain, periumbilical pain after eating, or diffuse abdominal pain that is often relieved by a bowel movement, are the typical presenting symptoms. Not unlike other hollow organ pain disorders (e.g., dysmenorrhea, bladder spasms, renal colic), the abdominal pain is often described as ‘crampy’, may be intermittent or constant, and accompany acute bouts of recurrent pain spikes. Muscle spasms or joint inflammation often produce nociceptive pain, which is often described as a dull ache that is constant. Chronic daily headaches may occur alone or in addition to intermittent migraines and may be the result of persistent muscle spasm at the shoulders, back of the neck, scalp and even masseter muscles from teeth clenching and grinding. Joint pain is likewise often described as a dull ache and may be at the site of the affected joint or referred to another location, similar to referred hip pain that may be felt on the ipsilateral knee. Back pain in children may be myofascial and relate to carrying of heavy backpacks or poor posture. Neuropathic pain, defined as “pain initiated or caused by a primary lesion or dysfunction in the nervous system,” is distinguished from nociceptive pain by the fact that it serves no purpose other than to alarm the body about a potential neural injury. The etiology of neuropathic pain may be injury to the peripheral (e.g., plexus, dorsal root ganglion) or central

future science group

Treatment of chronic pain in children & adolescents  (e.g., spine, thalamus, and cortex) nervous system from a number of conditions such as neurodegenerative or metabolic diseases, cancer, trauma, or poisoning. Such is the case for many children with Fabry’s disease, a lysosomal genetic condition that affects peripheral nerves and can produce neuropathic pain at the extremities. Neuropathic pain can also derive from central neural processing problems, as in complex regional pain syndrome (CRPS; previously known as ref lex sympathetic dystrophy or neurovascular dystrophy). CRPS can present anywhere on the body but typically occurs on the extremities (legs more often than arms), and can be diagnosed by the presence of allodynia (a typically non-noxious sensation that has become painful, such as light touch), hyperpathia (acute pain that lingers longer than is usual), swelling, color change and decreased perfusion. What distinguishes CRPS from neural injury pain is the nondermatome distribution of the former. When occurring in the extremities, CRPS may take on a stocking or glove distribution and may also spread to other parts of the body, crossing midline. Whether related to neural injury or abnormal neural signaling, neuropathic pain is typically described as burning, stinging, sharp or stabbing. Although neuropathic pain and CRPS type I (CRPS I) comprise a small segment of all types of chronic pain in children, with an increasing number of children who survive cancer and various transplants, neuropathic pain continues to be a growing and important issue. Similarly, CRPS I may be underdiagnosed and its incidence could be larger than generally perceived. Fibromyalgia is an example of widespread bodily pain, typically accompanied by multiple tender points within the body of muscles but more commonly at tendon insertion points. The latter should be differentiated from enthesitis in which inflammation occurs at the tendon insertions and can be noted on MRI scans of the affected regions. Typically children presenting with fibromyalgia undergo extensive immunological evaluations and when no documented evidence of an immunopathy is found, the fibromyalgia label is often given. However, it is becoming increasingly clear that fibromyalgia comprises a wide array of symptoms that frequently include diffuse pain (97%), headache (76%), sleep disturbance (69%), stiffness (29%), joint swelling (24%), fatigue (20%) and abdominal pain (17%) [1]. The constellation of these

future science group

Review

symptoms is suggestive of central sensitization and/or reduced pain inhibitory mechanisms and is particularly detrimental to a child’s sleep, function, school attendance and performance, and overall emotional wellbeing. Etiology & prevalence An estimated 15–25% of children and adolescents suffer from recurrent and chronic pain conditions [2,3]. These conditions may be part of an underlying chronic medical disease such as sickle cell or inflammatory bowel disease, or pain sequelae of a disease, such as bone malignancy or burn injury. However, as noted previously and exemplified by CRPS I, pain itself may be the primary disease. The most common types of chronic pain in childhood are headaches, abdominal pain and musculoskeletal pain, with pain prevalence increasing during adolescence and with a higher female prevalence during pubertal development [2–6]. Developmental neurobiology of pain Nociceptive capacity is present at birth and goes through a variety of changes that depend on both the intrinsic growth and development of the neural system and brain, as well as the environmental experiences that shape a child’s perception and response to pain [7]. Therefore, postnatal pre- and post-synaptic alterations may not only affect the perception and threshold for pain, but also influence a child’s response to pharmacologic interventions [8,9]. The effect of chronic abdominal pain leading to visceral hyperalgesia through maladaptive changes in peripheral and central sensory transmission and perception is an example of the possible link between the early introduction to pain, and later altered response to pain and its treatment [10]. „„ Impact of pain

Children

Chronic pain during early development appears to have a negative impact on quality of life that may last beyond the immediate period of pain. Studies involving children and adolescents with chronic pain have demonstrated the detrimental effects of pain on the academic performance and social function of these individuals [11,12]. A study of children suffering from chronic pain found continued difficulty with pain, years after the end of their pain treatment [13]. Similar studies in adult survivors of childhood cancer have found a higher risk of prescription pain medication use

www.futuremedicine.com

305

Review  Yazdani & Zeltzer and reporting of painful conditions compared with a sibling control cohort [14]. Also, some studies have suggested that children with early introduction to recurrent painful stimuli such as neonatal intensive care unit procedures have altered heat pain perception and threshold [15]. One study of experimentally induced central pain modulation in 7-year-old children found that those born pre-term with a history of significant early pain exposure demonstrated lower central pain modulation than those who were born full- or pre-term without significant early neonatal pain exposure [16]. Family

Children with chronic pain have a bidirectional effect on their families [17]. Parents and caretakers who provide pain treatment and support for their children often experience distress during the course of the treatment [18,19]. Inversely, the attitude of the parents and caretakers, their focus on the pain, and level of anxiety appear to affect children’s disability and school attendance, and the treatment process such as the use of healthcare resources and outcome of chronic pain [20,21]. However, there is little known about the long-term effect of childhood chronic pain on families. Economic impact

Although some studies to date have implicated an increased use of healthcare dollars in children with chronic pain, quantifying the true economic impact of this condition is a difficult task that is yet to be determined [21–23]. The true economic impact of chronic pain in children and their families requires calculation of direct and indirect medical costs, disease-related non-medical cost, and loss of productivity, all of which require long-term follow-up and adjustment for other comorbidities. However, albeit the unknown number of affected children, with nearly 100 million adults in the USA experiencing chronic pain, many of which begin during childhood, pediatric chronic pain may have an even greater future economic impact than previously expected [102]. Pain assessment in children Pain assessment in children, especially in those with complex diseases and developmental or cognitive deficits, poses a challenge to clinicians because of these children’s limited ability to express the location, timing, intensity or quality

306

Pain Manage. (2013) 3(4)

of pain. Children may also experience altered perception and responses to pain that is affected by their past experiences, developmental status and other reasons for individual variations. Nevertheless, a thorough current- and pastmedical and social history, review of systems and physical examination in addition to the child’s self-report and behavior can help clinicians determine the extent of the pain (intensity, quality, location, frequency, duration and timing of the pain), as well as pain-related disruption of function. Assessing factors that affect the intensity or nature of the pain such as posture, food and environmental stressors may also be useful in deciphering the etiology and contributors to the pain. Furthermore, as Zeltzer and Krane point out in their chapter in Nelson’s Textbook of Pediatrics, various methods, that are developmentally appropriate, can be used to assess pain intensity and its effect on the child’s function (school, sleep, social and physical activities or appetite) and emotional wellbeing [24]. The importance of this approach becomes particularly obvious while devising a treatment plan for the child with chronic pain. While caretakers are the primary providers of history for nonverbal children, verbal older children should be directly and individually interviewed to assess not only their self-reported level of discomfort but also other factors that might not come up in an interview together with the parent. Verbal numerical pain rating scales provided by children and adolescents are considered the gold standard for assessing the intensity of pain. Often narrative stories provided by these children about their pain may prove to be more informative than posing a series of questions [25,26]. Similarly, description of the home setting and the possible psychosocial stressors that may instigate, exacerbate, or simply accompany pain are also extremely important in both diagnosing and treating chronic pain. Diagnosis of depression and anxiety in the patient (and history of such in other family members) is of particular importance in developing an integrative treatment plan for the child with chronic pain, and is part of the biopsychosocial model of evaluation [27]. To assist clinicians in assessing the intensity of pain in nonverbal children in an acute ambulatory or inpatient setting, a number of pain scales have been created that primarily rely on body posture, movement and facial expression of pain [28–33]. Attention to overall

future science group

Treatment of chronic pain in children & adolescents  behavior and physiologic findings may also be of benefit in chronic pain assessment. However, lack of such findings may also be misleading and cause dismissal of pain in a child who uses play as a means of distraction, or in those who avoid any expression of pain in order to prevent distressing their parents. Similarly, the aforementioned vital signs may be normal in cases of chronic pain, or if elevated, may be dismissed as the sympathetic autonomic changes that are attributable to a concurring medical problem such as infection or heart disease [24]. Treatment Clinicians and experts in the field of chronic pain have long realized the importance of a multifaceted approach to address pain and its predisposing factors and comorbidities. Additionally, these children may be treated in various settings such as outpatient multidisciplinary clinics, partial hospitalization rehabilitation programs, or inpatient settings. More interestingly, there has been some recent progress in web-based and telemedicine treatment of children with chronic pain [34–37]. Children with chronic pain, regardless of their underlying medical condition, often have different responses to pain treatment that depend on many intrinsic and situational factors. Therefore assessing and treating the underlying and ongoing psychological, physical developmental and situational issues are essential to any effective treatment. It is noteworthy that certain treatment modalities and medications are in their preliminary stages of clinical trials or have simply been ‘grandfathered’ into pediatric use, and therefore their application is based on the extrapolation of adult literature, and experience. „„ Psychological & psychoeducational

counseling

As the Institute of Medicine report on “Pain in America” highlights, a biopsychosocial approach to evaluation and treatment has been documented to be the most effective approach to chronic pain, including in children [102]. Children with chronic pain need to learn coping skills to help them increase their function and reduce painrelated distress. In fact, as the Cochrane review by Eccleston et al. notes, cognitive–behavioral therapies have been shown to be a major effective treatment modality in pediatric chronic pain management [38]. While not all children with chronic pain have significant diagnosable psychiatric comorbidities, identification of those

future science group

Review

who do and treating their problems is crucial to reducing the morbidity associated with chronic pain. For example, a study of German children with severe chronic pain by Zernikow et al. found clinically significant depression in 24%, and generalized anxiety in 19% of their population [39]. Findings from a similar study by Hunfeld et al. looking at the impact of chronic pain on the patients and their families highlighted the importance of addressing the psychosocial and medical impact of pain [12]. Collaboration with a mental health expert who has experience working with pediatric chronic pain can greatly benefit both the clinicians and their patients. This collaborative team effort may be particularly important in cases where pain is compounded by a chronic physical illness. It is also important to address the psychological impact of the child’s pain and illness on the family [38,40]. A study by Wallander found adjustment difficulty in parents of children with chronic conditions [41], while Brown et al. found that 21% of the mothers of children with sickle cell disease meet the diagnostic criteria for major depression or other affective disorders [42]. „„ Pharmacologic treatments

Pharmacologic treatments in pediatric chronic pain are typically aimed at reducing the severity of the pain and its comorbidities such as decreased appetite, fatigue, anxiety, depression and sleep disturbance, as well as improving the overall tolerance of any necessary physical and occupational therapies. Medications are particularly useful when children experience recurrent exacerbation of their chronic pain and its comorbidities as a result of an underlying disease such as cancer or chronic disease [43,44]. Unfortunately, few clinical trials have been aimed at studying the effect of various pain medications in pediatric chronic pain. Instead, clinicians treating chronic pain in children are often left with extrapolation of the adult chronic pain literature, or anecdotal experiences shared amongst clinicians. Similarly, certain treatment modalities and medications are in their preliminary stages of clinical trials or have simply been ‘grandfathered’ into pediatric use, and therefore their application is also based on the adult literature and experience. We have cited adult literature for medications where clinical trials in children are lagging. For review of the pediatric analgesic literature, we refer readers to Zeltzer and Krane [24]. We chose to provide

www.futuremedicine.com

307

Review  Yazdani & Zeltzer more detail for some of the key analgesics used in children here. Physiologic changes in children such as changes in the total body size and composition, organ and metabolic maturity leading to altered elimination dynamics, along with change in bioavailability of medications are some of the reasons for the unique drug dosage and response in children [45–47]. The following is a summary of the medications that are commonly used in the management of pediatric chronic pain. Readers are encouraged to refer to the provided references for further detail. Acetaminophen, aspirin & NSAIDs

In the USA, acetaminophen and NSAIDs such as ibuprofen have replaced aspirin, due to its possible causative role in Reye’s syndrome, as the first-line drug for analgesia and fever reduction. Acetaminophen, also known as paracetamol in Europe, Africa and most of Asia, is an effective and readily available aniline analgesic that can be administered in oral, rectal and intravenous form. While this medication is effective for low-grade pain, in combination with other medications such as opioids, it may also be used for the more severe types of pain. Acetaminophen is primarily metabolized in the liver and subsequently detoxified and excreted in the bile and urine [48]. However, if any of the electrophilic toxic metabolites escape the detoxification process, they can bind to hepatocytes and cause necrosis and liver damage. Therefore, high-dose, frequent and/or chronic use of this medication is not advisable in children and particularly those with any liver compromise. NSAIDs include a large variety of medications and are available in both oral and intravenous form. These medications are best suited for nociceptive pain with an inflammatory component by preventing the production of arachidonic acid through cyclooxygenase isoenzymes [49]. All NSAIDs can cause bronchospasm, gastrointestinal and cardiorenal side effects, and increase the risk of cardiac death in patients with history of myocardial infarction [50–54]. Hence, despite ease of administration and relative low toxicity of acetaminophen and NSAIDs, their chronic use, especially in children with an underlying medical problem should be considered with great caution. Opioids

In cases of moderate-to-severe pain, typically acetaminophen and NSAIDs may be skipped

308

Pain Manage. (2013) 3(4)

in favor of opioids. Despite their usefulness in managing various types of severe chronic pain, concern over the potential for addiction, hyperalgesia and respiratory depression has led to restricted use of this class of medications in children and, in particular, teenagers [55–57]. Thus, many institutions and practitioners use opioids minimally in the setting of chronic pain. Use of codeine analgesics, including hydrocodone that breaks down into codeine, is strongly discouraged because of the unpredictable individual genetic variation in codeine metabolism [58]. Commonly used opioids include oxycodone, morphine, oxymorphone, fentanyl and metha­ done. The duration of action for most of the aforementioned medications, with the exception of fentanyl (0.5–1 h) and methadone (4–12 h), tends to be 3–4 h. Therefore, these medications are most useful for acute, recurrent, or episodic exacerbation of chronic pain. Longer acting opioids, such as the long-acting forms of oxycodone and morphine, methadone and transdermal form of fentanyl, are more useful in chronic pain when opioids are needed. The commonly shared side effects of opioids include respiratory depression, decreased peristalsis and increased sphincter tone, biliary tract spasm, euphoria and nausea [59–61]. It is worth noting that the typical side effects of opioids are essentially equal at the same ‘equipotent’ analgesic dosage [60,61]. µ‑opioids are considered pure agonists while k‑opioids such as butorphanol, nalbuphine and pentazocine are considered mixed agonist–antagonists. This latter group of opioids causes far less respiratory depression and biliary spasm than pure µ‑opioids, but are less potent than pure agonists [60]. Atypical analgesics

A number of drugs that were created for other purposes, such as anticonvulsants and antidepressants, have been found to have useful analgesic properties [62]. Often these drugs are used in conjunction with other analgesics, hence the name adjuvant treatment. However, in treating non-malignant chronic pain, these medications may be used alone, and thus the term adjuvant would be a misnomer. Antidepressants such as serotonin- and serotonin-norepinephrine reuptake inhibitors and tricyclic antidepressant medications have proven to be useful in chronic malignant and non-malignant pain in adults [63–66]. However, almost all pain-related application of these medications and other atypical analgesics in

future science group

Treatment of chronic pain in children & adolescents  children are based on adult studies rather than pediatric clinical trials. Antidepressants are often used to address the primary pain problem along with the concurring anxiety and depression in these children. Special caution should be taken in monitoring the possible appearance of side effects and suicidal ideation in patients taking antidepressant drugs. Similarly, a2‑adrenergic agonists, such as clonidine and tizanidine, have also proven to be useful in treating chronic pain. Clonidine is available as a transdermal patch, orally and intraspinal injection for non-malignant neuropathic pain, while tizanidine, although studied only in adults, is approved for myofascial pain and chronic migraine prophylaxis [67–72]. Clonidine may be useful orally at night to both facilitate sleep as well as to reduce pain. With the advent of gabapentin as an effective analgesic for neuropathic pain, other neuroleptics have been used to help control malignant and non-malignant chronic neuropathic pain in adults. The success of gabapentin and newer anticonvulsants, such as lamotrigine, oxcarbazepine and pregabalin, have led to the use of these medications in children with chronic pain. We recommend slow titration and constant monitoring of these medications for their allergic (Stevens–Johnson) and neurologic symptoms (somnolence and ataxia) [73–77]. Other medications worth considering in the management of children with chronic pain include sodium channel blockers (e.g., lidocaine), benzodiazepines (e.g., Diazepam), N-methyl-daspartate receptor antagonists (e.g., ketamine, amantadine), muscle relaxants (cyclobenzaprine), anticholinergics (e.g., glycopyrrolate) and cannabinoids (e.g., dronabinol).

with chemotherapy. The ultimate goal of these techniques is to help children and adolescents progress towards self-management of their pain and anxiety without the need for pharmacologic interventions, and thus regain their normal daily function as they work towards the resolution of their pain.

„„ Nonpharmacologic treatments

Massage therapy

Clearly medications can facilitate some but not all the aforementioned issues in children with chronic pain, and therefore, it is best to complement these treatments with nonpharmacologic treatments. The treatments mentioned below not only have the potential to improve pain and enhance quality of life, but also help avoid inpatient pain treatments, which can potentially have negative sequelae in these children. More importantly, some of these techniques can be applied to other painful situations. For example, cancer patients can use relaxation and distraction techniques to help overcome nausea and discomfort associated

Massage therapy is the application of varied degrees of pressure on the patient’s body. This technique can be applied to younger children who suffer from myofascial pain. For children with chronic pain, therapists can often teach parents to apply massage therapy in-between therapy sessions. The efficacy of this technique is perhaps most evident through the studies focusing on pain and anxiety reduction in pediatric burn patients [83,84].

future science group

Review

Physical therapy

Physical therapy has proven to be an effective tool in treating back pain in adults [78]. Similarly in children, physical therapy is most useful in the cases of myofascial pain and can be implemented by both the therapist and parents at a facility, home or school. Often these exercises can take the form of play that is designed to progressively improve musculoskeletal function, fine and gross motor function, posture, endurance and circulation. Regaining physical ability often helps children resume their daily activities and return to the life they enjoyed before the onset of pain. Yoga

Yoga is an ancient self-realization discipline that was designed in India to bring awareness and balance through asanas (body postures), pranayama (patterns of breathing) and meditation. A recent review of the evidence for the possible health benefits of yoga in adults concluded that this technique can provide psychophysiological benefits for adults with musculoskeletal conditions [79]. Similar study in children and adolescents with arthritis has shown improved pain and functionality using Iyengar yoga [80,81]. A pilot study of yoga in adolescents with irritable bowel syndrome also demonstrated promising results [82].

Acupuncture

Modern day acupuncture uses a variety of tools such as needles, pressure, laser or electrical

www.futuremedicine.com

309

Review  Yazdani & Zeltzer stimulation on the acupuncture points along the meridian or energy field. Despite this technique’s proven effectiveness in adults, there are very few studies in children. A review by Waterhouse et al. has indicated that this technique can be effective in children as young as 6 years old in controlling their chronic pain [85]. However, further controlled studies are needed to measure the efficacy of this technique. Transcutaneous electrical nerve stimulation

Transcutaneous electrical nerve stimulation delivers a small electrical current of varying frequency transcutaneously to the painful area to modulate pain perception. Transcutaneous electrical nerve stimulation has been shown to be effective and safe in adults with traumatic pain, but there are no good studies in children with acute or chronic pain [86]. Cognitive–behavioral therapy & other mind–body therapies

There are a variety of psychological inter­ ventions, including cognitive–behavioral therapies, for treating chronic pain in children [26]. Cognitive–behavioral techniques are a series of mental exercises that help children cope with pain and enhance their function through a variety of mind–body strategies [87,88]. These strategies are aimed at reducing catastrophization through thought-stopping, reframing an experience, relaxing, distracting, various breathing techniques, mindfulness, biofeedback and/or hypnotherapy. As noted previously, cognitive–behavioral therapy has a long history in well-designed studies documenting its positive effects on chronic pain in children. For example, Kashikar-Zuck et al. have shown the effects of cognitive–behavioral therapy in adolescents with fibromyalgia [87]. Relaxation strategies can even be taught to preschool-aged children through breathing, blowing bubbles or involving the child in an imaginary adventure or story. Distraction can be used at any age through any means of redirecting the child’s attention from pain or worry about pain onto other more interesting things, such as videogames, television, stories and other activities. Hypnotherapy involves engaging children in their imagination and helping them learn how to develop imaginative involvement. Often, children as young as 3–4 years of age can easily become involved in imaginary play, which can serve both to distract the child from

310

Pain Manage. (2013) 3(4)

the pain experience, and also to enhance feelings of safety, comfort and control. Biofeedback uses many of the above strategies to help the child relax with an observable feedback system such as using computers or color changing tapes to document changes in muscle tension or peripheral skin temperature [89]. Music & art therapy

Music and art therapy can help children to express themselves in less direct, nonverbal ways. Studies in adult burn patients suggest positive effects on pain and anxiety [90]. Young children who are nonverbal or too young to express themselves through psychotherapy can express their negative emotions and problem-solve through creative play. Conclusion & future perspective Chronic pain in children is an important, yet challenging problem in clinical practice that requires a multifaceted approach to assess the etiology(ies) and eventually treat the pain. Often, chronic pain is not a manifestation of a disease, but the disease itself. Detailed history and physical exam along with a thorough psychosocial history and review of systems are the first necessary steps to understand the pain and to devise a treatment plan. Although asking children to repeatedly quantify their pain may help clinicians assess the extent and fluctuations in discomfort, such continual self-reporting or questioning may lead to children overly focusing on their pain and suffering. On the other hand, absence of observable or physiologic signs of pain in children with chronic pain may lead to a false dismissal of the pain. By evaluating children’s chronic pain within a biopsychosocial model, clinicians can appreciate the need for a multidisciplinary approach to treating children with chronic pain. Pharmacologic treatments may play an important role in the treatment of pediatric chronic pain, but much of the knowledge has been extrapolated from the adult literature and anecdotal clinical experience. Since children are not ‘little adults’, this approach needs to be re-evaluated in order to improve the efficacy of these medications in children. The US FDA Pediatric Research Equity Act (PREA) has enabled pharmaceutical companies to extend their patents by studying their drug in children. Future drug trials aimed at treating children and adolescents with chronic pain may better enable

future science group

Treatment of chronic pain in children & adolescents  clinicians to optimize treatment and provide parents with a higher safety assurance. More importantly, use of any medications in treating chronic pain needs to be accompanied with a longitudinal evaluation and treatment of the comorbid conditions such as anxiety, depression and family stressors. Thus, psychiatrists, psychologists, social workers and other mental health professionals who are familiar with this population should be considered an essential part of the team treating these children. Longitudinal psychotherapy for the children and their families, aimed at improving their coping ability and function while in pain, and education of parents about the pain rehabilitation model (“function first, significant pain reduction comes later”), along with physical therapies and complementary treatments such as acupuncture, massage, yoga, biofeedback, hypnotherapy, and music and art therapies, can significantly help in reaching an optimal outcome. Typically, treating chronic pain requires patience on the part of the clinician and family, as rarely are there any ‘quick fixes’. However, the long-term prognosis of children with chronic pain is excellent and many can be helped to cope, return to school, and function physically and socially. As this article notes, there is still much to be done in terms of a better understanding of the underlying biopsychosocial mechanisms and interaction of factors contributing to the development and maintenance of chronic pain in childhood. Research aimed at identifying risk factors and vulnerable populations can References Papers of special note have been highlighted as: of interest of considerable interest n

1

2

3

4

Gedalia A, Garcia CO, Molina JF, Bradford NJ, Espinoza LR. Fibromyalgia syndrome: experience in a pediatric rheumatology clinic. Clin. Exp. Rheumatol. 18, 415–419 (2000). Perquin CW, Hazebroek-Kampschreur AA, Hunfeld JA et al. Pain in children and adolescents: a common experience. Pain 87, 51–58 (2000). Stanford EA, Chambers CT, Biesanz JC, Chen E. The frequency, trajectories and predictors of adolescent recurrent pain: a population-based approach. Pain 138(1), 11–21 (2008). King S, Chambers CT, Huguet A et al. The epidemiology of chronic pain in children

future science group

help to determine preventive interventions that can be tested. Additional research should be aimed at targeting specific interventions for subgroups of children with chronic pain. Often clinical intervention trials use a ‘one-size-fits-all’ approach without identifying individual differences in response, nor do they recommend or modify interventions that are focused on the needs of subgroups within a chronic pain population. Future research should examine interventions that promote a ‘who gets what’ focus so that outcomes may be improved with a more tailored approach to children with chronic pain. Presently, clinical trials aimed at testing the efficacy of pharmacological, psychological, physical and complementary therapies face many obstacles such as a scattered, low population of patients. Thus multi-institution studies are needed in order to accrue a sizable population to determine the efficacy and response variations to respective interventions. Formation of collaborative clinical trial networks in the future can address the concerns above, and help move the field of pediatric pain treatment forward. Financial & competing interests disclosure The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert t­estimony, grants or patents received or p­ending, or royalties. No writing assistance was utilized in the production of this manuscript. and adolescents revisited: a systematic review. Pain 152(12), 2729–2738 (2011).

n n

n n

5

6

Review

Provides a detailed discussion of the prevalence and types of chronic pain in children and adolescents. Roth-Isigkeit A, Thyen U, Stöven H, Schwarzenberger J, Schmucker P. Pain among children and adolescents: restrictions in daily living and triggering factors. Pediatrics 115(2), e152–e162 (2005). Chitkara DK, Rawat DJ, Talley NJ. The epidemiology of childhood recurrent abdominal pain in western countries: a systematic review. Am. J. Gastroenterol. 100(8), 1868–1875 (2005).

7

Fitzgerald M. The development of nociceptive circuits. Nat. Rev. Neurosci. 6, 507–520 (2005).

8

Taddio A, Katz J, Ilersich AL, Koren G. Effect of neonatal circumcision on pain

response during subsequent routine vaccination. Lancet 349, 599–603 (1997). 9

Taddio A, Ohlsson A, Einarson TR, Stevens B, Koren G. A systematic review of lidocaine – prilocaine cream (EMLA) in the treatment of acute pain in neonates. Pediatrics 101, e1 (1998).

10 Drossman DA. What does the future hold for

irritable bowel syndrome and the functional gastrointestinal disorders? J. Clin. Gastroenterol. 39 (Suppl. 5), S251–S256 (2005). 11 Eccleston C, Wastell S, Crombez G, Jordan

A. Adolescent social development chronic pain. Eur. J. Pain 12(6), 765–774 (2008). 12 Hunfeld JA, Perquin CW, Duivenvoorden

HJ et al. Chronic pain and its impact on quality of life in adolescents and their families. J. Pediatr. Psychol. 26, 145–153 (2001).

www.futuremedicine.com

311

Review  Yazdani & Zeltzer n n

In-depth discussion of the bidirectional impact of chronic pain in adolescents and their families.

23 Sleed M, Eccleston C, Beecham J, Knapp M,

13 Martin AL, McGrath PA, Brown SC, Katz J.

Children with chronic pain: Impact of sex and age on long-term outcomes. Pain 128, 13–19 (2007).

24 Zeltzer LK, Krane EJ. Pediatric pain

25 Krane EJ. Relieve Your Child’s Chronic Pain: A

17 Grunau RVE, Whitfield MF, Petrie JH, Fryer

Child’s Chronic Pain: A Pediatrician’s Guide for Reclaiming a Normal Childhood. Harper Collins, NY, USA (2005). n

Connell H, Clinch J. The Bath Adolescent Pain-Parental Impact Questionnaire (BAP-PIQ): development preliminary psychometric evaluation of an instrument to assess the impact of parenting an adolescent with chronic pain. Pain 137(3), 478–487 (2008). 19 Levy RL, Langer SL, Walker LS, Feld LD,

Whitehead WE. Relationship between the decision to take a child to the clinic for abdominal pain and maternal psychological distress. Arch. Pediatr. Adolesc. Med. 160, 961–965 (2006). 20 Walker LS, Williams SE, Smith CA, Garber

J, Van Slyke DA, Lipani TA. Parent attention versus distraction: impact on symptom complaints by children with and without chronic functional abdominal pain. Pain 122, 43–52 (2006). 21 Goubert L, Eccleston C, Vervoort T, Jordan

A, Crombez G. Parental catastrophizing about their child’s pain. The parent version of the Pain Catastrophizing Scale (PCS-C): a preliminary validation. Pain 123(3), 254–263 (2006). 22 Perquin CW, Hunfeld JA, Hazebroek-

Kampschreur AA et al. Insights in the use of health care services in chronic benign pain in childhood and adolescence. Pain 94(2), 205–213 (2001).

312

36 Jacob E, Duran J, Stinson J, Lewis MA,

Zeltzer L. Remote monitoring of pain and symptoms using wireless technology in children and adolescents with sickle cell disease. J. Am. Acad. Nurs. Pract. 25(1), 42–54 (2013).

In-depth explanation of the nature of chronic pain and different therapeutic approaches in children and adolescents.

37 Jacob E, Stinson J, Duran J et al. Usability

testing of a Smartphone for accessing a web-based e-diary for self-monitoring of pain and symptoms in sickle cell disease. J. Pediatr. Hematol. Oncol. 34(5), 326–335 (2012). 38 Eccleston C, Palermo TM, de C Williams AC

et al. Psychological therapies for the management of chronic and recurrent pain in children and adolescents. Cochrane Database Syst. Rev. 12, CD003968 (2012).

27 McGrath PJ, Walco GA, Turk DC et al. Core

EL. Early pain experience, child and family factors, as precursors of somatization: a prospective study of extremely premature and full term children. Pain 56(3), 353–359 (1994). 18 Jordan A, Eccleston C, McCracken LM,

Usability testing of an online selfmanagement program for adolescents with juvenile idiopathic arthritis. J. Med. Internet Res. 12(3), e30 (2010).

26 Zeltzer LK, Schlank CB. Conquering Your

16 Goffaux P, Lafrenaye S, Morin M, Patural H,

Demers G, Marchand S. Preterm births: can neonatal pain alter the development of endogenous gating systems? Eur. J. Pain 12, 945–951 (2008).

35 Stinson J, McGrath P, Hodnett E et al.

Doctor’s Program for Easing Headaches, Abdominal Pain, Fibromyalgia, Juvenile Rheumatoid Arthritis, and More. Simon and Schuster (Fireside), NY, USA (2005).

15 Hermann C, Hohmeister J, Demirakça S,

Zohsel K, Flor H. Long-term alteration of pain sensitivity in school-aged children with early pain experiences. Pain 125, 278–285 (2006).

Evaluating treatment participation in an internet-based behavioral intervention for pediatric chronic pain. J. Pediatr Psychol. 37(8), 893–903 (2012).

management. In: Nelson’s Textbook of Pediatrics (19th Edition). Kliegman RM, Behrman RE, Stanton BF, Schor N, St Geme J (Eds). Elsevier, London, UK, 360–375 (2011).

14 Lu Q, Krull KR, Leisenring W et al. Pain in

long-term adult survivors of childhood cancers and their siblings: a report from the Childhood Cancer Survivor Study. Pain 152(11), 2616–2624 (2011).

34 Law EF, Murphy LK, Palermo TM.

Jordan A. The economic impact of chronic pain in adolescence: methodological considerations and a preliminary costs-ofillness study. Pain 119(1–3), 183–90 (2005).

outcome domains and measures for pediatric acute and chronic/recurrent pain clinical trials: PedIMMPACT recommendations. J. Pain 9(9), 771–783 (2008). n n

Identifies core outcome domains and measures used in assessing the efficacy of treatments for acute and chronic pain in children and adolescents.

28 Breau LM, McGrath PJ, Camfield CS, Finley

39 Zernikow B, Wager J, Hechler T et al.

Characteristics of highly impaired children with severe chronic pain: a 5‑year retrospective study on 2249 pediatric pain patients. BMC Pediatrics 12, 54 (2012). 40 Palermo TM, Eccleston C, Lewandowski AS,

Williams AC, Morley S. Randomized controlled trials of psychological therapies for management of chronic pain in children and adolescents: an updated meta-analytic review. Pain 148(3), 387–397 (2010).

GA. Psychometric properties of the noncommunicating children’s pain checklistrevised. Pain 99(1–2), 349–357 (2002). 29 Breau LM, Camfield CS, Symons FJ et al.

Relation between pain and self-injurious behavior in nonverbal children with severe cognitive impairments. J. Pediatr. 142(5), 498–503 (2003). 30 Breau LM, Burkitt C. Assessing pain in

41 Wallander JL. Special section editorial:

current research on pediatric chronic illness. J. Pediatric Psychol. 18(1), 7–10 (1993). 42 Brown RT, Kaslow NJ, Doepke K et al.

Psychosocial and family functioning in children with sickle cell syndrome and their mothers. J. Am. Acad. Child Adolesc. Psychiatry 32, 545–553 (1993).

children with intellectual disabilities. Pain Res. Manag. 14(2), 116–120 (2009). 31 Breau LM, Camfield CS, McGrath PJ, Finley

GA. The incidence of pain in children with severe cognitive impairments. Arch. Pediatr. Adolesc. Med. 157(12), 1219–1226 (2003). 32 Symons FJ, Harper VN, McGrath PJ, Breau

LM, Bodfish JW. Evidence of increased nonverbal behavioral signs of pain in adults with neurodevelopmental disorders and chronic self-injury. Res. Dev. Disabil. 30(3), 521–528 (2009). 33 Voepel-Lewis T, Malviya S, Tait AR et al.

A comparison of the clinical utility of pain assessment tools for children with cognitive impairment. Anesth. Analg. 106(1), 72–78 (2008).

Pain Manage. (2013) 3(4)

43 Yazdani S, McGhee SA, Stiehm ER. Chronic

Complex Diseases of Childhood. Brown Walker Press, FL, USA (2011). n

Provides a detailed practical guide for clinicians caring for children with chronic diseases that may have chronic or recurrent pain.

44 Prapaitrakool S, Hollmann MW, Wartenberg

HC, Preckel B, Brugger S. Use of buprenorphine in children with chronic pseudoobstruction syndrome: case series and review of literature. Clin. J. Pain 28(8), 722–725 (2012).

future science group

Treatment of chronic pain in children & adolescents  45 Berde CB, Sethna NF. Analgesics for the

treatment of pain in children. N. Engl. J. Med. 347, 1094–1103 (2002). n

Provides an overview of pharmacologic treatments for chronic pain in children.

46 Walker SM. Pain in children: recent advances

and ongoing challenges. Br. J. Anaesth. 101(1), 101–110 (2008). 47 Anderson BJ, Holford NH. Mechanism-based

concepts of size and maturity in pharmacokinetics. Annu. Rev. Pharmacol. Toxicol. 48, 303–332 (2008). 48 American Academy of Pediatrics. Committee

on drugs. Acetaminophen toxicity in children. Pediatrics 108(4), 1020–1024 (2001). 49 Rao P, Knaus EE. Evolution of nonsteroidal

anti-inflammatory drugs (NSAIDs): cyclooxygenase (COX) inhibition and beyond. J. Pharm. Pharm. Sci. 11(2), S81–S110 (2008). 50 Leuppi JD, Schnyder P, Hartmann K,

Reinhart WH, Kuhn M. Drug-induced bronchospasm: analysis of 187 spontaneously reported cases. Respiration 68(4), 345–351 (2001). 51 van der Linden MW, van der Bij S, Welsing P,

Kupiers EJ, Herings RM. The balance between severe cardiovascular and gastrointestinal events among users of selective and non-selective non-steroidal antiinflammatory drugs. Ann. Rheum. Dis. 68(5), 668–673 (2009). 52 Ng SC, Chan FK. NSAID-induced

gastrointestinal and cardiovascular injury. Curr. Opin. Gastroenterol. 26(6), 611–617 (2010). 53 Lanas A, Perez-Aisa MA, Feu F et al.

Investigators of the Asociación Española de Gastroenterología (AEG) A nationwide study of mortality associated with hospital admission due to severe gastrointestinal events and those associated with nonsteroidal antiinflammatory drug use. Am. J. Gastroenterol. 100(8), 1685–1693 (2005). 54 Schjerning Olsen AM, Fosbøl EL,

Lindhardsen J et al. Duration of treatment with nonsteroidal anti-inflammatory drugs and impact on risk of death and recurrent myocardial infarction in patients with prior myocardial infarction: a nationwide cohort study. Circulation 123, 2226–2235 (2011). 55 Vijayan V, Moran R, Elder ME, Sukumaran

S. Acute-onset opioid-induced hyperalgesia in a child with juvenile idiopathic arthritis. J. Clin. Rheumatol. 18(7), 349–351 (2012). 56 Niesters M, Overdyk F, Smith T, Aarts L,

Dahan A. Opioid-induced respiratory

future science group

depression in paediatrics: a review of case reports. Br. J. Anaesth. 110(2), 175–182 (2013). 57 Log T, Skurtveit S, Selmer R, Tverdal A, Furu

K, Hartz I. The association between prescribed opioid use for mothers and children: a record-linkage study. Eur. J. Clin. Pharmacol. 69(1), 111–118 (2013). 58 Sadhasivam S, Krekels EH, Chidambaran V

et al. Morphine clearance in children: does race or genetics matter? J. Opioid. Manag. 8(4), 217–226 (2012). 59 Jaffe JH, Martin WR. Opioid analgesics and

antagonists. In: The Pharmacological Basis of Therapeutics. Gillman AG, Goodman LS, Rail TW, Murad F (Eds). Macmillan, NY, USA, 491–531 (1985). 60 Wood M. Narcotic analgesics and

antagonists. In: Drugs and Anesthesia: Pharmacology for Anesthesiologists. Wood M, Wood AJJ (Eds). Williams & Wilkins, MD, USA, 163–197 (1982). 61 Mather LE, Phillips GD. Opioids and

adjuvants: principles of use. In: Acute Pain Management. Cousins MJ, Phillips GD (Eds). Churchill Livingstone, NY, USA, 77–103 (1986). 62 Lussier D, Portenoy RK. Adjuvant analgesics

in pain management. In: Oxford Textbook of Palliative Medicine (3rd Edition). Doyle D, Hanks G, Cherny N et al. (Eds). Oxford University Press, Oxford, UK, 349–377 (2003). 63 Onghena P, Van Houdenhove B.

Antidepressant-induced analgesia in chronic non-malignant pain: a meta-analysis of 39 placebo-controlled studies. Pain 49(2), 205–219 (1992). 64 Watson CP. The treatment of neuropathic

pain: antidepressants and opioids. Clin. J. Pain 16(Suppl. 2), S49–S55 (2000). 65 Collins SL, Moore RA, McQuay HJ et al.

Antidepressants and anticonvulsants for diabetic neuropathy and postherpetic neuralgia: a quantitative systematic review. J. Pain Symptom Manage. 20, 449–458 (2000). 66 Dworkin RH, Backonja M, Rowbotham MC

et al. Advances in neuropathic pain: diagnosis, mechanisms, and treatment recommendations. Arch. Neurol. 60, 1524–1534 (2003). 67 Nadler SF, Malanga GA, Smith R et al.

Open-label trial evaluating tizanidine for myofascial pain syndrome. Presented at: The 10th World Congress on Pain, International Association for the Study of Pain. San Diego, CA, USA, 17–22 August 2002.

Review

68 Vallejo R, Santigo-Palma J, Barna S et al.

Tizanidine for the treatment of chronic myofascial pain. Presented at: The 10th World Congress on Pain, International Association for the Study of Pain. San Diego, CA, USA, 17–22 August 2002. 69 Saper JR, Lake AE 3rd, Cantrell DT et al.

Chronic daily headache prophylaxis with tizanidine: a double-blind, placebocontrolled, multicenter outcome study. Headache 42(6), 470–482 (2002). 70 Byas-Smith MG, Max MB, Muir J et al.

Transdermal clonidine compared to placebo in painful diabetic neuropathy using a twostage ‘enriched enrollment’ design. Pain 60(3), 267–274 (1995). 71 Zeigler D, Lynch SA, Muir J et al.

Transdermal clonidine versus placebo in painful diabetic neuropathy. Pain 48(3), 403–408 (1992). 72 Rauck RL, Eisenach JC, Jackson K et al.

Epidural clonidine treatment for refractory reflex sympathetic dystrophy. Anesthesiology 79(6), 1163–1169; Discussion 27A (1993). 73 Backonja MM. Use of anticonvulsants for

treatment of neuropathic pain. Neurology 59(Suppl. 2), S14–S17 (2002). 74 Backonja M, Glanzman RL. Gabapentin

dosing for neuropathic pain: evidence from randomized, placebo-controlled clinical trials. Clin. Ther. 25, 81–104 (2003). 75 Zakrzewska JM, Chaudhry Z, Nurmikko TJ

et al. Lamotrigine (lamictal) in refractory trigeminal neuralgia: results from a doubleblind placebo controlled crossover trial. Pain 73, 223–230 (1997). 76 Carrazana E, Mikoshiba I. Rationale and

evidence for the use of oxcarbazepine in neuropathic pain. J. Pain Symptom Manage. 25(5), S31–S35 (2003). 77 Dworkin RH, Corbin AE, Young JP Jr et al.

Pregabalin for the treatment of postherpetic neuralgia: a randomized, placebo-controlled trial. Neurology 60, 1274–1283 (2003). 78 Airaksinen O, Brox JI, Cedraschi C et al.

COST B13 Working Group on guidelines for prevention in low back pain. European guidelines for the management of chronic nonspecific low back pain. Eur. Spine J. 15(2), S192–S300 (2006). 79 Raub JA. Psychophysiologic effects of Hatha

yoga on musculoskeletal and cardiopulmonary function: a literature review. J. Altern. Complement. Med. 8, 797–812 (2002). 80 Evans S, Cousins L, Tsao JC, Subramanian S,

Sternlieb B, Zeltzer LK. A randomized controlled trial examining Iyengar yoga for

www.futuremedicine.com

313

Review  Yazdani & Zeltzer young adults with rheumatoid arthritis: a study protocol. Trials 12, 19 (2011).

a randomized double-blind controlled study in acute traumatic pain. Am. J. Emerg. Med. 5(1), 6–10 (1987).

81 Evans S, Tsao JC, Sternlieb B, Zeltzer LK.

Using the biopsychosocial model to understand the health benefits of yoga. J. Complement. Integr. Med. 6(1), 1553–3840 (2009).

83 Hernandez-Reif M, Field T, Largie S et al.

Childrens’ distress during burn treatment is reduced by massage therapy. J. Burn Care Rehabil. 22(2), 191–195 (2001).

Cognitive behavioral therapy for the treatment of juvenile fibromyalgia: a multisite, single-blind, randomized, controlled clinical trial. Arthritis Rheum. 64(1), 297–305 (2012). n

Chronic Pain in Children and Adolescents. Oxford University Press, Oxford, UK (2012).

84 Parlak Gürol A, Polat S, Akçay MN. Itching,

314

with Chronic Pain. A Position Statement from the American Pain Society. www.americanpainsociety.org/uploads/pdfs/ aps12-pcp.pdf (Accessed 4 June 2012) 102 Relieving Pain in America: A Blueprint for

Transforming Prevention, Care, Education, and Research; Institute of Medicine of the National Academies, Washington, D.C. www.iom.edu/reports/2011/relieving-pain-inamerica-a-blueprint-for-transformingprevention-care-education-research.aspx (Accessed 17 June 2013)

Provides a more detailed understanding of cognitive–behavioral therapy in children with chronic pain. The Oxford Textbook of Pediatric Pain. McGrath P, Stevens B, Walker S, Zempsky W (Eds). Oxford University Press, Oxford, UK (In Press).

Commentary on the use of acupuncture in chronic pediatric pain. J. Dev. Behav. Pediatr. 30(1), 69–71 (2009). stimulation versus oral analgesic:

101 Assessment and Management of Children

89 Zeltzer LK. Complementary therapies. In:

85 Waterhouse M, Tsao JC, Zeltzer LK.

86 Ordog GJ. Transcutaneous electrical nerve

Provides a better understanding of cognitive–behavioral therapy and its efficacy through an application trial in the research setting.

„„ Websites

88 Palermo TM. Cognitive Behavioral Therapy for

n

pain, and anxiety levels are reduced with massage therapy in burned adolescents. J. Burn Care Res. 31(3), 429–432 (2010).

The efficacy of music therapy protocols for decreasing pain, anxiety, and muscle tension levels during burn dressing changes: a prospective randomized crossover trial. J. Burn Care Res. 31(4), 590–597 (2010).

87 Kashikar-Zuck S, Ting TV, Arnold LM et al.

82 Kuttner L, Chambers CT, Hardial J, Israel

DM, Jacobson K, Evans K. A randomized trial of yoga for adolescents with irritable bowel syndrome. Pain Res. Manag. 11(4), 217–223 (2006).

90 Tan X, Yowler CJ, Super DM, Fratianne RB.

n

Provides pediatricians with a detailed review and state of the science on complementary therapies in pediatric pain.

Pain Manage. (2013) 3(4)

n n

Overview of common approaches to treating chronic pain in children and adolescents.

future science group

Treatment of chronic pain in children and adolescents.

SUMMARY Chronic pain in children is a poorly recognized entity that is challenging to treat and leaves many families frustrated. Often, lack of an ide...
1MB Sizes 2 Downloads 3 Views