Best practice management of pediatric chronic pain involves multiple treatment modalities in a multidisciplinary pain clinic. Current conventional treatments include pharmacologic therapy, psychotherapy, and physical therapy. Despite the widespread use of these strategies, management of pediatric chronic pain, like adult chronic pain, remains elusive. Chronic pain often involves a myriad of triggers and exacerbations. Management efforts may be most fruitful when the whole person’s functioning is considered. To this end, complementary and alternative medicine (CAM) can be considered alongside conventional approaches. Complementary and alternative medicine interventions attempt to restore balance and harmony in the mind and body, whereas the goal of Western medicine is to restore homeostasis or balance to bodily functions. Under a biopsychosocial conceptualization of chronic pain, the integration of CAM with more traditional psychological and pharmacologic therapies may be the most effective way of dealing with chronic pain in young patients.
A more in-depth analysis of the various CAM modalities that may be therapeutic for children dealing with chronic pain is available in our previous work.7–9
Later in the text, we present a brief overview of some of the treatments currently being used in the UCLA PPP. We then turn to a detailed description of IY, a CAM modality we have been incorporating into the treatment plan of many children with chronic pain and for which we have recently embarked upon a research program to document feasibility, safety, and efficacy using a series of randomized controlled trials. It is worth noting that, to date, many of these interventions have been poorly studied in adults, and even less empirical work has been done with children experiencing chronic pain.
is thought to harness and redirect “Qi” or energy throughout the body. It is believed that if blocked, this energy force can cause imbalance and sickness. Acupuncture is intended to restore Qi through the insertion of needles into points along energy pathways (meridians) in the body. The needles help stimulate the energy flow. Although the precise analgesic mechanisms have not been identified, it is likely that the body’s nervous system, neurotransmitters, and endogenous substances are involved in needle stimulation.10
For an overview of acupuncture in pediatric populations see 2 of our recent reviews.11,12
Preliminary evidence supports the efficacy of acupuncture for migraine in children.13
We have also found initial evidence in our clinic for the utility of acupuncture combined with hypnotherapy (described below) in alleviating pediatric head pain, abdominal pain, fibromyalgia, and complex regional pain syndrome type I.14
used for chronic pain is based on a mind-body approach to healing. Hypnotherapy and guided imagery are thought to calm the nervous system and release stress and pain in the child. During hypnosis, modification or enhancement of sensation and perception often occurs, and children are especially susceptible to these effects. Neuroimaging research shows that hypnosis is associated with activation of brain areas consistent with decreased arousal, visual imagery, and the likely reinterpretation of perceptual experiences.15
A review of multiple studies testing the use of hypnosis for pediatric headaches indicated relaxation/self-hypnosis to be a well-established and efficacious treatment.16
A recent clinical trial has shown benefits for children with recurrent abdominal pain and irritable bowel syndrome (IBS).17
uses a computer or other feedback device to assist children in managing symptoms by becoming aware of and learning to voluntarily control physiologic changes associated with the stress response. These monitored changes may include muscle tension, skin temperature, sweat gland response, brain wave activity, or breathing rate, with the goal of increasing relaxation in the body. Biofeedback teaches children to be aware of how their body reacts to experiences and to gain physiologic control of the branch of the nervous system that is activated by pain or stress. Studies have reported significant reductions in children’s symptoms of headache and migraine18
and recurrent abdominal pain.19
therapy is based on the belief that when muscles are overworked, waste products can accumulate in the muscle, causing soreness and stiffness. The therapy aims to improve circulation in the muscle, increase flow of nutrients, and eliminate waste products. Although the underlying mechanisms are unknown, it is likely that massage involves increased parasympathetic activity and a relaxed physiologic state.20
Studies have shown massage to alleviate juvenile RA pain21
and to reduce pain, tension, and distress in a group of children with a range of chronic pain conditions presenting to a pediatric pain clinic.22
involves the conscious monitoring of one’s attention and focusing on the present moment to promote stabilizing the mind and a sense of calm. By adjusting practices to the child’s development, mindfulness meditation can be taught to children of almost all ages. It is likely that mindfulness meditation minimizes pain through the individual’s acceptance of pain and a reduction in stress. Meditation has shown beneficial effects on blood pressure and heart rate in adolescents,23
although trials expressly studying children with chronic pain are wanting.
is a traditional form of yoga taught by B.K.S. Iyengar who uses props such as blankets, bolster, blocks, to allow even those individuals with limiting disabilities to practice yoga. Other hallmarks of the Iyengar tradition include extensive training for teachers, modifications to adjust for the individual’s particular needs, and the use of therapeutic sequences that are condition specific. Yoga poses are intended to correct health-related problems, both in body structure and in internal organ function, and to develop a sense of mastery. The poses allow children to look at the underlying causes and habits that may contribute to their pain problems and to learn how to change them. A number of positive effects have been reported for yoga in young people. Practice of IY appears to be associated with improvements in mood and function.24
One randomized trial also demonstrated that regular home practice of yoga assisted with pain and disability related to IBS in adolescents.25
Our recent pilot study found positive effects in young patients with RA.26
To illustrate the use of CAM within the PPP clinic and research program we follow with a more in-depth overview of IY.