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1.  Conditioned pain modulation (CPM) in children and adolescents: Effects of sex and age 
Conditioned pain modulation (CPM) refers to the diminution of perceived pain intensity for a test stimulus following application of a conditioning stimulus to a remote area of the body, and is thought to reflect the descending inhibition of nociceptive signals. Studying CPM in children may inform interventions to enhance central pain inhibition within a developmental framework. We assessed CPM in 133 healthy children (mean age = 13 years; 52.6% girls) and tested the effects of sex and age. Participants were exposed to four trials of a pressure test stimulus before, during, and after the application of a cold water conditioning stimulus. CPM was documented by a reduction in pressure pain ratings during cold water administration. Older children (12–17 years) exhibited greater CPM than younger (8–11 years) children. No sex differences in CPM were found. Lower heart rate variability (HRV) at baseline and after pain induction was associated with less CPM controlling for child age. The findings of greater CPM in the older age cohort suggest a developmental improvement in central pain inhibitory mechanisms. The results highlight the need to examine developmental and contributory factors in central pain inhibitory mechanisms in children to guide effective, age appropriate, pain interventions.
doi:10.1016/j.jpain.2013.01.010
PMCID: PMC3672325  PMID: 23541066
diffuse noxious inhibitory controls; experimental pain; descending modulation; endogenous inhibition; pediatric pain
2.  Psychological aspects and hospitalization for pain crises in youth with sickle-cell disease 
Journal of health psychology  2013;19(3):407-416.
Sickle-cell disease is a genetic disorder characterized by severe pain episodes or “vaso-occlusive crises” that may require hospitalization. This study examined the associations among emotion regulation, somatization, positive and negative affect, and hospitalizations for pain crises in youth with sickle-cell disease. Multivariate analyses indicated that emotional suppression and somatization were significantly associated with more frequent hospitalizations for pain crises in the previous year after controlling for sickle-cell disease type and pain. These results suggest that efforts to reduce emotional suppression and somatization may assist in decreasing the frequency of hospitalizations for pain crises among youth with sickle-cell disease.
doi:10.1177/1359105312471570
PMCID: PMC3744610  PMID: 23407129
adolescence; children; emotion regulation; health-care utilization; somatization
4.  Heart rate variability as a biomarker for autonomic nervous system response differences between children with chronic pain and healthy control children 
Journal of Pain Research  2013;6:449-457.
Studies in adults have demonstrated a relationship between lowered heart rate variability (HRV) and poor health. However, less is known about the role of autonomic arousal in children’s well-being. The aim of the current study was to examine resting HRV in children with chronic pain compared to healthy control children and, further, to examine children’s HRV following a series of acute experimental pain tasks in both groups. Participants included 104 healthy control children and 48 children with chronic pain aged 8–17 years. The laboratory session involved a 5-minute baseline electrocardiogram followed by four pain induction tasks: evoked pressure, cold pressor, focal pressure, and a conditioned pain modulation task. After the tasks were complete, a 5-minute post-task electrocardiogram recording was taken. Spectral analysis was used to capture high-frequency normalized power and the ratio of low-to-high frequency band power, signifying cardiac vagal tone and sympathetic balance, respectively. Results revealed that children with chronic pain had significantly lower resting HRV (signified by low high-frequency normalized power and high ratio of low-to-high frequency band power) compared to healthy children; moreover, a significant interaction between groups and time revealed that children with chronic pain displayed a static HRV response to the pain session compared to healthy children, whose HRV was reduced concomitant with the pain session. These findings suggest that children with chronic pain may have a sustained stress response with minimal variability in response to new acute pain stressors.
doi:10.2147/JPR.S43849
PMCID: PMC3684221  PMID: 23788839
laboratory pain; pediatric pain; cold pressor; experimental pain; childhood pain; stress task
5.  Sex differences in the relationship between maternal fear of pain and children’s conditioned pain modulation 
Journal of Pain Research  2013;6:231-238.
Background
Parental behaviors, emotions, and cognitions are known to influence children’s response to pain. However, prior work has not tested the association between maternal psychological factors and children’s responses to a conditioned pain modulation (CPM) task. CPM refers to the reduction in perceived pain intensity for a test stimulus following application of a conditioning stimulus to a remote area of the body, and is thought to reflect the descending inhibition of nociceptive signals.
Methods
The present study examined sex differences in the association between maternal anxiety about pain and children’s CPM responses in 133 healthy children aged 8–17 years. Maternal pain anxiety was assessed using the Pain Anxiety Symptoms Scale-20. In addition to the magnitude of CPM, children’s anticipatory anxiety and pain-related fear of the CPM task were measured.
Results
Sequential multiple linear regression revealed that even after controlling for child age and general maternal psychological distress, greater maternal pain anxiety was significantly related to greater CPM anticipatory anxiety and pain-related fear in girls, and to less CPM (ie, less pain inhibition) in boys.
Conclusion
The findings indicate sex-specific relationships between maternal pain anxiety and children’s responses to a CPM task over and above that accounted for by the age of the child and the mother’s general psychological distress.
doi:10.2147/JPR.S43172
PMCID: PMC3615838  PMID: 23569396
diffuse noxious inhibitory controls; pediatric pain; mother-child relationship; cold pressor; pressure pain; laboratory pain
6.  Experimental pain responses in children with chronic pain and in healthy children: How do they differ? 
BACKGROUND:
Extant research comparing laboratory pain responses of children with chronic pain with healthy controls is mixed, with some studies indicating lower pain responsivity for controls and others showing no differences. Few studies have included different pain modalities or assessment protocols.
OBJECTIVES:
To compare pain responses among 26 children (18 girls) with chronic pain and matched controls (mean age 14.8 years), to laboratory tasks involving thermal heat, pressure and cold pain. Responses to cold pain were assessed using two different protocols: an initial trial of unspecified duration and a second trial of specified duration.
METHODS:
Four trials of pressure pain and of thermal heat pain stimuli, all of unspecified duration, were administered, as well as the two cold pain trials. Heart rate and blood pressure were assessed at baseline and after completion of the pain tasks.
RESULTS:
Pain tolerance and pain intensity did not differ between children with chronic pain and controls for the unspecified trials. For the specified cold pressor trial, 92% of children with chronic pain completed the entire trial compared with only 61.5% of controls. Children with chronic pain exhibited a trend toward higher baseline and postsession heart rate and reported more anxiety and depression symptoms compared with control children.
CONCLUSIONS:
Contextual factors related to the fixed trial may have exerted a greater influence on pain tolerance in children with chronic pain relative to controls. Children with chronic pain demonstrated a tendency toward increased arousal in anticipation of and following pain induction compared with controls.
PMCID: PMC3393051  PMID: 22518373
Acute pain; Cold pressor task; Laboratory pain; Pain intensity; Pressure pain; Thermal heat pain
7.  Health care utilization for pain in children and adolescents: a prospective study of laboratory and non-laboratory predictors of care-seeking 
Background
Few studies have focused on identifying predictors of medical consultation for pain in healthy children and adolescents.
Objective
This investigation sought to identify parent and child laboratory and non-laboratory predictors of pediatric healthcare utilization for pain problems.
Study group
Participants were 210 healthy children and adolescents (102 girls), aged 8–17 years who took part in a laboratory pain session.
Methods
Three months after the laboratory session, participants were contacted by telephone to ascertain whether they had experienced pain and whether they had seen a healthcare professional for pain. Zero-order correlations among sociodemographics, child laboratory pain responses, parent physical/mental health status and medical consultation for pain were conducted to identify relevant correlates of pediatric healthcare utilization; these correlates were subjected to multivariate analyses.
Results
Bivariate analyses indicated that higher anticipated pain and bother for the cold pressor task, as well as poorer parent physical health status, were associated with pediatric medical consultation for pain, but only among girls. Sequential logistic regression analyses controlling for child age indicated that only parent physical health status, not the laboratory indicators, significantly predicted healthcare consultation for pain among girls. No parent or child correlates of care-seeking for pain emerged for boys.
Conclusion
The findings suggest that parents’ perceived physical health plays a role in determining whether medical care is sought for pain complaints in healthy girls. These results suggest that interventions to assist parents in managing their own physical health problems may lead to reductions in medical consultation for girls’ pain.
PMCID: PMC3246362  PMID: 22191197
pediatric health care; parent health status; parent-child relationship; experimental pain; acute pain
8.  Pain charts (body maps or manikins) in assessment of the location of pediatric pain 
Pain management  2011;1(1):61-68.
SUMMARY
This article surveys the use of pain charts or pain drawings in eliciting information about the location of pain symptoms from children and adolescents. While pain charts are widely used and have been incorporated in multidimensional pediatric pain questionnaires and diaries, they present a number of issues requiring further study. These include, in particular, the number and size of different locations or areas of pain that need to be differentiated; the age at which children are able to complete pain charts unassisted; and whether the intensity and other qualities of pain can be accurately recorded on pain charts by children and adolescents. Based on data currently available, it is suggested that the unassisted use of pain charts be restricted to children aged 8 years or over, while for clinical purposes many younger children can complete pain charts with adult support. Where the investigator’s interest is restricted to a few areas of the body, checklists of body parts may have greater utility than pain charts. A new pain chart adapted for use in studies of pediatric recurrent and chronic pain is presented.
doi:10.2217/pmt.10.2
PMCID: PMC3091382  PMID: 21572558

Results 1-8 (8)