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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.  Pain, psychological symptoms and prescription drug misuse in HIV: A literature review 
Journal of pain management  2012;5(2):111-118.
Background
Pain is a common problem among persons living with HIV. In this population, pain often co-occurs with psychological symptoms, as well as illicit drug abuse. Recently, the misuse of prescription drugs, including the misuse of opioid medications for pain relief, has emerged as a significant public health problem. The purpose of this article is to review the literature on the associations among pain, illicit drug use, and symptoms of depression and anxiety in the misuse of prescription medications in HIV disease.
Results and Conclusions
Although relatively little attention has centered on the management of pain, psychological symptoms and other distressing, yet treatable symptoms in HIV, the fact that drug abuse behaviors now constitute a primary risk factor for HIV infection requires a shift in focus for clinicians and researchers alike. There is currently little agreement regarding the medical provision of opioids to persons with a history of illicit drug use. Thus, additional research is required to ensure adequate treatment of pain and psychological symptoms in persons living with HIV while minimizing the risk of prescription drug misuse.
PMCID: PMC3697768  PMID: 23826434
prescription drug abuse; opioids; pain medications; pain management; anxiety; depression
3.  The mediating role of pain in substance use and depressive symptoms among Multicenter AIDS Cohort Study (MACS) participants 
Pain  2011;152(12):2757-2764.
Pain in HIV frequently co-occurs with substance use and depression. The complex associations among patient characteristics, pain, depression, and drug use in HIV suggests a role for testing models that can account for relationships simultaneously, control for HIV status and also test for mediation. Using structural equation modeling (SEM), the current study examined associations among pain, sociodemographics, illicit drug use and depressive symptoms in 921 HIV seropositive and 1,019 HIV seronegative men from the Multicenter AIDS Cohort Study (MACS), an ongoing prospective study of the natural history of HIV infection among gay/bisexual men. Longitudinal repeated measures data collected over a 6 year period were analyzed using predictive path models in which sociodemographics, HIV status and CD4+ cell counts predicted pain which in turn predicted depressive symptoms and illicit drug use. The path models did not differ substantially between HIV seropositive and seronegative men. Analyses using the total sample indicated that pain served both as a mediator and as a predictor of more use of cannabis, cocaine and heroin, as well as more depressive symptoms. HIV seropositive status predicted more use of inhaled nitrites. In this cohort, having lower CD4+ cell counts (predicted by HIV status), being African-American, less educated, and older were all associated with more pain which in turn was associated with more illicit drug use and more depressive symptoms. The results underscore the need for adequate pain management, particularly among vulnerable subgroups of HIV seropositive and HIV seronegative men to reduce the risk of drug use and depression.
doi:10.1016/j.pain.2011.08.024
PMCID: PMC3215839  PMID: 21962911
substance use; depression; HIV; pain; drug use
4.  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
5.  Sex differences in pain and misuse of prescription analgesics among persons with HIV 
Pain medicine (Malden, Mass.)  2010;11(6):815-824.
Objective
Women represent the largest percentage of new HIV infections globally. Yet, no large-scale studies have examined the experience of pain and its treatment in women living with HIV.
Design
This study used structural equation modeling (SEM) to examine sex differences in pain and the use and misuse of prescription analgesics in a representative sample of HIV+ persons in the United Stated (US) within a prospective, longitudinal design.
Outcome Measures
Bodily Pain subscale of the Short-Form 36; Modified Short Form of the World Health Organization’s Composite International Diagnostic Interview (Opioid Misuse).
Results
Women reported more pain than men over a roughly 6 month period regardless of mode of HIV transmission or prior drug use history. Men acknowledged more misuse of prescription analgesics over an approximate 1 year period compared to women, after taking into account pain, use of analgesics specifically for pain and drug use history. Weaker associations between pain and use of analgesics specifically for pain that persisted over time were found among women compared to men. For both men and women, pain was stable over time. Problem drug use history exerted significant direct and indirect effects on pain, opioid misuse and pain-specific analgesic use across sex.
Conclusion
The current findings are consistent with prior evidence indicating female pain predominance as well as the under treatment of pain among women with HIV. Efforts should be made to improve the assessment and long-term management of pain in HIV+ persons.
doi:10.1111/j.1526-4637.2010.00858.x
PMCID: PMC3088098  PMID: 20456074
pain; substance abuse; opioid misuse; women; gender differences; AIDS
6.  Sex differences in anxiety sensitivity among children with chronic pain and non-clinical children 
Journal of pain management  2009;2(2):151-161.
Although sex differences in anxiety sensitivity or the specific tendency to fear anxiety-related sensations have been reported in adults with clinical pain, there is a dearth of relevant research among children. This study examined sex differences in anxiety sensitivity across unselected samples of 187 children with chronic pain (71.7% girls; mean age = 14.5) and 202 non-clinical children (52% girls; mean age = 13.6). Girls in the chronic pain and non-clinical samples reported elevated anxiety sensitivity relative to boys irrespective of clinical status. Girls with chronic pain also reported heightened fears of the physical consequences of anxiety compared to non-clinical girls but there were no such differences for psychological or social concerns. Among boys, anxiety sensitivity did not differ between the chronic pain and non-clinical groups. Future longitudinal research may examine whether specific fears of anxiety-related somatic sensations constitutes a sex-based vulnerability factor in the development of chronic pain.
PMCID: PMC3072583  PMID: 21479126
chronic pain; children; anxiety sensitivity; anxiety; sex differences
7.  Anxiety sensitivity and catastrophizing: Associations with pain and somatization in non-clinical children 
Journal of health psychology  2009;14(8):1085-1094.
This study examined the relationships among anxiety sensitivity (AS), catastrophizing, somatization, and pain in 240 non-clinical children (121 girls; mean age = 12.7 years). Children with pain problems (n = 81; 33.8%) reported greater AS and catastrophizing (p’s < .01) relative to children without pain problems. AS but not catastrophizing was significantly associated with current pain. However, both AS and catastrophizing were significantly associated with somatization. AS and catastrophizing represent related but partially distinct cognitive constructs that may be targeted by interventions aimed at alleviating pain and somatization in children.
doi:10.1177/1359105309342306
PMCID: PMC2770141  PMID: 19858329
Children; pain; somatization; catastrophizing; anxiety sensitivity
9.  Pain in persons living with HIV and comorbid psychological and substance use disorders 
The Clinical journal of pain  2009;25(4):307-312.
Objectives
There is a dearth of information on the experience of pain in persons living with HIV and co-occurring psychological and substance use problems. This study examined the prevalence and correlates of pain in 162 HIV+ persons diagnosed with mood and/or anxiety disorders as well as substance use disorders.
Methods
Bodily pain scores in the current sample were compared to pain scores in the United States (US) general population and HIV+ persons who screened negative for psychological and substance use problems. Bivariate analyses were used to identify significant correlates of pain scores in the current sample which were then subjected to multiple regression analysis.
Results
Pain scores in the current sample were significantly lower (indicating more pain) than the general population and HIV+ persons who screened negative for psychological and substance use problems. Multivariate analysis indicated that the presence of mood disorder, older age and lower CD4 cell counts (below 200) were associated with increased pain. Presence of mood disorder accounted for the largest amount of unique variance in pain scores.
Discussion
HIV+ persons with diagnosed mood/anxiety and substance use disorders reported substantially higher levels of pain than the general population and HIV+ persons without these comorbid conditions. The presence of mood disorder emerged as an important marker for pain in the current sample. Given that individuals living with HIV and comorbid psychological and substance use disorders are at increased risk for pain, concerted efforts should be directed at identifying and treating pain in this population.
doi:10.1097/AJP.0b013e31819294b7
PMCID: PMC2745215  PMID: 19590479
Pain; human immunodeficiency virus; anxiety; depression; drug abuse
10.  Iyengar Yoga and the Use of Props for Pediatric Chronic Pain: A Case Study 
Iyengar yoga uses postures and props to support the body so that practitioners can engage in poses that would otherwise be more difficult. This type of yoga may be useful in treating children and adolescents who have chronic pain and disability. In this case study, the authors discuss a 14-y-old girl who had two surgeries for gastro-esophageal reflux disease (GERD) and who had continued chest and abdominal pain, as well as vomiting, difficulty eating, weight loss, and anxiety. Having significantly impaired functioning, she was unable to attend school, sleep, socialize, or eat, and she had become wheelchair-bound. Despite evaluations and treatments by specialists over an extended period of time, her symptoms had not improved. This case history describes how the authors used a 4-mo treatment of Iyengar yoga to help the adolescent resume activities and re-engage with her environment. The authors intend this report to stimulate scientific study of this form of treatment for children and adolescents with chronic pain.
PMCID: PMC3836371  PMID: 23981408
11.  A Review of CAM for Procedural Pain in Infancy: Part I. Sucrose and Non-nutritive Sucking 
There is increasing concern regarding the number of painful medical procedures that infants must undergo and the potential risks of alleviating infant pain with conventional pharmacologic agents. This article is Part I of a two-part series that aims to provide an overview of the literature on complementary and alternative (CAM) approaches for pain and distress related to medical procedures among infants up to six weeks of age. The focus of this article is a review of the empirical literature on sucrose with or without non-nutritive sucking (NNS) for procedural pain in infancy. Computerized databases were searched for relevant studies including prior reviews and primary trials. The most robust evidence was found for the analgesic effects of sucrose with or without NNS on minor procedural pain in healthy full-term infants. Despite some methodological weaknesses, the literature to date supports the use of sucrose, NNS and other sweetened solutions for the management of procedural pain in infancy.
doi:10.1093/ecam/nem084
PMCID: PMC2586318  PMID: 18955276
infant; neonate; nonnutritive sucking; procedural pain; sucrose
12.  A Review of CAM for Procedural Pain in Infancy: Part II. Other Interventions 
This article is the second in a two-part series reviewing the empirical evidence for complementary and alternative medicine (CAM) approaches for the management of pain related to medical procedures in infants up to 6 weeks of age. Part I of this series investigated the effects of sucrose with or without non-nutritive sucking (NNS). The present article examines other CAM interventions for procedural pain including music-based interventions, olfactory stimulation, kangaroo care and swaddling. Computerized databases were searched for relevant studies including prior reviews and primary trials. Preliminary support was revealed for the analgesic effects of the CAM modalities reviewed. However, the overall quality of the evidence for these approaches remains relatively weak. Additional well-designed trials incorporating rigorous methodology are required. Such investigations will assist in the development of evidence-based guidelines on the use of CAM interventions either alone or in concert with conventional approaches to provide safe, reliable analgesia for infant procedural pain.
doi:10.1093/ecam/nem089
PMCID: PMC2586313  PMID: 18955254
13.  Anxiety sensitivity and health-related quality of life in children with chronic pain 
Anxiety sensitivity (AS), or the fear of anxiety sensations has been shown to independently predict poorer health-related quality of life (HRQOL) in adults with chronic pain. Specifically, AS was found to contribute to decrements in psychological well-being and social functioning but not to decrements in physical functioning. Existing studies have not examined the relationship between AS and HRQOL in children with chronic pain. The present study used multivariate regression analysis to test the association between AS and self-reported HRQOL in 87 children (62 girls; mean age = 14.4 years ± 2.3) presenting for treatment at a tertiary, multidisciplinary clinic specializing in pediatric chronic pain. After controlling for key sociodemographic and pain-related characteristics, higher AS was associated with poorer perceived general and mental health, greater impairment in family activities, lower self-esteem, increased behavior problems, and more social/academic limitations due to emotional problems. AS accounted for 4% – 28% of incremental variance in these HRQOL domains above and beyond the demographic and pain-related variables. However, AS was not significantly associated with physical functioning or with academic/social limitations due to physical health. Additional research is required to delineate possible mechanisms by which AS may influence certain aspects of children's HRQOL but not others.
Perspective
The present findings support the evaluation of AS in pediatric chronic pain patients as part of a comprehensive assessment battery. The links between AS and multiple HRQOL domains suggests that treatment components aimed at reducing AS may lead to enhanced psychosocial well-being in children with chronic pain.
doi:10.1016/j.jpain.2007.05.011
PMCID: PMC2084210  PMID: 17613277
health-related quality of life; anxiety sensitivity; children; chronic pain; pain-related anxiety; functional impairment
14.  Role of Anticipatory Anxiety and Anxiety Sensitivity in Children’s and Adolescents’ Laboratory Pain Responses 
Journal of pediatric psychology  2004;29(5):379-388.
Objective
To examine relationships among trait anxiety sensitivity, state task-specific anticipatory anxiety, and laboratory pain responses in healthy children and adolescents.
Methods
Participants (N=118, 49.2% female, ages 8-18 years) completed a measure of anxiety sensitivity and rated anticipatory anxiety prior to undergoing thermal, pressure, and cold pain tasks. Linear and logistic regressions were used to test the hypothesis that anxiety sensitivity and anticipatory anxiety would predict incremental variance in pain response after controlling for sex, age, and anxious symptoms.
Results
Anticipatory anxiety accounted for 35-38% of unique variance in pain report across tasks, and 10% of unique variance in thermal tolerance. Anxiety sensitivity was unrelated to pain responses.
Conclusions
Task-specific anxiety is an important predictor of pain report and, in certain cases, pain tolerance. Interventions designed to reduce task-specific anticipatory anxiety may help reduce pain responses in children and adolescents.
PMCID: PMC2373257  PMID: 15187176
laboratory pain; anxiety; anxiety sensitivity; children; adolescents
15.  Relationships among Anxious Symptomatology, Anxiety Sensitivity and Laboratory Pain Responsivity in Children 
Cognitive behaviour therapy  2006;35(4):207-215.
Existing laboratory-based research in adult samples has suggested that anxiety sensitivity (AS) increases an individual’s propensity to experience pain-related anxiety which in turn enhances pain responsivity. Such relationships have not been examined in younger populations. Thus, the present study used structural equation modeling (SEM) to test a conceptual model in which AS would evidence an indirect relationship with pain intensity via its contribution to state-specific anticipatory anxiety in relation to a variety of laboratory pain tasks (cold pressor, thermal heat, and pressure pain) in 234 healthy children (116 girls; mean age = 12.6 years, range = 8–18 years). The model further hypothesized that existing anxious symptomatology would demonstrate a direct relationship with pain intensity. Results of the SEM supported the proposed conceptual model with the total indirect effect of AS accounting for 29% of the variance in laboratory pain intensity via its effects on pain-related anticipatory anxiety. AS did not however, evidence a direct relationship with pain intensity. Anxious symptomatology on the other hand, demonstrated a significant direct effect on pain intensity, accounting for 15% of variance. The combined effects of AS, anxiety symptoms, and anticipatory anxiety together explained 62% of the variance in pain intensity. These relationships did not differ for boys and girls indicating no moderating effect of sex in the proposed model. The present results support the potential benefit of assessing both AS and anxiety symptoms in children prior to undergoing painful stimulation.
doi:10.1080/16506070600898272
PMCID: PMC1783843  PMID: 17189238
children; adolescents; anxiety; anxiety sensitivity; laboratory pain; experimental pain; pain intensity
16.  Parent and child anxiety sensitivity: Relationship to children’s experimental pain responsivity 
Anxiety sensitivity (AS) or fear of anxiety sensations has been linked to childhood learning history for somatic symptoms, suggesting that parental AS may impact children’s responses to pain. Using structural equation modeling (SEM), we tested a conceptual model in which parent AS predicted child AS, which in turn predicted a hypothesized latent construct consisting of children’s pain intensity ratings for three laboratory pain tasks (cold pressor, thermal heat and pressure). This conceptual model was tested in 211 non-clinical parent-child pairs (104 girls, mean age = 12.4 years; 178 mothers). Our model was supported in girls only indicating that the sex of the child moderated the hypothesized relationships. Thus, parent AS was related to child laboratory pain intensity via its contribution to child AS in girls but not in boys. In girls, 42% of the effect of parent AS on laboratory pain intensity was explained via child AS. In boys, there was no clear link between parent AS and child AS, although child AS was predictive of experimental pain intensity across sex. Our results are consistent with the notion that parent AS may operate via healthy girls’ own fear of anxiety symptoms to influence their responses to laboratory pain stimuli.
Perspective-The present study highlights sex differences in the links among parent and child anxiety sensitivity (AS; fear of anxiety sensations) and children’s experimental pain responses. Among girls, childhood learning history related to somatic symptoms may be a particularly salient factor in the development of AS and pain responsivity.
doi:10.1016/j.jpain.2005.12.004
PMCID: PMC1540407  PMID: 16632321
anxiety sensitivity; laboratory pain; children; adolescents; parent; sex differences
17.  Pain and Use of Complementary and Alternative Medicine in a National Sample of Persons Living with HIV 
The current study investigated the relationship of pain to use of complementary and alternative medicine (CAM) in a U.S. nationally representative sample of 2466 persons with HIV using data from the HIV Cost and Services Utilization Study (HCSUS). Pain was conceptualized as a need characteristic within the context of predisposing, enabling, and need (PEN) characteristics following Andersen's Behavioral Model of Health Services Use. Multivariate analyses were used to examine the association of baseline PEN characteristics with CAM use by follow-up (approximately 6 months later), including use of five specific CAM domains. Change in pain from baseline to follow-up was also examined in relation to CAM use. Baseline pain was a strong predictor of CAM use, and increased pain over time was associated with use of unlicensed or underground drugs with potential for harm. These results highlight the importance of medical efforts to control pain in persons living with HIV.
doi:10.1016/j.jpainsymman.2005.05.012
PMCID: PMC1420635  PMID: 16310616
Complementary medicine; alternative medicine; human immunodeficiency virus; pain
18.  Pain, problem drug use history, and aberrant analgesic use behaviors in persons living with HIV 
Pain  2007;133(1-3):128-137.
Little is known about the relationship between pain and aberrant use of prescription analgesics in persons living with HIV. We examined the predictive and concurrent associations among pain, aberrant use of opioids, and problem drug use history in a nationally representative longitudinal sample of 2267 HIV+ persons. Covariance structure analyses tested a conceptual model wherein HIV+ patients with a history of problematic drug use (n = 870), compared to those without such history (n = 1397), were hypothesized to report more pain and aberrant opioid use, as well as use of opioids specifically for pain at baseline and 6 and 12 month follow-ups, after controlling for key sociodemographic characteristics. In support of the hypothesized model, patients with a history of problematic drug use reported more pain, and were more likely to report aberrant use of prescription analgesics, as well as use of such medications specifically for pain, compared to patients without such history. We also found a trend toward greater stability of aberrant opioid use over time in problem drug users compared with non-problem users suggesting a persistent pattern of inappropriate medication use in the former group. Our findings suggest that even though HIV+ persons with a history of problematic drug use report on-going patterns of using prescription analgesics specifically for pain, these patients continued to experience persistently higher levels of pain, relative to non-problem users. Among non-problem users, pain was not linked to aberrant use of opioids, but was linked to the use of such medications specifically for pain.
doi:10.1016/j.pain.2007.03.016
PMCID: PMC2173909  PMID: 17449182
pain; opioids; substance abuse; problem drug use; HIV; AIDS
19.  Treatment Preferences for CAM in Children with Chronic Pain 
CAM therapies have become increasingly popular in pediatric populations. Yet, little is known about children's preferences for CAM. This study examined treatment preferences in chronic pediatric pain patients offered a choice of CAM therapies for their pain. Participants were 129 children (94 girls) (mean age = 14.5 years ± 2.4; range = 8–18 years) presenting at a multidisciplinary, tertiary clinic specializing in pediatric chronic pain. Bivariate and multivariate analyses were used to examine the relationships between CAM treatment preferences and patient's sociodemographic and clinical characteristics, as well as their self-reported level of functioning. Over 60% of patients elected to try at least one CAM approach for pain. The most popular CAM therapies were biofeedback, yoga and hypnosis; the least popular were art therapy and energy healing, with craniosacral, acupuncture and massage being intermediate. Patients with a diagnosis of fibromyalgia (80%) were the most likely to try CAM versus those with other pain diagnoses. In multivariate analyses, pain duration emerged as a significant predictor of CAM preferences. For mind-based approaches (i.e. hypnosis, biofeedback and art therapy), pain duration and limitations in family activities were both significant predictors. When given a choice of CAM therapies, this sample of children with chronic pain, irrespective of pain diagnosis, preferred non-invasive approaches that enhanced relaxation and increased somatic control. Longer duration of pain and greater impairment in functioning, particularly during family activities increased the likelihood that such patients agreed to engage in CAM treatments, especially those that were categorized as mind-based modalities.
doi:10.1093/ecam/nel084
PMCID: PMC1978240  PMID: 17965769
functional impairment; mind–body approaches; pain management; pediatric pain; quality of life
20.  Effectiveness of Massage Therapy for Chronic, Non-malignant Pain: A Review 
Previous reviews of massage therapy for chronic, non-malignant pain have focused on discrete pain conditions. This article aims to provide a broad overview of the literature on the effectiveness of massage for a variety of chronic, non-malignant pain complaints to identify gaps in the research and to inform future clinical trials. Computerized databases were searched for relevant studies including prior reviews and primary trials of massage therapy for chronic, non-malignant pain. Existing research provides fairly robust support for the analgesic effects of massage for non-specific low back pain, but only moderate support for such effects on shoulder pain and headache pain. There is only modest, preliminary support for massage in the treatment of fibromyalgia, mixed chronic pain conditions, neck pain and carpal tunnel syndrome. Thus, research to date provides varying levels of evidence for the benefits of massage therapy for different chronic pain conditions. Future studies should employ rigorous study designs and include follow-up assessments for additional quantification of the longer-term effects of massage on chronic pain.
doi:10.1093/ecam/nel109
PMCID: PMC1876616  PMID: 17549233
Fibroymalgia; headache pain; low back pain; musculoskeletal pain; recurrent pain
21.  CAM for Pediatric Pain: What is State-of-the-Research? 
Previously, we reviewed the evidence for the efficacy of CAM approaches for pediatric pain (volume 2; issue 2; 2005) using criteria developed by the American Psychological Association Division 12 Task Force. Our review focused on CAM modalities that had been tested with at least one controlled trial or multiple baseline study. In addition, only those trials in which children comprised the study sample were included. Thus, several CAM modalities were not included in our review. Key ethical and other reasons for the limited literature on CAM for pediatric pain as well as directions for future studies are discussed.
doi:10.1093/ecam/nek003
PMCID: PMC1375226  PMID: 16550236
22.  Treatment Expectations for CAM Interventions in Pediatric Chronic Pain Patients and their Parents 
Patient expectations regarding complementary and alternative medicine (CAM) interventions have important implications for treatment adherence, attrition and clinical outcome. Little is known, however, about parent and child treatment expectations regarding CAM approaches for pediatric chronic pain problems. The present study examined ratings of the expected benefits of CAM (i.e. hypnosis, massage, acupuncture, yoga and relaxation) and conventional medicine (i.e. medications, surgery) interventions in 45 children (32 girls; mean age = 13.8 years ± 2.5) and parents (39 mothers) presenting for treatment at a specialty clinic for chronic pediatric pain. Among children, medications and relaxation were expected to be significantly more helpful than the remaining approaches (P < 0.01). However, children expected the three lowest rated interventions, acupuncture, surgery and hypnosis, to be of equal benefit. Results among parents were similar to those found in children but there were fewer significant differences between ratings of the various interventions. Only surgery was expected by parents to be significantly less helpful than the other approaches (P < 0.01). When parent and child perceptions were compared, parents expected hypnosis, acupuncture and yoga, to be more beneficial than did children, whereas children expected surgery to be more helpful than did parents (P < 0.01). Overall, children expected the benefits of CAM to be fairly low with parents' expectations only somewhat more positive. The current findings suggest that educational efforts directed at enhancing treatment expectations regarding CAM, particularly among children with chronic pain, are warranted.
doi:10.1093/ecam/neh132
PMCID: PMC1297505  PMID: 16322810
Pain; expectation; child; parent; alternative therapies
23.  Complementary and Alternative Medicine Approaches for Pediatric Pain: A Review of the State-of-the-science 
In recent years, the use of complementary and alternative medicine (CAM) in pediatric populations has increased considerably, especially for chronic conditions such as cancer, rheumatoid arthritis and cystic fibrosis in which pain may be a significant problem. Despite the growing popularity of CAM approaches for pediatric pain, questions regarding the efficacy of these interventions remain. This review critically evaluates the existing empirical evidence for the efficacy of CAM interventions for pain symptoms in children. CAM modalities that possess a published literature, including controlled trials and/or multiple baseline studies, that focused on either chronic or acute, procedural pain were included in this review. The efficacy of the CAM interventions was evaluated according to the framework developed by the American Psychological Association (APA) Division 12 Task Force on Promotion and Dissemination of Psychological Procedures. According to these criteria, only one CAM approach reviewed herein (self-hypnosis/guided imagery/relaxation for recurrent pediatric headache) qualified as an empirically supported therapy (EST), although many may be considered possibly efficacious or promising treatments for pediatric pain. Several methodological limitations of the existing literature on CAM interventions for pain problems in children are highlighted and future avenues for research are outlined.
doi:10.1093/ecam/neh092
PMCID: PMC1142204  PMID: 15937555
complementary medicine; alternative medicine; pediatric pain; pain; children
24.  Relationship Between Resting Blood Pressure and Laboratory-Induced Pain Among Healthy Children 
Gender Medicine  2011;8(6):388-398.
Background
Adult studies have demonstrated that increased resting blood pressure (BP) levels correlate with decreased pain sensitivity. However, few studies have examined the relationship between BP and experimental pain sensitivity among children.
Objectives
This study investigated the association between resting BP levels and experimental pain tolerance, intensity, and unpleasantness in healthy children. We also explored whether these BP–pain relationships were age and gender dependent.
Methods
Participants underwent separate 4-trial blocks of cutaneous pressure and thermal pain stimuli, and 1 trial of a cold pain stimulus in counterbalanced order.
Results
A total of 235 healthy children (49.6% female; mean age 12.7 [2.9] years; age range 8–18 years) participated. The study revealed specific gender-based BP–pain relationships. Girls with higher resting systolic BP levels were found to have lower thermal intensity ratings than girls with lower resting systolic BP levels; this relationship was stronger among adolescent girls than among younger girls. Among young girls (8–11 years), those with higher resting diastolic BP (DBP) levels were found to have lower cold intensity and unpleasantness as well as lower thermal intensity ratings than did young girls with lower resting DBP levels; these DBP–pain response relationships were not seen among adolescent girls.
Conclusions
Age, rather than resting BP, was predictive of laboratory pain ratings in boys. The findings suggest that the relationship between BP and experimental pain is age and gender dependent. These aspects of cardiovascular relationships to pain in males and females need further attention to understand their clinical importance.
doi:10.1016/j.genm.2011.07.002
PMCID: PMC3319441  PMID: 22035675
blood pressure; children; gender differences; laboratory pain
25.  “Now I see a brighter day”: expectations and perceived benefits of an Iyengar yoga intervention for young patients with rheumatoid arthritis 
Rheumatoid arthritis (RA) is a chronic disease characterized by inflammation of joints and associated fatigue, deteriorated range of motion, and impaired psychosocial functioning. Young adults with RA are at a particular risk for compromised health-related quality of life, and there is a need for safe, effective complementary treatment in addition to traditional medical approaches. The aim of the present study was to use face-to-face participant interviews, conducted before and after an Iyengar yoga (IY) program, to examine mechanisms through which yoga may be beneficial to young adults with RA.
This pilot study utilized a single-arm design where all participants received the intervention. Classes were taught twice per week (1.5 hours each) for 6 weeks by an IY teacher qualified in therapeutics. Interview themes included participants’ baseline expectations about yoga and viewpoints as to how their functioning had been impacted by the IY intervention were examined. Five young adults with RA aged 24–31 years (mean = 28; 80% female) completed the yoga intervention. Participants consistently reported that yoga helped with energy, relaxation and mood and they discussed perceived mechanisms for how yoga impacted well-being. Mechanisms included physical changes such as range of motion and physiological awareness, and psychospiritual developments such as acceptance, coping, self-efficacy and mindfulness. Though the study is limited, participants’ responses provide compelling evidence that IY for RA patients is an intervention worthy of further exploration. The mechanisms and outcomes reported by participants support a biopsychosocial model, which proposes that yoga benefits patients through both physiological and psychospiritual changes.
doi:10.4172/2157-7595.1000101
PMCID: PMC3493157  PMID: 23145356
Iyengar yoga; Rheumatoid arthritis; Qualitative data

Results 1-25 (38)