Author’s Accepted Manuscript

Non-Pharmacologic Treatment of Pain

A. Monica Agoston, Christine B. Sieberg

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PII: S1071-9091(16)30026-2
DOI: http://dx.doi.org/10.1016/j.spen.2016.10.005
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To appear in: Seminars in Pediatric Neurology
Cite this article as: A. Monica Agoston and Christine B. Sieberg, Non-
Pharmacologic Treatment of Pain, Seminars in Pediatric Neurology,
http://dx.doi.org/10.1016/j.spen.2016.10.005
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 Non-Pharmacologic Treatment of Pain

A. Monica Agoston1, Christine B. Sieberg2

1
Department of Psychiatry, Boston Children’s Hospital, Boston, MA 02115; 21Division of Pain

Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s

Hospital, 2Department of Psychiatry, Harvard Medical School, 3 Biobehavioral Pediatric Pain

Lab, Boston Children’s Hospital

Acknowledgements: Dr. Sieberg is supported by a Boston Children’s Hospital Career

Development Fellowship Award and the Sara Page Mayo Endowment for Pediatric Pain

Research and Treatment and the Department of Anesthesiology, Perioperative and Pain Medicine

at Boston Children’s Hospital.

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ABSTRACT

Pain is a complex biopsychosocial experience that is influenced by neurological

processes and psychosocial factors1. Systematic reviews and meta-analyses of randomized

controlled trials of psychological interventions have demonstrated evidence for psychological

approaches in treating procedural pain2,3 as well as multiple types of chronic pain, including

headaches, abdominal pain, and musculoskeletal pain4,5. This chapter is directed toward

clinicians and will provide an overview of cognitive-behavioral therapy, including specific

cognitive-behavioral techniques for pediatric pain. A review is provided of preparation and

psychoeducation, distraction, exposure and psychological desensitization, relaxation techniques,

additional cognitive and behavioral approaches, exercise and alternative approaches, use of

technology, multicomponent approaches, and final considerations in treating acute and chronic

pain. It is important to consider multiple characteristics of the child when selecting an

intervention for chronic pain, which are reviewed in the chapter.

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Introduction

Pain is a complex biopsychosocial experience that is influenced by neurological

processes and psychosocial factors1. Systematic reviews and meta-analyses of randomized

controlled trials of psychological interventions have demonstrated evidence for psychological

approaches in treating procedural pain2,3 as well as multiple types of chronic pain, including

headaches, abdominal pain, and musculoskeletal pain4,5. This chapter is directed toward

clinicians and will provide an overview of cognitive-behavioral therapy, including specific

cognitive-behavioral techniques for pediatric pain. A review is provided of preparation and

psychoeducation, distraction, exposure and psychological desensitization, and relaxation

techniques, as well as additional cognitive and behavioral approaches. Exercise and alternative

approaches, the use of technology in pediatric pain, multicomponent approaches, and final

considerations in treating acute and chronic pain will also be addressed.

Optimal interventions for a given child may depend on several factors. It is important to

consider the age of the child, their level of development, cognitive functioning, family factors,

family resources, type of pain, diagnosis, and pain areas in treating pediatric pain. It is also

important to consider the type of pain involved and whether it is acute or chronic. Procedural

pain may involve some of the same interventions used for chronic pain or it may involve

different interventions.

Cognitive-Behavioral Therapy

Cognitive-behavioral therapy (CBT) is a brief, goal-oriented form of psychotherapy that

is the most commonly researched and empirically supported treatment for the management of

pediatric pain. CBT includes a combination of cognitive and behavioral techniques that involve a

variety of cognitive skills (e.g., reframing, cognitive distraction, and positive self-talk

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statements) and behavioral strategies (e.g., relaxation, exposure and desensitization, and

modeling)6. CBT also involves setting goals for treatment and tracking symptoms over time,

usually in a diary-type format. Therapists and patients work as co-collaborators to modify

negative thoughts and maladaptive behaviors through problem-solving and developing learning

experiences to counter these negative thoughts and behaviors6.

Specific CBT Techniques for Pediatric Pain.

Considering that pain is a complex biopsychosocial problem1, it is influenced by

thoughts, feelings, and behaviors in addition to the underlying pathophysiology of the individual.

Using a CBT framework, therapists teach children strategies to identify and restructure

maladaptive pain-related thoughts and address behaviors that may be contributing to pain-related

disability, discomfort, and maintenance of pain-related symptoms. Goals include directing

attention away from pain, enhancing a sense of control over pain, and diminishing negative

thoughts and feelings related to pain7.

CBT has been shown to be effective in reducing procedural pain3 and for reducing

chronic pain in children and adolescents with a variety of pain conditions, including headaches,

abdominal pain, and fibromyalgia8. CBT works to modify pain sensations, promote self-control

and self-management, increase functioning and reduce maladaptive behavioral responses to pain,

as well as modify negative thoughts that may contribute to emotional distress related to pain9.

Preparation and Psychoeducation

Considering that education is a key component of all CBT interventions, preparation is a

useful tool for reducing anxiety and uncertainty. Preparation for procedural pain involves

breaking down the procedure and introducing the specific equipment being used. Research

supports efficacy of the effects of preparation and psychoeducation in reducing procedural pain3.

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For chronic pain sufferers, psychoeducation involves presenting a detailed explanation of chronic

pain for families, specifically the biopsychosocial model of pain, the non-protective nature of

chronic pain, and details of pain transmission in the body10.

Distraction

Distraction involves the shifting of attention away from pain toward other stimuli that

may be more pleasant or enjoyable10. This technique is commonly used in both procedural and

chronic pain, although the types of distractions may differ depending on the type of pain. For

example, distraction during a needle procedure may involve blowing bubbles or playing a

videogame, whereas distraction for chronic pain may involve spending time with friends and

family. Distraction techniques have been well-studied and have been shown to have large effect

sizes, particularly as an intervention for procedural pain2,3.

Exposure and Psychological Desensitization

Cognitive-behavioral techniques for pain often include exposure and psychological

desensitization11. These approaches help children confront feared stimuli, such as a needle prick,

often in a systematic manner, which then results in habituation and decreases in anxiety and fear

toward the stimulus. Children often avoid activities believed to increase pain because of fear of

experiencing pain, which leads to greater pain and pain-related disability. In children with

chronic pain, exposure treatments are effective in reducing pain-related fear and avoidance and

increasing functioning11,12.

Relaxation Techniques

Relaxation techniques are skills that enhance physical and psychological well-being with

the goal of decreasing pain. These techniques involve a variety of different strategies, such as

deep breathing13, guided imagery14, progressive muscle relaxation14, and hypnosis2,3, that help

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calm the nervous system and achieve a state that is incongruent with pain perception. Relaxation

techniques are effective in reducing acute and chronic pain in children and adolescents with

different pain conditions, including headache, abdominal pain, and fibromyalgia2,3,8,13,14.

Deep or diaphragmatic breathing is a commonly used strategy in both acute and chronic

pain. Deep breathing is effective in reducing pain during immunization procedures13 and is often

a part of multidisciplinary relaxation approaches to treating chronic pain in children and

adolescents8. Self-imagery, guided imagery, and progressive muscle relaxation have been

considered to be an empirically supported therapy for recurrent pediatric headache, although

many other complementary and alternative treatments may be considered possibly efficacious or

promising treatments for pediatric pain14. Finally, hypnosis has been shown to be effective,

particularly as an intervention for procedural pain2,3. It has also been determined to be possibly

effective in the treatment of post-operative pain and efficacious in the treatment of recurrent

pediatric headaches14.

Additional Cognitive and Behavioral Approaches: Acceptance and Commitment

Therapy for Chronic Pain

Acceptance and Commitment Therapy (ACT) is a form of psychotherapy that

incorporates elements of cognitive-behavioral therapy but also focuses on teaching acceptance

and mindfulness strategies. This treatment approach involves helping patients discover their core

values and establish ways to live consistently with their values despite experiencing pain15.

Symptom control, specifically reduction of pain, is not the focus of ACT. Rather, ACT aims to

reduce distress related to pain and help children and adolescents lead meaningful lives despite

pain16. There is support for the effectiveness of ACT in children with chronic pain, particularly

in self-reported functioning16 and quality of life17.

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Exercise and Alternative Approaches

Exercise through physical therapy and occupational therapy is a key component of

multidisciplinary approaches to pediatric pain and often includes transcutaneous electrical nerve

stimulation, aerobic exercise, stretching, progressive weight bearing, tactile desensitization,

massage, and contrast baths18. Other approaches, such as yoga, are currently being studied as part

of a treatment model for pediatric pain19. Finally, acupuncture has shown promise in the

treatment of chronic pain and possibly efficacious in the treatment of pediatric migraines14.

Use of Technology

Biofeedback is one technological strategy that is commonly used in the treatment of

chronic pain8. Biofeedback allows for the child to achieve a state of relaxation, build increased

awareness and greater control over their physiological arousal through receiving feedback from

physiological processes such as respiration, heart rate variability, peripheral skin temperature,

and surface electromyography. This feedback then enables the child to regulate their arousal

through various relaxation strategies, such as deep breathing. Biofeedback has been shown to be

effective in reducing chronic pain in children and adolescents with different pain conditions,

including headache, abdominal pain, and fibromyalgia8. Biofeedback has also been found to be

efficacious in pediatric migraines and shows promise in treating tension headaches14.

Other technologies that are being examined for both acute and chronic pain include

virtual reality, which has been shown to be efficacious in reducing acute pain during dressing

changes in children with severe burn injuries20. Internet-based interventions are also being

developed. An online family cognitive behavioral therapy intervention has shown effectiveness

for children and adolescents with chronic pain21.

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Multicomponent Approaches

Multicomponent approaches involve combining strategies such as behaviorally-oriented

strategies, such as distraction, breathing, muscle relaxation, modeling/rehearsal, or

desensitization, with one or more cognitively-focused strategies, such as imagery/ hypnosis,

education, cognitive reframing, or positive coping statements3. Parent or staff coaching may also

be another component of a treatment approach for both pediatric procedural and chronic pain.

There is strong support for multicomponent CBT approaches for reducing pain in children during

needle pain procedures3 and for reducing pain in children with chronic pain8. Multidisciplinary

treatment approaches, often consisting of pharmacological, physical/occupational therapy, and

psychological approaches, are becoming the treatment of choice for pediatric pain18.

Concluding considerations in treating acute and chronic pain

When treating families with acute and chronic pain, parental involvement is extremely

beneficial. Parents can provide critical information about factors that contribute and maintain

their child’s pain6, and adult behavior often influences child distress and pain-related

behaviors22,23. Decreased parental attention on pain and discomfort and encouragement of their

children’s use of positive coping skills has been shown to reduce child pain and distress for both

procedural22 and chronic pain23. In contrast, reassurance by parents is associated with increased

child distress for procedural pain, possibly because it communicates parents’ own fears about the

procedure or the child’s reaction24. Finally, the developmental age of the child is an important

consideration considering children are likely to respond differently to interventions based on

their developmental stage, maturity level, and age25.

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