move- ments. She also learned an Iyengar yoga practice to strengthen and stretch key weak a nd contracted muscles, enhance joint fl exibility within proper alignment, and to work towa rds maintaining emo- tional and musculoskeletal homeostasis within a mindful aware- ness pa radigm. Family therapy, while needed, was not undertaken. Here is her story: In the beginning of the process I just viewed my appointments as fun ways to relax, but tho se three alternative treatments ended up saving my life. Th ey felt so easy and I enjoyed t hem so much that it didn \200\231t feel like therapy and they didn \200\231t make me feel l ike a sick kid. Th e hypnotherapy taught me how to force myself to relax and to respect my personality. Th e art therapy gave me an easy and healthy way to express myself that I \200 \231d never even con- sidered. Th e Iyengar yoga helped me balance my body but also, surpri singly, to balance my mind. Th e stress was being resolved and the pain was fi nally going away. I don \200\231t feel like either one of the therapies helped me drasti- cally more than the others. I think it took the combination to heal and regain my health. I used to be embarra ssed about my weird therapies, but now I wish I could get everyone to try them. Th e intere sting part about these alternative therapies is that they are so personalized it really dep ends on what works for you. Just because hypnotherapy, art therapy, and Iyengar yoga worked for me doesn \200\231t mean they will work for everyone. Other kids might need music thera py and biofeedback to feel better. Th at is the best part about this method \200\224it \200 \231s whatever works for you. It doesn \200\231t just address your body \200\224it includes your mind \200\224your brain. Th ese unique therapies gave me the tools I needed to take back control of my life. When I am about to have a panic attack at a party I say I am going to use the bathroom, close the door, and do my hypnotherapy. When I come out, I feel as good as new. When I am feeling rea lly stressed and overwhelmed but don \200\231t necessar- ily know specifi cally what is wro ng, I draw about it. Th at usually helps me realize the problem so I can address it. When I \200\231m shop- ping and I start to feel pain, I go in a dressing room, lock the door, and do Iyengar yoga on the fl oor. Th en I can keep walking around and not have to worry about going home early. Case example I was lost. I was depressed. I was confused. I had never been in such a dark place as I was my freshman year of high school, expe- riencing pain that was strong enough to make me dro p out of school and sports. While I was in bed crying, alone and scared, doctors were telli ng me there was no reason for my pain. Th e ones who had more pride than passion would gues s how to fi x me with treatments ranging from pills to a full body cast. I went to thirty o f the top doctors in my state and they all eventually threw up their hands. I told them my back and leg hurt so they took X-rays, MRIs, and bone scans of my back and leg \200\224noth ing showed up. Th ey ran nerve tests on me and got into fi ghts with my dad when he wouldn \200\231t let them try an epidural on me or give me morphine. It was the most frustrating e xperience because with every doctor who gave up and every method that failed, my pain incre ased and fewer people believed me. It was an endless Even though I still have pain I feel confi dent that it will no longer inhibit my life or r estrict what I do. I have taken back con- trol of my body and I am happy with my health. Th ese alternative methods work and I am the proof. Th ey didn \200\231t mask the symp- toms like medication, but they didn \200\231t solve them right away either. Th ey just gave me t he tools I needed to be successful. I will forever be grateful to these therapies because I have my life back. SECTION 9 special topics 630 Conclusion Research in complementary therapies for pediatric pain is still in its infancy. While families turn to complementary therapies, there are reports of some cautions to be ap plied (Adams et al., 2011; Anonymous, 2011). Study designs are oft en not optimal because o f lack of randomized controlled trials, appropriate controls, blinded assessors, use of sta ndardized measures, intervention and assess- ment fi delity checks, and insuffi cient sampl e size for appropriate power to test the study outcomes. Age ranges are oft en so wide that they cross developmental stages and standardized norms for a spe- cifi c measure. With sma ll sample sizes, puberty, age and sex eff ects of the intervention cannot be assessed. As a n example of a report intended to improve such studies, an assessment of the quality of mea sures in studies of complementary therapies was reviewed by Toupin et al. (2012). with complementary clinicians in an integrative, team format is the best way to insure safe ty and maximize effi cacy of the treat- ment plan, even if the communication with these cli nicians is via telephone or email. Depending upon the country, cost to the family might dic tate or limit the options of therapies available to the child. Complementary therapy integr ated into the traditional biopsycho- social model of evaluation and treatment for the child with chronic pain provides, in this author \200\231s opinion, optimal care for the child w ith pain. References Ackerman, S. L., Lown, A., Dvorak, C.C., Dunn, E.A., Abrams, D.I., Horn, B.N., e t al . (2012). Massage for children undergoing hematopoietic cell transplantation: a qualit ative report. Evid Based Complement Alternat Med , 2012, Art. 792042. Adams, D., Cheng, F., Jou, H., Aung, S., Yasui, Y., and Vohra, S. (2011). Th e safety of pe diatric acupuncture: a systematic review. Pediatrics , 128 (6), 1575 \200\2231587 . Investigators who are knowledgeable about the populations that they are studying are necess ary to move the fi eld forward. Th is process could start with clinical experience in n = 1 studies or ABA designs (where there is baseline assessment, intervention, and then assessm ent again aft er removal of the intervention), case series to determine feasibility, measur ement and intervention issues, and eff ect size in pre/post format. Such data will help in the develop- ment and implementation of appropriate randomized clinical trials with careful attention to the control condition. One example of a control condition would be to control for social support and other group eff ects if the therapeutic eff ects of a complementary modal- ity are being tested in a group format, such as a yoga program. In this case the co ntrol condition might be a group education pro- gramme or group light exercise. Another stu dy factor warranting attention is the need for appropriate placebos for the intervention, s uch as placebo needling without skin puncture for acupuncture studies. Appropriate statisti cal methods, with intention to treat analyzes, descriptions of methods used for addressing missing data, treatment fi delity and data integrity checks, recruitment methods, and attri tion are needed. Collaborations between the complemen- tary therapy practitioners and the c linician/research scientists are optimal. Manualized intervention protocols, while allowing for needed individualization, will allow replication of the study and generalizability of the fi ndings. Mixed methodologies that include both quantitative and qualitative data will provide, through patient narratives, a fuller understanding of potential reasons for eff e ctive- ness or barriers to implementation and will guide future studies. Aitken, J. C., Wilson, S., Coury, D., and Moursi, A. M. (2002). Th e eff ect of music distr action on pain, anxiety and behavior in pediatric dental patients. Pediatr Dent , 24 , 114 \200\223118 . Anonymous. (2011). Supplement. Pediatrics , 128 (Suppl.4), 149 \200\223212 . Arndorfer, R. E., and Allen, K. D. (2001). Extending the effi cacy of a thermal biofeedback treatment pac kage to the management of tension-type headaches in children. Headache , 4 , 183 \200\22319 2 . Arts, S. E., Abu-Saad, H. H., Champion, G. D., Crawford, M. R., Fisher, R. J., Juniper, K. H., et al . (1994). Age-related response to lidocaine- prilocaine (EMLA) emulsion and eff e ct of music distraction on the pain of intravenous cannulation. Pediatrics , 93 (5), 797 \200\223801 . Austin, D. (2010). Th e psychophysiological eff ects of music therapy in intensive care units. Paediatr Nurs , 22 (3), 14 \200\22320 . Barnes, P. M., Bloom, B., and Nahin, R. (2008). Complementary and alternative medicine use among adults and children: United States 2007. Natl Health Stat Report , 12 , 1 \200\22323 . Brands, M. M. M. G., Purperhart, H., and Deckers-Kocken, J. M. (2011). A pilot study of yog a treatment in children with functional abdominal pain and irritable bowel syndrome. Comple ment Th er Med , 19 (3), 109 \200\223114 . Braun, C., Stangler, T., Narveson, J., and Pettingell, S. (2009). Animal-assisted therapy a s a pain relief intervention for children. Complement Th er Clin Pract , 15 (2), 105 \200 \223109 . Bussone, G., Grazzi, L., D \200\231Amico, D., Leone, M., and Andrasik, F. (1998). Biofeedba ck-assisted relaxation training for young adolescents with tension-type headache: a control led study. Cephalalgia , 18 , 463 \200\223467 . Davis, M. P., and Darden, P. M. (2003). Use of complementary and alternative medicine by children in the United States. Arch Pediatr A dolesc Med , 157 (4), 393 \200\223396 . Most clinical programs that serve children who have chronic pain use the biopsychosocial me thod for evaluation and treatment. Within this model, complementary therapies play an impor tant role within the entire treatment plan. While studies are stronger for some modalities compared to others, as noted, the lack of research does not mean that these modalities are not eff ective. For example, our program includes clinicians in Iyengar yoga, hypnotherapy, acupuncture, biofeedback, craniosacral therapy, art and music ther- apy, physiotherapy, ps ychotherapy, and psychopharmacology. Th e team mostly resides in community practice and we meet weekly as a team for an integrative approach to treatment. Determining the specifi c t herapy to incorporate into the child \200\231s treatment plan depends upon the type of chil d and the needs of the child thera- peutically (e.g. complex regional pain syndrome = physi otherapy and a mind therapy such as psychotherapy, biofeedback, hypno- therapy, or mindfuln ess, with family psycho-education). Working de Jong, M., Lucas, C., Bredero, H., van, A. L., Tibboel, D., and van, D. M. (2012). Does p ostoperative \200\230M \200\231 technique massage with or without mandarin oil reduce in fants \200\231 distress aft er major craniofacial surgery? J Adv Nurs , 68 (8), 1748 \200 \2231757 . Efe, E., I \237 ler, A., Sarvan, S., Ba \237 er, H., and Ye \237 ilipek, A. (2013). Comp lementary and alternative medicine use in children with thalassaemia. J Clin Nurs , 22 (5 \200\2236), 760 \200\223769 . Eisenberg, D. M., Kessler, R. C., Foster, C., Norlock, F. E., Calkins, D. R., and Delbanco, T. L. (1993). Unconventional medicine in the United States. 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(2003). Herbal remedies and children: do they work? Are they harmful?. Pediatrics , 112 (1 Pt 2), 240 \200\223246 . Wu, S., Sapru, A., Stewart, M. A., Milet, M. J., Hudes, M., Livermore, L. F., et al . (2009 ). Using acupuncture for acute pain in hospitalized children. Pediatr Crit Care Med , 10 (3 ), 291 . Siponen, S. M., Ahonen, R. S., Kettis, A., and H meen-Anttila, K. P. (2012). Complementa ry or alternative? Patterns of complementary and alternative medicine (CAM) use among Finni sh children. Eur J Clin Pharmacol , 68 (12), 1639 \200\2231645 . Young, T., Griffi n, E., Phillips, E., and Stanley, E. (2010). Music as distraction in a pe diatric emergency department. J Emerg Nurs , 36 (5), 472 \200\223473 . Yussman, S. M., Ryan , S. A., Auinger, P., et al. (2004). Visits to complementary and alternative medicine provi ders by children and adolescents in the United States. Ambulat Pediatr , 4 (5), 429 \200 \223435 . Snyder, J. and Brown, P. (2012). Complementary and alternative medicine in children: an ana lysis of the recent literature. Curr Opin Pediatr , 24 (4), 539 \200\223546 . Sobo, E. J., Eng, B., and Kassity-Krich, N. (2006). Canine visitation (pet) therapy: pilot data on decreases in child pain perception. J Holist Nurs , 24 (1), 51 \200\22357 . Zeltzer, L. K., Krane, E. J. (2011). Pediatric pain management. In R. M. Kliegman, R. E. Be hrman, B. F. Stanton, N. Schor, and J. St. Geme (eds) Nelson \200\231s textbook of pediatri cs (19th edn), pp. 360 \200\22375 . Philadelphia, PA : Saunders Elsevier . Sowder, E., Gevirtz, R., Ebert, C., and Shapiro, W. (2010). Restoration of vagal tone: a po ssible mechanism for functional abdominal pain. Appl Psychophysiol Biofeedback , 35 (3), 19 9 \200\223206 . Zeltzer, L. K., Tsao, J. C., Stelling, C., Powers, M., Levy, S., and Waterhouse, M. (2002). A phase I study on the feasibility and acceptability of an acupuncture/hypnosis interventi on for chronic pediatric pain. J Pain Symptom Manage , 24 (4), 437 \200\223446 . Spigelblatt, L., Laine-Ammara, G., Pless, I. B., and Guyver, A. (1994). Th e use of alterna tive medicine by children. Pediatrics , 94 (6 Pt 1), 811 \200\223814 . CHAPTER 61 Th eory-informed approaches to translating pain evidence into practice Janet Yam ada and Alison M. Hutchinson Summary Despite great strides in evidence-based pain assessment and man- agement strategies , infants and children still experience acute pain (including multiple painful procedures) and chronic pain dur- ing hospitalization. Translating best evidence on pain assessment and management into clinical practice remains a challenge. Th e knowledge- or evidence-to-prac tice gap in pain in children can be addressed by implementing strategies, underpinned by kn owledge translation theories, frameworks, and models, to promote and sus- tain practice cha nge. A range of factors related to the organizational context and individual behavior play a role in the adoption of new pain assessment and management practices. 18.2% painful procedures were managed using non-pharmacologi- cal strategies, and 79.2% pat ients received no pre-procedural anal- gesia. Similarly, Johnston and colleagues (2011) fou nd that 46% of infants in neonatal intensive care units (NICUs) who were exposed to tissue damaging procedures were administered opioids for 14.5% of procedures, while in 14.3% sweet tasting solutions such as sucrose or glucose were used. Th ese fi ndings highlight the ext ent of the gap between evidence for acute pain in infants and children and its translation into practice. Th is research-to-practice gap is not unique to pain manage- ment or the pediatric setting. Scholars have been exploring bar- riers to and facilitators of research use and studying a pproaches to promote uptake of evidence across a range of healthcare set- tings. Additional ly, behavioral, psychological, and social theo- ries, frameworks, and models have been used to guide and explain health professionals \200\231 practice changes. In this chapter, know ledge translation (KT) in the context of pediatric pain assessment and management is descri bed and discussed. Introduction Access to evidence-based pain guidelines, policies, standards, and consensus s tatements has increased over the past decade, high- lighting the importance of providing ap propriate procedural pain management for infants and children anonymous (2000). In par- tic ular, evidence-based recommendations have been developed for the management of procedural p ain in infants and children (Lago et al., 2009; Royal Australasian College of Physicians PC HD 2005a, 2005b), post-surgical pain and sedation (Anand et al., 2006; Yamada et al., 2008) . Despite strong evidence to support the eff ec- tiveness of pain assessment and management strategies, use of such strategies for infants and children remains a challenge, highlight ing a knowledge-to-practice gap (Scott-Findlay and Estabrooks, 2006). In a recent audit of pediatric pain practices from 32 hospital units in eight pediatric centers across Canada, o nly 28% of children who had undergone a painful procedure also received a pain manage- ment intervention specifi cally linked to the procedure documented in their medical chart (Stev ens et al., 2011). Hospitalized infants experience an average of 12 tissue damaging procedu res per day (Carbajal et al., 2008). Carbajal and colleagues (2008) reported that, of 42 41 3 painful procedures performed on 430 infants, pharma- cological interventions were provide d to only 2.1% of the infants; De \201 nition of knowledge translation Numerous terms are used to describe KT; the purpos e is to pro- mote the use of evidence to optimize outcomes for recipients of healthcare. Th e term knowledge translation is used to describe the process of translating evidence into practice and/or to refer to the use of research as an event or outcome . One comprehensive and frequently cited defi nition of KT is that of the Canadian Institutes of Health Researc h (CIHR), which is: A dynamic and iterative process that includes synthesis, dissemination, exchange and ethica lly-sound application of knowledge to improve the health of Canadians, provide more eff ect ive health services and products and strengthen the healthcare system. (Canadian Institutes of Health Research: <http://www.cihr-irsc.gc.ca/e/29418.html>) According to Graham et al. (2006), implicit in this defi nition is that knowledge refers pr edominantly to research evidence. Terms used synonymously with KT include knowledge transfe r, knowledge SECTION 9 special topics 634 uptake, knowledge utilization, knowledge exchange, knowledge implementation, knowledge diss emination, innovation diff usion, implementation science, and research utilization. Arguabl y, some of these terms have a diff erent and/or narrower meaning than that of KT. section, fi ve theories, frameworks, and models that can be used to guide and explain KT im plementation strategies are described. KT theories, frameworks, and models Di \200 usion of innovations In his classic and oft -c ited work, fi rst published in 1962, Rogers (2003) describes a theory that seeks to explain the process and rate of spread of an innovation (new ideas or technology) within a social system. Th e theory defi nes four main factors that are infl uen- tial in the process of in novation diff usion: (1) the innovation itself (referring to the idea, the practice or the object that is new); (2) the communication channel (the method used to inform others of the innovation); (3) time (the time taken for an individual to make the transition from fi rst knowledge of the innovation to its acceptance or dismissal); and (4) the social system (th ose involved in decision- making about adoption of the innovation). According to Rogers, di ff usion is a process whereby \200\230(a) an innovation (b) is commu- nicated through cert ain channels (c) over time (d) among the members of a social system \200\231 (2003, p. 11). According to the theory, individuals progress through fi ve stages in the process of decis ion- making about innovation adoption: (1) knowledge \200\224acquiring an awareness and un derstanding of the innovation; (2) persuasion \200\224 the stage of forming an opinion abo ut the value of the innovation; (3) decision \200\224the process of making a decision abou t adoption or rejection of the innovation; (4) implementation \200\224the act of using or applying the innovation in practice; and (5) confi rmation \200\224refl ec- tion upon the decision to adopt or reject the innovation, which may lead to a reversal of the decision. Why use a theory-informed approach to KT? In the fi eld of KT, increasing emphasis has been placed on the importance of using theory to inform: (1) selection and develop- ment of str ategies to promote implementation of KT interven- tions, and (2) evaluation of the implemen tation strategies (Eccles et al., 2005; Rycroft -Malone and Bucknall 2010; Sales et al., 20 06). Systematic review evidence exists for the eff ectiveness of a number of KT interventio ns (Bero et al., 1998; Grimshaw et al., 2001; Oxman et al., 1995; Prior et al., 2008; Wensi ng et al., 2006). However, the evidence indicates that eff ectiveness of such interventions var- ies; they are eff ective in some situations but not all (Hrisos et al., 2008a, 2008b) . A theory-informed approach can help provide an understanding of what has been described a s the \200\230black box \200\231; that is, theory can illuminate how, why and under what c ircumstances an intervention works (Hrisos et al., 2008a, 2008b; Rycroft -Malone, 2007). Ac cording to the UK Medical Research Council Framework for Developing and Evaluating Complex Interventions (2008), interventions should be underpinned by a coherent theory and the theo ry should be used, systematically, to develop the intervention. A theoretical understanding about how an intervention infl uences behavior enables weaknesses in, and barriers to the success of the intervention, to be targeted and overcome. Rogers (2003) suggests that individual (adopter) and setting characteristics infl uence the rate and extent of diff usion of an inno- vation. He defi nes fi ve adopter categories acc ording to the relative speed of uptake of an innovation: What do we mean by theory, frameworks, and models? Th eory Th eories can be used to describ e, explain, and predict, for exam- ple, health professionals \200\231 behaviors related to KT (Rycroft -Malone and Bucknall, 2010). Behavioral theories have been described on a knowl edge continuum ranging from broad to narrow in scope. Mid-range theories, such as the theor y of planned behavior (Azjen, 1991), are less abstract and more concrete compared to macro or grand theories. Mid-range theories are used in KT activi- ties and can focus on changing health professionals \200\231 behaviors at the level of the individual, group, or organiza tion (Rycroft -Malone and Bucknall, 2010). 1. Innovators , also described as venturesome, have an interest in new innovations and are responsible for introducing the new idea to the system. 2. Early adopters readily adopt the new idea, provide advice and information about the inno vation to others within the social network, and assist in hastening the diffusion process. 3. Early majority adopt the new idea following a period of decision- making, and prior to t he average member of the system adopting the initiative. 4. Late majority cautiously adopt the new idea once most other Conceptual framework Conceptual frameworks diff er from theories in that they inform or gui de practice, versus predicting practice (Rycroft -Malone and Bucknall, 2010). Examples of c onceptual frameworks applied to KT evaluations are the Promoting Action on Research Impleme ntation in Health Services (PARiHS) framework (Kitson et al., 1998) and the Knowledge to Ac tion (KTA) framework (Graham et al., 2006). members of the system have embraced the innovation. 5. Laggards who possess somewhat traditional values and are suspi- cious of new ideas are t he last members of the system to adopt the innovation. A critical mass is achieved when enough individuals have decided to adopt the innovation th at its continued adoption becomes self- sustaining. Model Models are more specifi c about the relationships that should be expected between con cepts in the model (Rycroft -Malone and Bucknall, 2010). Th e Ottawa Model of Research Use (Logan and Graham 1998) is an example of a KT model. In the following With respect to the innovation, several characteristics are con- sidered important to adopt ion, including the innovation \200\231s relative advantage (the extent to which the innovat ion is perceived as supe- rior to existing practices or technologies), compatibility (the e xtent to which the innovation is perceived as compatible with existing CHAPTER 61 theory-informed approaches to translating pain evidence into practice 635 values, practices and resources), complexity (perception of the ease with which the innovat ion can be understood and used), trialability (the ease with which the innovation can be tr ialed or tested), and observability (the extent to which the innovation and its eff ects ar e visible) (Rogers 2003). control in the development of interventions to promote the uptake of research evidence in p ractice might contribute to the success of such interventions. Edwards et al. (2001) used t he TPB to identify determinants of nurses \200\231 (including pediatric nurses) intention t o administer opioids for analgesia. Attitudes, subjective norms and perceived control predi cted nurses \200\231 intention to administer opioids to patients experiencing pain, account ing for 39.1% of variability in intention (F(4, 441) = 708, p <0.01). In the health literature, Roger \200\231s (2003) diff usion of innovation the- ory has been highly infl uential and has generally been assumed to represent, or be synonymous with, th e theoretical underpinnings of research utilization or KT. However, according to Estabrooks et al. (2006), this assumption is yet to be rigorously tested. Voepel-Lewis et al. (2008) used diff usion of innovation theory to assess the clini- cal utility of three tools design ed to assess pain in children in order to determine which tools were more likely to be adop ted in clini- cal practice. Th e attributes (complexity, compatibility and relative advanta ge) of the revised-Face, Legs, Activity, Cry, Consolability (r-FLACC) tool (Malviya et al., 2006) and the Nursing Assessment of Pain Intensity (NAPI) (Schade et al, 1996) instrument rated most favorably, when compared with those of the Non-Communicating Children \200\231s Pain Checklist-Postoperative Version (NCCPC-PV) (Breau et al., 2002).