(BFB-REL) intervention or a relaxation placebo (REL-PLAC) con- trol condition for ten sessi ons, two per week. Both groups had a 55% improvement in headache severity at the one month assessment, but only the BFB-REL group had improvement at the 6- and 12-month follow-ups, w ith an 85% improvement by the last assessment. Kroner-Herwig et al. (1998) randomized 40 children, ages 8 to 14 years, with tension-type o r combined headaches to an electro- myographic (EMG)-frontalis biofeedback or progressive r elaxation (PR) condition with and without parental involvement (PI) or to a wait list contr ol group. Th ere were12 bi-weekly sessions and the parent condition included three 1 h pare nt sessions. All four inter- vention groups had signifi cant main eff ects in all outcome d omains post-intervention. Yet, at the 6-month assessment, the biofeedback group without PI showing the greatest changes, followed by bio- feedback with PI, PR alone, PR with PI, and then the control group. Th e biofeedback group without PI had the highest mean eff ect size for headache outcomes. Adding parents did not appear to improve the intervention eff ects. Th ese studies (Kim et al., 2006; Lin et al., 2009) suggest a poten- tially safe complement ary therapy for reduction of opioid analgesic dosage for pediatric post-operative pain mana gement. Replication of the studies and improved study designs are warranted. Acupuncture practitioners are licensed and regulated health care professionals in about hal f the states in the US. In states that do not currently require licensing, the acupuncture practitioner should be asked if he/she is certifi ed by the National Commission for the Cer tifi cation of Acupuncturists. Th e acupuncturist should be asked to communicate with the c hild \200\231s pediatrician or pain specialist for optimal integrative care. Acupuncture in Canada developed in the late 1800 \200\231s primarily in Chinese communities but gradu- al ly spread to the communities until it was incorporated into the Governmental health care sy stem. For example, in the province of Ontario, it became part of the \200\230Traditional C hinese Medicine Act \200\231 in 2006 (Wang and Wu 2012). Across Asia, acupuncture has been accepted and used for hundreds of years. Th e governmental regula- tions for practicing acu puncture diff er by country worldwide but in most places few restrictions are in place. Grazzi et al. (1990) provided EMG biofeedback to ten children, ages 12 to 15 years, with te nsion headache twice weekly for 6 weeks. Pain Total Index collected with a headache diary a nd muscular ten- sion scores decreased in all patients from baseline to treatment completio n. Grazzi et al. (2001) provided an EMG biofeedback- assisted relaxation program in 54 chil dren, mean 12 years, with episodic tension-type headaches with two treatment sessions per w eek for 5 weeks. Pain Total Index via daily diaries were signifi - cant at treatment termin ation but not at the 1-year follow-up. At the 3-year assessment, 84% of the participants we re symptom-free. Given the lack of a control condition, the percentage of children who woul d have been headache free even without intervention at 3 years is unknown. Other study desi gn weaknesses limit strength of the fi ndings. Biofeedback Biofeedback uses a computer or other bodily feedback tool to help children to r educe pain or other symptoms by noticing and then learning strategies to control physiologi cal changes associated with the stress response. Th ese monitored changes (Evans and Zeltze r 2008) may include muscle tension, peripheral skin temperature, sweat gland response, brai n wave activity, or breathing rate, with the goal of increasing the body \200\231s relaxati on response. Using bio- feedback helps children learn about their body \200\231s responses to stress and become aware of their own abilities to alter those responses. Biofeedback is especially popular for the treatment of migraine and headaches in children (Evans and Zeltz er, 2008). Arndorfer and Allen (2001) conducted a within-subject, mul- tiple baseline, time-lagged stu dy to evaluate thermal biofeedback therapy in fi ve children, aged 8 to 14 years, with tens ion-type head- aches. Baseline data over 4 to 7 weeks were followed by six thermal biofeedb ack treatments. All participants showed clinical improve- ment via daily headache diaries a nd four of the fi ve were headache- free at 6 months. Lack of a control condition and small sample size limited the importance of the fi ndings. Biofeedback has been evaluated in its eff ectiveness for treating pediatric headaches (Arnd orfer and Allen, 2001; Bussone et al., 1998; Fentress et al., 1986; Grazzi et al., 1990, 20 01; Kroner-Herwig et al.1998; Scharff et al., 2002) and abdominal pain (Schurman et al., 20 10; Sowder et al., 2010). Fentress et al. (1986) randomized 18 children, ages 8 to 12 years , who had recurrent intermittent headaches and were not on preventive medication, to a biof eed- back with or without a relaxation response (RR) condition or to a control wait-list gr oup for seven weekly then two bi-weekly ses- sions. Headache diaries were evaluated through out the study and at a 1-year follow-up assessment. Outcome measures included frequency of headaches, total of hours of headache, and severity of headaches. Compared to control group , both treatment groups had improvement in their headache diary measures compared to baseli ne and at the end of the 15-week study period. However, no diff erences were found between baseline and the 1 year assessment. No diff erences in the RR groups were found with or wit hout bio- feedback. Th e study was limited by small sample size, no reporting of missing da ta, and other design problems. Scharff et al. \200\231s (2002) study randomized children (7 \200\22317 years) with migrain es to a stress management with thermal biofeedback (TB), hand-cooling biofeedback (HCB) wit hout stress manage- ment, and an assessment control condition to reduce pain, anxi- ety, an d depression. At the 6-week post-treatment assessment, no one in the control condition had headache improvement, while one child (10%) in the HCB and seven (54%) in TB group had sign ifi - cant reduction in headache severity. In a combined analysis, both treatment groups ha d reduced headache severity and frequency. No changes were in anxiety or depression measure s. Th e same fi nd- ings held for the 6-month follow-up. While this study is oft en cited a s evidence of thermal biofeedback for migraines in children and despite its promising title , caution is warranted because of the many confounds that limit generalizability of the fi ndings. Sowder et al. (2010) provided six sessions of heart rate vari- ability (HRV) biofeedback to restore vagal tone in 20 children, 5 to 17 years, with functional abdominal pain (FAP) and com- pared outcomes to ten children without FAP. Th e signifi cant decrease in low frequen cy/high frequency (LF/HF) ratio aft er Bussone et al. (1998) randomized 30 children, ages 11 to 15 years, with episodic tension-ty pe headache to either a biofeedback- relaxation SECTION 9 special topics 626 intervention suggested an improvement in cardiac vagal tone, along with a decrease in pain frequency and a signifi cant correla- tion between the decrease in LF/HF ratios and pain fr equency. Th is novel study of heart rate variability biofeedback in FAP was limited by the study design (no randomized trial with a control condition). pre- and postintervention eff ects, merging yoga groups including those who had yoga aft er being in the control condition found a signifi cant reduction in gastrointestinal symptoms . Th is study was limited by no monitoring for home practice adherence and small sample siz e. Brands et al. (2011) evaluated the eff ects of ten sessions of yoga in 20 children, 8 to 18 years, with functional abdominal pain (FAP), dividing participants into groups of 8 to 11 or 12 to 18 years. Pain frequency was signifi cantly reduced for children in both age group s at the end of the treatment, but only the younger group maintained reduced pain frequency at 3-month follow-up. Th is single arm study had multiple design problems. Schurman et al. (2010) randomized 20 children, ages 8 to 17 years, with functional abdomina l pain (FAP) to a ten-session biofeedback-assisted relaxation training (BART) or control co ndi- tion. Children in the intervention group demonstrated signifi cantly improved pain int ensity, duration of pain episodes, and overall clinical improvement in comparison to the co ntrol group. A good review of biofeedback for children \200\231s headache is found in Herma nn and Blanchard (2002). Geyer et al. (2011) carried out fi ve-weekly yoga sessions to determine feasibility in six hospitalized children with cancer, ages 6 to 19 years. Study feasibility with this populati on was supported. Does the discussed literature suggest strong support for the clinical utility of biofeedbac k for pain reduction in children? Th e data are suggestive but not strong. Th at being said , there are many individual children who report great benefi t and report that bio- feedbac k enables them to cope, attend school, and sleep well at night. Since the primary downside is cost in those countries where families have to pay out of pocket for this treatment, pro viding targeted biofeedback to children who need self-management tools to cope with pain an d become more functional and less distressed by the pain is recommended. Targeted biofeedba ck means tools for learning muscle tension reduction in those body areas where muscle tensi on is a primary cause or contributor to the pain. Skin temperature warming might be appropr iate for children with migraines, while adding EMG biofeedback would be useful if there wer e myofascial contributors to the headaches. Biofeedback seems to be especially useful for t he child who seems to enjoy and learn best from computers and other \200\230gadgets \200 \231. Th e biofeedback clinician should be well trained in his/her craft and not promise \200\230amazing \200\231 results so that children who do not fi nd it useful will not feel like they failed. Most yoga studies lack a manualized intervention where poses for the study are shown so the study could be replicated, even with individualized adjustments based on children \200\231 s needs during the sessions (Evans et al., 2009). More studies of yoga for children \200 \231s pain are needed and should include mechanisms and outcomes (Evans et al., 2011b). Th at being said, safe types of yoga, such as hatha yoga and Iyengar yoga in which practiti oners have extensive training and certifi cation processes, can be extremely benefi cial fo r stretching, relaxation, and body balance. Also the yoga poses give children a tool that t hey can use independent of requiring a clinician to \200\230do something \200\231 to them. In our program we have been study- ing Iyengar yoga for young people with arthritis, irrit able bowel syndrome, and fatigue in young survivors of childhood cancer. Across studies, pa rticipants overall feel better and want to con- tinue with the yoga (Evans et al., 2009, 20 10, 2011a, 2011b, 2011c; Woolery et al., 2004). Chiropractic Th ere is limited research in chiropractic care to treat pediatric pain. Hayde n et al. (2003) randomly selected 15 chiropractors from four cities in Canada to provide da ta on their paediat- ric patients with low back pain. Th e response was positive and there were no reported complications. Roberts and Wolfe (2009) describe complete resolution of pa in aft er chiropractic treat- ment with a 6-year-old girl with multiple sites of pain follo w- ing an injury with persistent long-term outcomes. Hewitt (1994) describes complete resol ution of head and neck pain in a 13-year- old girl whose symptoms had persisted for the pre vious year aft er four chiropractic treatments. Th e data on chiropractic care for children \200\231s pain are lacking. A recent literature review of studies of spinal manipulation i n children found limited studies of paediat- ric chiropractic overall, and nothing on spina l manipulation for back pain (Gleberzon et al., 2012). Th e most positive fi ndings in this review were for asthma. Yoga Th ere are many types of yoga, oft en named aft er the lineage of the school of yoga o r founder of a certain tradition (the guru). In Iyengar yoga, developed by B. K. S. Iyengar (Evans et al., 2010, 2011c; Woolery et al., 2004), therapeutics provides a series of poses matched to the symptom and medical needs of the child and the pose series changes as the c hild improves. Th e poses ( \200\230asanas \200\231) are intended to correct health-related problems, both in body structure and in internal organ function. Th e goal is to enhance m indfulness of the body, feelings of centeredness and calm, and a sense of self-control. Th e poses are intended to address underlying causes of symptoms and poor postural habits that may contribute to the child \200\231s pain. Th e goal of treatment is to help children to learn how to change these bodily contributors to pain. Yoga has been studied in with irritable bowel syndrome (IBS; Brands et al., 2011; Kuttner e t al., 2006) and in cancer (Geyer et al., 2011). Kuttner et al. (2006) randomly assigned 25 adolescents, 11 to 18 years, with IBS to a yoga or wait-list control group. Th e yoga grou p had a single yoga session in person followed by 4 weeks of expected home practice with vi deo guidance. Th e yoga group reported lower levels of emotion-focused avoidance, functiona l disability, and anxiety compared to the control group. Evaluating Another review found through analyzes of a national data set in the US that neck and back p ain were the most common reasons for chiropractic or osteopathic spinal manipulation, and t hat teens were more likely to use these therapies than were children (Ndetan et al., 2012). As Gilmour et al. (2011) note, practitioners should have training in the care of chiroprac tic with children before prac- tising this therapy on them. CHAPTER 60 complementary therapy in pediatric pain 627 Aromatherapy Th ere are very few studies evaluating the eff ects of aromatherapy as a compl ementary tool in alleviating pain in pediatric patients. Th e few studies conducted (de Jon g et al., 2012; Ndao et al., 2012) have concluded little or no signifi cant benefi ts. In a n observer blinded, randomized, controlled trial, de Jong et al. (2012) randomized to one o f two intervention conditions (massage with or without man- darin oil) or to a usual treatm ent control group 60 infants, ages 3 to 36 months, for improvement in postoperative pain af t er major craniofacial surgery. No signifi cant diff erences were found in pain or distres s aft er intervention in any of the three groups. Only heart rate and mean arterial blood p ressure were reduced in the two intervention conditions. Limitations were lack of assessmen t of treatment adherence, no delayed outcome evaluations, and other design fl aws. Massage and touch therapies Massage and various forms of touch have been reported clinicall y to be helpful and soothing, at least in adults. Th e eff ectiveness of mas- sage has been studied in children with chronic pain (Suresh et al., 2008), rheumatoid arthritis (Field e t al., 1997), sickle-cell disease (Lemanek et al., 2009), burns (Gurol et al., 2010; Hernan dez-Reif et al., 2001), cancer (Post-White et al., 2009), haematopoietic cell transplant (A ckerman et al., 2012; Wolf et al., 2012), and cerebral palsy (Nilsson et al., 2011). Suresh et al. (2008) compared symptom outcomes aft er 80 mas- sage sessions with 57 childre n, mean 13.9 years, in an outpatient chronic pain clinic. Pain and other symptoms were repo rted to have improved aft er the massage while no symptom improvements were found in a comp arison group of 25 children who did not receive massage. Th e study has many design fl aws. Ndao et al. (2012) randomly assigned to an aromatherapy (bergamot essential oil) or placebo group 37 children, ages 5 to 21 years, undergoing stem cell transplantation (SCT). Th e co n- trol group had an aromatherapy diff user with a non-essential oil-based scented shampoo during SCT. Th e intervention group had signifi cantly higher anxiety and more nausea than did the control group. Th e fi ndings suggest that bergamot essen- tial oil may increase ra ther than reduce symptoms in children undergoing SCT. Field et al. (1997) randomized 20 children, ages 5 to 15 years, with juvenile idiopathic ar thritis to a massage or relaxation group. Parents were trained to provide their child with a 15 min bedtime massage for a month, while the parents in the comparison condition guided their child in 15 min of relaxation. Outcome assessments were made pre/post intervention on the fi rst and last treatment ses- sions. Parent and child reported decreased anxiety and pain and lower salivary cortisol levels were found in the massage versus the relaxation gro ups. Methodological problems included no assess- ment of treatment adherence or integrity. In summary, the studies are weak or do not support specifi c ben- efi ts of aromatherapy on symptoms in children \200\231s pain. More studies are needed and clinically, unless reques ted by the child or adoles- cent, it should not be automatically used. Lemanek et al. (2009) randomly assigned 34 children with sickle cell disease to a massage o r attention control condition. Parents were trained and asked to provide a 20 min daily mas sage to their child for 30 days, while the massage therapist made weekly home visits to pro vide massages. Parents and children in the control condition completed weekly assessments. Parents in the intervention group had signifi cantly higher anxiety and depression than did those in the control group. Children in the intervention group reported higher functional status and lower depression, anxiety, and pain than did those in the control children. No s ignifi cant group diff er- ences were found in health care utilization. Limitations were la ck of measures of treatment integrity and adherence, and a control group that was not truly an attention control condition. Pet therapy Dogs have been trained to help distressed children in a process called pet ther apy, animal-assisted therapy (AAT), or canine visita- tion therapy (CVT). Braun et al. (200 9) evaluated AAT to reduce pain in 18 children, ages 3 to 17 years, in an acute care settin g with an established AAT program. Outcomes were compared to those in 39 children without A AT. Group assignment was not described. AAT was described as having the dog match the child \200\231s breathing pattern by sitting next to the child. How this was done or measured is not described. Th e AAT group had signifi cantly less pain but higher respiratory rates th an did the comparison group without AAT. Blood pressure, heart, and respiratory rates did n ot diff er between groups. Hernandez-Reif et al. (2001) randomly assigned 24 children, mean age 29.3 months, who were getting dressing changes for severe burns to a massage or standard care control condition. Th e massage group received a 15 min massage from a trained thera- pist before a dressing c hange, while the therapist talked with the control group for 15 min before the dressing cha nge. Children in the massage group had signifi cantly less behavioral distress, less nurse- reported diffi culty with dressing changes, and less therapist- reported child distress and less self-reported stress compared to the children in the control condition. While a good attention control condition was provided within the study design, child behavior was the on ly blinded assessment, and there was no assessment of treatment integrity. Sobo et al. (2006) found reduced pain aft er a single CVT for 25 children, ages 5 to 18 yea rs, with acute postoperative pain in a hos- pital already with an existing CVT. Th e childr en reported that the dog provided distraction from pain, entertainment, pleasure/hap- pines s, contact/snuggling, was calming, and eased the pain. Study limitations are clear in this descriptive study. Overall, the studies of AAT have covered horse-assisted ther- apy (hippotherapy), which has been used most commonly for children with cerebral palsy, and dogs as pet therapy. Many ch il- dren \200\231s hospitals now have trained pets spend time with children. Dogs are also trained in special programs to be of eye, hear- ing, limb extender, and other services to c hildren with specific disabilities. A recent study, while not in children, concludes after reviewing the literature that, while encouraging, study findings for specific significant s ymptom effects are weak (Mu oz et al., 2011). Gurol et al. (2010) compared 5 weeks of twice weekly massage to usual care in 63 burned ado lescents, 12 to 18 years of age, using convenience sampling method for group assignment. Ad olescents receiving massage reported lower itching, pain and anxiety pre/ post intervention while only itching was reduced in the control group. Lack of randomization and no measures of treatment integ- rity weakened the fi ndings. SECTION 9 special topics 628 Post-White et al. (2009) conducted a randomized crossover pilot study evaluating massage th erapy (MT) or quiet-time (QT) in 23 children, ages 1 to 18 years, with cancer receiving che motherapy. Th e MT group had four weekly sessions of parents receiving mas- sage followed b y child massage by massage therapists. Th e QT group had matched quiet rest or quite toy ti me. Heart rate was sig- nifi cantly lower in the MT children but no signifi cant diff erenc es were found in respiratory rate, systolic or diastolic blood pressure, nausea, fatigue, a nxiety or salivary cortisol. Parental anxiety was signifi cantly less in the MT group, but parental fatigue was signifi - cantly reduced only in the QT group. Th e study design was e xcel- lent but other weaknesses, including the wide age range of children weakened the gene ralizability of the fi ndings. Favara-Scacco et al. (2001) compared art therapy in 32 leukaemic children leukemia undergoi ng painful procedures with 17 previ- ously hospitalized children, and found more positive b ehaviors in the art therapy group. Madden et al. (2010) randomized 16 children with brain t umors, ages 2 to 18 years, to six weekly creative art therapy (CAT) sessions or a reading c ontrol condition. Th e CAT group was found to have greater parent-reported improvement in c hild pain and nausea. A single CAT session in a cohort of 32 children was found to reduce p ain and anxiety. Further study of art therapy for reduction or prevention of pain in childr en is still needed. While art therapy may be therapeutic for some children with chronic pain, more quality rese arch is needed before this modality as a complementary therapy for pain can be recommended broadly. Art therapy may be used within psychotherapeutic treatment for coping, anxiety, or depression in children with pain, but art ther- apy specifi cally for pain control is not yet supported by research fi ndings. Wolf et al. (2012) compared thrice weekly Swedish/acupressure massage to usual care in 23 c hildren, ages 5 to 18 years, receiving haematopoietic cell transplant (HCT). Lack of signif i cant fi ndings were likely related to insuffi cient power, but children receiving the mas sage-acupressure had fewer days of mucositis (ES 0.63), lower overall burden of symptoms (E S 0.26), improved fatigue (ES 0.86) and fewer symptoms of pain (ES 0.42), and nausea (ES 0. 62). Th ere was no diff erence in hospital stay between the groups. Music therapy Music can be considered as a distractor from pain and stud- ies have looked a t the use of music during acute pain settings. In music as a distractor, little is known ab out the eff ects of type of music, child choice, duration of the music, or music volume, pi tch, rhythm, or impact of instruments with or without vocals. Music as a distractor or rela xation tool is diff erent than music therapy. Unfortunately, there are few studies of music therapy for pediatric pain. A descriptive study suggests benefi ts in pediatric palliative care (Lindenfelser et al., 2012). Robb et al. (2011) report on fi delity strategies in a C hildren \200\231s Oncology Group clinical trial of a thera- peutic music video intervention for oncology patients, ages 11 to 24 years undergoing stem cell transplant. Ackerman et al. (2012) randomized 23 children, 5 to 18 years of age, who were undergoing st em cell transplantation to a three week parent-provided massage or control condition. Paren t interviews were positive about the massage eff ects on their child but coordina- tion wit h clinical hospital routine was diffi cult. During acute pain episodes, children did not wa nt the massage. Nilsson et al. (2011) studied eff ects of massage in orthopedic postoperati ve pain man- agement of six children with cerebral palsy. Th e massage therapists noted tha t it was important to assess the child \200\231s response to touch since some children have touch aversion. Other touch therapies, such as therapeutic touch and Reiki, are illustrate d by the pilot study by Kemper et al. (2009). While not a study in children, Tan et al. (2010) randomized 29 burn unit inpatients to musi c therapy or a control condition in ran- domized, crossover design for dressing changes in which patients were randomized to receive music therapy on the fi rst or second of two cons ecutive days. During intervention days, patients car- ried out music-assisted relaxation wi th self-guided imagery before and aft er dressing changes, while creating music during dres s- ing changes. Pain before (P <0.025), during (P <0.05), and aft er (P <0.025) dressing ch anges were found to be reduced on music therapy in contrast to control days, with a decreas e in anxiety and muscle tension during (P <0.05) and muscle tension aft er dress- ing chang es (P <0.025). Th e study needs replication in children. Austin (2010) reviewed evidence an d encouraged research on music therapy with children on mechanical ventilation in a paedi- atric intensive care unit. Th e state of the science suggests that massage and other touch therapies may be benefi cia l for pain control in children and use- ful clinically. Certainly children with any form of myofascial pain, unless they are hyperalgesic to light skin touch, would likely benefi t f rom massage therapy. Children with headaches and even those with abdominal pain may also be nefi t. Massage should not be off ered to children with a history of sexual abuse or who ar e otherwise averse to touch, such as some children with autism spectrum disorders. Th e pro blem to be studied is that we don \200\231t know how to match the child with the type of ma ssage to get the most therapeutic eff ects with the least negative eff ects. Variables to b e tested include child characteristic, relevant past history, and type and location of pain . Th erapist variables include training, experience with children, and sensitivity to child ren \200\231s body language. Massage variables include amount of pressure, muscle versus sk in massage, over clothes or with direct bodily contact, use of lotions or aromatic oils, an d duration, frequency, and total length of therapy. Context variables include location of m assage, timing, and others \200\231 presence. Kristj nsd ttir and Kristj nsd ttir (2011) randomly assigned 118 adolescents, a ged 14 years, to one of three groups receiving polio immunization: musical distraction with (n = 38) or without head- phones (n = 41) and standard care (n = 39). Music therapy withou t headphones emerged as a signifi cant predictor of no pain. Nilsson et al. (2009) randomiz ed 80 children, ages 7 to 18 years, undergoing day surgery to a 45 min music distraction at entry into the postop- erative care unit or to usual care. Th e music group had fewer chil - dren receiving morphine, lower total morphine dose, and a greater decrease in facial acti on coding scores than did the control group but no diff erences in vital signs, behavioral measures, or anxiety. Art therapy Art therapy is the use of various art media forms for both distrac- tion and fo r self-expression, sometimes with therapist/child inter- pretation, to help children to cop e with distress and pain. Th ere are early reports of the value of art therapy in the pedia tric hospital setting (Sundaram 1995). CHAPTER 60 complementary therapy in pediatric pain 629 Nguyen et al. (2010) randomized 40 children with cancer, ages 7 to 12 years, to music distr action or usual care for lumbar puncture (LP) pain. Both groups had earphones beginning 10 min before the LP, but self-selected music was provided only to the music group. Pain durin g and aft er procedures, anticipatory anxiety, heart and respiratory rates during and respi ratory rate aft er the LP were sig- nifi cantly decreased in the music group. Young et al. (2010) pro- vided music distraction to 50 children during an emergency room visit, with 86% reporting that listening to music was \200\230helpful \200\231 or \200\230very helpful \200\231. inner struggle between what people were telling me and what I was really feeling. I doubted my own sanity and felt myself slowly slipping away from the hours in waiting rooms, heavy medications, and maddening pain. I started passing out and hav- ing seizures. I did not fee l like a 14-year-old girl anymore. I was depressed beyond belief and I was utterly and comp letely alone. No one knew that the cause of the pain wasn \200\231t an injury \200\224it wa s an overactive nervous system. It was stress. When I reached the Pediatric Pain Clinic I had already lost everything. I honestly thought I was going crazy and those nega- tive feelings only increased as I was abandoned by my clo sest friends. I was as low as I could get when I met the pain doctor I thought I knew every thing about doctors and \200\230the system \200\231, but she completely surprised me. She took me off the drugs and threw away my body cast. She told me to start doing hypnotherapy, art therapy, and Iyengar yoga. At fi rst I felt like she wasn \200\231t taking me seriousl y. I thought there was no possible way that drawing or painting pictures could stop my pain . I had never heard about anything like this before. My family and I were as skeptical as c ould be, but we really had nothing to lose at that point. Others have also reported on music as a distraction in various pediatric settings to reduce pain (Aitken et al., 2002; Arts et al., 1994; Malone 1996; Megel et al., 1999). One recent review of music therapy in pediatrics did not include pain as an outcome (Naylor et al., 2 011). Case example introduction In the following paragraphs, GH, a 17-year-old girl, describes he r pain experiences and her use of complementary therapies. She was fi rst evaluated in the pain clinic when she was age 14 years with extreme leg and back pain and reduced ability to walk or sleep when the pain was severe. She had been absent from school for about 5 months because of pain. At one point she developed conversion pseudoseizures during extreme stres s, although these eventually resolved. She was diagnosed with myofascial back and leg pain, an anxiety disorder, and some family-related stressors. Because she reported that she used art to express her feelings and calm herself, she was referred to our pain program art the rapist for psychotherapy through creative expression with self-interpretation and discussio n. She also learned to use self-hypnosis to alter her sensory experiences, develop a sense of control over her pain, and regain control over what she described as involuntary bodily 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 .