SECTION 7 psychosocial interventions 574 study involved six participants (23 \200\22348 years) with chronic wide- spread pain who co mpleted multidimensional pain diary entries for 4 weeks on phones. A therapist then remotel y logged on to a secure website, viewed the diary entries, and provided individual- ized fe edback aimed at stimulating patient self-management of the current pain situation. Th is in tervention received high par- ticipant acceptability and usability ratings. In addition, co mpli- ance with diary entries was high (78 \200\22394% of entries completed) and technical problems with the intervention were infrequent and minor. Despite the rapid adoption of these therapies, a technological divide does still exist in t erms of age-related diff erences in technol- ogy confi dence, skill, and use and the unequa l provision of costly infrastructure (broadband computing) in diff erent communities. Th e extent to which these interventions can be independent of any human support (lay person, tr ained non-health care professionals, health care professionals) is not known. Th ere is evi dence that self- guided or minimal human involvement is associated with greater patient dro pout compared to face-to-face therapy. Determination of the minimum amount of support requi red to improve outcomes and the most appropriate person to provide that support is needed. In developing mobile phone-based pain management interven- tions, researchers and developer s should seek the expertise of health care professionals in the design and implementation o f mobile pain management programs to help ensure usefulness and safety. Rigorous testing of these interventions (i.e. via randomized control- led trials or RCTs) is also needed to de termine their eff ectiveness. Successful evidence-based development of m-health interventio ns for people with pain may result in accessible care and improved outcomes, making researc h exploration in this area important. Th e essential ingredients that are needed in ICT-based pro- grammes are also largely unkno wn and should be determined by conducting dismantling studies. We need to determine what ty pes of patients are best served by these programs and when in the pain trajectory, programs are the most eff ective. In addition, the cost eff ectiveness of these programs compared t o traditional approaches needs to be determined. Th e cost of the development of these prog rams can be reduced by developing a core set of pain coping skills that can be used across all types of chronic pain con- ditions. Clinicians and policy makers will need to rethink h ealth care processes around chronic pain management to ensure funding to support the sustai nability of these ICT-based therapies. Finally, we need to ensure data security, privacy, a nd confi dentiality of per- sonal health information. Telemedicine/telehealth Telemedicine or telehealth refers to telecommunication systems in t he broadest sense and includes the use of technology to help deliver and support health ser vices (e.g. call centers, cell phones, video-conferencing, and web-based platforms). Teleme dicine methods have been proposed as a means to improve access to pain management programmi ng provided that appropriate thera- pists and remuneration policies are in place (MacDonald et al., 2011 ). A recent systematic review of telehealth for pain manage- ment found that only a limited number of RCT examinations of telemedicine versus traditional therapies exis t (McGeary et al., 2012 ). However, based on currently available literature, there is good preliminary evidence to believe that telemedicine is an eff ective and viable means of mana ging pain (McGeary et al., 2012 ). Th e costing of telemedicine methods for pain management in adults with chronic pain has also been compared to traditional face-to-face therapies i n a RCT (Pronovost et al., 2009 ). Results showed that direct patient costs were signifi ca ntly lower in the telemedicine group than the face-to-face group and that more participants in the telemedicine group were satisfi ed with their consultation. In terms of research, standards on the reporting and evaluation of ICT have been recently e stablished and will provide important guidance for future studies (Eysenbach and CONSORT-EH EALTH Group, 2011 ). Multicentred RCTs of high quality are needed to compare ICT-based trea tments with active placebos as well as face- to-face CBT. Conducted trials should include t he measurement of broader biopsychosocial outcomes and move beyond simple pain intensity ex aminations. Dismantling studies can help determine the optimal length of interventions, spe cifi c treatment compo- nents which are eff ective, and whether social support or therapist involvement would improve outcomes. Finally, strategies to reduce dropout rates (e.g. moti vational interviewing and minimal online support) need to be evaluated. Conclusion ICT-based pain treatments are an innovative way to improve the access and availa bility of psycho-educational pain therapies for individuals with chronic pain. Th ere is gr owing evidence that ICT treatments not only reduce pain but also pain-related disability in various types of chronic pain conditions and in both pediatric and adult populations. We c an continue to harness the potential of these mediums by ensuring that we explore the needs and perceptions of people in pain regarding ICT-based pain treatments \200\224including wh en and under what circumstances the Internet is preferred to face-to-face therapies. Th is will help to tailor pain management eff orts to individual preferences and enhance complian ce and acceptability of these programs. Moreover, well-designed stud- ies with placebo cont rol groups that include diverse patient groups are needed to strengthen the growing evidenc e base concerning ICT-based interventions for people with pain. Finally, we need to ensure that these programs are publically available and that when they off er therapist involvemen t that this is remunerated by our health care system. Future directions for theory, research, and clinical practice Th ere is great excitement an d opportunity associated with new ICT for the management of long-term health conditions suc h as chronic pain. While there is enthusiasm, there are a number of theoretical, research a nd clinical issues that need further consideration. First, consensus and standards on metho ds of development and met- rics for evaluation of ICT-based health care treatments need to be developed. Th ere is currently little guidance on how to develop or translate therapy fr om traditional human face-to-face to ICT-based delivery system. To this end, user-centered designs must be the start- ing point. Th e needs and perspectives of people in pain regardi ng ICT-based therapies (i.e. when and under what conditions ICT therapy is preferred to fac e-to-face) needs to be the fi rst step guid- ing development of these interventions. CHAPTER 55 new information and communication technologies for pain 575 References Barak , A. , Klein , B. , and Proudfoot , J. G. ( 2009 ). Defi ning internet-sup ported Garg , A. X. , Adhikari , N. K. , McDonald , H. , Rosas-Arellano , M. P. , Devereaux , P. J . , Beyene , J. , et al . ( 2005 ). Eff ects of computerized clinical decision support syst ems on practitioner performance and patient outcomes: a systematic review . JAMA , 293 (10) , 1223 \200\2231238. therapeutic interventions . Ann Behav Med , 38 (1), 4 \200\22317. Bargh , J. A. , McKenna , K. 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Arch Phys Med Rehabil , 92 (2), 176 \200\223183. This page intentionally left blank SECTION 8 Physical interventions This page intentionally left blank CHAPTER 56 Physical therapy interventions for pain in childhood and adolescence Susan M. Tu pper , Mary S. Swiggum, Deborah O \200\231Rourke , and Michael L. Sangster Introduction: physical therapist perspectives on pain Physical therapists (PTs) consider pa in in young patients from three perspectives. First, pain is recognized as a symptom of an injury or disease, or the primary manifestation of the disease itself. From this perspectiv e, pain is monitored over the treat- ment course and treatment eff ectiveness may be examin ed by the overall reduction in pain. Second, pain may be provoked during physical assessmen t. From this perspective, pain is a dichoto- mous event which is either elicited with a pro vocation test, or not elicited. Pain from this perspective is useful to support diagno- sis and identify tissue structures that may be contributing to the symptoms, or to identify hy persensitivity or allodynia resulting from peripheral or central nervous system sensitizati on. Finally, pain may be an unpleasant consequence of treatment procedures. Discomfort that arises from the manual therapy, modalities, or prescribed therapeutic exercises (procedura l pain) may be con- sidered an adverse event (Chorney et al., 2010). From this per- spectiv e, PTs must be equipped to monitor for this reaction, and minimize or eliminate pain from t reatment. Th is chapter will focus on interventions which are aimed at minimizing or elimi- nating pain from two of these perspectives: pain as a component of injury or disease and p rocedural pain. literature on procedural pain from a PT perspective and provide recommendations on procedur al pain management. Although PT practice settings and the treatment needs of infants, child ren and adolescents with pain vary widely, this chapter will provide a struc- ture for deve lopment of a theoretical and evidence-based physical therapeutic approach for all children with pain. Th eoretical foundations in treatment planning Knowledge of pain mechanisms has evolved fro m the notion of pain as a uni-directional consequence of peripheral nociception, to that of a complex physical and emotional experience with biological, psychological, social, enviro nmental and behavioral infl uences. Similarly, PT treatment of pain is evolving from a tiss ue-oriented, bio-medical approach to both active and passive therapies with potential to mo dify nociception and pain through peripheral and central nervous systems (Flor and Diers, 2 009). Th eoretical models of pain and function enable the therapist to conceptualize causal mecha nisms of eff ect and to consider a comprehensive approach to management of pain. It is part icu- larly important that PTs use a theoretical framework for select- ing treatments in the absence of high-quality evidence to guide the treatment approach. Although evidence-based practice should be the paradigm for PTs, in many cases because of lack of research, treatme nts do not have strong evidence for eff ec- tiveness. Although future research may lead to more eff ective PT treatments and the development of treatment guidelines, a theory-based a pproach guided by regular evaluation of outcomes will serve in design and delivery of appro priate care. However, a treatment approach based only on theory does not necessar- ily ensu re that the treatments provided are eff ective. Clinicians need the knowledge of the latest research, combined with fre- quent evaluation of the eff ectiveness of their treatments wi th each patient (Jewell 2011). Th e chapter is divided into four sections. Th e fi rst section will provide an overview of the theoretical foundations that can be used as a framework for possible mechanisms of eff ect for physical therapy (PT) interventions and identifi cation of PT interventions orient ed towards maximizing participation of children with pain in valued roles and life activiti es. Th e second will review the lit- erature on active therapies as interventions for child ren with pain. Th e third section will review the literature on passive therapies and safet y and effi cacy for manual therapy or therapeutic modalities for pain. Th e importance of t he therapeutic relationship and pain education will also be discussed. Th e fi nal section will review the SECTION 8 physical interventions 582 Conceptual framework for pain Th e neuromatrix theory will be briefl y reviewed and discuss ed in terms of how it applies to PT treatment planning. Th e neuroma- trix theory (Melzack, 1999) is a conceptual model for the genesis of pain that builds on the gate control (GC) t heory (Melzack and Wall, 1970). Th e GC theory was revolutionary because it presented physi ological mechanisms for bi-directional infl uences on pain and began to explain how competi ng peripheral aff erent input (i.e. mechanoreceptor activity) and descending eff erent acti vity from the central nervous system (i.e. emotional states or cognitions) could infl uence pain perception (Melzack and Wall, 1970). the mechanisms by which PT treatments have an impact on pain in young patients. Based on what is known about the neurophysiology of nocicep- tion, it is hypothesized that sensory aff erent information may be modifi ed either by reducing activity in peripheral or central noci- ceptive pathways, increasing competing sensory information, such as mechanor eceptor input, or increasing central nervous system descending inhibition of pain (Woolf, 2 011). Th e goals of treatment with therapeutic exercises, manual therapies, and modalities are to alter nociceptive aff erent activity either directly (e.g. transcutane- ous electric al nerve stimulation (TENS)) or indirectly by reducing infl ammation (e.g. cryotherapy) or modifying structural impair- ments and the biomechanical stresses on tissues (e.g. mobiliza tion of scar tissue). Th e neuromatrix theory further reconceptualized pain as an out- put, or a \200\230neurosi gnature \200\231 which is generated by a complex neural network, the \200\230neuromatrix \200\231, as a noxious motivator to stimulate voluntary and involuntary actions that return the body to a state of homeostasis (Melzack, 1999). Melzack hypothesized that a pain neuro signature may be produced in the absence of identifi able tis- sue damage or disease and th at the threat value assigned to the sensory information through conscious and unconscious c ogni- tive and emotional appraisal will infl uence the sensory, aff ective, and cognitive d imensions of the pain neurosignature produced (Melzack, 1999). Education and change in knowledge and beliefs are hypothesized to modify cognitive and emot ional evaluation of sensory input. Graded exposure to sensory stimuli that provoke fear or distress, in combination with development of coping skills may also alter the patient \200 \231s evaluation of feared movements (Woods and Asmundson, 2008). For example, an adolescen t with idiopathic persistent pain may avoid walking long distances with the misunderstandin g that she is damaging tissues when she feels increased pain with activity. PT treatment fo r this patient may include education to address her beliefs and fear of pain with activity as well as a graded physical activity program. Although the ultimate goal of the activity p ro- gramme would be to increase muscle strength and cardiovascular conditioning, in the ini tial stages the exercises could be considered a form of systematic desensitization with gra dual exposure to the movements or positions that she fears (Woods and Asmundson, 2008). Th ese exposures, if paired with development of coping strat- egies to manage pain, may contri bute to increased function and reduction of fear-avoidance behaviors Using this model as a framework, PT interventions for chil- dren with pain have three possi ble eff ects: (1) modifi cation of the sensory aff erent information, (2) modifi cation of the cogni- tive and emotional evaluation (threat value) of the sensory infor- mation and (3 ) modifi cation of the threshold for generation of the pain neurosignature by providing tre atments that return the body to a state of homeostasis or regulate the stress-response sys- tems (Figure 56.1 ). Because of the lack of specifi c research, PTs treating pediatric pat ients rely on knowledge of general neu- rophysiology or extrapolations from adult research to explain treatment eff ects. Research with children is needed to identify PT treatments that aim to regulate the stress response would include general cardiovascular conditioning exercises, relaxation training, and education on sleep hygiene, diet, and hea lthy life- styles. Management of acute or persistent pain must be conceptu- alized as one c omponent of therapy oriented towards maximizing the child \200\231s participation in meanin gful life roles and activities. Direct TENS, interferential current, manual therapy, heat/cold, physical activity Modify Sensory A \200erent Input Indirect reduction of in \202ammation or change in structural impairments with therapeutic exercise s, ultrasound, heat/cold, laser, manual therapy International Classi \201 cation of Functioning Disability and Health as a framework for t reatment planning PT treatment for the child with pain is typically one component of a broa d interdisciplinary continuum of care. Use of a common classifi cation framework for evalua tion and treatment planning will facilitate communication between professions and ensure th at evaluation, goal setting and interventions are comprehensive and oriented towards improv ing the child \200\231s participation in valued activities (Goldstein et al., 2004). Pain neurophysiology education Modify Cognitive and Emotional Evaluation of Sensory Input Development of a therapeutic relationship Graded physical activity program Relaxation training The World Health Organization \200\231s (2007) International Classifi cation Framework for Children and Youth (ICF-CY) is a framework used to describe health as a state of maximum en gagement in desired activities within a continuum of health states (Goldstein et al., 2004) . Th e ICF-CY identifi es two main categories for assessment: functioning and disability, a nd con- textual factors. Functioning and disability are further subdivided into body functi ons and structures, activities, and participation (Figure 56.2). Contextual factors are an interrelated construct that can be subdivided into environmental or personal factors. General physical activity conditioning program Reduce Threshold for Generation of Pain Neurosignature Health behavior education (sleep hygiene, diet, weight loss, stress reduction, smoking cess ation) Relaxation training Figure 56.1 Hypothesized mechanism of e \200 ect for pain relief from PT interventions. CHAPTER 56 physical therapy interventions for pain in childhood and adolescence 583 exercises have been shown to be particularly benefi cial for main- tenance of functional ou tcomes and are recommended as part of a comprehensive treatment regimen for the management of patients with complex regional pain syndrome (CRPS; Bialocerkowski and Daly, 2012). Health condition Even in the absence of impairments, children are encouraged to be regularly physically acti ve (Tremblay et al., 2011). General cardi- ovascular conditioning is important for short- a nd long-term health (Tremblay et al., 2011). International guidelines on physical activity for children (World Health Organization, 2012) recommend par- ticipation in 1 h or more of moderate (e.g. brisk walking) to vigor- ous (e.g. running) physical activity daily and aero bic activity should make up most of that hour. Children living with pain tend to be less ph ysically active and have lower cardiovascular conditioning com- pared to their healthy peer s (Maggio et al. 2010). Improvements in cardiovascular fi tness will support the child \200 \231s return to participa- tion in activities of daily living and physical and social activ ities. Body structure and function Activity Participation Environmental factors Personal factors Figure 56.2 International classi \201 cation of functioning disability and health model. R eproduced with permission from World Health Organization, ICF-CY: International Classi \201 cation of Functioning, Disability and Health Children and Youth Version , Copyright World Health Organization 2007. Many children living with persistent pain present with signifi - cant mobility limitations due, in part, to the belief that movement will cause further tissue damage. Fear-avoidance behaviors can aff ect all domains of the child \200\231s health and functioning and result in disability (McCarthy et al., 2003). It is essential to elicit parents \200\231 and child ren \200\231s beliefs about the causes of pain, factors they believe exacerbate and relieve the pain, and fears related to movement and physical activity and to addresses specifi c a nd erroneous pain beliefs with education and graded activity programs (Ayling- Campos et al ., 2011). Active PT interventions for children with per- sistent pain may require a signifi cant change in movement-related behavior. An assessment of the child \200\231s readiness t o change and to participate in PT is important to include in the initial evaluation.