SECTION 7 psychosocial interventions 564 Vlieger and colleagues further concluded that the clinical success achieved with HT in thei r studies cannot be explained by improve- ment in rectal sensitivity (Vlieger et al., 2010 ). In one study they randomized 46 patients with FAP (n = 28) or IBS (n = 18) to either 12 weeks of SMT or HT. To assess rectal sensitivity, a pressure-con- trolled intermittent dist ension protocol (barostat) was performed before and aft er the therapy. Interestingly, no r elationship was established between treatment success and rectal pain thresholds. Rectal se nsitivity scores at baseline were not correlated with inten- sity, frequency, or duration o f abdominal pain. Hypnotic strategies and techniques for managing chronic pain, among others, include: creati ng anesthesia or analgesia, a decrease in pain, an increase in comfort and relaxation, chan ges in sensa- tions from unpleasant (burning) to more pleasant (warm) ones, feeling less bo thered by sensations, or changes in the meaning of pain, unconscious exploration to enhance insight or resolve con- fl ict, cognitive-perceptual alteration of pain (and pain behavior ), and decreasing awareness of pain (distraction techniques). Other useful hypnotic approac hes to pain management include self-sug- gestions for relaxation and a sense of global calm ness, ego strength- ening, being in a \200\230special place \200\231 (that is, a place tha t is beautiful, safe, relaxing, and calming to the young patient; see supplementary online material for video clip), decreased tension and emotional suff ering, maintaining an approp riate level of activity, focusing on life goals other than just pain reduction, increasing participation in distracting and healthy activities, appropriate activity pacing and Rossi \200\231s (Rossi et al., 2010 ) mind \200\223body healing approach. In this lat- ter approa ch, hypnotic suggestions can be given during the treat- ment session for the patient to reg ress and access past learning, memory, and experience and use them as therapeutic resources for pain management. Th e multifaceted and complex nature of chronic pain requires elaborate and comprehensive h ypnotic interventions delivered in a number of sessions and regular and consistent use of s elf-hypnosis by the patient (Wood and Bioy, 2008 ). Especially, when considering biopsychos ocial and neuropsychological models of pain, using a com- bination of pain-specifi c and no n-pain-related suggestions maybe par- ticularly eff ective because these suggestions can ta rget not only pain itself, but emotional (e.g. suggestions for improved mood), cognitive (e .g. suggestions for increased self-effi cacy), and behavioral (e.g. sug- gestions for impro ved sleep) factors that play an important role in the pain experience (Dillworth and Jensen , 2010 ). Details of the interven- tions will diff er depending on the exact nature of the problem, the purposes of the clinical endeavor, the goals of the health care pro- fessional , and the abilities and preferences of the young patient and their family (Liossi., 2011). Box 54.3 shows an example of a hypnotic session for chronic pain management and the case ex ample illustrates a hypnosis based therapeutic approach across time. However, it needs to be acknowledged that chronic pain in children is a multifactorial cond ition not easily addressed by one technique only. Multidisciplinary management is required and hypnosis should be part of a cognitive-behavioral treatment framework (see also Zeltzer and Blackett-Schlank, 2005 , Kuttner, 2010 ). Box 54.3 Example of a hypnotic treatment session for chronic pain management Induction and deepening suggestions Get ready to go aboard a submarine for an extraordinary journey under the sea ! Dive deeper and deeper until the water is dark blue \200 look th rough your periscope, peek under fl aps, put your scuba diving equipment on \200 open an airlock \200 and dive into the ocean \200 Analgesic suggestions Th e water temperature is pleasant \200 your body relaxes \200 yo u fl oat happily \200 any discomfort that you may be experiencing is leaving your body \200 dissolving into the water \200 meet ocean animals \200 look at the bottom of the sea \200 Imagine going back in time \200 to a time some time ago, before any pain or discomfort, w hen you were full of energy and had a sense of complete well-being \200 when you come back to the here and now you will feel again th e same sense of well-being \200 Now see the pain \200 what shape is it? \200 see its color? \200 feel its texture? \200 now change the shape, color and texture \200 Ego-strengthening You are going to feel physically stronger and fi tter in every way \200 you will be surprised how enthusiastically you fi nd yourself working on your physio exerc ises \200 you will notice feeling more alert \200 more wide awake \200 every day \200 you \200\231ll be more curious and interested in school and extracurricular activitie s \200 in your friends and family \200 in whatever is going on around you \200 so tha t your mind will become completely distracted away from yourself and your diffi culties \200 you will be able to think more clearly \200 and notice how you become emotionally c almer \200 every day \200 you will feel more and more independent \200 every day \200 you will feel a greater feeling of well-being \200 Post-hypnotic suggestion From now, each and every time you feel these sensations (pain) in your muscles and bones you will immediately take in a deep breath, and as you breathe out y our whole body will relax \200 Termination Now I would like you to count backwards from 5 to 1 \200 1 you are feeling ref reshed and alert and ready to continue with whatever you were doing before \200 CHAPTER 54 hypnosis and relaxation 565 Case example AB, a 17-year-old athlete sustained a severe injury to her shoulder in an unexpected fall. She had several months of physiotherapy with little progress and surgery was recommended to stabilize her shoulder joint. Following surgery she developed a frozen shoulder compli- ca tion resulting in a severely restricted range of motion and exquisitely tender shoulder cap sule. She continued with physiotherapy but now had signifi cant limitations in her capacity to care for herself. Daily pain became part of her life. As a result of continuous pain, she walked protecting h er shoulder from accidental bumps, avoiding crowded places and became increasingly anxious about incurring further pain. Aft er almost 2 years of living with daily pain, physical lim itations, and increasing despair, she was referred for pain management. She presented as an organized, motivated teen, who tearfully stated that pain was a steady part of her life. Despite pain and mobility restrictions, she successfully passed her exams . She complained of continual exhaustion and diffi culty sleeping. She experienced second- ary neck and back pain and presented as emotionally vulnerable and mildly depressed. Treatment Combined with ongoing physiotherapy and pharmacotherapy, hypnosis, and relaxation were used to repattern her brain-body connec- tion so that she could learn to: \227\206 Successfully release tension and relax more eff ectively. \227\206 Develop an awareness of well-being. \227\206 Experience her body as capable of healing. \227\206 Decrease intensity and areas of pain. \227\206 Sleep and wake refreshed. \227\206 Take accurate physical inventory. First hypnosis session \200\224therapeutic focus: use breath to release learned physical co nstrictions. Using her breath as induction, AB was coached into slow rhythmic diaphragmatic breathing to track sensory changes: \200\230Notice how easily your chest opens and how th is invites more comfort into \200 and throughout your body \200 \200\231 \200\230You c an do this eff ortlessly and experi- ence the soft ening throughout your body \200\231 (thi s a more eff ective way of saying, \200\230don \200\231t try so hard ! \200\231). AB reported: \200\230experiencing a huge weight lift ed from me. I feel free and so relaxe d. For the fi rst time in many months, or maybe years, I \200\231m breathing properly. I hadn \200\231t realized I wasn \200\231t breathing proper ly ! \200\231. She undertook to practice this daily Second hypnosis session \200\224therapeutic focus: tar geting release of her secondary neck and back pain. Using a helium balloon as hypnotic meta phor, AB was invited to focus her attention and experience her head \200\230fl oating free ly and light, so that her neck was freed of any needless holding, and her shoulders could h ang-down like an ordinary well-functioning coat-hanger \200\231 AB reported: becoming more aware of her body and wondering if \200\230this protection could be contributing to my pai n ! \200\231. Th is focus helped her stop guarding her arm. Th ird hypnosis session \200 \224therapeutic focus: recreating a stable reliable sleep pattern AB closed her eyes and fo cused on experiencing the physiological process of falling asleep. She was given the sugges tion that she could rely on this occurring each night and her body would restore itself whi le her mind drift ed easily into dreams. In the morning she would wake refreshed, getting o ut of bed with a sense of purpose knowing what needs to be done and doing it comfortably. AB reported improved sleep patterns and as a result, increased energy. Forth hypnosis sessi on \200\224therapeutic focus: empowering her to assess her physical status. Using the \200 \230body scan \200\231 hypnotic technique, AB was invited to shrink herself and travel insi de her body checking out her shoulder, neck, and back and take an inventory and adjust her- self for comfort. At termination AB was still using this technique. Her pain has diminishe d over time, range of motion greatly increased, and her mood improved. Relaxation McCaff ery and Beebe ( 1994 , p. 188) defi ne relaxation as \200\230a state of relative freedom from both anxiety and skeletal muscle tension, a quieting or calming of th e mind and muscles \200\231. Th is situation is char- acterized by decreased intake of oxyg en, decreased muscle tone, lower heart and respiratory rates, normal blood pressure, decrea sed skin resistance and intense, slow alpha-waves in the brain (Bulechek, 1992 ; McCaff ery and Beebe, 1994 ; Watt-Watson, 1992 ). relaxation involves slowly tensing and then releasing each muscle group individually, start ing either with the muscles in the toes and fi nishing with those in the head or visa verse . In autogenic training both visual imagery and body awareness are used to move a per- son into a deep state of relaxation. Th e person imagines a peace- ful place and then focuses o n diff erent physical sensations, moving from the feet to the head. For example, one might focus on warmth and heaviness in the limbs, easy, natural breathing, or a calm heartbeat. B ox 54.4 describes a simple autogenic relaxation exer- cise. Th e two most popular forms of meditation include transcen- dental meditation where the patient repeats a mantra, i.e. a s ingle Th ere are diff erent types of relaxation including tension-release (Jacobson, 1938 ), auto genic (Schultz and Luthe, 1969 ) and medi- tation (Perez-De-Albeniz and Holmes, 2000 ). Ten sion \200\223release SECTION 7 psychosocial interventions 566 headache, whereas small and non-signifi cant eff ects were found for improvements in disabi lity and emotional functioning. Long-term improvements over more than 3 years aft er treatm ent with relaxa- tion, for tension-type as well as migraine headaches, have also been shown . Recently, applied relaxation has been presented via the Internet to children and adolesce nts with recurrent headache with positive eff ects recorded in headache frequency and durat ion and pain catastrophizing (Trautmann and Kroner-Herwig, 2010 ). Box 54.4 Autogenic relaxation technique 1. Choose a quiet place where you won \200\231t be interrupted. 2. Before you start, do a few gentle stretching exercises to relieve muscular tension. 3. Make yourself comfortable, either sitting or lying down. 4. Start to breathe slowly and deeply, in a calm and effortless Th e choice of relaxation technique depends on the pain problem, the patient \200\231s pref erences and abilities, professional availability, and available time. Patterson (Patterson, 1992 ) points out that progres- sive muscle relaxation generally requires lengthy and freq uent train- ing before the technique is suffi ciently mastered. Certain patient populations , burned children for example, are oft en too exhausted and ill to invest the time or have the discipline required to learn these techniques. Taal ( 1998 ) expresses further objectio ns to this technique because the muscles must be tensed before they can be relaxed. Muscle tension in burned parts of the body can further increase pain during wound care. In other w ords, even a simple technique such as progressive muscle relaxation can be inappropri- ate for specifi c pain conditions. More benefi t for these patients can be expected from the us e of alternative techniques such as meditation, hypnosis, or autogenic relaxation (Patterso n, 1992 ; Taal, 1998 ). way. 5. Focus on each part of your body, starting with your feet and working your way up to your face and head. 6. As you focus on each area, think of warmth, heaviness (or lightness) and relaxation. 7. Imagine any distracting thoughts \202 oating away like the bub- bles in a \201 zzy drink. 8. Stay like this for about 20 min, then take some deep breaths and open your eyes, but sta y sitting or lying for a few moments before you get up. word or phrase and mindfulness meditation. Mindfulness refers to a particular way of paying attention, that is purposefully paying attention to moment-to-moment experience in a non-j udgemental and accepting manner (Kabat-Zinn, 1996 ). As yet, research within child and adol escent populations is in its initial stages, although preliminary results of a clinical tri al have evidenced the ability of children and adolescents with chronic pain to engage with the mindfulness material and adhere to regular home practice of the techniques and apply th em to presenting problems (Golianu and Waelde, 2012 ). Aft er successful implementation in adult health practice, mindfulness meditation groups are beginning to gain traction in pedi atric settings. Conclusion Hypnosis and relaxation are useful therapeutic techniques for the management of acute and chronic pediatric pain, although evidence for their effi cacy varies depending on the type of pain. Hypnosis is an evidence-based intervention for procedure-related pain, a nd appears promising in the management of chronic pain with large, well-designed studies wi th robust methodologies, adopting standardized formats for interventions, needed to develop a fi rm research evidence base. Th ere is strong evidence that relaxa- tion can reduce pai n in children with headache both in the short and long term and some evidence that it can r educe pain outcomes in both acute and chronic non-headache pain, but in these cases relaxat ion is better utilized as a part of multicomponent interven- tion rather than a standalone treatment. Although, approximately 43% to 58% of pediatric hospitals in the US use relaxation across a variety of acute pain situations (O \200\231Byrne et al., 1997 ) doubt exists in the pedia tric pain literature regarding the effi cacy of relaxation as an analgesic in acute pain ma nagement. Similarly relaxation in chronic pain is usually part of a multicomponent cognitiv e-behavioral intervention, and can be used as a fi rst step to establish changes in muscle tension release and some personal competency. References Apkarian , A. V. , Bushnell , M. C. , Treede , R. D. , and Zubieta , J. K. ( 200 5 ). Human brain mechanisms of pain perception and regulation in health and disease . Eur J Pain , 9 , 463 \200\223484. Th ere is a large body of related therapies with conceptual and prac- tical similarities th at are grouped together under the term \200\230relaxa- tion therapies \200\231 (NIH Techno logy Assessment Panel, 1996 ) and a corresponding large body of literature examining the ef f ectiveness of these treatments in children with headache. Overall, even though most of th ese studies include children with poorly defi ned or sev- eral diff erent types of headache s, this literature indicates that these techniques are eff ective. 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Online supplementary materials Video 54.1 Hypnosis for procedural pain management: \200 \234Favorite Place \200\235. Reproduced with permission from Leora Kuttner (dir.), No Fears No Tears , Copyright 1985. Trautmann , E. and Kroner-Herwig , B. ( 2010 ). A randomized controlled trial of Internet-b ased self-help training for recurrent headache in childhood and adolescence . Behav Res Th er , 48 , 28 \200\22337. Video 54.2 Hypnosis for procedural pain management: \200\234Th e Magic Glove \200\235. Rep roduced with permission from Leora Kuttner (dir.), No Fears No Tears , Copyright 1985. Trautmann , E. , Lackschewitz , H. , and Kroner-Herwig , B. ( 2006 ). Psychological treatme nt of recurrent headache in children and adolescents \200\224a meta- analysis . Cephalalgia , 26 , 1411 \200\2231426. Uddin , L. Q. , Supekar , K. S. , Ryali , S. , and Menon , V. ( 2011 ). Dynamic reconfi gur ation of structural and functional connectivity across core neurocognitive brain networks w ith development . J Neurosci , 31 , 18578 \200\22318589. Video 54.3 Hypnosis for acute pain management: Focussed breathing. Reproduced with permissi on from Leora Kuttner (dir.), No Fears No Tears , Copyright 1985. Uman , L. S. , Chambers , C. T. , McGrath , P. J. , and Kisely , S. ( 2006 ). Psychological interventions for needle-related procedural pain and distress in children and adolescents . Cochrane Database Syst Rev , 4 , CD005179 . Video 54.4 Hypnosis for persistent pain management: Dissociation Imagery. Reproduced with p ermission from Leora Kuttner (dir.), No Fears No Tears , Copyright 1985. CHAPTER 55 New information and communication technologies for pain Jennifer Stinson and Lin dsay Jibb Summary Th e rapid growth in the amount and availability of information and communication t echnology (ICT) in the last decade means that several new tools have become available to mo nitor and manage chronic pain. Th ese tools include the Internet (and associated social sup port networks), mobile phones, and telemedicine and they are being used to enable self-mana gement by people suff ering from persistent pain. Th e benefi ts of ICT-based pain therapie s are many and include improved treatment accessibility and satisfaction, as well as potent ial decreases in therapy cost. ICT therapies for people in pain represent exciting treatmen t possibilities. Future, rigorous research into the design and eff ectiveness of these ther apies will shed more light on how ICT might improve the quality of life for people with chr onic pain. Smartphone applications (apps) for the management of chronic pain are reviewed. Future dire ctions for theory, research, and clinical practice are also described. Chronic pain self-management Chronic pain is common in adults (Johannes et al., 2010 ) as w ell as children and adolescents (King et al., 2011 ) and can negatively impact all aspects of life including physical, emotional, social, and role functioning (Law et al., 2012 ; Pal ermo, 2000 ; Reid et al., 2011 ). Chronic pain may include varying amounts of disability an d may be independent of the amount of tissue damage and perceived severity of injury (Hugue t and Miro, 2008 ; Melzack and Wall 1965 ). In the likely absence of a cure or total pain r elief, the prevention of pain-related disability and the improve- ment of quality of life t hrough better chronic pain self-manage- ment are critical (Ritterband et al., 2003 ). Self- management can be defined as \200\230the individual \200\231s ability to manage the sympto ms, treatment, physical, and psychological consequences and life- style changes inherent in living with a chronic illness \200\231 (Barlow et al., 2002 ). Introduction Over the past decade there has been tremendous growth in the development and e valuation of ICT to deliver health care inter- ventions including those for the treatment o f chronic pain. Results from a 2010 telephone survey of 3001 American adults showed that 80 % of Internet users accessed health informa- tion online and 14% accessed information speci fi c to managing chronic pain (Fox, 2011 ). From a public health perspective, there is grea t potential for self-administered treatments to improve the health of individuals who suff er from chronic pain but are unable to access services. ICT-based programs off er an inno- vative approach to improve the availability, accessibility, and acceptability of these prog rams. Th is chapter will review ICT for pain by: defi ning chronic pain self-management, di scussing barriers to the provision of pain self-management and psycho- educational interven tions, and discussing methods by which ICT can overcome these barriers. Th e theories, proc esses, and content elements of ICT-based chronic pain programs are defi ned and described. Th e evidence, where available, from treatment inter- vention trials and the advantages and disadvantages of telehealth, internet-based programs, and mobile-health (m-health) or Self-management interventions that provide individuals with knowledge about pain, strategie s to manage pain (cognitive- behavioral therapies or CBT), and social support are needed to promote optimal health outcomes. Studies in adult chronic ill- nesses (Foster et al., 2007 ; Lorig and Holman, 1993 ; Smith et al., 2005 ) have shown that comprehensive interactive face-to-face psycho-educational interventions lead to symptom reduction and improved qualit y of life compared with care that is strictly medication focused. Th e proposed mechanism o f eff ect for this phenomenon is presumed to be enhanced self-effi cacy (i.e. belief in one \200\231s ability to successfully perform a behavior) and empow- erment over disease and s ymptom management (Marks et al., 2005a , 2005b ). For example, Lefort and colleagues (1998) found that a 12-h community-based, chronic pain psycho-educational program led to signifi cant short-term improvements in pain, independence, vitality, aspects of role functioning, life satisfaction, SECTION 7 psychosocial interventions 570 self-effi cacy and resourcefulness compared to a wait-list control group in adults with chr onic pain. (Griffi ths et al., 2006 ; Ritterband et al., 2003 ). Using ICT to deliver health intervent ions dramatically reduces geographic constraints, provides opportunities for access regardl ess of language spoken and travel constraints (fi nancial or due to physical disability) an d pro- vides more immediate access to information that can help patients feel less isolated and more in control of managing their chronic condition (Griffi ths et al., 2006 ; Nguyen et al., 2004 ). Variations in pain-related disability exist in young people and adults with chronic pain. H owever, the majority of the variance is related to several physical, psychological, and soc ial variables (Bargiel-Matusiewicz and Krzyszkowska, 2009 ; Lynch et al., 2007 ). Th us, in tervening in the pain experiences of young people and adults with chronic pain requires a b road framework that compre- hensively addresses the physical and psychosocial precipitants, as well as modifi ers and consequences, of chronic pain (Rapoff and Lindsley, 2000 ). Th e most successful interventions in improving pain and associated impairments in adults with chronic health conditions (including pain) are based on CBT (LeFort et al., 1998 ). CBT inc orporate normalization of the patient \200\231s experience through education about the cond ition and its impact, training in specifi c strategies, including managing disease-related and other stressors, and guidance on developing and implementing a long-term plan for self- managing the condition (Palermo et al., 2010 ).