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. Disability is an interaction between impairments in body struc- tures and functions and env ironmental and social contextual fac- tors experienced throughout life. For example, a scho ol-aged child with juvenile idiopathic arthritis with impaired lower extremity function res ulting from infl ammation, pain, and loss of muscle strength at the knee may be limited in the ability to run or walk for long distances. Th is may restrict participation in aft er s chool activi- ties such as a community basketball team. Th e traditional approach to PT treatment focused on strength- ening exercises and modaliti es to reduce pain and infl ammation. A participation focused approach also includes an eval uation of the specifi c activities and may include evaluation within the spe- cifi c enviro nment where the child experiences the participation restrictions to determine if the enviro nment or activities could be adapted to improve participation. Treatment planning would inc lude traditional therapies to address the impairments in body functions and structures, but may consist of specifi c functional activities aimed towards improved participation and pe rform- ance of the desired activities. For example, rather that providing a quadriceps stre ngthening exercise in isolation, the child may be provided with basketball drills that buil d quadriceps strength. Th is approach addresses the impairment in the context in which it i s needed, and improves the child \200\231s motivation to participate in the intervention. Motivational interviewing may be used to explore a youth \200\231s thoughts and feelings ab out the present functional abilities, dis- crepancies between the current state and wishes for the future, readiness to change, and confi dence in the ability to make changes (Suarez and Mullins, 2008). Information gathered from the inter- view is used to design a PT progr am that is individualized and tailored to the child \200\231s functional goals and refl ect s their interests and values (Ayling-Campos et al., 2011). By focusing on the child \200 \231s goals, their motivation and self-effi cacy is enhanced and their role as an active an d capable partner in their health and functioning is acknowledged. Using the ICF-CY framewo rk, this approach shift s the focus of therapy towards age appropriate activity and partici pa- tion goals and away from the impairment of pain or other func- tional limitations. Treatment may also include modifi cations to the activities or environments in which they a re performed, including prescription of adaptive equipment such as supportive braces as wel l as discus- sions with parents, teachers, and coaches to facilitate modifi cations that en able the child to fully and safely participate. Graded physical activity programs are a primary compo- nent of PT interventions that are ef f ective in reducing pain and improving physical functioning and participation (Woods and A smundson, 2008). Th e following guideline has been used in pre- scribing graded exercise pr ograms for children with chronic pain. For each form of activity or exercise, the therapist deter- mines the child \200\231s baseline, which represents 50% of that activity or exerci se performed to tolerance (Eccleston and Eccleston, 2004). Tolerance can be determined eith er through the subjective history, or a physical performance test. For example, if a child \200\231s tolerance for walking is 10 min, their baseline for walking would be 5 min. Targe ts for increasing activity, both physical activity interven- tions and activities of daily living, should be negotiated between the therapist and the patient, and performance of acti vity each day should be based on these goals, not based on the pain experienced Active therapies for pain in children Across diverse health conditions, treatment adherence , health out- comes, and satisfaction with care are improved when children and adolescents are treated as partners and are actively engaged in mak- ing decisions about managing their health (Levetown, 2008). Active therapies include therapeutic exercises and general condit ion- ing activities. Th erapeutic exercises address specifi c impairments of body structure s or functions such as limited range of motion of a joint or muscle, limited strength, impa ired proprioception or balance or impaired cardiovascular conditioning. Th erapeutic SECTION 8 physical interventions 584 (Eccleston and Eccleston, 2004). Th is \200\230pacing \200\231 approach provides a clear p lan for progression with specifi c physical activity targets for each day. Th e probable me chanism of reduction of pain by activity pacing is through modifi cation of the threshold f or generation of pain neurosignatures by re-establishing homeostasis. However, it is also p ossible that graded activity reduces fear of movement through successful participation in g entle activities. As the child performs movements and activities without eliciting feared r esponses (e.g. fl ares of pain or incapacitation) the child may alter his or her cogni- tiv e evaluation of the sensory information from the movement or position as non-threatening. Evidence to support the safety of PT manipulations and mobi- lizations of the spine and ext remities for pain in children is lack- ing (Bronfort et al. 2010); therefore literature on the incidence of adverse events from osteopathic and chiropractic manipulations will be dis cussed. Serious adverse events such as permanent neu- rological impairments have been repor ted (Humphreys 2010). Retrospective fi le reviews reported incidence rates of adverse event s with spinal manipulations in children ranging from 0.53% to 9% for minor adverse events s uch as temporary increase in signs or symptoms (Hayes and Bezilla, 2006; Miller and Benfi e ld, 2008). No serious adverse events were reported in these three studies; how- ever, retro spective chart reviews are prone to biases since there is not a rigorous standardized proto col or surveillance system, and results of these reports should be interpreted with these l imitations in mind. Adverse events may be underreported by children, given that the inciden ce of adverse events reported in the adult literature is much higher, and underreporting of symptoms is typical of chil- dren (Morrow et al., 2012). Th e risk of serious adverse even ts in adults is estimated to be approximately 0.01% (Th iel et al., 2007). Skeletal immatur ity at the growth plates results in a relative struc- tural laxity and reduced resilience o f the bone to withstand trauma in children (Scheuer and Black, 2004). Th e developing spine and soft -tissue structures should not be considered equivalent to adults for risk of adve rse events. Graded motor imagery (GMI) may be a helpful strategy to use early in the rehabilitation pro cess for children who experience such severe pain that movement of the aff ected body part is not tolerable (see case example at the end of the chapter) (Moseley et al., 2012). GMI c onsists of three components that are introduced in a spe- cifi c sequence: (1) laterality r econstruction where the child simply looks at pictures of hands or feet and identifi es the m as being left or right, (2) motor imagery training where the child is asked to imag- ine moving the painful limb and (3) mirror therapy which requires the child to place the painfu l limb inside a mirror box and watch the refl ection of the unaff ected limb as it appears to be the aff ected limb moving. Mirror therapy relies on a visual illusion to \200\230tri ck the brain \200\231 into assuming the painful limb is moving. GMI improved function and r educed pain in adults with chronic pain (Moseley et al., 2012). Massage Th ere is limited evidence to support the use of massage for the treat- ment of pai n in children. Massage has shown moderate eff ectiveness for treatment of pain from burns ( Parlak Gurol et al., 2010), head- ache (von Stulpnagel et al., 2009), juvenile idiopathic a rthritis (Field et al., 1997), and in children attending an outpatient chronic pain clinic (Suresh et al., 2008). None of these studies were blinded and are therefore prone to biases . No studies were found that examined incidence of adverse events from massage therapy for the treatment of pain in children; however, based on the adult literature on adverse events , the rate is expected to be low (Ernst, 2003). Passive therapies for pain in children PTs are trained in the use of manual therapy and the rapeutic modalities for treatment of pain and other functional and struc- tural impairments in the body. Th ere is currently limited evidence to support or refute the eff ectiveness or safety of these treatments for use with children. Passive therapies may have a place in the management of pain, particularly acute or procedural pain as they have the potential to modify sensory input and alter the production of a pain neurosignature; however, evidence is needed to support this hypothesis. In this section, the more commonly used passive thera pies will be reviewed. Th erapeutic modalities Th erapeutic modalities most commonly applied for pain relief inclu de TENS, thermal agents (heat and cold), therapeutic ultra- sound, and low-level laser. Manual therapy Mobilization and manipulation of the spine and extremities Th e therapeutic eff ect of joint mobilization or manipulation for pain in adults has been reported in sever al randomized control- led trials (RCTs) and systematic reviews (Bronfort et al., 2010). Fi ndings indicate generally favorable support for joint mobiliza- tions or manipulation for a cute or chronic non-specifi c low back pain without peripheral radiation, acute or chronic neck pain (when combined with exercise), migraine or cervicogenic head- ache, and several d isease or injuries of the upper or lower extremi- ties (Brantingham et al., 2009; Posadzki and Ernst, 2011). Studies on the eff ectiveness of joint manipulations or mobilizations in chil- dren have been primarily limited to non-pain conditions such as asthma (Bronfort et a l., 2010). An RCT comparing spinal manipu- lations to sham manipulations in children with c ervicogenic head- ache showed no diff erence between groups for days with headache, headach e duration, school absence, analgesic consumption, or pain intensity (Borusiak et al., 2010 ). Transcutaneous electrical nerve stimulation TENS is an easy to use therapy that delivers an electrical current through a stimulation unit with electrodes attached to the skin. TENS i s thought to decrease pain by delivering a competing sensa- tion through stimulation of A-b eta nerve fi bres that reduce aff erent nociceptive activity of A-delta and C nerve fi bres if the stimulus is below pain threshold (conventional, or high-frequency TENS), or through stimulation of endogenous opiate production and descending endogenous neural pathways if t he stimulus exceeds pain threshold (low-frequency, or motor-level TENS; Prentice, 2011). Se ttings for type of current, waveform shape, amplitude, duration, rate of rise and decay, an d frequency can be modifi ed to produce various physiological and therapeutic eff ects. Ele ctrode size and placement can be altered to aff ect the depth and density of tissue stimula tion. TENS is eff ective in reducing acute and chronic nociceptive and neuropathic pain in adults (Nnoaham and Kumbang, 2008; Yameen CHAPTER 56 physical therapy interventions for pain in childhood and adolescence 585 et al., 2011) and procedural pain in children (Lander and Fowler- Kerry, 1993). For pain re lief, electrodes should be placed over or around the painful area or over the appropriate c orresponding der- matome corresponding (Prentice, 2011). Alternatively, electrodes may be p laced over muscle trigger points, acupuncture points, or superfi cial peripheral nerves. Si nce there is wide interindividual variability in response to TENS, several trials of electr ode place- ment and nature of the current applied may be necessary to fi nd the greatest pa in relief for each client. thought to occur as a result of reduced nerve conduction velocities, anti-infl ammatory or tissue healing eff ects (Prentice, 2011). Precautions and limitations of passive therapies Th ere are specifi c precautions and contr aindications for the use of all thermal and electrophysical agents (Houghton et al., 2010). A qualifi ed health professional such as a PT should be consulted for appropriate home use of modalities such as TENS. Th erapeutic modalities may not be appropriate for children wi th vascular impairments, active infection, malignancy, recently radiated tissue, impaired s ensation of the treatment area, and inability to commu- nicate discomfort from the treatmen t (Houghton et al., 2010). Many patients can be taught to apply this therapy with a pre- programmed light-weight, port able, battery operated unit at home. Pain relief with conventional TENS has a rapid onset ( <1 h) for the majority of patients; however, pain levels typically return to pre- treatment levels within 1 h of discontinuation of the stimulation (Johnson et al., 1991). Th erapists are urged to carefully weigh the benefi ts and limitations of passive therapies for children with persistent pain conditions. Given the limited empirical support and lack of evidence for safety for use with children and adolescents, passive therapies should onl y be used as part of a comprehensive, goal-oriented program and not as a substitute for act ive therapies. Further research is needed to examine safety and eff ectiveness of these the rapeutic approaches for pain in childhood. Although passive therapies may have a place in t emporarily reducing symptoms, and may be particularly use- ful for treatment of acute or pr ocedural pain, PTs are urged to use caution in the application of these therapies with chil dren with persistent pain conditions. Injudicious use of passive therapies can provide fals e hope to patients for a \200\230cure \200\231 and foster dependence on passive therapies as a means of coping with pain. Th ermal agents PTs use heat and cold to reduce pain and infl ammation through the use of w arm or cold whirlpools, contrast baths, hot-packs (hydro- collator packs) or ice packs, ice massage, cryospray, warm paraf- fi n baths, or fl uidotherapy. Pain relief with the applic ation of heat or cold is thought to occur through stimulation of the cutaneous nerve recept ors and activation of A-beta nerve fi bres with both heat and cold and reduction of rate of fi ring of nociceptive A-delta nerve fi bres with tissue cooling (Prentice 2011). Physiolo gical eff ects of increased superfi cial circulation with the application of heat, or decre ased circulation with the application of cold can have indirect eff ects on pain through th e reduction of muscle spasm or infl am- mation (Prentice 2011). Hot and cold packs, warm or cold baths and ice massage are inexpensive treatments that can be taught to patients for h ome use as a component of the PT regimen for man- agement of pain. Th erapeutic relationship and pain education Th e relationship between the patient and the PT is integral to the therapeutic process and a predictor of outcome. PTs are uniquely posi tioned to develop a positive therapeutic relationship by virtue of the frequency and durati on of interventions with children and their families. Th e provision of pain education thro ugh a family centered lens which is individualized to the patient is a vital compo- nent to wards the development of a therapeutic relationship. Th erapeutic ultrasound Th erapeutic ultrasound delivers high-frequency sound waves (1 \200 \2233 MHz) which produce thermal and non-thermal physiologi- cal eff ects with deeper tissu e penetration than superfi cial thermal agents or electromagnetic radiation (Prentice, 2011 ). Ultrasound intensity, frequency, and pulse duration can be modifi ed to alter the depth of penetration, and clinical eff ects. Ultrasound is thought to increase local blood circul ation and tissue metabo- lism, thereby promoting soft -tissue healing, tissue remodel- ling , improved tissue mobility, and reduction of infl ammation (Prentice, 2011). Pain relief is thought to occur through thermal eff ects. In a systematic review of 13 studies involving adults with several pathologies, the therape utic alliance between patients and the PT was positively associated with improved treatment adherence, treat- ment satisfaction, physical function, and reduced pain (Hall et al. 2010 ). No studies were found that examined the impact of the thera- peutic relationship between the PT and child with chronic pain on treatment outcomes during rehabilitation. However, c hildren with chronic pain oft en report diffi culties in encounters with health care provid ers such as a perceived lack of understanding of their pain experience, judgment, and disbe lief. Th ese unsuccessful healthcare interactions can lead children and their families to b ecome disillu- sioned, develop a guarded approach and a tenuous relationship in dealing wit h healthcare professionals (Dell \200\231Api et al., 2007). Many studies reporting reduction of pain with ultrasound treat- ment have been criticized f or methodological quality (Rutjes et al. 2010). However, there is evidence to support use o f ultrasound for pain relief in adults with lower extremity osteoarthritis (Rutjes et al. 2 010) and upper extremity musculoskeletal injuries (Green et al., 2003). No studies were fou nd that examined ultrasound use for treatment of pain in children. Th ree main components of the therapeutic relationship have been identifi ed patient and PT agreement on treatment goals, agreement on the intervention, and the aff ective bond betwe en patient and PT (Daniels and Wearden, 2011). In a qualitative study involving 53 children ages 10 to 17 living with chronic pain, Meldrum et al. (2009) reported that solicitation o f a pain narrative is an important part of the therapeutic process and that clinicians who were willing to listen to the child \200\231s story about his or her pain condition would b e in a position to assist the child in making posi- tive therapeutic changes. Low-level laser Low-level laser is a form of electromagnetic energy that produces little or no thermal energy with outputs of less than 1 milliwatt (Prentice 2011). Laser has been us ed for wound healing, reduction of oedema, scar tissue, and bone remodeling, and pain reduc tion with lateral epicondylitis, acute and chronic neck pain, osteoarthritis, and myofascia l pain syndrome (Chung et al., 2012). Pain reduction is SECTION 8 physical interventions 586 Th is reinforces the importance of identifying patients \200\231 functional, structural, an d participation goals, and their expectations regard- ing the outcome of active and passive therapies. Agreement on the therapeutic goals and interventions can only be achieved with the provision of appropriate education about what are realistic expecta- tions of therapy, and what actions on the part of the PT and patient are required in order to attain these go als. therapy (McKearnan et al. 2004). Fift y-three per cent reported pain during a therapeutic h ome program. Almost one-third of children with cystic fi brosis complain of pain during PT (Sermet- Gaudelus et al. 2009). Th e management of burn injuries is a source of pain and fe ar for children and their caregivers (Ratcliff et al. 2006). Clearly, there is evidence tha t the procedures commonly used by PTs to address impairments that accompany multiple childh ood diagnoses are a source of stress and pain to the children and their caregivers. Pain education should not be considered a one-way delivery of information from the therapis t to the patient; rather, it is an oppor- tunity to build the therapeutic relationship (Van Oosterwijck et al., 2011). PT specifi c pain education should address gaps between the chi ld \200\231s beliefs about the expected outcome of PT and the types of PT needed to achieve the child \200\231s goals. It is essential to address misconceptions early in therapy and provide appropriate informa- tion to the child and his or her family on realistic outcomes from therapy regarding changes in pain, structural or functional impair- ments and return t o participation in activities. It is also essential to address any misconceptions about the types of therapy that would be required to achieve the set goals. By providing information on pain neurophysiology and the expected outcomes form various therapies the PT can addres s these misconceptions and work with the child to develop a mutually agreeable plan for the rapy. Research is urgently needed to identify the prevalence and con- sequences of procedural pai n from PT treatments, and pain-min- imizing interventions that can be used during PT. Th is research is necessary to support the development of PT-specifi c guidelines towards elimin ating unnecessary pain producing procedures and employment of prophylactic pain management techniques during procedures that are deemed necessary. As an example, this section will di scuss pain management during stretching exercises with sug- gested strategies for reducing pain. Pain management during stretching exercises Stretching exercises are necessary for improvem ent of joint, muscle, and scar tissue range of motion for a variety of painful conditions s uch as CP, burns, muscular dystrophy, and juvenile idiopathic arthritis (Tecklin, 2008). St retches may be performed independ- ently (active), or with full (passive) or partial assist ance (active- assisted) from a care-giver or health care provider such as a PT or PT aide. Interventions for pain management occur before, during and aft er the actual procedure. Tab le 56.1 provides an overview of examples at each stage. Procedural pain management in children Physical therapy procedures are increasingly being r ecognized as a source of pain for children receiving therapy services. Adults with cerebral palsy (CP) report that the pain related to PT interventions of stretching and bracing were the most salient negative memories of childhood (Kibele, 1989). Th e activity most frequen tly identi- fi ed as painful by parents of children with CP was assisted stretch- ing (Hadd en and von Baeyer, 2002). Additional painful activities included independent standing, assi sted walking, assisted sitting, and donning splints. Fift y-eight per cent of children with develop- mental disabilities reported pain during physical or occupational Caregivers should be provided with information regarding the necessity and goals of the exe rcise, what will occur, and expecta- tions of them during the stretches. Parents should be taught to avoid distress promoting behaviors, such as reassurance, apologies, or being over ly empathic about the child \200\231s pain (Chambers et al., 2002). Table 56.1 Strategies for procedural pain management during stretching exercises Timing Strategy Example Before procedure Prepare environment to facilitate relaxation Private space for stretching in school to avoid unwanted peer attention Prepare child or caregiver for procedure with age appropriate language. Sensory information: \200\230Some people say this feels like a pinch, others say it feels like a pull. I want you to tell me what it feels like for you \200\231 Procedural information: \200\230For this stretch you will reach up with both hands to touc h that mark on the wall, like this (demonstrate). We \200\231ll count backwards slowly from 20 and we \200\231ll do that 3 times with a rest between each stretch \200\231 Pair non-pharmacological and pharmacological strategies Time therapy with maximum pharmacological e \200 ectiveness or breakthrough medications During procedure Coping-promoting therapist behaviors Prompt to use coping skill, non-procedural talk Cognitive-behavioral methods Distraction (e.g. blowing bubbles, toys, storytelling, books, music, television, virtual re ality), guided imagery, relaxation, breathing exercises, thought stopping Positions of comfort Young child sitting in parent \200\231s lap reading a book during manual therapy After procedure Reinforce use of coping strategies Reinforcement: \200\230You did great using your deep breathing during that stretch \200 \231 Evaluate pain-relieving strategies Was child able to tolerate procedure? Can procedure or coping strategies be modi \201 ed t o improve e \200 ectiveness or pain relief? Source: data from von Baeyer, C.L. and Tupper, S.M, Procedural pain management for children receiving physiotherapy, Physiotherapy Canada , Volume 62, Number 4, pp.327 \200\223337, C opyright 2010 University of Toronto Press. CHAPTER 56 physical therapy interventions for pain in childhood and adolescence 587 Th erapist behaviors also infl uence pain and distress responses during painful procedures. Miller et al. (2001) found that when PTs promoted use of coping strategies, there was redu ced distress and increased coping in children with CP, whereas reassuring com- ments such a s \200\230it \200\231s almost over \200\231 and criticism increased distress and reduced c oping during rehabilitation. Physical therapy initial assessment: On observation, Will dis- played a left resting claw-h and deformity, wasting of the thenar eminence and fi rst interosseous muscles, oedema, and signifi - cant color changes (purple/blue skin color over the dorsal and palmar surface of the left hand and all digits to the distal third of the forearm). Active and passive range of motion, resisted tests, and strength testing could not be performed due to intense pain. Sensory examination revealed left hand and forearm light touch allodynia with temporal sum mation, decreased sensation and increased pain in response to cold stimulus, and pin prick hyperalgesia. Th ere was a positive modifi ed upper limb neuro- dynamic test 1. Will \200 \231s overall presentation was consistent with the Budapest clinical diagnostic criteria fo r CRPS probable type I (Harden et al., 2007). Cognitive behavioral methods that may be appropriate to lessen pain experiences of children during PT procedures include distrac- tion, guided imagery, relaxation, breathing exercise s, and thought stopping (von Baeyer and Tupper, 2010). Th e PT or caregiver may reinforce t he child \200\231s use of coping strategies by providing positive statements or tangible re wards, such as stickers, prizes, or praise. Th e PT should refl ect upon the procedure and evaluate the measures that were used to alle viate distress and pain responses. Questions to be considered include: Physical therapy management: PT management consisted of a 2-week trial of daily mirror ther apy. CRPS is considered a cen- tral nervous system condition with changes to the primary mo tor and sensory maps that represent the painful body part (McCabe, 2011). Mirror visual fee dback may correct sensory and motor remapping through short term cortical plasticity, there by reliev- ing pain. Th e mirror therapy approach involved Will placing his left hand behin d a mirror which was situated in front of his chest in a sagittal plane. Th is positioning hid his aff ected hand from view, allowing him to view the refl ection of his asymptomatic hand as if it were the aff ected side. Will performed a series of hand exercises with his r ight (asymptomatic) hand while observ- ing this hand refl ected in the mirror. Movement act ivities were structured according to diffi culty and were tailored to simulate his treatmen t goals. Each session began with cardinal hand and wrist active range or motion followed by more complex func- tional tasks requiring more upper extremity dexterity. Mirror therapy w as performed twice daily for 30 min each session. \227\206 Was the strategy appropriate for the child \200\231s developmental level? \227\206 Are the parent and child satisfi ed with the strategy for prevention of pain? \227\206 Was the strategy adequately eff ective in preventing or alleviating the child \200\231s pain? \227\206 Was it paired with pharmaceutical interventions if appropriate (i.e. burn care or post-surgical rehabilitation)? \227\206 If the procedure was experienced as painful despite appropriate measures, is ther e research to justify continuing with this proce- dure or can an alternative treatment be i mplemented? Recommendations PTs are an integral component of multidisciplinary management of pain in ch ildren. However, in view of the paucity of evidence supporting the use of passive therapies for pain management in this population, therapists are encouraged to consider a compre- he nsive theory-based approach to treatment with an emphasis on active therapies. Treatment pl anning must be focused on return- ing children to patient or care-giver identifi ed partici pation goals. Th erapists are encouraged to provide opportunities early in the therapeutic process for the child to tell in their own words the story about their pain experience in o rder to identify treatment goals and establish a benefi cial therapeutic alliance. Inactivi ty and fear of movement should be addressed through motivational interviewing, education, a nd graded activity programs. Many PT procedures are painful for young patients, and therapi sts are recommended to consider applying a wide range of procedural pain management techniq ues to minimize or eliminate pain during therapy. Outcomes: Will reported immediate pain reduction following each mirror therapy session by 2 to 4 points on a 10-point scale which was maintained for an increased amount of time with each successive session. In addition, Will reported a signifi cant decrease in the burning sensation and a \200\230more normal feeling \200\231 in his left hand following each sessi on. Aft er 2 weeks of daily mirror therapy, the distribution of his symptoms was reduced an d Will reported his baseline pain at 5/10 which he now characterized as \200\230tingling \200\231 over the palmar aspect of the third digit. On physical re-assessment, Will display ed persistent wasting of the left thenar eminence and fi rst interosseous, however the vaso motor and sudomotor changes observed on initial assessment were resolved. Full active range of motion of the hand, wrist, and forearm was observed. Sensory examination revealed the p resence of residual pin prick hyperalge- sia over the palmar aspect of the left third digit only. No allodynia and normal sensation to cold stimuli was noted. Despite persistent base line pain at 5/10, Will was able to successfully return to playing video games aft er the 2 -week PT mirror therapy. Case example: mirror therapy for unilateral upper extremity pain Patient history: Will, a 17-year-old male, was referred to PT by his palliative care physic ian, diagnosed with a nasopharyngeal rhadomyosarcoma with an abdominal recurrence of metast atic dis- ease. He received radical abdominal surgery including a nephrec- tomy, splenectom y, and distal pancreatectomy (see Box 56.1) . Acknowledgement Susan Tupper is the Coordinator of Integrated Pain Strategy and Research fo r the Saskatoon Health Region, and Clinical Assistant Professor at the School of Physical T h erapy, University of Saskatchewan. Medications: fentanyl and morphine as a part of abdominal surgery pain management. Gabapent in at 300 mg three times daily was added at the same time as the consult to PT. SECTION 8 physical interventions 588 Goldstein, D. N., Cohn, E., and Coster, W. (2004). Enhancing participation for children wit h disabilities: application of the ICF enablement framework to pediatric physical therapy p ractice. Pediatr Phys Th er , 16 , 114 \200\223120 . Hadden, K. and von Baeyer, C. (2002). Pain in children with cerebral palsy: Box 56.1 Patient history for case example 7-day history of acute left hand pain and decreased sensation following routine, uncomplica ted arterial line insertion. common triggers and expressive behaviors. Pain , 99 ( 1 \200\2232 ), 281 . Hall, A. M., Ferreira, P. H., Maher, C. G., Latimer, J., and Ferreira, M. L. (2010). Th e i nfl uence of the therapist-patient relationship on treatment outcome in physical rehabilita tion: a systematic review. Phys Th er , 90 (8), 1099 \200\2231110 .