A Mind–Body Approach to Pediatric Pain Management

Children 2017, 4, 50

Review

Melanie L. Brown 1,2,*, Enrique Rojas 1 and Suzanne Gouda 1

1 Department of Pediatrics, The University of Chicago, Chicago, IL 60637, USA erojas@peds.bsd.uchicago.edu (E.R.); Suzanne.Gouda@uchospitals.edu (S.G.)

2 Department of Pain, Palliative Care and Integrative Medicine, Children’s Hospitals and Clinics of Minnesota, Minneapolis, MN 55404, USA

* Correspondence: melanie.brown@childrensmn.org

https://www.mdpi.com/2227-9067/4/6/50/htm1

Academic Editor: Hilary McClafferty

Abstract: Pain is a significant public health problem that affects all populations and has significant financial, physical and psychological impact. Opioid medications, once the mainstay of pain therapy across the spectrum, can be associated with significant morbidity and mortality. Centers for Disease and Control(CDC) guidelines recommend that non-opioid pain medications are preferred for chronic pain outside of certain indications (cancer, palliative and end of life care). Mindfulness, hypnosis, acupuncture and yoga are four examples of mind–body techniques that are often used in the adult population for pain and symptom management. In addition to providing significant pain relief, several studies have reported reduced use of opioid medications when mind–body therapies are implemented. Mind–body medicine is another approach that can be used in children with both acute and chronic pain to improve pain management and quality of life.

Received: 1 March 2017; Accepted: 13 June 2017; Published: 20 June 2017

From the Review:

3.2. Selected Mind–Body Approaches
3.2.1. Meditation and Mindfulness. Over the past few decades, mindfulness has emerged as a fundamental component of numerous therapies and interventions for a wide spectrum of clinical aliments [55]. Mindfulness, described as “the awareness that emerges through paying attention on purpose, in the present moment, and non-judgmentally to the unfolding of experience moment by moment”, is a meditation practice with ancient Buddhist origins that focuses on experiencing the present moment unobstructed by bias or judgmental thinking in an effort to improve cognitive and emotional well-being [56]. One such application of mindfulness is Kabat Zinn’s Mindfulness-Based Stress Reduction (MBSR), a group intervention first introduced in 1990 that focuses on mindfulness meditation training as a complimentary therapy to the standard medical treatment of chronic pain and illness [57–64]. Research has suggested that mindfulness can improve symptoms associated with medical illnesses and increase quality of life [65]. From a neuroscientific perspective, magnetic resonance imaging (MRI) and functional magnetic resonance imaging (fMRI) studies have been conducted in hopes of identifying the neural mechanisms that are responsible for the efficacy of mindfulness meditation in pain relief [66–73]. In one study, thirteen skilled Zen mediators, each having had a minimum of 1000 hours of meditation experience, were recruited and experimentally exposed to pain via thermal stimuli while in an MRI [70]. During exposure to pain, the meditators exhibited increased brain activation in the insula, thalamus, and midcingulate cortex; areas associated with the sensory aspect of pain. Additionally, decreases in brain activity were observed within the hippocampus, amygdala, and caudate; areas responsible for there collection, emotion, and appraisal components of pain, respectively. The authors concluded that the participants were completely aware of the sensation of pain but were able to inhibit the appraisal and emotional responses of pain. In other words, changes in the perception of pain were facilitated through the cognitive and affective components of the pain matrix rather than through the sensory properties of pain. Furthermore, the differences in brain activity were found to be inversely proportional to meditation skill level, establishing a correlation that supports the authors’ hypothesis in regards to meditation’s therapeutic effect on pain. As for neurophysiological findings, structural MRI results overlapped with the fMRI results: meditators were found to have thicker grey-matter in the same pain-related regions of the brain where changes in functional activity were observed [66,68,69]. In terms of overall clinical outcome research, controlled trials of adults suffering from various forms of chronic pain (chronic low back pain, chronic headache/migraine, chronic neck pain, arthritis, cancer, and fibromyalgia) have indeed demonstrated improved pain ratings in regards to multiple dimensions of pain including intensity, acceptance, functional limitations, quality of life, and psychological well-being [62]. Nonetheless, mindfulness as it relates to pain in children has not been extensively studied and although mindfulness meditation has shown to be beneficial in classroom and school settings for improving psychological distress [74–77], more research is required in order to determine whether the same effects can be translated in children and pediatric medicine.
3.2.2. Hypnosis. Hypnosis as a form of therapy has a long history and has been widely used across various disciplines of health care. While the current research establishes hypnosis as a beneficial treatment for the management of pain in regards to both acute medical conditions, such as trauma and post-operative care, and chronic medical conditions, such as cancer and sickle cell anemia [78–80]; it is only since the 1980s that it has been meaningfully applied to pediatric care [81,82]. In general, hypnosis includes three phases: induction, suggestion, and emergence [82]. During induction, the provider encourages patient relaxation by asking them to imagine a calm and serene setting on which they can focus all of their attention. Next, the patient is given therapeutic suggestions to achieve the desired effect. Lastly, the patient is asked to leave their imagined setting and to return to normal consciousness. Hypnosis for pain management follows this same protocol with a focus on suggestions that either turn down or decrease pain perception or increase pain thresholds [83]. Given the significance of the suggestion stage of hypnosis, an important factor in clinical outcomes is the degree to which an individual is responsive or susceptible to hypnotic suggestions—a trait that is often referred to as hypnotizability. Of note, studies that have attempted to measure hypnotizability among children via the Children’s Hypnotic Susceptibility Scale and the Stanford Hypnotic Scale for Children have shown a positive correlation between hypnotizability [84,85] and age, thus suggesting that hypnosis may be an especially viable form of therapy for pain management in the pediatric population [82]. Taking a neuroscientific approach, neuro-imaging studies have attempted to measure the effects of hypnosis on the neuroanatomy and the neuro-cognitive functions of the brain in the context of pain [85–88]. In other words, many researchers have set out to investigate how hypnosis affects the brain’s neural-networks and physiology that in turn, are responsible for the perception of pain within an individual. This “pain matrix”, as it has been described, is comprised of specific areas of the brain that collectively produce the experience of pain. In the simplest summary of the current literature, the components of the pain matrix include: the prefrontal cortex, frontal lobes, anterior cingulate cortex, primary and secondary somatosensory cortices, thalamus and insula. The cerebellum, though not technically a component of the pain matrix, also plays a role. Using fMRIs to measure brain activity during hypnosis, researchers have concluded that by influencing activity in the various components of the pain matrix, hypnosis is indeed able to have a collective therapeutic effect on pain. Research focusing on clinical and experimental outcomes has also yielded positive results. A meta-analysis performed in 2000 of 18 studies found hypnosis to have a moderate to large analgesic effect[78]. When compared to groups receiving standard treatment and groups receiving no treatment, 75% of participants receiving hypnotic suggestion experienced a greater analgesic effect. Furthermore, the effect was seen with both clinical and experimental pain with no significant difference between the two settings. Hypnosis is a tool that carries minimal risk when used appropriately for pain management. It can be used by patients as well as practitioners. The goal is often to instruct the patient on the hypnotic technique so that hypnosis will become a tool of empowerment that the patient is able to use themselves at appropriate times for symptom management. It is important to note that hypnosis should only be performed by an appropriately trained practitioner and only to treat conditions that the practitioner is competent to treat.

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