Research suggests the severity of pain associated with juvenile idiopathic arthritis (JIA) has been underestimated in the past but is in fact a major problem. Eccleston and Malleson, and others have reported on the wide ranging effects of pain for families and children in general but also in regard to JIA.^1-4

Two studies have successfully addressed the issue of pain management for children with JIA. Walco, Varni and Ilowite trained children in self-management techniques such as progressive muscular relaxation, guided imagery and meditative breathing.⁵ They also reviewed these behavioral techniques with the parents of the children.

Lavigne et al., studied the effects of cognitive behavioral techniques in reducing pain intensity in children with JIA.⁶ The six-session intervention program incorporated relaxation training and biofeedback for the children. The researchers also provided training for the patients’ mothers on the use of behavioral techniques in managing the childrens’ school attendance and compliance with home physiotherapy regimens.

Researchers have successfully applied psychological approaches to pain management in a controlled research context. Whether one can teach and apply these techniques in ordinary clinical settings with children is less well known. Eccleston and Eccleston reported that physiotherapeutic treatments for chronic pain were at an early stage of development.²

Accordingly, we wanted to develop a method for teaching psychological techniques of pain control for children to pediatric physiotherapists and determine whether clinicians can use these techniques during routine clinical treatment in a clinic setting.

Can The Program Be Useful And Informative For Clinicians?
The first phase of the training program involved key areas in pain management: education on pain; physical relaxation exercises; breathing exercises; using imagery and distraction techniques; the effect of emotions; pacing and strength training; self-esteem; assertiveness; and reinforcement of non-pain behavior.

The second element of the training program was a JIA booklet containing information about pain processes and how to cope with pain. The booklet was designed for use for children with staff throughout the training program. Ten sections in the booklet paralleled training for the staff. Each section had homework exercises so children could practice the techniques at home.

In the first phase of the intervention program, two pediatric physiotherapists filled out a questionnaire that tested their knowledge of the program, what they had learned from the program and their level of satisfaction with the program.

Within the questionnaire, the pediatric physiotherapists were asked the following questions:

• What are the main methods of controlling pain?
• What factors may make a child’s pain worse?
• What is the “gate theory” of pain?
• What are the do’s and don’ts of changing pain behavior in children with JIA?
• What tactics can clinicians use to help children learn about self-care behaviors and JIA?

The physiotherapists noted that they had acquired new knowledge about relaxation, distraction and breathing techniques for pain control in children. They also learned about the potential impact of worry, unhappiness and low self-esteem as factors that can make pain worse. The physiotherapists gave a detailed description of an imagery technique, the gate theory of pain control. They also described a number of approaches to facilitate positive thought and help children be more assertive in taking more control of pain.
Overall, the physiotherapists expressed satisfaction with the program and rated it as very useful.

Can The Training Program Have An Impact In The Clinic Setting?
The second phase of the program was conducted in a local community health clinic. One 12-year-old child with JIA followed the training program through to completion.

A physiotherapist saw the child weekly for five to ten minutes a week over a six-week period. The meetings were held after a group practice session on physical exercises for JIA patients. The weekly intervention consisted of teaching the child pain management techniques and giving the child handouts covering the information from that week.

At the beginning of the study, the child completed a Varni-Thompson Pediatric Pain Questionnaire (PPQ), which involves a rating scale of pain intensity (via a visual analogue scale) and a questionnaire to measure knowledge of JIA and pain management techniques. In regard to the visual analogue scale, the patient identifies sites of pain with color-coding on a body outline. He completed a pain diary for one week prior to beginning the program to determine his daily, perceived pain.

He found relaxation techniques helpful on two of the five occasions that he used them. Breathing techniques and distraction techniques did not appear to facilitate much of a change between the patient’s pre- and post-intervention pain levels. However, use of visual imagery to reduce pain levels was much more effective and the child was very positive when talking about these exercises.
The child made up his own imagery exercises around the idea of the gate theory of pain, which he said was very helpful. The child imagined sheep passing through a gate with white sheep symbolizing no pain and red sheep symbolizing pain. He imagined closing the gate and not letting the red sheep pass through. The patient found this imagery exercise very effective.

What The Program Results Revealed
Pre- and post-program measures of pain according to the Varni-Thompson PPQ revealed only a slight decrease in one week’s average pain from a 5.2 before the program’s start to a 4.2 on a zero to ten scale. After the completion of the program, the child reported a slight increase in ankle and foot pain (moderate to mild). However, researchers noted no other changes in the distribution or severity of perceived pain.

Researchers interviewed the parent and child after completion of the program. The parent reported that the child had found the pain gate theory and some relaxation techniques useful, but she had no idea “of the frequency with which he uses (these techniques).” The parent did say the child “is now very much in control of his arthritis and manages it quite independently of me.”

The main change in the child’s beliefs was in using imagery and breathing techniques to help cope with and reduce perceived pain. Relaxation techniques helped him reduce pain levels although he favored his own visual gate imagery. He also noted that going to bed helped him cope with pain and eating distracted him from pain. These new constructs changed the child’s behavior and helped him to manage the pain.

In Conclusion
Results from the first phase of the study suggest that clinicians may find it useful to learn about psychological approaches to help patients with JIA mange their pain. Unfortunately, the reported effect on pain control was limited. This may have been due to factors specific to the training or to the study participant.

Successful implementation of psychological pain control approaches in past literature has been with intensive, clinic-based interventions. Accordingly, the amount of time for the training may have been insufficient. The study participant had low levels of pain prior to and after the exercises. Studying the program’s utility with a wider group of participants with higher levels of pain might be helpful.

The child did report that some of the techniques, particularly imagery techniques, were effective in reducing his pain levels and helping him cope with pain. His parent emphasized that the child was now “very much in control of his arthritis.” We would advocate replication of this study with more children with JIA in the future in order to further assess the merits of these techniques.

For a related article, see “Current Concepts In Juvenile Idiopathic Arthritis” in the January 2006 issue of Arthritis Practitioner. Visit the archives at www.arthritispractitioner.com.