Serotonin and Norepinephrine Neuropathic Pain

of sodium channels. TCAs used in management of neuropathic pain include amitriptyline, imip- ramine, doxepin, desipramine and nortriptyline. Amitriptyline, imipramine, and doxepin are ter- tiary amines and cause increased levels of seda- tion. Other side effects include anticholinergic effects such as urinary retention, dry mouth, con- stipation and blurred vision. Doses should be titrated upwards weekly. TCAs are contraindi- cated in epileptic children because they lower the seizure threshold and in children with heart fail- ure or cardiac conduction defects due to QTc pro- longation effects.

9.6 Non-pharmacologic

Treatment of Pain The combination of pharmacologic and non- pharmacologic techniques to relieve pain and improve comfort has become increasingly recog- nized as complementary components in pain management Twycross et al. 2009 . Non- pharmacologic treatments address both physical and psychological aspects of pain and are often combined for improved pain control Culbert and Olness 2010 . Children with cancer often use alternative therapies in conjunction with standard pharmacologic treatments Friedman et al. 1997 . It is important to create a treatment plan that combines non-pharmacologic modalities that engage the child and compliment the child’s energy level and comorbidities. Early introduc- tion of these techniques helps them become ther- apeutically effective over time. Ideally all patients would utilize complementary therapies, espe- cially when faced with chronic pain, although this is often limited by lack of resources.

9.6.1 Guided Imagery

Guided imagery uses personalized storytelling to aid children in mastering situations that provoke anxiety or fear. Parental involvement in the process is encouraged so the story can be retold during stressful treatments or procedures. Attention- distraction imagery involves teaching children to imagine a pleasant mental image during a painful experience Turk 1978 . Several studies have dem- onstrated the synergy of guided imagery with phar- macologic therapy in reducing pain and distress Kuttner et al. 1988 . In children undergoing bone marrow aspiration, an 18 reduction in behavioral distress scores and 25 reduction in self-reported pain scores has been noted with guided imagery Jay et al. 1987 . Imagery has been studied in older children and adults but has been particularly help- ful in children from the age of 3–6 years where the boundaries between fantasy and reality are less concrete Kuttner et al. 1988 ; Syrjala et al. 1995 .

9.6.2 Biofeedback

Biofeedback is the process of converting physio- logic signals such as blood pressure, pulse, mus- cle contractions, skin temperature and sweat response into audio or visual signals. Children are taught to observe these signals to help volun- tarily control their physiologic response to pain and stress. Biofeedback is commonly used by pediatric anesthesia services for pain and anxiety management Lin et al. 2005 . Most studies dem- onstrating success using biofeedback have been conducted in children with chronic headache, with a 50 symptom reduction in 23 of chil- dren Blanchard and Schwarz 1988 ; Hermann and Blanchard 2002 .

9.6.3 Acupuncture

Acupuncture is an ancient Chinese healing tradi- tion that inserts needles into acupuncture points to balance the body’s energy. Older children are more likely to prefer acupuncture as a comple- mentary technique to manage pain Tsao 2006 . Acupuncture has been shown effective in postop- erative and chronic pain, reducing cancer-related pain by 36 at 2 months from baseline Alimi et al. 2003 . An adult study of acupuncture and chemotherapy-induced nausea and vomiting showed that over a 5 day period, a median of ten less episodes of nausea and vomiting were reported per patient in those who received acupuncture with