Editor’s note: During the International Symposium on Pediatric Pain 2023 (ISPP), five pain researchers participated in the PRF-ISPP 2023 Correspondents Program – made possible by generous contributions from Solutions for Kids in Pain (SKIP) and the Centre for Pediatric Pain Research (CPPR). As we prepare for ISPP 2025 – taking place 17-20 June 2025 in Glasgow, UK – we’re taking a look back at some highlights of ISPP 2023, and some of the people who made them possible.
Susmita Kashikar-Zuck – clinical psychologist and professor of pediatrics and clinical anesthesiology at Cincinnati Children’s Hospital Medical Center (Ohio, USA) – has more than 20 years of experience working as a pediatric pain researcher. She has published more than 100 scientific articles and is passionate about finding solutions for children and parents of children living with chronic pain.
Following her plenary lecture at the International Symposium on Pediatric Pain 2023, Kashikar-Zuck spoke with PRF Correspondent Sarah Wallwork (University of South Australia, Adelaide) about her background, interest in exercise-based interventions, and the advent of neuromuscular training.
Tell us a little bit about yourself, your background, and how you came to be where you are now.
I’m a clinical psychologist by training. I actually grew up in India and really wanted to have a research career after I did my master’s in clinical psychology, but there weren’t too many opportunities to really dive into, especially in health psychology research. So I ended up in the [United] States and went to Wisconsin to do my doctoral degree there with an advisor who was a social psychologist who focused on research on stress and health. So I didn’t initially start off in pain. My doctoral dissertation was actually in cardiovascular reactivity and stress, but as part of my clinical rotations, I got some experience doing biofeedback, and psychophysiology was a part of my dissertation. The biofeedback was this very natural application of what I had learned in psychophysiology. I started to pick [clinical] rotations in pain management because I felt it was such a nice fit.
I did my internship at the University of Florida, which has a very strong program in behavioral medicine and pain, and then I did my fellowship at Duke University with Frank Keefe, who was a pioneer of the [cognitive behavioral therapy] CBT approach for pain management many years ago. Then I started off as a clinician, started my academic career as a faculty member at the University of Florida, and then an opportunity came up to set up a pain clinic at the Children’s Hospital in Cincinnati.
Now mind you, I was trained in adult pain management, but I had done a bunch of pediatric rotations, and I thought the idea of working with children with pain was so appealing, but I still wasn’t sure that was my thing. Then I interviewed with Ken Goldschneider who, at the time, was at Boston Children’s. He was the pain physician who was being recruited as the medical director of the pain clinic, and I felt like we agreed on what a new multidisciplinary pediatric pain program should look like. In 1999, we started the pain clinic, started off primarily clinical and small, set up a little clinical database, and started collecting observational data. It was a multidisciplinary clinic, and then we slowly became more interested in clinical trials in pediatric pain, and the rest is history.
As a clinical psychologist, how did you become interested in exercise-based interventions?
I grew up in India, and yoga is something we learned in school. I had taken some advanced courses and did some of their instructor training as well. For me, it was interesting to learn about awareness of your physical body and using yoga principles in daily life. I had a little bit of background in this mind-body medicine approach, but I wasn’t really thinking about that necessarily when I embarked on a pain management career.
When I started to watch some injury prevention work, it was so much about proprioceptive awareness of where your body is in space. My collaborator, Greg Myer, who was a sports medicine researcher in Cincinnati Children’s at the time (now at Emory University), had this beautiful motion capture lab that they were using for varsity athletes. I was like, “Wow, for children with musculoskeletal pain, I would love to know: How are they moving?” Visually, I could see how they’re moving, and the fear and hesitation with which they embark upon exercise. I thought to myself, “Instead of telling them to exercise or showing them how to exercise, why don’t we first just show them how to move safely, and build their movement skills and confidence?” The hope was that exercise would come more easily to them after that.
Can you tell me a bit about the FIT Teens project?
One of the things I had noticed, [particularly] in pediatric chronic pain, was that we just didn’t have a lot of really high-quality trials. I was used to reading in the pain literature about these large adult trials with samples of hundreds of participants. When I went to the pediatric literature at the time – now mind you, this was in the late 1990s/early 2000s – [I] really couldn’t come up with a whole lot in terms of things you could really say is truly evidence-based medicine, just because the trials were so small.
So part of me [thought] we’ve really got to do this better! That’s when I started with the first relatively large pediatric clinical trial – over a hundred kids – and we were looking at the effectiveness of CBT for musculoskeletal pain. We successfully showed that CBT improved clinical outcomes, and we could have said we published a significant paper, we added to the literature, and I could have moved on, but ultimately the kids were still experiencing some pain, and they were still not very active. So I thought we could do better. Now this trial was a multisite study, and one of my collaborators in Louisville – he was a very senior rheumatologist and a very active person himself – would recommend exercise to all his patients. So – this is kind of a funny story – because we had accelerometry as part of our assessments in the trial, and we had this ongoing conversation where [he’d say], “I know the patients at my site are going to be much more active at the end of the treatment because I do a very thorough job educating them about exercise and how to incorporate it into their routine.” From our actigraphy measurements, however, they were no different than anybody else in the trial. So even all that education about physical activity and exercise was not really doing anything, even though he would send them to [physical therapy]. They were still not active in the sort of way we want them to be active, in terms of bouts of sustained activity.
That’s when I began the search for the right kind of approach we should take for exercise, which is where this collaboration with sports medicine came from. And the neuromuscular training made so much sense to me because it was gentle; it was more strength-based. There wasn’t a lot of cardiovascular work, which is difficult when many of our patients are deconditioned and some may also have more dysautonomia.
I [thought], “Let’s take a step back. Let’s just approach exercise in a way that can help strengthen them, give them more confidence, and have them moving in a better way.” We wanted to reduce the factors that cause delayed-onset muscle soreness, which scares them away and makes them think they’re having a pain flare, when really they’re only using muscles that they haven’t used in a while. So really bringing the CBT portion together and integrating it with neuromuscular training is how the approach was born.
Can you explain a little bit about what is specialized neuromuscular exercise training and how it differs from other exercise-based interventions?
Sure! You can have more aerobic types of training and you can have more strength-based training, or resistance-based training. Neuromuscular training is more similar to resistance training, except that the person is primarily using their own body weight. We really focus on postural control, basic muscle strengthening, and functional movements. It’s derived from the field of injury prevention in athletes. Primarily, the research that my colleagues did was on preventing ACL injuries in young female athletes, really looking at which muscle groups are involved in stabilizing your movements in a way that you can move safely, without causing more injury and pain. So it could be how to properly do core exercises like a plank, a squat, or a wall sit, those sorts of things.
It is the method of delivery that’s new. And the method of delivery that we decided on, and by we, I mean my sports medicine colleagues who have much more knowledge about muscles and exercise, is to really break it down into four levels, training just in proper form first. Let’s say you’re going to do a squat, How do you hold the right position of a squat? We have that for each exercise, and the patients in our studies get two weeks of just basically learning that level one exercise: How you get yourself into the proper position. They could use the support of some TRX straps, get themselves into the position, and then the trainers would tell them, “You’re leaning forward too much,” adjustments like that. And this was amazing to me, that the subtlest change in posture can use an entirely different muscle group. They were very good about saying, “Okay, now which muscles are you working?” And then the participant can tell them, “Okay, I feel it here,” or “I feel it there.” And then they’ll just say, “Okay, now adjust your position a little bit,” or “Move a little bit away from the wall.” And then they really arrive at what muscle group we are targeting. So for two weeks, that is all they’re doing, that level one training – learning which muscles we are training.
Level two is the concentric part of exercise. So they can use supports to do everything else, but then they just focus on the “creating movement” aspect of it. They do the concentric portion for two weeks. And again, as they’re doing this, they’re building strength, they’re building that awareness of those muscles, but what they’re also doing is building strength while avoiding that delayed-onset muscle soreness. And then you build the eccentric component in, introducing the idea of working against resistance, and then you build a full functional movement in.
It is a very gradual approach. And that’s why we call it neuromuscular training, because when they first introduced the idea to me, I [thought], “What’s so neuro about it?” But we’re really training the brain. Ultimately, they are strengthening the muscles, but they’re also training the brain to know what you’re using as you do that. One of the benefits in this approach is in teaching them the difference between what is that initial soreness versus pain. And that, I think, really helps their awareness.
Anything else you would like to add?
Well, just for the field of pediatric pain researchers in general, I feel like I would love for people to really pursue the science, because there’s so much work to be done. I’m a clinical researcher myself, and I think we really have to reach out to our translational colleagues in basic neuroscience – as well as in translational neuroscience and other disciplines – because I think we really need to get to the bottom of this. Why are children starting on this journey to chronic pain so early in life? How are these pain pathways organized? What puts people at risk? What is the impact of early childhood trauma? What is the impact of the environment? I mean, oh my gosh, there is so much to be done. And I’m at a level in my career where it’s so wonderful to see all the young people here; I feel there’s so much to be done. If there’s one thing [that] I’d like to communicate with early-career folks is to talk to more types of researchers, even those outside our field, even if you don’t understand their scientific language. Just be curious and try to learn, because that’s really how we are going to push the field forward.
Sarah Wallwork, PhD, is a research fellow in IIMPACT in Health at the University of South Australia. You can follow her on Twitter/X – @SarahBWallwork.