non-pharmacological symptom relief: how palliative care...

Non-Pharmacological Symptom Relief: How Palliative Care Can Help

Andres F. LeoneMD, FAAFP, AGSF, DABHPM.

USC School of Medicine Assistant professor Hospice and Palliative Medicine Fellowship Program Director

Medical director of Palliative Medicine

Innovation and Excellence in Advanced Illness at End of Life 43rd Annual Hospice & Palliative Care Conference – September 2019 – Greenville, SC

Elena LiggettLISW-CP, APHSW-C, ASW-G, RBPR-C, BCH

Prisma Health Palliative Care Social Worker

Lauren KingLMSW, APHSW-C, RBPR-C, BCH, I-CARE/SHIP

Prisma Health Palliative Care Social Worker

USC School of Medicine Clinical Instructor

Objectives

• Identify evidence-based non-pharmacologic interventions for symptom relief

• Know the difference between mindfulness and hypnosis & understand how they can be used for symptom relief

• Recognize the applications for acupuncture in palliative medicine

Innovation and Excellence in Advanced Illness at End of Life

Mindfulness in Palliative Medicine

MindfulnessIntentional Engagement of Self and Space

Mindfulness and it’s impact on Psychological well being is becoming well documented- (1970’s to present day).

Mindfulness is the miracle by which we master and restore ourselves…..it is the miracle which can call back in a flash our dispersed mind and restore it to wholeness so that we can live each minute of life. (Hanh (1976, p.14)

Kabat-Zinn, 1982- Patients and Chronic Pain

Mindfulness Based Stress Reduction

Mindfulness Based Cognitive Therapy (MBCT)

Dialectal Behavior Therapy (DBT)

Acceptance and Commitment Therapy (ACT)

Mindfulness

Mindfulness has also been shown to fight:

Anxiety

Depression

Anger

Fear

Any emotion/mood that tends to encourage one to avoid, squelch, or not confront undesirable situations/thoughts/emotions.

Innovation and Excellence in Advanced Illness at End of Life

Mindfulness

Positive Impacts of Mindfulness on Psychological Health

Acceptance,

Values clarification, intentional mindfulness, Increased Spirituality,

And Personal emotional regulation

Mindfulness and Your Best Life

Intentional Engagement

What you can do to start your day

How you can be more productive in you work place

Ending you day your way

Playing with Intention

Self and Space

Gratitude

Being OK with yourself

Forgiving- yourself and others

Give!

References

• Keng, S. L., Smoski, M. J., & Robins, C. J. (2011). Effects of mindfulness on psychological health: a review of empirical studies. Clinical psychology review, 31(6), 1041–1056. doi:10.1016/j.cpr.2011.04.006

• Teasdale, J. D. (1997). The relationship between cognition and emotion: The mind-in-place in mood disorders. In D. M. Clark & C. G. Fairburn (Eds.), The science and practice of cognitive behaviourtherapy (pp. 67-93): Oxford University Press.

• Hofmann, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The effect of mindfulness based therapy on anxiety and depression: A meta-analytic review. Journal of Consulting and Clinical Psychology, 78(2), 169-83

• Sears, R. (2015). Building competence in mindfulness-based cognitive therapy: Transcripts and insights for working with stress, anxiety, depression, and other problems. New York: Routledge.

Hypnosis in Palliative Medicine

Hands of comfort

• Integrated Cancer Committee Grant

• To provide support for patients and encourage the involvement of family members, friends, and loved ones in the care of the patient with a cancer diagnosis to bridge that gap that may occur and provide another layer of help, support, and comfort to the patient

Hand Lotion

Hand Massage

Instructions

Spiritual Care

Lemongrass

Essential Oil

Reusable Bag

Notebook &

Pen

Project

Information

Lavender

Essential Oil

Supportive

Information

Guided Imagery

As part of the Hands of Comfort grant, we were able to receive training to become certified

hypnotherapists

No….not that

What is hypnotherapy?

• “People think that when you're hypnotized you're going to be instructed to do things you wouldn't otherwise do, like get up on stage and cluck like a chicken, or reveal deeply hidden secrets. Actually, it just allows people to dissociate from the place they're in and achieve a deep relaxation.”

-Lorenzo Cohen, Ph.D., professor of Palliative, Rehabilitation and Integrative Medicine and director of the Integrative Medicine Program.

• APA definition: A therapeutic technique in which clinicians make suggestions to individuals who have undergone a procedure designed to relax them and focus their minds.

• EEG cycles– 14-20 Hz Beta awareness– 14-9 Hz Alpha relaxation– 9-4 Hz Theta relaxation– <4 Hz Delta sleep

Mindfulness & hypnosis

• Hypnosis uses relaxation to create emotional change

• Mindfulness uses relaxation to facilitate acceptance of your emotions

Dr. G. Fredric Mau

What about pain?

• Brief interventions of hypnosis & mindfulness have been shown to be effective for acute pain management. (Swain 2014)

• Massage and hypnosis for pain relief in older patients: both decreased pain significantly. Hypnosis resulted in greater decrease of pain. (Ardigo, 2016)

• American College of Physicians clinical practice guidelines recommend mindfulness-based stress reduction, progressive relaxation, CBT as noninvasive treatment options for chronic low back pain. (Qaseem et al 2017)

• Clinical trials have shown that hypnosis is effective for reducing chronic pain. There’s an increase in neurophysiological evidence of hypnosis affecting brain and spinal-cord functioning. (Jensen 2014)

How does it work?

• Hypnotic anesthesia prevents neurological signals from reaching the frontal lobes (Apkarian, 2005; Schulz-Stubner, 2004)

Hypnosis and other symptoms

• Better sleep

• Increase activity

• Increase resilience

• Decrease anxiety

• Reduce depression

• Improve mood

Other medical applications

• “This is a shift or change in focus of awareness from what's in the center of your attention to what is in the periphery of your awareness. And this can be used in multiple environments within the perioperative setting, including the operating rooms, but also, what we've been using quite a bit is in the off-site kind of domain which includes MRI settings, bone marrow, interventional radiology, just to name a few. So that's primarily where we're using it.” –Dr. Ian Lipski Associate Professor in MD Anderson’s

Department of Anesthesiology and Perioperative Medicine 2013

Medical hypnosis assists with surgery and medical procedures

Other medical applications

A surgeon, anesthesiologist, mind-body specialist and other members of the health care team work together to perform a breast biopsy on a patient who chose hypnosedation over general anesthesia.

MD Anderson 2018

Dr. Dalliah Black is taking the lead in a study of hypnosedation in lieu of general anesthesia for women undergoing breast biopsies

Other Medical Applications

Case example

• 76 year old woman with diagnosis of end-stage COPD and severe anxiety. Located in stepdown ICU on nasal O2. Upon arrival, noted increased respirations (~40), decreased O2sats (84-86%), increased heartrate (140-160), and appearing anxious (wide-eyed, rapid breathing, grasping hand).

• Brief mindfulness and guided-imagery (hypnosis process) implemented

• Within 2-3 minutes, respirations decreased to around 16, O2 satsincreased to 99%, heartrate dropped to 102, and patient appeared relaxed & fell asleep with suggestion to close eyes comfortably.

Beautiful Winter

warm, healing walk

References

• Apkarian, A., Bushnell, M., Treede, R., & Zubieta, J. (2005). Human brain mechanisms of pain perception and

regulation in health and disease. European Journal of Pain, 9, 463-484.

• Ardigo, S., Herrmann, F. R., Moret, V., Déramé, L., Giannelli, S., Gold, G. and Pautex, S. (2016). Hypnosis can reduce

pain in hospitalized older patients: A randomized controlled study. BMC Geriatrics, 16(1).

• Hardy, M. (2018). A conscious decision in the operating room: Clinical trial tests the use of hypnosedation instead

of general anesthesia during some breast cancer surgeries. Conquest. Retrieved from https://www.mdanderson.org/publications/conquest/summer-2018/conscious-decision-in-operating-room.html.

• Cassileth BR, Vickers AJ. (2004)Massage therapy for symptom control: outcome study at a major cancer center.

Journal of Pain Symptom Management. 28(3):244–249.

• Mau, GF. (2014) A Different Reality: Adventures in narrative therapy & a protocol to address anxiety disorders and

insomnia.

• Mau, GF. (2017) Changes in Brain Function Clinical Pain and Anxiety Relief via Hypnosis and Mindfulness.

Powerpoint.

• Jensen, M. P., & Patterson, D. R. (2014). Hypnotic Approaches for Chronic Pain Management: Clinical Implications of

Recent Research Findings. American Psychologist, 69(2), 167–177.

• Kabat-Zinn, J. What is Mindfulness?. Greater Good Magazine. UC Berkeley.

References• Kutner JS, Smith MC, Corbin L, Hemphill L, Benton K, Mellis BK, Beaty B, Felton S, Yamashita TE, Bryant LL, Fairclough

DL. (2008) Massage therapy versus simple touch to improve pain and mood in patients with advanced cancer: a randomized trial. Ann Intern Med. 149(6):369–379.

• McCorkle R, Pasacreta J. (2001)Enhancing caregiver outcomes in palliative care. Cancer Control. 8(1):36–45

• Poulin MJ, Brown SL, Ubel PA, Smith DM, Jankovic A, Langa KM (2010). Does a helping hand mean a heavy heart?

Helping behavior and well-being among spouse caregivers. Psychol Aging. 25(1):108–117.

• Qaseem, A., Wilt, T. J., McLean, R.M., and Forciea, M.A. (2017). Noninvasive Treatments for Acute, Subacute, and

Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Annals of Internal

Medicine. Retrieved from: http://annals.org/aim/article/2603228/noninvasive-treatments-acute-subacute-chronic-low-

back-pain-clinical-practice

• Schulz-Stubner, S., Krings, T., Meister, I., Rex, S., Thron, A., & Rossaint, R. (2004). Clinical hypnosis modulates

functional magnetic resonance imaging signal intensities and pain perception in a thermal stimulation paradigm.

Regional Anesthesia & Pain Medicine, 29, 549-556.

• Swain, N. R., and Trevena, J. (2014). A comparison of therapist-present or therapist-free delivery of very brief

mindfulness and hypnosis for acute experimental pain. New Zealand Journal of Psychology, 43(3), 22-28.

Acupuncture inPalliative Medicine

Acupuncture in Palliative Medicine

GOALS

• Definition

• History

• Meridians and points

• Mechanism of action

• Important RCT trials

• Examples of helpful points

Acupuncture Background

• involves the insertion of very thin needles through your skin at strategic points on your body.

• most commonly used to treat pain. Increasingly, it is being used for overall wellness, symptom management and stress management.

• TCM explains acupuncture as a technique for balancing the flow of energy or life force — known as Qi (chee) — believed to flow through pathways (meridians) in your body. By inserting needles into specific points along these meridians, acupuncture practitioners believe that your energy flow will re-balance.

• In contrast, many Western practitioners view the acupuncture points as places to stimulate nerves, muscles and connective tissue. Some believe that this stimulation boosts your body's natural painkillers.

Acupuncture (Background)

• Originated in China. • Initially: sharpened stones

and long sharp bones 6000 BCE

• Documents sealed in 198 BCE within the Ma-Wang-Dui tomb in China -meridians

• The Yellow Emperor’s Classic of

Internal Medicine

• 475-221 BC

1950 Peking University and on…Scientific research -mechanism of action-

• Induction time of 15 to 20 minutes – required to develop an analgesic effect and proposed

the participation of chemical substances in the analgesic actions

– Endogenous opioid peptides (EOPs) considered major candidates for a role in acupuncture’s action, as electro-acupuncture analgesia (EAA) is antagonized by the opioid receptor antagonist naloxone.

– EOPs in plasma or cerebrospinal fluid (CSF) has been observed in humans following EAA

– a frequency-dependent involving EOPs in (EA)-induced analgesia

Scientific research -mechanism of action

– low-frequency activation of mu- and delta-opioid receptors via the release of enkephalin, beta-endorphin, and endomorphin in supraspinal CNS regions, whereas the effects of high-frequency EAA involve the actions of dynorphin on kappa opioid receptors in the spinal cord

– Substance P (SP) exists in primary afferents that respond to painful stimuli and appears to transmit pain information into the central nervous system• Immuno fluorescence studies of SP in the spinal cord, and dorsal root

ganglion tissues in rats also suggest a possible involvement of the primary SP-positive sensory neurons in the transmission of acupuncture stimulation signals

– up-regulation response of 5-hydroxytryptamine (5-HT)/ hydroxyindole acetic acid (5- HIAA), and down-regulation of tryptophan content in the frontal cortex. Another mechanism by which acupuncture has been reported in the literature is through the up-regulation of the GIutamate receptor 1 in the amygdala.

Enkephalin

Beta-endorphine

Dynorphin Endomorphin

Substance P

5-HT5-HIAA

Ah-Shi points and points associated with myofascial pain syndrome.

Experimentally:

Repetitive contractions of the forearm muscle, which induced delayed-onset muscle soreness. A localized tender locus was formed on the palpable band, and pressure applied to the locus induced a specific referred pain pattern similar to that observed in MPS patients

GERAC - RCT - Chronic Low back pain

• three parallel arms:– Real acupuncture employed deep needling to

classical acupuncture points with needle manipulation to produce the de-qi sensation. Ten treatments were given over a 6-week period.

– Sham acupuncture involved superficial needling to standardized non-acupuncture points (outside known acupuncture points).

– Standard care used best conventional care based on guidelines using multimodal treatment programs including physiotherapy, exercise, and treatment with non-steroidal anti-inflammatory drugs (NSAIDs). The response rates at 6 months were

47.6% (real acupuncture), 44.2% (sham acupuncture), and 27.4% (standard care).

Large Acupuncture Mega Trials - Complications

• United Kingdom ,Germany, and Japan. • German survey of over 9000 German physicians providing 760 000

acupuncture treatments– six reported cases of adverse events: pneumothorax, exacerbation of

depression, acute hypertensive crisis, vasovagal reaction, and asthma attack with hypertension and angina.

• In another large survey of 2.2 million consecutive acupuncture treatments, adverse events: – two patients: pneumothorax and lower limb nerve injury. – No deaths

*On the other hand, there is a known association between NSAID use and internal bleeding or perforated gastro-duodenal ulcers, and a rigorous survey demonstrated that, on average, 1 in 1200 patients taking NSAIDs for at least two months will die due to gastro-duodenal complications.

The Thalamic Neuron Theory (TNT)

• postulates that the CNS is involved in all disease processes, • processes incoming physical and chemical information from the periphery,

sends out physiological commands to the periphery in order to maintain homeostasis for the entire body.

• Inherent in its capacity to learn and adapt (i.e. to habituate) is the CNS' ability to learn to be sick (pathological habituation)

• Reversed by dehabituation through manipulation or modulation of the abnormal neural circuits by physical means (physical neuromodulation) like acupuncture, or chemical means (chemoneuromodulation)

• TNT assumes the blue print for embryological development is embodied in the phylogenetically ancient part of the brain. organized in the form of a homunculus.

• curled up embryo with its large head buried close to its pelvic region, with its large feet and hands crossed over to the contralateral sides.

Helpful points

• Large Intestine Channel: LI4, HeguThis point is located on the back side of the hand between the thumb and first finger. The primary use of this point is to relieve pain and treat inflammatory and feverish diseases

• Lung Channel: LU7, LiequeThis point is located above the wrist on the inside of the arm. It is used to treat several disorders of the upper body, including headache, neck stiffness, cough, asthma, sore throat, facial paralysis and wrist conditions.

Helpful points

• Gallbladder Channel: GB20, FengchiThis point is located at the base of the skull where it joins the neck in back. It is used in the treatment of acute disorders, such as the common cold, influenza, headache, neck pain and fever. In addition, it lowers blood pressure.

• Governor Channel: GV26Gallbladder Channel: GB20, FengchiAt the junction of the upper and middle third of the philtrum. Someone passes out, stimulator.

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References

Questions?

Innovation and Excellence in Advanced Illness at End of Life

Andres F. LeoneMD, FAAFP, AGSF, DABHPM.

USC School of Medicine Assistant professor Hospice and Palliative Medicine Fellowship Program Director

Medical director of Palliative MedicineAndres.Leone@Prismahealth.org

Elena LiggettLISW-CP, APHSW-C, ASW-G, RBPR-C, BCH

Prisma Health Palliative Care Social Worker

Elena.Liggett@Prismahealth.org

Lauren KingLMSW, APHSW-C, RBPR-C, BCH, I-CARE/SHIP

Prisma Health Palliative Care Social WorkerUSC School of Medicine Clinical Instructor

Lauren.King@Prismahealth.org