integrative pain and symptom management
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Integrative Pain and Symptom Management. William Zempsky, MD, FAAP Timothy Culbert, MD, FAAP Sessions S131 and S169. Faculty Disclosures. - PowerPoint PPT PresentationTRANSCRIPT
Integrative Pain and Symptom Management
William Zempsky, MD, FAAP
Timothy Culbert, MD, FAAP
Sessions S131 and S169
Faculty Disclosures
In the past 12 months, we have not had a significant financial interest or other relationship with the
manufacturer(s) of the product(s) or provider(s) of the service(s) that will be discussed in my presentation.
This presentation will include discussion of pharmaceuticals or devices that have not been approved by the FDA or if you will be discussing unapproved or “off-
label” uses of pharmaceuticals or devices.
Overview of Presentation
Introduction: Integrative Pediatrics Introduction: Pain and Symptom Management Description of Programs CAM Therapies in Pediatric Pain Clinical Applications
Headache Insomnia Experiential
Audience Q and A
Integrative Medicine Vs. CAM 1
CAM-complementary and alternative medicine Specific therapies/modalities Not typically taught, used or reimbursed in USA
hospitals A group of diverse practices not presently considered
part of conventional medicine 5 domains defined by NIH-NCCAM
Mind/Body Biological Manipulative/Body- based Alternative Systems Energetic
Integrative Medicine Vs. CAM 2
Integrative Medicine-A system of care that emphasizes wellness and healing Principles
Mind/body/spirit Patient –provider as collaborative partners Natural, less invasive approaches when possible Facilitating the body’s natural healing capacities Need for provider self-care Conventional and CAM in balance Customized to patient need and preference Balance of evidence and safety considerations
Note-over 20 Pediatric CAM Programs in USA
Kids and CAM
2%-30% in primary care settings 30%-70 % of kids with chronic illness 1999-2000 Children’s Hospitals and
Clinics of Minnesota Data Simpson, 1998 Ambul Child Health Ernst, 1999 Eur J Pediatrics Davis, 2003 Arch Peds Adol Med Grootenhuis, 1998, Cancer Nurs Stern, 1992, J Adol Health
CAM Use at Children’s Minnesota-52% Overall
59% of Oncology Patients 51% Pulmonary Patients 32% General Pediatrics 62% Pediatric Epilepsy 47% Pediatric Sickle Cell
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5
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Prayer Massage Chiropractic Vitamins Relaxation Herbals AromaRx
Oncology Pulmonary Gen Peds
Types of CAM Used
Doctors and CAM
Pediatricians in Michigan >50% would refer for CAM >50% used CAM themselves
Sikand, 1998, Arch Ped Adol Med
Pediatricians National Survey 66% believed CAM could be helpful
Kemper & O’connor, 2004, Ambul Peds
Pediatricians in Ohio and Minnesota 97% would refer kids with chronic pain for CAM if more was known about
efficacy 73% of female peds and 58% of male peds surveyed classified themselves as
“believers” Charmond, Banez, Culbert, 2006 Submission in process
**All-expressed need for more CAM education
CAM and Pain Management
Most common reason for CAM usage in adults surveys is chronic pain –particularly musculoskeletal pain
For many children with chronic pain-conventional options –psychotropic meds and PT-are not working
Increasing evidence that CAM is quite useful and also safe (particularly non-drug options)
Personal use of Cam by physicians pedicts likelihood of patient referral for CAM
CAM & Kids:Legal & Ethical Aspects
Complex issues at boundary of medicine, law and public policy
Cohen et al, 2005, Pediatrics
Clinical Risks Parents abandon effective care in life-threatening situation? Does CAM divert from or delay necessary treatment? Evidence for CAM treatment –known to unsafe or ineffective? Consent of proper parties? Is risk/benefit ratio acceptable? Your knowledge of CAM provider you are referring the patient to
Cohen and Kemper, 2005, Pediatrics
Evidence: Safety vs. Efficacy
SafeYes Safe NoeffectiveYes Recommend Monitor closely
effective No Tolerate Advise against
Weiger et al, 2002, Annals Int Med
Cohen, Pediatrics, 2005
Chronic Pain: Diagnosis
Study of general academic pediatricians-investigated opinions of children presenting with unexplained chronic pain
134 patients, 8-18 y.o.-chart review –3 M.D.’s 60% had psychiatric co-morbidity (kids not docs) Did not agree on cause of pain for 57% of pts Did not agree on appropriate diagnostic workup
for 37% of patients Konijnenberg et al, 2004, Pediatrics
Chronic Pain: Treatment
Feasiblity and acceptability of integrative treatment package for pediatric chronic pain (hypnosis and acupuncture)
33 kids chronic pain clinic, 6-18 years 6 weekly sessions Highly acceptable >90% completed
treatment, no adverse effects Zeltzer et al, 2002, J Pain Symptom Manage
Chronic Pain Book
Conquering Your Child’s Chronic Pain Lonnie Zeltzer, MD
Children in Pain
Long history of undertreatment of pain in children Perioperative pain Newborn pain Pain of Chronic Disease
Problems persist Emergency department Common pain problems Sickle Cell pain
Do children feel pain?
Pain fibers present at end of 2nd trimester Increased heel sensitivity post heel sticks Crying increases for days post
circumcision 6 month olds-anticipate and avoid pain
Pain Memory
3 groups Uncircumcised Circumcised with EMLA Circumcised with placebo
Pain scores at 4 and 6 mos shots Circumcised infants had higher pain
response
Taddio et al. Lancet, 1997
Children involved in a placebo trial of transmucosal fentanyl
Subsequent study all children received opiates Patients in original placebo group had higher
pain scores with subsequent procedures Inadequate analgesia effects future pain
response
Weisman et al, Arch Pediatr Adol Med, 1998.
What symptoms do we need to consider?
Pain Nausea Insomnia Anxiety Depression
Acute Symptoms
Pain Acupuncture Massage Relaxation Herbal Remedies
Arnica
Nausea Acupuncture Aromatherapy Herbal Remedies
Anxiety Acupuncture Relaxation
Chronic Symptom Management
Patients and families often looking for something else
Change the paradigm from a treatment of last resort
Make integrative approach the norm
Chronic Pain Management
Behavioral Therapy Herbal therapy Biofeedback Physical Therapy Osteopathic
Manipulation Craniosacral Therapy
Acupuncture Massage Yoga Reiki
16 yo with CRPS
Sprained ankle 2 months ago
Placed in a boot PE
Pain Allodynia Cool Swoolen Blue
Visit 1 PT program
Tens Unit Aquatic Therapy Desensitization
Behavioral Therapy Coping Meditation
Melatonin for sleep
Subsequent visits Acupuncture
Anxiety Pain
Yoga Massage area with
arnica gel
Children’s Minnesota Integrative Medicine Program: Overview
Clinical, Research and Educational Activities
Inpatient and Outpatient Services Collaborative Model with other disciplines System-Wide activities Are integrating services with new Pain and
Palliative Care Team
Children’s Minnesota Integrative Medicine Program: Staffing
MD-trained as developmental/behavioral pediatrician (1.0 FTE)
PhD-Pediatric Psychologist (2.0 FTE) APRN-research and education
background (1-2 FTE) Massage therapists (2-3 FTE) MD acupuncturist (0.2 FTE) Support Staff (3.0 FTE)
Integrative Medicine Clinical Services
Inpatient Volumes
Massage 2005 –1,453 2006-2,460 IM Consults 2005-378 2006-536
Massage Up 69% IM Consults Up 41.7%
Outpatient Volumes
Massage 2005-93 2006-303 Massage Up 212%
Medical 2005- 1063 2006-1188 Medical Visits Up 11.7%
Psychology 2005-506 2006-749 Psychology Visits Up 48%
Children’s Minnesota Integrative Medicine Program: Therapies
Mind/Body Skills Hypnosis, biofeedback, relaxation, groups
Massage and Bodywork Energy Therapies Acupuncture/Acupressure Clinical Aromatherapy Exercise Physiology and Nutrition Herbals and supplements Conventional (psychopharm and psychotherapy)
Children’s Minnesota Integrative Medicine Program: Diagnoses
Chronic Pain Functional GI Disorders Headaches (TT, Migraine, Chronic Daily) CRPS, Myofascial pain, somatoform
Holistic Mental Health Depression, anxiety, adhd, autism
BioBehavioral Problems Enuresis, encopresis, sleep disorders, habits
Chronic Illness Related Problems Adjustment issues, fatigue, other symptom management
Children’s Minnesota Integrative Medicine -Other Activities
Inpatient Consultation Services Massage Non-drug symptom management
Nausea, pain, insomnia, anxiety
Integrative Nurse Training 3 full cohorts of day surgery nurses 3 more to come 8 hour basic curriculum expanding to 40 hr AHNA model
Research Mind/body interventions for pediatric pain CAM and pediatric oncology Clinical Aromatherapy Massage, stress and cancer
Children’s Minnesota Integrative Medicine: What Works?
We complement and work closely with all subspecialties-value added
Work with difficult cases that are “stuck” –conventional approaches not getting it done
Psychologist and MD work very closely-assessment and treatment More willingness from patients and families to consider mind/body
approaches without “stigma” associated with “mental health” Carefully considered therapy mix and political milieux Great support from leadership team –we bring in philanthropic
dollars, great PR and academic notice (talks and publications)-even though we don’t make big $$-we have controlled revenue and expenses very well
Value of Pain Service* 23 hospitals, 5837 patients half anesthesia pain service, half control Decreased pain intensity, decreased
nausea, decreased itching, decreased sedation in pain service group
Less pain than patient expected; more likely to receive education; quicker discharge
*Miaskowski, Pain 199:80:23-29
Surveys of Adequacy of Pain Relief Cummings et al. 1996
Survey of all children in children’s hospital Clinically significant pain was present in 21%
of population Pain intensity not related to age, diagnosis Children offered less meds than prescribed “No one” identified as helping with pain
For nearly thirty years I have studied the reasons for inadequate management of pain, and they remain the same….inadequate or improper application of available information and therapies is certainly the most important reason for inadequate postoperative pain relief
John Bonica, 1990
We realized a traditional Pain Service We realized a traditional Pain Service only helps those patients with whom it only helps those patients with whom it interactsinteracts
Action plan which emphasizes CCMC’s fundamental commitment to pain control which suffuses through all disciplines and departments
Basic premise is that pain control and comfort measures will be a part of all patient encounters and that barriers to pain relief will be identified and removed. Affects the quality of life of all children in hospital and its community; not select few with complex pain
Mission
Provision of high quality clinical care in the area of pain control Direct care to inpatients and outpatients with pain Helping other disciplines treat pain problems more
effectively Creating an atmosphere throughout CCMC
where pain treatment is viewed as important Establishing a tradition of education and
scholarship in the area of pain management
Pain Relief Program at CCMC
Specific Aspects of Pain Program Acute Pain Consultation Service Chronic Pain Program Comfort Central
Patient Population(Acute)
Chronic Medical Illness Heme/Onc, Developmental Disabilities
Complicated postoperative pain care Weaning and dose escalation Alternative medications
Sleep, anxiety Pain out of proportion to illness NICU pain problems Sedation questions
Inpatient Complementary Programs
Acupuncture Hypnosis Biofeedback Yoga
Chronic Pain Clinic
Multidisciplinary Approach MD, Psychologist, PT, Nursing, MD-
Acupuncturist, Biofeedbacker, Yoga Therapist, Meditator
Focus on function Emphasize behavioral cognitive and physical
and complementary therapies
Patient Population(Chronic)
Referrals primarily from Rheumatology, Neurology, GI, Orthopedics, private practice
Frequently referred problems: CRPS Widespread pain and fatigue (fibromyalgia, CFS) Headache Abdominal pain Pain associated with genetic disorders (Stickler’s
syndrome, Ehlers-Danlos) Pain associated disability syndrome Prolonged postoperative pain
Complementary Programs
Acupuncture Biofeedback Meditation Yoga Massage
Comfort Central
Protocol Development Phlebotomy Lab Project Topical Anesthetic Trials Injection Protection Project
Mind-Body Skills Training: Applied Psychophysiology
Biofeedback Hypnosis Meditation Relaxation Training
Breathing PMR Autogenics
Sussman and Culbert, 1996, Developmental-Behavioral Pediatrics
Mind/Body Skills Indications
Primary Headache (TT and Migraine) FAP and IBS Acute Procedural Pain and Distress Somatoform Disorders
Adjunctive Cancer –associated symptoms Insomnia Anxiety, stress, panic Chronic Pain Burns Nausea
Biofeedback
The use of electronic or electromechanical equipment to measure and then feedback information about physiologic process which can then be controlled in desirable directions Video games for your body Peripheral-emg, temp, eda, hrv, png EEG
Culbert, 1996 , J Dev Behav Peds
Hypnosis
An altered state of awareness within which persons experience heightened suggestibility (and other phenomena) Mental imagery Self-hypnosis Visualization
Culbert, 1994, Internat J Clin Exp Hypnosis
Hypnosis Reduces Distress and Duration of VCUG I
Kids who had experienced previously distressing VCUG
Routine care group as controls N = 44
Hypnosis Reduces Distress and Duration of VCUG II
Results Parents rating of Child’s distress decreased Observations support less distress Improved compliance Duration of procedure shortened on average
by almost 14 minutes Butler et al, 2005, Pediatrics
Hypnosis versus Midazolam as Premedication
50 children ages 2-11 years randomized One group-midazolam preop Other group-hypnosis training preop Less children anxious in hypnosis with induction
of anesthesia Post-op-hypnosis group had less behavioral
distress by approximately 50% on both day 1 and day 7
Calipel et al, 2005, Pediatric Anesthesia
Comfort Kit for Kids & Families
Best of currently available psychological/behavioral strategies
Self-care design Booklet for kids with “exercises” Booklet for parents to be good coach Items to make it fun Trial of 100 kids (day surgery)
Pilot Study
132 kits out, 63 to kids, 56 parent responses (89% response rate)
Inpatient and Outpatient Mailed for day surgery kids 2 weeks prior
to procedure Diabetes and Heme/Onc clinic just given
out with planned follow-up Brief telephone survey
Day Surgery
Tonsillectomy Adenoidectomy Hernia Repair Orchiopexy
Pilot Study Preliminary Results
How Helpful was the Kit in Helping you/your child cope with pain and distress? Parents: n=56
Very Helpful: 31% Somewhat Helpful: 59% Not at all: 5%
Kids: n=12 mean age 9.9 years Very Helpful: 0 % Somewhat: 50% Not all: 25%
Pilot Study Preliminary Results II
Would you Recommend this Kit to Another Family? Parents:
Yes: 89% Kids:
Yes: 67%
Pilot Study Preliminary Results III
Were the Booklets Easy to Understand? Parents:
Yes: 86% No: 2%
Kids: Yes: 67% No: 8%
Pilot Study Preliminary Results IV
What Items did You use?
Squeeze Ball: 80% Massage Pen: 73% Stress Card: 61% Comfort Ruler: 57% Essential Oil: 45% Bubbles: 43% Pinwheel: 43% Stickers: 30%
Pilot Study Preliminary Results V
What Skills did you try? Breathing: 38% Muscle Relaxation: 30 % Imagery: 29% Self-Talk: 29%
Audience Experiential: Thermal Biofeedback
Peripheral temperature monitoring-indirect reflection of sympathetic nervous system arousal
Typical 75-85 degrees With relaxation training-looking for increase-
ideal if 90-95 degrees Many ways to facilitate temp warming-imagery,
breathing, autogenics Particularly relevant for Migraine and Raynaud’s
Anxious Parents
2 Studies Effectiveness of auricular
accupressure/acupuncture for anxious parents of children having surgery Wang et al, 2004, Anesthesiology Wang et al, 2005, Anesth Analges
Note: children of mothers also less anxious upon entry to operating room and during anesthesia induction
Acupuncture
AJ
14 year old Rhabdomyosarcoma Leg and back pain On narcotics and
other pain meds Needle Phobia
Immediate relief from pain
Lasts 2-4 days “Better than
morphine” Weaned self off of
narcotics
Acupuncture-Classical Concepts
Man functions harmoniously with the universe
Illness described in terms of Disharmony between Yin and
Yang Interior vs. Exterior Cold vs. Hot Dark vs. Light Passivity vs. Activity Deficiency vs. Excess
Balance maintained by flow of Qi
Elements
Wood Tree, firm but flexible
Fire Sun, heat, vitality, excitement
Earth Stability, grounded, balanced,
nurturing
Metal Cool, brittle, inflexible, durable
Water Movement, adaptable,
evolution
Organs Functional Energetic Metaphorical Kidney
Bones, marrow, joints, hearing and hair Will and motivation
Spleen Digestion, blood production, menstruation Nuturing, introspection
Organs
Yin Solid, Energy
Producing Kidney Liver Lung Spleen Heart Master of the Heart
Yang Hollow, transport
Bladder Small Intestine Large Intestine Gall Bladder Stomach Triple Heater
Energy pathways-Meridians
Tendinomuscular Most superficial First defense
Principal Through muscular layer Provide nourishment and
vitality Connected with zone of
organ influuence
Distinct Go deep to the organs Allow organ energy to
circulate
Curious Connections between
meridians
Patient Evaluation
Both western medical eval and eastern approach
Explore the characteristics and behaviors of the problem
Identify organ and energy circulation divisions involved in the problem
Biostructural psychotype
Takes into account traditional history
Also includes Personality traits Seasonal affinities Color and taste
affinities Elemental qualities
Patient Evaluation
Determine areas of deficiency or excess Discover underlying biostructural
psychotype Uncover obstructions to flow Insert needles along channels that
influence energy flow to restore balance
Physical Exam
Standard attention to muscular bands and trigger points
Inspect for tender spots (ashi points) which may indicate underlying organ problem
Somatotopic Systems
Evaluate somatotopic systems Tongue
Ear Pulse
How does it work?
Corrects imbalance of energy Movement of energy
through bioelectric channels
Activation of endogenous opioid system
Direct impact on brain FMRI data
Acupuncture analgesia (AA) –Opioid involvement
Naloxone blocks AA Those with less opioid receptors less AA Endorphins increase in CSF Can provide AA with cross circulation
Functional MRI
Different acupuncture sites activate different portions of the brain
Strong pain points activate structures of descending
antinociceptive pathway deactivate limbic areas involved in pain
association
Compared fMRI of 3 groups
Stimulation of visual acupoint
Stimulation of non-acupoint
Grad student looking at flashlight
Cool Stuff
Outcome Trials
Strong evidence PONV-Acupuncture equivalent to antiemetics in adult
and pediatric trials Not a traditional use of acupuncture
Moderate evidence Headache Back Pain
Weak or no evidence Almost everything else
J.M.
13 yo with dermoid cell tumor
Severe nausea and vomiting s/p chemotherapy
Rx with benadryl, zofran without relief
Stimulation of points in wrist and feet
Decreasing symptoms during procedure
N/V resolved l hour post procedure
Why are clinical trials difficult?
Evaluate eastern medicine with western techniques
Treatment is patient specific not drug specific Personality traits
Treatments vary with practitioners Underlying philosophy Needle placement Duration of needle placement Type of needle stimulation
CAM defined disorders do not equal biomedically defined disorders
Difficult to get adequate sample sizes Placebo difficult to accomplish
Needles placed at non acupoints have intermediate effect
Requires increased sample size to show differences
Patients can differentiate between real and sham needle
Results of studies may not be generalizable
Making clinical trials better
Improving placebo Manualizing treatment
Study particular acupuncture style Allowing flexibility within a framework Develop protocols through consensus Standardized point selection and outcome variables
Study both individual and standardized approaches
STRICTA
Designed to be analogous to CONSORT Acupuncture Rationale Needling Details Treatment Regimen Co-interventions Practitioner Background Control Interventions
Side effects
Needle Shock Bleeding Infection Pain Rare
Pneumothorax Cardiac tamponade
What about children?
Aren’t they afraid of needles? 67% rate it as pleasant Relaxing Many patients sleep
Don’t the needles hurt? Not really
J.M. 17 yo with sickle cell
disease Severe chronic pain
especially in back and hips
Opioid dependent Treatments focused on
relaxation and decreasing in back and hip pain
Treatments separated by 3 weeks
Children with Chronic Pain
Headache Abdominal Pain Arthritis RSD Sickle Cell Cancer Pain Fibromyalgia/Chronic Fatigue
O.J.
13 yo with Crohns disease persistent abdominal pain
Low energy and mood
Treatment focused on increasing energy, decreasing abdominal pain
Immediate feeling of relaxation
Incidentally noted decreased knee pain after first visit
Persistent improvement in energy, mood post 2nd treatment
Abdominal pain resolved post 5th treatment.
M.S.
16 yo with incapacitating migraine headaches
Likely stress induced Misses 1-3 days per
week of school Grades suffering
Hated it from the start No improvement in
headache over 6 weeks
Last treatment targeted relaxation
Patient fell asleep during therapy
G.M.
9 yo neuropathic pain both feet
Became anxious and extremely tearful
Pain improved post acupuncture
Returned for a 2nd try but couldn’t tolerate it
B.Z.
Long distance runner Chronic knee pain -
patellar tendinitis Left >> Right Took 2 mos off without
improvement in symptoms
Treatment with 2 needle technique on Left
Marked lasting improvement on Left
Integrative Approach to Pediatric Headache
Assess for psychiatric co-morbidity Adjust all lifestyle factors
Sleep, diet, overscheduling, exercise Review medications
analgesic rebound, polypharmacy Primary CAM Therapies (safety and efficacy)
Mind/Body, Acupuncture, Psychotherapy Adjunctive CAM Therapies (safety but unclear
efficacy) Massage, Aromatherapy, Cranial Sacral Therapy
Mind/Body Skills and Headache
Hypnosis Vs Propanolol for Migraine Prospective crossover-hypnosis,placebo and propanolol Significant decrease in frequency of HA with self-hypnosis
group only Olness & MacDonald, 1987, Pediatrics
Biofeedback for TT and Migraine HA SEMG with bifrontal placement Peripheral temperature biofeedback Heart rate Variability Biofedback Neurofeedback
Andrasik & Schwartz, 2006, Behavior Modification
Acupuncture and Headache
22 children with migraine Randomized to either acupuncture or sham
acupuncture groups 10 healthy controls Checked serum panopiod levels before and after
treatment on all groups True acupuncture group only-significant reduction
in HA freq and severity and also increase in panopiod levels back to normal (control)levels Pintov et al, 1997, Pediatric Neurology
Aromatherapy and Headache
The use of essential oils that are steam distilled from plants
Inhalation, topical application, ingestion Minimal published studies, but safe and kids
really enjoy it Kids preferences different from adults-study HA-inhalation-rosemary and chamomille HA-topical-lemongrass, peppermint Portable-bring to to school etc
Massage and Headache
Massage effects Increased blood flow ANS balancing Decrease muscle spasm Enhanced lymph drainage
Different Forms 6 sessions over 3-6 weeks Limited study evidence in kids-some in adults
Field, 2002, Med Clin NA
Botanicals/Supplements and Headache
Magnesium, B2 (riboflavin) Feverfew Anti-Inflammatory Diet and Omega 3 FA Butterbur for Migraine
108 kids, 6-17 years, multicenter, prospective open label trial
50-150 mg of butterbur for 4 months 77% of patients had decrease of at least 50% freq of
HA, few SE Pothman and Danesch, 2004, Headache
Headache: Pediatric Case Study
Video-common CAM therapies for pediatric HA
HA-Refractory to Conventional Rx
Tool Kit Approach Can still use abortive or preventative
medications if necessary Active versus passive strategies “Portability” a consideration DCG teaching model Self-management
Integrative Approaches for Insomnia
Aromatherapy Audio Visual Entrainment Relaxation Training Music Therapy Herbal Therapy-teas Melatonin
Training and Information
www.pangea2006.org www.childrensintegrativemed.org www.holistickids.org www.ahma.org www.csh.umn.edu www.integrativemedicine.arizona.edu www.longwoodherbal.org