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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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