Integrative Pain and Symptom Management

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 Types of CAM Used 45 40 35 O n c o lo g y 30 25 20 15 10 5 0 P ra y er M a s sa g e C hiro pra c tic V ita m in s R e la x a ti o n He rba ls A ro m a R x P u lm o n a r y G en P eds 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 painconventional 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 effectiveYes Safe No 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 pediatriciansinvestigated 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 Emergency department Common pain problems Sickle Cell pain  Problems persist    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      Nausea    Acupuncture Massage Relaxation Herbal Remedies  Acupuncture Aromatherapy Herbal Remedies Acupuncture Relaxation  Anxiety   Arnica 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   Subsequent visits  PT program    Acupuncture   Tens Unit Aquatic Therapy Desensitization Coping Meditation Anxiety Pain    Behavioral Therapy  Yoga Massage area with arnica gel   Melatonin for sleep 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 IM Consults 2005-378  2006-2,460 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 Visits Up 48%  Psychology 2005-506 2006-749  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 Depression, anxiety, adhd, autism Enuresis, encopresis, sleep disorders, habits Adjustment issues, fatigue, other symptom management    Holistic Mental Health  BioBehavioral Problems  Chronic Illness Related Problems  Children’s Minnesota Integrative Medicine -Other Activities  Inpatient Consultation Services   Massage Non-drug symptom management  Nausea, pain, insomnia, anxiety 3 full cohorts of day surgery nurses 3 more to come 8 hour basic curriculum expanding to 40 hr AHNA model Mind/body interventions for pediatric pain CAM and pediatric oncology Clinical Aromatherapy Massage, stress and cancer  Integrative Nurse Training     Research     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 only helps those patients with whom it interacts   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, MDAcupuncturist, 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 Cancer –associated symptoms Insomnia Anxiety, stress, panic Chronic Pain Burns Nausea  Adjunctive       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% Yes: 67%  Kids:  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 increaseideal 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 Sun, heat, vitality, excitement Fire   Earth  Stability, grounded, balanced, nurturing Cool, brittle, inflexible, durable Movement, adaptable, evolution   Metal  Water  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         Yang Hollow, transport     Kidney Liver Lung Spleen Heart Master of the Heart   Bladder Small Intestine Large Intestine Gall Bladder Stomach Triple Heater Energy pathways-Meridians  Tendinomuscular   Most superficial First defense Through muscular layer Provide nourishment and vitality Connected with zone of organ influuence  Principal     Distinct   Go deep to the organs Allow organ energy to circulate Connections between meridians  Curious  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 Cool Stuff Compared fMRI  of 3 groups Stimulation of visual acupoint   Stimulation of non-acupoint Grad student looking at flashlight Outcome Trials  Strong evidence   PONV-Acupuncture equivalent to antiemetics in adult and pediatric trials Not a traditional use of acupuncture Headache Back Pain Almost everything else  Moderate evidence    Weak or no evidence  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 Underlying philosophy Needle placement Duration of needle placement Type of needle stimulation Treatments vary with practitioners      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 Not really  Don’t the needles hurt?  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 analgesic rebound, polypharmacy Mind/Body, Acupuncture, Psychotherapy Review medications  Primary CAM Therapies (safety and efficacy)  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 selfhypnosis 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