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Integrative Pain and Symptom Management

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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 ... – PowerPoint PPT presentation

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Title: Integrative Pain and Symptom Management


1
Integrative Pain and Symptom Management
  • William Zempsky, MD, FAAP
  • Timothy Culbert, MD, FAAP
  • Sessions S131 and S169

2
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.
3
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

4
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5
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

6
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 bodys 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

7
Kids and CAM
  • 2-30 in primary care settings
  • 30-70 of kids with chronic illness
  • 1999-2000 Childrens 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

8
CAM Use at Childrens Minnesota-52 Overall
  • 59 of Oncology Patients
  • 51 Pulmonary Patients
  • 32 General Pediatrics
  • 62 Pediatric Epilepsy
  • 47 Pediatric Sickle Cell

9
Types of CAM Used
10
Doctors and CAM
  • Pediatricians in Michigan
  • gt50 would refer for CAM
  • gt50 used CAM themselves
  • Sikand, 1998, Arch Ped Adol Med
  • Pediatricians National Survey
  • 66 believed CAM could be helpful
  • Kemper Oconnor, 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

11
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

12
CAM KidsLegal 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

13
Evidence Safety vs. Efficacy
  • SafeYes Safe No
  • effectiveYes Recommend Monitor closely
  • effective No Tolerate Advise against
  • Weiger et al, 2002, Annals Int Med
  • Cohen, Pediatrics, 2005

14
Chronic Pain Diagnosis
  • Study of general academic pediatricians-investigat
    ed 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

15
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 gt90 completed treatment, no
    adverse effects
  • Zeltzer et al, 2002, J Pain Symptom Manage

16
Chronic Pain Book
  • Conquering Your Childs Chronic Pain
  • Lonnie Zeltzer, MD

17
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18
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

19
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

20
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
21
  • 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.
22
What symptoms do we need to consider?
  • Pain
  • Nausea
  • Insomnia
  • Anxiety
  • Depression

23
Acute Symptoms
  • Pain
  • Acupuncture
  • Massage
  • Relaxation
  • Herbal Remedies
  • Arnica
  • Nausea
  • Acupuncture
  • Aromatherapy
  • Herbal Remedies
  • Anxiety
  • Acupuncture
  • Relaxation

24
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

25
Chronic Pain Management
  • Behavioral Therapy
  • Herbal therapy
  • Biofeedback
  • Physical Therapy
  • Osteopathic Manipulation
  • Craniosacral Therapy
  • Acupuncture
  • Massage
  • Yoga
  • Reiki

26
16 yo with CRPS
  • Sprained ankle 2 months ago
  • Placed in a boot
  • PE
  • Pain
  • Allodynia
  • Cool
  • Swoolen
  • Blue

27
  • 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

28
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29
Childrens 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

30
Childrens 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)

31
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

32
Childrens 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)

33
Childrens 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

34
Childrens 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

35
Childrens 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
    dont make big -we have controlled revenue and
    expenses very well

36
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37
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 1998023-29

38
Surveys of Adequacy of Pain Relief
  • Cummings et al. 1996
  • Survey of all children in childrens 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

39
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
40
  • We realized a traditional Pain Service only helps
    those patients with whom it interacts

41
  • Action plan which emphasizes CCMCs 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

42
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

43
Pain Relief Program at CCMC
  • Specific Aspects of Pain Program
  • Acute Pain Consultation Service
  • Chronic Pain Program
  • Comfort Central

44
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

45
Inpatient Complementary Programs
  • Acupuncture
  • Hypnosis
  • Biofeedback
  • Yoga

46
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

47
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
    (Sticklers syndrome, Ehlers-Danlos)
  • Pain associated disability syndrome
  • Prolonged postoperative pain

48
Complementary Programs
  • Acupuncture
  • Biofeedback
  • Meditation
  • Yoga
  • Massage

49
Comfort Central
  • Protocol Development
  • Phlebotomy Lab Project
  • Topical Anesthetic Trials
  • Injection Protection Project

50
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51
Mind-Body Skills Training Applied
Psychophysiology
  • Biofeedback
  • Hypnosis
  • Meditation
  • Relaxation Training
  • Breathing
  • PMR
  • Autogenics
  • Sussman and Culbert, 1996, Developmental-Behaviora
    l Pediatrics

52
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

53
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

54
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

55
Hypnosis Reduces Distress and Duration of VCUG I
  • Kids who had experienced previously distressing
    VCUG
  • Routine care group as controls
  • N 44

56
Hypnosis Reduces Distress and Duration of VCUG II
  • Results
  • Parents rating of Childs distress decreased
  • Observations support less distress
  • Improved compliance
  • Duration of procedure shortened on average by
    almost 14 minutes
  • Butler et al, 2005, Pediatrics

57
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

58
Comfort Kit for Kids Families
  • Best of currently available psychological/behavior
    al 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)

59
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60
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61
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62
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

63
Day Surgery
  • Tonsillectomy
  • Adenoidectomy
  • Hernia Repair
  • Orchiopexy

64
Pilot Study Preliminary Results
  • How Helpful was the Kit in Helping you/your child
    cope with pain and distress?
  • Parents n56
  • Very Helpful 31
  • Somewhat Helpful 59
  • Not at all 5
  • Kids n12 mean age 9.9 years
  • Very Helpful 0
  • Somewhat 50
  • Not all 25

65
Pilot Study Preliminary Results II
  • Would you Recommend this Kit to Another Family?
  • Parents
  • Yes 89
  • Kids
  • Yes 67

66
Pilot Study Preliminary Results III
  • Were the Booklets Easy to Understand?
  • Parents
  • Yes 86
  • No 2
  • Kids
  • Yes 67
  • No 8

67
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

68
Pilot Study Preliminary Results V
  • What Skills did you try?
  • Breathing 38
  • Muscle Relaxation 30
  • Imagery 29
  • Self-Talk 29

69
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 Raynauds

70
Anxious Parents
  • 2 Studies
  • Effectiveness of auricular accupressure/acupunctur
    e 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

71
Acupuncture
72
AJ
  • 14 year old
  • Rhabdomyosarcoma
  • Leg and back pain
  • On narcotics and other pain meds
  • Needle Phobia

73
  • Immediate relief from pain
  • Lasts 2-4 days
  • Better than morphine
  • Weaned self off of narcotics

74
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

75
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

76
Organs
  • Functional
  • Energetic
  • Metaphorical
  • Kidney
  • Bones, marrow, joints, hearing and hair
  • Will and motivation
  • Spleen
  • Digestion, blood production, menstruation
  • Nuturing, introspection

77
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

78
Energy pathways-Meridians
  • Tendinomuscular
  • Most superficial
  • First defense
  • Principal
  • Through muscular layer
  • Provide nourishment and vitality
  • Connected with zone of organ influuence

79
  • Distinct
  • Go deep to the organs
  • Allow organ energy to circulate
  • Curious
  • Connections between meridians

80
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

81
Biostructural psychotype
  • Takes into account traditional history
  • Also includes
  • Personality traits
  • Seasonal affinities
  • Color and taste affinities
  • Elemental qualities

82
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

83
Physical Exam
  • Standard attention to muscular bands and trigger
    points
  • Inspect for tender spots (ashi points) which may
    indicate underlying organ problem

84
Somatotopic Systems
  • Evaluate somatotopic systems
  • Tongue

85
  • Ear
  • Pulse

86
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

87
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

88
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

89
Cool Stuff
  • Compared fMRI of 3 groups
  • Stimulation of visual acupoint
  • Stimulation of non-acupoint
  • Grad student looking at flashlight

90
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

91
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

92
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

93
  • 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

94
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

95
STRICTA
  • Designed to be analogous to CONSORT
  • Acupuncture Rationale
  • Needling Details
  • Treatment Regimen
  • Co-interventions
  • Practitioner Background
  • Control Interventions

96
Side effects
  • Needle Shock
  • Bleeding
  • Infection
  • Pain
  • Rare
  • Pneumothorax
  • Cardiac tamponade

97
What about children?
  • Arent they afraid of needles?
  • 67 rate it as pleasant
  • Relaxing
  • Many patients sleep
  • Dont the needles hurt?
  • Not really

98
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

99
Children with Chronic Pain
  • Headache
  • Abdominal Pain
  • Arthritis
  • RSD
  • Sickle Cell
  • Cancer Pain
  • Fibromyalgia/Chronic Fatigue

100
O.J.
  • 13 yo with Crohns disease persistent abdominal
    pain
  • Low energy and mood
  • Treatment focused on increasing energy,
    decreasing abdominal pain

101
  • 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.

102
M.S.
  • 16 yo with incapacitating migraine headaches
  • Likely stress induced
  • Misses 1-3 days per week of school
  • Grades suffering

103
  • Hated it from the start
  • No improvement in headache over 6 weeks
  • Last treatment targeted relaxation
  • Patient fell asleep during therapy

104
G.M.
  • 9 yo neuropathic pain both feet
  • Became anxious and extremely tearful
  • Pain improved post acupuncture
  • Returned for a 2nd try but couldnt tolerate it

105
B.Z.
  • Long distance runner
  • Chronic knee pain -patellar tendinitis
  • Left gtgt Right
  • Took 2 mos off without improvement in symptoms
  • Treatment with 2 needle technique on Left
  • Marked lasting improvement on Left

106
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107
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

108
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

109
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

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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

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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

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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

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Headache Pediatric Case Study
  • Video-common CAM therapies for pediatric HA

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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

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Integrative Approaches for Insomnia
  • Aromatherapy
  • Audio Visual Entrainment
  • Relaxation Training
  • Music Therapy
  • Herbal Therapy-teas
  • Melatonin

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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
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