Integrative Therapies for Pediatric Pain
Anjana Kundu, MBBS, DA
Associate Professor,
Dept of Anesthesiology & Pain Medicine
Seattle Children’s Hospital
University of Washington
Seattle
Objectives
• Introduction: Definitions
• Commonly used integrative therapies
• Evaluating commonly used integrative
therapies
• How to guide a patient/family
regarding CAM therapies
Complementary and Alternative
Medicine
• Complementary and Alternative Medicine Group of diverse medical and health care
systems, practices, and products that are not
presently considered to be part of conventional
medicine.
• Conventional medicine - medicine as
practiced by holders of M.D. or D.O. degrees
and by their allied health professionals, such as
physical therapists, psychologists, and
registered nurses.
Complementary or Alternative?
• Complementary medicine is used together with
conventional medicine.
• Alternative medicine is used in place of conventional
medicine.
• Integrative medicine combines treatments from
conventional medicine and CAM for which there is
evidence of safety and efficacy.
NIH-NCCAM Classification
• Alternate Medical systems
– Homeopathy, Traditional Chinese Medicine, Ayurveda,
Naturopathy
• Mind Body Medicine
– Hypnosis, Biofeedback, Guided imagery, Meditation,
spirituality
• Biologically based practices
– Herbs, Supplements, aromatherapy
• Manipulative or body based practices
– Massage, Chiropractic, Craniosacral, Yoga
• Energy medicine
– Therapeutic touch, Qi-gong, Reiki
– Acupuncture
Pain
• Chronic Pain
– More than 3 months duration
– Ongoing nerve damage, infection,
muscle spasm, inflammation
– Persists after initial injury healed
– And/or may relate to emotional,
cognitive, learned behavioral issues
Context
• Incidence of chronic pain 15-30%
• Significant disabilities
– School absence
– Sleep disturbance
– Higher distress, anxiety, depression
• Higher incidence of persistence into
adulthood
• Long history of under-treatment of pain in
children
Context
• Effective treatment may lessen the
economic burden and social impact
• Non-Drug Options for Pain –underutilized
• 25% of families were still unhappy with
pain management in 2006
Context
• General academic pediatricians (3 MD’s)investigated children presenting with chronic
pain
• 134 patients, 8-18 yrs, chart review
• 60% had psychiatric co-morbidity
• 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
CAM for Chronic Pain
Incidence
• 30% pediatric patients use CAM
• More than 75% for chronic illness, cancer
and pain
• Children use more Mind Body Medicine
based therapies compared to adults.
» Kundu et al, Clin Pediatr 2010
» Barnes et al 2007
» Hagen et al 2003
CAM for Chronic Pain
• Commonly used CAM for pediatric pain
• Mind Body Medicine
• Acupuncture
• Massage
• Aromatherapy
• Yoga
• Supplements
Mind Body Medicine
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Hypnosis
Biofeedback
Guided Imagery
Meditation
Relaxation Training
– Breathing
– PMR
– Autogenics
Hypnosis
• An altered state of awareness within which
persons experience heightened
suggestibility (and other phenomena)
– Mental imagery
– Self-hypnosis
– Visualization
• 8 -14 y/o have higher hypnotizability
Biofeedback (BFB)
 Records a physiological process,
processes information, presenting it to
subject
 Attends to the process and attempts to
alter the process
 The BFB loop is completed when the
person attends to the displayed
information
Provide signal
Process feedback
Biofeedback (BFB)
Feedback
Tool
Skin Temperature
Digital Thermal Gauge
Heart Rate
Respiratory rate
Pulse / Respiratory
Monitor
Galvonic Skin Response
GSR meter
sEMG
Electromyography
Heart Rate
Finger / Earlobe sensor
Variability (HRV)
Biofeedback (BFB)
Mind Body Medicine - Pain
• Twenty-eight trials, 1951 participants
• Largest effect sizes for treatment vs.
control
– Distraction (self-reported pain),
– Hypnosis (self-reported pain, self-reported
distress and behavioral measures of distress),
– Combined cognitive-behavioral interventions
(other-reported distress and behavioral
measures of distress).
» Cochrane Review 2006
Mind Body Medicine - Pain
• Meta-analysis, 25 trials, 1247 participants
• Inclusion:
– Psychological Rx vs. placebo, active Rx,
treatment as usual or waitlist
– Chronic pain other than cancer
– Pain, disability or emotional functioning
• Treatment: Omnibus CBT, relaxation,
Biofeedback
• Self guided vs. Therapist guided
» Palermo et al. Pain. March 2010
Mind Body Medicine - Pain
• Large positive effect on pain reduction (posttreatment and follow-up)
• Small/ non-significant effects for disability and
emotional functioning
• All techniques produced significant effects on
pain reduction
• Self-administered versus therapistadministered interventions had similar effects
on pain reduction
» Palermo et al. Pain. March 2010
MBM- Pediatric 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
MBM- Pediatric Headache
• Long term follow up of Hypnosis
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52 youth, previously trained
85% continued relief,
44% decrease headache frequency
31 % decreased severity
56% decreased intensity
50% reported importance of hypnosis with stressors.
• Cohen et al, 2010, Int J Clin Exp Hypn
MBM – Pediatric Headache
• Migraine Patient Seminar (MIPAS) – a multimodal
behavioral program for patient and family
• Compared with BFB, for HA
• 34 patients, 7-16 yrs, RCT
• MIPAS – 8 sessions for children , 4 sessions for
parents
• BFB – 20 sessions
• Both groups had decreased intensity and duration
of HA,
• No statistically significant differences between 2
groups
• Wolf-Dieter et al. J Headache Pain 2010
Acupuncture
Acupuncture
• Manipulation of specific points on the
body
• Meridians-14 invisible channels of energy
flow-forming a network
• Qi (chee) ebbs and flows with changes in
a person’s mental, physical and spiritual
well being
• Practiced in China for thousands of years
!
Acupuncture
Acupuncture
Acupuncture Mechanism
• CSF analysis following acupuncture treatment
shows increased levels of endorphins,
encephalins, monoamines
– Eriksson et al. 1977, Pomeranz 1996, Sims 1997
• Antagonism of EA by naloxone
– Mayer et al.1977 & Pomeranz et al 1989
• fMRI studies demonstrating effects of
stimulating various acupuncture points and
effects on CNS
– Cho et al. 2000, Liu et al 2004
• Polymodal Receptors Mechanism
– Kawakita et al. 2007
Acupuncture Mechanism
Fig. 1. Functional magnetic resonance imaging demonstrating a correlation between activation of specific areas of the brain and corresponding acupoint
stimulation predicted by ancient acupuncture literature. A = anterior nucleus; cADD = caudal anterior cingulated cortex; CM = centromedian nucleus; dACC =
dorsal anterior cingulate cortex; DM = dorsomedial nucleus; DsF = dorsal superficial nucleus; IL = intralaminar nuclei; PG = caudal inferior parietal lobule, area
7a; rACC = rostral anterior cingulate cortex; TA = tectal area. From the American Academy of Medical Acupuncture 27; used with permission.
Acupuncture - Safety
• Review of 22 RCTs
– Sedation 32%,
– Needle discomfort 26%
– Redness or Irritation at
puncture site 7%
– Hematoma 1%
– Faintness 1%
– Jindal et al Pediatr Hematol Oncol 2008,
Acupuncture - Acceptability
– Positive experience
– Relaxing
– Many patients sleep
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Zempsky,2005
Lin et al 2002
Zeltzer et al 2002
Kemper et al 2000
Chronic Pain- Acupuncture
• 47 participants, median age 16 yrs, with
chronic pain
• 70 % reported improvement in pain
• 59 % of parents rated improved pain
Kemper et al, Pediatrics 2000
Chronic Pain- Acupuncture
• N=33, 6-18 yrs, with chronic pain
• 6 weeks Acupuncture + hypnotherapy
• Pre - post treatment pain reduction 4.4,
interference reduction 2.6
• Parents rating - improved pain 3.4,
interference reduction 3.1
Zeltzer et al, J Pain Symptom Manag 2002
Chronic Pain- Acupuncture
• 243 patients, mean age 14.5 yrs
• Pilot study, 6 weeks treatment
• Reduction in VAS 8.3-3.4 at 6 weeks
• Improved overall well being, increased
school attendance, improved sleep
Lin et al, Medical Acupuncture 2002
Headache - Acupuncture
• 22 Children, 7-15 yrs, with migraine
• Acupuncture or sham acupuncture x 10 weeks, 10
healthy controls
• Frequency, severity of HA, serum panopioid and
β-endorphin levels before and after treatment
• Significant reduction in HA frequency, severity,
• Increase in panopioid & β-endorphin levels, back
to normal (control) levels,
• Pintov et al, 1997, Pediatric Neurology
Headache - Acupuncture
• 48 Children with migraine or TTH, median age
12.5 yrs
• Double blinded RCT, Laser acupuncture (22
active (verum) vs. 21 placebo)
• 4 weekly treatments
• Baseline HA, number of HA days, duration,
intensity
• Significant reduction in number of HA days (6.4
vs. 1), duration, and intensity
• Gottschling et al, 2008, Pain
Headache - Acupuncture
Headache - Acupuncture
Headache - Acupuncture
Massage
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57 patients, presenting to pain clinic
Prospective clinical trial,
Usual Rx + massage
Control ratings before & after a ‘no
intervention’ time period in 25
• Pain, distress, tension, discomfort, and
degree of upset mood significantly lower
» Santhanam et al, Paediatr Anesth 2008
Yoga
• 25 IBS patients, 11-18 yrs
• RCT, Yoga vs. wait list control
• Baseline GI sx, pain, functional disability,
coping and anxiety/depression
• Lower functional disability, GI sx, anxiety,
emotion focused avoidance with yoga
intervention
• Pain excluded from analysis due to
differences in baseline scores
» Kuttner et al, Pain Res Manage 2006
Aromatherapy
Aromatherapy
• 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
Aromatherapy
• Pain
• Anxiety
• Nausea
• Insomnia
Aromatherapy
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Insomnia-lavender, neroli
Anxiety-sweet orange, sandalwood
Nausea-spearmint, ginger
Fatigue-lemon, peppermint
Pain-rosemary, chamomille
Topical-lemongrass, black pepper
Aromatherapy preferences in Kids**
Aromatherapy - Headache
• Kids preferences different from adults-study
• HA-inhalation-rosemary and chamomille
• HA-topical-lemongrass, peppermint
• Portable-bring to to school etc
Supplements - Headache
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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
Supplements - Headache
Magnesium in Children
– One open and one DBPCT
– (N=118) 9 mg/kg Magnesium Oxide / day
vs. placebo
 Frequency of HA  pre-post:
–Mg (P = 0.0037)
–Placebo (P= 0.086)
 HA severity in Mg vs. Placebo (P <
0.003)
How to Advise Patients/Families?
• Encourage disclosure of CAM use
• Consider their choice and autonomy in the
determining therapy
• Age appropriate therapies
• Evidence based, whenever possible
FIGURE 1 Guide to CAM treatment recommendations
Kemper, K. J. et al. Pediatrics 2008;122:1374-1386
Copyright ©2008 American Academy of Pediatrics
Summary
• The impact of un/undertreated pain extends
beyond the patient and beyond childhood
• Use and acceptance of CAM prevalent in Kids
• Integrating appropriate CAM may enhance
therapeutic outcomes.
• Active participation and self-management
strategies should be encouraged
• Evidence base for CAM in Pediatric Pain is
increasing
Please save the date and join us in Seattle for
Regional Anesthesia in Children
August 26-28, 2011
Hosted by
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Local, national and international speakers including:
Bernard Dales (Quebec City, Canada)
Ben Walker (Madison, USA)
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Arjunan Ganesh (Philadelphia, USA)
Brian Ross (Seattle, USA)
Didactic lectures and small group workshops
Ultrasound practice on live models and phantoms
Team Stepps/Crew Resource Management Training
Regional anesthesia simulation
Cadaveric anatomy workshop
More information available on our website shortly: http://www.seattlechildrens.org/cme
anjana.kundu@seattlechildrens.org
Thank You