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Integrative Pain and Symptom Management William Zempsky, MD, FAAP Timothy Culbert, MD, FAAP Sessions S131 and S169 Faculty Disclosures

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integrative pain and symptom management

Integrative Pain and Symptom Management

William Zempsky, MD, FAAP

Timothy Culbert, MD, FAAP

Sessions S131 and S169

faculty disclosures
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
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
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 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
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
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
doctors and cam
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
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
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
Evidence: Safety vs. Efficacy

SafeYesSafe No

effectiveYesRecommendMonitor closely

effective NoTolerate Advise against

Weiger et al, 2002, Annals Int Med

Cohen, Pediatrics, 2005

chronic pain diagnosis
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
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
Chronic Pain Book
  • Conquering Your Child’s Chronic Pain
    • Lonnie Zeltzer, MD
children in pain
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
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
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
What symptoms do we need to consider?
  • Pain
  • Nausea
  • Insomnia
  • Anxiety
  • Depression
acute symptoms




Herbal Remedies





Herbal Remedies




Acute Symptoms
chronic symptom management
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


Physical Therapy

Osteopathic Manipulation

Craniosacral Therapy





Chronic Pain Management
16 yo with crps
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


Behavioral Therapy



Melatonin for sleep

Subsequent visits





Massage area with arnica gel

children s minnesota integrative medicine program overview
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
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
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
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
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
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
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
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
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

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
  • 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
Pain Relief Program at CCMC
  • Specific Aspects of Pain Program
    • Acute Pain Consultation Service
    • Chronic Pain Program
    • Comfort Central
patient population acute
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
Inpatient Complementary Programs
  • Acupuncture
  • Hypnosis
  • Biofeedback
  • Yoga
chronic pain clinic
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
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
Complementary Programs
  • Acupuncture
  • Biofeedback
  • Meditation
  • Yoga
  • Massage
comfort central
Comfort Central
  • Protocol Development
  • Phlebotomy Lab Project
  • Topical Anesthetic Trials
  • Injection Protection Project
mind body skills training applied psychophysiology
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
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
  • 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
  • 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
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
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
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
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
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
Day Surgery
  • Tonsillectomy
  • Adenoidectomy
  • Hernia Repair
  • Orchiopexy
pilot study preliminary results
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
Pilot Study Preliminary Results II
  • Would you Recommend this Kit to Another Family?
    • Parents:
      • Yes: 89%
    • Kids:
      • Yes: 67%
pilot study preliminary results iii
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
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
Pilot Study Preliminary Results V
  • What Skills did you try?
    • Breathing: 38%
    • Muscle Relaxation: 30 %
    • Imagery: 29%
    • Self-Talk: 29%
audience experiential thermal biofeedback
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
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
  • 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
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
  • Wood
    • Tree, firm but flexible
  • Fire
    • Sun, heat, vitality, excitement
  • Earth
    • Stability, grounded, balanced, nurturing
  • Metal
    • Cool, brittle, inflexible, durable
  • Water
    • Movement, adaptable, evolution
  • Functional
  • Energetic
  • Metaphorical
  • Kidney
    • Bones, marrow, joints, hearing and hair
    • Will and motivation
  • Spleen
    • Digestion, blood production, menstruation
    • Nuturing, introspection

Solid, Energy Producing






Master of the Heart


Hollow, transport


Small Intestine

Large Intestine

Gall Bladder


Triple Heater

energy pathways meridians
Energy pathways-Meridians
  • Tendinomuscular
    • Most superficial
    • First defense
  • Principal
    • Through muscular layer
    • Provide nourishment and vitality
    • Connected with zone of organ influuence
    • Go deep to the organs
    • Allow organ energy to circulate
  • Curious
    • Connections between meridians
patient evaluation
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
Biostructural psychotype
  • Takes into account traditional history
  • Also includes
    • Personality traits
    • Seasonal affinities
    • Color and taste affinities
    • Elemental qualities
patient evaluation82
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
Physical Exam
  • Standard attention to muscular bands and trigger points
  • Inspect for tender spots (ashi points) which may indicate underlying organ problem
somatotopic systems
Somatotopic Systems
  • Evaluate somatotopic systems
    • Tongue


how does it work
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
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
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
Cool Stuff
  • Compared fMRI of 3 groups
    • Stimulation of visual acupoint
    • Stimulation of non-acupoint
    • Grad student looking at flashlight
outcome trials
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
  • 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
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
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
  • Designed to be analogous to CONSORT
  • Acupuncture Rationale
  • Needling Details
  • Treatment Regimen
  • Co-interventions
  • Practitioner Background
  • Control Interventions
side effects
Side effects
  • Needle Shock
  • Bleeding
  • Infection
  • Pain
  • Rare
    • Pneumothorax
    • Cardiac tamponade
what about children
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
  • 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
Children with Chronic Pain
  • Headache
  • Abdominal Pain
  • Arthritis
  • RSD
  • Sickle Cell
  • Cancer Pain
  • Fibromyalgia/Chronic Fatigue
  • 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.
  • 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
  • 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
  • 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
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
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
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
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 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
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
Headache: Pediatric Case Study
  • Video-common CAM therapies for pediatric HA
ha refractory to conventional rx
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
Integrative Approaches for Insomnia
  • Aromatherapy
  • Audio Visual Entrainment
  • Relaxation Training
  • Music Therapy
  • Herbal Therapy-teas
  • Melatonin
training and information
Training and Information