This month’s ‘Pain in Childhood SIG’ blog comes from Dr. Stefan J. Friedrichsdorf, Associate Professor in Pediatrics at the University of Minnesota and medical director of the Department of Pain Medicine, Palliative Care and Integrative Medicine at Children’s Hospitals and Clinics in Minnesota, Minneapolis/St.Paul – one of the largest and most comprehensive programs of its kind in the US. The program is devoted to control acute, chronic/complex and procedural pain in all in- and outpatients and also provides holistic, interdisciplinary care for children and teens with life-limiting or terminal diseases and their families.
Dr. Friedrichsdorf will share with you in this blog a review of safe and effective integrative therapies that are currently be used for pain management at the Children’s Hospital of Minnesota (Minneapolis/St. Paul, MN, USA) www.childrensMN.org. He would also like to introduce the 1st Pediatric Integrative Medicine Master Class: Pain & Symptom Management to be held in Minneapolis this September 21-26, 2014. You can find out more about this exciting course here:
Integrative (non-pharmacological) therapies in managing acute, chronic and procedural pain in children.
The “Decade of Pain Control and Research” (2000-2010) has passed(Nelson, 2003), and the joint statement issued by the World Health Organization (WHO) and the International Association for the Study of Pain (IASP) declared that, “The relief of pain should be a human right” (WHO, 2004). However, pain in pediatric inpatients remains common, under-recognized and undertreated (Taylor et al 2008, Stevens et al 2012).
Children in a hospital may experience somatic, visceral, neuropathic, chronic and/or spiritual pain. This distressing symptom may be disease-related or treatment- (including procedure/intervention) related. The importance of providing multimodal analgesia and integrating non-pharmacological pain modalities is well documented in the literature (Cong et al 2012, Gray et al 2012, Gray et al 2002, Gray et al 2000, Uman et al 2008, Taddio et al 2010).
Unfortunately in 2014 in most children’s hospitals pain is not adequately addressed and managed. However, the children and their parents expect pain to be relieved and the parents’ greatest distress is actually failing to protect their child from pain. Data has shown that the younger children are, the less likely they receive appropriate analgesia (Broome et al 1996 , Nikanne et al 1999). Compared to adults, paediatric patients receive fewer and/or incorrectly dosed analgesics in daily routine (Ellis et al 2002). To reduce “needless pain”, The Children’s Hospitals and Clinics of Minnesota have established a 3-year system wide Toyota Lean quality improvement program. The philosophy of our practice is summarised in The No Needless Pain video here:
Integrative Pain Management
State of the art pain management in the 21st century demands that pharmacological management is no longer the sole approach to the management of a child’s pain and suffering (Taddio et al 2009). Integrative therapies, used on its own or together with pharmacology, include cognitive behavioural techniques (such as guided imagery, hypnosis, abdominal breathing, distraction) and physical methods (such as cuddle/hug, massage, Transcutaneous Electrical Nerve Stimulation [TENS], comfort positioning, heat, cold, aromatherapy). Children cope better with pain and other distressing symptom, when they understand what is happening and when they are encouraged fully in the process to attain relief from their pain (Vinall et al 2012). Comprehensive pain control requires tailoring to the needs of the individual child and integrating methods of pain management.
In this blog we will discuss:
- Mind-Body Medicine including:
f. Virtual Reality
- Manipulative and Body-Based Practices including:
c. Energy Medicine
e. Energy Healing
1. Mind-Body Medicine
Mind-body interventions constitute a major portion of the overall use of Complementary Alternative Medicine (CAM) by the public (NCCAM, 2007). Mind-body medicine focuses on intervention strategies that integrate mind processes with body function and experience in order to promote health. For children and teens, these include relaxation, hypnosis, imagery, meditation, yoga, biofeedback, tai chi, qi gong, cognitive-behavioral therapies, group support, autogenic training, and spiritual practices. Mind-body interventions constitute a major portion of the overall use of CAM by the public (NCCAM, 2007).
Imagery is a non-intrusive, child-centred, gentle therapeutic modality, which can provide a meaningful alternate experience when the present reality is fraught with pain, fear, fatigue, or physical tension. Imagery can be used in many ways. Two often-used techniques include, focusing directly on the distressing pain symptom and engaging with it so that it begins to change, or creating a favourite or familiar image that is a more pleasant alternative to the distressing symptom. Imagery is a precursor to hypnosis, and often used as an induction to hypnotic trance in which change can more rapidly occur.
When used for pain control, imagery works synergistically with analgesics to reduce pain and discomfort (Kuttner & Stutzer, 1995). This modality enables a child to focus attention on a personally meaningful imagery experience and as the imagery becomes more absorbing, the child or teen may dissociate from pain, increase comfort, reduce anxiety, or alter the pain sensations and perceptions (Kuttner 1997; LeBaron & Zeltzer 1984; Zeltzer & LeBaron 1982).
Hypnosis involves the cultivation of an altered state of awareness, leading to heightened suggestibility that allows for changes in a child’s perception and experience, bypassing conscious effort. In hypnosis the clinician enters the child’s world, engaging the child’s imagination as the agent of change and creating alternate experiences to promote therapeutic change. In trance, the child addresses distressing symptoms utilizing suggestions by the clinician for altering sensations, perceptions, and increasing comfort (Olness & Kohen, 1996). Hypnosis has been used over the last two decades in a number of Randomised Control Trials to control pain during invasive medical procedures (e.g., Kuttner, 1988; Liossi, 2002; Zeltzer & LeBaron, 1982).
Biofeedback is a self-regulatory skill that uses electronic or electromechanical equipment to measure and then return information about physiologic functions, which the child uses to gain control over these responses in a desired direction. The functions include, heartbeat, blood pressure, and muscle tension. The feedback is provided in auditory, visual and multimedia game formats that appeal to children (Palermo et al 2010).
Yoga is a 5000-year-old practice from Ayurvedic medicine that combines breathing exercises, physical postures, and meditation. It is intended to calm the nervous system and balance the body, mind, and spirit (NCCAM, 2007). Experience suggests that yoga can be of benefit during palliation if the child or teen is already familiar with the practice, has used diaphragmatic breathing, or has favourite postures (asanas) that ease pain, reduce anxiety or discomfort, such as the “child’s pose” or “cat stretch.” Yoga has been studied in a Randomised Controlled Trial (RCT) to treat adolescents with recurrent abdominal pain and irritable bowel syndrome and found to significantly lower functional disability, reduce anxiety and hold promise for reducing Gastrointestinal symptoms (Kuttner et al., 2006).
Music has been used for centuries to soothe distress and is thought to help reorganize and reregulate the nervous system, improving mood. There is evidence that classical music and lullabies among premature infants decreases distressed behaviour and episodes of oxygen desaturation and increase weight gain and non-nutritive sucking (Caine, 1991; Collins, 1991; Standley & Moore, 1995; Standley, 1998; Standley, 2002). The results from a Italian prospective RCT found that pediatric patients (4–13 years) exposed to music during venipuncture demonstrated significantly lower distress and pain intensity in the music group compared with the control group before, during, and after blood sampling (Caprilli et al., 2007). Songs and music performed by “professional” musicians have a beneficial effect in reducing distress before, during, and after blood tests and the presence of musicians has a significant effect on needle insertion pain. Music therapy improves the quality of end-of-life care and can ease communication between child and family (Aasgaard, 2001).
f. Virtual Reality
Virtual reality is a recent technology that fully absorbs and stimulates the human senses giving the feeling of being in another world. With children it is a popular form of play experience. Since 2005, the investigative clinical research using virtual reality has accelerated, bringing new evidence of its therapeutic potential for the alleviation of pain as a distraction technique during procedural pain (Das et al., 2005; Gold et al., 2006; Lange et al., 2006; Magora et al., 2005).
Aromatherapy is thought to work by promoting the release of neurotransmitters once the nasal receptor cells are stimulated by essential oils (Kyle, 2006). In the United Kingdom, aromatherapy combined with massage is the most widely used complementary therapy in nursing practice (Macmillan Cancer Relief, 2002; Rankin-Box, 1997). Sandalwood oil has been found to be effective in reducing anxiety (Kyle, 2006).
2. Manipulative and Body-Based Practices
Manipulative and body-based practices is a heterogeneous group of integrative interventions and therapies, which include chiropractic and osteopathic manipulation, massage therapy, Tui Na, reflexology, Rolfing, Bowen technique, Trager bodywork, Alexander technique, Feldenkrais method, and a host of others (NCCAM, 2007).
Massage includes pressing, rubbing, and moving muscles and other soft body tissues primarily using the hands and fingers. The aim is to increase blood-flow and oxygen to the massaged area (NCCAM, 2007). Massage Therapy in a pediatric hospice setting can have significantly unique demands, and therefore the term massage can be confusing. Hence the terminology is sometimes being changed into “Integrative Touch” or “Compassionate Touch” (Beider et al., 2007). Massage has been effective in ameliorating pain and distress in infants (Fields, 2002).
Reflexology is the process of gentle, but firm manipulations of the feet and/or hands to stimulate specific reflex points of the body. This is based on the principle that there are reflexes running along the body, which terminate in the feet and the hands, and that the body’s organs and systems are represented on the skin’s surface (Hodgson, 2000; Norman & Cowan, 1989). A Japanese study of 20 terminally ill cancer patients showed that combined modality treatment consisting of aromatherapy, foot soaking, and reflexology was found effective for alleviating fatigue at end-of-life (Kohara et al., 2004).
c. Energy Medicine
The National Center for Complementary and Alternative Medicine (2007) describes Energy Medicine as relating to the concept that human beings are filled with a subtle form of energy. Vital energy is believed to flow through the human body, but as yet has not been measured by conventional instruments. Herbal medicine, acupuncture, acupressure, moxibustion, and cupping, for example, are all believed to act by correcting imbalances in the internal energy field by restoring the flow of qi through meridians.
These approaches are among the most controversial of CAM practices because neither the external energy fields nor their therapeutic effects have as yet been demonstrated convincingly by biophysical means (NCCAM, 2007). Nonetheless, despite the controversy, there is increasing world-wide acceptance of these modalities.
Acupuncture includes a family of procedures originating in Traditional Chinese Medicine (TCM). Acupuncture is the stimulation of specific point on the body by a variety of techniques, including the insertion of thin metal needles through the skin, to remove blockages in the flow of qi, and to restore and maintain health (NCCAM, 2007).
TCM approaches the child in a holistic manner, recognizing the inseparable relationship of the body mind and spirit (Flaws, 1997). TCM teaches that, when a person is in a state of health, Qi or life energy is flowing smoothly through meridians or pathways that connect all systems of the human being, physical, mental and spiritual (Kaptchuk, 1983). When a child suffers from pain, associated symptoms, such as anxiety, stress, depression, insomnia, loss of appetite are also treated. Pain is considered a symptom of the stagnation of the flow of life energy or Qi. TCM treatments aim to restore a balance of these systems and the smooth flow of life energy in a coherent approach (Maciocia, 1994). Improving quality of life is the main objective of TCM treatment. There are no published adult RCTs or pediatric case reports about the use of acupuncture in palliative care.
e. Energy Healing
Energy healing is predicated on a structured system of dynamic energy surrounding and penetrating the human body; auras and chakras (energy centers) within individuals and from the Universal Energy Field. This energy system can be impacted, influenced, balanced, and strengthened or weakened by the person or other people. People can be trained to balance, strengthen, and repair their own and others’ energy systems. A well-functioning energy system allows the human body’s own self-healing mechanisms to function at optimal levels.
So, how do we combine all of the above and incorporate pharmacological and integrative (non-pharmacological) modalities into daily practice?
In my next blog, we will discuss how to combine both non-pharmacological and integrative therapies into your pain management practice. We will also address the non-negotiables of procedural pain management.
Stefan is the Medical Director
Department of Pain Medicine, Palliative Care & Integrative Medicine
Children’s Hospitals and Clinics of Minnesota
Associate Professor of Pediatrics, University of Minnesota, USA
Broome ME, Richtsmeier A, Maikler V, Alexander M. Pediatric pain practices: a national survey of health professionals. J Pain Symptom Manage. 1996 May;11(5):312-20
Nikanne E, Kokki H, Tuovinen K. Postoperative pain after adenoidectomy in children. Br J Anaesth. 1999 Jun;82(6):886-9.
Ellis JA, et al. The Clinical Journal of Pain. 2002;18:262-269]
Randomized controlled trials of psychological therapies for management of chronic pain in children and adolescents: an updated meta-analytic review.Palermo TM, Eccleston C, Lewandowski AS, Williams AC, Morley S. Pain. 2010 Mar;148(3):387-97
- Nelson, R., Decade of pain control and research gets into gear in USA. Lancet, 2003. 362(9390): p. 1129.
- WHO. 2004; World Health Organization supports global effort to relieve chronic pain]. Available from: http://www.who.int/mediacentre/news/releases/2004/pr70/en/.
- Taylor, E.M., K. Boyer, and F.A. Campbell, Pain in hospitalized children: a prospective cross-sectional survey of pain prevalence, intensity, assessment and management in a Canadian pediatric teaching hospital. Pain Res Manag, 2008. 13(1): p. 25-32.
- Stevens, B.J., et al., Pain assessment and intensity in hospitalized children in Canada. The journal of pain : official journal of the American Pain Society, 2012. 13(9): p. 857-65.
- Cong, X., et al., Effects of skin-to-skin contact on autonomic pain responses in preterm infants. The journal of pain : official journal of the American Pain Society, 2012. 13(7): p. 636-45.
- Gray, L., C.W. Lang, and S.W. Porges, Warmth is analgesic in healthy newborns. Pain, 2012. 153(5): p. 960-6.
- Gray, L., et al., Breastfeeding is analgesic in healthy newborns. Pediatrics, 2002. 109(4): p. 590-3.
- Gray, L., L. Watt, and E.M. Blass, Skin-to-skin contact is analgesic in healthy newborns. Pediatrics, 2000. 105(1): p. e14.
- Uman, L.S., et al., A systematic review of randomized controlled trials examining psychological interventions for needle-related procedural pain and distress in children and adolescents: an abbreviated cochrane review. J Pediatr Psychol, 2008. 33(8): p. 842-54.
- Taddio, A., et al., Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne, 2010. 182(18): p. E843-55.
- Taddio, A., et al., Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline (summary). CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne, 2010. 182(18): p. 1989-95.
- Taddio, A., et al., Inadequate pain management during routine childhood immunizations: the nerve of it. Clin Ther, 2009. 31 Suppl 2: p. S152-67.
- Vinall, J., et al., Neonatal pain in relation to postnatal growth in infants born very preterm. Pain, 2012. 153(7): p. 1374-81.