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1 The Role of Massage Therapy and Other Integrative Medicine Therapies with the Comprehensive Pain Service in the Development of a Pediatric Integrative Medicine Pain Clinic Susan Edgar, LSW, LMT Sharon Wrona RN, MS, PNP ASPMN Conference September 6, 2008 Welcome Nationwide Children s Hospital 1

2 The Evolution of the Comprehensive Pain Service Vision Through teamwork and excellence in patient care, research, education and advocacy Nationwide Children s Hospital Comprehensive Pain Service will become a world premier program. Clinical / Administrative Organization Perioperative Services Dr. Tingley Clinical Services & Case Coordination Homecare Dr. Joseph Jen Rogers Program Coordinator Sharon Wrona, CNP Clinical Lead APN Medical Director of Inpatient Pain Service Clinic Medical Director of Palliative Care CNP Nurse Clinician Palliative Care CNP CNP Psychology Palliative Care Social Worker Anesthesiologist Physical Therapy Hospice Home Palliative Care Anesthesiologist Massage Anesthesiologist Acupuncture 2

3 Inpatient Pain Service Any inpatient pain management issue Postoperative Medical PCA / NCA/ Epidural End of life Functional Inpatient Pain Service Patients

4 The Growth of the Massage Therapy Program Brief History: Physician advocate/ grant writer Credibility of massage therapist Available patient population July : Pulmonary Division October, 2003-present: Physical Therapy Department Challenges Ongoing funding Hospital administrative support Lack of research/ evidence-based studies Initial Funding 3-Year Business Plan Grants: Cystic Fibrosis Foundation Children s Research Institute Massage Therapy with Patients with Life-Threatening Asthma Anderson Family Foundation 4

5 Initial Programming Massage Therapy as a standard of care Word of mouth physician referrals Massage Therapist -initiated services Current Massage Therapy Program Consult-driven/ Physician orders Numbers: new orders per month Frequencies: Each patient 3-5 times per week Funding Insurance reimbursement Support from Physical Therapy Department Foundation 5

6 Massage Therapy Team Education: minimum 750 hours of instruction from an accredited school of massage therapy Licensure by the State of Ohio Medical Board: Massage Therapy as Limited Branch of Medicine Advanced Training Manual Lymphatic Drainage Cranial Sacral therapy Myofascial Therapy Reiki Healing Touch Aromatherapy Picture of team 6

7 Parent Teaching Helping Hands DVD s and Videotapes Modeling/ Hands-on Teaching Parent/ Primary Caregiver Massage Parents/ primary caregivers of hospitalized patients 15-minute chair massages 2 afternoons per week in Family Resource Center No cost to families CAM Research Treatment Preferences for CAM in Children with Chronic Pain, Tsao et. al., 2006 N=129 children (94 girls) Mean age = 14.5 years Over 60% elected to try at least one CAM approach 7

8 CAM Therapies included Yoga Biofeedback Hypnosis Massage therapy Acupuncture Art therapy Energy healing Findings Pain duration was a significant predictor of CAM preference and agreement to engage in CAM therapies Patients with Fibromyalgia (80%) were the most likely to try CAM therapy vs. those with other pain diagnoses Patients preferred non-invasive approaches that enhanced relaxation and increased somatic control, especially mind-based modalities CAM Research Treatment Expectations for CAM Interventions in Pediatric Chronic Pain Patients and their Parents, Tsao et.al., 2005 Children presented for treatment at a specialty clinic for chronic pediatric pain - N=45 children (32 girls) - Mean age= 13.8 years - Parents: 39 mothers 8

9 CAM therapies included: Hypnosis Massage therapy Acupuncture Yoga Relaxation Conventional medicine: Medication Surgery Findings Parents expected hypnosis, acupuncture and yoga to be more beneficial than did children Children expected surgery to be slightly more helpful than did parents Children rated acupuncture, surgery and hypnosis as the 3 lowest rated interventions Massage Therapy Clinical Outcomes Majority of research validates the effects of Massage Therapy on the reduction of: PAIN ANXIETY 9

10 Evidenced Based-Practice Massage Therapy and its Effects on Symptoms in Children who Suffer from Chronic Pain, Suresh, Abstract P60, The Effects of Massage Therapy with Children with Juvenile Rheumatoid Arthritis, Tiffany Field, et. al, The Touch Research Institute, Pediatric Massage Therapy: An overview for Clinicians Review of Research Literature, Beider, et al. The best empirical evidence shows reductions in anxiety, and reductions in pain. Review of 24 randomized control trials of pediatric MT for children between ages 2 and 19 years. Improvements in trait anxiety, muscle tone, arthritis pain, non-specific low back pain, shoulder pain, headache pain, neck pain, fibromyalgia, and carpal tunnel syndrome. Benefits of Massage Therapy Enhanced pulmonary function Increased circulation Removal of toxins Stress reduction Enhanced body image Overall sense of well-being 10

11 The Development of the Pediatric Integrative Medicine Pain Clinic Medical director for the Comprehensive Pain Service: September, 2007 Pain Clinic offers Medical Psychology PT Massage Acupuncture Steps in the Planning Process of the Development of a New Multidisciplinary Pain Clinic Professionals/ disciplines to be involved in the Clinic Communication among multiple disciplines and therapists Triaging of patients for specific integrative medicine therapies Scheduling of new patents Patient follow up Funding/ Insurance reimbursement Pain Service Clinic At the Westerville Sports Medicine Building Any patient that is disabled by pain Secondary to medical illness Oncology Sickle Cell Disease Rheumatologic disease Cystic fibrosis Primary Pain Syndrome Complex regional pain Myofascial pain / Fibromyalgia Functional abdominal pain Chronic Daily Headache (614)

12 Steps in the Planning Process of the Development of a New Multidisciplinary Pain Clinic Model used: consultation, disease-based, symptom-based Professionals/ disciplines to be involved in the Clinic (Eastern/ Western medicine) Communication among multiple disciplines and therapists Triaging/ assessment of patients for specific integrative medicine therapies Scheduling of new patents using assignment to different tracks, based upon needs of patients Patient follow up Funding/ Insurance reimbursement Northeast Outpatient Chronic Pain Clinic/Support Flow Physician Referral/ Self referral Referral rec vd In EPIC inbox or by fax Patient s medical Records are Reviewed for appropriateness By Chronic Pain Physician NO Chronic Pain Clinic candidate? YES Referring MD called w/ feedback; Pt referred to appropriate MD, specialty, etc. Referring MD called w/ feedback; Program Coord. Calls pt/family & sends welcome pkt and measures Prog Coord. calls pt & inform that packet was rec'vd & complete. Prog coord. puts pt name on new pt. work list COMMUNICATION Pt scheduled for follow up appts. by Central Sch., NE Regis., or Timken front desk (psych only) Initial (New Patient) Clinic Visit* MEDICAL PSYCHOLOGY PT Visit includes: Assessment, Team Discussion, Education, Develop treatment plan (~ hr visit: MON or THU AM) Clinic Code = NEPN Patient appointment scheduled for initial clinic visit YES NO Central Sch. chks for pt. on Work List 1 Pt calls central scheduling to set up new initial appt. Pt presented at 12-1 MON Team Planning mtg. 2 Follow Up Visits** MEDICAL F/U Clinic Code = NEPN PSYCH F/U Clinic Code = NEPN PT F/U Clinic Code = NEPT MASSAGE F/U Clinic Code = NEPT Prior to EPIC implementation, provider chks appropriate services on Pain clinic chg sheet. Prog Coord enters charges for Initial, Medical F/U, Massage F/U, and Acupuncture F/U. Psych and PT provider enter their charges. 3 KEY: Referral or Patient MD Program Coordinator Central Scheduling Registration Staff at Westerville or Timken ACUPUNC F/U Clinic Code = NEPT Clinical Providers * All disciplines see the patient at the same time, in the same room. ** The first 2-3 months of follow up visits will be more intense (weekly), but will then become more spread out (i.e. monthly) Challenges Administrative Clinical Financial 12

13 Pain Clinic Case Presentations Headaches Spinal fusions MASSAGE THERAPY EVALUATION NOTE Evaluation Time: 15 Minutes Treatment Time: 30 Minutes Patient Appearance/Observations: Patient was alert, verbal, and agreeable to Massage Therapy. She verbalized a positive attitude toward her pain symptoms and planned treatment. Pt Complained of: Patient complained of generalized pain which could begin in her hands, and then travel to her legs and feet. Mother was present during this phase of our therapy session, and she stated patient had an "attack" last night where she found patient with contracted muscles and "arched back". Assessment/Pain Scale: 10/10 during "pain attacks" Intervention/Plan: Therapeutic Medical Massage, repositioning, reassurance, gentle rocking Palpation Revealed: Tight muscles include: SCM, scalenes, suboccipitals, trapezius, levator scapula, rhomboideus, lumbar, iliotibial tract, quadratus lumborum, quadriceps, hamstrings Type of Treatment: Swedish: muscular kneading, circular friction, stroking, passive touch Deep tissue, Deep tissue rocking, and Myofascial Massage Therapy Lotion Used: Lubriderm 13

14 Response to Treatment: pain reduction, relaxation, stress reduction, sleeping Treatment Plan/ Recommendations: Frequency/Duration: MT to see patient 1 time per week Treatment goals: pain reduction, stress/anxiety reduction, improve eating and sleeping Recommendations: Therapeutic Medical Massage to address medical treatment goals Why Programs Do Not Succeed Budgetary constraints Physician resistance Lack of evidence-based studies Lack of internal expertise Identifying qualified practitioners in your area Developing your Unique Plan Establish a vision/ starting point Develop a mission statement Mission and vision statements should harmonize with the broader mission of the organization Define model to be used Decide which professionals to include 14

15 Integrative Therapies Predominant modalities used: Massage Therapy (37%) Yoga Guided Imagery/ Biofeedback/ Hypnosis Relaxation Training/ Meditation Acupuncture/ Acupressure Aromatherapy Need. administrative support and physician buy-in program director that will be liaison with other professionals/ disciplines quality control measures/data collection continuing education, focus upon licensure and certifications education of hospital professionals: target who to train and how often job descriptions, competencies, and minimum training requirements for practitioners staff with specialized training Then. Develop your strategic plan Develop and build team/ committee: create structure and hold regular meetings Develop referral mechanisms for referrals from community physicians Establish best practices for each discipline Develop information and teaching materials On-going research on effects of integrative medicine treatment with infants and children 15

16 Thank You 16