Learning Objectives. Advanced Multimodal Analgesia for Children in Pain: From Integrative Medicine to Mind-Body Techniques

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1 Advanced Multimodal Analgesia for Children in Pain: From Integrative Medicine to Mind-Body Techniques Stefan J. Friedrichsdorf, MD, FAAP Medical Director, Department of Pain Medicine, Palliative Care & Integrative Medicine Children's Hospitals and Clinics of Minnesota, Minneapolis/St. Paul, MN Associate Professor of Pediatrics, University of Minnesota Medical School Follow #childpain17 Stefan J. Friedrichsdorf, MD, FAAP (USA) Learning Objectives Explore how integrative medicine strategies can treat or prevent pain in children Observe 2 pediatric case examples demonstrating concurrent use medications and integrative therapies Practice Acupressure Point P6

2 Integrative Medicine Alternative implies either or Complementary implies primary and secondary Offers a range of modalities non-pharmacological vs non-pychological? Integrative Medicine is more inclusive Better fit with a pediatric pain care model This is why you shouldn t believe that exciting new medical Evidence: Safety vs. Efficacy Safe Yes No Effective Yes recommend monitor closely No tolerate advise against Weiger et al, 2002, Annals Internal Medicine

3 Integrative modalities Integrative modalities effective in management of pediatric pain Hunt, K.; Ernst, E. The evidence-base for complementary medicine in children: A critical overview of systematic reviews. Arch Dis Child 2011, 96, ; Friedrichsdorf, S.; Kuttner, L.; Westendorp, K.; McCarty, R. Integrative pediatric palliative care. In Integrative pediatrics, Culbert, T.; Olness, K., Eds. Oxford University Press: pp ; Evans, S.; Tsao, J.C.; Zeltzer, L.K. Complementary and alternative medicine for acute procedural pain in children. Alternative therapies in health and medicine 2008, 14, include hypnosis Kuttner, L.; Friedrichsdorf, S.J. Hypnosis and palliative care. In Therapeutic hypnosis with children and adolescents., 2nd ed.; Crown House Publishing Limited: Bethel, 2013; pp ; Richardson, J.; Smith, J.E.; McCall, G.; Pilkington, K. Hypnosis for procedure-related pain and distress in pediatric cancer patients: A systematic review of effectiveness and methodology related to hypnosis interventions. J Pain Symptom Manage 2006, 31, yoga Bussing, A.; Ostermann, T.; Ludtke, R.; Michalsen, A. Effects of yoga interventions on pain and pain-associated disability: A meta-analysis. The journal of pain : official journal of the American Pain Society 2012, 13, 1-9.; Evans, S.; Moieni, M.; Taub, R.; Subramanian, S.K.; Tsao, J.C.; Sternlieb, B.; Zeltzer, L.K. Iyengar yoga for young adults with rheumatoid arthritis: Results from a mixed-methods pilot study. J Pain Symptom Manage 2010, 39, acupuncture Vas, J.; Santos-Rey, K.; Navarro- Pablo, R.; Modesto, M.; Aguilar, I.; Campos, M.A.; Aguilar-Velasco, J.F.; Romero, M.; Parraga, P.; Hervas, V., et al. Acupuncture for fibromyalgia in primary care: A randomised controlled trial. Acupunct Med massage Verkamp, E.K.; Flowers, S.R.; Lynch-Jordan, A.M.; Taylor, J.; Ting, T.V.; Kashikar-Zuck, S. A survey of conventional and complementary therapies used by youth with juvenile-onset fibromyalgia. Pain Manag Nurs 2013, 14, e biofeedback Blume, H.K.; Brockman, L.N.; Breuner, C.C. Biofeedback therapy for pediatric headache: Factors associated with response. Headache 2012, 52, guided imagery Dobson, C.E.; Byrne, M.W. Original research: Using guided imagery to manage pain in young children with sickle cell disease. The American journal of nursing 2014, 114, 26-36; test 37, 47. Integrative Pain Management State of the art pain management in the 21st century demands that pharmacological management must be combined with supportive and integrative, nonpharmacological therapies to manage a child's pain. Physical methods (e.g. cuddle/ hug, massage, comfort positioning, heat, cold, TENS) Cognitive behavioral techniques (e.g. guided imagery, hypnosis, abdominal breathing, distraction, biofeedback) Acupuncture, acupressure, aromatherapy Nociceptive Pathways & Primary Sites of Action of Analgesics Thalamus 2nd Neuron Aδ or C fiber Acetaminophen (Paracetamol) Injury NSAIDs

4 6-year-old Cassandra with severe pain due to chest tube insertion Fentanyl PCA the pump and blowing bubbles going to bubble land Nociceptive Pathways & Primary Sites of Action of Analgesics Thalamus Periaqueductal grey (endorphins) Integrative (non-pharmacological) therapies Descending Inhibition + 2nd Neuron Descending pathways that modulate transmission of nociceptive signals originate in periaqueductal gray, locus coeruleus, anterior cingulate gyrus, amygdala & hypothalamus: are relayed through brainstem nuclei in the PEG and medulla to spinal cord. Inhibitory transmitters involved in these pathways incl. norepinephrine, 5-hydroxytryptamine, dopamine, & endogenous opioids. Opioids Acetaminophen (Paracetamol) Aδ or C fiber Injury NSAIDs How does this stuff work...? The periaqueductal gray and descending pain modulation: Hemington KS, Coulombe MA. The periaqueductal gray and descending pain modulation: Why should we study them and what role do they play in chronic pain? Journal of neurophysiology. Feb :jn Distraction significantly increased activation of cingulo-frontal cortex including orbitofrontal & perigenual anterior cingulate cortex (ACC), as well as periaquaeductal gray (PAG) & the posterior thalamus. Active distraction techniques, such as imagery, appear to modulate endorphine release in the midbrain, including the periaqueductal grey and thereby increase activity of descending inhibiting pathways thereby decreasing nociception from the dorsal horn resulting in gate pain modulation during distraction. Valet M, Sprenger T, Boecker H, et al. Distraction modulates connectivity of the cingulo-frontal cortex and the midbrain during pain--an fmri analysis. Pain. Jun 2004;109(3): ; Tracey I, Ploghaus A, Gati JS, et al. Imaging attentional modulation of pain in the periaqueductal gray in humans. The Journal of neuroscience : the official journal of the Society for Neuroscience. Apr ;22(7): ; Derbyshire SW, Osborn J. Modeling pain circuits: how imaging may modify perception. Neuroimaging clinics of North America. Nov 2007;17(4): , ix.; Bingel U, Wanigasekera V, Wiech K, et al. The effect of treatment expectation on drug efficacy: imaging the analgesic benefit of the opioid remifentanil. Sci Transl Med. Feb ;3(70):70ra14

5 Psychology Intervention Postoperative Pain - Systematic Review Davidson F, Snow S, Hayden JA, Chorney J. Psychological interventions in managing postoperative pain in children: a systematic review. Pain. 2016;157(9): psychological interventions effective in reducing children's self-reported pain in short term distraction/imagery interventions effective preparation/education interventions not effective Brain Regions that Modulate Pain and Emotion Somatosensory Cortex Insular Cortex Isnard J, Magnin M, Jung J, Mauguiere F, Garcia-Larrea L. Does the insula tell our brain that we are in pain? Pain Apr; 152(4): Both Pain Thalamus Prefrontal Cortex Hippocampus Anterior Cingulate Cortex Apkarian AV, et al. Eur J Pain. 2005;9: ; Casey KL, Tran TD. Cortical mechanisms mediating acute and chronic pain in humans. In: Cervero F, Jensen TS, eds. Handbook of Clin Neurology. 2006: ; Charney DS, Nestler EJ, Bunney BS, et al, eds. Neurobiology of Mental Illness. 2nd ed. 2004; Schweinhardt P, et al. Curr Opin Neurology. 2006;19: Amygdala Slide with Permission: Barry Cole, Bob Dworkin, Roy Freeman, Charles Argoff, Howard Fields

6 Nociceptive Pathways & Primary Sites of Action of Analgesics Thalamus Periaqueductal grey (endorphins) Integrative (non-pharmacological) therapies CORTEX: -Stress - Anxiety - Catastrophizing - Depression - perceived injustice - disturbed Sleep ON OFF 2nd Neuron Aδ or C fiber Opioids Acetaminophen (Paracetamol) Injury NSAIDs Integrative Pain & Symptom Management A Pediatrician s Top 10 Apps for Distraction & Pain Management NoNeedlessPain.org Stinson, J.N., et al., Construct validity and reliability of a real-time multidimensional smartphone app to assess pain in children and adolescents with cancer. Pain, (12): p

7 Diluted in carrier oils and applied topically Placed on a cotton ball and inhaled Used with a variety of diffusion devices Added to steaming water and inhaled Select oils are available orally Aromatherapy Lavender (Lavandula angustifolia) Lemon (Citrus limon) Peppermint (Mentha piperita) Spearmint (Mentha spicata) Sweet orange (sweet orange) Aromatherapy 1. Fitzgerald M, Culbert T, Finkelstein M, et al. The effect of gender and ethnicity on children's attitudes and preferences for essential oils: a pilot study. Explore (NY) 2007;3: Fitzgerald M, Culbert T, Finkelstein M, Green M, Liu M. The effect of gender and ethnicity on children's attitudes and preferences for essential oils: a follow up study. Explore (NY) 2010;6:172. Nausea & Vomiting Acupressure, Acupuncture P6 point (or "inner gate"): 2 or 3 finger widths down from the top crease in the wrist, centered in the groove between the two large tendons. Take thumb and index (or middle finger) and press firmly on the points on both sides of the wrist when nauseous; relief in seconds (may take up to five minutes)

8 Let s have a closer look at this Hypnosis What is Self-Hypnosis? Altered state of consciousness Increased attention leads to an openness to suggestion Goal: gives the child a sense of mastery and control of symptoms Therapist guides the child s stream of consciousness Adjunct

9 Misconceptions Being asleep or unconscious Loss of Control Magic or put under a spell Address child s and parents fears / concerns! Revelation of secrets Not being de-hypnotised Phenomena of Hypnosis Relaxation Dissociation Anesthesia Increased Suggestibility Ideomotor responses Post-hypnotic suggestion Self-hypnosis Do You Want to Go to Your Favorite Place?

10 Pediatric Hypnosis Workshops Minneapolis, MN Pediatric Clinical Hypnosis Training Introductory - Intermediate - Advanced Levels National Pediatric Hypnosis Training Institute (formerly associated with the SDBP) Withholding evidence-based analgesia to children in pain is not only unethical, but causes immediate and long-term harm Effective & safe integrative modalities can be easily taught and integrated into clinical practice Distraction, massage, aromatherapy, biofeedback, selfhypnosis appear to be highly effective in therapy of acute and chronic pain Conclusions Use multimodal (opioid-sparing) analgesia: Multiple agents, interventions, rehabilitation, psychological and integrative therapies act synergistically for more effective pediatric pain control with fewer side effects than single analgesic or modality Recommended Reading

11 Further Links The New York Times (June 28, 2016) Why Aren t We Managing Children s Pain? Covering Dr. Stefan Friedrichsdorf The New York Times (Dec 16, 2015) essay by Dr. Stefan Friedrichsdorf When a Baby Dies opinionator.blogs.nytimes.com/2015/12/16/when-a-baby-dies/?_r=1 Video: Kiran Stordalen and Horst Rechelbacher Pediatric Pain, Palliative and Integrative Medicine Clinic Tour Children s Comfort Promise: Doing everything possible to treat and prevent pain. Eliminating Needle Pain in children (Feb 2015) Staff video: Short Movie: Meet the Interdisciplinary Chronic Pain Clinic Team at Children s Minnesota: LittleStars TV Video: Tour of the Kiran Stordalen and Horst Rechelbacher Pediatric Pain, Palliative and Integrative Medicine Clinic at Children's Hospitals and Clinics of Minnesota and an overview of the three programs that are offered at Children's under this clinic. Short Movie: LittleStarsFilm 'Kali's Story - Beyond the NICU': This amazing pediatric palliative care short movie (7 min) features 8-year-old Kali's journey at Children's Hospitals and Clinics of Minnesota from NICU to today, receiving care by the Pain & Palliative & Integrative Medicine program while inpatient, in the clinic, and at home (Jan 22, 2015) Unintended Consequences of Integrative Medicine? Further Training Contact: CIPPC@ChildrensMN.org 11th Annual Pediatric Pain Master Class Minneapolis, Minnesota, USA June 9-15, Education in Palliative & End-of-life Care [EPEC]: Become an EPEC-Pediatrics Trainer September th International Symposium on Pediatric Pain (ISPP) Basel, Switzerland, June 16-20, Stefan J. Friedrichsdorf, MD, FAAP Medical Director, Department of Pain Medicine, Palliative Care & Integrative Medicine Associate Professor of Pediatrics, University of Minnesota Medical School Children's Hospitals and Clinics of Minnesota 2525 Chicago Ave S Minneapolis, MN USA phone fax stefan.friedrichsdorf@childrensmn.org Blog: