Pediatric Integrative Pain Medicine

Transcription

1 Pediatric Integrative Pain Medicine Thomas R. Vetter, M.D. Medical Director, The Riley Pain Center Pediatric Anesthesia Section Riley Hospital for Children Indiana University School of Medicine Systems of Alternative Medicine Conventional allopathic medicine represents just one system of medical care 8 major alternative medical systems exist -- each has its own unique history and knowledge base Ayurvedic Medicine Three constitutional types: vata = thin, light, quick pitta = muscular, smart, and determined kapha = heavier frame, live more leisurely Vital life energy based on five elements: Earth, water, fire, air, and ether Chiropractic Intimate relationship between the spinal column and nervous system function Manipulation of the spinal skeletal system to improve nervous system function Goal to reduce pain and increase overall health The most common CAM modality in USA Environmental Medicine Relative newcomer on the medical scene Stemming from the growing presence of toxins and pollutants in our environment Belief that many chronic illnesses are due to allergic reactions to one s environment Insidious nature of toxins results in very labor intensive and challenging care Ethno-Medicine, Shamanism & Native American Medicine An incredibly diverse and ancient system Goal of helping patients to discover the underlying spiritual meaning of their illness For in doing so, the remedy for their recovery is thus revealed to the patient Creditability gab for non-native American doctor Homeopathy Law of Similars = "like cures like" Minute doses or dilutions of plant, animal, and mineral materials stimulate in the body a reaction similar to the actual illness Thus promoting a healing response in the body Homeopathic Pharmacopeia of the United States is recognized by the FDA

2 Naturopathic Medicine Emphasizes natural therapies Relies on the body's innate healing abilities Utilizes selected therapies to increase the patient's vital life energy and thus healing Primary focus is to treat not only the root cause of illness but the whole person General holistic medical practice Osteopathic Medicine Focuses on the complex relationship between body structure and organ function Places heavy emphasis on the skeletal and muscular systems for re-establishing health Has lost some of its identity to allopathic medicine Bastions of osteopathic purists do still exist Traditional Chinese Medicine (TCM) Ancient system of preventive medicine Patient is a microcosm of the natural world Must balance the "yin" (feminine & receptive) and the "yang" (masculine & assertive) To maintain the flow of vital life force - Qi or chi - and hence one s optimum health CAM Therapies for Pain Control Acupuncture and Traditional Chinese Medicine Osteopathic Manipulation Chiropractic Mind Body Medicine Aromatherapy Trace Elements and Vitamin Therapy Herbal Therapy Other Odds & Ends (Yoga, Magnets and Soy) Medical Energetics Newer, possibly preferred term for acupuncture Physician-delivered acupuncture Underscores conflict with L.Ac. community Interrelationship between acupuncture and mainstream medical diagnoses and treatments Disease-related dynamics of vital energy Fundamental concept of vital life energy or Qi Osteopathic Manipulation Involves symptomatic joints & soft tissue Low velocity, high amplitude technique Variety of integrative techniques Domain of a traditional D.O. or L.M.T. Greenman muscle-energy Jones strain-counterstrain Myofascial release Cranial-sacral therapy

3 Chiropractic Manipulation mainly of the spine and pelvis High velocity, low amplitude technique Particularly indicated for facet joint syndromes Acute facet joint subluxation from sudden rotation or twisting of the spine Chronic facet joint dislocation from repetitive rotational spinal column stress from athletics, occupational duties, extracurricular activities How many sessions are enough? Mind Body Medicine Body-Oriented Psychotherapy Elements of behavioral therapy Stress management techniques Biofeedback Meditation and breathing exercises Visualization and guided imagery Distraction techniques Self-hypnosis therapy Aromatherapy Olfactory nerve has a direct connection to the limbic system Essential oils and aromas elicit a variety of physiologic and psychological responses Immune response: antiviral & antibacterial Enhances muscle relaxation when it is combined with traditional massage therapy Stress reduction by calming patient Analgesia via 1,8-cineole or eucalyptol Herbal Therapy Despite all the hype, only a few herbs are really all that useful for pain conditions No FDA regulation on quality control No adverse events safety testing Variable potencies among brands Contaminant concerns (Chinese herbs) Unknown drug and herbal interactions No well done dose-response studies Certainly even more of a pediatric issue Chronic Tension Headache Short Term Relief NSAID -- avoid acetaminophen and caffeine (rebound) Magnesium, Valerian and other nervines Peppermint oil (diluted) applied behind ears Intermediate Relief Tricyclic antidepressant (low dose) Chiropractic, acupuncture, aromatherapy, osteopathic methods: myofascial release

4 Long Term Relief Relaxation techniques, biofeedback and other various forms of behavioral psychotherapy Yoga, Qi Gong, T ai Chi Migraine Headache Primary Methods Acupuncture - Windows of the Sky + Four Gates Food allergen identification and avoidance Vitamin B2 supplementation: 50 to 400 mg/day Secondary Methods Feverfew Magnesium supplementation Chinese herbalism: fresh ginger or ginseng Related Muscular Tension Chiropractic for obvious spinal misalignment Osteopathic and cranial-sacral therapy A Controlled Trial of the Treatment of Migraine by Acupuncture Vincent: The Clinical Journal of Pain 1989; 5: Adult migraineurs with at least monthly headache Classic head and shoulder points for headache in addition to the so-called Four Gates versus sham acupuncture performed with needles inserted 2 to 3 cm away from the actual points Significant reduction in both peak and pain-free day pain scores with true versus sham treatment but no change in medication use or pain behavior Pharmacologic versus Non-Pharmacologic Prophylaxis of Recurrent Migraine Headache: A Meta- Analytic Review of Clinical Trials Holroyd and Penzien: Pain 1990; 42:1-13 Total N = 2445 patients 25 clinical trials evaluating effectiveness of propranolol 35 clinical trials evaluating effectiveness of combined relaxation and thermal biofeedback training Based upon daily diaries: 43% reduction in migraine activity in both beta-blocker and relaxation/biofeedback groups 14% average reduction in placebo group Conclusion: Need to assess cost and benefits, side effects Acupuncture versus Metoprolol in Migraine Prophylaxis: A Randomized Trial of Trigger Point Inactivation Hesse et al., Journal of Internal Medicine 1994; 235: Common or classic migraines of > 2 years in duration Initial 4 week run-in period, followed by 17-week regimen AP dry-needling of symptomatic TPs + placebo tablet Placebo stimulation + metoprolol 100 mg daily Both groups experienced significant reduction in headache attack frequency compared to baseline (p < 0.01) No difference in headache frequency or duration between the acupuncture and beta-blocker groups but fewer side effects reported in the acupuncture group

5 Effectiveness of High-Dose Riboflavin in Migraine Prophylaxis. A Randomized Controlled Trial Schoenen et al., Neurology 1998; 50: Enhanced mitochondria oxygen metabolism with B2 55 adults with 2 to 8 migraine headaches/month 400 mg/day of oral riboflavin versus daily placebo containing low-dose beta-carotene Four month study with each patient receiving a placebo during first month and B2 next 3 months B2 was superior to placebo in reducing attack frequency in month #4 versus #1 (p=0.005) Riboflavin also reduced headache days (p=0.012) Number needed to treat (NNT) = 2.3 Acupuncture and the Opioid System: Implications in the Management of Migraine Pintov et al., Pediatric Neurology 1997; 17: to 15 yo with at least monthly migraine headache Traditional Chinese medicine headache points involving subdermal needle placement versus Placebo acupuncture performed with AP needles inserted only into the epidermis layer Total of ten weekly acupuncture sessions Significant reduction in both migraine frequency and pain intensity with true versus sham treatment Significant increase in beta-endorphin with true AP Prophylaxis of Migraine with Oral Magnesium Peikert et al., Cephalagia 1996; 16: Migraineurs have lower serum and CNS Mg levels Adults with average of 3.6 migraines/month 600 mg/day of oral magnesium for 12 weeks Each patient received nothing during first 4 weeks, then either Mg or a placebo for the next 12 weeks Mg was superior to placebo in reducing attack frequency by 42% versus 16% (p<0.05) Mg also significantly reduced total number of days with migraine and symptomatic drug consumption Similar findings (1991) for menstrual migraines Myofascial Pain Syndromes Short and Intermediate Term Relief Tricyclic antidepressant (low dose) Osteopathic manipulation: myofascial release Acupuncture rather than trigger point injections Aromatherapy with sweet marjoram or lavender Long Term Relief Principal meridian acupuncture based on biopsychotype Physical therapy and directed exercise program Relaxation techniques, behavioral psychotherapy Yoga, Qi Gong, T ai Chi

6 Trigger Points and Acupuncture Points for Pain: Correlation and Implications Melzack et al., Pain 1977; 3:3-23 Identified a 71% correlation between Janet Travell s trigger points and Felix Mann s acupuncture points Based correlation on two criteria: surface spatial distribution and associated pain pattern This correlation suggests that trigger points and acupuncture points for pain, though discovered independently and labeled differently, represent the same phenomenon and can be explained in terms of the same underling mechanisms. Cortisol Decreases and Serotonin and Dopamine Increase Following Massage Therapy Field et al., International Journal of Neuroscience 2005; 115: Series of studies involving pain syndromes, depression, auto-immune disorders, HIV, cancer, and daily stress Urinary and salivary cortisol decreased an average 31% Urinary serotonin and dopamine increased an average 28% Supporting stress-alleviating effect of massage therapy Supporting activating effect of massage therapy Juvenile Fibromyalgia Type I: Diffuse muscular pain Graded aerobic exercise and strength/flexibility training Low dose tricyclic antidepressant Supportive psychotherapy Bodywork techniques and myofascial acupuncture Ketamine trial followed by low-dose dextromethorphan Type II: Symptoms of chronic fatigue syndrome Consider post-viral etiology & environmental sensitivities R/O hypothyroidism and adrenal insufficiency Principal Meridian and Five Elements acupuncture Re-establish normal sleep pattern (possibly with valerian) Malic acid 1200 to 2400 mg/day + Mg 300 to 600 mg/day Treatment of Fibromyalgia with Super Malic: A Randomized, Double Blind, Placebo Controlled, Crossover Pilot Study Russell et al., Journal of Rheumatology 1995; 22: Super Malic with 200 mg malic acid + 50 mg magnesium Two week washout period before and between courses Initially compared 3 tablets bid with placebo: no difference Subsequent open label, dose escalation treatment with up to 6 tablets bid: significant improvements in pain/tenderness, functional and psychological outcome variables No side effects noted at highest daily doses Often required at least 2 months at higher doses for effect