Integrative Pain and Symptom Management

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Integrative Pain and Symptom Management

• William Zempsky, MD, FAAP
• Timothy Culbert, MD, FAAP
• Sessions S131 and S169

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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.
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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

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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

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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 bodys 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

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Kids and CAM

• 2-30 in primary care settings
• 30-70 of kids with chronic illness
• 1999-2000 Childrens 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

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CAM Use at Childrens Minnesota-52 Overall

• 59 of Oncology Patients
• 51 Pulmonary Patients
• 32 General Pediatrics
• 62 Pediatric Epilepsy
• 47 Pediatric Sickle Cell

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Types of CAM Used
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Doctors and CAM

• Pediatricians in Michigan
• gt50 would refer for CAM
• gt50 used CAM themselves
• Sikand, 1998, Arch Ped Adol Med
• Pediatricians National Survey
• 66 believed CAM could be helpful
• Kemper Oconnor, 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

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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

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CAM KidsLegal 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

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Evidence Safety vs. Efficacy

• SafeYes Safe No
• effectiveYes Recommend Monitor closely
• effective No Tolerate Advise against
• Weiger et al, 2002, Annals Int Med
• Cohen, Pediatrics, 2005

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Chronic Pain Diagnosis

• Study of general academic pediatricians-investigat
  ed 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

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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 gt90 completed treatment, no
  adverse effects
• Zeltzer et al, 2002, J Pain Symptom Manage

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Chronic Pain Book

• Conquering Your Childs Chronic Pain
• Lonnie Zeltzer, MD

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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

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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

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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
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• 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.
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What symptoms do we need to consider?

• Pain
• Nausea
• Insomnia
• Anxiety
• Depression

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Acute Symptoms

• Pain
• Acupuncture
• Massage
• Relaxation
• Herbal Remedies
• Arnica

• Nausea
• Acupuncture
• Aromatherapy
• Herbal Remedies
• Anxiety
• Acupuncture
• Relaxation

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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

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Chronic Pain Management

• Behavioral Therapy
• Herbal therapy
• Biofeedback
• Physical Therapy
• Osteopathic Manipulation
• Craniosacral Therapy

• Acupuncture
• Massage
• Yoga
• Reiki

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16 yo with CRPS

• Sprained ankle 2 months ago
• Placed in a boot
• PE
• Pain
• Allodynia
• Cool
• Swoolen
• Blue

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• Visit 1
• PT program
• Tens Unit
• Aquatic Therapy
• Desensitization
• Behavioral Therapy
• Coping
• Meditation
• Melatonin for sleep

• Subsequent visits
• Acupuncture
• Anxiety
• Pain
• Yoga
• Massage area with arnica gel

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Childrens 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

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Childrens 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)

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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

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Childrens 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)

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Childrens 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

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Childrens 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

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Childrens 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
  dont make big -we have controlled revenue and
  expenses very well

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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 1998023-29

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Surveys of Adequacy of Pain Relief

• Cummings et al. 1996
• Survey of all children in childrens 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

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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
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• We realized a traditional Pain Service only helps
  those patients with whom it interacts

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• Action plan which emphasizes CCMCs 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

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Mission

• 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

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Pain Relief Program at CCMC

• Specific Aspects of Pain Program
• Acute Pain Consultation Service
• Chronic Pain Program
• Comfort Central

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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

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Inpatient Complementary Programs

• Acupuncture
• Hypnosis
• Biofeedback
• Yoga

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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

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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
  (Sticklers syndrome, Ehlers-Danlos)
• Pain associated disability syndrome
• Prolonged postoperative pain

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Complementary Programs

• Acupuncture
• Biofeedback
• Meditation
• Yoga
• Massage

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Comfort Central

• Protocol Development
• Phlebotomy Lab Project
• Topical Anesthetic Trials
• Injection Protection Project

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Mind-Body Skills Training Applied
Psychophysiology

• Biofeedback
• Hypnosis
• Meditation
• Relaxation Training
• Breathing
• PMR
• Autogenics
• Sussman and Culbert, 1996, Developmental-Behaviora
  l Pediatrics

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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

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Biofeedback

• 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

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Hypnosis

• 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

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Hypnosis Reduces Distress and Duration of VCUG I

• Kids who had experienced previously distressing
  VCUG
• Routine care group as controls
• N 44

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Hypnosis Reduces Distress and Duration of VCUG II

• Results
• Parents rating of Childs distress decreased
• Observations support less distress
• Improved compliance
• Duration of procedure shortened on average by
  almost 14 minutes
• Butler et al, 2005, Pediatrics

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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

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Comfort Kit for Kids Families

• Best of currently available psychological/behavior
  al 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)

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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

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Day Surgery

• Tonsillectomy
• Adenoidectomy
• Hernia Repair
• Orchiopexy

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Pilot Study Preliminary Results

• How Helpful was the Kit in Helping you/your child
  cope with pain and distress?
• Parents n56
• Very Helpful 31
• Somewhat Helpful 59
• Not at all 5
• Kids n12 mean age 9.9 years
• Very Helpful 0
• Somewhat 50
• Not all 25

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Pilot Study Preliminary Results II

• Would you Recommend this Kit to Another Family?
• Parents
• Yes 89
• Kids
• Yes 67

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Pilot Study Preliminary Results III

• Were the Booklets Easy to Understand?
• Parents
• Yes 86
• No 2
• Kids
• Yes 67
• No 8

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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

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Pilot Study Preliminary Results V

• What Skills did you try?
• Breathing 38
• Muscle Relaxation 30
• Imagery 29
• Self-Talk 29

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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 Raynauds

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Anxious Parents

• 2 Studies
• Effectiveness of auricular accupressure/acupunctur
  e 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

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Acupuncture
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AJ

• 14 year old
• Rhabdomyosarcoma
• Leg and back pain
• On narcotics and other pain meds
• Needle Phobia

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• Immediate relief from pain
• Lasts 2-4 days
• Better than morphine
• Weaned self off of narcotics

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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

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Elements

• Wood
• Tree, firm but flexible
• Fire
• Sun, heat, vitality, excitement
• Earth
• Stability, grounded, balanced, nurturing
• Metal
• Cool, brittle, inflexible, durable
• Water
• Movement, adaptable, evolution

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Organs

• Functional
• Energetic
• Metaphorical
• Kidney
• Bones, marrow, joints, hearing and hair
• Will and motivation
• Spleen
• Digestion, blood production, menstruation
• Nuturing, introspection

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Organs

• Yin
• Solid, Energy Producing
• Kidney
• Liver
• Lung
• Spleen
• Heart
• Master of the Heart

• Yang
• Hollow, transport
• Bladder
• Small Intestine
• Large Intestine
• Gall Bladder
• Stomach
• Triple Heater

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Energy pathways-Meridians

• Tendinomuscular
• Most superficial
• First defense
• Principal
• Through muscular layer
• Provide nourishment and vitality
• Connected with zone of organ influuence

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• Distinct
• Go deep to the organs
• Allow organ energy to circulate
• Curious
• Connections between meridians

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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

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Biostructural psychotype

• Takes into account traditional history
• Also includes
• Personality traits
• Seasonal affinities
• Color and taste affinities
• Elemental qualities

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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

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Physical Exam

• Standard attention to muscular bands and trigger
  points
• Inspect for tender spots (ashi points) which may
  indicate underlying organ problem

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Somatotopic Systems

• Evaluate somatotopic systems
• Tongue

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• Ear

• Pulse

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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

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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

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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

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Cool Stuff

• Compared fMRI of 3 groups
• Stimulation of visual acupoint
• Stimulation of non-acupoint
• Grad student looking at flashlight

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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

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J.M.

• 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

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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

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• 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

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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

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STRICTA

• Designed to be analogous to CONSORT
• Acupuncture Rationale
• Needling Details
• Treatment Regimen
• Co-interventions
• Practitioner Background
• Control Interventions

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Side effects

• Needle Shock
• Bleeding
• Infection
• Pain
• Rare
• Pneumothorax
• Cardiac tamponade

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What about children?

• Arent they afraid of needles?
• 67 rate it as pleasant
• Relaxing
• Many patients sleep
• Dont the needles hurt?
• Not really

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J.M.

• 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

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Children with Chronic Pain

• Headache
• Abdominal Pain
• Arthritis
• RSD
• Sickle Cell
• Cancer Pain
• Fibromyalgia/Chronic Fatigue

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O.J.

• 13 yo with Crohns disease persistent abdominal
  pain
• Low energy and mood
• Treatment focused on increasing energy,
  decreasing abdominal pain

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• 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.

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M.S.

• 16 yo with incapacitating migraine headaches
• Likely stress induced
• Misses 1-3 days per week of school
• Grades suffering

103

• Hated it from the start
• No improvement in headache over 6 weeks
• Last treatment targeted relaxation
• Patient fell asleep during therapy

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G.M.

• 9 yo neuropathic pain both feet
• Became anxious and extremely tearful
• Pain improved post acupuncture
• Returned for a 2nd try but couldnt tolerate it

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B.Z.

• Long distance runner
• Chronic knee pain -patellar tendinitis
• Left gtgt Right
• Took 2 mos off without improvement in symptoms
• Treatment with 2 needle technique on Left
• Marked lasting improvement on Left

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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

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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

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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

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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

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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

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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

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Headache Pediatric Case Study

• Video-common CAM therapies for pediatric HA

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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

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Integrative Approaches for Insomnia

• Aromatherapy
• Audio Visual Entrainment
• Relaxation Training
• Music Therapy
• Herbal Therapy-teas
• Melatonin

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Training and Information

• www.pangea2006.org
• www.childrensintegrativemed.org
• www.holistickids.org
• www.ahma.org
• www.csh.umn.edu
• www.integrativemedicine.arizona.edu
• www.longwoodherbal.org