Complementary and Alternative Therapies for Chronic Pulmonary Conditions in Children

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Complementary and Alternative Therapies for
Chronic Pulmonary Conditions in Children

• Kathi J Kemper, MD, MPH
• Caryl J Guth Chair for Holistic and Integrative
  Medicine
• Professor, Pediatrics
• Professor, Public Health Sciences
• Professor, Family and Community Medicine
• Wake Forest University School of Medicine, North
  Carolina, USA

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Asthma is common in children

• Prevalence increasing worldwide at approximately
  40 - 50 per decade
• 80 of onset prior to 6 years old

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Cystic fibrosis

• Major cause of severe chronic lung disease in
  pediatrics
• 1/400 births in Brittany 1/90,000 Asian infants
  in Hawaii

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Complementary and Alternative Medicine (CAM)
Epidemiology

• Least common in healthy populations (2 - 7)
• More common in clinic populations (11 - 60)
• Most common in those with chronic, incurable
  conditions (35 - 80) ADHD, arthritis, Asthma,
  cancer, CF, CP, IBD
• In US, most MD CAM referrals for acupuncturists
  (43) , chiropractors (40) and massage
  therapists (21)
• Most patients use Herbs/Dietary supplements,
  prayer massage

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Children likely to use CAM

• Older children and adolescents
• Chronic or incurable conditions worse QOL, worse
  prognosis worse symptoms, on steroids, side
  effects of bronchodilators, frequent MD visits
• Parents use CAM
• Why? Offer hope, peace of mind (tried
  everything), meaning, comfort, fear of medication
  side effects, decreased reliance on MDs and meds
  (empowerment)-- NOT cure

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CAM for pediatric asthmatics

• 52 - 55 in Australian children
• 79 of Indian children
• 80 American children of African or Caribbean
  background
• 81 of Texans, particularly in Latino patients
• Shenfield G, 2002
• Andrews L, 1998
• Singh V, 2002
• Dinkevich E, 2003
• Mazur L, 2001

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Symptoms treated by CAM

• Pain
• Fatigue
• GI complaints
• Anxiety
• Dyspnea

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Massage

• Systematic, scientific manipulation of soft
  tissues.
• Improves circulation thru vasodilation
• Increases lymphatic drainage
• Stimulates inactive muscles
• Reduces muscle tension
• Stimulates parasympathetic ANS activity

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Massage for pulmonary conditions

• Enhance chest wall mobility
• Decrease neck stiffness
• Help with rounded shoulders and barrel chest
• Decrease pain in inflamed muscles (2nd to
  coughing)
• Decrease low back pain from prolonged bed rest
• Enhances beta-endorphins for 60 -90 minutes

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Massage for low back pain

• Meta-analysis comparing acupuncture, spinal
  manipulation and massage found massage most
  effective for low back pain
• RCT of massage, soft tissue manipulation,
  exercise therapy or sham laser for one month
  massage most effective in treating pain
• RCT of acup vs massage vs. self-care X 10wks, 74
  helped with massage, signif better than others
• Cherkin D, et al. Ann Intern Med. 2003
• Hernandez-Rief, et al. Int J Neurosci, 2001
• Cherkin D, Arch Intern Med, 2001

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Massage for headaches?

• Global headaches, rule out CO2 retention
• Focal pain, in temporal or orbital regions,
  consider chronic muscle contraction
• Massage is helpful for chronic muscle contraction
  H/A
• Quinn T. Am J Pub Health, 2002
• Puustjarvi K. Acupunct Electrother Res, 1990

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Massage for other symptoms

• Anxiety, specifically for CF YES
• Depression YES
• Post-traumatic stress YES
• PFTs possibly increased FVC (24), increased
  FEF 25-75 (27) and PEFR (30) in pediatric
  asthmatics
• Field T. J Am Acad Child Adolesc Psychiatry, 1992
• Hernandez-Rief M. J Pediatr Pscyhol, 1999
• Field T. J Appl Dev Psychol, 1996
• Field T. Adolescence, 1996
• Field T. J Pediatr, 1998

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Boston ChildrensCenter for Holistic Pediatric
Education and Research (CHPER)

• Between 1999 2002, 43 of CHPER consults were
  from Pulmonary Dept. nearly all for CF patients
• Mean age 27.8 years
• CC back pain, upper body pain, chest pain, neck
  pain
• Objective rounded shoulders, shortened anterior
  chest muscles, tension in numerous muscles of
  chest and back
• 56 of patients requested repeat visits
• Subjective patients request PFTs after massage
  to boost scores
• 2003 CF CPG includes massage therapy

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Massage contraindications

• Not over pitting edema, impaired tissue
  integrity, indwelling catheters, lines or shunts
• CAUTION if prolonged bleeding times, low platelet
  count, liver failure
• If sudden onset of chest or back pain, rule out
  rib fractures before getting massage therapy

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Acupuncture enthusiastic case series

• 192 cases of bronchial asthma treated with
  acupuncture, 98.9 had immediate total effect
  rate
• Reduced need for bronchodilators
• Better symptoms of allergic asthma
• Helpful if needle sensation de qi felt
• Helpful for EIB if provided 20 minutes prior to
  exercise
• HOWEVER, later trials less enthusiastic
• In TCM, acupuncture is NOT sole treatment for
  asthma (HERBS)

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Acupuncture scientific trials

• Most trials have had negative results in adults
  and kids
• Short term treatment of no value in patients with
  moderate, persistent asthma
• Randomized, blinded, cross-over trial, no benefit
• Meta-analyses by Kleijnen and Linde, including
  Cochrane review no substantial benefit
• Mitchell P. Am J Acup, 1989
• Shapira MY. Chest, 2002
• Tamdon M. Med J Aust, 1991
• Kleijnen J Thorax, 1991
• Linde K. Cochrane, 1997

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Methodologic problems with acupuncture trials

• Western diagnosis does NOT equal TCM diagnosis
• Standardized points NOT TCM
• Blinding patients is challenging
• Placebo points may have activity
• Blinding clinician is even more challenging
• Number of doses/treatments?
• Sample sizes often too small
• Cost-benefit?

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Acupuncture for kids pain?

• Retrospective review of 47 patients referred out
  from Pain Treatment Service to acupuncturist
  between 1994-97
• Median age, 16 years
• 79 female 96 Caucasian
• 85 paid out of pocket
• Diagnoses Migraine HA (n7), endometriosis
  (n6), Reflex Sympathetic dystrophy (n5)
• Tx needles (98) heat (85) magnets (26)
• Rated pleasant by 67 of kids
• 70 of kids felt it helped pain only one said
  symptoms worse after treatment
• Kemper K. Pediatrics, 2000

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Acupuncture for dyspnea

• Our observations, YES. Surprise!
• Cancer-related dyspnea in 20 patients treated
  with acupuncture 70 of patients improved in
  dyspnea, anxiety and relaxation for up to 6 hours
  after treatment (Filshie, 1996)

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Acupuncture availability for children

• Licensed in over 40/50 states in US
• Survey of 227 acupuncturists in Boston area 140
  (62) responded
• 70 Caucasian 61 female
• About 1 per minute in 1998 initial visit 75
  minutes follow-up visits, 50 minutes
• Insurance paid only 5 of claims
• Those who saw children saw more patients per week
  (58 pts per week vs. 36) those who saw children
  more often used Japanese style or combined
  Japanese/Chinese style
• Lee A. WJM, 1999

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Acupuncture safety

• In US over past 20 years, approximately 50
  complications reported in medical literature
• Worldwide between 1981-94 193 patients reported
  adverse effects
• Types pneumothorax, death, failure to get
  life-saving medical therapy, infections,
  bruising, needles left in place
• White A. BMJ, 2001
• MacPherson H BMJ, 2001
• Ernst. Am J Med, 2001

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Acupuncture for asthma?

• Not without more studies.
• Probably safe if licensed acupuncturist and
  parents agree to continue conventional care

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Acupuncture for CF?

• At Boston Childrens, initial referrals of CF
  patients to acupuncture for constipation,
  anxiety, insomnia, or pain
• Patients spontaneously reported decreased
  dyspnea, improved sense of well-being/ I sleep
  really well the night I have had acupuncture.
• One terminal patient asked to receive a treatment
  shortly before he died. His mother agreed, It
  makes him feel so much better.
• Patients began asking for acupuncture soon after
  admission to hospital

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Acupuncture other effects

• Helpful for pain, including headaches, muscle
  aches, post-operative pain
• Reduced anxiety and depression
• Improved sense of well-being
• Improved sleep
• Zeltzer L. J Pain Symptom Management, 2002
• Molsberger AF. Pain, 2002
• Allais G. Headache, 2002
• NIH Consensus Confernce. JAMA, 1998
• Kober A. Anesthesiology, 2003
• Gallagher SM. Complement Ther Med, 2001

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Acupuncture for CF

• Now part of CPG for cystic fibrosis at Boston
  Childrens Hospital
• Next step, more rigorous outcomes research in
  this population and other kids with chronic
  pulmonary disease

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Therapeutic Touch/Healing Touch

• Nursing techniques, formalized about 30 years
• Steps Center, Focus, Assess, Treat, Release
• Useful for assessment in non-verbal patients
• Useful for treatment observe oxygen saturation
  rise
• I use for all pulmonary patients
• Questions duration of effects? Who is helped
  most? Frequency of treatments? Can family be
  trained?

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Special Exercise

• Yoga YES pranayama
• Buteyko breathing unusual theory possible
  benefit!

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Environment

• Ozone or ion generators? No data
• Cockroaches eliminate
• Animal dander reduce or avoid
• Dust mites reduce or avoid
• Pollen and dust reduce or avoid
• Magnets no data
• Crystals no data

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Hypnosis/Guided Imagery/Biofeedback/
Meditation/Autogenic training

• Yes, helps reduce stress
• Cost?
• Reimbursement?
• Daily practice

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Herbs and Vitamins

• Coffee and chocolate (methylxanthines)
• Ayurvedic coleus forskohli
• Licorice inhibit cortisol breakdown
• Ma huang beware
• Ginkgo?
• Onions
• Magnesium, vitamin C, B6, omega 3 fatty acids

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Goals of Medicine

• Yang goals
• Cure disease
• Manage symptoms
• Prevent specific disease
• Yin goals
• Promote well-being
• Promote peace, harmony, meaning
• Support, hope, trust

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SUMMARY

• Boston Childrens has added acupuncture and
  massage to professionals treating CF patients
• Attend to anxiety and depression and insomnia
  mind/body, environment, massage, acupuncture
• Attend to biochemistry diet and supplements as
  well as medications
• Attend to biomechanics - massage
• Attend to lifestyle allergens, mind/body stress
  management, exercise!
• Attend to relationship Therapeutic
  Touch/Healing Touch