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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

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The Evolution of the Comprehensive Pain Service

1999

2008

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

Dr. Tingley

Dr. Joseph

Medical Director of Inpatient

Medical Director of Palliative Care

Palliative Care CNP

Palliative Care Social Worker

Pain Service Clinic

Hospice – Home Palliative Care

Nurse Clinician

Psychology

Physical Therapy

Massage

Acupuncture

CNP

CNP

Anesthesiologist

Anesthesiologist

Anesthesiologist

Perioperative Services Clinical Services &Case Coordination Homecare

Jen RogersProgram Coordinator

Sharon Wrona, CNPClinical Lead APN

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Inpatient Pain Service

• Any inpatient pain management issue– Postoperative– Medical– PCA / NCA/ Epidural– End of life– Functional

Inpatient Pain Service

336 346

493

661

0

100

200

300

400

500

600

700

2004 2005 2006 2007

Patients

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The Growth of the Massage Therapy Program

• Brief History: Physician advocate/ grant writerCredibility of massage therapistAvailable patient population

• July 2001-2003: 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 FoundationChildren’s Research InstituteMassage Therapy with Patients with Life-Threatening Asthma

• Anderson Family Foundation

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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: 100-130 new orders per month• Frequencies: Each patient 3-5 times per

week

Funding

• Insurance reimbursement

• Support from Physical Therapy Department

• Foundation

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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 DrainageCranial Sacral therapy Myofascial TherapyReikiHealing TouchAromatherapy

• Picture of team

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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

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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

• 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

CAM Research

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• 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

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Evidenced Based-Practice

• Massage Therapy and its Effects on Symptoms in Children who Suffer from Chronic Pain, Suresh, Abstract P60, 2007.

• The Effects of Massage Therapy with Children with Juvenile Rheumatoid Arthritis, Tiffany Field, et. al, The Touch Research Institute, 1997.

• 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

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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

• 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) 722 - 4205

At the Westerville Sports Medicine Building

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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

Initial (New Patient) Clinic Visit*

PSYCHOLOGY PTMEDICAL

Visit includes: Assessment, Team Discussion,Education, Develop treatment plan(~ 1.5- 2 hr visit: MON or THU AM)

Clinic Code = NEPN

Northeast Outpatient Chronic Pain–Clinic/Support Flow

PhysicianReferral/

Self referral

Referring MD called w/ feedback; Pt

referred to appropriate MD, specialty, etc.

NO

YES

Chronic Pain Clinic

candidate?

Pt calls central scheduling to set

up new initial appt.

Follo

w U

p V

isits

**

* 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)

Patient’s medicalRecords are Reviewed for

appropriatenessBy Chronic

Pain Physician

Referral rec’vdIn EPIC inboxor by fax

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”

NO

YES

Patient appointment scheduled for

initial clinic visit

COMMUNICATION

Pt scheduled for follow up appts.by Central Sch.,

NE Regis., or Timken front desk

(psych only)

Central Sch. chks for pt. on

Work List

MEDICAL F/UClinic Code = NEPN

ACUPUNC F/UClinic Code = NEPT

PSYCH F/UClinic Code = NEPN

PT F/UClinic Code = NEPT

MASSAGE F/UClinic Code = NEPT

Pt presented

at 12-1 MON Team

Planning mtg.

Prior to EPIC implementation,

provider chksappropriate

services on Painclinic chg sheet.

Prog Coordenters charges

for Initial, Medical F/U,

Massage F/U,and

Acupuncture F/U.

KEY:

MD

Referral or Patient

Central Scheduling

Clinical Providers

Registration Staffat Westerville or

Timken

Program Coordinator

Psych andPT providerenter their charges.

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1

3

Challenges

• Administrative

• Clinical

• Financial

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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

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• 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

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Integrative Therapies

Predominant modalities used:

Massage Therapy (37%)YogaGuided Imagery/ Biofeedback/ HypnosisRelaxation Training/ MeditationAcupuncture/ AcupressureAromatherapy

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

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Thank You