Complementary and alternative medicine is one component of a comprehensive approach to treating chronic pain in children. The authors examine the use of CAM for managing headache, recurrent abdominal pain, and neuropathic pain.
Complementary and alternative medicineincluding biofeedback and other mind-body therapies, acupuncture, and herbal and dietary therapyis one component of a comprehensive approach to treating chronic pain in children. The authors examine the use of CAM for managing headache, recurrent abdominal pain, and neuropathic pain.
Chronic pain plagues 4% to 25% of children, depending on age and gender.1,2 Pediatric chronic pain complaints range from headache and abdominal pain to juvenile rheumatoid arthritis, back pain, and even chronic neuropathic pain. Often, as in the hypothetical cases reviewed above, complicating psychosocial factors leave children vulnerable to depression or anxiety. Secondary gain can lead to disability that is significantly greater than one would expect given the level of reported pain.
Assessment of chronic pain in children can be difficult: There may be no clear organic basis, and a child's ability to describe the quality and intensity of pain varies depending on developmental level and previous experience with pain. Treatment of these cases can be difficult, too. In the face of unrelenting pain and disability, the parents of a child in pain can easily become frustrated and desperate for any therapeutic modality that may offer relief.
A multidisciplinary treatment approach is highly recommended for children with complex chronic pain complaints. Complementary and alternative medicine (CAM) is increasingly a component of this approach. CAM therapies tend to fit in well with the physical therapy and psychological treatments that benefit these patients. CAM can be highly beneficial to both children and adults suffering from chronic pain but, because of behavioral, developmental, and physiologic differences, pediatric patients may respond differently than adults to complementary (and to mainstream) treatments for pain.
The purpose of this article is to provide an update and overview of the recommended use and the evidence behind CAM treatments for three types of chronic pain in pediatric patients in order to educate general practitioners who may be searching for treatment referrals. Chronic pain patients and their families often inquire about or request these services, and it is important for family practitioners to have enough information to address their patients' concerns.
This is the most common chronic pain complaint in children. The prevalence rate for migraine alone ranges from 3% to 18%.3 Tension-type and chronic daily headaches are increasingly common in childhood, and headache frequently runs in families. Chronic headache in childhood and adolescence is usually treated pharmaceutically with analgesics, anti-inflammatory medications, anticonvulsants, triptan agents, and multiple other types of medication. CAM therapies are often used only after diagnostic testing has failed to identify an organic cause for the headache and medication trials have failed.
CAM providers tend to pay particular attention to lifestyle specifics that may be vital components to headache treatment but that can be easily overlooked in a busy medical practice. These specifics include type of exercise, details of nutrition (including water and caffeine intake), sleep habits, and potential environmental pollutants.
Specific triggers of headache can often be identified through a careful history. Strong smells such as cigarette smoke or perfume; hunger; stress; and a lack of, or too much, sleep can frequently trigger headaches. Avoidance of triggers, when possible, is a simple solution.
Although we often see parents who suspect a food trigger and put their children on a restrictive diet, the yield from this dietary restriction is negligible. We have yet to see a child who has a clear and consistent food trigger for headache. The most important (and probably the only necessary) dietary restrictions for children with headache are an increase in water consumption and a limit on caffeine intake.
Drug overuse headache can also develop in these patients, so assessing over-the-counter medication intake is important, particularly in chronic daily headache. (See "Breaking the cycle of medication overuse headache" in this issue.)
Mind-body therapies, described in Table 1, are the most thoroughly researched of all the CAM strategies for headache management and have demonstrated consistent and impressive effectiveness for this type of chronic pain. Stress is the most common trigger of both migraine and tension-type headache, and mind-body therapies tend to focus on identifying and coping with stress triggers to avoid the sympathetic nervous system reaction to stress that is associated with pain. Mind-body approaches focus on the power of the person to control his (or her) body and to stop the cycle of anxiety and pain. The person is taught a set of skills he can draw upon to calm the sympathetic nervous system and lessen pain and affective distress. In turn, the person's point of view can shift from one of helplessness and looking externally for answers to pain, to one of hopefulness and confidence in one's internal coping resources. [For more on this topic, see "Managing headaches without drugs," in the August 1999 issue of Contemporary Pediatrics.]
Biofeedback and relaxation training are the most investigated mind-body modalities (Table 2). More than 20 studies utilizing biofeedback for pediatric headache have been published in the last 30 years. Most have demonstrated significant improvementat least a 50% reduction in reported headache painfor the majority of study participants. Biofeedback uses machines to provide information about what is happening inside the body, so that the person can use that information to change his or her physiologic responses. Most biofeedback practitioners use a computer-based system that provides visual or auditory feedback (or both) to the patient. The types of biofeedback most often used are electromyography (EMG) and thermal (Table 1). The number of treatment sessions typically ranges from four to 12.
Relaxation training and other mind-body treatments, such as imagery, self-hypnosis, and stress management, are often integrated with biofeedback, or with each other. It is impossible to distinguish whether one type of mind-body therapy is more powerful than another, although relaxation therapy alone is probably efficacious.4
Investigations of another type of CAM therapyacupuncturein pediatric headache and other chronic pain have focused mainly on the feasibility and acceptability of this treatment. Very little is known about the efficacy of acupuncture for chronic pain in pediatric patients. Two studies of children who were referred for acupuncture for various chronic pain conditions reported that it was well-tolerated and even enjoyed by children.5,6 Controlled, prospective studies have been conducted in adults, and the results indicate that acupuncture is an effective treatment when compared to medical management.7 However, two placebo-controlled studies comparing acupuncture to sham techniques in adults with tension-type headache (using non-acupuncture points) reported no differences between the two treatments.8,9 Given this research, there is some speculation about the role of placebo in acupuncture. Practitioners have also emphasized that acupuncture is a general approach that is not limited to needle insertion and manipulation, and that it is difficult to research the effect of Chinese medicine as a whole.
Practitioners of acupuncture who treat children often use non-needle techniques or Japanese needles that are of a relatively smaller gauge compared to Chinese needles.10 When referring a child to acupuncture, it is generally best to find a practitioner with experience and training in pediatrics. For information on referring a patient to an acupuncturist, see "When should you consider acupuncture for your patients?" in the December 2002 issue of Contemporary Pediatrics.
Scalp massage can be very soothing and relieve pain associated with tension-type headache and migraine in children and adults. Studies in adults have demonstrated that therapeutic massage can reduce headaches and improve sleep in migraineurs. Although care must be taken to be gentle over tender muscles, parents can easily learn to provide a gentle massage for children with recurrent headache. (For detailed instructions on scalp massage, see Kemper,11 page 269.) In cases where the scalp is too tender to touch comfortably, foot massage may provide relief. Therapeutic touch (TT), as well as Reiki, may be equally effective; however, no clinical studies to date have demonstrated scientific evidence of efficacy. Reiki is similar in principle to acupuncture in that it is based on the concept of chi, or energy flow in the body. A Reiki healing involves the practitioner placing his or her hands on the person to be healed, with the intent of allowing chi to flow. TT is similar to Reiki, but practitioners of TT believe that the energy field extends beyond the skin and is unbalanced or depleted when there is illness or injury. Physical touch is generally considered unnecessary to adjust a patient's energy fields.
Herbal therapies and dietary supplements are also available for treatment of headache. Very little is known about their efficacy in children. Magnesium and riboflavin supplements have been recommended for tension-type headache.12,13 The scarce research that has been conducted on supplements has focused exclusively on adults and has demonstrated equivocal results. Vitamin B6 has been suggested as a treatment for menstrual headache, but research into its efficacy has yielded mixed results.
Other herbal and dietary remedies that have been recommended for headache include feverfew, evening primrose oil, omega-3 fatty acids, hawthorn, valerian, peppermint, angelica, balm mint, lavender, chamomile, skullcap, violet flowers, and white willow bark. Few treatment outcome studies have been conducted, and almost all of them have been done with adult participants only.
Feverfew has been studied as a preventive therapy for migraine in adults, with varied results.14 Many children and adults anecdotally swear by the use of feverfew, however, and it remains the most popular dietary supplement for treating chronic headache. The recommended dosage for an adult is 25 milligrams twice a day. Unfortunately, there is a great deal of variability in the amount of the active ingredient, parthenolide, contained in any one feverfew product, despite package labeling. Care must be taken to select a product that has high quality standards whenever herbal medications are used.
One study of omega-3 fatty acid (fish oil) supplementation in adolescents with headache demonstrated no advantage of fish oil treatment in comparison to a placebo olive oil treatment in reducing reported pain.15 No other dietary supplement has been systematically tested in children or adolescents.
Peppermint oil or lavender oil administered as aromatherapy may be beneficial for acute headache, and some limited research supports their use in adults. Any symptomatic treatment that incorporates lying down and relaxing may decrease headache. Lavender does, however, appear to generate a sense of calm and relaxation not evident with other odors.
Once disability becomes an issue in a chronic headache patient, multiple therapies should be tried with an emphasis on a rehabilitative approach to pain management. Many patients and parents seek treatment for a chronic complaint with a mindset much like that for acute illness: They rest and expect that, with time and lack of activity, they will improve. We emphasize to our patients that chronic pain requires the opposite approach: A return to activity over time tends to improve the condition. Of course, in children who have been absent from school for a substantial amount of time, the stress of re-entry and make-up work can worsen the pain. In these patients it is often best to start with a partial day at school and gradually increase the amount of time spent there.
In the case of our fictional patient, Kim, it appears that stress is a major precipitant of her headaches and that her ability to cope with stress is very limited. She wishes to avoid situations that aggravate her headache (in this case, school) instead of learning how to cope with stress triggers. An appropriate referral should include mind-body strategies to aid in managing her pain.
Another frequent pain complaint in children is recurrent abdominal pain (RAP), defined as at least three episodes of abdominal pain within a span of three months that are severe enough to affect the child's activities. RAP in children may be related to irritable bowel syndrome (IBS) in adults, but the precise link between these two functional disorders is unclear.16 RAP has no set of symptom-focused diagnostic criteria (unlike IBS), and there is considerable controversy about its underlying cause. Almost all studies have found that only about 10% of children seem to have a recognizable organic disease that explains their complaint of pain.
Lifestyle factors should be investigated, including environment and diet. Some children with RAP report that spicy or greasy foods trigger pain. Switching to a bland diet can significantly ease discomfort. Lactose intolerance can be a factor in RAP, particularly in children of susceptible racial or ethnic background. Malabsorption of other carbohydrates, such as sorbitol or fructose, has also been implicated in RAP. It is important to be aware of these potential dietary factors, which are common in Western diets, even though they may account for only a small number of RAP cases.
Helicobacter pylori has also been implicated as a cause of RAP, but evidence of its involvement is controversial. Screening for this bacterium is not recommended in children whose symptoms meet the classic definition of RAP.
Few pharmaceutical treatments are effective for recurrent abdominal pain in children. Occasionally, constipation is present, and symptomatic treatment can be beneficial in relieving the pain. More often, though, RAP presents without the altered bowel habits found in IBS.
The most frequently cited approach in treating children with RAP is reassurance that there is no organic disease and that stomach pain occurs frequently and episodically in many people. This approach, in and of itself, can be comforting to the child and parent, and can ease stomach pain made worse by worry about the pain. We find that adding an explanation of sympathetic nervous system arousal and an age-appropriate description of the "fight-or-flight" response is helpful. It is natural for the body to respond to stressors with abdominal pain; some people are more prone to this response than others. It is important to validate the child's pain while you provide this education and to add helpful tips on how to prevent pain. Often, we see children who have received this message from their pediatricians and have heard, "the pain is in your head." The pain is most certainly in the abdomen, but the stimulus for a pain episode starts in the braina concept that can be difficult to explain.
As in pediatric headache, the most well-researched CAM treatments for abdominal pain in children are mind-body approaches.17 The majority of studies have combined elements of relaxation training, behavioral management, stress coping training, meditation, and biofeedback. A great deal of evidence supports the use of these treatments for functional gastrointestinal distress in both children and adults.16 Biofeedback can be beneficial for children who have difficulty recognizing that they do have control over different physiologic processes. Because this technique involves concrete visual feedback, the child readily sees that he can influence muscle tension, peripheral body temperature, heart rate, and any of a number of other measures. These skills, as well as the child's new insight, can be used during pain episodes.
Many children with chronic pain complaints such as RAP have complex problems in their life that act as psychosocial stressors. The pain can shift the focus from dealing with issues that cause the entire family emotional pain, to managing an identified patient with an identified medical problem. The use of mind-body approaches can teach coping skills for handling underlying issues. Referral to a mental health professional who uses these techniques can provide a "foot in the door" for dealing with larger, systemic family problems.
As with headache, acupuncture can, in our experience, be beneficial for RAP. Many of the children we see find acupuncture helpful, and we often combine this approach with mind-body strategies. Only one study of acupuncture in treating recurrent abdominal pain has been conducted, however, and it was done in adults. It reported equally beneficial effects in IBS patients treated with acupuncture as in those who received a sham acupuncture technique.18
Massage can create a calming and relaxing effect that eases pain associated with sympathetic nervous system arousal.19 Creating a general sense of calm tends to quickly resolve RAP episodes. Massage is one of multiple ways to create what is commonly referred to as "the relaxation response." While mind-body strategies tend to focus on emphasizing the internal resources of the child, massage, as well as modalities such as Reiki and therapeutic touch, can involve family members and create a calm bonding time between parent and child.
Dietary supplements and restrictions may be beneficial for children with RAP. Enteric-coated peppermint oil has been demonstrated to relieve pain associated with IBS in adults in several studies, and one randomized controlled study conducted with children demonstrated very good results.20 Teas with peppermint and chamomile can be remarkably soothing, with effects of calming the stomach and initiating relaxation. Dill, fennel, and anise may also be helpful because they tend to relax intestinal spasms, such as in colic.
In the case of our "patient" Charlie, his mother has asked whether herbal therapy and acupuncture would be appropriate treatments, and we would agree that he might benefit from them. An 8-year-old can tolerate and even enjoy acupuncture, and some herbal treatments (such as peppermint or chamomile tea) can be safely used.
Although neuropathic pain is uncommon in children, recognition is growing that specific types of neuropathic pain, such as complex regional pain syndrome (CRPS types I and II, also known as reflex sympathetic dystrophy and causalgia, respectively), are very different in children than in adults.21 Signs and symptoms of CRPS include severe pain (often constant and burning in character), hypersensitivity to light touch (allodynia), and signs suggestive of autonomic or microcirculatory dysfunction such as coldness of the extremity, cyanosis, delayed capillary refill, abnormal hair and nail growth, and diffuse brawny edema not confined to joints. If the extremity is not mobilized, atrophy and limb contractures may ensue.
Few reports have been published regarding the incidence, pathophysiology, and clinical course of CRPS in children. Compared with adults, however, CPRS in children is more often present in a lower limb than in an upper limb, occurs much more frequently in girls than in boys (among adults, it is diagnosed more often in males than in females), and tends to respond very well to rehabilitation-oriented approaches.
Because of the reported intense pain that is significantly out of proportion with physical findings, children and adolescents with neuropathic pain are frequently referred to mental health professionals for treatment. No evidence supports a psychogenic basis for pain in the majority of children and adolescents, although clinically it is often noted that children and adolescents with CRPS are involved in high-intensity competitive sports and have an enmeshed relationship with one parent.
Medications for neuropathic pain often include tricyclic antidepressants and anti-seizure agents. Frequently, these medications help "take the edge off" the pain or allow a patient to sleep for longer periods. Opioids tend to have little effect on the pain. In adults, nerve blocks are often used as first-line treatment. In children, however, less invasive forms of therapy are more highly recommended.
Exercise of the affected limb and physical therapywhich focuses on weight bearing and desensitization of the limbare the treatments of choice for neuropathic pain in children. In two studies, these approaches were demonstrated to be highly efficacious in children within a few weeks of initiation.22,23 Overall, very little has been published in regard to mainstream therapies for CRPS, and even less is known about CAM techniques in neuropathic pain syndromes. We do see a great deal of the use of CAM in these patients on a clinical basis. This is likely because so few treatment options are offered to these patientswho are suffering from intense painand the most beneficial treatment (physical therapy) results in a short-term increase in pain. CAM offers strategies to empower patients, which can encourage participation in exercise, and, judging from our clinical experience, CAM can be highly efficacious clinically.
One CAM strategy that is often integrated into physical therapy in CRPS is massage; desensitization and stimulation of the affected limb is a necessary component of successful treatment. Some clinicians combine aromatherapy with massage for these patients by using massage oils that can relax the patient and allow more stimulation than might otherwise be tolerated.
Mind-body techniques such as cognitive-behavioral therapy and self-hypnosis also can be easily integrated with physical therapy. These techniques often provide the additional encouragement and sense of control that allow patients to make good use of their time in treatment. Coping strategies and cognitive-behavioral therapies can help children identify discouraging and negative thoughts and learn to handle their pain better. One study conducted in our pain clinic in Boston demonstrated very good results with a combination of physical therapy and cognitive-behavioral treatment, including relaxation, self-hypnosis, and coping-skills training.23 The majority of children improved significantly after six weeks of this combined treatment.
Self-hypnosis is a useful technique for many children who suffer from chronic pain, and most children can easily learn it. This treatment modality allows the child to use her power of concentration and her imagination to change her perception of the sensations in the affected body part. Commonly used techniques include the "switchboard," in which the child imagines a panel of switches in her brain that controls the rest of her body and uses those switches to change her perception of signals such as pain. Another technique involves transferring some of the pain to an object, which is then destroyed. Yet another involves an invisible "magic glove" that is used to reduce sensation in an area of the body.
Although most children easily learn self-hypnosis, teaching this modality for pain control can be tricky, and it shouldn't be done without some training. It is important to allow the child to experience whatever change in sensation she does, and not to be too direct. Otherwise, the child who experiences only slight reduction in pain could become confused with suggestions of the disappearance of pain and lose any benefit she had experienced. In patients with CRPS, we often use hypnosis as an integrative treatment to help the child manage pain during physical therapy sessions or to get to sleep at night.
In terms of the value of acupuncture in patients with neuropathic pain, only one case report has been published showing benefit from the use of acupuncture in pediatric CRPS.24 We often use acupuncture in combination with other therapies for neuropathic pain.
Andrea, whose hypothetical case we described at the beginning of this article, is a typical CRPS patient. She is driven but having a great deal of difficulty working through the pain. Motivation doesn't appear to be an issue, and she is in an appropriate treatment program that emphasizes physical therapy. Mind-body strategies such as self-hypnosis, in combination with acupuncture, would be appropriate for her. Part of physical therapy for this condition generally integrates massage, both for stimulation of the affected limb and as a desensitization strategy when anxiety prevents full participation.
Children who suffer from chronic pain, along with their families, can experience a great deal of frustration, sadness, and anger when traditional medical therapies fail to help them. Incorporating additional integrative therapies into treatment can provide hope. These types of treatments can also benefit children by addressing complicating factors that often set in, such as disability and depression.
Too often, CAM therapies are seen as "last-ditch" treatment modalities when, in fact, they can easily be integrated into a comprehensive treatment plan. Pediatric chronic pain is one area where researchers and clinicians alike are increasingly appreciating the benefits of CAM, and research in this area is promising. Multiple resources are available for professionals and parents to investigate referral sources and treatment recommendations, and Web site resources are provided in Table 3. Although licensing and certification requirements for various practitioners vary by state, many national societies, such as ones listed in Table 3, maintain specific and stringent criteria for membership.
Herbal therapies, supplements
Evidence that CAM strategies work well in pediatric chronic pain is slowly growing. For the most part, mind-body techniques are the most well-researched, with the most evidence to support their use. We recommend mind-body strategies as part of a first line of treatment for most of our patients with chronic painparticularly in cases in which the picture is clouded by psychosocial issues or disability that is inconsistent with the amount of reported pain. Acupuncture and massage tend to be useful strategies as well, and can be powerful adjunctive treatments when chronic muscle tension is contributing to the pain. Reiki and therapeutic touch may well have roles to play, as may dietary supplements in some cases. At this point, however, not much is known about the efficacy of these modalities in pediatric patients.
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Lisa Scharff, Kathi Kemper. For chronic pain, complementary and alternative medical approaches.