Frontiers eNewsletter, January 2014
Ventricular Assist Devices: Experience Breeds Success
By John Lee, MD; Eiran Gorodeski, MD, MPH; and Kelly Walters, CNP
The rising prevalence of end-stage heart failure in the
United States has translated to an increase in the number
of patients awaiting heart transplant. Due to the limited
supply of donor organs, use of ventricular assist devices
(VADs) — as either a bridge to transplantation, a bridge to
recovery or destination therapy — has been increasing as
well. Cleveland Clinic has an active VAD program, with 59
VADs implanted in 2012. Of the 59 patients who received
those VADs, 47 were able to be discharged home, 10 were
discharged to our inpatient rehabilitation facility (IRF) on
Cleveland Clinic’s main campus and two were sent to a
skilled nursing facility.
Recent Rehab Experience by the Numbers
Patients who undergo VAD implantation often become
deconditioned as a result of multiple medical issues and
long hospital stays. Most require varying levels of postoperative
rehabilitation care. Treatment of VAD patients
in the IRF on Cleveland Clinic’s main campus began in
1998. Over the past 12 months, we accepted 17 patients,
of whom 13 were discharged to the community and four
required readmission to the acute-care hospital. The
average length of stay was 16.4 days (range, 4 to 34), and
the average change in Functional Independence Measure
(FIM) score was 22.5.
Training and Preparation
Treatment of VAD patients requires extensive staff
education. All nurses, therapists and physicians at our
main campus rehabilitation hospital recently underwent
training or retraining over a six-month period to learn
about the following:
- The VAD hardware
- The various alarms and how to respond to them
- How to change the battery and connect to
a power source
- Mobility issues with the VAD
- Activity precautions
- Driveline care
- Potential medical complications
Additionally, clear lines of communication are established
between the rehabilitation team and the VAD team.
Experience Breeds Success
Our experience with VAD patients has been very positive.
Most of these patients have achieved significant functional
gains and been able to be discharged to the community.
Nevertheless, caring for these patients poses challenges,
which include the need for close monitoring of their blood
pressure and cardiac and fluid status, vigilance for potential
medical complications, and thorough patient training and
education prior to discharge to the community. The medical
complications we have seen in these patients include bleeding,
infections, thrombus of the VAD and stroke.
Throughout the rehab course, the VAD team remains peripherally
involved, frequently consulting with the rehab team on
management and discharge planning issues. Initial staff trepidation
about caring for VAD patients quickly dissipates as our
comfort level rises with increased knowledge and experience
in caring for these patients. The rehab physicians and nurses
have become accustomed to managing patients’ medical
issues with support from the VAD team; the therapists have
become proficient in mobilizing and exercising these patients;
and the case managers and psychologists have gained
familiarity with addressing the psychosocial and discharge
considerations unique to this population.
On the acute-care hospital side, all patients are seen after
VAD implantation by a physical and occupational therapy
team dedicated to cardiovascular patients, and the physiatrist
is consulted on many of these patients as well.
As our experience with VAD patients continues to grow,
we encourage closer and earlier involvement of the PM&R
consult service following VAD implantation to facilitate
transfer to the next appropriate level of care. The goals of
changes along these lines would be to improve throughput
and accelerate admission of appropriate patients to inpatient
rehabilitation. We are also using our electronic medical
record branching logic to standardize therapy approaches
and goals across the acute and post-acute arenas, and we
are measuring patients’ changes in strength, endurance
and balance in addition to FIM score changes.
A Gratifying Patient Population
VAD patients are medically complex but are a very gratifying
population to treat on the inpatient rehab unit. As a result of
multiple medical comorbidities, they have complex rehabilitation
needs and are able to make rapid, meaningful functional
gains if medical stability is maintained (see sidebar on next
page). In many cases (e.g., stroke, critical illness neuromyopathy,
peripheral neuropathy) these patients qualify under the
Centers for Medicare and Medicaid Services’ 60 percent rule.
More than most other patient populations, VAD patients
require the resources of the entire interdisciplinary team
working toward the goal of discharge back to the community.
When such discharges are made possible, it is a
testament to the high degree of coordination among team
members and to the immense value inpatient rehabilitation
can yield in this population.
Dr. Lee is a staff physician in Cleveland Clinic’s Department
of Physical Medicine and Rehabilitation whose specialty
interests include rehabilitation of transplant patients. He
can be reached at 216.445.9987 or email@example.com.
Dr. Gorodeski is Director of Cleveland Clinic’s Center for
Connected Care and a staff physician in the Department
of Cardiovascular Medicine. His specialty interests include
heart failure, heart transplant and ventricular assist devices.
He can be reached at 216.636.6146 or firstname.lastname@example.org.
Ms. Walters is a nurse practitioner in the Department
of Physical Medicine and Rehabilitation whose specialty
interests include rehabilitation of transplant recipients
and other medically complicated patients. She can be
reached at 216.444.1959 or email@example.com.
The Spine Care Path:Reducing Practice Variability in Partnership with PM&R
By Daniel Mazanec, MD, and Ian Stephens, PT, DPT, OCS
Despite increased spending for spine care and a steep rise
in the use of imaging and interventional and surgical procedures,
the functional outcomes of spine treatment have not
improved. Though there is broad consensus among multiple
evidence-based clinical practice guidelines for back care,
variability in the diagnosis and treatment of spinal disorders
To reduce this needless and often costly variability and
improve patient outcomes, Cleveland Clinic’s Center for
Spine Health has developed the Cleveland Clinic Spine Care
Path. As physical therapy and rehabilitation medicine play
a key role in the spine care continuum, members of the
Department of Physical Medicine and Rehabilitation have
made important contributions to the Spine Care Path’s
development and implementation. These include guidance
on all the points in the spine care continuum where nonsurgical
treatment is encountered.
Care Path at a Glance
Developed with input from medical spine specialists,
spine surgeons, physical therapists and pain management
physicians, the Spine Care Path is designed to provide an
evidence-informed clinical road map to assist practitioners
in managing the full range of spinal disorders. The care path
begins with work flow diagrams outlining the progression
of evaluation and management across the continuum from
acute through chronic symptoms, incorporating medical,
interventional, surgical, psychosocial and rehabilitation
components. Figure 1 presents a portion of the care path’s
work flow for low back pain, focusing on the acute and
subacute phases. Similar work flows have been developed
for neck pain and radicular pain.
These work flows are supplemented by narrative care
path “guides” designed as clinical manuals for use by the
practitioner. They succinctly describe in useful detail the
appropriate steps in patient management with supportive
rationales and evidence.
Sharpening the Value Focus
Development of the Spine Care Path has led to a sharper
focus on measuring the value of care, including both patient
outcomes and clinical process. It will succeed only if it is
continually refreshed and refined using the outcomes data
collected, so that the care path becomes a “living organism”
The care path delineates a detailed timeline for delivery of
care across the spectrum of symptoms, raising important
questions about the organization of the spine care delivery
system. Such questions loom ever larger with the mounting
national imperative to focus on high-quality, value-based
care for populations. The care path serves as the organizing
principle for realigning our services to provide the highestquality
care in a timely manner to patients at all points
along the continuum.
Among the issues we are addressing is the need to match
appropriate clinicians to patients at various stages of care.
For example, acute back pain is common and generally
resolves with simple therapy. For patients without red flags,
imaging is rarely required. Providing such patients prompt
access to care with back education and recommended
activities to try may be best achieved using physical therapists
or nurse practitioners as entry-level providers. When
back pain persists, the care path defines when referral to
medical spine specialists, spine surgeons or behavioral
health providers is indicated.
Embedded in the EMR for Continuous Improvement
The Spine Care Path also presents an ideal opportunity to
develop a continuous quality improvement model for spine
care. By capturing patient outcomes in various domains
— including pain, function and mood — as well as defined
process measures such as imaging use and appropriate
referrals, the care path is designed to provide information
on the clinical effectiveness of treatment.
What’s in the Care Path’s Physical Therapy ‘Bolt-On’?
- A standardized approach to screening for red
flags and managing them
- Guidance on using validated instruments to
identify yellow flags, or factors that suggest
complicating psychosocial barriers to recovery
- Guidelines and decision-making support for
physical therapists to allow treatment-based
subgrouping of patients for matching with
- Recommendations for appropriate frequency and
duration of physical therapy for each subgroup
The ability to capture and analyze these data and modify
care as required is facilitated by integration of the care
path into the electronic medical record (EMR). Important
clinical data elements have been identified for inclusion
in structured documentation to be embedded in the EMR.
These retrievable data sets will facilitate retrospective study
of the process, the cost of an episode of care and its impact
on clinical outcomes.
‘Bolt-Ons’ Offer Added Physical Therapy Detail
Ongoing evolution of the Spine Care Path includes extending,
refining and standardizing treatment limbs such as
physical therapy and surgical care through what we’re
calling “bolt-ons” to the original work flow algorithms.
The physical therapy bolt-on is being developed by a group
of Cleveland Clinic physical therapists to promote a standardized,
evidence-based approach to physical therapy for
managing back pain. The bolt-on addresses
the breadth of physical therapy approaches to spinal disorders
and emphasizes active interventions including core
strengthening, manual therapy, aerobic conditioning and
directional preference exercises. It will provide guidelines
for physical therapists to assign patients to treatment-based
classifications to ensure that they receive interventions supported
Whereas the above bolt-on addresses the approach to
physical therapy in the acute and subacute phases of back
pain management, the surgical bolt-on details the role of
PM&R following complex spine surgeries, in both inpatient
and skilled nursing settings.
Dr. Mazanec is Associate Director of Cleveland Clinic’s Center
for Spine Health. His specialty interests include evaluation
and management of back pain, medical acupuncture,
and osteoporosis and bone disease. He can be reached
at 216.444.6191 or firstname.lastname@example.org.
Dr. Stephens is a physical therapist in the Department
of Physical Medicine and Rehabilitation who specializes
in back pain. He can be reached at 216.444.3230 or
Bridging Academics and Clinical Rehab: Research Collaboration Sizes Up the Relevance of 6 Clicks Tool
By Matthew Plow, PhD; Frederick S. Frost, MD; and Diane Jette, PT, MS, DSc
Translational research is typically defined as the process of
making basic science or laboratory science findings applicable
to the improvement of human health and function.
Many experts have argued for the need to conduct such
translational (bench-to-bedside) research, and it is now a
funding priority for the National Institutes of Health. Lost in
these arguments, however, is recognition of the additional
need to make patient-oriented research (i.e., conducted
with human subjects) translatable to the realities of healthcare
and public health services.
Cleveland Clinic is trying to address this need through a pair
of electronically administered short-form functional questionnaires
we call the “6 Clicks” tool — named for the six
questions contained in each of the questionnaires. Designed
as a practical tool for quickly measuring patients’ functional
status in the acute care setting, 6 Clicks is now being
evaluated by Cleveland Clinic in a patient-oriented research
collaboration with Boston University and the University of
Vermont to assess its potential to support clinical decisionmaking
in real-world practice.
Feasibility Needed in Patient-Oriented Research
When translational research is aimed at enhancing adoption
of best practices in the community, it cannot be conducted
as an independent line of inquiry as it can be in the benchto-
bedside context. Rather, patient-oriented research should
begin with the goals of clinical feasibility and community
dissemination in mind. Recognizing the need to conduct
such research, the Patient-Centered Outcomes Research
Institute, a new federal grant-making agency, prioritizes
funding of research that involves multiple key stakeholders
(researchers, patients and clinicians) and uses outcomes
that are meaningful to the patient. This type of translational
patient-oriented research could be used, for example, to
examine rehabilitation strategies that take into account the
clinician’s time constraints and the willingness of the patient
to adhere to therapy.
Unfortunately, although patient-oriented research identifies
effective strategies to improve human health and function,
too often these strategies are not feasible to implement
within healthcare and/or public health services. In these
cases, the strategy is then modified for implementation,
which makes its effectiveness uncertain. For this reason,
patient-oriented research should be more than just a collaborative
effort among key stakeholders; it should also be
designed with the goal of clinical feasibility and/or community
dissemination at the forefront.
6 Clicks as a Case in Point
6 Clicks is an example of such a research project. In
2011, implementation of a novel rehabilitation information
technology system throughout the Cleveland Clinic
health system provided a platform for easy collection of
discrete functional patient data. Although case mix index
has long provided a measure of disease severity, measuring
physical function for patients in the acute care hospital has
traditionally been a low priority. This is in contrast to other
rehabilitation settings, where reimbursement is tied
to patient participation.
The 6 Clicks tool was developed to provide a practical
means of documenting a baseline functional “footprint” for
all patients seen by therapists and rehabilitation physicians
in more than a dozen Cleveland Clinic hospitals and skilled
nursing facilities. Three priorities directed the development
of this tool:
- The time required to administer the tool needed to be
measured in seconds, not minutes.
- The tool needed to be integrated with a patient-reported
outcomes system while also allowing for proxy respondents.
- The tool had to share a pedigree with an outcomes
system that was agnostic to environment and relevant in
multiple care settings.
Creation of the tool was led by busy clinicians, with an eye
toward leveraging the data for research and management
purposes. It started with the goal of efficiently determining
how much rehabilitation therapy should be delivered in the
acute hospital setting, and to which patients. The broader
aim was to use discrete patient data to help distribute
rehabilitation resources rationally and ensure that patients’
discharge locations are optimally suited to their rehabilitation
The two 6 Clicks questionnaires — which measure
patients’ basic mobility and patients’ ability to perform daily
activities, respectively — were adapted from the Activity
Measure for Post-Acute Care™ (AM-PAC™) computeradapted
test developed by researchers at Boston University.
6 Clicks was adapted with the time constraints of acute
care clinical rehabilitation services in mind, and questions
were selected based on mobility and daily activities that are
meaningful to patients’ function in the acute care setting. In
addition, the items were chosen with a case management
function in mind, using those most germane to transitioning
patients to rehabilitation facilities.
The availability of a functional footprint for hospital patients
allowed managers to align provision of acute hospital
therapy services with patient needs. As reported in last
year’s issue of this publication (see page 4 at clevelandclinic.
org/frontiers2012), integration of 6 Clicks into the
electronic medical record has enabled our clinicians
to consult more intelligently and engage therapists
— particularly occupational therapists — to spend more
time treating patients who need them and less time evaluating
patients who won’t need them.
A Research Strategy to Ensure Relevance
To further improve the validity and utility of 6 Clicks and
possibly disseminate it beyond Cleveland Clinic, we are now
collaborating on a research project with Boston University
and the University of Vermont. Analyses of data proposed
by the University of Vermont’s Dr. Diane Jette will use a mix
of quantitative and qualitative methodologies to examine the
utility of 6 Clicks. Specifically, the five quantitative research
objectives are to determine whether 6 Clicks:
- Differentiates patients who are expected to have different
levels of function (e.g., we expect to see differences in
functional status with 6 Click scores between young and
- Correlates with other “gold standard” measures of
physical function used in rehabilitation settings, which
typically take much more time to administer
- Is accurate in predicting discharge location (e.g., home
vs. another setting)
- Is responsive to change in patients’ expected functional
status across the course of a hospital stay
- Produces consistent scores when two therapists independently
complete it on the same patient
To ensure that key stakeholders are involved in the refinement
of 6 Clicks, we are employing qualitative research methodology
to examine clinicians’ perspectives and attitudes on its
practicality and effectiveness in their daily practice.
Ultimately, the goal of 6 Clicks is to provide a quick and
relevant means of measuring physical function in the acute
hospital. Measurement of patient function, especially
patient-reported function, is at the heart of every strategy
to improve the rehabilitation treatments we provide.
Dr. Plow is a project scientist in the Department of Biomedical
Engineering and the Department of Physical Medicine and
Rehabilitation. He can be reached at 216.445.3288 or
Dr. Frost is Chairman of the Department of Physical Medicine
and Rehabilitation and Executive Director, Cleveland Clinic
Rehabilitation and Sports Therapy. He can be reached at
216.445.2006 or email@example.com.
Dr. Jette is Professor of Rehabilitation and Movement Science
and Chair, Department of Rehabilitation and Movement
Science, at the University of Vermont. She recently completed
a research sabbatical at Cleveland Clinic. She can be reached
Multiple Sclerosis Performance Testing: Novel App Seeks to Enhance Functional Assessment and Empower Patients
By Francois Bethoux, MD
Assessments of neurologic function in patients with multiple
sclerosis (MS) have traditionally been performed during
office visits. However, in a chronic disease such as MS,
characterized by an unpredictable course with exacerbations
and progression over time, more precise and more
frequent assessments are needed to guide increasingly
complex treatment decisions.
Cleveland Clinic’s Mellen Center for Multiple Sclerosis
Treatment and Research, under the leadership of Richard
Rudick, MD, together with the team of Jay Alberts, PhD,
in the Department of Biomedical Engineering, is addressing
this challenge with a set of performance tests developed
for the iPad® — the Cleveland Clinic Multiple Sclerosis
Performance Test (MSPT) app. The goal is to facilitate
assessments in a variety of settings, including the patient’s
home. In addition to providing enhanced information to
clinicians and researchers, the MSPT app will eventually
help empower patients with MS to participate more fully
in their own care.
Patient Assessment: The Need for a Better Way
The need for novel assessment tools in the management of
MS is driven by several factors:
- The best-practice model of care for MS is comprehensive
management, which involves assessing and monitoring
multiple consequences of the disease.
- Treatment options for the disease process and for resulting
symptoms and disability are rapidly growing, which
leads to increasingly complex decision-making and the
need to closely measure treatment outcomes.
- The disease course is unpredictable, requiring management
and monitoring to be individualized.
- Healthcare reimbursement is increasingly driven by performance,
which requires the ability to routinely generate
The duration and frequency of clinic or office visits currently
limits our ability to perform thorough and repeated assessments
of functional performance. Furthermore, patients
with neurologic disabilities may find it difficult to travel to
a medical clinic or may live far from an MS specialist. At
the same time, technological advances and progress in
measurement science offer opportunities to precisely quantify
performance while minimizing the time, personnel and
An App Is Born
These factors prompted development of the MSPT app to
enable easy and objective quantification of patients’ neurologic
function on an iPad. Using the sensors embedded in
the tablet, the MSPT app allows assessment of the following
functions across the spectrum of MS disability:
- Walking speed
- Upper extremity function
- Processing speed (a cognitive test)
- Low-contrast visual acuity
Cross-sectional validation of the MSPT is underway among
a target sample of 50 patients with MS and 50 healthy
controls. To date, data are available for 27 MS patients
and 23 healthy controls who completed the testing session.
A preliminary analysis showed excellent test-retest reproducibility
as well as agreement between MSPT components
and corresponding clinician-administered tests. Statistically
significant differences were observed between patients and
controls on walking speed, upper extremity function and
processing speed. More than 90 percent of participants
reported that the MSPT was easy to complete, and none
reported fatigue from testing.
The MSPT app will provide a validated battery of performance
tests that are easy to administer and will generate
quantitative results that are readily available for clinical and
research purposes. Computerized administration will allow
innovative approaches to analysis. Since the data can be
transmitted via secured link, the MSPT can be administered
in various settings, including nonacademic clinical practices
— and eventually patients’ homes.
Routine at-home assessments — performed as part of
a distance-health intervention — hold promise as a costeffective
method for acquiring more accurate and reliable
data in a real-life environment. Such an approach to patient
assessment has the added benefit of empowering patients
to take a more active role in monitoring and managing
The long-term management of MS and its many consequences
relies on patients performing exercises, improving
their general health, modifying their activities, using devices
and taking medications. In turn, the efficacy of these treatment
strategies depends on the ability to monitor outcomes
and provide direct and frequent feedback to patients and
their healthcare providers. Such feedback may also motivate
patients and improve their adherence to treatment.
The MSPT app represents a novel approach to assessing
functional performance in MS that uses a technology
available to the general public. It promises to enhance our
understanding of the evolution of MS-related disability and
contributing factors, provide more in-depth knowledge of
the outcomes of various treatments, and help empower
patients and their loved ones in their daily fight against the
devastating consequences of MS.
Dr. Bethoux is a physiatrist in Cleveland Clinic’s Mellen Center
for Multiple Sclerosis Treatment and Research specializing in
neurorehabilitation and spasticity management. He can be
reached at 216.444.9025 or firstname.lastname@example.org.
The validation study of the MSPT was funded by Novartis
Dedicated Cancer Rehabilitation: Improving Quality of Life Throughout the Course of Cancer Care
By Sree Battu, MD
The Department of Physical Medicine and Rehabilitation’s
cancer-related services have advanced significantly in the past
year, thanks to an active partnership with Cleveland Clinic’s
Taussig Cancer Institute and other Cleveland Clinic institutes
and programs (see sidebar below). This collaboration is
facilitated by Cleveland Clinic’s distinctive organizational
model, designed around disease-based institutes to
enhance cooperation across specialties and disciplines.
Though physiatrists play an integral role in this program,
access to a broad network of talented cancer rehabilitation
physical and occupational therapists is not restricted.
In fact, direct referrals to the therapists by surgeons and
oncologists is encouraged. As a result, hundreds of patients
benefit from contact with specialized rehabilitation providers,
and physiatric consultations become more meaningful
as the therapy team identifies and routes many patients
with compelling diagnostic and management needs.
Why Cancer Makes for Unique Rehab Patients
At the heart of the program, which currently focuses on
breast cancer patients and survivors, is a recognition that
patients with cancer often have physical, psychological
and social needs that go beyond their cancer diagnosis
and cancer-specific treatments. Cancer patients are
unique rehabilitation patients because their impairments
are remarkably complex and their personal goals are
very different at each stage of their disease process. Our
Cancer Rehabilitation Program offers a range of services
and resources focused on these multidimensional needs at
all stages of the cancer continuum: diagnosis, treatment,
post-treatment and long-term follow-up, survivorship, and
Early and Enduring Role for Rehab
Cancer rehabilitation encompasses a range of therapies,
educational interventions and support services that can
be offered to the patient at any point in the care continuum.
Our goal is to integrate rehabilitation early in the
care process and ensure that it is considered by oncology
specialists in patients’ overall treatment plans. This
early integration can be key to averting or ameliorating the
significant physical loss of function that cancer surgery and
treatments can cause.
Well-designed research studies in breast cancer patients
are limited, but they have shown that effective rehabilitation
services can improve the following:
- Upper and lower body
- Body image
- Bone density
- Symptoms of fatigue,
dyspnea, pain, anxiety
Collaboration Is Crucial
Our Cancer Rehabilitation Program works in conjunction
with the patient’s cancer team to provide an extra layer
of support and comprehensive care. We’ve found formal
educational programming on the importance of rehabilitation
at each stage of cancer management to be invaluable
in securing the cooperation and support of our oncology
specialist colleagues (surgeons, oncologists, hematologists,
radiation oncologists and hospice/palliative care providers)
and the oncology support staff.
Likewise, formal educational programming on common
medical issues and impairments among breast cancer
patients has been critical to enabling our rehabilitation
clinicians (occupational and physical therapists) to design
therapy programs that are patient-centered and appropriate
to the patient’s stage in the care continuum.
Importance of Tailoring and Regular Evaluations
Effective rehabilitation in this setting recognizes that cancer
can profoundly change a patient’s sense of personhood. Our
program assesses the whole patient in designing an individualized,
patient-centered rehabilitation plan to help achieve
the highest level of function possible within the limits of the
patient’s disease and in keeping with her/his personal goals.
We strive to enhance quality of life for patients living with
cancer and the effects of cancer treatments.
Since breast cancer patients are treated by occupational
and physical therapists, these disciplines have collaborated
from the start to develop programming using evidencebased
guidelines and best-practice models. One key to
our program design is having consistent functional evaluations
for every patient before surgery, after surgery and at
appropriate intervals. This is a collaborative effort. Surgical
nurses perform preoperative functional measurements that
can be referenced postoperatively by surgeons or rehab professionals.
When patients start rehabilitation after surgery,
they undergo more detailed evaluations that include functional
measurements and questionnaires assessing quality
of life. These evaluations are continued periodically to track
changes in each patient’s progress.
Ongoing Program Refinements
Our program is developing a prospective surveillance model
to evaluate how physical impairment develops in patients
with breast cancer and how best to treat and allocate
resources to reduce disability and suffering.
We’ve also developed a unique algorithm to help patients
find the most appropriate therapist for their needs at a location
near home. There is strong interest in treating breast
cancer patients among rehabilitation clinicians across the
Cleveland Clinic Rehabilitation and Sports Therapy network,
yet some clinicians have more experience than others. Our
algorithm accounts for the patient’s needs and the experience
and comfort of the clinician when matching patients
with therapists. Patients with more complex medical issues
that require a neuromuscular workup or symptom control
with medication management will see a rehabilitation physician
with specialty training in cancer rehabilitation.
Dr. Battu specializes in cancer rehabilitation, general rehabilitation,
palliative care and hospice medicine in the Department
of Physical Medicine and Rehabilitation. She can be reached
at 216.445.0915 or email@example.com.
Acupressure/Acupuncture in Pediatrics: Noninvasive Techniques Offer Options to Enhance Rehabilitative Care
By Benjamin Katholi, MD
Cleveland Clinic has added acupuncture — often without
needle insertion — to its armamentarium for PM&R care
Since mid-2012, I have been offering acupuncture and the
related technique of acupressure (see below) as options to
treat a variety of symptoms that can interfere with rehabilitation
in my PM&R practice at Cleveland Clinic Children’s.
The tailored application of these techniques as complementary
therapy can help select pediatric patients achieve their
Needles Often Not Required
After many years of use in Chinese medicine, acupuncture
has gained a foothold in the United States for use in
adults to treat headache, postoperative and chemotherapyinduced
vomiting, addiction, and musculoskeletal pain,
among other indications. Acupuncture’s use in pediatrics
has lagged because children tend to be more fearful of
needles, but needle stimulation is just one of the techniques
that can be offered.
Techniques that avoid puncturing the skin are generally
painless while producing many of the same effects as traditional
needle-based acupuncture. These techniques include:
- Acupressure, which involves application of gentle to firm
physical pressure at the same pressure points and meridians
used in acupuncture
- Laser acupuncture, a method used to stimulate acupuncture
- Microcurrent stimulation, which uses pads attached to a
stimulation device (see photo, opposite page) that generates
continuous electric impulses; the frequency and
intensity of pulses can be varied based on therapy goals
The mechanisms by which acupressure/acupuncture
controls symptoms are not fully understood. The pain
control effects may reflect release of neurochemicals such
as beta-endorphins and enkephalins. Other theories include
regulation of the autonomic nervous system, alterations in
sympathetic and parasympathetic nervous system activity,
increases in local blood flow, and nitric oxide production
changes in neurotransmitter activity in the brain. Research
on mechanisms continues to be pursued internationally.
Adjunctive Role for Many Indications
Acupressure/acupuncture is not meant as a replacement
for traditional medical or rehabilitative treatments but as
a supplement with a low risk of side effects. For instance,
despite advances in anti-emetic medications, children
still suffer from postoperative and chemotherapy-induced
nausea and vomiting, and control of medication-resistant
nausea and vomiting is one of acupressure/acupuncture’s
recognized indications in children. Additionally, in the
setting of postoperative pain, acupressure/acupuncture
may reduce the need for opioid medications.
Other pediatric indications include treatment of constipation,
headache, fatigue, musculoskeletal pain, drooling,
anxiety and sleep disorders. The ability to treat multiple
symptoms in a single session is a major advantage. In my
experience, acupressure/acupuncture can be especially
helpful in treating children and teens with complex problems
such as brain injury and chronic pain.
Nuts and Bolts of Clinical Use
Practitioners of pediatric acupressure/acupuncture offer
these techniques to patients from birth through the teen
years. Young children tend to be more sensitive to acupressure
techniques than are adolescents and adults; in teens,
needle insertion may be required to achieve the desired
effect. Four to six treatment sessions may be needed to
accurately gauge a technique’s success. The effect of
acupressure/acupuncture tends to be additive, similar to
consistent use of a medication.
The incidence of adverse effects may be lower with acupressure/
acupuncture than with medications used to treat
the same symptoms. Needle insertion is avoided in patients
with a high risk of infection (e.g., compromised immune
function) or a risk of bleeding, as well as in younger patients
who fear needles or may not tolerate long needle retention
times. Contraindications to noninvasive techniques are rare.
Collaboration with Fellow Caregivers — Including Patients
At Cleveland Clinic Children’s, acupressure/acupuncture
is provided in a context of close multidisciplinary collaboration.
I begin by discussing the potential utility of
acupressure/acupuncture in alleviating symptoms and promoting
rehabilitative goals with the patient’s other pediatric
physicians and therapists. Following a traditional comprehensive
assessment of symptoms, patients and/or their
families undergo an assessment specific to acupressure/
acupuncture. It is essential to establish a trusting relationship
with the child before treatments are administered.
Opportunities for collaboration extend to the point that acupressure/
acupuncture can sometimes be incorporated into
a child’s regular therapy sessions. For instance, if a physical
therapist is working to loosen tight muscles, I might assist
with acupressure/acupuncture during the same session.
Following acupressure treatment, the technique and appropriate
pressure points can be taught to parents and patients
so they can deliver treatment at home. In these cases the
patient is reassessed periodically, at which time additional
or different pressure points may be incorporated. Flexibility
in applying the treatment as a child’s body develops is
an advantage of acupressure. An additional advantage is
the empowerment patients and parents often derive from
directly participating in their rehabilitative care through
acupressure treatment at home.
Dr. Katholi is a physiatrist in Cleveland Clinic Children’s
Department of Developmental and Rehabilitation Pediatrics.
His specialty interests include acupressure/acupuncture.
He can be reached at 216.448.6254 or firstname.lastname@example.org.