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.
Future Directions
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 leej4@ccf.org.
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 gorodee@ccf.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 walterk5@ccf.org.
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 remains extreme.
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” of sorts.
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 evidence-based interventions
- 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 by evidence.
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 mazaned@ccf.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 stephei2@ccf.org.
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 needs.
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 older adults)
- 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 plowm@ccf.org.
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 frostf@ccf.org.
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 at Diane.Jette@uvm.edu.
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 outcomes data.
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 equipment needed.
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
- Balance
- Upper extremity function
- Processing speed (a cognitive test)
- Low-contrast visual acuity
Validation Underway
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.
Future Developments
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 their disease.
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 bethouf@ccf.org.
The validation study of the MSPT was funded by Novartis Pharmaceuticals Corp.
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 end-of-life care.
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 strength
- Flexibility
- Body image
- Bone density
- Symptoms of fatigue, dyspnea, pain, anxiety and depression
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 battus@ccf.org.
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 in children.
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 rehabilitative goals.
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 points
- 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
Mechanisms Uncertain
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 katholb@ccf.org.