Fig. 1. J&J Screen showing HR, Resp,temp, Skin Cond, and a spectral analysis. Peak valley differences are about 16
Cpmg naatc meeting presentation
Pediatric Functional Abdominal PainBiofeedback as a covered benefitbased on scientific evidence and medical necessityChildren’s Physicians Medical Group New Applications and Technology Committee Quarterly Meeting July 27, 2005
Epidemiology of FunctionalAbdominal Pain [Recurrent Abdominal Pain(RAP) and Irritable Bowel Syndrome (IBS)] The most Common GI disorders in Primary Care 11%-20% 0f US population (Drossman,1993, Talley et al., 1992) 25% seek care 12%-19.5% of Primary Care visits (Longstreth & Wolde-Tsadik,1993) $8 Billion annually in direct medical costs ($742 vs $429 Annual costs, Gralnek, 1998) $25 Billion annually in indirect costs
Functional Abdominal Painin the Pediatric Population Most common childhood G.I. Disorder Affects up to 34% of world’s children and adolescents. More than 1/3 of these children/ adolescents complain of pain lasting 2 weeks or longer.
Differential Diagnosis Less than 10% of abdominal pain cases have an organic etiology Nearly all children with these complaints are subjected to invasive and expensive testing.
Children’s HospitalPhysician Management Group, Inc.Gastroenterology New Patients (Outpatient only)in one year: 8-1-03 through 8-31-04 All DX ABD PAIN DX1 ABD PAIN ABD PAIN DX2 DX3 PATIENTS 1,813 392 59 18 % 23% 3% 1%
How does Biofeedback treatFunctional Abdominal Pain? Autonomic nervous system (ANS) imbalance exacerbates abdominal dysfunction. ANS feedback (i.e. heart rate, respiration, skin conductance) educates patients about effects of stress on their symptoms.
What is Biofeedback? Electronic biofeedback instruments connected to sensors on the body Real-time physiological information (feedback) is displayed to patient on computer monitor using audio and video signals A certified biofeedback professional provides instruction and interpretation
How does Biofeedback treatFunctional Abdominal Pain? Instruct patient that the problem is neither purely biological nor psychological but psychophysiological The therapist guides the patient through techniques to balance ANS. Home practice assignments reinforce techniques for better results
Why Biofeedback Treatment? Painless/Non-invasive techniques Research shows biofeedback is a successful treatment for functional abdominal conditions Engaging and fun treatment modality for children
Medical Journal Articles Weydert, JA, Ball, TM, & Davis, MF (2003) Pediatrics,111 Bassotti, G. & Whitehead, WE (1994). The American Journal of Gastroenterology, 89, 158-164 Mertz, H.(2003).The New England Journal of Medicine 349;22 Humphreys, P. and Gevirtz, R. (2000) Journal of Pediatric Gastroenterology and Nutrition, 31:47-51
Other Research Banez, G. and Bigham, E (2003). Recurrent abdominal pain in children and adolescents. Biofeedback 31:23-25. Blanchard, E. et al. (1993). Relaxation training as a treatment for irritable bowel syndrome. Biofeedback and Self Regulation 18:125-32. Blanchard, E., Schwarz, S., Neff, D (1988). Two-year follow-up of behavioral treatment of irritable bowel syndrome. Behavioral Therapy 19:67-73. Lynch, P. and Zamble, E. (1989). A controlled behavioral treatment study of irritable bowel syndrome. Behavioral Therapy 20: 509-23. Toner, M. (1998). Irritable bowel syndrome. International Journal of Group Psychotherapy 48: 215-242.
Bassotti, G. & Whitehead, WE (1994). Biofeedback as atreatment approach to gastro intestinal tract disorders.The American Journal of Gastroenterology, 89, 158-164 Methods: The article reviews which applications of biofeedback techniques have had the most success in various GI disorders. Relevant conclusions: Approaches using biofeedback have resulted in improvement of symptom severity of 50-60% in patients with IBS.
Mertz, H.(2003).The New EnglandJournal of Medicine 349;22 “Given the psychosocial factors involved and the limited benefits of current pharmacologic therapies, the treatment of irritable bowel syndrome requires physicians to attend to the minds as well as the bodies of their patients in order to help them find relief.”
Weydert, JA, Ball, TM, & Davis, MF (2003) Systematic review of treatments for recurrent abdominal pain, Pediatrics,111 Methods: – review of articles that met criteria: children between 5-10 y/o, dx, random assignment. Conclusions: – There is evidence for efficacy of treatments such as Biofeedback, Cognitive-Behavioral Therapy, and a number of other behavioral interventions. – Less conclusive finding for fiber and no improvement with lactose-free diets.
Humphreys, P. and Gevirtz, R. (2000)Treatment of Recurrent AbdominalPain: Components Analysis of FourTreatment ProtocolsJournal of Pediatric Gastroenterologyand Nutrition, 31:47-51
Figure 1. Visual Analog scale from daily pain diary records, pre & post treatment, by group (Humphreys, Gevirtz, & Jacobs, 1999) Pre = Pre-treatment Post = Post-treatment 4 component = fiber+biofeedback+cognitive restructuring+parental support 3 component = fiber+biofeedback+cognitive restructuring 2 component = fiber+biofeedback 7 6 5 4 Fiber OnlyVAS 2 Component 3 3 Component 4 Component 2 1 0 Pre Post
Example of Currently Running Biofeedback Program Kaiser Permanente Pediatric Gastroenterology Biofeedback Program Program has been in continuous service for past 4 years Biofeedback sessions held in GI clinic
Example of Currently RunningBiofeedback Program:Cost Considerations Billing through Kaiser Permanente Insurance Average number of sessions per patient= 6 Program Director: Warren L. Shapiro, M.D. Staff: AIU/CSPP doctoral psychology interns AIU/CSPP supervisor: Richard Gevirtz, Ph.D.
Alliant International University CaseStudy (Sowder et al., 2004)Conducted at Kaiser Permanente PediatricGastroenterology Biofeedback Program 36 kids with RAP/IBS Significantly lowered ratings of pain intensity and frequency post-treatment – Pain intensity: t(8) =4.494, p<.001**, ω2= 0.49 – Symptom frequency t(14)=4.498, p=.002*, , ω2=0.38 56% pain-free at follow up (3mo, to 2yrs)
C N E U Q E FRPre and Post Pain Intensity and IN A P T S Y O C P N E U Q E R F IN A P E R Y P IT S N TEFrequency (Means) IN IN A P T S O P Y IT S N E T IN IN A P E R P 10 8 6 4 2 0 Mean
Discussion Patients with RAP were able to significantly lower their ratings of pain intensity and frequency within an average of six sessions of Biofeedback administered by interns in a pediatric medical setting. This study attests to a non-invasive and timely treatment option. There is a significant potential to reduce costs and further distress (by avoiding unnecessary and uncomfortable GI testing) with the integration of Biofeedback in Pediatric GI clinics.