Complimentary and Alternative Medicine Uses in Pain for Bleeding Disorders - Part 1
By: Angela Lambing, MSN, ANP, GNP
Published: Lifelines for Health Summer 2020
Persons with bleeding disorders (PWBD) can suffer from many painful experiences, whether it is the result of the needle stick for factor administration or suffering bleeding episodes into a joint or muscle. Additionally, PWBD can suffer traumatic injuries such as sprains or fractures, where pain can result. Given the current climate of the Nation’s Opioid crisis, the ability to receive pain medications via conventional means is becoming increasingly difficult as providers face concerns over censure of prescribing practices, worries of addiction and/or diversion of the medications prescribed to patients, and the potential for patient overdose. As a result, it can be difficult to obtain pain medication when needed. Additionally, it has been well documented that non-steroidal anti-inflammatory pain medications (NSAIDs) can be very helpful for management of pain but are contraindicated in PWBD due to the increased potential for further bleeding as defined by MASAC2.
The United States’ National Center for Complementary and Integrative Health (NCCIH) defines:
Complementary medicine as a “non-mainstream practice” which can be used together with conventional medicine2.
Alternative medicine as “non-mainstream practice” used in place of conventional medicine.
Complimentary and Alternative Medicine (CAM) is further defined by complementary, alternative, and integrative approaches. These approaches are broad-based to health and well-being focusing on treating the whole person including emotions, mental health, social, spiritual, and community.
There are four distinct domains within CAM including::
1. Mind-body therapies
2. Manipulative and body-based therapies
3. Natural products
4. Energy therapies
People are now looking at CAM therapy as a potential option to manage pain. Currently, there is limited research in this area with respect to PWBD. This is the first of a 4-part series that will explore the use of CAM with PWBD, reviewing current research studies that explore each of the CAM domains. This article will review the current research available for PWBD within the Mind-body domain of CAM. Below are the different therapies that are considered under the Mind-body domain.
Tai chi
Tai chi has evolved into a graceful form of exercise used for stress reduction and other health conditions. Often described as meditation in motion, tai chi promotes serenity through gentle, flowing movements which allow controlled muscle stretching3. A study was conducted in 2012 with a team of Chinese researchers looking at how Tai Chi might help PWBD’s arthritis symptoms. Results indicated pain, fatigue, and depression decreased while mobility, muscle strength, and quality of life improved with Tai Chi practice.
Yoga
Yoga involves the practice of specific physical postures, breathing techniques, and sometimes meditation derived from Yoga but often practiced independently to promote physical and emotional well-being5. Behishtipoor and team in 2005 evaluated the effects of yoga on quality of life in children with hemophilia. His findings identified improvement in quality of life, decrease in bleeding episodes and number of school absences, citing that yoga improved the physical psychological, and social aspects of individuals6.
Relaxation
Relaxation exercises and guided imagery has been well documented to assist persons with pain management in a variety of medical conditions. In 1985, a study evaluated relaxation related to frequency of bleeding in hemophilia7. Although they were not able to prove a decrease in bleeding frequency, relaxation exercises were helpful in the management of pain.
Hypnosis & The Magic Glove®
Hypnosis involves progressive relaxation by a trained therapist that allows suggestive behaviors to improve the management of pain and other disorders. Several older references were identified where hypnosis was used in hemophilia in case reports, many where the therapy was used during dental procedures8, 9, 10,11. In each case, the level of distress was reduced as was the amount of factor usage to control bleeding. The Magic Glove® is a hypnotic technique used in children’s centers12. Through focused attention, the child’s imagination changes the sensations, creating decreased sensation or numbness in the area with the “Magic Glove” in place boosting a child’s confidence and comfort in the ability to cope with painful and
fearful procedures. There are currently no research studies using this technique in PWBD, although many pediatric hemophilia centers report using this technique successfully.
Psychotherapy
Psychotherapy, or talk therapy, is a way to help people with a broad variety of mental illnesses and emotional difficulties. Psychotherapy can help eliminate or control troubling symptoms so a person can function better and can increase well-being and healing. Problems helped by psychotherapy include difficulties in coping with daily life; the impact of trauma, medical illness or loss, like the death of a loved one; and specific mental disorders, like depression or anxiety13. In all cases identified within PWBD research, psychotherapy was found to be helpful14,15.
Biofeedback
Biofeedback is a mind-body technique that involves using visual or auditory feedback to gain control over involuntary bodily functions including the relaxation of certain muscles, slowing heart rate or respiration, or reducing feelings of pain16. This method has documented positive results17,18,19although studies were very old.
Cognitive Reframing
Cognitive reframing is a technique used in therapy to help create a different way of looking at a situation. Therapists often use this technique to help clients look at situations from a different perspective20. This therapy helps people in pain, to view their pain experience in a different way thus allowing them to improve coping of the pain experience. Elander (2013) studied this technique for males with hemophilia helping them to reduce pain intensity, improve quality of live, reduction of negative thoughts, and active pain coping21.
Distraction & The Buzzy Bee®
Distraction as a method of pain management is often used especially in young children. This can be something as easy as watching a movie, playing a video game, or talking with others. Many studies have demonstrated positive results in reducing pain during the distraction period22,23,24,25,26. Dr. Dunn and her team from Nationwide Childrens’ Hospital in Columbus Ohio recently studied the use of virtual reality (VR) during IV insertion with children. This method was found to be a positive distraction technique and the desire to VR for future procedures was positive for patients, nurses, and parents27. This method has also been used in a variety of painful procedures including painful burn procedures in soldiers. The Buzzy Bee® is also a method of distraction using a cold sensation and vibration device to distract children during needle sticks. There are no research studies using this method, although many pediatric hemophilia centers verbalize positive results when in practice.
Neuroplasticity
Neuroplasticity is a relatively new process in the community defined as; the ability of the brain to form and reorganize synaptic connections, especially in response to learning or experience or following injury28. Given the newness of this method, there is currently no research in PWBD.
The mind-body connection is a powerful relationship. By harnessing the brain and how we view painful experiences can help in improved coping of painful experiences. In many of these methods, the risk of use in PWBD is very low, and should be part of the discussion with the treatment center as additional measures to trial to assist with pain management.
In our next section, manipulative and body-based therapies will be reviewed.
References
MASAC guidelines for NSAID use; available from: https:// www.hemophilia.org/Researchers-Healthcare-Providers/ Medical-and-Scientific-Advisory-Council-MASAC/MASAC- Recommendations/MASAC-Recommendations-on-Use-of- COX-2-Inhibitors-in-Persons-with-Bleeding-Disorders.
National Center for Complementary ad Integrative Health. Complementary, alternative or integrative health: What's in a name? July 2018. Available from: https://nccih.nih.gov/health/ integrative-health.
What is Tai Chiu; available from: https://www.mayoclinic.org/ healthy-lifestyle/stress-management/in-depth/tai-chi/art- 20045184
Bak, Won-Sook, Yoo, Myung-Chul, Kang, Hyun-Sook. The Effect of Tai Chi Self Help GroupI Program for Hemophilic Arthritis Patients. Journal Muscle Joint Health. Vol.19 No.1, 71-83, April, 2012.
Definition of yoga. Available from: https://www.merriam- webster.com/dictionary/yoga.
Behistipoor N et, al. The effect of yoga on quality of life in the children and adolescents with haemophilia. International journal of Community based nursing Midwifery. 2015. 3(2): 150-55.
Lichstein KL, Eakin Tl. Progressive versus self-controlled relaxation to reduce spontaneous bleeding in hemophiliacs. Journal of Behavioral Medicine. 1975. 8(2): 149-62.
Swirsky-Sacchetti T & Margolis CG. The effects of comprehensive self-hypnosis training program on the use of factor VIII in severe hemophilia. Interational Journal of Clinical Exp Hypnosis. 1986, 34(2); 71-83.
Newman M. Hypnotic handling of the chronic bleeder in extraction: A case report. American Journal of Clinical Hypnosis. 1971. 14(2); 126-7.
LaBaw W. The use of hypnosis with hemophilia. Psychiatric Medicine. 1992. 10(4); 89-98.
Federicks LE. The use of hypnosis in hemophilia. American Journal of Clinical Hypnosis. 1967. 10(1).
What is Psychotherapy. Available from: https://www. psychiatry.org/patients-families/psychotherapy.
Magic Glove: Available from: http://pediatric-pain.ca/wp- content/uploads/2013/04/The_Magic_Glove12.pdf.
Caldwell HS, Leveque KL, Lane DM. Group psychotherapy in the management of hemophilia. Psychological Reports. 1974. Aug;35(1):339-42.
Mattsson A, & Agle DP. Group therapy with parents of hemophiliacs: Therapeutic process and observations of parental adaptation to chronic illness in children. Journal of the American Academy of Child Psychiatry. (1972). 11(3), 558–571.
16. Cherry K. What is Biofeedback. Available from: https://www. verywellmind.com/what-is-biofeedback-2794875.
17. Varni JW. Behavioral medicine in hemophilia arthritic pain management: Two case studies. Archives Physical Medicine Rehabilitation. 1981. 62(4): 183-7.
18. Lemanek KL, Ranalli MA, Green K, Biega C, & Lupia C. Diseases of the Blood: Sickle Cell Disease and Hemophilia. Handbook of Pediatric Psychology. (2003). p. 321–341. The Guilford Press.
19. Walco GA & Varni JW. Chronic and Recurrent Pain: Hemophilia, Juvenile Arthritis, & Sickle Cell Disease. 1991. Children in Pain. 297-335.
20. Morin A. Using cognitive reframing for mental health. Available from: https://www.verywellmind.com/reframing- defined-2610419.
21. Elander B, Morris J, Robinson G. Pain coping and acceptance as longitudinal predictors of health-related quality of life among people with haemophilia-related joint pain. European Journal of Pain. 2013. 17(6); 929-38.
22. Elander J, et al. An assessment of the relative influence of pain in coping, negative thoughts about pain, and pain acceptance on health-related quality of life among people with hemophilia. 2009. Pain. 145; 169-75.
23. Elander J ety al. Randomized trial of a DVD intervention to improve readiness to self=manage joint pain. 2011. Pain. 152; 2333-41.
24. Santavirta N. et al. Coping strategies, pain, and disability in patients with hemophilia and related disorders. 2001. Arthritis Rheumatology. 45(1); 48-55.
25. Varni JW. Self-regulation techniques in the management of chronic arthritic pain in hemophilia. 1981. Behavioral Therapy.
26. Dunn A, et al. A feasibility and usability study of a nursing orchestrated, customized 3-dimentional virtual reality environment in children with hemophilia undergoing routine intravenous procedures. 2017. Blood. 130;3691.
27. Buzzy Bee; Available from: https://buzzyhelps.com/.
28. Definition of neuroplasticy; Available from: https://www.google.com/search?rlz=1CAIUCU_enCA882&sxsrf=ALeKk00 nfhh2IoNGhIpUDQvmp3s9wVbV7g%3A1582233639869&ei =J_hOXrO7NIT3-gSax7rQBg&q=neuroplasticity+definition&oq =neuroplasticity&gs_l=psy-ab.1.1.0i273l2j0l8.1020223.1023448. .1024866...1.2..1.356.3898.0j6j8j3......0....1..gws-wiz.....10..0i71j0i6 7i70i249j0i67j0i131j35i362i39j35i39j0i131i67j0i273i70i249j0i20i 263j0i10.W21tlwsvkVw.
Angela Lambing has been a nurse for 40 years; 30 years as a nurse practitioner certified in adult primary care and geriatrics. She spent 15 years as the Henry Ford Hospital HTC nurse, responsible for
all aspects of bleeding and thrombotic disorders. She is an expert in pain management in the bleeding
disorders community, having completed many research projects in this area. She is widely published
and has given talks on a variety of topics, locally, nationally, and internationally. Her last 5 years was
spent as a clinical expert and educator for Bayer Health Care. She is now retired, but still focusing her
energies and knowledge in the area of bleeding disorders. In the past few years, she has been one of
many national experts on pain participating on the MASAC pain task force where she continues to provide support in this area.