Children’s Physicians Medical GroupChildren’s Physicians Medical Group New Applications and Technology New Applications and Technology

Committee Quarterly MeetingCommittee Quarterly MeetingJuly 27, 2005July 27, 2005

Pediatric Functional Abdominal Pain

Biofeedback as a covered benefit based on scientific evidence

and medical necessity

Epidemiology of Functional Epidemiology of Functional Abdominal Pain Abdominal Pain [Recurrent Abdominal Pain [Recurrent Abdominal Pain (RAP) and Irritable Bowel Syndrome (IBS)](RAP) and Irritable Bowel Syndrome (IBS)]

The most Common GI disorders in Primary The most Common GI disorders in Primary CareCare

11%-20% 0f US population11%-20% 0f US population (Drossman,1993, (Drossman,1993, Talley et al., 1992)Talley et al., 1992)

25% seek care25% seek care 12%-19.5% of Primary Care12%-19.5% of Primary Care visitsvisits (Longstreth (Longstreth

& Wolde-Tsadik,1993)& Wolde-Tsadik,1993) $8 Billion annually in direct medical costs$8 Billion annually in direct medical costs

($742 vs $429 Annual costs, Gralnek, 1998)($742 vs $429 Annual costs, Gralnek, 1998) $25 Billion annually in indirect costs$25 Billion annually in indirect costs

Functional Abdominal Pain Functional Abdominal Pain in the Pediatric Populationin the Pediatric Population

Most common childhood G.I. DisorderMost common childhood G.I. Disorder

Affects up to 34% of world’s children and Affects up to 34% of world’s children and adolescentsadolescents..

More than 1/3 of these children/ More than 1/3 of these children/ adolescents complain of pain lasting 2 adolescents complain of pain lasting 2 weeks or longer.weeks or longer.

Differential DiagnosisDifferential Diagnosis

Less than 10% of abdominal pain Less than 10% of abdominal pain cases have an organic etiologycases have an organic etiology

Nearly all children with these Nearly all children with these complaints are subjected to complaints are subjected to invasive and expensive testing.invasive and expensive testing.

All DXAll DX ABD PAIN DX1ABD PAIN DX1 ABD PAIN ABD PAIN DX2DX2

ABD PAIN ABD PAIN DX3DX3

PATIENTSPATIENTS 1,8131,813 392392 5959 1818

%% 23%23% 3%3% 1%1%

Gastroenterology New Patients (Outpatient only) in one year: 8-1-03 through 8-31-04

Children’s Hospital Physician Management Group, Inc.

How does Biofeedback treat How does Biofeedback treat Functional Abdominal Pain?Functional Abdominal Pain?

Autonomic nervous system (ANS) Autonomic nervous system (ANS) imbalance exacerbates abdominal imbalance exacerbates abdominal dysfunction. dysfunction.

ANS feedback (i.e. heart rate, ANS feedback (i.e. heart rate, respiration, skin conductance) respiration, skin conductance) educates patients about effects of educates patients about effects of stress on their symptoms.stress on their symptoms.

What is Biofeedback?What is Biofeedback?

Electronic biofeedback instruments Electronic biofeedback instruments connected to sensors on the bodyconnected to sensors on the body

Real-time physiological information Real-time physiological information (feedback) is displayed to patient on computer (feedback) is displayed to patient on computer monitor using audio and video signalsmonitor using audio and video signals

A certified biofeedback professional provides A certified biofeedback professional provides instruction and interpretation instruction and interpretation

Respiration

Heart Rate

How does Biofeedback treat How does Biofeedback treat Functional Abdominal Pain?Functional Abdominal Pain?

Instruct patient that the problem is Instruct patient that the problem is neither purely biological nor neither purely biological nor psychological but psychological but psychophysiologicalpsychophysiological

The therapist guides the patient through The therapist guides the patient through techniques to balance ANS. techniques to balance ANS.

Home practice assignments reinforce Home practice assignments reinforce techniques for better resultstechniques for better results

Why Biofeedback Why Biofeedback Treatment?Treatment?

Painless/Non-invasive techniquesPainless/Non-invasive techniques

Research shows biofeedback is a Research shows biofeedback is a successful treatment for functional successful treatment for functional abdominal conditionsabdominal conditions

Engaging and fun treatment modality Engaging and fun treatment modality for childrenfor children

Medical Journal Articles Medical Journal Articles

Weydert, JA, Ball, TM, & Davis, MF (2003) Weydert, JA, Ball, TM, & Davis, MF (2003) Pediatrics,111Pediatrics,111

Bassotti, G. & Whitehead, WE (1994). Bassotti, G. & Whitehead, WE (1994). The The American Journal of Gastroenterology, 89, American Journal of Gastroenterology, 89, 158-158-164164

Mertz, H.(2003).Mertz, H.(2003).The New England Journal of The New England Journal of Medicine Medicine 349;22349;22

Humphreys, P. and Gevirtz, R. (2000) Humphreys, P. and Gevirtz, R. (2000) Journal of Journal of Pediatric Gastroenterology and Nutrition, 31:47-Pediatric Gastroenterology and Nutrition, 31:47-5151

Other ResearchOther Research Banez, G. and Bigham, E (2003). Recurrent abdominal pain in Banez, G. and Bigham, E (2003). Recurrent abdominal pain in

children and adolescents. children and adolescents. BiofeedbackBiofeedback 31:23-25. 31:23-25.

Blanchard, E. et al. (1993). Relaxation training as a treatment Blanchard, E. et al. (1993). Relaxation training as a treatment for irritable bowel syndrome. for irritable bowel syndrome. Biofeedback and Self RegulationBiofeedback and Self Regulation 18:125-32.18:125-32.

Blanchard, E., Schwarz, S., Neff, D (1988). Two-year follow-up Blanchard, E., Schwarz, S., Neff, D (1988). Two-year follow-up of behavioral treatment of irritable bowel syndrome. of behavioral treatment of irritable bowel syndrome. Behavioral TherapyBehavioral Therapy 19:67-73. 19:67-73.

Lynch, P. and Zamble, E. (1989). A controlled behavioral Lynch, P. and Zamble, E. (1989). A controlled behavioral treatment study of irritable bowel syndrome. treatment study of irritable bowel syndrome. Behavioral Behavioral TherapyTherapy 20: 509-23. 20: 509-23.

Toner, M. (1998). Irritable bowel syndrome. Toner, M. (1998). Irritable bowel syndrome. International International Journal of Group PsychotherapyJournal of Group Psychotherapy 48: 215-242. 48: 215-242.

Bassotti, G. & Whitehead, WE (1994). Biofeedback as a Bassotti, G. & Whitehead, WE (1994). Biofeedback as a treatment approach to gastro intestinal tract disorders. treatment approach to gastro intestinal tract disorders. The American Journal of Gastroenterology, 89, The American Journal of Gastroenterology, 89, 158-164158-164

Methods: The article reviews which Methods: The article reviews which applications of biofeedback techniques applications of biofeedback techniques have had the most success in various GI have had the most success in various GI disorders.disorders.

Relevant conclusions: Approaches using Relevant conclusions: Approaches using biofeedback have resulted in biofeedback have resulted in improvement of symptom severity of 50-improvement of symptom severity of 50-60% in patients with IBS.60% in patients with IBS.

Mertz, H.(2003).Mertz, H.(2003).The New England The New England Journal of Medicine Journal of Medicine 349;22349;22

““Given the psychosocial factors Given the psychosocial factors involved and the limited benefits of involved and the limited benefits of current pharmacologic therapies, current pharmacologic therapies,

the treatment of irritable bowel the treatment of irritable bowel syndrome requires physicians to syndrome requires physicians to attend to the minds as well as the attend to the minds as well as the bodies of their patients in order to help bodies of their patients in order to help them find relief.”them find relief.”

Weydert, JA, Ball, TM, & Davis, MF (2003) Weydert, JA, Ball, TM, & Davis, MF (2003) Systematic review of treatments for Systematic review of treatments for recurrent abdominal pain, recurrent abdominal pain, Pediatrics,111Pediatrics,111

Methods: Methods: – review of articles that met criteria: children review of articles that met criteria: children

between 5-10 y/o, dx, random assignment.between 5-10 y/o, dx, random assignment.

Conclusions: Conclusions: – There is evidence for efficacy of treatments such There is evidence for efficacy of treatments such

as Biofeedback, Cognitive-Behavioral Therapy, as Biofeedback, Cognitive-Behavioral Therapy, and a number of other behavioral interventions. and a number of other behavioral interventions.

– Less conclusive finding for fiber and no Less conclusive finding for fiber and no improvement with lactose-free diets. improvement with lactose-free diets.

Humphreys, P. and Gevirtz, R. (2000) Humphreys, P. and Gevirtz, R. (2000) Treatment of Recurrent Abdominal Treatment of Recurrent Abdominal Pain: Components Analysis of Four Pain: Components Analysis of Four Treatment ProtocolsTreatment Protocols

Journal of Pediatric Gastroenterology Journal of Pediatric Gastroenterology and Nutrition, 31:47-51and Nutrition, 31:47-51

Figure 1. Visual Analog scale from daily pain diary records, Figure 1. Visual Analog scale from daily pain diary records, pre & post treatment, by group (Humphreys, Gevirtz, & Jacobs, 1999)pre & post treatment, by group (Humphreys, Gevirtz, & Jacobs, 1999)Pre = Pre-treatmentPre = Pre-treatmentPost = Post-treatmentPost = Post-treatment4 component = fiber+biofeedback+cognitive restructuring+parental support4 component = fiber+biofeedback+cognitive restructuring+parental support3 component = fiber+biofeedback+cognitive restructuring3 component = fiber+biofeedback+cognitive restructuring2 component = fiber+biofeedback2 component = fiber+biofeedback

0

1

2

3

4

5

6

7

VAS

Pre Post

Fiber Only2 Component3 Component4 Component

Example of Currently Running Example of Currently Running Biofeedback ProgramBiofeedback Program

Kaiser Permanente Kaiser Permanente Pediatric Gastroenterology Biofeedback ProgramPediatric Gastroenterology Biofeedback Program

Program has been in continuous Program has been in continuous service for past 4 yearsservice for past 4 years

Biofeedback sessions held in GI clinicBiofeedback sessions held in GI clinic

Example of Currently Running Example of Currently Running Biofeedback Program:Biofeedback Program:Cost ConsiderationsCost Considerations

Billing through Kaiser Permanente InsuranceBilling through Kaiser Permanente Insurance

Average number of sessions per patient= 6Average number of sessions per patient= 6

Program Director: Warren L. Shapiro, M.D.Program Director: Warren L. Shapiro, M.D.Staff: AIU/CSPP doctoral psychology interns Staff: AIU/CSPP doctoral psychology interns AIU/CSPP supervisor: Richard Gevirtz, Ph.D.AIU/CSPP supervisor: Richard Gevirtz, Ph.D.

Alliant International University Case Alliant International University Case Study (Sowder et al., 2004)Study (Sowder et al., 2004)Conducted at Kaiser Permanente Pediatric Conducted at Kaiser Permanente Pediatric Gastroenterology Biofeedback ProgramGastroenterology Biofeedback Program

36 kids with RAP/IBS36 kids with RAP/IBS Significantly lowered ratings of pain Significantly lowered ratings of pain

intensity and frequency post-treatmentintensity and frequency post-treatment– Pain intensity:Pain intensity:

tt(8)(8) =4.494, p<.001**, ω =4.494, p<.001**, ω22= 0.49= 0.49

– Symptom frequency Symptom frequency tt(14)(14)=4.498, p=.002*, , ω=4.498, p=.002*, , ω22=0.38=0.38

56% pain-free at follow up (3mo, to 2yrs)56% pain-free at follow up (3mo, to 2yrs)

Pre and Post Pain Intensity and Pre and Post Pain Intensity and Frequency (Means)Frequency (Means)

Me

an

10

8

6

4

2

0

DiscussionDiscussion

Patients with RAP were able to significantly lower Patients with RAP were able to significantly lower their ratings of pain intensity and frequency within their ratings of pain intensity and frequency within an average of six sessions of Biofeedback an average of six sessions of Biofeedback administered by interns in a pediatric medical administered by interns in a pediatric medical setting. setting.

This study attests to a This study attests to a non-invasive and timelynon-invasive and timely treatment option.treatment option.

There is a significant potential to reduce costs and There is a significant potential to reduce costs and further distress (by avoiding unnecessary and further distress (by avoiding unnecessary and uncomfortable GI testing) with the integration of uncomfortable GI testing) with the integration of Biofeedback in Pediatric GI clinics.Biofeedback in Pediatric GI clinics.