Abstract
Introduction. Despite its increasing use as a complementary therapy to treat pain, acupuncture is rarely considered by pediatricians, in part due to perceptions that it will not be acceptable to pediatric patients. We wished to describe pediatric pain patients' experience with acupuncture treatment for chronic pain.
Design. Retrospective case series.
Methods. Subjects were pediatric pain patients referred by the Pain Treatment Service at Children's Hospital in Boston, who went to a pediatric acupuncturist. A research assistant not involved in the patient's care conducted the survey by telephone. Data were analyzed qualitatively and descriptively.
Results. Of 50 eligible patients, 47 families were reached by telephone; all agreed to be interviewed. Patients had a median age of 16 years at the time of referral, 79% were female, and 96% were white. The most common three diagnoses were migraine headache (n = 7), endometriosis (n = 6), and reflex sympathetic dystrophy (n = 5). Patients had a median of 8 treatments (range: 0–60) within 3 months (range: 0–48 months); 85% of families paid out-of-pocket. Acupuncture therapies included needle insertion (98%), heat/moxa (85%), magnets (26%), and cupping (26%). Most patients and parents rated the therapy as pleasant (67% children/60% parents), and most (70% children/59% parents) felt the treatment had helped their symptoms; only 1 said that treatment made symptoms worse.
Conclusion. Pediatric patients with chronic, severe pain found acupuncture treatment pleasant and helpful. Additional, prospective studies are needed to quantify the costs and effectiveness of acupuncture treatment for pediatric pain.
Chronic childhood pain is a complex problem that often requires a multifaceted, multidisciplinary approach. Pediatric pain treatment services typically provide medications, psychological counseling, biofeedback, guided imagery and relaxation, physical therapy, massage and surgery. Despite this multifaceted approach, pain persists for some children.
Growing numbers of Americans are turning to complementary and alternative medical (CAM) therapies to treat chronic medical conditions.1 Acupuncture is one of the most popular of these therapies.2–4 There are approximately 11 000 licensed acupuncturists in the United States, and the number is expected to double within the next 10 years.5 Acupuncture is one of the CAM therapies most frequently recommended by internists and family physicians.6–10 Of the 43 pediatric Pain Treatment Services at North American children's hospitals, one third offer acupuncture services.11
A National Institutes of Health consensus conference concluded that acupuncture is effective in treating some types of nausea and pain in adults, such as dental pain, migraine headaches, back pain, and dysmenorrhea.12–24 Animal studies also support the use of acupuncture in treating pain.25 Fewer studies have focused on the effectiveness of acupuncture in treating pediatric pain.26
Reports of serious adverse effects from acupuncture are rare. Although there are case reports of acupuncture-associated fatal pneumothoraces,27 cardiac tamponade,28 and serious infections,29,,30 the reported incidence of serious side effects from acupuncture therapy when performed by a licensed acupuncturist are 1:10 000 to 1:100 000—about the same risk as a serious adverse event from taking penicillin.31–33
Despite its promise as a safe, effective adjunctive therapy in the treatment of childhood pain, pediatricians rarely think of acupuncture as a therapeutic option. This is due in part to the lack of training in and familiarity with acupuncture and a paucity of clinical trials of acupuncture in pediatric populations. But a larger factor seems to be the conventional wisdom that a) children are afraid of needles, b) acupuncture therapy involves needles, and c) kids and families won't accept another therapy (besides immunizations) that requires needles. These 3 elements are open to debate.
First, children and adolescents suffering from severe, chronic pain that has not been relieved through mainstream treatments, may be willing to undergo short-term discomfort to achieve long-term goals. Second, most persons who receive acupuncture remark on how much less painful it is than conventional needles, possibly because acupuncture needles are solid, very fine gauge needles.34 Third, acupuncturists can use a variety of nonneedle techniquesFNa to stimulate acupuncture points.35
Since 1995, the Boston Children's Hospital Pain Treatment Service has referred children and adolescents suffering from chronic pain unresponsive to mainstream treatments to a licensed acupuncturist in private practice (E.S.H.) who specializes in treating children.36 This licensed acupuncturist serves on the faculty of the New England School of Acupuncture and has developed a systematic approach to preparing pediatric patients for acupuncture therapy (Fig 1). The referred patients typically suffered from severe, chronic pain. Despite having been seen, evaluated and treated by their primary physicians and specialty physicians, these patients still had severe symptoms.
Preparation for pediatric acupuncture.
We wished to know how patients and families experienced acupuncture treatments and the extent to which they believed it helped or hurt their condition. We designed this study to assess qualitative questions about patients' and families' perceptions of acupuncture therapy to evaluate the feasibility of undertaking quantitative studies on acupuncture.
METHODS
This was a retrospective case series conducted by telephone interview. Subjects were eligible for inclusion if they were referred by the Pain Treatment Service at Children's Hospital, were <21 years old at the time of referral, and attended at least 1 visit with the acupuncturist. They were excluded if they could not be contacted by telephone (eg, moved and left no forwarding telephone or other contact information).
The study was primarily a qualitative interview. However, data collection also included demographic and diagnostic information extracted from the medical record. Pilot interviews were developed and tested among 4 parents and 3 adolescents who had received acupuncture therapy, but who were not eligible for the study. Based on this pilot information, the questions were modified for this study. The Appendix provides a list of survey questions.
The Director of the Pain Treatment Service sent a letter to all eligible patients and families informing them about the purpose of the study (to better understand and improve services). They were told that a research assistant would call to ask if they were willing to participate, that participation was voluntary and anonymous, and that their participation or nonparticipation in the project would not affect their ongoing medical care.
Families were called and a parent or guardian was asked if they would be willing to participate in the survey. In some cases, the parent suggested that we instead interview the patient who was an older adolescent or was over 21 by the time they were called. Some children did not want to come to the phone themselves, but told their parent what to say, such as “Tell them it didn't hurt.”
Quantitative data were entered into an Excel (Microsoft, Redmond, WA) spreadsheet and simple descriptive statistics were calculated.
RESULTS
Of 50 eligible families, 47 agreed to be interviewed. In some cases, the parent deferred to the child (eg, if the child was over 18 or living away from home); in other cases, the child preferred for the parent to be the only or primary respondent (eg, younger or shy children).
The sample was typical of patients seen at the Children's Hospital Pain Treatment Service—primarily female (79%), white (96%) teenagers (15 children were 12 years old or younger while 32 were 13–20 years old [Table 1]). They had a wide range of diagnoses; the most frequent were migraine headaches (n = 7), endometriosis (n = 6), and reflex sympathetic dystrophy (n = 5). Only 15% of patients reported insurance coverage for treatments.
Subject and Treatment Description
The median number of acupuncture treatments was 8. Most patients completed treatments within 3 months (Table 1). One child was referred, but refused all treatments; this was a developmentally delayed adolescent girl.
All but 1 patient was treated with regular acupuncture needles. A 5-year-old boy refused needles, but accepted nonneedle therapies, having a total of 6 treatments. Nearly half (45%) of patients also received intradermal (retained) needles.FNb The most common nonneedle methods of point stimulation were moxibustion or heat (85%), cupping (26%), and magnets (26%). Percentages add to >100% because many children received >1 type of point stimulation.
Parents' initial reactions to the recommendation for acupuncture therapy ranged from those who said that they themselves had suggested it, through “pleased,” “willing to try anything,” “open,” “skeptical,” to “afraid.” The most common response (10/42) was “pleased.”
Of the 30 patients, 20 (67%) reported that acupuncture had been a positive experience (Table 2). For example, a 17-year-old girl diagnosed with endometriosis, chronic fatigue syndrome, and headache said that “Acupuncture was not painful, and was very relaxing.” Most parents (60%) also felt that acupuncture was positive. For example, 1 father stated, “(My daughter's) visits to the acupuncturist were anticipated positively and she had a better attitude for studying, better appetite, and less pain afterward.”
What Was Acupuncture Like?
Perceptions of treatment tended to become more positive over the course of therapy. A 17-year-old boy said: “It was strange and weird, but then it became pleasant. I felt calm; it was better than taking all the meds.” An 18-year-old girl with reflex sympathetic dystrophy responded, “At first I was really scared, but then it wasn't so bad.” No children or parents felt more negatively about acupuncture over the course of treatment.
Of 30 patients, 70% felt that acupuncture had definitely helped their pain (Table 3). A 17-year-old girl with endometriosis said, “It definitely helped the pain. I recommend it to other people with endometriosis; it really works and is not painful, and it brought my energy back.” A 17-year-old boy replied, “Yes! It helped the pain. I'd tried a lot of treatments. This was the last resort, but the best. I wish I had tried it first. I had a lot of twitching because of nerve problems; after the acupuncture treatment, which eliminated the pain and twitching, it changed my life.” A few patients felt it had made no difference; a teenager with endometriosis stated, “ No, acupuncture did not help, but I'm open to having it again.”
Did the Treatment Help or Hurt?
Among the parents, 59% felt acupuncture had definitely improved the child's pain. The father of an adolescent with endometriosis said, “ It appears to have helped enormously. She has had an endometriosis situation for 4 years, had a bad flare-up last week (10 on a scale of 1 to 10), but saw the acupuncturist that day and had a miraculous recovery.” He noted that if pediatricians at Children's Hospital had not referred him, he would not have considered acupuncture for his daughter. The mother of the 17-year-old boy remarked, “Yes, it helped that [the pain] and also with relaxation. He had head-thrashing, violent twitching of his head, but all that's left is a twitch in his eye. If anybody ever wanted to speak to me, I would love to because it was such a good, positive experience.” Some parents felt that acupuncture had made the child neither worse nor better. The mother of a 17-year-old boy with chronic back pain and migraine headaches said: “It took the edge off, but he was never pain-free.”
Twelve families mentioned things they did not like about the acupuncture treatments. These included a) initial fear of needles, b) dislike of the smell of moxa burning in the office, c) time for commuting and treatment, and d) presence of trainees in the office. Only 1 parent reported that her child's pain seemed worse after the treatment.
Four parents spontaneously reported that they were glad to see doctors at Children's Hospital recommending alternative therapies. Two others mentioned that they wished acupuncture had been started sooner. The mother of a child whose symptoms had not been helped by acupuncture said, “I'm very grateful for the acupuncture. It had great value for me, let me feel like I was doing something, like I was a good mom.”
DISCUSSION
Acupuncture is one of the most popular therapies in the field of complementary medicine. However, this is the first study to examine childrens' and families' subjective experiences with acupuncture therapy. Our primary purpose was not to evaluate the effectiveness of acupuncture in treating specific types of pain, but to assess patients' qualitative experience.
The patients in this study were typical of those seen by the Children's Hospital Pain Treatment Service in terms of age, gender, race, and diagnoses. They typically received 8 treatments within 3 months; the vast majority (85%) paid out-of-pocket for acupuncture services. Most families found acupuncture pleasant and helpful, even for pain that had been very resistant to standard treatment. Although some began with anxiety about the needles and misgivings about the treatment, many developed more positive attitudes over the course of treatment.
This study has several limitations and potential biases. It was limited to highly motivated patients who were referred by specialist physicians in a pain treatment service at a children's hospital. Its results are not necessarily generalizable to patients with less severe conditions who are self-referred or who are referred by their primary care physician. Nor can it be generalized to general pediatric patients. Most of the patients in this study were adolescents; younger childrens' experiences might be quite different.
This study provides no information on acupuncture therapy for other pediatric conditions. In the United States, acupuncture is increasingly being used to treat a variety of conditions—from postextubation laryngospasm, to asthma and allergies, to abdominal complaints.37–43 Future studies will need to examine childrens' and families' experience with acupuncture for the entire spectrum of illnesses for which it is used.
All of the children in this study were treated by 1 pediatric acupuncturist who may not be representative of all acupuncturists. Because most acupuncturists rarely treat children, it is possible that patients treated in other settings may have different experiences.36
The survey was also limited to patients who actually went to see the acupuncturist. In this retrospective series we were unable to determine the full denominator of referrals. Thus, our data may overestimate families' acceptance of and positive experience with acupuncture. This bias might be enhanced by the fact that the interviewers identified themselves as affiliated with Children's Hospital, which might have led some families to respond more favorably about their experience.
Because of the chance that those who respond to retrospective surveys may differ from those who do not respond, we made every effort to reach all patients who had been treated by the acupuncturist. Of the 50 families who were eligible for this study, only 3 could not be reached. The remainder were assured that their answers would be kept confidential and would be used to help improve clinical services; they were encouraged to be honest, even if they didn't like something or felt it had not been helpful. Several parents spontaneously mentioned other things at Children's Hospital that could have been improved (eg, waiting times and delays in returning phone calls). Although 47 families agreed to be interviewed, only 30 patients responded directly; it is possible that nonrespondents had more negative attitudes about acupuncture.
This study focused on experiential aspects of treatment as opposed to objective efficacy. We did not specifically evaluate physiologic changes, medication requirements, or frequency of hospitalizations. Future studies may wish to use independent measures to verify symptomatic improvements. On the other hand, the extent of symptomatic improvements reported by families in this study highlights the necessity of physicians knowing all the different treatments used by patients. Without knowing which treatments a child is receiving, symptomatic improvements might mistakenly be attributed to other treatments that are potentially more costly or toxic.
Footnotes
- Received July 2, 1999.
- Accepted December 21, 1999.
Reprint requests to (K.J.K.) Center for Holistic Pediatric Education and Research, Children's Hospital, 333 Longwood Ave, Boston, MA 02115. E-mail: kemper_k{at}a1.tch.harvard.edu
↵‡ Program Evaluator, Children's Hospital, Boston, Massachusetts.
↵FNa Nonneedle techniques include heat (moxibustion), massage (shiatsu), rubbing (shoni shin), scraping (gua sha), tapping, magnets, lasers, and cupping.
↵FNb Intradermal needles are 3 mm long; they are inserted very shallowly nearly parallel to the skin surface rather than perpendicular to it. They are taped in and remain in place for up to 3 days. Very careful follow-up instructions are given with this form of treatment.
- CAM =
- complementary and alternative medicine
REFERENCES
- Copyright © 2000 American Academy of Pediatrics
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