28 February 2006

A non-drug bibliography for palliative care

Good stuff:

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Attention and distraction (and some hypnosis)

And now some material on attention and distraction:
Effects of attentional focusing on pain perception
Britton W. Brewer and Paul Karoly
Abstract Two experiments were conducted to examine the hypothesized differential effectiveness of two attentional focusing strategies in pain perception. In the first experiment, subjects (72 male college students) rated their levels of pain after being exposed to either low- or high-intensity pressure stimulation for 75 s. Subjects were instructed to use either an external or internal focus of attention during the pain induction. Results revealed that external focusing was more effective for coping than internal focusing across both levels of stimulus intensity. The second experiment was a replication of the first, and featured bolstered internal focusing and stimulus intensity manipulations. Results showed that high-intensity stimulation produced higher pain ratings than did low-intensity stimulation for subjects in the internal focusing conditions, but not for those in the external focusing conditions. The findings support the power of distraction strategies for dealing with short-term pain with a rapid onset. Theoretical implications are discussed.
Motivation and Emotion 13(3), 193-203 DOI: 10.1007/BF00995535

Laser-evoked potentials to noxious stimulation during hypnotic analgesia and distraction of attention suggest different brain mechanisms of pain control
Marc Friederich, Ralf H. Trippe, Mustafa özcan, Thomas Weiss, Holger Hecht and Wolfgang H.R. Miltner

Psychological accounts of hypnosis have hypothesized that hypnosis and attention might share similar mechanisms and that hypnosis simply represents an extensive state of reduced attention. This assumption implies that reports of pain and electrocortical brain responses to painful stimulation should be similarly reduced when subjects are exposed to suggestions of hypnotic analgesia (HA) or requested to distract their attention from painful stimuli (distraction of attention: DA) as compared to a control condition (CC). To test this hypothesis, we recorded event-related electrical brain potentials to noxious laser-heat stimuli and pain reports during HA, DA, and CC from subjects highly susceptible to hypnotic suggestions. Pain reports were significantly reduced during HA and DA as compared to CC. The amplitudes of the late laser-evoked brain potential (LEP) components N200 and P320 were also significantly smaller during DA than during CC. However, no significant difference of these late LEP amplitudes was obtained for HA as compared to CC. Results indicate that hypnotic analgesia and distraction of attention represent different mechanisms of pain control and involve different brain mechanisms. Psychophysiology
Volume 38 Page 768 - September 2001 doi:10.1111/1469-8986.3850768

A Comparison of Distraction Strategies for Venipuncture Distress in Children
MacLaren and Cohen
Objective To compare the effects of two pediatric venipuncture distress-management distraction strategies that differed in the degree to which they required children's interaction. Methods Eighty-eight 1- to 7-year-old children receiving venipuncture were randomly assigned to one of three treatment conditions: interactive toy distraction, passive movie distraction, or standard care. Distress was examined via parent, nurse, self-report (children over 4 years), and observational coding. Engagement in distraction was assessed via observational coding.ResultsChildren in the passive condition were more distracted and less distressed than children in the interactive condition. Although children in the interactive condition were more distracted than standard care children, there were no differences in distress between these groups. Conclusions Despite literature that suggests that interactive distraction should lower distress more than passive distraction, results indicate that a passive strategy might be most effective for children's venipuncture. It is possible that children's distress interfered with their ability to interact with the distractor.
J. Pediatr. Psychol..2005; 30: 387-396. doi:10.1093/jpepsy/jsi062

Parents' Positioning and Distracting Children During Venipuncture
Effects on Children's Pain, Fear, and Distress

Kim Cavender, Melinda D. Goff, Ellen C. Hollon, Cathie E. Guzzetta,
The purpose of this study was to determine the effectiveness of parental positioning and distraction on the pain, fear, and distress of pediatric patients undergoing venipuncture. An experimental-comparison group design was used to evaluate 43 patients (20 experimental and 23 comparison) who were 4 to 11 years old. Experimental participants used parental positioning and distraction. All participants rated their pain and fear; parents and child life specialists (CLS) rated the child's fear, and CLS rated the child's distress. Self-reported pain and fear were highly correlated (p < .001) but not significantly different between the two groups. Fear rated by CLS (p < .001) and parents (p = .003) was significantly lower in experimental participants. Although no difference was found in distress between the two groups, a significant time trend was discovered (p < .001). The parental positioning-distraction intervention has the potential to enhance positive clinical outcomes with a primary benefit of decreased fear. Further research is warranted.
Children's Medical Center of Dallas Journal of Holistic Nursing, Vol. 22, No. 1, 32-56 (2004)
DOI: 10.1177/0898010104263306
Link (full text)

Brief Cognitive Interventions for Burn Pain
Jennifer A. Haythornthwaite, John W. Lawrence, James A. Fauerbach
This study tested the efficacy of 2 brief cognitive interventions in supplementing regular medical treatment for pain during burn dressing change. Forty-two burn inpatients were randomly assigned to 3 groups: sensory focusing, music distraction, and usual care. Patients reported pain, pain relief, satisfaction with pain control, and pain coping strategies. The sensory focusing group reported greater pain relief compared to the music distraction group and a reduction in remembered pain compared to the usual care group, although group differences were not observed on serial pain ratings. In addition, after controlling for burn size and relevant covariates, regression analyses indicated that catastrophizing predicted pain, memory for pain, and satisfaction with pain control. Refinement of the sensory focusing intervention is warranted to reduce catastrophic thinking and improve pain relief.
Annals of Behavioral Medicine, 2001, Vol. 23, No. 1, Pages 42-49
(doi: 10.1207/S15324796ABM2301_7)

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I've written here before about the use of virtual reality in treating pain during medical procedures. Here's a collection of abstracts that I've come across recently:

Use of Virtual Reality as a Distractor for Painful Procedures in a Patient with Pediatric Cancer: A Case Study
Jonathan Gershon, Elana Zimand, Rosemarie Lemos, Barbara Olasov Rothbaum, Larry Hodges
Virtual reality (VR) has been demonstrated as an effective tool to help people overcome a variety of anxiety disorders. In this case study, the use of VR as a distractor to alleviate pain and anxiety associated with an invasive medical procedure for a pediatric cancer patient was explored. An A-B-C-A design during four consecutive medical appointments in an outpatient oncology clinic compared no distraction (A), non-VR distraction on a computer screen (B), and VR distraction with a head set (C). Behavioral observations of distress by the researcher and reports of pain and anxiety by the patient, parent, and nurse were taken before and during the procedure. The child's pulse was monitored throughout the procedure. The findings from this case study suggest benefit from using VR distraction, as indicated by lower pain and anxiety ratings, reduced pulse, and fewer observed behavioral indices of distress. The need for larger scale studies and application of VR with younger children is discussed in the context of confirming effectiveness of this technique and providing more generalizable information about efficacy. CyberPsychology & Behavior. Dec 2003, Vol. 6, No. 6: 657-661

Effects of Distraction Using Virtual Reality Glasses During Lumbar Punctures in Adolescents With Cancer
Suzanne Sander Wint, RN, BSN, CPON, Debra Eshelman, RN, MSN, CPNP, Jill Steele, RN, MSN, and Cathie E. Guzzetta, RN, PhD, HNC, FAAN

Purpose/Objectives: To determine the effects of virtual reality (VR) glasses on adolescents with cancer undergoing lumbar punctures (LPs).

Design: Pilot study using an experimental, control group design.

Setting: In-hospital oncology clinic.

Sample: 30 adolescents with cancer (17 in the VR and 13 in the control group) undergoing frequent LPs.

Methods: Subjects were randomly assigned to groups. Both groups received standard intervention during the LP, but the experimental group also wore VR glasses and watched a video. Following the LP, both groups rated their pain using a visual analog scale (VAS) and were interviewed to evaluate their experience.

Main Research Variables: Pain, subjective evaluation of experience.

Findings: Although VAS pain scores were not statistically different between the two groups (p = 0.77), VAS scores tended to be lower in the VR group (median VAS of 7.0, range 0-48) than in the control group (median VAS of 9.0, range 0-59). 77% of subjects in the experimental group said the VR glasses helped to distract them from the LP.

Conclusions: VR glasses are a feasible, age-appropriate, nonpharmacologic adjunct to conventional care in managing the pain associated with LPs in adolescents.

Implications for Practice: The clinical application of various age-appropriate distracters to reduce pain in adolescents undergoing painful procedures should be explored.

Immersive Virtual Reality for Reducing Experimental Ischemic Pain
Hunter G. Hoffman, Azucena Garcia-Palacios, Veronica Kapa, Jennifer Beecher, Sam R. Sharar
This study explored the novel use of immersive virtual environments as a nonpharmacologic pain control technique and whether it works for both men and women. Fourteen female and 8 male students underwent pain induced via a blood pressure cuff ischemia lasting 10 min or less. Pain ratings increased significantly every 2 min during the no distraction phase (0 to 8 min) and dropped dramatically during the last 2 min period when participants were in the virtual environment (a 59% drop for women and a 41% drop for men). Five visual analog pain scores for each treatment condition served as the primary dependent variables. All 22 participants reported a drop in pain in the virtual environment, and the magnitude of pain reduction from the virtual environment was large (a 52% drop) and statistically significant. This is the first study to show immersive virtual environment distraction is also effective for women. The results show that virtual environments can function as a strong nonpharmacologic pain reduction technique, showing the same pattern of results obtained from recent clinical studies using virtual environments with burn patients during physical therapy. Practical applications of virtual environment pain reduction, and the value of a multidisciplinary approach to studying pain are discussed. International Journal of Human-Computer Interaction, 2003, Vol. 15, No. 3, Pages 469-486 (doi: 10.1207/S15327590IJHC1503_10)

Effects of distraction using virtual reality glasses during lumbar punctures in adolescents with cancer Suzanne Sander and Jill Steele
Key points:
*Virtual reality glasses are a feasible, age-appropriate, nonpharmacologic adjunct to converntional care in managing pain associated with lumbar punctures in adolescents with cancer.
*visual analogue pain scores tended to be lower in the VR group
*The majority of adolescents who received the VR glasses felt the glasses distracted them from the lumbar puncture and wanted to use them again.
*More research is needed to explore novel distraction techniques for managing pediatric pain associated with procedures
Link (full text)

Virtual Reality Pain Distraction
Hunter Hoffman, PhD, and David Patterson, PhD ABPP ABPH
Patients commonly report experiencing excessive pain during medical procedures (Melzack, 1990), especially during severe burn wound care (Carrougher et al., 2003). Although opioid analgesics are currently essential for pain control during burn wound care, dosage amounts are limited by side effects (e.g., nausea, constipation, interference with appetite, sleep cycles) and other concerns associated with this class of medications (Cherny et al., 2001). Pain control is particularly challenging for patients with severe burn injuries. Patients treated for this form of trauma typically undergo daily wound care to clean, prevent infection, monitor the healing progress, and bandage again. Most burn patients report severe to excruciating pain during these medical procedures (Carrougher et al., 2003). APS Bulletin SPRING 2005 • VOLUME 15, NUMBER 2
Link (full text)

The effectiveness of virtual reality based pain control with multiple treatments.
Hoffman, H.G., Patterson, D.R., Carrougher, G.J., & Sharar, S. (2001).
Objective: The present study explored whether immersive virtual reality continues to reduce pain (via distraction) with repeated use.

Setting: Burn care unit at a regional trauma center.

Patients: Seven patients aged 9-32 years, mean age = 21.9 years (average of 23.7% total body surface area burned, range TBSA = 3% to 60%), performed range of motion exercises of their injured extremity under an occupational therapist’s direction on at least three separate days each.

Intervention: For each physical therapy session, each patient spent equal amounts of time in VR and in the control condition (no distraction). The mean duration of physical therapy in VR was 3.5, 4.9 and 6.4 minutes for the first, second and third session, respectively. Condition order was randomized and counterbalanced.

Outcome measures: For each of the three physical therapy sessions, five visual analog pain scores for each treatment condition served as the dependent variables.

Results: Pain ratings were statistically lower when patients were in VR, and the magnitude of VR pain reduction did not diminish with repeated use of VR. The results of this study may be examined in more detail at www.vrpain.com.

Conclusions: Although the small sample size limits generalizability, results provide converging preliminary evidence that virtual reality can function as a strong nonpharmacologic pain reduction technique for burn patients during physical therapy. Results suggest that virtual reality does not diminish in analgesic effectiveness with three (and possibly more) uses. Virtual reality may also have analgesic potential for other painful procedures or pain populations. Practical implications are discussed. Clinical Journal of Pain, 17, 229-235.
Link (full text)

And a link with even more resources: www.vrpain.com

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Self-efficacy and the opioid system

Perceived Self-Efficacy and Pain Control: Opioid and Nonopioid Mechanisms
[Personality Processes and Individual Differences]

Bandura, Albert; O'Leary, Ann; Taylor, C Barr; Gauthier, Janel; Gossard, Denis

Abstract: In this experiment, we tested for opioid and nonopioid mechanisms of pain control through cognitive means and the relation of opioid involvement to perceived coping efficacy. Subjects were taught cognitive methods of pain control, were administered a placebo, or received no intervention. Their pain tolerance was then measured at periodic intervals after they were administered either a saline solution or naloxone, an opiate antagonist that blocks the effects of endogenous opiates. Training in cognitive control strengthened perceived self-efficacy both to withstand and to reduce pain; placebo medication enhanced perceived efficacy to withstand pain but not reductive efficacy; and neither form of perceived self-efficacy changed without any intervention. Regardless of condition, the stronger the perceived self-efficacy to withstand pain, the longer subjects endured mounting pain stimulation. The findings provide evidence that attenuation of the impact of pain stimulation through cognitive control is mediated by both opioid and nonopioid mechanisms. Cognitive copers administered naloxone were less able to tolerate pain stimulation than were their saline counterparts. The stronger the perceived self-efficacy to reduce pain, the greater was the opioid activation. Cognitive copers were also able to achieve some increase in pain tolerance even when opioid mechanisms were blocked by naloxone, which is in keeping with a nonopioid component in cognitive pain control. We found suggestive evidence that placebo medication may also activate some opioid involvement. Because placebos do not impart pain reduction skills, it was perceived self-efficacy to endure pain that predicted degree of opioid activation. Journal of Personality & Social Psychology. 53(3):563-571, September 1987.