Kate Miller

Virtual reality for acute pain reduction in adolescents undergoing burn wound care: A prospective randomized controlled trial

BACKGROUND Effective pain management remains a challenge for adolescents during conscious burn wound care procedures. Virtual reality (VR) shows promise as a non-pharmacological adjunct in reducing pain. AIMS This study assessed off-the-shelf VR for (1) its effect on reducing acute pain intensity during adolescent burn wound care, and (2) its clinical utility in a busy hospital setting. METHODS Forty-one adolescents (11-17 years) participated in this prospective randomized controlled trial. Acute pain outcomes including adolescent self-report, nursing staff behavioral observation, caregiver observation and physiological measures were collected. Length of procedure times and adolescent reactions were also recorded to inform clinical utility. RESULTS Nursing staff reported a statistically significant reduction in pain scores during dressing removal, and significantly less rescue doses of Entonox given to those receiving VR, compared to those receiving standard distraction. For all other pain outcomes and length of treatment, there was a trend for lower pain scores and treatment times for those receiving VR, but these differences were not statistically significant. CONCLUSION Despite only minimal pain reduction achieved using off-the-shelf VR, other results from this trial and previous research on younger children with burns suggest a customized, adolescent and hospital friendly device may be more effective in pain reduction.

Multi-modal distraction. Using technology to combat pain in young children with burn injuries

BACKGROUND The use of non-pharmacological pain management remains adhoc within acute paediatric burns pain management protocols despite ongoing acknowledgement of its role. Advancements in adult based pain services including the integration of virtual reality has been adapted to meet the needs of children in pain, as exemplified by the development of multi-modal distraction (MMD). This easy to use, hand held interactive device uses customized programs designed to inform the child about the procedure he/she is about to experience and to distract the child during dressing changes. AIM (1) To investigate if either MMD procedural preparation (MMD-PP) or distraction (MMD-D) has a greater impact on child pain reduction compared to standard distraction (SD) or hand held video game distraction (VG), (2) to understand the impact of MMD-PP and MMD-D on clinic efficiency by measuring length of treatment across groups, and lastly, (3) to assess the efficacy of distraction techniques over three dressing change procedures. METHODS A prospective randomised control trial was completed in a paediatric tertiary hospital Burns Outpatient Clinic. Eighty participants were recruited and studied over their first three dressing changes. Pain was assessed using validated child report, caregiver report, nursing observation and physiological measures. RESULTS MMD-D and MMD-PP were both shown to significantly relieve reported pain (p<or=0.05) and reduce the time taken for dressings (p<or=0.05) compared to SD and VG. The positive effects of both MMD-D and MMD-PP were sustained with subsequent dressing changes. CONCLUSIONS The use of MMD as a preparatory or a distraction tool in an outpatient burns clinic offered superior pain reduction across three dressing changes to children when compared to standard practices or hand held video games. This device has the potential to improve clinic efficiency with reductions in treatment lengths.

The efficacy of an augmented virtual reality system to alleviate pain in children undergoing burns dressing changes : A randomised controlled trial

In children, the pain and anxiety associated with acute burn dressing changes can be severe, with drug treatment alone frequently proving to be inadequate. Virtual reality (VR) systems have been successfully trialled in limited numbers of adult and paediatric burn patients. Augmented reality (AR) differs from VR in that it overlays virtual images onto the physical world, instead of creating a complete virtual world. This prospective randomised controlled trial investigated the use of AR as an adjunct to analgesia and sedation in children with acute burns. Forty-two children (30 male and 12 female), with an age range of 3-14 years (median age 9 years) and a total burn surface area ranging from 1 to 16% were randomised into a treatment (AR) arm and a control (basic cognitive therapy) arm after administration of analgesia and/or sedation. Pain scores, pulse rates (PR), respiratory rates (RR) and oxygen saturations (SaO2) were recorded pre-procedurally, at 10 min intervals and post-procedurally. Parents were also asked to grade their childs overall pain score for the dressing change. Mean pain scores were significantly lower (p=0.0060) in the AR group compared to the control group, as were parental pain assessment scores (p=0.015). Respiratory and pulse rates showed significant changes over time within groups, however, these were not significantly different between the two study groups. Oxygen saturation did not differ significantly over time or between the two study groups. This trial shows that augmented reality is a useful adjunct to pharmacological analgesia.

A novel technology approach to pain management in children with burns: A prospective randomized controlled trial

BACKGROUND Non-pharmacological approaches to supporting young children through painful medical procedures are an essential component of burn pain management protocols. New technology developed from collaborations between healthcare professionals and IT teams can enhance the preparation and distraction approaches used with children. This study follows on from previous studies using such technology, and aim to determine whether levels of pain and distress using a combined preparation and distraction content can be further reduced, and offer more efficient clinical outcomes. METHODS Forty children (3-10 years) undergoing acute burn care procedures were randomized to two groups: (1) Standard Distraction (SD) Group and (2) Multi Modal Distraction (MMD) Group (combined protocol of procedural preparation and distraction). Pain intensity and child distress were measured prior to and during the procedure. Clinical utility end points were also included; length of treatment, days to healing and adverse pain events. RESULTS A combined MMD protocol significantly reduced pain intensity (p<0.001) and distress scores (p<0.001) when compared to SD. Length of treatment (p<0.05), days to healing and the number of pain adverse events were also reduced (p<0.05) with the use of the MMD protocol. CONCLUSIONS A combined MMD protocol reduces the pain experiences for young children during burn care procedures. When compared with a previous MMD trial, outcomes reiterated the use of procedural preparation as an essential component of non-pharmacological approaches. In addition to minimizing pain and distress, this innovative technology reduced treatment length and pain adverse events, and may have an impact on reducing days to healing, providing evidence of clinical efficacy and utility.

A prospective randomized controlled trial of nonpharmacological pain management during intravenous cannulation in a pediatric emergency department

Objectives Intravenous (IV) cannulation is commonly performed in pediatric emergency departments (EDs). The busy ED environment is often not conducive to conventional nonpharmacological pain management. This study assessed the use of Ditto (Diversionary Therapy Technologies, Brisbane, Australia), a handheld electronic device which provides procedural preparation and distraction, as a means of managing pain and distress during IV cannulation performed in the pediatric ED. Methods A randomized controlled trial with 98 participants, aged 3 to 12 years, was conducted in a pediatric ED. Participants were recruited and randomized into 5 intervention groups as follows: (1) Standard Distraction, (2) PlayStation Portable Distraction, (3) Ditto Distraction, (4) Ditto Procedural Preparation, and (5) Ditto Preparation and Distraction. Childrens pain and distress levels were assessed via self-reports and observational reports by caregivers and nursing staff across the following 3 time points: (1) before, (2) during, and (3) after IV cannulation. Results Caregivers and nursing staff reported significantly reduced pain and distress levels in children accessing the combined preparation and distraction Ditto protocol, as compared to standard distraction (P ⩽ 0.01). This intervention also saw the greatest reduction in pain and distress as reported by the child. Conclusions Caregiver reports indicate that using the combined Ditto protocol was most effective in reducing childrens pain experiences while undergoing IV cannulation in the ED. The use of Ditto offers a promising opportunity to negotiate barriers to the provision of nonpharmacological approaches encountered in the busy ED environment, and provide nonpharmacological pain-management interventions in pediatric EDs.

Occupational therapists' role in facilitating pain management in children with burn injuries

Pain is an obvious and significant side effect of burn injuries and the subsequent repeated wound care procedures used to heal them. The pain, anxiety and stress associated with burn injuries is well known and has long posed a significant challenge for treating health professionals. Childhood experiences of pain are different to those of adults where the pain sensation may be compounded by developmental experience and understanding, impacting on both pain mechanisms in the brain and the treatment options available (McGrath & Hillier, 2003; Stallings & March, 1995; The Royal Australasian College of Physicians, 2005). Current approaches have endeavoured to make adult models of effective preparation and distraction child friendly, without considering the impact of cognitive and emotional development on attenuation, motivation and the coping needs of the child (de Jong, Middelkoop, Faber & Van Loey, 2007; Hoffman, 2004; Miller, Kipping, Rodger, Greer & Kimble, 2010a; The Royal Australasian College of Physicians, 2005). This lack of paediatric focussed interventions likely contributed to the long-standing history of inadequate pain management control during burn wound care procedures (Summer, Puntillo, Miaskowski, Green & Levine, 2007). The shortand long-term negative sequalae associated with painful experiences are well documented and concerning for the child or adolescent, their family and the community whom provide their health care (Brown et al., 2014c; Crombez et al., 2003; Marshall, Stratton, Moore & Boxerman, 1980; von Baeyer, Marche, Rocha & Salmon, 2004; Wollgarten-Hadamek, Hohmeister, Zohsel, Flor & Hermann, 2011; Wollgarten-Hadamek et al., 2009). The impact of pain and stress experienced during burn wound care procedures are wide-ranging and can extend well into the future. Studies show the morbidity of these experiences may include prolonged healing, poor compliance with rehabilitation, chronic pain, sleep disturbances, poor feeding, altered arousal levels and other mental health issues (Crombez et al. 2003; Marshall et al. 1980; von Baeyer et al. 2004). Young people may also retain negative emotions and a sense of helplessness to stop the pain, which can then impact motivation and engagement in future health-related procedures and occupational roles (Crombez et al. 2003; Passaretti & Billmire, 2003; Stoddard et al., 2006; The Royal Australasian College of Physicians, 2005). A combination of pharmacology and non-pharmacology treatments such as procedural preparation and distraction are the gold standard in burn care (de Jong & Gamel, 2006; Foertsch, O’Hara, Stoddard & Kealey, 1998). Technology has asserted itself across many areas of daily life and advances at a rapid rate. Perhaps, this is most prominent in the younger generation where applications are firmly ingrained in daily activities of play, entertainment, social media, childhood development aids and health care. Attention-based technologies such as virtual reality (VR) offer a powerful non-pharmacological intervention that can be used to prepare and distract children and adolescents from their painful and anxiety-provoking procedures (Brown et al., 2014c; Hoffman, 2004; Kipping, Rodger, Miller & Kimble, 2012; Martin-Herz, Thurber & Patterson, 2000; Miller, 2011; Miller, Bucolo, Patterson & Kimble, 2008; Miller, Rodger, Kipping & Kimble, 2011; Miller et al., 2010a). The strength of VR in the acute hospital environment lies in its ability to engage attention prior to (preparation) and throughout (distraction) the wound care procedure, whereby reducing a child’s ability to attend to the pain, the procedure or their wound (Hoffman 2004; Kipping et al. 2012; Martin-Herz et al. 2000; Miller 2011; Miller et al. 2010a). In the past, VR pain research has focussed on adults, with little emphasis on children and adolescents. VRs ability to be customised to meet the physical, cognitive and emotional needs of a child undergoing burn wound care, asserts its potential as a true paediatric focussed intervention. Professor Sylvia Rodger’s contribution to this specific and niche area of practice for occupational therapy has Belinda Kipping BOccThy, MPhil; Kate Miller BOccThy, PhD.