Kristine L. Kwekkeboom

Music versus distraction for procedural pain and anxiety in patients with cancer

PURPOSE/OBJECTIVES To test the hypotheses that the effects of a music intervention are greater than those of simple distraction and that either intervention is better at controlling procedural pain and anxiety than treatment as usual. DESIGN Randomized, controlled experiment. SETTING A midwestern comprehensive cancer center. SAMPLE 60 people with cancer having noxious medical procedures such as tissue biopsy or port placement or removal; 58 provided usable data. METHODS Participants completed measures of pain and anxiety before and after their medical procedures and provided a rating of perceived control over pain and anxiety after the procedure. MAIN RESEARCH VARIABLES Procedural pain, state anxiety, and perceived control over pain and anxiety. FINDINGS Contrary to hypotheses, outcomes achieved with music did not differ from those achieved with simple distraction. Moreover, outcomes achieved under treatment as usual were not significantly different from those obtained with music or distraction interventions. Some patients found that the interventions were bothersome and reported that they wanted to attend to the activities of the surgeon and the medical procedure itself. CONCLUSIONS The effects of music, distraction, and treatment as usual are equivocal. In addition, patients have individual preferences for use of distraction during painful or anxiety-provoking procedures. IMPLICATIONS FOR NURSING Patients having noxious medical procedures should be asked about their desire to be distracted before and during the procedure and offered a strategy that is consistent with their preferences.

Feasibility of a Patient-Controlled Cognitive-Behavioral Intervention for Pain, Fatigue, and Sleep Disturbance in Cancer

PURPOSE/OBJECTIVES To evaluate the feasibility of a patient-controlled cognitive-behavioral intervention for pain, fatigue, and sleep disturbance during treatment for advanced cancer and to assess initial efficacy of the intervention. DESIGN One group pre- and post-test design. SETTING Outpatient oncology clinics at a comprehensive cancer center in the midwestern United States. SAMPLE 30 adults with advanced (recurrent or metastatic) colorectal, lung, prostate, or gynecologic cancer receiving chemotherapy or radiotherapy. METHODS Participants completed baseline measures (e.g., demographics, symptom inventory) and received education and training to use an MP3 player loaded with 12 cognitive-behavioral strategies (e.g., relaxation exercises, guided imagery, nature sound recordings). Participants used the strategies as needed for symptom management for two weeks, keeping a log of symptom ratings with each use. Following the two-week intervention, participants completed a second symptom inventory and an evaluation of the intervention. MAIN RESEARCH VARIABLES Feasibility, patient-controlled cognitive-behavioral intervention, pain, fatigue, and sleep disturbance. FINDINGS Thirty of 43 eligible patients (73%) agreed to participate; of them, 27 (90%) completed the study. Most reported that they enjoyed the intervention, had learned useful skills, and perceived improvement in their symptoms. Symptom scores at two weeks did not differ significantly from baseline; however, significant reductions in pain, fatigue, and sleep disturbance severity were found in ratings made immediately before and after use of a cognitive-behavioral strategy. CONCLUSIONS The patient-controlled cognitive-behavioral intervention appears to be feasible for additional study and could reduce day-to-day severity of co-occurring pain, fatigue, and sleep disturbance. IMPLICATIONS FOR NURSING A randomized, controlled trial is needed to test efficacy of the intervention for co-occurring pain, fatigue, and sleep disturbance. Meanwhile, based on previous efficacy studies, cognitive-behavioral strategies can be recommended for certain individual symptoms.

A pilot study to predict success with guided imagery for cancer pain.

Guided imagery, as other nonpharmacologic strategies, has been demonstrated to be useful for some patients. However, no tested method exists to identify which patients are likely to benefit from this pain management strategy. This pilot study tested a model to predict success with guided imagery. Major concepts tested included imaging ability, outcome expectancy, history of imagery use, match with preferred coping style, and perceived credibility of the imagery provider. A one-group pretest-posttest design was used. A sample of 62 hospitalized cancer patients currently experiencing pain rated >/=3 on a 0 to 10 scale completed questionnaires and used an audiotaped imagery intervention. Pain outcomes examined included mean pain intensity and distress, positive and negative affect, and perceived control over pain. A path analysis was conducted using multiple regression to evaluate relationships proposed in the model. Previous history with imagery predicted outcome expectancy. Imaging ability predicted mean pain intensity, positive affect, and perceived control over pain. Outcome expectancy was not a significant predictor of any pain outcomes. Baseline status and concurrent symptoms, measured as covariates, also played a significant role in predicting outcomes. Variance explained in pain outcomes ranged from 10% to 52% (adjusted R(2) = 3% to 48%). Further exploration of model variables is warranted. Findings suggest that after considering current symptom experience, imaging ability may be a useful variable to assess in order to determine whether guided imagery is an appropriate intervention for individual patients.

Measuring imaging ability: Psychometric testing of the Imaging Ability Questionnaire

Imaging ability, defined as the ability to create vivid mental images and to experience those images as if they were almost real, has been suggested as a moderator in effective use of guided imagery for symptom relief. Persons with good imaging ability are thought to be more likely to succeed in relieving a symptom with guided imagery than persons with poor imaging ability. The purpose of this paper is to describe the development of an instrument designed to measure imaging ability, the Imaging Ability Questionnaire (IAQ). A descriptive correlational design was used to conduct item analyses and explore psychometric properties of the IAQ. A total of 200 persons from the Midwest completed a 54-item version of the IAQ. Twenty-two items that failed to discriminate among levels of imaging ability were eliminated from the questionnaire. The final version of the IAQ contained 32 items and demonstrated good internal consistency (alpha =.93) and test-retest reliability (r =.92). Support for construct validity of the questionnaire was provided by demonstrating expected differences in IAQ score between persons for whom imagery worked and persons for whom imagery did not work. Future testing and use of the questionnaire in research and practice are discussed.

Assisting Older Clients With Pain Management in the Home

Older home health clients experience significant pain from a variety of age-related conditions. It is important for home health nurses to be knowledgeable about strategies for assessing and managing pain that are adapted to the unique needs of the older patient. A thorough pain assessment gathers key information guiding treatment decisions and follow-up evaluation of intervention effectiveness. Nonpharmacologic interventions, including comfort measures, cutaneous stimulation techniques, and cognitive-behavioral strategies, may help to relieve mild pain when used alone and moderate to severe pain when used in addition to analgesic medications. Assessment and treatment strategies can be tailored to meet the needs of the older clients, taking into account the clients’ cognitive ability and caregivers’ willingness to participate. Home health nurses, in their limited contact time, can educate both older clients and family caregivers in actively managing pain through frequent pain assessment and the use of nonpharmacologic interventions.

Prevalence, Duration, Severity, and Distress of Chemotherapy-Related Gastrointestinal Symptoms in Patients With a Hematologic Malignancy.

PURPOSE/OBJECTIVES To describe prevalence, duration, severity, and distress of chemotherapy-related gastrointestinal (GI) symptoms, and evaluate inclusion of clinically relevant GI symptom items on cancer symptom questionnaires.
. DESIGN Longitudinal descriptive design.
. SETTING Inpatient and outpatient hematology settings.
. SAMPLE 105 adults with a hematologic malignancy receiving their third or subsequent cycle of chemotherapy. 
. METHODS Participants completed weekly assessments of 19 GI symptoms during a three-week period of chemotherapy. Descriptive statistics were calculated to summarize GI symptom prevalence, duration, severity, and distress ratings at each week. Findings were compared to item content of 12 cancer multisymptom questionnaires identified in the literature.
. MAIN RESEARCH VARIABLES GI symptom prevalence, duration, severity, and distress.
. FINDINGS Participants reported an average of three to five GI symptoms at each time point that were typically experienced as mild to moderate in duration, severity, and distress. Only 3 of 11 clinically relevant GI symptoms were included on more than half of the cancer symptom questionnaires. 
. CONCLUSIONS Patients receiving chemotherapy experience a moderate GI symptom burden across a wide range of potential GI symptoms.
. IMPLICATIONS FOR NURSING Future research should include measures of clinically relevant GI symptoms that may be emerging with new cancer therapies and toxicity prevention protocols.