Pain management, cancer and hospitalized children

“Pain is one of the most distressing symptoms for children and young adults with cancer (Hedén, Pöder, von Essen, & Ljungman, 2013; Olson & Amari, 2015). Studies show that 49%–62% of children and young adults with cancer experience pain, often prolonged, during the course of their treatment (Baggott et al., 2010; Varni, Burwinkle, & Katz, 2004). Pain negatively affects a young person’s quality of life (Bhat et al., 2005; Sung et al., 2009; Varni et al., 2004), impedes cancer recovery (Shepherd, Woodgate, & Sawatzky, 2010), results in patient and family distress (Hedén et al., 2013; Miller, Jacob, & Hockenberry, 2011; Walker, Gedaly-Duff, Miaskowski, & Nail, 2010), and is associated with longterm morbidity (Chordas et al., 2013; Lu et al., 2011).

Pain related to cancer also represents a significant cost burden to the healthcare system and families (Abernethy, Samsa, & Matchar, 2003), with pain being the most common reason adult patients with cancer use emergency health services (Barbera, Taylor, & Dudgeon, 2010; Kuo, Saokaew, & Stenehjem, 2013; Tsai, Liu, Tang, Chen, & Chen, 2009; Walker et al., 2010). Despite this knowledge, the management of pain in pediatric and young adult patients with cancer has not kept pace with advancements in treatment protocols (Woodgate, 2008).

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Play interventions to reduce anxiety and negative emotions in hospitalized children

Children who received the hospital play interventions exhibited fewer negative emotions and experienced lower levels of anxiety than those children who received usual care.

Get children involved in different kinds of expressive play activities (e.g. painting, singing, dancing, journaling, sand play, puppets, etc.), and encourage them to share or express their feelings

Provide interesting games and toys (e.g. blowing bubbles, pop-up books, puppets, computer games, music, video, sensory toys, relaxation techniques, etc.) to distract children’s attention from medical procedures

Date: 2016





Current concepts in management of pain in children in the emergency department


Date: 2015



Primary outcome was pain intensity (0-10 metric). Results indicated that psychological interventions as a whole were effective in reducing children’s self-reported pain in the short term (SMD = −0.47, 95% CI = −0.76 to −0.18). Subgroup analysis indicated that distraction/imagery interventions were effective in reducing self-reported pain in the short term (24 hours, SMD = −0.63, 95% CI = −1.04 to −0.23)

Date: 2016





The aim of distraction in managing procedural anxiety, distress, and pain is to focus the child’s attention away from the painful procedure. Distraction is particularly effective for young children or when minimal preparation time is available and may take the form of counting, singing, watching a video, playing a game, or otherwise engaging the attention of the child away from the medical procedure (Doellman, 2003). Distraction was used as an interventional strategy in 18 of the 32 studies reviewed and was employed in various forms, ranging from controlled breathing with a party blower (Blount et al., 1994) to high-tech virtual reality games (Gershon et al., 2004; Gold et al., 2006).


Imagery focuses the child’s attention away from the procedure by harnessing the imagination. For example, a child may be asked to imagine themselves in a pleasant place (such as at the beach) and to focus on the physical sensations that they may experience in their imagined place (such as the sounds of the ocean and the warmth of the sun). This technique requires the active cooperation of the patient and is most effective when used for children over the age of 8 years (Doellman, 2003). Imagery was employed as an interventional strategy for management of procedural pain, anxiety, and distress in 6 of the 32 studies in this review and was commonly employed in combination with distraction, relaxation, and play (Broome et al., 1992; Kazak et al., 1998).

Other Mind–Body Interventions Additional mind–body interventions used in the studies in this review include relaxation (four studies); play (three studies); combined cognitive–behavioral therapy approaches (three studies); controlled breathing (two studies); positive incentive or reinforcement (two studies); and parental coaching, positive self-talk, behavioral rehearsal, transcutaneous electrical nerve stimulation, hand holding, humor, music, and memory reframing (one study each).

Detailed results:

Imagery, distraction, positive incentive, behavioral rehearsal – Lower levels of distress reported for the combined pharmacological + psychological intervention group than those for the pharmacological only group (p b .03 for mothers’ ratings; p b .05 for nurses’ ratings)

Distraction, focused breathing, relaxation, imagery – Following intervention, children had lower levels of self-reported pain (p = .06), fewer requests for emotional support (p = .07) fewer expression of verbal fear (p = .10) and fewer information-seeking questions (p = .10)

Hand holding – Adolescents perceived hand holding to be an effective coping strategy in ameliorating treatment related pain; strongly preferred mother’s hand, if not available, preferred specific nurse’s hand

Current nonpharmacologic pain interventions for pediatric and young adult patients with cancer are diverse. Several modalities significantly decreased pain intensity, suggesting that these strategies may be effective methods of pain treatment, particularly in the case of painful medical procedures.

Date: 2015

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The results of this study suggest that an evidence-based, interactive educational program can reduce young children’s expectations of needle pain and may help teach them procedural coping strategies.

Date: 2016



The pre-post group comparison suggested that youth increased active psychological coping attempts with the intervention. Daily diary data indicated that when children used CBT skills on days with higher pain, there were reductions in next day pain intensity. There was no such association between skill use and functional activity.

Date: 2015




High High levels of worry or nervousness related to anticipated pain or distress Reassurance, focus on gentle approaches to gaining compliance modeling of coping skills (distraction, breathing)
 Low Low levels of worry or nervousness More likely to show approach behaviors in novel situations Concise information about surgical environment, tailored modeling of coping skills by child animated character (character demonstrating approach behaviors)

Date: 2015



Psychological therapies delivered remotely, primarily via the Internet, confer benefit in reducing the intensity or severity of pain after treatment across conditions. There is considerable uncertainty around these estimates of effect and only eight studies with 371 children contribute to the conclusions. Future studies are likely to change the conclusions reported here. All included trials used either behavioural or cognitive behavioural therapies for children with chronic pain, therefore we cannot generalise our findings to other therapies. However, satisfaction with these treatments was generally positive. Larger trials are needed to increase our confidence in all conclusions regarding the efficacy of remotely delivered psychological therapies. Implications for practice and research are discussed.

Date: 2016



Can Experimentally Induced Positive Affect Attenuate

Generalization of Fear of Movement-Related Pain?


Results thus suggest that pos-

itive affect may enhance safety learning through promoting generalization from known safe move-

ments to novel yet related movements. Improved safety learning may be a central mechanism

underlying the association between positive affect and increased resilience against chronic pain.

Perspective: We investigated the extent to which positive affect influences the generalization (ie,

spreading) of pain-related fear inhibition in response to situations similar to the original, pain-

eliciting situation. Results suggest that increasing positive affect in the acute pain stage may limit the

spreading of pain-related fear, thereby potentially inhibiting transition to chronic pain conditions.





Our findings highlight that interoceptive sensitivity differentially interacts with pain and self-regulation both in healthy participants and somatoform patients. This might provide ideas for novel therapeutic interventions, e.g. a combined training of interoceptive sensitivity with certain aspects of self-regulation.



Selective attentional bias, conscious awareness and the fear of pain

Together, these findings suggest that the ability to orient away from pain-related stimuli may be under conscious control in low fearful people, whereas such a mechanism does not seem to exist in those high in the fear of pain.

Date: 2003



Oxytocin and the modulation of pain experience: Implications for chronic pain management

In this review, we discuss previous effective applications of oxytocin in pain-free clinical populations and its potential use in the modulation of pain experience. We also address the slowly growing body of literature investigating the administration of oxytocin in clinical and experimentally induced pain in order to investigate the potential mechanisms of its reported analgesic actions. We conclude that oxytocin offers a potential novel avenue for modulating the experience of pain, and that further research into this area is required to map its therapeutic benefit.

Date: 2015




Cognitive Behavioral Therapy for Depression and Anxiety

in an Interdisciplinary Rehabilitation Program for Chronic Pain:

a Randomized Controlled Trial with a 3-Year Follow-up

One hundred fifteen patients with chronic musculoskeletal

pain participated in an interdisciplinary pain management

program. Eighty of these patients meeting criteria for

CBT treatment were randomized to receive or not receive

CBT for depression and anxiety in addition to rehabilitation

pain management. The remaining 35 patients constituted a second

comparison group. Follow-up data were collected 1 and

3 years post-treatment with 19% of the patients dropping out

after 1 year and 34% after 3 years.


All three groups evidenced improved depression following

treatment (p < 0.001). The pre- to post-treatment effect

sizes (Cohen’s d) for depression in the CBT treatment group

was large (ES = 1.36). The CBT treatment group maintained

improvements on all measures at a 3-year follow-up, while the

comparison groups did not. This was especially evident with

respect to depression (pre-treatment to 3 years follow-up

ES = 1.35 and between-group ES = 0.57).


Conclusion The results indicate that providing CBT for depression

and anxiety as part of a rehabilitation pain management

program may enhance the long-term benefits of treatment.

This finding, if replicated in additional studies, has important

clinical and economic implications.




Slow breathing:




Mindfulness‐based interventions for coping with cancer

Our adaptation, mindfulness‐based cancer recovery (MBCR), has resulted in improvements across a range of psychological and biological outcomes, including cortisol slopes, blood pressure, and telomere length, in various groups of cancer survivors.

Date: 2016





Fear of Injections and Needle Phobia Among Children and Adolescents: An Overview of Psychological, Behavioral, and Contextual Factors

Fear of needles: Nature and prevalence in general practice



A mobile hospice nurse teaching team’s experience: training care workers in spiritual and existential care for the dying – a qualitative study

Nursing home and home care nursing staff must increasingly deal with palliative care challenges, due to cost cutting in specialized health care. Research indicates that a significant number of dying patients long for adequate spiritual and existential care. Several studies show that this is often a source of anxiety for care workers. Teaching care workers to alleviate dying patients’ spiritual and existential suffering is therefore important. The aim of this study is to illuminate a pioneering Norwegian mobile hospice nurse teaching team’s experience with teaching and training care workers in spiritual and existential care for the dying in nursing homes and home care settings.



The mobile teaching team taught care workers to identify spiritual and existential suffering, initiate existential and spiritual conversations and convey consolation through active presencing and silence. The team members transferred their personal spiritual and existential care knowledge through situated “bedside teaching” and reflective dialogues. “The mobile teaching team perceived that the care workers benefitted from the situated teaching because they observed that care workers became more courageous in addressing dying patients’ spiritual and existential suffering.


Educational research supports these results. Studies show that efficient workplace teaching schemes allowexpert practitioners to teach staff to integrate several different knowledge forms and skills, applying a holisticknowledge approach. One of the features of workplace learning is that expert nurses are able to guide novices through the complexities of practice. Situated learning is therefore central for becoming proficient.


Situated bedside teaching provided by expert mobile hospice nurses may be an efficient way to develop care workers’ courage and competency to provide spiritual and existential end-of-life-care. Further research is recommended on the use of mobile expert nurse teaching teams to improve nursing competency in the primary health care sector.


Date: 2015