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The Power of Distraction
Monday October 26, 2009

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> Buzzy, for needle pain relief:

> Cohen LL. Behavioral approaches to anxiety and pain management for pediatric venous access. Pediatrics. 2008;122(suppl 3):S134-139.


Amy Baxter, MD, an emergency room physician at Children’s Healthcare of Atlanta, was treating an 8-year-old girl who was hysterical from the pain of a forearm fracture. Baxter explained that she had a trick that worked for every patient. She asked the girl to look at the ceiling and count the number of tiles. The girl hardly noticed when a nurse inserted the IV needle.

Although Baxter’s pain distraction technique seems simple, she has seen how effective, well-timed methods such as this can dramatically decrease a child’s experience of pain.

“Adults can attribute meaning to their pain, such as knowing that it will help them heal, but younger children cannot abstract this concept. They perceive pain as punishment,” Baxter says. “I hate things that are unnecessary, and it seems unnecessary to cause suffering in children when there are some simple ways to prevent it.”

This desire to minimize pain prompted Baxter to join with Lindsey Cohen, PhD, an associate professor of psychology at Georgia State University in Atlanta, to study the benefits of distraction techniques during painful procedures for children. Their findings suggest that there are inexpensive, effective ways for practitioners to reduce the experience of pain in the pediatric patient population.

Attention Resources
Cohen and Baxter found that they could decrease a child’s perception of pain through two mechanisms. The first utilized the gate theory, which triggers pain relief by causing physical sensations other than pain. In this theory, sensations of cold and vibration are applied to stimulate the A-beta and the C nerve fibers, and these sensations occupy the same neural pathways along which pain is transmitted. The theory suggests that cold and vibration sensations arrive first and “shut the gate,” therefore dampening the sharp pain signals that are sent along the A-delta fibers.

During the research study, Baxter used “Buzzy,” a bumblebee-shaped medical device that emits both vibrations and cold when pressed against the skin. Cold also could be applied with an ice pack placed above the area of pain, and vibration could be administered using an electronic massager or manual massage.

In addition to physical distraction, Cohen added elements discovered from his experiments with mental distraction as a second mechanism to reduce pain perception. Cohen and Baxter discovered that the combination of the physical and mental distraction was the most effective method of reducing pain.

“The idea is that there is a limited amount of attention resources we can pay to anything, so if we can take up resources with distraction, then there are fewer resources available to focus on the pain,” Cohen says.

In fact, children who focus on an anticipated painful event will likely experience fear, and anxiety heightens the sensation of pain, Cohen says. The researchers found that the most effective mental distraction techniques required a response from the child, such as a parent or nurse who asked questions about a movie the child was watching during an immunization shot. Questions such as “Who is the good guy?” or “What is happening now?” are examples of good distractions.

Another technique that requires a child to respond is playing a game of “I spy.” They also found that the distraction techniques should start before the painful event to reduce anxiety and then continue a few minutes after the event to divert them from pain or other negative emotions immediately after. Children responded better to positive encouragements such as “You are such a good boy,” rather than empathetic statements about the pain such as “I’m so sorry that hurt.”

Rehab Applications
Jackie Nillasca, DPT, a physical therapist at Lucile Packard Children’s Hospital in Palo Alto, Calif., has seen firsthand the benefits of distraction when she works with children.
Children can become anxious when she enters the room because they anticipate the pain associated with physical therapy. To distract patients from fear and help them relax, Nillasca usually begins her session by asking children questions about their families, pets, or home life. She then explains that they will be going to a playroom or a therapy gym.

“The children become more focused on going somewhere new and this distracts them from the fact that they will be doing physical therapy,” she says.

In the therapy gym or playroom, Nillasca may place blocks, puzzles, cars, or dolls on a table to encourage younger children to play while standing up. While they are playing, the patients are increasing their endurance, balance, and strength.

For older children, deep breathing or engaging conversation during physical therapy can be an effective distraction tool. Anne Sinha, MOT, OTR/L, who also works at Lucile Packard, remembers working with a girl suffering from complex regional pain syndrome after a soccer injury. The girl arrived on crutches and was afraid to put any weight on her right leg. After doing desensitization massage on the leg, Sinha then started asking the girl questions about her soccer team to distract her as she helped the girl normalize her pain response. By the end of several sessions with both PTs and OTs, the girl had normal weight bearing and gait, and was looking into a summer job as a waitress.

“For me, any time I can help a patient reach their highest functional level, that is rewarding,” Sinha says. “Distraction is a tool to get there.”

Heather Stringer is a medical writer for the Gannett Healthcare Group.

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Monday October 26, 2009
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