Playing Away Pain: A customised technology approach to reducing pain and distress in children with burn injuries

Background. Burn injury has long been established as one of the most traumatic injuries of childhood . Children not only encounter physical injury but also emotional trauma due to the hospitalization, medical procedures and pain experiences that can result in lifelong functional disturbances [1]. Occupational therapists are interested in ensuring continued engagement in meaningful occupations and participation in life roles. In doing so, our aim is to facilitate appropriate functional and developmental outcomes of recovery from a burn injury. Reducing the psychological/emotional impact caused by pain is an important goal of therapists and other health care professionals working in burn teams. There is a current focus in child healthcare research on appropriately managing the distress and suffering caused by procedural pain. With this increased focus, research has allowed increasing acknowledgement of the role the perception of pain, alongside the nociception. This has led to demonstrating the necessity of including non-pharmacological approaches in reducing pain (through the perception pathway) associated with medical procedures. However, despite the acknowledgement of the need to address more than just nociception through medication, little evidence is available on non-pharmacological support of children undergoing wound care procedures. In adult pain, non-pharmacological modalities have advanced to make use of technologies (including virtual reality) to ensure reduced pain experiences through high level, multi-sensory distraction [2]. To date these advances have not been investigated thoroughly in children, and those approaches available are based on adult models. There is limited literature to support their use with children or during burn procedures in reducing pain intensity and hence poor clinical uptake for children [3, 4]. With this gap in the research, and clinical experience indicating continued distress during burns wound care procedures despite adequate pain medication protocols, a customised technology device, Multi-Modal Distraction (MMD), was developed at the Royal Children’s Hospital (RCH). The aim was to improve the non-pharmacological support used in pain management within paediatric burn outpatient clinics [5, 6]. Methods. Two prospective randomised clinical trials were undertaken (N=120), using different MMD approaches, prototypes and content (distraction and procedural preparation) compared to off the shelf technology and standard practices with children 3-10 years of age. The aims of these RCTs were to compare the impact of MMD on the child’s pain intensity, as reported by the child, caregiver and nursing staff and physiological measures during burn wound care procedures. These trials also aimed to understand the; (i) usability and effectiveness of the distractions across repeated burns wound procedures, (ii) the impact each distraction approach had on the efficiency of treatment procedures, including duration of procedures, time to healing and medication requirements, and (iii) the use of a combined MMD approach (procedural preparation and distraction) across the age span (3-10 years). Results. Study 1 compared four non-pharmacological approaches (standard distraction, off the shelf video game, MMD procedural preparation and MMD distraction) across three consecutive burn wound care procedures. Eighty participants aged 3-10 years were recruited (20 to each group). MMD procedural preparation and MMD distraction groups were found to significantly reduce the pain intensity and distress of children compared to standard practice and off the shelf video games. This reduction was consistent and constant over three dressing changes, whilst the standard and video game groups reported increasing pain and distress with subsequent procedures. The MMD procedural preparation group showed greater reduction of pre-procedural pain scores than the MMD distraction group. There was also a significant reduction in length of treatment for both the MMD groups. Study 2 drew on the findings from Study 1 and assessed whether a combined MMD approach (procedural preparation and distraction) could further reduce the mild-moderate levels of pain experienced with the separate approaches of Study 1. Forty participants were recruited and observed at their initial outpatient dressing change and were randomised to either the standard distraction (SD) group or MMD Combined group. Results showed significant reductions in pain intensity between the standard distraction and MMD group. However pain intensity measures were not significantly different when using a combined approach versus using MMD procedural preparation alone as per Study 1. When MMD combined (Study 2) was compared to the MMD Distraction group of Study 1 however, differences were observed. There was an obvious impact of providing procedural preparation, alongside distraction as distinct to distraction alone. These outcomes may indicate an influence of procedural preparation on the effectiveness of distraction during the procedure. This study also showed significant reductions in the length of treatment of children utilising the combined MMD compared to standard distraction, but not compared to individual approaches (MMD distraction or MMD procedural preparation alone). A surprising finding was the two day reduction in healing time in the combined MMD group compared to standard distraction. Conclusions. Overall the results from the two randomised control trials support the use of a customised technology approach, MMD, to managing pain and distress experiences in young (3-10 years) children undergoing burn wound care procedures. This research highlights the need to continue to develop pain management strategies that support the developmental needs of children, their motivations, experience and knowledge of procedures and the level of engagement needed to maintain attention. The outcomes of this thesis are paving the way for future integration of technology based devices into pain management protocols at the Stuart Pegg Paediatric Burn Centre, Brisbane, Australia. The impact of MMD on pain intensity and clinical utility, is driving paediatric burn pain protocols towards best practice, which aims for mild pain experiences for all children. Alongside reduced pain intensity the results also indicate significant impacts on clinical utility in terms of decreased length of treatment, decreased clinician time and reduced days to healing. Future work should focus on assessing the use of MMD in other procedural areas, as well as look into the impact levels of pain could have on wound healing