Psychological and Physical Interventions for the Management of Cancer-Related Pain in Pediatric and Young Adult Patients: An Integrative Review

Effectiveness of Virtual Reality in Reducing Perceived Pain and Anxiety Among Patients Within a Hospital System: Protocol for a Mixed Methods Study

BACKGROUND

Within hospital systems, diverse subsets of patients are subject to minimally invasive procedures that provide therapeutic relief and necessary health data that are often perceived as anxiogenic or painful. These feelings are particularly relevant to patients experiencing procedures where they are conscious and not sedated or placed under general anesthesia that renders them incapacitated. Pharmacologic pain management and topical anesthetic creams are used to manage these feelings; however, distraction-based methods can provide nonpharmacologic means to modify the painful experience and discomfort often associated with these procedures. Recent studies support distraction as a useful method for reducing anxiety and pain and as a result, improving patient experience. Virtual reality (VR) is an emerging technology that provides an immersive user experience and can operate through a distraction-based method to reduce the negative or painful experience often related to procedures where the patient is conscious. Given the possible short-term and long-term outcomes of poorly managed pain and enduring among patients, health care professionals are challenged to improve patient well-being during medically essential procedures.

OBJECTIVE

The purpose of this pilot project is to assess the efficacy of using VR as a distraction-based intervention for anxiety or pain management compared to other nonpharmacologic interventions in a variety of hospital settings, specifically in patients undergoing lumbar puncture procedures and bone marrow biopsies at the oncology ward, patients receiving nerve block for a broken bone at an anesthesia or surgical center, patients undergoing a cleaning at a dental clinic, patients conscious during an ablation procedure at a cardiology clinic, and patients awake during a kidney biopsy at a nephrology clinic. This will provide the framework for additional studies in other health care settings.

METHODS

In a single visit, patients eligible for the study will complete brief preprocedural and postprocedural questionnaires about their perceived fear, anxiety, and pain levels. During the procedure, research assistants will place a VR headset on the patient and the patient will undergo a VR experience to distract from any pain felt from the procedure. Participants' vitals, including blood pressure, heart rate, and rate of respiration, will also be recorded before, during, and after the procedure.

RESULTS

The study is already underway, and results support a decrease in perceived pain by 1.00 and a decrease in perceived anxiety by 0.3 compared to the control group (on a 10-point Likert scale). Among the VR intervention group, the average rating for comfort was 4.35 out of 5.

CONCLUSIONS

This study will provide greater insight into how patients' perception of anxiety and pain could potentially be altered. Furthermore, metrics related to the operational efficiency of providing a VR intervention compared to a control will provide insight into the feasibility and integration of such technologies in routine practice.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52649.

The effect of virtual reality on pain, fear and emotional appearance during blood draw in pediatric patients at the hematology-oncology outpatient clinic: A randomized controlled study

OBJECTIVE

Invasive attempts can be very painful and stressful for pediatric patients. Virtual Reality (VR) can be used to distract patients undergoing such procedures in pediatric hematology oncology patients.

METHODS

A parallel trial design approach was adopted for this randomized controlled trial, guided by the CONSORT checklist. The study sample (n = 69) was divided into a VR group (n = 34) and a control group (n = 35) using stratified randomization. For the blood draw attempt, no distraction method was applied to the control group, while the children in the VR group were distracted from the procedure with the Epic Roller Coasters VR application. The primary variable assessed was pain, while secondary variables were fear and emotional appearance. The scores of emotional appearance, fear, and pain were compared with a Mann-Whitney U Test.

RESULTS

The pre-procedure emotional appearance score was 11.3 ± 4.3 in the VR group and 11.0 ± 5.0 in the control group, and the post-procedure score was 6.5 ± 3.3 in the VR group and 11.8 ± 5.3 in the control group, indicating a difference in emotional appearance after the procedure. VR group had lower negative emotional appearance, lower pain, and lower fear scores after procedure compared to the control group.

CONCLUSION

VR can be considered an effective approach to reducing the negative emotional appearance and for relieving pain and fear in children aged 4-12 years undergoing blood draw procedures in pediatric hematology and oncology outpatient unit (ClinicalTrials.gov: NCT05675358).

Impact of Facility Dog and Certified Child Life Specialist Dyad on Children's Pain and Anxiety During Needlestick Procedures in a Pediatric Hematology Oncology Clinic Setting

BACKGROUND

Pediatric Hematology Oncology patients undergo frequent needlestick procedures, often leading to negative outcomes including pain and anxiety. Animal-assisted therapy has been shown to minimize pediatric patient distress; however, its utilization by a Certified Child Life Specialist (CCLS) to reduce patient distress has not been widely studied.

METHODS

Pediatric patients receiving needlesticks in the Hematology Oncology Clinic were enrolled between March 2018 and May 2021. Patients who had scheduled visits when the facility dog was present were assigned to the intervention group. Patients were assigned to the control group if the facility dog was not present. The primary objective was to use the Children's Anxiety and Pain Scale to determine whether the CCLS and facility dog dyad minimized patient pain and anxiety during procedures.

RESULTS

A total of 285 patients, 5 to 17 years of age, were enrolled. One hundred forty-three patients were assigned the intervention and received procedural support from the CCLS and facility dog; 142 patients were assigned the control group and received support from the CCLS only. Patient-reported pain scores were significantly lower among patients who received the intervention ( P =0.033).

CONCLUSIONS

Utilization of a CCLS and facility dog dyad during painful needlestick procedures decreases patient-reported pain compared with utilization of CCLS support alone.

Exploring reported distress before and pain during needle insertion into a venous access port in children with cancer

BACKGROUND

Venous access port is commonly used during cancer treatment in children, yet little is known about how children experience such needle insertion procedures.

AIM

To study distress before and pain after venous access port needle insertion among children and adolescents with cancer. A second aim was to explore associations between their self-report of procedure-related distress and pain with proxy reports by parents and nurses.

METHOD

The sample included 43 children/adolescents, aged 1-16 years with cancer, treated at two Norwegian university hospitals. The patient, parent(s), and the nurse performing the procedure completed developmentally appropriate 11-point distress and pain scales before and immediately after the venous access port procedure. Data were analysed using descriptive statistics and non-parametric correlations.

ETHICAL ISSUES

The ethical code of conduct was followed and conformed to the ethical guidelines adopted by the Regional Committee for Medicine and Health Research and the data protector officer at the hospitals.

RESULTS

For the youngest children (1-5 years), the median distress proxy score was 8 (range 0-9) and pain proxy score 4 (range 0-10). Median distress and pain scores for children aged 6-12 years were 3 (range 0-9) and 1 (range 0-10), respectively, and for the adolescents (age 13-16) 0 (range 0-6) and 1 (range 0-5), respectively. Patients' self-reported distress and pain correlated highly with parents' (distress: rho = 0.83, p < 0.001, pain: rho = 0.92, p < 0.001) and with nurses' proxy ratings (distress: rho = 0.89, p < 0.001, pain: rho = 0.88, p < 0.001).

CONCLUSION

There were individual age differences in experienced distress/pain associated with venous access port needle insertion, with a trend for younger children to experience higher levels of distress/ pain than the older children. Children's self-report of distress/ pain concurred with both parental and nurse proxy reports.

Virtual Reality for Pediatric Oncology Port-A-Cath Access: A Pilot Effectiveness Study

Introduction: Port-a-cath procedures are among the most distressing aspects of pediatric cancer treatment. The current study aimed to examine the usability of virtual reality (VR) interventions for children undergoing chemotherapy port-access procedures. Methods: Families (N = 20) of children with cancer, 4-17 years old (M = 8.70 years, SD = 3.71), were recruited. Patients and parents rated patients' dizziness, nausea, pain, and distress, and participants were shown how to use VR prior to the use of the procedure. After port-a-cath access, patients and parents rated pain and distress during the intervention. Semistructured interviews were conducted to examine the usability of the intervention. Result: A significant difference was identified for change in children's pain score for younger children, F(2, 11) = 4.16, p < .05. A significant decrease in fear scores was observed on child and parent reports. The VR headset was used during the procedure by 87.5% of the participants, while the rest used it before but took it off during the procedure, and 85.7% wished to use it again. No concerns were reported by 84.6% of the nurses and 92.3% reported no interference with their workflow. Discussion: More research is needed to fully understand the benefits of VR interventions during children's chemotherapy port procedures. The findings of this pilot study suggest that the use of commercially available VR intervention may reduce children's fear and pain levels during the port-a-cath procedure, especially for younger children.

Utilization, Delivery, and Outcomes of Dance/Movement Therapy for Pediatric Oncology Patients and their Caregivers: A Retrospective Chart Review

Children with cancer and their caregivers face physical and psychosocial challenges during and after treatment. Dance/movement therapy (DMT) has been used to improve well-being, promote healthy coping, and mitigate the impact of illness, but limited knowledge exists regarding DMT utilization, delivery, and outcomes in pediatric oncology. This retrospective study aimed to identify reasons for referral to DMT, DMT visit characteristics, key DMT techniques and processes, and clinician-reported outcomes. We examined the electronic medical records of 100 randomly selected pediatric patients (resulting in 1160 visits) who received DMT services between 2011 and 2021. Sociodemographic, clinical, and visit characteristics, referral reasons, and clinician-reported outcomes were reported as frequency and proportions. Qualitative thematic analysis was used to identify key DMT techniques and processes. Among 100 patients (63% female, aged 0-27 years), 77.9% were referred for psychological distress and 19.6% for pain. Two distinct DMT approaches were used during visits: a traditional DMT approach (77%) and a multisensory DMT approach (23%). The most common visit length was 15-25 min (41.6%), followed by sessions of 30-45 min (22.5%) and ≤10 min (18.1%). A total of 61.9% of DMT visits were inpatient and 38.1% outpatient. Of all visits, 8.8% were new and 91.2% were follow-ups. Caregivers were engaged in treatment in 43.7% of visits, and 5.5% of visits focused entirely on the work with the caregiver. DMT intervention focused on self-expression, emotional self-regulation, coping strategies, socialization, and caregiver-child interaction. Clinician-reported outcomes included enhanced coping with hospital experience (58%), improved pain management (27%), improved self-regulation (21%), and increased physical activation (13.2%). The results suggest DMT as a supportive intervention for psychological distress and pain management in pediatric oncology patients and provide insights into DMT practices and outcomes to guide intervention development and future research.

Pain mitigation and management strategies for anti-GD2 infusions: An expert consensus

Monoclonal antibodies (mAbs) targeting disialoganglioside 2 (GD2) are an important treatment advance for high-risk neuroblastoma, including in patients with refractory or relapsed disease. Dinutuximab and dinutuximab beta are administered for ≥8 hours (and up to 10 days for dinutuximab beta), whereas naxitamab is administered over 0.5 to 2 hours as tolerated. As acute pain is a class effect of anti-GD2 mAbs, effective pain management is crucial to successful treatment. Here, we provide an overview of current pain-management strategies for anti-GD2 mAb infusions, with a focus on strategies suitable for naxitamab infusions, which cause a more rapid onset of often severe pain. We discuss opioid analgesics, ketamine, gabapentin, and other similar agents and nonpharmacologic approaches. Potential future pain-management options are also discussed, in addition to the use of sedatives to reduce the anxiety that may be associated with infusion-related pain. In this expert consensus paper, specific guidance for pain management during naxitamab infusions is provided, as these infusions are administered over 0.5 to 2 hours and may not need overnight hospitalization based on the physician's assessment, and require rapid-onset analgesia options suitable for potential outpatient administration.

Evaluation of health-related quality of life and its domains in pediatric patients with cancer

BACKGROUND

Health-related quality of life has emerged as a significant component in pediatric oncology research during the last several decades. Measures of health-related quality of life provide a thorough assessment of the child's response to medical therapy, disease course, and adjustment outcomes in the context of pediatric oncology.

METHODS

The aim of the present study was to assess the cancer-specific health-related quality of life in cancer pediatric patients and to evaluate the contribution of its domains and some of the anthropometric, sociodemographic, and treatment-related variables on the overall quality of life, by using the PedsQL™ 3.0 Cancer Module.

RESULTS

The study included 110 cases. The mean value of the PedsQL™ 3.0 Cancer Module score was 49.3 ± 12.0. The lowest mean score of quality of life was for the "procedure anxiety" (8.7 ± 23.9), followed by the "worry" domains (16.6 ± 28.5). Higher "frequency of hospital visits" was associated with increased feeling of pain and treatment anxiety yet decrease in suffering from nausea and vice versa. The longer period of hospital admission for more than half of the recommended treatment period was associated with reduced pain suffering on the expense of increase in feeling of worry as well as communication problems. The perceived physical appearance was better among those patients who spent a treatment period for 3-6 months when compared to those who spent a treatment period less than 3 months or more than 6 months. There was a highly significant association between all the eight-cancer-specific quality-of-life domains except the pain domain- and the overall quality-of-life log scores. Nausea problem followed by worry and cognitive problems was the most effective domains on the overall quality-of-life score.

CONCLUSION

Cancer pediatric patients suffered low quality of life especially for anxiety procedure and worry domains with special consideration for the impact of nausea, worry, and cognitive problems on their perception of quality of life.

The physical and psychological outcomes of art therapy in pediatric palliative care: A systematic review

Background

The integration of art therapy in health care is a growing trend in the care of cancer patients. Therefore, this study aimed to identify the physical and mental benefits of art in children with cancer.

Materials and Methods

A systematic review of English articles using Google Scholar, MEDLINE via PubMed, Scopus, the Cochrane Database of Systematic Reviews, and the Web of Science was conducted. Relevant keywords for cancer, child, art therapy and their synonyms were used accordingly. All searches were conducted to December 31, 2021.Relevant articles were included studies published in English and involving children aged 0-18 years. Studies evaluated the effects of art therapy in children with cancer.

Results

Seventeen studies had inclusion criteria, of which 12 studies were performed by clinical trial and 5 studies were performed by quasi-experimental method. Sixteen studies evaluated one type of art-therapy intervention, while one study used a combination of art-therapy approaches.The results showed that art-based interventions in the physical dimension lead to more physical activity, stability in breathing, and heart rate, and these children reported less pain. In the dimensions of psychology had less anxiety, depression, and anger but at the same time had a better quality of life and more coping-related behaviors.

Conclusion

It seems that the use of art therapy in pediatric palliative care with cancer can have good physical and psychological results for the child, but it is suggested to evaluate the effects of these interventions in children at the end of life.

Implementing NIH Behavior Change Consortium Treatment Fidelity Recommendations in a Multi-Site Randomized Controlled Trial of an Active Music Engagement Intervention for Young Children with Cancer and Parents

Treatment fidelity is the use of methodological strategies to monitor and enhance reliability and validity of behavioral intervention trials. Despite availability of guidelines and checklists, treatment fidelity remains underreported, hindering evaluation, interpretation, and cross-study comparisons. Treatment fidelity is particularly important for music interventions given the inherent complexity of musical stimuli and flexibility required for tailored delivery. The purpose of this paper is to define and describe treatment fidelity strategies for our trial of a music-based play intervention for young children with cancer and parents grounded in the NIH Behavior Change Consortium Treatment Fidelity Recommendations. We report strategies for all 5 areas: study design, training providers, delivery of treatment, receipt of treatment, and enactment of treatment skills. We also discuss 4 challenges our team encountered, including: (1) standardizing live music delivery, (2) defining boundaries for tailored intervention delivery, (3) managing extended time between participants, and (4) minimizing risk for bias. This paper expands on current fidelity literature and may provide a working model for other investigators examining dyadic and/or active music interventions.

Barriers and Opportunities for Patient-Reported Outcome Implementation: A National Pediatrician Survey in the United States

Purpose: To characterize pediatricians’ perceived barriers and areas of confidence in assessing patient-reported outcomes (PROs) in the U.S., and to test associations of these factors with implementing PRO assessment. Methods: Using a random sample from the members of American Medical Association, we recruited general pediatricians and pediatric subspecialists to complete a survey (July 2011 to December 2013). Perceived barriers and confidence in PRO assessment were compared by age, pediatric specialty (general pediatrics, seven subspecialties), practice settings (academic, private), and region of practice. Multivariable logistic regressions tested associations of demographic factors, barriers, and confidence factors with the implementation of PRO assessment. Findings: The survey was completed by 458 participants (response rate 48.5%); of these, 40.4%, 15.9%, 15.5%, and 8.1% were general pediatricians, cardiology, hematology/oncology, and pulmonary specialists, respectively. PRO assessment was implemented by 29.0% of the pediatricians. The top five barriers for PRO assessment included limited time/manpower (79.0%), limited training (77.4%), lengthy PRO instruments (76%), lack of meaningful cut-offs on PRO scores (75.5%), and unavailable PRO instruments (75.0%). Limited knowledge of PROs (OR 4.10; 95% CI 2.21, 7.60) and unavailability of PRO instruments (OR 1.87; 95% CI 1.01, 3.49) increased the odds of not implementing the assessment, whereas confidence in PRO assessments compatible with norms (OR 0.41; 95% CI 0.23, 0.72) and perceived benefit over clinical judgment alone (OR 0.53; 95% CI 0.31, 0.93) decreased the odds of not implementing the assessment. Interpretation: significant barriers to PRO assessment in pediatric settings suggest the need for providing training, resources, and practical guidance toward implementation. Patient or Public Contribution: healthcare service users contributed to this study by completing a survey and providing feedback about the barriers and areas of confidence in assessing PROs for pediatric populations.

A Pilot Randomized Controlled Trial of Virtual Reality Distraction to Reduce Procedural Pain During Subcutaneous Port Access in Children and Adolescents With Cancer

OBJECTIVES

We aimed to determine the feasibility of virtual reality (VR) distraction for children with cancer undergoing subcutaneous port (SCP) access. We also aimed to estimate preliminary treatment effects of VR compared with an active distraction control (iPad).

MATERIALS AND METHODS

A single-site pilot randomized controlled trial comparing VR to iPad distraction was conducted. Eligible children and adolescents were aged 8 to 18 years undergoing treatment for cancer with upcoming SCP needle insertions. Intervention acceptability was evaluated by child, parent, and nurse self-report. Preliminary effectiveness outcomes included child-reported pain intensity, distress, and fear. Preliminary effectiveness was determined using logistic regression models with outcomes compared between groups using preprocedure scores as covariates.

RESULTS

Twenty participants (mean age 12 y) were randomized to each group. The most common diagnosis was acute lymphocytic leukemia (n=23, 58%). Most eligible children and adolescents (62%) participated, and 1 withdrew after randomization to the iPad group. Nurses, parents, and children reported the interventions in both groups to be acceptable, with the VR participants reporting significantly higher immersion in the distraction environment (P=0.0318). Although not statistically significant, more VR group participants indicated no pain (65% vs. 45%) and no distress (80% vs. 47%) during the procedure compared with the iPad group. Fear was similar across groups, with ~60% of the sample indicating no fear.

DISCUSSION

VR was feasible and acceptable to implement as an intervention during SCP access. Preliminary effectiveness results indicate that VR may reduce distress and distress compared with iPad distraction. These data will inform design of a future full-scale randomized controlled trial.

Identification and Characteristics of the Three Subgroups of Pain in Chinese Children and Adolescents with Cancer

PURPOSE

Pain is a distressing symptom for children and adolescents with cancer and is experienced by individuals differently. This study sought to determine subgroups according to their pain experiences, and how demographic, clinical, and quality of life (QOL)-related characteristics might differ across subgroups.

DESIGN AND METHODS

This cross-sectional study recruited 187 pediatric patients with cancer aged 8 to 17 years old and asked them to complete measures of pain intensity, pain duration, pain interference and pain control using the Chinese translation of the validated questionnaire from the Pain Squad app, as well as 7 PROMIS measures assessing QOL-related outcomes. Latent profile analysis (LPA) was used to identify latent subgroups.

RESULTS

Three subgroups of children were identified: low-pain/low-duration (69.5%), moderate-pain/high-duration (19.8%), and high-pain/moderate-duration (10.7%). Hospitalized children were more likely to be in the moderate-pain/high-duration subgroup. Children in the high-pain/moderate-duration subgroup were more likely to be cared for by unemployed caregivers. Scores on depressive symptoms (p = 0.002), anger (p < 0.001), anxiety (p = 0.045), fatigue (p = 0.044), and mobility (p = 0.008) questionnaire were significantly worse in the high-pain/moderate-duration subgroup than the other two subgroup.

PRACTICE IMPLICATIONS

This study provides a scientific foundation for further studies exploring predictive factors related to pain experiences. More targeted treatment strategies targeting the specific characteristics of each subgroup will help improve patients' QOL and use of medical resources.

CONCLUSIONS

The 3 identified pain subgroups demonstrate the heterogeneity in pain experiences among pediatric patients with cancer. Knowledge of these subgroups can assist clinicians in better identifying and targeting pain treatment for children with cancer.

Reducing pain in children with cancer at home: a feasibility study of the KLIK pain monitor app

PURPOSE

This study assessed adherence to, feasibility of, and barriers and facilitators of implementation of an app developed to monitor and follow-up with pain in children with cancer at home.

METHODS

Children (8-18 years) receiving cancer treatment (all diagnoses) or their parents (of children aged 0-7 years) used the KLIK Pain Monitor app for 3 weeks. Pain was assessed twice daily using an 11-point numeric rating scale (NRS-11) (ranging from 0 to 10). Healthcare professionals (HCP's) from the hospital's Pediatric Pain Service were instructed to follow-up with clinically significant pain scores (≥ 4) within 120 min (scores 4-6) or 30 min (scores 7-10). Adherence, feasibility, and implementation outcomes were assessed using questionnaires, app log data, and interviews.

RESULTS

Twenty-seven children (M age = 7.3 years, 51.8% male) and six HCP's participated. Sixty-three percent (N = 17) of families used the app on a daily basis during three weeks, and 18.5% (N = 5) reported pain scores twice daily during that time (family adherence). Twelve out of 27 children (44.4%) reported a clinically significant pain score at least once. In 70% (14/20) of clinically significant pain scores, HCP's followed-up with families within the set timeframe (HCP adherence). Outcomes reveal feasibility for the majority of app functions (i.e., positive evaluation by ≥ 70% families/HCP's), and non-feasible aspects could be resolved. Identified barriers and facilitators were used to improve future implementation efforts.

CONCLUSION

Use of the KLIK Pain Monitor app seems feasible. Future research will determine its effectiveness in reducing pain in children with cancer at home.

Use of active video games with or without videoconferencing on health outcomes in adolescent and young adult cancer survivors: a systematic review

PURPOSE

Adolescent and young adult (AYA) cancer survivors experience greater functional deficits compared to non-cancer peers or older survivors with a similar diagnosis. Physical activity (PA) is a key strategy for mitigating functional decline, and motivation and peer support are critical PA facilitators in AYA cancer survivors. Active video games (AVGs) may be a "gateway" method to promote PA. Further, integrating AVGs into group videoconferencing, a medium used by AYAs to socialize, can capitalize on peer support needed for PA motivation. Thus, we examined the use of AVGs and/or videoconferencing in PA interventions that included AYA survivors and the effect on physical function and health outcomes.

METHODS

Seven electronic databases were searched from incept to January 2020. Search terms included videoconferencing, video games, exercise, and cancer. The protocol is registered on PROSPERO: CRD42020163491. Two reviewers evaluated eligibility and methodological quality using Cochrane's risk of bias tools.

RESULTS

Six unique studies were included with 97% reviewer agreement. All used AVGs, none used videoconferencing alone, and one used both. Study designs and outcome measures were heterogeneous. Only one study solely targeted AYA survivors. Most were low to medium quality. Few showed significant improvements in quality of life (QOL) and fatigue (n=3), coordination/balance (n=2), and aerobic capacity (n=1).

CONCLUSIONS

PA interventions using AVGs and/or videoconferencing may improve QOL and fatigue, but evidence on function is lacking. Rigorous interventions targeting AYA survivors are needed.

IMPLICATIONS FOR CANCER SURVIVORS

Using AVGs and/or videoconferencing to facilitate PA may improve QOL and fatigue.

A scoping review of chronic pain in emerging adults

Much of the adult chronic pain literature addresses pain in typical pain cohorts of middle-aged to older individuals. To date, little research has focused on chronic pain in younger adults, who likely have a completely different pain experience. This scoping review aimed to address this gap by describing the emerging adult (18-29 years) chronic pain experience regarding prevalence, associated factors, outcomes, and pain management. Searches of primary electronic databases including PubMed, Embase, PsycINFO, and CINAHL were performed on February 26, 2020, restricting the publication date from database inception to December 31, 2019. The search strategy, conducted in English, covered search term combinations of "chronic pain" and "young adults." A total of 6,612 records were considered-3,141 after removing duplicates. These records were screened by title and abstract; 871 through full-text screening. Of these, 78 articles covered the topic of emerging adults with chronic pain. Collectively, results indicated that between 5% and 30% of emerging adults experience chronic pain, depending on the sample and exact chronic pain definition. The most consistent associated factors were female sex, familial chronic pain, and previous experiences of chronic pain in childhood. Anxiety, depression, and sleep issues appeared associated both before and after the onset of chronic pain. Outcomes of pain included interruptions to study and work, poorer physical functioning, and pain-related interference to socializing. We observed that few pain treatments have been tested specifically in this cohort. A greater ongoing focus on chronic pain in emerging adults is required to improve long-lasting outcomes.

Alleviating Terminal Pediatric Cancer Pain

Terminal cancer pain remains one of the most distressing aspects of pediatric oncology practice. Opioids are the cornerstone of cancer pain management at end-of-life and fortunately, most pain at end-of-life can be managed successfully. This article presents a practical step-by-step approach to alleviating pediatric terminal cancer pain, which can be delivered across settings.

Understanding the toolbox: A mixed methods study of attitudes, barriers and facilitators in parental intervention of children's cancer pain at home

Children with cancer experience pain throughout their cancer trajectory. Pain has short- and long-term negative consequences for children physically and psychologically. Children with cancer spend more time at home with their families and less time in hospital. While this has benefits for quality of life, it shifts responsibility for pain management from healthcare professionals to parents. Little is known about parents' pain management abilities in this setting. This study aimed to understand how parents of children with cancer manage their child's pain at home. A convergent, parallel, mixed methods design including pain diaries, surveys and interviews was used. Participants were parents of children with cancer on active treatment recruited from one tertiary cancer centre. Each data collection method was analysed separately and then integrated. Parents frequently under-medicate their child's pain at home. Practical barriers including the analgesic context and children finding medications unpalatable led parents to prefer non-pharmacological interventions. Attitudinal and practical barriers result in parents having an "empty toolbox" of pharmacological interventions. Consequently non-pharmacological interventions are essential to parents managing their child's cancer pain at home.

Exploring the Potential of Aromatherapy as an Adjuvant Therapy in Cancer and its Complications: A Comprehensive Update

BACKGROUND

Aromatherapy is a traditional practice of employing essential oils for the therapeutic purposes, currently headed under the category of complementary and adjuvant medicine.

OBJECTIVE

The aim of this review article is to summarize the potential health benefits of aromatic essential oil from traditional times till the present. It also proposed some mechanisms which can be utilized as basis for using aromatherapy in cancer and cancer linked complications.

METHODS

To find out the relevant and authentic data, several search engines like Science direct, Pubmed, research gate, etc. were thoroughly checked by inserting key words like aromatherapy, complementary, adjuvant therapy etc. to collect the relevant material in context of article. Also, the chemical components of essential oil were classified based on the presence of functional groups, which are further explored for their cytotoxic potential.

RESULTS

The result depicted the anti-cancer potential of chemical constituents of essential oil against different types of cancer. Moreover, the essential oils show promising anti-inflammatory, anti-microbial, anti-oxidant and anti-mutagenic potential in several studies, which collectively can form the basis for initiation of its anti-cancer utility.

CONCLUSION

Aromatherapy can serve as adjuvant economic therapy in cancer after the standardization of protocol.

Pain Squad+ smartphone app to support real-time pain treatment for adolescents with cancer: protocol for a randomised controlled trial

INTRODUCTION

Pain negatively affects the health-related quality of life (HRQL) of adolescents with cancer. The Pain Squad+ smartphone-based application (app), has been developed to provide adolescents with real-time pain self-management support. The app uses a validated pain assessment and personalised pain treatment advice with centralised decision support via a registered nurse to enable real-time pain treatment in all settings. The algorithm informing pain treatment advice is evidence-based and expert-vetted. This trial will longitudinally evaluate the impact of Pain Squad+, with or without the addition of nurse support, on adolescent health and cost outcomes.

METHODS AND ANALYSIS

This will be a pragmatic, multicentre, waitlist controlled, 3-arm parallel-group superiority randomised trial with 1:1:1 allocation enrolling 74 adolescents with cancer per arm from nine cancer centres. Participants will be 12 to 18 years, English-speaking and with ≥3/10 pain. Exclusion criteria are significant comorbidities, end-of-life status or enrolment in a concurrent pain study. The primary aim is to determine the effect of Pain Squad+, with and without nurse support, on pain intensity in adolescents with cancer, when compared with a waitlist control group. The secondary aims are to determine the immediate and sustained effect over time of using Pain Squad+, with and without nurse support, as per prospective outcome measurements of pain interference, HRQL, pain self-efficacy and cost. Linear mixed models with baseline scores as a covariate will be used. Qualitative interviews with adolescents from all trial arms will be conducted and analysed.

ETHICS AND DISSEMINATION

This trial is approved by the Hospital for Sick Children Research Ethics Board. Results will provide data to guide adolescents with cancer and healthcare teams in treating pain. Dissemination will occur through partnerships with stakeholder groups, scientific meetings, publications, mass media releases and consumer detailing.

TRIAL REGISTRATION NUMBER

NCT03632343 (ClinicalTrials.gov).

The Critical Role of Parents in Pediatric Cancer-Related Pain Management: a Review and Call to Action

PURPOSE OF REVIEW

Even with optimized medical management, pain remains an inevitable part of pediatric cancer care. The most effective interventions for nonpharmacologic pain management within pediatric psychology include parent skills training. This review specifically explored the role of parents in cancer-related pain management with the goal of defining a set of evidence-based skills that could translate to improved pediatric cancer pain management.

RECENT FINDINGS

Pain is now widely understood to be both a sensory and emotional experience. As a result, within pediatric non-cancer pain management there is increasing application of the biopsychosocial model for pain management, inclusive of evidence-based psychological intervention. This review, specifically focusing on the role of parent training in cancer-related pain management, finds few interventions that systematically included parents. There is a need for continued evidence-based innovation and knowledge dissemination in this area of care. This paper highlights a critical gap in translational science within pediatric cancer pain management, namely, that parents who have a child with cancer are not reliably gaining access to well-established, evidence-based psychological skills training that can help to mitigate pain and pain-related stress. Based on the literature, the authors provide recommendations for generating adaptable, evidence-informed interventions that support and empower parents to help their child with pain management through all phases of cancer treatment.

Quality of Life and Pain Experienced by Children and Adolescents With Cancer at Home Following Discharge From the Hospital

An exploratory study was conducted to examine the quality of life and pain experienced by patients with pediatric cancer at home after discharge. Physical, cognitive, social, and emotional aspects of quality of life were measured and how these may be affected by age, sex, diagnosis, and pain status. The authors also characterized intensity, location, and quality of pain experienced. A sample of 33 patients participating in a larger study was selected on the basis of having pain on the day of discharge and having completed the Pediatric Quality of Life Inventory Generic, Cancer Module, Multidimensional Fatigue Scale, and the Adolescent Pediatric Pain Tool at home. Cancer diagnoses were leukemias/lymphomas (42.4%), brain/central nervous system tumors (27.3%), sarcomas (24.2%), or other (6.1%). More than half of patients reported pain (n=17; 51.5%). Patients with pain had more fatigue affecting the quality of life (P=0.01), and lower physical and emotional functioning, leading to lower overall health-related quality of life scores (P=0.011). Female individuals and adolescents reported worse emotional functioning (P=0.02 and P=0.05, respectively). Physical, cognitive, and social functioning were lowest among patients diagnosed with sarcomas (P=0.00, P=0.01, and P=0.04, respectively). It is important to understand the symptom experience of patients at home as a first step in moving towards optimal discharge teaching and treatment.

Perspectives on Cancer Pain Assessment and Management in Children

OBJECTIVE

To report evidence regarding pain assessment and management for children and adolescents receiving treatment for cancer.

DATA SOURCES

Published research and clinical guidelines.

CONCLUSION

Children and adolescents experience multiple sources of pain across the cancer continuum. They require developmentally relevant approaches when assessing and managing pain. This review suggests that consideration of the developmental stage and age of the child are essential in both pain assessment and pain management.

IMPLICATIONS FOR NURSING PRACTICE

Pediatric oncology nurses play a key role in developmentally appropriate pain assessment, identification of potential strategies to manage pain, and delivery of pharmacologic and nonpharmacologic therapies.

The Evolution of Hypnosis in the Profession of Nursing: We've Come a Long Way, Baby, and Still Have a Long Way to Go

Registered nurses (RNs) are the largest, most diverse, and most respected of all healthcare professions in the United States, numbering over 3.5 million (Gallup poll, 2017). Nurses have evolved from being the handmaidens of physicians and bedpan handlers to highly trained and educated clinicians who have assumed an important, integral, and indispensable role in the healthcare system. The capabilities of nurses to expand the excellent care they can provide has historically been thwarted by others in the healthcare field, including in the area of hypnosis. This article begins with a historical perspective on the education, training, and ever-expanding profession of nursing. The multiplicity of settings where nurses have the opportunity to incorporate clinical hypnosis into the care of their patients is discussed.

Care management for the hospitalized child with chronic cancer pain: intervening conditions

ABSTRACT Objective: To understand the intervening conditions of care management for the hospitalized child with chronic cancer pain. Method: Qualitative research, anchored in the methodological and theoretical frameworks, respectively, Grounded Theory and Complex Thinking. The semi-structured interview and non-participant observation were used to collect the data. Twenty-one health professionals, organized in three sample groups: nurses; nursing technicians; and professionals of the multiprofessional health staff. Results: They emerged as intervening conditions of care management: human resources and materials, teamwork, absenteeism, professional relocation, professional qualification, family, playful, dialogue, empathy and caring relationship. Conclusion: It was understood as limiting conditions for care management: deficits of human resources and materials, absenteeism, ineffective teamwork, professional relocation, and insufficient professional qualification. On the other hand, they were presented as facilitating conditions: adequate professional knowledge, effective teamwork, dialogue, empathy, playful and affective relationship with the child.

The Implementation Effectiveness of a Freely Available Pediatric Cancer Pain Assessment App: A Pilot Implementation Study

Background

Pain Squad is an evidence-based, freely available iOS app designed to assess pain in children with cancer. Once research-based technologies such as Pain Squad are validated, it is important to evaluate their performance in natural settings to optimize their real-world clinical use.

Objective

The objective of this study was to evaluate the implementation effectiveness of Pain Squad in a natural setting.

Methods

Parents of 149 children with cancer (aged 8-18 years) were contacted to invite their child to participate. Participating children downloaded Pain Squad on their own iOS devices from the Apple App Store and reported their pain using the app twice daily for 1 week. Participants then emailed their pain reports from the app to the research team and completed an online survey on their experiences. Key implementation outcomes included acceptability, appropriateness, cost, feasibility, fidelity, penetration, and sustainability.

Results

Of the 149 parents contacted, 16 of their children agreed to participate. More than a third (6/16, 37.5%) of participating children returned their pain reports to the research team. Adherence to the pain assessments was 62.1% (mean 8.7/14 assessments). The 6 children who returned reports rated the app as highly feasible to download and use and rated their overall experience as acceptable. They also reported that they would be willing to sustain their Pain Squad use over several weeks and that they would recommend it to other children with cancer, which suggests that it may have potential for penetration.

Conclusions

While Pain Squad was well received by the small number of children who completed the study, user uptake, engagement, and adherence were significant barriers to the implementation of Pain Squad in a natural setting. Implementation studies such as this highlight important challenges and opportunities for promoting the use and uptake of evidence-based technologies by the intended end-users.

Psychosocial Issues and Lifestyle Changes for the Renal Patient

This article provides an overview of the psychosocial issues faced by those with renal disease. The article discusses the physiologic connection between anxiety, depression, and pain-symptoms commonly seen in renal disease and other chronic illnesses. The application of integrative medicine or nonallopathic medicine and its role in the management of anxiety, depression, and pain are presented. Also presented is evidence surrounding several frequently used nonallopathic modalities appropriate for incorporation into a comprehensive management regimen for renal patients to reduce symptom burden. The article concludes with a discussion on the role of palliative care in treatment decisions for renal patients.

Using the MEDiPORT humanoid robot to reduce procedural pain and distress in children with cancer: A pilot randomized controlled trial

BACKGROUND

Subcutaneous port needle insertions are painful and distressing for children with cancer. The interactive MEDiPORT robot has been programmed to implement psychological strategies to decrease pain and distress during this procedure. This study assessed the feasibility of a future MEDiPORT trial. The secondary aim was to determine the preliminary effectiveness of MEDiPORT in reducing child pain and distress during subcutaneous port accesses.

METHODS

This 5-month pilot randomized controlled trial used a web-based service to randomize 4- to 9-year-olds with cancer to the MEDiPORT cognitive-behavioral arm (robot using evidence-based cognitive-behavioral interventions) or active distraction arm (robot dancing and singing) while a nurse conducted a needle insertion. We assessed accrual and retention; technical difficulties; outcome measure completion by children, parents, and nurses; time taken to complete the study and clinical procedure; and child-, parent-, and nurse-rated acceptability. Descriptive analyses, with exploratory inferential testing of child pain and distress data, were used to address study aims.

RESULTS

Forty children were randomized across study arms. Most (85%) eligible children participated and no children withdrew. Technical difficulties were more common in the cognitive-behavioral arm. Completion times for the study and needle insertion were acceptable and >96% of outcome measure items were completed. Overall, MEDiPORT and the study were acceptable to participants. There was no difference in pain between arms, but distress during the procedure was less pronounced in the active distraction arm.

CONCLUSION

The MEDiPORT study appears feasible to implement as an adequately-powered effectiveness-assessing trial following modifications to the intervention and study protocol. ClinicalTrials.gov NCT02611739.

Mind-Body Therapies in Childhood Cancer

PURPOSE OF REVIEW

Advances in the field of Pediatric Oncology have led to increased survival rates in children with cancer, and addressing the emotional well-being and quality of life of this specific population is a critical component of care. Mind-body therapies (MBTs) are an adjuvant modality of treatment that appears to have a positive impact on patient quality of life, patient mental health, and family perceptions toward illness. In this review, we describe several evidence-based MBTs, such as art therapy, meditation, prayer, music therapy, hypnosis and relaxation techniques, their use, and our personal experience with MBT in our institution.

RECENT FINDINGS

Current data suggests that MBTs have been effective in decreasing symptoms related to oncologic pathology in children. Based on experience in our institution, the administration of these therapies can be expanded with the use of technology and also foster family inclusion in care, which can lead to improved quality of life for the patient and family. Further studies are warranted to ascertain the effects of MBTs in childhood cancer. MBTs are increasingly important in the care of youth with oncologic disease. It is necessary to increase the quantity and quality of research for the selection and inclusion of MBT in this population.

Usability Testing of an Interactive Virtual Reality Distraction Intervention to Reduce Procedural Pain in Children and Adolescents With Cancer [Formula: see text]

PURPOSE

Needle procedures are among the most distressing aspects of pediatric cancer-related treatment. Virtual reality (VR) distraction offers promise for needle-related pain and distress given its highly immersive and interactive virtual environment. This study assessed the usability (ease of use and understanding, acceptability) of a custom VR intervention for children with cancer undergoing implantable venous access device (IVAD) needle insertion.

METHOD

Three iterative cycles of mixed-method usability testing with semistructured interviews were undertaken to refine the VR.

RESULTS

Participants included 17 children and adolescents (8-18 years old) with cancer who used the VR intervention prior to or during IVAD access. Most participants reported the VR as easy to use (82%) and understand (94%), and would like to use it during subsequent needle procedures (94%). Based on usability testing, refinements were made to VR hardware, software, and clinical implementation. Refinements focused on increasing responsiveness, interaction, and immersion of the VR program, reducing head movement for VR interaction, and enabling participant alerts to steps of the procedure by clinical staff. No adverse events of nausea or dizziness were reported.

CONCLUSIONS

The VR intervention was deemed acceptable and safe. Next steps include assessing feasibility and effectiveness of the VR intervention for pain and distress.

Perceptions of Adolescents With Cancer Related to a Pain Management App and Its Evaluation: Qualitative Study Nested Within a Multicenter Pilot Feasibility Study

BACKGROUND

Pain in adolescents with cancer is common and negatively impacts health-related quality of life. The Pain Squad+ smartphone app, capable of providing adolescents with real-time pain management support, was developed to enhance pain management using a phased approach (ie, systematic review, consensus conference and vetting, iterative usability testing cycles). A 28-day Pain Squad+ pilot was conducted with 40 adolescents with cancer to evaluate the feasibility of implementing the app in a future clinical trial and to obtain estimates of treatment effect.

OBJECTIVE

The objective of our nested qualitative study was to elucidate the perceptions of adolescents with cancer to determine the acceptability and perceived helpfulness of Pain Squad+, suggestions for app improvement, and satisfaction with the pilot study protocol.

METHODS

Post pilot study participation, telephone-based, semistructured, and audio-recorded exit interviews were conducted with 20 adolescents with cancer (12-18 years). All interviews were transcribed and independently coded by 2 study team members. Content analysis was conducted to identify data categories and overarching themes.

RESULTS

Five major themes comprising multiple categories and codes emerged. These themes focused on the acceptability of the intervention, acceptability of the study, the perceived active ingredients of the intervention, the suitability of the intervention to adolescents' lives, and recommendations for intervention improvement.

CONCLUSIONS

Overall, Pain Squad+ and the pilot study protocol were acceptable to adolescents with cancer. Suggestions for intervention and study improvements will be incorporated into the design of a future randomized clinical trial (RCT) aimed at assessing the effectiveness of Pain Squad+ on adolescents with cancer health outcomes.

Children's experiences and responses towards an intervention for psychological preparation for radiotherapy

BACKGROUND

Children can experience distress when undergoing radiotherapy as a reaction to being scared of and unfamiliar with the procedure. The aim was to evaluate children's experiences and responses towards an intervention for psychological preparation for radiotherapy.

METHODS

A case control design with qualitative content analysis of semi-structured interviews and statistical analysis of anxiety ratings were used for evaluating a strategy for psychological preparation and distraction. Fifty-seven children aged 2 to 18 years and their parents participated - 30 children in the baseline group and 27 in the intervention group. Child interviews were performed and the child and their parents rated the child's anxiety.

RESULTS

The intervention was most appropriate for the younger children, who enjoyed the digital story, the stuffed animal and training with their parents. There were some technical problems and the digital story was not detailed enough to fit exactly with various cancer diagnoses. Children described suggestions for improvement of the intervention. The ratings of the child's anxiety during radiation treatment showed no differences between the baseline group and the intervention group.

CONCLUSIONS

The children of all the age groups experienced their interventions as positive. The strength of the intervention was that it encouraged interaction within the family and provided an opportunity for siblings and peers to take part in what the child was going through. Future research on children's experiences to interventions should be encouraged. The intervention and the technical solutions could improve by further development.

TRIAL REGISTRATION

The study design was structured as an un-matched case-control study, baseline group vs. intervention group.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02993978 , Protocol Record 2012-113-31 M. Retrospectively registered - 21 November 2016.

Parents' Voice in Managing the Pain of Children with Cancer during Palliative Care

Context:

Pain experienced by children can adversely affect their growth and development. Pain is a major health problem for cancer patients and remains an unresolved problem.

Aim:

To know how the experiences of mothers managing their children's pain during palliative care following cancer diagnosis.

Background:

Pain experienced by children can adversely affect their growth and development.

Subject and Methods:

Using qualitative methods within a descriptive phenomenological approach, in-depth interviews were conducted with parents (mostly mothers) of eight children diagnosed with cancer. The data were collected using the snowball sampling method.

Results:

Participants experienced in managing the pain of children with cancer. Analysis of the results identified 8 themes: the dimensions of pain experienced by children undergoing palliative care; mothers' physical and psychological responses; mothers' emotional responses; barriers encountered by mothers when taking care of their child at home; mothers' interventions to reduce their child's pain; mothers' efforts to distract their child from pain; giving encouragement when the child is in pain; and mothers' efforts and prayers to make their child comfort.

Conclusion:

It can be concluded that the child's pain is the main cause of mothers' stress and pressure and also affects the daily lives of mothers and children. Along with the most effective intervention, nurses need to provide mothers and children with adequate information about cancer pain.

Implementation and preliminary effectiveness of a real-time pain management smartphone app for adolescents with cancer: A multicenter pilot clinical study

BACKGROUND

Pain in adolescents with cancer (12-18 years) is common and negatively impacts health-related quality of life (HRQL). The Pain Squad+ smartphone app, which provides adolescents with real-time pain self-management support, was developed to address this issue. This study evaluated the implementation of the app to inform a future randomized controlled trial (RCT) and obtain treatment effect estimates for pain intensity, pain interference, HRQL, and self-efficacy.

PROCEDURE

A one-group baseline/poststudy design with 40 adolescents recruited from two pediatric tertiary care centers was used. Baseline questionnaires were completed and adolescents used the app at least twice daily for 28 days, receiving algorithm-informed self-management advice depending on their reported pain. A nurse received alerts in response to sustained pain and contacted adolescents to assist in pain care. Poststudy questionnaires were completed. Descriptive analyses, with exploratory inferential testing conducted on health outcome data, were used to address study aims.

RESULTS

Most (40/52; 77%) eligible adolescents participated. Two participants withdrew participation. Intervention fidelity was impacted by technical difficulties (occurring for 15% of participants) and a prolonged time for nurse contact in the event of sustained pain. Adherence to pain reporting was 68.8 ± 38.1%. Outcome measure completion rates were high and the intervention was acceptable to participants. Trends in improvements in pain intensity, pain interference, and HRQL were significant, with effect sizes of 0.23-0.67.

CONCLUSIONS

Implementation of Pain Squad+ is feasible and the app appears to improve pain-related outcomes for adolescents with cancer. A multicenter RCT will be undertaken to examine app effectiveness.

Development of a mHealth Real-Time Pain Self-Management App for Adolescents With Cancer: An Iterative Usability Testing Study [Formula: see text]

PURPOSE

A user-centered design approach was used to refine the mHealth Pain Squad+ real-time pain self-management app for adolescents with cancer for its usability (defined as being easy to use, easy to understand, efficient to complete, and acceptable).

METHOD

Three iterative usability testing cycles involving adolescent observation and interview were used to achieve this objective. During each cycle, adolescents used the app while "thinking aloud" about issues encountered. Observed difficulties and errors were recorded and a semistructured interview about the experience was conducted. Using a qualitative conventional content analysis approach, themes related to app usability were identified.

RESULTS

Participants required an average of 4.3 minutes to complete the pain assessment component of Pain Squad+. Overall, the app was acceptable. Problematic issues related to software malfunction, interface design flaws, and confusing text. Software revisions were made to address each issue.

CONCLUSION

The multifaceted usability approach used provided insight into how a real-time app can be made acceptable to adolescents with cancer and succeeded in developing a Pain Squad+ app that is fit for future effectiveness testing.

Pain assessment and management in paediatric oncology: a cross-sectional audit

AIMS AND OBJECTIVES

To describe the pain assessment and management practices documented by health professionals within a tertiary-level Children's Cancer Centre and to evaluate how these practices were compared with international recommendations.

BACKGROUND

Children with cancer are vulnerable to pain due to the intensity of antineoplastic therapy. Therefore, it is imperative to ensure that current pain management practices provided to paediatric oncology inpatients are of a high quality.

DESIGN

A single-site cross-sectional audit.

METHODS

A 24-hour period of documented pain-related care in randomly selected inpatients of an Australian tertiary-level Children's Cancer Centre was examined. The current pain management practices were audited over a two-month period resulting in 258 episodes of pain-related care being reviewed.

RESULTS

Pain related to medical treatment for cancer was common (n = 146/258, 57%) and persistent. The presence of pain was not consistently recorded by health professionals (n = 75/146, 51%). Pain was mild (n = 26/75, 35%) and opioids were the mainstay of pain management interventions (n = 63/112, 56%). Adjuvants were an important component of pain management (n = 47/112, 42%), and nonpharmacological methods of managing pain were under-represented in this audit (n = 38/146, 26%). According to the Pain Management Index, pain was appropriately managed for the majority of children (n = 65/76, 87%).

CONCLUSIONS

Pain management practices did not fully reflect the recommendations of contemporary paediatric pain management. Due to limitations in the documentation of children's pain, it was difficult to determine the effectiveness of pain management interventions.

RELEVANCE TO CLINICAL PRACTICE

This study highlights the ongoing problem of pain for children receiving antineoplastic therapy. It is recommended that health professionals routinely screen for the presence of pain during hospitalisation and assess the efficacy of pain-related care.