Best use yet for electronic toys: Easing treatment-related pain for children with cancer

For a child with cancer, an introduction to the pediatric oncology unit usually entails undergoing many procedures in quick succession. One study has shown that for these children pain associated with interventions is twice as common as the pain from the disease itself. Just as for adults who have cancer, experiencing pain is one of their greatest fears.

All of this being the case, you'd think medical science would have an intense focus on alleviating procedure-related pain in pediatric oncology, using the best tools at our disposal. But while children with cancer may play on their Wii after they get home, so far there's little solid evidence for the effectiveness of virtual reality or even ordinary video games to distract them during treatment.

Children's hospitals are using them nonetheless. At the cancer clinic in Texas Children's Hospital (a leader in exploring pain management techniques), among other strategies such as live performers, positioning for comfort, and medication, children have the benefit of hand-held video games to distract them from pain and anxiety, says child life specialist Breanna Hopkins. The clinic is in the process of installing Wii systems as well.

As electronic toys are booming in variety and popularity, only now has a randomized study evaluated the simple procedure of letting children listen to an iPod (as I myself always do at the dentist) before and during lumbar puncture for leukemia, and then asking them about the experience afterwards.

The study appears this month in the Journal of Pediatric Oncology Nursing.

Two years ago, a Cochrane Collaboration systematic review determined that only 3 kinds of noninvasive interventions have shown promise for reducing children's pain associated with procedures that involve needles: cognitive behavior therapy, hypnosis, and "distraction." The first two interventions (as well as the invasive kind) require considerable time, effort, and training for medical personnel. Use of an iPod, in contrast, is something about which an American child might actually instruct an oncologist.

Oncology nurse Than Nahn Nguyen of the National Hospital of Pediatrics in Hanoi approached Stefan Nilsson of Sweden to collaborate, because of his prior research testing "music medicine" and virtual reality for cancer-related pain in children. The Hanoi study involved 40 children with leukemia who had all had lumbar puncture previously.

This time, they got no other form of pain relief than music-if that. All were given headphones, but only half were randomized (by choosing a slip of paper) to hear music through them. The lucky half were given iPods and shown how to use them, selecting their own playlist. The music began 10 minutes before the procedure did. Afterwards, 20 were interviewed with open-ended questions.

Those in the iPod group scored significantly lower for pain, heart rate, respiratory rate, and anxiety. Some said afterwards that they didn't even notice when the injection began. Both groups wanted to hear music the next time around.

“I didn’t feel any pain," said one child in the iPod group, adding with a smile: "The last time, I had to hold my mother’s hand very tightly…I didn’t need to do that this time." Children in the control group called the procedure "very painful" and spoke of anxiety, a sense of chaos, and fear of death.
Music has a venerable record as a form of distraction. There's less experience with using virtual reality, which involves many technical issues and can be quite complicated.

Nilsson, who is a pain management nurse at The Queen Silvia Children's Hospital in Goteborg, has tested a 3D virtual reality game involving a hunt for diamonds in an amusement park, experienced via headset and remote control. The team created it from off-the-shelf software and tested it in a randomized controlled trial involving 42 children and adolescents with cancer, before and during  venous punctures or the installation of subcutaneous venous ports.

The subjects in this study did not get to choose their own entertainment, which may be a problem: Some of them (especially boys) called the game "corny," although most would choose to play it again because they all found it "distracting." There was no significant difference between the groups in self-reported measures of pain, although nurses scoring an objective scale noticed fewer visual or motor signals of pain during venipuncture. The researchers note that none of the subjects experienced intense pain; all had also received cold spray or lidocaine and prilocaine before the procedure.

Perhaps a more useful result from the study reported in European Journal of Oncology Nursing was that most subjects neither noticed nor cared about the 3D component. This could dispense with the headset. Something on a flat computer screen could be just as effective, especially if the patient could choose the game. In fact, any game a kid enjoys might work, as long as it doesn't involve much arm movement. This all needs to be tested further, of course.

Nilsson says he hasn't "yet" approached game manufacturers about further research or perhaps about donating video games to pediatric oncology units, but he's attracted to the idea. Short of that, even in the current economy, the outright purchase of a few iPods and a few dozen tracks might not be out of the question for a cancer hospital.

One might hazard a guess that the young patients would approve. During the post-procedure interview, one child in the Hanoi study asked about the next procedure. "Will I be able to listen to music, or not?"