Best Practice Recommendations for Non-

Pharmacological Pain Management in Pediatric

Oncology Patients
Honors Thesis by Sarah Brock
University of Arizona College of Nursing
Introduction

▪ Pain occurs in approximately 20-50%

of all cancer patients and 80% of
those with advanced-stage cancer
report moderate to severe pain
(National Cancer Institute, 2016)
▪ Pain is often a symptom of the
disease, but can also come from
treatments such as chemotherapy,
surgery, diagnostic tests, radiation,
etc.
Types of Pain

▪ Nociceptive Pain:
▪ Somatic: Originates in the skin, connective tissues, joints, muscles, and bones.
Localized, sharp, and intermittent.
▪ Visceral: Originates in the organs. Aching, pressure, or cramping.
▪ Neuropathic Pain:
▪ Peripheral: Between the spinal cord and periphery. Burning or numbness
▪ Central: Between the spinal cord and brain. Tingling and pins & needles.
▪ Acute Pain:
▪ Pain of short duration (usually < 6 months) usually from a known cause
▪ Chronic Pain:
▪ Pain lasting > 6 months with a cause that is not always clearly identifiable
Pediatric Pain Scales
Significance of the Problem

▪ Uncontrolled pain can greatly influence quality of life and functional

status (National Cancer Institute, 2016)
▪ The persistence of cancer-related pain can lead to emotional stress
and even depression (National Cancer Institute, 2016)
▪ Depending on their developmental stage, some children are not able
to describe their pain or understand the causes behind it
▪ Most common: Opioid and non-opioid drugs
▪ Research has shown the effectiveness of non-pharmacological
methods especially for managing pain (National Center for
Complementary and Alternative Medicine, 2013b)
Statement of Purpose

▪ To determine a best practice recommendations for educating nurses

on the benefits of various non-pharmacological pain management
methods for pediatric oncology patients
Literature Review

▪ Databases: CINAHL, PubMed, Google Scholar, and Cochrane

▪ Keywords: “nonpharmacological,” “pain management,” and
“pediatric oncology”
▪ Articles: 14 (between 2007-2016)
▪ Randomized controlled trials, quasi experimental studies, and
systematic reviews (Evidence Levels I-IV)
▪ 8 techniques: Breathing and Relaxation, Distraction, Healing Touch,
Hypnosis, Massage Therapy, Music Therapy, Neuropathic Pain
Management, Pet Therapy
Results Summary

▪ All studies yielded positive • Limitations: Small sample size,

results lack of supporting studies,
▪ Interventions present relatively overall expense, time, or need of
low–risk to patient safety specially trained professionals

▪ Suggests a wide-scope of • Need to discuss feasibility in

possibilities for effective practice
nonpharmacological pain
management techniques in
pediatric oncology patients
Distraction

▪ The more active and engaging the distractor is, the more effective it is
(Hedén et al., 2009)
▪ Both parents and children report the use of distractors as helpful and would
want to use them again (Windich-Biermeier et al., 2007)
▪ Distractors led to decreased FLACC scores (Nilsson et al., 2009)
▪ After using the distractors during needle procedures, children stated “You
think of the game and don’t notice the needle” and “I didn’t notice the pain”
(Nilsson et al., 2009)
▪ Benefits:
▪ Many forms and levels of this intervention.
Massage Therapy

▪ Massage is useful as a tool for relieving pain that interferes with

ambulation (da Cunha Batalha & Mota, 2015)
▪ Massage can significantly reduce pain and anxiety levels during bone
marrow aspirations and intrathecal therapy (Çelebiog˘lu et al., 2013)
▪ Massage can help reduce the incidence of nausea and vomiting due
to chemotherapy (Mazlum et al., 2013)
▪ Benefits:
▪ Reduces a variety of pain types
▪ Can be implemented by family members
▪ Benefits seen quickly
Music Therapy

▪ Music therapy can significantly reduce pain scores, heart rate and
respiratory rates during lumbar punctures. (Nguyen et al., 2010)
▪ After using music therapy children stated, “The music helped me stay
calm and feel less pain,” “I felt less pain than last time,” and “I felt a
little bit of pain…not like last time when I felt 10 points of pain”
(Nguyen et al., 2010)
▪ Benefits:
▪ Easy to offer
▪ Inexpensive
▪ Not-time consuming
Intervention

▪ Educate nursing staff through a computer-based training

program
▪ Computer-Based Training (CBT)
▪ Flexible and convenience
▪ Reduces the need for trained personnel to lead workshops
▪ Ensures that information is delivered in a consistent manner
▪ CDC’s characteristics for an effective education curriculum
▪ Age and developmentally appropriate
▪ Research-driven and incorporate various learning strategies
▪ Engaging and interactive—provide opportunities to reinforce
skills and knowledge
 The Johns Hopkins Evidence-Based Practice
Model of Translation

Implementation Evaluation

Secure Implement Evaluating Dissemination to

Resources Action Plan Outcomes Stakeholders
The Johns Hopkins Evidence-Based Practice
Model of Translation

▪ Present proposal to hospital management and gain support

▪ Identify roles, create plan, and make timeline
▪ Pilot test on a single unit
▪ Evaluation
▪ Process Measurements: documentation of process and surveys
▪ Outcome Measurements: data trends and chart audits
▪ Share results and implement hospital-wide
Recommendations for Future Research

▪ More comprehensive studies regarding nurses’

perceptions of using non-pharmacological
techniques in conjunction with pharmaceuticals to
treat pain in pediatric patients
▪ Alternative treatment styles that will advance the
study of pain management in healthcare
References

▪ Ackley, B. J., Swan, B. A., Ladwig, G., & Tucker, S. (2008). Evidence-based nursing care guidelines: Medical-surgical interventions. St. Louis,
MO: Mosby Elsevier.
▪ Anghelescu, D.L., Kelly, C.N., Steen, B.D., Wu, J., Wu, H., DeFeo, B., … Burgoyne, L. (2016). Mirror therapy for phantom limb pain at a
pediatric oncology institution. Rehabilitation Oncology, 34(3), 104-110.
▪ Casanova-Garcia, C., Lerma Lara, S., Perez Ruiz, M., Ruano Dominguez, D., & Santana Sosa, E. (2015). Non-pharmacological treatment for
neuropathic pain in children with cancer. Medical Hypotheses, 85, 791-797.
▪ Çelebiog˘lu, A., Gürol, A., Yildirim, Z. K., & Büyükavci, M. (2013). Effects of massage therapy on pain and anxiety arising from intrathecal
therapy on bone marrow aspiration in children with cancer. International Journal of Nursing Practice, 21, 797-804.
▪ Centers for Disease Control and Prevention [CDC]. (2015). Characteristics of an effective health education curriculum. Retrieved from
https://www.cdc.gov/healthyschools/sher/characteristics/index.htm
▪ da Cunha Batalha, L., & Mota, A. A. S. C. (2013). Massage in children with cancer: Effectiveness of a protocol. Jornal de Pediatria, 89(6), 595-
600.
▪ Hart, P., Eaton, L., Buckner, M., Morrow, B., Barrett, D., Fraser, D. & Sharrer, R. (2008). Effectiveness of a computer‐based educational
program on nurses' knowledge, attitude, and skill level related to evidence‐based practice. World Views on Evidence-Based Nursing, 5(2),
75-84. doi: 10.1111/j.1741-6787.2008.00123
▪ Hedén, L., Von Essen, L., & Ljungman, G. (2009). Randomized interventions for needle procedures in children with cancer. European Journal
of Cancer Care, 18, 358-363. doi: 10.1111/j.1365-2354.2008.00939
▪ Institute of Medicine (IOM). (2011). Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research.
Washington, DC: The National Academies Press. Retrieved May 3, 2017 from http://www.iom.edu/reports/2011/relieving-pain-in-america-
a-blueprint-for-transforming-prevention-care-education-research.aspx
References

▪ Liossi, C., White, P., & Hatira, P. (2007). Randomized clinical trial of local anesthetic versus a combination of local anesthetic with self-
hypnosis in the management of pediatric procedure-related pain. Health Psychology, 25(3), 307-315. doi: 10.1037/0278-6133.25.3.307
▪ Mazlum, S.,Chaharsoughi, N.T., Banihashem, A., & Vashani, H.B. (2013). The effect of massage therapy on chemotherapy-induced nausea
and vomiting in pediatric cancer. Iranian Journal of Nursing and Midwifery Research, 18(4), 280-284.
▪ National Cancer Institute (NCI). (2016). Pain PDQ. Retrieved May 3, 2017 from https://www.cancer.gov/about-cancer/treatment/side-
effects/pain/pain-pdq.
▪ National Center for Complementary and Alternative Medicine (NCCAM). (2013b). What Is Complementary and Alternative Medicine?
Retrieved May 3, 2017 from http://nccam.nih.gov/health/whatiscam/.
▪ Newhouse, R.P., Dearholt, S.L., Poe, S.S., Pugh, L.C., & White, K.M. (2012). Translation. In B. Burnham & C.L. Saver (Eds.), Johns hopkins
nursing evidence-based practice model and guidelines (129-142). Indianapolis, IN: Sigma Theta Tau International.
▪ Nguyen, T.N., Nilsson, S., Hellström, A., & Bengtson, A. (2010). Music therapy to reduce pain and anxiety in children with cancer
undergoing lumbar puncture: A randomized clinical trial. Journal of Pediatric Oncology Nursing, 27(3), 146-155. doi:
10.1177/1043454209355983
▪ Nilsson, S., Finnstrom, B., Kokinsky, E., & Enskar, K. (2009). The use of virtual reality for needle-related procedural pain and distress in
children and adolescents in a pediatric oncology unit. European Journal of Oncology Nursing, 13, 102-109.
▪ Rhodes, P. (2017). History of Medicine. In Encyclopedia Britannica Online. Retrieved from
https://www.britannica.com/topic/history-of-medicine
References

▪ Shockey, D. P., Menzies, V., Glick, D. F., Taylor, A. G., Boitnott, A., & Rovnyak, V. (2013). Preprocedural distress in children with cancer: An
intervention using biofeedback and relaxation. Journal of Pediatric Oncology Nursing, 30(3), 129-138. doi: 10.1177/1043454213479035
▪ Tomé Pires, C., & Miró, J. (2012). Hypnosis for the management of chronic and cancer
procedure-related pain in children. International Journal of Clinical and Experimental Hypnosis, 60(4), 432-457.
▪ Urbanski, B. L., & Lazenby, M. (2012). Distress among hospitalized pediatric cancer patients modified by pet-therapy intervention to
improve quality of life. Journal of Pediatric Oncology Nursing, 29(5), 272-282. doi: 10.1177/1043454212455697
▪ Windich-Biermeier, A., Sjoberg, I., Dale, J., Eshelman, D., & Guzzetta, C.E. (2007). Effects of distraction
on pain, fear, and distress during venous port access and venipuncture in children and adolescents with cancer. Journal of Pediatric
Oncology Nursing, 24(1), 8-19. doi: 10.1177/1043454206296018
▪ Wong, J., Ghlasuddin, A., Kimata, C., Patelesio, B., Sui, A. (2013). The impact of healing touch on
pediatric oncology patients. Integrative Cancer Therapies, 12(1), 25-30. doi: 10.1177/1534735412446864