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Article Excerpt
Managing children's postoperative pain continues to be a challenge because nearly 50% of children report severe pain after surgery (Gauthier, Finley, & McGrath, 1998; LaMontagne, Hepworth, & Salisbury, 2001). Effective post-operative pain management can lead to shorter lengths of stay in the hospital and better coping and emotional well being after discharge (Lambert, 1996). Analgesic medications are the most common form of pain management used with children post-operatively. However, studies report that pediatric patients suffer moderate to severe pain during hospitalization even after receiving analgesics (Gauthier et al., 1998; Gillies, Smith, & Parry-Jones, 1999; Polkki, Pietila, & Vehvilainen-Julkunen, 2003). The Agency for Health Care Policy and Research and the American Society of Anesthesiologists have developed guidelines that recommend the combination of pharmacological and non-pharmacological techniques to manage children's pain (Acute Pain Management Guideline Panel, 1992; American Society of Anesthesiologists, 2004). Pain results from the reciprocal relationship of sensory and affective components of a noxious stimulus (Melzak & Casey, 1968). Therefore, when a non-pharmacological intervention is combined with a pharmacologic agent for the management of postoperative pain, both sensory and affective pain may be reduced, more than with medication alone.
The need for interventions that reduce children's acute pain on a short-term basis is growing as a result of the continued demand for outpatient surgery, shortened hospital stays, and difficulties with pain management in the home. Non-pharmacologic cognitive interventions, such as guided imagery, reduce or alter the pain experience through focus on a thought or image, thereby competing for the attention of painful sensations (McCaul & Malott, 1984). Thus, imagery has the potential to modify pain by diverting attention to a pleasant, non-painful stimulus. Relaxation can be used to facilitate imagery and may reduce pain by diminishing the effects of stress, distress, anxiety, or muscle tension (McCaffery & Pasero, 1999). The purpose of this study was to evaluate the effectiveness of a guided imagery CD in reducing post-operative pain and increasing relaxation in children. A second goal was to evaluate the effectiveness of the CD to stimulate imagery in school-age children.
Literature Review
Age Related to Pain and Imagery
Studies have shown that school-age children are able to describe their intensity of pain and appropriately make suggestions on pain-relieving methods to their caregivers (Polkki et al., 2003). Children use vivid imaginations in their daily life, and can use this skill of imagination and fantasy to provide therapeutic distraction (Lambert, 1996). Children's involvement in images peaks between the ages of 8 to 12 years old (Olness & Kohen, 1996), and as children develop, they increase their ability to focus and pay attention (Thomas, 1985). School-age children can, and do, use imagery and have the capacity to create and become absorbed in vivid mental images as if they were real (Huth, Van Kuiken, & Broome, 2006).
Guided Imagery
Imagery interventions have been examined as methods of controlling pain and distress in children during intrusive procedures (Broome, Rehwaldt, & Fogg, 1998; Jeffs, 2007; Pederson, 1995; Smart, 1997). Few studies have reported the effectiveness of using guided imagery or non-pharmacological techniques in the relief of post-operative pain in children (Huth, Broome, & Good, 2004; Lambert, 1996; Polkki, Pietila, Vehvilainen-Julkunen, Laukkala, & Kiviluoma, 2008).
Lambert (1996) taught 26 children and adolescents (7 to 19 years of age) ways to relax and use their imaginations before and after general surgery. The study consisted of 52 patients randomly assigned to an experimental group or a control group. This technique incorporated individualized child selected images into relaxation exercises, and included suggestions for healing, minimal pain, and an uncomplicated recovery. Children in the experimental group experienced lower post-operative pain ratings and shorter hospital stays than the control group. Twenty children indicated they used this strategy for pain control and sleep while hospitalized. A limitation of this study was that the amount of opioid in effect at the time of the intervention was not controlled.
In a descriptive study, 52 Finnish school-age children were interviewed after surgery to obtain their experiences with pain relief methods while hospitalized. Children reported 13 different types of self-initiated methods they used to relieve pain. Ninety-eight percent of the children used distraction, 31% used imagery, and 8% used relaxation (Polkki et al., 2003).
In another experimental design, Huth and colleagues (2004) randomly assigned 73 school-age children (7 to 12) having a tonsillectomy and/or adenoidectomy to an imagery treatment group or an attention-control group. Children (n = 36) in the treatment group watched a professionally developed videotape on the use of imagery and then listened to an audiotape 1 week before surgery. They also listened to the audiotape after surgery and at home after discharge. Results indicated significantly lower pain and anxiety 1 to 4 hours after surgery in the treatment group when analgesics and trait anxiety were controlled. However, there were no significant differences at home 22 to 27 hours after discharge. A limitation of this study was the inability to provide a sham treatment for the attention-control group that would not act as distraction.
Based on the larger experimental study described previously, Huth and colleagues (2006) analyzed how children in the treatment group used imagery before and after surgery. On an investigator developed diary, children documented the reason for listening...
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