What Long-Term Issues Are Associated with Uncontrolled Pain?

Pain has come to be recognized as a substantial health problem, with pain treatment and relief noted as a human right by the World Health Organization and International Association for the Study of Pain. For children and adolescents, pain management is especially important, as untreated pain in infancy and childhood has been linked to lower pain thresholds as adolescents and adults. Therefore, it is imperative for healthcare providers to identify effective techniques and strategies to help alleviate pediatric pain. Non-pharmacological methods for pain management, including distraction techniques, have evidenced efficacy in contributing to pain relief, especially for acute medical procedures.

What Is Distraction?

Distraction is an effective pain management strategy and is defined (in the context of pain management) as a non-pharmacological cognitive or behavioral strategy that diverts attention from pain stimuli.

How Does Distraction Work to Reduce Pain?

Pain is modulated by various cognitive constructs, and distraction techniques make use of the brain’s natural ability to differentiate attention in order to impact pain perception. Given the brain’s restricted ability to process stimuli, engaging patients in distraction techniques limits their ability to experience painful stimuli. Distraction has been empirically shown to reduce pain perception, while increased attention to pain has been found to be associated with increased pain perception. Anesthesia providers are encouraged to implement the use of non-pharmacologic distraction activities as an effective and safe method, particularly for cases in which sedatives can pose substantial risks to the patient.

When and Where Can Distraction Techniques Be Used for Pain Management?

Distraction techniques have been deemed effective in multiple settings, including laboratory settings, during acute medical procedures, with burn patients, and in the context of chronic pain. Techniques provide pediatric patients and their parents tools for self-managing pain. Further, they help to alleviate not only self-reported pain, but also distress and anxiety, which are often potent contributors to pain exacerbation.

Distraction activities can aid the anesthesiologist when patient cooperation proves challenging and can be used to alleviate procedural distress in pediatric patients, which has been linked to lasting behavioral and emotional maladaptation in children. A systematic review and meta-analysis recently demonstrated that children’s self-reported pain and behavioral indicators of distress significantly decreased with the use of distraction techniques during painful procedures.

What Is the Role of a Child Life Specialist When Considering Distraction?

Child life specialists are trained to use age-appropriate and specifically tailored preparation methods based on the child’s chronological and developmental age, anxiety levels, and prior hospital experiences. Their involvement can benefit pediatric patients who typically respond well to instructional coaching through painful experiences.

Pain-related anxiety prior to surgery often predicts poor recovery outcomes and/or development of chronic post-surgical pain. Preoperative distraction techniques to allay anxiety range from humor to breathing to use of video games. Humorous environmental distractions and video glasses have been found to have a similar anxiolytic effect as oral midazolam, underscoring the benefit and cost-effectiveness of distraction technique teaching in the preoperative setting.

In chronic pain management, psychologists work with patients and parents to learn how to apply pain distraction techniques in daily life for purposes of restoring function.

How Do Distraction Techniques Work?

Multiple theories contribute to the understanding of how distraction techniques may affect undesired sensations and perceptions (such as pain). The gate control theory of pain, developed by Melzack and Wall in 1956, postulates that pain travels through various physiological “gates” that modulate pain signal intensity. Pain signals may be modulated as an ascending signal through the spinal cord or as a descending signal via interpretation by the brain. It is thought that when distraction is used for pain management, pain-inhibitory processes are triggered that affect nociceptive transmissions, helping to “close the gate” on pain signaling.

From a cognitive processing standpoint, distraction is thought to be effective because it steers cognitive resources away from painful stimuli. The role of attention in pain perception is key, and several models have been proposed to explain how distraction affects the pain experience. First, the capacity model of attention, proposed by McCaul and Malott (1985), suggests that one must actively attend to a painful stimulus in order for it to incur distress, as attention capacity is limited. Thus, if a distraction activity is able to use enough attention processing resources to lessen focus on the pain stimulus, distress will in turn be lessened. Cognitive-affective and neurocognitive models of attention and pain postulate that pain is “evolutionarily disposed to interrupt attention” and thus, distraction activities must be intentional, goal-directed tasks that engage “top-down” attentional control in order to be effective. A top-down approach entails a goal-directed process that engages working memory, as opposed to a bottom up approach, which is an unintentional capture of attention by stimuli.