Nerve distractions reduce pain associated with procedures

0809-Lio

Peter A. Lio, MD

Mary Poppins sang that a spoonful of sugar helps the medicine go down, and it turns out to be a hypothesis backed by both good music and good science. Studies show that a bit of sucrose — as well as distractions, ice, topical anesthetics, pleasant aromas, or vibrations — help reduce pain and calm patients of all ages during minor procedures.

“This is important not just in pediatrics, but in dermatology. An adult can, in theory, grin and bear it, but when they are uncomfortable, it makes the procedures much harder for everybody — not just for the patient, but the person performing the procedure. If the patient has a better experience, then I will have a better experience as an operator,” said Peter A. Lio, MD.

Dr. Lio was the course director for “Pain-Free Dermatology: Minimizing Discomfort in Procedures for Children and Adults” (U009) on July 29. During the session, he and Alisa McQueen, MD, discussed the benefits of reducing pain as well as pearls for reducing pain for patients of all ages.

“There is a fair amount of science behind this. All of the distraction efforts have been supported by really good studies. Each piece has multiple references,” said Dr. Lio, an assistant professor of clinical dermatology and pediatrics at Northwestern University Feinberg School of Medicine. “There are physiology studies on babies, trying to understand how long they are crying, what their face is doing, and what is the effect of these interventions to get a sense of what is happening to the whole body when there is pain.”

Dr. McQueen, an associate professor of pediatrics at University of Chicago Medicine Comer Children’s Hospital, has been involved in studies in the past five years where children were distracted with tablets, computers, and smartphones to see if they reduced the perception of pain.

“A group of us started studying it to see if what we are seeing is actually happening physiologically or if this is something we are misinterpreting,” she said. “We have done research where we put heart-rate monitors on children who are undergoing procedures. We compared what happened to their heart rate variability when they had distraction techniques and non-pharmacologics applied during the procedure and when they didn’t. We observed patterns in heart rate variability that demonstrate children who are effectively distracted are physiologically less traumatized by the whole experience.”

The research supports the gate control theory of pain that the central nervous system and peripheral nervous system process pain signals that pass through nerve gates as they go to the brain. Distractions, vibrations, or temperature changes can be used to alter the communication in this network of nerve impulses.

“You can’t get everything from point A to point B at once,” Dr. McQueen said. “There is a limited amount of information that can travel at any one time. You can overwhelm that with other stimulation so there is less pain that travels through.”

Applying topical anesthetics such as creams, ointments, or gels before a needle stick can provide pain relief within a few minutes, Dr. Lio said.

“It is pretty amazing,” he said. “One of my favorite pearls is that as soon as you freeze a wart, if you put on a topical anesthetic to that frozen wart, within seconds it will become painless, taking away that throbbing after-pain. It is such an elegant little pearl, especially for kids who are afraid of it.”

Dermatologists also can use sodium bicarbonate to buffer an injection of lidocaine, which is acidic and burns after the injection. Yet another inexpensive option is to use aromatherapy in a room to relax a patient. The use of a jar of orange or lavender oil has been shown to help calm a patient, reducing his or her heart rate, Dr. Lio said.

Cooling the skin using ice wrapped in aluminum foil or a rubber glove also helps reduce the pain of an injection. Ice also can be packaged with a Buzzy, a small device that vibrates, and they could even be used during botulinum toxin or filler injections, he said.

For children, the distraction of a video game, video, or music on a hand-held tablet has been shown in studies to be useful in calming them for procedures. For infants, a small amount of sucrose on a pacifier leads to reduced heart rate variation and less crying and grimacing.

“One of the things we have learned in pediatric emergency medicine is that there are a lot of ways we can mitigate some of that pain and anxiety that does not require pharmacologic treatment,” Dr. McQueen said. “It turns out that with young children, you are better off not explaining this to them because they get freaked out. When you tell them something will only hurt for a minute, all they hear is ‘hurt.’ You also have to get the parents on board.

“When you think about involving adults, not just children, it is a nice testament to how some of the most interesting ideas out there can be broadly applied and shared across disciplines.”

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