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Pain Medicine 2014; *: **–** Wiley Periodicals, Inc.
Can You Help When It Hurts? Dogs as Potential Pain Relief Stimuli for Children with Profound Intellectual and Multiple Disabilities: An Exploratory Study
Dear Editor, As it is widely recognized, individuals with profound intellectual and multiple disabilities (PIMDs), who are characterized by severe or profound motor disabilities combined with profound cognitive and sensory impairments [1], are at a significant high risk of pain from many sources, including daily care activities, medical procedures, and illness (e.g., [2,3]). Among the nonpharmacological interventions that have already been proposed for alleviating pain in individuals with significant neurologic impairments, increasing attention is currently being devoted to animal-assisted therapy (AAT) programs as effective pain relief interventions [4]. In this letter, we report first experimental data on the potential of therapy dogs as pain relief stimuli for children with PIMD. Given the lack of literature on AAT programs specifically developed for these individuals, we consider that the results here presented may constitute a promising platform to support further investigations. An exploratory study—approved by the Ethics Committee of the O’Porto University—was conducted aiming at assessing, in two children with PIMD, apparent pain relief induced by contact with a therapy dog immediately after a potentially painful care moment. Given the highly limited communication repertoire of the participants (and of children with PIMD in general), only behavioral (following Putten and Vlaskamp [3] and Green and Reid [5]) and heart rate (following Corff et al. [6]) measures were used to estimate pain levels. As to offer a comparison to pain alleviation that might be achieved through maternal touch, responses of the participants to contact with their mothers were also evaluated. Participant 1 was a 5-year-old Caucasian boy diagnosed with PIMD due to a perinatal hypoxic ischemic encephalopathy. Participant 2 was a 6-year-old Caucasian boy diagnosed with PIMD due to a mitochondrial cytopathy (complex I). Both participants presented a range of health problems, commonly associated with pain [3], namely, gastroesophageal reflux disease, bowel and abdominal problems, as well as chronic respiratory disorders. Importantly, none of the participants was diagnosed with epilepsy nor had any medical conditions that could be aggravated by the presence of an animal. Also noteworthy is the fact that parents of both participants reported a high frequency of everyday pain episodes in their children, occurring, for instance, during diaper changing, position-
ing on the wheelchair, and the stretcher and clothing processes. Nevertheless, none of the participants was using any muscle relaxant analgesics that could have affected their facial expressions during the experimental study. Five replicates were performed per each treatment condition (therapy dog and mother) so that a total of 10 experimental sessions were conducted. Each experimental session consisted of 9 minutes of data collection beginning with a 3-minute baseline period (period 1) followed by a 3-minute period of the scheduled condition (period 2) and a subsequent 3-minute postcondition period (period 3). Treatment conditions were counterbalanced. The therapy dog was positioned in a chair, next to, and at the eye level of, the participant and was silently instructed by the principal researcher to touch, lick the child’s foot, or vocalize. Similarly, the mother sat next to, and at the eye level of, the participant and provided him with sensory input by holding him close and firmly, caressing his face and foot, kissing, and/or singing. The type of interaction provided in both treatment conditions was planned so as to provide the children with potentially pleasant multisensory stimulation that, according to the literature, could contribute to reduce pain, namely through distraction (see the gate control theory [7]) or through the release of natural analgesics [8]. All experimental sessions were videotaped. A coding scheme was set up in the OBSERVER XT Software version 7.0 (Noldus Information Technologies, Wageningen, the Netherlands) to determine the duration of each behavior exhibited by the participant immediately before, during, and immediately after each treatment condition. The coding scheme comprised 1) four behaviors (frowning, grimacing, moaning, and crying) that have previously demonstrated the strongest relationship to pain during daily care routines in children with PIMD [3] and 2) one behavior (smiling) commonly identified as an indicator of comfort also in this population [5]. Consistent behavioral responses were considered as numerical changes from baseline occurring in all experimental sessions (e.g., an increase from baseline in the duration of a specific behavior, occurring in all five experimental sessions). Heart rate, in turn, was continuously recorded throughout all experimental sessions, with the noninvasive ambulatory Biopac MP100 Data Acquisition System (Biopac Systems, Santa Barbara, CA, USA) (following Lima and colleagues [9]). As for behavioral data, consistent heart rate 1
Lima et al. responses were considered as numerical changes from baseline occurring in all experimental sessions.
The importance of these results lies in two main points. First, they showed that, in both participants, contact with the therapy dog brought about consistent behavioral and cardiovascular changes that point to an apparent decrease in pain level. Second, they showed an interesting resemblance between the (apparent) pain attenuating effects of contact with the therapy dog and those achieved through maternal touch which has long been recognized as an efficient nonpharmacological intervention in the management of pain in children [8,11].
Overall, a number of consistent responses with large magnitudes (Cohen’s d ≥ 0.8 and effect size r ≥ 0.5 [10]) were observed (see Tables 1 and 2). An increase from baseline in the duration of smiling behavior was consistently observed during both treatment conditions for both participants. Simultaneously, a decrease in the duration of all or at least some indicators of pain was also consistently observed. Curiously, for both participants, the increase in the duration of smiling behaviour was more pronounced (in terms of magnitude) during contact with the therapy dog. With respect to cardiovascular responses, a decrease in the mean value of heart rate was consistently observed during the therapy dog condition for both participants. Although the same trend was observed during contact with the mother, the magnitudes of the responses related to this treatment condition were smaller. No consistent responses (either behavioral or cardiovascular) with large magnitudes were observed following any of the two treatment conditions.
The behavioral indicators of pain used in the present study have, to a high degree, the potential to estimate the likelihood of occurrence of pain in children with PIMD [3]. Notwithstanding, these behaviors can, sometimes, also be observed in nonpain distress states. Although one cannot assure that participants were actually experiencing pain before being presented with the therapy dog and the mother, the suspicion of pain is supported by the fact that data collection always occurred immediately after a day care situation considered by the parents as a source of significant pain. Parents of individuals with PIMD may, of
Table 1 Consistent responses exhibited by participant 1 during and following each treatment condition (therapy dog and mother) Therapy Dog During Smiling Mean change Cohen’s d Effect size r Frowning Mean change Cohen’s d Effect size r Grimacing Mean change Cohen’s d Effect size r Moaning Mean change Cohen’s d Effect size r Crying* Mean change Cohen’s d Effect size r Heart rate Mean change Cohen’s d Effect size r
37.2 12.178 0.987
Mother Following
0 0 0
During
9.4 3.024 0.834
Following
0 0 0
−14.0 −1.624 −0.638
n.c.r. n.c.r. n.c.r.
−9.7 −1.567 −0.617
7 0.972 0.437
−9.2 −0.860 −0.695
n.c.r. n.c.r. n.c.r.
−6.3 −0.996 −0.541
6.0 1.024 0.456
−19.4 −11.229 −0.984
n.c.r. n.c.r. n.c.r.
−22.6 −1.803 −0.670
n.c.r. n.c.r. n.c.r.
— — — −6.5 −0.881 −0.499
— — — 1.2 0.094 0.047
— — — −4.11 −0.372 −0.360
— — — n.c.r. n.c.r. n.c.r.
* Behaviour never exhibited by this participant. Mean changes refer to the calculated mean differences from baseline. Cohen’s d and effect size r are also shown. Mean changes are shown in seconds with exception of those referring to heart rate, which are shown in beats per minute. n.c.r. = nonconsistent response.
2
Letter to the Editor
Table 2 Consistent responses exhibited by participant 2 during and following each treatment condition (therapy dog and mother) Therapy Dog During Smiling Mean change Cohen’s d Effect size r Frowning Mean change Cohen’s d Effect size r Grimacing Mean change Cohen’s d Effect size r Moaning* Mean change Cohen’s d Effect size r Crying Mean change Cohen’s d Effect size r Heart rate Mean change Cohen’s d Effect size r
11.4 4.345 0.908 0 0 0 −18.2 −1.209 −0.517 — — — −31 −0.974 −0.761
Mother
Following During
0 0 0
6.3 1.561 0.615
0 0 0
n.c.r. n.c.r. n.c.r.
n.c.r. n.c.r. n.c.r. — — — n.c.r. n.c.r. n.c.r.
−12.04 −2.08 −1.315 −0.498 −0.550 −0.242
−19.5 −1.667 −0.640 — — —
Following
0 0 0 −5.1 −0.629 −0.300 −4.2 −1.190 −0.511 — — —
References 1 Nakken H, Vlaskamp C. A need for a taxonomy for profound intellectual and multiple disabilities. J Policy Pract Intellect Disabil 2007;4:83–7. 2 Breau LM, Camfield CS, McGrath PJ, et al. Risk factors for pain in children with severe cognitive impairments. Dev Med Child Neurol 2004;46:364–71. 3 van der Putten A, Vlaskamp C. Pain assessment in people with profound intellectual and multiple disabilities; a pilot study in to the use of the Pain Behavior Checklist in every day practice. Res Develop Dis 2007;32:1677–84. 4 Marcus DA. The science behind animal-assisted therapy. Curr Pain Headache Rep 2013;17:1–7.
−64.7 −11 −0.956 −0.127 −0.431 −0.0631 −3.01 −0.280 −0.139
*Escola Superior de Educação Paula Frassinetti; Departamento de Ciências do Comportamento, Instituto de Ciências Biomédicas Abel Salazar; § Instituto de Biologia Molecular e Celular, Universidade do Porto, Porto; ‡ Escola Superior de Saúde, Campus do Instituto Politécnico de Setúbal, Setúbal, Portugal †
2.49 0.165 0.082
* Behaviour never exhibited by this participant. Mean changes refer to the calculated mean differences from baseline. Cohen’s d and effect size r are also shown. Mean changes are shown in seconds with exception of those referring to heart rate, which are shown in beats per minute. n.c.r. = nonconsistent response.
course, have difficulties in differentiating pain from physical discomfort or mental unease. Nevertheless, and given that children with PIMD cannot verbally express their pain, attending to the practical knowledge of those who were the most familiar with the participants seemed the best way to capture some level of pain that could potentially be alleviated by contact with the therapy dog and with the mother. The present study is only exploratory and, because of the limited sample size, does not allow for generalizations. However, it constitutes the first attempt to directly quantify the potential of therapy dogs as effective stimuli to be used in planned interventions for managing pain in children with PIMD. MARIELY LIMA, PhD,* KARINE SILVA, PhD,† ISABEL AMARAL, PhD,‡ ANA MAGALHÃES, PhD,§ and LILIANA de SOUSA, PhD†
5 Green CW, Reid DH. Defining, validating, and increasing indices of happiness among people with profound multiple disabilities. J Appl Behav Anal 1996;293:67– 78. 6 Corff KE, Seideman R, Venkataraman PS, et al. Facilitated tucking: A nonpharmacologic comfort measure for pain in preterm neonates. J Obstet Gynecol Neonatal Nurs 1995;24:143–8. 7 Gray L, Watt L, Blass EM. Skin-to-skin contact is analgesic in healthy newborns. J Pediatr 2000; 105:14–22. 8 Chermont AG, Falcão LFM, de Souza Silva EHL, et al. Term newborn infants skin-to-skin contact and/or oral 25% dextrose for procedural pain relief. J Pediatr 2009;124:1101–7. 9 Lima M, Silva K, Magalhães A, et al. Beyond behavioral observations: A deeper view through the sensory reactions of children with profound intellectual and multiple disabilities. J Child Care Health Dev 2013;39:422–43. 10 Cohen J. Statistical Power Analysis for the Behavioral Sciences, 2nd edition. New Jersey: Lawrence Erlbaum Associates; 1988. 11 Cignacco E, Hamers JPH, Stoffel L, et al. The efficacy of non-pharmacological interventions in the management of procedural pain in preterm and term neonates. A systemic literature review. Europ J Pain 2007;11:139–52.
3
Pain Medicine 2014; *: **–** Wiley Periodicals, Inc.
Can You Help When It Hurts? Dogs as Potential Pain Relief Stimuli for Children with Profound Intellectual and Multiple Disabilities: An Exploratory Study
Dear Editor, As it is widely recognized, individuals with profound intellectual and multiple disabilities (PIMDs), who are characterized by severe or profound motor disabilities combined with profound cognitive and sensory impairments [1], are at a significant high risk of pain from many sources, including daily care activities, medical procedures, and illness (e.g., [2,3]). Among the nonpharmacological interventions that have already been proposed for alleviating pain in individuals with significant neurologic impairments, increasing attention is currently being devoted to animal-assisted therapy (AAT) programs as effective pain relief interventions [4]. In this letter, we report first experimental data on the potential of therapy dogs as pain relief stimuli for children with PIMD. Given the lack of literature on AAT programs specifically developed for these individuals, we consider that the results here presented may constitute a promising platform to support further investigations. An exploratory study—approved by the Ethics Committee of the O’Porto University—was conducted aiming at assessing, in two children with PIMD, apparent pain relief induced by contact with a therapy dog immediately after a potentially painful care moment. Given the highly limited communication repertoire of the participants (and of children with PIMD in general), only behavioral (following Putten and Vlaskamp [3] and Green and Reid [5]) and heart rate (following Corff et al. [6]) measures were used to estimate pain levels. As to offer a comparison to pain alleviation that might be achieved through maternal touch, responses of the participants to contact with their mothers were also evaluated. Participant 1 was a 5-year-old Caucasian boy diagnosed with PIMD due to a perinatal hypoxic ischemic encephalopathy. Participant 2 was a 6-year-old Caucasian boy diagnosed with PIMD due to a mitochondrial cytopathy (complex I). Both participants presented a range of health problems, commonly associated with pain [3], namely, gastroesophageal reflux disease, bowel and abdominal problems, as well as chronic respiratory disorders. Importantly, none of the participants was diagnosed with epilepsy nor had any medical conditions that could be aggravated by the presence of an animal. Also noteworthy is the fact that parents of both participants reported a high frequency of everyday pain episodes in their children, occurring, for instance, during diaper changing, position-
ing on the wheelchair, and the stretcher and clothing processes. Nevertheless, none of the participants was using any muscle relaxant analgesics that could have affected their facial expressions during the experimental study. Five replicates were performed per each treatment condition (therapy dog and mother) so that a total of 10 experimental sessions were conducted. Each experimental session consisted of 9 minutes of data collection beginning with a 3-minute baseline period (period 1) followed by a 3-minute period of the scheduled condition (period 2) and a subsequent 3-minute postcondition period (period 3). Treatment conditions were counterbalanced. The therapy dog was positioned in a chair, next to, and at the eye level of, the participant and was silently instructed by the principal researcher to touch, lick the child’s foot, or vocalize. Similarly, the mother sat next to, and at the eye level of, the participant and provided him with sensory input by holding him close and firmly, caressing his face and foot, kissing, and/or singing. The type of interaction provided in both treatment conditions was planned so as to provide the children with potentially pleasant multisensory stimulation that, according to the literature, could contribute to reduce pain, namely through distraction (see the gate control theory [7]) or through the release of natural analgesics [8]. All experimental sessions were videotaped. A coding scheme was set up in the OBSERVER XT Software version 7.0 (Noldus Information Technologies, Wageningen, the Netherlands) to determine the duration of each behavior exhibited by the participant immediately before, during, and immediately after each treatment condition. The coding scheme comprised 1) four behaviors (frowning, grimacing, moaning, and crying) that have previously demonstrated the strongest relationship to pain during daily care routines in children with PIMD [3] and 2) one behavior (smiling) commonly identified as an indicator of comfort also in this population [5]. Consistent behavioral responses were considered as numerical changes from baseline occurring in all experimental sessions (e.g., an increase from baseline in the duration of a specific behavior, occurring in all five experimental sessions). Heart rate, in turn, was continuously recorded throughout all experimental sessions, with the noninvasive ambulatory Biopac MP100 Data Acquisition System (Biopac Systems, Santa Barbara, CA, USA) (following Lima and colleagues [9]). As for behavioral data, consistent heart rate 1
Lima et al. responses were considered as numerical changes from baseline occurring in all experimental sessions.
The importance of these results lies in two main points. First, they showed that, in both participants, contact with the therapy dog brought about consistent behavioral and cardiovascular changes that point to an apparent decrease in pain level. Second, they showed an interesting resemblance between the (apparent) pain attenuating effects of contact with the therapy dog and those achieved through maternal touch which has long been recognized as an efficient nonpharmacological intervention in the management of pain in children [8,11].
Overall, a number of consistent responses with large magnitudes (Cohen’s d ≥ 0.8 and effect size r ≥ 0.5 [10]) were observed (see Tables 1 and 2). An increase from baseline in the duration of smiling behavior was consistently observed during both treatment conditions for both participants. Simultaneously, a decrease in the duration of all or at least some indicators of pain was also consistently observed. Curiously, for both participants, the increase in the duration of smiling behaviour was more pronounced (in terms of magnitude) during contact with the therapy dog. With respect to cardiovascular responses, a decrease in the mean value of heart rate was consistently observed during the therapy dog condition for both participants. Although the same trend was observed during contact with the mother, the magnitudes of the responses related to this treatment condition were smaller. No consistent responses (either behavioral or cardiovascular) with large magnitudes were observed following any of the two treatment conditions.
The behavioral indicators of pain used in the present study have, to a high degree, the potential to estimate the likelihood of occurrence of pain in children with PIMD [3]. Notwithstanding, these behaviors can, sometimes, also be observed in nonpain distress states. Although one cannot assure that participants were actually experiencing pain before being presented with the therapy dog and the mother, the suspicion of pain is supported by the fact that data collection always occurred immediately after a day care situation considered by the parents as a source of significant pain. Parents of individuals with PIMD may, of
Table 1 Consistent responses exhibited by participant 1 during and following each treatment condition (therapy dog and mother) Therapy Dog During Smiling Mean change Cohen’s d Effect size r Frowning Mean change Cohen’s d Effect size r Grimacing Mean change Cohen’s d Effect size r Moaning Mean change Cohen’s d Effect size r Crying* Mean change Cohen’s d Effect size r Heart rate Mean change Cohen’s d Effect size r
37.2 12.178 0.987
Mother Following
0 0 0
During
9.4 3.024 0.834
Following
0 0 0
−14.0 −1.624 −0.638
n.c.r. n.c.r. n.c.r.
−9.7 −1.567 −0.617
7 0.972 0.437
−9.2 −0.860 −0.695
n.c.r. n.c.r. n.c.r.
−6.3 −0.996 −0.541
6.0 1.024 0.456
−19.4 −11.229 −0.984
n.c.r. n.c.r. n.c.r.
−22.6 −1.803 −0.670
n.c.r. n.c.r. n.c.r.
— — — −6.5 −0.881 −0.499
— — — 1.2 0.094 0.047
— — — −4.11 −0.372 −0.360
— — — n.c.r. n.c.r. n.c.r.
* Behaviour never exhibited by this participant. Mean changes refer to the calculated mean differences from baseline. Cohen’s d and effect size r are also shown. Mean changes are shown in seconds with exception of those referring to heart rate, which are shown in beats per minute. n.c.r. = nonconsistent response.
2
Letter to the Editor
Table 2 Consistent responses exhibited by participant 2 during and following each treatment condition (therapy dog and mother) Therapy Dog During Smiling Mean change Cohen’s d Effect size r Frowning Mean change Cohen’s d Effect size r Grimacing Mean change Cohen’s d Effect size r Moaning* Mean change Cohen’s d Effect size r Crying Mean change Cohen’s d Effect size r Heart rate Mean change Cohen’s d Effect size r
11.4 4.345 0.908 0 0 0 −18.2 −1.209 −0.517 — — — −31 −0.974 −0.761
Mother
Following During
0 0 0
6.3 1.561 0.615
0 0 0
n.c.r. n.c.r. n.c.r.
n.c.r. n.c.r. n.c.r. — — — n.c.r. n.c.r. n.c.r.
−12.04 −2.08 −1.315 −0.498 −0.550 −0.242
−19.5 −1.667 −0.640 — — —
Following
0 0 0 −5.1 −0.629 −0.300 −4.2 −1.190 −0.511 — — —
References 1 Nakken H, Vlaskamp C. A need for a taxonomy for profound intellectual and multiple disabilities. J Policy Pract Intellect Disabil 2007;4:83–7. 2 Breau LM, Camfield CS, McGrath PJ, et al. Risk factors for pain in children with severe cognitive impairments. Dev Med Child Neurol 2004;46:364–71. 3 van der Putten A, Vlaskamp C. Pain assessment in people with profound intellectual and multiple disabilities; a pilot study in to the use of the Pain Behavior Checklist in every day practice. Res Develop Dis 2007;32:1677–84. 4 Marcus DA. The science behind animal-assisted therapy. Curr Pain Headache Rep 2013;17:1–7.
−64.7 −11 −0.956 −0.127 −0.431 −0.0631 −3.01 −0.280 −0.139
*Escola Superior de Educação Paula Frassinetti; Departamento de Ciências do Comportamento, Instituto de Ciências Biomédicas Abel Salazar; § Instituto de Biologia Molecular e Celular, Universidade do Porto, Porto; ‡ Escola Superior de Saúde, Campus do Instituto Politécnico de Setúbal, Setúbal, Portugal †
2.49 0.165 0.082
* Behaviour never exhibited by this participant. Mean changes refer to the calculated mean differences from baseline. Cohen’s d and effect size r are also shown. Mean changes are shown in seconds with exception of those referring to heart rate, which are shown in beats per minute. n.c.r. = nonconsistent response.
course, have difficulties in differentiating pain from physical discomfort or mental unease. Nevertheless, and given that children with PIMD cannot verbally express their pain, attending to the practical knowledge of those who were the most familiar with the participants seemed the best way to capture some level of pain that could potentially be alleviated by contact with the therapy dog and with the mother. The present study is only exploratory and, because of the limited sample size, does not allow for generalizations. However, it constitutes the first attempt to directly quantify the potential of therapy dogs as effective stimuli to be used in planned interventions for managing pain in children with PIMD. MARIELY LIMA, PhD,* KARINE SILVA, PhD,† ISABEL AMARAL, PhD,‡ ANA MAGALHÃES, PhD,§ and LILIANA de SOUSA, PhD†
5 Green CW, Reid DH. Defining, validating, and increasing indices of happiness among people with profound multiple disabilities. J Appl Behav Anal 1996;293:67– 78. 6 Corff KE, Seideman R, Venkataraman PS, et al. Facilitated tucking: A nonpharmacologic comfort measure for pain in preterm neonates. J Obstet Gynecol Neonatal Nurs 1995;24:143–8. 7 Gray L, Watt L, Blass EM. Skin-to-skin contact is analgesic in healthy newborns. J Pediatr 2000; 105:14–22. 8 Chermont AG, Falcão LFM, de Souza Silva EHL, et al. Term newborn infants skin-to-skin contact and/or oral 25% dextrose for procedural pain relief. J Pediatr 2009;124:1101–7. 9 Lima M, Silva K, Magalhães A, et al. Beyond behavioral observations: A deeper view through the sensory reactions of children with profound intellectual and multiple disabilities. J Child Care Health Dev 2013;39:422–43. 10 Cohen J. Statistical Power Analysis for the Behavioral Sciences, 2nd edition. New Jersey: Lawrence Erlbaum Associates; 1988. 11 Cignacco E, Hamers JPH, Stoffel L, et al. The efficacy of non-pharmacological interventions in the management of procedural pain in preterm and term neonates. A systemic literature review. Europ J Pain 2007;11:139–52.
3
