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EMPIRICAL STUDIES

doi: 10.1111/j.1471-6712.2010.00784.x

Randomized clinical trial of musical distraction with and without headphones for adolescents’ immunization pain
´ lo ´ nsdo ´ ttir RN, MS (Doctoral Candidate)1 and Guðru ´ nsdo ´ ttir RN, DrPH (Professor)2,3 ´ n Kristja O ¨ f Kristja
1

Dalhousie University and IWK Health Centre, Halifax, NS, Canada, 2Faculty of Nursing, University of Iceland and 3Landspitali-University Children’s Hospital, Reykjavı ´k, Iceland

Scand J Caring Sci; 2011; 25; 19–26 Randomized clinical trial of musical distraction with and without headphones for adolescents’ immunization pain Distraction has shown to be a helpful pain intervention for children; however, few investigations have studied the effectiveness of this method with adolescents. The aim of this study was to evaluate the usefulness of an easy and practical musical distraction in reducing adolescents’ immunization pain. Furthermore, to examine whether musical distraction techniques (with or without headphones) used influenced the pain outcome. Hundred and eighteen 14-year-old adolescents, scheduled for polio immunization, participated. Adolescents were randomly assigned to one of three research groups; musical distrac-

tion with headphones (n = 38), musical distraction without headphones (n = 41) and standard care control (n = 39). Results showed adolescents receiving musical distraction were less likely to report pain compared to the control group, controlling for covariates. Comparing musical distraction techniques, eliminating headphone emerged as a significant predictor of no pain. Results suggest that an easy and practical musical distraction intervention, implemented without headphones, can give some pain relief to adolescents during routine vaccination. Keywords: acute pain, distraction, music, adolescents, children, immunization, needles. Submitted 20 February 2009, Accepted 4 February 2010

Introduction
Injections, especially immunizations, are the most common universal health-related procedures in childhood. Although minor, these health care procedures cause pain and fear in both children and adolescents. It has been estimated that at least 10% of the general population has needle phobia, with the prevalence going up to 22% in a US sample of teenage girls needing prenatal care (1). Despite outward signs of coping with painful medical procedures in childhood, the pain and fear associated with these procedures can have future negative effects on seeking medical care as young adults (2). It is unknown how many adolescents refuse to receive further immunizations based on previous negative experiences as a young child. However, the use of pain intervention during paediatric immunization has been emphasized (3). Building a positive experience around immunization thus can lead to less fear and more positive health care experiences in adulthood.

Correspondence to: ´ lo ´ nsdo ´ ttir, 5850/5980 University Avenue, 8th flr Mrs O ¨ f Kristja (K8306) Halifax, Nova Scotia, B3K 6R8 Canada. E-mail: ol939557@dal.ca

Early adolescence is a crucial period during which teens take increasing responsibility for their own health (4), and begin to manage their own pain (5). For minor health-related procedures such as immunization, nonpharmacological, such as distraction can decrease reported pain experience and distress among children (6). Various distraction interventions are available for managing children’s pain and distress related to needles. These include looking through kaleidoscopes (7) or virtual reality glasses (8), blowing bubbles or air (9, 10), watching television (11), listening to music (8, 12, 13) or a combination of distraction techniques (14). However, the use of distraction techniques for adolescents specifically during needle pain has received little attention and only few studies have included adolescents as research subjects (8, 14). In clinical settings, music has been found to be a preferred coping strategy by adolescents over other coping methods (15). For nurses working with adolescents in school clinics, music distraction can potentially serve both as a pain intervention and as a coping method adolescents can utilize at home when coping with pain (e.g. headache, muscle ache/pain). Headphones are part of adolescent music culture, and are recommended as a part of music distraction interventions to reduce pain (16, 17). Studies using music distraction for children during a minor painful 19

Ó 2010 The Authors Scandinavian Journal of Caring Sciences Ó 2010 Nordic College of Caring Science

expected pain during procedure. that may influence children’s acute pain sensation (23).05 (25). Willingness to consent in the study did not affect the service offered to the students by the nursing staff. while in the health clinic. Adolescents were approached through their school where their classroom teacher introduced the study and distributed the information/consent forms for the parent(s) and adolescents. Of these students. These include for example. influence its effectiveness (21). emotional coping. administered by their homeroom teacher. as well as the central school authorities and the Educational Service Centre.8 and an a = 0. 21) is respected within nursing (22). controlling for covariates (see Fig. experienced control.e. expected pain during the procedure.e. controlling for pain related factors (see Fig. previous pain experiences. no study has compared whether the use of headphones influences pain outcome in clinical context. and (ii) that musical distraction with headphones is more effective in reducing self-reported immunization pain than musical distraction without headphones. unrelated to the pain stimuli. At the same time. 24) (see Fig. immun. behavioural. no. gender. 1). The study hypotheses predicts (i) that musical distraction [with(out) headphones] reduces self-reported immuniza- Method A randomized three-group experimental design was employed to test the stated hypotheses. to some extent. The adolescents were informed to which research group they were assigned. including pain. The brain stem may then project inhibitory impulses which help close the gate of transmission to the pain producing impulses (a normal or excessive sensory input may therefore relieve pain) (19). they completed a pre and postimmunization questionnaire focusing on pain intensity and distress. emotional and stable factors. 1). pain coping. we wanted to test whether covariates (i. Kristja ´ ttir O ´ nsdo ´ nsdo tion pain when compared with standard care (control treatment). Kristja ´ ttir. pain anxiety Control Pre-immun. Patricia McGraths’ child pain perception model (20. To our knowledge. fear Adolescent’s immunization pain sensation Musical distraction [with(out) headphones] intervention Figure 1 Theoretical frame on factors influencing adolescent’s immunization pain sensation (based on Patricia McGrath’s model with author’s approval). The school nurses were not blinded to the intervention groups.20 ´ . Inclusion criteria included all Icelandic speaking adolescents scheduled for a ninth grade immunization. Enlightened by the GCT. 1). previous pain experiences. situational. Participants A target sample of 121 adolescents aged 13–15 scheduled to undergo immunization at one of the largest primary schools in Iceland was used. G. On the immunization day in the health clinic location. The sample size was based on similar studies and an estimate of sample size for testing difference between three means with power of 0. Adolescents completed a background questionnaire before the immunization day in their classroom. Theoretical framework The gate control theory (GCT) provides a theoretical basis for using distraction (18). preprocedural anxiety and preprocedural fear) representing McGrath’s child pain perception model influence the effectiveness of the musical distraction intervention (see Fig. Ó 2010 The Authors Scandinavian Journal of Caring Sciences Ó 2010 Nordic College of Caring Science . procedure have all used headphones. A table of random numbers was used to randomize into groups. The aim of this study was to examine the effectiveness of an easy and practical pain intervention for reducing adolescents’ immunization pain sensation. 1). The analgesic effect produced when using distraction appears to work through the reticular system in the brain stem that can slow down incoming stimuli. Stable factors Gender Previous pain Behavioural factors Pain coping by music Emotional coping by music Situational Emotional factors factors Expected Pre-immun. This model brings forth the complexity of pain introducing four main factors. according to Reg. It took approximately 10 days to collect data in the classrooms and at the school’s health clinic. consent for the study was granted by the Chief Nurse Executive at the health care centre responsible for school health services. 286/2008 on scientific research within the health sector. i. These factors are considered significant to assess when providing a specific pain treatment as they may. 118 agreed to participate and completed the study. emotional coping. gender. but were blinded to the research hypothesis. preprocedural anxiety and preprocedural fear (23. experienced control. Procedure The study was approved by the National Bioethics Committee and the Data Protection Authority in Iceland. providing each participant with the equal probability of being assigned to either the control or the experimental groups (26). This element could prove to be an important factor when implementing musical distraction as a pain intervention within busy clinical settings. pain coping. Based on these approvals.

For pain intensity. Adolescents could choose the arm to be injected. and at the phrase ‘as painful as possibly imagined being’ and ‘10’ at the other end. Behavioural factors. Reliability and validity for the IHLC has been established (33). Adolescents’ preimmunization anxiety was measured using a 10-cm VAS with a line anchored at one end by the phrase ‘not anxious’ and ‘0’ and at the other end by the phrase ‘as anxious as possibly imagined being’ and ‘10’. As the study setting was a normal clinic. Emotional factors. different forms of VAS show a high correlation (31). the vaccine was injected into the teen’s deltoid muscle followed by a plaster. gender. 24) (see Fig. expected procedural pain. 1). For expected pain during the immunizations. evaluated immediately after the immunization. To limit contamination of effects. describing their level of health control ranging from statements such as: ‘good health is just a matter of luck’ to ‘good health only depends on what I do for myself and how I behave’ (coded 2 to )2. In line with the nurse’s standard protocol. Measures The WHO-Euro cross-nation study series of health-related behaviours in school children measurement tools were used in the design of the questionnaires (27). Eight covariates represented McGrath’s four factors in the study theoretical frame (see Fig. only one adolescent at a time came to the clinic for their immunization.Trial of musical distraction with(out) headphones Two registered school nurses. Distraction or active music listening was the pain intervention in the study. performed the injections. previous pain experiences. The authors adapted the questionnaire to include additional measures relevant to the context of the current study. Demographic variables. For internal health locus of control (IHLC). not use music). Age. one adolescent at a time came to the clinic for immunization. the school nurses responded to these with care. or discomfort after the immunization. there was regular coming and going of students not participating in the study. Gender was dummy coded (boys = 1). adolescents reported using a 10-cm VAS with anchor phrase ‘no pain’ and ‘0’ at one end. These measures have repeatedly been applied in international large surveys (28). These incidences were recorded by researchers and did not cause problems. The nurses attended the different study groups equally. experienced control. Distraction can be viewed as a cognitive coping strategy. and has wellestablished validity and reliability (34). which was to comfort and guide the adolescents verbally. All measures were pilot tested. Adolescents coping behaviour was measured by their use of music when in pain and when feeling bad (use vs. with a line anchored at one end by the phrase ‘not frightened’ and ‘0’ and at the other end by the phrase ‘as frightened as possibly imagined being’ and ‘10’. Pain intensity was the primary outcome measure. Adolescents’ preimmunization fear was Pain intervention and immunization procedure A school nurse prepared the adolescent for the polio immunization and answered any questions and concerns related to the procedure. both with years of experience in working with school children. These include. adolescents were asked: ‘How intense was the worst pain you have ever experienced?’ using a 10-cm visual analogue scale (VAS) with anchored phrase ‘no pain’ at one end and ‘the worst pain imaginable’ at the other end. indicating positive to negative statements of the items involved) (32). which usually was their none-dominant hand. the school nurses were encouraged to maintain their normal modes of caring. VAS scales have extensively been researched. For previous pain experience. This measure has widely been applied in paediatric pain studies. Musical distraction intervention [with(out) headphones]. 21 measured using a 10-cm VAS. Adolescents’ immunization pain intensity. Pain related factors (covariates). Further. adolescents responded to ten statements using a 5-point scale. Stable factors. health and parent’s cultural background were derived from the self-reported adolescents’ background questionnaire. as they are believed to affect children’s acute pain experiences. pain coping. Adolescent gender was collected through the self-reported background questionnaire. If the adolescents had any questions or concerns prior to the immunization. emotional coping. where attention is diverted from a noxious stimulus by passively redirecting the subject’s attention or Ó 2010 The Authors Scandinavian Journal of Caring Sciences Ó 2010 Nordic College of Caring Science . a yes/ no question whether they had a chronic disease and/or were physically handicapped (29). asking adolescents. Berger and Walker¢s definition of health was applied. The VAS is a uni-dimensional measure of pain. The nurse also responded to any discomfort or complaints related to the immunization. After rubbing alcohol on the injection site. showing good reliability and validity for children older than 8 years (30). 1). adolescents reported with a 10-cm VAS scale using dual anchors (expect no pain = 0) and (expected as much pain as possible = 10). In the standard care condition. preprocedural anxiety and preprocedural fear (23. Situational factors.

87 ± 1. almost all being Icelandic (97%) and healthy (Table 1).80) were significant predictors of adolescent immunization pain sensation (Table 2).84). In designing the intervention. musical distraction without headphones (compared to music with headphones and controls) and musical distraction with headphones (compared to music without headphones and controls). Apart from the musical distraction variables.e. and missing data was analysed.and Mann–Whitney U-tests. preimmunization anxiety (OR = 0.1–10 cm) categorical variables. 1).40 cm (range 0–7). whereas for the controls it was on average 1.83). with the exception of one relaxing classical CD. when entered jointly into a nine variable logistic regression analysis. on distraction to relieve pain (17) and music therapy (16).06 ± 3. Results Descriptive information Adolescents participating ranged in age from 13 to 15 (mean: 14. as the dependent variable (Fig. by actively involving the subject in the performance of a distractor’s task (35).e. For the logistic regression analysis. were included in a logistic regression model with pain outcome.0 (SPSS Inc. To compensate for the skewed distribution. These results are in accordance with other studies addressing music preferences by adolescents (36). The three research groups were compared on demographics and covariates with F. Only 23 adolescents (11.03 cm (range 0–10).00 ± 0. to distract and to help them cope during/after the immunization. Adolescent fear ratings prior to the immunization were on average 1. normal distribution. was sought. preimmunization anxiety.67. Kristja ´ ttir. However.. emotional coping via music. In selecting the top ten chart music for the study. pain coping by music.. The music for the study was selected based upon results from a pilot study. Ó 2010 The Authors Scandinavian Journal of Caring Sciences Ó 2010 Nordic College of Caring Science .69 ± 2. F-tests and Mann–Whitney U-tests found no significant differences between the three research groups on covariates (i. emotional coping by music.e.6%) girls.35 (range 0–9.48. were used.83) and expected immunization pain (OR = 0. experienced control. six teens (13–15 years old) were interviewed showing they preferred top ten chart music to relaxing music during the immunization. pain scores were dichotomized into no pain (0–0. For the first hypothesis. G. all variables were entered in one step. pain coping via music. or any of the demographic variables (Table 1). Their preimmunization anxiety was rated on average 3.78 ± 2. preimmunization fear (OR = 0. and continue to do so for a few minutes (2–3 minutes) before and after the immunization. Kristja ´ ttir O ´ nsdo ´ nsdo intensity.4%) and 55 (46. expected immunization pain intensity. (ii) asking them to concentrate on and ‘disappear into’ the music.01 ± 1. The dependent variable indicated presence or absence of pain (as determined by self-report). experienced control and expected immunization pain.e. and in nonhierarchical sequence. Descriptive statistics were used to assess violations of underlying assumptions (i. the pain intensity was on average 0. standard deviation 0. (iii) creating a sense of control in the adolescents by giving them choice i. The intervention protocol was the same for both intervention groups and included the following: (i) explaining the purpose of the music to the adolescents i. For the musical distraction group not using headphones. a music therapist was consulted. therapeutic nursing intervention guidelines. previous pain intensity. selecting a CD and controlling the volume setting and (iv) asking those getting musical distraction via headphones to wear them during the immunization. a logistic regression analysis was conducted to assess whether musical distraction (with and without headphones) would predict immunization pain. only musical distraction emerged as a significant predictor of immunization pain sensation (Table 2).95 (Table 1). Using a hypothetical immunization. extreme outliers). Acknowledging this. Chicago. Data analysis SPSS 17.09 cm) and pain (0. eight other independent variables including gender. USA) was used in all data analyses.49 cm (range 0–10). gender.9%) rated their pain equal to or higher than 2 cm. advice from a music marketing manager (Skifan). The p-value was set at <0.96 ± 1. IL. the music used in the study was largely chosen from top 10 charts of the day.9) (Table 1). musical distraction (OR = 2. The respondents’ expected immunization pain was on average 2. Logistic regression analysis was employed to assess the effects of musical distraction and model covariates on adolescent immunization pain scores.22 ´ . preimmunization anxiety and preimmunization fear). The intervention variable was coded as a dichotomous variable reflecting musical distraction intervention: musical distraction with and without headphones (compared to controls). The reported immunization pain intensity (VAS 0–10) among adolescents in the musical distraction group via headphones was on average 1. Immunization pain outcome across the sample was on average 0.18 years) with 63 boys (53.05 for statistical significance. who knew adolescent music preferences. In addition. while the other group was asked to listen to the music from the loudspeakers. preimmunization fear. Pain intensity scores were low and heavily skewed to the left (towards zero). enabling the use of multiple logistic regression (37).. previous pain Intervention effects Entered as single variables.

03 0.77 (0.83 0.56 (0.97 (0.72 (0.07 0.97 (0.78 (2.00 (0.79–1.50) 1.71–3.03 (0.999 0.53 (0. Statistical difference between groups not found.48 (0.80 0.80) 0. preimmunization fear (OR = 0.03 0.170 0.44–2.50 (3.84).91 1.044 0.79 (2.38) 2.70) 2.11) (0.51) 5. internal health locus of control.69 (2.67) 0.10 (2. when entered jointly into the ten variable logistic regression analysis.88) (0.50) 5.44–1.50 (0.8 times higher than those of an adolescent receiving standard nursing care (Table 2).50) 0.54 (0.46) 3.57) (0.76 (1.44) 0.02 0.22) 0.76 (0.53 (2.26) (0.35) 0.32 (2.83) and expected immunization pain (OR = 0.65–1.05 (0.84 1.179 0.02 0.23) (0.25 (0.12 1.01 (1.16) (0. visual analogue scale.86 (2.51) 0.95) 0.30) p 0.57–1.44) a VAS. internal health locus of control.23) (0.30 (3.04 0.021.67–0.90 (3.16) (0.50) 0.16) 0.05 0.33) 0. IHLC.90–1.02 0.30–1.16) (0.51 (0. IHLC.99) (0.00 (0.00 0.20) 0.06 (3.56 (0.29) (0.80) were significant predictors of adolescent immunization pain sensation (Table 2). 2 = positive] Immunization pain outcome Pain outcome Interval (VAS 0–10) Dichotomous (pain = 0) Music with headphones Music without headphones Controls 0.41 (0.00) 0.03) 1.16) (0.16) (0.43) 0. Results showed that the odds of adolescents experiencing ‘no pain’ during immunization were positively related to musical distraction without headphones 0.49) 0.27) (0.011 0.533 0.73–0.99) (0.30 (2.64–1.99 (1. The odds of an adolescent experiencing ‘no pain’ during the immunization if receiving musical distraction were approximately 2.22–6.Trial of musical distraction with(out) headphones Table 1 Descriptive information for study variables by total sample and study groupsa 23 Mean (SD) Sample Variables Demographic Age (14 years = 0) Health Chronic disease (n = 0) Handicapped (n = 0) Mother’s cultural background (icelandic = 1) Father’s cultural background (icelandic = 1) Pain-related factors (covariates) Stable factors Gender (girls = 0) Previous pain intensity (0–10) Emotional factors Preimmunization anxiety (0–10) Preimmunization fear (0–10) Behavioural factors Pain coping using music (not selected = 0) Emotional coping using music (not selected = 0) Situational factors Expected pain during immunization (0–10) Control (IHLC) [2 to ()2).08 0. musical distraction without headphones (OR = 2. 2.30) 0.52) 0.06 0. However.97 0.53) 0.96 (1.42) 2.43 (2.95 (0.17–6.10) 3.335 0.13 0.16) 0.45–2.87 (1.75 1.88) (0.24) (0. holding all other variables constant.61) (0.13) (0.95 0.20) 1.87 1.24 (0.318 controlling for covariates.976 Adjusted OR (95% CI) 2.50) 6.83 (0.21) 1. odds ratio.49) 1.11 0. Entered as single variables.18) (0.42 (0.74) (0.51) 5. preimmunization anxiety (OR = 0.96 (2.289 0.011 0.44) (0.016 0.16) (0.83 1.16) (0.55) p 0.18) 0. without controlling for (crude) and controlling for (adjusted) covariates (n = 118) Crude OR (95% CI) Musical distraction (control = 0) Gender (girls = 0) Previous pain intensity Pain coping by music (not selected = 0) Emotional coping by music (not selected = 0) Preimmunization anxiety Preimmunization fear Expected immunization pain Control (IHLC.10 (2.802 0.03 (0.03 (0.33–2.811 0.50) 0.16) 0. only musical distraction without headphones emerged as a Ó 2010 The Authors Scandinavian Journal of Caring Sciences Ó 2010 Nordic College of Caring Science .44–0.40) 0.21 (0.69–0.37) 0.95) (0. Table 2 Logistic regression of musical distraction on pain outcome.80 0.16) 0.30 (0.91) 3.48) 0.96) (0.51) 0.50) 0.765 0.98 1.96–1.84 0.43) 2.63) 1.925 0.54 (0.42 (0.26 (0.23) 0.50) (0.88) 3.96 0.021 0.18) (0. positive = 2) OR.71 (2.519 0.49 1.51).

99) (0.13 0.27) (1. effective distraction methods are able to keep the ‘pain gate’ (in the spinal cord) narrow and closed.91 1.50) (0.12) (1. For the second hypothesis.14 1.43–1. The odds of an adolescent experiencing ‘no pain’ during the immunization if receiving musical distraction without headphones were approximately 3. whether controlling for covariates or not (Table 3). Kristja ´ ttir O ´ nsdo ´ nsdo Table 3 Logistic regression of musical distraction. Patricia McGrath’s model (21) (see Fig.04 2. musical distraction. p = 0. In this study.90–1. Musical distraction via headphones was not a significant predictor (p = 0. Discussion The prediction that musical distraction would be associated with reduction in adolescents’ self-reported immunization pain sensation is supported. thus inhibiting ‘pain’ impulses entering the brain (18). a stress effect was connected to the fact that the children were unfamiliar with using headphones and the authors suggested that allowing them to choose whether to use headphones or not might help to avoid some of these difficulties.131) of adolescents immunization pain.441 0.44) (0.74 (0.80 0. the ineffectiveness of using headphones as part of the music distraction for adolescents’ immunization pain was unexpected. odds ratio. Results showed the odds of an adolescent experiencing ‘no pain’ during immunization were positively related to musical distraction without headphones (p = 0.45) (0. via headphones and via air.62) (0.6 times higher than those of an adolescent receiving musical distraction with headphones or standard nursing care (Table 3).44–0. 12.84 0. When adjusted for.011 0.51 1.96) (0.47–2.20 3. Also.83 0. The prediction that musical distraction via headphones would be more effective in reducing adolescents’ selfreported immunization pain compared to the other two groups was not supported.33–2.78 0.79–1.435–2.289 0.89 1.55) p 0. Ó 2010 The Authors Scandinavian Journal of Caring Sciences Ó 2010 Nordic College of Caring Science .925 0. positive = 2) OR.20) (0. along with musical distraction (see Table 2).50 1. The isolation effect of using the headphones may have produced more difficulty for adolescents in controlling what was going on during the immunization. preimmunization anxiety and preimmunization fear) emerged as single significant predictors of pain outcome.24 ´ . while contradicting others (7.79–6. The adolescents in this study did not seem uncomfortable with using the headphones per se.930 0. The percentage of adolescents reporting ‘no pain’ during the polio immunization was 56% for those in musical distraction group not using headphones.73–0. Further studies are needed to gauge the effectiveness of these methods. These findings are consistent with several studies of distraction for children and adolescents to reduce pain and/or distress (9–11.71–3.022). However. music via air = 0) Musical distraction via air (control.971 0. was the only significant predictor of the pain outcome variable. with the former being a stronger predictor. By controlling for the pain related factors (covariates) suggested by Patricia McGraths’s model.67–0. 38).139 0.04 0. on pain outcome.15–5.28) (0.73 0.31–9. Furthermore.28) p 0.82) (0.82) (0.66–1. 14). Three covariates (expected pain. these findings are in line with the GCT.58 1.020 0.011 0. (12) while studying 3–6-year-old children having immunizations. 8. G.10 0.95) (0. Kristja ´ ttir. A similar effect of using headphones during musical distraction was detected by Megel et al.86) (0. internal health locus of control.131 0.64. Headphones are commonly used by adolescents and have been recommended when giving musical distraction to reduce pain (16).09) (0.99 (0. previous studies have used headphones when applying musical distraction.773 0.802 0.508 0.56–1.013 0. Theoretically.98 0. however.46–2. 13.94–1.69–0. music via headphone = 0) Gender (girls = 0) Previous pain intensity Pain coping by music (not selected = 0) Emotional coping by music (not selected = 0) Preimmunization anxiety Preimmunization fear Expected immunization pain Control (IHLC. The headphones may also have interfered with the adolescents seeking comfort from the nurse administering the immunization.64–1.976 Adjusted OR (95% CI) 2. IHLC. controlling for covariates. Accordingly. holding all other variables constant.77) (0.13) (0. but they were observed removing the headphones to re-engage with the nurse.502 0.281 significant predictor of immunization pain sensation (Table 2).013).16) (0.044 0. a logistic regression analysis was conducted to assess whether musical distraction with and without headphones would predict adolescents’ immunization pain.229 0. 1.02 0. musical distraction unfolded in a stronger and significant intervention effect.765 0. 1 and Table 1) corroborates the pain reducing effect of musical distraction. without controlling for (crude) and controlling for (adjusted) covariates (n = 118) Crude OR (95% CI) Musical distraction via headphones (control. 42% for participants in musical distraction using headphone and 26% for the control group (v2 = 7.29–1. Therefore. results showed that musical distraction without headphones is effective in reducing immunization pain sensation compared to the other two groups.

Relevant statistical information was nonetheless gained. Champion GD. Saga Publication. Kristja ´ nsdo ´ ttir was responsible for drafting the manuO ´ nsdo ´ ttir script and making critical revisions. McGrath PJ. using the preferred pain interval measures (39). By dichotomizing the pain outcome variable. Child Health Care 1996. Vessey JA. In Handbook of Clinical Nursing Research (Suettinshaw A. intravenous canalization or suturing) to facilitate the detection of any variation in the musical distraction intervention. 93: 797–801. Author contributions ´ .g. 33: 842–854. Smith AJ. In regards to the nurses. Bright NS. This study has several limitations. Blount RL. A systematic review of randomized controlled trials examining psychological interventions for needle-related procedural pain and distress in children and adolescents: an abbreviated Cochrane review. Shaver JLF. G. 15: 313–20. 86: 737–41. procedures with stronger pain strength variability should be used (e.1–10 cm) categorical variables. Taking the ‘‘ouch’’ out of injections for children. McGrath PJ. Kristja ´ nsdo ´ ttir designed and implemented the study O ´ nsdo ´ ttir supervision (masters thesis). This is evident both in the paediatric pain literature (8) and the adult pain literature (41). fear. Martinez AM. In future studies. Cohen LL. It is not uncommon for children’s pain ratings to be skewed towards the ‘no pain’ end of the measurement scales for needle procedures (e. 6 Uman LS. Finally. time-efficient and easy-to-use nonpharmacological intervention may provide some comfort to adolescents during these routine distressing health care procedures. Kristja ´ . Pain reduction during pediatric immunizations: evidence-based review and recommendations. we dichotomized the pain scores into a ‘no pain’ (0–0. because of minor accidents. the Beatles and Nirvana. musical distraction in general and specifically used without headphones was a significant predictor of feeling less pain during polio immunization. 275–87. the data collection took a few days and was carried out in a busy school health clinic. however. Kristja participated in revising the manuscript. Zempsky WT. either positive or negative. Thus. In conclusion. Abu-Saad HH. 119: e1184–98. a wider choice of music is recommended in future studies. 8 Arts SE.e. Swafford MS. Also. Although the nurses were asked to go about as usual during the immunization procedure. Chambers CT. South Med J 1993. Using distraction to decrease pain. Feetham SL. we lost information on pain variability. Non-pharmacologic strategies used by adolescents for the management of menstrual discomfort.. as 56% of adolescents reported ‘no pain’ during the polio immunization. References 1 Cartwright PS. These findings suggest that a cost-effective. 26: 72–78. Researchers have compensated for this by dichotomizing the pain variable (8). Cohen LL. to compensate for this skewed distribution. Such incidents occurred randomly and should not have disrupted one study group more than another. Caul DE. the covariates controlled for were limited by its emphasis on psychological dimensions affecting children’s pain perception. e. Crawford MR. and behavioral distress in children and adolescents: a multisite study. Adolescents’ immunization pain intensity ratings were very low. which is consistent with previous findings showing low needle pain scores among older children and adolescents (8. Juniper KH. 5: 75–85. Pediatrics 1994. Hogan IG. The clinical effectiveness. health care professionals should evaluate whether headphone use is appropriate and assess their musical preference. Teenagers’ perceptions of barriers to prenatal care. on the outcome variables. under G. and if possible to allow the adolescents to bring their own music. they were blinded to the study hypothesis but not to the intervention groups. Interventions for promoting health in adolescents. but not for example analyses of variance (ANOVA). This made it difficult to control the adolescents’ comments to one another about the procedure and impossible to rule out the impact of rumours. Reed GW. 7 Carlson KL. Ó 2010 The Authors Scandinavian Journal of Caring Sciences Ó 2010 Nordic College of Caring Science . J Pediatr Psychol 2008. McMurtry CM. 25: 281–98. Using distraction to reduce reported pain. McGrath PJ. Broome M. Fisher RJ. 2 Pate JT. several adolescents found the music selection to be limited and recommended a greater variety. in reviewing the intervention variables. Pediatrics 2007. children and adolescents not participating in the study had to be attended to by the nurses during the study period i. 5 Campbell MA. we cannot rule out bias because of this. Age-related response to lidocaine-prilocaine (EMLA) emulsion and effect of music distraction on the pain of intravenous cannulation. immunization). Also. 1999. Ziegler JB. 4 Loveland-Cherry CJ. Further studies are needed to be able to recommend musical distraction as a routine clinical intervention during painful procedures such as immunization among adolescents. Before using musical distraction with adolescents. Thus. Clin J Pain 1999. 25 whereas the use of headphones was not. Further.g. J Soc Pediatr Nurs 2000. MCN Am J Matern Child Nurs 2001. and no behavioural differences towards adolescents depending on groups were observed. eds). Childhood medical experience and temperament as predictors of adult functioning in medical situations. 9 Sparks L. needs to be confirmed in future studies. 40). Kisely S. by adding music by David Bowie. compared to 26% in the control group. This enabled us to use multiple logistic regression (37).g. McLaughlin FJ. 3 Schechter NL.09 cm) and ‘pain’ (0.Trial of musical distraction with(out) headphones Musical distraction without headphones appears to be a clinically meaningful pain intervention strategy for adolescents. London.

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