A randomized, controlled trial of immersive virtual reality analgesia, during physical therapy for pediatric burns

This randomized, controlled, within-subjects (crossover design) study examined the effects of immersive virtual reality as an adjunctive analgesic technique for hospitalized pediatric burn inpatients undergoing painful physical therapy. Fifty-four subjects (6-19 years old) performed range-of-motion exercises under a therapist's direction for 1-5 days. During each session, subjects spent equivalent time in both the virtual reality and the control conditions (treatment order randomized and counterbalanced). Graphic rating scale scores assessing the sensory, affective, and cognitive components of pain were obtained for each treatment condition. Secondary outcomes assessed subjects’ perception of the virtual reality experience and maximum range-of-motion. Results showed that on study day one, subjects reported significant decreases (27-44%) in pain ratings during virtual reality. They also reported improved affect (“fun”) during virtual reality. The analgesia and affect improvements were maintained with repeated virtual reality use over multiple therapy sessions. Maximum range-of-motion was not different between treatment conditions, but was significantly greater after the second treatment condition (regardless of treatment order). These results suggest that immersive virtual reality is an effective nonpharmacologic, adjunctive pain reduction technique in the pediatric burn population undergoing painful rehabilitation therapy. The magnitude of the analgesic effect is clinically meaningful and is maintained with repeated use.     

Feasibility of virtual reality-delivered pain psychology therapy for cancer-related neuropathic pain: a pilot randomised controlled trial

Virtual reality-delivered psychological therapies have recently been investigated as non-pharmacological management for acute and chronic pain. However, no virtual reality pain therapy software existed that met the needs of cancer patients with neuropathic pain. We created a bespoke virtual reality-delivered pain therapy software programme to help cancer patients manage neuropathic pain incorporating guided visualisation and progressive muscle relaxation techniques, whilst minimising the risk of cybersickness in this vulnerable patient population. This randomised controlled pilot study evaluated the feasibility, acceptability, recruitment rates and risk of cybersickness of this pain therapy software programme. Clinical outcomes including opioid consumption, pain severity, pain interference and global quality of life scores were secondary aims. Of 87 eligible cancer patients with neuropathic pain, 39 were recruited (47%), allocated to either the intervention (20 patients, virtual reality pain therapy software programme) or control (19 patients, viewing virtual reality videos). Four patients withdrew before the 3-month follow-up (all in the control group). Pre-existing dizziness (Spearman ρ 0.37, p = 0.02) and pre-existing nausea (Spearman ρ 0.81, p < 0.001) were significantly associated with risk of cybersickness in both groups. Patients in the intervention group reported less cybersickness, as well as tolerated and completed all therapy sessions. At 1- and 3-month follow-up, there were trends in the intervention group towards reductions in: oral morphine equivalent daily dose opioid consumption (−8 mg and −4 mg; vs. control: 0 mg and +15 mg respectively); modified Brief Pain Inventory pain severity (−0.4, −0.8; vs. control +0.4, −0.3); and pain interference (−0.9, −1.8; vs. control −0.2, −0.3) scores. The global quality of life subscale from the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-C30 was not significantly changed between groups at 1 and 3 months (intervention: −5, −8; vs. control: +3, +4). This newly created virtual reality-delivered pain therapy software programme was shown to be feasible and acceptable to cancer patients with neuropathic pain. These results will aid the design of a definitive multicentre randomised controlled trial.     

A comparison of interactive immersive virtual reality and still nature pictures as distraction-based analgesia in burn wound care

PurposeNon-pharmacologic adjuncts to opioid analgesics for burn wound debridement enhance safety and cost effectiveness in care. The current study explored the feasibility of using a custom portable water-friendly immersive VR hardware during burn debridement in adults, and tested whether interactive VR would reduce pain more effectively than nature stimuli viewed in the same VR goggles.MethodsForty-eight patients with severe burn injuries (44 adults and 4 children) had their burn injuries debrided and dressed in a wet wound care environment on Study Day 1, and 13 also participated in Study Day 2.InterventionThe study used a within-subject design to test two hypotheses (one hypothesis per study day) with the condition order randomized. On Study Day 1, each individual (n = 44 participants) spent 5 min of wound care in an interactive immersive VR environment designed for burn care, and 5 min looking at still nature photos and sounds of nature in the same VR goggles. On Study Day 2 (n = 12 adult participants and one adolescent from Day 1), each participant spent 5 min of burn wound care with no distraction and 5 min of wound care in VR, using a new water-friendly VR system. On both days, during a post-wound care assessment, participants rated and compared the pain they had experienced in each condition.Outcome measures on Study Days 1 and 2Worst pain during burn wound care was the primary dependent variable. Secondary measures were ratings of time spent thinking about pain during wound care, pain unpleasantness, and positive affect during wound care.ResultsOn Study Day 1, no significant differences in worst pain ratings during wound care were found between the computer-generated world (Mean = 71.06, SD = 26.86) vs. Nature pictures conditions (Mean = 68.19, SD = 29.26; t < 1, NS). On secondary measures, positive affect (fun) was higher, and realism was lower during computer-generated VR. No significant differences in pain unpleasantness or “presence in VR” between the two conditions were found, however.VR vs. No VR. (Study Day 2)Participants reported significantly less worst pain when distracted with adjunctive computer generated VR than during standard wound care without distraction (Mean = 54.23, SD = 26.13 vs 63.85, SD = 31.50, t(11) = 1.91, p < .05, SD = 17.38). In addition, on Study Day 2, “time spent thinking about pain during wound care” was significantly less during the VR condition, and positive affect was significantly greater during VR, compared to the No VR condition.ConclusionThe current study is innovative in that it is the first to show the feasibility of using a custom portable water-friendly immersive VR hardware during burn debridement in adults. However, contrary to predictions, interactive VR did not reduce pain more effectively than nature stimuli viewed in the same VR goggles.     

Quantifying virtual reality pain modulation in healthy volunteers: A randomized,crossover study

Study ObjectiveVirtual reality (VR) is an emerging tool to reduce pain and anxiety during procedures. Although VR's clinical benefits are reported, biometric data quantifying VR's effect on pain tolerance is lacking. We used time-lapse, subjective, and biometric data to evaluate VR's effect on modulating pain.DesignRandomized, controlled crossover within-subject clinical trial.SettingThis study was conducted in the Chariot Lab at Lucile Packard Children's Hospital and outdoors at Stanford University School of Medicine.Patients156 healthy volunteers were included.InterventionsParticipants underwent pain-inducing ice immersions while connected to biometric sensors. Participants were randomized to immerse their dominant or non-dominant hand with VR or control (no VR) for one immersion, and then crossed-over to the other hand for the second immersion. We instructed participants to submerge their hand until they reached their pain tolerance or until four minutes elapsed.MeasurementsOutcomes included ice immersion duration, perceived pain scores, and skin conductance response density (SCRD), a marker of sympathetic arousal. We used survival analysis and mixed effects models to compare measurements with and without VR.Main Results153 participants were included in the analysis. Participants with VR were 64% less likely to remove their hands from the ice bath throughout the immersion's duration compared to control (P < 0.001). Participants with VR reported significantly lower pain scores after controlling for dominant hand treatment assignment, VR vs. no VR treatment order, and gender (P < 0.001). SCRD increased as time progressed for both VR and control groups (P = 0.047 combined), with no significant mean group differences.ConclusionsParticipants with VR were more likely to survive the 4-min ice bath challenge longer and with lower levels of pain perception, supporting VR's effectiveness as a distraction tool during painful procedures. We observed no differences in sympathetic response when comparing VR to no VR.     

Virtual reality for acute and chronic pain management in adult patients: a narrative review

Virtual reality is a computer-generated environment that immerses the user in an interactive artificial world. This ability to distract from reality has been utilised for the purposes of providing pain relief from noxious stimuli. As technology rapidly matures, there is potential for anaesthetists and pain physicians to incorporate virtual reality devices as non-pharmacological therapy in a multimodal pain management strategy. This systematic narrative review evaluates clinical studies that used virtual reality in adult patients for management of acute and chronic pain. A literature search found 690 citations, out of which 18 studies satisfied the inclusion criteria. Studies were assessed for quality using the Jadad and Nottingham-Ottawa Scales. Agreement on scores between independent assessors was 0.87 (95%CI 0.73–0.94). Studies investigated virtual reality use: intra-operatively; for labour analgesia; for wound dressing changes; and in multiple chronic pain conditions. Twelve studies showed reduced pain scores in acute or chronic pain with virtual reality therapy, five studies showed no superiority to control treatment arms and in one study, the virtual reality exposure group had a worsening of acute pain scores. Studies were heterogeneous in: methods; patient population; and type of virtual reality used. These limitations suggest the evidence-base in adult patients is currently immature and more rigorous studies are required to validate the use of virtual reality as a non-pharmacological adjunct in multimodal pain management.     

Therapeutic and stabilization exercises after manual therapy in patients with non-specific chronic neck pain: A randomised clinical trial

ObjectiveThis study aimed to determine and compare the effects of therapeutic and stabilization exercises prescribed to patients after manual therapy sessions on pain, neck range of motion and disability.MethodsThirty patients with non-specific chronic neck pain were recruited. After the initial examination, one session of manual therapy was conducted. The examinations were repeated to assess the effect of manual therapy on pain intensity and neck range of motion. After manual therapy, patients were randomly allocated into two groups: stabilization exercise group (SEG) and therapeutic exercise group (2 days/week/6 week). Pain intensity was assessed using the visual analog scale. Joint movements assessed using goniometer and the lateral scapular shift test for scapular dyskinesia. In addition, disability status was assessed using a neck disability index.ResultsIn all patients, manual therapy decreased pain intensity and increased joint movements (p < 0.05). After 6 weeks of exercise therapy, pain intensity, neck flexion, extension, lateral flexion movement and disability improved in SEG (p < 0.05).ConclusionThis study demonstrated that stabilization exercises combined with manual therapy had more positive effects among patients with non-specific chronic neck pain.Implications for practice

• •The treatment for non-specific chronic neck pain should be supported with exercises after manual therapy sessions for reducing neck pain.
• •Instead of therapeutic isometric exercises, which are often clinically prescribed as home exercises, stabilization exercises may be preferred as they are performed by maintaining the neutral position of the neck and include stretching.

     

Relationships between pain misconceptions,disability, patients' goals and interpretation of information from hand therapists

IntroductionPatient interpretation of advice from hand therapists may be related to nonadaptive pain thoughts (automatic, overprotective, unduly pessimistic statements triggered by nociception and exacerbated by psychological distress).Purpose of the studyThis study aimed to determine whether there were correlations between participants' hand therapy goals, interpretation of advice from hand therapists, nonadaptive pain thoughts, and upper extremity-specific disability.MethodsOne hundred and five participants completed questionnaires assessing nonadaptive pain thoughts, upper extremity-specific disability, lessons from hand therapists, and hand therapy goals.ResultsNonadaptive pain thoughts correlated with disability and were bi-directionally related to participant goals and interpretation of advice from hand therapists.DiscussionPatients' nonadapative pain thoughts and the words/concepts used by hand therapists are both important in recovery from upper extremity illness.ConclusionsHand therapists should be mindful that nonadaptive pain thoughts are an important determinant of disability and that such thoughts can affect and be affected by their recommendations.Level of evidencen/a     

Client buy-in: An essential consideration for graded motor imagery in hand therapy

Study DesignThis is a cross-sectional survey research.IntroductionCurrent evidence provides efficacy of graded motor imagery (GMI) in chronic pain conditions but also reveals barriers to its implementation.Purpose of the StudyThe purpose of this study was to describe current utilization of GMI in hand therapy practice.MethodsSurvey tool, informed by literature and Revised Neurophysiology of Pain Questionnaire (NPQ) was electronically distributed to members of the American Society of Hand Therapists.Results132 therapists completed the survey. 65.2% reported they would always or very likely use GMI in clients with central sensitization, but no relationship between the likelihood of therapists using GMI to score achieved on the NPQ was found. Lack of patient buy-in, was the main barrier cited. “Sell it well” with pain neuroscience education the most cited strategy.DiscussionGMI is frequently used in clients with central sensitization but requires client buy-in.ConclusionsUnderstanding and explaining pain mechanism is essential for implementing GMI.     

Prevention of complications in hand therapy

Basic principles stress that the injury or surgery is not to be extended through complications resulting from a failure to control edema, poor wound care, improper splinting, or forceful exercise. Prevention of these problems in hand therapy is discussed. Close rapport between surgeon, patient, and therapist is most important to support and motivate the patient. If that motivation is demolished or even impaired, the entire course of surgery and therapy may be complicated or impaired.     

The relationship between depression,anxiety, and pain interference with therapy referral and utilization among patients with hand conditions

IntroductionPatients with upper extremity conditions may also experience symptoms of depression, anxiety, and pain that limit functional recovery.Purpose of the StudyThis study examined the impact of mental health and pain symptoms on referral rates to therapy and utilization of therapy services to achieve functional recovery among patients with common hand conditions.Study DesignThis is a retrospective cohort study of patients from one orthopedic center.MethodsData extraction provided demographics, the International Classification of Diseases, 10th revision diagnoses, therapy referral, therapy visit counts, treatment goal attainment, and Patient-Reported Outcomes Measurement Information System (PROMIS) Depression, Anxiety, and Pain Interference scores. The chi-square test, t-test, and logistic regression analyses assessed associations between baseline PROMIS depression, anxiety, and pain interference to therapy referral, the number of therapy visits, and goal attainment.ResultsForty-nine percent (172/351) of patients were referred to hand therapy. There was no relationship between three baseline PROMIS scores based on physician referral (t-test P values .32-.67) and no association between PROMIS scores and therapy utilization or goal attainment (Pearson correlation (r): 0.002 to 0.020, P > .05). Referral to therapy was most strongly associated with having a traumatic condition (P < .01). Patients with high depression, anxiety, and pain interference scores on average required one more therapy visit to achieve treatment goals (average visits: 3.7 vs 3.1; 4.1 vs 2.7; 3.4 vs 2.3, respectively). Fewer patients with high depression scores (50%) achieved their long-term goals than patients with low depression scores (69%, P = .20).ConclusionsPatients' baseline level of depressive symptoms and anxiety do not predict referrals to hand therapy by orthopedic hand surgeons. There is some indication that patients with increased depressive symptoms, anxiety, and pain interference require more therapy with fewer achieving all goals, suggesting that mental health status may affect response to therapy. Therapists may address mental health needs in treatment plans. Future studies should examine if nonreferred patients with depressive symptoms achieve maximal functional recovery.     

Adjunctive virtual reality for procedural pain management of burn patients during dressing change or physical therapy: A systematic review and meta‐analysis of randomized controlled trials

Dressing change and physical therapy are extremely painful procedures for burn patients. Adjunctive virtual reality therapy reportedly reduces pain when added to analgesics, but a summary analysis of the data has yet to be performed. We conducted this systematic review and meta‐analysis of randomized controlled trials to verify the pain‐reducing efficacy of virtual reality among burn patients undergoing dressing change or physical therapy. We searched MEDLINE (via PubMed), EMBASE (via OVID), and the Cochrane Central Register of Controlled Trials (via OVID) for relevant trials based on predetermined eligibility criteria from database establishment to February 2018. Two reviewers screened citations and extracted data independently. The quality of the included studies was evaluated according to the Cochrane Handbook, whereas statistical heterogeneity was assessed using chi‐square tests and I² statistics. Review Manager 5.3 was used for statistical analysis. Thirteen randomized controlled trials with 362 patients who underwent 627 burn dressing change or physical therapy sessions were included. The additional use of virtual reality significantly reduced pain intensity, time spent thinking about pain, and unpleasantness, and was more fun compared with that of using analgesics alone. Virtual reality is an effective pain reduction measurement added to analgesics for burn patients undergoing dressing change or physical therapy. However, multicenter, parallel group design randomized controlled trials are still required.     

Evaluation of occupational therapy–led advanced practice hand therapy clinics for patients on surgical outpatient waiting lists at eight Australian public hospitals

Study DesignThis is a prospective cohort study.IntroductionEvidence is emerging that advanced practice hand therapy clinics improve patient outcomes.Purpose of the StudyThe aim of this study was to evaluate an advanced practice hand therapy model of care for patients with chronic hand conditions on surgical outpatient waiting lists at eight Australian public hospitals.MethodsNonurgent and semiurgent patients were screened and treated, as required, by an advanced practice hand therapist and then discharged from the surgical outpatient waiting list as appropriate. Outcomes included patient safety, impact on the waiting list, patient satisfaction, and patients' perception of change as measured by Global Rating of Change (GROC). The GROC score was also compared across diagnoses. The relationship between the waiting time and need for surgical review during hand therapy treatment was also assessed. As appropriate, T-tests and analysis of variance were used for statistical analyses.ResultsA total of 37.2% of patients who commenced hand therapy were removed or discharged from the surgical outpatient waiting lists. Of the subset of patients who completed hand therapy (n = 1116), 28.4% were discharged without requiring surgical follow-up. A further 7.53% requested return to the waiting list despite discharge being recommended. The model of care was safe, and patient satisfaction was above 90%. The mean GROC score was +2.09 (±3.58) but varied across diagnoses with trigger finger or trigger thumb showing the greatest improvement (+4.21 ± 2.92, P < .01). Patients who did not require surgical consultation during hand therapy had a shorter wait time for their initial hand therapy appointment (P < .001).ConclusionsThe advanced practice hand therapy model of care was safe and effective in reducing hospital surgical outpatient waiting lists. Patients reported high satisfaction.     

Sleight of hand: Magic,therapy and motor performance

Finding creative therapeutic activities to help patients regain range of motion and strength in fun ways are keys aspects to many rehabilitation programs. These authors examine the use of magic tricks as a way to enhance a hand therapy program – Victoria Priganc, PhD, OTR, CHT, CLT, Practice Forum Editor.     

Virtual reality as a pain distractor during physical rehabilitation in pediatric burns

The purpose of this study was to determine the immediate effect of adding Virtual reality (VR) to conventional burn rehabilitation program on pain and range of motion (ROM) in children with burn injuries during rehabilitation sessions after burn.MethodsTwenty-two pediatric children (13 boys & 9 girls) with burn injuries and inpatient hospitalization participated in this study. Their age ranged from 9 to 16 years old with 2nd degree deep partial thickness burn of TBSA (10%–25%). They were randomly classified into study and control groups of equal numbers; control group receive passive ROM and stretch exercises, and study group receive the same treatment of the control group in addition to VR training. children in the study group wear the Oculus Rift DK2 as a means for VR and they allowed to choose the favorite video they would like to view before starting the study. The children feel like they are actually in a game. The pain was measured using VAS and the maximum range-of-motion of the joints using electronic digital goniometer before and immediately after the rehabilitation session.ResultsThere was a significant decrease in pain intensity and increase of ROM after application of VR in the study group and a significant difference between groups after treatment for pain and ROM p < 0.05.ConclusionBased on the current findings adding VR to the rehabilitation program of pediatric burn victims had an immediate effect on decreasing pain and increase ROM.     

SMoC-Wrist: a sensorimotor control-based exercise program for patients with chronic wrist pain

Study designThis is a narrative review.IntroductionChronic wrist pain is a common disorder that can lead to considerable disability in performing activities in daily living and at work. Patients with nonspecific chronic wrist pain are regularly referred to a physiotherapist/hand therapist. Immobilization, avoiding excessive wrist load, steroid injections, and various physical therapy methods predominantly focus on the pain itself. However, these methods often do not result in a satisfactory long-term pain relief.Purpose of the studyIn this article, we will describe the principles behind and content of a sensorimotor control–based exercise program as introduced by Videler et al., modified and substantiated by current insights into sensorimotor control training and wrist kinetics.MethodsBoth structure and content of the modified exercise program (SMoC-wrist) are substantiated by recent scientific literature.ResultsA clear 4-level exercise model based on sensorimotor principles is presented, that is, proprioceptive level, conscious static/isometric level, conscious dynamic level, and unconscious dynamic level. The content of each level and the transition toward the next level are described in detail.DiscussionBesides the substantiation of the exercise program, possible outcome measures for joint position sense and kinesthesia of the wrist are discussed.ConclusionWe modified and substantiated a widely used exercise program for patients with nonspecific chronic wrist pain based on recent insights into sensorimotor control principles and wrist kinematics. The presented exercise program (SMoC-wrist) is not primarily focused on reducing pain but on functional reeducation and strengthening of the neuromusculoskeletal system on the basis of sensorimotor control principles.     

The effect of virtual reality on pain,anxiety, and fear during burn dressing in children: A randomized controlled study

Aim and objectivesVirtual Reality (VR) can be used during painful procedures in children. This research was conducted to determine the effect of VR on the pain, anxiety, and fear levels experienced by patients during burn dressing.MethodsA randomized between groups study design was used to test whether VR reduced pain, fear, and anxiety during burn wound cleaning. The experimental (VR group) (n = 33) and the control group (n = 32) were determined using the simple randomization method for the children participating in the study (n = 65). The data were collected using the Wong–Baker FACES Pain Rating Scale, Children’s Fear Scale, and State- Trait Anxiety Inventory for Children. In addition, oxygen saturation and heart rate measurements were recorded before and after the procedure.ResultsUsing a between groups t-test, burn injured children in the group that received virtual reality (M = 2.6, SD = 1.9, SE= 0.21) showed significantly less pain intensity during burn wound care than the No VR control group (M = 4.2, SD =1.0, SE= 0.19, t = −5.89, p < 0.005). Similarly, the VR group reported significantly lower fear during wound care (M= 2.24, SD = 1.1, SE=0.19) than the No VR control group (M=3.72, SD = 0.6, SE=0.10, t = 6.70, p < 0.005), and on a scale from 0 to 100, patients in the VR group showed significantly less anxiety (36.46, SD = 8.1, SE=1.40) than patients in the No VR group (M= 53.16, SD = 7.4, SE=1.35, t = 8.52, p < 0.005). Heart rate during wound care was significantly lower in the VR group (M=119.60, SD = 8.1, SE=1.40) than in the No VR control group (M=129.56, SD = 10.64, SE=1.88, t = −4.25, p < 0.005). However, no significant difference in Oxygen saturation was found, (VR = 97.03, SD = 0.90, SE= 0.17, vs. No VR = 96.94, SD = 0.29, SE=0.23, t = 0.326, p > 0.05).ConclusionsVR is an effective method in reducing pain, fear, and anxiety caused by burn dressing in children aged 7–12. The use of VR during burn dressing was determined to have positive results on some physical and psychological parameters.     

Neuromuscular exercises on pain intensity,functional disability,proprioception, and balance of military personnel with chronic low back pain

BackgroundDue to their occupational status, military personnel are a high-risk group for low back pain (LBP).PurposeThe aim of this study was to investigate the effect of neuromuscular exercises on the severity of pain, functional disability, proprioception, and balance in military personnel with LBP.MethodsMilitary personnel with LBP were randomly assigned into two groups: intervention (n=15) and control (n=15). The intervention group performed 60 minutes of neuromuscular exercises three times per week for eight weeks while the control group continued their routine physical activities.ResultsThe mean post-intervention pain intensity, disability, and proprioception error significantly decreased in the intervention group. Whereas their mean post-interventions static and dynamic balance scores significantly increased.ConclusionsThe results indicate eight weeks of neuromuscular exercise decreased pain intensity and improved functional ability, static and dynamic balance, and proprioception among military staff suffering chronic low back pain.     

Use of mobile applications in hand therapy

IntroductionMobile devices can be incorporated into therapy as an engaging alternative to traditional therapy options. The use of mobile devices and smartphone applications can enhance the quality of care provided by health care professionals.PurposeTo find mobile apps that can be incorporated into hand therapy practice.MethodsHand therapy evaluation, interventions, proprioception, laterality, and home exercise program applications can be incorporated into practice. Patient education can also be provided via the use of mobile applications.ConclusionSmartphone applications can be a valuable intervention and impact performance in individuals with impaired hand function. Smartphone applications offer a client-centered, and potentially motivating, activity option that can be utilized to aid the hand therapist.     

Reducing pain through distraction therapy in small acute paediatric burns

IntroductionThe majority of patients who sustained small (low % total body surface area [TBSA]) burns are assessed in an outpatient setting. This can be a traumatic experience, particularly, for paediatric patients. During the initial assessment pharmacological and non-pharmacological adjuncts, such as distraction therapy, can be employed to provide an environment that may reduce and minimise distress.In this study, we investigated whether distraction therapy reduces objective pain scores during the outpatient assessment of small acute burns in children.MethodsTwo cohorts of patients were formed. In the first group (group A), the children received analgesia and routine nursing care. In the second group (group B), the children received specialist distraction therapy in addition to the same analgesia and nursing care.We recorded patient demographics, TBSA, anatomical sites and mechanism of burn. The Wong Baker™ visual analogue scale (VAS) was used to convert perceived pain, as reported by the patient or parent, into a numerical value at three set intervals during the consultation.Results50 patients were recruited with 32 patients in group A and 18 in group B. A larger TBSA positively correlated with higher pain scores (p < 0.05).At the start of the consultation the mean pain score without distraction therapy was 1.55 and with specialist distraction therapy was 0.33 (p < 0.05). The mean peak pain score during dressing change without distraction therapy was 6.80 and with specialist distraction was 4.47 (p < 0.05). At the end of the procedure, the mean pain score was 2.12 without distraction therapy and with specialist distraction 1.75.ConclusionThis study of pain scores in small acute paediatric burns has shown that distraction therapy provided by a qualified play specialist can reduce maximal pain by over 2 points on the Wong-Baker™ VAS. Consideration should be given to ensure that distraction therapy is available at all times during initial consultations for children who have sustained small burns.