Hypnotherapy in management of pain in children with cancer: a case report : IJS Global Health

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Case Report

Hypnotherapy in management of pain in children with cancer: a case report

Choobi Anzali, Babak MDa; Muhammadi, Sheida MScb; Malkari, Behnam MScc; Goli, Rasoul MScd; Norouzrajabi, Samira MSNe; Talebiazar, Nasim MDf,

Author Information
International Journal of Surgery: Global Health: September 2022 - Volume 5 - Issue 5 - p e82
doi: 10.1097/GH9.0000000000000082
  • Open

Abstract

Pain is the most common symptom in cancer patients that can affect their performance and quality of life1. Cancer pain may be due to pathology, disease progression, metastasis, tumor growth, or diagnostic and therapeutic procedures2. Pain intensity increases with disease progression3. Despite recent advances in pain management, many cancer patients still encounter severe pain2. Severe pain is so stressful that can affect the patient’s lifestyle and his/her feelings of satisfaction and comfort. High levels of pain can also cause patients to suffer from loss of control, fatigue, poor quality of life, impaired personal relationships, sleep deprivation, and disruption in daily activities4. Therefore, cancer pain should be necessarily identified and relieved in the early stages of disease progression. In the meantime, the barriers to effective pain relief have to be identified and removed using appropriate measures5.

Therefore, cancer patients have various psychological and medical needs that can be met through psychological interventions, especially hypnotherapy6. Hypnotherapy has been used as a common approach to psychotherapy from the seventh century onwards7. Hypnosis is associated with a state of concentration and acceptance, which simultaneously consists of 3 components or combinations with different amounts and sizes of rupture, high attention or fascination and indoctrination and all 3 parts need to be applied together8. Hence, the main question of the present study is whether hypnotherapy is effective on the intensity of pain in children with cancer? This case report was reported according to the SCARE 2020 Guidelines to ensure the quality of reporting9.

Case presentation

Participant A

The first participant as a 12-year-old girl was living in Urmia. She was the only child in her family and had educated and employed parents with a good socioeconomic status. She did not have any problems at birth and only had a simple tonsillectomy at the age of four. She started to suffer from leg swelling about 2 years ago, which caused severe pain, especially at night. After several doctor’s visits, she was diagnosed with tibial torsion and physiotherapy was prescribed for her. At the time, a radiologist suggested having a biopsy after the magnetic resonance imaging (MRI). Based upon the biopsy results, the child’s disease was diagnosed and treatment was started. At first, the child and her parents were referred to the hematology ward once a week. She was at stage II of her disease. Chemotherapy was also conducted for the patient. She was taking her medication on time at home, but one of the additional problems that had made the condition worse and caused the child to be worried and scared was the quarrels and arguments between her parents. She felt better after conducting 3 sessions of hypnotherapy and the follow-up evaluation indicated that she has calmed down and her confusion and pain lessened somewhat. She seemed to be much happier after the completion of hypnotherapy sessions. Her mother stated that she was very interested in bike riding, but she did not care much about it. However, she was more physically active and had regular cycling during the hypnotherapy sessions and after that.

Participant B

The second participant as a 9-year-old girl was living in Urmia. She was the second child of a family with a good socioeconomic status. Besides, her parents had no problem with treating their child. It was about 3 years ago when the child’s mother realized that a part of her baby’s hair had fallen out and that part had been completely bald. This hair loss began to worsen day by day and the child’s forehead gradually became swollen. After referring to a hospital, doctors took a sample of the area and found out that the child had leukemia. She was at stage II of her disease. After the diagnosis, chemotherapy began immediately. After several days of treatment, the child showed up to have internal bleeding and went into a coma for 21 days. She was hospitalized in the Intensive Care Unit during this period. After recovery from the above condition, chemotherapy started again. The child is currently going to the clinic and visits her doctor as an outpatient. She has a lumbar injection every 3 months and intravenous (IV) chemotherapy every 35 days. According to the mother’s statements, the child’s pain significantly reduced during and after hypnotherapy sessions.

Participant C

The third participant as a 12-year-old girl was living in Urmia. She was the second child of a family with a good socioeconomic status. The child had no particular problem from birth to her 10-year-old when she was diagnosed with cancer. She caught a severe cold about 2 years ago that had led to the appearance of skin spots. After visiting a doctor and having several tests, an exact diagnosis of cancer was made for her. Treatment began and the child was referred to the hospital for conducting chemotherapy every 35 days. She was at stage II of her disease. She was prescribed with IV chemotherapy every 3 months. According to her mother’s statements, the child strongly resisted the drug administration and had high levels of pain so that she had to be taken around a few days before the chemotherapy and sleep in her mother’s arms during the night before the chemotherapy. She even resisted taking medicine at home. However, her mother stated that the child became calmer when she was receiving cancer agents after the hypnotherapy sessions and she better reacted to the hospital stay.

Intervention

This study was conducted in 2019 at Motahari Hospital, Urmia, Iran. Regarding the limited number of the target population, a total of 3 female children with cancer were recruited using voluntary response sampling. Data were collected using a demographic questionnaire and the Oucher Pain Scale (OPS). The OPS is a poster-shaped instrument consisting of 2 vertical scales; a number scale on the left for older children and a picture scale on the right for younger children. The number scale includes numbers ranging from “0=no pain” to “100=most severe pain.” Those 7-year-old and older children who are able to utilize numbers for describing their levels of pain point to a number that indicates their exact level of pain. The picture scale consists of 6 pictures arranged vertically, the top one of which shows worst pain and the bottom one shows no pain. The pictures can be also converted to the scores on the numerical scale from “10=picture at the top of the scale” to “ 0=picture at the bottom of the scale.” Children who are not able to understand numbers should use the picture scale and point to the picture that exactly shows their pain level. The content validity of the OPS was assessed using Kendall τ coefficient, which was obtained to be 0.6510.

In this study, participants first completed the OPS 3 times and then received hypnotherapy. Then participants recompleted the scales after the first, fourth, fifth, and eighth treatment sessions and the mean scores of the outcome variables were re-assessed at the same measurement time points (Table 1). For this purpose, the researcher tried to deepen patients’ level of trance by indoctrination. Then the patients were provided with mental imagery for 10 minutes. At first, this imagery was in pleasant and relaxing areas, while at the end, the mental imagery was provided about sleep and the indoctrination on conditioning participants was repeated. After entering the patients’ trance and deepening the indoctrination, they were indoctrinated on increasing the desired physical feeling. Moreover, hand anesthesia was practiced using direct indoctrination of cooling and ice numbing. Patients also received a pleasant feeling and mindfulness practices to manage and relieve their pain. Patients were conditioned to count to 10 and take 3 deep and slow breaths. Patients were also recommended to conduct these conditionings before bedtime or during early awakening to gain peace, relieve stress, and anxiety.

Table 1 - Hypnotherapy program.
Session No. Session Content
1st session The researcher became acquainted with patients and their parents and expressed the study objectives to them. Then patients’ medical history was taken and their misunderstandings of hypnotherapy were addressed. They were also provided with explanations on how to conduct the procedures. A pretest was performed so that participants and their parents were asked to complete the HADS
2nd session Participants were provided with complete explanations on hypnosis and trance and how to do it. Besides, they were explained about the changes they should expect in these few treatment sessions. Then, in order to begin the treatment, they were given general training on relaxation
3rd session First, the researcher tried to deepen patients’ level of trance by further indoctrination. Then the patients were provided with mental imagery for 10 min. At first, this imagery was in pleasant and relaxing areas, while at the end, the mental imagery was provided about sleep and the indoctrination on conditioning participants was repeated
4th session After entering the patients’ trance and deepening the indoctrination, they were indoctrinated on increasing the desired physical feeling. Moreover, hand anesthesia was practiced using direct indoctrination of cooling and ice numbing. Patients also received a pleasant feeling and mindfulness practices to manage and relieve their pain
5th session Patients received training about the impact of the disease on various dimensions of their lives, increasing their life expectancy, and improving their quality of life and life satisfaction using muscle relaxation, mental visualization, and mindfulness
6th session Hypnotic indoctrination was accompanied by indoctrination-related mental images to improve tolerance and resilience. So it was tried to promote the effectiveness of hypnotherapy
7th session Patients were conditioned to count to 10 and take 3 deep and slow breaths. Patients were also recommended to conduct these conditionings before bedtime or during early awakening to gain peace, relieve stress, and anxiety
8th session The content of previous sessions was reviewed. Patients were gradually progressed in the training areas and a disease-free life was visualized. Patients re-completed the scales as a posttest

Data analysis

The recovery rate formula was also used to analyze the results. The recovery rate formula is one of the methods used to measure the progress of clients in tackling target problems. The effect size was also used to analyze the effectiveness of the intervention. Various studies have suggested the value of 0.41 as a small effect size, 1.15 as a medium effect size, and 2.70 as large effect size. Another advantage of effect size is that it can be interpreted by the mean percentile gain.

Results

The mean and SD of the intensity of pain, in the first, third, fifth, eighth, and follow-up sessions are presented in Table 2. The intensity of pain mean scores of participant “A” had a decreasing trend after all postintervention measurement time points including third, fifth, eighth, and follow-up sessions (Fig. 1). The intensity of pain mean scores of participant “B” had a slightly decreasing trend compared with the baseline mean score. Nonetheless, this decreasing trend stopped at the follow-up stage so that the level of intensity of pain increased and was found to be higher than that in the fifth and eighth sessions but still less than that at the baseline and third session (Fig. 1). For participant “C,” the recovery rate in the intensity of intensity of pain for this participant was indicated to be significant at the treatment (94%) and the follow-up stage (81%). Therefore, it can be stated that the recovery rate of participant “C” was significant in the intensity of intensity of pain at the treatment and follow-up stages (Table 3). The effect size of the intensity of pain was indicated to be small in all 3 participants (Table 4).

Table 2 - Mean and SD of outcome variable.
1st Session 3rd Session 5th Session 8th Session Follow-up Session
Variable M SD M SD M SD M SD M SD
Pain 6 2 2 0 2 0 2 0 2.67 1.15

F1
Figure 1:
A–C, The intensify of pain mean scores of 3 participants at measurement time points.
Table 3 - Participants’ recovery rate in outcome variable.
Participant A Participant B Participant C
Variable Treatment Follow-up Treatment Follow-up Treatment Follow-up
Pain 75% 75% 60% 33% 50% 50%

Table 4 - The effect size of the outcome variable.
Variable Participant Baseline Mean Score Postintervention Mean Score Baseline SD Post-intervention SD Overall SD Effect Size
Pain A 5 2 4.24 0 2.68 1.11
B 5 1.33 1.41 1.15 2.28 1.65
C 3 2 1.40 0 0.89 1.12

Discussions

In a general explanation of the effectiveness of hypnotherapy in reducing the pain intensity among cancer patients, it can be stated that hypnosis, which is similar to attention training technique in cognitive-behavioral therapy, turns a person’s attention from the pain site to other subjects and this state causes the feeling of pain to be perceived weaker. Hypnosis often creates a state that increases attention to internal perceptions and decreases environmental stimuli6. Hypnotherapy acts as a facilitator in pain management by pain visualization and detailing sensory aspects of pain, including heat and physical sensations, for children with cancer, thereby reducing their pain intensity10.

In line with the results of our study, Fathi et al11 showed that hypnotherapy significantly reduces the sensory and emotional perception of pain and causes patients to have effective pain management. Császár et al12 indicated that hypnosis induction is an effective method for managing pain in patients. Ahmadi et al13 concluded that hypnosis induction is an effective way to treat tension headaches. Prasetya et al14 showed that hypnotherapy was effective in reducing pain in cancer patients. Sarafino and Smith15 reported that hypnosis can reduce the intensity of pain. Farshbaf Mani Sefat et al16 came to the result that pain intensity significantly reduced in 2 groups of cognitive-behavioral and hypnotherapy compared with the control group and that hypnotherapy was more effective than cognitive-behavioral education.

Conclusions

Based upon the results of this study, it is concluded that hypnotherapy is a promising approach in reducing the intensity of pain in children with cancer. Therefore, it is recommended to employ experienced and skilled psychologists and use hypnotherapy along with pharmacological treatments to reduce the intensity of pain in children with cancer.

Ethical approval

The Ethics Committee of Urmia Islamic Azad University approved this study (Ethics No. IR.IAU.URMIA.REC.1400.021).

Sources of funding

None.

Authors’ contribution

R.G.: study concept, data collection, writing the paper and making the revision of the manuscript following the reviewer’s instructions. N.T., S.M., B.C., S.N., B.M.: study concept, reviewing, and validating the manuscript’s credibility. R.G.: reviewing and validating the manuscript’s credibility.

Conflicts of interest disclosure

The authors declare that they have no financial conflict of interest with regard to the content of this report.

Research registration unique identifying number (UIN)

None.

Guarantor

Rasoul Goli.

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Keywords:

Cancer; Hypnotherapy; Pain intensity; Case report

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