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Using a Humanoid Robot to Distract Children With Cancer or Chronic Immune Deficiency Undergoing Painful Procedures

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ClinicalTrials.gov Identifier: NCT04003701
Recruitment Status : Not yet recruiting
First Posted : July 1, 2019
Last Update Posted : July 3, 2019
Sponsor:
Collaborators:
Universitair Ziekenhuis Brussel
University Ghent
Information provided by (Responsible Party):
Emma Rheel, Vrije Universiteit Brussel

Tracking Information
First Submitted Date  ICMJE June 19, 2019
First Posted Date  ICMJE July 1, 2019
Last Update Posted Date July 3, 2019
Estimated Study Start Date  ICMJE July 2019
Estimated Primary Completion Date December 2020   (Final data collection date for primary outcome measure)
Current Primary Outcome Measures  ICMJE
 (submitted: June 28, 2019)
  • Pain memory bias (numeric rating scale) (child) [ Time Frame: 1 week post-intervention (calculation method = T3-T1 and T3-T2) ]
    Pain rated by self-report on an 11-point numeric rating scale (NRS-11) reported 1 week post-intervention (T3) minus anticipated pain reported just before intervention (T1), and pain reported 1 week post-intervention (T3) minus experienced pain reported immediately after intervention (T2).
  • Pain memory bias (faces pain scale - revised) (child) [ Time Frame: 1 week post-intervention (calculation method = T3-T1 and T3-T2) ]
    Pain rated by self-report using the Faces Pain Scale Revised (FPS-R) reported 1 week post-intervention (T3) minus anticipated pain reported just before intervention (T1), and pain reported 1 week post-intervention (T3) minus experienced pain reported immediately after intervention (T2).
  • Pain-related fear memory bias (numeric rating scale) (child) [ Time Frame: 1 week post-intervention (calculation method = T3-T1 and T3-T2) ]
    Pain-related fear rated by self-report on an 11-point numeric rating scale (NRS-11) reported 1 week post-intervention (T3) minus anticipated pain-related fear reported just before intervention (T1), and pain-related fear reported 1 week post-intervention (T3) minus experienced pain-related fear reported immediately after intervention (T2).
  • Pain-related fear memory bias (children's fear scale) (child) [ Time Frame: 1 week post-intervention (calculation method = T3-T1 and T3-T2) ]
    Pain-related fear rated by self-report using the Children's Fear Scale (CFS) reported 1 week post-intervention (T3) minus anticipated pain-related fear reported just before intervention (T1), and pain-related fear reported 1 week post-intervention (T3) minus experienced pain-related fear reported immediately after intervention (T2).
Original Primary Outcome Measures  ICMJE Same as current
Change History Complete list of historical versions of study NCT04003701 on ClinicalTrials.gov Archive Site
Current Secondary Outcome Measures  ICMJE
 (submitted: June 28, 2019)
  • pain intensity (numeric rating scale) (self-report child) [ Time Frame: Just before intervention (T1), immediately after intervention (T2) and recall 1 week post-intervention (T3) ]
    Pain intensity by self-report on an 11-point numeric rating scale (NRS-11) with the anchors of 0 (no pain) and 10 (extremely painful). The higher the score, the higher the pain intensity.
  • pain intensity (numeric rating scale) (proxy report parent) [ Time Frame: Just before intervention (T1), immediately after intervention (T2) and recall 1 week post-intervention (T3) ]
    Pain intensity of the child on an 11-point numeric rating scale (NRS-11) with the anchors of 0 (no pain) and 10 (extremely painful). The higher the score, the higher the pain intensity.
  • pain intensity (faces pain scale - revised) (self-report child) [ Time Frame: Just before intervention (T1), immediately after intervention (T2) and recall 1 week post-intervention (T3) ]
    pain intensity by self-report using the Faces Pain Scale-Revised (FPS-R). This revised scale consists of 6 sex-neutral line drawings illustrating an increasing level of pain intensity from the most left face to the most right face.The participant responds by indicating which of the 6 faces corresponds to his or her level of pain. Scores ranges from 0 to 5 (0-1-2-3-4-5), with 5 being the highest possible pain intensity.
  • pain intensity (faces pain scale - revised) (proxy report parent) [ Time Frame: Just before intervention (T1), immediately after intervention (T2) and recall 1 week post-intervention (T3) ]
    pain intensity of the child using the Faces Pain Scale-Revised (FPS-R). This revised scale consists of 6 sex-neutral line drawings illustrating an increasing level of pain intensity from the most left face to the most right face.The parent responds by indicating which of the 6 faces corresponds to his or her child's level of pain. Scores ranges from 0 to 5 (0-1-2-3-4-5), with 5 being the highest possible pain intensity.
  • pain-related fear (numeric rating scale) (self-report child) [ Time Frame: Just before intervention (T1), immediately after intervention (T2) and recall 1 week post-intervention (T3) ]
    pain-related fear by self-report on a numeric rating scale (NRS-11) with the anchors of 0 (not scared) and 10 (extremely scared). The higher the score, the higher the pain intensity.
  • pain-related fear (numeric rating scale) (proxy report parent) [ Time Frame: Just before intervention (T1), immediately after intervention (T2) and recall 1 week post-intervention (T3) ]
    pain-related fear of the child on a numeric rating scale (NRS-11) with the anchors of 0 (not scared) and 10 (extremely scared). The higher the score, the higher the pain intensity.
  • pain-related fear (children's fear scale) (self-report child) [ Time Frame: Just before intervention (T1), immediately after intervention (T2) and recall 1 week post-intervention (T3) ]
    pain-related fear by self-report using the Children's Fear Scale (CFS). This one-item scale consists of a row of 5 sex-neutral faces varying from a not afraid (neutral) face on the left to a face that shows extreme fear on the right. The participant responds by indicating which of the 5 faces corresponds to his or her level of pain-related fear. Scores range from 0 to 4 (0-1-2-3-4) with 4 being the highest possible fear.
  • pain-related fear (children's fear scale) (proxy report parent) [ Time Frame: Just before intervention (T1), immediately after intervention (T2) and recall 1 week post-intervention (T3) ]
    pain-related fear of the child using the Children's Fear Scale (CFS). This one-item scale consists of a row of 5 sex-neutral faces varying from a not afraid (neutral) face on the left to a face that shows extreme fear on the right. The parent responds by indicating which of the 5 faces corresponds to his or her child's level of pain-related fear. Scores range from 0 to 4 (0-1-2-3-4) with 4 being the highest possible fear.
  • self-efficacy (numeric rating scale) (self-report child) [ Time Frame: Just before intervention (T1), immediately after intervention (T2) and recall 1 week post-intervention (T3) ]
    self-efficacy by self-report. All participants will score the same question about how they will deal/dealt with the puncture procedure on a standard 11-point numeric rating scale (NRS-11) from 0 (not good at all) to 10 (extremely good).
  • self-efficacy (numeric rating scale) (proxy report parent) [ Time Frame: Just before intervention (T1), immediately after intervention (T2) and recall 1 week post-intervention (T3) ]
    self-efficacy of the child. All parents will score the same question about how they think their child will deal/dealt with the puncture procedure on a standard 11-point numeric rating scale (NRS-11) from 0 (not good at all) to 10 (extremely good).
  • Pain memory bias (numeric rating scale) (parent) [ Time Frame: 1 week post-intervention (calculation method = T3-T1 and T3-T2) ]
    Child pain intensity rated by proxy report by the parent on an 11-point numeric rating scale (NRS-11) reported 1 week post-intervention (T3) minus anticipated pain reported just before intervention (T1), and pain reported 1 week post-intervention (T3) minus experienced pain reported immediately after intervention (T2).
  • Pain memory bias (faces pain scale - revised) (parent) [ Time Frame: 1 week post-intervention (calculation method = T3-T1 and T3-T2) ]
    Child pain intensity rated by proxy report of the parent on the Faces Pain Scale Revised (FPS-R) reported 1 week post-intervention (T3) minus anticipated pain reported just before intervention (T1), and pain reported 1 week post-intervention (T3) minus experienced pain reported immediately after intervention (T2).
  • Pain-related fear memory bias (numeric rating scale) (parent) [ Time Frame: 1 week post-intervention (calculation method = T3-T1 and T3-T2) ]
    Child pain-related fear rated by proxy report by the parent on an 11-point numeric rating scale (NRS-11) reported 1 week post-intervention (T3) minus anticipated pain-related fear reported just before intervention (T1), and pain-related fear reported 1 week post-intervention (T3) minus experienced pain-related fear reported immediately after intervention (T2).
  • Pain-related fear memory bias (children's fear scale) (parent) [ Time Frame: 1 week post-intervention (calculation method = T3-T1 and T3-T2) ]
    Child pain-related fear rated by proxy report by the parent on the Children's Fear Scale (CFS) reported 1 week post-intervention (T3) minus anticipated pain-related fear reported just before intervention (T1), and pain-related fear reported 1 week post-intervention (T3) minus experienced pain-related fear reported immediately after intervention (T2).
  • Responses to the children's pain experience (parent) [ Time Frame: Day before the intervention (T0) ]
    To measure the responses of the parent to their child's pain episodes, a shortened version of the inventory of parent/caregiver responses to the children's pain experience (IRPEDNA) will be used. The original scale is a self-administered questionnaire with three subscales: (1) solicitousness, (2) discouragement, and (3) promotion of well-behaviors and coping. The shortened version will only include subscale 1 and 3. All 10 items of the shortened version reflect actions and behaviors that the parents may enact after seeing the children's pain behaviors. Participating parents rate each item using a five-point response scale (1, never; 2, hardly ever; 3, sometimes; 4, often; 5, always), with final scores ranging from 10 to 50.
  • Emotions to children's pain experience (parent) [ Time Frame: Just before intervention (T1) and immediately after intervention (T2) ]
    A series of emotion adjectives is used to assess the emotions of the parents in response to the child's painful procedure. All emotion adjectives will be rated on an 11-point scale ranging from 0 (not at all) to 10 (extremely). Four adjectives will be presented (worried, upset, anxious and sad). The mean score of these 4 adjectives will be calculated, whereby higher scores represent higher levels of parental distress.
  • Waist circumference (child) [ Time Frame: Just before intervention (T0) ]
    Waist circumference of the child in centimeters, measured at umbilical level and at 4 centimeters above the umbilicus.
  • Body length (child) [ Time Frame: Just before intervention (T0) ]
    Body length of the child in centimeters.
  • Body weight (child) [ Time Frame: Just before intervention (T0) ]
    Body weight of the child in kilograms, determined with the TANITA MC-780SMA (from Tanita Corporation).
  • Body fat percentage (child) [ Time Frame: Just before intervention (T0) ]
    Body fat percentage of the child, determined with the TANITA MC-780SMA (from Tanita Corporation).
  • Fat mass (child) [ Time Frame: Just before intervention (T0) ]
    Fat mass of the child in kilograms, determined with the TANITA MC-780SMA (from Tanita Corporation).
  • Fat free mass (child) [ Time Frame: Just before intervention (T0) ]
    Fat free mass of the child in kilograms, determined with the TANITA MC-780SMA (from Tanita Corporation).
  • Muscle mass (child) [ Time Frame: Just before intervention (T0) ]
    Muscle mass of the child in kilograms, determined with the TANITA MC-780SMA (from Tanita Corporation).
  • Total body water (child) [ Time Frame: Just before intervention (T0) ]
    Total body water of the child in kilograms, determined with the TANITA MC-780SMA (from Tanita Corporation).
  • Total body water percentage (child) [ Time Frame: Just before intervention (T0) ]
    Total body water percentage of the child, determined with the TANITA MC-780SMA (from Tanita Corporation).
  • Intracellular water (child) [ Time Frame: Just before intervention (T0) ]
    Intracellular water (ICW) of the child in kilograms, determined with the TANITA MC-780SMA (from Tanita Corporation).
  • Extracellular water (child) [ Time Frame: Just before intervention (T0) ]
    Extracellular water (ECW) of the child in kilograms, determined with the TANITA MC-780SMA (from Tanita Corporation).
  • Body mass index (child) [ Time Frame: Just before intervention (T0) ]
    Body mass index of the child in kilograms/m^2, determined with the TANITA MC-780SMA (from Tanita Corporation).
  • Visceral fat rating (child) [ Time Frame: Just before intervention (T0) ]
    Visceral fat rating of the child on a scale from 1 to 59, determined with the TANITA MC-780SMA (from Tanita Corporation).
  • Basal metabolic rate (child) [ Time Frame: Just before intervention (T0) ]
    Basal metabolic rate of the child in kcal, determined with the TANITA MC-780SMA (from Tanita Corporation).
  • Attention control (child) [ Time Frame: Day before the intervention (T0) ]
    Attention control is defined as an individual's capacity to choose what they pay attention to and what they ignore. Attention control will be assessed using the Attentional Control Scale for Children (ACS-C), which is a 20 item self-rating scale that assesses abilities to focus and shift attention. Ten statements assess the focusing component of attention (''When I concentrate myself, I do not notice what is happening in the room around me'') and the other ten statements assess the shifting of attentional resources (''When I am doing something, I can easily stop and switch to some other task''). A higher score on this scale indicates a better capacity of attentional control.
  • Attention bias (child) [ Time Frame: Just before intervention (T0) ]
    Attention bias is defined as a selective attention to threat. All participating children will be asked to complete a dot-probe task, which is a well-investigated reaction time task designed to measure selective attention to threat. In this dot-probe task, a threatening (i.e., pain) and neutral stimulus are presented simultaneously (i.e., a painful child face paired with a neutral child face) at two different spatial locations on a screen for a short time. After the appearance of these stimuli, a dot probe emerges at the location of the threatening/pain stimulus (congruent presentation) or at the location of the neutral stimulus (incongruent presentation). The attentional bias is the response time to incongruent trials minus the response time to congruent trials: a positive index indicates more attention to pain; a negative index indicates attentional avoidance.
  • Pressure hyperalgesia (child) [ Time Frame: Just before intervention (T0) ]
    Pain response to stimuli that are not normally painful, induced by the lowering of the nociceptor threshold level and assessed by evaluating pressure pain thresholds (PPTs) at the dominant tibialis anterior and trapezius muscle by means of a digital pressure algometer (FPX 50, Wagner Instruments, Greenwich, CT, USA). Per test site, 3 measurements are performed with 30 seconds between each measurement. The measurements take place alternately between the two test sites, the first test site being randomly determined by an independent blinded researcher. The pressure pain threshold in kgf per muscle (test site) is determined by the mean of the 2nd and 3rd measurement.
  • Duration of procedure [ Time Frame: During intervention ]
    Total duration of the puncture procedure, starting at the point at which the door closes after arrival of each person concerned in the room and ending when the puncture procedure is totally finished (everything is fixated on the body with a bandage)
  • Satisfaction with the robot-interaction [ Time Frame: Immediately after the intervention (T2) ]
    How much did the child like the game with the robot on a scale from 0 (did not like it at all) to 10 (extremely liked it) (NRS-11). Higher scores indicate more satisfaction with the robot-interaction.
  • Desire for robot-interaction for future procedures [ Time Frame: Immediately after the intervention (T2) ]
    How much the child would like to have the robot with him/her again during a future similar procedure on a scale from 0 (does not want it at all) to 10 (extremely wants it) (NRS-11). Higher scores indicate a higher desire for robot-interaction during future similar procedures.
Original Secondary Outcome Measures  ICMJE Same as current
Current Other Pre-specified Outcome Measures
 (submitted: June 28, 2019)
  • Pain catastrophizing (trait) (child) [ Time Frame: Day before the intervention (T0) ]
    Thoughts and feelings which the child may experience when they are in pain. Children's catastrophic thinking about pain will be assessed with the Dutch version of the Pain Catastrophizing Scale for Children (PCS-C). The scale consists of 13 items describing different thoughts and feelings that children may experience when they are in pain. Children are asked to rate how frequently they experience these thoughts and feelings on a 5-point Likert scale (0 = 'not at all', 4 = 'extremely'). The PCS-C results in a total score (ranging from 0 to 52), and three subscale scores for rumination, magnification and helplessness.
  • Pain catastrophizing (state) (child) [ Time Frame: Just before the intervention (T1) and immediately after the intervention (T2) ]
    The extent of child state (i.e. situation-specific) catastrophizing thoughts about the procedure will be assessed using an adaptation of the PCS-C. Based on previous research, the investigators use a state version of the PCS-C, consisting of 1 adapted item from each of the 3 subscales. A mean score of these 3 items will be calculated ranging from 0 to 10.
  • Pain catastrophizing (trait) (parent) [ Time Frame: Day before the intervention (T0) ]
    Thoughts and feelings that parents may experience in relation to their child's pain. Parent's catastrophic thinking about their child's pain will be assessed with the Dutch version of the Pain Catastrophizing Scale for Parents (PCS-P). Similar to the PCS-C, the PCS-P consists of 13 items describing different thoughts and feelings that parents may experience in relation to their child's pain. Parents are asked to rate how frequently they experience these thoughts and feelings on a 5-point Likert scale (0 = 'not at all', 4 = 'extremely'). The PCS-P results in a total score (ranging from 0 to 52), and three subscale scores for rumination, magnification and helplessness.
  • Pain catastrophizing (state) (parent) [ Time Frame: Just before the intervention (T1) and immediately after the intervention (T2) ]
    The extent of parental state (i.e. situation-specific) catastrophizing thoughts about the puncture procedure will be assessed using an adaptation of the PCS-P. Based on previous research, the investigators use a PCS-P state, consisting of 1 adapted item from each of the 3 subscales. A mean score of these 3 items will be calculated ranging from 0 to 10.
  • Energy-balance related behavior [ Time Frame: Day before the intervention (T0) ]
    Physical activity and screen behavior. A selection of questions regarding physical activity (E1-E12) and sedentary behavior (F1-F2) of the ENERGY Cross-Sectional Survey (ENERGY CSS child) will be assessed by the participating children.
Original Other Pre-specified Outcome Measures Same as current
 
Descriptive Information
Brief Title  ICMJE Using a Humanoid Robot to Distract Children With Cancer or Chronic Immune Deficiency Undergoing Painful Procedures
Official Title  ICMJE Using a Humanoid Robot to Distract Children With Cancer or Chronic Immune Deficiency Undergoing Painful Procedures: a Pilot Randomized Controlled Trial Looking at Alterations of Children's and Parents' Pain and Fear Memories
Brief Summary

The aim of this study is to examine the effect of using a humanoid robot during a portal catheter (PAC) puncture in children with cancer and peripheral venous cannulation (PVC) in children with chronic immune deficiency (CID), on the pain and fear memory of child and parent in comparison to usual care. The use of a humanoid robot has proven to be effective on reducing healthy children's pain and distress towards vaccinations. Still, whether these benefits generalize to clinically ill children, such as children with cancer or CID, to pain memories and to the parents needs to be examined.

The current research proposal is the first one to examine the use of a humanoid robot to distract children with cancer or CID who undergo repeated painful procedures and, compared to usual care, its effectiveness in reducing negative pain and fear experience and reducing negative pain and fear memory biases.

Children aged 8-12y with cancer undergoing PAC-punctures weekly or every 2 weeks, or with CID having PVC every 2 to 6 weeks, and their parents will be recruited at the University Hospital Brussels. Baseline assessments include child's anticipated pain, pain-related fear and self-efficacy by child's self-report and parent proxy report, child's attention control, attention bias, pressure hyperalgesia, energy-balance related behavior, child's and parent's catastrophizing about the child's pain, parental behavioral responses to their child's pain and parent's emotions towards the child's painful procedure. Stratified block randomization will be used to assign the children to the control group (usual care) or intervention group (robot distraction). Immediately after the puncture procedure, experienced pain, pain-related fear, self-efficacy and pain catastrophizing (state) will be assessed again by child and parent, as well as emotions of the parent. One week post-procedure the participants will be contacted by telephone for a short interview in order to assess child's and parent's pain and pain-related fear memory, as well as child's and parent's future pain, pain-related fear and self-efficacy expectancies using the same scales as administered before and immediately after the procedure, with in addition a free recall and prompted recall about contextual details about the day of the procedure. Recalled pain and pain-related fear ratings that are higher compared to initial reports are considered indicative of negative memory biases.

Detailed Description

Objectives

The main objective of this pilot RCT is to examine if distraction by using a humanoid robot during a port-a-cath (PAC) puncture or peripheral venous cannulation (PVC) (I) contributes to less negative pain and pain-related fear memory biases (O) in comparison with the usual care (C) in children with cancer or CID between 8 and 12 years old and their parents (P). Furthermore, it wil bel investigated if the use of a humanoid robot to distract children with cancer or CID during respectively a PAC puncture or PVC contributes to lower levels of self-reported experienced pain-related fear and pain during the PAC puncture or PVC and less negative expectations regarding future painful procedures. The investigators expect to see the same positive effects in the proxy reports of the parents. Also, the role of possible moderator variables such as child's self-efficacy, attention control, attention bias and energy-balance related behavior, child's and parent's pain catastrophizing about the child's pain, parent's emotions and responses to children's pain episodes will be investigated.

Methods

Study preparation

This task includes preparation of information letters and consent forms, study insurance application, application and approval by the Ethics Committee of the University Hospital Brussels, registration at a clinical trials register, randomization procedure, training of the researchers in providing the interventions, preparation of the online questionnaires. The robot NAO is already available at our lab and is ready to use.

Participant recruitment

Patients will be recruited by the oncology department and day unit of the children's hospital of the University Hospital Brussels. All children between 8-12y with cancer and a PAC and children with a CID undergoing PVC every 2-6 weeks, and their parents will be informed about the study and receive a consent form. The recruitment procedure will start in July 2019 and pursue until the calculated sample size is reached.

Given the observation that children up to 12 years of age are more likely than children over 12 years to believe that a robot possesses human characteristics, the study will focus on children between the ages of 8 and 12 years. The lower age limit is chosen because child self-report questionnaires have been validated from that age. Self-reports in children also require a variety of cognitive skills, which develop gradually and are only acquired at the age of 7 or 8 in most children. Children and their parents can only be included in the study if they meet the inclusion criteria and after written informed consent from the (co-participating) parent/guardian and child is obtained. All parents/guardians and children will receive verbal and written information on all aspects of the study prior to consent for participation.

Sample size calculations were performed with G*Power 3.1.9.2. The a priori sample size calculation was based on the treatment effects on children's pain-related fear memories in the study of Pickrell et al. (2007) and targeting a study power of (80%) with α=0.05. Allocation ratio (N2/N1) was defined as 1, resulting in 47 patients in the experimental group and 47 in the control group (n=94 for the total sample size). Accounting for a 10% dropout and keeping in mind that every sample size calculation has its limitations, the investigators propose studying at least 52 patients per group for this study. Hence, the total number of participants to be included will be equal to 104. Because of the low number of new cases of childhood cancer (<15 years of age) per year in Belgium (2), the monocentric nature of this trial and the limited time for data collection (1 year 9 months) the calculated sample size remains as a target.

Risk management: In case of slow patient recruitment or a dropout rate that exceeds 10%, the age range of the participants will be extended (1) and French speaking children and their parents will no longer be excluded (2).

Assessments:

Using an online questionnaire battery (↑ study feasibility), a number of measures will be assessed in the participating children and their parent(s). Online questionnaires will set up with LimeSurvey.

Risk management: In case the online questionnaires are not filled in by the start of the procedure, the test day will be moved to the next puncture procedure.

Measurement time points: T0 = day before puncture procedure, T1 = immediately before puncture procedure, T2 = immediately after puncture procedure, T3 = one week after puncture procedure

Demographics and medical data

At T0 demographics (e.g. age, sex, ethnicity, socioeconomic status) and medical information will be collected from the patient's clinical charts and will be further supplemented by child and parent report.

Anthropometrics

At T1, basic anthropometrics (body height, body weight, waist circumference) will be gathered from each participating child. In addition, the body composition (i.e., body mass index, fat mass, fat free mass, muscle mass, intra- and extra cellular water, etc.) will be determined by a body composition analyzer (Tanita).

Pressure hyperalgesia: pressure pain threshold (PPT) - CHILD

At T1, pressure hyperalgesia of all participating children will be assessed by evaluating pressure pain thresholds (PPTs) at the dominant tibialis anterior and trapezius muscle by means of a digital pressure algometer (FPX 50, Wagner Instruments, Greenwich, CT, USA). To familiarize the subject with PPT measurements, one familiarization session will be done at the idominant upper leg. This technique to evaluate PPTs is a well-known and well validated method in the exploration of pathophysiological mechanisms involved in pain. High reliability levels of this technique are apparent from various studies. Also, pressure algometry has proven to have an excellent intra-rater agreement, a satisfactory inter-rater agreement and is well tolerated even by very young children.

Pain catastrophizing Scale for Children (PCS-C) - CHILD

At T0, children's catastrophic thinking about pain will be assessed with the Dutch version of the Pain Catastrophizing Scale for Children (PCS-C). The PCS-C consists of 13 items describing thoughts and feelings which the child may experience when they are in pain, in independent but strongly related dimensions of rumination, magnification and helplessness. Children are asked to rate how frequently they experience these thoughts and feelings on a 5-point Likert scale (0 = 'not at all', 4 = 'extremely'). The PCS-C results in a total score (ranging from 0 to 52). The PCS-C has been shown to be a reliable and valid tool for children of 9 to 15 years old and a strong internal consistency for pain catastrophizing (α=.90) is already demonstrated in the pediatric population.

Pain Catastrophizing Scale for Children (PCS-C state) - CHILD

Just before (T1) and immediately after (T2) the puncture procedure, the extent of child state (i.e. situation-specific) catastrophizing thoughts about the procedure will be assessed using an adaptation the PCS-C. Based on previous research, the investigators use a state version of the PCS-C, consisting of 1 adapted item from each of the 3 subscales. A mean score of these 3 items will be calculated ranging from 0 to 10. Research has shown a significant association between child state catastrophizing and child pain intensity.

Attentional Control Scale for Children (ACS-C) - CHILD

At T0, attention control will be assessed using the Attentional Control Scale for Children (ACS-C), which is a 20 item self-rating scale that assesses abilities to focus and shift attention. Ten statements assess the focusing component of attention (''When I concentrate myself, I do not notice what is happening in the room around me'') and the other ten statements assess the shifting of attentional resources (''When I am doing something, I can easily stop and switch to some other task''). A higher score on this scale indicates a better capacity of attentional control. Several studies report good internal consistency of the ACS-C.

Attention Bias Assessment (dot-probe task) - CHILD

At T1, all participating children will be asked to complete a dot-probe task, which is a well-investigated reaction time task designed to measure selective attention to threat. In this dot-probe task, a threatening (i.e., pain) and neutral stimulus are presented simultaneously (i.e., a painful child face paired with a neutral child face) at two different spatial locations on a screen for a short time. Because both stimuli are in different spatial locations, they compete for attention. After the appearance of these stimuli, a dot probe emerges at the location of the threatening/pain stimulus (congruent presentation) or at the location of the neutral stimulus (incongruent presentation). The assignment of attention is measured by the time needed to respond to the dot probe. It is reasoned that responding to the probe will be faster when the child's attention is already allocated to location where the probe appears. Most probe detection studies found indeed that anxious individuals respond faster to congruent trials than to incongruent trials (congruency effect). This task is implicit, does not require instruction, and subjects need no or minimal training to perform the test successfully. To enhance personal salience of the dot-probe task, children will be informed that pictures they will see during the dot-probe task are derived from other children who underwent a puncture procedure.

Energy balance-related behavior (ENERGY CSS child) - CHILD

At T0, a selection of questions regarding physical activity and sedentary behavior of the ENERGY Cross-Sectional Survey (ENERGY CSS child) used in the ENERGY-project will be assessed by the participating children. This ENERGY-child questionnaire was developed in order to assess energy balance-related behaviors of the child as well as personal, family and school-environmental determinants related to these behaviors. The questionnaire has been shown to have good test-retest reliability and moderate to good construct validity for the large majority of items.

Numerical Rating Scale for anticipated pain and pain-related fear (NRS-11) - CHILD&PROXY

Before (T1), immediately after (T2) and 1 week after (T3) the puncture procedure, child's pain-related fear and pain with regard to the procedure will be assessed using an 11-point 1-item scale with the anchors of 0 (not scared) and 10 (extremely scared), and 0 (no pain) and 10 (extremely painful). Research has shown that the NRS-11 and FPS-R are strongly associated (r = 0.78,p < 0.001) and that the score distribution of the NRS-11 is comparable with that of the FPS-R. Miró et al. (2009) showed good convergent, discriminant and criterion validity for the NRS-11.

Faces Pain Scale-Revised (FPS-R) - CHILD&PROXY

Before (T1), immediately after (T2) and 1 week after (T3) the puncture procedure, child's pain with regard to the puncture procedure will be assessed using The Faces Pain Scale-Revised (FPS-R). This is a revised version of the original scale, which was developed by Bieri et al. (1990) for the self-assessment of pain severity by children. The revised scale consists of 6 sex-neutral line drawings illustrating an increasing level of pain intensity from the most left face to the most right face. The participant responds by indicating which of the 6 faces corresponds to his or her level of pain. It is easy to administer and requires no equipment except for the photocopied faces. Its adequate psychometric properties have already emerged from several studies.

Children's fear scale (CFS) - CHILD&PROXY

Before (T1), immediately after (T2) and 1 week after (T3) the puncture procedure, child's pain-related fear with regard to the puncture procedure will be assessed using the Children's Fear Scale (CFS). This scale is based on the Faces Anxiety Scale, developed by McKinley et al. (2003). This one-item scale consists of a row of 5 sex-neutral faces varying from a not afraid (neutral) face on the left to a face that shows extreme fear on the right. The participant responds by indicating which of the 5 faces corresponds to his or her level of pain-related fear. It is easy to administer and requires no equipment except for the photocopied faces. The scale has been shown to have a good interrater reliability and test-retest reliability.

Self-efficacy (1 item) - CHILD&PROXY

Before (T1), immediately after (T2) and 1 week after (T3) the puncture procedure, the child and the parent will score the same question about how he/she or his/her child is dealing/dealt with the puncture procedure on a standard 11-point numeric rating scale from 0 (not good at all) to 10 (extremely good).

Pain Catastrophizing Scale for Parents (PCS-P) - PARENT

At T0, parent's catastrophic thinking about their child's pain will be assessed with the Dutch version of the Pain Catastrophizing Scale for Parents (PCS-P). The PCS-P consists of 13 items describing different thoughts and feelings that parents may experience in relation to their child's pain, in independent but strongly related dimensions of rumination, magnification and helplessness. Parents are asked to rate how frequently they experience these thoughts and feelings on a 5-point Likert scale (0 = 'not at all', 4 = 'extremely'). The developers reported strong internal consistency (α=.93) and validity as demonstrated by associations with parent distress and child disability.

Pain Catastrophizing Scale for Parents (PCS-P state) - PARENT

Before (T1) and immediately after (T2) the puncture procedure, the extent of parental state (i.e. situation-specific) catastrophizing thoughts about the procedure will be assessed using an adaptation of PCS-P. Based on previous research, the investigators use a PCS-P state, consisting of 1 adapted item from each of the 3 subscales. A mean score of these 3 items will be calculated ranging from 0 to 10.

Inventory of parent/caregiver responses to the children's pain experience (IRPEDNA) - PARENT

To measure the responses of the parent to their child's pain episodes at T0, a shortened of the inventory of parent/caregiver responses to the children's pain experience (IRPEDNA) will be used. This scale is a self-administered questionnaire with three subscales: (1) solicitousness, (2) discouragement, and (3) promotion of well-behaviors and coping. The shortened version of 10 items only includes solicitousness and promotion of well-behaviors. All items reflect actions and behaviors that the parents may enact after seeing the children's pain behaviors. A good internal consistency of the 3 subscales has been demonstrated (coefficient alphas of 0.87, 0.83 and 0.87 respectively) and the subscales also show good criterion-related validity.

Emotions of the parents regarding their child undergoing a painful procedure - PARENT

Before (T1) and immediately after (T2) the puncture procedure, a series of emotion adjectives is used to assess the emotions of the parents in response to the child's painful procedure. This method is based on the work of Batson et al. (1987). All emotion adjectives will be rated on an 11-point scale ranging from 0 (not at all) to 10 (extremely). This method is short and easy-to-complete, which lends itself well to adapt to assess distress in response to a specific situation, in this case parental distress as a reaction to their children's painful puncture procedure. Based on Batson et al. (1987) and with the aim of reflecting self-oriented emotional responses or distress, 4 adjectives will be presented (worried, upset, anxious and sad). The mean score of these 4 adjectives will be calculated, whereby higher scores represent higher levels of parental distress. This method has proven to be valid and reliable.

Total time of procedure

The total time of duration of the procedure will be registered for each participant using a stopwatch, starting at the point at which the door closes after arrival of each person concerned in the room and ending when the puncture procedure is totally finished (everything is fixated on the body with a bandage). In this way, a difference in the duration of the procedure can possibly be established between the usual care group and the robot intervention group.

Kalinox® registration

Whether or not and how much Kalinox® (mixture of nitrous oxide (50 %) and oxygen (50 %)) is administered via a respirator during the puncture procedure is registered for each participant.

Randomization procedure and intervention:

Randomization

Stratified block randomization (balanced by sex (M/F) and age (8-9 year/10-12 years)) will be used to assign patients to the control group or experimental group. Randomization will be executed by an independent researcher who will not be involved in treatment provision, assessments or in statistical analyses. This independent researcher will prepare a list with patient numbers/codes and the group allocation that results from this randomization procedure. Group allocation will take place after baseline assessments have been performed. Both groups will have the same people present in the operating room: 1 child, 1 parent, 1 or 2 nurses, 1 researcher.

Intervention:

Usual care

All the performed punctures are in any case part of the standard/usual care. So, no extra puncture procedures are scheduled for this study. Within the usual care, no one of the attendees in the room will have specific interaction with the child during this procedure, with the exception of normal/necessary interaction by the nurse and/or parent. The child will sit down on the treatment table with the legs stretched out in front of him and the puncture-side arm in a 90-90 position next to the head supported by the table (cancer patients) or stretched out and lying down along the body (CID patients), with the nurse at the puncture side and the parent at the other side standing next to him. The researcher is also present in the room, within the child's field of vision. At the end of the procedure, the nurse tells the child that he/she did very well.

Robot-assisted puncture procedure

During the experimental intervention, the child, a nurse, one of the parents/guardians, a researcher and the humanoid robot NAO (H25 Academic Edition, Aldebaran Robotics, Paris, France) will be present in the same room. The child will sit down in the same position as with the usual care. Next to the patient a humanoid robot of three-foot tall will sit on eye level on a slanted reading table, at the non-puncture side. The nurse will carry out the puncture procedure as performed as usual. The robot is programmed to distract the child during the entire procedure (before, during and after the puncture) by playing a game with the child based on his/her interests. The child can therefore choose between a number of games in different themes. In the end the robot tells the child that he/she did very well. During the whole intervention, the robot will be re-activated for each phase only when the child and the nurse are ready.

Remarks:

Whether or not and how much Kalinox® (mixture of nitrous oxide (50 %) and oxygen (50 %)) is administered via a respirator during the procedure is registered for each participant. Breathing the gas mixture causes the child to feel a bit drowsy, but the child's awareness and communication possibilities are preserved.

After all child and parent questions have been filled out, a closed envelope will be handed to the parent. This envelope contains the questionnaires that the parent and child will be asked to answer within 1 week after the procedure in a telephone interview. This telephone interview is aimed to assess child and parent (proxy) pain/pain-related fear memory, future pain/pain-related fear expectancies and child and parent self-efficacy expectancies towards future similar procedures. Also a free memory recall and a prompted recall about contextual details is conducted in the children. Parents and children are instructed to leave this envelope closed until they are asked to open it in the telephone interview.

Study Type  ICMJE Interventional
Study Phase  ICMJE Not Applicable
Study Design  ICMJE Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Double (Investigator, Outcomes Assessor)
Primary Purpose: Supportive Care
Condition  ICMJE Childhood Cancer
Intervention  ICMJE
  • Behavioral: Usual care
    Control group: minimal distraction
  • Behavioral: Robot-assisted puncture procedure
    Experimental group: distraction with robot
Study Arms  ICMJE
  • Active Comparator: Usual care group (control group)
    Within the usual care, no one of the attendees in the room will have specific interaction with the child during this procedure, with the exception of normal/necessary interaction by the nurse and/or parent. Only minimal distraction is allowed. The child will sit down on the treatment table with the legs stretched out in front of him and the puncture-side arm in a 90-90 position next to the head supported by the table (cancer patients) or stretched out and lying down along the body (CID patients), with the nurse at the puncture side and the parent at the other side standing next to him. The researcher is also present in the room, within the child's field of vision. At the end of the procedure, the nurse tells the child that he/she did very well.
    Intervention: Behavioral: Usual care
  • Experimental: Robot-assisted puncture procedure (experimental group)
    During the experimental intervention, the child, a nurse, one of the parents/guardians, a researcher and the humanoid robot NAO (H25 Academic Edition, Aldebaran Robotics, Paris, France) will be present in the same room. The child will sit down in the same position as with the usual care. Next to the patient a humanoid robot of three-foot tall will sit on eye level on a slanted reading table, at the non-puncture side. The nurse will carry out the puncture procedure as performed as usual. The robot is programmed to distract the child during the entire procedure (before, during and after the puncture) by playing a game with the child based on his/her interests. The child can therefore choose between a number of games in different themes. In the end the robot tells the child that he/she did very well. During the whole intervention, the robot will be re-activated for each phase only when the child and the nurse are ready.
    Intervention: Behavioral: Robot-assisted puncture procedure
Publications *

*   Includes publications given by the data provider as well as publications identified by ClinicalTrials.gov Identifier (NCT Number) in Medline.
 
Recruitment Information
Recruitment Status  ICMJE Not yet recruiting
Estimated Enrollment  ICMJE
 (submitted: June 28, 2019)
104
Original Estimated Enrollment  ICMJE Same as current
Estimated Study Completion Date  ICMJE December 2020
Estimated Primary Completion Date December 2020   (Final data collection date for primary outcome measure)
Eligibility Criteria  ICMJE

Inclusion Criteria:

All participants:

  • Willing to participate and comply with pre-determined interventions
  • 8-12y (children)
  • Child and parent(s)/guardian cohabited for the past 5 years or, in case of divided custody, for at least half of the child's lifetime

Cancer patients:

  • Established cancer diagnosis (any type)
  • First cancer diagnosis
  • Resident port-a-cath
  • Currently being treated for cancer (not necessarily hospitalized) in the University Hospital Brussels

CID patients:

  • Established CID diagnose (any type)
  • Having PVC every 2-6 weeks in the University Hospital Brussels

Exclusion Criteria:

  • Developmental disabilities (e.g.: autism spectrum disorder, Attention Deficit (Hyperactivity) Disorder)
  • Psychiatric disorders (e.g.: anxiety disorder, personality disorder)
  • Significant vision or hearing impairment
  • A primary chronic pain diagnosis (e.g.: fibromyalgia, chronic fatigue syndrome, chronic abdominal pain, migraine, etc.)
  • Not able to read and speak fluent Dutch (parent and child)
  • Already having undergone any kind of self-regulation and/or behavioral therapy for pain (i.e. relaxation, hypnosis, biofeedback, pain neuroscience education, cognitive behavioral therapy, etc.)
Sex/Gender  ICMJE
Sexes Eligible for Study: All
Ages  ICMJE 8 Years to 12 Years   (Child)
Accepts Healthy Volunteers  ICMJE No
Contacts  ICMJE
Contact: Emma Rheel, MSc +32496908353 emma.rheel@vub.be
Contact: Kelly Ickmans, Dr. +32498483347 kelly.ickmans@vub.be
Listed Location Countries  ICMJE Not Provided
Removed Location Countries  
 
Administrative Information
NCT Number  ICMJE NCT04003701
Other Study ID Numbers  ICMJE ROBOTDISTR_RCT_RE_2019-2020
Has Data Monitoring Committee No
U.S. FDA-regulated Product
Studies a U.S. FDA-regulated Drug Product: No
Studies a U.S. FDA-regulated Device Product: No
IPD Sharing Statement  ICMJE Not Provided
Responsible Party Emma Rheel, Vrije Universiteit Brussel
Study Sponsor  ICMJE Vrije Universiteit Brussel
Collaborators  ICMJE
  • Universitair Ziekenhuis Brussel
  • University Ghent
Investigators  ICMJE Not Provided
PRS Account Vrije Universiteit Brussel
Verification Date July 2019

ICMJE     Data element required by the International Committee of Medical Journal Editors and the World Health Organization ICTRP