Hypnosis for pediatric fracture reduction

Abstract

Hypnosis can diminish pain and anxiety for many emergency patients during examinations and procedures. While hypnosis has been used for millennia and was demonstrated to be of use in clinical medicine more than a century ago, modern physicians have been reluctant to adopt this technique in clinical practice. This article describes four children with angulated forearm fractures who had no possible access to other forms of analgesia during reduction, and in whom hypnosis was used successfully. A simple method for hypnotic induction is described.

Introduction

Hypnosis, a state of wakeful suggestibility, has been used for millennia in medical and religious practices under various names. Egyptian priests, under the name “sacred sleep,” used hypnosis for religious and medical purposes at least 4,000 years ago, while the ancient Greeks were treated with hypnosis in “sleep temples of the sick.” Mesmer, an Austrian physician, first formally described the phenomenon in the 18th century under the rubric “animal magnetism.” In 1831, Elliotson, a professor of medicine at London University, published the booklet, Numerous Cases of Surgical Operations Without Pain in the Mesmeric State. He was later forced to resign from University College Hospital because of his use of hypnosis. Braid first coined the term “hypnotism” in the 19th century, and many well-known physicians, including Charcot and Freud, used the method. Although articles that discuss emergency department (ED) or Emergency Medical Services (EMS) use of hypnosis have sporadically appeared over the past 40 years 1, 2, 3, 4, 5, 6, 7, most traditional physicians have been reluctant to use this simple technique in their practices. This may be due to a lack of training, the association of hypnosis with alternative (complementary) medicine, or because of its association with stage shows. The ED where patients in pain or with fear are frequently treated, represents one area in which hypnosis could be an effective tool in the physician’s armamentarium.

Among potential symptom-oriented uses of hypnosis in emergency medicine are: 1) to treat possible conversion reactions (for which the amobarbital interview has been described as chemical hypnosis) (8); 2) to treat pain associated with dislocation and fracture reductions 3, 9, 10, 11; 3) to treat acute stress reactions, post-traumatic stress disorders, and factitious seizure (12); 4) to relieve the anxiety of needle phobias (1); 5) to treat the pain of burns (13); 6) to treat headaches; 7) to prepare patients for surgery, pelvic or post-rape examinations (14), or labor (15); and 8) to relieve pain and anxiety prior to ED procedures, such as suturing or incisions and drainage (15).

This article describes a simple method for the use of hypnosis in the ED setting and the successful use of hypnosis in an emergency department for manipulative reductions of forearm fractures in children.

Although practitioners use many methods for inducing hypnosis (16), I have found the following method to be extremely easy for physicians and EMS personnel (3). (I was taught a form of this method in medical school and have used and taught this method in ED and in wilderness medicine for more than 20 years.) The process is described to patients as a way to relax, so as not to scare them and to easily explain what is to occur. Misconceptions about hypnosis can have a negative effect on the ability of patients to cooperate fully with the technique. Adults who have undergone hypnosis previously often recognize the process immediately, no matter what it is called, and then often achieve faster and deeper hypnosis. In children, even if the term “hypnosis” is used, it is not clear whether they would understand it. It is essential that the concept of patient and clinician cooperation, frequently described as permissive hypnosis, be explained to the patient. While such feelings are common in adults, children rarely experience unusual feelings of domination, control, or coercion by the clinician (17).

During the “preinduction” phase, rapport is established with the patient. (In adults, their prior experiences and the relationship between this technique and their experiences are discussed.) A key element in all cases, especially in the noisy environment of the ED, is to reinforce that the patient should listen only to the clinician, and that the process will proceed at the patient’s pace, without pressure. The clinician speaks in a firm, quiet manner, in no way reacting to any of the noisy or distracting activities in the immediate vicinity.

At this point, in a technique refined from Schultz’s texts on autohypnotic training, the patient is instructed to close the eyes and relax (18). Unlike adults, children in stressful conditions are already considered in the first stage of hypnosis (Table 1), and so are generally more susceptible to hypnotic suggestions. The patient is then asked to concentrate on the distal extremities (toes), to imagine sensations of heaviness and pleasant warmth in the limbs as “all of the muscles in the toes relax.” For most people, feelings of heaviness are easier to imagine than warmth, but this is not consistent. The clinician should continue to suggest both sensations.

A significant amount of time (30 to 45 s) is spent helping the patient to concentrate on and relax the toes. If this can be accomplished, the remainder of the procedure is much easier. The clinician then suggests that the patient feel the warmth or heaviness flow up into the feet, then the legs, thighs, etc. A significant indication that the technique has been successful is the regularization of the patient’s respiratory pattern. A suggestion to the patient at this time should be to slow the rate of breathing and further allow the entire body to relax. It is optimal to suggest that with each exhalation, another level of relaxation will be attained.

The patient is then told that he or she will feel relaxed, sleepy, and will “travel in the mind to a very pleasant place, perhaps a beach or mountain.” A suggestion can be made that the patient will not remember the process of, and pain during, the fracture reduction.

Although many tests have been devised to assess the depth of hypnosis, these tests have little clinical relevance 19, 20. In a clinical setting, results are what matter, and they do not always correspond to abstract measures of hypnotic success. It is, therefore, unnecessary for clinicians to administer any of these tests.

The techniques related to emergence from a hypnotic state may not be needed. The manipulation associated with reducing forearm fractures (or joint dislocations) normally arouses the patients to a prehypnotic state. However, if a posthypnotic suggestion for pain relief or selective amnesia has been given, this still may be in effect (Table 2 ).