International Journal of Health Sciences and Research

www.ijhsr.org ISSN: 2249-9571

Original Research Article

Effectiveness of Play Therapy on Pain and Anxiety

in Children Post Surgery
Renuka Deshpande1, Dr. Mayuri Rajesh Shah2
1
Intern, Dr. D.Y. Patil College of Physiotherapy, Pimpri, Pune
2
Assistant Professor, Dr. D.Y. Patil College of Physiotherapy, Pimpri, Pune
Corresponding Author: Renuka Deshpande

ABSTRACT

Background: Surgery can be a threatening experience for everyone, especially for children. Children are
more vulnerable to stress due to their lack of knowledge of procedures, lack of perceived control, lack of
explanation in child-appropriate terms and lack of pain management. Pain and anxiety in children is often
left untreated in children. There are evidences about play therapy being effective in reducing stress in
children between age 6-12 years but there isn’t any strong evidence whether they are effective in reducing
pain and anxiety.
Method: Group A was given play therapy in the form of picking up sticks, bubble blowing and building
blocks. Group B was given conventional physiotherapy in the form of general mobility exercises,
breathing exercises and ambulation. These exercises were given keeping in mind the surgery that the child
has undergone. Spence’s Children Anxiety Rating Scale (SCARS-parent reported) and Wong- Baker Pain
Rating Scale (face) were the outcome measures used. Readings were taken pre and post intervention for
both groups.
Result: Paired t- test was applied for SCARS and Wilcoxon test was applied for WBPS. The value of P
(level of significance) was found to be <0.05 for within group analysis and unpaired t test was applied for
between group analysis for SCARS and Mann- Whitney U test for WBPS, p value being <0.05.
Conclusion: Play therapy and conventional physiotherapy both were equally effective in reducing pain
and anxiety in the postsurgical children.

Keywords: Play therapy, children, post surgery

INTRODUCTION appropriate terms and lack of pain

Hospitalization to any child is a very management. More than a million children
unpleasant and traumatic experience. undergo surgery every year, and it is
Hospitalized children require more than reported that 50% of these children develop
recreational play because illness and significant stress and anxiety before surgery.
hospitalization constitute crisis in a child’s This causes significant hardship to parents
life and since these situation are brought too. (1) Anxiety is the most commonly
with overwhelming stress, children need to reported negative response and high levels
play out their fears and stress as a means of of anxiety can be harmful to children’s
coping with these stresses. Surgery can be a physiological and psychological health.
threatening experience for everyone, Excessive anxiety also impedes children’s
especially for children. Children are more efficacy in coping with medical treatment
vulnerable to stress due to their lack of and increases their uncooperative behavior
knowledge of procedures, lack of perceived and negative emotions towards medical
control, lack of explanation in child- professionals. (2) Anxiety and pain are

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 Renuka Deshpande et.al. Effectiveness of Play Therapy on Pain and Anxiety in Children Post Surgery

regarded as two common problems problems but age specific actions can be
experienced by children and adolescents more effective. If treatment is given
pre- and post- operatively. Increasing considering their age, the effects will really
anxiety is associated with anticipating more amaze us. There are evidences about play
pain and tolerating pain for less time. (3) therapy being effective in reducing stress in
Most surgeries cause some pain. No matter children between age 6-12 years but there
what kind of surgery a child has, most isn’t any strong evidence whether they are
postoperative pain can be prevented or at effective in reducing pain and anxiety.
least reduced. The psychological and Therefore, this study will focus on taking
physical methods used for short and sharp age-appropriate measures to treat anxiety
pain is useful for postoperative pain. They and pain in children of this age group who
can make a child much comfortable. (4) have undergone any kind of surgery.
Sometimes it is useful and can be a warning The aim of the study was to compare
of danger, injury or illness. Pain causes effects of conventional therapy and play
changes in brain and makes future pain therapy on anxiety and pain in children post
worse. It can slow healing, disrupt treatment surgery. The objectives of the study were to
and may cause medical problems. Untreated evaluate the effectiveness of play therapy in
pain causes anxiety, depression, irritability children on anxiety and pain after
and exhaustion. Pain in children is often undergoing surgery using Spence’s Children
undertreated. The reasons for the lack of Anxiety Rating Scale (SCARS-parent
adequate pain control may include; myths reported) and Wong- Baker Pain Rating
about pain and health professionals and lack Scale(face), to evaluate the effectiveness of
of appropriate assessment. Children can tell conventional therapy in children on anxiety
people about their own pain if they are and pain after undergoing surgery using
asked in a way they understand. Spence’s Children Anxiety Rating Scale
There are three ways to find out how much (SCARS-parent reported) and Wong- Baker
pain a child has: (5) Pain Rating Scale(face), and to compare the
1. What a child says effectiveness of conventional therapy and
2. What a child is doing play therapy on pain and anxiety using
3. How the child’s body is reacting Spence’s Children Anxiety Rating Scale
Non- directive play therapy looks at play as (SCARS-parent reported) and Wong- Baker
healing process. It gives the child the Pain Rating Scale(face).
opportunity to “play out” feelings and
problems and learn about themselves in MATERIALS AND METHODS
relation to therapist. The mean age of The study was an experimental
children benefiting from play therapy ranges study. It was carried out in Dr. D Y Patil
from 6-13 years. The proper selection and Hospital and Research centre. The sample
use of toys can reduce the traumatic effects size was 30 and sampling type was
of a hospitalization experiences and aid in purposive. Inclusion criteria was children
recovery phase of illness. Toys are the aged 6-12 years, both males and females
“tools” of play and provide a more natural gender, children undergone surgery, post
environment for a child. Proper selection operative 2 days to 2 weeks, and children
and use of toys can reduce the traumatic who have score >34 on SCARS(parent
effects of experience in hospital and aid in report). The exclusion criteria were children
recovery phase of illness. (1) Pain and with any complication post surgery eg.
anxiety in children is often left untreated. Infection, oozing wound, etc., parents not
The main reason behind this is the inability consenting for intervention, children with
of the child to express the pain and anxiety diagnosed psychological disorders and
after any surgery. There are many children who did not complain of pain. The
techniques to measure and treat these materials used were-

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 Renuka Deshpande et.al. Effectiveness of Play Therapy on Pain and Anxiety in Children Post Surgery

Play tools:  Building blocks: The therapist

i. Bubble solution introduces the activity to the child by
(commercial/homemade) saying “I am going to give you some
ii. Ice-cream sticks (colorful) blocks and I am going to set the timer
iii. Colorful blocks for 10 minutes. During that time, you
1. Timer are to build a tower with the blocks and
2. SCARS (parent report) not be distracted by anything around
3. Wong- Baker Pain Rating Scale (face) you. Do not stop building until you hear
Written and signed consent was the timer go off.”
taken from the parents of the child before Group B was given conventional
commencing the study. Readings were taken physiotherapy in the form of general
on Parent Rated Anxiety Scale and Wong- mobility exercises, breathing exercises and
Baker Pain Scale. Thereafter, the subjects ambulation. These exercises were given
were selected who fulfilled the inclusion keeping in mind the surgery that the child
and exclusion criteria. These subjects were has undergone. If he/ she have been
randomly allocated in two groups (Group A operated for any extremity fracture, mobility
and Group B) using chit method. exercises were given considering the
Group A was given play therapy in the form orthopedic condition of the extremity. The
of picking up sticks, bubble blowing and exercise protocol was given for five days
building blocks. (One session per day) in both the
 Bubble Breathing: The therapist begins interventions.
by filling the room with bubbles; most
children will immediately begin to pop DATA ANALYSIS AND RESULT
them as they fall. After a few minutes, Table 1: This table shows average number of males and
females in Group A and B.
the children are asked to blow only one Group A B
big bubble. The therapist teaches the Males 11 6
Females 4 9
children to take deep breaths from the Mean age 8.4 9.2
stomach and slowly exhale.
 Picking up sticks: Either the therapist or Table 2: This table shows mean pre- and post-intervention
scores of SCARS and WBPS of Group A.
the child holds the sticks in their fist and
then drops them on the table. The goal Group A SCARS WBPS
Pre Post Pre Post
of the game is for the individual to Mean 35.7 32 4.8 3.8
remove a stick without moving any of SD 1.4 1.7 1.6 0.9
the other sticks. The players take turns p < 0.05 p < 0.05
t = 10.1 r = 0.8
removing the sticks. A turn is ended
when the player accidentally moves one
of the other sticks.

Graph 1: These graphs represent within group analysis of pre- and post-intervention scores of SCARS and WBPS of Group A.

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 Renuka Deshpande et.al. Effectiveness of Play Therapy on Pain and Anxiety in Children Post Surgery

Interpretation: The above table and graph WBPS. The value of P (level of
shows average pre- and post- intervention significance) was found to be <0.01.
scores of SCARS and WBPS. The mean Table 3: This table shows mean pre- and post-intervention
pre- and post SCARS score were found to scores of SCARS and WBPS of Group B.
be 35.7+1.4 and 32+1.7. And for WBPS, the Group B SCARS WBPS
Pre Post Pre Post
mean pre- and post scores were 4.8+1.6 and Mean 35.5 32.4 3.6 3
3.8+0.9. Paired t- test was applied for SD 1.5 1.5 1.5 1
SCARS and Wilcoxin test was applied for p < 0.05 p < 0.05
t = 9.74 r = 0.73

Graph 2: These graphs represent within group analysis of pre- and post-intervention scores of SCARS and WBPS of Group B,
respectively.

Interpretation: The data presented in above significance (P) for SCARS and WBPS here
table shows the mean and standard deviation is <0.01.
of Group B with respect to the SCARS and
WBPS. The average pre-intervention score Table 4: This table shows post-intervention scores of Group A
and B for SCARS and WBPS.
of SCARS was found to be 35.5+1.5 and Between SCARS WBPS
that of WBPS was found to be 3.6+1.5. A B A B
Whereas, the post-intervention readings are Mean 32 32.4 0.93 0.53
SD 1.7 1.5 1.2 0.9
32.4+1.5 and 3+1, respectively; Paired t- p = 0.5 p = 0.48
test was applied for SCARS and Wilcoxon t = 0.5 U = 129.5
test was applied for WBPS. The level of

Graph 3: These graphs represent between group analysis of Group A and B for SCARS and WBPS, respectively.

Graph 3(a): The above graph compares the average pre and Graph 3(b): The above graph compares average pre and post
post intervention scores of SCARS of Group A and B intervention scores of WBPS scores of Group A and B.

Table 4 and Graph 3(a) and (b) shows where unpaired t-test for SCARS and Mann
between group analysis of group A and B, Whitney U test for WBPS was used. p was

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 Renuka Deshpande et.al. Effectiveness of Play Therapy on Pain and Anxiety in Children Post Surgery

found to be >0.05, which indicates the data Exercise increases endogenous opoid
being statistically not significant. But, for activity in central and peripheral nervous
within group analysis, the data was system and may induce euphoric state and
statistically significant which means that reduce pain. Distraction has been proposed
both the interventions, i.e., play therapy and as another reason why exercise is effective
conventional physiotherapy were effective at reducing anxiety. The anxiolytic benefits
in reducing anxiety and pain. of exercise may result from it being a
distraction from stressors and a “time out”
DISCUSSION from daily activities. Exercises and
The present study was conducted to cognitively based distraction techniques
assess the effectiveness of play therapy and were shown to have equal effectiveness at
conventional physiotherapy on anxiety and reducing state of anxiety. (9)
pain in post surgical children. Children are Exercise induces hypoalgesia (EIH)
vulnerable to the global surgical stress is characterized by increased pain threshold
response because of limited energy reserves, and tolerance in addition to reduction of
larger brain masses and obligatory glucose pain intensity rating during and after
requirements. The human response to exercises. (10) The central opioid systems are
surgical stress is characterized by series of activated by increased discharge from
hormonal, immunological and metabolic mechanosensitive afferent nerve fibres A-
changes that together constitute the global delta arising from skeletal muscles
surgical stress response. (6) Fernand secondary to rhythmic muscle contraction.
(11)
Seganfredo Weber et al in 2014 conducted a
study in Bangalore to assess the
effectiveness of play therapy in reducing CONCLUSION
stress among hospitalized children. For the Play therapy and conventional
experimental group mean and standard physiotherapy both were equally effective in
deviation was 53.4 and 1.73 respectively. reducing pain and anxiety in the
The findings showed that the children were postsurgical children. Small sample size, all
stressors pre-intervention and were not surgeries were considered and individual
stressors post intervention. (7) Play therapy attention was not given to any surgery was
or therapeutic play techniques have been the limitation of the study. The study can be
used by many clinicians for treating stress. carried out in adults, in other conditions.
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How to cite this article: Deshpande R, Shah MR. Effectiveness of play therapy on pain and
anxiety in children post surgery. Int J Health Sci Res. 2019; 9(4):84-89.

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