99Final Draft

TEXTING AS A DISTRACTION IS GOOD?
i
(2015)
Texting as a distraction
is good?
By Mohammed Badat
(U1275705)
BSc (Hons) Sociology & Psychology
(3rd
Year Undergraduate Student)
Final Year Project for the Social Sciences
(HHB2002)
Department of Human & Health Sciences
University Of Huddersfield
Mohammed Badat (U1275705)
BSC (HONS) SOCIOLOGY & PSYCHOLOGY
Dissertation submitted by Mohammed Badat in
accordance with the requirements of the
University of Huddersfield for the degree of
BSc (Hons) Sociology & Psychology.

ii
Abstract
Acute pain is necessary to treat to prevent chronic pain from developing
(Voscopoulos and Lema, 2010). Existing research into drug and non-drug alternative
pain management techniques found them to be very expensive, with lack of
accessibility to poorer socio-economic groups (Size, Soyannwo,and Justins, 2007).
The study aimed to investigate whether using texting on mobile phones (TOMP) was
an effective form of pain distraction in managing acute pain. A repeated-measures-
design experiment utilising 40 Psychology students conducted the cold-presser task
(CPT), with either using TOMP pain management technique or not (NTOMP). TOMP
involved participants replying using texting via Whatsapp to a standardised-
conversational-script with the researcher during the CPT. Pain experiences were
assessed subjectively using the Short-Form McGill Pain Questionnaire (Melzack,
1987); physiologically, through blood pressure and pulse rates, and objectively,
through pain tolerance times. Subjective pain measures of MPQ Total scores were
significantly lower in the TOMP condition than in the NTOMP condition. Physiological
measures of pulse rates, systolic, diastolic and mean arterial blood pressure were
significantly higher in the TOMP condition than in the NTOMP condition. Pain
tolerance times were significantly longer in the TOMP condition than in the NTOMP
condition. Overall, the TOMP condition experienced less pain in the CPT than in the
NTOMP condition. Thus, TOMP was concluded as an effective acute pain
management technique. However, further research is yet required into determining
specific causality of TOMP and long-term application of TOMP in clinical and chronic
settings.

iii
CONTENTS PAGE
FRONT COVER .................................................................................................... I
ABSTRACT ......................................................................................................... II
CONTENTS PAGE ............................................................................................. III
ACKNOWLEDGEMENTS...................................................................................IV
KEYS & ABBREVIATIONS .................................................................................V
LIST OF TABLES & FIGURES..........................................................................VII
CHAPTER 1 – INTRODUCTION ......................................................................... 1
CHAPTER 2 – LITERATURE REVIEW ............................................................... 5
CHAPTER 3 – METHODOLOGY....................................................................... 13
CHAPTER 4 – RESULTS .................................................................................. 23
CHAPTER 5 – DISCUSSION............................................................................. 38
CHAPTER 6 – CONCLUSIONS ........................................................................ 42
CHAPTER 7 – REFERENCES .......................................................................... 45
APPENDICES.................................................................................................... 54

iv
Acknowledgements
I would like to thank Ronald Melzak for being such a great inspiration in conducting
this research on pain management in order to advance the future challenges or
practical solutions in managing acute pain, and for granting me permission to use his
Short-Form McGill Pain Questionnaire (Melzack, 1987) in this research.
I would also like to thank my supervisor Jamie Halsall for his great assistance and
insightful advice provided to me and in aiding me to complete this research on pain
management, of whom without I could not have conducted this research.
Additionally, I would also to thank the Psychology technicians, especially to Sarah
Pearson, Adam Robson and Pete Cruikshank for providing me the vital assistance
and guidance in helping me make this research project possible.
I would also like to thank the participants, of whom without their partaking or
participation in the research project would not have allowed to me collect or gather
the data in supporting my findings for this research. I would also like to thank the
University of Huddersfield and all its staff and faculty for allowing me to use the
resources as well as
I would also like to thank my family and friends for supporting me throughout my life
and giving me the chance to research this study.
I would also like to thank all others whom have not been mentioned who have
contributed or have helped me make this research possible.
Conflicts of Interest
I can declare and confirm that there are no external conflicts of interest associated
with the conducting of this research, apart from my own personal experiences as
well as my methodological or theoretical stance as a positivist. Any faults or
inconsistencies are due to the researcher, and not influenced by any external
organisations or companies.

v
Keys & Abbreviations
Overall Key of Abbreviations & Symbols in this report.
Key Definition
TOMP Texting On Mobile Phones Condition
NTOMP No Texting On Mobile Phones Condition
CPT Cold-Pressor Task
MP Mobile Phones
OS Mobile Phone Operating System
MAP Mean Arterial Pressure
SBP Systolic Blood Pressure
DBP Diastolic Blood Pressure
PP Pulse Pressure
mmHg Millimetres of Mercury (Blood Pressure Levels Readings)
bpm Beats per minute (Pulse Rate Readings)
MPQ Short-Form McGill Pain Questionanire (Melzack, 1987)
SF-MPQ Short-Form McGill Pain Questionanire (Melzack, 1987)
LF-MPQ Long-Form McGill Pain Questionanire (Melzack, 1971)
RMD Repeated-measures-design
IV Independent Variable
DV Dependent Variable
WhatsApp WhatsApp – instant messaging mobile phone application
VAS Visual Analogue Scale (Alternative measure of pain intensity)
PPI Present Pain Intensity (Evaluative Dimensions of Pain)
PRI Pain Relative Index (Alternative measure of total score on MPQ)
Sensory Sensory Dimensions of Pain Scores (Sum of PRI Items 1 – 11)
Affective Affective Dimensions of Pain Scores (Sum of PRI Items 12 – 15)
MPQ Total MPQ Total Scores (Sum of combining PRI and PPI Scores)
*C Degrees Celsius (Measure of temperature)
Cronbach’s α Cronbach’s alpha statistic value (Measure of Consistency)
N Total Number of Participants in Sample
SPSS IBM SPSS V.22 (Statistical Package for the Social Sciences)

vi
α alpha value (Probability of Chance Criteria)
W Shapiro-Wilks Test Statistic
MixedANOVA A Mixed between-within subjects design ANOVA
dp decimal places
Mode Mode value or most common value
n Number of Participants in Proportion of Sample
M Mean
SD Standard Deviation
MD Mean Difference
95% CI 95% Confidence Interval of Mean
t T Value Statistic
df Degrees of Freedom
ƞ² Eta squared - Effect Size of Dependent-Samples t-test Statistic
Mdn Median
Z Z Score Statistic
p (2-tailed) Probability of Chance Value (2-tailed)
NS No Significant Differences
r Pearson’s R - Effect Size of Wilcoxon-Signed Ranks Test Statistic
& Pearson’s Correlation Coefficient for Correlations
Λ Wilk’s Lambda
F ANOVA F statistic
ηp
2 Partial eta squared – effect size of MixedANOVA’s
ρ Spearman’s rho statistic value (Spearman’s rank-order correlation)

vii
List of Tables & Figures
Tables & Figures
List of Figures Page
 Figure 3.1 – Gender differences in Research Sample Bar Chart 17
 Figure 4.1 – 3D Stacked Bar Chart to show differences in types of mobile phones. 24
 Figure 4.2 – Error Bar Plot - VAS Scores 26
 Figure 4.3 – Error Bar Plot – MPQ Total Scores 27
 Figure 4.4 – Error Bar Plot - PRI Scores 28
 Figure 4.5 – Error Bar Plot - Affective Scores 29
 Figure 4.6 – BoxPlot - Sensory Scores 30
 Figure 4.7 – BoxPlot - PPI Scores 31
 Figure 4.8 – BoxPlot – Pulse Rates 32
 Figure 4.9 – BoxPlot – Mean Arterial Pressure 33
 Figure 4.10 – BoxPlot – Systolic Blood Pressure 34
 Figure 4.11 – BoxPlot – Diastolic Blood Pressure 35
 Figure 4.12 – BoxPlot – Pain Tolerance Times 37

viii
Data of Differences in Data Variables between both conditions W df p Normally Distributed
Difference in VAS (Pain Intensity) Scores .97 40 .417 Yes
Difference in MPQ Total Scores .97 40 .243 Yes
Difference in MPQ PRI Scores .96 40 .182 Yes
Difference in MPQ Affective Scores .96 40 .214 Yes
Difference in MPQ Sensory Scores .94 40 .046 No
Difference in MPQ PPI (Evaluative) Scores .85 40 .000 No
Difference in Pulse Rates .79 40 .000 No
Difference in Mean Arterial Pressure (MAP) .73 40 .000 No
Difference in Systolic Blood Pressure (SBP) .85 40 .000 No
Difference in Diastolic Blood Pressure (DBP) .72 40 .000 No
Difference in Pulse Pressure (PP) .86 40 .000 No
Difference in Pain Tolerance Times .93 40 .011 No
Table 3.1 – A Series of Shapiro-Wilks Test to assess whether data of differences between TOMP & NTOMP
conditions was statistically significantly normally distributed

ix
Pain
Measure
Descriptive Statistics Paired Differences (TOMP - NTOMP)
Condition Mean SD
Mean
Difference
SD
95% CI
t df
p (2-
tailed)
ƞ²
Lower Upper
VAS
Score
TOMP 4.35 1.81
-1.68 2.41 -2.45 -0.91 -4.41 39 < .001 .33
NTOMP 6.03 2.42
MPQ Total
Score
TOMP 18.2 7.3
-6.18 8.33 -8.84 -3.51 -4.69 39 < .001 .36
NTOMP 24.38 10.81
PRI
Score
TOMP 15.53 7.2
-5.58 7.8 -8.07 -3.08 -4.52 39 < .001 .34
NTOMP 21.1 9.92
Affective
Score
TOMP 2.35 2.41
-1.15 2.29 -1.88 -4.2 -3.17 39 .003 .21
NTOMP 3.5 3.11
Table 4.1 – A Series of Dependent-Samples t-tests to assess significant differences between TOMP & NTOMP
conditions in the VAS Scores, MPQ Total Scores, PRI Scores & Affective Scores.

x
Pain
Measure
Descriptive Statistics Wilcoxon-Signed Ranks Test (NTOMP - TOMP)
Condition
Lower
Quartile
Median
Upper
Quartile
Direction
of Ranks
N
Mean
Rank
Sum of
Ranks
Z
p (2-
tailed)
R
Sensory
Score
TOMP 10.25 14 16
Negative 9a 12.44 112
-3.88- < .001 .62
Positive 30b 22.27 668
NTOMP 13 18 23.75
Ties 1c
Total 40
PPI
Score
TOMP 2 3 4
Negative 3a 19 57
-3.32- .001 .64
NTOMP 2 4 5
Ties 13c
Total 40
Pulse
Rate
(bpm)
TOMP 69.25 76.5 87
Negative 32a 19.89 636.5
-3.88+ < .001 .63
Positive 6b 17.42 104.5
NTOMP 67 73 84.75
Ties 2c
Total 40
Pulse
Pressure
(PP)
TOMP 32.25 40.5 45
-.73+ .467 NS
Positive 15b 16 240
NTOMP 35 39.5 44.75
Ties 7c
Total 40
Table 4.2 – A Series of Wilcoxon Signed-Ranks Tests to assess significant differences between TOMP &
NTOMP conditions in the Sensory Scores; PPI Scores; Pain Tolerance Times; Pulse Rates; Pulse Pressure;
Mean Arterial Pressure; Systolic Blood Pressure & Diastolic Blood Pressure.

xi
Pain
Measure
Descriptive Statistics Wilcoxon-Signed Ranks Test (NTOMP - TOMP)
Condition
Lower
Quartile
Median
Upper
Quartile
Direction
of Ranks
N
Mean
Rank
Sum of
Ranks
Z
p (2-
tailed)
R
Mean
Arterial
Pressure
(mmHg)
TOMP 85.5 93.83 99.58
Negative 35a 19.16 670.5
-3.92+ < .001 .63
Positive 4b 27.38 109.5
NTOMP 82.5 90.5 97.42
Ties 1c
Total 40
Systolic
Blood
Pressure
(mmHg)
TOMP 113.25 119.5 128
Negative 32a 19.67 629.5
-3.36+ .001 .54
Positive 7b 21.5 150.5
NTOMP 109 117 125.75
Ties 1c
Total 40
Diastolic
Blood
Pressure
(mmHg)
TOMP 72.5 80 87.75
-3.66+ < .001 .59
NTOMP 69 75 84
Ties 1c
Total 40
Pain
Tolerance
Time
(Seconds)
TOMP 305.5 759.5 1404.5
-5.51+ < .001 .87
Positive 0b 0 0
NTOMP 45.5 185.5 456
Ties 0c
Total 40
Table 4.2 (Continued) – A Series of Wilcoxon Signed-Ranks Tests to assess significant differences between
TOMP & NTOMP conditions in the Sensory Scores; PPI Scores; Pain Tolerance Times; Pulse Rates; Pulse
Pressure; Mean Arterial Pressure; Systolic Blood Pressure & Diastolic Blood Pressure.

Mohammed Badat (U1275705) 1
1 – Introduction
1.1 – Background
The American Pain Society (2009) emphasises alleviating pain is a basic human
right. International Association for the Study of Pain (1994) defines pain as “an
unpleasant sensory and emotional experience with actual or potential tissue damage
or described in terms of such damage”. Acute pain refers mainly to short-term pain
often resulting from post-operative procedures (Voscopoulos and Lema, 2010).
Acute pain is necessary to treat to prevent long-term chronic pain from developing
(Wilder-Smith, Möhrle and Martin, 2002; Dworkin, 1997).
Pain is largely psychological, with the relationship between the brain and peripheral
nervous system crucial in regulating pain (Hadjistavropoulos and Craig, 2004).
However, there are differing views in explaining this. Melzack and Wall’s (1965) gate
control theory has dominated understandings of pain today, stating that increased
arousal of stimuli increases pain and vice-versa, through opening nerve gates in the
dorsal horn broadcasting pain presence to the brain.
Healthcare systems across the world face increasing challenges, especially from an
aging population (Caley and Sidhu, 2010); and an increasing world population
(World Health Organisation, 2003). Consequently, this puts ever-increasing financial
strains upon healthcare systems, as evident in discussions upon funding the
National Health Service, but more so in the developing world, whereby many go
without healthcare as it is unaffordable.
Acute pain cannot be treated but rather managed. Pain signals can be blocked
through anaesthesia, paracetamol or other drugs; albeit with potential side-effects
with high costs. Alternatively, non-pharmacological techniques are cheaper,
including transcutaneous electrical nerve stimulation, cognitive, behavioural, or
combined techniques, decreasing arousal, thereby closing the gate (Cassileth and
Keefe, 2013). These include distractions, relaxation, comfort and companionship
(Carr and Mann, 2000).

Distraction techniques require them to be engaging in order for them to effective.
Previously, distraction techniques were too passive and simplistic. Contemporary
research has grasped technological advances and tended to focus upon virtual-
reality videogames as pain distraction techniques (Malloy and Milling, 2010).
However, these lack accessibility to poorer socio-economic groups, particularly in the
developing world, due to high costs and limited usefulness (Size, Soyannwo, and
Justins, 2007). Therefore, there is great need to investigate alternative pain
management techniques which are cost-effective and more accessible (Wolff, 2012)
to wider populations, and have multiple uses.
1.2 – Rationale
The number of mobile phones (MP) in the world has surpassed the world human
population (GSMA Intelligence, 2015), and yet increasing due to globalisation
(Golliama, 2011). Although MPs are initially costly, its uses outweigh the costs, as
reflected by its popularity (Kaur and Tao, 2014). MPs are universally available in all
domains, unlike the internet (Bowen, Green and James, 2008). MPs are utilised in
healthcare and termed as ‘mHealth’ (Mechael, 2009), rapidly rising in the developing
world, although limited mainly for health communication purposes (Koehler, Vujovic
and McMenamin, 2013).
Texting on mobile phones (TOMP) has been established as a major distraction in
everyday life activities, for example in driving (Nasar, Hecht and Wener, 2008), and
found to be a cognitive distraction for students in lectures (Dietz and Henrich, 2014).
Therefore, TOMP would be classified as a behavioural task distraction (Hawthorn
and Redmond, 1998) and fulfils McCaffery and Beebe’s (1994) criteria for it being
interesting, consistent and stimulating. Today, TOMP is cheaper through use of
interactive messaging applications such as WhatsApp rather than through SMS
(Reichenbach, 2015).
1.3 – Research Purpose
Research investigating the effectiveness of TOMP pain distraction management
technique would enable not only greater knowledge and understanding into
managing acute pain, but also allow the ability to implement TOMP as a pain

management technique in real life, if shown to be effective. Additionally, as TOMP is
highly cost-effective and accessible than existing pain management techniques, it
would reduce healthcare costs especially in the developing world, as there is little
need for specialist equipment and professionals. However, the research would be
limited at this stage as it would only assess the effectiveness of TOMP using a
controlled small-scale study, and thus limited in real-life applications. Therefore, this
research focuses upon TOMP as a proposed pain distraction management
technique.
1.4 – Aim and Objectives
1.4.1 - Aim
Overall, the research aimed to investigate the effectiveness of non-drug alternative
pain management techniques with TOMP as a pain distraction technique in
managing acute pain.
1.4.2 - Objectives
The aim was investigated through the achievement of 2 objectives:
1) To conduct, evaluate and discuss a review of the research and literature upon
existing non-drug alternative pain distraction techniques in managing acute
pain.
2) To conduct empirical research to assess whether TOMP was significantly
different to NTOMP in determining whether TOMP was an effective pain
distraction management technique.
1.5 - Research Question and Hypothesises
1.5.1 - Research Question
Therefore, this research asked whether TOMP was an effective acute pain
management technique?
1.5.2 - Research Hypothesises

The research hypothesises were a series of 2-tailed hypothesis, with no definitive
assumptions on whether TOMP would increase or decrease participants’ subjective,
physiological and objective pain levels during the cold pressor task (CPT).
Hypothesis 1
There would be significant differences in participant’s pain tolerance times measured
on a stopwatch in minutes and seconds, during the CPT between the TOMP and
NTOMP conditions.
Hypothesis 2
There would be significant differences in subjective pain ratings measured by total
scores on the Short-Form McGill Pain Questionanire (SF-MPQ; Melzack, 1987) after
conducting the CPT, between the TOMP and NTOMP conditions.
Hypothesis 3
There would be significant differences in participant’s physiological pain levels
assessed by pulse rates in beats per minute (bpm), measured on the blood pressure
monitor (BPressM) after conducting the CPT, between the TOMP and NTOMP
conditions.
1.6 – Summary
This report discusses a review of the existing literature and research regarding
TOMP as a pain distractor in Chapter 2. Next, Chapter 3 outlines the methodology
used to investigate the effectiveness of TOMP. The results are interpreted in Chapter
4, with a discussion of the findings offered in Chapter 5. Finally, chapter 6
conclusively answers the research question and evaluates the usefulness and
conducting of research.

2 – Literature Review
2.1 – Introduction
This chapter critically evaluates existing literature surrounding existing non-drug
alternative pain distraction techniques in managing acute pain. This review focused
upon several key themes, categorised into sub-sections for clarity, including the
future of healthcare and its challenges, acute pain management, videogames as
pain distractors, globalisation and development of mobile phones, and texting as a
distraction. Finally, the chapter concludes in offering a clear rationale for research.
Global costs of healthcare have been rising at a very high rate, especially in
managing acute pain, which is a challenge to all health professionals in the world.
For instance, using medical marijuana as an alternative pain reliever for chronic
illnesses has been embraced in most countries (Mosso, et al, 2008; Dahlquist et al.,
2010). Previous research has suggested using videogames in managing acute pain.
However, using videogames for pain management has not received global
recognition due to limitations in the affordability of the videogames (Jameson,
Trevena and Swain, 2011; Mosso et al, 2008). In lieu of these observations, this
research aimed to investigate using mobile phones as an alternative pain
management technique in managing acute pain.
2.2 – The Future of Healthcare and Its Challenges
The healthcare sector is experiencing a great challenge in the management of acute
pain. In both developed and developing countries, the challenge is eminent. Many
people, especially in developing countries cannot afford the cost of drug-based
management of pain. The need for non-drug pain-management methods is
therefore, huge. In the United Kingdom, there is a rising concern, especially in the
care for the aging (Dahlquist et al., 2010). The Department of Health and the
National Health Service (NHS) have agreed that the cost of medication is
increasingly becoming a challenge (Weiss et al., 2010). In regard to the prevailing
high costs of pain management, there is pressure emanating from all stakeholders
for the need to devise less costly methods. Such investments include using
alternative treatments other than drugs (Law et al., 2011). Alternatively, the

excessive use of drugs has also been castigated because of the tendency of body’s
resistance to the drugs. Indeed, some diseases such as kidney failure and liver
damage have been attributed to the use of drugs for prolonged periods (Sil, 2012).
Currently, using technology such as videogames is being suggested instead of using
drugs which are devastating and also expensive to purchase (Sil, Dahlquist and
Burns, 2013).
Additionally, many people in developing countries do not have the same level of
access to healthcare as people in developed countries (Thompson et al., 2014). In
this light, most are forced to endure with the acute pain due to the lack of resources
needed in better health services. It is clear that the population in the developing
world is in want and may not have the financial muscle needed to secure their basic
needs as well as health (Jameson et al., 2011; Mosso et al, 2008). However, there is
hope for better health in their countries with the incorporation of mobile phone
technology, especially in the management of acute pain, which is a common malady
across the world. People in developing countries may not have access to good
quality healthcare, but are likely to have access to a mobile phone in today’s
increasingly mobile, technological and globalized society. Wohlheiter’s (2012), study
on the challenges in pain research, suggests that there is a great need to move
away from expensive pain drugs to cheaper or alternative means. Conciecao (2012)
agrees that the healthcare sector has faced innumerable challenges and
emphasises research on more effective, less costly alternatives in the management
of pain. The research gaps in the management of pain call for aggressiveness in this
area in order to save the healthcare sector the high costs of care.
The future of healthcare remains delicate, but it depends on the cost. As such, it is
important to ensure that enough research is conducted, particularly on the
technology front in order to have cheaper and accessible healthcare. According to
Wolff’s (2012), Future of Healthcare in Europe Report, there is great pressure to
have lower healthcare costs, particularly in lowering pharmaceutical drug costs
(Wohlheiter, 2012). This would also ensure affordability in the developing world
where the cost of living is high and the wages are low. A solution for cheaper access
will be welcome as the future of healthcare becomes even more complex (Thompson
et al., 2014). However, scholars agree that the cost of healthcare will continue to

increase (Bagott, 2004). This is because the cost of research and medication is
gradually increasing. Birnie et al. (2014) suggest that mobile phones are an essential
technological innovation, which can be exploited to meet the needs of the healthcare
system, particularly for HIV care, mainly in Africa and Asia (Shet and de Costa,
2011). Mobile phones have already been established as useful in allowing self-
monitoring of health in the elderly (Kim, Lee, Kim and Kim, 2014). With such
considerations, it is important to ensure that technology is facilitated in order to
improve healthcare. The use of texting is a socialization approach that can help
patients to deal with acute pain. Although this has not been proved, it is projected
that the future of healthcare will require such interventions and more for a
progressive and healthy society (Thompson et al., 2014; Sil, 2012).
2.3 – Acute Pain Management
Acute pain is a type of pain that usually begins suddenly and is very sharp in regard
to quality (Thompson et al., 2014). In a number of times, acute pain acts as an
indication of an impending disease. Some of the factors for acute pain include
surgery, burns, labour, dental disease, and broken bones. Due to the sharpness of
acute pain, the patient experiences a lot of suffrage and, thus, they need immediate
intervention to manage the pain. There are a number of methods used in the
management of acute pain. These include use of drugs such as morphine, nerve
blocks using anaesthesia, physical therapy, electrical stimulation, behavioural
modification, and psychological counselling. The current acute pain management
systems are so expensive that many clients cannot afford them, both in the
developing and developed worlds. Despite that, some of these interventions come
with side effects, namely drug resistance in the case of drugs, and nerve damage in
electrical stimulations. As such, the need for more effective pain management
strategies is eminent (Sil et al., 2013). Alternative methods include videogames
among others, although the possibility of destructive side effects should be
considered. The use of mobile phones in the management of pain has been studied
and documented as effective, owing to globalization and the development of the
technology.

2.4 – Videogames as Pain Distractors
Scholars have conducted various studies on the use of technology for acute pain
management. Pain is psychological, not physical (Carter, 1998). There is a lack of
pain drug treatments in the developing world (Soyannwo, Justins and Size, 2007).
Mann and Carr (2009) emphasize distraction strategies are currently used by
patients suffering from chronic pain only. A common form of pain management using
technology is the use of videogames by patients experiencing acute pain (Chorney,
Twycross, Mifflin and Archibald, 2014). The level of concentration when playing
videogames acts as an effective distraction to pain. Thus, patients are able to
concentrate less on their pain and more on the games they are playing (De-Jong,
and Gamel, 2006). Although videogames have been used in the past as pain
distracters, the idea has remained restricted to a certain class of people due to the
expenses involved. The cost of a virtual reality videogame headset itself costs
$4000, (Dahlquist et al., 2010), a rate that proves to be expensive, especially for
those individuals in developing countries who live on less than 1 USD a day (DeMore
and Cohen, 2005). Videogame software has little additional use, other than for
playing games, thereby resulting in costs being higher than drug treatment (Kato,
2010). The disadvantages of videogames as an alternative to acute pain
management calls for the use of other techniques that are cheaper and easily
attainable compared to videogames (Frischenschlager, and Pucher, 2002).
2.5 – Globalization and Development of Mobile Phones
Globalization is a complex system of living where the world has been reduced into a
single unit of business, economics and technology (Kim et al., 2014). The
development of technology is among the many aspects that globalization has
facilitated, especially in poverty-stricken areas. The use of technology has thus,
increased significantly in the developing world. The use of phones has exceeded
other basic needs such as food. In this light, phones can offer more solutions that
are needed in the healthcare sector than other approaches such as offering
subsidies on drugs. Research has proved that although the cost of managing acute
pain is high, phones can offer a cheaper solution in form of texting and using other
applications such as WhatsApp, direct texts and social networks (Accardi and

Milling, 2009). Bowen, Green and James (2008) observe that globalization and the
development of mobile phones in Morocco have changed the ways in which
sexuality and relationships are formed and developed.
The world has seen a rise in the use of technology. Modern mobile phones which
emerged in the late 90’s with the inception of SMS texting are now a necessity in all
households across the world. Traditionally, the original mobile phones or “brick
phones” as it was commonly termed, was viewed sceptically, with a view that it
would never catch on. Nowadays, mobile phones are termed “smartphones,”
whereby they operate similarly to a computer. By 2011, 70% of the world had access
to mobile phones (Wohlheiter, 2012). Apart from the use of phones, there is also the
use of the internet. Currently, phones are also availing the internet, making
communication even easier and faster across the globe. On the other hand,
developing countries are benefiting from cheap phones made in the developed
world. Healthcare has benefitted from the innovations offered by technology. The
use of videogames has proved to reduce pain in patients suffering from acute pain
(Kim et al., 2014). On this note, phones have also been recommended for use in
healthcare. Mobile phones are a global phenomenon with at least 1.75 billion people
owning a mobile phone in the world (Mosso et al, 2008). Thanks to globalization, free
trade policies have allowed individuals, even in the farthest areas of developing
countries to access mobile phones at an affordable price (Law et al., 2011). Apart
from the traditional message texts, nascent technology such as the use of
WhatsApp, a mobile application that allows users to send and receives text
messages, pictures, videos and audio messages on their mobile devices, has
presented even more involving and entertaining texting services for mobile phones.
Texting on mobile phones can act as a distraction from pain psychologically, the
level of engagement when using mobile phones for texting allows the mobile device
to act as an effective pain distraction.
Mobile phones are linked to increasing trade and communication, both of which are
instrumental in economic advancement in the developing world. The African
continent, which houses the largest number of developing countries, has also
benefitted from globalization and technology (Baus and Bouchard, 2010). Aker and
Mbiti (2010) add that the mobile phone economy has been largely responsible for

much of the infrastructure and human development in the developing world.
Additionally, globalization has led to the development of free trade and free market
access. According to Askay, Patterson, Sharar, Mason and Faber (2009), free trade
has enabled ventures and investment by multinationals. These organizations,
consequently lead to the employment of the lower class and the middle class people
in the society, of whom are thus able to purchase phones and other basic elements.
Given the affordability of mobile phones, it would be important to explore ways in
which phones could be used in the healthcare sector which faces numerous
challenges, especially funding (Botella, Palacios, Baños, Quero and Breton-Lopez,
2008).
2.6 – Texting on Mobile Phones as a Distraction
Pain distraction refers to the act of directing the brain away from sensory pain. The
brain, which is the central processing unit, is responsible for all passive and active
reactions in the body (Espinoza, Baños, García-Palacios and Botella, 2005). The
brain cannot concentrate on more than one single task at a time (Eysenck, 2011),
thus discrediting myths of the brain’s ability to multitask (Rosen, 2008). The brain
has a limited cognitive load referring to the amount of data that the mind can process
at any given time (Flowers, 2007). In reference to texting and driving, Haque and
Washington (2015) observed that young drivers get problems when they text while
driving, indicating the difficulty involved in engaging the mind in multitasking.
This concept can apply to pain distraction through decreasing the amount of
concentration on the pain (Gilmartin and Wright, 2007). By introducing a second
activity such as texting, the mind can decrease its cognitive load, thus limiting the
amount of perceived pain by the patient. With advances in technology, mobile
phones have features that make the exercise of texting more intense and more
entertaining (Gold, Belmont and Thomas, 2007). Traditional mobile devices were
limited to simply sending basic conversational messages. However, with the current
mobile technology, mobile users can send more than conversational messages. The
‘chat’ option in many mobile devices ensures faster delivery of messages. As such,
individuals can engage in continuous conversations on a singular platform. Other

applications such as “WhatsApp” mobile application make texting an involving task
since users can send video and audio messages.
The ability to send all these forms of texts on the mobile phone can serve as a
sufficient distraction from other cognitive functions such as pain (Gutierrez-Martinez,
Guiterrez-Maldonado, Cabas-Hoyos, and Loreto, 2010). Allowing patients to text on
the mobile phones can succeed in reducing the cognitive load at a single time,
reducing their concentration on the pain. Texting on mobile phones is a form of
behavioural distraction since it entails altering one’s behaviour patterns (Hoffman et
al, 2011). Texting on mobile phones may be used as a form of sublimation. This is
whereby an individual focuses their emotion on something else other than the
causative factor, thereby lessening the intensity of the emotions. In this case,
patients can use texting as a means of subliming the emotion of pain. Concentrating
on texting, therefore, lessens the intensity of the feeling of pain.
The limitation to the use of texting on mobile phones as a pain distracter is that the
practice is addictive in nature (Richards et al, 2006). Hence, even after the patient
gets cured of the acute pain, he or she may still feel the need to text continuously.
This may be detrimental to the social life of the patient since it limits the time that the
patient interacts physically with their friends, acquaintances, and family. However, if
used successfully, using texting as a pain distraction has more advantages than
disadvantages. The effect of relieving pain is more than the possible addictive effect
of using texting on mobile phones as a method of relieving acute pain.
2.7 – Conclusion
Acute pain relieving techniques have for the longest time been limited to medical
drugs and treatments, which have proven to be expensive to the average citizen.
The healthcare challenges of both developing and developed countries warrants the
development of alternative pain relieving techniques that would cost less and be
easily accessible. According to the findings of this research, texting on mobile
phones can be used as a form of pain distraction for patients suffering from acute
pain. The inability of the brain to multitask makes it easy to divert the patient's mind
from their pain to the more involving task of texting or chatting on social platforms

such as WhatsApp. Texting on mobile phones can also act as a form of sublimation,
where the patients focus their pain on alternative behaviours such as texting. This in
turn reduces the intensity of the perceived pain. The only limitation to this proposition
is that texting is addictive and may negatively affect the social life of the patient after
he or she becomes cured from their pain. The viability of this pain relieving method
warrants more research and investigation to help build on the idea. The success of
this pain relieving method may be the answer to the global health challenge.

3 – Methodology
This chapter states the methodology and specifies methods undertaken to conduct
this research. The data analysis measures, barriers and ethical issues are also
discussed.
3.2 – Research Approach
Methodologies should be determined by the best ways in investigating the social
phenomenon (Bohman, 1994). A deductive approach was employed into
investigating whether TOMP, a proposed pain management technique, was
effective. This was best probed using a positivist approach, utilising an objectivist
ontology (Delanty, 2005), testing hypothesises through standardised measures,
using quantitative methods. Quantitative methodology is associated with positivism
and reduces facts into measureable phenomena (Bryman, 2012).This was evident
with the SF-MPQ simplifying pain into a standardised quantifiable manner through
closed questions. The experimental method allowed observation of causality on
TOMP on pain tolerance in a controlled environment. Additionally, scientific,
objective, physiological measures of pulse rates, blood pressure and pain tolerance
times were employed to assess pain tolerance. Focusing upon a theoretical
approach exclusively could reduce validity, as it may be considered reductionist. As
pain is psychological and difficult to measure (Gurung, 2013), it was vital in
understanding subjective experiences of pain, assessed by the SF-MPQ PPI and
PRI sub-items, although in a quantifiable manner, of the presence and severity of
different pain experience types.
3.3 – Design
A two-part snapshot laboratory experiment utilising a repeated-measures-design
(RMD) was used, whereby each participant experienced both conditions of the
independent variable (IV). The use of a RMD ensured control of pain tolerance
individual differences and a counterbalancing procedure with an alternating order of
conditions reduced likelihood of order-effects.

The IV was whether participants experienced the pain management technique of
using TOMP or NTOMP. The dependent variables (DV) are the subjective pain
ratings measured assessed by the total and sub-total scores on the SF-MPQ using
structured-interviews; the physiological experiences assessed by systolic, diastolic
and mean arterial blood pressure levels (mmHg) and pulse rates (bpm); and pain
tolerance times of total time (in seconds) of hand immersed in CPT.
3.3.1 – Setting
The research was undertaken in Rb/19a, a designated psychology lab, in the
Ramsden Building at the University of Huddersfield. The psychology technicians had
prepared the apparatus prior to each experiment. The length of each experimental-
timeslot was estimated to last 1 hour maximum, as individual differences in pain
tolerance created problems in devising a standardised time length for the duration of
each experiment.
3.3.2 – Apparatus
The CPT is regularly utilised in experimentally stimulating acute pain (Mitchell,
MacDonald and Brodie, 2004). The CPT was operationalised using a circulatory-
water-bath with distilled water at 10 *C, regulated consistently by a thermostat.
Although most research operates colder temperatures (Mitchell, 2013), this CPT was
faulty, thereby resulting in temperature only being maintained at 10 *C, with limited
timeframe available to utilise the apparatus before its return. Participants immersed
their non-dominant-hand in the CPT until they could no longer tolerate the pain.
3.3.3 – Conditions
The TOMP treatment condition was operationalised by participants’ texting with their
dominant-hand on their mobile phones via WhatsApp responding to the researcher’s
texts, formulated from a standardised-conversational-script, during the CPT. The
NTOMP non-treatment condition was operationalised with participants’ dominant-
hand laying across the desk during the CPT.
3.4 – Measures

There is no standardised measure of pain tolerance (Litcher-Kelly, Martino,
Broderick and Stone, 2007). Thus, pain tolerance was assessed quantitatively
through 3 different levels of subjective pain ratings; measured by the SF-MPQ using
a structured-interview method, physiological pain experiences; measured by pulse
rates and blood pressure on the blood pressure monitor (BPressM), and objectively;
through pain tolerance times measured on a stopwatch. This ensured a
multidimensional measure of pain tolerance, increasing concurrent validity in
assessing pain tolerance (Litwin, 1995).
3.4.1 – Pain Tolerance Times
Pain tolerance times were recorded on a stopwatch to objectively assess pain
tolerance during the total time participant’s hand was immersed in during the CPT
(Hayes et al., 1999). Times were recorded in the form of minutes and seconds, but
recoded into seconds to allow easier comparisons. Pain tolerance times collected
ratio level quantitative data in the form of seconds. Time was an objective, consistent
measure of pain tolerance although inaccuracies in recording time reduced reliability.
3.4.2 – Blood Pressure Monitor
A BPressM assessed physiological measures of pain (Carr and Mann, 2000),
measured by pulse rates; systolic blood pressure (SBP) and diastolic blood pressure
(DBP), after the CPT. The BPressM was attached to participant’s upper arm of the
CPT immersed hand and found to be better than using alternatives, as the BioPac
heart rate monitor could only record heart rate through attachments to participants
fingertips, which were already occupied during the experiment. SBP and DBP were
calculated into mean arterial pressures (MAP) to allow overall comparisons of blood
pressure. Differences between SBP and DBP were calculated into pulse pressure
(PP) to assess heart functioning changes. The BPressM gathered ratio level
quantitative data from pulse rates in beats per minute (bpm) and from SBP and DBP
in millimetres of mercury (mmHg). Although the BPressM was regarded as precise
and scientific, it lacked reliability as it encountered many errors in reading blood
pressure.
3.4.3 – Short-Form McGill Pain Questionnaire (Melzack, 1987)

The SF-MPQ was conducted using a structured-interview method after recording
blood pressure measurements to assess subjective pain ratings. The SF-MPQ is a
multidimensional (Hawker, Mian, Kendzerska and French, 2011) 17 item
questionnaire. Sensory, affective and evaluative dimensions of pain were assessed
quantitatively; through number-rating scales and a visual analogue scale (VAS), and
qualitatively; through the descriptors of pain (Loretz, 2005). Melzack’s (1987) SF-
MPQ summarised the original 78 item McGill Pain Questionnaire (LF-MPQ; Melzack,
1975), designed to allow measures of short-term pain experiences. Melzack’s (1987)
SF-MPQ was employed in assessing pain in similar contexts as in investigating hope
interventions effectiveness in CPT pain (Berg, Snyder and Hamilton, 2008). An in-
depth explanation of the questionnaire scoring system can be found in Appendix 2.
The SF-MPQ gathered interval level quantitative data from VAS scores and ordinal
level quantitative data from number-rating scales and total scores, with higher scores
indicating greater pain. Hsieh, Tripp, Ji and Sullivan (2010) found the SF-MPQ as
highly reliable in assessing CPT pain with Cronbach’s α for total scores at .78 for
Euro-Canadians, .77 for Chinese, in Sensory scores at .74 for Euro-Canadians, .71
for Chinese, and in Affective Scores at .71 for Euro-Canadians and .72 for Chinese.
The internal consistency of the SF-MPQ was high with Cronbach’s α for total scores
at .92 for NTOMP and .83 for TOMP. Additionally, Cronbach’s α for sensory scores
was .9 in NTOMP and .75 for TOMP, and in affective scores was .81 for NTOMP and
.79 for TOMP. Thus, Cronbach’s α were considered ideally reliable (above .7), for
statistical analysis (DeVellis, 2012). Permission to use the SF-MPQ was obtained
from the author (Appendix 2).
3.5 – Pilot Study
An initial pilot study determined the LF-MPQ as too long and identified faults with the
CPT machine. Participants struggled to define terminology used in the SF-MPQ, so a
glossary was developed (Appendix 2), to ensure accurate standardised definitions
of terminology to assist participants in completing questionnaires. A standardised
treatment-manual (Appendix 4) was also devised ensuring control and replicability
in each experiment.
3.6 – Participants

Forty psychology undergraduate students were recruited from the University of
Huddersfield, who gained 2 SONA credits for their module for participating. A priori
power analysis using G*Power (Faul, Erdfelder, Lang and Buchner, 2007) indicated
54 particpants were required to have 95% power for detecting a medium sized effect,
when employing α as .05 (two-tailed). However, limited timeframe in using apparatus
resulted the sample being recruited through non-probablity sample techniques of
self-selection sampling, as it was most convenient in obtaining a large sample.
Participants prone to risk of harm were excluded from participating (Appendix 3),
hence limiting ethical issues arising. Additionally, participants were prohibited from
consuming highly-sugary foods and drugs at least an hour before participation to
control for confounding variables. Participants were allocated a Unique Participant
Number (UPN), whereby odds and evens differentiated in the order of the conditions
participated in the first part of the experiment.
3.6.1 – Gender
N = 40

Overall, a gender imbalance was identified in the research sample (Mode = Female),
with disproportionately more females (n = 27) than males (n = 13). Non-probability
sampling techniques is likely to have contributed to this. Although the sample is
unrepresentative of the general population, it is representative of the target
population of social sciences students. Generally, students studying social sciences
subjects in UK universities, comprises 62.3% female and 37.7% male (Higher
Education Statistics Agency, 2015).
3.7 – Procedure
Initially, participants read C1 information guides (Appendix 3) and booked timeslots
on SONA if interested in participating. Participants were only confirmed as recruited
when C2 consent forms (Appendix 3) were completed, either online or in-person.
Participants were requested information regarding their dominant-hand; gender; and
mobile phone details to gather demographic data and in preparing the experiment
appropriately.
Upon gaining consent and informing participants of their rights, each participant was
directed to Rb/19a in their pre-booked hourly timeslot to conduct the experiment.
Participants were trained to use TOMP to counter individual differences in texting
ability. The order of the conditions for each individual participant was based upon
their Unique Participant Number (UPN); whereby odds experienced TOMP first; and
vice versa for evens.
In the first part of the experiment, each participant conducted the CPT by immersing
their non-dominant-hand into the water for as long as they tolerate. The
experimental-group were told to use TOMP with their dominant-hand, with the
researcher using the standardised conversational-script to interact with the
participant via texting on WhatsApp, whilst the control-group (NTOMP) were told to
leave their dominant-hand on the table. During the CPT, participants’ pain tolerance
times were recorded using a stopwatch. After the CPT, pain experiences were
initially measured using the BPressM attached to participants’ upper arms to record
pulse rates and blood pressure; followed by conducting the SF-MPQ through

structured-interviews. Participants hands were then immersed in a warm (30*C) jug
of water (Swain and Trevena, 2014), followed by drying their hand with a towel.
Thereafter, participants had a 5 minute break before proceeding with the second part
of the experiment.
In the second part of the experiment, each participant repeated the CPT in the
alternative condition to the first experiment. The measurements were then recorded
followed by another 5 minute break. Upon completing both parts of the experiment,
participants were thanked, debriefed and provided with opportunities to ask queries
and receive help through counselling. Finally, the experiment was complete and data
was processed using statistical analysis.
3.8 – Data Analysis
The ordinal and interval level data of scores gathered from the SF-MPQ and ratio
level data from pulse rates (bpm), blood pressure (mmHg) and pain tolerance times
(seconds) were analysed using SPSS. The α was set at the standard value for social
research (Field, 2013) of p < .05, signifying that any difference was 95% due to the
IV (Pallant, 2013). Any significant differences excluding tests of normality would
reject null hypothesises of no significant differences. The α was reported to a lower
value of when p < .001, to signify large significant differences, hence not increasing
likelihood of type 2 errors. The SF-MPQ was analysed adhering to Melzack’s (1984)
scoring procedures, and an in-depth explanation of this is provided (Appendix 2).
MPQ total scores were formulated from combining PRI and PPI scores. PRI scores
were configured from merging Sensory and Affective scores as alternative Total
scores. VAS Scores were interpreted in centimetres to 1 decimal place. Initially,
descriptive statistics were explored to understand basic assumptions of the data.
3.8.1 – Qualitative Pain Experiences
Although the SF-MPQ is mostly used in clinical research as a quantitative measure,
its main aim was to understand qualitative experiences of pain (Huysmans, 2008).
Therefore, measures of central tendency were computed upon the 15 PRI sub-items
to identify the pain experiences in CPT pain in both TOMP and NTOMP conditions
(Table 7.2).

3.8.2 – Tests of Normality
Next, tests of normality were conducted visually through analysing histograms with
lines-of-best-fit, and statistically. As there was a small sample, (less than 50
participants) in this research (N = 40), a Shapiro-Wilks Test was appropriate in
assessing whether data was normally distributed (Field, 2013). It is also known as a
Gaussian distribution, characterised by a bell curve (Lewis-Beck, Bryman and Liao,
2004). As a RMD was utilised, differences between TOMP and NTOMP conditions
were computed to assess normality. The null hypothesis of data being normally
distributed was rejected if p was significant. Therefore, Table 3.1 stated that
statistically, differences between TOMP and NTOMP conditions in VAS, MPQ Total,
PRI and Affective Pain scores were normally distributed. Alternatively, all other
differences of Sensory Pain scores; PPI scores; pain tolerance times; pulse rates;
MAP; PP; SBP; and DBP were all found to not be normally distributed. Additionally
all 15 PRI sub-items were also found to not be normally distributed (Table 8.1).
3.8.3 – Inferential Statistics
Consequently, after understanding basic assumptions surrounding the data,
inferential statistics were conducted. A series of two-tailed dependent-samples t-
tests (Table 4.1) were conducted to assess any significant mean differences in MPQ
measures of VAS, MPQ Total, PRI and Affective scores between TOMP and
NTOMP conditions. Dependent-samples t-test were employed as all parametric
assumptions were met, as data was normally distributed. A series of Wilcoxon-
Signed Ranks tests (Table 4.2) were conducted to compare any significant
differences in Sensory scores; PPI scores; pain tolerance times; pulse rates; MAP;
PP; SBP; DBP and PRI sub-item scores between TOMP and NTOMP conditions.
Although Wilcoxon-Signed Ranks tests are not as powerful as its parametric
alternative of the dependent-samples t-test (Allen and Bennett, 2012), it was utilised
as data was not normally distributed, hence failing parametric assumptions. PRI sub-
item analysis is reported in Appendix 5.
3.8.4 – Gender Differences

A series of mixed between-within subjects analysis of variances (MixedANOVA)
were conducted to assess significant differences in MPQ Total, PRI, PPI, VAS,
Sensory, and Affective scores, pain tolerance times, SBP, DBP, PP and MBP
between males and females in both TOMP and NTOMP conditions (Appendix 5) to
assess gender differences. Although the MixedANOVAs failed many parametric
assumptions, it was determined that there was lack of a suitable non-parametric
alternative.
3.8.5 – Order Effects
A series of MixedANOVA’s were also employed to assess significant differences
between the order of the conditions in both TOMP and NTOMP conditions
(Appendix 5) to assess order effects.
3.8.6 – Associations
A series of Pearson’s product moment correlation coefficients and Spearman’s rank-
order correlations were conducted to assess the relationship between all different
dimensions of pain in the SF-MPQ of Sensory, Affective, PPI, VAS and MPQ total
scores in TOMP, NTOMP and differences between conditions.
3.8.7 – Concurrent Validity
A series of Pearson’s product-moment correlation coefficients were conducted to
assess the relationship between PRI and MPQ total scores; between VAS and MPQ
total scores in TOMP, NTOMP and differences between conditions in assessing
concurrent validity of total pain scores, as data was normally distributed.
A series of Spearman’s rank-order correlations were also conducted to assess
whether there was an association between MAP and pulse rates in assessing
concurrent validity of the different physiological measures of pain tolerance, as data
was not normally distributed.
3.9 – Ethical Issues
The research adhered to British Psychological Society’s (BPS, 2009) code of ethics
and conduct; BPS’s (2014) code of human research ethics; the Data Protection Act

(1998); and the University of Huddersfield’s CPS Ethics Committee (CPS). A risk
assessment of the ethical issues prior to conducting the research ensured
consideration and controls implemented to limit ethical issues from arising
(Appendix (3). Ethical approval was granted by CPS before conducting this
research (Appendix 3), with minor alterations approved by the supervisor
(Appendix 3).
3.10 – Summary
In summary, an experiment assessing subjective, physiological and objective pain
measures in CPT pain was utilised to determine whether TOMP was effective in
managing pain.

4 – Results
4.1 - Introduction
This chapter reports and interprets the results achieved through statistical analysis
measures as discussed in Section 3.6. All results, except p values were reported to 2
decimal places. There was no missing data identified. The section focused upon the
main significant differences in subjective pain ratings (from MPQ total, VAS, PPI,
PRI, Sensory and Affective scores), physiological pain readings (pulse rates, PP,
MAP, and SBP and DBP) and pain tolerance times between TOMP and NTOMP
conditions. Further analysis is reported in-depth in appendix (5), with a discussion of
the results offered in Chapter 5.
4.2 - Mobile Phone Demographics
Measures of central tendency were computed to summarize the data regarding MPs.
The mode was used as it was appropriate in assessing nominal level data (Field,
2013). The Apple iPhone 5S was the most common type of MP specific model (n =
9), followed by the Apple iPhone 5C (n = 6), both comprising 37.5% of the sample (N
= 40). Overall, Apple’s iPhones (n = 23) dominated the type of MP model, followed
by Samsung’s Galaxy MPs (n = 12), both comprising 87.5% of the sample. All other
MP models were rare, encompassing only 12.5% of the sample. However, MP
makes did not match with MP operating systems (OS) as Google's Android OS was
more diverse, operating on a variety of different MP models as compared to Apple,
Blackberry and Windows which relied upon their own exclusive OS. In examining MP
market shares, the findings corroborated with Apple and Samsung’s Galaxy being
the most dominant MP models sold worldwide, albeit with a reduced share
(International Data Corporation, 2014).

N = 40

4.3 – Qualitative Pain Experiences
It was identified that from both TOMP and NTOMP conditions, throbbing, shooting
and stabbing pain experiences were most prevalent from CPT pain, as they were
consistently rated either as severe or moderate in both conditions, signifying a great
presence of those pain behaviours. Alternatively, it was found that gnawing,
sickening, fearful and punishing-cruel experiences were the least prevalent, with
each having median scores of 0 in both conditions signifying no presence of those
pain experiences.

4.4 – Subjective Pain Ratings
4.4.1 – Pain Intensity - VAS Scores
A dependent-samples t-test indicated that VAS scores were significantly higher in the NTOMP condition (M = 6.03, SD = 2.42),
than in the TOMP condition (M = 4.35, SD = 1.81), t(39) = -4.41, p < .001, suggesting greater pain intensity in the NTOMP condition
than in the TOMP condition. The mean difference was -1.68 with a 95% confidence interval ranging from -2.45 to -0.91. This effect
was considered as large (ƞ² = .33).

4.4.2 – Total Subjective Pain Scores - MPQ Total Scores
A dependent-samples t-test indicated that MPQ total scores were significantly higher in the NTOMP condition (M = 24.38, SD =
10.81), than in the TOMP condition (M = 18.2, SD = 7.3), t(39) = -4.69, p < .001, suggesting greater overall pain in the NTOMP
condition than in the TOMP condition. The mean difference was -6.18 with a 95% confidence interval ranging from -8.84 to -3.51.
This effect was considered as large (ƞ² = .36).

4.4.3 – Alternative Total Pain Scores - PRI Scores
A dependent-samples t-test indicated that PRI scores were significantly higher in the NTOMP condition (M = 21.1, SD = 9.92), than
in the TOMP condition (M = 15.53, SD = 7.2), t(39) = -4.52, p < .001, suggesting greater overall pain in the NTOMP condition than
in the TOMP condition. The mean difference was -5.58 with a 95% confidence interval ranging from -8.07 to -3.08. This effect was
considered as large (ƞ² = .34).

4.4.4 - Affective Dimensions of Pain - Affective Scores
A dependent-samples t-test indicated that Affective scores were significantly higher in the NTOMP condition (M = 3.5, SD = 3.11),
than in the TOMP condition (M = 2.35, SD = 2.41), t(39) = -3.17, p = .003, suggesting greater affective pain dimension levels in the
NTOMP condition than in the TOMP condition. The mean difference was -1.15 with a 95% confidence interval ranging from -1.88 to
-.42. This effect was considered as large (ƞ² = .21).

4.4.5 - Sensory Dimensions of Pain - Sensory Scores
A Wilcoxon signed-ranks test indicated that Sensory scores were significantly higher in the NTOMP condition (Mdn = 13) than in
the TOMP condition (Mdn = 10.25), Z = -3.88, p < .001, suggesting greater sensory pain dimension levels in the NTOMP condition
than in the TOMP condition. This effect was considered as large, (r = .64).

4.4.6 - Evaluative Dimensions of Pain - PPI Scores
A Wilcoxon signed-ranks test indicated that PPI scores were significantly higher in the NTOMP condition (Mdn = 4 = horrible) than
in the TOMP condition (Mdn = 3 = distressing), Z = -3.32, p = .001, suggesting greater evaluative pain dimension levels in the
NTOMP condition than in the TOMP condition. This effect was considered as large, (r = .64).

4.5 – Physiological Pain Levels
4.5.1 - Pulse Rates
A Wilcoxon signed-ranks test indicated that pulse rates were significantly higher in the TOMP condition (Mdn = 76.5 bpm) than in
the NTOMP condition (Mdn = 73 bpm), Z = -3.88, p < .001, suggesting greater heart contractions in the TOMP condition than in the
NTOMP condition. This effect was considered as large (r = .63).

4.5.2 – Mean Arterial Pressure
A Wilcoxon signed-ranks test indicated that MAP was significantly higher in the TOMP condition (Mdn = 93.83 mmHg) than in the
NTOMP condition (Mdn = 90.5 mmHg), Z = -3.92, p < .001, suggesting higher overall blood pressure in the TOMP condition than in
the NTOMP condition. This effect was considered as large (r = .63).

4.5.3 - Systolic Blood Pressure
A Wilcoxon signed-ranks test indicated that SBP was significantly higher in the TOMP condition (Mdn = 119.25 mmHg) than in the
NTOMP condition (Mdn = 117 mmHg), Z = -3.36, p = .001, suggesting higher SBP in the TOMP condition than in the NTOMP
condition. This effect was considered as large (r = .54).

4.5.4 - Diastolic Blood Pressure
A Wilcoxon signed-ranks test indicated that DBP was significantly higher in the TOMP condition (Mdn = 80 mmHg) than in the
NTOMP condition (Mdn = 75 mmHg), Z = -3.66, p < .001, suggesting higher DBP in the TOMP condition than in the NTOMP
condition. This effect was considered as large (r = .59).

4.5.5 – Pulse Pressure
A Wilcoxon signed-ranks test indicated no significant differences in PP between both conditions, Z = -.73, p > .05, suggesting no
significant variations in the difference between SBP and DBP between TOMP and NTOMP conditions. Although, PP was higher in
the TOMP condition (Mdn = 40.5 mmHg) than in the NTOMP condition (Mdn = 39.5 mmHg).

4.6 - Pain Tolerance Times
A Wilcoxon signed-ranks test indicated that pain tolerance times were significantly higher in the TOMP condition (Mdn = 759.5
seconds) than in the NTOMP condition (Mdn = 185.5 seconds), Z = -5.51, p < .001, suggesting longer pain tolerance times in the
TOMP condition than in the NTOMP condition. This effect was considered as large, (r = .87).

5 – Discussion
5.1 - Introduction
This chapter thoroughly discusses the reasons and explanations for the findings and
evaluates the validity of the findings. The results are discussed and applied in
relation to Melzack and Wall’s (1965) gate control theory. Overall, the results
indicated that CPT pain was tolerated longer in the TOMP condition than in the
NTOMP condition, with lower subjective experiences of pain as reflected in all MPQ
total and sub-total scores being significantly lower in the TOMP condition than in the
TOMP condition. Thereby, objective and subjective measures of pain suggested that
there was greater pain in the NTOMP condition than in the TOMP condition.
However, physiological pain measures apart from PP was significantly higher in the
TOMP condition than in the NTOMP condition.
5.2 - Qualitative Pain Experiences
Sensory experiences of throbbing, stabbing and shooting were found to be most
prevalent, whereas mainly affective experiences of sickening, punishing-cruel, fearful
along with sensory experience of gnawing were found to be least prevalent from both
TOMP and NTOMP conditions. Stein (2007) argues that affective experiences tend
to result from long-term pain experiences, often in chronic illness, as it is about the
emotional unpleasantness towards the pain experience. Additionally, gnawing is
unlikely to be prevalent in CPT pain, as it is more of a digestive system problem
(Streator, Ingersoll and Knight, 1995). However, assessing qualitative pain
experiences was not very clear due to the small range in values from 0 to 3.
5.3 – Gate Control Theory

Overall, pain tolerance times provided the clearest measure of pain tolerance directly
from the pain tolerance times. A comparison between TOMP and NTOMP conditions
showed clearly significant longer pain tolerance times in the TOMP condition
indicating, greater endurance of pain as a result of less being experienced (Wall,
1984). This is because the large fibre gates did not open as much (Melzack and
Casey, 1998) in the TOMP condition as TOMP, was the manipulated variable from
between both conditions. Furthermore, it was found that all MPQ totals and sub-
totals were significantly lower in the TOMP condition, suggesting that overall,
participants subjectively experienced less pain in the TOMP condition than in the
NTOMP condition. This compliments and supports the gate control theory, as it
suggests that participants had significantly longer pain tolerance times due to the
absence of consciousness in feeling the CPT pain due to the lack of attention
focused upon the pain, and is reflected through psychological measures, with
psychologically experiencing less pain.
The evaluative dimensions of pain were measured by PPI scores, which would best
reflect the presence of pain distraction, as it determines the level of attention directed
towards a stimulus (Frankenstein, Richter, McIntyre and Rémy, 2001). Although it
was found that PPI or evaluative scores were significantly lower in the TOMP
condition than in the NTOMP condition, the difference was not very clear, largely due
to the small range of ratings on the PPI from 0 to 5. Sensory dimensions of pain
were significantly lower in the TOMP condition, suggesting greater severity of pain
experiences in the NTOMP condition. This further supported TOMP as a distraction
as it can be suggested that the ability of the nervous system to receive pain
responses from the CPT was limited in the TOMP condition. Clark, Sita, Chokhatia,
Kashani, and Clark (2010) state that the affective dimension of pain reflects the
aversive and emotional aspects of pain. In relation to TOMP, it suggests TOMP is an
enjoyable, interesting activity, thereby meeting McAfferey and Beebe’s (1994) criteria
of behavioural pain distraction techniques.

Physiological measures did not directly measure pain, instead assessing circulatory
system activity of blood-flow. Despite the fact blood pressure was objective,
representations of what it suggests were socially constructed theories attached to
the data (Christenfeld, Glynn, Kulik, and Gerin, 1998). The results indicated that all
physiological measures (SBP, DBP, MAP, pulse rates) except PP were significantly
higher in the TOMP condition than in the NTOMP condition, although this did not
necessarily signify greater pain experiences itself. Pickering (2003) suggests that
increased arousal from the cold water in the CPT leads to dramatic increases in
muscle sympathetic nerve activity (MSNA), which is parallel to increases in blood
pressure Macintyre and Ready (1996). However, DBP was found to be not be highly
significant as p was close to α, with the MixedANOVA establishing no significant
difference between conditions. However, Silverthorn and Michael (2013), suggest
that DBP does not fluctuate as much as SBP in CPT pain. Additionally, PP,
suggested as an indication of heart health, was found to be not significant, although
this is unlikely to change in short-term pain inducing CPT, as well as heart conditions
less prevalent in younger people. Therefore, physiological measures arose due to
greater sympathetic nervous activity increasing blood flow throughout the body to
counteract the CPT pain perceived as a threat by the periphery nervous system
(Sacco et al., 2013). Thus, these results come into conflict with the gate control
theory, as it suggests that participants experienced greater activity in the nerve gates
in the TOMP condition, even though pain tolerance times and subjective experiences
suggested otherwise. However, Fagius, Karhuvaara & Sundlof (1989) noted that the
CPT significantly correlated with changes in blood pressure. Additionally, long
exposure to the CPT, owing to operation of high temperatures may have also
hindered in effectively creating pain. As a result, it can be suggested that TOMP is
an effective pain distraction technique as although physiological levels increased,
subjective pain experiences and pain tolerance times suggested otherwise. This is
important as pain is largely psychological, and thus although physiological activity
may arise, TOMP can be claimed as a distraction technique, as it does decrease
pain, even though it does not necessarily treat the pain as would be expected from
anaesthesia. Attention voluntarily directed away from pain has the capacity to reduce
the pain experience and increase pain tolerance (Johnson, 2005), rather than
controlling physiological responses to pain.

5.4 - Summary
In application with the results overall and its effect in the TOMP and NTOMP
conditions, it can be suggested that TOMP is an active behavioural distraction
technique. This can explained in terms of the CPT pain stimulus whereby, the TOMP
behavioural technique is suggested to have created a distraction prior and during the
CPT, thereby decreasing arousal of the nerve gate in the posterior horn of the dorsal
horn, thereby minimising or limiting the body to perceive pain from the CPT during
the TOMP task. However, issues arise with physiological measures which had
contradicted the gate control theory, as well as there being lack of empirical
evidence in assessing the gate control theory in this research. In specifying the
specific type of distraction technique, TOMP was an active distraction technique, as
participants were required to conduct activities of actively engaging in texting and
responding with their mobile phones. However, difficulty arises in specifying
distraction as the suggested exclusive causal factor, as the conversational script
could potentially be a causal factor itself creating a false positive (McLeod, 2015).
The results seem consistent or similar to research findings on virtual reality
videogames research, in that TOMP was shown to be an effective pain distraction
management technique, similar to using virtual reality videogames as a pain
distraction management technique. However, comparisons could or were hard to
make between TOMP and virtual-reality videogames as similar pain distraction
management techniques, as a comparison study between TOMP and virtual reality
videogames was not conducted. Therefore, a true assessment or claims about the
effectiveness of TOMP as a pain distraction management should not be
overemphasised.

6 – Conclusion
This chapter conclusively answers the research hypothesises in stating whether they
are accepted or rejected. The section also discusses usefulness of the findings and
evaluates the research process to assess improvements that could be implemented
in future research.
6.2 – Conclusion
Hypothesis 1 was accepted as it was concluded that participants had significantly
longer pain tolerance times in the TOMP condition than in the NTOMP condition.
Thus, overall suggesting that participants could tolerate pain longer in the TOMP
condition than in the NTOMP condition.
Hypothesis 2 was accepted as results suggested that participants had significantly
lower MPQ total scores in the TOMP condition than in the NTOMP condition. This
suggests that participants subjectively experienced less pain in the TOMP condition
than in the NTOMP condition. Additionally, all sub-measures of the sensory, affective
and evaluative dimensions of pain were found to be significantly lower in the TOMP
condition than in the NTOMP condition, thereby corroborating with the MPQ Total
Scores.
Finally, Hypothesis 3 was also accepted as it was established that participants had
significantly higher pulse rates in the TOMP condition than in the NTOMP condition.
This suggests that participants experienced greater physiological pain experience in
the TOMP than in the NTOMP condition. Furthermore, other physiological measures
of all different blood pressure apart from pulse pressure, were also found to be
significantly higher in the TOMP condition than in the NTOMP condition, thus
corroborating with the pulse rates.
6.3 – Usefulness of Findings
Primarily, this research enables greater understanding of the knowledge and
dynamics of TOMP as a non-drug alternative pain distraction technique in managing

acute pain. Additionally, it can also be inferred that the role of mobile phones should
be explored upon more in improving healthcare, apart from communication purposes
due to its affordability and accessibility. A review of the literature has also found that
mobile phones are one of the most accessible things on the planet, and is increasing
with globalisation. Thus, increasing numbers of mobile phones along with greater
advancement in mobile phone technology development such as of ‘Apps’ or
applications, suggests that there should be more innovative ways and techniques
devised in using mobile phones in healthcare. Any evidence of this is currently being
shown in the growth and development of health and fitness ‘Apps’ on mobile
smartphones, and a focal or important feature in the development of smartphone or
smart watches.
6.4 – Evaluation and Future Research
Firstly, the sample was too small and unrepresentative, thereby limiting statistical
power and generalizability. Future research should utilise larger samples which have
sufficient statistical power and representative of the general population, hence
allowing greater generalizability of findings. The absence of a treatment control
group doubts the effectiveness of TOMP as a placebo effect against alternative pain
distraction management techniques. Therefore, future research should utilise
videogames as a treatment control group, to allow an assessment of TOMP’s
effectiveness in comparison to existing treatments. Jameson, Trevena and Swain
(2011) add that passive distraction techniques should also be studied upon. Also,
there was a lack in explaining cause and effect in-depth about the factors of TOMP
which specifically caused lower pain ratings and increased pain tolerance. Therefore,
future research should explore the specific cause in TOMP such as whether it is the
conversational script or the texting activity itself which is the supposed cause, using
qualitative research through semi-structured interviews or diaries. Future research
could utilise stronger methodology, utilising a mixed-methods approach as in
Nilsson, Finnström, Kokinsky, and Enskär’s, (2009) research on virtual-reality and
pain, which used semi-structured interviews along with quantitative measures to
understand participants experiences of using the intervention of virtual-reality. As the
CPT was working faulty, alternative methods should be sought in future research,

especially in utilising existing pain sufferers which reduces lack of mundane realism
criticisms. This research utilised a snapshot design utilising CPT, which is
unrepresentative to chronic pain (Eccleston, 1995) and long-term effectiveness of
TOMP. Therefore, future research should utilise longitudinal designs, utilising
existing pain sufferers to allow greater generalizability and usefulness. Additionally,
the research can be argued to lack ecological validity due to the laboratory setting of
the research and how unrealistic or relative the research is to the real world. Thus,
research needs to be conducted in a real-life setting. The presence of order effects
and other confounding variables along with individual differences could be countered
through the utilisation of a matched-pairs-design in future research.
6.5 – Summary
In conclusion, or in response to answering the research question, it is concluded that
TOMP does in fact reduce subjective pain ratings, hence allowing greater pain
tolerance levels, but it does not necessarily treat the pain symptoms itself, as it is
only a pain distraction management technique. However, the degree to which TOMP
is effective requires further study. Overall, the research suggests that TOMP is an
effective pain distraction management technique.

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Appendix 1 - Specific Keys & Abbreviations
Tests of Normality: Key
Dependent-Samples T-Test: Key
Interpreting Effect Sizes - ƞ²
According to Cohen (1988), the following criteria should be used when interpreting
the effect size in a dependent-samples t-test utilising the eta squared statistic (ƞ²):
Key Definition
N Number of Population of Sample
W Shapiro-Wilks Test Value Statistic
p Probability of Chance Value (2-tailed)
Key Definition
M Mean Score or Value
SD Standard Deviation
N Number of Population of Sample
95% CI 95% Confidence Interval of Mean
t T Value Statistic
p Probability of Chance Value (2-tailed)
ƞ² Eta squared Statistic (Effect Size)
ƞ² Effect Size Interpretation
.01 Small Effect
.06 Moderate Effect
.14 Large Effect

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