Strategies to minimize procedure-related pain and anxiety: lessons from pediatric dermatology.

PURPOSE OF REVIEW: Recent studies have suggested that prolonged or repeated episodes of general anesthesia early in childhood may adversely affect neurodevelopment. This, combined with rising healthcare costs and decreasing access, has sparked interest in performing pediatric procedures in the office setting when possible. It is essential to address the physical and psychological discomfort that often accompany this experience, particularly in children. RECENT FINDINGS: Healthcare providers performing procedures on children can draw from a spectrum of established techniques, new technology, and novel use of medications to decrease peri-procedural pain and anxiety. These techniques include distraction, optimization of local anesthesia, and mild to moderate sedation. SUMMARY: We recommend using a combination of techniques to minimize pain and anxiety to improve safety, decrease healthcare costs, improve patient experience, and prevent childhood trauma and persistent negative perception of the healthcare system.

Description of pain associated with persistent postoperative pain after total knee arthroplasty.

After total knee arthroplasty (TKA), approximately 20% of patients experience persistent postoperative pain (PPP). Although preoperative and postoperative pain intensity is a relevant factor, more detailed description of pain is needed to determine specific intervention strategies for clinical conditions. This study aimed to clarify the associations between preoperative and postoperative descriptions of pain and PPP. Fifty-two TKA patients were evaluated for pain intensity and description of pain preoperatively and 2 weeks postoperatively, and the intensities were compared. In addition, the relationship between pain intensity and PPP at 3 and 6 months after surgery was analyzed using a Bayesian approach. Descriptions of arthritis ("Throbbing" and "aching") improved from preoperative to 2 weeks postoperative. Several preoperative ("Shooting", "Aching", "Caused by touch", "Numbness") and postoperative ("Cramping pain") descriptors were associated with pain intensity at 3 months postoperatively, but only "cramping pain" at 2 weeks postoperatively was associated with the presence of PPP at 3 and 6 months postoperatively. In conclusion, it is important to carefully listen to the patient's complaints and determine the appropriate intervention strategy for the clinical condition during perioperative pain management.

[Effectiveness and safety of multimodal analgesia in open gastrostomy in patients with end-stage head and neck cancer].

Objective: To investigate the effectiveness and safety of multimodal analgesia in patients with end-stage head and neck cancer in open gastrostomy surgery. Methods: This was a randomized controlled trial. From June to December 2023, 50 patients with end-stage head and neck cancer who underwent elective open gastrostomy surgery in Beijing Tongren Hospital Affiliated to Capital Medical University were prospectively selected. The patients were divided into multimodal analgesia group and local anesthesia group using the random number table method according to different anesthesia methods, with 25 cases in each group. In multimodal analgesia group, a multimodal analgesia regimen was adopted: ultrasound-guided abdominal wall nerve block (rectus sheath block and transverse abdominis plane block)+intravenous injection of oxycodone+intravenous injection of flurbiprofen axetil and dexamethasone. In local anesthesia group, local infiltration anesthesia with ropivacaine was adopted. The main outcome measure was the incidence of intraoperative pain numeric rating scale (NRS) score>3 points in the two groups. The secondary observation indicators included NRS score and hemodynamic indexes [mean arterial pressure (MAP) and heart rate (HR)] at various time points during surgery [before anesthesia (T0), at the time of incision (T1), 10 minutes after surgery (T2), during gastric body traction (T3), and at the end of surgery (T4)], incidence of adverse reactions, postoperative patient satisfaction score, as well as the NRS scores at rest and activity (coughing) within 24 hours after surgery. Results: The multimodal analgesia group included 21 males and 4 females, aged (61.4±9.9) years. There were 19 males and 6 females in the local anesthesia group, aged (58.6±10.8) years. The incidence of intraoperative NRS score>3 points and the incidence of salvage analgesia in the multimodal analgesia group were both 12.0% (3/25), which were lower than 60.0% (15/25) in the local anesthesia group, and the differences were statistically significant (all P<0.001); The NRS score [M (Q1, Q3)] at T3 in the multimodal analgesia group was 2 (2, 3) points, which were lower than 5 (3, 6) points in the local anesthesia group (P<0.05). There were smaller variabilities in MAP and HR in the multimodal analgesia group than those in the local anesthesia group (all P<0.05). The incidence of intraoperative tachycardia, surgical traction reaction, and nausea in the multimodal analgesia group was lower than that in the local anesthesia group (all P<0.05). The postoperative satisfaction score of patients in the multimodal analgesia group was (9.25±0.71) points, which were higher than (7.33±0.87) points in the local anesthesia group (P<0.001). NRS score during postoperative activity within 24 hours in the multimodal analgesia group were (2.36±0.75) points, which were lower than (3.03±0.81) points of the local anesthesia group (P=0.005). No adverse reactions such as urinary retention, nausea, vomiting and dizziness occurred in both groups. Conclusion: Compared with local anesthesia, the multimodal analgesic strategy could provide better analgesic effect and longer duration, better hemodynamic stability, and fewer intraoperative adverse reactions in patients with end-stage head and neck cancer undergoing open gastrostomy.

Use of Massage Therapy for Pain, 2018-2023: A Systematic Review.

Importance: Massage therapy is a popular treatment that has been advocated for dozens of painful adult health conditions and has a large evidence base. Objective: To map systematic reviews, conclusions, and certainty or quality of evidence for outcomes of massage therapy for painful adult health conditions. Evidence Review: In this systematic review, a computerized search was conducted of PubMed, the Allied and Complementary Medicine Database, the Cumulated Index to Nursing and Allied Health Literature, the Cochrane Database of Systematic Reviews, and Web of Science from 2018 to 2023. Included studies were systematic reviews of massage therapy for pain in adult health conditions that formally rated the certainty, quality, or strength of evidence for conclusions. Studies of sports massage therapy, osteopathy, dry cupping or dry needling, and internal massage therapy (eg, for pelvic floor pain) were ineligible, as were self-administered massage therapy techniques, such as foam rolling. Reviews were categorized as those with at least 1 conclusion rated as high-certainty evidence, at least 1 conclusion rated as moderate-certainty evidence, and all conclusions rated as low- or very low-certainty evidence; a full list of conclusions and certainty of evidence was collected. Findings: A total of 129 systematic reviews of massage therapy for painful adult health conditions were found; of these, 41 reviews used a formal method to rate certainty or quality of evidence of their conclusions and 17 reviews were mapped, covering 13 health conditions. Across these reviews, no conclusions were rated as high certainty of evidence. There were 7 conclusions that were rated as moderate-certainty evidence; all remaining conclusions were rated as low- or very low-certainty evidence. All conclusions rated as moderate certainty were that massage therapy had a beneficial associations with pain. Conclusions and Relevance: This study found that despite a large number of randomized clinical trials, systematic reviews of massage therapy for painful adult health conditions rated a minority of conclusions as moderate-certainty evidence and that conclusions with moderate- or high-certainty evidence that massage therapy was superior to other active therapies were rare.

Exploring Relations Between Unique Patient Characteristics and Virtual Reality Immersion Level on Anxiety and Pain in Patients Undergoing Venipuncture: Secondary Analysis of a Randomized Control Trial.

BACKGROUND: Virtual reality (VR) is a well-researched digital intervention that has been used for managing acute pain and anxiety in pediatric patients undergoing various medical procedures. This study focuses on investigating the role of unique patient characteristics and VR immersion level on the effectiveness of VR for managing pediatric pain and anxiety during venipuncture. OBJECTIVE: The purpose of this study is to determine how specific patient characteristics and level of immersion during a VR intervention impact anxiety and pain levels for pediatric patients undergoing venipuncture procedures. METHODS: This study is a secondary data analysis of 2 combined, previously published randomized control trials on 252 pediatric patients aged 10-21 years observed at Children's Hospital Los Angeles from April 12, 2017, to July 24, 2019. One randomized clinical trial was conducted in 3 clinical environments examining peripheral intravenous catheter placement (radiology and an infusion center) and blood draw (phlebotomy). Conditional process analysis was used to conduct moderation and mediation analyses to assess the impact of immersion level during the VR intervention. RESULTS: Significant moderation was found between the level of immersion and anxiety sensitivity when predicting postprocedural anxiety (P=.01). Patients exhibiting the highest anxiety sensitivity within the standard of care yielded a 1.9 (95% CI 0.9-2.8; P<.001)-point elevation in postprocedural anxiety relative to individuals with high immersion levels. No other significant factors were found to mediate or moderate the effect of immersion on either postprocedural anxiety or pain. CONCLUSIONS: VR is most effective for patients with higher anxiety sensitivity who report feeling highly immersed. Age, location of the procedure, and gender of the patient were not found to significantly impact VR's success in managing levels of postprocedural pain or anxiety, suggesting that immersive VR may be a beneficial intervention for a broad pediatric population. TRIAL REGISTRATION: ClinicalTrials.gov NCT04268901; https://clinicaltrials.gov/study/NCT04268901.

Cold therapy and pain relief after hot-iron disbudding in dairy calves.

Even when pain control is implemented, calves may experience pain for days after hot-iron disbudding. Whether calves seek pain relief post-disbudding offers a novel approach to assessing pain in these animals. By employing an approach-aversion paradigm, we explored the ability of cold therapy to provide immediate pain relief in disbudded calves. Calves were habituated to the manual placement of a cool or ambient pack on their forehead for a short duration simultaneous to milk reward consumption, prior to disbudding. Calves were then disbudded under local anaesthesia (procaine) and analgesia (meloxicam), and responses to the packs were observed over subsequent days. Individual calves were consistently exposed to either cool or ambient packs in different halves of a two-sided experimental pen, allowing for the testing of approach-aversion and conditioned place preference. We found calves approached milk rewards quicker and maintained contact for longer when receiving cold therapy compared to the ambient control. However, calves did not display any conditioned preference for the pen where they received the cool pack. These results add to the growing evidence of lasting pain following disbudding procedures and suggests that cold therapy provides some form of pain relief post-disbudding. Future studies should seek other ways to use cold therapy post-disbudding to reduce aversiveness and human involvement.

Anterior quadratus lumborum block provided superior pain control and reduced opioid consumption in kidney transplantation: A randomized controlled trial.

BACKGROUND: The research aimed to assess the effectiveness of inside-out anterior quadratus lumborum (QL3) block and local wound infiltration in managing postoperative pain and total morphine dosage following kidney transplantation. METHODS: In this prospective, randomized, double-blind study; 46 end-stage renal disease patients undergoing kidney transplantation were randomly allocated into 2 groups: a QL group (n = 23) receiving 20 mL of 0.25% bupivacaine using the ultrasound-assisted inside-out technique before wound closure, while the local wound infiltration (LA) group (n = 23) receiving the same dose around the surgical wound and drain at the time of skin closure. The primary outcome measure was the numerical pain rating scale, with secondary outcomes including amount of morphine consumption at various postoperative time points (2nd, 4th, 6th, 12th, 18th and 24th hours). RESULTS: Patients in the QL group had significantly lower numerical rating scale scores at the 2nd and 4th hours, both at rest and during movement (P < .05). Although pain scores at rest and during movement at later time points were lower in the QL group compared to the LA group, these differences were not statistically significant. Cumulative morphine consumption at postoperative 4th, 6th, 12th, 18th and 24th hours was significantly lower in the QL group (P < .05). No patients experienced complications from the QL3 block. CONCLUSION: Ultrasound-assisted inside-out QL3 block significantly reduced postoperative pain levels at the 2nd and 4th hours, both at rest and during movement, and led to a reduction in cumulative morphine consumption from the 4th hour postoperatively, and persisting throughout the 24-hour period.

Noninvasive transcranial brain stimulation in central post-stroke pain: A systematic review.

BACKGROUND: The aim of this systematic review is to analyze the efficacy of noninvasive brain stimulation (NBS) in the treatment of central post-stroke pain (CPSP). METHODS: We included randomized controlled trials testing the efficacy of transcranial magnetic stimulation (TMS) or transcranial direct current stimulation versus placebo or other usual therapy in patients with CPSP. Articles in English, Portuguese, Spanish, Italian, and French were included. A bibliographic search was independently conducted on June 1, 2022, by two authors, using the databases MEDLINE (PubMed), Embase (Elsevier), Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and Web of Science Core Collection. The risk of bias was assessed using the second version of the Cochrane risk of bias (RoB 2) tool and the certainty of the evidence was evaluated through Grading of Recommendations Assessment, Development and Evaluation. RESULTS: A total of 2,674 records were identified after removing duplicates, of which 5 eligible studies were included, involving a total of 119 patients. All five studies evaluated repetitive TMS, four of which stimulated the primary motor cortex (M1) and one stimulated the premotor/dorsolateral prefrontal cortex. Only the former one reported a significant pain reduction in the short term, while the latter one was interrupted due to a consistent lack of analgesic effect. CONCLUSION: NBS in the M1 area seems to be effective in reducing short-term pain; however, more high-quality homogeneous studies, with long-term follow-up, are required to determine the efficacy of this treatment in CSPS.

Analysis of Two Treatment Modalities for Post-surgical Pain after Hemorrhoidectomy.

Background: This non-randomized study aimed to compare the efficacy of two pharmacological treatments, "around-the-clock" analgesic treatment (ACAT) and "on-demand" analgesic treatment (ODAT), for managing postoperative pain following hemorrhoidectomy. Material and Methods: The study, conducted from July 2016 to December 2020, included 5335 hemorrhoidectomy patients. Participants were divided into ACAT (3767) and ODAT (1568) groups. The study was registered at clinicaltrials.gov (NCT04953182). Results: Patients had a mean age of 47.47 years, with 59.98% males. Postoperatively, 14.13% reported severe pain, 36.49% moderate, 34.28% mild, and 15.09% no pain. ACAT group's maximum pain was 3.04 (VAS), ODAT 4.95 (p; average pain was 0.79 (ACAT) and 1.45 (ODAT). Discharge pain was 0.42 (ACAT) and 0.63 (ODAT) VAS. The ACAT group consistently reported lower levels of pain across all measured instances. Higher BMI and younger age were pain risk factors (p=.049, p .001 respectively). ACAT administration resulted in reduced opioid usage, with meperidine showing a 68.38% decrease, morphine 43.57% less, tramadol 46.82% less, oxycodone reduced by 38.74%, and codeine by 53.40%. Additionally, the use of non-opioid analgesics was notably lower in the ACAT group, ranging from 16% to 59% less compared to the ODAT group. Conclusion: Hemorrhoidectomy induces moderate postoperative pain, with only 14% experiencing severe pain. A fixed schedule multimodal pain regimen, regardless of procedure and anesthesia type, reduces pain from moderate to mild post-hemorrhoidectomy. This approach also decreases opioid and non-opioid analgesic requirements. Higher BMI and younger age are identified as risk factors for elevated postoperative pain.

Brief behavioral intervention for chronic pain in integrated primary care: What are we waiting for?

Despite high rates of pain-related concerns among primary care patients and associated increases in health care costs (Gore et al., 2012; Mills et al., 2016), psychological or behavioral treatments that are well suited for use in integrated primary care (IPC) settings remain sparsely implemented. Psychological treatment for chronic pain has been recommended for many years (Darnall, 2021; Institute of Medicine (US) Committee on Advancing Pain Research, Care and Education, 2011; Kligler et al., 2018), and the emphasis on the application of nonpharmacological treatment has intensified following concerns about opioid safety. There is abundant empirical support for the use of psychological treatment for chronic pain, such as cognitive behavioral therapy (CBT) in specialty settings (Williams et al., 2021). The evidence to support the use of "brief treatments" in IPC is in a comparatively early stage. The limited state of the research might suggest that brief behavioral intervention for chronic pain is years away from being ready for translation to everyday clinical practice. But why wait? We therefore conducted a focused narrative review of peer-reviewed research on brief psychotherapy for chronic pain in adults that could be feasibly employed in IPC settings through more widely adopted models, such as primary care behavioral health. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Enhancing Emergency Department Pain Management for Older Adults with the Hip Fracture Fast-Track (HFFT) Protocol in a Middle-Income Country.

Purpose: This study aimed to evaluate the impact of the Hip Fracture Fast-Track (HFFT) protocol, designed specifically for older patients at our hospital, which commenced on January 1, 2022, on the management of emergency department (ED) pain in older adults with hip fractures. Patients and Methods: Retrospective pre- and post-study data from electronic health records (EHR) at our hospital, using the International Classification of Diseases (ICD)-10 codes S72.0, S72.1, S72.8, and S72.9, were utilized. The study included patients aged 65 years or older who presented to the ED with low-energy, non-pathologic isolated hip fractures or proximal femur fractures. The pre-HFFT period included patients from January 1, 2020, to December 31, 2021, and the post-HFFT period included patients from January 1, 2022, to October 31, 2023. Data were compared for the proportion of patients undergoing pain evaluation in the ED, before discharge, time to first analgesia, number of patients receiving pain relief in the ED, and the use of fascia iliaca compartment blocks (FICBs) and pericapsular nerve group blocks (PENGBs). Results: The final analysis involved 258 patients, with 116 in the pre-protocol group and 142 in the post-protocol group. The rate of analgesic use increased significantly in the post-HFFT group (78 [67.24%] vs 111 [78.17%], P = 0.049). The rate of pain score screening at triage increased from 51.72% before the HFFT protocol to 86.62% post-HFFT protocol (p < 0.001). Compared with the pre-HFFT protocol, the post-HFFT protocol exhibited a higher rate of FICB (0% vs 14.08%, p < 0.001) and PENGB (0% vs 5.63%, p = 0.009) administration. Conclusion: The HFFT protocol's implementation was associated with improved ED pain evaluation and analgesic administration in older adults with hip fractures. These findings indicate that tailored protocols, such as the HFFT, hold promise for enhancing emergency care for this vulnerable population.

Developing an Evidence-Based Patient Education Guide on Pain Management for Asian Patients on Hospice.

Asian Americans are the fastest-growing racial group in the United States. This article describes the development of a pain management assessment guide for Asian patients on hospice, their families, and their nurses. Thematic analysis was used to evaluate the applicability of research on pain, pain management, and barriers to pain management from primarily Asian countries to Asian patients on hospice in the United States. Thematic analysis of interviews with such patients concurs with research findings. Four themes emerged: enduring pain, preference for Chinese medicine remedies, fear of addiction, and concern about the side effects of pain medications. Interviews with experienced hospice nurses also aligned with these themes. Hospice nurses were asked to share their strategies for assessing and managing pain among their Asian hospice patients. Thematic analysis of their interviews revealed six strategies: focusing on treatment goals, involving family and caregivers, explaining the physiology of pain, explaining the progression of pain medications, addressing concerns about addiction, and managing the side effects of medications. The themes that emerged from patient and hospice nurse interviews were used to develop an evidence-based pain management assessment guide to support Asian patients on hospice, their family, and the nurses who care for them.

Technology-Based Music Interventions to Reduce Anxiety and Pain Among Patients Undergoing Surgery or Procedures: Systematic Review of the Literature.

BACKGROUND: Hospitalized patients undergoing surgery or procedures may experience negative symptoms. Music is a nonpharmacological complementary approach and is used as an intervention to reduce anxiety, stress, and pain in these patients. Recently, music has been used conveniently in clinical situations with technology devices, and the mode of providing music is an important factor in technology-based music interventions. However, many reviews have focused only on the effectiveness of music interventions. OBJECTIVE: We aimed to review randomized controlled trials (RCTs) of technology-based music interventions for reducing anxiety and pain among patients undergoing surgery or procedures. We examined the clinical situation, devices used, delivery methods, and effectiveness of technology-based music interventions in primary articles. METHODS: The search was performed in the following 5 electronic databases: PubMed, MEDLINE (OvidSP), CINAHL complete, PSYCINFO, and Embase. This systematic review focused on technology-based music interventions. The following articles were included: (1) RCTs, (2) studies using interactive technology (eg, smartphones, mHealth, tablets, applications, and virtual reality), (3) empirical studies reporting pain and anxiety outcomes, and (4) English articles published from 2018 to 2023 (as of January 18, 2023). The risk of bias was assessed using the Cochrane Risk of Bias tool version 2. RESULTS: Among 292 studies identified, 21 met the inclusion criteria and were included. Of these studies, 9 reported that anxiety scores decreased after music interventions and 7 reported that pain could be decreased before, during, and after procedures. The methodology of the music intervention was important to the results on anxiety and pain in the clinical trials. More than 50% (13/21, 62%) of the studies included in this review allowed participants to select themes themselves. However, it was difficult to distinguish differences in effects depending on the device or software used for the music interventions. CONCLUSIONS: Technology-based music interventions could help reduce anxiety and pain among patients undergoing surgery or procedures. The findings of this review could help medical teams to choose a practical methodology for music interventions. Future studies should examine the effects of advanced technology-based music interventions using smart devices and software that promote interactions between medical staff and patients.

Cannabidiol and pain.

Chronic pain presents significant personal, psychological, and socioeconomic hurdles, impacting over 30% of adults worldwide and substantially contributing to disability. Unfortunately, current pharmacotherapy often proves inadequate, leaving fewer than 70% of patients with relief. This shortfall has sparked a drive to seek alternative treatments offering superior safety and efficacy profiles. Cannabinoid-based pharmaceuticals, notably cannabidiol (CBD), hold promise in pain management, driven by their natural origins, versatility, and reduced risk of addiction. As we navigate the opioid crisis, ongoing research plunges into CBD's therapeutic potential, buoyed by animal studies revealing its pain-relieving prowess through various system tweaks. However, the efficacy of cannabis in chronic pain management remains a contentious and stigmatized issue. The International Association for the Study of Pain (IASP) presently refrains from endorsing cannabinoid use for pain relief. Nevertheless, evidence indicates their potential in alleviating cancer-related, neuropathic, arthritis, and musculoskeletal pain, necessitating further investigation. Crucially, our comprehension of CBD's role in pain management is a journey still unfolding, with animal studies illustrating its analgesic effects through interactions with the endocannabinoid, inflammatory, and nociceptive systems. As the plot thickens, it's clear: the saga of chronic pain and CBD's potential offers a compelling narrative ripe for further exploration and understanding.