Literature Review: Treatment and Management of Pain

INTRODUCTION

“The aim of the wise is not to secure pleasure but to avoid pain”

-Aristotle

The word pain is derived from the Greek word poine, which means penalty or punishment. Pain is a sensory experience associated with actual or potential damage of tissue,with physiological and psychological responses. Pain is a personal experience and varies from person to person. It is manifested in verbal and nonverbal behaviours, physiological responses like pulse rate, respiratory rate, blood pressure, emotional and spiritual reactions(Nursing clinics of America,2002).

Inadequate treatment of both acute and chronic pain is widespread throughout medical surgical wards, intensive care units, emergency departments and in general practice. This neglect is extended to all age groups, from neonates to the elderly. In September 2008, the World Health Organization estimated that nearly eighty percentage of the population in the world has either insufficient or no access to treatment for severe and moderate pain. Every year millions of people around the world, suffer from pain without treatment. Reasons for proper pain management failure include cultural, religious, societal, and political attitudes, including acceptance of torture(Taylor et al.,2008).

When surveyed 21% to 90% of adults expressed some about the pain associated with the needle based procedures. Up to 90% of young children shows serious distress during vaccination. This general level of anxiety can be severe, and is termed as injection phobia. This phobia can result in syncopal attacks with significant clinical impact (Yael et al.,2003).

In hospital practice intravascular lines are used for various purposes like recording pressure and to administer drugs, fluids and to draw out blood. Pain inflicted by the insertion of cannula into the skin is a significant concern. Effort should be made to assess and manage acute pain. As, by doing so, nurses can reduce pain, increase patient comfort , satisfaction and improve patient outcomes (Jacobson, 1999).

Research evidence shows that cutaneous stimulation is an independent nursing intervention to minimize patients pain. Gate control theory clearly explains the effect of cutaneous stimulation. Cutaneous stimulation modalities can be clubbed with acupressure to increase its effectiveness in pain management. Research studies have highlighted the fact that cryotherapy is equally effective and important in alleviating or minimizing pain as a cutaneous stimulation technique (Sabitha P.B, et al.,2008).

The analgesic effects of cutaneous stimulation (pressure, massage, vibration, heat, cold) are thought to be caused by activation of large A-beta fibers and inhibition of smaller A-delta and C fibers, thus closing the gate to pain impulses. The exact mechanism by which this gating occurs has not been established, but it may be through endorphin release (Ruth,2009).

NEED FOR THE STUDY

Research Studies reveals that, among nursing diagnosis pain constantly ranks the highest position. Nurses often have the closest contact with patients on a daily basis. They are the health care providers most directly responsible for the overall management of pain. Nurses play a pivotal role in pain assessment, pain intervention, monitoring the effects of treatment and communication of information about pain management (Keela A.Herr, et al.,1992).

The complementary therapies are used to relieve the symptoms of pain. These include relaxation technique, visual imagery, cryotherapy, massage, aromatherapy etc. Increasingly complementary therapies are attracting attention in contemporary nursing practice. These interventions are suitable for procedures like injections, venepuncture, that cause acute transitory pain (Barbara, 2000).

Cold application relaxes muscle and muscle contractility, vasoconstriction decreases capillary permeability, decreases blood flow, slows cellular metabolism, decreases pain by slowing nerve conduction rate and blocking nerve impulses, decreases edema by reducing capillary permeability (Barbara kozier, 2006).

The pain related to minor invasive nursing procedures can be

dealt with non-pharmacological measures than pharmacological measure. The pharmacologic measures like local anesthetic spray, eutectic mixture of local anesthetic (EMLA) have long term effects, which is undesirable. Also its cost effect should be kept in mind, as these simple but essential procedures are repeated for the same person for many times. Hence non-pharmacological measures can be the choice for relieving or preventing such minor invasive pain, like venepuncture pain (Saju T.P,2009).

A study conducted to find out the effects of two non-pharmacological pain management measures for IM injection pain recommended to use cold therapy and distraction to decrease pain intensity. The first group received local cold therapy, the second group received distraction and the control group received only routine care. The results shows that average pain intensity in local cold therapy, distraction and control groups was 26.3, 34.3 and 83.3 respectively. The findings indicate that pain intensity was significantly higher in the non-interventional group than the interventional groups. This study supports the efficacy of non-pharmacologic pain management methods (Hasanpour M et.al.,2005).

The large intestine energy meridian is an acupressure point located on the backside of the hand between index finger and the thumb. Largeintestine energy meridian point can be used for relieving pain in the scapula, arm and shoulder, rigidity of the neck, eye diseases and also in the treatment of other disorders like constipation. The large intestine energy meridian pathway is bilateral. Considering the anxiety due to painful procedures such as venepuncture, as well as the unpleasant feelings, the investigator felt that application of cryotherapy to the skin would decrease the pain-related responses associated with venepuncture. This study was therefore undertaken to asses the effect of cryotherapy on the large intestine energy meridian point (li4), during intracath insertion to reduce the perception of pain and variation in physiological responses like pulse rate, respiratory rate and blood pressure.

CHAPTER II

REVIEW OF LITERATURE

Review of literature is a key step in research process. It refers to an extensive, exhaustive and systematic examination of publications relevant to the research project. Nursing research may be considered as a continuing process in which knowledge gained from earlier studies is an integral part of research in general.

Literature review refers to the activities involved in searching for information on a topic and developing a comprehensive picture of the state as knowledge on that topic (Polit and Hungler,1993 ).

Therefore the investigator studied and reviewed the related literature to broaden the understandings about the topic to gain insight into the selected problem under study.

The literature has been reviewed under the following headings:

• SECTION A: Literature regarding pain and changes in physiological parameters during venepuncture.
• SECTION B: Literature regarding large intestine energy meridian point and pain.
• SECTION C: Literature regarding effectiveness of cryotherapy on pain and physiological parameters.

A quasi experimental pre test – post test control group study was conducted to assess the effectiveness of vibratory audio visual stimulation to reduce acute evoked procedural pain experienced by the individuals, during invasive procedures in a selected health centre. Convenient sampling technique was used to select 80 persons who were receiving IM injection. Among the participants 95% expressed a reduction in pain due to vibratory audio visual stimulation,15% said that they had not experienced any reduction in pain. Results of the study suggested that vibratory audio visual stimulation was effective in reducing acute evoked procedural pain (Saju T.P,2009).

A randomized, controlled study, in a convenience sample of 92 patients in the emergency department who required peripheral cannulation as part of their evaluation were enrolled in the study. All the subjects answered questionnaires pre and post IV placement and rated pain intensity during procedure on a 100 millimeter visual analogue scale. Participants in the study included 47(51.1%)of patients received the anesthetic spray and 45(48.9%) were randomly assigned to control group and had their IV line placed in a standard method. The mean pain score in the study group was 27 millimeter and 28 millimeter in the control group (p=0.934). Results revealed that anesthetic spray was an effective intervention in reducing pain during intravenous insertion (Hartstein B.H,et al.,2007).

A crossover single blind experimental study conducted on effectiveness of acupressure to reduce pain in IM injection. Each subject received an injection with acupressure applied to one buttock and an injection without acupressure to the other buttock or vice versa. The perception of pain was measured on a visual analog scale. Among 64 patients, 32(50%) were female. The mean score for perceived pain intensity for acupressure injection was 3+-2 and the mean score for the injection without acupressure was 5+-2. Results revealed that acupressure was effective in reducing IM injection pain (Alavi N.M,2006).

A prospective randomized clinical trial to evaluate the effect of a Valsalva manoeuver, which stimulates the vagus nerve, on perception of pain during peripheral venous cannulation in adult patients. Among 110 patients scheduled for elective surgery, half of them underwent venepuncture during a Valsalva manoeuvre and the other half underwent venepuncture without performing a Valsalva manoeuvre. The numerical rating scale score was 1.5+/-1.2 for Group A and 3.1+/-1.9 for Group B, the difference being statistically significant (P<0.0001). On the basis of data from this study, the Valsalva manoeuvre may be of the value before venous cannulation as a simple and practical method to reduce pain from venous cannulation (Basaranoglu G, et al.,2006).

Pain management is in the purview of all health professionals, specially nurses and is an important component of comprehensive nursing care, since it is the patient and nurse who faces the pain alone. Although most of the nurses have a commitment in pain reduction, far fewer work for alleviation. Ignoring patient’s pain may be causing harm. Unrelieved Pain can cause cell, tissue damage and even death. Health education on pain management for health professionals at all department levels have been noticed as an important measure towards changing ineffective pain management practices (Holleran R.S,2006).

Needle phobia is a term used to describe an anticipatory fear of needle insertion. If pain and anxiety are poorly managed, there can be significant negative consequences. The memory of traumatic venepuncture experiences can lead to extreme anxiety and physiological responses such as venous constriction . Some children and young people may have been conditioned by the fears of relatives or friends concerning needle procedures(Thurgate C. Heppell S, 2005).

A quasi experimental design was adopted to obtain data from 86 younger (between the age group of 25-55) and 89 older (between the age group of 65-94) volunteer samples. Subjects responses to experimentally induced thermal stimuli were measured with following pain scales: vertical visual analog scale,21-point numerical rating scale, verbal descriptor scale,11- point verbal rating scale and faces pain scale. For discriminating different levels of pain sensation all the five scales were effective. The most preferred scale to represent pain intensity in both cohorts was the numerical rating scale, followed by verbal descriptor scale (Frana Benini,M.D,2004).

Pain is a phenomenon that we experience to a greater or lesser extent, and the associations between blood pressure and pain are potentially of great interest . It is well recognized that pain can raise blood pressure acutely. Acute pain leads to generalized arousal and increased sympathetic nerve activity. Blood pressure increase during the application of physical pressure to the nail beds or the skin of the cheek, or during electrical stimulation of a digital nerve. Various studies found that inflated cuff leads to forearm ischemia and increases the degree of pain, which correlates with the increase in blood pressure (Pickering G.Thomas,2003).

SECTION B:Literatures regarding large intestine energy meridian point and pain.

The large intestine energy meridian point is referred to as LI4 or Hoku. The energy meridian pathway is bilateral and begins “in the surface of the skin at the root of the index fingernail. It courses through the arm and hand , and the outward end of the shoulder blade is crossed. Then the meridian leaves the skin surface to connect with the lower part of the lung and transverse colon. It then returns to the skin surface at a point under the chin. From that point, the meridian is again buried deep within the area referred to as the double chin. It follows the lower row of dental roots, passing then to the upper line of teeth roots, crossing the front of the mouth to emerge on the skin surface and the facial point next to the nostrils” (Chandramita Bora,2009).

A randomized controlled trial was conducted on 60 primiparous women who were randomly assigned in two groups (n = 30): ice massage (treatment) and sand bag group (control). The severity of the basal pain was measured at the beginning of active phase (4 cm cervical dilation) based on Visual Analogue Scale (VAS). Then, after two groups received intervention, the severity of the labor pain in 4, 6, 8 and 10 cm cervical dilation was measured. In the case group, the crushed ice twisted in a terry bag was rocked on the web of skin between thumb and forefinger. The massage was carried out in large intestine energy meridian point throughout three contractions. The sand bag tactile massage in large intestine energy meridian point was served in the control group. The data were analyzed using SPSS software and descriptive analysis using Mann- Whitney, χ 2, paired and independent t tests and P<0.05 was considered significant. After completion of intervention, the pain intensity in the treatment group was significantly less than the nontreatment group P<0.001).Results revealed that ice massage was effective in reducing labor pain (Mohammad Taghi,2008).

A one-group, pre test, post test study conducted to evaluate the the use of ice massage on acupressure energy meridian point large intestine 4 (LI4) to reduce the labor pain. The pain was measured using McGill Pain Questionnaire (MPQ) and 100-mm Visual Analog Scales (VAS). Participants noted a pain reduction mean on the VAS of 28.22 mm on the left hand and 11.93 mm on the right hand. The post delivery ranked McGill Pain Questionnaire dropped from distressing to discomforting. The study results suggest that ice massage is a safe, noninvasive, nonpharmacological method of reducing labor pain (Waters L.Bette, et al.,2003).

A study using ice massage for reducing labor pain was carried out by a researcher among twenty women on their admission to the labor and delivery unit at Florida. Ice massage of the energy meridian LI4 was performed during each contraction and was carried out over a 30-minute period. Data from the Visual Analog Scale (VAS) showed a mean reduction in pain of 25.15. The reduction of pain was statistically significant despite the small number of participants. The study results suggest that ice massage is a safe method of reducing labor pain (Naomi lester, et al., 2003).

A one group repeated measurement post test study was aimed at identifying the effect of cutaneous stimulation in large intestine energy meridian point on reduction of arteriovenous fistula puncture pain among forty five hemodialysis patient. First the arteriovenous fistula puncture pain of control group was measured, and then the arteriovenous fistula puncture pain of experimental group (with cutaneous stimulation) was measured using visual analogue scale and objective pain behaviour checklist. Analysis of data was done by use of paired t-test, t-test, ANOVA and Pearson correlation coefficient. The results concluded that the subjective pain score of arterial line (paired t = -0.28, p = 0.77) and the subjective pain score of venous line (paired t = 2.61, p = 0.01). The cardiopulmonary signs of arteriovenous fistula puncture pain in experimental period was (pulse paired t = -0.8, p = 0.42; systolic BP paired t = 0.98, p = 0.33; diastolic BP paired t = 0.43, p = 0.66).Results revealed that cutaneous stimulation in large intestine energy meridian point was effective in reducing arteriovenous fistula puncture pain(Kanho Taehan,2001).

A study in which patients having acute dental pain were treated with ice application on largeintestine energy meridian point of the hand on the same side of the painful region. Ice massage was administered by inserting ice cubes into wet gauze pad and gently massaging the skin around the large intestine energy meridian point. When the patient stated that the area is felt numb or after a period of 7 minutes whichever, occurred first, the massage was stopped. Control group received tactile massage alone. McGill pain questionnaire was used to measure the pain intensity of the patients.. Ice massage reduced the intensity of dental pain by fifty percentage or more in most of the patients, and reduction in pain were significantly greater than those produced by tactile massage alone (Melzack Ronald, et al.,2000).

SECTION C : Literatures regarding effectiveness of cryotherapy on pain and physiological parameters.

A study was conducted to determine the effectiveness of cryotherapy on arteriovenous fistula puncture pain in hemodialysis patients. A convenient sample of 60 patients (30 in experimental and 30 in control group) who had undergone hemodialysis through AVF, was assessed using randomized control trial. Both the objective and subjective pain scoring was performed on two consecutive days of hemodialysis. The tools used were a questionnaire assessing demographic data, an observation checklist for monitoring objective pain behaviour, and a numerical pain intensity scale for subjective pain assessment. The objective and subjective pain scores were significantly (p=0.001) reduced within the treatment group than the control group. Results revealed that cryotherapy was effective in reducing arterivenous fistula puncture pain in hemodialysis patients (Mahajan S, et al.,2008).

A quasi experimental study to assess the effectiveness of hot fomentation versus cold compress for decreasing intravenous infiltration in patients admitted in a selected hospital in Pune . The sample size was 60 and data collected with an observational checklist and behavioral pain scale. The pre treatment mean score of degree of infiltration was decreased from 7.1667 to 0.7071 in hot fomentation and from 6.9333 to 0.7571 in cold fomentation. The findings indicate that the hot fomentation and cold compress both are effective in treatment of intravenous therapy related infiltration (Anjum shabana,2007).

A quasi-experimental study to determine the effect of local refrigeration applied to skin prior to venepuncture on pain-related responses in 80 school-age children who got admitted in the emergency ward in the pediatrics center in Iran. Subjects were selected by purposive sampling and were divided into two equal groups: test and control. In the test group the physiological responses were measured prior to venepuncture. Then the skin on the area of venepuncture was refrigerated by an ice bag for 3 minutes and the procedure is performed immediately. After five minutes of the procedure the physiological responses, behavioural responses and subjective responses were measured. In terms of the physiological responses before and after the procedure in the experimental and control group, there was no significant difference (p=0.07) between the two groups. There was a significant difference (p=0.0011) between the test and control groups with regard to the behavioural responses to the painful procedure.There was also a significant difference (p=0.0097) in the subjective data in the two groups after venepuncture.Results revealed that the local refrigeration was effective in reducing venepuncture pain (Movahedi Fakhar Ali,et al.,2006).

An experimental study to assess the effectiveness of ice application on the treatment zone prior to type -A botulinum toxin treatment on the pain during injections . Totally, twenty four patients who underwent botulinum type-A toxin in upper face for esthetic purposes were undertaken in the study. Ice application was done five minutes prior the injections on the right lateral orbital zones of the patients, and on their left sides, toxin were injected without applying ice. The average visual analog scale values indicating the pain that the subjects felt in their right and left sides were found as 1.1 and 5.9, respectively. Results revealed that ice application is effective in reducing pain during injections (Sarifakioglu N,2004).

A study was conducted to evaluate the effect of the application of cold or hot on the pricking pain sensation based on autonomic responses. Electrical stimulations were applied to subjects arms as an artificial pricking pain, the skin blood flow and skin conductance level at the tip of the finger were measured. Pain was assessed using visual analog scale. Pain stimulation produced a significant rise in skin conductance level and a significant decrease in blood flow. Cold application to the stimulation site using an ice-water pack decreased blood flow and skin conductance responses and sensation of pain. Application of heat, by hot water bottle resulted in a significant rise in pain sensation . The results suggested that cold application promotes relief of pricking pain sensation and suppress the autonomic responses, and the application of heat has no such effect (Saeki Y,2002).

A one group pre test post test experimental study to evaluate the effect of cutaneous stimulation (cryotherapy) on pain reduction in Emergency Department patients . Second objective was to identify the effect of cutaneous stimulation on blood pressure and heart rate. Potential factors that could influence the dependent variables such as age, gender, educational level, location of pain, and site of cutaneous stimulation were tested. All 50 samples were treated with cutaneous stimulation to relieve pain. After cutaneous stimulation, subjects reported significant reduction in pain, and demonstrated decrease in heart rate, and blood pressure readings. The most effective site of cutaneous stimulation was contralateral to the pain. Age, gender and educational level had no significant effect. The results of this study provide empirical evidence that cutaneous stimulation effectively reduces pain, heart rate, and blood pressure (Sylvia M. Kubsch,2002).

A study was conducted to evaluate the effectiveness of local dry cold application on the bruising, haematoma and pain at the subcutaneous low molecular weight heparin injections site. The researcher selected sixty three patients who had received 2 x 20 milligram enoxaparine and divided the samples into four groups. In the first group, cold therapy was not given. Cold was applied to the injection site for five minutes before the injection in the second group, and in the third group five minutes after the injection. In the fourth group, it was applied to the injection site for five minutes pre and post injection.After each injection, the patients’ pain intensity and duration were measured, and the occurance of bruise and haematoma were monitered at 48 and 72 hours after the injection. Results showed that haematoma was absent at the injection site of all subjects. The subjects’ pain perception was significantly reduced with the application of ice (Kuzu N, et al.,2001).

In a paired clinical trial, the effectiveness of ice in reducing the pain of intravenous catheter placement was assessed in 28 adult volunteers. An ice pack was placed over one arm for 10 minutes, followed by insertion of an 18-gauge angio catheter in both arms. Patients recorded their pain assessment after each venepuncture on a previously validated 100-mm visual analog scale and identified their preferred method for the procedure (pretreatment with ice or no pretreatment). The mean pain score for catheter placement on arms pretreated with ice was 27.5 ± 15.9 mm; the mean pain score for the control arms was 34.2 ± 21.6 mm (P = 0.17).Results revealed that application of icepack was an effective method in reducing pain of intravenous catheter placement. Future studies should examine whether ice is effective at reducing pain from other more painful procedures and whether the response to ice is gender-related (Richman P B, et al.,2000).

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