TENS for children's procedural pain

Management of routine postoperative pain for children undergoing cardiac surgery: a Paediatric Acute Care Cardiology Collaborative Clinical Practice Guideline

BACKGROUND

Pain following surgery for cardiac disease is ubiquitous, and optimal management is important. Despite this, there is large practice variation. To address this, the Paediatric Acute Care Cardiology Collaborative undertook the effort to create this clinical practice guideline.

METHODS

A panel of experts consisting of paediatric cardiologists, advanced practice practitioners, pharmacists, a paediatric cardiothoracic surgeon, and a paediatric cardiac anaesthesiologist was convened. The literature was searched for relevant articles and Collaborative sites submitted centre-specific protocols for postoperative pain management. Using the modified Delphi technique, recommendations were generated and put through iterative Delphi rounds to achieve consensus.

RESULTS

60 recommendations achieved consensus and are included in this guideline. They address guideline use, pain assessment, general considerations, preoperative considerations, intraoperative considerations, regional anaesthesia, opioids, opioid-sparing, non-opioid medications, non-pharmaceutical pain management, and discharge considerations.

CONCLUSIONS

Postoperative pain among children following cardiac surgery is currently an area of significant practice variability despite a large body of literature and the presence of centre-specific protocols. Central to the recommendations included in this guideline is the concept that ideal pain management begins with preoperative counselling and continues through to patient discharge. Overall, the quality of evidence supporting recommendations is low. There is ongoing need for research in this area, particularly in paediatric populations.

Placebo response and effect in randomized clinical trials: meta-research with focus on contextual effects

BACKGROUND

Contextual effects (i.e., placebo response) refer to all health changes resulting from administering an apparently inactive treatment. In a randomized clinical trial (RCT), the overall treatment effect (i.e., the post-treatment effect in the intervention group) can be regarded as the true effect of the intervention plus the impact of contextual effects. This meta-research was conducted to examine the average proportion of the overall treatment effect attributable to contextual effects in RCTs across clinical conditions and treatments and explore whether it varies with trial contextual factors.

METHODS

Data was extracted from trials included in the main meta-analysis from the latest update of the Cochrane review on "Placebo interventions for all clinical conditions" (searched from 1966 to March 2008). Only RCTs reported in English having an experimental intervention group, a placebo comparator group, and a no-treatment control group were eligible.

RESULTS

In total, 186 trials (16,655 patients) were included. On average, 54% (0.54, 95%CI 0.46 to 0.64) of the overall treatment effect was attributable to contextual effects. The contextual effects were higher for trials with blinded outcome assessor and concealed allocation. The contextual effects appeared to increase proportional to the placebo effect, lower mean age, and proportion of females.

CONCLUSION

Approximately half of the overall treatment effect in RCTs seems attributable to contextual effects rather than to the specific effect of treatments. As the study did not include all important contextual factors (e.g., patient-provider interaction), the true proportion of contextual effects could differ from the study's results. However, contextual effects should be considered when assessing treatment effects in clinical practice.

TRIAL REGISTRATION

PROSPERO CRD42019130257 . Registered on April 19, 2019.

Procedural Pain in Hospitalized Children in a Chinese Children's Hospital

BACKGROUND

Pain prevalence in pediatric hospitals has been investigated in many developed countries, but little is known about this topic in China.

AIMS

This study sought to describe the frequency and pain intensity of procedures for medical care in hospitalized children in a Chinese children's hospital.

DESIGN

A cross-sectional study was designed to include interviews with children, their parents and the nurses.

SETTINGS

This survey was administered in a teaching hospital in southeast China.

PARTICIPANTS/SUBJECTS

Infants and children up to 16 years old who were admitted to the study units for more than 6 days were eligible for inclusion.

METHODS

Information regarding patient demographics, painful procedures and pain management strategies was obtained during the day shifts of the children's hospitalization.

RESULTS

A total of 3886 procedures were performed on 342 children during the data collection period. The reuse of intravenous indwelling needles ( n = 577), removal of tape from the skin (n = 420) and venipuncture on the back of the hand ( n = 401) were the most frequently performed procedures on children. A total of 1941 procedures, accounting for 49.9% (1941/3886) of painful procedures caused moderate to severe pain (pain score ≥4.0). However, only 25.3% (984/3886) received a valid pain assessment, and only 14.4% (560/3886) received pain interventions.

CONCLUSIONS

Most children, especially those who are younger (<4 years old), experienced moderate or severe pain during their hospitalization, but did not receive appropriate interventions.

Self-Reported Presence and Experience of Pain in Adults with Down Syndrome

Objective

The aim was to examine whether the presence of pain (based on physical conditions and participants' report) and self-reported pain experience in adults with Down syndrome (DS) differ from general population controls.

Design

Cross-sectional study of 224 adults with DS (mean age = 38.1 years, mild-severe intellectual disabilities) and 142 age-matched controls (median age = 40.5 years, mean estimated IQ = 105.7) in the Netherlands.

Methods

File-based medical information was evaluated. Self-reported presence and experience of pain were assessed in rest and after movement during a test session (affect with facial affective scale (FAS: 0.04-0.97), intensity assessed with numeric rating scale (NRS: 0-10).

Results

Compared with controls, more DS participants had physical conditions that may cause pain and/or discomfort ( p  = .004, 50% vs 35%), but fewer DS participants reported pain during the test session ( p  = .003, 58% vs 73%). Of the participants who indicated pain and comprehended self-reporting scales ( n  = 198 FAS, n  = 161 NRS), the DS group reported a higher pain affect and intensity than the controls ( p  < .001, FAS: 0.75-0.85 vs 0.50-0.59, NRS: 6.00-7.94 vs 2.00-3.73).

Conclusions

Not all adults with DS and painful/discomforting physical conditions reported pain. Those who did indicated a higher pain experience than adults from the general population. Research into spontaneous self-report of pain, repeated pain assessment, and acute pain is needed in people with DS for more insight into pain experience and mismatches between self-report and medical information.

Effects of transcutaneous electrical nerve stimulation on pain intensity during application of carboxytherapy in patients with cellulite: A randomized placebo-controlled trial

BACKGROUND

Carboxytherapy may generate local pain that is considered the main limiting factor in clinical practice. Transcutaneous electric nerve stimulation (TENS) is widely used in the control of acute pain; however, the effect of TENS on pain relief during carboxytherapy has not been studied to date.

AIMS

To assess the effect of TENS on pain intensity during carboxytherapy in patients with cellulite in the gluteal region.

PATIENTS/METHODS

This randomized clinical trial was conducted with 84 patients, 18-44 years of age, who had moderate cellulite in the gluteal region, according to Cellulite Severity Scale, but never received carboxytherapy. Patients were randomized into 3 groups: active TENS, placebo TENS, and control group. For the intervention, skin depressions with cellulite were outlined, and the gluteal area to be treated was defined. The subcutaneous injection of CO₂ was performed using 0.30 × 13 mm-needles at a 45° angle, with a controlled flow rate of 100 mL/min maintained for 1 minute at each puncture site. The parameters for TENS were as follows: frequency of 100 Hz and pulse duration of 200 μs; TENS intensity was adjusted until the patient reported strong paresthesia. The visual numeric pain rating scale was used to assess pain intensity after each puncture.

RESULTS

The active TENS group reported lower pain intensity compared to the placebo TENS (P < .0001) and control (P < .0001) groups.

CONCLUSIONS

Transcutaneous electric nerve stimulation (TENS) was effective in reducing pain intensity during carboxytherapy in patients with cellulite in the gluteal region.

Topical anaesthetics for pain control during repair of dermal laceration

BACKGROUND

Topical local anaesthetics provide effective analgesia for patients undergoing numerous superficial procedures, including repair of dermal lacerations. The need for cocaine in topical anaesthetic formulations has been questioned because of concern about adverse effects, thus novel preparations of cocaine-free anaesthetics have been developed. This review was originally published in 2011 and has been updated in 2017.

OBJECTIVES

To assess whether benefits of non-invasive topical anaesthetic application occur at the expense of decreased analgesic efficacy. To compare the efficacy of various single-component or multi-component topical anaesthetic agents for repair of dermal lacerations. To determine the clinical necessity for topical application of the ester anaesthetic, cocaine.

SEARCH METHODS

For this updated review, we searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 11), Cumulative Index to Nursing and Allied Health Literature (CINAHL; 2010 to December 2016), Embase (2010 to December 2016) and MEDLINE (2010 to December 2016). We did not limit this search by language or format of publication. We contacted manufacturers, international scientific societies and researchers in the field. Weemailed selected journalsand reviewed meta-registers of ongoing trials. For the previous version of this review, we searched these databases to November 2010.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that evaluated the efficacy and safety of topical anaesthetics for repair of dermal laceration in adult and paediatric participants.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. We contacted study authors for additional information when needed. We collected adverse event information from trial reports. We assessed methodological risk of bias for each included study and employed the GRADE approach to assess the overall quality of the evidence.

MAIN RESULTS

The present updated review included 25 RCTs involving 3278 participants. The small number of trials in each comparison group and the heterogeneity of outcome measures precluded quantitative analysis of data for all but one outcome: pain intensity. In two pooled studies, the mean self-reported visual analogue scale (VAS; 0 to 100 mm) score for topical prilocaine-phenylephrine (PP) was higher than the mean self-reported VAS (0 to 100 mm) score for topical tetracaine-epinephrine-cocaine (TAC) by 5.59 points (95% confidence interval (CI) 2.16 to 13.35). Most trials that compared infiltrated and topical anaesthetics were at high risk of bias, which is likely to have affected their results. Researchers found that several cocaine-free topical anaesthetics provided effective analgesic efficacy. However, data regarding the efficacy of each topical agent are based mostly on single comparisons in trials with unclear or high risk of bias. Mild, self-limited erythematous skin induration occurred in one of 1042 participants who had undergone application of TAC. Investigators reported no serious complications among any of the participants treated with cocaine-based or cocaine-free topical anaesthetics. The overall quality of the evidence according to the GRADE system is low owing to limitations in design and implementation, imprecision of results and high probability of publication bias (selective reporting of data). Additional well-designed RCTs with low risk of bias are necessary before definitive conclusions can be reached.

AUTHORS' CONCLUSIONS

We have found two new studies published since the last version of this review was prepared. We have added these studies to those previously included and have conducted an updated analysis, which resulted in the same review conclusions as were presented previously.Mostly descriptive analysis indicates that topical anaesthetics may offer an efficacious, non-invasive means of providing analgesia before suturing of dermal lacerations. Use of cocaine-based topical anaesthetics might be hard to justify, given the availability of other effective topical anaesthetics without cocaine. However, the overall quality of the evidence according to the GRADE system is low owing to limitations in design and implementation, imprecision of results and high probability of publication bias (selective reporting of data). Additional well-designed RCTs with low risk of bias are necessary before definitive conclusions can be reached.

Efficacy of vibration on venipuncture pain scores in a pediatric emergency department

OBJECTIVE

Venipuncture is a frequent source of painful procedures for infants. It has been well documented that infants react to pain with a combination of physiologic and behavioral responses. Infants are unable to describe pain and at particularly high risk for inadequate pain management. The Vibration Anesthesia Device is a specifically designed device for management of pain from minor procedures. It has been shown to reduce venipuncture pain in older children but has not been studied in infants. The mechanism of its effects has been described by a gate control theory, which states that vibration stimulates the dorsal horn neurons where the pain signal is being modulated. The objective of this study was to investigate the efficacy of this device on pain during and after venipuncture procedures in infants.

METHODS

Study participants were 60 healthy infants undergoing venipuncture procedure for routine laboratory tests. Infants were divided into 2 groups as follows: group 1 (n = 30) was placed vibration anesthesia device 5 to 10 cm proximally through the site of venipuncture, and group 2 (n = 30) underwent venipuncture only. A single observer rated pain responses using the Face, Legs, Activity, Cry, and Consolability scale before, during, and after the procedure. The χ distribution and Student t test were used for statistical analysis.

RESULTS

Groups did not differ by sex. Mean age of group 2 is less than group 1 and is statistically significant (P = 0.026). There were no differences between pain scores of groups assessed by Face, Legs, Activity, Cry, and Consolability scale before, during, and after venipuncture procedure (P = 0.359, P = 0.907, and P = 0.400 respectively).

CONCLUSIONS

We assessed the efficacy of a vibration anesthesia device, and our results suggested that this device did not reduce pain scores in infants during and after venipuncture procedure.

Procedure-related pain in children in a Danish University Hospital. A qualitative study

BACKGROUND

Children being cared for in hospital often undergo multiple diagnostic and therapeutic procedures. Procedure-related pain, anxiety, and distress may consequently place a significant burden on the children. Although standards for pain management exist, procedure-related pain remains inadequately treated.

OBJECTIVE

To determine the frequency and pain intensity of procedures in children, as well as the associated pharmacologic interventions to manage the pain in a Danish University Hospital.

METHODS

During a 3-month period in 2013, a structured questionnaire was used to prospectively record all procedures performed on children from 1 month to 18 years of age. Directly after the procedure, the pharmacologic pain management interventions and the pain intensity were recorded. Pain intensity was measured by using age-appropriate pain scales. Positioning and prior experience with the procedure were recorded.

RESULTS

Of the 316 children included in the study, 72% experienced none to mild pain, 8.5% experienced moderate to severe pain during the procedures, and 65% had a pharmacologic pain management intervention. Significant higher median VAS score was found during venipuncture in the children sitting on the lap of their parents compared with other positions (P < 0.05), and significant lower median VAS score was found in children who had experienced the procedure before (P < 0.05).

CONCLUSION

Most children experienced mild pain during procedures. The children's positioning during the procedure and prior experience with the procedure seem to influence their experience of procedural pain and it is therefore essential that therapy is tailored for each child and includes a multimodal approach.

Bias due to lack of patient blinding in clinical trials. A systematic review of trials randomizing patients to blind and nonblind sub-studies

BACKGROUND

Blinding patients in clinical trials is a key methodological procedure, but the expected degree of bias due to nonblinded patients on estimated treatment effects is unknown.

METHODS

Systematic review of randomized clinical trials with one sub-study (i.e. experimental vs control) involving blinded patients and another, otherwise identical, sub-study involving nonblinded patients. Within each trial, we compared the difference in effect sizes (i.e. standardized mean differences) between the sub-studies. A difference <0 indicates that nonblinded patients generated a more optimistic effect estimate. We pooled the differences with random-effects inverse variance meta-analysis, and explored reasons for heterogeneity.

RESULTS

Our main analysis included 12 trials (3869 patients). The average difference in effect size for patient-reported outcomes was -0.56 (95% confidence interval -0.71 to -0.41), (I(2)=60%, P=0.004), i.e. nonblinded patients exaggerated the effect size by an average of 0.56 standard deviation, but with considerable variation. Two of the 12 trials also used observer-reported outcomes, showing no indication of exaggerated effects due lack of patient blinding. There was a larger effect size difference in 10 acupuncture trials [-0.63 (-0.77 to -0.49)], than in the two non-acupuncture trials [-0.17 (-0.41 to 0.07)]. Lack of patient blinding also increased attrition and use of co-interventions: ratio of control group attrition risk 1.79 (1.18 to 2.70), and ratio of control group co-intervention risk 1.55 (0.99 to 2.43).

CONCLUSIONS

This study provides empirical evidence of pronounced bias due to lack of patient blinding in complementary/alternative randomized clinical trials with patient-reported outcomes.

An integration of vibration and cold relieves venipuncture pain in a pediatric emergency department

OBJECTIVE

A randomized controlled trial compared a reusable device combining cold and vibration to standard care for pediatric venous access pain relief.

METHODS

Pediatric emergency department patients received either the cold vibration device placed 5 to 10 cm proximally throughout venipuncture or standard care control (primarily vapocoolant spray). Block randomization of patients with or without lidocaine cream already in place ensured equal allocation in both intervention groups. Pain was measured via self- and parent-report using the 0- to 10-point Faces Pain Scale-Revised and with coded videotaped observed behaviors. Venipuncture success, use of distraction, and access times were also assessed.

RESULTS

Eighty-one 4- to 18-year-olds were randomized to the device (n = 41) or standard care (n = 40) (median age, 10.09 years; 95% confidence interval [95% CI], 8.91-10.89). Median patient-reported pain scores with the device were lower than with standard care (-2; 95% CI, -4 to 0), as were parent-assessed pain scores (-2; 95% CI, -4 to -2). Observed distress behaviors were more common with standard care (2; 95% CI, 1-3) than with the device (1; 95% CI, 0-2). Venipuncture success was more likely with the device (odds ratio, 3.05; 95% CI, 1.03-9.02). There were no device refusals.

CONCLUSIONS

The combination of cold and vibration decreased venipuncture pain significantly more than standard care without compromising procedural success. A device incorporating these elements could overcome the common barriers to needle procedure pain control.

Topical anaesthetics for repair of dermal laceration

BACKGROUND

Topical local anaesthetics are recognized as providing effective analgesia for numerous superficial procedures, including repair of dermal lacerations. The need for cocaine in topical anaesthetic formulations has been questioned due to concern about adverse effects, and so novel preparations of cocaine-free anaesthetics have been developed.

OBJECTIVES

To compare the efficacy and safety of infiltrated local anaesthetics with those of topical local anaesthetics for repair of dermal lacerations and to evaluate the efficacy and safety of various single or multi-component topical anaesthetics to identify cocaine-free topically applied local anaesthetics that may provide equivalent analgesia to those containing cocaine.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 10); MEDLINE (1966 to November 2010); EMBASE (1980 to November 2010); CINAHL (1982 to November 2010); and reference lists of articles. We also handsearched selected journals, reviewed abstracts presented at international society meetings, reviewed metaregisters of ongoing trials and contacted manufacturers and researchers in the field.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that evaluated the efficacy and safety of topical anaesthetics for repair of torn skin in adult and paediatric patients.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We collected adverse event information from the trials.

MAIN RESULTS

We included 23 RCTs involving 3128 patients. The small number of trials in each comparison group and the heterogeneity of outcome measures precluded quantitative analysis of data in all but one outcome, pain scores using a visual analogue scale. The majority of trials that compared infiltrated and topical anaesthetics are at high risk of bias, which is likely to affect the interpretation of the results. Several cocaine-free topical anaesthetics were found to provide effective analgesic efficacy. However, the data regarding the efficacy of each topical agent is mostly based upon single comparisons, in trials that have unclear or high risk of bias. Mild, self-limited erythematous skin induration occurred in one case after application of topical tetracaine-adrenaline-cocaine (TAC) where a total of 1042 patients were exposed. No serious complications were reported in any of the patients treated with either cocaine-based or cocaine-free topical anaesthetics.

AUTHORS' CONCLUSIONS

Based on mostly descriptive analysis, topical anaesthetics are possibly an efficacious, non-invasive means of providing analgesia prior to suturing of dermal lacerations. However, additional well designed RCTs with low risk of bias are necessary before definitive conclusions can be made.

The use of nonpharmacological methods for children's postoperative pain relief: Singapore nurses' perspectives

PURPOSE

The purpose of this study was to examine nurses' use of nonpharmacological methods for school-age children's postoperative pain relief.

DESIGN AND METHODS

A survey was conducted in 2008 with a convenience sample of 134 registered nurses from 7 pediatric wards in Singapore.

RESULTS

Nurses who were younger, had less education, lower designation, less working experience, and no children of their own used nonpharmacological methods less frequently.

PRACTICE IMPLICATIONS

Nurses need training and education on nonpharmacological pain relief methods, particularly on methods that have been shown to be effective in prior research but that were less often used by nurses in this study: massage, thermal regulation, imagery, and positive reinforcement.

Use of complementary and alternative medical interventions for the management of procedure-related pain, anxiety, and distress in pediatric oncology: an integrative review

This integrative review aims to identify evidence in four electronic databases (MEDLINE, CINAHL, PsyINFO, and COCHRANE) regarding the effectiveness of complementary and alternative medical interventions, either alone or as an adjunct to pharmacological therapy, in alleviating procedure-related pain, anxiety, and distress in children and adolescents with cancer. A total of 32 articles met inclusion criteria. Results suggest that mind-body interventions, including hypnosis, distraction, and imagery, may be effective, alone or as adjuncts to pharmacological interventions, in managing procedure-related pain, anxiety, and distress in pediatric oncology.

Procedural pain management for children receiving physiotherapy

PURPOSE

This article provides an overview of literature relevant to the prevention and relief of pain and distress during physiotherapy procedures, with guidance for physiotherapists treating children.

SUMMARY OF KEY POINTS

Physiotherapists are generally well trained in assessing and managing pain as a symptom of injury or disease, but there is a need to improve the identification and management of pain produced by physiotherapy procedures such as stretching and splinting. In contrast to physiotherapy, other health care disciplines, such as dentistry, nursing, paediatrics, emergency medicine, and paediatric psychology, produce extensive literature on painful procedures. Procedural pain in children is particularly important because it can lead to later fear and avoidance of necessary medical care.

RECOMMENDATIONS

We emphasize the need for physiotherapists to recognize procedural pain and fear in the course of treatment using verbal, nonverbal, and contextual cues. We present many methods that physiotherapists can use to prevent or relieve procedural pain and fear in paediatric patients and provide an example of a simple, integrated plan for prevention and relief of distress induced by painful procedures.

Placebo interventions for all clinical conditions

BACKGROUND

Placebo interventions are often claimed to substantially improve patient-reported and observer-reported outcomes in many clinical conditions, but most reports on effects of placebos are based on studies that have not randomised patients to placebo or no treatment. Two previous versions of this review from 2001 and 2004 found that placebo interventions in general did not have clinically important effects, but that there were possible beneficial effects on patient-reported outcomes, especially pain. Since then several relevant trials have been published.

OBJECTIVES

Our primary aims were to assess the effect of placebo interventions in general across all clinical conditions, and to investigate the effects of placebo interventions on specific clinical conditions. Our secondary aims were to assess whether the effect of placebo treatments differed for patient-reported and observer-reported outcomes, and to explore other reasons for variations in effect.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library Issue 4, 2007), MEDLINE (1966 to March 2008), EMBASE (1980 to March 2008), PsycINFO (1887 to March 2008) and Biological Abstracts (1986 to March 2008). We contacted experts on placebo research, and read references in the included trials.

SELECTION CRITERIA

We included randomised placebo trials with a no-treatment control group investigating any health problem.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. Trials with binary data were summarised using relative risk (a value of less than 1 indicates a beneficial effect of placebo), and trials with continuous outcomes were summarised using standardised mean difference (a negative value indicates a beneficial effect of placebo).

MAIN RESULTS

Outcome data were available in 202 out of 234 included trials, investigating 60 clinical conditions. We regarded the risk of bias as low in only 16 trials (8%), five of which had binary outcomes.In 44 studies with binary outcomes (6041 patients), there was moderate heterogeneity (P < 0.001; I(2) 45%) but no clear difference in effects between small and large trials (symmetrical funnel plot). The overall pooled effect of placebo was a relative risk of 0.93 (95% confidence interval (CI) 0.88 to 0.99). The pooled relative risk for patient-reported outcomes was 0.93 (95% CI 0.86 to 1.00) and for observer-reported outcomes 0.93 (95% CI 0.85 to 1.02). We found no statistically significant effect of placebo interventions in four clinical conditions that had been investigated in three trials or more: pain, nausea, smoking, and depression, but confidence intervals were wide. The effect on pain varied considerably, even among trials with low risk of bias.In 158 trials with continuous outcomes (10,525 patients), there was moderate heterogeneity (P < 0.001; I(2) 42%), and considerable variation in effects between small and large trials (asymmetrical funnel plot). It is therefore a questionable procedure to pool all the trials, and we did so mainly as a basis for exploring causes for heterogeneity. We found an overall effect of placebo treatments, standardised mean difference (SMD) -0.23 (95% CI -0.28 to -0.17). The SMD for patient-reported outcomes was -0.26 (95% CI -0.32 to -0.19), and for observer-reported outcomes, SMD -0.13 (95% CI -0.24 to -0.02). We found an effect on pain, SMD -0.28 (95% CI -0.36 to -0.19)); nausea, SMD -0.25 (-0.46 to -0.04)), asthma (-0.35 (-0.70 to -0.01)), and phobia (SMD -0.63 (95% CI -1.17 to -0.08)). The effect on pain was very variable, also among trials with low risk of bias. Four similarly-designed acupuncture trials conducted by an overlapping group of authors reported large effects (SMD -0.68 (-0.85 to -0.50)) whereas three other pain trials reported low or no effect (SMD -0.13 (-0.28 to 0.03)). The pooled effect on nausea was small, but consistent. The effects on phobia and asthma were very uncertain due to high risk of bias. There was no statistically significant effect of placebo interventions in the seven other clinical conditions investigated in three trials or more: smoking, dementia, depression, obesity, hypertension, insomnia and anxiety, but confidence intervals were wide.Meta-regression analyses showed that larger effects of placebo interventions were associated with physical placebo interventions (e.g. sham acupuncture), patient-involved outcomes (patient-reported outcomes and observer-reported outcomes involving patient cooperation), small trials, and trials with the explicit purpose of studying placebo. Larger effects of placebo were also found in trials that did not inform patients about the possible placebo intervention.

AUTHORS' CONCLUSIONS

We did not find that placebo interventions have important clinical effects in general. However, in certain settings placebo interventions can influence patient-reported outcomes, especially pain and nausea, though it is difficult to distinguish patient-reported effects of placebo from biased reporting. The effect on pain varied, even among trials with low risk of bias, from negligible to clinically important. Variations in the effect of placebo were partly explained by variations in how trials were conducted and how patients were informed.

Chinese parent's use of nonpharmacological methods in children's postoperative pain relief

Parental participation in paediatric postoperative care is common in China. However, the knowledge is limited on what methods parents use to relieve their children's postoperative pain in hospital. The purpose of this study was to describe what nonpharmacological methods parents use to relieve their children's postoperative pain and factors related to this. A previously validated Scandinavian questionnaire survey was conducted in five provincial hospitals in Fujian, China, in 2004. Parents (n = 206) whose children had undergone operation were asked to complete questionnaires concerning nonpharmacological methods for children's pain relief. The response rate was 88%. Results show that the most commonly used methods by parents were emotional support strategies, helping with daily activities, distraction and imagery. Breathing technique was the method used least frequently. Fathers and parents who were older, more educated, employed and with earlier hospitalization experience with their children used pain alleviation methods more frequently than mothers and parents without these characteristics. Moreover, parents used some methods more frequently with boys, younger children, as well as children admitted for selective operations, with longer duration of hospitalization and with moderate or severe pain. Parents utilized various nonpharmacological methods for children's pain relief, especially those easy to use. This study may serve to focus healthcare providers' efforts on educating parents with respect to various nonpharmacological pain alleviation methods available for postoperative pain. Furthermore, this study provides parents an opportunity to be aware of their role in their children's pain management.

Chinese nurses' use of non-pharmacological methods in children's postoperative pain relief

AIM

This paper reports a study describing Chinese nurses' use of non-pharmacological methods for relieving 6- to 12-year-old children's postoperative pain and factors related to this.

BACKGROUND

Non-pharmacological methods are stated to be effective in relieving children's postoperative pain when used independently or in conjunction with medication. However, little is known about the use of these methods by Chinese nurses.

METHODS

A questionnaire survey was carried out in 2002 with a convenience sample of 187 nurses working at 12 surgical wards in five hospitals of Fujian Province, China. A Likert-type instrument was used, and the average response rate was 98%. Descriptive statistics and content analysis were used to analyse the data.

RESULTS

The most commonly used non-pharmacological methods were giving preparatory information, comforting/reassurance, creating a comfortable environment, distraction, and positioning. Positive reinforcement and helping with daily activities were used less often, and transcutaneous electrical nerve stimulation was not used at all. Many nurse background factors were statistically significantly related to their use of pain alleviation methods. Furthermore, many factors limited their use of non-pharmacological methods, the most common being that there were too few nurses for the work that had to be done, followed by nurses' lack of knowledge about pain management.

CONCLUSIONS

While Chinese nurses used versatile non-pharmacological methods in school-aged children's postoperative pain relief, there remains a need for more education about pain management and for more frequent use of these methods in clinical care.

[Cancer-related bone pain in children]

Pain often discloses the existence of bone tumors in children. The complex physiopathology of pain in malignant bone tumors remains largely unknown and is currently investigated. Cancer-related bone pain is independent from the type and the location of the tumor, and from the number and size of the malignant lesions. It does not necessarily increase with tumor growth. Pain, which is the most common early symptom of bone cancer, may also be present at every step of the disease. It may arise from postsurgery injury, side effects of chemo- or radiotherapy, tumor evolution, secondary sequels of treatments, phantom pain. Tumor eradication using cancer therapeutic strategies is the major etiological treatment option for bone cancer pain. Symptom control requires multidisciplinary medical management with drugs effective against bone lysis, analgesics, drugs with anti-neuropathic activity, as well as non-pharmacological techniques and psycho-social management. This psycho-social management must be tailored to the specific needs of teenagers who are particularly prone to this pathological manifestation. Measures to prevent the occurrence of residual chronic pain must be implemented, whereas children and their family should be clearly informed of the risks and of analgesic options available.

Evaluation of a low-dose lidocaine iontophoresis system for topical anesthesia in adults and children: a randomized, controlled trial

BACKGROUND

Commonly used classes of topical anesthetics require 30 to 60 minutes to provide effective anesthesia. A new low-dose lidocaine iontophoresis system (LDLIS) may provide topical anesthesia in 10 minutes at a lower dose than previous systems, thereby limiting adverse events.

METHODS

This was a prospective, randomized, multicenter, double-blind, placebo-controlled, clinical trial. Adults and children aged 5 to 17 years (inclusive) received a 10-minute ionntophoretic treatment with either lidocaine or a saline placebo before venipuncture or venous cannulation. Intensity of pain associated with venipuncture or venous cannulation was assessed using either a 10-cm Visual Analog Scale (VAS) for adults and children aged 12 to 17 years or the Facial Affective Scale (FAS) for all children enrolled.

RESULTS

Five hundred forty-eight patients (276 adults, 272 children) participated. Mean (SD) VAS pain scores were lower in adults who received iontophoresis with lidocaine rather than with placebo (0.77 [1.49] vs 2.52 [2.30], P < 0.001) and in children aged 12 to 17 years (1.50 [1.87] vs 2.58 [2.26], P = 0.001). FAS pain scores were lower among children who received iontophoresis with lidocaine rather than with placebo (0.36 [0.26] vs 0.51 [0.27], P < 0.001). Similar results were found for children stratified by age group (5-7 years: 0.40 [0.30] vs 0.60 [0.31], P = 0.011; 8-11 years: 0.35 [0.27] vs 0.48 [0.27], P = 0.021; 12-17 years: 0.33 [0.21] vs 0.48 [0.24], P = 0.001). Mean (SD) parental ratings of pain on the FAS for children aged 5 to 11 years were also lower for the lidocaine group (0.45 [0.28] vs 0.55 [0.25], P = 0.018). Adverse events were similar between groups and included skin erythema and edema. One patient in the study experienced a partial-thickness burn.

CONCLUSION

In this study of adults and children, the LDLIS provided effective topical anesthesia for venipuncture and venous cannulation within 10 minutes.

Placebo interventions for all clinical conditions

BACKGROUND

Placebo interventions are often claimed to improve patient-reported and observer-reported outcomes, but this belief is not based on evidence from randomised trials that compare placebo with no treatment.

OBJECTIVES

To assess the effect of placebo interventions.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2002), MEDLINE (1966 to 2002), EMBASE (1980 to 2002), Biological Abstracts (1986 to 2002), and PsycLIT (1887 to 2002). We contacted experts on placebo research, and read references in the included trials.

SELECTION CRITERIA

We included randomised placebo trials with a no-treatment control group investigating any health problem.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. We contacted study authors for additional information.

MAIN RESULTS

Outcome data were available in 156 out of 182 included trials, investigating 46 clinical conditions. We found no statistically significant pooled effect of placebo in 38 studies with binary outcomes (4284 patients), relative risk 0.95 (95% confidence interval (CI) 0.89 to 1.01). The pooled relative risk for patient-reported outcomes was 0.95 (95% CI 0.88 to 1.03) and for observer-reported outcomes 0.91 (95% CI 0.81 to 1.03). There was heterogeneity (P=0.01) but the funnel plot was symmetrical. There was no statistically significant effect of placebo interventions in the four clinical conditions investigated in three trials or more: pain, nausea, smoking, and depression, but confidence intervals were wide. We found an overall effect of placebo treatments in 118 trials with continuous outcomes (7453 patients), standardised mean difference (SMD) -0.24 (95% CI -0.31 to -0.17). The SMD for patient-reported outcomes was -0.30 (95% CI -0.38 to -0.21), whereas no statistically significant effect was found for observer-reported outcomes, SMD -0.10 (95% CI -0.20 to -0.01). There was heterogeneity (P<0.001) and large variability in funnel plot results even for big trials. There was an apparent effect of placebo interventions on pain (SMD -0.25 (95% CI -0.35 to-0.16)), and phobia (SMD -0.63 (95% CI -1.17 to -0.08)); but also a substantial risk of bias. There was no statistically significant effect of placebo interventions in eight other clinical conditions investigated in three trials or more: nausea, smoking, depression, overweight, asthma, hypertension, insomnia and anxiety, but confidence intervals were wide.

REVIEWERS' CONCLUSIONS

There was no evidence that placebo interventions in general have clinically important effects. A possible small effect on continuous patient-reported outcomes, especially pain, could not be clearly distinguished from bias.

Major surgery within the first 3 months of life and subsequent biobehavioral pain responses to immunization at later age: a case comparison study

OBJECTIVES

Pain exposure during early infancy affects the pain perception beyond infancy into childhood. The objective of this study was to examine whether major surgery within the first 3 months of life in combination with preemptive analgesia alters pain responses to immunization at 14 or 45 months and to assess whether these alterations are greater in toddlers with a larger number of negative hospital experiences.

METHODS

Two groups of 50 toddlers each were compared: index group and control group. All index toddlers had participated within the first 3 months of their life in a randomized, clinical trial that evaluated the efficacy of preemptive morphine administration for postoperative analgesia. The controls were matched by type of immunization and community health care pediatrician. Pain reactions were recorded at routine immunization at either 14 (measles-mumps-rubella immunization) or 45 months (diphtheria-tetanus-trivalent polio immunization) of age. Outcome measures were facial reaction, coded by the Maximum Discriminative Facial Movement Coding System; heart rate (HR); and cortisol saliva concentration. Negative hospital experiences included number of operations requiring postoperative morphine administration, cumulative Therapeutic Intervention Scoring System scores, and length of stay in the intensive care unit or total hospitalization days.

RESULTS

No differences were found between the index and control groups in the facial display of pain, anger, or sadness or in physiologic parameters such as HR and cortisol concentrations. Intragroup analyses of the index group showed that after measles-mumps-rubella vaccination, the number of negative hospital experiences correlated positively with the facial responsiveness and negatively with HR responses. No effect was seen after diphtheria-tetanus-trivalent polio immunization.

CONCLUSIONS

Major surgery in combination with preemptive analgesia within the first months of life does not alter pain response to subsequent pain exposure in childhood. Greater exposure to early hospitalization influences the pain responses after prolonged time. These responses, however, diminish after a prolonged period of nonexposure.

Placebo treatment versus no treatment

BACKGROUND

Placebo interventions are often believed to improve patient reported and observer reported outcomes, but this belief is not based on evidence from randomised trials that compare placebo with no treatment.

OBJECTIVES

To assess the effect of placebo interventions.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register (The Cochrane Library, issue 3, 1998), MEDLINE (Jan 1966 to Dec 1998), EMBASE (Jan 1980 to Dec 1998), Biological Abstracts (Jan 1986 to Dec 1998), PsycLIT (Jan 1887 to Dec 1998). Experts on placebo research were contacted and references in the included trials were read.

SELECTION CRITERIA

Randomised placebo trials with a no-treatment control group investigating any health problem were included.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information.

MAIN RESULTS

Outcome data were available in 114 out of 130 included trials, investigating 40 clinical conditions. Outcomes were binary in 32 trials (3795 patients) and continuous in 82 (4730 patients). We found no statistically significant pooled effect of placebo in studies with binary outcomes, relative risk 0.95 (95 per cent confidence interval 0.88 to 1.02). The pooled relative risk for subjective (patient reported) outcomes was 0.95 (0.86 to 1.05) and for objective (observer reported) outcomes 0.91 (0.80 to 1.04). There was statistically significant heterogeneity (P < 0.03), but no evidence of sample size bias (P = 0.56). We found an overall positive effect of placebo treatments in trials with continuous outcomes, standardised mean difference -0.28 (95 per cent confidence interval -0.38 to -0.19). The standardised mean difference for subjective outcomes was -0.36 (-0.47 to -0.25), whereas no statistically significant effect was found for objective outcomes, standardised mean difference -0.12 (-0.27 to 0.03). There was statistically significant heterogeneity (P < 0.001), and evidence of sample size bias (P = 0.05). There was no statistically significant effect of placebo interventions in eight out of nine clinical conditions investigated in three trials or more (nausea, relapse in prevention of smoking and depression, overweight, asthma, hypertension, insomnia and anxiety), but confidence intervals were wide. There was a modest apparent analgesic effect of placebo interventions, standardised mean difference -0.27 (-0.40 to -0.15), but also a substantial risk of bias.

REVIEWER'S CONCLUSIONS

There was no evidence that placebo interventions in general have clinically important effects. A possible moderate effect on subjective continuous outcomes, especially pain, could not be clearly distinguished from bias.

A comparison of placebo effects in clinical analgesic trials versus studies of placebo analgesia

A previous meta-analysis of clinical analgesic trial studies showed generally low magnitudes of placebo analgesia (N. Engl. J. Med. 344 (2001) 1594). However, as studies included in their analysis used only placebo as a control condition, we conducted two meta-analyses, one in which 23 studies used only placebo as a control condition, and one in which 14 studies investigated placebo analgesic mechanisms. Magnitudes of placebo analgesic effects were much higher in the latter (mean effect size=0.95) as compared to the former (mean effect size=0.15) and were significantly different (P=0.003). This difference as well as differences in effect sizes within studies of placebo mechanisms may be parsimoniously explained by differences in expected pain levels produced by placebo suggestions and by conditioning. Furthermore, some of the studies of placebo analgesic mechanisms indicate that the magnitude of placebo analgesia is higher when the placebo analgesic effect is induced via suggestion combined with conditioning than via suggestion alone or conditioning alone. Based on these findings, we suggest that placebo analgesic effects are most optimally conceptualized in terms of perception of the placebo agent, and therefore a new definition of placebo response is proposed.

Parents' roles in using non-pharmacological methods in their child's postoperative pain alleviation

Increasingly nowadays, parents participate more fully in the care of their hospitalized children. The purpose of this study was to describe parents' utilization of selected non-pharmacological methods in relieving their hospitalized child's (aged 8-12 years) postoperative pain, and factors related to this function. Data were collected by a questionnaire survey completed by parents (n=192) with a child hospitalized on a paediatric surgical ward in the five university hospitals of Finland. The response rate was 90%. Results indicated that non-pharmacological methods, such as emotional support and helping with daily activities, were well utilized whereas cognitive-behavioural and physical methods were less frequently used strategies. Certain background factors specific to the parents and their hospitalized children were significantly related to the non-pharmacological methods used by the parents. The hospitalized child's gender, the time of the surgical procedure, and the parents' assessments of their child's pain intensity, were especially significantly related to many of these strategies. The findings of this study could be used in clinical practice to improve guidance provided to parents regarding interventions for children's pain relief.

New concepts in acute and extended postoperative pain management in children

Increased knowledge of the pathophysiology of pain in children and an improved understanding of the pharmacology and pharmacodynamics of multiple agents have provided the clinician with a wide variety of tools to treat postoperative pain in children. The interest in a multimodal approach is kindled by the realization that the combination of a number of therapies can enhance analgesia with fewer untoward side effects. The expertise of other health care professionals should be tapped to open new avenues of treatment. Many therapies still require critical evidence-based evaluations to assess how well they work in larger patient populations. Dedication to research, compassionate patient care, and a willingness to teach the next generation of clinicians will bring us closer to the goal of safe and pain-free surgery.

Nurses' perceptions of parental guidance in pediatric surgical pain relief

The aim of this study was to describe nurses' perceptions of how they guide parents in the relief of their child's (aged 8-12 years) surgical pain in the hospital, and factors related to this function. The convenience sample consisted of 162 nurses working on the pediatric surgical wards of five university hospitals in Finland. The data was collected with a Likert-type instrument designed for this purpose. The results of this study indicated that nurses felt parents were mostly well informed about their child's surgical procedure, including both cognitive and sensory information, and about the non-pharmacological methods employable for relieving their child's pain. However, some deficiency was identified in the preparatory information, as well as in the cognitive-behavioral and physical methods. Factors related to the nurses' background, such as age, education, work experience and the nurse's own experiences with prior hospitalizations of their children, appeared to have some effects on their perceptions regarding parental guidance.

Is transcutaneous electrical nerve stimulation an effective analgesia during colonoscopy?

OBJECTIVES

To evaluate the efficacy of transcutaneous electrical nerve stimulation (TENS) as analgesia during colonoscopy.

DESIGN

In a randomised controlled trial, patients undergoing diagnostic colonoscopy were assigned to one of three groups: standard medication only (midazolam); active TENS plus standard medication; or non-functioning TENS and standard medication. Efficacy of TENS was determined using numerical rating scores for pain and the post-procedural evaluation questionnaire.

SETTING

Patients undergoing diagnostic colonoscopy in a teaching hospital.

MAIN OUTCOME

There was no statistically significant differences between the three groups. However in the active TENS group there was a greater variation in "physical discomfort" and "psychological distress", suggesting TENS may be effective in subgroup of patients.

Is the placebo powerless? An analysis of clinical trials comparing placebo with no treatment

BACKGROUND

Placebo treatments have been reported to help patients with many diseases, but the quality of the evidence supporting this finding has not been rigorously evaluated.

METHODS

We conducted a systematic review of clinical trials in which patients were randomly assigned to either placebo or no treatment. A placebo could be pharmacologic (e.g., a tablet), physical (e.g., a manipulation), or psychological (e.g., a conversation).

RESULTS

We identified 130 trials that met our inclusion criteria. After the exclusion of 16 trials without relevant data on outcomes, there were 32 with binary outcomes (involving 3795 patients, with a median of 51 patients per trial) and 82 with continuous outcomes (involving 4730 patients, with a median of 27 patients per trial). As compared with no treatment, placebo had no significant effect on binary outcomes (pooled relative risk of an unwanted outcome with placebo, 0.95; 95 percent confidence interval, 0.88 to 1.02), regardless of whether these outcomes were subjective or objective. For the trials with continuous outcomes, placebo had a beneficial effect (pooled standardized mean difference in the value for an unwanted outcome between the placebo and untreated groups, -0.28; 95 percent confidence interval, -0.38 to -0.19), but the effect decreased with increasing sample size, indicating a possible bias related to the effects of small trials. The pooled standardized mean difference was significant for the trials with subjective outcomes (-0.36; 95 percent confidence interval, -0.47 to -0.25) but not for those with objective outcomes. In 27 trials involving the treatment of pain, placebo had a beneficial effect (-0.27; 95 percent confidence interval, -0.40 to -0.15). This corresponded to a reduction in the intensity of pain of 6.5 mm on a 100-mm visual-analogue scale.

CONCLUSIONS

We found little evidence in general that placebos had powerful clinical effects. Although placebos had no significant effects on objective or binary outcomes, they had possible small benefits in studies with continuous subjective outcomes and for the treatment of pain. Outside the setting of clinical trials, there is no justification for the use of placebos.

Nonpharmacological methods in relieving children's postoperative pain: a survey on hospital nurses in Finland

AIM OF THE STUDY

The aim of this study was to describe nurses' use of selected nonpharmacological methods in relieving 8-12-year-old children's postoperative pain in hospital.

METHODS

The convenience sample consisted of 162 nurses working on the paediatric surgical wards in the five Finnish university hospitals. An extensive questionnaire, including a five-point Likert-scale, on the nurses' use of selected nonpharmacological methods and demographic data was used as a method of data collection. The response rate was 99%. Descriptive statistics as well as nonparametric Kruskall-Wallis ANOVA and the chi-squared test were used as statistical methods.

RESULTS

The study indicates that emotional support, helping with daily activities and creating a comfortable environment were reported to be used routinely, whereas the cognitive-behavioural and physical methods included some less frequently used and less well known strategies. The results also show that attributes, such as the nurses' age, education, and work experience, the number of children the nurses had, the nurses' experiences of hospitalization of their children as well as the hospital and the place of work, were significantly related to the use of some nonpharmacological methods.

CONCLUSIONS

The nurses used versatile nonpharmacological methods in children's postoperative pain relief, although some defects could be observed. More research is needed on the methods used by nurses to relieve children's pain in different patient groups and the factors which hinder or promote nurses' use of pain alleviation methods in the clinical practice.

Painful pricks and prickle pains: is there a relation between children's ratings of venipuncture pain and parental assessments of usual reaction to other pains?

OBJECTIVE

The objective of this study was to examine whether parental assessment of a child's usual behavioral reaction to common painful events predicts the child's ratings of needle pain intensity from routine venipuncture.

DESIGN

Children aged 3 to 12 years (n = 88) used the Faces Pain Scale to rate how much venipuncture hurt and also indicated whether the pain was more, less, or the same as expected. The child's parent (mother) used the same scale to predict how much the needle would hurt the child as well as to rate the child's pain as observed at the time of venipuncture. Parents also estimated their child's usual reaction to six common painful events. An independent observer used a behavioral checklist to rate the child's pain response at the time of venipuncture as well as to assign a global pain rating on the Faces Pain Scale.

OUTCOME MEASURES

The Faces Pain Scale and a behavioral checklist (scoring facial, vocal, motor, and verbal reactions) were used in this study.

RESULTS AND CONCLUSIONS

Those children who reported venipuncture as hurting more than expected also gave the highest mean needle pain ratings and tended to have their pain underpredicted by their parents before venipuncture. For these children, parental estimates of reactions to other painful events proved to be a useful predictor of self-reported needle pain. Parent and child ratings of pain agreed more closely for those parents who indicated having relied on what their child "did" rather than "said." Additionally, and consistent with previous studies, independent observation of children's facial responses was the most useful indicator of needle pain severity. Preparation of children for venipuncture may be enhanced by asking a parent beforehand how the child usually responds to everyday pain. Specifically, reaction to other sharp time-limited pains (e.g., finger pinch, stepping on a prickle) may provide a useful guide to identifying which children will report experiencing greater pain than expected from venipuncture.

Use of transcutaneous electrical nerve stimulation in a young child with pain from open perineal lesions

Transcutaneous electrical nerve stimulation (TENS) has been shown to be an effective treatment modality in adults experiencing pain associated with a variety of conditions. Therapeutic measures that are effective with adults can often be used with children. However, the benefit of TENS for children has not been well established since few research or clinical data have been published in the literature. This case report of a 4-year-old female with open perineal skin lesions who received TENS as an adjuvant therapy for painful dressing changes illustrates that TENS can be an effective treatment in children. In addition to the pain reduction seen in our patient, TENS therapy also had an opioid-sparing effect.

Pain assessment in children with cognitive impairment. An exploration of self-report skills

Prior to surgery, 47 children (ages 8 to 17) with borderline to profound cognitive impairment were administered tasks to evaluate their understanding of the concepts of magnitude and ordinal position and their abilities to use a 0 to 5 numerical scale to rate pain levels in schematic faces. Of the 111 children (ages 4 to 14) without cognitive impairment, were administered the same tasks. Nurses conducting preoperative evaluations predicted whether children would understand the numerical scale. Fifty percent (n = 3) of children with borderline and 35% (n = 7) of children with mild cognitive impairment (and all children 8 years and older nonimpaired) correctly used the scale. Half of the children with cognitive impairment demonstrated skills (magnitude and ordinal position) that may allow them to use simpler pain rating methods. Nurses overestimated the abilities of cognitively impaired children (and younger children without cognitive impairment) to use the rating scale.

A partial double-blind, placebo-controlled study of electronic dental anaesthesia in children

This study was carried out to determine the effectiveness of electronic dental anaesthesia (EDA) in restorative dental treatment for children. Thirty children were allocated at random to three groups to receive either EDA, a placebo-EDA or anaesthesia by oral injection. One dentist, having introduced and administered these procedures, completed an occlusal restoration in a maxillary permanent first molar in each child. The results showed that the children changed the EDA controls in accordance with pain assessed by their reports and by their facial signs counted in video records by an observer. Both the children and the observer were 'blind' to the difference between EDA and placebo-EDA. There were no statistical differences in: (1) the number of additional oral injections required in all groups to complete treatment, (2) the depth of cavity prepared, (3) the frequency of disruptive activities, (4) the dentist's management behaviour, (5) the dentist's rating of the children's disruptiveness, (6) pain estimated by the children's reports and by facial signs. Treatment time was shortest in the oral injection group, but had no significant correlation with any measure of pain, disruptive behaviour or depth of cavity. It was concluded that EDA was no less effective than anaesthesia administered by injection but, being no more effective than a placebo-EDA, probably worked by distracting the patients.

A new analogue scale for assessing children's pain: an initial validation study

A new instrument was designed to provide a practical clinical measure for assessing children's pain intensity and pain affect. The pocket size measure includes a Coloured Analogue Scale (CAS) to assess intensity and a facial affective scale to assess the aversive component of pain. Both scales have numerical ratings on the back, so that the person administering it can quickly note the numbers that represent a child's pain. This study was conducted to determine the validity of the new instrument by evaluating the psychophysical properties of the intensity scale and by evaluating the discriminant validity of the intensity and affective scales. Since visual analogue scales (VAS) are valid and reliable measures for assessing children's pain, children's ability to use the new analog scale was compared with their performance on a VAS. Children's ability to rate pain affect using an affective scale, in which the 9 faces on a Facial Affective Scale (FAS) are presented in an ordered sequence from least to most distressed, was compared to their performance on the original FAS, in which the same faces were presented in a random order. Using a parallel groups design, 104 children (5-16 years; 60 female, 44 male; 51 healthy and 53 with recurrent headaches) were randomized into two groups: CAS or VAS. Children used the assigned scale to complete a calibration task, in which they rated the sizes of 7 circles varying in area (491, 804, 1385, 2923, 3848, 5675 and 7854 mm2). The psychophysical function relating perceived circle size to actual physical size was determined for the CAS and VAS. Children's CAS and VAS responses on the calibration task yielded similar mathematical relationships: psi cas = 0.035I0.87, psi vas = 0.027I0.89, where psi = perceived magnitude and I = stimulus intensity. The R2 values were 0.921 and 0.922 for the CAS and VAS groups, respectively. Analyses of covariance revealed no significant differences in the characteristics of these relationships, i.e., R2, slope, or y intercept, by scale type. Children used the same scale to complete the Children's Pain Inventory (CPI), in which they rated the intensity and affect of 16 painful events (varying in nature and extent of tissue damage). Children's CAS and VAS responses on the CPI were similar. Analyses of covariance indicated that there were no differences in either intensity or affective ratings by scale type. However, the mean number of painful events experienced by children increased significantly with age (P = 0.0001). Intensity ratings decreased significantly with age (P = 0.002), but affective ratings did not vary with age. The new instrument has equivalent psychometric properties to a 165 mm VAS. However, the CAS was rated as easier to administer and score than the VAS, so it may be more practical for routine clinical use. Since the CAS has fulfilled the first two criteria for a pain measure (psychophysical properties and discriminant validity), it is ethical to proceed with the formal definitive test for construct validity, in which children from various clinical populations use the CAS scale to assess their own pain.

Transcutaneous electric nerve stimulation (TENS) during distension shoulder arthrography: a controlled trial

Transcutaneous electric nerve stimulation (TENS) is a safe and simple form of analgesia but is little used as an adjunct to local anaesthesia during routine procedures. This trial investigates the use of TENS in the radiology department using distension shoulder arthrography for 'frozen shoulder', a moderately painful procedure, as a model. Sixty patients with a clinical diagnosis of 'frozen shoulder' were randomised to receive high-intensity TENS, low-intensity TENS or to act as controls. A standard procedure was then performed. Following the procedure patients completed a visual analogue pain scale. Mean recorded pain levels were lower in the TENS groups with a 50% difference between the high-intensity group and a 38% difference between the low-intensity group as compared to control (difference statistically significant P < 0.01 and P < 0.05, respectively). TENS was well tolerated by patients. The 50% reduction in mean pain levels supports the use of TENS for routine painful procedures.

Determinants of success and failure of EMLA

Although EMLA is known to be an effective topical anesthetic, its rate of success is unknown. Indeed, researchers have suggested that EMLA may fail with young and apprehensive children. Therefore, the objectives of this study were to assess EMLA's rate of success as well as factors which predict success. A double-blind, placebo-controlled design was utilized. The sample included 258 children and adolescents aged 5-18 years who were having venipuncture or intravenous (i.v.) cannulation. After having their anxiety assessed, subjects were randomly assigned to have EMLA or placebo applied over the procedure site for 90 min. The visual analogue scale was used to assess pain caused by removal of the semi-permeable dressing and by the procedure. Other information that was collected included: duration of drug application, interval between drug removal and procedure, skin changes at bandage and drug sites and rated difficulty of the procedure. EMLA was successful 84% of the time for venipuncture and 51% of the time for i.v. cannulation. Factors which predicted success of EMLA included type of procedure, duration of drug application and anxiety. EMLA was less successful for i.v. cannulation compared to venipuncture even with duration of drug application controlled. Those who had a poor outcome were more anxious than those with a good outcome. Age of child was not a factor. Strategies for improving efficient use of EMLA were recommended.

The use of a topical refrigerant anesthetic to reduce injection pain in children

Early childhood experiences with painful injections may lead to anxiety and fear. These reactions need not develop if steps are taken to reduce the pain associated with injections. The purpose of this study was to assess the efficacy of a refrigerant topical anesthetic in reducing injection pain in preschool children experiencing routine diphtheria-pertussis-tetanus (DPT) immunizations. This double-blind placebo-controlled study was conducted in community health clinics in conjunction with ongoing immunization programs. Ninety subjects, aged 4-5.5 years, were randomly assigned to one of three groups: (a) refrigerant topical anesthetic; (b) placebo topical spray; and (c) no-spray control. Pain was measured subjectively using a four-point visual analogue scale. Both the refrigerant topical anesthetic spray and the placebo spray significantly reduced injection pain. Age was found to be an important factor influencing pain response in this study. Parental anxiety was not a significant factor influencing pain response. In addition, parents were not good at predicting their child's pain. The results of the study support the use of an intervention, such as refrigerant topical anesthetic, as a practical, simple, and effective treatment strategy for reduction of short-term painful procedures like injections.