Psychological control of acute pain in medical settings

Effect of aligners on patients' oral health-related quality of life and anxiety: a prospective pilot study

BACKGROUND

This prospective study explored the impact of aligners on the oral health-related quality of life and anxiety of patients during the first month of orthodontic treatment and the first month of the retention phase.

METHODS

A total of 23 male and female patients (median age 25 y) treated with clear aligners were included. The OHRQoL questionnaire was used at certain time points during treatment (T1: placement of the first aligner; T2: after one day of use; T3: after seven days; T4: after one month; and T5: after one month in the retention phase). The State-Trait Anxiety Inventory (STAI) was also self-administered to assess state and trait anxiety (Y1 and Y2 subscales, respectively) at the T1, T4 and T5 time points. A population average generalized estimating equations logistic regression model was fit to assess the effect of time on the responses, and the Wald test was used to examine the overall effect of time.

RESULTS

Overall time was a significant predictor for most of the questions. However, time was marginally significant for the OHRQoL questions evaluating oral symptoms such as bad taste/smell, sores, and food accumulation. Tooth discolouration did not differ between time points. The general activity disturbance was significantly lower in the retention phase. Higher depression and anxiety scores were reported at the initial appointment and decreased thereafter.

CONCLUSIONS

CAT has a negative impact on quality of life and psychological status during the initial days of treatment. These impairments ameliorate at later treatment stages.

Intraindividual change in pain tolerance and negative affect over 20 years: findings from the MIDUS study

Pain tolerance, defined as the ability to withstand physical pain states, is a clinically important psychobiological process associated with several deleterious outcomes, including increased pain experience, mental health problems, physical health problems, and substance use. A significant body of experimental work indicates that negative affect is associated with pain tolerance, such that increased negative affect is associated with decreased pain tolerance. Although research has documented the associations between pain tolerance and negative affect, little work has examined these associations over time, and how change in pain tolerance is related to changes in negative affect. Therefore, the current study examined the relationship between intraindividual change in self-reported pain tolerance and intraindividual change in negative affect over 20 years in a large, longitudinal, observation-based national sample of adults (n = 4,665, Mage = 46.78, SD =12.50, 53.8% female). Results from parallel process latent growth curve models indicated that slope of pain tolerance and negative affect were associated with each other over time (r = .272, 95% CI [.08, .46] p = .006). Cohen's d effect size estimates provide initial, correlational evidence that changes in pain tolerance may precede changes in negative affect. Given the relevance of pain tolerance to deleterious health outcomes, better understanding how individual difference factors, including negative affect, influence pain tolerance over time, are clinically important to reduce disease-related burden.

A comparison of interactive immersive virtual reality and still nature pictures as distraction-based analgesia in burn wound care

PURPOSE

Non-pharmacologic adjuncts to opioid analgesics for burn wound debridement enhance safety and cost effectiveness in care. The current study explored the feasibility of using a custom portable water-friendly immersive VR hardware during burn debridement in adults, and tested whether interactive VR would reduce pain more effectively than nature stimuli viewed in the same VR goggles.

METHODS

Forty-eight patients with severe burn injuries (44 adults and 4 children) had their burn injuries debrided and dressed in a wet wound care environment on Study Day 1, and 13 also participated in Study Day 2.

INTERVENTION

The study used a within-subject design to test two hypotheses (one hypothesis per study day) with the condition order randomized. On Study Day 1, each individual (n = 44 participants) spent 5 min of wound care in an interactive immersive VR environment designed for burn care, and 5 min looking at still nature photos and sounds of nature in the same VR goggles. On Study Day 2 (n = 12 adult participants and one adolescent from Day 1), each participant spent 5 min of burn wound care with no distraction and 5 min of wound care in VR, using a new water-friendly VR system. On both days, during a post-wound care assessment, participants rated and compared the pain they had experienced in each condition. OUTCOME MEASURES ON STUDY DAYS 1 AND 2: Worst pain during burn wound care was the primary dependent variable. Secondary measures were ratings of time spent thinking about pain during wound care, pain unpleasantness, and positive affect during wound care.

RESULTS

On Study Day 1, no significant differences in worst pain ratings during wound care were found between the computer-generated world (Mean = 71.06, SD = 26.86) vs. Nature pictures conditions (Mean = 68.19, SD = 29.26; t < 1, NS). On secondary measures, positive affect (fun) was higher, and realism was lower during computer-generated VR. No significant differences in pain unpleasantness or "presence in VR" between the two conditions were found, however. VR VS. NO VR. (STUDY DAY 2): Participants reported significantly less worst pain when distracted with adjunctive computer generated VR than during standard wound care without distraction (Mean = 54.23, SD = 26.13 vs 63.85, SD = 31.50, t(11) = 1.91, p < .05, SD = 17.38). In addition, on Study Day 2, "time spent thinking about pain during wound care" was significantly less during the VR condition, and positive affect was significantly greater during VR, compared to the No VR condition.

CONCLUSION

The current study is innovative in that it is the first to show the feasibility of using a custom portable water-friendly immersive VR hardware during burn debridement in adults. However, contrary to predictions, interactive VR did not reduce pain more effectively than nature stimuli viewed in the same VR goggles.

Mindfulness-Based Stress Reduction in Advanced Nursing Practice: A Nonpharmacologic Approach to Health Promotion, Chronic Disease Management, and Symptom Control

The aim of this article is to discuss how advanced practice nurses (APNs) can incorporate mindfulness-based stress reduction (MBSR) as a nonpharmacologic clinical tool in their practice. Over the last 30 years, patients and providers have increasingly used complementary and holistic therapies for the nonpharmacologic management of acute and chronic diseases. Mindfulness-based interventions, specifically MBSR, have been tested and applied within a variety of patient populations. There is strong evidence to support that the use of MBSR can improve a range of biological and psychological outcomes in a variety of medical illnesses, including acute and chronic pain, hypertension, and disease prevention. This article will review the many ways APNs can incorporate MBSR approaches for health promotion and disease/symptom management into their practice. We conclude with a discussion of how nurses can obtain training and certification in MBSR. Given the significant and growing literature supporting the use of MBSR in the prevention and treatment of chronic disease, increased attention on how APNs can incorporate MBSR into clinical practice is necessary.

Effect of nicotine dependence on opioid requirements of patients after thoracic surgery

BACKGROUND

This retrospective study investigated the effect of nicotine dependence on required postoperative opioid administration in patients undergoing thoracic surgery.

METHODS

The subjects consisted of 215 male patients (112 nonsmokers, 103 smokers) who underwent thoracic surgery and received postoperative patient-controlled intravenous analgesia. Evaluations of nicotine dependence were based on results of Fagerstrom Test of Nicotine Dependence (FTND) questionnaires. Smokers were categorized as low-nicotine dependent (LD) (n = 58) or highly-nicotine dependent (HD, n = 45) with FTND scores < 6 or ≥ 6, respectively. Pain intensity was assessed every 2 h after surgery, using the numerical rating scale (NRS). The cumulative amount of self-administered sufentanil at 24 and 48 h after surgery was recorded.

RESULTS

There were no significant differences in baseline clinical characteristics among the nonsmoker (NS), LD, and HD groups. The NRS scores and total amount of self-administered sufentanil were significantly higher in the HD and LD groups compared with the NS group, and were significantly higher in the HD group than in the LD group. The FTND scores positively correlated with the cumulative quantity of sufentanil. Postoperative complications such as nausea and vomiting, sedation, and respiratory depression did not significantly differ among the groups.

CONCLUSIONS

Smokers had more severe postoperative pain and required a higher quantity of postoperative opioid than nonsmokers. With increasing nicotine dependence, postoperative pain severity and postoperative opioid requirement increased.

Understanding the relationship between smoking and pain

This review provides an overview of evidence regarding several key mechanisms pertinent to understanding the co-occurrence of smoking dependence and pain, both potentially costly conditions, and highlights treatment implications and future research directions. We describe each of pain and smoking dependence and introduce a revised integrative reciprocal model that explains their co-occurrence. We then provide a selective review of evidence pertinent to direct and indirect pathways between variables postulated in the model. We also provide general recommendations for improving assessment and treatment of smokers with clinically significant pain. We conclude with a targeted agenda for future investigation of the co-occurrence of smoking and pain. Empirical efforts directed at testing postulates of the proposed integrative model may yield a better understanding of the nature of the relationship between these prevalent and costly health conditions as well as evidence-based preventive and treatment strategies for people who experience nicotine dependence and pain-related disability.

The effects of lavender aromatherapy on pain following needle insertion into a fistula in hemodialysis patients

OBJECTIVE

This study sought to determine the effects of lavender aromatherapy on pain following needle insertion into a fistula in patients undergoing hemodialysis.

METHOD

This is a randomized controlled clinical trial in which 92 patients undergoing hemodialysis with arteriovenous fistulas were randomly divided into two groups. The experimental-group patients inhaled lavender essence with a concentration of 10% for 5 min during 3 hemodialysis sessions, while the control-group patients received aromatherapy free of lavender essence.

RESULTS

The mean VAS pain intensity score in the experimental and control groups before the intervention was 3.78 ± 0.24 and 4.16 ± 0.32, respectively (p = 0.35). The mean VAS pain intensity score in the experimental and control groups after three aromatherapy sessions was 2.36 ± 0.25 and 3.43 ± 0.31, respectively (p = 0.009).

CONCLUSION

Lavender aromatherapy may be an effective technique to reduce pain following needle insertion into a fistula in hemodialysis patients.

Do psychological and physiological stressors alter the acute pain response to castration and tail docking in lambs?

OBJECTIVE

To investigate whether events that may be stressful to young lambs, including simulated infection or social isolation, modulate pain experienced by lambs following castration and tail docking (C/D).

STUDY DESIGN

Randomised, controlled, prospective study.

ANIMALS

Fifty male lambs born to 46 second-parity Mule ewes.

METHODS

Lambs were allocated randomly to one of four groups, experiencing either a potential stressor or handling on day 2 after birth, followed by C/D or handling only on day 3. Quantitative sensory testing (QST) data [mechanical nociceptive thresholds (MNT), Semmes Weinstein filaments (SW), response to cold] and serum cortisol concentration were measured at time points after application of treatments to lambs on days 2 and 3 after birth. The treatment groups were LPS, injection of bacterial lipopolysaccharide IV on day 2, C/D on day 3; ISOL, isolation from the dam for 10 minutes on day 2, C/D on day 3; CAST, handling only on day 2, C/D on day 3; CONT, handled only on days 2 and 3.

RESULTS

Castration and tail docking caused transient hypoalgesia as measured by MNT and SW. Simulated infection and isolation caused hyperalgesia 3 hours after application, indicated by a reduction in MNT, however they did not alter the pain response to C/D compared to lambs in the CAST group. Injection of LPS and C/D caused increased serum cortisol concentration. The magnitude of the cortisol response to C/D was not altered by prior exposure to either LPS or isolation.

CONCLUSIONS AND CLINICAL RELEVANCE

LPS and isolation did not modulate the response to C/D but did cause hyperalgesia. This highlights the importance of flock health management and husbandry techniques to reduce the incidence of either systemic infection or psychological stressors in young lambs.

Stress and tension-type headache mechanisms

Stress is widely demonstrated as a contributing factor in tension-type headache (TTH). The mechanisms underlying this remain unclear at present. Recent research indicates the importance of central pain processes in tension-type headache (TTH) pathophysiology. Concurrently, research with animals and healthy humans has begun to elucidate the relationship between stress and pain processing in the central nervous system, including central pain processes putatively dysfunctional in TTH. Combined, these two fields of research present new insights and hypotheses into possible mechanisms by which stress may contribute to TTH. To date, however, there has been no comprehensive review of this literature. The present paper provides such a review, which may be valuable in facilitating a broader understanding of the central mechanisms by which stress may contribute to TTH.

Implementation of the guidelines for the management of patients with chest pain through a critical pathway approach improves length of stay and patient satisfaction but not anxiety

OBJECTIVE

To compare length of stay (LOS), clinical and psychological outcomes, and patient satisfaction before and after implementation of a chest pain critical pathway.

DESIGN

A pre- and post-test quasi-experimental design.

SETTING

The Chest Pain Unit (CPU) of the Antwerp University Hospital.

PATIENTS

Patients admitted to the CPU with symptoms suggestive of an acute coronary syndrome older than 18 years.

INTERVENTIONS

Implementation of a critical pathway focusing on implementation of the guidelines for the management of chest pain.

MAIN OUTCOME MEASURES

Patient satisfaction, length of stay and anxiety were evaluated.

RESULTS

The median LOS of intervention subjects was almost 4 hours shorter than that of control subjects (without, P = 0.04, or with propensity correction, P = 0.019). The overall patient satisfaction with CPU care of the intervention group was significantly higher than that of the control group (without, P < 0.001, or with propensity correction, P < 0.001). Differences in anxiety and occurrences of major adverse cardiac events between the groups were not statistically significant.

CONCLUSION

A critical pathway can effectively and safely reduce LOS, increase patient satisfaction, and improve adherence to the guidelines for managing patients with chest pain. Anxiety is not statistically significantly reduced by this intervention.

Nociception- and anxiety-like behavior in rats submitted to different periods of restraint stress

The aim of this study was to evaluate the effect of acute, sub-chronic and chronic stress on nociception induced by formalin injection in rats' temporomandibular joint (TMJ). It was evaluated the relation between blood levels of adrenocorticotropin, corticosterone, the levels of anxiety and nociceptive responses recorded after different stress protocols. Animals were initially submitted to acute restraint stress (15; 30 min and 1 h), or exposed to sub-chronic (3 days-1 h/day) or chronic stress (40 days-1 h/day). Then, animals were (1) killed immediately to collect blood for hormonal determinations; or (2) submitted to the elevated plus-maze to evaluate anxiety; or (3) submitted to the TMJ formalin test to evaluate nociception. It was also evaluated the role of serotoninergic and opioid systems in nociceptive changes induced by stress. For this, the serotonin-selective reuptake inhibitor (fluoxetine 10 mg/kg) and the opioid agonist (morphine 1-5 mg/kg) were administered before the nociception test. All stress protocols significantly raised the levels of ACTH or corticosterone, as well as the anxiety behavior. In relation to nociception, the chronic stressed animals showed an increase in nociceptive responses (hyperalgesia). In this group, there was a reduction in the morphine analgesic effects, suggesting dysfunction in the endogenous opioid system. Fluoxetine had an analgesic effect in both stressed and control groups, although this effect was more evident in the stressed group. It was concluded that stress-induced hyperalgesia may result from changes in the serotoninergic and opioid systems, which can explain, at least in part, the important link between stress and orofacial pain.

The meaning of pain influences its experienced intensity

This experiment tested whether meaning influences the experience of pain. Thirty-one healthy students participated in a study on evaluations of various stimuli placed against the neck. By suggesting that a very cold metal bar was either hot or cold, the potentially tissue-damaging property of the stimulus was experimentally manipulated. A manipulation check revealed that participants believed the experimenter's information, as they rated the bar as more hot in the corresponding condition than in the other condition. Confirming the hypothesis that tissue-damaging meaning influences the experience of pain, participants who were told that the bar was hot rated it as more painful than participants who were told that it was cold. Damage interpretations mediated the effect of information on pain intensity scores, which supported the theory that tissue-damage is a crucial aspect of meaning to influence the subjective intensity of pain.

Negative affect and sensitization to pain

Pain usually has a strong negative affective component, which is believed to modulate pain perception. After reviewing theories on the link between negative affect and pain, mechanisms are discussed by which negative affect may either increase or inhibit pain. Possible pain-inhibiting mechanisms are endogenous opioid release, blood pressure reactivity, and distraction of attention; possible pain-increasing mechanisms are autonomic and muscular reactivity, misattribution of arousal, hypervigilance to pain, worrying, and avoidance behavior. It is emphasized that each of these mechanisms can be very adaptive in acute pain situations to prevent injury and promote recovery. In chronic pain, however, ongoing physiological arousal and hypervigilance to pain, induced or magnified by negative affect, may cause sensitization to pain. Furthermore, worrying about pain and avoidance of pain-inducing activities may increase negative affect, ypervigilance, and functional disability. It is argued that, in the long run, pain-related negative affect has sensitizing and disabling effects.

Pain and emotion: effects of affective picture modulation

OBJECTIVE AND METHODS

Two experiments examined the impact of viewing unpleasant, pleasant, and neutral photographic slides on cold-pain perception in healthy men and women. In each experiment, participants viewed one of three slide shows (experiment 1 = fear, disgust, or neutral; experiment 2 = erotic, nurturant, or neutral) immediately before a cold-pressor task. Skin conductance and heart rate were recorded during the slide shows, whereas visual analog scale ratings of pain intensity and unpleasantness thresholds and pain tolerance were recorded during the cold-pressor task.

RESULTS

Viewing fear and disgust slides decreased pain intensity and unpleasantness thresholds, but only the fear slides decreased pain tolerance. In contrast, viewing erotic, but not nurturant, slides increased pain intensity and unpleasantness threshold ratings on the visual analog scale in men, whereas neither nurturant nor erotic slides altered pain tolerance.

CONCLUSIONS

These results are consistent with a motivational priming model that predicts that unpleasant affective states should enhance pain and that pleasant affective states should attenuate it.

Use of virtual reality for adjunctive treatment of adult burn pain during physical therapy: a controlled study

OBJECTIVE

The pain experienced by burn patients during physical therapy range of motion exercises can be extreme and can discourage patients from complying with their physical therapy. We explored the novel use of immersive virtual reality (VR) to distract patients from pain during physical therapy.

SETTING

This study was conducted at the burn care unit of a regional trauma center.

PATIENTS

Twelve patients aged 19 to 47 years (average of 21% total body surface area burned) performed range of motion exercises of their injured extremity under an occupational therapist's direction.

INTERVENTION

Each patient spent 3 minutes of physical therapy with no distraction and 3 minutes of physical therapy in VR (condition order randomized and counter-balanced).

OUTCOME MEASURES

Five visual analogue scale pain scores for each treatment condition served as the dependent variables.

RESULTS

All patients reported less pain when distracted with VR, and the magnitude of pain reduction by VR was statistically significant (e.g., time spent thinking about pain during physical therapy dropped from 60 to 14 mm on a 100-mm scale). The results of this study may be examined in more detail at www.hitL.washington.edu/projects/burn/.

CONCLUSIONS

Results provided preliminary evidence that VR can function as a strong nonpharmacologic pain reduction technique for adult burn patients during physical therapy and potentially for other painful procedures or pain populations.

Pain in orthodontics. A review and discussion of the literature

This literature review focuses on previous studies of pain and pain perception in dentistry with special emphasis on orthodontic treatment. The prevalence of pain and background factors such as age, gender and culture/society, in addition to pain physiology and the influence of concomitant emotional and cognitive factors, is examined. Pain during orthodontic tooth movement is reported from the point of view of its physiology and character and different assessment methods. These aspects are described both generally and specifically in relation to the type of orthodontic forces and to the experience of discomfort other than pain. Since the orthodontic treatment may cause some degree of suffering for the patients, it is important for orthodontists to handle this situation in the best possible way. Some ideas about the possibilities of avoiding, reducing or alleviating pain in orthodontics are discussed.

Virtual reality as an adjunctive pain control during burn wound care in adolescent patients

For daily burn wound care procedures, opioid analgesics alone are often inadequate. Since most burn patients experience severe to excruciating pain during wound care, analgesics that can be used in addition to opioids are needed. This case report provides the first evidence that entering an immersive virtual environment can serve as a powerful adjunctive, nonpharmacologic analgesic. Two patients received virtual reality (VR) to distract them from high levels of pain during wound care. The first was a 16-year-old male with a deep flash burn on his right leg requiring surgery and staple placement. On two occasions, the patient spent some of his wound care in VR, and some playing a video game. On a 100 mm scale, he provided sensory and affective pain ratings, anxiety and subjective estimates of time spent thinking about his pain during the procedure. For the first session of wound care, these scores decreased 80 mm, 80 mm, 58 mm, and 93 mm, respectively, during VR treatment compared with the video game control condition. For the second session involving staple removal, scores also decreased. The second patient was a 17-year-old male with 33.5% total body surface area deep flash burns on his face, neck, back, arms, hands and legs. He had difficulty tolerating wound care pain with traditional opioids alone and showed dramatic drops in pain ratings during VR compared to the video game (e.g. a 47 mm drop in pain intensity during wound care). We contend that VR is a uniquely attention-capturing medium capable of maximizing the amount of attention drawn away from the 'real world', allowing patients to tolerate painful procedures. These preliminary results suggest that immersive VR merits more attention as a potentially viable form of treatment for acute pain.

No interactive effects of naltrexone and benzodiazepines on pain during phobic fear

Animal research has shown that anxiety may inhibit pain through the release of endogenous opioids. On the other hand, anxiety is often believed to exacerbate pain in clinical situations, and anxiety reduction has been shown to attenuate the affective component of pain. In the present study phobic anxiety was induced by confronting forty-eight spider phobic subjects with a spider, after which they received two mildly painful electrical stimuli at two different current levels. The benzodiazepine alprazolam (1 mg) was administered to investigate the influence on pain of a reduction in anxiety, while the role of endogenous opioids was studied by administering the opioid antagonist naltrexone (50 mg). Alprazolam resulted in lower anxiety and pain ratings during pain stimulation, supporting the idea that (presumably pain-related) anxiety may increase the experience of pain. Naltrexone did not influence pain and anxiety ratings, nor was there a significant interaction between the two pharmacological manipulations. These findings confirm previous evidence that phobic fear does not necessarily induce an endogenous opioid-mediated analgesia.

Maintaining patient endurance. The comfort work of trauma nurses

The purpose of this article is to explicate patterns of comforting that assist the seriously injured patient to endure the pain of injury and subsequent treatments and to remain controlled. The care provided to 67 trauma patients in two trauma centers was videotaped and analyzed using observational methods and linguistic analysis. During painful procedures, when patients exhibited extreme distress, one nurse usually assumed the role of comforter. The nurses used a patterned mode of speech ("comfort talk"), touch, and distinctive posturing behaviors that enabled the patient to endure the agony and maintain control. In this article, the authors describe the comfort work of nursing in emerging situations, further develop the Comfort Talk Register, and describe the concomitant behaviors that facilitate patient endurance. They suggest that the comfort work of nurses in this situation enables patients to endure and reduces shock and posttraumatic stress following trauma care.

Cognitive aspects of pain and pain control

The cognitive and cognitive-behavioral approaches have been shown to be very effective in controlling pain and its sequelae both in the laboratory and in the clinical setting. As used in most research and treatment, cognitive approaches are concerned with the way the person perceives, interprets, and relates to his or her pain rather than with the elimination of the pain per se. This article reviews some of the origins of cognitive theory and pain theory, as well as examples of the techniques used and the research support for the approach. Special emphasis is given to self-efficacy, perceived control, and stress inoculation therapy. There is also discussion of some of the limitations of the cognitive approach. The overall conclusion is that the cognitive approach is a powerful and effective one for pain control despite its limitations.

No evidence for opioid-mediated analgesia induced by phobic fear

The influence of anxiety on acute pain sensation was investigated, studying the relative contribution of endogenous opioids and attentional mechanisms. Thirty-six spider phobics received mildly painful electrical stimulation, while anxiety and focus of attention were manipulated within subjects. The opioid antagonist naloxone or placebo was administered between subjects to examine an analgesia owing to anxiety-induced endorphinergic activity. In contrast to earlier findings, attention towards pain failed to increase pain as opposed to distraction from pain, probably owing to a less effective attention manipulation. Furthermore, despite high levels of anxiety, subjective pain ratings were not influenced by anxiety, although heart rate responses were slightly inhibited. Accordingly, there was no increase in subjective or physiological pain responses as a result of naloxone, nor did beta-endorphin plasma levels rise during anxiety. The results suggest that phobic anxiety does not induce an opioid-mediated analgesia. Curiously, naloxone itself effected a dose-dependent analgesia compared to placebo during both high and low anxiety, which is compatible with the assumption of agonist properties of naloxone in the absence of opioid activity.

Adjunctive methods of pain control in burns

Opiates remain the most common form of analgesic therapy in the burn patient today. Because of increased opiate requirements, optimal relief of burn pain continues to be a problem for these patients. The purpose of this article is to summarize those alternative pain control methods that appear in the literature. For instance, in minor burns acetominophen continues to be a useful first line analgesic. Non-steroidal anti-inflammatory drugs (NSAID) and benzodiazepine are generally combined with opiates while entonox seems to be used commonly in the adolescent patients to relieve procedural pain. Antidepressants appear to enhance opiate-induced analgesia while anticonvulsants are useful in the treatment of sympathetically maintained pain following burns. Ketamine has been extensively used during burn dressing changes but its psychological side-effects have limited its use. Clonidine, however, has shown promise in reducing pain without causing pruritus or respiratory depression. Other forms such as transcutaneous electrical nerve stimulation (TENS), psychological techniques, topical and systemic local anaesthetics are also useful adjuncts.

Pain and discomfort during mammography

The aim of this prospective study was to investigate associations of mammography pain and discomfort with sociodemographics, personal history and psychological and situational factors. Subjects were women with a negative screening finding (n = 883) from a random sample of 50-year-old Finnish women attending their first breast cancer screening. Questionnaires were sent 1 month before the screening invitation and 2 months after screening. Sixty-one per cent reported painful and 59% uncomfortable mammograms (4% severely). Linear regression analyses showed that anticipation of pain and discomfort was the most powerful factor explaining pain and discomfort among women with earlier mammography. However, it had no effect among women without earlier mammography, for whom screening-related nervousness and perceptions of staff were crucial. Suggested interventions include better information before screening, a friendly screening atmosphere and empathetic, supportive staff behaviour, especially towards women having their first mammogram, encouraging them to feel more at ease and distracted from pain.

Self-hypnotic relaxation during interventional radiological procedures: effects on pain perception and intravenous drug use

The authors evaluated whether self-hypnotic relaxation can reduce the need for intravenous conscious sedation during interventional radiological procedures. Sixteen patients were randomized to a test group, and 14 patients were randomized to a control group. All had patient-controlled analgesia. Test patients additionally had self-hypnotic relaxation and underwent a Hypnotic Induction Profile test. Compared to controls, test patients used less drugs (0.28 vs. 2.01 drug units; p < .01) and reported less pain (median pain rating 2 vs. 5 on a 0-10 scale; p < .01). Significantly more control patients exhibited oxygen desaturation and/or needed interruptions of their procedures for hemodynamic instability. Benefit did not correlate with hypnotizability. Self-hypnotic relaxation can reduce drug use and improve procedural safety.

Labor pain relief using bupivacaine and sufentanil: patient controlled epidural analgesia versus intermittent injections

OBJECTIVES

To determine whether the use of patient-controlled epidural analgesia (PCEA) versus intermittent injections (CIT) resulted in local anesthetic dose reduction.

STUDY DESIGN

PCEA and CIT using a mixture of 0.125% bupivacaine with sufentanil 1 or 0.75 microgram/ml were compared in 60 and 195 parturients, respectively. Assessments included pain scores, local anesthetic consumption, degree of motor blockade, type of delivery and neonatal outcome. Statistical analysis was done using Student's t test and Chi-squares.

RESULTS

PCEA and CIT provided effective analgesia during labor and delivery. A higher dose of opioid significantly reduced the use of local anesthetic solution in PCEA-patients. There was no difference in motor blockade, type of delivery and neonatal outcome.

CONCLUSION

Patient-controlled epidural analgesia is an effective, safe and acceptable alternative to conventional intermittent epidural injections for pain relief during labor and delivery.

The influence of anxiety on pain: attentional and attributional mediators

Two psychological processes mediating the influence of anxiety on pain have been proposed: an attributional process in which the pain-relevance of anxiety is the essential factor, and an attentional process in which the focus of attention is the essential factor. The present study investigated the influences of attentional focus, pain-irrelevant anxiety and pain-relevant anxiety in a within-subject design (n = 40). Subjects received painful electrical stimulation in each of 5 experimental conditions. The results indicate that pain ratings were only influenced by attentional focus and not by anxiety, regardless of whether it was pain-relevant or pain-irrelevant. Autonomic responses (skin conductance responses) were, however, only influenced by pain-relevant anxiety. Thus, it seems that with respect to subjective pain responses the attentional theory on the influence of anxiety on pain can explain the results. The attributional theory seems to hold for autonomic pain responses. However, these responses might as well be considered as fear responses. Whereas there is clear evidence for a role of attentional focus in the influence of anxiety on pain, the role of attributional processes remains to be demonstrated.

Anxiety, attention and pain

In a within-subject design the hypothesis was tested that focus of attention rather than anxiety influences pain. Twenty-four spider phobics received a moderately painful electrical stimulation in each of four conditions: low anxiety/attention directed towards pain; low anxiety/attention distracted from pain; high anxiety/attention directed towards pain; high anxiety/attention distracted from pain. Anxiety was induced by means of exposure to a spider. Subjective pain ratings strongly supported the hypothesis: pain was rated lower when the subject diverted attention away from than when the subject attended to the pain stimulus, regardless of level of anxiety. The Skin Conductance Response to the first pain stimulus of the series of four in each condition was, however, higher when the subject distracted than when the subject attended to the pain stimulus. There were no experimental effects on later Skin Conductance Responses. Most importantly, there was no influence of anxiety on any of the pain responses. Attentional focus rather than anxiety per se seems to influence pain.

A review of nursing strategies to reduce patient anxiety in coronary care. Part 2

Illness and associated hospitalisation are stressful events for any individual. The stress associated with an admission to a coronary care unit may be related to the severity and acuteness of the illness, the effects of hospitalisation on the individual, their family, their job and financial position, and often manifests itself as anxiety, fear or depression. This paper highlights the use of anxiety reduction strategies such as muscle relaxation, music, education and counseling. The literature reviewed does not provide any clear messages regarding the effectiveness of these strategies in the coronary care unit setting. As a consequence, there is a need to continue researching this important area of nursing practice.

Self-administration of midazolam for postoperative anxiety: a double blinded study

Anxiety is almost inevitably present in patients facing surgery. The optimal management of postoperative pain requires the acknowledgement of perioperative anxiety and the inclusion of pharmacological and/or non-pharmacological means of alleviating the fear and worry inherent in the surgical experience. In a double-blind randomized design, 39 patients undergoing total abdominal hysterectomies were given postoperative access to a standard patient-controlled analgesia (PCA) morphine pump for pain and a PCA pump dispensing either low-dose midazolam or saline for anxiety. Measures of anxiety and pain were completed pre-operatively and for 2 days postoperatively. Utilization of morphine and 'anxiolytic agent' were recorded. Analysis of covariance was applied to the data to control for the imbalance of cancer patients between the 2 groups. While both groups of patients chose to utilize their 'anxiety pump' throughout the study, those patients receiving midazolam had significantly lower postoperative Spielberger State Anxiety scores and visual analogue scale anxiety scores. Patient-controlled midazolam in doses used in this study were safe and effective in managing anxiety but did not influence pain scores or the amount of PCA morphine patients used. Pre-operative levels of depression were significantly associated with postoperative pain levels independent of treatment group or cancer diagnosis.

Patient-controlled epidural analgesia in labour--is a continuous infusion of benefit?

A randomised, single-blind study was conducted among 52 gravida in active labour, to investigate two variants of patient-controlled epidural analgesia--bolus only versus bolus plus infusion. Patient-controlled analgesia variables, using an epidural solution of 0.125% bupivacaine plus fentanyl 3 mcg per ml, were a 4 ml incremental bolus with 15 minute lockout, plus or minus a 4 ml per hour infusion. Up to three additional staff-administered supplements of 0.5% bupivacaine 4 ml (20 mg) were allowed. There was no significant difference between groups with respect to pain relief, supplementary boluses required, satisfaction, side-effects or details of patient-controlled epidural analgesia, with the exception of greater fentanyl usage in the bolus plus infusion group (P less than 0.003). Both groups had high quality analgesia, low rates of bupivacaine usage and were highly satisfied. However, under the conditions of the study, the addition of a continuous background infusion to self-administration conferred no benefit.

Can anxiety help us tolerate pain?

It was hypothesized that anxiety which is relevant to the source of pain exacerbates pain, whereas anxiety which is irrelevant to the source of pain reduces the experience of pain. Female subjects were given either high or low anxiety provoking information about a cold pressor task (relevant anxiety) or high or low anxiety provoking information about a potential shock (irrelevant anxiety). Subjects were then exposed to the cold pressor. The results demonstrated that subjects who were highly anxious about the cold pressor reported experiencing the most pain. Subjects who were highly anxious about the shock reported the least pain and reported significantly less pain than subjects who were highly anxious about the cold pressor. These findings clearly demonstrate that the relationship between anxiety and pain is not always positive or unidirectional.

Epidural analgesia in labour: constant infusion plus patient-controlled boluses

A randomised, single-blind study to investigate patient-controlled epidural analgesia during labour was conducted using a solution of low-dose bupivacaine-fentanyl. Two groups (n = 25 in each) received a constant infusion supplemented by patient demand boluses, and midwife-administered boluses if required, the size of the infusion and patient increments varying between groups. The quality of analgesia, as assessed by pain scores and patient ratings, was high and participant acceptability very high in both groups. Fourteen per cent of participants were withdrawn due to cephalad extension of block to T5 or supplementary bolus requirements outside the study protocol. Epidural side-effects were not troublesome and drug dose utilisation was low. Significantly greater pain relief (P less than 0.04) three hours after commencing patient-controlled epidural analgesia and a trend to fewer women requiring more than two supplementary midwife-administered boluses (P = 0.11) was seen in the group receiving a higher infusion rate. This group used significantly more bupivacaine (P less than 0.04) and fentanyl (P less than 0.001), but this did not appear to be clinically important with respect to degree of motor block or side-effects. Patient-controlled epidural analgesia appears to be an effective and well accepted method of obstetric analgesia and warrants further investigation.

Attention, not anxiety, influences pain

Four hypotheses about the influences of anxiety and attention on pain impact were tested in a critical experiment: (1) anxiety increases pain; (2) anxiety decreases pain; (3) attention to pain increases pain; (4) only the combination of anxiety and attention to pain increases pain (interaction hypothesis). In a 2 x 2 design, anxiety (low vs high) and attention (attention vs distraction from the pain) were experimentally manipulated. Subjects received 20 electrically produced painful stimuli. Subjective pain experiences, skin conductance responses and heart rate responses gave no support for a pain impact increasing effect of anxiety. The anxiety-attention interaction hypothesis did not receive any support either. There was some support, only from the heart rate responses, that anxiety reduces pain impact. The critical factor appeared to be attention. Attention to the pain stimulus was related to a stronger pain impact (indicated by all measures) and to less subjective habituation, compared to distraction.

The effects of incorrect pain expectations on acquired fear and pain responses

Previous experimental research on the effects of incorrect intensity expectations of aversive events can be criticized because intensity expectations were not manipulated independently from changes in objective intensity. The present study aims at investigating the effects of incorrect intensity expectations on the immediate and later responses to a painful stimulus, and on the acquisition of anticipatory responses, with proper experimental control. Subjects (n = 62) received 20 painful stimuli of varying intensity. In the control group intensities were correctly signalled on all trials by an analogue signal. On 3 trials the signal was too large in the overprediction condition, and too small in the underestimation condition. Underpredicted painful experiences were related to subsequent higher pain responses on the physiological level, but not on the subjective level; and to increased anticipatory responses (increased pain expectations, uncertainty, subjective fear, skin conductance responses). Skin conductance level also indicated increased fear after underpredicted experiences. Overpredicted painful experiences were related to a faster decrease in subjective fear compared to the control group, but did not influence other variables. The findings support the notion that underpredictions contribute to the acquisition of fear and disrupt habituation processes. The asymmetrical processing of the two kinds of incorrectly predicted experiences is discussed.

Predictions of dental pain: the fear of any expected evil, is worse than the evil itself

In a study of 40 subjects, who twice underwent extensive dental treatment, the relationships between expectations and experiences of pain and of anxiety were investigated. Inaccurate expectations were adjusted in the same way as observed in the laboratory. Especially anxious subjects expected more pain and anxiety than they experienced, and they appeared to need more experiences before their predictions became accurate. In the course of time, the expectations (and memories) of anxious subjects returned to their original more inaccurate level of prediction. The results suggest that the old schema is ultimately reinstated if disconfirmations are few and far between. Anxious subjects did not experience more pain, but they did experience more anxiety than fearless subjects. Detailed investigation of processes of change after disconfirmation showed that anxiety experienced during treatment is a factor that plays a part in maintaining the problem of inaccurate expectations and fear of treatment. Theoretical and clinical implications of these findings are discussed.