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Non-pharmacologcial techniques for management of postoperative pain


Non-pharmacological interventions include a variety of methods, amongst them preoperative assessment and providing patients with information interventions, Trans-cutaneous Electrical Nerve Stimulus (TENS), acupuncture, local cooling and heating. ANZCA chapter 8, p 221.

TENS and acupuncture may reduce pain by a spinal mechanism or release of endogenous opioids, however, a sound scientific explanation is lacking and placebo effects may at least partly explain the observed effects. Both techniques are relatively safe and without severe side effects.

TENS

TENS is recommended as an additional technique in some of types of surgery ANZCA Chapter 8.2, p 226; German Guidelines, section 3.3.1.4, p 5. TENS should be applied with a strong but not painful intensity of current (>15 mA) ANZCA Chapter 8.2, p 226; German Guidelines, section 3.3.1.4, p 5. Most TENS studies have been performed in thoracic and abdominal surgery. In some of these studies, pain intensity and analgesic requirements were reduced German Guidelines, section 3.3.1.4, p 4. However, PROSPECT concludes that TENS is not recommended in thoracotomies (Grade D) PROSPECT / thoracotomy / postoperative / alternate analgesic techniques / TENS nor in total knee arthroplasty (Grade B) PROSPECT / total knee arthroplasty / postoperative / Non-pharmacological techniques because the limited procedure-specific evidence available suggests lack of benefit. TENS is not recommended in herniorraphy (Grade A) because of a lack of analgesic benefit PROSPECT / herniorraphy / postoperative / Non-pharmacological techniques. TENS may reduce severe pain in labour but does not reliably reduce pain scores or analgesic requirements ANZCA Chapter 8.2, p 227.

Recommendations specific to the treatment

There are no guideline recommendations concerning duration or frequency of TENS stimulation.

Circumstances when the treatment is not recommended

TENS is contraindicated in patients with pace makers or with an automated implantable cardioverter-defibrillator(AICD).

Acupuncture

Acupuncture reduces postoperative pain but the analgesic effect is small (4 mm on a 100 mm VAS). It reduces opioid-related adverse effects like nausea (not vomiting), sedation, pruritus and urinary retention in a wide variety of surgeries ANZCA chapter 8.3, p 227. Some studies found a positive effect on pain intensity and analgesic consumption in some types of surgery (e.g., in hip replacement, arthroscopic shoulder, abdominal, oral cavity) German Guidelines, section 3.3.1.5, p 5-6. Acupuncture may reduce postprocedural dental pain ANZCA Chapter 9.6.7, p 274.There is weak evidence for improvement of back and pelvic pain during pregnancy with acupuncture ANZCA chapter 11, Key messages’, p 383. Acupuncture reduces analgesic requirements in labour ANZCA Chapter 11, p 388.PROSPECT concludes that auricular acupuncture is not recommended in thoracotomy due to limited evidence (Grade D) PROSPECT / thoracotomy / postoperative / alternate analgesic techniques / acupuncture. A significant positive effect was seen on PONV compared to placebo but not to antiemetic drugs Guidelines, section 3.3.1.5, p 5-6.

Recommendations specific to the treatment

There are no guideline recommendations concerning type, body location, duration or frequency of acupuncture. Most acupuncture studies have used needle or electroacupuncture, performed on the body or the ear (auricular acupuncture) on “traditional” Chinese Medicine (TCM) points, however, acupuncture on placebo points might be as effective German guidelines, section 3.3.1.5, p 5-6.

Local cold and heat

There is mixed evidence supporting use of local cooling after surgery. There is no evidence for using local heat. ANZCA chapter 8.4.2. p 228.

Summary

Two guidelines recommend TENS and acupuncture with low to medium grades of recommendation for different types of surgery based on findings which indicate a small to moderate reduction of pain. PROSPECT does not recommend TENS and/or acupuncture for three types of surgery (hernia repair, total knee arthroplasty, thoracotomy), and does not mention it in the other six surgeries assessed, indicating that there is no evidence for these surgeries up to the time the reviews were being carried out. Acupuncture might reduce PONV. There are very few contraindications for using TENS and acupuncture. The evidence for using local cooling is mixed. There is currently no evidence to recommend local heat.

Supplementary reading:

  1. E. Ernst, M.S. Lee, T.Y. Choi Acupuncture: Does it alleviate pain and are there serious risks? A review of reviews. Pain, 152 (2011), pp. 755–764