AUTHORS: Abraham CM et al
Pract Pain Manag. 2023 July/August;23(4).
In some hospitalized populations, about 44% of patients are in severe pain at dischage.1 High pain intensity during hospitalization is a risk factor for deleterious psychological outcomes, such as depression and PTSD,1 as well as the chronification of acute pain.2-4 In fact, anywhere from 3% to 20% of acute pain cases may develop into persistent pain. Pain is a biopsychosocial experience,5 and thus, clinicians should aim to target these factors early in the course of treatment during hospital stays to achieve optimal recovery, and ideally, to evade chronic pain development.
Long considered the “5th vital sign,” pain is the primary focus of assessment in early recovery in the acute hospital setting. The first-line treatment for acute pain management in the US tends to be opioids. Although successful, the use of opioids in acute pain management has shown significant adverse effects (eg, constipation, urinary retention, cardiac difficulties, and respiratory complications)4 and may lead to increased future use or misuse.6
Adjuvant medications (eg, anticonvulsants, antidepressants, corticosteroids) have also been used to offset the need for opioids in acute pain but come with their own side effects. Despite their benefits, medications can introduce an additional layer of physical and/or mental distress and only target pain on the biological level.
Despite hospitals being a place for healing and recovery, they are also known as a place replete with stressors.7 Patients experience constant beeping of monitors, call bells, interruptions for vital sign collection and medication administration, low lighting, waiting periods for bladder/bowel care, and limited privacy. This environment can contribute to anxiety, disrupted sleep, pain, and overall maladjustment to the hospital setting.7,8 Reducing stress and increasing relaxation within the hospital can have an impact on acute pain management and future outcomes.
One way the hospital environment can be improved is by changing the lighting. Sleep is imperative to pain management and overall recovery, and a human body primarily responds to daylight cycles to maintain its circadian rhythm – the natural sleep-wake cycle. Despite having good intentions, hospitals and staff tend to use low lighting under the assumption that dimmer light supports relaxation.8 Past research questions these assumptions. In a small, correlational study of hospitalized medical patients, Bernhofer and colleagues8 found fatigue and several mood subscales (eg, tension, depression, anger, and confusion) decreased with greater exposure to light. Although light exposure was not directly associated with pain, there was a link between fatigue and sleep improvement, which may moderate pain.8,9
Researchers have pointed to 1,500 lux of light for a minimum of 15 minutes per day and a preferred 4,000 lux for optimal circadian functioning.8 For reference, hospital lighting is typically 50 lux to 300 lux, whereas the typical day-to-day lighting is approximately 150 lux to 250 lux. Although the proper use of artificial light can improve goals of pain management, providing natural lighting is also recommended.8
Music is well supported as being beneficial in chronic pain management.11 There is also robust support for the use of music in acute pain management and during hospital stay. As typical hospital noise contributes to stress and increased pain,12 music can offset such negative responses and has shown to improve pain factors.13-17
Poulsen and Coto13 recommend playing music pre- and postoperatively for 15 to 30 minutes, at least twice per day; and throughout the surgery (with precautions as to not distract the surgical team). They also suggest playing music that follows the natural heart rate (60 bpm to 80 bpm), eg, calming sounds, such as classical or instrumental music, with lower decibel levels. For ICU patients, 20 to 30 minutes of music revealed a larger reduction in pain than music exposure of less than 20 min.15 Frequency of playing music during hospitalization was undetermined based on reviews. However, no adverse events resulted from more music exposure.
The medicinal use of essential oils has a long history, dating back to 2800 BC. In recent years, such aromatherapy has become a fast-growing practice in CIH treatments.18 Evidence to support its effect has mounted and concludes that it functions through transmission of signals from the olfactory system to the limbic system and neurotransmitter pathways.19
Despite some conflicting findings,20 the use of aromatherapy has shown positive results in acute pain management and in psychosocial factors related to pain in some hospitalized patients. In a systematic review of aromatherapy in both chronic and acute pain populations, Lakhan and colleagues21 concluded that aromatherapy is most consistently effective for nociceptive and acute pain. Moreover, aromatherapy was more effective in postoperative pain management along with obstetrical and gynecological pain populations.
An RCT conducted by Hekmatpou and colleagues22 showed a significant reduction in pain intensity using aromatherapy in a sample of traumatic orthopedic injury surgical patients. Sixty patients in the emergency department (ED) prior to surgery participated, and research personnel administered four drops of orange essential oil to a pad and pinned the pad to the clothing of 30 of the patients (approximately 20 cm from the head). The pad was replaced every hour and pain and vital signs were collected. There was no difference in pain intensity between both groups at baseline or at the one-hour time point. However, significant differences emerged starting at the second hour, showing a steady reduction in pain for the aromatherapy group during the following hours. Surprisingly, no differences emerged when measuring vitals at each time point, unlike those found in prior studies.21
Acupuncture’s utilization in the US has increased with a linear growth trend.23 Although there are different approaches to acupuncture, the most often used method is inserting thin, solid-core needles through the skin at specific points or a combination of points.24 In brief, the use of this treatment is based on the Chinese “Yin-Yang” balance where the body is stimulated at meridians to correct imbalances and consequently illness.25 Although still somewhat unclear, medical science has demonstrated how acupuncture may work on a biological level. For example, fMRI imaging identified that acupuncture targets areas of the brain responsible for regulating emotion, cognition, consciousness, sensorimotor, autonomic, endocrine, immune function, and pain processing (the limbic–paralimbic–neocortical network).26
Auricular acupuncture (needles inserted on the outer ear) also demonstrated immediate pain relief at 48 hours for acute and postoperative pain, equivalent to the pain-reducing results of analgesics. Similarly, acupuncture point stimulation (intramuscular stimulation with a focus on motor points) also demonstrated significant improvement in pain intensity scores (VAS) and total opioid use. Not only was acupuncture successful for surgical patients, but it was also beneficial in the treatment of pain and anxiety in the emergency department (ED), showing comparable results to analgesic use.
Mindfulness and Hypnotic Suggestion
As a metacognitive process, mindfulness, or being aware of the here-and-now, is the practice of attending to one’s own thoughts, feelings, and sensations without judgment. In their review, Zeidan and Vago27 provided a mechanistic account of how mindfulness meditation functions on pain management, pointing the activation of the right anterior insula and rostral aspects of the anterior cingulate cortex and orbitofrontal cortex and a deactivation of that thalamus.
Mindfulness as a self-regulatory process works to adjust pain through acceptance, whereas hypnotic suggestion is a more active intervention that aims to reduce pain. Although mindfulness is a type of active pain control, hypnotic suggestion is a vigorous approach that bolsters self-efficacy through pain reduction rather than withstanding or accepting pain.29,30 Hypnotic suggestions refer mostly to the beneficial outcomes rather than to the means in which these outcomes can supposedly be attained.31 For example, one may say silently or think to oneself “I am becoming calm and relaxed. My back is beginning to feel wonderful.” Past research has shown that hypnotic suggestions used to manage diseases evidenced significant improvement.32
Overall, a multitude of research outlines the benefits of a suitable environment and CIH modalities as ways to manage pain directly and indirectly (eg, anxiety, sleep) in hospitalized patients. In addition, these interventions can decrease analgesic use in some cases. As hospitalists and those working to manage pain begin to understand the importance of early intervention, they are encouraged to influence colleagues in hospital settings to address acute pain using some of these methods rather than relying solely on pharmacological interventions.
To our knowledge, no longitudinal work has been conducted to determine the lasting effects of the above treatments and their relationship to long-term outcomes, such as chronic pain. However, it is reasonable to assume that targeting pain via CIH modalities and other nonpharmacological processes early in the course of recovery can foster greater awareness of environmental effects and set the patient on a course for better pain self-management as they continue in their recovery; possibly evading the development of chronic pain.
- Archer KR, Heins SE, Abraham CM, Obremskey WT, Wegener ST, Castillo RC. Clinical significance of pain at hospital discharge following traumatic orthopedic injury: General health, depression, and PTSD outcomes at 1 year. Clin J Pain. 2016;32(3):196-202. doi:10.1097/AJP.0000000000000246
- Williamson OD, Epi GD, Gabbe BJ, et al. Predictors of moderate or severe pain 6 months after orthopaedic injury: a prospective cohort study. J Orthop Trauma. 2009;23(2):139-144. doi:10.1097/BOT.0b013e3181962e29
- Correll D. Chronic postoperative pain: recent findings in understanding and management. F1000Res. 2017;6:1054. Published 2017 Jul 4. doi:10.12688/f1000research.11101.1
- Herzig SJ, Stefan MS, Pekow PS, et al. Risk factors for severe opioid-related adverse events in a national cohort of medical hospitalizations. J Gen Intern Med. 2020;35(2):538-545. doi:10.1007/s11606-019-05490-w
- Raja SN, Carr DB, Cohen M, et al. The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain. 2020;161(9):1976-1982. doi:10.1097/j.pain.0000000000001939(Andersson et al., 2017)
- Calcaterra SL, Yamashita TE, Min SJ, et al. Opioid prescribing at hospital discharge contributes to chronic opioid use. J Gen Intern Med. 2016;31(5):478-485. doi:10.1007/s11606-015-3539-4
- Dijkstra K, Pieterse M, Pruyn A. Physical environmental stimuli that turn healthcare facilities into healing environments through psychologically mediated effects: systematic review. J Adv Nurs. 2006;56(2):166-181. doi:10.1111/j.1365-2648.2006.03990.x
- Bernhofer EI, Higgins PA, Daly BJ, et al. Hospital lighting and its association with sleep, mood and pain in medical inpatients. J Adv Nurs. 2014;70(5):1164-1173. doi:10.1111/jan.12282
- Andersen ML, Araujo P, Frange C, Tufik S. Sleep disturbance and pain: A tale of two common problems. Chest. 2018;154(5):1249-1259. doi:10.1016/j.chest.2018.07.019
- Walch JM, Rabin BS, Day R, et al. The effect of sunlight on postoperative analgesic medication use: a prospective study of patients undergoing spinal surgery. Psychosom Med. 2005;67(1):156-163. doi:10.1097/01.psy.0000149258.42508.70
- Crosse L. Utilizing music therapy to manage chronic pain. Pract Pain Manag. 2021;21(4)
- Hsu T, Ryherd EE, Waye KP, Ackerman J. Noise pollution in hospitals: Impact on patients. J Clin Outcome Manage. 2012 Jul;19(7):301-309.
- Poulsen MJ, Coto J. Nursing music protocol and postoperative pain. Pain Manag Nurs. 2018;19(2):172-176. doi:10.1016/j.pmn.2017.09.003
- Hole J, Hirsch M, Ball E, Meads C. Music as an aid for postoperative recovery in adults: a systematic review and meta-analysis [published correction appears in Lancet. 2015 Oct 24;386(10004):1630]. Lancet. 2015;386(10004):1659-1671. doi:10.1016/S0140-6736(15)60169-6
- Richard-Lalonde M, Gélinas C, Boitor M, et al. The effect of music on pain in the adult intensive care unit: A systematic review of randomized controlled trials. J Pain Symptom Manage. 2020;59(6):1304-1319.e6. doi:10.1016/j.jpainsymman.2019.12.359
- Lin CL, Hwang SL, Jiang P, Hsiung NH. Effect of music therapy on pain after orthopedic surgery-A systematic review and meta-analysis. Pain Pract. 2020;20(4):422-436. doi:10.1111/papr.12864
- Kühlmann AYR, de Rooij A, Kroese LF, et al. Meta-analysis evaluating music interventions for anxiety and pain in surgery. Br J Surg. 2018;105(7):773-783. doi:10.1002/bjs.10853
- Farrar AJ, Farrar FC. Clinical Aromatherapy. Nurs Clin North Am. 2020;55(4):489-504. doi:10.1016/j.cnur.2020.06.015
- Fung TKH, Lau BWM, Ngai SPC, Tsang HWH. Therapeutic effect and mechanisms of essential oils in mood disorders: Interaction between the nervous and respiratory systems. Int J Mol Sci. 2021;22(9):4844. Published 2021 May 3. doi:10.3390/ijms22094844
- Dimitriou V, Mavridou P, Manataki A, Damigos D. The use of aromatherapy for postoperative pain management: A systematic review of randomized controlled trials. J Perianesth Nurs. 2017;32(6):530-541. doi:10.1016/j.jopan.2016.12.003
- Lakhan SE, Sheafer H, Tepper D. The effectiveness of aromatherapy in reducing pain: A systematic review and meta-analysis. Pain Res Treat. 2016;2016:8158693. doi:10.1155/2016/8158693
- Hekmatpou D, Pourandish Y, Farahani PV, Parvizrad R. The effect of aromatherapy with the essential oil of orange on pain and vital signs of patients with fractured limbs admitted to the emergency ward: A randomized clinical trial. Indian J Palliat Care. 2017;23(4):431-436. doi:10.4103/IJPC.IJPC_37_17
- Clarke TC, Black LI, Stussman BJ, et al. Trends in the use of complementary health approaches among adults: United States, 2002-2012. Natl Health Stat Report. 2015;(79):1-16
- Nielsen A, Dusek JA, Taylor-Swanson L, Tick H. Acupuncture therapy as an evidence-based nonpharmacologic strategy for comprehensive acute pain care: The Academic Consortium Pain Task Force White Paper Update. Pain Med. 2022;23(9):1582-1612. doi:10.1093/pm/pnac056
- Patil S, Sen S, Bral M, et al. The role of acupuncture in pain management. Curr Pain Headache Rep. 2016 Apr;20(4):22. doi: 10.1007/s11916-016-0552-1. PMID: 26896946
- Hui KK, Marina O, Liu J, et al. Acupuncture, the limbic system, and the anticorrelated networks of the brain. Auton Neurosci. 2010;157(1-2):81-90. doi:10.1016/j.autneu.2010.03.022
- Zeidan F, Vago DR. Mindfulness meditation-based pain relief: a mechanistic account. Ann N Y Acad Sci. 2016;1373(1):114-127. doi:10.1111/nyas.13153
- Garland EL, Baker AK, Larsen P, et al. Randomized controlled trial of brief mindfulness training and hypnotic suggestion for acute pain relief in the hospital setting. J Gen Intern Med. 2017;32(10):1106-1113. doi:10.1007/s11606-017-4116-9
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