Pain vs Comfort Scores After Caesarean Section
Pain vs Comfort Scores After Caesarean Section
Background The use of negative words, such as 'sting' and 'pain', can increase patient pain and anxiety. We aimed to determine how pain scores compare with comfort scores and how the technique of pain assessment affects patient perceptions and experiences after operation.
Methods After Caesarean section, 300 women were randomized before post-anaesthesia review. Group P women were asked to rate their pain on a 0–10-point verbal numerical rating scale (VNRS), where '0' was 'no pain' and '10' was 'worst pain imaginable'. Group C women were asked to rate comfort on a 0–10-point VNRS, where '0' was 'no comfort' and '10' was 'most comfortable'. All women were asked whether the Caesarean wound was bothersome, unpleasant, associated with tissue damage, and whether additional analgesia was desired.
Results The median (inter-quartile range) VNRS pain scores was higher than inverted comfort scores at rest, 2 (1, 4) vs 2 (0.5, 3), P=0.001, and movement, 6 (4, 7) vs 4 (3, 5), P<0.001. Group P women were more likely to be bothered by their Caesarean section, had greater VNRS 'Bother' scores, 4 (2, 6) vs 1 (0, 3), P<0.001, perceived postoperative sensations as 'unpleasant' [relative risk (RR) 3.05, 95% confidence interval (CI) 2.20, 4.23], P<0.001, and related to tissue damage rather than healing and recovery (RR 2.03, 95% CI 1.30, 3.18), P=0.001. Group P women were also more likely to request additional analgesia (RR 4.33, 95% CI 1.84, 10.22), P<0.001.
Conclusions Asking about pain and pain scores after Caesarean section adversely affects patient reports of their postoperative experiences.
Recent studies have shown that the way healthcare workers (HCWs) communicate with patients can suggest perceptual experiences that can increase anxiety and pain. In the first randomized study investigating the effects of communication before a potentially painful procedure, participants were more likely to vocalize pain during i.v. cannula insertion where a negative suggestion was given. Similarly, in a well-designed, double-blind, randomized controlled trial of 140 women receiving spinal anaesthesia for Caesarean section or epidural analgesia for labour, those participants who were warned of a 'big bee sting' before local anaesthetic infiltration had higher pain scores than those informed that the anaesthetist was 'numbing the area'. The word 'nocebo' has been coined to describe non-pharmacological adverse effects of an intervention similar, but opposite, to the 'placebo' effect.
Advances in brain imaging have led to further understanding of the neurobiology of this phenomenon where the anterior cingulate cortex, which links the limbic system with the sensory cortex, appears to be modulated when a negative suggestion is given. It appears that a sensation can be associated and perceived as suffering, or not, dependent on the words used.
The International Association for the Study of Pain (IASP) defines pain as, 'an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage'. According to this definition, the word 'pain' may function as a negative suggestion or nocebo communication which elicits a subconscious change in a patient's mood, perception, or behaviour. Therefore, the assessment of postoperative pain using negatively valenced, nocebo communications might be expected to adversely affect patient perceptions of their postoperative experience.
Postoperative pain management is said to require accurate and reliable methods of assessment performed on a regular and ongoing basis. Although multiple outcome measures are required to adequately capture the complexity of the pain experience, in clinical practice, the assessment of pain typically uses simple scales such as the visual analogue scale (VAS) score or verbal numerical rating score (VNRS). In the postoperative setting, the functional capacity of the patient may also be assessed using the VAS for pain at rest (static) and movement (dynamic). The VNRS and VAS are widely used and have been found to correlate well with each other in a number of studies. In our institution on the post-anaesthetic ward round, healthcare providers usually ask patients 'Do you have pain?' and then ask for a rating of their pain using a verbal numerical rating scale (VNRS). These communications attempt to ensure patients receive adequate analgesia. However, the use of the negative word 'pain' may actually be causing patients to focus on their pain and interpret normal healing sensations as pain when this might not be the case with neutral or more positive language. Our anecdotal experience, and a previous study, has suggested that the use of the word 'comfort' rather than the word 'pain' may affect patients' experience of their recovery. The aim of this study was to investigate how standard pain scores compare with comfort scores after Caesarean section and determine whether the way pain is assessed affects patient reports of their perceptions and experiences after operation.
Abstract and Introduction
Abstract
Background The use of negative words, such as 'sting' and 'pain', can increase patient pain and anxiety. We aimed to determine how pain scores compare with comfort scores and how the technique of pain assessment affects patient perceptions and experiences after operation.
Methods After Caesarean section, 300 women were randomized before post-anaesthesia review. Group P women were asked to rate their pain on a 0–10-point verbal numerical rating scale (VNRS), where '0' was 'no pain' and '10' was 'worst pain imaginable'. Group C women were asked to rate comfort on a 0–10-point VNRS, where '0' was 'no comfort' and '10' was 'most comfortable'. All women were asked whether the Caesarean wound was bothersome, unpleasant, associated with tissue damage, and whether additional analgesia was desired.
Results The median (inter-quartile range) VNRS pain scores was higher than inverted comfort scores at rest, 2 (1, 4) vs 2 (0.5, 3), P=0.001, and movement, 6 (4, 7) vs 4 (3, 5), P<0.001. Group P women were more likely to be bothered by their Caesarean section, had greater VNRS 'Bother' scores, 4 (2, 6) vs 1 (0, 3), P<0.001, perceived postoperative sensations as 'unpleasant' [relative risk (RR) 3.05, 95% confidence interval (CI) 2.20, 4.23], P<0.001, and related to tissue damage rather than healing and recovery (RR 2.03, 95% CI 1.30, 3.18), P=0.001. Group P women were also more likely to request additional analgesia (RR 4.33, 95% CI 1.84, 10.22), P<0.001.
Conclusions Asking about pain and pain scores after Caesarean section adversely affects patient reports of their postoperative experiences.
Introduction
Recent studies have shown that the way healthcare workers (HCWs) communicate with patients can suggest perceptual experiences that can increase anxiety and pain. In the first randomized study investigating the effects of communication before a potentially painful procedure, participants were more likely to vocalize pain during i.v. cannula insertion where a negative suggestion was given. Similarly, in a well-designed, double-blind, randomized controlled trial of 140 women receiving spinal anaesthesia for Caesarean section or epidural analgesia for labour, those participants who were warned of a 'big bee sting' before local anaesthetic infiltration had higher pain scores than those informed that the anaesthetist was 'numbing the area'. The word 'nocebo' has been coined to describe non-pharmacological adverse effects of an intervention similar, but opposite, to the 'placebo' effect.
Advances in brain imaging have led to further understanding of the neurobiology of this phenomenon where the anterior cingulate cortex, which links the limbic system with the sensory cortex, appears to be modulated when a negative suggestion is given. It appears that a sensation can be associated and perceived as suffering, or not, dependent on the words used.
The International Association for the Study of Pain (IASP) defines pain as, 'an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage'. According to this definition, the word 'pain' may function as a negative suggestion or nocebo communication which elicits a subconscious change in a patient's mood, perception, or behaviour. Therefore, the assessment of postoperative pain using negatively valenced, nocebo communications might be expected to adversely affect patient perceptions of their postoperative experience.
Postoperative pain management is said to require accurate and reliable methods of assessment performed on a regular and ongoing basis. Although multiple outcome measures are required to adequately capture the complexity of the pain experience, in clinical practice, the assessment of pain typically uses simple scales such as the visual analogue scale (VAS) score or verbal numerical rating score (VNRS). In the postoperative setting, the functional capacity of the patient may also be assessed using the VAS for pain at rest (static) and movement (dynamic). The VNRS and VAS are widely used and have been found to correlate well with each other in a number of studies. In our institution on the post-anaesthetic ward round, healthcare providers usually ask patients 'Do you have pain?' and then ask for a rating of their pain using a verbal numerical rating scale (VNRS). These communications attempt to ensure patients receive adequate analgesia. However, the use of the negative word 'pain' may actually be causing patients to focus on their pain and interpret normal healing sensations as pain when this might not be the case with neutral or more positive language. Our anecdotal experience, and a previous study, has suggested that the use of the word 'comfort' rather than the word 'pain' may affect patients' experience of their recovery. The aim of this study was to investigate how standard pain scores compare with comfort scores after Caesarean section and determine whether the way pain is assessed affects patient reports of their perceptions and experiences after operation.