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behavioural intervention. These authors concluded that although a variety of behavioural
methods have been shown to reduce acute treatment‐related pain, the methods are not
equally effective, and hypnotic‐like methods, involving relaxation, suggestion and distracting
imagery, hold the greatest promise for pain management in acute treatment‐related pain
(Redd et al, 2001 Level IV).
Reports of benefit after surgery are less common. A study of three cognitive‐behavioural
interventions for reducing postoperative anxiety and pain following spinal fusion surgery
for scoliosis in adolescent patients showed that information plus training in coping strategies
achieved the greatest pain reduction (35%) compared with information only, coping strategies
only, and a control condition; the effect was most evident in those subjects aged 11 to
13 years, compared to those in the 14 to 18 year age range, where no differences between
interventions were found (LaMontagne et al, 2003 Level II).

Key messages
1. Listening to music produces a small reduction in postoperative pain and opioid
requirement (N) (Level I [Cochrane Review]).
2. The evidence that information is effective in reducing procedure‐related pain is tentatively
supportive and not sufficient to make recommendations (Q) (Level I).
3. Distraction is effective in procedure‐related pain in children (N) (Level I).
4. Training in coping methods or behavioural instruction prior to surgery reduces pain,
negative affect and analgesic use (U) (Level I).
5. Evidence of benefit of hypnosis in the management of acute pain is inconsistent (W)
(Level I).
6. Immersive virtual reality distraction is effective in reducing pain in some clinical situations
(N) (Level III‐2).
7. Evidence for any benefit of relaxation techniques in the treatment of acute pain is weak
CHAPTER 8 8.2 TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION
and inconsistent (N) (Level IV).

A systematic review published in 1996 concluded that transcutaneous electrical nerve
stimulation (TENS) was not effective for the relief of postoperative pain (Carroll et al 1996). The
authors noted that non‐randomised studies overestimated the beneficial effects of TENS. A
later Cochrane review included only RCTs looking at the benefit of TENS in the management of
acute pain generally and concluded that there were inadequate data on which to perform a
meta‐analysis (Walsh et al, 2009). However, these authors excluded studies where TENS was
used in combination with other treatments such as analgesic drugs. Hence, only one of the
12 included studies, but 62 of the 116 excluded studies related to postoperative pain.
It had been argued by Bjordal et al (Bjordal et al, 2003 Level I) that some of the studies reporting
no benefit from TENS may have used ineffective treatment doses — low and possibly
ineffective current intensities or sensory threshold intensity. They performed a systematic
review of publications using TENS after surgery where ‘assumed optimal TENS parameters’
were used; that is, if TENS was administered at an intensity described by the patients as
‘strong and/or definite subnoxious, and/or maximal non‐painful, and/or maximal tolerable’,
or at a current amplitude of greater than 15 mA. They concluded that strong, subnoxious
intensity TENS significantly reduced postoperative analgesic requirements.

226 Acute Pain Management: Scientific Evidence