Nonpharmacologic Therapies for Postoperative Pain in Cardiac Surgery

The objective of the systematic review by de Andrade et al1 was to determine the efficacy of nonpharmacologic therapies in relieving postoperative pain in adults undergoing cardiac surgeries.Effective pain management after cardiac surgery remains a complex challenge in critical care. More than 80% of surgical patients experience acute postoperative pain, with the majority reporting moderate, severe, or extreme pain.2 Cardiac surgery is associated with significant postoperative pain caused by surgical trauma, the sternotomy incision, tissue damage, and invasive devices such as chest tubes and catheters.3 Despite national and international recommendations for multimodal, opioid-sparing pain management, implementation of these recommendations remains inconsistent and often suboptimal, contributing to delayed recovery and complications.3The multimodal approach to pain management combines interventions to achieve pain relief. These interventions include a variety of medications, including nonopioid medications, and nonpharmacologic therapy options. Nonpharmacologic therapies are widely accessible, are simple to perform, and carry minimal risk when applied by health care professionals, making them valuable adjuncts to support pain control during hospitalization. Nonpharmacologic therapies include relaxation therapy, music therapy, massage, acupressure, virtual reality, and cognitive-behavioral approaches.4 Studies in surgical and critical care settings show that nonpharmacologic therapies can lessen pain, anxiety, and opioid use while enhancing recovery. However, nonpharmacologic therapies have yet to be widely incorporated into routine postoperative care.4 Given the ongoing challenges of managing postoperative pain after cardiac surgery, the authors of this systematic review aimed to evaluate the effectiveness of nonpharmacologic therapies as components of multimodal analgesia to guide clinical practice.This Evidence Review Summary is based on a systematic review conducted by de Andrade et al,1 which included 23 randomized controlled trials comprising data for 1999 adults who underwent cardiac surgery and received nonpharmacologic therapies for pain management. The authors independently assessed the risk of bias for each study, including selection, performance, detection, attrition, reporting, and publication biases. They resolved any disagreements by reviewing the data together and through discussion with a third reviewer. Methodologic quality assessment was conducted by using the JBI checklist for randomized controlled trials.5 The included studies examined 13 different nonpharmacologic pain management strategies, some of which were analyzed independently and some in combination with other therapies.Therapeutic massage was the most explored single intervention (8 studies), followed by musical intervention (4 studies) and hypnotherapy (2 studies). All other interventions were included in only a single study.A statistically significant reduction in pain was found in the postoperative period in 6 of 8 studies (75%) using therapeutic massage as the intervention. Massage was also found to reduce anxiety, stress, and fatigue. The most common area of massage was the feet, followed by other areas of the body as requested by the patients (eg, neck, shoulders, back). The most common duration was 20 minutes.A statistically significant reduction in pain was found in the postoperative period in all 4 studies (100%) that used music as the intervention. The musical interventions were delivered through headphones or a music pillow for durations of 20 to 30 minutes once or twice daily. Music styles varied from classical to nature sounds and pop.A statistically significant reduction in pain was found in the postoperative period in 1 to 2 studies (50%) using hypnotherapy as the intervention. Hypnotherapy was also found to reduce anxiety and stress. The authors emphasized that hypnotherapy should be performed only by those who have been properly trained.1Although only 1 study was included in each analysis, statistically significant reductions in pain in the postoperative period were found for osteopathic manipulative treatment, ice pack therapy, electroacupuncture, a set of complementary alternative therapies, scheduled rest, neurolinguistic programming, and guided imagery.Nurses play a central role in effective pain management given that they provide continuous patient care and are responsible for ongoing pain assessment and for implementing effective interventions. Although research supporting nonpharmacologic pain interventions is growing, these strategies remain underused in nursing practice.3 To achieve optimal outcomes, nurses must understand the benefits, mechanisms, and appropriate application of nonpharmacologic therapies for acute pain. This approach is especially important for patients who have undergone cardiac surgery.The systematic review identified several nonpharmacologic therapies with strong potential to relieve postoperative pain after cardiac surgery.1 Interventions such as massage, music therapy, and hypnotherapy are supported by strong evidence, pose minimal risk to patients, and require limited resources for implementation. These therapies may be valuable additions to postoperative pain management protocols in cardiac surgery. As awareness increases among clinicians and patients regarding the benefits of complementary approaches such as massage therapy, nurses are uniquely positioned to identify evidence-based techniques that alleviate pain and anxiety during hospitalization.The evidence from this systematic review can inform decisions when clinical care teams create pain management plans for patients after cardiac surgery. Care teams should consider their own protocols and evaluate future studies to provide additional guidance. Advocating for the best evidence-based treatment remains an important part of the role of nurses who care for critically ill patients. We must always consider the best available evidence and understand the feasibility, appropriateness, meaningfulness, and effectiveness of any intervention to determine whether it is suitable for implementation in each context.