Effect of a Vibratory Anesthetic Device on Pain Anticipation and Subsequent Pain Perception Among Patients Undergoing Cutaneous Cancer Removal Surgery

Abstract

IMPORTANCE Vibration has been shown to decrease injection site pain in patients; however, to date, this effect has not been assessed for patients who catastrophize pain (ie, patients who anticipate a higher pain level). The anticipation of a pain score greater than 4 on the 11-point Numeric Rating Scale (NRS) has been associated with an increase in a patient's perception of procedural pain.OBJECTIVE To assess the efficacy of vibration during cutaneous anesthetic injection for dermatologic surgery for patients who catastrophize pain (NRS score >4) and patients who do not (NRS score Յ4).DESIGN, SETTING, AND PARTICIPANTS Randomized, parallel-group clinical trial from June 19 to September 4, 2018, at a tertiary dermatologic surgery clinic among 87 adults undergoing cutaneous cancer removal surgery. Patients completed a preprocedural questionnaire detailing their baseline pain, anticipated pain, and drug use. Analysis was performed on an intent-to-treat basis.INTERVENTIONS Use of a vibratory anesthetic device (VAD) on the treatment site prior to anesthetic injection in the on (VAD ON) or off (VAD OFF) mode.MAIN OUTCOMES AND MEASURES Pain was reported using the 11-point NRS (where 0 indicates no pain and 11 indicates the worst pain imaginable). A minimum clinically important difference of 22% or more and a substantial clinically important difference of 57% or more were used to assess the efficacy of vibration in patient-reported NRS score during anesthetic injection (iNRS score).RESULTS A total of 87 patients were included, with 101 unique events reported (among the unique events, 37 were reported in women and 64 were reported in men; mean [SD] age, 66.0 [11.3] years). The mean (confidence level [CL]) iNRS score for patients who catastrophized pain was 2.27 (0.66) compared with 1.44 (0.39) for patients who did not (P = .03). A 38.9% decrease in mean (CL) iNRS score was reported with VAD ON compared with VAD OFF in all participants (1.24 [0.38] vs 2.04 [0.54]). Patients who catastrophized pain reported a 25.5% decrease in mean (CL) iNRS score with VAD ON vs VAD OFF (1.91 [0.99] vs 2.57 [0.98]), and patients who did not reported a 79.4% decrease (1.02 [0.40] vs 1.84 [0.66]). VAD ON was the only statistically significant variable to affect iNRS score (F statistic, 2.741; P = .03).CONCLUSIONS AND RELEVANCE This trial demonstrates that those who catastrophize pain prior to a procedure report a higher perceived level of pain. The application of vibration during local anesthetic injection resulted in a minimum clinically important difference in pain level for patients who catastrophize pain and a substantial clinically important difference in pain level for patients who do not. LEVEL OF EVIDENCE 2.TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03467685

Local anaesthetics in dermatological surgery: a review of adjuncts and pain reduction techniques

“…There is some evidence suggesting that the use of a vibrating device significantly reduces pain sensation during LA injection. 23,26,29 A randomized nonblinded trial of 47 patients reported that use of a vibrating device when administering buffered LA injections resulted in a mean decrease in pain of 15 mm (95% CI, 9.8-20.1; P < 0.001) on a 100-mm VAS. 23 In a partially blinded trial by Kazi et al, 39 assessing 101 test sites in 87 patients, the use of a vibrating device with LA infiltration resulted in a 40% reduction in pain as reported on an 11point numerical rating scale (2.0 AE 0.3 vs. 1.2 AE 0.2), which achieved statistical significance (P = 0.016).…”

“…Adjuncts such as epinephrine (adrenaline), sodium bicarbonate and hyaluronidase have a role in potentially reducing latency of onset, increasing duration of action or minimizing adverse effects (AEs) such as pain or associated bleeding 3–14 . Additional techniques to reduce associated pain such as warming the LA solution, cooling the skin prior to injection and use of a vibrating device on the skin, are described 15–34 . This review discusses the effectiveness of pain‐mitigating techniques associated with LA infiltration, as well as the use of LA adjuncts.…”

“…[3][4][5][6][7][8][9][10][11][12][13][14] Additional techniques to reduce associated pain such as warming the LA solution, cooling the skin prior to injection and use of a vibrating device on the skin, are described. [15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34] This review discusses the effectiveness of pain-mitigating techniques associated with LA infiltration, as well as the use of LA adjuncts.…”

Managing pain associated with dermatologic procedures

“…15 This theory may be applied through the use of vibration anesthesia, where concurrent local vibration during cutaneous injections has been found to decrease patient discomfort, especially in patients who catastrophize pain. 16,17 Devices intended for this purpose are widely available. Cooling of the injection site before and during injection has also been found to significantly decrease pain associated with infiltration of local anesthetic.…”

“…The gate control theory proposed by Wall and Melzack states that pain perception can be diminished by a simultaneous non‐noxious stimulus 15 . This theory may be applied through the use of vibration anesthesia, where concurrent local vibration during cutaneous injections has been found to decrease patient discomfort, especially in patients who catastrophize pain 16,17 . Devices intended for this purpose are widely available.…”