{
  "abstract": "A recent analysis of a large registry data (10415 patients from 10 countries) 1 reported that, despite considerable efforts to improvement during the last decades, postoperative pain is still a common experience for many patients. According to the findings, 50% of the patients endured severe pain (NRS > 7/10) and 25% spent more than 50% of their time in pain during the first 24 h. More, severe pain negatively interfered with functional and emotional recovery in at least 30% of the patients.1 How to explain these findings. On one hand, current guidelines for postoperative pain management as well as those promoting enhanced recovery after surgery remain poorly applied. Even multimodal analgesia is not systematically administered to all the patients.1 On the other hand, by definition, pain is an individual, complex,multifaceted experience, that is shaped by a lifetime of learning processes and influenced by sensory, affective, cognitive and sociocultural factors.2 That may explain the considerable variability of patients to experience pain and to respond to analgesic treatments. Thereby, it is not surprising that currently recommended postoperative pain management may not fit all the patients.Today, acute pain management, including postoperative pain, mostly relies on the administration of pharmacological treatments. As previously discussed, their effectiveness suffers limitations, particularly in some patients. In contrast, the use of non-pharmacological interventions remains unfrequent (average 28% utilization), distraction-based interventions proposed to 25% of the patients and physical modality i.e. cold pack proposed to 8% of the previously mentioned cohort of patients.1 The failures of classical perioperative analgesic treatments and the opioid health-related crisis have underscored the importance to optimize various approached to pain management and to further question the role and benefits of intergrating complementary medicine in perioperative pain management.3 Complementary Medicine and Integrative Health Complementary medicine (CM) is a term used to describe non-pharmacological approaches to health, healing and rehabilitation.3 CM interventions may be categorized in 5 subgroups: alternative medicines (e.g. homeopathy), natural product based therapy (e.g. dietary supplements), energy therapies (e.g. acupuncture), body-based interventions (e.g. massages) and mind-body interventions (e.g. hypnotherapy). Integrative Health is the practice of incorporating both traditional and CM into a comprehensive treatment plan.3 Practice of Integrative Health, also called holistic medicine, considers all the aspects of the patient when choosing the most appropriate treatment.3 Despite the patient’s preferences and their growing desire for a more integrated approach in their cares, several barriers to a regular use of CM in perioperative pain management are still present (see table 1). The lack of rigorous scientific evidence supporting the use of CM still stands as a major barrier for health care providers. However, as stated in an editorial4 ‘a little better is still better’ and the marginal gains provided by non-pharmacological interventions could be used to improve postoperative recovery as a global human experience, even without much impact on pain intensity or opioids consumption. Utilization of CM treatments may help to reduce excessive anxiety and may improve sleep quality, two factors which greatly affect the pain severity, the need of rescue analgesics and the speed of postoperative recovery.Evidence of CM usefulness in perioperative caresSome CM therapies have gained more popularity in the recent years, by examples acupuncture and psychological interventions.Acupuncture could be considered as the ‘most invasive’ of all CM therapies. Perioperative acupuncture may reduce the incidence of postoperative nausea and decrease the frequency of anti-emetic drugs use.3 It may also modulate the body stress response to the surgical injury. Decrease of stress biomarkers like troponin levels after open cardiac surgery or S100β levels after craniotomy has been observed.5 6 Always in relation with the modulation of the stress response, perioperative acupuncture has been associated with decreased vasopressor requirements and improved glucose control. Transcutaneous electrical acupoint stimulation (TEAS ) is an emerging therapeutic approach that combines the effects of TENS (transcutaneous electrical nerve stimulation) with acupuncture points stimulation.7 TEAS is a non-invasive technique by contrast with traditional acupuncture and needle-based electrostimulation. Despite multiple applications, the mechanisms of TEAS still remain poorly understood and a large heterogeneity exists among published studies in relation with stimulation frequencies and stimulation points used.8 Two systematic reviews seem to conclude to some benefit of TEAS on the control of perioperative nausea-vomiting and pain, allowing to reduce some hospitalization costs.7 8 Psychological interventions include an umbrella of different types of interventions and techniques, from psycho-education, relaxation and behavioral modification therapies.9 Because emotions and cognition are strongly associated with the development of acute and chronic pain, psychological interventions are defined as strategie targeted towards reducing stress, anxiety, negative emotions and depression. By these mechanisms, these interventions help to reduce postoperative opioids use and pain scores in some patients. Whether these interventions have demonstrated their efficacy in chronic pain management e.g. in cancer patients,10 there is a clear need to show the perioperative benefits and more specifically to determine the optimal technique, the optimal timing of administration and the optimal patient9 Two recent systematic reviews and meta-analysis have questioned the role of perioperative psychological interventions on postsurgical pain, disability and psychologic well-being.11 12 Psychological approaches considered included cognitive-behavioral therapy (CBT), acceptance and commitment therapy (ACT) and mindfulness-based interventions (MBIs). The last meta-analysis12 which extended the review published by Nadinda et al,11 included 27 RCTs (around 3000 patients). Compared with usual care or control treatment, moderate quality evidence exists that psychological interventions reduced pain intensity and anxiety after surgery12 but did not influence pain catastrophizing or depression. According to the results, CBT seemed the most beneficial for surgical patients.12 Both reviews underlined the fact that psychological interventions delivered by a psychologist were more effective than those delivered by other professionals (i.e. anesthesiologists, surgeons, nurses…). It is worth noting the limitations of these systematic reviews, related to the quality and heterogeneity of the RCTs results. Among relaxation techniques, hypnosis and virtual reality (VR) are now very popular and widely used in perioperative setting. While hypnosis requires a specific formation, the utilization of VR only necessitates a specific equipment.13 It is worth noting that virtual reality includes a huge variety in the type of applied VR, from augmented reality to mixed reality, even including hypnotic suggestions. Clinical studies suggest that therapeutic effects of VR in reducing acute pain may be most evident when VR is administered at the same time of the painful stimulus.13 Some authors consider that VR and analgesia achieved from hypnosis are similar in that the patient is detached from reality. However, for hypnosis, patient susceptibility to hypnotic suggestion is an important consideration. Low quality evidence suggests that VR alone can reduce pain independent of hypnotizability. Further, the effectiveness of combining VR and hypnosis remains unclear.13 14 A study comparing perioperative hypnosis versus enhanced standard of care after total knee arthroplasty15 pointed out the fact that hypnosis lessened postoperative pain intensity (35%) and opioid use (54%) only in the subgroup of patients who were taking opioids before surgery. Well- known difficult perioperative management of this patients population makes the results particularly interesting and deserving further confirmation. Actual benefits of psychological interventions in operative setting have been measured in populations where patients suffering chronic pain conditions, presenting with psychiatric illness or chronic opioids intake have been excluded.9 Finally, among available psychological interventions, patient’s education plays an important role although its real benefits in terms of postoperative pain and analgesics use are far from evident.9 A recent study in patients presenting with a significant preoperative anxiety level has found that a brief short-term individualized information and empathic conversation, paired with an educational video significantly reduced preoperative anxiety compared to a standard preanesthetic consultation.16 Further studies should assess the postoperative benefit of such intervention on global recovery.In conclusion, patient’s participation to their perioperative cares has a major impact on the overall benefit of the surgical procedure. The failures of classical analgesic treatments and the opioid health-related crisis point out the importance to optimize current perioperative management by promoting different approaches. Today, growing evidences support the utilization of CM as adjuvants to standard perioperative treatments, particularly to improve postoperative recovery as a global human experience. Future research should question the role, the indications and the benefits of integrating complementary medicine in perioperative pain management. Rigorous research protocols are mandatory and need to consider the patient’s global recovery experience, beyond postoperative pain scores and opioid consumption.Abstract FT39 Table 1Advantages and barriers for the use of perioperative complementary medicine Advantages Barriers - Holistic medicine- Opioid-free techniques- No side effects- Low cost - Scientific evidence lacking- Poor quality of existing studies- Need of trained providers (hypnosis, psychological techniques…)- Time to apply the technique- Individualization of available treatments References Jena PORG, Chinese POUTn, Dutch POUTn, Mexican POUTn, Serbian POUTn, Spanish POUTn, French POUTn, Italian POUTn, Swiss POUTn, Irish POUTn, et al. Status quo of pain-related patient-reported outcomes and perioperative pain management in 10,415 patients from 10 countries: analysis of registry data. Eur J Pain. 2022;26:2120–2140.Haythornthwaite JA, Campbell CM, Edwards RR. When thinking about pain contributes to suffering: the example of pain catastrophizing. Pain 2024;165:S68-S75.Kelleher DC, Kirksey MA, Wu CL, Cheng SI. Integrating complementary medicine in the perioperative period: a simple, opioid-sparing addition to your multimodal analgesia strategy? Reg Anesth Pain Med. 2020;45:468–473.Leng JC, Mariano ER. A little better is still better: using marginal gains to enhance ‘enhanced recovery’ after surgery. Reg Anesth Pain Med. 2020;45:173–175.Asmussen S, Przkora R, Maybauer DM, Fraser JF, Sanfilippo F, Jennings K, Adamzik M, Maybauer MO. Meta-analysis of electroacupuncture in cardiac anesthesia and intensive care. J Intensive Care Med. 2019;34:652–661.Asmussen S, Maybauer DM, Chen JD, Fraser JF, Toon MH, Przkora R, Jennings K, Maybauer MO. Effects of acupuncture in anesthesia for craniotomy: a meta-analysis. J Neurosurg Anesthesiol. 2017;29:219–227.Szmit M, Krajewski R, Rudnicki J, Agrawal S. Application and efficacy of transcutaneous electrical acupoint stimulation (TEAS) in clinical practice: a systematic review. Adv Clin Exp Med. 2023;32:1063–1074.Liu Y, Fan J, Zhang X, Xu W, Shi Z, Cai J, Wang P. Transcutaneous electrical acupoint stimulation reduces postoperative patients’ length of stay and hospitalization costs: a systematic review and meta-analysis. Int J Surg. 2024;110:5124–5135.Gorsky K, Black ND, Niazi A, Saripella A, Englesakis M, Leroux T, Chung F, Niazi AU. Psychological interventions to reduce postoperative pain and opioid consumption: a narrative review of literature. Reg Anesth Pain Med. 2021;46:893–903.Berliere M, Roelants F, Watremez C, Docquier MA, Piette N, Lamerant S, Megevand V, Van Maanen A, Piette P, Gerday A, et al. The advantages of hypnosis intervention on breast cancer surgery and adjuvant therapy. Breast 2018;37:114–118.Nadinda PG, van Ryckeghem DML, Peters ML. Can perioperative psychological interventions decrease the risk of postsurgical pain and disability? A systematic review and meta-analysis of randomized controlled trials. Pain 2022;163:1254–1273.Castano-Asins JR, Barcelo-Soler A, Royuela-Colomer E, Sanabria-Mazo JP, Garcia V, Neblett R, Bulbena A, Perez-Sola V, Montes-Perez A, Urrutia G, et al. Effectiveness of peri-operative psychological interventions for the reduction of postsurgical pain intensity, depression, anxiety and pain catastrophising: a systematic review and meta-analysis. Eur J Anaesthesiol. 2025;42:609–625.Shanthanna H, D’Souza RS, Johnson RL, YaDeau JT. How real are the effects of virtual reality in decreasing acute pain? Anesth Analg. 2024;138:746–750.Rousseaux F, Bicego A, Ledoux D, Massion P, Nyssen AS, Faymonville ME, Laureys S, Vanhaudenhuyse A. Hypnosis associated with 3D immersive virtual reality technology in the management of pain: a review of the literature. J Pain Res. 2020;13:1129–1138.Markovits J, Blaha O, Zhao E, Spiegel D. Effects of hypnosis versus enhanced standard of care on postoperative opioid use after total knee arthroplasty: the HYPNO-TKA randomized clinical trial. Reg Anesth Pain Med. 2022.Salzmann S, Kikker L, Tosberg E, Becker N, Spies M, Euteneuer F, Rusch D. Impact of a personalized intervention on preoperative anxiety and determination of the minimal clinically important difference in anxiety levels: a randomized clinical trial. Anesthesiology 2025;142:680–691.",
  "authors": [
    {
      "affiliations": [
        "Cliniques Universitaires St Luc, UCL, Brussels, Belgium"
      ],
      "name": "Patricia Lavand’hommep"
    }
  ],
  "title": "FT39 New stuff on the scene. Role of non-pharmacological treatments",
  "uid": "73c04522-9043-5257-815a-0082c17843a2"
}