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1. J Clin Nurs. 2002 Jul;11(4):457-61.
An experimental study on the use of manual pressure to reduce pain in intramuscular
injections.
Chung JW, Ng WM, Wong TK.
School of Nursing, The Hong Kong Polytechnic University, Kowloon, Hong Kong.
Abstract
To investigate whether the application of manual pressure to the injection site before
intramuscular injection reduces pain. An experimental study with intra subject
comparison was conducted using manual pressure to reduce pain associated with
intramuscular injection. Seventy-four subjects, participating in an immunization
vaccination campaign, were recruited by convenience sampling from a university. They
were required to receive two doses of vaccines via intramuscular injections. One was
given in a conventional way, i.e. without manual pressure being applied prior to the
injection (control condition). The other was given with manual pressure being applied
prior to the injection (experimental condition) for 10 seconds. The two conditions were
randomly allocated for each subject. The instrument for measuring the perceived pain
intensity was the Pain Intensity Verbal Rating Scale (Cantonese). To ensure the
consistency of manual pressure being applied to the injection site, a mechanical pressure
sensor device was used to record the manual pressure being applied. The mean manual
pressure applied was 190.82 mmHg (SD=5.25). Results demonstrated a significant
difference in the perceived pain intensity for experimental and control conditions.
Subjects with manual pressure applied before injections reported lower pain intensity
scores, whilst those without the application of manual pressure before injections reported
higher pain intensity scores. Applying manual pressure to an injection site before
performing an injection could be an effective means of decreasing pain intensity.
PMID: 12100641 [PubMed - indexed for MEDLINE]
2. J Pain Symptom Manage. 1996 Jul;12(1):52-8.
Using pressure to decrease the pain of intramuscular injections.
Barnhill BJ, Holbert MD, Jackson NM, Erickson RS.
Medford School District, Jackson County Department of Health and Human Services,
Medford, Oregon, USA.
Abstract
The purpose of this study was to determine if applying pressure to the site for 10 sec prior
to an intramuscular injection would reduce injection pain, an approach suggested by
anecdotal observation and the gate control theory. The subjects were 93 patients who had
dorsogluteal intramuscular injections of immune globulin at a county health department.
Forty-eight received the pressure treatment and 45 received a standard injection in which
no pressure was applied. Mean pain intensity on a 100-mm visual analogue scale,
adjusted for differences in injection volume, was 13.6 mm for the experimental group and
21.5 mm for the control group (P = 0.03). The findings suggest that simple manual
pressure applied to the site is a useful technique to decrease injection pain.
PMID: 8718917 [PubMed - indexed for MEDLINE]
3. Minerva Anestesiol. 2005 Oct;71(10):609-15.
A new method to reduce pin-prick pain of intra-muscular and subcutaneous injections.
[Article in English, Italian]
Romanò CL, Cecca E.
Orthopedic Institute Gaetano Pini, Piazza Cardinal Ferrari 1, 200122 Milan, Italy.
Abstract
AIM: Although about 10% of the normal population is thought to be needle-phobic, no
method to reduce pin-prick pain is currently available for large scale application. We
describe a new simple and easy-to-do method to reduce pin-prick pain through the
pressure of multiple blunt pins at the injection site. METHODS: Two-hundred and twelve
patients were randomly assigned to 2 groups. The treated group (n= 106) received
intramuscular and subcutaneous injections with the application of the blunt pins and the
control group (n= 106) with a placebo device. Pain was tested with the visual analogue
scale on a 0 (no pain)-10 (maximum pain) scale. RESULTS: After intramuscular
injections a significant (P< 0.0001) pain reduction in the treated group compared to
placebo was observed: 1.90+/-1.27 versus 5.16+/-1.37 (mean pain reduction: 63.2%);
88.5% of the patients in the treated group and 11.4% in placebo group rated the pain as =
or < 3. After subcutaneous injections mean reported pain in the treated group compared
to placebo was: 0.32+/-0.51 versus 2.61+/-0.77 (mean pain reduction: 87.7%) (P<
0.0001); 95.1% of the patients in the treated group and 9.8% in the placebo rated the pain
as = or <1. No side effects were observed. CONCLUSIONS: Multiple blunt pins pressure
on the skin, at the time of intramuscular or subcutaneous injection is able to significantly
reduce pin-prick pain. The underlying physiological mechanisms are briefly discussed.
PMID: 16163151 [PubMed - indexed for MEDLINE]
4. Physical interventions and injection techniques for reducing injection pain during
routine childhood immunizations: systematic review of randomized controlled
trials and quasi-randomized controlled trials.
Taddio A, Ilersich AL, Ipp M, Kikuta A, Shah V; HELPinKIDS Team.
Collaborators (14)
Taddio A, Appleton M, Bortolussi R, Chambers C, Dubey V, Halperin S, Ipp M, Lockett
D, MacDonald N, Midmer D, Mousmanis P, Rieder M, Scott J, Shah V.
Division of Pharmacy Practice, Leslie Dan Faculty of Pharmacy, University of Toronto,
Toronto, Ontario, Canada. [email protected]
Abstract
BACKGROUND: Vaccine injections are the most common reason for iatrogenic pain in
childhood. With the steadily increasing number of recommended vaccinations, there has
been a concomitant increase in concern regarding the adequacy of pain management.
Physical interventions and injection techniques that minimize pain during vaccine
injection offer an advantage over other techniques because they can be easily
incorporated into clinical practice without added cost or time. Their effectiveness,
however, has not previously been studied using a systematic approach. OBJECTIVE: The
purpose of this review was to determine the effectiveness of physical interventions and
injection techniques for reducing pain during vaccine injection in children. METHODS:
MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials
databases were searched to identify randomized controlled trials (RCTs) and quasi-RCTs
that determined the effect of physical interventions and injection techniques on pain
during injection of vaccines in children 0 to 18 years of age, using validated child self-
reported pain or assessments of child distress or pain made by others (parent, nurse,
physician, observer). We sought to determine the effects of: (1) different formulations of
the same vaccine; (2) position of the child during injection; (3) intramuscular versus
subcutaneous injection; (4) cooling of the skin at the injection site with ice before
injection; (5) stroking the skin or applying pressure close to the injection site before and
during injection; (6) order of vaccine injection when 2 vaccines were administered
sequentially; (7) simultaneous versus sequential injection of 2 vaccines; (8) vaccine
temperature; (9) aspiration before injection; (10) anatomic location of injection; (11)
aspects of the needle (gauge, length, angle of insertion, speed of injection); and (12)
combinations of these interventions. All meta-analyses were performed using a fixed-
effects model. RESULTS: Nineteen RCTs involving 2814 infants and children (0-18
years of age) were included in the systematic review. One study included children >or=16
years and adults (n = 150). Interventions with positive findings are summarized here. In 2
trials that used child self-reports of pain during administration of measles-mumps-rubella
vaccine (total, 680 children with complete data), the Priorix vaccine caused less pain than
the M-M-R(II) vaccine (standardized mean difference [SMD], -0.66; 95% CI, -0.81 to -
0.50; P < 0.001). In 3 trials (404 children), the number needed to treat (NNT) with Priorix
to prevent 1 child from crying was 3.2 (95% CI, 2.6-4.2). In 4 trials (281 infants and
children), sitting children up or having parents hold infants appeared to cause less pain
than the supine position, but the difference was not statistically significant; however,
significant heterogeneity was found among the studies, and a qualitative approach was
used for data analysis. A benefit was observed for 3 of the 4 studies; the SMD ranged
from -0.4 to -0.8 (P < 0.05 for all analyses). The negative findings observed for the
remaining study may have been the result of methodologic heterogeneity. Stroking the
skin close to the injection site before and during injection reduced pain in 1 trial (66
children; SMD, -0.53; P = 0.03). One study (120 children) found that when diphtheria-
polio-tetanus-acellular pertussis-Haemophilus influenzae type b (DPTaP-Hib; Pentacel)
and pneumococcus (Prevnar) were injected sequentially during the same office visit,
observer- and parent-reported pain scores were lower when DPTaP-Hib was injected first
(SMD, -0.40 and -0.57, respectively; P <or= 0.03). In 1 study (113 infants) comparing
rapid intramuscular injection without aspiration and slow intramuscular injection with
aspiration, the rapid injection without aspiration was associated with less pain (SMD, -
0.62 to -0.97 for parent, nurse, physician, and observer behavioral pain ratings; all, P <
0.05). The NNT to prevent 1 infant from crying was 2.5 (95% CI, 1.8-4.3).
CONCLUSIONS: Pain during immunization can be decreased by: (1) injecting the least
painful formulation of a vaccine; (2) having the child sit up (or holding an infant); (3)
stroking the skin or applying pressure close to the injection site before and during
injection; (4) injecting the least painful vaccine first when 2 vaccines are being
administered sequentially during a single office visit; and (5) performing a rapid
intramuscular injection without aspiration.
PMID: 19781436 [PubMed - indexed for MEDLINE]
5. Effectiveness of acupressure to reduce pain in intramuscular injections
Negin Masoudi Alavi
Received 22 April 2007; received in revised form 12 September 2007; accepted 25
September 2007.
Summary
Background
Acupressure is a massage technique which can induce relaxation. The effectiveness of
acupressure to reduce pain in intramuscular injection was studied in this research.
Methods
It was a crossover single blind experimental design. The patients who were prescribed
penicillin for at least two daily doses were included in the study. Each subject received an
injection with acupressure applied to one buttock and an injection without acupressure to
the other buttock or vice versa. The two conditions were randomly allocated. The
perception of pain was measured on a visual analogue scale.
Results
Sixty-four patients were recruited into the study. Thirty-two (50%) were female. The
mean age was 28 ± 9.9 years old. Fifty patients were injected with penicillin 6.3.3 (78%)
and 14 patients received penicillin G plus procaine (22%). The mean score for perceived
pain intensity for the acupressure injection was 3 ± 2 and the mean score for the injection
without acupressure was 5 ± 2. The result showed that the perceived pain intensity was at
average 2.5 lower in the acupressure group comparing to ordinary injection (P < 0.000).
Conclusions
According to findings the acupressure can reduce the pain of intramuscular injection.
Nicoll LH, Hesby A. Intramuscular injection: an integrative research review and guideline
for evidence-based practice. Appl Nurs Res 2002;15:149–62.
2 Halperin BA, Halperin SA, McGrath P, et al. Use of lidocaine-prilocaine patch to decreaseintramuscular injection pain does not adversely affect the antibody response todiphtheria-tetanus-acellular pertussis-inactivated poliovirus-Haemophilus influenzae typeb conjugate and hepatitis B vaccines in infants from birth to six months of age. Pediatr InfectDis J 2002;21:399–405.3 Cassidy KL, Reid GJ, McGrath PJ, et al. A randomized double-blind, placebo-controlledtrial of the EMLA patch for the reduction of pain associated with intramuscular injection
in four to six-year-old children. Acta Paediatr 2001;90:1329–36.
