Preemptive and Preventive Pain Psychoeducation and its Potential Application as a Multimodal Perioperative Pain Control Option

A Systematic Review

Audrey Horn, BS; Kelly Kaneshiro, BS; Ban C. H. Tsui, MD, FRCPC


Anesth Analg. 2020;130(3):559-573. 

In This Article


Studies range from 1955 to 2018, including a large percentage from the 80s, were identified. The search resulted a total of 338 publications (Supplemental Digital Content 2, Figure 1, All titles were manually screened by 2 authors. At the first stage, articles unrelated to human subjects or not in English were excluded, leaving a total of 55 publications for further evaluation. We further excluded 31 publications due to their focuses having no direct relationship to pain education such as prerehabilitation, performance of surgeons, virtual reality, observational studies, unpublished studies, therapeutic play, lack of postoperative outcome measures, supportive care intervention, and image guiding studies. We also evaluated an additional 6 articles that were referred by an expert colleague to our review. During the peer review process, 13 additional articles were evaluated as recommended by reviewers. The result of literature assessment based on Oxford levels of evidence is summarized in Table 1, Table 2, Table 3 and Table 4.

Preoperative Anticipated Pain Education

Koyama et al[13] conducted a study where patients were examined in functional magnetic resonance imaging (fMRI) machines, and different temperature stimulus was given to their legs at different time intervals (Table 2). They found that an inflated expectation of pain (illustrated by longer waiting time between temperature stimuli) more strongly activate neural processes that sense pain and influence the physical sensation (R2 = 0.88, P < .0001). An inflated expectation can lead to a stronger physical sensation of pain. For example, a study of 567 patients undergoing breast surgery found that patients with inflated expectations of postoperative pain experienced more pain up to 7 days after surgery compared to patients who had lower expectations of pain.[14] Furthermore, Wang et al[7] conducted a study of 259 surgical patients and examined the effects of preoperative beliefs on postsurgical pain score. Patients with long-term surgical fears were significantly correlated with developing CPSP.[7] In addition, the patient–practitioner relationship is negatively affected when a patient is told that a procedure will be painless because the patient will perceive their pain to be abnormal and/or something to be worried about.[38] Ridgeway and Mathews[15] found that patients who believe they understand the surgical process and deny information about their surgery form a mismatch between expectation and reality. These patients have consumed more analgesics and report higher levels of incisional pain compared to informed patients.[15] In addition, medical settings can lead to strong patient emotions such as anxiety and anger, impeding their abilities to communicate with medical staff.[38] Patients may feel overwhelmed, which can prevent physicians from having open conversations about medical procedures and their aftermath. Therefore, physicians should be truthful about postoperative pain to prevent a mismatch between patients' pain expectations and physical sensation. Inaccurate pain expectations will lead to increased severity of acute postoperative pain.

Authors' Interpretation. Based on 3 studies with Oxford levels of evidence of 1b, there is strong evidence suggesting that pain expectation will have an impact on postoperative recovery. Patients who are not fully informed about postoperative pain may develop a mismatch between pain expectation and physical sensation.[6] When physical pain sensory information matches the expected sensation, patients feel some degree of reassurance.[15] Hence, preoperative anticipated pain education should be considered by physicians in preemptive pain psychoeducation.

Procedural Pain Knowledge

Preoperative procedural and pain management information improves patient pain control and shortens their recovery time (Table 3). A review of 34 studies showed that psychological intervention and educational approaches during surgery preparation or recovery from surgery resulted in a 2.37-day shorter hospitalization.[11] Egbert et al[16] conducted a study where 97 patients were split into 2 groups: the control group was given general information about the hospital ward and the "special care" group was given preoperative pain education. The special care group received about half the narcotics and went home on average 2.7 days earlier than the control group.[16] Devine and Cook[39] did a meta-analysis of 49 studies and found that preoperative education about procedural information, pain management methods, and psychological support can reduce the length of hospitalization by 1.25 days. A systematic review of patient education for orthopedic surgery patients found that patient education significantly reduced the length of hospital stays compared to those who received no patient education or information.[17] Another study found that participation in a single preoperative multidisciplinary educational session resulted in about a 50% reduction in emergency room visits in the first 12 weeks after spine surgery compared to the controlled cohort (16 emergency room visits in the education cohort and 33 visits in the no education cohort).[18] With proper pain education and management, physicians may be able to prescribe fewer narcotics and decrease patient hospitalization.

Studies focusing on pain have shown a significant relationship between inadequate preoperative information and higher postoperative anxiety and pain score. In a study of 1609 elective total joint arthroplasty patients, Lemay et al[19] showed that patients who receive information about postoperative pain management options report lower current pain 24 hours after surgery and higher levels of pain relief than patients who did not receive pain management information. Six months after surgery, the informed patients also demonstrated higher mean physical function scores and were more likely to use pain management practices.[19] These factors may have played a role in decreasing their postoperative pain. Moreover, when physicians provided preoperative information about the effects of analgesics, there was a significant placebo effect causing a decrease in neuropathic pain intensity and unpleasantness.[20] Stomberg et al[21] demonstrated a significant correlation between poor preoperative information and increased postoperative nausea and vomiting among 110 surgical patients. A study by Sjöling et al,[40] involving 60 patients undergoing total knee arthroplasty, looked at the efficacy of educating patients about the importance of postoperative pain management and taking an active role in their own pain treatment. The treatment and control groups were given basic preoperative information, but the treatment group was also educated about their own role in pain management and instructed to inform medical staff about their pain.[40] The treatment group reported lower preoperative state anxiety and increased satisfaction of care than the control group.[40] These studies demonstrate the importance of preoperative patient education for patient anxiety, satisfaction, and pain.

Authors' Interpretation. In light of 3 studies with Oxford levels of evidence 1a, 3 studies with 1b, and 1 study with 1c, procedural pain knowledge has a significant impact on pain control and recovery time, and patients who opted out of procedural pain education had longer hospitalization and poor pain management. Therefore, procedural pain knowledge is a good potential tool for physicians to improve patient pain control and decrease length of hospital stays.

Anxiety and Pain Catastrophizing Effect

The lack of preoperative information not only leads to a mismatch between pain expectation and sensation but also increases anxiety and catastrophizing (Table 4). Catastrophizing is defined as an exaggerated negative mental state during actual or anticipated pain experiences and is one of the most important psychological predictors of pain.[8,22] Studies show a significant interaction between catastrophic thinking and postoperative pain intensity.[23] A systematic review and meta-analysis of 29 studies by Theunissen et al[24] showed that, in a majority (55%) of studies, preoperative anxiety and pain catastrophizing are significantly associated with greater pain 3 months postoperatively and with CPSP. A study of 64 cardiac surgery patients illustrated that a pain catastrophizing score above the median was associated on average with a 1.8 higher postoperative pain score (based on a 10-point verbal rating scale).[25] In addition, Kain et al[26] conducted a study with 53 women undergoing elective abdominal hysterectomy and found that preoperative state anxiety was significantly correlated with increased levels of postoperative pain directly after surgery and 1 week later (r = 0.35, P < .01; r = 0.29, P < .05). Another study found that catastrophizing, anxiety, and depression scores (on Pain Catastrophizing Scale, Hospital Anxiety and Depression Scale) were associated with higher pain scores and lower quality of recovery.[27] Some patients have a fear of the unknown, which can develop into medical phobias and increase their anxiety.[38] Similarly, higher levels of pain catastrophizing are linked to a weaker opioid analgesia response.[28,41] Pediatric research showed that high expected pain is a predictor of postoperative pain.[6,42,43] Adolescent surgery patients who expected higher levels of postoperative pain experienced greater intensity postoperative pain and utilized more patient-controlled analgesia (PCA) medication than those who expected lower levels of pain. In this study, adolescent anticipated pain score was the strongest predictor of postoperative pain.[29] Pain catastrophizing is thought to interrupt descending pain inhibition signals to the spinal cord preventing neuroplastic changes that normally respond to painful stimuli.[30] This stimulates pain sensitization and can hinder pain management. A study of patients undergoing lumbar spinal surgery demonstrated a significant correlation between higher preoperative Pain Catastrophizing Scale (PCS) scores and increased 3-year postoperative pain/disability.[33] Therefore, identification of patients at risk for catastrophizing before surgery could serve as a basis for initiating a more comprehensive preemptive pain psychoeducation.[31] Education about the postoperative care, surgical procedure, and operative environment has been shown to reduce preoperative anxiety, postoperative pain, and, in some cases, decreased number of postsurgical calls related to reassurance of their recovery.[32,44]

Authors' Interpretation. Two studies with the Oxford levels of evidence of 1a and seven 1b studies suggest that there is a strong negative relationship between preoperative anxiety/pain catastrophizing and postoperative recovery. Therefore, preemptive pain psychoeducation focusing on preoperative education and pain management should be considered as part of a multimodal approach in addressing the preoperative psychological state of patients to improve recovery.

Information Delivery Strategy

Presenting information on postoperative pain before surgery may affect patient outcome and satisfaction (Table 5). Patients' primary complaints are the lack of information and the complex nature of doctors' language.[35] Scientific language can make patients feel helpless and confused, and in turn, patients may attempt to regain control by withholding information from the physician, which could lead to a misdiagnosis. Using lay terms to explain the surgical process and outcomes can help patients feel more comfortable and avoid conflict of information control between both parties.[38] Patients can then more easily participate in conversations with a physician rather than blindly accepting the doctor's information. In fact, patients are most satisfied when they participate in the consultation by discussing their opinions and experiences with the physician.[34] Open conversation can help regain a patient's sense of control and diminish some fears about the surgical process.[38] By educating patients about pain management and encouraging open discussions, patients can verbalize their postoperative pain at an early stage to the medical staff, and physicians can use effective pain management methods to prevent high peaks of pain.[40]

According to Pereira et al,[45] a sympathetic patient-centered approach can reduce preoperative anxiety, improve surgical recovery and wound healing, and increase patient satisfaction. One hundred four ambulatory surgery patients were assigned to a control or intervention group. The intervention group received a 15-minute individual interview conducted by a trained nurse who sympathetically addressed questions regarding the surgery to validate each patient's concerns. On postoperative day 1, the intervention group had lower pain levels, better surgery recovery, more physical activity, and more satisfaction with the quality of preoperative information. One month later, the intervention group had lower levels of local pain and better wound tissue type.[45] Because anxiety is associated with slower wound healing and more postoperative pain, it is beneficial to provide sympathetic patient-centered care to reduce patient anxiety.[36]

Kastanias et al[48] conducted a survey of 150 surgical patients' wants and needs. The top 3 items of importance were all related to pain expectations, experience, and severity.[48] Patients wanted information about drugs prescribed, their effectiveness and side effects, and who to call if the pain is not well controlled.[48] When information is given by physicians, patients typically only accurately recall about half of the recommendations and information.[46] A solution would be to provide written information in a general format for all different types of populations undergoing surgery.[48] Hospitals can create a streamlined structure for preoperative patient education for health care. Individualized information could still be added to patient education, but the overall structure would be implemented to maximize patient outcome and minimize postoperative pain. In fact, 90% of patients undergoing arterial bypass surgery felt that a preoperative educational booklet was helpful.[47] However, only providing written information for patient education is not adequate. In a study comparing verbal information from a nurse or physician and written handouts, more knowledge was gained through verbal information.[9] Yek et al[37] conducted a survey in Singapore of 364 surgical patients' preferences regarding information during the anesthesia consent-taking process. They found that most patients prefer a clinic consult instead of audio–visual multimedia for preoperative anesthetic counseling. This reinforces the fact that physicians should provide better preoperative procedural and pain information in conjunction to distributing written materials to patients. Preoperative education classes are another effective method to provide procedural pain education to patients, but it may not be feasible due to the increase in time required by medical personnel to provide such classes.[32]

Authors' Interpretation. The way health care providers address patients and present psychoeducational pain information should be considered. An open and sympathetic discussion between providers and patients is crucial for optimal satisfaction and maximum recovery. Based on the strong Oxford level of evidence of three 1b articles, some form of written or electronic psychoeducation should be provided along with verbal information during preoperative consulting.

Psychoeducational Cost

Last but not least, an important question to address is the operation cost of patient education on today's limited resource economic environment (Table 6). It is a difficult topic to directly address because there is limited research on the cost of increasing preoperative education. Also, there has been a trend in hospitals to lessen interventions that treat preoperative patient anxiety due to increasing operational costs.[49] However, postoperative complications may cost patients up to $10,000 or more in hospital expenses.[50] Through increased preoperative education, physicians can reduce a patient's anxiety which lowers their risk to complications and ultimately lowers hospitalization time and analgesic use.[11,16] Similarly, Devine and Cook[10] did a meta-analysis of 102 studies and found that psychoeducational intervention can decrease recovery time and pain which can be cost-effective for hospitals. If hospitalization, complications, and analgesics are all decreased with the help of preoperative pain education, then hospitals can potentially save thousands of dollars per patient by implementing psychoeducational programs.

Authors' Interpretation. Although there is limited existing research within this topic, the Oxford levels of evidence of 2 1a papers and 1 1b paper strongly support that implementing preemptive pain psychoeducation could decrease health care costs.