Pain Management Strategies- A Scoping Review
Pain is a common problem among adults. It is even worse when it comes to chronic pain management. Various studies have shown that chronic pain affects quality of life. It is thus important that effective strategies are identified to help adults manage pain effectively improving their life quality. This study used a scoping review approach to identify pain management strategies among adults from the existing literature. The scoping review was done through the use of Arksey and O’Malley’s framework. A search was conducted using PubMed, Ovid, and ProQuest identifying scoping review sources. The search items were pain, pain management, scoping review, and Roy Adaptation Model. The search included articles published between 2000 and 2019 published in English. Twenty-five articles were considered for the scoping review. The study found two outcomes measures. The first was that pain is a common problem among adults which could be decreased through pain management. The second outcome was that managing pain improves general wellbeing for adults. Many interventions were reported to improve pain management among adults. However, nurses need to discover better strategies and understand the RAM concept to improve pain management.
Pain management, chronic pain, a scoping review
Pain is a common problem among adults. It is even worse when it comes to chronic pain management. Various studies have shown that chronic pain affects the quality of life (Reid, Eccleston, & Pillemer, 2015). Billions are used in addressing pain since it is a public health concern and also a major cause of disability (Reid, Eccleston, & Pillemer, 2015). People suffering from diabetes mellitus, sickle cell illness, respiratory illness, osteoarthritis, cancer, and peripheral vascular illness are more likely to experience pain. Of particular are minority groups who face disparities in pain management. Although there is an increasing focus on chronic pain, managing the main remains problematic (Reid, Eccleston, & Pillemer, 2015). This creates a research gap on the best strategies for managing pain.
Chronic pain overburdens individual patients, their families as well as society in general. It is associated with mobility-related falls and disability. Adults suffering from chronic pain show a substantial weakening in physical performance (Reid, Eccleston, & Pillemer, 2015). They also show lower confidence in balance. Studies have also shown that chronic pain creates a favorable environment for psychological symptoms such as anxiety, social isolation, and depression (Brown et al., 2011). Therefore, chronic pain impacts health care system. For example, it increases the rate of hospitalization. In the US, adults are regularly seeking healthcare for persistent musculoskeletal pain. This is also the most expensive non-malignant health issues in the country (Reid, Eccleston, & Pillemer, 2015). However, despite the increasing rate of chronic pain issues and the availability of various management strategies, inadequate documentation exists on pain management strategies among adults (Reid, Eccleston, & Pillemer, 2015). Since nurses serve in the first line in provision of healthcare, they are in a good position to push the implementation of national standards in giving proper services that ensure that people receive quality care that is respectful, understandable, effective, and most of all equitable (Eggermont et al., 2014). This care should also be responsive to different practices, and beliefs.
Increasing pain intensity requires nurses to understand the best strategies when it comes to pain management (Eggermont et al., 2014). In this case, pain interventions include factors that promote effective adaptation to pain. The purpose of this study was to describe pain management strategies through a scoping review of existing literature on pain and pain management. The three objectives of this review were 1) to conduct a search on published literature on pain and pain management, 2) to identify pain management strategies identified in these papers, and 3) to provide recommendations for future research.
A scoping review design was used. This methodology was necessary as it allows the assessment of emerging evidence. It is also the first step in research development (Peterson et al., 2016). Unlike the traditional systematic review, a scoping review allows the researcher to focus on a more general question. This design allows a researcher to explore relevant existing literature. This method was needed as it allows more flexibility in literature search and analysis (Peterson et al., 2016). It accounts for diversity when it comes to relevant literature. A researcher is also free to include quantitative as well as qualitative research in a scoping review. It is thus a perfect design in exploring a complex topic. Also, this design is not new in nursing field. Several scoping reviews have already been completed (Peterson et al., 2016). This shows that use of this design id developing essential for advancing nursing practices and theory.
Conceptual framework-The Roy Adaptation Model
This model is among the most useful conceptual framework in nursing. It does not only guide clinical practices but also organizes research in nursing and influences education of nurses (Fawcett & DeSanto-Madeya, 2013). The model conceptualizes a human being as a holistic adaptive system. It also focuses on life adaptation process in regard to a changeable environment. This process of adaptation starts when an individual responds to an internal or external stimulus (Fawcett & DeSanto-Madeya, 2013). Roy identified three environmental stimuli. The first one is focal stimuli. This is the immediate and apparent cause of a problem. Second is contextual stimuli which the causative factor. The last one is residual stimuli which relate to past experiences.
In this model, there are two coping mechanisms. There are cognator and regulator subsystems. The cognator subsystem responds through emotional, perception, or through the process of learning (Fawcett & DeSanto-Madeya, 2013). On the other hand, the regulator subsystem is physiological in nature. It responds through endocrine, neurological, and chemical systems. According to Roy, nurses are supposed to manage environmental stimuli so that the three stimuli fall on the positive coping field of an individual patient promoting adaptation (Fawcett & DeSanto-Madeya, 2013). Adaptation, in this case, refers to a positive response to environmental stimuli. Roy Adaptation model guided this study as a conceptual framework.
The methodology for the scoping review was based on Arksey and O’Malley’s framework (2005). This review framework involves five stages. These are the identification of research questions, identification of studies that are relevant, selection of relevant studies, extraction data, and summary and reporting of findings (Brien et al., 2009).
This scoping review was guided by the question, ‘What are the effective pain management strategies identified in the existing literature?’ For the purposes of this review, a scoping review is well-defined as a research synthesis, which aims at mapping literature on a certain research area providing an opportunity to identify sources of evidence to inform policymakers and practice and to identify research gap (Daudt et al., 2013).
For this study, a scoping search was conducted using ProQuest, PubMed, and Ovid. The search included citations published between 2000 and 2019 and published in English. The key search terms were scope review, pain, chronic pain, and pain management. A manual search was also conducted to identify original articles.
Two processes were used in identifying relevant sources. The inclusion criteria limited the search to those that included pain and pain management, those written in English, and those published between 2000 and 2019. The exclusion criterion was citations with irrelevant literature review. Also, citations written in other languages such as French were excluded.
The first step in screening was removing duplicates. Then the remaining articles were screened based on title and abstract. This helped in reducing the cost of procuring sources that may not be useful for this scoping review. This is why only sources that met the minimum inclusion criteria were used. The abstract and title of every citation were screened.
Then, all citations that were considered relevant were procured for full-text review. For some sources, attempts were made to contact the journal for help in procurement.
|Records identified through database searching|
(n = 95)
Figure 1. PRISMA flowchart of the study selection process.
The original search yielded 95 citations that were potentially relevant through the electronic database search. These citations were retrieved from Ovid, ProQuest, and PubMed. After relevance screening and deduplication, 42 citations met the eligibility criteria on the basis of abstract and title. The matching full-text articles were acquired for review. Five articles could not be acquired and were thus not included in the review. After categorizing data of these articles, 7 more were excluded. Therefore, 25 articles were selected and included for analysis. The selecting process is presented in figure 1(PRISMA flowchart). PRISMA is the most preferred reporting diagram for research reviews. The review excluded many citations during the screening process based on abstract and title since similar terms were used corresponding to other studies.
This scoping review used the PICO process for a quality review. First, it outlines the problem which was pain. Second, it outlined the intervention which was pain management. Third, it compared evidence in the existing literature review. Fourth, it presented the outcome which is used of pain management strategies on relieving pain. The researcher analyzed the article, identified research gaps, and summarized the findings of the existing literature on pain and pain management.
For this scoping review, from the search results, the researcher reviewed article titles and abstracts. Also, publication journals, names of the authors and their institutions were noted during the review. Various aspects were reviewed for each article including study purpose, design, population sample, and findings and their relevance.
For this scoping review, studies were grouped based on study subjects. The aim of this synthesis was discussing the available evidence on pain management and also identifying research gaps.
Of the 25 selected articles, 10 used a quantitative research method (see table). On the other hand, 15 used a qualitative research method.
Table 1. Study Findings
|Puia & McDonald (2014)||A quantitative descriptive design was used||Old black adults||Exercise regimen or physical therapy Current pain treatments|
|Booker (2015)||Qualitative research||Older African American||Biomedicine and spiritual medicine|
|Sewell Andreae, Luke & Saffor(2012)||Qualitative study||Middle-aged women||Generic medications|
|Buck & Meghani (2012)||Qualitative method||African American and white patients||use of spirituality|
|Janevic Janevic Robinson-Lane, Murphy & Piette (2019)||Quantitative research||African Americans age 60+ years||Use of self-care strategies|
|Walker, Thorpe Jr, Harrison, Baker, Cary, Szanton & Whitfield, 2016)||Quantitative research method||African American women and men||None|
|Robinson-Lane & Booker (2017)||Qualitative research||Older Black adults||Nurse engagement and persistence strategies|
|Bosch & Cano (2013)||Qualitative research||African-American adults||None|
|White, Jiang, Hall, Katz, Zimmerman, Sliwinski & Lipton(2014)||Quantitative research||Individuals aged 70 and above||No strategies|
|Gayman, Brown& Cui (2011||Quantitative research||Adults from different cultural groups||No strategies|
|Tait & Chibnall (2014)||Qualitative research||Older African Americans||None|
|Taylor, Taylor, Parker, Thorpe Jr & Whitfield (2019)||Quantitative research||Older blacks in the US||None|
|Booker (2015)||Qualitative research||Black Americans||None|
|Taylor, Campbell, Thorpe Jr, Whitfield, Nkimbeng, & Szanton (2018)||Quantitative research||Older African Americans|
|Xanthos, Treadwell & Holden (2010)||Qualitative research||African American men||None|
|Potter, Prather & Weiss, (2008)||Qualitative research||African American adults||Patient involvement in methadone treatment options|
|Ruben, Meterko & Bokhour (2018)||Quantitative research||African Americans||None|
|Gagnon, Matsuura, Smith & Stanos (2014)||Qualitative research||African Americans||None|
|NNP (2018)||Qualitative research||Older African American population||None|
|Rathbun, Stuart, Shardell, Yau, Baumgarten & Hochberg (2018)||Qualitative research||Older African American||None|
|Pasero & Herr (2015)||Qualitative research||Black American||Education-based treatment|
|Golightly, Allen, Stechuchak, Coffman & Keefe (2015)||Quantitative research||African American||Joint-pain ratings|
|Bazargan, Smith, Movassaghi, Martins, Yazdanshenas, Salehe Mortazavi & Orum,(2017)||Quantitative research||African American||Medications|
|Hawkins & Mitchell (2018)||Qualitative research||African American||Communication|
In all the 25 studies, all participants were adults. In 21 studies, participants were African Americans. 13 studies focused on pain management strategies (Puia & McDonald, 2014; Booker, 2015; Sewell Andreae, Luke & Saffor, 2012; Buck & Meghani, 2012; Janevic Janevic Robinson-Lane, Murphy & Piette, 2019; Robinson-Lane & Booker, 2017; Pasero & Herr, 2015; Golightly, Allen, Stechuchak, Coffman & Keefe, 2015; Bazargan, Smith, Movassaghi, Martins, Yazdanshenas, Salehe, Mortazavi & Orum, 2017; Hawkins & Mitchell, 2018). 12 studies were on pain and chronic pain (Walker, Thorpe Jr, Harrison, Baker, Cary, Szanton & Whitfield, 2016; Ruben, Meterko & Bokhour, 2018; Gagnon, Matsuura, Smith & Stanos, 2014; NNP, 2018; Rathbun, Stuart, Shardell, Yau, Baumgarten & Hochberg, 2018). Most studies used both males and females with a few focusing on men or women. The most common conditions that lead to chronic pain in these studies were arthritis, cancer, diabetes mellitus, sickle cell illness, respiratory and illness.
This scoping review found various pain management interventions including the use of medicines such as OTC and herbal medications, use of spiritual interventions such as reading the bible and prayers, and use of other interventions such as exercise as seen in Table 1. Most interventions were associated with the Roy Adaption Model. Based on the concept of stimuli in the model, several studies related to the focal stimuli concept. Pain intensity represented the focal stimuli in these studies. Other studies use concepts represented in contextual stimuli in RAM model. The studies used demographic data such as gender, age, and racial differences in determining pain intensity (Staja & Booker, 2014; Janevic et al., 2019). In regard to coping processes. Several studies related to cognator subsystem intervention. These were represented by medical and religious coping strategies. Religious coping strategies included reading the bible and prayers (Booker, 2015; Buck & Meghani, 2012; Janevic, 2019). Other article used non-religions strategies such as exercise (Janevic, 2019)
All selected articles reported two outcomes. First, pain is a common problem among adults which can be reduced through pain management strategies. Second, pain management strategies improve life quality among adults. This includes preventing psychological symptoms such as stress, anxiety, and depression.
The objectives of this study were to report the results of a scoping review of the existing literature on pain and pain management, specifically on adults. Other objectives were identifying research gaps and providing recommendations on future research on pain and pain management in adults. Based on older publications, pain and pain management are common problems for adults. This is associated with the various meaning given to pain as well as different responses given to treatment of pain (Reid et al., 2015).
With reference to the objectives of this study, 25 sources were included for review. In this review, two outcome measures were found. The first was that pain is a common problem among adults which could be decreased through pain management. The second outcome was that managing pain improves general wellbeing. The selected studies used pharmacological as well as non-pharmacological pain management interventions. Both of these interventions led to a reduction of pain, improvement of coping with pain, and as well as improvement of life quality in terms of physical, psychological, and spiritual wellbeing. Regarding pharmacological interventions, several pharmacological agents were used in the selected articles to treat pain in adults. These agents included generic medications, OTC, psychiatric medications and herbal supplements.
However, these interventions require providers to be keen especially when dealing with adults. Age changes affect the responsiveness to certain drugs. They also affect the risk of adverse effects. For example, for older adults, the risk of adverse effects from pharmacological treatment is higher. Therefore, healthcare providers are sometimes hesitant in prescribing pain drugs (Booker, 2015). According to Bazargan et al., (2017), there is increased use of polypharmacy among adults as well as increasing inappropriate use of medications. This shows that there is a problem with the use of medication to relieve pain among adults. The authors call for better strategies such as home-based pharmacists for better use of pharmacological pain interventions.
In these studies, several non-pharmacological interventions were used for pain management. Most of these studies found these interventions to have a positive effect on pain management. Some of the interventions used included communicating pain clearly with nurses, use of spiritual medicine such as bible reading and prayers, education on pain management, physical activity, and reduction of stress through self-care. For example, Sewell et al., (2012) show that educating African American adults about pain management can help them manage pain effectively. Still, some studies recommend the use of both pharmacological and non-pharmacological interventions for pain management among adults. For example, Booker (2015), recommends used of Biomedicine as well as spiritual medicine to effectively manage pain among adults.
Although all the selected studies suggested that pharmacological and non-pharmacological interventions are effective for pain management, they have some limitations. The first limitation is the choice of methodology. Some studies had a small sample size to gather enough evidence (Buck & Meghani, 2012). The sample size is a source of statistical power. It determines reliability of study findings. Otherwise generalizing findings from a small sample may be challenging. Large sample sizes were better for effective investigation of interventions through reduction of bias risk (Nicholas et al., 2013). Second, the used of survey questionnaires in most studies was a key limitation. This method of data collection may encourage subject bias. The subjects may answer questions in a way that will prevent shame. This means that they may provide imagined answers (Gong et al., 2013). The third limitation is that there was a lack of heterogeneity in target population. Some studies focused on middle-aged adults while others focused on older adults.
For this paper, a pragmatic philosophy was selected. This approach involves the use of a research method that appears most fit to a research problem. It avoids getting caught or being limited by philosophical debates in which the research method is most appropriate. Through this approach, the researcher has freedom to use any research method or technique (Kaushik & Walsh, 2019. The researcher recognizes that every method has some limitations and that these methods can be used as complementary. Pragmatism philosophy embraces the idea of method plurality. It is based on proposition that a researcher should use the methodological and philosophical approach that works best for a given research problem under investigation. Its focus is not on methods. Rather, it is research questions and research consequences (Kaushik & Walsh, 2019. Pragmatism philosophy emerged after some scholars rejected the assumption about inquiry, knowledge, and reality. The scholars argued that it is impossible to access reality exclusively through the use of one scientific method.
Javenic et al (2019), in the article ‘Chronic Pain Self-Management Practices and Preferences among Urban African American Older Adults’ used a pragmatic philosophy. The authors used several methods to best address their research problem. In their methodology, they used a focus group and a survey to collect data from aged African Americans on pain management practices. They recruited participants from the community who were required to report pain for 3+ months in terms of intensity on a 0 to 10 scale (Javenic et al., 2019). From the collected data, the authors were able to identify several pain management strategies including OTC medications, herbal supplements, prayer, bible reading, healthy eating, and exercise. From the focus groups, the authors collected more information including positive experiences with tropical treatments in pain management, the important role of social support, and positive experiences with movements. The authors also found reasons against use of pain medications including adverse side effects. Through the pragmatic approach, the authors the strong use of self-care in pain management in the sample population (Javenic et al., 2019). These findings are useful to available interventions especially on the use of spirituality to improve pain management.
Selected philosophy justification
Pragmatism philosophy was selected because of its ability to fully address the research problem. For thus scoping review, the research problem was identifying pain management strategies, especially among adults. Considering that there are many potential strategies, using a different philosophy may only lead to one-sided strategies. However, through a pragmatic research approach, the research problem is addressed in a holistic view.
According to Brierley (2017), a pragmatic approach in conducting research promotes flexibility and prevents researchers from being restricted by epistemological and ontological issues especially in behavioral research. This increases the chances of addressing a research problem effectively. According to Kalolo (2015), there have been conflicts in research theory and practices. In response, new types of research theories such as critical theory and positivists have emerged. From these theories even more disagreements have emerged. This minimizes the efficiency of every research methodology creating a challenge on how to select the most appropriate research methodology to address specific research problems (Kalolo, 2015). As a result, the need for a paradigm that can accommodate use of several research methodologies has developed. This promotes the use of pragmatism philosophy.
A research approach that accommodates the use of different research methodologies (Kalolo, 2015). According to the author, a pragmatic approach is more equipped than any other approach. This is considering that the weakness of one methodology is complemented by the strengths of another. Based on this narrative, using a pragmatic approach was considered a good step towards yielding better research outcomes. This approach is effective as it enriches data produced during research. Although the approach is not perfect, it carries substantial potential based on its strengths.
Implications for practice
The findings of the study have various implications for future research. First, a more detailed exploration of pain management is required. In particular, there is need to explore interventions that are most effective in pain management especially for adults. The study found some benefits of using pharmacological interventions and non-pharmacological interventions (Javenic et al., 2019). It is, however, necessary that these benefits are further explored especially for adults. The burden of pain is increasingly growing necessitating discovery of most effective pain management strategies. It is also important that studies on specific populations are explored. Middle-aged adults may respond differently to older adults. This suggests that certain pain management strategies may be more effective for one population and not the other. Therefore, future research should focus on exploring effective pain management strategies for different age groups.
Second, there is a need for nurses to be trained in the implementation of these strategies. Nurses are the major contact of adults suffering chronic pain. Therefore, it is necessary that they know how to help these adults. Also, nurses have ethical obligations to help adults respond to their needs including pain management (Carvalho et al., 2018). Therefore, they must monitor pain in adults, evaluate treatment needs, and provide most effective strategies. These strategies must meet professional standards. A patient-centered approach can help ethical issues, especially when dealing with adults. Nurses should work with patients in determining the best treatment option (Carvalho et al., 2018). Understanding a patient’s view of pain and also a nurse’s view of pain can help make the right decision in regard to pain management strategies. Moral principles including non-maleficence, autonomy, beneficence, and justice should also be key values in pain management (Carvalho et al., 2018).
Based on the assumptions of RAM, every patient should also be treated as an individual. People have different spiritual, psychological, and physical needs. Therefore, nurses must view a patient as a unique individual who is also an adaptive system. In general, it is necessary to consider pain management as a holistic process.
Strengths and Limitations of this scoping review
This study used a transparent and rigorous method throughout the entire process. The review was guided by a protocol and by a researcher with expertise in scoping reviews. Three search databases were used in the search strategy. Reliable articles were used as sources for this study. All the identified citations and full-text articles were properly. However, despite the attempts to conduct a comprehensive review, the study may not have reviewed all available literature on pain and pain management techniques. Other articles may be containing more pain management techniques for adults. Although the search included three databases, there is a possibility of bias towards health and sciences in the overall search strategy. Searching additional databases may have produced more articles on pain and pain management strategies. Also, interpretation of selected articles was subject to bias.
The purpose of this study was presenting pain management strategies from a scoping review of existing literature on pain and pain management. All selected studies showed that pain is a common problem for adults. The studies also showed that various pain management strategies can help reduce and coping with pain. Pain management also improves life quality, especially for adults. The findings show that pain management is a complex phenomenon that requires integration of physiological, sociological, and spiritual factors. It is also clear that pain promotes adaptation process. It activates an immediate response in adults. The RAM is appropriate for explaining pain and adaptation in adults. The findings from this scoping review study advance nursing knowledge in two ways. First, it presents some effective pain management strategies for adults. Nurses can, therefore, use these strategies to help their patients with pain management. Second, the study enlightens nurses in the use of RAM in dealing with adults suffering chronic pain. By understanding the RAM concepts, nurses will improve their skills in pain management among adults. This will eventually improve life quality in adults in the future.
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