Complementary and alternative therapies for post‐caesarean pain, 2020, Flumignan et al

Andy · Oct 8, 2020

Background

Pain after caesarean sections (CS) can affect the well‐being of the mother and her ability with her newborn. Conventional pain‐relieving strategies are often underused because of concerns about the adverse maternal and neonatal effects. Complementary alternative therapies (CAM) may offer an alternative for post‐CS pain.

Objectives
To assess the effects of CAM for post‐caesarean pain.

Search methods
We searched Cochrane Pregnancy and Childbirth’s Trials Register, LILACS, PEDro, CAMbase, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (6 September 2019), and checked the reference lists of retrieved articles.

Selection criteria
Randomised controlled trials (RCTs), including quasi‐RCTs and cluster‐RCTs, comparing CAM, alone or associated with other forms of pain relief, versus other treatments or placebo or no treatment, for the treatment of post‐CS pain.

Data collection and analysis
Two review authors independently performed study selection, extracted data, assessed risk of bias and assessed the certainty of evidence using GRADE.

Main results
We included 37 studies (3076 women) which investigated eight different CAM therapies for post‐CS pain relief. There is substantial heterogeneity among the trials. We downgraded the certainty of evidence due to small numbers of women participating in the trials and to risk of bias related to lack of blinding and inadequate reporting of randomisation processes. None of the trials reported pain at six weeks after discharge.

Primary outcomes were pain and adverse effects, reported per intervention below. Secondary outcomes included vital signs, rescue analgesic requirement at six weeks after discharge; all of which were poorly reported, not reported, or we are uncertain as to the effect

Acupuncture or acupressure

We are very uncertain if acupuncture or acupressure (versus no treatment) or acupuncture or acupressure plus analgesia (versus placebo plus analgesia) has any effect on pain because the quality of evidence is very low. Acupuncture or acupressure plus analgesia (versus analgesia) may reduce pain at 12 hours (standardised mean difference (SMD) ‐0.28, 95% confidence interval (CI) ‐0.64 to 0.07; 2 studies; 130 women; low‐certainty evidence) and 24 hours (SMD ‐0.63, 95% CI ‐0.99 to ‐0.26; 2 studies; 130 women; low‐certainty evidence).

It is uncertain whether acupuncture or acupressure (versus no treatment) or acupuncture or acupressure plus analgesia (versus analgesia) has any effect on the risk of adverse effects because the quality of evidence is very low.

Aromatherapy

Aromatherapy plus analgesia may reduce pain when compared with placebo plus analgesia at 12 hours (mean difference (MD) ‐2.63 visual analogue scale (VAS), 95% CI ‐3.48 to ‐1.77; 3 studies; 360 women; low‐certainty evidence) and 24 hours (MD ‐3.38 VAS, 95% CI ‐3.85 to ‐2.91; 1 study; 200 women; low‐certainty evidence). We are uncertain if aromatherapy plus analgesia has any effect on adverse effects (anxiety) compared with placebo plus analgesia.

Electromagnetic therapy

Electromagnetic therapy may reduce pain compared with placebo plus analgesia at 12 hours (MD ‐8.00, 95% CI ‐11.65 to ‐4.35; 1 study; 72 women; low‐certainty evidence) and 24 hours (MD ‐13.00 VAS, 95% CI ‐17.13 to ‐8.87; 1 study; 72 women; low‐certainty evidence).

Massage

We identified six studies (651 women), five of which were quasi‐RCTs, comparing massage (foot and hand) plus analgesia versus analgesia. All the evidence relating to pain, adverse effects (anxiety), vital signs and rescue analgesic requirement was very low‐certainty.

Music

Music plus analgesia may reduce pain when compared with placebo plus analgesia at one hour (SMD ‐0.84, 95% CI ‐1.23 to ‐0.46; 2 studies; 115 women; low‐certainty evidence), 24 hours (MD ‐1.79, 95% CI ‐2.67 to ‐0.91; 1 study; 38 women; low‐certainty evidence), and also when compared with analgesia at one hour (MD ‐2.11, 95% CI ‐3.11 to ‐1.10; 1 study; 38 women; low‐certainty evidence) and at 24 hours (MD ‐2.69, 95% CI ‐3.67 to ‐1.70; 1 study; 38 women; low‐certainty evidence). It is uncertain whether music plus analgesia has any effect on adverse effects (anxiety), when compared with placebo plus analgesia because the quality of evidence is very low.

Reiki

We are uncertain if Reiki plus analgesia compared with analgesia alone has any effect on pain, adverse effects, vital signs or rescue analgesic requirement because the quality of evidence is very low (one study, 90 women).

Relaxation

Relaxation may reduce pain compared with standard care at 24 hours (MD ‐0.53 VAS, 95% CI ‐1.05 to ‐0.01; 1 study; 60 women; low‐certainty evidence).

Transcutaneous electrical nerve stimulation

TENS (versus no treatment) may reduce pain at one hour (MD ‐2.26, 95% CI ‐3.35 to ‐1.17; 1 study; 40 women; low‐certainty evidence). TENS plus analgesia (versus placebo plus analgesia) may reduce pain at one hour (SMD ‐1.10 VAS, 95% CI ‐1.37 to ‐0.82; 3 studies; 238 women; low‐certainty evidence) and at 24 hours (MD ‐0.70 VAS, 95% CI ‐0.87 to ‐0.53; 1 study; 108 women; low‐certainty evidence).

TENS plus analgesia (versus placebo plus analgesia) may reduce heart rate (MD ‐7.00 bpm, 95% CI ‐7.63 to ‐6.37; 108 women; 1 study; low‐certainty evidence) and respiratory rate (MD ‐1.10 brpm, 95% CI ‐1.26 to ‐0.94; 108 women; 1 study; low‐certainty evidence).

We are uncertain if TENS plus analgesia (versus analgesia) has any effect on pain at six hours or 24 hours, or vital signs because the quality of evidence is very low (two studies, 92 women).

Authors' conclusions
Some CAM therapies may help reduce post‐CS pain for up to 24 hours. The evidence on adverse events is too uncertain to make any judgements on safety and we have no evidence about the longer‐term effects on pain.

Since pain control is the most relevant outcome for post‐CS women and their clinicians, it is important that future studies of CAM for post‐CS pain measure pain as a primary outcome, preferably as the proportion of participants with at least moderate (30%) or substantial (50%) pain relief. Measuring pain as a dichotomous variable would improve the certainty of evidence and it is easy to understand for non‐specialists. Future trials also need to be large enough to detect effects on clinical outcomes; measure other important outcomes as listed lin this review, and use validated scales.
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Open access, https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011216.pub2/full

So-called alternative medicine for post-caesarean pain? A Cochrane review

I feel that the Cochrane Collaboration does itself no favours by publishing such poor reviews. This one is both poorly conceived and badly reported. In fact, I see little reason to deal with pain after CS differently than with post-operative pain in general. Some of the modalities discussed are not truly SCAM. Most of the secondary endpoints are irrelevant. The inclusion of adverse effects as a primary endpoint seems nonsensical considering that SCAM studies are notoriously bad at reporting them. Many of the allegedly positive findings rely on trial designs that cannot control for placebo effects (e.g A+B versus B); therefore they tell us nothing about the effectiveness of the therapy.

Most importantly, the conclusions are not helpful. I would have simply stated that none of the SCAM modalities are supported by convincing evidence as treatments for pain control after CS.
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https://edzardernst.com/2020/10/so-...ne-for-post-caesarean-pain-a-cochrane-review/

Hutan · Oct 8, 2020

Reading through that review summary, it's a pretty searing indictment of the quality of research across the board, even if the conclusion doesn't say so. What a lot of time and money wasted.

Peter Trewhitt · Oct 8, 2020

At least it is reassuring that the authors took reporting or lack of reporting adverse events seriously unlike some review articles closer to home.

rvallee · Oct 8, 2020

Clownchrane

Invisible Woman · Oct 8, 2020

Lovely.

Speaking as a woman who has never given birth.

You have your C - section, which while routine is still fairly major surgery. Your bundle of joy (who is also probably extremely hard work and needing to lifted regularly for feeding and nappy changes and so forth) safely delivered.

You've now got hormones all over the place, a life to lead, maybe other kids to look after & they want to eff about being stingy with the pain meds?

You finally get the little tike off to sleep & what? You're supposed to listen to music? Get real. Any sense and Mum will be catching some zeds herself.

Are we sure robots didn't write this? Or someone who has never met a new mother?

Trish · Oct 8, 2020

I would think a much more useful thing in these circumstances in helping the mother cope with the pain, apart from pain meds, is someone who knows what they are doing helping her with all the things she needs help with so she can get the rest and recovery time she needs.

Invisible Woman · Oct 8, 2020

Trish said: ↑

I would think a much more useful thing in these circumstances in helping the mother cope with the pain, apart from pain meds, is someone who knows what they are doing helping her with all the things she needs help with so she can get the rest and recovery time she needs.
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Yeah, sadly in the modern world, unless you're very lucky, you may not have much help with day to day tasks. Mum's parents are probably still working themselves, if they're still around.

Life as a new Mum must be a blooming nightmare with covid, especially if you've got some additional condition.

It just annoys the heck out of me that because it's something a lot of women go through, it's trivialized. I'm fairly sure that kinda pain is not at all trivial.

Also, I remember being told when family members were happily hooked up to pumps for self administered pain meds that being in pain can slow healing. I'd be very surprised if it didn't slow bonding too.

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Complementary and alternative therapies for post‐caesarean pain, 2020, Flumignan et al

Andy Committee Member (& Outreach when energy allows)

Hutan Moderator Staff Member

Peter Trewhitt Senior Member (Voting Rights)

rvallee Senior Member (Voting Rights)

Invisible Woman Senior Member (Voting Rights)

Trish Moderator Staff Member

Invisible Woman Senior Member (Voting Rights)

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Complementary and alternative therapies for post‐caesarean pain, 2020, Flumignan et al

Andy Committee Member (& Outreach when energy allows)

Hutan Moderator Staff Member

Peter Trewhitt Senior Member (Voting Rights)

rvallee Senior Member (Voting Rights)

Invisible Woman Senior Member (Voting Rights)

Trish Moderator Staff Member

Invisible Woman Senior Member (Voting Rights)

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