Systematic review and meta‐analysis: Physical‐procedural interventions used to reduce pain during intramuscular injections in adults

Abstract

Aims To assess the effectiveness of physical‐procedural interventions in reducing pain during intramuscular injections. Design Systematic review and meta‐analysis. Method English keywords were used to search databases [MEDLINE (OVID, Ebsco), SCOPUS, Science Direct, COCHRANE and the reference lists from retrieved articles] from their inception to November 2017 and randomized and quasi‐experimental trials were selected based on inclusion and exclusion criteria. The standardized mean difference and random effects model were used. Results From 2,318 articles, 15 articles (1996–2017) met the criteria for the meta‐analysis. Physical‐procedural interventions described in the articles were included in this systematic review. The overall standardized mean difference was 0.595 (95% confidence interval (CI) = 0.417–0.773), indicating a moderate effect on pain levels. Generally, these interventions (two‐needle technique, acupressure, manual pressure, ShotBlocker, Z‐technique, air‐lock technique, injection site postinjection massage, and speed of injection) have been found to moderately reduce pain. Conclusion It seems difficult to conclude that a single intervention reduces pain in adults. However, we can state that the most effective interventions for reducing pain during intramuscular injections in adults involve the ventrogluteal site, the Z‐technique, and manual pressure. Impact The systematic review will provide guidance to clinicians, staff, and educator nurses and future studies. The systematic review will help nurses and educators apply techniques based on evidence in any setting. The systematic review will guide well‐designed and well‐reported studies to contribute to the accumulation of evidence in nursing research.

The effect of intramuscular injection technique on injection associated pain; a systematic review and meta-analysis

“…Mechanistically the benefits of applying local pressure to the injection site may be explained by the gate-control theory of pain which hypothesises that the stimulation of Aβ afferent nerve fibres (mechanoreceptors) inhibit transmission of nociceptive input (pain) to second-order neurons through gating at the substantia gelatinosa in the dorsal root ganglion of the spinal cord [53,54]. Our analysis of local pressure based IMI techniques on injection site pain updates and expands that of a previous systematic review in adults [15], and suggests that larger RCTs are required to strengthen the evidence for its use in routine practice. The application of local pressure over the injection site is potentially easy to teach and implement, however, standardisation of the amount of pressure and duration of applied pressure is required.…”

“…Our systematic review and meta-analysis provides updates on the evidence on intramuscular injection techniques beyond the systematic review of Şanlialp et al [15]. We identified additional evidence on the manual pressure, Z track, ShotBlocker, and acupressure techniques and report on other IMI techniques including the Helfer Skin tap, application of ice to injection site, and altering the temperature of the injectate.…”

“…We identified additional evidence on the manual pressure, Z track, ShotBlocker, and acupressure techniques and report on other IMI techniques including the Helfer Skin tap, application of ice to injection site, and altering the temperature of the injectate. Şanlialp et al [15] found the ventrogluteal site, Z track technique, and manual pressure to be the most effective IMI techniques in reducing injection pain, but also found that the two-needle technique, post injection massage and ShotBlocker IMI techniques were beneficial in reducing injection pain. The benefits of the manual pressure technique and post injection massage are similar to our assessment, however, our findings on ShotBlocker, acupressure, two-needle technique and Z track are in contrast to the findings of Şanlialp et al [15].…”

“…Şanlialp et al [15] found the ventrogluteal site, Z track technique, and manual pressure to be the most effective IMI techniques in reducing injection pain, but also found that the two-needle technique, post injection massage and ShotBlocker IMI techniques were beneficial in reducing injection pain. The benefits of the manual pressure technique and post injection massage are similar to our assessment, however, our findings on ShotBlocker, acupressure, two-needle technique and Z track are in contrast to the findings of Şanlialp et al [15]. We identified more studies on the acupressure and ShotBlocker IMI techniques which have influenced our assessments of these techniques.…”

“…In this younger population pain can be decreased by having the child sit up (or by holding an infant), stroking the skin or applying pressure close to the injection site before and during injection, and performing a rapid intramuscular injection without initial aspiration [14]. A recent systematic review of IMI techniques in adults suggests that IMI to the ventrogluteal site, the Z track, and manual pressure IMI techniques may be effective interventions in reducing IMI associated pain [15]. However, this review restricted the range of electronic databases searched and the language of studies included, and may have missed relevant studies.…”