Table 1.
Key Data Controlled Trials of Hypnosis for Acute and Procedural Pain
| First Author, Year | Study Design Quality Score Intention-to-Treat Analysis | Condition Sample Size (Randomized/Analyzed) | Intervention (regimen) | Control (regimen) | Pain Measurement Methods | Main Result | Authors’ Conclusion |
|---|---|---|---|---|---|---|---|
| Zeltner, 1982 | Parallel design 1 Not reported |
Bone marrow aspirations or lumbar puncture 33/33 |
Patients were helped to become increasingly involved in interesting and pleasant images. (n = 16) | Distraction. This involved asking the child to focus on objects in the room rather than on fantasy. (n = 17) | 1) pain self-report and observer rating aggregated (1–5) 2) anxiety self-report and observer rating aggregated (1–5) * Both measures collected at baseline and 1–3 BMAs post-baseline |
1) Pain self-ratings decreased in both groups significantly, but hypnosis was significantly better in pain reduction for bone marrow aspiration (p < .03) and lumbar puncture (p<.02). 2) Anxiety was also significantly more reduced by hypnosis for bone marrow aspiration (p < .05). |
‘(…) hypnosis was shown to be more effective than non-hypnotic techniques for reducing procedural distress in children and adolescents with cancer.’ |
| Katz, 1987 | Parallel design 2 Not reported |
Bone marrow aspirations or lumbar puncture (in some cases) 36/36 |
Training in hypnosis and self-hypnosis (two, 30 min. interventions prior to each BMA + 20 min session preceding each of three BMAs. (n= 17) | Play matched for time and attention to hypnosis group (n=19) | 1) Pain self-report (0–100 scale) patterned after thermometer. 2) PBRS during procedure * Both measures collected at baseline and 3 BMAs post-baseline |
1) Pain self-report scores decreased significantly from baseline at each subsequent BMA in both groups (p<.05). There were no significant intergroup differences in self-reported pain. 2) No significant intergroup differences in observational ratings. |
‘It appears that hypnosis and play are equally effective in reducing subjective pain for BMAs. |
| Kuttner, 1988 | Parallel design 2 Not reported |
Bone marrow aspiration 48/48 |
5–20 minute preparation just before procedure and hypnosis and guided imagery facilitating the involvement in an interesting story during procedure. Additionally participants could turn pain off with a ‘pain switch’. (n = 16) | 1) standard care (n = 16) 2) 5–20 minute preparation and training in breathing technique, and distraction with toys during procedure. (n = 16) |
1) PBRS during procedure by 2 observers 2) observed anxiety rating scale (1–5), 3) observed pain rating scale (1–5) 2) and 3) were the aggregated score of physician, nurse, parent, 2 observers 4) anxiety self-report (pictorial scale) 5) pain self-report (pictorial scale) |
1) no difference in the whole sample, but younger patients had a lower PBRS in the hypnosis group than both other groups (ps < .05). 2) observed anxiety was lower for older children in the hypnosis group and the distraction group compared to the control (p<.05), but not hypnosis vs. distraction. While hypnosis was better at anxiety reduction than distraction for younger patients (p<.05),. 3) no difference in the whole sample, observed pain was lower in in older patients in the hypnosis group compared to the standard care group.(p<.05). While for younger patients, hypnosis was better for pain reduction.(p<.05). 4) no effect on anxiety self-report 5) no effect on pain self-report |
‘(…) distress of younger children, 3–6 years old was best alleviated by hypnotic therapy, imaginative involvement, whereas older children’s observed pain and anxiety was reduced by both distraction and imaginative involvement techniques.’ |
| Wall, 1989 | Parallel design 3 Not reported |
Bone marrow aspirations or lumbar puncture 20/201 |
Hypnosis (two group training sessions during the week prior to the procedure, n= 11) | Active cognitive strategy (two group training sessions during the week prior to the procedure, n= 9) | 1) 10cm VAS2 (procedural pain, behavioral observation and self-reports, three times) 2) MPQ3 (affective and procedural components of pain, one time, subjects above 12yo) 3) independent observer blind to treatment assignment – rated procedural pain via 10 cm VAS |
1) Self-reported pain decreased in both groups (p = .003) with no significant between group differences. 2) MPQ present pain index (p<.02) and pain ratings index (p<.01) significantly decreased in both groups with no significant between group differences. 3) Observational pain ratings reflected decrease in procedural pain (p<.009). Between group differences were insignificant. |
‘(…) both strategies were effective in providing pain reduction.’ |
| Weinstein, 1991 | Parallel design 0 Not reported |
Angioplasty (by inflating balloons in occluded coronary arteries) 32/32 |
Hypnosis (30 min) before the day of the procedure, with posthypnotic suggestions for relaxation during angioplasty. (n = 16) | Standard care (n = 16) | 1) Pulse 2) Blood pressure 3) Pain medication used 4) balloon inflation time |
1) No difference in pulse 2) No difference in blood pressure 3) Fewer patients needed additional pain medication in the hypnosis group (p = .05) 4) Balloon could remain inflated 25% longer in the hypnosis group (not significant, p = .10) |
‘(…) reduction [of analgesic use] was significant, and in line with reports of less pain medication required by burn victims who have mad hypnotic therapy’ |
| Patterson, 1992 | Parallel design 3 Not reported |
33/30 | Hypnosis (25 min) prior to debridement + standard care | 1) Standard care 2) Attention and information control + standard care |
1) 10 cm VAS self-report 2) 10 cm nurse administered VAS 3) pain medication stability |
1a) significant within group difference in hypnosis group (p=.0001) not seen in controls. 1b) Hypnosis participants had significantly less post-treatment pain than attention (p=.03) and standard care control (p=.01). 2a) significant within group pre-post reduction in pain among hypnosis participants not seen in controls. 2b) no significant intergroup differences 3) no significant intergroup differences |
‘Hypnosis is a viable adjunct treatment for burn pain.’ |
| Syrjala, 1992 | Parallel design 2 Not reported |
Bone marrow aspiration 67/45 |
1) Hypnosis (2 pre-transplant sessions +10 booster sessions)+ standard medical care 2) Cognitive behavioral coping skills training (2 pre-transplant sessions +10 booster sessions) + standard medical care |
1) Therapist contact control (2 pre-transplant sessions+10 booster sessions)+ standard medical care 2) Treatment as usual (standard medical care |
1) VAS self-report of oral pain 2) opioid medication use |
1) Hypnosis participants experienced less pain than therapist contact or CBT participants (p= .033). 2) no significant differences between groups |
‘Hypnosis was effective in reducing oral pain for patients undergoing marrow transplantation. The CBT intervention was not effective in reducing symptoms measured.’ |
| Everett, 1993 | Parallel 2 Not reported |
Burn debridement 32/32 |
1) Hypnosis (25 min) before debridement +standard care 2) Hypnosis (25 min) intervention prior to debridement + Lorazepam + standard care |
1) standard care 2) hypnosis attention control: time and attention (25 min) + standard care |
1) VAS self-report 2) VAS nurse observation 3) pain medication stability |
1) No significant intergroup or within group differences 2) No significant intergroup or within group differences 3) Pain medication was equivalent across four groups. |
‘The results are argued to support the analgesic advantages of early, aggressive opioid use via PCA [patient-controlled analgesia apparatus] or through careful staff monitoring and titration of pain drugs.’ |
| Lambert, 1996 | Parallel design 2 Not reported |
Variety of elective surgical procedures 52/50 |
1 training session (30 min) 1 week before surgery, where children were taught guided imagery. Posthypnotic suggestions for better surgical outcome. (n =26) | Attention control: Equal amount of time spent with a research assistant discussing surgery and other topics of interest. (n=26) | 1) pain reported each hour after surgery on a numerical rating scale (0–10) 2) total analgesics used postoperatively 3) self-report anxiety (STAIC) |
1) lower pain ratings in the hypnosis group (p<.01) 2) no significant difference in analgesic use between groups 3) no significant difference in anxiety between groups |
‘This study demonstrates the positive effects of hypnosis/guided imagery for the pediatric surgical patient.’ |
| Lang, 1996 | Parallel design 3 Not reported |
Radiological procedures 30/30 |
Instruction in self Hypnosis to be used during operation + standard care (n=16) | Standard care (n=14) | 1) 0–10 numeric rating scale at baseline, at ‘20 min into every 40-min interval, and before leaving the intervention table’ 2) Blood pressure 3) Intravenous PCA4 |
1) Hypnosis participants reported significantly less pain than controls (p<.01) 2) No significant intergroup differences with regard to increases in blood pressure. 3) Controls self-administered significantly more medication than hypnosis participants (p<.01). |
‘Self-hypnotic relaxation can reduce drug use and improve procedural safety’ |
| Smith, 1996 | Crossover-design 2 Not reported |
venipuncture or infusaport access 36/27 |
Training for the child and parent to use a favorite place hypnotic induction where the parent and child go on an imaginary journey to a location of the child’s choosing during the medical procedure. Daily practice for 1 week before the procedure. (n = 36) | Training for the child and parent to apply distraction technique using a toy during the medical procedure. Daily practice for 1 week before the procedure. (n = 36) | 1) Children’s Global Rating Scale (CGRS) of pain by the patient 2) Children’s Global Rating Scale (CGRS) of anxiety by the patient 3) pain Likert scale by the parent 4) anxiety Likert scale by the parent 5) Independent observer-reported anxiety 6) Observational Scale of Behavioral Distress-Revised (OSBD-R) |
1) CGRS pain rating was lower in the hypnosis condition (p<.001), especially in high hypnotizables. 2) CGRS anxiety rating was lower in the hypnosis condition (p<.001), especially in high hypnotizables. 3), 4) and 5) parent reported pain and anxiety, and observer reported anxiety showed the same pattern (ps<.001). 6) no significant main effect of condition reported for OSBD-R scores. |
‘Hypnosis was significantly more effective than distraction in reducing perceptions of behavioral distress, pain, and anxiety in hypnotizable children.’ |
| Enqvist, 1997 | Parallel design 3 Not reported |
Surgical removal of third mandibular molars 72/69 |
20 min Hypnosis via audiotape one week prior to surgery with recommendations for daily listening + standard care (n= 33) | Standard care (n= 36) | postoperative analgesic use | Of participants randomized to hypnosis, 3% consumed three or more equipotent doses of postoperative analgesics in comparison to 28% of controls. | ‘The preoperative use of a carefully designed audiotape is an economical intervention, in this instance with the aim to give the patient better control over anxiety and pain. A patient-centered approach, together with the use of hypnotherapeutic principles, can be a useful addition to drug therapy. A preoperative hypnotic technique audiotape can be additionally helpful because it also gives the patient a tool for use in future stressful situations.’ |
| Faymonville, 1997 | Parallel design 2 Yes |
Plastic surgery 60/56 |
Hypnosis (just proceeding and during surgery) + standard care (n=31) | Emotional support (during surgery) + standard care (n=25) | 1) Intraoperative pain VAS 2) postoperative pain VAS (self-report) 3) intraoperative pain medication requirements |
1) Intraoperative was significantly lower among hypnosis participants than controls (p<.02). 2) Hypnosis participants reported significantly less postoperative pain than controls (p<.01) 3) Hypnosis participants required significantly less intraoperative midazolam (p<.001) and alfentanil (p<.001) than controls. |
‘(…) hypnosis provides better perioperative pain and anxiety relief, allows for significant reduction in alfentanil and midazolam requirements, and improves patient satisfaction and surgical conditions as compared with conventional stress reducing strategies support in patients receiving conscious sedation for plastic surgery.’ |
| Patterson, 1997 | Parallel Design 4 Not reported |
Burn debridement 63/57 |
1) hypnosis (25 min) prior to debridement +standard care | 1) attention and information control + standard care | 1) 100 mm VAS self-report 2) 100 VAS nurse observation 3) pain medication stability |
1a) No significant intergroup differences in the total sample. 1b) Hypnosis participants experienced less pain (p<.05) among patients with high baseline pain levels 2a) observer ratings indicated less pain among hypnosis participants than controls (p<.05) 2b) no intergroup differences among patients with high baseline pain according to nurses 3) no significant intergroup differences (comparing all patients or high pain patients) |
‘The findings provided further evidence that hypnosis can be a useful psychological intervention for reducing pain in patients who are being treated for a major burn injury. However, the findings also indicate that this technique is likely more useful for patients who are experiencing high levels of pain.’ |
| Liossi, 1999 | Parallel design 3 Not reported |
Bone marrow aspirations 30/30 |
Hypnosis (3, 30 min sessions prior to procedure, n= 10) | 1) Standard care (n = 10) 2) Cognitive behavioral (CB) coping skills (3, 30 min sessions prior to procedure, n= 10) |
1) PBCL5 (behavioral observation, pain, during one BMA6 at baseline and during BMA after interventions) 2) 6-point faces rating scale (self-report, pain, during one BMA at baseline and during BMA after interventions) |
1) PBCL indicated hypnosis (p=.001) and CB patients (p = .003) were less distressed than controls. Hypnosis participants also had less distress than CB (p = .025) participants. 2) Hypnosis participants (p = .005) or CB (p = .008) reported decreased pain in comparison to baseline that was not observed in controls. In addition, self-reported pain was less among hypnosis participants (p=.001) and CB participants (p=.002) than controls. There were no significant group differences of self-reported pain between hypnosis and CB participants. |
‘Hypnosis and CB were similarly effective in the relief of pain….It is concluded that hypnosis and CB coping skills are effective in preparing pediatric oncology patients for bone marrow aspiration.’ |
| Lang, 2000 | Parallel design 3 Not reported |
Percutaneous vascular and renal procedures 241/241 |
Guided self- hypnotic relaxation during surgery + standard medical care (n=82) | 1) Standard care (n=79) 2) structured attention during surgery + standard medical care(n=80) |
1) 0–10 verbal scales (pain, before surgery and every 15 min during it) 2) Amount of medication requested during procedure |
1) Participants experienced a linear increase in pain throughout the operation if randomized to attention (p= .0425) or standard care (p<.0001). However, hypnosis participants did not experience a significant pain increase. 2) Medication usage was significantly greater among participants randomized to standard care (1.9 units) in comparison to hypnosis (0.9 units) or structured attention participants (0.8 units). |
‘Structured attention and self-hypnotic relaxation proved beneficial during invasive medical procedures. Hypnosis had more pronounced effects on pain and anxiety reduction, and is superior, in that it also improves hemodynamic stability.’ |
| Wright, 2000 | Parallel design 1 Not reported |
Burn debridement 30/30 |
Hypnosis (15 min) prior to debridement procedures + standard care | Standard care | 1) Self report of sensory and affective pain during burn care 2) retrospective self-report of pain ratings after burn care 3) medication consumption |
1a) Significant pre-post decreases of sensory (p<.001) and affective (p<.001) pain were seen among hypnosis participants by end of first procedure. 1b) Self report of sensory (p<.05) and affective (p<.05) pain were lower among hypnosis participants than controls after the second debridement. 3) In the hypnosis group, consumption of paracetamol (p<.01) and codeine (p.=.01) decreased but remained unchanged in controls. |
Hypnosis is ‘a viable adjunct to narcotic treatment for pain control during burn care.’ |
| Montgomery, 2002 | Parallel design 1 Not reported |
Excisional breast biopsy 20/20; + 20 healthy controls | Hypnosis (10 min hypnotic induction before the procedure, n=20) | Standard-care (n=20) Healthy group (n=20) |
10cm VAS (pain). | Hypnosis group demonstrated decreased post-surgery pain in comparison to control (p<.001) | ‘The results of the present study revealed that a brief hypnosis intervention can be an effective means to reduce postsurgical pain and distress in women undergoing excisional breast biopsy. Postsurgical pain was reduced in patients receiving hypnosis relative to a standard care control group.’ |
| Liossi, 2003 | Parallel design 2 Not reported |
Lumbar punctures (LP) 80/80 |
1) Direct hypnosis (1, 40 minute session + administration directly before and during 2LP + self-hypnosis instruction + standard care, n=20) 2) Indirect hypnosis (1, 40 minutes session + administration directly before and during 2LP + self- hypnosis instruction + standard care, n=20) |
1) Standard care (n= 20) 2) ) Attention control (40 minutes session + standard care, n=20) |
1) PBCL (behavioral observation, pain, at baseline and during 2 LP with therapist directed interventions + 3 LP with self-hypnosis interventions) 2) 6-point faces rating scale (self-report, pain, during baseline, 2 consecutive LPs with therapist interventions + 3 LPs with self-hypnosis only) |
1) Observed distress in hypnosis group decreased significantly during intervention (p <.001) and was significantly lower than that of controls (p<.001). In addition, behavioral distress was lower among treatment groups during 1st and 3rd LPs using self- hypnosis than among controls (p<.001 for all comparisons between groups). However, distress increased to baseline levels at 6th LP using self-hypnosis. There were no significant intragroup differences between the treatment or control groups. 2) During the intervention phase, hypnosis participants experienced significantly less pain than attention (p<.02) and standard care (p<.001) controls. Pain decreases continued during 1st and 3rd LPs using self-hypnosis but increased to levels baseline levels by the 6th LP with self-hypnosis. No significant intragroup differences between the treatment or control groups. |
‘(…) Hypnosis is effective in preparing pediatric oncology patients for lumbar puncture, but the presence of the therapist may be critical.’ |
| Harandi, 2004 | Parallel design 0 Not reported |
Physiotherapy for burns 44/44 |
Hypnosis once a day for a period of 4 days, n=22) | Standard-care (n=22) | 100mm VAS7 (pain) | Hypnosis participants experienced less pain physiotherapy - related pain in comparison to controls (p<.001) | ‘Hypnosis is recommended as a complementary method in burns physiotherapy.’ |
| Massarini, 2005 | Parallel design 1 Not reported |
Surgical operation 42/42 |
15 – 30 min of Hypnosis 24 hours prior to operation (n=20) | Standard care (n=20) | 0–10 numeric rating scale combined with a scale of facial expressions (Faces Pain Rating Scale) recorded each day postoperatively for 4 days to assess affective and sensory pain | 1a) Hypnosis participants reported less pain intensity on day 1(p = .006) and 2 (p= .003) following their operation in comparison to controls. However, pain intensity in the hypnosis group was comparable to that of controls on day 3 and 4. 1b) Affective pain was also less among hypnosis participants in comparison to controls on day 1 (p=.010) and 2 (p=.010) postoperatively, but was equivocal on day 3 (p=.204) and 4 (p=.702) |
‘This controlled study showed that brief hypnotic treatment carried out in the preoperative period leads to good results with surgery patients in terms of reducing anxiety levels and pain perception.’ |
| Lang, 2006 | Parallel design 3 Not reported |
Breast biopsy 240/236 |
Hypnosis during procedure + empathetic attention (n= 78) | 1) Standard care (n = 76) 2) Structured emphatic attention during procedure (n= 82) |
1) Verbal 0–10 analog scale (intraoperative every 10 min) | Intraoperative pain increased significantly for all groups (p<.001). However, the pain increase among hypnosis participants was less steep than that of empathy (p = .024) or standard care (p = .018) participants. | ‘(…) while both structured empathy and hypnosis decrease procedural pain and anxiety, hypnosis provides more powerful anxiety relief without undue cost and thus appears attractive for outpatient pain management.’ |
| Liossi, 2006 | Parallel design 4 Yes |
Lumbar punctures 45/45 |
1) EMLA +Hypnosis (approximately 40 min session + self- hypnosis training, n= 15) | 1) EMLA =15 2) EMLA + Attention (approximately 40 minute session, n= 15) |
1) The Wong–Baker FACES Pain Rating Scale (self-report) 2) PBCL * Measures were collected 3 times - during therapist led intervention (time 2) – - during self-hypnosis intervention (time 3 and 4) |
1) During all 3 measurement times, hypnosis participants were found to report less pain that the attention controls: (p<.001) for times 2 and 3; (p<.002) for time 4. In addition, hypnosis participants experienced less pain than EMLA only controls: (p<.001) for times 2, 3, and 4 2) At times 2, 3, and 4, participants randomized to EMLA + hypnosis appeared significantly less distressed than those of the EMLA group (p<.001) or the EMLA + attention group (p<.001). There were no significant intergroup differences between controls. |
‘(…) self-hypnosis might be a time- and cost-effective method that nevertheless extends the benefits of traditional hetero-hypnosis.’ |
| Marc, 2007 | Parallel design 3 Not reported |
Abortion 30/29 |
Hypnosis (20 min before and during procedure, n=14) | Standard-care (n=15) | 1) Request for N2O sedation. 2) 11-point verbal numerical scale used during operation |
1) 36% of hypnosis participant needed N2O sedation compared to 87% of controls (p<.01). 2) No significant differences. |
‘(…) hypnosis can be integrated into standard care and reduces the need for N2O in patients undergoing first-trimester surgical abortion.’ |
| Montgomery, 2007 | Parallel design 4 Not reported |
Breast cancer surgery 200/200 |
Hypnosis (15 minute, pre-surgical intervention, n= 105) | Attention control (15 minute pre- surgical intervention, n= 95) | 1) Intraoperative medication use 2) 0–100 VAS pain intensity and unpleasantness |
1) Patients randomized to receive hypnosis required less Lidocaine (p<.001) and Propofol (p<.001) interoperatively than controls. Utilization of Fentanyl and Midazlam was not statistically different between groups, nor was use of postoperative analgesics. 2) Hypnosis participants reported also reported significantly less pain intensity (p<.001) and pain unpleasantness (p<.001) than controls. |
‘Overall, the present data support the use of hypnosis with breast cancer surgery patients.’ |
| Marc, 2008 | Parallel design 3 Not reported |
Abortion 350/347 |
Hypnotic analgesia (20 min before and during procedure, n=172) | Standard-care (n=175) | 1) Use of sedation. 2) 0–100 visual numeric scales (two separate ratings during operation) |
1) Hypnosis participants required less IV analgesia than controls (p <.0001) 2) Hypnosis participants did not report significant pain increase during suction evaluation. | ‘Hypnotic interventions can be effective as an adjunct to pharmacologic management of acute pain during abortion.’ |
| Liossi, 2009 | Parallel design 4 Yes |
Venipuncture 45/45 |
EMLA8 + hypnosis (15 min) prior to first venipuncture + self-hypnosis instruction (n= 15) | 1) EMLA (n=15) 2) EMLA + attention (15 minutes) prior to first venipuncture (n= 15) |
1) 100 mm VAS 2) PBCL (three times following baseline - during preparation, needle insertion, and post procedure) |
1a) Venipuncture 1:Self-reported pain was significantly less in hypnosis participants than in attention controls (p<.001) who reported significantly less pain than EMLA only controls (p<.04) 1b) Venipuncture 2& Venipuncture 3: Self-reported pain was significantly lower among hypnosis participants than attention (p<.001) or EMLA only controls (p<.001). There were no significant intergroup differences between controls. 2a) Venipuncture 1: Hypnosis participants displayed less observable distress than attention (p<.001) controls, who appeared less distressed than EMLA only (p<.001) controls. 2b) Venipuncture 2& 3: Hypnosis participants again displayed significantly less observable distress than attention controls (p <.001) in both venipunctures. Attention controls also appeared less distressed than EMLA only controls during both venipuncture 2 (p=.025) and 3 (p = .008). |
‘(…) the use of self-hypnosis prior to venipuncture can be considered a brief, easily implemented and an effective intervention in reducing venipuncture-related pain.’ |
| Mackey, 2010 | Parallel design 4 Not reported |
Molar extraction 91/91 |
Hypnosis + relaxing background music during surgery + standard care (n=46) | Relaxing background music during surgery + standard care (n= 54) | 1) postoperative pain - 10cm VAS 2) intraoperative medication use 3) postoperative prescription analgesic used |
1) Postoperative pain was significantly less among hypnosis participants than controls (p<.001). 2) Control participants required significantly more intraoperative medication than hypnosis participants (p<.01). 3) The use of postoperative analgesics was significantly less among hypnosis participants than controls (p<.01). |
‘(…) the use of hypnosis and therapeutic suggestion as an adjunct to intravenous sedation assists patients having third molar removal in an outpatient surgical setting.’ |
| Snow, 2012 | Parallel design 1 Not reported |
Bone marrow aspirates and biopsies 80/80 |
Hypnosis (15 min before and during the procedure) + standard care (n= 41) | Standard-care (n=39) | 100mm VAS (pain, anxiety) | No significant between group differences in pain ratings. | ‘(…) brief hypnosis concurrently administered reduces patient anxiety during bone marrow aspirates and biopsies but may not Adequately control pain.’ |
1
‘Due to changes in medical treatment protocols which eliminated or significantly reduced the number of BMA/LP’s done with patients, only 20 of the original group of 42 subjects who initially volunteered completed the study.’ Page 183
2
VAS, visual analog scale
3
MPQ, McGill Pain Questionnaire
4
PCA, Intravenous patient-controlled analgesia
5
PBCL, Procedure Behavior Checklist
6
BMA, Bone marrow aspiration
7
VAS, visual analog scale
8
EMLA, eutectic mixture of local anesthetics