Introduction

Evidence-Based Physical Therapy (EBP) uses the best research evidence with clinical expertise and user’s preferences to produce the most appropriate and effective care. At week 44 in 2025, we had International Course in Spain, A Coruna, in the Faculty of Physiotherapy at University of Coruña about EBP. The program was opened with welcome words of the president of The European Network of Physiotherapy in Higher Education (ENPHE) and followed with the basis of EBP and teachers who highlighted the main challenges at different Physical Therapy fields. More than 30 physiotherapy students and 9 teachers from six universities (Savonia University of Applied Sciences, Finland, Universidade da Coruña, Spain, Charles University Czech Republic, CERRFF and École D´Assas, France, and Escola de Santa María de O Porto, Portugal), actively participated this week and shared experiential group dynamics and social activities. The students collaborated and wrote articles on a range of topics, including evidence-based neurology, respiratory and musculoskeletal disorders, geriatric and pediatric care, as well as sports injuries and related issues.

This student team focused on physiotherapy in infancy. In cooperation, our objective was to identify evidence-based practices and current limitations within this field. Our work involved a systematic search and critical appraisal of recent literature, emphasizing the integration of physiotherapeutic interventions in neonatal care. The project culminated in the development of a blog article discussing pain management in NICUs, highlighting the importance of non-pharmacological strategies to ensure safe, effective, and developmentally appropriate care for preterm infants.

Background

Preterm infants, born before 37 weeks of gestation, have immature nervous systems that make them especially sensitive to pain. During hospitalization in Neonatal Intensive Care Units (NICUs), they are exposed to frequent medical procedures, which can cause repeated painful experiences. Research has shown that early and unmanaged pain negatively affects neurodevelopment, potentially leading to long-term behavioural and cognitive issues. (1).

Pain assessment in premature infants is particularly challenging due to communication and comprehension barriers between newborns and caregivers. Since infants cannot verbalize pain, healthcare professionals must rely on indirect physiological and behavioural cues that may be difficult to interpret accurately (2). While pharmacological treatments are often used for pain relief, they carry potential side effects and risks due to the infants´ immature organ systems and limited drug metabolism. Therefore, non-pharmacological interventions are considered first-line strategies for mild or procedural pain in the NICU, while pharmacological treatments may still be necessary for moderate to severe or prolonged pain. This combined approach ensures both safety and effective pain management in this vulnerable population. This review aims to identify and evaluate physiotherapy interventions available to reduce or prevent pain in premature infants during their NICU stay. Understanding these procedures may guide clinical practice toward more effective and safer pain management strategies that support healthy neurodevelopment.

Methods

The inclusion criteria are for the population premature infant, for the intervention we choose specifically physiotherapy intervention to compare with no intervention, the outcomes were pain, chronic pain and acute pain and for the study design we only search for randomized controlled trial or cross-over RCT. The exclusion criteria for population are infants born at term, adolescents, adults or elderly. For the intervention, we did not seek to study medical intervention as a treatment for pain or compared with a pharmacological treatment. We focus on the benefits of physiotherapy in preventing or treating pain. Articles which did not mention pain in the outcomes were discarded. For the study design we excluded literature review, systematic review, narrative review, meta-analysis, case study, cases series, case-control study, cohort study, interventional/experimental study, non-randomized study.

We used PEDro scale as a tool to evaluate the methodological quality of randomized controlled trials. It assesses the internal validity and statistical reporting of studies through 11 criteria, providing a score from 0 to 10. This scale helps to determine the reliability and validity of clinical trials to support evidence-based practice. The higher the PEDro score, the higher the methodological quality of the trial.

Criteria selections were based on PICOS criteria. Initial research was done through different database. In order to obtain diversity, we consulted several databases (PubMed, PEDro, Google Scholar, Cochrane and Science Direct) Our MeSH Terms were infant, premature and pain, cute pain, pain management, chronic pain, musculosketal pain, visceral pain, nociceptive pain, pain perception and Physical therapist assistant, physical therapy department, hospital, physical therapy specialty, physical therapy modalities.

Results

In total, we found 1259 articles. Recent studies highlight the effectiveness of simple, non-pharmacological techniques in reducing pain and improving comfort for newborns during medical procedures.

Tucking intervention: Without intervention, 38.2% of infants experienced moderate to severe pain during suctioning. With tucking, only 8.8% showed a significant reduction in pain scores (3). The effect of facilitated Tucking during endotracheal suctioning on procedural pain in preterm neonates: a randomized controlled crosse over study: PEDRO score 3/10 unfulfilled item: 3) concealed allocation; 4) group similar at the baseline; 5) subject blinding; 6) blinding of the therapists; 7) Assessor blinding; 8)less than 15% dropouts; 9) intention to treat.

Multimodal stimulation method (MMS): Infants in the MMS group showed an average 2-point decrease in pain scores (p < 0.001), while no change occurred in the control group. The large effect size (0.69) and strong statistical power indicate a marked reduction in behavioral signs of pain (4).

Short-term effects of multimodal stimulation on neuromotor behaviour and neonatal pain among hospitalized preterm infants: A feasibility, non-blinded randomized controlled trial. PEDRO score 6/10 unfulfilled item: 5) subject blinding; 6) blinding of the therapists; 7) Assessor blinding; 9) intention to treat.

Expiratory flow increase technique (EFIT) vs. conventional chest physiotherapy (CPT): Both methods had similar short-term respiratory effects, but EFIT was associated with a lower respiratory rate, higher oxygen saturation, and less pain, suggesting it may be a more effective and comfortable option for newborn respiratory care (5).

Short-term effects of conventional chest physiotherapy and expiratory flow increase technique on respiratory parameters, heart rate, and pain in mechanically ventilated premature neonates: A randomized controlled trial. PEDRO score 6/10 unfulfilled item: 5) subject blinding; 6) blinding of the therapists; 7) Assessor blinding; 9) intention to treat.

Auricular massage: Pain scores measured with the PIPP-R scale were significantly lower after auricular massage (3.63) compared to routine care (10.23). Heart rate and oxygen levels were more stable, and no adverse effects were reported (6). The Effect of Auricular Massage on Naso-Oral Suctioning Procedural Pain in Premature Neonates: A Randomized Controlled Crossover Study: PEDRO score 7/10 unfulfilled item: 5) blinding of the subjects; 6) blinding of the therapists; 9) intention to treat.

Conclusion

These findings show that gentle, non-invasive interventions such as tucking, MMS, EFIT, and auricular massage can significantly reduce neonatal pain. They represent safe, accessible, and effective approaches to improving newborn comfort in clinical care. Further studies should be conducted to prove the long-term effects of these technics and to establish high quality, evidence-based guidelines for physiotherapists.

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Authors:

Natálie Hvězdová, physiotherapy student, Charles University, Czech Republic

Léna Berthes, physiotherapy student, CEERRF, France

Gabriella SOW, physiotherapy student, ASSAS, France

Melania Busto, physiotherapy student, Universidade da Coruña, Spain

Dagmar Pavlu, PT. Assoc. Prof. Charles University, Czech Republic.

Ivana Vláčilová, PhD., PT. Charles University, Czech Republic.

Marja Äijö, PT, PhD Principal Lecturer of gerontology and rehabilitation, Savonia, University of Applied Sciences, Kuopio, Finland.

Veronica Robles García, PhD. PT. OT. Associate Professor, University of A Coruña, A Coruña, Spain.

Zeltia Naia Entonado, PhD. PT. University of A Coruña, A Coruña, Spain.

María Vilanova Pereira, PhD., PT. University of A Coruña, A Coruña, Spain.

Adrien Pallot, PT, MSc, Lecturer at École D´Assas, France.

Aurel Bellaïche, PT, Lecturer at CEERRF, France.

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References:

1) Cook KM, De Asis-Cruz J, Kim J-H, Basu SK, Andescavage N, Murnick J, et al. Experience of early-life pain in premature infants is associated with atypical cerebellar development and later neurodevelopmental deficits. BMC Med [Internet]. 2023;21(1):435. Available at: http://dx.doi.org/10.1186/s12916-023-03141-w

2) Raeside L. Physiological measures of assessing infant pain: a literature review. Br J Nurs [Internet]. 2011;20(21):1370–6. Available at: http://dx.doi.org/10.12968/bjon.2011.20.21.1370

3) Mona Alinejad-Naeini, Parisa Mohagheghi, Hamid Pe. The effect of facilitated Tucking during endotracheal suctioning on procedural pain in preterm neonates: a randomized controlled crosse over study. Glob J Health Sci. 2014 May 4;6(4):278-84. https://doi.org/10.5539/gjhs.v6n4p278.

4) Aranha VP, Chahal A, Bhardwaj AK. Short-term effects of multimodal stimulation on neuromotor behaviour and neonatal pain among hospitalized preterm infants: A feasibility, non-blinded randomized controlled trial. J Neonatal Perinatal Med [Internet]. 2023;16(2):325–37. Available at: http://dx.doi.org/10.3233/NPM-210889

5) Jacqueline Carla de Macedo, Clarice Rosa Olivo, Viviani Barnabé, Íbis Ariana Peña de Moraes, Iolanda de Fátima Lopes Calvo Tibério, Celso Ricardo Fernandes de Carvalho and Beatriz Mangueira Saraiva-Romanholo. Short-term effects of conventional chest physiotherapy and expiratory flow increase technique on respiratory parameters, heart rate, and pain in mechanically ventilated premature neonates: A randomized controlled trial. Healthcare (Basel). https://doi.org/10.3390/healthcare12232408.

6) Ali RA, Obeidat RF, Oweis AI. The effect of auricular massage on Naso-oral suctioning procedural pain in premature neonates: A randomized controlled crossover study. ScientificWorldJournal [Internet]. 2025;2025(1):8819743. Available at: http://dx.doi.org/10.1155/tswj/8819743

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