# What physiotherapy interventions are available to reduce pain in premature infants during their hospitalization in NICU’s?

> A review of evidence-based non-pharmacological physiotherapy interventions for managing pain in preterm infants within Neonatal Intensive Care Units.

## Introduction
Evidence-Based Physical Therapy (EBP) integrates research evidence, clinical expertise, and patient preferences to optimize care. In November 2025, an international course held at the University of A Coruña, Spain, brought together over 30 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)—to explore EBP across various clinical fields, including pediatric care.

## Pain Management in the NICU
Preterm infants (born before 37 weeks) possess immature nervous systems, making them highly sensitive to pain. Frequent medical procedures in the Neonatal Intensive Care Unit (NICU) can lead to repeated painful experiences, which research links to negative impacts on neurodevelopment and long-term behavioral and cognitive issues.

Assessing pain in this population is difficult due to the inability of infants to verbalize discomfort, requiring reliance on physiological and behavioral cues. While pharmacological treatments are used, they carry risks due to immature organ systems. Consequently, non-pharmacological physiotherapy interventions are prioritized as first-line strategies for mild or procedural pain.

## Methodology
The student team conducted a systematic search and critical appraisal of recent literature to identify effective physiotherapeutic interventions. 

*   **Inclusion Criteria:** Premature infants; physiotherapy interventions; outcomes including pain, chronic pain, or acute pain; study designs limited to randomized controlled trials (RCTs) or cross-over RCTs.
*   **Exclusion Criteria:** Term infants, adolescents, adults, elderly; pharmacological treatments; literature reviews, systematic reviews, meta-analyses, case studies, cohort studies, or non-randomized studies.
*   **Quality Assessment:** The PEDro scale (0–10) was used to evaluate the methodological quality of the selected trials.
*   **Databases Consulted:** PubMed, PEDro, Google Scholar, Cochrane, and Science Direct.

## Physiotherapy Interventions for Pain Reduction
The review identified 1,259 articles, from which the following non-pharmacological techniques were highlighted:

### Tucking Intervention
*   **Effectiveness:** Without intervention, 38.2% of infants experienced moderate to severe pain during suctioning; with tucking, this dropped to 8.8%.
*   **Study:** *The effect of facilitated Tucking during endotracheal suctioning on procedural pain in preterm neonates*
*   **PEDro Score:** 3/10

### Multimodal Stimulation Method (MMS)
*   **Effectiveness:** Infants in the MMS group showed an average 2-point decrease in pain scores (p < 0.001) compared to the control group.
*   **Study:** *Short-term effects of multimodal stimulation on neuromotor behaviour and neonatal pain among hospitalized preterm infants*
*   **PEDro Score:** 6/10

### Expiratory Flow Increase Technique (EFIT)
*   **Effectiveness:** Compared to conventional chest physiotherapy (CPT), EFIT was associated with lower respiratory rates, higher oxygen saturation, and less pain.
*   **Study:** *Short-term effects of conventional chest physiotherapy and expiratory flow increase technique on respiratory parameters, heart rate, and pain in mechanically ventilated premature neonates*
*   **PEDro Score:** 6/10

### Auricular Massage
*   **Effectiveness:** Pain scores (PIPP-R scale) were significantly lower after auricular massage (3.63) compared to routine care (10.23).
*   **Study:** *The Effect of Auricular Massage on Naso-Oral Suctioning Procedural Pain in Premature Neonates*
*   **PEDro Score:** 7/10

## Conclusion
Gentle, non-invasive interventions such as tucking, MMS, EFIT, and auricular massage are safe and effective methods for reducing neonatal pain. These findings support the integration of these techniques into clinical practice to improve newborn comfort and support healthy neurodevelopment. Further research is required to establish long-term effects and standardized evidence-based guidelines.

## 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

## References
1. Cook KM, et al. Experience of early-life pain in premature infants is associated with atypical cerebellar development and later neurodevelopmental deficits. *BMC Med*. 2023;21(1):435.
2. Raeside L. Physiological measures of assessing infant pain: a literature review. *Br J Nurs*. 2011;20(21):1370–6.
3. Alinejad-Naeini M, et al. 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;6(4):278-84.
4. Aranha VP, et al. 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*. 2023;16(2):325–37.
5. de Macedo JC, et al. 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)*.
6. Ali RA, et al. The effect of auricular massage on Naso-oral suctioning procedural pain in premature neonates: A randomized controlled crossover study. *ScientificWorldJournal*. 2025;2025(1):8819743.