Cite as: Singh W, Potru S. How I do it: trauma-informed care for the interventional pain patient. ASRA Pain Medicine News 2026;51. https://doi.org/10.52211/asra050126.013.

How I Do It

Introduction

While interventional pain procedures can often be life-changing for some patients, they can cause medical trauma, such as procedural pain, exposure to foreign sensations, concerns about inability to move due to potential nerve damage, and positioning in a physically exposed manner. All of these can precipitate apprehension, dissociation, fright, or procedural discomfort in patients, especially those suffering from trauma.^1,2 Epidemiological data show a high correlation of chronic pain in individuals with trauma histories, which can include medical trauma (defined as prior painful or distressing medical procedures), military combat or training trauma, adverse childhood experiences, sexual assault, and post-traumatic stress disorder (PTSD).^3-6

Unfortunately, trauma histories often remain overlooked during many types of procedures, despite this current evidence. Trauma-informed care (TIC) enables greater tolerance for procedures, reduced re-traumatization, and a strengthened therapeutic alliance, all without requiring significantly more time, additional tools, or medications.⁷ From initial diagnostic evaluation to post-procedural debriefing, we seek to provide a replicable and practical approach to trauma-informed care for patients undergoing interventional pain care.

The Role of Trauma-Informed Care in Interventional Pain

Adjusted pain processing, amplified autonomic responsiveness, and compromised threat regulation are exhibited by individuals with traumatic histories.^8-10 Lack of environmental familiarity, unanticipated physical contact, prone positioning of the patient, limited motor activity, and the hierarchical relationship between the patient and the doctor are frequently routine sources of these challenges.¹

Trauma intensifies operational discomfort and pain sensitivities by modulating the neurobiological pathways underlying amygdala-mediated threat responses and the hypothalamic-pituitary-adrenal (HPA) axis.^8,11,12 Instead of being seen as protective reactions, patient responses are often misconstrued as non-compliance, anxiety, or a decreased threshold for pain tolerance.

Clinician frustration, disproportionate use of sedation, aborted procedures, and eluding follow-up may all be caused by a delay in acknowledging trauma history or failing to do so entirely.^3,13 Procedural safety, productivity, and patient outcome, as well as the quality of the patient encounter itself, can be enriched by TIC.^1,14

The Fundamentals of Trauma-Informed Care

Six generally recognized doctrines form the basis of TIC:⁷

1. Collaboration and mutuality
2. Trustworthiness and transparency
3. Empowerment
4. Safety
5. Cultural, Historical, and Gender Issues
6. Choice

These concepts should drive specific behaviors when applied to interventional pain care, rather than remain mere buzzwords. The following is our practical guidance for this challenging population.

Normalizing the Patient’s Trauma Without Mandating Release

Lessened levels of stigma and re-traumatization are associated with broad, unobtrusive language.¹ Instead of using a question-and-answer approach (the usual standard in history-taking) to obtain trauma history, one could normalize a patient’s stress reaction by stating something like, “It is common for patients to feel nervous about these types of procedures, which could sometimes be due to past experiences. If there is anything we can do that would make you feel more comfortable or safer, please let us know.” Re-traumatization often occurs during mandated disclosure of traumatic events; gentle reassurance, such as the above, encourages patients to share their comfort zone, desires, and worries without concerns of re-traumatization or judgment.^7,15

Recognize Warning Signs in the Beginning

Specific characteristics, such as strong opposition to positioning, history of panic disorder, excessive fear of self-determination loss, diagnosis of acute stress disorder or PTSD, or a history of prior aborted procedures, indicate a greater probability of trauma-associated discomfort.^2,4 Fibromyalgia or complex regional pain syndrome, especially when afflicting veterans, may make those individuals notably susceptible.⁸

Recognizing these challenges during procedural scheduling can enable anticipatory guidance and potentially reduce procedural failure/discontinuation rates.

Trauma-Informed Practices on Procedure Day

Allow for preference and consistency. Describing the procedure step-by-step itself will likely reduce anxiety related to it and may reduce the likelihood of a panicked reaction. Sympathetic stimulation and anticipated danger can be diminished by consistency;⁹ as a result, the authors recommend addressing the anticipated duration of each portion of the procedure as well as potential sources of discomfort during the procedure. Procedural pacing (eg, taking short pauses between steps, decelerating needle advancement, and smoother needle passes), lighting, music choice, stress balls for squeezing, and arm positioning are all seemingly small details that could make a substantial difference in patient comfort.

Indeed, helplessness, which is a central characteristic of traumatic stress, can be curbed by small decision-making, which can also help improve or maintain an individual’s sense of free will.¹⁶

Present the team members and their tasks. For patients, especially those with interpersonal trauma, the anticipated danger may be diminished, and the environment may be familiarized via clear introductions, including the roles of each team member.¹ Certainly, team communication and ownership of particular tasks may also be enhanced with this, even with team members who are familiar with each other.

Maintain ongoing, evolving consent. Notably, obtaining trauma-informed consent (an ongoing process instead of a distinct pre-procedure event) is a repetitive process and is not negotiable.⁷ To improve patient autonomy in patients not receiving sedation or receiving only minimal sedation, it is likely best practice to educate immediately before skin preparation, positioning, and needle placement, as well as throughout the procedure, as indicated, particularly in patients who are feeling discomfort. This helps reduce procedural discomfort and corresponds with ethical consent guidelines.¹⁵

Acknowledge decency, vulnerability, and positioning. Feelings of loss of self-determination and helplessness may be fueled by exposure during prone placement, exposure of potentially sensitive areas, and subsequent draping.⁹ This is obviously of particular concern in patients who have experienced sexual trauma to the lower halves of their bodies. It is imperative to discuss the patient’s position and exposure prior to the day of the procedure. If possible, minimize the area exposed on the day of the procedure and intermittently assess the patient’s discomfort. While controversial, permitting a particularly traumatized patient’s supportive figure to stay in the procedure room is consistent with patient-centered procedural care and may be favorable in appropriate circumstances.¹³

Use sedatives deliberately. Operative and procedural implementation of sedation is not informed by trauma. Discomfort can be aggravated by unfamiliarity and detachment.⁹ While sedation can make procedures more comfortable for some patients, it is critical to specifically highlight that remaining awake and alert during the procedure is a choice, and that sedation is not mandatory.

Trauma-informed care (TIC) enables greater tolerance for procedures, reduced re-traumatization, and a strengthened therapeutic alliance, all without requiring significantly more time, additional tools, or medications.

In accordance with the ASA procedural sedation recommendations, it will likely be beneficial to take extra care in describing the potential effects of procedural sedation and to ask patients openly about their desire for sedation.¹³

Be sensitive to language. A patient’s sensitivity to danger can be increased, and confidence may erode when specific marginalizing terminology is used, particularly that which dismisses discomfort, including phrases like “just relax” or “this won’t hurt.”¹ Instead, indicating the experience of others may be beneficial, stating “Most people usually experience the most discomfort when we numb the skin and primarily pressure after that” (if such a statement is true in the practitioner’s experience). Generally, the clinician is advised to use cooperative, supportive terminology, including phrases like “Let me know if we need to pause or slow down,” “You are in control,” and “We are working together.” Intentionally and actively using empowering language strengthens consent and patient autonomy.

Monitor vigilantly throughout the procedure. In patients with trauma histories, signals such as abrupt withdrawal from stimuli, rigid musculature, withheld breathing, and disrupted perception of reality must be considered when performing procedures and given special attention. Premature procedure cessation can be avoided by implementing grounding techniques, including orienting statements, breath pacing, and short pauses throughout the procedure as indicated, which can help control autonomic stimulation.^9,11,17

Momentarily pausing to offer continued assurance can often save time and be significantly easier than handling deteriorating and intensifying discomfort or re-traumatization. After completion of the procedure, allowing for re-adjustment and re-orientation of patients can diminish discomfort, disorientation, and stress.¹³

Bolster triumph and competency. Self-efficacy improves when positive reinforcement helps the procedure feel tolerable.¹⁶ In patients with preceding medical trauma, this may be especially significant.

Documentation. Ideally, in the case of all patients, but particularly in the case of challenging ones, particular patient preferences, productive approaches, and outcomes should be carefully documented; this will improve the feasibility of replicating trauma-informed care in future procedural or pain clinic encounters as well as in other areas of the healthcare system.⁷

Conclusion

Typical interventional pain procedures can be remodeled into compassionate, protective, and more sheltering clinical encounters through trauma-informed care. Pain physicians may enhance patient resilience, reduce patient stress and suffering, and reinforce the therapeutic alliance without significantly increasing procedural complexity or duration by effectively educating patients, noting preferences, and fostering teamwork in patient-centered care.¹⁸ The elements of TIC correspond smoothly with the ideals of interventional pain medicine, maintaining individualized care and respect while easing pain.

References

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