8). A number of alternative treatment modalities have been used in an effort to avoid these adverse side effects, including various mind-body and therapeutical techniques that may prove efficacious in some orthopedic patients, but many healthcare providers remain unaware or untrained in their use (Lukas, 2004). For instance, one orthopedic nurse reports that, "In today's fast-paced surgical environment, perioperative nurses face many challenges to meet the needs of outpatients in helping to alleviate their pain and anxiety. Most nurses have not been taught non-pharmacologic methods for control of pain and anxiety" (Lukas, 2004 p. 8). Besides this lack of training in providing adjunct treatment modalities for pain management in the orthopedic patient, there is also a pronounced lack of training concerning efficacious treatment modalities for younger orthopedic patients. For instance, Bennett-Branson and Craig (1999) emphasize that, "Despite advances in pharmacological approaches to pain control, most children who undergo surgery continue to experience moderate to severe postoperative pain. Children and their parents are forced to rely on personal resources to cope with this severe stressor" (p. 355). As noted above, individual manifestations of pain exist along a continuum that differs from time to time and place to place, but most adults are better able to communicate their level of post-operative pain to their healthcare team, while children under 5 years may be at a distinct disadvantage in this area. For orthopedic patients 5 years and over, though, McGrath (1996) reports that there are several self report measures of pain for children available, as well as observational measures such as facial action scales which appear to be most sensitive to children's post-operative pain. Despite the availability of these measures, many authorities suggest that children's parents should be actively involved in this formulation of pain management approaches, before, during and following surgical interventions. In this regard, Bennett-Branson and Craig (1999) add that parents are a reliable source of accurate information concerning the pain levels being experienced by their children, but that their children's anxiety level corresponded to the parents', suggesting that a family-oriented approach to pain management in the post-operative orthopedic pediatric patient is most appropriate (Bennett-Branson & Craig, 1999).

Implications for Practice

The research to date indicates that postoperative pain management following orthopedic surgical interventions remains less than completely effective, indicating that many of the readily available pharmacological alternatives that are safe and effective for postoperative pain management continue...

This lack of effectiveness may be due in part to a need for additional training to improve awareness of the various efficacious treatment modalities that are available for adults and children, but the need appears especially pronounced for pediatric patients. In this regard, Bennett-Branson and Craig (1999) conclude that, "Given the increasing use of day surgery, with children discharged home the day of the operation, parents are assuming greater responsibility for the management of unrelieved postoperative pain, yet they currently receive little to no preparation for that role, and find it anxiety provoking" (p. 357). Therefore, parents of orthopedic pediatric patients should receive adequate training and information concerning the effective management of pain following their return home, both for the benefit of the young patient as well as to help reduce their anxiety levels which children can sense and which can contribute to elevated anxiety in them as well (Bennett-Branson & Craig, 1999).
Recommendations/Conclusion

Healthcare practitioners must improve their awareness of the need for efficacious, evidence-based pain management methods for adults and children alike. Because everyone experiences pain in different ways at different times, it is vitally important for clinicians to shake off their preconceptions about pain and develop an empathetic approach that is responsive to orthopedic patients' pain management needs. Not only is this a quality improvement indicators, it is also congruent with the overall need to improve patient satisfaction and facilitate improved clinical outcomes.