May the Z-Tracking Technique to Minimize or Avoid the Pain of Insulin Injection Be an Alternative to the 10-Second Waiting Technique? (2024)

Improving best practices in insulin injection technique is a main concern for bothpatients and the health care team.¹ If the injection technique is incorrect, then it can result in pain, insulinleakage, bleeding, inflammation, bruising, lipoatrophy, and lipohypertrophy.² Pain is perhaps the most common adverse event associated with insulinuse.^3,4 Pain on injectionmay be caused by inaccurate injection technique; however, information is lackingconcerning how to minimize the injection pain. Thus, the prompt mitigation of anxietyabout and fear of pain and, if possible, mitigation of the actual pain are of greatimportance to the health care team. In seeking to understand injection pain, patientself-reports become very important.³ In a study by Kalra and colleagues² just over half of Indian injectors reported having pain on injection. In a studyby Zijlstra and colleagues⁴ large volume and thigh injections were rated as being more painful, but injectionspeed did not influence pain sensation.

Application of best practice technique in insulin delivery is an important aspect of asuccessful insulin therapy.¹ Recent studies have indicated that leakage of liquid from the skin did not occurwhen administering subcutaneous tissue lateral to vertical lines drawn 5 cm away fromthe umbilicus with 30 units/mL in distilled water with shorter 4 mm prefilled pensneedles by the Z technique. Studies have included both healthy volunteers and personswith diabetes, and their results have been consistent. This suggests that Z-tracking(the cutaneous tissues are pulled 2 cm caudad before inserting a 90° needle into thesubcutaneous tissue after the button has been fully depressed, and then the needle isremoved from the skin) may be an alternative to the 10-second hold in time (a 90° needleis directly inserted into the subcutaneous tissue and patients wait at least 10 secondsafter the injection before the needle is withdrawn from the skin).^5,6

It was felt necessary to conduct this study to compare the effects on pain sensation ofthe 10-second waiting technique and the Z-track technique, which is claimed to behelpful in this regard.^5,6Perceived injection pain sensation was assessed using a 10-cm visual analog scale (VAS)(0 cm/no pain, 10 cm/extreme pain). The study conducted by Demirhan et al⁵ found that the healthy volunteers group using the Z technique had a meanperceived injection pain sensation with VAS was 0.3 ± 0.8 cm, whereas with the 10-secondwaiting technique these values were 0.9 ± 1.8 cm, respectively. In their other works,⁶ these authors found that in the persons with diabetes group with the Z techniquemean perceived injection pain sensation with VAS was 0.4 ± 1.1 cm, whereas with thestandard 10- seconds waiting group these values were 1.5 ± 1.8 cm, respectively. Whencompared to the 10 seconds waiting technique, the Z-tract insertion techniquedemonstrated a significantly lower mean perceived injection pain sensation with VAS fromthe skin with subcutaneous injections. These results suggest that the Z-tract insertiontechnique plays an important role in reducing injection pain. Painless (as opposed topainful) subcutaneous insulin injections may increase treatment adherence. The resultsof this study may be of value for guiding patients to use the appropriate injectiontechnique to reduce their injection pain.

To prevent pain sensation or minimize pain, an insulin injection should be performed withZ-tract technique insertion of a thin needle in the cutaneous tissues, rather than witha 10-second waiting technique.

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