Pain (Professional) (cont.)
Physical, Integrative, Cognitive-Behavioral, and Psychosocial Interventions
Patients should be encouraged to remain active and participate in self-care when possible. Noninvasive physical, integrative (complementary/alternative therapies), cognitive-behavioral, and psychosocial modalities are typically used in conjunction with pharmacotherapy to manage pain during all phases of treatment. These interventions have the potential to enhance pain control directly but also indirectly, by increasing a patient's sense of control over events. The effectiveness of these modalities depends on the patient's participation and communication of which methods best alleviate pain. Minority patients of various ethnicities have been noted to experience worse control of their pain, which may result from miscommunication issues within the medical setting. In a post hoc analysis of a small trial, minority (various ethnicities) (n = 15) and white (n = 52) cancer patients were randomly assigned either to a 20-minute individualized education-and-coaching session regarding pain management (including how to discuss their concerns with their physician) or to usual care. At baseline, minority patients reported significantly more pain than white patients (6.0 vs. 5.0), whereas at follow-up, disparities had been eliminated in the intervention group (4.0 vs. 4.3) but remained in the control group (6.4 vs. 4.7).[Level of evidence: I]
Generalized weakness, deconditioning, and musculoskeletal pain associated with cancer diagnosis and therapy may be treated by:
- Avoid burns by wrapping the heat source (e.g., hot pack or heating pad) in a towel. A timing device is useful to prevent burns from an electrical heating pad. The use of heat on recently irradiated tissue is contraindicated, and diathermy and ultrasound are not recommended for use over tumor sites.
- Apply flexible ice packs that conform to body contours for periods not to exceed 15 minutes. Cold treatment reduces swelling and may provide longer-lasting relief than heat but should be used cautiously in patients with peripheral vascular disease and on tissue damaged by radiation therapy.
- Exercise strengthens weak muscles, mobilizes stiff joints, helps restore coordination and balance, and provides cardiovascular conditioning. Therapists and trained family or other caregivers can assist the functionally limited patient with range-of-motion exercises to help preserve strength and joint function. During episodes of acute pain, exercise should be limited to self-administered range-of-motion. Weight-bearing exercise should be avoided when bone fracture is likely.
- Reposition the immobilized patient frequently to maintain correct body alignment, to prevent or alleviate pain, and to prevent pressure ulcers.
- Use restriction of movement to manage acute pain or to stabilize fractures or otherwise compromised limbs or joints. Use adjustable elastic or thermoplastic braces to help maintain correct body alignment. Keep joints in positions of maximal function rather than maximal range. Avoid prolonged immobilization.
- Transcutaneous Electrical Nerve Stimulation (TENS): Controlled low-voltage electrical stimulation applied to large myelinated peripheral nerve fibers via cutaneous electrodes to inhibit pain transmission. Patients with mild-to-moderate pain may benefit from a trial of TENS to see if it is effective in reducing the pain. TENS is a low-risk intervention. A small crossover study (N = 41) found that 72% of users rated TENS as effective or very effective, compared to those using the comparison intervention (27%) or placebo intervention (36%). Furthermore, a clinically meaningful number of participants was still using the TENS a year later (n = 10), in contrast to the other two conditions (combined n = 5). All three treatment arms were well tolerated, but there is no conclusive evidence demonstrating any benefit from TENS or transcutaneous spinal electroanalgesia (TSE) over placebo in this cancer pain population.[Level of evidence: I]
Massage, Pressure, and Vibration
- Physical stimulation techniques have direct mechanical effects on tissues and enhance relaxation when applied gently. Tumor masses should not be aggressively manipulated.
Massage therapy is an integrative modality that has been investigated as an adjunct to supportive care interventions in managing cancer-related pain. Preclinical and clinical trials have found that massage reduces pain by reducing cortisol levels, increasing serotonin and dopamine levels, stimulating the release of endorphins, and stimulating blood and lymphatic circulation. Massage may enhance the effects of analgesic medications and decrease inflammation and edema. There is a large body of evidence supporting the role of massage in reducing pain associated with muscle-related conditions such as muscle spasms and tension.[3,4,5,6] Massage may also play a role in the management of procedural pain.
In one of the largest randomized trials, 380 adults with advanced cancer received six sessions of either massage therapy or touch therapy for 30 minutes over a 2-week period. While immediate improvements from massage therapy were significantly greater than those from touch therapy, the benefits were not sustained, according to the Brief Pain Inventory. However, a large number of patients were not included in the assessments of immediate outcomes or sustained outcomes. Data collectors were also not blinded to the study arm, which may have led to overreporting the effects of massage therapy or touch therapy.
A number of reviews exploring the role of massage in the management of cancer pain or other areas of supportive care have been published. In a Cochrane review of the role of massage therapy with or without aromatherapy as a component of supportive care, three studies found a reduction in pain following intervention and reported reductions of 30% to 39% in pain scores after massage therapy, compared to usual care. Another study reported on the role of massage within the context of supportive care in cancer, highlighted pain, and concluded that evidence is encouraging but effect sizes are small. Additional trials are needed.
While the benefit of massage therapy on cancer pain may be mixed, existing trials suggest that massage therapy is safe in patients with cancer. However, certain precautions should be taken when providing massage therapy to patients with cancer:
- Avoid directly massaging any open wounds, hematomas, or areas with skin breakdown.
- Avoid massaging the site of the tumor.
- Avoid massaging areas with acute deep venous thrombosis.
- Avoid directly massaging radiated soft tissue.
- Acupuncture applies needles, heat, pressure, and other treatments to one or more places on the skin known as acupuncture points and is often sought by patients with cancer for the management of pain. (Refer to the PDQ summary on Acupuncture for a comprehensive review of the evidence supporting the role of acupuncture for the management of pain.)
Music Interventions for Pain
- Music Therapy and Music Medicine
There are generally two broad categories of music-based interventions referenced within health care research.
- Music therapy is the clinical and evidence-based use of active and receptive, tailored, music-based interventions to accomplish individualized goals within a therapeutic relationship, delivered by a credentialed professional (music therapist-board certified, or MT-BC) who has completed an approved program in music therapy.
Music therapists use a variety of music-based interventions that include live, interactive music making or carefully selected recorded music. Some examples include music improvisation, song writing and singing, and music relaxation.
A music therapist chooses interventions on the basis of an assessment of a patient's immediate and long-term needs (e.g., pain management, anxiety reduction, coping strategies, and skills).
- Music medicine is the use of passive music listening (usually prerecorded music) for distraction, delivered by a medical professional without specialized music training.
Music therapy and music medicine interventions have been used to relieve acute and chronic pain related to noxious procedures and treatments and the disease process. Music reduces pain via the mutually inhibitory neuroanatomical pathways that are shared between pain and reward processing. Neuroscience studies are consistent in suggesting that pleasant emotional responses to music activate brain structures related to reward, emotion, and attention and decrease activation in areas associated with aversive events.[12,13,14] Music from an individual's personal collection that elicits a positive emotional response has the most robust effect in increasing pain tolerance, decreasing anxiety, and increasing perceived control.[15,16,17]
Meta-analyses summarizing the effect of music on pain indicate small to moderate benefit, with a high level of heterogeneity. There is preliminary evidence that music interventions delivered by music therapists are more effective than music medicine interventions.[10,18]
Studies reporting rates of 50% pain reduction indicate that participants in music listening had a 70% greater probability of experiencing at least a 50% pain reduction than did controls (n = 4 studies). There is also preliminary evidence that music reduces opioid requirements, but the benefits are small and the clinical importance is unclear. Music-based interventions specifically for cancer patients found a moderate pain-reducing effect of a 0.54 standardized unit difference between music and usual-care groups (5 studies, n = 391).
While initial results are promising, the quality of evidence for music and cancer pain studies is low, often because of wide confidence intervals and high variability in study quality. Common sources of bias and low quality include nonblinding of participant and study personnel, lack of theory guiding music selection and delivery, and incomplete reporting of intervention details.[13,21,22]
- Characteristics of Music Interventions for Pain
Characteristics of music interventions for pain include the following:
- Music interventions can be used as adjuncts to analgesic medications.
- When available, live music is preferred, delivered by a board-certified music therapist.
- When recorded music is to be used, patients should be encouraged to choose music from their personal collections that is emotionally meaningful to them.
- When several pieces of music are to be used, they should be played so that up-tempo and more complex pieces are heard at the beginning, with tempo and overall complexity decreasing from beginning to end.
- A general orientation to music listening should be provided to patients and caregivers, to include the operation of any equipment and instructions to patients for when they need additional assistance.
- Music listening through headphones may be contraindicated during painful procedures because it prevents patients from hearing instructions or comments from physicians.
- Music introduced before a procedure is more effective than music introduced during or after a procedure.
Cognitive-behavioral interventions are an important part of a multimodal approach to pain management. They help the patient obtain a sense of control and develop coping skills to deal with the disease and its symptoms. Guidelines by a National Institutes of Health assessment panel suggest integration of pharmacologic and behavioral approaches for treatment of pain and insomnia. Other studies suggest that behavioral interventions targeted to specific symptoms, such as pain and fatigue, can significantly reduce symptom burden and improve the quality of life for patients with cancer.[Level of evidence: I] Realistic expectations are needed for delivery of cognitive-behavioral interventions. One study [Level of evidence: I] of cognitive-behavioral interventions for pain management randomly assigned 57 patients (most of whom were women with metastatic breast cancer who were maintained on daily opioid use for pain) to three 20-minute interventions delivered by audiotape (progressive muscle relaxation [PMR], positive mood induction, or a distraction condition) or to a no-intervention control. The patients were provided the audiotapes by a research nurse, given brief instructions, and asked to use the tapes at least five times a week for 2 weeks; more than half of the patients reported complying with these instructions. The relaxation condition and the "distraction" condition (self-selected informational tapes) produced significant immediate effects on pain, but the positive mood induction tapes showed no effects. The effects, however, neither carried over to general symptom management nor affected pain management at other times. One conclusion of this study is that ideally, interventions should be matched to patient preferences; for more extended effects, additional instruction and support may be needed, as suggested by other studies.
Interventions introduced early in the course of illness are more likely to succeed because they can be learned and practiced by patients while they have sufficient strength and energy. Patients and their families should be given information about and encouraged to try several strategies, and to select one or more of these cognitive-behavioral techniques to use regularly:
Relaxation and Imagery
- Simple relaxation techniques (see examples listed below) should be used for episodes of brief pain (e.g., during procedures). Brief, simple techniques are preferred when the patient's ability to concentrate is compromised by severe pain, a high level of anxiety, or fatigue.
- Hypnotic techniques may be used to induce relaxation and may be combined with other cognitive-behavioral strategies.[Level of evidence: I] Hypnosis is effective in relieving pain in individuals who can concentrate well, can use imagery, and are motivated to practice. A randomized but unblinded study of preoperative hypnosis in women undergoing excisional breast biopsy or lumpectomy revealed that women who underwent hypnosis required less propofol and lidocaine use during surgery and scored lower on measures of pain, nausea, fatigue, discomfort, and emotional upset at discharge.[Level of evidence: I]
Cognitive Distraction and Reframing
- Focusing attention on stimuli other than pain or negative emotions accompanying pain may involve distractions that are internal (e.g., counting, praying, or making self-statements such as "I can cope") or external (e.g., listening to music, watching television, talking, listening to someone read, or using a visual focal point). In the related technique, cognitive reappraisal, patients learn to monitor and evaluate negative thoughts and replace them with more positive thoughts and images.
- Both oral and written information and instructions should be provided about pain, pain assessment, and the use of drugs and other methods of pain relief.[29,30,31][Level of evidence: I] Patient education should emphasize that almost all pain can be effectively managed. Major barriers to effective pain management (refer to the list of Barriers to Effective Cancer Pain Management in the Overview section of this summary) should be discussed to correct patient and family misconceptions. Health care providers need to take into consideration family members' interpretation of patient pain when providing pain management education services, as some caregivers overestimate patient pain.[Level of evidence: II] Educational intervention programs to help patients who have cancer and their families manage pain have been described and may improve clinical outcomes.[Level of evidence: II] These programs are based on adult learning principles and incorporate key strategies, including provision of information using academic detailing, skill building with ongoing nurse-coaching, and interactive nursing support.[Level of evidence: IV];[Level of evidence: I] Training partners to participate in management of cancer pain increases partner self-efficacy for controlling their loved one's pain and other symptoms.[Level of evidence: II]
Psychotherapy and Structured Support
- Some patients benefit from short-term psychotherapy provided by trained professionals. Patients whose pain is particularly difficult to manage and who develop symptoms of clinical depression or adjustment disorder should be referred to a psychiatrist or psychologist for diagnosis. The relationship between poorly controlled pain, depression, and thoughts of suicide should not be ignored.
Support Groups and Pastoral Counseling
- Because many patients benefit from peer support groups, clinicians should be aware of locally active groups and offer this information to patients and their families. Pastoral counseling members of the health care team should participate in meetings to discuss patients' needs and treatment. They should also be a source of information on community resources for spiritual care and social support.
Relaxation Exercises [Note: Adapted and reprinted with permission from McCaffery M, Beebe A: Pain: Clinical Manual for Nursing Practice. St. Louis, Mo: CV Mosby Co, 1989.]
- Exercise 1. Slow Rhythmic Breathing for Relaxation
- Breathe in slowly and deeply, keeping your stomach relaxed and your shoulders relaxed.
- As you breathe out slowly, feel yourself beginning to relax; feel the tension leaving your body.
- Now breathe in and out slowly and regularly, at whatever rate is comfortable for you. Let the breath come all the way down to your stomach, as it completely relaxes.
- To help you focus on your breathing and breathe slowly and rhythmically: (a) breathe in as you say silently to yourself, "in, two, three"; (b) breathe out as you say silently to yourself, "out, two, three." Or, each time you breathe out, say silently to yourself a word such as "peace" or "relax."
- Do steps 1 through 4 only once or repeat steps 3 and 4 for up to 20 minutes.
- End with a slow deep breath. As you breathe out say to yourself, "I feel alert and relaxed."
- Exercise 2. Simple Touch, Massage, or Warmth for Relaxation
- Touch and massage are age-old methods of helping others relax. Examples include the following:
- Brief touch or massage (e.g., handholding or briefly touching or rubbing a person's shoulder).
- Warm foot soak in a basin of warm water, or wrap the feet in a warm, wet towel.
- Massage (3–10 minutes) may consist of whole body or be restricted to back, feet, or hands. If the patient is modest or cannot move or turn easily in bed, consider massage of the hands and feet.
- Use a warm lubricant (e.g., a small bowl of hand lotion may be warmed in the microwave oven, or a bottle of lotion may be warmed by placing it in a sink of hot water for about 10 minutes).
- Massage for relaxation is usually done with smooth, long, slow strokes. (Rapid strokes, circular movements, and squeezing of tissues tend to stimulate circulation and increase arousal.) However, try several degrees of pressure along with different types of massage (e.g., kneading and stroking). Determine which is preferred.
- Especially for the older person, a back rub that effectively produces relaxation may consist of no more than 3 minutes of slow, rhythmic stroking (about 60 strokes per minute) on both sides of the spinous process from the crown of the head to the lower back. Continuous hand contact is maintained by starting one hand down the back as the other hand stops at the lower back and is raised. Set aside a regular time for the massage. This gives the patient something to look forward to and depend on.
- Exercise 3. Peaceful Past Experiences
Something may have happened to you a while ago that brought you peace and comfort. You may be able to draw on that past experience to bring you peace or comfort now. Think about these questions:
- Can you remember any situation, even when you were a child, when you felt calm, peaceful, secure, hopeful, or comfortable?
- Have you ever daydreamed about something peaceful? What were you thinking of?
- Do you get a dreamy feeling when you listen to music? Do you have any favorite music?
- Do you have any favorite poetry that you find uplifting or reassuring?
- Have you ever been religiously active? Do you have favorite readings, hymns, or prayers? Even if you haven't heard or thought of them for many years, childhood religious experiences may still be very soothing.
Additional points: Some of the things you think of in answer to these questions, such as your favorite music or a prayer, can probably be recorded for you. Then you can listen to the tape whenever you wish. If your memory is strong, you may simply be able to close your eyes and recall the events or words.
- Exercise 4. Active Listening to Recorded Music
- Obtain the following:
- A cassette player or tape recorder. (Small battery-operated machines are more convenient.)
- Earphones or a headset. (This is a more compelling stimulus than a speaker a few feet away, and it avoids disturbing others.)
- Cassette recording of music you like. (Most people prefer fast, lively music, but some people select relaxing music. Other options are comedy routines, sporting events, old radio shows, or stories.)
- Mark time to the music, e.g., tap out the rhythm with your finger or nod your head. This helps you concentrate on the music rather than your discomfort.
- Keep your eyes open and focus steadily on one stationary spot or object. If you wish to close your eyes, picture something about the music.
- Listen to the music at a comfortable volume. If the discomfort increases, try increasing the volume; decrease the volume when the discomfort decreases.
- If these steps are not effective enough, try adding or changing one or more of the following: massage your body in rhythm to the music; try other music; mark time to the music in more than one manner (e.g., tap your foot and finger at the same time).
Additional points: Many patients have found this technique to be helpful. It tends to be very popular, probably because the equipment is usually readily available and is a part of daily life. Other advantages are that it is easy to learn and is not physically or mentally demanding. If you are very tired, you may simply listen to the music and omit marking time or focusing on a spot.
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