4. Nonpharmacological management: Physical and Psychological modalities

Recommendations

31. Cutaneous stimulation techniques, including applications of superficial heat and cold, massage, pressure or vibration, should be offered to alleviate pain associated with muscle tension or muscle spasm. (C)
32. Patients should be encouraged to remain active and to participate in self-care when possible. (A)
33. Clinicians should reposition patients on a scheduled basis during long-term bedrest and provide active and passive range-of-motion exercises. For a patient in acute pain, exercise should be limited to self-administered range of motion. (C)
34. Prolonged immobilization should be avoided whenever possible to prevent joint contracture, muscle atrophy, cardiovascular deconditioning, and other untoward effects. (B)
35. Patients who choose to have acupuncture for pain management should be encouraged to report new pain problems to their health care team before seeking palliation through acupuncture. (Panel Consensus)
36. Psychosocial interventions should be introduced early in the course of illness as part of a multimodal approach to pain management They generally should not be used as substitutes for analgesics. (A)
37. Because of the many misconceptions regarding pain and its treatment, education about the ability to control pain effectively and correction of myths about the use of opioids should be included as part of the treatment plan for all patients. (B)
38. Clinicians should offer patients and families means to contact peer support groups. (Panel Consensus)
39. Pastoral care members should participate in health care team meetings that discuss the needs and treatment of patients. They should develop information about community resources that provide the spiritual care and support of patients and their families. (Panel Consensus)

Introduction

Physical arid psychosocial therapies can be used concurrently with drugs and other modalities to manage pain. These interventions can be carried out by professional staff and often by the patient or family members.

Physical Modalities

Physical modalities include cutaneous stimulation, exercise, immobilization, transcutaneous electrical nerve stimulation (TENS), and acupuncture (Lee, Itoh, Yang, et al., 1990). Their use may decrease the need for pain-reducing drugs, but they should not be used as substitutes for medication. These modalities should be introduced early to treat generalized weakness and deconditioning as well as aches and pains associated with periods of inactivity and immobility related to cancer diagnosis and therapy.

Cutaneous Stimulation

Cutaneous stimulation includes the application of superficial heat (thermotherapy) and cold (cryotherapy) (Mayer, 1985). Other methods, such as massage, pressure, and vibration, may help patients to relax or distract them from their pain. Cutaneous stimulation sometimes increases pain briefly before pain relief occurs (McCaffery and Beebe, 1989). These methods are noninvasive and usually can be easily taught to the patient or family caregiver.

Superficial applications of heat act through conduction or convection to increase the blood flow to the skin and superficial organs and to decrease the blood flow to inactive tissues such as the underlying musculature (Lehmann and de Lateur, 1990). Heat induces vasodilation, which increases oxygen and nutrient delivery to damaged tissues (Whitney, 1989). Heat also decreases joint stiffness by increasing the elastic properties of muscles (Vasudevan, Hegmann, Moore, et al., 1992). Superficial heat can be applied by hot packs, hot water bottles, hot and moist compresses, electric heating pads (dry or moist), commercially available chemical and gel packs, and immersion in water (tub, basin, or whirlpool) (McCaffery and Wolff, 1992). For all types of hot packs, care should be taken to wrap them well to prevent burns and to discourage patients from lying directly on them. In most cases, the protection of one towel between the skin and the heating device is sufficient. If the patient has decreased skin sensation, is using an electrical heating device, or tends to lie on top of a hot pack, more layers of cloth are needed for skin protection and close monitoring of the skin condition is required. Heat should not be applied to tissue that has been exposed to radiation therapy.

The literature is divided on the use of heat in patients with cancer. Superficial heat is commonly used by patients to reduce pain (Barbour, McGuire, and Kirchhoff, 1986; Davis, Cortex, and Rubin, 1990; Donovan and Dillon, 1987; Rhiner, Ferrell, Ferrell, et al., 1993; Wilkie, Lovejoy, Dodd, et al., 1988), and some texts recommend heat to reduce pain and discomfort (Ferrell, Rhiner, and Ferrell, 1993; McCaffery and Wolff, 1992; Vasudevan, Hegmann, Moore, et al., 1992). Other texts, however, caution against the use of heat because of concern that the use of heat over tumor sites will increase tumor growth and the metastatic spread of the disease (Lee, Itoh, Yang, et al., 1990; Lehmann and de Lateur, 1990; Pfalzer, 1992). Research evidence cited in support of this cautionary statement is from a 1940 study of rats (Hayashi, 1940), as well as several studies of fetal tissue cells exposed to high degrees of temperature (Lehmann and de Lateur, 1990).

In view of the lack of research findings that clearly contraindicate this use of superficial heat, the panel recommends that it be used as a method of pain control in patients with cancer. Modalities to deliver deep heat—such as short wave diathermy, microwave diathermy, and ultrasound—should be used with caution in patients with active cancer; they should not be applied directly over a cancer site (Lehmann and de Lateur, 1990).

Cold therapy, which causes vasoconstriction and local hyperesthesia, is effective in reducing inflammation, edema soon after an injury, burning perineal pain (Evans, Lloyd, and Jack, 1981), and muscle spasm (Vasudevan, Hegmann, Moore, et al., 1992), and is recommended when superficial heat is ineffective in reducing spasm. Ice packs, towels soaked in ice water, or commercially prepared chemical gel packs can be used. Cold packs should be sealed to prevent dripping, they should be flexible to conform to body contours, they should be applied so as to produce a comfortable and safe intensity of cold, and they should be adequately wrapped (e.g., in one layer of towel or pillowcase) to prevent skin irritation. The duration of ice application is shorter than that of heat, usually lasting less than 15 minutes; however, it produces a longer acting effect, provided that the muscle is actually cooled (Lehmann and de Lateur, 1990; Michlovitz, 1990).

Cold should not be applied to tissue that has been damaged by radiation therapy and is contraindicated for any condition in which vasoconstriction increases symptoms, such as in peripheral vascular disease. Raynaud's syndrome, or other vascular or connective tissue diseases (Lehmann and de Lateur, 1990; Whitney, 1989). In some patients, cooling painful joints will increase range of motion, but in others, this may increase joint stiffness and should therefore be avoided.

Massage is a comfort measure used to aid relaxation and ease general aches and pains, particularly those associated with periods of treatment related immobility. Massage may also decrease pain in a specific area by increasing superficial circulation (Fairchild, Salemo, Wedding, et al., 1986; McCaffery and Wolff, 1992). Common techniques of massage are stroking, kneading, and rubbing with rhythmic, circular, distal-to-proximal motions (Lee, Itoh, Yang, et al., 1990). An alcohol-free lotion can be used to reduce friction. The patient should be encouraged to choose movements that provide the greatest comfort. Massage cannot strengthen debilitated muscles, and it should not be used in place of exercise and activity for patients who are able to walk. Manual or mechanical vibration can also be used to increase superficial circulation. Specific instructions for the use of a variety of cutaneous stimulation methods for pain relief are available elsewhere (McCaffery and Beebe, 1989). An example of a relaxation technique that uses massage, touch, and warmth is included in Attachment C.

Exercise

Exercise is important for the treatment of subacute and chronic pain because it strengthens weak muscles, mobilizes stiff joints, helps restore coordination and balance, enhances patient comfort, and provides cardiovascular conditioning (Vasudevan, Hegmann, Moore, et al., 1992). Barbour, McGuire, and Kirchhoff (1986) found that some patients use position change or exercise as a self-initiated strategy for pain relief; of those who used these strategies, 86 percent reported pain relief with change of position and 25 percent reported pain relief after exercise. Patients should be encouraged to remain active and participate in self-care when possible (Kohl, LaPorte and Blair, 1988; Kovar, Allegrante, MacKenzie, et al., 1992; Powell, Thompson, Caspersen, et al., 1987; Siscovick, LaPorte, and Newman, 1985).

When patients are unable to maintain function, families should be taught a simple routine of range-of-motion exercises and massage to minimize discomfort and preserve muscle length and joint function during periods of decreased function and immobility (Kisner and Colby, 1985). Passive exercises should not be carried out if they increase pain. During acute pain, exercise should be limited to self" administered range of motion (Lee, Itoh, Yang, et al., 1990). All forms of exercise that involve weight bearing should be avoided when pathologic fracture is likely because of tumor invasion.

Positioning is another simple method to promote comfort and to prevent or relieve pain. Clinicians should ensure that patients who are bedridden are positioned in correct body alignment, that patients are repositioned frequently, that skin condition is monitored, and that range-of-motion exercises are provided. Clinicians should educate ancillary personnel and family caregivers so that they are able to perform range of motion exercises correctly and safely position patients.

Immobilization or restriction of movement is often used to manage episodes of acute pain and to stabilize fractures or otherwise compromised limbs, joints, or both. When immobility is desired, supportive devices such as adjustable elastic or thermoplastic braces can be used to maintain optimal body alignment. Joints should not be maintained at their maximal range but in their position of optimal function (i.e., wrist at 30° of dorsiflexion with thumb opposed to fingers, ankle at 90° flexion with 5° to 10° flexion of the knee, etc.) to allow for maximal function after an immobilization period (Lee, Itoh, Yang, et al., 1990). In patients with bone metastasis, immobilization may be necessary to prevent fractures. These patients and their families should be taught how to apply orthotic devices properly and how to prevent torsion during positioning and turning. Prolonged immobilization should be avoided whenever possible to prevent joint contracture, muscle atrophy, cardiovascular deconditioning, and other untoward effects.

Counterstimulation

Counterstimulation denotes techniques, such as TENS therapy and acupuncture, that are believed to activate endogenous pain-modulating pathways by direct stimulation of peripheral nerves (Sjolund and Eriksson, 1979). The literature in support of these interventions is inconclusive, although some patients report that they obtain relief from their use (Avellanosa and West, 1982; Bauer, 1983).

Transcutaneous Electrical Nerve Stimulation (TENS). TENS is a method of applying controlled, low-voltage electrical stimulation to large, myelinated peripheral nerve fibers via cutaneous electrodes for the purpose of modulating stimulus transmission and relieving pain. Research on TENS therapy in patients with cancer is limited to single-group studies and case reports (Avellanosa and West, 1982; Bauer, 1983). A meta-analysis of studies of TENS therapy in postoperative patients (Acute Pain Management Guideline Panel, in press) found that both TENS and sham TENS significantly reduced pain intensity; no significant differences were found between the two for either analgesic use or pain intensity. These results suggest that, just as with some other interventions, part of the efficacy of TENS can be attributed to a placebo effect. Patients with mild pain may benefit from a trial of TENS.

Acupuncture. Acupuncture is a neurostimulatory technique that treats pain by the insertion of small, solid needles into the skin at varying depths, typically penetrating the underlying musculature. There are few controlled studies of its use; recent meta-analyses (Patel, Gutzwiller, Paccaud, et al., 1989; ter Riet, Kleijnen, and Knipschild, 1990) are inconclusive and do not specify which types of pain problems acupuncture can or cannot alleviate.

Pain can signal disease progression, the emergence of adventitious infection, or some significant complication of treatment. Therefore, patients who choose to have acupuncture for pain management should be encouraged to report new pain problems to their health care team before seeking palliation through acupuncture. Maintaining an open and accepting relationship will make it easier for the patient and the practitioner to discuss negative as well as positive experiences and situations where acupuncture might be contraindicated.

When a patient seeks TENS therapy or acupuncture, clinicians should listen for clues that would indicate that the pain is uncontrolled. If the patient is seeking these modalities because of poorly managed pain, the clinician, in cooperation with the patient, should revise the pain management plan by:

• Correcting misconceptions the patient might have concerning the use of analgesic drugs, especially the phenomena of addiction and tolerance with opioids.
• Increasing an analgesic dosage.
• Adding an adjuvant drug to manage a specific pain complaint or to counteract a side effect.
• Prescribing a psychotropic drug to manage coexisting anxiety or depression.
• Providing training in the use of cognitive-behavioral strategies.

Controlled studies are needed to test the effectiveness of counter-stimulation in the treatment of cancer-related pain.

Psychosocial Interventions

Psychosocial interventions are an important part of a multimodal approach to pain management. Such interventions do not replace, but rather, are used in conjunction with appropriate analgesics for the management of pain. When psychosocial interventions are successful in relieving pain, clinicians should never conclude that the pain was not "real."

One goal is to help the patient gain a sense of control over the pain. A simple rationale underlies such intervention: How people think affects how they feel, and changing how they think about pain can change their sensitivity to it and their feelings and reactions toward it (McGrath, 1990b).

Psychosocial intervention may use cognitive or behavioral techniques or both. Focusing on perception and thought, cognitive techniques are designed to influence how one interprets events and bodily sensations. Giving patients information about pain and its management and helping patients to think differently about their pain are both cognitive techniques. Behavioral techniques, by contrast, are directed at helping patients develop skills to cope with pain and helping them modify their reactions to pain.

Many patients with cancer are highly motivated to use cognitive behavioral methods, which are often effective not only in controlling symptoms, but also in restoring the patient's sense of self control, personal efficacy, and active participation in his/her own care.

In recommending psychosocial interventions, the clinician should consider:

• Intensity of pain.
• Expected duration of pain.
• Patient's mental clarity.
• Patient's past experience with the technique.
• Patient's physical ability.
• Patient's desire to employ active or passive techniques.

Psychosocial interventions should be introduced early in the course of illness so that patients can learn and practice these strategies while they have sufficient strength and energy. When introduced early, they are more likely to succeed, which fosters the patient's motivation to continue using them. Patients and their families should be given information that describes strategies commonly used to manage pain and anxiety and encouraged to try several strategies, then select one or more to use regularly when they experience pain.

As with other modalities, psychosocial interventions can require different levels of training and expertise on the part of clinicians. The interventions discussed here, however, can be performed by most clinicians. In addition to these interventions, some patients will benefit from short-term psychotherapy (see Chapter 7).

Relaxation and Imagery

Relaxation techniques and imagery are used to achieve a state of mental and physical relaxation. Mental relaxation means alleviation of anxiety; physical relaxation means reduction in skeletal muscle tension. Relaxation techniques include simple focused-breathing exercises, progressive muscle relaxation, meditation, and music-assisted relaxation (McCaffery and Beebe, 1989) (Attachment C). Simple relaxation techniques should be used for episodes of brief pain, e.g. during procedures, as well as when the patient’s ability to concentrate is compromised by severe pain, a high level of anxiety, or fatigue.

Pleasant mental images can be used to aid relaxation. For example, patients might be encouraged to visualize a peaceful scene, such as waves softly hitting the beach, or to take slow, deep breaths as they visualize pain leaving the body. Both pleasant imagery and progressive muscle relaxation have been shown to decrease self-reported pain intensity and pain distress (Graffam and Johnson, 1987).

Relaxation techniques are most helpful when combined with imagery, especially when the image is individualized to the patient's needs or preferences (Syrjala, in press). The advantages include:

• They are easy to learn.
• No special equipment is required.
• Staff do not require extensive training.
• They are often readily accepted by patients (Hendler and Redd, 1986; Syrjala, 1990).

Tapes and other resources are available for teaching relaxation (McCaffery and Beebe, 1989; Syrjala, 1990).

Distraction and Reframing.

Distraction is the strategy of focusing one's attention on stimuli other than pain or the accompanying negative emotions (McCaffery and Beebe, 1989; McCaul and Malott, 1984). Distractions may be internal, for example, counting, singing mentally to one's self, praying, or making self-statements such as "I can cope," or external, for example, listening to music as an aid to relaxation (Beck, 1991; Munro and Mount, 1978), watching television, talking to family and friends, or listening to someone read. Distraction exercises often include repetitive actions or cognitive activity, such as rhythmic massage or the use of a visual focal point. Distraction may be used alone to manage mild pain or as an adjunct to analgesic drugs to manage brief episodes of severe pain, such as procedure-related pain.

A related technique, reframing or cognitive reappraisal, teaches patients to monitor and evaluate negative thoughts and images and replace them with more positive ones. For example, patients who are preoccupied with a fear of pain can be encouraged to use positive self-statements to facilitate coping (e.g., "I've had similar pain and it's gotten better"). Reframing can add to patients' feelings of control over their situations (see Attachment C).

Patient Education

Patient education entails giving patients and families accurate and understandable information about pain, pain assessment, and the use of drugs and other methods of pain relief, emphasizing that almost all pain can be effectively managed. It should also address major barriers to effective pain management, namely, patients* reluctance to talk about their pain with their care providers, their unfounded fears about becoming addicted to opioids, and their fears that the pain cannot be effectively controlled without unacceptable consequences. Patient education should address other misconceptions, such as the thought that pain medication should be saved for when pain is severe, or else it might not be effective (Ward, Goldberg, Miller-McCauley, et al., 1993). Some believe that analgesics might produce unacceptable side effects or that choices might have to be made between treating the disease or treating the pain.

A goal of patient education is to involve patients in their pain management: one of the most important steps toward improved control of cancer pain is better understanding by patients of the nature of the pain, its treatment, and the role that they need to play in pain control. Patients should be encouraged to report pain as active participants in their own care. To improve their understanding of drug therapy and its effects, patients should be told that:

• The use of opioid analgesics will not lead to addiction.
• Tolerance to opioid analgesics can be dealt with by upward dosage adjustments.

Many patients worry that, if they complain of pain, their health care providers might not think of them as "good" patients (Ward, Goldberg, Miller-McCauley, et al., 1993). Because of these concerns, some patients who are taking opioids and have been told to take them regularly may take them only when their pain is severe. Patients should be taught that the prevention of pain by the use of regularly scheduled analgesics is desirable. Because of the many misconceptions regarding pain and its treatment, education about the ability to control pain effectively and correction of myths about the use of opioids should be included as part of the treatment plan.

Table 16 specifies some of the major topics of a patient education program. The literature indicates that, to have the desired effect, information should be presented more than once and, because patients seek information from multiple sources, in more than one way.

Because uncertainty increases distress and threatens the perception of ability to cope, informing patients about what is going to happen to them can help them think about a situation differently and feel less helpless (Mishel, 1984). Research has shown that patients who receive medication-related education have a higher rate of compliance with analgesic prescriptions, fewer concerns about taking opioid analgesics, and lower pain levels than do patients not given such information (Rimer, Levy, Keintz, et al., 1987). Other research has demonstrated that informing patients about possible side effects of therapy will not increase the occurrence of side effects or have other adverse effects (Howland, Baker, and Poe, 1990; Wilson, 1981).

After the clinician has told patients that they are expected to take an active role in their pain management and has reassured them that pain relief is an important goal, then patients should be able to use clinicians as sources of information and reassurance about pain control. Information presented orally to patients should be supplemented with written material (Table 17). Additional information is included in a discussion of discharge planning in Chapter 3.

Psychotherapy and Structured Support

Some patients benefit from short-term psychotherapy or more complex cognitive-behavioral interventions provided by a psychiatrist, clinical psychologist, psychiatric nurse, or psychiatric social worker. Short-term supportive psychotherapy based on a crisis intervention model can provide emotional support, continuity, and information while helping the patient adapt to the crisis. The therapist emphasizes the patient's past strengths, supports the patient's use of previously successful coping strategies, and teaches new coping skills. Studies have shown that patients with cancer who receive active, structured psychological support report less pain and live longer (Fawzy, Cousins, Fawzy, et al., 1990; Spiegel and Bloom, 1983; Spiegel, Bloom, Kraemer, et al., 1989). Psychotherapy should be offered to patients whose pain is particularly difficult to manage (e.g., substance abusers), those who develop symptoms of clinical depression or another adjustment disorder, and those with a history of psychiatric illness.

Hypnosis

The hypnotic trance is a state of heightened awareness and focused concentration that can be used to manipulate the perception of pain and has been effective in the treatment of cancer-related pain (Reeves, Redd, Storm, et al., 1983; Spiegel and Bloom, 1983; Syrjala, Cummings, and Donaldson, 1992). It should only be administered by specially trained professionals.

Peer Support Groups

Programs of self-help and mutual support of patients with cancer have been available since the 1940s, when the American Cancer Society (ACS) established visitor programs to offer practical help for patients at home (Mastrovito, Moynihan, and Parsonnet, 1989). Some, such as the National Coalition for Cancer Survivorship and many of their local chapters, enroll survivors of any type of cancer and their relatives. Others target specific cancers; these include the International Association of Laryngectomees, the United Ostomy Association, and the ACS's Reach to Recovery program for breast surgery patients. Many of the peer support groups work closely with health care teams who refer patients to them.

The experience and empathy of people who have experienced a disease can provide credible support to others with the same disease or problem and can help new patients learn to cope more effectively (Mantell, Alexander, and Kleiman, 1976). Support networks can also help patients to maintain social identity and provide emotional support, material aid, and access to information (Walker, MacBride, and Vachon, 1977). Because of the benefits provided by these groups, clinicians should know which are active in their area and provide this information to patients who wish to join them.

Pastoral Counseling

Having cancer and pain frequently raises issues of spirituality for patients and their families, both of whom may be helped by pastoral counseling. The experience of pain can often lead patients to fear abandonment and to question meaning and the possibility of hope. Many religions address these concerns and offer an important dimension in a multidisciplinary approach to pain management. Thus:

• Ecumenical pastoral care should be made available.
• Pastoral care members should participate in health care team meetings that discuss the needs and treatment of patients.
• Pastoral care members should develop information about community resources that provide spiritual care and support.