Physical, Integrative, Behavioral, and Psychosocial Interventions
Noninvasive physical, integrative, thinking and behavioral, and psychological methods can be used along with drugs and other treatments to manage pain during all phases of cancer treatment. These interventions may help with pain control both directly and indirectly, by making patients feel they have more control over events. The effectiveness of the pain interventions depends on the patient's participation in treatment and his or her ability to tell the health care provider which methods work best to relieve pain.Physical Interventions
Weakness, muscle wasting, and muscle/bone pain may be treated with heat (a hot pack or heating pad); cold (flexible ice packs); exercise (to strengthen weak muscles, loosen stiff joints, help restore coordination and balance, and strengthen the heart); changing the position of the patient; restricting the movement of painful areas or broken bones; or controlled low-voltage electrical stimulation.Integrative Interventions
Massage therapy has been studied as part of supportive care in managing cancer-related pain. Massage may help improve relaxation and benefit mood. Preclinical and clinical trials show that massage therapy may:
- Stimulate the release of endorphins (substances that relieve pain and give a feeling of well-being).
- Increase the flow of blood and lymphatic fluid.
- Strengthen the effects of pain medications.
- Decrease inflammation and edema.
- Lower pain caused by muscle spasms and tension.
Physical methods to help relieve pain have direct effects on tissues of the body and should be used with caution in patients with cancer. Studies suggest that massage therapy may be safe in patients with cancer with the following precautions:
- Avoid massaging any open wounds, bruises, or areas with skin breakdown.
- Avoid massaging directly over the tumor site.
- Avoid massaging areas with deep vein thrombosis (blood clot in a vein). Symptoms may include pain, swelling, warmth, and redness in the affected area.
- Avoid massaging soft tissue when the skin is sensitive following radiation therapy.
(For more information on massage, see Exercise 2 in the following section.)
Acupuncture is an integrative intervention that applies needles, heat, pressure, and other treatments to one or more places on the skin called acupuncture points. Acupuncture may be used to manage pain, including cancer-related pain. See the PDQ summary on Acupuncture for more information.
Music interventions may help relieve pain and decrease anxiety in some patients. Music has been used to relieve pain caused by the cancer and by procedures and treatments. Studies have reported that music may work on areas of the brain that increase pleasant feelings and decrease unpleasant responses. Favorite music from the patient's own collection has been shown to help the most. Music that begins before a procedure is more effective than music that begins during or after a procedure. Music may be used along with pain medicine.
There are two main types of music intervention, music therapy and music medicine:
- Music therapy is given by a trained specialist. The music used may be live or recorded. Therapy may include music improvisation (making up music), song writing and singing, and relaxing to music. The music therapist bases treatment on the patient’s needs, such as controlling pain, decreasing anxiety, or learning new coping skills.
- Music medicine is listening to music (usually recorded music) to take attention away from the pain. Music medicine is guided by a medical professional who does not have specialized training in music therapy.
The use of music for pain related to cancer is still being studied.
Music is also used in relaxation exercises. See the next section, on Thinking, Behavioral, and Psychosocial Interventions.Thinking, Behavioral, and Psychosocial Interventions
Thinking, behavioral, and psychosocial interventions are also important in treating pain. These interventions help give patients a sense of control and help them develop coping skills to deal with the disease and its symptoms. Beginning these interventions early in the course of the disease is useful so that patients can learn and practice the skills while they have enough strength and energy. Several methods should be tried, and one or more should be used regularly.
- Relaxation and imagery: Simple relaxation techniques may be used for episodes of brief pain (for example, during cancer treatment procedures). Brief, simple techniques are suitable for periods when the patient's ability to concentrate is limited by severe pain, high anxiety, or fatigue. (See Relaxation exercises below.)
- Hypnosis: Hypnotic techniques may be used to encourage relaxation and may be combined with other thinking/behavior methods. Hypnosis is effective in relieving pain in people who are able to concentrate and use imagery and who are willing to practice the technique.
- Redirecting thinking: Focusing attention on triggers other than pain or negative emotions that come with pain may involve distractions that are internal (for example, counting, praying, or saying things like "I can cope") or external (for example, music, television, talking, listening to someone read, or looking at something specific). Patients can also learn to monitor and evaluate negative thoughts and replace them with more positive thoughts and images.
- Patient education: Health care providers can give patients and their families information and instructions about pain and pain management and assure them that most pain can be controlled effectively. Health care providers should also discuss the major barriers that interfere with effective pain management.
- Psychological support: Short-term psychological therapy helps some patients. Patients who develop clinical depression or adjustment disorder may see a psychiatrist for diagnosis.
- Support groups and religious counseling: Support groups help many patients. Religious counseling may also help by providing spiritual care and social support.
The following relaxation exercises may be helpful in relieving pain.
Exercise 1. Slow rhythmic breathing for relaxation *
- Breathe in slowly and deeply, keeping your stomach and shoulders relaxed.
- As you breathe out slowly, feel yourself beginning to relax; feel the tension leaving your body.
- Breathe in and out slowly and regularly at a comfortable rate. Let the breath come all the way down to your stomach, as it completely relaxes.
- To help you focus on your breathing and to breathe slowly and rhythmically: Breathe in as you say silently to yourself, "in, 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 traditional methods of helping others relax. Some examples are:
- Brief touch or massage, such as hand holding or briefly touching or rubbing a person's shoulders.
- Soaking feet in a basin of warm water or wrapping the feet in a warm, wet towel.
- Massage (3 to 10 minutes) of the whole body or just the 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. A small bowl of hand lotion may be warmed in the microwave oven or a bottle of lotion may be warmed in a sink of hot water for about 10 minutes.
- Massage for relaxation is usually done with smooth, long, slow strokes. Try several degrees of pressure along with different types of massage, such as kneading and stroking, to determine which is preferred.
Especially for the elderly 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 spine, 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 pleasant to anticipate.
Exercise 3. Peaceful past experiences *
- Something may have happened to you a while ago that brought you peace or comfort. You may be able to draw on that 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?
- 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 active religiously? 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 that may comfort you, such as your favorite music or a prayer, can probably be recorded for you. Then you can listen to the tape whenever you wish. Or, if your memory is strong, you may simply 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 ones are more convenient.)
- Earphones or a headset. (Helps focus the attention better than a speaker a few feet away, and avoids disturbing others.)
- A cassette of music you like. (Most people prefer fast, lively music, but some select relaxing music. Other options are comedy routines, sporting events, old radio shows, or stories.)
- Mark time to the music; for example, tap out the rhythm with your finger or nod your head. This helps you concentrate on the music rather than on your discomfort.
- Keep your eyes open and focus on a fixed 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 this is not effective enough, try adding or changing one or more of the following: massage your body in rhythm to the music; try other music; or mark time to the music in more than one manner, such as tapping 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 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.
* [Note: Adapted and reprinted with permission from McCaffery M, Beebe A: Pain: Clinical Manual for Nursing Practice. St. Louis, Mo: CV Mosby: 1989.]