Physical Modalities
Cognitive-Behavioral Interventions

Patients should be encouraged to remain active and participate in self-care when possible. Noninvasive physical and psychosocial modalities can be used concurrently with drugs and other interventions to manage pain during all phases of treatment. 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).[1]

Generalized weakness, deconditioning, and musculoskeletal pain associated with cancer diagnosis and therapy may be treated by:

Heat

• 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.

Cold

• 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.

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 is not a substitute for active exercise in ambulatory patients.

Exercise

• 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 acute pain, exercise should be limited to self-administered range-of-motion. Weight-bearing exercise should be avoided when bone fracture is likely.

Repositioning

• Reposition the immobilized patient frequently to maintain correct body alignment, to prevent or alleviate pain, and to prevent pressure ulcers.

Immobilization

• 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.

Stimulation Techniques

• 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.[2]



• Acupuncture: Pain is treated by inserting small, solid needles into the skin, with or without the application of electrical current. Needle placement follows the Eastern theory of vital energy flow. (Refer to the PDQ summary on Acupuncture for more information.)

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.[3] Recent 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.[4] Realistic expectations are needed for delivery of cognitive-behavioral interventions. One study [5] 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.

Hypnosis

• Hypnotic techniques may be used to induce relaxation and may be combined with other cognitive-behavioral strategies. Hypnosis is effective in relieving pain in individuals who can concentrate well, can use imagery, and are motivated to practice.

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.

Patient/Family Education

• 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.[6-8] 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.[9] Educational intervention programs to help patients who have cancer and their families manage pain have been described and may improve clinical outcomes.[10] 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.[11,12] Training partners to participate in management of cancer pain increases partner self-efficacy for controlling their loved one's pain and other symptoms.[13]

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

• Exercise 1. Slow Rhythmic Breathing for Relaxation*
  1. Breathe in slowly and deeply, keeping your stomach relaxed and your shoulders relaxed.
  
  
  
  2. As you breathe out slowly, feel yourself beginning to relax; feel the tension leaving your body.
  
  
  
  3. 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.
  
  
  
  4. 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.”
  
  
  
  5. Do steps 1 through 4 only once or repeat steps 3 and 4 for up to 20 minutes.
  
  
  
  6. 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
  1. Touch and massage are age-old methods of helping others relax. Some examples are
     • 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.
  
  
  
  2. 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).
  
  
  
  3. 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.
  
  
  
  4. 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:

  1. Can you remember any situation, even when you were a child, when you felt calm, peaceful, secure, hopeful, or comfortable?
  2. Have you ever daydreamed about something peaceful? What were you thinking of?
  3. Do you get a dreamy feeling when you listen to music? Do you have any favorite music?
  4. Do you have any favorite poetry that you find uplifting or reassuring?
  5. 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
  1. 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.)
  
  
  
  2. 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.
  
  
  
  3. 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.
  
  
  
  4. Listen to the music at a comfortable volume. If the discomfort increases, try increasing the volume; decrease the volume when the discomfort decreases.
  
  
  
  5. 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.

* [Note: Adapted and reprinted with permission from McCaffery M, Beebe A: Pain: Clinical Manual for Nursing Practice. St. Louis, Mo: CV Mosby Co, 1989.]

References

1. Kalauokalani D, Franks P, Oliver JW, et al.: Can patient coaching reduce racial/ethnic disparities in cancer pain control? Secondary analysis of a randomized controlled trial. Pain Med 8 (1): 17-24, 2007 Jan-Feb.  [PUBMED Abstract]
   
   
2. Robb KA, Newham DJ, Williams JE: Transcutaneous electrical nerve stimulation vs. transcutaneous spinal electroanalgesia for chronic pain associated with breast cancer treatments. J Pain Symptom Manage 33 (4): 410-9, 2007.  [PUBMED Abstract]
   
   
3. Integration of behavioral and relaxation approaches into the treatment of chronic pain and insomnia. NIH Technology Assessment Panel on Integration of Behavioral and Relaxation Approaches into the Treatment of Chronic Pain and Insomnia. JAMA 276 (4): 313-8, 1996 Jul 24-31.  [PUBMED Abstract]
   
   
4. Given B, Given CW, McCorkle R, et al.: Pain and fatigue management: results of a nursing randomized clinical trial. Oncol Nurs Forum 29 (6): 949-56, 2002.  [PUBMED Abstract]
   
   
5. Anderson KO, Cohen MZ, Mendoza TR, et al.: Brief cognitive-behavioral audiotape interventions for cancer-related pain: Immediate but not long-term effectiveness. Cancer 107 (1): 207-14, 2006.  [PUBMED Abstract]
   
   
6. Oliver JW, Kravitz RL, Kaplan SH, et al.: Individualized patient education and coaching to improve pain control among cancer outpatients. J Clin Oncol 19 (8): 2206-12, 2001.  [PUBMED Abstract]
   
   
7. Miaskowski C, Dodd M, West C, et al.: Randomized clinical trial of the effectiveness of a self-care intervention to improve cancer pain management. J Clin Oncol 22 (9): 1713-20, 2004.  [PUBMED Abstract]
   
   
8. Miaskowski C, Dodd M, West C, et al.: The use of a responder analysis to identify differences in patient outcomes following a self-care intervention to improve cancer pain management. Pain 129 (1-2): 55-63, 2007.  [PUBMED Abstract]
   
   
9. Redinbaugh EM, Baum A, DeMoss C, et al.: Factors associated with the accuracy of family caregiver estimates of patient pain. J Pain Symptom Manage 23 (1): 31-8, 2002.  [PUBMED Abstract]
   
   
10. Aubin M, Vézina L, Parent R, et al.: Impact of an educational program on pain management in patients with cancer living at home. Oncol Nurs Forum 33 (6): 1183-8, 2006.  [PUBMED Abstract]
    
    
11. West CM, Dodd MJ, Paul SM, et al.: The PRO-SELF(c): Pain Control Program--an effective approach for cancer pain management. Oncol Nurs Forum 30 (1): 65-73, 2003 Jan-Feb.  [PUBMED Abstract]
    
    
12. Lin CC, Chou PL, Wu SL, et al.: Long-term effectiveness of a patient and family pain education program on overcoming barriers to management of cancer pain. Pain 122 (3): 271-81, 2006.  [PUBMED Abstract]
    
    
13. Keefe FJ, Ahles TA, Sutton L, et al.: Partner-guided cancer pain management at the end of life: a preliminary study. J Pain Symptom Manage 29 (3): 263-72, 2005.  [PUBMED Abstract]
    
    

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