4.01 Physical and Psychological Modalities in Pain Relief; In General

4.02 Slow Rhythmic Breathing For Relaxation

4.03 Psychosocial Intervention

4.04 Cutaneous Stimulation

4.05 Exercise/Positioning

4.06 Massage Therapy

4.07 Acupuncture

4.08 Relaxation and Imagery

4.09 Distraction and Reframing

4.10 Hypnosis

4.11 Pastoral Counseling

4.12 TENS Therapy

4.13 Peer Support Groups

4.01 Physical and Psychological Modalities in Pain Relief; In General

As in all health care, many methods of therapy have been used to treat the pain of terminal illness outside the realm of traditional medicine. While many physicians frown on these techniques, others accept them gladly -- any help in dealing with this most difficult problem being welcomed by the clinician.

Without taking sides, the author suggests it is extremely important for patients and families to recognize the inherent difficulties physicians face when asked to recommend or comment on these alternative therapies. Because these alternative therapies by and large do not require government approval, they have not undergone the usual scientific studies typical of traditional medical approaches, thus leaving physicians without good evidence for or against their use. Thus, when asked "might so and so help?" the answer is likely to be "Yes, it might." At the same time, if the physician is asked "Do you recommend its use?" the answer is likely to be "No." This may make little sense to most laymen, but perfect sense to me. As a physician, I have no scientific evidence it doesnít work, so certainly it "might" help. I also have no scientific evidence it does work, so I see myself as not being in a position to recommend its use to my patients -- and that would be true even if I used it and believed in it for myself. People come to physicians for advise based on scientific evidence. They do not want advise based on the physicianís reading of ads from Madison Avenue or the unsupported claims of salesmen or writers in Prevention Magazine.

In the following I will try to separate what seems to be proven from that which is purely claims of those involved in the various forms of therapy. In trying to be fair, I draw heavily on the suggestions of the Department of Health and Human Services guidelines, although the guidelines do not correspond totally with my own views. The following are some of their overall recommendations regarding alternative medical care of pain in the terminally ill:

1. Stimulation techniques of the body surface, including applications of superficial heat and cold, massage, pressure or vibration, should be offered to alleviate pain associated with muscle tension or muscle spasm.

2. Patients should be encouraged to remain active and to participate in self-care when possible.

3. 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 exercises.

4. Prolonged immobilization should be avoided whenever possible to prevent stiffening of joints, muscle wasting, cardiovascular deconditioning, and other untoward effects.

5. 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.

6. 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 pain medications.

7. 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 opioid narcotics should be included as part of the treatment plan for all patients.

8. Clinicians should offer patients and families means to contact peer support groups.

9. 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.

10. Physical modalities for pain relief include stimulation of the body surfaces (cutaneous stimulation), exercise, immobilization, transcutaneous electrical nerve stimulation (TENS), and acupuncture. Their use may decrease the need for pain-reducing drugs, but they should not be used as substitutes for medication.

11. Physical modalities should be introduced early to treat or avoid generalized weakness and loss of conditioning as well as aches and pains associated with periods of inactivity and immobility caused by the underlying disease.

12. Other techniques commonly employed for pain relief include distraction with music, handicrafts or exercises, breathing exercises, relaxation techniques, visualization techniques, a technique referred to as "inner smile" and numerous approaches involving human touch.

4.02 Slow Rhythmic Breathing For Relaxation

In some patients slow rhythmic breathing may help them relax and thereby lessen the need for pain medication, especially when there are occasional episodes of worse pain which occurs in spite of taking around-the-clock medication. To do this, the following instructions may be given to the patient:

1. Breathe in slowly and deeply.

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.

4. To help you focus on your breathing, 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."

4.03 Psychosocial Intervention

Psychosocial interventions are an important part of an approach to pain management to be used in conjunction with appropriate analgesics for the management of pain. The fact they work, however, should not be held as an indication the pain was not "real," because relief of the underlying anxiety has a direct effect on the perception of pain. "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."

Psychosocial interventions are usually differentiated into cognitive or behavioral techniques and can be undertaken by general medical practitioners or specially trained psychiatric workers. 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. [Note: In some ways, this book is part of a cognitive technique.] Behavioral techniques, by contrast, are directed at helping patients develop skills to cope with pain and helping them modify their reactions to pain.

The therapist typically emphasizes the patient's past strengths, supports the patient's use of previously successful strategies for coping with problems, and teaches new coping skills. Studies have shown patients with cancer who receive active, structured psychological support report less pain and may even live longer. Psychotherapy is particularly likely to be helpful in patients whose pain is difficult to manage, those who develop symptoms of clinical depression, and those with a history of psychiatric illness, including drug addiction.

4.04 Cutaneous Stimulation

Cutaneous stimulation has been used for centuries to detract the patient from more worrisome internal pains. An early form of cutaneous stimulation was the use of "mustard plasters" which irritated the skin deflecting concern to a problem which the patient readily recognized as being unimportant. Present methods include the application of superficial heat (thermotherapy) and cold (cryotherapy), as well as massage, pressure, and vibration, all aimed at helping the patient relax or to distract them from their pain. These methods are noninvasive and usually can be easily applied by family caregivers if not by the patient himself or herself. Because there is no strong evidence these methods are actually beneficial in the treatment of pain, they should only be continued in patients who appear to obtain a benefit, and should be discontinued when they do not provide clinical relief. [This analysis may not be true if the underlying cause of pain is muscle spasms, for instance.]

Superficial applications of heat may not only act as a detractor, but may also increase oxygen and nutrient delivery to damaged tissues as well as decreasing joint stiffness by increasing the elastic properties of muscles. 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). 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.

In contrast to superficial heat, the recommendations of the DHHS suggests that means of delivering 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.

Cold therapy is specifically recommended when superficial heat is ineffective in reducing muscle spasms. 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 the muscle is actually cooled.

Cold should not be applied to tissue which has been damaged by radiation therapy and is contraindicated for condition involving poor blood supply to an area of the body. In some patients, cooling painful joints will increase range of motion, but in others, this may increase joint stiffness and should therefore be avoided.

4.05 Exercise/Positioning

Exercise is frequently suggested 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 conditioning of the heart. These effects may be helpful in some forms of pain related to terminal disease, but may not be helpful in others. When patients are unable to maintain function, families should assist in simple range-of-motion exercises and massage to minimize discomfort and preserve muscle length and joint function during periods of decreased function and immobility if possible. Passive exercises should not be carried out if they increase pain. During acute pain, exercise should be limited to self-administered range of motion. All forms of exercise which involve weight bearing should be avoided when cancer related fractures are likely because of known tumor spread to the bones of the legs.

At times, exercise must be restricted in parts of the body immobilized to manage episodes of acute pain, allow fractures to heal or to prevent fractures at sites of bony metastases. When immobility is desired, supportive devices such as adjustable elastic or plastic braces can be used to maintain the desired body alignment.

Unlike exercise, which is only infrequently helpful in the actual management of pain, repositioning of the body frequently is helpful in reducing pain. Family members are wise to note such relief, for later in the course of the disease process the patient may not be able to reposition himself or herself, but is still likely to obtain relief when repositioned by others.

4.06 Massage Therapy

Massage therapy is a comfort measure used to aid relaxation and ease general aches and pains, particularly those associated with periods of immobility. Massage may also decrease pain in a specific area by increasing superficial circulation. Common techniques of massage are stroking, kneading, and rubbing with rhythmic, circular, distal-to-proximal motions. An alcohol-free lotion can be used to reduce friction. The patient should be encouraged to choose movements which 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.

A somewhat different use of massage is aimed primarily at enabling people to deepen spiritual contact with the dying patient. This often involves a visitor massaging the patientís hands or feet instead of just sitting doing nothing while they talk, listen, or just share time.

Suggestions regarding massage include:

1. Massage (3 to 10 minutes) may consist of whole body massage 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, stroking, and circling. Determine which is preferred.

4. Especially for the elderly person, a back rub which 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 superficial part of the backbone (spinous processes) from the top 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.

[For more instruction on the use of massage as a means of communicating care and concern and breathing exercises, see Richard Reoch, To Die Well; A Holistic Approach for the dying and Their Caregivers, (Harper Perennial, New York, 1996)]

4.07 Acupuncture

Acupuncture is a technique which 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 and those that exist are inconclusive, making it difficult to suggest which specific types of pain problems are likely to be alleviated by its use.

When acupuncture is employed, it is important the physician know about its use because it may rarely cause pain through introduction of infection, or other means. The physician should also be made aware of any new pains before acupuncture is employed so they can be checked to make sure they do not indicate a change in disease status requiring additional medical intervention. Knowledge that acupuncture is being sought may also be helpful to the physician by indicating present medical management is not producing adequate pain relief.

4.08 Relaxation and Imagery

Relaxation techniques and imagery may be used singly or together 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, as discussed above, progressive muscle relaxation, meditation, and music-assisted relaxation. Simple relaxation techniques are most effective during 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.

Relaxation and imagery are particularly helpful because they are easy to learn, do not require special equipment, and are readily accepted by most patients. [Many tapes are available]

A suggested approach to relaxation and imagery, say:

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.

6. Additional points: Very likely some of the things you think of in answer to these questions can be recorded for you, such as your favorite music or a prayer. 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.

4.09 Distraction and Reframing

Distraction is the strategy of focusing one's attention on stimuli other than pain or the accompanying negative emotions. 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, watching television, talking to family and friends, or listening to someone read. Distraction exercises often include repetitive actions or activities of thought, such as rhythmic massage or the use of a visual focal point. Distraction may be used alone to manage mild pain or along with analgesic drugs to manage brief episodes of severe pain, such as procedure-related pain.

A related technique, reframing, 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.

A suggested method of distraction:

Active listening to recorded music:

1. Obtain a cassette player or tape recorder (small, battery-operated ones are more convenient); earphone or headsets (these are more demanding stimuli than a speaker a few feet away, and it avoids disturbing others); and a cassette of music like 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.)

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 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; mark time to the music in more than one manner, e.g., tap your foot and finger at the same time.

6. 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.

4.10 Hypnosis

The hypnotic trance is a state of highly focused concentration which can be used to manipulate the perception of pain. In skilled hands, it is frequently effective in obtaining at least partial relief from cancer related pain. Often the problem is finding the appropriate person to undertake the therapy without producing a risk of danger, such as failure to recognize the presence of a new pain indicative of a medical emergency at a time when intervention would be desirable to prolong the patientís life.

4.11 Pastoral Counseling

Having a terminal illness frequently raises issues for patients and their families commonly addressed by religion and/or spirituality. Questions related to the meaning of life, pain and suffering, evil, punishment, reconciliation, guilt, forgiving, afterlife, etc., all of which 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 provide highly skilled counseling services to terminally ill patients and their families even when they are not regular members of the congregation. As their training and approaches are likely to be effective and different from those normally employed by health care providers, it is important they be included in any multidisciplinary approach to pain management.

4.12 TENS Therapy

TENS (Transcutaneous Electrical Nerve Stimulation) therapy is a method of applying controlled, low-voltage electrical stimulation to large peripheral nerves through skin electrodes as a means of relieving pain. Like acupuncture, TENS is believed to activate natural nerve pathways which change or limit the perception of pain. Whether this is in fact the correct explanation of the pain relief observed by many patients is difficult to know, as many studies also suggest most relief may in fact be due to placebo effect. Nevertheless, patients with mild to moderate pain may benefit from a trial of TENS which, if successful, should be continued as it is not prone to causing significant side effects.

4.13 Peer Support Groups

Self-help and mutual support groups for cancer patients and their families are widely available. Some enroll survivors of any type of cancer and their relatives. Others target specific cancers like breast, larynx and prostate. Many of the peer support groups work closely with health care teams who refer patients to them.

The experience and understanding 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. Support networks can also help patients to maintain social identity and provide emotional support, material aid, and access to information. Obviously, these types of support groups are helpful in many areas involved with dealing with dying in addition to pain. The following are suggestions of how to find a support group.

1. Call the local unit of the American Cancer Society; see the phone book in the business white pages.

2. Contact the National Coalition for Cancer Survivorship: 1010 Wayne Avenue, 5th Floor Silver Spring, MD 20910 (301) 650-8868.

3. Call the National Cancer Information Service, 1-800-4-CANCER.

4. Call the State self-help clearinghouse; the American Self-Help Clearinghouse at (201) 642-7101 has information on State clearinghouses.

5. Call the local mental health department.

6. Call the local United Way office or other community fund offices.

Table of Contents Introduction Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Chapter 6 Chapter 7
Chapter 8 Chapter 9 Chapter 10 Chapter 11 Chapter 12 Chapter 13 Chapter 14 Chapter 15 Chapter 16 Chapter 17

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