Non-pharmacological approaches may contribute to effective analgesia and are often well accepted by patients. Some simple measures which are sometimes recommended (eg, hot or cold packs) have not been well studied. Complementary therapies for pain are often sought out by patients, and require evaluation for their potential role in the palliative care setting.
What is known
- Patient education about managing cancer pain has been studied. A systematic review  shows that educational interventions can have a modest but clinically significant impact on pain, and that this is an underutilised strategy.
- The role of TENS (transcutaneous electrical nerve stimulation) has been studied in acute  and chronic pain,  and in cancer pain.  In both acute and chronic pain there was not enough evidence to support the use of TENS, because the studies were of poor quality, and provided little information about the stimulation parameters needed to give pain relief. A lack of Suitable RCTs meant that it was not possible to assess the value of TENS in cancer patients.
- Complementary therapies specifically for neuropathic pain have been reviewed, and topical capsaicin has been shown to be effective. Other strategies that seemed to show promise, but require further study, are cannabis extract, magnets, carnitine, and electrostimulation. 
- An overview of the systematic reviews of acupuncture found no evidence to support its use in managing cancer pain, and concluded that the only evidence-based indication for acupuncture in cancer currently is for nausea and vomiting. [6-7]
- Hypnosis is sometimes used to reduce procedure related pain in children. A systematic review which studied the use of hypnosis for this type of pain  found it is beneficial, however there were methodological problems with many of the studies identified.
- Music therapy has been studied and a systematic review of music therapy in cancer pain suggests that benefits may be derived from music therapy.  The evidence base is very small. In a separate review, no benefits in regard to pain were demonstrated in the end of life context. 
- Massage (not including aromatherapy or reflexology) has been the subject of a systematic review and, despite methodological problems with the studies included, it appears that massage may potentially have a positive effect on a number of symptoms in advanced cancer including pain. 
- Reflexology has been studied in a number of conditions, including for palliation of cancer,  and in breast cancer.  Whilst some studies yielded positive results, the methodological quality was poor, the risk of bias was high, and the studies were small. A systematic review concluded that there is no evidence that reflexology is an effective treatment for any of the conditions studied. 
- Mind-body therapies as a group (which include relaxation, imagery / hypnosis, cognitive-behavioral therapy / coping skills training [CBT / CST], meditation, music, and virtual reality) have been studied for their impact on the symptom cluster of pain / fatigue / sleep disturbance. It was concluded that there is some evidence for the efficacy of a number of these approaches for pain as a single symptom, although the symptom cluster has not been studied. Strategies for which there is some evidence supporting their role in pain are: Imagery/hypnosis and CBT / CST, relaxation and music. [14,16] The use of Guided Imagery as a pain management strategy has also been specifically reviewed, and it was concluded that the results are contradictory and the evidence base is small, so further investigation is suggested. [15-16]
- Biofield therapies - which include Reiki, therapeutic touch, and healing touch – have been reviewed for their potential to improve cancer pain. A systematic review concluded that there is moderate evidence for an improvement in acute pain, but longer term impacts on cancer pain have not been studied. [16-18]
- Art therapy is increasingly being provided in palliative care settings as a psychotherapeutic modality and as part of a supportive care approach. However few studies of its impact on pain or other symptoms are available at this stage. 
What it means in practice
The role of non-pharmacological approaches to pain management is evolving, and some non-pharmacological and complementary therapies have an increasingly important contribution to make to holistic patient care alongside analgesics. There is evidence to support the use of patient education, cognitive behavioural therapy (CBT), relaxation, and music. Importantly, however, some approaches have not been shown to be of benefit, including TENS, reflexology and acupuncture. For this reason, research on non-pharmacological approaches to pain management is very important, so that patients are provided with information that ensures them the most effective options for treating their pain. It is essential that palliative care patients with anything more than mild pain who are using complementary therapies should also be treated with appropriate analgesics and adjuvants, using an evidence-based approach.