Non Pharmacological Approaches

Evidence Summary

Non-pharmacological pain management approaches may contribute to effective analgesia and are often well accepted by patients. While possibly not effective as stand-alone treatments for pain, the combination of non-pharmacological techniques with pharmacological approaches may improve pain management outcomes for patients. [1] In groups that are particularly vulnerable to side effects from a pharmacological approach there is benefit to using these non-medication approaches. [2-5] However, there is limited research and low quality evidence in this area, which makes specific recommendations difficult. [6,7] Studies examining non-pharmacological approaches often produce variable results due to a lack of standardisation in intervention implementation. [8,9] Very few studies specifically target the same outcome, and few target pain in palliative care.

Psychological Interventions

The role of psychological interventions in the management of pain in a palliative setting are generally seen as adjunctive to other therapeutic interventions. They are often implemented as part of the holistic palliative approach for individual patients, rather than specifically for pain management. Commonly psychological approaches include patient and carer education, stress reduction, distraction and cognitive-behavioural interventions.

A recent review of interventions designed to improve pain management knowledge among palliative care patients and carers found that targeted patient education on pain management does improve adherence to a pain plan and improves patient satisfaction. [10] A systematic review examining patient education targeting people with cancer shows that educational interventions can have a modest but clinically significant impact on pain, and that this is an underutilised strategy. [11]

Strategies targeting stress reduction are used to reduce pain and these include relaxation techniques and hypnosis. A systematic review reporting on the use of hypnosis in pain management did find hypnosis had an analgesic effect but this was dependant on the suggestibility of the patient and the specific technique used by the therapist. [12] Another review examining the use of hypnosis to reduce procedure related pain in children and adolescents with cancer suggested it may be beneficial, but the evidence is of low quality. [3] There is no specific research examining the effectiveness of hypnosis on terminally ill cancer patients. [13]

Attentional strategies, such as music therapy have been studied and a systematic review of music therapy in cancer pain suggests that it may be beneficial. [14] Another systematic review suggested music therapy was useful in managing pain in terminally ill patients, although the evidence base remains limited in quality. [15]

Cognitive behavioural interventions are well established in chronic pain management. [16] Specific evidence establishing its use in managing pain in the palliative care context is lacking. A recent systematic review examining cognitive behavioural therapy and mindfulness found both may be useful in reducing pain in chronic pain conditions. [16] Mindfulness has also been found to be useful in reducing cancer pain. [17] There is some evidence that both mindfulness and cognitive behavioural therapy may benefit from being delivered in a group situation, particularly for older people. [4] However, there is limited evidence to support these interventions in a palliative care setting, particularly in managing pain.

Transcutaneous Electrical Nerve Stimulation

The role of transcutaneous electrical nerve stimulation (TENs) has been studied in acute [18] and neuropathic pain, [19] and in cancer pain. [20] A systematic review of TENs and cancer pain was unable to establish evidence to support its use. [21] Two other systematic reviews agreed that the quality of evidence for using TENS to manage cancer pain was low, but suggested there may be some slight benefit to using this treatment approach. [7,20] A review specifically focused on palliative care patients was unable to recommend the use of TENs in this group. [22]

Acupuncture

There have been several systematic reviews examining acupuncture in pain management and the results have been generally poor. There is no evidence to support the use of acupuncture to manage pain in renal disease, [2] or in palliating cancer pain. [22] There is low quality evidence to support its use in children [23] and in some peripheral neuropathies. [24] There is also low quality evidence that acupuncture may improve analgesia in cancer pain when combined with pharmacological treatments. [1]

Physical and Manual Therapies

Massage 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 symptoms in advanced cancer including pain. [25] There is limited evidence to support its use in a palliative care setting. [7,26]

Reflexology has been studied in many conditions, including for palliation of cancer, [27] and in breast cancer. [28] Whilst some studies yielded positive results, the methodological quality was poor, the risk of bias high, and the studies small. A systematic review concluded that there is no evidence that reflexology is an effective treatment for any of the conditions studied. [27]

Other Interventions

Other non-pharmacological interventions which were considered for pain management in a palliative care context included Reiki. There is low quality evidence to support the use of Reiki therapy in palliative care. [26]

Practice Implications

  • The role of non-pharmacological approaches in 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.
  • There is limited evidence to support the use of TENS and acupuncture in some conditions.
  • 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 patients assessed with significant pain in palliative care who are using complementary therapies should also be treated with appropriate analgesics and adjuvants, using an evidence-based approach.
  1. Hu C, Zhang H, Wu W, Yu W, Li Y, Bai J, et al. Acupuncture for Pain Management in Cancer: A Systematic Review and Meta-Analysis. Evid Based Complement Alternat Med. 2016;2016:1720239. doi: 10.1155/2016/1720239. Epub 2016 Feb 10.
  2. Kim KH, Lee MS, Kim TH, Kang JW, Choi TY, Lee JD. Acupuncture and related interventions for symptoms of chronic kidney disease. Cochrane Database Syst Rev. 2016 Jun 28;(6):CD009440.
  3. Nunns M, Mayhew D, Ford T, Rogers M, Curle C, Logan S, et al. Effectiveness of non-pharmacological interventions to reduce procedural anxiety in children and adolescents undergoing treatment for cancer: a systematic review and meta-analysis. Psychooncology. 2018 Aug;27(8):1889-1899. doi: 10.1002/pon.4749. Epub 2018 May 22.
  4. Niknejad B, Bolier R, Henderson CR Jr, Delgado D, Kozlov E, Löckenhoff CE, et al. Association Between Psychological Interventions and Chronic Pain Outcomes in Older Adults: A Systematic Review and Meta-analysis. JAMA Intern Med. 2018 Jun 1;178(6):830-839. doi: 10.1001/jamainternmed.2018.0756.
  5. Zins S, Gross R, Hooke MC. Complementary Therapies for Pain Among Individuals Receiving Hemodialysis: A Systematic Review. Nephrol Nurs J. 2018 Jan-Feb;45(1):13-23.
  6. Mercadante S. Non pharmacological interventions and non-fentanyl pharmacological treatments for breakthrough cancer pain: A systematic and critical review. Crit Rev Oncol Hematol. 2018 Feb;122:60-63. doi: 10.1016/j.critrevonc.2017.12.016. Epub 2017 Dec 23.
  7. Hökkä M, Kaakinen P, Pölkki T. A systematic review: non-pharmacological interventions in treating pain in patients with advanced cancer. J Adv Nurs. 2014 Sep;70(9):1954-69.
  8. Coelho A, Parola V, Cardoso D, Bravo ME, Apóstolo J. Use of non-pharmacological interventions for comforting patients in palliative care: a scoping review. JBI Database System Rev Implement Rep. 2017 Jul;15(7):1867-1904. doi: 10.11124/JBISRIR-2016-003204.
  9. Pu L, Moyle W, Jones C, Todorovic M. Psychosocial interventions for pain management in older adults with dementia: A systematic review of randomized controlled trials. J Adv Nurs. 2019 Aug;75(8):1608-1620. doi: 10.1111/jan.13929. Epub 2019 Jan 15.
  10. Mayahara M, Wilbur J, Fogg L, Breitenstein SM. Behavioral Pain Intervention for Hospice and Palliative Care Patients: An Integrative Review. Am J Hosp Palliat Care. 2018 Sep;35(9):1245-1255. doi: 10.1177/1049909118775421. Epub 2018 May 17.
  11. Bennett MI, Bagnall AM, José Closs S. How effective are patient-based educational interventions in the management of cancer pain? Systematic review and meta-analysis. Pain. 2009 Jun;143(3):192-9. Epub 2009 Mar 12.
  12. Thompson T, Terhune DB, Oram C, Sharangparni J, Rouf R, Solmi M, et al. The effectiveness of hypnosis for pain relief: A systematic review and meta-analysis of 85 controlled experimental trials. Neurosci Biobehav Rev. 2019 Apr;99:298-310. doi: 10.1016/j.neubiorev.2019.02.013. Epub 2019 Feb 18.
  13. Montgomery GH, Sucala M, Baum T, Schnur JB. Hypnosis for Symptom Control in Cancer Patients at the End-of-Life: A Systematic Review. Int J Clin Exp Hypn. 2017 Jul-Sep;65(3):296-307. doi: 10.1080/00207144.2017.1314728.
  14. Bradt J, Dileo C, Grocke D, Magill L. Music interventions for improving psychological and physical outcomes in cancer patients. Cochrane Database Syst Rev. 2011 Aug 10;(8):CD006911.
  15. Gao Y, Wei Y, Yang W, Jiang L, Li X, Ding J, et al. The Effectiveness of Music Therapy for Terminally Ill Patients: A Meta-Analysis and Systematic Review. J Pain Symptom Manage. 2019 Feb;57(2):319-329. doi: 10.1016/j.jpainsymman.2018.10.504. Epub 2018 Oct 30.
  16. Khoo EL, Small R, Cheng W, Hatchard T, Glynn B, Rice DB, et al. Comparative evaluation of group-based mindfulness-based stress reduction and cognitive behavioural therapy for the treatment and management of chronic pain: A systematic review and network meta-analysis. Evid Based Ment Health. 2019 Feb;22(1):26-35. doi: 10.1136/ebmental-2018-300062.
  17. Ngamkham S, Holden JE, Smith EL. A Systematic Review: Mindfulness Intervention for Cancer-Related Pain. Asia Pac J Oncol Nurs. 2019 Apr-Jun;6(2):161-169. doi: 10.4103/apjon.apjon_67_18.
  18. Walsh DM, Howe TE, Johnson MI, Sluka KA. Transcutaneous electrical nerve stimulation for acute pain. Cochrane Database Syst Rev. 2009 Apr 15;(2):CD006142.
  19. Gibson W, Wand BM, O'Connell NE. Transcutaneous electrical nerve stimulation (TENS) for neuropathic pain in adults. Cochrane Database Syst Rev. 2017 Sep 14;9:CD011976. doi: 10.1002/14651858.CD011976.pub2.
  20. Hurlow A, Bennett MI, Robb KA, Johnson MI, Simpson KH, Oxberry SG. Transcutaneous electric nerve stimulation (TENS) for cancer pain in adults. Cochrane Database Syst Rev. 2012 Mar14;(3):CD006276.
  21. Robb K, Oxberry SG, Bennett MI, Johnson MI, Simpson KH, Searle RD. A cochrane systematic review of transcutaneous electrical nerve stimulation for cancer pain. J Pain Symptom Manage. 2009 Apr;37(4):746-53. Epub 2008 Sep 14.
  22. Wu X, Chung VC, Hui EP, Ziea ET, Ng BF, Ho RS, et al. Effectiveness of acupuncture and related therapies for palliative care of cancer: overview of systematic reviews. Sci Rep. 2015 Nov 26;5:16776. doi: 10.1038/srep16776.
  23. Yang C, Hao Z, Zhang LL, Guo Q. Efficacy and safety of acupuncture in children: an overview of systematic reviews. Pediatr Res. 2015 Aug;78(2):112-9. doi: 10.1038/pr.2015.91. Epub 2015 May 7.
  24. Dimitrova A, Murchison C, Oken B. Acupuncture for the Treatment of Peripheral Neuropathy: A Systematic Review and Meta-Analysis. J Altern Complement Med. 2017 Mar;23(3):164-179. doi: 10.1089/acm.2016.0155. Epub 2017 Jan 23.
  25. Ernst E. Massage therapy for cancer palliation and supportive care: a systematic review of randomised clinical trials. Support Care Cancer. 2009 Apr;17(4):333-7. Epub 2009 Jan 13.
  26. Zeng YS, Wang C, Ward KE, Hume AL. Complementary and Alternative Medicine in Hospice and Palliative Care: A Systematic Review. J Pain Symptom Manage. 2018 Nov;56(5):781-794.e4. doi: 10.1016/j.jpainsymman.2018.07.016. Epub 2018 Aug 2.
  27. Ernst E. Is reflexology an effective intervention? A systematic review of randomised controlled trials. Med J Aust. 2009 Sep 7;191(5):263-6.
  28. Kim JI, Lee MS, Kang JW, Choi do Y, Ernst E. Reflexology for the symptomatic treatment of breast cancer: a systematic review. Integr Cancer Ther. 2010 Dec;9(4):326-30.

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Last updated 31 October 2019