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.  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.
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.  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. 
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.  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.  There is no specific research examining the effectiveness of hypnosis on terminally ill cancer patients. 
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.  Another systematic review suggested music therapy was useful in managing pain in terminally ill patients, although the evidence base remains limited in quality. 
Cognitive behavioural interventions are well established in chronic pain management.  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.  Mindfulness has also been found to be useful in reducing cancer pain.  There is some evidence that both mindfulness and cognitive behavioural therapy may benefit from being delivered in a group situation, particularly for older people.  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  and neuropathic pain,  and in cancer pain.  A systematic review of TENs and cancer pain was unable to establish evidence to support its use.  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. 
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,  or in palliating cancer pain.  There is low quality evidence to support its use in children  and in some peripheral neuropathies.  There is also low quality evidence that acupuncture may improve analgesia in cancer pain when combined with pharmacological treatments. 
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.  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,  and in breast cancer.  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. 
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. 
- 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.