Nondrug treatment for Pain

Nondrug treatments are now widely used to help manage cancer pain. There are many techniques that are used alone or along with medicine. Some people find they can take a lower dose of medicine with such techniques. These methods include: relaxation, biofeedback, imagery, distraction, hypnosis, skin stimulation, transcutaneous electric nerve stimulation (TENS), acupuncture, exercise or physical therapy, and emotional support and counseling.

You may need the help of health professionals — social workers, physical therapists, psychologists, nurses, or others — to learn these techniques. Family and friends can also help. To find names and numbers of practitioners who specialize in and organizations knowledgeable about these techniques:

• Talk with your doctor or nurse.
• Contact a local hospice, cancer treatment center, or pain clinic.
• Visit your local bookstores or library.
• Contact the National Center for Complementary and Alternative Medicine Clearinghouse toll-free at 1-888-644-6226 or via e-mail at nccamc@altmedinfo.org.

Because pain may be a sign that the cancer has spread, an infection is present, or there are problems caused by the cancer treatment, report any new pain problems to the doctor or nurse before trying to have the pain relieved by any of the following methods.

Some general guidelines for relieving pain with nondrug methods include:

• Learn which methods work for you. Try using a non- medicine method along with your medicine. For instance, you might use a relaxation technique (to lessen tension, reduce anxiety, and manage pain) at the same time you take medicine.
• Know yourself and what you can do. Often when people are rested and alert, they can use a method that demands more attention and energy. When tired, people may need to use a method that requires less effort. For example, try distraction when you are rested and alert; use hot or cold packs when you are tired.
• Be open-minded and keep trying. Keep a record of what makes you feel better and what doesn't help.
• Try each method more than once. If it doesn't work the first time, try it a few more times before you decide it is not helping you.

Relaxation

Relaxation relieves pain or keeps it from getting worse by reducing tension in the muscles. It can help you fall asleep, give you more energy, make you less tired, reduce your anxiety, and help other pain relief methods work better. Some people, for instance, find that taking pain medicine or using a cold or hot pack works faster and better when they relax at the same time.

How to Use Relaxation

Relaxation may be done sitting up or lying down. Choose a quiet place whenever possible.

Close your eyes. Do not cross your arms and legs because that may cut off circulation and cause numbness or tingling. If you are lying down, be sure you are comfortable. Put a small pillow under your neck and under your knees or use a low stool to support your lower legs.

There are many methods. Here are some for you to try:

Visual concentration and rhythmic massage:

• Open your eyes and stare at an object, or close your eyes and think of a peaceful, calm scene.
• With the palm of your hand, massage near the area of pain in a circular, firm manner. Avoid red, raw, or swollen areas. You may wish to ask a family member or friend to do this for you.

Inhale/tense, exhale/relax:

• Breathe in deeply. At the same time, tense your muscles or a group of muscles. For example, you can squeeze your eyes shut, frown, clench your teeth, make a fist, stiffen your arms and legs, or draw up your arms and legs as tightly as you can.
• Hold your breath and keep your muscles tense for a second or two.
• Let go! Breathe out and let your body go limp.

Slow rhythmic breathing:

• Stare at an object or close your eyes and concentrate on your breathing or on a peaceful scene.
• Take a slow, deep breath and, as you breathe in, tense your muscles (such as your arms).
• As you breathe out, relax your muscles and feel the tension draining.
• Now remain relaxed and begin breathing slowly and comfortably, concentrating on your breathing, taking about 9 to 12 breaths a minute. Do not breathe too deeply.
• To maintain a slow, even rhythm as you breathe out, you can say silently to yourself, "In, one, two; out, one, two." It may be helpful at first if someone counts out loud for you. If you ever feel out of breath, take a deep breath and then continue the slow breathing. Each time you breathe out, feel yourself relaxing and going limp. If some muscles, such as your shoulder muscles, are not relaxed, tense them as you breathe in and relax them as you breathe out. Do this only once or twice for each specific muscle group.
• Continue slow, rhythmic breathing for a few seconds up to 10 minutes, depending on your need.
• To end your slow rhythmic breathing, count silently and slowly from one to three. Open your eyes. Say silently to yourself, "I feel alert and relaxed." Begin moving about slowly.

Other methods you can add to slow rhythmic breathing:

• Imagery.
• Listening to slow, familiar music through an earphone or headset.
• Progressive relaxation of body parts. Once you are breathing slowly and comfortably, you may relax different body parts, starting with your feet and working up to your head. Think of words such as limp, heavy, light, warm, or floating. Each time you breathe out, you can focus on a particular area of the body and feel it relaxing. Try to imagine that the tension is draining from that area. For example, as you breathe out, feel your feet and ankles relaxing; the next time you breathe out, feel your calves and knees relaxing, and so on up your body.
• Ask your doctor or nurse to recommend commercially available relaxation tapes. These tape recordings provide step-by-step instructions in relaxation techniques.

Precautions:

Some people who have used relaxation for pain relief have reported the following problems and have suggested the following solutions:

• Relaxation may be difficult to use with severe pain. If you have this problem, use quick and easy relaxation methods such as visual concentration with rhythmic massage or breathe in/tense, breathe out/relax.
• Sometimes breathing too deeply for a while can cause shortness of breath. If this happens to you, take shallow breaths and/or breathe more slowly.
• You may fall asleep. This can be especially helpful if you are ready to go to bed. If you do not wish to fall asleep, sit in a hard chair while doing the relaxation exercise or set a timer or alarm.

If you have trouble using these methods, ask your doctor, nurse, social worker, or pain specialist to refer you to someone who is experienced in relaxation techniques. Do not continue any technique that increases your pain, makes you feel uneasy, or causes unpleasant effects.

Biofeedback

Learning this technique requires the help of a licensed biofeedback technician. With the help of special machines, people can learn to control certain body functions such as heart rate, blood pressure, and muscle tension. Biofeedback is sometimes used to help people learn to relax. You can use biofeedback techniques to help you relax and to help you cope with pain. This technique is usually used with other pain relief methods.

Imagery

Imagery is using your imagination to create mental pictures or situations. The way imagery relieves pain is not completely understood. Imagery can be thought of as a deliberate daydream that uses all of your senses — sight, touch, hearing, smell, and taste. Some people believe that imagery is a form of self-hypnosis.

Certain images may reduce your pain both during imagery and for hours afterward. If you must stay in bed or can't leave the house, you may find that imagery helps reduce the closed-in feeling; you can imagine and revisit your favorite spots in your mind. Imagery can help you relax, relieve boredom, decrease anxiety, and help you sleep.

How to Use Imagery

Imagery usually works best with your eyes closed. You may want to use a relaxation technique before using imagery. The image can be something like a ball of healing energy or a picture drawn in your mind of yourself as a person without pain (for example, imagine that you are cutting the wires that send pain signals from each part of your body to your brain). Or think of a pleasant, safe, relaxing place or activity that has made you happy. Exploring this place or activity in your mind in great detail can help you feel calm.

Here is an exercise with the ball of energy.

• Close your eyes. Breathe slowly and feel yourself relax.
• Concentrate on your breathing. Breathe slowly and comfortably from your abdomen. As you breathe in, say silently and slowly to yourself, "In, one, two." As you breathe out, say, "Out, one, two." Breathe in this slow rhythm for a few minutes.
• Imagine a ball of healing energy forming in your lungs or on your chest. It may be like a white light. It can be vague. It does not have to be vivid. Imagine this ball forming, taking shape.
• When you are ready, imagine that the air you breathe in blows this healing ball of energy to the area of your pain. Once there, the ball heals and relaxes you.
• When you breathe out, imagine the air blows the ball away from your body. As it goes, the ball takes your pain with it.
• Repeat the last two steps each time you breathe in and out.
• You may imagine that the ball gets bigger and bigger as it takes more and more discomfort away from your body.
• To end the imagery, count slowly to three, breathe in deeply, open your eyes, and say silently to yourself, "I feel alert and relaxed." Begin by moving about slowly.

Problems that may occur with imagery are similar to the ones that occur with the relaxation techniques.

Distraction

Distraction means turning your attention to something other than the pain. People use this method without realizing it when they watch television or listen to the radio to "take their minds off" a worry or their pain.

Distraction may be used alone to manage mild pain or used with medicine to manage brief episodes of severe pain, such as pain related to procedures. Distraction is useful when you are waiting for pain medicine to start working. If the pain is mild, you may be able to distract yourself for hours. Distraction can be a powerful way of relieving even the most intense pain for awhile.

How to Use Distraction

Any activity that occupies your attention can be used for distraction. Distractions can be internal, for example, such as counting, singing mentally to yourself, praying, or repeating to yourself statements such as "I can cope." Or distractions can be external, for example, doing crafts such as needlework, model building, or painting. Losing yourself in a good book might divert your mind from the pain. Going to a movie, watching television, or listening to music are also good distraction methods. Slow, rhythmic breathing can be used as distraction as well as relaxation. Visiting with friends or family is another useful distraction technique.

You may find it helpful to listen to rather fast music through a headset or earphones. To help keep your attention on the music, tap out the rhythm. You can adjust the volume to match the intensity of the pain, making it louder for very severe pain. This technique does not require much energy, so it may be very useful when you are tired.

After using a distraction technique, some people report that they are tired, irritable, and feel more pain. If this is a problem for you, you may not wish to use distraction or to be careful about which distraction methods you use and when you use them.

Hypnosis

Hypnosis is a trance-like state of high concentration between sleeping and waking. In this relaxed state, a person becomes more receptive or open to suggestion. Hypnosis can be used to block the awareness of pain, to substitute another feeling for the pain, and to change the sensation to one that is not painful. This can be brought on by a person trained in hypnosis, often a psychologist or psychiatrist. You can also be trained to hypnotize yourself.

During hypnosis, many people feel similar to the state we experience when we begin to awaken in the morning. We can't quite open our eyes, but are very aware. We can hear sounds inside or outside our house. Our eyes remain closed, and we feel as though we either can't or don't want to wake up and open our eyes.

People can easily be taught, by a hypnotherapist, to place themselves in a hypnotic state, make positive suggestions to themselves, and to leave the hypnotic state.

Choose a hypnotherapist who is licensed in the healing arts or who works under the supervision of someone who is licensed. To locate a therapist skilled in hypnosis, contact the behavioral medicine department at a cancer center near you.

Skin Stimulation

In this series of techniques, the skin is stimulated so that pressure, warmth, or cold is felt, but the feeling of pain is lessened or blocked. Massage, pressure, vibration, heat, cold, and menthol preparations are used to stimulate the skin. These techniques also change the flow of blood to the area that is stimulated. Sometimes skin stimulation will get rid of pain or lessen pain during the stimulation and for hours after it is finished.

Skin stimulation is done either on or near the area of pain. You can also use skin stimulation on the side of the body opposite the pain. For example, you might stimulate the left knee to decrease the pain in the right knee. Stimulating the skin in areas away from the pain can be used to increase relaxation and may relieve pain.

Precautions:

• If you are having radiation therapy, check with your doctor or nurse before using skin stimulation.
• If you are receiving chemotherapy, check with your doctor before using hot or cold packs.
• You should not apply ointments, salves, or liniments to the treatment area, and you should not use heat or extreme cold on treated areas.

Massage

Using a slow, steady, circular motion, massage over or near the area of pain with just your bare hand or with any substance that feels good, such as talcum powder, warm oil, or hand lotion. Depending upon where your pain is located, you may do it yourself or ask a family member, friend, or a massage therapist to give you a massage. Some people find brushing or stroking lightly more comforting than deep massage. Use whatever works best for you.

Precaution:

• If you are having radiation therapy, avoid massage in the treatment area as well as over red, raw, tender, or swollen areas.

Pressure

To use pressure, press on various areas over and near your pain with your entire hand, the heel of your hand, your fingertip or knuckle, the ball of your thumb, or by using one or both hands to encircle your arm or leg. You can experiment by applying pressure for about 10 seconds to see if it helps. You can also feel around your pain and outward to see if you can find "trigger points," small areas under the skin that are especially sensitive or that trigger pain. Pressure usually works best if it is applied as firmly as possible without causing more pain. You can use pressure for up to 1 minute. This often will relieve pain for several minutes to several hours after the pressure is released.

Vibration

Vibration over and near the area of the pain may bring temporary relief. For example, the scalp attachment of a hand-held vibrator often relieves a headache. For low back pain, a long, slender battery-operated vibrator placed at the small of the back may be helpful. You may use a vibrating device such as a small battery-operated vibrator, a hand-held electric vibrator, a large heat-massage electric pad, or a bed vibrator. Do not use a vibrator on the stomach. Avoid vibration over red, raw, tender, or swollen areas.

Precaution:

• If you are having radiation therapy, avoid vibration in the treatment area.

Cold or Heat

As with any of the techniques described, you should use what works best for you. Heat often relieves sore muscles; cold lessens pain sensations by numbing the painful area. Many people with prolonged pain use only heat and have never tried cold. Some people find that cold relieves pain faster, and relief may last longer. Also, you can alternate heat and cold for added relief in some cases.

For cold, try gel packs that are sealed in plastic and remain soft and flexible even at freezing temperatures. Gel packs are available at drugstores and medical supply stores. They can be used again and stored in the freezer. You may want to wrap the pack in a towel to make it more comfortable. An ice pack, ice cubes wrapped in a towel, or water frozen in a paper cup also work.

Precaution:

• If you start to shiver when using cold, stop right away. Do not use cold so intense or for so long that the cold itself causes more pain.

To use heat for pain relief, a heating pad that generates its own moisture is convenient. You can also try gel packs heated in hot water, hot water bottles, a hot, moist towel, a regular heating pad, a hot bath or shower, or a hot tub to apply heat. For aching joints, such as elbows and knees, wrap the joint in a lightweight plastic wrap (tape the plastic to itself). This retains body heat and moisture.

Precautions:

• Do not use a heating pad on bare skin. Do not go to sleep for the night with the heating pad turned on. Also, be very careful, if you are taking medicines that make you sleepy or if you do not have much feeling in the area.
• Do not use heat over a new injury because heat can increase bleeding — wait at least 24 hours.
• Avoid heat or cold over any treatment area receiving radiation therapy and for 6 months after therapy has ended.
• If you are receiving chemotherapy, check with your doctor before using a cold pack.
• Do not use heat or cold over any area where your circulation or sensation is poor.
• Do not use heat or cold application for more than 5 to 10 minutes.

Menthol

Many menthol preparations are available for pain relief. There are creams, lotions, liniments, or gels that contain menthol. When they are rubbed into the skin, they increase blood circulation to the affected area and produce a warm (sometimes cool) soothing feeling that lasts for several hours.

How to Use Menthol

To use menthol preparations, test your skin by rubbing a small amount of the substance in a circle about the size of a quarter in the area of the pain (or the area to be stimulated). This will let you know whether menthol is uncomfortable to you or irritates your skin. If the menthol does not create a problem, rub some more into the area. The feeling from the menthol gradually increases and remains up to several hours. To increase the strength and length of the feeling, you can open your skin pores with heat (e.g., shower, sun) or wrap a plastic sheet over the area after the menthol application. (Don't use a heating pad because it may cause a burn). If you are concerned about the odor, you can use the menthol when you are alone, or perhaps in the evening or through the night.

Precautions:

• Do not rub menthol near your eyes, over broken skin, a skin rash, or mucous membranes (such as inside your mouth, or around your genitals and rectum).
• Make sure you do not get menthol in your eyes (wash your hands after applying menthol).
• Do not use menthol in the treatment area during radiation therapy.
• If you have been told not to take aspirin, do not use these preparations until you check with your doctor. Many menthol preparations contain an additional ingredient similar to aspirin. A small amount of this aspirin-like substance may be absorbed through the skin.

Transcutaneous Electric Nerve Stimulation (TENS)

This is a technique in which mild electric currents are applied to some areas of the skin by a small power pack connected to two electrodes. The feeling is described as a buzzing, tingling, or tapping feeling. The small electric impulses seem to interfere with pain sensations. The current can be adjusted so that the sensation is pleasant and relieves pain. Pain relief lasts beyond the time that the current is applied. Your doctor or a physical therapist can tell you where to get a TENS unit, and how to use it properly.

Acupuncture

In acupuncture, thin needles are inserted into the body at certain points and at various depths and angles. Each point controls the pain sensation of a different part of the body. When the needle is inserted, a slight ache, dull pain, tingling, or electrical sensation is felt for a few seconds. Once the needles are in place, no further discomfort should be experienced. The needles are usually left in place for between 15 and 30 minutes, depending on the condition treated. No discomfort is felt when the needles are removed. Acupuncture is now a widely accepted and proven method of pain relief. Acupuncture should be performed by a licensed acupuncturist. Ask your doctor, nurse, or social worker where to get acupuncture.

Precautions:

• Make sure your acupuncturist uses sterile needles.
• If you are receiving chemotherapy, talk to your doctor before beginning acupuncture.

Emotional Support and Counseling

If you feel anxious or depressed, your pain may seem worse. Also, pain can cause you to feel worried, depressed, or easily discouraged. Some people feel hopeless or helpless. Others may feel embarrassed, inadequate, or angry, frightened, isolated, or frantic. These are normal feelings that can be relieved.

Finding Support

Try to talk about your feelings with someone you feel comfortable with — doctors, nurses, social workers, family or friends, a member of the clergy, or other people with cancer. You may also wish to talk to a counselor or a mental health professional. Your doctor, nurse or the social services department at your local hospital can help you find a counselor who is specially trained to help people with chronic illnesses.

You may also want to join a support group where people with cancer meet and share their feelings about how they have coped with cancer. For information about support groups, ask your doctor, nurse, or hospital social worker. Also, many newspapers carry a special health supplement containing information about where to find support groups.

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