Alternative Pain Control

Cristin A. McMurray

Fred E. Shapiro

The traditional “Western view” of science and medicine involves the use of pharmacopoeias to control pain; however, there are other ways of understanding human behavior, medicine, and pain that deserve attention. As previously mentioned, the biopsychosocial model of pain suggests that other factors play into an individual’s experience of pain. A significant amount of research has gone into mind-body therapies (MBTs) for the treatment of different types of pain, including postoperative pain. Often these techniques are used in conjunction with more traditional management in an attempt to improve patient comfort and reduce drug requirements. This is an area that has garnered much public and media attention in the last 20 years.

Several explanations have been offered for the success of MBTs (see Box 16.1).

Pain is frequently mediated by emotional and psychological factors; it is exacerbated by anxiety and a feeling of helplessness in the face of suffering. Researchers have hypothesized that MBTs may lessen the patient’s state of sympathetic arousal and cause a “relaxation response” to facilitate greater control over stress reactivity. The state of hypoarousal induced by some MBTs may allow patients to develop a more detached stance toward their sensory experience of pain and reduce the emotional aspects of their pain. These MBT modalities also offer patients a means of asserting some control over their situation. Studies have shown that perceived self-efficacy is an important factor in pain tolerance. Although the actual physical experience of pain may not be altered by various MBTs, the patient’s emotional and cognitive response may be lessened, allowing them to remain calmer, less anxious, and less distressed by the pain (1).

This chapter will explain some of the different MBT modalities, specifically those areas that are supported by evidence-based research and their use in the perioperative setting (see Box 16.2).

MASSAGE

Massage is the manipulation (touching, kneading) of soft tissues of the body for therapeutic purposes. Studies have shown that, when integrated in conjunction with opioid pain relief, massage is more effective than opioids alone in the treatment of acute postoperative pain.

Piotrowski et al. published an article in the Journal of the American College of Surgeons in 2003. They evaluated postoperative pain in 202 patients who underwent major operations and divided them into three groups of nursing interventions: massage (81), focused attention (66), or routine care (55). The interventions were performed twice daily for 10 minutes, beginning 24 hours after the operation through postoperative day 7. The patient population was fairly homogeneous, with more than 50% of the patients 60 years or older, 97% male, with the sternum as the most common incision site (77%). Routine care included administering medications, checking the patients’ vital signs, checking the patients for comfort and safety, and performing wound care and dressing changes. In the focused attention group, in addition to the routine care described, dedicated time (10 minutes with the research nurse) was added to assess the effect of emotional support, independent of massage, on pain relief. No visitors were present and the door or curtain was closed to maintain privacy. The nurse sat close to the bed, facing the patient at a comfortable speaking distance in order to promote patient-nurse interaction. Either party could initiate a conversation or not; silence was acceptable.

The massage group, in addition to routine care, received a 10-minute effleurage back massage provided by the research nurse who had no prior formal training in massage. (Before the research study, each nurse was trained in this process by a 3- to 4-hour session with a certified massage therapist.) The back massage was given in the prone or lateral position, depending on where the wound was located. Moderate, firm massage strokes were used while the patient was urged to relax and advise the research nurse of any discomfort, or if he wanted to change positions, stop the massage, or change the technique.

During 82% of the focused attention group sessions and 71% of the massage sessions, participants discussed health care concerns. The two most common topics were pain and physical activities and limitations. Patients in the massage group believed that their treatment decreased discomfort 77% of the time; the focused attention group believed that the intervention decreased pain 64% of the time.

The greatest impact of this effect of focused attention or massage was during the first 72 hours postoperatively. When rating patient satisfaction, both experimental groups admitted that interventions improved their pain control, more so in the massage group. The most interesting finding of this study is that massage significantly accelerated the rate of decline in pain unpleasantness, as perceived by the patients. This aspect of pain is often not elicited from patients but significantly impacts their recovery and experience of pain. Based on the results of this study, it was recommended that massage might be a useful tool to palliate a patient’s distress postoperatively (2).

In the office-based setting, massage may be a useful intervention to recommend to patients at home; many insurance plans are starting to reimburse patients for doctor-prescribed massage therapy sessions.

Acupuncture

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