Vol. 2 No.
2 Spring 1987 Journal of Pain and Symptom A1anagement
Nonpharmacological Management
of Cancer Pain
.Charles S. Cleeland
A variety of modalities of cancer pain man-
agement complement the pharmacologic treat-
ment scheme. All pain therapies supplement
the fundamental analgesic role played by anti-
tumor therapy in the total management of
tumor-related pain. These therapies become
more pertinent when antitumor measures have
been exhausted or when the risk-to-benefit
ratio dictates that the reduction of tumor is not
appropriate at a particular time in the course
of the patient's disease.
Nondrug therapies should never be consid-
ered acceptable alternatives to a carefully
planned analgesic program tatlored to the spe-
9 it .
ClfiC needs of the patient. Should analgesics
produce satisfactory relief of pain with accept-
able side effects, the primary objective has been
met, and no further need for therapy exists.
Too often, nonpharmacologic techniques have
been called into play because the patient was
inappropriately considered to have failed
analgesic therapy due to inadequate dose
titration.
With these qualifications in mind, what role
do nonpharmacologic therapies play in the
management of patients with cancer pain? Of
several hundred cancer patients at our cancer
center, approximately half rated their pain
t r e a t m e n t as 70% to 100% effective and
approximately 40% gave their analgesics a rat-
ing of fair (30% to 69% effective). The patients
who had fair control of pain might benefit
from careful titration of their analgesic, substi-
tution of another analgesic, or addition of non-
pharmacologic therap): A significant minority
of around 15% reported little pain relief from
their analgesics and, clearly, these patients are
prime candidates for nondrug interventions.
Charles S. Cleeland, PhD, is Professor of Neurology
at the University of Wisconsin Medical School and
Director of the Pain Research Group9 In addition
he is a Principal in the World Health Organization
Cancer Pain Relief Program.
$23
EL_--21
These data are similar to recent evaluations
conducted as part of the World Health Organi-
zation's cancer pain relief program, which indi-
cated that cancer pain can be effectively con-
t r o l l e d with a p p r o p r i a t e p h a r m a c o l o g i c
m a n a g e m e n t in a p p r o x i m a t e l y 85% o f
patients.
Although n o n d r u g therapies, especially
neurodestructive measures, are primary modal-
ities when a reasonable trial o f pharma-
cotherapy fails, they may also be useful in com-
bination with analgesic management. These
therapies include psychological techniques,
peripheral stimulation, physical medicine
approaches, anesthetic methods, and surgical
techniques 9 O f these, several measures deser~'e
special consideration as adjuvants to analgesic
therapy (Table 1). These include psychological
techniques, supportive orthotic devices for the
patient with movement-related or incident
pain, and peripheral stimulation to support
the control of localized pain.
Table 1
Assessing the Need for Adjuvant Therapies
(Nondrug)
Cognitive techniques indicated:
Prominent muscle spasms
Predictable pain periods
Depression/anxiety
9 Psychological assessment and intervention
indicated, including psychotherapy:
9. History of chronic pain prominent
component of suffering
Mechanical measures indicated (OT/PT):
Prominent component of incident pain
Bez~t~fitfi-om orthotic or prosthetic devices
Peripheral neuroaugmentative procedures
indicated:
Localized pain
Deafferemation-type pain
$24 VoL 2 No. 2 Spring 1987
[sz2J
Sensitivity to the psychological needs of the
patient is the halhnark of good pain manage-
ment. Just as there is the continuing need to
monitor the severity of the patient's pain, there
is a parallel need to monitor the possibility that
anxiety and depression are playing a role in the
pain experience. Psychological techniques of
pain control may be beneficial to patients who
have no history of psychiatric disturbance but
who could benefit from learning special skills
"to help them cope with pain or the typical
accompaniments of pain such as anxiet);
depression, and sleep problems. Psychological
therapies may also be essential in patients who
come to their disease with a long history of
behavioral psychiatric disturbance.
Patients without a history of psychiatric dis-
order represent the vast majority of cancer
patients. As severity of pain increases, these
patients report increasing interference with
many aspects of their lives. In one stud), for
example, we asked a group of 300 cancer
patients with pain to report the severity of their
pain and the degree to which their pain inter-
fered with other dimensions of their lives. As
expected, interference with life activities
increased as pain became more severe. When
patients rated their pain at the midpoint or
higher on the pain severity scales, there was
significant impairment in many aspects of their
lives, including mood state, sleep, and general
activity; reduction to below the midpoint on
pain rating scales dramatically reduced the
degree to which patients were disabled by pain.
Patients with at least moderate pain, therefore,
appear to be particularly good candidates for
psychological learning mechanisms to cope
with its impact.
Behavioral Techniques
The indicated therapies in this psychologi-
call)' healthy population are often referred to
as cognitive or behavioral techniques to differ-
entiate them from more traditional psychiatric
interventions and standard psychotherapy
(Table 2). The)' are based on the assumption
that patients can learn specific skills to lielp
them cope with pain, as well as reduce the sen-
sation of pain itself. As with other n o n d r u g
therapies, use of these psychological tech-
niques shotdd never substitute for t~e adminis-
tration of appropriate analgesics. Furthermore,
Cleeland Journal of Pain and Symptom Management
Table 2
Behavioral Techniques for Pain Management
9 Biofeedback learning
9 Relaxation training
9 Hypnosis
9 Desensitization
9 Cognitive behavioral modification
successful use of these techniques should never
suggest that the associated pain relief is psycho-
genie. In fact, there is evidence suggesting that
these techniques are best used by persons who
have little or no emotional disturbance.
While the precise mechanisms by which
b e h a v i o r a l t e c h n i q u e s relieve p a i n are
unknown, the production of deep relaxation
and a redirecting of attention are common fea-
tures of most of the methods. Relaxation can
reduce muscle tension, which, in turn can
reduce strain on pain-sensitive structures.
Relaxation. can also decrease sympathetic
arousal, which may help to lessen pain trans-
mission and reaction. Redirection of attention
may also operate to reduce awareness of pain.
There are several behavioral techniques for
pain m a n a g e m e n t i n c l u d i n g biofeedback
learning, relaxation training, hypnosis, and
cognitive behavioral modification. Biofeed-
back uses electronic amplification of the body's
physiological signals to help tile patient reduce
physiological activity. Two types of biofeedback
are used for pain control. The first type
employs surface electromyography to provide
patients with continuous and immediate infor-
mation about the level o f their muscle contrac-
tion. The patient is able to follow this activity
by hearing a tone or by watching a visual dis-
play which changes as the patient relaxes. The
second type of biofeedback uses temperature
sensors to give the patient information about
extremity blood tlo~: With greater relaxation,
both peripheral circulation and extremity tem-
perature increase. Tiffs second technique may
be esp'ecially helpful for relieving ischemic
pain. For biofeedback to be successful, it must
be used by an active therapist who helps the
patient to understand the task of relaxation
and continually reinforces small gains.
IbL 2 No. 2 Spring 1987 Nonpharmacologic Management
Progressive relaxation training is a m e t h o d
o f teaching muscle relaxation in a highly sys-
tematic fashion but without the e q u i p m e n t o f
biofeedback. In this technique, patients con-
tract and then relax different muscle groups in
a specific order. As the patients contract mus-
cles, they begin to recognize the sensations of
fiauscle tension and relaxation. Trainers can
make an audio cassette o f instructions for indi-
vidual patients to guide them through practice.
Cancer patients often find practicing this tech-
nique is especially useful when sleep distur-
bance is a problem.
Hypnosis has a long history in the manage-
ment o f pain. It can induce deep relaxation,
but its major additional advantage api3ears to
be its capacity to redirect the attention o f the
patient away for his or her pain. When using
hypnosis for pain control, most therapists teach
their 15atients self-hypnosis. T h e patients can
subsequently use the technique when pain is
particularly troublesome for them. Patients dif-
fer in their innate ability to utilize hypnogis,
and some patients may experience negative
as well as positive g motions when using the
technique.
T h e techniques o f imagery and self-talk,
sometimes described as cognitive behavioral
modification, may be very useful. Cognitive
behavioral modification may be particularly
beneficial when patients mislabel the source of
their pain or minimize their ability to cope
with it. For example, patients can be taught to
reinforce themselves for being active despite
their pain.
Psychological techniques are most clearly
indicated in patients without significant prior
psychiatric history who have p r o m i n e n t muscle
spasm (relaxation), predictable pain periods
(distraction), and anxiety and/or mild depres-
sion (directed counseling). Although there are
few controlled studies demonstrating the effec-
tiveness o f these techniques in the control o f
cancer pain, they trove been shown to be effec-
tive in controlling other types o f clinical pain,
inchiding those o f a similar severity to cancer
pain, and are likely to provide substantial bene-
fit to a proportion o f cancer patients. It must
be noted, however, that these methods are labor
intensive and require a significant commit-
ment o f staff time.
Patients with a previous psychiatric histor);
especially one in which chronic pain, physical
symptoms, and "suffering" have played a prom-
$25
inent role, require special care. These patients
need carefid psychological assessment, psycho-
tropic medications and psychotherap); usually
including family therap): They have a special
need to learn to distinguish new cancer-related
pain, which can be controlled through analge-
sics, from the constellation o f symptoms that
has typically represented their somatic com-
plaints over many years.
Neurostimulato~7 Techniques
Another technique adjunctive to analgesic
therapy is a peripheral neurostimulatory pro-
cedure called transcutaneous nerve stimulation
(TENS). Historicall~; acupuncture can be con-
sidered the earliest example o f neurostimula-
tion as a method of pain control, and there are
practitioners who routinely use this procedure
in the management o f malignant pain. TENS is
xnuch more widely available and may be useful
as part of the total management of cancer
patients, but seldom provides adequate and
durable analgesia by itself. Clinical studies sug-
gest that it is associated with a temporal win-
dow o f effectiveness (usually not exceeding 30
days) in cancer patients. It has been especially
r e c o m m e n d e d for managing localized pain
occurring during a n t i t u m o r therapy and for
localized neuropathic pain, such as phantom
limb pain and pain associated with tumor infil-
tration of the brachial plexus. Patients can be
trained to place the surface electrodes them-
selves, or the help o f family members can be
elicited. The only c o m m o n side effect is m i n o r
skin irritation in a minority o f patients.
When pain is precipitated by a movement or
posture, often called incident pain, an orthotic
device may be a useful adjunctive measure.
This physical medicine approach may provide
especial benefit to patients with incident pain.
Neurodestructive Techniques
For the approximately 15% of patients who
do not obtain adequate pain relief or accept-
able side effects from adequately prescribed
analgesics, interruption o f the pain pathway
must be c,tansidered. Neurodestructive proce-
dures can be arbitrarily divided into anesthetic
and neurosurgical techniques. Whether one
uses a needle or a knife, the aim is the same: the
9 destruction o f the path by which a nociceptive
signal reaches the level o f sensation and per-
$26 VoL 2 No. 2 Spring 1987
ception.
The simplest anesthetic procedure is trigge r
point injection with local anesthetic. Selected
patients with cancer pain may benefit from this
technique. Other anesthetic methods involve
the use of neurodestructive agents, eg, alcohol
or phenol, for the permanent disruption of
pain pathways. Table 3 lists the most common
sites of pain and corresponding anesthetic
nerve blocks. The celiac plexus block may be
especially-effective for pain due to pancreatic
cancer. Destructive nerve blocks should be pre-
ceded by a temporary block, both to assess the
potential effectiveness of the destructive proce-
dure and to determine potential side effects.
As with destructive neurosurgical proce-
dures, p a t i e n t s a n d families n e e d to be
informed about possible complications and
about realistic expectations for success. The
success rate for these techniques is reported to
average about 60%, but the complications,
though uncommon, can be very significant
when the)' oecur. As with all the neurbdestruc-
tire procedures, controlled studies to assess
risk v benefit have not been conducted. Thus,
while these r~urodestructive procedures are
probably underutilized, they should be per-
formed only by practitioners skilled in the tech-
niques and knowledgeable in the overall man-
Table 3
Anesthetic Nerve Blocks for Cancer Pain
Site of pain Procedure
Discrete dermatomes, Peripheral nerve block
chest, abdomen
Unilateral lumbar Epidural
or sacral
Midline perineal
Bilateral iumbosacral
Midline perineal Intrathecal
Bilateral lumbosacral
.Frozen shoulder (RSDS) Stellate ganglion
Arm pain
RSDS Lumbar sympathetic
Lumbosacral plexopathy
Lower extremity
ischemic
Mid-abdominal Celiac plexus
Cleeland Journal of Pain and Symptom Management
a g e m e n t o f c a n c e r pain. T h e r e are no
satisfactory guidelines to indicate when neuro-
surgical procedures should be performed and
more conservative management abandoned.
The decision is best made with input from the
interdisciplinary health care team and both
patient and family after it appears that nonin.
vasive treatments have been exhausted. The
decision depends on such factors as chance of
success, risk of mortality and morbidit); and
prognosis of disease.
The choice of neurosurgicai procedure is
based on the location of the pain. Trigeminal
pain may respond to trigeminal rhizotomy;
extensive neurodestruction may be needed for
cancers involving the nasopharnyx and perina-
sal sinuses. For pain below the neck, cordotomy
is the single most common neurosurgical pro-
cedure. Although cordotomy can be performed
by an open surgical approach, it is most often
accomplished by a percutaneous stereotaxic
procedure. With this technique,, a thermo-
coagulative lesion is made in the lateral spino-
thalamic tract in either the cervical oi" thoracic
region. Although there are few controlled
studies, pain relief has been r e p o r t e d in as
many as 80% of patients who were adequately
selected for the procednre. The technique is
best suited for patients with unilateral pain,
especially that below the waist. For those
patients surviving the cordotomy after one
year, approximately one half will report a
return of pain. In addition, a significant num-
ber of patients will report previously unrecog-
nized pain immediately after tile cordotom);
which perhaps had been masked by the pain
eliufinated by the procedure. Associated risks
of unilateral cordotomy include loss of sensa-
tion to heat, as well as weakness a n d / o r
impaired bowel a n d b l a d d e r function in
roughly 10% o f patients. Side effects are
increased following bilateral cordotom);
including the risk of sleep-induced apnea.
Patients who have intractable diffuse pain
due to bone metastases are candidates for
another neuroablative procedure, hypophysec-
tom): In its simplest form, destruction of the
pituitary is accomplished by injection of alco-
hol iiIJ,o the sella turcica under radiographic
control. Originally used as an anti-tumor treat-
m e n t for h o r m o n a l l y - r e s p o n s i v e tumors,
hypophysectomy has been noted to relieve pain
also in patients with malignancies unrespon-
Vol. 2 No. 2 Spring 1987 Nonpharmacologic Management $27
F__-YA.

sire to hormone manipulation. A success rate 70% o f the p h y s i c i a n s r o u t i n e l y u s e d

of 35% to 80% has been reported. This proce- radiotherapy for pain control. Approximately
dure is most appropriate for patients with a 45% also used psychoactive agents as part of
short life expectanc); since many will need care- pain therap): Comfort techniques, as provided
ful medical management until death. Again, as by nursing services, were used by 38%, a n d a
with all neurodestructive procedures for con- similar proportion used physical therapy and
trol of cancer pain, controlled studies have not counseling techniques. Twenty percent or less,
been performed. however, used TENS, neurosurgery, nerve
As discussed earlier, neuroaugmentative pro- blocks, or cognitive relaxation therapy. It is
cedures such as TENS or acupuncture are often clear that more adequate demonstrations of
used as adjuvant therapy with analgesics. efficacy through carefully controlled studies
Neuroaugmenation can also be accomplished and improved education of practitioners are
via an invasive procedure. For example, dorsal needed to enhance the appropriate use of the
column stimulation has been advocated for nondrug therapies for cancer pain.
cancer patients who have diffuse pain, with
relief reported for approximately 50% of the
patients. Tire procedure has been primarily
Pain Asses~nent Problems
used to treat patients with chronic stable pain Finall); it must be emphasized that the
and lumbosacral involvement. A few compre- sophisticated use of nonpharmacological tech-
hensive cancer centers have used stimulation of niques is d e p e n d e n t u p o n proper clinical
deep brain structures (such as the periaqueduc- assessment of pain. Both patient and physician
tal gray region), by implanted electrodes to approach the treatment setting with certain
obtain pain relief. These techniques are biases that may be barriers to good communi-
unproven and should be employed only by cation about pain. The patient may be reluc-
practitioners skilled in tire management of can- tant to complain of pain or to indicate when
cer pain. pain therapy is no longer working. Many want
to be regarded as good patients~and believe that
The Problem of Availability good patients do not complain. Some patients
fear that complaining about pain will distract
Major problems in the use of the nonphar- the physician's attention away from curing tile
macologic techniques are availability and phy- disease. Patients may also reject narcotic medi-
sician acceptance. We asked 86 Wisconsin phy- cation because they associate its use with termi-
sicians who treat cancer patients how often nal illness or fear of drug addiction or drug-
they had referred patients for nonanalgesic related side effects.
management of cancer pain (Table 4). Nearly Similarly physicians may not ask about pain
or give the patients permission to report unre-
Table 4 lieved pain. Some assume that tile analgesics
Percent Using Non-Analgesic Treatments always c o n t i n u e to work and ignore the
for Cancer Pain dynamic and progressive nature of pain pathol-
9 86 Wisconsin Physicians 9
ogy and cancer. Many believe that reports of
analgesic failure are related to depression or
Radiotherapy 67.9
Sedative hypnotics anxiety about the disease rather than a true
45.2
Antidepressants 42.0 change in pain. Finally, a smaller number worry
Antianxiety agents 40.2 unduly about opiate addiction or the manage-
Comfort techniques 38.8 tfient of increasing opiate tolerance.
Ph'ysical therapy 37.8 Barriers to communication about pain can
Counseling 35.7
Steroids be minimized through the development of a
32.5
Orthopedic surgery 30.9 standard format for evaluating and monitoring
Debulking procedures 26.6 pain. Ear patient needs to be asked standar-
Occupational therapy 26.5 dized questions which are repeated at each clin-
Trigger point injections 24.7 ical contact. Pain questionnaires or pain mea-
TENS 20.0
Neurosurgery s u r e m e n t scales, therefore, present many
14.5
Nerve blocks 14.3 advantages. A variety of pain measurement
BFB relaxation 9.5
$28 Vol. 2 No. 2 Spring 1987
questionnaires exist, including word descriptor
scales, visual analog scales, and n u m b e r scales.
Obviousl); cancer pain is multi-dimensional in
its impact on the patient, and the degree to
which pain influences the patient's life must
also be assessed. T h e comprehensive assess-
m e n t is especially helpful in d e t e r m i n i n g the
a p p r o p r i a t e nonpharrnacologic treatment for
the patient.
Cleeland Journal of Pain and Symptom Management
SuggestedReadings
Bernstein DA, Borkovec TD. Progressive relaxation
training: a manual for the helping profes~inn~
Champaign, IL: Research Press, 1973.
Cleeland CS, Rotondi A, Brechner T, et al. A model
for the treatment of cancer pain. J Pain Sympt
Manag 1986;1:209-15.
Cleeland CS, Tearnan BH. Behavioral control of
cancer pain. In: Holzman AD, Turk DC, eds. Pain
Management. New York: Pergamon, 1986.
Foley KM. The treatment of cancer pain. N EngJ
Med 1985;313:84.