Incorporating Alternative Therapies into Pain Management (2001)

Martha Heller was 56 years old when she was diagnosed with breast cancer. She followed the traditional approach to treatment: a mastectomy, chemotherapy, and radiation therapy. Toward the end of the radiation treatment regimen, she was diagnosed with lung cancer. Again, she followed traditional treatment protocols. Although she was not diagnosed with bone metastasis, her back pain became excruciating. With nothing to lose, she decided to try acupuncture. After two sessions, however, she still felt uncomfortable with the needles and took a massage therapy session instead. Massage comforted her somewhat, but not enough to satisfactorily diminish the pain. She then tried Reiki therapy and myofascial release, and experienced significant pain relief. As a result, her analgesic use also decreased. She was able to take walks again, an activity that brought her joy, and her quality of life was thereby enhanced despite the diagnoses. Also, finding the appropriate complementary care gave her a sense of control over the treatment. Pain, “a subjective, unpleasant sensory and emotional experience associated with actual or potential tissue damage,”1 is the most feared symptom associated with cancer. 2 And, to an extent, this fear is justifiable, as chronic pain is experienced by 30% to 50% of patients undergoing cancer treatment. In the patient with advanced cancer, there is a 90% chance of experiencing pain at the end of life. 3 In August of 1999, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) announced new standards for the assessment and management of pain in JCAHO-accredited hospitals. The standards acknowledge the patient’s right to appropriate assessment and management of pain, as well as insist on staff competency in these areas. 4 Among the responsibilities of the medical professional that are thus entailed are the assessment of patient descriptions of pain and its intensity, the documentation of assessment results, the establishment of policies and procedures for ordering analgesia, and the education of patients and their families on effective pain management. 5 Patients with cancer often hesitate to inform the physician when pain worsens for fear that it is indicative of disease progression. They may also fear addiction to pain medication and have concerns about the side effects of pain management. Sometimes, limited clinical knowledge on how to manage pain, or a system that prevents optimal analgesic dosing, may also contribute to the under-treatment of pain. In 1994, the Agency for Health Care Policy and Research reported, “Cancer pain control remains a significant problem even though it can be effectively managed in up to 90% of patients.”2 For these reasons, pain is often neglected in the hospital. Patients with cancer are frustrated with depersonalized, conventional medicine, and feel discontent with the side effects of treatment. As a result, there is increasing interest in complementary and alternative medicine. At the same time, the public has a greater understanding of the mind-body-spirit connection, and there is a growing awareness of successful health care practices of other cultures. 6 In 1998, a review of 21 studies of adult cancer patients’ use of complementary therapy found that the percentage of patients engaged in some form of it ranged from 7% to 64%, with an average of 31.4% across the studies. 7 David Eisbenberg and colleagues discovered that Americans spent, out-of-pocket, $14.6 billion in 1990 and $21.2 billion in 1997 on alternative care. 8 Despite limited knowledge on the efficacy of alternative and complementary therapies, they are clearly gaining popularity. The public is taking control of pain management, and, in doing so discovering the benefits of alternative and complementary care. Nurses will not only be required to fulfill the JCAHO standards but, in keeping pace with the public, they will be obliged to familiarize themselves with alternative and complementary pain management, including benefits and risks. Nurses may also be expected to provide referrals to local credentialed alternative health care providers. Whether to better communicate with a patient who is receiving acupuncture for oncologic pain relief, or to suggest it as an option, nurses will want to be conversant in alternative pain remedies. And to enhance their own practices, nurses should be aware of the complementary therapies that can be learned within the scope of their work. 6 ALTERNATIVE VS. COMPLEMENTARY The terms “alternative” and “complementary” are often used interchangeably, leading to confusion and miscommunication, as they are quite different. Alternative therapy supplants conventional treatment, whereas complementary therapy complements it. 9 In this article, the term “complementary” will be used, as the methods are suggested as means of enhancing—or complementing—conventional medical practices. More and more medical schools are offering didactic and experiential courses on complementary therapies or are devoting part of required classes to the subject. (There are at least 75 medical schools in the United States offering elective courses on the subject.) Many medical centers and cancer programs have started research and clinical service programs in alternative and complementary therapies. 10 In 1999, the National Institutes of Health established The National Center for Complementary and Alternative Medicine (NCCAM), formerly known as the Office of Alternative Medicine (OAM). The NCCAM has defined seven categories of alternative and complementary therapy: herbal medicine; diet, nutrition and lifestyle changes (macrobiotic diet); mind-body medicine (meditation, biofeedback); manual healing methods (massage, therapeutic touch, Reiki); bioelectromagnetic therapies (magnets); and pharmacologic and biologic therapies. 10,11 The following is a discussion of several complementary therapies selected from the NIH categories. As in any medical procedure, an alternative practitioner will perform a thorough assessment before administering treatment. Based on this information, the practitioner will proceed with therapy only if it is deemed appropriate and beneficial. DRAWING POWER FROM COMPASSION Certain healing therapies deal either with the energy fields, called biofields, that surround and penetrate the body, or with other sources (electromagnetic fields). Biofield therapy manipulates energy by applying pressure to, or through, these fields. Therapeutic touch and Reiki therapy are two examples of this approach. 11 Therapeutic touch, developed in 1972 by Dolores Krieger, PhD, RN, a professor of nursing at New York University, and Dora Kunz, a metaphysician, is an energy-healing system that many medical professionals and hospitals have been incorporating into pain management practice. In Krieger’s words, “Therapeutic touch is a primitive, simple (that is, direct), and elegant use of human energies in the service of a humane act. It is from compassion that it draws its power.”12 By its nature, it is a complementary therapy very accessible to nursing practice. Endorsed by the American Holistic Nurses Association since 1990, 12 therapeutic touch, ironically, does not involve the actual touching of the patient (although hands-on touching may be necessary when treating a fracture). Typically, a session, which lasts approximately 25 minutes, begins with the practitioner “centering” herself. In doing this, she quiets the mind, clearing it of thoughts and anxieties in order to have unimpeded access to full compassion. 12 Once centered, the practitioner holds her hands approximately four inches above the patient and, using slow, rhythmic motions, determines where the patient’s “blocks” are within the energy field. (Therapeutic touch is rooted in the belief that disruptions in a person’s surrounding energy fields are manifested as disease and illness.) 12 The practitioner then works to relieve those blocks by “rebalancing” the patient’s energy with her hand movements. 12 During this time, the patient remains relaxed and comfortable, sometimes experiencing a release of suppressed emotions or a deep sense of well-being. Patients interviewed for this article reported that they felt calmer and needed less analgesia after receiving this therapy. Instruction in therapeutic touch is readily available. Classes generally range from a one-day session in basic techniques to two-or three-day sessions for the advanced practitioner. TAUGHT TO TOUCH Reiki therapy is an ancient Tibetan therapy involving the transfer of energy from the practitioner to the patient, and like therapeutic touch, is a manual healing method. However, the Reiki therapist may actually touch the patient in order to transfer energy. Placing her hands on or near the parts of the patient’s body where the pain is most intense, the practitioner uses energy to bring balance and promote healing. The practitioner acts as a conduit: energy comes through and from her, follows the patient’s meridians, and goes to the source of his pain. (“Meridian” is the traditional Chinese term for each of the 14 pathways in the body through which vital energy flows. 13) This energy strengthens the body’s natural ability to heal. Generally used in conjunction with conventional Western therapeutic practices such as radiation treatment and analgesics, Reiki therapy relieves anxiety and stress and, as a result, medication use is generally decreased. 14 A Reiki therapist can teach the patient how to perform the therapy on himself, to minimize out-of-pocket expense. The cost of a Reiki session ranges from $45 to $70. At this time, most health insurance does not cover the cost of Reiki treatment. Reiki therapy is not recommended for patients with psychiatric disorders, such as psychosis or dissociation, or for those with a shunt or seizure disorder, as it may exacerbate these conditions. AN ANCIENT ART OF HEALING Acupuncture originated in China more than 3,500 years ago. Although brought to the United States in the mid-1800s, it began to gain general acceptance only in the early 1970s. Today it is one of the most commonly used forms of alternative or complementary therapy. 15 In 1998, there were approximately 9,000 to 10,000 acupuncturists providing nine to 12 million treatments. 16 Acupuncture is a neurostimulatory therapy that treats pain by the insertion of microfilaments (needles) into the skin, with the objective of improving energy flow that restores health. For the patient who is wary of needles, there are alternative forms of acupuncture: color puncture (the application of light pressure with crystals); cupping (with glass globes that create suction on the skin); electrostimulation (with electrodes placed on the area of pain); and heat puncture (the warm end of filament touching the skin). In 1996, the Food and Drug Administration determined that the needles used in acupuncture are safe and effective medical devices. 16 The World Health Organization (WHO) has identified more than 100 different conditions that acupuncture can treat effectively, including headache, back pain, and constipation. 15,16 The Agency for Health Care Policy and Research (AHCPR) has also acknowledged the benefits of acupuncture therapy, but cautions that pain may be symptomatic of disease progression and an accurate diagnosis of its cause in advance of treatment is important. Because of this, its guidelines encourage the patient to keep in communication with his physician. A typical acupuncture treatment lasts approximately 30 to 60 minutes. 16 The patient in chronic pain seeks treatment once a week, on average. With acute pain exacerbation, however, the patient may be treated two or more times weekly until the pain subsides. Acupuncture needles are thin, and the effect of their insertion has been described as a mild tugging sensation. Some patients may need to rest after treatment; others may feel an increase in energy. There is evidence that acupuncture stimulates the release of endorphins, the body’s natural pain-killing hormones, which alters the perception of pain. Furthermore, if a patient continues acupuncture treatment regularly, acute pain episodes occur less frequently. Acupuncture has minimal side effects, including fatigue and bruising. An acupuncturist always performs a patient assessment before treatment to determine whether the patient is fit for this type of therapy. Perhaps because of acupuncture’s acceptance by WHO and AHCPR, physicians are less reluctant to refer patients to its practitioners for complementary treatment. Some insurance companies provide limited coverage of the acupuncture sessions. Training to become an acupuncturist is thorough, although it varies from state to state. The American Academy of Medical Acupuncture recommends a minimum of 220 hours of formal training, after having earned an undergraduate science degree. 16 When seeking an acupuncturist, look for one who is licensed or certified and meets state requirements to practice. In certain states, only MDs or DOs may practice acupuncture; 27 states regulate practice and 22 states require licensure or certification. MORE THAN RELAXATION Massage therapy is one of the most widely accepted and practiced forms of complementary therapy. In the last decade, research has begun to support its many benefits. Although mostly used for musculoskeletal disorders, massage therapy is also particularly useful in controlling pain. Massage therapy alleviates pain by reducing stress and tension, as well as promoting relaxation. 17 There are more than 15 methods of massage therapy, including Swedish massage and shiatsu. 14 Among its many benefits, message therapy reduces muscle tension, improves blood circulation, eases lymph drainage, improves joint mobility, stimulates or smoothes the nervous system, improves skin conditions, eases digestion, reduces swelling, alleviates stress, and, of course, promotes relaxation. A massage therapy session lasts 30 to 60 minutes. Acute episodes of pain may require weekly sessions, whereas a monthly massage is sufficient for maintenance. As massage therapy is widely practiced, the patient will often engage a practitioner without a physician’s recommendation. After a session, the muscles may be sore. The patient may feel as if he had a strenuous physical workout, which can be alleviated by increasing fluid intake and applying warm packs to sore areas. There is often a feeling of relaxation and ease after a session. Although there is limited insurance coverage for massage, the cost of a therapy session by a licensed therapist averages $45 to $70. STRETCHING AND SWAYING Myofascial release is a passive procedure, meaning the movement does not arise from a patient’s voluntary exertion or resistance. It is a low-intensity, long-duration stretch directed toward the soft tissue. The practitioner, generally a physical or massage therapist (depending on state regulations), holds the treatment area for three to five minutes until a release of tension or constriction occurs. While improvement may occur immediately, maintenance treatment may continue for several months. The practitioner first assesses the patient’s structural asymmetry. Then the patient lies on an examination table and the practitioner places his hands on the treatment area. After several minutes the patient begins to feel a rocking or swaying motion caused by the myofascia releasing through the deep stretch. It is virtually painless, although the patient may feel some muscle soreness the next day. As after massage therapy, increased fluid intake and the application of a warm compress will help relieve soreness. Because treatment is administered by a physical therapist, some insurance companies cover the cost. A physician referral or prescription is required for reimbursed treatment. HEALING ATTRACTION Magnet therapy is a bioelectromagnetic application based on the belief that the body has various energy processes that generate magnetic fields, and that there is therapeutic potential in manipulating these fields. Used for centuries in Asia and India to treat and cure ailments, it gained popularity in the United States as early as the 19th century. 19 The magnets should not replace analgesics, but they are effective as a complementary treatment. Magnets should not be used until a physician has identified both the cause of pain and the appropriate treatment. 18 This form of therapy has been used effectively in treating tendonitis, carpal tunnel syndrome, lower back pain, knee pain, muscle spasms, and headaches. Magnets are placed on the body at or near the source of pain. By stimulating a nerve, the magnets depolarize the neuronal cells––meaning that “positively charged ions on the exterior surface of the cell change places with the negatively charged ions on the interior.”18 Although rarely covered by health insurance, this therapy is costs $40 to $200 for tools, depending on the magnet item, is noninvasive, and sometimes effects immediate relief of pain or discomfort. It is suggested that, as a safety precaution, patients with pacemakers or insulin pumps avoid magnetic therapy, as it may interfere with the magnetic properties of these devices. Because it is not known whether magnets affect the fetus, pregnant women should not use them. Finally, patients using transdermal drug delivery systems should not place a magnet close to the patches, as it could increase the drug’s absorption rate. 19 IMPLICATIONS FOR NURSES A patient may have gleaned what he knows about complementary health care through informal conversation, browsing through magazines, and reading newspaper articles. Perhaps he has heard his family or friends speak of the benefits they have received from it. Feeling more comfortable with the idea, the patient explores his options, perhaps seeing various practitioners before finding a form of complementary care that best addresses his needs. In gathering information and trying a complementary approach to alleviate pain, the patient gains a certain control over it 20 —which in itself is beneficial. Because the nurse–patient relationship is based on trust, nurses must be up to date on the various types of complementary approaches patients are using, in order to provide accurate information and to help them make educated decisions. It is equally important that nurses educate patients in an unbiased manner, maintaining respect for their values. A nurse need not become an expert in all forms of complementary care, but she should be well informed in regard to those that are accessible to the patient. It may be a good idea to compile a list of local alternative practitioners to share with patients.