Mind-Body Treatments for the Pain-Fatigue-Sleep Disturbance Symptom Cluster in Persons with Cancer

ContextCo-occurring pain, fatigue, and sleep disturbance comprise a common symptom cluster in patients with cancer. Treatment approaches that target the cluster of symptoms rather than just a single symptom need to be identified and tested.ObjectivesTo synthesize evidence regarding mind-body interventions that have shown efficacy in treating two or more symptoms in the pain-fatigue-sleep disturbance cancer symptom cluster.MethodsA literature search was conducted using CINAHL, Medline, and PsychInfo databases through March 2009. Studies were categorized based on the type of mind-body intervention (relaxation, imagery/hypnosis, cognitive-behavioral therapy/coping skills training [CBT/CST], meditation, music, and virtual reality), and a preliminary review was conducted with respect to efficacy for pain, fatigue, and sleep disturbance. Mind-body interventions were selected for review if there was evidence of efficacy for at least two of the three symptoms. Forty-three studies addressing five types of mind-body interventions met criteria and are summarized in this review.ResultsImagery/hypnosis and CBT/CST interventions have produced improvement in all the three cancer-related symptoms individually: pain, fatigue, and sleep disturbance. Relaxation has resulted in improvements in pain and sleep disturbance. Meditation interventions have demonstrated beneficial effects on fatigue and sleep disturbance. Music interventions have demonstrated efficacy for pain and fatigue. No trials were found that tested the mind-body interventions specifically for the pain-fatigue-sleep disturbance symptom cluster.ConclusionEfficacy studies are needed to test the impact of relaxation, imagery/hypnosis, CBT/CST, meditation, and music interventions in persons with cancer experiencing concurrent pain, fatigue, and sleep disturbance. These mind-body interventions could help patients manage all the symptoms in the cluster with a single treatment strategy.     

The Effectiveness of an Online Mind-Body Intervention for Older Adults With Chronic Pain

The Self-care Pain Management Project assessed the feasibility and efficacy of delivering online mind-body self-care techniques to 78 adults aged 55 and older with chronic pain. To assess feasibility, the study monitored use of the intervention and documented participant satisfaction. A randomized trial with intervention (n = 41) and waiting list comparison groups (n = 37) was used to assess changes in pain intensity, limitations due to pain, pain self-efficacy, depression, anxiety, and awareness of responses to pain from baseline to follow-up at 6 weeks. There were statistically significant results for between-group difference in awareness of responses to pain, improvements in pain intensity and pain interference for both groups, and increases in confidence with using nonmedical self-care techniques to manage pain for the intervention group. Reductions in mean pain scores reported by the intervention group at log on and log off also suggest that the intervention may have an immediate impact on reducing pain. Findings document the feasibility of a relatively short-term, online mind-body pain management intervention that can have benefits for participants. The characteristics of those who volunteered for an online self-care pain management intervention also have implications for identifying target populations for such interventions.PerspectiveThis article documents the outcomes of an Internet-based self-care pain management intervention that focused on mind-body exercises. The study suggests that the Internet can be an efficient mode for delivering self-care education to older adults with chronic pain and has potential benefits that complement clinical care.     

Mind-Body Exercise Performed by Physical Therapists for Reducing Pain and Disability in Low Back Pain: A Systematic Review With Meta-analysis

ObjectiveTo assess the effectiveness of mind-body (MB) exercise interventions provided by physical therapists for reducing pain and disability in people with low back pain (LBP).Data SourcesMEDLINE, Embase, CINAHL, and the Cochrane Library were searched for articles published in English between December 2010 and June 2020.Study SelectionRandomized controlled trials evaluating the effects of Pilates, yoga, and tai chi interventions performed by physical therapists on pain or disability outcomes in adults with musculoskeletal LBP were included.Data ExtractionData were extracted by 2 independent reviewers. Quality of evidence and risk of bias were assessed using the Grading of Recommendations Assessment, Development, and Evaluation framework and Cochrane risk of bias tools, respectively.Data Synthesis21,230 exercise trials were identified; 161 progressed to full-text review. Eight trials, 7 reporting on Pilates and 1 reporting on yoga, were included. Short-term outcomes for pain (SMD: -0.93; 95% confidence interval [CI]: -1.65 to -0.021) and disability (SMD: -0.74 95% CI: -1.36 to -0.012) indicated MB exercise was more effective than control intervention. Tests for subgroup differences between studies with exercise vs non-exercise control groups revealed a moderating effect on short-term outcomes where larger effects were observed in studies with non-exercise comparators. Long-term outcomes for pain (SMD: -0.60; 95% CI:-1.43 to 0.23) and disability (SMD: -1.05; 95% CI:-3.51 to 1.41) suggested that MB exercise is not more effective than control interventions for pain or disability. Quality of the evidence ranged from very low to low.ConclusionsPhysical therapist-delivered MB exercise interventions, which overwhelmingly consisted of Pilates, were more effective than control in the short and long-term for pain and in the short-term for disability, with differences in the short-term effects lessened when compared with an active intervention. Pilates interventions delivered by physical therapists represent a viable tool for the clinical management of chronic LBP.     

Mind-body therapies in traditional Chinese medicine for Neuropathic Pain: A Systematic Review of Randomized Controlled Trials

ObjectivesTo evaluate the effectiveness and safety of traditional Chinese medicine (TCM) mind-body therapies in patients with neuropathic pain. Design: This systematic review was undertaken according to the PRISMA 2020 statement.Data sourcesWe searched randomized controlled trials (RCTs) in seven English databases and four Chinese databases up to March 2022.Review/Analysis methodsThe Cochrane Risk of Bias 2 was used for the quality assessment, and the mean difference with a 95% confidence interval for data pooling. The review was registered in the INPLASY (INPLASY202240016).ResultsTwenty-three RCTs were identified, including 1,693 patients with lumbar herniated discs (LHD), cervical spondylotic radiculopathy (CSR), sympathetic cervical spondylosis (SCS), trigeminal neuralgia, and central poststroke pain. Pooled results showed that for LHD, TCM mind-body therapy used alone (MD: -0.57, [-0.77, -0.36], P＜0.01, week 8) or combined with physiotherapy (MD: -1.02, [-1.12, -0.91], P＜0.01, week 4) showed advantages over physiotherapy alone on pain relief. However, there was no statistical difference on physical function. For CSR, TCM mind-body movement combined with physiotherapy had better effect than physiotherapy alone on pain relief (MD: -1.15, [-1.37, -0.94], P＜0.01, week 4). Six trials reported safety. Nausea, dizziness, fatigue, and pain at the acupuncture point were observed.ConclusionsLow-quality evidence showed that TCM mind-body therapies might reduce pain intensity and improve physical function when used as an adjuvant therapy or monotherapy. There is a need to conduct high-quality trials to confirm the effectiveness and safety of TCM mind-body therapies for neuropathic pain.     

Mechanisms of chronic pain – key considerations for appropriate physical therapy management

Abstract

In last decades, knowledge of nociceptive pain mechanisms has expanded rapidly. The use of quantitative sensory testing has provided evidence that peripheral and central sensitization mechanisms play a relevant role in localized and widespread chronic pain syndromes. In fact, almost any patient suffering with a chronic pain condition will demonstrate impairments in the central nervous system. In addition, it is accepted that pain is associated with different types of trigger factors including social, physiological, and psychological. This rational has provoked a change in the understanding of potential mechanisms of manual therapies, changing from a biomechanical/medical viewpoint, to a neurophysiological/nociceptive viewpoint. Therefore, interventions for patients with chronic pain should be applied based on current knowledge of nociceptive mechanisms since determining potential drivers of the sensitization process is critical for effective management. The current paper reviews mechanisms of chronic pain from a clinical and neurophysiological point of view and summarizes key messages for clinicians for proper management of individuals with chronic pain.     

Ageing well with chronic musculoskeletal pain: protocol for a systematic review of non-pharmacological interventions aimed at reducing pain in an ageing population

Background: Chronic musculoskeletal pain in the elderly is highly prevalent, with osteoarthritis, low back pain, neck pain and other musculoskeletal disorders as the leading contributors to pain chronicity and disability. Previous reviews identifying effective components of non-pharmacological interventions for treating chronic pain have either few studies or the included studies examine outcome over a limited time span. This systematic review will investigate the effectiveness and components of interventions associated with management of chronic musculoskeletal pain in older adults (≥65 years).

Methods/Design: This systematic review will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance. Randomised controlled trials of non-pharmacological interventions aimed at reducing pain in older adults with chronic musculoskeletal pain will be included. Articles will be identified through a comprehensive search of the following databases: Ovid MEDLINE, Embase, CINAHL, AMED, Scopus, Web of Science and PEDro. Two review authors will independently screen articles retrieved from the search for eligibility, and extract relevant data on methodological issues. A narrative synthesis will be completed if there are insufficient data for a meta-analysis. The narrative synthesis will summarise the current state of knowledge, interventions, study designs and robustness of evidence.

Discussion: Findings of the study will inform support programs and interventions to assist people aging with pain, carers and other supporters and practitioners.

Systematic review registration: PROSPERO 2017:CRD42017074173.     

Pain and Palliative Care Pharmacotherapy Literature Summaries and Analyses

ABSTRACT

Timely and important studies are reviewed and commentaries provided by leading palliative care clinicians. Symptoms, interventions, and treatment-related adverse events addressed in this issue are effective management of cancer pain; validity of multiple self-reported pain assessment scales in medically ill populations; sleep duration and mortality in older adults; depression and survival in metastatic breast cancer patients; safety and effectiveness of tanezumab for osteoarthritis pain of the knee; and plotting the functional trajectory of certain patients with end-stage renal disease.     

Critical Summaries of Innovations in Palliative Care Pharmacotherapy

ABSTRACT

Timely and important studies are reviewed and commentaries provided by leading palliative care clinicians. Symptoms, interventions, and treatment-related adverse events addressed in this issue are: the effect of sorafenib on sarcopenia; defining, classifying, and assessing cancer breakthrough pain; treatment of opioid-dependent human immunodeficiency virus (HIV) patients (clinic-based versus referred treatment); the predictors and course of depression in metastatic cancer patients; and the effectiveness of treatment agreements and urine analysis for reducing opioid misuse in outpatients with chronic noncancer pain.     

A Healthcare Improvement Initiative to Increase Multidisciplinary Pain Management Referrals for Youth with Sickle Cell Disease

BackgroundChronic pain is a complex integration of biological, psychological, and social variables. Multidisciplinary pain management experts design interventions that treat the multidimensional experience. Children and adolescents with sickle cell disease (SCD) are at risk for chronic pain. Increased risk is associated with multiple characteristics including sickle cell genotype, age, gender, frequency of hospitalization, duration of hospitalization, and certain comorbid diagnoses. Referral to pain management professionals for this population is often delayed.AimsTo increase multidisciplinary pain management referrals for youth with SCD identified to be at risk for chronic pain.DesignImplementation research.SettingOne pediatric, academic medical facility serving as a regional sickle cell treatment center in the Midwest.ParticipantsChildren greater than 2 years of age and less than 21 years of age with laboratory confirmed SCD.MethodsImplementation of an evidence-based screening tool using the consolidated framework for implementation research (CFIR) to guide project planning, design, and evaluation. The CFIR model was paired with the Plan-Do-Study-Act (PDSA) quality improvement methodology to operationalize workflow and sustain project aims.Results and ConclusionsEighty-four percent of all eligible patients were screened during their routine sickle cell appointments resulting in a 110% increase in multidisciplinary pain management referrals. Future interventions and PDSA cycles are targeted at improving attendance at scheduled appointments, reducing hospitalizations, decreasing 30-day readmissions, and shortening length of stay.     

Toward a Theoretical Model for Mindfulness-Based Pain Management

Mindfulness, as both a process and a practice, has received substantial research attention across a range of health conditions, including chronic pain. Previously proposed mechanisms underlying the potential health-related benefits of mindfulness and mindfulness-based interventions (MBIs) are based on a strong theoretical background. However, to date, an empirically grounded, integrated theoretical model of the mechanisms of MBIs within the context of chronic pain has yet to be proposed. This is a surprising gap in the literature given the exponential growth of studies reporting on the benefits of MBIs for heterogeneous chronic pain conditions. Moreover, given the importance of determining how, and for whom, psychological interventions for pain management are effective, it is imperative that this gap in the literature be addressed. The overarching aim of the current theoretical paper was to propose an initial integrated, theoretically driven, and empirically based model of the mechanisms of MBIs for chronic pain management. Theoretical and research implications of the model are discussed. The theoretical considerations proposed herein can be used to help organize and guide future research that will identify the mechanisms underlying the benefits of mindfulness-based treatments, and perhaps psychosocial treatments more broadly, for chronic pain management.PerspectiveThis focus article presents an initial framework for an empirically based, theoretical model of the mechanisms of MBIs for chronic pain management. Implications of the framework for refining theory and for future research are addressed.     

Effectiveness of knowledge translation interventions to improve cancer pain management

ContextCancer pain is prevalent, yet patients do not receive best care despite widely available evidence. Although national cancer control policies call for education, effectiveness of such programs is unclear and best practices are not well defined.ObjectivesTo examine existing evidence on whether knowledge translation (KT) interventions targeting health care providers, patients, and caregivers improve cancer pain outcomes.MethodsA systematic review and meta-analysis were undertaken to evaluate primary studies that examined effects of KT interventions on providers and patients.ResultsTwenty-six studies met the inclusion criteria. Five studies reported interventions targeting health care providers, four focused on patients or their families, one study examined patients and their significant others, and 16 studies examined patients only. Seven quantitative comparisons measured the statistical effects of interventions. A significant difference favoring the treatment group in least pain intensity (95% confidence interval [CI]: 0.44, 1.42) and in usual pain/average pain (95% CI: 0.13, 0.74) was observed. No other statistical differences were observed. However, most studies were assessed as having high risk of bias and failed to report sufficient information about the intervention dose, quality of educational material, fidelity, and other key factors required to evaluate effectiveness of intervention design.ConclusionTrials that used a higher dose of KT intervention (characterized by extensive follow-up, comprehensive educational program, and higher resource allocation) were significantly more likely to have positive results than trials that did not use this approach. Further attention to methodological issues to improve educational interventions and research to clarify factors that lead to better pain control are urgently needed.     

Protocol for the MATCH study (Mindfulness and Tai Chi for cancer health): A preference-based multi-site randomized comparative effectiveness trial (CET) of Mindfulness-Based Cancer Recovery (MBCR) vs. Tai Chi/Qigong (TCQ) for cancer survivors

PurposeA growing number of cancer survivors suffer high levels of distress, depression and stress, as well as sleep disturbance, pain and fatigue. Two different mind-body interventions helpful for treating these problems are Mindfulness-Based Cancer Recovery (MBCR) and Tai Chi/Qigong (TCQ). However, while both interventions show efficacy compared to usual care, they have never been evaluated in the same study or directly compared. This study will be the first to incorporate innovative design features including patient choice while evaluating two interventions to treat distressed cancer survivors. It will also allow for secondary analyses of which program best targets specific symptoms in particular groups of survivors, based on preferences and baseline characteristics.Methods and significanceThe design is a preference-based multi-site randomized comparative effectiveness trial. Participants (N = 600) with a preference for either MBCR or TCQ will receive their preferred intervention; while those without a preference will be randomized into either intervention. Further, within the preference and non-preference groups, participants will be randomized into immediate intervention or wait-list control. Total mood disturbance on the Profile of mood states (POMS) post-intervention is the primary outcome. Other measures taken pre- and post-intervention and at 6-month follow-up include quality of life, psychological functioning, cancer-related symptoms and physical functioning. Exploratory analyses investigate biomarkers (cortisol, cytokines, blood pressure/Heart Rate Variability, telomere length, gene expression), which may uncover potentially important effects on key biological regulatory and antineoplastic functions. Health economic measures will determine potential savings to the health system.     

Patient Patterns and Perspectives on Using Opioid Regimens for Chronic Cancer Pain

ContextWith increasing attention to the undertreatment of cancer pain in parallel with concerns about opioid misuse, little is known about how patients with advanced cancer adhere to opioid regimens for chronic cancer pain.ObjectivesWe explored patient approaches to managing chronic cancer pain with long-acting opioids.MethodsIn a multimethods study at an academic medical center, adult patients with chronic cancer pain (n = 17) used electronic pill caps to record adherence to prescribed long-acting opioid regimens. After eight weeks, patients viewed their adherence records and completed a semistructured interview about their opioid use. With a framework approach, we coded interview data (Kappa >0.95) and identified themes in how patients perceived and used opioids to manage cancer pain.ResultsPatients (59% female; 94% non-Hispanic white; median age = 65 years) felt grateful about pain benefit from opioids yet concerned about opioid side effects and addiction/tolerance. Main reasons for nonadherence included both intentional decisions (e.g., skipping doses) and unintentional barriers (e.g., missing doses due to inconsistent sleep schedules). Overall, patients set their own opioid adherence goals and developed routines to achieve them. Residual pain varied and was not consistently linked with opioid adherence.ConclusionPatients commonly felt conflicted about using prescribed long-acting opioids to manage cancer pain due to concurrent perceptions of their risks and benefits, and they set their own parameters for opioid-taking practices. Intentional and unintentional deviations from prescribed opioid schedules highlight the need to enhance adherence communication, education, and counseling, to optimize the use of long-acting opioids as a component of cancer pain management.     

The Assessment and Management of Acute and Chronic Cancer Pain Syndromes

ObjectivesTo provide an overview of the most common acute and chronic cancer-related pain syndromes along with their assessment and management.Data SourcesData sources include peer-reviewed articles, textbooks, and the internet.ConclusionVarious pain syndromes occur throughout the cancer trajectory. Assessing and managing these syndromes, up to years’ after treatment, can assure that comfort is provided from diagnosis throughout survivorship.Implications for Nursing PracticeOncology nurses are essential in assessing and managing acute and chronic cancer-related pain syndromes. Nurses have both a professional and an ethical responsibility to understand these syndromes and to provide optimal pain management.     

Optimizing delivery of a behavioral pain intervention in cancer patients using a sequential multiple assignment randomized trial SMART

Background/aimsPain is common in cancer patients and results in lower quality of life, depression, poor physical functioning, financial difficulty, and decreased survival time. Behavioral pain interventions are effective and nonpharmacologic. Traditional randomized controlled trials (RCT) test interventions of fixed time and dose, which poorly represent successive treatment decisions in clinical practice. We utilize a novel approach to conduct a RCT, the sequential multiple assignment randomized trial (SMART) design, to provide comparative evidence of: 1) response to differing initial doses of a pain coping skills training (PCST) intervention and 2) intervention dose sequences adjusted based on patient response. We also examine: 3) participant characteristics moderating intervention responses and 4) cost-effectiveness and practicality.Methods/designBreast cancer patients (N = 327) having pain (ratings ≥ 5) are recruited and randomly assigned to: 1) PCST-Full or 2) PCST-Brief. PCST-Full consists of 5 PCST sessions. PCST-Brief consists of one 60-min PCST session. Five weeks post-randomization, participants re-rate their pain and are re-randomized, based on intervention response, to receive additional PCST sessions, maintenance calls, or no further intervention. Participants complete measures of pain intensity, interference and catastrophizing.ConclusionsNovel RCT designs may provide information that can be used to optimize behavioral pain interventions to be adaptive, better meet patients' needs, reduce barriers, and match with clinical practice. This is one of the first trials to use a novel design to evaluate symptom management in cancer patients and in chronic illness; if successful, it could serve as a model for future work with a wide range of chronic illnesses.     

Virtual Reality Technology for Pain and Anxiety Management among Patients with Cancer: A Systematic Review

BackgroundPain and anxiety have negative effects on the treatment of patients with cancer. Virtual reality technology is a form of distraction which is still unclear in its methodological quality in reducing pain and anxiety.AimsTo summarize and evaluate the methodological quality of primary studies on the virtual reality (VR) technology for the management of pain and anxiety among patients with cancer, and to analyze the effectiveness of VR in the reviewed studies.DesignThis review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.SettingMultiple databases from their inception through November 2018.MethodsA comprehensive search was performed to identify studies that evaluated the effectiveness of VR in managing pain and anxiety among patients with cancer. The methodological quality of included studies was appraised using the modified Downs and Black checklist.ResultsThirteen studies published between 1999 and 2018 were eligible for inclusion. These included studies were classified as being of good or fair quality. The consensus across the included studies was that compared with standard care, VR plus standard care were more effective in reducing pain and anxiety especially in children and adolescent patients who were undergoing painful procedures, and in adult and elderly patients who were undergoing anti-cancer treatments and during their hospitalization.ConclusionAlthough more high- methodological quality studies are needed to determine whether VR technology is effective in controlling symptoms in patients with cancer, the results of this review suggested that VR intervention may be beneficial for the management of pain and anxiety in patients with cancer. Therefore, clinicians may consider VR technology as an adjunctive intervention for pain and anxiety management.     

Do quality of life,anxiety, depression and acceptance improve after interdisciplinary pain rehabilitation? A multicentre matched control study of acceptance and commitment therapy-based versus cognitive–behavioural therapy-based programmes

ObjectiveInterdisciplinary pain rehabilitation (IPR) usually employs a cognitive–behavioural therapeutic (CBT) approach. However, there is growing support for chronic pain treatments based on acceptance and commitment therapy (ACT). Most studies of ACT and CBT for chronic pain have evaluated their effects after psychological interventions, not after IPR. We compared the results of an ACT-based IPR programme with two CBT-based IPR programmes.MethodsWe used a retrospective multicentre pretest–posttest design with matched patient groups at three centres. Data were collected from the Swedish Quality Registry for Pain Rehabilitation before and after IPR participation. Participants completed the EQ-5D health-related quality of life questionnaire, the Chronic Pain Acceptance Questionnaire, (CPAQ) and the Hospital Anxiety and Depression Scale (HADS). Analyses were performed to compare the effects of the different interventions.ResultsNeither EQ-5D nor HADS depression scores were affected by the psychological approach used. The score changes on both CPAQ subscales (activity engagement and pain willingness) indicated significant improvements between admission and discharge at all centres.ConclusionsThese findings indicate the effectiveness of using psychological approaches to manage chronic pain. Both CBT and ACT had a beneficial effect on most of the assessed health-related parameters.