Evidence-Based Practice Corner: Easing Pain without Medications

“Everything is intensified when cure isn’t possible,” explains University of Wisconsin–Madison School of Nursing Professor Kris Kwekkeboom, PhD, RN. “Even small changes are important.”

That understanding drives Kwekkeboom’s research into non-drug interventions to ease pain and other challenging symptoms towards the end of life. Even slight improvements in their quality of life can mean a great deal for people suffering from advanced cancer or other life-limiting illnesses, as well as their loved ones.

Kwekkeboom’s research is inspired by her early clinical experiences. As a young oncology nurse, she saw many patients struggling with significant side effects from hematologic cancers and their treatment regimens.

“It was really frustrating for me,” she remembers. “It was a time when doctors weren’t very comfortable prescribing analgesic medications.” Kwekkeboom and her fellow nurses frequently found themselves, for “eight to twelve hours, repeatedly looking at that person and seeing they’re suffering.”

As she learned more about pain management techniques, Kwekkeboom became interested in non-drug, cognitive-behavioral interventions—because “I didn’t need a physician’s order,” she says. They were approaches “that I and my nurse colleagues could do independently to help patients be more comfortable.”

Around the same time, in the early 1990s, the book Love, Medicine and Miracles introduced the use of guided imagery to a wider audience. Kwekkeboom was enthusiastic, but struggled with the approach of simply using words to call up visualizations vivid enough to be relaxing.

In sessions teaching guided imagery, “We’d all be lying on the floor, trying to imagine ourselves on the beach, or in whatever peaceful, relaxing scene, and I always felt I didn’t get it,” says Kwekkeboom. “There were people around me oohing and aahing, having a fantastic time in their images, and I was struggling to create a picture in my mind of what looked like probably a five year-old’s sketch drawing.”

She realized that this must also be true of patients—some can easily create and focus on a mental image, while others simply can’t.

That’s why, in her research, Kwekkeboom offers twelve different non-drug interventions and allows patients to decide which one or ones might work best for them, such as guided imagery, progressive muscle relaxation or distraction through nature sound recordings. This patient-centered intervention takes into account the range of abilities and preferences for different techniques that Kwekkeboom experienced herself.

Kwekkeboom’s approach is tailored to seriously ill patients in that it is simple and brief. Using an MP3 player, patients practice by listening to a recording of 15 minutes or less, at least once a day.

Her work builds on the growing understanding that the symptoms seriously ill people struggle with—like pain, fatigue and sleep problems—are often linked in what’s called a symptom cluster.

“These are really sick patients,” she says. “They’ve got multiple symptoms. If I can provide a single approach that treats all three symptoms, that is less burdensome for them.”

An additional benefit of non-drug, cognitive-behavioral interventions is that they “get at patients’ underlying fears and their stress.” It’s not unusual for study participants to find that an intervention not only eases their symptoms, but also helps them deal with anxiety around medical tests or family conflicts.

While Kwekkeboom’s research has focused on cancer patients, non-drug interventions have shown promise with different conditions. “Unlike diseases, which have different causes, symptoms often share similar cause,” she explains. The “underlying physiology or underlying psychological reasons [are] why people have symptoms or those symptoms intensify.”

She’s collaborating with UW–Madison School of Nursing Assistant Professor Lisa Bratzke, PhD, RN, ANP-BC, on a study involving heart failure patients. They’re hoping to find non-drug, cognitive-behavioral interventions that ease the common heart failure symptom cluster of pain, sleep disturbance, fatigue and breathing difficulty. Their study will also explore whether heart failure patients’ cognitive function improves, as earlier research suggests meditation and relaxation may increase blood flow to the brain.

In another study, Kwekkeboom is looking at the impact of non-drug interventions on patients’ levels of stress hormones and inflammatory cytokines. She hopes to better understand the physiologic causes of symptom clusters. “If we can get at the mechanism, that will open up a whole world of different, potentially better treatments,” she explains.

While more research is needed on non-drug, cognitive-behavioral interventions in symptom management, the psychosocial benefits are well established. Many health care organizations offer further information on their websites, including UW Hospital, Kaiser Permanente and the NIH’s National Center for Complementary and Integrative Health.

–Diane Farsetta