Learning Objectives
By the end of this section, you will be able to:
- Describe different types of nonpharmacological pain treatment and their effectiveness
- Analyze the nurse’s role in pain management using nonpharmacological methods
- Describe the nurse’s role in educating patients about nonpharmacological pain management therapies
Nonpharmacological interventions can be used with or without pharmacologic interventions. They often provide tremendous benefits to the patient, who can choose from a variety of techniques based on what best fits their needs and goals. Like all treatments, nonpharmacological interventions should be documented in the plan of care and their effectiveness evaluated in terms of their ability to meet the patient’s goals for pain relief.
Nonpharmacological Pain Management
Nonpharmacological pain management techniques may be categorized as complementary or alternative medicine. Although these terms are sometimes used interchangeably, there is a distinct difference. A therapy that is used in combination with pharmacological pain management is called a complementary therapy, whereas one used in place of pharmacological pain management is called an alternative therapy.
Physical Modifications
Physical interventions include techniques such as rest, compression, elevation, and thermotherapy. Slight adjustments to the patient’s environment may also alter the patient’s response to pain. For example, adjusting the temperature in the room—making it warmer or cooler—may cause the patient to feel more comfortable. Other strategies include dimming the lights, reducing loud noises, and closing the patient’s door.
To provide the opportunity for rest, consider clustering care (planning to include care tasks in as few visits as possible) to reduce unnecessary interruptions. Rest is important whether the pain is caused by illness or injury, as it allows the body to focus on healing. As much as possible, patients should avoid moving the injured body part, keeping weight off it, and using assistive devices, such as canes, crutches, splints, braces, or wheelchairs. Nurses can also support an injury by tightly wrapping the area in a compression bandage such as an ACE wrap. When using a compression bandage, the nurse must carefully assess the area to ensure proper blood flow to the extremity.
A treatment called thermotherapy is the application of heat or cold to alter the cutaneous, intra-articular, and core temperatures of soft tissues. Hot and cold therapies are one of the most commonly used nonpharmacological strategies for managing pain. Heat decreases pain by increasing blood flow through vasodilation, which promotes relaxation and alleviates muscle stiffness or chronic pain. Heat may be applied for five to twenty minutes at a time. Heat can be beneficial for chronic or ongoing issues, such as chronic back pain, muscle stiffness, and menstrual cramps. Cold decreases pain by reducing the blood flow through vasoconstriction; it also numbs nerve sensations. Cold should be applied for no longer than twenty minutes at a time. Cold is frequently given first after an injury to decrease inflammation, which will help decrease pain. It can be beneficial for various types of acute injuries, such as sprains and strains. Later heat may be applied to increase circulation, which then helps deliver oxygen and nutrients for healing. Heat and ice should never be directly applied to the skin. The nurse should routinely examine the site to assess for potential skin burns.
A combination of these strategies may be used to control pain for mild to moderate injuries, such as sprains, strains, and bruises. A combination referred to as RICE, stands for rest, ice, compression, and elevation. RICE is most effective when implemented immediately following an injury, and for the twenty-four to forty-eight hours that follow, to decreased inflammation, pain, and risk for further injury. After the first forty-eight hours, the goals of care often shift from reducing inflammation and further injury, to supporting tissue healing and rehabilitation, while managing any residual pain or discomfort. Therefore, the use of RICE may be modified or reduced after the first forty-eight hours to support the patient’s healing and mobility progress.
Mind-Body Therapies
Mind-body therapies take advantage of the fact that although pain begins in the body, it is perceived in the mind. One simple way to keep the patient’s mind off their pain is to distract them, for example, by watching TV, playing games, reading, coloring, dancing, or telling jokes. Research has also shown that virtual reality may ease pain, particularly in pediatric patients (Tas et al., 2022; Teh et al., 2024). This technique allows patients to fully immerse themselves in a computer-generated, 3-D, virtual environment and engage in games and other methods of entertainment. Another approach to mind-body therapy is through cognitive behavioral therapy (CBT) in which individuals are taught how to manage and cope with pain more effectively by changing their negative thought pattern, identifying and reducing stressors that exacerbate pain perception, and focusing on adapting to pain in situations when pain cannot be eliminated.
Relaxation therapies may also be used for pain management. Activities that promote relaxation can be as simple as listening to music, praying, or breathing rhythmically, but more involved techniques are also available. For example, patients may be guided to create positive guided imagery, pleasant images in the mind, such as relaxing on a beach or strolling through a forest; to engage in meditation, the practice of breathing and repeating certain sounds or words, such as “om” or “gratitude,” to put the mind at ease; to practice mindfulness, focusing on the present moment to create awareness of thoughts, feelings, the body, and the environment; to participate in hypnosis, the creation of a trance-like state to enhance awareness of feelings, thoughts, and sensations; or to engage in animal-assisted therapy, using animals to reduce pain, anxiety, and depression.
Movement is also an important consideration for reducing pain stimuli. Stretching and strengthening routines, therapeutic exercise, can help to improve muscle strength and flexibility, reduce joint stiffness, and enhance range of motion. Patients can restore functional ability and quality of life through physical therapy, manipulating joints and soft tissues in a manner that is tailored to the individual’s specific needs. Certain movements can also help to decrease pain and promote relaxation. For example, tai chi is a practice that combines exercise and meditation through slow body movement and controlled breathing, and yoga is the practice of using specific stretches, poses, meditation, and controlled breathing to balance the mind and body (Figure 7.5).
Natural Therapies
Natural products are those found in nature rather than synthesized by humans in a lab. They include herbs, vitamins, and other dietary supplements. All these remedies may add small amounts of necessary nutrients to the body, though they are not regulated by the Food and Drug Administration (FDA) for safety and effectiveness.
The inhalation or dermal application of essential oils—aromatherapy—is another strategy that can be used for nonpharmacological pain management. Essential oils are extracted from flowers, fruits, leaves, or seeds; they capture the smell of the plants from which they are derived. Studies have shown aromatherapy can be used not only to manage pain but also to reduce anxiety, calm stress, boost immunity, and improve sleep quality (Tanvisut et al., 2018; Gong et al., 2020). Essential oils linked to pain relief include lavender, rose, peppermint, eucalyptus, and chamomile.
Link to Learning
The National Institutes of Health has created fact sheets about herbal remedies that identify their potential uses, side effects, cautions for use, and interactions with other drugs.
Certain diets, such as vegan or Mediterranean, have been shown to decrease inflammation in the body (Schieber & Mank, 2023). Research shows that anti-inflammatory diets can be particularly helpful for those with fibromyalgia and chronic pain. Anti-inflammatory diets typically recommend consuming numerous servings of vegetables, limiting dairy, refraining from simple carbohydrates with refined sugar, opting for whole grains, limiting red meat, and choosing lean proteins, such as fish, tofu, and legumes.
Manipulative Practices
Some pain can be relieved by physically working on or manipulating the body. For example, massage involves manipulating soft tissues to relieve tension, promote relaxation, and reduce pain. It may help to relieve lower back, neck, shoulder, cancer, arthritic, headache, and fibromyalgia pain. Due to the risk of injury if not performed correctly, massage should only be performed by trained individuals. It should be used with caution in patients on blood thinners or with wounds, fractures, blood clots, infection, or weakened bones.
Other types of manipulative practices include chiropractic therapy and reflexology. The practice that manipulates the spine, joints, and skeletal system is chiropractic therapy. The type of massage applied to specific pressure points aligned with the body in the hands and feet is called reflexology.
Energy Healing
Energy healing is used to balance the flow of energy within the patient. Although considered an alternative therapy, there is anecdotal evidence to support its effectiveness, along with a growing scientific body of evidence exploring the clinical effectiveness of these therapies. One technique, reiki, entails one person placing their hands lightly on and above another person, with the intention of guiding energy throughout that person’s body. Therapeutic touch also involves gently touching a person’s body in order to affect its energy fields. Magnet therapy utilizes magnets on the body to reduce pain. Though there is limited evidence supporting the use of magnet therapy, it is thought to influence blood flow by attracting or repelling red blood cells, which could improve oxygenation and nutrient delivery and, in turn, promote healing and reduce pain. It is also thought that magnets could have an anti-inflammatory effect by affecting the ion channels in cell membranes and influence the perception of pain by altering the electrical activity in the nervous system.
A popular technique, acupuncture (Figure 7.6) is performed by inserting thin steel needles into the skin to stimulate specific points throughout the body. It is a traditional Chinese medicine that is used to rebalance the body’s energy and prompt the body to release natural chemicals to relieve the body of pain. Acupuncture is commonly used to relieve chronic pain resulting from arthritis; back, neck, knee, and muscle pain; headaches and migraines; menstrual cramps; sports injuries; and nerve discomfort. It is not recommended for those with pacemakers, those taking blood thinners, or those who are pregnant.
Electrical Stimulation
Another type of nonpharmacological pain management is transcutaneous electrical nerve stimulation (TENS) therapy (Figure 7.7), which delivers low-voltage electrical current to reduce pain. TENS therapies block or change the patient’s perception of pain. Electrodes are placed on the body at or near where the relevant nerves are located. The electrodes are connected to a battery-powered device that delivers the electrical current. TENS therapy has been shown to relieve pain associated with osteoarthritis, fibromyalgia, labor pains, and diabetes-related neuropathy (Njogu et al., 2021; Wu et al., 2022). TENS therapy should not be used for those with an implantable device; those who have cancer, epilepsy, deep vein thrombosis, or hemorrhaging; or those who are pregnant.
Effectiveness of Nonpharmacological Pain Treatment
Although some nonpharmacological therapies have been scientifically proven to be effective in managing pain, it is important to note that some of these therapies are based on anecdotal evidence of effectiveness and lack scientific research to support their effectiveness (Vickers et al., 2017; Hilton et al., 2017; Thorn et al., 2011; Daily et al., 2016; Yuan et al., 2015). Plus, each patient’s response to nonpharmacological therapies is unique. Nonpharmacological pain therapies may be extremely beneficial in reducing pain for some patients and ineffective in others. Effectiveness may also vary according to the type of therapy used. For example, one person may find massage useful at reducing back pain but acupuncture to be ineffective.
When formulating a pain management plan, it is important to meet the needs of the individual patient. For some, nonpharmacological therapies alone may manage the pain. Others may require pharmacological therapies or a combination of pharmacological and nonpharmacological. It is important to consider the risks and benefits of trying a nonpharmacological intervention to assess its effectiveness in managing pain versus not trying the therapy. Unless it will negatively affect the patient, it is generally acceptable to try different nonpharmacological therapies to see what works for the individual. Sometimes, this may even mean implementing several nonpharmacological interventions to serve as complementary therapies to each other.
Clinical Judgment Measurement Model
Evaluating Outcomes: Exploring the Use of Nonpharmacological Approaches to Pain Management
The nurse notices an older adult patient grimacing and moaning. Upon recognizing the cues, the nurse completes a comprehensive pain assessment utilizing the PQRSTU mnemonic for pain assessment and determines the patient is experiencing pain (analyze cues). The nurse considers whether to administer pharmacological and/or nonpharmacological therapies (generate solutions). Understanding the risks associated with older adults taking analgesics, the nurse decides to start with nonpharmacological interventions first and repositions the patient (take action). Upon reassessment, the nurse notes the patient is resting comfortably, sleeping, and does not appear to be in pain (evaluating the outcome).
The Nurse’s Role in Nonpharmacological Pain Treatment
The nurse’s role in nonpharmacological pain treatment is to generate ideas about which therapies may be beneficial to the patient, implement the interventions, and then assess the effectiveness of the interventions. The nurse must first assess whether nonpharmacological treatments would be beneficial according to the patient’s condition, as well as assess the patient’s preferences for treatment. Just like treatments utilizing medications, nonpharmacological treatments should be reassessed within a reasonable time frame, and the patient’s response to the intervention should be documented in the medical record. If the patient has not reached their identified pain goal, the nurse may then consider additional therapies to add to the treatment plan, followed by reassessment and documentation of the reassessment.
Collaboration between the provider and the patient is key. The nurse acts as a liaison between the provider and the patient to advocate for the most optimal therapeutic plan for pain control. There may also be times when the nurse must advocate for better pain control. For example, the nurse may need to discuss benefits of nonpharmacological interventions with some patients, whereas other patients may need to consider adding pharmacological interventions as complementary therapy. Although the ultimate treatment decision is up to the patient, collaborative discussions provide the patient with the necessary information to make an informed decision about their plan of care.
Patient Education
Complementary therapies deemed safe for healthy patients may not be safe for patients with certain medical conditions. It is important to instruct patients to discuss complementary therapies with their provider before initiating them. The provider will assist with decision-making to determine if the therapy is appropriate given the patient’s condition and any other therapies they are currently receiving. Similarly, patients who opt for alternative therapies should be instructed to discuss the possible benefits and harms caused by initiating the alternative therapy versus using a pharmacological therapy. Patients should be informed to never stop taking their prescribed medications without first discussing their plan of care with their provider.
When completing medical histories, it is important to ask the patient about any dietary, herbal, or supplemental products they may be taking and to explain why it is important to add all such usages to their medication history. Patients should also be instructed to consult with their provider before beginning use of a supplemental product. Remind patients that a product labeled “natural” is not necessarily safe. For example, St. John’s wart may interact with certain drugs, making them less effective. Taking vitamin K supplements with warfarin may reduce the effectiveness of the medication in thinning the blood.