Nonpharmacologic Management of Postoperative Pain

Nonpharmacologic interventions can be classified as either cognitive–behavioral interventions or physical agents. Cognitive and behaviorally based approaches include several ways to help patients understand more about their pain and take an active part in its assessment and control. The goals of interventions classified as cognitive–behavioral therapies are to change patients' perceptions of pain, alter pain behavior, and provide patients with a greater sense of control over pain. The goals of interventions classified as physical agents or modalities are to provide comfort, correct physical dysfunction, alter physiological responses, and reduce fears associated with pain–related immobility or activity restriction. Nonphartnacologic approaches are intended to supplement, not substitute for, the pharinacologic or invasive techniques described above.

Nonpharmacologic interventions are appropriate for the patient who: 1) finds such interventions appealing; 2) expresses anxiety or fear, as long as the anxiety is not incapacitating or due to a medical or psychiatric condition that has a –nore specific treatment; 3) may benefit from avoiding or reducing drug therapy (e.g., history of adverse reactions, fear of or physiological reason to avoid oversedation); 4) is likely to experience and need to cope with a prolonged interval of postoperative pain, particularly if punctuated by recurrent episodes of intense treatment– or procedure–related pain; or 5) has incomplete pain relief following appropriate pharmacologic interventions. Cognitive–behavioral approaches include preparatory information, simple relaxation, imagery, hypnosis, and biofeedback. Physical therapeutic agents and modalities include application of superficial heat or cold, massage, exercise, immobility, and electroanalgesia such as TENS therapy.

Giving a patient a detailed description of all medical procedures, expected postoperative discomfort, and instruction aimed at decreasing treatment– and mobility–related pain can decrease self–reported pain, analgesic use, and postoperative length of stay (Guideline Report, in press; Egbert, Battit, Welch, and Bartlett, 1964; Fortin and Kirouac, 1976; Schmitt and Wooldridge, 1973; Voshall, 1980). Patients should receive sufficient procedural and sensory information to satisfy their interest and enable them to assess, evaluate, and communicate postoperative pain. In addition, all preoperative patients should receive instruction emphasizing the importance of coughing, deep breathing, turning, and walking, along with suggestions on how to decrease physical discomforts from such activities. When fear or anxiety occur, it is important to assess psychological coping skills and provide practical suggestions for managing pain and maintaining a positive outlook. Patients who appear anxious or fearful before surgery, and others who express an, interest in cognitive–behavioral strategies, should be assisted in selecting an intervention (e.g., simple relaxation or imagery) and taught how to use it. In some patients, particularly those with high levels of anxiety, too much information, or too many demanding decisions can exacerbate fear and pain (Johnson, Fuller, Endress, and Rice, 1978; Johnson, Rice, Fuller, and Endress, 1978). Psychiatric evaluation is appropriate for patients who manifest disabling or disruptive anxiety symptoms such as emotional instability, restlessness, inability to sleep, and dulled thinking.

Relaxation is the most widely evaluated cognitive–behavioral approach to postoperative pain management. Relaxation strategies, including simple relaxation (Horowitz, Fitzpatrick, and Flaherty, 1984; Lawlis, Selby, Hinnant, and McCoy, 1985; Levin, Malloy, and Hyman, 1987); imagery (Daake and Gueldner, 1989; Horan, Laying, and Pursell, 1976); hypnosis (Kiefer and Hospodarsky, 1980); biofeedback (Madden, Singer, Peck, and Nayman, 1978); and music–assisted relaxation (Locsin, 1981; Mullooly, Levin, and Feldman, 1988), have all shown some degree of effectiveness in reducing pain. Relaxation strategies and imagery techniques need not be complex to be effective. Relatively simple approaches such as the brief jaw relaxation procedure described on page 25 have been successful in decreasing self–reported pain and analgesic use (Flaherty and Fitzpatrick, 1978; Wells, 1982). These strategies take only a few minutes to teach but require periodic reinforcement through encouragement and coaching. Supportive family members or audiotapes often can sustain patient skills. [Sample relaxation and imagery exercises are included in appendix B and printed resource materials or manuals are available elsewhere (McCaffery and Beebe, 1989; Syrjaia, 1990).] A relaxation strategy that can be used informally is music distraction. Both patients' personally preferred music (Locsin, 1981) and "easy listening" music (Mullooly, Levin, and Feldman, 1988) have significantly decreased postoperative pain in clinical studies. Patients who need repeated coaching may benefit from the use of a commercially prepared relaxation or music–assisted relaxation audiotape.

Other cognitive–behavioral strategies require greater professional involvement; these include complex imagery, hypnosis, biofeedback, and combined therapies. Such strategies are commonly applied when patients have chronic pain even before surgery.