Examples of Nonpharmacologic Interventions for Postoperative Pain

• Cognitive–Behavioral
• education/instruction
• relaxation
• music distraction
• biofeedback

Physical Agents

• applications of heat or cold
• massage, exercise, and immobilization
• transcutaneous electrical nerve stimulation

Although some data suggest that the use of complex imagery may reduce pain (Daake and Gueldner, 1989; Horan, Laying and Pursell, 1976), that biofeedback may lessen pain and operative site muscle tension (Madden, Singer, Peck, and Nayman, 1978; Moon and Gibbs, 1984), and that interventions which combine imagery and relaxation may decrease pain (Mogan, Wells, and Robertson, 1985; Pickett and Clum, 1982; Swinford, 1987), each requires specialized training and, for biofeedback, the use of special equipment. Findings from studies of hypnosis for control of postoperative pain are inconsistent (Daniels, 1976; John and Parrino, 1983; Kiefer and Hospodarsky, 1980; Snow, 1985). Insufficient research to demonstrate effectiveness in reducing postoperative pain and the need for special training or equipment preclude the recommendation of complex imagery, biofeedback, or hypnosis for routine postoperative pain control. This is not to say that patients who have a high level of preoperative anxiety, whose pain is severe and enduring, or who suffer recurrent episodes of procedure–related pain will not benefit from these strategies. However, for such patients a more comprehensive pain management program must include active involvement of professionals skilled in cognitive–behavioral therapy and psychological assessment.

In addition to cognitive–behavioral interventions, several physical therapeutic methods can be used to manage pain (Lee, ltoh, Yang, and Eason, 1990). Commonly used physical agents include applications of heat and cold, massage, exercise, and rest or immobilization. Applications of heat or cold are used to alter pain threshold, reduce muscle spasm, and decrease congestion in an injured area. Applications of cold are used initially to decrease tissue injury response. Later, heat is used to facilitate clearance of tissue toxins and accumulated fluids.
Massage and exercise are used to stretch and regain muscle and tendon length. Immobilization is used following many musculoskeletal procedures to provide rest and maintain the alignment necessary for proper healing. With the exception of applications of cold and immobilization, these interventions typically are not used following surgery unless complications occur or an extended postoperative course is expected. When physical modalities are used, it is often for a physiological goal other than pain relief. Of these modalities only cryotherapy (application of cold) has been evaluated in the literature (Cohn, Draeger and Jackson, 1989; Lanham, Powell and Hendrix, 1984; Rooney, Jain, McCormack, Bains, Martini, and Goldiner, 1986). Lanham and colleagues (1984) and Rooney and colleagues (1986) used cryotherapy in association with TENS therapy. There is insufficient evidence to suggest that cryotherapy alone is effective in reducing postoperative pain. Cryotherapy is different from cryoanalgesia (application of a cryoprobe to specific peripheral nerves), which has proven effective for post–thoracotomy pain (Guideline Report, in press).