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Physical Medicine Approaches To Pain Relief |
Pain Relief
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Pain relief for bedridden cancer patients can be facilitated by various nursing and physical therapy procedures. These range from simple ways to position the body to more complex techniques that require special equipment and trained personnel. Some of the simple procedures can be taught to family members.
The first step in reducing pain is to evaluate the cause and source of pain. Once it has been established through appropriate diagnostics that surgical intervention, radiation therapy or other treatments will not help, one needs to know if the pain comes from movement, lack of movement, postion of limbs, position of entire body or such sources as muscle tension.
Positioning
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Positioning or placing the body or a body part in a certain way can be effective for pain relief.
Back pain is relieved by several positions. The first is to place the head and trunk at 20° to 30° angle. Wedge pillows are used to accomplish this. Then place one or two pillows under the knees, If you have a hospital bed, this is done easily without pillows. The patient can usually do it himselfusing the bed controls.
A second positioning is used to relieve back pain specifically. Roll up two towels and tie them with string or rubber bands at either end. This keeps the roll tight and firm. Place the roll in the lumbar lordosis (the round of the back at the waist). If you put a long tie in the middle, the roll can be held around the waist. It helps to put the roll at the waist during side lying also. This same roll can be used in a chair when the patient is sitting up.
Decubitus and Contractures
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Patients who are not moving much on their own need to be positioned in various ways for pain and also to prevent decubiti (bedsores) and contractures (tight joints). If the patient iscomfortable with knees bent, for at least one hour every four, they need to be positioned with theknees extended. If the arm is always held against the body, shoulder range of motion will decrease and washing under the arm becomes painful. The arm should be positioned at a 60° angle from thebody for half an hour three times a day. If possible, you should try to externally rotate the shoulderand place the elbow at 90° angle also. Gravity wants to pull the arm down, sometimes the wrist can be secured to the sheets with soft restraint. The hips want to roll into external rotation. Sand bags can be used at the greater trochanters and knees to help prevent external rotation contractures.
Any place that a bone protrudes must be protected from pressure sores, malleoli (bony bumps), kyphosis (rounded back), ischial tuberosities (sitting bones), sacrurn (flat area just above the buttocks). Any patients who are not moving and turning on their own must be positioned from side to side with pillows secured behind them every two hours. The bony areas should be massaged for two to three minutes after they are relieved.
The skin should be protected. It must be dried carefully after washing so that friction when moving is decreased. The use of draw sheets not only prevents friction, but also the pain of pulling on the patient's body parts.
If sores start to form, pads can be made to relieve them, i.e.: rolls around the ankles will keep heels and malleoli clear of the bed. Pads on elbows can protect them. Circular pads with holes in the center can relieve sores over vertebrae. If he patient can be turned on his stomach, this is the best relief for the buttocks and back area. Placing a pillow under the chest, stomach, and hips sometimes helps to tolerate this position better. It keeps the face from being pressed into the mattress and helps with breathing also.
Corsets
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Corsets and rib belts can be used to reduce pain. It is important that they be of a rigid type to be effective. They must have at least two staves in back or either side of the spine and one on both sides. The two in front can be omitted for bedridden patients. A plastic body jacket can be made to fit patients that have vertebral instability. They control pain and make it easier to move from bed to chair or while ambulating.
Pain from fractured ribs can be helped by a rigid belt over the thoracic area. This, plus holding a pillow tightly against the chest wall will make coughing less painful.
Cervical collars can help with neck pain from widespread metastatic disease. The collars need to be rigid enough to stop movement. Neck extension is usually the major offender and should be prevented. The Philadelphia collar or four poster will effectively stop cervical movement. A round,long pillow roll about 8 inches in diameter placed on top of the patient's pillow in the cervical lordosis will help support the head in proper position. There are many types of cervical pillows to try for controlling neck pain..
For neurological problems, a splint can be used to support a weakened or paralyzed joint. This not only relieves pain but also prevents deformity from occurring.
Splints
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Splints can be made of plastics, plaster or simply from cardboard or wadded newspaper. They must be properly padded so they don't cause pressure sores on the area to which they are applied. They cannot just be put on and left there. A time schedule needs to be set up for their use, i.e.: two hours on and two hours off. The skin should be checked for breakdown, redness, or particular points of pressure, which must then be relieved in the splint.
Slings
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Subluxed shoulders painful arms and legs can be relieved by slings. The triangle bandage is the easiest to make. They can be made from torn sheets. A long belt with a loop at both ends can be used for an arm sling. These should be secured around the back, not around the neck. The neck gets tired and painful much quicker.
Simple slings can be rigged up for legs. One only needs a wide (about 6 inches) strap at the thigh and another at the ankle. Pressure must be monitored in these also and a time schedule setup for use.
Painful, swollen limbs can be supported by pillows of various shapes. These can also be used to elevate the limb to reduce edema.
Ace wraps or taping of joints can also relieve pain. Family members should be taught to use spiral, not circular, turns when using the Ace wraps. If the patient feels coolness or numbness in the extremity of the wrapped limb, it is wrapped too tightly. Taping requires special training and skill, but may also be taught to family members.
Limbs that need to be permanently immobilized like in non-union fractures should be handled with metal or plastic braces. The joints should lock to enable positioning of the limb in both a flexed and extended position. If braces are not available, casts can be made and bivalved and Aced or strapped on for periods of time. This can be used when moving patients.
ROM Exercises
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If the patient is immobile for long periods of time, the joints will start to stiffen. They are then painful when the patient tries to move. The family can be taught to support limbs while doing ROM exercises, if the patient is unable to do it himself. The limbs should go through each motion ten times daily at minimum.
Here is a series of range of motion exercises that can be done daily by your patients. If the patient cannot move the limb on his own the family should gently support the limb and instruct the patient to tell them if it hurts while you move it.
Breathing
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Breathing properly is a key factor in all exercise programs. By itself, breathing is a good exercise. Its benefits are twofold: therapeutic and relaxing. Breathing exercises can be used to improve the habits of those who breathe lightly, expanding only the upper chest. They are also a good way to rest between exercises. Urge your patient to let go of all the muscles in his neck and shoulders and fill his lungs all the way. This will break the cycle of shallow tension breathing.
Breathing Guidelines:
- Breathe in through your nose and blow out through your mouth, if this is comfortable for you (this will avoid drying out the throat and mouth). If you can only breathe in through your mouth, go ahead, but keep a glass of water handy.
- Never hold your breath while doing an exercise. This will exert pressure on your heart and could even cause you to faint. Either blow out or in while performing any of the exercises.
- You will want to be sure that you are breathing with the lower part of your lungs as well as the upper to increase your lung capacity.
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To do this,
a. Place a hand on your stomach.
b. If you are using your diaphragm and correctly expanding your lungs, your hand will rise as you breathe in and fall as you blow out.
Shoulder and Chest Exercises
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Exercises 1, 2, and 3 work the shoulder joints and strengthen the chest muscles. Begin by having the patient take ten deep, relaxing breaths. You can do this along with your patient. Remind the patient not to hold his breath while he is exercising. Encourage him to breathe rhythmically in and out.
Give the following instructions to our patient. As he does the movements, watch him. Make sure he is doing the exercise correctly. Also, make sure he is remembering to breathe as deeply and regularly as possible. You can quote these directions to your patient or rephrase them if you like.
- Straight Arm Lifts
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a. Lying on your back, place your arms down by your side.
b. Keeping your elbows straight, lift your arms up and as far back over your head as you can.
c. Now,still keeping your elbows straight, lower your arms down to your side. - Elbow Touches
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a. Lying on your back, place your hands behind your head, elbows flat on your bed.
b. Bring your elbows together in front of your body.
c. Lower your elbows back down to the bed. - Straight Arm Crosses
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a. Lying on your back, put your right arm straight out to the side. It should be at a right angle to your body.
b. Keeping your elbows straight, bring your arm across your chest to your left side.
c. Still keeping your elbow straight, return your arm to its original position.
d. Repeat this exercise with your left arm. - Elbow Bends (This exercise preserves elbow mobility)
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a. Lying on your back, place your arms down by your sides. Make a fist with each hand.
b. Bring your fists up to your shoulders, bending your elbows.
c. Lower your fists to their original positions. - Wrist Rotation
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a. Lying on your back, hold your arms out in front of you. Make a fist with each hand.
b. Make small inward circles with your fists.
c. Reverse directions and make small outward circles. - Hip, Knee and Ankles
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a. Lying on your back, place your legs together flat on the bed.
b. Bend your left leg and bring your knee up toward your chest.
c. Straighten your knee while lowering your leg slowly to the bed.
d. Repeat this exercise with your right leg. - Straight Leg Lifts
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a. Lying on your back, place your legs together flat on the bed.
b. Keeping your knee straight, lift your left leg as high as you can.
c. Still keeping you knee straight, lower your leg slowly to the bed.
d. Repeat this exercise with your right leg. - Knee Touches
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a. Lying on your back, bend both knees, keeping your feet flat on the bed.
b. Relax and let your knees fall outward as far as they will comfortably go.
c. Bring your knees back up together. - Ankle Rotation
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a. Lying on your back, bend your left knee and place your left foot flat on the bed to brace yourself
b. Lift your right heel a little off the bed and make small inward circles with your foot.
c. Reverse the directions and made small outward circles.
d. Repeat this exercise with your left foot. - Side-to-side Rolls (This exercise helps prevent bedsores)
Caution: This exercise should be donewith the bed rails raised if the patient is in a hospital bed, or with someone on the other side ofthe bed to make sure that the patient does not rollout of bed.
Give the patient the following instructions:
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a. Lying on your back, slightly bend your knees and elbows.
b. Lift your left shoulder and roll to the right, reaching with your left arm for the bedrail or other side of the mattress.
c. Roll back and repeat the exercise on your other side.This series can be done either alone or assisted by family members.
Relaxation Exercises
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Body relaxation techniques can be effective in pain control because they teach the patient how to reduce muscular tension. The body's natural response to pain is to contract the muscles. This contraction intensifies the pain cycles and increases lactic acid accumulation. By getting the patient to relax the muscles, he or she can experience some relief from pain.
You must start with the patient in a position that is totally relaxed. Have him lie down with his legs loosely out straight and his arms at his sides. You may want to put one pillow under his head and another under his knees.
Tighten and Release
The first exercise in the series is to tighten and release muscles in a fixed sequence. Start with the head and work down. First have the patient tighten the muscles of the forehead. When these are tightly contracted, instruct him to let them go. Move to the nose, and tell the patient to tighten the nose as if he had smelled a bad odor. Then instruct the patient to let it go. Touch each part you instruct the patient to tighten.
Move to the mouth, telling the patient to tighten the mouth muscles as if he had just bitten into something very sour. Then tell him to release the mouth. Move to the tongue, neck, shoulders,arms and on down the body in turn. Instruct the patient to hold his breath and then release it. Tell him to pull in his stomach muscles and then release them; tighten his buttock muscles, and then release them and so on. Cover each major body area-the hands, arms, shoulders, pelvis, buttocks, legs feet and toes.
This exercise lets the patient learn what each muscle group feels like, both tightened and released. Soon the patient is able to recognize when his muscles are tight.
Visualization
The second exercise in the series again begins with the head. This time, have your patient visualize things that make each muscle group feel heavy. You may want to instruct your patient to imagine something that makes his nose feel heavy or his neck feel heavy and so on. After you have gone from the head to the toes, covering all the body parts in the same sequence, return to the head once again.
Images
The third exercise follows the same progression of body parts-forehead, nose, mouth, tongue, neck, shoulders, down to the feet again. This time, instruct the patient to imagine or see images that made each part in turn feel warm.
Touch
The final exercise in the series starts with the head again. As you touch each body part, ask your patient to see images that make him feel that his forehead, nose, mouth, neck, shoulders and soon, are gently floating.
Have your patient practice these four exercises in sequence for two or three weeks, in a lying down position for 20 minutes per day. This gives the patient time to find images that please him. It is important that each patient find images that are personally pleasing. By the end of two or three weeks, your patient should know how to do the whole series without help from you.
After the patient has established comforting images and knows the exercise series well, you can move to the next stage. Have the patient practice the entire series using the same images while sitting up. Then have the patient do the series while walking around. Once learned, these body relaxation techniques can be done as often as needed.
Massage
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Another technique that can relieve generalized pain is massage. It is also a soothing technique for bedridden patients. Massage is useful in several ways. It can help reduce pain locally for up to one or two hours. Massage can also help achieve overall relaxation. You can use the following instructions to perform massage on the patient yourself; or you can teach someone else to do massage for the patient, perhaps a relative.
A comfortable position at the start is very important. No matter how soothing the massage is, the patient must be comfortable or he or she will not be able to tolerate the massage for very long.
There are four basic massage strokes:
- Effleurage-light and deep stroking.
- Petrisage-kneading.
- Tapotement-hacking or slapping
- Friction-working with the fingertips
The first two strokes are the most useful with bedridden patients.
Effleurage
is the stroke used to begin every massage. The two types of effleurage are light stroking, used to relax the patient and deep stroking which actually empties the blood and lympatic vessels.
Effleurage is done very slowly. It is used to totally relax the patient and it begins and ends every massage. Start by placing your hands very lightly on the area massaged. Using the least pressure you can, run your hands over the area at a slow pace. Make full contact with the skin, using both hands. Once you begin keep your hands on the patient's body until you are finished. All strokes should be done in a continuous motion. After five minutes of light stroking, deepen the strokes in the direction toward the heart. Increase the pressure to a deep effleurage. Lighten the strokes going away from the heart. Be careful if the patient complains, youare doing it too hard. Massage should never hurt. That defeats the purpose of relaxation. Some people can tolerate only light effleurage and nothing more. Deep effleurage can be used to decrease edema. It should only be used with approval of the physician in charge.
Petrisage
can be done in two ways. You can knead the muscles with the palms or heels of your hands, or you can use your fingertips. In this stroke, you can actually pick the muscle tissue away from the bones and you work on the right areas to decrease muscle spasm. Again, it should not hurt unless the patient tells you it hurts good. This is the usual description of an effectively given petrisage.
Foot massage
is an excellent type of massage. It gives relief from pain and increases relaxation. It can relieve pain in other parts of the body. Use effleurage to begin with. Then go to petrisage if comfortable for the patient. Use friction for most of the foot massage. Then end with gentle overall light stroking of effleurage again.
Taping
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Taping joints with adhesive tape can be used for temporary immobilization. The most important consideration should be the integrity of the skin. Malnourishment syndromes and open areas of any kind should not ever be taped over. Tape should not be left on the skin any longer than 8 hours. Johnson & Johnson has published a free booklet that demonstrates the correct taping procedure for each joint. Longitudinal strips are first placed to oppose the instability of the joint. These are secured at the top and bottom with circular turns. A figure 8 is done over the whole area. Tape size varies with the size of the joint. One inch can be used on a finger, 4 inch tape is needed over a hip. The areas should be shaved first and treated with a skin prep. There should not be any creases in the tape. When removing tape, always try to push the skin away from the tape rather than just pulling the tape off. Taping will not help well in humid conditions.
Water Therapy
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If available, a whirlpool bath can be helpful. It provides the benefits of both heat and massage to the entire body. The patient must be helped into and out of the tub carefully. Get someone to assist you if possible and have your helper watch to make sure limbs are bent as they should be. The patient must be placed in a comfortable position in the tub. If the patient is not comfortable, the whirlpool will do no good.
The water is kept between 103° to 105° Fahrenheit. The patient may stay in for 20 to 30minutes. For a patient with ischemic disease, the water should not exceed 96° Fahrenheit. Because this feels too cold for a full-body whirlpool; such a patient may not want to have this treatment.
Care must be taken with anyone that has cardiac disease, an infection or some kind ofcompromised circulation or mental status. Warm water over the entire body increase the cardiac output. Patients can faint or lose consciousness. All patients in a water bath should be closely supervised, but those with compromised mental status should never be left alone.
In cases of infections, the bath must be sterile. Clean the empty tub with a strong betadine(iodine solution) product or other disinfectant. You should add betadine or another disinfectant to the bath as well, unless the patient is allergic to this product. The turbulent water will also debride(cleanse) the wound.
Heat
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There are several techniques that can be used for localized pain. Heat has been used successfully to relieve pain and increase relaxation in a specific joint or musculoskeletal area. Two types of heat treatment can be use: superficial and deep. The dividing point between superficial and deep is the superficial treatment only extends to a depth of I cm.
The traditional medical literature on cancer contraindicated the use of deep heat modalities for patients. This has changed. Recent studies using microwave and ultrasound have shown that they can shrink tumors rather then spreading them. This means that a cancer patient with any painful musculoskeletal condition can be treated in the conventional way.
Relief produced by heat probably comes from its primary effects on the body's physiology. Heat works to increase metabolism where it is applied. This leads to the faster removal of waste products, including lactic acid. Heat also opens up blood vessels and increase arteriolar dilation. This results in more delivery of oxygen nutrients, antibodies and leukocytes to the area of application.
There are many sources of superficial heat: moist hot towels, hot water bottles, steam packs(hydrocollators), infrared lamps, electric heating pads and ultraviolet lights. Deep heat techniques include ultrasound, diathermy and microwave.
Caution: Care should be taken whenever heat is used with patients who have decreased sensation. Also, patients should not be allowed to fall asleep on a hot water bottle or heating pad. Because they are asleep, they may not feel if they are getting burned.
Cold or Ice
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Cold or ice has the opposite effect of heat. Cold is particularly effective in muscle spasm or spasticity. An application of 10- 15 minutes will achieve maximum effect. Anything longer is not necessary as it starts producing the same effect as heat.
Jobst Pump
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The Jobst compression pump is a unit that has been used successfully in controlling lymphedema. It is recommended that 30mm. be used on the arm and 60mm. on the leg. The limb should be elevated while using the pump. To be effective, 2-4 hours of pumping must be done daily if edema is severe. An elastic garment or Ace wrap should be applied after pumping for best results.The patient's blood pressure should always be taken. The systolic pressure should never be exceeded with the pump.
Pain experienced by the mastectomy patient can be minimized by immediate initiation of ROM of the shoulder, massage in the direction of the heart, use of the compression pump with edema and fitting with elastic garment before the problem becomes chronic.
Conclusion
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In summary, there are several effective techniques for pain control which do not require advanced technology. Exercise, relaxation and massage will not alleviate pain totally, but are tools which help patients cope with complicated pain problems. We have presented a step-by-step approach so that you can teach your patients these techniques. The patients can then carry them onto their own home environments. These techniques are applicable to any socio-economic sphere.
The more technological approaches discussed for pain control are best supervised in hospital or office situations where the physician can more closely observe reactions and progressions.
These techniques are the most widely used and accepted in present day oncological practice. In our opinion, anything that is available should be tried in an attempt to improve the quality of life of cancer patients including those that are terminal.
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- From Supportive Cancer Care
- by Ernest H. Rosenbaum, MD & Isadora R. Rosenbaum, MA
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