**7. Non-pharmacological pain management after thoracic and breast surgery**

Nonpharmacological interventions are essential to multimodal postoperative pain management and have been reported in the previous literatures to effectively relieve postoperative pain [54]. Notably, non-pharmacological pain management is not clearly presented in the existing pain management in an enhanced recovery pathways because it lacks high-quality evidence to support its use [44, 45]. According to clinical practice guidelines, non-pharmacological interventions are considered as adjunctive therapies of pharmacological interventions for postoperative pain management. These are transcutaneous electrical nerve stimulation (TENS), music therapy, cognitive–behavioural techniques, breathing relaxation technique, and cold therapy, massage, and acupuncture [47]. In accordance with the recommendations from national Centre for Complementary and Alternative Medicine about non-pharmacological pain management therapies for adults, the mechanism of each intervention is summarised in **Table 1**.

Non-pharmacological therapies can be beneficial in decreasing patients' pain [56], and they are suitable for use because they are non-invasive, have more benefits than harm and can be readily used by nurses [57]. However, consideration of patients' preference when using non-pharmacological interventions is essential [47, 58].

#### **7.1 Preoperative education**

Preoperative education is defined as the provision of information to patients awaiting surgery as a means of psychological preparation for surgery and the

#### **Figure 1.**

*Pain management in an enhanced recovery pathway after thoracic surgery according to Mehran et al. [45].*


#### **Table 1.**

*Mechanism of action for various non-pharmacological methods. Adapted from national centre for complementary and integrative health (NCCIH) [55].*

postsurgical recovery process [59]. Preoperative education is one of the most effective ways to control anxiety in patients awaiting surgery [60], and it serves to enhance patient involvement in their postoperative pain management through informed decision-making [47, 61]. Additionally, preoperative education allows the patient to adequately prepare for the surgery and to manage postoperative pain effectively [60].

#### *Non-Pharmacological Management of Acute Pain after Breast and Thoracic Surgery DOI: http://dx.doi.org/10.5772/intechopen.109863*

The information provided during preoperative education usually covers the surgical process, anaesthesia, pain, and what to expect after surgery [62–64].

The key thing to remember is preoperative preparedness as well as preoperative education and counselling for appropriate pain relief and control after surgery [8, 47]. Before surgery, according to Chou and colleagues, individualised and family-oriented education as well as mutual goal setting should be allocated in relation to appropriate pain relief after surgery [47]. For instance, education about types of pain, sources of pain, when and how to report pain using pain chart, pain medications commonly used, and side effects should be included in preoperative teaching [47].

Adequate information regarding pain assessment, proposed analgesic medication and technique, complications, and its management are recommended whenever possible [8]. The patient education does not exclude non-pharmacological pain management methods or techniques according to preference of each individual patient (e.g. massage, music therapy, cold application, and distraction techniques). Encouragements to use and choose a preferred non-pharmacological therapy in combination with skill development are also performed preoperatively [46, 47]. Oftentimes, surgery-related information is provided by surgeons. However, it is more effective when the anaesthesiologist also provides patients with information related to anaesthesia alongside the information provided by the surgeon [65]. According to Chou and colleagues, effective preoperative education should include detailed information related to treatment options, type of pain, expectations, and goal setting for the pain intensity the client intend to achieve postoperatively [47]. The information that is included in a preoperative education is especially important for younger women because they have higher risk for severe postoperative pain [37].

The effectiveness of preoperative teaching using a variety of teaching strategies has been examined by the previous studies, which revealed the benefit of it [59, 66, 67]. According to Ramesh and colleagues, patients who are well informed before surgery tend to experience little pain [59]. Preoperative education can be delivered to patients individually or in groups [60] through face-to-face sessions or technological devices [47]. Information can be provided by lecture, booklets, pamphlets, videos, audiotapes, and technology-assisted devices [47, 68]. Written information can also be used to reinforce information provided verbally to patients and vice versa [60, 64]. Using either of these means, preoperative education can be provided to different surgical patients.

Irrespective of the patient education method chosen, delivering the information too quickly and inadequately can hinder the patient's understanding of and the sufficiency of the information, as well as their satisfaction with the preoperative education [60]. This includes patients awaiting all types of surgery [66], knee surgery [64], spinal surgery [62], cardiac surgery [61, 69, 70], abdominal surgery [71], renal surgery [63] and breast cancer surgery [72]. Most of the studies reported that preoperative education was effective in controlling anxiety in patients awaiting surgery and pain after surgery.

#### **7.2 Acupuncture**

Acupuncture is a non-pharmacological intervention that helps to reduce pain by stimulating specific nerve points called acupoints. Acupoints are a few dynamic, complex structures that consist of blood vessels, mast cells, and nerve fibres [73]. The acupoints are reached with the help of thin, solid metallic needles that penetrate the skin. Acupuncture technique has been used in Asia for thousands of years as part

of traditional Chinese, Japanese, and Korean medicine [74]. Acupuncture can be delivered as manual acupuncture or electroacupuncture [73, 74]. Manual acupuncture is conducted by inserting the needle into the skin at the corresponding acupoint, and then, the needle is moved in different direction to stimulate the acupoint mechanically. Meanwhile for electroacupuncture, mechanical and electrical stimulations of acupoints are achieved by passing electric currents through acupuncture needles [73].

Acupuncture is believed to be governed by three main principles which are modulating yin and yang, differentiating between primary and secondary *Qi* (i.e. vital energy), and inhibiting pathogenicity and enhancing immunity [75]. The achievement of these main principles is based on the theory of meridians, collaterals, and acupoints. Meridians ("Jing and Luo", 'links or connection') are the transport pathways for *Qi* and blood, controlling yin and yang, connecting Zang organs with Fu organs, and connecting the external and internal as well as the upper and lower body of humans [76]. Collaterals are thin networks of small interwoven channels that run throughout the body [75]. According to this theory, diseases are treatable through acupoints as they are closest to the body's surface. Through acupoints, meridian obstructions can be removed, *Qi* and blood can be controlled, inadequacies can be reinforced, and excesses can be curtailed [76].

Although acupuncture's mode of action in pain relief is not fully understood, some studies have posited that acupuncture triggers the release of endogenous opioids and neurotransmitters that are responsible for pain control [77]. Pain control begins at the acupoint where acupuncture-induced signals are generated and transmitted to the brain via the spinal cord. As the signals reach the brain, there is a rise or decline in many neurotransmitters, inflammatory factors, and pain relief modulators [73]. The ability of acupuncture to control pain depends on acupuncture manipulation, sensation, acupoint, pathological status, and the type of pain [78].

In general, the effectiveness of acupuncture has been widely contested because its mechanism is yet to be fully understood [79]. However, some systematic reviews have reported that acupuncture is effective in relieving cancer pain [80, 81], low back pain [82–84] and postoperative pain [85–87]. For women who have undergone mastectomy, acupuncture was used in one study for acute pain management and was found to be effective [77].

#### **8. Relaxation therapies**

Relaxation therapies have also been recommended for pain management after surgery [46, 47]. A few interventions belong to this group of therapies because they share some similar components and requires patient's acceptance and rapport building before its initiation [46]. These interventions include breathing exercises, music therapy, aromatherapy, and meditation [5, 46, 47].

Previous studies about relaxation therapies have focused on music therapy [88, 89], meditation [90, 91], and aromatherapy [92, 93]. These studies have supported that after breast or thoracic surgery, relaxation therapies reduce pain intensity as well as pain distress at rest, during deep breathing and turning.

#### **8.1 Music interventions**

The history of utilising music for healthcare purposes dates to the sixth century. However, Florence Nightingale recognised its importance in the clinical area in the

#### *Non-Pharmacological Management of Acute Pain after Breast and Thoracic Surgery DOI: http://dx.doi.org/10.5772/intechopen.109863*

eighteenth century [94]. Since then, music has been widely used for anxiety reduction and pain management across various patient populations—including preoperative and postoperative patients—because it is not physically or cognitively tasking [95]. Music has also been used to control blood pressure, respiratory rates, and heart rates of various groups of patients because it promotes relaxation [5, 96–99].

The way patients respond to music differs and is mainly dependent on the patients' knowledge about the music, culture, environment, and preferences [100]. Finlay and Anil concluded in their study that the types of music that have been successfully used to improve patient outcomes include music that the listener is familiar with, prefers, and can resonate with emotionally [101], because personal preferences and familiarity can stimulate attention to the music, thus distracting patients [102].

The positive effects of music on anxiety are made possible through distraction, which occurs when lyrics or the sound of familiar music occupies the attention centre of the brain, creating meaningful auditory stimuli [100]. However, the precise mechanism of pain reduction that music elicits is not widely understood [103], though the benefits have been established through research [104]. One of the methods that music is believed to use to relieve pain is inherent in the cognitive and emotional characteristics it possesses, which allows it to act as an external and distracting stimulus [102].

Music can be used passively through listening to downloaded songs or songs on compact discs or actively through singing and drumming [100, 105]. Beyond the familiarity, culture, and environment of the patients and the mode of music delivery (i.e. active or passive), music has six main components that also influence patient's response to music. Each of these components is processed by the brain through different pathways [106]. These components include volume, tempo, rhythm, pitch, melody, and timbre. Controlling these components will result in either relaxing music or stimulating music [107], which will have different effects on patients, depending on their preference and familiarity with the music [108]. To further enhance the effectiveness of music in clinical settings, music should be set at 60 to 80 beats per minute [109], and patients should be allowed to control the volume of the music [105]. Music should also be played for 20 to 60 minutes on portable devices for individuals or public address systems for groups [100, 105, 109].

Evidence from the previous literature has revealed that music is beneficial to patients experiencing pain [106, 110], and music is effective in reducing pain among cancer patients [111] and patients awaiting surgery [112]. Previous studies have also reported that music is effective in reducing pain in patients who have undergone a bone marrow transplant [113] and knee surgery [114]. For patients undergoing breast cancer surgery, a recent systematic review also reported that music interventions effectively reduced acute postoperative pain [87].

#### **8.2 Meditation**

Meditation is the process of training one's attention and consciousness via the voluntary regulation of mental processes [115]. Meditation is an important method of understanding the nature of the mind and a means to attain a certain degree of consciousness. Meditation is a common religious practice in both the East and West. The techniques used in the East and West are similar, including "breath-oriented multitasking meditation", mindfulness meditation, and relaxation response [116]. Meditation involves a self-regulatory process that can improve symptoms through the maintenance of the balance of autonomic responses [117]. These responses include improved vital signs (i.e. pulse rate and blood pressure), cardiac activities,

and oxygen consumption [116], all of which are cardinal consequences of inadequate anxiety and pain management.

Meditation as a non-pharmacological intervention engages three main structures in the brain, including the anterior cingulate cortex, the anterior insula, and the ventromedial prefrontal cortices [118, 119]. A steady practice of meditation results in higher activities at the ventromedial prefrontal cortices, causing a greater level of anxiety reduction [119]. Meanwhile, when meditation is used for pain management, the three main structures interact with pain in the limbic–thalamic region because both pain and meditation elicit affective, sensory, and cognitive responses [118]. This interaction results in the activation of the endogenous opioid system [120].

Although meditation has three main techniques, the most commonly researched one is mindfulness meditation. In general, meditation has been found to be effective in reducing anxiety in patients undergoing cardiac surgery [121] and for pain management in patients with cancer, fibromyalgia, migraines, and irritable bowel syndrome [122], as well as for patients after abdominal surgery [91]. However, there is limited evidence on its use after breast surgery, thus creating a dearth in evidence on its effectiveness for postoperative pain management in patients undergoing breast surgery.

#### **8.3 Aromatherapy**

Aromatherapy is a botanical therapy that reinforces the therapeutic value of smell and sometimes touch during care delivery [123]. The botanical nature of this therapy involves the use of plant oil for health purposes. According to Tamaki and colleagues, aromatherapy is the application of extracted essential oils—from flowers, herbs, and other parts of the plant—to treat different illnesses [124]. The use of aromatherapy has a long history as it was practiced in ancient Mesopotamia, Egypt, China, Greece, Rome, and Israel. However, modern-day aromatherapy was developed by a French scientist who accidentally dipped his burnt hand into a jar of lavender oil, and the wound healed rapidly without a scar. Since then, modern medicine has researched the use of essential oils for health purposes [125].

Although aromatherapy's mechanism of action has been widely contested by different scientists, most believe that the link between the olfactory and limbic systems is the main pathway for its action of influencing mood and emotions [126]. Once the odour of an essential oil binds to a certain protein in the olfactory cells, it stimulates the olfactory nerve, which transmits a signal to the limbic system and the hypothalamus [125]. In the limbic system, the amygdala, which controls emotional responses, and the hippocampus, which controls explicit memory formation and retrieval, then transmit a signal to the cerebral cortex. The cerebral cortex allows interaction between thoughts and feelings and the brain centre that controls stress and hormone levels and vital signs [123]. Aside from the assimilation of essential oil through the olfactory system, it can also be assimilated through the skin and mucous membranes by diffusion [123, 125, 127, 128]. However, inhalation appears to provide the most rapid effect. Similarly, it is believed that the chemical properties and composition of an essential oil are what determines how effective a specific type of oil may be [123]. According to Halcon, there are various essential oils that can be used when delivering aromatherapy, but the commonest essential oil used in the previous studies was lavender oil through inhalation [123].

In the clinical setting, aromatherapy has been mainly used to manage pain, anxiety, agitation, nausea, and insomnia and to prevent infection. For each symptom, *Non-Pharmacological Management of Acute Pain after Breast and Thoracic Surgery DOI: http://dx.doi.org/10.5772/intechopen.109863*

the mode of application may vary from inhalation and ingestion to topical application [123]. However, most of the previous research has focused on the use of aromatherapy to control stress symptoms, especially anxiety among various patient populations including patients waiting for surgery [129–131]. This can be due to the already established understanding of the connection between aromatherapy and the limbic system, which is the centre of emotions. Meanwhile, some other studies have been conducted to test the effects of aromatherapy on the mood and pain of patients undergoing various breast cancer treatments including surgery and thoracic surgery [124, 132–137].

#### **8.4 Physical therapies**

#### *8.4.1 Massage*

Massage belongs to the group of physical therapies, and it is seen as essential to health and well-being [138] which provides pain relief either during or immediately after the intervention [47]. Massage is the use of manual methods and adjunctive treatments to positively affect patient's health and well-being. The root word of massage is from the Arabic word "mass'h", which means "press gently" [139]. Massage has gained widespread popularity for preoperative anxiety management [140] and for pain management among hospitalised patients [90, 141]. However, massage has been mostly used for pain management [142]. Massage provides relief for anxiety and pain, but its mechanism of action is yet to be understood [143]. Many scientists have suggested that massage works to relieve anxiety by promoting relaxation [139] and working on the subconscious mind to promote positive emotions [144]. Likewise, massage can relieve pain by producing a localised effect on muscles [144] and by activating non-myelinated C-fibres which inhibits the perception of pain [139].

Massage can be provided in the hospital, and it has yielded a considerable level of positive effects [145]. There are various types of massage techniques that have evolved from different cultures. The taxonomy of these techniques is based on both Western massage and Eastern massage. Eastern massage technique includes Thai massage, reflexology, acupressure, shiatsu, polarity therapy, and others. Meanwhile, Western massage technique includes Swedish, myofascial, reflexive, soft-tissue release, circulatory, lymphatic, neuromuscular massage, and others [144]. Different massage techniques may produce different effects or expected outcomes in patients. However, for pain management, patient involvement in the decision-making process about where to massage, as well as patient assessment prior to massage, may help to increase the positive effects of massage [145]. Despite the popularity of massage for pain management among postoperative patients who have undergone cardiac surgery [140, 145–149] and thoracic surgery [141, 150], only a few types of massage have been used for pain management in women undergoing breast surgery. The studies conducted among thoracic and breast surgery patients found that massage can be used routinely in the hospital to help patients who have undergone mastectomy or breast cancer surgery control their pain better [90, 140–142, 146, 151, 152].

#### *8.4.2 Cold applications*

Application of cold on the skin which may need a compression or an equipment that can recirculate mechanically for cold temperature maintenance is described as cold therapy [47]. Cold therapy is a common nursing intervention and has proven

effective in most surgeries especially open-heart surgeries by reducing patient's incisional pain [153].

Application of cold therapy is common in acute pain settings including postoperative pain settings, and its effect has been identified to be related to tissue temperature reduction at the surgical which results in localised pain relief and oedema reduction [153]. Previous studies have recorded success in the use of cold therapy in pain management after thoracic surgery. Ice pack placed on incision site reduced pain in the previous studies by reducing the temperature at the surgical site, numbness, and promoting feeling of coolness [153–156]. The implementation of cold therapy by nurses can be done independently, and patient's acceptability is feasible because it is cost-effective and easy to use [154].

#### **8.5 Transcutaneous electrical nerve stimulation**

Transcutaneous electrical nerve stimulation (TENS) is a non-pharmacological intervention that utilises low electrical currents on intact skin to stimulate nerve activities that inhibit or enhance certain nerve impulses [157]. TENS was basically developed for pain relief; however, it also enhances venous haemostasis through motor and skeletal nerve stimulation [158, 159]. TENS is an intervention that has been delivered by many healthcare providers, including nurses, because it is safe, cheap, non-invasive, and does not require physician expertise [157]. The mechanism of action of TENS is based on the gate control theory developed by Melzack [160]. TENS activates the descending inhibitory pain pathway [158] by first activating the large unmyelinated A-β fibres that prevent noxious stimuli transmission [161]. When TENS is delivered at a high frequency, certain receptors in the bloodstream (i.e. betaendorphins) and cerebrospinal fluid (i.e. methionine-enkephalin) increase in concentration creating a myriad of opioid-receptor blockades in the rostral ventromedial medulla and the spinal cord [161].

According to Vance and colleagues, TENS has been utilised for pain management in various patient populations including patients with neck cancer, those with phantom limb pain, those undergoing labour, and those who have undergone thoracic surgery [161]. TENS has also been tested in patients undergoing cardiac surgery. Nonetheless, there are inconsistent findings on the effects of TENS on pain after surgery [158]. There is also a lack of evidence on the utilisation of TENS for anxiety prevention and in women undergoing breast cancer surgery. However, TENS may be beneficial in reducing pain in patients with undergoing breast surgery.
