**2. Physical (sensory) interventions**

#### **2.1. Massage**

Pain can complicate the patient condition as it can elevate stress, altering posture, and reduce one's ability to participate in daily activity [1]. It is the process of rubbing and kneading parts of the body, especially joints and muscles with hands to relieve pain and decrease tension. Massage can interrupt the patient's cycle of distress. It can increase the blood circulation as well as lymphatic circulation. Massage can also initiate an analgesic effect to the area being rubbed and decrease inflammation and edema. Moreover, it can release muscle spasms manually while increasing endogenous endorphin release, and conflicting sensory stimuli that override pain signals [2].

The process of rubbing and kneading soft tissues of the body can lead to relaxation of the tense muscles, increase blood flow to the underlying tissues and decrease pain. The exact mechanism of pain reduction in massage is still unknown; however, there are some studies and expert's hypothesis suggest that the process of massage can lead to an increase in dopamine levels which decrease pain. In addition to that, massage can lead to relaxation of the muscles tension that often arise when pain present [3].

There are many benefits of massage as it can reduce stress, promote muscle relaxation, lower blood pressure, improve circulation, help improve posture, and strengthen the body immune system. Moreover, there are some studies suggest that massage had been found to decrease pain and anxiety in many of the surgical and nonsurgical patients [3].

Massage can be beneficial in cancer patient as it can improve mood and quality of life among patients suffering from cancer. Both the massage and simple-touch groups had statistically, although not clinically, significant improvements in pain and quality of life over time despite no increases in total analgesic medication use [4]. In addition to that, there are some short-term benefits of massage which include improve psychological well-being and, in some cases, reduced severity of physical symptoms. Depression and anxiety have shown significantly improve with massage.

#### **2.2. Positioning**

**2.** Psychological interventions

2 Pain Management in Special Circumstances

imagery and biofeedback.

**2. Physical (sensory) interventions**

muscles tension that often arise when pain present [3].

pain and anxiety in many of the surgical and nonsurgical patients [3].

**3.** Others

**2.1. Massage**

Continuous pain may lead to development of maladaptive status and behavior that worsen day to day function, increase distress, or enhancing the experience of pain. Patients suffering pain tend to show increased vulnerability to a variety of psychiatric illnesses, including depressive and anxiety disorders, and posttraumatic stress disorder. In fact, the relationship between depression and pain is likely to be bidirectional, so that the presence of a depressive disorder has been identified as a key risk factor in the transition from acute to chronic pain. Most commonly used psychological interventions are: cognitive behavioral therapy, mindfulness-based stress reduction, acceptance and commitment therapy (ACT), guided

Pain can complicate the patient condition as it can elevate stress, altering posture, and reduce one's ability to participate in daily activity [1]. It is the process of rubbing and kneading parts of the body, especially joints and muscles with hands to relieve pain and decrease tension. Massage can interrupt the patient's cycle of distress. It can increase the blood circulation as well as lymphatic circulation. Massage can also initiate an analgesic effect to the area being rubbed and decrease inflammation and edema. Moreover, it can release muscle spasms manually while increasing endogenous endorphin release, and conflicting sensory stimuli that override pain signals [2].

The process of rubbing and kneading soft tissues of the body can lead to relaxation of the tense muscles, increase blood flow to the underlying tissues and decrease pain. The exact mechanism of pain reduction in massage is still unknown; however, there are some studies and expert's hypothesis suggest that the process of massage can lead to an increase in dopamine levels which decrease pain. In addition to that, massage can lead to relaxation of the

There are many benefits of massage as it can reduce stress, promote muscle relaxation, lower blood pressure, improve circulation, help improve posture, and strengthen the body immune system. Moreover, there are some studies suggest that massage had been found to decrease

Massage can be beneficial in cancer patient as it can improve mood and quality of life among patients suffering from cancer. Both the massage and simple-touch groups had statistically, although not clinically, significant improvements in pain and quality of life over time despite no increases in total analgesic medication use [4]. In addition to that, there are some short-term benefits of massage which include improve psychological well-being and,

Spirituality and religion in pain management and music therapy.

Positioning is a physical intervention that includes maintaining a proper body alignment to reduce stress and anxiety, especially in children.

It helps to prevent further complications, reduces the risk for developing injuries, prevents developing bed ulcers and most importantly reduce alleviate pain. Therefore, positioning the patient correctly and re-positioning can help with the above complications [5].

Positioning can help with many patients as it can relieve muscle pain, tension and discomfort. It can improve blood circulation which in turn prevents ulcers from developing. Moreover, elevating extremities while positioning can be beneficial in decreasing pain and prevent edema as well.

#### **2.3. Hot and cold**

Several studies have shown reduction in pain, anxiety, nausea and heart rate in patients treated with active warming for pain related to mild trauma, cystitis, urolithiasis, cholelithiasis, appendicitis, colitis, and rectal trauma. This is an inexpensive and easy-to-use therapy with minimal side effects when used appropriately. Cold therapy includes applying a cool substance or device to any part of the body. Numerous studies have reported that cold treatment can increase pain threshold, decrease edema, and suppress the inflammatory process. Cold compresses may be used between 15 and 30 min time periods and up to 2–3 times per day.

Hot and cold therapy has been used for many decades and centuries to relieve pain, which includes muscle pain, joints pain, extremities pain, back pain and arthritis. Some studies show evidence that ice and heat therapies are effective and can reduce pain when compared to over the counter meds such as Paracetamol and Ibuprofen.

One study showed that "superficial heat relieves pain in a number of different ways:


Although through history hot and cold-water therapy is frequently used in home environment. However, these home therapies can create some complications such as burns and water leak. Nowadays, mostly in hospital setting, they use wheat-based heat packs and electrical heating pads, which are safer and give the maximum effect of analgesics [6].

#### **2.4. Acupuncture**

This has been used for around 5000 years, and it is considered one of the world's oldest arts of an empiric body healing. Basically, acupuncture works by putting the needle in specific region of the body, which stimulates the nerve. Each needle will cause no discomfort to little discomfort to the patient, but it will produce a small injury at the insertion area which will stimulate the body and the immune system to increase circulation, wound healing, pain modulation and pain analgesia [7].

TENS is virtually side effect free, and the mechanism includes activation of descending mod-

Non-Pharmacological Pain Management http://dx.doi.org/10.5772/intechopen.79689 5

TENS should not be used in patients with cardiac pacemakers or a history of cardiac dys-

Progressive muscle relaxation is a technique where the participant involved tightens and relaxes different muscle groups throughout the body in a progressive manner that would

There are many indications to the use of PMR, including back pain, phantom limb pain, headache and stress. PMR is a safe technique with minimal if any adverse effects have been

In a double-blinded randomized clinical trial the use of PMR was found to decrease intensity of pain, tenderness of masticatory muscles and maximum opening of mouth with and with-

Relaxation techniques have shown positive results for patients with chronic neck pain, tension headache, low back pain and chronic pain related to rheumatologic and non-rheumatologic

The global spine care initiative for communities with low and medium income supports the use of biofeedback and progressive muscle relaxation techniques as an initial therapy for

In a randomized controlled trial, it was found that the use of PMR in combination with guided imagery and phantom exercises were useful in reducing phantom limb pain and phantom

In an interesting study which looked into deploying relaxation techniques over the Internet was found to be effective for patient suffering from chronic headaches. Other trials are ongoing that utilizes phone applications in other conditions like chronic back pain and neck

Incorporating the biopsychosocial (BPS) model to pain management by targeting cognitive responses to pain and maladaptive behavioral in addition to social and environmental factors that may play an important role in modifying reactions to pain [23]. Such therapy has shown efficacy for many physical disorders and psychiatric illnesses, as well as pain [24]. Cognitive behavioral therapy (CBT) helps to develop important set of coping skills intended

patient without a serious pathology chronic low back pain and neck pain [20].

out pain in patient with myofascial pain dysfunction syndrome [12].

ulation systems and blocking of sympathetic outflow.

rhythmia [11].

reported.

limb sensation [21].

pain [14, 22].

**2.6. Progressive muscle relaxation**

provoke a sense of relaxation and comfort.

chronic inflammatory disorders [13–19].

**3. Psychological interventions**

**3.1. Cognitive behavioral therapy**

The unit can be attached to the patient's belt for ease of use.

The number and location of the acupuncture used by Chinese ancient times has changed by the science of modern practitioners, and nowadays they are using clinical and physical observation of the patient and the therapeutic effect of the pricking. According to Lewin (1974) "Two therapeutic modes of acupuncture are used in practice today: (1) acupuncture used for the treatment of many diseases and (2) acupuncture employed as an anesthetic procedure (a more accurate term for this would be surgical analgesia)" [8].

Acupuncture can be used to treat many conditions and studies claiming that it can be helpful with allergies, anxiety and depression, chronic back, neck, or shoulders pain, hypertension, insomnia, migraines, morning sickness, strokes and menstrual cramps. In addition to that studies suggest that it can be beneficial with cancer and multiple sclerosis patients as well [9]. The benefits of acupuncture can go beyond conditions to go far to help with relaxation and pain management as well. Acupuncture can be helpful as an analgesic effect to patients who experience pain as well [7].

#### **2.5. Transcutaneous electrical nerve stimulation**

Transcutaneous electrical nerve stimulation (TENS) is an electrical device used to treat pain. It consists of battery-powered unit and has 2–4 leads connected to sticky pads, which are positioned over the skin to cover or surround the painful area.

The TENS unit delivers a low-voltage electrical impulse to the padded surface electrodes in a series of alternating electrical current impulses.

The larger impulses are postulated to activate large myelinated fibers.

Large nerve fiber stimulation is thought to block small pain-transmitting fibers. Some experts also believe that TENS unit activates the release of natural endorphins at the pituitary level by using alternating low-540 frequency pulses.

It is thought that TENS produce analgesia by stimulating large afferent fibers. It can help those patients with chronic back pain, arthritis, and neuropathic pain. In addition, it can help patients with mild to moderate acute pain.

When the TENS unit is turned on, patient feeling a light tingling sensation over the area where the pads are placed.

The signal intensity also known as pulse width (duration of the pulse) produced from the TENS device can be adjusted, the goal being to produce paresthesia without muscle contraction. At initial use, the patient adjusts the settings to find the most comfortable effective sensation [10].

TENS is virtually side effect free, and the mechanism includes activation of descending modulation systems and blocking of sympathetic outflow.

The unit can be attached to the patient's belt for ease of use.

TENS should not be used in patients with cardiac pacemakers or a history of cardiac dysrhythmia [11].

#### **2.6. Progressive muscle relaxation**

**2.4. Acupuncture**

modulation and pain analgesia [7].

4 Pain Management in Special Circumstances

experience pain as well [7].

more accurate term for this would be surgical analgesia)" [8].

positioned over the skin to cover or surround the painful area.

The larger impulses are postulated to activate large myelinated fibers.

**2.5. Transcutaneous electrical nerve stimulation**

series of alternating electrical current impulses.

using alternating low-540 frequency pulses.

patients with mild to moderate acute pain.

where the pads are placed.

sensation [10].

This has been used for around 5000 years, and it is considered one of the world's oldest arts of an empiric body healing. Basically, acupuncture works by putting the needle in specific region of the body, which stimulates the nerve. Each needle will cause no discomfort to little discomfort to the patient, but it will produce a small injury at the insertion area which will stimulate the body and the immune system to increase circulation, wound healing, pain

The number and location of the acupuncture used by Chinese ancient times has changed by the science of modern practitioners, and nowadays they are using clinical and physical observation of the patient and the therapeutic effect of the pricking. According to Lewin (1974) "Two therapeutic modes of acupuncture are used in practice today: (1) acupuncture used for the treatment of many diseases and (2) acupuncture employed as an anesthetic procedure (a

Acupuncture can be used to treat many conditions and studies claiming that it can be helpful with allergies, anxiety and depression, chronic back, neck, or shoulders pain, hypertension, insomnia, migraines, morning sickness, strokes and menstrual cramps. In addition to that studies suggest that it can be beneficial with cancer and multiple sclerosis patients as well [9]. The benefits of acupuncture can go beyond conditions to go far to help with relaxation and pain management as well. Acupuncture can be helpful as an analgesic effect to patients who

Transcutaneous electrical nerve stimulation (TENS) is an electrical device used to treat pain. It consists of battery-powered unit and has 2–4 leads connected to sticky pads, which are

The TENS unit delivers a low-voltage electrical impulse to the padded surface electrodes in a

Large nerve fiber stimulation is thought to block small pain-transmitting fibers. Some experts also believe that TENS unit activates the release of natural endorphins at the pituitary level by

It is thought that TENS produce analgesia by stimulating large afferent fibers. It can help those patients with chronic back pain, arthritis, and neuropathic pain. In addition, it can help

When the TENS unit is turned on, patient feeling a light tingling sensation over the area

The signal intensity also known as pulse width (duration of the pulse) produced from the TENS device can be adjusted, the goal being to produce paresthesia without muscle contraction. At initial use, the patient adjusts the settings to find the most comfortable effective Progressive muscle relaxation is a technique where the participant involved tightens and relaxes different muscle groups throughout the body in a progressive manner that would provoke a sense of relaxation and comfort.

There are many indications to the use of PMR, including back pain, phantom limb pain, headache and stress. PMR is a safe technique with minimal if any adverse effects have been reported.

In a double-blinded randomized clinical trial the use of PMR was found to decrease intensity of pain, tenderness of masticatory muscles and maximum opening of mouth with and without pain in patient with myofascial pain dysfunction syndrome [12].

Relaxation techniques have shown positive results for patients with chronic neck pain, tension headache, low back pain and chronic pain related to rheumatologic and non-rheumatologic chronic inflammatory disorders [13–19].

The global spine care initiative for communities with low and medium income supports the use of biofeedback and progressive muscle relaxation techniques as an initial therapy for patient without a serious pathology chronic low back pain and neck pain [20].

In a randomized controlled trial, it was found that the use of PMR in combination with guided imagery and phantom exercises were useful in reducing phantom limb pain and phantom limb sensation [21].

In an interesting study which looked into deploying relaxation techniques over the Internet was found to be effective for patient suffering from chronic headaches. Other trials are ongoing that utilizes phone applications in other conditions like chronic back pain and neck pain [14, 22].
