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Rehabilitative and integrative therapies for pain in patients with cancer

Rehabilitative and integrative therapies for pain in patients with cancer
Literature review current through: Jan 2024.
This topic last updated: Dec 23, 2022.

INTRODUCTION — Pain is one of the most feared consequences of cancer and cancer treatment. Pain affects the psychological, cognitive, physical, social, and spiritual domains of patients' lives, and its burden is manifested not only through the experience of the symptom itself, but also through impaired function, decreased activity, and alterations in one's sense of identity and social role. Poorly relieved pain can have a profoundly negative impact on the quality of life and can trigger hopelessness, despair, and a desire for a hastened death. Caregivers who are witnesses to pain also may experience helplessness, distress, and burden. For both patients and caregivers, the assumption that pain heralds progressive disease may cause fear and distress.

Although opioid-based pharmacotherapy is widely accepted as the mainstay of treatment for moderate to severe pain in patients with active cancer, other treatment approaches should be considered in every case. A multimodality approach that includes nonpharmacologic therapies in conjunction with opioids has the potential to augment pain relief, reduce opioid side effects through lower opioid doses, and yield better physical and psychosocial outcomes. There are numerous nonpharmacologic therapies, including primary treatments for the etiology of the pain (eg, radiotherapy), and both invasive (eg, nerve blocks) and noninvasive symptomatic therapies.

This topic review discusses a diverse group of noninvasive, nonpharmacologic therapies that are widely used as adjuncts to opioid therapy for patients with cancer pain. Included are the so called integrative (complementary) approaches and rehabilitative therapies that employ physical medicine techniques for analgesic purposes. Classification approaches for integrative therapies vary and this review encompasses well accepted psychologic approaches that are sometimes included among the integrative therapies, specifically mind-body approaches (eg, relaxation training, meditation, guided imagery and clinical hypnosis). Cognitive behavioral therapy is considered a mainstream, conventional psychologic approach. However, because it often incorporates mind-body practices (eg mindfulness) it can be described as an integrative therapy [1,2].

Assessment of cancer pain, a review of specific cancer pain syndromes, general principles of cancer pain management, the clinical use of opioid analgesics, non-opioid analgesics (including adjuvant analgesics), invasive symptomatic therapies for cancer pain management, and an overview of complementary and integrative therapies in oncology care are covered separately:

(See "Assessment of cancer pain".)

(See "Overview of cancer pain syndromes".)

(See "Cancer pain management: General principles and risk management for patients receiving opioids".)

(See "Cancer pain management with opioids: Optimizing analgesia".)

(See "Cancer pain management: Role of adjuvant analgesics (coanalgesics)".)

(See "Interventional therapies for chronic pain".)

(See "Radiation therapy for the management of painful bone metastases".)

(See "Overview of complementary, alternative, and integrative medicine practices in oncology care, and potential risks and harm".)

REHABILITATIVE INTERVENTIONS — The primary goal of rehabilitative interventions may be functional improvement, symptom control, or both. The sections that follow will focus on role in symptom management. Interventions include various types of therapeutic exercise (usually initiated or guided by a physical therapist); hydrotherapy; the use of orthoses, ambulation aids, or other devices; and the use of modalities, such as the application of heat and cold, vibration, ultrasound, or electricity (eg, transcutaneous electrical nerve stimulation [TENS]). A focused approach to the treatment of cancer or cancer-treatment-related lymphedema that includes massage therapy also may be included if this condition is present and contributing to symptom distress. (See 'Lymphedema treatment' below and 'Massage therapy' below.)

Other approaches that use electricity or magnetic waves are invasive (eg, dorsal column stimulation) or yet rarely considered for cancer patients (eg, transcranial neuromodulation) and are not discussed in this topic. Some of these techniques and other invasive interventional therapies for cancer pain are discussed elsewhere. (See "Interventional therapies for chronic pain".)

Therapeutic exercise — Therapeutic exercise has the potential for analgesia resulting from both direct and indirect effects, and also improves self-efficacy, functional gains, and quality of life. A role in cancer pain management is particularly suggested when the pain is related to musculoskeletal pathology that may be addressed by supervised exercise. Safe and effective therapy is most assured when treatment is implemented by a physical therapist who has experience with pain and is competent in dealing with the specific concerns related to cancer and its treatment.

Therapeutic exercise (physical therapy) can be a time-limited intervention that may ameliorate pain and other musculoskeletal symptoms. Therapeutic exercise involves the systematic implementation of planned physical movements, postures, or activities designed to ameliorate impairment, improve function, and enhance overall wellbeing. Manual stretching, myofascial therapy, passive mobilization, and active exercises are some of the modalities utilized within this approach. The type, frequency, and duration of exercise is always informed by the specific needs and medical condition of the patient and the overall goals of care. Self-exercises using an inflatable ball and Pilates (a low-impact exercise program that focuses on improving flexibility, stability, core strength and range of motion) may be considered in tandem with therapeutic exercise as approaches that may address pain and function impairment in cancer patients.

Particularly in patients who have musculoskeletal pathology contributing to pain or dysfunction, physical therapy may address this pathology and yield positive effects. Indirect positive effects resulting from general conditioning or other physiologic or psychologic changes also may occur [3].

There are very few data from high-quality controlled studies that assess the impact of therapeutic exercise on pain [4]. Nonetheless, studies in cancer populations, including populations with advanced cancer [5], suggest benefits for exercise in terms of symptom control and other aspects of quality of life:

A systematic review of 18 randomized studies demonstrated the effectiveness of physical therapy for improving postoperative pain and range of motion after breast cancer treatment [6].

A multicenter trial that randomized 355 patients with chemotherapy-induced peripheral neuropathy (CIPN) to usual care or usual care plus Exercise for Cancer Patients (EXCAP; a six-week, individualized, moderate-intensity program of progressive walking and resistance training) found that EXCAP was effective in reducing numbness and tingling and hot/coldness in hands and feet [7]. Another randomized trial of a 10-week, home-based exercise program (incorporating muscle strengthening and balancing exercise) in 45 patients with CIPN showed that this program yielded significant positive change in neuropathic pain scores and quality of life [8]. The benefits of exercise in patients with chemotherapy-induced chronic neuropathy are addressed in more detail elsewhere. (See "Prevention and treatment of chemotherapy-induced peripheral neuropathy", section on 'Exercise'.)

Another randomized trial of 121 breast cancer survivors with aromatase inhibitor-induced arthralgia found that 150 minutes of aerobic exercise a week and supervised strength training sessions twice a week yielded a significant reduction of joint pain, pain severity, and interference group [9]. A similar benefit was shown in the randomized HOPE trial [10]. (See "Adjuvant endocrine and targeted therapy for postmenopausal women with hormone receptor-positive breast cancer", section on 'Musculoskeletal pains and stiffness'.)

A retrospective study of 102 adult cancer patients found that an individualized exercise program resulted in a significant improvement in cardiopulmonary function and both fatigue and pain [11]. (See "Cancer-related fatigue: Treatment", section on 'Exercise'.)

A quasi-experimental study of inflatable ball exercise in breast cancer survivors found that the intervention significantly improved flexion and extension of shoulder range of motion compared with conventional exercise (n = 38 in inflatable exercise group and n = 34 in conventional exercise group). The authors concluded that inflatable ball exercise could be appropriate to start a physical rehabilitation program and should be followed by conventional exercise after the pain and range of motion have improved [12].

A systematic review and meta-analysis of five randomized studies and two uncontrolled trials evaluating Pilates concluded that this approach was superior to other therapeutic exercise programs in improving pain and self-reported upper extremity function in patients with breast cancer [13].

Hydrotherapy — Hydrotherapy involves the supervised submersion into water of the patient or a part of the patient's body to address symptoms or impairments. It provides a reduced-gravity environment and sensory experience that may decrease pain with movement, augment muscle relaxation, improve emotional state, and facilitate physical therapy (ie, aquatic exercise) because of the effect of buoyancy and decreased stress on joints. Patients may report both physical and psychologic benefits.

Hydrotherapy has been used in many disorders, such as rheumatoid arthritis, ankylosing spondylitis, and fibromyalgia [14-16]. (See "Treatment of axial spondyloarthritis (ankylosing spondylitis and nonradiographic axial spondyloarthritis) in adults", section on 'Nonpharmacologic interventions' and "Nonpharmacologic therapies for patients with rheumatoid arthritis", section on 'Physical therapy'.)

Hydrotherapy has also been used in the management of pain and other symptoms in populations with cancer. A 2022 systematic review of studies reporting the use, effectiveness, and potential harms associated with water therapy for cancer-related symptoms identified 12 studies describing 430 patients [17]; outcomes were heterogeneous and definitive conclusions were not possible, but the data suggested that the approaches are generally safe and can benefit some patients. For example, a single-blind randomized trial of 40 breast cancer survivors with aromatase inhibitor-induced arthralgia found that aquatic exercise in a chest-high pool (three sessions/week for a total of 24 sessions over two months) decreased the pressure pain threshold in neck, hand, shoulder, and leg, with no worsening of pain, compared with controls [18]. (See "Managing the side effects of tamoxifen and aromatase inhibitors", section on 'Musculoskeletal pains and stiffness'.)

As with other therapeutic exercise approaches, hydrotherapy and aquatic exercise should always be preceded by a consultation between the physiatrist and the oncologist and careful evaluation of the patient.

Orthoses and other devices — Examples of orthoses include:

Immobilizers of the shoulder and arm for a painful brachial plexopathy.

Corsets for persistent pain after treatment for vertebral metastases.

Wrist or ankle splints for distal extremity weakness or pain related to neuropathy.

Patients with pain on movement may benefit from a splint that is designed to limit those motions that incite the pain. In the cancer population, and particularly in the setting of advanced illness, the use of an orthosis may be preferable to other interventions, such as physical therapy, that attempt to improve function. A return to full function may not be possible, or it may not be the primary treatment goal. Evaluation by an occupational therapist, with input by the oncologist, can clarify the availability and cost of various options.

Stump pain may be ameliorated by a well-fitting prosthesis, an ambulation aid may reduce pain exacerbation with walking, and devices designed to facilitate specific functions such as toileting or eating can have analgesic consequences or reduce the risk of secondary painful complications related to immobility.

Other modalities — The therapeutic application of heat or cold, ultrasound, and electrical stimulation to focal sites of pain that are unrelated to cancer (eg, sprains) is widely accepted. However, there have been very few studies evaluating short-term efficacy, long-term effectiveness, and safety of these physical modalities in populations with cancer pain, and the evidence in other populations is extremely limited [19].

Physical modalities may be especially useful as adjuncts for mild to moderate pain and while awaiting the effect of a breakthrough analgesic. They are never adequate alone for managing moderate or severe cancer pain. There are no comparative data to guide suggestions concerning the selection of specific modalities when used as adjunctive treatment for pain, and the choice of technique is empirical. Based on inference and concern about adverse cutaneous effects, guidelines often suggest avoiding the topical application of these stimuli to areas with reduced sensation and those that are directly superficial to tumor masses.

Cold — Cold application with ice packs, malleable chemical gel packs, and vapocoolant sprays may reduce muscle spasm, inflammation, and edema. Cold produces an initial vasoconstriction, followed by vasodilation, but the extent to which these effects relate to analgesia is unknown. Despite widespread use, there are no controlled studies of cold-induced analgesia for cancer pain. Application of cold should be avoided in ischemic and irradiated tissues [20].

Heat — Various heating methods may be used to help manage focal or regional, acute or chronic pain. Heat increases local blood flow and may decrease joint stiffness; it also may induce a state of mental relaxation. Pain relief may be related to these effects. Evidence for efficacy in cancer pain is lacking but heating approaches often are tried for musculoskeletal pains. Superficial heating can be accomplished with hot packs, medicated heat patches (eg, containing capsaicin), heating pads, or hot baths.

TENS and other electrostimulation devices — Transcutaneous electrical nerve stimulation (TENS) is widely used, despite limited evidence of efficacy in any type of chronic pain, including cancer-related pain [21]. Although case reports and uncontrolled studies suggest efficacy with limited duration of benefit [22], two small randomized trials of TENS in patients with cancer pain were negative [23,24], and five systematic reviews concluded that there was insufficient evidence to judge whether TENS should be used in adults with cancer-related pain [21,25-28].

Nevertheless, clinical experience suggests that some patients with cancer-related pain benefit from TENS, and TENS is included in the list of potential nonpharmacologic interventions for adult cancer pain in guidelines from the National Comprehensive Cancer Network [29].

TENS can be tried during a home trial or as a supervised trial when working with a physical therapist. Given the lack of certainly about the stimulation parameters most likely to help in an individual patient, a serious trial of TENS requires many days and should explore various sites and timing of stimulation, as well as a variety of stimulation parameters (amplitude, frequency, and pattern).

Scrambler therapy — Scrambler therapy is a novel transcutaneous neurostimulatory approach that involves the delivery of electrical current through electrocardiogram-like pads that are placed bilaterally on the skin, above and below the site of pain. It has been evaluated through case series, surveys, and small trials involving patients with chronic noncancer neuropathic pain [29-31] or CIPN [32-34].

A prospective survey of 219 patients treated with Scrambler therapy for different types of chronic pain (37.9 percent with cancer pain) documented pain reduction for at least two weeks [35].

On the other hand, two randomized, sham-controlled pilot trials of scrambler therapy for CIPN yielded conflicting results, one positive [33] and one negative [34].

The available data support the conclusion that Scrambler therapy is safe [36], and notwithstanding the need for larger randomized studies, the available data suggest that Scrambler therapy may be a useful alternative for some patients [37,38]. A neuropathic component to the pain may increase the likelihood of benefit. The use of Scrambler therapy for treatment of patients with CIPN is discussed in more detail elsewhere. (See "Prevention and treatment of chemotherapy-induced peripheral neuropathy", section on 'Scrambler therapy'.)

Ultrasound — Focal musculoskeletal pains also may be treated with ultrasound. The technique is widely regarded as safe but there have been no studies that assess efficacy or effectiveness relative to other modalities. (See "Overview of soft tissue musculoskeletal disorders", section on 'Myofascial pain syndrome'.)

Lymphedema treatment — In the cancer population, lymphedema usually occurs in an extremity and results from cancer treatment; it is often painful. (See "Lower extremity lymphedema" and "Clinical features and diagnosis of peripheral lymphedema" and "Breast cancer-associated lymphedema".)

Numerous clinical guidelines have been developed to guide the treatment of lymphedema; several focus on the cancer population [39]. Most of these guidelines, whether cancer-related or not, recommend an integrated approach that considers both physical and psychologic interventions. Rigorous treatment protocols may start with education focused on skin care and avoidance of trauma, and depending on the cause and other factors, may recommend manual lymph drainage, intermittent pneumatic compression, compression bandaging, complete decongestive physiotherapy, taping, or exercises (including aquatic exercises). If the girth in the affected limb can be reduced, patients usually experience a decline in uncomfortable heaviness or stretch, and in secondary myofascial pains [40]. (See "Clinical staging and conservative management of peripheral lymphedema" and "Breast cancer-associated lymphedema", section on 'Effectiveness of conservative treatments' and "Lower extremity lymphedema", section on 'Conservative care'.)

Exercise may also be beneficial, particularly for breast cancer-related lymphedema. Specific recommendations are provided in more detail elsewhere. (See "Breast cancer-associated lymphedema".)

Some of the approaches for extremity lymphedema also may benefit lymphedema in other sites, such as in the head and neck region. As an example, a retrospective study of 32 patients with head and neck cancer who received physical therapy (lymphatic drainage; massage; compression therapy; facial, tongue, and neck exercises) and patient education for lymphedema showed significant improvement in face and neck lymphedema and pain after an average of 23.9 sessions [41]. (See "Management of late complications of head and neck cancer and its treatment", section on 'Lymphedema and fibrosis'.)

INTEGRATIVE THERAPIES

Definition and frequency of use — Integrative therapy may be viewed as a care model in which conventional medical approaches are coordinated and combined with any of a large number of complementary treatments. These are treatments that are not generally part of conventional medical care and/or originated outside of Western approaches. Integrative therapy is intended to pursue a holistic course that includes specific objectives (eg, pain control [1]) and a broader goal of improved quality of life. (See "Overview of complementary, alternative, and integrative medicine practices in oncology care, and potential risks and harm", section on 'Definitions' and "Overview of complementary, alternative, and integrative medicine practices in oncology care, and potential risks and harm", section on 'Epidemiology'.)

Some classifications distinguish complementary therapies into the following broad categories:

Traditional and whole medical systems, such as traditional East Asian medicine, Ayurveda, homeopathy, naturopathy, and chiropractic care.

Mind and body practices, such as meditation, mindfulness-based interventions (eg, Mindfulness-Based Stress Reduction [MBSR]), meditation, cognitive-behavioral therapy (CBT), clinical hypnosis, creative arts therapy, yoga, and manipulative body-based practices such as massage, reflexology, and acupuncture/acupressure.

Biologic-based therapies, such as herbal therapies (dietary supplements and botanicals), specialized diets.

Energy therapies, such a therapeutic touch, healing touch, and reiki.

Like traditional allopathic medical approaches, all integrative therapies are associated with risks, which must be evaluated for the individual patient and balanced with the potential for benefits. Some treatments have inherently high risks (eg, spinal manipulation in the setting of symptomatic bone metastases or the use of herbal remedies that directly interact with other anticancer therapies, such as chemotherapy) and clinicians should strongly recommend against these. Many others, however, carry very low levels of risk and may be supported by clinicians despite limited evidence of benefit. If practitioners are available and the cost is affordable, there is no reason to discourage patients from integrating these latter types of treatments with other conventional therapies, at least for a therapeutic trial. (See "Overview of complementary, alternative, and integrative medicine practices in oncology care, and potential risks and harm", section on 'Potential risks and harms of caim use'.)

Studies that have evaluated clinician-patient communications about the use of integrative therapies have highlighted concerns about disclosure and the need for improvements [42]. A trusting relationship with a treating clinician will encourage patients not only to disclose their interest in complementary therapies, but also to be forthcoming in discussing therapies they are already following. This will allow the clinician to discuss any contraindications and risks with the patient and to make treatment recommendations. (See "Overview of complementary, alternative, and integrative medicine practices in oncology care, and potential risks and harm", section on 'Discussing CAIM with patients'.)

Mind and body practices — Mind and body practices (MBPs) refer to a group of therapies that share a common perspective: emphasizing the potential value of training the "mind" (by shifting cognitions and/or creating a desirable emotional state) in a way that favorably influences bodily functions. MBPs are usually considered as an adjunct to pharmacotherapy, within the context of a broader approach that may include other unrelated noninvasive therapies. However, occasionally, they are offered alone as specific treatments for a single discrete problem (eg, pain related to a specific procedure). (See 'Procedure-related pain' below.)

Many of these treatments require a competent and specifically trained health professional, but some, such as relaxation training based on slow and mindful breathing, may be taught by a knowledgeable primary care provider. (See "Overview of complementary, alternative, and integrative medicine practices in oncology care, and potential risks and harm".)

Overall benefits — There have been numerous studies of MBPs. A systematic review of systematic reviews identified 129 papers but noted the substantial deficiencies of the entire evidence base [43]. Studies have evaluated many different types of treatments in highly diverse clinical contexts using procedures that have not been well standardized. The conclusion drawn from this work is that the evidence base to support benefit from MBPs in oncology patients with pain is highly variable and often limited to specific treatments and settings. However, information concerning risk has been reassuring, and for most of these approaches, it is likely that the potential for benefit outweighs harms. For patients who desire it, and if practitioners are available, a trial of one of these therapies can be offered.

The benefits of some mainstream MBPs (meditation, hypnosis, relaxation, guided imagery, therapeutic suggestion, and CBT) have been addressed in the following systematic reviews:

In a systematic review and meta-analysis of 60 randomized trials (6404 participants) that evaluated the use of MBPs for symptom management in adults also prescribed opioids for clinical pain (acute or chronic); only five of the trials focused on patients with cancer pain [44]. The trials evaluated meditation/mindfulness (n = 5), hypnosis (n = 25), relaxation (n = 14), guided imagery (n = 7), therapeutic suggestion (n = 6), and CBT (n = 7) interventions. The primary outcome was pain intensity, which was standardized using a 0 to 10-point numeric rating scale.

Taken together, MBPs had a significant, albeit moderate, association with reduced pain (29 studies, 2916 patients, mean difference -0.51, 95% CI -0.76 to -0.27, with some heterogeneity of effect size). Whether this change represents a clinically meaningful result is unclear. Benefits for cancer pain were not reported separately. The analysis also addressed the benefits of MBPs in terms of opioid dose. MBPs also had a significant but small association with reduced opioid use (eight studies, 435 patients, mean difference -0.26, 95% CI -0.44 to -0.08, with homogeneous effect sizes).

In a meta-analysis of 37 randomized trials of psychotherapy, CBT, and some other MBPs (relaxation, hypnosis, desensitization with imagery or biofeedback, meditation) in 4199 cancer patients in whom pain intensity and interference were measured as outcomes, the mean effect size for reduction in pain intensity, the primary outcome, was 0.34 (95% CI 0.23-0.46), and for pain interference, it was 0.40 (95% CI 0.21-0.60) [45]. These differences between intervention and control were defined as medium effect sizes.

In a systematic review of 10 randomized controlled trials published between 28 January, 2015 and December 15, 2020 evaluating various MBPs for cancer pain, the most effective therapies were mindfulness-based cognitive therapy, guided imagery, progressive muscle relaxation, and emotional and symptom focused engagement [46]. Music therapy and brief cognitive behavioral strategies require more research, while coping skills training and yoga did not show positive effects. Effect sizes were moderate and tended to increase at follow-up.

Another systematic review and meta-analysis of 40 randomized controlled studies involving a total of 3569 participants showed a significant effect of MBPS on intensity of cancer pain (mean difference -0.39, 95% CI -0.62 to -0.16) but with considerable heterogeneity [47]. Excluding four "outlier" studies in sensitivity analyses resulted in an effect size that remained significant but was weaker. There was a high risk of bias in all studies and many were of low quality.

Benefit of specific strategies — Many studies have focused on the use of specific integrative practices in particular clinical contexts. A description of these practices, including information about credentialing, licensing, and regulation is provided separately. (See "Overview of complementary, alternative, and integrative medicine practices in oncology care, and potential risks and harm".)

Acupuncture, acupressure, and reflexology — The word "acupuncture" is derived from the Latin words "acus" (needle) and "punctura" (penetration) and can refer to a family of procedures used to stimulate anatomical points, most commonly with thin needles. By contrast, acupressure and reflexology are both body work techniques which involve applying pressure to specific points on the body; acupressure involves the whole body, while reflexology involves the feet, hands, ears, and face [48]. Additional descriptions of these practices, including the credentialing, licensure, and regulation are provided separately. (See "Overview of complementary, alternative, and integrative medicine practices in oncology care, and potential risks and harm", section on 'Acupuncture, acupressure, and reflexology'.)

Acupuncture, acupressure, and reflexology may be effective integrative therapies for a variety of cancer pain conditions. In 2008, the National Institutes of Health (NIH) and US Food and Drug Administration (FDA) declared in a consensus statement that acupuncture is not an experimental therapy but a sound medical technique comparable in effectiveness to common conventional medical treatments for certain clinical conditions, such as nausea and pain [49]. Despite this statement, the effectiveness of acupuncture for patients with cancer pain has been difficult to prove. Although some studies have suggested that acupuncture and electroacupuncture can be useful in ameliorating cancer-related and cancer treatment-related neuropathic pain, there are few well-conducted, rigorous trials that include a sham acupuncture control group, which is necessary because of the strong placebo effect of both acupuncture and sham acupuncture. (See "Overview of the clinical uses of acupuncture", section on 'Research challenges'.)

The clinical uses and evidence base to support benefit for acupuncture, acupressure, and reflexology are outlined in the following sections.

Pain related to aromatase inhibitor use or chemotherapy-induced peripheral neuropathy — The evidence base to support benefit from acupuncture and acupressure for musculoskeletal pain related to aromatase inhibitors, and for pain related to chemotherapy-induced peripheral neuropathy is described elsewhere. (See "Managing the side effects of tamoxifen and aromatase inhibitors", section on 'Musculoskeletal pains and stiffness' and "Prevention and treatment of chemotherapy-induced peripheral neuropathy", section on 'Acupuncture'.)

Pain during systemic anticancer therapy — Given the low potential for harm, and the potential for benefit, a trial of acupressure or reflexology may be offered to patients experiencing pain during systemic therapy other than an aromatase inhibitor for cancer. Treatment should end after a few sessions, unless there is demonstrable benefit.

At least seven trials have explored the benefit of foot reflexology for general or musculoskeletal pain during cancer therapy (cytotoxic therapy, chemoradiotherapy, molecularly targeted and/or hormonal therapy) [50-56]. They were mostly small (four trials had fewer than 50 patients per arm), all used different methods to implement the reflexology intervention, and the type of control varied between trials (attention control, in which the individuals receive the same dose of interpersonal interaction as intervention participants but no other elements of the intervention to control for the benefits of attention that may come from behavioral interventions, usual or standard care, or other active treatment such as relaxation). Nevertheless, six of the seven noted significantly less pain in the intervention group compared with controls.

A 2022 joint American Society of Clinical Oncology (ASCO)/Society for Integrative Oncology (SIO) guideline endorsed the use of reflexology for pain during systemic therapy for cancer (benefits outweigh harms, evidence quality intermediate, strength of recommendation moderate) [57]. (See 'Clinical practice guidelines' below.)

Chronic pain related to cancer — Given the low potential for harm and the evidence for moderate benefit, a trial of acupuncture may be offered as part of a comprehensive pain management approach for patients with chronic cancer pain, including musculoskeletal pain. Treatment should end after a few sessions, unless there is demonstrable benefit.

Multiple meta-analyses have addressed the benefits of acupuncture and acupressure for a variety of types of cancer-related pain, including general or musculoskeletal pain unrelated to aromatase inhibitor use, and postsurgical pain:

A 2015 Cochrane review of five randomized trials (only one of which included a sham acupuncture control group [58]; the others compared acupuncture to placebo or systemically administered analgesics) totaling 285 patients with cancer pain concluded that there was insufficient evidence to judge whether acupuncture was effective in treating cancer pain from a variety of etiologies in adults [59].

A similar conclusion was reached in a later Cochrane review of acupuncture for chronic peripheral neuropathic pain in adults, including cancer-related neuropathy [60].

On the other hand, a benefit for acupuncture and acupressure in reducing pain in patients with cancer was supported by a more rigorous systematic review and meta-analysis of 17 randomized trials (with 1111 patients) [61], including seven sham-controlled randomized trials [62-68]. The primary outcome was pain intensity, as measured by a score of 1 to 10 on the Brief Pain Inventory (BPI), Numeric Rating Scale, Visual Analog Scale (VAS), or Verbal Rating Scale. Thirteen studies focused on a specific type of cancer pain (six on aromatase inhibitor-associated arthralgias, two on lung cancer pain, one on gastric cancer pain, one on pancreatic cancer pain, one on malignant neuropathic pain, one on bone metastatic pain, and one on persistent pain after a surgical procedure), while four investigated general cancer pain with a mix of diagnoses.

An analysis of the seven sham-controlled trials, which were judged to be of high quality and at a low risk of bias, showed that real (as compared with sham) acupuncture was associated with reduced pain intensity (mean difference -1.38 points, 95% CI -2.13 to -0.64). In the non-sham-controlled studies, a favorable association was also noted when acupuncture and acupressure were combined with analgesic therapy versus analgesic therapy alone (six trials, mean difference in pain intensity -1.44 points, 95% CI -1.98 to -0.89) and in two trials of acupressure or acupuncture plus analgesic therapy versus analgesic therapy alone for reduced opioid dose (mean difference -30 mg, 95% CI -37.5 to -22.5). The certainty of evidence was judged to be moderate because of the substantial heterogeneity among studies.

A later randomized trial of electroacupuncture or auricular acupuncture versus usual care for chronic musculoskeletal cancer pain included 360 cancer survivors; the group receiving usual care received standard pain management including analgesic medications, physical therapy, and glucocorticoid injections; they were offered the option of receiving 10 acupuncture treatments after week 12 (the duration of the primary end point) [69]. Compared with usual care, electroacupuncture reduced pain severity by 1.9 points on a scale of 0 to 10 (97.5% CI 1.4-2.4 points), and auricular acupuncture reduced pain severity by 1.6 points (97.5% CI 1.0-2.1) from baseline to week 12. Adverse events were mild; only 10 percent of those receiving auricular acupuncture and 1 percent of those receiving electroacupuncture discontinued treatment for adverse effects.

Surgical or procedural pain — Although the certainty of evidence is low, potential benefits seem to outweigh risks, and a trial of acupressure or acupuncture may be offered to patients undergoing cancer surgery or other cancer-related procedures such as bone marrow biopsy.

At least 12 randomized trials assessing the impact of acupuncture or acupressure in reducing pain associated with surgery or other procedures in cancer patients, all of which are limited by small size, and either uncertain or high risk of bias [70-81]. Of the nine trials addressing postoperative pain, six showed no significant difference between the acupuncture and control groups, while three demonstrated a lower pain score compared with usual postoperative care [74-76]. Two trials on bone marrow aspiration and biopsy pain concluded that acupressure significantly reduced procedure-related pain compared with a sham control group [70,71], and one trial showed that acupuncture significantly reduced pain, nausea, and anxiety in the first two postoperative days compared with usual care [72].

Two published guidelines on the role of integrative therapy in patients with cancer concluded that acupuncture can be offered to patients with pain after cancer surgery, but the certainty of the evidence was low [57,82]. (See 'Clinical practice guidelines' below.)

Cognitive-behavioral therapy — A trial of CBT may be offered as part of a comprehensive pain management approach for patients with chronic cancer pain.

Cancer pain is significantly affected by psychologic factors and an individual's cognitive style. According to the cognitive-behavioral model, an individual's interpretation of external events and bodily sensations directly affects his or her emotional reactions to these events and subsequent behavior. The three main components of CBT are: cognitive restructuring, behavioral activation, and problem solving. Cognitive restructuring involves identifying and modifying unhelpful thinking patterns that are believed to increase distress [83-85]. Dichotomous thinking, catastrophizing, and overgeneralization, among others, are considered dysfunctional cognitive patterns because they typically arise from limited information and do not accurately reflect reality (table 1).

CBT approaches to management of cancer pain can effectively improve coping, self-efficacy, and a sense of control over the pain [86]. Many of these interventions were initially developed for patients with chronic, noncancer pain and subsequently applied to the treatment of patients with cancer. (See "Approach to the management of chronic non-cancer pain in adults", section on 'Cognitive-behavioral therapy'.)

While numerous studies have investigated the role of CBT in the treatment of mood disturbances in patients with cancer, few have considered cancer-related pain as the outcome variable:

At least three well-designed randomized controlled trials [87-89] demonstrated that behavioral skill training could reduce cancer-related pain during a short follow-up period of six months. On the other hand, two other trials of CBT to reduce treatment-related pain (mainly from mucositis) in patients undergoing hematopoietic cell transplantation failed to show a benefit [90,91].

A meta-analysis of randomized trials examining CBT for distress and pain in breast cancer patients, which included two randomized trials in which pain was an outcome measure [92,93], concluded that patients who were administered CBT had significantly less distress and pain compared with those in control groups [94].

A systematic review and meta-analysis examined 95 clinical trials evaluating the impact of CBT and mindfulness-based cognitive therapy approaches on functional health variables, including pain, in cancer survivors [95,96]. Subgroup analyses of common outcomes within the functional health domain revealed a small but statistically significant treatment effect for pain (0.209, 95% CI 0.051-0.367). Overall, CBT had a significant positive treatment effect on functional health outcomes in patients receiving active cancer treatment and during the survivorship phase but not in those with newly diagnosed cancers. The authors postulated that newly diagnosed patients may feel overwhelmed by the news and may not respond well, at least initially, to a structured approach such as CBT. However, as patients adjust to the diagnosis and focus on identifying strategies to improve coping, CBT has a significant positive impact across cancer diagnoses.

Yoga — The techniques of yoga include ethical daily living ("yamas" and "niyamas"), physical postures ("asanas"), breathing techniques ("pranayama"), and meditation training ("dhyana"). There are a wide range of yoga forms and styles, the most commonly practiced form in the United States and Canada is Hatha yoga, which emphasizes postures and often breathing exercises. Restorative yoga (RY) is a gentle type of yoga that requires minimal physical effort and emphasizes breathing and relaxation. RY poses can be easily adapted for cancer patients. The use of pillows and other props allows for poses that promote ease and comfort. (See "Overview of complementary, alternative, and integrative medicine practices in oncology care, and potential risks and harm", section on 'Description of practice'.)

Pain related to aromatase inhibitor use — The evidence base to support benefit yoga for musculoskeletal pain related to aromatase inhibitors is described elsewhere. (See "Managing the side effects of tamoxifen and aromatase inhibitors", section on 'Musculoskeletal pains and stiffness'.)

Other settings — Given the likelihood that benefits outweigh risks, a trial of Hatha yoga may be offered to patients experiencing pain after breast or head and neck cancer treatment, although the certainty of evidence of benefit is low. Benefit in other settings is unclear. As with therapeutic exercise, the presence of a qualified instructor familiar with working with patients who are medically ill will increase safety and desirable outcomes.

At least three small randomized trials suggest potential benefits for yoga in the management of pain in cancer patients [97-99]:

Two of these trials included patients with chronic musculoskeletal pain after treatment for breast cancer [97] or head and neck cancer [98]; both had small sample sizes (≤42 patients), both assessed outcomes at 2 to 2.5 months, and both showed modest but significant benefits for yoga when comparing baseline versus posttreatment outcomes.

In the third trial, 62 individuals with a myeloproliferative neoplasms were randomly assigned to a 12-week online yoga intervention or wait list controlled [99]. Only 48 completed the intervention (27 yoga, 21 control group). There were small effects of yoga on patient-reported pain intensity from scores at baseline, that were evident at week 7, and persisted through week 16, but it is not clear that any achieved a clinically important difference.

The year 2022 ASCO/SIO Clinical Practice Guideline on use of integrative therapies for pain in oncology patients concluded that a trial of yoga may be offered to patients with general cancer pain/musculoskeletal pain (benefits outweigh risks, low certainty of evidence, weak recommendation) [57]. (See 'Clinical practice guidelines' below.)

Clinical hypnosis — Where practitioners are available, a trial of hypnosis can be offered to patients experiencing pain during cancer treatment procedures or diagnostic workups. Benefit in other settings is unclear.

Hypnosis can be defined as an induced state of attentive, focused concentration with suspension of some peripheral awareness. Major components of the hypnotic state include absorption (capacity to contemplate deeply a selected theme or focal point), controlled alteration of one's attention, dissociation (the capacity to compartmentalize different aspects of an individual experience), and suggestibility (the capacity for heightened responsiveness to instructions). Hypnosis has been increasingly utilized for chronic and acute pain conditions and is increasingly accepted for both acute and procedure-related pain [100].

Patients vary widely in their ability to achieve a hypnotic state. (See "Overview of complementary, alternative, and integrative medicine practices in oncology care, and potential risks and harm", section on 'Hypnotherapy'.)

There is some evidence in favor of the positive effects of hypnosis on pain in cancer patients, mainly for control of procedure-related pain, but the quality of the evidence is generally low. On the other hand, few adverse events are reported with hypnosis [101].

Procedure-related pain — The benefit of hypnosis for procedural pain in adults has been evaluated in several randomized trials and at least one systematic review; several of these have focused on breast cancer [102-108]:

One review of hypnosis for breast cancer care, which included three randomized trials of females undergoing diagnostic breast biopsy [103,104,109], found that preprocedure hypnosis decreased perioperative pain and distress [105]. Although all studies were judged to have a low risk of bias, there was no meta-analysis to quantify benefit, and the control groups in these studies were variable, and consisted of standard care or no treatment, or a standardized attention control group.

A systematic review of available data on hypnosis prior to diagnostic procedures conducted by the expert panel convened by ASCO/SIO [57] noted that of the five available trials that evaluated the use of hypnosis during procedures in cancer patients [103,104,106-108], three had methodologic weaknesses; the two most robust trials are described below:

The first trial randomly assigned 200 patients with breast cancer scheduled for excisional biopsy or lumpectomy to a 15-minute hypnosis intervention before surgery versus an attention control [103]. Individuals in the hypnosis group reported less pain intensity (means 22.43 versus 47.83, difference 25.40, 95% CI 17.56-33.25) and pain unpleasantness (means 21.29 versus 39.05, difference 17.86, 95% CI 9.92-25.80). Hypnosis also led to decreased utilization of propofol and lidocaine compared with controls.

In a second trial of 201 patients undergoing percutaneous tumor embolization or radiofrequency ablation for liver metastases who were randomly assigned to standard care empathic attention with defined behaviors displayed by an additional provider, or self-hypnotic relaxation combined with the empathic attention to defined behaviors, patients treated with hypnosis experienced significantly less pain and anxiety than both control groups at multiple postprocedure time intervals, and required significantly less analgesic therapy [107]. Adverse events were experienced by 8 of 66 patients in the hypnosis group (including blood pressure fluctuations, bradycardia, and vasovagal reaction).

The expert panel concluded that hypnosis may be offered to patients experiencing pain during cancer treatment procedures or diagnostic workups (benefits outweigh harms, evidence quality intermediate, strength of recommendation moderate) [57].

Other types of pain — Given that benefits are likely to outweigh risks, a trial of hypnosis could be offered to patients with cancer pain if a skilled practitioner is available and an informed patient is interested in a trial. With the exception of chronic pain associated with breast cancer [110], the evidence is very limited, however, and this should be considered when helping patients consider priorities when multiple approaches are available. The available data are as follows:

A systematic review evaluating the role of hypnosis in breast cancer found promising effects of hypnosis on pain and distress in females with metastatic breast cancer and concluded that hypnosis can be considered as an ancillary intervention in symptoms management related to breast cancer [105]. Three randomized trials have found modest beneficial effects on pain and distress in patients with metastatic breast cancer [111-113]. In the largest of these, 125 females with metastatic breast cancer were randomized to hypnosis plus supportive-expressive therapy or to use of self-directed educational material [112]. Over 12 months, intervention resulted in significantly less of an increase in the intensity of pain and suffering compared with the education-only group, but there were no significant effects on the frequency of pain episodes or the amount of constant pain.

An analysis of the published literature performed by the NIH Technology Assessment Panel concluded that there was strong evidence to support benefit from hypnosis in management of chronic cancer pain [114]. However, a separate systematic review concluded that low methodologic quality and small sample size limited the conclusions that could be drawn from the available literature [115].

In the systematic review and meta-analysis described above of a variety of MBPs, 15 of 23 hypnosis studies reported significant improvements in pain outcomes, although very few were conducted in patients with cancer pain. Meta-analytic results indicated a significant moderate association with pain reduction (mean difference in pain intensity -0.54, 95% CI -0.87 to -0.20) [44].

Four randomized trials that addressed the benefit of hypnosis for pain during palliative care or radiation therapy have shown some benefit, but all were small and the benefits were modest, at best [90,112,116,117].

Overall, it is clear that hypnosis research would benefit from more rigorous methodology, including standardization of interventions [110]. A year 2022 ASCO/SIO Clinical Practice Guideline on use of integrative therapies for pain in oncology patients concluded that while hypnosis may be offered to patients with procedural pain, the evidence in other settings was insufficient or inconclusive [57]. (See 'Clinical practice guidelines' below.)

Relaxation training

General benefits and safety — Given that benefits are likely to outweigh harms, a trial of relaxation training may be offered to patients with chronic cancer pain. Relaxation techniques can take many forms and are increasingly being incorporated in several therapeutic exercise and psychotherapy approaches. Relaxation is also an essential component in clinical hypnosis and yoga. In its simplest form, relaxation practice involves focusing attention on the breath. The patient is invited to breathe in and out slowly and regularly (eg, "Take a slow, deep breath" or "Take three slow, cleansing breaths"). Simple imagery can be suggested, such as imagining releasing tension with the outbreath and receiving energizing or soothing energy during the inbreath.

Relaxation techniques share two components: the repetitive focus on a word or phrase, sound, or breath, body sensation such as muscular activity, and the adoption of a passive attitude towards intrusive thoughts. As a group, relaxation techniques attempt to induce a so-called relaxation response characterized by decreased arousal and diminished sympathetic activity (eg, decreased heart rate and lower blood pressure). This is accompanied by increased electroencephalographic slow wave activity. When used therapeutically, relaxation techniques may be divided into two methods, deep and brief, or by the specific strategy used to induce the relaxed state, including progressive muscle relaxation, autogenic training, and breath training. The data are currently insufficient to conclude that any one technique is more effective than another for any given condition.

A benefit for relaxation for cancer pain has been shown in several small randomized trials [91,92,118-120], but in some cases, the benefits have been transient. In a trial of 59 patients with cancer pain requiring opioid therapy who were randomly assigned to one of three active CBTs (distraction, positive mood, or relaxation interventions) or to a control, patients in the relaxation and distraction groups reported significantly decreased pain intensity immediately after intervention [120]. However, at two weeks after enrollment, no differences were apparent between any of the treatment groups.

The results of systematic reviews and meta-analyses are conflicting:

A year 2022 systematic review and meta-analysis of randomized controlled trials evaluating progressive muscle relaxation for cancer-related outcomes included twelve studies involving 1147 patients and found significant albeit modest effects on pain (standardized mean difference -1.02, 95% CI -1.93 to -0.11) [121]. The overall quality of the evidence was moderate to very low.

An earlier systematic review also concluded that relaxation techniques were effective in reducing chronic pain in a variety of medical conditions, including cancer [114].

However, a later systematic literature review concluded that low methodologic quality and small sample size limited the conclusions that could be drawn from the available literature [115].

In the systematic review described above, 12 of 16 relaxation studies (only four of which were conducted in patients with cancer pain) reported significant improvements in pain outcomes; however, when subjected to meta-analysis, the results were not significantly different (mean difference -0.45, 95% CI -1.13 to +0.22) [44]. (See 'Mind and body practices' above.)

There is a small chance of adverse reactions during relaxation training:

In a survey of 116 clinicians who conducted relaxation practice with 17,542 patients, the most common adverse reactions were intrusive thoughts, fear of losing control, upsetting sensory experiences, muscle cramps, sexual arousal, and psychotic symptoms [122].

Adverse reactions to relaxation practice have also been described as relaxation-induced anxiety or relaxation-induced panic. In contrast to relaxation-induced anxiety, relaxation-induced panic is more severe anxiety and has a rapid onset [123]. Patients with a history of generalized anxiety disorder or panic disorder and those with a history of hyperventilation are more likely to experience these adverse effects. Although the risk is small, patients with these histories should be carefully monitored during the relaxation process.

Because of these issues, the deep breathing techniques used in relaxation training (eg, diaphragmatic breathing) should be introduced in a gradual manner. Until a relaxation technique is mastered by the patient under supervision from a clinician, patients with risk factors (eg, anxiety disorders) should be discouraged from practicing deep breathing on their own for more than a couple of minutes at a time.

Specific techniques — The National Center for Complementary and Integrative Health (NCCIH) defines relaxation techniques as including progressive muscle relaxation, guided imagery, biofeedback, self-hypnosis, and deep breathing exercises [124]. The following sections will describe benefits of imagery with or without progressive muscle relaxation and biofeedback-assisted relaxation. Studies on self-hypnosis are included in the section on hypnosis above. (See 'Clinical hypnosis' above.)

Imagery with or without progressive muscle relaxation – Given that benefits are likely to outweigh risks, a trial of guided imagery with progressive muscle relaxation may be offered to patients with treatment-related cancer pain, although the certainty of the evidence for benefit is very low. Benefit in other settings is unclear.

Guided imagery utilizes recall of pleasant sights, smells, sounds, tastes, or somatic sensations (touch, movements, or positions) to create a positive cognitive and emotional state that can prevent or ameliorate pain or other sources of distress. Guided imagery practitioners use words to create states of focused attention that are thought to alter the experience of pain. Other techniques, such as distraction, mental dissociation, muscle relaxation, and controlled abdominal breathing, are also practiced as part of guided imagery.

Two of the most common clinical imagery techniques are mental rehearsal imagery and end-state imagery.

Mental rehearsal imagery is a technique that is often used to prepare patients for painful treatments or surgical procedures (eg, biopsies). It is primarily used to relieve anxiety, pain, and side effects that are exacerbated by a heightened emotional reaction. Typically, a relaxation strategy is taught to the patients, who are then led through a "guided imagery trip" from the treatment through the recovery period.

During mental rehearsal imagery, it is important to be factual, to avoid emotionally-charged or fear-provoking words, and to reframe the medical procedure in realistic yet positive terms.

End-state imagery is a technique intended to produce a specific physiologic or biologic change in the body. Its clearest objective is to reduce sympathetic nervous system arousal. End-state imagery has been successfully used to alleviate chemotherapy-induced nausea and to assist in the control of cancer pain.

End state imagery for the treatment of pain is called analgesic imagery; it is either pain-transforming or pain-incompatible. Pain-transforming imagery concentrates on changing specific aspects of the pain experience, such as the contextual aspect of the painful experience (eg, imagining that the moment the chemotherapy needle touches the skin and before it is inserted, it releases a massive amount of powerful analgesic medication that completely numbs the arm). Pain incompatible-imagery can be used to evoke positive emotions and feelings of relaxation, excitement, or peace that are not compatible with the image of pain.

Published outcomes from older studies on mental rehearsal imagery were almost uniformly positive, reporting significant reductions in pain and anxiety, length of postoperative hospital stay, pain medication use, and fewer treatment-related side effects [91,115,119,125,126]. However, a systematic review concluded that low methodologic quality and small sample size limited the conclusions that could be drawn from these available studies [115].

More recently, at least three trials suggest benefit:

A multicenter randomized controlled trial compared the analgesic effectiveness of a progressive muscle relaxation and interactive-guided imagery versus usual care in 104 hospice/palliative care patients with advanced cancer found that the intervention significantly reduced pain and mood disturbance during the day following treatment [127].

A second trial conducted in patients receiving chemotherapy also concluded that guided imagery and progressive muscle relaxation was effective at improving a cluster of symptoms, including pain, fatigue, nausea, vomiting, anxiety, and depression [128].

A third trial suggested benefit following resection of colorectal cancer, but the intervention arm had only 20 patients [129].

The joint ASCO/SIO guidelines panel on integrative therapy for pain in cancer patients endorsed offering guided imagery with progressive muscle relaxation to patients experiencing cancer treatment-related pain, but the small size of several studies, the inconsistent lack of blinding, and overall lack of safety data and quality concerns led the panel to conclude that the relative benefits and harms were not assessable, the evidence quality was low, and the strength of recommendation weak [57]. (See 'Clinical practice guidelines' below.)

Biofeedback – The benefits of biofeedback for management of cancer pain are uncertain, and there is insufficient evidence to recommend for or against use. However, for interested patients, a trial of biofeedback might be considered for any motivated patient with pain or distress, if the resources exist.

Biofeedback is a form of relaxation therapy that involves the use of a machine to allow monitoring and feedback control over a specific physiologic parameter. The instrument transforms a physiologic response, such as skin temperature, into an electrical signal, which is amplified and displayed in the form of a visible and/or audible stimulus such as a changing tone, a light bar, or a moving line on a computer screen [130,131]. By monitoring the stimulus and learning to control the physiologic response that generates it, biofeedback can facilitate healthier cognitive and behavioral response patterns to pain and stress. It can help patients learn to modify the internal, subjective experience by providing corrective information to either validate the strategy that is being used to achieve a desired state (eg, relaxation) or show its inadequacy [132].

The physiologic responses that are most commonly used for biofeedback are respiration, heart rate or pulse, peripheral skin temperature, electrical skin conductance, and muscle tension (surface electromyography [EMG]). Surface EMG biofeedback, for example, has been used for the treatment of cancer-related pain by targeting muscle groups associated with the patient's response to pain; relaxing these muscles can also help induce a general relaxation response, which can further alter pain perception or reduce anxiety [133,134]. Neurofeedback may also be accomplished using electroencephalograms [135].

The available data on biofeedback to cancer-related pain are as follows:

The value of surface EMG biofeedback was suggested in a small trial in which 37 patients with advanced cancer and chronic pain were randomly assigned to EMG biofeedback-assisted relaxation (six sessions over four weeks) or conventional care only [136]. The main endpoint was pain, as assessed at baseline and following the intervention using a version of the BPI. In an analysis of the 24 patients who completed the study (12 experimental, 12 control), relaxation training supplemented with biofeedback was effective in reducing cancer–related pain, whereas in the control group, pain increased.

An intriguing pilot study suggests potential benefit for chemotherapy induced peripheral neuropathy using electroencephalogram-based neurofeedback. (See "Prevention and treatment of chemotherapy-induced peripheral neuropathy", section on 'Neurofeedback'.)

Additional studies are needed to evaluate approaches to biofeedback and the analgesic effectiveness of these approaches compared with other integrative therapies. The NIH Technology Assessment Panel and a later meta-analysis both concluded that there was only moderate evidence to support benefit from any form of biofeedback in the management of chronic cancer pain [114,115].

Meditation and mindfulness-based interventions — The benefits of meditation and mindfulness-based interventions to control pain in patients with cancer are uncertain. However, given that benefits are likely to outweigh risks, a trial may be offered to interested patients.

The term "meditation" is an umbrella term that covers a large number of traditions and practices with specific evidence on their effectiveness for improved symptom management and ability to improve the stress response. They all require focused attention and involve specific training in the ability to adopt a witness stance and "let go," of thoughts, feeling sensations, and external distractions. Generally, meditation involves consistent daily or regular practice. Some examples include mindfulness meditation, transcendental meditation, and Zen meditation.

Mindfulness is the practice of focusing attention on internal or external stimuli without evaluating or judging and it can be a core component of several interventions. Among these, MBSR developed by Jon Kabat-Zinn, has been investigated in several studies. It is an eight-week, evidence-based and group intervention that uses meditation practices to increase awareness, learn self-regulation strategies, and improve adaptation to stress and physical and psychologic discomfort. This patient-centered educational and training approach essentially teaches people how to live in the moment and take better care of themselves. (See "Overview of complementary, alternative, and integrative medicine practices in oncology care, and potential risks and harm", section on 'Meditation and mindfulness-based stress reduction'.)

These self-regulation practices focus on training attention and awareness to bring mental processes under greater voluntary control. Most meditation practices have four elements in common: a quiet location with few distractions; a specific, comfortable posture achieved by sitting or lying down; a focus of attention; and an open attitude of letting thoughts come and go naturally without judgment [137]. The focus of attention may be on a specific target, such as the breath or a repeated sound or mantra (known as concentration meditation); on all experiences that enter the field of awareness (called open awareness or mindfulness meditation); or a combination of both.

Very few studies have suggested benefit for meditation in controlling pain in cancer patients:

In a prospective single arm study, for example, 75 breast cancer survivors practiced Pranic meditation 20 minutes at a time, twice daily, for eight weeks and experienced a significant improvement in quality of life scores and scores for pain, as well as fatigue self-image, and sleep disturbance [138].

In a retrospective analysis of 34 children receiving anti-GD2 monoclonal antibody treatment (which is associated with a high prevalence of visceral pain during the infusion) for high-risk neuroblastoma [139], 24 were able to complete 11 minutes of meditation on the first or second attempt, and this group received significantly fewer doses of analgesic medication. (See "Treatment and prognosis of neuroblastoma", section on 'High-risk disease'.)

The absence of control groups in these studies does not permit the conclusion that the observed benefits were due to the intervention, but the positive findings warrant additional research.

By contrast, studies of mindfulness-based interventions suggest that these approaches have efficacy for cancer pain in some contexts:

A meta-analysis of 10 randomized controlled trials evaluating mindfulness-based interventions included 843 patients [140] and found significant pooled effects on pain intensity at both short-term (standard mean difference [SMD] = -0.19, 95% CI -0.33 to -0.04) and long-term (SMD = -0.20, 95% CI -0.35 to -0.05) follow-up, but no significant effects on pain interference with function. In subgroup analyses, significant intervention effects were only seen in clinic-based programs, and pooled effects on pain had a relatively small effect size. GRADE ratings showed moderate certainty of evidence in mindfulness-based interventions for pain intensity but low certainty for benefit in pain interference.

A systematic review of mindfulness meditation for cancer-related pain [141], which included six randomized trials published between 2000 and 2017 in which pain was a defined primary or secondary outcome [87,142-146], came to the following conclusions:

The types of mindfulness interventions varied; two studies used MBSR, one utilized mindfulness-based cognitive therapy, one used breathing meditation plus massage, and one employed mindfulness awareness practices.

Outcomes were assessed variably at three weeks, three months, or six months.

Four of the six studies provided some evidence that mindfulness interventions resulted in statistically significant improvements in pain severity [84,137,138,140]. However, generalizability was limited because nearly all participants had a breast cancer diagnosis, and the studies were conducted only in the United States and Danish populations.

A more recent randomized controlled trial of MBSR in breast cancer survivors with chronic neuropathic pain found no significant differences between patients enrolled in the eight-week intervention (n = 49) as compared with patients who were in the wait list control group (n = 49) [147]. These results suggest that the effectiveness of MBSR may vary significantly across patient presentations and conditions.

Adverse effects may also occur with meditation. In a study of a small group of meditators, participants reported a 63 percent incidence of at least one adverse event, which included disorientation, confusion, depression, increased awareness of one's negative qualities and emotions, increased fears and anxiety, boredom, and pain [148].

Creative arts therapy — Given that the benefits are likely to outweigh the risks, music therapy can be offered to patients with cancer pain, including patients experiencing pain after cancer surgery although the certainty of the evidence of benefit is low.

Creative arts therapies attempt to ameliorate physical and emotional distress through the use of music, dance/movement, and art. Music therapy can improve pain symptoms, anxiety, and depression in a variety of populations. (See "Management of psychiatric disorders in patients with cancer", section on 'Other modalities'.)

Creative arts therapy can also improve pain and other symptoms, and improve quality of life among cancer patients, although the effect may be transient [57,149-151]. Most of the data on relief of cancer pain are with music therapy [150-157]:

A 2022 systematic review of randomized controlled trials evaluating music therapy for physical, cognitive, and psychosocial outcomes associated with cancer, including pain [158], found that 23 of 25 included trials reported statistically and clinically significant improvements across outcome variables.

A 2021 Cochrane review of music interventions (defined as music therapy offered by trained music therapists) for improving psychologic and physical outcomes in people with cancer included 81 trials with a total of 5576 participants; 74 trials involved adults and 7 trials included children [157]. There was a moderate pain-reducing effect of music interventions (12 studies, 632 adult participants; SMD, on a 0 to 10 point VAS scale, -0.67, 95% CI -1.07 to -0.26, very low certainty evidence).

The benefit of music therapy for postsurgical pain has been addressed in three trials [159-161]:

In a randomized trial in 60 patients undergoing lung resection, those who were assigned to a preoperative and postoperative music therapy intervention versus usual care had significantly lower pain VAS scores at each time point up to 24 hours after surgery, and a need for less analgesics, including opioids [161].

A second trial of music therapy in 120 females with breast cancer undergoing radical mastectomy found that pain scores improved over time in both the intervention and control groups [160]. However, while there was a significantly greater improvement in the change of pain rating index scores from baseline (first day after the procedure) with music therapy compared with the control group at the first posttest evaluation (the day before discharge [difference between groups -2.38, 95% CI -2.80 to -1.95]), the differences became less apparent (and no longer statistically significant) at later evaluation time points.

A third trial of only 30 mastectomy patients found that music therapy intervention (four hours of recorded music beginning after the induction of preoperative anesthesia) was associated with significantly less worsening of pain (as measured on a 100-mm VAS scale) from preoperative to postoperative time points compared with females in the control group (29.7 versus 50.7, a decrease of 41 percent) [159].

While all three studies showed a significant effect of music therapy in improving surgical pain scores over usual care, two trials had a high risk of bias [160,161], and the third was very small [159].

Notably, all of these trials just used prerecorded music, and did not employ a trained music therapist to deliver a specific music therapy intervention. (See "Overview of complementary, alternative, and integrative medicine practices in oncology care, and potential risks and harm", section on 'Music therapy'.)

A year 2022 ASCO/SIO Clinical Practice Guideline on use of integrative therapies for pain in oncology patients concluded that music therapy may be offered to patients with postsurgical pain, but that the evidence in other settings was insufficient or inconclusive [57].

Other potential benefits of music therapy for cancer symptoms and treatment-related side effects are addressed elsewhere. (See "Overview of complementary, alternative, and integrative medicine practices in oncology care, and potential risks and harm", section on 'Music therapy'.)

The benefits of dance/movement therapy are less certain. A Cochrane review of three studies totaling 207 participants that focused on dance/movement therapy provided to patients with cancer by a formally trained dance/movement therapist concluded that there was no demonstrable effect on mood, mental health, body image, fatigue, or pain [162].

Massage therapy — Massage therapy can result in harms if the therapist is not cautious or performs massage in a vulnerable area (ie, an area that is denervated by nerve injury; has skin breakdown, fragility, or sensitivity; or overlies a medical device, superficial tumor, or area of thrombosis). As long as these harms are avoided, the benefits are likely to outweigh risks and a trial of massage therapy can be offered to patients experiencing pain after breast cancer treatment, and those with chronic cancer pain.

Massage therapy has been used as a form of medical therapy since ancient times. Some of the earliest references are found in ancient Chinese medical texts. The Yellow Emperor's Classic of Internal Medicine, written more than 2500 years ago and believed to be the first book on Chinese medicine, includes information on Tuina, an ancient form of massage and acupressure (applied finger pressure to points that are putatively sensitized by organ impairment) [163].

Massage is defined as the systematic manipulation of the soft tissues of the body to enhance health and healing [164]. It includes a group of manual techniques that include applying fixed or movable pressure. The primary characteristics are the application of touch and movement. The goals of massage therapy are to promote relaxation, address muscle stiffness and pain, and resolve musculoskeletal complaints.

Some studies conducted with adult and pediatric patients with both limited and advanced cancer have suggested that massage can yield at least temporary benefit for pain, other symptoms, and mood [165-171]; however, others have not [172-174], and methodologic limitations preclude definitive conclusions about outcomes in many of these studies [115,175]. The bulk of the data are in patients with breast cancer and those receiving palliative care.

Patients with breast cancer — Results have been mixed in breast cancer:

In a quasi-experimental study of 70 post-breast surgery patients, 35 were randomized to receiving oral analgesics only and 35 received oral analgesics and foot massage; pain and analgesic use were significantly lower in the latter group [171].

A small randomized trial in 42 advanced cancer patients (22 with breast cancer) found that massage therapy transiently improved quality of life compared with no touch control or usual care, but there was no significant change in pain scores from baseline to one-week or one-month follow-up times [176].

A 2016 Cochrane review that evaluated the effects of massage with or without the addition of aromatherapy on pain and other symptoms (eg, anxiety and depression) in patients with cancer (the majority with breast cancer) concluded that there is a lack of evidence due to low reliability of studies and poor methodologic quality [175].

On the other hand, a later systematic review and meta-analysis of five randomized trials (total 127 patients) with chronic musculoskeletal pain after breast cancer treatment did find a benefit for massage therapy [177]. The interventions included myofascial induction, myofascial release, classic massage, ischemic compression of trigger points, and myofascial therapy; controls included an educational session, physical therapy, or sham massage. Massage therapy significantly reduced pain but the effect size was small to moderate (SMD 0.32, 95% CI 0.06-0.57) compared with controls.

Palliative care settings — Massage in patients with advanced cancer treated by palliative care specialists has been the subject of multiple randomized trials. At least two systematic reviews are available:

A year 2009 systematic review of 14 trials (mostly low-quality) concluded on the basis of four trials that there is evidence that massage therapy can alleviate various types of pain in palliative care patients [178].

The largest of these studies [169] was a multisite randomized trial that in which 380 patients with advanced cancer who were experiencing moderate to severe pain were randomly assigned to either six 30-minute massage sessions or simple-touch sessions over two weeks. A total of 298 patients were included in the immediate outcome analysis and 348 were included in the sustained outcome analysis. Both groups demonstrated immediate improvement in pain (on a 0 to 10 point scale), massage decreased pain (-1.87, 95% CI -2.07 to -1.67) as did simple touch (-0.97, 95% CI -1.18 to -0.76), mean pain difference 0.90, p <0.001. However, there was no significant difference in sustained pain relief between the groups. The authors concluded that massage may have immediately beneficial effects on pain and mood in a population with advanced cancer, but given the lack of sustained effects, the potential benefits of attention and simple touch should also be considered.

A later systematic review included three randomized trials of massage therapy for pain in patients receiving palliative care [179], one of which was included in the above systematic review [169]. All three trials showed favorable results for massage.

Clinicians who refer a cancer patient to a massage therapist should ensure that information about potential risk is transmitted to the therapist. The therapist should individualize treatment to minimize risk and specifically avoid vulnerable areas.

Biofield therapies: Reiki, therapeutic touch, and healing touch — There are only limited data on the effectiveness of biofield therapies such as Reiki, therapeutic touch, and healing touch, and these complementary treatments cannot be recommended with the same confidence as other integrative therapies such as acupuncture and acupressure, relaxation, imagery, hypnosis, and music therapy. Nevertheless, there is little, if any, harm from these approaches, and the benefits are likely to outweigh any risks. A trial could be offered to interested patients who have pain related to cancer. This position is consistent with evidence-based guidelines from SIO (endorsed by ASCO) for integrative therapies during and after treatment for breast cancer, which suggest that healing touch can be considered for the management of postchemotherapy pain in such patients [48,82]. (See 'Clinical practice guidelines' below.)

Reiki — The NCCIH classifies Reiki as a complementary health approach in which practitioners place their hands lightly on or just above a person, with the goal of directing energy to help facilitate the person's own healing response. It's based on an Eastern belief in an energy that supports the body's innate or natural healing abilities. (See "Overview of complementary, alternative, and integrative medicine practices in oncology care, and potential risks and harm", section on 'Reiki'.)

Importantly, there is no scientific evidence supporting the existence of the energy field thought to play a role in Reiki. Proponents of Reiki suggest that it can reduce stress and induce a relaxation response, which may be therapeutic in a manner similar to other MBPs. The Reiki practitioner can provide a calm and reassuring presence. Additionally, they will typically attune their breathing to the patient's and progressively slowing and deepening their breath, which can have a beneficial effect on the patient's well-being.

Reiki for patients with cancer has received increasing interest in clinical settings, including palliative care, but the limited data on effectiveness and the lack of large and well-controlled studies prevent drawing firm conclusions as to its benefits for pain management [180,181]. The following data are available:

In the only randomized trial, 24 patients with cancer pain received either standard opioid therapy plus rest or opioid therapy plus two Reiki treatments one hour after their first afternoon analgesic dose [182]. The addition of Reiki to opioid therapy significantly reduced pain, but not opioid use, immediately after treatment. The statistical power of the study to demonstrate benefits such as this was limited because the study was terminated prematurely because of the unwillingness of patients to be randomly assigned to the control arm.

A review of seven randomized trials of Reiki, which included the study above, evaluated the technique as a treatment for pain and anxiety in cancer patients, postsurgical patients, and community-dwelling older adults [183]. Although the quality of the studies was limited, a comparison of effect sizes led the authors to conclude that Reiki may be effective for pain and anxiety.

A mixed-method study that evaluated the impact of a volunteer-based Reiki program on 213 cancer patients who were receiving treatment for the first time found an immediate decrease in pain, fatigue, depression, anxiety, and distress [184]; most patients reported that they liked the session, found it helpful, planned on receiving more sessions, and would recommend Reiki to others.

Another study explored the impact of Reiki on patients attending an oncology clinic for chemotherapy treatment [185]. Twenty-two of 118 patients enrolled received the full cycle of four Reiki treatments. Their mean anxiety score decreased from 6.77 to 2.28 (p <0.000001) and their mean pain score decreased from 4.4 to 2.32 (p = 0.0191).

A 2008 Cochrane review included some studies conducted in cancer patients and concluded that touch therapies such as Reiki may have a modest effect in pain relief, but that more studies were needed [186].

Therapeutic and healing touch — Therapeutic touch is defined as an "intentionally directed process of energy modulation during which the practitioner uses the hands as a focus to facilitate healing" [187]. Like Reiki, there is no evidence to support the physiologic implications of this definition [188].

Nonetheless, some observations support the view that cancer patients may perceive benefit when this approach is tried [189-191]. A single randomized trial evaluating therapeutic massage also assessed healing touch as a separate intervention for symptom control in patients with cancer receiving chemotherapy, the majority for breast cancer [172]. This study included 230 subjects with cancer pain who were randomly assigned to therapeutic massage, healing touch (eight 45 minute sessions, by a specifically trained registered nurse), presence alone, or standard care. Of the 56 patients assigned to healing touch who completed all eight sessions, compared with both control and presence alone, healing touch provided significantly better immediate pain reduction compared with the pretreatment baseline, but the intervention effects were not sustained over four weeks either in the pain index or the interference in living due to pain.

Homeopathy — There is insufficient evidence to recommend for or against the use of homeopathy for management of cancer pain. Given the lack of known biologic effects produced by the substances employed in this approach, the impact of treatment may be entirely related to the placebo response. However, informed patients who desire a trial of a homeopathic remedy need not be discouraged, if knowledgeable practitioners are available.

There is sparse research about the adverse effects of homeopathy. However, initial and temporary worsening of symptoms before improvement is noted (ie homeopathic aggravations), and is frequently reported in trials and case reports. Additionally, a case report seems to suggest that ethanol in homeopathic preparations may interact with escitalopram, as they are both metabolized by enzymes CYP450 [192].

Derived from the Greek words Homoios, "similar" and Pathos, "suffering," homeopathy was founded by the German physician Samuel Hahnemann in the 1790s. It is based on the premise that cure can result from stimulation of the body's natural healing abilities. This is achieved by introducing into the body a substance that, in a healthy person, can induce symptoms that are identical to the symptoms of the disease. The philosophical foundations of homeopathy can be found in Hippocrates' teachings of the Law of Similars, or "like cures like." It is also based on the "law of minimum dose," the notion that the lower the dose of the medication, the greater its effectiveness. Thus, homeopathic remedies are dilutions of substances that are derived from plants, minerals, and animals; patients are prescribed the remedies that most closely match their symptom profile. (See "Overview of complementary, alternative, and integrative medicine practices in oncology care, and potential risks and harm", section on 'Homeopathy' and "Homeopathy".)

Homeopathy is one of the most popular complementary/integrative therapies chosen to address chemotherapy side effects among cancer patients in Europe [193]. Similarly, its use is prevalent in Italy [194], Germany [195], and the United Kingdom [196]. Despite its popularity, the evidence to support benefit from homeopathy in patients with cancer and cancer treatment-related pain is very limited:

A 2022 systematic review of 18 trials with a total of 2016 patients found that the majority of studies had low methodologic quality and concluded that the available evidence was inconclusive and failed to provide a scientifically based hypothesis for the use of homeopathy in cancer care [197].

One case report series and two small prospective observational studies found that homeopathy was helpful in controlling posttreatment pain and radiation-induced itching, and in relieving adverse effects associated with estrogen withdrawal in breast cancer patients [198-200].

However, a systematic review of six trials in which homeopathy was used as a sole or adjunctive treatment in cancer care concluded that methodologic quality was variable and the evidence was insufficient to recommend its use in any setting [201].

A randomized trial that studied the effectiveness of Arnica montana on pain and other outcomes after mastectomy for breast cancer (n = 53) found that surgical drainage was lower among those receiving the Arnica montana, but other outcomes (including pain) were unaffected [202].

A pilot observational study explored the homeopathic remedies Ruta graveolens 5CH and Rhus toxicodendron 9CH for reducing joint pain and stiffness in 40 females taking aromatase inhibitors who received the treatment for three months; relative to a comparison group, the treated females experienced a significant decrease in pain scores and a more rapid disappearance of morning stiffness [203].

These outcomes may be nonspecific or related to placebo effects. The NCCIH considers that there is little evidence to support homeopathy as an effective treatment for any specific health condition. Larger randomized controlled trials are needed to better understand the potential contribution of homeopathy to management of cancer and cancer treatment-related pain, and to understand the adverse effect profile.

Clinical practice guidelines — Although there are many clinical practice guidelines that could be consulted for recommendations concerning the use of integrative techniques, the severe limitations in the evidence base for these therapies is reflected in the lack of consensus and quality concerns about the guidelines that exist.

As an example, a systematic review of cancer pain clinical practice guidelines identified 11 that made recommendations for the use of complementary or alternative medicine therapies [204]. These guidelines recommended acupuncture (n = 8), mind-body modalities (n = 7), application of heat or cold (n = 6), massage (n = 6), distraction and relaxation techniques (n = 3), music therapy (n = 3), behavioral and cognitive therapies (n = 3), coping skills training (n = 1), exercise (n = 1), yoga (n = 1), capsaicin (n = 1), emotional counseling (n = 1), and herbal remedies (n = 1). Using the AGREE II tool to assess 23 characteristics of these guidelines, the authors noted significant variability in quality, content, and evidence level.

Nonetheless, two guidelines from expert groups may be worthy of consultation:

A 2017 clinical practice guideline on the use of integrative therapies in patients during and after breast cancer treatment from the SIO rated the strength of available evidence for each integrative modality based upon a modified version of the recommendations of the US Preventive Services Task Force [48]. They emphasized the continued lack of A- or B-graded (ie, high-quality) integrative therapies for cancer and cancer treatment-associated pain compared with an earlier guideline [82]. Healing touch for postchemotherapy pain, music therapy and hypnosis for postsurgery pain, and acupuncture for aromatase inhibitor-related pain and for pain after surgery each received a "C" grade (weak evidence of benefit) due primarily to a lack of multiple large trials. The authors concluded that these modalities could be offered or recommended to selected patients based on the understanding that they may bring a small benefit. Of note, music therapy, meditation, and yoga received higher grades for the evidence-based treatment of anxiety and stress, as well as depression and mood disorder.

These guidelines were subsequently endorsed by the ASCO in 2018 [149].

A later joint guideline from ASCO and SIO that covered evidence-based recommendations for integrative medicine for pain management in a broader range of cancer patients was subsequently published in 2022 [57]. The evidence quality was judged low to intermediate for most interventions, and most recommendations were weak or moderate. The specific recommendations are summarized in the table (table 2), outlined in the algorithm (algorithm 1), and discussed in more detail in the sections below. Recommendations that are sorted by type of pain and stratified according to the quality of evidence and strength of the recommendation are outlined in the table (table 3).

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Palliative care" and "Society guideline links: Neuropathic pain" and "Society guideline links: Cancer pain".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Managing pain when you have cancer (The Basics)" and "Patient education: Complementary and alternative medicine (The Basics)")

SUMMARY AND RECOMMENDATIONS

Role in treatment of cancer pain – Opioid-based pharmacotherapy is a mainstay of treatment for moderate to severe pain in patients with active cancer. For many patients with moderate to severe cancer pain, a multimodality approach that includes nonpharmacologic therapies in conjunction with opioids may improve pain relief with fewer drug side effects, and/or provide better outcomes with regard to physical and psychosocial functioning.

Nonpharmacologic therapies treatments that target pain etiology (eg, radiotherapy), invasive symptom-directed therapies (eg, nerve blocks), and noninvasive symptomatic therapies, such as rehabilitation and complementary/integrative therapies. (See 'Introduction' above.)

Rehabilitation

The primary goal of rehabilitative interventions may be functional improvement, symptom control, or both. (See 'Rehabilitative interventions' above.)

Potentially beneficial rehabilitative interventions include therapeutic exercise, usually initiated or guided by a physical therapist; hydrotherapy, which may be particularly helpful in the medically ill; orthoses, ambulation aids, and other devices. (See 'Therapeutic exercise' above and 'Orthoses and other devices' above.)

Other "physical modalities" such as application of heat and cold, ultrasound, electrical stimuli (eg, as with a transcutaneous electrical nerve stimulation device), scrambler therapy, and therapy for lymphedema, may be appropriate in selected patients, depending on the nature and location of the pain. These approaches may be especially useful as adjuncts for focal mild to moderate pain and while awaiting the effect of a breakthrough analgesic. (See 'Other modalities' above.)

The evidence base to support benefit of any of these approaches for cancer pain is extremely limited, and there are no comparative data to guide the selection of specific modality. We suggest avoiding the topical application of these stimuli to areas with reduced sensation and those that are directly superficial to tumor masses.

Integrative/complementary therapies

Patients with cancer pain may benefit from one or more of a group of complementary therapies that emphasize the potential value of training the "mind" (by shifting cognitions and/or creating a desirable emotional state) in a way that favorably influences bodily functions (collectively termed mind-body practices [MBPs]). While usually considered as an adjunct to pharmacotherapy, MBPs may be offered alone to treat a single discrete problem (eg, procedure-related pain). Most of these treatments require a competent and specifically trained health professional. (See 'Mind and body practices' above.)

Complementary therapies that may provide benefit include acupuncture/acupressure/reflexology, yoga, hypnosis, relaxation therapy, meditation, mindfulness-based practices, music therapy, and massage therapy. There is a variable evidence base to support benefit from MBPs in oncology patients with pain, and it is limited in some cases to specific settings. However, for most of these approaches, it is likely that the potential for benefit outweighs harms. For patients who desire it, and if practitioners are available, a trial of one of these therapies can be offered. (See 'Mind and body practices' above.)

There are only limited data on the effectiveness of biofield therapies such as Reiki, therapeutic touch, and healing touch, and these complementary treatments cannot be endorsed with the same confidence as other integrative therapies. Nevertheless, there is little, if any harm from these approaches. If practitioners are available, and the cost is affordable, there is no reason to discourage patients with cancer pain from trying these interventions. (See 'Biofield therapies: Reiki, therapeutic touch, and healing touch' above.)

Our approach to integrative therapy parallels that of a joint guideline from ASCO and SIO on integrative medicine for pain management in cancer patients. The specific recommendations are summarized in the table (table 2), outlined in the algorithm (algorithm 1), and stratified according to the quality of evidence and strength of the recommendation in the table (table 3).

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Topic 14249 Version 50.0

References

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