Nonpharmacologic pain interventions: a review of evidence-based practices for reducing chronic cancer pain.
General
Guideline Title
Nonpharmacologic pain interventions: a review of evidence-based practices for reducing chronic cancer pain.
Bibliographic Source(s)
- Eaton LH, Brant JM, McLeod K, Yeh C. Nonpharmacologic pain interventions: a review of evidence-based practices for reducing chronic cancer pain. Clin J Oncol Nurs. 2017 Jun 1;21(3):54-70. PubMed
Guideline Status
This is the current release of the guideline.
This guideline updates a previous version: Aiello-Laws L, Reynolds J, Deizer N, Peterson M, Ameringer S, Bakitas M. Putting evidence into practice: what are the pharmacologic interventions for nociceptive and neuropathic cancer pain in adults. Clin J Oncol Nurs. 2009 Dec;13(6):649-55. [55 references]
This guideline meets NGC’s 2013 (revised) inclusion criteria.
NEATS Assessment
Disclosure of Guideline Funding Source
- No
Disclosure and Management of Financial Conflict of Interests
- 3
Guideline Development Group Composition: Multidisciplinary Group
- Yes
Guideline Development Group Composition: Methodologist Involvement
- Yes
Guideline Development Group Composition: Patient and Public Perspectives
- 1
Use of a Systematic Review of Evidence: Search Strategy
- 4
Use of a Systematic Review of Evidence: Study Selection
- 5
Use of a Systematic Review of Evidence: Synthesis of Evidence
- 5
Evidence Foundations for and Rating Strength of Recommendations: Grading the Quality or Strength of Evidence
- 3
Evidence Foundations for and Rating Strength of Recommendations: Benefits and Harms of Recommendations
- 4
Evidence Foundations for and Rating Strength of Recommendations: Evidence Summary Supporting Recommendations
- 5
Evidence Foundations for and Rating Strength of Recommendations: Rating the Strength of Recommendations
- 4
Specific and Unambiguous Articulation of Recommendations
- 1
External Review
- 1
Updating
- 2
Recommendations
Major Recommendations
Note from the National Guideline Clearinghouse (NGC) : Refer to the original guideline document for full dosages, references, and other essential information about the evidence. The recommendation ratings ( Recommended for Practice, Likely To Be Effective, Effectiveness Not Established, Effectiveness Unlikely, Not Recommended for Practice, Expert Opinion ) are defined at the end of the “Major Recommendations” field.
See also the NGC summaries of the related Oncology Nursing Society (ONS) guidelines on cancer-related pain:
- Cancer-related acute pain: a systematic review of evidence-based interventions for Putting Evidence Into Practice .
- Chronic and refractory pain: a systematic review of pharmacologic management in oncology .
- Breakthrough cancer pain: a systematic review of pharmacologic management .
Recommended for Practice
Procedural
- Celiac plexus block
- Radiation therapy
Likely to Be Effective
Educational
Psychoeducational Interventions
- Nurse-led education sessions
- Interactive cognitive behavioral therapies
- Telehealth interviews
- Psychosocial interventions
- Structural education with a booklet
- Tailored education
- Coaching
Effectiveness Not Established
Behavioral
- Dance movement therapy
- Exercise
- Expressive writing
- Hypnosis
- Relaxation/progressive muscle relaxation and guided imagery
- Yoga
Body-based
- Acupressure
- Acupuncture
- Foot massage
- Massage
Energy-based
- Reiki
- Therapeutic touch
Organizational
- Institutional initiative
- Multicomponent rehabilitation
- Palliative care
Procedural
- Celiac ganglion irradiation
- Cranial stimulation
- Cryoablation
- Fat graft
- Gene therapy
- Hypogastric neurolysis
- Microwave ablation
- Neural block
- Radiofrequency ablation and osteoplasty
- Radiosurgery
- Scrambler therapy
- Spinal cord stimulation
- Transcutaneous electrical nerve stimulation (TENS)
- Ultrasound
Definitions
Recommended for Practice
Interventions for which effectiveness has been demonstrated by strong evidence from rigorously designed studies, meta-analysis, or systematic reviews, and for which expectation of harms is small compared to the benefits
Likely To Be Effective
Interventions for which effectiveness has been demonstrated from a single rigorously designed conducted controlled trial, consistent supportive evidence from well-designed controlled trials using small samples, or guidelines developed from evidence and supported by expert opinion
Benefits Balanced With Harm
Interventions for which clinicians and patients should weigh the beneficial and harmful effects according to individual circumstances and priorities
Effectiveness Not Established
Interventions for insufficient or conflicting data or data of inadequate quality currently exist, with no clear indication of harm
Effectiveness Unlikely
Interventions for which lack of effectiveness has been demonstrated by negative evidence from a single rigorously conducted controlled trial, consistent negative evidence from well-designed controlled trials using small samples, or guidelines developed from evidence and supported by expert opinion
Not Recommended for Practice
Interventions for which lack of effectiveness or harmfulness has been demonstrated by strong evidence from rigorously conducted studies, meta-analyses, or systematic reviews, or interventions where the costs, burden, or harm associated with the intervention exceed anticipated benefit
Expert Opinion
Low-risk interventions that are consistent with sound clinical practice, suggested by an expert in a peer reviewed publication, and for which limited evidence exists (an expert is an individual who has published peer reviewed material in the domain of interest.)
For further information, see the “Decision rules for summative evaluation of a body of evidence” document (see the “Availability of Companion Documents” field).
Clinical Algorithm(s)
None provided
Scope
Disease/Condition(s)
Chronic cancer pain
Guideline Category
- Management
- Treatment
Clinical Specialty
- Nursing
- Oncology
Intended Users
- Advanced Practice Nurses
- Health Care Providers
- Nurses
Guideline Objective(s)
To critically appraise the strength and quality of the empirical evidence for nonpharmacologic interventions in reducing chronic cancer pain
Target Population
Patients with chronic cancer pain
Interventions and Practices Considered
- Celiac plexus block
- Radiation therapy
- Psychoeducational interventions
Note : The following were considered, but their effectiveness is not established: dance movement therapy, exercise, expressive writing, hypnosis, relaxation/progressive muscle relaxation and guided imagery, yoga, acupressure, acupuncture, foot massage, massage, reiki, therapeutic touch, institutional initiative, multicomponent rehabilitation, palliative care, celiac ganglion irradiation, cranial stimulation, cryoablation, fat graft, gene therapy, hypogastric neurolysis, microwave ablation, neural block, radiofrequency ablation and osteoplasty, radiosurgery, scrambler therapy, spinal cord stimulation, transcutaneous nerve stimulation, ultrasound.
Major Outcomes Considered
- Pain intensity/relief
- Quality of life
Methodology
Methods Used to Collect/Select the Evidence
- Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence
A comprehensive review was conducted of the PubMed and CINAHL® databases, as well as the National Comprehensive Cancer Network guidelines from January 1, 2009 to July 31, 2016.
The Oncology Nursing Society (ONS) Putting Evidence Into Practice (PEP) program conducted a literature search for pain prior to 2009. Thirty-four articles from the previous search were included in the cancer-related pain guidelines. These articles were subject to the same inclusion and exclusion criteria as the articles for the new search.
Articles from January 2002 to June 2016 are represented in this guideline.
Pain Topic Search Strategy
The following strategy was used across all four pain guidelines (see the “Major Recommendations” field).
Databases Used
PubMed
(pain[ti] AND cancer[ti]) OR ((pain[ti] OR pain[majr]) AND neoplasms[majr]) AND ((“2009/01/01”[PDAT] : “2016/07/31”[PDAT]) AND “humans”[MeSH Terms] AND English[lang] AND cancer[sb])
CINAHL ®
- (MH “Cancer Pain” OR (TI cancer AND TI pain)) OR ( MM pain AND (cancer OR neoplasms OR oncolog*))
- Limiters: English language; clinical queries: therapy–high sensitivity, therapy–high specificity, therapy–best balance
Inclusion Criteria
- Full research report, systematic review, guideline, or meta-analysis
- Study must report results of measurement of pain, including acute, chronic, breakthrough, or refractory pain.
- The study examines a pharmacologic or nonpharmacologic intervention aimed at affecting pain.
- Sample must include patients with cancer.
- Include pediatric and/or adult studies
- Studies aimed at treatment of pain (may include other symptoms) rather than treatment of the cancer
- Sample size of at least 40, or 20 per study group
- For complex interventions, the description of the intervention must be sufficient to identify the components of that intervention.
Exclusion Criteria
- Gray literature
- Descriptive study
- Studies involving the use of standard short-acting or sustained or extended-release opioids (Only studies involving new formulations or unusual use of these medications will be included.)
- Studies involving examination of effects of different types of surgical anesthesia
- Studies involving surgical procedures as the primary intervention
Number of Source Documents
After removal of duplicates and studies that did not meet the inclusion criteria, the current authors found 154 studies that addressed nonpharmacologic interventions for chronic cancer pain management.
Methods Used to Assess the Quality and Strength of the Evidence
- Expert Consensus (Committee)
- Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
Panels of advanced practice nurses, staff nurses, and doctorally-prepared nurse researchers reviewed the literature base in the identified outcome areas. Professional health services librarians assisted in the conduct of the literature searches. Based on their analysis, the panels then formulated a judgment about the body of evidence related to the intervention under consideration. Three major components were considered by the panels in classifying the collective evidence into one of six Weight of Evidence categories (see the "Rating Scheme for the Strength of the Recommendations" field):
- Quality of the data, with more weight assigned to levels of evidence higher in the PRISM categorization (such as randomized trials and meta-analyses)
- Magnitude of the outcome (e.g., effect size or minimal clinically important difference)
- Concurrence among the evidence (based on the premise that an investigator has less confidence in findings in which the lines of evidence contradict one another)
Methods Used to Analyze the Evidence
- Review of Published Meta-Analyses
- Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence
The Oncology Nursing Society (ONS) information resources supervisor thoroughly searched the literature according to the strategy and search terms shown in the “Description of Methods Used to Collect/Select the Evidence” field. Studies that met inclusion criteria were assigned to pairs of pain Putting Evidence Into Practice (PEP) team members, who reviewed and summarized included articles using a standard form. Each article was reviewed by one pain PEP team member and then peer-reviewed by the second pain PEP team member. The form included information about the purpose of the study and a brief description of the intervention, sample size and characteristics, study design, measurement instruments, conclusions, limitations that show risk of bias and threats to validity in design, and implications for nursing practice.
Methods Used to Formulate the Recommendations
- Expert Consensus (Consensus Development Conference)
Description of Methods Used to Formulate the Recommendations
The Putting Evidence Into Practice (PEP) program is a multifaceted project that involves the coordination of Oncology Nursing Society (ONS) staff as well as volunteer team contributors. PEP topic teams are comprised of volunteer nurse researchers, advanced practice nurses, and staff nurses who have demonstrated experience and interest in a PEP topic. Topic leaders are nurse scientists or advanced practice nurses with demonstrated expertise in the topic through research and/or publications.
PEP team members applied the ONS PEP classification scheme (see the “Rating Scheme for the Recommendations” field) to individual interventions via Web-based meetings occurring about every six months. PEP team members included nurse scientists, advanced practice nurses, and staff nurses. Classification considers all previous as well as new evidence for each intervention. Conferences are facilitated by ONS research staff and classification of individual interventions is determined by team consensus.
Teams categorize interventions based on the ONS PEP weight-of-evidence classification schema. The schema is intended to be used with existing research-based knowledge on health interventions and is based on previous research. PEP teams consider the entire body of evidence rather than a single study for classification, and more weight is given to studies that rank higher in ONS’s priority symptom management project categorization. Team members also consider the magnitude of the outcome and the concurrence of the evidence for an intervention prior to assigning a classification. Interventions are classified by team consensus after application of the schema.
Rating Scheme for the Strength of the Recommendations
Recommended for Practice
Interventions for which effectiveness has been demonstrated by strong evidence from rigorously designed studies, meta-analysis, or systematic reviews, and for which expectation of harms is small compared to the benefits
Likely To Be Effective
Interventions for which effectiveness has been demonstrated from a single rigorously designed conducted controlled trial, consistent supportive evidence from well-designed controlled trials using small samples, or guidelines developed from evidence and supported by expert opinion
Benefits Balanced With Harm
Interventions for which clinicians and patients should weigh the beneficial and harmful effects according to individual circumstances and priorities
Effectiveness Not Established
Interventions for insufficient or conflicting data or data of inadequate quality currently exist, with no clear indication of harm
Effectiveness Unlikely
Interventions for which lack of effectiveness has been demonstrated by negative evidence from a single rigorously conducted controlled trial, consistent negative evidence from well-designed controlled trials using small samples, or guidelines developed from evidence and supported by expert opinion
Not Recommended for Practice
Interventions for which lack of effectiveness or harmfulness has been demonstrated by strong evidence from rigorously conducted studies, meta-analyses, or systematic reviews, or interventions where the costs, burden, or harm associated with the intervention exceed anticipated benefit
Expert Opinion
Low-risk interventions that are consistent with sound clinical practice, suggested by an expert in a peer reviewed publication, and for which limited evidence exists (an expert is an individual who has published peer reviewed material in the domain of interest.)
For further information, see the “Decision rules for summative evaluation of a body of evidence” document (see the “Availability of Companion Documents” field).
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
- External Peer Review
Description of Method of Guideline Validation
The article has been reviewed by independent peer reviewers to ensure that it is objective and free from bias.
Evidence Supporting the Recommendations
Type of Evidence Supporting the Recommendations
The type of supporting evidence is identified for each recommendation (see the original guideline document).
Benefits/Harms of Implementing the Guideline Recommendations
Potential Benefits
- In a meta-analysis of 10 randomized controlled trials (RCTs), approximately 60% of patients with painful bone metastases received some benefit from re-irradiation of radiation-refractory bone pain.
- The National Comprehensive Cancer Network (NCCN) (2016) guidelines for adult cancer pain conclude that celiac plexus block (CPB) may provide improvement in pain reduction compared to systemic analgesics.
- One meta-analysis of studies using coaching sessions showed significant differences in average pain intensity compared to usual care or control.
Potential Harms
Toxicity associated with radiation therapy
Qualifying Statements
Qualifying Statements
The authors take full responsibility for the content of the article. The authors did not receive honoraria for this work. The content of this article has been reviewed by independent peer reviewers to ensure that it is balanced, objective, and free from commercial bias.
Implementation of the Guideline
Description of Implementation Strategy
An implementation strategy was not provided.
Implementation Tools
- Resources
- Staff Training/Competency Material
Institute of Medicine (IOM) National Healthcare Quality Report Categories
IOM Care Need
- Getting Better
- Living with Illness
IOM Domain
- Effectiveness
- Patient-centeredness
Identifying Information and Availability
Bibliographic Source(s)
- Eaton LH, Brant JM, McLeod K, Yeh C. Nonpharmacologic pain interventions: a review of evidence-based practices for reducing chronic cancer pain. Clin J Oncol Nurs. 2017 Jun 1;21(3):54-70. PubMed
Adaptation
Not applicable: The guideline was not adapted from another source.
Date Released
2017 Jun 1
Guideline Developer(s)
- Oncology Nursing Society - Professional Association
Source(s) of Funding
Oncology Nursing Society
Guideline Committee
Oncology Nursing Society Putting Evidence Into Practice® (ONS PEP) Expert Panel
Composition of Group That Authored the Guideline
Authors : Linda H. Eaton, PhD, RN, AOCN®; Jeannine M. Brant, PhD, APRN, AOCN®, FAAN; Karen McLeod, MSN, RN, OCN®, CNL; Chao Yeh, PhD, RN
Financial Disclosures/Conflicts of Interest
All volunteers complete the standardized Oncology Nursing Society (ONS) conflict of interest and confidentiality forms.
The authors take full responsibility for this content and did not receive honoraria or disclose any relevant financial relationships.
Guideline Status
This is the current release of the guideline.
This guideline updates a previous version: Aiello-Laws L, Reynolds J, Deizer N, Peterson M, Ameringer S, Bakitas M. Putting evidence into practice: what are the pharmacologic interventions for nociceptive and neuropathic cancer pain in adults. Clin J Oncol Nurs. 2009 Dec;13(6):649-55. [55 references]
This guideline meets NGC’s 2013 (revised) inclusion criteria.
Guideline Availability
Available to subscribers from the Clinical Journal of Oncology Nursing Web site.
Availability of Companion Documents
The following are available:
- Brant JM, Eaton LH, Irwin MM. Cancer-related pain: assessment and management with Putting Evidence Into Practice interventions. Clin J Oncol Nurs. 2017 Jun 1;21(3):4-7. Available to subscribers from the Clinical Journal of Oncology Nursing Web site.
- Chronic pain. [internet]. Pittsburgh (PA): Oncology Nursing Society. 2017 Mar 30. Available from the Oncology Nursing Society (ONS) Web site.
- Mitchell SA, Friese CR. Decision rules for summative evaluation of a body of evidence. [internet]. Pittsburgh (PA): Oncology Nursing Society. Available from the ONS Web site.
- Johnson LA. Putting Evidence Into Practice: the process for evidence-based research. Clin J Oncol Nurs. 2014 Dec;18(6 Suppl):2-4. Available from the Clinical Journal of Oncology Nursing Web site.
- Putting Evidence Into Practice (PEP) rating system overview. [internet]. Pittsburgh (PA): Oncology Nursing Society. Available from the ONS Web site.
- ONS journal activity 2017: nonpharmacologic pain interventions: a review of evidence-based practices for reducing chronic cancer pain. [internet]. Pittsburgh (PA): Oncology Nursing Society. Available from the ONS Web site.
Patient Resources
None available
NGC Status
This NGC summary was completed by ECRI Institute on December 3, 2010. The information was verified by the guideline developer on February 3, 2011. This summary was updated by ECRI Institute on October 28, 2013 following the U.S. Food and Drug Administration advisory on Acetaminophen. The currency of the guideline was reaffirmed by the developer in 2011 and this summary was updated by ECRI Institute on November 8, 2013. This summary was updated by ECRI Institute on September 18, 2015 following the U.S. Food and Drug Administration advisory on non-aspirin nonsteroidal anti-inflammatory drugs (NSAIDs). This summary was updated by ECRI Institute on February 5, 2018. The updated information was verified by the guideline developer on February 21, 2018.
This NEATS assessment was completed by ECRI Institute on November 16, 2017. The information was verified by the guideline developer on February 21, 2018.
Copyright Statement
This summary is based on the original guideline, which is copyrighted by the Oncology Nursing Society (ONS).
Disclaimer
NGC Disclaimer
The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.
All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public or private organizations, other government agencies, health care organizations or plans, and similar entities.
Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria.
NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.
Readers with questions regarding guideline content are directed to contact the guideline developer.