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418 Rassegne Recenti Prog Med 2016; 107: 418-421 The underestimated role of psychological and rehabilitation approaches for management of cancer pain. A brief commentary MARCO CASCELLA1, NICHOLAS SIMONDS THOMPSON2, MARIA ROSARIA MUZIO3, CIRA ANTONIETTA FORTE4, ARTURO CUOMO1 1 Division of Anesthesia, Department of Anesthesia, Endoscopy and Cardiology, Istituto Nazionale Tumori “Fondazione G. Pascale” - IRCCS, Naples, Italy; 2Department of Psychology Clark University, Worcester, MA, US; 3Division of Infantile Neuropsychiatry , UOMI - Maternal and Infant Health, Torre del Greco, Naples, Italy; 4Psychology, Division of Pain Medicine, Department of Anesthesia, Endoscopy and Cardiology Istituto Nazionale Tumori “Fondazione G. Pascale” - IRCCS, Naples, Italy. Pervenuto il 16 aprile 2016. Accettato dopo revisione il 1° luglio 2016. Summary. Individually tailored pharmacological regimen is the standard approach for treating patients affected by cancer pain, allowing the control of symptoms in approximately 90% of cases. If this strategy is ineffective it is possible to use more complex invasive, or minimally invasive, techniques. Nevertheless, both patients and health care professionals often underestimate the impact of cancer pain on psychological distress, and do not consider the potential benefits of psychological treatments to help manage cancer pain. These non-pharmacological strategies should be part of the multidisciplinary pain therapy, supporting and strengthening drug therapy. The purpose of this brief commentary is to discuss the role of psychological and rehabilitation approaches for improving the quality of life and the psychosocial outcomes in patients with cancer pain. Breve commento sull’importanza spesso sottovalutata degli approcci psicologici e riabilitativi nella gestione del dolore oncologico. Key words. Cancer pain, cognitive behavioral therapy, pain management, physical medicine, psychological techniques. Parole chiave. Dolore oncologico, gestione del dolore, medicina fisica, tecniche psicologiche, terapia cognitivocomportamentale. Introduction Individually tailored pharmacological regimen is the standard approach for treating patients affected by cancer pain, allowing the control of symptoms in approximately 90% of cases1. If this approach is ineffective it is possible to use more complex invasive, or minimally invasive, techniques1. Nevertheless, both patients and health care professionals often underestimate the impact of cancer pain on psychological distress, and do not consider the potential benefits of psychological treatments to help manage cancer pain2. According to Dame Cicely Saunders cancer pain is a “total pain” because the patient’s pain experience has physical, emotional, social and spiritual dimensions3. Cancer diseases can have a great psychological impact. For instance, cancers of the cervix can lead to well-known problems involving sexuality, femi- Riassunto. L’approccio farmacologico personalizzato (tailored) rappresenta la terapia standard per i pazienti affetti da dolore oncologico, consentendo il controllo della sintomatologia in circa il 90% dei casi. Qualora tale strategia risulti inefficace è possibile ricorrere a più complesse tecniche, invasive o mini-invasive. Tuttavia, sia da parte dei pazienti sia degli operatori viene sottostimato il disagio psicologico sotteso al dolore oncologico e non si considerano i potenziali benefici dei trattamenti di supporto psicologico e riabilitativi nella gestione del dolore da cancro. Queste strategie non farmacologiche dovrebbero essere parte integrante di un più globale approccio multidisciplinare alla terapia del dolore, affiancando e amplificando gli effetti della terapia farmacologica. Tale breve rassegna narrativa ha la finalità di offrire una panoramica sul ruolo dei possibili interventi psicologici e riabilitativi atti al miglioramento della qualità della vita in pazienti affetti da dolore oncologico. ninity and social isolation; thus, sexual dysfunction and alteration of the body image often represent a major concern, as well as an important cause of distress among women4. For survivors of prostate cancer, overall satisfaction with follow-up care was high, but was lower for psychosocial than physical aspects of care. A survey found that 17% of men reported potentially moderate-to-severe levels of anxiety and 10.2% reported moderate-to-severe levels of depression5. Moreover, the emotional state of patients with permanent colostomy is typically characterized by fear, and worry about their current process, and body image, self-esteem, social activities and sexuality are the aspects that most affect the patients6. Psychological distress is related to the symptoms of patients with cancer of the pelvis and, consequently, psychological support and care must be integral to the cancer treatment. According to previous finding, there is a strong linkage between the degree, and the M. Cascella et al.: The underestimated role of psychological and rehabilitation approaches for management of cancer pain length of the cancer pain experience, and the psychological functioning, especially in terms of negative effect on mood, with anxiety, depressive feelings and suicidal thoughts7. Compared to pain-free cancer patients, cancer patients with pain had significantly higher levels of anxiety, depression, and anger, and patients with higher pain intensity and longer duration of pain had the highest levels of mood disturbance8. Several studies showed that social activities, such as visits and conversations decreased significantly with increasing pain; thus, pain not only causes physical suffering, but also influences different aspects of Quality of life (QoL)9, becoming a significant source of emotional, social and existential distress10. In addition, especially in patients with advanced cancer, unrelieved emotions, depressive or anxious symptoms, delirium, difficulties communicating, greatly influence the expression of pain. Because all these findings indicate that in cancer patients psychological factors influence both the experience of pain and the response to pain treatment, psychological and behavioral treatments are not of secondary importance in cancer patient management, and the possibility of reducing psychological distress, may improve pain management in any phase of care11. The aim of this work is to provide an exhaustive summary of current literature on psychological, and rehabilitation approaches for management of pain in cancer patients. Psychological interventions Numerous kinds of non-medical interventions are used to manage cancer pain, including interventions often designated psychological and behavioral with the purpose to teach patients to respond to pain awareness with a shift in their thoughts and/ or coping behaviors. The rationale is that people who experience cancer pain typically develop and use a number of coping strategies to cope with, deal with, or minimize the effects of pain12. On this basis, because health professionals should make efforts to understand how each patient copes with pain, also supporting the patient in developing pain coping skills, the presence of a cognitivist psychologist as component of the pain management team is often mandatory. As support of these observations, a meta-analysis concluded that cognitive behavioral therapy techniques have beneficial effects on pain and distress in women with breast cancer, finding moderate effect sizes of drugs used in pain management13. Psychological therapy may help patients cope with cancer and the psychosocial problems associated with cancer and cancer treatment, but is less likely to help with common physical issues such as loss of strength and flexibility, weight gain, and reduced physical function14. Thus, some authors prefer behavioral approaches that are based on behavioral training studied to teach patients the use of adaptive behaviors, like engaging in distracting activities, pacing activities, and appropriate use of medications or physical modalities15. Patients may be taught to observe what increases pain and to take a pain medication before that activity, or they may learn when their pain is less severe in a specific moment of the day, in order to do their priority activities during that time. Behavioral approaches are also relaxation, imagery, exercise, or yoga. These treatments provide physiologic benefits, adding competing sensory input to the brain, which can shift thoughts and emotional responses. Yoga, for example, is feasible for patients with cancer, with improved sleep, QoL, mood and levels of stress16. Other strategies, such as meditation or hypnosis, shift focus away from pain, in adult and pediatric patients, in which these therapies has been shown to reduce anticipatory anxiety, procedure-related pain, procedure-related anxiety, and behavioral distress during venipuncture17. Educational interventions often include both behavioral approaches and cognitive behavioral therapy elements that provide adaptive coping skills and address barriers to the use of treatments for pain, as well as increase understanding of how to use treatment options and how to communicate with health care providers about pain. Other psychosocial methods include a focus on partner/caregiver responses to pain or supportive-expressive or meaning-centered therapies that allow patients to explore their feelings, needs, and interpretation of their experiences with a supportive and facilitating therapist. Psychologists have also a paramount role in the doctor-patient relationship. In fact, cancer patients should be full partners in decision-making, and the pluses and minuses of each option should be explained and in most instances the patient should have the final call. Nevertheless, physicians may encounter communication difficulties, then the opportunity to receive help from psychologist is not to be underestimated, for example, to better explain to patients probable side-effects and complications of treatments. Rehabilitation approaches Because cancer pain may be due to the cancer itself or secondary to immobility and debilitation, it may benefit from interventions that focus on function. For this purpose, mobility – and consequently pain – may be improved by strengthening, stretching, and the use of assistive devices, thus, including a rehabilitation medicine specialist in the pain management team is often a winning move. Treatment objectives of cancer rehabilitation are preventive, to improve function and reduce morbidity and disability, restorative, for patients with potential cure of cancer whose residual disability can be appropriately controlled or eliminated, supportive for patients who must continue with cancer but can expect 419 420 Recenti Progressi in Medicina, 107 (8), agosto 2016 relative control or remission of appreciable time, and palliative. Rehabilitative and physical modalities used to manage pain can be grouped into four categories: those that modulate nociception, stabilize or unload painful structures, influence physiological processes that indirectly influence nociception, or alleviate pain arising from the overloading of muscles and connective tissues that often occurs after surgery or with sarcopenia in late-stage cancer. Cancer rehabilitative treatments include physical therapy, occupational therapy, lymphedema therapy, recreational therapy, speech and language pathology therapies, and the use of prosthetics and orthotics. These treatments may be particularly beneficial to patients with movementassociated pain18 and in some clinical condition, for instance to manage post radiation complications, like neuromuscular and musculoskeletal complications of the radiation fibrosis syndrome19. Specific therapies, such as occupational therapy, can be particularly effective to help pain management in selected cases of cancer patients, also in pelvic neoplastic diseases. The role of occupational therapy in oncology and cancer-related pain management is well recognized today20. Occupational therapy is a rehabilitation approach which uses assessment and treatment to develop, recover, or maintain the daily living and work skills of people with a physical, mental, or cognitive disorder. In oncology it can help patients to continue or resume usual roles despite cancer-related pain, indeed, by this intervention the patient receives a constructive help to build perceived personal control or self-efficacy to manage cancer pain21. Occupational therapy works through interventions on productivity and leisure, self-care – for instance with the purpose of maintaining or increasing autonomy in performing activities of daily living, or creating an action plan to optimize treatment adherence – cognitive and affective aspects, physical aspect of the person and spirituality22. According to Lapointe, an optimal occupational intervention should be personalized. It should be well chosen, carefully graded and monitored, and appropriate to the patient’s cancer stage23. Occupational therapy could be effective in sick cancer patients and in those with cognitive impairments, mental illness, language barriers or suspected substance abuse. Probably, the odds of having any potentially modifiable functional deficit are higher in patients with increasing age, comorbid conditions, and with less than a college degree24. However, as reported by Mackenzie Pergolotti et colleagues only 32% of adult patients used occupational therapy within the first two years of their cancer diagnosis (also prostate and colorectal cancer), a rate lower that the estimated 87% who are in need of such approach25. Conclusions For all these considerations, in cancer pain the most suitable psychological and rehabilitation approach should be chosen after a case-by-case analysis, to improve the QoL and the psychosocial outcomes, the compliance to the therapy and the doctor-patient interaction/relationship. Conflict of interests: the authors declare that there are no conflicts of interest. References 1. Miguel R. Interventional treatment of cancer pain: the fourth step in the World Health Organization analgesic ladder? Cancer Control 2000; 7: 149-56. 2. 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