570410 research-article2015

PMJ0010.1177/0269216315570410Palliative MedicinePollak et al.

Research Letter

A brief relaxation intervention for pain delivered by palliative care physicians: A pilot study

Palliative Medicine 2015, Vol. 29(6) 569­–570 © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0269216315570410 pmj.sagepub.com

Kathryn I Pollak1,2, Pauline Lyna1, Alicia Bilheimer1 and Laura S Porter1,3 Cancer pain management guidelines recommend cognitive-behavioral strategies, such as relaxation, as adjuvants to pain medication.1 However, cancer patients with pain rarely receive cognitive-behavioral treatments from their palliative care clinicians. The primary aim of this pilot study was to test the feasibility and acceptability of training physicians to deliver a relaxation intervention in the context of routine palliative care. We also examined the effect of the intervention on patient outcomes.

pain, each rated on a 0–10 scale (see Table 2 for anchors).2 On the post-visit survey, patients reported whether their physician did relaxation techniques with them, and they completed three items assessing the credibility and acceptability of the intervention, each rated on a 0–10 scale with higher ratings indicating more favorable responses. All study procedures were approved by the Duke University Medical Center Institutional Review Board.

Results

Methods Participants were three palliative care physicians (two male, one female, practicing in inpatient and outpatient settings, none of whom had been trained in relaxation techniques) and 35 patients who were recruited anonymously. Patient eligibility criteria (assessed by physicians) were experiencing pain and cognitively able to do relaxation techniques. The intervention consisted of a brief 10-min version of progressive muscle relaxation combined with deep breathing and guided imagery (see Table 1). At the start of the study, physicians attended a 60-min group training session followed by a brief individual session to role-play and ensure they were adhering to the script and competent in delivery. Physicians were trained to guide patients through the relaxation exercise and encourage them to practice it on their own. There were 20 designated study days over 14 weeks. Half were randomized to be “intervention days” on which physicians were asked to do the intervention with at least one patient. The other half were “control days” on which physicians were asked not to do the intervention with any patients. Physicians recruited and obtained verbal consent from all study patients. Nurses delivered anonymous surveys to patients as obtaining informed consent would interrupt clinic flow. We conducted informal interviews with the physicians to assess their impressions of delivering the relaxation intervention. Before and after their clinic visit, patients completed a survey with one-item measures of their current level of pain, psychological distress, tension, and confidence for managing

Nurses delivered surveys on 15 of the 20 designated study days (8 control, 7 intervention). When asked whether their physician did the relaxation intervention with them, none of the control patients and all but one intervention patient answered “yes.” This indicates that physicians were able to keep control and intervention days separate and that they delivered the intervention to one patient on the designated days. All patients felt less pain and distress after their visit. Intervention patients had somewhat greater decreases in pain and tension and greater increases in self-efficacy than control patients; however, the small sample size precluded inferential statistics (See Table 2). Most patients reported favorable credibility and acceptability ratings. Physicians reported that while at first they found taking 10 extra minutes to deliver the relaxation intervention to be difficult, as they saw positive results, they felt it was worth the time. While they said they could not incorporate it into all of their encounters, just as they would not 1Cancer

Control and Population Sciences, Duke Cancer Institute, Durham, NC, USA 2Department of Community and Family Medicine, Duke University School of Medicine, Durham, NC, USA 3Department of Psychiatry and Behavioral Science, Duke University School of Medicine, Durham, NC, USA Corresponding author: Kathryn I Pollak, Department of Community and Family Medicine, Duke University School of Medicine, 2424 Erwin Road, Suite 602, Durham, NC 27705, USA. Email: [email protected]

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Table 1.  Components of the relaxation intervention and physician training. Intervention

Physician training

1. Brief introduction to relaxation as an effective strategy for managing pain that can be used along with medication; 2. Rationale for why relaxation strategies are helpful;

1. Rationale for the use of relaxation techniques to help patients manage pain and distress; 2. Demonstration of how to train patients in the relaxation technique; 3. Role plays in which the physicians practice delivering the intervention and receive feedback from the trainers; 4. Discussion of how best to incorporate the relaxation technique into a medical encounter; and

3. Assisting the patient in identifying and describing a pleasant scene to use for the imagery exercise; 4. Leading the patient through a brief relaxation exercise consisting of deep breathing, muscle relaxation, and pleasant imagery; 5. Eliciting feedback and recommending practice.

5. Discussion of common questions and problems that patients may have and how to address them.

Table 2.  Patient reports before and after palliative care visits and perceptions of relaxation techniques. Variable

Control-pre, mean (SE)

Control-post, mean (SE)

Difference, mean (SE)

Tx-pre, mean (SE)

Tx-post, mean (SE)

Difference, mean (SE)

Paina Distressb Tensionc Confident can cope with paind   Useful to cope with pain Recommend to a friend Likely to practice on your own

4.5 (0.6) 3.5 (0.6) 3.5 (0.6) 5.5 (0.7)

4.2 (0.6) 2.1 (0.6) 2.2 (0.6) 6.4 (0.7)

−0.3 (0.3) −1.4 (0.5) −1.3 (0.4) 0.9 (0.7)

4.3 (0.6) 5.7 (0.6) 5.5 (0.6) 6.2 (0.7)

– – –

– – –

– – –

– – –

3.5 (0.6) 4.3 (0.6) 3.5 (0.6) 7.5 (0.7) Median (IQR) 7.0 (5.0–8.5) 8.0 (7.0–9.0) 8.0 (7.0–10.0)

−0.8 (0.3) −1.4 (0.5) −2.0 (0.5) 1.3 (0.7)   – – –

SE: standard error; IQR: inter-quartile range. Analysis based on 29 patients. Six patients were missing data for the after assessment (5 intervention and 1 control). aCurrent level of pain measured on a scale from 0 (“no pain”) to 10 (“as bad as you can imagine”). bCurrent level of distress (feeling worried or down) measured on a scale from 0 (“no distress”) to 10 (“extreme distress”). cCurrent level of tension measured from 0 (“completely calm and relaxed”) to 10 (“extremely tense”). dConfidence in ability to cope with pain measured from 0 (“not at all confident”) to 10 (“completely confident”).

prescribe every pain medication to every patient, they could clearly see the value and would use it in the future.

Discussion This innovative pilot study examined whether it was feasible and acceptable for palliative care physicians to provide a relaxation intervention to their patients in the context of their routine outpatient and inpatient encounters. We found that palliative care physicians felt it was beneficial for patients. Interestingly, all patients reported improvements in pain, distress, and tension from pre- to post-visit, which is a testament to effective palliative care encounters. However, patients who received the relaxation intervention reported somewhat greater improvements in pain, tension, and confidence for handling pain. This suggests that the relaxation intervention may provide additional benefits to patients. This preliminary pilot study has several limitations, including small samples of physicians and patients, no demographic data on patients, potential bias in recruitment of patients, and lack of objective data on length of time the relaxation techniques added to encounters.

Despite these limitations, this pilot study shows promise for having palliative care physicians incorporate relaxation training as part of their routine clinical care. Patients were receptive to the relaxation intervention and tended to report better outcomes than patients in the control arm. This study needs to be replicated on a larger scale. Declaration of conflicting interests The authors declare that there is no conflict of interest.

Funding This work was supported by internal institutional funds.

References 1. Gordon DB, Dahl JL, Miaskowski C, et al. American Pain Society recommendations for improving the quality of acute and cancer pain management: American Pain Society Quality of Care Task Force. Arch Intern Med 2005; 165: 1574–1580. 2. Cella D and Perry SW. Reliability and concurrent validity of three visual-analogue mood scales. Psychol Rep 1986; 59: 827–833.

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A brief relaxation intervention for pain delivered by palliative care physicians: A pilot study.

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