Indian Journal of Palliative Care
Open access journal 
  Print this page Email this page   Small font sizeDefault font sizeIncrease font size Users online: 494  
     Home | About | Feedback | Login 
  Current Issue Back Issues Editorial Board Authors and Reviewers How to Subscribe Advertise with us Contact Us Analgesic Prescription  
  Navigate Here 
 Search
 
  
 Resource Links
  ╗  Similar in PUBMED
 ╗  Search Pubmed for
 ╗  Search in Google Scholar for
 ╗Related articles
  ╗  Article in PDF (513 KB)
  ╗  Citation Manager
  ╗  Access Statistics
  ╗  Reader Comments
  ╗  Email Alert *
  ╗  Add to My List *
* Registration required (free)  

 
  In this Article
 ╗  Abstract
 ╗ Introduction
 ╗  Cancer Pain-Symp...
 ╗  Cancer Pain - Sy...
 ╗  Cancer Pain - Ev...
 ╗  Mechanism-Based ...
 ╗  Physical Therapy...
 ╗ Discussion
 ╗ Conclusion
 ╗  References

 Article Access Statistics
    Viewed8084    
    Printed248    
    Emailed4    
    PDF Downloaded460    
    Comments [Add]    
    Cited by others 12    

Recommend this journal

 


 
Table of Contents 
REVIEW ARTICLE
Year : 2011  |  Volume : 17  |  Issue : 2  |  Page : 116-126

Cancer pain: A critical review of mechanism-based classification and physical therapy management in palliative care


Department of Physiotherapy, Kasturba Medical College, Manipal University, Mangalore, India

Date of Web Publication5-Sep-2011

Correspondence Address:
Senthil P Kumar
Department of Physiotherapy, Kasturba Medical College, Manipal University, Mangalore
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1075.84532

Rights and Permissions

 ╗ Abstract 

Mechanism-based classification and physical therapy management of pain is essential to effectively manage painful symptoms in patients attending palliative care. The objective of this review is to provide a detailed review of mechanism-based classification and physical therapy management of patients with cancer pain. Cancer pain can be classified based upon pain symptoms, pain mechanisms and pain syndromes. Classification based upon mechanisms not only addresses the underlying pathophysiology but also provides us with an understanding behind patient's symptoms and treatment responses. Existing evidence suggests that the five mechanisms - central sensitization, peripheral sensitization, sympathetically maintained pain, nociceptive and cognitive-affective - operate in patients with cancer pain. Summary of studies showing evidence for physical therapy treatment methods for cancer pain follows with suggested therapeutic implications. Effective palliative physical therapy care using a mechanism-based classification model should be tailored to suit each patient's findings, using a biopsychosocial model of pain.


Keywords: Mechanism-based classification, Pain pathomechanisms, Pain rehabilitation, Palliative oncology, Physical therapy


How to cite this article:
Kumar SP. Cancer pain: A critical review of mechanism-based classification and physical therapy management in palliative care. Indian J Palliat Care 2011;17:116-26

How to cite this URL:
Kumar SP. Cancer pain: A critical review of mechanism-based classification and physical therapy management in palliative care. Indian J Palliat Care [serial online] 2011 [cited 2019 Oct 22];17:116-26. Available from: http://www.jpalliativecare.com/text.asp?2011/17/2/116/84532



 ╗ Introduction Top


Cancer is the common condition where addressing pain relief is often the leading concern for the patient and palliative care team at end-of-life care. [1]

The incidence of cancer worldwide is 6-7 million patients per year, with half or more occurring in developing countries. Every year, approximately 4.5 million patients die from cancer, and 3.5 million suffer from cancer pain daily, with only a limited number of them receiving adequate pain treatment. [2]

The pain in cancer patients may be caused by direct tumor involvement, diagnostic or therapeutic procedures, side effects, or toxicities of cancer treatment. No matter its source, uncontrolled pain can affect every aspect of a patient's quality of life, causing suffering, interference with sleep, and reduced physical and social activity and appetite. [3] Though specialist palliative care teams are available for treating cancer pain, the deaths due to cancer pain are alarmingly at 28%. [4]

Approximately 30-50% of all cancer patients experience pain, and of them, 75-90% experience substantial life-altering cancer-induced pain. [5] The good news for patients with cancer is that with improvements in detection and treatment, cancer patients are surviving for significantly longer periods than in the past. Unfortunately, the quality of life of these patients is frequently diminished [6] and pain can be a major contributor to this decrease in the quality of life. [7],[8]

In India, of 156 patients who were receiving radiotherapy for their cancer pain, 61% had incidence of pain. [9] Bisht et al,[10] found that pain was the most common prevalent symptom (96% of 100 patients assessed) among cancer patients attending a palliative care unit in Uttarakhand, India.

World Health Organization (WHO) analgesic ladder management is currently the most accepted and widely employed pain management strategy in patients with cancer pain. Despite their well-known adverse effects ranging from local to general in bodily distribution, opioids are still the most recommended drug therapy of choice for patients with cancer pain. [11] Despite great advances in the fields of pain management and palliative care, pain directly or indirectly associated with a cancer diagnosis remains significantly undertreated. [12]

Non-pharmacologic methods used in conjunction with analgesics have as their goal to help the patient with cancer gain or maintain functionality and restore a sense of psychological control over their pain and their circumstances. These approaches ordinarily have no negative side effects. [13] Physical interventions form a part of non-pharmacological interventions that include a variety of therapeutic methods for pain relief in palliative care, administered by physical therapists. [14]

One of the recent developments in conceptualization of physical therapy management for pain relief in palliative care is the mechanism-based classification of pain. [15] Identification of a cancer patient's clinical presentation and its relationship to symptoms is essential for initiation of appropriate therapeutic strategy for pain relief. Classification of cancer pain was considered to be a controversial issue. [16] Earliest categorization of cancer pain was done broadly into three categories: primary cancer pain, secondary cancer pain or pain secondary to treatment, and pain unrelated to cancer. [17] Later, symptom-based and syndrome-based classifications started evolving, thus leading to heterogeneity in cancer pain terminology and treatments which are based upon such diverse classification methods.

Pain necessarily involves three different levels of classification - based upon pain symptoms, pain mechanisms and pain syndromes. [18] The three levels can be applicable for cancer pain as follows.


 ╗ Cancer Pain-Symptom-Based Classification Top


Lasheen et al,[19] designed a clinical classification of cancer pain and they classified the pain into continuous and intermittent pain. Intermittent pain alone category can be divided further into incident, non-incident and mixed pain. The category of continuous pain [termed as breakthrough pain (BTP)] was further similarly divided into incident, non-incident, mixed and end-of-dose failure pain.

Serlin et al,[20] classified cancer pain into mild (1-4), moderate (5-6) and severe (7-10) depending upon the level of interference with function, using a numeric pain rating scale from 0 to 10.


 ╗ Cancer Pain - Syndrome-Based Classification Top


Grond et al,[21] found prevalence and characteristics of cancer pain syndromes among patients with cancer pain and they found that 30% of the patients presented with one, 39% with two and 31% with three or more distinct pain syndromes. The majority of patients had pain caused by cancer (85%) or anti-neoplastic treatment (17%); 9% had pain related to cancer disease and 9% due to etiologies unrelated to cancer. Pain was classified as originating from nociceptors in bone (35%), soft tissue (45%) or visceral structures (33%), or otherwise as of as neuropathic origin (34%). Region-wise, pain syndromes were located in the lower back (36%), abdominal region (27%), thoracic region (23%), lower limbs (21%), head (17%) and pelvic region (15%).


 ╗ Cancer Pain - Evolution of Mechanism-Based Classification Top


The influence of mechanism into pain perception, evaluation and management was evident from 1950s in cancer pain [22] and cancer pain syndromes. Mantyh [23] suggested that a shift was necessary and imperative in understanding cancer pain by moving toward a mechanism-based model for classification. Mantyh [24] identified three mechanisms in bone cancer pain - inflammatory, neuropathic and tumorigenic. Such a classification aided not only in diagnosis but also in analgesic management of bone cancer pain. [25]

Cancer pain was classified into ongoing pain and BTP, both of which have been identified to have central and peripheral mechanisms. [26] BTP has been defined as "the transient exacerbation of pain occurring in a patient with otherwise stable, persistent pain". It is usually unpredictable and heterogeneous. [27] The predominant pain pathophysiology involves three - somatic, visceral and neuropathic. Somatic pain involves pain arising from external structures (soma) such as skin, soft tissues and musculoskeletal tissues. It is likely to be felt as 'localized, superficial and sharp' pain. Visceral pain involves pain arising from internal organs (viscera) like vital organs, systemic organs and organ systems. It is likely to be felt as 'diffuse, deep and dull'. Neuropathic pain involves pain arising from structures of the somatosensory system such as receptors, peripheral nerves, autonomic nerves and central nervous system. It is likely to be felt as 'tingling and numbness, pins and needles, and, sensory and motor deficits. Overall prevalence for BTP is 40-86% and is the most common and feared symptom of cancer. [27] Portenoy et al,[28] utilized an assessment algorithm that categorized BTP patients into three groups: (1) those with uncontrolled background pain; (2) those with controlled background pain and no BTP, and (3) those with controlled background pain and BTP. The authors found that the presence of BTP was a marker of a generally more severe pain syndrome, and was associated with both pain-related functional impairment and psychological distress.

Looking to the future, if we acknowledge that rigorous classification and assessment of break-through pain allows for more efficient diagnosis, more timely access to appropriate treatment and more detailed study of prognosis, then every effort should be made in this direction to produce a meaningful system of classification and assessment.

-Bennett [29]

Haugen et al,[30] in their systematic review of classification for cancer pain found that there existed no formal classification system for BTP in spite of it being a huge public health issue with a high prevalence rate of 40-80%. Knudsen et al,[31] in their recent systematic review on classification of cancer pain emphasized the need to develop better classification systems to enhance symptom evaluation, to facilitate homogenous subgrouping of patients, and to adequately address the underlying source of cancer patients' symptoms.

Siddall and Duggan [32] suggested that pain medicine should shift its focus on mechanism-based approach to management. Pharmacological treatments were suggested by Woolf [33] along a mechanism-based approach.

Non-pharmacological treatments such as physical therapy have their range of treatment options, whose effects not only involve symptom control but are also toward improving the quality of life in cancer patients receiving pain rehabilitation and palliative care. [14] Recent studies by Smart and Doody [34],[35] found using qualitative methodology that expert musculoskeletal physiotherapists used mechanism-based classification in their clinical reasoning process of evaluation of pain in their patients. Mechanism-based treatments are most likely to succeed [36] compared to symptomatic treatments or diagnosis-based treatments.

There are five operating mechanisms in pain perception that are categorized under mechanism-based classification of pain by Kumar and Saha, [15] who described in detail the individual mechanisms, their clinical features, assessment findings and probable physical therapy treatment techniques. The five mechanisms are:

  • central sensitization/central neurogenic mechanism/central nociceptive mechanism
  • peripheral sensitization/peripheral neurogenic mechanism
  • peripheral nociceptive mechanism
  • sympathetically maintained pain/sympathetically dependent pain mechanism and
  • cognitive-affective (psychosocial) mechanism.


The objective of this paper is to update the physical therapists, oncologists and cancer rehabilitation professionals working in palliative care on the application of mechanism-based classification to cancer pain and its interpretation, with available therapeutic evidence for providing optimal patient care using physical therapy.


 ╗ Mechanism-Based Classification of Cancer Pain Top


Ballantyne [37] outlined the common causes for chronic pain among cancer patients as: peripheral neuropathies (due to radiation, chemotherapy, tumor erosion); radiation fibrosis; chronic postsurgical incisional pain; phantom pain; arthropathies and musculoskeletal pain due to posture and mobility; visceral pain due to visceral damage or treatment-related blockage (opioid-induced constipation).

From the above description, syndrome-specific mechanisms for chronic pain in cancer patients can be seen as follows: peripheral neuropathies presenting as either peripheral sensitization or sympathetically maintained pain; radiation fibrosis presenting as nociceptive pain; chronic postsurgical incisional pain presenting as nociceptive and central sensitization; phantom pain presenting as central sensitization; musculoskeletal pain being nociceptive or central sensitization; and visceral pain being nociceptive or sympathetically maintained.

Central sensitization and cancer pain

In short, central sensitization denotes increased sensitivity of higher order neurons of the central nervous system, which causes an "ongoing pain" in the absence of peripheral nociceptive stimulus. Presence of either hyperalgesia or allodynia in a patient with cancer pain who has "spontaneous or ongoing" pain was highly indicative of central pain mechanisms.

Presence of hyperalgesia was demonstrated in animal models [38],[39],[40],[41],[42],[43] of cancer pain and in a very few studies on human beings [44] with cancer pain. Allodynia was also shown in animal [45] and human [46] models of cancer pain. Hyperalgesia is an exaggerated pain perception to a painful stimulus and allodynia is pain perception in response to a non-painful stimulus.

Taber et al,[47] described the functional anatomical basis for central pain and explained the role played by amygdala and somatosensory cortex in "pain memory" and cortical representation of pain. Deafferentiated pain was common in patients with phantom limb pain. [48] Spiritual pain due to emotional influences and spirituality was also described as a central sensitization phenomenon among cancer patients. [49]

Clinical examination and objective screening for central neuropathic pain could be done using Leeds assessment of neuropathic signs and symptoms (LANSS) scale, [50] wherein Potter et al, used the scale to identify cancer-related central neuropathic pain among patients with head and neck cancer, and found its sensitivity to be 79% and the specificity was 100%.

Peripheral sensitization/peripheral neuropathic mechanism and cancer pain

Paice [51] described in her review on the cancer-related and non-cancer-related causes of peripheral neuropathic pain in cancer patients as follows:

Cancer-related: Brachial plexus neuropathies, chemotherapy-induced neuropathy, cranial neuropathies, post-herpetic neuropathy, post-radiation plexopathies and surgical neuropathies

Non-cancer-related: Alcohol-induced neuropathy, brachial plexus avulsion (trauma), carpal tunnel syndrome, complex regional pain syndrome (CRPS), diabetic neuropathy, Fabry's disease, failed-back syndrome, Guillain-Barré syndrome, HIV-associated neuropathy, post-stroke pain, trigeminal neuralgia and vitamin deficiencies

Sympathetic pain and cancer

Over- or under-activation of the sympathetic nervous system associated with pain in patients with cancer is not new. [52],[53] Churcher [54] emphasized identification of sympathetic dependent pain (SDP) or sympathetic maintained pain (SMP) in cancer patients by looking for cutaneous dysesthesia often accompanied by sympathetic overactivity, and relieved by sympathetic block. The pain descriptors are "burning" and "throbbing" and are present with allodynia (pain caused by a non-noxious stimulus and often tested by light touch), hyperpathia (delayed pain response to touch stimulus) and hypoalgesia to pin prick testing (nondermatomal and in circumferential vasotopographic distribution) in the painful area. Signs of excessive sweating and vasoconstriction (pale, cold and white extremities) indicate sympathetic overactivity. In cancer patients, the SDP is often observed in lower limbs, chest, head and neck and rarely in upper extremities.

Though a direct mechanism-based relationship with cancer symptoms was not established, earlier authors found evidence for SMP mechanism in patients with cancer pain [55],[5]6,[5]7,[58],[59] through relief of symptoms with sympathetic blocks in patients with cancer pain.

Lack of proper understanding of SDP in cancer pain patients would lead to misdiagnosis of "tumor spread" (since increased radionuclide uptake is noticed in both situations) and unnecessary radiotherapy to which the patients are often unresponsive at this stage. [60]

Nociceptive mechanisms in cancer pain

Nociceptive pain could be mostly secondary to disuse, deconditioning and abnormal movements or postures adopted by a cancer patient due to symptoms. Cancer treatment related nociceptive pain mechanisms were demonstrated in two studies. Winters et al,[61] showed the clinical manifestation of musculoskeletal pain among patients with breast cancer treated with aromatase inhibitors and Frieze et al,[62] showed the same in cancer patients who underwent long-term corticosteroid therapy. Krakowski et al,[63] provided evidence-based clinical practice guidelines for WHO analgesic recommendations for patients with cancer pain to specifically address nociceptive pain mechanism. Other clinical findings of nociceptive or musculoskeletal pain among patients with cancer pain are pain which is essentially provoked by specific postures and/or movements, present in anatomically relevant areas, and is intermittent and of bearable intensity.

Cognitive-affective mechanisms in cancer pain

Cognitive-affective dysfunction in cancer pain could be due to two causes - cancer-related and treatment-related. Chen et al,[64] showed that compared to cancer patients without pain, the patients with cancer pain exhibited greater anxiety and depression scores which related with their reduced levels of function.

The causes for cognitive-affective dysfunction in patients with cancer are multifold. It may be due to narcotic analgesic prescription [65] and opioids. [66],[67] Cognitive functioning influences the pain reporting characteristics [68] and mostly self-reports do not coincide with objective examination findings in such patients. [69] Cognitive status of patients also bear a relationship with other affective factors such as depression, hopelessness and spirituality [70] in those patients.

Dalton and Feuerstein [71] in their detailed review listed psychological characteristics such as anxiety, depression and guilt, preoccupation with pain, emotions, low ego strength, high neuroticism, low self-confidence, and high dependence on external locus of control; and social/environmental factors such as general stressors, family and work strain, social networks, family support, social functioning, coping response, family modeling as associated with reporting higher pain intensity, pain frequency and diminished quality of life in cancer patients compared to their controls. The responses to cancer pain were thus categorized into affective, cognitive, behavioral and physiological.


 ╗ Physical Therapy Treatment of Cancer Pain - Application of Mechanism-Based Classification Top


Use of this mechanism-based classification for pain is not new for physical therapists. Schafer et al,[72] proposed the pathomechanism-based classification system for neural low back related leg pain and this system was studied for its reliability [73] and the four subgroups (central sensitization, denervation, peripheral sensitization and nociceptive) were differentiated based upon their levels of disability and psychosocial factors. [74] Treatment for low back pain was studied and utilized a combination of treatment-based and mechanism-based classification.

American Pain Society quality of care task force for treatment of acute and chronic cancer pain had recommended relaxation, heat, cold, deep breathing, walking, imagery or visualization under non-pharmacological methods for cancer pain relief. [75]

Thus, the physical therapists have a very important role to play in holistic care of patients diagnosed with cancer as stated by Flomenhoft [76] and Rashleigh. [77] Rashleigh [77] listed the therapeutic strategies employed by physical therapists in palliative oncology as ambulation and musculoskeletal therapy, neurological therapy, respiratory therapy, electrophysical agents, mechanical therapy, decongestive physiotherapy, and education. Santiago-Palma and Payne [78] listed treatments used by physical therapists on cancer patients as therapeutic massage, therapeutic heat, therapeutic cold, patient education (advice on activity modification), range of motion and strengthening exercise, training ambulation using assistive devices, environmental modification, energy conservation and work simplification techniques. Twycross [79] mentioned that physical treatment methods like massage, heat pads and TENS are useful for pain management in cancer patients.

Physical therapy treatment techniques have also been reported in cancer-related fatigue by Watson and Mock, [80] in breast cancer, [81],[82] prostate cancer [83] and breast cancer-related lymphedema, [84],[85] older women with cancer, [86] cancer therapy-related hyperthermia [87] and colorectal cancer. [88]

The physical therapy treatment modalities and methods are listed here building upon existing evidence under the five mechanism-based classification categories of cancer pain.

Central sensitization mechanism-based physical therapy for cancer pain

Bennett et al,[89] in their detailed systematic review with meta-analysis of 15 studies found that educational interventions (written and/or audiovisual learning materials) improved knowledge and attitudes toward cancer pain and analgesia, and perceived pain intensity among cancer patients. Pain educational programs were shown to be highly effective not only in reducing pain and associated pain behaviours, but also in reducing treatment-related barriers in cancer patients. One such method is the use of pain management diary. [90]

Evidence for using TENS for pain relief in cancer patients is continuously growing. [91] TENS addresses the central component of cancer pain and is a very useful therapeutic adjunct in patients with central sensitization.

Peripheral sensitization mechanism-based physical therapy for cancer pain

Paice [51] opined that regardless of the patient's prognosis, rehabilitation for neuropathic pain in cancer patients may enhance function, and attention to safety factors may avoid serious accidents.

Rehabilitation of patients with motor deficits on neurological examination begins with assessment of the patient's functional dependence - their ability to walk, dress, prepare meals, and perform other activities. Assistive devices may be useful when there is impairment in any of these activities. Physical therapy can increase the strength of involved muscles as well as accessory muscles, which can improve coordination and sensory integration. Physical activity also maintains muscle and ligament length, preventing later deformities. Ankle foot orthotics (AFO)-type braces, which fit easily within a standard shoe, can help prevent falls when patients experience a slapping gait or foot drop. [51]

Using neurodynamic testing on patients with "nerve trunk pain" (stimulus-evoked pain along the course of the nerve) and nerve mobilization (neural manual therapy technique as described by Kumar and Jim [14] ) and nerve massage are useful therapeutic adjuncts. [92]

Hypersensitive skin can be treated with desensitization measures with other alternative sensory stimuli that are tolerated fairly by the patient. A hyposensitive skin can be treated with sensory re-education methods using various forms and textures of materials. A variety of physiotherapy treatment methods like electrical simulation, magnetic therapy, pulsed electromagnetic energy, photon stimulation, monochromatic near infrared therapy for peripheral neuropathic pain are used. [93]

Sympathetically maintained mechanism-based physical therapy for cancer pain

Cold therapy may reduce swelling and relieve pain longer than heat therapy by decreasing nerve conduction velocity and desensitization of free nerve endings of the skin. [94] This method can either be utilized at the painful region itself or as remote desensitization. Though studies on physical therapy management for sympathetic pain in cancer do not exist, management in CRPS and other altered sympathetic states includes TENS (burst mode) application to the related spinal level, combined with relaxation and biofeedback techniques to restore vasomotor balance. [15]

One of the manual therapy techniques (neural manual therapy technique as described by Kumar and Jim [14] ) commonly employed by physical therapists was the "sympathetic slump" or "slump long sitting with sympathetic emphasis", [95] a sympathetic nervous system mobilization technique, [96],[97] which was shown to have sympathoexicitatory effects in extremities including sudomotor and vasomotor effects. [98] The technique is very simple and is well tolerated by patients and was shown to be useful in CRPS patients. [97] Another technique is the use of thoracic spine mobilization [99] in patients who had spinal dysfunction which is another useful manual physical therapy method.

Nociceptive-mechanism-based physical therapy for cancer pain

Massage therapy improves local circulation and gently stimulates the free nerve endings, the pressure of which may also help in draining local tissue edema and induce local and general relaxation. One of the well-established scientific forms of massage is the manual lymphatic drainage therapy [100] and complete decongestive therapy (manual lymphatic drainage, compression garments, skin care and range of motion exercises). Massage therapy was shown to be very effective to relieve symptoms of cancer pain in numerous studies. [101],[102],[103],[104]

Reeves [94] explained the importance of physical interventions such as changes in patient positioning, relaxation techniques for sleeplessness, and energy conservation techniques for fatigue in patients with cancer pain. Therapeutic modalities such as electrical stimulation (including transcutaneous electrical neurostimulation), heat, or cryotherapy, can be useful adjuncts to standard analgesic therapy in patients with cancer-treatment-related lymphedema and pain. The treatment of lymphedema by use of wraps, pressure stockings, or pneumatic pump devices may both improve function and relieve pain and heaviness. [105]

Mufazalov and Gazizov [106] showed that laser therapy enhanced therapeutic efficacy of pain-relieving drug regimen in patients with cancer pain. Cancer treatments like radiation therapy can induce mucositis in patients with oral or head and neck cancer and can cause oral pain due to impaired wound healing. Bensadoun [107] commented on the importance of low-level laser therapy on wound healing and its role in mucositis treatments. Maiya et al,[108] subsequently showed that helium-neon laser therapy was effective to reduce pain and improve healing of radiation-induced mucositis after 6 weeks of therapy in head and neck cancer patients.

The benefits of exercise and increased physical activity on people diagnosed with cancer are many, including improved function, quality of life, strength, and endurance, and reduced depression, nausea, and pain. [109] Beaton et al,[110] in their systematic review found strong, high-quality evidence in favor of exercise interventions (aerobic exercises and strength training given alone or as part of a multimodal physical therapy intervention) in patients with metastatic cancer for improving physical and quality of life measures. McNeely et al,[111] found that progressive resisted exercise training (PRET) program significantly reduced shoulder pain and disability and improved upper extremity muscular strength and endurance in postsurgical head and neck cancer survivors who had shoulder dysfunction because of spinal accessory nerve damage.

Keays et al,[82] found improvements in shoulder range of motion and function in women with breast cancer undergoing radiation therapy, who were given pilates exercises which involves whole body movements with breath control. Similar improvements in pain and mobility were observed following physiotherapy intervention (exercises, advice, soft tissue massage to surgical scar) in breast cancer patients who underwent axillary dissection. [112]

Graded activity prescription and regular physical activity as a component of multimodal approach in treatment of cancer pain [113] have a direct influence on the peripheral musculoskeletal system via the exercising muscles. Regular physical activity bears a direct effect on tissue functions, thus leading to counterirritation phenomenon of pain relief. However, for these programs to be effective, it should be accompanied with behavioral training and patient education.

Cognitive-affective mechanism-based physical therapy for cancer pain

Cognitive behavioral therapy (CBT) intervention comprising education, distraction, relaxation, positive mood development and self-coping strategies for pain helps the patient develop acceptance toward symptom persistence and enables them to lead a functionally active life. CBT was studied extensively and shown to be effective in a large number of studies. [114],[115],[116],[117],[118],[119],[120],[121],[122],[123]

Music therapy for pain relief in cancer patients was shown to be effective by many authors across the globe [124],[125],[126],[127],[128],[129],[130],[131] in cancer patients.


 ╗ Discussion Top


Any therapeutic strategy developed for patients experiencing cancer pain depends on the goals of care, which can be broadly categorized as prolonging survival, optimizing comfort, and optimizing function.

-Cherny [132]

While physicians and oncologists are responsible for prolonging survival and nurses and counselors for optimizing comfort, the physical therapists have a major role to play in optimizing function in cancer pain patients. Pharmacotherapy [133] and surgery [134] continue to be mainstay interventions for patients with cancer pain in "prolonging survival" domain of care. A biopsychosocial spiritual care [135] and interventional pain management procedures such as anesthetic blocks [136] would provide "optimizing comfort" domain of care and the physical therapy would address the "optimizing function" domain of care. Is it not true then, "Physicians add years to life; physical therapists add life to those years?"

Physical therapists can thus be an inherent team member in the integrated care pathway for cancer pain management in primary, secondary and tertiary care. [137] Molecular mechanisms in pain perception [138] will direct mechanism-based drug therapy prescription [139] in palliative care, whereas mechanism-based understanding will direct physical therapy treatment decision-making and efficient treatment delivery in patients with cancer pain. Pain relieving therapy should always accompany disease-modifying therapy and can never substitute the latter. Understanding and recognizing pain by mechanisms will lead to efficient management of underlying pathobiological process behind pain perception and reporting. [36] Accurate identification of mechanisms is probably best achieved by accurate identification of clusters of information on the basis of a combination of findings from history, examination, and other investigations. [32]

The evidence from animal models should be very carefully extrapolated to clinical situations and hence successful management of patient symptoms in palliative care depend upon an individualized comprehensive multidisciplinary biopsychosocial model of care. [140] Such a holistic examination of a patient with cancer pain will lead to sustainable improvements in the quality of life in a multidisciplinary setting. [141] An integrated psychosocial-spiritual model of care [135] for cancer pain is the most essential therapeutic strategy for these suffering patients. Physical therapists have the ability and potential to integrate physical aspects of treatment in a biopsychosocial model of pain [142] into a comprehensive rehabilitation [143] program for cancer patients.

Physical modalities can be applied by the patient, family, and health care providers, and include physical therapy, external electrical stimuli (TENS), heat, cold, acupuncture, and immobilization. As with psychological measures, their use is intended to augment, not replace, analgesic drug therapy. Importantly, physical measures should be applied early on to minimize the generalized deconditioning and myofascial pain associated with reduced activity and intervals of immobility associated with cancer and its therapy. [13]

Blaney et al,[144] found that exercise barriers in cancer patients were mainly related to treatment side effects, particularly fatigue. Fatigue was associated with additional barriers such as physical deconditioning, social isolation, and the difficulty of making exercise a routine. Environmental factors and the timing of exercise initiation also were barriers. Exercise facilitators included an exercise program being group-based, supervised, individually tailored, and gradually progressed. Exercise motivators were related to perceived exercise benefits. These should be kept borne in mind during evaluation and exercise prescription for pain relief in such population.

Sloan et al,[145] demonstrated positive learning benefits and experiences among medical students on cancer pain and its management after they visited a home-care hospice center. Such an educational approach to physical therapy students would facilitate positive health attitudes and behaviors. Earlier study by Kumar et al,[146] showed similar positive benefits in knowledge, attitudes, beliefs and experiences about palliative care among physical therapy students following a focused group training program.

Future studies on treatment of cancer pain using such a mechanism-based classification and management is warranted before extrapolating the current evidence into oncological palliative care physical therapy practice.


"Alone we can do so little, together we can do so much…"

-Helen Keller (1880-1968)


 ╗ Conclusion Top


The paper outlined the mechanism-based classification of cancer pain with evidence for physical therapy treatments for symptomatic relief and toward better quality of life among those with cancer.

 
 ╗ References Top

1.Nair SN, Mary TR, Prarthana S, Harrison P. Prevalence of pain in patients with HIV/AIDS: A cross-sectional survey in a south Indian state. Indian J Palliat Care 2009;15:67-70.   Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.Murthy NS, Mathew A. Cancer epidemiology, prevention and control. Curr Sci 2004;86:518-27.  Back to cited text no. 2
    
3.Brawley OW, Smith DE, Kirch RA. Taking action to ease suffering: Advancing cancer pain control as a healthcare priority. CA Cancer J Clin 2009;59:285-9.  Back to cited text no. 3
    
4.Bhatnagar S. Interventional pain management: need of the hour for cancer pain patients. Indian J Palliat Care 2009;15:93-4.  Back to cited text no. 4
[PUBMED]  Medknow Journal  
5.Luger NM, Mach DB, Sevcik MA, Mantyh PW. Bone cancer pain: from model to mechanism to therapy. J Pain Symptom Manage 2005;29:S32-46.  Back to cited text no. 5
    
6.Wang XS, Cleeland CS, Mendoza TR, Engstrom MC, Liu S, Xu S, et al. The effects of pain severity on health-related quality of life: A study of Chinese cancer patients. Cancer 1999;86:1848-55.  Back to cited text no. 6
    
7.Foley KM. Advances in cancer pain. Arch Neurol 1999;56:413-7.  Back to cited text no. 7
    
8.Singh DP. Quality of life in cancer patients receiving palliative care. Indian J Palliat Care 2010;16:36-43.  Back to cited text no. 8
[PUBMED]  Medknow Journal  
9.Sharma K, Mohanti BK, Rath GK, Bhatnagar S. Pattern of palliative care, pain management and referral trends in patients receiving radiotherapy at a tertiary cancer center. Indian J Palliat Care 2009;15:148-54.  Back to cited text no. 9
[PUBMED]  Medknow Journal  
10.Bisht M, Bist SS, Dhasmana DC, Saini S. Palliative care in advanced cancer patients in a tertiary care hospital in Uttarakhand. Indian J Palliat Care 2008;14:75-9.  Back to cited text no. 10
  Medknow Journal  
11.Ripamonti C, Dickerson ED. Strategies for the treatment of cancer pain in the new millennium. Drugs 2001;61:955-77.  Back to cited text no. 11
    
12.Myers J, Shetty N. Going beyond efficacy: Strategies for cancer pain management. Curr Oncol 2008;15:S41-9.  Back to cited text no. 12
    
13.Guptill WE, Carr DB. Cancer pain assessment and management: A survey. J Back Musculoskel Rehab 1999;12:89-99.  Back to cited text no. 13
    
14.Kumar SP, Jim A. Physical therapy in palliative care: From symptom control to quality of life- a critical review. Indian J Palliat Care 2010;16:174-82.  Back to cited text no. 14
    
15.Kumar SP, Saha S. Mechanism-based classification of pain for physical therapy in palliative care: A critical review. Indian J Palliat Care 2011;17:80-6.  Back to cited text no. 15
[PUBMED]  Medknow Journal  
16.Ventafridda V, Caraceni A. Cancer pain classification: A controversial issue. Pain 1991;46:1-2.  Back to cited text no. 16
    
17.Banning A, Sjogren P, Henrikesen H. Pain causes in 200 patients referred to a multidisciplinary pain clinic. Pain 1991;45:45-8.  Back to cited text no. 17
    
18.Woolf CJ, Bennett GJ, Doherty M, Dubner R, Kidd B, Koltzenburg M, et al. Towards a mechanism-based classification of pain? Pain 1998;77:227-9.  Back to cited text no. 18
    
19.Lasheen W, Walsh D, Sarhill N, Davis M. Intermittent cancer pain: Clinical importance and an updated cancer pain classification. Am J Hosp Palliat Care 2010;27:182-6.  Back to cited text no. 19
    
20.Serlin RC, Mendoza TR, Nakamura Y, Edwards KR, Cleeland CS. When is cancer pain mild, moderate or severe? Grading pain severity by its interference with function. Pain 1995;61:277-84.   Back to cited text no. 20
    
21.Grond S, Zech D, Diefenbach C, Radbruch L, Lehmann KA. Assessment of cancer pain: A prospective evaluation in 2266 cancer patients referred to a pain service. Pain 1996;64:107-14.  Back to cited text no. 21
    
22.Morrel A, Josserand A. Considerations of the mechanism of pain during the evolution of cancer. Lyon Med 1950;183:320-2.  Back to cited text no. 22
    
23.Mantyh PW. A mechanism-based understanding of cancer pain. Pain 2002;96:1-2.  Back to cited text no. 23
    
24.Mantyh PW. A mechanism-based understanding of bone cancer pain. Novartis Found Symp 2004;261:194-214.  Back to cited text no. 24
    
25.Honore P, Mantyh PW. Bone cancer pain: From mechanism to model to therapy. Pain Med 2000;1:303-9.  Back to cited text no. 25
    
26.Schmidt BL, Hamamoto DT, Simone DA, Wilcox GL. Mechanism of cancer pain. Mol Interv 2010;10:164-78.  Back to cited text no. 26
    
27.Mishra S, Bhatnagar S, Chaudhary P, Rana SP. Breakthrough cancer pain: Review of prevalence, characteristics and management. Indian J Palliat Care 2009;15:14-8.  Back to cited text no. 27
    
28.Portenoy RK, Payne D, Jacobsen P. Breakthrough pain: Characteristics and impact in patients with cancer pain. Pain 1999;81:129-34.  Back to cited text no. 28
    
29.Bennett MI. Cancer pain terminology: time to develop a taxonomy that promotes good clinical practice and allows research to progress. Pain 2010;149:426-7.  Back to cited text no. 29
    
30.Haugen DF, Hjermstad MJ, Hagen N, Caraceni A, Kaasa S. On behalf of the European palliative care research collaborative (EPCRC). Assessment and classification of cancer breakthrough pain: A systematic literature review. Pain 2010;149:476-82.  Back to cited text no. 30
    
31.Knudsen AK, Aass N, Fainsinger R, Caraceni A, Klepstad P, Jordhoy M, et al. Classification of pain in cancer patients: A systematic literature review. Palliat Med 2009;23:295-308.  Back to cited text no. 31
    
32.Siddall PJ, Duggan AW. Towards a mechanisms-based approach to pain medicine. Anesth Analg 2004;99:455-6.  Back to cited text no. 32
    
33.Woolf CJ. Pain: Moving from symptom control toward mechanism-specific pharmacologic management. Ann Intern Med 2004;140:441-51.  Back to cited text no. 33
    
34.Smart K, Doody C. Mechanism-based clinical reasoning of pain by experienced musculoskeletal physiotherapists. Physiotherapy 2006;92:171-8.  Back to cited text no. 34
    
35.Smart K, Doody C. The clinical reasoning of pain by experienced musculoskeletal physiotherapists. Man Ther 2007;12:40-9.  Back to cited text no. 35
    
36.Levin M. Changing the face of pain management- mechanism-based treatment most likely to succeed. Postgrad Med 2004;116:45-8.  Back to cited text no. 36
    
37.Ballantyne JC. Chronic pain following treatment of cancer: The role of opioids. Oncologist 2003;8:567-75.  Back to cited text no. 37
    
38.Menéndez L, Lastra A, Fresno MF, Llames S, Meana A, Hidalgo A. Initial thermal heat hypoalgesia and delayed hyperalgesia in a murine model of bone cancer pain. Brain Res 2003;969:102-9.   Back to cited text no. 38
    
39.Kehl LJ, Hamamoto DT, Wacnik PW, Croft DL, Norsted BD, Wilcox GL, et al. A cannabinoid agonist differentially attenuates deep tissue hyperalgesia in animal models of cancer and inflammatory muscle pain. Pain 2003;103:175-86.   Back to cited text no. 39
    
40.Donovan-Rodriguez T, Dickenson AH, Urch CE. Superficial dorsal horn neuronal responses and the emergence of behavioural hyperalgesia in a rat model of cancer-induced bone pain. Neurosci Lett 2004;360:29-32.   Back to cited text no. 40
    
41.Asai H, Ozaki N, Shinoda M, Nagamine K, Tohnai I, Ueda M, et al. Heat and mechanical hyperalgesia in mice model of cancer pain. Pain 2005;117:19-29.   Back to cited text no. 41
    
42.Khasabov SG, Hamamoto DT, Harding-Rose C, Simone DA. Tumor-evoked hyperalgesia and sensitization of nociceptive dorsal horn neurons in a murine model of cancer pain. Brain Res 2007;1180:7-19.   Back to cited text no. 42
    
43.Khasabova IA, Khasabov SG, Harding-Rose C, Coicou LG, Seybold BA, Lindberg AE. et al. A decrease in anandamide signaling contributes to the maintenance of cutaneous mechanical hyperalgesia in a model of bone cancer pain. J Neurosci 2008;28:11141-52.   Back to cited text no. 43
    
44.Reznikov I, Pud D, Eisenberg E. Oral opioid administration and hyperalgesia in patients with cancer or chronic nonmalignant pain. Br J Clin Pharmacol 2005;60:311-8.   Back to cited text no. 44
    
45.Tong W, Wang W, Huang J, Ren N, Wu SX, Li YQ. Spinal high-mobility group box 1 contributes to mechanical allodynia in a rat model of bone cancer pain. Biochem Biophys Res Commun 2010;395:572-6.  Back to cited text no. 45
    
46.Lam DK, Schmidt BL. Serine proteases and protease-activated receptor 2-dependent allodynia: a novel cancer pain pathway. Pain 2010;149:263-72.  Back to cited text no. 46
    
47.Taber KH, Rashid A, Hurley RA. Functional anatomy of central pain. J Neuropsychiatry Clin Neurosci 2001;13:437-40.  Back to cited text no. 47
    
48.Coderre TJ, Katz J, Vaccarino AL, Melzack R. Contribution of central neuroplasticity to pathological pain: Review of clinical and experimental evidence. Pain 1993;52:259-85.   Back to cited text no. 48
    
49.Vasudevan S. Coping with terminal illness: A spiritual perspective. Indian J Palliat Care 2003;9:19-24.  Back to cited text no. 49
  Medknow Journal  
50.Potter J, Higginson IJ, Scadding JW, Quigley C. Identifying neuropathic pain in patients with head and neck cancer: Use of leeds assessment of neuropathic signs and symptoms scale. J Royal Soc Med 2003;96:379-83.   Back to cited text no. 50
    
51.Paice JA. Mechanisms and management of neuropathic pain in cancer. J Support Oncol 2003;1:107-20.  Back to cited text no. 51
    
52.Wilsey B, Teicheira D, Caneris OA, Fishman SM. A review of sympathetically maintained pain syndromes in the cancer pain population: The spectrum of ambiguous entities of RSD, CRPS, SMP and other pain states related to the sympathetic nervous system. Pain Pract 2001;1:307-23.  Back to cited text no. 52
    
53.Thornton LM, Andersen BL, Blakely WP. The pain, depression, and fatigue symptom cluster in advanced breast cancer: Covariation with the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system. Health Psychol 2010;29:333-7.  Back to cited text no. 53
    
54.Churcher MD. Cancer and sympathetic dependent pain. Palliat Med 1990;4:113-6.  Back to cited text no. 54
    
55.Lin CC, Mo LR, Lin YW, Yau MP. Bilateral thoracoscopic lower sympathetic-splanchnicectomy for upper abdominal cancer pain. Eur J Surg Suppl 1994;572:59-62.  Back to cited text no. 55
    
56.Figuerola Mde L, Guadalupe Pallotta M, Levin G, Vindrola O, Leston J, Barontini M. Lack of response of proenkephalin A and sympathetic nervous system in chronic pain associated with lung cancer. Funct Neurol 1994;9:23-8.  Back to cited text no. 56
    
57.de Leon-Casasola OA. Neurolytic blocks of the sympathetic axis for the treatment of visceral pain in cancer. Curr Rev Pain 1999;3:173-7.  Back to cited text no. 57
    
58.de Leon-Casasola OA. Critical evaluation of chemical neurolysis of the sympathetic axis for cancer pain. Cancer Control, 2000;7:142-8.   Back to cited text no. 58
    
59.de Oliveira R, dos Reis MP, Prado WA. The effects of early or late neurolytic sympathetic plexus block on the management of abdominal or pelvic cancer pain. Pain 2004;110:400-8.  Back to cited text no. 59
    
60.Churcher MD. Sympathetic dependent pain mimicking tumour spread. Pain Clin 1989;2:169-70.  Back to cited text no. 60
    
61.Winters L, Habin K, Gallagher J. Aromatase inhibitors and musculoskeletal pain in patients with breast cancer. Clin J Oncol Nurs 2007;11:433-9.  Back to cited text no. 61
    
62.Frieze DA. Musculoskeletal pain associated with corticosteroid therapy in cancer. Curr Pain Headache Rep 2010;14:256-60.  Back to cited text no. 62
    
63.Krakowski I, Theobald S, Balp L, Bonnefoi MP, Chvetzoff G, Collard O, et al. Summary version of the standards, options and recommendations for the use of analgesia for the treatment of nociceptive pain in adults with cancer (update 2002). Br J Cancer 2003;89:S67-72.  Back to cited text no. 63
    
64.Chen M, Chang H, Yeh C. Anxiety and depression in Taiwanese cancer patients with and without pain. J Adv Nurs 2000;32:944-51.  Back to cited text no. 64
    
65.Bruera E, Macmillan K, Hanson J, MacDonald RN. The cognitive effects of the administration of narcotic analgesics in patients with cancer pain. Pain 1989;39:13-6.  Back to cited text no. 65
    
66.O'Neill WM. The cognitive and psychomotor effects of opioid drugs in cancer pain management. Cancer Surv 1994;21:67-84.  Back to cited text no. 66
    
67.Kurita GP, de Mattos Pimenta CA. Cognitive impairment in cancer pain patients receiving opioids: A pilot study. Cancer Nurs 2008;31:49-57.  Back to cited text no. 67
    
68.Allen RS, Haley WE, Small BJ, McMillan SC. Pain reports by older hospice cancer patients and family caregivers: The role of cognitive functioning. Gerontologist 2002;42:507-14.  Back to cited text no. 68
    
69.Klepstad P, Hilton P, Moen J, Fougner B, Borchgrevink PC, Kaasa S. Self-reports are not related to objective assessments of cognitive function and sedation in patients with cancer pain admitted to a palliative care unit. Palliat Med 2002;16:513-9.  Back to cited text no. 69
    
70.Mystakidou K, Tsilika E, Parpa E, Pathiaki M, Patiraki E, Galanos A, et al. Exploring the relationships between depression, hopelessness, cognitive status, pain, and spirituality in patients with advanced cancer. Arch Psychiatr Nurs 2007;21:150-61.  Back to cited text no. 70
    
71.Dalton JA, Feuerstein M. Biobehavioral factors in cancer pain. Pain 1988;33:137-47.  Back to cited text no. 71
    
72.Schafer A, Hall T, Briffa K. Classification of low back-related leg pain: A proposed pathomechanism-based approach. Man Ther 2009;14:222-30.  Back to cited text no. 72
    
73.Schafer A, Hall T, Ludtke K, Mallwitz J, Briffa NK. Inter-rater reliability of a new classification system for neural low back-related leg pain. J Man Manip Ther 2009;17:109-17.   Back to cited text no. 73
    
74.Walsh J, Hall T. Classification of low back-related leg pain: Do subgroups differ in disability and psychosocial factors? J Man Manip Ther 2009;17:118-23.  Back to cited text no. 74
    
75.Gordon DB, Dahl JL, Miaskowski C, McCarberg B, Todd KH, Paice JA, 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;165:1574-80  Back to cited text no. 75
    
76.Flomenhoft D. Understanding and helping people who have cancer: A special communication. Phys Ther 1984;64:1232-4.  Back to cited text no. 76
    
77.Rashleigh LS. Physiotherapy in palliative oncology. Aust J Physiother 1996;42:307-12.  Back to cited text no. 77
    
78.Santiago-Palma J, Payne R. Palliative care and rehabilitation. Cancer 2001;92:1049-52.  Back to cited text no. 78
    
79.Twycross R. Factors associated with difficult-to-manage pain. Indian J Palliat Care 2004;10:67-78.   Back to cited text no. 79
  Medknow Journal  
80.Watson T, Mock V. Exercise as an intervention for cancer-related fatigue. Phys Ther 2004;84:736-43.  Back to cited text no. 80
    
81.Molinaro J, Kleinfeld M, Lebed S. Physical therapy and dance in the surgical management of breast cancer: A clinical report. Phys Ther 1986;66:967-9.  Back to cited text no. 81
    
82.Keays KS, Harris SR, Lucyshyn JM, MacIntyre DL. Effects of Pilates exercises on shoulder range of motion, pain, mood, and upper extremity function in women living with breast cancer: A pilot study. Phys Ther 2008;88:494-510.  Back to cited text no. 82
    
83.Clay CA, Perera S, Wagner JM, Miller ME, Nelson JB, Grrenspan SL. Physical function in men with prostate cancer on androgen deprivation therapy. Phys Ther 2007;87:1325-33.  Back to cited text no. 83
    
84.Megens A, Harris SR. Physical therapist management of lymphedema following treatment for breast cancer: A critical review of its effectiveness. Phys Ther 1998;78:1302-11.  Back to cited text no. 84
    
85.Bicego D, Brown K, Ruddick M, Storey D, Wong C, Harris SR. Exercise for women with or at risk for breast cancer-related lymphedema. Phys Ther 2006;86:1398-405.  Back to cited text no. 85
    
86.Mackey KM, Sparling JW. Experiences of older women with cancer receiving hospice care: significance for physical therapy. Phys Ther 2000;80:459-68.  Back to cited text no. 86
    
87.Luk KH, Drennan T, Anderson K. Potential role of physical therapists in hyperthermia in cancer therapy- the need for further training. Phys Ther 1986;66:340-3.  Back to cited text no. 87
    
88.Courneya KS, Friednreich CM, Arthur K, Bobick TM. Understanding exercise motivation in colorectal cancer patients: A prospective study using the theory of planned behavior. Rehabil Psychol 1999;44:68-84.  Back to cited text no. 88
    
89.Bennett MI, Bagnall AM, Closs SJ. How effective are patient-based educational interventions in the management of cancer pain? Syst Rev Meta Anal Pain 2009;143:192-9.  Back to cited text no. 89
    
90.Schumacher KL, Koresawa S, West C, Dodd M, Paul SM, Tripathy D, et al. The usefulness of a daily pain management diary for outpatients with cancer-related pain. Oncol Nurs Forum 2002;29:1304-13.  Back to cited text no. 90
    
91.Robb KA, Bennett MI, Johnson MI, Simpson KJ, Oxberry SG. Transcutaneous electric nerve stimulation (TENS) for cancer pain in adults. Cochrane Database Syst Rev 2008;3:CD006276.  Back to cited text no. 91
    
92.Kumar SP, Adhikari P, Jeganathan PS. Immediate effects of longitudinal vs. Transverse tibial nerve massage on vibration perception thresholds and thermal perception thresholds in asymptomatic subjects: A pilot randomized clinical trial. Physiother Occup Ther J 2010;3:13-23.  Back to cited text no. 92
    
93.Kumar SP, Adhikari P, Jeganathan PS, D'Souza SC. Physiotherapy management of painful diabetic peripheral neuropathy: A current concepts review of treatment methods for clinical decision-making in practice and research. Int J Curr Res Rev 2010;2:29-39.  Back to cited text no. 93
    
94.Reeves K. A cancer pain primer. Medsurg Nurs 2006;17:413-9.  Back to cited text no. 94
    
95.Slater H, Vicenzino B, Wright A. Sympathetic Slump: the effects of a novel manual therapy technique on peripheral sympathetic nervous system function. J Man Manip Ther 1994;2:156-63.  Back to cited text no. 95
    
96.Cleland JA, Durall C, Scott SA. Effects of slump long sitting on peripheral sudomotor and vasomotor function: A pilot study. J Manual Manip Ther 2002;10:67-75.  Back to cited text no. 96
    
97.Cleland JA, McRae M. Complex regional pain syndrome I: management through the use of vertebral and sympathetic trunk mobilization. J Manual Manip Ther 2002;10:188-99.  Back to cited text no. 97
    
98.Kornberg, McCarthy T. The effect of neural stretching technique on sympathetic outflow to the lower limbs. J Orthop Sports Phys Ther 1992;16:269-74.  Back to cited text no. 98
    
99.Menck JY, Requejo SM, Kulig K. Thoracic spine dysfunction in upper extremity dysfunction complex regional pain syndrome type-1. J Orthop Sports Phys Ther 2000;30:401-9.  Back to cited text no. 99
    
100.Hamner JB, Fleming MD. Lymphedema therapy reduces the volume of edema and pain in patients with breast cancer. Ann Surg Oncol 2007;14:1904-8.  Back to cited text no. 100
    
101.Cassileth BR, Vickers AJ. Massage therapy for symptom control: Outcome study at a major cancer center. J Pain Symptom Manage 2004;28:244-9.  Back to cited text no. 101
    
102.Puthusseril V. Special foot massage as a complementary therapy in palliative care. Indian J Palliat Care 2006;12:71-7.  Back to cited text no. 102
  Medknow Journal  
103.Liu Y, Fawcett TN. The role of massage therapy in the relief of cancer pain. Nurs Stand 2008;22:35-40.  Back to cited text no. 103
    
104.Kutner JS, Smith MC, Corbin L, Hemphill L, Benton K, Mellis K, et al. Massage therapy vs. simple touch to improve pain and mood in patients with advanced cancer: A randomized trial. Ann Intern Med 2008;149:369-79.  Back to cited text no. 104
    
105.Cherny NI, Portenoy RK. The management of cancer pain. CA Cancer J Clin 1994;44:262-303.  Back to cited text no. 105
    
106.Mufazalov FF, Gazizov AA. Laser therapy for chronic pain in cancer patients. Vopr Onkol 2002;48:91-4.  Back to cited text no. 106
    
107.Bensadoun R. Low level laser therapy (LLT): A new paradigm in the management of cancer therapy-induced mucositis. Indian J Med Res 2006;124:375-8.  Back to cited text no. 107
[PUBMED]  Medknow Journal  
108.Maiya GA, Sagar MS, Fernandes D. Effect of low level helium-neon (He-Ne) laser therapy in the prevention and treatment of radiation induced mucositis in head and neck cancer patients. Indian J Med Res 2006;124:399-402.  Back to cited text no. 108
    
109.Barbaric M, Brooks E, Moore L, Cheifetz O. Effects of physical activity on cancer survival: A systematic review. Physiother Can 2010;62:25-34.  Back to cited text no. 109
    
110.Beaton R, Pagdin-Friesen W, Robertson C, Vigar C, Watson H, Harris SR. Effects of exercise intervention on persons with metastatic cancer: A systematic review. Physiother Can 2009;61:141-53.  Back to cited text no. 110
    
111.McNeely ML, Parliament MB, Seikaly H, Jha N, Magee DJ, Haykowsky MJ, et al. Effect of exercise on upper extremity pain and dysfunction in head and neck cancer survivors: A randomized controlled trial. Cancer 2008;113:214-22.   Back to cited text no. 111
    
112.Beurskens CH, van Uden CJ, Strobbe LJ, Oostendorp RA, Wobbes T. The efficacy of physiotherapy upon shoulder function following axillary dissection in breast cancer, a randomized controlled study. BMC Cancer 2007;7:166.  Back to cited text no. 112
    
113.Guilherme-Soares L, Chan VW. The rationale for a multimodal approach in the management of breakthrough cancer pain: A review. Am J Hosp Palliat Care 2007;24:430-9.  Back to cited text no. 113
    
114.Arathuzik D. Effects of cognitive-behavioral strategies on pain in cancer patients. Cancer Nurs 1994;17:207-14.  Back to cited text no. 114
    
115.Syrjala KL, Cummings C, Donaldson GW. Hypnosis or cognitive behavioral training for the reduction of pain and nausea during cancer treatment: A controlled clinical trial. Pain 1992;48:137-46.  Back to cited text no. 115
    
116.Fishman B, Loscalzo M. Cognitive-behavioral interventions in management of cancer pain: Principles and applications. Med Clin North Am 1987;71:271-87.  Back to cited text no. 116
    
117.Syrjala KL, Donaldson GW, Davis MW, Kippes ME, Carr JE. Relaxation and imagery and cognitive-behavioral training reduce pain during cancer treatment: A controlled clinical trial. Pain 1995;63:189-98.  Back to cited text no. 117
    
118.Liossi C, Hatira P. Clinical hypnosis versus cognitive behavioral training for pain management with pediatric cancer patients undergoing bone marrow aspirations. Int J Clin Exp Hypn 1999;47:104-16.  Back to cited text no. 118
    
119.Kwekkeboom KL. A model for cognitive-behavioral interventions in cancer pain management. Image J Nurs Sch 1999;31:151-6.  Back to cited text no. 119
    
120.Dalton JA, Keefe FJ, Carlson J, Youngblood R. Tailoring cognitive-behavioral treatment for cancer pain. Pain Manag Nurs 2004;5:3-18.  Back to cited text no. 120
    
121.Tatrow K, Montgomery GH. Cognitive behavioral therapy techniques for distress and pain in breast cancer patients: A meta-analysis. J Behav Med 2006;29:17-27.   Back to cited text no. 121
    
122.Anderson KO, Cohen MZ, Mendoza TR, Guo H, Harle MT, Cleeland CS. Brief cognitive-behavioral audiotape interventions for cancer-related pain: Immediate but not long-term effectiveness. Cancer 2006;107:207-14.  Back to cited text no. 122
    
123.Kwekkeboom KL, Abbott-Anderson K, Wanta B. Feasibility of a patient-controlled cognitive-behavioral intervention for pain, fatigue, and sleep disturbance in cancer. Oncol Nurs Forum 2010;37:E151-9.  Back to cited text no. 123
    
124.Zimmerman L, Pozehl B, Duncan K, Schmitz R. Effects of music in patients who had chronic cancer pain. West J Nurs Res 1989;11:298-309.  Back to cited text no. 124
    
125.Kerkvliet GJ. Music therapy may help control cancer pain. J Natl Cancer Inst 1990;82:350-2.  Back to cited text no. 125
    
126.Beck SL. The therapeutic use of music for cancer-related pain. Oncol Nurs Forum 1991;18:1327-37.  Back to cited text no. 126
    
127.Magill L. The use of music therapy to address the suffering in advanced cancer pain. J Palliat Care 2001;17:167-72.  Back to cited text no. 127
    
128.Kwekkeboom KL. Music versus distraction for procedural pain and anxiety in patients with cancer. Oncol Nurs Forum 2003;30:433-40.  Back to cited text no. 128
    
129.Igawa-Silva W, Wu S, Harrigan R. Music and cancer pain management. Hawaii Med J 2007;66:292-5.  Back to cited text no. 129
    
130.Nguyen TN, Nilsson S, Hellström AL, Bengtson A. Music therapy to reduce pain and anxiety in children with cancer undergoing lumbar puncture: A randomized clinical trial. J Pediatr Oncol Nurs 2010;27:146-55.  Back to cited text no. 130
    
131.Huang ST, Good M, Zauszniewski JA. The effectiveness of music in relieving pain in cancer patients: A randomized controlled trial. Int J Nurs Stud 2010;47:1354-62.  Back to cited text no. 131
    
132.Cherny NI. The management of cancer pain. CA Cancer J Clin 2000;50:70-116.  Back to cited text no. 132
    
133.Lucas LK, Lipman AG. Recent advances in pharmacotherapy for cancer pain management. Cancer Pract 2002;10:S14-20.  Back to cited text no. 133
    
134.Cullinane CA, Chu DZ, Mamelak AN. Current surgical options in the control of cancer pain. Cancer Pract 2002;10:S21-6.  Back to cited text no. 134
    
135.Otis-Green S, Sherman R, Perez M, Baird RP. An integrated psychosocial-spiritual model for cancer pain management. Cancer Pract 2002;10:S58-65.  Back to cited text no. 135
    
136.Chambers PC. Coeliac plexus block for upper abdominal cancer pain. Br J Nurs 2003;12:838-44.  Back to cited text no. 136
    
137.Cringles MC. Developing an integrated care pathway to manage cancer pain across primary, secondary and tertiary care. Int J Palliat Nurs 2002;8:247-55.  Back to cited text no. 137
    
138.Hill RG. Molecular basis for the perception of pain. Neuroscientist 2001;7:282-92.  Back to cited text no. 138
    
139.Block BM, Hurley RW, Raja SN. Mechanism-based therapies for pain. Drug News Perspect 2004;17:172-86.  Back to cited text no. 139
    
140.Holdcroft A, Power I. Management of pain. BMJ 2003;326:635-9.  Back to cited text no. 140
    
141.Locker S. Holistic assessment of cancer patient's pain: Reflections on current practice. Int J Palliat Nurs 2008;14:77-84.  Back to cited text no. 141
    
142.Jones M, Edwards I, Gifford L. Conceptual models for implementing biopsychosocial theory in clinical practice. Man Ther 2002;7:2-9.  Back to cited text no. 142
    
143.Kumar SP. Thinking out of the box- from physiotherapy to rehabilitation. Int J Physiother Rehabil 2010;1:1-4.  Back to cited text no. 143
    
144.Blaney J, Lowe-Strong A, Rankin J, Campbell A, Allen J, Gracey J. The cancer rehabilitation journey: Barriers to and facilitators of exercise among patients with cancer-related fatigue. Phys Ther 2010;90:1135-47.  Back to cited text no. 144
    
145.Sloan PA, LaFountain P, Plymale M, Johnson M, Montgomery C, Snapp J, et al. Implementing cancer pain education for medical students. Cancer Pract 2001;9:225-9.  Back to cited text no. 145
    
146.Kumar SP, Saha S. Mechanism-based classification of pain for physical therapy in palliative care- a clinical commentary. Indian J Palliat Care 2011;17:80-6.  Back to cited text no. 146
[PUBMED]  Medknow Journal  



This article has been cited by
1 Effects of Integrative Medicine on Pain and Anxiety Among Oncology Inpatients
J. R. Johnson,D. J. Crespin,K. H. Griffin,M. D. Finch,J. A. Dusek
JNCI Monographs. 2014; 2014(50): 330
[Pubmed] | [DOI]
2 Chemotherapy-induced or chemotherapy-associated? Does physical therapy play a role in prevention and/or management of peripheral neurotoxicity and neuropathy?
SenthilParamasivam Kumar,Vaishali Sisodia
Indian Journal of Palliative Care. 2013; 19(1): 77
[Pubmed] | [DOI]
3 The perspectives on including palliative care in the indian undergraduate physiotherapy curriculum
Veqar, Z.
Journal of Clinical and Diagnostic Research. 2013; 7(4): 782-786
[Pubmed]
4 Physical therapy and central sensitization: Are we explaining to patients with ŠunexplainedŠ pain?
Kumar, S.P.
Journal of Physical Therapy. 2013; 6(2): 41-45
[Pubmed]
5 Chemotherapy-induced or chemotherapy-associated? Does physical therapy play a role in prevention and/or management of peripheral neurotoxicity and neuropathy?
Kumar, S.P. and Sisodia, V.
Indian Journal of Palliative Care. 2013; 19(1): 77-78
[Pubmed]
6 Mechanism-based classification and physical therapy management of persons with cancer pain: A prospective case series
Kumar, S.P. and Prasad, K. and Kumar, V.K. and Shenoy, K. and Sisodia, V.
Indian Journal of Palliative Care. 2013; 19(1): 27-33
[Pubmed]
7 A profile of hospice-at-home physiotherapy for community-dwelling palliative care patients
Cobbe, S. and Nugent, K. and Real, S. and Slattery, S. and Lynch, M.
International Journal of Palliative Nursing. 2013; 19(1): 39-45
[Pubmed]
8 Guided/graded motor imagery for cancer pain: Exploring the mind-brain inter-relationship
SenthilParamasivam Kumar,Anup Kumar,Mariella D'Souza,VijayaK Kumar,Kamalaksha Shenoy
Indian Journal of Palliative Care. 2013; 19(2): 125
[Pubmed] | [DOI]
9 Mechanism-based classification and physical therapy management of persons with cancer pain: A prospective case series
SenthilP Kumar,Krishna Prasad,VijayaK Kumar,Kamalaksha Shenoy,Vaishali Sisodia
Indian Journal of Palliative Care. 2013; 19(1): 27
[Pubmed] | [DOI]
10 Reporting characteristics of cancer pain: A systematic review and quantitative analysis of articles published in cancer journals
SenthilP Kumar,Vijaya Kumar,Krishna Prasad,Kamalaksha Shenoy,Vaishali Sisodia
Saudi Journal for Health Sciences. 2013; 2(3): 184
[Pubmed] | [DOI]
11 Treatment planning and decisions for therapy how and why?
Kumar, S.P.
Journal of Physical Therapy. 2011; 3(1): 1-3
[Pubmed]
12 Utilization of brief pain inventory as an assessment tool for pain in patients with cancer: A focused review
Kumar, S.P.
Indian Journal of Palliative Care. 2011; 17(2): 108-115
[Pubmed]



 

Top
Print this article  Email this article
Online since 1st October '05
Published by Wolters Kluwer - Medknow