Mind and Body
The nursing home, being predominately a medical environment, relies overwhelming on pharmacology for addressing issues of pain management. However, as I have mentioned in previous articles, pain is more than just a biological issue. The subjective nature of the pain response, and the psychology of the individual, too often fails to be adequately considered in pain management.
More can be done to assist with pain management in health care, especially within the nursing home environment. Many non-drug issues can not only enhance the emotional and psychological wellbeing of the nursing home resident, but can also help the person gain a sense of control over their lives, something that pharmacological remedies often fail to provide.
The feeling of control is a necessary part of human existence. Human beings need to feel a sense of control over their lives. Pain, especially when it is chronic in nature, confers feelings of helplessness and a loss of control. Furthermore, although pharmacological intervention helps with pain, many individuals often feel powerless to control their pain and become totally and exclusively reliant on pain medication.
There is nothing wrong with using pain medication to control pain, but for many, pain relief can happen through other means or can also be enhanced through using medication with other nondrug complementary mind-body interventions. Many of these interventions can not only help control pain, but also psychologically empower the resident to feel that they have a sense of control over their lives, something that pain often robs them of.
Even though there is greater acceptance of complementary nondrug treatments for pain, the dearth of such types of intervention within long-term care environments is quite conspicuous. Although there has been a continuing emphasis for proper pain evaluation and management in nursing homes, the overwhelming level of intervention is pharmacological, driven by the extant medical model that continues to dominant within the nursing home environment.
This subsequently raises the question, "Are we truly doing everything that we can do to manage and control pain among nursing home residents?" From my perspective the answer would be no. Although we have become much better at evaluating and managing pain through the use of medications, we still have a number of strategies available that are never employed in the nursing home environment. Furthermore, many of these strategies often hold a greater psychological potential for removing the helplessness and powerlessness that many residents feel about their pain.
So What Are Some of These Complementary Treatments?
Two very common types of mind-body complementary treatments are distraction and meditation. Distraction allows a person to move their attention from the pain that they are feeling. Getting involved in activities of any type, in which the nursing home resident focuses their attention on something other than their pain, can be a productive method of assisting in pain management.
However, all too often nursing home residents fail to obtain the necessary level of activity that focuses their attention outward. Since many older adults with pain live in nursing home settings that fail to provide an optimal level of activity that can distract the resident from their pain, most residents are left focusing on their body, ruminating about the pain that they feel and sensitizing themselves toward noticing other forms of somatic complaints.
Meditation is another means that can help the older adult feel a sense of empowerment and help to reduce the experience of pain. Meditation frequently works by calming the sympathetic nervous system that, when activated, can produce feelings of anxiety as well as possibly lead to the release of neuropeptides such as endorphins that act as the body's natural painkillers and can also enhance the mood of a person. Meditation however is a technique that often relies on practice to achieve effective results. Therefore it can be a harder technique to use among many older adults in nursing care facilities. However, this technique should not be excluded from being used on long-term care residents as part of a pain management regimen.
Imagery and visualization are similar to meditation. However, typically they are easier to employ, especially when using guided imagery. The basic principle of imagery and visualization is to help the resident imagine or visualize, typically with their eyes closed, an image. The image is usually pleasant and nonthreatening and it often confers a feeling of relaxation.
For instance, visualizing walking on a sanding ocean beach, with warm ocean waves splashing against your feet, whiling also seeing a calm, deep blue ocean, can be a very relaxing as well as a pleasant image for many people. The goal is for the visualization to become so vivid that one can feel the grains of sand on your feet, the sun warming your skin, the water splashing your ankles, and even smell the ocean water through your visualization. This further leads to a type of distraction and relieves the person of many of the ruminating features that locks the on their pain experience. It further can also induce those endogenous opioids to be released naturally in the body, providing further natural pain reduction.
Also important with imagery and visualization as well as with meditation is proper breathing. Breathing is very important for achieving a sense of calm and relaxation. Breathing by itself can be used as an effective relaxation technique. Slow rhythmic breathing and even visualizing one's breathing as one inhales and exhales can be one of the best means for total body relaxation as well as helping to address pain management issues. Breathing from the diaphragm and not the chest allows for the person to achieve a greater relaxation response.
Unfortunately, pain often leads to anxiety and anxiety leads to shallow chest breathing. This chain of events further accentuates the anxiety a person feels and the pain that they experience. Frequently, when individuals learn to breathe diaphragmatically, the anxiety-pain cycle is short circuited.
One of the most common responses to pain is to move away from activity. However, as many rheumatologists will tell you, conditions such as arthritis often benefit from exercise. Rheumatic pain conditions are among the most common found in the elderly.
Here again, many nursing care facilities often fail to use an optimal level of exercise to assist with pain management. Often, after many residents come out of physical therapy, they will experience little, if any, regular exercise. However, one of the best ways to address many issues of pain is through regular exercise. In fact, many forms of pain are often the result of a lack of movement and regular exercise, where through disuse we see contracting of muscle groups, tightening of ligaments and tendons, or even injuries that lead to pain after atrophied muscles groups contributed to falls and fractures. Therefore, instituting some form of regular exercise among all nursing home residents can prevent many forms of pain due to stiffening, tightening and contracting of muscles, tendons and ligaments.
How many nursing care facilities use humor or music therapy as part of their pain management approach? Again, there are very few that use these approaches even though they have been found to be effective is assisting with pain management. Music has been found to be very productive in its therapeutic impact, and humor has been found to help assist with pain relief. In fact, Norman Vincent Peale championed the use of humor therapy and credited its use for helping him with his recovery from cancer.
With the growing body of work that is being done in mind-body medicine many hospitals have started to adopt many of the techniques that have been discussed, as well as others such as biofeedback, acupuncture, hypnosis, skin stimulation, yoga, and even spirituality and prayer. However, nursing care facilities are still lagging far behind in this area.
In fact, many of these types of intervention are practically nonexistent in nursing care centers, especially as part of a pain management program. One has to ask why this is so? Pain and pain management is one of the key indicators that is often examined as part of quality found in nursing home care. Yet, pain management continues to frequently exist on a single dimension, with continuous emphasis on the pharmacological management of pain with very little attention given to other mind-body complementary treatments.
Even though the benefits of complementary mind-body approaches hold not only the benefit for improving pain management, but also augmenting the psychological and emotional status of the resident, they still are not frequently found as part of standard nursing home pain management intervention. When an awakening happens among nursing care facilities, realizing the benefits that these complementary approaches hold, we will then be able to say that the nursing home environments are not only addressing the quality of care as it relates to resident pain management, but the quality of life as well.
Click here for an archive of Brian's Gerotalk columns.