Tuesday, January 5, 2016

Few Try Evidence-based Nonpharmacologic Alternatives, Such as Yoga or Massage


Heart failure patients rarely use evidence-based alternative treatments for comorbid chronic pain. 
Heart failure patients rarely use evidence-based alternative treatments for comorbid chronic pain
Heart failure patients rarely use evidence-based alternative treatments for comorbid chronic pain, often resorting to opioids or contraindicated NSAIDs, according to a small, single-center study published in Heart & Lung: The Journal of Acute and Critical Care.1 (published site)

Polling 25 patients hospitalized for heart failure who used at least 1 alternative pain treatment for chronic non-cardiac pain, researchers found that 18 (72%) were currently taking an analgesic or co-analgesic for their chronic pain.

Although these findings are concerning, the surprising aspect was that few patients had tried evidence-based alternative pain therapies that might also provide cardiovascular benefit, such as yoga for chronic low back pain and fibromyalgia.

"We expected participants to have more alternative pain management treatments," lead author Deborah McDonald, PhD, from the University of Connecticut School of Nursing, told Clinical Pain Advisor.

According to Dr. McDonald, the preliminary study was prompted by nursing staff at Saint Francis Hospital and Medical Center in Hartford, Connecticut, who raised concerns about the therapeutic choices of inpatient heart failure patients admitted to the hospital with comorbid pain.

"Many alternative or complementary pain treatments are within the scope of nursing practice, and therefore nurses can support patients with safe alternative pain treatments and perhaps reduce the symptom burden for patients,"Dr. McDonald pointed out.

Alternative Treatments Rarely Used
For the study, nursing staff invited patients in the heart failure unit to participate in a brief research study during their hospital stay. Patients were screened within 24 hours of admission; inclusion criteria included having pain of at least 3 months' duration experienced during the majority of days in the previous month, and current use of at least 1 alternative non-nutraceutical pain management strategy at home on a regular basis.

Mean patient age was 65.5 ± 15.42 years, and mean pain duration was 17.3 ± 21.06 years. The most common pain syndromes were back pain (44.0%), osteoarthritis (24.0%), fibromyalgia (16.0%), and neuropathic pain (16.0%).

Of 25 study patients, 9 (36%) were currently taking acetaminophen, 11 were on opioid therapy (44%), and 3 (12%) took NSAIDs. Eight patients (32%) limited their use of analgesics or co-analgesics to 1 agent; 1 patient was taking 5 different medications. 

Only 5 patients (20%) used evidence-based treatments to manage all of their chronic pain conditions; all 5 had back pain, and 1 also had osteoarthritic pain.  Seven others (28%) did not use any available evidence-based treatments to treat back pain, headache, and/or fibromyalgia. An additional 9 patients (36%) had chronic pain conditions without clear evidence-based alternative pain treatment.

Five of 11 patients (45.5%) with chronic back pain reported using stretching exercises and walking, but none used massage, progressive relaxation, or yoga. Of the 6 patients with osteoarthritis, 2 (33.3%) reported walking and 5 (83.3%) used heat. None of the 4 patients with fibromyalgia reported use of meditative movement therapies, such as tai chi or yoga, and neither of the 2 with headache reported use of biofeedback.

Use of alternative evidence-based treatments for chronic pain was significantly correlated with male gender (P < .003). Five of 11 men (45.5%) used evidence-based treatments specific to all of their chronic pain conditions, such as walking and/or heat for back and/or osteoarthritis pain. Of 14 women, 8  (57.1%) did not use evidence-based treatments available for their pain syndrome.

No additional correlations were found between age, gender, education, or New York Heart Association (NYHA) status.

The study authors urge caution in interpreting these results because the small sample size amplifies effects. However, the paucity of heart failure patients using alternative chronic pain treatments highlights educational needs in this population.

According to Dr. McDonald, the findings also suggest a need for additional research — possibly a national survey of people with heart failure and comorbid chronic pain — to better determine the safety and efficacy of pain treatments currently used, and identify other ways to reduce pain and enhance cardiac outcomes.

More Research Needed
Sarah Goodlin, MD, chief of geriatrics at the Veterans Administration Medical Center in Portland, Oregon, and president of the Patient-Centered Education and Research Institute, has focused much of her research on outpatient studies. She says the findings of this inpatient study are not inconsistent with her findings.


"We found a high percentage of people using medications that might make their heart failure worse. I think about 15% of the patients in our study were using NSAIDs, which are contraindicated in moderate to advanced heart failure. We also found that one in 8 patients were using gabapentin, which often causes fluid retention and edema," Dr. Goodlin said.

Dr. Goodlin notes that while the focus of the current study on alternative, non-medical therapies is encouraging, data is lacking and more research into alternative treatments for patients with chronic pain and heart failure is needed.

"There have been no studies that I'm aware of looking at what [alternative] treatments work best specifically in patients with heart failure," Dr. Goodlin pointed out. “In general for patients with chronic pain, however, we should be using a spectrum of therapies that include exercise, physical therapy, and modalities like transcutaneous nerve stimulation, heat, or cold, as well as topical medications in addition to medication treatments." 

In the interim, clinicians should assess heart failure patients for comorbid pain conditions, such as osteoarthritis and diabetic peripheral neuropathy, and assist them in using safe alternative pain treatments to reduce symptoms and improve quality of life,” Dr. McDonald suggested.

Dr. Goodlin agrees, emphasizing that clinicians need to pay more attention to the pain medications heart failure patients choose.

"I think the important things to be aware of are that pain is common, and we should be asking about it. Also, patients can access NSAIDs over the counter, so we need to be working with patients to develop strategies that won't worsen their heart failure," Dr. Goodlin concluded.

Reference


McDonald DD, Soutar C, Chan MA, Afriyie A. A closer look: Alternative pain management practices by heart failure patients with chronic pain. Heart Lung. 2015 Sep-Oct;44(5):395-9, doi: 10.1016/j.hrtlng.2015.06.001. Epub 2015 Jun 16.

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