Pei-Yao Li, Yun-Lan Jiao, Chun-Hua Zhang, Ling Wang,Wen-Wen Zhao, Hui-Xin Ding, Chun-Guang Yu, *

?

The effects of TCM nursing intervention on the life quality of cancer patients with pain: a review of recent research

Pei-Yao Li1, Yun-Lan Jiao1, Chun-Hua Zhang1, Ling Wang1,Wen-Wen Zhao1, Hui-Xin Ding1, Chun-Guang Yu1, *

1College of Nursing, Beijing University of Traditional Chinese Medicine, Beijing, China.

Tumor pain is common in patients with advanced cancer, 70-80 % have varying degrees of pain. Treatment of cancer pain has become a difficult issue in oncology, poor pain control often seriously affects the patients' quality of life (QOL). Traditional Chinese medicine (TCM) nursing intervention can improve symptoms and QOL through massage, external treatment of TCM, and auricular therapy, which have unique curative effects such as regulating Qi (a vital force that forms part of living entity in traditional Chinese culture) and blood, stabilizing the mind, and enhancing immunity. Not only does TCM nursing intervention prevent disease but also cultivates the mind, helps achieve systemic relaxation, and reduces the pain of cancer patients and the toxic side effects of painkillers, so as to improve QOL and satisfaction, making it worthy of clinical popularization and application. At present, there is an urgent need to carry out high-quality, multi-center, large-sample randomized controlled trials and develop a standardized TCM nursing intervention implementation scheme and efficacy standards to promote its application.

Cancer pain, TCM, Nursing, Quality of life.

As aalternative therapy to Western analgesics, traditional Chinese medicine nursing has unique advantages in relieving pain in patient with cancer and can effectively improve quality of life.

The conventional analgesics are selected to relieve pain in patient with cancer; however, their adverse reactions seriously affect the patient’s quality of life (QOL). Traditional Chinese medicine nursing can improve clinical symptoms and QOL through massage, external treatment of Chinese herbs, auricular therapy, etc. as well as reduce the toxic side effects of analgesics, making it worthy of clinical popularization and application.

TCM, Traditional Chinese medicine; QOL, Quality of life; WHO, World Health Organization; WHOQOL-100, WHO QOL assessment-100; QLICP, QOL Instruments for Cancer Patients.

The authors declare that there is no conflict of interests regarding the publication of this paper.

Chang Liu

Introduction

Pain has been listed as the fifth vital sign after respiration, pulse, blood pressure, and body temperature. Although it is an important factor affecting quality of life (QOL), the negative effects of pain on the human body are difficult to measure. In 1972, the International Pain Association defined pain as “an unpleasant sensation or emotional experience caused by actual or potential tissue damage.” According to the World Health Organization (WHO), there are 10 million new cases of cancer worldwide every year, and six million people die of cancer. Among them, 50 % of patients have cancer pain symptoms, and 70-80 % of patients with advanced cancer have pain as the main symptom. Cancer pain worsens patients’ psychological state, thereby affecting clinical efficacy. QOL is a major factor affecting patients’ mental state and physical and social functioning, as well as being a sensitive indicator of physical and mental health. With the transformation of the medical model, improving QOL has become one of the important goals of clinical nursing [1].

In the context of cancer patients, Western nursing mainly involves a comprehensive pain evaluation, analysis of the reason for pain, and three stages of analgesia according to the doctor’s advice. The three-stage analgesic scheme regulated by the WHO can alleviate cancer pain to a certain extent; however, the clinical effects of some painkillers are not satisfactory and some drugs cause dependency and addiction. Traditional Chinese medicine (TCM) nursing combines dialectical nursing with TCM techniques to guide clinical nursing, prevention, health care, and rehabilitation [2]. In the TCM framework, tumors are believed to be caused by deficiencies of the body and vital energy and the invasion of external pathogens, resulting in the stagnation of Qi(a vital force that forms part of living entity. https://en.wikipedia.org/wiki/Qi) and blood stasis, obstruction of meridians and collaterals, and internal knots of heat and toxins [3]. TCM nursing intervention, such as TCM external application and massage, dredges the channels and collaterals, harmonizes Qi and blood, effectively and humanely reduces pain, and improves QOL. Scales used to assess the QOL of patients with pain and the implementation of TCM nursing intervention in the field of cancer pain are described below.

Definition of QOL and its role in cancer-related research

At present, there is no unified definition of the concept of QOL. In general, it is affected by the individual’s physical health, psychological status, economic ability, social relations, and environmental factors. It not only considers the cultural value system but also embodies the spirit of humanism. The WHO defines QOL as “the experience of living as individuals in different cultures and value systems related to their goals, expectations, standards, and concerns” [4]. China put the WHO cancer pain three-step ladder treatment into effect nearly 20 years ago. However, owing to the large population and insufficient cognition of cancer pain treatment, cancer pain can not be effectively treated and the QOL of patients is greatly affected. With the development over time, QOL assessment of cancer patients has been widely incorporated in the selection of anti-cancer drugs and the evaluation of treatment methods [5].

QOL scales for patients with cancer pain

The tools used to measure QOL in patients with pain fall into two categories. The first is the WHO QOL assessment-100 (WHOQOL-100) that comprehensively evaluates QOL in all aspects of the general population. The second is the commonly used Medical Outcomes Study 36-item Short Form Health Survey (MOS SF-36). Compared with the SF-36, the WHOQOL-100 is more credible and responsive with regard to clinical changes [6]. In addition, there is a specific QOL scale for evaluating health-related aspects of pain in patients; the Functional Living Index-Cancer, developed by Schipper (1984), is one of the most widely used in the world [7]. In addition, the European Organization for Research and Treatment of Cancer QOL Questionnaire and the Pain and QOL Cancer Patients Investigation Form are also commonly used [8, 9]. Wu YP. considered that the Chinese Cancer Pain Assessment Tool has good reliability and validity, and has reference value to evaluate the degree of pain in cancer patients [10].

QOL Instruments for Cancer Patients (QLICP), developed by Chinese scholars Wan CH. in 1997, has Chinese cultural characteristics and is suitable for Chinese people [11, 12]. The specific items and scoring criteria have been developed taking into consideration the manner in which the Chinese understand and answer questions. Based on it, we have developed various kinds of tools to evaluate the QOL of cancer patients, for example, the QLICP-Stomach Cancer, the QLICP-Prostate Cancer, and the QOLICP-Ovarian Cancer [13-15]. The QLICP has good credibility, validity, and clinical feasibility, and can be used to evaluate the QOL of patients with cancer in China. However, the breadth and depth of the application of pain QOL evaluation should be expanded to enable pain workers to understand, recognize, and adequately use the assessment. More domestic QOL scales must be developed, and there must be a focus on the introduction, translation, and adjustment of foreign scales, making QOL evaluation more convenient and effective in the field of pain [16].

Effect of TCM nursing intervention on QOL of patients with cancer pain

In developed countries in Europe and America, the responsibility of cancer pain management is shifting from physicians and anesthesiologists to clinical nurses [17]. Nursing intervention can reduce anxiety, depression, negative psychological effects, and the degree of physical pain and improve the QOL of patients [18]. The outline of China’s nursing development plan (2011-2015) demonstrates that the goal of TCM nursing development is to “improve TCM nursing technology and give full play to TCM nursing characteristics and advantages.” According to Chinese medicine, cancer pain is divided into “Qi stagnation and blood stasis” and “Qi and blood deficiency.” In view of its etiology, the method of dredging channels and collaterals and replenishing Qi and blood was adopted. TCM nursing intervention emphasizes the concepts of “holistic” and “dialectical” nursing. TCM nursing, which involves massage, acupuncture, fumigation wash, emotional nursing, and so on, not only has the ability to alleviate cancer pain but also improve the symptoms and QOL of patients.

Massage

Acupoint massage, guided by the Chinese medicine theory of the Zang-Xiang (the external features of physiological activities and pathological changes of human viscera. https://tcmwiki.com/wiki/zang-xiang -theory) and meridian, is one of the main methods to promote blood circulation and remove blood stasis in TCM [20]. Acupoint massage can dredge channels and collaterals, harmonize Qi and blood, balance Yin and Yang (a concept of dualismin describing how contrary forces depend on and give rise to each other in Chinese philosophy. https://en.wikipedia.org/wiki/Yin_and_yang), remove collaterals, and relieve pain. Studies demonstrate that massaging the acupoints of Feishu (BL13), Geshu (BL17), Zhongfu (LU1), Hegu (LI4), Taichong (LR3), and Ashi can relieve the pain of lung cancer patients and improve their pain tolerance [21]. Ge YF. chose to massage the acupoints of Taiyang (EX-HN5), Fengchi (GB20), Xinshu (BL15), Shenshu (BL23), Zusanli (ST36), and Yongquan (KI1). This helps blood circulation and reduces the patient’s sense of pain. Besides, physical contact can reduce patients’ anxiety and depression and enhance their confidence in treatment [22]. Ju CXdemonstrated that massaging the acupoints of Neiguan (PC6) and Zusanli (ST36) combined with analgesics could effectively relieve cancer pain symptoms in patients with advanced malignant tumors [23]. The massage process involves ensuring that the patient is kept warm for up to two hours later. At the same time, the doctor must ensure that the patient remains emotionally stable. Besides, patients with a weak constitution, serious heart disease, liver cirrhosis, cerebral pathological changes, cachexia, serious skin conditions, blood diseases such as leukemia and sepsis, and pathologic fractures can not undergo TCM massages.

Acupuncture

Through its stimulating function, acupuncture can dredge the meridians, regulate Qi and blood, give strength, and dispel evil, thus achieving the purpose of preventing and treating diseases [18]. Foreign research institutions have issued guidelines on acupuncture treatment of cancer pain [24]. Common analgesic acupuncture therapies include moxibustion, auricular therapy, and so on.

Moxibustion

Moxibustion is an important part of acupuncture. During this process, the surface acupoints of moxa sticks are directly or indirectly cauterized after lighting, which can stimulate and improve the immune function. Studies have shown that stimulation of acupoints such as Xuehai (SP10), Zusanli (ST36), Zhongwan (CV12), and Sanyinjiao (SP6) can improve immunity and reduce cancer-induced pain [25]. Moreover, during the treatment, psychological counseling can effectively alleviate patients’ negative emotions. Studies have shown that, for patients with stomachache, local acupoint selection is the main method, combined with syndrome differentiation and distal acupoint selection [26]. The main acupoints for moxibustion therapy are Shenque (CV8), Zhongwan (CV12), bilateral Zusanli (ST36), Xuehai (SP10) and Sanyinjiao (SP6). It can dredge the channels and collaterals, activate blood circulation, and remove blood stasis.

Auricular therapy

According to TCM, the ear is closely related to the viscera meridians. When the auricular acupoints are stimulated, there is a therapeutic effect on the corresponding viscera. The main methods of stimulating the auricular acupoints are acupuncture, bloodletting, auricular acupoint stick pressure, magnetic cure, and massage. The heart, Shen Men (HT7), and sympathetic, endocrine, subcortical, and corresponding carcinogenic organ holographic reflex areas were selected as auricular points [27]. Gong WH. conducted a meta-analysis of auricular therapy for cancer pain based on the GRADE system. The results showed that auricular therapy combined with drug therapy was better than drug therapy alone [27]. Vaccaria seeds have the effect of activating blood circulation and relieving swelling and pain through the selection of the Shen Men, sympathetic, heart, cortex, and endocrine point pressure beans. Further, they can play the role of drugs and regulate the body by alleviating congestion [28].

TCM sticking

According to TCM, cancer pain is divided into the Yin and Yang syndromes. In patients with Yin syndrome, the skin color of the mass remains unchanged, pain local afraid of cold, like warm and stress. By means of Wenyang dispersing cold and detoxifying dispersing knot, warm channels and collaterals, and promoting Qi and blood circulation, local cold coagulation, Qi stagnation, and blood stasis can be resolved to achieve pain relief. The local pain in patients with Yang syndrome is characterized by redness, swelling, and heat, for which the treatment method involves clearing heat, detoxifying, and cooling the blood [29]. Studies have shown that for patients with lung cancer, external application of TCM (,,,,,,, and) at the points of pain can alleviate pain, reduce the content of serum inflammatory factors in the body, and improve QOL [30]. Liu Qdemonstrated that combining topical analgesic herbs (,,,,,,,,) with heat therapy is a safe and reliable method of significantly easing the symptoms of patients with moderate to severe cancer pain, as well as alleviating depression, anxiety, and other adverse emotions [31].

TCM foot bath

TCM foot bath, a health care treatment method of soaking the feet in a decoction of Chinese medicine, it is an important part of TCM external therapy [32]. Cancer-painful foot bath is the most commonly used TCM to promote blood circulation, remove blood stasis, clear heat, and achieve detoxification, such as:,,, and. When the water temperature is 50-60 °C, fumigation 20-30 minutes, stay at 30-40 °C, the feet are soaked for three minutes. Temperature regulation is specific to the patient’s age, physical condition, and so on. After waiting for the foot bath to end, massagist can press, knead, push to undertake massaging to corresponding acupuncture point, strength is advisable with acerbity feeling. Liu Yused TCM foot bath for patients with cancer pain (,,,,,,,,,,,,,, and) to increase blood circulation, regulate the viscera, relieve spasmodic pain, and promote sleep [33]. Jin JX demonstrated the effects of TCM foot bath (,,,,,,, and) for patients with advanced tumor via reducing pain, improving sleep quality and achieving a high level of safety and few adverse reactions [34].

TCM emotional nursing

According to TCM, when emotion is excessive, it brings about Zang-fu (functional organs stipulated by TCM. https://en.wikipedia.org/wiki/Zang-fu) function disorder, maladjusted Qi, and meridian stagnation, forming bumps. Suwen (, Han Dynasty) said that too much anger is harmful for the liver, too much happiness is harmful for the heart, overthinking is harmful for the spleen, worry is harmful for the lungs, and fear is harmful for the kidneys. The most commonly used methods of emotional nursing in TCM include language enlightenment, transference, and psychological suggestion, which involve giving patients the faith to fight disease, thereby reducing their psychological burden.

In their study, Wang Jcompared the conventional nursing group with the emotional nursing group, demonstrating that the TCM emotional nursing intervention improved patients’ medication compliance and satisfaction and reduced pain (< 0.05) [35]. Chen Cconducted Wuxing (a systematic view of Taoism originated from ancient times of China. https://en.wikipedia.org/wiki/Wuxing) music intervention therapy on patients with advanced cancer pain to alleviate their anxiety and depression [36]. Research shows that, in such therapy, selections must be made dialectally according to the inherent characteristics of Wuxing music and its relationship with the organs [37]. In the liver-Qi stagnation syndrome, the liver is subsumed to wood and metal restricts wood, so the selected music must be in Jue melody (one of the China's ancient pentatonic scale. https://en.wikipedia.org/wiki/Jue). For Qi, blood, and spleen deficiency syndromes, the chosen music must be in Gong melody (one of the China's ancient pentatonic scale. https://en.wikipedia.org/wiki/Gong). For the kidney Yin deficiency syndrome, the chosen music must be in Yu melody (one of the China's ancient pentatonic scale. https://en.wikipedia.org/wiki/Yu). It is a scientific and effective adjuvant cancer pain relief method that can reduce the pain of patients with urological cancer and improve QOL, making it worthy of clinical promotion.

Discussion

Pain is the most common and unbearable symptom of cancer patients. Therefore, alleviating pain is a pressing matter in clinical work. Three-step therapy is currently recognized as the best treatment for cancer pain. The appropriate analgesics are selected after the evaluation of the nature and degree of cancer pain; however, adverse reactions of analgesic drugs seriously affect the QOL of patients. TCM therapy is effective in treating cancer pain. Working by dredging the channels and collaterals and harmonizing Qi and blood, it does not lead to addiction, and adverse reactions are unlikely. The operation method is simple and diverse, based on the solid theoretical foundation of TCM. Moreover, with low cost, it can reduce the dosage of Western medicine and adverse drug reactions, and conserve social resources at the same time.

According to the relevant literature and clinical observations, the following problems with TCM nursing should be discussed: the lack of domestic and foreign research reports, related high-quality literature, objective and unified quantitative indicators, and the inability of domestic research to move beyond theory. At present, medical institutions pay little attention to TCM nursing, and it is difficult to carry out multi-center, large-sample clinical research. TCM nursing lacks unified operating standards, and the specialized training of nursing staff needs to be improved. Keeping in mind differences in patients’ constitutions and syndromes, the development of personalized TCM nursing schemes and clinical promotion need to be improved.

Above all, as aalternative therapy to Western analgesics, TCM nursing has unique advantages in cancer pain relief and can effectively improve QOL. In the future, high-quality, multi-center, and large-sample randomized controlled trials should be carried out, and standardized TCM nursing implementation plans should be formulated. This will help improve cancer pain symptoms and QOL of patients, and carry forward the characteristic culture of TCM.

1. Long HB, Wang QL, Zhao H,. Observation on the effect of comfort nursing intervention on improving psychological status and quality of life of cancer patients.J International Psychiatry 2015, 42: 111-114.

2. Xu GH, Liu H. Basis of TCM nursing. Beijing: Chinese Medicine Press, 2012.

3. Deng Y. Evaluation of the effect of TCM comprehensive therapy on cancer pain.Clinical J Chin Med 2014, 20: 77-78.

4. Guo HQ, Ding HL, Wang YM. Current status of research on quality of life evaluation of patients with malignant tumors. Chin J Health Statistics 2010, 27: 104-110.

5. Wan CH, Tang XL. Quality of life measurement scale for cancer patients FACT-G. J Pract Oncol 2006, 21: 77-80.

6. Skeington SM, Carse MS, Williams AC,Validation of the WHOQOL-100: pain management improves quality of life for chronic pain patients. Clin J Pain 2001, 17: 266-275.

7. Schipper H, Clinch J, McMurray A,Measuring the quality of life of cancer patients: the functional living Index-cancer: development and validation. J Clin Oncol 1984, 2: 472-483.

8. Wan CH, Chen MQ, Zhang CZ,. Quality of life measurement scale EORTC qol-c30 for cancer patients. J Pract Oncol 2005, 20: 353-355.

9. Sun Y, Zhou JC. Clinical oncology internal medicine manual. Beijing: People's Medical Publishing House, 1996.

10. Wu YP, Qin HY, Fan YY,Validity and reliability analysis of Chinese cancer pain assessment tool. J Nurses Training 2001, 16: 737-738.

11. Tang XL, Zhang CZ, Lu YB,The application of quality of life assessment in clinical oncology. Kunming: Yunnan science and technology press, 2009.

12. Wan CH, Luo JH, Zhang HZ,Quality of life measurement scale system of cancer patients. Chin Behavioral Med Sci 2003, 12: 341-342.

13. Ding ZY, Cun YL, Cha Y,The quality of life scale (QLICP - ST V2) was used to measure gastric cancer. J Kunming Med Univer 2017, 38: 50-54.

14. Luo SM, Meng KQ, Li RQ,Screening of qlicp-pr items in the prostate cancer scale for quality of life measurement in cancer patients. J Kunming Med Univer 2015, 36: 39-42.

15. Zhang XX, Shi QF, Wan CH,Development and preliminary evaluation of the ovarian cancer scale for quality of life assessment of cancer patients. Chin General Practice 2012, 15: 3233-3236.

16. Zhu YB. Quality of life (QOL) measurement and evaluation. Beijing: People's Military Medical Publishing House, 2010.

17. Donna I. Effective control pain in cancer. Tumor Del 2011, 32: 17-21.

18. Wang YL. Research on the application of Chinese traditional culture-traditional Chinese medicine belief therapy in the comprehensive nursing of cancer pain patients. J Clinical Med Literature 2018, 5: 197-198.

19. Ministry of Health of the People's Republic of China. Outline of the plan for the development of nursing in China (2011-2015), 2011.

20. Ni YW, Hu HL, Zhang WL,Clinical practice of "anti-cancer acupoint drug injection therapy. China Association Chin Med 2013, 23: 200-204．

21. Xia XM. Application of acupoint massage combined with psychological intervention in pain nursing of patients with lung cancer. International J Nursing 2018, 37: 3260-3263.

22. Ge YF. Effects of acupoint massage combined with auricular pressure on pain and quality of life in patients with malignant tumor. Contemporary Nurse 2018, 25: 146-148.

23. Ju CX. Clinical effect of Neiguan and Zusanli acupoint massage combined with analgesic drugs in relieving severe cancer pain in advanced tumors. Journal of practical clinical medicine 2017, 17: 24-25.

24. Filshie J, Hester J. Guidelines for providing acupuncture treatment for cancer patients-apeer- reviewed sample policy document. Acupunc Med 2006, 24: 172-182.

25. Zou M. Effects of moxibustion on pain relief and quality of life in patients with advanced gastric cancer. Med Equipment 2017, 30: 171-172.

26. Guo TT, Chen JJ, Huk CL,The thinking and exploration of integrated external treatment of cancer pain in traditional Chinese medicine. Chin Med Emergency 2017, 26: 442-444.

27. Gong WH, Zou Y, Wang J,Meta analysis of ear point therapy based on GRADE system for the treatment of cancer pain. TCM clinical nursing 2018, 10: 5-11.

28. Zhou YM, Wang JF, Li WY,. Nursing effect analysis of acupoint application of traditional Chinese medicine combined with auricular acupoint pressing bean on cancer pain. Guide China Med 2017, 15: 248-249.

29. Wang F, Zuo MH, Hu KW,Clinical analysis of 50 cases of cancer pain with Yin syndrome treated by Wenjing Tongluo and detoxification and dispersing. J Beijing Univer Tradit Chin Med 2011, 18: 23-24.

30. Gao JQ, Lei YR, Chen HB. Application effect of external application of traditional Chinese medicine and acupoints combined with acupuncture in cancer pain treatment of lung cancer patients. China Med Herald 2018, 15: 92-95.

31. Liu M. Effects of self-designed analgesic Chinese medicine external application combined with hyperthermia on pain, adverse emotions and quality of life in patients with moderate to severe cancer pain. J Integrated Tradit Chin Western Med 2017, 26: 3034-3036.

32. Wang SJ, Zhang R. Research progress of TCM nursing for cancer pain patients. J Nursing Science 2014, 29: 93-95.

33. Liu Y, Qu ZY, Wan LX. Chinese medicine foot bath combined with foot massage can improve the pain and sleep quality of elderly cancer patients 2016, 14: 25-27.

34. Jin JX. Chinese medicine foot bath combined with foot massage can improve cancer pain and sleep quality of cancer patients. Feet Health Care 2017, 1: 188-189.

35. Wang J, Wang SJ, Wang JX,Observation on the effect of emotional nursing of TCM in improving drug compliance of cancer pain patients. Western Chin Med 2016, 29: 129-131.

36. Chen C, Zhu HZ, Xia Y,. Effect of TCM Wuxing music on cancer pain and quality of life in patients with advanced tumors. Shanghai J Tradit Chin Med 2017, 12: 17.

37. Gong YF. TCM syndrome differentiation combined with wuxing music therapy to relieve cancer pain in patients with urinary system tumors. Contemporary nurse 2015, 11: 79.

10.12032/TMRND201902007

Li PY, Jiao YL, Zhang CH,The effects of TCM nursing intervention on the life quality of cancer patients with pain: a review of recent research. TMR Non-Drug Therapy 2019, 2(2): 55-61.

3 February 2019,

Submitted: 12 November 2018,

Online: 20 March 2019.

*Corresponding to:Chun-Guang Yu, College of Nursing, Beijing University of Traditional Chinese Medicine, 11 Beisanhuandong Road, Chaoyang District, Beijing, 100029, China. Email: bjchunguang@163.com