|Year : 2017 | Volume
| Issue : 2 | Page : 100-106
Evaluation of hypnotherapy in pain management of cancer patients: A clinical trial from India
Vikas Kumar Sharma1, Pranav Pandya2, Rakesh Kumar3, Gaurav Gupta4
1 Department of Applied Psychology, Amity Institute of Behavioural and Allied Sciences, Amity University Madhya Pradesh, Gwalior, Madhya Pradesh, India
2 Department of Clinical Psychology, Dev Sanskriti Vishwavidyalaya, Haridwar, Uttarakhand, India
3 Department of Clinical Psychology, Institute of Mental Health and Hospital, Agra, Uttar Pradesh, India
4 Department of Radiation Oncology, Chirayu Medical College and Hospital, Bhopal, Madhya Pradesh, India
|Date of Web Publication||6-Sep-2017|
Vikas Kumar Sharma
Department of Applied Psychology, Amity Institute of Behavioural and Allied Sciences, Amity University Madhya Pradesh, Maharajpura Dang, Gwalior - 474 005, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Context: In the present era, cancer is one of the major growing diseases in human beings. People with cancer often experience a lot of problems ranging from psychological impairments to pain, fatigue, and sleep disorders. Pain is closely associated with all types of cancer. Cancer patients feel intense pain in the affected organ not only because of cancer but also because of the medical treatment procedure. Aim: The present study aimed at exploring the efficacy of hypnotherapy in mollifying the pain in persons with cancer. Settings and Design: This study was systematically planned through before and after control group design with matching; a quasi-experimental research design.Subjects and Methods: The present study was carried out by taking a total of 57 cancer patients as per inclusion/exclusion criteria from Jawaharlal Nehru Cancer Hospital and Research Center, Bhopal, Madhya Pradesh, through convenience sampling method. Out of these 57 participants, the experimental group consisted of thirty participants who were given intervention in the form of 15 sessions of hypnotherapy along with medical treatments. The control group consisted of another 27 participants who were administered medical treatments alone. Participants were given Numerical Rating Scale for a rating of pain in cancer patients. Statistical Analysis Used: Independent samples t-test and Eta-squared statistics were used to analyze the mean difference between experimental group and control group on pain and computing the magnitude of the effect of intervention, respectively. Results: The directional hypothesis was accepted P < 0.005 (one-tailed). Thus, mean score of pain (mean = 3.23, standard deviation [SD] = 1.36) for experimental group is statistically significant lower than posttest score (mean = 6.00, SD = 2.15) for control group. For power analysis, Cohen's d was estimated at 0.38 which indicates a large effect of the intervention on pain. Conclusions: The finding of the present study indicates that hypnotherapeutic interventions are effective in the management of pain in individuals with cancer.
Keywords: Cancer pain, hot flashes, hypnosis, hypnotherapy, pain
|How to cite this article:|
Sharma VK, Pandya P, Kumar R, Gupta G. Evaluation of hypnotherapy in pain management of cancer patients: A clinical trial from India. Indian J Pain 2017;31:100-6
|How to cite this URL:|
Sharma VK, Pandya P, Kumar R, Gupta G. Evaluation of hypnotherapy in pain management of cancer patients: A clinical trial from India. Indian J Pain [serial online] 2017 [cited 2018 Jul 22];31:100-6. Available from: http://www.indianjpain.org/text.asp?2017/31/2/100/214120
| Introduction|| |
In the present era, cancer is one of the major growing diseases in human beings. According to the World Cancer Report 2014, cancer is the leading cause of death worldwide, accounting for 8.2 million deaths in 2012 and is projected to continue to rise to over 11 million in 2030. Furthermore, in India, it has emerged as a major public health concern. Almost 1.25 million new cases are diagnosed every year and around 2.8 million cases of cancer are prevalent at any given point of time. According to the WHO, death from cancer in India is projected to rise to 13.1 million by the year 2030.
Cancer is a group of diseases characterized by an uncontrolled growth and spread of abnormal cells. It can be defined as a disease, in which a group of abnormal cells grows uncontrollably by disregarding the normal rules of cell division. Cancer is probably the disease people fear the most. The word “cancer” itself scares many people, and they often overestimate the deaths that cancer causes. People with cancer often experience a lot of problems ranging from psychological impairments to pain, fatigue, and sleep disorders. Pain is closely associated with all types of cancer. Cancer patients feel intense pain in the affected organ not only because of cancer but also because of the medical treatment procedure. Most of the cancer pain is caused by tumor itself. If a tumor grows and spreads to the bones or other organs, it may put pressure on nerves and damage them, causing pain. Sometimes, pain is also related to treatment. Treatments such as chemotherapy, radiation therapy, and surgery may cause pain. For example, chemotherapy drugs can cause numbness and tingling in hands and feet or a burning sensation at the place where they are injected. Radiation therapy can also cause pain, depending on the area of the body that is treated. Cancer pain is a complex, multidimensional phenomenon composed of sensory, affective, cognitive, and behavioral components. It is resulted from a complex interaction between physiological, cognitive, social, and other factors. The incidence of pain in cancer patients is between 51% and 70%. It is reported by 59% of people receiving anticancer treatment and 64%–70% of those with advanced, metastatic, or terminal disease., It is known that 40%–50% of pain is moderate to severe, whereas 20%–30% is very severe. In the presence of a terminal illness, pain may have a soul-destroying effect and may create emotional and behavioral changes in a patient.
Clinical studies have shown that hypnotherapy is effective in controlling a variety of psychophysical symptoms and improving patient treatment course and recovery, for example, reduced pain, anxiety, depression, nausea, and hospital stays.,,,, Hypnotherapy is a therapeutic form of hypnosis. Hypnosis is a mental state usually induced by a procedure known as hypnotic induction, which is commonly composed of a long series of preliminary instructions and suggestions. Suggestions may include that patients experience changes in sensorial or cognitive processes, physiology, or behaviour. It is also an effective tool in cancer care. One of the earliest documented uses of hypnosis with a cancer patient was as anesthesia for breast cancer surgery. In 1829, it was used (then referred to as mesmerism) over a period of several months to relieve the suffering of Madame Plantin, who had cancer of the right breast with massive enlargement of the right axillary lymph nodes. On April 1, 1829, in Paris, M. le Docteur Chapelain used hypnosis as an anesthetic during mastectomy and axillary node dissection. This was before the introduction of modern anesthesia techniques. During the operation, the patient was calm and evidenced good pain control. According to another new study, women who received hypnosis before breast cancer surgery needed less anesthesia during the procedure, reported less pain afterward, needed less time in the operating room, and had reduced costs. “This helps women at a time when they could use help, and it has no side effects. It really only has side benefits,” said Montgomery, lead author of the report and associate professor in the Department of Oncological Sciences at Mount Sinai School of Medicine in New York City.
So many previous researches, conducted in the field of psycho-oncology, show that hypnotherapy is so effective nonconventional method in mollifying cancer pain, reducing fatigue and sleep disturbances, and alleviating the psychological disturbances in cancer patients. However, all researches have been conducted outside of India so far. In India, not a single empirical research was done on hypnosis and cancer as per the record of internet search on CINAHL, Medline, PsycINFO, PubMed, and ScienceDaily databases were searched through October 2016. In India, hypnotherapy studies on cancer are at embryonic stage. It indicates a need for more productive studies. Hence, the present study has been designed to examine the efficacy of hypnotherapy in healing pain as a result of cancer or receipt of systematic cancer treatment.
Cancer patients who receive hypnotherapy will show a greater reduction in outcome measures of cancer pain than patients not receiving hypnotherapy.
| Subjects and Methods|| |
The present study was carried out by taking a total of 57 participants using convenience sampling method; a nonprobability sampling technique. Patients who were diagnosed as having cancer and who met the requirements of inclusion and exclusion criteria were included in the study. They were selected from Jawaharlal Nehru Cancer Hospital and Research Center, Bhopal, Madhya Pradesh, India. Before conducting the study, approval from the Institutional Ethical Committee was taken. Out of these 57 participants, the first group which was the experimental group consisted of 30 participants who were given intervention in the form of hypnotherapy along with medical treatments. The second group which was the control group consisted of another 27 participants who were administered medical treatments alone. Participants of both the groups were given morphine (10 and 20 mg); a prescribed medicine for pain. Sociodemographic and clinical characteristics of the study sample are displayed in [Table 1].
|Table 1: Individual characteristics of the study sample (percentage data in parentheses)|
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- Individuals having cervix cancer or other cancer with external tumor
- Patients with stages III or IV, whose pain score on Numerical Rating Scale (NRS) must be between 4 and 7
- Individuals must be under medical treatment in the hospital
- Individuals must be above the age of 18 years
- Individuals must be able to understand and speak Hindi language
- Individuals must be volunteers.
- Clinical history suggestive of psychosis, mental retardation, substance abuse, or personality disorders
- Previous or ongoing exposure to structured psychotherapy
- Terminally ill patients.
Design of the study
The present study was systematically planned through before and after control group design with matching; a quasi-experimental research design. The individuals who volunteered to participate were assigned to the experimental group and those who declined to participate were assigned to the control group. “Matching” of preintervention assessment scores on dependent variables was done for both groups, before conducting post-post analysis.
NRS was used to measure the intensity of pain in cancer patients. It is a unidimensional measure of pain intensity introduced by McCaffery and Pasero in 1999. NRS is a numeric version of visual analog scale (VAS), in which an individual selects a number (0–10) that best describes the intensity of pain. Participants are most commonly asked to report their pain “in the past 24 h” or average pain intensity. Each response is awarded score as circled. Scores range from 0 to 10 points with higher scores specifying greater pain intensity. The interpretation of scores is as 0 = “no pain,” 1–3 = “mild pain,” 4–6 = “moderate pain,” 7–9 = “severe pain,” and 10 = “worst possible pain.” NRS-11 demonstrated construct validity with r = 0.78 and 0.95 when correlated with Faces Pain Scale-Revised  and VAS, respectively. In another study, high test–retest reliability has been examined in both literate and illiterate people with r = 0.96 and 0.95, respectively.
From March 2015 to December 2015, a total of 86 cancer patients were assessed for eligibility to participate in the study. These patients regularly visited Jawaharlal Nehru Cancer Hospital and Research Centre, Bhopal, Madhya Pradesh, India, for medical treatments. Four patients out of them were excluded for not meeting inclusion criteria and 15 patients declined to participate in the study at all. NRS was administered to remaining 67 patients to measure pain. The results obtained at this point were constituted pretest scores. Out of 67, only 37 cancer patients showed interest to take hypnotherapy as well as with their medical treatments. Consent forms were duly signed by all 37 volunteers. Remaining thirty patients were put in the control group.
The semi-structured pro forma for both groups was utilized by the researcher. The patients' demographic information (which included their name, date of birth, age, current working status, current educational status, current address, and marital status) and information about the present problem (diagnosis, onset and course of cancer, and stage of cancer) were noted down carefully. After this, sessions of hypnotherapy along with medical treatments were conducted to each participant of experimental group and the control group underwent only medical treatments; radiotherapy or chemotherapy or the combination of both.
In experimental group, only thirty clients (out of 37) completed the course of intervention successfully. Seven patients left their intervention program in between for the variety of reasons including loss of interest in hypnotherapy, left the hospital during the course of therapy, and health issues. In control group, three participants (out of thirty) were excluded so as to establish the “matching” on preintervention assessment scores. NRS was again administered on all 57 participants after the completion of the intervention. The results obtained at this point were constituted the posttest scores. [Figure 1] also illustrates the number of cases screened and allotment of cases in experimental and control group, preintervention assessment, treatment conditions, and postintervention assessment.
|Figure 1: Flow of participants through a nonrandomized clinical trial. Participant's flow diagram illustrating the number of cases screened and allotment of cases in experimental and control group, preintervention assessment, treatment conditions, and postintervention assessment|
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| Results|| |
The efficacy of hypnotherapy intervention on cancer pain was analyzed by comparing the postintervention assessment scores for experimental group and control group. Independent samples t-test was applied to test the hypotheses. Each group was received an average of twenty sessions of radiotherapy and three sessions of chemotherapy during the course of hypnotherapy intervention. Thus, it is summarized that a total of 23 sessions of conventional medical treatment along with 15 sessions of hypnotherapy were provided to experimental group, whereas only 23 sessions of same were provided to control group. Hence, both groups are homogeneous with respect to clinical measures. To ascertain whether experimental and control group are comparable, an independent samples t-test was applied to test the significance of mean difference on pain between both groups at preintervention stage. As shown in [Table 2], obtained t-value (t = 0.31) is too less than the critical t-value at df = 55, P > 0.05. Thus, there is no statistically significant difference between experimental and control group at preintervention time point with respect to their mean scores on pain. It is, therefore, concluded that both groups are comparable at postintervention stage.
For postanalysis, first of all, the assumption of normality for distributed difference scores was scrutinized. The assumption was considered satisfied, as the skew and kurtosis levels were examined at 0.07 and 0.88, respectively, which is less than the maximum acceptable values for a t-test (i.e., skew < ǀ2.0ǀ and kurtosis < ǀ9.0ǀ). As displayed in [Table 3] and [Figure 2], directional hypothesis was accepted, t (55) = 5.87, P < 0.005 (one tailed). Thus, mean pain score (mean = 3.23, standard deviation [SD] = 1.36) for experimental group is statistically significant lower than mean pain score (mean = 6.00, SD = 2.15) for control group. It is, therefore, concluded that hypnotherapy intervention is associated with decreasing the pain in cancer patients. To conduct power analysis, Cohen's d was estimated at 0.38 specified a large effect size based on Cohen (1988) guidelines.
|Figure 2: Pre- and post-test mean scores of the experimental and control group on cancer pain|
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| Discussion|| |
The findings displayed indicate that directional hypothesis is accepted, t (55) = 5.87, P < 0.005 (one tailed). It demonstrates that hypnotherapy intervention is associated with decreasing the pain in cancer patients. Hypnotherapy has been established as an effective nonpharmacological remedy for cancer pain in many researches.,,,,, Hypnosis is very beneficial in a variety of conditions including venipuncture-related pain of pediatric cancer patients, pain during percutaneous tumor treatments, pain in pediatric cancer patients, postbiopsy pain in breast cancer patients, pain in leukemia, and pain in terminally ill cancer patients. In a classic case of female cancer patient with thigh skin tumor, hypnosis was used as a sole anesthesia. A 42-year-old female presented with a skin tumor in the right thigh. She was admitted for removal of tumour, but she had been suffering from “multiple chemicals sensitivity,” especially to local anesthetics. Hence, she was admitted for removal of tumor under hypnosis as sole anesthesia. After inducing hypnosis, a wide excision was done, and the tumour was removed. The patient's heart rate and blood pressure did not rise during the procedure. When the patient was dehypnotized, she reported no pain and was discharged immediately. This case confirms the efficacy of hypnosis not only in the pain management but also in preventing the pain perception.
Mechanism of action: Neurophysiological model
Recently, there is a steady increase in scientific interest in clinical application of hypnotic analgesia. From latest neurophysiological studies of pain, it is known that there is no “single” pain center in the brain. Rather, pain is linked with multiple areas of peripheral and central nervous system, each of which makes contributions to overall experience of pain. The cortical areas frequently activated during pain are the anterior cingulate cortex (ACC), insular cortex, prefrontal cortex, primary and secondary sensory cortices, and thalamus. Each of these brain areas has been demonstrated to respond to hypnosis in many studies; ACC,,,,, insular cortex,, prefrontal cortex,, primary or secondary cortex, and thalamus. Thus, hypnosis appears to influence the different brain areas to reduce the pain. In a neurophysiological study, Vanhaudenhuyse et al. explored activation within the pain matrix when comparing painful and nonpainful stimulation, using a thulium-yttrium aluminum garnet laser to induce pain. As expected, activity within the pain matrix was significantly decreased during hypnoanalgesia.
In addition, the experience of pain is also associated with brainwave activity. During pain, an increase is shown in beta activity (13–30 Hz) whereas alpha activity (8–13 Hz) is decreased. Research indicates that with hypnosis, there is a decrease in relative beta activity and an increase in relative alpha activity. Therefore, it can be said that hypnotic analgesia may affect the pain both by changing the brain activity in specific areas and by facilitating shift in general brain states.
Mechanism of action: Psychological model
Pain is a psychosomatic phenomenon, always characterizing tissue damage and physiological reaction to it. International Association for the Study of Pain defines, “Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” Hypnosis analgesia seems to work through “attention control” mechanism.,, Hypnosis engages in narrowing of the focus of attention. In hypnotic state, individuals place their pain at the periphery of their awareness by replacing it with some metaphor, images, or scenes at the center of their attention. Research also indicates that hypnosis alters the pain experience and reduces perceptions of unpleasantness as well as pain intensity.
Hypnotic techniques are much better than standard treatments of pain in cancer care. Depending on the nature of hypnotic suggestions, the sensory and affective aspects of pain and associated brain areas are affected.
Limitations of the study
- The major limitation of this study is small sample size (n = 30 in a group) which limits the generalizability of the findings
- Participants were selected arbitrarily. Randomization was used neither in sample selection nor in group allocations.
| Conclusions|| |
To conclude, the present study shows that there is a significant positive effect of hypnotherapy on pain in cancer patients. The practice of hypnotherapy significantly decreases the pain in cancer patients.
The authors would like to thank the participants of this study. A special note of thanks to the administration of Jawaharlal Nehru Cancer Hospital and Research Centre, Bhopal, Madhya Pradesh, for permitting me to conduct my empirical work.
Financial support and sponsorship
This study was financially supported by Indian Council of Social Science Research, New Delhi.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]