The Management of Pain in Metastatic Bone Disease

Sorin Buga, MD; Jose E. Sarria, MD


Cancer Control. 2012;19(2):154-166. 

In This Article

Nonpharmacologic Management

Cutaneous Stimulation

Cutaneous stimulation includes the application of superficial heat (thermotherapy) and cold (cryotherapy). Thermotherapy employs local hot packs, hot water bottles, electric heating pads, and immersion in warm water, whereas cryotherapy utilizes ice packs, towels soaked in ice water, or commercially prepared chemical gel packs. These forms of cutaneous stimulation should not be applied over tissues that have been exposed to and damaged by radiation therapy. Modalities to deliver deep heat, such as short-wave diathermy, microwave diathermy, and ultrasound, should be used with caution in patients with active cancer disease, and they should never be applied directly over a cancer site.[8]

Transcutaneous Electrical Nerve Stimulation

Transcutaneous electrical stimulation (TENS) is a method of applying low-voltage electrical stimulation to large, myelinated fibers. The TENS unit may provide pain relief by keeping the pain gate closed. According to the gate-control theory proposed by Melzack and Wall in l962 (Brain. 1962;331–356), stimulation of the large myelinated nerve fibers inhibits the transmission of the pain stimuli via unmyelinated C fibers and small myelinated delta fibers. TENS might also ameliorate pain by causing the release of beta endorphins and Metenkephalins (endorphins involved in pain transmission).

However, the use of TENS to alleviate cancer pain is controversial, and further research is needed to help guide clinical practice. Two Cochrane reviews showed that there is insufficient evidence to determine the effectiveness of TENS in treating cancer-related pain[9] and that large randomized controlled multicenter trials of TENS in chronic pain are needed.[10]

Massage Therapy

Massage therapy can help ease general aches and pains, especially in patients who are bed-bound or who have limited mobility. A recent pilot study that included 30 Taiwanese cancer patients with bone metastases assessed the effects of massage therapy on pain, anxiety, and physiologic relaxation over a 16- to 18-hour period.[11] Massage therapy had a positive impact on pain and anxiety, providing an effective immediate benefit [t(29) = 16.5, P = .000; t(29) = 8.9, P = .000], short-term benefit, in 20 to 30 minutes [t(29) = 9.3, P = .000; t(29) = 10.1, P = .000], intermediate benefit, in 1 to 2.5 hours [t(29) = 7.9, P = .000; t(29) = 8.9, P = .000], and long-term benefit, in 16 to 18 hours [t(29) = 4.0, P = .000; t(29) = 5.7, P = .000]. The most significant effect occurred 15 minutes after the intervention [F = 11.5 (1, 29), P < .002] or 20 minutes after the intervention [F = 20.4 (1, 29), P < .000], and no patients have reported any adverse effects as a result of massage therapy.


As a general rule, patients should be encouraged to remain active; prolonged immobilization could lead to decreased musculoskeletal endurance and psychosocial regress. For these patients, hydrotherapy can provide a reduced-gravity environment and thus decrease pain experienced with movement, facilitate muscle relaxation, and improve overall emotional state. If immobilization is required to prevent or stabilize fractures, exercise should be limited to a self-administered range of motion. In addition, clinicians need to educate families and caregivers on the proper application of orthotic devices as well as assistance with exercises that would not significantly increase pain.

Chiropractic or Osteopathic Manipulative Techniques

Due to the potential for harm in patients with metastatic cancer of the bone, the use of chiropractic or osteopathic manipulative techniques is not recommended.


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