Pain Management by Non-Pharmacologic Therapies Among to Persons Suffer from Pain: A Systematic Review and Meta-Analysis

Non-Pharmacologic Therapies Among to Persons Suffer from Pain: A Systematic Review


Introduction
Pain is an uncomfortable experience or feeling caused by the destruction of body tissues or by an illness that causes suffering.(International Association for the Study of PAIN (IASP), 2020) Pain affects the respiratory system, cardiovascular system, and digestive system.This causes complications such as lung atelectasis, myocardial infarction, etc.It also results in changes in Volume 06; Issue 09 Int J Nurs Health Care Res, an open access journal ISSN: 2688-9501 emotional behavior, such as fear, anxiety, lack of concentration, irritability, and insomnia [1].Many factors influence pain as follows: 1) Age: Elderly people have less pain perception than other ages [2].2) Gender: Females have a lower pain threshold and tolerance than males.Moreover, the perception of pain is higher in women than in other genders [3]. 3) Occupation: Agriculture industry, such as textile industry (76.00%), manufacturing and assembly industry (66.20%), farmers (52.40 -73.31%), and corn farmers (69.23%).It may be because working in the same posture, twisting, twisting, or using heavy-duty machines with vibration can cause chronic back pain and in occupations that do not require manual labor such as garbage workers (77.50%), taxi drivers (71.00%), public health personnel (65.51%), those who sat working with computers for more than 6 hours (53.14%) percent, etc., Having to sit in the same position, the back muscles repeatedly contract all the time, causing inflammation and causing chronic back pain [4].4) Body mass index: people with a body mass index above the criteria (BMI > 22.5 Kg/m2) (56.00%), especially those with abdominal obesity (44.20%) [5].Furthermore, those who were overweight or obese had pain intensity levels 2.29 times higher than those with a normal BMI [6].5) Congenital disease: Diabetes and Hypertension (28.79%), with people with congenital disease having a greater chance of having pain than those without congenital disease [7].Pain management is currently divided into two methods: pharmacological pain management and nonpharmacological pain management.A general approach for pain management using drugs is opioids, which are commonly used but cause side effects to patients, such as dizziness, drowsiness, nausea, vomiting, constipation, etc. [8].Although pain management through medication is the primary method of pain relief for patients, it may cause side effects for patients.Moreover, it is not an independent role of the nurse.Therefore, nursing care for pain management without drugs is an approach that can help reduce pain.It is a method that increases the effectiveness of drug use and reduces the use of analgesic drugs.Reduce the occurrence of complications from the side effects of pain relievers.From the literature review, it was found that non-pharmacological pain management is a complement to your doctor's treatment.It is the role of nurses independently to reduce pain, such as Music therapy [9][10], Aromatherapy [11], and foot reflexology [12].Currently, literature reviews and meta-analyses of non-medicated pain management interventions in people with pain have not been able to conclude the magnitude of the effect on non-medicated pain management, and promising interventions are best for those in pain.The researcher was therefore interested in a literature review and meta-analysis to obtain methodological characteristics and effect sizes to be used in developing an appropriate non-drug pain management program.Increase quality of life and promote the independent role of nurses more clearly.

Objective
The purpose including 1) To study a systematic literature review and analysis of research evidence related to the Effects of pain management without medication in people with pain, 2) To describe the characteristics of research related to pain management without medication among people with pain, 3) To analyze the influence of non-drug pain management methods among people with pain, and 4) To synthesize the knowledge from the study to develop a pain management program without using drugs for people with pain.In further research Research Questions 1) How effective are non-drug pain management methods for people with pain? and 2) What is the magnitude of the influence of non-drug pain management methods among people with pain?

Materials and Methods
This quantitative analysis uses a meta-analysis research method and calculates the influence size of Glass, McGaw, and Smith.This research aims to study non-pharmacological pain management among people with acute and chronic pain.The studies were only Randomized Controlled Trials (RCTs) published in Thai or English from 2013 to 2023.
The sample group is a research report on Randomized Controlled Trials (RCT) that studies pain management methods without drugs in people with pain.By specifying properties of the sample (Inclusion criteria) as follows: sample group in each research study, there is a group of patients with acute or chronic pain.The articles are in Thai or English.The sample subjects in the research articles must be over 18.There are 2 sample groups, and quantitative research methods are used.Research that is a randomized controlled trial (Randomized Controlled Trials: RCT) only.

Data collection procedures and methods
Searching for information sources Data were collected manually by searching electronic databases including Science Direct, Wiley Online Library, Scopus, PubMed (US Library of Medicine and National Institutes of Health), EBSCOhost, Thai-Journal Citation Index Center since 2013 to 2023, define keywords such as non-pharmacological pain management complementary alternative pain groups with pain.
The researcher selects research studies by reading assessment.Subsequently, trials that met the eligibility criteria were selected in the Cochrane review-RCTs only Summary of Data and Research Characteristics for analysis and grading the certainty of the evidence according to The Joanna Briggs Institute's criteria.

Data Analysis
Analysis of research characteristics using descriptive statistics Calculate the percentage of variable data.Characteristics of research studies on pain management by non-pharmacotherapy and content analysis Influence value analysis and risk of bias using the Review Manager 5.3 program.Comparison of pain scores between the two groups and between the two periods in the same group Determined by the difference in mean pain scores.(Standardized mean difference: SMD) is shown with the 95% Confidence Interval (95% CI).Meta-analysis of differences in pain score (pre and post treatment) used the 'metan' command in a random effect model when there were differences in the values of each study (Heterogeneity) where the I 2 ≥25% or the p value of Cochrane's (Q test) < 0.1 and use the 'metan' command in the constant influence model (fixed-effect model) when there are differences in the values of each research (Heterogeneity) at I 2 statistics < 25% or p value of Cochrane's (Q test) > 0.1.The subgroup analyzes were grouped by treatment methods, including Relaxation techniques, Music therapy, Pressure, Aromatherapy and Massage, and divided by type of pain are acute or chronic pain.
Music therapy; 5 studies [21,24,[26][27][28] studied in patients with 3 cases of acute pain [21,24,28] 2 cases of chronic pain [26][27] Music characteristics There are differences and similarities, including two research studies that asked samples to choose their favorite songs [24,28].The types of music are pop music, classical music, jazz music, spa music [28], light music, and relaxing music [24].Research that had the sample listen to music from a saxophone, including one subject of pop, classical, film scores, folk, and jazz [27] listening to local Turkish Sufi music, one story [21] and 1 study using music therapy using ocean drum and harp instruments [26].The time spent listening to music was 20-30 minutes.
Massage; 3 studies [14,23,25] 2 studies in patients with chronic pain [14,25] One case of acute pain [23] used Chinese massage techniques by massaging the lower back.Use for 40 minutes at a time, one time per day for eight weeks, one story [25], Swedish massage for the hands, 30 minutes for one story [14], and foot massage with oil.Sweet almond, 10 minutes at a time, for four weeks, one story [23].

Publication Bias
Unpublished data sources should have been searched.

Risk Bias
The investigator's percentage risk of bias estimates of the studies included in the meta-analysis are shown in Figures 2 and 3.
Most studies were at low risk of bias

Poor Result
The forest plot shows the meta-analysis, in which the author has selected only 18 Randomized Controlled Trials (RCTs).The results can be combined to get the highest quality work to use the results and develop further research.Results from 18 studies were analyzed from a total of 1,554 people in the research group, divided into an experimental group of 774 people who received non-pharmacology pain management and a control group of 780.As for the results, the author was able to compare the effect size and conclusion in 5 results, including music therapy, aromatherapy, relaxation techniques, Reflexology, and massage.

Music Therapy Techniques
Forest plot 1 The researcher has divided the influence of pain management using music therapy into five papers [21,24,[26][27][28] all studied in patients with acute pain and chronic pain with 499 participants.From evaluating the size of the differences, there was a significant heterogeneity.(χ 2 = 18.71,I2 = 79%, P = 0.0009).When combining the effect sizes between music therapy and the control group.It found a significant difference (SMD=-0.34,95% CI: -0.60, -0.09, P=0.008).

Aromatherapy Techniques
Pain management using Relaxation techniques, which evaluates pain results among persons with acute and chronic pain by comparing the influence of four RCTs [11,13 ,16,20], all studied in patients with acute pain and chronic pain with 295 participants.When comparing the effect sizes between the aromatherapy therapy and the control group, evaluating the size of the differences was a non-significant heterogeneity (χ 2 = 128.73,I2 =98%, P=0.93).It found that there was a significant difference (SMD=-3.49,95% CI: -4.23, -3.66, P<0.00001).

Relaxation Techniques
Forest plot 3: Pain management using Relaxation techniques, which evaluates pain results among persons with acute and chronic pain by comparing the influence of three RCTs [15,[17][18], all studied in patients with acute pain and chronic pain with 279 participants.When comparing the effect sizes between relaxation techniques therapy and the control group, evaluating the size of the differences was a non-significant heterogeneity (χ 2 = 0.16, I2 =0%, P=0.93).It found that there was a significant difference (SMD=-1.78,95% CI: -2.01, -1.54, P<0.00001).

Reflexology Techniques
Forest plot 4: Pain management using Reflexology, which evaluates pain results among persons with acute and chronic pain by comparing the influence of three RCTs [19,22,29] all studied in patients with acute pain and chronic pain with 264 participants.When comparing the effect sizes between the Reflexology therapy and the control group, evaluating the size of the differences was a significant heterogeneity (χ 2 =21.45,I2 =91%, P<0.0001).It found that there was a significant difference (SMD=-2.49,95% CI: -2.83, -2.15, P<0.00001)

Massage Techniques
Forest plot 5: Pain management using Massage 5, which evaluates pain results among persons with acute and chronic pain by comparing the influence of three RCTs [14,23,25], all studied in patients with acute pain and chronic pain with 217 participants.From evaluating the size of the differences, there was a significant heterogeneity (χ 2 =8.80,I2 =77%, P=0.01)When combining the effect sizes between the massage therapy and the control group.It found that there was a significant difference (SMD= -1.96, 95% CI: -2.32, -1.59, P=0.00001).

Discussion
From the literature review, it was found that Nonpharmacological pain management can help reduce pain.It is a method that increases the effectiveness of drug use and reduces the use of analgesic drugs.Reduce the occurrence of complications from the side effects of pain relievers.The report used in this literature review and meta-analysis were level 1 trials (Randomized Controlled Trials (RCTs)); 18 trials were from 7 countries, and no trials were conducted in Thailand.
From this study, it was found that There are many ways to manage pain without medication.Five methods include music therapy, aromatherapy, and relaxation techniques.Reflexology and massage, each of which helps in reducing pain.Modifying emotions and feelings causes enjoyment and concentration and affects the autonomic nervous system, stimulating the pituitary gland to release endorphins that have properties similar to morphine.Which has the effect of inhibiting the transmission of nerve impulses at the level of the spinal cord and Helps to relieve pain [30].This is from a study of pain management methods using music therapy.The music should be soothing, with a rhythm of 60-80 beats per minute to match the heart rate.Moreover, it would help to listen to music at least two times a day, 15-30 minutes each time.The music used to reduce pain should have a steady rhythm.Prevent squeaky sounds; soft music such as nature sounds, playful music, or the patient's preferred songs are recommended.
How to manage pain through aromatherapy or essential oil inhalation: Most scents used for pain relief are lavender.The time spent inhaling essential oils for only 2-5 minutes can help reduce pain.Pain management through relaxation techniques is a way to make the patient feel calm by various means, such as listening to sound from a voice recorder, focusing attention on the pulling of the muscles following the rhythm of breathing, etc. Reflexology is an alternative medical science that can help reduce pain.It is a natural way.It does not use any equipment or pose a risk to the patient.Reflexology promotes the normal flow of energy.Help adjust the functioning of various organs.To work normally, promote blood circulation, reduce tension, reduce pain, and feel relaxed, creating balance for the body.[31] Popular locations for Reflexology include the ears, palms, and soles of the feet.Reflexology helps patients feel comfortable and relaxed [32], and massage.There are many massage techniques, such as Chinese massage, Swedish massage, foot massage with oil, etc.

Figure 1 :
Figure 1: Flow diagram of study selection.

Figures 2 :
Figures 2: Risk of bias graph: review authors' judgments about each risk of bias item presented as percentages across all included studies.

Figures 3 :
Figures 3: Risk of bias summary: review authors' judgments about each risk of bias item for each included study.

Table 1 :
The characteristics of systemic review in 18 studies.