Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Management of Pain: Non-Pharmacological Management

Heat & Cold

Heat and cold have been used for centuries as a treatment for pain. There are at least four reasons why a nurse should advocate for a trial of heat or cold:

  • it works well for some patients.
  • it works quickly.
  • adverse effects are virtually non-existent.
  • it can provide some patients/families with an important sense of control over the relief of pain.

Rationale for treatment: Well-controlled research is lacking, however the premise is that applying heat to skin will increase blood flow and reduce neurotransmitters, which sensitize pain nerve fibres. Heat may compete for nerve transmission with pain and therefore, in the brain there is a perception of heat and a reduced perception of pain.

Cold works through a similar pathway as heat, competing for nerve transmission. It creates numbness in the area of pain and may be especially helpful when the pain has a burning quality.

Nursing Role: Assess for prior use of heat or cold. Remember that some patients may think that you are “trivializing” their pain. You need to be able to describe the scientific rationale to encourage patients with even severe pain on large doses of medication to try heat or cold as an adjunct to their pain management. Heat and cold can be used in children older than six months of age.

Contraindications: Avoid use of heat in following situations:

  • any area that is bleeding.
  • any area with decreased feeling.
  • any injury within the first 24 hours.
  • if the person is using any menthol-containing products (Vicks, Ben Gay etc.).
  • within a site of radiation therapy while receiving radiation - may use on this area five days after completing treatment, provided that the skin is not flaky, red or tender.

Avoid use of cold in the following situations:

  • any area with poor circulation (diabetic feet).
  • within a site of radiation therapy while receiving radiation – may use on this area five days after completing treatment, provided that the skin is not flaky, red or tender.
  • on a wound in the healing phase.

Application of Heat or Cold:

  • Heat can be obtained from a variety of sources including heating pad, hot water bottle, topical ointment.
  • Use low to medium setting to avoid burns.
  • Placement is usually over painful site. When this is not possible (too painful, open wound) other options include:
    • above the site.
    • below the site.
    • prevent direct contact with heat/cold source on the skin.
    • on the opposite side of the body (e.g. pain on right hip, place on left hip).
      Adapted from: Ferrell, B. & Rhiner, M. (1993).Managing cancer pain at home. Duarte, CA: City of Hope National Medical Centre.
  • Prevent direct contact with heat/cold source on the skin.
  • Heating pad placed on a child should be monitored every five minutes and the child should not be left unattended.
  • Cold can be enhanced by using it in conjunction with menthol-containing products (eg. A535® with ice bag over top).
  • When using a topical ointment, test the skin with a small amount of product to check for allergic reaction prior to using it on the painful site.

Relaxation & Imagery

Relaxation may be appropriate for almost any type of pain with a goal of reducing muscle tension and anxiety. It may also be used in children of 7 years and older. Patients who are already tense and in pain may benefit from simple relaxation centred on slow, deep breathing. Progressive muscle relaxation in which the patient uses isometric exercise to systematically relax muscles from head to foot may also be helpful.
Lengthy relaxation techniques are enhanced by a quiet environment and having the patient in a comfortable, well supported position. Listening to a taped relaxation session may help the patient to focus more easily, and become less distracted by their pain.
Children over 5 years old can usually participate in guided imagery. Imagination is spontaneous and natural for children. They are able to focus easily, thus taking their attention away from their pain. However, caution should be used in using relaxation and imagery techniques in patients who are either:

  • confused.
  • drowsy.
  • have a poor grasp of the language of the relaxation therapist.
  • have a previous history of significant psychiatric history, such as having hallucinations.


Distraction is another pain reducing technique used in children. The idea is to divert the child’s attention by actively involving him in the performance of a distracting task that is interesting and more pleasant than the painful procedure. He can choose anything of interest such as blowing bubbles, a special book, a musical toy, a magical wand (Kleiber et al., 1999).

Other Therapies

Recognize that complementary therapies such as therapeutic touch, massage, reflexology,

Reiki and aromatherapy may be useful non-pharmacological adjuncts to pain management. These modalities should be administered by individuals with training in their application.


Used with the permission of the Canadian Association of Nurses in Oncology.