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. 2025 Apr 15:6:1447075.
doi: 10.3389/fpain.2025.1447075. eCollection 2025.

Assessment of non-pharmacological nursing strategies for pain management in tumor patients: a systematic review and meta-analysis

Shen Yan  1 , Feng Yan  1 , Pei Liangyu  1 , Xu Fei  1
Affiliations

Assessment of non-pharmacological nursing strategies for pain management in tumor patients: a systematic review and meta-analysis

Shen Yan et al. Front Pain Res (Lausanne). .

Abstract

Summary background: Cancer is a multifactorial disease associated with intense pain and fatigue. Pain is the main discomfort experienced during cancer treatment, particularly as a major side effect of chemotherapy.

Objective: This study has aimed to investigate the effectiveness of non-pharmacological nursing strategies, including reflexology, aromatherapy, acupressure, massage therapy and acupuncture, in the management of cancer-associated pain. Moreover, it provides evidence-based recommendations for integrating these interventions into standard pain management protocols.

Search methodology: We gathered data from three major online databases; PubMed, the Cochrane Library and Embase. For the analysis, we exclusively targeted randomized controlled trials (RCTs) assessing the effectiveness of non-pharmacological interventions in managing cancer-related pain. No language restrictions were applied, and pain was considered the primary outcome measure.

Results: Seventeen RCTs (n = 1,070) were included in this meta-analysis from 166 eligible studies. The pooled effect size demonstrated that all evaluated non-pharmacological nursing strategies, including aromatherapy, massage, reflexology, acupressure and acupuncture significantly reduced cancer-related pain compared to usual care (p < 0.001). Moreover, the reflexology and massage showed negligible heterogeneity among other interventions.

Conclusion: This meta-analysis found the significant effectiveness of non-pharmacological nursing strategies, particularly reflexology and massage in reducing cancer-related pain. The findings support their integration into clinical practice, providing evidence-based recommendations for enhancing standard pain management protocols.

Keywords: acupressure; acupuncture; aromatherapy; cancer-related pain; massage; reflexology.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as potential conflicts of interest.

Figures

PRISMA flow diagram outlining the study selection process for a meta-analysis. From 788 records identified across three databases, 113 duplicates were removed. After screening 675 records, 29 were excluded based on abstract review and 480 more during retrieval. Of 166 full-text articles assessed, 149 were excluded due to duplicate data, small sample size, multifactor data, or irrelevant outcomes. Seventeen studies were included in the final quantitative synthesis.
Figure 1
PRISMA flow diagram illustrating the study selection process, including the identification, screening, eligibility assessment and final inclusion of studies for meta-analysis.
Forest plot comparing mean differences in outcomes between reflexology and control groups across four studies. All studies show negative mean differences, favoring reflexology, with a pooled mean difference of −0.63 (95% CI: −0.71 to −0.54). Kim et al. 2008 contributes the highest weight at 63.8%. Heterogeneity is low (I2 = 0%), indicating consistent results across studies. The overall effect is statistically significant (Z = 14.63, P < 0.00001).
Figure 2
Risk of bias assessment for the included studies. The assessment was conducted using the Cochrane Risk of Bias Tool. Green circles (+) indicate a low risk of bias, yellow circles (?) represent an unclear risk of bias and red circles (−) denote a high risk of bias. This visual representation of outcomes provides an overview of the methodological quality and potential limitations of the studies included in the analysis.
Forest plot comparing massage versus control across seven studies on a continuous outcome. Green squares represent individual study effect sizes with 95% confidence intervals. The pooled mean difference is −0.88 with a 95% confidence interval of −1.31 to −0.45, indicating a significant effect favoring massage. Study weights vary, with the largest contribution from Chang et al. 2008. Heterogeneity is high, with I2 at 85 percent. The diamond represents the overall effect size, positioned left of zero on the x-axis, supporting the conclusion that massage is more effective than control.
Figure 3
Forest plot showing the effect of aromatherapy on pain reduction compared to the control group. The X-axis represents the mean difference with a 95% confidence interval (CI), where negative values favor aromatherapy. Each study’s effect size is depicted as a green square, with the size proportional to its weight in the meta-analysis. The black diamond represents the overall pooled estimate. moderate heterogeneity (I2 = 42%) suggests variability in study design, sample sizes or intervention protocols. The overall effect (p < 0.00001) indicates a statistically significant benefit of aromatherapy.
Forest plot showing the comparison of acupressure versus control across three studies, with individual mean differences and 95% confidence intervals depicted as green squares. The pooled mean difference is −1.06 with a 95% confidence interval of −1.28 to −0.85, indicating a statistically significant benefit of acupressure. The largest weight is assigned to Yeh et al. 2015. Moderate heterogeneity is indicated by an I2 value of 67 percent. The overall effect, represented by a black diamond, lies entirely on the left of the null line, favoring acupressure.
Figure 4
Forest plot showing the effect of massage on pain reduction compared to the control group. The X-axis represents the mean difference with a 95% confidence interval (CI), where negative values favor massage. Each study’s effect size is depicted as a green square, with the size proportional to its weight in the meta-analysis. The black diamond represents the overall pooled estimate. Low heterogeneity (I2 = 0%) suggests consistency across studies. The overall effect (p < 0.00001) indicates a statistically significant benefit of massage.
Forest plot comparing aromatherapy versus control across four studies, with green squares representing individual study mean differences and 95% confidence intervals. The pooled mean difference is −0.67 with a 95% confidence interval of −0.98 to −0.36, indicating a statistically significant effect favoring aromatherapy. Chang et al. 2008 contributes the largest weight. Moderate heterogeneity is present with I2 at 42 percent. The overall effect, shown by a black diamond, lies to the left of the null line, supporting the efficacy of aromatherapy.
Figure 5
Forest plot showing the effect of reflexology on pain reduction compared to the control group. The X-axis represents the mean difference with a 95% confidence interval (CI), where negative values favor reflexology. Each study’s effect size is depicted as a green square, with the size proportional to its weight in the meta-analysis. The black diamond represents the overall pooled estimate. Low heterogeneity (I2 = 0%) suggests consistency across studies. The overall effect (p < 0.00001) indicates a statistically significant benefit of reflexology in pain alleviation.
Forest plot illustrating the effect of acupuncture versus control across three studies, with individual mean differences and 95% confidence intervals represented by green squares. The pooled mean difference is −2.09 with a 95% confidence interval of −2.92 to −1.26, indicating a significant benefit of acupuncture. Bao et al. 2013 contributes the greatest weight. High heterogeneity is indicated by an I2 value of 88 percent. The overall effect, shown as a black diamond, is positioned left of the null line, favoring acupuncture.
Figure 6
Forest plot showing the effect of acupressure on pain alleviation compared to the control group. The X-axis represents the mean difference with a 95% confidence interval (CI), where negative values favor acupressure. Each study’s effect size is shown as a green square, with the black diamond representing the overall pooled estimate. High heterogeneity (I2 = 67%) suggests variability in study design, sample sizes or intervention protocols. The overall effect (p < 0.00001) indicates a statistically significant benefit of acupressure.
Risk of bias summary table showing methodological quality assessments for eighteen studies across nine bias domains. Each cell contains a color-coded symbol indicating risk: green plus for low risk, yellow question mark for unclear risk, and red minus for high risk. Most studies show a mix of low and unclear risk across domains, with high risk appearing most frequently in allocation concealment and blinding-related categories. Yeh et al. 2015 and Bao et al. 2013 display multiple high-risk assessments, while Jane et al. 2011 and Kim et al. 2008 show consistently low risk across all domains.
Figure 7
Forest plot showing the effect of acupuncture on pain alleviation compared to the control group. The X-axis represents the mean difference with a 95% confidence interval (CI), where negative values favor acupuncture. Each study’s effect size is shown as a green square, with the black diamond representing the overall pooled estimate. High heterogeneity (I2 = 88%) suggests variability in study design, sample sizes or intervention protocols. The overall effect (p < 0.00001) indicates a statistically significant benefit of acupuncture.
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