Prevention and Rehabilitation
Pain Neuroscience Education in cancer survivors with persistent pain: A pilot study

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Abstract

Purpose

To describe the Pilot Study: Pain Neuroscience Education in Cancer Survivors and describe the innovative educational component of Pain Neuroscience Education (PNE).

Design

Quasi experimental design.

Method

The PNE program, encompassing a one-on-one education session and an information leaflet was given to 30 cancer survivors. At baseline and two weeks after the PNE, participants were asked to fill out following outcome measures; pain intensity, pain catastrophizing, and HRQoL.

Findings

Following PNE, a significant decrease on pain intensity (p = 0.001), on the SF-36 subscale pain (p = 0.003) and for the following PCS subscales: Helplessness (p < 0.001), Rumination (p = 0.002) and Total score (p < 0.001) was found compared to baseline.

Conclusions

Although the current results need to be verified in a larger randomized, controlled trial, preliminary evidence shows a decrease in pain intensity and pain catastrophizing following PNE in cancer survivors with persistent pain.

Introduction

Cancer is a health problem worldwide. The Union for International Cancer Control (GLOBOCAN) estimates 18.1 million people were diagnosed with cancer in 2018 and this incidence rate is expected to increase to 21.4 million new cancer patients by 2030 (Ferlay et al., 2010, 2019). Fortunately, more people survive cancer due to new developments in cancer diagnosis and treatment (De Angelis et al., 2014). Despite the probability of surviving cancer, many cancer survivors are confronted with unfavorable disease- and treatment-related side-effects; which can result in prolonged pain (Cleeland et al., 2012; Glare et al., 2014; Harrington et al., 2010). For example, some breast cancer treatment-related effects are; adhesive capsulitis, cervical radiculopathy, radiation fibrosis and lymphedema (Cleeland et al., 2012).

Approximately 36% of breast cancer survivors experience pain symptoms following his/her cancer treatment, which may last for several months, years, or even a lifetime (Leysen et al., 2019; Leysen et al., 2018). Persistent (i.e. chronic) pain, defined as the presence of pain for at least 3 months (Merskey and Bogduk, 1994), influences the cancer survivors’ Health-Related Quality of Life (HRQoL) and exposes them to an increased risk for depression and anxiety (Bredal et al., 2014). Furthermore, a considerable number of cancer patients indicate that they do not have enough knowledge regarding pain during or after cancer treatments, what the possibilities of pain relief are; and how to access help when needed (Binkley et al., 2012; McGuire, 2004). Cancer survivors suffering from persistent pain, should be treated as fast as possible and in the most optimal way.

Currently, pain management in cancer survivors includes a multidisciplinary approach consisting of an individually tailored combination of medication, physical therapy and psychosocial interventions (Glare et al., 2014; Levy et al., 2008; Syrjala et al., 2014). In most cases, patient education is embedded within one of the aforementioned interventions (Lovell et al., 2014). Evidence exists that pain education improves the knowledge of pain and reduces pain intensity in cancer patients (Adam et al., 2015). However, these educational interventions are directed towards cancer patients suffering from pain during the treatment phase rather than the post-treatment phase (Bennett et al., 2009). Consequently, the content of these educational interventions is restricted to more biomedical pain management instructions, including tips on analgesic usage, enhancing pain assessment and tackling barriers to analgesic non-adherence (Bennett et al., 2009). Therefore, the educational content of these programs might be less relevant for cancer survivors with persistent pain.

During and after their cancer treatment, the cancer patient is faced with many challenges: (a) a new body image; (b) self-image; and (c) waiting on additional diagnostic findings (Hungr et al., 2017). The additional burden of persistent pain is an extra stressor to cope with and makes it more difficult for the patient to resume their daily life activities (Kudel et al., 2007; Sun et al., 2017). Therefore, breast cancer survivors might benefit from a more biopsychosocial explanation of pain (Malfliet et al., 2017). The misunderstanding of pain holds several consequences for the cancer survivor itself; they consider pain to be more threatening, they present with lower pain tolerance, and they have more catastrophic thoughts and less adaptive coping strategies which might result in worse treatment outcomes (Malfliet et al., 2017). The goal of the innovative project, Pain Neuroscience Education, is to provide information regarding the biological and physiological aspects of pain, and to discuss myths and negative views of pain. During the one-on-one session, various neurophysiological pain concepts are explained to the patient by using pictures and metaphors. More specifically, the PNE session provided information about the central and peripheral nervous system; the changes that occur in the case of chronic pain; and the influence of stress and emotions on pain perception (Nijs et al., 2018).

Firm evidence exists for the effectiveness of PNE in decreasing pain intensity, pain catastrophizing and increasing HRQoL in several non-cancer populations with chronic pain, such as musculoskeletal pain, osteoarthritis and chronic whiplash associated disorders (Louw et al., 2016, Louw et al., 2016b; Meeus et al., 2010; Van Oosterwijck et al., 2011). A systematic review investigating different kinds of pain educational interventions in adults with chronic pain, concluded that a PNE approach significantly improves pain catastrophizing and knowledge of pain (Geneen et al., 2015). Thus, the content of the pain education interventions is of great importance, with most benefits when the content is adjusted to the specific pain population (chronic neck -and low back pain, post-cancer pain,…)(Louw et al., 2016, Louw et al., 2016b; Malfliet et al., 2017).

To date, it is still unknown whether PNE is beneficial in cancer survivors with persistent pain after finishing active cancer treatment. The purpose of this paper is to describe the Pilot Study: Pain Neuroscience Education in Cancer Survivors and describe the innovative educational component of Pain Neuroscience Education (PNE). The innovative educational component/project consists of two components, a one-on-one education session and an educational leaflet.

Section snippets

Cancer survivors

Cancer survivors who met following eligibility criteria were selected; (1) 18 years or older; (2) self-reported chronic pain, defined as the experience of pain for a period of at least 3 months; (3) last session of their primary cancer treatment (surgery, radiotherapy, chemotherapy and immunotherapy) at least three months ago. In addition, the cancer survivors had to be able to understand, read, and speak the Dutch language. Cancer survivors who reported pain before cancer diagnosis and/or

Cancer survivors

A total of 30 cancer survivors participated in the study with a mean age of 62.97 years (±13.62 SD). Twenty-four women (n = 24) and six men (n = 6) were included. Seven different cancer types were included, with breast cancer being the most prevalent cancer type (n = 19; 63%). Other cancer types were prostate cancer (n = 3), colorectal cancer (n = 2), brain tumor (n = 2), stomach cancer (n = 2), cervical cancer (n = 1), and neck cancer (n = 1). Twenty-three women (n = 23) and six men (n = 6)

Discussion

To our knowledge, this is the first study exploring the use of a PNE program in cancer survivors with persistent pain. After one PNE session, positive effects were found on pain catastrophizing and pain intensity.

The benefit of PNE for cancer survivors with persistent pain is similar with previous findings in research with non-cancer chronic pain populations (Louw et al., 2016, Louw et al., 2016b; Meeus et al., 2010). Analogous to the non-cancer chronic pain population, pain catastrophizing in

Conclusion

Educating the cancer survivor about the neurophysiology of pain provides the cancer survivor with information about the various concepts about pain. Information about the persistence of pain, despite being told the cancer is gone, decreases the patients’ rumination about painful sensations. In addition, when patients apply the PNE knowledge and develop new insights about pain in their daily life, their perceived inability to control pain (helplessness) improves. Although the current results

CRediT authorship contribution statement

Roselien Pas: Conceptualization, Writing - original draft, Formal analysis. Laurence Leysen: Data curation, Writing - review & editing. Wanda De Goeij: Investigation. Leonieke Vossebeld: Investigation. Paul Van Wilgen: Methodology, Writing - review & editing. An De Groef: Methodology, Writing - review & editing. Margot De Kooning: Supervision, Writing - review & editing, Formal analysis, Visualization.

Declaration of competing interest

The authors have no conflicts of interest to declare.

Acknowledgements

This work was supported by a Chair funded by the Berekuyl Academy/European College for Decongestive Lymphatic Therapy, the Netherlands and awarded to the Vrije Universiteit Brussel, Belgium.

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