Effect of perceived injustice-targeted pain neuroscience education compared with biomedically focused education in breast cancer survivors: a study protocol for a multicentre randomised controlled trial (BCS-PI trial).

INTRODUCTION: Current treatments for pain in breast cancer survivors (BCSs) are mostly biomedically focused rather than biopsychosocially driven. However, 22% of BCSs with pain are experiencing perceived injustice, which is a known predictor for adverse pain outcomes and opioid prescription due to increased maladaptive pain behaviour. Educational interventions such as pain neuroscience education (PNE) are suggested to target perceived injustice. In addition, motivational interviewing can be an effective behavioural change technique. This trial aims to examine whether perceived injustice-targeted PNE with the integration of motivational interviewing is superior to biomedically focused pain education in reducing pain after 12 months in BCS with perceived injustice and pain. In addition, improvements in quality of life, perceived injustice and opioid use are evaluated, and a cost-effectiveness analysis will finally result in a recommendation concerning the use of perceived injustice-targeted PNE in BCSs with perceived injustice and pain. METHODS AND ANALYSIS: This two-arm multicentre randomised controlled trial will recruit female BCS (n=156) with pain and perceived injustice. Participants will be randomly assigned to perceived injustice-targeted PNE or biomedically focused pain education in each centre. Both interventions include an online session, an information leaflet and three one-to-one sessions. The primary outcome (pain), secondary outcomes (quality of life, perceived injustice and outcomes for cost-effectiveness analysis) and explanatory outcomes (pain phenotyping, sleep, fatigue and cognitive-emotional factors) will be assessed at baseline and at 0, 6, 12 and 24 months postintervention using self-reported questionnaires online. Treatment effects over time will be evaluated using linear mixed model analyses. Additionally, a cost-utility analysis will be done from a healthcare payer and societal perspective. ETHICS AND DISSEMINATION: The ethical agreement was obtained from the Main Ethics Committee (B.U.N.1432020000068) at the University Hospital Brussels and all other participating hospitals. Study results will be disseminated through presentations, conferences, social media, press and journals. TRIAL REGISTRATION NUMBER: NCT04730154.

Perceived Injustice in Cancer Survivors: Population-Specific Cut-Off Score and Relations with Personal Factors, Symptoms and Quality of Life-A Cross-Sectional Study.

Fatigue and pain are the most common side effects impacting quality of life (QoL) in cancer survivors. Recent insights have shown that perceived injustice (PI) can play a substantial role in these side effects, but research on cancer survivors is scarce. Furthermore, guidelines for recognizing clinically relevant levels of PI in cancer survivors are missing. The aims of this study are to provide a clinically relevant cut-off for PI and to explore relationships between personal characteristics, symptoms, and QoL with PI. This multicenter, cross-sectional study uses the Injustice Experience Questionnaire (IEQ), Numeric Pain Rating Scale (NPRS), Patient-Specific Complaints (PSC), Multidimensional Fatigue Index (MFI), and European Organization for Research and Treatment of Cancer QoL Questionnaire-C30 (EORTC-QLQ-C30). A clinical cut-off for PI was identified based on the 75th percentile of IEQ scores. Univariate and multivariate regressions explored the relationship between PI and personal characteristics (sex, age, cancer type, treatment type), symptoms (pain intensity, fatigue), and QoL (daily activity complaints, cancer-related QoL). Cancer survivors (n = 121) were included, and a cut-off of 20 was identified. Significant indirect associations were found between chemotherapy, NPRS, PSC, MFI, and EORTC-QLQ-C30 with PI. In the multivariate model, only MFI (B = 0.205; 95% CI: 0.125-0.018) and age (B = 0.086; 95% CI: -0.191-0.285) maintained a significant association with PI.

The Prevalence of Perceived Injustice and Factors Associated With Perceived Injustice in People With Pain: A Systematic Review With Meta-analysis.

BACKGROUND: Perceived injustice (PI) is a multidimensional appraisal cognition comprising the severity of loss consequent to injury, blame, a sense of unfairness, and/or irreparability of loss. PI gained increasing interest in pain research since it potentially contributes to the experience and burden of (chronic) pain. OBJECTIVES: This systematic review aimed to determine the prevalence of PI and factors associated with PI in people with pain. STUDY DESIGN: Systematic review with meta-analysis. METHODS: Web of Science, PubMed, and Embase were screened for cross-sectional or cohort studies encompassing human patients who were diagnosed with a condition causing pain and reported prevalence rates for PI and/or associations between a factor and PI. Meta-analyses were carried out, and subgroup analyses were undertaken based on the methodological quality of the studies, the type of pain population, and whether the outcome measure was valid or not in case of heterogeneity (P < 0.05). RESULTS: Fifty-four studies were found eligible. The prevalence of PI ranged from 23% to 77% (I2 = 99%, P < 0.001). Association with PI, assessed using the Injustice Experienced Questionnaire, were found with pain catastrophizing (pooled Pearson's r [rp] = 0.66 [0.64, 0.69], P < 0.00001), posttraumatic stress (rp = 0.63 [0.59, 0.67], P < 0.00001), anger (rp = 0.59 [0.49, 0.67], P < 0.00001), anxiety (rp = 0.59 [0.52, 0.64], P < 0.00001), pain acceptance (rp = -0.59 [-0.66, -0.49], P < 0.00001), depressive symptoms (rp = 0.57 [0.52, 0.60], P < 0.00001), kinesiophobia (rp = 0.57 [0.50, 0.64], P < 0.00001), academic functioning (rp = -0.54 [-0.65, -0.41], P < 0.00001), disability (rp = 0.53 [0.47, 0.59], P < 0.00001), emotional functioning (rp = -0.52 [-0.64, -0.39], P < 0.00001), pain interference (rp = 0.49 [0.35, 0.60], P < 0.00001), state anger (rp = 0.48 [0.41, 0.54], P < 0.00001), mental functioning (rp = -0.48 [-0.57, -0.38], P < 0.00001), symptoms of central sensitization (rp = 0.47 [0.39, 0.55], P < 0.00001), social functioning (rp = -0.47 [-0.60, -0.31], P < 0.00001), and physical functioning (rp = -0.43 [-0.53, -0.33], P < 0.00001), pain perceptions (rp = 0.40 [0.40, 0.64], P < 0.00001), trait anger (rp = 0.40 [0.29, 0.49], P < 0.00001), pain intensity (rp = 0.37 [0.33, 0.42], P < 0.00001), and anger inhibition (rp = 0.35 [0.26, 0.43], P < 0.00001). LIMITATIONS: Some articles had to be excluded due to the absence of a full-text version. The findings can largely be applied to developed and high-income countries, but further research is needed in developing countries. Also, no validated cutoff values were available for the National Institutes of Health to determine the methodological quality of the included studies. Lastly, high heterogeneity was observed in many of the performed analyses. However, this was addressed by performing subgroup analyses, which could decrease heterogeneity in some cases. CONCLUSIONS: The prevalence of PI was >= 33% in 75% of the studies indicating that PI is important to consider in people with pain. There is evidence for the association of PI with psychological, pain, and quality of life characteristics in people with pain. The associations of PI with personal, injury, and recovery characteristics were overall not significant or negligible.

Effectiveness of a Primary Care Multidisciplinary Treatment for Patients with Chronic Pain Compared with Treatment as Usual.

To manage chronic pain, multidisciplinary interventions have been increasingly deployed, mostly in secondary or tertiary care settings. Evidence on the effectiveness of multidisciplinary intervention within primary care is scarce. This study examined the effectiveness of a primary care multidisciplinary treatment for chronic pain compared with treatment as usual (TAU). The intervention consisted of pain neuroscience education and treatment by a GP, psychologist, and physiotherapist. Both groups filled out patient-reported outcome measures at baseline, 6 months, and 12 months. The results indicated there were no statistically significant differences for the primary outcomes of pain intensity, number of pain sites, and health-related quality of life (HR-QoL). There was a statistically significant difference in the secondary outcome perceived health change in favor of the intervention group. None of the other differences were statistically significant. A post-hoc analysis showed that there were statistically significant effects on patients' illness perceptions in favor of the intervention group. Based on the results, the findings do not support effectiveness of a low intensity outpatient multidisciplinary primary care treatment to treat chronic pain compared with TAU. However, as a result of several study limitations, it is considered unwarranted to conclude that multidisciplinary treatment in primary care is not valuable at all.

Pain and Opioid Use in Cancer Survivors: A Practical Guide to Account for Perceived Injustice.

BACKGROUND: The presence of pain decreases survival rates in cancer. Pain management in clinical settings is often suboptimal and secondary to other cancer-related treatments, leaving many people undertreated. Opioid use is associated with side effects and decreased survival rate in cancer patients. Hence, there is an urgent need for considering factors such as perceived injustice that sustain post-cancer pain and trigger a behavioral pattern associated with opioid use. Injustice beliefs represent a maladaptive pattern of cognitive appraisal that may be a salient target for improving pain-related coping in these patients. Perceived injustice is associated with increased opioid prescription and prospectively predicted opioid use at 1-year follow-up, urging the need for targeted interventions to diminish perceived injustice. OBJECTIVES: Explain the importance of screening for perceived injustice in patients with pain following cancer treatment, its potential relevance for opioid abuse, and its potential impact on the management of pain following cancer. Also, prove clinicians with a clinical guide for an approach comprising of modified pain neuroscience education, motivational interviewing, and acceptance-based interventions to account for perceived injustice in patients having pain following cancer. STUDY DESIGN: A narrative review, perspective and treatment manual. SETTING: Several universities, a university of applied science department, a university hospital, and a private clinic (i.e., transdisciplinary pain treatment center). METHODS: Patients were cancer survivors with pain. Intervention included modified pain neuroscience education, motivational interviewing, and acceptance-based interventions. Measurements were taken through the Injustice Experience Questionnaire (IEQ). RESULTS: The IEQ can be used to assess perceived injustice in a valid way. Education about pain, including discussing perceived injustice, should be the first part of the management of pain in cancer survivors. In order to obtain the often-required behavioral change towards a more adaptive lifestyle, motivational interviewing can be used. To thoroughly tackle perceived injustice in patients having pain following cancer, special emphasis should be given to the individual reasons patients identify for experiencing (continued) pain and related symptoms. Pain acceptance should also be thoroughly addressed. LIMITATIONS: Clinical trials exploring the benefits, including cost-effectiveness, of such a multimodal approach in patients with pain following cancer treatment are needed. CONCLUSIONS: In light of its potential relevance for opioid abuse and potential impact on conservative management strategies, clinicians are advised to screen for perceived injustice in patients with pain following cancer treatment. Therapeutic targeting of perceived injustice can be done through an approach comprising of modified pain neuroscience education, motivational interviewing, and acceptance-based interventions.

The mediating effect of pain catastrophizing and perceived injustice in the relationship of pain on health-related quality of life in breast cancer survivors.

BACKGROUND: The importance of cognitive appraisals in the effectiveness of pain coping is well established. Two key variables in these appraisal processes are pain catastrophizing (PC) and perceived injustice (PI), which are known to increase the risk of long-term disability and aggravate the pain-related distress through maladaptive behavioral responses. However, to date, the mediating effects of these appraisals have not been examined concurrently in the breast cancer survivor (BCS) population, nor have they been related to health-related quality of life (HRQoL). METHODS: Using cross-sectional data from 110 BCS, structural path analyses were used to examine the mediating effects of PC and PI in the relationship of pain on the HRQoL in BCS. RESULTS: Results demonstrated a significant direct effect of pain and PI on HRQoL combined with a significant indirect effect through PI, but not through PC. An increase in pain is suggested to result in a decrease in quality of life. On the other hand, an increase in pain also is suggested to increase the PI. A similar relation with PC was not retained as significant. CONCLUSION: The relative salience of PI as a mediator of HRQoL underscores the fact that PI is not only understudied but also underappreciated and undertreated in the BCS population. The results of our study warrant replication across longitudinal studies but continue to expand upon the evidence of the multifactorial nature of pain coping in BCS.

The moderating effects of pain catastrophizing on the relationship between illness perceptions and self-reported signs of central sensitization in patients with persistent pain.

Two factors related to the continuation of persistent pain are pain catastrophizing and illness perceptions. Pain neuroscience education is known to positively influence both in patients with persistent pain. As the integration of pain neuroscience education in monodisciplinary physiotherapy treatments is effective, integration in transdisciplinary cognitive-behavioral treatments seems recommendable. When doing so, the moderating effect of pain catastrophizing and perceptions on treatment results have to be examined, as these provide valuable information under which conditions treatment works. A bottom-up retrospective observational study evaluated the changes in clinical outcomes, and relationships between clinical outcomes and cognitive and emotional factors in patients with persistent pain. Multiple regression analysis, PROCESS macro, explored the moderating effects of pain catastrophizing on the relationship between illness perceptions and self-reported symptoms of central sensitization. In total, 78 patients were included in the study. A correlation between pretreatment scores and change scores in illness perceptions and self-reported symptoms of central sensitization following treatment were found (resp. R-sq 0.407, F(10,99) = 0.638, P = 0.000; R-sq 0.361, F(5, 54) = 0.609, P = 0.000; and R-sq 0.314, F(4,55) = 0.560, P = 0.00), however, moderation of pain catastrophizing scores on these correlations was not found. Even though an association between changes in pain catastrophizing and illness perceptions in patients with persistent pain was found, the direction or strength between the changes in illness perceptions and changes in self-reported symptoms of central sensitization was not influenced by pretreatment scores of pain catastrophizing.