Investigation of the Efficiency of Pain Neuroscience Education in Patients With Chronic Pain After Breast Cancer Surgery

Study Overview
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Brief Summary
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Breast cancer is the most common type of cancer among women worldwide. Various side effects are seen after the treatments (surgery, chemotherapy, radiotherapy, etc.). Fatigue and pain are the most common and persistent side effects of breast cancer treatments. Pain management in patients currently undergoing breast cancer surgery: It consists of medical treatment, physiotherapy program and psychosocial practices. Psychosocial practices include educational interventions. The most widely used is Biomedical Education. Biomedical Education explains pain to the patient from a biological point of view and may be insufficient in curing and preventing chronic pain. The increase in the knowledge of pain physiology has revealed the modern neuroscience-based Pain Neuroscience Education. Pain Neuroscience Education explains the neurophysiology of pain and the ability of the nervous system to modulate the experience of pain. When we look at the literature, it has been seen that the lack of studies in which my Pain Neuroscience Education was applied in chronic pain after breast cancer surgery and the results of existing studies were contradictory. The aim of this study to compare the effects of Pain Neuroscience Education applied together with a standard physiotherapy program on pain, somatode function, psychological function and quality of life in patients with chronic pain after breast cancer surgery in a randomized desing. The hypotheses of this study are as follows; H1(1): The effect of Pain Neuroscience Education and Biomedical Education applied in addition to standard physiotherapy on pain-related outcomes (pain severity and disability) is different in patients with chronic pain after breast cancer surgery. H1(2): The effect of Pain Neuroscience Education and Biomedical Education applied in addition to standard physiotherapy on somatosensory function (pressure pain threshold and mechanical perception threshold) is different in patients with chronic pain after breast cancer surgery. H1(3) : The effect of Pain Neuroscience Education and Biomedical Education applied in addition to standard physiotherapy on psychological state (psychological symptoms (stress, anxiety and depression), pain-related catastrophe) in patients with chronic pain after breast cancer surgery is different. H1(4) : Pain Neuroscience Education and Biomedical Education applied in addition to standard physiotherapy have different effects on quality of life in patients with chronic pain after breast cancer surgery. The patients were over the age of 18, diagnosed with breast cancer, had at least three months after primary cancer treatments (surgery, chemotherapy, radiotherapy), had pain in the upper extremity and shoulder region for more than three months, and were evaluated on the Visual Analogue Scale in terms of pain intensity in the last week. Patients who indicate at least 40 points out of 100 (VAS) will be included. The Mini Mental Test will be applied to individuals over 65 years of age in terms of cooperation suitability and those with a score of 24 and above will be included in the study. Cases who met the inclusion criteria and accepted to participate in the study will be randomly assigned to 2 separate groups according to the online computer-based block randomization list. Pain Neuroscience Education and standard physiotherapy program (soft tissue mobilization + exercise) will be applied to the individuals in the 1st group, and Biomedical Education and standard physiotherapy program (soft tissue mobilization + exercise) will be applied to the individuals in the 2nd group. The working period is 6 weeks. Individuals in the 1st group will receive 4 sessions of Pain Neuroscience Training, and 4 sessions of Biomedical Pain Training will be applied to the individuals in the 2nd group. Standard physiotherapy will be applied to the cases in both groups for 6 weeks, 2 sessions per week. In the first session of the treatment, individuals in both groups will be informed about the treatment process. Individuals will be evaluated in terms of research and outcome measurements twice, at the beginning of the study and at the end of the 6th week, in line with the control frequencies used routinely in the clinic. The assessment will take approximately 45 minutes for each individual. At the beginning of the study, demographic and physical characteristics of individuals, medical and surgical background (cancer history, treatments, number of sessions and/or cures), drugs used (type and dosage), and lifestyle characteristics (alcohol and smoking and regular physical activity/exercise habits) ) related information will be saved. In the evaluation; Visual Analogue Scale, Pain Disability Index, Digital Pressure Algometer, Semmes Weinstein Monoflames, Pain Disaster Scale, Depression, Anxiety-Stress Scale-21(DASS-21), Functional Assessment of Cancer Treatment-Breast ( FACT-B+4) scale will be used.

Official Title
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Investigation of the Efficiency of Pain Neuroscience Education in Patients With Chronic Pain After Breast Cancer Surgery

Conditions
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Breast Cancer

Intervention / Treatment
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* Other: Pain Neuroscience Education
* Other: Biomedical Pain Education
* Other: Standard Physiotherapy Program


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Women over 18 years old Women diagnosed with breast cancer Patients who have passed at least 3 months after their primary treatment such as surgery, radiotherapy, chemotherapy Women who have pain in the upper extremity and shoulder region for more than three months and have achieved at least 40 points out of 100 on the Visual Analogue Scale (VAS) in the last week Exclusion Criteria: Patients with chronic pain in the upper extremity/shoulder before the diagnosis of breast cancer, Patients who have previously undergone a pain education program, Those with metastases, bilateral or recurrent breast cancer, Lack of cooperation in assessment and/or treatment and illiteracy, Patients who did not consent to the study and did not have an informed consent form

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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Female

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Pain Neuroscience Education<br>Pain Neuroscience Education; Four sessions of education will be applied. The neurophysiology of pain and the ability of the nervous system to modulate the experience of pain will be explained to the patient. Standard Physiotherapy Program; Soft tissue mobilization will be applied to the upper extremity twice a week for 6 weeks. Upper extremity exercises including breathing, warming, stretching and strengthening will be performed twice a week for 6 weeks. | Other: Pain Neuroscience Education<br>* Four sessions of Pain Neuroscience Education will be applied. The neurophysiology of pain and the ability of the nervous system to modulate the experience of pain will be explained to the patient.<br>Other: Standard Physiotherapy Program<br>* Soft tissue mobilization will be applied to the upper extremity twice a week for 6 weeks. Upper extremity exercises including breathing, warming, stretching and strengthening will be performed twice a week for 6 weeks.<br>|
| Active Comparator: Biomedical Pain Education<br>Biomedical Pain Education; 4 sessions of education will be applied in 6 weeks. Pain will be explained to the patient from a biological point of view. Standard Physiotherapy Program; Soft tissue mobilization will be applied to the upper extremity twice a week for 6 weeks. Upper extremity exercises including breathing, warming, stretching and strengthening will be performed twice a week for 6 weeks. | Other: Biomedical Pain Education<br>* 4 sessions of Biomedical Pain Education will be applied in 6 weeks. Pain will be explained to the patient from a biological point of view.<br>Other: Standard Physiotherapy Program<br>* Soft tissue mobilization will be applied to the upper extremity twice a week for 6 weeks. Upper extremity exercises including breathing, warming, stretching and strengthening will be performed twice a week for 6 weeks.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Pain intensity of the upper extremity | In our study, Visual Analog Scale(VAS) will be used to measure subjectively perceived pain. The Visual Analogue Scale (VAS) is a horizontal line of 0-10 cm denoting the absence of pain at one end and the most severe pain possible at the other. The subjects will be asked to mark the pain they have experienced in the last 3 days on the VAS. | Change in pain intensity from baseline up to the end of the 6th week | 
| Pain Related Dysfunction | Pain Disability Questionnaire (PDQ) will be used to measure pain-related disability. The Pain Disability Questionnaire (PDQ) is a seven-item scale aiming to determine the functional losses related to the musculoskeletal system suffered by the patient due to pain. From the patient, by giving 0 to 10 points to all questions; are asked to rate the impact on daily living activities, including family-home responsibilities, leisure activities, occupation, social activities, sexuality, and self-care. The total score ranges from 0 to 70. If the result is over 40 points, it means high disability. | Change in pain-related dysfunction from baseline to end of week 6 | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Somatosensory function: Pressure Pain Threshold | A Digital Pressure Algometer will be used to evaluate the pressure pain threshold. Pressure pain threshold is the amount of pressure at which pressure perception is first perceived as painful. It is applied until the participant states the point where the pressure is perceived as painful for the first time by saying 'stop'. The average of the two measurements is taken. The pressure pain threshold will be evaluated at the points in the pectoral muscle region, the lateral trunk side, and the upper trapezius muscle. | Change in pressure pain threshold from baseline to end of 6 weeks | 
| Somatosensory function: Mechanical Detection Threshold | Semmes Weinstein Monofilaments will be used. The mechanical sensing threshold and the mechanical pain threshold will be measured. The mechanical sensing threshold is the point at which the stimulus is first felt. The mechanical pain threshold is the point at which the stimulus is first felt painful. It will be applied to the inner side of the upper arm, the lateral trunk side and the quadriceps muscle. | Change in mechanical detection threshold from baseline up to the end of the 6th week | 
| Psychological Function: Pain Related Catastrophization | The Pain Catastrophizing Scale (PCS) will be used to measure pain-related catastrophication. This scale is a 14-item scale developed to examine catastrophic factors such as rumination, magnification, and weakness that are effective in the mechanism of pain. PCS scores range from 0 to 52 points. It is understood that the higher the score, the higher the catastrophization. | Change in Pain Related Catastrophization from baseline to end of week 6 | 
| Psychological Function:Psychological Symptoms | Psychological Symptoms will be measured using the Depression Anxiety-Stress Scale-21(DASS-21). This scale measures the level of depression, anxiety and stress. It consists of 21 items and seven items in each subscale. | Change in psychological symptoms from baseline to end of week 6 | 
| Life Quality | Functional Assesment of Cancer Treatment (FACT-B+4) Scale Coster et al. to evaluate the effects of arm morbidity on quality of life after breast cancer surgery. It consists of 42 items and 6 subscales: physical well-being, social/family well-being, emotional well-being, functional well-being, breast cancer and arm. | Change in life quality from baseline to end of week 6 | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Cronic pain, Side effect, Pain neuroscience education