Non-pharmacological cancer pain interventions in populations with social disparities: a systematic review and meta-analysis

Pain in individuals with idiopathic inflammatory myopathies, other systemic autoimmune rheumatic diseases, and without rheumatic diseases: A report from the COVAD study

OBJECTIVES

To compare pain intensity among individuals with idiopathic inflammatory myopathies (IIMs), other systemic autoimmune rheumatic diseases (AIRDs), and without rheumatic disease (wAIDs).

METHODS

Data were collected from the COVID-19 Vaccination in Autoimmune Diseases (COVAD) study, an international cross-sectional online survey, from December 2020 to August 2021. Pain experienced in the preceding week was assessed using numeral rating scale (NRS). We performed a negative binomial regression analysis to assess pain in IIMs subtypes and whether demographics, disease activity, general health status, and physical function had an impact on pain scores.

RESULTS

Of 6988 participants included, 15.1% had IIMs, 27.9% had other AIRDs, and 57.0% were wAIDs. The median pain NRS in patients with IIMs, other AIRDs, and wAIDs were 2.0 (interquartile range [IQR] = 1.0-5.0), 3.0 (IQR = 1.0-6.0), and 1.0 (IQR = 0-2.0), respectively (P < 0.001). Regression analysis adjusted for gender, age, and ethnicity revealed that overlap myositis and antisynthetase syndrome had the highest pain (NRS = 4.0, 95% CI = 3.5-4.5, and NRS = 3.6, 95% CI = 3.1-4.1, respectively). An additional association between pain and poor functional status was observed in all groups. Female gender was associated with higher pain scores in almost all scenarios. Increasing age was associated with higher pain NRS scores in some scenarios of disease activity, and Asian and Hispanic ethnicities had reduced pain scores in some functional status scenarios.

CONCLUSION

Patients with IIMs reported higher pain levels than wAIDs, but less than patients with other AIRDs. Pain is a disabling manifestation of IIMs and is associated with a poor functional status.

What is the volume, diversity and nature of recent, robust evidence for the use of peer support in health and social care? An evidence and gap map

Background

Peer support interventions involve people drawing on shared personal experience to help one another improve their physical or mental health, or reduce social isolation. If effective, they may also lessen the demand on health and social care services, reducing costs. However, the design and delivery of peer support varies greatly, from the targeted problem or need, the setting and mode of delivery, to the number and content of sessions. Robust evidence is essential for policymakers commissioning peer support and practitioners delivering services in health care and community settings. This map draws together evidence on different types of peer support to support the design and delivery of interventions.

Objectives

The aim of this map was to provide an overview of the volume, diversity and nature of recent, high quality evidence on the effectiveness and cost-effectiveness of the use of peer support in health and social care.

Search Methods

We searched MEDLINE, seven further bibliographic databases, and Epistemonikos for systematic reviews (in October 2020), randomised controlled trials (in March 2021) and economic evaluations (in May 2021) on the effectiveness of peer support interventions in health and social care. We also conducted searches of Google Scholar, two trial registers, PROSPERO, and completed citation chasing on included studies.

Selection Criteria

Systematic reviews, randomised controlled trials and economic evaluations were included in the map. Included studies focused on adult populations with a defined health or social care need, were conducted in high-income countries, and published since 2015. Any measure of effectiveness was included, as was any form of peer support providing the peer had shared experience with the participant and a formalised role.

Data Collection and Analysis

Data were extracted on the type of peer support intervention and outcomes assessed in included studies. Standardised tools were used to assess study quality for all studies: assessing the methodological quality of systematic reviews 2 for systematic reviews; Cochrane risk of bias tool for randomised controlled trials; and consensus health economic criteria list for economic evaluations.

Main Results

We included 91 studies: 32 systematic reviews; 52 randomised controlled trials; and 7 economic evaluations. Whilst most included systematic reviews and economic evaluations were assessed to be of low or medium quality, the majority of randomised controlled trials were of higher quality. There were concentrations of evidence relating to different types of peer support, including education, psychological support, self-care/self-management and social support. Populations with long-term health conditions were most commonly studied. The majority of studies measured health-related indicators as outcomes; few studies assessed cost-effectiveness. Studies were unevenly distributed geographically, with most being conducted in the USA. Several gaps were evident regarding the delivery of peer support, particularly the integration of peers and professionals in delivering support and interventions of longer duration.

Authors' Conclusions

Although there is evidence available to inform the commissioning and delivery of peer support in health and social care, there are also clear gaps that need to be addressed to further support provision, particularly regarding cost-effectiveness. The effectiveness of peer support in different countries, with varying health and social care systems, is a priority for future research, as is the integration of peers with professionals in delivering peer support.

Psychological and Non-Pharmacologic Treatments for Pain in Cancer Patients: A Systematic Review and Meta-Analysis

CONTEXT

Pain is the most fearful symptom in cancer. Although there is a relationship between psychosocial variables and oncologic pain, psychological and non-pharmacological treatments for pain management in cancer patients are not very widespread.

OBJECTIVES

To analyze the efficacy of psychological and non-pharmacological treatments for reducing pain in cancer patients.

METHODS

We performed a systematic review following the PRISMA protocol. In January 2021, data were extracted from PubMed, Web of Science and Scopus, including randomised controlled trials (RCT) published in the last five years (from 28 January, 2015 to December 15, 2020), in the English language and whose sample was patients with cancer pain. The database search used the following keywords: cancer, cancer-related pain, psychological intervention, non-pharmacologic intervention. The Cochrane risk of bias assess ment for randomised trials (RoB 2) was used for quality appraisal.

RESULTS

After the inclusion and exclusion criteria were applied, ten papers were fully screened. The evidence suggested that the most effective interventions to reduce cancer pain were mindfulness-based cognitive therapy, guided imagery and progressive muscle relaxation and emotional and symptom focused engagement (EASE). Music therapy and brief cognitive behavioral strategies (CBS) require more research, while coping skills training and yoga did not show positive effects. Overall, we obtained a moderate size effect (d = 0.642, 95% CI: 0.125-1.158) favourable to psychological and non-pharmacologic treatments at post-treatment, which increased at follow-up (k = 5, d = 0.826, 95% CI: 0.141-1.511).

CONCLUSION

This study provides insight into psychological interventions which might be applied and contribute to cancer-related pain reduction in adults. Although the results are not completely consistent, they may shed light on psychology applications in the oncology environment.

Does ethnicity affect pain management for people with advanced disease? A mixed methods cross-national systematic review of 'very high' Human Development Index English-speaking countries

BACKGROUND

Racial disparities in pain management have been observed in the USA since the 1990s in settings such as the emergency department and oncology. However, the palliative care context is not well described, and little research has focused outside of the USA or on advanced disease. This review takes a cross-national approach to exploring pain management in advanced disease for people of different racial and ethnic groups.

METHODS

Mixed methods systematic review. The primary outcome measure was differences in receiving pain medication between people from different racial and ethnic groups. Five electronic databases were searched. Two researchers independently assessed quality using JBI checklists, weighted evidence, and extracted data. The quantitative findings on the primary outcome measure were cross-tabulated, and a thematic analysis was undertaken on the mixed methods studies. Themes were formulated into a conceptual/thematic matrix. Patient representatives from UK ethnically diverse groups were consulted. PRISMA 2020 guidelines were followed.

RESULTS

Eighteen papers were included in the primary outcome analysis. Three papers were rated 'High' weight of evidence, and 17/18 (94%) were based in the USA. Ten of the eighteen (56%) found no significant difference in the pain medication received between people of different ethnic groups. Forty-six papers were included in the mixed methods synthesis; 41/46 (89%) were based in the USA. Key themes: Patients from different ethnically diverse groups had concerns about tolerance, addiction and side effects. The evidence also showed: cultural and social doctor-patient communication issues; many patients with unmet pain management needs; differences in pain assessment by racial group, and two studies found racial and ethnic stereotyping.

CONCLUSIONS

There was not enough high quality evidence to draw a conclusion on differences in receiving pain medication for people with advanced disease from different racial and ethnic groups. The mixed methods findings showed commonalities in fears about pain medication side effects, tolerance and addiction across diverse ethnic groups. However, these fears may have different foundations and are differently prioritised according to culture, faith, educational and social factors. There is a need to develop culturally competent pain management to address doctor-patient communication issues and patients' pain management concerns.

TRIAL REGISTRATION

PROSPERO- CRD42020167890 .

The Benefits of a Therapeutic Exercise and Educational Intervention Program on Central Sensitization Symptoms and Pain-Related Fear Avoidance in Breast Cancer Survivors

BACKGROUND

Central sensitization symptoms and pain-related fear avoidance are two common problems in breast cancer survivors. Non-pharmacologic interventions such as therapeutic exercise and patient education can be effective in this population.

AIMS

This study aimed to: (1) analyze the benefits of a therapeutic exercise and educational program on central sensitization symptoms and pain-related fear avoidance in breast cancer survivors, and (2) explore the association between pain-related fear avoidance and central sensitization symptoms.

DESIGN

A single group pre-post intervention study was conducted.

METHODS

Patients were recruited from the service of Medical Oncology of the University Clinical Hospital Virgen de la Victoria, in Málaga (Spain). The intervention consisted of a therapeutic exercise and educational program that lasted 12 weeks, twice a week, for 1 hour. Two instruments were used: the Spanish version of the Central Sensitization Inventory and the Spanish Fear Avoidance Components Scale.

RESULTS

A total of 82 breast cancer survivors participated in the study. Pre-post change on Central Sensitization Inventory was statistically significant (p = .007). There was a trend towards a significant difference for the Spanish Fear Avoidance Components Scale (p = .062). There was a statistically significant correlation between pain-related fear avoidance and central sensitization symptoms (r = 0.536, p < .001).

CONCLUSIONS

The current study has provided preliminary evidence on the benefits of this intervention in pain-related fear avoidance and central sensitization symptoms in breast cancer survivors. The Spanish version of the Central Sensitization Inventory and the Spanish Fear Avoidance Components Scale demonstrated responsiveness to change.

Limitations in Activities of Daily Living Among Spanish Women Diagnosed With Endometriosis

IMPORTANCE

Understanding the impact of endometriosis symptoms on patients' activities of daily living (ADLs) is a priority to establish effective and personalized intervention programs.

OBJECTIVE

To explore limitations in ADLs and instrumental ADLs (IADLs) and their association with pelvic pain (PP), chronic fatigue, and pain-catastrophizing thoughts among women with endometriosis.

DESIGN

Cross-sectional study.

SETTING

Spain.

PARTICIPANTS

Two hundred thirty women with endometriosis. Outcomes and Measures: Information regarding performance of ADLs (Barthel Index) and IADLs (Lawton-Brody questionnaire), PP intensity (Numeric Rating Scale), chronic fatigue (Piper Fatigue Scale), and pain-catastrophizing thoughts (Pain Catastrophizing Scale) was gathered. Multivariate regression analyses were created, and mediating effects of fatigue and pain-catastrophizing thoughts on the association between PP and ADL and IADL limitations were assessed.

RESULTS

The prevalence of limitations in at least one ADL and one IADL was 22.6% (95% confidence interval [CI] [17.2, 28.1]) and 39.1% (95% CI [32.8, 45.5]), respectively. Limitations in bowel continence, housework, shopping, and meal preparation were reported most frequently. Women reporting severe PP showed higher risk for ADL (odds ratio [OR] = 3.33, 95% CI [1.10, 10.10]) and IADL (OR = 7.99, 95% CI [2.86, 22.34]) limitations. Chronic fatigue and pain-catastrophizing thoughts were also positively related to ADL-IADL limitations, showing a mediating effect on the association between PP and ADL-IADL limitations.

CONCLUSIONS AND RELEVANCE

This study reveals the widespread presence of difficulties in ADL-IADL performance among women with endometriosis, with some symptoms underlying these difficulties in occupational performance. This study points to the need for cost-effective occupational therapy interventions for affected women. What This Article Adds: This research shows that the occupational performance of women with endometriosis is frequently impaired; therefore, the effectiveness of occupational therapy interventions should be addressed in the near future.

Nonpharmacological Interventions for Pain Management in Lung Cancer Patients: A Systematic Review

Background:

The presence of lung cancer is almost always associated with pain, a symptom that causes severe distress in patients. Although many pharmacological methods are available to manage pain in this oncologic population, the medications often cause undesirable sideeffects and inadequate relief. Nonpharmacological interventions can be used as adjuvants to pharmacological interventions in reducing pain and increasing quality of life.

Objectives:

The purpose of this review is to compare the efficacy of nonpharmacological interventions in reducing pain in lung cancer patients.

Materials and Methods:

This is a systematic review study guided by the Preferred Reporting Items of Systematic reviews and Meta-Analysis Protocol. Interventions identified in the present systematic review have been categorized as physical treatment, technologybased, cognitive behavioral, coping, and coaching.

Results:

Results indicate that the nonpharmacological interventions such as physical treatment interventions, selfmanagement and coaching interventions, cognitive behavioral interventions, and technologybased interventions or coping skills interventions had limited and shortterm effects on alleviating pain among the patients. However, previous studies have provided limited evidence regarding nonpharmacologic therapy due to the lack of a comparison group, small sample sizes, and lack of longterm followup periods to determine whether sustained effects are feasible.

Conclusion:

Healthcare professionals should consider additional research on the added advantage of utilizing the nonpharmacological interventions as an adjunct option while managing pain in lung cancer patients.

Pain in low-income older women with disabilities: a qualitative descriptive study

The purpose of this qualitative study was to identify how low-income older women with disabilities perceive pain, pain management, and communication with healthcare providers. We interviewed 26 low-income women (average age 75 years; SD 7.0), eliciting the following overarching themes: "Invisibility of Pain: Unnoticed or Undetected," "Escalating Pain Leads to Help Seeking," "Communication with Healthcare Providers and Outcomes," "Pain Management Facilitates Function and Accomplishment," and "The Intersection of Pain, Disability, and Depressive Symptoms." Study findings support the ways in which behavior changes from pain can impede pain management.

Cost-Effectiveness of Pain Management Strategies in Advanced Cancer

OBJECTIVES

Uncontrolled pain in advanced cancer is a common problem and has significant impact on individuals' quality of life and use of healthcare resources. Interventions to help manage pain at the end of life are available, but there is limited economic evidence to support their wider implementation. We conducted a case study economic evaluation of two pain self-management interventions (PainCheck and Tackling Cancer Pain Toolkit [TCPT]) compared with usual care.

METHODS

We generated a decision-analytic model to facilitate the evaluation. This modelled the survival of individuals at the end of life as they moved through pain severity categories. Intervention effectiveness was based on published meta-analyses results. The evaluation was conducted from the perspective of the U.K. health service provider and reported cost per quality-adjusted life-year (QALY).

RESULTS

PainCheck and TCPT were cheaper (respective incremental costs -GBP148 [-EUR168.53] and -GBP474 [-EUR539.74]) and more effective (respective incremental QALYs of 0.010 and 0.013) than usual care. There was a 65 percent and 99.5 percent chance of cost-effectiveness for PainCheck and TCPT, respectively. Results were relatively robust to sensitivity analyses. The most important driver of cost-effectiveness was level of pain reduction (intervention effectiveness). Although cost savings were modest per patient, these were considerable when accounting for the number of potential intervention beneficiaries.

CONCLUSIONS

Educational and monitoring/feedback interventions have the potential to be cost-effective. Economic evaluations based on estimates of effectiveness from published meta-analyses and using a decision modeling approach can support commissioning decisions and implementation of pain management strategies.

Parallel and serial mediation analysis between pain, anxiety, depression, fatigue and nausea, vomiting and retching within a randomised controlled trial in patients with breast and prostate cancer

OBJECTIVE

Cancer treatment is a particularly stressful period for the patient. The reasons vary and include fear of treatment outcome as well as treatment induced side effects. The patient frequently experiences simultaneously various side effects resulting in a diminishing of the patient's health-related quality of life (HRQoL). The study provides evidence on the co-occurrence and inter-relations between pain, anxiety, depression and fatigue in patients with breast and prostate cancer.

DESIGN

This paper presents a secondary analysis of the data from a randomised control trial designed to test the effectiveness of guided imagery and progressive muscle relaxation on pain, fatigue, anxiety and depression. Non-parametric bootstrapping analyses were used to test the mediational model of anxiety, fatigue and depression as parallel mediators of the relationship between pain and HRQoL.

SETTING

The study was undertaken at the home setting.

PARTICIPANTS

In total 208 patients were included in the study (assigned equally in two groups), referred at the outpatient clinics of the three participating cancer care centres.

RESULTS

The three mediators fully mediate the relationship between pain and HRQoL indirect effect (IE_overall=-0.3839, 95% CI: lower limit (LL)=-0.5073 to upper limit (UL)=-0.2825) indicating that patients with increased pain are likely to have higher levels of anxiety, fatigue and depression. Gender significantly moderated the mediational effect of Fatigue Index of Moderated Mediation (IMM=-0.2867 SE=0.1526, LL=-0.6127, UL=-0.0226) but did not moderate mediational effect of anxiety (IMM=-0.0709, SE=0.1414, LL=-0.3459, UL=+0.2089). The results show that the three mediators in a serial causal order fully mediate the relationship between pain and HRQoL (IE_overall=-0.384, 95% CI: LL=-0.51 to UL=-0.284) and the ratio of the overall indirect effect to the total effect is 0.8315 (95% CI: LL=0.5683 to UL=1.1718).

CONCLUSION

This work provides evidence that targeting fatigue, anxiety and depression may have a meaningful effect on pain as a related symptom and potentially have a positive impact on HRQoL of patients with breast and prostate cancer TRIAL REGISTRATION NUMBER: NCT01275872; Post-results.

Development and validation of a search filter to identify equity-focused studies: reducing the number needed to screen

Background

Health inequalities, worse health associated with social and economic disadvantage, are reported by a minority of research articles. Locating these studies when conducting an equity-focused systematic review is challenging due to a deficit in standardised terminology, indexing, and lack of validated search filters. Current reporting guidelines recommend not applying filters, meaning that increased resources are needed at the screening stage.

Methods

We aimed to design and test search filters to locate studies that reported outcomes by a social determinant of health. We developed and expanded a ‘specific terms strategy’ using keywords and subject headings compiled from recent systematic reviews that applied an equity filter. A ‘non-specific strategy’ was compiled from phrases used to describe equity analyses that were reported in titles and abstracts, and related subject headings. Gold standard evaluation and validation sets were compiled. The filters were developed in MEDLINE, adapted for Embase and tested in both. We set a target of 0.90 sensitivity (95% CI; 0.84, 0.94) in retrieving 150 gold standard validation papers. We noted the reduction in the number needed to screen in a proposed equity-focused systematic review and the proportion of equity-focused reviews we assessed in the project that applied an equity filter to their search strategy.

Results

The specific terms strategy filtered out 93-95% of all records, and retrieved a validation set of articles with a sensitivity of 0.84 in MEDLINE (0.77, 0.89), and 0.87 (0.81, 0.92) in Embase. When combined (Boolean ‘OR’) with the non-specific strategy sensitivity was 0.92 (0.86, 0.96) in MEDLINE (Embase 0.94; 0.89, 0.97). The number needed to screen was reduced by 77% by applying the specific terms strategy, and by 59.7% (MEDLINE) and 63.5% (Embase) by applying the combined strategy. Eighty-one per cent of systematic reviews filtered studies by equity.

Conclusions

A combined approach of using specific and non-specific terms is recommended if systematic reviewers wish to filter studies for reporting outcomes by social determinants. Future research should concentrate on the indexing standardisation for equity studies and further development and testing of both specific and non-specific terms for accurate study retrieval.

Electronic supplementary material

The online version of this article (10.1186/s12874-018-0567-x) contains supplementary material, which is available to authorized users.

Nonpharmacologic Pain Interventions: A Review of Evidence-Based Practices for Reducing Chronic Cancer Pain

BACKGROUND

Pain is a common issue for patients with cancer and can be challenging to manage effectively. Healthcare professionals need to be knowledgeable about evidence-based nonpharmacologic interventions.
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OBJECTIVES

This systematic review critically appraises the strength and quality of the empirical evidence for nonpharmacologic interventions in reducing chronic cancer pain.
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METHODS

Intervention studies were critically appraised and summarized by an Oncology Nursing Society Putting Evidence Into Practice team of RNs, advanced practice nurses, and nurse scientists. A level of evidence and a practice recommendation was assigned to each intervention.
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FINDINGS

Based on evidence, recommended interventions to reduce chronic cancer pain are celiac plexus block for pain related to pancreatic and abdominal cancers and radiation therapy for bone pain. Although psychoeducational interventions are considered likely to be effective, the effective components of these interventions and their dose and duration need to be determined through additional research.

Profile of Patients Opting for Palliative Care in India

Introduction

Understanding the profile of end users is a key input for designing a service. Centers that provide full-scale palliative care are few and far between in our country, and there is a need to open more centers to extend the services to a larger percentage of patients.

Methods

Patient data from the inception of the center till January 2016 have been stored in a database. The data were mined, exported to Excel, and analyzed.

Results

The data of 11,258 patients revealed the profile of patients, including their age, gender distribution, marital status, symptomology, and outcome. The present paper describes the profile of patients opting for palliative care in our country.

Conclusions

The profile of patients registered at this center validates certain assumptions while debunking others. It is hoped that this profile gives some guidance to those desirous of setting up palliative care services.