Rustøen, T., Valeberg, B.T., Kolstad, E., Wist, E., Paul, S., & Miaskowski, C. (2012). The Pro-Self^© Pain Control Program improves patients' knowledge of cancer pain management. Journal of Pain and Symptom Management, 44, 321–330.

To evaluate the effects of a psychoeducational intervention on increasing patients’ knowledge and attitudes of cancer pain management

Prior to the intervention, nurses were trained by the PI and study oncologist. The PI listened to audio recordings of the sessions with nurses and patients in the intervention and control groups to ensure fidelity. The Norwegian version of the Pro-Self Pain Control Program intervention was used. A trained oncology nurse made home visits at 1, 3, and 6 weeks and telephone interviews at 2, 4, and 5 weeks. At the week 1 visit, the nurse delivered educational information tailored to each patient’s needs and patients received written instructions about pain and side effect management and were taught how to use a pillbox and how to use a script to help discuss pain management with their physician. At weeks 2, 4, and 5, the intervention group was contacted via phone to review pain score and medication use. The consent of the Pro-Self Pain Control Program was reinforced, and patients received coaching on how to address pain management needs. The same was done for home visits on weeks 3 and 6. The control group was given a booklet about cancer pain management and received home visits and telephone calls on the same schedule as intervention patients. The focus of interaction in the control group was adherence with completing the study diary. Both groups recorded measurements in a pain diary every night.

• N = 179
• MEAN AGE = Pro-Self group: 64.32 years (SD = 11.4 years), control group: 67.38 years (SD = 11.4 years)
• MALES: 47.1% in the Pro-Self group, 55.4% in the control group; FEMALES: 52.9% in the Pro-Self group, 44.6% in the control group
• KEY DISEASE CHARACTERISTICS: Patients with cancer who had bone metastasis, confirmed radiographically
• OTHER KEY SAMPLE CHARACTERISTICS: Primary diagnoses include breast, prostate, and colon cancer; 19.5% with other diagnosis; outpatients; able to read, write, and understand; Karnofsky Performance Status (KPS) of 50 or greater; pain intensity score of 2.5 or greater on a 0–10 scale

• SITE: Single site 
• SETTING TYPE: Outpatient 
• LOCATION: Norway

• PHASE OF CARE: Multiple phases of care
• APPLICATIONS: Elder care, palliative care

• Randomized, controlled trial

• KPS
• 0–10 pain intensity scale
• Pain experience scale (PES)
• Demographic questionnaire
• Independent student t-tests or chi-squared analysis, mixed-model analysis

At baseline, control patients reported a higher KPS score than those in the intervention group (p = 0.0003). Improvement in all individual and overall (p < 0.001) scores on the PES was noted for patients in the Pro-Self group. A statistically significant improvement was seen in nine items on the PES scale for patients in the intervention group.

The study resulted in an increase in knowledge of cancer pain management in the Pro-Self group.

• Baseline sample/group differences of import: Difference in KPS scores
• Risk of bias (no blinding)
• Risk of bias(sample characteristics): Control group had higher KPS score than the Pro-Self group at enrollment, and patients in the Pro-Self group had a lower PES score on one item than the control group
• Other limitations/explanation: The PES was modified when it was translated into Norwegian, some items on the PES were reverse coded, a drug dependence item on the PES was deleted (because of translational issues), and an item was added because it was included on another pain questionnaire by the American Pain Society’s Quality of Care Committee.

Additional research is recommended to examine the influence of the level of education of participants on interventions to improve cancer pain management.  A similar study was completed in the United States using a similar intervention, but the results were not as dramatic (the U.S. study yielded significant improvements in only five of the nine items on the PES, versus significant improvements in all 9 areas in the Norwegian study), which suggests cultural, educational, and demographic influences. Although individualized patient education tends to be more effective, this requires additional time and resources for planning and intervention.