https://doi.org/10.5812/ijcm.9450

The Relationships between Self-Care and Pain Perception: Experience in Iranian Patients with Cancer

authors:

avatar Amir Hossein Goudarzian ORCID 1 , avatar Fatemeh Zamani ORCID 2 , avatar Mahdi Babaei Hatkehlouei 3 , avatar Masoumeh Bagheri Nesami ORCID 4 , * , avatar Sima Beik 5

BSc of Nursing, Student Research Committee, Mazandaran University of Medical Sciences, Sari, IR Iran
Nursing Student, Student Research Committee, Mazandaran University of Medical Sciences, Sari, IR Iran
Dentistry Student, Student Research Committee, Mazandaran University of Medical Sciences, Sari, IR Iran
Department of Medical- Surgical Nursing, Pediatric Infectious Diseases Research Center, Mazandaran University of Medical Sciences, Sari, IR Iran
MSc of Biostatistics, Mazandaran University of Medical Sciences, Sari, IR Iran
International Journal of Cancer Management: Vol.10, issue 12; e9450
published online: December 31, 2017
article type: Research Article
received: October 23, 2016
revised: December 27, 2016
accepted: December 20, 2017

how to cite: Goudarzian A H, Zamani F, Babaei Hatkehlouei M, Bagheri Nesami M, Beik S. The Relationships between Self-Care and Pain Perception: Experience in Iranian Patients with Cancer. Int J Cancer Manag. 2017;10(12):e9450. https://doi.org/10.5812/ijcm.9450.

Abstract

Background:

The present study aimed to investigate the relationship between self-care and pain control in patients with cancer.

Methods:

In this cross-sectional study (October to December, 2015) 380 cancer patients were admitted to one of the hospitals affiliated to Mazandaran University of Medical Sciences (Sari, Iran) entered to the study using simple random sampling. Data was collected by a demographic questionnaire, self-care scale and McGill pain questionnaire. The statistical package for social sciences, version 20.0 (SPSS Inc., Chicago, IL, USA) was utilized for data analysis by descriptive and infernal statistic tests (Spearman’s correlation and Generalized Linear models).

Results:

Males in the study (48.39 ± 13 ± 39; CI95: 46.41 - 50.38) were older than females (45.33 ± 18.44; CI95: 42.79 - 47.87). Based on the results of the processing of the Generalized Linear Models, there was not a significant relationship between pain perception and self-care in cancer patients (P > 0.05). But there was a significant relationship between pain perception and its two subsets of physical self-care (B = -1.102, P < 0.001) and emotional self -care (B = 0.823, P < 0.001).

Conclusions:

Considering the adverse effects of chronic pain treatment process and secondary problems, more comprehensive studies must be done about the effects of self-care behaviors on the perception of pain so that effective steps can be taken to intervene and promote the health of these patients.

1. Background

Cancer is the second leading cause of death in most industrialized countries. Reports indicate global growth of cancer patients up to 16 million people in 2002 (1). According to the world health organization’s report, it is estimated that the number of deaths due to cancer in the United States of America increase to more than 800 thousand people and it is expected that this trend continues to be upward (2). In Iran, from 1985 to 2005 the number of cancer patients has increased by 3.3 times (3).

Cancer as the most common chronic diseases is often associated with chronic pain (4). Cancer pain can has many different causes, including tumor growth and spread, effects of therapies such as chemotherapy, radiotherapy and surgery, and underlying diseases (5). The prevalence of pain varies from 5% in patients with leukemia to 85% in patients with primary bone tumors (6). There are several ways to treat and relieve pain in these patients, but these methods do not seem sufficient to manage their pain (7).

Many people believe that to organize (such as reducing complications and symptoms) patients with chronic diseases, self-care should be taken (8). Self-care, according to Orem includes learned behaviors done to maintain or promote health, to prevent diseases or to treat them (9). In studies conducted by McCain et al. it was suggested that cardiovascular training can be effective in controlling and reducing symptoms of fibromyalgia including pain reduction and improvement of mental indicators of patients (10, 11). Also, according to studies, aerobic exercise is introduced as a reducing agent which improves patients’ moods and those of healthy people (10, 12). This is while in some studies no significant relationship was found between physical care and pain (13, 14). Of course, pain is a natural mechanism to protect the body against injuries and helps to diagnose a critical illness (15). So a deeper knowledge about the effect of physical activity on pain perception and its process on the treatment of patients and the consequences of its behavior is required (16-18). According to available databases, it seems that no study on self-care behaviors associated with pain perception in cancer patients has been done despite the high prevalence of this disease in Iran (19).

2. Objectives

The present study aimed to investigate the relationship between self-care and pain control in patients with cancer. The following hypotheses were considered in this study: 1) Self-care behaviors are significantly associated with pain perception, 2) subsets of self-care (physical, psychological, emotional and spiritual) are significantly associated with pain perception, and 3) The demographic variables are associated with pain perception.

3. Methods

In this cross-sectional study (October to December, 2015) 380 cancer patients that were admitted to one of the hospitals of Mazandaran University Medical Sciences (Sari, Iran) were entered to the study using random sampling. In this interval of four months, about 600 patients were admitted to the oncology ward of these hospitals. The rate of patient participation was 63.3 %.

The adequacy of the sample size was calculated to be 380 based on a two-sided significant degree α=0.05 and test power of 80 (d = 0.3) by G*power 3.0.10 software. Inclusion criteria included age (18 years or older), cancer treatment with radiation, chemotherapy or surgery. Exclusion criteria included taking antidepressants in the last 6 months, the transfer of patients to other hospitals and occurrence of acute medical conditions (such as loss of consciousness).

After explaining the purpose of the study and how to complete the questionnaire, informed consent form was signed by qualified patients. Then the necessary explanation regarding the objectives of the study was given to patients and the questionnaires were distributed. Explanation was given to the patients if a question was vague. It should be noted that this explanation was only in order to avoid ambiguity and any kind of bias.

3.1. Data Collection Tools

Data was collected by a socio-demographic questionnaire, self-care tools and McGill pain questionnaire (MPQ). The socio-demographic questionnaire includes age, sex, education level, economic status, history of drug use, family history of cancer and stage of the cancer.

Self-care questionnaire (adapted from checklists published by the ministry of health, treatment and medical education) contained 34 parameters which include 4 general scales of physical self-care, psychological self-care, emotional self-care, and spiritual self-care (20). The scoring method was based on Likert’s 5 scales from 1 to 5 (in this case, I do not have a plan, never, rarely, sometimes or always) (21). In this test, the scores range from 34 to 170 and the scores of 34 - 67, 68 - 101, 102 - 135 and 136 - 170 indicate poor, average, good and excellent level of self-care, respectively. Bagheri-Nesami et al. (2015) by investigating this tool on the elderly, calculated its reliability with Cronbach’s alpha to be 0.83 (22). Also, in another study, the reliability of this instrument was calculated to be 0.841 with class correlation coefficient (22). In this study, content validity was approved with reading of the tool by 5 oncology experts and acquiring their opinions. The reliability of this tool on cancer patients was calculated to be 0.792 with the aid of Cronbach’s alpha.

McGill pain questionnaire contains 78-word descriptive of the 20 subclasses forming in three main sensory, affective and evaluative domains (23). The patients were asked to identify the best description of their pain with selecting just one word from each group. If all options of a group did not provide a proper description of a patient’s pain, patients would select no option from that group. When patients chose more than one option in each group, the highest rating (maximum pain) was considered for the final analysis (24). The score of each group was collected separately to calculate the final score. MPQ total score described as "pain rating index based on the scores taken from the words" is the sum of the scores of each group (25). Scores range varied from 0 (when no word is selected) to 78 (maximum pain when selected in each group) (24). Dworkin et al. (2015), using Cronbach’s alpha, have calculated the reliability of this instrument to be 0.77. In the present study, using Cronbach’s alpha, the reliability of this tool was calculated to be 0.94.

3.2. Ethical Considerations

This study was confirmed by the ethics committee of Mazandaran University of Medical Sciences. Patients were informed about the goals and stages of the study; so that their participation was voluntary. Patients passed the study’s stages in a quiet room. To ensure that a wide range of patients involved in the study, a trained researcher who was a member of the study provided the supplies. All patients’ information was undetectable by assigning a code to each patient.

3.3. Statistical Analysis

The statistical package for social sciences, version 20.0 (SPSS Inc., Chicago, IL, USA) was utilized for data analysis. First descriptive statistics for continuous variables were shown as means with standard deviation (SD) and n (%) for the categorical variables. Single dummy variables were created for sex, education (Illiterate, diploma and higher), socio-economic status (lower income reference versus middle or upper income level), cancer stage (1 to 4), history of drug use (yes or no), history of cancer in family (yes or no) and past medical history (yes or no). Then univariate tests were conducted using the Mann-Whitney U test and variables with P < 0.3 were considered. Spearman’s correlations were used to probe the relationship between self-care and pain perception. Finally the predictors associating with pain perception were determined using Generalized Linear models (GLM) with bonferroni correction for pair-wise comparisons. Statistical significance was set at P < 0.05.

4. Results

4.1. Patients’ Demographic Profile

Demographic characteristics of 380 patients with cancer are summarized in Table 1. Males (48.39 ± 13 ± 39; CI95: 46.41 - 50.38) are older than females (45.33 ± 18.44; CI95: 42.79 - 47.87).

Table 1.

Sample Characteristics of Cancer Patients Included in the Study

CharacteristicNo. (%)
Sex
Male175 (46.1)
Female205 (53.9)
Economic Status
Weak110 (28.9)
Average204 (53.7)
Good66 (17.4)
Education
Illiterate210 (55.3)
Diploma138 (36.3)
BS22 (5.8)
MSs and above10 (2.6)
Material Status
Single51 (13.4)
Married329 (86.6)
Cancer stage
One132(34.7)
Two133(35)
Tree92(24.2)
Four23(6.1)
Family history of cancer
Yes112 (29.5)
No268 (70.5)
Depression
Down261 (68.7)
Up119 (31.3)
Past medical historya
Cardiac diseases46 (12.1)
Respiratory diseases34 (8.9)
Gastric diseases41 (10.78)
Urinary diseases26 (6.84)
History of cigarette smoking
Yes71 (18.7)
No309 (81.3)
Ageb46.74 (16.328)
Self-Careb131.72 (12.45)
Painb21.61 (13.55)

aNumber of patients who had these diseases.

bValues are expressed as mean (SD).

69.7 % of patients were at an early stage of disease (Stage I - II disease) and 31.3 % were in an advanced stage of cancer (Stage III-IV disease). 29.5 % had a family history of cancer, and 38.7% had a history of drug use. The mean total score of positive and negative religious coping and depression, was (24.14 ± 5.45; CI95: 23.59 - 24.69), (18.22 ± 3.25; CI95: 18.12 - 18.74) and (18.43 ± 3.11; CI95: 17.89 - 18.55), respectively. 69.9 % of patients under treatment had higher depression in early stages of the disease.

4.2. The Relationship Between Self-Care and Its Sub-Sets with Pain Perception

Based on the results obtained from the processing of the Generalized Linear Models, there was not a significant relationship between pain perception and self-care in cancer patients (P > 0.05). But there was a significant relationship between pain perception and its two subsets of physical self-care (B = -1.102, P < 0.001) and emotional self -care (B = 0.823, P < 0.001) (Table 2).

Table 2.

Relationship Between Pain and Sub-Scales of Self-Care in Cancer Patients (N = 380)

VariableBSE95% CIP Value
Physical Self-care-1.1020.1527-1.40152.0610.000a
Psychological Self-care0.2250.2301-0.2260.9600.327
Emotional Self-care0.8230.18940.45218.8870.000a
Spiritual Self-care0.0070.1404-0.2680.0020.962

aStatistically significant at P ≤ 0.05.

4.3. The Relationship Between Pain Perception and Demographic Variables

In addition, according to Table 3, there was a significant relationship between pain perception and economic status (P < 0.05), age (B= -0.225, P < 0.001), sex (B = -4.41, P = 0.001), Family history of cancer (B = -13.21, P < 0.001), history of drug use (B = 7.438, P < 0.001) and the third stage of the cancer (B = -10.77, P < 0.001) in patients with cancer.

Table 3.

Relationship Between Pain and Its Covariates in Cancer Patients (N = 380)

VariableBSE95% CIP Value
Education
Illiterate0.0773.8680-7.5057.6580.984
Diploma-0.0693.6957-7.3127.1740.985
BS-3.9064.1926-12.1234.3110.352
MSc and upper0a
Economic Status
Weak4.3821.90350.6518.1130.021b
Average3.8861.76220.4327.3400.027b
Good0a
Cancer stage
One-2.8782.8827-8.5282.7720.318
Two1.2512.6026-3.8506.3520.631
Tree-10.772.8713-16.400-5.1440.000b
Four0a
Past medical history
Cardiac diseases-0.7420.35-1.6520.190.23
Respiratory diseases-0.8650.423-1.3410.1140.129
Gastric diseases-0.9800.487-2.2210.150.092
Urinary diseases0a
Age-0.2250.0572-0.33715.4440.000b
Sex-4.4101.4685-7.2889.0180.003b
Marital Status-3.4862.2878-7.9702.3220.128
Drug history7.4381.76423.98017.7740.000b
Family history of cancer-13.211.3843-15.92691.0930.000b
Self-Care-0.0550.0528-0.1581.0810.298

aSet to zero because this parameter is redundant.

bStatistically significant at P ≤ 0.05.

5. Discussion

This study aimed to determine the relationship between self-care and pain perception in cancer patients in Iran. According to the results, there was a significant relationship between pain perception and physical activity. The results of Kallen (2000), Tesarz et al. (2012), Kuphal et al. (2007) and Cherkin et al. (1998) were in line with the present study (26-29). It seems that this relationship is due to the impact of physical activity as an effective, safe and non-invasive factor for pain management (30) while a Swedish study was conducted to determine the effect of exercise and physiotherapy on low back pain in the patients. The study was conducted on 323 patients of 18 to 60 years of age. The pain was measured by visual analogue scale (VAS). No significant relationship between physical activity and perception of pain was reported (13). According to the above description, this difference could be due to the type of disease and religious and cultural differences of patients that will have a potential effect on the perception of patients (31).

Today, it is certain that all humans have constant pain tolerance threshold but pain tolerance is strongly influenced by physical and psychological factors (32, 33). Coping skills can facilitate pain control (34). It can be assumed that psychological factors may affect the present results because they are never directly observed and measured. According to the survey conducted, measures such as physical activity are more effective on chronic pain (13). Jafari and colleagues (2014) stated that it seems that sport practices will not have a significant effect on acute pain as it was confirmed in his empirical study on laboratory mice (14). Cancer patients often suffer from chronic and debilitating pain; therefore, physical self-care can ultimately improve their quality of life (35). It is known that acute and chronic pain mechanisms are different in terms of the route and neurotransmitters which are released fast and slowly from the end of pain fibers (36). So, perhaps it can be said that the effect of the sport exercises, in this study and similar studies, on the release of the transmitters involved in acute and chronic pain have been different and sport exercise in the long run (chronic phase) have been more likely to be able to release more opioid peptides and reduce pain by affecting central system of pain management (internal analgesia system).

Another important result of this study is the fact that there was a significant relationship between pain perception and emotional self-care which is consistent with the result of Linton (2011) (37). Bushnell et al. (2013) in a review study have stated that control and use of cognitive and emotional skills (psychological factors) could have a desirable effect on pain (38). Of course, in general the key point of this study is that no significant correlation was found between total self-care of patients and pain perception. Self-care has several sub-groups that are distinct from each other (22). Also pain perception and socioeconomic status, cancer stage, age, gender, medical history and family history of cancer were significantly correlated which is in line with the results of Sherman et al. (2011) (39) while the study of Shaban et al. (2004) reported no association between the stage of cancer and pain perception (40). In another study, a significant relationship was found between self-care and pain perception in patients with heart disease (41). Among the possible causes of these discrepancies one can refer to differences in the types of patients, cultural differences and methodology attributed Studies.

5.1. Limitations of the Study

The most important limitation of this study: 1) cultural differences which was not controllable in this study, 2) Impatience and lack of accuracy when completing the questionnaire due to disease-related treatment. Therefore, it is suggested that because of the importance of this issue, these kinds of studies in the future be performed more frequently with greater extent and greater accuracy on patients with various categories of cancers.

5.2. Application of the Results

Pain as one of the consequences of cancer must be one of the important nursing diagnoses in health care centers. Given the prevalence of pain in these patients, finding ways to reduce pain is necessary. Considering the significant effect of physical and emotional self-care on pain perception, it is anticipated that training can have beneficial effects on pain perception in these patients.

5.3. Conclusion

According to the results, no significant relationship was found between the total of self-care behaviors and pain perception. But a significant inverse relationship between physical self-care behaviors and a significant positive relationship between emotional self-care behaviors with the level of pain perception in patients with cancer was discovered. Considering the adverse effects of chronic pain treatment process and secondary problems, more comprehensive studies must be done on the effects of self-care behaviors on the perception of pain so that effective steps can be taken to intervene and promote the health of these patients.

Acknowledgements

References

  • 1.

    Eheman C, Henley SJ, Ballard-Barbash R, Jacobs EJ, Schymura MJ, Noone AM, et al. Annual Report to the Nation on the status of cancer, 1975-2008, featuring cancers associated with excess weight and lack of sufficient physical activity. Cancer. 2012;118(9):2338-66. [PubMed ID: 22460733]. https://doi.org/10.1002/cncr.27514.

  • 2.

    Sharif Nia H, Sharif SP, Esmaeili R, Goudarzian AH, Tahmasbii B, Yaghoobzadeh A, et al. Factors influencing the level of death depression in patients with cancer: A path analysis. J Mazandaran Univ Med Sci. 2017;26(145):318-31.

  • 3.

    Mousavi SM, Gouya MM, Ramazani R, Davanlou M, Hajsadeghi N, Seddighi Z. Cancer incidence and mortality in Iran. Ann Oncol. 2009;20(3):556-63. [PubMed ID: 19073863]. https://doi.org/10.1093/annonc/mdn642.

  • 4.

    Rose L, Smith O, Gelinas C, Haslam L, Dale C, Luk E, et al. Critical care nurses' pain assessment and management practices: a survey in Canada. Am J Crit Care. 2012;21(4):251-9. [PubMed ID: 22751367]. https://doi.org/10.4037/ajcc2012611.

  • 5.

    Goya M. Iranian Annual Cancer Registration Report 2005/2006. Ministry of Health and Medical Education, Health Deputy. Center Dis Control Prevent. 2007;2007.

  • 6.

    Goudarzian AH, M Bagheri Nesami, F Zamani, A Nasiri, S Beik. Relationship between Depression and Self-care in Iranian Patients with Cancer. Asian Pac J Cancer Prev. 2017;18(1):101-6.

  • 7.

    Pizzo PA, Poplack DG. Principles and practice of pediatric oncology. Lippincott Williams & Wilkins; 2015.

  • 8.

    Mellen PB, Gao SK, Vitolins MZ, Goff DC. Deteriorating dietary habits among adults with hypertension: DASH dietary accordance, NHANES 1988-1994 and 1999-2004. Arch Intern Med. 2008;168(3):308-14.

  • 9.

    Akyol AD, Cetinkaya Y, Bakan G, Yarali S, Akkus S. Self-care agency and factors related to this agency among patients with hypertension. J Clin Nurs. 2007;16(4):679-87. [PubMed ID: 17402949]. https://doi.org/10.1111/j.1365-2702.2006.01656.x.

  • 10.

    McCain GA. Role of physical fitness training in the fibrositis/fibromyalgia syndrome. Am J Med. 1986;81(3A):73-7. [PubMed ID: 3532784].

  • 11.

    McCain GA, Bell DA, Mai FM, Halliday PD. A controlled study of the effects of a supervised cardiovascular fitness training program on the manifestations of primary fibromyalgia. Arthritis Rheum. 1988;31(9):1135-41. [PubMed ID: 3048273].

  • 12.

    Paulev PE, Thorboll JE, Nielsen U, Kruse P, Jordal R, Bach FW, et al. Opioid involvement in the perception of pain due to endurance exercise in trained man. Jpn J Physiol. 1989;39(1):67-74. [PubMed ID: 2542682].

  • 13.

    Skargren EI, Oberg BE, Carlsson PG, Gade M. Cost and effectiveness analysis of chiropractic and physiotherapy treatment for low back and neck pain. Six-month follow-up. Spine (Phila Pa 1976). 1997;22(18):2167-77. [PubMed ID: 9322328].

  • 14.

    Jafari H, Daryanoosh F, Zarifkar A, Mohammadi M. Effect of Exercise on Pain and Morphine-Induced Analgesia in the Formalin Test in Male Mice. J Rafsanjan Univ Med Sci. 2014;13(1):97-108.

  • 15.

    Hasselstrom J, Liu-Palmgren J, Rasjo-Wraak G. Prevalence of pain in general practice. Eur J Pain. 2002;6(5):375-85. [PubMed ID: 12160512].

  • 16.

    Hatfield JA, Simmons S, editors. Perception of pain in athletes. Int J Exerc Sci Conference Proc. 2014. 48 p.

  • 17.

    Ord P, Gijsbers K. Pain thresholds and tolerances of competitive rowers and their use of spontaneous self-generated pain-coping strategies. Percept Mot Skills. 2003;97(3 Pt 2):1219-22. [PubMed ID: 15002867]. https://doi.org/10.2466/pms.2003.97.3f.1219.

  • 18.

    Tajet-Foxell B, Rose FD. Pain and pain tolerance in professional ballet dancers. Br J Sports Med. 1995;29(1):31-4. [PubMed ID: 7788215].

  • 19.

    Dolatkhah R, Somi MH, Bonyadi MJ, Asvadi Kermani I, Farassati F, Dastgiri S. Colorectal cancer in iran: molecular epidemiology and screening strategies. J Cancer Epidemiol. 2015;2015:643020. [PubMed ID: 25685149]. https://doi.org/10.1155/2015/643020.

  • 20.

    Education MoHaM. Health Education & Promotion Dept. 2014. Available from: http://iec.behdasht.gov.ir/index.aspx?fkeyid=&siteid=143&pageid=52912&p=2.

  • 21.

    Bagheri-Nesami M, Goudarzian AH, Mirani H, Jouybari SS, Nasiri D. Association between Self-Care Behaviors and Self-Esteem of Rural Elderlies; Necessity of Health Promotion. Mater Sociomed. 2016;28(1):41-5. [PubMed ID: 27047266]. https://doi.org/10.5455/msm.2016.28.41-45.

  • 22.

    Bagheri Nesami M, Goudarzian AH, Ardeshiri M, Babaie Holari M. Self-care behavior and its related factors in the community-dwelling elderlies in Sari, 2014. J Clin Nurs Midwifery. 2016;4(4).

  • 23.

    Gauthier LR, Young A, Dworkin RH, Rodin G, Zimmermann C, Warr D, et al. Validation of the short-form McGill pain questionnaire-2 in younger and older people with cancer pain. J Pain. 2014;15(7):756-70. [PubMed ID: 24780200]. https://doi.org/10.1016/j.jpain.2014.04.004.

  • 24.

    Berger MB, Damico NJ, Haefner HK. Responses to the McGill Pain Questionnaire predict neuropathic pain medication use in women in with vulvar lichen sclerosus. J Low Genit Tract Dis. 2015;19(2):135-9. [PubMed ID: 25036743]. https://doi.org/10.1097/LGT.0000000000000056.

  • 25.

    Melzack R. The McGill Pain Questionnaire: major properties and scoring methods. Pain. 1975;1(3):277-99. [PubMed ID: 1235985].

  • 26.

    Cherkin DC, Deyo RA, Battie M, Street J, Barlow W. A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. N Engl J Med. 1998;339(15):1021-9. [PubMed ID: 9761803]. https://doi.org/10.1056/NEJM199810083391502.

  • 27.

    Koltyn KF. Analgesia Following Exercise. Sports Med. 2000;29(2):85-98. https://doi.org/10.2165/00007256-200029020-00002.

  • 28.

    Kuphal KE, Fibuch EE, Taylor BK. Extended swimming exercise reduces inflammatory and peripheral neuropathic pain in rodents. J Pain. 2007;8(12):989-97. [PubMed ID: 17890162]. https://doi.org/10.1016/j.jpain.2007.08.001.

  • 29.

    Tesarz J, Schuster AK, Hartmann M, Gerhardt A, Eich W. Pain perception in athletes compared to normally active controls: a systematic review with meta-analysis. Pain. 2012;153(6):1253-62. [PubMed ID: 22607985]. https://doi.org/10.1016/j.pain.2012.03.005.

  • 30.

    Masoudi R, Mohammadi I, Nabavi SM, Ahmadi F. Effect of self-care program based on the Orem model on the Physical dimensions of life quality of patients with multiple sclerosis. J Yazd Univ Med Sci. 2010;7:20-9.

  • 31.

    Closs SJ, Edwards J, Swift C, Briggs M. Religious Identity and the Experience and Expression of Chronic Pain: A Review. J Religion Disabil Health. 2013;17(2):91-124. https://doi.org/10.1080/15228967.2013.778515.

  • 32.

    Moloney NA, Hall TM, O'Sullivan TC, Doody CM. Reliability of thermal quantitative sensory testing of the hand in a cohort of young, healthy adults. Muscle Nerve. 2011;44(4):547-52. [PubMed ID: 21826684]. https://doi.org/10.1002/mus.22121.

  • 33.

    Quiton RL, Greenspan JD. Across- and within-session variability of ratings of painful contact heat stimuli. Pain. 2008;137(2):245-56. [PubMed ID: 17942227]. https://doi.org/10.1016/j.pain.2007.08.034.

  • 34.

    Fernandez E, Turk DC. The utility of cognitive coping strategies for altering pain perception: a meta-analysis. Pain. 1989;38(2):123-35. [PubMed ID: 2674861].

  • 35.

    Portenoy RK. Treatment of cancer pain. Lancet. 2011;377(9784):2236-47. https://doi.org/10.1016/s0140-6736(11)60236-5.

  • 36.

    Bennett MI, Rayment C, Hjermstad M, Aass N, Caraceni A, Kaasa S. Prevalence and aetiology of neuropathic pain in cancer patients: a systematic review. Pain. 2012;153(2):359-65. [PubMed ID: 22115921]. https://doi.org/10.1016/j.pain.2011.10.028.

  • 37.

    Linton SJ, Shaw WS. Impact of psychological factors in the experience of pain. Phys Ther. 2011;91(5):700-11. [PubMed ID: 21451097]. https://doi.org/10.2522/ptj.20100330.

  • 38.

    Bushnell MC, Ceko M, Low LA. Cognitive and emotional control of pain and its disruption in chronic pain. Nat Rev Neurosci. 2013;14(7):502-11. [PubMed ID: 23719569]. https://doi.org/10.1038/nrn3516.

  • 39.

    Sherman KJ, Cherkin DC, Wellman RD, Cook AJ, Hawkes RJ, Delaney K, et al. A randomized trial comparing yoga, stretching, and a self-care book for chronic low back pain. Arch Intern Med. 2011;171(22):2019-26. [PubMed ID: 22025101]. https://doi.org/10.1001/archinternmed.2011.524.

  • 40.

    Shaban M, Monjamed Z, Mehran A, Hasanpour Dehkordi A. The relation between the cancer characteristics and quality of life in the patients under chemotherapy. J Hayat. 2004;10(3):79-84.

  • 41.

    MOHAMMAD HMR, Farahani B, Zohour AR, PANAHI ASH. Self-care ability based on Orem’s theory in individuals with coronary artery disease. 2010.