Time-course of attentional bias for pain-related cues in chronic daily headache sufferers

Attentional Processing of Unpleasant Stimuli in Alexithymia

Alexithymia is a multi-faceted personality trait defined by difficulties in identifying and describing emotions and is considered a risk factor for multiple psychiatric disorders. Current alexithymia research debates the type of attention bias involved in the processing of negative emotional information, especially in anxiety-evoking situations that are frequently associated with stress states. Relatedly, this study aims to examine the role of emotional influence on the attentional processing of Taiwanese alexithymic individuals. Using the Chinese version of the Toronto Alexithymia Scale-20 (TAS-20), individuals with high alexithymia (HA: TAS > 60, n = 26; Mage = 23.36) and individuals with low alexithymia (LA: TAS < 39, n = 26; Mage = 25.76) were recruited. Participants performed an emotional counting Stroop task preceded by anxiety-evoking (threatening and aversive pictures) or neutral pictures. Reaction times (RTs) of the emotional Stroop task were compared between HA and LA groups. Our results demonstrate that compared to individuals with LA, individuals with HA show early avoidance tendency (i.e., allocate less attentional resources to anxiety-evoking stimuli), and that negative affect therefore does not interfere with subsequent attention processing during the Stroop task, resulting in faster RT for unpleasant stimuli (Mthreatening = 683.87, Maversive = 685.87) than neutral stimuli (Mneutral = 695.64) (ps < .05). In addition, the attentional bias toward specific types of negative emotion was not differentiated in individuals with HA (p < .05), suggesting that alexithymic individuals' emotion schemas may be underdeveloped in terms of ability to specify exact emotions. This study provides evidence regarding early sensitization to negative stimuli during information processing, consistent with the notion that alexithymia is related to avoidant emotion regulation processes.

The impact of maternal child- and self-oriented pain-related injustice appraisals upon maternal attention to child pain, attention to anger, and pain-attending behavior

Objectives

The current study investigated the role of maternal child- and self-oriented injustice appraisals about child pain in understanding maternal attention for child pain and adult anger cues and pain-attending behavior.

Methods

Forty-four children underwent a painful cold pressor task (CPT) while their mother observed. Eye tracking was used to measure maternal attention to child pain and adult anger cues. Initial attention allocation and attentional maintenance were indexed by probability of first fixation and gaze duration, respectively. Maternal pain-attending behaviors toward the child were videotaped and coded after CPT completion. Mothers also rated the intensity of pain and anger cues used in the free-viewing tasks. All analyses controlled for maternal catastrophizing about child pain.

Results

Neither child-oriented nor self-oriented injustice was associated with maternal attentional bias toward child pain. Regarding attention toward self-relevant anger cues, differential associations were observed for self- and child-oriented injustice appraisals, with maternal self-oriented injustice being associated with a greater probability of first fixating on anger and with higher anger ratings, whereas maternal child-oriented injustice was associated with enhanced attentional maintenance toward anger. Neither type of maternal injustice appraisals was associated with maternal pain-attending behavior, which was only associated with maternal catastrophizing.

Conclusions

The current study sheds light on potential differential mechanisms through which maternal self- vs. child-oriented injustice appraisals may exert their impact on parent and child pain-related outcomes. Theoretical implications and future directions are discussed.

Neural correlates of the attentional bias towards pain-related faces in fibromyalgia patients: An ERP study using a dot-probe task

BACKGROUND

One of the major cognitive deficits in fibromyalgia has been linked to the hypervigilance phenomenon. It is mainly reflected as a negative bias for allocating attentional resources towards both threatening and pain-related information. Although the interest in its study has recently grown, the neural temporal dynamics of the attentional bias in fibromyalgia still remains an open question.

METHOD

Fifty participants (25 fibromyalgia patients and 25 healthy control subjects) performed a dot-probe task. Two types of facial expressions (pain-related and neutral) were employed as signal stimuli. Then, as a target stimulus, a single dot replaced the location of one of these two faces. Event-related potentials (ERP) in response to facial expressions and target stimulation (i.e., dot) were recorded. Reaction time (RT) and accuracy measures in the experimental task were collected as behavioural outcomes.

RESULTS

Temporal dynamics of brain electrical activity were analysed on two ERP components (P2 and N2a) sensitive to the facial expressions meaning. Pain-related faces elicited higher frontal P2 amplitudes than neutral faces for the whole sample. Interestingly, an interaction effect between group and facial expressions was also found showing that pain-related faces elicited enhanced P2 amplitudes (at fronto-central regions, in this case) compared to neutral faces only when the group of patients was considered. Furthermore, higher P2 amplitudes were observed in response to pain-related faces in patients with fibromyalgia compared to healthy control participants. Additionally, a shorter latency of P2 (at centro-parietal regions) was also detected for pain-related facial expressions compared to neutral faces. Regarding the amplitude of N2a, it was lower for patients as compared to the control group. Non-relevant effects of the target stimulation on the ERPs were found. However, patients with fibromyalgia exhibited slower RT to locate the single dot for incongruent trials as compared to congruent and neutral trials.

CONCLUSIONS

Data suggest the presence of an attentional bias in fibromyalgia that it would be followed by a deficit in the allocation of attentional resources to further process pain-related information. Altogether the current results suggest that attentional biases in fibromyalgia might be explained by automatic attentional mechanisms, which seem to be accompanied by an alteration of more strategic or controlled attentional components.

Emotional and Attentional Bias in Fibromyalgia: A Pilot ERP Study of the Dot-Probe Task

Introduction

The present research investigates the neural correlates of attentional bias in fibromyalgia (FM) with a dot-probe task performed during an electroencephalogram (EEG) recording.

Methods

For this purpose, 30 female participants were recruited, divided into two groups: a group of patients with FM (FM, n = 15, M_age = 51.87) and a healthy control group (HC) (HC, n = 15, M_age = 46.13).

Results

The results did not show behavioral differences between groups, but the EEG results showed that healthy controls had larger P300 amplitudes than patients with FM. Regarding late positive potentials (LPP), we found that patients with FM had larger amplitudes than healthy controls in a later time window.

Conclusion

In summary, while the P300 results suggest that patients allocate less attentional resources to the task, the increased amplitudes of their LPP suggest augmented emotional processing of the target stimuli. Altogether, our results seem to support the thesis of generalized attentional deficits in FM.

Fibromyalgia (FM) is a chronic musculoskeletal pain condition. There has been discussion in the scientific literature as to whether patients with FM suffer from a generalized attentional deficit or an attentional bias—preferentially selecting pain-related information. Attentional bias in FM patients has been studied as hypervigilance, which refers to early detection of pain-related information or innocuous information. Thus, the aim of this study was to test whether there is a generalized attentional deficit or attentional bias in relation to pain in patients with FM, by studying the neural activity underlying cognitive processes, specifically with evoked potentials (P300 and late positive potential—LPP). The P300 has been related to the use of attentional resources and the LPP to affective modulation. For this purpose, we studied two groups: a group of patients with FM and a healthy control group. Our hypotheses considered that FM patients, compared to healthy controls, would show an attentional bias for pain-related words (1) reflected in higher hits and shorter reaction time when detecting the target of a cognitive task (dot-probe), and (2) manifested by increased amplitudes of P300 and LPP evoked potentials while performing the task. The electrophysiological results suggest that FM patients may have a generalized attentional deficit and, despite this being the case, FM patients are more emotionally involved in the task.

Cognitive-emotional processing in alexithymia: an integrative review

Alexithymia is a multifaceted personality construct characterised by difficulties identifying one's feelings and distinguishing them from bodily sensations, difficulties describing one's feelings to others, and an externally oriented cognitive style. Over the past 25 years, a burgeoning body of research has examined how alexithymia moderates processing at the cognition-emotion interface. We review the findings in five domains: attention, appraisals, memory, language, and behaviours. The preponderance of studies linked alexithymia with deficits in emotion processing, which was apparent across all domains, except behaviours. All studies on behaviours and a proportion of studies in other domains demonstrated emotional over-responding. Analysis at the facet level revealed deficits in memory and language that are primarily associated with externally oriented thinking, while over-responding was most often linked to difficulty identifying feelings and difficulty describing feelings. The review also found evidence for contextual modulation: The pattern of deficits and over-responding was not restricted to emotional contexts but also occurred in neutral contexts, and in some circumstances, emotional over-responding in alexithymia was beneficial. Taken together, this review highlights alexithymia as a central personality dimension in the interplay between cognition and emotion.

Emotional affection on a sustained attention task: The importance the aging process and depression

Chronic pain is a complex experience that has now become a major public health issue. This has prompted many researchers to study attention, understanding it to be a crucial factor that allows altering the experience of pain, while attributing considerable importance to sustained attention. Accordingly, the main studies in this field stress the importance of emotion regulation processes and emotions on the perception of painful stimuli and attentional processes themselves. Nevertheless, only a handful of studies have been found that directly study the relationship between these variables. Within this context, this article sets out to analyse emotional regulation processes, emotional variables (depression and anxiety), the experience of pain, and age on the ability to maintain the vigilance response in a sample of patients with chronic pain. This involved selecting a sample of 49 patients with rheumatoid arthritis and examining their performance in an ad-hoc sustained attention test. With a view to complying with the study's main purpose, the participants were also assessed through the use of the following self-report measures: the Beck Depression Inventory (BDI-I); the Hospital Anxiety and Depression Scale (HADS); the McGill Pain Questionnaire, and the Difficulties in Emotion Regulation Scale (DERS). Linear regression analyses revealed a significant impact of the aging process on the performance times in the attention task. Likewise, age and depression recorded a significant correlation with the mistakes made during the task. These results suggest that higher depression levels and an older age might be related to a worse adaptation to pain management techniques based on attention processes, such as mindfulness.

Internet-delivered attentional bias modification training (iABMT) for the management of chronic musculoskeletal pain: a protocol for a randomised controlled trial

INTRODUCTION

Chronic musculoskeletal pain is a complex medical condition that can significantly impact quality of life. Patients with chronic pain demonstrate attentional biases towards pain-related information. The therapeutic benefits of modifying attentional biases by implicitly training attention away from pain-related information towards neutral information have been supported in a small number of published studies. Limited research however has explored the efficacy of modifying pain-related biases via the internet. This protocol describes a randomised, double-blind, internet-delivered attentional bias modification intervention, aimed to evaluate the efficacy of the intervention on reducing pain interference. Secondary outcomes are pain intensity, state and trait anxiety, depression, pain-related fear, and sleep impairment. This study will also explore the effects of training intensity on these outcomes, along with participants' perceptions about the therapy.

METHODS AND ANALYSIS

The study is a double-blind, randomised controlled trial with four arms exploring the efficacy of online attentional bias modification training versus placebo training theorised to offer no specific therapeutic benefit. Participants with chronic musculoskeletal pain will be randomised to one of four groups: (1) 10-session attentional modification group; (2) 10-session placebo training group; (3) 18-session attentional modification group; or (4) 18-session placebo training group. In the attentional modification groups, the probe-classification version of the visual-probe task will be used to implicitly train attention away from threatening information towards neutral information. Following the intervention, participants will complete a short interview exploring their perceptions about the online training. In addition, a subgroup analysis for participants aged 16-24 and 25-60 will be undertaken.

ETHICS AND DISSEMINATION

This study has been approved by the University of Southampton Research Ethics Committee. Results will be published in peer-reviewed journals, academic conferences, and in lay reports for pain charities and patient support groups.

TRIAL REGISTRATION NUMBER

NCT02232100; Pre-results.

Attentional bias and its temporal dynamics among war veterans suffering from chronic pain: Investigating the contribution of post-traumatic stress symptoms

BACKGROUND

Cognitive models propose that attentional dysregulation, including an attentional bias towards threat, is one of the factors through which chronic pain and post-traumatic stress symptoms (PTSS) maintain and exacerbate one another. The current investigation assessed the attentional bias for painful facial expressions and its relationship with PTSS, using both traditional and variability-based attentional bias measures, among veterans with chronic pain and PTSS and controls.

METHOD

Fifty-four veterans with chronic pain and 30 age/education-matched controls participated in this investigation. Participants completed a self-report measure of PTSS and a modified version of the dot-probe task with painful, happy, and neutral facial expressions. Attention was assessed using both traditional and variability-based reaction time measures of attentional bias.

RESULTS

Veterans directed attention away from painful facial expressions (i.e., avoidance) relative to both the control group (between-subject effect) and relative to neutral faces (within-subject effect). Veterans also showed significantly elevated attentional bias variability for both happy and painful facial expressions compared to controls. Attentional bias variability for happy and painful facial expressions was correlated with PTSS among all participants.

CONCLUSION

Veterans with chronic pain and PTSS avoided pain-related stimuli and displayed an overall attentional dysregulation for emotional facial expressions. Avoidance of pain cues may be a coping strategy that these individuals develop under stressful conditions. Implications, limitations, and directions for future research are discussed.

Attentional, interpretation and memory biases for sensory-pain words in individuals with chronic headache

INTRODUCTION

Cognitive biases in attention, interpretation and less consistently memory have been observed in individuals with chronic pain and play a critical role in the onset and maintenance of chronic pain. Despite operating in combination cognitive biases are typically explored in isolation.

AIM

The primary aim of this study was to explore attentional, interpretation and memory biases and their interrelationship in individuals with chronic headache.

METHODS

Twenty-eight participants with chronic headache and 34 healthy controls completed paradigms assessing attentional, interpretation and memory biases with ambiguous sensory-pain and neutral words.

RESULTS

Individuals with chronic pain showed significantly greater pain-related attentional and interpretation biases relative to controls, with no differences in memory bias. No significant correlation was found between any of the three forms of cognitive bias assessed.

DISCUSSION AND CONCLUSION

The clinical implications of cognitive biases in individuals with chronic pain remain to be fully explored, although one avenue for future research would be specific investigation of the implications of biased interpretations considering the consistency of results found across the literature for this form of bias.

The relationship between alexithymia and headache impact: the role of somatization and pain catastrophizing

PURPOSE

The present study compared psychological factors (i.e., alexithymia, somatization, pain catastrophizing (PC), anxiety, and depression) and QOL for headache patients and headache-free individuals, and examined whether somatization and PC mediate the relationship between alexithymia and headache impact in headache patients.

METHODS

Study participants consisted of 123 headache patients from an outpatient clinic at a university hospital and 124 headache-free individuals in Daegu, Korea. The survey employed the somatization and anxiety subscales of the Symptom Checklist-90-revised, the Patient Health Questionnaire-9, Pain Catastrophizing Scale, Toronto Alexithymia Scale, Short-Form Health survey-8 (SF-8), and the Headache Impact Test-6.

RESULTS

Headache patients showed a higher level of all psychological factors and lower level of two summary scores (physical and mental health) as well as the seven dimensions of the SF-8 compared with headache-free individuals. Examination employing the SPSS Process macro found that the direct effect of alexithymia on headache impact was not significant after controlling for somatization and PC. The total indirect effects of alexithymia on headache impact were significant without anxiety and depression as covariates with the significant indirect effects of alexithymia on headache impact via somatization or via PC as well as via somatization and PC. However, after controlling for anxiety and depression, PC was the only significant pathway through which alexithymia was related to headache impact.

CONCLUSIONS

Headache patients may benefit from interventions aiming at improving psychological factors in order to improve the functioning and QOL of headache patients.

Combined cognitive biases for pain and disability information in individuals with chronic headache: A preliminary investigation

Pain-related cognitive biases have been demonstrated in chronic pain patients, yet despite theoretical predictions are rarely investigated in combination. Combined cognitive biases were explored in individuals with chronic headache ( n = 17) and pain-free controls ( n = 20). Participants completed spatial cueing (attentional bias), sentence generation (interpretation bias) and free recall tasks (memory bias), with ambiguous sensory-pain, disability and neutral words. Individuals with chronic headache, relative to controls, showed significantly greater interpretation and memory biases favouring ambiguous sensory-pain words and interpretation bias favouring ambiguous disability words. No attentional bias was found. Further research is needed exploring the temporal pattern of cognitive biases.

Keeping an eye on pain: investigating visual attention biases in individuals with chronic pain using eye-tracking methodology

Attentional biases to painful stimuli are evident in individuals with chronic pain, although the directional tendency of these biases (ie, toward or away from threat-related stimuli) remains unclear. This study used eye-tracking technology, a measure of visual attention, to evaluate the attentional patterns of individuals with and without chronic pain during exposure to injury-related and neutral pictures. Individuals with (N=51) and without chronic pain (N=62) completed a dot-probe task using injury-related and neutral pictures while their eye movements were recorded. Mixed-design analysis of variance evaluated the interaction between group (chronic pain, pain-free) and picture type (injury-related, neutral). Reaction time results showed that regardless of chronic pain status, participants responded faster to trials with neutral stimuli in comparison to trials that included injury-related pictures. Eye-tracking measures showed within-group differences whereby injury-related pictures received more frequent fixations and visits, as well as longer average visit durations. Between-group differences showed that individuals with chronic pain had fewer fixations and shorter average visit durations for all stimuli. An examination of how biases change over the time-course of stimulus presentation showed that during the late phase of attention, individuals with chronic pain had longer average gaze durations on injury pictures relative to pain-free individuals. The results show the advantage of incorporating eye-tracking methodology when examining attentional biases, and suggest future avenues of research.

Caregivers' attentional bias to pain: does it affect caregiver accuracy in detecting patient pain behaviors?

Attentional bias to pain among family caregivers of patients with pain may enhance the detection of pain behaviors in patients. However, both relatively high and low levels of attentional bias may increase disagreement between patients and caregivers in reporting pain behaviors. This study aims to provide further evidence for the presence of attentional bias to pain among family caregivers, to examine the association between caregivers' attentional bias to pain and detecting pain behaviors, and test whether caregivers' attentional bias to pain is curvilinearly related to patient and caregiver disagreement in reporting pain behaviors. The sample consisted of 96 caregivers, 94 patients with chronic pain, and 42 control participants. Caregivers and controls completed a dot-probe task assessing attention to painful and happy stimuli. Both patients and caregivers completed a checklist assessing patients' pain behavior. Although caregivers did not respond faster to pain congruent than pain incongruent trials, caregiver responses were slower in pain incongruent trials compared with happy incongruent trials. Caregivers showed more bias toward pain faces than happy faces, whereas control participants showed more bias toward happy faces than pain faces. Importantly, caregivers' attentional bias to pain was significantly positively associated with reporting pain behaviors in patients above and beyond pain severity. It is reassuring that attentional bias to pain was not related to disagreement between patients and caregivers in reporting pain behaviors. In other words, attentional bias does not seem to cause overestimation of pain signals.

Painful faces-induced attentional blink modulated by top-down and bottom-up mechanisms

Pain-related stimuli can capture attention in an automatic (bottom–up) or intentional (top–down) fashion. Previous studies have examined attentional capture by pain-related information using spatial attention paradigms that involve mainly a bottom–up mechanism. In the current study, we investigated the pain information-induced attentional blink (AB) using a rapid serial visual presentation (RSVP) task, and compared the effects of task-irrelevant and task-relevant pain distractors. Relationships between accuracy of target identification and individual traits (i.e., empathy and catastrophizing thinking about pain) were also examined. The results demonstrated that task-relevant painful faces had a significant pain information-induced AB effect, whereas task-irrelevant faces showed a near-significant trend of this effect, supporting the notion that pain-related stimuli can influence the temporal dynamics of attention. Furthermore, we found a significant negative correlation between response accuracy and pain catastrophizing score in task-relevant trials. These findings suggest that active scanning of environmental information related to pain produces greater deficits in cognition than does unintentional attention toward pain, which may represent the different ways in which healthy individuals and patients with chronic pain process pain-relevant information. These results may provide insight into the understanding of maladaptive attentional processing in patients with chronic pain.

Pain-related and negative semantic priming enhances perceived pain intensity

BACKGROUND

Negative affective and pain-related cues, such as pictures or words, have been shown to act as primes and enhance the perceived intensity of subsequent painful events. For pain-related semantic primes, it remains unclear whether this effect depends on negative valence itself or, specifically, on the pain-relatedness of the words.

OBJECTIVES

To investigate the effect of pain-related, negative affective (pain-unrelated) and neutral semantic primes on the perception of subsequent noxious target stimuli.

METHODS

Pain ratings in response to noxious electrical stimulation of light and moderate intensity were examined in 39 healthy subjects after subjects were exposed to semantic primes of different meaning and valence (pain-related, negative, positive and neutral adjectives) presented with different interstimulus intervals (0 ms, 500 ms and 1500 ms).

RESULTS

Increased pain ratings of noxious stimuli were observed following pain-related and negative compared with neutral primes.

DISCUSSION

The results support the motivational priming theory for semantic stimuli, indicating that affectively negative semantic primes increase subjective pain intensity. However, a specific pain-related priming effect was not reliably demonstrated. Additionally, it is shown that experimental parameters (ie, stimulus intensity and interstimulus interval) modify the extent of negative and pain-related semantic priming.

CONCLUSIONS

Verbal priming plays a role for the perception of noxious stimuli in a time-dependent manner.

Mindfulness-oriented recovery enhancement reduces pain attentional bias in chronic pain patients

BACKGROUND

Chronic pain involves hypervigilance for pain-related stimuli. Selective attention to pain-related stimuli, known as pain attentional bias (AB), can exacerbate chronic pain, prolong suffering, and undermine quality of life. The aim of this study was to determine if a multimodal mindfulness-oriented intervention could significantly reduce pain AB among chronic pain patients receiving opioid analgesics.

METHODS

A total of 67 chronic pain patients were randomized to an 8-week Mindfulness-Oriented Recovery Enhancement (MORE) intervention or a social support group intervention and began treatment. A dot probe task was used to measure pain AB. Primary outcomes were pain AB scores for cues presented for 2,000 and 200 ms.

RESULTS

Prior to intervention, participants exhibited a significant bias towards pain-related cues presented for 2,000 ms, but no bias for cues presented for 200 ms. A statistically significant time × intervention condition interaction was observed for 2,000 ms pain AB, such that participants in MORE evidenced significantly reduced posttreatment pain AB relative to pretreatment levels, whereas no significant pre-post treatment changes in pain AB were observed for support group participants. Decreases in pain AB were associated with increased perceived control over pain and attenuated reactivity to distressing thoughts and emotions.

CONCLUSION

Study findings provide the first indication that a mindfulness-oriented intervention may reduce pain AB among adults suffering from chronic pain. Given the magnitude of chronic pain in postindustrial societies, coupled with the dramatic escalation in prescription opioid misuse, future studies should evaluate MORE as a nonpharmacological means of addressing factors linked with chronic pain.

Children's selective attention to pain and avoidance behaviour: the role of child and parental catastrophizing about pain

The present study investigated selective attention to pain in children, its implications for child avoidance behaviour, and the moderating role of dimensions comprising child and parental catastrophizing about pain (ie, rumination, magnification, and helplessness). Participants were 59 children (31 boys) aged 10-16 years and one of their parents (41 mothers). Children performed a dot-probe task in which child facial pain displays of varying pain expressiveness were presented. Child avoidance behaviour was indexed by child pain tolerance during a cold-pressor task. Children and parents completed measures of child and parent pain catastrophizing, respectively. Findings indicated that both the nature of child selective attention to pain and the impact of selective attention upon child avoidance behaviour were differentially sensitive to specific dimensions of child and parental catastrophizing. Specifically, findings showed greater tendency to shift attention away from pain faces (i.e.,, attentional avoidance) among children reporting greater pain magnification. A similar pattern was observed in terms of parental characteristics, such that children increasingly shifted attention away from pain with increasing levels of parental rumination and helplessness. Furthermore, child attentional avoidance was associated with greater avoidance behaviour (i.e., lower pain tolerance) among children reporting high levels of pain magnification and those whose parents reported greater rumination about pain. The current findings corroborate catastrophizing as a multidimensional construct that may differentially impact outcomes and attest to the importance of assessing both child and parental characteristics in relation to child pain-related attention and avoidance behaviour. Further research directions are discussed.

The role of threat expectancy in attentional bias and thermal pain perception in healthy individuals

The influence of threat expectancy upon attentional biases for pain-related information and pain thresholds was explored in healthy participants. Participants were randomized to receive either threatening ( n = 32) or nonthreatening ( n = 31) information regarding an upcoming computerized task assessing cold and heat pain thresholds. Participants receiving threatening information were more worried about the pain task and, relative to those receiving nonthreatening information, showed attentional bias toward sensory-pain words. No between-group differences were found in terms of cold and heat pain thresholds. These results show that the type of information participants receive can influence their attentional processes and emotional concerns.

Cancer pain: part 2: physical, interventional and complimentary therapies; management in the community; acute, treatment-related and complex cancer pain: a perspective from the British Pain Society endorsed by the UK Association of Palliative Medicine and the Royal College of General Practitioners

OBJECTIVE

This discussion document about the management of cancer pain is written from the pain specialists' perspective in order to provoke thought and interest in a multimodal approach to the management of cancer pain, not just towards the end of life, but pain at diagnosis, as a consequence of cancer therapies, and in cancer survivors. It relates the science of pain to the clinical setting and explains the role of psychological, physical, interventional and complementary therapies in cancer pain.

METHODS

This document has been produced by a consensus group of relevant healthcare professionals in the United Kingdom and patients' representatives making reference to the current body of evidence relating to cancer pain. In the second of two parts, physical, invasive and complementary cancer pain therapies; treatment in the community; acute, treatment-related and complex cancer pain are considered.

CONCLUSIONS

It is recognized that the World Health Organization (WHO) analgesic ladder, whilst providing relief of cancer pain towards the end of life for many sufferers world-wide, may have limitations in the context of longer survival and increasing disease complexity. To complement this, it is suggested that a more comprehensive model of managing cancer pain is needed that is mechanism-based and multimodal, using combination therapies including interventions where appropriate, tailored to the needs of an individual, with the aim to optimize pain relief with minimization of adverse effects.