Beyond Negative Pain-Related Psychological Factors: Resilience Is Related to Lower Pain Affect in Healthy Adults

Relationship between pain resilience and pain catastrophizing in older patients after total knee arthroplasty: Chain-mediating effects of cognitive emotion regulation and pain management self-efficacy

This study aimed to determine whether the relationship between pain resilience and pain catastrophizing in older patients after total knee arthroplasty (TKA) was mediated by cognitive emotion regulation strategies (CERS) and pain management self-efficacy (PMSE). Convenience cluster sampling was used in this cross-sectional study to recruit 382 older adults. The results revealed that pain catastrophizing was negatively correlated with pain resilience, adaptive CERS, and PMSE; however, it was positively correlated with maladaptive CERS (all p < 0.01). Mediation analysis revealed that both CERS (adaptive and maladaptive) and self-management independently and sequentially mediated the relationship between pain resilience and pain catastrophizing in older patients who underwent TKA. These findings demonstrate that CERS (adaptive and maladaptive) and PMSE play chain-mediating roles in the correlation between pain resilience and pain catastrophizing in older patients after TKA.

Broadening the Scope of Resilience in Chronic Pain: Methods, Social Context, and Development

PURPOSE OF REVIEW

A wellspring of new research has offered varying models of resilience in chronic pain populations; however, resilience is a multifaceted and occasionally nebulous construct. The current review explores definitional and methodological issues in existing observational and clinical studies and offers new directions for future studies of pain resilience.

RECENT FINDINGS

Definitions of pain resilience have historically relied heavily upon self-report and from relatively narrow scientific domains (e.g., positive psychology) and in narrow demographic groups (i.e., Caucasian, affluent, or highly educated adults). Meta-analytic and systematic reviews have noted moderate overall quality of resilience-focused assessment and treatment in chronic pain, which may be attributable to these narrow definitions. Integration of research from affiliated fields (developmental models, neuroimaging, research on historically underrepresented groups, trauma psychology) has the potential to enrich current models of pain resilience and ultimately improve the empirical and clinical utility of resilience models in chronic pain.

Pain relief and associated factors: a cross-sectional observational web-based study in a Quebec cohort of persons living with chronic pain

Objectives

Randomized clinical trials are used to evaluate the efficacy of various pain treatments individually, while a limited number of observational studies have portrayed the overall relief experienced by persons living with chronic pain. This study aimed to describe pain relief in real-world clinical settings and to identify associated factors.

Methods

This exploratory web-based cross-sectional study used data from 1,419 persons recruited in the community. Overall pain relief brought by treatments used by participants was assessed using a 0%-100% scale (10-unit increments).

Results

A total of 18.2% of participants reported minimal pain relief (0%-20%), 60.0% moderate to substantial pain relief (30%-60%), and 21.8% extensive pain relief (70%-100%). Multivariable multinomial regression analysis revealed factors significantly associated with greater pain relief, including reporting a stressful event as circumstances surrounding the onset of pain, living with pain for ≥10 years, milder pain intensity, less catastrophic thinking, use of prescribed pain medications, use of nonpharmacological pain treatments, access to a trusted healthcare professional, higher general health scores, and polypharmacy. Factors associated with lower pain relief included surgery as circumstances surrounding pain onset, use of over-the-counter pain medications, and severe psychological distress.

Discussion

In this community sample of persons living with chronic pain, 8 out of 10 persons reported experiencing at least moderate relief with their treatment. The analysis has enabled us to explore potential modifiable factors as opportunities for improving the well-being of persons living with chronic pain.

Finding a path in a methodological jungle: a qualitative research of resilience

Qualitative research provides an in-depth understanding of lived experiences. However, these experiences can be hard to apprehend by using just one method of data analysis. A good example is the experience of resilience. In this paper, the authors describe the chain of the decision-making process in the research of the construct of "resilience". s The authors justify the implications of a multi-method, pluralistic approach, and show how the triangulation of two or more qualitative methods and integration of several qualitative data analysis methods can improve a deeper understanding of the resilience among people with chronic pain. By combining the thematic analysis, narrative analysis, and critical incident technique, lived experiences can be seen from different perspectives.Therefore, the thematic analysis describes the content and answers to "what" regarding resilience, the narrative analysis describes the dynamics of resilience, and answers to "how", while the critical incident technique clarifies the most significant experience and the answers to "why" changes happen. This integrative approach could be used in the analysis of other psychological constructs and can serve as an example of how the rigour of qualitative research could be provided.

Resilience is associated with cortical gray matter of the antinociceptive pathway in people with chronic pain

Resilience is an important personal characteristic that influences health and recovery. Previous studies of chronic pain suggest that highly resilient people may be more effective at modulating their pain. Since brain gray matter in the antinociceptive pathway has also been shown to be abnormal in people with chronic pain, we examined whether resilience is related to gray matter in regions of interest (ROIs) of the antinociceptive pathway (rostral and subgenual anterior cingulate cortex (rACC, sgACC), anterior insula (aINS), dorsolateral prefrontal cortex (dlPFC)) normally and in people who are experiencing chronic pain. We extracted gray matter volume (GMV) and cortical thickness (CT) from 3T MRIs of 88 people with chronic pain (half males/females) and 86 healthy controls (HCs), who completed The Resilience Scale and Brief Pain Inventory. We found that resilience scores were significantly lower in people with chronic pain compared to HCs, whereas ROI GMV and CT were not different between groups. Resilience negatively correlated with average pain scores and positively correlated with GMV in the bilateral rACC, sgACC, and left dlPFC of people with chronic pain. Mediation analyses revealed that GMV in the right rACC and left sgACC partially co-mediated the relationship between resilience and average pain in people with chronic pain. The resilience-pain and some resilience-GMV relationships were sex-dependent. These findings suggest that the antinociceptive pathway may play a role in the impact of resilience on one's ability to modulate chronic pain. A better understanding of the brain-resilience relationship may help advance evidence-based approaches to pain management.

Irritable Bowel Syndrome and Resilience

Irritable bowel syndrome (IBS) is a disorder of the gut-brain interaction (DGBI), characterized, mainly in severe cases, by altered psychological stress reactivity, psychological disorders, and dysfunction of the brain-gut-microbiota axis. Prior studies have highlighted significant physical and emotional impairments in the health-related quality of life of patients with IBS. Resilience is a psychosocial ability that reduces negative emotions while enhancing adaptation to adversities. Resilience is essential for health promotion and stress response. The present study aimed to carry out a review of the literature in multiple databases, using the descriptors "resilience", "resiliency", and "irritable bowel syndrome". The inclusion criteria for obtaining the most relevant papers were research articles on resilience and irritable bowel syndrome written in English, published in a peer-reviewed journal, and involving human subjects. Studies specifically on resilience in IBS were sparse. These results need to be understood in light of these limitations. As resilience appears to be modifiable, it is essential to conduct direct research on resilience-enhancing interventions for people with IBS. The study of the factors involved in successful adaptation must be extended, to possibly yield new interventions that help the patients overcome the difficulties imposed by the disease.

Neurophysiological and Psychosocial Mechanisms of Fibromyalgia: A Comprehensive Review and Call for An Integrative Model

Research into the neurobiological and psychosocial mechanisms involved in fibromyalgia has progressed remarkably in recent years. Despite this, current accounts of fibromyalgia fail to capture the complex, dynamic, and mutual crosstalk between neurophysiological and psychosocial domains. We conducted a comprehensive review of the existing literature in order to: a) synthesize current knowledge on fibromyalgia; b) explore and highlight multi-level links and pathways between different systems; and c) build bridges connecting disparate perspectives. An extensive panel of international experts in neurophysiological and psychosocial aspects of fibromyalgia discussed the collected evidence and progressively refined and conceptualized its interpretation. This work constitutes an essential step towards the development of a model capable of integrating the main factors implicated in fibromyalgia into a single, unified construct which appears indispensable to foster the understanding, assessment, and intervention for fibromyalgia.

Effects of psychosocial stress and performance feedback on pain processing and its correlation with subjective and neuroendocrine parameters

OBJECTIVES

Previous research on stress-induced pain modulation suggests that moderate psychological stress usually leads to hyperalgesia while more severe threat results in hypoalgesia. However, existing studies often lack suitable control conditions imperative to identify mere stress effects. Similarly, research mainly focused on pure anticipation of a social threat, not taking into consideration actual experiences of social evaluation. Therefore, we set out to investigate actual social up- and downgrading combined with a standardized stress paradigm to evaluate short-term and prolonged changes in pain perception and their potential association with neuroendocrine and subjective stress parameters.

METHODS

We allocated 177 healthy women to four experimental conditions, either the standard version of the Trier Social Stress Test (TSST) followed by positive, negative or no performance feedback, or a well-matched but less demanding placebo version of the TSST. Stress responses were assessed with ratings, salivary alpha-amylase, and salivary cortisol. To capture putative effects of stress on pain, heat pain threshold, ratings of phasic heat pain stimuli, and conditioned pain modulation were measured.

RESULTS

Despite a largely successful stress induction, results do not support a reliable influence of experimentally induced social stress-with or without subsequent performance feedback-on pain in women. Further, we found no clear association of pain modulation and changes in neuroendocrine or subjective stress responses.

CONCLUSIONS

Our results contrast previous studies, which repeatedly demonstrated stress-induced hypo- or hyperalgesia. This might be due to methodological reasons as former research was often characterized by high heterogeneity regarding the applied stressors, low sample sizes, and lacking or inconclusive control conditions. Thus, our results raise the question whether pain modulation in women by experimental psychosocial stress might have been overestimated in the past. Future research is necessary, which should employ parametric stress induction methods including well-matched control tasks, taking into consideration the participants' gender/sex and the time course of the stress response relative to pain assessment. The study is registered as DRKS00026946 at 'Deutsches Register Klinischer Studien' (DRKS) and can be also found at the World Health Organization's search portal.

Vulnerable Dispositional Traits and Chronic Pain: Predisposing but not Predetermining

Dispositional traits can be protective or contribute to increased vulnerability in individuals with chronic pain. This study aims to evaluate the association between two dispositional trait measures, affect balance style and multi-domain trait groups, with psychosocial measures, clinical pain, functional pain, and experimental pain at two years in individuals with chronic knee pain. The study is a prospective analysis of 168 community dwelling individuals aged 45 to 85 years old with knee pain with or at risk for knee osteoarthritis. At baseline, affect balance style and multi-domain trait groups were associated with psychosocial measures, clinical pain, and functional status. At the two-year time point, the multi-domain trait groups were associated with the clinical pain measures. Interestingly, individuals with previously demonstrated vulnerable traits showed more variability in dispositional trait status at the two-year time point compared to those with dispositional traits previously demonstrated as more protective. Findings reiterate that dispositional traits are predisposing but are not predetermining regarding pain-related experiences. PERSPECTIVE: Vulnerable and protective dispositional traits are positively and negatively associated with clinical pain and functional limitations respectively. Although considered relatively stable, a 30-50% shift in dispositional traits was indicated over a two-year period. Findings highlight that dispositional trait are modifiable and thus, predisposing but not predetermining for persisting chronic pain.

Subjective perception of life stress events affects long-term pain: the role of resilience

OBJECTIVE

There is evidence that experiencing childhood trauma and life stressors across the lifespan together with lower resilience is associated with chronic pain-related conditions. The aim of this study was to explore the potential mediating role of resilience in the relationship between childhood trauma and long-term pain and to explore a possible moderating role of serious life stressors in the last year.

METHODS

The participants, drawn from a representative sample of citizens of the Czech Republic (n = 1800, mean age: 46.6 years, 48.7% male), were asked to report various long-term pain conditions, childhood trauma (Childhood Trauma Questionnaire, CTQ), life stressors (Life Stressor Checklist Revised, LSC-R) and resilience (Brief Resilience Scale, BRS) in a cross-sectional face-to-face study conducted in 2016. A conditional process SEM model of moderated mediation was performed.

RESULTS

The occurrence of life stress events affecting the participant's last year moderated the relationship between childhood trauma, resilience and health. In the group of participants who experienced at least one life stress event affecting their last year, resilience fully mediated the effect of past childhood trauma on long-term pain. In participants who did not experience life stressors with an impact on the last year, the direct path from childhood trauma to health through resilience lost its significance.

CONCLUSION

The subjective meaning of stress events on one's life has an impact on the trajectory between childhood trauma and health and acts as a moderator. Resilience may buffer the negative effect of trauma on later long-term pain.

Baseline resting-state functional connectivity determines subsequent pain ratings to a tonic ecologically valid experimental model of orofacial pain

ABSTRACT

Pain is a subjective experience with significant individual differences. Laboratory studies investigating pain thresholds and experimental acute pain have identified structural and functional neural correlates. However, these types of pain stimuli have limited ecological validity to real-life pain experiences. Here, we use an orthodontic procedure-the insertion of an elastomeric separator between teeth-which typically induces mild to moderate pain that peaks within 2 days and lasts several days. We aimed to determine whether the baseline structure and resting-state functional connectivity of key regions along the trigeminal nociceptive and pain modulatory pathways correlate with subsequent peak pain ratings. Twenty-six healthy individuals underwent structural and resting-state functional MRI scanning before the placement of a separator between the first molar and second premolar, which was kept in place for 5 days. Participants recorded pain ratings 3 times daily on a 100-mm visual analogue scale. Peak pain was not significantly correlated with diffusion metrics of the trigeminal nerve or gray matter volume of any brain region. Peak pain did, however, positively correlate with baseline resting-state functional connectivity between the thalamus contralateral to the separator and bilateral insula, and negatively correlated with connectivity between the periaqueductal gray (PAG) and core nodes of the default mode network (medial prefrontal and posterior cingulate cortices). The ascending (thalamic) nociceptive and the descending (PAG) pain modulatory pathways at baseline each explained unique variation in peak pain intensity ratings. In sum, preinterventional functional neural architecture of both systems determined the individual pain experience to a subsequent ecologically valid pain stimulus.

The Effect of Pain Resilience on Experimental Pain Experience Across Different Stimuli

OBJECTIVE

Pain resilience, one's ability to maintain behavioral engagement and adaptively regulate cognitions and emotions despite intense or prolonged pain, has been shown to protect against negative pain-related outcomes in experimental settings. A weakness of this research, and much of experimental pain research in general, has been the lack of rationale behind the selection of noxious stimuli, which can activate different nociceptive fibers. The present study sought to determine if the relationship between pain resilience and pain ratings differed across stimuli based on the stimulated nociceptors.

METHODS

Healthy undergraduate students (N = 100; mean [SD] age = 19.4 [1.2] years; 60% female) completed the Pain Resilience Scale and provided continuous pain ratings during exposure to three different tasks, each selected based on their ability to stimulate specific combinations of nociceptive fibers: pinprick (Aδ fibers), cold water immersion (Aδ and C fibers), and ischemic tourniquet (C fibers).

RESULTS

Participants with high pain resilience reported lower pain ratings over time during cold water immersion than did those with low pain resilience (F(1, 39) = 8.526, p = .006); however, there was no relationship between pain resilience and pain ratings during either of the pinprick or ischemic tourniquet stimuli.

CONCLUSIONS

This study provides further support for the use of multiple pain stimuli for pain assessment given their unique characteristics and concludes that outcome variables aside from pain ratings may provide additional insight into the role of resilience on pain adaptation.

Resilience in the Orthopaedic Patient

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Resilience is a dynamic psychological construct that refers to the ability to adapt and improve when facing adversity or other stressors.

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Recent investigations in various orthopaedic subspecialties have demonstrated that resilience may contribute to favorable mental health and physical function after a surgical procedure.

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More research, using well-designed prospective studies, is necessary to better define the role that resilience and other factors play in the health and outcomes of patients with orthopaedic conditions.

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Orthopaedic surgeons can consider incorporating resilience assessments into their practices to aid in identifying patients who will do well with a surgical procedure and those who may benefit from specialized therapy to optimize their health and function.

Clinical outcome assessment in clinical trials of chronic pain treatments

Clinical outcome assessments (COAs) measure outcomes that are meaningful to patients in clinical trials and are critical for determining whether a treatment is effective. The objectives of this study are to (1) describe the different types of COAs and provide an overview of key considerations for evaluating COAs, (2) review COAs and other outcome measures for chronic pain treatments that are recommended by the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) or other expert groups, and (3) review advances in understanding pain-related COAs that are relevant to clinical trials. The authors reviewed relevant articles, chapters, and guidance documents from the European Medicines Agency and U.S. Food and Drug Administration. Since the original core set of outcome measures were recommended by IMMPACT 14 years ago, several new advancements and publications relevant to the measurement or interpretation of COAs for chronic pain trials have emerged, presenting new research opportunities. Despite progress in the quality of measurement of several outcome domains for clinical trials of chronic pain, there remain some measurement challenges that require further methodological investigation.

Virtual Reality Analgesia for Children With Large Severe Burn Wounds During Burn Wound Debridement

The objective of this study was to compare the effect of adjunctive virtual reality vs. standard analgesic pain medications during burn wound cleaning/debridement. Participants were predominantly Hispanic children aged 6-17 years of age, with large severe burn injuries (TBSA = 44%) reporting moderate or higher baseline pain during burn wound care. Using a randomized between-groups design, participants were randomly assigned to one of two groups, (a) the Control Group = pain medications only or (b) the VR Group = pain medications + virtual reality. A total of 50 children (88% Hispanic) with large severe burns (mean TBSA > 10%) received severe burn wound cleaning sessions. For the primary outcome measure of worst pain (intensity) on Study Day 1, using a between groups ANOVA, burn injured children in the group that received virtual reality during wound care showed significantly less pain intensity than the No VR control group, [mean worst pain ratings for the No VR group = 7.46 (SD = 2.93) vs. 5.54 (SD = 3.56), F (1,48) = 4.29, <0.05, MSE = 46.00]. Similarly, one of the secondary pain measures, "lowest pain during wound care" was significantly lower in the VR group, No VR = 4.29 (SD = 3.75) vs. 1.68 (2.04) for the VR group, F(147) = 9.29, < 0.005, MSE = 83.52 for Study Day 1. The other secondary pain measures showed the predicted pattern on Study Day 1, but were non-significant. Regarding whether VR reduced pain beyond Study Day 1, absolute change in pain intensity (analgesia = baseline pain minus the mean of the worst pain scores on Study days 1-10) was significantly greater for the VR group, F (148) = 4.88, p < 0.05, MSE = 34.26, partial eta squared = 0.09, but contrary to predictions, absolute change scores were non-significant for all secondary measures.

Case Report: Virtual Reality Analgesia in an Opioid Sparing Orthopedic Outpatient Clinic Setting: A Case Study

Immersive virtual reality is proving effective as a non-pharmacologic analgesic for a growing number of painful medical procedures. External fixator surgical pins provide adjunctive stability to a broken pelvic bone until the bones heal back together, then pins are removed. The purpose of the present case study was to measure for the first time, whether immersive virtual reality could be used to help reduce pain and anxiety during the orthopedic process of removing external fixator pins from a conscious patient in the orthopedic outpatient clinic, and whether it is feasible to use VR in this context. Using a within-subject within wound care design with treatment order randomized, the patient had his first ex-fix pin unscrewed and removed from his healing pelvic bone while he wore a VR helmet and explored an immersive snowy 3D computer generated world, adjunctive VR. He then had his second pin removed during no VR, standard of care pain medications. The patient reported having 43% less pain intensity, 67% less time spent thinking about pain, and 43% lower anxiety during VR vs. during No VR. In addition, the patient reported that his satisfaction with pain management was improved with the use of VR. Conducting simple orthopedic procedures using oral pain pills in an outpatient setting instead of anesthesia in the operating room greatly reduces the amount of opioids used, lowers medical costs and reduces rare but real risks of expensive complications from anesthesia including oversedation, death, and post-surgical dementia. These preliminary results suggest that immersive VR merits more attention as a potentially viable adjunctive non-pharmacologic form of treatment for acute pain and anxiety during medical procedures in the orthopedic outpatient clinic. Recent multi-billion dollar investments into R and D and mass production have made inexpensive immersive virtual reality products commercially available and cost effective for medical applications. We speculate that in the future, patients may be more willing to have minor surgery procedures in the outpatient clinic, with much lower opioid doses, while fully awake, if offered adjunctive virtual reality as a non-pharmacologic analgesic during the procedure. Additional research and development is recommended.

Sweet taste does not modulate pain perception in adult humans

Background: Sugar is routinely used to comfort neonates undergoing painful procedures, and animal studies have shown that sucrose increases the time to withdrawal from painful stimuli. However, there are no published studies examining the effects of sweet substances on heat pain thresholds and percept in adult humans. Methods: Healthy adult volunteers (n=27, aged 18-48 years) were recruited to a controlled, double-blind, randomised, cross-over study to characterise the effect of tasting solutions of equivalent sweetness (10% sucrose and 0.016% sucralose) on warm detection and heat pain thresholds and the percept ratings of painfully hot stimuli. The effect of anticipation of a sweet taste on heat pain threshold was also assessed. Results: Tasting either sucrose or sucralose had no significant effect on the percept of an individually titrated hot stimulus (54.5±4.2 and 54.9±3.2 vs 53.2±3.5 for water, 0-100 visual analogue scale), on the warm detection or heat pain threshold (43.3±0.8, 43.2±0.8 vs 43.0±0.8°C). Anticipation of a sweet substance similarly did not affect heat pain thresholds. Conclusions: Sucrose and sucralose solutions had no analgesic effect when assessed using heat detection thresholds and percept ratings of painfully hot stimuli despite being perceived as sweeter and more pleasant than water. These findings are in contrast to results reported from previous animal studies in which thermal analgesia from sweet solutions is robust. Given the ubiquitous availability of sugar rich drinks in the modern environment, the lack of observable effect may be due to an insufficient hedonic value of the test solutions when compared to the experience of a laboratory rodent. Alternatively, sweet tastes may have a specific effect on pain tolerance rather than the threshold and acute percept measures assayed in this study.

Sweet taste does not modulate pain perception in adult humans

Background: It is commonly observed that humans who are in pain or discomfort seek solace in the form of sweet foods and drinks. Sugar is routinely used to comfort neonates undergoing painful procedures, and animal studies have shown that sucrose increases the time to withdrawal from painful stimuli. However, there are no published studies examining the effects of sweet substances on heat pain thresholds and percept in adult humans. Methods: Healthy adult volunteers (n=27, aged 18-48 years) were recruited to a controlled, double-blind, randomised, cross-over study to characterise the effect of tasting solutions of equivalent sweetness (10% sucrose and 0.016% sucralose) on warm detection and heat pain thresholds and the percept ratings of painfully hot stimuli. The effect of anticipation of a sweet taste on heat pain threshold was also assessed. Results: Tasting either sucrose or sucralose had no significant effect on the percept of an individually titrated hot stimulus (54.5±4.2 and 54.9±3.2 vs 53.2±3.5 for water, 0-100 visual analogue scale), on the warm detection or heat pain threshold (43.3±0.8, 43.2±0.8 vs 43.0±0.8°C). Anticipation of a sweet substance similarly did not affect heat pain thresholds. Conclusions: Sucrose and sucralose solutions had no analgesic effect when assessed using heat detection thresholds and percept ratings of painfully hot stimuli despite being perceived as sweeter and more pleasant than water. These findings are in contrast to results reported from previous animal studies in which thermal analgesia from sweet solutions is robust. Given the ubiquitous availability of sugar rich drinks in the modern environment, the lack of observable effect may be due to an insufficient hedonic value of the test solutions when compared to the experience of a laboratory rodent. Alternatively, sweet tastes may have a specific effect on pain tolerance rather than the threshold and acute percept measures assayed in this study.

Individual variability and sex differences in conditioned pain modulation and the impact of resilience, and conditioning stimulus pain unpleasantness and salience

Distinct pain experiences are shaped both by personal attributes and characteristics of noxious stimuli. An Individual's capacity for endogenous pain inhibition (reflected by conditioned pain modulation [CPM]), their resilience, and the pain unpleasantness and salience of painful stimuli can impact their pain perception. Here, we aimed to determine how individual variability in CPM relates to sex and resilience as personal attributes, and pain unpleasantness and salience of the CPM conditioning stimulus (CS). We evaluated CPM in 106 healthy participants (51 female and 55 male) based on the change in test stimulus pain applied concurrently with a painful CS, both delivered by painful heat. The CS reduced test stimulus pain in only half of the participants (CPM subgroup), but did not do so for the other half (no-CPM subgroup), many who exhibited pain facilitation. A regression model explained CPM effects after accounting for sex, resilience, CS pain unpleasantness and salience. In the CPM subgroup regression model, the CPM effect was positively related to CS pain unpleasantness, while the CPM effect was not related to any variable in the no-CPM subgroup model. Correlation analyses revealed that the CPM effect was anticorrelated with resilience in males with no-CPM. The CPM effect was correlated with CS pain unpleasantness in males with CPM and in females with no-CPM. The CPM effect and CS salience were correlated in the whole group more strongly than in the subgroups. These data reveal that the complexity of contributors to CPM variability include both personal attributes and attributes of the CS.

Psychological resilience associates with pain experience in women treated for breast cancer

Background and aims Psychological resilience refers to successful adaptation or a positive outcome in the context of significant life adversity, such as chronic pain. On the other hand, anxiety closely associates with pain. The aim of this study was to explore how anxiety and psychological resilience together associate with persistent and experimental pain. Methods In a cross-sectional design, we studied 160 patients who had previously been treated for breast cancer and who now reported at least moderate pain (NRS ≥ 4) in any area of the body. Psychological resilience was measured on the Resilience Scale-14, anxiety on the Hospital Anxiety and Depression Scale, and intensity and interference of persistent pain by means of the Brief Pain Inventory. The cold pressor test was conducted to assess sensitivity to experimental cold pain. Results The results showed that resilience associated with pain interference in persistent pain, and that anxiety moderated this effect. Higher psychological resilience was associated with lower pain interference and this association was stronger in patients with low anxiety than among patients with high anxiety. These effects were visible with regard to persistent pain but not in experimental cold pain. Conclusions These results indicate that chronic pain and experimental pain as well as pain severity and pain interference are psychologically different phenomena. Psychological resilience protects against pain interference but effectively only in patients with low anxiety. It is necessary also to consider protective factors in addition to vulnerability factors in cases of persistent pain. Implications Resilience has been considered a potential target for intervention in chronic pain. However, high levels of anxiety might diminish the protective effect of psychological resilience in clinical settings. Therefore, it is important to treat anxiety in addition to resilience enhancing interventions. Patients with low psychological distress might be more suitable for resilience enhancing interventions than patients with high anxiety.

Acceptance-Based Emotion Regulation Reduces Subjective and Physiological Pain Responses

Acceptance-based regulation of pain, which focuses on the allowing of pain and pain related thoughts and emotions, was found to modulate pain. However, results so far are inconsistent regarding different pain modalities and indices. Moreover, studies so far often lack a suitable control condition, focus on behavioral pain measures rather than physiological correlates, and often use between-subject designs, which potentially impede the evaluation of the effectiveness of the strategies. Therefore, we investigated whether acceptance-based strategies can reduce subjective and physiological markers of acute pain in comparison to a control condition in a within-subject design. To this end, participants (N = 30) completed 24 trials comprising 10 s of heat pain stimulation. Each trial started with a cue instructing participants to welcome and experience pain (acceptance trials) or to react to the pain as it is without employing any regulation strategies (control trials). In addition to pain intensity and unpleasantness ratings, heart rate (HR) and skin conductance (SC) were recorded. Results showed significantly decreased pain intensity and unpleasantness ratings for acceptance compared to control trials. Additionally, HR was significantly lower during acceptance compared to control trials, whereas SC revealed no significant differences. These results demonstrate the effectiveness of acceptance-based strategies in reducing subjective and physiological pain responses relative to a control condition, even after short training. Therefore, the systematic investigation of acceptance in different pain modalities in healthy and chronic pain patients is warranted.

The Relationship Between Psychological Resilience and Pain Threshold and Tolerance: Optimism and Grit as Moderators

This study examined factors that may enhance the relationship between resilience and time to pain threshold and tolerance during experimentally induced pain among 62 healthy adults recruited from a student population. Specifically, dispositional optimism and psychological grit were examined as moderators of the relationship between resilience and pain outcomes. Zero-order correlations revealed that resilience was positively related to grit and optimism, though grit and optimism were not significantly related to each other. Resilience, grit and optimism were all positively related to time to pain threshold and tolerance, but not pain severity. Moderation models showed that dispositional optimism enhanced the effect of resilience on both time to pain threshold and tolerance. Grit, on the other hand, was found to enhance the effect of resilience on time to pain threshold, but not time to pain tolerance. These results suggest that positive psychological factors and their interactions may be important with persevering during adverse experiences such as pain.

Imaging vs quantitative sensory testing to predict chronic pain treatment outcomes

In this article, I review the concept of personalized pain management and consider how brain imaging and quantitative sensory testing can be used to derive biomarkers of chronic pain treatment outcome. I review how different modalities of brain imaging can be used to acquire information about brain structure and function and how this information can be linked to individual measures of pain.

Virtual Reality Analgesia With Interactive Eye Tracking During Brief Thermal Pain Stimuli: A Randomized Controlled Trial (Crossover Design)

In light of growing concerns about opioid analgesics, developing new non-pharmacologic pain control techniques has become a high priority. Adjunctive virtual reality can help reduce acute pain during painful medical procedures. However, for some especially painful medical procedures such as burn wound cleaning, clinical researchers recommend that more distracting versions of virtual reality are needed, to further amplify the potency of virtual reality analgesia. The current study with healthy volunteers explores for the first time whether interacting with virtual objects in Virtual Reality (VR) via "hands free" eye-tracking technology integrated into the VR helmet makes VR more effective/powerful than non-interactive/passive VR (no eye-tracking) for reducing pain during brief thermal pain stimuli.

METHOD

Forty eight healthy volunteers participated in the main study. Using a within-subject design, each participant received one brief thermal pain stimulus during interactive eye tracked virtual reality, and each participant received another thermal pain stimulus during non-interactive VR (treatment order randomized). After each pain stimulus, participants provided subjective 0-10 ratings of cognitive, sensory and affective components of pain, and rated the amount of fun they had during the pain stimulus.

RESULTS

As predicted, interactive eye tracking increased the analgesic effectiveness of immersive virtual reality. Compared to the passive non-interactive VR condition, during the interactive eye tracked VR condition, participants reported significant reductions in worst pain (p < 0.001) and pain unpleasantness (p < 0.001). Participants reported a significantly stronger illusion of presence (p < 0.001), and significantly more fun in VR (p < 0.001) during the interactive condition compared to during passive VR. In summary, as predicted by our primary hypothesis, in the current laboratory acute pain analog study with healthy volunteers, increasing the immersiveness of the VR system via interactive eye tracking significantly increased how effectively VR reduced worst pain during a brief thermal pain stimulus. Although attention was not directly measured, the pattern of pain ratings, presence ratings, and fun ratings are consistent with an attentional mechanism for how VR reduces pain. Whether the current results generalize to clinical patient populations is another important topic for future research. Additional research and development is recommended.

Virtual reality hand therapy: A new tool for nonopioid analgesia for acute procedural pain, hand rehabilitation, and VR embodiment therapy for phantom limb pain

INTRODUCTION

Affordable virtual reality (VR) technology is now widely available. Billions of dollars are currently being invested into improving and mass producing VR and augmented reality products.

PURPOSE OF THE STUDY

The purpose of the present study is to explore the potential of immersive VR to make physical therapy/occupational therapy less painful, more fun, and to help motivate patients to cooperate with their hand therapist.

DISCUSSION

The following topics are covered: a) psychological influences on pain perception, b) the logic of how VR analgesia works, c) evidence for reduction of acute procedural pain during hand therapy, d) recent major advances in VR technology, and e) future directions-immersive VR embodiment therapy for phantom limb (chronic) pain.

CONCLUSION

VR hand therapy has potential for a wide range of patient populations needing hand therapy, including acute pain and potentially chronic pain patients. Being in VR helps reduce the patients' pain, making it less painful for patients to move their hand/fingers during hand therapy, and gamified VR can help motivate the patient to perform therapeutic hand exercises, and make hand therapy more fun. In addition, VR camera-based hand tracking technology may be used to help therapists monitor how well patients are doing their hand therapy exercises, and to quantify whether adherence to treatment increases long-term functionality. Additional research and development into using VR as a tool for hand therapist is recommended for both acute pain and persistent pain patient populations.

Longitudinal Analysis Supports a Fear-Avoidance Model That Incorporates Pain Resilience Alongside Pain Catastrophizing

Background

The fear-avoidance model of chronic pain holds that individuals who catastrophize in response to injury are at risk for pain-related fear and avoidance behavior, and ultimately prolonged pain and disability.

Purpose

Based on the hypothesis that the predictive power of the fear-avoidance model would be enhanced by consideration of positive psychological constructs, the present study examined inclusion of pain resilience and self-efficacy in the model.

Methods

Men and women (N = 343) who experienced a recent episode of back pain were recruited in a longitudinal online survey study. Over a 3-month interval, participants repeated the Pain Resilience Scale, Pain Catastrophizing Scale, Tampa Scale of Kinesiophobia, Pain Self-Efficacy Questionnaire, the McGill Pain Questionnaire, and NIH-recommended measures of pain, depressive symptoms, and physical dysfunction. Structural equation modeling assessed the combined contribution of pain resilience and pain catastrophizing to 3-month outcomes through the simultaneous combination of kinesiophobia and self-efficacy.

Results

An expanded fear-avoidance model that incorporated pain resilience and self-efficacy provided a good fit to the data, Χ2 (df = 14, N = 343) = 42.09, p = .0001, RMSEA = 0.076 (90% CI: 0.05, 0.10), CFI = 0.97, SRMR = 0.03, with higher levels of pain resilience associated with improved 3-month outcomes on measures of pain intensity, physical dysfunction, and depression symptoms.

Conclusions

This study supports the notion that the predictive power of the fear-avoidance model of pain is enhanced when individual differences in both pain-related vulnerability (e.g., catastrophizing) and pain-related protective resources (e.g., resilience) are considered.

Pain resilience moderates the influence of negative pain beliefs on movement-evoked pain in older adults

Negative pain beliefs are associated with adverse pain outcomes; however, less is known regarding how positive, adaptive factors influence pain and functioning. These relationships are especially important to examine in older adults with pain, given increased disability and functional limitations in this population. We investigated whether pain resilience moderated the relationships between negative pain beliefs (fear-avoidance, pain catastrophizing) and pain outcomes (functional performance, movement-evoked pain) in sixty older adults with low back pain. Higher pain resilience was associated with lower fear-avoidance (p < .05) and pain catastrophizing (p = .05). After controlling for demographic variables, higher fear-avoidance (p = .03) and catastrophizing (p = .03) were associated with greater movement-evoked pain in individuals with low pain resilience, but not among those high in resilience. No significant moderation effects were observed for functional performance. Resilience may attenuate the relationship between negative psychological processes and pain-related disability, highlighting the need for interventions that enhance pain resilience in older adults.

Chronic pain: breaking free from stickiness

By introducing the concept of “pain stickiness” underlying treatment-resistant pain, Borsook et al. take a neurobiological perspective to capture the factors that may contribute to the transition of pain from acute to chronic form. However, there is more to consider, including the interconnected influences of resilience, brain gray matter and connectivity, sex differences, and the role of the environment. There still remains the question of how to eliminate this stickiness.

Immersive Virtual Reality as an Adjunctive Non-opioid Analgesic for Pre-dominantly Latin American Children With Large Severe Burn Wounds During Burn Wound Cleaning in the Intensive Care Unit: A Pilot Study

Background/Aim: Using a within-subjects, within-wound care design, this pilot study tested for the first time, whether immersive virtual reality (VR) can serve as an adjunctive non-opioid analgesic for children with large severe burn wounds during burn wound cleaning in the ICU, in a regional burn center in the United States, between 2014–2016.

Methods: Participants included 48 children from 6 years old to 17 years of age with >10% TBSA burn injuries reporting moderate or higher worst pain during no VR on Day 1. Forty-four of the 48 children were from developing Latin American countries. Patients played adjunctive SnowWorld, an interactive 3D snowy canyon in virtual reality during some portions of wound care, vs. No VR during comparable portions of the same wound care session (initial treatment condition randomized). Using Graphic Rating scales, children's worst pain ratings during “No VR” (treatment as usual pain medications) vs. their worst pain during “Yes VR” was measured during at least 1 day of wound care, and was measured for up to 10 study days the patient used VR.

Results: VR significantly reduced children's “worst pain” ratings during burn wound cleaning procedures in the ICU on Day 1. Worst pain during No VR = 8.52 (SD = 1.75) vs. during Yes VR = 5.10 (SD = 3.27), t₍₄₇₎ = 7.11, p < 0.001, SD = 3.33, CI = 2.45–4.38, Cohen's d = 1.03 (indicating large effect size). Patients continued to report the predicted pattern of lower pain and more fun during VR, during multiple sessions.

Conclusion: Immersive virtual reality can help reduce the pain of children with large severe burn wounds during burn wound cleaning in the Intensive Care Unit. Additional research and development is recommended.

Pain distress: the negative emotion associated with procedures in ICU patients

PURPOSE

The intensity of procedural pain in intensive care unit (ICU) patients is well documented. However, little is known about procedural pain distress, the psychological response to pain.

METHODS

Post hoc analysis of a multicenter, multinational study of procedural pain. Pain distress was measured before and during procedures (0-10 numeric rating scale). Factors that influenced procedural pain distress were identified by multivariable analyses using a hierarchical model with ICU and country as random effects.

RESULTS

A total of 4812 procedures were recorded (3851 patients, 192 ICUs, 28 countries). Pain distress scores were highest for endotracheal suctioning (ETS) and tracheal suctioning, chest tube removal (CTR), and wound drain removal (median [IQRs] = 4 [1.6, 1.7]). Significant relative risks (RR) for a higher degree of pain distress included certain procedures: turning (RR = 1.18), ETS (RR = 1.45), tracheal suctioning (RR = 1.38), CTR (RR = 1.39), wound drain removal (RR = 1.56), and arterial line insertion (RR = 1.41); certain pain behaviors (RR = 1.19-1.28); pre-procedural pain intensity (RR = 1.15); and use of opioids (RR = 1.15-1.22). Patient-related variables that significantly increased the odds of patients having higher procedural pain distress than pain intensity were pre-procedural pain intensity (odds ratio [OR] = 1.05); pre-hospital anxiety (OR = 1.76); receiving pethidine/meperidine (OR = 4.11); or receiving haloperidol (OR = 1.77) prior to the procedure.

CONCLUSIONS

Procedural pain has both sensory and emotional dimensions. We found that, although procedural pain intensity (the sensory dimension) and distress (the emotional dimension) may closely covary, there are certain factors than can preferentially influence each of the dimensions. Clinicians are encouraged to appreciate the multidimensionality of pain when they perform procedures and use this knowledge to minimize the patient's pain experience.

Biological and Psychological Perspectives of Resilience: Is It Possible to Improve Stress Resistance?

The term “resilience” refers to the ability to adapt successfully to stress, trauma and adversity, enabling individuals to avoid stress-induced mental disorders such as depression, posttraumatic stress disorder (PTSD) and anxiety. Here, we review evidence from both animal models and humans that is increasingly revealing the neurophysiological and neuropsychological mechanisms that underlie stress susceptibility, as well as active mechanisms underlying the resilience phenotype. Ultimately, this growing understanding of the neurobiological mechanisms of resilience should result in the development of novel interventions that specifically target neural circuitry and brain areas that enhance resilience and lead to more effective treatments for stress-induced disorders. Stress resilience can be improved, but the outcomes and effects depend on the type of intervention and the species treated.

Psychiatric and physical comorbidities and pain in patients with multiple sclerosis

Background

It has been observed that patients with multiple sclerosis (MS), who have psychiatric and physical comorbidities such as depression and COPD, have an increased risk of experiencing more pain. In this study, we have distinguished between pain intensity and pain affect, as the latter, particularly, requires treatment. Furthermore, while pain and comorbidities have been assessed using questionnaires, this is possibly a less reliable method for those who are cognitively vulnerable.

Objective

The aim of this study was to determine whether psychiatric and physical comorbidities can predict pain intensity and pain affect in MS patients, susceptible to cognitive impairment.

Methods

Ninety-four patients with MS and 80 control participants participated in this cross-sectional study. Besides depression and anxiety, 47 additional comorbidities were extracted from patients’ medical records. Depression and anxiety were assessed using the Beck Depression Inventory and the Symptom Check List-90. Pain was assessed using the Number of Words Chosen Affective, Coloured Analog Scale, and the Faces Pain Scale. Cognitive functions, for example, memory and executive functions, were assessed using several neuropsychological tests.

Results

The main findings indicate that psychiatric comorbidities (depression and anxiety) predict both pain intensity and pain affect and that total physical comorbidity predicts only pain affect in MS patients, susceptible to cognitive impairment.

Conclusion

Both psychiatric and physical comorbidities predict pain affect. All three clinical outcomes enhance MS patients’ suffering.