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Pavy F, Zaman J, Van den Noortgate W, Scarpa A, von Leupoldt A, Torta DM. The effect of unpredictability on the perception of pain: a systematic review and meta-analysis. Pain 2024; 165:1702-1718. [PMID: 38422488 DOI: 10.1097/j.pain.0000000000003199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 01/11/2024] [Indexed: 03/02/2024]
Abstract
ABSTRACT Despite being widely assumed, the worsening impact of unpredictability on pain perception remains unclear because of conflicting empirical evidence, and a lack of systematic integration of past research findings. To fill this gap, we conducted a systematic review and meta-analysis focusing on the effect of unpredictability on pain perception. We also conducted meta-regression analyses to examine the moderating effect of several moderators associated with pain and unpredictability: stimulus duration, calibrated stimulus pain intensity, pain intensity expectation, controllability, anticipation delay, state and trait negative affectivity, sex/gender and age of the participants, type of unpredictability (intensity, onset, duration, location), and method of pain induction (thermal, electrical, mechanical pressure, mechanical distention). We included 73 experimental studies with adult volunteers manipulating the (un)predictability of painful stimuli and measuring perceived pain intensity and pain unpleasantness in predictable and unpredictable contexts. Because there are insufficient studies with patients, we focused on healthy volunteers. Our results did not reveal any effect of unpredictability on pain perception. However, several significant moderators were found, ie, targeted stimulus pain intensity, expected pain intensity, and state negative affectivity. Trait negative affectivity and uncontrollability showed no significant effect, presumably because of the low number of included studies. Thus, further investigation is necessary to clearly determine their role in unpredictable pain perception.
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Affiliation(s)
- Fabien Pavy
- Research Group Health Psychology, Faculty of Psychology and Educational Sciences, KU Leuven, Belgium
| | - Jonas Zaman
- Research Group Health Psychology, Faculty of Psychology and Educational Sciences, KU Leuven, Belgium
- Centre for the Psychology of Learning and Experimental Psychopathology, Faculty of Psychology and Educational Sciences, KU Leuven, Belgium
- School of Social Sciences, Hasselt University, Hasselt, Belgium
| | - Wim Van den Noortgate
- Methodology of Educational Sciences, Faculty of Psychology and Educational Sciences, & Itec, an Imec Research Group, KU Leuven, Belgium
| | - Aurelia Scarpa
- Research Group Health Psychology, Faculty of Psychology and Educational Sciences, KU Leuven, Belgium
| | - Andreas von Leupoldt
- Research Group Health Psychology, Faculty of Psychology and Educational Sciences, KU Leuven, Belgium
| | - Diana M Torta
- Research Group Health Psychology, Faculty of Psychology and Educational Sciences, KU Leuven, Belgium
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2
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Schmidt K, Schlitt F, Wiech K, Merz CJ, Kleine-Borgmann J, Wolf OT, Engler H, Forkmann K, Elsenbruch S, Bingel U. Hydrocortisone Differentially Affects Reinstatement of Pain-related Responses in Patients With Chronic Back Pain and Healthy Volunteers. THE JOURNAL OF PAIN 2024; 25:1082-1093. [PMID: 37956744 DOI: 10.1016/j.jpain.2023.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 10/11/2023] [Accepted: 10/31/2023] [Indexed: 11/15/2023]
Abstract
Despite the crucial role of effective and sustained extinction of conditioned pain-related fear in cognitive-behavioral treatment approaches for chronic pain, experimental research on extinction memory retrieval in chronic pain remains scarce. In healthy populations, extinction efficacy of fear memory is affected by stress. Therefore, we investigated the effects of oral hydrocortisone administration on the reinstatement of pain-related associations in 57 patients with non-specific chronic back pain (CBP) and 59 healthy control (HC) participants in a differential pain-related conditioning paradigm within a placebo-controlled, randomized, and double-blind design. Participants' skin conductance responses indicate hydrocortisone-induced reinstatement effects in HCs but no observable reinstatement in HCs receiving placebo treatment. Interestingly, these effects were reversed in patients with CBP, that is, reinstatement responses were only observed in the placebo and not in the hydrocortisone group. Our findings corroborate previous evidence of stress-induced effects on extinction efficacy and reinstatement of fear memory in HCs, extending them into the pain context, and call for more research to clarify the role of stress in fear extinction and return of fear phenomena possibly contributing to treatment failure in chronic pain treatment. PERSPECTIVE: Opposing effects in HCs and patients with non-specific CBP may be associated with changes in the patients' stress systems. These findings could be of relevance to optimizing psychological, extinction-based treatment approaches.
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Affiliation(s)
- Katharina Schmidt
- Department of Neurology, Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Frederik Schlitt
- Department of Neurology, Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Katja Wiech
- Department of Neurology, Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany; Wellcome Centre for Integrative Neuroimaging (WIN), Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Christian J Merz
- Department of Cognitive Psychology, Institute of Cognitive Neuroscience, Faculty of Psychology, Ruhr University Bochum, Bochum, Germany
| | - Julian Kleine-Borgmann
- Department of Neurology, Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Oliver T Wolf
- Department of Cognitive Psychology, Institute of Cognitive Neuroscience, Faculty of Psychology, Ruhr University Bochum, Bochum, Germany
| | - Harald Engler
- Institute of Medical Psychology and Behavioral Immunobiology, Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Katarina Forkmann
- Department of Neurology, Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Sigrid Elsenbruch
- Department of Neurology, Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany; Department of Medical Psychology and Medical Sociology, Ruhr University Bochum, Bochum, Germany
| | - Ulrike Bingel
- Department of Neurology, Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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Murray GM, Sessle BJ. Pain-sensorimotor interactions: New perspectives and a new model. NEUROBIOLOGY OF PAIN (CAMBRIDGE, MASS.) 2024; 15:100150. [PMID: 38327725 PMCID: PMC10847382 DOI: 10.1016/j.ynpai.2024.100150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 11/25/2023] [Accepted: 01/19/2024] [Indexed: 02/09/2024]
Abstract
How pain and sensorimotor behavior interact has been the subject of research and debate for many decades. This article reviews theories bearing on pain-sensorimotor interactions and considers their strengths and limitations in the light of findings from experimental and clinical studies of pain-sensorimotor interactions in the spinal and craniofacial sensorimotor systems. A strength of recent theories is that they have incorporated concepts and features missing from earlier theories to account for the role of the sensory-discriminative, motivational-affective, and cognitive-evaluative dimensions of pain in pain-sensorimotor interactions. Findings acquired since the formulation of these recent theories indicate that additional features need to be considered to provide a more comprehensive conceptualization of pain-sensorimotor interactions. These features include biopsychosocial influences that range from biological factors such as genetics and epigenetics to psychological factors and social factors encompassing environmental and cultural influences. Also needing consideration is a mechanistic framework that includes other biological factors reflecting nociceptive processes and glioplastic and neuroplastic changes in sensorimotor and related brain and spinal cord circuits in acute or chronic pain conditions. The literature reviewed and the limitations of previous theories bearing on pain-sensorimotor interactions have led us to provide new perspectives on these interactions, and this has prompted our development of a new concept, the Theory of Pain-Sensorimotor Interactions (TOPSMI) that we suggest gives a more comprehensive framework to consider the interactions and their complexity. This theory states that pain is associated with plastic changes in the central nervous system (CNS) that lead to an activation pattern of motor units that contributes to the individual's adaptive sensorimotor behavior. This activation pattern takes account of the biological, psychological, and social influences on the musculoskeletal tissues involved in sensorimotor behavior and on the plastic changes and the experience of pain in that individual. The pattern is normally optimized in terms of biomechanical advantage and metabolic cost related to the features of the individual's musculoskeletal tissues and aims to minimize pain and any associated sensorimotor changes, and thereby maintain homeostasis. However, adverse biopsychosocial factors and their interactions may result in plastic CNS changes leading to less optimal, even maladaptive, sensorimotor changes producing motor unit activation patterns associated with the development of further pain. This more comprehensive theory points towards customized treatment strategies, in line with the management approaches to pain proposed in the biopsychosocial model of pain.
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Affiliation(s)
- Greg M. Murray
- Discipline of Restorative and Reconstructive Dentistry, Sydney School of Dentistry, Faculty of Medicine and Health, The University of Sydney, Darcy Road, Westmead, NSW 2145, Australia
| | - Barry J. Sessle
- Faculty of Dentistry and Temerty Faculty of Medicine Department of Physiology, and Centre for the Study of Pain, University of Toronto, 124 Edward St, Toronto, ON M5G 1G6, Canada
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4
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Devecchi V, Falla D, Cabral HV, Gallina A. Neuromuscular adaptations to experimentally induced pain in the lumbar region: systematic review and meta-analysis. Pain 2023; 164:1159-1180. [PMID: 36730706 DOI: 10.1097/j.pain.0000000000002819] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 10/20/2022] [Indexed: 02/04/2023]
Abstract
ABSTRACT Experimental pain models are frequently used to understand the influence of pain on the control of human movement. In this systematic review, we assessed the effects of experimentally induced pain in the lumbar region of healthy individuals on trunk muscle activity and spine kinematics. Databases were searched from inception up to January 31, 2022. In total, 26 studies using either hypertonic saline injection (n = 19), heat thermal stimulation (n = 3), nociceptive electrical stimulation (n = 3), or capsaicin (n = 1) were included. The identified adaptations were task dependent, and their heterogeneity was partially explained by the experimental pain model adopted. Meta-analyses revealed an increase of erector spinae activity (standardized mean difference = 0.71, 95% confidence interval [CI] = 0.22-1.19) during full trunk flexion and delayed onset of transversus abdominis to postural perturbation tasks (mean difference = 25.2 ms, 95% CI = 4.09-46.30) in the presence of pain. Low quality of evidence supported an increase in the activity of the superficial lumbar muscles during locomotion and during voluntary trunk movements during painful conditions. By contrast, activity of erector spinae, deep multifidus, and transversus abdominis was reduced during postural perturbation tasks. Reduced range of motion of the lumbar spine in the presence of pain was supported by low quality of evidence. Given the agreement between our findings and the adaptations observed in clinical populations, the use of experimental pain models may help to better understand the mechanisms underlying motor adaptations to low back pain.
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Affiliation(s)
- Valter Devecchi
- Centre of Precision Rehabilitation for Spinal Pain (CPR Spine), School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham, United Kingdom
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Schneider L, Egle UT, Klinger D, Schulz W, Villringer A, Fritz TH. Effects of active musical engagement during physical exercise on anxiety, pain and motivation in patients with chronic pain. FRONTIERS IN PAIN RESEARCH 2022; 3:944181. [DOI: 10.3389/fpain.2022.944181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 10/26/2022] [Indexed: 11/23/2022] Open
Abstract
The experience of anxiety is central to the development of chronic pain. Music listening has been previously shown to exert analgesic effects. Here we tested if an active engagement in music making is more beneficial than music listening in terms of anxiety and pain levels during physical activity that is often avoided in patients with chronic pain. We applied a music feedback paradigm that combines music making and sports exercise, and which has been previously shown to enhance mood. We explored this method as an intervention to potentially reduce anxiety in a group of patients with chronic pain (N = 24, 20 female and 4 men; age range 34–64, M = 51.67, SD = 6.84) and with various anxiety levels. All participants performed two conditions: one condition, Jymmin, where exercise equipment was modified with music feedback so that it could be played like musical instruments by groups of three. Second, a conventional workout condition where groups of three performed exercise on the same devices but where they listened to the same type of music passively. Participants' levels of anxiety, mood, pain and self-efficacy were assessed with standardized psychological questionnaires before the experiment and after each condition. Results demonstrate that exercise with musical feedback reduced anxiety values in patients with chronic pain significantly as compared to conventional workout with passive music listening. There were no significant overall changes in pain, but patients with greater anxiety levels compared to those with moderate anxiety levels were observed to potentially benefit more from the music feedback intervention in terms of alleviation of pain. Furthermore, it was observed that patients during Jymmin more strongly perceived motivation through others. The observed diminishing effects of Jymmin on anxiety have a high clinical relevance, and in a longer term the therapeutic application could help to break the Anxiety Loop of Pain, reducing chronic pain. The intervention method, however, also has immediate benefits to chronic pain rehabilitation, increasing the motivation to work out, and facilitating social bonding.
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Schlitt F, Schmidt K, Merz CJ, Wolf OT, Kleine-Borgmann J, Elsenbruch S, Wiech K, Forkmann K, Bingel U. Impaired pain-related threat and safety learning in patients with chronic back pain. Pain 2022; 163:1560-1570. [PMID: 35135995 PMCID: PMC9341232 DOI: 10.1097/j.pain.0000000000002544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 10/28/2021] [Accepted: 11/16/2021] [Indexed: 11/29/2022]
Abstract
ABSTRACT Pain-related learning mechanisms likely play a key role in the development and maintenance of chronic pain. Previous smaller-scale studies have suggested impaired pain-related learning in patients with chronic pain, but results are mixed, and chronic back pain (CBP) particularly has been poorly studied. In a differential conditioning paradigm with painful heat as unconditioned stimuli, we examined pain-related acquisition and extinction learning in 62 patients with CBP and 61 pain-free healthy male and female volunteers using valence and contingency ratings and skin conductance responses. Valence ratings indicate significantly reduced threat and safety learning in patients with CBP, whereas no significant differences were observed in contingency awareness and physiological responding. Moreover, threat learning in this group was more impaired the longer patients had been in pain. State anxiety was linked to increased safety learning in healthy volunteers but enhanced threat learning in the patient group. Our findings corroborate previous evidence of altered pain-related threat and safety learning in patients with chronic pain. Longitudinal studies exploring pain-related learning in (sub)acute and chronic pain are needed to further unravel the role of aberrant pain-related learning in the development and maintenance of chronic pain.
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Affiliation(s)
- Frederik Schlitt
- Department of Neurology, Center for Translational Neuro- and Behavioral Sciences, University Medicine Essen, Essen, Germany
| | - Katharina Schmidt
- Department of Neurology, Center for Translational Neuro- and Behavioral Sciences, University Medicine Essen, Essen, Germany
| | - Christian J. Merz
- Department of Cognitive Psychology, Institute of Cognitive Neuroscience, Faculty of Psychology, Ruhr University Bochum, Bochum, Germany
| | - Oliver T. Wolf
- Department of Cognitive Psychology, Institute of Cognitive Neuroscience, Faculty of Psychology, Ruhr University Bochum, Bochum, Germany
| | - Julian Kleine-Borgmann
- Department of Neurology, Center for Translational Neuro- and Behavioral Sciences, University Medicine Essen, Essen, Germany
| | - Sigrid Elsenbruch
- Department of Neurology, Center for Translational Neuro- and Behavioral Sciences, University Medicine Essen, Essen, Germany
- Department of Medical Psychology and Medical Sociology, Ruhr University Bochum, Bochum, Germany
| | - Katja Wiech
- Nuffield Department of Clinical Neurosciences, Wellcome Centre for Integrative Neuroimaging (WIN), University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, United Kingdom
| | - Katarina Forkmann
- Department of Neurology, Center for Translational Neuro- and Behavioral Sciences, University Medicine Essen, Essen, Germany
| | - Ulrike Bingel
- Department of Neurology, Center for Translational Neuro- and Behavioral Sciences, University Medicine Essen, Essen, Germany
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Koenig S, Körfer K, Lachnit H, Glombiewski JA. An attentional perspective on differential fear conditioning in chronic pain: The informational value of safety cues. Behav Res Ther 2021; 144:103917. [PMID: 34325187 DOI: 10.1016/j.brat.2021.103917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 05/20/2021] [Accepted: 06/21/2021] [Indexed: 10/21/2022]
Abstract
Differences in fear conditioning between individuals suffering from chronic pain and healthy controls may indicate a learning bias that contributes to the acquisition and persistence of chronic pain. However, evidence from lab-controlled conditioning studies is sparse and previous experiments have produced inconsistent findings. Twenty-five participants suffering from chronic back pain and twenty-five controls not reporting chronic pain took part in a differential fear conditioning experiment measuring attention (eye tracking) and autonomic arousal (pupil dilation and skin conductance) elicited by visual cues predicting the presence or absence of electric shock. In contrast to the healthy control group, participants with chronic pain did not acquire differential autonomic responding to cues of threat and safety and specifically failed to acquire any attentional preference for the safety cue over irrelevant contextual cues (while such preference was intact for the threat cue). We present simulations of a reinforcement learning model to show how the pattern of data can be explained by assuming that participants with chronic pain might have experienced less positive emotion (relief) when the electric shock was absent following safety cues. Our model shows how this assumption can explain both, reduced differential responding to cues of threat and safety as well as less selective attention to the safety cue.
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Affiliation(s)
- Stephan Koenig
- Department of Psychology, Universität Koblenz-Landau, Germany; Department of Psychology, Philipps-Universität Marburg, Germany.
| | - Karoline Körfer
- Department of Psychology, Philipps-Universität Marburg, Germany
| | - Harald Lachnit
- Department of Psychology, Philipps-Universität Marburg, Germany
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8
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Gatzounis R, van Vliet C, Meulders A. Will that hurt? A contingency learning task to assess pain-expectancy judgments for low back postures. J Behav Ther Exp Psychiatry 2021; 70:101622. [PMID: 33129131 DOI: 10.1016/j.jbtep.2020.101622] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 10/02/2020] [Accepted: 10/21/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Contingency learning, i.e. learning that a cue predicts the presence (or absence) of an event, is central to the formation of beliefs regarding painfulness of body postures. Such beliefs may spread to safe cues due to compromised learning (e.g., excessive generalization, impaired safety learning), prompting avoidance and leading to disability. Despite its importance, compromised learning about low back pain is underinvestigated. We propose a low back pain scenario contingency learning task for the investigation of back pain-related learning. METHODS Sixty healthy participants viewed pictures of an avatar in various back postures, and for each posture gave pain-expectancy judgments and viewed the verbal outcome (pain/no pain) for a fictive back pain patient. During acquisition, one posture was followed by pain (conditioned stimulus; CS+), whereas another was not (CS-). During generalization, unreinforced novel intermediate back postures (generalization stimuli; GSs) were tested. During extinction, only the CSs were presented, not followed by pain. During generalization of extinction, only the GSs were presented, not followed by pain. RESULTS Participants expected pain more for the CS + than the CS- (differential acquisition) and generalized their pain-expectancy to the GS most similar to the CS+ (generalization). During extinction, pain-expectancy for the CS + decreased and generalized to the GS most similar to the CS+ (generalization of extinction). LIMITATIONS Future research should investigate generalizability of findings to clinical samples and consider the role of pre-existing pain threat beliefs. CONCLUSIONS This task is an easily applicable, non-invasive way to investigate the formation of back pain-related threat beliefs.
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Affiliation(s)
- Rena Gatzounis
- Experimental Health Psychology, Department of Clinical Psychological Science, Maastricht University, the Netherlands.
| | - Christine van Vliet
- Experimental Health Psychology, Department of Clinical Psychological Science, Maastricht University, the Netherlands; Research Group Health Psychology, Faculty of Psychology and Educational Sciences, KU Leuven, Belgium
| | - Ann Meulders
- Experimental Health Psychology, Department of Clinical Psychological Science, Maastricht University, the Netherlands; Research Group Health Psychology, Faculty of Psychology and Educational Sciences, KU Leuven, Belgium
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9
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Meulders A. Fear in the context of pain: Lessons learned from 100 years of fear conditioning research. Behav Res Ther 2020; 131:103635. [DOI: 10.1016/j.brat.2020.103635] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 04/20/2020] [Accepted: 04/24/2020] [Indexed: 02/06/2023]
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10
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Harvie DS, Weermeijer JD, Olthof NA, Meulders A. Learning to predict pain: differences in people with persistent neck pain and pain-free controls. PeerJ 2020; 8:e9345. [PMID: 32612886 PMCID: PMC7319024 DOI: 10.7717/peerj.9345] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 05/21/2020] [Indexed: 11/20/2022] Open
Abstract
Background Learning to predict threatening events enables an organism to engage in protective behavior and prevent harm. Failure to differentiate between cues that truly predict danger and those that do not, however, may lead to indiscriminate fear and avoidance behaviors, which in turn may contribute to disability in people with persistent pain. We aimed to test whether people with persistent neck pain exhibit contingency learning deficits in predicting pain relative to pain-free, gender-and age-matched controls. Method We developed a differential predictive learning task with a neck pain-relevant scenario. During the acquisition phase, images displaying two distinct neck positions were presented and participants were asked to predict whether these neck positions would lead to pain in a fictive patient with persistent neck pain (see fictive patient scenario details in Appendix A). After participants gave their pain-expectancy judgment in the hypothetical scenario, the verbal outcome (PAIN or NO PAIN) was shown on the screen. One image (CS+) was followed by the outcome “PAIN”, while another image (CS−) was followed by the outcome “NO PAIN”. During the generalization phase, novel but related images depicting neck positions along a continuum between the CS+ and CS− images (generalization stimuli; GSs) were introduced to assess the generalization of acquired predictive learning to the novel images; the GSs were always followed by the verbal outcome “NOTES UNREADABLE” to prevent extinction learning. Finally, an extinction phase was included in which all images were followed by “NO PAIN” assessing the persistence of pain-expectancy judgments following disconfirming information. Results Differential pain-expectancy learning was reduced in people with neck pain relative to controls, resulting from patients giving significantly lower pain-expectancy judgments for the CS+, and significantly higher pain-expectancy judgments for the CS−. People with neck pain also demonstrated flatter generalization gradients relative to controls. No differences in extinction were noted. Discussion The results support the hypothesis that people with persistent neck pain exhibit reduced differential pain-expectancy learning and flatter generalization gradients, reflecting deficits in predictive learning. Contrary to our hypothesis, no differences in extinction were found. These findings may be relevant to understanding behavioral aspects of chronic pain.
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Affiliation(s)
- Daniel S Harvie
- The Hopkins Centre, Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia.,School of Allied Health Sciences, Griffith University, Gold Coast, QLD, Australia
| | | | - Nick A Olthof
- The Hopkins Centre, Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia.,School of Allied Health Sciences, Griffith University, Gold Coast, QLD, Australia
| | - Ann Meulders
- Research Group Health Psychology, KU Leuven, Leuven, Belgium.,Experimental Health Psychology, Maastricht University, Maastricht, The Netherlands
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11
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Schmidt K, Forkmann K, Elsenbruch S, Bingel U. Enhanced pain-related conditioning for face compared to hand pain. PLoS One 2020; 15:e0234160. [PMID: 32559202 PMCID: PMC7304572 DOI: 10.1371/journal.pone.0234160] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 05/19/2020] [Indexed: 11/29/2022] Open
Abstract
Pain is evolutionarily hardwired to signal potential danger and threat. It has been proposed that altered pain-related associative learning processes, i.e., emotional or fear conditioning, might contribute to the development and maintenance of chronic pain. Pain in or near the face plays a special role in pain perception and processing, especially with regard to increased pain-related fear and unpleasantness. However, differences in pain-related learning mechanisms between the face and other body parts have not yet been investigated. Here, we examined body-site specific differences in associative emotional conditioning using electrical stimuli applied to the face and the hand. Acquisition, extinction, and reinstatement of cue-pain associations were assessed in a 2-day emotional conditioning paradigm using a within-subject design. Data of 34 healthy subjects revealed higher fear of face pain as compared to hand pain. During acquisition, face pain (as compared to hand pain) led to a steeper increase in pain-related negative emotions in response to conditioned stimuli (CS) as assessed using valence ratings. While no significant differences between both conditions were observed during the extinction phase, a reinstatement effect for face but not for hand pain was revealed on the descriptive level and contingency awareness was higher for face pain compared to hand pain. Our results indicate a stronger propensity to acquire cue-pain-associations for face compared to hand pain, which might also be reinstated more easily. These differences in learning and resultant pain-related emotions might play an important role in the chronification and high prevalence of chronic facial pain and stress the evolutionary significance of pain in the head and face.
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Affiliation(s)
- Katharina Schmidt
- Department of Neurology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
- * E-mail:
| | - Katarina Forkmann
- Department of Neurology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Sigrid Elsenbruch
- Institute of Medical Psychology and Behavioral Immunobiology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
- Department of Medical Psychology and Medical Sociology, Ruhr University Bochum, Bochum, Germany
| | - Ulrike Bingel
- Department of Neurology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
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Abstract
Pain is considered a hardwired signal of bodily disturbance belonging to a basic motivational system that urges the individual to act and to restore the body's integrity, rather than just a sensory and emotional experience. Given its eminent survival value, pain is a strong motivator for learning. Response to repeated pain increases when harm risks are high (sensitization) and decreases in the absence of such risks (habituation). Discovering relations between pain and other events provides the possibility to predict (Pavlovian conditioning) and control (operant conditioning) harmful events. Avoidance is adaptive in the short term but paradoxically may have detrimental long-term effects. Pain and pain-related responses compete with other demands in the environment. Exposure-based treatments share the aim of facilitating or restoring the pursuit of individual valued life goals in the face of persistent pain, and further improvements in pain treatment may require a paradigm shift toward more personalized approaches.
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Affiliation(s)
- Johan W S Vlaeyen
- Research Group on Health Psychology, Faculty of Psychology and Educational Sciences, University of Leuven, 3000 Leuven, Belgium; .,Experimental Health Psychology, Maastricht University, 6211 LK Maastricht, The Netherlands
| | - Geert Crombez
- Department of Experimental-Clinical and Health Psychology, Faculty of Psychology and Educational Sciences, Ghent University, 9000 Ghent, Belgium.,Centre for Pain Research, University of Bath, Bath BA2 7AY, United Kingdom
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13
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Timmers I, Quaedflieg CWEM, Hsu C, Heathcote LC, Rovnaghi CR, Simons LE. The interaction between stress and chronic pain through the lens of threat learning. Neurosci Biobehav Rev 2019; 107:641-655. [PMID: 31622630 DOI: 10.1016/j.neubiorev.2019.10.007] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 10/08/2019] [Accepted: 10/09/2019] [Indexed: 02/06/2023]
Abstract
Stress and pain are interleaved at multiple levels - interacting and influencing each other. Both are modulated by psychosocial factors including fears, beliefs, and goals, and are served by overlapping neural substrates. One major contributing factor in the development and maintenance of chronic pain is threat learning, with pain as an emotionally-salient threat - or stressor. Here, we argue that threat learning is a central mechanism and contributor, mediating the relationship between stress and chronic pain. We review the state of the art on (mal)adaptive learning in chronic pain, and on effects of stress and particularly cortisol on learning. We then provide a theoretical integration of how stress may affect chronic pain through its effect on threat learning. Prolonged stress, as may be experienced by patients with chronic pain, and its resulting changes in key brain networks modulating stress responses and threat learning, may further exacerbate these impairing effects on threat learning. We provide testable hypotheses and suggestions for how this integration may guide future research and clinical approaches in chronic pain.
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Affiliation(s)
- Inge Timmers
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, 1070 Arastradero Road, Suite 300, Palo Alto, CA 94304, United States.
| | - Conny W E M Quaedflieg
- Department of Clinical Psychological Science, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Connie Hsu
- Feinberg School of Medicine, Northwestern University, 420 E Superior St, Chicago, IL 60611, United States
| | - Lauren C Heathcote
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, 1070 Arastradero Road, Suite 300, Palo Alto, CA 94304, United States
| | - Cynthia R Rovnaghi
- Department of Pediatrics, Stanford University School of Medicine, 770 Welch Road, Suite 435, Stanford, CA 94304, United States
| | - Laura E Simons
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, 1070 Arastradero Road, Suite 300, Palo Alto, CA 94304, United States
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Traxler J, Madden VJ, Moseley GL, Vlaeyen JWS. Modulating pain thresholds through classical conditioning. PeerJ 2019; 7:e6486. [PMID: 30867984 PMCID: PMC6410694 DOI: 10.7717/peerj.6486] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 01/17/2019] [Indexed: 12/04/2022] Open
Abstract
Background Classical conditioning has frequently been shown to be capable of evoking fear of pain and avoidance behavior in the context of chronic pain. However, whether pain itself can be conditioned has rarely been investigated and remains a matter of debate. Therefore, the present study investigated whether pain threshold ratings can be modified by the presence of conditioned non-nociceptive sensory stimuli in healthy participant. Methods In 51 healthy volunteers, pain threshold to electrocutaneous stimuli was determined prior to participation in a simultaneous conditioning paradigm. Participants underwent an acquisition phase in which one non-painful vibrotactile stimulus (CS+) was repeatedly paired with a painful electrocutaneous stimulus, whereas a second vibrotactile stimulus of the same quality and intensity (CS−) was paired with a non-painful electrocutaneous stimulus. Stimulation was provided on the lower back with close proximity between the conditioned stimulus and the unconditioned stimulus. In the test phase, electrocutaneous stimuli at the individually-set threshold intensity were simultaneously delivered together with either a CS+ or CS−. Pain intensity ratings were obtained after each trial; expectancy ratings were obtained after each block. The primary outcome was the percentage of test stimuli that were rated as painful. Results Test stimuli were more likely to be rated as painful when they were paired with the CS+ than when they were paired with the CS−. This effect was not influenced by contingency awareness, nor by expectancies or mood states. Discussion The findings support the notion that the judgement of an event being painful or non-painful can be influenced by classical conditioning and corroborate the possible role of associative learning in the development and maintenance of chronic pain.
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Affiliation(s)
- Juliane Traxler
- Research Centre for Health Psychology, KU Leuven, Leuven, Belgium.,Experimental Health Psychology, Maastricht University, Maastricht, Netherlands
| | - Victoria J Madden
- Research Centre for Health Psychology, KU Leuven, Leuven, Belgium.,Department of Psychiatry and Mental Health, Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - G Lorimer Moseley
- Body in Mind Research Group, University of South Australia, Adelaide, SA, Australia
| | - Johan W S Vlaeyen
- Research Centre for Health Psychology, KU Leuven, Leuven, Belgium.,Experimental Health Psychology, Maastricht University, Maastricht, Netherlands
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Pavlov’s Pain: the Effect of Classical Conditioning on Pain Perception and its Clinical Implications. Curr Pain Headache Rep 2019; 23:19. [DOI: 10.1007/s11916-019-0766-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Psychological Processes in Chronic Pain: Influences of Reward and Fear Learning as Key Mechanisms – Behavioral Evidence, Neural Circuits, and Maladaptive Changes. Neuroscience 2018; 387:72-84. [DOI: 10.1016/j.neuroscience.2017.08.051] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Revised: 08/22/2017] [Accepted: 08/29/2017] [Indexed: 01/09/2023]
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Effects of Aversive Classical Conditioning on Sexual Response in Women With Dyspareunia and Sexually Functional Controls. J Sex Med 2017; 14:687-701. [DOI: 10.1016/j.jsxm.2017.03.244] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 02/14/2017] [Accepted: 03/03/2017] [Indexed: 01/23/2023]
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Greater fear of visceral pain contributes to differences between visceral and somatic pain in healthy women. Pain 2017; 158:1599-1608. [DOI: 10.1097/j.pain.0000000000000924] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Harvie DS, Moseley GL, Hillier SL, Meulders A. Classical Conditioning Differences Associated With Chronic Pain: A Systematic Review. THE JOURNAL OF PAIN 2017; 18:889-898. [PMID: 28385510 DOI: 10.1016/j.jpain.2017.02.430] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 02/01/2017] [Accepted: 02/20/2017] [Indexed: 01/14/2023]
Abstract
Prominent clinical models of chronic pain propose a fundamental role of classical conditioning in the development of pain-related disability. If classical conditioning is key to this process, then people with chronic pain may show a different response to pain-related conditioned stimuli than healthy control subjects. We set out to determine whether this is the case by undertaking a comprehensive and systematic review of the literature. To identify studies comparing classical conditioning between people with chronic pain and healthy control subjects, the databases MEDLINE, PsychINFO, PsychARTICLES, Scopus, and CINAHL were searched using key words and medical subject headings consistent with 'classical conditioning' and 'pain.' Articles were included when: 1) pain-free control and chronic pain groups were included, and 2) a differential classical conditioning design was used. The systematic search revealed 7 studies investigating differences in classical conditioning between people with chronic pain and healthy control participants. The included studies involved a total of 129 people with chronic pain (fibromyalgia syndrome, spinal pain, hand pain, irritable bowel syndrome), and 104 healthy control participants. Outcomes included indices of pain-related conditioning such as unconditioned stimulus (US) expectancy and contingency awareness, self-report and physiological measures of pain-related fear, evaluative judgements of conditioned stimulus pleasantness, and muscular and cortical responses. Because of variability in outcomes, meta-analyses included a maximum of 4 studies. People with chronic pain tended to show reduced differential learning and flatter generalization gradients with respect to US expectancy and fear-potentiated eyeblink startle responses. Some studies showed a propensity for greater muscular responses and perceptions of unpleasantness in response to pain-associated cues, relative to control cues. PERSPECTIVE The review revealed preliminary evidence that people with chronic pain may exhibit less differential US expectancy and fear learning. This characteristic may contribute to widespread fear-avoidance behavior. The assumption that altered classical conditioning may be a predisposing or maintaining factor for chronic pain remains to be verified.
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Affiliation(s)
- Daniel S Harvie
- Body in Mind Research Group, Sansom Institute for Health Research, University of South Australia, Adelaide, Australia; Recover Injury Research Centre, Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia.
| | - G Lorimer Moseley
- Body in Mind Research Group, Sansom Institute for Health Research, University of South Australia, Adelaide, Australia; Neuroscience Research Australia, Sydney, Australia
| | - Susan L Hillier
- Body in Mind Research Group, Sansom Institute for Health Research, University of South Australia, Adelaide, Australia
| | - Ann Meulders
- Research Group on Health Psychology, University of Leuven, Leuven, Belgium; Center for Excellence on Generalization Research in Health and Psychopathology, University of Leuven, Leuven, Belgium
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Abstract
Pain perception is a complex experience that entails somatic and psychological factors. This is especially true for chronic pain where increasing chronicity leads to a growing significance of psychological factors such as learning and memory processes or cognitive evaluation at the expense of nociceptive processes. Hardly any other area of health-related research and health care has such an interdisciplinary organization of research, treatment, and education. Psychological pain research and psychological treatment of pain have become specializations in their own right. For the future of this research area, a differential analysis of the contribution of psychological factors to chronicity is important. For a mechanism-oriented treatment, the development of new treatment approaches and the analysis of specific subgroups for a better differential indication of treatments is needed.
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Affiliation(s)
- M Pfingsten
- Schmerzmedizin, Klinik für Anästhesiologie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland.
| | - H Flor
- Zentralinstitut für Seelische Gesundheit, Institut für Neuropsychologie und Klinische Psychologie, Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Deutschland
| | - P Nilges
- DRK Schmerz-Zentrum Mainz, Mainz, Deutschland
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Elmerstig E, Thomtén J. Vulvar Pain-Associations Between First-Time Vaginal Intercourse, Tampon Insertion, and Later Experiences of Pain. JOURNAL OF SEX & MARITAL THERAPY 2016; 42:707-720. [PMID: 26643915 DOI: 10.1080/0092623x.2015.1113589] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
This study examines associations between the first experience of vaginal intercourse/tampon insertion and later experiences of vulvar pain. The study is based on questionnaire data from 1,259 Swedish female senior high-school students, aged 18 to 22 years old. Of these, 592 women reported present vulvar pain. Present vulvar pain was associated with first-time experiences of vaginal intercourse (pain, negative experience, against will) and with pain at tampon insertion. First-time experiences were also related to temporal aspects of present vulvar pain during vaginal intercourse (at the beginning, after a while during, and after). Implications of first-time experiences of vaginal intercourse for future symptoms of vulvar pain are discussed.
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Affiliation(s)
- Eva Elmerstig
- a Centre for Sexology and Sexuality Studies, Faculty of Health and Society, Malmö University , Malmö , Sweden
| | - Johanna Thomtén
- b Department of Psychology , Mid Sweden University , Östersund , Sweden
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Madden VJ, Russek LN, Harvie DS, Vlaeyen JW, Moseley GL. Classical Conditioning Fails to Elicit Allodynia in an Experimental Study with Healthy Humans. PAIN MEDICINE 2016; 18:1314-1325. [DOI: 10.1093/pm/pnw221] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Do clinicians think that pain can be a classically conditioned response to a non-noxious stimulus? ACTA ACUST UNITED AC 2016; 22:165-73. [DOI: 10.1016/j.math.2015.12.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 12/03/2015] [Accepted: 12/12/2015] [Indexed: 11/22/2022]
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Madden VJ, Harvie DS, Parker R, Jensen KB, Vlaeyen JWS, Moseley GL, Stanton TR. Can Pain or Hyperalgesia Be a Classically Conditioned Response in Humans? A Systematic Review and Meta-Analysis. PAIN MEDICINE 2015; 17:1094-111. [PMID: 26814278 DOI: 10.1093/pm/pnv044] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 09/30/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND Clinical scenarios of repeated pain usually involve both nociceptive and non-nociceptive input. It is likely that associations between these stimuli are learned over time. Such learning may underlie subsequent amplification of pain, or evocation of pain in the absence of nociception. METHODS We undertook a systematic review and meta-analysis to evaluate the evidence that allodynia or hyperalgesia can be a classically conditioned response. A sensitive search of the literature covered Medline, Embase, CINAHL, AMED, PubMed, Scopus, PsycArticles, PsycINFO, Cochrane Library, and Web of Science. Additional studies were identified by contacting experts and searching published reviews. Two reviewers independently assessed studies for inclusion, evaluated risk of bias, and extracted data. Studies were included if they aimed to elicit or amplify pain using a classical conditioning procedure in healthy, adult humans. Studies were excluded if they did not distinguish between classical conditioning and explicit verbal suggestion as learning sources, or did not use experiential learning. RESULTS Thirteen studies, with varying risk of bias, were included. Ten studies evaluated classically conditioned hyperalgesia: nine found hyperalgesia; one did not. Pooled effects (n = 8 with full data) showed a significant pain increase after conditioning (mean difference of 7.40 [95%CI: 4.00-10.80] on a 0-100 pain scale). Three studies evaluated conditioned allodynia and found conflicting results. CONCLUSION The existing literature suggests that classical conditioning can amplify pain. No conclusions can be drawn about whether or not classical conditioning can elicit pain. Rigorous experimental conditioning studies with nociceptive unconditioned stimuli are needed to fill this gap in knowledge.
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Affiliation(s)
- Victoria J Madden
- *Sansom Institute for Health Research, University of South Australia, Adelaide, Australia
| | - Daniel S Harvie
- *Sansom Institute for Health Research, University of South Australia, Adelaide, Australia; CONROD, Menzies Health Institute Queensland, Griffith University, Australia
| | - Romy Parker
- Department of Health and Rehabilitation Sciences, University of Cape Town, Cape Town, South Africa
| | - Karin B Jensen
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Johan W S Vlaeyen
- Research Group Health Psychology, KU Leuven, Leuven, Belgium; Department Clinical Psychological Science, Maastricht University, Maastricht, The Netherlands
| | - G Lorimer Moseley
- *Sansom Institute for Health Research, University of South Australia, Adelaide, Australia; Neuroscience Research Australia, Sydney, Australia
| | - Tasha R Stanton
- *Sansom Institute for Health Research, University of South Australia, Adelaide, Australia; Neuroscience Research Australia, Sydney, Australia
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Icenhour A, Kattoor J, Benson S, Boekstegers A, Schlamann M, Merz CJ, Forsting M, Elsenbruch S. Neural circuitry underlying effects of context on human pain-related fear extinction in a renewal paradigm. Hum Brain Mapp 2015; 36:3179-93. [PMID: 26058893 DOI: 10.1002/hbm.22837] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 04/20/2015] [Accepted: 04/27/2015] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES The role of context in pain-related extinction learning remains poorly understood. We analyzed the neural mechanisms underlying context-dependent extinction and renewal in a clinically relevant model of conditioned abdominal pain-related fear. EXPERIMENTAL DESIGN In this functional magnetic resonance imaging study, two groups of healthy volunteers underwent differential fear conditioning with painful rectal distensions as unconditioned stimuli (US) and visual conditioned stimuli (CS(+) ; CS(-) ). The extinction context was changed in an experimental group (context group), which was subsequently returned into the original learning context to test for renewal. No context changes occurred in the control group. Group differences in CS-induced differential neural activation were analyzed along with skin conductance responses (SCR), CS valence and CS-US contingency ratings. PRINCIPAL OBSERVATIONS During extinction, group differences in differential neural activation were observed in dorsolateral (dlPFC) and ventromedial (vmPFC) prefrontal cortex and amygdala, mainly driven by enhanced activation in response to the CS(-) in the control group. During renewal, observed group differences in activation of dlPFC and orbitofrontal cortex (OFC) resulted primarily from differential modulation of the CS(-) in the absence of group differences in response to CS(+) or SCR. CONCLUSION The extinction context affects the neural processing of nonpain predictive safety cues, supporting a role of safety learning in pain-related memory processes.
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Affiliation(s)
- Adriane Icenhour
- Institute of Medical Psychology & Behavioral Immunobiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Joswin Kattoor
- Institute of Medical Psychology & Behavioral Immunobiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Sven Benson
- Institute of Medical Psychology & Behavioral Immunobiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Armgard Boekstegers
- Institute of Medical Psychology & Behavioral Immunobiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Marc Schlamann
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Christian J Merz
- Department of Biological and Clinical Psychology, University of Trier, Trier, Germany
| | - Michael Forsting
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Sigrid Elsenbruch
- Institute of Medical Psychology & Behavioral Immunobiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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Icenhour A, Langhorst J, Benson S, Schlamann M, Hampel S, Engler H, Forsting M, Elsenbruch S. Neural circuitry of abdominal pain-related fear learning and reinstatement in irritable bowel syndrome. Neurogastroenterol Motil 2015; 27:114-27. [PMID: 25557224 DOI: 10.1111/nmo.12489] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 11/18/2014] [Indexed: 12/29/2022]
Abstract
BACKGROUND Altered pain anticipation likely contributes to disturbed central pain processing in chronic pain conditions like irritable bowel syndrome (IBS), but the learning processes shaping the expectation of pain remain poorly understood. We assessed the neural circuitry mediating the formation, extinction, and reactivation of abdominal pain-related memories in IBS patients compared to healthy controls (HC) in a differential fear conditioning paradigm. METHODS During fear acquisition, predictive visual cues (CS(+)) were paired with rectal distensions (US), while control cues (CS(-)) were presented unpaired. During extinction, only CSs were presented. Subsequently, memory reactivation was assessed with a reinstatement procedure involving unexpected USs. Using functional magnetic resonance imaging, group differences in neural activation to CS(+) vs CS(-) were analyzed, along with skin conductance responses (SCR), CS valence, CS-US contingency, state anxiety, salivary cortisol, and alpha-amylase activity. The contribution of anxiety symptoms was addressed in covariance analyses. KEY RESULTS Fear acquisition was altered in IBS, as indicated by more accurate contingency awareness, greater CS-related valence change, and enhanced CS(+)-induced differential activation of prefrontal cortex and amygdala. IBS patients further revealed enhanced differential cingulate activation during extinction and greater differential hippocampal activation during reinstatement. Anxiety affected neural responses during memory formation and reinstatement. CONCLUSIONS & INFERENCES Abdominal pain-related fear learning and memory processes are altered in IBS, mediated by amygdala, cingulate cortex, prefrontal areas, and hippocampus. Enhanced reinstatement may contribute to hypervigilance and central pain amplification, especially in anxious patients. Preventing a 'relapse' of learned fear utilizing extinction-based interventions may be a promising treatment goal in IBS.
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Affiliation(s)
- A Icenhour
- Institute of Medical Psychology & Behavioral Immunobiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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Learning pain-related fear: Neural mechanisms mediating rapid differential conditioning, extinction and reinstatement processes in human visceral pain. Neurobiol Learn Mem 2014; 116:36-45. [DOI: 10.1016/j.nlm.2014.08.003] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Revised: 07/14/2014] [Accepted: 08/06/2014] [Indexed: 01/20/2023]
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Abstract
OBJECTIVE The current study provides the first measure of pain-related fear for pediatric headache patients. METHODS From a large pediatric headache clinic, a cross-sectional cohort of 206 children and adolescents completed measures of pain-related fear, anxiety sensitivity, catastrophizing, pain acceptance, functional disability, and school functioning. RESULTS The two-factor solution of the Fear of Pain Questionnaire (FOPQ) was confirmed from the originally derived structure with pediatric headache patients. Simultaneously regressing FOPQ subscales fear of pain and activity avoidance on theorized construct validity measures demonstrated that fear of pain was more closely linked with anxiety sensitivity and pain catastrophizing while activity avoidance had a strong negative association with pain acceptance (activity engagement and pain willingness). Pain-related fear was not significantly associated with pain level. After controlling for demographic factors and pain, fear of pain and activity avoidance accounted for an additional 26% of the variance in functional disability and school functioning outcomes, with activity avoidance accounting for much of this relationship. CONCLUSIONS Although typically considered an influential construct among musculoskeletal patients, pain-related fear is also an important factor influencing functioning among pediatric headache patients, with the dimension of activity avoidance particularly salient.
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Affiliation(s)
- Laura E Simons
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, MA, USA Department of Psychiatry, Harvard Medical School, MA, USA
| | - Melissa Pielech
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, MA, USA
| | - Stefanie Cappucci
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, MA, USA
| | - Alyssa Lebel
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, MA, USA
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Benson S, Kattoor J, Kullmann JS, Hofmann S, Engler H, Forsting M, Gizewski ER, Elsenbruch S. Towards understanding sex differences in visceral pain: Enhanced reactivation of classically-conditioned fear in healthy women. Neurobiol Learn Mem 2014; 109:113-21. [DOI: 10.1016/j.nlm.2013.12.014] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 12/19/2013] [Accepted: 12/27/2013] [Indexed: 01/03/2023]
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Simons LE, Elman I, Borsook D. Psychological processing in chronic pain: a neural systems approach. Neurosci Biobehav Rev 2013; 39:61-78. [PMID: 24374383 DOI: 10.1016/j.neubiorev.2013.12.006] [Citation(s) in RCA: 246] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2013] [Revised: 12/17/2013] [Accepted: 12/19/2013] [Indexed: 12/22/2022]
Abstract
Our understanding of chronic pain involves complex brain circuits that include sensory, emotional, cognitive and interoceptive processing. The feed-forward interactions between physical (e.g., trauma) and emotional pain and the consequences of altered psychological status on the expression of pain have made the evaluation and treatment of chronic pain a challenge in the clinic. By understanding the neural circuits involved in psychological processes, a mechanistic approach to the implementation of psychology-based treatments may be better understood. In this review we evaluate some of the principle processes that may be altered as a consequence of chronic pain in the context of localized and integrated neural networks. These changes are ongoing, vary in their magnitude, and their hierarchical manifestations, and may be temporally and sequentially altered by treatments, and all contribute to an overall pain phenotype. Furthermore, we link altered psychological processes to specific evidence-based treatments to put forth a model of pain neuroscience psychology.
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Affiliation(s)
- Laura E Simons
- Center for Pain and the Brain, P.A.I.N. Group, Boston Children's Hospital, United States; Department of Psychiatry, United States; Harvard Medical School, United States.
| | | | - David Borsook
- Center for Pain and the Brain, P.A.I.N. Group, Boston Children's Hospital, United States; Harvard Medical School, United States
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Maihofner C, Heskamp ML. Prospective, non-interventional study on the tolerability and analgesic effectiveness over 12 weeks after a single application of capsaicin 8% cutaneous patch in 1044 patients with peripheral neuropathic pain: first results of the QUEPP study. Curr Med Res Opin 2013; 29:673-83. [PMID: 23551064 DOI: 10.1185/03007995.2013.792246] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Reversible defunctionalisation of nociceptors by the TRPV1 agonist capsaicin in high concentration is an emerging new concept for the treatment of peripheral neuropathic pain. OBJECTIVES The capsaicin 8% cutaneous patch with a long-lasting effect for up to 3 months after a single application is available in Germany by prescription since October 2010. The aim of this study was to monitor its usage and therapeutic performance in clinical practice. METHODS Patients had a single patch application with up to 4 patches and were followed up after 7-14 days, 4, 8, and 12 weeks. Average pain intensity (NPRS-11), pain attacks, neuropathy symptoms, sleep parameters, quality of life, working capacity and concomitant neuropathic pain medication were assessed during at least two visits. RESULTS A total of 509 females (48.8%; effectiveness population N = 1044) and 531 males (50.9%) were included; the mean age was 61.2 ± 14.4 (SD) years. Postherpetic neuralgia was the most frequent diagnosis (31.9%), followed by postsurgical neuralgia (22.8%), post-traumatic neuropathy (12.4%), polyneuropathy (14.3%), and mixed pain syndromes (16.6%). Thirty and 50% responder rates were 42.7% and 23.7%, respectively, with a mean relative reduction of pain intensity during weeks 1-12 of 24.7% (1.1 SEM) and significant improvements in pain attacks, sleep duration and sleep quality, while the consumption of opioids and antiepileptics decreased significantly. In 106 patients (10.0%; safety population n = 1063) 146 adverse drug reactions (ADRs) were reported, mainly application site reactions (erythema, pain). A total of 27 serious ADRs were documented in 17 patients (1.6%). CONCLUSIONS Analgesic treatment of peripheral neuropathic pain with the capsaicin 8% cutaneous patch is safe and effective. LIMITATIONS The study did not include a control group; therefore, a comparison of the results with that of therapeutic alternatives is not justified.
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Affiliation(s)
- C Maihofner
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany.
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Kattoor J, Gizewski ER, Kotsis V, Benson S, Gramsch C, Theysohn N, Maderwald S, Forsting M, Schedlowski M, Elsenbruch S. Fear conditioning in an abdominal pain model: neural responses during associative learning and extinction in healthy subjects. PLoS One 2013; 8:e51149. [PMID: 23468832 PMCID: PMC3582635 DOI: 10.1371/journal.pone.0051149] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Accepted: 10/29/2012] [Indexed: 12/17/2022] Open
Abstract
Fear conditioning is relevant for elucidating the pathophysiology of anxiety, but may also be useful in the context of chronic pain syndromes which often overlap with anxiety. Thus far, no fear conditioning studies have employed aversive visceral stimuli from the lower gastrointestinal tract. Therefore, we implemented a fear conditioning paradigm to analyze the conditioned response to rectal pain stimuli using fMRI during associative learning, extinction and reinstatement. In N = 21 healthy humans, visual conditioned stimuli (CS+) were paired with painful rectal distensions as unconditioned stimuli (US), while different visual stimuli (CS−) were presented without US. During extinction, all CSs were presented without US, whereas during reinstatement, a single, unpaired US was presented. In region-of-interest analyses, conditioned anticipatory neural activation was assessed along with perceived CS-US contingency and CS unpleasantness. Fear conditioning resulted in significant contingency awareness and valence change, i.e., learned unpleasantness of a previously neutral stimulus. This was paralleled by anticipatory activation of the anterior cingulate cortex, the somatosensory cortex and precuneus (all during early acquisition) and the amygdala (late acquisition) in response to the CS+. During extinction, anticipatory activation of the dorsolateral prefrontal cortex to the CS− was observed. In the reinstatement phase, a tendency for parahippocampal activation was found. Fear conditioning with rectal pain stimuli is feasible and leads to learned unpleasantness of previously neutral stimuli. Within the brain, conditioned anticipatory activations are seen in core areas of the central fear network including the amygdala and the anterior cingulate cortex. During extinction, conditioned responses quickly disappear, and learning of new predictive cue properties is paralleled by prefrontal activation. A tendency for parahippocampal activation during reinstatement could indicate a reactivation of the old memory trace. Together, these findings contribute to our understanding of aversive visceral learning and memory processes relevant to the pathophysiology of chronic abdominal pain.
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Affiliation(s)
- Joswin Kattoor
- Inst. of Medical Psychology & Behavioral Immunobiology, University Hospital of Essen, University of Duisburg-Essen, Essen, Germany
| | - Elke R. Gizewski
- Clinic of Neuroradiology, Innsbruck Medical University, Innsbruck, Austria
| | - Vassilios Kotsis
- Inst. of Medical Psychology & Behavioral Immunobiology, University Hospital of Essen, University of Duisburg-Essen, Essen, Germany
| | - Sven Benson
- Inst. of Medical Psychology & Behavioral Immunobiology, University Hospital of Essen, University of Duisburg-Essen, Essen, Germany
| | - Carolin Gramsch
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital of Essen, University of Duisburg-Essen, Essen, Germany
| | - Nina Theysohn
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital of Essen, University of Duisburg-Essen, Essen, Germany
| | - Stefan Maderwald
- Erwin L. Hahn Institute for Resonance Imaging, University of Duisburg-Essen, Essen, Germany
| | - Michael Forsting
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital of Essen, University of Duisburg-Essen, Essen, Germany
| | - Manfred Schedlowski
- Inst. of Medical Psychology & Behavioral Immunobiology, University Hospital of Essen, University of Duisburg-Essen, Essen, Germany
| | - Sigrid Elsenbruch
- Inst. of Medical Psychology & Behavioral Immunobiology, University Hospital of Essen, University of Duisburg-Essen, Essen, Germany
- * E-mail:
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Woldendorp KH, van de Werk P, Boonstra AM, Stewart RE, Otten E. Relation between muscle activation pattern and pain: an explorative study in a bassists population. Arch Phys Med Rehabil 2012; 94:1095-106. [PMID: 23220344 DOI: 10.1016/j.apmr.2012.11.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Revised: 11/16/2012] [Accepted: 11/25/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To explore the muscle activation patterns in relation to pain complaints in bassists studied during a musical task. This study was based on the assumption that pain complaints are caused by increased muscle activation during playing or relaxation and/or faster onset of fatigue of muscles. DESIGN Cross-sectional study. SETTING Nonclinical. PARTICIPANTS Student bass guitarists (N=36) from conservatories in the Netherlands. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Bassists played a standard music piece for 30 minutes. Muscle activation levels and pain were recorded. Pain was registered with a Numeric Rating Scale (NRS 0-10). The muscle activation level of both the trapezius muscles and flexor carpi radialis was measured with sEMG: sEMG as the percentage of the maximal voluntary isometric contraction (%MVC) and the slope of the sEMG (slope of %MVC) were calculated. The %MVC as a function of time and the slope of %MVC were calculated during playing and for rest periods before and after playing. For statistic analysis, the Mann-Whitney U test and a multilevel multiregression analysis were used for comparing the sEMG data of bassists with and without pain. RESULTS No significant differences in %MVC or the slope of %MVC were between the bassists with and without pain complaints. CONCLUSIONS The results surprisingly indicate that pain complaints of bassists may not be associated with another muscle activation pattern. It is, therefore, not likely that pain is caused by increased muscle activation during playing and/or relaxation, nor by faster onset of fatigue.
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Affiliation(s)
- Kees H Woldendorp
- Revalidatie Friesland Centre for Rehabilitation, Beetsterzwaag, The Netherlands.
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Abstract
PURPOSE OF REVIEW It is proposed that central rather than peripheral factors may be important in pain chronicity. We review recent empirical findings on these processes and discuss implications for treatment and prevention. RECENT FINDINGS The literature on neuroimaging of pain and on learning processes shows that learning-induced functional and structural brain changes involving sensorimotor, as well as limbic and frontal, areas are important in the transition from acute to chronic pain. These alterations share many similarities with brain changes in emotional disorders and the specificity for pain needs to be determined. Further important contributors to chronic pain may be disturbed processing of the body image, impaired multisensory integration and faulty feedback from interoceptive processes. These findings have led to new treatment approaches that focus on the extinction of aversive memories, restoration of the body image and normal brain function and include approaches such as brain stimulation, mirror training, virtual reality applications or behavioral extinction training. SUMMARY We propose that chronic pain is characterized by learning-related and memory-related plastic changes of the central nervous system with concomitant maladaptive changes in body perception. These alterations require new treatments that focus on the alteration of central pain memories and maladaptive body perception.
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Gatzounis R, Schrooten MGS, Crombez G, Vlaeyen JWS. Operant Learning Theory in Pain and Chronic Pain Rehabilitation. Curr Pain Headache Rep 2012; 16:117-26. [DOI: 10.1007/s11916-012-0247-1] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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The acquisition of fear of movement-related pain and associative learning: A novel pain-relevant human fear conditioning paradigm. Pain 2011; 152:2460-2469. [DOI: 10.1016/j.pain.2011.05.015] [Citation(s) in RCA: 135] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Revised: 04/26/2011] [Accepted: 05/13/2011] [Indexed: 11/23/2022]
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Operant learning of perceptual sensitization and habituation is impaired in fibromyalgia patients with and without irritable bowel syndrome. Pain 2011; 152:1408-1417. [DOI: 10.1016/j.pain.2011.02.027] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2010] [Revised: 02/08/2011] [Accepted: 02/09/2011] [Indexed: 12/28/2022]
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Abdominal pain in Irritable Bowel Syndrome: a review of putative psychological, neural and neuro-immune mechanisms. Brain Behav Immun 2011; 25:386-94. [PMID: 21094682 DOI: 10.1016/j.bbi.2010.11.010] [Citation(s) in RCA: 209] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2010] [Revised: 10/22/2010] [Accepted: 11/16/2010] [Indexed: 12/12/2022] Open
Abstract
Chronic abdominal pain is a common symptom of great clinical significance in several areas of medicine. In many cases no organic cause can be established resulting in the classification as functional gastrointestinal disorder. Irritable Bowel Syndrome (IBS) is the most common of these conditions and is considered an important public health problem because it can be disabling and constitutes a major social and economic burden given the lack of effective treatments. IBS aetiology is most likely multi-factorial involving biological, psychological and social factors. Visceral hyperalgesia (or hypersensitivity) and visceral hypervigilance, which could be mediated by peripheral, spinal, and/or central pathways, constitute key concepts in current research on pathophysiological mechanisms of visceral hyperalgesia. The role of central nervous system mechanisms along the "brain-gut axis" is increasingly appreciated, owing to accumulating evidence from brain imaging studies that neural processing of visceral stimuli is altered in IBS together with long-standing knowledge regarding the contribution of stress and negative emotions to symptom frequency and severity. At the same time, there is also growing evidence suggesting that peripheral immune mechanisms and disturbed neuro-immune communication could play a role in the pathophysiology of visceral hyperalgesia. This review presents recent advances in research on the pathophysiology of visceral hyperalgesia in IBS, with a focus on the role of stress and anxiety in central and peripheral response to visceral pain stimuli. Together, these findings support that in addition to lower pain thresholds displayed by a significant proportion of patients, the evaluation of pain appears to be altered in IBS. This may be attributable to affective disturbances, negative emotions in anticipation of or during visceral stimulation, and altered pain-related expectations and learning processes. Disturbed "top-down" emotional and cognitive pain modulation in IBS is reflected by functional and possibly structural brain changes involving prefrontal as well as cingulate regions. At the same time, there is growing evidence linking peripheral and mucosal immune changes and abdominal pain in IBS, supporting disturbed peripheral pain signalling. Findings in post-infectious IBS emphasize the interaction between centrally-mediated psychosocial risk factors and local inflammation in predicting long-term IBS symptoms. Investigating afferent immune-to-brain communication in visceral hyperalgesia as a component of the sickness response constitutes a promising future research goal.
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