1
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Alemany-González M, Wokke ME, Chiba T, Narumi T, Kaneko N, Yokoyama H, Watanabe K, Nakazawa K, Imamizu H, Koizumi A. Fear in action: Fear conditioning and alleviation through body movements. iScience 2024; 27:109099. [PMID: 38414854 PMCID: PMC10897899 DOI: 10.1016/j.isci.2024.109099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 11/11/2023] [Accepted: 01/30/2024] [Indexed: 02/29/2024] Open
Abstract
Fear memories enhance survival especially when the memories guide defensive movements to minimize harm. Accordingly, fear memories and body movements have tight relationships in animals: Fear memory acquisition results in adapting reactive defense movements, while training active defense movements reduces fear memory. However, evidence in humans is scarce because their movements are typically suppressed in experiments. Here, we tracked adult participants' body motions while they underwent ecologically valid fear conditioning in a 3D virtual space. First, with body motion tracking, we revealed that distinct spatiotemporal body movement patterns emerge through fear conditioning. Second, subsequent training to actively avoid threats with naturalistic defensive actions led to a long-term (24 h) reduction of physiological and embodied conditioned responses, while extinction or vicarious training only transiently reduced the responses. Together, our results highlight the role of body movements in human fear memory and its intervention.
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Affiliation(s)
| | - Martijn E. Wokke
- Sony Computer Science Laboratories, Inc., Tokyo, Japan
- Centre for Mind, Brain and Behavior, University of Granada, Granada, Spain
- Neuroscience Institute, New York University Grossman School of Medicine, New York, NY, USA
| | - Toshinori Chiba
- The Department of Decoded Neurofeedback, Computational Neuroscience Laboratories, Advanced Telecommunications Research Institute International, Kyoto, Japan
- The Department of Psychiatry, Self-Defense Forces Hanshin Hospital, Kawanishi, Japan
- The Department of Psychiatry, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takuji Narumi
- Graduate School of Information Science and Technology, The University of Tokyo, Tokyo, Japan
| | - Naotsugu Kaneko
- Department of Life Sciences, Graduate School of Arts and Sciences, The University of Tokyo, Tokyo, Japan
| | - Hikaru Yokoyama
- Institute of Engineering, Tokyo University of Agriculture and Technology, Tokyo, Japan
| | - Katsumi Watanabe
- Faculty of Science and Engineering, Waseda University, Tokyo, Japan
- Department of Psychology, University of New South Wales, Sydney, NSW, Australia
| | - Kimitaka Nakazawa
- Department of Life Sciences, Graduate School of Arts and Sciences, The University of Tokyo, Tokyo, Japan
| | - Hiroshi Imamizu
- Research Into Artifacts, Center for Engineering, Graduate School of Engineering, The University of Tokyo, Tokyo, Japan
- Department of Psychology, Graduate School of Humanities and Sociology, The University of Tokyo, Tokyo, Japan
- Department of Cognitive Neuroscience, Cognitive Mechanisms Laboratories, Advanced Telecommunications Research Institute International, Kyoto, Japan
| | - Ai Koizumi
- Sony Computer Science Laboratories, Inc., Tokyo, Japan
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2
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Optimizing Long-term Outcomes of Exposure for Chronic Primary Pain from the Lens of Learning Theory. THE JOURNAL OF PAIN 2021; 22:1315-1327. [PMID: 34029684 DOI: 10.1016/j.jpain.2021.04.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/14/2021] [Accepted: 04/23/2021] [Indexed: 01/04/2023]
Abstract
Exposure in vivo is a theory-driven and widely used treatment to tackle functional disability in people with chronic primary pain. Exposure is quite effective; yet, in line with exposure outcomes for anxiety disorders, a number of patients may not profit from it, or relapse. In this focus article, we critically reflect on the current exposure protocols in chronic primary pain, and provide recommendations on how to optimize them. We propose several adaptations that are expected to strengthen inhibitory learning and/or retrieval of the extinction memory, thus likely decreasing relapse. We summarize the limited, but emerging experimental data in the pain domain, and draw parallels with experimental evidence in the anxiety literature. Our reflections and suggestions pertain to the use of the fear hierarchy, reassurance, positive psychology interventions, exposure with a range of stimuli and within different contexts, and the use of safety behaviors during treatment, as well as associating the fear-inducing stimuli with novel outcomes. In addition, we reflect on the importance of specifically tackling (the return of) pain-related avoidance behavior with techniques such as disentangling fear from avoidance and reinforcing approach behaviors. Finally, we discuss challenges in the clinical application of exposure to improve functioning in chronic primary pain and possible avenues for future research. Perspectives: Inspired by recent advances in learning theory and its applications on the treatment of anxiety disorders, we reflect on the delivery of exposure treatment for chronic primary pain and propose strategies to improve its long-term outcomes.
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3
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Vaughan S, McGlone F, Poole H, Moore DJ. A Quantitative Sensory Testing Approach to Pain in Autism Spectrum Disorders. J Autism Dev Disord 2020; 50:1607-1620. [PMID: 30771132 PMCID: PMC7211210 DOI: 10.1007/s10803-019-03918-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Sensory abnormalities in autism has been noted clinically, with pain insensitivity as a specified diagnostic criterion. However, there is limited research using psychophysically robust techniques. Thirteen adults with ASD and 13 matched controls completed an established quantitative sensory testing (QST) battery, supplemented with measures of pain tolerance and central modulation. The ASD group showed higher thresholds for light touch detection and mechanical pain. Notably, the ASD group had a greater range of extreme scores (the number of z-scores outside of the 95% CI > 2), dynamic mechanical allodynia and paradoxical heat sensation; phenomena not typically seen in neurotypical individuals. These data support the need for research examining central mechanisms for pain in ASD and greater consideration of individual difference.
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Affiliation(s)
- Sarah Vaughan
- School of Natural Sciences and Psychology, Psychology Department, Liverpool John Moores University, Liverpool, L3 3AF, UK.,Faculty of Social Sciences, School of Psychology, Chester University, Chester, CH1 4BJ, UK
| | - Francis McGlone
- School of Natural Sciences and Psychology, Psychology Department, Liverpool John Moores University, Liverpool, L3 3AF, UK.,Institute of Psychology, Health and Society, University of Liverpool, Liverpool, L69 3GL, UK
| | - Helen Poole
- School of Natural Sciences and Psychology, Psychology Department, Liverpool John Moores University, Liverpool, L3 3AF, UK
| | - David J Moore
- School of Natural Sciences and Psychology, Psychology Department, Liverpool John Moores University, Liverpool, L3 3AF, UK. .,Department of Natural Sciences and Psychology, Liverpool John Moores University, Liverpool, L3 3AF, UK.
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4
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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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5
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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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6
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De Vroey H, Claeys K, Shariatmadar K, Weygers I, Vereecke E, Van Damme G, Hallez H, Staes F. High Levels of Kinesiophobia at Discharge from the Hospital May Negatively Affect the Short-Term Functional Outcome of Patients Who Have Undergone Knee Replacement Surgery. J Clin Med 2020; 9:jcm9030738. [PMID: 32182895 PMCID: PMC7141217 DOI: 10.3390/jcm9030738] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 03/04/2020] [Accepted: 03/05/2020] [Indexed: 01/17/2023] Open
Abstract
Background: Kinesiophobia is a psycho-cognitive factor that hampers recovery after orthopedic surgery. No evidence exists on the influence of kinesiophobia on the short-term recovery of function in patients with knee replacement (KR). Therefore, the aim of the present study is to investigate the impact of kinesiophobia on short-term patient-reported outcomes (PROMs) and performance-based measures (PBMs). Methods: Forty-three KR patients filled in the Tampa scale for kinesiophobia (TSK) at time of discharge. Patients with TSK ≥ 37 were allocated to the kinesiophobia group (n = 24), others to the no-kinesiophobia group (n = 19). Patients were asked to complete PROMs and to execute PBMs at discharge and at 6-weeks follow-up. An independent samples t-test was used to compare group differences for PROMs and PBMs at both measurement sessions. Multiple linear regression analysis models were used to model PBM outcomes from age, pain and TSK scores. Results: Significant differences were observed between groups for PROMs and PBMs. Kinesiophobia significantly contributed to the reduced functional outcomes. Conclusion: At discharge from the hospital, 55.8% of KR patients demonstrated high levels of kinesiophobia (TSK ≥ 37). This may negatively influence short-term recovery of these patients, by putting them at higher risk for falling and reduced functionality.
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Affiliation(s)
- Henri De Vroey
- KU Leuven, Campus Bruges, Department of Rehabilitation Sciences, Spoorwegstraat 12, 8200 Bruges, Belgium; (K.C.); (I.W.)
- Correspondence: ; Tel.: +32-473-41-58-71
| | - Kurt Claeys
- KU Leuven, Campus Bruges, Department of Rehabilitation Sciences, Spoorwegstraat 12, 8200 Bruges, Belgium; (K.C.); (I.W.)
| | - Keivan Shariatmadar
- KU Leuven, Campus Bruges, Department of Mechanical Engineering, Spoorwegstraat 12, 8200 Bruges, Belgium;
| | - Ive Weygers
- KU Leuven, Campus Bruges, Department of Rehabilitation Sciences, Spoorwegstraat 12, 8200 Bruges, Belgium; (K.C.); (I.W.)
| | - Evie Vereecke
- KU Leuven, Campus Kulak Kortrijk, Department of Development and Regeneration, Etienne Sabbelaan 53, 8500 Kortrijk, Belgium;
| | - Geert Van Damme
- AZ Sint Lucas Hospital, Department of Orthopedic Surgery, Sint-Lucaslaan 29, 8310 Bruges, Belgium;
| | - Hans Hallez
- KU Leuven, Campus Bruges, Department of Computer Science, Spoorwegstraat 12, 8200 Bruges, Belgium;
| | - Filip Staes
- KU Leuven, Campus Leuven, Department of Rehabilitation Sciences, Tervuursevest 101, 3001 Leuven, Belgium;
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7
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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: 65] [Impact Index Per Article: 13.0] [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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8
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Nishi Y, Osumi M, Nobusako S, Takeda K, Morioka S. Avoidance Behavioral Difference in Acquisition and Extinction of Pain-Related Fear. Front Behav Neurosci 2019; 13:236. [PMID: 31680893 PMCID: PMC6797557 DOI: 10.3389/fnbeh.2019.00236] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 09/19/2019] [Indexed: 11/25/2022] Open
Abstract
Fear of movement-related pain leads to two types of avoidance behavior: excessive avoidance and pain-inhibited movement. Excessive avoidance is an absence of movement by fear, and pain-inhibited movements involve a change in motor behavior for the purpose of protecting the painful part. Here, we sought to clarify the acquisition process and adaptation of fear for each avoidance behavior. Thirty-one female and 13 male (age 20.9 ± 2.1 years) subjects could decide persistent behaviors: approach with an intense pain stimulus, pain-inhibited movement with weak pain stimulus, or excessive avoidance with no pain in acquisition and test phases. In the subsequent extinction phase, the pain stimulus was omitted. Subjects were divided into an approach group (n = 24), a pain-inhibited movement group (n = 10), and an excessive avoidance group (n = 10) by cluster analysis. The response latencies in approach and pain-inhibited movement groups were not affected by conditioned pain. The subjects in the excessive avoidance group exhibited delayed response latencies, and their high-fear responses remained in the acquisition, test, and extinction phases. In addition, the excessive avoidance group showed high harm avoidance and high trait anxiety. This study demonstrated that differences in pain-related avoidance behaviors are affected by psychological traits. Pain-related excessive avoidance behavior indicated a maladaptive fear, but pain-inhibited movement did not.
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Affiliation(s)
- Yuki Nishi
- Graduate School of Health Sciences, Kio University, Nara, Japan
| | - Michihiro Osumi
- Neurorehabilitation Research Center, Kio University, Nara, Japan
| | - Satoshi Nobusako
- Graduate School of Health Sciences, Kio University, Nara, Japan.,Neurorehabilitation Research Center, Kio University, Nara, Japan
| | - Kenta Takeda
- Department of Rehabilitation for the Movement Functions, Research Institute, National Rehabilitation Center for Persons with Disabilities, Saitama, Japan
| | - Shu Morioka
- Graduate School of Health Sciences, Kio University, Nara, Japan.,Neurorehabilitation Research Center, Kio University, Nara, Japan
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9
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Placebo analgesia induced by verbal suggestion in the context of experimentally induced fear and anxiety. PLoS One 2019; 14:e0222805. [PMID: 31550290 PMCID: PMC6759192 DOI: 10.1371/journal.pone.0222805] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 09/07/2019] [Indexed: 11/19/2022] Open
Abstract
The role of state anxiety and state fear in placebo effects is still to be determined. We aimed to investigate the effect of fear of movement-related pain (FMRP) and contextual pain related anxiety (CPRA) on the magnitude of placebo analgesia induced by verbal suggestion. Fifty-six female participants completed a modified voluntary joystick movement paradigm (VJMP) where half participated in a predictable pain condition (PC), in which one of the joystick movements is always followed by pain and the other movement is never followed by pain, and half in an unpredictable pain condition (UC), in which pain was delivered unpredictably. By varying the level of pain predictability, FMRP and CPRA were induced in PC and UC respectively. Colour stimuli were presented at the beginning of each trail. Half of the participants were verbally informed that the green or red colour indicated less painful stimuli (experimental groups), the other half did not receive any suggestion (control groups). We measured self-reported pain intensity, expectancy of pain intensity (PC only), pain related fear and anxiety (eyeblink startle response and self-ratings) and avoidance behaviour (movement-onset latency and duration). The results indicate that the placebo effect was successfully induced in both experimental conditions. In the PC, the placebo effect was predicted by expectancy. Despite the fact that FMRP and CPRA were successfully induced, no difference was found in the magnitude of the placebo effect between PC and UC. Concluding, we did not find a divergent effect of fear and anxiety on placebo analgesia.
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10
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Timmers I, de Jong JR, Goossens M, Verbunt JA, Smeets RJ, Kaas AL. Exposure in vivo Induced Changes in Neural Circuitry for Pain-Related Fear: A Longitudinal fMRI Study in Chronic Low Back Pain. Front Neurosci 2019; 13:970. [PMID: 31607840 PMCID: PMC6758595 DOI: 10.3389/fnins.2019.00970] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 08/29/2019] [Indexed: 12/14/2022] Open
Abstract
Exposure in vivo (EXP) is a cognitive-behavioral treatment aimed at reducing pain-related fear in chronic pain, and has proven successful in reducing pain-related disability in patients with chronic low back pain (cLBP). The current longitudinal study aimed to reveal the neural correlates of changes in pain-related fear as a result of EXP. Twenty-three patients with cLBP were included in this study. Patients with cLBP underwent MRI scanning pre-treatment (pre-EXP), post-treatment (post-EXP), and 6 months after end of treatment (FU-EXP). Pain-free controls were scanned at two time points. In the scanner, participants were presented with pictures involving back-related movements, evoking pain-related fear in patients. Pre-treatment, functional MRI revealed increased activation in right posterior insula and increased deactivation in medial prefrontal cortex (mPFC) in patients compared to controls. Post-treatment, patients reported reduced fear and pre-EXP group differences were no longer present. Contrasting pre- to post- and FU-EXP in patients revealed that stimulus-evoked neural responses changed in sensorimotor as well as cognitive/affective brain regions. Lastly, exploratory analyses revealed a tendency toward an association between changes in neural activation and changes in fear ratings, including the hippocampus and temporal lobe (pre- to post-EXP changes), and mPFC and posterior cingulate cortex (pre- to FU-EXP changes). Taken together, we show evidence that neural circuitry for pain-related fear is modulated by EXP, and that changes are associated with self-reported decreases in pain-related fear.
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Affiliation(s)
- Inge Timmers
- Department of Rehabilitation Medicine, Maastricht University, Maastricht, Netherlands.,Department of Cognitive Neuroscience, Maastricht University, Maastricht, Netherlands.,Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Palo Alto, CA, United States
| | - Jeroen R de Jong
- Department of Rehabilitation Medicine, Maastricht University, Maastricht, Netherlands.,Department of Rehabilitation Medicine, Maastricht University Medical Center, Maastricht, Netherlands.,Adelante Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, Netherlands
| | - Mariëlle Goossens
- Department of Rehabilitation Medicine, Maastricht University, Maastricht, Netherlands.,Department of Clinical Psychological Science, Maastricht University, Maastricht, Netherlands
| | - Jeanine A Verbunt
- Department of Rehabilitation Medicine, Maastricht University, Maastricht, Netherlands.,Department of Rehabilitation Medicine, Maastricht University Medical Center, Maastricht, Netherlands.,Adelante Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, Netherlands
| | - Rob J Smeets
- Department of Rehabilitation Medicine, Maastricht University, Maastricht, Netherlands.,CIR Revalidatie, Zwolle/Eindhoven, Netherlands
| | - Amanda L Kaas
- Department of Cognitive Neuroscience, Maastricht University, Maastricht, Netherlands
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11
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Simons LE, Harrison LE, O'Brien SF, Heirich MS, Loecher N, Boothroyd DB, Vlaeyen JW, Wicksell RK, Schofield D, Hood KK, Orendurff M, Chan S, Lyons S. Graded exposure treatment for adolescents with chronic pain (GET Living): Protocol for a randomized controlled trial enhanced with single case experimental design. Contemp Clin Trials Commun 2019; 16:100448. [PMID: 31650069 PMCID: PMC6804549 DOI: 10.1016/j.conctc.2019.100448] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 08/22/2019] [Accepted: 09/05/2019] [Indexed: 01/06/2023] Open
Abstract
Chronic musculoskeletal pain in adolescence is a significant public health concern with 3-5% of adolescents suffering from significant pain-related disability. Pain-related fear and avoidance of activities has been found to have a significant influence on pain outcomes in children and adolescents and is a risk factor for less favorable response to treatment. To address this need, we developed graded exposure treatment for youth with chronic pain (GET Living). We describe the rationale, design, and implementation of a two-group randomized controlled trial (RCT) enhanced with single-case experimental design (SCED) methodology with a sample of 74 adolescents with chronic musculosketal pain and their parent caregivers. GET Living includes education, behavioral exposures, and parent intervention jointly delivered by pain psychology and physical therapy providers. The multidisciplinary pain management control group includes pain psychology delivered education and pain self-management skills training (e.g., relaxation, cognitive skills) and separate physical therapy. Assessments include brief daily diaries (baseline to discharge, 7-days at 3-month and 6-month follow-up), comprehensive in-person evaluations at baseline and discharge, and questionnaire across all time points (baseline, discharge, 3-month and 6-month follow-up). Primary outcome is pain-related fear avoidance. Secondary outcome is functional disability. We also outline all additional outcomes, exploratory outcomes, covariates, and implementation measures. The objective is to offer a mechanism-based, targeted intervention to youth with musculoskeletal pain to enhance likelihood of return to function.
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Affiliation(s)
- Laura E. Simons
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Corresponding author. Stanford University School of Medicine, 1070 Arastradero Road, Palo Alto, CA, 94304, USA.
| | - Lauren E. Harrison
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Shannon F. O'Brien
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Marissa S. Heirich
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Nele Loecher
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Derek B. Boothroyd
- Quantitative Statistical Unit, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Johan W.S. Vlaeyen
- Research Group Health Psychology, KU Leuven, Leuven, Belgium
- Research Group Experimental Health Psychology, Maastricht University, Maastricht, The Netherlands
| | - Rikard K. Wicksell
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Deborah Schofield
- Center for Economic Impacts of Genomic Medicine, Department of Economics, Macquarie University, Sydney, Australia
| | - Korey K. Hood
- Division of Endocrinology and Diabetes, Diabetes Research Center, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael Orendurff
- Motion and Sports Performance Lab, Department of Orthopedic Sports Medicine, Lucile Packard Children's Hospital, Stanford, CA, USA
| | - Salinda Chan
- Motion and Sports Performance Lab, Department of Orthopedic Sports Medicine, Lucile Packard Children's Hospital, Stanford, CA, USA
| | - Sam Lyons
- Motion and Sports Performance Lab, Department of Orthopedic Sports Medicine, Lucile Packard Children's Hospital, Stanford, CA, USA
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12
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The effect of exercise therapy combined with psychological therapy on physical activity and quality of life in patients with painful diabetic neuropathy: a systematic review. Scand J Pain 2019; 19:433-439. [DOI: 10.1515/sjpain-2019-0001] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 04/15/2019] [Indexed: 12/26/2022]
Abstract
Abstract
Background and aims
Approximately 25% of patients with diabetes mellitus type 2 (DMII) develop painful diabetic neuropathy (PDN). PDN is known to affect both mental and physical wellbeing, resulting in anxiety, depression, low quality of life and physical disability. Pharmacological treatment of PDN aims at pain relief and is often ineffective and/or has many side effects. Rehabilitation treatment modalities that are designed to help the patient deal with PDN related complaints, are mostly focussed on either physical (e.g. exercise therapy) or psychological aspects (e.g. cognitive behavioural therapy, CBT). There is emerging evidence that PDN can be approached from a biopsychosocial perspective, in which physical and psychosocial aspects are integrated. From this biopsychosocial approach it is plausible that integrated treatment modalities such as acceptance commitment therapy (ACT) or exposure in vivo (EXP) could be effective in patients with PDN. The objective of this review was to provide an overview of the current evidence on the effects of rehabilitation treatments that combine exercise therapies with psychological therapies in order to improve physical activity (PA) and quality of life (QoL) in patients with PDN.
Methods
Systematic review of the current literature. EMBASE, MEDLINE, Medline In-Process citations and e-Pubs ahead-of-print, Pedro, Web of Science, PsycINFO, CENTRAL, PubMed and Google Scholar were searched. All studies on interventions combining exercise therapy with psychological interventions in patients with PDN, aged >18 years, were included. Outcome measures were PA, QoL.
Results
The search resulted in 1603 records after removing duplicates. After screening on titles and abstracts, 100 records remained. From these, not one study reported on interventions that combined exercise therapy with psychological interventions. Through a secondary hand search, a total of three reviews were identified that described a total of five studies regarding either physical or psychological interventions in patients with PDN. These studies reported moderate effects of (1) mindfulness meditation on QoL, (2) CBT on pain severity, (3) mindfulness-based stress reduction intervention on function, health-related QoL, pain catastrophizing and depression, (4) aerobic exercise on QoL and (5) Tai Chi on glucose control, balance, neuropathic symptoms, and some dimensions of QoL in patients with PDN. All studies were of a moderate quality, and results should be interpreted with caution.
Conclusions
Based on increasing knowledge in the domain of chronic pain, it could be assumed that integrated rehabilitation treatments for patients with PDN are beneficial. There is no literature to support this and more research should be done on integrated biopsychosocial interventions in patients with PDN.
Implications
This empty review highlights the importance that more research should be done on integrated biopsychosocial interventions in patients with PDN. Currently, our research group is performing a study on the effects of EXP treatment in patients with PDN.
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13
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Generalization and Extinction of Concept-BasedPain-Related Fear. THE JOURNAL OF PAIN 2019; 20:325-338. [DOI: 10.1016/j.jpain.2018.09.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 08/02/2018] [Accepted: 09/23/2018] [Indexed: 11/17/2022]
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14
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Kanera IM, van Laake-Geelen CCM, Ruijgrok JM, Goossens MEJB, de Jong JR, Verbunt JA, Geerts M, Smeets RJEM, Kindermans HPJ. Living with painful diabetic neuropathy: insights from focus groups into fears and coping strategies. Psychol Health 2018; 34:84-105. [PMID: 30320508 DOI: 10.1080/08870446.2018.1518526] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Painful diabetic neuropathy (PDN) is known to negatively affect quality of life. Being physically active is a crucial part of successful diabetes self-management, but regimen adherence is often low. Coping strategies and fears have shown to be related to less physical activity (PA). The aim of the present study was to obtain more in-depth information on psychological risk factors leading to less PA in persons with PDN. DESIGN Three semi-structured focus group interviews were conducted with a representative sample of persons with PDN (N = 12). Data were transcribed verbatim and analysed using a hybrid method of thematic analyses and a grounded theory approach. MAIN OUTCOME MEASURES Fears and coping strategies related to PA in persons with PDN. RESULTS Several specific fears were identified; fear of hypoglycaemia, fear of pain increase, fear of total exhaustion, fear of physical injury, fear of falling, fear of loss of identity, and fear of negative evaluation by others. To cope with these fears, avoidance, remaining active, cognitive distraction, and acceptance strategies were described. CONCLUSION In persons with PDN, diabetes-related fears and pain-related fears play a role in less engagement in PA, indicating the need for new methods for improving self-management in persons with PDN.
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Affiliation(s)
- Iris M Kanera
- a Research Centre for Nutrition, Lifestyle, and Exercise, Faculty of Health , Zuyd University of Applied Sciences , Heerlen , The Netherlands.,b Department of Rehabilitation Medicine , Maastricht University , Maastricht , The Netherlands
| | - Charlotte C M van Laake-Geelen
- b Department of Rehabilitation Medicine , Maastricht University , Maastricht , The Netherlands.,c Department of Rehabilitation Medicine , Maastricht University Medical Centre (MUMC+) , Maastricht , The Netherlands.,d Adelante Centre of Expertise in Rehabilitation and Audiology , Hoensbroek , The Netherlands
| | - Joop M Ruijgrok
- b Department of Rehabilitation Medicine , Maastricht University , Maastricht , The Netherlands.,e Neurorehabilitation Centre , Klinik Bethesda Tschugg , Tschugg , Switzerland
| | - Marielle E J B Goossens
- b Department of Rehabilitation Medicine , Maastricht University , Maastricht , The Netherlands
| | - Jeroen R de Jong
- b Department of Rehabilitation Medicine , Maastricht University , Maastricht , The Netherlands.,c Department of Rehabilitation Medicine , Maastricht University Medical Centre (MUMC+) , Maastricht , The Netherlands
| | - Jeanine A Verbunt
- b Department of Rehabilitation Medicine , Maastricht University , Maastricht , The Netherlands.,c Department of Rehabilitation Medicine , Maastricht University Medical Centre (MUMC+) , Maastricht , The Netherlands.,d Adelante Centre of Expertise in Rehabilitation and Audiology , Hoensbroek , The Netherlands
| | - Margot Geerts
- f Department of Neurology , Maastricht University Medical Centre (MUMC+) , Maastricht , The Netherlands
| | - Rob J E M Smeets
- b Department of Rehabilitation Medicine , Maastricht University , Maastricht , The Netherlands.,g Libra Rehabilitation and Audiology , Eindhoven , The Netherlands
| | - Hanne P J Kindermans
- b Department of Rehabilitation Medicine , Maastricht University , Maastricht , The Netherlands.,h Department of Clinical Psychological Science , Maastricht University , Maastricht , The Netherlands
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Maeda Y, Kan S, Fujino Y, Shibata M. Verbal Instruction Can Induce Extinction of Fear of Movement-Related Pain. THE JOURNAL OF PAIN 2018; 19:1063-1073. [PMID: 29702257 DOI: 10.1016/j.jpain.2018.03.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 03/06/2018] [Accepted: 03/27/2018] [Indexed: 12/01/2022]
Abstract
The fear avoidance model of chronic musculoskeletal pain highlights the importance of pain-related fear in chronification of pain. Although several interventions have been developed on the basis of this model, the following issues remain unresolved: first, whether movement conditioned to pain can evoke fear responses particularly sympathetic activation, and second, whether verbal instructions can attenuate conditioned fear of movement-related pain as with direct experience. To investigate these issues, we induced proprioceptive conditioning (learning the relationship between proprioceptive sensations and an aversive event) and extinction learning in healthy volunteers, and we compared psychophysiological and subjective indices of fear between an instructed and a normal extinction group. Using paired presentation of painful heat stimuli as an unconditioned stimulus and flexion of the wrist as a conditioned stimulus, all participants acquired the conditioned fear response (skin potential response) to the conditioned stimulus. The instructed extinction group was then told that the movement was no longer followed by painful stimulus at the beginning of the extinction phase, and only this group showed significant decreases on both indices of fear. This finding indicates that verbal instruction can attenuate conditioned fear of movement-related pain, supporting the clinical importance of providing information regarding the relationship between movement and pain. PERSPECTIVE This article presents evidence that, in a laboratory setting, verbal instructions rapidly decrease conditioned fear of movement-related pain on psychophysiological as well as subjective indices. This result indicates that it is important for chronic musculoskeletal pain patients to precisely understand the relationship between movement and pain in clinical situations.
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Affiliation(s)
- Yoshiki Maeda
- Faculty of Health Science, Naragakuen University, Nara, Nara, Japan; Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Shigeyuki Kan
- Department of Pain Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
| | - Yuji Fujino
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Masahiko Shibata
- Department of Pain Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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Biggs EE, Meulders A, Kaas AL, Goebel R, Vlaeyen JWS. The Acquisition and Extinction of Fear of Painful Touch: A Novel Tactile Fear Conditioning Paradigm. THE JOURNAL OF PAIN 2017; 18:1505-1516. [PMID: 28842367 DOI: 10.1016/j.jpain.2017.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 08/04/2017] [Accepted: 08/10/2017] [Indexed: 12/13/2022]
Abstract
Fear of touch, due to allodynia and spontaneous pain, is not well understood. Experimental methods to advance this topic are lacking, and therefore we propose a novel tactile conditioning paradigm. Seventy-six pain-free participants underwent acquisition in a predictable as well as an unpredictable pain context. In the predictable context, vibrotactile stimulation was paired with painful electrocutaneous stimulation (simulating allodynia). In the unpredictable context, vibrotactile stimulation was unpaired with pain (simulating spontaneous pain). During an extinction phase, a cue exposure and context exposure group continued in the predictable and unpredictable context, respectively, without pain. A control group received continued acquisition in both contexts. Self-reported fear and skin conductance responses, but not startle responses, showed fear of touch was acquired in the predictable context. Context-related startle responses showed contextual fear emerged in the unpredictable context, together with elevated self-reported fear and skin conductance responses evoked by the unpaired vibrotactile stimulations. Cue exposure reduced fear of touch, whereas context exposure reduced contextual fear. Thus, painful touch leads to increased fear, as does touch in the same context as unpredictable pain, and extinction protocols can reduce this fear. We conclude that tactile conditioning is valuable for investigating fear of touch and can advance our understanding of chronic pain. PERSPECTIVES The acquisition and extinction of fear of touch was investigated in a clinical analog study using a novel tactile fear conditioning paradigm. The results have implications for research on the development and treatment of chronic pain conditions characterized by allodynia and spontaneous pain fluctuations.
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Affiliation(s)
- Emma E Biggs
- Research Group Health Psychology, University of Leuven, Leuven, Belgium; Department of Cognitive Neuroscience, Maastricht University, Maastricht, The Netherlands; Department of Clinical Psychological Science, Maastricht University, Maastricht, The Netherlands.
| | - Ann Meulders
- Research Group Health Psychology, University of Leuven, Leuven, Belgium; Department of Clinical Psychological Science, Maastricht University, Maastricht, The Netherlands; Center for Excellence Generalization on Research in Health and Psychopathology, University of Leuven, Leuven, Belgium
| | - Amanda L Kaas
- Department of Cognitive Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - Rainer Goebel
- Department of Cognitive Neuroscience, Maastricht University, Maastricht, The Netherlands; Department of Neuroimaging and Neuromodeling, Netherlands Institute for Neuroscience, An institute of the Royal Netherlands Academy of Art and Sciences (KNAW), The Netherlands
| | - Johan W S Vlaeyen
- Research Group Health Psychology, University of Leuven, Leuven, Belgium; Department of Clinical Psychological Science, Maastricht University, Maastricht, The Netherlands; Center for Excellence Generalization on Research in Health and Psychopathology, University of Leuven, Leuven, Belgium
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Meulders A, Vandael K, Vlaeyen JWS. Generalization of Pain-Related Fear Based on Conceptual Knowledge. Behav Ther 2017; 48:295-310. [PMID: 28390494 DOI: 10.1016/j.beth.2016.11.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 10/27/2016] [Accepted: 11/28/2016] [Indexed: 11/18/2022]
Abstract
Increasing evidence suggests that pain-related fear is key to the transition from acute to chronic pain. Previous research has shown that perceptual similarity with a pain-associated movement fosters the generalization of fear to novel movements. Perceptual generalization of pain-related fear is adaptive as it enables individuals to extrapolate the threat value of one movement to another without the necessity to learn anew. However, excessive spreading of fear to safe movements may become maladaptive and may lead to sustained anxiety, dysfunctional avoidance behaviors, and severe disability. A hallmark of human cognition is the ability to extract conceptual knowledge from a learning episode as well. Although this conceptual pathway may be important to understand fear generalization in chronic pain, research on this topic is lacking. We investigated acquisition and generalization of concept-based pain-related fear. During acquisition, unique exemplars of one action category (CS+; e.g., opening boxes) were followed by pain, whereas exemplars of another action category (CS-; e.g., closing boxes) were not. Subsequently, spreading of pain-related fear to novel exemplars of both action categories was tested. Participants learned to expect the pain to occur and reported more pain-related fear to the exemplars of the CS+ category compared with those of the CS- category. During generalization, fear and expectancy generalized to novel exemplars of the CS+ category, but not to the CS- category. This pattern was not corroborated in the eyeblink startle measures. This is the first study that demonstrates that pain-related fear can be acquired and generalized based on conceptual knowledge.
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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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Meulders A, Meulders M, Stouten I, De Bie J, Vlaeyen JW. Extinction of Fear Generalization: A Comparison Between Fibromyalgia Patients and Healthy Control Participants. THE JOURNAL OF PAIN 2017; 18:79-95. [DOI: 10.1016/j.jpain.2016.10.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 09/02/2016] [Accepted: 10/03/2016] [Indexed: 12/31/2022]
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Expose or protect? A randomized controlled trial of exposure in vivo vs pain-contingent treatment as usual in patients with complex regional pain syndrome type 1. Pain 2016; 157:2318-2329. [DOI: 10.1097/j.pain.0000000000000651] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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The use of safety-seeking behavior in exposure-based treatments for fear and anxiety: Benefit or burden? A meta-analytic review. Clin Psychol Rev 2016; 45:144-56. [DOI: 10.1016/j.cpr.2016.02.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Revised: 01/05/2016] [Accepted: 02/05/2016] [Indexed: 11/21/2022]
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Claes N, Crombez G, Meulders A, Vlaeyen JW. Between the Devil and the Deep Blue Sea: Avoidance-Avoidance Competition Increases Pain-Related Fear and Slows Decision-Making. THE JOURNAL OF PAIN 2016; 17:424-35. [DOI: 10.1016/j.jpain.2015.12.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 10/20/2015] [Accepted: 12/10/2015] [Indexed: 02/06/2023]
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Elsenbruch S, Wolf OT. Could Stress Contribute to Pain-Related Fear in Chronic Pain? Front Behav Neurosci 2015; 9:340. [PMID: 26733831 PMCID: PMC4681808 DOI: 10.3389/fnbeh.2015.00340] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 11/23/2015] [Indexed: 12/11/2022] Open
Abstract
Learning to predict pain based on internal or external cues constitutes a fundamental and highly adaptive process aimed at self-protection. Pain-related fear is an essential component of this response, which is formed by associative and instrumental learning processes. In chronic pain, pain-related fear may become maladaptive, drive avoidance behaviors and contribute to symptom chronicity. Pavlovian fear conditioning has proven fruitful to elucidate associative learning and extinction involving aversive stimuli, including pain, but studies in chronic pain remain scarce. Stress demonstrably exerts differential effects on emotional learning and memory processes, but this has not been transferred to pain-related fear. Within this perspective, we propose that stress could contribute to impaired pain-related associative learning and extinction processes and call for interdisciplinary research. Specifically, we suggest to test the hypotheses that: (1) extinction-related phenomena inducing a re-activation of maladaptive pain-related fear (e.g., reinstatement, renewal) likely occur in everyday life of chronic pain patients and may alter pain processing, impair perceptual discrimination and favor overgeneralization; (2) acute stress prior to or during acquisition of pain-related fear may facilitate the formation and/or consolidation of pain-related fear memories; (3) stress during or after extinction may impair extinction efficacy resulting in greater reinstatement or context-dependent renewal of pain-related fear; and (4) these effects could be amplified by chronic stress due to early adversity and/or psychiatric comorbidity such depression or anxiety in patients with chronic pain.
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Affiliation(s)
- Sigrid Elsenbruch
- Institute of Medical Psychology and Behavioral Immunobiology, University Hospital Essen, University of Duisburg-EssenEssen, Germany
- *Correspondence: Sigrid Elsenbruch
| | - Oliver T. Wolf
- Department of Cognitive Psychology, Institute of Cognitive Neuroscience, Faculty of Psychology, Ruhr University BochumBochum, Germany
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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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den Hollander M, Meulders A, Jakobs M, Vlaeyen JW. The effect of threat information on acquisition, extinction, and reinstatement of experimentally conditioned fear of movement-related pain. PAIN MEDICINE 2015; 16:2302-15. [DOI: 10.1111/pme.12836] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 05/14/2015] [Accepted: 05/18/2015] [Indexed: 11/28/2022]
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Comparing Counterconditioning and Extinction as Methods to Reduce Fear of Movement-Related Pain. THE JOURNAL OF PAIN 2015; 16:1353-1365. [DOI: 10.1016/j.jpain.2015.09.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 08/13/2015] [Accepted: 09/05/2015] [Indexed: 11/17/2022]
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Meulders A, Harvie DS, Lorimer Moseley G, Vlaeyen JWS. Generalization of Pain-Related Fear Using a Left-Right Hand Judgment Conditioning Task. Behav Ther 2015; 46:699-716. [PMID: 26459849 DOI: 10.1016/j.beth.2015.02.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 01/19/2015] [Accepted: 02/24/2015] [Indexed: 10/23/2022]
Abstract
Recent research suggests that the mere intention to perform a painful movement can elicit pain-related fear. Based on these findings, the present study aimed to determine whether imagining a movement that is associated with pain (CS+) can start to elicit conditioned pain-related fear as well and whether pain-related fear elicited by imagining a painful movement can spread towards novel, similar but distinct imagined movements. We proposed a new experimental paradigm that integrates the left-right hand judgment task (HJT) with a differential fear conditioning procedure. During Acquisition, one hand posture (CS+) was consistently followed by a painful electrocutaneous stimulus (pain-US) and another hand posture (CS-) was not. Participants were instructed to make left-right judgments, which involve mentally rotating their own hand to match the displayed hand postures (i.e., motor imagery). During Generalization, participants were presented with a series of novel hand postures with six grades of perceptual similarity to the CS+ (generalization stimuli; GSs). Finally, during Extinction, the CS+ hand posture was no longer reinforced. The results showed that (1) a painful hand posture triggers fear and increased US-expectancy as compared to a nonpainful hand posture, (2) this pain-related fear spreads to similar but distinct hand postures following a generalization gradient, and subsequently, (3) it can be successfully reduced during extinction. These effects were apparent in the verbal ratings, but not in the startle measures. Because of the lack of effect in the startle measures, we cannot draw firm conclusions about whether the "imagined movements" (i.e., motor imagery of the hand postures) gained associative strength rather than the hand posture pictures itself. From a clinical perspective, basic research into generalization of pain-related fear triggered by covert CSs such as intentions, imagined movements and movement-related cognitions might further our understanding of how pain and fear avoidance spread and persevere.
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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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Karos K, Meulders A, Vlaeyen JW. Threatening Social Context Facilitates Pain-Related Fear Learning. THE JOURNAL OF PAIN 2015; 16:214-25. [DOI: 10.1016/j.jpain.2014.11.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 11/17/2014] [Accepted: 11/22/2014] [Indexed: 12/14/2022]
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Avoidance behavior in chronic pain research: A cold case revisited. Behav Res Ther 2015; 64:31-7. [DOI: 10.1016/j.brat.2014.11.003] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 10/27/2014] [Accepted: 11/04/2014] [Indexed: 11/18/2022]
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Claes N, Karos K, Meulders A, Crombez G, Vlaeyen JW. Competing Goals Attenuate Avoidance Behavior in the Context of Pain. THE JOURNAL OF PAIN 2014; 15:1120-1129. [DOI: 10.1016/j.jpain.2014.08.003] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 07/17/2014] [Accepted: 08/06/2014] [Indexed: 01/12/2023]
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Sueki DG, Dunleavy K, Puentedura EJ, Spielholz NI, Cheng MS. The role of associative learning and fear in the development of chronic pain – a comparison of chronic pain and post-traumatic stress disorder. PHYSICAL THERAPY REVIEWS 2014. [DOI: 10.1179/1743288x14y.0000000154] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Abstract
SUMMARY Recent experimental and clinical studies into the nature of chronic pain and its development have highlighted the importance of psychosocial factors on the perception of pain and response to it. There have been advances in the understanding of not only the biological substrate, but also the nature and influence of specific psychological and social factors in particular. A range of new explanatory models have stimulated new approaches to treatment directed not only at the reduction of pain and its impact, but also at the identification of early indicators or risk factors for the development of chronicity. The purpose of this paper is to attempt a summary and integration of these diverse research findings and identify the next set of research challenges that might serve as a basis for more clearly focused and targeted approaches to multifaceted pain management and perhaps contribute to reduction in the burden of chronic pain.
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Affiliation(s)
- Chris J Main
- Arthritis Care UK National Primary Care Centre, Keele University, North Staffordshire, ST5 5BG, UK
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39
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Meulders A, Vandebroek N, Vervliet B, Vlaeyen JWS. Generalization gradients in cued and contextual pain-related fear: an experimental study in healthy participants. Front Hum Neurosci 2013; 7:345. [PMID: 23847513 PMCID: PMC3701862 DOI: 10.3389/fnhum.2013.00345] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Accepted: 06/17/2013] [Indexed: 12/27/2022] Open
Abstract
Increasing evidence supports the notion that pain-related fear plays a key role in the transition from acute to chronic pain. Recent experimental data show that associative learning processes are involved in the acquisition of pain-related fear. An intriguing yet underinvestigated question entails how spreading of pain-related fear in chronic pain occurs. In a voluntary movement paradigm in which one arm movement (CS+) was followed by a painful stimulus and another was not (CS−) in the predictable group and painful stimuli were delivered during the intertrial interval (context alone) in the unpredictable group, we tested generalization of fear to six novel generalization movements (GSs) with varying levels of similarity between the original CS+ movement and CS− movement. Healthy participants (N = 58) were randomly assigned to the predictable or unpredictable group. Fear was measured via verbal ratings and eyeblink startle responses. Results indicated that cued pain-related fear spreads selectively to novel movements that are proprioceptively more similar to the CS+ than to those similar to the CS− in the predictable group, but not in the unpredictable group. This is the first study to demonstrate a generalization gradient of cued pain-related fear. However, this effect was only present in the startle eyeblink responses, but not in the verbal ratings. Taken together, this paradigm represents a novel tool to scrutinize the largely understudied phenomenon of the spreading of fear and avoidance in patients with chronic musculoskeletal pain and mapping possible pathological differences in generalization gradients and the spreading of pain in patients as compared with healthy controls.
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Affiliation(s)
- Ann Meulders
- Department of Psychology, University of Leuven , Leuven , Belgium
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40
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Mere Intention to Perform Painful Movements Elicits Fear of Movement-Related Pain: An Experimental Study on Fear Acquisition Beyond Actual Movements. THE JOURNAL OF PAIN 2013; 14:412-23. [DOI: 10.1016/j.jpain.2012.12.014] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Revised: 11/07/2012] [Accepted: 12/11/2012] [Indexed: 11/21/2022]
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Thibodeau MA, Fetzner MG, Carleton RN, Kachur SS, Asmundson GJG. Fear of injury predicts self-reported and behavioral impairment in patients with chronic low back pain. THE JOURNAL OF PAIN 2012; 14:172-81. [PMID: 23260450 DOI: 10.1016/j.jpain.2012.10.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Revised: 09/19/2012] [Accepted: 10/31/2012] [Indexed: 10/27/2022]
Abstract
UNLABELLED Fear of injury has been posited as crucial in pain-related anxiety and in the development of chronic pain; however, research has only measured fear of injury indirectly through other constructs (eg, fear of illness and fear of movement). The current study tested fear of injury as an independent contributor to pain-related anxiety and impairment. Patients (n = 78; 37% women) in a work-hardening treatment program for chronic low back pain completed self-report measures of pain-related anxiety, anxiety sensitivity, fear of injury, current pain, and impairment. Behavioral measures of impairment included lifting capacity, treatment outcomes, and days absent from treatment. Structural equation modeling tested the role of fear of injury within contemporary theory. Fit for the theoretical model was excellent and superior to an alternative model. Variance accounted for in pain-related anxiety by fear of injury, anxiety sensitivity, and current pain was 64%, while pain-related anxiety and current pain predicted 49% of variance in latent impairment. Fear of injury directly predicted pain-related anxiety (β = .42) and indirectly predicted impairment through pain-related anxiety (β = .19). Fear of injury may warrant theoretical and clinical consideration as an important contributor to pain-related anxiety and impairment; however, research is needed to explore how it may be causally related with other constructs. PERSPECTIVE Fear of injury directly predicts pain-related anxiety and indirectly predicts self-reported and behavioral impairment. Fear of injury may warrant inclusion in contemporary theories of chronic pain. Clinicians may benefit from considering the construct in interventions for chronic pain.
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Affiliation(s)
- Michel A Thibodeau
- Department of Psychology, University of Regina, Regina, Saskatchewan, Canada.
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42
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Meulders A, Vlaeyen JWS. The acquisition and generalization of cued and contextual pain-related fear: an experimental study using a voluntary movement paradigm. Pain 2012; 154:272-282. [PMID: 23211100 DOI: 10.1016/j.pain.2012.10.025] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2012] [Revised: 09/03/2012] [Accepted: 10/30/2012] [Indexed: 02/01/2023]
Abstract
Recent evidence indicates that pain-related fear can be acquired through associative learning. In the clinic, however, spreading of fear and avoidance is observed beyond movements/activities that were associated with pain during the original pain episode. One mechanism accounting for this spreading of fear is stimulus generalization. In a voluntary movement-conditioning paradigm, healthy participants received predictable pain (ie, one movement predicts pain, another does not) in one context, and unpredictable pain in another context. The former procedure is known to induce cued pain-related fear to the painful movement, whereas the latter procedure generates contextual pain-related fear. In both experimental pain contexts, we subsequently tested fear generalization to novel movements (having either proprioceptive features in common with the original painful movement or nonpainful movement). Results indicated that in the predictable pain context, pain-related fear spreads selectively to novel movements proprioceptively related to the original painful movement, and not to those resembling the original nonpainful movement. In the unpredictable context, nondifferential fear generalization was observed, suggesting persistent contextual pain-related fear and poor safety learning. These data illustrate that spreading of pain-related fear is fostered by previously acquired movement-pain contingencies. Based on recent advances in anxiety research, we proposed an innovative approach conceptualizing predictable pain as a laboratory model for fear of movement in regional musculoskeletal pain, and unpredictable pain generating contextual pain-related fear as a prototype of widespread musculoskeletal pain. Consequently, fear generalization might play an important role in spreading of pain-related fear and avoidance behavior in regional and widespread musculoskeletal pain.
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Affiliation(s)
- Ann Meulders
- Research Group on Health Psychology, University of Leuven, Leuven, Belgium Center of Excellence Generalization Research in Ill Health and Psychopathology, University of Leuven, Leuven, Belgium Department of Clinical Psychological Science, Maastricht University, The Netherlands
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Volders S, Meulders A, De Peuter S, Vervliet B, Vlaeyen JW. Safety behavior can hamper the extinction of fear of movement-related pain: An experimental investigation in healthy participants. Behav Res Ther 2012; 50:735-46. [DOI: 10.1016/j.brat.2012.06.004] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Revised: 06/06/2012] [Accepted: 06/14/2012] [Indexed: 10/28/2022]
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