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Alito A, Cifalinò ME, Fontana JM, Verme F, Piterà P, Capodaglio P. Tackling Kinesiophobia in Chronic Shoulder Pain: A Case Report on the Combined Effect of Pain Education and Whole-Body Cryostimulation. J Clin Med 2024; 13:2094. [PMID: 38610859 PMCID: PMC11012551 DOI: 10.3390/jcm13072094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 03/25/2024] [Accepted: 04/02/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Chronic shoulder pain may cause significant functional disability and reduced psychosocial well-being. Detailed Case Description: In this case, we propose the use of pain neuroscience education and whole-body cryostimulation (WBC) to treat a 64-year-old woman with severe functional limitations and chronic right shoulder pain. The aim was to overcome kinesiophobia and improve her motor function, autonomy, and quality of life. Functional and clinical assessments were conducted at admission, discharge, and at a one-month follow-up via phone call. The patient's global health, shoulder function, and quality of life showed improvement during hospitalisation and were maintained after one month. DISCUSSION Pain education is crucial in managing chronic shoulder pain, especially in addressing kinesiophobia and promoting positive patient outcomes. In this context, WBC was used as a supplementary treatment to traditional pain relief and exercise tolerance therapies. This can help individuals to participate more actively in their rehabilitation process, ultimately promoting functional recovery and an improved quality of life. CONCLUSION The combination of cryostimulation, tailored physical exercises, pain education, manual therapy, and psychological support created a synergistic effect that addressed both the physical and psychological aspects of pain and kinesiophobia.
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Affiliation(s)
- Angelo Alito
- Department of Biomedical, Dental Sciences and Morphological and Functional Images, University of Messina, 98125 Messina, Italy;
| | - Mariachiara Elisabetta Cifalinò
- Research Laboratory in Biomechanics, Rehabilitation and Ergonomics, IRCCS, Istituto Auxologico Italiano, San Giuseppe Hospital, Piancavallo, 28824 Verbania, Italy; (M.E.C.); (F.V.); (P.C.)
| | - Jacopo Maria Fontana
- Research Laboratory in Biomechanics, Rehabilitation and Ergonomics, IRCCS, Istituto Auxologico Italiano, San Giuseppe Hospital, Piancavallo, 28824 Verbania, Italy; (M.E.C.); (F.V.); (P.C.)
| | - Federica Verme
- Research Laboratory in Biomechanics, Rehabilitation and Ergonomics, IRCCS, Istituto Auxologico Italiano, San Giuseppe Hospital, Piancavallo, 28824 Verbania, Italy; (M.E.C.); (F.V.); (P.C.)
| | - Paolo Piterà
- Department of Clinical and Biological Sciences, University of Turin, Orbassano, 10043 Torino, Italy;
| | - Paolo Capodaglio
- Research Laboratory in Biomechanics, Rehabilitation and Ergonomics, IRCCS, Istituto Auxologico Italiano, San Giuseppe Hospital, Piancavallo, 28824 Verbania, Italy; (M.E.C.); (F.V.); (P.C.)
- Department of Surgical Sciences, Physical and Rehabilitation Medicine, University of Torino, 10121 Torino, Italy
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2
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Meulders A, Traxler J, Vandael K, Scheepers S. High-Anxious People Generalize Costly Pain-Related Avoidance Behavior More to Novel Safe Contexts Compared to Low-Anxious People. THE JOURNAL OF PAIN 2024; 25:702-714. [PMID: 37832901 DOI: 10.1016/j.jpain.2023.09.023] [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: 04/06/2023] [Revised: 08/01/2023] [Accepted: 09/29/2023] [Indexed: 10/15/2023]
Abstract
Pain-related avoidance is adaptive when there is a bodily threat, but when it generalizes to safe movements/situations, it may become disabling. Both subclinical anxiety-a vulnerability marker for chronic pain-and chronic pain are associated with excessive fear generalization to safe stimuli/situations. Previous research focused mainly on passive fear correlates (psychophysiological arousal and self-reports) leaving avoidance behavior poorly understood. Therefore, we tested whether high-anxious individuals generalize their pain-related avoidance behavior more to novel, safe contexts than low-anxious people. In a robotic-arm-reaching task, both groups (low vs high trait anxiety) performed 1 of 3 movements to reach a target. In the threat context (black background), a painful stimulus could be partly/completely prevented by performing more effortful trajectories (longer and more force needed); in the safe context (white background), no pain occurred. Generalization of avoidance was tested in 2 novel contexts (light/dark gray backgrounds). We assessed pain expectancy, pain-related fear, startle eyeblink responses for all trajectories, and avoidance behavior (ie, maximal deviation from shortest trajectory). Results indicated that differential fear and expectancy selectively generalized to the novel context resembling the original threat context in both groups. Interestingly and in contrast with the verbal reports, high-anxious participants avoided more in the novel context resembling the original safe context, but not in the 1 resembling the threat context. No generalization emerged in the startle data. Because excessive pain-related avoidance specifically may cause withdrawal from daily life activities, these findings suggest that high-anxious individuals may be vulnerable to developing chronic pain disability. PERSPECTIVE: This paper shows that high-anxious people do not overgeneralize pain-related fear and pain expectancy learned in a threat context more to novel, safe contexts than low-anxious individuals, but that they do avoid more in those contexts. These findings suggest that high-anxious individuals may be vulnerable to developing chronic pain disability.
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Affiliation(s)
- Ann Meulders
- Experimental Health Psychology, Department of Clinical Psychological Science, Maastricht University, Maastricht, the Netherlands; Research Group Health Psychology, Faculty of Psychology and Educational Sciences, Leuven, Belgium
| | - Juliane Traxler
- Experimental Health Psychology, Department of Clinical Psychological Science, Maastricht University, Maastricht, the Netherlands; Research Group Health Psychology, Faculty of Psychology and Educational Sciences, Leuven, Belgium; Institute for Health Services Research in Dermatology and Nursing, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kristof Vandael
- Experimental Health Psychology, Department of Clinical Psychological Science, Maastricht University, Maastricht, the Netherlands; Centre for the Psychology of Learning and Experimental Psychopathology, Faculty of Psychology and Educational Sciences, Leuven, Belgium
| | - Silke Scheepers
- Research Group Health Psychology, Faculty of Psychology and Educational Sciences, Leuven, Belgium
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3
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Vandael K, Vervliet B, Peters M, Meulders A. Excessive generalization of pain-related avoidance behavior: mechanisms, targets for intervention, and future directions. Pain 2023; 164:2405-2410. [PMID: 37498749 PMCID: PMC10578424 DOI: 10.1097/j.pain.0000000000002990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 05/22/2023] [Accepted: 05/26/2023] [Indexed: 07/29/2023]
Affiliation(s)
- Kristof Vandael
- Experimental Health Psychology, Maastricht University, Maastricht, the Netherlands
- Laboratory of Biological Psychology, KU Leuven, Leuven, Belgium
| | - Bram Vervliet
- Laboratory of Biological Psychology, KU Leuven, Leuven, Belgium
| | - Madelon Peters
- Experimental Health Psychology, Maastricht University, Maastricht, the Netherlands
| | - Ann Meulders
- Experimental Health Psychology, Maastricht University, Maastricht, the Netherlands
- Research Group Health Psychology, KU Leuven, Leuven, Belgium
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4
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Kang S, Van Ryckeghem DML, Vlaeyen JWS, De Paepe AL, Crombez G. In search of conditioned pain: an experimental analysis. Pain 2023; 164:2596-2605. [PMID: 37288937 DOI: 10.1097/j.pain.0000000000002964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 04/26/2023] [Indexed: 06/09/2023]
Abstract
ABSTRACT There is an ongoing debate about whether pain can be classically conditioned, but surprisingly, evidence is scarce. Here, we report 3 experiments investigating this idea. In a virtual reality task, healthy participants were approached and touched near or on their hand with a coloured pen (blue or yellow). During acquisition, participants learned that one of the colours of the pen (CS+) was predictive of a painful electrocutaneous stimulus (ECS) whereas the other coloured pen (CS-) was not. During the test phase, more frequent reports of experiencing an US when none was delivered ("false alarm") for the CS+ vs CS- qualified as evidence of conditioned pain. Notable differences between experiments were that the US was delivered when the pen touched a spot between the thumb and index finger (experiment 1; n = 23), when it virtually touched the hand (experiment 2; n = 28) and when participants were informed that the pen caused pain rather than simply predicting something (experiment 3; n = 21). The conditioning procedure proved successful in all 3 experiments: Self-reported fear, attention, pain, fear, and US expectancy were higher ( P < 0.0005) for the CS+ than the CS-. There was no evidence for conditioned pain in experiment 1, but there was some evidence in experiments 2 and 3. Our findings indicate that conditioned pain may exist, albeit most likely in rare cases or under specific situations. More research is needed to understand the specific conditions under which conditioned pain exists and the underlying processes (eg, response bias).
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Affiliation(s)
- Sahaj Kang
- Department of Experimental Clinical and Health Psychology, Ghent University, Ghent, Belgium
- Research Group Health Psychology, KU Leuven, Leuven, Belgium
| | - Dimitri M L Van Ryckeghem
- Department of Experimental Clinical and Health Psychology, Ghent University, Ghent, Belgium
- Experimental Health Psychology, Maastricht University, Maastricht, the Netherlands
- Department of Behavioural and Cognitive Sciences, University of Luxembourg, Esch-sur-Alzette, Luxembourg
| | - Johan W S Vlaeyen
- Research Group Health Psychology, KU Leuven, Leuven, Belgium
- Experimental Health Psychology, Maastricht University, Maastricht, the Netherlands
| | - Annick L De Paepe
- Department of Experimental Clinical and Health Psychology, Ghent University, Ghent, Belgium
| | - Geert Crombez
- Department of Experimental Clinical and Health Psychology, Ghent University, Ghent, Belgium
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5
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González Aroca J, Díaz ÁP, Navarrete C, Albarnez L. Fear-Avoidance Beliefs Are Associated with Pain Intensity and Shoulder Disability in Adults with Chronic Shoulder Pain: A Cross-Sectional Study. J Clin Med 2023; 12:jcm12103376. [PMID: 37240482 DOI: 10.3390/jcm12103376] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 02/17/2023] [Accepted: 02/23/2023] [Indexed: 05/28/2023] Open
Abstract
Shoulder pain is one of the most common musculoskeletal conditions, and for people over 40 years old, it represents the musculoskeletal pain with the greatest impact on quality of life. Psychological factors, such as fear-avoidance beliefs, are associated with musculoskeletal pain, and several studies suggest that they can influence various treatment outcomes. Our objective was to explore the cross-sectional association between fear-avoidance beliefs and shoulder pain intensity and disability in subjects with chronic shoulder pain. A cross-sectional study was conducted, and 208 participants with chronic unilateral subacromial shoulder pain were recruited. The shoulder pain and disability index assessed pain intensity and disability. The Spanish fear-avoidance components scale assessed the presence of fear-avoidance beliefs. The association between fear-avoidance beliefs and pain intensity and disability was analyzed by means of multiple linear regression models and proportional odds models, reporting odds ratios and 95% confidence intervals. Shoulder and pain disability scores were significantly associated with fear-avoidance beliefs (p < 0.0001, adjusted R-square 0.93, multiple linear regression). There was no evidence of an association between sex and age in this study. The regression coefficient for shoulder pain intensity and disability score was 0.67446. The proportional odds model showed an odds ratio of 1.39 (1.29-1.50) for shoulder pain intensity and disability total score. This study suggests that greater levels of fear-avoidance beliefs are associated with greater levels of shoulder pain and disability in adults with chronic shoulder pain.
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Affiliation(s)
| | | | - Carlos Navarrete
- Department of Mathematics, Faculty of Science, University of La Serena, La Serena 1700000, Chile
| | - Loreto Albarnez
- School of Kinesiology, University of La Serena, La Serena 1700000, Chile
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6
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Glogan E, Meulders M, Pfeiffer L, Vlaeyen JWS, Meulders A. Alike, But Not Quite: Comparing the Generalization of Pain-Related Fear and Pain-Related Avoidance. THE JOURNAL OF PAIN 2022; 23:1616-1628. [PMID: 35508274 DOI: 10.1016/j.jpain.2022.04.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/29/2022] [Accepted: 04/11/2022] [Indexed: 10/18/2022]
Abstract
Pain-related fear and -avoidance crucially contribute to pain chronification. People with chronic pain may adopt costly avoidance strategies above and beyond what is necessary, aligning with experimental findings of excessive fear generalization to safe movements in these populations. Furthermore, recent evidence suggests that, when avoidance is costly, it can dissociate from fear. Here, we investigated whether concurrently measured pain-related fear and costly avoidance generalization correspond in one task. We also explored whether healthy participants avoid excessively despite associated costs, and if avoidance would decrease as a function of dissimilarity from a pain-associated movement. In a robotic arm-reaching task, participants could avoid a low-cost, pain-associated movement trajectory (T+), by choosing a high-cost non-painful movement trajectory (T-), at opposite ends of a movement plane. Subsequently, in the absence of pain, we introduced three movement trajectories (G1-3) between T+ and T-, and one movement trajectory on the side of T- opposite to T+ (G4), linearly increasing in costs from T+ to G4. Avoidance was operationalized as maximal deviation from T+, and as trajectory choice. Fear learning was measured using self-reported pain-expectancy, pain-related fear, and startle eye-blink electromyography. Self-reports generalized, both decreasing with increasing distance from T+. In contrast, all generalization trajectories were chosen equally, suggesting that avoidance-costs and previous pain balanced each other out. No effects emerged in the electromyography. These results add to a growing body of literature showing that (pain-related) avoidance, especially when costly, can dissociate from fear, calling for a better understanding of the factors motivating, and mitigating, disabling avoidance. PERSPECTIVE: This article presents a comparison of pain-related fear- and avoidance generalization, and an exploration of excessive avoidance in healthy participants. Our findings show that pain-related avoidance can dissociate from fear, especially when avoidance is costly, calling for a better understanding of the factors motivating and mitigating disabling avoidance.
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Affiliation(s)
- Eveliina Glogan
- Centre for the Psychology of Learning and Experimental Psychopathology, KU Leuven, Leuven, Belgium; Experimental Health Psychology, Maastricht University, Maastricht, The Netherlands
| | - Michel Meulders
- Research Centre for Mathematics, Education, Econometrics and Statistics, KU Leuven, Leuven, Belgium; Research Group Quantitative Psychology and Individual Differences, KU Leuven, Leuven, Belgium
| | - Leon Pfeiffer
- Centre for the Psychology of Learning and Experimental Psychopathology, KU Leuven, Leuven, Belgium
| | - Johan W S Vlaeyen
- Centre for the Psychology of Learning and Experimental Psychopathology, KU Leuven, Leuven, Belgium; Research Group Health Psychology, KU Leuven, Leuven, Belgium
| | - Ann Meulders
- Centre for the Psychology of Learning and Experimental Psychopathology, KU Leuven, Leuven, Belgium; Research Group Health Psychology, KU Leuven, Leuven, Belgium.
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7
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Stimulus Generalization in Mice during Pavlovian Eyeblink Conditioning. eNeuro 2022; 9:ENEURO.0400-21.2022. [PMID: 35228312 PMCID: PMC8941640 DOI: 10.1523/eneuro.0400-21.2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 01/24/2022] [Accepted: 02/15/2022] [Indexed: 11/21/2022] Open
Abstract
Here, we investigate stimulus generalization in a cerebellar learning paradigm, called eyeblink conditioning. Mice were conditioned to close their eyes in response to a 10-kHz tone by repeatedly pairing this tone with an air puff to the eye 250 ms after tone onset. After 10 consecutive days of training, when mice showed reliable conditioned eyelid responses to the 10-kHz tone, we started to expose them to tones with other frequencies, ranging from 2 to 20 kHz. We found that mice had a strong generalization gradient, whereby the probability and amplitude of conditioned eyelid responses gradually decreases depending on the dissimilarity with the 10-kHz tone. Tones with frequencies closest to 10 kHz evoked the most and largest conditioned eyelid responses and each step away from the 10-kHz tone resulted in fewer and smaller conditioned responses (CRs). In addition, we found that tones with lower frequencies resulted in CRs that peaked earlier after tone onset compared with those to tones with higher frequencies. Together, our data show prominent generalization patterns in cerebellar learning. Since the known function of cerebellum is rapidly expanding from pure motor control to domains that include cognition, reward-learning, fear-learning, social function, and even addiction, our data imply generalization controlled by cerebellum in all these domains.
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8
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Masuy R, Bamelis L, Bogaerts K, Depreitere B, De Smedt K, Ceuppens J, Lenaert B, Lonneville S, Peuskens D, Van Lerbeirghe J, Van Schaeybroeck P, Vorlat P, Zijlstra S, Meulders A, Vlaeyen JWS. Generalization of fear of movement-related pain and avoidance behavior as predictors of work resumption after back surgery: a study protocol for a prospective study (WABS). BMC Psychol 2022; 10:39. [PMID: 35193697 PMCID: PMC8862001 DOI: 10.1186/s40359-022-00736-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 02/01/2022] [Indexed: 11/25/2022] Open
Abstract
Background Previous studies indicated that about 20% of the individuals undergoing back surgery are unable to return to work 3 months to 1 year after surgery. The specific factors that predict individual trajectories in postoperative pain, recovery, and work resumption are largely unknown. The aim of this study is to identify modifiable predictors of work resumption after back surgery. Methods In this multisite, prospective, longitudinal study, 300 individuals with radicular pain undergoing a lumbar decompression will be followed until 1-year post-surgery. Prior to surgery, participants will perform a computer task to assess fear of movement-related pain, avoidance behavior, and their generalization to novel situations. Before and immediately after surgery, participants will additionally complete questionnaires to assess fear of movement-related pain, avoidance behavior, optimism, expectancies towards recovery and work resumption, and the duration and severity of the pain. Six weeks, 3 months, 6 months, and 12 months after surgery, they will again complete questionnaires to assess sustainable work resumption, pain severity, disability, and quality of life. The primary hypothesis is that (generalization of) fear of movement-related pain and avoidance behavior will negatively affect sustainable work resumption after back surgery. Second, we hypothesize that (generalization of) fear of movement-related pain and avoidance behavior, negative expectancies towards recovery and work resumption, longer pain duration, and more severe pain before the surgery will negatively affect work resumption, pain severity, disability, and quality of life after back surgery. In contrast, optimism and positive expectancies towards recovery and work resumption are expected to predict more favorable work resumption, better quality of life, and lower levels of pain severity and disability after back surgery. Discussion With the results of this research, we hope to contribute to the development of strategies for early identification of risk factors and appropriate guidance and interventions before and after back surgery. Trial registration The study was preregistered on ClinicalTrials.gov: NCT04747860 on February 9, 2021. Supplementary Information The online version contains supplementary material available at 10.1186/s40359-022-00736-5.
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Affiliation(s)
- Rini Masuy
- Research Group Health Psychology, KU Leuven, Leuven, Belgium.
| | - Lotte Bamelis
- Research Group Health Psychology, KU Leuven, Leuven, Belgium.,Centre for Translational Psychological Research TRACE, Genk, Belgium.,Department of Psychology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Katleen Bogaerts
- Research Group Health Psychology, KU Leuven, Leuven, Belgium.,REVAL - Rehabilitation Research Center, Faculty of Rehabilitation Sciences, Hasselt University, Diepenbeek, Belgium
| | - Bart Depreitere
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
| | - Kris De Smedt
- Department of Neurosurgery, GasthuisZusters Antwerpen, Wilrijk, Belgium
| | | | - Bert Lenaert
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, The Netherlands.,School for Mental Health and Neuroscience, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.,Limburg Brain Injury Centre, Maastricht, The Netherlands
| | - Sarah Lonneville
- Department of Neurosurgery, Centre Hospitalier de Wallonie picarde, Tournai, Belgium
| | - Dieter Peuskens
- Department of Neurosurgery, Ziekenhuis Oost-Limburg, Genk, Belgium.,Department of Neurosurgery, Noorderhart Mariaziekenhuis, Pelt, Belgium
| | | | - Patrick Van Schaeybroeck
- Department of Neurosurgery, Imeldaziekenhuis, Bonheiden, Belgium.,Department of Neurosurgery, Regional Hospital Sacred Heart Tienen, Tienen, Belgium
| | - Peter Vorlat
- Department of Orthopedics, Noorderhart Mariaziekenhuis, Pelt, Belgium
| | | | - Ann Meulders
- Research Group Health Psychology, KU Leuven, Leuven, Belgium.,Experimental Health Psychology, Maastricht University, Maastricht, The Netherlands
| | - Johan W S Vlaeyen
- Research Group Health Psychology, KU Leuven, Leuven, Belgium.,Experimental Health Psychology, Maastricht University, Maastricht, The Netherlands
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9
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Krypotos AM, Crombez G, Alves M, Claes N, Vlaeyen JWS. The exploration-exploitation dilemma in pain: an experimental investigation. Pain 2022; 163:e215-e233. [PMID: 34108434 DOI: 10.1097/j.pain.0000000000002352] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 05/21/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Daily life consists of a chain of decisions. Typically, individuals may choose to pursue what they already know (exploitation) or to search for other options (exploration). This exploration-exploitation dilemma is a topic of interest across multiple scientific fields. Here we propose that investigating how individuals solve this dilemma may improve our understanding of how individuals make behavioral decisions (eg, avoidance) when facing pain. To this end, we present the data of 3 experiments in which healthy individuals were given the opportunity to choose between 4 different movements, with each movement being associated with different probabilities of receiving a painful outcome only (experiment 1) or pain and/or a reward (experiment 2). We also investigated whether participants stuck to their decisions when the contingencies between each movement and the painful/rewarding outcome changed during the task (experiment 3). The key findings across all experiments are the following: First, after initial exploration, participants most often exploited the safest option. Second, participants weighted rewards more heavily than receiving pain. Finally, after receiving a painful outcome, participants were more inclined to explore than to exploit a rewarding movement. We argue that by focusing more on how individuals in pain solve the exploration-exploitation dilemma is helpful in understanding behavioral decision making in pain.
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Affiliation(s)
- Angelos-Miltiadis Krypotos
- Research Group Health Psychology, KU Leuven, Leuven, Belgium
- Department of Clinical Psychology, Utrecht University
| | - Geert Crombez
- Department of Experimental-Clinical and Heath Psychology, Ghent University, Ghent, Belgium
| | - Maryna Alves
- Research Group Health Psychology, KU Leuven, Leuven, Belgium
| | - Nathalie Claes
- Research Group Health Psychology, KU Leuven, Leuven, Belgium
| | - Johan W S Vlaeyen
- Research Group Health Psychology, KU Leuven, Leuven, Belgium
- Experimental Health Psychology, Maastricht University, Maastricht, the Netherlands
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10
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Kloos T, van Vliet C, Riecke J, Meulders A. Indoor or outdoor? Generalization of costly pain-related avoidance behavior to conceptually related contexts. THE JOURNAL OF PAIN 2021; 23:657-668. [PMID: 34793960 DOI: 10.1016/j.jpain.2021.10.010] [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: 06/09/2021] [Revised: 10/22/2021] [Accepted: 10/29/2021] [Indexed: 11/19/2022]
Abstract
When pain persists beyond healing time and becomes a "false alarm" of bodily threat, protective strategies, such as avoidance, are no longer adaptive. More specifically, generalization of avoidance based on conceptual knowledge may contribute to chronic pain disability. Using an operant robotic-arm avoidance paradigm, healthy participants (N=50), could perform more effortful movements in the threat context (e.g. pictures of outdoor scenes) to avoid painful stimuli, whereas no pain occured in the safe context (e.g. pictures of indoor scenes). Next, we investigated avoidance generalization to conceptually related contexts (i.e. novel outdoor/indoor scenes). As expected, participants avoided more when presented with novel contexts conceptually related to the threat context than in novel exemplars of the safe context. Yet, exemplars belonging to one category (outdoor/indoor scenes) were not interchangeable; there was a generalization decrement. Posthoc analyses revealed that contingency-aware participants (n=27), but not non-aware participants (n=23), showed the avoidance generalization effect and also generalized their differential pain-expectancy and pain-related fear more to novel background scenes conceptually related to the original threat context. In contrast, the fear-potentiated startle response was not modulated by context.
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Affiliation(s)
- Tabea Kloos
- Clinical Psychology and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Christine van Vliet
- Experimental Health Psychology, Maastricht University, Maastricht, The Netherlands; Research Group Health Psychology, KU Leuven, Leuven, Belgium
| | - Jenny Riecke
- Clinical Psychology and Psychotherapy, Philipps-University Marburg, Marburg, Germany
| | - Ann Meulders
- Experimental Health Psychology, Maastricht University, Maastricht, The Netherlands; Research Group Health Psychology, KU Leuven, Leuven, Belgium.
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11
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Gregus AM, Levine IS, Eddinger KA, Yaksh TL, Buczynski MW. Sex differences in neuroimmune and glial mechanisms of pain. Pain 2021; 162:2186-2200. [PMID: 34256379 PMCID: PMC8277970 DOI: 10.1097/j.pain.0000000000002215] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 12/03/2020] [Indexed: 02/07/2023]
Abstract
ABSTRACT Pain is the primary motivation for seeking medical care. Although pain may subside as inflammation resolves or an injury heals, it is increasingly evident that persistency of the pain state can occur with significant regularity. Chronic pain requires aggressive management to minimize its physiological consequences and diminish its impact on quality of life. Although opioids commonly are prescribed for intractable pain, concerns regarding reduced efficacy, as well as risks of tolerance and dependence, misuse, diversion, and overdose mortality rates limit their utility. Advances in development of nonopioid interventions hinge on our appreciation of underlying mechanisms of pain hypersensitivity. For instance, the contributory role of immunity and the associated presence of autoimmune syndromes has become of particular interest. Males and females exhibit fundamental differences in innate and adaptive immune responses, some of which are present throughout life, whereas others manifest with reproductive maturation. In general, the incidence of chronic pain conditions, particularly those with likely autoimmune covariates, is significantly higher in women. Accordingly, evidence is now accruing in support of neuroimmune interactions driving sex differences in the development and maintenance of pain hypersensitivity and chronicity. This review highlights known sexual dimorphisms of neuroimmune signaling in pain states modeled in rodents, which may yield potential high-value sex-specific targets to inform future analgesic drug discovery efforts.
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Affiliation(s)
- Ann M Gregus
- School of Neuroscience, Virginia Polytechnic and State University, Blacksburg, VA, United States
| | - Ian S Levine
- School of Neuroscience, Virginia Polytechnic and State University, Blacksburg, VA, United States
| | | | - Tony L Yaksh
- Departments of Anesthesiology and
- Pharmacology, University of California San Diego, La Jolla, CA, United States
| | - Matthew W Buczynski
- School of Neuroscience, Virginia Polytechnic and State University, Blacksburg, VA, United States
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12
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Pain by mistake: investigating a link between error-related negativity and pain avoidance behavior. Pain 2021; 163:e190-e201. [PMID: 34074947 DOI: 10.1097/j.pain.0000000000002358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 04/14/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Pain can be considered as a signal of "bodily error": Errors put organisms at danger and activate behavioral defensive systems. If the error is of physical nature, pain is the warning signal that motivates protective action such as avoidance behavior to safeguard our body's integrity. Interestingly, an important component of neural error processing, the error-related negativity (ERN), has been found to be related to avoidance in anxiety disorders. The present study is the first to extend these findings to pain and investigate the relationship between ERN and pain-related avoidance behavior. It was hypothesized that individuals with larger ERN amplitudes would show more pain-related avoidance behavior and would be more persistent in their avoidance despite changes in the environment. Fifty-three healthy individuals performed the Eriksen Flanker task during which their brain activity upon correct and erroneous motor responses was recorded by means of high-density electroencephalography. Avoidance behavior was assessed with an arm-reaching task using the HapticMaster robot arm. Results showed that, in contrast to our hypothesis, avoidance was not related to ERN amplitudes. Surprisingly, persons with elevated ERN amplitudes showed low levels of avoidance specifically during early acquisition trials. In contrast to earlier findings in anxiety disorders, individuals with elevated ERN amplitudes did not engage in more pain-related avoidance behavior. In fact, the opposite pattern was found at the start of acquisition: individuals with higher compared to lower ERN amplitudes were slower in learning to avoid pain. Replications and future studies on the relationship between ERN and avoidance behavior are needed.
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Individual Differences in the Focus: Understanding Variations in Pain-Related Fear and Avoidance Behavior from the Perspective of Personality Science. Pain 2021; 163:e151-e152. [PMID: 34074946 DOI: 10.1097/j.pain.0000000000002359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 05/20/2021] [Indexed: 11/27/2022]
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14
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Thomaidou MA, Veldhuijzen DS, Meulders A, Evers AWM. An experimental investigation into the mediating role of pain-related fear in boosting nocebo hyperalgesia. Pain 2021; 162:287-299. [PMID: 32910630 PMCID: PMC7737877 DOI: 10.1097/j.pain.0000000000002017] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/29/2020] [Accepted: 07/14/2020] [Indexed: 11/26/2022]
Abstract
Nocebo hyperalgesia refers to increases in perceived pain that putatively result from negative expectations regarding a nocebo stimulus (eg, an inert treatment, compared with no treatment). The precise cognitive-emotional factors contributing to the origins of nocebo effects are poorly understood. We aimed to test the effects of experimentally induced pain-related fear on the acquisition and extinction of nocebo hyperalgesia in healthy participants (N = 72). Acquisition and extinction of nocebo hyperalgesia were compared between a group receiving standard nocebo conditioning (Control group) and 2 groups receiving distinct fear inductions: high intensity of pain stimulations (High-pain group) or a threat manipulation (High-threat group). During nocebo acquisition, the Control and High-threat groups were administered thermal pain stimulations of moderate intensity paired with sham electrical stimulation (nocebo trials), whereas high pain intensity was administered to the High-pain group. During extinction, equivalent pain intensities were administered across all trials. Pain-related fear was measured by eyeblink startle electromyography and self-report. Nocebo hyperalgesia occurred in all groups. Nocebo effects were significantly larger in the High-pain group than those in the Control group. This effect was mediated by self-reported fear, but not by fear-potentiated startle. Groups did not differ in the extinction rate. However, only the High-pain group maintained significant nocebo responses at the end of extinction. Anticipatory pain-related fear induced through a threat manipulation did not amplify nocebo hyperalgesia. These findings suggest that fear of high pain may be a key contributor to the amplification of nocebo hyperalgesia, only when high pain is experienced and not when it is merely anticipated.
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Affiliation(s)
- Mia Athina Thomaidou
- Faculty of Social and Behavioral Sciences, Leiden University, Leiden, the Netherlands
- Leiden Institute for Brain & Cognition, Leiden, the Netherlands
| | - Dieuwke Swaantje Veldhuijzen
- Faculty of Social and Behavioral Sciences, Leiden University, Leiden, the Netherlands
- Leiden Institute for Brain & Cognition, Leiden, the Netherlands
| | - Ann Meulders
- Faculty of Psychology and Educational Sciences, KU Leuven, Leuven, Belgium
- Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Andrea Walburga Maria Evers
- Faculty of Social and Behavioral Sciences, Leiden University, Leiden, the Netherlands
- Leiden Institute for Brain & Cognition, Leiden, the Netherlands
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15
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Karos K, Meulders A, Leyssen T, Vlaeyen JW. Freeze-like responses to pain in humans and its modulation by social context. PeerJ 2020; 8:e10094. [PMID: 33240593 PMCID: PMC7680627 DOI: 10.7717/peerj.10094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 09/14/2020] [Indexed: 11/20/2022] Open
Abstract
Background Maladaptive defensive responses such as excessive avoidance behavior have received increasing attention as a main mechanism for the development and maintenance of chronic pain complaints. However, another defensive response which is commonly studied in animals as a proxy for fear is freezing behavior. No research to date has investigated human freezing behavior in the context of pain. In addition, there is an increasing realization that social context can affect pain-relevant processes such as pain experience and pain behavior but less is known about the effects of social context on defensive responses to pain. Hence, this study investigated freezing behavior and facial pain expression in the context of pain, and their modulation by social context. Methods Healthy, pain-free participants (N = 39) stood on a stabilometric force platform in a threatening or safe social context, which was manipulated using angry or happy facial stimuli. In some trials, an auditory cue (conditioned stimulus; CS) predicted the occurrence of painful electrocutaneous stimulus (unconditioned stimulus; pain-US). We assessed body sway (an index of freezing), heart rate, facial pain expression, self-reported pain intensity, unpleasantness, and pain-US expectancy during the CS and the context alone (no CS). Results The results were mixed. Neither the anticipation of pain, nor social context affected body sway. Heart rate and painful facial expression were reduced in the threatening social context at high anxiety levels. A threatening social context also elicited higher pain-US expectancy ratings. In sum, a threatening social context increases the expectation of pain, but reduces the facial expression of pain and lowers heart rate in highly anxious individuals.
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Affiliation(s)
- Kai Karos
- Centre for the Psychology of Learning and Experimental Psychopathology, Faculty of Psychology and Educational Sciences, KU Leuven, Leuven, Vlanders, Belgium.,Experimental Health Psychology, Clinical Psychological Science, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, Limburg, Netherlands
| | - Ann Meulders
- Experimental Health Psychology, Clinical Psychological Science, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, Limburg, Netherlands.,Research Group on Health Psychology, Faculty of Psychology and Educational Sciences, KU Leuven, Leuven, Vlanders, Belgium
| | - Tine Leyssen
- Research Group on Health Psychology, Faculty of Psychology and Educational Sciences, KU Leuven, Leuven, Vlanders, Belgium
| | - Johan W Vlaeyen
- Experimental Health Psychology, Clinical Psychological Science, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, Limburg, Netherlands.,Research Group on Health Psychology, Faculty of Psychology and Educational Sciences, KU Leuven, Leuven, Vlanders, Belgium
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16
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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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17
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Oversensitivity and overgeneralization of the error withdrawal response in different obsessive-compulsive traits. CURRENT PSYCHOLOGY 2020. [DOI: 10.1007/s12144-018-9835-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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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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19
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Biggs EE, Meulders A, Kaas AL, Goebel R, Vlaeyen JWS. The acquisition and generalization of fear of touch. Scand J Pain 2020; 20:809-819. [PMID: 32712594 DOI: 10.1515/sjpain-2019-0177] [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: 12/06/2019] [Accepted: 06/01/2020] [Indexed: 12/17/2022]
Abstract
Objectives Contemporary fear-avoidance models of chronic pain posit that fear of pain, and overgeneralization of fear to non-threatening stimuli is a potential pathway to chronic pain. While increasing experimental evidence supports this hypothesis, a comprehensive investigation requires testing in multiple modalities due to the diversity of symptomatology among individuals with chronic pain. In the present study we used an established tactile fear conditioning paradigm as an experimental model of allodynia and spontaneous pain fluctuations, to investigate whether stimulus generalization occurs resulting in fear of touch spreading to new locations. Methods In our paradigm, innocuous touch is presented either paired (predictable context) or unpaired (unpredictable context) with a painful electrocutaneous stimulus (pain-US). In the predictable context, vibrotactile stimulation to the index or little finger was paired with the pain-US (CS+), whilst stimulation of the other finger was never paired with pain (CS-). In the unpredictable context, vibrotactile stimulation to the index and little fingers of the opposite hand (CS1 and CS2) was unpaired with pain, but pain-USs occurred unpredictable during the intertrial interval. During the subsequent generalization phase, we tested the spreading of conditioned responses (self-reported fear of touch and pain expectancy) to the (middle and ring) fingers between the CS+ and CS-, and between the CS1 and CS2. Results Differential fear acquisition was evident in the predictable context from increased self-reported pain expectancy and self-reported fear for the CS + compared to the CS-. However, expectancy and fear ratings to the novel generalization stimuli (GS+ and GS-) were comparable to the responses elicited by the CS-. Participants reported equal levels of pain expectancy and fear to the CS1 and CS2 in the unpredictable context. However, the acquired fear did not spread in this context either: participants reported less pain expectancy and fear to the GS1 and GS2 than to the CS1 and CS2. As in our previous study, we did not observe differential acquisition in the startle responses. Conclusions Whilst our findings for the acquisition of fear of touch replicate the results from our previous study (Biggs et al., 2017), there was no evidence of fear generalization. We discuss the limitations of the present study, with a primary focus on procedural issues that were further investigated with post-hoc analyses, concluding that the present results do not show support for the hypothesis that stimulus generalization underlies spreading of fear of touch to new locations, and discuss how this may be the consequence of a context change that prevented transfer of acquisition.
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Affiliation(s)
- Emma E Biggs
- Research Group Health Psychology, KU Leuven, Leuven, Belgium.,Department of Cognitive Neuroscience, Maastricht University, Maastricht, The Netherlands.,Experimental Health Psychology, Maastricht University, Maastricht, The Netherlands
| | - Ann Meulders
- Research Group Health Psychology, KU Leuven, Leuven, Belgium.,Experimental Health Psychology, Maastricht University, Maastricht, The Netherlands
| | - Amanda L Kaas
- Department of Cognitive Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - Rainer Goebel
- Department of Cognitive Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - Johan W S Vlaeyen
- Research Group Health Psychology, KU Leuven, Leuven, Belgium.,Experimental Health Psychology, Maastricht University, Maastricht, The Netherlands
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20
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Pain can be conditioned to voluntary movements through associative learning: an experimental study in healthy participants. Pain 2020; 161:2321-2329. [PMID: 32404653 DOI: 10.1097/j.pain.0000000000001919] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Experimental data suggest that associative learning can influence defensive avoidance behavior and pain perception in humans. However, whether voluntary movements can become conditioned stimuli (CSs) and influence pain responses is yet to be evaluated. Forty healthy volunteers participated in this study. Electrocutaneous stimuli applied to the shoulder at pain threshold level (US) and at pain tolerance level (US) were determined before a movement-conditioning paradigm. First, reaching movements to visual cues shown on one side of a computer screen were associated with the US (CS+ movements) on 80% of trials, whereas reaching movements to visual stimuli shown on the other side were never associated with the nociceptive-US (CS- movements). Next, participants underwent a test phase in which movements to visual cues on both sides were paired with the US on 50% of trials. During the test phase, participants were asked to evaluate whether the movement was painful (yes/no) and to rate pain intensity after each trial. Movement onset and duration as well as skin conductance responses were collected. The US stimuli were more likely to be perceived as painful and were also rated as more painful during CS+ movements. Movement onset latency and skin conductance responses were significantly higher in anticipation of the CS+ movement as compared to the CS- movement. These findings suggest that pain can be conditioned to voluntary movements.
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21
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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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22
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Somatosensory attentional modulations during pain-related movement execution. Exp Brain Res 2020; 238:1169-1176. [DOI: 10.1007/s00221-020-05790-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 03/18/2020] [Indexed: 10/24/2022]
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23
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Hypervigilance for Bodily Sensations in the Back During a Movement Task in People With Chronic and Recurrent Low Back Pain. Clin J Pain 2020; 36:524-532. [PMID: 32080002 DOI: 10.1097/ajp.0000000000000823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The current study assessed the role of hypervigilance for bodily sensations in the back in long-term low back pain problems. METHODS People with chronic low back pain, recurrent low back pain, and no low back pain were compared on the extent to which they attended to somatosensory stimuli on the back during a movement task. To measure hypervigilance, somatosensory event-related potentials (SEPs) to task-irrelevant tactile stimuli on the back were measured when preparing movements in either a threatening or a neutral condition, indicated by a cue signaling possible pain on the back during movement or not. RESULTS Results showed stronger attending to stimuli on the back in the threat condition than in the neutral condition, as reflected by increased amplitude of the N96 SEP. However, this effect did not differ between groups. Similarly, for all 3 groups the amplitude of the P172 was larger for the threatening condition, suggesting a more general state of arousal resulting in increased somatosensory responsiveness. No significant associations were found between somatosensory attending to the back and theorized antecedents such as pain catastrophizing, pain-related fear, and pain vigilance. DISCUSSION The current study confirmed that individuals preparing a movement attended more toward somatosensory stimuli at the lower back when anticipating back pain during the movement, as measured by the N96 SEP. However, no differences were found between participants with chronic low back pain or recurrent low back pain, or the pain-free controls.
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24
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Glogan E, Gatzounis R, Meulders M, Meulders A. Generalization of instrumentally acquired pain-related avoidance to novel but similar movements using a robotic arm-reaching paradigm. Behav Res Ther 2020; 124:103525. [DOI: 10.1016/j.brat.2019.103525] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 10/01/2019] [Accepted: 11/19/2019] [Indexed: 12/14/2022]
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25
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Somatosensory attending to the lower back is associated with response speed of movements signaling back pain. Brain Res 2019; 1723:146383. [PMID: 31419425 DOI: 10.1016/j.brainres.2019.146383] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 06/14/2019] [Accepted: 08/12/2019] [Indexed: 11/22/2022]
Abstract
The present study investigated if preparing a movement that is expected to evoke pain results in hesitation to initiate the movement (i.e., avoidance) and, especially, if the allocation of attention to the threatened body part mediates such effect. To this end, healthy volunteers (N = 33) performed a postural perturbation task recruiting lower back muscles. In 'threat trials', the movement was sometimes followed by an experimental pain stimulus on the back, whereas in 'no-threat trials', a non-painful control stimulus was applied. Electroencephalography (EEG) was used to assess attending to the lower back. Specifically, somatosensory evoked potentials (SEPs) to task-irrelevant tactile stimuli administered to the lower back were recorded during movement preparation. Reaction times (RTs) were recorded to assess movement initiation. The results revealed faster responses and enhanced somatosensory attending to the lower back on threat trials than on no-threat trials. Importantly, the amplitude of the N95 SEP component predicted RTs and was found to partially mediate the effect of pain anticipation on movement initiation. These findings suggest that somatosensory attending might be a potential mechanism by which pain anticipation can modulate motor execution.
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26
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Slepian PM, Ankawi B, France CR. Longitudinal Analysis Supports a Fear-Avoidance Model That Incorporates Pain Resilience Alongside Pain Catastrophizing. Ann Behav Med 2019; 54:335-345. [DOI: 10.1093/abm/kaz051] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Abstract
Background
The fear-avoidance model of chronic pain holds that individuals who catastrophize in response to injury are at risk for pain-related fear and avoidance behavior, and ultimately prolonged pain and disability.
Purpose
Based on the hypothesis that the predictive power of the fear-avoidance model would be enhanced by consideration of positive psychological constructs, the present study examined inclusion of pain resilience and self-efficacy in the model.
Methods
Men and women (N = 343) who experienced a recent episode of back pain were recruited in a longitudinal online survey study. Over a 3-month interval, participants repeated the Pain Resilience Scale, Pain Catastrophizing Scale, Tampa Scale of Kinesiophobia, Pain Self-Efficacy Questionnaire, the McGill Pain Questionnaire, and NIH-recommended measures of pain, depressive symptoms, and physical dysfunction. Structural equation modeling assessed the combined contribution of pain resilience and pain catastrophizing to 3-month outcomes through the simultaneous combination of kinesiophobia and self-efficacy.
Results
An expanded fear-avoidance model that incorporated pain resilience and self-efficacy provided a good fit to the data, Χ2 (df = 14, N = 343) = 42.09, p = .0001, RMSEA = 0.076 (90% CI: 0.05, 0.10), CFI = 0.97, SRMR = 0.03, with higher levels of pain resilience associated with improved 3-month outcomes on measures of pain intensity, physical dysfunction, and depression symptoms.
Conclusions
This study supports the notion that the predictive power of the fear-avoidance model of pain is enhanced when individual differences in both pain-related vulnerability (e.g., catastrophizing) and pain-related protective resources (e.g., resilience) are considered.
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Affiliation(s)
| | - Brett Ankawi
- Department of Psychology, Ohio University, Athens, OH, USA
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27
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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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28
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Vandael K, Meulders M, Vanden Boer C, Meulders A. The relationship between fear generalization and pain modulation: an investigation in healthy participants. Scand J Pain 2019; 20:151-165. [DOI: 10.1515/sjpain-2019-0065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 07/29/2019] [Indexed: 11/15/2022]
Abstract
Abstract
Background and aims
Pain-related fear and its subsequent generalization is key to the development and maintenance of chronic pain disability. Research has shown that pain-related fear acquired through classical conditioning generalizes following a gradient, that is, novel movements that are proprioceptively similar to the original pain-associated movement elicit more fear. Studies suggest that classical conditioning can also modulate pain and conditioned fear seems to mediate this effect. However, it remains uninvestigated whether this is also the case for generalized fear.
Methods
In a voluntary joystick movement paradigm, one movement (conditioned stimulus; CS+) was followed by pain (pain-US), and another was not (CS−). Generalization to five novel movements (generalization stimuli; GSs) with varying levels of similarity to the CSs was tested when paired with an at-pain-threshold intensity stimulus (threshold-USs). We collected self-reported fear and pain, as well as eyeblink startle responses as an additional index of conditioned fear.
Results
Results showed a fear generalization gradient in the ratings, but not in the startle measures. The data did not support the idea that fear generalization mediates spreading of pain.
Conclusions
Despite the lack of effects in the current study, this is a promising novel approach to investigate pain modulation in the context of chronic pain.
Implications
This study replicates the finding that pain-related fear spreads selectively towards movements that are proprioceptively more similar to the original pain-eliciting movement. Although results did not support the idea that such generalized fear mediates spreading of pain, the study provides a promising approach to investigate pain modulation by pain-associated movements.
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Affiliation(s)
- Kristof Vandael
- Experimental Health Psychology, Maastricht University , Maastricht , The Netherlands
| | - Michel Meulders
- Center for Information Management, Modeling and Simulation, KU Leuven , Brussels , Belgium
- Research Group on Quantitative Psychology and Individual Differences, KU Leuven , Leuven , Belgium
| | | | - Ann Meulders
- Experimental Health Psychology, Maastricht University , Maastricht , The Netherlands
- Research Group Health Psychology, KU Leuven , Leuven , Belgium
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Abstract
While the contribution of social processes to pain perception is well documented, surprisingly little is known about the influence of pain on social perception. In particular, an important question is how pain modulates the processing of other people's actions. To address this question, the current study tests, using automatic imitation, the hypothesis that pain interferes with motor simulation-that is, the processing of observed actions in the motor system. Participants in both experiments performed an automatic imitation task requiring them to abduct their index or little finger while they saw someone else performing either a congruent or incongruent action. Automatic imitation was measured in a pain-free context, a context where pain was coupled to the execution of a movement (experiment 1), and a context where pain occurred randomly (experiment 2). The results revealed that automatic imitation, indexed by slower responses on incongruent compared with congruent trials, was reduced when experiencing pain, both when pain was linked to movement execution and when it was not. Thus, the current study shows that pain leads to reduced motor processing of others' behavior and, as such, has important implications for understanding the social difficulties associated with pain.
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30
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Meulders A, Vlaeyen JW. The effect of differential spatiotopic information on the acquisition and generalization of fear of movement-related pain. PeerJ 2019; 7:e6913. [PMID: 31143542 PMCID: PMC6525585 DOI: 10.7717/peerj.6913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 04/03/2019] [Indexed: 01/16/2023] Open
Abstract
Fear of movement-related pain significantly contributes to musculoskeletal chronic pain disability. Previous research has shown that fear of movement-related pain can be classically conditioned. That is, in a differential fear conditioning paradigm, after (repeatedly) pairing a neutral joystick movement (conditioned stimulus; CS+) with a painful stimulus (unconditioned stimulus; pain-US), that movement in itself starts to elicit self-reported fear and elevated psychophysiological arousal compared to a control joystick movement (CS−) that was never paired with pain. Further, it has been demonstrated that novel movements that are more similar to the original CS+ elicit more fear than novel movements that are more similar to the CS−, an adaptive process referred to as stimulus generalization. By default, movement/action takes place in reference to the three-dimensional space: a movement thus not only involves proprioceptive information, but it also contains spatiotopic information. Therefore, the aim of this study was to investigate to what extent spatiotopic information (i.e., endpoint location of movement) contributes to the acquisition and generalization of such fear of movement-related pain besides proprioception (i.e., movement direction). In a between-subjects design, the location group performed joystick movements from the middle position to left and right; the movement group moved the joystick from left and right to the middle. One movement (CS+) was paired with pain, another not (CS−). Feature overlap between CSs typically reduces differential learning. The endpoint of both CSs in the movement group is an overlapping feature whereas in the location group the endpoint of both CSs is distinct; therefore we hypothesized that there would be less differential fear learning in the movement group compared to the location group. We also tested generalization to movements with similar proprioceptive features but different endpoint location. Following the principle of stimulus generalization, we expected that novel movements in the same direction as the CS+ but with a different endpoint would elicit more fear than novel movement in the same direction of the CS− but with a different endpoint. Main outcome variables were self-reported fear and pain-US expectancy and eyeblink startle responses (electromyographic). Corroborating the feature overlap hypothesis, the location group showed greater differential fear acquisition. Fear generalization emerged for both groups in the verbal ratings, suggesting that fear indeed accrued to proprioceptive CS features; these effects, however, were not replicated in the startle measures.
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Affiliation(s)
- Ann Meulders
- Experimental Health Psychology, Maastricht University, Maastricht, Netherlands.,Research Group Health Psychology, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Johan W Vlaeyen
- Experimental Health Psychology, Maastricht University, Maastricht, Netherlands.,Research Group Health Psychology, Katholieke Universiteit Leuven, Leuven, Belgium
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Janssens T, Meulders A, Cuyvers B, Colloca L, Vlaeyen JW. Placebo and nocebo effects and operant pain-related avoidance learning. Pain Rep 2019; 4:e748. [PMID: 31583361 PMCID: PMC6749895 DOI: 10.1097/pr9.0000000000000748] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 03/25/2019] [Accepted: 03/26/2019] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Research on learning in placebo and nocebo has relied predominantly on Pavlovian conditioning procedures. Operant learning procedures may more accurately model learning in real-life situations in which placebo and nocebo effects occur. OBJECTIVES To investigate the development and persistence of placebo and nocebo effects using an operant avoidance learning task. METHODS Pain-free participants (n = 58) could learn to avoid pain by performing movements that differed in difficulty and intensity of painful stimulation. Participants performed movements in 2 contexts. In the high cost of avoidance context, pain stimulus intensity reduced with increasing movement difficulty. In the low cost of avoidance context, contingencies were reversed. Participants rated pain expectations and pain intensity. During test, movement difficulties were unchanged, but participants always received a medium-intensity pain stimulus. Placebo and nocebo effects were defined as lower/higher pain intensity ratings for trajectories that previously resulted in low/high-intensity compared with medium-intensity stimulation. RESULTS As expected, participants acquired differential movement-pain expectations and differential movement choices. Testing with a medium-intensity pain stimulus quickly erased differences in movement choice across contexts, but differences in pain expectations were maintained. Pain modulation across context was in line with movement-pain expectations. However, we only observed placebo effects within the low cost of avoidance context and found no evidence of nocebo effects. CONCLUSION Operant learning can change pain expectations, pain modulation, and pain-related avoidance behavior. Persisting pain expectations suggest that acquired pain beliefs may be resistant to disconfirmation, despite self-initiated experience with novel pain-movement contingencies.
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Affiliation(s)
- Thomas Janssens
- Health Psychology, KU Leuven (University of Leuven), Leuven, Belgium
| | - Ann Meulders
- Health Psychology, KU Leuven (University of Leuven), Leuven, Belgium
- Research Group Behavioral Medicine, Maastricht University, Maastricht, the Netherlands
| | - Bien Cuyvers
- Health Psychology, KU Leuven (University of Leuven), Leuven, Belgium
| | - Luana Colloca
- Department of Pain Translational Symptom Science, School of Nursing, University of Maryland, BaltimoreMD, USA
- Department of Anesthesiology/Psychiatry, School of Medicine, University of Maryland, Baltimore, MD, USA
- Center to Advance Chronic Pain Research, University of Maryland, Baltimore, MD, USA
| | - Johan W.S. Vlaeyen
- Health Psychology, KU Leuven (University of Leuven), Leuven, Belgium
- Research Group Behavioral Medicine, Maastricht University, Maastricht, the Netherlands
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Traxler J, Schrooten MGS, Dibbets P, Vancleef LMG. Interpretation bias in the face of pain: a discriminatory fear conditioning approach. Scand J Pain 2019; 19:383-395. [PMID: 30379643 DOI: 10.1515/sjpain-2018-0112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 10/01/2018] [Indexed: 11/15/2022]
Abstract
Background and aims Interpreting pain- and illness-related stimuli as health-threatening is common among chronic pain patients but also occurs in the general population. As interpretation bias (IB) may affect pain perception and might even play part in the development and maintenance of chronic pain, it is important to improve our understanding of this concept. Several studies suggest an association between IB and pain-related anxiety. However, those studies often rely on verbal and pictorial IB tasks that do not entail a threat of actual pain, therefore lacking personal relevance for healthy participants. The current study investigated whether healthy individuals show an IB towards ambiguous health-related stimuli in a context of actual pain threat, and explored whether this bias is associated to pain anxiety constructs. Methods Thirty-six healthy participants were conditioned to expect painful electrocutaneous shocks (unconditioned stimulus - US) after health-threat words (CS+) but not after neutral (non-health-threat) words (CS-) in order to establish fear of pain. Subsequently, they completed a verbal interpretation task that contained new CS+ and CS- stimuli as well as ambiguous non-reinforced health-threat and non-health-threat words. IB was assessed through shock expectancy ratings and startle responses to ambiguous and evident health threatening or neutral word stimuli. Pain-related anxiety was measured with validated questionnaires. Results The results show a general IB towards ambiguous health-related words on pain expectancies but not on startle response. An exploratory analysis suggests that this effect exists irrespective of pain-related anxiety levels which however may be due to a lack of power. Conclusion We present a novel experimental paradigm employing actual health threat that captures IB towards health-related stimuli in healthy individuals. Taken together, results provide evidence for the further consideration of IB as a latent vulnerability factor in the onset and maintenance of pain chronicity. In contrast to previous studies employing a safe, pain-free context, we found that healthy participants show an IB towards ambiguous health-related stimuli, when confronted with pain threat. Implications Like chronic pain patients, healthy individuals display an IB towards health-threat stimuli when these stimuli become personally relevant by carrying information about pending health threat. Therefore, the presented paradigm could be valuable for pain-related cognitive bias research in healthy participants as it may have a higher ecological validity than previous study designs. Future studies will have to elucidate the influence of anxiety constructs on IB in larger samples.
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Affiliation(s)
- Juliane Traxler
- Department of Clinical Psychological Science, Maastricht University, Maastricht, The Netherlands.,Research Centre for Health Psychology, University of Leuven, Leuven, Belgium
| | - Martien G S Schrooten
- Research Centre for Health Psychology, University of Leuven, Leuven, Belgium.,Center for Health and Medical Psychology, Örebro University, Örebro, Sweden
| | - Pauline Dibbets
- Department of Clinical Psychological Science, Maastricht University, Maastricht, The Netherlands
| | - Linda M G Vancleef
- Department of Clinical Psychological Science, Maastricht University, P.O. Box 616, Maastricht 6200 MD, The Netherlands, Phone: +31433882485
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Meulders A. From fear of movement-related pain and avoidance to chronic pain disability: a state-of-the-art review. Curr Opin Behav Sci 2019. [DOI: 10.1016/j.cobeha.2018.12.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Matheve T, De Baets L, Bogaerts K, Timmermans A. Lumbar range of motion in chronic low back pain is predicted by task-specific, but not by general measures of pain-related fear. Eur J Pain 2019; 23:1171-1184. [PMID: 30793429 DOI: 10.1002/ejp.1384] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 01/30/2019] [Accepted: 02/17/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Most studies fail to show an association between higher levels of pain-related fear and protective movement behaviour in patients with chronic low back pain (CLBP). This may be explained by the fact that only general measures of pain-related fear have been used to examine the association with movement patterns. This study explored whether task-specific, instead of general measures of pain-related fear can predict movement behaviour. METHODS Fifty-five patients with CLBP and 54 healthy persons performed a lifting task while kinematic measurements were obtained to assess lumbar range of motion (ROM). Scores on the Photograph Daily Activities Series-Short Electronic Version (PHODA-SeV), Tampa Scale for Kinesiophobia and its Activity Avoidance and Somatic Focus subscales were used as general measures of pain-related fear. The score on a picture of the PHODA-SeV, showing a person lifting a heavy object with a bent back, was used as task-specific measure of pain-related fear. RESULTS Lumbar ROM was predicted by task-specific, but not by general measures of pain-related fear. Only the scores on one other picture of the PHODA-SeV, similar to the task-specific picture regarding threat value and movement characteristics, predicted the lumbar ROM. Compared to healthy persons, patients with CLBP used significantly less ROM, except the subgroup with a low score on the task-specific measure of pain-related fear, who used a similar ROM. CONCLUSIONS Our results suggest to use task-specific measures of pain-related fear when assessing the relationship with movement. It would be of interest to investigate whether reducing task-specific fear changes protective movement behaviour. SIGNIFICANCE This study shows that lumbar range of motion in CLBP is predicted by task-specific, but not by general measures of pain-related fear. This suggests that both in clinical practice and for research purposes, it might be recommended to use task-specific measures of pain-related fear when assessing the relationship with movement behaviour. This may help to disentangle the complex interactions between pain-related fear, movement and disability in patients with CLBP.
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Affiliation(s)
- Thomas Matheve
- REVAL - Rehabilitation Research Center, Faculty of Rehabilitation Sciences, Hasselt University, Hasselt, Belgium
| | - Liesbet De Baets
- REVAL - Rehabilitation Research Center, Faculty of Rehabilitation Sciences, Hasselt University, Hasselt, Belgium
| | - Katleen Bogaerts
- REVAL - Rehabilitation Research Center, Faculty of Rehabilitation Sciences, Hasselt University, Hasselt, Belgium.,Health Psychology, University of Leuven, Leuven, Belgium
| | - Annick Timmermans
- REVAL - Rehabilitation Research Center, Faculty of Rehabilitation Sciences, Hasselt University, Hasselt, Belgium
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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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Martin LJ, Acland EL, Cho C, Gandhi W, Chen D, Corley E, Kadoura B, Levy T, Mirali S, Tohyama S, Khan S, MacIntyre LC, Carlson EN, Schweinhardt P, Mogil JS. Male-Specific Conditioned Pain Hypersensitivity in Mice and Humans. Curr Biol 2019; 29:192-201.e4. [DOI: 10.1016/j.cub.2018.11.030] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 09/24/2018] [Accepted: 11/09/2018] [Indexed: 12/19/2022]
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Hughes S, Barnes-Holmes D, Van Dessel P, de Almeida JH, Stewart I, De Houwer J. On the symbolic generalization of likes and dislikes. JOURNAL OF EXPERIMENTAL SOCIAL PSYCHOLOGY 2018. [DOI: 10.1016/j.jesp.2018.09.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Bustan S, Gonzalez-Roldan AM, Schommer C, Kamping S, Löffler M, Brunner M, Flor H, Anton F. Psychological, cognitive factors and contextual influences in pain and pain-related suffering as revealed by a combined qualitative and quantitative assessment approach. PLoS One 2018; 13:e0199814. [PMID: 30063704 PMCID: PMC6067693 DOI: 10.1371/journal.pone.0199814] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 06/14/2018] [Indexed: 11/18/2022] Open
Abstract
Previous psychophysiological research suggests that pain measurement needs to go beyond the assessment of Pain Intensity and Unpleasantness by adding the evaluation of Pain-Related Suffering. Based on this three-dimensional approach, we attempted to elucidate who is more likely to suffer by identifying reasons that may lead individuals to report Pain and Pain-Related Suffering more than others. A sample of 24 healthy participants (age range 18-33) underwent four different sessions involving the evaluation of experimentally induced phasic and tonic pain. We applied two decision tree models to identify variables (selected from psychological questionnaires regarding pain and descriptors from post-session interviews) that provided a qualitative characterization of the degrees of Pain Intensity, Unpleasantness and Suffering and assessed the respective impact of contextual influences. The overall classification accuracy of the decision trees was 75% for Intensity, 77% for Unpleasantness and 78% for Pain-Related Suffering. The reporting of suffering was predominantly associated with fear of pain and active cognitive coping strategies, pain intensity with bodily competence conveying strength and resistance and unpleasantness with the degree of fear of pain and catastrophizing. These results indicate that the appraisal of the three pain dimensions was largely determined by stable psychological constructs. They also suggest that individuals manifesting higher active coping strategies may suffer less despite enhanced pain and those who fear pain may suffer even under low pain. The second decision tree model revealed that suffering did not depend on pain alone, but that the complex rating-related decision making can be shifted by situational factors (context, emotional and cognitive). The impact of coping and fear of pain on individual Pain-Related Suffering may highlight the importance of improving cognitive coping strategies in clinical settings.
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Affiliation(s)
- Smadar Bustan
- INSERM U-987, CHU « Pathophysiology and Clinical Pharmacology of Pain» Hospital Ambroise Paré, Boulogne-Billancourt, France
- Department of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
- Institute for Health and Behavior, FLSHASE/INSIDE, University of Luxembourg, Esch-sur-Alzette, Luxembourg
- * E-mail:
| | - Ana Maria Gonzalez-Roldan
- Institute for Health and Behavior, FLSHASE/INSIDE, University of Luxembourg, Esch-sur-Alzette, Luxembourg
- Research Institute on Health Sciences (IUNICS), University of Balearic Islands, Palma de Mallorca, Spain
| | - Christoph Schommer
- ILIAS Laboratory, Dept. of Computer Science and Communication, FSTC, University of Luxembourg, Esch-sur-Alzette, Luxembourg
| | - Sandra Kamping
- Department of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Martin Löffler
- Department of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Michael Brunner
- Department of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Herta Flor
- Department of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Fernand Anton
- Institute for Health and Behavior, FLSHASE/INSIDE, University of Luxembourg, Esch-sur-Alzette, Luxembourg
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Dymond S, Bennett M, Boyle S, Roche B, Schlund M. Related to Anxiety: Arbitrarily Applicable Relational Responding and Experimental Psychopathology Research on Fear and Avoidance. Perspect Behav Sci 2018; 41:189-213. [PMID: 32004365 PMCID: PMC6701705 DOI: 10.1007/s40614-017-0133-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Humans have an unparalleled ability to engage in arbitrarily applicable relational responding (AARR). One of the consequences of this ability to spontaneously combine and relate events from the past, present, and future may, in fact, be a propensity to suffer. For instance, maladaptive fear and avoidance of remote or derived threats may actually perpetuate anxiety. In this narrative review, we consider contemporary AARR research on fear and avoidance as it relates to anxiety. We first describe laboratory-based research on the emergent spread of fear- and avoidance-eliciting functions in humans. Next, we consider the validity of AARR research on fear and avoidance and address the therapeutic implications of the work. Finally, we outline challenges and opportunities for a greater synthesis between behavior analysis research on AARR and experimental psychopathology.
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Affiliation(s)
- Simon Dymond
- Experimental Psychopathology Lab, Department of Psychology, Swansea University, Singleton Campus, Swansea, SA2 8PP UK
- Department of Psychology, Reykjavík University, Menntavegur 1, Nauthólsvík, 101 Reykjavík, Iceland
| | - Marc Bennett
- Trinity College Institute of Neuroscience, Trinity College Dublin, Lloyd Building, Dublin 2, Ireland
| | - Sean Boyle
- Department of Psychology, Maynooth University, Maynooth, Co. Kildare Ireland
| | - Bryan Roche
- Department of Psychology, Maynooth University, Maynooth, Co. Kildare Ireland
| | - Michael Schlund
- Department of Psychiatry, University of Pittsburgh, Loeffler Building, Room 316, 121 Meyran Avenue, Pittsburgh, PA 15213 USA
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Koban L, Kusko D, Wager TD. Generalization of learned pain modulation depends on explicit learning. Acta Psychol (Amst) 2018; 184:75-84. [PMID: 29025685 DOI: 10.1016/j.actpsy.2017.09.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Revised: 08/28/2017] [Accepted: 09/19/2017] [Indexed: 11/30/2022] Open
Abstract
The experience of pain is strongly influenced by contextual and socio-affective factors, including learning from previous experiences. Pain is typically perceived as more intense when preceded by a conditioned cue (CSHIGH) that has previously been associated with higher pain intensities, compared to cues associated with lower intensities (CSLOW). In three studies (total N=134), we tested whether this learned pain modulation generalizes to perceptually similar cues (Studies 1 and 2) and conceptually similar cues (Study 3). The results showed that participants report higher pain when heat stimulation was preceded by novel stimuli that were either perceptually (Studies 1 and 2) or conceptually (Study 3) similar to the previously conditioned CSHIGH. In all three studies, the strength of this generalization effect was strongly correlated with individual differences in explicitly learned expectations. Together, these findings suggest an important role of conscious expectations and higher-order conceptual inference during generalization of learned pain modulation. We discuss implications for the understanding of placebo and nocebo effects as well as for chronic pain and anxiety.
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Affiliation(s)
- Leonie Koban
- Department of Psychology and Neuroscience, University of Colorado Boulder, United States; Institute of Cognitive Science, University of Colorado Boulder, United States.
| | - Daniel Kusko
- Department of Psychology and Neuroscience, University of Colorado Boulder, United States; Institute of Cognitive Science, University of Colorado Boulder, United States
| | - Tor D Wager
- Department of Psychology and Neuroscience, University of Colorado Boulder, United States; Institute of Cognitive Science, University of Colorado Boulder, United States
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Clauwaert A, Torta DM, Danneels L, Van Damme S. Attentional Modulation of Somatosensory Processing During the Anticipation of Movements Accompanying Pain: An Event-Related Potential Study. THE JOURNAL OF PAIN 2018; 19:219-227. [DOI: 10.1016/j.jpain.2017.10.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 10/05/2017] [Accepted: 10/27/2017] [Indexed: 11/16/2022]
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The Concept of Contexts in Pain: Generalization of Contextual Pain-Related Fear Within a de Novo Category of Unique Contexts. THE JOURNAL OF PAIN 2018; 19:76-87. [DOI: 10.1016/j.jpain.2017.09.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 08/23/2017] [Accepted: 09/05/2017] [Indexed: 11/22/2022]
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Swinnen TW, Vlaeyen JW, Dankaerts W, Westhovens R, de Vlam K. Activity Limitations in Patients with Axial Spondyloarthritis: A Role for Fear of Movement and (Re)injury Beliefs. J Rheumatol 2017; 45:357-366. [DOI: 10.3899/jrheum.170318] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2017] [Indexed: 10/18/2022]
Abstract
Objective.To determine whether fear of movement and (re)injury [FOM/(R)I] beliefs, measured with the Tampa Scale for Kinesiophobia 11-item version (TSK-11), influence activity limitations and mediate the relationship between pain severity and activity limitations in axial spondyloarthritis (axSpA).Methods.In 173 patients with axSpA, these data were collected: sex, body mass index, disease duration, medication, activity limitations (BASFI; Bath Ankylosing Spondylitis Functional Index), disease activity [Bath Ankylosing Spondylitis Disease Activity Index (BASDAI); BASDAIinf, items 5 and 6; BASDAIpain, items 2 and 3; C-reactive protein and physician’s global assessment], spinal mobility (BASMI; Bath Ankylosing Spondylitis Metrology Index), and FOM/(R)I (TSK-11). Scaling assumptions and reliability of TSK-11 were tested with item-to-total correlations, item variances, and Cronbach’s alpha coefficient. Hypothesis testing determined TSK-11’s construct validity. Multiple linear regression showed the contribution of TSK-11 to BASFI (enter and backward modeling). Mediation by TSK-11 was analyzed (bias-corrected bootstrapping and Sobel test).Results.Adequate scale (Cronbach’s alpha = 0.80) and item internal consistency (range item-scale correlations 0.41–0.58, except for item 5, r = 0.23), equal item-scale correlations, and item variances were found for TSK-11. Construct validity was confirmed, except for the hypothesized positive relationship between TSK-11 and BASMI. Regression models (enter method, adjusted R2 range 53–74%) consistently identified TSK-11 as a determinant of BASFI (β range 0.155 to 0.321, p < 0.05), although BASMI (β range 0.441 to 0.537) and disease activity (β range 0.243 to 0.571, p < 0.05) were the largest determinants. TSK-11 partially mediated the BASDAIpain/BASFI relationship (B = 0.107; Sobel test, p = 0.004; bias-corrected CI 0.046–0.197).Conclusion.TSK-11 is a promising and valid tool to assess fearful beliefs in relation to activity limitations in axSpA. Future research applying TSK-11 may reveal FOM/(R)I as a novel treatment target in axSpA.
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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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Lonsdorf TB, Menz MM, Andreatta M, Fullana MA, Golkar A, Haaker J, Heitland I, Hermann A, Kuhn M, Kruse O, Meir Drexler S, Meulders A, Nees F, Pittig A, Richter J, Römer S, Shiban Y, Schmitz A, Straube B, Vervliet B, Wendt J, Baas JMP, Merz CJ. Don't fear 'fear conditioning': Methodological considerations for the design and analysis of studies on human fear acquisition, extinction, and return of fear. Neurosci Biobehav Rev 2017; 77:247-285. [PMID: 28263758 DOI: 10.1016/j.neubiorev.2017.02.026] [Citation(s) in RCA: 463] [Impact Index Per Article: 66.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 02/23/2017] [Accepted: 02/28/2017] [Indexed: 12/24/2022]
Abstract
The so-called 'replicability crisis' has sparked methodological discussions in many areas of science in general, and in psychology in particular. This has led to recent endeavours to promote the transparency, rigour, and ultimately, replicability of research. Originating from this zeitgeist, the challenge to discuss critical issues on terminology, design, methods, and analysis considerations in fear conditioning research is taken up by this work, which involved representatives from fourteen of the major human fear conditioning laboratories in Europe. This compendium is intended to provide a basis for the development of a common procedural and terminology framework for the field of human fear conditioning. Whenever possible, we give general recommendations. When this is not feasible, we provide evidence-based guidance for methodological decisions on study design, outcome measures, and analyses. Importantly, this work is also intended to raise awareness and initiate discussions on crucial questions with respect to data collection, processing, statistical analyses, the impact of subtle procedural changes, and data reporting specifically tailored to the research on fear conditioning.
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Affiliation(s)
- Tina B Lonsdorf
- University Medical Center Hamburg-Eppendorf, Department of Systems Neuroscience, Hamburg, Germany.
| | - Mareike M Menz
- University Medical Center Hamburg-Eppendorf, Department of Systems Neuroscience, Hamburg, Germany
| | - Marta Andreatta
- University of Würzburg, Department of Psychology, Biological Psychology, Clinical Psychology and Psychotherapy, Würzburg, Germany
| | - Miguel A Fullana
- Anxiety Unit, Institute of Neuropsychiatry and Addictions, Hospital del Mar, CIBERSAM, Barcelona, Spain; IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain; Department of Psychiatry, Autonomous University of Barcelona, Barcelona, Spain
| | - Armita Golkar
- Karolinska Institutet, Department of Clinical Neuroscience, Psychology Section, Stockholm, Sweden; University of Amsterdam, Department of Clinical Psychology, Amsterdam, Netherlands
| | - Jan Haaker
- University Medical Center Hamburg-Eppendorf, Department of Systems Neuroscience, Hamburg, Germany; Karolinska Institutet, Department of Clinical Neuroscience, Psychology Section, Stockholm, Sweden
| | - Ivo Heitland
- Utrecht University, Department of Experimental Psychology and Helmholtz Institute, Utrecht, The Netherlands
| | - Andrea Hermann
- Justus Liebig University Giessen, Department of Psychology, Psychotherapy and Systems Neuroscience, Giessen, Germany
| | - Manuel Kuhn
- University Medical Center Hamburg-Eppendorf, Department of Systems Neuroscience, Hamburg, Germany
| | - Onno Kruse
- Justus Liebig University Giessen, Department of Psychology, Psychotherapy and Systems Neuroscience, Giessen, Germany
| | - Shira Meir Drexler
- Ruhr-University Bochum, Institute of Cognitive Neuroscience, Department of Cognitive Psychology, Bochum, Germany
| | - Ann Meulders
- KU Leuven, Health Psychology, Leuven, Belgium; Maastricht University, Research Group Behavioral Medicine, Maastricht, The Netherlands
| | - Frauke Nees
- Heidelberg University, Medical Faculty Mannheim, Central Institute of Mental Health, Department of Cognitive and Clinical Neuroscience, Mannheim, Germany
| | - Andre Pittig
- Technische Universität Dresden, Institute of Clinical Psychology and Psychotherapy, Dresden, Germany
| | - Jan Richter
- University of Greifswald, Department of Physiological and Clinical Psychology/Psychotherapy, Greifswald, Germany
| | - Sonja Römer
- Saarland University, Department of Clinical Psychology and Psychotherapy, Saarbrücken, Germany
| | - Youssef Shiban
- University of Regensburg, Department of Psychology, Clinical Psychology and Psychotherapy, Regensburg, Germany
| | - Anja Schmitz
- University of Regensburg, Department of Psychology, Clinical Psychology and Psychotherapy, Regensburg, Germany
| | - Benjamin Straube
- Philipps-University Marburg, Department of Psychiatry and Psychotherapy, Marburg, Germany
| | - Bram Vervliet
- KU Leuven, Centre for the Psychology of Learning and Experimental Psychopathology, Leuven, Belgium; Center for Excellence on Generalization, University of Leuven, Leuven, Belgium; Department of Psychiatry, Harvard Medical School, Boston, MA, USA; Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Julia Wendt
- University of Greifswald, Department of Physiological and Clinical Psychology/Psychotherapy, Greifswald, Germany
| | - Johanna M P Baas
- Utrecht University, Department of Experimental Psychology and Helmholtz Institute, Utrecht, The Netherlands
| | - Christian J Merz
- Ruhr-University Bochum, Institute of Cognitive Neuroscience, Department of Cognitive Psychology, Bochum, Germany
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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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Garcia NM, Zoellner LA. Fear generalisation in individuals with high neuroticism: increasing predictability is not necessarily better. Cogn Emot 2016; 31:1647-1662. [PMID: 27892819 DOI: 10.1080/02699931.2016.1259160] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Natalia M. Garcia
- Department of Psychology, University of Washington, Seattle, WA, USA
| | - Lori A. Zoellner
- Department of Psychology, University of Washington, Seattle, WA, USA
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Vlaeyen JW, Morley S, Crombez G. The experimental analysis of the interruptive, interfering, and identity-distorting effects of chronic pain. Behav Res Ther 2016; 86:23-34. [DOI: 10.1016/j.brat.2016.08.016] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 08/17/2016] [Accepted: 08/22/2016] [Indexed: 02/07/2023]
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50
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Pain in context: Cues predicting a reward decrease fear of movement related pain and avoidance behavior. Behav Res Ther 2016; 84:35-44. [DOI: 10.1016/j.brat.2016.07.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 06/13/2016] [Accepted: 07/14/2016] [Indexed: 11/21/2022]
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