An evolutionary medicine perspective on pain and its disorders

Contemporary small-scale subsistence populations offer unique insights into human musculoskeletal health and aging

Human foragers avoid noncommunicable diseases that are leading causes of mortality, partly because physically active lifestyles promote healthy aging. High activity levels also promote tissue damage accumulation from wear-and-tear, increase risk of injury and disability which compromise productivity, and reduce energetic investments in somatic maintenance given constrained energy expenditure. Constraints intensify when nutrient supply is limited and surplus energy is directed toward pathogen defense and reproduction, as occurred throughout hominin evolution. This paper reviews evidence linking exposomes to musculoskeletal health in subsistence populations, focusing on effects of physical activity, pathogens, diet, and reproduction. Chronic musculoskeletal conditions are common for humans and possibly prehistoric hominins but rarer in quadrupedal apes. We propose that transition to bipedalism ~6 to 8 million years ago constituted an early "mismatch scenario," increasing hominin susceptibility to musculoskeletal conditions vis-à-vis quadrupedal apes due to changes in mechanical loading environments. Mismatched musculoskeletal traits were not targets of selection because of trade-offs favoring bipedal extractive foraging and higher fertility.

An evolutionary perspective for integrating mechanisms of acupuncture therapy

This study applies an evolutionary medicine perspective to comprehend the therapeutic effects of acupuncture. It draws upon modern evolutionary theory to integrate the currently fragmented theories regarding the efficacy of acupuncture in alleviating pain and promoting healing. We explore the interaction between the nervous and immune systems in the context of survival and homeostasis, and elucidate both the local and systemic effects of acupuncture therapy on pain relief and tissue healing. The mechanisms involved are categorized into two main types: local effects, which include immune cell migration, local vasodilation, and the release of adenosine; and distal systemic effects, which involve the regulation of the descending pain control system and the autonomic nervous system, with a particular focus on the parasympathetic nervous system. In conclusion, this integrated perspective not only deepens our understanding of acupuncture within a scientific narrative but also underscores the need for further research to validate and expand our knowledge, thereby enhancing its scientific credibility and clinical applicability.

Shared and distinct aberrations in frontal-striatal system functional patterns among patients with irritable bowel syndrome and major depressive disorder

BACKGROUND

Considering the high comorbidity, shared risk factors, and genetic pathways between irritable bowel syndrome (IBS) and major depressive disorder (MDD), we hypothesized that there would be both shared and disorder-specific alterations in brain function.

METHODS

A total of 39 IBS patients, 39 MDD patients, and 40 healthy controls (HCs) were enrolled and matched for sex, age, and educational level. All subjects underwent resting-state functional MRI. The clinical variables of anxiety, depression, gastrointestinal symptoms and alexithymia were recorded. The 12 subregions of the striatum were employed as seeds to assess their functional connectivity (FC) with every voxel throughout the whole brain.

RESULTS

Compared to HC, IBS and MDD patients exhibited aberrant frontal-striatal circuitry. We observed a common decrease in FC between the dorsal striatum and regions of the hippocampus, sensorimotor cortex, and prefrontal cortex (PFC) in both IBS and MDD patients. Patients with IBS exhibited disorder-specific decreases in FC within the striatum, along with reduced connectivity between the ventral striatum and sensorimotor cortex. In contrast, MDD patients showed disorder-specific hyperconnectivity in the medial PFC-limbic system. Receiver operating characteristic curve analysis showed that frontal-striatal FC values could serve as transdiagnostic markers of IBS and MDD. Within the IBS group, striatal connectivity was not only negatively associated with weekly abdominal pain days but also negatively correlated with the levels of anxiety and alexithymia.

CONCLUSIONS

This exploratory analysis indicated that patients with IBS and MDD exhibited both shared and disorder-specific frontal-striatal circuit impairments, potentially explaining both comorbidity and distinct phenotypes.

Relation Between Obesity and Type 2 Diabetes: Evolutionary Insights, Perspectives and Controversies

PURPOSE OF REVIEW

Since the mid-twentieth century, obesity and its related comorbidities, notably insulin resistance (IR) and type 2 diabetes (T2D), have surged. Nevertheless, their underlying mechanisms remain elusive. Evolutionary medicine (EM) sheds light on these issues by examining how evolutionary processes shape traits and diseases, offering insights for medical practice. This review summarizes the pathogenesis and genetics of obesity-related IR and T2D. Subsequently, delving into their evolutionary connections. Addressing limitations and proposing future research directions aims to enhance our understanding of these conditions, paving the way for improved treatments and prevention strategies.

RECENT FINDINGS

Several evolutionary hypotheses have been proposed to unmask the origin of obesity-related IR and T2D, e.g., the "thrifty genotype" hypothesis suggests that certain "thrifty genes" that helped hunter-gatherer populations efficiently store energy as fat during feast-famine cycles are now maladaptive in our modern obesogenic environment. The "drifty genotype" theory suggests that if thrifty genes were advantageous, they would have spread widely, but proposes genetic drift instead. The "behavioral switch" and "carnivore connection" hypotheses propose insulin resistance as an adaptation for a brain-dependent, low-carbohydrate lifestyle. The thrifty phenotype theory suggests various metabolic outcomes shaped by genes and environment during development. However, the majority of these hypotheses lack experimental validation. Understanding why ancestral advantages now predispose us to diseases may aid in drug development and prevention of disease. EM helps us to understand the evolutionary relation between obesity-related IR and T2D. But still gaps and contradictions persist. Further interdisciplinary research is required to elucidate complete mechanisms.

Differential behavioral response to predator odor in neuropathic pain in mice

Neuropathic pain, a type of chronic pain caused by injury or disease of the somatosensory system, affects ∼10% of the general population and is difficult to treat. It is strongly associated with mood disorder comorbidities and impairs quality of life. It was recently suggested that hypervigilance caused by chronic pain might be of advantage in some species, helping them avoid predators during injury when they are most vulnerable. Here, we sought to confirm the hypervigilance hypothesis by using two predator odor (PO) paradigms, one with transient and one with continuous odor presentation. We observed behavioral responses to PO in neuropathic and control mice in an open field setting. We find that neuropathic mice show hypervigilance to PO, confirming previous results. However, we also find increased anxiety responses to neutral odor in neuropathic mice, which manifests as maladaptive pain. This demonstrates that this maladaptive nature of pain could be an evolutionary adaptation aimed at reducing injury-induced vulnerability.

Does Active Inference Provide a Comprehensive Theory of Placebo Analgesia?

Placebo interventions generate mismatches between expected pain and sensory signals from which pain states are inferred. Because we lack direct access to bodily states, we can only infer whether nociceptive activity indicates tissue damage or results from noise in sensory channels. Predictive processing models propose to make optimal inferences using prior knowledge given noisy sensory data. However, these models do not provide a satisfactory explanation of how pain relief expectations are translated into physiological manifestations of placebo responses. Furthermore, they do not account for individual differences in the ability to endogenously regulate nociceptive activity in predicting placebo analgesia. The brain not only passively integrates prior pain expectations with nociceptive activity to infer pain states (perceptual inference) but also initiates various types of actions to ensure that sensory data are consistent with prior pain expectations (active inference). We argue that depending on whether the brain interprets conflicting sensory data (prediction errors) as a signal to learn from or noise to be attenuated, the brain initiates opposing types of action to facilitate learning from sensory data or, conversely, to enhance the biasing influence of prior pain expectations on pain perception. Furthermore, we discuss the role of stress, anxiety, and unpredictability of pain in influencing the weighting of prior pain expectations and sensory data and how they relate to the individual ability to regulate nociceptive activity (endogenous pain modulation). Finally, we provide suggestions for future studies to test the implications of the active inference model of placebo analgesia.

Exaptation and Evolutionary Adaptation in Nociceptor Mechanisms Driving Persistent Pain

BACKGROUND

Several evolutionary explanations have been proposed for why chronic pain is a major clinical problem. One is that some mechanisms important for driving chronic pain, while maladaptive for modern humans, were adaptive because they enhanced survival. Evidence is reviewed for persistent nociceptor hyperactivity (PNH), known to promote chronic pain in rodents and humans, being an evolutionarily adaptive response to significant bodily injury, and primitive molecular mechanisms related to cellular injury and stress being exapted (co-opted or repurposed) to drive PNH and consequent pain.

SUMMARY

PNH in a snail (Aplysia californica), squid (Doryteuthis pealeii), fruit fly (Drosophila melanogaster), mice, rats, and humans has been documented as long-lasting enhancement of action potential discharge evoked by peripheral stimuli, and in some of these species as persistent extrinsically driven ongoing activity and/or intrinsic spontaneous activity (OA and SA, respectively). In mammals, OA and SA are often initiated within the protected nociceptor soma long after an inducing injury. Generation of OA or SA in nociceptor somata may be very rare in invertebrates, but prolonged afterdischarge in nociceptor somata readily occurs in sensitized Aplysia. Evidence for the adaptiveness of injury-induced PNH has come from observations of decreased survival of injured squid exposed to predators when PNH is blocked, from plausible survival benefits of chronic sensitization after severe injuries such as amputation, and from the functional coherence and intricacy of mammalian PNH mechanisms. Major contributions of cAMP-PKA signaling (with associated calcium signaling) to the maintenance of PNH both in mammals and molluscs suggest that this ancient stress signaling system was exapted early during the evolution of nociceptors to drive hyperactivity following bodily injury. Vertebrates have retained core cAMP-PKA signaling modules for PNH while adding new extracellular modulators (e.g., opioids) and cAMP-regulated ion channels (e.g., TRPV1 and Nav1.8 channels).

KEY MESSAGES

Evidence from multiple phyla indicates that PNH is a physiological adaptation that decreases the risk of attacks on injured animals. Core cAMP-PKA signaling modules make major contributions to the maintenance of PNH in molluscs and mammals. This conserved signaling has been linked to ancient cellular responses to stress, which may have been exapted in early nociceptors to drive protective hyperactivity that can persist while bodily functions recover after significant injury.

Pain: Behavioural expression and response in an evolutionary framework

An evolutionary perspective offers insights into the major public health problem of chronic (persistent) pain; behaviours associated with it perpetuate both pain and disability. Pain is motivating, and pain-related behaviours promote recovery by immediate active or passive defence; subsequent protection of wounds; suppression of competing responses; energy conservation; vigilance to threat; and learned avoidance of associated cues. When these persist beyond healing, as in chronic pain, they are disabling. In mammals, facial and bodily expression of pain is visible and identifiable by others, while social context, including conspecifics' responses, modulate pain. Studies of responses to pain emphasize onlooker empathy, but people with chronic pain report feeling disbelieved and stigmatized. Observers frequently discount others' pain, best understood in terms of cheater detection-alertness to free riders that underpins the capacity for prosocial behaviours. These dynamics occur both in everyday life and in clinical encounters, providing an account of the adaptiveness of pain-related behaviours.

I Feel! Therefore, I Am from Pain to Consciousness in DOC Patients

Pain assessment and management in patients with disorders of consciousness (DOC) is a challenging and important aspect of care, with implications for detecting consciousness and promoting recovery. This narrative review explores the role of pain in consciousness, the challenges of pain assessment, pharmacological treatment in DOC, and the implications of pain assessment when detecting changes in consciousness. The review discusses the Nociception Coma Scale and its revised version, which are behavioral scales used to assess pain in DOC patients, and the challenges and controversies surrounding the appropriate pharmacological treatment of pain in these patients. Moreover, we highlight recent evidence suggesting that an accurate pain assessment may predict changes in the level of consciousness in unresponsive wakefulness syndrome/vegetative state patients, underscoring the importance of ongoing pain management in these patients.

Impact and centrality of attention dysregulation on cognition, anxiety, and low mood in adolescents

Functional impairments in cognition are frequently thought to be a feature of individuals with depression or anxiety. However, documented impairments are both broad and inconsistent, with little known about when they emerge, whether they are causes or effects of affective symptoms, or whether specific cognitive systems are implicated. Here, we show, in the adolescent ABCD cohort (N = 11,876), that attention dysregulation is a robust factor underlying wide-ranging cognitive task impairments seen in adolescents with moderate to severe anxiety or low mood. We stratified individuals high in DSM-oriented depression or anxiety symptomology, and low in attention deficit hyperactivity disorder (ADHD), as well as vice versa - demonstrating that those high in depression or anxiety dimensions but low in ADHD symptoms not only exhibited normal task performance across several commonly studied cognitive paradigms, but out-performed controls in several domains, as well as in those low in both dimensions. Similarly, we showed that there were no associations between psychopathological dimensions and performance on an extensive cognitive battery after controlling for attention dysregulation. Further, corroborating previous research, the co-occurrence of attention dysregulation was associated with a wide range of other adverse outcomes, psychopathological features, and executive functioning (EF) impairments. To assess how attention dysregulation relates to and generates diverse psychopathology, we performed confirmatory and exploratory network analysis with different analytic approaches using Gaussian Graphical Models and Directed Acyclic Graphs to examine interactions between ADHD, anxiety, low mood, oppositional defiant disorder (ODD), social relationships, and cognition. Confirmatory centrality analysis indicated that features of attention dysregulation were indeed central and robustly connected to a wide range of psychopathological traits across different categories, scales, and time points. Exploratory network analysis indicated potentially important bridging traits and socioenvironmental influences in the relationships between ADHD symptoms and mood/anxiety disorders. Trait perfectionism was uniquely associated with both better cognitive performance and broad psychopathological dimensions. This work suggests that attentional dysregulation may moderate the breadth of EF, fluid, and crystalized cognitive task outcomes seen in adolescents with anxiety and low mood, and may be central to disparate pathological features, and thus a target for attenuating wide-ranging negative developmental outcomes.

Depression, Cognition, and Pain: Exploring Individual, Cultural and Country-Level Effects Across Europe

The aim of this paper was to investigate the role of economic (eg, GDP per capita), political (eg, healthcare spending), cultural (country-level aggregates norms) and individual correlates (eg, depression) of pain in a secondary analysis of a sample of 76,000 adults in 19 countries across Europe. The sample was aggregated from 2 waves of the Study of Health, Ageing and Retirement in Europe cohort, using multilevel models with cross-level interactions between individual and country-level effects. While there has been extensive focus on individual risk factors (eg, depression, cognition, BMI), the role of social, political and cultural contextual factors has been relatively underexplored. In addition to replicating well-established individual risk factors (eg, increased depression), we demonstrate that higher levels of depression, chronic pain diagnosis, and collectivism, aggregated at the country-level, are also associated with increased pain severity. There was evidence that these country-level effects moderate the effect of individual correlates of pain. These results contribute to the literature by identifying the importance of broader cultural factors alongside individual psychological indices of pain reporting. PERSPECTIVE: In this study we model how individual, political and cultural factors influence pain in a large cross-national sample. In addition to replicating established individual effects, it shows how cultural (ie, collectivism) and political (eg, GDP, healthcare spending) factors affect individual expressions of pain, and how the cultural and individual factors interact with each other.

Evolutionary psychiatry: foundations, progress and challenges

Evolutionary biology provides a crucial foundation for medicine and behavioral science that has been missing from psychiatry. Its absence helps to explain slow progress; its advent promises major advances. Instead of offering a new kind of treatment, evolutionary psychiatry provides a scientific foundation useful for all kinds of treatment. It expands the search for causes from mechanistic explanations for disease in some individuals to evolutionary explanations for traits that make all members of a species vulnerable to disease. For instance, capacities for symptoms such as pain, cough, anxiety and low mood are universal because they are useful in certain situations. Failing to recognize the utility of anxiety and low mood is at the root of many problems in psychiatry. Determining if an emotion is normal and if it is useful requires understanding an individual's life situation. Conducting a review of social systems, parallel to the review of systems in the rest of medicine, can help achieve that understanding. Coping with substance abuse is advanced by acknowledging how substances available in modern environments hijack chemically mediated learning mechanisms. Understanding why eating spirals out of control in modern environments is aided by recognizing the motivations for caloric restriction and how it arouses famine protection mechanisms that induce binge eating. Finally, explaining the persistence of alleles that cause serious mental disorders requires evolutionary explanations of why some systems are intrinsically vulnerable to failure. The thrill of finding functions for apparent diseases is evolutionary psychiatry's greatest strength and weakness. Recognizing bad feelings as evolved adaptations corrects psychiatry's pervasive mistake of viewing all symptoms as if they were disease manifestations. However, viewing diseases such as panic disorder, melancholia and schizophrenia as if they are adaptations is an equally serious mistake in evolutionary psychiatry. Progress will come from framing and testing specific hypotheses about why natural selection left us vulnerable to mental disorders. The efforts of many people over many years will be needed before we will know if evolutionary biology can provide a new paradigm for understanding and treating mental disorders.

The influence of cultural and religious factors on cross-national variations in the prevalence of chronic back and neck pain: an analysis of data from the global burden of disease 2019 study

Introduction

Low back pain and neck pain are among the most commonly reported forms of chronic pain worldwide, and are associated with significant distress, disability and impairment in quality of life. Though these categories of pain can be analyzed and treated from a biomedical perspective, there is evidence that they are both related to psychological variables such as depression and anxiety. The experience of pain can be significantly influenced by cultural values. For example, cultural beliefs and attitudes can influence the meaning attached to the experience of pain, the responses of others to a sufferer's pain, and the likelihood of seeking medical care for particular symptoms. Likewise, religious beliefs and practices can influence the both experience of pain and the responses to it. These factors have also been associated with variations in the severity of depression and anxiety.

Methods

In the current study, data on the estimated national prevalence of both low back pain and neck pain, obtained from the 2019 Global Burden of Disease Study (GBD 2019), is analyzed in relation to cross-national variations in cultural values, as measured using Hofstede's model (n =115 countries) and in religious belief and practice, based on the most recent Pew Research Center survey (n = 105 countries). To address possible confounding factors, these analyses were adjusted for variables known to be associated with chronic low back or neck pain, namely smoking, alcohol use, obesity, anxiety, depression and insufficient physical activity.

Results

It was found that the cultural dimensions of Power Distance and Collectivism were inversely correlated with the prevalence of chronic low back pain, and Uncertainty Avoidance was inversely correlated with the prevalence of chronic neck pain, even after adjustment for potential confounders. Measures of religious affiliation and practice were negatively correlated with the prevalence of both conditions, but these associations were not significant after adjusting for cultural values and confounders.

Discussion

These results highlight the existence of meaningful cross-cultural variations in the occurrence of common forms of chronic musculoskeletal pain. Psychological and social factors that could account for these variations are reviewed, along with their implications for the holistic management of patients with these disorders.

Labour's pain: strenuous subsistence work, mechanical wear-and-tear and musculoskeletal pain in a non-industrialized population

Musculoskeletal pain is the most debilitating human health condition. Neurophysiological pain mechanisms are highly conserved and promote somatic maintenance and learning to avoid future harm. However, some chronic pain might be more common owing to mismatches between modern lifestyles and traits that originally evolved under distinct premodern conditions. To inform assumptions about factors affecting chronic pain vulnerability prior to industrialization, we assess pain prevalence, perceived causes, and predictors among Tsimane forager-horticulturalists. Habitual subsistence work is the primary reported cause of pain throughout life for both sexes, and pain is more common with age, especially in the back, and for those with more musculoskeletal problems. Sex differences in pain are relatively weak, and we find no association between women's reproductive history and pain, contrary to the hypothesis that reproduction causes women's greater pain susceptibility. Age-standardized current pain prevalence is 1.7-8.2 times higher for Tsimane than other select populations, and Tsimane chronic pain prevalence is within the range of variation observed elsewhere. Chronic low back pain is not a 'mismatch disease' limited to post-industrialized populations. Hominin musculoskeletal changes supporting bipedalism probably imposed health costs, which, after millions of years of evolution, remain an epidemiological burden that may be exacerbated by modern conditions.

Chloride-dependent mechanisms of multimodal sensory discrimination and nociceptive sensitization in Drosophila

Individual sensory neurons can be tuned to many stimuli, each driving unique, stimulus-relevant behaviors, and the ability of multimodal nociceptor neurons to discriminate between potentially harmful and innocuous stimuli is broadly important for organismal survival. Moreover, disruptions in the capacity to differentiate between noxious and innocuous stimuli can result in neuropathic pain. Drosophila larval class III (CIII) neurons are peripheral noxious cold nociceptors and innocuous touch mechanosensors; high levels of activation drive cold-evoked contraction (CT) behavior, while low levels of activation result in a suite of touch-associated behaviors. However, it is unknown what molecular factors underlie CIII multimodality. Here, we show that the TMEM16/anoctamins subdued and white walker (wwk; CG15270) are required for cold-evoked CT, but not for touch-associated behavior, indicating a conserved role for anoctamins in nociception. We also evidence that CIII neurons make use of atypical depolarizing chloride currents to encode cold, and that overexpression of ncc69-a fly homologue of NKCC1-results in phenotypes consistent with neuropathic sensitization, including behavioral sensitization and neuronal hyperexcitability, making Drosophila CIII neurons a candidate system for future studies of the basic mechanisms underlying neuropathic pain.

The Consciousness of Pain: A Thalamocortical Perspective

Deep, dreamless sleep is considered the only "normal" state under which consciousness is lost. The main reason for the voluntary, external induction of an unconscious state, via general anesthesia, is to silence the brain circuitry of nociception. In this article, I describe the perception of pain as a neural and behavioral correlate of consciousness. I briefly mention the brain areas and parameters that are connected to the presence of consciousness, mainly by virtue of their absence under deep anesthesia, and parallel those to brain areas responsible for the perception of pain. Activity in certain parts of the cortex and thalamus, and the interaction between them, will be the main focus of discussion as they represent a common ground that connects our general conscious state and our ability to sense the environment around us, including the painful stimuli. A plethora of correlative and causal evidence has been described thus far to explain the brain's involvement in consciousness and nociception. Despite the great advancement in our current knowledge, the manifestation and true nature of the perception of pain, or any conscious experience, are far from being fully understood.

A Pilot Clinical Study of the Efficacy and Safety of Phellinus Linteus (Sanghuang) Extract Treatment for Knee Osteoarthritis

Background: To evaluate the efficacy and safety of Phellinus linteus (PL) extract for the treatment of knee osteoarthritis (KOA) a pilot clinical study was performed.Methods: There were 24 patients with KOA who enrolled in this double-blind, randomized, controlled, clinical trial. There were 3 groups: PL 1,000 mg/day (PL 1,000), PL 1,500 mg/day (PL 1,500), and dextrin 3,000 mg/day (placebo). Patients took capsules twice a day, 3 capsules at a time, over 8 weeks. Patients were monitored prior to treatment (Visit 1: Week 0), and followed up every 4 weeks (Visit 2: Week 4 and Visit 3: Week 8) where outcome measurements were taken. The primary outcome measure was the score from the Korean version of the Western Ontario and McMasters Universities from baseline to Week 8. The secondary outcomes were measurements from the visual analog scale, quality of life scale, erythrocyte sedimentation, and c-reactive protein. Adverse events were recorded at every visit.Results: The Korean version of the Western Ontario and McMasters Universities score showed the greatest improvement in symptoms of KOA in the PL 1,500 group compared with the placebo group. The erythrocyte sedimentation tended to decrease in the PL 1,500 group compared with the placebo group (which was within the normal range). The visual analog scale score decreased in all groups, with no significant differences between groups. No adverse events related to PL were reported. There were no abnormal hematological or physical findings.Conclusion: This pilot clinical trial was the first step to assess the efficacy and safety of PL used in the treatment of patients with KOA.

Common and specific large-scale brain changes in major depressive disorder, anxiety disorders, and chronic pain: a transdiagnostic multimodal meta-analysis of structural and functional MRI studies

Major depressive disorder (MDD), anxiety disorders (ANX), and chronic pain (CP) are closely-related disorders with both high degrees of comorbidity among them and shared risk factors. Considering this multi-level overlap, but also the distinct phenotypes of the disorders, we hypothesized both common and disorder-specific changes of large-scale brain systems, which mediate neural mechanisms and impaired behavioral traits, in MDD, ANX, and CP. To identify such common and disorder-specific brain changes, we conducted a transdiagnostic, multimodal meta-analysis of structural and functional MRI-studies investigating changes of gray matter volume (GMV) and intrinsic functional connectivity (iFC) of large-scale intrinsic brain networks across MDD, ANX, and CP. The study was preregistered at PROSPERO (CRD42019119709). 320 studies comprising 10,931 patients and 11,135 healthy controls were included. Across disorders, common changes focused on GMV-decrease in insular and medial-prefrontal cortices, located mainly within the so-called default-mode and salience networks. Disorder-specific changes comprised hyperconnectivity between default-mode and frontoparietal networks and hypoconnectivity between limbic and salience networks in MDD; limbic network hyperconnectivity and GMV-decrease in insular and medial-temporal cortices in ANX; and hypoconnectivity between salience and default-mode networks and GMV-increase in medial temporal lobes in CP. Common changes suggested a neural correlate for comorbidity and possibly shared neuro-behavioral chronification mechanisms. Disorder-specific changes might underlie distinct phenotypes and possibly additional disorder-specific mechanisms.

Painful Truth: The Need to Re-Center Chronic Pain on the Functional Role of Pain

Pain is undesirable, whether it is a symptom of mild or severe illness or instead indicates disorder in the nervous system’s ability to perceive and process sensory information. Nonetheless, pain is part of the body’s ability to defend itself and promote its own survival—this is its fundamental evolutionary function. This normal expression of pain is not limited to what is considered useful because it alerts us to the initiation of illness. It also applies to pain that continues when illness or noxious stimuli persist. However, the parameters of what is here termed functional pain are not fully understood and are seldom explicitly the focus of research. This paper posits that failure to appreciate the functional role of pain in research has had significant unintended consequences and may be contributing to inconsistent research findings. To that end, the paper describes the misclassification issue at the core of chronic pain research—whether a given pain reflects functional or pathological processes—and discusses research areas where reconsidering the functional role of pain may lead to advancements.

Brain Imaging Biomarkers for Chronic Pain

The prevalence of chronic pain has reached epidemic levels. In addition to personal suffering chronic pain is associated with psychiatric and medical co-morbidities, notably substance misuse, and a huge a societal cost amounting to hundreds of billions of dollars annually in medical cost, lost wages, and productivity. Chronic pain does not have a cure or quantitative diagnostic or prognostic tools. In this manuscript we provide evidence that this situation is about to change. We first start by summarizing our current understanding of the role of the brain in the pathogenesis of chronic pain. We particularly focus on the concept of learning in the emergence of chronic pain, and the implication of the limbic brain circuitry and dopaminergic signaling, which underly emotional learning and decision making, in this process. Next, we summarize data from our labs and from other groups on the latest brain imaging findings in different chronic pain conditions focusing on results with significant potential for translation into clinical applications. The gaps in the study of chronic pain and brain imaging are highlighted in throughout the overview. Finally, we conclude by discussing the costs and benefits of using brain biomarkers of chronic pain and compare to other potential markers.

Cytokine storms, evolution and COVID-19

Many treatments for COVID-19 are aimed at calming a cytokine storm, a dangerous immune overreaction to the infection. Treating cytokine storms has been tried for decades in sepsis and other viral illnesses, but these treatments most often do not work. We explain why cytokine storms should be rare, and what special evolutionary circumstances can cause them to occur.

Since the identification of severe illness caused by the novel coronavirus SARS-CoV-2, the role of the host immune system in causing disease has attracted widespread attention, along with intense interest in medical interventions that target the host immune response. A wide variety of agents have been proposed to treat a cytokine storm in coronavirus disease 2019 (COVID-19), but so far, only one class of medications, corticosteroids, has proved useful. In recent decades, experimental therapies for cytokine storms have been tried and mostly failed to help patients with severe sepsis and other infections. We summarize this history in order to frame expectations for novel interventions in COVID-19 and to bring an evolutionary medicine perspective to the concept of cytokine storms and their treatment.

Chronic pain produces hypervigilance to predator odor in mice

The adaptive significance of acute pain (to withdraw from tissue-damaging or potentially tissue-damaging external stimuli, and to enhance the salience of the stimulus resulting in escape and avoidance learning) and tonic pain (to enforce recuperation by punishing movement) are well-accepted [1]. Pain researchers, however, generally assert that chronic pain has no adaptive significance, representing instead a pathophysiological state. This belief was recently challenged by the observation [2] that nociceptive sensitization caused by a chronic pain-producing injury reduced predation risk in squid (Doryteuthis pealeii). In that study, injury to an arm (removal of the tip with a scalpel) 6 hours prior led to increased targeting by black sea bass, resulting in decreased survival of the squid in a 30-minute trial featuring free interaction between predator and prey. The surprising finding was that anesthesia during surgery, preventing the chronic nociceptor sensitization associated with such injuries, led to even lower probability of survival. That is, the likely presence of pain increased apparent fitness, and the authors concluded that the chronic pain state and its associated nociceptive sensitization represented an adaptive function. Pain-induced defensive behaviors affecting fitness have also been reported in crustaceans (Gammarus fossarum) [3]. It is, however, currently unknown whether this may also be true in any other species, including in Mammalia.

A possible evolutionary function of phenomenal conscious experience of pain

Evolutionary accounts of feelings, and in particular of negative affect and of pain, assume that creatures that feel and care about the outcomes of their behavior outperform those that do not in terms of their evolutionary fitness. Such accounts, however, can only work if feelings can be shown to contribute to fitness-influencing outcomes. Simply assuming that a learner that feels and cares about outcomes is more strongly motivated than one that does is not enough, if only because motivation can be tied directly to outcomes by incorporating an appropriate reward function, without leaving any apparent role to feelings (as it is done in state-of-the-art engineered systems based on reinforcement learning). Here, we propose a possible mechanism whereby pain contributes to fitness: an actor-critic functional architecture for reinforcement learning, in which pain reflects the costs imposed on actors in their bidding for control, so as to promote honest signaling and ultimately help the system optimize learning and future behavior.

Cognition in the Chronic Pain Experience: Preclinical Insights

Acutely, pain is protective. It promotes escape from, and future avoidance of, noxious stimuli through strong and often lifetime associative memories. However, with persistent acute pain or when pain becomes chronic, these memories can promote negative emotions and poor decisions often associated with deleterious behaviors. In this review, we discuss how preclinical studies can provide insights into the relationship between cognition and chronic pain. We also discuss the concept of pain as a cognitive disorder and new strategies for treating chronic pain that emphasize inhibiting the formation of pain memories or promoting 'forgetting' of established pain memories.

Offset analgesia and onset hyperalgesia with different stimulus ranges

A comparison between the effects of offset analgesia and onset hyperalgesia and how these effects relate to the stimulus range of thermal stimulation.

Introduction:

Offset analgesia (OA), a large reduction in pain after a brief increase in intensity of an otherwise stable painful stimulus, has been established by a large body of research. But the opposite effect, onset hyperalgesia (OH), a disproportional hyperalgesic response after a briefly decreased intensity of a painful stimulus, has only been investigated in one previous study.

Objectives:

The aim of this study was to induce OA and OH in healthy participants and explore the effects of different stimulus ranges (increase/decrease of temperature) on OA and OH.

Methods:

A total of 62 participants were tested in 2 identical experiments. Offset analgesia and OH conditions included 2 different temperature deviations (±1°C/±2°C) from initial temperature and were compared with a constant temperature (control).

Results:

Offset analgesia was successfully elicited in OA_1°C in experiment 1, and in OA_1°C and OA_2°C in experiment 2. Results indicate a continuous stimulus–response relationship between the stimulus range and the resulting hypoalgesic response. Onset hyperalgesia was only elicited in OH_2°C in experiment 1. Exploratory analysis showed that the lack of OH response in experiment 2 could be explained by sex differences, and that OA and OH responses were only weakly correlated.

Conclusions:

The asymmetry between pain responses after a brief temperature increase and decrease suggests that different mechanisms are involved in the pain responses to increasing and decreasing temperature. This asymmetry may also be explained by high temperatures in OA condition (+1°C/+2°C above baseline) that could be seen as salient “learning signals,” which augment the response to following changes in temperature.

Sensor Technologies to Manage the Physiological Traits of Chronic Pain: A Review

Non-oncologic chronic pain is a common high-morbidity impairment worldwide and acknowledged as a condition with significant incidence on quality of life. Pain intensity is largely perceived as a subjective experience, what makes challenging its objective measurement. However, the physiological traces of pain make possible its correlation with vital signs, such as heart rate variability, skin conductance, electromyogram, etc., or health performance metrics derived from daily activity monitoring or facial expressions, which can be acquired with diverse sensor technologies and multisensory approaches. As the assessment and management of pain are essential issues for a wide range of clinical disorders and treatments, this paper reviews different sensor-based approaches applied to the objective evaluation of non-oncological chronic pain. The space of available technologies and resources aimed at pain assessment represent a diversified set of alternatives that can be exploited to address the multidimensional nature of pain.

Evolution of mechanisms and behaviour important for pain

Our understanding of the biology of pain is limited by our ignorance about its evolution. We know little about how states in other species showing various degrees of apparent similarity to human pain states are related to human pain, or how the mechanisms essential for pain-related states evolved. Nevertheless, insights into the evolution of mechanisms and behaviour important for pain are beginning to emerge from wide-ranging investigations of cellular mechanisms and behavioural responses linked to nociceptor activation, tissue injury, inflammation and the environmental context of these responses in diverse species. In February 2019, an unprecedented meeting on the evolution of pain hosted by the Royal Society brought together scientists from disparate fields who investigate nociception and pain-related behaviour in crustaceans, insects, leeches, gastropod and cephalopod molluscs, fish and mammals (primarily rodents and humans). Here, we identify evolutionary themes that connect these research efforts, including adaptive and maladaptive features of pain-related behavioural and neuronal alterations-some of which are quite general, and some that may apply primarily to humans. We also highlight major questions, including how pain should be defined, that need to be answered as we seek to understand the evolution of pain. This article is part of the Theo Murphy meeting issue 'Evolution of mechanisms and behaviour important for pain'.

Adaptive mechanisms driving maladaptive pain: how chronic ongoing activity in primary nociceptors can enhance evolutionary fitness after severe injury

Chronic pain is considered maladaptive by clinicians because it provides no apparent protective or recuperative benefits. Similarly, evolutionary speculations have assumed that chronic pain represents maladaptive or evolutionarily neutral dysregulation of acute pain mechanisms. By contrast, the present hypothesis proposes that chronic pain can be driven by mechanisms that evolved to reduce increased vulnerability to attack from predators and aggressive conspecifics, which often target prey showing physical impairment after severe injury. Ongoing pain and anxiety persisting long after severe injury continue to enhance vigilance and behavioural caution, decreasing the heightened vulnerability to attack that results from motor impairment and disfigurement, thereby increasing survival and reproduction (fitness). This hypothesis is supported by evidence of animals surviving and reproducing after traumatic amputations, and by complex specializations that enable primary nociceptors to detect local and systemic signs of injury and inflammation, and to maintain low-frequency discharge that can promote ongoing pain indefinitely. Ongoing activity in nociceptors involves intricate electrophysiological and anatomical specializations, including inducible alterations in the expression of ion channels and receptors that produce persistent hyperexcitability and hypersensitivity to chemical signals of injury. Clinically maladaptive chronic pain may sometimes result from the recruitment of this powerful evolutionary adaptation to severe bodily injury. This article is part of the Theo Murphy meeting issue 'Evolution of mechanisms and behaviour important for pain'.