Description of Common Clinical Presentations and Associated Short Term Physical Therapy Clinical Outcomes and Utilization in Patients with Neck Pain.

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Description of Common Clinical Presentations and Associated Short Term Physical Therapy Clinical Outcomes and Utilization in Patients with Neck Pain.

Arch Phys Med Rehabil. 2015 Jul 9;

Authors: Horn ME, Brennan GP, George SZ, Harman JS, Bishop MD

Abstract
OBJECTIVE: To determine the effect of clinical presentations of neck pain on short term physical therapy outcomes.
DESIGN: Retrospective analysis of pair matched groups from a clinical cohort SETTING: 13 outpatient physical therapy clinics in one healthcare system.
PARTICIPANTS: 1069 patients grouped by common clinical presentations of neck pain: Nonspecific neck pain (NSNP) with a duration less than 4weeks, NSNP greater than 4weeks, neck pain with arm pain, neck pain with headache and whiplash.
INTERVENTION: Conservative interventions provided by physical therapists MAIN OUTCOME MEASURES: Neck Disability Index (NDI) and Numerical Pain Rating Scale (NPRS) recorded at the initial and last visits. The main outcome of interest was achieving recovery status on the NDI. Change in NDI and NPRS were compared between clinical presentation groups.
RESULTS: Compared to patients presenting with NSNP >4weeks, patients with NSNP <4weeks had increased odds of achieving recovery status on the NDI (p<0.0001), demonstrated the greatest changes in clinical outcomes of pain (p=<0.0001) and disability (p=<0.0001). Patients with neck pain and arm pain demonstrated an increased odds of achieving recovery status on the NDI (p=0.03) compared to patients presenting with NSNP >4weeks.
CONCLUSIONS: Treating patients with NSNP within <4weeks of onset of symptoms may lead to improved clinical outcomes from physical therapy compared to other common clinical presentations.

PMID: 26166733 [PubMed - as supplied by publisher]

Test-retest reliability of pain-related brain activity in healthy controls undergoing experimental thermal pain.

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Test-retest reliability of pain-related brain activity in healthy controls undergoing experimental thermal pain.

J Pain. 2014 Oct;15(10):1008-14

Authors: Letzen JE, Sevel LS, Gay CW, O'Shea AM, Craggs JG, Price DD, Robinson ME

Abstract
UNLABELLED: Although functional magnetic resonance imaging (fMRI) has been proposed as a method to elucidate pain-related biomarkers, little information exists related to psychometric properties of fMRI findings. This knowledge is essential for potential translation of this technology to clinical settings. The purpose of this study was to assess the test-retest reliability of pain-related brain activity and how it compares to the reliability of self-report. Twenty-two healthy controls (mean age = 22.6 years, standard deviation = 2.9) underwent 3 runs of an fMRI paradigm that used thermal stimuli to elicit experimental pain. Functional MRI summary statistics related to brain activity during thermal stimulation periods were extracted from bilateral anterior cingulate cortices and anterior insula. Intraclass correlations (ICCs) were conducted on these summary statistics and generally showed "good" test-retest reliability in all regions of interest (ICC range = .32-.88; mean = .71); however, these results did not surpass ICC values from pain ratings, which fell within the "excellent" range (ICC range = .93-.96; mean = .94). Findings suggest that fMRI is a valuable tool for measuring pain mechanisms but did not show an adequate level of test-retest reliability for fMRI to potentially act as a surrogate for individuals' self-report of pain.
PERSPECTIVE: This study is one of the first reports to demonstrate the test-retest reliability of fMRI findings related to pain processing and provides a comparison to the reliability of subjective reports of pain. This information is essential for determining whether fMRI technology should be potentially translated for clinical use.

PMID: 24998897 [PubMed - indexed for MEDLINE]

The influence of health care professional characteristics on pain management decisions.

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The influence of health care professional characteristics on pain management decisions.

Pain Med. 2015 Jan;16(1):99-111

Authors: Bartley EJ, Boissoneault J, Vargovich AM, Wandner LD, Hirsh AT, Lok BC, Heft MW, Robinson ME

Abstract
OBJECTIVE: Evidence suggests that patient characteristics such as sex, race, and age influence the pain management decisions of health care providers. Although this signifies that patient demographics may be important determinants of health care decisions, pain-related care also may be impacted by the personal characteristics of the health care practitioner. However, the extent to which health care provider characteristics affect pain management decisions is unclear, underscoring the need for further research in this area.
METHODS: A total of 154 health care providers (77 physicians, 77 dentists) viewed video vignettes of virtual human (VH) patients varying in sex, race, and age. Practitioners provided computerized ratings of VH patients' pain intensity and unpleasantness, and also reported their willingness to prescribe non-opioid and opioid analgesics for each patient. Practitioner sex, race, age, and duration of professional experience were included as predictors to determine their impact on pain management decisions.
RESULTS: When assessing and treating pain, practitioner sex, race, age, and duration of experience were all significantly associated with pain management decisions. Further, the role of these characteristics differed across VH patient sex, race, and age.
CONCLUSIONS: These findings suggest that pain assessment and treatment decisions may be impacted by the health care providers' demographic characteristics, effects which may contribute to pain management disparities. Future research is warranted to determine whether findings replicate in other health care disciplines and medical conditions, and identify other practitioner characteristics (e.g., culture) that may affect pain management decisions.

PMID: 25339248 [PubMed - in process]

Painful intercourse is significantly associated with evoked pain perception and cognitive aspects of pain in women with pelvic pain.

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Painful intercourse is significantly associated with evoked pain perception and cognitive aspects of pain in women with pelvic pain.

Sex Med. 2015 Mar;3(1):14-23

Authors: Alappattu MJ, George SZ, Robinson ME, Fillingim RB, Moawad N, LeBrun EW, Bishop MD

Abstract
INTRODUCTION: Evidence suggests that painful intercourse, pain-related psychosocial factors, and altered pain processing magnify the pain experience, but it is not clear how these factors are related to each other.
AIM: The aims were to (i) characterize differences between women with pelvic pain and pain-free women using a battery of pain-related psychosocial measures, clinical pain ratings, and evoked local and remote pain sensitivity; and (ii) examine the relationship between intercourse pain, clinical pain, and local and remote evoked pain sensitivity.
METHODS: Women with pelvic pain lasting at least 3 months and pain-free women completed questionnaires and underwent pain sensitivity testing. Self-report measures included clinical pain intensity, pain catastrophizing, pain-related fear, pain anxiety, depression, sexual function, and self-efficacy. Pain sensitivity measures included threshold and tolerance and temporal summation of pain. Separate analyses of variance (anova) were used to test group differences in self-report and pain sensitivity measures. Correlations were calculated among dyspareunia, psychosocial factors, and evoked pain.
MAIN OUTCOME MEASURES: Self-reported pain and pain sensitivity measures.
RESULTS: Twenty-eight pain-free women and 14 women with pelvic pain participated in this study. Women with pelvic pain reported greater pain intensity and greater psychosocial involvement compared with pain-free women. No differences existed between groups for thermal or pressure measures, but women with pelvic pain rated their pain with pain testing significantly higher than pain-free women. Intercourse pain was significantly associated with affective and sensory pain and pressure pain ratings at the puborectalis, vulvar vestibule, adductor longus tendons, and tibialis anterior muscle.
CONCLUSIONS: Differences in local pain ratings suggest that women with pelvic pain perceive stimuli in this region as more painful than pain-free women although the magnitude of stimuli does not differ. Alappattu MJ, George SZ, Robinson ME, Fillingim RB, Moawad N, LeBrun EW, and Bishop MD. Painful intercourse is significantly associated with evoked pain perception and cognitive aspects of pain in women with pelvic pain. Sex Med 2015;3:14-23.

PMID: 25844171 [PubMed]

Placebo Analgesia Enhances Descending Pain-Related Effective Connectivity: A dynamic causal modeling study of endogenous pain modulation.

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Placebo Analgesia Enhances Descending Pain-Related Effective Connectivity: A dynamic causal modeling study of endogenous pain modulation.

J Pain. 2015 May 25;

Authors: Sevel LS, Craggs JG, Price DD, Staud R, Robinson ME

Abstract
The use of placebo to reduce pain is well documented; however, knowledge of the neural mechanisms underlying placebo analgesia (PA) remains incomplete. This study used fMRI data from 30 healthy subjects, and dynamic causal modeling (DCM) to investigate changes in effective connectivity associated with the placebo analgesic response. Before scanning, subjects were conditioned to expect less thermal pain at 2-of-4 sites on their feet. VAS pain ratings revealed a significant but small difference between the baseline and placebo sites [mean difference = 6.63, t (29) = 3.91, p≤0.001, d =0.97], confirming an analgesic effect. However, no significant differences in magnitude of brain activation between conditions were observed via traditional random effects general linear modeling. DCM was then used to investigate changes in effective connectivity during PA. The results indicate that during the PA but not baseline condition, the couplings between brain regions including those involved in cognitive processes (e.g., attention, expectation, and evaluation) were significantly enhanced. Specifically, a significantly consistent decrease in the DLPFC→PAG coupling was found. These findings highlight the differences between pain processing and modulation at the network level. Moreover, our results suggest that small placebo effects may be better characterized via changes in the temporal dynamics among pain modulatory regions rather than only changes in the magnitude of BOLD activation. Further application of nuanced analytical approaches that are sensitive to temporal dynamics of pain-related processes such as DCM are necessary to better understand the neural mechanisms underlying pain processing in patient populations.
PERSPECTIVE: Changes in effective connectivity among pain-related brain regions may be more sensitive detectors of the neural representation of small placebo effects than changes in the magnitude of brain activation. Knowledge of these mechanisms highlights the importance of integrated neural networks in the understanding of pain modulation.

PMID: 26022539 [PubMed - as supplied by publisher]

Pain Sensitivity and Pain Catastrophizing are Associated with Persistent Pain and Disability after Lumbar Spine Surgery.

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Pain Sensitivity and Pain Catastrophizing are Associated with Persistent Pain and Disability after Lumbar Spine Surgery.

Arch Phys Med Rehabil. 2015 Jun 20;

Authors: Coronado RA, George SZ, Devin CJ, Wegener ST, Archer KR

Abstract
OBJECTIVE: To examine whether pain sensitivity and pain catastrophizing are associated with persistent pain and disability after lumbar spine surgery.
DESIGN: Prospective observational cohort study.
SETTING: Academic medical center.
PARTICIPANTS: Patients (N = 68, mean ± SD age = 57.9 ± 13.1 years, N female = 40) undergoing spine surgery for a degenerative condition from March 2012 to April 2013 were assessed 6 weeks, 3 months, and 6 months after surgery.
INTERVENTIONS: Not applicable.
MAIN OUTCOME MEASURE(S): The main outcome measures were persistent back pain intensity, pain interference, and disability. Patients with persistent back pain intensity, pain interference, or disability were identified as those patients reporting Brief Pain Inventory scores ≥ 4 and Oswestry Disability Index scores ≥ 21 at all postoperative time points.
RESULTS: From 6 weeks to 6 months after surgery, approximately 12.9%, 24.2%, and 46.8% of patients reported persistent back pain intensity, pain interference, or disability, respectively. Increased pain sensitivity at 6 weeks was associated with having persistent back pain intensity (OR = 2.0, 95% CI = 1.0; 4.1) after surgery. Increased pain catastrophizing at 6 weeks was associated with having persistent back pain intensity (OR = 1.1, 95% CI = 1.0; 1.2), pain interference (OR = 1.1, 95% CI = 1.0; 1.2), and disability (OR = 1.3, 95% CI = 1.1; 1.4). An interaction effect was not found between pain sensitivity and pain catastrophizing on persistent outcomes (p > 0.05).
CONCLUSION: (s): Findings suggest the importance of early postoperative screening for pain sensitivity and pain catastrophizing in order to identify patients at-risk for poor postoperative pain intensity, interference, and/or disability outcomes. Future research should consider the benefit of targeted therapeutic strategies for patients with these postoperative prognostic factors.

PMID: 26101845 [PubMed - as supplied by publisher]

Opioid therapy for chronic pain in the United States: promises and perils.

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Opioid therapy for chronic pain in the United States: promises and perils.

Pain. 2013 Dec;154 Suppl 1:S94-100

Authors: Sullivan MD, Howe CQ

Abstract
Opioid therapy offers the promise of reducing the burden of chronic pain in not just individual patients, but among the broad population of patients with chronic pain. Randomized trials have demonstrated that opioid therapy for up to 12-16weeks is superior to placebo, but have not addressed longer-term use. In the United States, opioid sales have quadrupled during 2000-2010, with parallel increases in opioid accidental overdose deaths and substance abuse admissions. Clinical use of long-term opioid therapy is characterized by a pattern of adverse selection, where high-risk patients are prescribed high-risk opioid regimens. This adverse selection may link these trends in use, abuse, and overdose. Long-term opioid therapy appears to be associated with iatrogenic harm to the patients who receive the prescriptions and to the general population. The United States has, in effect, conducted an experiment of population-wide treatment of chronic pain with long-term opioid therapy. The population-wide benefits have been hard to demonstrate, but the harms are now well demonstrated.

PMID: 24036286 [PubMed - indexed for MEDLINE]

Development of a cumulative psychosocial factor index for problematic recovery following work-related musculoskeletal injuries.

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Development of a cumulative psychosocial factor index for problematic recovery following work-related musculoskeletal injuries.

Phys Ther. 2012 Jan;92(1):58-68

Authors: Wideman TH, Sullivan MJ

Abstract
BACKGROUND: Psychosocial variables such as fear of movement, depression, and pain catastrophizing have been shown to be important prognostic factors for a wide range of pain-related outcomes. The potential for a cumulative relationship between different elevated psychosocial factors and problematic recovery following physical therapy has not been fully explored.
OBJECTIVE: The purpose of this study was to determine whether the level of risk for problematic recovery following work-related injuries is associated with the number of elevated psychosocial factors.
DESIGN: This was a prospective cohort study.
METHODS: Two hundred two individuals with subacute, work-related musculoskeletal injuries completed a 7-week physical therapy intervention and participated in testing at treatment onset and 1 year later. An index of psychosocial risk was created from measures of fear of movement, depression, and pain catastrophizing. This index was used to predict the likelihood of experiencing problematic recovery in reference to pain intensity and return-to-work status at the 1-year follow-up.
RESULTS: Logistic regression analysis revealed that the number of prognostic factors was a significant predictor of persistent pain and work disability at the 1-year follow-up. Chi-square analysis revealed that the risk for problematic recovery increased for patients with elevated levels on at least 1 psychosocial factor and was highest when patients had elevated scores on all 3 psychosocial factors.
LIMITATIONS: The physical therapy interventions used in this study were not standardized. This study did not include a specific measure for physical function.
CONCLUSIONS: The number of elevated psychosocial factors present in the subacute phase of recovery has a cumulative effect on the level of risk for problematic recovery 1 year later. This research suggests that a cumulative prognostic factor index could be used in clinical settings to improve prognostic accuracy and to facilitate clinical decision making.

PMID: 22033071 [PubMed - indexed for MEDLINE]

Patients who display protective pain behaviors are viewed as less likable, less dependable, and less likely to return to work.

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Patients who display protective pain behaviors are viewed as less likable, less dependable, and less likely to return to work.

Pain. 2012 Apr;153(4):843-9

Authors: Martel MO, Wideman TH, Sullivan MJ

Abstract
In the present study, participants (ie, observers) watched video sequences of patients with chronic back pain performing a physically demanding lifting task. Participants were asked to make judgments about patients' levels of pain and readiness to work. For each patient, observers were also asked to make judgments about personality traits relevant to work performance and employment. The primary objective of this study was to examine the differential influence of communicative and protective pain behaviors on observers' judgments about patients' pain intensity and readiness to work. Consistent with previous research, analyses indicated that patients displaying either communicative (eg, facial expressions) or protective (eg, guarding) pain behaviors were perceived as having significantly more pain than patients displaying no pain behavior. Analyses also revealed that patients displaying protective pain behaviors were perceived as being significantly less likable, less dependable, and less ready to work than patients displaying other forms of pain behavior. Discussion addresses the processes by which pain behaviors might influence observers' judgments about patients' personality traits and readiness to work. Implications of the present findings for clinical practice and the management of patients presenting with pain conditions are also discussed.

PMID: 22325743 [PubMed - indexed for MEDLINE]

Recovery from depressive symptoms over the course of physical therapy: a prospective cohort study of individuals with work-related orthopaedic injuries and symptoms of depression.

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Recovery from depressive symptoms over the course of physical therapy: a prospective cohort study of individuals with work-related orthopaedic injuries and symptoms of depression.

J Orthop Sports Phys Ther. 2012 Nov;42(11):957-67

Authors: Wideman TH, Scott W, Martel MO, Sullivan MJ

Abstract
STUDY DESIGN: Prospective cohort.
OBJECTIVES: (1) To determine the trajectory of depressive symptoms over the course of physical therapy, (2) to identify variables that best predict the resolution of depressive symptoms, and (3) to explore the relationship between recovery from depressive symptoms and long-term outcomes.
BACKGROUND: Twenty-five percent to 50% of patients referred to physical therapy for orthopaedic injuries suffer from symptoms of depression. Depressive symptoms have been identified as an influential risk factor for problematic response to physical therapy. Despite these findings, there is a dearth of research specifically exploring the trajectory and determinants of patients' depressive symptoms over the course of physical therapy, which has impeded the evidence-based management of patients with depressive symptoms.
METHODS: One hundred six patients with work-related musculoskeletal injuries and symptoms of depression received 7 weeks of physical therapy and were followed 1 year after treatment onset. Pain intensity, depressive symptoms, and other psychosocial factors were evaluated throughout treatment, and data were collected at 1-year follow-up.
RESULTS: Depressive symptoms resolved in 40% of patients, and resolution was linked to pain and disability at 1-year follow-up. Persistence of depressive symptoms at treatment completion was predicted by elevated levels of depressive symptoms and pain catastrophizing at pretreatment, and by lack of improvement in levels of depressive symptoms and pain self-efficacy at midtreatment.
CONCLUSION: For many patients, depressive symptoms resolve over the course of physical therapy, and resolution is associated with long-term improvements in pain and disability. These findings will help identify patients whose depressive symptoms are least likely to respond to physical therapy and may therefore warrant additional treatment.

PMID: 22711267 [PubMed - indexed for MEDLINE]

An experimental examination of catastrophizing-related interpretation bias for ambiguous facial expressions of pain using an incidental learning task.

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An experimental examination of catastrophizing-related interpretation bias for ambiguous facial expressions of pain using an incidental learning task.

Front Psychol. 2014;5:1002

Authors: Khatibi A, Schrooten MG, Vancleef LM, Vlaeyen JW

Abstract
Individuals with pain-related concerns are likely to interpret ambiguous pain-related information in a threatening manner. It is unknown whether this interpretation bias also occurs for ambiguous pain-related facial expressions. This study examined whether individuals who habitually attach a catastrophic meaning to pain are characterized by negative interpretation bias for ambiguous pain-related facial expressions. Sixty-four female undergraduates completed an incidental learning task during which pictures of faces were presented, each followed by a visual target at one of two locations. Participants indicated target location by pressing one of two response keys. During the learning phase, happy and painful facial expressions predicted target location. During two test phases, morphed facial expressions of pain and happiness were added, equally often followed by a target at either location. Faster responses following morphs to targets at the location predicted by painful expressions compared to targets at the location predicted by happy expressions were taken to reflect pain-related interpretation bias. During one test phase, faces were preceded by either a safe or threatening context cue. High, but not low, pain-catastrophizers responded faster following morphs to targets at the location predicted by painful expressions than to targets at the other location (when participants were aware of the contingency between expression type and target location). When context cues were presented, there was no indication of interpretation bias. Participants were also asked to directly classify the facial expressions that were presented during the incidental learning task. Participants classified morphs more often as happy than as painful, independent of their level of pain catastrophizing. This observation is discussed in terms of differences between indirect and direct measures of interpretation bias.

PMID: 25278913 [PubMed]

Attention allocation to ambiguous health/somatic threat cues.

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Attention allocation to ambiguous health/somatic threat cues.

Eur J Pain. 2014 Nov 25;

Authors: Schrooten MG, Vancleef L, Vlaeyen JW

Abstract
BACKGROUND: An influential idea is that attentional bias to information related to pain or pain-related negative affect underlies persistent pain problems. Such information is however often ambiguous. If ambiguous input is perceived as pain or threat related, attention to this stimulus would be enhanced compared with stimuli with no (dominant) pain-/threat-related meaning. Attentional bias to ambiguous stimuli related to somatic/health threat was expected to be more pronounced with higher levels of pain catastrophizing.
METHODS: University students performed a spatial cueing task including four types of word cues that were combinations of word content (somatic/health threat vs. non-threat), and word ambiguity (unambiguous vs. ambiguous), each presented for 500 or 750 ms. Attentional bias to somatic/health threat is reflected in larger cue validity effects for somatic/heath threat words than for non-threat words.
RESULTS: In the 500-ms condition, cue validity effects were larger for threat than for non-threat words in participants reporting low catastrophizing, but did not depend on word content in participants reporting higher catastrophizing. In the 750-ms condition, cue validity effects did not depend on pain catastrophizing or word content. Cue validity effects did not significantly differ between unambiguous words and ambiguous homographs.
CONCLUSIONS: Low catastrophizers demonstrated attentional bias to threat content. Participants reporting higher catastrophizing showed overall enhanced attentional orienting. There was no evidence for differences in (biased) attention to unambiguous and ambiguous words. Further research is needed to determine attentional bias for ambiguous pain-/threat-related stimuli in the context of consistent attentional bias for unambiguous pain-/threat-related stimuli.

PMID: 25421151 [PubMed - as supplied by publisher]

The Reduction of Fear of Movement-related Pain: Does Motivational Context Matter?

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The Reduction of Fear of Movement-related Pain: Does Motivational Context Matter?

Clin J Pain. 2014 Dec 11;

Authors: Volders S, Meulders A, De Peuter S, Vlaeyen JW

Abstract
OBJECTIVES:: Previous research indicates that reducing fear of movement-related pain is hampered by engaging in safety-seeking behavior. We tested the hypothesis that fear reduction is only disrupted by behavior that serves a pain avoidance goal (safety-seeking), but not when it is serving an achievement goal.
METHODS:: Using the voluntary joystick movement paradigm, fear of a painful joystick arm movement was successfully acquired by repeatedly pairing this joystick movement with a painful electrocutaneous stimulus (unconditioned stimulus; pain-US) and this fear was subsequently extinguished using a Pavlovian extinction procedure. During extinction, a Safety Group and Reward Group both pressed a safety button, while a third Control group did not.
RESULTS:: Pain-US expectancy and fear of movement-related pain ratings show a gradual fear reduction in the Control Group, but a return of fear when the button is pressed to avoid the pain-US (Safety Group). When the same button is used to attain a reward (Reward Group), subsequent return of fear is attenuated. Additionally, we investigated the reliability of the return of fear in the Safety Group and Reward Group, using a customized Reliable Change Index. This index confirms that the return of fear was only reliable in the Safety Group, and that this return of fear is associated with more perceived control over the nonoccurrence of the pain-US when pressing the button.
DISCUSSION:: These results highlight the importance of motivational context in understanding the role of safety-seeking behavior in exposure-based therapies.

PMID: 25503594 [PubMed - as supplied by publisher]

Avoidance behavior in chronic pain research: a cold case revisited.

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Avoidance behavior in chronic pain research: a cold case revisited.

Behav Res Ther. 2015 Jan;64:31-7

Authors: Volders S, Boddez Y, De Peuter S, Meulders A, Vlaeyen JW

Abstract
In chronic musculoskeletal pain, avoidance behavior is a prominent behavioral characteristic that can manifest itself in various ways. It is also considered a crucial component in the development and maintenance of chronic pain-related disability, supposedly fueled by pain-related fear and catastrophic beliefs. Despite the frequent occurrence of avoidance behavior and its potential impact on quality of life, relatively little research has been dedicated to the nature of avoidance in chronic pain and its assessment, leaving its underlying mechanisms poorly understood. In the current paper, we stipulate some of the existing parallels between chronic pain research and more basic fear and anxiety research inspired by modern learning theories. After a brief introduction, we discuss avoidance theories that are likely apt to be applied to chronic pain, including avoidance as a response that can affect fear responding, and the role of avoidant decision making and motivational context. Finally, we will outline how these theories may impact clinical treatment.

PMID: 25506905 [PubMed - in process]

Threatening social context facilitates pain-related fear learning.

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Threatening social context facilitates pain-related fear learning.

J Pain. 2015 Mar;16(3):214-25

Authors: Karos K, Meulders A, Vlaeyen JW

Abstract
UNLABELLED: This study investigated the effects of a threatening and a safe social context on learning pain-related fear, a key factor in the development and maintenance of chronic pain. We measured self-reported pain intensity, pain expectancy, pain-related fear (verbal ratings and eyeblink startle responses), and behavioral measures of avoidance (movement-onset latency and duration) using an established differential voluntary movement fear conditioning paradigm. Participants (N = 42) performed different movements with a joystick: during fear acquisition, movement in one direction (CS+) was followed by a painful stimulus (pain-US) whereas movement in another direction (CS-) was not. For participants in the threat group, an angry face was continuously presented in the background during the task, whereas in the safe group, a happy face was presented. During the extinction phase the pain-US was omitted. As compared to the safe social context, a threatening social context led to increased contextual fear and facilitated differentiation between CS+ and CS- movements regarding self-reported pain expectancy, fear of pain, eyeblink startle responses, and movement-onset latency. In contrast, self-reported pain intensity was not affected by social context. These data support the modulation of pain-related fear by social context.
PERSPECTIVE: A threatening social context leads to stronger acquisition of (pain-related) fear and simultaneous contextual fear but does not affect pain intensity ratings. This knowledge may aid in the prevention of chronic pain and anxiety disorders and shows that social context might modulate pain-related fear without immediately affecting pain intensity itself.

PMID: 25510542 [PubMed - in process]

Can experimentally induced positive affect attenuate generalization of fear of movement-related pain?

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Can experimentally induced positive affect attenuate generalization of fear of movement-related pain?

J Pain. 2015 Mar;16(3):258-69

Authors: Geschwind N, Meulders M, Peters ML, Vlaeyen JW, Meulders A

Abstract
UNLABELLED: Recent experimental data show that associative learning processes are involved not only in the acquisition but also in the spreading of pain-related fear. Clinical studies suggest involvement of positive affect in resilience against chronic pain. Surprisingly, the role of positive affect in associative learning in general, and in fear generalization in particular, has received scant attention. In a voluntary movement paradigm, in which one arm movement (reinforced conditioned stimulus [CS+]) was followed by a painful stimulus and another was not (unreinforced conditioned stimulus [CS-]), we tested generalization of fear inhibition in response to 5 novel but related generalization movements (GSs; within-subjects) after either a positive affect induction or a control exercise (Group = between-subjects) in healthy participants (N = 50). The GSs' similarity with the original CS+ movement and CS- movement varied. Fear learning was assessed via verbal ratings. Results indicated that there was an interaction between the increase in positive affect and the linear generalization gradient. Stronger increases in positive affect were associated with steeper generalization curves because of relatively lower pain-unconditioned stimulus expectancy and less fear of stimuli more similar to the CS-. There was no Group by Stimulus interaction. Results thus suggest that positive affect may enhance safety learning through promoting generalization from known safe movements to novel yet related movements. Improved safety learning may be a central mechanism underlying the association between positive affect and increased resilience against chronic pain.
PERSPECTIVE: We investigated the extent to which positive affect influences the generalization (ie, spreading) of pain-related fear inhibition in response to situations similar to the original, pain-eliciting situation. Results suggest that increasing positive affect in the acute pain stage may limit the spreading of pain-related fear, thereby potentially inhibiting transition to chronic pain conditions.

PMID: 25536535 [PubMed - in process]

Associative fear learning and perceptual discrimination: a perceptual pathway in the development of chronic pain.

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Associative fear learning and perceptual discrimination: a perceptual pathway in the development of chronic pain.

Neurosci Biobehav Rev. 2015 Apr;51:118-25

Authors: Zaman J, Vlaeyen JW, Van Oudenhove L, Wiech K, Van Diest I

Abstract
Recent neuropsychological theories emphasize the influence of maladaptive learning and memory processes on pain perception. However, the precise relationship between these processes as well as the underlying mechanisms remain poorly understood; especially the role of perceptual discrimination and its modulation by associative fear learning has received little attention so far. Experimental work with exteroceptive stimuli consistently points to effects of fear learning on perceptual discrimination acuity. In addition, clinical observations have revealed that in individuals with chronic pain perceptual discrimination is impaired, and that tactile discrimination training reduces pain. Based on these findings, we present a theoretical model of which the central tenet is that associative fear learning contributes to the development of chronic pain through impaired interoceptive and proprioceptive discrimination acuity.

PMID: 25603316 [PubMed - in process]

PAIN-AVOIDANCE VERSUS REWARD-SEEKING: AN EXPERIMENTAL INVESTIGATION.

PAIN-AVOIDANCE VERSUS REWARD-SEEKING: AN EXPERIMENTAL INVESTIGATION.

Pain. 2015 Mar 13;

Authors: Claes N, Crombez G, Vlaeyen JW

Abstract
According to fear-avoidance models, a catastrophic interpretation of a painful experience may give rise to pain-related fear and avoidance, leading to the development and maintenance of chronic pain problems in the long term. However, little is known about how exactly motivation and goal prioritization play a role in the development of pain-related fear. The present study investigates these processes in healthy volunteers using an experimental context with multiple, competing goals. In a differential human fear conditioning paradigm, 57 participants performed joystick movements. In the control condition, one movement (conditioned stimulus; CS+) was followed by a painful electrocutaneous unconditioned stimulus (pain-US) in 50% of the trials, whereas another movement (non-reinforced conditioned stimulus; CS-) was not. In the experimental condition, a reward in the form of lottery tickets (reward-US) accompanied the presentation of the pain-US. Participants were classified in three groups, as a function of the goal they reported to be the most important: (1) pain-avoidance, (2) reward-seeking, and (3) both goals being equally important. Results indicated that neither the reward co-occurring with pain, nor the prioritized goal modulated pain-related fear. However, during subsequent choice trials, participants selected the painful movement more often when the reward was presented compared to the context in which the reward was absent. The latter effect was dependent on goal prioritization, with more frequent selections in the reward-seeking group, and the least selections in the pain-avoidance group. Taken together, these results underscore the importance of competing goals and goal prioritization in the attenuation of avoidance behavior.

PMID: 25775360 [PubMed - as supplied by publisher]

Learning to predict and control harmful events: chronic pain and conditioning.

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Learning to predict and control harmful events: chronic pain and conditioning.

Pain. 2015 Apr;156 Suppl 1:S86-93

Authors: Vlaeyen JW

Abstract
Pain is a biologically relevant signal and response to bodily threat, associated with the urge to restore the integrity of the body. Immediate protective responses include increased arousal, selective attention, escape, and facial expressions, followed by recuperative avoidance and safety-seeking behaviors. To facilitate early and effective protection against future bodily threat or injury, learning takes place rapidly. Learning is the observable change in behavior due to events in the internal and external environmental and includes nonassociative (habituation and sensitization) and associative learning (Pavlovian and operant conditioning). Once acquired, these knowledge representations remain stored in memory and may generalize to perceptually or functionally similar events. Moreover, these processes are not just a consequence of pain; they may directly influence pain perception. In contrast to the rapid acquisition of learned responses, their extinction is slow, fragile, context dependent and only occurs through inhibitory processes. Here, we review features of associative forms of learning in humans that contribute to pain, pain-related distress, and disability and discuss promising future directions. Although conditioning has a long and honorable history, a conditioning perspective still might open new windows on novel treatment modalities that facilitate the well-being of individuals with chronic pain.

PMID: 25789440 [PubMed - in process]

Indirect acquisition of pain-related fear: an experimental study of observational learning using coloured cold metal bars.

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Indirect acquisition of pain-related fear: an experimental study of observational learning using coloured cold metal bars.

PLoS One. 2015;10(3):e0117236

Authors: Helsen K, Vlaeyen JW, Goubert L

Abstract
BACKGROUND: Previous research has demonstrated that pain-related fear can be acquired through observation of another's pain behaviour during an encounter with a painful stimulus. The results of two experimental studies were presented, each with a different pain stimulus, of which the aim was to investigate the effect of observational learning on pain expectancies, avoidance behaviour, and physiological responding. Additionally, the study investigated whether certain individuals are at heightened risk to develop pain-related fear through observation. Finally, changes in pain-related fear and pain intensity after exposure to the feared stimulus were examined.
METHODS: During observational acquisition, healthy female participants watched a video showing coloured cold metal bars being placed against the neck of several models. In a differential fear conditioning paradigm, one colour was paired with painful facial expressions, and another colour was paired with neutral facial expressions of the video models. During exposure, both metal bars with equal temperatures (-25° or +8° Celsius) were placed repeatedly against participants' own neck.
RESULTS: Results showed that pain-related beliefs can be acquired by observing pain in others, but do not necessarily cause behavioural changes. Additionally, dispositional empathy might play a role in the acquisition of these beliefs. Furthermore, skin conductance responses were higher when exposed to the pain-associated bar, but only in one of two experiments. Differential pain-related beliefs rapidly disappeared after first-hand exposure to the stimuli.
CONCLUSIONS: This study enhances our understanding of pain-related fear acquisition and subsequent exposure to the feared stimulus, providing leads for pain prevention and management strategies.

PMID: 25806969 [PubMed - in process]