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When pain gets stuck: the evolution of pain chronification and treatment resistance.

ABSTRACT: It is well-recognized that, despite similar pain characteristics, some people with chronic pain recover, whereas others do not. In this review, we discuss possible contributions and interactions of biological, social, and psychological perturbations that underlie the evolution of treatment-resistant chronic pain. Behavior and brain are intimately implicated in the production and maintenance of perception. Our understandings of potential mechanisms that produce or exacerbate persistent pain remain relatively unclear. We provide an overview of these interactions and how differences in relative contribution of dimensions such as stress, age, genetics, environment, and immune responsivity may produce different risk profiles for disease development, pain severity, and chronicity. We propose the concept of "stickiness" as a soubriquet for capturing the multiple influences on the persistence of pain and pain behavior, and their stubborn resistance to therapeutic intervention. We then focus on the neurobiology of reward and aversion to address how alterations in synaptic complexity, neural networks, and systems (eg, opioidergic and dopaminergic) may contribute to pain stickiness. Finally, we propose an integration of the neurobiological with what is known about environmental and social demands on pain behavior and explore treatment approaches based on the nature of the individual's vulnerability to or protection from allostatic load.

SUBMITTER: Borsook D

PROVIDER: S-EPMC6240430 | biostudies-literature | 2018 Dec

REPOSITORIES: biostudies-literature

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When pain gets stuck: the evolution of pain chronification and treatment resistance.

Borsook David D Youssef Andrew M AM Simons Laura L Elman Igor I Eccleston Christopher C

Pain 20181201 12

It is well-recognized that, despite similar pain characteristics, some people with chronic pain recover, whereas others do not. In this review, we discuss possible contributions and interactions of biological, social, and psychological perturbations that underlie the evolution of treatment-resistant chronic pain. Behavior and brain are intimately implicated in the production and maintenance of perception. Our understandings of potential mechanisms that produce or exacerbate persistent pain remai ...[more]

PMID: 30234696

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Project description:BackgroundAttending towards pain is proposed as a key mechanism influencing the experience and chronification of pain. Persistent attention towards pain is proposed to drive poor outcomes in both adults and children with chronic pain. However, there are no validated self-report measures of pain-related attention for children.MethodsThe goals of this study were to adapt the Pain Vigilance and Awareness Questionnaire (PVAQ) for use in a child sample, to preliminary examine its psychometric properties, and to assess its utility over and above a measure of general attentional capacities. We adapted the language of the PVAQ to be more easily understood by children as young as 8 years. In a sample of 160 children (8-18 years) with chronic pain, we examined the factor structure, internal consistency and criterion validity of the PVAQ-C.ResultsThe PVAQ-C demonstrated excellent internal consistency (α = 0.92) and moderate-to-strong criterion validity. A one-factor structure best fit the data. Children who reported greater attention to pain also reported greater pain catastrophizing, fear of pain, avoidance of activities and poorer physical functioning. Pain-related attention remained a significant predictor of functioning while controlling for demographics, catastrophizing and fear-avoidance. Pain-related attention also significantly predicted child outcomes independent of the child's general attention control capacities, indicating added value of a pain-specific measure of attention.ConclusionsThe PVAQ-C shows strong indices of internal reliability and criterion validity, and indicates unique predictive utility. It will be important to study the role of pain-related attention in youth within developmental and functional-motivational frameworks.SignificancePain-related attention is proposed as a key factor influencing fear-avoidance outcomes in both adults and youth with chronic pain, yet no self-report measures of pain-related attention have been validated for children. This paper presents a child version of the Pain Vigilance and Awareness Questionnaire (PVAQ-C), which indicates strong internal consistency, criterion validity and unique predictive validity, and provides evidence to support the Fear-Avoidance Model in youth with chronic pain.

Project description:Chronic pain conditions are associated with abnormalities in brain structure and function. Moreover, some studies indicate that brain activity related to the subjective perception of chronic pain may be distinct from activity for acute pain. However, the latter are based on observations from cross-sectional studies. How brain activity reorganizes with transition from acute to chronic pain has remained unexplored. Here we study this transition by examining brain activity for rating fluctuations of back pain magnitude. First we compared back pain-related brain activity between subjects who have had the condition for ?2 months with no prior history of back pain for 1 year (early, acute/subacute back pain group, n = 94), to subjects who have lived with back pain for >10 years (chronic back pain group, n = 59). In a subset of subacute back pain patients, we followed brain activity for back pain longitudinally over a 1-year period, and compared brain activity between those who recover (recovered acute/sub-acute back pain group, n = 19) and those in which the back pain persists (persistent acute/sub-acute back pain group, n = 20; based on a 20% decrease in intensity of back pain in 1 year). We report results in relation to meta-analytic probabilistic maps related to the terms pain, emotion, and reward (each map is based on >200 brain imaging studies, derived from neurosynth.org). We observed that brain activity for back pain in the early, acute/subacute back pain group is limited to regions involved in acute pain, whereas in the chronic back pain group, activity is confined to emotion-related circuitry. Reward circuitry was equally represented in both groups. In the recovered acute/subacute back pain group, brain activity diminished in time, whereas in the persistent acute/subacute back pain group, activity diminished in acute pain regions, increased in emotion-related circuitry, and remained unchanged in reward circuitry. The results demonstrate that brain representation for a constant percept, back pain, can undergo large-scale shifts in brain activity with the transition to chronic pain. These observations challenge long-standing theoretical concepts regarding brain and mind relationships, as well as provide important novel insights regarding definitions and mechanisms of chronic pain.

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When pain gets stuck: the evolution of pain chronification and treatment resistance.

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When pain gets stuck: the evolution of pain chronification and treatment resistance.

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