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How does distraction work in the management of pain?
Abstract
Engaging in thoughts or activities that distract attention from pain is one of the most commonly used and highly endorsed strategies for controlling pain. The process of distraction appears to involve competition for attention between a highly salient sensation (pain) and consciously directed focus on some other information processing activity. In this article, the evidence for distraction from pain is examined and the qualities of pain, the distractor, and some individual difference variables that have been shown influence the effectiveness of distraction are described. There has been little examination of the use of distraction in chronic pain, but some ancillary evidence suggests that it should be used with caution.
... By diverting the patient's attention, afferent pain signals in the spinal cord are often inhibited, preventing many of these signals from reaching pain-processing areas in the brain, such as the primary sensory cortex, which remains less active under distraction. 15,33,43 The underlying mechanism of VR in reducing pain, rather than just anxiety, is based on the limited attentional capacity of humans. Pain demands attention, and if part of that attention is redirected, the patient's response to pain signals can be delayed. ...
... Pain demands attention, and if part of that attention is redirected, the patient's response to pain signals can be delayed. However, VR does not block pain signals directly; instead, it influences pain perception and signaling both directly and indirectly by engaging attention, emotion, concentration, memory, and other sensory modalities 15,16,43 . In this context, VR should be tailored to the individual, allowing patients to select topics or applications that align with their personal interests and hobbies. ...
... For instance, asking someone who experiences pain and has a history of struggling with mathematics to do mental arithmetic as a distraction is unlikely to work, unlike someone who enjoys solving math puzzles in their free time. 43 The use of VR is particularly effective in pediatric patients, as children exhibit a higher level of imagination and engage in "magical thinking," which results in both greater anticipatory anxiety and distress, as well as more profound immersion in the virtual environment. 15,33,43 Consequently, VR tends to be more effective in younger patients, as evidenced by several studies. ...
Virtual reality (VR) represents an innovative and effective tool for reducing pain and anxiety in children undergoing painful procedures in pediatric emergency departments and burn units. VR has the ability to modulate both the sensory and emotional components of pain by immersing children in a virtual world, effectively diverting their attention from the painful experience. Specifically, VR distraction competes for the patient’s attentional resources, reducing their focus on the painful stimulus and, consequently, diminishing the perception of pain. The primary objective of this review was to assess and summarize the current knowledge regarding the use of VR for painful procedures in pediatric emergency and burn units by comparing and analyzing the existing literature. Of the 340 articles reviewed, 25 met the selection criteria and were included in the analysis. These studies examined the use of VR in venous procedures (such as venipuncture, cannulation, and blood sampling) as well as other procedures, including laceration repair and burn wound care. The findings indicated that 20 studies reported a reduction in pain scores, while 9 studies noted a reduction in anxiety scores. Additionally, three studies demonstrated a reduction in procedural time. Overall, the studies supported the efficacy, safety, and feasibility of VR in managing procedural pain and anxiety in pediatric settings. Furthermore, VR use contributed to a reduction in parental and medical stress levels, as well as a decrease in the time spent in the pediatric emergency room. Studies involving larger sample sizes may provide further evidence of VR’s effectiveness across different procedures and age groups.
... 18,19 Some types of distractions that are effective in reducing pain include auditory distraction, visual distraction, and cognitive distraction. 18,20 Distraction can suppress pain-related nervous system activity; activity in neurons in the cornu dorsal medulla that respond to pain will be reduced. Distraction provides analgesic stimulation through the release of endogenous opioids at opioid receptor sites. ...
... Brain regions involved in pain modulation during distraction. 19,20 Previous studies mention that Audiovisual is used as one of the distraction techniques in overcoming pain in children. 21 Children also favor 17 Audiovisual because of its attractive appearance. ...
... Internal distraction directs attention towards the psychological, ie through deliberate activation of the mind, whereas external distraction directs attention towards environmental stimuli. 20 Distraction-based techniques offer a variety of options for children undergoing painful medical procedures, providing a comprehensive approach to reduce the experience of pain in children. 19,20 These techniques, including auditory, visual, and cognitive distraction, offer a range of options. ...
Background
Invasive procedures in children can lead to painful and uncooperative procedures. It is essential to determine the appropriate method to create a comfortable environment for children during invasive procedures. However, audiovisuals are one of the distraction techniques used in pain management.
Purpose
This study aims to identify and categorize related audiovisual distraction techniques in reducing pain due to invasive procedures among children.
Methods
This study uses a systematic scoping review. A literature review was conducted using PubMed, EBSCO, Science Direct, Scopus and grey literature through Google Scholar. The study was eligible for inclusion if it included articles published from 2012 to 2022, full-text and open accessed articles, and in Indonesian and English language. Studies were excluded if they were review studies and the adult population. The keywords in English were ”Children” OR ‘Child’ OR ”Kids” OR ‘Youth’ OR ‘Adolescents’ OR ‘Teenager’ OR ‘Teens’ OR ‘Young People’ OR ‘Pediatric’ OR ‘Paediatric’ OR ‘Childhood’ AND ”Audiovisual” OR ‘Movie’ OR ‘Video’ OR ‘Animation’ AND ”Pain” AND ”Invasive procedures” and keyword in Indonesia were ”Anak” OR ‘Remaja’ OR ‘Bayi’ OR ‘Balita’ AND ”Audiovisual” OR ‘Film’ OR ”Video” OR ‘Animasi’ OR “Nyeri” AND ‘Prosedur invasif’.
Results
We found 15 articles showing audiovisual distraction techniques in managing pain among children undergoing invasive procedures. Three types of audiovisual interventions were used, including virtual reality (VR), video music, and animated cartoons. In addition, types of invasive procedures that benefited from the analyzed interventions were infusion, surgery, injection, blood draw, dressing change, circumcision, endoscopy, and phlebotomy.
Conclusion
Our findings highlight that virtual reality, video music, and animated cartoons have clinical implications in helping to distract from pain in children undergoing invasive procedures. Our study indicates that the potential of audiovisual intervention can be used as an intervention strategy in the pediatric nursing area.
... 172 An alternative approach to understanding the effect of emotion induction on the pain experience comes from the literature on the role of cognitive processing for pain. 12,75,102,161 Founded in research on cognitive processing, the distraction hypothesis is that distraction (ie, directing attention away from pain) may attenuate pain by enhancing processing of nonpainful sensory input and suppressing processing of painful sensations. 75,95 According to this hypothesis, any distraction that diverts attention away from pain may attenuate pain. ...
... 12,75,102,161 Founded in research on cognitive processing, the distraction hypothesis is that distraction (ie, directing attention away from pain) may attenuate pain by enhancing processing of nonpainful sensory input and suppressing processing of painful sensations. 75,95 According to this hypothesis, any distraction that diverts attention away from pain may attenuate pain. It follows that emotion induction methods, such as film clips, may attenuate pain by diverting attention away from the painful sensory input. ...
... According to the distraction hypothesis, distractors may attenuate pain by directing attention and processing resources toward nonpainful information and away from painful sensations. 75,95 However, in the context of emotional distractors, this pain-attenuating effect may vary according to the valence of the distractor. Consistent with the MPT framework, 19,87 emotion induction may activate the defensive or appetitive motivational system, thereby inducing emotion-congruent attentional biases that may moderate the distraction effect. ...
The idea that emotions can influence pain is generally recognized. However, a synthesis of the numerous individual experimental studies on this subject is lacking. The aim of the present systematic review and meta-analysis was to synthesize the existing evidence on the effect of experimental emotion induction on experimental pain in nonclinical adults. PsycInfo and PubMed were searched up until April 10, 2023, for studies assessing differences in self-reported pain between emotion induction groups and/or control groups or between conditions within group. Risk of bias was assessed for the individual studies. The literature search yielded 78 relevant records of 71 independent studies. When compared with control conditions, the pooled results revealed a statistically significant pain-attenuating effect of positive emotion induction (between-group: Hedges g = −0.48, 95% CI: −0.72; −0.25, K = 9; within-group: g = −0.24, 95% CI: −0.32; −0.15, K = 40), and a statistically significant pain-exacerbating effect of negative emotion induction in within-group analyses but not between-group analyses (between-group: g = −0.29, 95% CI: −0.66; 0.07, K = 10; within-group: g = 0.14, 95% CI: 0.06; 0.23, K = 39). Bayesian meta-analysis provided strong support for an effect of positive emotion induction but weak support for an effect of negative emotion induction. Taken together, the findings indicate a pain-attenuating effect of positive emotion induction, while the findings for negative emotion induction are less clear. The findings are discussed with reference to theoretical work emphasizing the role of motivational systems and distraction for pain. Limitations include considerable heterogeneity across studies limiting the generalizability of the findings.
... Distraction methods work by decreasing patient perception of pain [34]. By diverting the patient's attention, afferent pain signals in the spinal cord are often inhibited, and less signals reach the brain. ...
... By diverting the patient's attention, afferent pain signals in the spinal cord are often inhibited, and less signals reach the brain. Moreover, certain pain-sensing areas in the brain, such as the primary sensory cortex, are reported to be less active when under distraction [34]. To be an effective analgesic tool, a good distractor must effectively alter the mood, anxiety, and attention of the targeted patient [34]. ...
... Moreover, certain pain-sensing areas in the brain, such as the primary sensory cortex, are reported to be less active when under distraction [34]. To be an effective analgesic tool, a good distractor must effectively alter the mood, anxiety, and attention of the targeted patient [34]. On this basis, many distraction methods have been tested, such as music, kaleidoscopes, and cartoons. ...
Context: Virtual Reality immersion is a more recent form of distraction that may have been used in the pediatric setting for reducing pain and fear in children undergoing needle-based intravenous procedures. A systematic review and meta-analysis was conducted to determine the efficacy of Virtual Reality compared to non-pharmacological standard care in reducing periprocedural pain and anxiety. Methods: PubMed, Cochrane Central Register of Controlled Trials, and Google Scholar were searched from inception till March 5, 2023. Data was extracted by two reviewers and independently verified. The primary outcomes were patient-reported pain and fear using numerically graded scales. Results: A total of 11 randomized controlled trials comparing the effect of VR with any form of non-pharmacological methods of pain and anxiety relief in children ≤ 12 years old were included. While the risk of bias across the studies was moderate, there was a high risk of bias regarding blinding of personnel and outcome assessment. A few studies also showed moderate attrition bias and the same in allocation concealment. VR reduced patient-reported pain (SMD = -1.55, 95% CI = -2.11 to -0.98, P<0.00001, I2 = 95%) and fear (SMD = -1.19, 95% CI = -1.64 to -0.74, P < 0.00001, I2 = 90%). This was consistent in our analysis of sub-groups, such as phlebotomy-associated pain (SMD = -1.84, 95% CI = -2.52 to -1.16, P<0.00001) and fear (SMD = -1.42, 95% CI = -1.86 to -0.97, P < 0.00001, I2 = 85%). Conclusions: Evidence suggests VR may be more effective than traditional non-pharmacological pain and fear relief. This result seems to be consistent through different procedures. More rigorous studies are required under standardized conditions to truly gauge the effect of VR.
... The concept of pain distraction therapy has proven interest in VR pain applications, particularly for acute pain. Distraction therapy involves interventions that shift a person's attention away from the pain they are experiencing, to experiences that require greater information processing [28,29]. This can be a powerful moderator of the pain experience, and active distractions, such as playing a game or solving a puzzle, or passive distractions such as listening to music appear effective [29,30]. ...
... Distraction therapy involves interventions that shift a person's attention away from the pain they are experiencing, to experiences that require greater information processing [28,29]. This can be a powerful moderator of the pain experience, and active distractions, such as playing a game or solving a puzzle, or passive distractions such as listening to music appear effective [29,30]. The more engaging the activity, the more likely it will distract attention from the pain experience, relegating pain to a less salient "background" of attention [31,32]. ...
Background
The growing popularity and affordability of immersive virtual reality (VR), as adjunctive non-pharmacological interventions (NPIs) for chronic pain, has resulted in increasing research, with mixed results of its effectiveness reported. This randomized controlled superiority trial explored the effects of a home-based adjunctive 3D VR NPI for chronic pain in cancer patients, compared to the same NPI experienced through a two-dimensional (2D) medium.
Methods
The NPI used four different applications experienced for 30 min for six days a week at home for four weeks using established cognitive distraction and mindfulness meditation techniques. Participants were randomly assigned ( N = 110) into two arms: a VR group ( n = 57) where the NPI was delivered through a VR system, and a control group ( n = 53) which used a computer screen for delivery. Participants were blinded to which arm of the study they were in, and sequence of the NPI applications experienced was randomized. Primary outcomes of daily pre/post/during exposure, and weekly average pain scores were assessed via the Visual Analog Scale (VAS) and the Short Form McGill Pain Questionnaire (SF-MPQ), and secondary outcomes of weekly Quality of Life (SF-12), and sleep quality (Pittsburgh Sleep Quality Index) were measured.
Results
Findings indicate VR applications were not significantly superior to the 2D group, but both VR and control NPIs provided clinically important pain reduction for participants when experiencing significant daily pain of a VAS ≥ 4. No significant adverse effects were encountered, although many of the participants in the VR group reported some cybersickness in certain applications (VR group n = 46 vs 2D group n = 28).
Conclusions
Overall, VR did not provide superiority as an NPI for pain relief compared to 2D computer-based applications. For those experiencing significant pain, cognitive distractive applications appeared superior for VR-based pain reduction during exposure, whilst meditative applications supplied better pain relief post-exposure. Findings from this trial support some clinical efficacy of home-based VR immersive experiences as NPIs for chronic cancer-related pain but in this context the 2D computer-based applications demonstrated similar value.
Trial registration
Clinicaltrials.gov, identifier NCT02995434, registered 2017–07-31.
... Distraction is a common noninvasive strategy for coping with pain used in various ways. The aim is to divert attention away from noxious stimuli (7)(8)(9)(10). In this process, pain signals still exist, but the individual's attention is on a more demanding task. ...
... Many studies have investigated the effects of distraction on pain perception, focusing on different aspects, such as experimental pain induction, age, patients with chronic pain, and healthy subjects (6,7,18). In two separate studies, Van Ryckeghem et al. showed that distraction was effective for healthy adults during electrically induced pain using auditory and somatosensory distraction. ...
Introduction
Distraction is commonly used to reduce pain, but the effectiveness of distractions remains inconclusive. Studies have shown that pain catastrophizing could modulate the effectiveness of distraction strategies. The present study aimed to compare various distraction tasks, then control for pain catastrophizing, and examine how this relationship varies with pain intensity and unpleasantness across different distraction tasks.
Methods
Forty-one pain-free participants (aged 27.00 ± 5.41) were recruited for a cross-sectional study. Four types of distraction (cognitive, sensory, emotional, and social) were presented, while moderate pain intensity was induced by electrical stimulation. Before starting the experiment, moderate pain intensity was individually calibrated as six on the Numerical Pain Rating Scale (NRS) to control individual differences in pain sensitivity. Each participant performed all four distraction tasks in a random order. NRS measured pain assessment. Pain catastrophizing was measured by the Pain Catastrophizing Scale (PCS). A repeated measure ANCOVA was conducted to examine the effects of pain dimensions during distraction tasks as a within-subject and pain catastrophizing as a covariate factor.
Results
A significant difference was observed in the pain intensity and unpleasantness during cognitive distraction. After controlling for PCS, there were diverse associations between PCS and pain intensity across distinct distraction tasks: social vs. sensory, and cognitive vs. sensory distraction. A consistent pattern in pain unpleasantness emerged with minor variations. This interaction underscored notable distinctions between social vs. sensory and emotional distractions, as well as between cognitive vs. sensory and emotional distractions. However, only the correlation in social distraction remained significant in both pain dimensions.
Discussion
Our findings reveal that the link between PCS and pain dimensions varies across different distraction tasks, suggesting diverse interactions. Particularly, social distraction, characterized by both emotional and cognitive states, proves beneficial with lower PCS scores; however, this advantage diminishes as PCS scores increase.
... In research studying the use of distraction for pain management, distractions are often referred to as processes that involve competition for attention between salient sensations (pain) and consciously directed attention on some other activity that requires some information processing [42]. The limited capacity theory of human cognition explains that a limited pool of information processing resources exist and that using capacity for one task limits the availability for another [43]. ...
... 2) Distractor Choices and Their Implications: Clinical research has found several types of distractors to be effective in pain reduction. Pleasant imaginings, rhythmic cognitive activities, the external focus of attention, neutral imaginings, etc., have found success on this front [42]. In general, cognitive activities have proven to be successful in the majority of efforts investigating the use of distractions for pain relief [25]. ...
Cybersickness (CS) is one of the challenges that has hindered the widespread adoption of Virtual Reality (VR). Consequently, researchers continue to explore novel means to mitigate the undesirable effects associated with this affliction, one that may require a combination of remedies as opposed to a solitary stratagem. Inspired by research probing into the use of distractions as a means to control pain, we investigated the efficacy of this countermeasure against CS, studying how the introduction of temporally time-gated distractions affects this malady during a virtual experience featuring active exploration. Downstream of this, we studied how other aspects of the VR experience are affected by this intervention. We discuss the results of a between-subjects study manipulating the presence, sensory modality, and nature of periodic and short-lived (5–12 seconds) distractor stimuli across four experimental conditions: 1) no-distractors (ND); 2) auditory distractors (AD); 3) visual distractors (VD); 4) cognitive distractors (CD). Two of these conditions (VD and AD) formed a yoked control design wherein every matched pair of ‘seers’ and ‘hearers’ was periodically exposed to distractors that were identical in terms of content, temporality, duration, and sequence. In the CD condition, each participant had to periodically perform a 2-back working memory task, the duration and temporality of which was matched to distractors presented in each matched pair of the yoked conditions. These three conditions were compared to a baseline control group featuring no distractions. Results indicated that the reported sickness levels were lower in all three distraction groups in comparison to the control group. The intervention also increased the amount of time users were able to endure the VR simulation and avoided causing detriments to spatial memory and virtual travel efficiency. Overall, it appears that it may be possible to make users less consciously aware and bothered by the symptoms of CS, thereby reducing its perceived severity.
... This indicates that 'bottom-up' attention to pain can be modulated through 'top-down' mechanisms. In pain management, 'top-down' regulation of attention using distraction tasks has demonstrated efficacy in reducing pain perception (Johnson, 2005;Kohl et al., 2013). For example, engaging participants in highly demanding visual tasks reduces the amplitude of the P2 component of nociceptiveevoked potentials (Legrain et al., 2005). ...
Background and objective
The psychological mechanisms that make Conditioned Pain Modulation (CPM) an effective non-pharmacological intervention are still not fully understood. Expectancy is believed to be a critical psychological factor affecting CPM effects, but its specific role has yet to be fully clarified. This study aims to explore the relationship between expectancy and CPM while providing physiological evidence using functional near-infrared spectroscopy (fNIRS).
Method
A standardized CPM induction paradigm was implemented, with verbal guidance used to induce expectancy. The Numeric Rating Scale (NRS) assessed the intensity of the test stimulus (TS), while an 11-point scale evaluated participants’ attentional focus on the TS and the effect of expectancy. fNIRS was employed to monitor changes in prefrontal cortex (PFC) activity.
Results
Expectancy significantly amplified the CPM effect ( p = 0.036) while markedly reducing attention to the experimental stimulus ( p = 0.004). fNIRS findings indicated significant reductions in activity within the left frontal eye field, left dorsolateral prefrontal cortex, and left frontal pole regions. In the post-test, the control group demonstrated significantly higher cortical activity in the right frontal pole region compared to the expectancy group ( p < 0.05). Within the expectancy group, bilateral frontal pole cortical activity was significantly lower in the post-test compared to the pre-test ( p < 0.05).
Conclusion
Expectancy represents a key psychological mechanism underlying the CPM effect, potentially modulating its magnitude through attention regulation and accompanied by a reduction in oxygenated hemoglobin activity in the frontal pole region and introduced the Expectancy-Attention-CPM Modulation Model (ECAM).
... Distraction, a popular non-pharmacologic approach for pain management, involves diverting attention from pain through engaging thoughts or activities 20 . Virtual reality (VR) may hold promise for distracting patients' attention from pain 21 . ...
Objective measurements of pain and safe methods to alleviate it could revolutionize medicine. This study used functional near-infrared spectroscopy (fNIRS) and virtual reality (VR) to improve pain assessment and explore non-pharmacological pain relief in cancer patients. Using resting-state fNIRS (rs-fNIRS) data and multinomial logistic regression (MLR), we identified brain-based pain biomarkers and classified pain severity in cancer patients. Participants included healthy individuals who underwent rs-fNIRS recording without VR (Group A), cancer patients who underwent rs-fNIRS recording both before and after engaging in the Oceania relaxation program VR intervention (Group B), and cancer patients who underwent rs-fNIRS recording without VR (Group C). All participants wore a wireless fNIRS headcap for brain activity recording. Pain severity was self-reported by patients using the FACES Pain Scale-Revised (FPS-R). fNIRS data were analyzed with MLR, categorizing pain into no/mild (0–4/10), moderate (5–7/10), and severe (8–10/10) levels. The MLR model classified pain severity in an unseen test group, selected using the leave-one-participant-out technique and repeated across all participants, achieving an accuracy of 74%. VR significantly reduced pain intensity (Wilcoxon signed-rank test, P < 0.001), with significant changes in brain functional connectivity patterns (P < 0.05). Additionally, 75.61% of patients experienced pain reductions exceeding the clinically relevant threshold of 30%. These findings underscore the potential of fNIRS for pain assessment and VR as a useful non-pharmacological intervention for cancer-related pain management, with broader implications for clinical pain management.
... A key feature of gaming, as opposed to other media types, is its active nature. When gaming, individuals must actively analyze and respond to situations, which provides significant distraction from pain-an effect often advised to seek when treating chronic pain conditions [46]. This distracting effect has been demonstrated in virtual reality, which likely shares similarities with gaming experiences [47]. ...
Background/Objectives: The use of digital media, and especially social media, has been increasing over recent years. Previous research has reported a negative impact of media use on headaches; however, most of these studies are cross-sectional. Therefore, we conducted a longitudinal study to explore the relationship between different types of media usage (watching videos, gaming, and social media) and headache frequency and headache intensity over time. Methods: School-aged children from five German schools completed five assessments between 2017 and 2018. In total, N = 575 (72.9% female; Mage = 13.3, SDage = 1.86) children and adolescents reporting consistent headaches across all assessments were analyzed. Multilevel linear modeling was used to assess the relationships between media use and headache frequency and intensity over time. Results: There were only minor associations between media use and headache intensity or frequency. Notably, only high social media usage was linked with worse headache intensity (t(1989) = 4.109, p < 0.001). Conclusions: The impact of media use on headaches seems to be less harmful than previous research might suggest. We believe that increased time spent consuming media should not be considered a risk factor for pain conditions but rather a helpful resource for pain management.
... Due to its immersive quality, which encompasses a patient's auditory and visual processing as well as physical movements, which require more attention in theory. 33,34 According to a meta-analysis in 2019, the effectiveness of VR in treating shoulder impingement syndrome and persistent neck pain seems promising. Rheumatoid arthritis, osteoarthritis of the knee, ankle instability, and post-anterior cruciate reconstruction all respond similarly to VR and physical activity. ...
Introduction: Virtual reality (VR) is effective in several healthcare domains. As of date, there have been no systematic reviews investigating the efficacy of VR technology in episiotomy repair in women. This systematic review and meta-analysis examined the effects of using VR on pain, anxiety and satisfaction in women under episiotomy repair. Methods: For the original articles, six databases were searched using relevant keywords without restriction on time or languages until June 6, 2024. The Cochrane risk-of-bias tool for randomized trials (RoB) and the Risk of Bias Assessment Tool for Nonrandomized Studies (RoBANS) were both used to assess the risk of bias in randomized and non-randomized studies, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) also determined the quality of our evidence. All analyses employed Comprehensive Meta-Analysis (CMA) V.2. Results: Five randomized clinical trial and two quasi-experimental studies with poor-to high-quality met the inclusion criteria. The VR significantly decreased perineal pain during [MD (95% CI)=-1.622 (-2.598, -0.645), P=0.001], immediately after [MD (95% CI)=-1.931 (-2.785, -1.076), P<0.001], and one hour after [MD (95% CI)=-1.596 (-2.436, -0.765), P<0.001]. It also significantly decreased anxiety [SMD (95% CI)=-1.48 (-2.451, -0.509), P=0.003] after repair. VR group participants were significantly more satisfied than the control group. The quality of was moderate for perineal pain intensity one hour after episiotomy repair and anxiety after episiotomy repair. Conclusion: Given the efficacy of VR on pain, anxiety, and satisfaction, it is suggested that it be utilized as a novel modality to enhance the quality of maternity hospital care.
... Whether interoceptive exposure can be helpful with chronic pain is an old unresolved question within the field of the psychology of chronic pain, that goes beyond the concept of pain as a homeostatic emotion and asks: could paying close attention to the phenomenological details of the experience of pain be an alternative approach to chronic pain management compared with the typical coping style of distraction and ignoring? (Boersma et al. 2004) That latter habitual coping style is prevalent (Johnson 2005;Mehling et al. 2013) but of questionable benefit in chronic pain (Goubert et al. 2004) (review in Rad and Wippert (2024)). In the language of the predictive processing model, paying closer attention to bottomup afferent sensations would be understood as giving the interoceptive afference more precision weight and thereby potentially updating priors and top-down predictions. ...
With his elegant studies, Bud Craig determined the structural neural basis for interoception and critically expanded our conceptual understanding of it. Importantly, he placed pain in the framework of interoception and redefined pain as a homeostatic emotion. Craig understood emotions and pain as experiences based on inferential brain processes within the theoretical model of prediction processing. This chapter aims to give a brief overview of relevant research. Mind–body therapies, such as meditation, mindfulness, yoga, Tai Chi, and others, are included as first-line non-pharmacological approaches in clinical guidelines for the management of chronic pain. Craig’s groundbreaking work provided the background for our contemporary understanding of mind–body therapies and for the key role that interoceptive processes play in these therapies as they apply to a wide range of clinical conditions, including pain. This chapter reviews the tremendous influence that Craig’s work had on the current state of research on mind–body therapies for managing chronic pain and how it led to new directions for cutting-edge clinical and neuroscientific research.
... Overall, distraction mechanisms for acute pain can be understood through cognitive, learning, and neurobiological perspectives [49]. Cognitive theories, such as the limited attentional capacity and multiple resource theories, suggest that distraction tasks reduce the attention to pain by utilizing attentional resources, with more effective distractions competing for the same resources used to process pain [50,51]. In this regard, the neurocognitive model indicates that distraction tasks work by modulating involuntary pain attention through a voluntary focus on specific stimuli, though it is less effective when the pain is highly salient, unless goal-directed motivation is present [49,52]. ...
The aim of this study was to investigate the influence of executive functioning and cognitive performance on individual experimentally induced pain perception during distractor tasks in an asymptomatic pain-free population. A total of 59 healthy pain-free subjects (59.3% women, mean age: 46.5 ± 24.7 years) completed a battery test that assessed execution functions (cognitive flexibility, working memory, mental inhibition), attention level, and psychological aspects (anxiety/depressive levels—HADS, pain catastrophizing—PCS, pain anxiety symptoms—PASS 20, sleep quality—PSQI) before conducting two n-back distraction tasks. Pain was experimentally induced with a thermal stimulus that was able to induce moderate pain (70/100 points) and applied to the non-dominant forearm. The thermal stimulus was applied before and during both (one-back and two-back) distraction tasks. The analyses consisted of separated repeated-measures ANOVA that considered the functioning on each test (cognitive flexibility, working memory, mental inhibition, selective attention) and controlled for sociodemographic and psychological aspects by comparing the pain intensity at the baseline and during the one-back and two-back distractor tasks. All ANOVAs found a significant effect of the distraction task, which indicates that the perceived pain intensity scores were lower during the one-back and two-back tasks (p < 0.001) as compared with the baseline. No interaction effect between the distractor tasks and working memory (p = 0.546), mental inhibition (p = 0.16), cognitive flexibility (p = 0.069), or selective attention (p = 0.105) was identified. The current study found that a distraction task decreased the perceived intensity of experimentally induced pain in asymptomatic pain-free individuals and that this effect was not related to executive function or attention levels.
... Other suggested mechanisms for enhanced descending inhibition related to PA are, for example, increased levels of endocannabinoid, 61 endogenous opioids, 87 increased levels of anti-inflammatory cytokines, 13 and reduced levels of other inflammation markers. 95 PA may also affect pain through cognitive processes 93 such as distraction 42 and selective attention. 75 The question remains whether LTPA and OPA affect such mechanisms differently. ...
Paradoxical associations have been observed for leisure-time physical activity (LTPA) and occupational physical activity (OPA) and several health-related outcomes. Typically, higher LTPA is associated with health benefits and high OPA with health hazards. Using data from the Tromsø Study (2015-2016), we assessed how questionnaire-based LTPA and OPA (n = 21,083) and accelerometer-measured physical activity (PA) (n = 6778) relate to pain outcomes. Leisure-time physical activity and OPA were categorized as inactive PA, low PA, and moderate-to-vigorous PA and then aggregated into 9 levels, eg, inactive LTPA/inactive OPA. Accelerometer-measured PA included counts/minute, steps/day, and WHO PA recommendations from 2010 to 2020. Three binary pain outcomes (any pain, any chronic pain, and moderate-to-severe chronic pain) were constructed based on pain location, intensity, duration, and impact on daily activities. By using Poisson regression to estimate absolute and relative associations, we found that high LTPA was associated with lower pain prevalence and vice versa for OPA. Compared to inactive LTPA, prevalence ratio (PR) with 95% confidence intervals was lowest for moderate-to-vigorous LTPA, 0.93 (0.89-0.96) for any pain, 0.88 (0.84-0.93) for any chronic pain, and 0.66 (0.59-0.75) for moderate-to-severe chronic pain. Compared to sedentary OPA, the ratio was highest for moderate-to-vigorous OPA, 1.04 (1.01-1.07) for any pain, 1.06 (1.02-1.10) for any chronic pain, and 1.33 (1.21-1.46) for moderate-to-severe chronic pain. Aggregated LTPA and OPA showed lower outcomes for moderate-to-vigorous LTPA combined with lower levels of OPA. Higher levels of accelerometer-measured PA were associated with less pain. To summarize, we found inverse associations for LTPA and OPA. Benefits from LTPA seem to depend on low levels of OPA.
... Distraction involves redirecting an individual's attentional resources to pain by diverting attention from pain to other sensory stimuli or cognitive tasks, activities, or thoughts, and although it is commonly used and widely acknowledged as a strategy to modulate the experience of pain control, its effectiveness varies according to different factors [66]. This implies that the nervous system's processing of sensory signals requires attention and, due to the individuals' limited cognitive capacity for attention at any given time, the ability to manage nociceptive stimuli will be reduced and thus the painful experience will emerge [67]. Distraction in children will be highly dependent on various factors, from developmental age and the ability to maintain concentration to the behavioral responses of parents and clinicians during the treatment [18,19,47]. ...
Pain is the most common reason for medical consultation and use of health care resources. The high socio-economic burden of pain justifies seeking an appropriate therapeutic strategy. Immersive virtual reality (VR) has emerged as a first-line non-pharmacological option for pain management. However, the growing literature has not been accompanied by substantial progress in understanding how VR could reduce the pain experience, with some user experience factors being associated with the hypoalgesic effects of immersive VR. The aim of this review is (i) to summarize the state of the art on the effects of VR on adults and children suffering from pain conditions; (ii) to identify and summarize how mechanisms across immersive VR user experience influence hypoalgesic effects in patients with acute and chronic pain among adults and children. A critical narrative review based on PICOT criteria (P = Patient or Population and Problem; I = Intervention or Indicator; C = O = Outcome; T = Type) was conducted that includes experimental studies or systematic reviews involving studies in experimentally induced pain, acute pain, or chronic pain in adults and children. The results suggest an association between immersive VR-induced hypoalgesia and user experience such as distraction, presence, interactivity, gamification, and virtual embodiment. These findings suggest that hierarchical relationships might exist between user experience-related factors and greater hypoalgesic effects following an immersive VR intervention. This relationship needs to be considered in the design and development of VR-based strategies for pain management.
... Pain has the capacity to captivate attention involuntarily, especially when it is severe, novel, or menacing [26]. Conversely, directing attention away from pain can prevent its further processing and result an analgetic effect [22]. However, our results showed that this does not result in a reduced CPM. ...
Chronic pain is a public health issue, leading to substantial healthcare costs and diminished quality of life for sufferers. While the role of anxiety in pain modulation has been extensively studied, the effects of other emotional states on the body’s pain control mechanisms remain less understood. This study sought to explore how different emotions (happiness, anger, sadness, and interest) affect conditioned pain modulation (CPM) and the wind-up phenomenon in healthy adults.
This randomized controlled, cross-over trial involved 28 healthy participants aged 18–60. Participants watched video clips designed to induce specific emotions: happiness, anger, sadness, and interest. Emotional states were assessed using a 7-point Likert scale. Pain modulation was measured using CPM and the wind-up phenomenon. CPM was assessed with a hot water bath as the conditioning stimulus and pressure pain tolerance as the test stimulus. Wind-up was measured using pinprick needle stimulators and a visual analog scale. Data were analyzed using paired t tests to compare pre- and post-emotion induction values.
Significant changes in emotional self-assessment values were observed for all emotions. Happiness increased CPM (4.6 ± 11.4, p = 0.04277), while sadness − 9.9 ± 23.1, p = 0.03211) and anger − 9.1 ± 23.3, p = 0.04804) decreased it. Interest did not significantly alter CPM (− 5.1 ± 25.8, p = 0.31042). No significant effects were found for the wind-up phenomenon across any emotional states.
This study shows that emotional states significantly affect the body’s ability to modulate pain. Positive emotions like happiness enhance pain inhibition, while negative emotions such as sadness and anger impair it. These findings suggest that emotional modulation techniques could be integrated into pain management strategies to improve patient outcomes. Further research should explore a broader range of emotions and include objective measures to validate these results.
... Distraction involves redirecting an individual's attentional resources to pain by diverting attention from pain to other sensory stimuli or cognitive tasks, activities, or thoughts, and although it is commonly used and widely acknowledged as a strategy to modulate the experience of pain control, its effectiveness varies according to different factors [66]. This implies that the nervous system's processing of sensory signals requires attention and, due to the individuals' limited cognitive capacity for attention at any given time, the ability to manage nociceptive stimuli will be reduced and thus the painful experience will emerge [67]. Distraction in children will be highly dependent on various factors, from developmental age and the ability to maintain concentration to the behavioral responses of parents and clinicians during the treatment [18,19,47]. ...
Pain is the most common reason for medical consultation and use of health care resources. The high socioeconomic burden of pain justifies seeking an appropriate therapeutic strategy. Immer-sive virtual reality (VR) has emerged as a first-line non-pharmacological option for pain management. However, the growing literature has not been accompanied by substantial progress in understanding how VR could reduce the pain experience, with some user experience factors being associated with the hypoalgesic effects of immersive VR. The aim of this review is (i) to summarize the state of the art on the effects of VR on adults and children suffering from pain conditions; (ii) to identify and summarize how mechanisms across immersive VR user experience influence hypoalgesic effects in patients with acute and chronic pain among adults and children. A critical narrative review based on PICOT criteria (P = Patient or Population and Problem; I = Intervention or Indicator; C = O = Outcome; T = Type) was conducted that includes experimental studies or systematic reviews involving studies in experimentally induced pain, acute pain, or chronic pain in adults and children. The results suggest an association between immersive VR-induced hypoalgesia and user experience such as distraction, presence, interactivity, gamification, and virtual embodiment. These findings suggest that hierarchical relationships might exist between user experience-related factors and greater hypoalgesic effects following an immersive VR intervention. This relationship needs to be considered in the design and development of VR-based strategies for pain management.
... The most common use of VR for pain management is distraction. Distraction involves reducing the attention paid to the pain stimulus through consciously directing one's focus to another information processing activity (Johnson, 2005), under the premise that the extent to which pain is experienced depends partly on the attention paid to the pain signal (Melzack & Wall, 1965). An effective distractor should thus be highly engaging, so attention is effectively diverted to the distractor over the pain sensation (Czech et al., 2022). ...
... To address these challenges, various pharmacological and non-pharmacological techniques have been employed. Among them, virtual reality (VR) emerges as a promising non-pharmacological approach, offering an effective and visually engaging distraction method [11,12]. VR also provides an interactive interface that enhances procedural understanding and has demonstrated efficacy in mitigating anxiety and pain across various medical settings [13][14][15] including cardio-pulmonary rehabilitation and surgical procedures [16][17][18]. ...
Cardiac procedure-related anxiety and pain can adversely affect outcomes and lead to patient dissatisfaction. Virtual reality (VR) offers a promising alternative to traditional therapies for improving patient experience. Our objective is to synthesize evidence and assess the effectiveness of VR in reducing cardiac procedure-related anxiety and pain compared to standard of care. We conducted a comprehensive search across various online databases, including MEDLINE, EMBASE, CINAHL, Web of Sciences, and COCHRANE, to identify relevant randomized controlled trials (RCTs) focusing on VR, cardiac procedures, anxiety, and pain. We utilized a random-effect model to generate effect estimates reported as standardized mean differences (SMD) with a 95% confidence interval. Our review comprised 10 studies with a total of 621 participants (intervention arm: 301, control arm: 320). Overall, among the seven studies evaluating anxiety outcomes, no significant difference in anxiety reduction was observed between the intervention and control groups (standardized mean difference (SMD) -0.62, 95% CI -1.61, 0.37, p=0.22). However, studies using the same anxiety assessment tool demonstrated a significant improvement in the VR arm (SMD -1.01, 95% CI -1.98, -0.04, p=0.04). Conversely, the narrative synthesis of four studies examining pain revealed mixed results. Our findings suggest no significant difference in anxiety reduction between the VR and control groups. Future studies should employ standardized tools for assessing and reporting anxiety and pain to better understand the potential of VR in enhancing patient experience during cardiac procedures.
... Subsequently, progressively more demanding physical activities were undertaken, integrating simultaneous cognitive tasks, such as interacting with illuminated targets using Fit-Light technology ( Figure 11). One of the employed cognitive techniques is distraction, intentionally creating a "mismatch" between internal information (pain) and external task-related stimuli, effectively alleviating the Patient's symptoms during functional activities (Johnson, 2005;Schreiber et al., 2014;Van Ryckeghem, van Damme, Eccleston, and Crombez, 2018). Additionally, an external focus was integrated as part of the cognitive strategy. ...
Purpose:
Pain is a complex, intimate, and subjective experience influenced by biological, psychological, and social factors. This case report investigates the effectiveness of a multidisciplinary team approach in addressing chronic pain and pain-related fear.
Case description:
The case report describes a 22-year-old female who experienced anterior knee pain for seven years, despite undergoing two knee surgeries and physiotherapy without improvement. Following a comprehensive assessment, which included a detailed medical history, clinical examination, and thoughtful clinical analysis, a multidisciplinary approach was recommended. Employing an evidence-based methodology that integrated neurocognitive rehabilitation techniques, including Pain Neuroscience Education, Graded Motor Imagery, and Tactile Discrimination Training, alongside psychological rehabilitation strategies such as Mindfulness, Acceptance and Commitment Therapy, and Problem-Solving Therapy, the report presents a comprehensive in-depth rehabilitation plan exemplifying the application of this multimodal approach within a clinical setting in a patient with chronic pain. This approach is designed not to address the biomechanical aspects but to delve into the cognitive facets associated with pain perception and avoidance, as well as potential psychological factors that may be influencing the onset and persistence of symptoms.
Outcomes:
The scores from the rating scales provided valuable insights into patient progress in pain management, functional improvement, fear of movement, and overall physical, psychological, and emotional well-being, at six months.
Conclusion:
This case report offers valuable insights into the usefulness of this multidisciplinary and multimodal approach, highlighting its potential as an avenue in the management of chronic pain and pain-related fear.
... A multivariable logistic regression model was created with the dichotomized USD pain score as the outcome variable and continuous symptom scores of anxiety, fatigue, loss of appetite, insomnia, nausea, dyspnoea, and bowel problems as predictor variables. Covariates (age, sex, and living situation) were selected based on known relevance [22][23][24]. The predicting symptoms and covariates were selected according to the minimum Akaike Information Criterion(AIC), which results in the best predictive model [25]. ...
Background: Pain assessment is a necessary step in pain management in older people in palliative care. In older people, pain assessment can be challenging due to underreporting and atypical pain manifestations by other distressing symptoms. Anxiety, fatigue, loss of appetite, insomnia, dyspnoea, and bowel problems correlate with pain in palliative care patients. Insight into these symptoms as predictors may help to identify the underlying presence of pain. This study aimed to develop a prediction model for pain in independently living frail older people in palliative care.
Methods: In this cross-sectional observational study, community-care nurses from multiple organizations across the Netherlands included eligible patients (life expectancy < 1 year, aged 65+, independently living and frail). The outcome pain and symptoms were assessed by means of the Utrecht Symptom Diary. Also, demographic and illness information, including relevant covariates age, sex and living situation, was collected. Multivariable logistic regression and minimum Akaike Information Criterion(AIC) were used for model development and Receiver Operating Characteristics(ROC)-analysis for model performance. Additionally, predicted probability of pain are given for groups differing in age and sex.
Results: A total of 157 patients were included. The final model consisted of insomnia(Odds Ratio[OR]=2.13, 95% Confidence Interval[CI]=1.013-1.300), fatigue(OR=3.47, 95% CI=1.107-1.431), sex(female)(OR=3.83, 95% CI=2.111-9.806) and age(OR=-1.59, 95% CI=0.922-1.008) as predicting variables. There is an overall decreasing trend for age, older persons suffer less from pain and females have a higher probability of experiencing pain. Model performance was indicated as fair with a sensitivity of 0.74(95% CI=0.64-0.83) and a positive predictive value of 0.80(95% CI=0.70-0.88).
Conclusion: Insomnia and fatigue are predicting symptoms for pain, especially in women and younger patients. The use of a symptom diary in primary care can support the identification of pain.
... The limited attentional capacity theory suggests that when a distractor competes with pain for the same attentional resources, these are divided for the cognitive processing of both stimuli. Thus, as the distractor consumes more attentional resources, fewer attentional resources are allocated to the painful stimuli, diminishing pain perception (Birnie et al., 2017;Johnson, 2005). To date, there are mixed results on the effectiveness of distraction (Damme et al., 2008), prior studies have found that distraction reduces perceived pain intensity when the intensity of the painful stimuli is low (Devine & Spanos, 1990;Dubreuil et al., 1987;García-Larrea et al., 1997;Gaultney et al., 2021) and/or moderate (Buhle & Wager, 2010;Devine & Spanos, 1990;Dubreuil et al., 1987;Gaultney et al., 2021;Georgescu et al., 2018;Schulz et al., 2019;Villemure & Bushnell, 2009;Villemure et al., 2003), whereas other authors have shown that distraction does not reduce perceived pain intensity at all (Jokic-Begic et al., 2009;Shires et al., 2019;Verhoeven et al., 2012). ...
Objetivo: La reevaluación cognitiva y la distracción modulan el dolor; sin embargo, se sabe poco sobre su eficacia en diferentes niveles de intensidad del dolor. Así, el objetivo de este estudio ha sido analizar la eficacia diferencial de ambas estrategias para reducir la intensidad del dolor percibido y el malestar del dolor en niveles de dolor bajos y moderados. Método: 3 (Estrategia de regulación emocional: reevaluación cognitiva, distracción y control) por 2 (Intensidad de los estímulos dolorosos: intensidad baja y moderada) por 2 (tiempo: pre-prueba y post-prueba) diseño factorial mixto. Noventa adultos sanos fueron asignados aleatoriamente a una de seis condiciones experimentales, el dolor se indujo mediante un estimulador térmico avanzado. Todos los participantes completaron las fases experimentales de pre-prueba y post-prueba, en cada fase se administraron doce estímulos de dolor. Al final de cada estímulo de dolor, los participantes calificaron el nivel de intensidad del dolor percibido y el dolor desagradable experimentado durante la estimulación dolorosa utilizando el CoVAS. Los datos se recopilaron desde mayo de 2022 hasta noviembre de 2022. Resultados: Los análisis de covarianza (ANCOVA) mostraron que en la prueba posterior (n = 90), la reevaluación cognitiva y la distracción fueron igualmente efectivas para reducir la intensidad del dolor percibido en niveles bajos de dolor, mientras la distracción fue mas efectiva que la reevaluación cognitiva para disminuir la intensidad de dolor percibido en niveles moderados de dolor. Tanto la distracción como la reevaluación cognitiva fueron efectivas para disminuir el malestar causado por el dolor. Conclusiones: Estos hallazgos resaltaron el uso beneficioso de ambas estrategias a corto plazo para el alivio del dolor, siendo la distracción más efectiva en niveles de dolor moderado. Aplicar ambas estrategias a situaciones cotidianas que puedan provocar dolor agudo a corto plazo podría tener gran relevancia clínica.
... This effectively reduces the suffering brought on by unpleasant events. 6 Distraction through virtual reality has gained importance in the healthcare field. There is a paucity of studies conducted in Puducherry related to the usage of virtual reality as a method of distraction to reduce pain among children. ...
... Researchers interchangeably refer to them as distractions [2,9,40], defining them as any activity that draws a driver's attention away from the task of driving [26,58]. In clinical research exploring the usage of distractions for pain relief, secondary tasks are considered processes that compete for attention against the salient sensations of pain [29]. Researchers studying the effects of secondary tasks on cybersickness generally subscribe to one of two major schools of thought. ...
Active exploration in virtual reality (VR) involves users navigating immersive virtual environments, going from one place to another. While navigating, users often engage in secondary tasks that require attentional resources, as in the case of distracted driving. Inspired by research generally studying the effects of task demands on cybersickness (CS), we investigated how the attentional demands specifically associated with secondary tasks performed during exploration affect CS. Downstream of this, we studied how increased attentional demands from secondary tasks affect spatial memory and navigational performance. We discuss the results of a multi-factorial between-subjects study, manipulating a secondary task's demand across two levels and studying its effects on CS in two different sickness-inducing levels of an exploration experience. The secondary task's demand was manipulated by parametrically varying n in an aural n-back working memory task and the provocativeness of the experience was manipulated by varying how frequently users experienced a yaw-rotational reorientation effect during the exploration. Results revealed that increases in the secondary task's demand increased sickness levels, also resulting in a higher temporal onset rate, especially when the experience was not already highly sickening. Increased attentional demand from the secondary task also vitiated navigational performance and spatial memory. Overall, increased demands from secondary tasks performed during navigation produce deleterious effects on the VR experience.
... Looking at the Multidimensional Assessment of Interoceptive Awareness scale, chronic pain patients scored lower levels in the non-worrying, non-distracting, as well as body-trusting, domains compared to healthy controls. Lower scores of non-worrying and non-distracting could be due to the use of worrying and distracting as methods of coping among chronic pain patients [85][86][87][88]. While lower scores of body-trusting could partially be due to the higher depression seen in chronic pain patients as body-trusting is considered to be impacted in depression [89]. ...
In the context of chronic pain management, opioid-based treatments have been heavily relied upon, raising concerns related to addiction and misuse. Non-pharmacological approaches, such as Mindfulness-Based Pain Management, offer alternative strategies. We conducted a mechanistic clinical study to investigate the impact of an 8-week Mindfulness-Based Pain Management intervention on chronic pain, the modulation of inflammatory markers, stress physiology, and oxytocin, and their interplay with clinical pain symptoms and perception, in comparison to a patient wait-list active control. A total of 65 participants, including 50 chronic pain patients and 15 healthy controls, underwent salivary assays to assess endocrine markers, oxytocin, interleukin (IL)-1b, IL-6, IL-8, tumor necrosis factor (TNF)-a, and dehydroepiandrosterone sulphate (DHEA-S). Psychological assessments were also conducted to evaluate aspects of pain perception, mindfulness, mood, and well-being. Findings revealed significant differences between chronic pain patients and healthy controls in various clinical metrics, highlighting the psychological distress experienced by patients. Following Mindfulness-Based Pain Management, oxytocin levels significantly increased in chronic pain patients, that was not observed in the patient wait-list control group. In contrast, cytokine and DHEA-S levels decreased (not to statistically significant margins) supporting anti-inflammatory effects of Mindfulness-Based Pain Management. The fact DHEA-S levels, a marker of stress, did attenuate but not to statistically meaningful levels, suggests that pain reduction was not solely related to stress reduction, and that oxytocin pathways may be more salient than previously considered. Psychological assessments demonstrated substantial improvements in pain perception and mood in the intervention group. These results contribute to the growing body of evidence regarding the effectiveness of mindfulness-based interventions in chronic pain management and underscore oxytocin’s potential role as a therapeutic target.
... Distraction as a simple complementary and non-pharmacological approach can reduce pain severity and anxiety by drawing patients' attention to pleasant stimuli [19][20][21]. Distraction inhibits the activity of the thalamus, insular cortex, and anterior cingulate cortex (ACC) and ultimately reduces pain [22]. Moreover, distraction improves patients' feelings and helps them to feel more comfortable [23]. ...
Citation: Moradipoor, Y.; Rejeh, N.; Heravi Karimooi, M.; Tadrisi, S.D.; Dahmardehei, M.; Bahrami, T.; Vaismoradi, M. Comparing Auditory and Visual Distractions for Reducing Pain Severity and Pain Anxiety in Older Outpatients with Burn: A Randomized Controlled Trial. Geriatrics 2022, 7, 54. https://
... Increases in frontal θ have been previously reported during cognitive tasks involving attention and concentration (such as working memory tasks, mental arithmetic, and meditation) [29][30][31][32] . Some of these tasks have previously been shown to have implications for pain management, such as the positive clinical outcomes associated with meditation or the phenomenon of distraction-induced analgesia [32][33][34][35][36][37] . Recent reviews of studies that have elucidated the neural correlates of acute and chronic pain have revealed divergent evidence. ...
Limitations in chronic pain therapies necessitate novel interventions that are effective, accessible, and safe. Brain–computer interfaces (BCIs) provide a promising modality for targeting neuropathology underlying chronic pain by converting recorded neural activity into perceivable outputs. Recent evidence suggests that increased frontal theta power (4–7 Hz) reflects pain relief from chronic and acute pain. Further studies have suggested that vibrotactile stimulation decreases pain intensity in experimental and clinical models. This longitudinal, non-randomized, open-label pilot study's objective was to reinforce frontal theta activity in six patients with chronic upper extremity pain using a novel vibrotactile neurofeedback BCI system. Patients increased their BCI performance, reflecting thought-driven control of neurofeedback, and showed a significant decrease in pain severity (1.29 ± 0.25 MAD, p = 0.03, q = 0.05) and pain interference (1.79 ± 1.10 MAD p = 0.03, q = 0.05) scores without any adverse events. Pain relief significantly correlated with frontal theta modulation. These findings highlight the potential of BCI-mediated cortico-sensory coupling of frontal theta with vibrotactile stimulation for alleviating chronic pain.
... Estudios recientes describen que mantener la atención en un estímulo doloroso amplificaba la percepción del dolor, mientras que la distracción la atenuaba (Chayadi & McConnell, 2019). El proceso de distracción parece implicar una competencia por la atención entre el estímulo nociceptivo muy destacado y una atención dirigida conscientemente a alguna otra actividad de procesamiento de información (Johnson, 2005). Esto supone que el procesamiento del sistema nervioso de las señales sensoriales requiere atención y, debido a la limitada capacidad cognitiva de atención de los individuos en un momento dado, se verá reducida la capacidad para gestionar los estímulos nociceptivos y por tanto, emerger la experiencia dolorosa (Bushnell et al., 2013) ...
Esta editorial reflexiona sobre el papel de los sesgos atencionales y las estrategias de distracción en la percepción y gestión del dolor. En el texto se resalta la participación de la hipervigilancia y el sesgo atencional, en el contexto de dolor crónico como un factor influyente en la percepción del dolor. El papel de las técnicas de distracción, como la realidad virtual y la música, varía significativamente según las habilidades cognitivas y la motivación del individuo. Aunque la distracción se presenta como una herramienta útil, la eficacia relativa de las distracciones auditivas frente a las visuales indica una compleja dinámica que merece más investigación. La comprensión y aplicación de estrategias que influyan sobre variables cognitivas y emocionales son fundamentales en la intervención terapéutica del paciente con dolor, es necesario la realización de futuros estudios que puedan explorar estos mecanismos en profundidad.
... Las técnicas de control atencional se basan en que nuestra atención presenta unas características que pueden hacer que el dolor aumente o disminuya. La atención es selectiva (podemos elegir qué atendemos), limitada (no podemos atender profundamente a varias cosas a la vez), y tiene la capacidad de magnificar aquello que atendemos (33). ...
... While seemingly contradictory that attention towards internal bodily sensations may actually benefit people with pain, attempts to suppress awareness of pain may actually be unhelpful [37,38] and for individuals with a high level of catastrophic thinking about pain, mindfulness-based coping strategies may be more beneficial than distraction [39]. From a behavioral perspective, interoception plays a role in pain maintenance not through increased attention towards bodily sensations, but rather through learned avoidance of internal stimuli often associated with pain and the reinforcement of avoidance behaviors, resulting in a cycle that ultimately perpetuates fear of internal sensations and a catastrophic misinterpretation of pain [40]. ...
Emerging literature has demonstrated deficits in interoception (i.e., the perception of physical sensations from inside the body) in individuals with chronic pain conditions. Mind-body therapies (MBTs) are purported to improve chronic pain in part through improving or restoring interoceptive abilities. The present systematic review and meta-analysis aimed to examine changes in interoception in MBTs for chronic pain conditions.
A systematic search of PubMed, PsycINFO, Scopus, CINAHL, and ProQuest Dissertation and Theses was conducted from database inception to February 2023. English language intervention studies evaluating the effect of MBTs on interoception in adults with chronic pain conditions were examined. Changes in pain (severity and interference) following treatment were examined as secondary outcomes.
A total of 11 studies (10 unique samples) were identified. Meta-analytic results reveal significant improvements in total interoceptive awareness (Becker’s d = 1.168, p < .01) as well as improvements in seven of eight subdomains of interoceptive awareness (ds = 0.28 to 0.81). MBTs were also associated with reductions in both pain intensity (d = -1.46, p = .01) and pain interference (d = -1.07, p < .001).
Preliminary research suggests that MBTs demonstrate improvements in interoceptive awareness and reduce pain in adults with chronic pain. Literature on changes in other domains of interoception, such as interoceptive accuracy, following MBTs is severely lacking. Although more rigorous studies are needed to corroborate results, the present findings lay an important foundation for future research to examine interoception as a possible underlying mechanism of MBTs to improve pain outcomes.
... The main principle of VR is to provide strong and sufficient distraction to redirect attention initially focused on pain to a calm environment [37][38][39][40]. Thereby, VR can effectively modify sensory perceptions such as pain by monopolizing a high amount of attentional resources [41]. ...
Background and Objectives: Botulinum toxin injections are commonly used for the treatment of spasticity. However, injection procedures are associated with pain and procedural anxiety. While pharmacological approaches are commonly used to reduce these, innovative technology might be considered as a potential non-pharmacological alternative. Given this context, immersive virtual reality (VR) has shown effectiveness in the management of procedural pain. Our retrospective pilot study aimed to assess the potential added value of virtual reality in the management of pain and anxiety during intramuscular injections of botulinum toxin. Materials and Methods: Seventeen adult patients receiving botulinum toxin injections were included. A numerical rating scale was used to assess pain and anxiety during the injection procedure. The patients reported the pain experienced during previous injections without VR before injection and the pain experienced in the current procedure with VR after the end of the procedure. The level of satisfaction of VR experience, whether or not they agreed to reuse VR for the subsequent toxin botulinum injection, and whether or not they would recommend VR to other patients were assessed. Results: The use of virtual reality led to a decrease of 1.8 pain-related points compared to the procedure without technology. No significant improvement in the level of anxiety was reported. Patients were very satisfied with their VR experiences (7.9 out of 10), and many would agree to reuse VR in their next injection procedure (88%) and to recommend the use of VR in other patients (100%). Conclusion: VR was useful for managing procedural pain related to botulinum toxin injection in adults, with a high level of satisfaction reported by the patients. VR should be considered as a valuable alternative to pharmacological approaches to manage procedural pain during botulinum toxin injection in adults.
... 8 Shifting the focus of attention from pain sensations to different mental tasks may be beneficial in reducing pain, indeed, previous studies on experimental pain or other models of acute pain show such benefits. 15, 16 Preliminary evidence suggests that body awareness may have significant benefits in the management of chronic painful diseases and improving health-related quality of life. 17, 18 Our knowledge about body awareness in axSpA characterized by chronic musculoskeletal pain, fatigue, systemic inflammation, and other complaints are limited. ...
Aims: The aim of this study was to investigate the effects of disease activity on body awareness and central sensitization in patients with axial spondyloarthritis (axSpA). Methods: This cross-sectional study included patients diagnosed with axSpA. Disease activity was evaluated using the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), and a score of four or higher was considered high disease activity. Patients were divided into two groups according to BASDAI: high disease activity (BASDAI ≥ 4) group (HG) and the low disease activity (BASDAI0.05). The CSI-A score was higher in HG compared to LG (44 (31-54) vs. 31 (21-41), p=0.008). The HG had poorer BAQ scores than the LG (61 (52-85) vs. 85 (64-96), p=0.017). BASDAI was moderately associated with CSI-A (r=0.145, R2=0.172, p=0.001). No significant correlation was found between BASDAI and BAQ (p=0.167). The results of the simple linear regression analysis suggested that CSI-A explained 17.2% of the disease activity. BASDAI (β = 0.415, p=0.001) significantly predicted central sensitization. BASDAI was strongly correlated with VAS (r=0.665, R2= 0.442, p
... Distraction techniques are based on the attention-control mechanism. Promoting thoughts and focusing attention away from negative feelings may interfere with the neuronal activity associated with the processing of afferent pain stimuli and cognitive pain perception [31]. ...
More than 50% of children report considerable pain during venipuncture or intravenous cannulation. Despite the tools and techniques may be employed to reduce pain and distress in everyday clinical practice, the care offered is frequently insufficient. Music’s potential effect in healthcare settings has received increasing attention. This study aimed to verify if the active production of music with a Leap Motion Controller could help decreasing pain and distress during venipuncture in children and adolescents. We conducted an open-label randomized controlled clinical trial with parallel arms. Children aged 8 to 17 were enrolled at the blood-drawing center of the Institute for Maternal and Child Health IRCCS Burlo Garofolo of Trieste, Italy. We hypothesized that in order to demonstrate an adequate improvement in the pain score in the intervention group, at least 200 children, 100 in each group, were needed, with alpha 5% and 1-beta 80%. Differences between the groups were evaluated with the nonparametric Mann–Whitney U-test. The subjects were randomly assigned either to the active production of music group or to the standard of care group. The primary outcome was the median self-reported procedural pain score between experimental and standard of care group. Secondary outcomes were: the median pain and distress scores according to parental judgment and operators’ judgment between the experimental and control group. Three hundred subjects entered the study and were randomized, 150 in the active production of music group and 150 in the standard of care group. Median self-reported pain scores were 1 (0–2) in the active production of music group and 2 (1–2) in the standard of care group and this difference was statistically significant (p = 0.0016). Median procedural distress was 1 (0–3) in the active production of music group and 3 (1–6) in the standard of care group, according to parental judgment, and this difference was statistically significant (p = 0.0000016).
Conclusion: This research showed that the active production of music is a valuable distraction technique to decrease venipuncture related pain and distress in children and adolescents.
Trial registration: The study protocol was registered with ClinicalTrial.gov (June 28[th] 2022, NCT05441241) before the start of the subjects’ enrolment. What is Known:
• The benefits of music on pain and anxiety are well known and have been tested during different painful procedures.
• The effect of active production of music has never been tested in children during venipuncture.
What is New:
• In our study median self-reported pain scores and median procedural distress, according to parental judgment, were lower in the active production of music group than in the standard of care group and these differences were statistically significant.
... In Study 2, participants might have interrupted their activities in anticipation of the questionnaires before their scheduled assessment times, which could have influenced the present-moment awareness measure. Finally, the relationship between mindfulness and pain might be non-linear; previous research has shown that low-level pain is often best responded to with distraction, but that once pain is above a critical threshold, an active response is needed that involves behaviors (e.g., taking medication) or psychological processing (e.g., re-interpretation; Johnson, 2005). ...
This study investigated everyday associations between one key facet of mindfulness (allocating attention to the present moment) and pain. In Study 1, 89 community-dwelling adults (33-88 years; Mage = 68.6) who had experienced a stroke provided 14 daily end-of-day present-moment awareness and pain ratings. In Study 2, 100 adults (50-85 years; Mage = 67.0 years) provided momentary present-moment awareness and pain ratings three times daily for 10 days. Multi-level models showed that higher trait present-moment awareness was linked with lower overall pain (both studies). In Study 1, participants reported less pain on days on which they indicated higher present-moment awareness. In Study 2, only individuals with no post-secondary education reported less pain in moments when they indicated higher present-moment awareness. Findings add to previous research using global retrospective pain measures by showing that present-moment awareness might correlate with reduced pain experiences, assessed close in time to when they occur.
... The limited attentional capacity theory suggests that when a distractor competes with pain for the same attentional resources, these are divided for the cognitive processing of both stimuli. Thus, as the distractor consumes more attentional resources, fewer attentional resources are allocated to the painful stimuli, diminishing pain perception (Birnie et al., 2017;Johnson, 2005). To date, there are mixed results on the effectiveness of distraction (Damme et al., 2008), prior studies have found that distraction reduces perceived pain intensity when the intensity of the painful stimuli is low (Devine & Spanos, 1990;Dubreuil et al., 1987;García-Larrea et al., 1997;Gaultney et al., 2021) and/or moderate (Buhle & Wager, 2010;Devine & Spanos, 1990;Dubreuil et al., 1987;Gaultney et al., 2021;Georgescu et al., 2018;Schulz et al., 2019;Villemure & Bushnell, 2009;Villemure et al., 2003), whereas other authors have shown that distraction does not reduce perceived pain intensity at all (Jokic-Begic et al., 2009;Shires et al., 2019;Verhoeven et al., 2012). ...
Objective: Cognitive reappraisal and distraction modulate pain; however, little is known about their effectiveness at different levels of pain intensity. Thus, the aim of this study has been to analyze the differential efficacy of both strategies to reduce perceived pain intensity and pain unpleasantness in low and moderate pain levels.
Method: 3 (emotion regulation strategy: cognitive reappraisal, distraction, and control) ×2 (intensity of the painful stimuli: low and moderate intensity)×2 (time: pretest and posttest) mixed factorial design. Ninety healthy adults were randomly assigned to one of six experimental conditions. Pain-heat stimuli were administered with an advanced thermal stimulator. All participants completed the experimental pretest and posttest phases; in each phase, 12 pain stimuli were administered. Participants received brief training on how to apply cognitive reappraisal, distraction, and the control condition for the posttest phase. Datawere collected from May 2022 to November 2022. Results: Analyses of repeated-measure analysis of variance
showed that at posttest cognitive reappraisal and distraction were equally effective in reducing perceived pain intensity in low pain levels, while distraction was more effective than cognitive reappraisal in decreasing perceived pain intensity in moderate pain levels. Both distraction and cognitive reappraisal were effective in decreasing pain unpleasantness regardless of the intensity of the painful stimuli. Conclusion: These findings highlighted the beneficial use of both strategies in the short term for pain relief, distraction being more effective in moderate pain levels. Applying both strategies to everyday situations that may cause short-term acute pain could be of great clinical relevance.
This study explores the perceptions and experiences of Chinese registered nurses regarding the clinical use of alternative medicine. The research focuses on nurses from various departments and roles, including specialist nurses, clinical nurses, and nursing management personnel. Through interviews, participants share their experiences, challenges, and views on alternative medicine in their daily work. The data collected will be analyzed using the Collaizi method. The study identifies four main themes: the development of alternative medicine in China, the challenges faced by nurses, how they overcome these challenges, and their predictions for the future of alternative medicine in the country. Key findings highlight the emotional impact of work changes, the difficulties encountered in the nursing profession, and nurses’ resilience. Lastly, participants offer insights into the future of alternative medical practices in China.
Objective
People commonly cope with chronic low back pain (cLBP) by ignoring and distraction. Can mindful interoceptive exposure to the pain sensation itself and its phenomenological components be an alternative approach?
Methods
Single-arm feasibility study in patients with cLBP using a 2-minute attention exercise guided by a smartphone app several times per day over 8 weeks. We assessed feasibility, pre/post pain, function, and psychological parameters using mixed methods: standard questionnaires, ecological momentary assessment, and exit interviews that included micro-phenomenology technique and subsequent reflexive thematic qualitative analysis.
Results
We enrolled 31 participants, mostly female, mean age 48, the majority had pain for >5 years; 29 completed. Mean pain intensity [0–10] improved from 4.8 ±1.7 to 3.1 ±1.9 (p < .0001); mean PEG scores (intensity and interference with daily life; range 0–30) improved from 13.7 ±6.2 to 8.4 ±6.6 (p < .0001); pain impact (9 items incl physical function) 22.3 ±8.7 to 19.7 ±8.1 (p = .0010). Twenty-one of 29 improved PEG score ≥30%. There were significant improvements in PCS Rumination and MAIA Not-Worrying. Participants became aware of their usual habit of avoidance and the challenge of and resistance to focusing on pain. They were surprised how pain sensations varied over time, and that pain intensity and the threat value of pain could diminish by focusing on it. They described a variety of 3D pain shapes (e.g., football, pool ball, rod, nail, brick, stars) with a range of colors, transparency, temperature, and density that for some changed with mindful attention. Most struggled to find appropriate words for sensory awareness and attention regulation and found that the threat value of their pain diminished.
Conclusions
Mindful interoceptive exposure to the sensations of their cLBP using a 2-minute attention exercise with a phone app—rather than ignoring and distracting from it—may be a beneficial intervention for cLBP.
Trial registration
ClinicalTrials.gov #NCT06186193.
Aim: Acute and chronic noncancer pain is a common healthcare problem locally and globally, and remains under treated and poorly controlled. We created a virtual reality (VR)-based prototype with customization of content to our local population. Materials & methods: This was an open-label, single center, single-arm study to examine the safety, acceptability and tolerability of the use of VR as an adjunctive tool for pain relief in hospitalized patients. The participants rated their baseline and post-VR pain and anxiety scores. Results & conclusion: All 50 patients completed the VR sessions with good tolerability and safety. Preliminary exploration of pain reduction indicated a positive effect (for pain and anxiety visual analog scale scores; p < 0.001). We believe VR is a potentially beneficial tool for use in pain management.
Background and Objectives: Botulinum toxin injections are commonly used for the treatment of spasticity. However, injection procedures are associated with pain and procedural anxiety. While pharmacological approaches are commonly used to reduce these, inno-vative technology might be considered as a potential non-pharmacological alternative. Given this context, immersive virtual reality (VR) has shown effectiveness in the man-agement of procedural pain[1]. Our retrospective pilot study aimed to assess the potential added value of virtual reality in the management of pain and anxiety during intra-muscular injections of botulinum toxin. Materials and Methods: Twenty-one adult patients receiving botulinum toxin injections were included. A numerical rating scale was used to assess pain and anxiety during the injection procedure. The patient reported the pain experienced during previous injections without VR before injection and the pain expe-rienced in the current procedure with VR after the end of the procedure. Level of satis-faction of VR experience, if they agreed to reuse VR for the subsequent toxin botulinum injection, and if they would recommend VR to other patients were assessed. Results: The use of virtual reality showed a decrease of 1.8 pain-related points compared to without technology. No significant improvement in the level of anxiety was reported. Patients were very satisfied by their VR experience (7.9 out of 10) and would agree to reuse VR in their next injection procedure (88%) and to recommend the use of VR in other patients (100%). Conclusion: VR was useful for managing procedural pain related to botulinum toxin injection in adults, with a high level of satisfaction reported by the patient. VR should be considered as a valuable alternative to pharmacological approach to manage procedural pain during Botulinum toxin injection in adults.
Introduction:
Anxiety and pain associated with cardiac procedures can lead to worse outcomes and poor satisfaction. Virtual reality (VR) can offer an innovative approach to a more informative experience that may enhance procedural understanding and reduce anxiety. It may also provide a more enjoyable experience by controlling procedure-related pain and improving satisfaction. Previous studies have shown benefits of VR-related therapies in improving anxiety related to cardiac rehabilitation and different surgical procedures. We aim to evaluate the effectiveness of VR technology in comparison to the standard of care in reducing anxiety and pain related to cardiac procedures.
Methods and analysis:
This systematic review and meta-analysis protocol is structured according to the Preferred Reporting for Systematic Review and Meta-analysis-Protocol (PRISMA-P) guidelines. A comprehensive search strategy will be used to search the online databases for randomised controlled trials (RCTs) on VR, cardiac procedures, anxiety, and pain. Risk of bias will be analysed using revised Cochrane risk of bias tool for RCTs. Effect estimates will be reported as standardised mean differences with a 95% CI. Random effect model will be used to generate effect estimates if heterogeneity is significant (I2>60%), otherwise fixed effect model will be used. A p value of <0.05 will be taken as statistically significant. Publication bias will be reported using Egger's regression test. Statistical analysis will be performed using Stata SE V.17.0 and RevMan5.
Ethics and dissemination:
There will be no direct involvement of the patient or the public in the conception, design, data collection, and analysis of this systematic review and meta-analysis. Results of this systematic review and meta-analysis will be disseminated via journal articles.
Prospero registration number:
CRD 42023395395.
Cognitive interventions, including distraction, have been successfully utilized in the manipulation of experimental pain and the treatment of clinical pain. Attentional diversions can reduce the experience of pain, a phenomenon known as distraction analgesia (DA). Prior research has suggested that variations in stimulus intensity may influence the magnitude of DA. However, the neural substrates of DA remain largely unknown. Converging evidence suggests that the infralimbic cortex (IL) in the brains of rats may contribute to the phenomenon of DA. The function of the rat IL in DA has never been directly investigated, therefore, this study sought to identify the role of the IL at two levels of noxious stimulus intensity among brain-intact and IL lesioned male rats within an established rat model of DA. A distractor object reduced formalin-induced nociceptive behavior in brain-intact rats, and this DA effect was detectable during low- (.5% formalin) and high-intensity (1% formalin) stimulation. IL lesion resulted in a near-complete elimination of the DA effect and an overall reduction in formalin pain. These results provide the first known evidence that (i) the IL is involved in processing DA in rats, (ii) the IL contributes to formalin-induced nociceptive behavior irrespective of distraction, and (iii) a high-intensity stimulation was generally more susceptible to DA than low-intensity stimulation. These findings may further inform the mechanisms and future development of non-pharmacological strategies to reduce pain.
Pain interrupts and demands attention. The authors review evidence for how and why this interruption of attention is achieved. The interruptive function of pain depends on the relationship between pain-related characteristics (e.g., the threat value of pain) and the characteristics of the environmental demands (e.g., emotional arousal). A model of the interruptive function of pain is developed that holds that pain is selected for action from within complex affective and motivational environments to urge escape. The implications of this model for research and therapy are outlined with an emphasis on the redefinition of chronic pain as chronic interruption.
College students in four experiments placed their hands in ice water (the cold-pressor task) and reported their distress. They simultaneously engaged in different reaction-time (RT) tasks that varied in the amount of attention required for successful performance. In each experiment, which differed in numerous procedural details, RT, error-rate, and self-report measures all demonstrated that the distraction tasks differed in the degree of attention required. Greater distraction, however, failed to reduce physiological, self-report, or behavioral responses to the cold-pressor task. These data call into question the hypothesis that attention mediates the process whereby distraction tasks reduce pain-produced distress.
Key words: distraction, attention, laboratory pain
Offers explicit conceptual explanations of why and when distraction will be effective in coping with pain-produced distress and reviews research related to this conceptual scheme. A theoretical case for the effectiveness of distraction is drawn from assumptions about the importance of cognition in mediating the pain experience and the limited capacity available for focusing attention on different stimulus events. Combining these assumptions led to 4 principles that were examined with available data. Principle 1 holds that distractions will reduce stress as compared with uninstructed and placebo control conditions. Principle 2 maintains that distraction techniques that require more attentional capacity will be more effective. Principle 3 contends that distraction will have stronger effects on pain stimuli of low intensity. Principle 4 predicts that distraction will be more effective than sensation redefinition for mild pain stimuli, but the reverse will be true for intense pain stimuli. Data support these principles. Research is needed to compare distraction and expectancy control conditions, to test distraction for clinical as opposed to acute pain, to compare distraction strategies that vary in quantified attentional requirements, and to discover the features of pain stimuli. (89 ref) (PsycINFO Database Record (c) 2006 APA, all rights reserved).
Resistance is high to findings negating commonsense beliefs. If McCaul, Monson, and Maki's (1992) four studies are taken seriously, we will address new questions about the components of analgesic interventions--specifically, whether distraction works only when combined with a competing affect, an analgesic cognition, or both. Addressing these questions should increase our understanding of the mechanisms involved in pain processing and may increase our ability to intervene and modify chronic as well as acute pain. Laboratory studies offer an efficient route to such understanding, although the question of generalization will always lurk in the background.
In this experiment, we tested for opioid and nonopioid mechanisms of pain control through cognitive means and the relation of opioid involvement to perceived coping efficacy. Subjects were taught cognitive methods of pain control, were administered a placebo, or received no intervention. Their pain tolerance was then measured at periodic intervals after they were administered either a saline solution or naloxone, an opiate antagonist that blocks the effects of endogenous opiates. Training in cognitive control strengthened perceived self-efficacy both to withstand and to reduce pain; placebo medication enhanced perceived efficacy to withstand pain but not reductive efficacy; and neither form of perceived self-efficacy changed without any intervention. Regardless of condition, the stronger the perceived self-efficacy to withstand pain, the longer subjects endured mounting pain stimulation. The findings provide evidence that attenuation of the impact of pain stimulation through cognitive control is mediated by both opioid and nonopioid mechanisms. Cognitive copers administered naloxone were less able to tolerate pain stimulation than were their saline counterparts. The stronger the perceived self-efficacy to reduce pain, the greater was the opioid activation. Cognitive copers were also able to achieve some increase in pain tolerance even when opioid mechanisms were blocked by naloxone, which is in keeping with a nonopioid component in cognitive pain control. We found suggestive evidence that placebo medication may also activate some opioid involvement. Because placebos do not impart pain reduction skills, it was perceived self-efficacy to endure pain that predicted degree of opioid activation.
The study demonstrates that the rebound effect of thought suppression (Wegner, 1989) has an analog in the experience of somatic discomfort. During a cold-pressor pain induction, 63 Ss were instructed either to concentrate on their room at home (distraction), to pay close attention to their hand sensations (monitoring), or to remove awareness of those sensations from mind (suppression). Two min of postpressor pain ratings showed that monitoring produced the most rapid recovery from the pain and that suppression produced the slowest. Suppression also contaminated the interpretation of a subsequent somatic stimulation; later in the experimental hour, Ss who had suppressed their cold-pressor discomfort rated an innocuous vibration as more unpleasant than did other Ss. The strategies are discussed for their necessarily distinct processes of goal evaluation and their possibly differential drain on perceived coping capacities.
Recent evidence demonstrating multiple regions of human cerebral cortex activated by pain has prompted speculation about their individual contributions to this complex experience. To differentiate cortical areas involved in pain affect, hypnotic suggestions were used to alter selectively the unpleasantness of noxious stimuli, without changing the perceived intensity. Positron emission tomography revealed significant changes in pain-evoked activity within anterior cingulate cortex, consistent with the encoding of perceived unpleasantness, whereas primary somatosensory cortex activation was unaltered. These findings provide direct experimental evidence in humans linking frontal-lobe limbic activity with pain affect, as originally suggested by early clinical lesion studies.
Pain interrupts and demands attention. The authors review evidence for how and why this interruption of attention is achieved. The interruptive function of pain depends on the relationship between pain-related characteristics (e.g., the threat value of pain) and the characteristics of the environmental demands (e.g., emotional arousal). A model of the interruptive function of pain is developed that holds that pain is selected for action from within complex affective and motivational environments to urge escape. The implications of this model for research and therapy are outlined with an emphasis on the redefinition of chronic pain as chronic interruption.
Pain is an unpleasant sensory and emotional experience usually triggered by stimulation of peripheral nerves and often associated with actual or potential tissue damage. It is well known that pain perception for patients and normal subjects can be modulated by psychological factors, such as attention, stress, and arousal. Our understanding of how this modulation occurs at a neuroanatomical level is poor. Here we neuroanatomically defined a key area in the network of brain regions active in response to pain that is modulated by attention to the painful stimulus. High-resolution functional magnetic resonance imaging was used to define brain activation to painful heat stimulation applied to the hand of nine normal subjects within the periaqueductal gray region. Subjects were asked to either focus on or distract themselves from the painful stimuli, which were cued using colored lights. During the distraction condition, subjects rated the pain intensity as significantly lower compared with when they attended to the stimulus. Activation in the periaqueductal gray was significantly increased during the distraction condition, and the total increase in activation was predictive of changes in perceived intensity. This provides direct evidence supporting the notion that the periaqueductal gray is a site for higher cortical control of pain modulation in humans.
Emotions have been shown to alter pain perception, but the underlying mechanism is unclear since emotions also affect attention, which itself changes nociceptive transmission. We manipulated independently direction of attention and emotional state, using tasks involving heat pain and pleasant and unpleasant odors. Shifts in attention between the thermal and olfactory modalities did not alter mood or anxiety. Yet, when subjects focused attention on the pain, they perceived it as clearly more intense and somewhat more unpleasant than when they attended to the odor. In contrast, odor valence altered mood, anxiety level, and pain unpleasantness, but did not change the perception of pain intensity. Pain unpleasantness ratings correlated with mood, but not with odor valence, suggesting that emotional changes underlie the selective modulation of pain affect. These results show that emotion and attention differentially alter pain perception and thus invoke at least partially separable neural modulatory circuits.
What is cognitive science? Foundations of Cognitive Science answers this question in a way that gives a feeling for the excitement, ferment, and accomplishments of this new field. It is the first broad treatment of cognitive science at an advanced level.
Complete and authoritative, Foundations of Cognitive Science covers the major architectures; provides background in philosophy, linguistics, cognitive psychology, and neuroscience; and deals with methods for studying both brain and mind. All of the chapters have been written especially for the book by the leading scholars in the field.
Bradford Books imprint
• In preparing the following abridgment of my larger work, the Principles of Psychology, my chief aim has been to make it more directly available for class-room use. For this purpose I have omitted several whole chapters and rewritten, others. I have left out all the polemical and historical matter, all the metaphysical discussions and purely speculative passages, most of the quotations, all the book-references, and (I trust) all the impertinences, of the larger work, leaving to the teacher the choice of orally restoring as much of this material as may seem to him good, along with his own remarks on the topics successively studied. Knowing how ignorant the average student is of physiology, I have added brief chapters on the various senses. In this shorter work the general point of view, which I have adopted as that of 'natural science,' has, I imagine, gained in clearness by its extrication from so much critical matter and its more simple and dogmatic statement. About two fifths of the volume is either new or rewritten, the rest is 'scissors and paste.' I regret to have been unable to supply chapters on pleasure and pain, aesthetics, and the moral sense. Possibly the defect may be made up in a later edition, if such a thing should ever be demanded. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
• In preparing the following abridgment of my larger work, the Principles of Psychology, my chief aim has been to make it more directly available for class-room use. For this purpose I have omitted several whole chapters and rewritten, others. I have left out all the polemical and historical matter, all the metaphysical discussions and purely speculative passages, most of the quotations, all the book-references, and (I trust) all the impertinences, of the larger work, leaving to the teacher the choice of orally restoring as much of this material as may seem to him good, along with his own remarks on the topics successively studied. Knowing how ignorant the average student is of physiology, I have added brief chapters on the various senses. In this shorter work the general point of view, which I have adopted as that of 'natural science,' has, I imagine, gained in clearness by its extrication from so much critical matter and its more simple and dogmatic statement. About two fifths of the volume is either new or rewritten, the rest is 'scissors and paste.' I regret to have been unable to supply chapters on pleasure and pain, aesthetics, and the moral sense. Possibly the defect may be made up in a later edition, if such a thing should ever be demanded. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Subjects performed a visual tracking task while performing a concurrent task in which tones were covertly counted. The P300 component of the event-related potentials elicited by the tones was examined to determine the extent to which its amplitude was affected by variations in the forcing-function bandwidth, or difficulty, of the tracking task. P300 decreased in magnitude when tones were counted in conjunction with the performance of the tracking task, relative to a single-task counting condition. Increasing tracking difficulty failed to reduce P300 amplitude further. A second experiment obviated the possibility that movement-related potentials caused the P300 attenuation resulting from the introduction of the tracking task. In Experiment 3, subjects performed a reaction time task in conjunction with tracking in order to establish the validity of the tracking difficulty manipulation. The results are interpreted in terms of a theory of functionally-specific processing resources.
One hundred male and 100 female chronic pain patients in a multidisciplinary pain clinic completed a 34-item Pain Coping Questionnaire (PCQ). Factor analysis identified four pain coping factors: self-management, helplessness, social support, and medical remedies. Multiple-regression analyses were conducted to determine the relation between PCQ factors and measures of adjustment at admission to the pain program as well as admission to discharge changes in adjustment measures. The following concepts relevant to coping with chronic pain were defined: cognitive strategies, self-efficacy, helplessness, catastrophizing, and cognitive distortion. Suggestions were made for integrating these concepts in the development of scales for assessing strategies for coping with chronic pain.
Cognitive and behavioral pain coping strategies were assessed by means of questionnaire in a sample of 61 chronic low back pain patients. Data analysis indicated that the questionnaire was internally reliable. While patients reported using a variety of coping strategies, certain strategies were used frequently whereas others were rarely used. Three factors: (a) Cognitive Coping and Suppression, (b) Helplessness and (c) Diverting Attention or Praying, accounted for a large proportion of variance in questionnaire responses. These 3 factors were found to be predictive of measures of behavioral and emotional adjustment to chronic pain above and beyond what may be predicted on the basis of patient history variables (length of continuous pain, disability status and number of pain surgeries) and the tendency of patients to somaticize. Each of the 3 coping factors was related to specific measures of adjustment to chronic pain.
Sixty-two chronic low back pain patients were administered the Coping Strategies Questionnaire (CSQ) to assess the frequency of use and perceived effectiveness of a variety of cognitive and behavioral pain coping strategies. Analysis of individual variables revealed that CSQ factors, gender, physical examination findings, and chronicity of pain had significant effects on one or more of a series of pain, psychological distress or behavioral measures. To assess the relative contribution of each of these variables hierarchical stepwise regression analyses were carried out. These analyses revealed that the Helplessness factor of the CSQ explained 50% of the variance in psychological distress (Global Severity Index of the SCL-90R), and 46% of the variance in depression (Beck Depression Inventory). Patients scoring high on this CSQ factor had significantly higher levels of psychological distress. None of the demographic or medical status variables explained a significant proportion of variance in the psychological distress measures. The Diverting Attention and Praying factor of the CSQ explained a moderate (9%), but significant amount of variance in pain report. Patients scoring high on this factor had higher scores on the McGill Pain Questionnaire. Coping strategies were not strongly related to pain behavior measures such as guarding or uptime. A consideration of pain coping strategies may allow one to design pain coping skills training interventions so as to fit the needs of the individual low back pain patient.
First published in 1958, this book has become recognized as a classic in its field. It marked a transition between behaviourist learning theory and the modern 'information processing' or 'cognitive' approach to perception and communication skills. It continues to provide a principal starting point for theoretical and experimental work on selective attention. As Professor Posner writes in his Foreword to the reissue: 'it remains of great interest to view the work in its original form and to ponder those creative moments when the mind first grasps a new insight and then struggles to work out its consequences.
The present research sought to examine the importance of cognitive factors in the experience and treatment of chronic pain. An attempt was made to explore possible mediational influences by testing the effectiveness of several cognitive strategies. Experimental conditions were manipulated to examine the influence of three types of cognitive strategies: (1) reinterpreting the pain stimuli, (2) diverting one's attention from it, and (3) concentrating on the sensation itself. Dependent measures such as subjective indices of pain, behavioral observations, and an unobtrusive measure of pain behavior were obtained in an attempt to explore the experience of pain. Results demonstrated that, within a physical rehabilitation hospital setting, patients with a history of persistent pain showed a significant change in their ratings of the quality and intensity of this experience, and in their behavior, through the use of reinterpretive cognitive instructions.
College students in four experiments placed their hands in ice water (the cold-pressor task) and reported their distress. They simultaneously engaged in different reaction-time (RT) tasks that varied in the amount of attention required for successful performance. In each experiment, which differed in numerous procedural details, RT, error-rate, and self-report measures all demonstrated that the distraction tasks differed in the degree of attention required. Greater distraction, however, failed to reduce physiological, self-report, or behavioral responses to the cold-pressor task. These data call into question the hypothesis that attention mediates the process whereby distraction tasks reduce pain-produced distress.
Subjective pain ratings and tolerance time were obtained during 2 cold pressor immersions for 3 groups of subjects. During the second immersion 1 group performed no task and the other 2 groups performed either an easy or difficult mental arithmetic task. The sensory-discriminative response to pain was measured by pain ratings. Pain ratings were collected every minute until subjects removed their arm from the cold pressor or until 4 min passed. Relative to a baseline cold pressor immersion, subjects in both the distraction conditions reduced their 1 min pain ratings more than control subjects. This effect was weaker at the 2 min pain rating and absent at the later ratings. The affective-reactive response to pain was measured by pain tolerance times. Tolerance time was defined as the time when subjects removed their arm from the cold pressor. Tolerance time was not altered by the distraction tasks. These findings suggest that affectively neutral distraction alters the sensory but not the reactive response to pain. Clinical implications are discussed.
This study examined the effects of age on the frequency of use and perceived effectiveness of coping strategies in patients
having chronic pain. Subjects were chronic pain patients in four age groups (young, middle, older, and geriatric). All subjects
completed the Coping Strategies Questionnaire, which measures the use and perceived effectiveness of a variety of cognitive
and behavioral coping strategies in controlling and decreasing pain. Subjects also completed measures of pain, depression,
and psychological distress. Data analysis revealed that there were no significant age differences in either the use or perceived
effectiveness of pain coping strategies. Correlational analyses based on data combined from the different age groups suggested
that, while certain pain coping strategies appear to be adaptive (e.g., coping self-statements), other coping strategies appear
to be maladaptive (e.g., catastrophizing, diverting attention, increasing behavioral activities). Patients who rated their
ability to decrease pain as relatively high, reported lower levels of depression and pain. These findings are consistent with
a contextual perspective on coping which postulates that few, if any, age differences in coping are to be expected when individuals
are coping with a similar life event
The literature on the utility of cognitive coping strategies in pain control has been unclear because of 2 principal limitations: the lack of a validated classification system, and reliance on qualitative and quasi-statistical reviews. In this study, an empirically based multidimensional taxonomy was employed to categorize the variety of cognitive coping strategies into 6 major classes: external focus of attention, neutral imaginings, pleasant imaginings, dramatized coping, rhythmic cognitive activity and pain acknowledging. Meta-analytic techniques were introduced to evaluate the overall efficacy of cognitive strategies (in comparison to no-treatment controls), the relative efficacy of these strategies (how the different groups of strategies compare with one another), and the substantive efficacy of such strategies (how cognitive strategies fare against placebo/expectancy conditions). Results revealed that, in general, cognitive coping strategies are more effective in alleviating pain as compared to either no-treatment or expectancy controls. Each individual class of strategies significantly attenuates pain although the imagery methods are the most effective whereas pain acknowledging is the least effective. Positive expectancy is no better than no treatment. These findings stand in contrast with previous reviews that have not assigned prime importance to imagery or for that matter have not shown cognitive strategies to be particularly effective. Results are discussed with reference to attentional models and methodological issues.
A gate control system modulates sensory input from the skin before it evokes pain perception and response.
Offers explicit conceptual explanations of why and when distraction will be effective in coping with pain-produced distress and reviews research related to this conceptual scheme. A theoretical case for the effectiveness of distraction is drawn from assumptions about the importance of cognition in mediating the pain experience and the limited capacity available for focusing attention on different stimulus events. Combining these assumptions led to 4 principles that were examined with available data. Principle 1 holds that distractions will reduce stress as compared with uninstructed and placebo control conditions. Principle 2 maintains that distraction techniques that require more attentional capacity will be more effective. Principle 3 contends that distraction will have stronger effects on pain stimuli of low intensity. Principle 4 predicts that distraction will be more effective than sensation redefinition for mild pain stimuli, but the reverse will be true for intense pain stimuli. Data support these principles. Research is needed to compare distraction and expectancy control conditions, to test distraction for clinical as opposed to acute pain, to compare distraction strategies that vary in quantified attentional requirements, and to discover the features of pain stimuli. (89 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
We studied the influence of different behavioral situations on the responses of the wide-dynamic-range (WDR) and nociceptive-specific (NS) neurons described in the preceding paper. Activity was recorded from cells in the medullary dorsal horn (trigeminal nucleus caudalis) of monkeys trained in a thermal task to respond differentially to noxious (45-49°C) and innocuous (37-43°C) stimuli applied to the face. The same monkeys also were trained in a visual task to detect the onset of a variable-intensity light. In the visual task, behaviorally irrelevant thermal stimuli (37-49°C) of a fixed duration were applied to the face on some trials. Behaviorally relevant thermal stimuli presented during performance of the thermal task produced a greater neuronal response than equivalent irrelevant thermal stimuli presented either during the intertrial interval (ITI) in the thermal task or during performance of the visual task. Behaviorally relevant noxious thermal stimuli also produced a neuronal response when applied outside of receptive fields that had been determined with irrelevant stimuli. Neuronal responses to mechanical stimulation produced by lip movements under the thermal probe were less during performance of the visual task than during the thermal task. The effects of changes in attentional demands were studied in the visual task by systematically reducing the intensity of the light cue. A reduction in light intensity required monkeys to attend more rigorously to the light cue and was associated with a reduction in neuronal responses to noxious and innocuous thermal stimuli. When the light intensity was further reduced to levels resulting in behavioral disruption, the magnitude of neuronal responses to thermal stimuli returned to levels observed with maximum light intensity. In the thermal task, attentional demands also were reduced by having the experimenter rather than the monkey initiate the trials and reward the monkey independent of his behavior on innocuous thermal trials. Reduced neuronal responses to thermal stimuli were observed on experimenter-initiated trials. A warning signal preceding noxious heat stimuli presented during the thermal task produced systematic differences in response to those stimuli. The warning signal reduced the latency and maximum neuronal discharge frequency in the first monkey and increased the maximum discharge frequency in the second monkey, as compared to unsignaled noxious heat stimuli. These differences between the two monkeys may be related to the fact that the warning signal did not reliably predict the onset of noxious heat stimuli in the second monkey. Simultaneous recordings of neuronal activity and EMG activity from the lip musculature indicated that behaviorally associated changes in neuronal responses to thermal stimuli were not attributable to changes in peripheral stimulation of mechanosensitive afferents located under the thermal probe. Thus, the behavioral modulation of neuronal activity is of central origin and unrelated to peripherally produced changes in mechanoreceptive input. These findings indicate that the behavioral context in which stimuli are presented can modulate the responses of dorsal horn WDR and NS neurons coding sensory-discriminative information. Significant behavioral variables include the relevance of the stimulus to the behavioral task, the attentional demands placed on the monkey, and the reliability of warning signals in predicting the occurrence of noxious heat stimuli. Numerous descending supraspinal modulatory pathways may participate in these different behavioral effects.
The present study draws upon resource-based models of attention in suggesting that the processing of chronic and persistent pain is a task that demands the application of central and executive attention. If a chronic and persistent pain stimulus is demanding of central, attentional resources, it follows that it will compete with a second attention-demanding task for those limited resources. Here it is hypothesized that performance of an attention-demanding interference task will be detrimentally affected by the demands of persistent pain. In Expt 1, patients in high pain, patients in low pain and control subjects without pain performed an attention-demanding numerical interference task. There were no significant differences between any of the groups on any measure of performance. Expt 2 repeated Expt 1 with a more difficult and more complex task. Only when the task was at its most difficult and its most complex (i.e. at the greatest demand of limited resources) did those patients in high levels of pain (i.e. at the greatest demand of limited resources) show performance decrements. The results of both experiments are discussed in relation to the debate concerning the use of cognitive methods for pain control and in relation to the application of cognitive psychology to the study of chronic pain.
Theories disagree about whether a verbal warning for pain has a detrimental or beneficial effect on the impact of an actual pain stimulus. Scheme-based theories predict a detrimental effect, whereas more representation-based, stimulus-comparator theories propose a beneficial effect. In this study, the influence of sensory predictability and temporal predictability is investigated. To control for attentional processes and to obtain a behavioral measure of the intrusive character of pain, an auditory discrimination task was introduced. This study firmly demonstrates that information about the painful nature of a heat stimulus does not a priori have detrimental effects on the impact of the stimulus. In fact, conditions in which a pain warning was given displayed a diminished impact in the SCR amplitude as well as in the subjectively reported intensity of the heat stimulus. Informing Ss about the exact time of administration did not add to the impact modulation, but instead resulted in a less-anxious state between signals. Although an overall behavioral disruption, particularly at onset, was observed, the behavioral data did not parallel the results of the two other response systems. Results are discussed in terms of scheme-based models, stimulus-comparator theories and the safety-signal hypothesis.
In a within-subject design the hypothesis was tested that focus of attention rather than anxiety influences pain. Twenty-four spider phobics received a moderately painful electrical stimulation in each of four conditions: low anxiety/attention directed towards pain; low anxiety/attention distracted from pain; high anxiety/attention directed towards pain; high anxiety/attention distracted from pain. Anxiety was induced by means of exposure to a spider. Subjective pain ratings strongly supported the hypothesis: pain was rated lower when the subject diverted attention away from than when the subject attended to the pain stimulus, regardless of level of anxiety. The Skin Conductance Response to the first pain stimulus of the series of four in each condition was, however, higher when the subject distracted than when the subject attended to the pain stimulus. There were no experimental effects on later Skin Conductance Responses. Most importantly, there was no influence of anxiety on any of the pain responses. Attentional focus rather than anxiety per se seems to influence pain.
Pain interrupts, distracts and takes effort to ignore. Focusing our research attention upon this central aspect of pain experience, an experimental paradigm is introduced to study the disruptive nature of pain. Healthy volunteers were exposed several times to an electrical pain stimulus and a control stimulus. Tone probes were presented immediately (100 ms) and later on (1500 ms) after pain/control onset, and after pain/control offset (1000 ms). Results clearly showed disruption during pain. This disruptive effect was most marked immediately after onset. No differential results between pain and control conditions were observed later on during the pain experience. These results are interpreted within current cognitive and psychophysiological theories of attention. Emphasis is placed upon the importance of the experimental investigation of the role of attention in pain processing.
Distraction has been found to be effective for the attenuation of experimental and acute clinical pain but its efficacy for chronic pain management remains unclear. There are even some suggestions that distraction may be a counterproductive strategy for chronic pain sufferers. In this study we found that a word shadowing distraction task increased the ability of a group of 12 female and eight male chronic low back pain (CLBP) sufferers to carry out a brief (maximum 300 s) step-up exercise that temporarily increased their pain (P < 0.05). This 15% increase in exercise time was not accompanied by an increase in reported pain after the exercise. Interestingly, the same distraction task did not increase the cold pressor (CP) tolerance time for the CLBP group but produced a 26% increase in tolerance time for a pain-free control group consisting of nine females and nine males (P < 0.05). Also, performance on the distraction task during the CP was worse for the CLBP group than the controls (P < 0.05). Although these findings should be interpreted cautiously because of the parameters of the experiment, they do suggest that distraction is a potentially useful technique to assist chronic pain sufferers.
Pain interrupts, distracts and is difficult to disengage from. In this experiment the attentional interference during pain is studied with a primary task paradigm. We were interested in the strength of attentional interference with repeated presentations of pain. Healthy volunteers (n = 24) performed a tone discrimination task in the presence of two types of distractors (an electrical pain stimulus and a control stimulus) which they were instructed to ignore. On some trials, tone probes were presented immediately (250 ms) after distractor onset, further on (750 ms) during the distractor, and immediately (250 ms) after distractor offset. Habituation of the task interference during the early processing of both the pain and the control stimulus was observed. It was also found that the attentional interference during pain did not completely disappear with repeated presentations. Finally, results clearly showed a more prolonged processing time of the tones during pain trials than during control trials. These results are discussed in terms of cognitive theories of habituation.
The aims of the study were to use functional magnetic resonance imaging (fMRI) to 1) locate pain-related regions in the anterior cingulate cortex (ACC) of normal human subjects and 2) determine whether each subject's pain-related activation is congruent with ACC regions involved in attention-demanding cognitive processes. Ten normal subjects underwent fMRI with a 1.5-T standard commercial MRI scanner. A conventional gradient echo technique was used to obtain data from a single 4-mm sagittal slice of the left ACC, approximately 3.5 mm from midline. For each subject, interleaved sets of 6 images were obtained during a pain task, an attention-demanding task, and at rest, for a total of 36 images per task. Pain of different intensities was evoked via electrical stimulation of the right median nerve. The attention-demanding task consisted of silent word generation (verbal fluency). Additional experiments obtained data from the right ACC. A pixel-by-pixel statistical analysis of task versus rest images was used to determine task-related activated regions. The pain task resulted in a 1.6-4.0% increase in mean signal intensity within a small region of the ACC. The exact location of this activation varied from subject to subject, but was typically in the posterior part of area 24. The signal intensity changes within this region correlated with pain intensity reported by the subject. The attention-demanding tasks increased the mean signal intensity by 1.3-3.3% in a region anterior and/or superior to the pain-related activation in each subject. The activated region was typically larger than the pain-related activation. In some cases this activation was at or superior to the ACC border, near the supplementary motor area. These regions did not show any pain-intensity-related activation. In one subject both right and left ACC were imaged, revealing bilateral ACC activation during the attention task but only contralateral pain-related activation. These findings shed light on pain- and attention-related cognitive processes. The results provide evidence for a region in the posterior part of the ACC that is involved in pain and a more anterior region involved in other attention-demanding cognitive tasks.
Empirical methods are used to explore the relationship between chronic pain, somatic awareness and attention. Using a primary task paradigm, 46 chronic pain patients performed an attentionally demanding task. Patients were classified according to self reported pain intensity and the extent of their reporting of the perception of bodily sensations (somatic awareness). Results showed that, as predicted, disruption of attentional performance was most pronounced in those who reported high pain intensity and high somatic awareness. Further analysis revealed that these patients also reported high negative affect. These findings are discussed in terms of their theoretical implications for the concept of hypervigilance and their clinical implications for chronic pain control.
Styles of catastrophic thinking about pain have been related to an inability to divert attention away from pain. We investigated whether pain catastrophizers displayed high attentional interference during a threatening low-intensity electrocutaneous stimulus (ES). In Experiment 1, 44 undergraduates performed a tone discrimination task whilst experiencing several times an ES on the left or right arms. Tones were also presented 250 ms and 750 ms after ES onset. Participants were threatened that a high-intensity painful stimulus would occur at one site. As predicted, pain catastrophizers displayed pronounced task interference immediately after threat stimulus onset. In Experiment 2, threat was induced in 36 undergraduates by informing them that an ES excites pain fibres. Again, catastrophizers had marked interference immediately after onset. The results are discussed in terms of how catastrophizing amplifies somatosensory information and primes fear mechanisms.
Using a primary task paradigm this study investigated whether attentional disruption to a low-intensity electrocutaneous pain stimulus is enhanced by the threat of intense pain. Healthy volunteers (n = 38) performed a tone discrimination task in the presence of two types of distractors (a low-intensity electrocutaneous stimulus and a control stimulus) which they were instructed to ignore. In some trials, tone probes were presented immediately (250 ms) after distractor onset, further on (750 ms) during the distractor, and immediately (250 ms) after distractor offset. In a threat condition half of the participants were informed that a high-intensity painful stimulus would occur. As predicted, those participants who received the threat instructions, displayed a specific larger disruption of task performance immediately after the onset of the low-intensity pain stimulus in comparison with the control group.
Two experiments compared the effects of different distraction tasks on pain. Based on multiple-resource theory, Expt 1 predicted that the more a distractor shares processing resources with pain perception the greater the interference between the two. Experiment 2 tested whether the emotional content of the distractor would differentially effect measures that are supposedly reflective of the affective component of pain.
Both experiments used repeated measures designs, with counterbalanced distraction conditions.
In Expt 1 20 participants indicated their pain threshold. No instructions, or one of three distraction conditions were presented across four blocks of potassium iontophoresis. The distractors were: thermal and light detection, and neutral imagining. In Expt 2 30 participants had three blocks of pain threshold, pain tolerance, and pain rating trials. For threshold, tolerance, and rating trials, one block was without distraction, a second block was completed during light detection, and a third block while imagining an enjoyable holiday.
In Expt 1 all the distractors increased pain threshold. The two detection tasks were similarly effective, and more so than the imagination task. Performance on the two detection tasks was impaired by painful stimulation similarly for both tasks. In Expt 2 the visual detection distractor increased pain threshold and tolerance and reduced pain ratings while pleasant imagery only increased pain threshold.
These results indicate that a task that requires attention to external cues has more impact on pain than either a positive or neutral imagination task. However, it is not clear that the specific resources used by the distraction tasks moderated pain differentially as predicted by multiple-resource theory.
The present study examined the role of catastrophizing in predicting levels of pain and disability in a sample of individuals who had sustained soft-tissue injuries to the neck, shoulders or back following work or motor vehicle accidents. Participants were 86 (27 men, 59 women) consecutive referrals to the Atlantic Pain Clinic, a multidisciplinary treatment centre for the management of persistent pain disorders. Findings revealed that catastrophizing, measured by the Pain Catastrophizing Scale (PCS; Sullivan, M.J.L. et al., Psychol. Assess., 7 (1995) 524-532) was significantly correlated with patients' reported pain intensity, perceived disability and employment status. The results of a regression analysis further showed that catastrophizing contributed to the prediction of disability over and above the variance accounted for by pain intensity. In addition, catastrophizing was associated with disability independent of the levels of depression and anxiety. The rumination subscale of the PCS was the strongest predictor of pain and disability. Theoretical and clinical implications of the findings are discussed.
Pain interrupts, distracts, and is difficult to disengage from. In this study, the role of pain-related fear in moderating attentional interference produced by chronic pain was investigated. Forty chronic pain patients completed a list of questionnaires assessing pain severity, pain-related fear (Tampa Scale for Kinesiophobia), and negative affect (Negative Emotionality scale). Attentional interference was measured by a numerical interference test. Multiple regression analysis revealed that the attentional interference was best predicted by the interaction between pain severity and pain-related fear. These results are discussed in terms of how pain-related fear creates a hypervigilance to pain.
In an attempt to explain how and why some individuals with musculoskeletal pain develop a chronic pain syndrome, Lethem et al. (Lethem J, Slade PD, Troup JDG, Bentley G. Outline of fear-avoidance model of exaggerated pain perceptions. Behav Res Ther 1983; 21: 401-408).ntroduced a so-called 'fear-avoidance' model. The central concept of their model is fear of pain. 'Confrontation' and 'avoidance' are postulated as the two extreme responses to this fear, of which the former leads to the reduction of fear over time. The latter, however, leads to the maintenance or exacerbation of fear, possibly generating a phobic state. In the last decade, an increasing number of investigations have corroborated and refined the fear-avoidance model. The aim of this paper is to review the existing evidence for the mediating role of pain-related fear, and its immediate and long-term consequences in the initiation and maintenance of chronic pain disability. We first highlight possible precursors of pain-related fear including the role negative appraisal of internal and external stimuli, negative affectivity and anxiety sensitivity may play. Subsequently, a number of fear-related processes will be discussed including escape and avoidance behaviors resulting in poor behavioral performance, hypervigilance to internal and external illness information, muscular reactivity, and physical disuse in terms of deconditioning and guarded movement. We also review the available assessment methods for the quantification of pain-related fear and avoidance. Finally, we discuss the implications of the recent findings for the prevention and treatment of chronic musculoskeletal pain. Although there are still a number of unresolved issues which merit future research attention, pain-related fear and avoidance appear to be an essential feature of the development of a chronic problem for a substantial number of patients with musculoskeletal pain.
Pain-related fear has been found to be associated with increased disability and increased pain perception in patients with chronic low back pain. A possible mechanism by which pain-related fear could lead to increased pain perception is heightened attention to somatosensory sensations. In the present study, chronic pain patients reporting either a high or low level of pain related fear and control participants performed an auditory reaction time task, while occasionally non-painful electrical stimuli--accompanied by threatening instructions--were given to the arm or back. In the primary task condition, participants had to perform the auditory task while ignoring the electrical stimuli. Next, the task was presented under dual task conditions in which participants had to respond both to tones as well as to detection of electrical stimuli. It was hypothesized that for the primary task, high fearful patients would show greater disruption of performance on the auditory task than low fearful patients and controls when stimuli were presented to the back. For the dual task, slower reaction times for the auditory task, in combination with faster detection of electrical stimuli was expected. The hypotheses were not confirmed but patients scoring high on pain-related fear did show an overall increase in reaction time for all conditions of the primary task, with or without simultaneous stimulation. Regression analyses demonstrated that high pain-related fear was associated with increased reaction time to tones both in patients and healthy controls, and that within patients pain-related fear was a better predictor of reaction time to tones than present pain intensity. The findings may be interpreted as showing that patients with elevated levels of pain-related fear habitually attend to somatic sensations, giving less priority to other attention-demanding tasks.
Current clinical and experimental literature strongly supports the phenomenon of reduced pain perception whilst attention is distracted away from noxious stimuli. This study used functional MRI to elucidate the underlying neural systems and mechanisms involved. An analogue of the Stroop task, the counting Stroop, was used as a cognitive distraction task whilst subjects received intermittent painful thermal stimuli. Pain intensity scores were significantly reduced when subjects took part in the more cognitively demanding interference task of the counting Stroop than in the less demanding neutral task. When subjects were distracted during painful stimulation, brain areas associated with the affective division of the anterior cingulate cortex (ACC) and orbitofrontal regions showed increased activation. In contrast, many areas of the pain matrix (i.e. thalamus, insula, cognitive division of the ACC) displayed reduced activation, supporting the behavioural results of reduced pain perception.
Recent animal studies reveal ascending nociceptive and descending modulatory pathways that may contribute to the affective-motivational aspects of pain and play a critical role in the modulation of pain. In humans, a reliable pattern of cerebral activity occurs during the subjective experience of pain. Activity within the anterior cingulate cortex and possibly in other classical limbic structures, appears to be closely related to the subjective experience of pain unpleasantness and may reflect the regulation of endogenous mechanisms of pain modulation.
Time-dependent increases of local metabolic or blood flow rates have been described in spinal cord and brain during acute and chronic pain states in experimental animals, in parallel with changes of different behavioral endpoints of pain and hyperalgesia. In healthy human volunteers, pain intensity-related hemodynamic changes have been identified in a widespread, bilateral brain system including parietal, insular, cingulate, and frontal cortical areas, as well as thalamus, amygdala, and midbrain. Specific patterns of activity may characterize hyperalgesic states and some chronic pain conditions. Forebrain nociceptive systems are under inhibitory control by endogenous opioids and can be affected by acute administration of mu-opioid receptor agonists. Anticipation of pain may in itself induce changes in brain nociceptive networks. Moreover, pain-related cortical activity can be modulated by hypnotic suggestions, focusing or diverting attention, and placebo. These findings begin to disclose the spatio-temporal dynamics of brain networks underlying pain perception and modulation.