Abstract
Pain-related anxiety and fear are associated with increased difficulties in attention, increased awareness of pain, impaired disengagement from pain, and can moderate the effects of attentional coping attempts. Accurately assessing the direct impact of pain-related anxiety and fear on pain behavior has proved difficult. Studies have demonstrated no or limited influence of pain-related fear and anxiety on behavior but this may be due to inherent problems with the scales used. Neuroimaging has improved the understanding of neural processes underlying the factors that influence pain perception. This study aimed to establish if a Picture and Imagination Task (PIT), largely developed from the Photographs of Daily Activity (PHODA) assessment tool, could help explore how people living with chronic pain process information about daily activities. Blood oxygenation level dependent (BOLD) functional magnetic resonance imaging (fMRI) was used to compare brain responses in patients with chronic musculoskeletal pain (CMSKP) (n = 15) and healthy controls (n = 15). Subjects were asked to imagine how they would feel mentally and physically if asked to perform daily activities illustrated in PIT. The results found that a number of regions involved in pain processing saw increased BOLD activation in patients compared with controls when undertaking the task and included the insula, anterior cingulate cortex, thalamus and inferior and superior parietal cortices. Similarly, increased BOLD responses in patients compared to controls in the frontal pole, paracingulate and the supplementary motor cortex may be suggestive of a memory component to the responses The amygdala, orbitofrontal cortex, substantia nigra/ventral tegmentum, putamen, thalamus, pallidum, inferior parietal (supramarginal and angular gyrus) and cingulate cortex were also seen to have greater differences in BOLD signal changes in patients compared with controls and many of these regions are also associated with general phobic responses. Therefore, we suggest that PIT is a useful task to explore pain- and movement-related anxiety and fear in fMRI studies. Regions in the Default Mode Network remained active or were less deactivated during the PIT task in patients with CMSKP compared to healthy controls supporting the contention that the DMN is abnormal in patients with CMSKP.
Highlights
The way in which chronic musculoskeletal pain (CMSKP) is perceived is modified by many factors [1,2,3,4,5,6,7]; the strongest and most consistent being pain-related fear, anxiety, and catastrophizing [1]
Criteria for patient inclusion in the study were: a physician-diagnosis of chronic nonmalignant pain (International Association for the Study of Pain; [63]); non-inflammatory musculoskeletal pain; a pain score of 50 or above on a numerical rating scale (NRS) of 0–100 (‘No Pain’—‘Worst Possible Pain’) for average pain experienced over the month prior to enrolment; that lying down would not provoke pain, and participants perceived that they would be comfortable in the scanner
We found that a number of pain processing regions including the insula, ACC and inferior and superior parietal cortices were seen to have increase Blood oxygenation level dependent (BOLD) responses in patients compared to controls in response to observing the photographs and rating the perceived level of anxiety at performing the activity
Summary
The way in which chronic musculoskeletal pain (CMSKP) is perceived is modified by many factors [1,2,3,4,5,6,7]; the strongest and most consistent being pain-related fear, anxiety, and catastrophizing [1]. Thibodeau et al [15] found that fear of injury contributes to pain-related anxiety and functional impairment causing catastrophic interpretation of pain. Such is the impact of pain-related anxiety, merely the intention to perform a painful movement can induce behavioral defensive responses [16, 17]. Reduction in movement-related fear and anxiety predict improvements in functioning, reduced affective distress, pain, and interference with daily activity [18,19,20], and understanding these processes has important therapeutic implications. Pincus et al [32] felt this statement was premature as a better understanding is needed of the relationship between beliefs about pain, movement, painrelated fear and avoidance and behavior
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