Neuromatrix Research Articles

The impact of a single music therapy session on pain perception of patients with sickle cell disease

Sickle Cell Disease (SCD) is a genetic condition characterized by pain. The neuromatrix theory of pain suggests pain is a multimodal experience, recognizing the importance of interventions like music therapy (MT), which address the physical and emotional pain experience. This study examined the impact of a MT session on 21 hospitalized patients’ self-reported VOC and its overall benefits. Utilizing a convergent mixed methods design, pain scores were collected prior to, during, and after sessions, with a follow-up interview. Significant changes were observed. Patients reported an average 3.03-point difference between their pre-intervention and MT-intervention score (p<0.001). When pre- and post-intervention scores were compared, patients reported an average 1.9-point pain reduction (p<0.001). Five themes emerged: decreased pain, increased insight, openness in verbal engagement, improved mood, and expressive freedom. The ways in which patients engaged suggest the importance of simultaneously addressing the physical, cognitive and emotional pain experience. When patients became agents of their own pain management, it engaged them in a reflexive process that altered their pain perception, improved their mood, and changed their relationship with SCD. MT is beneficial in reducing pain, simultaneously addressing the multidimensional pain experience. Further research is needed to evaluate mechanisms of impact, including addressing medication dosage. Keywords: Music therapy, sickle cell disease, pain management, neuromatrix theory, hematology

Phantom limb pain: actual concepts of pathophysiology and therapeutic targets

In the review, we present the main pathogenetic mechanisms of the development of phantom limb pain (PLP) after limb amputation, the prevalence of which can reach 87%. The exact mechanism of PLP remains unknown. The involvement of peripheral and central mechanisms of the formation of PLP is assumed. Peripheral mechanisms include increased excitability and the formation of ectopic activity in the amputation neuromas and in the ganglion cells of the dorsal roots of the spinal cord. The central mechanisms are represented by central sensitization in the dorsal horns of the spinal cord with the development of the “wind up” phenomenon, reorganization processes in the thalamus and cortex with thalamic and cortical remapping, and proprioceptive memory. Also significant is the neuromatrix theory, the reduction of feedback from the visual and other sensory systems after deafferentation. PLP therapy methods focused on central mechanisms are: spinal cord stimulation, transcutaneous electrical neurostimulation, deep brain stimulation, non-invasive and invasive methods of cerebral cortex stimulation, mirror therapy, virtual and augmented reality technologies, movement representation and its modification “phantom exercises”. In addition, pharmacologic treatment options based on PLP mechanisms can be used: NMDA receptor antagonists, anticonvulsants, tricyclic antidepressants, opioids.

Precision, integrative medicine for pain management in sickle cell disease.

Sickle cell disease (SCD) is a prevalent and complex inherited pain disorder that can manifest as acute vaso-occlusive crises (VOC) and/or chronic pain. Despite their known risks, opioids are often prescribed routinely and indiscriminately in managing SCD pain, because it is so often severe and debilitating. Integrative medicine strategies, particularly non-opioid therapies, hold promise in safe and effective management of SCD pain. However, the lack of evidence-based methods for managing SCD pain hinders the widespread implementation of non-opioid therapies. In this review, we acknowledge that implementing personalized pain treatment strategies in SCD, which is a guideline-recommended strategy, is currently fraught with limitations. The full implementation of pharmacological and biobehavioral pain approaches targeting mechanistic pain pathways faces challenges due to limited knowledge and limited financial and personnel support. We recommend personalized medicine, pharmacogenomics, and integrative medicine as aspirational strategies for improving pain care in SCD. As an organizing model that is a comprehensive framework for classifying pain subphenotypes and mechanisms in SCD, and for guiding selection of specific strategies, we present evidence updating pain research pioneer Richard Melzack's neuromatrix theory of pain. We advocate for using the updated neuromatrix model to subphenotype individuals with SCD, to better select personalized multimodal treatment strategies, and to identify research gaps fruitful for exploration. We present a fairly complete list of currently used pharmacologic and non-pharmacologic SCD pain therapies, classified by their mechanism of action and by their hypothesized targets in the updated neuromatrix model.

The Neuromatrix Theory of Pain and Transactional Theory of Stress and Coping: Improving Understanding of Pain Catastrophizing in Individuals With ACL Reconstruction and Knee Osteoarthritis

Individuals with anterior cruciate ligament reconstruction and early knee osteoarthritis symptoms commonly exhibit psychological impairments, such as pain catastrophizing. Pain catastrophizing is a negative cognitive–affective response to anticipated or actual pain and has been linked to greater pain intensity and decreased function in this population. However, an examination of the neuromatrix theory of pain and the transactional theory of stress and coping may help to explain the development and consequences of pain catastrophizing in individuals with anterior cruciate ligament reconstruction and early knee osteoarthritis symptoms. Exploration of these theoretical models will help clinicians better understand the impact of pain catastrophizing on post-injury outcomes, as well as help to identify intervention strategies to address maladaptive psychological responses and improve outcomes for individuals with anterior cruciate ligament reconstruction and early knee osteoarthritis symptoms.

Chronic craniomandibular pain after craniotomy: A long-term clinical study

ABSTRACT Objective Chronic craniomandibular/cervical pain and temporomandibular disorders have not been studied in patients who had a craniotomy several years previously. The aim of the current clinical work was to address these issues. Methods A total group of 150 ambulant patients who had a previous craniotomy was subclassified according to whether or not the temporalis muscle was manipulated. Results The average incidence of multiple subsite regional head and neck pain was 69.3% a number of years after a craniotomy. Evidence of internal derangement of the temporomandibular joint was significantly higher in the group that required manipulation of the temporalis muscle during the procedure. Conclusion The pattern of chronic craniomandibular/cervical pain experienced years after a craniotomy supports the brain neuromatrix theory of pain.

Ronald Melzack (1929–2019).

Presents an obituary of Ronald Melzack (1929-2019). Melzack died on Sunday, December 22, 2019, at 10:00 p.m. News of his death spread like wildfire through the network of long-time friends and colleagues who had heard of his imminent passing. At that moment, the world lost a compassionate and caring soul, an advocate for chronic pain sufferers around the globe, and a giant in the international pain community. He is survived by his wife of 59 years, Lucy (née Birch), their son, Joel, and daughter, Lauren. Ron is known for four major accomplishments: establishing Canada's first multidisciplinary pain center at the Montreal General Hospital with neurosurgeon colleague and friend the late Joseph Stratford; the 1965 publication, in Science, of the gate control theory of pain with the late Patrick Wall; development of the McGill Pain Questionnaire and its derivatives; and later in his career, at 60 years of age, publication of the neuromatrix theory of pain, moving the field beyond the spinal gating mechanism into the brain. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Facilitated music listening: Music therapy in an invasive cardiac procedure

This article presents and discusses a clinical music therapy protocol for use during an invasive cardiac procedure and the theoretical rationale behind it. The protocol was developed for a specific invasive cardiac procedure performed transvenously with local anaesthesia: cardiac implantable electronic device lead extraction. The music listening intervention presented in the protocol aims to optimise stress and pain management for patients through patient involvement, communication, individualised music listening and relaxation techniques. The Music Therapist remains present throughout the peri-operative phase (in the operating theatre during the operation). The music is chosen from a limited set of prepared playlists through a process involving assessment and patient preference. Biological, psychological and social components are integrated into the protocol, which is also informed by the theory of music therapy as procedural support, the neuromatrix theory of pain and receptive music therapy techniques. The protocol was developed to be standardised for implementation into the existing medical procedure, yet flexible enough to meet individual patient needs. It is the cornerstone of the research protocol of an ongoing randomised controlled trial at the Department of Cardiology at Oslo University Hospital Ulleval. Results of the randomised controlled trial, focussing on quantitative efficacy outcomes, are expected in 2020.

Theories of pain, up to Descartes and after neuromatrix: what role do they have to develop future paradigms?

The article represents a synthesis of literature about antique, medieval and modern pain theories. In short there are described the most relevant theories about nociception and pain. Chronologically there are presented the discoveries in physiology, anatomy, histology and other methods and investigations of pain. There is discussed the character of past pain theories and its influence on elaboration of the new ones. There was elaborated the hypothesis about the neuromatrix theory and impact of human microbiota on pain perception or other comorbidities with psychological and pain component.

Altered structural connectivity of pain-related brain network in burning mouth syndrome-investigation by graph analysis of probabilistic tractography.

Burning mouth syndrome (BMS) is a chronic intraoral pain syndrome featuring idiopathic oral pain and burning discomfort despite clinically normal oral mucosa. The etiology of chronic pain syndrome is unclear, but preliminary neuroimaging research has suggested the alteration of volume, metabolism, blood flow, and diffusion at multiple brain regions. According to the neuromatrix theory of Melzack, pain sense is generated in the brain by the network of multiple pain-related brain regions. Therefore, the alteration of pain-related network is also assumed as an etiology of chronic pain. In this study, we investigated the brain network of BMS brain by using probabilistic tractography and graph analysis. Fourteen BMS patients and 14 age-matched healthy controls underwent 1.5T MRI. Structural connectivity was calculated in 83 anatomically defined regions with probabilistic tractography of 60-axis diffusion tensor imaging and 3D T1-weighted imaging. Graph theory network analysis was used to evaluate the brain network at local and global connectivity. In BMS brain, a significant difference of local brain connectivity was recognized at the bilateral rostral anterior cingulate cortex, right medial orbitofrontal cortex, and left pars orbitalis which belong to the medial pain system; however, no significant difference was recognized at the lateral system including the somatic sensory cortex. A strengthened connection of the anterior cingulate cortex and medial prefrontal cortex with the basal ganglia, thalamus, and brain stem was revealed. Structural brain network analysis revealed the alteration of the medial system of the pain-related brain network in chronic pain syndrome.

Integrative health through music therapy

This session demonstrates music therapy strategies intended to connect mind, body and spirit in an approach that addresses new models of integrative medicine and health. There is a revolution in health care demanding attention to the whole person, not just symptoms and diagnoses. Music therapy addresses the psychological, cognitive, spiritual, and existential needs of individuals who are ill, working toward wellness of the individual, as opposed to cure of disease. The music therapy techniques presented in this session hale from Eastern philosophies related to ayurvedic and yogic practices of meditation and mantra, but also integrate contemporary thinking in the third wave of cognitive behavioral therapies and research supporting modern music therapy applications. Specifically, the presenter will identify certain mechanisms underlying efficacy, e.g. the neuromatrix theory of pain and psychoneuroimmunology of music;demonstrate music-facilitated strategies for stress and pain management, e.g. music-facilita...

Ağrının Tarihçesi: Avicenna'dan Melzack'a ve Gelecek

The concept of pain has remained a topic of long debate since its emergence in ancient times. The history of pain problems is as long as that of human beings; however, the understanding of pain mechanisms is still far from sufficient. Avicenna who was a Muslim philosopher and physician noted that, in disease, pain can dissociate from touch or temperature recognition, and proposed pain to be an independent sensation so that Avicenna was first to recognize pain as a discrete and separate sense. By the mid twentieth century, the biased methodology of researching pain mechanisms left many questions unanswered when it came to pain conditions occurring in the absence of seemingly inappropriate stimulus. As such, Melzack and Wall developed the Gate Control theory (GCT) of pain in the 1965 which combined aspects of previous theories. This theory offered a physiological explanation for the previously observed effect of psychology on pain perception. In the early 2000s, the mystery of association of psychological or physical stres with chronic pain syndromes, attracted the attention. Then the neuromatrix theory of pain proposed by Melzack provides a new conceptual frame work to examine these problems. The explanation of Ibn Sina as ''nerves carry nociceptive pain sensations to the brain which itself acts as the organisational centre and subsequent source of the painful feeling experienced by the patient'' in the year 1000 is similar to the explanation of Melzack as ''brain has a very important dynamic role in the formation of pain'' in the year 2000.

Dissociable cortical and ventral striatal responses to painful somatosensory stimulation measured using functional MRI imaging

INTRODUCTION Investigation of the neural responses of chronic pain have traditionally involved establishing the BOLD fMRI response to acute pain in a nodal network that has been referred to as the ‘pain matrix’ or the ‘pain neuromatrix’ (1). However, Melzack originally used the term ‘matrix’ because the system to which he referred was multimodal in function and lacked specificity. This might explain why, over 20 years after the term was coined, there has been little translational benefit to patients in terms of improved management of chronic pain states despite numerous studies examining the ‘pain matrix response’. The basal ganglia form part of this matrix and are worthy of further investigation. Destruction of nigrostriatal neurones in the ventral basal ganglia are associated with reduced pain thresholds, the inverse effect occurring with nigrostriatal stimulation(2). However, inactivation of the accumbens core in the ventral basal ganglia with local anaesthetic has demonstrated a hyperalgesic response (3). Molecular imaging has been used to examine the differential roles of dorsal and ventral basal ganglia in pain perception (4) . These authors found that whilst nigrostriatal D2-dopamine activity correlates with sensory and affective ratings, in accumbens the dopamine response is positively associated with negative affect and fear ratings during pain, aspects of the pain experience that are thought to better explain interindividual variations in chronic pain (5) and response to analgesia. In establishing a region of interest approach to the investigation of chronic pain through the application of acutely painful stimuli, the ventral striatum may therefore be an important target. The role of the ventral striatum in response to aversive stimuli is receiving increasing attention, in counterpart to studies of its responsivity to rewarding stimuli. Recent work (6) suggests that the differential striatal responses to acute pain may provide a meaningful insight into the neural substrates of chronic pain perception, including idiopathic pain disorders and the functional somatic syndromes, where activation of the ‘pain matrix’ as a whole has proved unable to. We have investigated the brain response to somatosensory pain, specifically examining the response of the ventral striatum in contrast to other components of the ‘pain matrix’.

Cerebral Stimulation for the Affective Component of Neuropathic Pain

To review the current state of cerebral stimulation for neuropathic pain and to propose that cerebral stimulation should aim also at the affective sphere of chronic pain rather than solely focusing on the primary sensory-discriminative sphere. The past and current goals of cerebral stimulation are reviewed as well as its limitations. A novel deep brain stimulation approach is proposed to evaluate this conceptual shift from somatosensory to affective sphere of pain targeting. Thalamic and other central pain syndromes are typically intractable to current treatment methods, including cerebral neuromodulation of somatosensory pathways, leading to long-term distress and disability. Our modern understanding of chronic pain pathophysiology is based largely on the neuromatrix theory, where cognitive, affective, and sensory-discriminative spheres contribute equally to the overall pain experience. During the last decade, the safety and feasibility of chronic stimulation of neural pathways related to mood and affect has been explored with promising results. Here, we propose a novel approach to modulate the affective sphere of chronic pain by targeting similar networks in patients with treatment-refractory central pain. Our primary goal is not to produce (or measure) analgesia, but rather to modulate the affective burden of chronic pain. Cerebral neuromodulation for neuropathic pain has had limited efficacy thus far. Shifting our aim to neural networks related to the affective sphere of pain may allow us to reduce pain conditioning and pain-related disability. Our ultimate goal is to promote rehabilitation from chronic pain-social and occupational.

Pain.

Pain has many valuable functions. It often signals injury or disease, generates a wide range of adaptive behaviors, and promotes healing through rest. Despite these beneficial aspects of pain, there are negative features that challenge our understanding of the puzzle of pain, including persistent phantom limb pain after amputation or total spinal cord transection. Pain is a personal, subjective experience influenced by cultural learning, the meaning of the situation, attention, and other psychological variables. Pain processes do not begin with the stimulation of receptors. Rather, injury or disease produces neural signals that enter an active nervous system that (in the adult organism) is the substrate of past experience, culture, and a host of other environmental and personal factors. These brain processes actively participate in the selection, abstraction, and synthesis of information from the total sensory input. Pain is not simply the end product of a linear sensory transmission system; it is a dynamic process that involves continuous interactions among complex ascending and descending systems. The neuromatrix theory guides us away from the Cartesian concept of pain as a sensation produced by injury, inflammation, or other tissue pathology and toward the concept of pain as a multidimensional experience produced by multiple influences. These influences range from the existing synaptic architecture of the neuromatrix-which is determined by genetic and sensory factors-to influences from within the body and from other areas in the brain. Genetic influences on synaptic architecture may determine-or predispose toward-the development of chronic pain syndromes. WIREs Cogn Sci 2013, 4:1-15. doi: 10.1002/wcs.1201 For further resources related to this article, please visit the WIREs website.

Viewpoint: From ladder to platform: a new concept for pain management

Pain remains one of the top five reasons for consultations in general practice, presenting either alone or as comorbidity. The World Health Organization (WHO) analgesic ladder proposed in 1986 has been the cornerstone of pain management, but is often inadequate in daily practice, especially when dealing with the diverse nature and etiology of various pain conditions. There is a need for a better concept which is universally applicable that acknowledges the value of, and need for, other domains of treatment for pain. This article reviews the original ideas of the WHO analgesic ladder and proposes its extension to a platform model in the context of pain management. Pain affects both the physical and psychological wellbeing of patients and should not be treated with pharmacotherapy alone. The model of WHO analgesic ladder provides guidelines for choosing the analgesic agents, but has its limitations. Incorporating the latest paradigm of neuromatrix theory, both acute and chronic pain should be best managed with a broader perspective incorporating multimodal non-pharmacological and supportive treatments, illustrated by the concept of interacting domains on a broad platform as presented in this article. Different levels of pain severity and chronicity necessitate different analgesic platforms of management, and the clinician should move up or down the appropriate platform to explore the various treatment options as per the status and needs of the patient.

Physiology and Treatment of Pain

Physiology and Treatment of Pain

The Challenge of Chronic Pain: A Psychoanalytic Approach

Although patients with medically unexplained chronic pain are sometimes referred for psychiatric consultation, it is rare for them to be recommended for a psychoanalytically informed treatment. Moreover, because they experience their distress as primarily physical, it is difficult to engage such patients in psychoanalysis. Nonetheless, the psychoanalytic understanding of conversion symptom formation, and of how childhood trauma and adverse attachment experiences impact on the mind-brain-body-complex, can be integrated with the current neuromatrix theory of pain and thereby offer a comprehensive theoretical model and guide for the psychoanalytic treatment of some patients with chronic pain syndromes. The author illustrates this approach by reporting the analysis of a patient with chronic pelvic pain who had obtained no relief from a host of medical and psychiatric therapies. The analytic process of linking the pain with emotional trauma and pathologic internal object relations, and thereby symbolizing the pain, allowed the patient to discover multiple meanings for the symptom and make important life changes as the pain subsided.

Pain: Psychological Perspectives

As physiotherapists, we can learn and adapt many concepts from a psychological perspective on pain. Many theories and models of pain have come from psychological research, most notably the gate control theory,1 used by many to explain how treatments work in modulating pain. Hadjistavropoulos and Craig's book highlights new concepts of pain and identifies some factors that influence clients' perception of nociception or other somatic input. Although primarily intended for psychologists managing and studying pain, the editors acknowledge that their book “would also be of interest to a variety of other professionals working in this area (e.g., physicians, nurses, physiotherapists).” (p. xi). In Pain: Psychological Perspectives, the editors have invited many top experts in pain research to share their findings and to indicate the direction in which their research is heading and how it can be used in clinical practice. In most of the book's 12 chapters, discussion of empirical evidence outlining the strengths and weaknesses of certain theories and treatment approaches was provided to assist in understanding the overall evolution of pain theory and treatment. The introduction outlines the book's framework and presents a brief historical review of pain from the Middle Ages to the present, as well as an overview of material that will be discussed in detail in the following chapters. Chapter 1 identifies shortcomings of the traditional biomedical specificity theory and underscores the need for the gate control theory to explain observed clinical phenomena. The authors then focus on the progression of the gate control theory to the new neuromatrix concept. Chapter 2 presents the biopsychosocial model and how the interplay among biology, psychology and social factors affects one's perception and response to pain. The biopsychosocial model has led to fear-avoidance theories that are used to explain chronic pain and disability. The implications of how pain experience can alter the autonomic nervous system and how negative cognition can impact pain perception and experience are discussed in Chapter 3. Chapters 4 through 7 address social influences and ethnocultural differences and their influence on how pain is communicated, as well as how pain perception and communication change over the life cycle. Chapter 8 deals with chronic pain assessment and discusses interview strategies and risk factors for chronic pain, as well as assessment of impairment, disability, vocational assessment and malingering. Chapters 9 and 10 describe psychological interventions for persons with acute or chronic pain. The discussion on cognitive-behavioural therapy provided interesting and helpful approaches for treatment of chronic pain, such as how graded activity and exercises “guided by physiotherapists” (p. 280) can address fears of certain movements and other physical demands. Chapters 11 and 12 discuss controversies and ethical concerns. The discussion on operant conditioning, malingering and pain in the workplace was very helpful. It was encouraging to see that our skill as physiotherapists can be linked to positive results for persons with pain-related disability. With our focus on function, we inherently move clients forward. We are often the first to initiate the return to work planning, and “when return to work during treatment is encouraged, outcomes are more favorable” (p. 315). Ethical concerns addressed include treatment of pain in the elderly and assessment of malingering and symptom exaggeration. Therapists working with workmen's compensation boards or other third-party payers may find these chapters especially useful. As physiotherapists, pain is one of the most common concerns we address, with many of our treatment goals geared toward decreasing pain. At times, we must make value judgments about clients' reports of pain to third-party payers, who require comment on the reliability of complaints considering the clients' diagnoses. In today's evidence-based world, we need to have a sound, research-based understanding of the complicated factors that mediate pain and disability. This book will enhance our understanding of the meaning of pain and ultimately make us more effective and informed clinicians.

Fear-Avoidance Beliefs and Temporal Summation of Evoked Thermal Pain Influence Self-Report of Disability in Patients With Chronic Low Back Pain

Quantitative sensory testing has demonstrated a promising link between experimentally determined pain sensitivity and clinical pain. However, previous studies of quantitative sensory testing have not routinely considered the important influence of psychological factors on clinical pain. This study investigated whether measures of thermal pain sensitivity (temporal summation, first pulse response, and tolerance) contributed to clinical pain reports for patients with chronic low back pain, after controlling for depression or fear-avoidance beliefs about work. Consecutive patients (n=27) with chronic low back pain were recruited from an interdisciplinary pain rehabilitation program in Jacksonville, FL. Patients completed validated self-report questionnaires for depression, fear-avoidance beliefs, clinical pain intensity, and clinical pain related disability. Patients also underwent quantitative sensory testing from previously described protocols to determine thermal pain sensitivity (temporal summation, first pulse response, and tolerance). Hierarchical regression models investigated the contribution of depression and thermal pain sensitivity to clinical pain intensity, and fear-avoidance beliefs and thermal pain sensitivity to clinical pain related disability. None of the measures of thermal pain sensitivity contributed to clinical pain intensity after controlling for depression. Temporal summation of evoked thermal pain significantly contributed to clinical pain disability after controlling for fear-avoidance beliefs about work. Measures of thermal pain sensitivity did not contribute to pain intensity, after controlling for depression. Fear-avoidance beliefs about work and temporal summation of evoked thermal pain significantly influenced pain related disability. These factors should be considered as potential outcome predictors for patients with work-related low back pain. This study supported the neuromatrix theory of pain for patients with CLBP, as cognitive-evaluative factor contributed to pain perception, and cognitive-evaluative and sensory-discriminative factors uniquely contributed to an action program in response to chronic pain. Future research will determine if a predictive model consisting of fear-avoidance beliefs and temporal summation of evoked thermal pain has predictive validity for determining clinical outcome in rehabilitation or vocational settings.

Understanding pain, part 1: physiology of pain

This article is the first in a two-part series which explores pain and its management from a physiological perspective. Pain is a common experience which is often inadequately managed in hospital and community settings. While nurses are in a key position to contribute to successful pain management there are frequent accounts in the literature that nurses lack knowledge about pain management. Knowledge of pain physiology is fundamental to its successful management. This article introduces nurses to the components in the pain pathway and describes nociceptors which respond to pain stimuli and identifies pain fibres which carry pain information to the spinal cord. The processing of pain in the spinal cord is explained and the role of the brain in the manifestation of the pain experience is also explored. The gate control theory of pain and the more recent neuromatrix theory are discussed.