Evaluating the efficacy of an attention modification program for patients with fibromyalgia: a randomized controlled trial

Gamified Web-Delivered Attentional Bias Modification Training for Adults With Chronic Pain: Randomized, Double-Blind, Placebo-Controlled Trial

BACKGROUND

Attentional bias to pain-related information has been implicated in pain chronicity. To date, research investigating attentional bias modification training (ABMT) procedures in people with chronic pain has found variable success, perhaps because training paradigms are typically repetitive and monotonous, which could negatively affect engagement and adherence. Increasing engagement through the gamification (ie, the use of game elements) of ABMT may provide the opportunity to overcome some of these barriers. However, ABMT studies applied to the chronic pain field have not yet incorporated gamification elements.

OBJECTIVE

This study aimed to investigate the effects of a gamified web-delivered ABMT intervention in a sample of adults with chronic pain via a randomized, double-blind, placebo-controlled trial.

METHODS

A final sample of 129 adults with chronic musculoskeletal pain, recruited from clinical (hospital outpatient waiting list) and nonclinical (wider community) settings, were included in this randomized, double-blind, placebo-controlled, 3-arm trial. Participants were randomly assigned to complete 6 web-based sessions of nongamified standard ABMT (n=43), gamified ABMT (n=41), or a control condition (nongamified sham ABMT; n=45) over a period of 3 weeks. Active ABMT conditions trained attention away from pain-related words. The gamified task included a combination of 5 game elements. Participant outcomes were assessed before training, during training, immediately after training, and at 1-month follow-up. Primary outcomes included self-reported and behavioral engagement, pain intensity, and pain interference. Secondary outcomes included anxiety, depression, cognitive biases, and perceived improvement.

RESULTS

Results of the linear mixed model analyses suggest that across all conditions, there was an overall small to medium decline in self-reported task-related engagement between sessions 1 and 2 (P<.001; Cohen d=0.257; 95% CI 0.13-0.39), sessions 1 and 3 (P<.001; Cohen d=0.368; 95% CI 0.23-0.50), sessions 1 and 4 (P<.001; Cohen d=0.473; 95% CI 0.34-0.61), sessions 1 and 5 (P<.001; Cohen d=0.488; 95% CI 0.35-0.63), and sessions 1 and 6 (P<.001; Cohen d=0.596; 95% CI 0.46-0.73). There was also an overall small decrease in depressive symptoms from baseline to posttraining assessment (P=.007; Cohen d=0.180; 95% CI 0.05-0.31) and in pain intensity (P=.008; Cohen d=0.180; 95% CI 0.05-0.31) and pain interference (P<.001; Cohen d=0.237; 95% CI 0.10-0.37) from baseline to follow-up assessment. However, no differential effects were observed over time between the 3 conditions on measures of engagement, pain intensity, pain interference, attentional bias, anxiety, depression, interpretation bias, or perceived improvement (all P values>.05).

CONCLUSIONS

These findings suggest that gamification, in this context, was not effective at enhancing engagement, and they do not support the widespread clinical use of web-delivered ABMT in treating individuals with chronic musculoskeletal pain. The implications of these findings are discussed, and future directions for research are suggested.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12620000803998; https://anzctr.org.au/ACTRN12620000803998.aspx.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/32359.

Attentional Processes in Pain: The Importance of Context and Attentional Alignment

The attentional bias literature has consistently failed to take context into account. We developed a novel paradigm in immersive virtual reality (VR) with pain stimuli where it would be adaptive or nonadaptive to attend to the stimuli. Participants had to indicate the location of the stimuli. Seventy participants were recruited. The VR-attention task assessed overall attentional bias (the tendency to prioritize pain compared with nonpain stimuli) and attentional alignment (the tendency to attend to pain more in adaptive than nonadaptive situations). Pain tolerance and threshold were measured using electrocutaneous stimulation and thermal pain. We conducted 2 (context: adaptive vs nonadaptive) × 2 (congruence: congruent vs incongruent) Analysis of Covariance, controlling for threat. Participants responded to pain probes more quickly in adaptive than nonadaptive contexts. There was an overall bias away from pain-related stimuli (avoidance) in reaction time to the target. There was also an interaction where avoidance was greater in nonadaptive contexts, indicative of attentional alignment. For gaze behavior, both attentional alignment and attentional bias were observed for latency to first fixation on the target, such that participants showed vigilance for pain particularly in the adaptive context. Attentional alignment was correlated with threshold and tolerance from electrocutaneous stimulation but not thermal pain. In conclusion, we found overall attentional biases indicating vigilance (latency to first fixation) and avoidance (response to target). We also found that participants evidenced a pattern of attention favoring adaptive over nonadaptive contexts (attentional alignment). It was attentional alignment, but not overall attentional bias, that predicted pain tolerance and threshold. PERSPECTIVE: The study explored attentional processes in pain through a novel paradigm designed in VR. The results found that positive attentional alignment, or the tendency to attend to pain more in adaptive contexts rather than nonadaptive contexts, predicted pain outcomes.

Understanding the Associations between Executive Function and Psychological Variables in Fibromyalgia Syndrome: A Network Analysis Approach

The aim of this study was to quantify the multivariate relationships between clinical, cognitive performance, executive functioning, and psychological outcomes in women with fibromyalgia (FMS) using network analyses. Demographic (age, height, weight), clinical (pain history, pain intensity, and related disability), neurocognitive (D2 Attention test, Rey-Osterrieth Complex Figure for visual perception, "Digits D/R/I" tests of the WAIS-IV battery for working memory, the 5-Digit Test for mental inhibition, the Symbol Search for processing speed and the Zoo Test for planning/decision making) and psychological (depressive symptoms, anxiety levels, sleep quality, pain hypervigilance) variables were collected in 129 women with FMS and 111 healthy women. Network analyses were conducted separately for each group to quantify the adjusted correlations between the modeled variables and to assess their centrality indices (i.e., connectivity with other symptoms in the network and their importance in the network). The network identified 74 associations in FMS women and 46 associations in controls with small differences. The strongest correlations in both groups were found between different attention variables: d2_CON with d2_C, d2_O with d_2TR, and d2_CON with d2_TA. The most central variables were d2_TA, d2_C, and d2_CON (highest strength centrality in both groups) and anxiety levels and pain hypervigilance (highest harmonic centrality in FMS women). The strength centrality of the network was stable for women with FMS (CScor0.7: 0.68) but not for healthy women (CScor0.7: 0.28). This study found that attention variables are most relevant within a neurocognitive network and that psychological variables are most important for the treatment of women with FMS. The clinical implications of the current findings, such as the development of treatments targeting these variables, are discussed.

Neural mechanisms underlying attentional bias modification in fibromyalgia patients: a double-blind ERP study

There is a growing interest in the potential benefits of attentional bias modification (ABM) training in chronic pain patients. However, studies examining the effectiveness of ABM programs in fibromyalgia patients have demonstrated inconclusive effects on both behavioral indices and clinical symptoms. Additionally, underlying neural dynamics of ABM effects could yield new insights but remain yet unexplored. Current study, therefore, aims to investigate the effects of ABM training on known neural electrophysiological indicators of attentional bias to pain (P2, N2a). Thirty-two fibromyalgia patients were enrolled and randomly assigned to an ABM training (N = 16) or control (N = 16) condition (2 weeks duration). Within the ABM training condition participants performed five sessions consisting of a modified version of the dot-probe task in which patients were trained to avoid facial pain expressions, whereas in the control group participants performed five sessions consisting of a standard version of the dot-probe task. Potential ABM training effects were evaluated by comparing a single pre- and post-treatment session, in which event-related potentials (ERPs) were recorded in response to both facial expressions and target stimuli. Furthermore, patients filled out a series of self-report questionnaires assessing anxiety, depression, pain-related worrying, fear of pain, fatigue and pain status. After training, results indicated an overall reduction of the amplitude of the P2 component followed by an enhancement of N2a amplitude for the ABM condition compared to control condition. In addition, scores on anxiety and depression decreased in patients assigned to the training condition. However, we found no effects derived from the training on pain-related and fatigue status. Present study offers new insights related to the possible neural mechanisms underlying the effect of ABM training in fibromyalgia. Clinical trial (TRN: NCT05905159) retrospectively registered (30/05/2023).

The autobiographical memory system and chronic pain: A neurocognitive framework for the initiation and maintenance of chronic pain

Chronic pain affects approximately 20% of the world's population, exerting a substantial burden on the affected individual, their families, and healthcare systems globally. Deficits in autobiographical memory have been identified among individuals living with chronic pain, and even found to pose a risk for the transition to chronicity. Recent neuroimaging studies have simultaneously implicated common brain regions central to autobiographical memory processing in the maintenance of and susceptibility to chronic pain. The present review proposes a novel neurocognitive framework for chronic pain explained by mechanisms underlying the autobiographical memory system. Here, we 1) summarize the current literature on autobiographical memory in pain, 2) discuss the role of the hippocampus and cortical brain regions including the ventromedial prefrontal cortex, anterior temporal lobe, and amygdala in relation to autobiographical memory, memory schemas, emotional processing, and pain, 3) synthesize these findings in a neurocognitive framework that explains these relationships and their implications for patients' pain outcomes, and 4) propose translational directions for the prevention, management, and treatment of chronic pain.

The role of attention bias malleability in experiencing pain and associated disability

Background

Attentional processing of pain has been theorized to play a key role in the severity of pain and associated disability. In particular attentional bias towards pain information, resulting in poor pain outcomes, has been extensively researched. Recently, the idea was put forward that attention bias malleability (AM), i.e., the readiness to acquire an attentional bias irrespective of its direction, may be key in predicting poor pain outcomes. We tested this hypothesis in two studies.

Methods

In Study 1, 55 healthy participants completed an AM paradigm, followed by an experimental heat pain paradigm probing pain experience and pain-related task interference. In Study 2, 71 people with chronic pain completed an AM paradigm and questionnaires probing pain experience and associated disability.

Results

In Study 1, including healthy participants, no relationship was found between AM indices and experimental pain outcomes. In Study 2, including chronic pain patients, results indicated that higher levels of overall AM were related to higher levels of pain experience and disability.

Conclusion

This study partially supports the hypotheses that the degree to which individuals can adapt their attentional preference in line with changing environmental conditions is associated with poor pain outcomes. However, future research is needed to clarify inconsistent findings between healthy volunteers and chronic pain patients as well as to determine the causal status of AM in poor pain outcomes.

Investigating attention toward pain-related cues in an Arabic-speaking population with and without chronic pain

There is some evidence for attentional biases in individuals with chronic pain (CP). Cultural and linguistic differences might affect the manifestation of these processes across populations. However, such attentional biases have not been explored in the Arabic-speaking population. The current study investigated these attentional biases and possible associations with resilience. Two matched groups of Arabic-speaking participants with (58) and without (58) CP were recruited from Jordan and the United Kingdom. They completed emotionally modified versions of the Posner cueing and Stroop tasks, alongside questionnaires. Significant group differences were found for the Posner task, with the CP group exhibiting disengagement revealed by the inhibition of return (IOR) effect for sensory pain-related cues compared to delayed disengagement for the other cue types. The control group showed IOR across cue types. No group differences were found on the Stroop task. The CP group had lower resilience scores than healthy controls, and resilience moderated performance on the Posner task. The study provides preliminary evidence about the attentional processes in the Arabic population; the speed of disengagement is affected in the CP group with early disengagement for sensory pain-related information compared to affect pain and neutral stimuli. Furthermore, resilience levels in the CP and control group moderated the performance on the Posner task, suggesting that it influences attentional allocation. This study can help in understanding how the phenomenon of attention bias intertwines with the cultural and linguistic factors. Future research should further explore attentional dynamics across different time points in this population and the modulatory effect of resilience.

Landau model for illustrating the learning and unlearning process of nociplastic pain

Recent advancements in understanding the consolidation of nociplastic pain point to a complex, non-conscious learned process of threat perception. Neurobiological pain education is emerging as a promising approach to unlearn nociplastic pain, supported by biopsychosocial tools such as exposure to movement, mindfulness, and group sharing formats. However, this approach is still not well-known among clinicians and the society at large, creating a communication problem that unfortunately perpetuates the suffering of patients. Herein, we propose a Landau model to describe the learning and unlearning process of nociplastic pain, aiming to clarify this complex situation and facilitate communication across different sectors of the society. Nociplastic pain corresponds to a first-order transition, with attention more likely in the alert-protection state than in the trust-explore state. Two appealing results of the model are that the perception of the critical context depends on personal history regarding the symptom and that biopsychosocial loops are formed when there is alarming learned historical information about the symptom, along with confused and contradictory expert information, as seen in nocebo messages. Learning and unlearning in the model correspond to a chang in control parametrs that can weigh more on the alert-protection state, trust-explore state, uncertain state or neutral state. This description clarifies why neurobiological education is the foundational therapy from which others must be built to embody the accessible, clear, and trustworthy information.

The effectiveness of home-based transcranial direct current stimulation on chronic pain: A systematic review and meta-analysis

Objective

As highlighted by the COVID-19 pandemic, identifying strategies for home-based patient management is crucial. As pain is highly prevalent and imposes significant burdens, interest in its remote management is steadily increasing. Transcranial Direct Current Stimulation (tDCS) seems promising in this context.

Methods

This systematic review and meta-analysis aimed to determine the effectiveness of home-based tDCS in pain management (PROSPERO, CRD42023452899). The extracted data included clinical conditions, interventions, comparators, outcome measures, adverse effects, and risk of bias; the Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessment was carried out.

Results

12 records (9 randomized controlled trials [RCTs], 446 participants, 266 undergoing tDCS) were included in the systematic review. The meta-analysis showed that home-based tDCS might produce large and clinically relevant improvement in chronic pain intensity at the end of the intervention (standard mean difference [SMD] -0.95, 95% CI -1.34 to -0.56; p < 0.01; 404 participants, low certainty), as well as small clinically unimportant improvement at short-term follow-up (SMD -0.50, 95% CI -0.82 to -0.19; p < 0.01; 160 participants, moderate certainty). A subgroup analysis showed that it might clinically improve the chronic pain related to fibromyalgia and knee osteoarthritis. Moreover, home-based tDCS seems to modulate pressure pain threshold, heat pain threshold, and heat and cold tolerance at the end of the intervention. Notably, tDCS appeared to be generally safe, well-accepted and easily applied at home.

Conclusions

Low to moderate certainty evidence suggests that home-based self-administered tDCS is a safe and effective tool for managing various types of chronic pain. Further well-designed, large-scale RCTs are warranted.

Exploring chronic pain related attentional experiences, distress and coping strategies among Arabic-speaking individuals in Jordan and the United Kingdom

Introduction

The lived experiences of chronic pain (CP) among Arabic-speaking populations remain underexplored. A better understanding of these experiences and their associations with attention difficulties, coping mechanisms, and treatment options could lead to improved support for this group.

Methods

This qualitative study utilised a descriptive design and involved one-to-one interviews with 51 participants with CP who had just completed two attention tasks. Interviews were conducted using a semi-structured topic guide, transcribed verbatim and translated from Arabic to English before agreeing on the coding framework. Themes and subthemes were extracted using a framework analysis approach.

Results

The study identified six main themes: Factors contributing towards developing or exacerbating CP, the impact of CP on psychosocial functions, including attention, the perceived role of social support, coping strategies for managing CP, perceptions about available treatments and recommendations for interventions.

Discussion

CP significantly impacts individuals' physical and psychosocial functions, and it is reciprocally associated with attentional difficulties. Despite using various approaches to manage their CP, none of the participants used psychological interventions or counselling. Understanding the diverse impacts of CP and the coping strategies employed to develop culturally sensitive interventions, review current related policies, and improve healthcare services is crucial to managing CP among this population.

Psychological therapies delivered remotely for the management of chronic pain (excluding headache) in adults

BACKGROUND

Chronic pain (pain lasting three months or more) is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Common types (excluding headache) include back pain, fibromyalgia, and neuropathic pain. Access to traditional face-to-face therapies can be restricted by healthcare resources, geography, and cost. Remote technology-based delivery of psychological therapies has the potential to overcome treatment barriers. However, their therapeutic effectiveness compared to traditional delivery methods requires further investigation.

OBJECTIVES

To determine the benefits and harms of remotely-delivered psychological therapies compared to active control, waiting list, or treatment as usual for the management of chronic pain in adults.

SEARCH METHODS

We searched for randomised controlled trials (RCTs) in CENTRAL, MEDLINE, Embase, and PsycINFO to 29 June 2022. We also searched clinical trials registers and reference lists. We conducted a citation search of included trials to identify any further eligible trials.

SELECTION CRITERIA

We included RCTs in adults (≥ 18 years old) with chronic pain. Interventions included psychological therapies with recognisable psychotherapeutic content or based on psychological theory. Trials had to have delivered therapy remote from the therapist (e.g. Internet, smartphone application) and involve no more than 30% contact time with a clinician. Comparators included treatment as usual (including waiting-list controls) and active controls (e.g. education).

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures.

MAIN RESULTS

We included 32 trials (4924 participants) in the analyses. Twenty-five studies delivered cognitive behavioural therapy (CBT) to participants, and seven delivered acceptance and commitment therapy (ACT). Participants had back pain, musculoskeletal pain, opioid-treated chronic pain, mixed chronic pain, hip or knee osteoarthritis, spinal cord injury, fibromyalgia, provoked vestibulodynia, or rheumatoid arthritis. We assessed 25 studies as having an unclear or high risk of bias for selective reporting. However, across studies overall, risk of bias was generally low. We downgraded evidence certainty for primary outcomes for inconsistency, imprecision, and study limitations. Certainty of evidence ranged from moderate to very low. Adverse events were inadequately reported or recorded across studies. We report results only for studies in CBT here. Cognitive behavioural therapy (CBT) versus treatment as usual (TAU) Pain intensity Immediately after treatment, CBT likely demonstrates a small beneficial effect compared to TAU (standardised mean difference (SMD) -0.28, 95% confidence interval (CI) -0.39 to -0.16; 20 studies, 3206 participants; moderate-certainty evidence). Participants receiving CBT are probably more likely to achieve a 30% improvement in pain intensity compared to TAU (23% versus 11%; risk ratio (RR) 2.15, 95% CI 1.62 to 2.85; 5 studies, 1347 participants; moderate-certainty evidence). They may also be more likely to achieve a 50% improvement in pain intensity (6% versus 2%; RR 2.31, 95% CI 1.14 to 4.66; 4 studies, 1229 participants), but the evidence is of low certainty. At follow-up, there is likely little to no difference in pain intensity between CBT and TAU (SMD -0.04, 95% CI -0.17 to 0.09; 8 studies, 959 participants; moderate-certainty evidence). The evidence comparing CBT to TAU on achieving a 30% improvement in pain is very uncertain (40% versus 24%; RR 1.70, 95% CI 0.82 to 3.53; 1 study, 69 participants). No evidence was available regarding a 50% improvement in pain. Functional disability Immediately after treatment, CBT may demonstrate a small beneficial improvement compared to TAU (SMD -0.38, 95% CI -0.53 to -0.22; 14 studies, 2672 participants; low-certainty evidence). At follow-up, there is likely little to no difference between treatments (SMD -0.05, 95% CI -0.23 to 0.14; 3 studies, 461 participants; moderate-certainty evidence). Quality of life Immediately after treatment, CBT may not have resulted in a beneficial effect on quality of life compared to TAU, but the evidence is very uncertain (SMD -0.16, 95% CI -0.43 to 0.11; 7 studies, 1423 participants). There is likely little to no difference between CBT and TAU on quality of life at follow-up (SMD -0.16, 95% CI -0.37 to 0.05; 3 studies, 352 participants; moderate-certainty evidence). Adverse events Immediately after treatment, evidence about the number of people experiencing adverse events is very uncertain (34% in TAU versus 6% in CBT; RR 6.00, 95% CI 2.2 to 16.40; 1 study, 140 participants). No evidence was available at follow-up. Cognitive behavioural therapy (CBT) versus active control Pain intensity Immediately after treatment, CBT likely demonstrates a small beneficial effect compared to active control (SMD -0.28, 95% CI -0.52 to -0.04; 3 studies, 261 participants; moderate-certainty evidence). The evidence at follow-up is very uncertain (mean difference (MD) 0.50, 95% CI -0.30 to 1.30; 1 study, 127 participants). No evidence was available for a 30% or 50% pain intensity improvement. Functional disability Immediately after treatment, there may be little to no difference between CBT and active control on functional disability (SMD -0.26, 95% CI -0.55 to 0.02; 2 studies, 189 participants; low-certainty evidence). The evidence at follow-up is very uncertain (MD 3.40, 95% CI -1.15 to 7.95; 1 study, 127 participants). Quality of life Immediately after treatment, there is likely little to no difference in CBT and active control (SMD -0.22, 95% CI -1.11 to 0.66; 3 studies, 261 participants; moderate-certainty evidence). The evidence at follow-up is very uncertain (MD 0.00, 95% CI -0.06 to 0.06; 1 study, 127 participants). Adverse events Immediately after treatment, the evidence comparing CBT to active control is very uncertain (2% versus 0%; RR 3.23, 95% CI 0.13 to 77.84; 1 study, 135 participants). No evidence was available at follow-up.

AUTHORS' CONCLUSIONS

Currently, evidence about remotely-delivered psychological therapies is largely limited to Internet-based delivery of CBT. We found evidence that remotely-delivered CBT has small benefits for pain intensity (moderate certainty) and functional disability (moderate to low certainty) in adults experiencing chronic pain. Benefits were not maintained at follow-up. Our appraisal of quality of life and adverse events outcomes post-treatment were limited by study numbers, evidence certainty, or both. We found limited research (mostly low to very low certainty) exploring other psychological therapies (i.e. ACT). More high-quality studies are needed to assess the broad translatability of psychological therapies to remote delivery, the different delivery technologies, treatment longevity, comparison with active control, and adverse events.

e-Health Interventions Targeting Pain-Related Psychological Variables in Fibromyalgia: A Systematic Review

There is growing evidence to support the potential benefit of e-Health interventions targeting psychosocial outcomes and/or pain-related psychological variables for chronic pain conditions, including fibromyalgia syndrome (FMS). This systematic review aims at providing an in-depth description of the available e-Health psychological and/or multicomponent interventions for patients with FMS. Searches were made in PubMed, Cochrane, Web of Science, and PsycINFO up to 15 May 2023, finally including twenty-six articles. The quality of the included articles was medium-high (average quality assessment score of 77.1%). 50% of studies were randomized controlled trials (RCTs) (n = 13), and the majority of them focused exclusively on adult patients with FMS (n = 23) who were predominantly female. Four categories of e-Health modalities were identified: web-based (n = 19), mobile application (m-Health) (n = 3), virtual reality (VR) (n = 2), and video consulting (n = 2). Interventions were mainly based on the cognitive behavioral therapy (CBT) approach (n = 14) and mostly involved contact with a healthcare professional through different digital tools. Overall, a growing number of psychological and multicomponent interventions have been created and delivered using digital tools in the context of FMS, showing their potentiality for improving psychosocial outcomes and pain-related psychological variables. However, some digital tools resulted as underrepresented, and the literature on this topic appears highly heterogeneous precluding robust conclusions.

Neurophysiological and Psychosocial Mechanisms of Fibromyalgia: A Comprehensive Review and Call for An Integrative Model

Research into the neurobiological and psychosocial mechanisms involved in fibromyalgia has progressed remarkably in recent years. Despite this, current accounts of fibromyalgia fail to capture the complex, dynamic, and mutual crosstalk between neurophysiological and psychosocial domains. We conducted a comprehensive review of the existing literature in order to: a) synthesize current knowledge on fibromyalgia; b) explore and highlight multi-level links and pathways between different systems; and c) build bridges connecting disparate perspectives. An extensive panel of international experts in neurophysiological and psychosocial aspects of fibromyalgia discussed the collected evidence and progressively refined and conceptualized its interpretation. This work constitutes an essential step towards the development of a model capable of integrating the main factors implicated in fibromyalgia into a single, unified construct which appears indispensable to foster the understanding, assessment, and intervention for fibromyalgia.

What can we learn about selective attention processes in individuals with chronic pain using reaction time tasks? A systematic review and meta-analysis

ABSTRACT

Information-processing biases such as attentional, interpretation, and memory biases are believed to play a role in exacerbating and maintaining chronic pain (CP). Evidence suggests that individuals with CP show attentional bias toward pain-related information. However, the selective attentional processes that underpin this bias are not always well outlined in the literature. To improve current understanding, a systematic review was performed using a descriptive synthesis of reaction time-based studies. A random-effects meta-analysis was added to explore whether the results of previous meta-analyses would be confirmed using studies with a larger sample size. For this review, 2008 studies were screened from 4 databases, of which 34 (participant n = 3154) were included in the review and a subset of 15 (participant n = 1339) were included in the meta-analysis. Review results were summarised by producing a descriptive synthesis for all studies. Meta-analysis results indicated a mild significant attentional bias toward sensory pain-related information (k = 15, g = 0.28, 95% CI [0.16, 0.39], I2 = 43.2%, P = 0.038), and preliminary evidence of significant moderate bias towards affective pain-related information (k = 3, g = 0.48, 95% CI [0.23, 0.72], I2 = 7.1%, P = 0.341) for CP groups compared with control groups. We explored the main tasks, stimuli, and CP subtypes used to address attentional biases and related processes. However, variation across studies did not allow for a decisive conclusion about the role of stimulus, task type, or related attentional processes. In addition, a table of CP attention-related models was produced and tested for reliability. Finally, other results and recommendations are discussed.

A double-blind phase II randomized controlled trial of an online cognitive bias modification for interpretation program with and without psychoeducation for people with chronic pain

ABSTRACT

Cognitive bias modification for interpretation (CBM-I) is an effective intervention for anxiety, but there is only a single trial in people with chronic pain. The aim of this randomized controlled trial was to test CBM-I with and without psychoeducation for people with chronic pain. We randomized 288 participants to 4 groups comprising treatment (CBM-I vs placebo) with or without psychoeducation. One hundred and eighty-three participants (64%) completed 4, 15-minute training sessions over 2 weeks. The coprimary outcomes were pain interference and pain intensity. We also measured interpretation bias, fear of movement, catastrophizing, depression, anxiety, and stress. Participants with more psychopathology at baseline were more likely to dropout, as were those allocated to psychoeducation. Intention-to-treat analyses using linear mixed models regression were conducted. Training effects of CBM-I were found on interpretation bias, but not a near-transfer task. Cognitive bias modification of interpretation improved both primary outcomes compared with placebo. For pain interference, there was also a main effect favoring psychoeducation. The CBM-I group improved significantly more than placebo for fear of movement, but not catastrophizing, depression, or anxiety. Cognitive bias modification of interpretation reduced stress but only for those who also received psychoeducation. This trial shows that CBM-I has promise in the management of pain, but there was limited evidence that psychoeducation improved the efficacy of CBM-I. Cognitive bias modification of interpretation was administered entirely remotely and is highly scalable, but future research should focus on paradigms that lead to better engagement of people with chronic pain with CBM-I.

Gamified Web-Delivered Attentional Bias Modification Training for Adults With Chronic Pain: Protocol for a Randomized, Double-blind, Placebo-Controlled Trial

Background

To date, research has found variable success in using attentional bias modification training (ABMT) procedures in pain samples. Several factors could contribute to these mixed findings, including boredom and low motivation. Indeed, training paradigms are repetitive, which can lead to disengagement and high dropout rates. A potential approach to overcoming some of these barriers is to attempt to increase motivation and engagement through gamification (ie, the use of game elements) of this procedure. To date, research has yet to explore the gamified format of ABMT for chronic pain and its potential for the transfer of benefits.

Objective

The aim of this study is to investigate the effects of a gamified web-delivered ABMT intervention in a sample of adults with chronic pain via a randomized, double-blind, placebo-controlled trial.

Methods

A total of 120 adults with chronic musculoskeletal pain, recruited from clinical (hospital outpatient waiting list) and nonclinical (wider community) settings, will be included in this randomized, double-blind, placebo-controlled, 3-arm trial. Participants will be randomly assigned to complete 6 web-based sessions of dot-probe nongamified sham control ABMT, nongamified standard ABMT, or gamified ABMT across a period of 3 weeks. Active ABMT conditions will aim to train attention away from pain-relevant words. Participant outcomes will be assessed at pretraining, during training, immediately after training, and at the 1-month follow-up. Primary outcomes include pain intensity, pain interference, and behavioral and self-reported engagement. Secondary outcomes include attentional bias for pain, anxiety, depression, interpretation bias for pain, and perceived improvement.

Results

The ethical aspects of this research project have been approved by the human research ethics committees of the Royal Brisbane and Women’s Hospital (HREC/2020/QRBW/61743) and Queensland University of Technology (2000000395). Study recruitment commenced in August 2021 and is ongoing. Data collection and analysis are expected to be concluded by October 2022 and January 2023, respectively.

Conclusions

This trial will be the first to evaluate the effects of gamification techniques in a pain ABMT intervention. The findings will provide important information on the potential therapeutic benefits of gamified pain ABMT programs, shed light on the motivational influences of certain game elements in the context of pain, and advance our understanding of chronic pain.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12620000803998; https://anzctr.org.au/ACTRN12620000803998.aspx

International Registered Report Identifier (IRRID)

PRR1-10.2196/32359

Neural correlates of the attentional bias towards pain-related faces in fibromyalgia patients: An ERP study using a dot-probe task

BACKGROUND

One of the major cognitive deficits in fibromyalgia has been linked to the hypervigilance phenomenon. It is mainly reflected as a negative bias for allocating attentional resources towards both threatening and pain-related information. Although the interest in its study has recently grown, the neural temporal dynamics of the attentional bias in fibromyalgia still remains an open question.

METHOD

Fifty participants (25 fibromyalgia patients and 25 healthy control subjects) performed a dot-probe task. Two types of facial expressions (pain-related and neutral) were employed as signal stimuli. Then, as a target stimulus, a single dot replaced the location of one of these two faces. Event-related potentials (ERP) in response to facial expressions and target stimulation (i.e., dot) were recorded. Reaction time (RT) and accuracy measures in the experimental task were collected as behavioural outcomes.

RESULTS

Temporal dynamics of brain electrical activity were analysed on two ERP components (P2 and N2a) sensitive to the facial expressions meaning. Pain-related faces elicited higher frontal P2 amplitudes than neutral faces for the whole sample. Interestingly, an interaction effect between group and facial expressions was also found showing that pain-related faces elicited enhanced P2 amplitudes (at fronto-central regions, in this case) compared to neutral faces only when the group of patients was considered. Furthermore, higher P2 amplitudes were observed in response to pain-related faces in patients with fibromyalgia compared to healthy control participants. Additionally, a shorter latency of P2 (at centro-parietal regions) was also detected for pain-related facial expressions compared to neutral faces. Regarding the amplitude of N2a, it was lower for patients as compared to the control group. Non-relevant effects of the target stimulation on the ERPs were found. However, patients with fibromyalgia exhibited slower RT to locate the single dot for incongruent trials as compared to congruent and neutral trials.

CONCLUSIONS

Data suggest the presence of an attentional bias in fibromyalgia that it would be followed by a deficit in the allocation of attentional resources to further process pain-related information. Altogether the current results suggest that attentional biases in fibromyalgia might be explained by automatic attentional mechanisms, which seem to be accompanied by an alteration of more strategic or controlled attentional components.

Attention Bias to Pain Words Comes Early and Cognitive Load Matters: Evidence from an ERP Study on Experimental Pain

Attention bias (AB) is a common cognitive challenge for patients with pain. In this study, we tested at what stage AB to pain occurs in participants with experimental pain (EP) and tested whether cognitive load interferes with it. We recruited 40 healthy adults aged 18-27 years, and randomized them into control and EP groups. We sprayed the participants in the EP group with 10% capsaicin paste to mimic acute pain and those in the control group with water, accessing both groups' behavioral results and event-related potential data. We found that high-load tasks had longer response times and lower accuracies than low-load tasks did and that different neural processing of words occurred between the groups. The EP group exhibited AB to pain at an early stage with both attentional avoidance (N1 latency) and facilitated attention (P2 amplitude) to pain words. The control group coped with semantic differentiation (N1) at first, followed by pain word discrimination (P2). In addition, AB to pain occurred only in low-load tasks. As the cognitive load multiplied, we did not find AB in the EP group. Therefore, our study adds further evidence for AB to pain, suggesting the implementation of cognitive load in future AB therapy.

The effects of attentional and interpretation biases on later pain outcomes among younger and older adults: A prospective study

BACKGROUND

Studies examining the effect of biased cognitions on later pain outcomes have primarily focused on attentional biases, leaving the role of interpretation biases largely unexplored. Also, few studies have examined pain-related cognitive biases in elderly persons. The current study aims to fill these research gaps.

METHODS

Younger and older adults with and without chronic pain (N = 126) completed an interpretation bias task and a free-viewing task of injury and neutral scenes at baseline. Participants' pain intensity and disability were assessed at baseline and at a 6-month follow-up. A machine-learning data-driven approach to analysing eye movement data was adopted.

RESULTS

Eye movement analyses revealed two common attentional pattern subgroups for scene-viewing: an "explorative" group and a "focused" group. At baseline, participants with chronic pain endorsed more injury-/illness-related interpretations compared to pain-free controls, but they did not differ in eye movements on scene images. Older adults interpreted illness-related scenarios more negatively compared to younger adults, but there was also no difference in eye movements between age groups. Moreover, negative interpretation biases were associated with baseline but not follow-up pain disability, whereas a focused gaze tendency for injury scenes was associated with follow-up but not baseline pain disability. Additionally, there was an indirect effect of interpretation biases on pain disability 6 months later through attentional bias for pain-related images.

CONCLUSIONS

The present study provided evidence for pain status and age group differences in injury-/illness-related interpretation biases. Results also revealed distinct roles of interpretation and attentional biases in pain chronicity.

SIGNIFICANCE

Adults with chronic pain endorsed more injury-/illness-related interpretations than pain-free controls. Older adults endorsed more illness interpretations than younger adults. A more negative interpretation bias indirectly predicted pain disability 6 months later through hypervigilance towards pain.

Spa Therapy for the Treatment of Fibromyalgia: An Open, Randomized Multicenter Trial

Fibromyalgia is a common chronic pain pathology with an incidence of 4.3 per 1,000 person-years. An open, randomized clinical trial of patients with fibromyalgia comparing an immediate vs. delayed 18-day spa therapy in five spa therapy care facilities in France enrolled 220 patients. Randomization was in blocks of four, stratified by center, severity of fibromyalgia and previous spa therapy. Patients continued usual treatment. The main endpoint was the number of patients achieving minimal clinically important difference at 6 months, defined as 14% change in their baseline fibromyalgia impact questionnaire score. The intention-to-treat analysis included 100 and 106 patients in the intervention and control groups, respectively. At 6 months, 45/100 (45.0%) and 30/106 (28.3%) patients in the intervention and control groups, respectively, achieved a minimal clinically important difference (P= .013). There was also a significant improvement in pain, fatigue, and symptom severity (secondary outcomes) in the intervention group but not for generic quality of life (QOL), sleep or physical activity. None of the 33 serious adverse events reported by 25 patients were related to the spa therapy. Our results demonstrate the benefit of spa treatment in patients with fibromyalgia. PERSPECTIVE: A 12-month, open, randomized clinical trial of 220 patients with fibromyalgia compared an immediate versus delayed (ie, after 6 months) 18-day spa therapy. The results showed a clinically significant improvement at 6 months for those who received immediate therapy which was maintained up to 12 months. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov: NCT02265029.

Transdiagnostic Cognitive Processes in Chronic Pain and Comorbid PTSD and Depression in Veterans

BACKGROUND

Chronic pain in Veterans is a major problem compounded by comorbid posttraumatic stress disorder (PTSD) and depression. Adopting a transdiagnostic framework to understanding "shared territory" among these diagnoses has the potential to inform our understanding of the underlying cognitive processes and mechanisms that transverse diagnostic boundaries.

PURPOSE

To examine the associations between pain-related cognitive processes (diversion, distancing, absorption, and openness), pain intensity, PTSD and depressive symptoms, and the extent to which Veterans with chronic pain with and without comorbid PTSD and depression engage in different/similar pain-related cognitive processes.

METHODS

Secondary analysis of pretreatment data with a subsample (n = 147) of Veterans with chronic pain from a larger clinical trial. Pretreatment PCL-5 and PROMIS Depression scales were used to categorize participants into three groups: (a) Pain-only; (b) Pain-PTSD; and (c) Pain-PTSD-DEP.

RESULTS

Compared to the Pain-only group, the Pain-PTSD and Pain-PTSD-DEP groups reported significantly greater pain intensity, PTSD and depressive symptoms, and ruminative pain absorption. The Pain-PTSD-DEP group had significantly lower pain diversion and pain openness scores. When diversion and openness were used within the Pain-PTSD-DEP group, however, they were both associated with lower pain intensity and openness was additionally associated with lower PTSD scores. However, in the Pain-PTSD group, pain openness was associated with higher depression scores.

CONCLUSIONS

Across increasing complexity of comorbidity profiles (i.e., one vs. two comorbid conditions), ruminative absorption with pain emerged as a cognitive process that transverses diagnoses and contributes to worse outcomes. Nonjudgmental acceptance may not be universally beneficial, potentially depending upon the nature of comorbidity profiles.

Intervention Therapies to Reduce Pain-Related Fear in Fibromyalgia Syndrome: A Systematic Review of Randomized Clinical Trials

OBJECTIVE

This systematic review aimed to evaluate the effectiveness of different interventions at reducing pain-related fear in people with fibromyalgia and to analyze whether the included trials reported their interventions in full detail.

DESIGN

Systematic review.

SETTING

No restrictions.

METHODS

The Cochrane Library, CINAHL, EMBASE, PsycINFO, PubMed, and Scopus were searched from their inception to April 2020, along with manual searches and a gray literature search. Randomized clinical trials were included if they assessed pain-related fear constructs as the primary or secondary outcome in adults with fibromyalgia. Two reviewers independently performed the study selection, data extraction, risk-of-bias assessment, Template for Intervention Description and Replication (TIDieR) checklist assessment, and grading the quality of evidence.

RESULTS

Twelve randomized clinical trials satisfied the eligibility criteria, including 11 cohorts with a total sample of 1,441 participants. Exercise, multicomponent, and psychological interventions were more effective than controls were in reducing kinesiophobia. However, there were no differences in decreasing kinesiophobia when self-management and electrotherapy were used. There were also no differences between groups with regard to the rest of the interventions and pain-related constructs (fear-avoidance beliefs, fear of pain, and pain-related anxiety). However, a serious risk of bias and a very serious risk of imprecision were detected across the included trials. This caused the overall certainty of the judged evidence to be low and very low. Additionally, the included trials reported insufficient details to allow the full replication of their interventions.

CONCLUSIONS

This systematic review shows that there are promising interventions, such as exercise, multicomponent, and psychological therapies, that may decrease one specific type of fear in people with fibromyalgia, i.e., kinesiophobia. However, because of the low-very low certainty of the evidence found, a call for action is needed to improve the quality of randomized clinical trials, which will lead to more definitive information about the clinical efficacy of interventions in this field.

Association of Gender, Painkiller Use, and Experienced Pain with Pain-Related Fear and Anxiety among University Students According to the Fear of Pain Questionnaire-9

Anxiety and fear are determinants of acute and chronic pain. Effectively measuring fear associated with pain is critical for identifying individuals’ vulnerable to pain. This study aimed to assess fear of pain among students and evaluate factors associated with pain-related fear. We used the Fear of Pain Questionnaire-9 to measure this fear. We searched for factors associated with fear of pain: gender, size of the city where the subjects lived, subject of academic study, year of study, the greatest extent of experienced pain, frequency of painkiller use, presence of chronic or mental illness, and past hospitalization. We enrolled 717 participants. Median fear of minor pain was 5 (4–7) fear of medical pain 7 (5–9), fear of severe pain 10 (8–12), and overall fear of pain 22 (19–26). Fear of pain was associated with gender, frequency of painkiller use, and previously experienced pain intensity. We found a correlation between the greatest pain the participant can remember and fear of minor pain (r = 0.112), fear of medical pain (r = 0.116), and overall fear of pain (r = 0.133). Participants studying medicine had the lowest fear of minor pain while stomatology students had the lowest fear of medical pain. As students advanced in their studies, their fear of medical pain lowered. Addressing fear of pain according to sex of the patient, frequency of painkiller use, and greatest extent of experienced pain could ameliorate medical training and improve the quality of pain management in patients.