Doctor trustworthiness influences pain and its neural correlates in virtual medical interactions.

Trust is an important component of the doctor-patient relationship and is associated with improved patient satisfaction and health outcomes. Previously, we reported that patient feelings of trust and similarity toward their clinician predicted reductions in evoked pain in response to painful heat stimulations. In the present study, we investigated the brain mechanisms underlying this effect. We used face stimuli previously developed using a data-driven computational modeling approach that differ in perceived trustworthiness and superimposed them on bodies dressed in doctors' attire. During functional magnetic resonance imaging, participants (n = 42) underwent a series of virtual medical interactions with these doctors during which they received painful heat stimulation as an analogue of a painful diagnostic procedure. Participants reported increased pain when receiving painful heat stimulations from low-trust doctors, which was accompanied by increased activity in pain-related brain regions and a multivariate pain-predictive neuromarker. Findings suggest that patient trust in their doctor may have tangible impacts on pain and point to a potential brain basis for trust-related reductions in pain through the modulation of brain circuitry associated with the sensory-discriminative and affective-motivational dimensions of pain.

Expressive suppression to pain in others reduces negative emotion but not vicarious pain in the observer.

Although there are situations where it may be appropriate to reduce one's emotional response to the pain of others, the impact of an observer's emotional expressivity on their response to pain in others is still not well understood. In the present study, we examined how the emotion regulation strategy expressive suppression influences responses to pain in others. Based on prior research findings on expressive suppression and pain empathy, we hypothesized that expressive suppression to pain expression faces would reduce neural representations of negative emotion, vicarious pain, or both. To test this, we applied two multivariate pattern analysis (MVPA)-derived neural signatures to our data, the Picture Induced Negative Emotion Signature (PINES; Chang, Gianaros, Manuck, Krishnan, and Wager (2015)) and a neural signature of facial expression induced vicarious pain (Zhou et al., 2020). In a sample of 60 healthy individuals, we found that viewing pain expression faces increased neural representations of negative emotion and vicarious pain. However, expressive suppression to pain faces reduced neural representations of negative emotion only. Providing support for a connection between neural representations of negative emotion and pain empathy, PINES responses to pain faces were associated with participants' trait-level empathy and the perceived unpleasantness of pain faces. Findings suggest that a consequence of suppressing one's facial expressions in response to the pain of others may be a reduction in the affective aspect of empathy but not the experience of vicarious pain itself.

Clinician-Patient Racial/Ethnic Concordance Influences Racial/Ethnic Minority Pain: Evidence from Simulated Clinical Interactions.

OBJECTIVE: Racial and ethnic minorities in the United States report higher levels of both clinical and experimental pain, yet frequently receive inadequate pain treatment. Although these disparities are well documented, their underlying causes remain largely unknown. Evidence from social psychological and health disparities research suggests that clinician-patient racial/ethnic concordance may improve minority patient health outcomes. Yet whether clinician-patient racial/ethnic concordance influences pain remains poorly understood. METHODS: Medical trainees and community members/undergraduates played the role of "clinicians" and "patients," respectively, in simulated clinical interactions. All participants identified as non-Hispanic Black/African American, Hispanic white, or non-Hispanic white. Interactions were randomized to be either racially/ethnically concordant or discordant in a 3 (clinician race/ethnicity) × 2 (clinician-patient racial/ethnic concordance) factorial design. Clinicians took the medical history and vital signs of the patient and administered an analogue of a painful medical procedure. RESULTS: As predicted, clinician-patient racial/ethnic concordance reduced self-reported and physiological indicators of pain for non-Hispanic Black/African American patients and did not influence pain for non-Hispanic white patients. Contrary to our prediction, concordance was associated with increased pain report in Hispanic white patients. Finally, the influence of concordance on pain-induced physiological arousal was largest for patients who reported prior experience with or current worry about racial/ethnic discrimination. CONCLUSIONS: Our findings inform our understanding of the sociocultural factors that influence pain within medical contexts and suggest that increasing minority, particularly non-Hispanic Black/African American, physician numbers may help reduce persistent racial/ethnic pain disparities.

Social Determinants and Consequences of Pain: Toward Multilevel, Intersectional, and Life Course Perspectives.

Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain remain rarely addressed in the context of pain prevention and management. In this review, we aim to 1) examine the broad scope of social determinants and consequences of pain and their interactions across multiple levels of organization, and 2) provide a framework synthesizing existing concepts and potential areas for future work on social aspects of pain, drawing upon socioecological, intersectional, and life course approaches. Integrating interdisciplinary theory and evidence, we outline pathways through which multilevel social factors and pain may affect each other over time. We also provide a brief summary of intrapersonal aspects of pain, which are thought to operate at the interface between individuals and the social context. Progressing from micro- to macrolevel factors, we illustrate how social determinants of pain can directly or indirectly contribute to pain experiences, expression, risk, prognosis, and impact across populations. We consider 1) at the interpersonal level, the roles of social comparison, social relatedness, social support, social exclusion, empathy, and interpersonal conflict; 2) at the group or community level, the roles of intimacy groups, task groups, social categories, and loose associations; and 3) at the societal level, the roles of political, economic, and cultural systems, as well as their policies and practices. We present examples of multilevel consequences of pain across these levels and discuss opportunities to reduce the burden and inequities of pain by expanding multilevel social approaches in pain research and practice. PERSPECTIVE: Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain are often unclearly defined, hindering their use in pain prevention, management, and research. We summarize the scope of social aspects of pain and provide a framework synthesizing existing concepts and potential areas for future work.

A Longitudinal Investigation of the Impact of COVID-19 on Patients With Chronic Pain.

The COVID-19 pandemic prompted unexpected changes in the healthcare system. This current longitudinal study had 2 aims: 1) describe the trajectory of pandemic-associated stressors and patient-reported health outcomes among patients receiving treatment at a tertiary pain clinic over 2 years (May 2020 to June 2022); and 2) identify vulnerable subgroups. We assessed changes in pandemic-associated stressors and patient-reported health outcome measures. The study sample included 1270 adult patients who were predominantly female (74.6%), White (66.2%), non-Hispanic (80.6%), married (66.1%), not on disability (71.2%), college-educated (59.45%), and not currently working (57.9%). We conducted linear mixed effect modeling to examine the main effect of time with controlling for a random intercept. Findings revealed a significant main effect of time for all pandemic-associated stressors except financial impact. Over time, patients reported increased proximity to COVID-19, but decreased pandemic-associated stressors. A significant improvement was also observed in pain intensity, pain catastrophizing, and PROMIS-pain interference, sleep, anxiety, anger, and depression scores. Demographic-based subgroup analyses for pandemic-associated stressors revealed that younger adults, Hispanics, Asians, and patients receiving disability compensation were vulnerable groups either during the initial visit or follow-up visits. We observed additional differential pandemic effects between groups based on participant sex, education level, and working status. In conclusion, despite unanticipated changes in pain care services during the pandemic, patients receiving pain treatments adjusted to pandemic-related stressors and improved their health status over time. As the current study observed differential pandemic impacts on patient subgroups, future studies should investigate and address the unmet needs of vulnerable subgroups. PERSPECTIVE: Over a 2-year timeframe, the pandemic did not adversely influence physical and mental health among treatment-seeking patients with chronic pain. Patients reported small but significant improvements across indices of physical and psychosocial health. Differential impacts emerged among groups based on ethnicity, age, disability status, gender, education level, and working status.

The impact of COVID-19 on patients with chronic pain seeking care at a tertiary pain clinic.

Empirical data on the health impacts of the COVID-19 pandemic remain scarce, especially among patients with chronic pain. We conducted a cross-sectional study matched by season to examine patient-reported health symptoms among patients with chronic pain pre- and post-COVID-19 pandemic onset. Survey responses were analyzed from 7535 patients during their initial visit at a tertiary pain clinic between April 2017-October 2020. Surveys included measures of pain and pain-related physical, emotional, and social function. The post-COVID-19 onset cohort included 1798 initial evaluations, and the control pre-COVID-19 cohort included 5737 initial evaluations. Patients were majority female, White/Caucasian, and middle-aged. The results indicated that pain ratings remained unchanged among patients after the pandemic onset. However, pain catastrophizing scores were elevated when COVID-19 cases peaked in July 2020. Pain interference, physical function, sleep impairment, and emotional support were improved in the post-COVID-19 cohort. Depression, anxiety, anger, and social isolation remained unchanged. Our findings provide evidence of encouraging resilience among patients seeking treatment for pain conditions in the face of the COVID-19 pandemic. However, our findings that pain catastrophizing increased when COVID-19 cases peaked in July 2020 suggests that future monitoring and consideration of the impacts of the pandemic on patients' pain is warranted.

Comparative efficacy of a single-session "Empowered Relief" videoconference-delivered group intervention for chronic pain: study protocol for a randomized controlled trial.

BACKGROUND: Chronic pain is naturally aversive and often distressing for patients. Pain coping and self-regulatory skills have been shown to effectively reduce pain-related distress and other symptoms. In this trial, the primary goal is to pilot test the comparative efficacy of a single-session videoconference-delivered group pain education class to a waitlist control among patients with chronic pain. METHODS: Our study is a randomized clinical trial pilot testing the superiority of our 2-h single-session videoconference-delivered group pain education class against a waitlist control. We will enroll 120 adult patients with mixed etiology chronic pain and randomize 1:1 to one of the two study arms. We hypothesize superiority for the pain education class for bolstering pain and symptom management. Team researchers masked to treatment assignment will assess the outcomes up to 3 months post-treatment. DISCUSSION: This study aims to test the utility of a single-session videoconference-delivered group pain education class to improve self-regulation of pain and pain-related outcomes. Findings from our project have the potential to significantly reduce barriers to effective psychological treatment for pain, optimizing the delivery of increasingly vital online and remote-delivered intervention options. TRIAL REGISTRATION: ClinicalTrials.gov NCT04546685 . Registered on 04 September 2020.

Modeling neural and self-reported factors of affective distress in the relationship between pain and working memory in healthy individuals.

The relationship between pain and cognition has primarily been investigated in patients with chronic pain and healthy participants undergoing experimental pain. Recently, there has been interest in understanding the disruptive effects of non-experimental pain in otherwise healthy individuals. Recent studies suggest that healthy individuals reporting pain also demonstrate decrements in working memory (WM) performance, however factors contributing to this relationship remain poorly understood. The present study examined the association between pain and WM in a large community-based sample of healthy individuals and investigated whether self-reported affective distress and medial frontal cortex activity might help to explain this relationship. To address these research questions, a large publicly available dataset from the Human Connectome Project (N = 416) was sourced and structural equation modeling was utilized to examine relationships between pain intensity experienced over the past 7 days, self-reported affective distress, performance on a WM (n-back) task, and task-related activation in the medial frontal cortex. Examining participants who reported non-zero pain intensity in the past 7 days (n = 228), we found a direct negative association between pain intensity and performance on the WM n-back task, consistent with prior findings. Self-reported affective distress was not associated with WM performance. Additionally, pain intensity was indirectly associated with WM performance via WM task-related activity in the ventromedial prefrontal cortex (vmPFC). Our findings suggest that pain experienced in everyday life by otherwise healthy individuals may directly impact WM performance. Furthermore, WM task-related increases in vmPFC activity may be a factor contributing to this relationship.

Clinician-Patient Movement Synchrony Mediates Social Group Effects on Interpersonal Trust and Perceived Pain.

Pain is an unfortunate consequence of many medical procedures, which in some patients becomes chronic and debilitating. Among the factors affecting medical pain, clinician-patient (C-P) similarity and nonverbal communication are particularly important for pain diagnosis and treatment. Participants (N = 66) were randomly assigned to clinician and patient roles and were grouped into C-P dyads. Clinicians administered painful stimuli to patients as an analogue of a painful medical procedure. We manipulated the perceived C-P similarity of each dyad using groups ostensibly based on shared beliefs and values, and each patient was tested twice: Once with a same group clinician (concordant, CC) and once with a clinician from the other group (discordant, DC). Movement synchrony was calculated as a marker of nonverbal communication. We tested whether movement synchrony mediated the effects of group concordance on patients' pain and trust in the clinician. Movement synchrony was higher in CC than DC dyads. Higher movement synchrony predicted reduced pain and increased trust in the clinician. Movement synchrony also formally mediated the group concordance effects on pain and trust. These findings increase our understanding of the role of nonverbal C-P communication on pain and related outcomes. Interpersonal synchrony may be associated with better pain outcomes, independent of the specific treatment provided. PERSPECTIVE: This article demonstrates that movement synchrony in C-P interactions is an unobtrusive measure related to their relationship quality, trust toward the clinician, and pain. These findings suggest that interpersonal synchrony may be associated with better patient outcomes, independent of the specific treatment provided.

Feelings of Clinician-Patient Similarity and Trust Influence Pain: Evidence From Simulated Clinical Interactions.

Pain is influenced by many factors other than external sources of tissue damage. Among these, the clinician-patient relationship is particularly important for pain diagnosis and treatment. However, the effects of the clinician-patient relationship on pain remain underexamined. We tested the hypothesis that patients who believe they share core beliefs and values with their clinician will report less pain than patients who do not. We also measured feelings of perceived clinician-patient similarity and trust to see if these interpersonal factors influenced pain. We did so by experimentally manipulating perceptions of similarity between participants playing the role of clinicians and participants playing the role of patients in simulated clinical interactions. Participants were placed in 2 groups on the basis of their responses to a questionnaire about their personal beliefs and values, and painful thermal stimulation was used as an analog of a painful medical procedure. We found that patients reported feeling more similarity and trust toward their clinician when they were paired with clinicians from their own group. In turn, patients' positive feelings of similarity and trust toward their clinicians-but not clinicians' feelings toward patients or whether the clinician and patient were from the same group-predicted lower pain ratings. Finally, the most anxious patients exhibited the strongest relationship between their feelings about their clinicians and their pain report. These findings increase our understanding of context-driven pain modulation and suggest that interventions aimed at increasing patients' feelings of similarity to and trust in health care providers may help reduce the pain experienced during medical care. PERSPECTIVE: We present novel evidence that the clinician-patient relationship can affect the pain experienced during medical care. We found that "patients" in simulated clinical interactions who reported feeling more similarity and trust toward their "clinicians" reported less pain, suggesting that increasing feelings of clinician-patient similarity and trust may reduce pain disparities.

Biomechanical comparison of transosseous and capsular repair of peripheral triangular fibrocartilage tears.

PURPOSE: The purpose of this study was to biomechanically compare the repair strength of peripheral triangular fibrocartilage complex (TFCC) repairs to the distal ulna using transosseous sutures (group I) versus TFCC repairs to the extensor carpi ulnaris tendon subsheath and surrounding dorsal capsule (group II). TYPE OF STUDY: Cadaveric biomechanical study. METHODS: Six matched pairs of fresh-frozen cadaveric upper extremities were procured. Each underwent the creation and repair of a peripheral, ulnar-sided detachment of the TFCC. Following stabilization of the humerus and radius, the maximum translations of the ulna in the dorsal and palmar directions were measured in response to an 8-lb traction load before disrupting the TFCC, after disrupting the TFCC, and after repairing the TFCC. RESULTS: There was a significant increase in the total translation of the ulna following disruption of the TFCC (P <.001) in both groups. The mean and standard deviation of the percent total translation eliminated following TFCC repair for group I specimens (transosseous suture) were 33.8% and 11.6%, respectively. The mean and standard deviation of the percent total translation eliminated following TFCC repair for group II specimens (capsular implantation) were 59.3% and 29.7%, respectively. The observed difference between the repair groups is not significant (P =.157). CONCLUSIONS: While disruption of the TFCC does significantly increase distal radioulnar joint (DRUJ) instability and repair of the TFCC does significantly restore DRUJ stability, the results of this study do not show a significant biomechanical difference between the 2 TFCC repair techniques in a cadaveric model.

Time-driven activity-based costing.

In the classroom, activity-based costing (ABC) looks like a great way to manage a company's limited resources. But executives who have tried to implement ABC in their organizations on any significant scale have often abandoned the attempt in the face of rising costs and employee irritation. They should try again, because a new approach sidesteps the difficulties associated with large-scale ABC implementation. In the revised model, managers estimate the resource demands imposed by each transaction, product, or customer, rather than relying on time-consuming and costly employee surveys. This method is simpler since it requires, for each group of resources, estimates of only two parameters: how much it costs per time unit to supply resources to the business's activities (the total overhead expenditure of a department divided by the total number of minutes of employee time available) and how much time it takes to carry out one unit of each kind of activity (as estimated or observed by the manager). This approach also overcomes a serious technical problem associated with employee surveys: the fact that, when asked to estimate time spent on activities, employees invariably report percentages that add up to 100. Under the new system, managers take into account time that is idle or unused. Armed with the data, managers then construct time equations, a new feature that enables the model to reflect the complexity of real-world operations by showing how specific order, customer, and activity characteristics cause processing times to vary. This Tool Kit uses concrete examples to demonstrate how managers can obtain meaningful cost and profitability information, quickly and inexpensively. Rather than endlessly updating and maintaining ABC data,they can now spend their time addressing the deficiencies the model reveals: inefficient processes, unprofitable products and customers, and excess capacity.