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.

Sensing behavior change in chronic pain: a scoping review of sensor technology for use in daily life.

ABSTRACT: Technology offers possibilities for quantification of behaviors and physiological changes of relevance to chronic pain, using wearable sensors and devices suitable for data collection in daily life contexts. We conducted a scoping review of wearable and passive sensor technologies that sample data of psychological interest in chronic pain, including in social situations. Sixty articles met our criteria from the 2783 citations retrieved from searching. Three-quarters of recruited people were with chronic pain, mostly musculoskeletal, and the remainder with acute or episodic pain; those with chronic pain had a mean age of 43 (few studies sampled adolescents or children) and 60% were women. Thirty-seven studies were performed in laboratory or clinical settings and the remainder in daily life settings. Most used only 1 type of technology, with 76 sensor types overall. The commonest was accelerometry (mainly used in daily life contexts), followed by motion capture (mainly in laboratory settings), with a smaller number collecting autonomic activity, vocal signals, or brain activity. Subjective self-report provided "ground truth" for pain, mood, and other variables, but often at a different timescale from the automatically collected data, and many studies reported weak relationships between technological data and relevant psychological constructs, for instance, between fear of movement and muscle activity. There was relatively little discussion of practical issues: frequency of sampling, missing data for human or technological reasons, and the users' experience, particularly when users did not receive data in any form. We conclude the review with some suggestions for content and process of future studies in this field.

A developmental framework for understanding the influence of sex and gender on health: Pediatric pain as an exemplar.

Sex differences are a robust finding in many areas of adult health, including cardiovascular disease, psychiatric disorders, and chronic pain. However, many sex differences are not consistently observed until after the onset of puberty. This has led to the hypothesis that hormones are primary contributors to sex differences in health outcomes, largely ignoring the relative contributions of early developmental influences, emerging psychosocial factors, gender, and the interaction between these variables. In this paper, we argue that a comprehensive understanding of sex and gender contributions to health outcomes should start as early as conception and take an iterative biopsychosocial-developmental perspective that considers intersecting social positions. We present a conceptual framework, informed by a review of the literature in basic, clinical, and social science that captures how critical developmental stages for both sex and gender can affect children's health and longer-term outcomes. The literature on pediatric chronic pain is used as a worked example of how the framework can be applied to understanding different chronic conditions.

Challenges with embedding an integrated sex and gender perspective into pain research: Recommendations and opportunities.

The focus of this article, within this BBI horizons special issue, is on sex, gender, and pain. We summarise what is currently known about sex- and gender-related variations in pain, exploring intersectional biological and psychosocial mechanisms, and highlight gaps in knowledge and understanding. Five key challenges with the exploration of sex and gender in pain research are presented, relating to: conceptual imprecision, research bias, limitations with binary descriptions, integrating sex and gender, and timely adoption/implementation of good research practice. Guidance on how to overcome such challenges is provided. Despite clear evidence for sex and gender differences in pain, there are conceptual and methodological barriers to overcome. Innovation in methods and approach can help develop more effective and tailored treatment approaches for men, women, boys, girls, and gender-diverse people.

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.

Comparing the Effects of Thought Suppression and Focused Distraction on Pain-Related Attentional Biases in Men and Women.

Increasing attentional focus away from pain can affect pain experience, suggesting that cognitive strategies that move attentional allocation may be a moderator of pain. In a pre-post-design, the present study examined the effects of 2 cognitive strategies used in pain contexts, thought suppression and focused distraction, on subsequent pain-related attention. Thought suppression was hypothesized to increase pain-related attention, whereas focused distraction was expected to reduce it. Influences of both anxiety and sex were also considered, as secondary questions. 139 (86 women, 53 men) healthy, pain-free participants were randomly assigned to use either thought suppression or focused distraction during a mild cold pressor test (CPT). Pain-related attention was examined using a dot-probe and an attentional blink task, pre-and post-CPT. Questionnaires about relevant cognitive and emotional aspects, demographics, and pain were completed. Results showed no difference in the effect of the 2 pain inhibition strategies on pain-related attention. The hypothesized rebound effect in thought suppression on pain-related attention did not emerge. However, thought suppression showed a short-term benefit in comparison to focused distraction regarding reported pain and perceived threat during the cold pressor test. Few sex differences were found. Thus, the cognitive strategies affected pain outcomes, but did not influence pain-related attention. PERSPECTIVE: Cognitive strategies could help with pain through changing attention allocation. In this study, the effects of the 2 cognitive strategies thought suppression and focused distraction on pain-related attention in men and women were examined. Elucidating mechanisms that lie behind pain strategies that focus on changing attention may help improve treatments.

Attentional Biases Towards Body Expressions of Pain in Men and Women.

This study investigated whether there are gender differences in attention to bodily expressions of pain and core emotions. Three experiments are reported using the attentional dot probe task. Images of men and women displaying bodily expressions, including pain, were presented. The task was used to determine whether participants' attention was drawn towards or away from target expressions. Inconsistent evidence was found for an attentional bias towards body expressions, including pain. While biases were affected by gender, patterns varied across the Experiments. Experiment 1, which had a presentation duration of 500 ms, found a relative bias towards the location of male body expressions compared to female expressions. Experiments 2 and 3 varied stimulus exposure times by including both shorter and longer duration conditions (e.g., 100 vs. 500 vs. 1250 ms). In these experiments, a bias towards pain was confirmed. Gender differences were also found, especially in the longer presentation conditions. Expressive body postures captured the attention of women for longer compared to men. These results are discussed in light of their implications for why there are gender differences in attention to pain, and what impact this has on pain behaviour. PERSPECTIVE: We show that men and women might differ in how they direct their attention towards bodily expressions, including pain. These results have relevance to understanding how carers might attend to the pain of others, as well as highlighting the wider role that social-contextual factors have in pain.

Ignoring space around a painful limb? No evidence for a body-related visuospatial attention bias in complex regional pain syndrome.

BACKGROUND: Complex Regional Pain Syndrome (CRPS) is a disorder of severe chronic pain in one or more limb(s). People with CRPS report unusual perceptions of the painful limb suggesting altered body representations, as well as difficulty attending to their affected limb (i.e., a 'neglect-like' attention bias). Altered body representations and attention in CRPS might be related, however, existing evidence is unclear. We hypothesized that if there were a body-related visuospatial attention bias in CRPS, then any attention bias away from the affected side should be larger for or limited to circumstances when the (impaired) body representation is involved in the task versus when this is not the case. METHODS: We included 40 people with CRPS, 40 with other limb pain conditions, and 40 pain-free controls. In half of the people with pain, their upper limb was affected, in the other half their lower limb. We administered computerized tasks of spatial attention, including free viewing of images, shape cancellation, temporal order judgement, and dot-probe. The degree to which different versions of each task involved body representation was manipulated by one or more of the following: (1) presenting stimuli nearer versus further away from the body, (2) using body related versus neutral stimuli, and (3) inducing mental rotation of body parts versus no mental rotation. In addition to perceptual judgements, eye movements were recorded as a sensitive index of spatial attention. Bayesian repeated measures analyses were performed. RESULTS: We found no evidence for a (body-related) visuospatial attention bias in upper limb CRPS. Secondary analyses suggested the presence of a body-related visuospatial attention bias away from the affected side in some participants with lower limb CRPS. DISCUSSION: Our results add to growing evidence that there might be no general visuospatial attention bias away from the affected side in CRPS.

The gender context of pain.

Pain is a major source of global suffering, with women bearing the greatest burden. Alongside biology, psychological and social factors, including gender, help explain these differences. However, there has been no direct attempt to develop a unified social psychological model of men and women's pain. By drawing on approaches to both gender and pain, a gender context model of pain is presented. It proposes that pain is partly influenced by the gender context in which it occurs, which operates at both individual and interpersonal levels. The model is used to structure an appraisal of the existing evidence around gender and pain, and explore whether the model helps explain why such variation occurs. It is argued that despite evidence for an association between gender and pain, there are empirical gaps that need to be addressed. Implications and directions for future investigations into sex, gender and pain are considered.

The Time Course of Facial Expression Recognition Using Spatial Frequency Information: Comparing Pain and Core Emotions.

We are able to recognize others' experience of pain from their facial expressions. However, little is known about what makes the recognition of pain possible and whether it is similar or different from core emotions. This study investigated the mechanisms underpinning the recognition of pain expressions, in terms of spatial frequency (SF) information analysis, and compared pain with 2 core emotions (ie, fear and happiness). Two experiments using a backward masking paradigm were conducted to examine the time course of low- and high-SF information processing, by manipulating the presentation duration of face stimuli and target-mask onset asynchrony. Overall, we found a temporal advantage of low-SF over high-SF information for expression recognition, including pain. This asynchrony between low- and high-SF happened at a very early stage of information extraction, which indicates that the decoding of low-SF expression information is not only faster but possibly occurs before the processing of high-SF information. Interestingly, the recognition of pain was also found to be slower and more difficult than core emotions. It is suggested that more complex decoding process may be involved in the successful recognition of pain from facial expressions, possibly due to the multidimensional nature of pain experiences. PERSPECTIVE: Two studies explore the perceptual and temporal properties of the decoding of pain facial expressions. At very early stages of attention, the recognition of pain was found to be more difficult than fear and happiness. It suggests that pain is a complex expression, and requires additional time to detect and process.

Gender differences in attention to pain body postures in a social context: a novel use of the bodies in the crowd task.

Pain signals the presence of potential harm, captures attention, and can inhibit performance on concurrent tasks. What is less well known, however, is whether such attentional capture also occurs in a wider social context, such as when observing people in pain. To explore this possibility, we adopted a novel social-cue detection methodology: the bodies-in-the-crowd task. Two experiments are reported that consider whether nonverbal cues of pain, happiness, and anger as expressed through body postures would capture and hold attention. Both experiments recruited 40 (20 male and 20 female) pain-free individuals. Overall, results show that pain postures do not capture attention any more than happiness or anger postures, but disengagement from pain postures was significantly slower across both studies. Gender differences were also found, and were more likely to be found when crowds comprised both men and women. Male pain postures were more likely to capture attention. However, female observers had faster target detection speed, and were quicker to disengage from distractors. They also showed slower disengagement from female expressions overall. Male observers showed no variation based on target or distractor gender. Implications and potential directions for future research are discussed.

Exploring the relationship between male norm beliefs, pain-related beliefs and behaviours: An online questionnaire study.

BACKGROUND: Gender beliefs help explain the variation found in pain among men and women. Gender norms and expectations are thought to affect how men and women report and express pain. However, less is known about how such beliefs are related to pain outside of laboratory settings. The aim of this study was therefore to consider the relationship between beliefs in male role norms, pain and pain behaviours in men and women. METHODS: An online questionnaire study was conducted. A total of 468 adults (352 women), with or without pain, completed a series of self-report measures relating to beliefs about pain and male role norms, as well as pain and general health behaviours. RESULTS: An experience of pain was associated with lower beliefs in traditional male norms. Endorsing stereotypical male norms was related to increased stigma associated with seeking professional help for pain in both men and women, but to a lesser extent associated with general health behaviours. There also seemed to be gender-based beliefs associated with the expression of pain. CONCLUSIONS: Together these findings suggest that beliefs in gender (male) norms are relevant to pain, and that there is utility in exploring the variation in pain beyond binary male-female categories.

Predicting the consequences of physical activity: An investigation into the relationship between anxiety sensitivity, interoceptive accuracy and action.

The ability to predict the consequences of our actions is imperative for the everyday success of our interactions. From negotiating an uneven surface, to mounting an immune response, we continually infer the limits of our body. The current investigation considered the impact that the inferred consequences of action has on the placement of limits. We hypothesised that the performance of individuals in a novel, sprint task would reflect both their ability to accurately detect changes in bodily arousal (Interoceptive Accuracy) and the inferred consequences associated with heightened arousal signals (Anxiety Sensitivity). We found that individuals who demonstrated accuracy associated with physiological arousal changes, and who showed a heightened fear of the consequences of arousal symptoms, modified their actions by decreasing their power output (mean Watts•kg-1) in a sprint task (ΔR2 = 0.19; F(1,34) = 19.87); p<0.001). These findings provide a basis for understanding the varying actions taken as we encounter bodily perturbation.

People in pain make poorer decisions.

Chronic pain affects 1 in 5 people and has been shown to disrupt attention. Here, we investigated whether pain disrupts everyday decision making. In study 1, 1322 participants completed 2 tasks online: a shopping-decisions task and a measure of decision outcomes over the previous 10 years. Participants who were in pain during the study made more errors on the shopping task than those who were pain-free. Participants with a recurrent pain condition reported more negative outcomes from their past decisions than those without recurrent pain. In study 2, 44 healthy participants completed the shopping-decisions task with and without experimentally induced pain. Participants made more errors while in pain than while pain-free. We suggest that the disruptive effect of pain on attending translates into poorer decisions in more complex and ecologically valid contexts, that the effect is causal, and that the consequences are not only attentional but also financial.

An investigation of the effect of experimental pain on logical reasoning.

Pain disrupts attention to prioritise avoidance of harm and promote analgesic behaviour. This could in turn have negative effects on higher-level cognitions, which rely on attention. In the current article, we examined the effect of thermal pain induction on 3 measures of reasoning: the Cognitive Reflection Test, Belief Bias Syllogisms task, and Conditional Inference task. In experiment 1, the thermal pain was set at each participant's pain threshold. In experiment 2, it was set to a minimum of 44°C or 7/10 on a visual analogue scale (whichever was higher). In experiment 3, performance was compared in no pain, low-intensity pain, and high-intensity pain conditions. We predicted that the experience of pain would reduce correct responding on the reasoning tasks. However, this was not supported in any of the 3 studies. We discuss possible interpretations of our failure to reject the null hypothesis and the importance of publishing null results.

Perceptions of gendered and ungendered pain relief norms and stereotypes using Q-methodology.

Pain is ubiquitous, but effective pain relief eludes many. Research has shown that some pain behaviours are perceived as gendered, and this may influence the way men and women express and cope with pain, but such enquiries have not extended to specific methods of pain relief. Our aim was to explore perceptions of the most socially acceptable ways for men and women to relieve pain. Across 2 studies, 60 participants (50% men) aged 18 to 78 years completed a Q-sort task, sorting different pain relief strategies by the social acceptability for either women (study 1; N = 30) or men (study 2; N = 30). Analyses revealed 2 stereotypes for each sex. The overarching stereotype for women suggested it is most acceptable for them to use pain relief strategies considered conventional and effective. However, a second stereotype suggested it is most acceptable for women to use strategies that generally conform to feminine gender norms and stereotypes. The overarching male stereotype suggested it is most acceptable for men to use pain relief aligned with stereotypical masculinity; however, a second stereotype also emerged, characterised by conventional and effective responses to pain, much like the overarching stereotype for women. These differing viewpoints seem to depend on whether gender norm conformity or perceived analgesic efficacy is believed to determine social acceptability. These studies provide initial evidence of both a gendered and ungendered lens through which pain relief can be viewed, which may influence how men and women use pain relief.

The tripartite structure of pain-related affect: a confirmatory factor analysis.

Numerous emotion-based constructs seem related to pain and pain-related disability. These include general affect constructs such as anxiety and depression, as well as specific anxiety-related constructs such as anxiety sensitivity and fear of pain. Few studies examine the relationships between these constructs. Those that have suggest they can be reduced to three or four underlying components. We used a confirmatory approach to test the models of pain-related anxiety found in previous exploratory studies. Adult participants (N = 294) completed commonly used measures of affect-related constructs relevant to pain. Confirmatory Factor Analyses tested three models to determine the best fit. The tripartite model, with small modifications, was found to provide the best fit. The model consisted of: 1) General distress, 2) Fear of pain from injury/insult, and 3) Cognitive intrusion of pain.