pain & the ‘second brain’ · moseley gl, arntz a. the context of a noxious stimulus affects...

Pain & The ‘Second Brain’:The Importance of Understanding, & Applying,

Modern Pain Science To GI Related Pain

Kevin Cuccaro, D.O.

1

Faculty Disclosure:

The speaker, Dr. Kevin Cuccaro, has declared

they have no relevant financial disclosures.

Learning Objectives

• Define modern pain science using a new conceptual

model.

• Describe how to assess and ‘deconstruct’ pain to direct

treatment.

• Apply constructed thinking to pain-related GI disorders

(e.g. Functional GI Disorders)

3

Goals:

Challenge Beliefs

‘Categorical Awareness’

Think Differently

Outline:

1. Intro Pain Science

2. Risk Factors &

Amplifiers

3. FGID & Pain

4

Kevin Cuccaro, D.O.

Before:

• Anesthesiology (Univ. of Chicago)

• ‘Pain Medicine’ (Univ. of Michigan)

• Assoc. Program Dir. (NMCSD)

• Board Certified ‘Pain Injection Specialist’

“Why aren’t people better?”

Now:

• Pain Specialist & Consultant

✓ Healthcare Systems/PCPCH’s

✓ OHA Clinical Innovations

Fellow

✓ Oregon Pain Management

Commission

✓ OHA HERC Chronic Pain Task

Force

5

Understanding Pain &

Modern Pain Science

(Part 1)

6

Three ‘Key’ Pain Concepts:

• Key Concept #1: (The Purpose of Pain & How People Can Hurt Even If It

Appears “Nothing’s Wrong”)

• Key Concept #2: (The Most Common Misconception About Pain Almost

Everyone Makes & Which Causes Treatments To Fail)

• Key Concept #3: (How To Think Differently For Safe & Effective

Treatment)

7

“We cannot solve our

problems with the same

thinking we used when

we created them.”

Opioid…Or Pain Problem?

Pain

• Common presenting

symptom

• Most common disability

• $600+ Billion annually

• ‘100 Million Americans’Available at: http://www.iom.edu/Reports/2011/Relieving-Pain-in-America-A-Blueprint-for-

Transforming-Prevention-Care-Education-Research/Report-Brief.aspx. Accessed May 5,

2015

Back Pain

• 2nd Most Common Reason for

ALL Physician Visits

• Lifetime Prevalence of 60-90%

• Industrialized & Developing

World

• Disability Rates Very Different

Waddell G. 1987 Volvo award in clinical sciences. A new clinical model for the treatment of

low-back pain. Spine. 1987;12(7):632-44.

Allan DB, Waddell G. An historical perspective on low back pain and disability. Acta Orthop

Scand Suppl. 1989;234:1-23.

9

Cost & Benefit

What We Did…

• MRI’s 300%

• Procedures 130-700+%

• Surgeries 300+%

• Opioids 690+%

What We Got…

• Disability Rates

• Complication Rates

• Healthcare Costs

No Improvement in Self

Reports

10

Deyo RA, Mirza SK, Turner JA, Martin BI. Overtreating chronic back pain: time to back off?. J Am Board Fam Med. 2009;22(1):62-8Friedly J, Standaert C, Chan L. Epidemiology of spine care: the back pain dilemma. Phys Med Rehabil Clin N Am. 2010;21(4):659-77Mafi JN, Mccarthy EP, Davis RB, Landon BE. Worsening trends in the management and treatment of back pain. JAMA Intern Med. 2013;173(17):1573-81.Atluri S, Sudarshan G, Manchikanti L. Assessment of the trends in medical use and misuse of opioid analgesics from 2004 to 2011. Pain Physician. 2014;17(2):E119-28.Sehgal N, Colson J, Smith HS. Chronic pain treatment with opioid analgesics: benefits versus harms of long-term therapy. Expert Rev Neurother. 2013;13(11):1201-20.

Overall Results

2000 U.S. Population 2010 U.S. Population (9.6%)

100 Million Chronic Pain45 Million Chronic Pain

122%

Fishman S, Berger L. The War on Pain. Harper Collins; 2001.Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington (DC): National Academies Press (US); 2011. 1, Introduction. Available from: https://www.ncbi.nlm.nih.gov/books/NBK92525/

122%?!?Despite More Treatment?

How?

©Kevin Cuccaro, D.O. 12

What Is Pain?Key Pain Concept #1: (The Purpose of Pain & How People Can

Hurt Even If It Appears “Nothing’s Wrong”)


Pain or No Pain?

J P Fisher et al. BMJ 1995;310:7014

Pain or No Pain?

Available at: http://www.contractortalk.com/f14/forthcoming-nail-gun-injury-40719/. Accessed May 18, 2016.15

Who Has Pain?

16

How can someone…

Severe pain in their foot… but no spike?

Have a nail in their thumb…but little pain?

‘Spinal deformity’…but no pain?

‘Normal’ X-Rays…but tremendous pain?


What Is Pain?

“Pain is an

unpleasant sensory & emotional

experience

associated with actual or potential

tissue damage or described in

terms of such damage.”

IASP 1994

Unpleasant

Sensory AND Emotional

Bodily Experience

In Response To Perceived

Danger

Revised from Moseley GL, Butler DS. Explain Pain Supercharged. 2017.


Key Pain Concept #1The Purpose of Pain Is Protection Not Punishment

“Hurt ≠Harm”

Protection

NOT Punishment

‘Danger’

NOT ‘Damage’

© 2018 Straight Shot Health, LLC

The Pain Course 20

Protection Not Punishment(“Hurt” ≠ “Harm”)

‘Harm WITHOUT Hurt’

• Distraction

• Life or Death Events

• Belief of Harmlessness

• General Anesthesia

‘Hurt WITHOUT Harm’

• High (But Not Too High) Threat

• Expectation of Harm or

‘Vulnerable’ Expectation

• Belief of Harm

Wall P, McMahon S. The relationship of perceived pain to afferent nerve impulses. Trends Neurosci. 9(6), 254–255 (1986).Beecher HK. Pain in Men Wounded in Battle. Ann Surg. 1946;123(1):96-105.Arntz A, Claassens L. The meaning of pain influences its experienced intensity. Pain. 2004;109(1-2):20-5.Moseley GL, Arntz A. The context of a noxious stimulus affects the pain it evokes. Pain. 2007;133(1-3):64-71.Helsen K, Vlaeyen JW, Goubert L. Indirect acquisition of pain-related fear: an experimental study of observational learning using coloured cold metal bars. PLoS ONE. 2015;10(3):e0117236.Urquhart DM, Bell RJ, Cicuttini FM, Cui J, Forbes A, Davis SR. Negative beliefs about low back pain are associated with high pain intensity and high level disability in community-based women. BMC Musculoskelet Disord. 2008;9:148

21

Tissue Damage ≠ Pain

Beecher HK. Pain in Men Wounded in Battle. Ann Surg. 1946;123(1):96-105. 22

Pain ≠ Damage!No Pain Pain!

Key Concept #1: The Purpose of Pain Is Protection“Hurt ≠ Harm”

Key Pain Concept #2(The Most Common Misconception About Pain Almost

Everyone Makes & Which Causes Treatments To Fail)

Dr. Ignaz Semmelweis 1818-8165

Women Are Dying!

We Must Wash Our Hands!

No!

We are ‘Gentleman’!

(& Threw Him Into An Insane Asylum)

Assumptions & Misconceptions

Can Be Harmful

So Let’s Test Some…

Where Is The Pain “Coming From...?”

IF Pain “Came From…”

…Then structural imaging or

examination would

consistently &

predictably detect who is &

who isn’t experiencing pain

But is this true?

30

Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of

spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811-6.

IF Pain “Came From…”

…Then cutting, poking, popping,

drugging, ‘Pain Pus Pathways’

would consistently &

predictably work with

sustained results…

But is this true?

32

Surgery For Back Pain

“No subset of patients with chronic

LBP could be identified for whom

spinal fusion is a predictable and

effective treatment “

Willems PC, Staal JB, Walenkamp GH, De bie RA. Spinal fusion for chronic low back pain: systematic review on the accuracy of tests for patient selection. Spine J. 2013;13(2):99-109.

33

Current Treatment Model

What We Do…

• MRI’s 300%


• Surgeries 300+%

• Opioids 690+%

What We Get…

• Disability Rates

• Complication Rates

• Healthcare Costs

No Improvement in

Self Reports

34

Deyo RA, Mirza SK, Turner JA, Martin BI. Overtreating chronic back pain: time to back off?. J Am Board Fam Med. 2009;22(1):62-8Friedly J, Standaert C, Chan L. Epidemiology of spine care: the back pain dilemma. Phys Med Rehabil Clin N Am. 2010;21(4):659-77Mafi JN, Mccarthy EP, Davis RB, Landon BE. Worsening trends in the management and treatment of back pain. JAMA Intern Med. 2013;173(17):1573-81.Atluri S, Sudarshan G, Manchikanti L. Assessment of the trends in medical use and misuse of opioid analgesics from 2004 to 2011. Pain Physician. 2014;17(2):E119-28.Sehgal N, Colson J, Smith HS. Chronic pain treatment with opioid analgesics: benefits versus harms of long-term therapy. Expert Rev Neurother. 2013;13(11):1201-20.

Maybe Our Model Needs An Update…?

Melzack R. From the gate to the neuromatrix. Pain. 1999;Suppl 6:S121-6.

17th Century 21st Century

Key Pain Concept #2

Pain Does NOT “Come From…” The Body

Pain Is “Constructed” In The Brain

How We Construct Pain

Unpleasant

Sensory AND Emotional

Bodily Experience

In Response To

Perceived Danger

Sensation (Feeling)

‘Where is it?’ & ‘What is it like?’

+

Emotion (Meaning)

‘What does this mean?’

+

Cognition (Thinking)

‘Does it matter right now?

& What should I do?’


Confusing? Not Really

All Fires Are Constructed

• Fuel

• Oxygen

• Heat

38

Pain Is Similar

Fire Triangle Pain Triangle

39

‘Fuel’, ‘Heat’, & ‘Oxygen’ of Pain

Cognition/Attention (“Heat”)

– Threat Appraisal

– Accidental vs. Intentional

– Uncertainty & Anxiety

Sensation/Transmission (“Fuel”)

– A-Beta vs. A-Delta vs. C-fibers

– Interoceptive, Exteroceptive,

Proprioceptive…

– ‘Top-Down’ Influences

Emotion/Meaning

(“Oxygen”)

– Fear & Loss Meaning

• Ex. Abd Pain

– Anger & Injustice

– Loss & Depression

40

All Pain Is Constructed

• Sensation/Transmission

(“Fuel”)

• Cognition/Attention

(“Heat”)

• Emotion/Meaning

(“Oxygen”)

41

Important: What Is This?


Structure OR Sensation Alone ≠ Pain


& NOCICEPTION

Is NOT Pain!

Nociception ≠ Pain

Nociception

• Specific nerve stimulation that

conveys information to the brain of

potential tissue damage

• Inferred from structure.

• Feedback Mechanisms or

• Anesthesia INDEPENDENT

• OBJECTIVE (‘Cause-Effect’)

Pain

• Perception & Response to

Sensory Information

• Genetics, prior learning, current

psychological status,

sociocultural influences, etc.

• Anesthesia DEPENDENT

• SUBJECTIVE (‘Constructed’)

WALL, PD.; MCMAHON, SB. The relationship of perceived pain to afferent nerve impulses. Trends in Neurosciences. 1986;96: 254-255 44

Key Pain Concept #2: Pain is Constructed.It Does Not “Come From…”


(Nociception Is One of Many Sensory Inputs)

So Far…

• Key Pain Concept #1

The Purpose of Pain Is Protection Not Punishment

“Hurt ≠ Harm”

• Key Pain Concept #2

Pain Does NOT “Come From…” The Body

Pain Is “Constructed” In The Brain


Key Pain Concept #3(How To Think Differently For Safe &

Effective Treatment)

Kuwait 1991

All Fires Extinguished…(9 months)

Key Pain Concept #3

If You Know What You’re Treating…

You Know How To Treat It

Firefighters Understand Fire

Then ‘Deconstruct’ It To

Target Treatment

(e.g. They don’t spray water on every fire!!!)

51

The Same Applies To Pain

‘Pain Fire’ Examples…

52

Spike In Boot

53


– ‘Tissue Issues’ or No?


– Threat, Uncertainty, Anxiety?

Emotion/Meaning (“Oxygen”)

– Fear, Loss/Harm Meaning?

Nail In Thumb







55

‘Normal Spine’





57

Scoliosis







59

No Pain

60

Why This Matters

What We Assume About Pain So We Focus Treatment Here.

“Your Pain is coming from…”

61

• MRI’s 300%


• Surgeries 300+%

• Opioids 690+

• Structure-Focused Therapy

• Body-Focused Messaging

But Structure ≠ Pain

(& ‘Acute Pain’ ≠ ‘Wood Burning) (& ‘Chronic Pain’ ≠ ‘Brain Fire’)

© 2018 Straight Shot Health, LLC

The Pain Course 62

However…

“Structure” or “Fuel”

Are NOT Irrelevant!

(Especially ‘Acute’ Scenarios)

But “Structure” or “Fuel”

Often NOT 1°Contributor

(Usually ‘Chronic’ Scenarios)

63

Different Thinking(For Different Categories)

64

Different Thinking is more than‘Acute’ vs. ‘Chronic’…

‘Acute’? ‘Chronic’ ?

65

Same Primary ‘Target’?

66

Only One Way To ‘Treat’?

67

But What About Risk Factors?

68

That’s Next

Understanding Pain

& Risk Factors

(Part 2)

69

Fire Season

70

Fire Forecasting

Available at https://www.fs.fed.us/science-technology/fire/forecasting Accessed 9/12/18

71

‘Pain Fire’ Risk Factors (& Amplifiers)

• Genetic/Epigenetic

• Developmental

– Childhood Illness, Abuse, Neglect

• Adult Victimization/PTSD

• High Stress

– Early Life

– Chronic Stress

– Acute Stressors

• Anxiety

• Depression

• Pain Beliefs & Expectations

• Maladaptive Coping– Pain Intensity

– Nonorganic Signs

– High Baseline Impairment


‘Pain Fire’ Risk Factors (& Amplifiers)

• Genetic/Epigenetic

• Developmental

– Childhood Illness, Abuse, Neglect

• Adult Victimization/PTSD

• High Stress

– Early Life

– Chronic Stress

– Acute Stressors

Changes:

Structure

(Hippocampus, Amygdala, ACC, PFC, etc.)

Connections & Network

(LC-NE, HPAA, DMN,Salience

Function

‘Threat Sensitivity & Reactivity’Mcewen BS. Physiology and neurobiology of stress and adaptation: central role of the brain. Physiol Rev. 2007;87(3):873-904.

Pechtel P, Pizzagalli DA. Effects of early life stress on cognitive and affective function: an integrated review of human literature. Psychopharmacology (Berl). 2011;214(1):55-70.

Valentino RJ, Van bockstaele E. Endogenous opioids: opposing stress with a cost. F1000Prime Rep. 2015;7:58.

Philip NS, Tyrka AR, Albright SE, et al. Early life stress predicts thalamic hyperconnectivity: A transdiagnostic study of global connectivity. J Psychiatr Res. 2016;79:93-100.

73

Threat Sensitivity & Reactivity(Stressed Physiology)



Threat Sensory Focus


– Nociceptive Δ’s (cortical/spinal)

– Interoceptive, Exteroceptive, Proprioceptive…


Emotion/Meaning

(“Oxygen”)

– Fear & Harm Association

– Emotional Reactivity &

Decision making

O'donovan A, Slavich GM, Epel ES, Neylan TC. Exaggerated neurobiological sensitivity to threat as a mechanism linking anxiety with increased risk for diseases of aging. Neurosci Biobehav Rev. 2013;37(1):96-108.Zheng G, Hong S, Hayes JM, Wiley JW. Chronic stress and peripheral pain: Evidence for distinct, region-specific changes in visceral and somatosensory pain regulatory pathways. Exp Neurol. 2015;273:301-11.Drevin J, Stern J, Annerbäck EM, et al. Adverse childhood experiences influence development of pain during pregnancy. Acta Obstet Gynecol Scand. 2015;94(8):840-6.Apkarian AV, Sosa Y, Krauss BR, et al. Chronic pain patients are impaired on an emotional decision-making task. Pain. 2004;108(1-2):129-36

74

‘High Heat’, ‘High O2’ (Not ‘Fuel’)

75

‘High Heat’, ‘High O2’ (aka ‘Central Sensitivity’ Syndrome)

Fibromyalgia, Chronic low-back

pain, Myofascial Pain Syndrome,

Tension-Type Headache, Migraine,

Chronic Fatigue, Irritable Bowel

Syndrome, Restless Legs Syndrome,

Multiple Chemical Sensitivity, TMD,

Fleming KC, Volcheck MM. Central sensitization syndrome and the initial evaluation of a patient with fibromyalgia: a review. Rambam Maimonides Med J. 2015;6(2):e0020.

76

“Okay, But I don’t treat ‘Chronic Pain’…”

What happens when this

person has surgery or

breaks a leg?

77


Or what happens if

someone else throws

‘water’ on the wrong

fire…& they’re back in

your office?

78


Or what if they don’t

have chronic pain

(yet)…but are high risk?

79


Or what affects do you

think this has with other

health conditions?

80


And what if they present

with symptoms in

their belly?

81

Understanding Pain

& Functional GI

Disorders

(Part 3)

82

What Are FGID’s?(Functional Gastrointestinal Disorders)

• Disorders of “Gut-Brain Interaction.” (33 adult, 20 pediatric)

• Classified by any combination of GI symptoms related to:

“motility disturbance, visceral hypersensitivity, altered

mucosal and immune function, altered gut microbiota, and

altered CNS processing”

• Organized by anatomic region (esophageal, gastroduodenal, bowel, etc.)

Drossman DA. Functional Gastrointestinal Disorders: History, Pathophysiology, Clinical Features and Rome IV. Gastroenterology. 2016;

83

What Are FGID’s?(Functional Gastrointestinal Disorders)

• Most common Irritable Bowel Syndrome & Functional

Dyspepsia

• Characterized by disturbed Brain-Gut Axis (Stress) physiology

• Overlap w/ other ‘functional’ disorders (FMS, TMD, CFS, etc).

84

‘High Heat’, ‘High O2’ (aka ‘Central Sensitivity’ Syndrome)

Fibromyalgia, Chronic low-back

pain, Myofascial Pain Syndrome,

Tension-Type Headache, Migraine,

Chronic Fatigue, Irritable Bowel

Syndrome, Restless Legs

Syndrome, Multiple Chemical

Sensitivity, TMD,

Fleming KC, Volcheck MM. Central sensitization syndrome and the initial evaluation of a patient with fibromyalgia: a review. Rambam Maimonides Med J. 2015;6(2):e0020.

85

FGID Risk Factors, Influencers

• Genetic

• Environmental Exposure

• Sociocultural Influences

• High Stress

– Early Life Stress

– Chronic

– Acute

• Anxiety

– Attentional Bias, Hypervigiliance

• Depression

• Illness Beliefs

• Brain-Gut Axis

– Physiology Δ’s

• Abnormal Motility

• Immune dysregulation,

Inflammation, barrier dys.

• Microbiome Δ’sVan oudenhove L, Crowell MD, Drossman DA, et al. Biopsychosocial Aspects of Functional Gastrointestinal Disorders. Gastroenterology. 2016;Quigley EMM, Hongo M, Fukudo S (eds): Functional and GI Motility Disorders. Front Gastrointest Res. Basel,

Karger, 2014, vol 33, pp 104-116Kanuri N, Cassell B, Bruce SE, et al. The impact of abuse and mood on bowel symptoms and health-related quality of life in irritable bowel syndrome (IBS). Neurogastroenterol Motil. 2016;28(10):1508-17. 86

Threat Sensitivity & Reactivity



Symptom-specific Anxiety


– Visceral Hypersensitivity


Emotion/Meaning

(“Oxygen”)

– Fear & Harm Association

Liu X, Silverman A, Kern M, et al. Excessive coupling of the salience network with intrinsic neurocognitive brain networks during rectal distension in adolescents with irritable bowel syndrome: a preliminary report. Neurogastroenterol Motil. 2016;28(1):43-53.Jerndal P, Ringström G, Agerforz P, et al. Gastrointestinal-specific anxiety: an important factor for severity of GI symptoms and quality of life in IBS. Neurogastroenterol Motil. 2010;22(6):646-e179.Videlock EJ, Adeyemo M, Licudine A, et al. Childhood trauma is associated with hypothalamic-pituitary-adrenal axis responsiveness in irritable bowel syndrome. Gastroenterology. 2009;137(6):1954-62.Kim SE, Chang L. Overlap between functional GI disorders and other functional syndromes: what are the underlying mechanisms?. Neurogastroenterol Motil. 2012;24(10):895-913. 87

‘Heat’ & ‘Oxygen’

88

Functional GI Disorders

89

Key To Treatment Is Different Thinking


90

What ‘Category’ is Primary Treatment Focus?


91

While recognizing what else is present…

92

Easy, Right?“The product of the interacting effects of the brain and GI

tract in any individual with an FGID relates to the clinical

expression of illness; namely, the symptom experience, its

severity, and subsequent illness-related behaviors.”

…”All of these factors can be addressed and potentially

modified by the physician’s ability to listen, engage, and

effect good communication skills,…regardless of the

diagnostic condition.”

Drossman DA. Functional Gastrointestinal Disorders: History, Pathophysiology, Clinical Features and Rome IV. Gastroenterology. 2016; 93

Challenges

“Symptom Experiences” =

Different (Constructed) Thinking

Medical Treatments are Limited

Awareness, Understanding, Communication, &

Engagement, are Crucial

94

Questions?

Goals:

Challenge Beliefs

‘Categorical Awareness’

Think Differently

Summary

1. The Purpose of Pain Is Protection NOT

Punishment.

2. Pain Is Constructed, (3 Dimensions-Not 1)

3. Understand Pain & How It Is

Constructed to ‘Target’ ‘Treatments’

4. Risk Factors (& Amplifiers) are Heat & O2

5. FGID = Symptom (Constructed)

Experience

(Constructed Thinking)

Pain BibliographyInstitute of Medicine (US) Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming

Prevention, Care, Education, and Research. Washington (DC): National Academies Press (US); 2011. Available from:

https://www.ncbi.nlm.nih.gov/books/NBK91497/doi: 10.17226/13172

Sehgal N, Colson J, Smith HS. Chronic pain treatment with opioid analgesics: benefits versus harms of long-term therapy. Expert Rev Neurother.

2013;13(11):1201-20.

Deyo RA, Mirza SK, Turner JA, Martin BI. Overtreating chronic back pain: time to back off?. J Am Board Fam Med. 2009;22(1):62-8.

Freburger JK, Holmes GM, Agans RP, et al. The rising prevalence of chronic low back pain. Arch Intern Med. 2009;169(3):251-8.

O'neill CW. Commentary: Diagnostic tests for chronic low back pain--a dismal science. Spine J. 2013;13(2):113-5.

Atluri S, Sudarshan G, Manchikanti L. Assessment of the trends in medical use and misuse of opioid analgesics from 2004 to 2011. Pain Physician.

2014;17(2):E119-28.

Mafi JN, Mccarthy EP, Davis RB, Landon BE. Worsening trends in the management and treatment of back pain. JAMA Intern Med. 2013;173(17):1573-81.

Friedly J, Standaert C, Chan L. Epidemiology of spine care: the back pain dilemma. Phys Med Rehabil Clin N Am. 2010;21(4):659-77

Olsen Y, Daumit GL. Chronic pain and narcotics: a dilemma for primary care. J Gen Intern Med. 2002;17(3):238-40.

Fishman S, Berger L. The War on Pain. Harper Collins; 2001.

Brennan F. The US Congressional "Decade on Pain Control and Research" 2001-2011: A Review. J Pain Palliat Care Pharmacother. 2015;29(3):212-27.

J P Fisher et al. BMJ 1995;310:70 (Boot & Nail Image)

“Nail gun injury” Available at: http://www.contractortalk.com/f14/forthcoming-nail-gun-injury-40719/. Accessed May 18, 2016.

96

Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR

Am J Neuroradiol. 2015;36(4):811

Jarvik JJ, Hollingworth W, et al. The Longitudinal Assessment of Imaging and Disability of the Back (LAIDBack) Study. Baseline Data. Spine 2001;26:1156-

1166

Suri P, Boyko EJ, Goldberg J, Forsberg CW, Jarvik JG. Longitudinal associations between incident lumbar spine MRI findings and chronic low back pain or

radicular symptoms: retrospective analysis of data from the longitudinal assessment of imaging and disability of the back (LAIDBACK). BMC

Musculoskelet Disord. 2014;15:152.

Jarvik JG, Hollingworth W, Heagerty PJ, Haynor DR, Boyko EJ, Deyo RA. Three-year incidence of low back pain in an initially asymptomatic cohort: clinical

and imaging risk factors. Spine. 2005;30(13):1541-8

Kalichman L, Kim DH, Li L, Guermazi A, Hunter DJ. Computed tomography-evaluated features of spinal degeneration: prevalence, intercorrelation, and

association with self-reported low back pain. Spine J. 2010;10(3):200-8

Carragee EJ, Alamin TF, Miller JL, Carragee JM. Discographic, MRI and psychosocial determinants of low back pain disability and remission: a prospective

study in subjects with benign persistent back pain. Spine J. 2005;5(1):24-35.

Carragee E, Alamin T, Cheng I, Franklin T, Van den haak E, Hurwitz E. Are first-time episodes of serious LBP associated with new MRI findings?. Spine J.

2006;6(6):624-35.

Melzack R. From the gate to the neuromatrix. Pain. 1999;Suppl 6:S121-6.

Melzack R, Katz J. Pain. Wiley Interdiscip Rev Cogn Sci. 2013;4(1):1-15.

97

Wikipedia, the free encyclopedia. Fire triangle. Available at: https://en.wikipedia.org/wiki/Fire_triangle. Accessed May 16, 2015].

Wall P, McMahon S. The relationship of perceived pain to afferent nerve impulses. Trends Neurosci. 9(6), 254–255 (1986).

Beecher HK. Pain in Men Wounded in Battle. Ann Surg. 1946;123(1):96-105

Carlino E, Frisaldi E, Benedetti F. Pain and the context. Nat Rev Rheumatol. 2014;10(6):348-55.

Arntz A, Claassens L. The meaning of pain influences its experienced intensity. Pain. 2004;109(1-2):20-5.

Moseley GL, Arntz A. The context of a noxious stimulus affects the pain it evokes. Pain. 2007;133(1-3):64-71.

Helsen K, Vlaeyen JW, Goubert L. Indirect acquisition of pain-related fear: an experimental study of observational learning using coloured cold metal bars. PLoS ONE. 2015;10(3):e0117236.

Pazzaglia C, Testani E, Giordano R, Padua L, Valeriani M. Expectation to feel more pain disrupts the habituation of laser-pain rating and laser-evoked potential amplitudes. Neuroscience. 2016;333:244-51.

Blasini M, Corsi N, Klinger R, Colloca L. Nocebo and pain: An overview of the psychoneurobiological mechanisms. Pain Rep. 2017;2(2)

Urquhart DM, Bell RJ, Cicuttini FM, Cui J, Forbes A, Davis SR. Negative beliefs about low back pain are associated with high pain intensity and high level disability in community-based women. BMC Musculoskelet Disord. 2008;9:148.

Hurter S, Paloyelis Y, Williams AC, Fotopoulou A. Partners' empathy increases pain ratings: effects of perceived empathy and attachment style on pain report and display. J Pain. 2014;15(9):934-44.

Karos K, Meulders A, Vlaeyen JW. Threatening social context facilitates pain-related fear learning. J Pain. 2015;16(3):214-25.

Lee H, Hübscher M, Moseley GL, et al. How does pain lead to disability? A systematic review and meta-analysis of mediation studies in people with back and neck pain. Pain. 2015;156(6):988-97.

De rooij A, Van der leeden M, Roorda LD, Steultjens MP, Dekker J. Predictors of outcome of multidisciplinary treatment in chronic widespread pain: an observational study. BMC Musculoskelet Disord. 2013;14:133.

Jackson T, Wang Y, Wang Y, Fan H. Self-efficacy and chronic pain outcomes: a meta-analytic review. J Pain. 2014;15(8):800-14.

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pain & the ‘second brain’ · moseley gl, arntz a. the context of a noxious stimulus affects...

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