Correlations between brain changes and pain management after cognitive and meditative therapies: A systematic review of neuroimaging studies

https://doi.org/10.1016/j.ctim.2018.06.006Get rights and content

Highlights

  • Nine reviewed studies examined brain activation promoted by cognitive or meditative therapy for pain management.

  • Cognitive strategies alter nociceptive and non-nociceptive brain regions activity.

  • Changes on brain activity after cognitive strategies was more associated with affective than sensory components of pain.

Abstract

Background

There are different ways of dealing with pain and cognitive and meditative therapies (CMT) are alternative ways to regulate the emotions associated with pain. Current studies apply neuroimaging techniques trying to elucidate the neural mechanisms of cognitive strategies for pain. This systematic review aimed to summarize the evidence on brain activity changes after CMT, which include cognitive behavioral therapy, mindfulness and/or meditation, for pain management as well as to evaluate clinical pain outcomes.

Methods

Electronic databases – Pubmed, EMBASE, PsycINFO, Science Direct, Scopus – were searched to find randomized controlled trials (RCTs) examining neuroimaging data of CMT for chronic pain patients or healthy individuals with experimental pain. Two reviewers independently selected the relevant trials, rated for quality assessment and extracted all data using a standardized form. Primary outcome was brain activity changes (activation, deactivation or functional connectivity). Secondary outcomes were pain intensity, self-management, pain coping, quality of life, anxiety and depression.

Results

Nine RCTs were included involving 280 adults (18–59 years), 139 chronic pain patients vs. 148 healthy subjects. Three main kinds of intervention were identified: cognitive-behavioral therapy (n = 4), mindfulness meditation (n = 4) and transcendental meditation technique (n = 1). Neuroimaging results revealed distinct patterns of activity, but the main findings were related to increased activation of prefrontal cortex (PFC), specially dorsolateral prefrontal cortex (dlPFC) and ventrolateral prefrontal cortex (vlPFC), orbitofrontal cortex (OBF), somatosensory cortices (SSC) and limbic system in chronic pain population; and increased activation of anterior cingulate cortex (ACC), anterior insular cortex (AI) and decreased activation of thalamus in healthy individuals following CMT.

Conclusion

This result means that regulation of pain by CMT can alter functioning of brain regions in an extensive network including non-nociceptive regions. CMT reduced the affective experience of pain, while reductions of pain intensity ratings were less consistent. Brain changes have been demonstrated as a result of the application of psychological measures and may represent the clinical implications of changes in brain activity or morphology.

Introduction

Pain was defined by the International Association for the Study of Pain (IASP) as an unpleasant sensory and emotional experience, associated with actual or potential tissue damage, or described in terms of such injuries.1 The World Health Organization (WHO) recognizes pain as an important global, public health concern. However, when pain becomes chronic, it has a strong impact on the patient's life and a high cost for the health system. In 2007, WHO identified a need for improved and standardized management of chronic pain (both malignant and non-malignant) and acute pain.2 Pain affects function, relationships, and behaviour and it is more than a sensory experience; it involves immune, endocrine, meaning making, emotional, and behavioral responses.3

Since psychosocial factors play important roles in pain and associated physical and psychosocial disability,4 patients and researchers on the pain field seek therapeutic approaches on pain management involving psychological strategies as such as cognitive and meditative therapies (CMT). CMT is an evidence-based psychotherapeutic method, rooted in behaviorism and cognitive psychological theory,5 Since the introduction of CMT for chronic pain more than 35 years ago,6,7 there have been many published reports of symptom improvements in patients with various forms of chronic pain.8,9,10 A systematic review and meta-analysis of randomised controlled trials (RCT’s) of CMT for fibromyalgia patients concluded that CMT improves coping with pain, reduces depressed mood and healthcare-seeking behaviour in such patients.11

Brain is a proven source of endogenous modulation of pain and brain imaging studies have contributed to the understanding of cerebral changes associated with chronic pain.12,13 Recent evidence of neuroimaging studies has established a connection between cognitive dysfunction and specific changes in brain structure14 and function.15 Evidence of neural networks that support such modulation has probably opened alternative pathways of treatment and CMT have demonstrated promising options for the multidisciplinar pain management. A better understanding of brain mechanisms underlying therapy can promote improvements in the therapeutic interventions as well as increase our knowledge on the formation and maintenance of symptoms.16

Treatments involving CMT have been well investigated by behavioral studies, but few randomized studies bring up the neurological mechanisms involved. This systematic review aimed to analyze the existing data on brain changes recruited throught CMT, including cognitive behavioral therapy, mindfulness and/or meditation, for clinical and/or experimental pain management detected through neuroimaging techniques and to identify the effects of CMT over clinical pain outcomes.

Section snippets

Methods

The protocol defined to this systematic review adhered to the recommendations proposed by the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) and the Cochrane Handbook for Systematic Reviews of Interventions.17,18 The review question was: “What is the neuroimaging evidence and neuromodulatory effects of CMT on pain management?” This current study has been registered at PROSPERO CRD42016046312.

http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016046312).

Studies description

Fig. 1 presents flow diagram summarizing the study selection process. The initial search identified a total of 1371 studies. From those, following removal of 112 duplicates, screening of titles and abstracts identified 63 potential studies. After a detailed review of full text of retrieved studies, final sample for analysis was composed of nine studies. The most prevalent reasons for study exclusion were a non-randomized clinical trial, treatment intervention other than meditation, mindfulness

Discussion

To our knowledge, this is the first image-based systematic review of fMRI or EEG studies assessing brain regions recruited through cognitive strategies for pain modulation. Among nine RCTs included in this review, eight studied experimental pain-induced brain activation in chronic pain population, including FM, or in healthy subjects, and one looked resting state functional activity in patients with chronic pain, all focusing on neural and behavioral modifications after cognitive strategies.

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