Shining a light on chronic pain and decision-making
Fibromyalgia (FM) is a medical condition characterised by chronic widespread pain, fatigue and cognitive symptoms. FM appears to affect the way the brain and spinal cord process painful and nonpainful signals and is more likely to target women. There is currently no cure for FM. While treatment for pain typically includes exercise and other long-term interventions, adherence to these treatments is often low. “This suggests that people with long-term pain may have altered decision-making around delayed and effortful rewards,” says PAID(opens in new window) project fellow Aleksandra Herman from the Nencki Institute at the Polish Academy of Sciences(opens in new window). “This can undermine uptake and persistence with effective interventions.”
Underlying neural and body–brain mechanisms
Understanding the aspects of pain – emotional versus physical – as well as the underlying neural and body–brain mechanisms that drive these decision patterns, is therefore essential to improving treatment effectiveness. The PAID project, which was supported by the Marie Skłodowska-Curie Actions(opens in new window) programme, set out to shine a light on this understudied area. “We wanted to evaluate delay and effort attitudes in people with FM versus matched pain-free controls,” explains Herman. “We also wanted to investigate the role of emotions and bodily sensation perception as potential contributors to altered decision-making about delayed and effortful rewards.” One way of doing this was to set a group of patients with FM, along with a set of pain-free controls, a number of tasks. These involved either physical effort or cognitive effort, with a weighted reward at the end. Participants could either exert effort to achieve the task and claim a reward or delay the task to receive a lesser reward. The project then set out to map the neural underpinnings of these altered decision processes using an interdisciplinary toolkit that incorporated behavioural economics, psychophysiology and neuroimaging.
Protective decision-making for physical effort
“What we found was heightened protective decision-making for physical effort,” adds Herman. “This means that people with FM were more likely to avoid physical effort but not cognitive effort. Difficulties with treatment adherence may stem from over-protective physical effort-related decision-making rather than low-motivation, offering a potential target for intervention in clinical care.” The findings of this project have been widely shared, with Herman delivering the Nencki Foundation Popular Science Lecture(opens in new window) on decision-making in FM and some key information about pain in general. Herman also participated in a recent webinar(opens in new window) on pain and activity, which was targeted at patients, advocacy groups and clinicians. Herman and her colleagues also published a paper in the Journal of Pain(opens in new window), which details how individuals with FM exhibit heightened protective decision-making for physical, but not cognitive, effort.
Tailored interventions for fibromyalgia patients
The hope is that the findings of the PAID project will lead to more tailored interventions that reduce immediate perceived costs or reframe rewards for FM patients. This could improve clinical guidance for designing rehabilitation programmes that explicitly address decision barriers, improving treatment uptake and thus long-term outcomes. “Next steps include designing mechanism-targeted interventions, designed to modify identified decision biases,” says Herman. “The feasibility and efficacy of these would then need to be tested in randomised trials. This work would be co-produced with patients and clinicians.”
