Stress-system activation in children with chronic pain: A focus for clinical intervention

Abstract

Accumulating evidence indicates that psychological and neurophysiological processes interconnect and interact to activate the body’s stress system and to trigger and maintain functional somatic symptoms. This study used the Early Life Stress Questionnaire, Depression Anxiety Stress Scales and biological markers (heart rate, heart rate variability, skin conductance, C-reactive protein (CRP) titre, respiratory rate, and accuracy and reaction time in an emotion-face identification task), to examine childhood adversity, psychological distress and stress-system activation in 35 children and adolescents (23 girls and 12 boys, 9–17 years old) disabled by chronic pain (vs two groups of age- and sex-matched healthy controls). Patients reported more early-life stress ( U = 798.5, p = .026) and more psychological distress ( U = 978, p < .001). They showed activation of the autonomic system: elevated heart rate ( U = 862.5, p = .003), elevated electrodermal activity ( U = 804.5, p = .024) and lower heart rate variability in the time domain ( U = 380.5, p = .007) and frequency domain ( U = 409.5, p = .017). The group showed an upward shift of CRP titres (with 75th and 90th CRP percentiles of 4.5 and 10.5 mg/L, respectively), suggesting the activation of the immune–inflammatory system. Elevated CRP titres were associated with elevated heart rate ( p = .028). There were no differences in respiratory rate or in accuracy and reaction time in the emotion-face identification task. The results indicate that interventions for children and adolescents with chronic pain need a multidisciplinary mind–body approach that concurrently addresses psychological distress, physical impairment and stress-system dysregulation.

Stressful experiences in youth: “Set-up” for diminished resilience to chronic pain

“…published a conceptual framework that identified potential shared mechanisms such as nervous system sensitization, HPA axis activity, and allostatic load underlying the association between ACEs and chronic pain in pediatric populations ( Nelson et al., 2016 ). Other investigations by Timmers and colleagues ( Timmers et al., 2019 ) and McInnis and colleagues ( McInnis et al., 2019 ) have highlighted specific aspects of the stress response, mainly cortisol via cognitive threat detection (the former) and HPA-axis activity (the latter), in relation to chronic pain in youth. However, these models do not fully capture the complexities of the human stress response (i.e., neuroendocrine, neurobiological) and the vast array of ways in which stress, trauma, or ACEs can impact the biopsychosocial functioning of youth.…”

“…Evidence of this has been found in targeted studies examining various biomarkers of the stress-response and/or allostatic load in youth populations. For example, a recently published study found higher rates of early life stress concomitantly with increased activation of the autonomic nervous system (e.g., heart rate, electrodermal activity) and immune response (i.e., c-reactive protein) in youth with chronic pain vs. healthy controls ( McInnis et al., 2019 ). Cortisol, a primary stress hormone, regulator of HPA-axis function, and biomarker for allostatic load, has also been identified as a pain-related outcome and target for intervention in pediatric pain populations ( Chadi et al., 2016 ).…”

“…Within the past several years, various reports ( Abdallah and Geha, 2017 ; Romero-Grimaldi et al., 2015 ; Borsook et al., 2012 ) have highlighted aspects of how stressful events and chronic pain may interact in youth or adult populations, such as via glucocorticoid release and/or altered cognitive processes (i.e., threat learning) ( Timmers et al., 2019 ; Nelson et al., 2016 ), HPA-axis variability ( Nelson et al., 2016 ; McInnis et al., 2019 ), hippocampal volume ( Vachon-Presseau et al., 2013a ), etc. However, no research to-date has put forth a comprehensive model of stress and pain, taking into account psychosocial, cognitive, neuroendocrine, and neurobiological indices.…”

The Stress-System Model for Functional Somatic Symptoms

“…More recent studies have confirmed the long-observed association between adverse childhood experiences and functional somatic symptoms and syndromes (see studies listed in Online Supplement 1.3). In our own studies of children with functional neurological disorder (FND) and chronic/complex pain, antecedent illness or injury, family conflict, and bullying in the school and peer contexts have also consistently emerged as additional important antecedents (Kozlowska et al 2011;McInnis et al 2020).…”

Instrumentos De Avaliação Neuropsicológica Em Crianças Com Dor Crônica: Uma Revisão Sistemática De Literatura

“…É importante, nessa população, o cuidado no processo de avaliação neuropsicológica, levando-se em consideração a faixa etária, o desenvolvimento cognitivo e a capacidade de autorrelato (SILVA; PINTO; GOMES; BARBOSA, 2011). Variáveis associadas à dor (intensidade, duração e catastrofização) são significativamente relacionadas ao desempenho do funcionamento cognitivo, com erros na execução de tarefas de atenção sustentada, resultando em baixa autoestima, maiores taxas de ansiedade, depressão, com maior ativação e desregulação do sistema de enfrentamento ao estresse (MCINNIS; BRAUND; CHUA; KOZLOWSKA, 2020, FRIEDRICHSDORF et al, 2016E SIMONS 2016WEISS et al, 2018). Impactos na inteligência, raciocínio verbal e não verbal, memória, atenção, velocidade de processamento e o funcionamento executivo também se apresentam como fatores de preocupações significativas nas crianças com dor crônica (HOCKING; ALDERFER, 2012).…”