Background & Aims
Positive clinical interactions are crucial for persons living with chronic pain as they often face socio-emotional challenges related to their pain (1,2). Hyperscanning (i.e. synchronized imaging from 2 or more individuals) can be applied to explore brain mechanisms underlying therapeutic alliance and their link to pain-related outcomes. Our previous studies applied hyperscanning to demonstrate that patient-clinician brain concordance in specific regions was up-regulated following a clinical interaction and associated with analgesia and therapeutic alliance (3–5). Our follow-up EEG hyperscanning study assessed patient-clinician brain-to-brain connectivity using scalp neuroelectrical signals. As EEG is a non-invasive neuroimaging technique with millisecond time resolution, inter-brain connectivity can be estimated in real-time and linked to social dynamics during clinical interactions and pain treatment.
Methods
Our EEG-hyperscanning study (N=34 dyads) collected brain signals simultaneously from chronic low back pain patients and treating clinicians (licensed acupuncturists). Patients experienced either an augmented or a limited style clinical intake from trained clinicians followed by an evoked pain task with electro-acupuncture (EA) therapy. Evoked cuff pain at the left leg was chosen as deep sustained pain better mimics clinical pain. Self-report measures included therapeutic alliance, assessed using the Consultation and Relational Empathy (CARE) scale (6), and psycho-emotional affect, using the Positive and Negative Affect Schedule (PANAS) (7). Brain data were acquired using two 64-channel EEG systems. Adopting a previously validated analysis pipeline (8), we focused on six scalp regions: frontal, temporal, and central from both left and right hemispheres. Statistical brain-to-brain connectivity was estimated using a relatively novel multivariate multi-brain model (9).
Results
While the quality of the patient-clinician interaction (augmented versus limit) did not directly modulate pain analgesia, patients randomized to the augmented group compared to the limited group reported decreased negative affect and higher expectations and interest in future acupuncture therapy. The brain-to-brain connectivity analysis revealed a greater linkage in the Alpha and Beta bands between right temporal-central areas following augmented versus limited interaction during pain treatment. No significant differences were found in the left hemisphere. Additionally, following augmented interaction, clinicians’ right frontal region was highly connected with all patients’ brain regions, particularly with cross-hemispheric (left) frontal areas. This result suggests a unique role for clinicians’ right frontal area in sustaining inter-brain synchrony during pain treatment, confirming its involvement in higher-order social functions, including recognition of social clues.
Conclusions
Although the quality of the patient-clinician interaction in a single visit intervention was not linked to pain relief in chronic pain patients, augmented interactions did impact other important variables of pain management. Chronic pain patients undergoing a warm and friendly clinical encounter were more likely to continue to see their acupuncturist and expected higher pain relief from future acupuncture, suggesting better treatment adherence. Underlying brain mechanisms involve increased brain-to-brain connectivity between regions involved in cognitive and executive processing (patients’ frontal left region), empathy and mentalizing (clinicians’ frontal left region). Future studies will synthesize the main features of the patient-clinician inter-brain networks and investigate the potential of these indices as descriptors of the quality of the interaction and predictor of clinical and behavioral outcomes for longitudinal therapy.
References
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2.Kaptchuk TJ Kelley, JM, Conboy, LA, Davis, RB, Kerr, CE, Jacobson, EE, Kirsch, I, Schyner, RN, Nam, BH, Nguyen, LT, Park, M, Rivers, AL, McManus, C, Kokkotou, E, Drossman, DA, Goldman, P, Lembo, AJ. Components of placebo effect: randomised controlled trial in pateints with irritable bowel syndrome. BMJ. 2008;(336):999–1003.
3.Ellingsen DM, Isenburg K, Jung C, Lee J, Gerber J, Mawla I, et al. Dynamic brain-to-brain concordance and behavioral mirroring as a mechanism of the patient-clinician interaction. Sci Adv. 2020 Oct;6(43).
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5.Ellingsen DM, Isenburg K, Jung C, Lee J, Gerber J, Mawla I, et al. Brain-to-brain mechanisms underlying pain empathy and social modulation of pain in the patient-clinician interaction. Proc Natl Acad Sci. 2023 Jun 27;120(26):e2212910120.
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8.Schwartz L, Levy J, Endevelt-Shapira Y, Djalovski A, Hayut O, Dumas G, et al. Technologically-assisted communication attenuates inter-brain synchrony. NeuroImage. 2022 Dec 1;264:119677.
9.Toppi J, Borghini G, Petti M, He EJ, Giusti VD, He B, et al. Investigating Cooperative Behavior in Ecological Settings: An EEG Hyperscanning Study. PLOS ONE. 2016 Apr 28;11(4):e0154236.
Presenting Author
Alessandra Anzolin
Poster Authors
Alessandra Anzolin
PhD
Spaulding Rehabilitation Hospital
Lead Author
Arvina Grahl
Spaulding Rehabilitation Hospital/Harvard Medical School
Lead Author
Seneca Ellis
Spaulding Rehabilitation Hospital, HMS
Lead Author
Lara Gardiner
Spaulding Rehabilitation Hospital, HMS
Lead Author
Jeungchan Lee
PhD
Spaulding Rehabilitation Hospital, HMS
Lead Author
Norman Kettner
Logan College of Chiropractic
Lead Author
Ted Kaptchuk
Beth Israel Deaconess Medical Center, HMS
Lead Author
Vitaly Napadow
Spaulding Rehabilitation Hospital
Lead Author
Topics
- Mechanisms: Psychosocial and Biopsychosocial