Broadening the Scope of Resilience in Chronic Pain: Methods, Social Context, and Development

Abstract

Purpose of review:

A wellspring of new research has offered varying models of resilience in chronic pain populations; however, resilience is a multifaceted and occasionally nebulous construct. The current review explores definitional and methodological issues in existing observational and clinical studies and offers new directions for future studies of pain resilience.

Recent findings:

Definitions of pain resilience have historically relied heavily upon self-report and from relatively narrow scientific domains (e.g., positive psychology) and in narrow demographic groups (i.e., Caucasian, affluent, or highly educated adults). Meta-analytic and systematic reviews have noted moderate overall quality of resilience-focused assessment and treatment in chronic pain, which may be attributable to these narrow definitions.

Summary:

Integration of research from affiliated fields (developmental models, neuroimaging, research on historically underrepresented groups, trauma psychology) has the potential to enrich current models of pain resilience and ultimately improve the empirical and clinical utility of resilience models in chronic pain.

Introduction

Resilience is a construct with broad clinical applicability that, over the past two decades, has been increasingly applied to specific domains of health. Zautra and colleagues proposed a 3-factor model in 2008 that defined resilience according to a temporal model of adaptation: (1) sustained positive function despite the presence of significant stress or adversity; (2) effective or efficient recovery from negative effects of stress or adversity; and (3) long-term growth or learning in response to stress or adversity that leads to future positive adaptation and function[1]. This stress resilience model was subsequently adapted for adult[2] and pediatric[3] chronic pain, with subsequent reviews delineating between stable, trait-like resilience resources (e.g., genetics, personality factors) and dynamic, state-like aspects that relate to positive pain coping (e.g., positive affective states, adaptive patterns of cognition and coping behavior)[4]. Further, the focus of resilience models in chronic pain has extended beyond intra-individual processes to encompass social mechanisms (e.g., positive and negative social interactions) and broader social contexts (e.g., social support, situation-specific goal contexts that facilitate behavioral persistence despite ongoing pain)[5, 6].

As research on chronic pain resilience has expanded, methodological and conceptual questions have emerged about the most useful way to define resilience and apply resilience models to chronic pain in research and clinical contexts. This paper will review issues of defining and measuring pain resilience, the incorporation of salient constructs in other domains of resilience (developmental processes, trauma, and experiences of discrimination and disparity in minoritized groups), new directions in methodological inquiry beyond the use of self-report, and current evidence regarding the use of resilience concepts in clinical intervention.

Definitional issues in pain resilience measurement

Self-report assessment of resilience emerged within developmental psychopathology and stress research and remains the most common way resilience is measured. Generally, self-report measures either (1) directly assess an individual’s belief that they are resilient, or (2) assess other constructs found to confer resilience. An example of the former is the Brief Resilience Scale (BRS), which measures an individual’s belief in their ability to “bounce back” from stress, with items such as “I tend to bounce back quickly after hard times”[7]. As an example of the latter, the Connor Davidson Resilience Scale includes items similar to the BRS, and also probes beliefs regarding personal competence, tenacity, trust in instincts, tolerance of negative affect, strengthening effects of stress, secure relationships, acceptance of change, control, and spirituality[8]. General resilience measures have been subsequently examined in chronic pain populations and are associated with meaningful differences in pain perception and adaptation to chronic pain[9–12]. However, existing general resilience measures show moderate validity overall, due in part to the difficulty of matching broad resilience concepts with distinct characteristics and lived experiences of specific patient populations[13].

Concurrent with the emergence of general resilience measures, chronic pain models have begun to incorporate positive psychology constructs to better understand individual differences in pain experience and adaptation. This approach has yielded research on a diverse range of constructs, including positive affect, hope, optimism, self-efficacy, and acceptance, all of which have been identified as protective against pain and its negative consequences[14–18]. Inclusion of these related positive psychology constructs in the measurement of resilience can help broaden the construct beyond directly asking respondents about their belief in their own resilience.

The Pain Resilience Scale (PRS) was developed to capture both the expectation of resilience that is a hallmark of general resilience scales, and elements of related resilience resources related to pain, in particular positive affect, hope, and optimism[19]. Initial development of the PRS identified two factors, labeled ‘behavioral perseverance’ and ‘cognitive-affective positive’. Behavioral perseverance items directly assess individuals’ belief in their ability to continue despite pain (e.g., “I get back out there”, “I push through it”), whereas cognitive-affective positive items focus on related resilience resources such as hope (e.g., “I keep a hopeful attitude), and positive affect (“I still find joy in my life”). Pain-specific resilience measures like the PRS show stronger associations with pain-relevant outcomes than general scales of resilience[19, 20].

However, notable criticisms of self-report resilience assessment remain. Although self-report resilience measures are psychometrically sound in terms of scale development and external validity, construct validity remains questionable, as these measures also lack specificity in how resilience is assessed (e.g., across domains of function) and rely on individuals’ conscious report of their resilience capacity. Outstanding questions remain. For example, it is unclear whether interpersonal or environmental factors, which are known to be important but are not represented in most resilience measures, can meaningfully be incorporated into existing resilience measures, which focus almost exclusively on intrapersonal processes (e.g., cognitive or behavioral coping processes). Further, to what degree is resilience in one domain (e.g., being able to maintain meaningful behavioral pursuits in the presence of pain) related to other aspects of pain resilience (e.g., maintaining positive relationships despite ongoing pain), and how can consistent or inconsistent indications of resilience across domains be reconciled? Such refinement can be driven by both theory and empirical examination of existing scales.

Additionally, recent studies have begun to utilize multi-method approaches that include self-report resilience measures alongside objective assessments such as actigraphy-based assessment of physical activity[21], physiological indices associated with resilience (e.g., heart rate variability)[22], sensory function (e.g., quantitative sensory testing)[23], and neuroimaging. These objective measures may offer an alternative to self-reported appraisals free from potential social desirability responses. Nascent research on the neuroscience of pain and other objective measurements has the potential to identify physiological mechanisms underlying resilience, which will clarify important definitional aspects of this construct and inform future multidisciplinary research on chronic pain conceptualization and treatment.

Current neuroimaging research on resilience and pain

Much of the extant knowledge concerning brain morphology and networks underlying resilience is drawn from studies of healthy individuals who have experienced significant stress or trauma[24]. In general, greater stress resilience is associated with decreased activity, reactivity, and functional connectivity within salience network (SLN) regions such as the insula and anterior cingulate cortex and in emotional processing and threat detection regions such as the amygdala[24–27]. Conversely, high prefrontal cortex (PFC) activity is associated with increased likelihood of showing resilience to traumatic exposures[24, 28]. For example, PFC activity dynamically increases during stressful as opposed to neutral imagery; this degree of dynamic activity is positively associated with active coping responses and behaviors[29]. Similarly, increased PFC gray matter volume is associated with positive coping in healthy adults and youth who experience adversity[30, 31]. Holz and colleagues argue that the perigenual anterior cingulate (pgACC) may be specifically important for conveying risk or resilience, as studies show decreased volume in individuals who have experienced more social adversity (e.g., poverty, social exclusion); conversely, larger pgACC volumes are positively associated with resilience factors (e.g., positive coping, optimism)[32]. Finally, the ability to regulate and reappraise emotions, which involves the interaction between prefrontal and limbic regions (i.e., amygdala), may also confer resilience[33]. Indeed, individuals who show a resilient response to childhood trauma (i.e., no current mood disturbance) have stronger connectivity between prefrontal and limbic regions[28].

To date, few neuroimaging studies have examined resilience processes in chronic pain. Participants with high pain intensity scores demonstrate increased functional connectivity between the DMN (Default Mode Network) and SMN (Sensorimotor Network)[34]. Higher resilience scores, conversely, are associated with reduced functional connectivity between regions of the DMN in healthy controls and individuals reporting lower pain intensity but not in individuals reporting high pain intensity[34]. These findings are consistent with studies linking increased within-DMN connectivity with rumination and pain intensity in individuals with chronic pain[35, 36].

Gray matter volume may also be related to self-rated general resilience in chronic pain. Among individuals with chronic musculoskeletal pain, larger gray matter volumes in the DMN, the PFC and mid cingulate were associated with more resilient responses to highly aversive visual stimuli[37]. Higher gray matter volume in the anterior cingulate and PFC is associated with higher self-rated general resilience in adults with chronic pain[38], and gray matter volume partially mediates the relationship between resilience and pain intensity[38]. Importantly, multiple studies have noted sex differences (e.g., in relationships between gray matter volume and self-rated resilience); as a result, future studies may benefit from defining brain-based models of resilience as sex-dependent processes[38, 39].

Interventions that work towards building aspects of resilience (e.g., increasing adaptive coping skills) may act in part by targeting neural circuitry associated with resilience. Gray matter volume in the PFC, anterior cingulate, somatosensory cortex and hippocampus increased from pre- to post-treatment in a trial of cognitive-behavioral therapy (CBT); these changes were associated with reduced pain catastrophizing[40]. These structural findings echo studies examining neural activity and functional connectivity after CBT. Individuals with fibromyalgia who completed CBT had increased activity in the PFC during experimental pain[41]. Further, CBT reduced functional connectivity between the somatosensory cortex (involved in the SMN), the insula (involved in the SLN) and DMN regions in patients with fibromyalgia; these changes were again associated with reduced pain catastrophizing[42].

In sum, studies suggest that the anterior cingulate and PFC are key regions of the descending pain modulatory system (DPMS) and highly relevant to resilience (see Figure 1). Resilient individuals may be more able to engage in cognitive modulation of pain via engaging ‘top-down’ inhibitory control in the DPMS and suppressing pronociceptive activity in DMN, SLN and SMN regions[43]. Unfortunately, the resilience neuroimaging literature is hindered by the same definitional problems described elsewhere in this review, in addition to generally small sample sizes. Thus, while resilience represents a promising target for neuroscience research, it is important to interpret existing research with these limitations in mind[44].

Figure 1. The neural networks involved in chronic nociplastic pain and resilience.

Decades of research have definitively shown that, in some individuals, altered brain function and structure can produce or sustain pain perception in absence of concurrent tissue or nerve damage. This pain mechanism is termed nociplastic pain. While the precise neurobiology of nociplastic pain remains unknown, increased activity and functional connectivity between the default mode, salience, and somatosensory networks is among the most reproduced findings in nociplastic pain[36, 84–91]. In addition, decreased activity and connectivity in the descending pain modulatory system (DPMS), which includes the periaqueductal gray (PAG) is also consistently reported[92–96]. Many of these networks and brain regions may also confer risk or resilience to chronic pain. Neuroimaging studies of resilience have implicated brain regions that are also part of the DPMS, including the prefrontal cortex, perigenual anterior cingulate cortex (pgACC), and amygdala. Increased gray matter volume, activity, and connectivity in these regions are associated with high resilience.

Note: Figure created with BioRender.com

Developmental aspects of resilience in pain

Balanced models of pain adaptation must incorporate both positive (resilience) and negative (vulnerability) processes that shape responses to pain. Further, balanced models of risk and resilience necessitate a developmental perspective, as current nervous system function may be subject to both proximal (immediate) and distal (remote or historical) factors and experiences, as well as how individuals conceptualize or overcome such experiences.

Chronic stress and childhood trauma are key developmental factors that have been increasingly implicated in the onset, severity, and impact of chronic pain[45, 46]. Adverse childhood experiences (ACEs) and traumatic events across the lifespan have been identified as sources of vulnerability for chronic pain and associated symptoms, particularly in nociplastic pain (pain arising from alteration and sensitization of brain networks associated with pain processing and threat detection)[47, 48]. For example, higher violence exposure and safety concerns have been linked to higher rates of chronic pain among adolescents[49]. Family dysfunction is also associated with lower resilience resources (e.g., hope) among children with chronic pain[50]. ACEs also predict a greater likelihood of experiencing adversity at later stages of life[51], thereby amplifying the impact of early adversity on negative pain-related outcomes. Numerous mechanisms may contribute to heightened susceptibility to chronic pain following prolonged stress and trauma, including alterations in inflammatory systems[52], functional brain connectivity[53, 54], interpersonal stress[52], and psychological (e.g., post-traumatic stress) symptoms[55] and coping profiles[47].

Given the role of developmental factors in pain experience, addressing vulnerability and resilience factors during childhood is particularly important for the prevention of chronic pain and successful transitions in the face of chronic pain[56, 57]. Recent research suggests that more positive childhood experiences, primarily encompassing social connections and support as well as opportunities to practice agency, were directly associated with a lower likelihood of pain among children and adolescents and also buffered the impact of adversity on pain[58]. Self-rated resilient coping has been found to buffer the impact of ACEs on trauma-related symptoms in adulthood, which can have downstream effects on chronic pain[47]. Although resilience resources and mechanisms may be hindered among individuals who experienced inconsistent or unresponsive parenting early in life, resilience may be amplified when affiliative processes are intact in other domains or if the caregiver maintains a positive connection with the child despite high stress[59].

Relatedly, social relationships are an important pain-related resilience resource for children and adults alike[59]. For example, social network density has been shown to buffer the association between depression, stress, and pain outcomes among older adults with chronic pain[60]. The nature of interpersonal connections also appears salient, most evident in existing research on parent-child dyadic models of pain adaptation; resilience among parents of children with pain is important for children’s outcomes[50]. Parents’ levels of psychological flexibility (e.g., openness to negative experiences while still acting in line with broader life values) appear to foster better psychosocial and emotional functioning in their children by increasing children’s psychological flexibility and pain acceptance.[61] Furthermore, parental psychological flexibility may contribute to lower day-to-day protectiveness and more support for child engagement in meaningful activities, in turn associated with less avoidance behavior in adolescents with pain[62]. However, high levels of parental instruction may also foster greater levels of maladaptive behavior (e.g., extreme behavioral avoidance), suggesting that optimal parental flexibility encompasses adaptation and awareness of adolescents’ needs and when encouragement will be beneficial[62].

Trait measures of resilience also show significant but nuanced associations with adaptation to trauma across the lifespan. For adults who have experienced a traumatic event, greater self-rated general resilience is associated with lower levels of adverse outcomes including chronic pain[63]. However, the association between self-rated resilience and pain outcomes after trauma is often contingent on other factors: self-rated resilience does not demonstrate a significant relationship with pain outcomes among individuals living under chronic stress, such as socioeconomic disadvantage[55]. Age also appears to modulate the relationships between resilience and pain outcomes; while older adults may possess more resilience resources (i.e., endorsing greater levels of pain acceptance and self-efficacy), these resources may more effectively buffer the impact of pain on depression and disability among younger adults[64].

In summary, longitudinal conceptualizations and measurement are necessary to fully encompass the processes of risk and adaptation inherent within the interconnected issues of chronic pain and stress/trauma. Intrinsic (e.g., coping) and extrinsic (e.g., social roles, social support) may buffer the effects of stress/trauma on chronic pain but also play different roles at different developmental stages.

Measuring resilience in underrepresented racial/ethnic populations

Echoing the broader pain literature[65], research on pain resilience in minoritized and underrepresented groups is still in its infancy. In line with the broader expansion of chronic pain models to include goal and social context, recent research has begun to elucidate both intrapersonal and broader contextual factors that may underpin well-documented disparities in pain outcomes[65–67]. This work consistently highlights that underrepresented/minoritized populations are differentially susceptible to specific risks associated with resilience (e.g., trauma)[68]. A smaller but growing area of research suggests that underrepresented groups may draw on unique and culturally relevant protective factors that likewise contribute to resilience.

In considering the relationship between trauma and resilience, it is informative to examine recent work conceptualizing the relationship between trauma, stress, and pain in minoritized populations. Examples include recent models of racism-based traumatic stress[68], (in)justice-based mechanisms[66], and racism as a source of pain as mediated through alterations in neural networks associated with threat and emotional processing[67]. Collectively, these models radically diverge from the traditional focus on individual-level (intrapersonal) processes as sources of racial disparities in pain. Rather, they outline a complex interacting cultural, structural, interpersonal, as well as biological and psychological context that informs pain experience among minoritized individuals. Simply put, the “context” that informs resilience processes in underrepresented groups is unique, multilayered, and has yet to be subject to systematic empirical scrutiny. Future discussions of pain resilience among underrepresented groups must take this complexity into account.

Resilience-related constructs may be differentially defined and expressed across marginalized groups and may interact differentially with pain-related constructs. For example, for Black/African American individuals with chronic pain, a more “threat-oriented” orientation (both toward pain and the possibility of inaccurate or invalidating interactions with the medical system) may be reframed as adaptive and resilient in the context of broader race-related barriers and disparities, within which such threatening interactions may be more common[65, 67]. In a recent qualitative study of Muslim Arab Americans with chronic low back pain (CLBP)[69], participants spontaneously referenced faith-related acceptance of pain experience as a central countervailing force against perceptions of pain as a source of injustice. This finding supports the proposed orthogonal relationship between acceptance and perceived injustice[70] and points to the role of specific cultural values in resilience-related coping.

Recent studies likewise suggest that resilience constructs may not show the same relationship with other traditionally examined factors in marginalized versus mainstream (e.g., Caucasian) patient populations. For example, common resilience factors (optimism, engagement, social support) were unrelated to pain intensity and pain-related interference in a predominantly Black/African American sample of women with acute pain in an emergency department setting[55]. Although White and Black participants with CLBP showed similar levels of gratitude and trait resilience[71], these factors emerged as protective against movement-evoked pain for White but not Black individuals. Similarly, among adults with CLBP, stronger beliefs in a just world predicted greater levels of pain acceptance in White respondents but not in Black and Hispanic respondents, suggesting that this resilience-related construct may be underpinned by different processes in White versus marginalized groups[72]. Notably, this study was also the first to demonstrate that White participants endorsed significantly greater pain-related acceptance than individuals of color, highlighting the general paucity of research in this domain.

Incorporation of resilience principles in clinical intervention

To date, interventions that target resilience have largely been drawn from the field of positive psychology. Such interventions are often referred to as positive activity interventions (PAIs) and include strategies designed to boost positive emotions, healthy social connections, feelings of gratitude, optimistic thinking, and resilience directly. Unique benefits of PAIs compared to other mental health interventions include that: (1) they tend to be highly engaging because activities are often pleasant or enjoyable; (2) PAIs do not require a licensed professional for delivery; and, (3) they are less stigmatizing given the focus on building strengths rather than mitigating psychiatric symptoms[73].

Resilience-based interventions have shown effectiveness in chronic pain populations. In a meta-analysis of chronic pain studies from 1990 to 2020, PAIs demonstrated significant post-treatment improvements in pain intensity and cognitive and emotional functioning (e.g., higher positive affect; reduced depressive symptoms, pain catastrophizing, and negative affect)[74]. Furthermore, beneficial effects on depressive symptoms, positive affect, and negative affect were maintained at 3 months following treatment. In this review, we considered more recent studies (2017 to 2023) that specifically leveraged PAIs alone or as an adjunct therapy to other behavioral treatments for chronic pain. Tables 1 and 2 summarize the design and findings of these studies.

Table 1:

Descriptive summary of PAI clinical trials.

No.	First author, year of publication	Country	Health condition	Sample size at baseline	Female gender (%)	Mean age (SD), years	Intervention characteristics
							Topic of intervention	Delivery mode	No. of sessions, period	Follow-up measure	Control condition
1	Peters, 2017[75]	NL	Fibromyalgia or musculoskeletal pain	276	85.0	48.6 (12.0)	Positive psychology program “Happy despite pain”	Self-help instructions online	8. 8 weeks	6 months	WL and CBT (cognitive behavioral therapy)
2	Hausmann, 2018[80]	USA	Knee osteoarthritis	360	23.6	64.2 (8.8)	Positive psychological skill-building activities	Self-help instructions via telephone	6, 6 weeks	3 and 6 months	AC (neural control activities)
3	Molinari, 2018[76]	ES	Fibromyalgia	71	100.0	51.08 (10.5)	“Best Possible Self” intervention	Individual face-to-face instructions and practice at home via online platform	Minimum 12, 4 weeks	1 and 3 months	AC (diary of daily activities)
4	Müller, 2020[77]	CH	Spinal cord injury	168	35.7	55.5 (12.0)	Tailored positive psychology intervention	Self-help instructions via email or post mail	Minimum 8, 8 weeks	3 months	AC (being mindful and writing about current life events)
5	Janevic, 2022[78]	USA	Chronic pain	46	89	72.1 (7.2)	Pain self-management positive psychology intervention “Positive STEPS”	Telephone sessions with a community health worker and web-based videos	7, 7 weeks	2 months	AC (one-time educational session)
6	Murphy, 2023[79]	USA	Systemic sclerosis	173	93	54.4 (11.7)	“RENEW” resilience-building and energy management intervention	Web/application-based modules and peer-led health coaching	12, 12 weeks	--	WL

PAI = positive activity intervention; WL = waiting list; AC = active control; CBT = cognitive behavioral therapy

Table 2:

Overview of observed changes in pain intensity, physical functioning, and psychosocial factors from baseline to post-intervention or follow-up for the PAI group.

Outcome	No. of studies	Pre- to post-intervention effect within PAI group		Pre- to post-intervention effect between PAI and control group		Pre-intervention to follow-up effect between PAI and control group		Measurement instruments/scale
		Beneficial	No Benefits	Beneficial	No Benefits	Beneficial	No Benefits
Pain intensity
Average	3	2, 4		4	1CBT, WL, 2		1CBT, 2, 4	NRS 0 to 10 [4] NRS 0 to 100 [1] WOMAC Index [2]
Physical functioning
Pain interference
General interference	3	4, 6		6	4	5	4	BPI NRS 0 to 10 [4] PROMIS [5, 6]
Interference on relations	1						5	PROMIS [5]
Global impression of change	2	6		5, 6				PGIC [5, 6]
Disease-specific physical impairment
Fibromyalgia	2	1	3		1CBT, WL, 3		1CBT, 3	FIQ [1, 3]
Osteoarthritis	1	2			2		2	WOMAC Index [2]
Psychosocial factors
Depressive symptoms	4	1, 3, 4, 6		1WL, 6	1CBT, 3, 4		1CBT, 3, 4	HADS [1, 4] BDI-II [3] PROMIS [6]
Anxiety	1	1		1WL	1CBT		1CBT	HADS [1]
Positive affect	3	1, 3, 4		1WL	1CBT, 3, 4		1CBT, 3	PANAS [2, 3, 4]
Negative affect	3	1, 3, 4		1WL	1CBT, 3, 4		1CBT, 3, 4	PANAS [2, 3, 4]
Pain catastrophizing	3	3, 4		1WL	1CBT, 3, 4		1CBT, 3, 4	PCS [1, 3, 4]
Pain control	1	4			4		4	SOPA [4]
Pain self-efficacy	2		3	5	3		3	GSE [3, 5]
Life satisfaction	2		2, 4		2, 4		2, 4	NRS 0 to 5 [2] WHOQOL-BREF [4]
Resilience	2	6		6	5			CDRS [5, 6]

^*Findings for study 1 reflect significant changes for the PAI group when compared to either the active control group (CBT) or the waitlist control (WL).

PAI = positive activity intervention; WL = waiting list; iCBT = internet-delivered cognitive behavioral therapy; NRS = numeric rating scale; WOMAC = Western Ontario McMaster Osteoarthritis; BPI = Brief Pain Inventory; PROMIS = Patient-Reported Outcomes Measurement Information System; PGIC = Patient Global Impression of Change; FIQ = Fibromyalgia Impact Questionnaire; HADS = Hospital Anxiety and Depression Scale; BDI-II = Beck Depression Inventory-II; BSI = Brief Symptom Inventory; PANAS = Positive and Negative Affect Schedule; PCS = Pain Catastrophizing Scale; SOPA = Survey of Pain Attitudes; GSE = General Self-Efficacy Scale; WHOQOL-BREF = World Health Organization Quality of Life Brief Version; CDRS = Connor-Davidson Resilience Scale.

Both an internet-delivered PAI program and internet-delivered CBT program for chronic musculoskeletal pain showed significant improvements in depressive symptoms and increases in happiness but no significant differences in physical impairment, compared to a waitlist control[75]; notably, high levels of education were associated with greater benefit from PAIs than from CBT. Individuals with fibromyalgia [76] randomized to a “Best Possible Self” PAI intervention showed greater improvement in depression, positive affect, and self-efficacy compared to a control relaxation intervention. In a large feasibility study of chronic pain secondary to spinal cord injury[77], participants randomized 4 personalized PAIs over 8 weeks showed greater decreases in pain compared to a control group directed to be mindful and write about current life events; at 3 months following treatment, PAI participants had continued pain relief and improvement in positive emotions.

Recent pilot trials by our team showed the promise of adding PAIs to more traditional behavioral therapies. The ‘Positive STEPS’ walking intervention integrated PAIs to boost engagement and well-being[78] and consisted of a 7-week web-based program that included weekly telephone sessions with a community health worker. Videos taught pain self-management skills and PAIs (e.g., savoring, gratitude, kindness). Compared to waitlist controls, participants receiving Positive STEPS reported greater improvement in pain interference, pain self-efficacy, global functioning, and pain severity. The ‘RENEW’ program[79] added PAIs to cognitive-behavioral self-management to reduce fatigue and pain interference in patients with systemic sclerosis. RENEW participants accessed 12 weekly modules using a phone or website and received 9 peer health coaching sessions. Compared to controls, RENEW reported less fatigue, pain interference, and depression, as well as greater resilience. Participants with < 1 year disease duration benefitted the most from RENEW.

While most published studies favored the PAI group, benefit was not uniform across all studies. For example, the “Staying Positive with Arthritis” study[80] found no differences in effectiveness of a 6-week PAI program to build positive psychological skills (e.g., gratitude and kindness) compared to a similarly structured neutral control condition. The authors concluded that the trial did not support the use of PAIs as a stand-alone treatment for this population.

Taken together, there is mounting evidence that a variety of chronic pain populations may benefit from PAIs in terms of pain severity, pain interference, mood, adaptive coping, and functional status. Still, for some patient populations, PAIs may not be sufficient to enact clinically significant improvements in pain or function, particularly if delivered as a monotherapy. The greatest promise of PAIs may be their addition to established behavioral therapies to boost engagement and effectiveness.

Future Directions

One avenue for future research concerns the longitudinal evaluation of neural and psychosocial factors that may protect against the development of pain. Although such studies are difficult given the need for large, longitudinal populations (and who may need to be pain-free at study initiation), we recently conducted complementary studies of behavioral and neural risk factors for the development of multisite pain in children using data from the Adolescent Brain and Cognitive Development (ABCD) Study. We found that poor sleep, attention problems, high somatic awareness, as well as increased functional connectivity between DMN, SLN and SMN regions predicted the development of pain one year later[81, 82]. Future studies could examine trajectories of pain development and subsequent recovery in children and adolescents, which would constitute underrepresented area in pain research. A recent systematic review examined the neural correlates of resilience in children who experienced adversity and found that resilient children tended to have increased gray matter volume in the PFC and hippocampus, lower amygdala reactivity, and increased functional connectivity between the PFC and amygdala, suggestive of increased top-down regulation or emotion regulation[83]. Conceptualizing resilience as an active process, rather than simply the absence of risk, one potential hypothesis is that children who are resilient to pain have increased gray matter volume and connectivity in top-down cognitive control and emotional regulation pathways, which overlaps with regions of the DPMS. Indeed, it is well understood that the dorsolateral PFC can exert a ‘top-down’ inhibitory effect on cortical and cortical-subcortical pathways involved in pain processing[43].

As noted above, we strongly encourage future pain resilience research to incorporate relevant social/contextual risk factors (chronic stress, trauma, experiences of discrimination and disparity) and developmentally and culturally circumscribed resilience factors (e.g., personal/social identity, social support, acceptance- and justice-based beliefs). There is also a significant need to expand beyond the use of only self-report measures to assess pain resilience and to validate existing resilience constructs in future studies, particularly in populations historically underrepresented in pain research. These cautions also extend to resilience-based treatment models: without understanding the potential for different interpretations, goals, and contributors to pain resilience within specific clinical or demographic populations, it is likely that the efficacy of these principles in treatment will not reach their full potential.

Conclusions

Increasingly, it has become necessary to distinguish chronic pain resilience from its component mechanisms and distinct traits that contribute to it; instead of viewing resilience as a trait or mechanism, it may be better framed as an integrative, dynamic process that incorporates cognitive, affective, and physiological states that are embedded within past and immediate social and goal contexts. In other words, understanding resilience to pain, whether it is in the form of sustained goal pursuit, diminished negative reactivity to pain, or development of new coping responses to pain, necessitates an understanding of the prior learning and current goals of the individual alongside their immediate physical and psychological states. Not all aspects of pain resilience are easily or appropriately captured via self-report; accordingly, future research would benefit from a broader focus on historical, cultural, and social contextual factors as well as multimethod approaches that complement self-report measures with objective data.