Cognitive load selectively influences the interruptive effect of pain on attention

Challenging Cognitive Load Theory: The Role of Educational Neuroscience and Artificial Intelligence in Redefining Learning Efficacy

Background/Objectives: This systematic review integrates Cognitive Load Theory (CLT), Educational Neuroscience (EdNeuro), Artificial Intelligence (AI), and Machine Learning (ML) to examine their combined impact on optimizing learning environments. It explores how AI-driven adaptive learning systems, informed by neurophysiological insights, enhance personalized education for K-12 students and adult learners. This study emphasizes the role of Electroencephalography (EEG), Functional Near-Infrared Spectroscopy (fNIRS), and other neurophysiological tools in assessing cognitive states and guiding AI-powered interventions to refine instructional strategies dynamically. Methods: This study reviews n = 103 papers related to the integration of principles of CLT with AI and ML in educational settings. It evaluates the progress made in neuroadaptive learning technologies, especially the real-time management of cognitive load, personalized feedback systems, and the multimodal applications of AI. Besides that, this research examines key hurdles such as data privacy, ethical concerns, algorithmic bias, and scalability issues while pinpointing best practices for robust and effective implementation. Results: The results show that AI and ML significantly improve Learning Efficacy due to managing cognitive load automatically, providing personalized instruction, and adapting learning pathways dynamically based on real-time neurophysiological data. Deep Learning models such as Convolutional Neural Networks (CNNs), Recurrent Neural Networks (RNNs), and Support Vector Machines (SVMs) improve classification accuracy, making AI-powered adaptive learning systems more efficient and scalable. Multimodal approaches enhance system robustness by mitigating signal variability and noise-related limitations by combining EEG with fMRI, Electrocardiography (ECG), and Galvanic Skin Response (GSR). Despite these advances, practical implementation challenges remain, including ethical considerations, data security risks, and accessibility disparities across learner demographics. Conclusions: AI and ML are epitomes of redefinition potentials that solid ethical frameworks, inclusive design, and scalable methodologies must inform. Future studies will be necessary for refining pre-processing techniques, expanding the variety of datasets, and advancing multimodal neuroadaptive learning for developing high-accuracy, affordable, and ethically responsible AI-driven educational systems. The future of AI-enhanced education should be inclusive, equitable, and effective across various learning populations that would surmount technological limitations and ethical dilemmas.

A regression model on work-related musculoskeletal disorders and associated risk factors among radiographers

Objectives. This study aimed to develop a predictive model for work-related musculoskeletal disorders (WRMSDs) among radiographers. Methods. A survey was conducted in seven hospitals in two cities with radiographers using the ergonomic assessment for radiographers questionnaire. Logistic regression, confirmatory factor analysis and structural equation modelling (SEM) were utilized to establish statistical relationships between independent factors and musculoskeletal complaints. Results. Of 165 respondents, 75.2% reported musculoskeletal pain in the past 12 months, with lower back pain the most prevalent (58.8%). Adjusting for covariates, musculoskeletal pain significantly correlated with body mass index < 23 (odds ratio [OR] 0.06, 95% confidence interval [CI] [0.005, 0.914]), smoking status (OR 0.274, 95% CI [0.751, 6.195]), fixed work break schedule (OR 2.839, 95% CI [1.123, 7.176]), sustained posture (OR 4.854, 95% CI [1.203,19.594]) and prolonged standing or walking (OR 7.499, 95% CI [1.086, 51.753]). The fit measures indicate a moderately good fit of the proposed model to the observed data. However, latent variables did not exhibit significant associations with WRMSD in SEM. Conclusions. The model suggests that WRMSDs among radiographers moderately correlate with underweight, smoking status, fixed work breaks, sustained posture and extended periods of standing or walking. The absence of significant associations between latent variables and WRMSDs suggests the presence of unexplored factors influencing the outcome.Trial registration: Clinical Trials Registry India identifier: CTRI/2021/09/036992.

Impact of Experimentally Induced Pain on Logical Reasoning and Underlying Attention-Related Psychophysiological Mechanisms

BACKGROUND

Pain is known to negatively impact attention, but its influence on more complex cognitive abilities, such as logical reasoning, remains inconsistent. This may be due to compensatory mechanisms (e.g., investing additional resources), which might not be detectable at the behavioral level but can be observed through psychophysiological measures. In this study, we investigated whether experimentally induced pain affects logical reasoning and underlying attentional mechanisms, using both behavioral and electroencephalographic (EEG) measures.

METHODS

A total of 98 female participants were divided into a pain-free control group (N = 47) and a pain group (N = 51). Both groups completed the Advanced Progressive Matrices (APM) task, with EEG recordings capturing task-related power (TRP) changes in the upper alpha frequency band (10-12 Hz). We used a mixed design where all participants completed half of the APM task in a pain-free state (control condition); the second half was completed under pain induction by the pain group but not the pain-free group (experimental condition).

RESULTS

Logical reasoning performance, as measured by APM scores and response times, declined during the experimental condition, compared to the control condition for both groups, indicating that the second part of the APM was more difficult than the first part. However, no significant differences were found between the pain and pain-free groups, suggesting that pain did not impair cognitive performance at the behavioral level. In contrast, EEG measures revealed significant differences in upper alpha band power, particularly at fronto-central sites. In the pain group, the decrease in TRP during the experimental condition was significantly smaller compared to both the control condition and the pain-free group.

CONCLUSIONS

Pain did not impair task performance at the behavioral level but reduced attentional resources, as reflected by changes in upper alpha band activity. This underscores the importance of incorporating more sensitive psychophysiological measures alongside behavioral measures to better understand the impact of pain on cognitive processes.

The effects of experimental pain on episodic memory and its top-down modulation: a preregistered pooled analysis

Introduction

Pain can automatically interfere with ongoing cognitive processes such as attention and memory. The extent of pain's negative effects on cognitive functioning seems to depend on a balance between top-down and bottom-up factors.

Objectives

In this large, preregistered, pooled reanalysis of 8 studies, we investigated the robustness of the detrimental effect of acute pain on recognition memory and whether top-down mechanisms such as pain-related expectations or cognitions (pain-related fear, pain catastrophizing) modulate this effect.

Methods

Two hundred forty-seven healthy participants underwent similar experimental paradigms, including a visual categorization task with images randomly paired with (or without) concomitant painful stimulation and a subsequent unannounced recognition task. Recognition memory (ie, d', recollection, and familiarity) and categorization performance (ie, reaction time, accuracy) served as proxies for the effect of pain on cognitive performance.

Results

Acute painful stimulation significantly impaired recognition performance (d', familiarity). However, recognition performance was not significantly modulated by participants' expectations regarding the effect of pain on task performance or pain-related cognitions in this sample of healthy participants.

Conclusion

Our results corroborate the negative effects of pain on (visual) memory encoding reported in previous studies and reports of "memory problems" from patients with chronic pain. To characterize the role of bottom-up and top-down factors for the detrimental effects of pain, large-scale studies with more nuanced study designs are necessary. Future studies in patient cohorts must unravel the interaction of maladaptive pain-related cognitions and the often-reported impaired cognitive performance in chronic pain patients.

Cross-sectional and comparative study of comprehensive neuropsychological profiles in headache using the AIIMS comprehensive neuropsychological battery

Background

Headache presents as a common symptom turned disorder ranging from harmless to life threatening. The inconsistent conclusions across various studies or methodological lacunae have resulted in absence of a unified neuropsychological profile. Thus, the efficacy of establishing a holistic picture of deficits and their rehabilitation in Indian context creates a need for comprehensive investigative tools.

Aim

To explore the impact of headache, on the neuropsychological functioning of individuals using AIIMS Comprehensive Neuropsychological Battery.

Materials and Methods

This was a cross-sectional and comparative hospital-based study. The sample compared 20 patients with diagnosis of any kind of headache, according to International Classification of Headache Disorders-3 (ICHD-3) criteria with 20 matched healthy controls selected via purposive sampling. Both the groups were subjected to AIIMS Comprehensive Neuropsychological Battery and NEO-Five Factor Inventory-3, and a comprehensive neuropsychological profile was obtained. The profile obtained was further subjected to analysis using the independent samples t-test and product moment correlation using Statistical Package for Social Sciences software (Version 27.0).

Results

The findings indicate no significant impairment in any of the groups for neuropsychological correlates due to all scores being within normal ranges. Higher scores on neuroticism were found in patients with headache, with a higher incidence in females of the clinical group.

Conclusion

The present study underscores neuropsychological deficits as perceived component among the headache population as conducted using a complete battery standardized in the Indian context. A longitudinal approach with greater sample size and randomized sampling might promise better results and generalizability.

Social prioritisation in scene viewing and the effects of a spatial memory load

When free-viewing scenes, participants tend to preferentially fixate social elements (e.g., people). In the present study, we tested whether this bias would be disrupted by increasing the demands of a secondary dual-task: holding a set of (one or six) spatial locations in memory, presented either simultaneously or sequentially. Following a retention interval, participants judged whether a test location was present in the to-be-remembered stimuli. During the retention interval participants free-viewed scenes containing a social element (a person) and a non-social element (an object) that served as regions of interest. In order to assess the impact of physical salience, the non-social element was presented in both an unaltered baseline version, and in a version where its salience was artificially increased. The results showed that the preference to look at social elements decreased when the demands of the spatial memory task were increased from one to six locations, regardless of presentation mode (simultaneous or sequential). The high-load condition also resulted in more central fixations and reduced exploration of the scene. The results indicate that the social prioritisation effect, and scene viewing more generally, can be affected by a concurrent memory load.

Spatial working memory in a disappearing object task is impaired in female but not male dogs with chronic osteoarthritis

Chronic pain in humans is associated with impaired working memory but it is not known whether this is the case in long-lived companion animals, such as dogs, who are especially vulnerable to developing age-related chronic pain conditions. Pain-related impairment of cognitive function could have detrimental effects on an animal's ability to engage with its owners and environment or to respond to training or novel situations, which may in turn affect its quality of life. This study compared the performance of 20 dogs with chronic pain from osteoarthritis and 21 healthy control dogs in a disappearing object task of spatial working memory. Female neutered osteoarthritic dogs, but not male neutered osteoarthritic dogs, were found to have lower predicted probabilities of successfully performing the task compared to control dogs of the same sex. In addition, as memory retention interval in the task increased, osteoarthritic dogs showed a steeper decline in working memory performance than control dogs. This suggests that the effects of osteoarthritis, and potentially other pain-related conditions, on cognitive function are more clearly revealed in tasks that present a greater cognitive load. Our finding that chronic pain from osteoarthritis may be associated with impaired working memory in dogs parallels results from studies of human chronic pain disorders. That female dogs may be particularly prone to these effects warrants further investigation.

Brain Networks With Modified Connectivity in Patients With Neuropathic Pain and Spinal Cord Injury

Background. Neuropathic pain (NP) following spinal cord injury (SCI) affects the quality of life of almost 40% of the injured population. The modified brain connectivity was reported under different NP conditions. Therefore, brain connectivity was studied in the SCI population with and without NP with the aim to identify networks that are altered due to injury, pain, or both. Methods. The study cohort is classified into 3 groups, SCI patients with NP, SCI patients without NP, and able-bodied. EEG of each participant was recorded during motor imagery (MI) of paralyzed and painful, and nonparalyzed and nonpainful limbs. Phased locked value was calculated using Hilbert transform to study altered functional connectivity between different regions. Results. The posterior region connectivity with frontal, fronto-central, and temporal regions is strongly decreased mainly during MI of dominant upper limb (nonparalyzed and nonpainful limbs) in SCI no pain group. This modified connectivity is prominent in the alpha and high-frequency bands (beta and gamma). Moreover, oscillatory modified global connectivity is observed in the pain group during MI of painful and paralyzed limb which is more evident between fronto-posterior, frontocentral-posterior, and within posterior and within frontal regions in the theta and SMR frequency bands. Cluster coefficient and local efficiency values are reduced in patients with no reported pain group while increased in the PWP group. Conclusion. The altered theta band connectivity found in the fronto-parietal network along with a global increase in local efficiency is a consequence of pain only, while altered connectivity in the beta and gamma bands along with a decrease in cluster coefficient values observed in the sensory-motor network is dominantly a consequence of injury only. The outcomes of this study may be used as a potential diagnostic biomarker for the NP. Further, the expected insight holds great clinical relevance in the design of neurofeedback-based neurorehabilitation and connectivity-based brain-computer interfaces for SCI patients.

Cognitive function in patients with irritable bowel syndrome: impairment is common and only weakly correlated with depression/anxiety and severity of gastrointestinal symptoms

OBJECTIVE

To investigate cognitive function in patients with irritable bowel syndrome (IBS) and its relation to anxiety/depression and severity of gastrointestinal (GI) symptoms.

METHODS

Patients with IBS (n = 65) and healthy controls (HCs, n = 37) performed the ten subtests of the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). Age-normed index scores of five cognitive domains (Immediate memory, Visuospatial function, Language function, Attention, Recall) and a total (Fullscale) score were derived from the performance. Emotional function was assessed using the Hospital Anxiety and Depression Scale (HADS), and the IBS Symptom Scoring System (IBS-SSS) was used to define the severity of GI symptoms.

RESULTS

Patients with IBS reported significantly higher scores than the HC group on symptom measures of anxiety and depression, and significantly lower scores on the Immediate memory, Recall, and Fullscale RBANS indexes. Approximately 30% of the IBS patients obtained index scores at least one standard deviation below the population mean, and more than 50% scored above the screening threshold for an anxiety disorder. The severity of GI symptoms was significantly correlated with the severity level of anxiety symptoms (p=.006), but neither the severity level of emotional nor GI symptoms was significantly correlated with the RBANS index scores in the IBS group.

CONCLUSION

Cognitive and emotional function were more severely affected in patients with IBS than in HCs. The weak correlation between the two functional areas suggests that both should be assessed as part of a clinical examination of patients with IBS.

Fibromyalgia is associated with hypersensitivity but not with abnormal pain modulation: evidence from QST trials and spinal fMRI

Widespread pain and hyperalgesia are characteristics of chronic musculoskeletal pain conditions, including fibromyalgia syndrome (FM). Despite mixed evidence, there is increasing consensus that these characteristics depend on abnormal pain augmentation and dysfunctional pain inhibition. Our recent investigations of pain modulation with individually adjusted nociceptive stimuli have confirmed the mechanical and thermal hyperalgesia of FM patients but failed to detect abnormalities of pain summation or descending pain inhibition. Furthermore, our functional magnetic resonance imaging evaluations of spinal and brainstem pain processing during application of sensitivity-adjusted heat stimuli demonstrated similar temporal patterns of spinal cord activation in FM and HC participants. However, detailed modeling of brainstem activation showed that BOLD activity during "pain summation" was increased in FM subjects, suggesting differences in brain stem modulation of nociceptive stimuli compared to HC. Whereas these differences in brain stem activation are likely related to the hypersensitivity of FM patients, the overall central pain modulation of FM showed no significant abnormalities. These findings suggest that FM patients are hyperalgesic but modulate nociceptive input as effectively as HC.

The effect of high versus low cognitive load on the development of nociceptive hypersensitivity: The roles of sympathetic arousal, sex and pain-related fear

BACKGROUND

According to limited-capacity theories of attention, less attentional resources remain available when engaging in a high- versus a low-demanding cognitive task. This may reduce the perceived intensity and the evoked cortical responses of concomitant nociceptive stimuli. Whether and how the competition for limited attentional resources between a cognitive task and pain impacts the development of long-lasting hypersensitivity is unclear.

METHODS

Eighty-four healthy participants were randomized into a low or high cognitive load group. Low-frequency electrical stimulation (LFS) of the skin was used to induce secondary hypersensitivity. We hypothesized that performing the high-load task during LFS would reduce the development of hypersensitivity. We examined whether painfulness, nonpain-related sympathetic arousal, or sex related to hypersensitivity, by assessing intensity and unpleasantness of mechanical pinprick stimulation. During task execution, we recorded steady-state evoked potentials evoked by LFS and skin conductance level for sympathetic arousal. Afterwards, participants reported task difficulty and LFS-related fear. For the primary outcomes, we used mixed analysis of variances.

RESULTS

The results confirmed the difference in cognitive load. Although LFS successfully induced hypersensitivity, the high-load task did not reduce its development. Next, the steady-state evoked potentials did not differ between groups. Hypersensitivity correlated positively with pain-related fear and negatively with skin conductance level before LFS, despite the lack of group differences in skin conductance level. We did not find any sex differences in hypersensitivity.

CONCLUSIONS

These results do not confirm that high cognitive load or sex modulate hypersensitivity, but show associations with pain-related fear and non-pain-related sympathetic arousal.

SIGNIFICANCE

Previous research has mainly focused on cognitive load effects on the perception of acute painful stimuli. Yet this study extends our understanding by investigating cognitive load effects on the development of long-lasting secondary hypersensitivity, a common aspect in numerous persistent pain conditions. As cognitive tasks are presented during a painful procedure inducing secondary hypersensitivity, we test the long-lasting effects of cognitive load. Additionally, we used psychophysiological measurements to explored potential underlying mechanisms involving limited attentional resources and sympathetic arousal.

Functional connectivity across dorsal and ventral attention networks in response to task difficulty and experimental pain

The dorsal and ventral attention networks (DAN & VAN) provide a framework for studying attentional modulation of pain. It has been argued that cognitive demand distracts attention from painful stimuli via top-down reinforcement of task goals (DAN), whereas pain exerts an interruptive effect on cognitive performance via bottom-up pathways (VAN). The current study explores this explanatory framework by manipulating pain and task demand in combination with functional near-infrared spectroscopy (fNIRS) and Granger Causal Connectivity Analyses (GCCA). Twenty-one participants played a racing game at low and high difficulty levels with or without experimental pain (administered via a cold pressor test). Six channels of fNIRS were collected from bilateral frontal eye fields and intraparietal sulci (DAN), with right-lateralised channels at the inferior frontal gyrus and temporoparietal junction (VAN). Our first analysis revealed increased G-causality from bottom-up pathways (VAN) during the cold pressor test. However, an equivalent experience of experimental pain during gameplay increased G-causality in top-down (DAN) pathways, with the left intraparietal sulcus serving a hub of connectivity. High game difficulty increased G-causality via top-down pathways and implicated the right inferior frontal gyrus as an interhemispheric hub. Our results are discussed with reference to existing models of both networks and attentional modulation of pain.

Computational and neural mechanisms of statistical pain learning

Pain invariably changes over time. These fluctuations contain statistical regularities which, in theory, could be learned by the brain to generate expectations and control responses. We demonstrate that humans learn to extract these regularities and explicitly predict the likelihood of forthcoming pain intensities in a manner consistent with optimal Bayesian inference with dynamic update of beliefs. Healthy participants received probabilistic, volatile sequences of low and high-intensity electrical stimuli to the hand during brain fMRI. The inferred frequency of pain correlated with activity in sensorimotor cortical regions and dorsal striatum, whereas the uncertainty of these inferences was encoded in the right superior parietal cortex. Unexpected changes in stimulus frequencies drove the update of internal models by engaging premotor, prefrontal and posterior parietal regions. This study extends our understanding of sensory processing of pain to include the generation of Bayesian internal models of the temporal statistics of pain.

Brain responses to painful electrical stimuli and cognitive tasks interact in the precuneus, posterior cingulate cortex, and inferior parietal cortex and do not vary across the menstrual cycle

INTRODUCTION

Bidirectional effects between cognition and pain have been extensively reported. Although brain regions involved in cognitive and pain processing seem to partly overlap, it is unknown what specific brain regions are involved in the interaction between pain and cognition. Furthermore, the role of gonadal hormones on these interacting effects has not been examined. This study investigated brain activation patterns of the interaction between pain and cognition over different phases of the naturally occurring menstrual cycle.

METHODS

Fifteen healthy normally cycling females were examined over the course of 4 different cycle phases. Sensory stimulation was applied using electrical pulses and cognitive performance was assessed using the Multi-Source Interference Task. Brain imaging consisted of functional magnetic resonance imaging using a repeated measures ANOVA group analysis approach.

RESULTS

Sensory stimulation was found to interact with task performance in the left precuneus, left posterior cingulate cortex and right inferior parietal lobule. No effects of cycle phase were observed to interact with main effects of stimulation, task or interaction effects between task performance and sensory stimulation.

CONCLUSION

Potential neural correlates of shared resources between pain and cognition were demonstrated providing further insights into the potential mechanisms behind cognitive performance difficulties in pain patients and opening avenues for new treatment options including targeting specific cognitive factors in pain treatment such as cognitive interference.

Virtual reality-based distraction on pain, performance, and anxiety during and after moderate-vigorous intensity cycling

PURPOSE

To determine whether increased visual perceptual load (PL) within an immersive virtual environment may help explain previously shown pain-relieving effects of virtual reality (VR) during high intensity cycling.

METHODS

Using a within-subjects design, participants cycled at a perceptually "hard" intensity for 10 min on three separate occasions. The first session did not use VR (i.e., no perceptual load - NPL). Subsequent sessions employed VR during cycling with either a low or high perceptual load (LPL or HPL). Quadriceps pain intensity (PI) was reported by participants throughout cycling.

RESULTS

Data were analyzed for 43 healthy participants (20 females, mean age 21  [SD 1.4]). For PI, ANOVA showed there were significant main effects of condition (F = 13.458, df =1.579, 66.334, p<0.001) and time (F = 113.045, df =1.618, 227.683, p<0.001). At every time point, t-tests revealed mean PI was significantly lower in the NPL than in the LPL condition (t(42)=4.737, p<0.001, d = 0.472) and HPL condition (t(42)=3.380, p = 0.002, d = 0.391). Dependent t-tests showed that more work (kilojoules) was performed during the LPL condition than the NPL (t(42)=2.992, p = 0.005) and HPL (t(42)=5.810, p<0.001) conditions.

CONCLUSIONS

Compared to a traditional 10-minute bout of cycle ergometry (NPL), individuals who cycled in the LPL condition chose to exercise at a higher intensity despite greater PI. Those who cycled in the HPL condition did not change their exercise intensity, but did report higher PI, possibly, because of the greater mental effort/energy requirement.

The interaction between pain and cognition: on the roles of task complexity and pain intensity

OBJECTIVES

The interaction between pain and cognition includes a concurrent negative effect of pain on cognitive performance and an analgesic effect of cognitive distraction on pain experience. The purpose of this exploratory study was to investigate the role of pain intensity and task complexity on this interaction.

METHODS

Two experiments were conducted in healthy volunteers. In both experiments, participants completed 3 conditions: a pain only condition (consisting of the cold pressor test), a cognition only condition (consisting of the cognitive task) and a combined condition (concurrent administration of the cold pressor and cognitive task). In experiment I, participants performed one out of three possible tasks that differed in cognitive load (low, medium, high). In experiment II the parameters of the pain stimulus, induced by a cold pressor test, were adapted and only the high load cognitive task was employed. Pain scores, reaction times, and accuracy rates were recorded.

RESULTS

In experiment I, cognitive distraction significantly decreased pain scores, irrespective of the cognitive load of the task. Pain did not affect cognitive performance. In experiment II, pain diminished accuracy rates. No effect of cognitive distraction on pain was observed. Individual characteristics did not noticeably influence the interaction between pain and cognition.

CONCLUSIONS

The results of this study suggest a two-way interaction, however no evidence for a simultaneous bidirectional relationship was found. Cognitive distraction successfully reduces pain, up until a certain point where this relationship is reversed, and pain starts to interfere with cognitive performance. This may imply that priorities shift at a certain pain-threshold, however further research should confirm this hypothesis. This study could contribute to further understanding of cognitive mechanisms related to pain perception.

Does pain modality play a role in the interruptive function of acute visceral compared with somatic pain?

ABSTRACT

Acute pain captures attentional resources and interferes with ongoing cognitive processes, including memory encoding. Despite broad clinical implications of this interruptive function of pain for the pathophysiology and treatment of chronic pain conditions, existing knowledge exclusively relies on studies using somatic pain models. Visceral pain is highly prevalent and seems to be more salient and threatening, suggesting that the interruptive function of pain may be higher in acute visceral compared with somatic pain. Implementing rectal distensions as a clinically relevant experimental model of visceral pain along with thermal cutaneous pain for the somatic modality, we herein examined the impact of pain modality on visual processing and memory performance in a visual encoding and recognition task and explored the modulatory role of pain-related fear and expectation in 30 healthy participants. Despite careful and dynamically adjusted matching of stimulus intensities to perceived pain unpleasantness over the course of trials, we observed greater impairment of cognition performance for the visceral modality with a medium effect size. Task performance was not modulated by expectations or by pain-related fear. Hence, even at matched unpleasantness levels, acute visceral pain is capable of interfering with memory encoding, and this impact seems to be relatively independent of pain-related cognitions or emotions, at least in healthy individuals. These results likely underestimate the detrimental effect of chronic pain on cognitive performance, which may be particularly pronounced in acute and chronic visceral pain.

Positive affect and distraction enhance while negative affect impairs pain modulation in recurrent low back pain patients and matched controls

ABSTRACT

Pathophysiological causes of low back pain (LBP) remain generally unclear, so focus has shifted to psychosocial features and central pain processing. Effects of attentional and affective manipulation on conditioned pain modulation (CPM) and tonic pain perception were examined in thirty recurrent LBP patients in two sessions, one with and one without clinical pain, and compared to healthy participants. Phasic cuff pressure on one leg, scored on a numerical rating scale (NRS), was used for test-stimuli (TS) and contralateral tonic cuff pain rated on an electronic visual analogue scale (eVAS) was the conditioning-stimulus (CS). TS were assessed before and during: 1) control with no manipulation/CS, 2) three attentional manipulations (Flanker with/without CS or CS-Only), and 3) three affective manipulations (positive, neutral, negative pictures) with CS. Greater inhibition of TS-NRS scores was observed in CS-only (P=0.028), combined CS&attention (P=0.026), and CS&Positive (P=0.006) than Control paradigms, and greater in CS&Positive (P=0.019) than CS&Negative paradigms. eVAS scores of CS pain increased throughout all paradigms with CS (P<0.05), except the CS&Positive paradigm, and greater facilitation was observed in the CS-Only paradigm than all others (P<0.02) and lower facilitation was additionally observed in the CS&Positive paradigm compared to CS&Attention and CS&Negative paradigms (P<0.01). Flanker effects and interruptive effects of CS pain on attention were observed consistent with prior findings, and affective manipulation produced less shift in valence among people with RLBP than controls (P<0.05). Attention and positive affect with CS pain evoked CPM, and all attentional/affective tasks, especially positive affect, reduced facilitation of CS pain.

Pain Catastrophizing Mediates and Moderates the Link Between Acute Pain and Working Memory

The bidirectional relationship between pain and working memory (WM) deficits is well-documented but poorly understood. Pain catastrophizing-exaggerated, negative cognitive and emotional responses toward pain-may contribute to WM deficits by occupying finite, shared cognitive resources. The present study assessed the role of pain catastrophizing as both a state-level process and trait-level disposition in the link between acute pain and WM. Healthy, young adults were randomized to an experimentally-induced ischemic pain or control task, during which they completed verbal and non-verbal WM tests. Participants also completed measures of state- and trait-level pain catastrophizing. Simple mediation analyses indicated that participants in the pain group (vs. control) engaged in more state-level catastrophizing about pain, which led to worse verbal and non-verbal WM. Moderated mediation analyses indicated that the indirect (mediation) effect of state-level pain catastrophizing was moderated by trait-level pain catastrophizing for both verbal and non-verbal WM. Participants in the pain group who reported a greater trait-level tendency to catastrophize about pain experienced greater state-level catastrophizing about pain during the ischemic task, which led to worse verbal and non-verbal WM performance. These results provide evidence for pain catastrophizing as an important mechanism and moderating factor of WM deficits in acute pain. Future research should replicate these results in chronic pain samples, investigate other potential mechanisms (e.g., sleep disturbances), and determine if interventions that target pain catastrophizing directly can ameliorate cognitive deficits in people with pain. PERSPECTIVE: This article presents a laboratory study examining the relationships among pain, pain catastrophizing, and working memory in healthy participants. The results shed new light on these relationships and raise the possibility that interventions that reduce catastrophizing may lead to improved cognitive function among people with pain.

Factors mediating pain-related risk for opioid use disorder

Pain is a complex experience with far-reaching organismal influences ranging from biological factors to those that are psychological and social. Such influences can serve as pain-related risk factors that represent susceptibilities to opioid use disorder. This review evaluates various pain-related risk factors to form a consensus on those that facilitate opioid abuse. Epidemiological findings represent a high degree of co-occurrence between chronic pain and opioid use disorder that is, in part, driven by an increase in the availability of opioid analgesics and the diversion of their use in a non-medical context. Brain imaging studies in individuals with chronic pain that use/abuse opioids suggest abuse-related mechanisms that are rooted within mesocorticolimbic processing. Preclinical studies suggest that pain states have a limited impact on increasing the rewarding effects of opioids. Indeed, many findings indicate a reduction in the rewarding and reinforcing effects of opioids during pain states. An increase in opioid use may be facilitated by an increase in the availability of opioids and a decrease in access to non-opioid reinforcers that require mobility or social interaction. Moreover, chronic pain and substance abuse conditions are known to impair cognitive function, resulting in deficits in attention and decision making that may promote opioid abuse. A better understanding of pain-related risk factors can improve our knowledge in the development of OUD in persons with pain conditions and can help identify appropriate treatment strategies. This article is part of the special issue on 'Vulnerabilities to Substance Abuse.'.

Medial Prefrontal Transcranial Direct Current Stimulation Aimed to Improve Affective and Attentional Modulation of Pain in Chronic Low Back Pain Patients

Chronic low back pain (CLBP) is often without clear underlying pathology. Affective disturbance and dysfunctional pain mechanisms, commonly observed in populations with CLBP, have, therefore, been suggested as potential contributors to CLBP development and maintenance. However, little consensus exists on how these features interact and if they can be targeted using non-invasive brain stimulation. In this pilot trial, 12 participants completed two phases (Active or Sham) of high-definition transcranial direct current stimulation (HD-tDCS) to the medial prefrontal cortex, applied for 20 min on three consecutive days. Clinical pain ratings, questionnaires, and sensitivity to painful cuff pressure were completed at baseline, then 4 trials of conditioned pain modulation (CPM; alone, with distraction using a Flanker task, with positive affect induction, and with negative affect induction using an image slideshow) were performed prior to HD-tDCS on Day 1 and Day 4 (24 h post-HD-tDCS). At baseline, attentional and affective manipulations were effective in inducing the desired state (p < 0.001) but did not significantly change the magnitude of CPM-effect. Active HD-tDCS was unable to significantly alter the magnitude of the shift in valence and arousal due to affective manipulations, nor did it alter the magnitude of CPM under any basal, attentional, or affective manipulation trial significantly on Day 4 compared to sham. The CPM-effect was greater across all manipulations on Day 1 than Day 4 (p < 0.02) but also showed poor reliability across days. Future work is needed to expand upon these findings and better understand how and if HD-tDCS can be used to enhance attentional and affective effects on pain modulation.

Comparing objective cognitive impairments in patients with peripheral neuropathic pain or fibromyalgia

Existing studies on cognitive impairments in chronic pain do not investigate peripheral neuropathic pain (PNP) or compare pain conditions in a satisfactory manner. Here we aimed to compare executive dysfunctions in PNP patients with fibromyalgia (FM) and healthy controls (HC). Patients who self-reported cognitive impairments were assessed according to criteria for PNP or FM. Seventy-three patients met criteria and completed testing on executive functioning and IQ measures. We also included twenty matched healthy controls. Regression models controlling for age, sex and IQ, tested associations between group category (PNP, FM or HC) and outcomes. If a substantial association was detected, we followed up with head-to-head comparisons between PNP and FM. Multivariate regression models then tested associations between executive functioning and pain type, controlling for significant confounders. Results from head-to-head comparison between pain conditions showed significant differences on years lived with pain (FM > PNP), the use of anticonvulsants (PNP > FM) and use of analgesics (PNP > FM). When controlled for all significant differences, PNP patients had significantly lower scores on an attention-demanding cued-recall task compared to FM. Poor performance on attention-demanding cued-recall task was associated with PNP, which translate into problems with retaining fast-pace or advanced information.

Distraction from pain: The role of selective attention and pain catastrophizing

Background

Previous research has demonstrated the efficacy of cognitive engagement in reducing concurrent pain. However, little is known about the role of individual differences in inhibitory control abilities and negative pain‐related cognitions in modulating the magnitude of this type of distraction from pain.

Methods

In a pain distraction paradigm, 41 participants completed a working memory task with both a demanding high load condition (2‐back) and an easy low load condition (0‐back), while receiving warm or painful thermal stimuli to their left forearm. To control for individual differences in sensitivity to pain and perceived task difficulty, nociceptive stimulus intensity and task speed were individually calibrated. Additionally, participants completed a set of cognitive inhibition tasks (flanker, go/nogo, Stroop) and questionnaires about negative pain‐related cognitions (fear of pain, pain catastrophizing) prior to the distraction paradigm.

Results

As expected, engaging in the high load condition significantly reduced perceived intensity and unpleasantness of nociceptive stimuli, compared to the low load condition. The size of the distraction effect correlated significantly with better cognitive inhibition and selective attention abilities, as measured by the flanker task. A moderation analysis revealed a significant interaction between pain catastrophizing and performance in the flanker task in predicting the distraction effect size: Participants who performed well on the flanker task showed more pain reduction, but only when they were average to high pain catastrophizers.

Conclusions

Selective attention abilities and pain catastrophizing seem to be important factors in explaining individual differences in the size of the analgesic response to a distractive task.

Significance

Understanding which factors influence the effectiveness of cognitive engagement in distracting from pain could help to optimize its therapeutic application in patient care. This study shows that a complex interplay of cognitive inhibition abilities, specifically selective attention, and negative pain‐related cognitions, such as pain catastrophizing, modulate the magnitude of the distraction effect.

Performance of healthy persons under pain in different cognitive load tasks: An event-related potential study on experimental pain individuals

OBJECTIVE

This study aims to determine how brain activities underlying task with different cognitive load would be modulated by the painful state using electroencephalography.

METHODS

The pain state was established by spraying capsaicin on subjects' left inner forearm. A total of 20 experimental pain subjects and 20 matched nonpain controls underwent cognitive tasks with electroencephalogram recording. We collected and analyzed behavioral and event-related potential (ERP) data.

RESULTS

High cognitive tasks exhibited significantly longer response times and lower accuracies than low-load tasks. The experimental pain group displayed a significantly lower accuracy than the control group. In addition, the experimental pain group showed no significance between high and low cognitive tasks in early ERP components (amplitude of N1, P2, N2, and early part of late positive potential), whereas the control group exhibited significance between different load tasks. Furthermore, we observed a delay peak energy for delta and theta oscillation in Fz 500-800 ms after the onset for pain persons and high cognitive load tasks.

CONCLUSIONS

Inadequate early attention modulation, along with delayed peak energy for brain oscillation (delta and theta), could be accountable for a worse performance in cognitive tasks in the experimental pain group. Thus, cognitive load is a highly considerable factor. Overall, this study offers more insights into how healthy population works with cognitive tasks under pain neurologically.

Time Course of Attention Interruption After Transient Pain Stimulation

Although pain has been shown to affect attentional performance, little is known about the time course of attention interruption after pain stimulus perception. The present study examined the time course of the effects of transient heat pain stimulation on 2 components of attention. Three groups of subjects performed attention tasks under pain, warmth, and no-stimulation control conditions, respectively. The pain and warmth groups received brief physical stimulation. Attention tasks were presented 0 ms, 250 ms, 750 ms, or 1500 ms after the end of stimulation. The 2 attention tasks, namely the spatial cue task (Experiment 1, N = 92) and a Stroop task (Experiment 2, N = 86), were conducted separately. In Experiment 1, attentional orientation of the pain and warmth groups was significantly impaired for at least 1.5 seconds after the physical stimulation had ended. Interestingly, this effect lasted longer for the warmth group than for the pain group. In Experiment 2, pain stimulation had no effect on executive attention at any time. We concluded that attentional orientation is selectively disrupted by both pain and warmth stimuli, but recovers earlier from pain. PERSPECTIVE: This article is concerned with the subsequent interruptive effect of pain on attentional orientation and executive attention by using the spatial cue task and the Stroop task, respectively. These measures offer options for investigating the time course of attention interruption after transient pain stimulation.

The Effects of Alcohol Hangover on Executive Functions

Recent research has suggested that processes reliant on executive functions are impaired by an alcohol hangover, yet few studies have investigated the effect of hangovers on core executive function processes. Therefore, the current study investigated the effect of hangovers on the three core components of the unity/diversity model of executive functions: the ability to switch attention, update information in working memory, and maintain goals. Thirty-five 18-to-30-year-old non-smoking individuals who reported experiencing a hangover at least once in the previous month participated in this study. They completed tasks measuring switching (number-switching task), updating (n-back task), and goal maintenance (AX Continuous Performance Test, AX-CPT) whilst experiencing a hangover and without a hangover in a 'naturalistic' within-subjects crossover design. Participants made more errors in the switching task (p = 0.019), more errors in both the 1- (p < 0.001) and 2-back (p < 0.001) versions of the n-back, and more errors in the AX-CPT (p = 0.007) tasks when experiencing a hangover, compared to the no-hangover condition. These results suggest that an alcohol hangover impairs core executive function processes that are important for everyday behaviours, such as decision-making, planning, and mental flexibility.

Dorsal Root Ganglion Stimulation Modulates Cortical Gamma Activity in the Cognitive Dimension of Chronic Pain

A cognitive task, the n-back task, was used to interrogate the cognitive dimension of pain in patients with implanted dorsal root ganglion stimulators (DRGS). Magnetoencephalography (MEG) signals from thirteen patients with implanted DRGS were recorded at rest and while performing the n-back task at three increasing working memory loads with DRGS-OFF and the task repeated with DRGS-ON. MEG recordings were pre-processed, then power spectral analysis and source localization were conducted. DRGS resulted in a significant reduction in reported pain scores (mean 23%, p = 0.001) and gamma oscillatory activity (p = 0.036) during task performance. DRGS-induced pain relief also resulted in a significantly reduced reaction time during high working memory load (p = 0.011). A significant increase in average gamma power was observed during task performance compared to the resting state. However, patients who reported exacerbations of pain demonstrated a significantly elevated gamma power (F(3,80) = 65.011612, p < 0.001, adjusted p-value = 0.01), compared to those who reported pain relief during the task. Our findings demonstrate that gamma oscillatory activity is differentially modulated by cognitive load in the presence of pain, and this activity is predominantly localized to the prefrontal and anterior cingulate cortices in a chronic pain cohort.

Publications on the Association Between Cognitive Function and Pain from 2000 to 2018: A Bibliometric Analysis Using CiteSpace

BACKGROUND This study aimed to use CiteSpace software to conduct a bibliometric analysis of published studies on the association between pain and cognitive function from 2000 to 2018. The study also aimed to determine publication patterns and authorship and to identify recent trends for research in this field. MATERIAL AND METHODS Publications on the association between cognitive function and pain between 2000 and 2018 were identified from the Web of Science database. Bibliographic information, including authorship, country, citation frequency, changes in citation, and interactive visualization were generated using CiteSpace software. Co-citation, or frequency of two publications cited together by another publication, was also studied. RESULTS On 8th January 2019, 4,889 publications were identified. The United States (1132 publications) and the University of Washington (87 publications) were the most productive country and institution, respectively. The journal, Pain (182 publications) had the largest number of publications and was the most frequently cited journal (citation counts, 1569) with the highest centrality (0.62). Author A had the largest number of publications (21). Author B had the greatest co-citation count (223). Author C tied with Author D as the first co-cited author in terms of centrality (0.18). Author E in 2011 (co-citation count, 96) and Author F in 2008 (centrality: 0.11) had the highest co-citation counts and centrality, respectively. The keyword 'empathy' ranked first for research developments with the highest citation burst (10.045). CONCLUSIONS Bibliometric analysis of the association between pain and cognitive function might identify new directions for future research.

Executive Functions and Pain

Abstract. A growing body of literature suggests that chronic-pain patients suffer from problems in various neuropsychological domains, including executive functioning. In order to better understand which components of executive functioning (inhibition, shifting and/or updating) might be especially affected by pain and which mechanisms might underlie this association, we conducted a systematic review, including both chronic-pain studies as well as experimental-pain studies. The chronic-pain studies (N = 57) show that pain is associated with poorer executive functioning. The findings of experimental-pain studies (N = 28) suggest that this might be a bidirectional relationship: Pain can disrupt executive functioning, but poorer executive functioning might also be a risk factor for higher vulnerability to pain.

Medium-term effects of a two-desk sit/stand workstation on cognitive performance and workload for healthy people performing sedentary work: a secondary analysis of a randomised controlled trial

Implementing sit/stand workstations in sedentary work environments is a common way to reduce sedentary time, but their medium-term effect on cognitive performance is unclear. To address this circumstance, eighteen office workers participated in a two-arm, randomised controlled cross-over trial (ClinicalTrials.gov Identifier: NCT02825303), either working at a traditional (sit) or an interventional (sit/stand) workplace for 23 weeks. Cognitive performance (working speed, reaction time, concentration performance, accuracy), workload and relevant covariates (salivary cortisol level, heart rate, physical activity, sitting time) were measured pre- and post-intervention under laboratory conditions. MANOVA and RMANOVA results did not show differences in performance parameters and workload, respectively, between sit/stand and traditional workplace users. Differences in text editing accuracy and cortisol levels for sit/stand workstation users indicate potential connectivity to cognitive parameters which should be further examined with large-scale studies. Practitioner summary: Medium-term effects of working at sit/stand workstations on cognitive performance and workload are unexplored. This randomised controlled trial suggests that cognitive performance and workload are unaffected for sit/stand workstation users after 23 weeks of use. However, accuracy appeared to improve and physiological stress appeared to be altered. Abbreviations: BMI: body mass index; IPAQ: International physical activity questionnaire; MET: metabolic equivalent of task; MANOVA: multivariate ANOVA; NASA TLX: NASA task load index; RMANOVA: repeated measures ANOVA.

Trauma-related psychiatric and behavioral conditions are uniquely associated with sustained attention dysfunction

OBJECTIVE

It is increasingly recognized that trauma victims, particularly Veterans, have co-occurring psychological and physical conditions that impact cognition, especially the domains of sustained attention and executive functioning. Although previous work has generally attempted to isolate the unique cognitive effects of common combat-related comorbidities, less work has been done to examine how these conditions co-occur, and whether unique cognitive signatures accompany certain clinical combinations.

METHOD

To address this gap, we examined how several deployment-related conditions were associated with performance on a well-validated measure of sustained attention (i.e., gradual onset continuous performance task [gradCPT]) and a battery of standard neuropsychological measures in 123 Veterans from the Translational Research Center for TBI and Stress Disorders. Initially, a Principal component analysis was conducted to investigate how comorbid conditions grouped together.

RESULTS

Several sustained attention measures from the gradCPT were differentially associated with four unique combinations of trauma-related pathology. Specifically, a somatic component representing the combination of current pain, sleep disturbance, and mild traumatic brain injury was associated with a higher rate of failures of attentional engagement. On the other hand, a comorbid posttraumatic stress disorder (PTSD) and mood disorder component (moodPTSD), as well as a substance use disorder component, were associated with higher rates of inhibitory control failures. Increased attentional instability was associated with moodPTSD as well as an anxiety disorder component. In contrast, the cognitive effects of deployment-related trauma were not observed on standard neuropsychological measures.

CONCLUSION

These findings suggest that unique combinations of trauma-related pathology have dissociable effects on sustained attentional control. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

An incremental dual-task paradigm to investigate pain attenuation by task difficulty, affective content and threat value

There is accumulating evidence that task demands and psychological states can affect perceived pain intensity. Different accounts have been proposed to explain this attenuation based either on how limited attentional resources are allocated to the pain stimulus or on how the threat value of the pain stimulus biases attention. However, the evidence for both proposals remains mixed. Here we introduce an incremental dual-task paradigm in which participants were asked to detect pain on their fingertip without any additional tasks during baseline phases or while concurrently detecting visual targets during task phases. The force applied to participants' fingertip in all phases increased incrementally until they detected moderate pain. In Experiment 1, we used coloured shapes and in Experiment 2 we used affective images as visual targets. We also manipulated the threat value of the pain stimulus in Experiment 2. For both experiments, we found that a concurrent task attenuated perceived pain intensity: mean force was significantly greater for the same moderate pain during task compared to baseline phases. Furthermore although task difficulty and affective content did not affect pain perception, the threat value of the pain stimulus moderated the magnitude of pain attenuation.

Acute pain disrupts prospective memory cue detection processes

Prospective memory refers to the planning, retention, retrieval, and execution of intentions for future behaviours and it is integral to the enterprise of daily living. Although prospective memory relies upon retrospective memory and executive processes often disrupted by pain, limited research has explored the influence of acute or chronic pain on the ability to complete prospective memory tasks. In the present study we investigated the influence of acute pain on prospective memory tasks that varied in their demands on executive processes (i.e., non-focal versus focal prospective memory cues). Complex-span working memory tasks were also administered to examine whether individual differences in working memory capacity moderated any negative impact of pain on prospective memory. Acute pain significantly impaired prospective memory performance in conditions that encouraged non-focal strategic processing of prospective memory cues, but not in conditions that encouraged more spontaneous focal processing. Individual differences in working memory capacity did not moderate the effect of acute pain on non-focal prospective memory. These findings provide new insights into prospective memory dysfunction created by painful experiences.

Effect of alternating postures on cognitive performance for healthy people performing sedentary work

Prolonged sitting is a risk factor for several diseases and the prevalence of worksite-based interventions such as sit-to-stand workstations is increasing. Although their impact on sedentary behaviour has been regularly investigated, the effect of working in alternating body postures on cognitive performance is unclear. To address this uncertainty, 45 students participated in a two-arm, randomised controlled cross-over trial under laboratory conditions. Subjects executed validated cognitive tests (working speed, reaction time, concentration performance) either in sitting or alternating working postures on two separate days (ClinicalTrials.gov Identifier: NCT02863731). MANOVA results showed no significant difference in cognitive performance between trials executed in alternating, standing or sitting postures. Perceived workload did not differ between sitting and alternating days. Repeated measures ANOVA revealed significant learning effects regarding concentration performance and working speed for both days. These results suggest that working posture did not affect cognitive performance in the short term. Practitioner Summary: Prior reports indicated health-related benefits based on alternated (sit/stand) body postures. Nevertheless, their effect on cognitive performance is unknown. This randomised controlled trial showed that working in alternating body postures did not influence reaction time, concentration performance, working speed or workload perception in the short term.