Executive Functions, Self-Regulation, and Chronic Pain: A Review

Pain research & management : the journal of the Canadian Pain Society = journal de la société canadienne pour le traitement de la douleur

Diminished executive function and attentional control has been reported in chronic pain patients. However, the precise pattern of impairment in these aspects of cognition in chronic pain remains unclear. Moreover, a decline in psychomotor speed could potentially influence executive and attentional control performance in pain patients. To examine different aspects of executive and attentional control in chronic pain together with the confounding role of psychomotor slowing. Neuropsychological tests of sustained attention, planning ability, inhibition and mental flexibility were administered to 34 participants with chronic pain and 32 control participants. Compared with the controls, participants with chronic pain took longer to complete tests of sustained attention and mental flexibility, but did not perform worse on inhibition or planning tasks. The decreased performance on the mental flexibility task likely reflects a reduction in psychomotor speed. The pattern of performance on th...

Critical Reviews in Physical and Rehabilitation Medicine, 2012

Executive function (EF) is a control mechanism of human cognition that provides the capability to select actions in relation to internal goals organized by the prefrontal cortex (PFC). The PFC is essential for the temporal integration of sensory information in the sequencing of optimum motor behavior to achieve an internal goal. The temporal integration of sensory information also explains why the PFC has an additional role in the central modulation of pain. Pain modulation and motor function are altered in chronic pain, and this alteration can contribute to the reduced physical activity. EF is the driver of conscious control of thought and action that is critical to rehabilitation in chronic pain. However, EF is impaired in chronic pain. Rehabilitation practitioners typically use activity modification, exercise, and movement to enhance function in patients with chronic pain; exercise has beneficial effects on EF. However, impairments in EF can be barriers to adherence to exercise, activity, and lifestyle modifications required to optimize rehabilitation. Greater awareness of EF can enhance rehabilitation. This narrative review explores current theories of EF structure and function, how impairment of EF can be assessed in a clinical context, and its implications for rehabilitation in chronic pain.

Background / Purpose: We wanted to study if executive function being impaired is a strongly held belief in our concepts about people with chronic pain. Individual studies reveal conflicting information about the nature and magnitude of this association between pain and cognitive function. This systematic review and meta-analysis aimed to establish the current evidence for executive function impairment in people with chronic pain. Main conclusion: People with chronic pain showed consistent impairment in reaction time outcomes across three of four executive function cognitive domains.There are several caveats to the interpretation of these conclusions: most studies were limited by small sample numbers, executive function is inherently difficult to test, and moderators of executive function such as sleep and medication were rarely controlled for in the studies.

• People with chronic pain show small to medium impairments in executive function. • Small sample sizes meant a moderate risk of bias across the evidence base. • Moderators of executive function were seldom controlled for in study design. • Studies could not isolate processes more or less affected in people with chronic pain. a b s t r a c t A widely held belief within the clinical community is that chronic pain is associated with cognitive impairment, despite the absence of a definitive systematic review or meta-analysis on the topic. The current systematic review and meta-analysis aimed to establish the current evidence concerning the difference in executive function between people with chronic pain and healthy controls. Six databases were searched for citations related to executive function and chronic pain from inception to June 24, 2013. Two reviewers independently assessed studies for eligibility and extracted relevant data according to the Cochrane Collaboration and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Twenty five studies were included in the review and twenty two studies in the meta-analysis. A small to moderate impairment in executive function performance was found in people with chronic pain across cognitive components, although all studies had a high risk of bias. The current evidence suggests impairment of executive function in people with chronic pain, however, important caveats exist. First, executive function involves many cognitive components and there is no standard test for it. Second, moderators of executive function, such as medication and sleep, were seldom controlled for in studies of executive function performance.

PLOS One

Pain interferes and disrupts attention. What is less clear is how pain affects performance on complex tasks, and the strategies used to ensure optimal outcomes. The aim of the current study was to examine the effect of pain on higher-order executive control processes involved in managing complex tasks. Sixty-two adult volunteers (40 female) completed two computer-based tasks: a breakfast making task and a word generation puzzle. Both were complex, involving executive control functions, including goal-directed planning and switching. Half of those recruited performed the tasks under conditions of thermal heat pain, and half with no accompanying pain. Whilst pain did not affect central performance on either task, it did have indirect effects. For the breakfast task, pain resulted in a decreased ability to multitask, with performance decrements found on the secondary task. However, no effects of pain were found on the processes thought to underpin this task. For the word generation puzzle, pain did not affect task performance, but did alter subjective accounts of the processes used to complete the task; pain affected the perceived allocation of time to the task, as well as switching perceptions. Sex differences were also found. When studying higher-order cognitive processes, pain-related interference effects are varied, and may result in subtle or indirect changes in cognition.

2017

We investigated the relations between several aspects of Perceived Pain (PP) and different measurements of Executive Functions (EFs), above the influence of depression, in the context of medical rehabilitation. Eighty-one neurologically intact patients participated in this study in their sub-acute stage of recovery. Different aspects of EFs were assessed using the Wisconsin Card Sorting Test (WCST), the Stop-Signal Test (SST) and the Digit Span Backward subtest of the WAIS-III (Span-B). Different aspects of PP were measured: Pain Disability Index (PDI), The Short-Form McGill Questionnaire (SF-MPQ) and the Pain Catastrophizing Scale (PCS). Depression symptoms were assessed using the Patient Health Questionnaire. The results indicate that irrespective of the presence of depression, mental flexibility is correlated with pain disability and pain severity (WSCT – PDI partial correlation: r = −.23; p=.047, WSCT – SF-MPQ partial correlation: r = −.31; p = .006). Response inhibition is correlated with pain disability (SST – PDI partial correlation: r = .37; p = .001). Updating was not correlated with any of the PP aspects. These results remain much the same after removing the chronic pain patients from the analyses. The present study emphasizes the multidimensional nature of the term “perceived pain”, as well as the term “executive functions”, and the relations between them.

Psychophysiology, 2019

Self‐regulatory (SR) ability is an important resource for managing pain, but chronic pain patients experience chronic self‐regulatory fatigue even when they are not in pain. Pressure pain thresholds (PPT) and pain inhibition are two mechanisms that differentiate people with and without chronic pain. It was hypothesized that trait SR ability would be associated with higher PPT and better pain inhibition and that PPT and pain inhibition would be lower following high versus low SR fatigue. Three studies tested these hypotheses. Study 1 had 240 pain‐free undergraduates complete measures of trait SR ability and PPT; 122 also provided data on pain inhibition. Study 2 had 38 of Study 1’s participants return for two additional sessions in which they underwent PPT testing under conditions of high or low SR fatigue (within‐person, counterbalanced). Study 3 repeated these procedures with pain inhibition as the outcome (n = 39). Results revealed that individual differences in SR ability were no...

Cognitive Therapy and Research, 2000

Adjustment to chronic pain is examined within the context of a model that emphasizes goal-centered self-regulatory processing. Individual differences in adjustment to chronic illness have typically been examined from within the framework of stressful person-environment transactions. However, it may be useful to examine a broader array of person-environment transactions encountered in the context of working toward personal goals. Self-regulation may be especially challenging for people with chronic pain because of the link between pain and emotion. Consistent with this perspective, we will focus on the role of emotion as an energizing force in self-regulation and discuss the implications for managing pain. We will suggest that pain and concomitant negative emotion pervasively bias information processing, constrain the selection of goals, and the ongoing process of self-regulation.

European Journal of Pain, 2018

Background: Chronic pain is associated with emotional problems as well as difficulties in cognitive functioning. Prior experimental studies have shown that optimism, the tendency to expect that good things happen in the future, and positive emotions can counteract paininduced task performance deficits in healthy participants. More specifically, induced optimism was found to buffer against the negative effects of experimental pain on executive functioning. This clinical experiment examined whether this beneficial effect can be extended to a chronic pain population. Methods: Patients (N = 122) were randomized to a positive psychology Internet-based intervention (PPI; n = 74) or a waiting list control condition (WLC; n = 48). The PPI consisted of positive psychology exercises that particularly target optimism, positive emotions and selfcompassion. Results: Results demonstrated that patients in the PPI condition scored higher on happiness, optimism, positive future expectancies, positive affect, self-compassion and ability to live a desired life despite pain, and scored lower on pain catastrophizing, depression and anxiety compared to patients in the WLC condition. However, executive task performance did not improve following completion of the PPI, compared to the WLC condition. Conclusions: Despite the lack of evidence that positive emotions and optimism can improve executive task performance in chronic pain patients, this study did convincingly demonstrate that it is possible to increase positive emotions and optimism in chronic pain patients with an online positive psychology intervention. It is imperative to further explore amendable psychological factors that may reduce the negative impact of pain on executive functioning. Significance: We demonstrated that an Internet-based positive psychology intervention strengthens optimism and positive emotions in chronic pain patients. These emotional improvements are not associated with improved executive task performance. As pain itself often cannot be relieved, it is imperative to have techniques to reduce the burden of living with chronic pain.

European Journal of Pain, 2013

The higher order processes involved in self-regulation are generally thought to depend on cognitive (attentional/executive) functions with limited resources. Experimental studies further show that exerting self-control in a first task results in decreased performance in other following self-control tasks, which may be interpreted as the consequence of either effective or perceived resource depletion outlasting the first task. Given that higher order cognitive/attentional processes are also considered to be involved in pain modulatory mechanisms, we tested the idea that pain could be influenced by prior mobilization of cognitive resources. Methods: The present study investigated the consequences of performing a cognitively demanding task on subsequent pain (ratings) and spinal nociceptive responses (nociceptive flexion reflex, NFR) elicited by noxious electrical stimulations in healthy volunteers. Participants received four noxious stimulations immediately after each of six successive blocks (2 min each) of a numerical Stroop task in a neutral condition (low cognitive demand) and six successive blocks in an interference condition (high cognitive demand). Results: Results revealed that pain was rated higher following the condition requiring higher cognitive control. A similar effect was observed on the NFR. Conclusions: These findings suggest that pain regulation mechanisms including the descending pain modulatory system may be less efficient after the performance of tasks requiring high cognitive control resulting in stronger pain experience.