Neuroscience and Behavioral Physiology, Vol. 41, No.

1, 2011

Characteristics of Cognitive Functions in Patients

with Chronic Spinal Pain

K. A. Melkumova, E. V. Podchufarova,
and N. N. Yakhno

Translated from Zhurnal Nevrologii i Psikhiatrii imeni S. S. Korsakova, Vol. 109, No. 11, pp. 20–24,
November, 2009.

A total of 64 patients with musculoskeletal pain syndromes in the lumbosacral area for more than three
months were studied. Patients were divided into age groups: 30–50 years (41 patients) and 51–60 years
(23 patients). The reference group consisted of 20 healthy volunteers comparable in terms of gender, age,
and level of education. Patients underwent neurological, neuro-orthopedic, clinical-pathopsychological,
and neuropsychological investigations. Complaints of difficulty with mental concentration were present in
17.3% of patients and problems with remembering information in 20.2%. Both groups of patients with
chronic pain showed mild neurodynamic impairments. As compared with healthy subjects, they had sig-
nificantly worse performance in tests assessing memory (delayed reproduction in the 12-word test), atten-
tion, mental flexibility, and visuomotor coordination (the sequential number-letter combination test, digit
symbol substitution test, and, in younger patients, the forward and backward number series repetition test).
Cognitive functions in younger patients were affected by the sensory-discriminant (intensity) and affec-
tive-motivational (negative emotions, particularly anxiety) characteristics of pain. Cognitive functions in
older patients were affected by the affective-motivational (anxiety, level of psychoemotional distress) and
cognitive (level of catastrophization) components of pain. Treatment directed at correcting the peripheral
sources of pain and emotional disorders (rational psychotherapy, tranquilizers, antidepressants) could
potentially have positive effects on cognitive functions in patients with chronic pain.

KEY WORDS: chronic spinal pain, cognitive functions.

WHO data indicate that pain syndromes represent one
of the leading causes of medical consultations in the prima-
ry healthcare system (from 11.3% to 40% of cases) [17].
Among neurological conditions, patients with chronic pain
(CP) account for up to 52.5% of cases [4]. Epidemiological
studies of chronic pain syndromes in the adult population of
Russia show that their incidence ranges from 13.8% to
56.7%, averaging 34.3 per 100 questioned [9].
CP is more common among women and people with
low income, and its incidence increases with age. A rela-
tionship between CP and depression and emotionally stress-
ful factors has been demonstrated. CP is dominated by pain
of musculoskeletal origin and headache [1, 2, 8]. Spinal
Department of Nervous Diseases, Therapeutic Faculty,
I. M. Sechenov Moscow Medical Academy;
e-mail: kar-mel@mail.ru.
42
0097-0549/11/4101-0042 ©2011 Springer Science+Business Media, Inc.
pain is the most common cause of temporary disability and
restriction of activity among people of working age [26].
In Russia, lower spinal pain accounts for from 20% to 80%
of cases of temporary disability in the active social group
and 20.4% of all disability due to degenerative diseases of
the musculoskeletal system [10].
Around 80% of people experience lumbosacral pain at
some time in their lives; in 80–90% of patients, the pain
regresses over six weeks, though 10–20% of patients develop
CP and disability. This group of patients has an unfavorable
prognosis for recovery and represent a major medical-social
problem, as they account for up to 80% of healthcare costs
[11, 15, 34]. The incidence of disability and spinal pain does
not increase with age and does not correlate with age-relat-
ed degenerative change in the spine. The peak incidence of
CP occurs at working age (up to 40 years) [25]. The severi-
ty of pain sensations in the spine, disability, and pain-related
Characteristics of Cognitive Functions in Patients with Chronic Spinal Pain
behavior in CP do not correspond to objective lesions, which
can be minimal. CP and disability are more associated with
the presence of emotional distress, depression, failed treat-
ment, and adoption of the “patient role” [34].
Results obtained from numerous studies have demon-
strated that CP (regardless of the presence of traumatic brain
damage or other neurological diseases in the history) has
adverse influences on cognitive functions. In addition, it is
often accompanied by anxiety, depression, and restricted
daily activities, resulting in significant decreases in patients’
quality of life [2, 13, 18, 23, 29]. Cognitive disorders in
patients with CP consist mainly of impairments to memory,
attention, information processing speed, and the flexibility
of thought. Cognitive impairments in CP and their underly-
ing mechanisms are currently being actively studied [6].
Normal aging involves moderate reductions in informa-
tion processing speed, memory, and regulatory functions [12,
27, 28]. It has been suggested that with age, patients with CP
can show increasingly severe cognitive disorders due to the
negative effects of pain on attention and memory [21].
The aims of the present work were to obtain more data
on the nature of impairments to cognitive functions in CP
and to identify the factors influencing them, with the aim of
optimizing the treatment of this group of patients.
MATERIALS AND METHODS
A total of 64 patients (22 men and 42 women) with
chronic musculoskeletal pain syndromes in the lumbosacral
area for more than three months were studied.
Patients were divided into two age groups with no sig-
nificant differences in gender composition or levels of educa-
tion. Group 1 consisted of 41 patients (29 women, 12 men)
aged from 30 to 50 years (mean age 44.4 ± 5.7 years).
Group 2 included 23 patients (13 women, 10 men) aged from
51 to 60 years (mean age 53.8 ± 2.5 years). The reference
group consisted of 20 healthy volunteers and was compara-
ble in terms of gender, age, and level of education with the
study groups.
Patients with neurological and somatic diseases
(hypothyroidism, marked impairments of liver and kidney
function, severe systemic and metabolic abnormalities, etc.),
which can be accompanied by cognitive function impair-
ments were excluded from the study, as were physician-
dependent patients, and those with exacerbation of pain
syndrome and cognitive impairments, and patients taking
agents with the potential to influence cognitive functions.
Clinical investigations included analysis of the devel-
opment of the condition, neurological and neuro-orthope-
dic, clinical-psychopathological, and neuropsychological
investigations.
Pain syndrome was studied using visual analog scales
(VAS) and the McGill pain questionnaire [3]. The level of
disability was evaluated using the Oswestry Disability Scale,
43
which identifies the extent to which spinal pain affects the
patient’s daily activity [7]. The University of Alabama Pain
Behavior Scale was used to assess the degree of pain-related
behavior [24]. Catastrophization (the patient having extreme-
ly negative views of his/her status) was assessed using the
Chronic Pain Catastrophizing Scale [31]. Anxiety levels were
assessed using the Spielberger–Hanin self-assessment anxi-
ety scale [5]. Depression was detected using the Hamilton
scale [1]: results from 0 to 6 were evaluated as showing the
absence of depression, while patients with scores of 7 and
above were excluded from the study. Psychological changes
and levels of psychological distress were assessed using the
Symptom Check List 90 (SCL-90) [5].
Neuropsychological investigations included analysis of
complaints of impairments to memory and attention, as well
as evaluation of cognitive functions using neuropsychologi-
cal methods. Visuomotor coordination and mental flexibility
(the ability to adapt and develop individual intellectual
schemes when working with new information) were
assessed using the sequential number-letter combination test
[30]. Information processing speed, visuomotor coordina-
tion, and selective attention were assessed using the digit
symbol substitution test [22]. Attention-switching ability
and left frontal lobe function were tested using the Stroop
test (University of Victoria version) [30]. The ability to solve
tasks in response to changes in stimulus and the ability to
switch and maintain a defined program using feedback were
assessed using the Wisconsin card sorting test, which allows
impairments to the dorsolateral areas of the prefrontal cortex
to be evaluated [30]. Verbal fluency and semantic memory
were assessed using the verbal associations test (literal and
categorial) [30]. The 12-word memorization and reproduc-
tion test with the modification of Grober and Buschke (the
12-word test) was used (immediate and delayed reproduc-
tion) to assess memory [30]. Short-term memory and atten-
tion were evaluated using the number sequence repetition
test in the forward and reverse directions by the Wechsler
method [22]. Exaggeration and simulation of reduced mem-
ory were monitored in all patients and the reference group
using the Rey test for memory assessment [30].
Data were analyzed statistically using EpiInfo 5.0,
which is freely distributed and recommended by the WHO.
RESULTS
Comparative analysis of the various characteristics of
pain in the two study groups showed that the mean dura-
tions of lumbar pain were 10.83 ± 6.92 years in group 1 and
10.09 ± 7.57 years in group 2; the mean durations of current
exacerbations were 4.46 ± 3.54 and 5.78 ± 4.45 months; pain
intensities on the VAS were 5.07 ± 1.71 and 5.17 ± 1.59
points, respectively. Assessment of pain using the McGill
pain questionnaire showed that in patients of group 1, the
index of the number of descriptors identified (INDI), a mea-
44
TABLE 1. Results Obtained from Neuropsychological Tests Showing Significant Differences between Groups of Patients with CP and the
Reference Groups
Note. *Significant differences compared with reference group (p < 0.05).
sure of the number of pain characteristic descriptors identi-
fied on the sensory and affective scales, and the rank pain
index (RPI), reflecting the severity of the pain characteris-
tic descriptors on the sensory, affective, and evaluative
scales, were somewhat higher than those in patients of
group 2 (sensory INDI: 5.46 ± 3.67 and 3.83 ± 2.15 points,
affective INDI: 3.22 ± 1.62 and 2.74 ± 1.21 points, sensory
RPI: 12.41 ± 10.65 and 7.17 ± 5.06 points, affective RPI:
5.24 ± 3.24 and 5.0 ± 3.06 points, evaluative RPI: 3.1 ± 1.46
and 2.43 ± 0.51 points, respectively). Invalidity levels on
the Oswestry scale showed no difference, with values of
35.17 ± 15.67% in group 1 and 35.22 ± 13.41% in group 2,
which corresponded to moderate decreases in functionality.
The level of catastrophization was somewhat higher in
group 1, at 18.8 ± 10.94 points, compared with 15.83 ± 6.15
points in group 2. Significant differences were seen on eval-
uation of pain behavior: 4.38 ± 2.01 points in group 1 and
2.78 ± 1.62 points in group 2 (p = 0.023).
Analysis of neuro-orthopedic impairments showed that
dysfunction of the sacroiliac joint was present in 90.6% of
cases (90.2% in group 1 and 91.3% in group 2), facet joint
syndrome in 78.1% (73.2% and 87% in groups 1 and 2,
respectively), myofascial pain syndrome in 23.4% (24.4%
and 21.7%, respectively), and myotonic syndrome in 76.6%
(75.6% and 78.3%, respectively). There were no statistical-
ly significant differences in the frequencies of neuro-ortho-
pedic derangements between the two groups.
Assessment of reactive and endogenous anxiety using
the Spielberger–Hanin scale revealed moderate reactive
anxiety in both groups: 45.54 ± 10.45 points in group 1 and
41.87 ± 6.17 points in group 2. In patients of group 1, the
level of endogenous anxiety was higher (47.27 ± 11.64
points) than that in group 2 (42.4 ± 7.37 points), though the
differences were not significant.
Comparative evaluation of mean values on the SCL-90
scale (the somatization, endogenous anxiety, depression,
and anxiety scales, and measures reflecting the overall
index of anxiety, which is a measure of psychological dis-
tress) showed that there were no significant differences
between patients of groups 1 and 2. Both men and women
of the two groups showed differences from population
mean values on the somatization (the ability of the patient
Melkumova, Podchufarova, and Yakhno
to express emotional problems through physical symptoms)
and psychological distress scales. The value on the anxiety
and depression scale for women of group 1 was greater than
the population mean. In group 2, there were also increases
in values on the somatization, psychological distress, and
anxiety scales as compared with population means, while in
men, there was also an increase on the depression scale.
Analysis of complaints of cognitive impairments
showed that complaints of difficulty with mental concentra-
tion were made by 17.3% of patients. These were present
significantly more often (31.7%) among patients of group 1
than among patients of group 2 (21.7%) (p = 0.03). Com-
plaints of difficulties with remembering information were
made by 20.2% of patients. Complaints of memory impair-
ments were more common in patients of group 1 (39%) than
in patients of group 2 (21.7%), though this difference was
not statistically significant (p = 0.15).
Patients complaining of memory impairments per-
formed significantly less well on the 12-word test with
delayed reproduction than patients without these com-
plaints, scoring 11.0 ± 1.3 and 11.68 ± 0.69 words, respec-
tively (p = 0.003). Patients complaining of impaired atten-
tion performed the digit symbol substitution test
significantly worse than patients lacking these complaints,
with scores of 43.27 ± 5.73 and 51.04 ± 10.53 symbols,
respectively (p = 0.004).
Comparison of the results obtained from neuropsycho-
logical tests of the two study groups revealed significant
differences (p < 0.05) only on the Stroop test (assessment of
the switching of attention). Patients of group 2 took more
time to perform the test with the “words” (18.17 ± 3.58 sec)
and “colors” (31.09 ± 6.32 sec) cards than patients of group
1 (16.13 ± 3.08 and 26.03 ± 6.12 sec, respectively). In terms
of the remaining neuropsychological methods, there were
no significant differences between the two study groups.
Spearman correlation analysis revealed a statistically
significant interaction (p < 0.001) between the results
obtained on the Stroop test (“words” and “colors” cards)
and patients’ age – increases in age were associated with
increases in the time taken to perform the test.
Patients of both groups differed from healthy volun-
teers in performance on memory assessment (delayed
Characteristics of Cognitive Functions in Patients with Chronic Spinal Pain
reproduction in the 12-word test) and attention and regula-
tory functions tests (the sequential number-letter combina-
tion test, the digit symbol substitution test). Patients of
group 1 also showed significant differences from healthy
subjects in terms of the digit repetition test in the forward
and reverse directions.
On performance of the 12-word test, patients of both
age groups named significantly fewer words on delayed
reproduction as compared with healthy subjects (p = 0.0027
and p = 0.0035, respectively). The sequential digit-letter
combination test were performed significantly worse by
patients of group 1 (p = 0.0004) and group 2 (p = 0.0011);
patients of both groups required more time than healthy
subjects to perform this test, pointing to impairments to
attention functions, mental flexibility, and visuomotor coor-
dination in patients of both age groups. Decreases in infor-
mation processing speed and impairments to attention and
visuomotor coordination were identified by results obtained
on the digit symbol substitution test. On performance of this
test, CP patients of both groups substituted fewer symbols
in the 90-sec test period than healthy subjects (p = 0.0015).
In the digit repetition test in the forward and reverse direc-
tions (patients were told to repeat series of digits after the
investigator first in the forward direction then in the reverse
direction), the total points score of patients of group 1 was
significantly lower than that in the control group (p = 0.0091)
(see Table 1).
Spearman correlation analysis revealed a significant
(p < 0.05) negative relationship between the results obtained
from the 12-word test (delayed reproduction) and pain
intensity in the VAS, the results on the evaluative scale of
the McGill pain questionnaire, and the level of invalidity on
the Oswestry scale. There was a positive correlational rela-
tionship between pain INDI on the sensory scale of the
McGill pain questionnaire and results obtained from
the sequential digit-letter combination test assessing mental
flexibility and visuomotor coordination. There was a nega-
tive correlational relationship between the level of endoge-
nous anxiety on the SCL-90 scale and results obtained from
the digit symbol substitution test addressing information
processing speed, visuomotor coordination, and selective
attention.
Patients of group 2 showed a negative correlational
relationship between the results obtained from the 12-word
test (delayed reproduction) and the level of psychological
distress on the SCL-90 scale and a positive relationship
between the level of catastrophization and results obtained
from the sequential digit-letter combination test.
DISCUSSION
Thus, both younger and older patients with CP in the
spine had mild neurodynamic impairments to attention, men-
tal flexibility, information processing speed, and memory.
45
Cognitive functions in patients of group 1 were affect-
ed by the sensory-discriminative (intensity) and affective-
motivational (negative emotions, particularly anxiety) char-
acteristics of pain.
In patients of group 2, cognitive functions were affect-
ed by the affective-motivational (anxiety, level of psycho-
logical distress) and cognitive (level of catastrophization)
characteristics. These data are consistent with results
obtained in other studies.
Published data [20] indicate that elderly patients with
CP in the spine showed an interaction between the severity
of pain syndrome and impairments to regulatory functions,
particularly mental flexibility. Pain intensity and the severi-
ty of anxiety (but not depression) had negative influences
on memory and information processing speed [16]. A num-
ber of studies [32] have demonstrated that negative attitudes
to pain, pain behavior, and the severity of emotional distress
on cognitive functions (impairments to attention) have
influences. Patients with high levels of emotional distress
showed impairments to attention and psychomotor process-
ing speed (in the Stroop test), memory and regulatory func-
tions as compared with the results obtained from these tests
by patients with low levels of emotional distress [19].
Eccleston et al. [14] demonstrated that psychological dis-
tress and increased concentration on bodily sensations
(somatization) affected the severity of cognitive impair-
ments in patients with CP. Thus, cognitive functions in
patients with CP affected the sensory-discriminative, emo-
tional-motivational, and cognitive components of CP.
The present study did not identify any effects of the level
of somatization or the severity of pain behavior on cognitive
functions: these were was greater than the population mean
but within the ranges typical of patients with chronic diseases,
especially in-patients. The present study did not include any
patients with marked depressive disorders which could influ-
ence measures of cognitive functions. In the absence of
depression, cognitive functions were more influenced by the
sensory-discriminative characteristics of pain (pain intensity
on the VAS, descriptive characteristics on the McGill pain
questionnaire). Increased anxiety, psychological distress, and
catastrophization could also be seen to have a role in the
appearance of mild neurodynamic cognitive impairments.
Data obtained by various authors [33] indicate that the pres-
ence of anxiety disorders is typical of patients with chronic
pain syndromes. Among patients with CP in the spine, more
than 22% had marked anxiety disorders and more than 23%
had depression [13]. Anxiety as an indicator of psychological
stress is known to influence cognitive functions to a signifi-
cant extent [12]. Investigation of the influence of anxiety on
cognitive functions performed on healthy volunteers have
shown that it has negative effects on working memory, infor-
mation processing speed, learning, the abilities to perform
abstraction and solve tasks, and response suppression [35].
Treatment directed to correcting peripheral sources of
pain and emotional disorders (rational psychotherapy, tran-
46
quilizers, and antidepressants) may potentially have posi-
tive influences on cognitive functions in patients with CP.
Thus, the need to optimize the treatment of CP with
the aim of decreasing its negative influences on cognitive
functions is evident.
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