Many times, I’ve been told by those I evaluate that they can’t think right anymore. Even in the absence of a concussion or mild brain injury, people report poor memory, inability to multi-task, decreased concentration, and other cognitive deficits.
Quite a few studies have been performed which look at the effects of various chronic pain syndromes and several aspects of cognition. In 2011, the article The Effect of Pain on Cognitive Function: A review of Clinical and Preclinical Research was featured in Progress in Neurobiology which nicely summarized many of these studies that looked at effects of pain on attention, several types of memory, psychomotor efficiency, speed of information processing, visual scanning, decision making, mental flexibility, executive function, learning, and visuospatial awareness among others.
That article provided insight as to the mechanisms involved in pain-related cognitive impairment including:
- Brain morphology and electrophysiology.
- Neurotransmitters and receptors in pain and cognition.
- Glial cells and cytokines in pain and cognition.
- Neurotrophic factors in pain and cognition.
- Effects of analgesic treatments for chronic pain on cognitive function.
Needless to say, there were a lot of very big words in that article. Thank goodness for the Summary and Conclusions section! It states that there is sufficient evidence that supports the fact that pain does in fact affect cognitive processes. The more difficult the cognitive demands are, the greater the chance of functional limitations. They cite three theories for this:
- Competing limited resources.
- Dysregulated neurochemistry.
How do we measure these affects in an FCE? Here is how I do it …
Pain levels are tracked using The Functional Pain Scale. This scale has specific definitions of how pain is impacting the person’s ability to function in that moment. Along with physical tasks, provide tasks that require various types of cognitive processes and note problems, slowness, and errors. Formal cognitive testing is also performed. Academic testing may be used as well. As the day progresses, observations are made of cognitive deterioration that may be associated with changes in pain.
I’m often challenged on the stand about using pain or fatigue as an end point for stopping an activity. I’m challenged about the effects of pain on both physical and cognitive function. Yes, everyone’s pain experience is different, but just because it’s different from person to person doesn’t mean it should be ignored. It is the PRIMARY barrier to daily function; both physically and cognitively. Pain is real and can be measured. Cognitive dysfunction is real and can be measured. Is every method perfect? No, of course not. But we as evaluators have a responsibility to do our very best to quantify dysfunction of all types.
I’m seeing more and more clients with diagnoses such as fibromyalgia, chronic fatigue syndrome, Postural Orthostatic Tachycardia Syndrome, and other autoimmune disorders. Nearly all of them report some type of “brain fog” so cognitive testing must be part of the functional capacity evaluation. There still seems to be a lack of understanding in the medical community about the cognitive problems associated with these conditions despite the large body of research available on the topic. Hopefully awareness will continue to grow as cognitive testing becomes more accepted as part of functional capacity evaluations for a wide range of diagnoses. Sherry Young