The Effectiveness of Attention Bias Modification with and without Trans Cranial Direct Current Stimulation in Chronic Low Back Pain
Objective: The present study aimed to compare the effect of ABM (attention bias modification) with and without tDCS (transcranial direct current stimulation) on attention bias, pain intensity, and disability due to pain and pain-related psychological consequences, such as depression, anxiety, and stress.
Method: Using convenience sampling, 60 individuals who met the criteria for chronic low back pain (LBP) were selected and randomly assigned in to 2 experimental groups and 2 control and sham-tDCS groups. The experimental ABM group received 5 sessions of the dot-probe task, while the second experimental group received 5 sessions of dot-probe task combined with tDCS.
Results: The findings indicated that ABM and ABM+tDCS could reduce attention bias and pain-related psychological consequences significantly, compared to the control and sham groups. Also, attention bias and pain outcomes (depression, anxiety, disability due to pain and pain intensity) remained in ABM+tDCS group than in ABM group in a 1-month follow-up.
Conclusion: It was found that tDCS + ABM had no additional effects at the end of intervention, but led to more long-lasting effects in 1-month follow-up.
Randomized clinical trial registry number: IRCT20171107037306N1.
2. Asmundson GJ. Do attentional biases for pain depend on threat value of pain and competing motivation toward non-pain goals? Pain. 2012;153(6):1140-1.
3. Liossi C. Attentional biases in chronic pain: Do they exist and does it really matter? Pain. 2012;153(1):9-10.
4. Van Damme S, Crombez G, Eccleston C, Koster EHW. Hypervigilance to Learned Pain Signals: A Componential Analysis. The Journal of Pain. 2006;7(5):346-57.
5. Brooks S, Prince A, Stahl D, Campbell IC, Treasure J. A systematic review and meta-analysis of cognitive bias to food stimuli in people with disordered eating behaviour. Clin Psychol Rev. 2011;31(1):37-51.
6. Peckham AD, McHugh RK, Otto MW. A meta-analysis of the magnitude of biased attention in depression. Depress Anxiety. 2010;27(12):1135-42.
7. Yiend J. The effects of emotion on attention: A review of attentional processing of emotional information. Cogn Emot. 2010;24(1):3-47.
8. Pincus T, Morley S. Cognitive-processing bias in chronic pain: a review and integration. Psychol Bull. 2001;127(5):599-617.
9. Todd J, Sharpe L, Johnson A, Nicholson Perry K, Colagiuri B, Dear BF. Towards a new model of attentional biases in the development, maintenance, and management of pain. Pain. 2015;156(9):1589-600.
10. Crombez G, Van Ryckeghem DM, Eccleston C, Van Damme S. Attentional bias to pain-related information: a meta-analysis. Pain. 2013;154(4):497-510.
11. Schoth DE, Nunes VD, Liossi C. Attentional bias towards pain-related information in chronic pain; a meta-analysis of visual-probe investigations. Clin Psychol Rev. 2012;32(1):13-25.
12. Haggman SP, Sharpe LA, Nicholas MK, Refshauge KM. Attentional biases toward sensory pain words in acute and chronic pain patients. J Pain. 2010;11(11):1136-45.
13. Liossi C, White P, Schoth DE. Time-course of attentional bias for threat-related cues in patients with chronic daily headache-tension type: evidence for the role of anger. Eur J Pain. 2011;15(1):92-8.
14. Schoth DE, Liossi C. Attentional bias toward pictorial representations of pain in individuals with chronic headache. Clin J Pain. 2010;26(3):244-50.
15. Schoth DE, Nunes VD, Liossi C. Attentional bias towards pain-related information in chronic pain; a meta-analysis of visual-probe investigations. Clin Psychol Rev. 2012;32(1):13-25.
16. Crombez G, Van Ryckeghem DM, Eccleston C, Van Damme S. Attentional bias to pain-related information: a meta-analysis. Pain. 2013;154(4):497-510.
17. MacLeod C, Mathews A, Tata P. Attentional bias in emotional disorders. J Abnorm Psychol. 1986;95(1):15-20.
18. Bowler JO, Bartholomew KJ, Kellar I, Mackintosh B, Hoppitt L, Bayliss AP. Attentional bias modification for acute experimental pain: A randomized controlled trial of retraining early versus later attention on pain severity, threshold and tolerance. Eur J Pain. 2017;21(1):112-24.
19. McGowan N, Sharpe L, Refshauge K, Nicholas MK. The effect of attentional re-training and threat expectancy in response to acute pain. Pain. 2009;142(1-2):101-7.
20. Sharpe L, Johnson A, Dear BF. Attention bias modification and its impact on experimental pain outcomes: Comparison of training with words versus faces in pain. Eur J Pain. 2015;19(9):1248-57.
21. Carleton RN, Richter AA, Asmundson GJ. Attention modification in persons with fibromyalgia: a double blind, randomized clinical trial. Cogn Behav Ther. 2011;40(4):279-90.
22. Nitsche MA, Paulus W. Transcranial direct current stimulation--update 2011. Restor Neurol Neurosci. 2011;29(6):463-92.
23. Filmer HL, Dux PE, Mattingley JB. Applications of transcranial direct current stimulation for understanding brain function. Trends Neurosci. 2014;37(12):742-53.
24. Nitsche MA, Fregni F. Transcranial direct current stimulation-an adjuvant tool for the treatment of neuropsychiatric diseases? Curr Psychiatry Rev. 2007;3(3):222-32.
25. Nitsche MA, Cohen LG, Wassermann EM, Priori A, Lang N, Antal A, et al. Transcranial direct current stimulation: State of the art 2008. Brain Stimul. 2008;1(3):206-23.
26. Fregni F, Gimenes R, Valle AC, Ferreira MJ, Rocha RR, Natalle L, et al. A randomized, sham-controlled, proof of principle study of transcranial direct current stimulation for the treatment of pain in fibromyalgia. Arthritis Rheum. 2006;54(12):3988-98.
27. Fregni F, Boggio PS, Lima MC, Ferreira MJL, Wagner T, Rigonatti SP, et al. A sham-controlled, phase II trial of transcranial direct current stimulation for the treatment of central pain in traumatic spinal cord injury. PAIN. 2006;122(1):197-209.
28. Silva G, Miksad R, Freedman SD, Pascual-Leone A, Jain S, Gomes DL, et al. Treatment of cancer pain with noninvasive brain stimulation. J Pain Symptom Manage. 2007;34(4):342-5.
29. Leo A, De Luca R, Russo M, Naro A, Bramanti P, Calabrò RS. Role of tDCS in potentiating poststroke computerized cognitive rehabilitation: lessons learned from a case study. Appl Neuropsychol Adult. 2016;23(3):162-6.
30. Ditye T, Jacobson L, Walsh V, Lavidor M. Modulating behavioral inhibition by tDCS combined with cognitive training. Exp Brain Res. 2012;219(3):363-8.
31. Powers A, Madan A, Hilbert M, Reeves ST, George M, Nash MR, et al. Effects of Combining a Brief Cognitive Intervention with Transcranial Direct Current Stimulation on Pain Tolerance: A Randomized Controlled Pilot Study. Pain Med. 2018;19(4):677-85.
32. World Medical A. World Medical Association Declaration of Helsinki. Ethical principles for medical research involving human subjects. Bull World Health Organ. 2001;79(4):373-4.
33. MacLeod C, Rutherford E, Campbell L, Ebsworthy G, Holker L. Selective attention and emotional vulnerability: assessing the causal basis of their association through the experimental manipulation of attentional bias. J Abnorm Psychol. 2002;111(1):107-23.
34. Dehghani M, Sharpe L, Nicholas MK. Modification of attentional biases in chronic pain patients: a preliminary study. Eur J Pain. 2004;8(6):585-94.
35. Sharpe L, Dear BF, Schrieber L. Attentional biases in chronic pain associated with rheumatoid arthritis: hypervigilance or difficulties disengaging? J Pain. 2009;10(3):329-35.
36. Lang P. Behavioral treatment and bio-behavioral assessment: Computer applications. Technology in mental health care delivery systems. 1980:119-37.
37. Cleeland CS, Ryan KM. Pain assessment: global use of the Brief Pain Inventory. Ann Acad Med Singapore. 1994;23(2):129-38.
38. Jensen MP. The validity and reliability of pain measures in adults with cancer. J Pain. 2003;4(1):2-21.
39. Stevens ML, Lin CC, Maher CG. The Roland Morris Disability Questionnaire. J Physiother. 2016;62(2):116.
40. Lovibond PF, Lovibond SH. The structure of negative emotional states: comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behav Res Ther. 1995;33(3):335-43.
41. Brown TA, Chorpita BF, Korotitsch W, Barlow DH. Psychometric properties of the Depression Anxiety Stress Scales (DASS) in clinical samples. Behav Res Ther. 1997;35(1):79-89.
42. Nitsche MA, Doemkes S, Karakose T, Antal A, Liebetanz D, Lang N, et al. Shaping the effects of transcranial direct current stimulation of the human motor cortex. J Neurophysiol. 2007;97(4):3109-17.
43. Ambrus GG, Al-Moyed H, Chaieb L, Sarp L, Antal A, Paulus W. The fade-in--short stimulation--fade out approach to sham tDCS--reliable at 1 mA for naive and experienced subjects, but not investigators. Brain Stimul. 2012;5(4):499-504.
44. Bowler JO, Bartholomew KJ, Kellar I, Mackintosh B, Hoppitt L, Bayliss AP. Attentional bias modification for acute experimental pain: A randomized controlled trial of retraining early versus later attention on pain severity, threshold and tolerance. Eur J Pain. 2017;21(1):112-24.
45. Schoth DE, Georgallis T, Liossi C. Attentional bias modification in people with chronic pain: a proof of concept study. Cogn Behav Ther. 2013;42(3):233-43.
46. Sharpe L, Ianiello M, Dear BF, Perry KN, Refshauge K, Nicholas MK. Is there a potential role for attention bias modification in pain patients? Results of 2 randomised, controlled trials. Pain. 2012;153(3):722-31.
47. Liossi C. Attentional biases in chronic pain: do they exist and does it really matter? Pain. 2012;153(1):9-10.
48. Thayer JF, Lane RD. A model of neurovisceral integration in emotion regulation and dysregulation. J Affect Disord. 2000;61(3):201-16.
49. Helzer EG, Connor-Smith JK, Reed MA. Traits, states, and attentional gates: temperament and threat relevance as predictors of attentional bias to social threat. Anxiety Stress Coping. 2009;22(1):57-76.
50. Lautenbacher S, Huber C, Baum C, Rossaint R, Hochrein S, Heesen M. Attentional avoidance of negative experiences as predictor of postoperative pain ratings and consumption of analgesics: comparison with other psychological predictors. Pain Med. 2011;12(4):645-53.
51. Bar-Haim Y. Research review: Attention bias modification (ABM): a novel treatment for anxiety disorders. J Child Psychol Psychiatry. 2010;51(8):859-70.
52. Heathcote LC, Vervoort T, Eccleston C, Fox E, Jacobs K, Van Ryckeghem DM, et al. The relationship between adolescents' pain catastrophizing and attention bias to pain faces is moderated by attention control. Pain. 2015;156(7):1334-41.
53. MacLeod C, Clarke PJ. The attentional bias modification approach to anxiety intervention. Clin Psychol Sci. 2015;3(1):58-78.
54. Martin M, Williams RM, Clark DM. Does anxiety lead to selective processing of threat-related information? Behav Res Ther. 1991;29(2):147-60.
55. Goubert L, Crombez G, Van Damme S. The role of neuroticism, pain catastrophizing and pain-related fear in vigilance to pain: a structural equations approach. Pain. 2004;107(3):234-41.
56. Taylor AM, Harris AD, Varnava A, Phillips R, Hughes O, Wilkes AR, et al. Neural responses to a modified Stroop paradigm in patients with complex chronic musculoskeletal pain compared to matched controls: an experimental functional magnetic resonance imaging study. BMC Psychol. 2016;4:5.
57. Luedtke K, Rushton A, Wright C, Jurgens T, Polzer A, Mueller G, et al. Effectiveness of transcranial direct current stimulation preceding cognitive behavioural management for chronic low back pain: sham controlled double blinded randomised controlled trial. BMJ. 2015;350:h1640.
58. Antal A, Brepohl N, Poreisz C, Boros K, Csifcsak G, Paulus W. Transcranial direct current stimulation over somatosensory cortex decreases experimentally induced acute pain perception. Clin J Pain. 2008;24(1):56-63.
59. De Luca R, Calabro RS, Gervasi G, De Salvo S, Bonanno L, Corallo F, et al. Is computer-assisted training effective in improving rehabilitative outcomes after brain injury? A case-control hospital-based study. Disabil Health J. 2014;7(3):356-60.
60. Jeon SY, Han SJ. Improvement of the working memory and naming by transcranial direct current stimulation. Ann Rehabil Med. 2012;36(5):585-95.
61. Park S-H, Koh E-J, Choi H-Y, Ko M-H. A double-blind, sham-controlled, pilot study to assess the effects of the concomitant use of transcranial direct current stimulation with the computer assisted cognitive rehabilitation to the prefrontal cortex on cognitive functions in patients with stroke. J Korean Neurosurg Soc. 2013;54(6):484-8.
62. Javadi AH, Walsh V. Transcranial direct current stimulation (tDCS) of the left dorsolateral prefrontal cortex modulates declarative memory. Brain Stimul. 2012;5(3):231-41.
63. Andrews SC, Hoy KE, Enticott PG, Daskalakis ZJ, Fitzgerald PB. Improving working memory: the effect of combining cognitive activity and anodal transcranial direct current stimulation to the left dorsolateral prefrontal cortex. Brain Stimul. 2011;4(2):84-9.