Sustained Attention Instability as a Cognitive Biomarker in Chronic Spine Pain: A 90-second Visual Attention Test

Abstract

Background: Chronic spine pain is linked to self-reported cognitive complaints. However, objective markers are lacking. The 90-s Continuous Visual Attention Test (CVAT) quantifies key attention subdomains: reaction time (RT, alertness), RT variability (VRT, sustained attention), omission errors (focused attention) and commission errors (impulsivity).

Objective: This study aimed to identify which specific attentional subdomains, measured by the CVAT, are impaired in adults with chronic spine pain.

Methods: This prospective case-control study included 84 adults with chronic lumbar/cervical pain (≥ 3 months) and 118 healthy controls. A MANCOVA tested group differences on CVAT variables, controlling for age and sex, followed by Bonferroni-corrected ANCOVAs. To isolate cognitive variability from general processing speed, the coefficient of variability (VRT/RT) was also analysed. Logistic regression assessed the predictive power of CVAT indices for pain status.

Results: The MANCOVA showed a significant group effect (Pillai's Trace = 0.46, F(4,195) = 41.43, p < 0.001). Patients exhibited impairments in all measures p < 0.001 (η² = 0.093-0.44). The VRT deficit persisted when using VRT/RT. Logistic regression identified VRT as the strongest predictor of chronic spine pain (χ²(1) = 147.53, p < 0.001), correctly classifying 86.6% of participants. This finding remained when using VRT/RT (χ²(1) = 130.55, p < 0.001; 82.7% accuracy).

Conclusions: Patients with chronic spine pain demonstrate attentional deficits, with sustained attention instability (VRT and VRT/RT) as the most robust marker. The CVAT detects this impairment, offering a practical tool for clinical assessment to inform treatment and monitor cognitive function in pain management.

Level of evidence: III (prospective case-control).

Significance statement: A brief, 90-s computerized attention test provides an objective, clinic-ready screen for sustained-attention instability in spine pain patients. Identifying cognitive vulnerability at the point of care can inform perioperative counselling, driving/work-safety guidance and rehabilitation planning, and it may help monitor treatment response alongside pain metrics, offering a noninvasive, nonpharmacologic complement to standard pain assessment.

Keywords: attention; cognitive dysfunction; executive function; low back pain; neck pain; neuropsychological tests; pain measurement; psychomotor performance; reaction time; spinal diseases.