European Journal of Applied Physiology

, Volume 119, Issue 9, pp 2053–2064 | Cite as

Experimental knee-related pain enhances attentional interference on postural control

  • Eneida Yuri Suda
  • Rogerio Pessoto HirataEmail author
  • Thorvaldur Palsson
  • Nicolas Vuillerme
  • Isabel C. N. Sacco
  • Thomas Graven-Nielsen
Original Article



To quantify how postural stability is modified during experimental pain while performing different cognitively demanding tasks.


Sixteen healthy young adults participated in the experiment. Pain was induced by intramuscular injection of hypertonic saline solution (1 mL, 6%) in both vastus medialis and vastus lateralis muscles (0.9% isotonic saline was used as control). The participants stood barefoot in tandem position for 1 min on a force plate. Center of pressure (CoP) was recorded before and immediately after injections, while performing two cognitive tasks: (i) counting forwards by adding one; (ii) counting backwards by subtracting three. CoP variables—total area of displacement, velocity in anterior–posterior (AP-velocity) and medial–lateral (ML-velocity) directions, and CoP sample entropy in anterior–posterior and medial–lateral directions were displayed as the difference between the values obtained after and before each injection and compared between tasks and injections.


CoP total area ( − 84.5 ± 145.5 vs. 28.9 ± 78.5 cm2) and ML-velocity ( − 1.71 ± 2.61 vs. 0.98 ± 1.93 cm/s) decreased after the painful injection vs. Control injection while counting forward (P < 0.05). CoP total area (12.8 ± 53.9 vs. − 84.5 ± 145.5 cm2), ML-velocity ( − 0.34 ± 1.92 vs. − 1.71 ± 2.61 cm/s) and AP-velocity (1.07 ± 2.35 vs. − 0.39 ± 1.82 cm/s) increased while counting backwards vs. forwards after the painful injection (P < 0.05).


Pain interfered with postural stability according to the type of cognitive task performed, suggesting that pain may occupy cognitive resources, potentially resulting in poorer balance performance.


Postural stability Center of pressure Attention Distraction Pain 



Analysis of variance


Arbitrary units


Center of pressure


Sample entropy


Standard deviation


Visual analogue scale


Vastus medialis


Vastus lateralis



Center for Neuroplasticity and Pain (CNAP) is supported by the Danish National Research Foundation (DNRF121). The authors thank the State of São Paulo Research Foundation (FAPESP) for the Suda scholarship (FAPESP 2017/15449–4, 2015/00214–6).

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. Andersson G, Hagman J, Talianzadeh R et al (2002) Effect of cognitive load on postural control. Brain Res Bull 58:135–139CrossRefPubMedGoogle Scholar
  2. Bair MJ, Robinson RL, Katon W, Kroenke K (2003) Depression and pain comorbidity. Arch Intern Med 163:2433. CrossRefPubMedGoogle Scholar
  3. Brauer SG, Broome A, Stone C et al (2004) Simplest tasks have greatest dual task interference with balance in brain injured adults. Hum Mov Sci 23:489–502. CrossRefPubMedGoogle Scholar
  4. Bronstein AM, Buckwell D (1997) Automatic control of postural sway by visual motion parallax. Exp Brain Res 113:243–248. CrossRefPubMedGoogle Scholar
  5. Day BL, Steiger MJ, Thompson PD, Marsden CD (1993) Effect of vision and stance width on human body motion when standing: implications for afferent control of lateral sway. J Physiol 469:479–499CrossRefPubMedPubMedCentralGoogle Scholar
  6. Donker SF, Roerdink M, Greven AJ, Beek PJ (2007) Regularity of center-of-pressure trajectories depends on the amount of attention invested in postural control. Exp Brain Res 181:1–11. CrossRefPubMedPubMedCentralGoogle Scholar
  7. Duarte M, Sternad D (2008) Complexity of human postural control in young and older adults during prolonged standing. Exp Brain Res 191:265–276. CrossRefPubMedGoogle Scholar
  8. Eccleston C, Crombez G (1999) Pain Demands attention : a cognitive-affective model of the interruptive function of pain. Psychol Bull 125(3):356–366CrossRefPubMedGoogle Scholar
  9. Era P, Sainio P, Koskinen S et al (2006) Postural balance in a random sample of 7979 subjects aged 30 years and over. Gerontology 52:204–213. CrossRefPubMedGoogle Scholar
  10. Etemadi Y, Salavati M, Arab AM, Ghanavati T (2016) Balance recovery reactions in individuals with recurrent nonspecific low back pain: effect of attention. Gait Posture 44:123–127. CrossRefPubMedGoogle Scholar
  11. Falla D, Farina D, Dahl MK, Graven-Nielsen T (2006) Muscle pain induces task-dependent changes in cervical agonist/antagonist activity. J Appl Physiol 102:601–609. CrossRefPubMedGoogle Scholar
  12. Farina D (2003) Effect of Experimental Muscle Pain on Motor Unit Firing Rate and Conduction Velocity. J Neurophysiol 91:1250–1259. CrossRefPubMedGoogle Scholar
  13. Fewster KM, Gallagher KM, Howarth SH, Callaghan JP (2017) Low back pain development differentially influences centre of pressure regularity following prolonged standing. Gait Posture 1:1. CrossRefGoogle Scholar
  14. Fraizer EV, Mitra S (2008) Methodological and interpretive issues in posture-cognition dual-tasking in upright stance. Gait Posture 27:271–279. CrossRefPubMedGoogle Scholar
  15. Graven-Nielsen T, Arendt-Nielsen L, Svensson P, Jensen TS (1997) Quantification of local and referred muscle pain in humans after sequential im injections of hypertonic saline. Pain 69:111–117CrossRefPubMedGoogle Scholar
  16. Ha H, Cho K, Lee W (2014) Reliability of the Good Balance System® for Postural sway measurement in poststroke patients. J Phys Ther Sci 26:121–124. CrossRefPubMedPubMedCentralGoogle Scholar
  17. Harbourne RT, Stergiou N (2003) Nonlinear analysis of the development of sitting postural control. Dev Psychobiol 42:368–377. CrossRefPubMedGoogle Scholar
  18. Hirata RP, Arendt-Nielsen L, Graven-Nielsen T (2010) Experimental calf muscle pain attenuates the postural stability during quiet stance and perturbation. Clin Biomech 25:931–937. CrossRefGoogle Scholar
  19. Hirata RP, Ervilha UF, Arendt-Nielsen L, Graven-Nielsen T (2011) Experimental muscle pain challenges the postural stability during quiet stance and unexpected posture perturbation. J Pain 12:911–919. CrossRefPubMedGoogle Scholar
  20. Hirata RP, Jørgensen TS, Rosager S et al (2013) Altered Visual and feet proprioceptive feedbacks during quiet standing increase postural sway in patients with severe knee osteoarthritis. PLoS ONE 8:1–8. CrossRefGoogle Scholar
  21. Huxhold O, Li SC, Schmiedek F, Lindenberger U (2006) Dual-tasking postural control: Aging and the effects of cognitive demand in conjunction with focus of attention. Brain Res Bull 69:294–305. CrossRefPubMedGoogle Scholar
  22. Kahneman D (1973) Attention and effort. Prentice-HallGoogle Scholar
  23. Kapoula Z, Lê TT (2006) Effects of distance and gaze position on postural stability in young and old subjects. Exp Brain Res 173:438–445. CrossRefPubMedGoogle Scholar
  24. Knoop J, Van Der Leeden M, Van Der Esch M et al (2012) Association of lower muscle strength with self-reported knee instability in osteoarthritis of the knee: Results from the Amsterdam Osteoarthritis Cohort. Arthritis Care Res 64:38–45. CrossRefGoogle Scholar
  25. Kuczyński M, Szymańska M, Bieć E (2011) Dual-task effect on postural control in high-level competitive dancers. J Sports Sci 29:539–545. CrossRefPubMedGoogle Scholar
  26. Larivière C, Butler H, Sullivan MJL, Fung J (2013) An exploratory study on the effect of pain interference and attentional interference on neuromuscular responses during rapid arm flexion movements. Clin J Pain 29:265–275. CrossRefPubMedGoogle Scholar
  27. Lemaire P (1996) The Role of working memory resources in simple cognitive arithmetic. Eur J Cogn Psychol 8:73–104. CrossRefGoogle Scholar
  28. Levinger P, Nagano H, Downie C et al (2016) Biomechanical balance response during induced falls under dual task conditions in people with knee osteoarthritis. Gait Posture 48:106–112. CrossRefPubMedGoogle Scholar
  29. Liston MB, Bergmann JH, Keating N et al (2014) Postural prioritization is differentially altered in healthy older compared to younger adults during visual and auditory coded spatial multitasking. Gait Posture 39:198–204. CrossRefPubMedGoogle Scholar
  30. Madeleine P, Nielsen M, Arendt-Nielsen L (2011) Characterization of postural control deficit in whiplash patients by means of linear and nonlinear analyses—a pilot study. J Electromyogr Kinesiol 21:291–297. CrossRefPubMedGoogle Scholar
  31. Manor B, Costa MD, Hu K et al (2010) Physiological complexity and system adaptability: evidence from postural control dynamics of older adults. J Appl Physiol 109:1786–1791. CrossRefPubMedPubMedCentralGoogle Scholar
  32. Matre D, Arendt-Neilsen L, Knardahl S (2002) Effects of localization and intensity of experimental muscle pain on ankle joint proprioception. Eur J Pain 6:245–260. CrossRefPubMedGoogle Scholar
  33. Mazaheri M, Coenen P, Parnianpour M et al (2013) Low back pain and postural sway during quiet standing with and without sensory manipulation: a systematic review. Gait Posture 37:12–22. CrossRefPubMedGoogle Scholar
  34. Mazaheri M, Heidari E, Mostamand J et al (2014) Competing effects of pain and fear of pain on postural control in low back pain? Spine 39:E1518–E1523. CrossRefPubMedGoogle Scholar
  35. McWilliams LA, Cox BJ, Enns MW (2003) Mood and anxiety disorders associated with chronic pain: an examination in a nationally representative sample. Pain 106:127–133CrossRefPubMedGoogle Scholar
  36. Melzack R (1975) The McGill Pain Questionnaire: major properties and scoring methods. Pain 1:277–299CrossRefPubMedPubMedCentralGoogle Scholar
  37. Mense S (1993) Nociception from skeletal muscle in relation to clinical muscle pain. Pain 54:241–289CrossRefPubMedGoogle Scholar
  38. Morasso PGP, Sanguineti V (2002) Ankle muscle stiffness alone cannot stabilize balance during quiet standing. J Neurophysiol 88:2157–2162. CrossRefPubMedGoogle Scholar
  39. Nebes RD, Butters MA, Houck PR et al (2001) Dual-task performance in depressed geriatric patients. Psychiatry Res 102:139–151. CrossRefPubMedGoogle Scholar
  40. Pellecchia GL (2003) Postural sway increases with attentional demands of concurrent cognitive task. Gait Posture 18:29–34. CrossRefGoogle Scholar
  41. Peterka RJ (2003) Dynamic Regulation of sensorimotor integration in human postural control. J Neurophysiol 91:410–423. CrossRefPubMedGoogle Scholar
  42. Richman JS, Moorman JR (2000) Physiological time-series analysis using approximate entropy and sample entropy. Am J Physiol Heart Circ Physiol 278(6):H2039–H2049Google Scholar
  43. Schulte E, Ciubotariu A, Arendt-Nielsen L et al (2004) Experimental muscle pain increases trapezius muscle activity during sustained isometric contractions of arm muscles. Clin Neurophysiol 115:1767–1778. CrossRefPubMedGoogle Scholar
  44. Scoppa F, Capra R, Gallamini M, Shiffer R (2013) Clinical stabilometry standardization: basic definitions—acquisition interval—sampling frequency. Gait Posture 37:290–292. CrossRefGoogle Scholar
  45. Seminowicz DA, Davis KD (2007) Interactions of pain intensity and cognitive load: the brain stays on task. Cereb Cortex 17:1412–1422. CrossRefPubMedGoogle Scholar
  46. Sherafat S, Salavati M, Takamjani IE et al (2014) Effect of dual-tasking on dynamic postural control in individuals with and without nonspecific low back pain. J Manip Physiol Ther 37:170–179. CrossRefGoogle Scholar
  47. Shiozawa S, Hirata RP, Graven-Nielsen T (2013) Reorganised anticipatory postural adjustments due to experimental lower extremity muscle pain. Hum Mov Sci 32:1239–1252. CrossRefPubMedGoogle Scholar
  48. Siu KC, Woollacott MH (2007) Attentional demands of postural control: the ability to selectively allocate information-processing resources. Gait Posture 25:121–126. CrossRefPubMedGoogle Scholar
  49. Slifkin AB, Newell KM (1999) Noise, information transmission, and force variability. J Exp Psychol Hum Percept Perform 25:837–851. CrossRefPubMedGoogle Scholar
  50. Søndergaard KHE, Olesen CG, Søndergaard EK et al (2010) The variability and complexity of sitting postural control are associated with discomfort. J Biomech 43:1997–2001. CrossRefPubMedGoogle Scholar
  51. Stins JF, Michielsen ME, Roerdink M, Beek PJ (2009) Sway regularity reflects attentional involvement in postural control: effects of expertise, vision and cognition. Gait Posture 30:106–109. CrossRefPubMedGoogle Scholar
  52. Swan L, Otani H, Loubert PV (2007) Reducing postural sway by manipulating the difficulty levels of a cognitive task and a balance task. Gait Posture 26:470–474. CrossRefPubMedGoogle Scholar
  53. Vaillancourt DE, Newell KM (2002) Changing complexity in human behavior and physiology through aging and disease. Neurobiol Aging 23:1–11. CrossRefPubMedGoogle Scholar
  54. Vaillancourt DE, Newell KM (2000) The dynamics of resting and postural tremor in Parkinson’s disease. Clin Neurophysiol 111:2046–2056. CrossRefPubMedGoogle Scholar
  55. Van Daele U, Hagman F, Truijen S et al (2010) Decrease in postural sway and trunk stiffness during cognitive dual-task in nonspecific chronic low back pain patients, performance compared to healthy control subjects. Spine 35:583–589. CrossRefPubMedGoogle Scholar
  56. Van Ryckeghem DM, Van Damme S, Eccleston C, Crombez G (2018) The efficacy of attentional distraction and sensory monitoring in chronic pain patients: a meta-analysis. Clin Psychol Rev 59:16–29. CrossRefPubMedGoogle Scholar
  57. Veldhuijzen DS, Kenemans JL, De Bruin CM et al (2006) Pain and attention: attentional disruption or distraction? J Pain 7:11–20. CrossRefPubMedGoogle Scholar
  58. Voos MC, Piemonte MEP, Castelli LZ et al (2015) Association between Educational Status and dual-task performance in Young Adults. Percept Mot Skills 120:416–437. CrossRefPubMedGoogle Scholar
  59. Vuillerme N, Nafati G (2007) How attentional focus on body sway affects postural control during quiet standing. Psychol Res 71:192–200. CrossRefPubMedGoogle Scholar
  60. Winter DA (1995) Human balance and posture control during standing and walking. Gait Posture 3(4):193–214CrossRefGoogle Scholar
  61. Woollacott M, Shumway-Cook A (2002) Attention and the control of posture and gait: a review of an emerging area of research. Gait Posture 16:1–14. CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Laboratory of Biomechanics of Human Movement, Department Physical Therapy, Speech and Occupational Therapy, School of MedicineUniversity of Sao PauloSão PauloBrazil
  2. 2.Department of Health Science and Technology, Faculty of Medicine, Center for Sensory Motor InteractionSMI, Aalborg UniversityÅlborgDenmark
  3. 3.University of Grenoble-Alpes, EA AGEISGrenobleFrance
  4. 4.Institut Universitaire de FranceParisFrance
  5. 5.Department of Health Science and Technology, Center for Neuroplasticity and Pain (CNAP)SMI, Aalborg UniversityÅlborgDenmark

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