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Congratulations on this interesting new paper.
[# PeerJ Staff Note - this decision was reviewed and approved by Jafri Abdullah, a PeerJ Section Editor covering this Section #]
Please consider and implement in the manuscript the minor comments made by Reviewer 1.
Line 48-49: "(...) if chronic pain can lose its adaptive function, becoming a major health problem."
The sentence lacks clarity due to the missing comma after "CHRONIC."
Regarding my remark no. 7, I would have been completely satisfied with justifying additional variables given the exploratory aim of this part of the study. However, I also appreciate the brief rationale that was added. In my opinion, the Authors can choose whether to revert to the previous version, simply stating that those variables were selected for exploratory purposes, or to retain the comment they added during the initial revision.
Regarding my comment number 8, I have some reservations about the response provided. This may stem from differing perspectives on the topic. Being fluent in English does not necessarily imply the ability to process semantic and emotional content in the same automatic manner as it is processed in one's native language. However, I am not an expert on bilingualism. As a future direction, I strongly believe that replicating this study with native speakers would be worthwhile.
As for my comment number 18, it's up to you, but I don't think you should mention it as a limitation of the study. Once clarified in the methods that for some participants the threshold of 43.5, typically used as a moderate pain intensity stimulus, was perceived as pain above the tolerance threshold, that's it. It's not necessarily a limitation. If I were you, I would remove it from the Limitation section, as it seems you applied the methodology thoughtfully, adapting it to the participants' needs. But again, the decision is yours.
I am satisfied with the Authors' responses to my comments and the subsequent corrections/integrations to the paper, which have clarified not only my doubts but also those of any other potential reader. I would also thank them for the clarity with which the rebuttal letter has been written. It greatly facilitates the revision process, although it goes beyond the elements that are evaluated for possible publication of the manuscript.
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Dear Authors,
Your manuscript has been thoroughly reviewed by two expert reviewers, and having gone through their feedback, I concur with all their observations and recommendations. It's evident from their comments and my own assessment that the manuscript requires a series of major revisions.
We are interested in the possibility of publishing your study in PeerJ but would like to consider your response to these concerns in the form of a revised manuscript before we make a final decision on publication.
Both reviewers and I emphasize the need for a more comprehensive theoretical narrative, both in the introduction and discussion. Incorporating this will not only place your novel contributions in a wider context but will also enhance the ease with which readers comprehend your findings.
The reviewers have pinpointed certain major concerns regarding your experimental design, methods, and results. I ask you to address all these matters thoroughly. Do ensure to elucidate methodological specifics as requested.
Additionally, there is also an expressed interest in seeing more detailed information related to the accompanying study data. Please rectify any issues pertaining to the R scripts and raw data to enhance replicability.
Finally, we noticed a reference to a third study which doesn't seem to be included in your manuscript. Kindly provide clarity.
To facilitate the review, please highlight all changes made to the manuscript upon resubmission and provide a point-by-point response letter to the reviewers' comments.
While we typically anticipate revisions of this nature to span around two months, we understand that each study is unique in its requirements. Hence, please take the necessary time to make these improvements, as there isn't a stringent deadline for the revision.
Should you have any questions or wish to discuss the revisions in greater depth, I am at your disposal.
Warm regards,
Giovanni Federico, PhD
Editor, PeerJ
**PeerJ Staff Note:** Please ensure that all review and editorial comments are addressed in a response letter and any edits or clarifications mentioned in the letter are also inserted into the revised manuscript where appropriate.
**Language Note:** The review process has identified that the English language must be improved. PeerJ can provide language editing services - please contact us at [email protected] for pricing (be sure to provide your manuscript number and title). Alternatively, you should make your own arrangements to improve the language quality and provide details in your response letter. – PeerJ Staff
The present Manuscript investigated the relationship between AM towards and away from pain-related words, as well as overall AM, and pain perception, pain threshold, pain tolerance, and pain interference in a sample of healthy participants. Additionally, it examined the association between AM towards and away from pain-related words, as well as overall AM, and pain intensity and pain disability in a sample of chronic pain patients. The manuscript also explored the relationship between AM towards and away from pain-related words, as well as overall AM, and individual differences in pain catastrophizing, depression, anxiety, and stress in both samples.
I really appreciated the reading. The topic is both contemporary and captivating, carrying substantial implications for translational and clinical applications, and I believe it can provide an interesting contribution to the literature.
I just have some comments for Authors that I hope can help enhance the quality of the Manuscript.
INTRODUCTION
I appreciated the concise yet comprehensive presentation of a complex topic such as pain, its potential maladaptive implications, and the role of attention in its chronicity. Despite the extensive literature on the subject, the explanation provided is succinct and thorough.
However, I believe that adding even a few more words to clarify specific concepts, without the need to review all studies or enumerate consistent and inconsistent findings, could be advantageous for less experienced readers. In particular, I recommend delving into the following aspects:
- Lines 51-52: “Despite its importance for survival, if chronic, pain can lose its adaptive function”. Please, briefly explain why, while acute pain is considered to be adaptive, chronic pain is not.
- Lines 52-54: “Contemporary models propose that attentional processing of pain information plays a pivotal role in the development and maintenance of chronic pain”. Please, briefly explain why scholars hypnotize that attention to pain-related stimuli may be involved in the development of chronic pain.
- Lines 59-60: “One avenue for researchers has been to further refine training tasks to enhance the intended bias change”. It would be helpful to introduce an example on how these type of tasks work.
There is a little bit of inconsistence in the use of verb mode, i.e., sometimes experiments are described using the past (e.g., “We performed two studies”) and sometimes using the present (e.g., “This first study takes place at the University of Luxembourg.”). Please, check it throughout the Manuscript.
Lines 64-65: “Clarke, MacLeod & Shirazee, 2008”. I think the correct year of publication is 2009, as stated in the references list. Please, verify.
Lines 74-92: The last paragraph of the Introduction, which typically offers a brief overview of the conducted studies and hypotheses, lacks clarity in its structure. Concepts, such as the tasks employed, are introduced without immediate explanation, leading to some confusion. This confusion is eventually resolved when reading the Method section. However, in its current form, the paragraph proves challenging to comprehend. I recommend condensing it as much as possible, with a primary focus on highlighting the hypotheses and studied variables, while avoiding excessive procedural details. Alternatively, consider providing a more thorough explanation of the tasks.
Lines 89-91: Furthermore, I suggest that the rationale for including additional variables such as pain catastrophizing, anxiety, depression, and stress should be presented in the Introduction rather than within the Method section.
METHOD
I find the Methods section to be the most challenging part. The stimulus description, tasks, and procedures lack clarity, which hinders my full comprehension of the study. I recommend to revise it. Below, I've raised some concerns. The one about line 100 is the one that has raised the most concern for me.
Line 100: I guess that “a good understanding of English” does not mean that participants had to be English mother toungue. If this is correct, how was the “good English understanding” assessed?
As far as I know, English is neither the first nor the second language in Luxembourg. Employing a task that includes emotionally charged words, such as those related to pain, with a non-native population could present a notable limitation and potentially impact the results. Indeed, the results supported the null hypothesis. However, I am not suggesting that Experiment 1 failed to yield significant results due to this reason (the speculation Authors do in lines 470-471 also sounds a reasonable explanation). Nonetheless, it would have been more correct to utilize words in the participants' native language. Alternatively, an assessment of the participants' English proficiency on a continuous scale could have been conducted, with the results considered as a factor or covariate. Please, explain in the Discussion.
Line 105: I appreciate that the sample size was determined a priori through power calculations. However, I suggest relocating the sentence “Power calculations indicated that for a linear regression with one primary predictor and three control variables, to detect a medium effect size with 80% power, a sample size of 55 participants was needed” to the Data Analysis Plan section. This change will provide more context as it mentions the predictor and three control variables explicitly, preventing any potential confusion about their identity. However, this is just a personal suggestion, please feel free not to consider it.
Line 118: Please, provide the citation for the prior research from which the words have been sourced.
When the authors mention that the words (72 pain words and 72 neutral words) were randomly divided into three lists of 24 words, it should be clarified that this means 24 words for each category, and that each pain word in the list was paired with a neutral word. We are talking about 24 couple of words, not 24 words, correct?
Line 120: Please, explain what assessment block and training block refer to. I guess the first assessment was used as a baseline, to measure the “spontaneous” AM of the participant, then each participant did a training block “toward” followed by the assessment and then a training block “away” followed by the assessment, in a within sbj design. Is this correct?
Line 120: It is clear how Auithors dealt to avoid a familiarity effect between list, but how did they deal with the possible different familiarity between the two words of each couple?
Familiarity, as a psycholinguistic variable, refers to how well we know or recognize or process a word. It relates to our prior exposure to a word and our ability to quickly and effortlessly process it when encountered in written or spoken language. Thus the level of familiarity of the two words in each couple should be something to assess and deal with. Please, explain.
Line 129: Please provide a reference to a study that explains the traditional dot-probe paradigm, in case the reader wishes to delve deeper into the topic.
Line 134: I guess “60cm viewing distance” was also the distance of the participant from the monitor, correct?
Lines 136-137: Did the participant have to press the same symbol that appeared on the screen? What about correct responses? What was the ISI in case of correct response?
Line 156: Authors say that tones were presented at RANDOM stimulus intervals, but they also say in the previous line that ISI was 900 and 1500ms. This is not clear, please explain.
Line 157: Authors say that the total RIR-task duration was 4 minutes during which 241 tones were presented. Does this mean that there was one tone each second? What about the ISI of 900 and 1500 ms mentioned above?
Lines 178-179: Authors mention that a stimulus of 43.5°C was employed for assessing task interference, except for cases in which the pain tolerance level was below this temperature, where the tolerance temperature was used instead. Why wasn't the individual tolerance temperature used for all participants?
Lines 225-229: It is not clear to me why pain experience measures during the RIR task were not included in the analyses. Please, explain.
Line 235-236: On what basis did the Authors decide to exclude responses faster than 200ms or slower than 2000ms in the AM task? Isn't a threshold of 2000ms somewhat high for data cleaning in reaction times (RTs)?
Lines 198-199: Does the Depression Anxiety Stress Scales assess the traits or the states?
Lines 245-247: Is a word missing here? If it has been intentionally omitted, I suggest to add it. “Similarly, an index of AM towards pain information was calculated by subtracting the AB index from the assessment block after TRAINING, from the assessment block before training attention towards pain information (AMTowards index).”
RESULTS
The direction of significant results is not always reported. For example, in line 279: “(…), with Gender, specifically female being a significant predictor of Attention to pain”. Same problem in line 290.
Line 286: Apart from in section titles, I suggest being more consistent in the use of acronyms (sometimes I find "attentional bias malleability," and at other times, I find "AM").
Line 369: Did the online information statement reported the same explanation of the study provided to participants in the Study 1?
Lines 379-380: The rate of removed trials due to response latencies having a median absolute deviation of >2.5 appears to be significantly higher in the chronic pain group when compared to the healthy group. Is there any explanation for this discrepancy?
DISCUSSION
To be frank, initially, I didn't quite grasp the necessity of including AMOverall in the analyses. Then, I recollected that the Abstract mentioned, "attention bias malleability (AM), i.e., the readiness to acquire an attentional bias irrespective of its direction, may be key in predicting poor pain outcomes."
This "irrespective of its direction" is crucial information, which, if I'm not mistaken, explains why AMOverall was included as a variable. However, this key detail is only found in the Abstract and anywhere else in the Manuscript. For those unfamiliar with this construct, it might lead to the assumption that AMToward is the one associated with poor pain outcomes. But that's not accurate. I apologize to the Authors if I've misinterpreted this. Otherwise, I suggest providing further clarification on the "irrespective of the direction" aspect in the Introduction.
Line 514: Which third study?
I suggest a proof reading to correct some typos here and there.
The authors wrote a very interesting article that is highly relevant to the field as new directions/paradigms are needed within the research on attention and pain. In the following, I would like to suggest a few things that need clarification/elaboration to help the reader understand the matter well.
1. The conclusion part of the abstract is rather vague with quite general statements that would fit nearly every paper. I would suggest giving more concrete arguments, corresponding to the points that are raised in the actual discussion of the paper.
2. From the introduction, I feel like an exact definition of attention malleability is lacking. As this is a new concept that has not yet been studied extensively, a clear example of what AM means after lines 61-63 might clarify this to the reader. This might also be due to the discussion of ABM training in the same paragraph. Even though I fully agree that eventually finding interventions is the main goal, and the paradigm used has ABM training methodology, a description of what attentional bias is and what we know about this might make more sense here, as the current study is not an intervention study in itself.
3. I would suggest omitting the extensive description of the methodological details of the current experiments (lines 74-85). I would use the extra space to elaborate on the concepts and their relationship with interference and individual characteristics, like catastrophizing, and what we know about them so far.
4. Within the paper, the authors sometimes refer to AB towards and sometimes to vigilance. Even though, I know that they refer to the same concept, I would suggest to use the same terminology thoughout the paper to prevent confusion.
4. The hypothesis of Study 1 (lines 85-87) is not entirely clear to me. Why do the authors suggest that adapting AB towards or away from pain will lead to increased attention to pain? Is it not equally likely that it could lead to decreased attention to pain? This point might actually also be solved by point 2 if AM is better described as a new concept and corresponding earlier findings.
5. Overall the paper is clearly written with some minor informalities, such as didn't instead of did not (line 305). The text is well structured. Line 514 states that the authors report three studies instead of two.
6. The tables do not include in the title that also descriptive information is given and this is also not referred to in the text. I would suggest to include this information in the table header to make it self-explanatory. In addition, I would refer to the tables at the end of paragraph 2.1 and 4.1. During my first read, I actually wanted to ask whether descriptive statistics of all variables could be given and only found them later in the tables.
7. The R files containing the steps to reach the AM and RIR scores are overall clear. However, the data files cannot be opened in a readable manner (Windows) and also do not correspond to the R scripts that are given here, hence replication is not possible at this moment. In addition, I was wondering why the actual analyses SPSS syntax files are not given?
1. In part 1.2.2, lines 137-139 explain that feedback on incorrect responses is shown. Does this apply to the whole task or only to a practice block?
2. At the end of paragraph 1.2.3. I would add an explanation of which RT/error rate pattern would suggest interference, in line with the explanation on AB at the end of 1.2.2.
3. The first paragraph of 1.3.1. would belong in the introduction from my point of view.
4. Sometimes, the authors refer to (see supra) and it is unclear whether this is supplementary material that is not yet included in the files that I received as a reviewer.
5. The data analysis plan is overall clearly described. I do have a question about the reasoning on why to exclude trials having a median absolute deviation of > 2.5 (lines 236-237). First of all, it is unclear whether this refers to for example, ms or standard deviations or something else. Second, I would usually be very cautious in excluding deviating scores as we usually do not know whether this is an actual variation within the sample or a measurement error. I would always include all data except when there is a very good reason why it is not meaningful data or if in doubt, I would suggest doing a sensitivity analysis instead to see whether the deviating data has an actual impact on the results and conclusions. The same applies in my opinion to the exclusion of outliers. Also here, I would personally prefer a sensitivity analysis (lines 252-253). The same comments apply to the analyses of study 2.
6. It is difficult to understand what the actual outcome variable of the RIR is, see point 2 as well. After the description of data loss in line 255, I would expect an explanation of how the data is analyzed.
7. I was wondering whether the individual AB indices were tested for significance. Even though I see that the goal of the current studies is to investigate AM, I was wondering whether there was an AB at baseline in these two samples. In addition, this could also give some more insight into whether the training blocks actually resulted in any differences in the assessment blocks. I might be mistaken, but if there is no significant change in AB across the blocks, it could be that the AM score is random variability not related to the actual manipulation of the task. However, I admit that I do find the exact operationalisation of the AM scores quite difficult and would hence highly appreciate clarification on this matter by the authors.
8. In 3.3. lines 355 and 359 the authors state that a combined score was used. Does this refer to an average?
1. Concerning the results of all regression analyses, I would prefer if the authors could also give the coefficients and corresponding statistics for all models that are described. Concerning the space that this might cost, maybe a big overview table, perhaps in a supplement could be considered.
2. I am struggling again with the RIR task in 2.3. lines 303-304, because it is unclear to me whether mean and errors are reported for all blocks together or separately for pain and no-pain blocks. Due to this and the earlier comments about the RIR, I am not sure how to interpret the results, e.g., lines 308-309, how does AM towards predict pain interference on mean latency?
3. For all correlations, it is unclear whether assumptions, like normality was taken into account and accordingly, which correlation coefficient was calculated. From my own experience, this data is mostly skewed in healthy individuals with many low scores.
4. In line 411 an effect size is given while this was not done for all other analyses that are described in the current paper. I would suggest to give effect sizes for all analyses to be consistent and adhere to the current standard of giving effect sizes for all results, also non-significant results.
5. In the discussion, I also miss a clear definition and conceptualisation of the AM scores. Line 443 refers to overall AM while the distinction between AM overall, towards and away is still difficult to grasp as a naive reader. The same difficulty arises when results of earlier findings are discussed and it is not specified which AM is meant here, see line 468.
6. Lines 468 refers to improved therapy outcomes but it is unclear whether this refers to physical or psychological outcomes. Based on this, I would also suggest to be more specific in lines 474-475. Is this effect assumed based on the fact that someone is getting any kind of treatment or a specific kind of treatment?
7. In lines 494-495 it is stated that the effects cannot solely be attributed to ABM training itself. It is unclear to me why this actually is not possible.
8. In line 504 the authors refer to inconsistent findings while thereafter only one reference is given.
9. In lines 508-512, the authors refer to earlier findings on ABM training. In this discussion, I do miss earlier findings about the effect of ABM on pain outcomes, while there was no effect on AB measures, e.g., Sharpe et al. 2012, Sharpe et al 2015. I would suggest adding these findings for completeness.
10. From line 512 till 517 the authors discuss findings in the field of anxiety and threat. This shift feels rather sudden to me and I would suggest translating them directly, or just more precisely, to pain within this discussion.
11. In lines 547, the authors state that the dot-probe paradigm has limitations. I would suggest to give at least one example of concerns that where raised together with a reference.
In conclusion, I would like to highlight again that the paper is a very interesting read and will make a good contribution to the field after publication. I acknowledge that the studies were carefully designed and analysed and have no doubt that the points I have raised can be clarified.
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