Facing pain is effortful: key role of the supplementary motor area and anterior midcingulate cortex

Pain captures attention and interferes with executive and motor processes. In the presence of pain, increasing effort may represent a compensatory mechanism to counteract pain-related disruption and maintain task performance. In this preregistered fMRI study, we investigated neural mechanisms underlying preserved task performance during pain and increased perceived effort. Forty right-handed participants performed a visuomotor force-matching task consisting of isometric handgrip contractions at a low and high force levels under individually calibrated painful or non-painful thermal stimulation. Thermal stimulation was applied to the left forearm, and participants rated the intensity of perceived effort after each isometric contraction. Maintaining task performance under pain was associated with increased perceived effort and recruited brain regions involved in pain modulation and cognitive control. Region-of-interest analysis showed perceived effort was consistently linked to decreased anterior midcingulate cortex activity, whereas supplementary motor area contributions varied depending on its role in motor execution or pain processing. Across experimental condition, motor, pain-modulatory and cognitive-control regions were associated with effort perception. Independently of condition, effort perception was modulated by ventromedial prefrontal cortex and ventral striatum. These findings indicate that effort perception is a complex phenomenon reflecting brain activity within areas involved in motor, executive and valuation processes. Significance StatementThis study advances our understanding of the neural mechanisms underlying task performance under pain and increased effort perception. Brain activity was measured during a visuomotor force-matching task performed in the presence or absence of pain. By contrasting task-related activity between painful and non-painful conditions, we identified regions associated with cognitive control and pain modulation involved in preserving task performance under pain. By correlating activity in regions of interest with ratings of perceived effort, we demonstrated the involvement of the supplementary motor area and midcingulate cortex in effort perception. These findings suggest that additional neural resources are recruited to maintain performance during pain and that the supplementary motor area and midcingulate cortex contribute to heightening the effort experienced.