In this article we take the Cognitive Burden Simulator (CBS) and apply it to a simple COA item:

"In the past week, did you experience any pain?" (Yes/No)

What is Easy About This Item?

1.   It has simple syntax

• It is a short sentence, basic word order (Subject-Object-Verb)

• There are no embedded clauses or long noun phrases.

2.   Familiar vocabulary

• It contains everyday terms, such as “week” and “pain”, although “experience” a little higher register (“feel” or “have”, maybe, for clearer communication?)

• There is no medical jargon.

3.   Clear time frame

• "In the past week” sets a recent, bounded recall window.

• Patients do not need to consider their whole medical history.

4.   Binary response format (Yes/No)

• This creates minimal decision-making burden.

• There is no need to weigh frequency or intensity.

  
  

What is Difficult About This Item?

1.   Memory recall

• The patient must scan back over seven days.

• Episodic recall is cognitively demanding, especially for people with fatigue, pain or cognitive impairment.

2.   Ambiguity in the definition of “pain”

• Pain is subjective and multidimensional: sharp, dull, burning, fleeting, persistent.

• Does a headache count? What about stiffness? Is discomfort the same as pain?

3.   Binary oversimplification

• The Yes/no choice forces reduction of a complex experience.

• A patient with minor, infrequent pain may hesitate: Is that worth a “Yes”?

4.   The timeframe can only ever be an estimation

• Difficulty distinguishing whether a pain episode occurred within the exact window, i.e. “was that headache I had 6 or 8 days ago?”

• Boundary effects: events just outside the window may still influence the answer.   

5.    Emotional/cognitive interference

• Pain can carry emotional weight plus anxiety, frustration and avoidance.

• This may bias recall or encourage under-reporting.

6.   Cultural and/or linguistic variation

• In some languages or cultures, “pain” as a concept may overlap with “soreness”, “ache” and “discomfort”.

• Translation issues can shift the cognitive burden: is the term in the target translation broader or narrower? In the translation process, has it gain nuances through cultural coating or lost something through cultural stripping?

  
  

CBS Breakdown Table

And the CBS Visual Map for this item:

What we learn from this CBS analysis is that even a question that looks deceptively simple requires the patient to juggle multiple concepts simultaneously. To answer, they must hold in mind the timeframe (“in the past week”) and the concept of pain, which itself may be ambiguous: does a mild headache count? What about stiffness? Then, the act of recall across recent days and the mapping of that recollection to a binary Yes/No response.

In effect, a patient is carrying four or five separate chunks of information in working memory just to process and respond to this single, simple item. For a healthy respondent in ideal conditions, this may sit at the end of cognitive capacity; for a patient under stress, pain, fatigue or with limited health literacy, it may already exceed it. What looks like a straightforward Yes/No question is, in practice, a small exercise in mental gymnastics.

The next articles will look at other Clinical Outcome Assessment items that gradually increase in their complexity and, of course, the cognitive burden imposed on patients.

Thank you for reading,

Mark Gibson, Harrogate, United Kingdom

Nur Ferrante Morales, Ávila, Spain

September 2025