A theoretical framework for understanding self-report and observational measures of pain: a communications model

Use of pain threshold reports to satisfy social needs

OBJECTIVE

To examine the hypothesis that experimental threats to social belongingness, interacting with individual differences in attachment security, cause modification of pain threshold reports by individuals who report high pain thresholds at baseline.

METHODS

In each of three studies, baseline pain threshold and tolerance were assessed in response to a pain task (cold pressor pain in Studies 1 and 2, finger pressure pain in Study 3). Participants then completed a measure of attachment security and were randomly assigned to a social exclusion or control condition (exclusion from a computer game in Study 1, recalling past rejection experiences in Studies 2 and 3). The pain task was administered again to examine the effects on pain threshold and tolerance.

RESULTS

Those with high anxious attachment and high baseline pain thresholds reported higher postmanipulation pain thresholds in the exclusion conditions than in the control conditions. Those with low anxious attachment and high baseline pain thresholds reported lower postmanipulation pain thresholds in the exclusion conditions than in the control conditions. No differences were found for pain tolerance.

CONCLUSIONS

Across studies, results suggested that postmanipulation pain threshold reports of individuals with high baseline pain thresholds were particularly responsive to social exclusion. The form of the response was dependent on the level of anxious attachment. The present studies provide evidence that variance in pain threshold reports not accounted for by pain intensity may reflect the use of pain reports to satisfy social needs. This work also suggests that baseline measures of pain thresholds may, in interaction with psychological variables, have predictive power beyond serving as a control variable.

Contextual determinants of pain judgments

The objective of this study was to examine the influence of variations in contextual features of a physically demanding lifting task on the judgments of others' pain. Healthy undergraduates (n=98) were asked to estimate the pain experience of chronic pain patients who were filmed while lifting canisters at different distances from their body. Of interest was whether contextual information (i.e., lifting posture) contributed to pain estimates beyond the variance accounted for by pain behavior. Results indicated that the judgments of others' pain varied significantly as a function of the contextual features of the pain-eliciting task; observers estimated significantly more pain when watching patients lifting canisters positioned further away from the body than canisters closest from the body. Canister position contributed significant unique variance to the prediction of pain estimates even after controlling for observers' use of pain behavior as a basis of pain estimates. Correlational analyses revealed that greater use of the contextual features when judging others' pain was related to a lower discrepancy (higher accuracy) between estimated and self-reported pain ratings. Results also indicated that observers' level of catastrophizing was associated with more accurate pain estimates. The results of a regression analysis further showed that observers' level of catastrophizing contributed to the prediction of the accuracy of pain estimates over and above the variance accounted for by the utilisation of contextual features. Discussion addresses the processes that might underlie the utilisation of contextual features of a pain-eliciting task when estimating others' pain.

The FLACC behavioral scale for procedural pain assessment in children aged 5-16 years

OBJECTIVES

To evaluate the concurrent and construct validity and the interrater reliability of the Face, Legs, Activity, Cry and Consolability (FLACC) scale during procedural pain in children aged 5-16 years.

BACKGROUND

Self-reporting of pain is considered to be the primary source of information on pain intensity for older children but a validated observational tool will provide augment information to self-reports during painful procedures.

METHODS

Eighty children scheduled for peripheral venous cannulation or percutaneous puncture of a venous port were included. In 40 cases two nurses simultaneously and independently assessed pain by using the FLACC scale and in 40 cases one of these nurses assessed the child. All children scored the intensity of pain by using the Coloured Analogue Scale (CAS) and distress by the Facial Affective Scale (FAS).

RESULTS

Concurrent validity was supported by the correlation between FLACC scores and the children's self-reported CAS scores during the procedure (r = 0.59, P < 0.05). A weaker correlation was found between the FLACC scores and children's self-reported FAS (r = 0.35, P < 0.05). Construct validity was demonstrated by the increase in median FLACC score to 1 during the procedure compared with 0 before and after the procedure (P < 0.001). Interrater reliability during the procedure was supported by adequate kappa statistics for all items and for the total FLACC scores (kappa = 0.85, P < 0.001).

CONCLUSIONS

The findings of this study support the use of FLACC as a valid and reliable tool for assessing procedural pain in children aged 5-16 years.

Toward a biopsychomotor conceptualization of pain: implications for research and intervention

OBJECTIVES

Nearly 400 years ago, René Descartes proposed a model of pain perception that characterized pain as a purely physical phenomenon, devoid of psychologic influence. The characterization of pain as an exclusively sensory (or experiential) phenomenon continues to dominate current conceptualizations of pain.

METHODS

This paper advances the view that the exclusive focus on pain sensation or experience as the essential feature of the pain system has given rise to conceptual frameworks that are incomplete and flawed. It is argued that individuals with pain differ from individuals without pain not only in how they "feel" but they differ in how they "behave."

RESULTS

Arguments are put forward advocating for a biopsychomotor conceptualization of pain where pain behaviors are construed as integral components of the pain system. The biopsychomotor model proposes that at least 3 partially independent behavioral subsystems are integral components of pain. These include communicative pain behaviors, protective pain behaviors, and social response behaviors. Evidence is reviewed suggesting that different dimensions of pain behavior are functionally distinct, and questions are raised about the nature of motor programs responsible for the elicitation and maintenance of different forms of pain behavior.

DISCUSSION

Clinical and theoretical implications of a biopsychomotor conceptualization of pain are discussed.

Advances in understanding the mechanisms and management of persistent pain in older adults

Older adults with persistent pain are not simply a chronologically older version of younger pain patients. Pain-related disability in older adults may be driven by pain 'homeostenosis', that is, diminished ability to effectively respond to the stress of persistent pain. Some of the comorbidities of ageing that can contribute to pain homeostenosis include cognitive and physical impairments, increased sensitivity to suprathreshold pain stimuli, medical and psychological comorbidities, altered pharmacokinetics and pharmacodynamics, and social isolation. A key distinction between older and younger individuals with persistent pain is the normal and pathological ageing-associated brain changes. These may alter the expression and experience of pain with impaired descending inhibition and dysfunction of pain gating mechanisms. Cognizance of these brain changes is needed to guide appropriate evaluation and treatment approaches. This paper reviews data that support these ageing-associated phenomena. Specifically, we discuss age-related changes in the brain (both normal and pathological) and in pain physiology; changes in experience and expression of pain that occur with dementia and contribute to pain homeostenosis; and unique aspects of age and pain-associated psychological function and their contribution to disability. We also present data demonstrating changes in brain morphology and neuropsychological performance that accompany persistent non-malignant pain in older adults and the treatment implications of these brain changes. Finally, preliminary data are presented on the efficacy of mindfulness meditation, a treatment that has been examined explicitly in older adults and targets optimizing brain function and descending inhibition.

Pain behavior in rheumatoid arthritis patients: identification of pain behavior subgroups

This study used Ward's minimum variance hierarchical cluster analysis to identify homogeneous subgroups of rheumatoid arthritis patients suffering from chronic pain who exhibited similar pain behavior patterns during a videotaped behavior sample. Ninety-two rheumatoid arthritis patients were divided into two samples. Six motor pain behaviors were examined: guarding, bracing, active rubbing, rigidity, grimacing, and sighing. The cluster analysis procedure identified four similar subgroups in Samples 1 and 2. The first subgroup exhibited low levels of all pain behaviors. The second subgroup exhibited a high level of guarding and low levels of other pain behaviors. The third subgroup exhibited high levels of guarding and rigidity and low levels of other pain behaviors. The fourth subgroup exhibited high levels of guarding and active rubbing and low levels of other pain behaviors. Sample 1 contained a fifth subgroup that exhibited a high level of active rubbing and low levels of other pain measures. The results of this study suggest that there are homogeneous subgroups within rheumatoid arthritis patient populations who differ in the motor pain behaviors they exhibit.

Impact of age on the facial expression of pain

OBJECTIVE

Old age has traditionally been viewed as being associated with a decline in emotional expressivity. Interestingly, empirical evidence based on analyses of facial expressions contradicts this traditionally view and points to absence of (or only very slight) age-related changes in emotional expressivity. However, this research on emotional expressivity in older persons has neglected one important emotionally colored state-expression of pain. In order to close this gap, we aimed to investigate the influence of age on the facial expression of pain.

METHODS

Forty young (mean age, 24.1 years) and 61 elderly (mean age, 72.3 years) subjects were investigated for their facial (Facial Action Coding System) and subjective responses to noxious mechanical and electrical stimuli of various intensities.

RESULTS

Young and elderly subjects did not differ with respect to the frequency of facial responses during noxious mechanical and electrical stimulations. Moreover, age had no significant impact on the pain specificity of these facial responses. Furthermore, we found no significant age differences in self-report ratings of pressure and electrical pain, thus indicating that both age groups experienced comparable amounts of pain intensities.

CONCLUSION

These findings suggest that the facial expression of pain, like facial expressions of other affective states, remains unchanged in older persons. Consequently, elderly individuals seem to communicate pain through their facial expression as validly as younger individuals do.

The effects of parental presence upon the facial expression of pain: the moderating role of child pain catastrophizing

This experiment investigated the effects of child catastrophic thinking and parental presence on the facial expressions of children when experiencing pain. School children experienced pressure pain in either one of two conditions: (1) when observed by a parent (n=53 children and their parent), or (2) when observed by an adult stranger (n=31 children). Analyses revealed that children showed more facial pain expression in the presence of their parent than in the presence of the stranger. This effect was, however, only found for children with infrequent catastrophic thoughts about pain. Children who have frequent catastrophic thoughts expressed high pain regardless of who they believed was observing them. Results are discussed in terms of the social consequences of pain catastrophizing, and the variables contributing to the expression or suppression of pain display in children and its impact upon others.

Pain perception of children undergoing nasendoscopy for investigation of voice and resonance disorders

The primary objective of this descriptive and correlational study was to determine the level of pain and discomfort perceived by children undergoing nasendoscopy for investigation of voice and resonance disorders. The secondary objective was to explore whether gender, age, previous experience of painful or distressing medical procedures, and previous experience of nasendoscopy influenced the perception of pain during nasendoscopy. Twenty-three children self-reported the degree of pain perceived during nasendoscopy using the Wong-Baker Faces Pain Rating Scale. Parents also used this scale to rate their child's perceived pain. Otolaryngologists and speech pathologists rated the intensity and frequency of observed pain-related behaviors using the Child-Adult Medical Procedure Interaction Scale-Revised and the Procedure Behavior Checklist. Children perceived the procedure, on average, to be moderately painful, as did their parents. Only two children reported perceiving no pain during the procedure. The most frequently observed pain-related behaviors were muscle tension (86.96%), physical resistance (69.57%), requiring physical restraint (60.87%), crying (43.48%), and expressions of verbal pain (39.13%). No significant correlations were found between self-reported pain or observed pain and the variables of age, gender, previous experience of nasendoscopy, and previous experience of painful or distressing medical procedures, although children aged 4-7 years reported significantly more pain than children aged 8-18 years. Most children perceive nasendoscopy to be painful to some degree. This perceived pain occurred in conjunction with several observable pain-related behaviors that have the potential to interfere with the success of the procedure.

Doloplus-2, a valid tool for behavioural pain assessment?

BACKGROUND

The Doloplus-2 is used for behavioural pain assessment in cognitively impaired patients. Little data exists on the psychometric properties of the Doloplus-2. Our objectives were to test the criterion validity and inter-rater reliability of the Doloplus-2, and to explore a design for validations of behavioural pain assessment tools.

METHODS

Fifty-one nursing home patients and 22 patients admitted to a geriatric hospital ward were included. All were cognitively impaired and unable to self-report pain. Each patient was examined by an expert in pain evaluation and treatment, who rated the pain on a numerical rating scale. The ratings were based on information from the medical record, reports from nurses and patients (if possible) about pain during the past 24 hours, and a clinical examination. These ratings were used as pain criterion. The Doloplus-2 was administered by the attending nurse. Regression analyses were used to estimate the ability of the Doloplus-2 to explain the expert's ratings. The inter-rater reliability of the Doloplus-2 was evaluated in 16 patients by comparing the ratings of two nurses administrating the Doloplus-2.

RESULTS

There was no association between the Doloplus-2 and the expert's pain ratings (R2 = 0.02). There was an association (R2 = 0.54) between the expert's ratings and the Doloplus-2 scores in a subgroup of 16 patients assessed by a geriatric expert nurse (the most experienced Doloplus-2 administrator). The inter-rater reliability between the Doloplus-2 administrators assessed by the intra-class coefficient was 0.77. The pain expert's ratings were compared with ratings of two independent geriatricians in a sub sample of 15, and were found satisfactory (intra-class correlation 0.74).

CONCLUSION

It was challenging to conduct such a study in patients with cognitive impairment and the study has several limitations. The results do not support the validity of the Doloplus-2 in its present version and they indicate that it demands specific administration skills.

Computerized anesthesia delivery system vs. traditional syringe: comparing pain and pain-related behavior in children

The aim of this study was to compare the behavioral reaction of children who receive local anesthesia with a traditional syringe with the behavioral reaction of children who receive local anesthesia with a computerized device (Wand) and to differentiate between the reactions of highly anxious children with those displaying low anxiety. One hundred and twenty-five children aged 4-11 yr were randomly allocated to receive local anesthesia with the Wand or a traditional injection. Parents completed the Dental Subscale of the Children's Fear Survey Schedule (CFSS-DS). Two independent observers scored videotapes of the anesthesia in 15-s intervals. The occurrence of muscle tension, crying, verbal protest, movement, and resistance was registered and a score was given on the Venham distress scale. The mean injection time with the Wand was four times as long as with the traditional syringe. During the first 15 s of the injection, low-anxious children receiving local anesthesia with the Wand displayed less muscle tension, less verbal protest and less movement than children receiving local anesthesia with the traditional syringe. Within the high-anxious group no differences were found. It was concluded that low-anxious children seem to benefit from the use of the Wand instead of the traditional syringe in receiving local anesthesia.

Expressive dimensions of pain catastrophizing: a comparative analysis of school children and children with clinical pain

We investigated the role of the child's pain catastrophizing in explaining (1) children's self-reported tendency to verbally share their pain experience with others and (2) different dimensions of pain expression, as described by the mother and the father, including non-verbal and verbal communicative pain behaviour and protective pain behaviour. Participants were school children, children with chronic or recurrent pain, and their parents. The results showed that: (1) Pain catastrophizing was associated with children's greater self-acknowledged tendency to verbally share their pain experience with others. (2) Mothers and fathers perceived highly catastrophizing children to be more communicative about their pain. (3) The role of pain catastrophizing in the child's verbal sharing of pain experiences and in explaining expressive behaviour as rated by parents did not differ between the school children and children with recurrent and chronic pain. (4) Nevertheless, findings indicated marked differences between school children and the clinical sample. Children of the clinical sample experienced more severe pain, more pain catastrophizing, more protective pain behaviour, but less verbal communications about their pain. These results further corroborate the position that catastrophic thoughts about pain have interpersonal consequences. Findings are discussed in terms of the possible functions and effects upon others of pain catastrophizing and associated categories of pain behaviour.

An Interdisciplinary Expert Consensus Statement on Assessment of Pain in Older Persons

This paper represents an expert-based consensus statement on pain assessment among older adults. It is intended to provide recommendations that will be useful for both researchers and clinicians. Contributors were identified based on literature prominence and with the aim of achieving a broad representation of disciplines. Recommendations are provided regarding the physical examination and the assessment of pain using self-report and observational methods (suitable for seniors with dementia). In addition, recommendations are provided regarding the assessment of the physical and emotional functioning of older adults experiencing pain. The literature underlying the consensus recommendations is reviewed. Multiple revisions led to final reviews of 2 complete drafts before consensus was reached.

The influence of communication goals and physical demands on different dimensions of pain behavior

The purpose of the present research was to examine the influence of communication goals and physical demands on the expression of communicative (e.g., facial grimaces) and protective (e.g., guarding) pain behaviors. Participants with musculoskeletal conditions (N=50) were asked to lift a series of weights under two communication goal conditions. In one condition, participants were asked to estimate the weight of the object they lifted. In a second condition, participants were asked to rate their pain while lifting the same objects. The display of communicative pain behaviors varied as a function of the communication goal manipulation; participants displayed more communicative pain behavior when asked to rate their pain while lifting objects than when they estimated the weight of the object. Protective pain behaviors varied with the physical demands of the task, but not as a function of the communication goals manipulation. Pain ratings and self-reported disability were significantly correlated with protective pain behaviors but not with communicative pain behaviors. The results of this study support the functional distinctiveness of different forms of pain behavior. Findings are discussed in terms of evolutionary and learning theory models of pain behavior. Clinical implications of the findings are addressed.

The Burden of Pain of Inpatients Undergoing Radiotherapy – Discrepancies in the Ratings of Physicians and Nurses

BACKGROUND

The aim of this study was to rate the burden of pain of cancer patients receiving radiotherapy from the point of view of the patients themselves as well as the physicians and nurses caring for the patient, and to examine possible differences in the ratings.

PATIENTS AND METHODS

68 cancer patients received a pain questionnaire about pain intensity and subjective well-being. At the same time, physicians and nurses answered 7 pain-related questions about each patient.

RESULTS

34% of the patients reported strong or very strong pain in the past week, 8% even unbearable pain. 66% felt psychologically distressed, 70% developed anxiety because of pain. 74% believed that pain is an essential part of the disease. Nurses and physicians often underestimate patients' burden of pain. Nevertheless, the rating of the nurses is more accurate than that of the physicians.

CONCLUSION

Physicians and nurses often underestimate pain intensity. It seems that several patients are unable or unwilling to express their pain or that therapists lack adequate methods of pain assessment. To optimize pain treatment, communication between patients, physicians and nurses needs to be improved.

Catastrophic thinking and heightened perception of pain in others

Past research has shown that pain catastrophizing contributes to heightened pain experience. The hypothesis advanced in this study was that individuals who score high on measures of pain catastrophizing would also perceive more intense pain in others. The study also examined the role of pain behaviour as a determinant of the relation between catastrophizing and estimates of others' pain. To test the hypothesis, 60 undergraduates were asked to view videotapes of individuals taking part in a cold pressor procedure. Each individual in the videotapes was shown three times over the course of a 1min immersion such that the same individual was observed experiencing different levels of pain. Correlational analyses revealed a significant positive correlation between levels of pain catastrophizing and inferred pain intensity, r=.31, p<.01. Follow-up analyses indicated that catastrophizing was associated with a heightened propensity to rely on pain behaviour as a basis for drawing inferences about others' pain experience. Catastrophizing was associated with more accurate pain inferences on only one of three indices of inferential accuracy. The pattern of findings suggests that increasing reliance on pain behaviour as a means of inferring others' pain will not necessarily yield more accurate estimates. Discussion addresses the processes that might underlie the propensity to attend more to others' pain behaviour, and the clinical and interpersonal consequences of perceiving more pain in others.

The use of a self-reported pain measure, a nurse-reported pain measure and the PAINAD in nursing home residents with moderate and severe dementia: a validation study

OBJECTIVES

To assess the construct validity of three measures of pain and to determine a categorical version of the Pain Assessment in Advanced Dementia (PAINAD) scale.

DESIGN

Validation study determining the concurrent validity of a self-reported pain score (SRPS), a nurse-reported pain score (NRPS) and the PAINAD; the divergent validity of the three pain measures with the Abbreviated Mental Test (AMT) and the Cornell Scale for Depression in Dementia (CSDD).

SETTING AND SUBJECTS

eighty-eight nursing home residents with moderate and severe dementia.

METHODS

Residents were asked to rate the severity of their pain in the previous week on a verbal descriptor scale (VDS). Nurses rated the resident's pain on a VDS, scored the PAINAD scale and the CSDD scale. Research assistants administered the AMT.

RESULTS

The PAINAD correlated with the NRPS (Kendall's tau [tau] = 0.842); both scales correlated poorly with the SRPS (tau = 0.304 for both correlations). The PAINAD was significantly different for each level of the NRPS. On the SRPS, the PAINAD for the group with moderate+ pain was significantly different from the groups with mild pain and no pain. There was a difference between the SRPS and the NRPS when residents were depressed, but no difference when they were not. Our categorical version of the PAINAD showed good agreement with the NRPS.

CONCLUSION

The NRPS and the PAINAD measure pain differently from the SRPS, especially in the presence of depression. Our categorical version of the PAINAD shows good agreement with the NRPS.

The relation between catastrophizing and the communication of pain experience

The Communal Coping Model of pain catastrophizing proposes that pain catastrophizers enact pain behaviors in order to solicit support or empathy from their social environment. By this account, pain catastrophizers might be expected to engage in behavior aimed at maximizing the probability that their pain will be perceived by others in their social environment. To test this prediction, 40 undergraduates were videotaped during a cold pressor procedure. A separate sample of 20 (10 men, 10 women) undergraduates were asked to view the video sequences and infer the pain ratings of the cold pressor participants. Correlational analyses revealed that higher levels of pain catastrophizing of the cold pressor participants were associated with observer inferences of more intense pain, r=.39, p<.01. The relation between cold pressor participants' level of pain catastrophizing and observer inferences of pain intensity was mediated by the cold pressor participants' pain behavior. Although pain catastrophizing was associated with observers' inferences of more intense pain, cold pressor participants' level of pain catastrophizing was not associated with observers' accuracy in inferring self-reported pain. Implications of the findings for theory and clinical practice are addressed.

Supporting patients who have intellectual disabilities: a survey investigating staff training needs

AIMS

This article reports on a small exploratory survey aimed at establishing the perceived training needs of palliative care staff related to supporting people with intellectual disabilities.

METHODS

Questionnaires were collected from a sample of 46 palliative care staff. Respondents were asked to describe 'worrying issues' about supporting a person with intellectual disabilities. Answers were analysed using content analysis.

RESULTS

Most respondents (37, 80%) highlighted communication as a concern. Other major issues included assessment and symptom control, patient comprehension, empowerment and ethical issues/consent.

DISCUSSION

Communication and symptom assessment can be challenging, particularly in people with limited verbal communication skills. Palliative care staff need to be aware of the range of communication methods used by people with intellectual disabilities.

CONCLUSION

There is a lack of information and training materials around intellectual disabilities for palliative care staff. This needs to be addressed. More work is needed to develop appropriate training in this area.

Viewing facial expressions of pain engages cortical areas involved in the direct experience of pain

Recent neuroimaging and neuropsychological work has begun to shed light on how the brain responds to the viewing of facial expressions of emotion. However, one important category of facial expression that has not been studied on this level is the facial expression of pain. We investigated the neural response to pain expressions by performing functional magnetic resonance imaging (fMRI) as subjects viewed short video sequences showing faces expressing either moderate pain or, for comparison, no pain. In alternate blocks, the same subjects received both painful and non-painful thermal stimulation. Facial expressions of pain were found to engage cortical areas also engaged by the first-hand experience of pain, including anterior cingulate cortex and insula. The reported findings corroborate other work in which the neural response to witnessed pain has been examined from other perspectives. In addition, they lend support to the idea that common neural substrates are involved in representing one's own and others' affective states.

Cues for the identification of pain in nursing home residents

The aim of this section of a larger study was to identify the range of cues from which pain was inferred for a sample of residents with various levels of cognitive impairment in 15 UK nursing homes. Sixty-five nursing home staff and 36 informal carers of the 113 residents were interviewed. There was extensive use of body movements, facial expressions, and verbal and vocal cues and a considerable degree of interpretation of cues was used. There was little difference between the types of cue used by formal and informal carers, although informal carers tended to identify more of all types. There were differences in cues identified according to level of cognitive impairment, in particular, the interpretation of body movements. A simple model of the interaction between cognitive deficit, cue type and level of cue interpretation was proposed.

A Conceptual Model of Pain Assessment for Noncommunicative Persons With Dementia

PURPOSE

Our objectives are to present a conceptual model of the pain assessment process in persons with dementia and discuss methods for validating our model within this population.

DESIGN AND METHODS

This conceptual work is based on an integrative review and current pain theory, pain assessment research in demented and nondemented populations, and research on the science of self-report.

RESULTS

We present a multidimensional model of pain assessment that emphasizes the role of the external rater. Our model posits that a nociceptive stimulus leads to pain sensation, followed by pain perception, followed by the exhibition of external signs of pain by the patient, followed by an external rater's observation and interpretation of those external signs. Further, the model specifies the effects of nociceptive stimulus factors on pain sensation; patient-specific factors on pain perception; method-specific factors on external sign observation; and rater-specific factors on external sign interpretation.

IMPLICATIONS

Pain assessment in persons with dementia must go beyond a unidimensional model of pain assessment. This multidimensional model also directly addresses the challenges of using external ratings to assess pain in persons with dementia. Finally, we present clinical recommendations for applying the model to pain assessment endeavors and research recommendations for evaluating models of pain in this population.

Detecting Deception in Facial Expressions of Pain

Clinicians tend to assign greater weight to nonverbal expression than to patient self-report when judging the location and severity of pain. However, patients can be successful at dissimulating facial expressions of pain, as posed expressions resemble genuine expressions in the frequency and intensity of pain-related facial actions. The present research examined individual differences in the ability to discriminate genuine and deceptive facial pain displays and whether different models of training in cues to deception would improve detection skills. Judges (60 male, 60 female) were randomly assigned to 1 of 4 experimental groups: 1) control; 2) corrective feedback; 3) deception training; and 4) deception training plus feedback. Judges were shown 4 videotaped facial expressions for each chronic pain patient: neutral expressions, genuine pain instigated by physiotherapy range of motion assessment, masked pain, and faked pain. For each condition, the participants rated pain intensity and unpleasantness, decided which category each of the 4 video clips represented, and described cues they used to arrive at decisions. There were significant individual differences in accuracy, with females more accurate than males, but accuracy was unrelated to past pain experience, empathy, or the number or type of facial cues used. Immediate corrective feedback led to significant improvements in participants' detection accuracy, whereas there was no support for the use of an information-based training program.

Gender differences in patient–spouse interactions: a sequential analysis of behavioral interactions in patients having osteoarthritic knee pain

Theory and research suggest that spousal responses to displays of pain behavior can vary markedly. To our knowledge, observational research on spousal responses to pain behavior has been carried out only in chronic low back pain patients, but not in other populations. In this study systematic observations were conducted of interactions occurring between 50 married osteoarthritis patients (25 male and 25 female) and their respective spouses. Observations were conducted as the patient and spouse performed three common household tasks: sweeping the floor, folding laundry, and carrying small, artificial logs from one side of the room to the other. Contrary to prior research on chronic low back pain this study found that in osteoarthritis patients spouse facilitative behavior preceded and followed patient pain behavior significantly more often than did spouse solicitous behavior. A gender difference in spousal responding to pain behavior also was observed in that wives were significantly more likely to show facilitative behavior preceding and following patient pain behavior than were husbands. The implications of these findings for future research and clinical interventions focused on patient-spouse interactions are discussed.

The problem of pain management among persons with dementia, personhood, and the ontology of relationships

While pain is common among seniors, it is not adequately treated or managed. In particular, pain in seniors with dementia is often undertreated and undermanaged. Although the undertreatment of pain among persons with cognitive impairments represents a serious ethical concern for pain clinicians, most writers in the area explain the undertreatment of pain by focusing on issues related to liability, fears of addiction to opioids, and erroneous beliefs that pain is a normal part of the ageing process. We argue that the philosophical notion of personhood must also be given careful attention when considering the problem of pain undermanagement. In this paper, we consider the undertreatment of pain among seniors with dementia, while focusing on the ontology of relationships and on existential philosophy. Moreover, we outline a series of recommendations to help minimize the probability of pain undertreatment in this population and to encourage considerations relating to personhood when treating people with dementia.

Comparison of subcutaneous infusion needles for transfusion-dependent thalassemia patients by the intrapersonal cross-over assessment model

Needle-induced trauma is one of the major contributing factors for poor compliance in patients with thalassaemia major on iron chelation therapy. A new generation of needles is currently available on the market, but their theoretical advantages have not been tested clinically. We performed a study to compare the pros and cons of the representative prototypes from each of the new (Thalaset needle) and old (butterfly scalp vein needle) generations of needles. Patients with thalassemia major who had been receiving subcutaneous iron chelation therapy for at least 2 years were recruited. Patients using butterfly needles were instructed to switch to the newer form of needle (Thalaset) for 2.5 months and then to change back to butterfly needles for another 2.5 months. Comparison was done by the intrapersonal cross-over model using three identical sets of questionnaires collected at the beginning of the study and after the use of Thalaset and butterfly needles, respectively. Fifty-four (22 females; 32 males) patients were included in the statistical analysis. The median age was 24.1 years (range = 7.6-47.2 years). Local reactions such as pain, itchiness, tenderness, and swelling were significantly different among the three evaluation periods and were all in favor of the Thalaset needle (all with P < 0.001), even after adjusting for the intention-to-treat calculation. The Thalaset needle is significantly better than the butterfly needle in reducing needle-related trauma. It induced fewer local skin reactions such as pain, itchiness, tenderness, and swelling. However, recommendations for its routine clinical use require further cost-effectiveness analysis.

Expression of Pain in Children With Autism

OBJECTIVES

Reduced pain sensitivity is widely reported to be a common feature of children with autism, yet this conclusion frequently has been based on anecdotal observations and questionable measures of pain. The aims of the study were to (1) characterize the behavioral response of children with autism experiencing a venepuncture using objective observational measures of pain and distress, (2) examine parents' assessments of pain behavior in children with and without autism, including comparison of the relationship of parental reports with behavioral measures, and (3) compare the behavioral reactions and parental assessments of children with autism with children without autism undergoing venepuncture.

METHODS

Pain reactions to the invasive procedure of venepuncture were videotaped, systematically described and compared in 21 children with autism (3-7 years old) and 22 nonimpaired children, the latter providing a chronological age and gender equivalent comparison group. Parents provided observer reports of pain, and facial activity was used as an objective behavioral measure of pain.

RESULTS

The children with autism displayed a significant facial pain reaction in response to the venepuncture procedure. There was a lack of concordance between parental reports of pain and observed pain responses for the children with autism. Behavioral responses of the children with autism were generally similar to the comparison group, except the substantial facial pain reactivity instigated by the venepuncture in the children with autism exceeded that displayed by the nonimpaired comparison children. Parent reports of pain severity did not differ between the autism and comparison groups. The degree of concordance between parental report and observed pain responses was consistently better for the comparison group.

DISCUSSION

The findings demonstrate that children with autism display a significant behavioral reaction in response to a painful stimulus, and these findings are in sharp contrast to the prevailing beliefs of pain insensitivity described in the literature to date. The findings also raise questions about the appropriateness of parental global report as an assessment tool for pain in children with autism.

Communicative dimensions of pain catastrophizing: social cueing effects on pain behaviour and coping

The study was designed to assess whether the social context of a pain experience impacted on the relation between catastrophizing and duration of pain behaviour. Based on a communal coping model, the prediction was that the presence of an observer during a pain procedure would differentially influence the display of pain behaviour in high and low catastrophizers. University undergraduates taking part in a cold pressor procedure were randomly assigned to one of two conditions: (1) participant alone (n=30), or (2) observer present (n=34). Analysis of video records revealed that high pain catastrophizers displayed communicative pain behaviours (e.g. facial displays, vocalizations) for a longer duration when an observer was present compared to high pain catastrophizers who were alone during the pain procedure. The duration of pain management behaviours (e.g. holding, rubbing) did not vary significantly as a function of catastrophizing. When the observer was present, high catastrophizers also reported using fewer cognitive coping strategies than low catastrophizers. The pattern of findings suggests that in the presence of an observer, high pain catastrophizers show a propensity to engage in strategies that more effectively communicate their pain, and are less likely to engage in strategies that might minimize pain. Theoretical implications of the findings are discussed.

Pain syndromes in children

This review discusses the recent literature on pain conditions in children that should be of interest to rheumatologists. The focus of the review is therefore on musculoskeletal pains in children, particularly chronic or recurrent musculoskeletal pain. Articles that have a broader focus on pain are discussed when these are likely to be of general interest to rheumatologists. Chronic or recurrent pain in childhood is common and can be caused by a wide variety of conditions, several of which are discussed here. The importance of being able to measure pain in children has been emphasized repeatedly in the recent literature. With increased understanding of how to evaluate pain in children has come the recognition that pain in children is multifactorial and that even when there are obvious "organic" causes of the pain (such as arthritis), psychosocial factors are critical in how pain is perceived, and they influence the extent to which pain leads to dysfunction. There is also increasing evidence that cognitive-behavioral therapies are effective in managing chronic pain in children. The frequency of back pain in children is increasingly recognized, and the role of children's work and play, carrying heavy backpacks, and sitting for long periods of time at computers in causing back pain is of interest. The studies reviewed here add to an increasingly rich and informative literature on musculoskeletal and other chronic pain in children, and they help emphasize the importance of proper evaluation and management of pain in children.

Self-reports of pain intensity and direct observations of pain behavior: when are they correlated?

Meta-analytic techniques were utilized to investigate the relationship between self-reports of pain intensity and direct observations of pain behavior. Estimation of the overall effect size from 29 studies and 85 effect sizes yielded a moderately positive association, z=0.26. High variability across studies permitted a random-effects moderator analysis that determined chronicity of pain, the timing of the pain assessment, the use of global measures of pain behavior, and pain site significantly moderate the relationship between self-reports of pain intensity and direct observations of pain behavior. These findings indicate that self-reports of pain intensity and direct observations of pain behavior are more likely to be significantly related to each other when the individual being studied has acute pain (z=0.35), when the self-report of pain intensity data are collected soon after the observation of pain behavior (z=0.40), when global composite measures are used to quantify pain behavior (z=0.37), and when the person being observed suffers from chronic low back pain (z=0.30). Other factors not found to be significant moderators include: extent of observer training, relevance of the pain-inducing task, and pain behavior observation measure used. The implications of the findings for the assessment of pain are discussed.

Using facial expressions to assess musculoskeletal pain in older persons

Past research examined measures of pain among seniors who were experiencing movement-related exacerbations of musculoskeletal pain and obtained clear support for the utility of the behavioural coding of pain-related body movements (e.g., bracing, guarding). Support for the utility of the Facial Action Coding System (FACS), which involves the objective coding of facial reactions, was not as strong. The findings concerning FACS could have been an artifact of the methodology that was used. Specifically, the duration of the facial reactions was not taken into account and the patients suffered from a variety of painful conditions. Thus, the physical activities involved in the study could have been painful for some patients but not for others. The present study corrected these methodological concerns by accounting for the duration of facial reactions and ensuring that all patients suffered from the same painful condition. Participants were 82 post-surgical (knee replacement) inpatients. Cognitive status was assessed using the Modified Mini Mental Status Examination. Under physiotherapist's supervision, the patients performed structured activities (i.e., reclining, standing, knee bends). Facial reactions were coded using FACS. Facial reactions varied as a function of the degree to which the various activities were strenuous. The results support the utility of FACS in the assessment of musculoskeletal pain among seniors undergoing rehabilitation following knee surgery.

Does graded activity increase activity? A case study of chronic fatigue syndrome

The reliance on self-report outcome measures in clinical trials of graded activity-oriented cognitive-behavior therapy in chronic fatigue syndrome (CFS) makes it difficult to draw definitive conclusions about actual behavioral change. The participant in this case study was a 52-year-old married male with CFS who was working full-time. Outcome measures included a step counter to objectively measure physical activity as well as a daily diary measure of exercise activity and in vivo ratings of perceived energy, fatigue, and affect. The following psychometric instruments were also used: the CFS Symptom Inventory, the SF-36, the Beck Depression Inventory, and the Beck Anxiety Inventory. The 26-session graded activity intervention involved gradual increases in physical activity. From baseline to treatment termination, the patient's self-reported increase in walk time from 0 to 155 min a week contrasted with a surprising 10.6% decrease in mean weekly step counts. The final follow-up assessment revealed a "much improved" global rating, substantial increases in patient-recorded walk time and weight lifting intensity, yet a relatively modest increment in weekly step counts. It appeared that improvement was associated with mood-enhancing, stress-reducing activities that were substituted for stress-exacerbating activities.