Use of the Faces Pain Scale by left and right hemispheric stroke patients

Assessment approaches for hemiplegic shoulder pain in people living with stroke - A scoping review

PURPOSE

Hemiplegic shoulder pain (HSP) is reported in up to 40% of people with stroke. Causes of HSP are often multifactorial. To inform appropriate treatment, reliable/valid assessments are critical. The aim of this scoping review was to collate assessment approaches used in studies where the primary outcome was HSP, and to identify how frequently each assessment approach was used.

METHODS

A systematic search, including studies from 2000-2023 was conducted of the MEDLINE, EMBASE, CINAHL, AMED, Biomed Central, and Cochrane Library databases, with four key terms used: "assess", "stroke", "pain" and "shoulder". All primary studies published in English language fulfilling the reviews inclusion criteria were included. Six reviewers extracted the data.

RESULTS

A total of 29 assessment methods for HSP were identified from 124 studies. The common assessments were: Visual Analogue Scale (n = 75, 60%), Passive Range of Movement (n = 65, 52%), Fugl-Meyer Assessment (n = 32, 26%), glenohumeral subluxation (n = 30, 24%) and Numerical Rating Scale (n = 27, 22%).

CONCLUSION

A wide range of assessment approaches was identified for HSP, and some are used more than others. A fully comprehensive assessment that considers different aspects of pain including severity and timing, functioning, and the psychological burden, is needed in this area of practice to be able to guide appropriate treatment.

Validation of general pain scores from multidomain assessment tools in stroke

Purpose

We describe how well general pain reported in multidomain assessment tools correlated with pain-specific assessment tools; associations between general pain, activities of daily living and independence after stroke.

Materials and methods

Analyses of individual participant data (IPD) from the Virtual International Stroke Trials Archive (VISTA) described correlation coefficients examining (i) direct comparisons of assessments from pain-specific and multidomain assessment tools that included pain, (ii) indirect comparisons of pain assessments with the Barthel Index (BI) and modified Rankin Scale (mRS), and (iii) whether pain identification could be enhanced by accounting for reported usual activities, self-care, mobility and anxiety/depression; factors associated with pain.

Results

European Quality of Life 3- and 5-Level (EQ-5D-3L and EQ-5D-5L), RAND 36 Item Health Survey 1.0 (SF-36) or the 0-10 Numeric Pain Rating Scale (NPRS) were available from 10/94 studies (IPD = 10,002). The 0-10 NPRS was the only available pain-specific assessment tool and was a reference for comparison with other tools. Pearson correlation coefficients between the 0-10 NPRS and (A) the EQ-5D-3L and (B) EQ5D-5 L were r = 0.572 (n = 436) and r = 0.305 (n = 1,134), respectively. mRS was better aligned with pain by EQ-5D-3L (n = 8,966; r = 0.340) than by SF-36 (n = 623; r = 0.318). BI aligned better with pain by SF-36 (n = 623; r = -0.320). Creating a composite score using the EQ-5D 3 L and 5 L comprising pain, mobility, usual-activities, self-care and anxiety/depression did not improve correlation with the 0-10 NPRS.

Discussion

The EQ-5D-3L pain domain aligned better than the EQ-5D-5L with the 0-10 NPRS and may inform general pain description where resources and assessment burden hinder use of additional, pain-specific assessments.

Computer-controlled Intraligamentary local anaesthesia in extraction of mandibular primary molars: randomised controlled clinical trial

BACKGROUND

Local anesthesia (LA) poses a threat in children more than the treatment process itself, so pediatric dentists are always demanding less painful techniques. Computer-controlled Intraligamentary anaesthesia (CC-ILA) is designed to reduce injection pain and side effects of conventional techniques. The present study aims to assess the pain experience using Computer-controlled Intraligamentary anaesthesia (CC-ILA) during injection and its effectiveness in controlling pain during extraction of mandibular primary molars in pediatric patients.

METHODS

This randomized controlled clinical trial includes 50 healthy cooperative children, aged 5-7 years with mandibular primary molars indicated for extraction. They were randomly allocated to two groups according to LA technique: test group received CC-ILA and control group received Inferior alveolar nerve block (IANB). Pain was measured during injection and extraction: physiologically using Heart rate (HR), subjectively using Face-Pain-Scale (FPS), and objectively using Sound-Eye-Motor scale (SEM). Patients were recalled after 24-h to record lip-biting events. Data was collected and statistically analysed.

RESULTS

A total of 50 children (29 females and 21 males) with mean age 6.10 ± 0.76 participated in the study. There were significantly lower scores in the heart rate in the CC-ILA group during injection (p = 0.04), but no significant difference was recorded between the two groups during extraction (p = 0.17). The SEM and FPS showed significant lower scores in the CC-ILA group during injection (p < 0.0001, p < 0.0001) and extraction (p < 0.0001, p = 0.01) respectively. No children in CC-ILA group reported lip-biting after 24-h compared to 32% in IANB (p < 0.0001).

CONCLUSION

CC-ILA provides significantly less painful injections than conventional techniques and has proved to be as effective as IANB during extraction of mandibular primary molars. An important advantage of this technique was the complete absence of any lip/cheek biting events. Trial registration The study was prospectively registered in ClinicalTrials.gov with the identifier: NCT04739735 on 26th of January 2021, https://clinicaltrials.gov/ct2/show/NCT04739735 .

Scales in pain control in patients post-ictus with aphasia: A comparative study

The assessment of pain and its control is a key point in the care received by patients during their hospital stay, with the nurse being an essential figure, especially in stroke patients with secondary aphasia, which makes it difficult to verbalise pain. The aim of this study was to find out whether the use of a specific pain control scale and the more precise administration of analgesic treatment has a positive impact on indicators such as average stay length, dependence degree and agitation episodes. By means of a longitudinal randomised group design study, within a two-week period, we compared the management and recording of pain using a Pain Indicator Behaviour Scale (N = 41) and a Verbal Numerical Scale or Visual Analogue Scale (N = 39), in patients with language impairment after suffering a stroke who were admitted to the Stroke Unit of the Neurology Department of the Hospital Clínic de Barcelona. The results obtained, despite being in line with what was conjectured, are not statistically significant. However, some statistical models have shown the usefulness of some factors (level of training, nurses experience, previous episodes of stroke, among others) in the prediction of a better evolution, with a predictive capacity between 20-37%, which justifies the necessity of further studies and reinforces the role of the variables studied in the care of this type of patient.

Finding "Zen" in Aphasia: The Benefits of Yoga as Described by Key Stakeholders

PURPOSE

Recently, the literature has witnessed a surging interest regarding the use of mind-body approaches with people who have aphasia, generating a plethora of possible outcome measures. During this same time, a core outcome set for aphasia has been recommended. The purpose of this clinical focus article is to give our survivor, co-survivor, and clinician stakeholder coauthors a platform to share their personal narrative regarding their yoga journey, with the goal of identifying primary outcome domains central to capturing the impact of yoga on the recovery process for people with poststroke aphasia. Ultimately, we hope this clinical focus article helps clinicians understand how yoga might benefit their patients and draws attention to potential outcome measures, while also highlighting the important fact that traditional aphasia assessments do not capture the improvements stakeholders pinpoint as crucial to the essence of mind-body interventions.

METHOD

This clinical focus article summarizes the case reports of Terri's and Chase's poststroke yoga journeys using the power of personal narrative and an adapted photovoice method. Additional stakeholders share in this storytelling process, using a variety of narrative tools. As this story is unveiled, several patient-identified outcome domains are highlighted as essential to document the impact of yoga on survivors.

RESULTS

Terri's and Chase's yoga journeys revealed the multifaceted impact of yoga on five domains: (a) feelings of wholeness and "zen," (b) increased attentional capacity for language tasks, (c) increased verbal fluency, (d) decreased pain, and (e) relationship mutuality.

CONCLUSION

Team Yoga realized that the practice of yoga-whether as a stand-alone practice or integrated into therapy sessions-fosters feelings of wholeness or "zen," which likely correlates with decreased pain with a simultaneous increase in resilience and flexibility of coping strategies to manage the host of chronic poststroke challenges. Supplemental Material https://doi.org/10.23641/asha.17003464.

Speech Entrainment for Aphasia Recovery (SpARc) phase II trial design

Background

and purpose: Speech entrainment therapy (SET) is a computerized therapeutic approach that involves mimicking an audiovisual speech model to improve speech production. In a pilot study using SET for treatment of post-stroke non-fluent aphasia, significant gains were achieved in verbs per minute (VPM) during discourse using untrained items 1 and 6 weeks after treatment, suggesting that SET may yield meaningful improvements in fluent spontaneous speech for individuals with non-fluent aphasia.

Methods

The Speech Entrainment for Aphasia Recovery (SpARc) trial is a prospective, randomized, assessor-blinded, multicenter phase II clinical trial studying persons with chronic post-stroke non-fluent aphasia. Participants will be randomized to 3 weeks, 4.5 weeks, or 6 weeks of SET delivered via telehealth or a no SET control condition for 6 weeks. 80 adults (ages 21–81) with history of left hemisphere ischemic or hemorrhagic stroke with residual chronic (>6 months post stroke) non-fluent aphasia diagnosed by the Western Aphasia Battery-Revised (WAB-R) will be randomized (1:1:1:1) over 4 years. The trial will be conducted at the clinical research facilities at three sites: the Medical University of South Carolina, the University of South Carolina, and the University of Utah.

Conclusions

This paper details the trial design of the SpARc trial, which aims to determine the dose of SET that will generate the highest effect size on speech fluency, VPM, sustained at 3 months post-treatment compared to a no SET control arm, for individuals with chronic post-stroke non-fluent aphasia to permit a future definitive trial to test the clinical utility of SET.

Psychometric Evaluation of the Revised Iowa Pain Thermometer-Czech for Patients with Stroke

BACKGROUND AND PURPOSE

Pain is a frequent yet underdiagnosed problem in patients with stroke due to stroke-related cognitive limitations that may hamper effective usage of pain tools. The Revised Iowa Pain Thermometer-Czech (IPT-R-CZ) is a linguistically validated translation of an English-language self-report pain instrument; however, the psychometric properties of the Czech version are unknown. This study aimed to psychometrically evaluate the IPT-R-CZ in cognitively intact and impaired Czech-speaking patients with stroke.

METHODS

Fifty-four patients rated their pain intensity using the IPT-R-CZ, the Faces Pain Scale-Revised, and the Numerical Rating Scale, ranking them in terms of usability.

RESULTS

Correlations among pain scores across the tools were very strong. The IPTR-CZ ranked first in terms of usability.

CONCLUSION

Convergent validity, test-retest reliability, and usability of the IPT-R-CZ in Czech-speaking cooperative patients with stroke were acceptable.

Predictors of death within 6 months of stroke onset: A model with Barthel index, platelet/lymphocyte ratio and serum albumin

AIMS

To develop and internally validate a nomogram to predict the risk of death within 6 months of onset of stroke in Chinese. Identifying risk factors with potentially direct effects on the nomogram will improve the quality of risk assessment and help nurses implement preventive measures based on patient-specific risk factors.

DESIGN

A retrospective study.

METHODS

We performed a least absolute shrinkage and selection operator (LASSO) regression modelling and multivariate logistic regression analysis to establish a prediction model of death risk in stroke patients within 6 months of onset. LASSO and time-dependent Cox regression models were further used to analyse the 6-month survival of stroke patients. Data were collected from 21 October 2013-6 May 2019.

RESULTS

The independent predictors of the nomogram were Barthel index (odds ratio (OR) = 0.980, 95% confidence interval (CI) = 0.961-0.998, p = .03), platelet/lymphocyte ratio (OR = 1.005, 95% CI = 1.000-1.010, p = .04) and serum albumin (OR = 0.854, 95% CI = 0.774-0.931, p < .01). This model showed good discrimination and consistency, and its discrimination evaluation C-statistic was 0.879 in the training set and 0.891 in the internal validation set. The DCA indicated that the nomogram had a higher overall net benefit over most of the threshold probability range. The time-dependent Cox regression model established the impact of the time effect of the age variable on survival time.

CONCLUSIONS

Our results identified three predictors of death within 6 months of stroke in Chinese. These predictors can be used as risk assessment indicators to help caregivers performing clinical nursing work, and in clinical practice, it is suggested that nurses should evaluate the self-care ability of stroke patients in detail. The constructed nomogram can help identify patients at high risk of death within 6 months, so that intervention can be performed as early as possible.

The EmojiGrid as a rating tool for the affective appraisal of touch

In this study we evaluate the convergent validity of a new graphical self-report tool (the EmojiGrid) for the affective appraisal of perceived touch events. The EmojiGrid is a square grid labeled with facial icons (emoji) showing different levels of valence and arousal. The EmojiGrid is language independent and efficient (a single click suffices to report both valence and arousal), making it a practical instrument for studies on affective appraisal. We previously showed that participants can intuitively and reliably report their affective appraisal (valence and arousal) of visual, auditory and olfactory stimuli using the EmojiGrid, even without additional (verbal) instructions. However, because touch events can be bidirectional and dynamic, these previous results cannot be generalized to the touch domain. In this study, participants reported their affective appraisal of video clips showing different interpersonal (social) and object-based touch events, using either the validated 9-point SAM (Self-Assessment Mannikin) scale or the EmojiGrid. The valence ratings obtained with the EmojiGrid and the SAM are in excellent agreement. The arousal ratings show good agreement for object-based touch and moderate agreement for social touch. For social touch and at more extreme levels of valence, the EmojiGrid appears more sensitive to arousal than the SAM. We conclude that the EmojiGrid can also serve as a valid and efficient graphical self-report instrument to measure human affective response to a wide range of tactile signals.

Perceived Sensitivity to Pain and Responsiveness to Non-noxious Sensation in Substance Use Disorder

OBJECTIVE

This comparative cross-sectional study aimed to characterize individuals with substance use disorder (SUD) in self-perception of pain sensitivity, experimental auditory aversiveness, and non-noxious sensory responsiveness, as well as examine the associations with SUD.

METHODS

Therapeutic community (TC) individuals with SUD (N = 63, male 88.9%) and healthy controls (N = 60, male 86.7%) completed the Pain Sensitivity Questionnaire (PSQ) and the Sensory Responsiveness Questionnaire-Intensity Scale (SRQ-IS), followed by a psychophysical auditory battery, the Battery of Averseness to Sounds (BAS)-Revised.

RESULTS

The SUD group scored higher on the PSQ (P < 0.0001), BAS-R aversiveness (P < 0.0001), BAS-R-unpleasantness (P < 0.0001), and on the aftersensation of auditory aversiveness (P < 0.0001) and unpleasantness (P < 0.000). Fifty-four percent of the SUD group vs 11.7% of the control group were identified as having sensory modulation dysfunction (SMD; P < 0.0001). Logistic regression modeling revealed that the SRQ-IS-Aversive score had a stronger relationship, indicating a 12.6-times odds ratio for SUD (P = 0.0002). Finally, a risk score calculated from a linear combination of the logistic regression model parameters is presented based on the PSQ and SRQ.

CONCLUSIONS

This is the first study to explore sensory and aversive domains using experimental and self-reporting in situ, revealing pain perception alteration that co-occurs with high prevalence of SMD, specifically of the over-responsive type. Findings may be significant in clinical practice for treating pain, and for expanding therapeutic modalities as part of broader rehabilitation in TC and beyond, to better meet personalized therapy.

Properties of Pain Assessment Tools for Use in People Living With Stroke: Systematic Review

Background: Pain is a common problem after stroke and is associated with poor outcomes. There is no consensus on the optimal method of pain assessment in stroke. A review of the properties of tools should allow an evidence based approach to assessment.

Objectives: We aimed to systematically review published data on pain assessment tools used in stroke, with particular focus on classical test properties of: validity, reliability, feasibility, responsiveness.

Methods: We searched multiple, cross-disciplinary databases for studies evaluating properties of pain assessment tools used in stroke. We assessed risk of bias using the Quality Assessment of Diagnostic Accuracy Studies tool. We used a modified harvest plot to visually represent psychometric properties across tests.

Results: The search yielded 12 relevant articles, describing 10 different tools (n = 1,106 participants). There was substantial heterogeneity and an overall high risk of bias. The most commonly assessed property was validity (eight studies) and responsiveness the least (one study). There were no studies with a neuropathic or headache focus. Included tools were either scales or questionnaires. The most commonly assessed tool was the Faces Pain Scale (FPS) (6 studies). The limited number of papers precluded meaningful meta-analysis at level of pain assessment tool or pain syndrome. Even where common data were available across papers, results were conflicting e.g., two papers described FPS as feasible and two described the scale as having feasibility issues.

Conclusion: Robust data on the properties of pain assessment tools for stroke are limited. Our review highlights specific areas where evidence is lacking and could guide further research to identify the best tool(s) for assessing post-stroke pain. Improving feasibility of assessment in stroke survivors should be a future research target.

Systematic Review Registration Number: PROSPERO CRD42019160679

Available online at: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019160679.

Effectiveness of dry needling for upper extremity spasticity, quality of life and function in subacute phase stroke patients

BACKGROUND

Stroke is the fourth leading cause of death in Europe, represents one of the most common causes of disability in adult patients, and involves considerable short- and long-term social and healthcare costs. The effectiveness of deep dry needling (DDN) on affected arm functionality was assessed throughout 8 weeks of treatment in patients with stroke in the subacute phase.

METHODS

Eighty patients were included in this two-group non-randomised study after a propensity score analysis was carried out. Both groups received standard physiotherapy treatment on the affected arm. The needling group also received six sessions of DDN during the 8-week period. Patients were evaluated before and after each session using the Fugl-Meyer upper extremity (FM UE) scale, the modified modified Ashworth scale (MMAS), the resistance to passive movement scale (REPAS) and a 10-point numeric pain rating scale (NPRS 10). The Brunnstrom recovery stage was recorded at the beginning and at the end of the study, and the EuroQoL quality of life survey was completed at the beginning of the study, after the first month of treatment and at the end of the study.

RESULTS

Patients treated with DDN showed a reduction in spasticity measured using the REPAS (p < 0.001) and the MMAS (p < 0.05). There was also an improvement in the Brunnstrom recovery stages (p < 0.05).

CONCLUSION

The addition of a specific DDN treatment to a standard physiotherapy treatment appeared to lead to a higher reduction in spasticity in the affected arm; however, it did not provide additional changes in functionality, pain and quality of life. Further studies with a randomised controlled trial design are required to confirm our findings.

Outcome measurement of hand function following mirror therapy for stroke rehabilitation: A systematic review

STUDY DESIGN

Systematic review.

INTRODUCTION

Mirror therapy is a treatment used to address hand function following a stroke. Measurement of outcomes using appropriate assessment tools is crucial; however, many assessment options exist.

PURPOSE OF THE STUDY

The purpose of this study is to systematically review outcome measures that are used to assess hand function following mirror therapy after stroke and, in addition, to identify the psychometric and descriptive properties of the included measures and through the linking process determine if the outcome measures are representative of the International Classification of Functioning, Disability and Health (ICF).

METHODS

Following a comprehensive literature search, outcome measures used in the included studies were linked to the ICF and analyzed based on descriptive information and psychometric properties.

RESULTS

Eleven studies met inclusion criteria and included 24 different assessment tools to measure hand or upper limb function. Most outcome measures used in the selected studies (63%) were rated by the evaluating therapist. Thirteen outcome measures (54%) linked to the ICF body function category and 10 measures (42%) linked to activities and participation. One outcome measure was linked to not defined, and all other ICF categories were not represented. A majority of outcome measures have been assessed for validity, reliability, and responsiveness, but responsiveness was the least investigated psychometric property.

DISCUSSION

Current studies on mirror therapy after stroke are not consistent in the assessment tools used to determine hand function. Understanding of study outcomes requires analysis of the assessment tools. The outcome measures used in the included studies are not representative of personal and environmental factors, but tools linking to body functions and activities and participations provide important information on functional outcome.

CONCLUSIONS

Integrating a combination of measures that are psychometrically sound and reflective of the ICF should be considered for assessment of hand function after mirror therapy after stroke.

Use of analgesics in acute stroke patients with inability to self-report pain: a retrospective cohort study

BACKGROUND

Pain is a common and burdensome complication in patients with acute stroke. We assessed the impact of impaired communication in stroke patients on pain assessment and treatment.

METHODS

We included 909 (507 male, mean age 71.8 years) patients admitted to our stroke unit from 01/2015 to 12/2015 in the analysis. Patients were assigned to four groups: able to communicate (AC), not able to communicate prior to index stroke (P-NAC), due to focal symptoms of index stroke (S-NAC), due to a reduced level of consciousness (C-NAC). Pain prevalence, documentation of pain and use of analgesics were evaluated. C-NAC patients were excluded from analyses regarding analgesic treatment due to relevant differences in patient characteristics.

RESULTS

746 patients (82.1%) were classified as AC, 25 (2.8%) as P-NAC, 90 (9.9%) as S-NAC and 48 (5.3%) as C-NAC. Pain was documented on the Numeric Rating Scale and in form of free text by nurses and physicians. Nurses documented pain more frequently than physicians (p < 0.001). Pain prevalence was 47.0% (n.s. between groups). The use of analgesic medication increased from 48.7% in the AC group, to 76.0% in the P-NAC group, and 77.8% in the S-NAC group (p < 0.001). Opioid use was significantly more frequent in NAC patients (p < 0.001). The response to the treatment was poorly documented with significantly lowest rates in S-NAC patients (p < 0.001).

CONCLUSIONS

Our study suggests that post-stroke pain in patients with inability to communicate is not attended enough, not systematically assessed and therefore not sufficiently treated.

The validity of pain intensity measures: what do the NRS, VAS, VRS, and FPS-R measure?

BACKGROUND AND AIMS

The Numerical Rating Scale (NRS), Visual Analogue Scale (VAS), Verbal Rating Scale (VRS), and Faces Pain Scale-Revised (FPS-R) are valid measures of pain intensity. However, ratings on these measures may be influenced by factors other than pain intensity. The purpose of this study was to evaluate the influence of non-pain intensity factors on the pain intensity scales.

METHODS

We administered measures of pain intensity (NRS, VAS, VRS, FPS-R), pain unpleasantness, catastrophizing, depressive symptoms, and pain interference to 101 individuals with chronic lower back or knee pain. Correlation analyses examined the associations among the pain intensity scales, and regression analyses evaluated the contributions of the non-pain intensity factors (depressive symptoms, and pain unpleasantness, catastrophizing, and interference) to the VAS, VRS, and FPS-R ratings, while controlling for NRS, age, and gender.

RESULTS

Although the NRS, VAS, VRS, FPR-S, scales were strongly associated with one another, supporting their validity as measures of pain intensity, regression analyses showed that the VRS also reflected pain interference, the FPS-R also reflected pain unpleasantness, and the VAS was not associated with any of the additional non-pain intensity factors when controlling for NRS, age, and gender.

CONCLUSIONS

The VAS appears to be most similar to the NRS and less influenced by non-pain intensity factors than the VRS or FPS-R. Although the VRS and FPS-R ratings both reflect pain intensity, they also contain additional information about pain interference and pain unpleasantness, respectively. These findings should be kept in mind when selecting pain measures and interpreting the results of research studies using these scales.

IMPLICATIONS

The influence of pain interference and pain unpleasantness on VRS and FPS-R, respectively should be kept in mind when selecting pain measures and interpreting the results of research studies using these scales.

The Silhouettes Fatigue Scale: comprehensibility and validity in older individuals

Purpose: Fatigue has been shown to be one of the key factors that interfere in the quality of life of elderly individuals. In order to understand its impact and evaluate the efficacy of treatments that target fatigue, researchers and clinicians need psychometrically sound and easy to use assessment instruments. The aim of this work was to address this need by evaluating the comprehensibility and validity of the Silhouettes Fatigue Scale (SFS) in a sample of older individuals.Methods: A total of 70 older individuals participated in the study. Participants were interviewed individually and asked to rate their level of fatigue during the week before the interview using the SFS and the FACIT-Fatigue Scale (to help evaluate convergent validity), and respond to the Pain Catastrophizing Scale (to help evaluate discriminant validity).Results: The results indicate that the SFS is understandable and that the scores have an adequate convergent validity and discriminant validity when used with older adults.Conclusions: The SFS is a valid measure of fatigue that can be used with older adults. It fills the need for a brief and easy to administer and score measure, which can be used in situations where assessment burden is a significant issue.Implications for rehabilitationFatigue is a significant problem among the elderly resulting in significant disability, and psychometrically sound and easy to use questionnaires are needed.The Silhouettes Fatigue Scale (SFS) is a new single-item self-report fatigue rating scale.Results show that the SFS is understandable, and that the scores have discriminant and convergent validity when used with older adults.As it does not use written items, it may be more easily understood by people who have basic or even no literacy level, thus making it easier to use for a wider audience.

Experimental pain assessment in patients with poststroke aphasia

OBJECTIVE

To evaluate an observational-behavioral pain tool among individuals with acute poststroke aphasia.

METHODS

We performed a randomized, double-blind, controlled study of experimental pain assessment among 36 adult patients with acute poststroke aphasia. Patients were administered 3 levels of mechanical pain, including placebo. The behavioral responses were video recorded and then evaluated by 3 neurology nurses using the Pain Assessment Checklist for Seniors With Limited Ability to Communicate (PACSLAC-II). Pain-specific facial action units were quantified with FaceReader version 6.1.

RESULTS

Median PACSLAC-II ratings for 0-, 2-, and 4.5-lb weight stimuli were 2 (0, 3), 1 (0, 3), and 2 (1, 5), respectively. Overall, differences were not detected (p = 0.06). Pairwise comparisons with the Wilcoxon method demonstrated significance in differentiating PACSLAC-II ratings of patients experiencing the 4.5-lb stimulus vs either the 2-lb weight (p = 0.03) or placebo (p = 0.05). Overall interrater reliability by the Cronbach α was strong at 0.87, 0.94, and 0.96 for weights of 0, 2, and 4.5 lb, respectively. Pain-specific facial activation and negative valence were observed similarly in placebo and experimental pain groups.

CONCLUSIONS

Among our cohort with acute poststroke aphasia, the PACSLAC-II was not able to overall differentiate patients experiencing experimental mechanical pain, although differences in those experiencing the strongest pain stimulus were significant. The detection of pain-specific facial activation and negative valence in the placebo group indicates that pain and distress are unmet needs among stroke patients who are unable to verbally communicate.

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential.

CONCLUSIONS

As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.).

Clinical feasibility of interactive motion-controlled games for stroke rehabilitation

BACKGROUND

Active gaming technologies, including the Nintendo Wii and Xbox Kinect, have become increasingly popular for use in stroke rehabilitation. However, these systems are not specifically designed for this purpose and have limitations. The aim of this study was to investigate the feasibility of using a suite of motion-controlled games in individuals with stroke undergoing rehabilitation.

METHODS

Four games, which utilised a depth-sensing camera (PrimeSense), were developed and tested. The games could be played in a seated or standing position. Three games were controlled by movement of the torso and one by upper limb movement. Phase 1 involved consecutive recruitment of 40 individuals with stroke who were able to sit unsupported. Participants were randomly assigned to trial one game during a single session. Sixteen individuals from Phase 1 were recruited to Phase 2. These participants were randomly assigned to an intervention or control group. Intervention participants performed an additional eight sessions over four weeks using all four game activities. Feasibility was assessed by examining recruitment, adherence, acceptability and safety in both phases of the study.

RESULTS

Forty individuals (mean age 63 years) completed Phase 1, with an average session time of 34 min. The majority of Phase 1 participants reported the session to be enjoyable (93 %), helpful (80 %) and something they would like to include in their therapy (88 %). Sixteen individuals (mean age 61 years) took part in Phase 2, with an average of seven 26-min sessions over four weeks. Reported acceptability was high for the intervention group and improvements over time were seen in several functional outcome measures. There were no serious adverse safety events reported in either phase of the study; however, a number of participants reported minor increases in pain.

CONCLUSIONS

A post-stroke intervention using interactive motion-controlled games shows promise as a feasible and potentially effective treatment approach. This paper presents important recommendations for future game development and research to further explore long-term adherence, acceptability, safety and efficacy.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ( ACTRN12613000220763 ).

Reliability and validity of a vertical numerical rating scale supplemented with a faces rating scale in measuring fatigue after stroke

Background

Poststroke fatigue is a persistent and distressing symptom among stroke survivors. In this study, we investigated the reliability and validity of a vertical numerical rating scale supplemented with a faces rating scale (NRS-FRS) in measuring poststroke fatigue.

Methods

The fatigue intensity of 106 individuals with stroke was measured twice, 1 week apart, using a vertical NRS-FRS to measure test-retest reliability. The intraclass correlation coefficient, a relative reliability index, was calculated to examine the degree of consistency and agreement between the two test occasions. Absolute reliability indices, including the standard error of measurement, minimal detectable change, and Bland-Altman limits of agreement, were used to quantify measurement errors and determine systematic biases of the two test occasions. We also administered the vertical NRS concurrently as a comparator measure for assessing fatigue in 50 consecutive patients with stroke who were recruited later in the study period. The Spearman rank correlation coefficient (ρ) was used to examine the concurrent validity of the NRS-FRS. Discriminant validity was assessed by means of receiver operating characteristic curves, sensitivity, and specificity.

Results

The intraclass correlation coefficient was 0.95 for the NRS-FRS. The standard error of measurement and the minimal detectable change at the 95 % confidence interval of the NRS-FRS were 0.50 and 1.39, respectively. The Bland-Altman analyses showed no significant systematic bias between the repeated measurements. A narrow range of the limits of agreement was shown on the Bland-Altman plot, indicating the NRS-FRS had high stability and low variation between the two test occasions. The correlations between the NRS-FRS and NRS were good at test (ρ = 0.85) and retest (ρ = 0.84). Compared with the NRS cutoff value of ≥1, sensitivity with the NRS-FRS at test and retest was 94 and 92 % and specificity was 79 and 90 %, respectively.

Conclusions

This study provides further evidence of the reliability and validity of the NRS-FRS in measuring fatigue intensity in patients with stroke. The NRS-FRS had high sensitivity and specificity. The NRS-FRS may be a reliable and valid measure for clinicians and researchers to assess fatigue and determine whether a real change has occurred in groups and at the individual level of patients with stroke.

Stroke impact scale version 2: validation of the French version

BACKGROUND

Almost 1 person in 1,000 experiences a stroke annually in France. Health-related quality-of-life (HRQoL) measurement with specific questionnaires is useful to study the consequences of stroke on patients' daily lives.

OBJECTIVE

The purpose of this study was to validate the French version of the Stroke Impact Scale (SIS) questionnaire, as no disease-specific questionnaire was validated in French heretofore.

METHODS

Two hundred eighty-eight patients with stroke were classified into 2 groups (158 acute, 130 chronic). Rate of item completion, test-retest reliability, sensitivity to change, and construct validity, convergent validity, and discriminant validity of the questionnaire were assessed. Acute group patients were recruited during the first month poststroke and followed for 3 months. Chronic group patients (stroke dating from 1 year) were recruited from outpatient consultations. The first 100 patients in the chronic group were called back 15 days after inclusion for test-retest measurements. The Barthel Index, Hospital Anxiety and Depression Scale (HADS), and Duke Health Profile questionnaires were administered.

RESULTS

The French version of the SIS was well accepted by all participants. It had good reproducibility. Cronbach alpha was 89% for all scales. A ceiling effect was noted in the majority of scales. Physical domains were significantly correlated to other measures of physical capacity (Barthel Index and Duke Health Profile; Spearman coefficients were between .5 and .73), and the emotional and social domains were significantly correlated to almost all domains of the Duke Health Profile. Psychometric properties were similar to those of the US version. Responsiveness was good for physical and emotional domains.

LIMITATIONS

Validation was conducted only on people who were able to answer the questionnaire.

CONCLUSIONS

The French SIS version presents good psychometric properties, except for ceiling effect. This is the first stroke-specific questionnaire evaluating perceived health after stroke to be validated in France and could be useful for further investigations of HRQoL after stroke.

The impact of pain on health-related quality of life 3 months after stroke

BACKGROUND

Pain is common in stroke; however, its impacts on health-related quality of life (HRQoL) are unclear due to the limitations of previous studies.

OBJECTIVES

The current study aims to examine and compare the demographic and clinical characteristics of Chinese stroke patients with and without pain and explore the correlations between poststroke pain and HRQoL.

METHOD

Four hundreds and forty-one participants recruited in an acute stroke unit in a regional hospital. They were assessed 3 months after the index stroke with the following instruments. HRQoL was measured using the Short Form-12 (SF-12). The Chinese version of the Faces Pain Rating Scale-Revised (FPS-R) was used to determine the presence and intensity of pain. The demographic and clinical characteristics of patients were obtained using Barthel Index (BI), Fatigue Severity Scale (FSS), Geriatric Depression Scale (GDS), Anxiety subscale of the Hospital Anxiety and Depression Scale (HADSA), Instrumental Activities of Daily Living (IADL), Mini Mental State Examination (MMSE), Modified Rankin Scale (MRS), and National Institutes of Health Stroke Scale (NIHSS).

RESULTS

Of all participants screened, 167 reported pain and 69 had novel pain. The pain group had significantly lower physical component summary (PCS) scores after adjusting for sex, education, DSM-IV depression and BI, GDS, HADSA, and FSS scores. The FPS score was negatively correlated with a lower PCS score in patients with pain and with novel pain.

CONCLUSION

The presence and intensity of pain have significant negative effects on HRQoL in stroke survivors. Interventions for pain could make a valuable contribution to improving HRQoL in stroke survivors.

Post stroke pain: identification, assessment, and therapy

BACKGROUND

Pain is a common complication after stroke and is associated with the presence of depression, cognitive dysfunction, and impaired quality of life. It remains underdiagnosed and undertreated, despite evidence that effective treatment of pain may improve function and quality of life.

SUMMARY

We provide an overview of the means for clinical assessment and risk factors for the development of post-stroke pain, then review the newest available literature regarding the commonest post-stroke pain syndromes, including central post-stroke pain, complex regional pain syndrome, musculoskeletal pain including shoulder subluxation, spasticity-related pain, and post-stroke headache, as well as the available epidemiology and current treatment options. Key Messages: In the best interests of optimizing quality of life and function after stroke, clinicians should be aware of pain as a common complication after stroke, identify those patients at highest risk, directly inquire as to the presence and characteristics of pain, and should be aware of the options for treatment for the various pain syndromes.

Screening for mood disorders after stroke: a systematic review of psychometric properties and clinical utility

BACKGROUND

Routine mood screening is recommended after stroke. However, clinicians report difficulty selecting appropriate tools from the wide range available. We aimed to systematically review the psychometric properties and clinical utility of mood screening tools for stroke survivors.

METHOD

Electronic databases (AMED, EMBASE, CINAHL, Medline and PsycINFO) were searched to identify studies assessing the sensitivity and specificity of mood screening tools. Tools that demonstrated at least 80% sensitivity and 60% specificity with stroke survivors with identifiable cut-off scores indicating major and/or any mood disorder in at least one study were selected and clinical utility was assessed. Those with high clinical utility (against predefined criteria) were selected for recommendation.

RESULTS

Thirty papers examining 27 screening tools were identified and 16 tools met the psychometric and clinical utility criteria: 10 were verbal self-report tools, four were observational and two incorporated visual prompts for those with communication problems. Only the Stroke Aphasic Depression Questionnaire -Hospital version (SADQ-H) met all the psychometric and utility criteria. The nine-item Patient Health Questionnaire (PHQ-9) can detect major depression and the 15-item Geriatric Depression Scale (GDS-15) can identify milder symptoms; both are feasible to use in clinical practice. The Hospital Anxiety and Depression Scale (HADS) was the only tool able to identify anxiety accurately, but clinical utility was mixed.

CONCLUSIONS

Valid and clinically feasible mood screening tools for stroke have been identified but methodological inconsistency prevented recommendations about the optimal cut-off scores.

Feasibility of the cognitive assessment scale for stroke patients (CASP) vs. MMSE and MoCA in aphasic left hemispheric stroke patients

INTRODUCTION

Post-stroke aphasia makes it difficult to assess cognitive deficiencies. We thus developed the CASP, which can be administered without using language. Our objective was to compare the feasibility of the CASP, the Mini Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA) in aphasic stroke patients.

MATERIAL AND METHODS

All aphasic patients consecutively admitted to seven French rehabilitation units during a 4-month period after a recent first left hemispheric stroke were assessed with CASP, MMSE and MoCA. We determined the proportion of patients in whom it was impossible to administer at least one item from these 3 scales, and compared their administration times.

RESULTS

Forty-four patients were included (age 64±15, 26 males). The CASP was impossible to administer in eight of them (18%), compared with 16 for the MMSE (36%, P=0.05) and 13 for the MoCA (30%, P=0.21, NS). It was possible to administer the CASP in all of the patients with expressive aphasia, whereas the MMSE and the MoCA could not be administered. Administration times were longer for the CASP (13±4min) than for the MMSE (8±3min, P<10(-6)) and the MoCA (11±5min, P=0.23, NS).

CONCLUSION

The CASP is more feasible than the MMSE and the MoCA in aphasic stroke patients.

The reliability and predictive ability of a biomarker of oxidative DNA damage on functional outcomes after stroke rehabilitation

We evaluated the reliability of 8-hydroxy-2′-deoxyguanosine (8-OHdG), and determined its ability to predict functional outcomes in stroke survivors. The rehabilitation effect on 8-OHdG and functional outcomes were also assessed. Sixty-one stroke patients received a 4-week rehabilitation. Urinary 8-OHdG levels were determined by liquid chromatography–tandem mass spectrometry. The test-retest reliability of 8-OHdG was good (interclass correlation coefficient = 0.76). Upper-limb motor function and muscle power determined by the Fugl-Meyer Assessment (FMA) and Medical Research Council (MRC) scales before rehabilitation showed significant negative correlation with 8-OHdG (r = −0.38, r = −0.30; p < 0.05). After rehabilitation, we found a fair and significant correlation between 8-OHdG and FMA (r = −0.34) and 8-OHdG and pain (r = 0.26, p < 0.05). Baseline 8-OHdG was significantly correlated with post-treatment FMA, MRC, and pain scores (r = −0.34, −0.31, and 0.25; p < 0.05), indicating its ability to predict functional outcomes. 8-OHdG levels were significantly decreased, and functional outcomes were improved after rehabilitation. The exploratory study findings conclude that 8-OHdG is a reliable and promising biomarker of oxidative stress and could be a valid predictor of functional outcomes in patients. Monitoring of behavioral indicators along with biomarkers may have crucial benefits in translational stroke research.

Relative and absolute reliability of a vertical numerical pain rating scale supplemented with a faces pain scale after stroke

BACKGROUND

Pain is a serious adverse complication after stroke. The combination of a vertical numerical pain rating scale (NPRS) and a faces pain scale (FPS) has been advocated to measure pain after stroke.

OBJECTIVE

This study was conducted to investigate whether an NPRS supplemented with an FPS (NPRS-FPS) would show good test-retest reliability in people with stroke. The relative and absolute reliability of the NPRS-FPS were examined.

DESIGN

A test-retest design was used for this study.

METHODS

Fifty people (>3 months after stroke) participating in an outpatient occupational therapy program were recruited through medical centers to rate current pain intensity twice, at a 1-week interval, with the NPRS-FPS (on a scale from 0 to 10). The relative reliability of the NPRS-FPS was analyzed with the intraclass correlation coefficient for determining the degree of consistency and agreement between 2 measures. The standard error of measurement, the smallest real difference, and Bland-Altman limits of agreement were the absolute reliability indexes used to quantify measurement errors and determine systematic biases of repeated measurements.

RESULTS

The relative reliability of the NPRS-FPS was substantial (intraclass correlation coefficient=.82). The standard error of measurement and the smallest real difference at the 90% confidence interval of the NPRS-FPS were 0.81 and 1.87, respectively. The Bland-Altman analyses revealed no significant systematic bias between repeated measurements for the NPRS-FPS. The range of the limits of agreement for the NPRS-FPS was narrow (-2.50 to 1.90), indicating a high level of stability and little variation over time.

LIMITATIONS

The pain intensity of the participants ranged from no pain to a moderate level of pain.

CONCLUSIONS

These findings suggest that the NPRS-FPS is a reliable measure of pain in people with stroke, with good relative and absolute reliability.

How to measure pain in neurological conditions? A systematic review of psychometric properties and clinical utility of measurement tools

OBJECTIVE

To systematically review the psychometric properties and clinical utility of measures of pain in neurological conditions.

DATA SOURCES

Electronic databases (AMED, CINAHL, MEDLINE, PEDro and Web of Knowledge) were searched from their inception to February 2013.

REVIEW METHODS

Studies investigating any measurement tool to assess pain in central nervous system conditions were systematically identified. Data about their psychometric properties and clinical utility were extracted and analysed independently. The strength of the psychometric properties and clinical utility were assessed.

RESULTS

A total of 13 articles met the selection criteria, which assessed 11 measurement tools; eight pain rating scales; one Neuropathic Pain Scale; and two measures of pain interference with every-day life. Most of the pain rating scales were specifically for hemiplegic shoulder pain. None had been sufficiently developed to recommend for use in clinical practice or research. Evaluation of reliability and the ability to detect change were particularly sparse. Reliability depended on the type of tools used. Patients with right hemisphere damage favoured verbal/written responses, while people with left hemisphere damage preferred and reported more effectively using visual/numeric responses. Validity between measures of pain intensity was moderate, while validity with mood or quality of life was weak to moderate.

CONCLUSION

None of the selected measures of pain have been fully developed or evaluated to demonstrate that they provide accurate, relevant reproducible information.

Prevalence and correlates of pain and pain treatment in a western Kenya referral hospital

BACKGROUND

Pain is often inadequately evaluated and treated in sub-Saharan Africa (SSA).

OBJECTIVE

We sought to assess pain levels and pain treatment in 400 hospitalized patients at a national referral hospital in western Kenya, and to identify factors associated with pain and pain treatment.

DESIGN

Using face-validated Kiswahili versions of two single-item pain assessment tools, the Numerical Rating Scale (NRS) and the Faces Pain Scale-Revised (FPS-R), we determined patients' pain levels. Additional data collected included patient demographics, prescribed analgesics, and administered analgesics. We calculated mean pain ratings and pain management index (PMI) scores.

RESULTS

Averaged between the NRS and FPS-R, 80.5% of patients endorsed a nonzero level of pain and 30% of patients reported moderate to severe pain. Older patients, patients with HIV, and cancer patients had higher pain ratings. Sixty-six percent of patients had been prescribed analgesics at some point during their hospitalization, the majority of which were nonopioids. A majority of patients (66%) had undertreated pain (negative scores on the PMI).

CONCLUSION

This study shows that hospitalized patients in Kenya are experiencing pain and that this pain is often undertreated.

Scheduled analgesic regimen improves rehabilitation after hip fracture surgery

BACKGROUND

Postoperative pain often is the limiting factor in the rehabilitation of patients after hip fracture surgery.

QUESTIONS/PURPOSES

We compared an approach using scheduled analgesic dosing with as-needed analgesic dosing in patients after hip fracture surgery, to compare these approaches in terms of (1) resting and dynamic pain intensity, (2) postoperative patient mobility, and (3) functional end points.

METHODS

We conducted a prospective cohort study of 400 patients who underwent surgical treatment of hip fractures at our hospital. The groups were formed sequentially, such that the first 200 patients formed the intervention group (treated with scheduled analgesic intake for the first 3 weeks after surgery), and the next 200 patients were the control group (treated using a protocol of analgesic administration on request). Resting and dynamic pain intensity, mobility, and functional performance were compared between the two analgesic protocols.

RESULTS

As expected, analgesic consumption was lower in the control group (tramadol doses, 27 versus 63; paracetamol doses, 29 versus 63). Despite the large difference in the amounts of analgesics consumed, resting and dynamic pain intensity showed improvement in each group and there was no difference between groups in terms of postoperative pain. However, there was a positive correlation between functional outcomes and analgesic consumption in the control group. The intervention group achieved higher functional performance on discharge (elderly mobility scale, 11 versus 8; functional independence measure, 88 versus 79). On discharge, fewer patients in the intervention group were wheelchair ambulators (3 versus 32), meaning more patients in the intervention group were able to walk.

CONCLUSIONS

The study showed that a scheduled analgesic intake can improve the functional outcomes of patients with geriatric hip fractures after surgery.

LEVEL OF EVIDENCE

Level II, therapeutic study. See the guidelines for authors for a complete description of levels of evidence.

Is pain associated with suicidality in stroke?

OBJECTIVE

To evaluate the relation between poststroke pain and suicidality (SI) in Chinese patients with first or recurrent stroke.

DESIGN

Cross-sectional survey.

SETTING

Acute stroke unit of a university-affiliated general hospital.

PARTICIPANTS

Patients (N=496) with acute ischemic stroke admitted to the Acute Stroke Unit.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Patients were interviewed 3 months after the index stroke. SI was assessed with the Geriatric Mental State Examination. Pain was evaluated with the Faces Pain Rating Scale-Revised (FPS-R). The association between FPS-R scores and SI was examined and adjusted for potential confounders, including marital status, depression, neurologic deficits assessed by the National Institute of Health Stroke Scale, and functioning measured by the Barthel Index.

RESULTS

Thirty-seven (7.5%) of the patients had SI (the SI group). Compared with the non-SI group, patients in the SI group were more likely to experience pain (59.5% vs 37.7%), had a higher mean FPS-R score (6.0±2.5 vs 4.5±2.3), and had an FPS-R score of >4 (43.2% vs 15.9%). After adjustment for possible confounders, the FPS-R score of >4 (odds ratio=2.9) remained a significant predictor of SI in the subsequent forward logistic regression models.

CONCLUSIONS

These findings should alert clinicians that the early identification and treatment of pain may reduce suicide risk in patients with stroke.

Assessment of the face validity of two pain scales in Kenya: a validation study using cognitive interviewing

BACKGROUND

Patients in sub-Saharan Africa commonly experience pain, which often is un-assessed and undertreated. One hindrance to routine pain assessment in these settings is the lack of a single-item pain rating scale validated for the particular context. The goal of this study was to examine the face validity and cultural acceptability of two single-item pain scales, the Numerical Rating Scale (NRS) and the Faces Pain Scale-Revised (FPS-R), in a population of patients on the medical, surgical, and pediatric wards of Moi Teaching and Referral Hospital in Kenya.

METHODS

Swahili versions of the NRS and FPS-R were developed by standard translation and back-translation. Cognitive interviews were performed with 15 patients at Moi Teaching and Referral Hospital in Eldoret, Kenya. Interview transcripts were analyzed on a question-by-question basis to identify major themes revealed through the cognitive interviewing process and to uncover any significant problems participants encountered with understanding and using the pain scales.

RESULTS

Cognitive interview analysis demonstrated that participants had good comprehension of both the NRS and the FPS-R and showed rational decision-making processes in choosing their responses. Participants felt that both scales were easy to use. The FPS-R was preferred almost unanimously to the NRS.

CONCLUSIONS

The face validity and acceptability of the Swahili versions of the NRS and FPS-R has been demonstrated for use in Kenyan patients. The broader application of these scales should be evaluated and may benefit patients who currently suffer from pain.

A New Faces Scale in Pain Measurement: A Test of Bias From Current Mood, Trait Affectivity, and Scale Range

Background and Purpose: Faces pain rating scales used among children have been criticized to confound affective states with pain when smiling faces are included. This experimental study is an attempt to examine the possible confounding of affective states with pain when smiling faces are used as part of a faces scale. The meaning of the faces was tested to depend on current mood, current pain, trait affectivity, and inclusion versus exclusion of smiling faces. Methods: Sixty-four participants made 6,720 two-categorical pain judgments on faces with different mouth curvature. Results: In multilevel regression analysis, current level of pain and negative trait affectivity biased faces’ meaning only when the smiling faces were excluded from the scale. Conclusions: In adults, the new full range faces pain scale including a midpoint neutral face and smiling faces was more robust than the restricted scale. The faces scale that was tested in this study is not applicable for patient measurement but it is an interesting tool for psychological research.

The utility of faces pain scale in a chronic musculoskeletal pain model

OBJECTIVES

The main aim of this study was to investigate the clinical utility and sensitivity to change of faces pain scale (FPS) in patients with shoulder pain, chosen as a chronic pain model. The secondary aim was to determine the association of FPS with psychologic status and quality of life of these patients.

METHODS

Thirty Turkish patients with chronic shoulder pain were included in the study. Pain intensity was evaluated by visual analog scale (VAS), which is a commonly used pain scale besides FPS. Depression and quality of life were screened by Beck Depression Inventory (BDI) and Short Form-36 (SF-36). All assessments were done before and after the physical therapy.

RESULTS

There was a statistically significant decrease in pain severity after the treatment as indicated by FPS and VAS (P=0.000). The standardized response mean (SRM) value of FPS of 2.35 was accepted as a good responsiveness. The FPS showed a strong correlation with VAS (r=0.62 and 0.73) both before and after the treatment. Also, moderate to strong correlations were detected between the FPS and physical functioning (PF), physical role (PR), bodily pain (BP), emotional role (ER), general health (GH), mental health (MH) subscales of SF-36 (r=-0.58-0.80), and BDI scores (r=0.39) before the treatment. However, there were moderate and weak correlations with FPS and PR and social functioning (SF) subscales of SF-36 only after the treatment (r=-0.52 and r=-0.39).

CONCLUSIONS

FPS is a satisfactory tool to assess pain in patients with chronic pain conditions and demonstrates sensitivity to detect changes after the treatment.

Depression and the hyperactive right-hemisphere

Depression is associated with an inter-hemispheric imbalance; a hyperactive right-hemisphere (RH) and a relatively hypoactive left-hemisphere (LH). Nevertheless, the underlying mechanisms which can explain why depression is associated with a RH dominance remain elusive. This article points out the potential links between functional cerebral asymmetries and specific symptoms and features of depression. There is evidence that the RH is selectively involved in processing negative emotions, pessimistic thoughts and unconstructive thinking styles--all which comprise the cognitive phenomenology of depression and in turn contribute to the elevated anxiety, stress and pain associated with the illness. Additionally, the RH mediates vigilance and arousal which may explain the sleep disturbances often reported in depression. The RH had also been linked with self-reflection, accounting for the tendency of depressed individuals to withdraw from their external environments and focus attention inward. Physiologically, RH activation is associated with hyprecortisolemia, which contributes to the deterioration of the immune system functioning and puts depressed patients at a greater risk of developing other illnesses, accounting for depression's high comorbidity with other diseases. Conversely, the LH is specifically involved in processing pleasurable experiences, and its relative attenuation is in line with the symptoms of anhedonia that characterize depression. The LH is also relatively more involved in decision-making processes, accounting for the indecisiveness that is often accompanied with depression.