The experience of pain is often represented by changes in facial expression. Evidence of pain that is available from facial expression has been the subject of considerable scientific investigation. The present paper reviews the history of pain assessment via facial expression in the context of a model of pain expression as a nexus connecting internal experience with social influence. Evidence about the structure of facial expressions of pain across the lifespan is reviewed. Applications of facial assessment in the study of adult and pediatric pain are also reviewed, focusing on how such techniques facilitate the discovery and articulation of novel phenomena. Emerging applications of facial assessment in clinical settings are also described. Alternative techniques that have the potential to overcome barriers to the application of facial assessment arising out of its resource intensiveness are described and evaluated, including recent work on computer- based automatic assessment.
Chronic lumbar radicular pain can be described as neuropathic pain along the distribution of a particular nerve root. The dorsal root ganglion has been implicated in its pathogenesis by giving rise to abnormal impulse generation as a result of irritation, direct compression and sensitization. Chronic lumbar radicular pain is commonly treated with medications, physiotherapy and epidural steroid injections. Epidural steroid injections are associated with several common and rarer side effects such as spinal cord infarction and death. It is essential and advantageous to look for alternate interventions which could be effective with fewer side effects. Pulse radio frequency is a relatively new technique and is less destructive then conventional radiofrequency. Safety and effectiveness of pulse radio frequency in neuropathic pain has been demonstrated in animal and humans studies. Although its effects on dorsal root ganglion have been studied in animals there is only one randomized control trial in literature demonstrating its effectiveness in cervical radicular pain and none in lumbar radicular pain. Our primary objective is to study the feasibility of a larger trial in terms of recruitment and methodology. Secondary objectives are to compare the treatment effects and side effects.
This is a single-center, parallel, placebo-controlled, triple-blinded (patients, care-givers, and outcome assessors), randomized control trial. Participants will have a history of chronic lumbar radicular pain for at least 4 months in duration. Once randomized, all patients will have an intervention involving fluoroscopy guided needle placement to appropriate dorsal root ganglion. After test stimulation in both groups; the study group will have a pulse radio frequency treatment at 42°C for 120?s to the dorsal root ganglion, with the control group having only low intensity test stimulation for the same duration. Primary outcome is to recruit at least four patients every month with 80% of eligible patients being recruited. Secondary outcomes would be to assess success of intervention through change in the visual analogue scale measured at 4 weeks post intervention and side effects. Allocation to each group will be a 1:1 ratio with allocation block sizes of 2, 4, and 6.
In this paper I consider 30 Finnish women's written narratives about the process of getting back pain diagnosed. From the beginning of the early discomfort of back pain, the women were sure of its bodily and subjective reality. They struggled repeatedly to be taken seriously, and only after years of medical disparagement did they encounter medical professionals who were able solve the riddle and give it a name, a diagnosis. Since back pain is a baffling problem and challenges the central biomedical epistemology-objective knowledge and measurable findings separate from subjective experience-it allowed the doctors to show a disrespectful attitude toward back pain sufferers. The moral essence of the women's common story was the stigmatizing experience when doctors did not take subjective pain seriously. Instead, doctors' neglectful attitudes became part of the prolonged problem. During the long-lasting uncertainty, women tried multiple coping strategies to ease their lives and developed mental attitudes to endure the pain. Since the protagonists did not give up the lived certainty of back pain they were gradually able to challenge medical uncertainty and to demand a thorough medical examination, and/or through random circumstance they encountered doctors who were willing to take their symptoms seriously. This triggered turning points that immediately or very soon resulted in solving the riddle of the puzzling pain. To be finally diagnosed was a great relief. However, to be taken seriously as a person was considered to be the greatest relief.
The purpose of present study was to investigate important measurement properties of the Body Awareness Rating Questionnaire (BARQ) subscales: Function; Mood; Feelings; and Awareness. Samples of 50 patients with prolonged musculoskeletal pain and psychosomatic disorders, and 50 gender and age-matched healthy persons participated in the study. Relative (ICC 2,1) and absolute reliability (S(w)) were calculated. Construct validity was examined by testing hypothesis using Pearson (r) or Spearman rank (r(s)) correlation. Discriminate ability was examined using a receiver operating characteristic (ROC) curve, the area under the curve (aROC) being the measure of discriminative validity. All patients reported more or less improvement after treatment, using the Patient Global Impression of Change (PGIC) as an external indicator of important change. Responsiveness to important change was therefore examined by one-way repeated measures analysis of variance (ANOVA), relating change scores of BARQ subscales to the PGIC categories. Relative and absolute reliability values were within recommended limits for all four subscales. Construct and discriminate validity was indicated for Function, Feelings and Awareness, but not for Mood. Responsiveness was indicated for the subscales Function and Awareness, but not for Feelings and Mood. Further research is needed to complement the subscales of BARQ, found with appropriate measurement properties.
Only a fraction of patients with irritable bowel syndrome (IBS) have increased perceptual sensitivity to rectal distension, indicating differences in processing and/or modulation of visceral afferent signals. We investigated the brain mechanisms of these perceptual differences.
We analyzed data from 44 women with IBS and 20 female healthy subjects (controls). IBS symptom severity was determined by a severity scoring system. Anxiety and depression symptoms were assessed using the hospital anxiety and depression score. Blood oxygen level-dependent signals were measured by functional magnetic resonance imaging during expectation and delivery of high (45 mmHg) and low (15 mmHg) intensity rectal distensions. Perception thresholds to rectal distension were determined in the scanner. Brain imaging data were compared among 18 normosensitive and 15 hypersensitive patients with IBS and 18 controls. Results were reported significant if peak P-values were =.05, with family-wise error correction in regions of interest.
The subgroups of patients with IBS were similar in age, symptom duration, psychological symptoms, and IBS symptom severity. Although brain responses to distension were similar between normosensitive patients and controls, hypersensitive patients with IBS had greater activation of insula and reduced deactivation in pregenual anterior cingulate cortex during noxious rectal distensions, compared to controls and normosensitive patients with IBS. During expectation of rectal distension, normosensitive patients with IBS had more activation in right hippocampus than controls.
Despite similarities in symptoms, hyper- and normosensitive patients with IBS differ in cerebral responses to standardized rectal distensions and their expectation, consistent with differences in ascending visceral afferent input.
Cites: World J Gastroenterol. 2007 Jul 21;13(27):3699-70417659729
The paper draws on data from a Norwegian online discussion list for back pain sufferers and from open, in-depth interviews with Norwegian back pain sufferers. In both sources, back pain sufferers express a fear that the reality of their pain is being questioned. The paper discusses how these experiences of delegitimation can be understood as a result of the back pain sufferers' inability to achieve the sick role. Many of these individuals strive and frequently fail to achieve clinical and social characteristics that make up appropriate sickness behaviour. A lack of proof that they are sick, including a lack of medical diagnosis, appropriate health care treatment, and visible disabilities, can lead to accusations, both felt and enacted, of malingering, hypochondria and/or mental illness. This in turn can lead to problems in the achievement and/or legitimisation of sick role benefits such as sick leave and medication. The sick role concept has been criticised as being inappropriate for describing the experiences of the chronically ill. The paper argues that the sick role concept still appears to reflect the expectations of health professionals, the public and the patient himself. The study does not support the view that chronic illness is related to a decreased dependency on the medical profession. Instead, doctors' inability to offer chronic back pain sufferers a clear diagnosis, explanation, and/or a course of treatment or cure appears not to liberate the patient but rather prolongs his or her dependence on the doctor.
To examine the validity of the Disabilities of Arm, Shoulder, and Hand (DASH) and the QuickDASH in patients with neck pain in comparison with the Neck Disability Index (NDI), the Cervical Spine Outcome Questionnaire (CSOQ), and the Visual Analogue Scale (VAS) for pain. To examine the agreement between the DASH and the QuickDASH and assess whether the QuickDASH can be used instead of full DASH in patients with neck pain.
NDI is commonly used for measuring neck-related disability in patients with neck pain; but it does not offer to assess the potential for upper extremity disability.
Patients with neck pain (N = 66) were assessed on one occasion. They completed the NDI and the DASH, and 42 of them completed the CSOQ. The QuickDASH scores were extracted from the full DASH. Correlations were tested between both versions of the DASH, the NDI, the subscales of the CSOQ, and the VAS-pain. Correlations were considered high with r >0.75. Ranked item difficulty analysis was performed for both versions of the DASH and the NDI. The Bland and Altman technique was used to assess the nature and size of score differences between 2 versions of the DASH.
Item ranks identified the DASH and the QuickDASH items to be as problematic to patients as NDI items. Both the versions of DASH showed high correlation (0.82-0.83) with the NDI and moderate correlation with the CSOQ and VAS-pain. The mean QuickDASH scores were higher (2.77 points) compared to the full DASH.
Though the QuickDASH reported higher disability compared to the full DASH in this patient group, high correlation between the QuickDASH and the NDI and agreement between both versions of the DASH provide preliminary evidence that the QuickDASH can be used to measure upper extremity disability in patients with neck pain.
To improve the understanding of chronic pelvic pain (CPP) and to provide evidence-based guidelines of value to primary care health professionals, general obstetricians and gynaecologists, and those who specialize in chronic pain. BURDEN OF SUFFERING: CPP is a common, debilitating condition affecting women. It accounts for substantial personal suffering and health care expenditure for interventions, including multiple consultations and medical and surgical therapies. Because the underlying pathophysiology of this complex condition is poorly understood, these treatments have met with variable success rates.
Effectiveness of diagnostic and therapeutic options, including assessment of myofascial dysfunction, multidisciplinary care, a rehabilitation model that emphasizes achieving higher function with some pain rather than a cure, and appropriate use of opiates for the chronic pain state.
Medline and the Cochrane Database from 1982 to 2004 were searched for articles in English on subjects related to CPP, including acute care management, myofascial dysfunction, and medical and surgical therapeutic options. The committee reviewed the literature and available data from a needs assessment of subjects with CPP, using a consensus approach to develop recommendations.
The quality of the evidence was rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. Recommendations for practice were ranked according to the method described in that report (Table 1).
The recommendations are directed to the following areas: (a) an understanding of the needs of women with CPP; (b) general clinical assessment; (c) practical assessment of pain levels; (d) myofascial pain; (e) medications and surgical procedures; (f) principles of opiate management; (g) increased use of magnetic resonance imaging (MRI); (h) documentation of the surgically observed extent of disease; (i) alternative therapies; (j) access to multidisciplinary care models that have components of physical therapy (such as exercise and posture) and psychology (such as cognitive-behavioural therapy), along with other medical isciplines, such as gynaecology and anesthesia; (k) increased attention to CPP in the training of health care professionals; and (l) increased attention to CPP in formal, high-calibre research. The committee recommends that provincial ministries of health pursue the creation of multidisciplinary teams to manage the condition. CHAPTER 7: MYOFASCIAL DYSFUNCTION: 1. Health care providers should become more aware of myofascial dysfunction as a cause of chronic pelvic pain (CPP) and the available treatment options (IB). 2. Patients should participate in the management of CPP due to myofascial dysfunction by actively using a home stretching and exercise program (ll-2B). CHAPTER 8: MEDICAL THERAPY--EVIDENCE ON EFFECTIVENESS: 1. Opioid therapy can be considered for pain control under adequate supervision (II-3B). 2. Hormonal treatment of chronic pelvic pain of gynaecologic origin, including oral contraceptives, progestins, danazol, and gonadotropin-releasing hormone agonists, has been studied extensively and should be considered as the first line for many women, especially those with endometriosis (I and II-1A). 3. Adjuvant medications, such as antidepressants and antibiotics, can be of supporting help in specific situations (II-3B). CHAPTER 9: SURGERY-EVIDENCE ON EFFECTIVENESS: 1. The lack of robust clinical trials of the surgical management of chronic pelvic pain should be addressed. The use of alternative epidemiologic models, including case-controlled and cohort-controlled trials, should be considered (III-A). 2. Further delineation of the role of appendectomy and of presacral neurectomy appears warranted in the management of endometriosis-related pain (III-A). CHAPTER 11: MULTIDISCIPLINARY CHRONIC PAIN MANAGEMENT: 1. Multidisciplinary chronic pain management should be available for women with chronic pelvic pain within the publicly funded health care system in each province and territory of Canada (III-B). CHAPTER 14:
1. The curriculum for professional development should be expanded to include theory and techniques in the management of myofascial dysfunction (A). 2. Research into CPP should be encouraged, particularly in the areas of the impact of CPP on the use of health services, the pathophysiology of myofascial dysfunction, and gene therapy. Because randomized trials for qualitative outcomes are exceedingly difficult, alternative robust models, such as case-controlled or cohort-controlled trials, should be pursued (A). 3. Methods of improving interaction with patients should be explored. They might include formal contractual approaches to managing pain with opiates and efforts to better appreciate the patient's perceived needs (A).
Cross-cultural translation and psychometric testing.
To translate, culturally adapt, and validate the Oswestry Disability Index (ODI) version 2.0 for the French-Canadian population.
Many authors have recommended the administration of standardized instruments, rather than the creation of new scales, and advocate the adaptation of validated questionnaires in other languages. The application of these scales in different countries and by cultural groups necessitates cross-cultural adaptation. Many scales evaluate the functional incapacity resulting from low back pain. The ODI is among the most commonly used for this purpose.
The French-Canadian ODI (ODI-FC) was developed by cross-cultural adaptation following internationally recommended methodology: forward translation, back translation, expert committee revision, and clinical evaluation of the prefinal version. Psychometric testing was performed on 72 patients with chronic low back pain. The subjects were recruited from a physiatry department in a university hospital and from a private practice physiatry clinic. They came from the Montreal area. The psychometric testing included internal consistency (Cronbach a), test-retest reliability (intraclass correlation coefficient) with a time interval set at 48 hours, and construct validity, comparing the ODI-FC with the Roland-Morris Disability Questionnaire and the Quebec Back Pain Disability Scale (Pearson correlation coefficient).
In 44.4% of the subjects, the average duration of low-back pain varied between 1 and 5 years. Average score for the ODI-FC was 29.2. Good internal consistency was found (Cronbach a = 0.88). Reliability was excellent, with intraclass correlation coefficient = 0.92 (95% confidence interval, 0.87-0.95). Construct validity results revealed excellent correlations between the ODI and the Quebec Back Pain Disability Scale (r = 0.90) and between the ODI and the Roland-Morris Disability Questionnaire (r = 0.84).
Cross-cultural translation and adaptation of the ODI-FC were successful. Psychometric testing determined that the instrument was homogeneous, reliable, and valid. It could be employed in future clinical trials in Canada and possibly in other French-speaking countries.
The purpose of this study was to develop a new Movement domain, based on 16 items from the Global Physiotherapy Examination-52 (GPE-52) and 18 items from the Comprehensive Body Examination (CBE). Furthermore, we examined how well the new domain and its scales would discriminate between healthy individuals and different groups of patients, compared to the original methods. Two physiotherapists, each using one method, independently examined 132 individuals (34 healthy, 32 with localized pain, 32 with generalized pain, and 34 with psychoses). The number of items was reduced by means of correlational and exploratory factor analysis. Internal consistency was examined with Cronbach's alpha. For examination of discriminative validity, Mann-Whitney U-test and Area under the Curve (AUC) were used. The initial 34 items were reduced to two subscales with 13 items: one for range of movement and balance and one for flexibility. Cronbach's alpha was 0.84 and 0.87 for the two subscales. The new subscales showed very good to excellent discriminating ability between healthy persons and the different patient groups (p