The meaning and process of pain acceptance. Perceptions of women living with arthritis and fibromyalgia.

BACKGROUND: Within the past 10 years, cognitive-behavioural pain management models have moved beyond the traditional focus on coping strategies and perceived control over pain, to incorporate mindfulness- and acceptance-based approaches. Pain acceptance is the process of giving up the struggle with pain and learning to live life despite pain. Acceptance is associated with lower levels of pain, disability and psychological distress. Relatively little is known, however, about how patients arrive at a state of acceptance without the aid of therapy. OBJECTIVES: To explore personal definitions of acceptance and the factors that facilitate or hinder acceptance. METHODS: Eleven focus groups, involving a total of 45 women with arthritis and fibromyalgia, were conducted. RESULTS: The qualitative analysis revealed that, while the women rejected the word 'acceptance', they did agree with the main components of existing research definitions. The women's responses revealed that acceptance was a process of realizations and acknowledgements, including realizing that the pain was not normal and help was needed, receiving a diagnosis, acknowledging that there was no cure and realizing that they needed to redefine 'normal'. Diagnosis, social support, educating self and others, and self-care were factors that promoted acceptance. Struggling to retain a prepain identity, negative impacts on relationships, others not accepting their pain and the unspoken message that the pain was 'all in their head' were barriers to acceptance. CONCLUSION: The implications of these findings, distinctions between the diagnostic groups and recommendations regarding how health professionals can facilitate the process of acceptance are discussed.

Contributions of pain-related adjustment and perceptions of control to coping strategy use among cervical sprain patients.

Coping is a cyclical process in which an individual evaluates stressful events, chooses and implements coping strategies, re-evaluates the outcome of the coping effort and modifies the strategy if necessary. The intent of the present study was to evaluate the extent to which pain-related adjustment (i.e. pain severity, pain interference, negative affect) and perceptions of control are associated with the implementation of particular coping strategies. Participants were 136 patients assessed at an interdisciplinary pain clinic for cervical sprain injuries. As part of a routine assessment, participants completed a questionnaire package regarding background, pain severity, pain interference, negative affect, perceived control and use of particular coping strategies. Results of hierarchical multiple regression analyses revealed that pain interference, after controlling for all other variables, was associated with greater use of less physically demanding strategies (i.e. resting, guarding, asking for assistance, seeking social support and coping self-statements). Negative affect, on the other hand, after controlling for other variables, was associated with reduced use of task persistence. Finally, perceived control, independent of other variables, was associated with greater use of cognitive and social coping strategies (i.e. asking for assistance, seeking social support and coping self-statements). The results of the study shed light on the complex relationship between use of particular coping strategies and situational variables of pain-related adjustment and perceived control. Implications for clinicians who assist patients via implementation or modification of particular coping techniques are discussed.

Measuring movement-exacerbated pain in cognitively impaired frail elders.

OBJECTIVE: Prior research examining the utility of nonverbal measures of pain in persons with cognitive impairments has focused on acute procedurally-induced phasic pain (i.e., venipuncture and needle injections). The goal of the current project was to examine the utility of both self-report and nonverbal measures of pain in frail elders experiencing exacerbations of chronic musculoskeletal pain. These were assumed to be more representative of the day-to-day pain experience of elderly patients. DESIGN: Participants were 58 frail elders, 29 of whom had been found to have significant cognitive impairments. All were filmed as they undertook a series of structured activities (e.g., walking and reclining), and pain was assessed using self-report. Trained coders identified the incidence of pain-related behaviors using the videotapes. The various pain measures (i.e., self-report and nonverbal indices) were compared across both patient groups and the several activities. RESULTS: Consistent with our hypotheses, more pain was identified (using both self-report and nonverbal measures) when patients engaged in more physically demanding activities. Facial reactions varied as a function of patient cognitive status, with those participants who were cognitively impaired more responsive. Of the various nonverbal indices that we examined, guarded behavior appeared to be especially sensitive. The various pain indices were only modestly correlated with one another. CONCLUSIONS: This study supports the validity of self-report and behavioral measures of pain in frail elders with and without cognitive impairments. Each of the measures used contributed different information to pain assessment, suggesting that investigations of pain in elders with cognitive impairments should employ varying types of pain assessment tools.

Extent and nature of anxiety experienced during physical examination of chronic low back pain.

There is strong evidence to suggest that anxiety is a common problem for many chronic pain patients and can exacerbate a patient's pain condition. Notwithstanding, there is little information about the extent and nature of anxiety experienced during physical examination of pain, or the primary factors associated with anxiety in this context. In the present study, 45 chronic low back pain patients completed a questionnaire battery at the time of intake to an interdisciplinary treatment program. After approximately four weeks on program, patients underwent a routine standardized physiotherapy review of their condition following which they completed a second questionnaire battery. The examination was videotaped and coded for pain behavior. Physiotherapists provided objective scoring of non-organic signs and physical impairment. Results suggested that participants experienced substantial anxiety at the point of examination with scores on the Beck Anxiety Inventory (M = 30.47, S.D. = 6.96) comparable to scores that have been found with DSM-IV panic disorder patients. Regression analyses revealed that catastrophic cognitions, behavioral displays of pain and somatic sensations measured during examination uniquely predicted anxiety experienced during examination. Demographic, injury-related, personality, and patient-practitioner variables did not significantly contribute to explaining examination anxiety. Findings support cognitive-behavioral formulations of anxiety and strongly suggest that anxiety may complicate the assessment process. Implications for the assessment and treatment of pain are presented along with future research directions.

Pain measurement in persons with intellectual disabilities.

OBJECTIVE: The goal was to study the utility of nonverbal facial expressions as a research tool for assessing pain in persons with intellectual disabilities. Biases and stereotypes related to age, gender, physical attractiveness, and intellectual disability that may influence the ability of observers to evaluate pain reactions were also examined. DESIGN: Facial reactions to an intramuscular injection of 40 adults (mean age = 49.6 years) with an intellectual disability were videotaped and objectively examined using the Facial Action Coding System. Self-reported pain ratings were obtained using a Colored Visual Analogue Scale for pain. Pain reactions were also rated by untrained observers. RESULTS: A significant proportion of participants (35%) was unable to provide valid self-report. The intensity of objectively coded facial activity as well as observer-rated pain intensity showed significant increases from baseline to injection segments. Observers' pain ratings were primarily determined by the intensity of facial activity and were not significantly affected by stereotypes based on perceived level of intellectual disability, gender, age, or physical attractiveness. CONCLUSIONS: The findings support the validity of both objectively coded and observer-rated facial expressions of pain as research tools in treatment outcome studies involving persons with intellectual disabilities. Self-report has substantial limitations for the assessment of pain in this population.

An evaluation of subjective and objective measures of fatigue in patients with brain injury and healthy controls.

Three self-report scales and an objective measure were examined for their value in assessing fatigue in patients with brain injury. Patients with brain injury and healthy controls completed the Fatigue Impact Scale (FIS), Visual Analogue Scale for Fatigue (VAS-F) and Fatigue Severity Scale (FSS). Fatigue was objectively measured via a continuous thumb pressing task. Patients scored higher on all fatigue measures than did participants without brain injury. Significant group differences were found on the FIS, the vigour subscale of the VAS-F, and the FSS. The FIS provided a comprehensive assessment of patients' fatigue experience. The FSS, although differentiating between groups, did not provide as comprehensive an examination of fatigue as the FIS and the scale's internal consistency requires review. No significant group differences in fatigue ratings were found on the VAS-F, possibly due to the scale's failure to differentiate between fatigue and sleepiness. The objective measure of fatigue found patients with brain injury fatigued more quickly than participants without brain injury. Although group differences were not significant, this trend suggest that further examination of this fatigue measure is warranted. Overall, patients with brain injury were found to experience significant levels of fatigue and the FIS provided the most comprehensive examination of fatigue.