Lateralization and Bodily Patterns of Segmental Signs and Spontaneous Pain in Acute Visceral Disease: Observational Study.

BACKGROUND: The differential diagnosis of acute visceral diseases is a challenging clinical problem. Older literature suggests that patients with acute visceral problems show segmental signs such as hyperalgesia, skin resistance, or muscular defense as manifestations of referred visceral pain in somatic or visceral tissues with overlapping segmental innervation. According to these sources, the lateralization and segmental distribution of such signs may be used for differential diagnosis. Segmental signs and symptoms may be accompanied by spontaneous (visceral) pain, which, however, shows a nonsegmental distribution. OBJECTIVE: This study aimed to investigate the lateralization (ie, localization on one side of the body, in preference to the other) and segmental distribution (ie, surface ratio of the affected segments) of spontaneous pain and (referred) segmental signs in acute visceral diseases using digital pain drawing technology. METHODS: We recruited 208 emergency room patients that were presenting for acute medical problems considered by triage as related to internal organ disease. All patients underwent a structured 10-minute bodily examination to test for various segmental signs and spontaneous visceral pain. They were further asked their segmental symptoms such as nausea, meteorism, and urinary retention. We collected spontaneous pain and segmental signs as digital drawings and segmental symptoms as binary values on a tablet PC. After the final diagnosis, patients were divided into groups according to the organ affected. Using statistical image analysis, we calculated mean distributions of pain and segmental signs for the heart, lungs, stomach, liver/gallbladder, and kidneys/ureters, analyzing the segmental distribution of these signs and the lateralization. RESULTS: Of the 208 recruited patients, 110 (52.9%) were later diagnosed with a single-organ problem. These recruited patients had a mean age of 57.3 (SD 17.2) years, and 40.9% (85/208) were female. Of these 110 patients, 85 (77.3%) reported spontaneous visceral pain. Of the 110, 81 (73.6%) had at least 1 segmental sign, and the most frequent signs were hyperalgesia (46/81, 57%), and muscle resistance (39/81, 48%). While pain was distributed along the body midline, segmental signs for the heart, stomach, and liver/gallbladder appeared mostly ipsilateral to the affected organ. An unexpectedly high number of patients (37/110, 33.6%) further showed ipsilateral mydriasis. CONCLUSIONS: This study underlines the usefulness of including digitally recorded segmental signs in bodily examinations of patients with acute medical problems.

Figure Correction: Digital Pain Drawings Can Improve Doctors' Understanding of Acute Pain Patients: Survey and Pain Drawing Analysis.

[This corrects the article DOI: 10.2196/11412.].

From Paper to Digital Applications of the Pain Drawing: Systematic Review of Methodological Milestones.

BACKGROUND: In a pain drawing (PD), the patient shades or marks painful areas on an illustration of the human body. This simple yet powerful tool captures essential aspects of the subjective pain experience, such as localization, intensity, and distribution of pain, and enables the extraction of meaningful information, such as pain area, widespreadness, and segmental pattern. Starting as a simple pen-on-paper tool, PDs are now sophisticated digital health applications paving the way for many new and exciting basic translational and clinical applications. OBJECTIVE: Grasping the full potential of digital PDs and laying the groundwork for future medical PD apps requires an understanding of the methodological developments that have shaped our current understanding of uses and design. This review presents methodological milestones in the development of both pen-on-paper and digital PDs, thereby offering insight into future possibilities created by the transition from paper to digital. METHODS: We conducted a systematic literature search covering PD acquisition, conception of PDs, PD analysis, and PD visualization. RESULTS: The literature search yielded 435 potentially relevant papers, from which 53 methodological milestones were identified. These milestones include, for example, the grid method to quantify pain area, the pain-frequency maps, and the use of artificial neural networks to facilitate diagnosis. CONCLUSIONS: Digital technologies have had a significant influence on the evolution of PDs, whereas their versatility is leading to ever new applications in the field of medical apps and beyond. In this process, however, there is a clear need for better standardization and a re-evaluation of methodological and technical limitations that no longer apply today.

Digital Pain Drawings Can Improve Doctors' Understanding of Acute Pain Patients: Survey and Pain Drawing Analysis.

BACKGROUND: Pain drawings (PDs) are an important tool to evaluate, communicate, and objectify pain. In the past few years, there has been a shift toward tablet-based acquisition of PDs, and several studies have been conducted to test the usefulness, reliability, and repeatability of electronic PDs. However, to our knowledge, no study has investigated the potential role of electronic PDs in the clinical assessment and treatment of inpatients in acute pain situations. OBJECTIVE: The aim of this study was to evaluate whether knowledge of the patients' electronic PD has the potential to improve the doctors' understanding of their patients and to influence their clinical decision making. Furthermore, we sought to identify differences between electronic PDs of patients and their treating pain specialists in an acute pain situation and to find those specific characteristics derived from the PDs that had the largest impact on doctors' understanding. METHODS: We obtained electronic PDs from 47 inpatients in acute pain situations before their consultation with a pain specialist on a tablet personal computer with a stylus. Before looking at their patients' drawings, these specialists drew their own conception of the patients' pain after anamnesis and physical examination. Patients' drawings were then revealed to the doctors, and they were asked to evaluate how much the additional information improved their understanding of the case and how much it influenced their clinical decision on an 11-point Likert scale (0="not at all" and 10="very much"). Similarities and differences of patients' and doctors' PDs were assessed by visual inspection and by calculating Jaccard index and intraclass correlation coefficient (ICC) of the pain area and the number of pain clusters. Exploratory analyses were conducted by means of correlation tables to identify specific factors that influenced doctors' understanding. RESULTS: Patients' PDs significantly improved the doctors' understanding (mean score 4.81, SD 2.60, P<.001) and to a lesser extent their clinical decision (mean 2.68, SD 1.18, P<.001). Electronic PDs of patients and doctors showed fair to good similarity for pain extent (r=.454, P=.001) and widespreadness (P=.447, r=.002) were important factors helping doctors to understand their patients. CONCLUSIONS: In a clinical setting, electronic PDs can improve doctors' understanding of patients in acute pain situations. The ability of electronic PDs to visualize differences between doctors' and patients' conception of pain has the potential to improve doctor-patient communication.