Accommodating Students with Disabilities: Fieldwork Educators' Experiences.

Background. Fieldwork is an essential part of experiential learning in occupational therapy education. Fieldwork educators identify limits on reasonable accommodation and difficulty implementing disability-related accommodations. Student occupational therapists with disabilities report discrimination from within the profession, including inflexible fieldwork environments. Purpose. To understand the experiences of occupational therapy fieldwork educators in Canada in accommodating students with disabilities and to develop action-oriented practice recommendations. Method. In this interpretive description study, we interviewed 11 fieldwork educators about their experiences accommodating students with disabilities. Interviews were recorded, transcribed, and analyzed using a constant comparative approach. Findings. Educators emphasized a meta-theme of "Learning" when asked about disability-related accommodations. Three subthemes about student learning emerged: 1. Educators focused on "Student Learning in Preparation for Professional Practice" rather than their fieldwork setting only; 2. Educators were "Using Occupational Therapy Skills for Student Learning" in fieldwork; and 3. Educators recognized that their professional and personal "Context Influences Student Learning." Conclusion. Fieldwork educators can work with students to align their accommodations with required learning outcomes for professional practice and use their occupational therapy skills to assist with implementation. Fieldwork educators require time and other supports to work effectively with all students.

Faces of clinical pain: Inter-individual facial activity patterns in shoulder pain patients.

BACKGROUND: Facial activity during pain is composed of varying combinations of a few elementary facial responses (so-called Action Units). A previous study of experimental pain showed that these varying combinations can be clustered into distinct facial activity patterns of pain. In the present study, we examined whether comparable facial activity patterns can also be identified among people suffering from clinical pain; namely, shoulder pain. METHODS: Facial expressions of patients suffering from shoulder pain (N = 126) were recorded while twice undergoing a battery of passive range-of-motion tests to their affected limbs (UNBC-McMaster Shoulder Pain Expression Archive Database), which elicited peaks of acute pain. Facial expressions were analysed using the Facial Action Coding System to extract facial Action Units (AUs). Hierarchical cluster analyses were used to look for characteristic combinations of these AUs. RESULTS: Cluster analyses revealed four distinct activity patterns during painful movements. Each cluster was composed of different combinations of pain-indicative AUs, with one AU common to all clusters, namely, "narrowed eyes". Besides these four clusters, there was a "stoic" pattern, characterized by no discernible facial action. The identified clusters were relatively stable across time and comparable to the facial activity patterns found previously for experimental heat pain. CONCLUSIONS: These findings corroborate the hypothesis that facial expressions of acute pain are not uniform. Instead, they are composed of different combinations of pain-indicative facial responses, with one omnipresent response, namely, "narrowed eyes". Raising awareness about these inter-individually different "faces of pain" could improve the recognition and, thereby, its diagnostic training for professionals, like nurses and physicians. SIGNIFICANCE: Similar to experimental pain, facial activity during evoked pain episodes in shoulder pain patients could be clustered into distinct faces of pain. Each cluster was composed of different combinations of single facial responses, namely: narrowed eyes, which is displayed either alone or in combination with opened mouth or wrinkled nose, or furrowed brows and closed eyes. These distinct faces of pain may inform the training of professionals and computers how to best recognize pain based on facial expressions.

Assessing the efficacy of a manual-based intervention for improving the detection of facial pain expression.

BACKGROUND: This article presents the results of a parallel-group, non-randomized, controlled study that evaluated the feasibility of an online training program for improving observer detection of facial pain expression. METHOD: Fifty-four undergraduate students attended two laboratory sessions interspersed by an intervention period where they were assigned to complete the Index of Facial Pain Expression (IFPE)-an online training environment designed to teach observers to code facial muscle movements associated with pain-or a no-contact control. Participants completed questionnaires during the first session and watched parallel versions of the Sensitivity to Expression of Pain (STEP) test during laboratory sessions. STEP tests contained excerpts of facial expressions taken from patients with shoulder pain. Reliability of coding following the IFPE was measured. Signal detection methods were applied to pain ratings to the STEP tests to calculate measures of sensitivity and response bias to facial pain expression. RESULTS: Participants took 3.5 hr to complete the IFPE. Training resulted in reliable coding of facial muscle movements associated with pain and improvements in sensitivity (from 0.75 to 0.87 in experimental relative to 0.75 to 0.80 in control), but not response bias, to facial expressions of clinical pain. Training was influenced by observer traits, including empathy, emotional intelligence (EI), and prior experience with individuals who experience chronic pain. CONCLUSIONS: The IFPE represents a brief measurement system for facial pain expression with research applicability and potential clinical utility. The IFPE could help clinicians be more sensitive to expressions of clinical pain. SIGNIFICANCE: The index of facial pain expression (IFPE) is an online training program that can improve an observer's ability to reliably detect expressions of clinical pain after as few as 3.5-hr of training.

Perceptions of HIV-related health services in Zambia for people with disabilities who are HIV-positive.

INTRODUCTION: Despite the emerging body of literature on increased vulnerability to HIV among people with disabilities (PWDs), there is a dearth of evidence related to experiences of PWDs who have become HIV-positive. This priority was identified by a disability advocacy organization in Lusaka, Zambia, where the prevalence of HIV and of disability is each approximately 15%. The purpose of this study was to explore perceptions and experiences of HIV-related health services for PWDs who are also living with HIV in Lusaka, Zambia. METHODS: This qualitative, interpretive study involved in-depth, semi-structured, one-on-one interviews with two groups of participants in Lusaka, Zambia: 21 PWDs who had become HIV-positive, and 11 people working in HIV and/or disability. PWDs had physical, hearing, visual and/or intellectual impairments. Interviews were conducted in English, Nyanja, Bemba or Zambian sign language. Descriptive and thematic analyses were conducted by a multidisciplinary, international research team. RESULTS: Participants described their experiences with HIV-related health services in terms of the challenges they faced. In particular, they encountered three main challenges while seeking care and treatment: (1) disability-related discrimination heightened when seeking HIV services, (2) communication barriers and related concerns with confidentiality, and (3) movement and mobility challenges related to seeking care and collecting antiretroviral therapy. These experiences were further shaped by participants' profound concerns about poverty and unmet basic needs. DISCUSSION: This study demonstrates how PWDs who are HIV-positive have the same HIV care, treatment and support needs as able-bodied counterparts, but face avoidable barriers to care. Many challenges mirror concerns identified with HIV prevention, suggesting that efforts to promote inclusion and reduce stigma could have widespread benefits. CONCLUSIONS: Despite the growing body of literature on increased risk of exposure to HIV among HIV-negative PWDs, this is the first published study to examine perceptions of testing, treatment and other HIV services for PWDs who have become HIV-positive. Findings reveal far-reaching opportunities for improving the quality of care for this population.

A grounded theory of social participation among older women living with HIV.

BACKGROUND: As adults age with human immunodeficiency virus (HIV), the role for rehabilitation continues to emerge. Understanding how social participation is affected among women aging with HIV can inform occupational therapy assessment and treatment. PURPOSE: Our purpose was to develop a theoretical model that describes the experiences of social participation from the perspective of older women living with HIV. METHOD: A grounded theory methodological approach was utilized. We conducted interviews with 20 women living with HIV, age 50 or older, to explore various aspects of social participation, including self-care, relationships with others, and access to health and social services. Emergent themes informed the theoretical model. FINDINGS: The theoretical model comprises four concepts related to social participation: social engagement, social isolation, contrasting perceptions about factors variably influencing participation, and contextual influences that may enhance or hinder social participation. IMPLICATIONS: Women aging with HIV experience social participation as a dynamic process involving social engagement and isolation. Contextual influences may promote and impede social participation.

The Painful Face - Pain Expression Recognition Using Active Appearance Models.

Pain is typically assessed by patient self-report. Self-reported pain, however, is difficult to interpret and may be impaired or in some circumstances (i.e., young children and the severely ill) not even possible. To circumvent these problems behavioral scientists have identified reliable and valid facial indicators of pain. Hitherto, these methods have required manual measurement by highly skilled human observers. In this paper we explore an approach for automatically recognizing acute pain without the need for human observers. Specifically, our study was restricted to automatically detecting pain in adult patients with rotator cuff injuries. The system employed video input of the patients as they moved their affected and unaffected shoulder. Two types of ground truth were considered. Sequence-level ground truth consisted of Likert-type ratings by skilled observers. Frame-level ground truth was calculated from presence/absence and intensity of facial actions previously associated with pain. Active appearance models (AAM) were used to decouple shape and appearance in the digitized face images. Support vector machines (SVM) were compared for several representations from the AAM and of ground truth of varying granularity. We explored two questions pertinent to the construction, design and development of automatic pain detection systems. First, at what level (i.e., sequence- or frame-level) should datasets be labeled in order to obtain satisfactory automatic pain detection performance? Second, how important is it, at both levels of labeling, that we non-rigidly register the face?

The structure, reliability and validity of pain expression: evidence from patients with shoulder pain.

The present study examined psychometric properties of facial expressions of pain. A diverse sample of 129 people suffering from shoulder pain underwent a battery of active and passive range-of-motion tests to their affected and unaffected limbs. The same tests were repeated on a second occasion. Participants rated the maximum pain induced by each test on three self-report scales. Facial actions were measured with the Facial Action Coding System. Several facial actions discriminated painful from non-painful movements; however, brow-lowering, orbit tightening, levator contraction and eye closing appeared to constitute a distinct, unitary action. An index of pain expression based on these actions demonstrated test-retest reliability and concurrent validity with self-reports of pain. The findings support the concept of a core pain expression with desirable psychometric properties. They are also consistent with the suggestion of individual differences in pain expressiveness. Reasons for varying reports of relations between pain expression and self-reports in previous studies are discussed.

Underestimation of pain by health-care providers: towards a model of the process of inferring pain in others.

Health professionals are routinely exposed to evidence of pain in others. It is important that the processes by which they evaluate pain be understood. The purposes of this article are to review and synthesize recent research on how health professionals judge the pain of others and to present a conceptual model of this process. Methodological and conceptual issues in the conduct of pain judgement studies are addressed. Research in this field over the last 40 years has indicated that, when compared with the pain judgements of patients themselves, health professionals tend to underestimate pain. The authors review the relation of this underestimation bias to such variables as the nature of the patient's pain and the clinical experience of the judge. They also review experiential and cognitive-perceptual variables found to influence the degree of underestimation bias, such as the amount of exposure to evidence of pain and suspicion about the motivations of the patient. A model of the pain decoding process is presented. The issue of whether underestimation has implications for treatment outcome is addressed and priorities for future research are identified.

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

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

The evaluation of change in pain intensity: a comparison of the P4 and single-item numeric pain rating scales.

STUDY DESIGN: Prospective observation study. OBJECTIVES: To compare the test-retest reliability and longitudinal validity (sensitivity to change) of 2 single-item numeric pain rating scales (NPRSs) with a 4-item pain intensity measure (P4). BACKGROUND: Pain is a frequent outcome measure for patients seen in physical therapy; however, the error associated with efficient pain measures, such as the single-item NPRS, is greater than for self-report measures of functional status. Initial evaluation of the P4 suggests that it is more reliable and sensitive to change than the NPRS. METHODS AND MEASURES: Two single-item NPRSs and the P4 were administered on 3 occasions--initial visit (n = 220), within 72 hours of baseline (n = 213), and 12 days following baseline assessment (n = 183)--to patients with musculoskeletal problems receiving physical therapy. Reliability was assessed using a type 2,1 intraclass correlation coefficient. Longitudinal validity was assessed by correlating the measures' change scores with a retrospective rating of change that included patients' and clinicians' perspectives. RESULTS: The test-retest reliability and longitudinal validity of the P4 were significantly greater (P1<.05) than both single-item NPRSs. Minimal detectable change of the P4 at the 90% confidence level was estimated to be a change of 22% of the scale range (9 points) compared to 27.3% (3 points) and 31.8% (3.5 points) for the 2-day NPRS and 24-hour NPRS, respectively. CONCLUSIONS: The findings of this study suggest the P4 is more adept at assessing change in pain intensity than popular versions of single-item NPRSs.