Abstract
Background. Through real-time behavioral observation systems, pain behaviors are commonly used by clinicians to estimate pain intensity in patients with low back pain. However, little is known about how clinicians rely on pain-related behaviors to make their judgment. According to the Information Integration Theory (IIT) framework, this study aimed at investigating how clinicians value and integrate information from lumbopelvic kinematics (LK), a protective pain behavior, and facial expression intensity (FEI), a communicative pain behavior, to estimate pain in patients with chronic low back pain (cLBP). Methods. Twenty-one experienced clinicians and twenty-one novice clinicians were asked to estimate back pain intensity from a virtual character performing a trunk flexion-extension task. Results. Results revealed that both populations relied on facial expression and that only half of the participants in each group integrated FEI and LK to estimate cLBP intensity. Among participants who integrated the two pain behaviors, averaging rule predominated among others. Results showed that experienced clinicians relied equally on FEI and LK to estimate pain, whereas novice clinicians mostly relied on FEI. Discussion. The use of additive rule of integration does not appear to be systematic when assessing others' pain. When assessing pain intensity, communicative and protective pain behaviors may have different relevance.
Highlights
It is widely accepted that clinicians usually estimate and manage others’ pain by drawing inferences from several pain-related behaviors they perceive [1, 2]
Since chronic low back pain constitutes a major public health issue, as more than 85% of patients who suffer from it are diagnosed with LBP from nonspecific origin [7], and since real-time behavioral observation systems have been used to infer pain in this population [8], the present study focuses on the way clinicians rely on two LBP prototypical behaviors to assess pain intensity
Post hoc analyses showed that pain estimates of facial expression intensity (FEI) conditions differed between each other within each level of lumbopelvic kinematics (LK) [for healthy LK, MFEI 0% = 2.35, Mmasked FEI = 3.23, MFEI 50% = 3.71, and MFEI 100% = 5.04; for LBP LK, MFEI 0% = 2.11, Mmasked FEI = 2.83, MFEI 50% = 3.71, and MFEI 100% = 5.07]
Summary
It is widely accepted that clinicians usually estimate and manage others’ pain by drawing inferences from several pain-related behaviors they perceive [1, 2]. Various actions, including language, paralinguistic vocalizations, and facial expressions (i.e., communicative pain behaviors), and body posture and escape or avoidance behaviors (i.e., protective pain behaviors) may signal pain to clinicians [3] These pain behaviors are deeply rooted in real-time behavioral observation systems commonly used by clinicians in order to assess patient’s pain [4]. All these systems have common features: they use a standardized test situation to elicit controlled behavioral responding; the sequence in which the tests are carried out is randomized to prevent order effect; trained observers estimate the presence/severity of each behavior characteristic of pain on a two- or three-point rating scale; examiners count/sum the amounts of pain behaviors coded to provide an overall score reflecting the intensity of the pain experienced by the patient. Communicative and protective pain behaviors may have different relevance
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