Affective Qualities Of Pain Research Articles

Multidimensional Pain Assessment Tools for Ambulatory and Inpatient Nursing Practice

BackgroundOne of the critical components in pain management is the assessment of pain. Multidimensional measurement tools capture multiple aspects of a patient's pain experience but can be cumbersome to administer in busy clinical settings. AimWe conducted a systematic review to identify brief multidimensional pain assessment tools that nurses can use in both ambulatory and acute care settings. MethodsWe searched PUBMED/MEDLINE, PsychInfo, and CINAHL databases from January 1977 through December 2019. Eligible English-language articles were systematically screened and data were extracted independently by two raters. Main outcomes included the number and types of domains captured by each instrument (e.g., sensory, impact on function, temporal components) and tool characteristics (e.g., administration time, validity) that may affect instrument uptake in practice. ResultsOur search identified eight multidimensional assessment tools, all of which measured sensory or affective qualities of pain and its impact on functioning. Most tools measured impact of pain on affective functioning, mood, or enjoyment of life. One tool used ecological momentary assessment via a web-based app to assess pain symptoms. Time to administer the varying tools ranged from less than 2 minutes to 10 minutes, and evidence of validity was reported for seven of the eight tools. ConclusionsOur review identified eight multidimensional pain measurement tools that nurses can use in ambulatory or acute care settings to capture patients’ experience of pain. The most important element in selecting a multidimensional pain measure, though, is that one tool is selected that best fits the practice and is used consistently over time.

Sex matters in complex regional pain syndrome.

BackgroundComplex regional pain syndrome (CRPS) is much more prevalent in women than men but potential differences in clinical phenotype have not been thoroughly explored to date. Differences in the clinical presentation between sexes may point at new avenues for a more tailored management approach of CRPS. We therefore explored if in CRPS, the patient's sex is associated with differences in clinical and psychological characteristics.MethodsIn this cross‐sectional study of 698 CRPS patients (599 females) fulfilling the Budapest clinical or research criteria, CRPS signs and symptoms, CRPS severity, pain (average pain intensity in the previous week and McGill pain rating index), pain coping (Pain Coping Inventory), physical limitations (Radboud Skills Questionnaire (upper limb), Walking and Rising questionnaire (lower limb)), anxiety and depression (Hospital Anxiety and Depression scale) and kinesiophobia (Tampa scale for kinesiophobia) were evaluated.ResultsMale CRPS patients used more often extreme words to describe the affective qualities of pain, used more passive pain coping strategies, and were more likely to suffer from depression and kinesiophobia.ConclusionSex‐related differences are present in CRPS, but the effect is generally small and mainly concerns psychological functioning. A greater awareness of sex‐specific factors in the management of CRPS may contribute to achieving better outcomes.SignificanceWhat is known? Nonsex‐specific clinical data of CRPS patients. What is new? Male CRPS patients used more often extreme words to describe the affective qualities of pain, used more passive pain coping strategies, and were more likely to suffer from depression and kinesiophobia.

Morphine effects within the rodent anterior cingulate cortex and rostral ventromedial medulla reveal separable modulation of affective and sensory qualities of acute or chronic pain.

Modulation of pain may result from engagement of opioid receptors in multiple brain regions. Whether sensory and affective qualities of pain are differentially affected by brain opioid receptor circuits remains unclear. We previously reported that opioid actions within the rostral anterior cingulate cortex (ACC) produce selective modulation of affective qualities of neuropathic pain in rodents, but whether such effects may occur in other areas of the ACC is not known. Here, morphine was microinjected into 3 regions of the ACC or into the rostral ventromedial medulla (RVM), and pain behaviors in naive, sham, or spinal nerve ligated (SNL) rats were evaluated. In naive animals, the tail-flick response was inhibited by RVM, but not ACC, morphine. Anterior cingulate cortex morphine did not affect tactile allodynia (the von Frey test) or mechanical (Randall-Selitto) or thermal (Hargreaves) hyperalgesia in spinal nerve ligated rats. In contrary, RVM morphine reduced tactile allodynia and produced both antihyperalgesic and analgesic effects against mechanical and thermal stimuli as well as conditioned place preference selectively in nerve-injured rats. Within the RVM, opioids inhibit nociceptive transmission reflected in both withdrawal thresholds and affective pain behaviors. Activation of mu opioid receptors within specific rostral ACC circuits, however, selectively modulates affective dimensions of ongoing pain without altering withdrawal behaviors. These data suggest that RVM and ACC opioid circuits differentially modulate sensory and affective qualities of pain, allowing for optimal behaviors that promote escape and survival. Targeting specific ACC opioid circuits may allow for treatment of chronic pain while preserving the physiological function of acute pain.

Pain assessment in native and non-native language: difficulties in reporting the affective dimensions of pain.

Background and aims The language in assessing intensity or quality of pain has been studied but the results have been inconsistent. The physicians' language skills might affect the estimation of the severity of pain possibly leading to insufficient use of analgesics. Several interfering cultural factors have complicated studies aimed at exploring the language used to detect the quality of pain. We aimed to compare native and non-native language related qualitative aspects of pain chosen by Swedish speaking patients with diabetes. Methods In the study participated 10 Finnish and 51 Swedish speaking patients with diabetes. The Pain Detect-questionnaire was used for clarifying the patients' pain and the mechanism of their pain (neuropathic or not) and for assessing the intensity and quality of pain. In addition, the patients completed the short-form McGill Pain Questionnaire (sfMPQ) in Finnish (test I). After 30 min the subjects completed the sfMPQ a second time in their native language (test II). The Swedish speakers estimated their second language, Finnish, proficiency on a 5-graded scale. Results There were significantly more discrepancies between sfMPQ test I and test II among the Swedish speaking respondents who reported poor (hardly none) Finnish language proficiency compared with those with good Finnish proficiency. Discrepancies occurred especially between the affective qualities of pain. Conclusions Poor second language proficiency exposes Swedish speakers to pain communication difficulties related to the affective aspects of pain. Consequently, discordant language communication could cause underestimation of the severity of pain and pain undertreatment. Implications To ensure adequate pain treatment measuring the affective dimension of pain in the patient's native language is crucial.

Multiple sites and actions of gabapentin-induced relief of ongoing experimental neuropathic pain.

Gabapentin (GBP) is a first-line therapy for neuropathic pain, but its mechanisms and sites of action remain uncertain. We investigated GBP-induced modulation of neuropathic pain following spinal nerve ligation (SNL) in rats. Intravenous or intrathecal GBP reversed evoked mechanical hypersensitivity and produced conditioned place preference (CPP) and dopamine (DA) release in the nucleus accumbens (NAc) selectively in SNL rats. Spinal GBP also significantly inhibited dorsal horn wide-dynamic-range neuronal responses to a range of evoked stimuli in SNL rats. By contrast, GBP microinjected bilaterally into the rostral anterior cingulate cortex (rACC), produced CPP, and elicited NAc DA release selectively in SNL rats but did not reverse tactile allodynia and had marginal effects on wide-dynamic-range neuronal activity. Moreover, blockade of endogenous opioid signaling in the rACC prevented intravenous GBP-induced CPP and NAc DA release but failed to block its inhibition of tactile allodynia. Gabapentin, therefore, can potentially act to produce its pain relieving effects by (a) inhibition of injury-induced spinal neuronal excitability, evoked hypersensitivity, and ongoing pain and (b) selective supraspinal modulation of affective qualities of pain, without alteration of reflexive behaviors. Consistent with previous findings of pain relief from nonopioid analgesics, GBP requires engagement of rACC endogenous opioid circuits and downstream activation of mesolimbic reward circuits reflected in learned pain-motivated behaviors. These findings support the partial separation of sensory and affective dimensions of pain in this experimental model and suggest that modulation of affective-motivational qualities of pain may be the preferential mechanism of GBP's analgesic effects in patients.

Assessment of Chronic Pain: Domains, Methods, and Mechanisms.

Accurate classification of chronic pain conditions requires reliable and valid pain assessment. Moreover, pain assessment serves several additional functions, including documenting the severity of the pain condition, tracking the longitudinal course of pain, and providing mechanistic information. Thorough pain assessment must address multiple domains of pain, including the sensory and affective qualities of pain, temporal dimensions of pain, and the location and bodily distribution of pain. Where possible, pain assessment should also incorporate methods to identify pathophysiological mechanisms underlying the pain. This article discusses assessment of chronic pain, including approaches available for assessing multiple pain domains and for addressing pathophysiological mechanisms. We conclude with recommendations for optimal pain assessment. Pain assessment is a critical prerequisite for accurate pain classification. This article describes important features of pain that should be assessed, and discusses methods that can be used to assess the features and identify pathophysiological mechanisms contributing to pain.

Three subgroups of pain profiles identified in 227 women with arthritis: a latent class analysis.

The objectives were to identify subgroups of women with arthritis based upon the multi-dimensional nature of their pain experience and to compare health and socio-demographic variables between subgroups. A latent class analysis of 227 women with self-reported arthritis was used to identify clusters of women based upon the sensory, affective, and cognitive dimensions of the pain experience. Multivariate multinomial logistic regression analysis was used to determine the relationship between cluster membership and health and sociodemographic characteristics. A three-class cluster model was most parsimonious. 39.5% of women had a unidimensional pain profile; 38.6% of women had moderate multidimensional pain profile that included additional pain symptomatology such as sensory qualities and pain catastrophizing; and 21.9% of women had severe multidimensional pain profile that included prominent pain symptomatology such as sensory and affective qualities of pain, pain catastrophizing, and neuropathic pain. Women with severe multidimensional pain profile have a 30.5% higher risk of poorer quality of life and a 7.3% higher risk of suffering depression, and women with moderate multidimensional pain profile have a 6.4% higher risk of poorer quality of life when compared to women with unidimensional pain. This study identified three distinct subgroups of pain profiles in older women with arthritis. Women had very different experiences of pain, and cluster membership impacted significantly on health-related quality of life. These preliminary findings provide a stronger understanding of profiles of pain and may contribute to the development of tailored treatment options in arthritis.

Analogous responses in the nucleus accumbens and cingulate cortex to pain onset (aversion) and offset (relief) in rats and humans

In humans, functional magnetic resonance imaging (fMRI) activity in the anterior cingulate cortex (ACC) and the nucleus accumbens (NAc) appears to reflect affective and motivational aspects of pain. The responses of this reward-aversion circuit to relief of pain, however, have not been investigated in detail. Moreover, it is not clear whether brain processing of the affective qualities of pain in animals parallels the mechanisms observed in humans. In the present study, we analyzed fMRI blood oxygen level-dependent (BOLD) activity separately in response to an onset (aversion) and offset (reward) of a noxious heat stimulus to a dorsal part of a limb in both humans and rats. We show that pain onset results in negative activity change in the NAc and pain offset produces positive activity change in the ACC and NAc. These changes were analogous in humans and rats, suggesting that translational studies of brain circuits modulated by pain are plausible and may offer an opportunity for mechanistic investigation of pain and pain relief.

Amygdala activity contributes to the dissociative effect of cannabis on pain perception

Cannabis is reported to be remarkably effective for the relief of otherwise intractable pain. However, the bases for pain relief afforded by this psychotropic agent are debatable. Nonetheless, the frontal-limbic distribution of cannabinoid receptors in the brain suggests that cannabis may target preferentially the affective qualities of pain. This central mechanism of action may be relevant to cannabinoid analgesia in humans, but has yet to be demonstrated. Here, we employed functional magnetic resonance imaging to investigate the effects of delta-9-tetrahydrocannabinol (THC), a naturally occurring cannabinoid, on brain activity related to cutaneous ongoing pain and hyperalgesia that were temporarily induced by capsaicin in healthy volunteers. On average, THC reduced the reported unpleasantness, but not the intensity of ongoing pain and hyperalgesia: the specific analgesic effect on hyperalgesia was substantiated by diminished activity in the anterior mid cingulate cortex. In individuals, the drug-induced reduction in the unpleasantness of hyperalgesia was positively correlated with right amygdala activity. THC also reduced functional connectivity between the amygdala and primary sensorimotor areas during the ongoing-pain state. Critically, the reduction in sensory-limbic functional connectivity was positively correlated with the difference in drug effects on the unpleasantness and the intensity of ongoing pain. Peripheral mechanisms alone cannot account for the dissociative effects of THC on the pain that was observed. Instead, the data reveal that amygdala activity contributes to interindividual response to cannabinoid analgesia, and suggest that dissociative effects of THC in the brain are relevant to pain relief in humans.

Unexpected effect of aripiprazole on nociceptive pain

Aripiprazole (ARP) is an antipsychotic that acts as a modulating partial agonist of the dopamine-2 (D2) receptor, approved for the treatment of schizophrenic disorders [DeLeon et al. 2004] and recently for the treatment of manic mixed episodes associated with bipolar type I disorder [Aitchison et al. 2009; Dhillon, 2012]. Compared with other antipsychotics, its safety and tolerability (low risk of extrapyramidal symptoms [EPS], weight gain and hyperprolactinemia) encourage its use in psychiatric patients with comorbidities. Five psychiatric patients with severe painful internal comorbidities showed unexpected pain improvements during effective treatments of their psychopathological conditions by ARP monotherapy (from 2.5 to 15 mg daily). Pain was assessed regularly in relation to the fact that is considered the ‘fifth vital sign’. These patients had developed nociceptive painful syndromes that responded poorly to opioid and/or non-steroidal anti- inflammatory drugs therapy. They had no symptoms related to non-nociceptive (neurological) pain. With reference to pain and psychology, patients showed a moderate improvement after 2 weeks of treatment and a significant improvement after 4 weeks, as demonstrated by CGI (Clinical Global Impression for severity and improvement scales with endpoints labelled 1 ‘normal, not at all ill’ to 7 ‘among the most extremely ill patients’ and 1 ‘very much improved’ to 7 ‘very much worse’, respectively) and NRS-o (0–10 oral Numeric Rating Scale: visual scale anchored with the endpoints labelled ‘no pain’ near the ‘0’ number and ‘extreme pain’ near the ‘10’ number) scales’ scores used for the assessment of psychopathological state and pain level, respectively (Table 1). No changes in the internal condition, which could account for the improvements concerning pain, were observed. Table 1. Sample features These clinical observations suggest the involvement of brain dopamine (DA) transmission in nociceptive pain pathways as a result of the ‘modulation’ of the dopaminergic system by ARP, although ARP-mediated antagonism on 5HT2A receptors [DeLeon et al. 2004] known as facilitating spinal nociception [Oyama et al. 1996], is possible. The activation of nigrostriatal (dorsal nucleus caudate and putamen) DA D2 receptor-mediated neurotransmission is positively associated with individual variations in subjective ratings of sensory and affective qualities of pain with an increased threshold as outcome [Scott et al. 2006]. In contrast, mesolimbic (nucleus accumbens) DA activation, which may have an impact on both D2 and D3 receptors, is exclusively associated with variations in the emotional responses of the individual during pain challenge (increases in negative affect and fear ratings) [Stahl, 2002]. The ARP antipsychotic mechanism is based on the blockade of mesolimbic D3 receptors, whereas nigrostriatal D2 receptor-mediated activity is not changed by it [Oyama et al. 1996]. So its effect could result in a direct involvement on reduction of pain perception even if a positive unspecific role on pain threshold psychological-mediated is possible. However, these effects on pain perception could be particularly evident owing to the poor effectiveness of common pain treatments in our sample. This is the first report about the relationship between aripiprazole and subjective experience of pain.

Lidocaine Patch (5%) is No More Potent than Placebo in Treating Chronic Back Pain When Tested in a Randomised Double Blind Placebo Controlled Brain Imaging Study

BackgroundThe 5% Lidocaine patch is used for treating chronic neuropathic pain conditions such as chronic back pain (CBP), diabetic neuropathy and complex regional pain syndrome, but is effective in a variable proportion of patients. Our lab has reported that this treatment reduces CBP intensity and associated brain activations when tested in an open labelled preliminary study. Notably, effectiveness of the 5% Lidocaine patch has not been tested against placebo for treating CBP. In this study, effectiveness of the 5% Lidocaine patch was compared with placebo in 30 CBP patients in a randomised double-blind study where 15 patients received 5% Lidocaine patches and the remaining patients received placebo patches. Functional MRI was used to identify brain activity for fluctuations of spontaneous pain, at baseline and at two time points after start of treatment (6 hours and 2 weeks).ResultsThere was no significant difference between the treatment groups in either pain intensity, sensory and affective qualities of pain or in pain related brain activation at any time point. However, 50% patients in both the Lidocaine and placebo arms reported a greater than 50% decrease in pain suggesting a marked placebo effect. When tested against an untreated CBP group at similar time points, the patch treated subjects showed significantly greater decrease in pain compared to the untreated group (n = 15).ConclusionsThese findings suggest that although the 5% Lidocaine is not better than placebo in its effectiveness for treating pain, the patch itself induces a potent placebo effect in a significant proportion of CBP patients.

Is There Physician Bias Against Eliciting Affective Qualities of Pain?

The purpose of this study is to determine the weight given to each of 3 pain dimensions by physicians who assess patients' pain experiences. Pain is a subjective experience that has profound impact on the quality of life. The 101-Multidimensional Affect and Pain Survey (101-MAPS) is currently the only available instrument that takes into account all 3 validated dimensions of pain by classifying 101 items into "superclusters" of sensory pain, suffering, and well-being. Fourteen gastroenterologists, 11 internists, and 11 medicine residents from 2 teaching hospitals rated the items on the 101-MAPS based on their perception of the items' relevance to pain in gastrointestinal diseases, on a scale of 0 (least relevant) to 5 (most relevant). Of the 101 items in the MAPS rated by gastroenterologists, 25 items received a median rating of 4 or above. Of these, 23 were selected from the 57 items in the sensory pain supercluster (40%) and only 1 item each from the 26 in the suffering (3.8%), and the 18 in the well-being (5.5%) dimensions. These proportions were significantly lower for the suffering (P<0.01) and well-being (P<0.05) superclusters than for the sensory pain dimension. These findings suggest a bias among physicians toward sensory and against affective qualities when eliciting patients' pain experiences. The results also suggest that this bias is found as early as residency training and persists among specialists.

Is There Physician Bias Against Eliciting Affective Qualities of Pain?

Is There Physician Bias Against Eliciting Affective Qualities of Pain?

Belief or Need? Accounting for individual variations in the neurochemistry of the placebo effect

The activation of pain-suppressive, endogenous opioid neurotransmission after administration of a placebo with expectation of analgesia has been directly demonstrated in humans using molecular imaging techniques in recent work. Regional effects were described in the dorsolateral prefrontal cortex, pregenual anterior cingulate, anterior insula, and nucleus accumbens. However, it was also observed that the magnitude of these responses was subject to substantial individual and regional variation. The present study was undertaken to examine the contribution of various factors to the observed variability in the neurochemical responses to placebo administration. Multiple regression analyses were conducted on data from 19 healthy males to study to what degree expectations of analgesia and various elements of the experience of pain itself, in the absence of placebo, were associated with the individual and brain regional variability in endogenous opioid neurochemical responses to placebo. A model that included affective qualities of pain, the volume of algesic stimulus required to maintain pain over the experimental period within a moderate range, and the internal affective state of the volunteers contributed to 40–68% of the variance in the regional neurochemical responses to placebo. These initial data suggests that in the case of endogenous opioid mediated placebo analgesic responses, the individual experience of pain, in particular its affective elements, the internal affective state of the individuals during pain and a measure of sustained pain sensitivity are important factors contributing to the formation of a placebo effect. Further examination of individual variations in placebo responding will need to take into account the underlying process for which relief is required.

Associations among pain intensity, sensory characteristics, affective qualities, and activity limitations in patients with chronic pain: A momentary, within-person perspective

Abstract The purpose of this article is to explore the multidimensionality of the pain experience for patients with chronic pain by using a within-person, longitudinal approach. An Ecological Momentary Assessment design with a patient electronic diary was used to collect random momentary pain assessments several times a day for 2 weeks. We examined the within-person relationships between pain intensity, sensory characteristics, affective qualities, and activities limited by pain. All 3 dimensions (sensory, affective, and activities) were significantly related to pain intensity in a monotonic, but nonlinear, manner. These results expand our understanding of the pain experience by showing that changes of pain over time are associated with changes in sensory symptoms, affective distress, and activity limitations. Perspective Although the relationships between pain dimensions have been examined between people, the results have been interpreted as within-persons. This article confirms that pain intensity is significantly related to sensory characteristics of pain, affective qualities of pain, and activity limitations due to pain within a person.

Integrating experiential–phenomenological methods and neuroscience to study neural mechanisms of pain and consciousness

Understanding the nature of pain at least partly depends on recognizing its inherent first person epistemology and on using a first person experiential and third person experimental approach to study it. This approach may help to understand some of the neural mechanisms of pain and consciousness by integrating experiential–phenomenological methods with those of neuroscience. Examples that approximate this strategy include studies of second pain summation and its relationship to neural activities and brain imaging-psychophysical studies wherein sensory and affective qualities of pain are correlated with cerebral cortical activity. The experiential paradigm of Price and Barrell (1980) offers the possibility of improved designs and methods for investigating neural mechanisms underlying pain and consciousness.

The molecular dynamics of pain control.

Pain is necessary for survival, but persistent pain can result in anxiety, depression and a reduction in the quality of life. The discriminative and affective qualities of pain are both thought to be regulated in an activity-dependent fashion. Recent studies have identified cells and molecules that regulate pain sensitivity and the parallel pathways that distribute nociceptive information to limbic or sensory areas of the forebrain. Here, we emphasize the cellular and neurobiological consequences of pain, especially those that are involved in the generation and maintenance of chronic pain. These new insights into pain processing will significantly alter our approach to pain control and the development of new analgesics.

An intrusive impact of anchors in children's faces pain scales

The numerous pain rating scales using faces depicting varying degrees of distress to elicit reports of pain from children fall into two categories; those with a neutral face as the `no pain' anchor, and those with a smiling face as the `no pain' anchor. This study examined the potentially biasing impact of these anchor types on children's self-reports of pain in response to a series of vignettes. Participants were 100 children stratified by age (5–6 years, 7–8 years, 9–12 years) and randomly assigned to one of three groups: (1) neutral scale/sensory instructions; (2) smiling scale/sensory instructions; (3) smiling scale/affective instructions. Children completed a faces scale, a VAS, and emotions ratings in response to four scenarios depicting: (1) no pain/negative emotions; (2) pain/negative emotions; (3) no pain/positive emotions; (4) pain/positive emotions. Results showed that children who used the smiling scale had significantly higher pain scores for no pain and pain/negative emotions vignettes and significantly lower faces scale scores for pain/positive vignettes than children who used the neutral faces scale. Instructions varying in focus on sensory or affective qualities of pain had no effect on children's pain ratings. Group differences in children's ratings with the VAS and emotions measure suggested that rating pain with a smiling faces scale may alter a child's concept of pain. Age differences indicated the younger children rated the negative emotion vignettes as more painful than the older children. These findings suggest that children's pain ratings vary depending on the types of faces scale used, and that faces scales with smiling anchors may confound affective states with pain ratings.