Pain Cues Research Articles

Health-Care Workers' Judgments About Pain in Older Palliative Care Patients With and Without Delirium.

Delirium complicates pain assessment and management in advanced cancer. This retrospective cohort study compared health-care workers' (HCWs) cancer pain judgments between older patients with advanced cancer with and without a diagnosis of delirium. We reviewed HCWs' daily chart notations about pain presence and good pain control in 149 inpatients with advanced cancer, ≥65 years of age, admitted to a palliative care inpatient unit. Any day with 1 or more notations of pain presence was counted as 1 day with pain; days with notation(s) indicating good pain control were similarly counted. Proportions of days that HCWs judged inpatients to have pain and good pain control were calculated. Patients with and without a delirium diagnosis were compared on both pain outcomes. The moderating effect of highest analgesic class administered was examined. Although most patients received opioid analgesics, mean proportions of days with judged pain were high (39%-60%) and mean proportions of days with judged good pain control were low (<25%) across groups. Among patients receiving either opioid or nonopioid medication, patients with delirium demonstrated lower proportions of days with judged good pain control than patients without delirium ( P ≤ .001), even though groups did not differ in proportions of days with judged pain ( P = .62). Cancer pain is difficult to manage in advanced cancer, especially when delirium is present; however, misinterpretation of delirium symptoms as pain cues may inflate pain judgments. Findings require replication but suggest the need for better pain assessment in older patients with advanced cancer and delirium.

Child attention to pain and pain tolerance are dependent upon anxiety and attention control: An eye-tracking study.

Pain is common and can be debilitating in childhood. Theoretical models propose that attention to pain plays a key role in pain outcomes, however, very little research has investigated this in youth. This study examined how anxiety-related variables and attention control interacted to predict children's attention to pain cues using eye-tracking methodology, and their pain tolerance on the cold pressor test (CPT). Children aged 8-17years had their eye-gaze tracked whilst they viewed photographs of other children displaying painful facial expressions during the CPT, before completing the CPT themselves. Children also completed self-report measures of anxiety and attention control. Findings indicated that anxiety and attention control did not impact children's initial fixations on pain or neutral faces, but did impact how long they dwelled on pain versus neutral faces. For children reporting low levels of attention control, higher anxiety was associated with less dwell time on pain faces as opposed to neutral faces, and the opposite pattern was observed for children with high attention control. Anxiety and attention control also interacted to predict pain outcomes. For children with low attention control, increasing anxiety was associated with anticipating more pain and tolerating pain for less time. This is the first study to examine children's attention to pain cues using eye-tracking technology in the context of a salient painful experience. Data suggest that attention control is an important moderator of anxiety on multiple outcomes relevant to young people's pain experiences. This study uses eye tracking to study attention to pain cues in children. Attention control is an important moderator of anxiety on attention bias to pain and tolerance of cold pressor pain in youth.

Healthcare Providers’ Nonverbal Behavior can Lead Patients to Show Their Pain More Accurately: An Analogue Study

Accurate pain assessment is a joint function of both the judge perceiving correct (valid) cues of pain and targets displaying valid indicators of pain. The present research examined whether the judgeability of pain expressions could be altered by manipulating the nonverbal supportiveness of a videotaped physician who guided targets through an experimentally induced pain experience in the laboratory. Ten-s video clips of these targets during their pain experience were viewed by 95 naive judges who assessed each target’s pain on an 11-point numeric rating scale. In addition, the video clips were rated by independent coders on 9-point scales (focused, calm, tense, distressed, composed, fidgety, determined, bored, and nervous). Judges’ pain assessment accuracy was calculated by correlating their inferred pain rating for each target with targets’ self-reported pain. Pain targets assigned to interact with the nonverbally supportive physician displayed more valid impressions of their pain and judges had higher pain assessment accuracy when viewing these targets compared to targets assigned to interact with the nonverbally unsupportive physician. Interventions for caregivers and healthcare providers that emphasize the importance of nonverbal behavior when interacting with pain sufferers are discussed.

Management of persistent pain in older people

AbstractPersistent pain is a commonly experienced symptom. It affects 25% of community‐dwelling older adults and up to 80% of nursing home residents, and can have a major impact on quality of life and functional capacity. Unfortunately pain in older patients is often undertreated and misunderstood. Assessment of pain type and severity is important. Most older people, even with moderately impaired cognition, are able to self‐report pain. Validated assessment tools using non‐verbal pain cues are available for people with more advanced cognitive impairment. Management of pain in older people can be challenging. Physiological changes may impact on pain perception and the pharmacodynamics and pharmacokinetics of medications. Older people are often more sensitive to the adverse effects of analgesic medications and are at risk of drug–drug interactions due to the presence of co‐morbidities and polypharmacy. In general, analgesic medications should be commenced at low doses, titrated based on effect and tolerability, and regularly reviewed. Contemporary pain management often utilises multiple analgesics in lower doses to optimise efficacy and avoid dose‐related toxicity. A bio‐psycho‐social approach to the management of persistent pain, utilising a multidisciplinary team and including non‐drug strategies, may produce the best results. The goal of pain management is not always to eliminate pain, since this may not be attainable, but rather to enhance function and improve quality of life. This article discusses persistent non‐cancer pain in older people, its assessment and management, and the risks and benefits of pharmacological treatment in this population.

G230 Supporting parents ofchildren who have complex needs to assess and manage their children’s pain: health care practitioners’ perspectives

Aim The aim of this paper is to present findings on the ways in which health care practitioners who work with children with complex needs can support parents in assessing and managing their child’s pain. Methods The data reported here are from semi-structured interviews undertaken with health care practitioners based at a tertiary children’s hospital in the UK. These data are part of a larger mixed methods study. Data were analysed using thematic analysis. Results Nineteen healthcare practitioners from a variety of disciplinary backgrounds (e.g. neurologists, nurses, physiotherapists) and with different experience (1–27 years) of working with children with complex needs participated in the study. Only one of the nineteen practitioners interviewed had had formal training on the management of pain in children with complex needs. Practitioners reported taking a multi-layered approach to managing pain in children with complex needs, which meant including parents, using skills of observation and referring to other members of the multidisciplinary team. The practitioners supported parents in the management of their child’s pain by engaging with them, listening to them and also managing their expectations, although it was noted that parents’ relationships with nurses could be problematic. Most practitioners felt parents had a central role in the management of their child’s pain, although it was noted the role could vary and that the multidisciplinary team needed to provide opportunities for parents to give feedback. Practitioners felt that parents had a critical knowledge of their child’s pain but not of pain itself. It was suggested that a critical knowledge of their child’s pain takes time to develop and that some parents can misread pain cues. Most practitioners felt that parents did not receive adequate training and support to manage their child’s pain. Conclusion Practitioners value the knowledge of parents of children with complex needs and acknowledge the central role parents play in managing their child’s pain. However, there is a need for practitioners to have formal education in the management of pain in children with complex needs so that they in turn can provide training and support for parents.

Inducing bias modulates sensitivity to nonverbal cues of others' pain.

There is ample research to support the existence of bias in the perception of others' pain. Both studies involving health-care professionals and student surrogate samples have found that, firstly, pain is under-perceived when using nonverbal cues to gauge another's suffering and, secondly, that personal characteristics of both the viewer and the target (such as gender) can bias pain perception, affecting the allocation of help. However, the extant research shows conflicts about the direction of the bias that target gender exerts on pain perception. Our study aims to address these challenges by examining whether under-perception of pain can be attenuated or exacerbated with gender primes and how target gender affects nonverbal pain perception, in particular. University students (N = 120) were primed with either masculine, neutral, or feminine concepts followed by photos of male and female targets displaying various levels of pain and asked to quantify the photographed targets' distress. Participants perceived lower target distress when this task was preceded by a masculine gender prime, as compared to a neutral or feminine gender prime. Pain was underestimated for all targets; however, this underestimation was significantly more pronounced for female targets. These results suggest that gender cues may influence the perception of observed pain and, as a result, clinical decision making. They also support the conjecture that nonverbal pain cues may be under-perceived in women.

Surgeons’ aims and pain assessment strategies when managing paediatric post-operative pain

Children experience moderate to severe pain post-operatively. Nurses have been found to have a variety of aims in this context. Surgeons' aims when managing post-operative pain have not been explored. This qualitative study set out to explore paediatric surgeons' aims when managing post-operative pain in one paediatric hospital in Canada. Consultant surgeons (n = 8) across various specialities took part in semi-structured interviews. Surgeons' overarching aim was to keep the child comfortable. Various definitions of comfortable were given, relating to the child's experience of pain itself and their ability to undertake activities of daily living. Children's behavioural pain cues seem to be a primary consideration when making treatment decisions. Parents' views regarding their child's pain were also seen as important, suggesting children may not be seen as competent to make decisions on their own behalf. The need to maintain a realistic approach was emphasised and pain management described as a balancing act. Surgeons may draw on both tacit and explicit knowledge when assessing children's pain. There appears to be an expectation among surgeons that some pain is to be expected post-operatively and that the diagnostic value of pain may, in some cases, supersede concerns for the child's pain experience.

Expectancy-related modulation of pain: altered sensory processing or biased perceptual decision-making?

age: 23.4)  Two forced choice task (perceptual categorization: high or low pain)  Probabilistic cueing paradigm Cue (80/20): predictive of high pain (80%) Cue (50/50): non-predictive  Cue contingency test  Electrical stimulation (individually calibrated) High pain intensity (8/10 on VAS, 4.37mA + 3.37)) Low pain intensity (2/10 on VAS, 1.43 mA + 0.94))  160 trials (4 block with 40 trials)  ITI ( 3,5 or 7s) 750 800 850

Contextual and time dependent pain in fibromyalgia: An explorative study

BackgroundLittle is known about contextual effects on chronic pain, and how vulnerability factors influence pain in different contexts. We wanted to examine if fibromyalgia (FM) pain varied between two social contexts, i.e. at home versus in a doctor office, when it was measured the same day, and if pain was stable for 14 years when measured in similar contexts (doctor office). Our secondary aim was to explore if pain vulnerability factors varied in the two different contexts.FindingsFifty-five female FM patients were included in the study and scored pain in both contexts at baseline. Their age ranged between 21–68 years (mean 45.7), mean education level was 11 years and mean FM-duration was 15.6 years. Their mean pain was perceived significantly lower at home than in a doctor context the same day. However, pain was much more stable when measured in two similar contexts 14 year apart where 30 subjects (54.5%) completed. Predictor analyses revealed that pain vulnerability factors apparently varied by home and doctor contexts.ConclusionPain and pain predictors seem to vary by contexts and time, with less pain at home than to a doctor the same day, but with unchanged pain in the same context after 14 years. Thus, contextual pain cues should be accounted for when pain is measured and treated, e.g. by focusing more on home-measured pain and by optimizing the doctor office context. This explorative study should be followed up by a larger full-scale study.

Attentional bias towards pain-related information diminishes the efficacy of distraction

Distraction is a strategy that is commonly used to cope with pain. Results concerning the efficacy of distraction from both experimental and clinical studies are variable, however, and indicate that its efficacy may depend on particular circumstances. Several models propose that distraction may be less effective for people who display a large attentional bias towards pain-related information. This hypothesis was tested in an experimental context with 53 pain-free volunteers. First, attentional bias towards cues signalling the occurrence of pain (electrocutaneous stimuli) and towards words describing the sensory experience of this painful stimulus was independently assessed by means of 2 behavioural paradigms (respectively, spatial cueing task and dot-probe task). This was followed by a subsequent distraction task during which the efficacy of distraction, by directing attention away from the electrocutaneous stimuli, was tested. In addition, state–trait anxiety, catastrophic thinking, and initial pain intensity were measured. Results indicated that people who display a large attentional bias towards predictive cues of pain or who initially experience the pain as more painful benefit less from distraction on a subsequent test. No effects were found between attentional bias towards pain words, state–trait anxiety, catastrophic thinking, and the efficacy of distraction. Current findings suggest that distraction should not be used as a ‘one size fits all’ method to control pain, but only under more specific conditions.

Nonconscious activation of placebo and nocebo pain responses

The dominant theories of human placebo effects rely on a notion that consciously perceptible cues, such as verbal information or distinct stimuli in classical conditioning, provide signals that activate placebo effects. However, growing evidence suggest that behavior can be triggered by stimuli presented outside of conscious awareness. Here, we performed two experiments in which the responses to thermal pain stimuli were assessed. The first experiment assessed whether a conditioning paradigm, using clearly visible cues for high and low pain, could induce placebo and nocebo responses. The second experiment, in a separate group of subjects, assessed whether conditioned placebo and nocebo responses could be triggered in response to nonconscious (masked) exposures to the same cues. A total of 40 healthy volunteers (24 female, mean age 23 y) were investigated in a laboratory setting. Participants rated each pain stimulus on a numeric response scale, ranging from 0 = no pain to 100 = worst imaginable pain. Significant placebo and nocebo effects were found in both experiment 1 (using clearly visible stimuli) and experiment 2 (using nonconscious stimuli), indicating that the mechanisms responsible for placebo and nocebo effects can operate without conscious awareness of the triggering cues. This is a unique experimental verification of the influence of nonconscious conditioned stimuli on placebo/nocebo effects and the results challenge the exclusive role of awareness and conscious cognitions in placebo responses.

Nonpain goal pursuit inhibits attentional bias to pain

Although dealing with pain is a vital goal to pursue, most individuals are also engaged in the pursuit of other goals. The aim of the present experiment was to investigate whether attentional bias to pain signals is inhibited when one is pursuing a concurrent salient but nonpain task goal. Attentional bias to pain signals was measured in pain-free volunteers (n=63) using a spatial cueing task with pain cues and neutral cues. The pursuit of a concurrent goal was manipulated by including additional trials in which a digit appeared at the middle of the screen. Half of the participants (goal group) were instructed to name these additional stimuli aloud. In order to increase the affective-motivational value of this non-pain-related goal, monetary reward and punishment were made contingent upon the performance of this task. Participants of the control group did not perform the additional task. As predicted, the results show attentional bias to pain signals in the control group, but not in the goal group. This indicates that attentional bias to signals of impending pain is inhibited when one is engaged in the pursuit of another salient but nonpain goal. The results of this study underscore a motivational view on attention to pain, in which the pursuit of multiple goals, including nonpain goals, is taken into account.

Critical care nurses’ judgement of pain status: A case study design

In the performance of their professional activities, critical care nurses routinely make important judgements based on uncertain, fallible and inter-substitutable data. It is anticipated that this study will make visible the strategy by which critical care nurses use and combine multiple fallible cues, of which little is known, to reach a judgement about the pain status of the ventilated patient after coronary artery bypass graft (CABG) surgery. The study was conducted in one intensive care unit in a large university hospital with thirty critical care nurses and thirty ventilated patients. Nurses providing care for critically ill ventilated patients post CABG surgery were asked to think aloud, whilst the researcher simultaneously observed patient pain behaviours. For the purposes of this article, two contrasting pain episodes will be presented, namely, incident pain related to repositioning (initial hour) versus pain at rest (five hours later) post CABG surgery. Critical care nurses utilised different combinations of pain cues to make a judgement that the ventilated patient was either at 'risk for acute pain' during repositioning (initial hour) or was 'in acute pain' at rest (five hours) post CABG surgery. The combinations were: a 'primary preventative pain cue pattern' and a 'pain behaviour cue pattern', which were reliant on the critical care nurse's constant surveillance at the bedside linked with a theoretical and practical understanding of how pain, against a background of rapidly changing haemodynamics, could lead to a swift deterioration in a ventilated patient post CABG surgery.

Parental attention to their child's pain is modulated by threat-value of pain.

The present study investigated parental attention and sensitivity to their child's pain and the moderating role of child's facial pain expressiveness and induced threat. Sixty-two parents (49 mothers; 13 fathers) of schoolchildren observed their child undergoing painful and nonpainful heat trials and were requested to rate the presence of pain after each trial. Painful versus nonpainful trials were signaled by the presence of either a yellow or blue circle; one color served as a cue for possible pain delivery (i.e., conditioned pain cue), whereas the other served as a cue for a nonpainful trial. A subsequent visual search task (VST) assessed attention to pain cues by asking parents to identify a target presented within the conditioned pain cue or one of several other colored circles. Parents were randomly assigned to a "high threat" or "low threat" group in which either threatening or neutral information about the child's pain was provided. Signal detection analyses indicated that parents' ability to detect pain (i.e., sensitivity) was enhanced for parents in the high-threat group and for parents whose children expressed high pain. Visual search analyses indicated attentional engagement to child pain only among parents in the high-threat group whose child showed high-pain expressiveness. In all other circumstances, a tendency to avoid pain cues was observed. These findings attest to the importance of pain-related threat in understanding parent attention to child pain. Theoretical and clinical implications and future research directions are discussed.

Empathy for Pain from Adolescence through Adulthood: An Event-Related Brain Potential Study

Affective and cognitive empathy are traditionally differentiated, the affective component being concerned with resonating with another’s emotional state, whereas the cognitive component reflects regulation of the resulting distress and understanding of another’s mental states (see Decety and Jackson, 2004 for a review). Adolescence is a critical period for the development of cognitive control processes necessary to regulate affective processes: it is only in young adulthood that these control processes achieve maturity (Steinberg, 2005). Thus, one should expect adolescents to show greater automatic empathy than young adults. The present study aimed at exploring the neural correlates of affective (automatic) and cognitive empathy for pain from adolescence to young adulthood. With this aim, Event Related Potentials (ERPs) were recorded in 32 participants (aged 11–39) in a task designed to dissociate these components. ERPs results showed an early automatic fronto-central response to pain (that was not modulated by task demand) and a late parietal response to painful stimuli modulated by attention to pain cues. Adolescents exhibited earlier automatic responses to painful situations than young adults did and showed greater activity in the late cognitive component even when viewing neutral stimuli. Results are discussed in the context of the development of regulatory abilities during adolescence.

Pain in the Elderly

Assessing pain in elderly persons, who have diminished capacity to communicate verbally, requires use of observational scales that focus upon nonverbal behavior. Facial expression has been recognized as providing the most specific and sensitive nonverbal cues for pain. This study examined the validity of facial expression components of 6 widely used pain assessment scales developed for elders with dementia. Descriptions of the facial expression of pain vary widely on these scales. The detailed, anatomically based, objectively coded, and validated Facial Action Coding System was used as a criterion index to provide a definitive description of the facial expression of pain. Thirty elderly inpatients with clinically significant pain in the back or hip, the majority of whom had cognitive impairments, provided videotaped reactions to physical activities. Participants' facial expressions were videotaped during 4 randomly ordered physical activities and coded by a qualified Facial Action Coding System coder. Three 6-second clips indicative of mild, moderate, and severe pain intensities were selected for study for each participant. The 90 clips were coded by 5 raters using the facial expression components of the following observational scales: Doloplus-2, Mahoney, Abbey, pain assessment checklist for seniors with limited ability to communicate, noncommunicative patient's Pain Assessment Instrument, and Pain Assessment in Advanced Dementia. Overall, scales that provided specific descriptions using the empirically displayed facial actions associated with pain yielded greater sensitivity, interjudge reliability, and validity as indices of pain. Facial expression items on observational scales for assessing pain in the elderly benefit from adherence to empirically derived descriptions. Those using the scales should receive specific direction concerning cues to be assessed. Observational scales that provide descriptors that correspond to how people actually display facial expressions of pain perform better at differentiating intensities of pain.

Parent Involvement in Pain Management for NICU Infants: A Randomized Controlled Trial

To demonstrate feasibility and estimate the effect of an intervention to increase parental involvement in infant pain management in the NICU on parents' stress and postdischarge parenting competence and confidence. The study involved a randomized controlled trial. Parents recruited from 4 NICUs were randomly assigned by site to receive (1) a pain information booklet and instruction on infant comforting techniques (n = 84 intervention) in addition to a generic NICU care booklet or (2) the generic NICU care booklet alone (n = 85 control). The primary outcome was postintervention Parent Stressor Scale: NICU (PSS:NICU) scores. Secondary outcomes included parent attitudes about infant pain, nursing pain assessment, and parenting competence and role attainment after discharge. No differences were found between groups in PSS:NICU scores. Significant differences favoring the intervention group were found for satisfaction with pain information, parents shown infant pain cues and comforting techniques, nursing pain assessment, and parent preference for involvement during painful procedures. Role attainment after discharge was higher for the intervention group than for the control group. Both the intervention and control groups highly valued attention to infant pain and wanted information and involvement. These results provide no evidence of a reduction in NICU-related stress for parents who receive an intervention to increase their understanding and involvement in infant pain management. However, parents in the intervention group were better prepared to take an active role in infant pain care and had more positive views about their role attainment in the postdischarge period.

Some Thoughts on Trauma, Pain, Posttraumatic Stress Disorder and Traumatic Brain Injury

Aversive learning and memory processes are common in pain and post-traumatic stress disorder (PTSD) and involve some of the same brain areas such as the amygdala, the insula and the anterior cingulate cortex. It is very likely that the deficient extinction of fear or pain responses is the core deficit in these disorders rather than enhanced acquisition (Flor, 2009; Milad, Rauch, Pitman, & Quirk, 2006). A special role for extinction is played by the prefrontal cortex, which shows structural and functional abnormalities in pain and PTSD (e.g., Daniels et al., 2010; Geha et al., 2008). In addition, severe forms of PTSD are accompanied by dissociative states and research shows that dissociation impedes learning (Ebner-Priemer et al., 2009). This may explain why we often have great difficulties in teaching extinction to those affected by PTSD—they do not process and store new information properly. In addition, the hippocampal deficits that have been observed in patients with PTSD impair context conditioning (Pohlack et al., in press) and this keeps these individuals from differentiating safe and dangerous contexts and subsequently danger cues may prevail and become dominant (Gilbertson et al., 2007). Another interesting phenomenon is the fact that stress analgesia is enhanced in PTSD patients suggesting that they have more attenuation of acute pain in stress situations than traumatized persons without PTSD or healthy controls (Diener et al., 2011; Pitman, van der Kolk, Orr, & Greenberg, 1990). This is in contrast to the enhanced rate of chronic pain problems in this group and not easily explained. Another problem is that cognitive deficits are frequent in chronic pain, PTSD and of, course in TBI (Gualtieri & Morgan, 2008; Moriarty, McGuire, & Finn, in press; Skandsen et al., 2010). How this negatively impacts assessment is not really known and new methods for reporting pain may have to be devised. For example, measures of functioning may be more appropriate. In addition, there may be long-lasting changes in the brain after TBI symptoms have already subsided (Chen, Epstein, & Stern, 2010) and this may also be the case with PTSD and pain making it difficult to predict if being sent to a war zone after recovery might not again trigger the same problem due to the long-lasting cognitive and thus also neuroplastic changes. A special problem in the context of assessment is memory distortion that is frequent in both pain and PTSD and that may lead to wrong conclusions about signs and symptoms. DSM-V might improve on postconcussive symptom definition by including overlap or a new category such as ‘‘combat stress’’ including polytrauma. Sleep disorders are frequent in these multiply affected individuals and we know now that sleep is essential for memory and learning (Diekelmann & Born, 2010) and it can be assumed that sleep deficits are related to both symptoms and difficulty in acquiring new information about fear and pain cues. When addiction is present, the processing of reinforcing stimuli other than those related to addiction may also be impaired and this may enhance anxiety, depression and pain (Park et al., 2010). There is a great need for comparative studies for these disorders and their combination and specifically for the analysis of neuropsychological and neurobiological mechanisms that may partially be overlapping between these disorders. H. Flor (&) Department of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Heidelberg University, J5, 68159 Mannheim, Germany e-mail: herta.flor@zi-mannheim.de

Examining Nurse Empathy for Infant Procedural Pain: Testing a New Video Measure

Research reporting effective pain care strategies exists, yet it is not translated to care. Little is known about how repeated pain exposure has affected nurses' ability to be empathetic and use their knowledge to provide evidence-based care. Concerns have been raised regarding the validity of self-report empathy instruments; therefore, a novel video program was developed for testing. It was hypothesized that those who viewed infants in painful and nonpainful states would have a measureable empathy (pain rating) response correlating to the level of pain expressed by the infants. To validate the newly developed Empathy for Infant Pain video program (EIPvp) by determining whether nurse and non-nurse control groups' pain scores of 24 video clips showing infants undergoing real medical procedures were equal. A descriptive cross-sectional video judgement study. Fifty female participants (25 nurses and 25 allied health controls) were asked to score the infant procedural pain level displayed in the EIPvp using a visual analogue scale and a composite score of known infant pain cues. Participants also scored their own sensitivity to painful events. Participants rated the videos contained in the EIPvp similarly in three categories (no, low or high pain); however, there were consistent differences between groups within the categories. Nurses scored facial cues for all categories higher than the control group. Nurses scored their own pain in hypothetical situations and that of the infants consistently higher than the control group. The EIPvp yielded predictable responses from both the nurse and non-nurse control groups when scoring the pain expressed in the video clips. Nurses' detection of pain more often than controls may have been an indication that they have greater knowledge of pain cues, or their empathy levels may have been different as a result of their exposure to, or their perceived relationship with, patients. The EIPvp was validated and has promising potential for training and research purposes.

Pain in People with Dementia and Impaired Verbal Communication

EDITOR'S ABSTRACTAssessment and management of pain in patients with dementia is described. How cognitively impaired patients communicate pain is addressed. Inability to express pain verbally, pain cues, and behavioral disturbances are described. Discomfort, agitation, and dementia behavior are described.