This paper proposes that human expression of pain in the presence or absence of caregivers, and the detection of pain by observers, arises from evolved propensities. The function of pain is to demand attention and prioritise escape, recovery, and healing; where others can help achieve these goals, effective communication of pain is required. Evidence is reviewed of a distinct and specific facial expression of pain from infancy to old age, consistent across stimuli, and recognizable as pain by observers. Voluntary control over amplitude is incomplete, and observers can better detect pain that the individual attempts to suppress rather than amplify or simulate. In many clinical and experimental settings, the facial expression of pain is incorporated with verbal and nonverbal vocal activity, posture, and movement in an overall category of pain behaviour. This is assumed by clinicians to be under operant control of social contingencies such as sympathy, caregiving, and practical help; thus, strong facial expression is presumed to constitute and attempt to manipulate these contingencies by amplification of the normal expression. Operant formulations support skepticism about the presence or extent of pain, judgments of malingering, and sometimes the withholding of caregiving and help. To the extent that pain expression is influenced by environmental contingencies, however, "amplification" could equally plausibly constitute the release of suppression according to evolved contingent propensities that guide behaviour. Pain has been largely neglected in the evolutionary literature and the literature on expression of emotion, but an evolutionary account can generate improved assessment of pain and reactions to it.

/pdf/facial-expression-of-pain-an-evolutionary-account-5fdom5b8ec.pdf

Facial expression of pain: an evolutionary account.

http://www.aspmn.org/documents/PainAssessmentinthePatientUnabletoSelfReport.pdf

Pain assessment in the patient unable to self-report: position statement with clinical practice recommendations.

Summary Background: Difﬁculty with pain assessment in individuals whocannot self-report their pain poses a signiﬁcant barrier to effective painmanagement. However, available assessment tools lack consistentreliability as pain measures in children with cognitive impairment(CI). This study evaluated the validity and reliability of the revisedand individualized Face Legs Activity Cry and Consolability (FLACC)behavioral pain assessment tool in children with CI.Methods: Children with CI scheduled for elective surgery werestudied. The FLACC was revised to include speciﬁc descriptors andparent-identiﬁed, unique behaviors for individual children. Thechild’s ability to self-report pain was evaluated. Postoperatively, twonurses scored pain using the revised FLACC scale before and afteranalgesic administration, and, children self-reported a pain score, ifable. Observations were videotaped and later viewed by experiencednurses blinded to analgesic administration.Results: Eighty observations were recorded in 52 children aged4–19 years. Twenty-one parents added individualized pain behaviorsto the revised FLACC. Interrater reliability was supported by excellentintraclass correlation coefﬁcients (ICC, ranging from 0.76 to 0.90) andadequate j statistics (0.44–0.57). Criterion validity was supported bythe correlations between FLACC, parent, and child scores (q ¼ 0.65–0.87; P < 0.001). Construct validity was demonstrated by the decreasein FLACC scores following analgesic administration (6.1 ± 2.6 vs1.9 ± 2.7; P < 0.001).Conclusions: Findings support the reliability and validity of theFLACC as a measure of pain in children with CI.Keywords: pain assessment; developmentally delayed children; facelegs activity cry and consolability pain tool

/pdf/the-revised-flacc-observational-pain-tool-improved-2wtqpeqlkk.pdf

The revised FLACC observational pain tool: improved reliability and validity for pain assessment in children with cognitive impairment

https://www.jpsmjournal.com/article/S0885-3924(05)00611-1/pdf

Tools for Assessment of Pain in Nonverbal Older Adults with Dementia: A State-of-the-Science Review

A theoretical framework for understanding self-report and observational measures of pain: a communications model

To create a checklist of behaviours that caregivers could use to determine pain in non-verbal individuals with mental retardation, primary caregivers were recruited by the Division of Neurology and interviewed using a semistructured interview. Caregivers of 20 individuals were asked to recall two instances of short, sharp pain and two of longer-lasting pain and describe the individual's behaviour. Transcribed interviews were reviewed by two of the authors and sets of non-overlapping items were developed. Average age of the 20 individuals was 14.5 years (range 6 to 29 years) and language level averaged 10 months as scored by the MacArthur Communicative Development Inventory. All had mental retardation and 18 had epilepsy and spastic quadriplegia or hemiparesis. Thirty-one behaviours were extracted from the interviews. The specific behaviours were often different from one child to another but the classes of behaviours (Vocal, Eating/Sleeping, Social/Personality, Facial expression of pain, Activity, Body and limbs, and Physiological) were common to almost all children. Reliability of using the checklist on interviews was very good (kappa=0.77). The checklist has excellent content validity and will be useful for caregivers of cognitively-impaired, non-verbal individuals to report on pain behaviours. Further research is needed to additionally assess its validity and sensitivity.

Behaviours caregivers use to determine pain in non-verbal, cognitively impaired individuals

To obtain a preliminary validation of the Non-Communicating Children's Pain Checklist for individuals with an inability to communicate verbally, 32 caregivers of individuals with cognitive impairments aged 3 to 44 years retrospectively completed the Non-Communicating Children's Pain Checklist and rated item usefulness (0 to 10). In the second part of the study 33 caregivers completed the Checklist after two painful (e.g. burns, falls, surgery), one distressful (e.g. unwanted grooming, feared animal/noise), and one calm event (e.g. watching television). Checklist scores did not correlate with the age, sex, or physical limitations of individuals with an inability to communicate verbally. In the first part of the study Cronbach's alpha was 0.66; all mean usefulness ratings exceeded 5 out of 10. In the second part of the study after four items were removed, Cronbach's alpha was 0.79. Checklist scores during pain correlated with numerical ratings of pain intensity did not differ between the two pain events, and differed significantly from calm scores. Differences in Checklist scores during pain and distress were found for two subscales. The Checklist exhibits internal consistency, and preliminary evidence suggests it can detect pain and is reliable over time.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1469-8749.2000.tb00366.x

Christina Rosmus

Papers

Behaviours caregivers use to determine pain in non-verbal, cognitively impaired individuals

Preliminary validation of an observational pain checklist for persons with cognitive impairments and inability to communicate verbally.

Measuring pain accurately in children with cognitive impairments: refinement of a caregiver scale.