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The Revised IASP Definition of Pain and Accompanying Notes: Considerations for the Physiotherapy Profession
... 3) A (AlAttar et al., 2017;Lauersen et al., 2018); 4) C(Chia et al., 2020;De Blaiser et al., 2018;Lederman, 2010;Silfies et al., 2015); 5) D(Ceyssens et al., 2019;Dos'Santos et al., 2019;Helme et al., 2021); 6) A(Anderson et al., 2020;Culvenor et al., 2021;Van der Worp et al., 2016); 7) C(Amoako et al., 2017;Freckleton and Pizzari, 2013;Hulme et al., 2017;Neal et al., 2019) 8) D(Andrade et al., 2020;Carey et al., 2018;Damsted et al., 2018;Impellizzeri et al., 2020aImpellizzeri et al., , 2021Johnston et al., 2018;Wang et al., 2020); 9) CToohey et al., 2017;Van der Worp et al., 2015); 10) D(Vader et al., 2021). ...
Background:
Being up-to-date with evidence-based knowledge of lower limb sports injuries is essential for Healthcare professionals (HCPs).
Purpose:
To assess whether HCPs possess up-to-date knowledge of lower limb sports injuries by comparing their knowledge to that of athletes.
Methods:
With an expert panel, we developed an online quiz of 10 multiple-choice questions on various topics related to lower-limb sports injuries. Maximal score was 100. We used social media to invite HCPs (5 groups: Physiotherapists, Chiropractors, Medical Doctors, Trainers, and Other therapists) and athletes of all levels (amateur, semi-pro, and pro) to participate. We drafted the questions according to conclusions from the latest systematic reviews and meta-analyses.
Results:
1526 participants completed the study. Final quiz scores ranged from zero (n = 28, 1.8%) to 100 (n = 2, 0.1%) and were distributed normally with a mean score of 45.4 ± 20.6. None of the 6 groups' means surpassed the set threshold of 60 points. Multiple linear regressions of covariates indicated that age, gender, engagement in physical activity, learning hours per week, reading scientific journals, reading popular magazines and blogs, trainers, and other therapists' groups explained 19% of the variances (-5.914<β < 15.082, 0.000<p < 0.038).
Conclusions:
HCPs have insufficient up-to-date knowledge of lower limb sports injuries, and their knowledge is similar to that of athletes of all levels. HCPs probably do not possess the proper tools to assess scientific literature Academic and sports medicine societies should look into ways to improve the scientific knowledge integration of HCPs.
Endometriosis-associated pain can be managed by either surgery or hormonal therapy. The final decision as to which treatment modality to take is based on efficacy and possible complications of different treatment modalities, risk of recurrence, and the patient's wishes and preferences. But in the thicket of fears, doubts, and murky facts, the choice may ultimately be the trade-off between irrational fears and ignorance versus scientific evidence. We elaborate some pros and cons of the two treatment modalities and highlight some notable downsides of hormonal therapy, in particular the possible yet unquantified risk of long-term hormonal therapy for malignant transformation, perhaps with the only exception of combined oral contraceptives. Thus, when discussing with patients, we advocate the approach of discussing the advantages and disadvantages of all treatment options in detail, accounting for the known pros and cons with a full understanding of the predictive irrationality of human beings. For endometriosis-associated pain, surgery is definitely not a failure of medicine but, rather, a viable option, especially given the recently surfaced undercurrent of wariness and dissatisfaction with the current hormonal drugs among patients with endometriosis. Above all, there is a pressing need to fill the knowledge gap of perioperative interventions intended to reduce the risk of recurrence and to fulfill the demand for the development of safe and efficacious non-hormonal therapeutics.
Objectives:
Pain is the most common cause of seeking healthcare and the leading cause of disability worldwide. Although cannabidiol and transcutaneous electrical nerve stimulation (TENS) are effective and safe strategies for treating chronic pain, the combined effect of these interventions remains overlooked. To compare the isolated and combined effect of cannabidiol and TENS in the treatment of experimental neuropathic and inflammatory pain.
Methods:
Swiss mice were subjected to chronic constriction injury (CCI)-induced neuropathic or carrageenan-induced inflammatory pain models. Cannabidiol or TENS alone and the combination of these therapies were administered once. The nociceptive threshold was measured by the von Frey test. IL-1β, TNF-α and IL-10 cytokine levels were measured by ELISA from spinal cord samples.
Results:
Combined, cannabidiol and TENS potentiate antinociception only in neuropathic pain. IL-1β and TNF-α levels were similarly reduced when TENS or cannabidiol were administered alone or in combination. However, only cannabidiol and TENS combined increased IL-10 levels.
Conclusions:
Our findings indicated TENS and cannabidiol combined were effective in potentiating antinociception in a neuropathic pain model, an effect potentially associated with spinal IL-10 upregulation.
Background
Under-explored to date are the interacting influences of patient sex on multi-modal evaluation techniques that tap different domains of the pain experience.
Objectives
The primary aim of Study 1 was to explore the accuracy of sex-specific personal pain beliefs in relation to quantitative pain indicators within sexes, and the secondary objective was to compare the accuracy of sex-specific personal pain beliefs in relation to quantitative pain indicators between sexes. The primary objective of Study 2 was to explore the accuracy of sex-specific personal pain beliefs and self-rated pain severity within sexes, and the secondary objective was to compare sex-specific personal pain beliefs and pain severity ratings between sexes.
Methods
A cross-sectional analysis on two datasets was performed (Study 1, n = 50; Study 2, n = 111). For both studies, independent samples t-tests were used to identify differences in clinical pain evaluations based on sex-specific pain beliefs. Receiver Operating Characteristic (ROC) curves were used to compare the predictive accuracy of males and females clinical pain evaluations based on their ability to handle pain.
Results
There were no statistically significant differences in clinical pain evaluations based on self-rated pain beliefs in either study. In Study 2, males were descriptively more accurate predictors of their clinical pain evaluations than were females, though none of the between sex comparisons were statistically significant.
Conclusion
This work highlights the importance of considering all available clinical pain evaluations as one technique is unlikely to represent the patients pain experience.
In brief
Traditionally viewed as enigmatic and elusive, adenomyosis is a fairly common gynecological disease but is under-recognized and under-researched. This review summarizes the latest development on the pathogenesis and pathophysiology of adenomyosis, which have important implications for imaging diagnosis of the disease and for the development of non-hormonal therapeutics.
Abstract
Traditionally considered as an enigmatic disease, adenomyosis is a uterine disease that affects many women of reproductive age and is a contributing factor for pelvic pain, heavy menstrual bleeding (HMB), and subfertility. In this review, the new development in the pathogenesis and pathophysiology of adenomyosis has been summarized, along with their clinical implications. After reviewing the progress in our understanding of the pathogenesis and describing the prevailing theories, in conjunction with their deficiencies, a new hypothesis, called endometrial–myometrial interface disruption (EMID), which is backed by extensive epidemiologic data and demonstrated by a mouse model, is reviewed, along with recent data implicating the role of Schwann cells in the EMI area in the genesis of adenomyosis. Additionally, the natural history of adenomyotic lesions is elaborated and underscores that, in essence, adenomyotic lesions are fundamentally wounds undergoing repeated tissue injury and repair (ReTIAR), which progress to fibrosis through epithelial–mesenchymal transition, fibroblast-to-myofibroblast transdifferentiation, and smooth muscle metaplasia. Increasing lesional fibrosis propagates into the neighboring EMI and endometrium. The increased endometrial fibrosis, with ensuing greater tissue stiffness, results in attenuated prostaglandin E2, hypoxia signaling and glycolysis, impairing endometrial repair and causing HMB. Compared with adenomyosis-associated HMB, the mechanisms underlying adenomyosis-associated pain are less understood but presumably involve increased uterine contractility, hyperinnervation, increased lesional production of pain mediators, and central sensitization. Viewed through the prism of ReTIAR, a new imaging technique can be used to diagnose adenomyosis more accurately and informatively and possibly help to choose the best treatment modality.
Objective
To investigate whether lesional immunostaining of putative biomarkers of recurrence and the extent of lesional and cortical fibroses are correlated with the severity of dysmenorrhea and serum antimüllerian hormone (AMH) levels in women with ovarian endometriomas (OEs).
Design
Retrospective cohort study.
Setting
Academic hospital.
Patient(s)
A total of 313 women with histologically confirmed OEs were recruited. Their demographic and clinical information and data on their preoperative AMH levels were collected. Additionally, samples of their lesional tissues and ovarian cortex tissues adjacent to the OE lesions were procured for histologic and immunohistochemistry analyses.
Intervention(s)
None.
Main Outcome Measure(s)
All OE tissue samples were stained for phosphorylated nuclear factor κB p65 subunit, progesterone receptor isoform B, Slit2, and α-smooth muscle actin. In addition, the extent of lesional and cortical fibroses was quantitated by Masson trichrome staining. We evaluated the relationship between the lesion size; laterality; extent of lesional and cortical fibroses, along with the putative markers of recurrence; and severity of dysmenorrhea and preoperative serum AMH levels in patients with OE.
Result(s)
We found that the extent of lesional fibrosis was positively correlated with the severity of dysmenorrhea but had no impact on the AMH levels. On the other hand, the extent of cortical fibrosis, along with age, was negatively correlated with the AMH levels.
Conclusion(s)
The correlation between lesional fibrosis and the severity of dysmenorrhea and between cortical fibrosis and the AMH levels would call an early intervention once OE is diagnosed or suspected to prevent further pain and diminished ovarian reserve.
The definition of the word “pain” has recently been changed by the International agency for the studies of pain (IASP), to include also non-verbal and pre-verbal people. During the COVID pandemic, we have seen a new category of people who cannot speak: in many countries, anxiety and isolation and the cuts to home-assistance and to many hospital services, have brought to de-crease the explicit request for healthcare. This is a problem to be solved and an important alert about what is still an unsatisfactory response given by the national healthcare systems: the care of those who are most frail and voiceless. In this article, this scenario is described, and proposals for a future improvement of pain treatment for those who cannot speak are described. The first is to create a “Medicine of Abundance”: it is possible to avoid wastes in healthcare, and with these funds, a better welcoming of people in hospitals, a better stay, and more motivated personnel can be provided. Abundance is a right of the poorest and sickest even more than the general population; when people are at their ease, they can express better their wishes and their sufferings. The hospital should become a place of hospitality, its walls should be the first care for the sick: now in too many cases it is a cold hub/container of services. The second proposal is having caregivers always measure the pain level in hospitalized patients before taking decisions on implementing or withdrawing medical treatments, in particular those that can accelerate their end-of-life; this is called the “pain principle”.
Much of what we know about the meaning and experience of pain has been facilitated through qualitative research. However, qualitative inquiry continues to be underrepresented in the pain literature relative to quantitative approaches. In this Commentary and Introduction to the Special Issue on Qualitative Research and Pain, we present a collection of high quality, cutting-edge qualitative studies in pain that highlight theoretical and methodological advancements in the field. The articles included in this Special Issue feature a range of designs (e.g., grounded theory, phenomenology, qualitative description), methods of data collection (e.g., interviews, object elicitation, photovoice), and populations (e.g., immigrant women, individuals with heart disease). Throughout this Commentary we also address three common controversies regarding the quality of qualitative research and the stance we took on them for the Issue. These primarily deal with the procedure-related issues of sample size, generalizability, and saturation. We discuss how a more substantive-centered approach to evaluation, that is an approach that considers the methodological and theoretical significance of the work, is crucial for advancing qualitative research in pain.
The current International Association for the Study of Pain (IASP) definition of pain as “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” was recommended by the Subcommittee on Taxonomy and adopted by the IASP Council in 1979. This definition has become accepted widely by health care professionals and researchers in the pain field and adopted by several professional, governmental, and nongovernmental organizations, including the World Health Organization. In recent years, some in the field have reasoned that advances in our understanding of pain warrant a reevaluation of the definition and have proposed modifications. Therefore, in 2018, the IASP formed a 14-member, multinational Presidential Task Force comprising individuals with broad expertise in clinical and basic science related to pain, to evaluate the current definition and accompanying note and recommend whether they should be retained or changed. This review provides a synopsis of the critical concepts, the analysis of comments from the IASP membership and public, and the committee’s final recommendations for revisions to the definition and notes, which were discussed over a 2-year period. The task force ultimately recommended that the definition of pain be revised to “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage,” and that the accompanying notes be updated to a bulleted list that included the etymology. The revised definition and notes were unanimously accepted by the IASP Council early this year.
Chronic pain is a major source of suffering. It interferes with daily functioning and often is accompanied by distress. Yet, in the International Classification of Diseases, chronic pain diagnoses are not represented systematically. The lack of appropriate codes renders accurate epidemiological investigations difficult and impedes health policy decisions regarding chronic pain such as adequate financing of access to multimodal pain management. In cooperation with the WHO, an IASP Working Group has developed a classification system that is applicable in a wide range of contexts, including pain medicine, primary care, and low-resource environments. Chronic pain is defined as pain that persists or recurs for more than 3 months. In chronic pain syndromes, pain can be the sole or a leading complaint and requires special treatment and care. In conditions such as fibromyalgia or nonspecific low-back pain, chronic pain may be conceived as a disease in its own right; in our proposal, we call this subgroup "chronic primary pain." In 6 other subgroups, pain is secondary to an underlying disease: chronic cancer-related pain, chronic neuropathic pain, chronic secondary visceral pain, chronic posttraumatic and postsurgical pain, chronic secondary headache and orofacial pain, and chronic secondary musculoskeletal pain. These conditions are summarized as "chronic secondary pain" where pain may at least initially be conceived as a symptom. Implementation of these codes in the upcoming 11th edition of International Classification of Diseases will lead to improved classification and diagnostic coding, thereby advancing the recognition of chronic pain as a health condition in its own right.
Objectives:
Pain assessment is enigmatic. Although clinicians and researchers must rely upon observations to evaluate pain, the personal experience of pain is fundamentally unobservable. This raises the question of how the inherent subjectivity of pain can and should be integrated within assessment. Current models fail to tackle key facets of this problem, such as what essential aspects of pain are overlooked when we only rely on numeric forms of assessment, and what types of assessment need to be prioritized to ensure alignment with our conceptualization of pain as a subjective experience. We present the multimodal assessment model of pain (MAP) as offering practical frameworks for navigating these challenges.
Methods:
This is a narrative review.
Results:
MAP delineates qualitative (words, behaviors) and quantitative (self-reported measures, non-self-reported measures) assessment and regards the qualitative pain narrative as the best available root proxy for inferring pain in others. MAP offers frameworks to better address pain subjectivity by: (1) delineating separate criteria for identifying versus assessing pain. Pain is identified through narrative reports, while comprehensive assessment is used to infer why pain is reported; (2) integrating compassion-based and mechanism-based management by both validating pain reports and assessing underlying processes; (3) conceptualizing comprehensive pain assessment as both multidimensional and multimodal (listening/observing and measuring); and (4) describing how qualitative data help validate and contextualize quantitative pain measures.
Discussion:
MAP is expected to help clinicians validate pain reports as important and legitimate, regardless of other findings, and help our field develop more comprehensive, valid, and compassionate approaches to assessing pain.
There has been growing interest in psychologically oriented pain management over the past 3 to 4 decades, including a 2011 description of psychologically informed practice (PIP) for low back pain. PIP requires a broader focus than traditional biomechanical and pathology-based approaches that have been traditionally used to manage musculoskeletal pain. A major focus of PIP is addressing the behavioral aspects of pain (ie, peoples' responses to pain) by identifying individual expectations, beliefs, and feelings as prognostic factors for clinical and occupational outcomes indicating progression to chronicity. Since 2011, the interest in PIP seems to be growing, as evidenced by its use in large trials, inclusion in scientific conferences, increasing evidence base, and expansion to other musculoskeletal pain conditions. Primary care physicians and physical therapists have delivered PIP as part of a stratified care approach involving screening and targeting of treatment for people at high risk for continued pain-associated disability. Furthermore, PIP is consistent with recent national priorities emphasizing nonpharmacological pain management options. In this perspective, PIP techniques that range in complexity are described, considerations for implementation in clinical practice are offered, and future directions that will advance the understanding of PIP are outlined.
Purpose: Problems with access to outpatient physiotherapy services have been reported in publicly funded healthcare systems worldwide. A few studies have reported management strategies aimed at reducing extensive waiting lists, but their association with waiting times is not fully understood. The purpose of this study was to document access to public outpatient physiotherapy services for persons with musculoskeletal disorders in hospitals and explore organizational factors associated with waiting time.
Methods: We surveyed outpatient physiotherapy services in publicly funded hospitals in the province of Quebec (Canada).
Results: A total of 97 sites responded (99%) to the survey. The median waiting time was more than six months for 41% of outpatient physiotherapy services. The waiting time management strategies most frequently used were attendance and cancelation policies (99.0%) and referral prioritization (95.9%). Based on multivariate analyses, the use of a prioritization process with an initial evaluation and intervention was associated with shorter waiting times (p = 0.008).
Conclusions: Our findings provide evidence that a large number of persons wait a long time for publicly funded physiotherapy services in Quebec. Based on our results, implementation of a prioritization process with an initial evaluation and intervention could help improve timely access to outpatient physiotherapy services.
Implications for Rehabilitation:
• Access to publicly funded outpatient physiotherapy services is limited by long waiting times in a great proportion of Quebec’s hospitals.
• The use of a specific prioritization process that combines an evaluation and an intervention could possibly help improve timely access to services.
• Policy-makers, managers, and other stakeholders should work together to address the issue of limited access to publicly funded outpatient physiotherapy services.
Frail patients with dementia most frequently present with musculoskeletal pain and mobility concerns; therefore, physiotherapy interventions for this population are likely to be of great benefit. However, physiotherapists who work with older adults with dementia confront a considerable challenge: the communication impairments that characterize dementia make it difficult to assess pain and determine its source. For an effective physiotherapy programme to be implemented, valid pain assessment is necessary. This paper is intended to provide practice guidelines for pain assessment among older persons with dementia.
Over the last several years, there has been tremendous research progress in this area. While more research is needed, several promising assessment methodologies are available. These methodologies most often involve the use of observational checklists to record specific pain behaviours.
We encourage the ongoing and regular evidence-based pain assessment of older persons with dementia, using standardized procedures. Without regular and systematic assessment, pain problems will often go undetected in this population. Given the need for systematic pain assessment and intervention for long-term care populations with mobility concerns and muculoskeletal pain problems, we call for increased involvement of physical therapists in long-term care facilities.
Children with intellectual and developmental disabilities suffer more often from pain than their typically developing peers. Their pain can be difficult to manage, and assessment is often complicated by their limited communication skills, multiple complex pain problems and the presence of maladaptive behaviours. However, current research does provide some guidance for assessing their pain. Although self-report is an alternative for a small number of higher-functioning children, observational measures have the most consistent evidence to support their use at this time. For this reason, the Noncommunicating Children's Pain Checklist--Postoperative Version is recommended for children and youth 18 years of age or younger. However, other measures should be consulted for specific applications. Changes in function and maladaptive behaviour should also be considered as possible reflections of pain. In addition, children's coping skills should be considered because improving these may reduce the negative impact of pain.
Background:
Multidisciplinary pain treatment facilities (MPTFs) are considered the optimal settings for the management of chronic pain (CP). This study aimed (1) to determine the distribution of MPTFs across Canada, (2) to document time to access and types of services, and (3) to compare the results to those obtained in 2005-2006.
Methods:
This cross-sectional study used the same MPTF definition as in 2005-2006-that is, a clinic staffed with professionals from a minimum of three different disciplines (including at least one medical specialty) and whose services were integrated within the facility. A comprehensive search strategy was used to identify existing MPTFs across Canada. Administrative leads at each MPTF were invited to complete an online questionnaire regarding their facilities.
Results:
Questionnaires were completed by 104 MPTFs (response rate 79.4%). Few changes were observed in the distribution of MPTFs across Canada compared with 12 years ago. Most (91.3%) are concentrated in large urban cities. Prince Edward Island and the Territories still lack MPTFs. The number of pediatric-only MPTFs has nearly doubled but remains small (n=9). The median wait time for a first appointment in publicly funded MPTFs is about the same as 12 years ago (5.5 vs 6 months). Small but positive changes were also observed.
Conclusion:
Accessibility to public MPTFs continues to be limited in Canada, resulting in lengthy wait times for a first appointment. Community-based MPTFs and virtual care initiatives to distribute pain services into regional and remote communities are needed to provide patients with CP with optimal care.
Purpose:
This article reports on a national stakeholder workshop that focused on advancing pain education in physiotherapy programmes across Canada.
Methods:
Workshop participants included national leaders from the following stakeholder groups: people living with pain; physiotherapy students and recent graduates; pain educators; physiotherapy programme administrators; and representatives from the Canadian Alliance of Physiotherapy Regulators, Physiotherapy Education Accreditation Canada, Canadian Physiotherapy Association, and Physiotherapy Practice Profile project. During the workshop, barriers to, facilitators of, and strategies for advancing pain education were discussed, and a stakeholder-endorsed consensus statement was generated. The workshop was recorded, and data were thematically analyzed.
Results:
Participants identified important barriers and facilitators associated with the field of pain, standards and regulatory processes, physiotherapy programmes, and physiotherapy students and people living with pain. Strategies for advancing pain education included integrating pain competencies into standards and regulatory policy, encouraging the development of best teaching practices, partnering with people living with pain, building awareness, and setting goals and assessing clear outcomes. The consensus statement highlighted the central importance of pain education for physiotherapists and the need for a reference standard to guide its implementation in the Canadian context.
Conclusion:
This was the first initiative to specifically explore national stakeholders' perceptions of pain education. The workshop outcomes provide a strong mandate and direction for advancing pain education across Canadian physiotherapy programmes.
T here is growing recognition that pain communication is important, and the way that people (eg, partners, health care providers) respond to patients sharing their pain-related thoughts and feelings may have significant implications for pain-related outcomes. 8 One potentially important factor that has been relatively understudied until recently is the level of validation that may or may not be provided by people who are the recipients of a pain communication. 4 Many patients with chronic pain believe that others do not understand their pain or even consider their pain condition to be legitimate, 9 beliefs that are likely to lead to increases in psychological distress and negative affect. It is possible that validation of pain-related thoughts and feelings for these patients may lead to reductions in negative affect. Furthermore, validation from a romantic partner may enhance relationship intimacy, which is related to several positive benefits (eg, increased positive affect, improved psychological well-being). 10,11 Despite the potential benefits of validation, some research suggests that receiving social reinforcement (including validation) after sharing pain-related thoughts and feelings may be associated with worse patient outcomes such as increased pain. 22 This article highlights studies examining the effects of validation of pain-related thoughts and feelings. It is divided into 4 sections. In the first section, we describe the concept of validation. The second section describes several theories that attempt to explain the impact of validation on patient outcomes (eg, affect, report of pain intensity). In the third section, we review a number of studies examining validation and in-validation in the context of pain. In the final section of the article, we highlight several important future directions for research on the influence of validation on chronic pain.
The current definition of pain adopted by the International Association for the Study of Pain (IASP) and the American Pain Society (APS) chapter of the IASP is unacceptable because its claims and consequences are inconsistent with the IASP's stated purpose. The definition's apparent claims that (1) only effective communication of pain brings pain into existence, and that (2) researchers and clinicians are merely objective evaluators of whether such communication has occurred are inconsistent with the lASP's purpose to improve care of patients with acute and chronic pain through attention to patients, to the relationship between them and their caregivers, and to social policy. The definition's success at rejecting the consequences of Cartesian dualism is only partial. The definition contributes to a lack of justice for nonverbal patients.
At the conclusion of the 13th World Congress on Pain in Montreal, Quebec, Canada, the International Association for the Study of Pain (IASP) hosted an International Pain Summit on September 3, 2010, to address the tragedy of unrelieved pain in the world. At the conclusion of the Summit, the delegates adopted a Declaration that Access to Pain Management is a Fundamental Human Right. That Declaration is presented.
Pain catastrophizing is conceptualized as a negative cognitive-affective response to anticipated or actual pain and has been associated with a number of important pain-related outcomes. In the present review, we first focus our efforts on the conceptualization of pain catastrophizing, highlighting its conceptual history and potential problem areas. We then focus our discussion on a number of theoretical mechanisms of action: appraisal theory, attention bias/information processing, communal coping, CNS pain processing mechanisms, psychophysiological pathways and neural pathways. We then offer evidence to suggest that pain catastrophizing represents an important process factor in pain treatment. We conclude by offering what we believe represents an integrated heuristic model for use by researchers over the next 5 years; a model we believe will advance the field most expediently.
( This reprinted article originally appeared in Science, 1977, Vol 196[4286], 129–236. The following abstract of the original article appeared in PA, Vol 59:1423. ) Although it seems that acceptance of the medical model by psychiatry would finally end confusion about its goals, methods, and outcomes, the present article argues that current crises in both psychiatry and medicine as a whole stem from their adherence to a model of disease that is no longer adequate for the work and responsibilities of either field. It is noted that psychiatrists have responded to their crisis by endorsing 2 apparently contradictory positions, one that would exclude psychiatry from the field of medicine and one that would strictly adhere to the medical model and limit the work of psychiatry to behavioral disorders of an organic nature. Characteristics of the dominant biomedical model of disease are identified, and historical origins and limitations of this reductionistic view are examined. A biopsychosocial model is proposed that would encompass all factors related to both illness and patienthood. Implications for teaching and health care delivery are considered.
To examine the issue of pain assessment in infants by acquiring all available published pain assessment tools and evaluating their reported reliability, validity, clinical utility, and feasibility.
A systematic integrative review of the literature was conducted using the following databases: MEDLINE and CINAHL (through February 2004), and Health and Psychosocial Instruments, and Cochrane Systematic Reviews (through 2003). MeSH headings searched included "pain measurement," with limit of "newborn infant"; "infant newborn"; and "pain perception."
Thirty-five neonatal pain assessment tools were found and evaluated using predetermined criteria. The critique consisted of a structured comparison of the classification and dimensions measured. Further, the population tested and reports of reliability, validity, clinical utility, and feasibility were reviewed.
Of the 35 measures reviewed, 18 were unidimensional and 17 were multidimensional. Six of the multidimensional measures were published as abstracts only, were not published at all, or the original work could not be obtained. None of the existing instruments fulfilled all criteria for an ideal measure; many require further psychometric testing.
When choosing a pain assessment tool, one must also consider the infant population and setting, and the type of pain experienced. The decision should be made after carefully considering the existing published options. Confidence that the instrument will assess pain in a reproducible way is essential, and must be demonstrated with validity and reliability testing. Using an untested instrument is not recommended, and should only occur within a research protocol, with appropriate ethics and parental approval. Because pain is a multidimensional phenomenon, well-tested multidimensional instruments may be preferable.
International Association for the Study of Pain. IASP Council adopts task force recommendation for third mechanistic descriptor of pain
International Association for the Study of Pain. IASP Council adopts
task force recommendation for third mechanistic descriptor of pain
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The multimodal assessment model of pain: a novel framework for further integrating
- T H Wideman
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- D M Walton
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assessment model of pain: a novel framework for further integrating
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