The meaning and process of pain acceptance. Perceptions of women living with arthritis and fibromyalgia.

BACKGROUND: Within the past 10 years, cognitive-behavioural pain management models have moved beyond the traditional focus on coping strategies and perceived control over pain, to incorporate mindfulness- and acceptance-based approaches. Pain acceptance is the process of giving up the struggle with pain and learning to live life despite pain. Acceptance is associated with lower levels of pain, disability and psychological distress. Relatively little is known, however, about how patients arrive at a state of acceptance without the aid of therapy. OBJECTIVES: To explore personal definitions of acceptance and the factors that facilitate or hinder acceptance. METHODS: Eleven focus groups, involving a total of 45 women with arthritis and fibromyalgia, were conducted. RESULTS: The qualitative analysis revealed that, while the women rejected the word 'acceptance', they did agree with the main components of existing research definitions. The women's responses revealed that acceptance was a process of realizations and acknowledgements, including realizing that the pain was not normal and help was needed, receiving a diagnosis, acknowledging that there was no cure and realizing that they needed to redefine 'normal'. Diagnosis, social support, educating self and others, and self-care were factors that promoted acceptance. Struggling to retain a prepain identity, negative impacts on relationships, others not accepting their pain and the unspoken message that the pain was 'all in their head' were barriers to acceptance. CONCLUSION: The implications of these findings, distinctions between the diagnostic groups and recommendations regarding how health professionals can facilitate the process of acceptance are discussed.

Contributions of pain-related adjustment and perceptions of control to coping strategy use among cervical sprain patients.

Coping is a cyclical process in which an individual evaluates stressful events, chooses and implements coping strategies, re-evaluates the outcome of the coping effort and modifies the strategy if necessary. The intent of the present study was to evaluate the extent to which pain-related adjustment (i.e. pain severity, pain interference, negative affect) and perceptions of control are associated with the implementation of particular coping strategies. Participants were 136 patients assessed at an interdisciplinary pain clinic for cervical sprain injuries. As part of a routine assessment, participants completed a questionnaire package regarding background, pain severity, pain interference, negative affect, perceived control and use of particular coping strategies. Results of hierarchical multiple regression analyses revealed that pain interference, after controlling for all other variables, was associated with greater use of less physically demanding strategies (i.e. resting, guarding, asking for assistance, seeking social support and coping self-statements). Negative affect, on the other hand, after controlling for other variables, was associated with reduced use of task persistence. Finally, perceived control, independent of other variables, was associated with greater use of cognitive and social coping strategies (i.e. asking for assistance, seeking social support and coping self-statements). The results of the study shed light on the complex relationship between use of particular coping strategies and situational variables of pain-related adjustment and perceived control. Implications for clinicians who assist patients via implementation or modification of particular coping techniques are discussed.

Measuring movement-exacerbated pain in cognitively impaired frail elders.

OBJECTIVE: Prior research examining the utility of nonverbal measures of pain in persons with cognitive impairments has focused on acute procedurally-induced phasic pain (i.e., venipuncture and needle injections). The goal of the current project was to examine the utility of both self-report and nonverbal measures of pain in frail elders experiencing exacerbations of chronic musculoskeletal pain. These were assumed to be more representative of the day-to-day pain experience of elderly patients. DESIGN: Participants were 58 frail elders, 29 of whom had been found to have significant cognitive impairments. All were filmed as they undertook a series of structured activities (e.g., walking and reclining), and pain was assessed using self-report. Trained coders identified the incidence of pain-related behaviors using the videotapes. The various pain measures (i.e., self-report and nonverbal indices) were compared across both patient groups and the several activities. RESULTS: Consistent with our hypotheses, more pain was identified (using both self-report and nonverbal measures) when patients engaged in more physically demanding activities. Facial reactions varied as a function of patient cognitive status, with those participants who were cognitively impaired more responsive. Of the various nonverbal indices that we examined, guarded behavior appeared to be especially sensitive. The various pain indices were only modestly correlated with one another. CONCLUSIONS: This study supports the validity of self-report and behavioral measures of pain in frail elders with and without cognitive impairments. Each of the measures used contributed different information to pain assessment, suggesting that investigations of pain in elders with cognitive impairments should employ varying types of pain assessment tools.

Extent and nature of anxiety experienced during physical examination of chronic low back pain.

There is strong evidence to suggest that anxiety is a common problem for many chronic pain patients and can exacerbate a patient's pain condition. Notwithstanding, there is little information about the extent and nature of anxiety experienced during physical examination of pain, or the primary factors associated with anxiety in this context. In the present study, 45 chronic low back pain patients completed a questionnaire battery at the time of intake to an interdisciplinary treatment program. After approximately four weeks on program, patients underwent a routine standardized physiotherapy review of their condition following which they completed a second questionnaire battery. The examination was videotaped and coded for pain behavior. Physiotherapists provided objective scoring of non-organic signs and physical impairment. Results suggested that participants experienced substantial anxiety at the point of examination with scores on the Beck Anxiety Inventory (M = 30.47, S.D. = 6.96) comparable to scores that have been found with DSM-IV panic disorder patients. Regression analyses revealed that catastrophic cognitions, behavioral displays of pain and somatic sensations measured during examination uniquely predicted anxiety experienced during examination. Demographic, injury-related, personality, and patient-practitioner variables did not significantly contribute to explaining examination anxiety. Findings support cognitive-behavioral formulations of anxiety and strongly suggest that anxiety may complicate the assessment process. Implications for the assessment and treatment of pain are presented along with future research directions.

Pain measurement in persons with intellectual disabilities.

OBJECTIVE: The goal was to study the utility of nonverbal facial expressions as a research tool for assessing pain in persons with intellectual disabilities. Biases and stereotypes related to age, gender, physical attractiveness, and intellectual disability that may influence the ability of observers to evaluate pain reactions were also examined. DESIGN: Facial reactions to an intramuscular injection of 40 adults (mean age = 49.6 years) with an intellectual disability were videotaped and objectively examined using the Facial Action Coding System. Self-reported pain ratings were obtained using a Colored Visual Analogue Scale for pain. Pain reactions were also rated by untrained observers. RESULTS: A significant proportion of participants (35%) was unable to provide valid self-report. The intensity of objectively coded facial activity as well as observer-rated pain intensity showed significant increases from baseline to injection segments. Observers' pain ratings were primarily determined by the intensity of facial activity and were not significantly affected by stereotypes based on perceived level of intellectual disability, gender, age, or physical attractiveness. CONCLUSIONS: The findings support the validity of both objectively coded and observer-rated facial expressions of pain as research tools in treatment outcome studies involving persons with intellectual disabilities. Self-report has substantial limitations for the assessment of pain in this population.

An evaluation of subjective and objective measures of fatigue in patients with brain injury and healthy controls.

Three self-report scales and an objective measure were examined for their value in assessing fatigue in patients with brain injury. Patients with brain injury and healthy controls completed the Fatigue Impact Scale (FIS), Visual Analogue Scale for Fatigue (VAS-F) and Fatigue Severity Scale (FSS). Fatigue was objectively measured via a continuous thumb pressing task. Patients scored higher on all fatigue measures than did participants without brain injury. Significant group differences were found on the FIS, the vigour subscale of the VAS-F, and the FSS. The FIS provided a comprehensive assessment of patients' fatigue experience. The FSS, although differentiating between groups, did not provide as comprehensive an examination of fatigue as the FIS and the scale's internal consistency requires review. No significant group differences in fatigue ratings were found on the VAS-F, possibly due to the scale's failure to differentiate between fatigue and sleepiness. The objective measure of fatigue found patients with brain injury fatigued more quickly than participants without brain injury. Although group differences were not significant, this trend suggest that further examination of this fatigue measure is warranted. Overall, patients with brain injury were found to experience significant levels of fatigue and the FIS provided the most comprehensive examination of fatigue.

Nutritive and nonnutritive sucking habits: a review.

The habit of sucking is the first coordinated muscular activity of the infant. There are essentially two forms of sucking: the nutritive form which provides essential nutrients, while non-nutritive sucking insures a feeling of warmth and a sense of security. This review gives a description of the anatomy and physiology of sucking together with the influence of breastfeeding and bottle-feeding (conventional or orthodontic nipples) on the dentofacial structures of the infant. Factors involved in the choice of feeding are also discussed. Children who do not have access to unrestricted breastfeeding or bottle-fed children may satisfy their instinctive sucking urge with a pacifier. This paper presents the different types of pacifiers (conventional or orthodontic) along with the beneficial effects provided by pacifiers. Detrimental effects caused by incorrect use of pacifiers or digit-sucking habits are also summarized. Health professionals should inform expectant mothers about the dentofacial advantages of breastfeeding.

Fibre intake in elderly individuals with poor masticatory performance.

The effects of masticatory performance on food selection and nutrient intake in non-institutionalized elderly subjects wearing dental prostheses were investigated. A poor masticatory performance was associated with significantly lower intakes of insoluble and dietary fibre for both sexes (as compared to subjects with a good masticatory performance) and with lower intakes of vitamin A in women only. Further, 37 per cent of subjects with low masticatory performance were taking gastrointestinal drugs, as compared to 20 per cent of subjects with good performance. A reduced consumption of hard-textured fibrous foods due to the deficient masticatory performance of elderly people wearing prostheses may promote the development of gastrointestinal disorders in susceptible individuals.

Nutrient intake and gastrointestinal disorders related to masticatory performance in the edentulous elderly.

The effects of chewing efficiency on nutrient intake and the prevalence of gastrointestinal disorders were determined in edentulous elderly subjects. Three hundred sixty-seven noninstitutionalized individuals aged 60 years and over were interviewed. Denture masticatory performance and the collection of dietary information were assessed with the "Swallowing Threshold Test Index" and a food-frequency questionnaire. Approximately half (47%) of the participants exhibited a low masticatory performance classification. Thirty-nine percent used the same prosthesis for more than 10 years and 28% were taking some medication for gastrointestinal disorders. Lower intakes of fruits and vegetables for both sexes and of vitamin A by women were observed in subjects with poor masticatory performance. Furthermore, subjects with poor masticatory performance took significantly more drugs (37%) than those with superior performance (20%). A reduced consumption of high-fiber foods could therefore induce the development of gastrointestinal disorders in edentulous elderly subjects with a deficient masticatory performance.

Nutritional deficiencies and gastrointestinal disorders in the edentulous elderly: a literature review.

Many factors influence the food selection and nutritional status of elderly individuals. In this brief review, it is hypothesized that the functional status of dental prostheses is a prime determinant in the food selection, dietary fibre intake and prevalence of gastrointestinal disorders in edentulous elderly subjects.

Factors affecting the ingestion of fluoride dentifrice by children.

Several factors affecting the amount of fluoride ingested during toothbrushing by 2- to 7-year-old children were investigated. The specific purpose of this study was to determine the contribution of age, the amount of dentifrice used, and rinsing after brushing to the variation in the ingestion of fluoride dentifrice. Four hundred and five children brushed their teeth in front of a portable sink. The tubes of dentifrice in gel (0.24% NaF) were weighed before and after use to determine the amount of toothpaste used. The fluoride content of the collected liquids was determined with a fluoride-ion-specific electrode. The amount of fluoride ingested was derived by determining the difference between the amounts used and recovered. The amount of dentifrice used, the age, and the rinsing habits, entered in a multiple regression model, explained up to 66 percent of the total variation in the amount of fluoride ingested. The amount of dentifrice used accounted by itself for 60 percent of the total variation. Therefore, these results indicate that the quantity of dentifrice used was the most important factor affecting the ingestion of fluoride through toothbrushing by young children.

Ingestion of fluoride from dentifrices by children aged 12 to 24 months.

The increase of dental fluorosis is largely imputable to the ingestion of dietary fluoride supplements and fluoride toothpastes. However, the toothbrushing habits of very young children is poorly documented. The purpose of this pilot study was to determine the toothbrushing habits of 12- to 24-month-old children and to estimate the quantity of fluoride ingested during toothbrushing. Fifty-nine parents completed a questionnaire regarding the toothcleaning habits of their children. When a dentifrice was used, a dental hygienist scheduled a meeting with the parents in order to observe and measure the amount of toothpaste used. Of the 36 parents who cleaned the teeth of their children, 69% used a toothpaste. Furthermore 20% of the children ingested more than 0.25 mg of fluoride per day by toothbrushing alone. Therefore the practice of toothbrushing and the use of fluoridated dentifrices are widespread among 12- to 24-month old children, and the amount of fluoride ingested from toothpaste could constitute a substantial proportion of the total daily intake of fluoride. Several measures are suggested to enhance the safe use of fluoride dentifrices.

[The influence of medical and nutritional factors in gerodontology]. / Influence des facteurs médicaux et alimentaires sur l'approche gérodontologique.

Nutritional and medical factors may influence dental treatment for the elderly. The aim of this paper is to review these factors for the practitioner who provides treatment for the aged. Better knowledge should lead to a greater facility in providing treatment for this group of people.

The effects of nutritional quality and frequency of consumption of sugary foods on dental caries increment.

This study investigates the association of dietary quality with dental caries increment of 11-year-old children. A 3-day dietary record including one weekend day was completed by the subjects and their parents. The nutritional quality was evaluated using a quality index based on the eating frequency of foods recommended in food guides and divided into 8 levels. The frequency of consumption of sugary foods, liquid and solid, at and between meals was also calculated. Two oral examinations 20 months apart were made in 1983-85; each time, the quality of oral hygiene was determined by using the simplified oral hygiene was determined by using the simplified oral hygiene index of Greene and Vermillon. the dental caries increment between the two examinations was evaluated using the DMFS index. When the subjects were distributed into 3 groups according to their nutritional quality index, the mean dental caries increment had a tendency to decrease as the nutritional quality increased for the total sample as well as for boys and girls considered separately; however, the analysis of variance did not reveal any differences of statistical significance. No association was established for children in this study between frequency of consumption of sugary foods and caries increment. No association was observed between nutritional quality and oral hygiene nor between the mother's education and the children's frequency of consumption of sugary foods. Thus, in our study, children with the highest dental caries increment are not necessarily the ones having a diet of poor nutritional quality nor the ones consuming sugary foods more frequently.

[Behavior and conditions related to denture wearing in edentulous Quebecers over 60 years of age]. / Comportements et états reliés au port de prothèses chez des Québécois édentés âgés de 60 ans et plus.

A study was conducted among 367 persons aged 60 and over in order to determine the type and severity of digestive and nutritional problems experienced by edentulous elderly not wearing functional dentures. This article summarizes the information collected through an interview. The data describes the prosthetic status and experience of the elderly, their use of dental services and their methods of hygiene. In addition, information is provided on the level of satisfaction relative to their dentures and the need for repair or replacement of the latter.

Recruitment and compliance in school-based FMR programs.

A study on the effectiveness of a fluoride mouthrinse program was conducted over a 20-month period among 610 children attending grade 5 in two unfluoridated communities. The results showed that the preventive agent had no significant cariostatic effect. Participation and compliance problems were investigated as possible explanations. Comparisons were made between children who refused to participate or dropped out of the program and those who completed it, to see whether group-specific characteristics could be responsible for the low reduction of caries resulting from the mouthrinse. The relationship between compliance and DMFS increment was also examined. The analysis revealed that the children who refused to participate in the study or who dropped out showed sociodemographic characteristics associated with a high caries risk. This suggests that children who need the program most might not benefit because of low participation or failure to remain in the program. Moreover, the DMFS increment over the 20-month period was lower among the children exposed to 50 rinse sessions or more.

Dental health education for adolescents: assessing attitude and knowledge following two educational approaches.

A study of knowledge and attitudes towards dental health of 666 youths in their early teens has been conducted in Quebec. Its purpose is to compare the effectiveness of two instructional approaches often used in dental health education: a sound and slide presentation or a verbal demonstration. This experiment also included a control group. The measures were two scores obtained from a knowledge and an attitude test, which were the two dependent variables. These measures were repeated on four occasions: pre-test, immediate post-test, post-test after two months, and post-test after six months. During the experimental months, no other form of dental education was given by community health workers. The statistically significant interaction of time with treatments allowed reaching the conclusion that the evolution of subjects was different according to the treatment they had received, considering both dependent variables simultaneously. The sound and slide presentation appeared to be better than the verbal presentation for improving dental knowledge in young adolescents. Both educational approaches enhanced adolescents' attitude towards better dental health for a short period, but results were no longer significant after two months, thus reinforcing the importance of repetition in dental health education. Measures for knowledge tests revealed significant differences between boys and girls.

The ingestion of fluoride dentifrice by young children.

Through the fluoridation of drinking water, fluorides are becoming an increasing part of the human environment in industrialized countries. Fluoridated toothpastes are widely used in the United States and Canada. The younger a subject is, the greater proportion of toothpaste he or she tends to swallow.

[Frequency of food consumption in children. Weekdays versus weekends]. / Fréquence de consommation d'aliments chez des enfants. Jours de semaine versus fin de semaine.

The accurate assessment of nutritional quality or of food eating frequency in epidemiologic studies depends among other things on the internal validity of the method. The purpose of this study was to compare the mean food eating frequencies at meals and between-meals of 20 specific food items obtained from a two-weekday-diet record to those obtained from one weekend-day. A three-day-diet record including a weekend-day was completed by 549 eleven-year old children with the help of their parents. For each pair of food frequencies observed, a Student t test was performed. The results showed that when comparing the means for two weekdays to one weekend-day, significant differences (p less than 0.05) were observed for soft drinks, pastries, milk and vegetables. Also fruit juices, whole grain cereals, fresh fruits, milk, green and yellow vegetables were eaten significantly less at meals during the weekend-day. Between-meal eating is generally more salted or more sweetened during the weekend-day. Foods generally considered to be more nutritious are eaten less during the weekend-day. The differences in food frequencies obtained showed the need of including one weekend-day in a three-day-diet record to avoid the overestimation of food consumption and of the quality of the diet.