[From external assessment of pain to automated multimodal measurement of pain intensity : Narrative review of state of research and clinical perspectives]. / Von der Fremdbeurteilung des Schmerzes zur automatisierten multimodalen Messung der Schmerzintensität : Narrativer Review zum Stand der Forschung und zur klinischen Perspektive.

BACKGROUND: In patients with limited communication skills, the use of conventional scales or external assessment is only possible to a limited extent or not at all. Multimodal pain recognition based on artificial intelligence (AI) algorithms could be a solution. OBJECTIVE: Overview of the methods of automated multimodal pain measurement and their recognition rates that were calculated with AI algorithms. METHODS: In April 2018, 101 studies on automated pain recognition were found in the Web of Science database to illustrate the current state of research. A selective literature review with special consideration of recognition rates of automated multimodal pain measurement yielded 14 studies, which are the focus of this review. RESULTS: The variance in recognition rates was 52.9-55.0% (pain threshold) and 66.8-85.7%; in nine studies the recognition rate was ≥80% (pain tolerance), while one study reported recognition rates of 79.3% (pain threshold) and 90.9% (pain tolerance). CONCLUSION: Pain is generally recorded multimodally, based on external observation scales. With regard to automated pain recognition and on the basis of the 14 selected studies, there is to date no conclusive evidence that multimodal automated pain recognition is superior to unimodal pain recognition. In the clinical context, multimodal pain recognition could be advantageous, because this approach is more flexible. In the case of one modality not being available, e.g., electrodermal activity in hand burns, the algorithm could use other modalities (video) and thus compensate for missing information.

[Multimodal recognition of pain intensity and pain modality with machine learning]. / Multimodale Erkennung von Schmerzintensität und -modalität mit maschinellen Lernverfahren.

BACKGROUND: The objective recording of subjectively experienced pain is a problem that has not been sufficiently solved to date. In recent years, data sets have been created to train artificial intelligence algorithms to recognize patterns of pain intensity. The multimodal recognition of pain with machine learning could provide a way to reduce an over- or undersupply of analgesics, explicitly in patients with limited communication skills. OBJECTIVES: This study investigated the methodology of automated multimodal recognition of pain intensity and modality using machine-learning techniques of artificial intelligence. Multimodal recognition rates of experimentally induced phasic electrical and heat pain stimuli were compared with uni- and bimodal recognition rates. MATERIAL AND METHODS: On the basis of the X­ITE Pain Database, healthy subjects were stimulated with phasic electro-induced pain and heat pain, and their corresponding pain responses were recorded with multimodal sensors (acoustic, video-based, physiological). After complex signal processing, machine-learning methods were used to calculate recognition rates with respect to pain intensity (baseline vs. pain threshold, pain tolerance, mean value of pain threshold and tolerance) and pain modality (electrical vs. heat). Finally, a statistical comparison of uni- vs. multimodal and bi- vs. multimodal detection rates was performed. RESULTS: With few exceptions, multimodal recognition of pain intensity rates was statistically superior to unimodal recognition rates, regardless of the pain modality. Multimodal pain recognition distinguished significantly better between heat and electro-induced pain. Further, multimodal recognition rates were predominantly superior to bimodal recognition rates. CONCLUSION: Priority should be given to the multimodal approach to the recognition of pain intensity and modality compared with unimodality. Further clinical studies should clarify whether multimodal automated recognition of pain intensity and modality is in fact superior to bimodal recognition.

["What you will": Results of an Empirical Analysis of the Need to Improve Work-life Balance for Physicians]. / "Was ihr wollt", Ergebnisse einer empirischen Bedarfsanalyse zur Verbesserung der Vereinbarkeit von Familie und Beruf bei Ärztinnen und Ärzten.

STUDY AIMS: This study assessed the perceived need for clinics to improve work-life balance of physicians. Hospitals are increasingly facing demands to offer physicians working conditions that allow greater balance between family life and pursuit of career. Simultaneously, hospitals could consider this an opportunity to stand out as attractive employers. METHODS: N=120 doctors of the medical faculty and N=679 medical students in their premedical and clinical training participated online. RESULTS: The results of the Work-Family/Family-Work Conflict Scale (WFC/FWC) showed physicians to have a decreased work/life balance when starting to work professionally, especially with a child. Ninety percent of the respondents considered the following arrangements to be especially helpful: temporary work interruptions in an emergency, part-time positions or emergency childcare. The doctors also expressed their wish to be actively supported by their supervisors on the topic of work/life balance. CONCLUSION: This analysis on work-family balance shows the need for change in the studied samples. Based on the measures that were determined to be helpful, hospitals can make conclusions about what concrete steps of action can be taken. Additionally, WFC/FWC could be used as a standardized analysis measure to assess the load imposed on physicians by family on work place and vice versa.

[Mimic activity of differentiated pain intensities : Correlation of characteristics of Facial Action Coding System and electromyography]. / Mimische Aktivität differenzierter Schmerzintensitäten : Korrelation der Merkmale von Facial Action Coding System und Elektromyographie.

BACKGROUND: The monitoring of facial expressions to assess pain intensity provides a way to determine the need for pain medication in patients who are not able to do so verbally. OBJECTIVES: In this study two methods for facial expression analysis - Facial Action Coding System (FACS) and electromyography (EMG) of the zygomaticus muscle and corrugator supercilii - were compared to verify the possibility of using EMG for pain monitoring. MATERIAL AND METHODS: Eighty-seven subjects received painful heat stimuli via a thermode on the right forearm in two identical experimental sequences - with and without EMG recording. RESULTS: With FACS, pain threshold and pain tolerance could be distinguished reliably. Multiple regression analyses indicated that some facial expressions had a predictive value. Correlations between FACS and pain intensity and EMG and pain intensity were high, indicating a closer relationship for EMG and increasing pain intensity. For EMG and FACS, a low correlation was observed, whereas EMG correlates much better with pain intensity. CONCLUSIONS: Results show that the facial expression analysis based on FACS represents a credible method to detect pain. Because of the expenditure of time and personal costs, FACS cannot be used properly until automatic systems work accurately. The use of EMG seems to be helpful in the meantime to enable continuous pain monitoring for patients with acute post-operative pain.

Alexithymic and somatisation scores in patients with temporomandibular pain disorder correlate with deficits in facial emotion recognition.

Current studies suggest dysfunctional emotional processing as a key factor in the aetiology of temporomandibular disorder (TMD). Investigating facial emotion recognition (FER) may offer an elegant and reliable way to study emotional processing in patients with TMD. Twenty patients with TMD and the same number of age-, sex- and education-matched controls were measured with the Facially Expressed Emotion Labelling (FEEL) test, the 26-item Toronto Alexithymia Scale (TAS-26), the Screening for Somatoform Symptoms (SOMS-2a), the German Pain Questionnaire and the 21-item Hamilton Depression Rating Scale (HAMD). The patients had significantly lower Total FEEL Scores (P = 0·021) as compared to the controls, indicating a lower accuracy of FER. Furthermore, we were able to demonstrate significant group differences with respect to the following issues: patients were more alexithymic (P = 0·006), stated more somatoform symptoms (P < 0·004) and had higher depressive scores in the HAMD (P < 0·003). The factors alexithymia and somatisation could explain 31% (adjusted 27%) of the variance of the FEEL Scores in the sample. The estimation of the standardised regression coefficients suggests an equivalent influence of TAS-26 and SOMS-2a on the FEEL Scores, whereas 'group' (patients versus healthy controls) and depressive symptoms did not contribute significantly to the model. Our findings highlight FER deficits in patients with TMD, which are partially explained by concomitant alexithymia and somatisation. As suggested previously, impaired FER in patients with TMD may further point to probable aetiological proximities between TMD and somatoform disorders.

[Ethic charter of the German Society for the Study of Pain (DGSS)]. / Ethik-Charta der Deutschen Gesellschaft zum Studium des Schmerzes (DGSS).

The German Society for the Study of Pain has formed an interdisciplinary committee to answer urgent ethical questions on the diagnosis and treatment of pain and to give an ethical orientation on the care of pain and palliative patients. The treatment of pain is a fundamental objective of medicine. Competent and adequate relief of pain in all stages of life is a basic characteristic of a humane medicine oriented to the quality and meaning of life for people. However, there are substantial deficits in all areas, especially in the knowledge of physicians and patients, in training and further education, diagnosis and therapy. Freedom from pain is a substantial element of quality of life. A central duty of all physicians is an adequate diagnosis and treatment of acute pain and thereby the prophylaxis of chronic pain. If pain persists over a longer period of time, it loses the warning function and becomes taken for granted. Alterations, disabilities and limitations of the physical, psychic and social levels are the consequences. For these patients an interdisciplinary approach is necessary by which various medical disciplines, psychologists and physiotherapists are involved and all collaborate on the diagnosis and therapy of pain. All patients have the right to sufficient and individually tailored treatment of pain. Special attention must be paid to vulnerable patient groups, such as newborns, children and adolescents, as well as aged and mentally retarded patients. For cancer patients pain relief of their tumor pain is totally in the forefront. Indications of "unbearable pain" must not lead to resignation or even be seen as an argument for legalization of "death on request". The nursing of terminally ill patients necessitates a special measure not only of clinical, but also ethical competence, communication and multiprofessional collaboration. The modern options for palliative care are real alternatives to demands for legalization of "death on request". Physician-assisted suicide does not belong to the scope of functions of palliative medicine. The basic constitutional law makes an appropriate treatment of pain obligatory. Neglect of pain treatment fulfils the elements of criminal bodily harm. As a consequence, there is a legal right to a comprehensive pain diagnosis and a pain treatment corresponding to the appropriate standard. The state is obliged to provide the legal, social and financial prerequisites for an adequate treatment of pain. Continuous efforts in research are necessary to fill the existing gaps in our knowledge. The transfer between basic research and clinical application of pain therapy must be urgently improved. Of central importance for the German Pain Society are therefore: Improvement of training and further education in pain therapy. Chronic pain must be accepted and coded as an autonomous sickness. Graded structures for care of pain patients must be realized. Interdisciplinary structures of care must be made available to patients with chronic pain. Palliative medical care is a basic right of all terminally ill patients. Politics and health care providers must establish prerequisites for adequate pain diagnosis, pain therapy and palliative medicine.

[Awareness of memory deficits in patients with probable Alzheimer's disease]. / Metagedächtnisleistungen bei Alzheimerpatienten.

Thirty-eight patients with Alzheimer's disease were asked to give a qualitative (estimation of memory changes) and quantitative assessment of their own performance on memory tasks and also of their relatives' performance. Qualitative assessment showed to be independent from measured memory-deficits, while the precision of quantitative prediction of performance deteriorated with increased cognitive impairment. Cognitive impairment of the demented patients did not influence the prediction of the performance of their relatives. Both, qualitative and quantitative assessment of memory performance were influenced by premorbid coping-strategies. Patients, who were attributed to use strategies of cognitive avoidance, more often claimed to have no changes in memory function or over-estimated their memory performance. The results of this investigation reveal that methodological issues influence studies on the association of meta-cognitive abilities with the severity of dementia to a great extent. They also suggest that awareness of deficits should be based on a complex, multi-dimensional concept.

Emotion recognition in stroke patients with left and right hemispheric lesion: results with a new instrument-the FEEL Test.

The aim of this study was to investigate the effect of a stroke event on people's ability to recognize basic emotions. In particular, the hypothesis that right brain-damaged (RBD) patients would show less of emotion recognition ability compared with left brain-damaged (LBD) patients and healthy controls, was tested. To investigate this the FEEL Test (Facially Expressed Emotion Labeling) was used, a computer based psychometric test that assesses one's ability to recognize facially displayed basic emotions via a forced-choice paradigm. We examined 24 patients after a stroke event (13 RBD, 11 LBD) and compared them with a matched group of healthy controls (HC, n=29). Results showed that the stroke patients performed significantly worse in the FEEL Test than did HC (p<.001). This deficit was especially evident for negative emotions (fear, anger, sadness, and disgust). In contrast to other studies we did not find any significant differences between RBD and LBD patients in their ability to recognize emotions. These results indicate that a stroke event has a negative effect on the recognition of facially displayed emotions but suggest that this effect is apparently not dependent on the side of the brain damage.

Everyday stress and Crohn's disease activity: a time series analysis of 20 single cases.

In a 84-day long-term study involving 20 patients with active Crohn's disease, the relation between daily stress and symptomatology was investigated. The diagnoses were verified clinically, endoscopically, radiologically, and histologically. The Crohn symptomatology was assessed by a daily symptoms diary. The degree of everyday stress was measured with a daily hassles scale. Additionally, the disease activity was measured 4 times. The data were evaluated using a time series analysis method following the ARIMA model (autoregressive integrative moving average model), which takes the autocorrelation of the data into account. In 55% of the cases, a significant correlation between daily hassles and disease activity was found. Patients whose symptomatology responded to stress did not differ from nonresponders in age, duration of the disease, disease activity, frequency of abdominal surgery, partnership situation, or statements concerning their average level of daily hassles. Disease activity in general did not change during the observation period. A verified influence of daily hassles on Crohn symptomatology as a rule occurs on the same day with time lag 0. According to these results, the group of Crohn's disease patients is not homogenous. The widely held assumption that daily hassles influence the symptomatology cannot generally be confirmed. Variations may result from different ways of coping with stress. Long-term effects of daily hassles on the disease are not clear.

[Associations between back pain, quality of sleep and quality of mattresses. Double-blind pilot study with hotel guests]. / Zusammenhänge zwischen Rückenschmerzen, Schlaf und Matratzenqualität. Doppelblinde Pilotstudie bei Hotelgästen.

BACKGROUND: Associations between back pain, the quality of sleep and the quality of mattress have not yet been investigated systematically. METHODS: At check-out we asked 265 consecutive guests of a trade fair hotel about the subjective quality of sleep in the previous night. Nine rooms had been equipped with new mattresses of three different qualities and prices, but this was kept blind to the hotel staff and the guests. Sleep quality was assessed on an analog scale between 1 (very good) and 5 (very bad) and was analyzed in comparison to the remaining 8-year old mattresses of the hotel, but also with respect to social (e.g. private vs. professional reason for the stay) as well as personal (e.g. previous experience with low back and sleep complaints) characteristics of the guests. RESULTS: The three qualities of the mattresses correlated significantly and positively with the perceived quality of sleep, but the difference to the "old" mattresses was most pronounced for those guests who were staying overnight for professional reasons, or who frequently were suffering from low back pain or sleep disturbances. CONCLUSION: At least for chronic sufferers from back pain and sleep problems, the association between sleep quality and quality of the mattress is significant.

[Work site health promotion in Germany--1: Program availability and effect on occupational characteristics]. / Betriebliche Gesundheitsförderung in Deutschland--Teil 1: Programmangebot und Einfluss betrieblicher Rahmenbedingungen.

Worksite health promotion and disease prevention is becoming more and more established in Germany. This study investigates the state of the health programmes utilising a representative sample of 116 companies with company health insurance. 105 companies answered the detailed questions during phone interviews or using written questionnaires. 60% of the companies offer worksite health promotion and disease prevention programmes. The focus is mainly on behavioural aspects, while structural aspects play a minor role within the programmes. To a great extent the health promotion and disease prevention programmes are independent of structural characteristics of the company and the company location. At present, an evaluation of the health benefits and cost-effectiveness of the health programmes is only of secondary interest.

[Pain intensity, mood and pain-alleviating actions in pre-chronic low back pain patients]. / Schmerzintensität, Stimmung und medizinische Massnahmen bei Patienten mit prächronischen Rückenschmerzen.

INTRODUCTION: The present study examines the correlations between pain intensity, mood and pain-alleviating actions in pre-chronic low back pain patients. The three variables were obtained with the Ulm Pain Diary (Ulmer Schmerztagebuch, UST). METHODS: Thirty-eight patients with low back pain described pain intensity, effect of pain on mood and medication as well as other therapies over a 3-week period (21 days). The patients had a history of pain for between 6 weeks and 6 months. Clinical and orthopedic examinations revealed no relevant organic findings explaining the pain process. RESULTS: Pain occurred on 18.1 (of 21) days. Half of the patients (n=19) used medication or took other actions against their pain. Correlations between the three variables demonstrated that all three were significantly related. Partial correlations showed in addition to a high correlation between pain intensity and mood, that the frequency of pain-relieving actions was far less related to pain intensity than to mood. The group that took actions against their pain had a higher level of pain intensity than the no-action group. Furthermore, the effect of pain on mood was significantly greater in this group than in the no-action group. CONCLUSION: The findings indicate that pain intensity, mood and actions against pain are highly correlated. When pain intensity is statistically controlled, the influence of mood on taking medication or other actions against pain becomes more pronounced. It can be concluded that self-initiated actions against pain depend much more on mood than on pain intensity in pre-chronic low back pain patients.

[Occupational health promotion in Germany--2: Prevention of musculoskeletal disorders]. / Betriebliche Gesundheitsförderung in Deutschland--Teil 2: Prävention von Erkrankungen des Stütz- und Bewegungsapparates.

As a major part of a detailed study about worksite health promotion and disease prevention the standard of prevention programmes for musculoskeletal disorders was investigated. Only every 10th company doesn't offer such programmes. Within these programmes the prevention concept is based on a reduced narrow understanding of musculoskeletal disorders, mainly focussed on behavioural biomechanical risk factors. The organisational aspects of the programmes are well designed. The number of programme participants in relation to epidemiological measures is low. Scientific evaluation of the health benefits of the worksite health programmes is rare.

Surface EMG topography and pain distribution in pre-chronic back pain patients.

The relationship between surface EMG recordings from paraspinalis recording sites and subjective pain ratings were examined in a group of pre-chronic back pain patients. thirty-eight back pain patients without major orthopedic diagnosis and a pain duration between 2 to 6 months participated in a three week long subjective pain rating. Following the completion of their pain diary, the paraspinal sites were assessed under the "static" postural conditions of sitting and standing using an EMG scanning procedure. Results of the correlational analysis revealed significant and positive relationships between pain and muscle activity in the upper back (Trapezius, T1 paraspinalis sites) and significant but negative relationships between erector spinae activity (L3 paraspinalis site) and pain. When considering etiological factors of pre-chronic back pain, the results support both the organicity model for upper back, as well as the biomechanical model for the lower back.