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Previous literature indicates that biases exist in pain ratings. Healthcare professionals have been found to use patient demographic cues such as sex, race, and age when making decisions about pain treatment. However, there has been little research comparing healthcare professionals’ (i.e., physicians and nurses) pain decision policies based on patient demographic cues.
The current study used virtual human technology to examine the impact of patients’ sex, race, and age on healthcare professionals’ pain ratings. One hundred and ninety-three healthcare professionals (nurses and physicians) participated in this online study.
Healthcare professionals assessed virtual human patients who were male and African American to be experiencing greater pain intensity and were more willing to administer opioid analgesics to them than to their demographic counterparts. Similarly, nurses were more willing to administer opioids make treatment decisions than physicians. There was also a significant virtual human-sex by healthcare professional interaction for pain assessment and treatment decisions. The sex difference (male > female) was greater for nurses than physicians.
Results replicated findings of previous studies using virtual human patients to assess the effect of sex, race, and age in pain decision-making. In addition, healthcare professionals” pain ratings differed depending on healthcare profession. Nurses were more likely to rate pain higher and be more willing to administer opioid analgesics than were physicians. Healthcare professionals rated male and African American virtual human patients as having higher pain in most pain assessment and treatment domains compared to their demographic counterparts. Similarly the virtual human-sex difference ratings were more pronounced for nurses than physicians. Given the large number of patients seen throughout the healthcare professionals’ careers, these pain practice biases have important public health implications. This study suggests attention to the influence of patient demographic cues in pain management education is needed.
PMCID: PMC3969773  PMID: 24128374
Healthcare Professionals; Pain Assessment; Pain Treatment; Virtual Technology
2.  Acceptance of Pain in Neurological Disorders: Associations With Functioning and Psychosocial Well-Being 
Rehabilitation psychology  2013;58(1):1-9.
Chronic pain acceptance has been shown to be related to positive adjustment to chronic pain in patients presenting with pain as a primary problem. However, the role of pain acceptance in adjustment to chronic pain secondary to a neurological disorder that is often associated with physical disability has not been determined. The purpose of this study was to examine whether two domains of chronic pain acceptance—activity engagement and pain willingness—predict adjustment to pain, controlling for pain intensity and key demographic and clinical variables in individuals with muscular dystrophy (MD), multiple sclerosis (MS), post-polio syndrome (PPS), or spinal cord injury (SCI).
Participants were 508 community-dwelling adults with a diagnosis of MD, MS, PPS, or SCI who also endorsed a chronic pain problem. Participants completed self-report measures of pain acceptance, quality of life, pain interference, pain intensity, depression, and social role satisfaction.
Hierarchical linear regressions indicated that activity engagement predicted lower pain interference and depression, and greater quality of life and social role satisfaction. Pain willingness predicted less pain interference and depression. Together, the two pain acceptance subscales accounted for more variance in outcomes than did self-reported pain intensity.
Findings correspond with the broader pain acceptance literature, although activity engagement appears to be a more robust predictor of adjustment than does pain willingness. This research supports the need for future studies to determine the extent to which treatments that increase acceptance result in positive outcomes in persons with chronic pain secondary to neurological disorders.
PMCID: PMC3670089  PMID: 23437995
chronic pain acceptance; multiple sclerosis; muscular dystrophy; post-polio syndrome; spinal cord injury
3.  Repeated visual distracter exposure enhances new discrimination learning and sustained attention task performance in rats 
Behavioural processes  2012;92:147-151.
Repeated exposure to distraction requires attentional effort to restore task performance. However, the impact of repeated distracter exposure and exertion of attentional effort on new learning has not been examined. In the present experiment, rats were trained in a two-lever sustained attention task. Rats then continued to train, for 12 sessions, in this task either with or without a flashing houselight distracter throughout the session. The flashing houselight transiently decreased attentional performance. Trials that were part of a new light-location discrimination task were then interspersed within the sustained attention task sessions. The frequency of these new light-location discrimination trials increased with additional training. Rats exposed to the distracter exhibited higher accuracy levels during some blocks of sessions in the new light-location discrimination task trials and in the remaining sustained attention task trials compared to rats that were not exposed to the distracter. The effects of repeated distracter exposure are interpreted in the context of an “occasion-setting” model that has been used to describe performance in this task.
PMCID: PMC3538932  PMID: 23174336
attention; cognitive flexibility; distracter; occasion-setting
4.  The influence of sex, race, and age on pain assessment and treatment decisions using virtual human technology: a cross-national comparison 
Journal of Pain Research  2013;6:577-588.
Studies in the United States have found that patients’ sex, race, and age influence the pain assessment and treatment decisions of laypeople and medical professionals. However, there is limited research as to whether people of other nationalities make pain management decisions differently based on demographic characteristics. Therefore, the purpose of the following study was to compare pain assessment and treatment decisions of undergraduate students in Jordan and the United States as a preliminary examination of nationality as a potential proxy for cultural differences in pain decisions.
Virtual human (VH) technology was used to examine the influences of patients’ sex (male or female), race (light-skinned or dark-skinned), and age (younger or older) on students’ pain management decisions. Seventy-five American and 104 Jordanian undergraduate students participated in this web-based study.
American and Jordanian students rated pain intensity higher in females and older adults and were more likely to recommend medical help to these groups, relative to males and younger adults. Furthermore, Jordanian participants rated pain intensity higher and were more likely to recommend medical help for all patient demographic groups (ie, sex, race, age) than American participants.
This is the first cross-national study that compares pain decisions between undergraduate students. The results suggest that sex, race, and age cues are used in pain assessment and treatment by both Americans and Jordanians, with Jordanians more likely to rate pain higher and recommend medical help to patients. Additional research is needed to determine the cultural determinants of these differences.
PMCID: PMC3724685  PMID: 23901291
pain management; pain disparities; nationality; stereotypes; biases
The Journal of Pain  2012;13(3):220-227.
Sex, race/ethnic, and age differences in pain have been reported in clinical and experimental research. Gender role expectations have partly explained the variability in sex differences in pain, and the Gender Role Expectations of Pain questionnaire (GREP) was developed to measure sex-related stereotypic attributions about pain. It is hypothesized that similar expectations exist for age and race-related pain decisions. This study investigated new measures of race/ethnic- and age-related stereotypic attributions of pain sensitivity and willingness to report pain, and examined the psychometric properties of a modified GREP. Participants completed the Race/Ethnicity Expectations of Pain questionnaire, Age Expectations of Pain questionnaire, and modified GREP. Results revealed a 3-factor solution to the race/ethnicity questionnaire and a 2-factor solution to the age questionnaire, consistent with theoretical construction of the items. Results revealed a 4-factor solution to the modified GREP that differed from the original GREP and theoretical construction of the items. Participants’ pain-related stereotypic attributions differed across racial/ethnic, age, and gender groups. These findings provide psychometric support for the measures examined herein and suggest that stereotypic attributions of pain in others differ across demographic categories. Future work can refine the measures and examine whether select demographic variables influence pain perception, assessment, and/or treatment.
PMCID: PMC3294006  PMID: 22225969
Gender; Race; Age; Pain; Expectations
6.  Patient demographic characteristics and facial expressions influence nurses’ assessment of mood in the context of pain: A Virtual Human and lens model investigation 
Sex, race, and age disparities in pain assessment and treatment have been reported in the literature. However, less is known about how these demographic characteristics influence nurses’ assessment of the emotional experiences of patients who are in pain.
To investigate the influence of patient demographic characteristics and facial expressions on nurses’ assessment of patient mood in the context of pain.
A cross-sectional study employing Virtual Human (VH) technology and lens model methodology.
The current study was delivered via the internet.
Participants consisted of 54 registered nurses currently engaged in clinical practice. Nurses were recruited from healthcare settings across the United States.
Nurses viewed 32 patient vignettes consisting of a video clip of the VH patient and text-based clinical summary information describing a post-surgical context. Patient sex, race, age, and facial expression of pain were systematically manipulated across vignettes. Participants made positive and negative mood assessment ratings on computerized visual analogue scales. Idiographic multiple regression analyses were used to examine the patient characteristics that were significant predictors of nurses’ assessment ratings. Nomothetic paired samples t-tests were used to compare ratings within cue for the entire sample.
The results of idiographic and nomothetic analyses indicated that VH sex, race, age, and facial expression cues were significant predictors of the mood assessment ratings of many nurses. The age cue had the largest impact among the demographic variables.
The results of the current study suggest that patient demographic characteristics and facial expressions may influence how nurses assess patient emotional status in the clinical pain context. These findings may lead to greater awareness by individual nurses and nursing administrators about the influence of patient demographic characteristics on clinical decision-making. Future research is needed to better understand these relationships, with the ultimate goal of improving patient care.
PMCID: PMC3170511  PMID: 21596378
Decision making; Disparities; Lens model; Mood; Virtual Human technology
7.  Psychometric Properties of the Community Integration Questionnaire in a Heterogeneous Sample of Adults With Physical Disability 
To investigate the psychometric properties of the Community Integration Questionnaire (CIQ) in a mixed sample of adults with physical disabilities.
Cross-sectional, survey study.
Academic and community medical clinics, national registry, and self-referral.
Community-dwelling adults with spinal cord injury (n=146), multiple sclerosis (n=174), limb loss (n=158), or muscular dystrophy (n=273).
Not applicable.
Main Outcome Measures
CIQ, General Health item from the Medical Outcomes Study 36-Item Short-Form Health Survey, and Mental Health Scale from the Medical Outcomes Study 36-Item Short-Form Health Survey.
Based on the original scoring procedures, the CIQ Total scale and Home Integration subscale demonstrated acceptable internal consistency; however, reliability indices for the Social Integration and Productive Activities subscales were suboptimal. The exploratory factor analysis yielded a 4-factor solution (accounting for approximately 63% of the variance) that did not replicate the original factor structure of the CIQ. The results of the confirmatory factor analyses indicated that a modified 3-factor solution provided the best fit to the data from our samples. Using a revised scoring system based on these findings, the CIQ demonstrated improved reliability relative to the original scoring and good concurrent validity.
The results provide general support for the validity of the CIQ as a measure of participation in adults with physical disabilities. However, our results indicate that some small modifications to the original scoring system are needed to optimize its use in this patient group. Additional research is needed to refine the measurement of participation in these and other populations.
PMCID: PMC3371822  PMID: 21851927
Disabled persons; Outcome assessment (health care); Psychometrics; Quality of life; Rehabilitation
8.  Catastrophizing, Pain, and Pain Interference in Individuals with Disabilities 
To examine the influence of sex and disability on catastrophizing, pain intensity, and pain interference in individuals with a spinal cord injury (SCI) or multiple sclerosis (MS).
A cross-sectional survey design was employed. 248 community-dwelling adults with a physical disability (SCI=124; MS=124) and chronic pain completed measures of demographic and clinical characteristics, pain intensity and interference, psychological functioning, and pain catastrophizing.
Men reported marginally greater catastrophizing (p<.10) than women across both disability groups; however, there was no significant difference in catastrophizing between disability groups. Catastrophizing was the only significant predictor of pain intensity in the multivariate regression analysis, with greater catastrophizing associated with greater pain. Pain intensity and catastrophizing were the only significant variables in the regression analyses predicting pain interference and psychological functioning; as hypothesized, greater pain intensity and catastrophizing were associated with more pain interference and poorer psychological functioning. There was also a trend (p<.10) for females, relative to males, to have a stronger association between catastrophizing and pain interference.
These findings are consistent with a biopsychosocial conceptualization of pain and functioning in individuals with chronic pain secondary to a physical disability. In addition, these data suggest that assessment and treatment (when indicated) of catastrophizing should be a regular part of the clinical management of these patients.
PMCID: PMC3153610  PMID: 21814133
Pain; Catastrophizing; Multiple Sclerosis; Spinal Cord Injury; Biopsychosocial
9.  Survey Results of Pain Treatments in Adults with Cerebral Palsy 
To identify the types and frequencies of pain treatments used by individuals with cerebral palsy (CP); examine the perceived effectiveness of these treatments; and identify the types of healthcare providers that were accessed for pain-related services.
A cross-sectional survey design was employed. 83 adults (mean age=40.3 years, SD=13.6) with CP indicated their pain location and intensity during the past 3 months. Next, they indicated their use of 24 different pain treatments and the effectiveness of each. Finally, participants indicated the frequency of pain-related healthcare visits to specific providers over the past 6 months.
63% of participants reported experiencing chronic pain and rated their pain intensity over the past week as 5.1/10, on average. The most common pain locations were the lower back, hips, and legs. Physical interventions (e.g., physical therapy, strengthening) were the most common pain treatments reportedly used, and were rated as moderately effective. Many other treatments were also used, and participants sought pain-related care from a variety of providers.
Although participants reportedly accessed pain care from a variety of providers, and perceived that several types of treatments were effective, many of the treatments rated as effective were rarely used or provided. Future research using clinical trial methods would further elucidate the specific pain treatments that are most beneficial for adults with CP.
PMCID: PMC3036542  PMID: 21273894
Pain; Cerebral Palsy; Health Services Accessibility
10.  Investigating patient characteristics on pain assessment using virtual human technology 
Pain assessment and treatment is challenging and can be influenced by patient demographic characteristics. Few research studies have been able to specifically examine these influences experimentally. The present study investigated the effects of patients' sex, race, age, and pain expression on healthcare students' assessment of pain and pain-related sequelae using virtual human (VH) technology. A lens model design was employed, which is an analogue method for capturing how individuals use environmental information to make judgments. In this study, decision-making policies were captured at the nomothetic and idiographic level. Participants included 107 healthcare students who viewed 32 VH patients that differed in sex, race, age, and pain expression in an online study. Participants provided ratings on a 100-point scale on the VH pain intensity, pain unpleasantness, negative mood, coping, and need for medical treatment. Nomothetic analyses revealed that female, African American, older, and high pain expression VH were rated higher than male, Caucasian, younger, and low pain expression VH, respectively, on most of the five ratings. Idiographic analyses revealed detailed findings for individuals' decision-making policies. VH technology and the lens model design were shown to be highly effective in examining individuals' decision making policies. Pain assessment often varied among individuals based on patient demographic and facial expression cues. This study could serve as a model for future investigations of pain assessment and treatment in healthcare students and providers.
PMCID: PMC2980573  PMID: 20435492
assessment; psychology; virtual technology; healthcare students
11.  Symptom burden in individuals with cerebral palsy 
The current study sought to (1) determine the relative frequency and severity of eight symptoms in adults with cerebral palsy (CP), (2) examine the perceived course of these eight symptoms over time, and (3) determine the associations between the severity of these symptoms and psychosocial functioning. Eighty-three adults with CP completed a measure assessing the frequency, severity, and perceived course of eight symptoms (pain, weakness, fatigue, imbalance, numbness, memory loss, vision loss, and shortness of breath). Respondents also completed measures of community integration and psychological functioning. The results indicated that pain, fatigue, imbalance, and weakness were the most common and severe symptoms reported. All symptoms were reported to have either stayed the same or worsened, rather than resolved, over time. The symptoms were more closely related to social integration than to home integration, productive activity, or psychological functioning. Memory loss was a unique predictor of social integration in the multivariate context. This study highlighted several common and problematic symptoms experienced by adults with CP. Additional research is needed to identify the most effective treatments for those symptoms that affect community integration and psychological functioning as a way to improve the quality of life of individuals with CP.
PMCID: PMC3158669  PMID: 21174251
cerebral palsy; community integration; fatigue; imbalance; pain; psychological functioning; quality of life; rehabilitation; signs and symptoms; weakness
12.  Psychosocial Factors and Adjustment to Pain in Individuals with Postpolio Syndrome 
The purpose of the current study was to examine the associations among measures of psychosocial factors, pain, and adjustment in persons with postpoliomyelitis syndrome.
A cross-sectional survey design was used. Sixty-three community-dwelling individuals with postpoliomyelitis syndrome returned completed questionnaires (71% response rate) that included measures of pain intensity and interference, psychological functioning, pain catastrophizing, social support, and pain-related beliefs and coping.
After controlling for demographic variables, the group of psychosocial variables accounted for an additional 23% of the variance in pain intensity. These variables explained an additional 35% and 50% of the variance in pain interference and psychological functioning, respectively, after accounting for demographic variables and pain intensity. Social support was associated with both psychological functioning and pain interference, whereas catastrophizing was most closely related to psychological functioning. Individual pain beliefs and coping strategies were variably related to the three criterion measures.
The overall results of the current study are consistent with a biopsychosocial framework for understanding pain and functioning in individuals with postpoliomyelitis syndrome. Although additional research is needed to clarify the nature of the relationships between individual psychosocial variables and functional indices, the findings suggest the need for a multidisciplinary approach to pain management in individuals with postpoliomyelitis syndrome.
PMCID: PMC3157697  PMID: 20068433
Postpolio Syndrome; Pain; Biopsychosocial; Adjustment
13.  Evaluation of Nurses' Self-Insight into their Pain Assessment and Treatment Decisions 
Research generally indicates that providers demonstrate modest insight into their clinical decision processes. In a previous study utilizing virtual human (VH) technology, we found that patient demographic characteristics and facial expressions of pain were statistically significant predictors of many nurses' pain-related decisions. The current study examined the correspondence between the statistically-identified and self-reported influences of contextual information on pain-related decisions. Fifty-four nurses viewed vignettes containing a video of a VH patient and text describing a post-surgical context. VH sex, race, age, and facial expression varied across vignettes. Participants made pain assessment and treatment decisions on visual analogue scales. Participants subsequently indicated the information they relied on when making decisions. None of the participants reported using VH sex, race, or age in their decision process. Statistical modeling indicated that 28–54% of participants (depending on the decision) used VH demographic cues. 76% of participants demonstrated concordance between their reported and actual use of the VH facial expression cue. Vital signs, text-based clinical summary, and VH movement were also reported as influential factors. These data suggest that biases may be prominent in practitioner decision-making about pain, but that providers have minimal awareness of and/or a lack of willingness to acknowledge this bias.
The current study highlights the complexity of provider decision-making about pain management. The VH technology could be used in future research and education applications aimed at improving the care of all persons in pain.
PMCID: PMC2864339  PMID: 20015702
pain management; disparities; virtual human technology; decision policies; self awareness
This study examined the influence of Virtual Humans’ (VH) sex and race on participants’ ratings of pain intensity, pain unpleasantness, pain-related negative mood, pain coping, and recommendations for medical help. Seventy-five undergraduates viewed a series of VHs and provided computerized visual analog scale (VAS) ratings for the five domains listed above. Mixed model ANOVA analyses showed that participants of both sexes and races viewed female VHs as experiencing greater pain intensity, greater pain unpleasantness, a greater number of pain-related negative moods, poorer coping skills, and a greater need to seek medical help for their pain. Participants of both races rated Caucasian VHs as experiencing more negative moods and poorer coping skills do deal with their pain. The novel computerized VH technology used herein allowed for the standardization of pain expression across sexes and races of VH stimuli, thus allowing us to remove the influence of biases when creating the study stimuli. This is a notable advantage over other research methodologies in this line of inquiry. Several future research and education applications of this VH technology are discussed.
PMCID: PMC3077073  PMID: 21499447
Pain Assessment; Virtual Technology; Mood; Coping; Medical Help
15.  Prevalence and Impact of Pain in Multiple Sclerosis: Physical and Psychologic Contributors 
To characterize the prevalence and impact of pain in veterans with multiple sclerosis (MS) and to assess their association with demographic, biologic, and psychologic variables.
Cross-sectional cohort study linking computerized medical record information to mailed survey data.
Veterans Health Administration (VHA).
Sixty-four percent (2994/4685) of veterans with MS who received services in VHA and also returned survey questionnaires.
Not applicable.
Main Outcome Measures
Items assessing pain intensity, pain interference, and physical and mental health functioning.
Ninety-two percent of participants reported bodily pain within the prior 4 weeks, with 69% of the total sample indicating pain of moderate or higher intensity. Eighty-five percent indicated that pain caused functional interference during the past 4 weeks, with 71% of the total sample reporting pain-related interference that was moderate or greater. No significant sex or race differences emerged for the pain indices. A significant but modest relationship between increasing age and pain interference emerged (r=.05, P<.01); however, age was not significantly related to pain intensity. Multivariate regression analyses identified pain intensity (β=.73), physical health functioning (β=−.07), and mental health functioning (β=−.13) variables as significant, unique contributors to the prediction of pain interference. The interaction of pain intensity and physical functioning was also significant but of minimal effect size (β=−.03).
Pain is highly prevalent and causes substantial interference in the lives of veterans with MS. The functional impact of pain in veterans with MS is influenced by pain intensity, physical health, and emotional functioning. Clinical practice should take each of these domains into consideration and reflect a biopsychosocial conceptualization.
PMCID: PMC3034239  PMID: 19345781
Mental health; Multiple sclerosis; Pain; Rehabilitation
16.  The Relationship of Chronological Age, Age at Injury, and Duration of Injury to Employment Status in Individuals with Spinal Cord Injury 
Psychological injury and law  2009;2(3-4):263-275.
Employment status following spinal cord injury (SCI) has important implications for financial and psychosocial well-being. Several age-related variables—in particular chronological age, duration of SCI, and age at SCI onset—have been identified as being associated with employment among individuals with SCI. Cross-sectional investigations of this topic are complicated by methodological and statistical issues associated with aging and disability. The purpose of the current study was to examine the associations between three aging variables and employment status in individuals with SCI through a series of regression analyses. Six hundred twenty individuals with SCI completed a survey that included measures of demographic characteristics, pain, psychological functioning, physical functioning, fatigue, and sleep. The results indicated that chronological age and age at SCI onset were significant predictors of employment status. A significantly greater proportion of individuals aged 45–54 were employed compared to those aged 55–64 even after controlling for biopsychosocial variables. Additionally, there was a negative linear relationship between percent employed and age at SCI onset, and this relationship was not accounted for by the biopsychosocial variables. The analyses used in this study provide one method by which to disentangle the effects of different age-related variables on important SCI outcomes in cross-sectional research. Continued research in this area is needed to better understand age-related effects on employment status, which could be used to help maximize the quality of life in individuals with SCI.
PMCID: PMC3033017  PMID: 21297893
Spinal cord injury; Employment; Aging; Disability
17.  Cognitive and Behavioral Treatments for Anxiety and Depression in a Patient with an Implantable Cardioverter Defibrillator (ICD): A Case Report and Clinical Discussion 
Implantable cardioverter-defibrillators (ICDs) are the treatment of choice for patients at risk for potentially life threatening arrhythmias. The associated stress of living with an implanted device and receiving ICD shock therapy has been noted to exert a psychological toll on the individual patient and family. Anxious and depressive symptomatology is frequently reported by these patients, thus creating a demand for tailored psychological interventions for this population. The current case report describes the components, delivery, and effectiveness of a targeted treatment approach for anxiety and depression in an individual with an ICD. Test results and interview data revealed significant improvements in multiple domains of cognitive, emotional, and behavioral functioning. Improvements in marital relations were also achieved. These treatment effects were maintained at follow-up and in the context of acute, medical stressors. Future clinical and research directions are also discussed.
PMCID: PMC3033116  PMID: 19404725
Implantable cardioverter-defibrillator (ICD); Anxiety; Depression; Cognitive and behavioral treatment
18.  Sex Differences in Pain and Psychological Functioning in Persons with Limb Loss 
Sex differences in pain are frequently reported in the literature. However, less is known about possible sex differences in the experience of pain secondary to a disability. The current study explored these issues in persons with limb loss (N = 335, 72% men) who were recruited as part of a postal survey. Participants provided ratings of phantom limb pain (PLP), residual limb pain (RLP), and general pain intensity. Participants also completed measures of pain-related interference, catastrophizing, coping, and beliefs. Results indicated that a greater proportion of males than females (86% vs. 77%, respectively) reported the presence of PLP; however, this difference was no longer prominent when cause of limb loss was controlled. No sex differences were found in the presence of RLP, or in average intensity ratings of PLP or RLP. In contrast, females reported greater overall average pain intensity and interference than males. Females also endorsed significantly greater catastrophizing, use of certain pain coping strategies, and beliefs related to several aspects of pain. This study did not find prominent sex differences in pain specific to limb loss. However, several sex differences in the overall biopsychosocial experience of pain did emerge that are consistent with the broader literature.
The current study contributes to the literature on sex differences in the experience of pain. Although males and females with limb loss did not significantly differ in their disability-specific pain, sex differences in their broader experience of pain were significant and are worthy of future clinical and empirical attention.
PMCID: PMC2818017  PMID: 19734105
sex differences; pain; mental health; limb loss; amputation
19.  Virtual human technology: patient demographics and healthcare training factors in pain observation and treatment recommendations 
Journal of Pain Research  2010;3:241-247.
Patients’ sex, race, and age have been found to affect others’ perception of their pain. However, the influence of these characteristics on treatment recommendations from laypersons and healthcare providers is understudied.
To address this issue, 75 undergraduates and 107 healthcare trainees (HTs) used a web-based delivery system to view video clips of virtual human (VH) patients presenting with different standardized levels of pain. Subjects then rated the VHs’ pain intensity and recommended the amount of medical treatment the VHs should receive.
Results indicated that, compared with undergraduates, HTs perceived African Americans and older adults as having less pain but were more willing to recommend medical treatment for these patients than were undergraduate participants. HTs and undergraduates rated female, African American, older, and high-pain-expressing adults as having greater pain intensity than male, Caucasian, younger, and lower-pain-expressing adults. Moreover, they also recommended that female, older, and high-pain-expressing adults receive more medical treatment than male, younger, and lower-pain-expressing adults.
This study found that the characteristics of the VHs and whether the participants were undergraduates or HTs influenced the ratings of pain assessment and treatment recommendations. The findings are consistent with the previous VH literature showing that VH characteristics are important cues in the perception and treatment of pain. However, this is the first study to identify differences in pain-related decisions between individuals who are pursuing healthcare careers and those who are not. Finally, not only does this study serve as further evidence for the validity and potential of VH technology but also it confirms prior research that has shown that biases regarding patient sex, race, and age can affect pain assessment and treatment.
PMCID: PMC3033032  PMID: 21311717
pain; virtual human; race; age; gender; perception
20.  Sleep Problems in Individuals With Spinal Cord Injury: Frequency and Age Effects 
Rehabilitation psychology  2009;54(3):323-331.
The two objectives of this study were (a) to replicate the previous finding of more severe sleep difficulties in a sample of individuals with spinal cord injury (SCI) compared with normative samples, and (b) to examine the associations between aging variables (specifically, chronological age, duration of SCI, age at SCI onset) and the severity of sleep difficulties.
Cross-sectional survey.
Research Method
A survey was administered to 620 individuals with SCI that included measures of demographic characteristics and sleep difficulties.
The findings indicated that sleep problems are more common in individuals with SCI than in normative samples. In addition, younger participants in our sample reported more sleep problems than did older participants. Duration of SCI and age at onset, however, were not significantly associated with sleep difficulties.
The analyses used in this study provide a model for examining age effects using concurrent survey data that may be useful for other investigators interested in studying the associations between age-related variables and important health-related domains.
PMCID: PMC2848672  PMID: 19702431
spinal cord injury; sleep problems; aging; multiple regression
21.  Pain Assessment and Treatment Disparities: A Virtual Human Technology Investigation 
Pain  2009;143(1-2):106-113.
Pain assessment and treatment is influenced by patient demographic characteristics and nonverbal expressions. Methodological challenges have limited the empirical investigation of these issues. The current analogue study employed an innovative research design and novel virtual human (VH) technology to investigate disparities in pain-related clinical decision making. Fifty-four nurses viewed vignettes consisting of a video clip of the VH patient and clinical summary information describing a post-surgical context. Participants made assessment (pain intensity and unpleasantness) and treatment (non-opioid and opioid medications) decisions on computerized visual analogue scales. VH demographic cues of sex, race, and age, as well as facial expression of pain, were systematically manipulated and hypothesized to influence decision ratings. Idiographic and nomothetic statistical analyses were conducted to test these hypotheses. Idiographic results indicated that sex, race, age, and pain expression cues accounted for significant, unique variance in decision policies among many nurses. Pain expression was the most salient cue in this context. Nomothetic results indicated differences within VH cues of interest; the size and consistency of these differences varied across policy domains. This study demonstrates the application of VH technology and lens model methodology to the study of disparities in pain-related decision making. Assessment and treatment of acute post-surgical pain often varies based on VH demographic and facial expression cues. These data contribute to the existing literature on disparities in pain practice and highlight the potential of a novel approach that may serve as a model for future investigation of these critical issues.
PMCID: PMC2666785  PMID: 19269742
pain assessment; pain treatment; disparities; virtual technology; decision policies
22.  Psychologic Influence on Experimental Pain Sensitivity and Clinical Pain Intensity for Patients with Shoulder Pain 
Pain-related fear and pain catastrophizing are two central psychologic factors in fear-avoidance models. Our previous studies in healthy subjects indicated that pain-related fear, but not pain catastrophizing, was associated with cold pressor pain outcomes. The current study extends previous work by investigating pain-related fear and pain catastrophizing in a group of subjects with shoulder pain, and included concurrent measures of experimental and clinical pain. Fifty nine consecutive subjects seeking operative treatment of shoulder pain were enrolled in this study (24 females, mean age = 50.4, sd = 14.9). Subjects completed validated measures of pain-related fear, pain catastrophizing, and clinical pain intensity and then underwent a cold pressor task to determine experimental pain sensitivity. Multivariate regression models used sex, age, pain-related fear, and pain catastrophizing to predict experimental pain sensitivity and clinical pain intensity. Results indicated that only pain-related fear uniquely contributed to variance in experimental pain sensitivity (beta = −.42, p < .01). In contrast, sex (beta = −.29, p = .02) and pain catastrophizing (beta = .43, p < .01) uniquely contributed to variance in clinical pain intensity. These data provide additional support for application of fear-avoidance models to subjects with shoulder pain. Our results also suggest that pain-related fear and pain catastrophizing may influence different components of the pain experience, providing preliminary support for recent theoretical conceptualizations of the role of pain catastrophizing.
PMCID: PMC2672100  PMID: 19070551
Chronic pain; biopsychosocial; pain-related fear; pain catastrophizing; quantitative sensory testing; fear-avoidance model
23.  Virtual Human Technology: Capturing Sex, Race, and Age Influences in Individual Pain Decision Policies 
Pain  2008;140(1):231-238.
Pain assessment is subject to bias due to characteristics of the individual in pain and of the observing person. Few research studies have examined pain assessment biases in an experimental setting. The present study employs innovative virtual human technology to achieve greater experimental control. A lens model design was used to capture decision-making policies at the idiographic and nomothetic level. Seventy-five undergraduates viewed virtual humans (VH) that varied in sex, race, age, and pain expression. Participants provided computerized ratings with Visual Analogue Scales on the VH's pain intensity, pain unpleasantness, negative mood, coping, and need for medical treatment. Idiographic analyses revealed that individuals used pain expression most frequently as a significant cue. Nomothetic analyses showed that higher pain expression VH and female VH were viewed as having higher pain intensity, higher pain unpleasantness, greater negative mood, worse coping, and a greater need to seek medical treatment than lower pain expression VH and male VH, respectively. Older VH were viewed as having worse coping and a greater need to seek medical treatment than younger VH. This innovative paradigm involving VH technology and a lens model design was shown to be highly effective and could serve as a model for future studies investigating pain-related decision making in healthcare providers.
PMCID: PMC2586418  PMID: 18930596
pain assessment; sex differences; race differences; age differences; virtual technology; decision policies
24.  Fear of Pain, Pain Catastrophizing, and Acute Pain Perception: Relative Prediction and Timing of Assessment 
Pain-related fear and catastrophizing are important variables of consideration in an individual’s pain experience. Methodological limitations of previous studies limit strong conclusions regarding these relationships. In this follow-up study, we examined the relationships between fear of pain, pain catastrophizing, and experimental pain perception. One hundred healthy volunteers completed the Fear of Pain Questionnaire (FPQ-III), Pain Catastrophizing Scale (PCS), and Coping Strategies Questionnaire-Catastrophizing scale (CSQ-CAT) before undergoing the cold pressor test (CPT). The CSQ-CAT and PCS were completed again following the CPT, with participants instructed to complete these measures based on their experience during the procedure. Measures of pain threshold, tolerance, and intensity were collected and served as dependent variables in separate regression models. Sex, pain catastrophizing, and pain-related fear were included as predictor variables. Results of regression analyses indicated that after controlling for sex, pain-related fear was a consistently stronger predictor of pain in comparison to catastrophizing. These results were consistent when separate measures (CSQ-CAT vs. PCS) and time points (pre-task vs. “in-vivo”) of catastrophizing were used. These findings largely corroborate those from our previous study and are suggestive of the absolute and relative importance of pain-related fear in the experimental pain experience.
Although pain-related fear has received less attention in the experimental literature than pain catastrophizing, results of the current study are consistent with clinical reports highlighting this variable as an important aspect of the experience of pain.
PMCID: PMC2568976  PMID: 18486557
fear; catastrophizing; assessment; pain; experimental
25.  Manipulation of pain catastrophizing: An experimental study of healthy participants 
Journal of pain research  2008;1:35-41.
Pain catastrophizing is associated with the pain experience; however, causation has not been established. Studies which specifically manipulate catastrophizing are necessary to establish causation. The present study enrolled 100 healthy individuals. Participants were randomly assigned to repeat a positive, neutral, or one of three catastrophizing statements during a cold pressor task (CPT). Outcome measures of pain tolerance and pain intensity were recorded. No change was noted in catastrophizing immediately following the CPT (F(1,84) = 0.10, p = 0.75, partial η2 < 0.01) independent of group assignment (F(4,84) = 0.78, p = 0.54, partial η2 = 0.04). Pain tolerance (F(4) = 0.67, p = 0.62, partial η2 = 0.03) and pain intensity (F(4) = 0.73, p = 0.58, partial η2 = 0.03) did not differ by group. This study suggests catastrophizing may be difficult to manipulate through experimental pain procedures and repetition of specific catastrophizing statements was not sufficient to change levels of catastrophizing. Additionally, pain tolerance and pain intensity did not differ by group assignment. This study has implications for future studies attempting to experimentally manipulate pain catastrophizing.
PMCID: PMC3004615  PMID: 21197286
pain; catastrophizing; experimental; cold pressor task; pain catastrophizing scale

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