=Paper=
{{Paper
|id=Vol-1309/paper5
|storemode=property
|title=An alternative terminology for pain assessment
|pdfUrl=https://ceur-ws.org/Vol-1309/paper5.pdf
|volume=Vol-1309
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==An alternative terminology for pain assessment==
https://ceur-ws.org/Vol-1309/paper5.pdf
An alternative terminology for pain assessment
Werner Ceusters
Department of Biomedical Informatics
University at Buffalo
Buffalo, NY 14203, USA
Email: ceusters@buffalo.edu
Abstract — Background: the International Association for unpleasant sensory and emotional experience associated
the Study of Pain (IASP) publishes since 1986 a relatively with actual or potential tissue damage, or described in
frequently updated list of pain terms with corresponding terms of such damage’.
definitions and clarificatory notes currently known as the For terms to be eligible as representational units in a
‘IASP Taxonomy’. The last update, i.e. the May 2012 version
realism-based ontology such as OPMQoL, they must not
of this taxonomy, was subjected to an analysis with the goal to
assess whether the definitions of the IASP terms that are used only (1) denote entities that can be classified following the
to describe findings of somatosensory testing and pain principles of Ontological Realism [7], but also (2) be
assessment satisfy the conditions for these terms to become defined using Aristotelian definitions which specify the
part of a realism-based ontology. Results: the taxonomy was necessary and sufficient conditions for class membership,
found to be built on definitions that are not in every case based and further lead to a taxonomy based on single inheritance
on necessary and sufficient conditions, nor satisfy the single [8]. The goal of the work reported on here was to assess the
inheritance principle for realism-based ontologies. adherence of the IASP pain assessment definitions to this
Furthermore, although the documentation about introduced second condition and to find ways for remediation if non-
changes provided by the IASP makes it clear that the
compliance was found.
terminology authors tried to solve ambiguities and unclarities
present in previous versions, they did not succeed completely
and introduced even some inconsistencies. The analysis Allodynia: pain due to a stimulus that does not normally provoke pain.
demonstrates that the main cause for this is not the choice of Note: The stimulus leads to an unexpectedly painful response.
differentiating characteristics, but rather insufficient attention Analgesia: absence of pain in response to stimulation which would
to the wide variability in stimulus/response combinations that normally be painful.
these characteristics reveal. Conclusions: the IASP taxonomy is Dysesthesia: an unpleasant abnormal sensation, whether spontaneous or
not fit to form the basis for a realism-based ontology. A new evoked. Note: Special cases of dysesthesia include hyperalgesia and
allodynia.
representation framework for describing pain assessment
Hyperalgesia: increased pain from a stimulus that normally provokes
findings more accurately using the same set of differentiae is
pain.
proposed and its correspondence with the traditional
Hyperesthesia: increased sensitivity to stimulation, excluding the
terminology explained.
special senses.
Hyperpathia: a painful syndrome characterized by an abnormally
Keywords—pain terminology, ontological realism
painful reaction to a stimulus.
Hypoalgesia: diminished pain in response to a normally painful
I. BACKGROUND stimulus.
The Ontology for Pain-Related Mental Health and Quality Hypoesthesia: decreased sensitivity to stimulation, excluding the
special senses.
of Life (OPMQoL) is being developed as part of the
Paresthesia: an abnormal sensation, whether spontaneous or evoked.
NIDCR-funded project R01DE021917 with the goal to Note: paresthesia is to be used to describe an abnormal sensation that
integrate five datasets gathered in four different countries is not unpleasant.
from patients suffering from one or other form of orofacial Table 1 - Pain terms analyzed
pain [1, 2]. Part of the data in these datasets describe
findings that are based on the various kinds of responses II. METHODS
that patients may report when subjected to stimuli to test Based on the definitions of the terms studied – note that
their somatosensory status and that are typically described table 1 contains only part of the relevant notes and that the
using terms such as ‘allodynia’, ‘hyperesthesia’, and so reader should for complete understanding of the analysis
forth. Although these terms were already in practice since at method consult reference [6] - an analysis framework was
least the early 19th century [3], standard definitions for these designed by introducing nine hierarchically organized
terms were first proposed in 1979 [4] and are since then variables reflecting the type of stimulus, the presence or
regularly updated by the International Association for the absence of a response, and the type of response when
Study of Pain (IASP), in print for the last time in 1994 [5], present, when a patient is subjected to a pain assessment
with more regular electronic updates on the IASP webpage investigation. The allowed values for these variables were
[6] the last one in May 2012 (Table 1). These definitions are defined, depending on what the variable stands for, either on
further based on the IASP definition for ‘pain’ as ‘an a nominal or ordinal scale (Table 2).
49
Variable Values 4. if a response is present, it may be either (4a) selective,
Stimulus application Y(es) i.e. exclusively being unpleasant, painful, or of modus
modus M level Threshold B(elow), O(n), A(bove) M in isolation, or (4b) combining either a modus M and
Pain level Threshold B(elow), O(n), A(bove)
non-painful unpleasant response, or a modus M and
Response to stimulus Y(es), N(o)
painful response;
modus M Response Y(es), N(o)
modus M Intensity L(ess), C(oncordant), H(igh)
5. all pain responses are unpleasant, thus following the
Unpleasant response Y(es), N(o) IASP definition for ‘pain’ as ‘an unpleasant sensory
Pain Response Y(es), N(o) and emotional experience associated with actual or
Pain Intensity L(ess), C(oncordant), H(igh) potential tissue damage, or described in terms of such
Table 2 - Basic analysis framework variables, values and definitions damage’, but an unpleasant response does not need to
be painful.
The next step consisted of identifying and representing As a third step, each combination was assessed for whether
all theoretically possible stimulus/response combinations, a it could figure as an exemplar for each of the terms of Table
part of which is displayed in Table 3. 1. Table 4 provides an example of this step for the IASP-
Although the maximal theoretical number of possible definition of ‘allodynia’ without taking the note into
combinations would be 1296 (1*3*3*2*2*3*2*2*3), the account. A complication at this phase was that the
actual number is only 130 because of the hierarchical definitions and notes left certain questions with respect to
organization of the variables which implements the inclusion and exclusion criteria unanswered. It was thus for
following dependencies typical for somatosensory and pain many definitions required to find meaningful subgroups and
assessment studies [9]: for some of these subgroups the IASP documentation did
1. each stimulus, whether to test either somatosensory not provide enough information to assess whether they
status (e.g. temperature, pressure, pin prick, and so represent intended interpretations, although from a
forth, henceforth called ‘modus M’) or pain sensitivity, terminological and ontological perspective perfectly
falls under one of three disjoint categories: (1) below plausible. Table 5 shows the subgroups identified as well as
threshold, (2) on threshold, or (3) above threshold; the counts of stimulus/response combinations that fall under
2. modus M and pain stimuli may be given selectively or them. When subgroups were defined, the count for the
together, thus resulting in 4 stimulation modes: (1) sub- (direct or indirect) parent terms were obtained by applying a
threshold (for both pain and modus M), (2-3) modus M- Boolean OR operation on the combinations (and not the
or pain-selective, and (4) bimodal (i.e. on or supra- mere addition as subgroups are not necessarily mutually
threshold for both modus M and pain); exclusive). This information was in a fourth step used to
3. if there is no response to a stimulus, then there are no compute the exact overlap between these terms in function
values for the intensity of modus M sensation and pain; of positive and negative co-occurrence.
S Stimulus given Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
MT Modus M threshold A A A A A A A A A A A A A A A A A A A A
PT Pain Threshold A A A A A A A A A A A A A A A A A A A A
R Response N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
MR Modus M response N N N N N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
MI Modus M response Intensity - - - - - L L L L L C C C C C H H H H H
U Unpleasant response N Y Y Y Y N Y Y Y Y N Y Y Y Y N Y Y Y Y
PR Pain Response - N Y Y Y - N Y Y Y - N Y Y Y - N Y Y Y
PI Pain Response Intensity - - L C H - - L C H - - L C H - - L C H
Table 3 - Different stimulus/response combinations possible for bimodal above (but not ‘on’) threshold stimulation. Legend for values: Y = Yes, N = No, B
= Below threshold stimulus, O = On threshold stimulus, A = Above threshold stimulus, H = Higher than expected response intensity, C = response intensity
Concordant with stimulus, L = Lower than expected response intensity.
S Stimulus given Y Y Y Y Y Y Y Y Y Y
MT Modus M threshold B B O O O O A A A A
PT Pain Threshold B B B B B B B B B B
R Response Y Y Y Y Y Y Y Y Y Y
MR Modus M response N Y N Y Y Y N Y Y Y
MI Modus M response Intensity - H - L C H - L C H
U Unpleasant response Y Y Y Y Y Y Y Y Y Y
PR Pain Response Y Y Y Y Y Y Y Y Y Y
PI Pain Response Intensity H H H H H H H H H H
ALLO-D Y Y Y Y Y Y Y Y Y Y
Table 4 - Possible stimulus/response combinations for Allodynia (following the IASP definition strictly). Legend for values: Y = Yes, N = No, B = Below
threshold stimulus, O = On threshold stimulus, A = Above threshold stimulus, H = Higher than expected response intensity, C = response intensity
Concordant with stimulus, L = Lower than expected response intensity.
50
Acronym Term (plus meaning) N Figure 1 - IASP pain assessment terminology hierarchy
CONC Normal case 9 ABSENCE SENSATION SENSITIVITY SYNDROME
ALLO-D allodynia (definition): unexpected evoked pain 10
ALLO-N allodynia (note): unexpected more intense evoked pain 30
Paresthesia
ANAL analgesia: unexpected absence of evoked pain 40
DYS-E evoked dysesthesia 80
DYS-EP painful evoked dysesthesia 50 PAIN Dysesthesia Hyperesthesia Hypoesthesia
DYS-EU non-painful evoked dysesthesia 30
HYPERA hyperalgesia: unexpected more intense evoked pain 20
HYPERE hyperesthesia = increased sensitivity to stimulation 81
HYPERE-I unexpected more intense evoked sensation 42 Analgesia Hypoalgesia Allodynia Hyperalgesia Hyperpathia
HYPERE-IP unexpected more intense evoked pain 20
HYPERE-IM unexpected more intense evoked modus M 26
HYPERE-P unexpected presence of evoked sensation 49 nothing which is a kind of one can also be a kind of the other.
HYPERE-PU unexpected evoked unpleasant sensation other than 30 In addition, already a superficial reading of these terms and
pain accompanying notes reveals ambiguities and inconsistencies.
HYPERE-PP unexpected pain 10 The definition of ‘allodynia’, for instance, indicates that the
HYPERE-PM unexpected modus M 13
term should be used for pain evoked after applying a stimulus
HYPERP hyperpathia 30
HYPOALG hypoalgesia 20 which is below the normal pain threshold. The corresponding
HYPOE hypoesthesia = decreased sensitivity to stimulation 58 note however suggests that also a response on an above-
HYPOE-P decreased sensitivity to pain stimulation 40 threshold stimulus may count as such when the stimulus leads
HYPOE-PL less pain to pain stimulation 20 to more pain than expected. The note for ‘dysesthesia’, as
HYPOE-PA non painful unpleasant response to pain stimulation 20 many similar notes for other terms which for space reasons are
HYPOE-M decreased sensitivity to modus M stimulation 26 not reproduced in Table 1 but can be found in reference [6],
HYPOE-BI decreased sensitivity to both kinds of stimulation 8
PAR-D-E evoked paresthesia (definition) 81
indicate that there is considerable overlap between the terms.
PAR-D-EP painful evoked paresthesia 30 B. Traditional pain assessment terminology shows
PAR-D-EU non-painful unpleasant evoked paresthesia 30
considerable overlap
PAR-D-EN non-painful not unpleasant evoked paresthesia 39
PAR-N-E evoked paresthesia (note) 19 All terms of Table 1 could be mapped to the stimulus/response
Table 5 - Terms and ontological subgroups for the IASP pain assessment combinations. Table 6 illustrates how the parent terms relate
terminology. Legend: N = number of stimulus/response combinations to each other in function of the stimulus/response
applicable (max = 130).
combinations. The individual cells contain the counts for the
This step answers thus for each term pair ‘A B’ the question overlap, if any. For example, the overlap cells between
which and how many of the possible stimulus/response hyperesthesia and hypoalgesia show - surprisingly - that these
combinations can occur in the pair combinations A+/B+, two conditions do not exclude each other: 6 of the 130
A+/B-, A-/B+,A-/B- where ‘+’ and ‘-’ indicate that the combinations fall under both definitions, 14 are such that
stimulus/response combination can, resp. cannot occur under hypoalgesia is present without hyperesthesia, 75 have
the definition of the term. As it became clear at this point that hyperesthesia without hypoalgesia, and 35 don’t exhibit either.
overlap was considerable, we designed a new terminology An additional color coding is used to highlight the type of
based on definitions that minimize the potential overlap using overlap: white indicates a symmetric overlap for all 4 types of
categories that are mutually exclusive. We then compared this co-occurrence as exemplified by the hyperesthesia/
new terminology with the traditional one, again using the hypoalgesia pair; green indicates mutual exclusion of the
stimulus/response combinations as benchmark. positive occurrences, the other three colors indicate an
asymmetric overlap. An ideal terminology would be such that
the classes defined are mutually disjoint. For 12 (n) classes as
III. RESULTS
is the case here, there are 66 possible overlaps ( n*(n-1)/2 )
A. The IASP terms do not satisfy the criteria for direct between any pair of these classes, not counting overlap of a
integration in a realism-based ontology. class with itself. As displayed in Table 6, there is no overlap in
only 2 cases of these 66: (1) for hyperpathia versus allodynia
Figure 1 - in which terms displayed in SMALL CAPS are the (taking the note into account), and (2) for hyperesthesia and
immediate superordinate terms found in the definitions and the paresthesia (when the note is not taken into account).
arrows stand for the classical subsumption relation [10] –
demonstrates that although the individual definitions follow C. Novel terminology with less overlap
the Aristotelian form ‘an A is a B which C’, the defined terms Table 7 provides an overview of the proposed terminology
do not lead all together to a complete directed graph with an which uses 6 variables (Response expectation, Main finding,
overarching top, not even if all 29 IASP terms would be Sensation expectation, Sensation intensity, Sensation mode,
included. Furthermore, the terms ‘allodynia’ and and Stimulation type) that can take a number of values and
‘hyperalgesia’ have superordinate terms which under their which are strongly related to the variables and values used to
standard meanings should represent disjoined classes: design the analysis framework of the 130 stimulus/response
although sensation and sensitivity are certainly related, combinations.
51
/CONC
CONC
/ALLO-D
ALLO-D
CONC 9 0
/ALLO-N
ALLO-N
/CONC 0 121
ALLO-D 0 10 10 0
/ALLO-D 9 111 0 120
/ANAL
ANAL
ALLO-N 0 30 10 20 30 0
/ALLO-N 9 91 0 100 0 100
/DYS-E
DYS-E
ANAL 0 40 0 40 0 40 40 0
/HYPERA
HYPERA
/ANAL 9 81 10 80 30 60 0 90
DYS-E 0 80 10 70 30 50 20 60 80 0
/HYPERE
HYPERE
/DYS-E 9 41 0 50 0 50 20 30 0 50
HYPERA 0 20 0 20 20 0 0 20 20 0 20 0
/HYPERP
HYPERP
/HYPERA 9 101 10 100 10 100 40 70 60 50 0 110
/HYPOALG
HYPERE 0 81 10 71 30 51 26 55 66 15 20 61 81 0
HYPOALG
/HYPERE 9 40 0 49 0 49 14 35 14 35 0 49 0 49
HYPERP 0 30 10 20 30 0 0 30 30 0 20 10 30 0 30 0
/HYPOE
/HYPERP 9 91 0 100 0 100 40 60 50 50 0 100 51 49 0 100
HYPOE
HYPOALG 0 20 0 20 0 20 0 20 20 0 0 20 6 14 0 20 20 0
/PAR-D-E
PAR-D-E
/HYPOALG 9 101 10 100 30 80 40 70 60 50 20 90 75 35 30 80 0 110
HYPOE 0 58 2 56 6 52 24 34 48 10 4 54 34 24 6 52 20 38 58 0
/PAR-N-E
PAR-N-E
/HYPOE 9 63 8 64 24 48 16 56 32 40 16 56 47 25 24 48 0 72 0 72
PAR-D-E 0 81 10 71 30 51 26 55 66 15 20 61 81 0 30 51 6 75 34 47 81 0
/PAR-D-E 9 40 0 49 0 49 14 35 14 35 0 49 0 49 0 49 14 35 24 25 0 49
PAR-N-E 0 19 0 19 0 19 14 5 0 19 0 19 9 10 0 19 0 19 6 13 9 10 19 0
/PAR-N-E 9 102 10 101 30 81 26 85 80 31 20 91 72 39 30 81 20 91 52 59 72 39 0 111
Table 6 - Positive/negative contingency table for traditional pain terminology. A color coding is used for the 2-by-2 contingency tables to
highlight the type of overlap: white indicates a symmetric overlap for all 4 types of co-occurrence; green indicates mutual exclusion of the
positive occurrences, the other three colors indicate an asymmetric overlap.
Response Main finding Sensation Sensation Sensation Stimulation
expectation expectation intensity mode type
Concordant Absence Concordant hypOresponsive Modal Sensation Subthreshold Stimulation
Discordant Presence Discordant hypErresponsive Unpleasant Pain-specific
Configuration Painful Modus-specific
Bimodal
CA---SS C A S S S
DPDEMSS D P D E M S S S
DPDEUSS D P D E U S S S
DPDEPSS D P D E P S S S
DC---SS D C S S S
CA—MSP C A M S P S
CPC-PSP C P C P S P S
CC---SP C C S P S
DA—PSP D A P S P S
DPDOUSP D P D O U S P S
DPDOPSP D P D O P S P S
DPDEMSP D P D E M S P S
DPDEPSP D P D E P S P S
DC---SP D C S P S
CA—USM C A U S M S
CPC-MSM C P C M S M S
CC---SM C C S M S
DA—MSM D A M S M S
DPDEMSM D P D E M S M S
DPDEUSM D P D E U S M S
DPDEPSM D P D E P S M S
DC---SM D C S M S
CPC-MSB C P C M S B S
CPC-PSB C P C P S B S
CC---SB C C S B S
DA—MSB D A M S B S
DA—PSB D A P S B S
DPDOMSB D P D O M S B S
DPDOUSB D P D O U S B S
DPDOPSB D P D O P S B S
DPDEMSB D P D E M S B S
DPDEPSB D P D E P S B S
DC---SB D C S B S
Table 7 - Proposed alternative terminology
52
The values for sensation mode are to be interpreted as stimulation’ and ‘discordant presence of discordant hyper-
follows: ‘modal’ means that there is only a modal response responsive modal sensation after subthreshold stimulation’.
which is not unpleasant or painful, ‘unpleasant’ means that the The left column of Table 7 contains for further reference in
response is unpleasant but not painful, irrespective of whether Table 8 acronyms for the various possibilities formed by
there is a modal response as well, whereas ‘painful’ means means of the concatenation of the individual values for a
there is only a painful response. ‘Subthreshold’ for stimulation certain variable, excluding, for space reasons, the last
type reflects a subthreshold stimulation for both pain and (constant) ‘S’ for ‘Stimulation’.
modus M, while ‘bimodal’ indicates an above threshold Table 8 shows the extent to which the proposed
stimulation for both modus M and pain. terminology categories suffer from a far less degree of
As is the case for the analysis framework, some values are overlap, overlap being indicated by the cells in light and dark
constrained by the values for some other variables. As an red background: only 23 overlaps of the total possible 325.
example, when the value for stimulus intensity is
‘subthreshold’, there is either (1) no response in which case IV. DISCUSSION
the value for response expectation is constrained to Our results in Table 5, combined with Table 1, clearly indicate
‘concordant’, the value for main finding to ‘absence’, and all that the traditional terminology is based on rather ambiguous
other variables have no value, or (2) a response is present, in definitions and application recommendations some of which
which case the values for response expectation and sensation lead to interpretations for which it is not clear whether they
expectation are both constrained to ‘discordant’, the value for are intended or not. This is overwhelmingly obvious for the
main finding to ‘presence’, and the value for sensation terms ‘hyperesthesia’, ‘hypoesthesia’ and ‘paresthesia’. The
intensity to ‘hyper-responsive’. The constraints make once latter is very broadly defined as an abnormal sensation,
again the total number of possibilities lower than can be without making it explicit what ‘abnormal’ exactly means:
expected: 26, excluding the combinations with the value ‘abnormal’ may indeed be interpreted as anything what is not
‘configuration’ for main finding which are constructed by the expected, such as more or less intense pain than expected after
boolean AND-ing and OR-ing of concordant and discordant giving a supra-threshold pain stimulus, or more or less intense
situations. The terms for this terminology are then all of the pressure sensation than expected when giving a supra-
form ‘(Response expectation) (Main finding) of (Sensation threshold pressure stimulus.
expectation) (Sensation intensity) (Sensation mode) sensation It may also be interpreted as feeling an itch - a form of
after (Stimulation type) stimulation’ whereby the variables in unpleasant sensation - when giving a pressure stimulus with or
italics are replaced by the terms for the allowed values, and without there being a pressure sensation, and so forth. The
the words in bold are constant. As an example, the terms for note for paresthesia, in contrast, tells us that only ‘not
the first two combinations in Table 7 are respectively unpleasant’ sensations should count as qualifying, which
‘concordant absence of sensation after subthreshold limits the number of possibilities considerably.
CA---SS
CA---SS 1 DPDEMSS
DPDEMSS 1 DPDEUSS
DPDEUSS 2 DPDEPSS
DPDEPSS 2 CA--MSP
CA--MSP 10 CPC-PSP
CPC-PSP 2 4 DA--PSP
DA--PSP 4 8 DPDOUSP
DPDOUSP 2 4 4 DPDOPSP
DPDOPSP 2 4 DPDEMSP
DPDEMSP 2 2 DPDEPSP
DPDEPSP 2 4 CA--USM
CA--USM 8 CPC-MSM
CPC-MSM 2 2 DA--MSM
DA--MSM 2 6 DPDEMSM
DPDEMSM 2 2 DPDEUSM
DPDEUSM 2 8 DPDEPSM
DPDEPSM 2 8 CPC-MSB
CPC-MSB 20 CPC-PSB
CPC-PSB 4 16 DA--MSB
DA--MSB 4 20 DA--PSB
DA--PSB 4 4 16 DPDOMSB
DPDOMSB 4 DPDOUSB
DPDOUSB 4 4 16 16 DPDOPSB
DPDOPSB 4 4 16 DPDEMSB
DPDEMSB 4 DPDEPSB
DPDEPSB 4 4 16
Table 8 - Overlap between proposed pain assessment categories
53
It leaves however still many interpretations open, such as VIII. ACKNOWLEDGEMENTS
whether the resulting sensation must be alien to the given The work described is funded in part by grant 1R01-
stimulus - would an erotic feeling induced by providing a
DE021917-01A1 from the National Institute of Dental and
pressure stimulus to the hand count as such a non-unpleasant
Craniofacial Research. The content of the paper is solely the
abnormal sensation? - or whether it may be special cases of
responsibility of the authors and does not necessarily represent
hypo- and hyperesthesia.
These reflections provide at the same time explanations for the official views of the NIDCR or the NIH.
the very high degree of overlap between the majority of the
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54