Pain and pain assessment in stroke patients with aphasia: a systematic review

Figures & data

Table 1. Pain rating scales.

Pain rating scale	Description	Scoring	Author(s)
Horizontal VAS	This VAS is presented as a 10-cm line, whose ends are labelled as the extremes of pain, for example: “no pain” and “worst imaginable pain”. The patient is asked to mark the 10-cm line to indicate pain intensity	The distance in centimetre from “no pain” and to the mark made by the patient represents that patient’s pain intensity scores	Jensen, Karoly, and Braver (1986)
Vertical VAS	This is a vertical 10-cm line labelled at the bottom with “no pain” and at the top with “worst imaginable pain”. The patient is asked to mark the 10-cm line to indicate pain intensity	The distance from “no pain” and to the mark made by the patient represents that patient’s pain intensity scores	Scott and Huskisson (1979)
Mechanical VAS	Usually consists of laminated or plastic VAS scales with a sliding marker with which the patient is asked to rate their pain intensity. The side with the sliding marker is facing the patient. The reverse side indicates numerically, usually in millimetres, how far the patient has moved the marker from the “no pain” end towards the “worst imaginable pain”. An additional cue, such as graduations of colour from pale pink on “no pain” to dark red on “worst imaginable pain”, can be provided	After the patient rates his or her pain, the researcher or clinician examines the other side of the scale to obtain the intensity score	Jensen et al. (1986)
FPS	Horizontal 7-point scale of photographs, line drawings or “smileys” that illustrate facial expressions of persons experiencing different levels of pain severity. Patients select the face that best describes their present state of pain	Face 0 represents “no pain”, and face 6 represents “the worst possible pain ever”. NB. Additional FPS tools are available with less or more than 7 faces or smileys	Wong and Baker (1988)
NRS	The NRS involves asking the patients to rate their pain from 0 to 10 (an 11-point scale) or from 0 to 100 (a 101-point scale). A verbal NRS does not require paper and pencil	The number that is indicated by the patient is the pain intensity score	Jensen et al. (1986)
VRS	Usually lists the adjectives in rank order of pain intensity and assigns each one a score as a function of its rank. The 4 points consist of: “no pain”, “mild pain”, “moderate pain” and “severe pain”	No pain is given a score of 0, mild pain a score of 1, moderate pain a score of 2 and severe pain a score of 3. NB. Additional VRS tools are available with less or more points to rate the patient’s pain	Seymour (1982)

The Categorical site-of-pain scale (shoulder) and the Scale Pain INtensity (SPIN) do not appear in Table 1, because they could not be evaluated using COSMIN.

VAS: Visual Analogue Scale; FPS: Faces Pain Scale; NRS: Numeric Rating Scale; VRS: Verbal Rating Scale.

Table 2. Characteristics of included articles.

Author (year of publication)	Country	Design	Setting	Sample (size)	Mean age (range) (years)	Mean post onset time (range) (months)	Exclusion criteria	Prevalence of aphasia/inability to communicate	Prevalence of pain
1. Pomeroy et al., (2000)	United Kingdom	Prospective cohort study	Community	n = 33 Groups: 1. Without aphasia and neglect (12) 2. Receptive aphasia (8) 3. Neglect (8) 4 4. Receptive aphasia + neglect (5)	74 (57–89)	42 (7–360)	–	39.4 % (13/33)	78.8% (26/33) Groups: 1. 83.3% (10/12) 2. 75% (6/8) 3. 87.5% (7/8) 4. 60% (3/5)
2. Benaim et al., (2007)	France	Prospective cohort study (2001–2006)	Rehabilitation unit	n = 127 Groups: 1. 21 Controls 2. LHSP (63) 3. RHSP (64) 82% (104) ischemia, 18% (23) haemorrhage	63 (18–80)	2.3	7.9% (5/63) of LHSP could not participate because of severe language disorders affecting comprehension (BDAE: 0–2/5)	60% (38) of LHSP presented aphasia	–
3. Korner-Bitensky et al., (2006)	Canada	Prospective cohort study	University hospital	n = 90 Groups: 1. 18 Controls 2. Stroke, without aphasia (20) 3. mild–moderate aphasia (23) 4. Aphasia severe expressive deficits (12) 5. Aphasia comprehension and expressive deficits (17)	Groups: 1: 65.1 (37–86) 2: 73.7 (48–86) 3: 74.4 (35–89) 4: 73.8 (59–85) 5. 75.1 (43–90)	Groups: 2: 1.1 (0.2–3) 3: 3.1 (0.3–37) 4: 1.16 (0.1–4.2) 5: 2.8 (0.2–15.5)	Those with insufficient cognitive status to understand the purpose	Groups: 3: 20.7% (23) mild–moderate aphasia 4: 9.9% (12) severe expr deficit 5: 15.3% (17) severe compr + expr deficits	–
4. Price et al., (1999)	United Kingdom	Prospective cohort study	General hospital	n = 96 + 48 controls	72.5	<6	Those too drowsy or dysphasic to understand simple motor command and further instructions. Severe aphasia was excluded	33% (32/96)	–
5. Kehayia and Korner-Bitensky (1997)	Canada	Retrospective cohort study (1988–1993)	Rehabilitation hospital	n = 207 Groups: 1. Without aphasia (69) 2. Mild–moderate aphasia (69) 3. severe aphasia (69)	Groups: 1: 70.4 (50–92) 2: 67 (36–92) 3: 65.7 (27–88)	Groups: 1: 2.4 (0.4–1.6) 2: 3.1 (0.4–6.3) 3. 2.9 (0.5–5.6)	With severe cognitive and/or psychological problems	Groups: 2: 33.3% (69/207) 3. 33.3% (69/207)	Pain medication in groups: 1: 15.9% (n = 11) 2: 23.2% (n = 16) 3: 19.3% (n = 13)
6. Cruice et al., (2010)	Australia	Prospective cohort study (1999–2001)	Community	n = 105 aphasic n = 30 + 75 controls	70.1 (57–88)	41.1 (10–108)	Those who cannot self-report and had no moderate comprehension ability	28.6% (30/105) mild–moderate aphasia	–
7. Cruice et al., (2005)	Australia	Retrospective cohort study	Community	Aphasic n = 30 + 30 proxies	70.7 (57–88)	41 (10–108)	–	100% mild–moderate aphasia. Fluent + good auditory comprehension. 15 anomic, 8 conduction, 3 Brocas, 3 Wernicke, 1 transcortical sensory	–
8. Mazzocato et al. (2010)	Switzerland	Retrospective cohort study (2000–2005)	Hospital	n = 42	84	0.4 (0.1–3.8)	–	38.1% (16/42) unable to communicate	69% (29/42). Specify pain type: 45% (13/29). Pain on inability communicate: one pain 43.8% (7/16). Two or more pains 56.2% (9/16)
9. Jackson et al., (2006)	United Kingdom	Case study	Rehabilitation centre	n = 1	43	2.3	–	Used hand gestures and able to indicate Y + N and understand pictures easier than words; severe aphasia + significant semantic impairment + verbal dyspraxia	–
10. Smith et al.,(2013)	United States of America	Prospective cohort study (2008–2012)	Hospital	n = 388 inpatients and outpatients Groups: 1. 85% (331) infraction 2. 15% (57) haemorrhage	Groups: 1. 78 (66–86) 2. 75 (63.5–83.5)	–	–	–	–

LHSP: Left hemisphere stroke patient; RHSP: right hemisphere stroke patient; BDAE: Boston Diagnostic Aphasia Examination  (Goodglass et al., 2001).

Figure 1. PRISMA flow chart of study selection.

Table 3. Quality of measurement properties per scale.

Pain scale	Reliability	Content validity	Criterion validity	Responsiveness
VAS vertical	+	+++	+	±
FPS	LHSP: ± RHSP: −	+++	++	+
VRS	LHSP: − RHSP: −	+++		–
Quality of Life scale used by proxy respondents
Short Form 36 Health Survey			–
Dartmouth COOP Charts			–

VAS: Visual analoque scale; FPS: faces pain scale; LHSP: left hemisphere stroke patient; RHSP: right hemisphere stroke patient; VRS: verbal rating scale.

The categorical site-of-pain scale (shoulder) and the Scale Pain INtensitye (SPIN) do not appear in Table 1, because they could not be evaluated using COSMIN.

Table 4. Methodological quality of each study per measurement property and pain scale.

Study:	Reliability	Content validity	Criterion validity	Responsiveness
VAS vertical
Pomeroy et al. (2000)	Fair			Fair
Benaim et al. (2007)	Fair	Excellent	Good	Fair
Korner-Bitensky et al. (2006)				Poor
FPS
Benaim et al. (2007)	Fair	Excellent	Good	Fair
VRS
Benaim et al. (2007)	Fair	Excellent
Validity of proxy respondents:
Short Form 36 Health Survey
Cruice et al. (2005)			Poor
Dartmouth COOP Charts
Cruice et al. (2005)			Poor

VAS: Visual analoque scale; FPS: faces pain scale; VRS: verbal rating scale.

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