Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Viewpoint
  • Published:

Facial expressions, pain and nociception—are they related?

Nature Clinical Practice Neurology volume 4, pages 304–305 (2008)Cite this article

Patients with dementia often have a diminished capacity to verbally report and accurately describe pain symptoms because of their cognitive impairment.1 Thus, there is a need for the development of alternative, nonverbal ways to clinically assess pain in these patients. Observation of facial behaviors has been suggested as a clinically useful means of assessing pain in this population because of the unique facial expressions associated with pain compared with other affective states.1

A recent publication by Kunz and colleagues explored the degree to which pain was facially expressed by patients with dementia, by use of controlled noxious stimuli and quantitative assessment of facial expressions.1 The authors studied 42 patients with various types of dementia and 54 healthy, age-matched controls. Graded pressure stimulation was delivered to the forearm by use of a Fischer algometer. Each of the participants verbally rated the severity of their pain on a six-point Likert scale. In addition, their facial expressions were video-taped, and the Facial Action Coding System was used to quantify the frequency and intensity of facial responses on a five-point Likert scale. As expected, the authors found that patients with dementia had a reduced capacity to verbally report their degree of pain that was highly correlated to the severity of their cognitive decline. However, these patients showed markedly greater frequency and increased intensity of typical facial reactions to pain in response to 'pain-relevant' and also 'pain-irrelevant' stimuli compared with controls. In other words, patients showed facial pain when there was no pain source, and if there was a pain source they showed excessive facial pain, which indicates that facial expressions of pain are augmented in patients with dementia and, thus, a poor marker for nociception. These findings were unexpected and, from a clinical perspective, limit the usefulness of facial expressions in patients with dementia as an accurate behavioral response to nociceptive stimuli. To better understand why these results occurred, it is necessary to explore how facial expressions, pain and nociception are related to each other.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

References

  1. Kunz M et al. (2007) The facial expression of pain in patients with dementia. Pain 133: 221–228

    Article  Google Scholar 

  2. Schnitzler A and Ploner M (2000) Neurophysiology and functional neuroanatomy of pain perception. J Clin Neurophysiol 17: 592–603

    Article  CAS  Google Scholar 

  3. Bowsher D (1957) Termination of the central pain pathway in man: the conscious appreciation of pain. Brain 80: 606–621

    Article  CAS  Google Scholar 

  4. Wall PD (1979) On the relationship of injury to pain. Pain 6: 253–264

    Article  CAS  Google Scholar 

  5. Barber TX (1959) Toward a theory of pain: relief of chronic pain by prefrontal leucotomy, opiates, placebos, and hypnosis. Psychol Bull 56: 430–460

    Article  CAS  Google Scholar 

  6. Berthier M et al. (1988) Asymbolia for pain: a sensory-limbic disconnection syndrome. Ann Neurol 24: 41–49

    Article  CAS  Google Scholar 

  7. Weisenberg M (1984) Cognitive aspects of pain. In Textbook of Pain, 162–172 (Eds Wall PD and Melzack R) Edinburgh: Churchill-Livingstone

    Google Scholar 

  8. Melzack R and Scott TH (1957) The effects of early experience on the response to pain. J Comp Physiol Psychol 50: 155–161

    Article  CAS  Google Scholar 

  9. Craig KD (1984) Emotional aspects of pain. In Textbook of Pain, 153–161 (Eds Wall PD and Melzack R) Edinburgh: Churchill-Livingstone

    Google Scholar 

  10. Williams AC (2002) Facial expression of pain: an evolutionary account. Behav Brain Sci 25: 439–488

    PubMed  Google Scholar 

  11. Craig KD et al. (1991) Genuine suppressed and faked facial behavior during exacerbation of chronic low back pain. Pain 46: 161–171

    Article  CAS  Google Scholar 

  12. Ross ED et al. (2007) Human facial expressions are organized functionally across the upper-lower facial axis. Neuroscientist 13: 433–446

    Article  Google Scholar 

Download references

Author information

Author notes

  1. Oklahoma City VA Medical Center (11AZ), 921 NE 13th Street, Oklahoma City, OK 73104, USA elliott-ross@ouhsc.edu

Authors and Affiliations

  1. ED Ross is Professor of Neurology at the University of Oklahoma Health Sciences Center and Director of the Center for Alzheimer's and Neurodegenerative Disorders at Oklahoma City VA Medical Center, Oklahoma City, OK, USA.,

    Elliott D Ross

Authors
  1. Elliott D Ross
    View author publications

    You can also search for this author in PubMed Google Scholar

Ethics declarations

Competing interests

The author declares no competing financial interests.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Ross, E. Facial expressions, pain and nociception—are they related?. Nat Rev Neurol 4, 304–305 (2008). https://doi.org/10.1038/ncpneuro0791

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/ncpneuro0791

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing