Event-Aligned Analysis of Multi-Rater Pain Assessments Using Continuous Wearable Physiology

Pain is a complex and pervasive phenomenon affecting a large percentage of the population, and accurate assessment is essential for effective clinical management and intervention. Computational pain recognition systems enable continuous monitoring, support clinical decision-making, and help mitigate pain-related distress and functional decline. This study introduces a unified tokenization framework for heterogeneous 3D modalities in pain recognition that provides a single processing pipeline across behavioral and brain-activity 3D data, without requiring separate architectures for each modality or handcrafted inductive biases. The framework preserves spatial, temporal, and time--frequency structure while mapping diverse inputs into a shared token space. Extensive experiments show that the proposed approach effectively processes facial videos and fNIRS data in both raw-signal and spectrogram-based representations. On the AI4Pain benchmark dataset, the proposed framework achieves state-of-the-art performance while maintaining high computational efficiency and enabling real-time assessment on both GPU and CPU hardware.

Automatic pain assessment from facial video remains challenging due to the spatial heterogeneity of pain-related facial cues. This study proposes ReFace, a spatial reorganization pipeline that divides facial input into four spatial quadrants before tokenization, rather than processing the entire face as a single region. Evaluated on the AI4Pain dataset, the proposed approach achieves $56.00\%$ accuracy on the test set using video only, achieving the highest reported accuracy under the fixed AI4Pain benchmark protocol among the compared methods. Notably, the four-quadrant configuration processes the same total pixel budget as the full-face input, yet achieves higher accuracy, suggesting that spatial reorganization can improve performance under the proposed tokenization design. A single quadrant region, processing just one quarter of those pixels, remains competitive at a fraction of the computational cost.

Automatic pain localization, which involves identifying the anatomical origin of pain from peripheral physiological signals without patient self-report, is a clinically critical but largely unaddressed problem, particularly for non-verbal patients. This paper presents a systematic comparison of classical feature engineering and deep sequence learning for subject-independent three-class pain localization using the AI4Pain 2026 Challenge dataset, which comprises four synchronously recorded wearable modalities: electrodermal activity, blood volume pulse, respiration, and peripheral oxygen saturation recorded from 65 participants under controlled TENS-induced pain. A 115-dimensional hand-crafted feature set spanning time-domain, frequency-domain, modality-specific, and cross-modal descriptors is benchmarked against end-to-end deep architectures. Extremely Randomized Trees achieves the highest macro-F1 of 0.539, outperforming the best deep model by 7.4 percentage points, with EDA spectral features emerging as the dominant discriminators. A consistent 26-point gap between pain detection (F1,=,0.815) and localization (F1,=,0.552) across all models points to a fundamental ceiling imposed by the anatomical diffuseness of peripheral autonomic pathways at 10-second resolution.