Showing papers on "Pain assessment published in 2006"

Pain assessment

Abstract: Pain usually is the major complaint of patients with problems of the back, thus making pain evaluation a fundamental requisite in the outcome assessment in spinal surgery. Pain intensity, pain-related disability, pain duration and pain affect are the aspects that define pain and its effects. For each of these aspects, different assessment instruments exist and are discussed in terms of advantages and disadvantages. Risk factors for the development of chronic pain have been a major topic in pain research in the past two decades. Now, it has been realised that psychological and psychosocial factors may substantially influence pain perception in patients with chronic pain and thus may influence the surgical outcome. With this background, pain acceptance, pain tolerance and pain-related anxiety as factors influencing coping strategies are discussed. Finally, a recommendation for a minimum as well as for a more comprehensive pain assessment is given.

Validation of the Critical-Care Pain Observation Tool in Adult Patients

Abstract: • BACKGROUND Little research has been conducted to validate pain assessment tools in critical care, especially for patients who cannot communicate verbally. • OBJECTIVE To validate the Critical-Care Pain Observation Tool. • METHODS A total of 105 cardiac surgery patients in the intensive care unit, recruited in a cardiology health center in Quebec, Canada, participated in the study. Following surgery, 33 of the 105 were evaluated while unconscious and intubated and 99 while conscious and intubated; all 105 were evaluated after extubation. For each of the 3 testing periods, patients were evaluated by using the Critical-Care Pain Observation Tool at rest, during a nociceptive procedure (positioning), and 20 minutes after the procedure, for a total of 9 assessments. Each patient’s self-report of pain was obtained while the patient was conscious and intubated and after extubation. • RESULTS The reliability and validity of the Critical-Care Pain Observation Tool were acceptable. Interrater reliability was supported by moderate to high weighted κ coefficients. For criterion validity, significant associations were found between the patients’ self-reports of pain and the scores on the Critical-Care Pain Observation Tool. Discriminant validity was supported by higher scores during positioning (a nociceptive procedure) versus at rest. • CONCLUSIONS The Critical-Care Pain Observation Tool showed that no matter their level of consciousness, critically ill adult patients react to a noxious stimulus by expressing different behaviors that may be associated with pain. Therefore, the tool could be used to assess the effect of various measures for the management of pain. (American Journal of Critical Care. 2006;15:420-427)

Pain in elderly people with severe dementia: A systematic review of behavioural pain assessment tools

Abstract: Pain is a common and major problem among nursing home residents. The prevalence of pain in elderly nursing home people is 40–80%, showing that they are at great risk of experiencing pain. Since assessment of pain is an important step towards the treatment of pain, there is a need for manageable, valid and reliable tools to assess pain in elderly people with dementia. This systematic review identifies pain assessment scales for elderly people with severe dementia and evaluates the psychometric properties and clinical utility of these instruments. Relevant publications in English, German, French or Dutch, from 1988 to 2005, were identified by means of an extensive search strategy in Medline, Psychinfo and CINAHL, supplemented by screening citations and references. Quality judgement criteria were formulated and used to evaluate the psychometric aspects of the scales. Twenty-nine publications reporting on behavioural pain assessment instruments were selected for this review. Twelve observational pain assessment scales (DOLOPLUS2; ECPA; ECS; Observational Pain Behavior Tool; CNPI; PACSLAC; PAINAD; PADE; RaPID; Abbey Pain Scale; NOPPAIN; Pain assessment scale for use with cognitively impaired adults) were identified. Findings indicate that most observational scales are under development and show moderate psychometric qualities. Based on the psychometric qualities and criteria regarding sensitivity and clinical utility, we conclude that PACSLAC and DOLOPLUS2 are the most appropriate scales currently available. Further research should focus on improving these scales by further testing their validity, reliability and clinical utility.

The revised FLACC observational pain tool: improved reliability and validity for pain assessment in children with cognitive impairment

Abstract: Summary Background: Difficulty with pain assessment in individuals whocannot self-report their pain poses a significant barrier to effective painmanagement. However, available assessment tools lack consistentreliability as pain measures in children with cognitive impairment(CI). This study evaluated the validity and reliability of the revisedand individualized Face Legs Activity Cry and Consolability (FLACC)behavioral pain assessment tool in children with CI.Methods: Children with CI scheduled for elective surgery werestudied. The FLACC was revised to include specific descriptors andparent-identified, unique behaviors for individual children. Thechild’s ability to self-report pain was evaluated. Postoperatively, twonurses scored pain using the revised FLACC scale before and afteranalgesic administration, and, children self-reported a pain score, ifable. Observations were videotaped and later viewed by experiencednurses blinded to analgesic administration.Results: Eighty observations were recorded in 52 children aged4–19 years. Twenty-one parents added individualized pain behaviorsto the revised FLACC. Interrater reliability was supported by excellentintraclass correlation coefficients (ICC, ranging from 0.76 to 0.90) andadequate j statistics (0.44–0.57). Criterion validity was supported bythe correlations between FLACC, parent, and child scores (q ¼ 0.65–0.87; P < 0.001). Construct validity was demonstrated by the decreasein FLACC scores following analgesic administration (6.1 ± 2.6 vs1.9 ± 2.7; P < 0.001).Conclusions: Findings support the reliability and validity of theFLACC as a measure of pain in children with CI.Keywords: pain assessment; developmentally delayed children; facelegs activity cry and consolability pain tool

The effect of emergency department crowding on the management of pain in older adults with hip fracture.

Abstract: OBJECTIVES: To evaluate the effect of emergency department (ED) crowding on assessment and treatment of pain in older adults. DESIGN: Retrospective review of ED records from a prospective cohort study. SETTING: Urban, academically affiliated, tertiary medical center. PARTICIPANTS: One hundred fifty-eight patients, aged 50 and older, evaluated and hospitalized from the ED with hip fracture. MEASUREMENTS: Patient-related risk factors: age, sex, nursing home residence, ED triage status, dementia, Acute Physiology in Age and Chronic Health Evaluation II physiological score, and RAND comorbidity score. ED crowding risk factors: ED census and mean length of stay. Outcomes: documentation of pain assessment, time to pain assessment, time to pain treatment, patients reporting pain receiving analgesia, and meperidine use. RESULTS: Mean age was 83 (range 52‐101), 81.0% of patients complained of pain, mean time to pain assessment was 40 minutes (range 0‐600), time to treatment was 141 minutes (range 10‐525), and mean delay to treatment was 122 minutes (range 0‐526). Of those with pain, 35.9% received no analgesia, 7.0% received nonopioids, and 57.0% received opioids. Of those receiving opioids, 32.8% received meperidine. ED crowding at census levels greater than 120% bed capacity was significantly associated with a lower likelihood of documentation of pain assessment (P 5.05) and longer times to pain assessment (P 5.01). CONCLUSION: Older adults with hip fracture are at risk for underassessment of pain, considerable delays in analgesic administration after pain is identified, and treatment with inappropriate analgesics (e.g., meperidine) in the ED. Higher levels of ED census are significantly associated with poorer pain management. J Am Geriatr Soc 54:270–275, 2006.

Pain and ethnicity in the United States: A systematic review.

Abstract: Background: Evidence suggests that racial and ethnic disparities exist in access to effective pain treatment. Purpose: To review evidence of these disparities and provide recommendations for care and further research. Design: Systematic review Methods: We conducted a MEDLINE search using the MeSH terms of ethnic groups, minority groups, pain, analgesia, and analgesics. We included studies describing current practice patterns, utilization of available treatments, treatment outcomes, and patient and provider knowledge, attitudes, and behaviors. Results: Our search identified 35 journal articles describing the effect of patient race and ethnicity on pain assessment and management. Three studies on pain assessment revealed that minority patients are more likely to have their pain underestimated by providers and less likely to have pain scores documented in the medical record compared to whites. Eleven of 17 studies found that African Americans and Hispanics are less likely to receive opioid analgesics and mor...

Development and testing of a neuropathic pain screening questionnaire: ID Pain

Abstract: Objective: To develop a patient-completed screening tool to help differentiate nociceptive and neuropathic pain.Research design and methods: A multicenter study was performed for item reduction (initial 89-item questionnaire) and model building. Patients (N = 586) with non-headache chronic pain completed the questionnaire and were referred to pain specialists for diagnosis. Factor and regression analyses were used to derive a final, 6-item questionnaire – ID Pain. A second multicenter study evaluated reliability and validity. Patients (N = 308) treated by pain specialists completed ID Pain and validation measures.Main outcome measures: Sensitivity and specificity were assessed using receiver operating characteristic curves and the concordance c index. Reliability was assessed using a κ statistic and intraclass correlation coefficient.Results: Final 6 items were: did the pain feel: (1) like pins and needles? (2) hot/burning? (3) numb? (4) like electrical shocks? (5) is the pain made worse with the ...

Pediatric Procedural Pain

Abstract: This article reviews the various settings in which infants, children, and adolescents experience pain during acute medical procedures and issues related to referral of children to pain management teams. In addition, self-report, reports by others, physiological monitoring, and direct observation methods of assessment of pain and related constructs are discussed and recommendations are provided. Pharmacological, other medical approaches, and empirically supported cognitive behavioral interventions are reviewed. Salient features of the interventions are discussed, and recommendations are made for necessary components of effective treatment interventions.

The psychometric quality and clinical usefulness of three pain assessment tools for elderly people with dementia.

Abstract: In view of the need for valid, reliable, and clinically useful scales to assess pain in elderly people with dementia, this study evaluated the psychometric properties of translated versions of the PAINAD, PACSLAC, and DOLOPLUS-2 scales. In an observational study design, two raters simultaneously assessed the nursing home residents (n=128) for pain during influenza vaccination and care situations. The PACSLAC was valued as the most useful scale by nurses. Cronbach's alpha was high (>.80) for the total scale at T2 and T3 and adequate for the 'Facial expression' and 'Social/personality/mood' subscales. IC scores for the 'Activity/body movement' and 'Physiological indicators/eating/sleeping changes/vocal behaviors' subscales were low. It demonstrated good validity and reliability, although the scale should be further refined. This refinement should increase homogeneity. The PAINAD showed good psychometric qualities in terms of reliability, validity, and homogeneity (alpha ranged .69-.74 at T2 and T3) (except for the 'Breathing' item). The PAINAD scale had lower scores for clinical usefulness in this sample. The Dutch version of the DOLOPLUS-2 was considered more difficult to use but showed acceptable psychometric qualities in terms of the issues assessed, except for the 'psychosocial reactions' subscale. IC of the DOLOPLUS were adequate for the total scale (alpha ranged .74-.75) and almost all subscales (alpha ranged .58-.80). Findings of this study provide evidence of validity and reliability of the three pain assessment scales. Now that a pain scale is available, future studies also need to focus on its implementation in nursing practice.

Pain in severe dementia: self-assessment or observational scales?

Abstract: OBJECTIVES: To assess the performance of self-assessment scales in severely demented hospitalized patients and to compare it with observational data. DESIGN: Prospective clinical study. SETTING: Geriatrics hospital and a geriatric psychiatry service. PARTICIPANTS: All patients who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for dementia, with a Mini-Mental State Examination score less than 11 and a Clinical Dementia Rating score of 3. MEASUREMENTS: Three self-assessment tools—the verbal, horizontal visual, and faces pain scales—were administered in randomized order. A nursing team independently completed an observational pain rating scale. Main outcomes were comprehension (ability to explain scale use and correctly indicate positions for no pain and extreme pain, on two separate occasions), inter- and intrarater reliability, and comparison of pain intensities measured by the different scales. RESULTS: Sixty-one percent of 129 severely demented patients (mean age 83.7, 69% women) demonstrated comprehension of at least one scale. Comprehension rates were significantly better for the verbal and the faces pain scales. For patients who demonstrated good comprehension, the inter- and intrarater reliability of the three self-assessment scales was high (intraclass correlation coefficient=0.88–0.98). Correlation between the three self-assessment scales was moderate to strong (Spearman correlation coefficient (r)=0.45–0.94; P<.001). Observational rating correlated at least moderately with self-assessment (r=0.25–0.63), although for patients reporting pain, the observational rating scale underestimated severity compared with all three self-assessment scales. CONCLUSION: Clinicians should not apply observational scales routinely in severely demented patients, because many are capable of reliably reporting their own pain.

Pain Assessment for Pediatric Patients in the Emergency Department

Abstract: OBJECTIVE. To examine the relationship between pediatric patient visit characteristics and pain score documentation in the emergency department (ED) and determine whether documentation of a pain score is associated with increased analgesic use. METHODS. A cross-sectional analysis was conducted of ED visits for pediatric patients from the National Hospital Ambulatory Medical Care Survey (1997–2000). Survey weighted regression first was used to assess the association between patient visit characteristics and pain score documentation. The regression then was repeated to determine the association between documentation of a pain score and analgesic use, adjusting for visit characteristics. RESULTS. A total of 24707 visits were included. Only 44.5% of visits had documented pain scores. In the regression analysis, younger age, self-pay, visits to pediatric facilities, and visits that were not designated as injury related were associated with decreased pain score documentation. Documentation of pain score was associated with increased odds of an analgesic prescription and opioid prescription. When no pain score was documented, the odds of receiving any analgesic was similar to visits with pain documented as mild. CONCLUSION. ED pain score documentation is suboptimal in the pediatric population. Infants and toddlers are at particular risk for not having a pain score documented. There is a significant association between pain score documentation and the use of any analgesic, particularly opioids. Improvements in pain documentation for acutely ill and injured children are needed to improve pain management.

Pain assessment: Current status and challenges

Abstract: Neonatal pain assessment has received much attention over the past decade. Behavioural indicators of pain include facial action, body movement and tone, cry, state/sleep, and consolability. Physiological indicators of pain include increased heart rate, respiratory rate, and blood pressure, as well as decreased heart rate variability and oxygen desaturation. Pain assessment in neonates is difficult in neurologically compromised, chemically paralyzed, and non-responsive infants. Multiple pain assessment tools are summarized. Pain assessment and management protocols are delineated.

Nursing attitudes and beliefs in pain assessment and management

Abstract: Aims. This paper reports a study to determine nurses’ attitudes towards pain assessment tools and the relationship of these attitudes to education and experience. Background. The issue of pain management is of interest to caregivers nationally and internationally. For example, in the United States of America, the National Health and Medical Research Council set guidelines to assist clinicians in pain management. Research on whether healthcare teams use pain assessment tools has yielded contradictory findings. Methods. Using an open-ended questionnaire developed for this study, which was based on Fishbein and Ajzen expectancy-value model, a convenience sample of 52 nurses on an acute care unit were asked: (1) What do you believe about the assessment of pain? (2) What do you believe about the use of pain assessment tools? and (3) What do you believe about the use of pain assessment tools in improving the patient's outcome? The nurses then rated their attitudes about each belief and how each belief made them feel. The data were collected in 2003. Results. When Fishbein and Ajzen's formula for calculating attitude was used, attitude scores ranged from −6 to 28 with an overall mean score of +8·3. The amount of education and experience of each nurse and the attitude measure in regard to the use of pain assessment tools were compared. Conclusions. The Fishbein and Ajzen model provides a useful way to obtain information on the attitude of nurses towards the use of pain assessment instruments. To provide further information, this study with an open-ended instrument should be followed with a fixed-response survey with a larger sample size and in various settings.

The role of developmental factors in predicting young children's use of a self-report scale for pain.

Abstract: Accurate pain assessment is the foundation for effective pain management in children. At present, there is no clear consensus regarding the age at which young children are able to appropriately use self-report scales for pain. This study examined young children's ability to use the Faces Pain Scale-Revised; (FPS-R; [Hicks CL, von Baeyer CL, Spafford PA, van Korlaar I, Goodenough B. The Faces Pain Scale-Revised: toward a common metric in pediatric pain measurement. Pain 2001; 93: 173-83]) for pain in response to vignettes and investigated the role of developmental factors in predicting their ability to use the scale. One hundred and twelve healthy children (3-6 years old) were assessed for their ability to accurately use a common faces scale to rate pain in hypothetical vignettes depicting pain scenarios common in childhood. Accuracy was determined by considering whether children's judgements of pain severity matched the pain severity depicted in the various vignettes. Children were also administered measures of numerical reasoning, language, and overall cognitive development. Results indicated that 5- and 6-year-old children were significantly more accurate in their use of the FPS-R in response to the vignettes than 4-year-old children, who in turn were significantly more accurate than 3-year-old children. However, over half of the 6-year-olds demonstrated difficulties using the FPS-R in response to the vignettes. Child age was the only significant predictor of children's ability to use the scale in response to the vignettes. Thus, a substantial number of young children experienced difficulties using the FPS-R when rating pain in hypothetical vignettes, although the ability to use the scale did improve with age.

The measurement of pain from metastatic bone disease: capturing the patient's experience.

Abstract: Pain is prevalent for large numbers of patients with metastatic cancer, and this pain is often due to bone metastases. Despite the availability of effective pain treatments and various pain management guidelines, multiple studies document the undertreatment of pain in patients with cancer. The most frequently identified barriers to appropriate pain management are physician underestimation of the patient's pain, inadequate pain assessment, and patient reluctance to report pain. A first step toward reducing inadequate pain control in clinical practice is adequate assessment of cancer pain using validated pain measurement instruments. Using treatment for bone pain as an example, we discuss how patient satisfaction measures and self-report measures of pain and other symptoms, symptom interference with patient function, and related adverse effects can be combined with appropriate trial design to provide the information needed to choose the best possible treatment for bone pain. Symptom assessment needs to be done via standardized questionnaires, administered at appropriate times during the trial. The Brief Pain Inventory uses 11-point numerical rating scales to measure both pain severity and the resulting functional interference caused by pain. These severity and interference ratings can be further categorized as mild, moderate, or severe, as required to implement most pain management guidelines and define outcome expectations for clinical trials. Consistent pain measurement and standardized recording of analgesic use across clinical trials would enhance comparability and increase the chances that treatment decisions for management of bone pain could be evidence based. These and other considerations in the design of clinical trials are discussed.

Pain assessment and procedural pain management practices in neonatal units in Australia

Abstract: Objective: To identify current pain assessment and procedural pain management practices in neonatal units in Australia. Methods: Postal survey conducted during December 2003 and January 2004. The survey comprised questions relating to pain assessment scores, pain reduction strategies for minor painful procedures and the use of articulated policies relating to procedural pain management. Participants were the Nurse Unit Managers or their nominees of neonatal intensive care units, special care units and newborn emergency transport services in Australia. Results: Surveys were sent to 181 eligible organizations, and 105 of these were returned (58%). Six units (6%) used pain assessment scores on a regular basis, and 16 units (15%) had an articulated policy directing pain management practices during painful procedures. Non-nutritive sucking and various nursing comfort measures were the pain reduction strategies most frequently used during minor painful procedures. Twenty-four units (23%) used sucrose or other sweet-tasting solutions during procedures; however, the reported frequency of their usage was low. Breast-feeding during venepuncture, heel lance and intramuscular or subcutaneous injection was infrequently practised and topical anaesthetic agents were rarely used. Conclusion: This survey demonstrates that the majority of Australian neonatal units have no articulated policy to guide pain management during painful procedures and do not regularly undertake pain assessments. Current evidence-based strategies to reduce procedural pain in hospitalized infants are used infrequently.

Sleep bruxism: Clinical aspects and characteristics in patients with and without chronic orofacial pain

Abstract: Objective Evaluation of long-standing sleep bruxism (SB) patients. Study Design Descriptive study. Results One hundred subjects with SB (80 women and 20 men, mean age: 36.1±11.3 years) were evaluated according to the RDC/TMD and a pain questionnaire (EDOF-HC). The patients were divided into 2 groups: Group A-without (30.0%) and Group B-with orofacial pain (70.0%). AM stiffness: 36.4% in Group A and 88.6% in Group B; mean pain duration: 6.92 years; mean intensity of pain: 4.33 (VAS); quality of pain: tightness/pressure (84,3%); 95.7% of Group B had myofascial pain. Depression and somatization levels were different between the groups (p = 0.001). Higher frequency of depression was found with body pain or presence of comorbidities. Conclusion The data presented in this study showed statistical differences between long-standing bruxism without and with chronic facial pain; the two questionnaires allowed interaction between the chief complaint and the clinical findings; depression levels increased with pain in several regions of the body.

The use of a self-reported pain measure, a nurse-reported pain measure and the PAINAD in nursing home residents with moderate and severe dementia: a validation study

Abstract: Objectives: to assess the construct validity of three measures of pain and to determine a categorical version of the Pain Assessment in Advanced Dementia (PAINAD) scale. Design: validation study determining the concurrent validity of a self-reported pain score (SRPS), a nurse-reported pain score (NRPS) and the PAINAD; the divergent validity of the three pain measures with the Abbreviated Mental Test (AMT) and the Cornell Scale for Depression in Dementia (CSDD). Setting and subjects: eighty-eight nursing home residents with moderate and severe dementia. Methods: residents were asked to rate the severity of their pain in the previous week on a verbal descriptor scale (VDS). Nurses rated the resident’s pain on a VDS, scored the PAINAD scale and the CSDD scale. Research assistants administered the AMT. Results: the PAINAD correlated with the NRPS (Kendall’s tau [τ] = 0.842); both scales correlated poorly with the SRPS (τ = 0.304 for both correlations). The PAINAD was significantly different for each level of the NRPS. On the SRPS, the PAINAD for the group with moderate+ pain was significantly different from the groups with mild pain and no pain. There was a difference between the SRPS and the NRPS when residents were depressed, but no difference when they were not. Our categorical version of the PAINAD showed good agreement with the NRPS. Conclusion: the NRPS and the PAINAD measure pain differently from the SRPS, especially in the presence of depression. Our categorical version of the PAINAD shows good agreement with the NRPS.

Monitoring of skin conductance to assess postoperative pain intensity.

Abstract: Background Pain is known to alter the electrogalvanic properties of the skin. The aim of this pilot study was to investigate the influence of postoperative pain on skin conductance (SC) readings. Methods After obtaining ethical approval and written informed consent, 25 postoperative patients were asked to quantify their level of pain on a numeric rating scale (NRS, 0–10) at different time points in the recovery room. As a parameter of SC, the number of fluctuations within the mean SC per second (NFSC) was recorded. Simultaneously, the NRS was obtained from patients by a different observer who was blinded to the NFSC values. Results Data from 110 readings of 25 patients (14 female, 11 male; 21–67 yr) were included. NFSC showed a significant correlation with the NRS (r=0.625; P 3 on the NRS was predicted with sensitivity of 89% and specificity of 74%. Conclusions The severity of postoperative pain significantly influences SC. Using cut-off values, NFSC may prove a useful tool for pain assessment in the postoperative period.