Sep 21, It must be underlined that other measures of pain assessment, such as Study population. Patients who fulfilled inclusion criteria were. There is a need for an adequate pain measurement tool for use in conscious sedated In this study, we evaluated the use of the Behavioral Pain Scale (BPS) in conscious sedated .. () and conscious sedated patients (). It was also. To measure postoperative pain we chose the COMFORT scale (Ambuel et al., (). (). COMFORT 'behaviour'. 12 (2). 14 (6). 14 (5). 13 (4).
pain measurements Behavioural 2.4.
In addition, interpretation of crying in infants is especially difficult as it may indicate general distress rather than pain. Cry characteristics are also not good indicators in preterm or acutely ill infants, as it is difficult for them to produce a robust cry [ 12 ]. Other scales used with infants are composite measurement scales, meaning they use a combination of behavioral and physiological measures.
Some scales also take into consideration gestational age and the general behavioral state of the infant [ 13 ]. The system looks at eight indicators to measure pain intensity: The indicators are recorded on videotape, coded, and scored. It has been proven reliable for short duration, acute pain in infants and neonates [ 18 ]. The system is also difficult to assess in intubated neonates [ 19 ]. It is a behavioral assessment tool to measure pain [ 20 ].
The scale takes into account pain measurement before, during and after a painful procedure, scored in one-minute intervals. Results are obtained by summing up the scores for the six indicators where 0 indicates no pain, and 2 indicates pain , with a maximum sore of 7 [ 20 ].
It is a good system to measure responses to acute painful stimuli. Although it has been fully validated, it is time consuming and hard to interpret in intubated infants. It has been validated in studies using synchronized videotaping of infants undergoing painful procedures [ 14 , 21 ].
The indicators include 1 gestational age, 2 behavioral state before painful stimulus, 3 change in heart rate during stimulus, 4 change in oxygen saturation, 5 brow bulge during painful stimulus, 6 eye squeeze during stimulus, and 7 nasolabial furrow during painful stimulus [ 14 ]. Gestational age is taken into consideration. Scoring is initially done before the painful procedure. The infant is observed for 15 seconds and vital signs recorded.
Infants are then observed for 30 seconds during the procedure where physiological and facial changes are recorded and scored. The score ranges from 0—21, with the higher score indicating more pain [ 14 ]. It is commonly used in neonates in the first month of life [ 15 ]. CRIES looks at five parameters: Indicators are scored from 0—2 with the maximum possible score of 10, a higher score indicating a higher pain expression [ 15 ].
It looks at brow, eye, and mouth movements [ 16 , 23 ]. MAX provides a system for measuring emotional signals, and identifies nine fundamental emotions: The scoring entails 68 MAX number codes, each representing a different facial expression.
The description of the expression of each number code is based on the anatomically possible movements of the facial muscles and is a description of what the face looks like when the movements have taken place [ 16 ]. Critical studies argue that MAX only includes measurements that are said to correspond with emotions and does not differentiate between anatomically distinct facial movements inner and outer brow raise [ 24 , 25 ]. In toddlers, verbal skills remain limited and quite inconsistent.
Pain-related behaviors are still the main indicator for assessments in this age group. Nonverbal behaviors, such as facial expression, limb movement, grasping, holding, and crying, are considered more reliable and objective, measures of pain than self-reports [ 26 ]. Most children of this age however are capable of voluntarily producing displays of distress, with older children displaying fewer pain behaviors e. Most two-year-old children can report the incidence and location of pain, but do not have the adequate cognitive skills to describe its severity [ 27 ].
The following section describes common scales used for this age group. It used to assess the efficacy of interventions used in alleviating pain. It includes six categories of behavior: Each is scored separately ranging from 0—2 or 1—3 and calculated for a pain score ranging from 4—13 [ 28 ].
Its length and changeable scoring system among categories makes it complicated and impractical to use compared to other observational scales. It includes five indicators face, legs, activity, cry, and consolability with each item ranking on a three point scale 0—2 for severity by behavioral descriptions resulting in a total score between 0—10 [ 29 ]. FLACC is an easy and practical scale to use in evaluating and measuring pain especially in pre-verbal children from 2 months to 7 years.
Numerous studies have proven its validity and reliability [ 30 ]. This scale is composed of 8 indicators: Each indicator is given a score between 1 and 5 depending on behaviors displayed by the child and the total score is gathered by adding all indicators range from 8— Patients are monitored for two minutes. It consists of 11 distress behaviors identified by specialists to be associated with paediatric procedure-related distress, anxiety, and pain. Scores are calculated from summing up all 11 distress behaviors.
The behaviors are usually organized into categories of growing intensity, considering their level of interference with medical procedures e. The validity and reliability of the OSBD has been widely reported [ 35 , 36 ].
Limitations of the OSBD are noted, where the explanations of the different phases of the procedure: In instances where procedural phases are constant, differences arise in initiating the procedure e. This ultimately increases or decreases the scores [ 37 ]. Observational Pain Scale OPS It is intended to measure pain in children aged 1 to 4 years, and is used to assess pain of short or long duration [ 38 ]. The scale was primarily produced at the University of Amsterdam in the Netherlands.
The scale measures 7 parameters: The OPS has a simple scoring system which makes it easy to use by all healthcare professionals to obtain valid and reliable results [ 39 ]. The indicators are rated from with a maximum score of 7, where the higher score indicates greater discomfort [ 38 ].
It is most commonly used for children aged 1—5 years [ 40 ]. In order to observe verbal, facial, and bodily movement, the child needs to be awake. This scale relies on behavioral observations, but also includes a self report element. It is a useful tool for evaluating the effectiveness of medication administration in children, but does not measure pain intensity [ 42 ]. If a behavior is present during a 5-minute observation period, a score if 1 is given whereas a score of 0 is given if the behavior was not present.
The maximum score obtained is 7, which indicates a high pain intensity [ 40 ]. By the age of four years, most children are usually able to use item pain discrimination scales [ 43 ]. Their ability to recognize the influence of pain appears around the age of five years when they are able to rate the intensity of pain [ 44 ].
Facial expression scales are most commonly used with this age group to obtain self-reports of pain. These scales require children to point to the face that represents how they feel or the amount of pain they are experiencing [ 45 ].
The following section describes scales commonly used with this age group. It consists of 13 facial actions: The CFCS has been useful with acute short-duration procedural pain [ 47 ]. The tool is used to assess pain intensity. Faces Pain Scale It was developed by Wong and Baker and is recommended for children ages 3 and older [ 51 ]. The scale requires health care professionals to point to each face and describe the pain intensity associated with it, and then ask the child to choose the face that most accurately describes his or her pain level [ 51 ].
Most pain rating scales using faces that portray degrees of distress are divided into two categories: Results showed that children exposed to smiling scale had considerably higher pain scores in the no pain categories and lower scores for positive pain than children who used the neutral faces scale [ 52 ].
A study by Chambers and colleagues indicated that children's pain ratings differ depending on the types of faces scale used, and that faces scales with smiling faces may confuse emotional states with pain ratings [ 52 ].
It does not contain smiling faces or tears thus avoiding the confounding of affect and pain intensity [ 45 ]. It is an ethnically based self-report scale, which has three versions: Caucasian, African-American, and Hispanic [ 54 , 55 ]. Even though it covers a wide array of patients, it still has limits. For example, females are not represented, as well as other cultures. It is used for children older than 5 years [ 55 ].
The tool has two separate scales: Children are asked to choose the picture or number that closely corresponds to the amount of pain they feel [ 56 ]. Health care professionals depend more comfortably on self-reports from school-aged children. Although children at this age understand pain, their use of language to report it is different from adults.
At roughly 7 to 8 years of age children, begin to understand the quality of pain [ 57 ]. Self-report visual analogue and numerical scales are effective in this age group. A few pain questionnaires have also proven effective for this age such as the pediatric pain questionnaire and the adolescent pediatric pain tool [ 58 , 59 ]. A brief discussion of these tools is presented here.
The children are asked to mark on the line the point that they feel represents their pain at this moment [ 60 ]. A color analogue scale can also be used, where darker more intense colors i. The questionnaire usually takes about 10—15 minutes to complete [ 62 ]. Adolescent Pediatric Pain Tool APPT It is a valid all encompassing pain assessment tool used for individual pain assessments and measures intensity, location, and quality of pain in children older than 8 years of age [ 63 ].
The APPT is most useful with children and adolescents who are experiencing complex, difficult to manage pain [ 59 ]. It consists of a body map drawing to allow children to point to the location of pain on their body and a word graphic scale to measure pain intensity.
Adolescents tend to minimize or deny pain, especially in front of friends, so it is important to provide them with privacy and choice. For example, they may or may not choose to have parents present. They expect developmentally appropriate information about procedures and accompanying sensations. Some adolescents regress in behavior under stress [ 3 ]. They also need to feel able to accept or refuse strategies and medications to make procedures more tolerable.
To assess pain and, specifically chronic pain, the adolescent pediatric pain tool see above section or the McGill pain questionnaire are helpful.
It is an assessment tool that combines a list of questions about the nature and frequency of pain with a body-map diagram to pinpoint its location [ 68 ]. The questionnaire uses word lists separated into 4 classes to assess the total pain experience.
The categories are 1 sensory, which contains words describing pain in terms of time, space, pressure, heat, and brightness, 2 affective category which describes pain in terms of tension, fear, and autonomic properties, 3 evaluative, and 4 miscellaneous. Scores vary from 0—78 with the higher score indicating greater pain [ 68 ]. Pain is one of the most frequent complaints presented in paediatric emergency settings. The emergency department itself is a very stressful place for children.
Thus it is important for health care providers to follow a child centered or individual approach in their assessment and management of pain and painful procedures [ 70 ]. This approach promotes the right of the child to be fully involved in the procedure, to choose, associate, and communicate. It allows freedom for children to think, experience, explore, question, and search for answers, and allows them to feel proud for doing things for themselves. The child and family should be active participants in the procedure.
In fact, allowing parents or family members to act as positive assistants rather than negative restraints helps to reduce stress in both children and parents and minimizes the pain experience [ 70 ]. It is also essential to ensure that all procedures are truly necessary, and can be performed safely by experienced personnel.
Ideally procedures should be done in a child-friendly environment, using appropriate pharmacologic and nonpharmacologic interventions with routine pain assessment and reassessment [ 70 ].
It is most effective when adapted to the developmental level of the child [ 71 ]. Distraction techniques are often provided by nurses, parents or child life specialists.
A total of nine AD subjects in the study all sAD were nursing home residents. Subjects were required to abstain from all standing order analgesic medication for 24 hours prior to testing. No subjects with subjective complaints of current pain were included. Subjects receiving beta-blocker medications were allowed if their primary physician agreed to temporarily discontinue drug treatment for a period equal to three half-lives prior to study.
Further exclusions included history of: Type II diabetes, major depression, history of stroke or transient ischemic attack, central or peripheral neuropathy, diagnosis of neurological or psychiatric disorders other than AD, current opioid analgesic use, history of chronic pain conditions such as rheumatoid arthritis, fibromyalgia, low back, and shoulder pain.
We also excluded those with current osteoarthritic pain, those with osteoarthritis in the stimulus application region distal forearms , and those requiring daily analgesics to reduced osteoarthritic pain. Flow chart describing procedures for study sample assembly. Cornell Scale for Depression in Dementia. This study was conducted in accordance with the Declaration of Helsinki and approved by the Michigan State University institutional review board.
Written informed consent was obtained for all HS as well as for AD subjects via named health care proxies identified as a power of attorney for health care or guardian. We obtained assent from all participants verbal or non-verbal before beginning testing.
Testing was discontinued if any subjects became inconsolably agitated or verbally stated that they wished to end participation. This occurred with one AD subject, who was excluded from analysis. We recruited more than 15 subjects per group to obtain adequate sampling and for a concurrent neuroimaging study. Study design was controlled and cross-sectional with repeated measures testing of behavioral, subjective, and autonomic responses to mechanical pressure stimuli.
Testing occurred between 1 p. Testing sessions took place within quiet rooms within long-term care facilities or clinical research suites at Michigan State University. Pressure testing occurred last. The instrument is fitted with a 1 cm wide rubber disk to prevent skin abrasion. Pressures were applied to the lateral volar surface of the distal forearm, 2—5 cm from the wrist.
Subjects were seated, upright, during testing and without arm restraint. Because standardization of pain levels is not feasible in sAD subjects, pressure application was adapted from a previous dementia-related pain study. Twenty stimuli of 1—5 kg of pressure intensity were applied to left and right forearms four stimuli per intensity. Stimulus order was determined once for use in all subjects through creation of a randomization algorithm in MATLAB software.
The algorithm produced the stimulus order according to the following rules: Subjects were first familiarized to the stimuli via single application of each intensity to the thigh. Interstimulus intervals were approximately 50 seconds. Two trained investigators performed all cognitive and behavioral testing in a standardized manner PAB, MM.
Video recording allowed for scoring of behavioral responses and HR changes after testing procedures were completed. Behavioral acute pain responses were scored only for the 5 seconds stimulus application period. The interstimulus interval allowed for a return to resting behavior. Subjects who did not return to baseline shortly after stimulus application ceased were considered too agitated to continue this occurred for one subject, as mentioned above.
Acute pain behaviors were scored using portions of the Pain Assessment in Advanced Dementia PAINAD scale, a validated observational scale for assessing pain in demented patients in both long term care and acute care settings.
The full version of the PAINAD assesses breathing, negative vocalization, facial expression, body language, and consolability. Each domain is scored 0—2 for a maximum score of 10 points. A recent panel review of studies examining the validity and reliability of the PAINAD found that breathing had low internal consistency and construct validity.
In the same review, consolability was considered more likely to reflect an intervention than a measure of pain. Consolability was also considered a poor indicator of pain and was not rated higher in nursing residents with vs without pain. Furthermore, pilot work with patients and controls yielded rater impressions that application of the consolation portion of the PAINAD was biased toward patients due to perceived vulnerability, which would have artificially inflated patient PAINAD scores.
All raters underwent identical training procedures via an online resource meant to aid in training nursing staff on use of the PAINAD.
However, as they were not blinded to stimulus order or group designation a third rater JTH was added who was blinded to both group designation and stimulus order. This rater rescored all original sessions, blinded to the original rater scores, as well as all remaining sessions. Final mPAINAD ratings for doubly-scored subjects were determined through a modified Delphi-type consensus procedure between the blinded rater and the relevant original rater.
The original ratings of doubly-scored subjects were used as part of rater reliability testing. Autonomic responses were monitored by way of HR. A response was determined by subtracting the HR at stimulus onset baseline from the maximum response within 30 seconds after offset, resulting in an overall positive or negative response.
Interstimulus intervals allowed for return to resting HR. Third, internal consistency of all subject scores over repeated applications of each intensity was determined by calculating Crohnbach's Alpha. This latter measure was also used to determine test-retest reliability of repeated pressure applications. Previous studies of pain in AD indicated increased pain-specific facial expressions, compared with controls. We attempted to extend this finding by examining whether groups differentially utilized mPAINAD domains verbal, facial, and body to behaviorally express pain.
Individual mPAINAD scores were dissected for domain-specific points summed across repeated trials of stimulus intensities. GLMM and subsequent post hoc testing, described above, were then utilized. To probe potential AD severity-dependent effects, a secondary analysis was performed whereby AD patients were split into subgroups: Significant effects were further investigated with appropriate post hoc testing, described above.
Family-wise error was controlled for as described above. General subject demographics are found in Table ICC for inter-rater reliability testing scored, on average, 0.
Crohnbach's Alpha testing yielded an overall average score of 0. Average HR changes from baseline beats per minute, bpm across stimulus intensities kilograms, kg. Error bars represent standard error of the mean SEM. Error bars represent SEM. Post hoc Kruskal—Wallis testing of each domain yielded significant increases for AD subjects in: Secondary GLMM testing found no severity-dependent effects for individual domains vocal: Subjective pain ratings results. Average subjective pain-report scores for each stimulus intensity kg.
We, therefore, examined acute pain responses autonomic, pain behaviors, and potential self-report in mAD and sAD patients, as well as HS, during repeated application of multiple forearm pressure intensities. A secondary analysis probed for severity-dependent differences for mAD and sAD subgroups. However, consistent with our prediction, secondary analyses found that sAD patients had diminished responses compared with both HS and mAD. A tendency for AD patients to show blunted autonomic responses to mild pain is a consistent finding in the literature.
Our findings extend these prior results to patients with MMSE as low as 0. Blunted autonomic responses have been interpreted by some authors as evidence of reduced pain affect in AD. However, it is equally likely that central autonomic dysfunction is responsible. Altered autonomic function has been described in AD , and cortical and subcortical autonomic regulators are affected by AD pathology.
The result may be a disconnect between pain-related autonomic and affective-behavioral responses that worsens with AD progression. Considering our pain behavioral findings, it would appear that autonomic responses are not a reliable predictor of pain in AD. Prior studies also reported increased behavioral expression of pain in AD and other dementia patients. Greater degrees of body-based pain responses, namely stiffness, guarding, and nociceptive flexion, were also found in prior studies of cognitively impaired patients.
Using portions of the PAINAD, which scores behaviors such as facial expressions on a more approximate level, we also found increases in pain-related facial responsiveness, bodily responses, and negative vocalizations contributed relatively equally to overall increased pain behaviors in AD patients, regardless of severity.
The level of cognitive impairment played a role in whether subjects could self-report, as no sAD subjects could reliability rate pain with the FPS-R. However, mAD subjects, all reliable reporters, rated low-level stimuli, and to a lesser degree mid-level stimuli, as more painful than HS. Our findings here imply greater subjective pain in AD patients.
However, some caution is merited as our primary group differences occurred at low levels of pressure, becoming more equivalent at higher pressures. Thus, an alternative explanation of our FPS-R findings could be an exaggerated patient response to innocuous pressures or weak pain by patients.
The latter could have occurred, despite all mAD patients passing reliability testing, perhaps through misunderstanding of the context or the clinical scale utilized. However, greater degrees of pain behaviors in patients vs controls, via mPAINAD scores, at the same low pressure levels makes it equally likely that pain sensitivity is increased in AD. Indeed, our findings are in accordance with recent studies that showed increased unpleasantness to low level pain and reduced pain tolerance in mAD patients experiencing mechanical pressure.
These results contradict early findings of increased pain tolerance in AD patients , which included some advanced patients MMSE Early studies utilized electrical and ischemic pain modalities, which may account for some differences in results.
It should be noted that increased cognitive deterioration was associated with impaired subjective pain report here and in other studies. In healthy adults, pain memories deteriorate on the order or seconds ; this effect is likely far worse AD patients.
Indeed, reduced pain-related semantic memory in AD was associated with reduced self-report of pain in one study , suggesting patients may under-report pain due to cognitive impairment. A neural mechanism for increased subjective and behavioral acute pain responses in AD is currently not known. In advanced stages, even sensory cortices are affected. AD may thus increase acute pain sensitivity and pain behavior through its effects on cognitive control, salience, and self-reflective neural processing.
Indeed, fibromyalgia and chronic back pain patients have altered connectivity between self-reflective and salience processing structures. Supporting this notion, Cole et al.
Nevertheless, a reduction in cognitive control mechanisms cannot be ruled out as a driver of increased pain behaviors, and perhaps pain ratings, in patients. This could then lead to increased pain behaviors and ratings seen in this study and others more so at lower stimulus levels.
As late AD pathology does affect somatosensory cortex , altered sensory pain may also have contributed to behavioral findings in patients. Further examination of AD-related brain function in the context of acute pain would be advantageous to further test these hypotheses.
A strength of this study is its inclusion of a relatively large number of sAD subjects. However, this precluded a more detailed examination of pain threshold and tolerance. We also only tested pain responses using one stimulus modality, pressure, and only in one session. However, increased behavioral pain responses and similar pain ratings in AD compared with HS have also been found using electrical, laser, and needle stick modalities.
It would be interesting for future studies to investigate pain behaviors across multiple acute pain modalities to examine whether AD patients exhibit varied sensitivities in that regard.
Although subjective pain ratings and pain behaviors were increased in patients, compared with controls, the two were not increased concurrently. While subjective ratings of patients were higher than controls primarily at low-level pressures, pain behaviors were consistently higher across most pressure levels.
This discrepancy has occurred in multiple studies and may relate to differences in the effects of AD on the neural processes differentially responsible for subjective pain and pain behaviors. Impairment of pain memories and use of pain scales may also be involved.
Future work could investigate the specificity of global pain behavioral measures such as the PAINAD by correlating scores with experimental tools such as the Facial Action Coding System, which may more precisely measure pain-specific facial expressions.
Finally, because we focused our efforts on acute pain responses, we cannot speak to whether our results extend to chronic clinical pain states.
There was a problem providing the content you requested
Whereas, feasibility and validity of behavioral pain scales have been . Validity. The validation of an instrument measuring a subjective variable (such as . ESCID is valid and reliable for measuring pain in mechanically ventilated unable to For these patients, the behavioral pain scale (BPS) and the critical care pain .. pain scores when the procedures were carried out: (BPS) and Jul 31, Pain measurement in mechanically ventilated critically ill patients: Behavioral Pain . Purpose: The Behavioral Pain Scale (BPS) and Critical-Care Pain .. Study procedures. The bedside nurse screened and included.