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).
measurements 2.4. Behavioural 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.
Future study could, therefore, involve replicative work strictly related to AD patients. This study examined various biobehavioral pain indicators including autonomic responses, behavioral, and subjective pain ratings in mild, moderate, and severe AD patients.
We found that while sAD patients had overall blunted autonomic pain responses, both sAD and mAD patients showed greater degrees of pain behaviors, compared with HS. Further inclusion of sAD patients in experimental study is necessary to further validate findings here.
However, our data support the notion that acute pain may be exacerbated in AD, regardless of severity or ability to self-report. Our findings thus have a number of translational consequences. First, autonomic responses lose utility as a measure of pain as AD advances; we cannot endorse their use in a clinical context. In contrast, assessment of non-verbal pain behaviors was rather sensitive to pain in patients of all severities. Importantly, we found that the behavioral components of the PAINAD were able to measure gradations in pain intensity, rather than simply the presence or absence of pain.
Mild and severe patients alike showed increased sensitivity to pressure pain, compared with controls. Thus, it should not be assumed that reductions in self-report represents and absence of pain, particularly in advanced AD. Indeed, all AD patients should receive frequent behavioral assessments to increase comfort and reduce behavioral and psychological symptoms of dementia.
We would thus recommend that clinicians and caregivers integrate frequent proxy and self-report measures of pain in AD patients as part of an overall assessment strategy to improve clinical pain management and patient quality of life. We also thank funding sources: Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide.
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An exploration of nursing home managers' knowledge of and attitudes towards the management of pain in residents with dementia. That is, the interval between no pain and mild pain may be much smaller than that between moderate pain and severe pain, yet the interval is scored as if the difference were equivalent . A VAS consists of a line, usually 10cms long whose ends are labelled as the extremes of pain - 'no pain' to 'worst pain'.
A VAS may have specific points along the line that are labelled with intensity denoting adjectives or numbers. Those scales that use adjectives are called graphic rating scales.
Patients are asked to rate their pain along the line that best represents the intensity of their pain. This distance between the no end and the mark provided by the patient is measured and this gives the pain intensity score. There is much evidence to support the validity of VAS for pain intensity. Such scales demonstrate positive relations to other self-report measures of pain intensity  ,  , to observed pain behaviour  and are sensitive to treatment effects .
The VAS is also more sensitive than other measures especially those with a limited number of response categories because there are in fact response levels 0 to mm .
Mechanical VAS have been developed and these usually look like a ruler with a red line on a slide that can be moved by the patient on one side of the ruler, and scored by the nurse on the other side.
The problems with VAS include:. A NRS involves asking the patient to rate his or her pain from 0 to 10 11 point scale or from 0 to point scale with the understanding that 0 is equal to no pain and 10 or is equal to worst possible pain. This does not require the patient to write or use a ruler and he or she provides a verbal response which the healthcare provider can then document.
A number of written response NRS exist. Jensen et al  ,  describes one where patients are asked to record the number that best represents their pain intensity. The Brief Pain Inventory  utilises a NRS but presents the numbers in ascending order with the endpoint descriptors near the 0 and the highest number of the scale, it asks patients to circle the number that best represents their pain intensity.
NRS are valid and demonstrate positive and significant correlations with other measures of pain intensity . They have also demonstrated sensitivity to treatments that are expected to have an impact on pain intensity . The NRS is extremely easy to administer and score and therefore can be used with a greater variety of patients e. It is also useful for telephone assessments. The simplicity of the measure means that individuals comply better than with other tools. The only real drawback is, as for the other rating scales, that it assesses only pain intensity.
Picture or face scales employ photographs or drawings that illustrate facial expressions or persons experiencing different levels of pain severity  , . Patients are asked to indicate which one of the illustrations best represents their pain experience. Each face has a number representing the rank order of the pain illustrated and the number of the picture chosen by the patient represents that patient's pain intensity score.
These types of scales do not require patients to be literate and provide an option for those patients who have problems with written language. They are particularly useful in the paediatric population where scales have demonstrated validity through their association with other measures of pain intensity  ,  and through their ability to detect the effects of analgesics .
Children also seem to prefer face scales . There is also evidence that they are valid for use in adults . The DDS-I consists of a list of 12 descriptors describing different levels of pain intensity . Patients are asked to rate the intensity of their pain as being more, or less than each descriptor on the list.
If their pain is worse than the descriptor, they place a mark to the right of the word in proportion to how much greater their pain is.
If their pain is less than the descriptor, they place a mark on the left of the chart. If the descriptor exactly describes their pain, they place a mark directly below the descriptor. There are 10 points along which patients can rate their pain intensity to the right and left of each descriptor, so the pain is rated on a 21 point scale for each descriptor.
Pain intensity is defined as a mean of the ratings and can range from 0 to The scale is valid and reliable and is associated with other measures of pain intensity  and is sensitive to treatment effects . Examples of behaviour usually expected of patients with pain include grimacing, rigid body posture, limping, frowning or crying. Vital signs are also expected to be elevated. However, it may not be appreciated that both physiological and behavioural adaptation occurs leading to periods of minimal, or no signs of pain.
Absence of signs does not necessarily mean absence of pain. When pain is sudden or severe, behavioural and physiological indicators may be present, but only for a brief time.
However, very quickly the patient may make an effort to cease behaviours, such as crying or moaning, because it may be seen as unacceptable. This is especially true within Western cultures. The patient may also be exhausted. Physiological indicators, such as increased blood pressure and pulse rate may also disappear as the body seeks to maintain homeostasis.
The patient may have a medical condition or may be undergoing treatment, which may prevent physiological reactions e. The guidelines from the American Pain Society  offer the following advice on using behavioural and physiological assessments:. Therefore, behavioural and physiological indictors should not be used for patients who are able to self-report and indicate to the health carer that they are in pain.
However, there are some patients who may not be able to tell you that they are in pain yet we need to try and assess their pain in some meaningful way.
Cognitively impaired adults, children, and the very young fall into this category and nonverbal communication can be a source of information in this instance . To sum up, no ideal pain assessment tools exists so it is important to use pain tools that are valid and reliable.
There are many myths and misconceptions that need to be confronted to ensure that when a patient is reporting his or her pain, it is believed. Behavioural tools, while useful for those who are unable to self report, can assess fear, anxiety and depression also so care is needed when interpreting them in clinical practice.
Where possible, self report pain tools should be used and pain scores documented as the 5 th vital sign. Study Learning Materials Bibliography. Pain Assessment Tools Time Required: Learning Outcomes To be able to recognise the importance of utilising a validated pain assessment tool To accurately describe a variety of validated tools and recognise when their individual use is indicated To discuss the advantages and disadvantages of multiple pain assessment tools To recognise the limitations of behavioural assessment tools Pain Assessment Tools A pain assessment tool requires reliability, consistent results when performed under similar conditions or circumstances and validity the measurement does actually scale 'pain' and not some other quantity such as anxiety; this is problematic in assessment tools that assess behaviour in those unable to respond.
The ideal pain assessment tool would have the following attributes but when you consider these attributes and measure them against the tools available you realise that no one tool has all attributes: Sensitive and free from bias; Immediate information about accuracy and reliability; Distinguishes between pain, unpleasantness and emotion; Assesses experimental and clinical pain; Absolute rather than relative scales; Estimates confidence of predictions.
Verbal rating scales The VRS consists of a list of adjectives describing different levels of pain intensity. Other issues are that: Visual analogue scales and graphic rating scales A VAS consists of a line, usually 10cms long whose ends are labelled as the extremes of pain - 'no pain' to 'worst pain'.
The problems with VAS include: Numerical rating scale A NRS involves asking the patient to rate his or her pain from 0 to 10 11 point scale or from 0 to point scale with the understanding that 0 is equal to no pain and 10 or is equal to worst possible pain. Picture or Face Scales Picture or face scales employ photographs or drawings that illustrate facial expressions or persons experiencing different levels of pain severity  , .
There are problems with face scales in clinical practice and these include:
International Journal of Pediatrics
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.