Pain in older persons with severe dementia. Psychometric properties of the Mobilization–Observation–Behaviour–Intensity–Dementia (MOBID‐2) Pain Scale in a clinical setting

Scand J Caring Sci; 2010; 24; 380–391
Pain in older persons with severe dementia. Psychometric properties of the Mobilization–Observation–Behaviour–Intensity–Dementia (MOBID‐2) Pain Scale in a clinical setting Background: To assess pain in older persons with severe dementia is a challenge due to reduced self‐report capacity. Recently, the development and psychometric property testing of the Mobilization–Observation–Behaviour–Intensity–Dementia (MOBID) Pain Scale was described using video‐recording. The purpose of this article was to present the further development of this instrument. In MOBID‐2 Pain Scale, the assessment of inferred pain intensity is based on patient’s pain behaviours in connection with standardized, guided movements of different body parts (Part 1). In addition, MOBID‐2 includes the observation of pain behaviours related to internal organs, head and skin registered on pain drawings and monitored over time (Part 2). Objective: The aim of this study was to examine psychometric properties of the MOBID‐2 Pain Scale, like inter‐rater and test–retest reliability, internal consistency, as well as face‐, construct‐ and concurrent validity. Subjects and Setting: Patients with severe dementia (n = 77) were examined by 28 primary caregivers in clinical practice, who concurrently and independently completed the MOBID‐2 Pain Scale. Characteristics of the patients’ pain were also investigated by their physicians (n = 4). Results: Prevalence of any pain was 81%, with predominance to the musculoskeletal system, highly associated with the MOBID‐2 overall pain score (rho = 0.82). Most frequent and painful were mobilizing legs. Pain in pelvis and/or genital organs was frequently observed. Moderate to excellent agreement was demonstrated for behaviours and pain drawings (κ = 0.41–0.90 and κ = 0.46–0.93). Inter‐rater and test–retest reliability for pain intensity was very good, ICC (1, 1) ranging 0.80–0.94 and 0.60–0.94. Internal consistency was highly satisfactory; Cronbach’s α ranging 0.82–0.84. Face‐, construct‐ and concurrent validity was good. Overall pain intensity by MOBID‐2 was well correlated with physicians’ clinical examination and defined pain variables (rho = 0.41–0.64). Conclusion: On the basis of pain behaviours, standardized movements and pain drawings, MOBID‐2 Pain Scale was shown to be sufficiently reliable, valid and time‐effective for nurses to assess pain in patients with severe dementia.     

Validity of weekly recall ratings of average pain intensity in neck pain patients

ObjectiveRatings of usual pain over a period of 1 week are commonly used to rate a patient's usual level of pain intensity. This study investigated the validity of weekly recall pain ratings and biasing effects of pain levels on these ratings.MethodsSeventy-eight patients presenting to a chiropractic outpatient clinic with nonspecific neck pain completed a 7-day diary rating their pain 4 times each day on an 11-point numerical rating scale. From these 28 ratings, the patients' “actual average” pain was computed. On day 8, patients were asked to rate their current pain, as well as recall their pain “on average,” at its “worst,” and at its “least” over the previous week.ResultsRecall of average pain over the previous week was shown to be a valid measure using ratings of actual pain as the criterion standard (Pearson r = 0.95). The error between actual and recall readings was random and consistent across all levels of actual pain. Patients were also able to accurately recall their pain at its worst (r = 0.93) and at its least (r = 0.92) over the preceding week. In regression analyses, there were no appreciable biasing effects on the recall of average pain of either current pain at the time of recall, or of pain at its worst or at its least during the recall period.ConclusionThese results suggest that recall ratings of pain intensity may be valid for use in clinical research and practice on patients with nonspecific neck pain.     

Pain behaviour and pain intensity in older persons with severe dementia: reliability of the MOBID Pain Scale by video uptake

Advancing age is associated with high prevalence of dementia, often combined with under-diagnosed and under-treated pain. A nurse-administered assessment tool has been developed to unmask pain during standardised, guided movements, called Mobilisation–Observation–Behaviour–Intensity–Dementia (MOBID) Pain Scale. The aim was to examine intra- and inter-rater reliability of pain behaviour indicators, inferred pain intensity, and the overall MOBID Pain Score. Twenty-six nursing home patients with severe dementia and chronic pain, 11 primary caregivers and three external raters at the Red Cross Nursing Home, Bergen were included. During video uptake the patients were guided by their primary caregivers to standardised movements of different body parts. Pain behaviour indicators (pain noises, facial expression and defence) were registered for each movement with subsequent rating of pain intensity by external raters, who assessed and scored the videos concurrently and independently at day 1, 4 and 8. Facial expression was most commonly observed, followed by pain noises and defence. Repeated assessments increased the number of observed pain behaviours, but did not improve reliability. Inter-rater reliability was highest for noises, followed by defence and facial expression (κ = 0.44–0.92, κ = 0.10–0.76 and κ = 0.05–0.76 respectively, at day 8). Mobilisation of arms and legs were rated most painful. Intra- and inter-rater reliability of overall pain were very good [intraclass correlation coefficient (1,1) ranging 0.92–0.97 and 0.94–0.96 respectively, at day 8]. Reliability of pain intensity scores tended to increase by repeated assessment. Using video uptake, MOBID Pain Scale was shown to be sufficiently reliable to assess pain in older persons with severe dementia.     

Mobilization-Observation-Behavior-Intensity-Dementia Pain Scale (MOBID): development and validation of a nurse-administered pain assessment tool for use in dementia

Pain assessment in older persons with severe cognitive impairment (SCI) is a challenge due to reduced self-report capacity and lack of movement-related pain assessment instruments. The purpose of this article was to describe the development of the Mobilization-Observation-Behaviour-Intensity-Dementia Pain Scale (MOBID) and to investigate aspects of reliability and validity. MOBID is a nurse-administered instrument developed for use in patients with SCI, where presence of pain behavior indicators (pain noises, facial expression, and defense) may be observed during standardized active, guided movements, and then inferred to represent pain intensity. Initially, the MOBID contained seven items (observing at rest, mobilization of the hands, arms, legs, turn over in bed, sitting on bedside, and teeth/mouth care). This was tested in 26 nursing home patients with SCI. Their primary caregivers, five registered nurses and six licensed practical nurses (LPNs), rated the patients' pain intensity during regular morning care, and by MOBID, both at bedside and from video uptakes. Three external raters (LPNs), not knowing the patients, also completed the MOBID by rating the videos. Internal consistency of the MOBID indicated high Cronbach's alpha (alpha=0.90) after deleting the items for observation at rest and observation of teeth/mouth care. MOBID disclosed significantly more pain than did pain scorings during regular morning care, and video observation demonstrated higher pain intensity than bedside scoring. Intertester reliability for inferred pain intensity was high to excellent (intraclass correlation coefficient=0.70-0.96), but varied between poor and excellent for pain behavior indicators (kappa=0.05-0.84). These results suggest that registration of pain behavior indicators during active, guided movements, as performed by the MOBID procedure, is useful to disclose reliable and valid pain intensity scores in patients with SCI.     

Core Aspects of Satisfaction with Pain Management: Cancer Patients' Perspectives

ContextThe coexistence of high levels of satisfaction and high levels of pain has been perplexing.ObjectivesThe aims of this study were to 1) describe patient expectations related to the experience of cancer-related pain, 2) explore the cognitive processes and meaning that underlie patient judgments about satisfaction and dissatisfaction with pain management, and 3) explore the discrepancies between ratings of high satisfaction with pain management with high pain intensity.MethodsThe sample included 33 patients: 18 with advanced cancer and 15 experiencing pain after a surgery for a cancer diagnosis. All patients had experienced “worst pain” of at least moderate intensity and were interviewed using standard pain measures from the American Pain Society Patient Outcome Questionnaire and open-ended questions about the underlying meaning of their answers. We systematically analyzed the transcribed qualitative data using NVivo software.ResultsFifty-five percent of patients were females and were aged 25–78 years. Most (75%) were satisfied or very satisfied with their overall pain management. Key findings indicate that for some, the worst pain rating was often brief, even momentary. Most patients expected pain relief. Four key themes were important to the quality of pain management: being treated right, having a safety net, being in a partnership with their health care team, and having pain treatment that was efficacious. Key aspects of the patient-provider relationship that mattered were how the nurses and doctors behaved toward them and how quickly they responded to reports of pain. For some, an important factor was whether they had control of the amount of pain they experienced.ConclusionThe findings inform measurement of patient satisfaction with the quality of pain management.     

Quantification of the pain terms hurt, ache and pain among nursing students

The aim of this study was to determine the quantitative meaning nursing students ascribe to the pain terms hurt (ont), ache (värk) and pain (smärta). In total, 549 nursing students filled in a questionnaire including questions about age, gender, and health care work experience. The students were also requested to rate response using a Visual Analogue Scale (VAS) rating for different statements about hurt, ache and pain. The results show that there were significant differences (p < 0.001) between rated intensity of the statements of hurt, ache and pain. There were, however, large variations in the students’ ratings of the pain terms; hurt ranged from 3 to 97 mm, ache from 7 to 97 mm and pain from 27 to 100 mm. There were no significant differences between male and female students regarding their ratings of hurt and ache when they were used to describe the worst self‐experienced pain. Female students rated their experience of pain significantly higher (p < 0.001) on the VAS compared with male students. There was no significant correlation between previous experience of health care work and rated intensity of hurt, ache and pain. In conclusion, this study shows that there exist significant differences between the pain terms hurt, ache and pain according to a rating on a VAS. However, the results also demonstrate that there are large individual variations in how the students quantify the fictitious patient statements of hurt, ache and pain.     

Nursing degree students’ clinical placement experiences in Australia: A survey design

AimThis study aimed to evaluate Australian nursing students’ views of placements at seven tertiary education institutions with the use of the Placement Evaluation Tool (PET).BackgroundClinical placements are a core element of healthcare education programs around the world (Chuan and Barnett, 2012) with undergraduate nursing students required to complete a prescribed number of hours as part of their degree. The quality of nursing clinical placements varies with a range of positive and negative learning experiences.DesignA survey design was used with a contemporary survey tool– the Placement Evaluation Tool (PET). Using Qualtrics software (Qualtrics, 2005) the on-line survey was distributed to approximately 6265 undergraduate nursing students at six Australian universities and one Technical and Further Education (TAFE) college where Bachelor of Nursing degree students were enrolled. Three Australian States were covered. Sites were selected where a project team member was employed.MethodsA total of 1263 nursing students completed the Placement Evaluation Tool (PET) − 19 items (rated 1–5), one global rating (rated 1–10) − following placement in three Australian States (July 2019−February 2020). Most - 618 (48.9%) completed a placement in acute care with placements positively rated overall.ResultsThe total PET mean score was 78.3% with 29.8% being ‘extremely satisfied’ (10 out of 10 – Item 20). However, 11.0% were dissatisfied with global ratings of four or less, whilst ratings between States differed significantly (p = <0.001). One third of respondents answered a free text statement relating to placement experiences, with significantly more comments from older students (p = <0.001) and from those with ratings in the lower range (p = <0.001). Three core themes emerged: 1. Staff Attitudes to Students, 2. Environment and 3. Lifestyle.ConclusionsWhilst students’ clinical experiences in Australia tend to be positive a minority reported exposure to negative staff attitudes, in unsafe environments, with lifestyle detriments. Further work is required to understand and enhance student experiences.     

Decreasing Pain and Fear in Medical Procedures with a Pediatric Population (DREAM): A Pilot Randomized Within-Subject Trial

BackgroundMany children with injuries, including burns and fractures, experience moderate to severe pain during medical procedures. Recent studies claim that nonpharmacologic pain management using virtual reality (VR) could distract children from procedural pain by engaging multiple senses.AimsThe aims of this pilot randomized clinical trial were to assess the acceptability and feasibility of VR distraction in children with burns or fractures undergoing painful medical procedures, as well as the staff nurses, and assess the preliminary efficacy of VR distraction on pain intensity, pain-related fear, and subsequent recall of both.Materials and MethodA within-subject study design, in which participants served as their own control, was used. A total of 20 children from 7 to 17 years old with an injury were recruited at the surgical-trauma outpatient clinics of the Centre hospitalier universitaire Sainte-Justine (CHU Sainte-Justine). Each participant received both standard and experimental treatments through randomized order. Pain (numerical rating scale) and pain-related fear (Children's Fear Scale) measures were taken before the procedure and after each sequence, followed by a measure of children's (graphic rating scale) and nurses' acceptability of the intervention through their satisfaction level. Recall of pain intensity and pain-related fear were assessed 24 hours after the procedure. Wilcoxon signed-rank tests were used, with a significance level at 0.05.ResultsResults showed that VR distraction was an acceptable and feasible intervention for children and nurses of these outpatient clinics. Preliminary effects showed that, compared to standard of care, children participants reported a significant decrease in pain intensity (p = .023) and pain-related fear (p = .011) during VR as well as less recalled pain-related fear (p = .012) at 24 hours after the procedure. No side effects were reported.ConclusionVR is a promising intervention with children undergoing painful procedures because it is immersive and engages multiple senses. It is a low-cost intervention well accepted by children and nursing staff at this clinical site and is easy to implement in daily practice for procedural pain management.     

Development of a composite pain measure for persons with advanced dementia: exploratory analyses in self-reporting nursing home residents

ContextExperts agree that pain assessment in noncommunicative persons requires data from sources that do not rely on self-report, including proxy reports, health history, and observation of pain behaviors. However, there is little empirical evidence to guide clinicians in weighting or combining these sources to best approximate the person’s experience.ObjectivesThe aim of this exploratory study was to identify a combination of observer-dependent pain indicators that would be significantly more predictive of self-reported pain intensity than any single indicator. Because self-reported pain is usually viewed as the criterion measure for pain, self-reported usual and worst pains were the dependent variables.MethodsThe sample consisted of 326 residents (mean age: 83.2 years; 69% female) living in one of 24 nursing homes. Independent variables did not rely on self-report: surrogate reports from certified nursing assistants (CNAs) using the Iowa Pain Thermometer (IPT), Checklist of Nonverbal Pain Indicators (CNPI), Cornell Scale for Depression in Dementia (CSDD), Pittsburgh Agitation Scale (PAS), number of painful diagnoses, and Minimum Data Set (MDS) pain variables.ResultsIn univariate analyses, the CNA IPT scores were correlated most highly with self-reported pain. The final multivariate model for self-reported usual pain included CNA IPT, CSDD, PAS, and education; this model accounted for only 14% of the variance. The more extensive of the two final models for worst pain included MDS pain frequency, CSDD, CNA IPT, CNPI, and age (R² = 0.14).ConclusionAdditional research is needed to develop a predictive pain model for nonverbal persons.     

Worst experiences of pain and conceptions of worst pain imaginable among nursing students

Title. Worst experiences of pain and conceptions of worst pain imaginable among nursing students Aim. This paper is a report of a study to explore nursing students’ own worst experiences of pain as well as their conceptions of the worst pain imaginable. Background. Pain is a personal experience, often assessed using a visual analogue scale. The endpoints of this scale are labelled with the extremes for pain experience (e.g. no pain to worst pain imaginable). People may understand the meaning of ‘no pain’, but it is unclear what meaning they assign to ‘worst pain imaginable’. This indicates that a rating along the Visual Analogue Scale‐line is dependent on the individual’s previous experiences. Methods. Data were collected during the autumn of 2002. In total, 549 nursing students completed a questionnaire focusing on two main questions: ‘What is the worst experience of hurt, ache or pain you have had?’ and ‘What is the worst pain imaginable for you?’ Content analysis was used for data analysis. Results. The students’ worst experience of pain was mostly related to acute or traumatic painful conditions, pain associated with female physiology, inflicted pain, psychological suffering and chronic painful conditions. The worst pain imaginable was described as condition‐related pain, overwhelming pain, experiences of losses, deliberately inflicted pain, psychological suffering and as vicarious pain. Conclusion. The findings imply that nursing students, when they are imagining pain, include dimensions such as hope of relief, grief, control over the situation, powerlessness and empathy for and suffer with other people’s pain. Further research is needed to explore why professional experience as a nurse diminishes the ability to imagine patients’ pain.     

Trajectories of Pain in Patients Undergoing Lung Cancer Surgery: A Longitudinal Prospective Study

ContextLung cancer surgery is among the surgical procedures associated with the highest prevalence of pain, but prospective longitudinal studies after the pain trajectory are scarce.ObjectivesWe aimed to describe the pain trajectory in patients undergoing surgery for primary lung cancer and investigate whether distinct groups of patients could be identified based on different pain trajectories.MethodsPatients (n = 264; 95% thoracotomies) provided data on the average and worst pain intensity, pain location, and comorbidities before, and at one month and five, nine, and 12 months after surgery. Pain profiles were analyzed by latent class mixed models.ResultsThe occurrence of any pain increased from 40% before surgery to 69% after one month and decreased to 56%, 57%, and 55% at five, nine, and 12 months, respectively. Latent class mixed models identified two classes both for average and worst pain; one class started low with high ratings after one month, then returning to a level slightly higher than baseline. The other class started higher with similar scores through the trajectory. Patients reporting no pain (8%) were placed in a separate class. Higher comorbidity score, preoperative use of both pain and psychotropic medicine characterized the class with overall highest pain for average and/or worst pain.ConclusionPain was highly prevalent after surgery, and subgroups could be identified based on different pain trajectories. Patients reported both postoperative pain and pain from chronic conditions. Knowledge about vulnerable patients and risk factors for pain is important to tailor interventions and information about pain.     

Screening for pain in patients with cognitive and communication difficulties: evaluation of the SPIN-screen

ABSTRACT - The scale of pain intensity (SPIN)-screen is a simple visual tool for the screening and measurement of pain intensity, which is designed to be accessible by patients with cognitive and communication problems. It was applied prospectively in a consecutive cohort of 79 patients admitted to a tertiary specialist neurorehabilitation unit, of which 86% had significant cognitive/communicative disabilities. In all, 71 patients (90%) responded to the SPIN. Concurrent validation against a standard numbered graphic rating scale (NGRS) showed a strong overall correlation (rho 0.94 p < 0.0001). When the NGRS was converted to an equivalent six-point scale, weighted Kappa tests demonstrated 'almost perfect' agreement (K = 0.81, SE 0.083) between the two sets of ratings. Repeat testing after 24 hours provided preliminary evidence for the stability and responsiveness of the SPIN-screen, but these require further evaluation. Of those who expressed a preference for one tool over the other, 70% preferred the SPIN. The study provides support for application of the SPIN-screen as a routine screening tool in this group of patients.     

Sex Differences in Prior Pain Experience

Sex differences in clinical and experimental pain experiences are well documented. However, there has been little work investigating men's and women's experiences with common painful events. This study examined sex differences in the nature and intensity of common pain experiences. Participants (102 women and 85 men) completed the Prior Pain Experience Questionnaire, which is a 79-item assessment of an individual's pain experience, recalled pain ratings, and imagined pain ratings. Analyses of variance were conducted to assess for sex differences in overall pain experience and pain ratings. Men and women did not have significant differences in the overall number of reported pain experiences or in the overall mean pain rating of those experiences. However, they differed in specific pain events experienced (eg, men experienced concussions more than women) and pain ratings (eg, women rated minor surgery as significantly more painful than men). Individuals who imagined pain events tended to rate them as equally or more painful than individuals who experienced those pain events.PerspectiveResults of this study demonstrate that men and women have varying types of pain experiences without evidence that the overall pain experience differs between sexes. It was also found that imagined pain ratings are often worse than experienced pain ratings, lending support for the tendency of individuals to catastrophize.     

Schmerzerfassung bei invasiven diagnostischen Prozeduren

Background and objective

Pain measurement during diagnostic procedures is an accepted prerequisite for appropriate therapy. In this study, the agreement between rankings of pain intensity on a numerical and a verbal rating scale was analyzed.

Methods

Patients attending a haematological outpatient clinic who underwent bone marrow puncture were requested to assess pain intensity perceived during the procedure on a elenpoint numerical and a six-point verbal rating scale.

Results

Analysis of patients’ pain ratings in 263 bone marrow punctures showed a very good correlation between numerical and verbal rating scale (Spearman correlation coefficient 0,86). By means of a transfer instruction categories of the verbal rating scale were assigned to figures of the numerical rating scale (0 - no pain, 1 or 2 - mild p., 3, 4 or 5 moderate p., 6 or 7 severe p., 8, 9 or 10 - very severe and worst possible pain). The resulting transfer table showed a good agreement with a weighted kappa of 0.72 (95% confidence interval: 0.66–0.79).

Conclusion

Both scales can be employed efficiently for pain assessment during diagnostic procedures. Verbal categories can be assigned to numerical values and vice versa numerical values to verbal categories. However, in view of the inter-individual variations it appears appropriate to re-assure pain perception with each patient in order to avoid over- or undertreatment.     

Postoperative paediatric pain prevalence: A retrospective analysis in a university teaching hospital

BackgroundOverall pain prevalence in paediatric patients is well documented, but relatively little attention has been paid to pain prevalence and intensity on specific postoperative days within the first week following an operation.ObjectivesTo evaluate reported pain prevalence on the day of surgery and each day during the following week and to analyse pain trajectories.DesignRetrospective study.SettingSingle centre university hospital.Participants815 postoperative children and adolescents (age ≤ 18 years) were included (female: 36%, age 9.8 ± 5.8). Children with ear, nose, throat (e.g. tonsillectomy), eye (e.g. strabismus repair) or dental surgery (e.g. dental extraction) were treated at other departments and therefore were not included in this study.MethodsRetrospective analysis of the overall and clinically relevant (pain score ≥4/10) postoperative pain prevalence in children and adolescents during the first week after surgery. Possible influencing factors (age, sex, body mass index, type of anaesthesia, type of surgery and duration of surgery) on pain trajectories are analysed using mixed model techniques.ResultsOverall, 36% of 815 analysed children and adolescents suffered from pain ≥4 during their entire hospital stay. Compared to the day of surgery, the number of patients with pain ≥4 was slightly higher on day 1 after surgery (21% vs. 25%, respectively). In self-reported pain intensity rating (done for patients age ≥ 4 years) the type of surgery (p < .001) was the only significant variable influencing pain intensity. In observational pain assessment (age < 4 years) pain scores increased with patient's age (p = .004). In this patient group, pain intensity ratings did not differ between types of surgery (p = .278).ConclusionType of surgery is an important predictor for self-reported pain intensity ratings in children but not for observational pain assessment in younger children. In younger children observational pain assessment ratings increase with age.     

Detecting the emergence of chronic pain in sickle cell disease

ContextSickle cell disease (SCD) is an inherited hematological disease marked by intense pain. Early in life the pain is episodic, but it becomes increasingly chronic in many cases. Little is known about this emergence of a chronic pain state.ObjectivesThe goal of this study was to determine whether adult SCD patients whose pain is still largely episodic show early signs of the disturbed pain processing (hyperalgesia and increased temporal summation) and cognition (hypervigilance and catastrophizing) that are characteristic of a chronic pain state.MethodsSCD patients (n = 22) and healthy controls (n = 52) received noxious pressure stimulation for up to three minutes and periodically reported pain intensity and unpleasantness on 0–10 scales, allowing the rate of pain increase (temporal summation) to be determined. Pain intensity discrimination also was measured, and attitudes toward pain were assessed.ResultsThere were no overall differences in pain ratings or temporal summation between patient and control groups. However, patients’ experimental pain ratings tended to increase with age and those reporting a history of very painful episodes showed particularly rapid temporal summation of pain unpleasantness. Patients were significantly impaired at discriminating intensities of noxious stimulation. Patients were more hypervigilant than controls, but catastrophizing was elevated only during pain episodes.ConclusionMost SCD patients whose pain remits entirely between episodes are not in a chronic pain state, but some—those who are older and have a history of highly painful episodes—appear to be transitioning into it. These early signs of disturbed processing may aid clinicians seeking to forestall disease progression.