Behavioral and Physiologic Indicators of Pain in Nonverbal Patients with a Traumatic Brain Injury: An Integrative Review

The use of behavioral and physiologic indicators is recommended for pain assessment in nonverbal patients. Traumatic brain injuries (TBI) can lead to neurologic changes and affect the way patients respond to pain. As such, commonly used indicators of pain may not apply to TBI patients. This study aimed to review the literature about behavioral/physiologic indicators of pain in nonverbal TBI patients. An integrative review method was used. Medline (from 1948 to June 2011), Cinahl, and Cochrane databases were searched using any combination of the terms brain injury, behavioral indicators, behavioral scale, physiologic indicators, pain, pain assessment, and pain measurement. All articles reporting expert opinion or original data about the validity of behavioral and/or physiologic indicators of pain in TBI patients were considered. For each article included, the quality of findings/clinical recommendations was graded independently by two raters using SORT taxonomy. Eight papers were reviewed. Overall, TBI patients seemed to present a wider range of behavioral reactions to pain than other adult populations. In addition to the commonly observed grimace, agitation, and increased muscle tension, 14%-72% of TBI patients showed raising eyebrows, opening eyes, weeping eyes, and absence of muscle tension when exposed to pain. Those atypical reactions appeared to be present only in the acute phase of TBIs recovery. Similarly to other populations, vital signs were identified as potential indicators of pain in TBI patients. Further research studying TBI patients and considering changes in level of consciousness, location/severity of brain injury, and administration of analgesic/sedative is needed. Until then, nurses should follow the current clinical recommendations.     

Psychometric Properties of the Behavioral Pain Scale in Traumatic Brain Injury

BackgroundPain assessment of patients with traumatic brain injury is a challenge because they are unable to self-report their pain experience.AimsTo investigate the psychometric properties of validity, reliability, and responsiveness of the Brazilian version of the Behavioral Pain Scale (BPS-Br) in patients with traumatic brain injury.MethodsThis was an observational, cross-sectional, repeated-measure and analytical study. This study was developed at the medical and surgical ICUs in a high-complexity public hospital at Aracaju, Sergipe, Brazil. Thirty-seven adult patients with moderate or severe TBI were included. This study was completed with 444 independent observations, a pairwise comparison, and was performed simultaneously before, during, and after eye cleaning and endotracheal suctioning of 37 adult patients with moderate to severe traumatic brain injury.ResultsThe BPS-Br had good internal consistency (.7 ≤ α ≤ .9), good discriminant validity (p < .001), moderate to excellent reliability based on inter-rater agreement (intraclass correlation coefficient = 0.66-1.00; κ = 0.5-1.0), and high responsiveness (0.7-1.7). The upper limbs subscale had the highest score during the nociceptive procedure (1.8 ± 0.9). Deep sedation affected the increase of grading during painful procedures (p < .001).ConclusionsOur results suggest the BPS-Br is a useful tool for clinical practice to evaluate the pain experienced by patients with traumatic brain injury. Further studies of different samples are needed to evaluate the benefits of systematic pain assessment of critically ill patients.     

Quality Assessment of Neonatal Pain Scales Translated and Validated to Brazilian Portuguese: A Systematic Review of Psychometric Properties

ObjectivesThe objective of this systematic review was to identify and describe the psychometric properties of neonatal pain scales that were translated into Brazilian Portuguese and to verify the methodological quality of these translation, transcultural adaptations and validation.DesignThe present study is a systematic review. A systematic search in the literature included studies of development, validation, and transcultural adaptation of neonatal pain scales to Brazilian Portuguese. The instruments must have been developed for health care professionals to evaluate neonatal pain and stress in full-term and preterm newborns.Data SourcesThe search strategy was conducted in PubMed, Web of Science, Scopus, and Scielo databases following The PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses).Review /Analysis MethodsA total of 1,479 publications were identified and 5 fulfilled the inclusion criteria, with 4 instruments evaluated. For the methodological quality analysis of the measurement properties of the instruments the Consensus-based Standards for Health Measurement Instruments (COSMIN) Risk of Bias checklist was used. The psychometric properties verified were internal consistency, content validity, reliability, and construct validity.ResultsThree instruments reviewed were inadequate and one was doubtful.ConclusionsThe neonatal pain scales wich were cross culturally adapted to Brazilian Portuguese were shown to be of low methodological quality based on COSMIM checklist. Caution should be considered for clinical decisions about pain management judgment coming from these instruments.     

疼痛强度评估量表应用于老年腰痛患者的同时效度与偏好性

目的探讨疼痛强度评估量表在老年腰痛患者疼痛评估中的同时效度与选择量表时的偏好。方法由测评人员对30例有腰痛临床症状的老年患者进行疼痛强度评估量表测试,包括数字评定量表(NRS)、视觉模拟评分表(VAS)、词语描述量表(VDS)、修改版面部表情疼痛量表(FPS-R)和组合型疼痛评估表(MIX)。以NRS为校标工具,通过Spearman相关系数检验NRS与FPS-R、MIX、VAS和VDS之间的相关程度来确定FPS-R、MIX、VAS和VDS的同时效度。统计患者对5种评估量表的首选率。结果 FPS-R、MIX、VAS和VDS与NRS高度正相关(r=0.753～0.957,P<0.001)。首选疼痛强度评估量表依次为FPS-R、NRS、VDS、MIX、VAS。结论 FPS-R、MIX、VAS和VDS具有良好的同时效度,疼痛强度评估量表的同时效度适用于老年腰痛人群的评估。FPS-R是首选率最高的量表。     

Initial validation of the Behavioral Indicators of Infant Pain (BIIP)

Accurate pain assessment in preterm infants in the neonatal intensive care unit (NICU) is complex. Infants who are born at early gestational ages (GA), and who have had greater early pain exposure, have dampened facial responses which may lead to under-treatment. Since behavioral and physiological responses to pain in infants are often dissociated, using multidimensional scales which combine these indicators into a single score may limit our ability to determine the effects of interventions on each system. Our aim was to design a unidimensional scale which would combine the relatively most specific, individual, behavioral indicators for assessing acute pain in this population. The Behavioral Indicators of Infant Pain (BIIP) combines sleep/wake states, 5 facial actions and 2 hand actions. Ninety-two infants born between 23 and 32 weeks GA were assessed during 3, 1 min Phases of blood collection. Outcome measures included changes in BIIP and in Neonatal Infant Pain Scale (NIPS) scores coded in real time from continuous bedside video recordings; changes in heart rate (HR) were obtained using custom physiological processing software. Scores on the BIIP changed significantly across Phases of blood collection (p<0.01). Internal consistency (0.82) and inter-rater reliability (0.80-0.92) were high. Correlations between the BIIP and NIPS were modest (r=0.64, p<0.01) as were correlations between the BIIP and mean heart rate (r=0.45, p<0.01). In this initial study, the BIIP has been shown to be a reliable, valid scale for assessing acute pain in preterm infants in the NICU.     

The 21-Item and 12-Item Versions of the Depression Anxiety Stress Scales: Psychometric Evaluation in a Korean Population

Purpose

This study aimed to evaluate the psychometric properties of the Depression Anxiety Stress Scales 21 and 12 in a Korean population.

Kangaroo Care and Behavioral and Physiologic Pain Responses in Very-Low-Birth-Weight Twins: A Case Study

The purpose of this case study was to describe pain responses in three study conditions: longer (30 minutes) kangaroo care (KC) before and throughout heel stick (KC30), shorter (15 minutes) KC before and throughout heel stick (KC15), and incubator care throughout heel stick (IC) in 28-week gestational age twins. Pain responses were measured by crying time, Preterm Infant Pain Profile (PIPP), and heart rate variability indexes, including low-frequency power (LF, representing sympathetic activity), high-frequency power (HF, parasympathetic activity), and LF/HF ratio (sympathetic-parasympathetic balance). Both twins cried more and had higher PIPP pain scores and tachycardia during heel stick in the IC condition. Infant B had an incident of apnea and tachycardia by the end of the heel stick and a bradycardia episode during recovery in the IC condition. The twins had lower LF/HF ratios (better autonomic nervous system balance) during recovery in both longer and shorter KC conditions compared with the IC condition. Infant B had difficulty returning to LF/HF ratio baseline level after the painful procedure in the IC condition. These data suggest that both longer and shorter KC before and throughout painful procedures can be helpful in reducing behavioral and physiologic pain responses in preterm infants.     

Behavioral Pain Indicators in People With Intellectual Disabilities: A Systematic Review

People with intellectual disabilities (IDs) have a higher risk of painful medical conditions. Partly because of the impaired ability to communicate about it, pain is often undertreated. To strengthen pain assessment in this population, we conducted a systematic review to identify behavioral pain indicators in people with IDs by using Embase, PubMed, PsycINFO, CINAHL, and Cochrane. Inclusion criteria were 1) scientific papers; 2) published in the last 20 years, that is, 1992 to 2012; 3) written in English, 4) using human subjects, 5) intellectual disabilities, 6) pain, 7) behavior, and 8) an association between observable behavior and pain experience. From 527 publications, 27 studies were included. Pain was acute in 14 studies, chronic in 2 studies, both acute and chronic in 2 studies, and unspecified in 9 studies. Methodological quality was assessed with the Mixed Methods Appraisal Tool. Of the 14 categories with behavioral pain indicators, motor activity, facial activity, social-emotional indicators, and nonverbal vocal expression were the most frequently reported. Most of the behavioral pain indicators are reported in more than 1 study and form a possible clinical relevant set of indicators for pain in people with IDs. Determination of a behavioral pattern specific for pain, however, remains a challenge for future research.PerspectiveThis review focuses on categories of behavior indicators related to pain in people with IDs. The quality of evidence is critically discussed per category. This set of indicators could potentially help clinicians to recognize pain in this population, especially when unique individual pain responses are also identified.     

Evaluation of the Reliability and Validity of the Behavioral Indicators of Infant Pain Scale in Chinese Neonates

BackgroundBehavioral Indicators of Infant Pain scale (BIIP) has been shown to be a good tool to assess pain in infants.AimsThis paper aimed to translate BIIP into Chinese and evaluate its reliability and validity for neonates in China.DesignA prospective observational study.Setting and ParticipantsA convenience sample of 396 neonates (preterm and term infants) were recruited from neonatal intensive care units in China from July to October 2016.MethodsThe BIIP was translated and adjusted for semantic adaption.396 neonates were assessed during 3 phases of blood collection from an artery/vein. A video camera was positioned for a close-up view of the face and body. The neonates’ pain was rated independently by 2 nurses who were trained and familiar with the Chinese version of BIIP (C-BIIP)and FLACC (Facial expression, Legs, Activity, Crying and Consolability).ResultsThe internal consistency were 0.904 (preterm) and 0.895 (term). The test-retest reliability were 0.947 (preterm) and 0.938 (term) and the interclass correlation coefficients were 0.921 to 0.959 (preterm) and 0.921 to 0.959 (term). The correlations between the C-BIIP and FLACC were high (preterm: r = 0.948, term: r = 0.896). Using the C-BIIP, the 3 phases of blood collection were found to be statistically different (preterm: F = 635.76, term: F = 675.54; P < 0.001), which showed that the construct validity of C-BIIP was good.ConclusionThe BIIP is a reliable and valid tool to assess pain in term and preterm neonates in China.     

Infant Clinical Pain Assessment: Core Behavioral Cues

Diverse behavioral cues have been proposed to be useful cues in infant pain assessment, but there is a paucity of evidence on the basis of formal psychometric evaluation to establish their validity for this purpose. We aimed to examine 2 widely used coding systems, the Neonatal Facial Coding System (NFCS) and the Modified Behavior Pain Scale (MBPS), by examining their factor structures with confirmatory factor analysis using a large archival data set. The results indicated that an item-reduced NFCS scale with 3 items produced a 1-factor pain model that maintained the good psychometric properties of the 7-item scale. In addition, it was found that MBPS also has challenging internal consistency, with items that are weakly correlated as well as highly redundant. One item of the MBPS may be able to capture the construct of pain equally well or potentially improve its psychometric properties. Redefinition of the MBPS with cry as a sole indicator was suggested. This analysis provides 2 new iterations of the NFCS and MBPS that improve construct validity and internal consistency. These shorter versions also improve the feasibility of both measures and increase their potential for clinical use because less time is required for their administration.

Pediatric Pain Assessment by Drawn Faces Scales: A Review

Pediatric pain assessment is a significant issue yet the topic is understudied. Unique challenges, namely reporting biases, are present when assessing pain in children. The aim of this review of the literature is to increase awareness of biases when assessing pain in children, suggest changes in practice, and state priorities for future research. Five computerized databases were searched to identify original research pertaining to the use of drawn faces scales for pediatric pain assessment. Twelve studies met inclusion criteria. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines provided a framework for this review. Relevant articles were identified and data were extracted from the studies. Content analyses were then used to synthesize the findings. The age of a child being assessed contributed to biases in pain assessment. Drawn faces scales may provide inaccurate pain assessment results if a child has difficulty separating the feelings of pain and mood. Smiling faces on pain assessment scales may lead to overestimation of pain intensity. Nurses should consider biases when selecting and implementing a drawn faces pain assessment tool and when planning pain management interventions. An increase in the use of technology in pediatric pain assessment practices may provide opportunities to implement individualized pain assessment in practice. Further research is needed to determine the most reliable methods for pediatric pain assessment including the use of technology. Evidence would assist nurses in determining the best tool to assess each child based on cognitive abilities and developmental level.     

A Psychometric Evaluation of Three Pain Rating Scales for People with Moderate to Severe Dementia

Little comparative information exists regarding the reliability and validity of pain rating scales for nurses to assess pain in people with moderate to severe dementia in residential aged care facilities. The objective of this study was to evaluate the relative psychometric merits of the Abbey Pain Scale, the DOLOPLUS-2 Scale, and the Checklist of Nonverbal Pain Indicators Scale, three well-known pain rating scales that have previously been used to assess pain in nonverbal people with dementia. An observational study design was used. Nurses (n = 26) independently rated a cross-section of people with moderate to severe dementia (n = 126) on two occasions. The Abbey Pain Scale and the DOLOPLUS-2 Scale showed good psychometric qualities in terms of reliability and validity, including resistance to the influence of rater characteristics. The Checklist of Nonverbal Pain Indicators Scale also had reasonable results but was not as psychometrically strong as the Abbey Pain Scale and DOLOPLUS-2 Scale. This study has provided comparative evidence for the reliability and validity of three pain rating scales in a single sample. These scales are strong, objective adjuncts in making comprehensive assessments of pain in people who are unable to self-report pain due to moderate to severe dementia, with each having their own strengths and weaknesses. The DOLOPLUS-2 Scale provides more reliable measurement, and the Abbey Pain Scale may be better suited than the other two scales for use by nurse raters who only occasionally use pain rating scales or who have lower level nursing qualifications.     

3种量表用于新生儿足跟采血疼痛评估的信效度分析

目的：评价新生儿面部编码系统、新生儿疼痛量表和新生儿急性疼痛评估量表用于新生儿足跟采血疼痛评估的信度和效度。方法入选102例胎龄为29~42周行足跟采血操作的新生儿。通过床边录像,3名护士用3种量表独立完成操作前1 min、操作中和操作后1 min共918次疼痛评估。结果新生儿面部编码系统、新生儿疼痛量表和新生儿急性疼痛评估量表操作中疼痛评分均值最高,且同一量表操作前、中、后的疼痛评分差异均有统计学意义（P均<0.001）。操作前、中、后3种量表疼痛评分的Cronbachα系数分别为0.663、0.887、0.942;0.286、0.868、0.924;0.215、0.845、0.873。3种量表评估者间疼痛评分的组内相关系数分别为0.841~0.938、0.674~0.948、0.740~0.948。结论以上3种量表用于评估新生儿足跟采血疼痛,具有良好的信度和效度。     

FLACC Behavioral Pain Assessment Scale: a comparison with the child's self-report

The purpose of this study was to further test the validity of the Faces, Legs, Activity, Cry and Consolability (FLACC) Behavioral Pain Assessment Scale for use with children. Thirty children aged 3-7 years (5.01 +/- 1.44) who had undergone a variety of surgical procedures were observed and assessed for pain intensity at 20 + 2 hours after surgery. FLACC scores were assigned by one of the nurse investigators, and a self-report of pain using the FACES scale was obtained from the child. There were significant and positive correlations between the FLACC and FACES scores for the entire sample and for the scores of children 5-7 years of age, but not for children < age 5. These findings provide additional support for the construct validity of the FLACC Pain Assessment Tool.     

Development and Psychometric Evaluation of the Pain Impact Inventory

Objectives:   The aim of this study was to develop and psychometrically evaluate an instrument for measuring the impact of chronic pain on daily life.
Methods:   The study comprised 384 respondents (aged between 18–102 years) who reported chronic pain. The instrument "Pain Impact Inventory" (PII) was evaluated in terms of face, content, construct and criterion validity, as well as two reliability measures. Reliability was measured by means of test–retest (with a 2-week interval) while Cronbach's alpha was used to measure internal consistency.
Results:   The results showed that the PII had acceptable validity and reliability. The PII contains 20 items and was found to have a nested design with five sub-scales (Physical impact, Psychological impact, Impact on social life, Social support, and Control) and two overarching dimensions ("Impact" and "Support").
Conclusions:   The initial tests showed that the PII seems to be a psychometrically sound instrument for measuring the impact of pain on daily life from a multidimensional perspective.