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.
Because studies have shown under-detection and under-treatment of pain in sAD and little is known about pain processing in advanced stages of AD, further examination of these patients in an experimental setting is merited. AD progressively affects brain structures associated with different aspects of pain e. Limbic structures are affected early by AD, likely causing changes in pain affect and memory.
Finally, sensory cortices, associated with processing pain's intensity and localization aspects , are affected at late stages of AD.
Progressive impairment of brain structural and functional integrity supports the premise that clinical indicators of pain may vary based on disease severity. However, experimental studies further characterizing pain indicators in sAD and the modulating effects of disease severity are limited. In addressing these gaps in the literature, the primary aim of this study was to examine multiple acute pain responses autonomic, pain behaviors, and potential self-report in mAD and sAD patients during repeated application of multiple forearm pressure intensities.
Mechanical pressure algometry was the applied modality as it has been utilized in multiple studies of pain in the elderly with and without dementia.
In conjunction with testing for differences between AD patients and HS, a secondary aim was to determine if any pain responses varied according to AD severity. Considering past findings with respect to autonomic responses , we predicted that advancing AD would lead to blunted heart rate HR responses. In contrast, we predicted that sAD patients would show fewer pain behaviors than both mAD and HS subjects owing to advanced brain structural and functional deterioration as discussed above.
General subject demographics, including percentage of subjects using of cholinesterase and selective serotonin reuptake inhibitor medications, are found in Table Ages of HS subjects were HS subjects were required to have no history of subjective memory complaints. HS were recruited via ads in newsletters and local AD support groups. Study sample assembly procedures are outlined in Figure 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. Therefore, their validation is still required for other specific patient population, such as cardiac, trauma, or burn patients.
It must be underlined that other measures of pain assessment, such as changes in vital signs heart rate, respiratory rate, pupil size, or blood pressure have been identified as unreliable measures for pain evaluation.
Variation in vital signs, especially after a major operation or during critical illness, may be associated with hemodynamic instability or may be the side-effect of concomitant medications. Initially, the process included receiving authorization from the first author of the original scale J. Due to the detailed process of translation and back translation, the linguistic and cultural differences were eliminated, and the Polish version of the scale does not differ from the original.
The rater can appoint between 1 and 4 points in each category to a total of between 3 and 12 points. The Bioethical Committee of the Pomeranian Medical University approved the study and waived a need to obtain consent from participants of this study due to its observational noninterventional character, waiver number: The main investigator re-evaluated inclusion and exclusion criteria for all patients enrolled into the study after initial evaluation by 2 members of the study team.
This prospective observational cohort study underwent registration at the ClinicalTrials. Patients who fulfilled inclusion criteria were enrolled into this prospective observational cohort study on the 6-bed postcardiac surgery unit and a 6-bed cardiac intensive care unit ICU at a tertiary teaching hospital in June and July All patients underwent a planned cardiac operation with the use of cardiopulmonary bypass CPB according to standard practice.
Anesthesia was performed using general anesthetic technique with intravenous induction using fentanyl, etomidate, and pancuronium and maintenance of anesthesia using sevoflurane and fentanyl, as per local protocol. All patients were transferred to the postoperative unit where analgesia and sedation was initiated. The unit has implemented a minimal analgesia protocol for intubated postoperative patients, including morphine intravenous infusion with the concomitant use of nonopioid analgesics metamizole or paracetamol.
Each NRS result was obtained from the patient by the bedside nurse. Both raters rater A and rater B were blinded to each other and to the NRS result collected from the patient by the bedside nurse. They were supervised by the primary investigator who also verified inclusion criteria. All pain assessments were carried out during rest and routine nursing procedures in the postoperative cardiac unit and cardiac ICU with the nociceptive procedures NPs , including patient positioning and turning in bed.
Two sets of assessments were performed during prespecified timepoints: Each evaluation consisted of 2 elements: The study procedures were performed in 2 clinical situations: Analgesia was provided as per local protocol with a continuous intravenous infusion of morphine 0.
The assessments were as follows: We collected basic demographic data including: Each patient was asked to self-report pain using the NRS using a large-scale print-out and indicate a number between 0 no pain and 10 the worst pain ever. Standardized Cronbach alpha was used as an internal consistency estimate of reliability for BPS domains. Interrater reliability for BPS was calculated using intraclass correlation coefficient interrater correlation [ICC] 3,1.
To address the issue of multiple testing, we calculated Bonferroni-corrected threshold P -value. The statistical analysis was performed with the use of Excel Microsoft and Statistica 13 with Medical Bundle 4. During the 2-month study period patients underwent cardiac surgery with the use of cardiopulmonary by-pass and were screened for eligibility. All patients underwent an open heart surgery with the use of CPB. All patients received intravenous morphine and dexmedetomidine infusion during T1 to T3 and only morphine infusion during T4 to T6.
For opioid-sparing effect coanalgesics were administered with frequencies as follows: Similar values were not calculated for assessment before or after NP since at least 1 BPS domain showed zero variance the lowest possible score value: Standardized Cronbach alpha values for rater A and rater B, reflecting internal consistency of behavioral pain scale domains assessed during NPs. Therefore, high intraclass correlation coefficients were measures of interrater reliability of the POL-BPS in both sedated and unsedated postcardiac surgery patients.
The pain was rated higher during NPs T2 and T5 both by the patients and by the observers who had no access to data reported by the patient as compared to assessments at rest. The results of NRS were available for all 59 patients. The diameter of the circles is proportional to the number of values at respective coordinates.
Overall no statistically significant correlation was found between physiologic parameters and BPS. The POL-BPS study was performed to validate the POL-BPS in a special population of patients undergoing cardiac surgery who were assessed both sedated and unsedated, but intubated and mechanically ventilated at time of data collection. Two important elements occurred in this study.
Second, we were able to reliably assess pain in sedated postoperative cardiac patients using BPS and their self-assessment. According to international recommendations and guidelines, adequate pain assessment is a prerequisite not only for optimal pain treatment, but also for effective therapy of agitation and delirium associated with critical illness. Moreover, we have shown good discriminant validity, identified by higher BPS results during painful procedures than at the time before or after these procedures, both with and without sedation.
Other authors have shown similar results. The original study performed by Payen et al that introduced BPS to clinical practice showed that it can validly and reliably be used in sedated mechanically ventilated patients. In contrast to our study, the type of anesthetic technique and analgesia used intraoperatively and postoperatively by Rijkenberg et al differed greatly between the patients. There are not many studies assessing pain in the postcardiac surgery patient group.
The uniqueness of our study lies in the fact that we included observations in both sedated and unsedated patients. Despite receiving sedation dexmedetomidine and analgesia morphine , they were able to interact with the bed-side nurses and raters and self-assess pain using the NRS. Although difficult to obtain in the vulnerable postcardiac surgery period, this led to an appropriate validation of a BPS against patient self-report of pain.
Similar recent studies performed in conscious patients suggested that concomitant use of both BPS and CPOT during painful interventions or nursing care may improve the evaluation of pain. Moreover, our study group was very homogenous due to a standard anesthesia protocol during the procedure same set of medications for each patient and in the postoperative period dexmedetomidine and morphine was used in all patients. Opioid delivery was a part of routine postoperative analgesia and did not differ between patients, which adds to the homogeneity of the study group.
Continuous morphine infusion along with nonopioid analgesics provides a well-balanced analgesia, but may influence patient responsiveness. This was possible in our study, but usually when the patient is able to do self-evaluation, they do not require assessment with a behavioral scale.
Some authors suggest that to obtain most reliable results both verbal and nonverbal tools should be used, [ 18 ] as this leads to better optimization of the pain treatment in postcardiac surgery patients. The assessment of pain should be multi-dimensional and take into account both patient's report as the gold standard VAS or NRS , as well as observer's report usually a nurse using a behavioral scale and other issues, namely patient's previous experience or expectations.
It has been much debated recently that carers should move beyond pain scores [ 23 ] and acknowledge not only pain intensity measurement, but also patient's personal pain experience, pain threshold, verbal pain evaluation, and opinion. It has been highlighted that some healthcare professionals and patients differ in their interpretation of the postoperative NRS scores, therefore we should take into account the patient's preference for pharmacologic treatment.
Our study is not without limitations. This observational research was performed in a specific group of patients: This indicated that this validation study does not cover all potential critically ill patients and that further studies may be required to address specific population trauma, burn, children, etc.
We excluded emergency patients to provide homogeneity of the analyzed population, but there is a need to validate the BPS tool also in this group of patients. The results of this study show that the POL-BPS can be regarded as a useful and validated tool for pain assessment in adult intubated patients.
This study should be regarded as one of the many steps along the way to improve pain assessment and control. The authors of this study are grateful to the patients, physicians, nurses, and physiotherapists at the Pomeranian Medical University in Szczecin, Poland, for their collaboration. They also thank J. KK designed the study, collected the data, analyzed the results and wrote the manuscript.
MS collected the data and provided critical review of the manuscript. KS designed and performed statistical analysis. All of the authors read and approved the final manuscript. Writing — original draft: Katarzyna Kotfis, Krzysztof Safranow. The authors have no funding and conflicts of interest to disclose. National Center for Biotechnology Information , U. Journal List Medicine Baltimore v. Published online Sep Find articles by Eugene Wesley Ely.
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International Journal of Pediatrics
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