Numeric rating scale: patients' perceptions of its use in postoperative pain assessments

Comparison of Pain Assessment Tools and Numeric Rating Scale Thresholds for Analgesic Administration in the Postanaesthetic Care Unit

PURPOSE

The aim of this study was to assess the correlation between the Visual Analog Scale (VAS), Numeric Rating Scale (NRS), and Verbal Rating Scale (VRS). Additionally, the study aimed to determine NRS threshold values for both mild analgesic administration (= without risk of nausea and vomiting [NV] side effects) and strong analgesic administration (= with risk of NV side effects) in the postanaesthetic care unit (PACU).

DESIGN

Prospective, observational study design.

METHODS

The study was conducted between August 2019 and April 2022. Patients scheduled for elective surgery under general anesthesia were included. The primary outcome was the correlation between the VAS, NRS, and VRS, assessed at PACU admission and discharge. Secondary outcomes included pain evolution, desire for analgesic administration with or without risk of NV side effects, and preferred tool for pain assessment.

FINDINGS

VAS, NRS, and VRS were significantly correlated (r = 0.82 to 0.94, P < .001) at both PACU admission and discharge. The median VAS scores significantly improved from 32 (interquartile range [IQR]: 9 to 22) at PACU admission to 27 (IQR: 8 to 39) at PACU discharge (P < .001), while the median NRS scores significantly improved from 3 (IQR: 1 to 6) at PACU admission to 3 (IQR: 1 to 4) at PACU discharge (P < .001). At PACU admission, receiver-operating characteristics curve analysis indicated that an optimal NRS threshold value for the administration of a mild analgesic (= without risk of NV side effects) was greater than 2, and greater than 5 for the administration of a strong analgesic (= with risk of NV side effects). At PACU discharge, patients reported a preferred median NRS score of 5 to be treated with a mild analgesic (= without risk of NV side effects), and a preferred median NRS score of 8 to be treated with a strong analgesic (= with risk of NV side effects).

CONCLUSIONS

All three pain assessment tools can be used to evaluate postoperative pain in the PACU setting during the recovery from general anesthesia.

Clinical and socioeconomic factors predicting return-to-work times after cholecystectomy

BACKGROUND

Cholecystectomy, a type of surgery commonly performed globally, has possible mutual effects on the socioeconomic conditions of different countries due to various postoperative recovery times.

AIMS

This study evaluated the medical and socioeconomic factors affecting delayed return-to-work (RTW) time after elective cholecystectomy.

METHODS

This retrospective study analysed patients who underwent elective cholecystectomy for benign gallbladder diseases from January 2022 to April 2023. The patients' medical and socioeconomic data were collected to investigate the clinical and socioeconomic factors correlated with RTW time of >30 days after surgery.

RESULTS

This study included 180 consecutive patients. Significant correlations were found between delayed RTW time (>30 days) and age (odds ratio [OR]: 1.059, 95% confidence interval [CI] 1.008-1.113, P = 0.024), lack of medical insurance (OR: 2.935, 95% CI 1.189-7.249, P = 0.02) and high-intensity labour jobs (OR: 3.649, 95% CI 1.495-8.909, P = 0.004). Patients without medical insurance (26.6 versus 18.9 days) and those with high-intensity labour jobs (23.9 versus 18.8 days) had a higher mean RTW time than those with insurance and a less-intense labour job (P < 0.001).

CONCLUSIONS

After cholecystectomy, older age, lack of medical insurance and high-intensity labour job were correlated with a delayed RTW time. Informing patients about their expected RTW time after surgery can help reduce costs.

Sleep quality after autologous breast reconstruction

BACKGROUND

Sleep is a fundamental aspect of human health and well-being, but is often interrupted in a hospital setting. Especially after surgery, poor sleep quality can negatively affect postoperative recovery and quality of life. Therefore, the aim of this study was to gain insights into the quality of sleep in patients after autologous breast reconstruction and evaluate factors associated with the quality of sleep.

MATERIALS AND METHODS

In this single-center observational cohort study, participants completed a sleep diary, including the Pittsburgh sleep quality index (PSQI) and EQ-5D-5L quality of life questionnaire, before surgery, during hospital admission, and two weeks and three months postoperative. Additional variables such as pain and anesthesia duration were collected.

RESULTS

Twenty-nine patients were included. Before the surgery, 58% of them experienced poor quality of sleep, with a median PSQI score of 5.0. During hospital admission, 83% of the patients had poor quality of sleep, with a PSQI score of 6.0. The PSQI score two weeks postoperative increased to 7.0 and decreased three months postoperative to 5.0. Patients with pain scores >4 ("pain" group), had higher median PSQI scores than patients with pain scores ≤4 ("no pain" group) at all postoperative time points previously mentioned. No correlation was observed between anesthesia duration or quality of life.

CONCLUSION

Poor sleep quality was experienced by most women after autologous breast reconstruction, especially in those with higher postoperative pain scores. This knowledge offers an opportunity to improve the postoperative care for such patients.

Update of the European Society of Anaesthesiology and Intensive Care Medicine evidence-based and consensus-based guideline on postoperative delirium in adult patients

Postoperative delirium (POD) remains a common, dangerous and resource-consuming adverse event but is often preventable. The whole peri-operative team can play a key role in its management. This update to the 2017 ESAIC Guideline on the prevention of POD is evidence-based and consensus-based and considers the literature between 01 April 2015, and 28 February 2022. The search terms of the broad literature search were identical to those used in the first version of the guideline published in 2017. POD was defined in accordance with the DSM-5 criteria. POD had to be measured with a validated POD screening tool, at least once per day for at least 3 days starting in the recovery room or postanaesthesia care unit on the day of surgery or, at latest, on postoperative day 1. Recent literature confirmed the pathogenic role of surgery-induced inflammation, and this concept reinforces the positive role of multicomponent strategies aimed to reduce the surgical stress response. Although some putative precipitating risk factors are not modifiable (length of surgery, surgical site), others (such as depth of anaesthesia, appropriate analgesia and haemodynamic stability) are under the control of the anaesthesiologists. Multicomponent preoperative, intra-operative and postoperative preventive measures showed potential to reduce the incidence and duration of POD, confirming the pivotal role of a comprehensive and team-based approach to improve patients' clinical and functional status.

Surgery patients' perspectives of their role in postoperative pain: A scoping review

Background

Post-operative pain is a major factor in surgical recovery. There is evidence that pain remains undermanaged. Complications related to the undermanagement of acute pain can increase length of stay and contribute to readmission and the development of chronic pain. It is well acknowledged that pain assessment is critical to pain management and that self-report of pain is the gold standard. As a result, patients play a central role in their own pain management. A preliminary review of the literature failed to provide a clear or consistent description of this key patient role.

Objective

A scoping review was conducted with the objective of reviewing literature that described adult patients' perspectives or highlighted the adult patient's role in post-operative pain management, including assessment. Understanding patients' attitudes toward their roles in pain management through a scoping review of the current literature is critical for informing research and improvements in post-operative pain management.

Design

Scoping review.

Methods

The databases searched for the review included CINAHL, MEDLINE, PubMed, and SCOPUS (ending May 2022). Thematic analysis, using the methodology of Arksey and O'Malley, was applied to the records identified.

Results

Of the 106 abstracts initially identified, 26 papers were included in the final analysis. Two major themes identified through thematic analysis were attitudes toward pain and pain management, with the subthemes of patient expectations and beliefs and desire to treat; and care and communication, with the subthemes of pain assessment and education.

Conclusions

This paper provides one of the first known comprehensive scoping reviews of surgical patients' perspectives of their role in pain management, including assessment, and offers an important global awareness of this patient role. The findings suggest that improved understanding of patients' perspectives of their roles in pain assessment and treatment is critical to improving post-operative pain management. Engaging patients as partners in their care can facilitate enhanced communication and improving congruence in pain assessment and treatment decisions. The complex nature of patients' beliefs, expectations, and subjective experiences of pain present challenges for health care practitioners. These challenges can be met with enhanced education for patients, respect for patients' beliefs and expectations, and the provision of dignified care.

Detroit Interventional Pain Assessment Scale: A Pain Score and Method for Measuring and Evaluating Post-Operative Pain Management-A Prospective Study

Background and Objectives: Orthopedic surgeons commonly prescribe opioids, surpassing all medical specialties. Our objective was to develop a pain management scale that captures medication use, patient-reported pain scores, and helps orthopedic surgeons evaluate their post-operative prescribing practice. Materials and Methods: An IRB-approved prospective study followed 502 post-operative orthopedic surgery patients over a six-month period. All patients were surveyed in an orthopedic clinic at a Level 1 US Trauma Center, during a routine follow-up. Patient pain satisfaction was assessed using the validated Interventional Pain Assessment (IPA) scale, which uses three categories: 0 (no pain), 1 (tolerable pain), and 2 (intolerable pain). Daily narcotic use was translated to morphine milligram equivalents (MMEs) using the Michigan Automated Prescription System (MAPS) narcotics registry. When patient pain satisfaction and narcotic usage were combined, this scale was called the Detroit Interventional Pain Assessment (DIPA) scale. Results: The five classes based on common prescription and usage of narcotics in this cohort include the following: A (no pain medication), B (over-the-counter medication), C (occasional use of short-acting narcotics 1-30 MMEs), D (consistent/regular use of short-acting narcotics 31-79 MMEs), and E (long-duration or stronger short-acting narcotics 80+ MMEs). Patients were most satisfied with their pain management at six weeks (80.5%) and three months (75.65%), and least satisfied at two weeks (62.5%) and six months (60.9%). Additional information displayed on the DIPA graph revealed there was a significant decrease in the percentage of patients on narcotics at two weeks (65.2%) to six months (32.6%) at p < 0.001. Conclusions: The DIPA pain scale shows the relationship between patient pain perception and opioid prescription/usage, while also tracking prescriber tendencies. Providers were able to visualize their post-operative pain management progression at each designated clinic visit with corresponding alphabetical daily MME categories. In this study, results suggest that surgeons were not effective at managing the pain of patients at two weeks post-operative, which is attributed to an inadequate number of pain pills prescribed upon discharge. Overall, the DIPA graph signaled that better pain management interventions are necessitated in periods with lower efficiency scores.

Minimally invasive versus open transforaminal lumbar interbody fusion: a prospective, controlled observational study of short-term outcome

Instrumented stabilization with intersomatic fusion can be achieved by open (O-TLIF) or minimally invasive (MIS-TLIF) transforaminal surgical access. While less invasive techniques have been associated with reduced postoperative pain and disability, increased manipulation and insufficient decompression may contradict MIS techniques. In order to detect differences between both techniques in the short-term, a prospective, controlled study was conducted. Thirty-eight patients with isthmic or degenerative spondylolisthesis or degenerative disk disease were included in this prospective, controlled study (15 MIS-TLIF group vs. 23 O-TLIF group) after failed conservative treatment. Patients were examined preoperatively, on the first, third, and sixth postoperative day as well as after 2, 4, and 12 weeks postoperatively. Outcome parameters included blood loss, duration of surgery, pre- and postoperative pain (numeric rating scale [NRS], visual analog scale [VAS]), functionality (Timed Up and Go test [TUG]), disability (Oswestry Disability index [ODI]), and quality of life (EQ-5D). Intraoperative blood loss (IBL) as well as postoperative blood loss (PBL) was significantly higher in the O-TLIF group ([IBL O-TLIF 528 ml vs. MIS-TLIF 213 ml, p = 0.001], [PBL O-TLIF 322 ml vs. MIS-TLIF 30 ml, p = 0.004]). The O-TLIF cohort showed significantly less leg pain postoperatively compared to the MIS-TLIF group ([NRS leg 3rd postoperative day, p = 0.027], [VAS leg 12 weeks post-op, p = 0.02]). The MIS group showed a significantly better improvement in the overall ODI (40.8 ± 13 vs. 56.0 ± 16; p = 0.05). After 3 months in the short-term follow-up, the MIS procedure tends to have better results in terms of patient-reported quality of life. MIS-TLIF offers perioperative advantages but may carry the risk of increased nerve root manipulation with consecutive higher radicular pain, which may be related to the learning curve of the procedure.

Medical-Surgical Patients' and Registered Nurses' Satisfaction and Comprehensiveness of Patient Assessment Using the Clinically Aligned Pain Assessment Tool

BACKGROUND

The pain experience is complex, and nurses are challenged to objectively assess and document patients' subjective reports of pain. There is a clear need for an assessment tool that is easy to use and provides meaningful, actionable information for patients and nurses.

AIMS

This study explored nurses' and patients' satisfaction with the Clinically Aligned Pain Assessment (CAPA) as well as nurses' charting.

SETTING AND PARTICIPANTS

A convenience sample of adult patients and nurses on four medical-surgical units in one community hospital.

METHODS

A quantitative, two-group comparison design between patients and nurses using questionnaires to determine satisfaction and a retrospective chart review to determine comprehensiveness of nurse charting.

RESULTS

No significant differences existed between patients' and nurses' responses to seven of eight satisfaction questions The median score for seven of eight questions was 5 (using a 6-point Likert scale with 1 = strongly disagree and 6 = strongly agree), which demonstrated more than 80% agreement (somewhat agree, agree, strongly agree) among both groups that CAPA was superior to the NRS, based on individual responses. The one significant difference (p = 0.03) revealed patients were more likely to respond "agree or strongly agree" compared to nurses regarding the nurse thoroughly addressing patients' needs using CAPA. Inter-rater reliability using CAPA was determined to be 89.5%, and a panel of clinical experts determined CAPA had strong content validity of 88.33%. In addition, 70.41% of nurses charted comprehensively using CAPA.

CONCLUSION

As a result, CAPA was determined to be convenient, accurate, and valuable in guiding intervention decisions.

The IPA, a Modified Numerical System for Pain Assessment and Intervention

The objective of this study was to (1) construct a pain scale that improves communication between healthcare providers and patients (Interventional Pain Assessment [IPA] tool) and (2) to validate this new pain scale with the numeric rating scale of 0 to 10 Numerical Rating System (NRS).

Positive effects of the enhanced recovery after surgery (ERAS) protocol in DIEP flap breast reconstruction

BACKGROUND

Enhanced recovery after surgery protocols are successfully implemented in different surgical specialties, but a specific protocol for autologous breast reconstruction is missing. The aim of this study was to determine whether an enhanced recovery after surgery (ERAS) protocol contributes to a reduced length of stay without an increase in postoperative complications for patients undergoing a DIEP flap breast reconstruction.

MATERIALS EN METHODS

The effect of the ERAS protocol was examined using a single-center patient-control study comparing two groups of patients. Patients who underwent surgery between November 2017 and November 2018 using the ERAS protocol were compared with a historical control group (pre-ERAS) who underwent surgery between November 2016 and November 2017. The primary outcome measure was hospital length of stay. Secondary outcome measures were postoperative pain and postoperative complications.

RESULTS

152 patients were included (ERAS group, n = 73; control group, n = 79). Mean hospital length of stay was significantly shorter in the ERAS group than in the control group (5 vs. 6 days, p < 0.001). The average pain score was 1.73 in de the ERAS group compared to 2.17 in the control group (p = 0.032). There were no significant differences between the groups in postoperative complications. The ERAS group experienced less constipation (41 vs. 25 patients, p = 0.028).

CONCLUSION

An enhanced recovery after surgery protocol contributes an accelerated postoperative recovery of patients undergoing a DIEP flap breast reconstruction. In this study a significant decrease was found in hospital length of stay, patient-reported pain score and adverse health issues.

The effects of Reiki and back massage on women's pain and vital signs post-abdominal hysterectomy: A randomized controlled trial: The Effects of Reiki and Back Massage on Women's Pain and Vital Signs

BACKGROUND

Using Reiki and back massage to support pharmacological treatments is increasingly common in nursing. This study aimed to determine the effects of Reiki and back massage on pain, analgesic use, and vital signs among women who had undergone an open abdominal hysterectomy.

METHODS

This experimental study involved a single, blinded, pretest-posttest design. The study population comprised women who had undergone an abdominal hysterectomy at the obstetrics clinics of Gazi Yaşargil Training and Research Hospital and Dicle University Hospital between July 2017 and February 2018. Patients were divided into three groups: a Reiki group, a back massage group, and a control group. Each group comprised 34 patients. Reiki or back massage was applied to patients in the respective non-control groups for 20 min once a day. Data were collected using a patient information form, the "Numeric Pain Rating Scale," and the "Vital Signs and Postoperative Analgesic Follow-up Form."

RESULTS

Statistically significant differences in pain intensity and analgesic use were observed between the women in the Reiki group and the women in the back massage and control groups (p < 0.001). Significant differences in vital signs were observed between the groups before and after their respective procedures; in the Reiki group, they tended to decrease, while in the back massage and control groups, they tended to increase.

CONCLUSION

This study's findings confirmed that pain, analgesic use, and vital signs decreased after Reiki among women who had undergone an abdominal hysterectomy.

Disjunction, tension and dissonance within nursing pain care provision for the older hospitalized person: A focused ethnographic insight

AIMS

This study presents an ethnographic insight into the older hospitalized persons' experiences on how nurses provide pain care provision. The older persons' perceptions of culturally mediated barriers and facilitators are presented.

DESIGN

Focused ethnography.

METHODS

Multi-site across eight acute care units within two tertiary referral hospitals on the east coast of Australia collected over a one-year period from 2014 to 2015. Semi-structured interviews (n = 12) of older persons (11 hr). Twenty-three (23) semi-structured interviews with nine (9) registered nurses (12 hr 38 min). Participant observation (1,041 hr) during day, night and evening shifts.

RESULTS

The older person experienced disjunction within pain assessment by the reliance of nurses on objective measurement gained during functional task completion. Tension emerged during pain management when the older person was not included and/or options provided were not deemed effective. For some older persons this meant they undertook a decision to exclude their nurse from involvement in pain management. A thread woven throughout was a lack of communication, continuity of care and input from the older person.

CONCLUSION

This study has implications for the provision of nursing care of the older hospitalized person. Dissonance within pain care provision for the older person occurs during episodes of missed pain care. Understanding and insight is gained into aspects of missed communication opportunities between nurses and the experiences of missed pain care of the older person.

Recognising and assessing acute pain

This article considers two areas of practice that are fundamental to the provision of high-quality nursing care for people experiencing acute pain: the initial recognition of pain, and the formal assessment of pain. The initial recognition of a patient's pain is a subject that is frequently overlooked in the literature. However, if nurses are unable to identify that a patient is experiencing pain, then a formal pain assessment may not take place, which in turn negatively affects the quality of any subsequent pain management. This article explores some of the barriers to the initial recognition of pain and examines how a formal pain assessment can support optimal patient care.

Influence of interpretation of pain scores on patients' perception of pain: A prospective study

Background and Aims:

Assessment of pain using pain scales is essential. In the Numeric Rating Scale (NRS), patients are asked to score their pain intensity on a scale from 0 to 10 (10- worst pain). This requires some abstract thinking by the patient, also the pain scores (PS) may not essentially communicate the patients’ need for more analgesia. We planned a study to evaluate the change in patients’ self-assessed PS after understanding clinical interpretation of the NRS.

Methods:

This prospective study was registered after approval from our hospital ethics board. Sample size estimated for the trial was 360 patients. All postoperative patients were recruited after informed consent. Patients having prolonged stay in Intensive Care Unit (more than 48 h), or those who underwent emergency surgeries were excluded. During Acute Pain Service (APS) rounds, patients were asked to rate their PS on the NRS. This was followed by a briefing about the clinical interpretation of the scale, and the patients were asked to re score their pain using the same scale. The change in pain severity was compared using Chi-square test.

Results:

Following explanation, a change in severity was seen for PS at rest [X² (9, N- 360) = 441, P < 0.001] and at movement [X² (9, N- 360) = 508, P < 0.001]. Overall, a change in PS severity was seen in 162 patients (45%). A decrease and an increase in the severity of pain was seen in 119 and 41 patients respectively.

Conclusion:

Explaining the clinical interpretation of PS on a NRS does lead to a change in patients’ self-assessed PS.

Pain drawings as a diagnostic tool for the differentiation between two pain-associated rare diseases (Ehlers-Danlos-Syndrome, Guillain-Barré-Syndrome)

Background

The diagnosis of rare diseases poses a particular challenge to clinicians. This study analyzes whether patients’ pain drawings (PDs) help in the differentiation of two pain-associated rare diseases, Ehlers-Danlos Syndrome (EDS) and Guillain-Barré Syndrome (GBS).

Method

The study was designed as a prospective, observational, single-center study. The sample comprised 60 patients with EDS (3 male, 52 female, 5 without gender information; 39.2 ± 11.4 years) and 32 patients with GBS (10 male, 20 female, 2 without gender information; 50.5 ± 13.7 years). Patients marked areas afflicted by pain on a sketch of a human body with anterior, posterior, and lateral views. PDs were electronically scanned and processed. Each PD was classified based on the Ružička similarity to the EDS and the GBS averaged image (pain profile) in a leave-one-out cross validation approach. A receiver operating characteristic (ROC) curve was plotted.

Results

60–80% of EDS patients marked the vertebral column with the neck and the tailbone and the knee joints as pain areas, 40–50% the shoulder-region, the elbows and the thumb saddle joint. 60–70% of GBS patients marked the dorsal and plantar side of the feet as pain areas, 40–50% the palmar side of the fingertips, the dorsal side of the left palm and the tailbone. 86% of the EDS patients and 96% of the GBS patients were correctly identified by computing the Ružička similarity. The ROC curve yielded an excellent area under the curve value of 0.95.

Conclusion

PDs are a useful and economic tool to differentiate between GBS and EDS. Further studies should investigate its usefulness in the diagnosis of other pain-associated rare diseases. This study was registered in the German Clinical Trials Register, No. DRKS00014777 (Deutsches Register klinischer Studien, DRKS), on 01.06.2018.

Viscum pleurodesis is as effective as talc pleurodesis and tends to have less adverse effect

PURPOSE

Many patients diagnosed with advanced cancer have malignant pleural effusion that does not respond to chemotherapy or radiation therapy. These patients often have respiratory symptoms, especially dyspnea. In order to relieve these symptoms, various procedures including chemical pleurodesis have been performed. Although talc is the most widely used and effective sclerosing agent, there it has various adverse effects. The objective of this study was to determine whether Viscum (ABNOVA Viscum® Fraxini Injection, manufactured by ABNOVA GmbH, Germany) could be used as an agent to replace talc in clinical practice.

METHODS

Data of 56 patients with malignant pleural effusion who received chemical pleurodesis after tube thoracostomy from January 2003 to December 2017 were retrospectively reviewed to analyze clinical course and response after pleurodesis with each agent.

RESULTS

After pleurodesis, changes in numeric rating scale (NRS) was 1.4 ± 1.6 in the talc group and 0.5 ± 1.5 in the Viscum group (p = 0.108). Changes in white blood cell counts after pleurodesis were 4154.8 ± 6710.7 in the talc group and 3487.3 ± 6067.7 in the Viscum group (p = 0.702). Changes in C-reactive protein (CRP) were 9.03 ± 6.86 in the talc group and 6.3 ± 7.5 in the Viscum group (p = 0.366). The success rate of pleurodesis was 93.3% in the talc group and 96% in the Viscum group (p = 0.225).

CONCLUSION

Viscum pleurodesis showed comparable treatment results with talc pleurodesis while its adverse effects such as chest pain and fever tended to be relatively weak.

"Asking Is Never Bad, I Would Venture on That": Patients' Perspectives on Routine Pain Screening in VA Primary Care

OBJECTIVE

Screening for pain in routine care is one of the efforts that the Veterans Health Administration has adopted in its national pain management strategy. We aimed to understand patients' perspectives and preferences about the experience of being screened for pain in primary care.

DESIGN

Semistructured interviews captured patient perceptions and preferences of pain screening, assessment, and management.

SUBJECTS

We completed interviews with 36 patients: 29 males and seven females ranging in age from 28 to 94 years from three geographically distinct VA health care systems.

METHODS

We evaluated transcripts using constant comparison and identified emergent themes.

RESULTS

Theme 1: Pain screening can "determine the tone of the examination"; Theme 2: Screening can initiate communication about pain; Theme 3: Screening can facilitate patient recall and reflection; Theme 4: Screening for pain may help identify under-reported psychological pain, mental distress, and suicidality; Theme 5: Patient recommendations about how to improve screening for pain.

CONCLUSION

Our results indicate that patients perceive meaningful, positive impacts of routine pain screening that as yet have not been considered in the literature. Specifically, screening for pain may help capture mental health concerns that may otherwise not emerge.

Reliability, validity, and responsiveness of multidimensional pain assessment tools used in postoperative adult patients: a systematic review of measurement properties

OBJECTIVE

The objective of this systematic review was to synthesize the best available evidence relating to the measurement properties of the multidimensional pain assessment tools used to assess postoperative pain in adults.

INTRODUCTION

Pain is a common and poorly managed occurrence in patients during the postoperative period. Currently, postoperative pain is usually evaluated with assessment tools that measure one dimension of pain, namely pain intensity, resulting in inadequate management of postoperative pain. It is important to understand the complex nature of pain by considering all dimensions for optimal postoperative pain management. Systematic, robust evidence is lacking regarding the most psychometrically reliable and valid multidimensional pain assessment tool for adult postoperative patients.

INCLUSION CRITERIA

This systematic review considered all study types for inclusion. Studies were considered if they assessed the measurement properties of a multidimensional pain assessment tool in adult postoperative patients within two weeks post-surgery. The outcomes included measurement of at least one of the psychometric properties, including reliability, validity, and responsiveness.

METHODS

A three-step search strategy was undertaken, including a search of the MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and CINAHL databases performed in October 2019. We also searched Dissertation Abstracts International, ProQuest Dissertations and Theses, MedNar, and ClinicalTrials.gov to identify unpublished studies. The title and abstracts of the studies were reviewed by two independent reviewers against the inclusion/exclusion criteria. The methodological quality of the potential studies was assessed independently by three reviewers using the COSMIN checklist.

RESULTS

Seventeen studies involving five multidimensional postoperative pain assessment tools were included in the review: American Pain Society Pain Outcomes Questionnaire-Revised; Brief Pain Inventory; Houston Pain Outcome Instrument; McGill Pain Questionnaire; and the Quality Improvement in Postoperative Pain Management Postoperative Pain Questionnaire. The two most commonly used tools were the Brief Pain Inventory and the American Pain Society Pain Outcomes Questionnaire-Revised, which were assessed in six studies each. The included studies mainly reported internal consistency reliability, with four of the five identified tools demonstrating high Cronbach's alpha values ranging from 0.72 to 0.92. However, the Houston Pain Outcome Instrument demonstrated mixed findings, with eight of the nine subscales having moderate to high reliability while the expectations about pain subscale had poor reliability (α=0.003).

CONCLUSIONS

This review provides much needed information about the current tools used in many clinical, educational, and research settings. Of the five tools included in this review, the Brief Pain Inventory demonstrated strong evidence of psychometric validity and is recommended for use in assessing postoperative pain. Further psychometric validation of multidimensional postoperative pain assessment tools with emphasis on responsiveness and measurement error is required in order to accurately assess the minimal clinically important difference in postoperative pain outcomes.

Postoperative Pain after Treatment Using the GentleWave System: A Randomized Controlled Trial

INTRODUCTION

Cleaning and shaping are necessary to allow for the delivery of irrigants and medicaments to the apical third of the canal. Standard treatment irrigation generally uses a conventional needle and some frequency of sonic activation. The GentleWave System (GWS; Sonendo, Inc, Laguna Hills, CA) combines irrigant delivery with multisonic activation. This randomized clinical trial aimed to determine if the GWS significantly decreases the incidence and intensity of postoperative pain.

METHODS

Patients used a numeric rating scale to record their pain level at the 6-hour time point before treatment. All participants were randomly divided into 2 groups and were blind to the treatment they received. The standard (control) group received endodontic treatment with conventional side-vented needle irrigation and ultrasonic activation. The second group received treatment with the GWS. Following treatment, patients used a numeric rating scale to record their pain level at 6, 24, 72, and 168 hours.

RESULTS

In the standard treatment group, 72.2% of patients experienced at least 1 occurrence of postoperative pain, whereas in the GWS group, 83.3% of patients experienced at least 1 occurrence of postoperative pain. The highest pain intensity level for both treatments occurred at the 6-hour posttreatment time point. All pain decreased with time after the 6-hour posttreatment time point (P < 1.237e-7).

CONCLUSIONS

There was no significant difference in the incidence or intensity of postoperative pain after either treatment group. However, both groups reported a statistically significant decrease in pain with time.

The association of patients' daily summarized self-rated "real-time" pain scores with physical recovery after major surgery - A repeated measurement design

Aim

To determine the associations of patients' documented self-rated pain with self-rated early postoperative physical recovery.

Design

Observational with repeated measures.

Methods

General and orthopaedic inpatients (N = 479) were during the period 2012-2015 screened for pain. Individual daily median pain scores at rest and during activity were based on 4-9 self-ratings on postoperative days 1 and 2, using the Numeric Rating Scale. Nine items reflecting physical recovery from the "Postoperative Recovery Profile" were used in a questionnaire.

Results

Associations between median pain scores on postoperative day 1 and physical recovery (fatigue, sleeping difficulties, bladder function, mobilization, muscle weakness and personal hygiene) the same day were found. Additionally, associations were found between median pain scores on day 1 and physical recovery (fatigue, sleeping difficulties, mobilization and muscle weakness) on day 2.

Association of Early Postoperative Pain Trajectories With Longer-term Pain Outcome After Primary Total Knee Arthroplasty

IMPORTANCE

Studies to date have not comprehensively examined pain experience after total knee arthroplasty (TKA). Discrete patterns of pain in this period might be associated with pain outcomes at 6 to 12 months after TKA.

OBJECTIVES

To examine patterns of individual post-TKA pain trajectories and to assess their independent associations with longer-term pain outcome after TKA.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study combined data from a national US TKA cohort with ancillary pain severity data at 2 weeks and 8 weeks after the index TKA using a numeric rating scale. All participants received primary, unilateral TKA within the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR) national network of community sites in 22 states or at the lead site (University of Massachusetts Medical School). Participants had a date of surgery between May 1, 2013, and December 1, 2014. The data analysis was performed between January 13, 2015, and July 5, 2016.

EXPOSURES

Pain trajectories in the postoperative period (8 weeks).

MAIN OUTCOMES AND MEASURES

Index knee pain at 6 months after TKA using the Knee Injury and Osteoarthritis Outcome Score (KOOS) pain scale. Group-based trajectory methods examined the presence of pain trajectories in the postoperative period (8 weeks) and assessed whether trajectories were independently associated with longer-term pain (6 months).

RESULTS

The cohort included 659 patients who underwent primary TKA with complete data at 4 points (preoperative, 2 weeks, 8 weeks, and 26 weeks). Their mean (SD) age was 67.1 (8.0) years, 64.5% (425 of 659) were female, the mean (SD) body mass index (calculated as weight in kilograms divided by height in meters squared) was 30.77 (5.66), 94.5% (613 of 649) were white, and the mean (SD) preoperative 36-Item Short Form Health Survey physical component summary and mental component summary scores were 34.1 (8.2) and 53.8 (11.4), respectively. Two pain trajectory subgroups were identified at 8 weeks after TKA: patients who experienced fast pain relief in the first 8 weeks after TKA (fast pain responders, composing 72.4% [477 of 659] of the sample) and patients who did not (slow pain responders, composing 27.6% [182 of 659] of the sample). After adjusting for patient factors, the pain trajectory at 8 weeks after TKA was independently associated with the mean KOOS pain score at 6 months, with a between-trajectory difference of -11.3 (95% CI, -13.9 to -8.7).

CONCLUSIONS AND RELEVANCE

The trajectory among slow pain responders at 8 weeks after surgery was independently associated with improved but greater persistent index knee pain at 6 months after TKA compared with that among fast pain responders. Early identification of patients with a trajectory of slow pain response at 8 weeks after TKA may offer an opportunity for interventions in the perioperative period to potentially improve the long-term pain outcomes after TKA.

The effect of the application of cold on hematoma, ecchymosis, and pain at the catheter site in patients undergoing percutaneous coronary intervention

Objective

This study was conducted to determine the effect of the application of cold on hematoma, ecchymosis, and pain in patients undergoing percutaneous coronary intervention.

Methods

It is a quasi-experimental study with a control group. A total of 200 patients (100 in the control group and 100 in the experimental group) were included in the research. In the experimental group, a cold pack was applied to the bottom of the sandbag for the first 15 min after withdrawing the femoral arterial catheter. Both groups were assessed and followed up at the first 15th minute and 4th, 48th and 72 nd h.

Results

After the femoral arterial catheter was withdrawn, ecchymosis and hematoma were smaller and pain was less in the experimental group at the catheter entry site compared to the control group, and the difference was statistically significant (P < 0.01).

Conclusion

It was determined that the application of cold reduced the formation of hematomas, ecchymoses and pain in patients after the withdrawal of the femoral arterial catheter.

Reliability, validity and generalizability of multidimensional pain assessment tools used in postoperative adult patients: a systematic review protocol

OBJECTIVE

The objective of this review is to evaluate the measurement properties of multidimensional pain assessment tools for postoperative pain in adults.

INTRODUCTION

Effective postoperative pain management increases patient safety and satisfaction, and reduces healthcare costs. The most commonly used postoperative pain assessment tools only evaluate pain intensity, which is only one aspect of the sensory dimension of pain. Pain is a subjective phenomenon, and variability exists among patients. Efforts are underway to incorporate multidimensional assessment tools for postoperative pain assessment in clinical practice.

INCLUSION CRITERIA

Eligible studies will include postoperative patients aged 18 years and older from all surgical disciplines. Studies evaluating multidimensional assessment instruments for the measurement of postoperative pain during the first two weeks following surgery will be considered. Studies will include the following measurement properties of assessment tools as outcomes: reliability, validity and generalizability.

METHODS

MEDLINE, CINAHL, Embase, PsycINFO and Cochrane Trials (CENTRAL) will be searched, as well as ClinicalTrials.gov and multiple gray literature sources. There will be no limitations on publication date. Titles and abstracts will be screened by independent reviewers for inclusion. The full text of selected papers will be retrieved and assessed against the inclusion criteria. Two independent reviewers will assess papers for methodological quality using the COSMIN checklist, and papers with poor scores on relevant items will be excluded. Data will be extracted by two independent reviewers using a standardized data extraction tool. Statistical pooling will be performed, if possible.

Frailty is associated with pain and cognitive function in older people in post-acute care settings

BACKGROUND

To describe pain, cognitive function, and frailty of older people in post-acute care settings and examine the association between the three elements.

METHODS

This cross-sectional study involved 142 participants from a rehabilitation ward and a geriatric day centre. Pain, cognitive function and frailty were assessed using Brief Pain Inventory, Abbreviated Mental Test, and 5-item Frail Scale respectively.

RESULTS

Participants were mostly women (51.7%) with a mean age of 76.5 (SD 7.8). Mean scores for pain, cognition, and frailty were 9.0 ± 1.0, 4.0 ± 2.8, and 2.2 ± 1.2, respectively. Cognition had a significant inverse association with frailty (β = -0.160, p = 0.047), and pain had a significant positive association with frailty (β = 5.122, p < 0.001). This linear regression model explained a variance of 0.269.

CONCLUSIONS

The study demonstrated the association between pain, cognitive function, and frailty. In predicting frailty, however, more studies are required to determine the predictive value and cut-off points for pain and cognitive measures.

Listening to Patients' Voices: Workarounds Patients Use to Construct Pain Intensity Ratings

This study analyzed patients' perspectives about a measure of current, usual, and extreme pain and a measure of activity-related pain. Thirty-one patients with osteoarthritis participated in focus groups. Researchers completed thematic analysis of transcripts using coding software and an inductive approach. Three emerging themes were that many factors affected patients' perceptions and ratings of pain intensity, patients used different approaches to construct pain ratings, and patients interpreted maximal response anchors differently. Particularly, novel findings were that patients evaluated pain fluctuation, location, duration, and quality when constructing pain intensity ratings. Also, activity items helped patients to remember pain and provided a valued context for communicating pain experiences. However, the activities needed to be sufficiently described and personally relevant. These findings further clarify the challenges patients face and the workarounds they use when rating pain intensity. The patients' suggestions for improved administration methods and items warrant future investigation.

The perception of procedural vascular laser pain and discrepancies amongst patients, physicians, and industry

BACKGROUND

The inherent subjectivity of pain perception makes pre-procedural pain counseling especially challenging. Setting the wrong pain expectations will negatively impact the patient's experience and affect their physiologic and emotional state. Best practices for sourcing pain related information about a given procedure, however, remains understudied. This retrospective study explores the accuracy of industry materials for describing procedural pain in a clinical trial when compared to subject reported pain scores from the same clinical trial.

METHODS

Median and mode pain scores were collected from the data of a past clinical trial investigating a dual wavelength laser used for 4 different types of treatments. Industry provided materials were reviewed to ascertain language regarding procedural pain. The principal investigator was interviewed about setting pain expectations during the trial. Subject-reported pain scores and verbal pain descriptors were transferred to validated pain scales, the Numerical Rating Scale and the Verbal Rating Scale, for comparison.

RESULTS

A total of 85 procedural pain scores were collected from 22 subject charts. The average procedural pain scores for 3 of 4 treatment types reported by subjects were translated to entirely different verbal and numerical categories of pain than that described by industry materials.

CONCLUSIONS

Industry materials failed to capture the range of procedural pain scores reported by subjects for 3 of 4 treatment types in a clinical trial setting. When counseling patients on procedural pain, physicians should take extra care to not mislead patients and cause undue physiological or emotional stress.

Chemical Pleurodesis Using Doxycycline and Viscum album Extract

Background

In chemical pleurodesis for managing pulmonary air leak, tetracycline derivatives are commonly used, and their effectiveness has been established in many studies. Recently, a Viscum album extract was used in chemical pleurodesis. We compared the effects of V. album with those of a tetracycline derivative (doxycycline) to demonstrate the therapeutic effectiveness of the V. album extract in chemical pleurodesis for managing pulmonary air leak.

Methods

Between October 2010 and October 2016, chemical pleurodesis was performed using doxycycline in 40 patients and the V. album extract in 37 patients. Thirty-three patients were in the postoperative state after pulmonary resection, and 44 patients suffered from spontaneous pneumothorax.

Results

No statistically significant difference in the success rate was observed between the 2 groups (V. album extract and doxycycline). In both groups, chest pain was the most common complication. More patients in the doxycycline group complained of severe chest pain (42.1% vs. 13.5%, p=0.006). In the V. album extract group, 24.3% of the patients required a chest tube to drain the pleural effusion after cessation of the air leak (doxycycline group: 5%, p=0.022). Further, the amount of pleural effusion drained on the day after the last chemical pleurodesis in the V. album extract group was greater than that in the doxycycline group (162.2±170.2 mL vs. 97.0±77.2 mL, p=0.032). All patients were discharged from the hospital without complications after pleural effusion drainage.

Conclusion

Considering that treatment using the V. album extract was less painful, V. album might be a feasible option for chemical pleurodesis. However, pleural effusion should be monitored carefully when using V. album extract for treating patients suffering from air leak.

[Patient perspective of pain assessment by nursing personnel : Qualitative cross-sectional study on use of the NRS]

BACKGROUND

The assessment of pain as a part of adequate pain management is an integral part of the clinical routine. Much research has been carried out concerning use, relevance and validity of different assessment scales; however, patients' perspective of pain assessment has not yet been studied in Germany. The aim of the present study was to collate patients' experiences regarding pain assessment based on the numeric rating scale (NRS).

MATERIALS AND METHODS

The survey was conducted as a qualitative cross-sectional study based on the grounded theory methodology by Strauss and Corbin. Interviews were carried out with 15 surgery patients. A semi-structured interview guide was used to collect data. The structured analysis was performed using MAXQDA. Data were first openly coded followed by thematic coding. Finally, the codes were compared and linked via axial coding. The data analysis was completed by object-related theory construction.

RESULTS

Patients have only vague ideas about the consequences of their responses. They experience pain assessment as a nursing routine, which was perceived as being largely insignificant for therapy. On reflection patients sporadically saw the scaling as being a problem as a reference value is missing and the quality of pain as well as the procedure fail the predetermined measurement system. Metric values not only reflect the level of pain but are also intentionally used to enable targeted measures, e.g. discharge from hospital.

CONCLUSION

The survey results indicate that the validity of the measurement and therefore the indicated therapy is influenced by subjective concepts. Patients themselves suggested alternatives for detecting the quality of pain. The data should be replicated in larger samples and also take possible influences on the perception of the assessment into account.

Pain among hospitalized older people with heart failure and their preparation to manage this symptom on discharge: a descriptive-observational study

Globally, heart failure (HF) is one of the major health issues faced by many older people. It causes significant symptom burden that requires ongoing management. This paper reports on a descriptive-observational study undertaken to: (1) describe the prevalence of pain and analgesic prescription usage in hospitalized older HF patients; (2) determine the degree to which these patients are provided with a pain self-management strategy prior to discharge; and (3) determine if the patients' pain self-management strategy has been detailed in the discharge summary. A total of 122 older HF patients were included in this study. Results indicated that moderate to severe pain (Numeric Rating Scale score ≥4) is experienced by a substantial number of older people hospitalized with HF. There is little documented evidence that older people are provided with adequate analgesic prescriptions and the instructions required to effectively manage their pain on discharge to the community.

Postoperative hyperalgesia does not predict persistent post-sternotomy pain; observational study based on clinical examination

BACKGROUND

Persistent post-sternotomy pain is a common problem, but the risk of developing it varies among patients. We sought to find out whether the risk of persistent post-sternotomy pain could be predicted by measuring the area of acute sensory dysfunction around the sternotomy wound. The secondary aim was to determine risk factors for persistent post-sternotomy pain.

PATIENTS AND METHODS

Hundred patients who were scheduled to undergo elective coronary artery bypass surgery were recruited to the study. Patients were excluded if they had undergone previous cardiac surgery or if they lacked co-operation. Preoperative pain scores were determined and the patients filled in questionnaires about depression, anxiety, and pain. The area of sensory dysfunction around the sternotomy wound was assessed by pin prick on postoperative day 4. The presence of persistent post-sternotomy pain was determined at a follow-up evaluation at 4-6 months after surgery.

RESULTS

The sizes of the area of hyperalgesia or overall sensory dysfunction were not associated with persistent post-sternotomy pain. Independent risk factors for persistent post-sternotomy pain were found to be smoking and high pain score on postoperative day 1. The prevalence of persistent post-sternotomy pain in our study population was 38% analyzed by only the questionnaire and 15% according to the clinical examination.

CONCLUSION

Measuring the area of hyperalgesia in the acute phase does not give any additional information on the risk of developing a persistent post-sternotomy pain. We do thus not recommend measuring the area in this particular group of patients. Evaluation of pain by only a questionnaire risks to overestimate the presence of persistent post-sternotomy pain as compared to clinical examination.

Patients' experiences and actions when describing pain after surgery--a critical incident technique analysis

BACKGROUND

Postoperative pain assessment remains a significant problem in clinical care despite patients wanting to describe their pain and be treated as unique individuals. Deeper knowledge about variations in patients' experiences and actions could help healthcare professionals to improve pain management and could increase patients' participation in pain assessments.

OBJECTIVE

The aim of this study was, through an examination of critical incidents, to describe patients' experiences and actions when needing to describe pain after surgery.

METHODS

An explorative design involving the critical incident technique was used. Patients from one university and three county hospitals in both urban and rural areas were included. To ensure variation of patients a strategic sampling was made according to age, gender, education and surgery. A total of 25 patients who had undergone orthopaedic or general surgery was asked to participate in an interview, of whom three declined.

FINDINGS

Pain experiences were described according to two main areas: "Patients' resources when in need of pain assessment" and "Ward resources for performing pain assessments". Patients were affected by their expectations and tolerance for pain. Ability to describe pain could be limited by a fear of coming into conflict with healthcare professionals or being perceived as whining. Furthermore, attitudes from healthcare professionals and their lack of adherence to procedures affected patients' ability to describe pain. Two main areas regarding actions emerged: "Patients used active strategies when needing to describe pain" and "Patients used passive strategies when needing to describe pain". Patients informed healthcare professionals about their pain and asked questions in order to make decisions about their pain situation. Selfcare was performed by distraction and avoiding pain or treating pain by themselves, while others were passive and endured pain or refrained from contact with healthcare professionals due to healthcare professionals' large work load.

Healthcare professionals' descriptions of care experiences and actions when assessing postoperative pain - a critical incident technique analysis

BACKGROUND

Pain is a common postoperative symptom, and length of hospital stay after surgery is short which highlights the importance of pain assessments. Experiences of assessing pain are mainly described from the perspective of nurses. In postoperative care, enrolled nurses and physicians also assess pain. It is therefore important to take note of their experiences to improve postoperative pain assessments.

OBJECTIVES

The aim of this study was, through considering critical incidents, to describe care experiences and actions taken by healthcare professionals when assessing postoperative pain.

METHODS

An explorative design employing critical incidents technique analysis was used. A total of 24 strategically selected enrolled nurses, nurses and physicians employed at orthopaedic or general surgery wards in four Swedish hospitals were interviewed. The intention was to reach variation in age, sex, profession and professional experience.

FINDINGS

In pain assessments, patient-related facilitators were patients' verbal and emotional expressions including pain ratings, while lack of consistency with observed behaviours was a barrier. Clinical competence, continuity in care and time were healthcare-related facilitators. The actions healthcare professionals took were gathering facts about patients' pain manifestations and adapting to patients' communication abilities. Patient observations, either passive or active were used to confirm or detect pain. Collaboration between healthcare professionals, including consultations with pain experts, social workers and relatives, strengthened understanding of pain.

CONCLUSIONS

Communication skills and working conditions have an impact on performance of pain assessment. Patient comfort without compromising safety is reached by including healthcare professionals' dissimilar responsibilities when collecting patients' and relatives' perspectives on current pain.

Postoperative patients' perspectives on rating pain: A qualitative study

BACKGROUND

In postoperative pain treatment patients are asked to rate their pain experience on a single uni-dimensional pain scale. Such pain scores are also used as indicator to assess the quality of pain treatment. However, patients may differ in how they interpret the Numeric Rating Scale (NRS) score.

OBJECTIVES

This study examines how patients assign a number to their currently experienced postoperative pain and which considerations influence this process.

METHODS

A qualitative approach according to grounded theory was used. Twenty-seven patients were interviewed one day after surgery.

RESULTS

Three main themes emerged that influenced the Numeric Rating Scale scores (0-10) that patients actually reported to professionals: score-related factors, intrapersonal factors, and the anticipated consequences of a given pain score. Anticipated consequences were analgesic administration-which could be desired or undesired-and possible judgements by professionals. We also propose a conceptual model for the relationship between factors that influence the pain rating process. Based on patients' score-related and intrapersonal factors, a preliminary pain score was "internally" set. Before reporting the pain score to the healthcare professional, patients considered the anticipated consequences (i.e., expected judgements by professionals and anticipation of analgesic administration) of current Numeric Rating Scale scores.

CONCLUSIONS

This study provides insight into the process of how patients translate their current postoperative pain into a numeric rating score. The proposed model may help professionals to understand the factors that influence a given Numeric Rating Scale score and suggest the most appropriate questions for clarification. In this way, patients and professionals may arrive at a shared understanding of the pain score, resulting in a tailored decision regarding the most appropriate treatment of current postoperative pain, particularly the dosing and timing of opioid administration.

Minimally invasive palliative procedures in oncology: a review of a multidisciplinary collaboration

INTRODUCTION

Minimally invasive palliative procedures (MIPPs) are sometimes considered step 4 of the World Health Organization's three-step ladder. A case conference has been created at the BC Cancer Agency to facilitate access to MIPPs for advanced cancer patients with severe pain not responding to conventional analgesics. The twice monthly conference discusses referrals for pain control procedures and reviews imaging, with palliative care, musculoskeletal interventional radiology, radiation oncology, medical oncology, and anesthesia experts in attendance.

STUDY OBJECTIVES

The aims of this study are: first, to determine the benefit to patients from the procedures recommended by the case conference, and second, to explore the impact of the case conference on clinical decision-making.

METHODS

A retrospective review of electronic charts of all cancer patients referred to the MIPP case conference between December 20, 2011 and June 25, 2013.

RESULTS

There were 103 referrals, resulting in 69 procedures performed among 63 patients. Over 80 % of procedures provided analgesic benefit. Pain scores fell across all categories post-procedure. Mean worst pain scores fell from 8.1 ± 1.4 to 4.6 ± 2.8 (P < 0.001). Patient function, mobility, and symptoms measured by the Edmonton Symptom Assessment System also improved post-procedure. At time of abstract submission, 37/63 (58.7 %) patients had died, and the mean survival post-procedure was 200 days. The documented rate of major adverse events attributable to MIPPs was 2/69 (2.9 %).

CONCLUSIONS

MIPPs are valuable treatment options in patients with severe cancer pain despite use of appropriate step 3 WHO ladder medications. The case conference facilitates excellent communication and sharing of expertise, ensuring optimal patient care.