Validation of the Individualized Numeric Rating Scale (INRS): a pain assessment tool for nonverbal children with intellectual disability

Individualized Numeric Rating Scale to Assess Pain in Critically Ill Children With Neurodevelopmental Disabilities

BACKGROUND

Pain is a significant burden for children with neurodevelopmental disabilities but is difficult for clinicians to identify. No pain assessment tools for children with neurodevelopmental disabilities have been validated for use in pediatric intensive care units. The Individualized Numeric Rating Scale (INRS) is an adapted 0-to-10 rating that includes parents' input on their child's pain indicators.

OBJECTIVES

To evaluate the reliability, validity, and feasibility and acceptability of use of the INRS for assessing pain in critically ill children with neurodevelopmental disabilities.

METHODS

This observational study enrolled critically ill patients with neurodevelopmental disabilities aged 3 to 17 years in 2 pediatric intensive care units at a children's hospital using a prospective repeated-measures cohort design. Structured parent interviews were used to populate each patient's INRS. Bedside nurses assessed pain using the INRS throughout the study. The research team completed independent INRS ratings using video clips. Participating parents and nurses completed feasibility and acceptability surveys. Psychometric properties of the INRS and survey responses were evaluated with appropriate statistical methods.

RESULTS

For 481 paired INRS pain ratings in 34 patients, interrater reliability between nurse and research team ratings was moderate (weighted κ = 0.56). Parents said that creating the INRS was easy, made them feel more involved in care, and helped them communicate with nurses.

CONCLUSIONS

The INRS has adequate measurement properties for assessing pain in critically ill children with neurodevelopmental disabilities. It furthers goals of patient- and family-centered care but may have implementation barriers.

Effectiveness and safety of motion-style acupuncture treatment using traction for inpatients with acute low back pain caused by a traffic accident: A randomized controlled trial

BACKGROUND

Musculoskeletal symptoms, such as neck pain and low back pain (LBP) are common after a traffic accident (TA). While motion-style acupuncture treatment (MSAT) is effective in relieving pain, MSAT using traction (T-MSAT) has rarely been studied, and evidence for its efficacy and safety is lacking. To address this gap, this study aimed to assess the effectiveness and safety of T-MSAT for pain and functional disturbances in patients with acute LBP caused by a TA.

METHODS

This two-armed, parallel, assessor blinded randomized controlled trial, conducted at Jaseng Hospital of Korean Medicine, included 100 patients with acute LBP occurring within 1 week of a TA. The participants were randomly allocated (1:1 ratio) to receive either combined T-MSAT and integrative Korean medicine treatment (IKMT) or only conventional IKMT, applied for 3 consecutive days after admission. The primary outcome was the difference between numerical rating scale (NRS) scores for LBP at baseline and after treatment completion on day 4 after admission.

RESULTS

At the primary endpoint, the difference in NRS scores for LBP between the T-MSAT and control groups was 0.94 (95% confidence interval [CI] 0.40-1.48). The T-MSAT group showed a significantly lower NRS score for LBP than the control group. Differences in visual analogue scale (VAS) scores between the T-MSAT and control groups were significant at baseline and discharge. The area under the curve of the VAS score showed a significant difference (-46.86 [95% CI -85.13 to -8.59]), indicating faster pain reduction in the T-MSAT group than in the control group. Recovery (30% pain reduction) was achieved more rapidly in the T-MSAT group than in the control group (log-rank test P = .005). Meanwhile, the NRS, VAS, Oswestry disability index, and quality of life scores at discharge or at the 12-week follow-up showed no significant difference. The rates of mild adverse events (AEs) were comparable between the groups. No severe AEs were reported, and none of the AEs were associated with the clinical trial.

CONCLUSIONS

T-MSAT combined with IKMT is a safe treatment that can effectively and quickly reduce initial pain in patients with LBP.

Safety and effectiveness of integrative Korean medicine for the management of patients sustaining injuries in traffic accidents during pregnancy: A retrospective chart review and questionnaire survey

The number of traffic accidents (TAs) is rising each year, and the severity of injuries can vary. Many people experience limitations in activities of daily living following TAs, affecting their quality of life. In pregnant women, even simple injuries caused by a TA could lead to unfavorable obstetric outcomes. Thus, we conducted a retrospective chart review and follow-up questionnaire survey to assess the safety and effectiveness of integrative Korean medicine (KM) treatment for pregnant women injured in TAs. To assess integrative KM effectiveness, the numeric rating scale (NRS) for TA-related symptoms, neck disability index (NDI) score, Oswestry disability index (ODI) score, shoulder pain and disability index score, Western Ontario and McMaster Universities Arthritis Index score, EuroQol 5-dimension 5-level (EQ-5D-5L) score, and patient global impression of change score were investigated for pregnant women injured in TAs. Additionally, for safety evaluation, obstetric and neonatal outcomes, as well as symptoms related to pregnancy, were assessed. At the end of treatment and follow-up, there were significant reductions in NDI and ODI scores, as well as NRS for neck pain, lower back pain, and headache, compared to scores at baseline. EQ-5D-5L scores significantly increased. A follow-up of 50 patients showed no major differences in obstetric and neonatal outcomes compared to the typical outcomes that occur in pregnant women and neonates. Major improvements were observed in the symptoms of patients who underwent integrative KM treatment after being injured in TAs. The symptoms occurred at a rate similar to those in typical pregnant women, while causality with integrative KM treatment was assessed to be unlikely or unclear. Therefore, integrative KM treatment may be considered an alternative treatment option for pregnant women who currently have limited treatment options.

A systematic review of self and observer assessment of pain and related functioning in youth with brain-based developmental disabilities

ABSTRACT

Pain experiences of youth with brain-based developmental disabilities are often overlooked and/or misinterpreted, increasing the risk for poor or inadequate pain assessment and management. Ample measures exist to assess acute and chronic pain, yet their utility and frequency of use in youth with brain-based developmental disabilities is unclear and available measures do not have strong measurement properties for this diverse group. This systematic review identified the scope of self-reported and observer-reported pain assessment in studies of youth (aged 3-24 years) with brain-based developmental disabilities (phase 1) and summarized other measures of pain-related functioning for acute and chronic pain (ie, physical, emotional, social, sleep, and quality of life, within the subset of quantitative studies focused primarily on pain, phase 2). A comprehensive search for English-language studies was conducted in August 2022 in Web of Science, CINAHL, MEDLINE, Cochrane CENTRAL, EMBASE, and APA PsychINFO (PROSPERO registration: CRD42021237444). A total of 17,029 unique records were screened. Of the 707 articles included in phase 1, most assessed chronic pain (n = 314; 62.0%) and primarily used observer-report (n = 155; 31%) over self-report (n = 67; 13%). Of the 137 articles included in phase 2, other outcomes assessed alongside pain intensity included motor ability (16.8%), adaptive functioning (11%), quality of life (8%), pain interference (6.6%), mental health (5.8%), and communication ability (2.9%). Cerebral palsy was the most common population in both phase 1 (n = 343; 48.5%) and phase 2 (n = 83; 59.7%). This review provides a foundational understanding of pain assessment in brain-based developmental disabilities and highlights continued inequities in holistic pain assessment for this population.

The Efficacy and Feasibility of an Interoceptive Exposure Technique for Preventing the Transition From Subacute to Chronic Back Pain by Altering the Emotional Response to Pain: Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

Psychological factors such as stress, anxiety, mood, emotions, cognitive functioning, and pain behavior are relevant to the onset of pain and its continuation in the transition to chronic conditions. Subacute low back pain (LBP), a precursor to chronic LBP, is particularly poorly understood, and its relationships with psychological factors are understudied.

OBJECTIVE

We will conduct a study aiming to prevent the chronicity of subacute LBP by altering the emotional response to pain using an interoceptive exposure technique (IET). Considering the recent increase in knowledge about psychological risk factors, as well as recent findings in cognitive neuroscience regarding emotional and cognitive background factors in the LBP chronicity process, efforts should be made to discover effective preventive methods.

METHODS

We present a novel method aiming to prevent the transition from subacute to chronic back pain by altering the emotional response to pain using an IET. In this pilot randomized controlled trial, participants who are at a higher risk of LBP chronification due to the presence of a biomarker (ie, functional connectivity between the medial prefrontal cortex and nucleus accumbens) will be randomly assigned to the IET intervention group or control group A (treatment as usual). Participants who do not present with the biomarker will be assigned to control group B (treatment as usual) to assess how well this biomarker predicts the chronification of subacute LBP in this study population. Questionnaires measuring the pain experience and psychological distress will be used before the intervention, after the intervention (at 3 months), and at the 12-month follow-up.

RESULTS

This research project will combine 2 novel methods: a biomarker as the inclusion criterion and an IET as the intervention. The comparative study design enables evaluation of the efficacy of the IET, as well as replication of the biomarker's validity as a possible clinical screening method.

CONCLUSIONS

If found to be useful, the IET would offer a cost-effective and reasonable way to develop treatment for acute and subacute back pain conditions. Potential benefits include increased pain management and quality of life for the individual patient with the addition of a potentially useful functional pain management method at the societal level.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05450263; https://clinicaltrials.gov/ct2/show/NCT05450263.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/45701.

Are Primary Outcomes Really Primary? An Exploratory Cross-Sectional Nationwide Web-Based Survey Study for Outcomes Reflecting Real Symptoms and Needs of Patients with Lumbar Disc Herniation

As primary outcomes differ among clinical lumbar disc herniation (LDH) studies, this study aimed to explore outcomes reflecting real-world patient experiences through an exploratory questionnaire survey. Those diagnosed with LDH having radiating leg pain in South Korea in November of 2022 (N = 500) were administered a questionnaire including basic characteristics, disease onset, symptoms and severity, priority symptoms for improvement, and important treatment factors. Outcome measures included the identification of priority symptoms and disabilities. Most common symptoms were numbness in the leg (N = 435, 87.0%) and back pain (N = 406, 81.2%); most common disabilities were discomfort in sitting (N = 323, 64.6%) and lifting (N = 318, 63.6%). The highest priority symptom was back pain (N = 242, 48.4%). A satisfactory degree of symptom improvement was a decrease of at least 3 points on the numeric rating scale. The majority of respondents preferred improvement in disability over pain (N = 270, 55.8%), a stable effect over a rapid effect (N = 391, 78.2%), and safety over treatment efficacy (N = 282, 56.4%). Safety (N = 129, 25.8%) and cost (N = 111, 22.2%) were the most important treatment factors. Improvements in back pain, leg pain, sitting, and sleeping were prioritized, and safety, stable treatment effect, and functional recovery were desired. Clinical trials for LDH should be designed to reflect this real-world patient need. Further study to examine the patients' symptoms and needs in details is needed.

High Parental Concern in Children With Medical Complexity: An Early Indicator of Illness

OBJECTIVES

High concern about child's health is a common reason parents of children with medical complexity (CMC) seek care in emergency departments and hospitals. Factors driving parental concern are unknown. This study explores associations of parent's sociodemographic and child's clinical factors with high parental concern.

PATIENT AND METHODS

Secondary analysis of a pilot study of CMC and parents who used daily for 3 months MyChildCMC, a home monitoring app. Parents recorded their child's vital signs (temperature, heart rate, respiratory rate, oximetry), symptoms (pain, seizures, fluid intake/feeding, mental status), and oxygen use, and received immediate feedback. Parents rated their child's health concern on a 4-point Likert scale. Concern scores were dichotomized (3-4 = high, 1-2 = low) and modeled in a mixed-effects logistic regression to explore important associations.

RESULTS

We analyzed 1223 measurements from 24 CMC/parents, with 113 (9.24%) instances of high concern. Child factors associated with high parental concern were increased pain (odds ratio [OR], 5.10; 95% confidence interval [CI], 2.53-10.29; P < .01), increased oxygen requirement (OR, 28.91; 95% CI, 10.07-82.96; P < .01), reduced nutrition/fluid intake (OR, 71.58; 95% CI, 13.01-393.80; P < .01), and worsened mental status (OR, 2.15; 95% CI, 1.10-4.17, P = .02). No other associations existed.

CONCLUSIONS

Changes in CMC's clinical parameters were associated with high concern, which may be an early indicator of acute illness in CMC when it is the primary complaint. Monitoring and responding to high parental concerns may support CMC care at home.

Efficacy and Safety of Korean Herbal Medicine for Patients with Post-Accident Syndrome, Persistent after Acute Phase: A Pragmatic Randomized Controlled Trial

This is a pragmatic, two-armed, parallel, single-center, randomized controlled clinical trial for comparative evaluation between the effectiveness of integrated Korean medicine (IKM) and herbal medicine treatment with that of IKM monotherapy (control) for post-accident syndrome persistent after the acute phase. Participants were randomized into Herbal Medicine (HM, n = 20) and Control groups (n = 20) to receive the allocated treatment of 1-3 sessions/week for 4 weeks. Intention-to-treat analysis was conducted. The Difference of Numeric Rating Scale (NRS) change of overall post-accident syndromes from baseline to week 5 for the two groups was 1.78 (95% CI: 1.08-2.48; p < 0.001). Regarding secondary outcomes, a significant decrease compared to the baseline values was confirmed for NRS of musculoskeletal, neurological, psychiatric complaints and general symptoms of post-accident syndromes. In a survival analysis based on the recovery criteria of "patients with a reduction in the NRS of overall post-accident syndromes of ≥50%," the HM group showed a shorter time to recovery than the control group during the 17-week study period (p < 0.001 by the log-rank test). IKM combined with herbal medicine treatment significantly improved the quality of life by relieving somatic pain and alleviating the overall post-accident syndrome persistent after the acute phase; this effect was maintained for at least 17 weeks.

Validation of the Critical-Care Pain Observation Tool (CPOT) in pediatric patients undergoing orthopedic surgery

Background

Postoperative pain cannot be measured accurately among many children with intellectual and developmental disabilities, resulting in underrecognition or delay in recognition of pain. The Critical-Care Pain Observation Tool (CPOT) is a pain assessment tool that has been widely validated in critically ill and postoperative adults.

Aims

The objective of this study was to validate the CPOT for use with pediatric patients able to self-report and undergoing posterior spinal fusion surgery.

Methods

Twenty-four patients (10-18 years old) scheduled to undergo surgery were consented to this repeated-measure, within-subject study. To examine discriminative and criterion validation, CPOT scores and patients' self-reports of pain intensity were collected prospectively by a bedside rater before, during, and after a nonnociceptive and nociceptive procedure on the day following surgery. Patients' behavioral reactions were video recorded at the bedside and retrospectively viewed by two independent video raters to examine interrater and intrarater reliability of CPOT scores.

Results

Discriminative validation was supported with higher CPOT scores during the nociceptive procedure than during the nonnociceptive procedure. Criterion validation was supported with a moderate positive correlation between the CPOT scores and the patients' self-reported pain intensity during the nociceptive procedure. A CPOT cutoff score of ≥2 was associated with the maximum sensitivity (61.3%) and specificity (94.1%). Reliability analyses revealed poor to moderate agreement between bedside and video raters and moderate to excellent consistency within video raters.

Conclusions

These findings suggest that the CPOT may be a valid tool to detect pain in pediatric patients in the acute postoperative inpatient care unit after posterior spinal fusion.

Postsurgical pain assessment in children and adolescents with cerebral palsy: A scoping review

AIM

To investigate factors that influence the assessment of postoperative pain in children and adolescents with cerebral palsy (CP) and the tools available to determine pain intensity.

METHOD

The search was performed in January 2022 using six databases. Articles focused on paediatric patients with CP; we included instruments for postsurgical pain assessment in this population published in the last 11 years.

RESULTS

Eight of 441 studies were included. Males and females behave differently; their families can be called on to describe their pain responses. Seven instruments for pain assessment were identified: the Non-Communicating Children's Pain Checklist and its Postoperative Version; the Paediatric Pain Profile; the revised Face, Legs, Activity, Cry and Consolability (FLACC) pain scale; the Douleur Enfant San Salvador scale; the Pain Indicator for Communicatively Impaired Children; the University of Wisconsin Children's Hospital Pain Scale; and the Individualized Numeric Rating Scale.

INTERPRETATION

The revised FLACC pain scale is suited to postsurgical units because of its ease of use and the fact that parental collaboration is not required. More studies are needed to demonstrate the clinical utility of these scales in postsurgical units and the factors that influence pain assessment.

WHAT THIS PAPER ADDS

Families should be asked to collaborate when assessing pain in children and adolescents whenever possible. Larger studies that focus on the factors influencing pain assessment in this population are required.

The efficacy and safety of non-resistance manual therapy in inpatients with acute neck pain caused by traffic accidents: A randomized controlled trial

BACKGROUND

Neck pain and functional impairment are common complications of traffic accidents (TAs); however, the effects of manual therapy on these symptoms have rarely been studied in the literature. Thus, this randomized controlled trial aims to assess the effectiveness and safety of non-resistance manual therapy (NRT)-a treatment combining mobilization and pressure release techniques-on acute neck pain caused by TA.

METHOD

This study will use a two-armed, parallel, assessor-blinded randomized controlled trial design and will be conducted in the Daejeon Jaseng Hospital of Korean Medicine in South Korea. One hundred twenty patients will be recruited and randomized into an integrative Korean medicine treatment (IMKT) + NRT group and IMKT group in a 1:1 ratio. The primary outcome is a change in the numeric rating scale for neck pain immediately after treatment on hospital day 5 compared to those at baseline. The secondary outcomes are numeric rating scale for radiating arm pain, visual analogue scale for neck pain and radiating arm pain, cervical active range of motion, neck disability index, Patient Global Impression of Change, Short Form-12 Health Survey, and Posttraumatic Stress Disorder Checklist for DSM-5.

DISCUSSION

The findings of this study on the effectiveness and safety of NRT will be helpful for patients with TA-induced neck pain in clinical practice and will provide evidence for developing relevant healthcare-related policies.

TRIAL REGISTRATION

This protocol has been registered at Clinicaltrials.gov (NCT04660175).

Long-Term Follow-Up of Patients with Neck Pain Associated with Ossification of the Posterior Longitudinal Ligament Treated with Integrative Complementary and Alternative Medicine: A Retrospective Analysis and Questionnaire Survey

Purpose

Integrative Korean medicine treatment (KMT) is a conservative treatment approach for the ossification of the posterior longitudinal ligament (OPLL) in Korea; nonetheless, relevant studies focusing on KMT for OPLL are lacking. A multicenter retrospective analysis of patient medical records and a questionnaire survey were conducted to investigate the effectiveness of integrative KMT in patients with OPLL treated for neck pain.

Patients and Methods

A total of 78 inpatients radiologically diagnosed with OPLL and treated for neck pain at four Korean medicine hospitals from April 1, 2016, to December 31, 2019, were enrolled. The primary index was an improvement in the numeric rating scale (NRS) score for neck pain, whereas the secondary outcome indices were improvements in the NRS score for arm pain, neck disability index (NDI) score, and EuroQol 5-dimension 5-level (EQ-5D-5L) score.

Results

At discharge, the NRS score for neck pain, NRS score for arm pain, and NDI score decreased by 2.47 (95% confidence interval [CI], −2.81 to −2.14), 1.32 (95% CI, −1.73 to −0.91), and 16.02 (95% CI, −18.89 to −13.15), respectively, as compared with the scores at admission (p < 0.001). The EQ-5D-5L score increased by 0.12 (95% CI, 0.09 to 0.16) as compared with the score at admission (p < 0.001). This trend was also evident during follow-up. With respect to Patient Global Impression of Change evaluation, 33 (61.1%) patients claimed to have very much improved, whereas 17 (31.5%) patients reported to have much improved.

Conclusion

Inpatients with OPLL who received integrative KMT showed improvements in neck pain, arm pain, the NDI, and quality of life, which were retained throughout the follow-up period.

Nursing Care at End of Life in Pediatric Intensive Care Unit Patients Requiring Mechanical Ventilation

BACKGROUND

Parents' perceptions of critical care during the final days of their child's life shape their grief for decades. Little is known about nursing care needs of children actively dying in the pediatric intensive care unit (PICU).

OBJECTIVES

To examine associations between patient characteristics, circumstances of death, and nursing care requirements for children who died in the PICU.

METHODS

A secondary analysis of the data set from the Randomized Evaluation of Sedation Titration for Respiratory Failure trial was conducted.

RESULTS

This analysis included 104 children; 67 died after withdrawal of life-sustaining treatments; 21, after failed resuscitation; and 16, after brain death. Patients had a median age of 7.5 years, were cognitively appropriate, and were intubated for acute respiratory failure. Daily pain and sedation scores indicated patients' comfort was well managed (mean pain scores: modal, 0; peak, 2; mean sedation scores: modal, -2; peak, -1). Patients with longer PICU stays more often experienced pain and agitation on the day of death. Illness trajectory (acute, complex chronic condition, or cancer) was associated with pain scores (P = .04). Specifically, children with cancer had higher pain scores than children with acute illness trajectories (P = .01). Many patients (62%) had no change in critical care devices in their last days of life (median, 5 devices). Patterns of pain, sedation, comfort medications, and nursing care requirements did not differ by circumstances of death.

CONCLUSION

Children with cancer and longer PICU stays may need comprehensive comfort management. Invasive devices left in place during withdrawal of life support may have inhibited parents' ability to connect with their child. Future research should incorporate parents' perspectives.

Detection and assessment of postoperative pain in children with cognitive impairment: A systematic literature review and meta-analysis

Background and Objective

Children with cognitive impairment (CI) are at risk of experiencing pain. Several specific pain rating scales have been developed to date. Thus, the aim of this meta‐analysis was to estimate the degree of reliability of different pain assessment scales for the postoperative pain in children with CI.

Databases and Data Treatment

PubMed, Scopus and Web of Science databases were approached: all studies validating and/or using pain assessment tool in children (0–20 years) with CI published in English from the 1st of January 2000 to the 1st of January 2022 were included. Only studies reporting the interclass correlation coefficient (ICC) to evaluate the concordance between caregivers’ and external researchers’ scores were eligible.

Results

Twelve studies were included (586 children with CI, 60% males; weighted mean age 9.9 years – range 2–20). Five of them evaluated the Non‐Communicating Children's Pain Checklist‐Postoperative Version (NCCPC‐PV) scale whereas four the original and revised Face, Legs, Activity, Cry, Consolability (FLACC) scale. The analysis showed an overall ICC value of 0.76 (0.74–0.78) for the NCCPC‐PV scale, with a high heterogeneity index (I² = 97%) and 0.87 (0.84–0.90) for the FLACC scale, with a discrete I² index (59%).

Conclusions

The NCCPC‐PV and FLACC pain rating scales showed the strongest evidence for validity and reliability for assessing postoperative pain in children with CI. However, due to the high heterogeneity of the studies available, these results should not be considered conclusive.

Significance

This review is focused on the assessment of pain in children with CI in the postoperative period. Simplified observation‐based pain assessment tools that rely on evaluating non‐verbal expressions of pain should be recommended for children with difficulties to communicate their feelings. Even if there is a high degree of heterogeneity in clinical presentations among youth with CI, two tools (NCCPC‐PV and FLACC) have emerged as reliable and valid in this population.

Remote Monitoring of Patient- and Family-Generated Health Data in Pediatrics

In this article, we provide an overview of remote monitoring of pediatric PGHD and family-generated health data, including its current uses, future opportunities, and implementation resources.

A Pragmatic Approach to Assessment of Chronic and Recurrent Pain in Children with Severe Neurologic Impairment

The term “severe neurologic impairment” (SNI) is used to describe a group of disorders of the central nervous system which arise in childhood, resulting in motor impairment, cognitive impairment and medical complexity. As a result, much assistance is required with activities of daily living. Since these patients are often unable to self-report pain, or they may exhibit uncommon behaviors when suffering, pain manifestations may go unrecognized. In this article, the basic principles of how to approach pain in children with SNI are discussed.

A Systematic Review of Assessments and Interventions for Chronic Pain in Young Children With or at High Risk for Cerebral Palsy

BACKGROUND

Pain is common in children with cerebral palsy. The purpose of this systematic review was to evaluate the evidence regarding assessments and interventions for chronic pain in children aged ≤2 years with or at high risk for cerebral palsy.

METHODS

A comprehensive literature search was performed. Included articles were screened using PRISMA guidelines and quality of evidence was reviewed using best-evidence tools by independent reviewers. Using social media channels, an online survey was conducted to elicit parent preferences.

RESULTS

Six articles met criteria. Parent perception was an assessment option. Three pharmacologic interventions (gabapentin, medical cannabis, botulinum toxin type A) and 1 nonpharmacologic intervention were identified. Parent survey report parent-comfort and other nonpharmacologic interventions ranked as most preferable.

CONCLUSION

A conditional GRADE recommendation was in favor of parent report for pain assessment. Clinical trials are sorely needed because of the lack of evidence for safety and efficacy of pharmacologic interventions.

Validity of the Rotterdam Elderly Pain Observation Scale for institutionalised cognitively impaired Dutch adults

BACKGROUND

The Rotterdam Elderly Pain Observation Scale (REPOS) has not yet been validated for institutionalised cognitively impaired adults. To fill this gap of knowledge, we tested psychometric properties of the REPOS when used for pain assessment in this population.

METHODS

In this multicentre observational study, residents were filmed during a possibly painful moment and at rest. Healthcare professionals were asked to rate residents' pain by means of a Numeric Rating Scale (NRS)-proxy. Two researchers assessed pain with the REPOS and the Chronic Pain Scale for Non Verbal Adults with Intellectual Disabilities (CPS-NAID) from video-recordings.

RESULTS

In total, 168 observations from 84 residents were assessed. Inter-observer reliability between the two researchers was good, with Cohen's kappa 0.72 [95% confidence interval (CI) 0.64 to 0.79]. Correlation between the REPOS and CPS-NAID for a possibly painful moment was 0.73 (95% CI 0.65 to 0.79). Sensitivity (85%) and specificity (61%) for the detection of pain were calculated with REPOS ≥ 3 and NRS ≥ 4 as a reference value. Item response theory analysis shows that the item grimace displayed perfect discrimination between residents with and without pain.

CONCLUSION

The REPOS is a reliable and valid instrument to assess pain in cognitively impaired individuals.

Home-Monitoring Application for Children With Medical Complexity: A Feasibility Trial

OBJECTIVES

Mobile apps are suggested for supporting home monitoring and reducing emergency department (ED) visits and hospitalizations for children with medical complexity (CMC). None have been implemented. We sought to assess the MyChildCMC app (1) feasibility for CMC home monitoring, (2) ability to detect early deteriorations before ED and hospital admissions, and (3) preliminary impact.

METHODS

Parents of CMC (aged 1-21 years) admitted to a children's hospital were randomly assigned to MyChildCMC or usual care. MyChildCMC subjects recorded their child's vital signs and symptoms daily for 3 months postdischarge and received real-time feedback. Feasibility measures included parent's enrollment, retention, and engagement. The preliminary impact was determined by using quality of life, parent satisfaction with care, and subsequent ED and hospital admissions and hospital days.

RESULTS

A total of 62 parents and CMC were invited to participate: 50 enrolled (80.6% enrollment rate) and were randomly assigned to MyChildCMC (n = 24) or usual care (n = 26). Retention at 1 and 3 months was 80% and 74%, and engagement was 68.3% and 62.6%. Run-chart shifts in vital signs were common findings preceding admissions. The satisfaction score was 26.9 in the MyChildCMC group and 24.1 in the control group (P = .035). No quality of life or subsequent admission differences occurred between groups. The 3-month hospital days (pre-post enrollment) decreased from 9.25 to 4.54 days (rate ratio = 0.49; 95% confidence interval = 0.39-0.62; P < .001) in the MyChildCMC group and increased from 1.08 to 2.46 days (rate ratio = 2.29; 95% confidence interval = 1.47-3.56; P < .001) in the control group.

CONCLUSIONS

MyChildCMC was feasible and appears effective, with the potential to detect early deteriorations in health for timely interventions that might avoid ED and hospitalizations. A larger and definitive study of MyChildCMC's impact and sustainability is needed.

The Effectiveness and safety of T-MSAT on inpatients with acute low back pain caused by traffic accidents: A protocol for randomized controlled trial

BACKGROUND

Presentation of musculoskeletal symptoms, such as pain, discomfort, or disability, caused by a traffic accident (TA) is a common occurrence. However, studies on treatment and management of sudden low back pain (LBP) caused by a TA are very scarce, while studies on the effectiveness of motion style acupuncture therapy (MSAT) used on such patients are also rare. Accordingly, a randomized controlled trial (RCT) is planned to assess the effectiveness and safety of MSAT using traction (T-MSAT) for the treatment of pain and functional problems in patients with acute LBP caused by a TA.

METHODS

This study will be conducted at Jaseng Hospital of Korean Medicine in South Korea, using a two-armed, parallel, assessor-blinded RCT design. The study population will consist of 100 participants who will be randomly assigned in a 1:1 ratio to either the T-MSAT+integrative Korean medicine therapy (IKMT) group or IKMT control group. The treatment will be applied continuously for 3 days after admission. The primary outcome will be the difference between the numeric rating scale (NRS) scores at admission and immediately after treatment on the fourth day of admission. Secondary outcomes will include visual analogue scale (VAS) for LBP and radiating leg pain; NRS for radiating leg pain; lumbar active range of motion; Oswestry Disability Index (ODI); Patient Global Impression of Change (PGIC); the Post-traumatic Stress Disorder Checklist for DSM-5 (PCL-5-K); and 12-item short-form health survey (SF-12).

DISCUSSION

This study is a RCT to assess the effectiveness and safety of T-MSAT for acute LBP caused by a TA. The findings could be used by healthcare-related policy makers and clinicians in primary care institutions, which are frequently visited by patients suffering from LBP caused by a TA.

Cancer Care of Children, Adolescents and Adults With Autism Spectrum Disorders: Key Information and Strategies for Oncology Teams

Delivering optimal cancer care to children, adolescents and adults with ASD has recently become a healthcare priority and represents a major challenge for all providers involved. In this review, and after consideration of the available evidence, we concisely deliver key information on this heterogenous group of neurodevelopmental disorders, as well as recommendations and concrete tools for the enhanced oncological care of this vulnerable population of patients.

Long-Term Follow-Up of Spinal Stenosis Inpatients Treated with Integrative Korean Medicine Treatment

The present prospective observational study aimed to analyze the outcomes of inpatients who received integrative Korean medicine treatment in order to provide evidence on its effects on lumbar spinal stenosis (LSS). Patients with LSS who received inpatient treatment at four Korean medicine hospitals from January 2015 to December 2018 were followed up. Outcomes measured included the numeric rating scale (NRS) scores for back and leg pain, and Oswestry Disability Index (ODI). Changes in outcomes at admission, discharge, and follow-up, as well as associated predictors that could account for the improvement in outcomes were analyzed. The NRS score for back pain, NRS score for leg pain, and ODI decreased by 2.20 points (95% confidence interval (CI), -2.41 to -1.99), 2.28 points (95% CI, -2.59 to -1.96), and 17.31 points (95% CI, -19.6 to -15.02), respectively, at long-term follow-up compared with at admission. Patients with LSS who received inpatient integrative Korean medicine treatment exhibited an improvement in pain and functional disability. Further studies are required to determine the effects of integrative Korean medicine treatment.

The effectiveness and cost-effectiveness of motion style acupuncture treatment (MSAT) for acute neck pain: A multi-center randomized controlled trial

BACKGROUND

Neck pain is a common complaint in the general population. Despite the consistent ongoing pain and the resulting economic burden on affected individuals, there have only been a few studies investigating the treatment of acute neck pain. This study aims to evaluate the effectiveness, safety, and cost-effectiveness of the motion style acupuncture treatment (MSAT) and acupuncture treatment for acute neck pain.

METHODS

This 2-armed, parallel, multi-centered randomized controlled trial will be conducted at 4 community-based hospitals in Korea. A total of 128 subjects will be randomly assigned, at a 1:1 ratio, to the MSAT and the acupuncture treatment groups. Treatment will be administered 2 to 3 times a week for 2 weeks. The primary outcome will be the visual analog scale of neck pain on movement. The secondary outcomes will be the numeric rating scale of the neck, neck disability index, Northwick Park questionnaire, patient global impression of change, range of motion of the neck, 5-level EuroQol-5 dimension, 12-item Short-Form Health Survey, and EuroQol visual analogue scale. This protocol has been registered at the Clinicaltrials.gov (NCT04539184).

DISCUSSION

To our knowledge, this study is the first well-designed multi-centered randomized controlled trial to evaluate the effectiveness, safety, and cost-effectiveness of MSAT on acute neck pain. The results of this study will be useful for clinicians in primary medical institutions that frequently treat acute neck pain patients and for policymakers working with national health insurance.

Initial Validation of GRASP: A Differential Diagnoses Algorithm for Children With Medical Complexity and an Unknown Source of Pain

OBJECTIVES

Identifying the source of pain for children with medical complexity (MC) is challenging. The purpose of this study was the initial validation of a tool to guide the medical evaluation for identifying the source of pain in children with MC by using differential diagnoses. The tool is entitled Guidelines for Ruling Out and Assessing Source of Pain (GRASP).

METHODS

A mixed-methods approach that included expert review, focus groups, Web-based surveys, and a trial of the GRASP was used to determine validity as well as perceived clinical utility.

RESULTS

Focus groups were held with 26 inpatient and outpatient clinicians. Participants consistently responded in support of the GRASP. Participants advised several suggestions for tool organization such as designing the tool as a flow diagram. Seven clinicians participated in Web-based surveys and made specific suggestions for making the GRASP more comprehensive. Six participants trialed the GRASP for 14 children with MC and pain of unknown origin. Overall, participants found that the GRASP was a clinically effective tool for guiding medical evaluation.

CONCLUSIONS

These results provide preliminary evidence that the GRASP has content and face validity in evaluating the source of pain in children with MC. This tool can be used to systematically guide clinicians through a balanced approach to evaluation with a goal of determining the pain source, preventing harm, and relieving suffering without unnecessary tests.

Intensive Motion Style Acupuncture Treatment (MSAT) Is Effective for Patients with Acute Whiplash Injury: A Randomized Controlled Trial

In this single-center, parallel, randomized controlled trial, we aim to examine the effects and safety of motion style acupuncture treatment (MSAT; a combination of acupuncture and Doin therapy) on pain reduction and functional improvement in patients with whiplash-associated disorders (WADs). Ninety-seven patients with cervical pain admitted to the Bucheon Jaseng Hospital of Korean Medicine, South Korea, due to acute whiplash injury were treated with integrative Korean medicine (IKM) with (MSAT group, 48 patients) or without (control group, 49 patients) an additional 3-day MSAT during hospitalization (5-14 days) and followed-up for 90 days. The mean numeric rating scale (NRS) scores of the MSAT and control groups at baseline were 5.67 (95% confidence interval (CI), 5.33, 6.01) and 5.44 (95% CI, 5.06, 5.82), respectively, and on day 5, 3.55 (95% CI, 3.04, 4.06) and 4.59 (95% CI, 4.10-5.07), respectively. The NRS change difference between the groups was -1.07 (95% CI, -1.76, -0.37). The rate of recovery of neck pain (NRS score change ≥ 2 points) was significantly faster in the MSAT than in the control group (log-rank test p = 0.0055). IKM treatment combined with MSAT may be effective in reducing the pain and improving the range of motion in patients with WADs.

Effects of sweet orange aromatherapy on pain and anxiety during needle insertion among patients undergoing hemodialysis: A quasi-experimental study

PURPOSE

Patients undergoing hemodialysis experience pain and anxiety during needle insertion, and the scientific interest in aromatherapy in reducing pain and anxiety is increasing. Thus, this study aimed to determine the effects of sweet orange aromatherapy on pain and anxiety during needle insertion in hemodialysis.

DESIGN

Quasi-experimental, pretest, and posttest.

METHODS

This study was carried out among 50 patients with chronic kidney disease who were non-randomly assigned to either sweet orange aromatherapy or calm breathing in three outpatient hemodialysis centers in the Philippines between July and August 2015. The numeric rating scale and adapted state-trait anxiety inventory were utilized to measure pain and anxiety.

RESULTS

After the intervention, both the pain and anxiety scores were significantly lower for patients who received sweet orange aromatherapy than those who received calm breathing. The results obtained modest effect sizes that imply high practical significance.

CONCLUSION

The sweet orange aromatherapy can be effective in reducing pain and anxiety. Thus, this can be used by nurses as an alternative and complementary approach to reduce both pain and anxiety in painful procedures like needle insertion.

Autonomic Cardiac Reactivity to Painful Procedures Under Hypnosis in Pediatric Emergencies: A Feasibility Study

Pain sensation is characterized by abrupt changes in central nervous system activity producing autonomic reactivity. While clinical hypnosis has demonstrated its benefits for children in pain management, it is not clear whether hypnosis modulated autonomic pain response in children in clinical conditions. Here, we studied autonomic responses under hypnosis to sutures in pediatric emergencies. For that, 42 children (mean age: 6.5 years, range 1.5 to 13) were divided into two groups consecutively (hypnosis and control groups), according to their choice. Time-frequency analysis was applied on RR intervals (heart rate interbeat intervals, or RRI) to estimate parasympathetic reactivity based on high frequency power (HF) and the Analgesia Nociception Index (ANI®) and on sympathetic reactivity (low frequency power [LF]) and LF/HF ratio). We observed that RRI and LF/HF ratio varied according to suture and hypnosis (p < 0.05): RRI was higher and LF/HF ratio was lower during sutures in the hypnosis group in comparison to the control group whereas HF and ANI® increased only during hypnosis. To conclude, hypnosis in pediatric emergencies reduces sympathetic cardiac pain reactivity and could be a marker of pain relief under hypnosis, while parasympathetic activity seems to be a better marker of hypnosis.

Cancer Pain in People With Intellectual Disabilities: Systematic Review and Survey of Health Care Professionals

CONTEXT

Owing to life expectancy improvements for people with intellectual disabilities, their risk of developing cancer is increasing. Pain is an inevitable aspect of cancerous diseases. However, as pain experience and expression can be atypical in people with intellectual disabilities, this population is vulnerable to late diagnosis of cancer and undertreatment of cancer pain.

OBJECTIVES

The objective of this study was to investigate what is currently known about cancer pain in people with intellectual disabilities and provide specific recommendations to improve this knowledge.

METHODS

A systematic review using PubMed, PsycINFO, and CINAHL and an anonymous online survey of Dutch health care professionals were conducted.

RESULTS

From 10,146 publications, with intellectual disabilities in the title, and pain or cancer in the title or abstract, 11 articles underwent qualitative synthesis. Discussions within these articles were predominantly unspecific and brief, frequently indicating challenges in symptom presentation, communication, as well as assessment and treatment of cancer pain. The survey received 102 responses. The 63 health care professionals experienced with cancer in people with intellectual disabilities indicated challenges recognizing, assessing, and treating their cancer pain.

CONCLUSION

Cancer pain in people with intellectual disabilities is a topic lacking specific and comprehensive research within scientific literature. We suggest this is due to inherent difficulties regarding the complex interplay of comorbidities and communication issues in people with intellectual disabilities.

Pain Assessment in the Patient Unable to Self-Report: Clinical Practice Recommendations in Support of the ASPMN 2019 Position Statement

Pain is a subjective experience, unfortunately, some patients cannot provide a self-report of pain verbally, in writing, or by other means. In patients who are unable to self-report pain, other strategies must be used to infer pain and evaluate interventions. In support of the ASPMN position statement "Pain Assessment in the Patient Unable to Self-Report", this paper provides clinical practice recommendations for five populations in which difficulty communicating pain often exists: neonates, toddlers and young children, persons with intellectual disabilities, critically ill/unconscious patients, older adults with advanced dementia, and patients at the end of life. Nurses are integral to ensuring assessment and treatment of these vulnerable populations.

Monitoring Procedural Pain and Distress in a Child With Rett Syndrome: A Case Report

BACKGROUND AND PURPOSE

Whole body vibration training is a viable option for children with Rett syndrome; however, the positioning requirements and intense vibration may be interpreted as pain.

CASE

A 13-year-old girl with a diagnosis of Rett syndrome, Stage IV, participated. The Individualized Numeric Rating Scale was developed in collaboration with the caregiver and scored by a physical therapist and student physical therapists during 16 sessions of whole body vibration training.

OUTCOMES

The therapist and students reached 100% agreement on the Individualized Numeric Rating Scale ratings and successfully provided distractions to prevent pain and distress from reaching a level 5 out of 10 for 139 of 144 sessions.

CONCLUSION

This is the first case in the literature to demonstrate use of the Individualized Numeric Rating Scale with a child who is nonverbal during a potentially painful physical therapy procedure.

P-CPOT: An Adaptation of the Critical-Care Pain Observation Tool for Pediatric Intensive Care Unit Patients

BACKGROUND

The Pediatric Critical-Care Observation Tool (P-CPOT) is an adaption of the Critical-Care Pain Observation Tool (CPOT) originally designed to assess pain in nonverbal critically-ill adults.

AIM

The study validated the P-CPOT in assessing nociceptive procedure pain in pediatric intensive care unit (PICU) children who are unable to verbalize pain.

METHODS

Content validity was tested using a two-round expert panel review with 8 experts. With a sample of 78 PICU patients, prospective repeated measures were designed to detect the change over time at pre- (T1), during (T2), and post- (T3) for routinely scheduled nociceptive procedures. Each measure was independently completed by two raters using two scales, the P-CPOT and the FLACC (Faces, Legs, Activity, Cry and Consolability).

RESULTS

All categories had Item-level content validity indices of 0.88 to 1.00. A one-factor structure containing 5 items was established and accounted for 85% variance in P-CPOT scores. Inter-rater reliability was substantial with correlation coefficient of 0.996 and Kappa value of 0.90. A threshold value of 4 resulted in excellent balance between sensitivity (98.6%) and specificity (97.6%). Both tools detected the score changes over time (p = .025). P-CPOT had a larger effect size (Cohen's d = 4.1) as well as a higher score than FLACC at T2 (p = .039). Linear regression revealed that patients being ventilated tended to have a P-CPOT score of 1.1 higher than the FLACC score while controlling for heart rates (p < .001), meaning that P-CPOT is more sensitive than FLACC for detecting pain increase during nociceptive procedures in ventilated patients.

CONCLUSION

The P-CPOT is a valid scale for assessing pain in PICU patients with very good psychometric performance. It is especially adept in detecting pain in ventilated patients.

Pain in Children With Developmental Disabilities: Development and Preliminary Effectiveness of a Pain Training Workshop for Respite Workers

INTRODUCTION

Pain in children with intellectual disabilities (ID) is common and complex, yet there is no standard pain training for their secondary caregivers (ie, respite staff).

OBJECTIVES

Determine perceived pain training needs/preferences of children's respite staff (phase 1) and, use this information combined with extant research and guidelines to develop and pilot a training (phase 2).

METHODS

In phase 1, 22 participants responded to questionnaires and engaged in individual interviews/focus groups about their experiences with pain in children with ID, and perceived training needs/preferences. In phase 2, 50 participants completed knowledge measures and rated the feasibility of, and their own confidence and skill in, pain assessment and management for children with ID immediately before and after completing a pain training. They also completed a training evaluation.

RESULTS

Participants viewed pain training as beneficial. Their ideal training involved a half-day, multifaceted in-person program with a relatively small group of trainees incorporating a variety of learning activities, and an emphasis on active learning. Phase 2 results suggested that completion of the 3 to 3.5-hour pain training significantly increased respite workers' pain-related knowledge (effect sizes: r=0.81 to 0.88), as well as their ratings of the feasibility of, and their own confidence and skill in, pain assessment and management in children with ID (effect sizes: r=0.41 to 0.70). The training was rated favorably.

DISCUSSION

Training can positively impact respite workers' knowledge and perceptions about pain assessment and management. As such, they may be better equipped to care for children with ID in this area.

Sedation Management for Critically Ill Children with Pre-Existing Cognitive Impairment

OBJECTIVE

To compare current analgesia and sedation management practices between critically ill children with pre-existing cognitive impairment and critically ill neurotypical children, including possible indicators of therapeutic efficacy.

STUDY DESIGN

This study used secondary analysis of prospective data from the RESTORE clinical trial, with 2449 children admitted to the pediatric intensive care unit and receiving mechanical ventilation for acute respiratory failure. Subjects with a baseline Pediatric Cerebral Performance Category ≥3 were defined as subjects with cognitive impairment, and differences between groups were explored using regression methods accounting for pediatric intensive care unit as a cluster variable.

RESULTS

This study identified 412 subjects (17%) with cognitive impairment. Compared with neurotypical subjects, subjects with cognitive impairment were older (median, years, 6.2 vs 1.4; P < .001) with more severe pediatric acute respiratory distress syndrome (40% vs 33%; P = .009). They received significantly lower cumulative doses of opioids (median, mg/kg, 14.2 vs 16.2; P < .001) and benzodiazepines (10.6 vs 14.4; P < .001). Three nonverbal subjects with cognitive impairment received no analgesia or sedation. Subjects with cognitive impairment were assessed as having more study days awake and calm and fewer study days with an episode of pain. They were less likely to be assessed as having inadequate pain/sedation management or unplanned endotracheal/invasive tube removal. Subjects with cognitive impairment had more documented iatrogenic withdrawal symptoms than neurotypical subjects.

CONCLUSIONS

Subjects with cognitive impairment in this study received less medication, but it is unclear whether they have authentically lower analgesic and/or sedative requirements or are vulnerable to inadequate assessment of discomfort because of the lack of validated assessment tools. We recommend the development of pain and sedation assessment tools specific to this patient population.

The challenge of pain assessment in children with cognitive disabilities: Features and clinical applicability of different observational tools

Children with cognitive disabilities are at greater risk of experiencing pain. It has been shown that this paediatric population often receive inadequate pain management. Pain may be very difficult to assess, especially in a defined subgroup with non-communicating intellectual disability or severe cognitive disability. Accordingly, several observational pain assessment tools have been proposed to overcome this issue. Due to the absence of an ideal measurement tool, accurate pain assessment requires, after a case-by-case analysis, selecting the more appropriate tool or a variety of combined instruments. The aim of this work is to provide a comprehensive review of the pain assessment tools commonly used in cognitively impaired children. Critical discussion on features and clinical applicability may suggest how to overcome this difficult challenge. Furthermore, this review will help further research aiming to design new instruments and to improve already-in-use tools.

Primary care for people with an intellectual disability - what is prescribed? An analysis of medication recommendations from the BEACH dataset

BACKGROUND

People with intellectual disability (ID) experience a range of health disparities. Little is known about differential primary care prescribing patterns for people with and without ID.

AIM

To compare medications recommended by GPs at encounters where ID is recorded versus other encounters.

DESIGN & SETTING

Analysis of national Australian GP medication data from the Bettering the Evaluation and Care of Health (BEACH) programme, January 2003-December 2012 inclusive.

METHOD

Medication recommendations made at encounters where an ID-defining problem was recorded as a reason for encounter (RFE) and/or as a problem managed, were allocated to the 'ID group' (n = 563). These encounters were compared with all other encounters (the 'non-ID group', n = 1 004 095) during the study period. Following age-sex standardisation of ID group encounters, significant differences were determined by non-overlapping 95% confidence intervals (CIs).

RESULTS

Antipsychotics and anticonvulsants were recommended more frequently at ID group encounters than at non-ID group encounters. Antidepressant and anxiolytic recommendation rates did not differ between groups. Narcotic analgesic and antihypertensive recommendations were significantly lower at ID group encounters.

CONCLUSION

Higher rates of epilepsy and mental illness, and off-label use of some antipsychotics and anticonvulsants for behaviour management in people with ID, may have contributed to medication recommendations observed in this analysis. Lower narcotic analgesic recommendations at ID group encounters may relate to complex presentations and the nature of problems managed, while lower antihypertensive recommendations may indicate some potential omission of routine blood pressure measurement.

Intrathecal Baclofen Therapy Prior to Spinal Fusion for Patients With Gross Motor Function Classification System IV-V Cerebral Palsy

BACKGROUND

Patients with Gross Motor Function Classification System (GMFCS) IV-V cerebral palsy (CP) have significant spasticity and frequently develop scoliosis. Intrathecal baclofen (ITB) pumps are effective in managing spasticity. The effect of ITB therapy on the postoperative course following spinal fusion in patients with GMFCS IV-V CP has not been described. This study sought to compare postoperative recovery, including complications, in patients using ITB therapy with those with no ITB therapy.

PURPOSE

Evaluate the effect of ITB on the postoperative recovery for patients with GMFCS IV-V CP who undergo spinal fusion for scoliosis.

METHODS

Health records for patients with GMFCS IV-V CP who underwent a spinal fusion for scoliosis at a major quaternary-care children's hospital from January 2009 to October 2015 were reviewed and relevant data were abstracted. Descriptive statistics and regression models were used to compare patients.

RESULTS

Sixty-nine patients were included-19 ITB therapy and 50 no ITB therapy. Demographic and operative characteristics were similar across groups. The mean length of stay for patients in the ITB therapy group was 11.2 days and 14.3 days for the no ITB therapy group, with no difference between groups (p = .12). Pain scores in both groups decreased at the same rate, with scores in the ITB therapy group averaging one-half point lower (p = .32). The average amount of morphine equivalents (p = .71) and benzodiazepine equivalents (p = .53) used were similar between groups. Complication rates were significantly different between groups. Four (21%) of the ITB therapy patients had 1 or more complications whereas 28 (56%, p = .01) in the no ITB therapy group had 1 or more complications. The average number of complications per patient in the ITB therapy group was 0.3 (SD: 0.075, range: 0-3) and the no ITB therapy group was 1.1 (SD: 1.1, range: 0-6, p = .01).

CONCLUSIONS

There was no significant difference in length of stay, pain scores, or pain/spasticity medication use between groups after spinal fusion, but there was a significantly lower incidence of complications in the ITB therapy group.

Nurse Practitioner-Administered Chloroprocaine in Children with Postoperative Pain

BACKGROUND

Pain is a complex physical and emotional experience. Therefore, assessment of acute pain requires self-report when possible, observations of emotional and behavioral responses and changes in vital signs. Peripheral nerve and epidural catheters often provide postoperative analgesia in children. Administration of chloroprocaine (a short acting local anesthetic) via a peripheral nerve or epidural catheter allows for a comparison of pain scores, observations of emotional and behavioral responses and changes in vital signs to determine catheter function.

AIMS

The aims of this study are to describe the use chloroprocaine injections for testing catheters; patient response; and how changes to pain management are guided by the patient response.

METHODS

This study describes the use of chloroprocaine injections to manage pain and assess the function of peripheral nerve or epidural catheters in a pediatric population. We examined 128 surgical patients, (0-25 years old), who received chloroprocaine injections for testing peripheral nerve or epidural catheters. Patient outcomes included: blood pressure, respiratory rate, heart rate and pain intensity scores.

RESULTS

There were no significant adverse events. The injection guided intervention by determining the function of regional analgesia in the majority (98.5%) of patients.

DISCUSSION

Chloroprocaine injections appear to be useful to evaluate functionality of peripheral nerve and epidural catheters after surgery in a pediatric population.

Educators’ Experiences Identifying Pain Among Students in Special Education Settings

If special educators cannot identify pain in students with intellectual disability (ID), students cannot be referred to the school nurse for assessment and management. The purpose of this study was to examine how special educators identify pain in the school setting. Twenty-four special educators participated in focus groups aiming to (1) identify educators’ observations and perceptions of pain in students with ID and (2) determine the decision-making processes educators use to determine the need for student presentation or referral to the health office. Overall, special educators know students well enough to differentiate pain-related behaviors from normal well-child behaviors, prioritize student safety, and draw on personal experiences with pain when addressing pain in students with ID. Special educators welcome opportunities to learn more about pain in children with ID. Teachers, nurses, and other professionals should share knowledge about and experiences of working with students in pain to improve practices.

Measuring Musculoskeletal Pain in Infants, Children, and Adolescents

Synopsis Accurate, reliable, and timely assessment of pain is critical for effective management of musculoskeletal pain conditions. The assessment of pain in infants, children, and adolescents with and without cognitive impairment can be particularly challenging to clinicians for a number of reasons, including factors related to the consultation (eg, heterogeneous patient population, time constraints), the clinician (eg, awareness/knowledge of available pain scales), standardized assessment scales (eg, availability, psychometric properties, and application of each scale), the patient (eg, developmental stage, ability to communicate), and the context in which the interaction took place (eg, familiarity with the setting and physiological and psychological state). As a result, pain is frequently not assessed or measured during the consultation and, in many instances, underestimated and undertreated in this population. The purpose of this article is to provide clinicians with an overview of scales that may be used to measure pain in infants, children, and adolescents. Specifically, the paper reviews the various approaches to measure pain intensity; identifies factors that can influence the pain experience, expression, and assessment in infants, children, and adolescents; provides age-appropriate suggestions for measuring pain intensity in patients with and without cognitive impairment; and identifies ways to assess the impact of pain using multidimensional pain scales. J Orthop Sports Phys Ther 2017;47(10):712-730. doi:10.2519/jospt.2017.7469.

Pain Assessment in Newborns, Infants, and Children

Pain in children is underestimated and undertreated because of lack of pain assessment tools. Pain assessment depends on the cognitive development of the child being tested, clinical context, and pain typology. For children older than age 6 years, pain assessment is based on a self-report. For children younger than age 6 years, behavioral pain scales are needed to assess pain. Numerous pain scales exist. Many are reliable and some are recommended, but all have specific conditions for their use. In this article, we review the available pain scales for children from birth to adolescence. We provide the validity criteria of each pain scale to help caregivers use the adapted tools. We then propose a synthesis of the reliable tools to use based on the pain context. [Pediatr Ann. 2017;46(10):e387-e395.].

Noninvasive submental fat reduction using colder cryolipolysis

BACKGROUND

Cryolipolysis has shown to significantly reduce localized subcutaneous fat, including submental fat. Temperatures below -11°C have not been used to treat the submental region.

OBJECTIVE

The purpose of this study was to evaluate safety and efficacy of Cryolipolysis for noninvasive reduction of submental fat using lower temperatures and reduced treatment time.

METHODS

A small volume applicator was used to treat 15 subjects, using a noninvasive tissue cooling device (CoolSculpting System, ZELTIQ Aesthetics, Pleasanton, CA, USA) during 45 and 30 minutes at -12 and -15°C, respectively, to induce reduction of submental fat. Two treatments with an interval of 10 weeks were performed. Adverse events were monitored to assess safety. Treated area was evaluated using digital photography, and caliper measurements prior treatment, 10 weeks after first treatment and 12 weeks after second treatment. All patients were also evaluated before and after 12-week postlast treatment by Magnetic Resonance Imaging (MRI).

RESULTS

The mean (SD) reduction measured by skin fold caliper was 33% (3.2 mm [1.7 mm]), (95% CI, 0.2297-0.4236; P=.05), and by MRI, mean (SD) reduction was 1.78 mm (1.157 mm). Independent blinded panel was able to correctly identify 60% of before and after photographs; 12 of 15 subjects (80%) were satisfied or very satisfied with the treatment. Side effects were mild and resolved completely within 10 weeks, except for one hyperpigmentation, which resolved spontaneously within 6 months after last treatment.

CONCLUSION

Cryolipolysis with colder temperature and reduced treatment time continues to be effective and is safe for noninvasive reduction of the submental fat.

Improving School Nurse Pain Assessment Practices for Students With Intellectual Disability

School nurses are afforded minimal resources related to assessing pain in students with intellectual disability (ID) and have called for continuing education. The purpose of this study was to measure the effectiveness of an education program regarding best practices for assessing pain in students with ID. Educational sessions were presented to 248 school nurses. Pre-, post-, and follow-up surveys measured (1) difficulty school nurses face when assessing pain, (2) knowledge and use of pain assessment methods, and (3) intent to change and actual changes to professional practices. Participants experienced less difficulty assessing pain following the educational program. Almost all participants intended to change pain assessment practices, but large caseloads limited new practice adoption. Policy makers must consider population size and acuity when determining school nurse staffing. Trainings and other resources should be made available to school nurses in order to make pain assessments for students with ID more thorough and efficient.

Pain Assessment and Treatment in Children With Significant Impairment of the Central Nervous System

Pain is a frequent and significant problem for children with impairment of the central nervous system, with the highest frequency and severity occurring in children with the greatest impairment. Despite the significance of the problem, this population remains vulnerable to underrecognition and undertreatment of pain. Barriers to treatment may include uncertainty in identifying pain along with limited experience and fear with the use of medications for pain treatment. Behavioral pain-assessment tools are reviewed in this clinical report, along with other strategies for monitoring pain after an intervention. Sources of pain in this population include acute-onset pain attributable to tissue injury or inflammation resulting in nociceptive pain, with pain then expected to resolve after treatment directed at the source. Other sources can result in chronic intermittent pain that, for many, occurs on a weekly to daily basis, commonly attributed to gastroesophageal reflux, spasticity, and hip subluxation. Most challenging are pain sources attributable to the impaired central nervous system, requiring empirical medication trials directed at causes that cannot be identified by diagnostic tests, such as central neuropathic pain. Interventions reviewed include integrative therapies and medications, such as gabapentinoids, tricyclic antidepressants, α-agonists, and opioids. This clinical report aims to address, with evidence-based guidance, the inherent challenges with the goal to improve comfort throughout life in this vulnerable group of children.

Caring for children with intellectual disabilities part 1: Experience with the population, pain-related beliefs, and care decisions

Some children with intellectual disabilities (ID): experience pain more frequently than children without ID, express their pain differently, and are incapable of providing self-reports. No research has examined disability and pain-related beliefs of respite workers (RW) and their relations to pain assessment and management decisions for children with ID.

OBJECTIVES

(1) compare disability and pain-related beliefs between RW and a sample with little experience in ID; (2) determine whether individuals' beliefs and personal characteristics are related to pain assessment and management decisions.

PARTICIPANTS

Fifty-six RW (aged: 18-67 years, M_age=33.37, 46 female) and 141 emerging adults (aged: 18-31 years, M_age=19.67, 137 female).

PROCEDURE/MEASURES

In an online survey, participants responded to six vignettes depicting pain in children with ID, and completed measures of pain and disability-related beliefs.

RESULTS/DISCUSSION

Compared to those without experience, RW held more positive disability-related beliefs, t(192)=4.23, p<0.001. Participants' pain-related beliefs (e.g., sensitivity to pain) differed depending on severity of the child's ID and participant group. Participants' pain-related beliefs predicted care decisions. Results provide initial insight into RW pain-related beliefs about children with ID, and a basic understanding of the relations among pain beliefs, personal characteristics and pain-related decisions.

Primary Caregiver Perception of Pain Control following Pediatric Adenotonsillectomy

Objectives

To (1) review pain medications prescribed following pediatric adenotonsillectomy (T&A), (2) identify pain medications reported to be helpful, and (3) compare parent-reported outcomes among various combinations of pain medications.

Study Design

Case series with planned data collection.

Setting

Multihospital network.

Subjects and Methods

The primary caregivers of children aged 1 to 18 years who underwent isolated T&A from June to December 2014 were contacted 14 to 21 days after surgery. Data collected included pain medications prescribed, medications most helpful in controlling pain, and duration that pain medication was required. Parents rated their children’s pain on postoperative days 2, 3, 7, and 14 and reported the time to resumption of normal diet/activity, as well as any hospital return visits.

Results

The study cohort included 672 subjects of 1444 potential participants (46% response rate). The mean age of the patients was 7.9 ± 3.6 years. Narcotics were prescribed in 71.9%, and 70.4% were told to use ibuprofen. Children who took ibuprofen alone were significantly younger ( P < .001). Pain was significantly less on postoperative days 2 and 3 in the ibuprofen-only group as compared with the groups taking narcotics only ( P < .001) and ibuprofen with narcotics ( P = .002). Those taking ibuprofen alone returned to normal activity ( P < .001) and diet ( P = .026) sooner than those taking ibuprofen with narcotics. No difference was seen in pain control on subgroup analysis comparing oxycodone and hydrocodone.

Conclusions

For pediatric T&A, significant variation exists in the management of postoperative pain. Parents of children given ibuprofen reported less pain than those given narcotics with and without ibuprofen. Further studies are needed to identify the optimal pain regimen for children after T&A.