Behavioral and physiologic indicators of pain in nonverbal patients with a traumatic brain injury: an integrative review

Nurses' assessment and management practices of pain among intensive care patients in King Khalid Hospital, Kharj, Riyadh

Background

Pain is a disagreeable combination of sensory and emotional sensations. Employing behavioral pain assessment tools is strongly associated with improved identification of pain.

Purpose

The main purpose of the study is to investigate Nurses' Assessment and Management Practices of Pain among Intensive Care Patients in King Khalid Hospital, Kharj, Riyadh.

Materials and methods

A self-administered questionnaire was employed in a descriptive cross-sectional study. The study focused on nurses employed in the intensive care unit at King Khalid Hospital in Al-Kharj Province. The researchers utilized convenience sampling to recruit participants. Out of the total 48 nurses approached 45 of them provided responses, leading to a response rate of 94%. The Critically Ill questionnaire was utilized to gather information regarding the treatment and evaluation of pain in patients who were in critical condition. Descriptive statistics and inferential statistics were employed to analyze the collected data.

Principal results

it was found that 88% of them utilized instruments to evaluate pain in patients who could express themselves. Among these instruments, the numeric rating scale was the most commonly employed. Furthermore, 77% of the nurses (35 in total) used a pain assessment tool for patients who were unable to communicate, with the Adult Nonverbal Pain Scale being the most frequently used tool in this case. The nurses' perception of the significance of pain assessment was positively associated with the regular utilization of pain assessment tools. Additionally, the nurses considered the use of pain assessment tools with patients who could communicate as more important compared to using such tools with patients who could not communicate.

Conclusions

Most ICU nurses utilized nurses' pain assessment instruments to assess the discomfort levels of both patients who could communicate and those who couldn't express themselves effectively. By employing such tools, nurses can improve patient outcomes, ensure effective pain management, and demonstrate a high standard of professional care.

External validation of binary machine learning models for pain intensity perception classification from EEG in healthy individuals

Discrimination of pain intensity using machine learning (ML) and electroencephalography (EEG) has significant potential for clinical applications, especially in scenarios where self-report is unsuitable. However, existing research is limited due to a lack of external validation (assessing performance using novel data). We aimed for the first external validation study for pain intensity classification with EEG. Pneumatic pressure stimuli were delivered to the fingernail bed at high and low pain intensities during two independent EEG experiments with healthy participants. Study one (n = 25) was utilised for training and cross-validation. Study two (n = 15) was used for external validation one (identical stimulation parameters to study one) and external validation two (new stimulation parameters). Time-frequency features of peri-stimulus EEG were computed on a single-trial basis for all electrodes. ML training and analysis were performed on a subset of features, identified through feature selection, which were distributed across scalp electrodes and included frontal, central, and parietal regions. Results demonstrated that ML models outperformed chance. The Random Forest (RF) achieved the greatest accuracies of 73.18, 68.32 and 60.42% for cross-validation, external validation one and two, respectively. Importantly, this research is the first to externally validate ML and EEG for the classification of intensity during experimental pain, demonstrating promising performance which generalises to novel samples and paradigms. These findings offer the most rigorous estimates of ML's clinical potential for pain classification.

Neuropalliative Care in the Inpatient Setting

The palliative care needs of inpatients with neurologic illness are varied, depending on diagnosis, acuity of illness, available treatment options, prognosis, and goals of care. Inpatient neurologists ought to be proficient at providing primary palliative care and effective at determining when palliative care consultants are needed. In the acute setting, palliative care should be integrated with lifesaving treatments using a framework of determining goals of care, thoughtfully prognosticating, and engaging in shared decision-making. This framework remains important when aggressive treatments are not desired or not available, or when patients are admitted to the hospital for conditions related to advanced stages of chronic neurologic disease. Because prognostic uncertainty characterizes much of neurology, inpatient neurologists must develop communication strategies that account for uncertainty while supporting shared decision-making and allowing patients and families to preserve hope. In this article, we illustrate the approach to palliative care in inpatient neurology.

A Communicative Intervention to Improve the Psychoemotional State of Critical Care Patients Transported by Ambulance

BACKGROUND

Communication is key to understanding the emotional state of critical care patients.

OBJECTIVE

To analyze the effectiveness of the communicative intervention known as CONECTEM, which incorporates basic communication skills and augmentative alternative communication, in improving pain, anxiety, and posttraumatic stress disorder symptoms in critical care patients transported by ambulance.

METHODS

This study had a quasi-experimental design with intervention and control groups. It was carried out at 4 emergency medical centers in northern Spain. One of the centers served as the intervention unit, with the other 3 serving as control units. The nurses at the intervention center underwent training in CONECTEM. Pretest and posttest measurements were obtained using a visual analog scale to measure pain, the short-version State-Trait Anxiety Inventory to measure anxiety, and the Impact of Event Scale to measure posttraumatic stress disorder symptoms.

RESULTS

In the comparative pretest-posttest analysis of the groups, significant differences were found in favor of the intervention group (Pillai multivariate, F2,110 = 57.973, P < .001). The intervention was associated with improvements in pain (mean visual analog scale score, 3.3 pretest vs 1.1 posttest; P < .001) and posttraumatic stress disorder symptoms (mean Impact of Event Scale score, 17.8 pretest vs 11.2 posttest; P < .001). Moreover, the percentage of patients whose anxiety improved was higher in the intervention group than in the control group (62% vs 4%, P < .001).

CONCLUSION

The communicative intervention CONECTEM was effective in improving psychoemotional state among critical care patients during medical transport.

Physiological Measures of Acute and Chronic Pain within Different Subject Groups: A Systematic Review

Results

The methods' heart rate variability and electroencephalogram show clear and consistent results as acute pain assessment. Magnetic resonance imaging can measure chronic pain. Ordered by invasiveness and vulnerability, a trend shows that the invasive methods are used more with less vulnerable subjects. Only instruments used for skin conductance and automatic facial recognition have a lower-than-average technological maturity.

Conclusions

Some pain assessment methods show good and consistent results and have high technological maturity; however, using them as pain assessment for persons with ID is uncommon. Since this addition can ameliorate caregiving, more research of assessment methods should occur.

Assessing pain in critically ill brain-injured patients: a psychometric comparison of 3 pain scales and videopupillometry

Three clinical scales (the Nociception Coma Scale adapted for Intubated patients [NCS-I], its Revised version [NCS-R-I], and the Behavioral Pain Scale [BPS]) and videopupillometry were compared for measuring pain in intubated, noncommunicating, critically ill, brain-injured patients. Pain assessment was performed before, during, just after, and 5 minutes after 3 procedures: the reference non-nociceptive procedure (assessment of the Richmond Agitation Sedation Scale) and 2 nociceptive procedures (turning and tracheal suctioning). The primary endpoint was construct validity (discriminant and criterion validation), determined by comparing pain measurements between different times/procedures. Secondary endpoints were internal consistency, inter-rater reliability, and feasibility. Fifty patients (54% women, median age 63 years [56-68]) were included 13 [7-24] days after brain injury (76% hemorrhagic or ischemic strokes). All tools increased significantly more (P < 0.001) during the nociceptive procedures vs the non-nociceptive procedure. The BPS was the only pain tool that did not increase significantly during the non-nociceptive procedure (P = 0.41), suggesting that it was the most discriminant tool. The BPS, NCS-I, and NCS-R-I were good predictors of nociception with areas under the curves ≥0.96, contrary to videopupillometry (area under the curve = 0.67). The BPS, NCS-I, and NCS-I-R had high inter-rater reliabilities (weighted kappa = 0.86, 0.82 and 0.84, respectively). Internal consistency was moderate (>0.60) for all pain scales. Factor analysis represented a majority of information on a first dimension, with motor domains represented on a second dimension. Scale feasibility was better for the NCS-I and NCS-R-I than for the BPS. In conclusion, the BPS, NCS-I, and NCS-R-I are valid, reliable, and acceptable pain scales for use in intubated critically ill, brain-injured patients, unlike videopupillometry. Future research requires tool design centered on domains of observation adapted to this very specific population.

Application of the Behavioural Indicators of Pain Scale in patients with traumatic brain injury

AIM

To develop and psychometrically test the Behavioural Indicators of Pain Scale (ESCID) in patients with traumatic brain injury (TBI).

DESIGN

A prospective observational study to test the psychometric properties of the Behavioural Indicators of Pain Scale in patients with TBI.

METHOD

A convenience sample of patients with TBI, who were non-communicative and using invasive mechanical ventilation was selected. Pain was evaluated by two observers who were blinded from each other. Assessments were performed at baseline via the performance of a painful procedure (aspiration of secretions) and a non-painful procedure (rubbing with a gauze). Assessments were repeated after application of procedures on days 1 and 6 of hospitalization in an intensive care unit. Data were collected between January-December 2016.

RESULTS

About 134 patients were included in the study. Of these, 76.1% were men. The mean age of participants was 45.2 (SD 17.5) years. The pain score significantly increased during the painful procedure when compared with the baseline measure and non-painful procedure (p < .001). Patients displayed a greater number of pain-indicating behaviours during the painful procedure on day 6, compared with day 1 (p < .05). This finding coincided with a reduced level of sedation and a greater level of consciousness.

CONCLUSION

The ESCID scale detects pain behaviours and discriminates among the different types of stimulation in patients with brain injury, who are uncommunicative and with mechanical ventilation, with good reliability. The ability for patients with brain injury to express behaviours is limited because of the low level of consciousness and the deep level of sedation.

IMPACT

This research will have an impact on the practice of pain assessment in patients with brain injury, representing a first step to adapt the content of the ESCID.

Nurses' Assessment Practices of Pain Among Critically Ill Patients

BACKGROUND

Systematic pain assessment is necessary to ensure effective pain management. Despite the availability of recommendations, guidelines, and valid tools for pain assessment, the actual implementation in clinical practice is inconsistent.

AIMS

The purpose of this study was to investigate intensive care nurses' pain assessment practices among critically ill patients in Jordanian hospitals.

DESIGN

A descriptive cross sectional design was used in this study.

SETTINGS

This study was conducted in 22 intensive care unites located in eight hospitals in Jordan.

PARTICIPANTS/SUBJECTS

Convenience sampling was used to recruit a sample of 300 nurses working in intensive care units.

METHODS

The Pain Assessment and Management for the Critically Ill survey was used to collect data. Descriptive statistics, χ², and correlational analysis were used to analyze data.

RESULTS

A total of 89.7% of nurses (N = 300) used pain assessment tools with patients able to communicate, and the numeric rating scale was the most commonly used tool. A total of 81.7% of the nurses used a pain assessment tool with patients unable to communicate, and the Adult Nonverbal Pain Scale was the most commonly used tool. Nurses' perceived importance of pain assessment was positively associated with frequent use of pain assessment tools. Nurses perceived the use of pain assessment tools for patients able to communicate as being more important than the use of pain assessment tools for patients unable to communicate.

CONCLUSIONS

The majority of intensive care unit nurses used pain assessment tools for patients both able and unable to communicate; however, the most valid and reliable tools were not used often. Nurses were not aware of the pain behaviors most indicative of pain among critically ill patients.

Pros and Cons of Clinically Relevant Methods to Assess Pain in Rodents

The primary objective of preclinical pain research is to improve the treatment of pain. Decades of research using pain-evoked tests has revealed much about mechanisms but failed to deliver new treatments. Evoked pain-tests are often limited because they ignore spontaneous pain and motor or disruptive side effects confound interpretation of results. New tests have been developed to focus more closely on clinical goals such as reducing pathological pain and restoring function. The objective of this review is to describe and discuss several of these tests. We focus on: Grimace Scale, Operant Behavior, Wheel Running, Burrowing, Nesting, Home Cage Monitoring, Gait Analysis and Conditioned Place Preference/ Aversion. A brief description of each method is presented along with an analysis of the advantages and limitations. The pros and cons of each test will help researchers identify the assessment tool most appropriate to meet their particular objective to assess pain in rodents. These tests provide another tool to unravel the mechanisms underlying chronic pain and help overcome the translational gap in drug development.

Psychometric Properties of the Behavioral Pain Scale in Traumatic Brain Injury

BACKGROUND

Pain assessment of patients with traumatic brain injury is a challenge because they are unable to self-report their pain experience.

AIMS

To investigate the psychometric properties of validity, reliability, and responsiveness of the Brazilian version of the Behavioral Pain Scale (BPS-Br) in patients with traumatic brain injury.

METHODS

This was an observational, cross-sectional, repeated-measure and analytical study. This study was developed at the medical and surgical ICUs in a high-complexity public hospital at Aracaju, Sergipe, Brazil. Thirty-seven adult patients with moderate or severe TBI were included. This study was completed with 444 independent observations, a pairwise comparison, and was performed simultaneously before, during, and after eye cleaning and endotracheal suctioning of 37 adult patients with moderate to severe traumatic brain injury.

RESULTS

The BPS-Br had good internal consistency (.7 ≤ α ≤ .9), good discriminant validity (p < .001), moderate to excellent reliability based on inter-rater agreement (intraclass correlation coefficient = 0.66-1.00; κ = 0.5-1.0), and high responsiveness (0.7-1.7). The upper limbs subscale had the highest score during the nociceptive procedure (1.8 ± 0.9). Deep sedation affected the increase of grading during painful procedures (p < .001).

CONCLUSIONS

Our results suggest the BPS-Br is a useful tool for clinical practice to evaluate the pain experienced by patients with traumatic brain injury. Further studies of different samples are needed to evaluate the benefits of systematic pain assessment of critically ill patients.

Pain assessment of traumatic brain injury victims using the Brazilian version of the Behavioral Pain Scale

Objective

To evaluate the validity and reliability of the Brazilian version of the Behavioral Pain Scale (BPS-Br) in victims of traumatic brain injury.

Methods

Observational prospective study with paired and repeated measures conducted at two intensive care units (clinical and surgical) of a large general hospital. The convenience sample consisted of adult victims of moderate or severe penetrating or blunt craniocerebral trauma who were sedated and mechanically ventilated. A total of 432 paired observations were performed by independent evaluators simultaneously, prior to eye cleaning, during eye cleaning, during tracheal aspiration and after tracheal aspiration. Sociodemographic, clinical, trauma-related, sedoanalgesia and physiological parameter data (heart rate, systolic and diastolic blood pressure) were collected. The discriminant validity was tested using the Friedman and Wilcoxon paired tests. The intraclass correlation coefficient and Cohen's Kappa coefficient were used to evaluate the reliability. The Spearman correlation test was used to test the association between clinical variables and BPS-Br scores during tracheal aspiration.

Results

There was a significant increase in the physiological parameters during tracheal aspiration, but without correlation with the BPS-Br scores. Pain was significantly more intense during tracheal aspiration (p < 0.005). Satisfactory interobserver agreement was found, with an intraclass correlation coefficient of 0.95 (0.90 - 0.98) and Kappa coefficient of 0.70.

Conclusion

Brazilian version of the Behavioral Pain Scale scores increased during tracheal aspiration. The Brazilian version of the scale was valid and reliable for pain assessment of traumatic brain injury victims undergoing tracheal aspiration.

Pain Assessment Scale for Patients With Disorders of Consciousness: A Preliminary Validation Study

BACKGROUND

Patients with acquired brain injury undergoing rehabilitation are often unable to verbalize pain because of disorders of consciousness. Hence, observational pain assessment instruments are warranted for these patients.

AIM

The aim of this study was to study interrater agreement and sensitivity to change over time of an assessment scale developed for the evaluation of pain in severely brain-injured patients with disorders of consciousness.

METHODS

We developed a pain assessment scale based on scientific literature and clinical experience with severely brain-injured patients. It consists of four domains: physiological/autonomic, body language, verbal communication, and behavior. The domains consist of 27 items. Interrater reliability was tested through three experienced nurses who rated 26 patients with acquired brain injury. The patients were rated in two different situations: before and after repositioning in bed and before and after administration of analgesics. We used Cohen's kappa test for interrater reliability. Sensitivity to change was tested by Wilcoxon signed rank test.

RESULTS

Cohen's kappa for the presence or absence of each item was above 0.8 for 13 items, between 0.6 and 0.8 for eight items, and less than 0.6 for only three items. The sensitivity test showed a significant change from before to after repositioning (p = .004).

CONCLUSION

It appeared that many of the pain assessment scale items held potential for inclusion in a new, more comprehensively developed and validated scale for the assessment of pain in patients with disorders of consciousness.