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El-Tallawy SN, Ahmed RS, Nagiub MS. Pain Management in the Most Vulnerable Intellectual Disability: A Review. Pain Ther 2023; 12:939-961. [PMID: 37284926 PMCID: PMC10290021 DOI: 10.1007/s40122-023-00526-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 05/10/2023] [Indexed: 06/08/2023] Open
Abstract
This review is made up of two parts; the first part discussing intellectual disability (ID) in general, while the second part covers the pain associated with intellectual disability and the challenges and practical tips for the management of pain associated with (ID). Intellectual disability is characterized by deficits in general mental abilities, such as reasoning, problem solving, planning, abstract thinking, judgment, academic learning, and learning from experience. ID is a disorder with no definite cause but has multiple risk factors, including genetic, medical, and acquired. Vulnerable populations such as individuals with intellectual disability may experience more pain than the general population due to additional comorbidities and secondary conditions, or at least the same frequency of pain as in the general population. Pain in patients with ID remains largely unrecognized and untreated due to barriers to verbal and non-verbal communication. It is important to identify patients at risk to promptly prevent or minimize those risk factors. As pain is multifactorial, thus, a multimodal approach using both pharmacotherapy and non-pharmacological management is often the most beneficial. Parents and caregivers should be oriented to this disorder, given adequate training and education, and be actively involved with the treatment program. Significant work to create new pain assessment tools to improve pain practices for individuals with ID has taken place, including neuroimaging and electrophysiological studies. Recent advances in technology-based interventions such as virtual reality and artificial intelligence are rapidly growing to help give patients with ID promising results to develop pain coping skills with effective reduction of pain and anxiety. Therefore, this narrative review highlights the different aspects regarding the current status of the pain associated with intellectual disability, with more emphasis on the recent pieces of evidence for the assessment and management of pain among populations with intellectual disability.
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Affiliation(s)
- Salah N. El-Tallawy
- King Khalid University Hospital, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Anesthesia Department, Faculty of Medicine, Minia University and NCI, Cairo University, Giza, Egypt
| | - Rania S. Ahmed
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
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Kildal ESM, Quintana DS, Szabo A, Tronstad C, Andreassen O, Nærland T, Hassel B. Heart rate monitoring to detect acute pain in non-verbal patients: a study protocol for a randomized controlled clinical trial. BMC Psychiatry 2023; 23:252. [PMID: 37060049 PMCID: PMC10103503 DOI: 10.1186/s12888-023-04757-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 04/06/2023] [Indexed: 04/16/2023] Open
Abstract
BACKGROUND Autism entails reduced communicative abilities. Approximately 30% of individuals with autism have intellectual disability (ID). Some people with autism and ID are virtually non-communicative and unable to notify their caregivers when they are in pain. In a pilot study, we showed that heart rate (HR) monitoring may identify painful situations in this patient group, as HR increases in acutely painful situations. OBJECTIVES This study aims to generate knowledge to reduce the number of painful episodes in non-communicative patients' everyday lives. We will 1) assess the effectiveness of HR as a tool for identifying potentially painful care procedures, 2) test the effect of HR-informed changes in potentially painful care procedures on biomarkers of pain, and 3) assess how six weeks of communication through HR affects the quality of communication between patient and caregiver. METHODS We will recruit 38 non-communicative patients with autism and ID residing in care homes. ASSESSMENTS HR is measured continuously to identify acutely painful situations. HR variability and pain-related cytokines (MCP-1, IL-1RA, IL-8, TGFβ1, and IL-17) are collected as measures of long-term pain. Caregivers will be asked to what degree they observe pain in their patients and how well they believe they understand their patient's expressions of emotion and pain. Pre-intervention: HR is measured 8 h/day over 2 weeks to identify potentially painful situations across four settings: physiotherapy, cast use, lifting, and personal hygiene. INTERVENTION Changes in procedures for identified painful situations are in the form of changes in 1) physiotherapy techniques, 2) preparations for putting on casts, 3) lifting techniques or 4) personal hygiene procedures. DESIGN Nineteen patients will start intervention in week 3 while 19 patients will continue data collection for another 2 weeks before procedure changes are introduced. This is done to distinguish between specific effects of changes in procedures and non-specific effects, such as caregivers increased attention. DISCUSSION This study will advance the field of wearable physiological sensor use in patient care. TRIAL REGISTRATION Registered prospectively at ClinicalTrials.gov (NCT05738278).
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Affiliation(s)
- Emilie S M Kildal
- K.G. Jebsen, Centre for Neurodevelopmental Disorders, University of Oslo, Oslo, Norway.
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
- Department of Psychiatry, Lovisenberg Diakonale Sykehus, Oslo, Norway.
| | - Daniel S Quintana
- K.G. Jebsen, Centre for Neurodevelopmental Disorders, University of Oslo, Oslo, Norway
- Department of Psychology, University of Oslo, Oslo, Norway
- NORMENT, Division of Mental Health and Addiction, University of Oslo, Oslo, Norway
- NevSom, Department of Rare Disorders, Oslo University Hospital, Oslo, Norway
| | - Attila Szabo
- K.G. Jebsen, Centre for Neurodevelopmental Disorders, University of Oslo, Oslo, Norway
- NORMENT, Division of Mental Health and Addiction, University of Oslo, Oslo, Norway
| | - Christian Tronstad
- Department of Clinical and Biomedical Engineering, Oslo University Hospital, Oslo, Norway
| | - Ole Andreassen
- K.G. Jebsen, Centre for Neurodevelopmental Disorders, University of Oslo, Oslo, Norway
- NORMENT, Division of Mental Health and Addiction, University of Oslo, Oslo, Norway
| | - Terje Nærland
- K.G. Jebsen, Centre for Neurodevelopmental Disorders, University of Oslo, Oslo, Norway.
- NevSom, Department of Rare Disorders, Oslo University Hospital, Oslo, Norway.
| | - Bjørnar Hassel
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Neurohabilitation, Oslo University Hospital, Oslo, Norway
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Bernal-Celestino RJ, León-Martín A, Martín-López MM, Ruiz-García J, Muñoz-Romera S, Lozano-Diaz AI. Evaluating and Handling the Pain of People With Intellectual Disability. Pain Manag Nurs 2021; 23:311-317. [PMID: 34493439 DOI: 10.1016/j.pmn.2021.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 05/30/2021] [Accepted: 08/10/2021] [Indexed: 10/20/2022]
Abstract
Anecdotal reports have suggested people with intellectual disabilities experience more pain than the general population due to additional co-morbidities and secondary conditions. This multicenter comparative cross-sectional study aimed to evaluate the prevalence, factors, and treatment modalities in people with intellectual disabilities (PID) as observed by their caregivers and reported through distributed questionnaires. The study sample included 130 PID users of centers in Ciudad Real (Spain). Variables related to sociodemographic characteristics, health problems, problem behaviors, and pain were collected. Among participants, 78 (60%) of PID were males, and their mean age was 43.8 years (SD = 13.57). Pain was identified in 29 PID (22.3%; 95% confidence interval [CI] 14.99-29.81), and drugs for pain were administered to 33 PID (26.4%; 95%CI 19-34). The prevalence of pain in the sampled PID, its severity, and the analgesic administration rate were lower than those in the general population. This situation may be aggravated for PID with communication problems.
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Affiliation(s)
- Rubén J Bernal-Celestino
- Gerencia de Atención Integrada de Ciudad Real, Supervisor of the Teaching and Training Research Area, Ciudad Real, Spain.
| | - Alberto León-Martín
- Public Health Technician, Quality Unit, Gerencia de Atención Integrada de Ciudad Real, Ciudad Real, Spain
| | - María Mairena Martín-López
- Professor, Department of Inorganic and Organic Biochemistry, Faculty of Chemistry, Regional Center for Biomedical Research, University of Castilla, La Mancha, Spain
| | - Jacinto Ruiz-García
- Mental Health Nursing Supervisor, Gerencia de Atención Integrada de Ciudad Real, Ciudad Real, Spain
| | - Silvia Muñoz-Romera
- Mental Health Specialist. Residential Center for People with Intellectual Disabilities, "Guadiana" Gerencia de Atención Integrada de Ciudad Real, Ciudad Real, Spain
| | - Ana Isabel Lozano-Diaz
- Mental Health Specialist. Residential Center for People with Intellectual Disabilities, "Guadiana" Gerencia de Atención Integrada de Ciudad Real, Ciudad Real, Spain
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Boerlage AA, Sneep L, van Rosmalen J, van Dijk M. Validity of the Rotterdam Elderly Pain Observation Scale for institutionalised cognitively impaired Dutch adults. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2021; 65:675-687. [PMID: 33955082 PMCID: PMC8252534 DOI: 10.1111/jir.12843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 04/06/2021] [Accepted: 04/12/2021] [Indexed: 06/12/2023]
Abstract
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.
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Affiliation(s)
- A. A. Boerlage
- Intensive Care and Department of Pediatric SurgeryErasmus MC‐Sophia Children's HospitalRotterdamThe Netherlands
- Department of AnesthesiologyErasmus MCRotterdamThe Netherlands
| | - L. Sneep
- Department of PhysiotherapyIpse de BruggenNootdorpThe Netherlands
| | - J. van Rosmalen
- Department of BiostatisticsErasmus MCRotterdamThe Netherlands
| | - M. van Dijk
- Intensive Care and Department of Pediatric SurgeryErasmus MC‐Sophia Children's HospitalRotterdamThe Netherlands
- Department of Internal Medicine, Section of Nursing ScienceErasmus MCRotterdamThe Netherlands
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Increased heart rate functions as a signal of acute distress in non-communicating persons with intellectual disability. Sci Rep 2021; 11:6479. [PMID: 33742078 PMCID: PMC7979830 DOI: 10.1038/s41598-021-86023-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 03/05/2021] [Indexed: 01/10/2023] Open
Abstract
Intellectual disability (ID) affects approximately 1% of the population. Some patients with severe or profound ID are essentially non-communicating and therefore risk experiencing pain and distress without being able to notify their caregivers, which is a major health issue. This real-world proof of concept study aimed to see if heart rate (HR) monitoring could reveal whether non-communicating persons with ID experience acute pain or distress in their daily lives. We monitored HR in 14 non-communicating participants with ID in their daily environment to see if specific situations were associated with increased HR. We defined increased HR as being > 1 standard deviation above the daily mean and lasting > 5 s. In 11 out of 14 participants, increased HR indicated pain or distress in situations that were not previously suspected to be stressful, e.g. passive stretching of spastic limbs or being transported in patient lifts. Increased HR suggesting joy was detected in three participants (during car rides, movies). In some situations that were previously suspected to be stressful, absence of HR increase suggested absence of pain or distress. We conclude that HR monitoring may identify acute pain and distress in non-communicating persons with ID, allowing for improved health care for this patient group.
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Lonchampt S, Gerber F, Aubry JM, Desmeules J, Kosel M, Besson M. Pain interventions in adults with intellectual disability: A scoping review and pharmacological considerations. Eur J Pain 2020; 24:875-885. [PMID: 32060971 DOI: 10.1002/ejp.1547] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 01/31/2020] [Accepted: 02/09/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVE Having to deal on a daily routine with prescriptions in adults with intellectual disability (ID), we systematically reviewed the literature on the specificities of pain interventions in that population, focusing on medication and trying to gather practical information on appropriate pain treatments. Given the scarcity of the literature on the topic, we also discussed the pharmacological considerations to be taken into account when prescribing analgesic drugs in that vulnerable population. DATABASES AND DATA TREATMENT Articles on pain and ID were searched in the Medline and Google scholar electronic databases using the key words "Intellectual Disability," "Developmental Disability" and specific keywords for pharmacological and non-pharmacological pain interventions. Preset outcomes about pharmacological treatment specificity, efficacy and safety were then collected. RESULTS One hundred and fifty-two articles were found and 16 were retained based on our inclusion and exclusion criteria. Of the 16 articles, five were topical reviews. Among the 11 remaining articles, five discussed pharmacological interventions, four considered non-pharmacological interventions and two discussed both. As anticipated, the literature matching our specific outcomes about the pharmacological treatment of pain was scarce and for the most part not designed to answer the questions of specificity, efficacy and safety of pain treatment in adults with ID. CONCLUSION The specificity of analgesic treatments in adults with ID is a totally unexplored domain. In the absence of clinical guidelines, pharmacological facts-such as inter-individual variability in drug response, pharmacokinetic and pharmacodynamic interactions, frequent co-morbidities and ease of administration-must be systematically integrated, when prescribing in the population of adults with ID. SIGNIFICANCE This review synthesizes the state of research on pain interventions in adults with ID and is one of the rare articles addressing the specificities of analgesic prescriptions in this population.
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Affiliation(s)
- Sophie Lonchampt
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Psychopharmacology Unit, Geneva University Hospitals, Geneva, Switzerland.,Division of Psychiatric Specialties, Department of Psychiatry and Mental Health, Unit for Intellectual Disabilities and Autism in Adults, Geneva University Hospitals, Geneva, Switzerland
| | - Fabienne Gerber
- Division of Psychiatric Specialties, Department of Psychiatry and Mental Health, Unit for Intellectual Disabilities and Autism in Adults, Geneva University Hospitals, Geneva, Switzerland
| | - Jean-Michel Aubry
- Division of Psychiatric Specialties, Department of Psychiatry and Mental Health, Geneva University Hospitals, Geneva, Switzerland
| | - Jules Desmeules
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Markus Kosel
- Division of Psychiatric Specialties, Department of Psychiatry and Mental Health, Unit for Intellectual Disabilities and Autism in Adults, Geneva University Hospitals, Geneva, Switzerland
| | - Marie Besson
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Psychopharmacology Unit, Geneva University Hospitals, Geneva, Switzerland.,Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Intensive care and Pharmacology, Multidisciplinary Pain Center, Geneva University Hospitals, Geneva, Switzerland
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Axmon A, Ahlström G, Westergren H. Pain and Pain Medication among Older People with Intellectual Disabilities in Comparison with the General Population. Healthcare (Basel) 2018; 6:healthcare6020067. [PMID: 29914061 PMCID: PMC6023323 DOI: 10.3390/healthcare6020067] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 06/11/2018] [Accepted: 06/12/2018] [Indexed: 12/14/2022] Open
Abstract
Little is known about pain and pain treatment among people with intellectual disabilities (IDs). We aimed to describe pain and pain medications among older people with ID compared to the general population. Data on diagnoses and prescriptions were collected from national registers for the period between 2006 and 2012 for 7936 people with an ID and a referent cohort from the general population. IDs were associated with a decreased risk of being diagnosed with headaches, musculoskeletal pain, and pain related to the circulatory and respiratory systems, but they were associated with increased risk of being diagnosed with pain related to the urinary system. Among men, IDs were associated with an increased risk of being diagnosed with visceral pain. People with IDs were more likely to be prescribed paracetamol and fentanyl regardless of the type of pain but were less likely to be prescribed COX(1+2) and COX2 inhibitors and weak opioids. Healthcare staff and caregivers must be made aware of signs of pain among people with IDs who may not be able to communicate it themselves. Further research is needed to investigate whether people with IDs are prescribed paracetamol rather than other pain drugs due to physicians trying to avoid polypharmacy or if there are other reasons not to prescribe a greater range of pain treatments.
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Affiliation(s)
- Anna Axmon
- Division of Occupational and Environmental Medicine, Department of Laboratory Medicine, Lund University, SE-221 00 Lund, Sweden.
| | - Gerd Ahlström
- Department of Health Sciences, Lund University, SE-221 00 Lund, Sweden.
| | - Hans Westergren
- Department of Health Sciences, Lund University, SE-221 00 Lund, Sweden.
- Department of Pain rehabilitation, Skane University hospital, 222 85 Lund, Sweden.
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de Knegt NC, Lobbezoo F, Schuengel C, Evenhuis HM, Scherder EJA. Self-Reported Presence and Experience of Pain in Adults with Down Syndrome. PAIN MEDICINE 2018; 18:1247-1263. [PMID: 27694149 DOI: 10.1093/pm/pnw226] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Objective The aim was to examine whether the presence of pain (based on physical conditions and participants' report) and self-reported pain experience in adults with Down syndrome (DS) differ from general population controls. Design Cross-sectional study of 224 adults with DS (mean age = 38.1 years, mild-severe intellectual disabilities) and 142 age-matched controls (median age = 40.5 years, mean estimated IQ = 105.7) in the Netherlands. Methods File-based medical information was evaluated. Self-reported presence and experience of pain were assessed in rest and after movement during a test session (affect with facial affective scale (FAS: 0.04-0.97), intensity assessed with numeric rating scale (NRS: 0-10). Results Compared with controls, more DS participants had physical conditions that may cause pain and/or discomfort ( p = .004, 50% vs 35%), but fewer DS participants reported pain during the test session ( p = .003, 58% vs 73%). Of the participants who indicated pain and comprehended self-reporting scales ( n = 198 FAS, n = 161 NRS), the DS group reported a higher pain affect and intensity than the controls ( p < .001, FAS: 0.75-0.85 vs 0.50-0.59, NRS: 6.00-7.94 vs 2.00-3.73). Conclusions Not all adults with DS and painful/discomforting physical conditions reported pain. Those who did indicated a higher pain experience than adults from the general population. Research into spontaneous self-report of pain, repeated pain assessment, and acute pain is needed in people with DS for more insight into pain experience and mismatches between self-report and medical information.
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Affiliation(s)
- Nanda C de Knegt
- Department of Clinical Neuropsychology, VU University, Amsterdam, the Netherlands
| | - Frank Lobbezoo
- Department of Oral Kinesiology, Academic Center for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, MOVE Research Institute Amsterdam, Amsterdam, the Netherlands
| | - Carlo Schuengel
- Department of Clinical Child and Family Studies and EMGO+ Institute for Health and Care Research
| | - Heleen M Evenhuis
- Department of General Practice, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Erik J A Scherder
- Department of Clinical Neuropsychology, VU University, Amsterdam, the Netherlands
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Frasca M, Burucoa B, Domecq S, Robinson N, Dousset V, Cadenne M, Sztark F, Floccia M. Validation of the Behavioural Observation Scale 3 for the evaluation of pain in adults. Eur J Pain 2017; 21:1475-1484. [DOI: 10.1002/ejp.1049] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2017] [Indexed: 11/10/2022]
Affiliation(s)
- M. Frasca
- Department of Palliative Care; University Hospital of Bordeaux; France
| | - B. Burucoa
- Department of Palliative Care; University Hospital of Bordeaux; France
| | - S. Domecq
- CCECQA Coordination and Clinical Evaluation of Quality in Aquitaine; Bordeaux France
| | - N. Robinson
- CCECQA Coordination and Clinical Evaluation of Quality in Aquitaine; Bordeaux France
| | - V. Dousset
- Centre of Evaluation and Treatment of the Pain; University Hospital of Bordeaux; France
| | - M. Cadenne
- Centre of Evaluation and Treatment of the Pain; University Hospital of Bordeaux; France
| | - F. Sztark
- Department of Anaesthesia and Resuscitation; University Hospital of Bordeaux; France
| | - M. Floccia
- Department of Geriatrics; University Hospital of Bordeaux; France
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Vrijmoeth C, Christians MG, Festen DA, Groot M, van der Heide A, van der Rijt CC, Tonino M, Echteld MA. Physician-Reported Symptoms and Interventions in People with Intellectual Disabilities Approaching End of Life. J Palliat Med 2016; 19:1142-1147. [DOI: 10.1089/jpm.2015.0544] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Cis Vrijmoeth
- Intellectual Disabilities and Health, Department of Primary and Community Health Care, Radboudumc, Nijmegen, The Netherlands
- Intellectual Disability Medicine, Department of General Practice, Erasmus MC, Rotterdam, The Netherlands
| | - Milou G.M. Christians
- Intellectual Disabilities and Health, Department of Primary and Community Health Care, Radboudumc, Nijmegen, The Netherlands
| | - Dederieke A.M. Festen
- Intellectual Disability Medicine, Department of General Practice, Erasmus MC, Rotterdam, The Netherlands
| | - Marieke Groot
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboudumc, Nijmegen, The Netherlands
| | | | | | | | - Michael A. Echteld
- Prisma Foundation, Biezenmortel, The Netherlands
- Science in Balance Foundation, Rotterdam, The Netherlands
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de Knegt NC, Lobbezoo F, Schuengel C, Evenhuis HM, Scherder EJA. Self-Reporting Tool On Pain in People with Intellectual Disabilities (STOP-ID!): a Usability Study. Augment Altern Commun 2015; 32:1-11. [DOI: 10.3109/07434618.2015.1100677] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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