Challenges in pain assessment and management among individuals with intellectual and developmental disabilities

Multicenter study. Nursing professionals' perception of training needs in pain assessment in pediatric patients with cognitive dysfunction

INTRODUCTION

Pediatric patients with cognitive dysfunction are at greater risk of pain than typically developing children. Pain assessment in these patients is complex and could generate uncertainty in health professionals about what the key aspects are.

AIM

To determine the training needs perceived by nursing professionals regarding acute pain assessment in pediatric patients with cognitive dysfunction.

METHODS

A descriptive, cross-sectional, and multicenter study was performed using a survey addressed to nursing professionals who work in pediatrics during the months of August and September 2022.

RESULTS

163 responses were obtained. Most of the professionals who responded were female (92.6%, n = 151), with a mean age of 38.98 ± 10.40 years. The most frequent work unit was the pediatric intensive care unit (PICU), in 36% (n = 58). Most of the participants reported not having previously received training on pain assessment in pediatric patients with cognitive disabilities (85.9%, n = 139). However, 70.4% (n = 114) considered it "very necessary" for the development of their work to receive specific training on this topic. Knowing how to assess acute pain in this population (85.3%, n = 139) and knowing the clinical and behavioral manifestations of pain in this type of patient (84.7%, n = 138) were the aspects that obtained higher scores.

CONCLUSION

This research notes more than 90% of participants consider "quite necessary" and "strong necessary" to be training in pediatric cognitive dysfunction patients pain assessment. Furthermore, work experience, academic education and to be pediatric specialist obtain statistical significance data.

Chronic pain in children and young people with cerebral palsy: a narrative review of challenges, advances, and future directions

BACKGROUND

Cerebral palsy (CP), the most common physical disability of childhood, is often accompanied by a range of comorbidities including pain. Pain is highly prevalent in children and young people with CP, yet has been poorly understood, inaccurately assessed, and inadequately managed in this vulnerable population. This narrative review presents recent research advances for understanding and managing pain in children and young people with CP, focusing on chronic pain, and highlights future research directions.

MAIN BODY

Pain prevalence rates in CP vary due to different methodologies of studies. Recent systematic reviews report up to 85% of children experience pain; higher in older children, females, and those with dyskinesia and greater motor impairment. Research examining the lived experience perspectives of children and their families demonstrate that even those with mild motor impairments have pain, children want to self-report pain where possible to feel heard and believed, and management approaches should be individualized. Notably, many children with cognitive and communication impairments can self-report their pain if adjustments are provided and they are given a chance. Past inadequacies of pain assessment in CP relate to a focus on pain intensity and frequency with little focus on pain interference and coping, a lack of tools appropriate for the CP population, and an assumption that many children with cognitive and/or communication limitations are unable to self-report. Recent systematic reviews have identified the most reliable and valid assessment tools for assessing chronic pain. Many were not developed for people with CP and, in their current form, are not appropriate for the spectrum of physical, communication, and cognitive limitations seen. Recently, consensus and co-design in partnership with people with lived experience and clinicians have identified tools appropriate for use in CP considering the biopsychosocial framework. Modifications to tools are underway to ensure feasibility and applicability for the spectrum of abilities seen.

CONCLUSION

Recent research advances have improved our understanding of the prevalence, characteristics and lived experience of chronic pain, and refined assessment methods in children and young people with CP. However, the very limited evidence for effective and novel management of chronic pain in this population is where research should now focus.

Measurement properties and feasibility of chronic pain assessment tools for use with children and young people with cerebral palsy

PURPOSE

Chronic pain assessment tools exist for children, but may not be valid, reliable, and feasible for populations with functional, cognitive or communication limitations, for example, cerebral palsy (CP). This study aimed to (i) identify chronic pain assessment tools used with children and young people and rate their measurement properties; (ii) develop a CP specific feasibility rating tool to assess the feasibility of tools in CP; and (iii) categorise tools according to reporting method.

MATERIALS AND METHODS

Assessment tools were identified by literature review. Their measurement properties were rated using the COnsensus based standards for the Selection of health Measurement INstruments. The CP specific Feasibility Rating Tool was developed and used to rate the tools.

RESULTS

Fifty-seven chronic pain assessment tools were identified. Six have content validity for CP, four of these use proxy-report. Forty-two tools were considered feasible for people with CP; 24 self report and 18 observational/proxy-report. Only the Paediatric Pain Profile has content validity and feasibility for people with CP unable to self-report.

CONCLUSIONS

There are few valid, reliable and feasible tools to assess chronic pain in CP. Further research is required to modify tools to enable people with cognitive limitations and/or complex communication to self-report pain.

Pain in Neonates: Perceptions and Current Practices

All newborns experience pain during routine care, which can have long-lasting negative effects. Despite the availability of effective methods to prevent and reduce pain, most infants will receive ineffective or no treatment. Optimal pain management includes the reduction of the number of procedures performed, routine pain assessment and the use of effective pain-reducing interventions, most notably breastfeeding, skin-to-skin contact and sweet-tasting solutions. Parents are an essential component of the comprehensive assessment and management of infant pain; however, a gap exists regarding the uptake of parent-led interventions and the engagement of families. Practice recommendations for infant pain care are discussed.

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.

Being a child with intellectual disabilities in hospital: The need for an individualised approach to care

BACKGROUND

There is limited qualitative research focussed specifically on what it is like for children and young people with intellectual disabilities coming into hospital, with much of the evidence-base being about those with Autism Spectrum Condition or adults with intellectual disabilities.

AIM

To share rich detail of the emotional and physical impact on children and young people with intellectual disabilities of attending hospital, from their own and their parent's perspective.

METHODS

Talking Mats interviews, sticker survey and photography with children and young people with intellectual disabilities, and in-depth interviews, hospital diaries and photography with their parents.

RESULTS AND CONCLUSIONS

The multiple and compounding layers of complexity surrounding hospital care of children and young people with intellectual disabilities resulted in challenges associated with loss of familiarity and routine, undergoing procedures, managing sensory overload, managing pain and having a lack of safety awareness. An individualised approach to their care is needed.

Medicine use in people with intellectual disabilities: a Finnish nationwide register study

BACKGROUND

People with intellectual disability (ID) are a vulnerable group in our society; many of them depend on other people for assistance in their everyday lives. Compared with the general population, people with ID have poorer general health and, therefore, need more healthcare services and use more medicines. The aim of this study is to define the population of all Finnish people with ID using administrative data and to compare their medicine use and expenditure on medicines to those of the age-matched and sex-matched controls.

METHODS

People with ID and their age-matched and sex-matched controls (1:1) were extracted from nationwide healthcare and social allowance registers. Administrative register data on all prescription medicine purchases in 2019 were used to determine the prevalence of medicine use in both groups on a general level and by medicine categories. The differences in the prevalence of medicine use between the two groups were analysed using the logistic regression model. In addition, we studied the total expenditure on reimbursable medicine purchases covered by the National Health Insurance between people with ID and control group.

RESULTS

The subpopulation of people with ID consisted 37 196 individuals, of whom 82.7% purchased prescription medicines in 2019. The corresponding share of individuals purchasing prescription medicines in the control group was 70.3%. The differences in the prevalence of medicine use between the two populations were highest in the younger age groups (0-6, 7-12 and 13-17). In the study population, 28.1% (OR = 12.28; 95% CI: 11.54-13.07) of the people used antipsychotics, making it the most used medicine category in people with ID. In the control group, 3.3% of people used antipsychotics. Compared with the control group, the use of antiepileptics, drugs for constipation, mineral supplements and anxiolytics was four to seven times higher among people with ID. Furthermore, the median expenditure on medicine use among people with ID was four times higher than in the control group.

CONCLUSIONS

Compared with the control group, people with ID used more medicines, especially psychotropics, and their expenditure on medicine use was higher.

The recognition, assessment and perceptions of total pain in people with profound intellectual disabilities: A mixed methods systematic review

BACKGROUND

People with profound intellectual disabilities are a population with complex comorbidities. Total pain recognises the interconnectedness of aspects of pain; social, psychological, physical, emotional, spiritual. Pain is under-recognised due to communication challenges and carers perceptions. This review's purpose is to synthesise current literature and provide guidance for future research and care.

METHODS

Five databases were searched in this mixed methods systematic review (Cinahl, Medline, Psycinfo, Web of Science, Scopus). Articles retrieved were reported via a PRISMA flow diagram. Quality appraisal utilised the mixed methods appraisal tool (MMAT). A convergent qualitative design was the method of data synthesis.

RESULTS

Data from 16 included articles generated four themes; Absent voices, reductionist assessment, pain intensity, valuing expertise. Data included physical pain only.

CONCLUSION

Multifaceted pain needs inclusion in research. Assessment must consider the unique expressions of pain by individuals with profound intellectual disabilities. A sharing of expertise may improve pain care.

Chronic pain interference assessment tools for children and adults who are unable to self-report: A systematic review of psychometric properties

AIM

To identify and evaluate psychometric properties of assessment tools for assessing pain interference in children, adolescents, and adults with chronic pain and the inability to self-report.

METHOD

The protocol was registered with PROSPERO (CRD42022310102). A search was run in MEDLINE, Embase, and PsycInfo (29th March 2022) to identify articles reporting psychometric properties of pain interference assessment tools for children, adolescents, and adults with chronic pain and the inability to objectively self-report pain. Retrieved studies were reviewed by two authors (MGS, LCF) and study quality was assessed using COSMIN.

RESULTS

Psychometric properties of 10 pain interference tools were assessed from 33 studies. The Paediatric Pain Profile (PPP) had low-quality evidence for content validity and internal consistency with children and adolescents who are unable to self-report. No tools for adults had evidence for content validity and internal consistency. No tool had evidence for all nine psychometric properties.

INTERPRETATION

The PPP is recommended for pain interference assessment in children and adolescents with chronic pain and the inability to self-report. Few tools are available for adults. Three tools for children (Patient-Reported Outcome Measurement Information System Pediatric Proxy Pain Interference Scale; Bath Adolescent Pain Questionnaire for Parents; modified Brief Pain Inventory-Proxy [mBPI]) and three tools for adults (Doloplus-2; Patient-Reported Outcome Measurement Information System Pain Interference Scale-proxy; Brief Pain Inventory-proxy) are promising but require further investigation.

Pain Management in the Most Vulnerable Intellectual Disability: A Review

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.

Long-term Pain Symptomatology in PICU Survivors Aged 8-18 Years

BACKGROUND AND OBJECTIVES

Children discharged from the PICU often experience long-term physical, psychological, social and cognitive challenges, described as postintensive care syndrome. This study fills a critical gap by describing the long-term pain symptoms many children experience using child self-report.

METHODS

Participants in this cross-sectional study were children aged 8 to 18 years (and 1 parent, n = 64 dyads) who were 8 to 24 months post-PICU discharge. Participants completed measures assessing pain, psychosocial function, and treatment utilization. Health information relevant to the PICU admission was obtained from the electronic medical record.

RESULTS

Children were an average age of 14.3 years and 50% female. Average pain intensity in the past month was 3.65 (0-10 numeric rating scale), with 36% of children reporting pain ≥2 to 3 days a week. Youth with higher intensity (≥4) and more frequent pain (≥2-3 days a week) had greater pain catastrophizing, pain-related fear, anxiety, and sleep disturbance than those with less frequent and intense pain. Higher pain frequency was also associated with greater pain-related disability and depressive symptoms. Pain was not associated with any PICU-related variables abstracted from the electronic medical record. Parents reported children frequently accessed pain treatment services postdischarge; however, 37.5% reported the coronavirus disease 2019 pandemic impacted access to recommended services.

CONCLUSIONS

A significant portion of children experience pain post-PICU discharge. For many of these children, pain is frequent and is associated with impairments in psychosocial function. Future prospective research studies can be used to identify risk factors of poor pain outcomes so children can receive targeted interventions.

Pain research and children and adolescents with severe intellectual disability: ethical challenges and imperatives

Children with severe intellectual disabilities encounter inequities in pain-related care, yet little pain research involves this population. A considerable issue with pain research in this population is its ethical complexity. This Viewpoint delineates the ethical challenges of pain research involving children (aged 2-12 years) and adolescents (aged 13-21 years) with severe intellectual disabilities. There are two main issues. First, some of the standard methods for assessing pain and pain sensitivity are not suitable for individuals with severe intellectual disability, who are often non-verbal and unable to understand or follow instructions. Second, children and adolescents with severe intellectual disability cannot provide informed consent or assent to participate in pain research, and their dissent is not always recognised. The existing ethical guidelines for pain research by the International Association for the Study of Pain provide helpful, but general, guidance. This Viewpoint supplements these guidelines and uses a well established framework for assessing the ethics of clinical research to highlight points relevant to designing, doing, reviewing, and evaluating research involving children and adolescents with severe intellectual disability, focusing on issues that are unaddressed in existing guidance.

Reliable assessment of pain behaviour in adults with profound intellectual and multiple disabilities: The development of an instruction protocol

BACKGROUND

Persons with profound intellectual and multiple disabilities (PIMD) are vulnerable when it comes to experiencing pain. Reliable assessment of pain-related behaviour in these persons is difficult. Aim To determine how pain items can be reliably scored in adults with PIMD.

METHODS

We developed an instruction protocol for the assessment of pain-related behaviour in four phases. We used videos of 57 adults with PIMD during potentially painful situations. The items were assessed for inter-rater reliability (Cohen's kappa or percentage of agreement).

RESULTS

The developed instruction protocol appeared to be adequate. Twelve items had satisfactory inter-rater reliability (n = 9: .30-1.00; n = 3: 85%-100%).

DISCUSSION

Calibrating and adjustments to the instructions and item set appeared to be crucial to reliably score 12 items in adults with PIMD. Further research should focus on creating an assessment instrument based on these reliably scored items.

Comprehensive assessment and classification of upper and lower limb pain in athletes: a scoping review

BACKGROUND

Upper and lower limb (peripheral) pain is prevalent in athletes. Contemporary research prioritises multidimensional pain assessment and classification. This study aims to review comprehensive athlete pain assessment practices against the reference standard (International Olympic Committee, IOC Athlete Pain framework), identifying trends and highlighting gaps.

METHODS AND ANALYSIS

Six databases were searched using a comprehensive search strategy. This review followed the Joanna Briggs Institute standardised methodology for scoping reviews and is reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Title and abstract, full-text screening and data charting were completed by two independent reviewers.

INCLUSION CRITERIA

Original research, systematic reviews and clinical practice guidelines reporting assessment or classification of pain in athletes of any age with chronic or acute peripheral pain in English on human participants from database inception.

RESULTS

470 studies with 175 different pain assessment tools were mapped against the IOC Athlete Pain Framework. Papers included tools from neurophysiological (470/100%), biomechanical (425/90%), affective (103/22%), cognitive (59/13%) and socioenvironmental (182/39%) domains. Pain classification was included in 108 studies (23%). 4 studies (0.85%) defined pain. Athletes with physical disability were included in 13 (3%) studies and no studies included athletes with intellectual disabilities. Socioeconomic factors were addressed in 29 (6%) studies.

DISCUSSION

Neurophysiological and biomechanical domains are frequently addressed. Affective, socioenvironmental and cognitive tools are under-represented. Potential tools for use by researchers and clinicians are highlighted. Defining and classifying pain and determining predominant pain mechanisms is needed in both research and clinical practice. More work on underrepresented populations is needed.

CONCLUSION

This review informs researchers and clinicians working with athletes in pain how pain assessment and classification is currently conducted and highlights future priorities.

Anxiety in Wiedemann-Steiner syndrome

This study examined anxiety in Wiedemann-Steiner syndrome (WSS). Eighteen caregivers and participants with WSS completed the parent- and self-report versions of the Screen for Child Anxiety Related Disorder or the adapted version of the Screen for Adult Anxiety Related Disorder. Approximately 33.33% of parents and 65% of participants with WSS rated in the clinical range for overall anxiety. Across anxiety subtypes, parents primarily indicated concerns with Separation Anxiety (72%), which was also endorsed by the majority of participants with WSS (82%). The emergent trend showed Total Anxiety increased with age based on parent-informant ratings. The behavioral phenotype of WSS includes elevated anxiety. Clinical management should include incorporating early behavioral interventions to bolster emotion regulation given the observed risk of anxiety with age.

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.

Top Ten Tips Palliative Care Clinicians Should Know About Navigating the Needs of Adults with Intellectual Disabilities

As many people with intellectual disabilities (ID) live longer, the need for access to quality palliative care (PC) rises. People with ID realize significant barriers and inequities in accessing health care and PC. The need for integrated disability and PC services with extensive collaboration is great. The following tips are for PC clinicians caring for people with ID, their families, caregivers, and the community. While patient-centered care is difficult to distill into "tips," this article, written by an interdisciplinary team of PC and ID specialists, offers resources and references to improve the care provided to people with ID and serious illnesses.

Preliminary study: quantification of chronic pain from physiological data

Supplemental Digital Content is Available in the Text.

Preliminary evidence suggests that physiological variables collected with our low-cost pain meter are correlated with chronic pain, both for individuals and populations.

Introduction:

It is unknown if physiological changes associated with chronic pain could be measured with inexpensive physiological sensors. Recently, acute pain and laboratory-induced pain have been quantified with physiological sensors.

Objectives:

To investigate the extent to which chronic pain can be quantified with physiological sensors.

Methods:

Data were collected from chronic pain sufferers who subjectively rated their pain on a 0 to 10 visual analogue scale, using our recently developed pain meter. Physiological variables, including pulse, temperature, and motion signals, were measured at head, neck, wrist, and finger with multiple sensors. To quantify pain, features were first extracted from 10-second windows. Linear models with recursive feature elimination were fit for each subject. A random forest regression model was used for pain score prediction for the population-level model.

Results:

Predictive performance was assessed using leave-one-recording-out cross-validation and nonparametric permutation testing. For individual-level models, 5 of 12 subjects yielded intraclass correlation coefficients between actual and predicted pain scores of 0.46 to 0.75. For the population-level model, the random forest method yielded an intraclass correlation coefficient of 0.58. Bland–Altman analysis shows that our model tends to overestimate the lower end of the pain scores and underestimate the higher end.

Conclusion:

This is the first demonstration that physiological data can be correlated with chronic pain, both for individuals and populations. Further research and more extensive data will be required to assess whether this approach could be used as a “chronic pain meter” to assess the level of chronic pain in patients.

Unique Pain Responses in Different Etiological Subgroups of Intellectual and Developmental Disabilities

We studied whether there exist variations in pain responses between different intellectual and developmental disability (IDD) etiologies. Self-reports and facial expressions (Facial Action Coding System = FACS) were recorded during experimental pressure stimuli and compared among 31 individuals with IDD-13 with cerebral palsy (CP), nine with Down syndrome (DS), nine with unspecified origin (UIDD)-and among 15 typically developing controls (TDCs). The CP and DS groups had higher pain ratings and FACS scores compared to the UIDD and TDC groups, and steeper stimulus-response functions. The DS group exhibited the most diverse facial expressions. There were variations in the foci of facial expressions between groups. It appears that different IDD etiologies display distinct pain responses.

Improving pain-related communication in children with autism spectrum disorder and intellectual disability

The communication of pain in individuals with co-morbid Autism Spectrum Disorder and intellectual disability (ASD-ID) is largely unexplored. The communication deficits associated with ASD-ID can result in nonverbal behavior such as self-injurious behavior, aggression, irritability, and reduced activity as a means to communicate that pain is present. The objective of this study was to determine whether a behavioral-based educational intervention could increase the pain-related communication of children with ASD-ID who experience pain frequently. Specifically, the study aimed to determine if children with ASD-ID can label the location of their pain or quantify pain severity and request pain relief. The sample included three children with ASD-ID who experienced pain frequently. The intervention utilized educational materials and behavioral reinforcements and the intervention was conducted using a series of case studies. Pain was assessed daily by caregivers using the Non-Communicating Children's Pain Checklist-Postoperative (NCCPC-PV) and the ability of the individual to identify and express pain was recorded using the Wong Baker FACES Pain (WBFPS) Scale. Challenging behavior was recorded based on frequency count. The results indicated that all participants displayed the ability to independently respond to a question about how they were feeling by vocalizing the location of pain or indicating their level of pain on the WBFPS and requesting pain relief. The results suggest a role for behavioral-based educational interventions to promote communication of pain in people with ASD-ID.

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.

Pain burden in children with cerebral palsy (CPPain) survey: Study protocol

Pain is a significant health concern for children living with cerebral palsy (CP). There are no population‐level or large‐scale multi‐national datasets using common measures characterizing pain experience and interference (ie, pain burden) and management practices for children with CP. The aim of the CPPain survey is to generate a comprehensive understanding of pain burden and current management of pain to change clinical practice in CP. The CPPain survey is a comprehensive cross‐sectional study. Researchers plan to recruit approximately 1400 children with CP (primary participants) across several countries over 6‐12 months using multimodal recruitment strategies. Data will be collected from parents or guardians of children with CP (0‐17 years) and from children with CP (8‐17 years) who are able to self‐report. Siblings (12‐17 years) will be invited to participate as controls. The CPPain survey consists of previously validated and study‐specific questionnaires addressing demographic and diagnostic information, pain experience, pain management, pain interference, pain coping, activity and participation in everyday life, nutritional status, mental health, health‐related quality of life, and the effect of the COVID‐19 pandemic on pain and access to pain care. The survey will be distributed primarily online. Data will be analyzed using appropriate statistical methods for comparing groups. Stratification will be used to investigate subgroups, and analyses will be adjusted for appropriate sociodemographic variables. The Norwegian Regional Committee for Medical and Health Research Ethics and the Research Ethics Board at the University of Minnesota in USA have approved the study. Ethics approval in Canada, Sweden, and Finland is pending. In addition to dissemination through peer‐reviewed journals and conferences, findings will be communicated through the CPPain Web site (www.sthf.no/cppain), Web sites directed toward users or clinicians, social media, special interest groups, stakeholder engagement activities, articles in user organization journals, and presentations in public media.

“Communicating Lily’s Pain”: A reflective narrative commentary about co‐creating a resource to provoke thinking and change about assessing and managing the pain of children with profound cognitive impairment

This paper draws together about 20 years of research work and discovery and the development of a resource about pain assessment and management in children with profound cognitive impairment. The animation tells the story of an imagined child called Lily and the skills her mother uses and the challenges that her mother faces in assessing and managing Lily's pain. The animation is built on stories drawn from qualitative research findings, conversations while in clinical practice and with members of the general public, parent advisers and other sources. Most of the “evidence” came from stories shared by parents and healthcare professionals. This paper draws on some elements of socio‐narratology and is predicated on the basis that stories are important and they can act on and with us. By using an animation to tell Lily's story, the intention was to communicate research findings to a wider and more diverse audience than the typical readership of an academic journal. The intention was to act in and on people's consciousness about children's pain and to strengthen relationships and create bonds between clinicians, parents, and children in pain to make their dialog more social, connected, and meaningful. All three of us—the researcher, the writer, and the animator—have been marked and “re‐shaped” by our work related to creating Lily; we have learned more about children like Lily and their mothers, and we have learned more about ourselves and our humanity. This animation is still a story in progress, a story ‘in the wild’, a story (and a resource) we would like you to re‐tell and share. The story of Lily's pain aimed to change the lives of parents and children and professionals. Our hope is that you can be part of that change.

Modified Sensory Testing in Non-verbal Patients Receiving Novel Intrathecal Therapies for Neurological Disorders

Several neurological disorders may be amenable to treatment with gene-targeting therapies such as antisense oligonucleotides (ASOs) or viral vector-based gene therapy. The US FDA has approved several of these treatments; many others are in clinical trials. Preclinical toxicity studies of ASO candidates have identified dose-dependent neurotoxicity patterns. These include degeneration of dorsal root ganglia, the cell bodies of peripheral sensory neurons. Quantitative sensory testing (QST) refers to a series of standardized mechanical and/or thermal measures that complement clinical neurologic examination in detecting sensory dysfunction. QST primarily relies on patient self-report or task performance (i.e., button-pushing). This brief report illustrates individualized pragmatic approaches to QST in non-verbal subjects receiving early phase investigational intrathecal drug therapies as a component of clinical trial safety protocols. Three children with neurodevelopmental disorders that include Neuronal Ceroid Lipofuscinosis Type 7, Ataxia-Telangiectasia, and Epilepsy of Infancy with Migrating Focal Seizures are presented. These case studies discuss individualized testing protocols, accounting for disease presentation, cognitive and motor function. We outline specific considerations for developing assessments for detecting changes in sensory processing in diverse patient groups and safety monitoring trials of early phase investigational intrathecal drug therapies. QST may complement information obtained from the standard neurologic examination, electrophysiologic studies, skin biopsies, and imaging. QST has limitations and challenges, especially in non-verbal subjects, as shown in the three cases discussed in this report. Future directions call for collaborative efforts to generate sensory datasets and share data registries in the pediatric neurology field.

CHRONIC PAIN AND PHYSICAL THERAPY IN CHILDREN WITH PARALYTIC SYNDROMES: ARE THERE ANY CHANGES DURING LOCKDOWN?

OBJECTIVE

The aim: To evaluate an influence of physical therapy on chronic pain in children with paralytic's syndrome and to maternal emotional status on lockdown time during the COVID-19 pandemic.

PATIENTS AND METHODS

Materials and methods: Data from 96 children and their mothers (96 persons) were included in the study. On-site services of physical therapists before the pandemic (2018- 2019) were received by 64 children and by 32 children during quarantine measures due to COVID-19 pandemic (2020). The age of the children ranged from 1 to 6 years, the median age was 3 years and 3 months.

RESULTS

Results: We note that there were more boys with paralytic syndromes. Among the leading paralytic syndromes, the most common was spastic tetraparesis. The frequency of children with level III-V motor disorders prevailed.

CONCLUSION

Conclusions: The authors consider that physical rehabilitation in children with paralytic syndromes reduces the incidence of moderate chronic pain and improves the emotional state of parents. But, these changes do not occur during the pandemic.

Pain Behavior of People with Intellectual and Developmental Disabilities Coded with the New PAIC-15 and Validation of Its Arabic Translation

Pain management necessitates assessment of pain; the gold standard being self-report. Among individuals with intellectual and developmental disabilities (IDD), self-report may be limited and therefore indirect methods for pain assessment are required. A new, internationally agreed upon and user-friendly observational tool was recently published—the Pain Assessment in Impaired Cognition (PAIC-15). The current study’s aims were: to test the use of the PAIC-15 in assessing pain among people with IDD and to translate the PAIC-15 into Arabic for dissemination among Arabic-speaking professionals. Pain behavior following experimental pressure stimuli was analyzed among 30 individuals with IDD and 15 typically developing controls (TDCs). Translation of the PAIC followed the forward–backward approach; and reliability between the two versions and between raters was calculated. Observational scores with the PAIC-15 exhibited a stimulus–response relationship with pressure stimulation. Those of the IDD group were greater than those of the TDC group. The overall agreement between the English and Arabic versions was high (ICC = 0.89); single items exhibited moderate to high agreement levels. Inter-rater reliability was high (ICC = 0.92). Both versions of the PAIC-15 are feasible and reliable tools to record pain behavior in individuals with IDD. Future studies using these tools in clinical settings are warranted.

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.

Best practices for virtual care to support youth with chronic pain and their families: a rapid systematic review to inform health care and policy during COVID-19 and beyond

Supplemental Digital Content is Available in the Text.

Evidence-informed guidance to better leverage, implement, and select virtual care platforms for pediatric chronic pain, and identified knowledge gaps are in need of additional research.

The COVID-19 pandemic has acutely challenged health systems and catalyzed the need for widescale virtual care and digital solutions across all areas of health, including pediatric chronic pain. The objective of this rapid systematic review was to identify recommendations, guidelines, and/or best practices for using virtual care to support youth with chronic pain and their families (CRD42020184498). MEDLINE, CINAHL, Embase, APA PsychINFO, and Web of Science were searched the week of May 25, 2020, for English language peer-reviewed articles published since 2010 that (1) discussed children and adolescents aged <18 years reporting any type of chronic pain (ie, pain lasting >3 months); (2) focused on any type of virtual care (eg, telephone, telehealth, telemedicine, mHealth, eHealth, online, or digital); and (3) reported on guidelines, best practices, considerations, or recommendations for virtual care. Abstract and full text screening and data extraction were performed in duplicate. Meta-ethnography was used to synthesize concepts across articles. Of 4161 unique records screened, 16 were included addressing diverse virtual care and pediatric chronic pain conditions. Four key themes were identified: (1) opportunities to better leverage virtual care, (2) direct effective implementation of virtual care, (3) selection of virtual care platforms, and (4) gaps in need of further consideration when using virtual care to support youth with chronic pain and their families. No existing guidelines for virtual care for pediatric chronic pain were identified; however, best practices for virtual care were identified and should be used by health professionals, decision makers, and policymakers in implementing virtual care.

Paediatricians' Views on Pain in Children with Profound Intellectual and Multiple Disabilities

Pain is a frequent issue in children with profound intellectual and multiple disabilities (PIMD). Its identification and treatment can prove highly challenging for primary care physicians, mainly because of the children’s limited communication abilities. We used an online survey to explore paediatricians’ views regarding the experience and management of pain in children with PIMD and invited 480 professionals working in the canton of Vaud, Switzerland, to take part. We received 121 responses (participation rate 25.5%). A large majority of respondents provided care to children with PIMD. All paediatricians considered that these children feel pain at least as much as typically developing children. However, paediatricians had mixed views on their tolerance to pain. More than 90% held the view that their pain is under-assessed and undertreated. The principal barriers they reported to appropriate management were communication limitations with the child, difficulties in pain assessment, lack of knowledge about children with disabilities and lack of experience. Paediatricians have complex opinions regarding how children with PIMD experience pain and how to manage this problem. Professional education and training on the specificities of children with PIMD, including how to address their pain, seem necessary to foster paediatricians’ ability and confidence in approaching this complex issue.

Specific Behavioral Responses Rather Than Autonomic Responses Can Indicate and Quantify Acute Pain among Individuals with Intellectual and Developmental Disabilities

Individuals with intellectual and developmental disabilities (IDD) are at a high risk of experiencing pain. Pain management requires assessment, a challenging mission considering the impaired communication skills in IDD. We analyzed subjective and objective responses following calibrated experimental stimuli to determine whether they can differentiate between painful and non-painful states, and adequately quantify pain among individuals with IDD. Eighteen adults with IDD and 21 healthy controls (HC) received experimental pressure stimuli (innocuous, mildly noxious, and moderately noxious). Facial expressions (analyzed with the Facial Action Coding System (FACS)) and autonomic function (heart rate, heart rate variability (HRV), pulse, and galvanic skin response (GSR)) were continuously monitored, and self-reports using a pyramid and a numeric scale were obtained. Significant stimulus-response relationships were observed for the FACS and pyramid scores (but not for the numeric scores), and specific action units could differentiate between the noxious levels among the IDD group. FACS scores of the IDD group were higher and steeper than those of HC. HRV was overall lower among the IDD group, and GSR increased during noxious stimulation in both groups. In conclusion, the facial expressions and self-reports seem to reliably detect and quantify pain among individuals with mild-moderate IDD; their enhanced responses may indicate increased pain sensitivity that requires careful clinical consideration.