Information

Are there any pain scales which measure how much of the body is in pain?

Are there any pain scales which measure how much of the body is in pain?

Are there any pain scales which talk about the extent of pain, i.e. how much of the body is in pain?

I'm in the process of trying to work out whether several lesions, hurt with the same intensity as a single lesion of the same severity.


I can tell you this, in RA the addition of swollen joints in a flair up increases the pain until your number exceeds so many than the pain levels. In arthritis of the spine, spondylosis seams to stay the same as the gradual increase of more arthritic vertebra increases. But when spondyolithisis increased from one to two the pain was double. (The movement forward or sideways of the vertebra) That's all I know,10 years experience.


AUTHOR CONTRIBUTIONS

Dr. Cook: manuscript concept and design. Dr. Dunn, Dr. Griffith, Dr. Morrison, Dr. Tanquary, Dr. Sabata, Dr. Victorson: domain conceptualization and critical review of the manuscript for important intellectual content. Dr. Carey: study supervision, domain conceptualization and critical review of the manuscript for important intellectual content, domain conceptualization, and critical review of the manuscript for important intellectual content. Dr. MacDermid, Dr. Dudgeon, Dr. Gershon: study supervision, domain conceptualization and critical review of the manuscript for important intellectual content.


How Do Doctors Find the Cause of Pain?

If you have pain, your doctor has many ways to find out what’s causing it. They will ask about your symptoms and your medical history, including any illness, injury, or surgery.

Your doctor will also examine you and may order blood tests or X-rays. Among the tests that can help pinpoint the cause of your pain are:

  • CT scan: Computed tomography scans use X-rays and computers to produce an image of a cross-section of the body. During the test, you lie as still as possible on a table. It will move through a large, doughnut-shaped scanning device. Sometimes, your doctor may inject a solution into a vein before your scan. It can help make it easier to see what’s going on inside. Most CT scans take 15 minutes to an hour.
  • MRI:Magnetic resonance imaging can give your doctor clear pictures without X-rays. This test uses a large magnet, radio waves, and a computer to make images. An MRI can take 15 minutes to more than an hour, depending on the number of images made. For certain MRIs, you’ll need a shot of a contrast material to help make clearer images. Because an MRI uses magnets, some people, such as people who have pacemakers, shouldn’t have one.
  • Nerve blocks: These tests can treat and diagnose the cause of your pain. Your doctor injects something to numb pain (an anesthetic) into nerve locations. They may use an imaging test to find the best right place for the needle. Your response to the nerve block may help find out what’s causing your pain or where it’s coming from.
  • Discography: This test is for people who are considering surgery for their back pain. Doctors also use it when they want to do tests before deciding on a treatment. During this test, a dye is injected into the disk that’s thought to be causing the pain. The dye outlines damaged areas on X-rays.
  • Myelogram: This test is for back pain, too. During a myelogram, a dye is injected into your spinal canal. The test helps identify nerve compression caused by herniated disks or fractures.
  • EMG: An electromyogram allows doctors to check muscle activity. Your doctor puts fine needles into your muscles to measure their response to electrical signals.
  • Bone scans: These help diagnose and track infection, fracture, or other disorders in the bone. A doctor injects a small amount of radioactive material into your bloodstream. The material will collect in the bones, particularly in areas that aren't normal. A computer then can identify those specific areas.
  • Ultrasound imaging: Also called ultrasound scanning or sonography, this test uses high-frequency sound waves to get images of the inside of the body. The sound wave echoes are recorded and displayed as a real-time image.

Sources

National Institutes of Health.

Johns Hopkins Medicine: “Sympathetic Nerve Blocks for Pain.”

PubMed Journals: “The Impact of Discography on the Surgical Decision in Patients with Chronic Low Back Pain.”


Pain in Children: Assessment and Nonpharmacological Management

Pain perception in children is complex, and is often difficult to assess. In addition, pain management in children is not always optimized in various healthcare settings, including emergency departments. A review of pain assessment scales that can be used in children across all ages, and a discussion of the importance of pain in control and distraction techniques during painful procedures are presented. Age specific nonpharmacological interventions used to manage pain in children are most effective when adapted to the developmental level of the child. Distraction techniques are often provided by nurses, parents or child life specialists and help in pain alleviation during procedures.

1. Introduction

For pediatric patients presenting to the emergency department, medical procedures are often painful, unexpected, and heightened by situational stress and anxiety leading to an overall unpleasant experience. Although the principles of pain evaluation and management apply across the human lifespan, infants and children present unique challenges that necessitate consideration of the child’s age, developmental level, cognitive and communication skills, previous pain experiences, and associated beliefs [1]. According to the International Association for the Study of Pain, “Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage”. Perception of pain in pediatrics is complex, and entails physiological, psychological, behavioral, and developmental factors [1]. However, in spite of its frequency, pain in infants, children, and adolescent is often underestimated and under treated [2]. It has also been shown that infants and children, who experience pain in early life, show long-term changes in terms of pain perception and related behaviors [2]. Health care professionals in this setting have a responsibility to reduce pain and anxiety as much as possible while maintaining patient safety.

Pain in infants and children can be difficult to assess which has led to the creation of numerous age-specific pain management tools and scores. Health care workers need to be able to detect the symptoms and signs of pain in different age groups and determine whether these symptoms are caused by pain or other factors [1]. It is difficult for health care professionals to foresee which measurement systems apply to accurately measure pain in the pediatric population [1]. Health care professionals often prefer practical methods, which reliably track the child’s pain experience and pain control over time whereas researchers tend to focus on tools, which are meticulously proven for reliability with different observers. Thus a balance may be hard to achieve [1]. Barriers to pain management in children are numerous and include inaccuracies regarding pathophysiological mechanisms of pain with statements such as “children do not feel pain the way adults do” [3], fears regarding the use of pharmacological agents and deficits in knowledge of methods of pain assessment [3, 4]. These myths and other factors such as personal values and beliefs, prevent adequate identification and alleviation of pain for all children [2, 3].

Effective care in pediatrics requires special attention to the developmental stage of the child. Current research does not adequately discuss the effectiveness of certain tools and measurements used to assess pain in children at various ages [5]. The experience of pain and coping strategies from developmental perspective is also limited. In this paper, our aim is to address potential sources of pain measurement, and responses to pain control and distraction based on pediatric developmental stages. Pharmacological pain management will not be discussed, as it is beyond the intended scope of this article.

2. Pain Assessment Tools

Accurate pain measurements in children are difficult to achieve. Three main methods are currently used to measure pain intensity: self report, behavioral, and physiological measures. Self-report measures are optimal and the most valid [4]. Both verbal and nonverbal reports require a certain level of cognitive and language development for the child to understand and give reliable responses [4]. Children’s capability to describe pain increases with age and experience, and changes throughout their developmental stages [4]. Although, observed reports of pain and distress provide helpful information, particularly for younger children, they are reliant on the individuals completing the report [6]. Behavioral measures consist of assessment of crying, facial expressions, body postures, and movements. They are more frequently used with neonates, infants, and younger children where communication is difficult [7]. Physiological measures include assessment of heart rate, blood pressure, respiration, oxygen saturation, palmer sweating, and sometimes neuro-endocrine responses [8]. They are however generally used in combination with behavioral and self-report measures, as they are usually valid for short duration acute pain and differ with the general health and maturational age of the infant or child [8]. In addition, similar physiological responses also occur during stress which results in difficulty distinguishing stress versus pain responses. A summary of the following pain assessment tools by age can be found in Table 1.

2.1. Neonates and Infants

Despite early studies, current research supports that infants possess the anatomical and functional requirements to perceive pain [9]. Recent studies also demonstrate that infants elicit certain behavioral responses to pain perception [10]. Pain in infants, despite this data, remains under-treated and often mismanaged [11]. The most common pain measures used for infants are behavioral. These measures include crying, facial expressions, body posture, and movements. The quality of these behaviors depends on the infant’s gestational age, and maturity [12]. Preterm or acutely ill infants, for example, do not illicit similar responses to pain due to illness and lack of energy. In addition, interpretation of crying in infants is especially difficult as it may indicate general distress rather than pain. Cry characteristics are also not good indicators in preterm or acutely ill infants, as it is difficult for them to produce a robust cry [12].

Numerous scales are currently available to measure behavioral indicators in infants, the most common being the Neonatal Facial Coding System (NFCS) and the Neonatal Infant Pain Scale (NIPS). Other scales used with infants are composite measurement scales, meaning they use a combination of behavioral and physiological measures. Some scales also take into consideration gestational age and the general behavioral state of the infant [13]. Examples of these scales are The Premature Infant Pain Profile (PIPP), Crying Requires Increased Vital Signs Expression Sleeplessness (CRIES), and the Maximally Discriminate Facial Movement Coding System (MAX) [14–16].

Neonatal Facial Coding System (NFCS)
It is used to monitor facial actions in newborns. It was developed at the University of British Columbia, and the British Columbia children’s hospital [17]. The system looks at eight indicators to measure pain intensity: brow bulge, eye squeeze, nasolabial furrow, open lips, stretched mouth (horizontal or vertical), lip purse, tout tongue, and chin quiver [17]. The indicators are recorded on videotape, coded, and scored. It has been proven reliable for short duration, acute pain in infants and neonates [18]. Since some facial actions occur in nonpainful situations, while others (horizontal and vertical mouth stretch) are present in less than 50% of painful situations, NFCS is able to discriminate between degrees of distress, but not between pain-related and nonpain-related distress [19]. The system is also difficult to assess in intubated neonates [19].

Neonatal Infant Pain Scale (NIPS)
It was developed at the Children’s Hospital of Eastern Ontario. It is a behavioral assessment tool to measure pain [20]. The scale takes into account pain measurement before, during and after a painful procedure, scored in one-minute intervals. The indicators include: face, cry, breathing pattern, arms, legs, and state of arousal [20]. Results are obtained by summing up the scores for the six indicators (where 0 indicates no pain, and 2 indicates pain), with a maximum sore of 7 [20]. It is a good system to measure responses to acute painful stimuli. Although it has been fully validated, it is time consuming and hard to interpret in intubated infants.

The Premature Infant Pain Profile (PIPP)
It is a 7-indicator composite measure that was developed at the University of Toronto and McGill University to assess acute pain in preterm and term neonates. It has been validated in studies using synchronized videotaping of infants undergoing painful procedures [14, 21]. The indicators include (1) gestational age, (2) behavioral state before painful stimulus, (3) change in heart rate during stimulus, (4) change in oxygen saturation, (5) brow bulge during painful stimulus, (6) eye squeeze during stimulus, and (7) nasolabial furrow during painful stimulus [14]. Gestational age is taken into consideration. Scoring is initially done before the painful procedure. The infant is observed for 15 seconds and vital signs recorded. Infants are then observed for 30 seconds during the procedure where physiological and facial changes are recorded and scored. The score ranges from 0–21, with the higher score indicating more pain [14]. The PIPP is however burdensome and time consuming for clinical purposes, especially in the emergency department, and its use for intubated neonates remains questionable” [21].

Crying Requires Increased Vital Signs Expression Sleeplessness (CRIES)
It is an acronym of five physiological and behavioral variables proven to indicate neonatal pain. It is commonly used in neonates in the first month of life [15]. The scale was developed at the University of Missouri and may be recorded over time to monitor the infant’s recovery or response to different interventions [22]. CRIES looks at five parameters: (1) crying, where a high pitched cry is usually associated with pain, (2) increased oxygen requirements, as neonates in pain show decrease oxygen saturation, (3) facial expression where grimacing is the expression most associated with pain, (4) vitals signs, which are usually assessed last as to not awaken or disturb the child, and (5) sleeping patterns where increased sleeplessness is associated with pain [15]. Indicators are scored from 0–2 with the maximum possible score of 10, a higher score indicating a higher pain expression [15].

Maximally Discriminate Facial Movement Coding System (MAX)
It is used for infants to assess emotions associated with facial expression. It looks at brow, eye, and mouth movements [16, 23]. MAX provides a system for measuring emotional signals, and identifies nine fundamental emotions: interest, joy, surprise, sadness, anger, disgust, contempt, fear, and physical distress or pain. The scoring entails 68 MAX number codes, each representing a different facial expression. The description of the expression of each number code is based on the anatomically possible movements of the facial muscles and is a description of what the face looks like when the movements have taken place [16]. Critical studies argue that MAX only includes measurements that are said to correspond with emotions and does not differentiate between anatomically distinct facial movements (inner and outer brow raise) [24, 25].

2.2. Toddlers

In toddlers, verbal skills remain limited and quite inconsistent. Pain-related behaviors are still the main indicator for assessments in this age group. Nonverbal behaviors, such as facial expression, limb movement, grasping, holding, and crying, are considered more reliable and objective, measures of pain than self-reports [26]. Most children of this age however are capable of voluntarily producing displays of distress, with older children displaying fewer pain behaviors (e.g., they cry, moan, and groan less often). Most two-year-old children can report the incidence and location of pain, but do not have the adequate cognitive skills to describe its severity [27]. Three-year-old children, however, can start to differentiate the severity of pain, and are able to use a three-level pain intensity scale with simple terms like “no pain, little pain or a lot” [27]. Children in this age group are usually able to participate in simple dialogue and state whether they feel pain and “how bad it is” [27]. The following section describes common scales used for this age group.

The Children's Hospital of Eastern Ontario Pain Scales (CHEOPS)
It is one of the earliest tools used to assess and document pain behaviors in young children [28]. It used to assess the efficacy of interventions used in alleviating pain. It includes six categories of behavior: cry, facial, child verbal, torso, touch, and legs. Each is scored separately (ranging from 0–2 or 1–3) and calculated for a pain score ranging from 4–13 [28]. Its length and changeable scoring system among categories makes it complicated and impractical to use compared to other observational scales.

The Faces Legs Activity Cry Consolability Scale (FLACC)
It is a behavioral scale for measuring the intensity of postprocedural pain in young children [29]. It includes five indicators (face, legs, activity, cry, and consolability) with each item ranking on a three point scale (0–2) for severity by behavioral descriptions resulting in a total score between 0–10 [29]. FLACC is an easy and practical scale to use in evaluating and measuring pain especially in pre-verbal children from 2 months to 7 years. Numerous studies have proven its validity and reliability [30].

The COMFORT Scale
It is a behavioral scale used to measure distress in critically ill unconscious and ventilated infants, children, and adolescents [31, 32]. This scale is composed of 8 indicators: alertness, calmness/agitation, respiratory response, physical movement, blood pressure, heart rate, muscle tone, and facial tension. Each indicator is given a score between 1 and 5 depending on behaviors displayed by the child and the total score is gathered by adding all indicators (range from 8–40). Patients are monitored for two minutes. The COMFORT scale has been proven to be clinically useful to determine if a child is adequately sedated [32].

The Observational Scale of Behavioral Distress (OSBD)
It remains the most frequently used measurement in procedure-related distress studies [33]. It consists of 11 distress behaviors identified by specialists to be associated with paediatric procedure-related distress, anxiety, and pain. Scores are calculated from summing up all 11 distress behaviors. The behaviors are usually organized into categories of growing intensity, considering their level of interference with medical procedures (e.g., moaning, flinching, and disruption of medical materials) [34]. The validity and reliability of the OSBD has been widely reported [35, 36]. Limitations of the OSBD are noted, where the explanations of the different phases of the procedure: anticipatory (when the child is waiting for the procedure), procedural (distress while the procedure is taking place), and recovery (postprocedural distress) are interchangeable among studies [35, 36]. In instances where procedural phases are constant, differences arise in initiating the procedure (e.g., venipunctures) which are frequently independent of the child's behavior, and affect the duration of the procedure and the number of observation intervals. This ultimately increases or decreases the scores [37].

Observational Pain Scale (OPS)
It is intended to measure pain in children aged 1 to 4 years, and is used to assess pain of short or long duration [38]. The scale was primarily produced at the University of Amsterdam in the Netherlands. The scale measures 7 parameters: facial expression, cry, breathing, torso, arms and fingers, legs and toes, and states of arousal [38]. The OPS has a simple scoring system which makes it easy to use by all healthcare professionals to obtain valid and reliable results [39]. The indicators are rated from 0-1 with a maximum score of 7, where the higher score indicates greater discomfort [38].

The Toddler-Preschooler Postoperative Pain Scale (TPPPS)
It is used to assess pain in young children during and after a medical or surgical procedure. It is most commonly used for children aged 1–5 years [40]. In order to observe verbal, facial, and bodily movement, the child needs to be awake. This scale relies on behavioral observations, but also includes a self report element. The TPPPS includes seven indicators divided into three pain behavior groups: vocal pain expression, (verbal complaint, cry, moan) facial pain expression (open mouth, squinted eyes, brow bulging and furrowed forehead) and bodily pain expression (restlessness, rubbing touching painful area) [41]. It is a useful tool for evaluating the effectiveness of medication administration in children, but does not measure pain intensity [42]. If a behavior is present during a 5-minute observation period, a score if 1 is given whereas a score of 0 is given if the behavior was not present. The maximum score obtained is 7, which indicates a high pain intensity [40].

2.3. Preschoolers

By the age of four years, most children are usually able to use 4-5 item pain discrimination scales [43]. Their ability to recognize the influence of pain appears around the age of five years when they are able to rate the intensity of pain [44]. Facial expression scales are most commonly used with this age group to obtain self-reports of pain. These scales require children to point to the face that represents how they feel or the amount of pain they are experiencing [45]. The following section describes scales commonly used with this age group.

The Child Facial Coding System (CFCS)
It is adapted from the neonatal facial coding system and developed for use with preschool children (aged 2–5 years). It consists of 13 facial actions: brow lower, squint, eye squeeze, blink, flared nostril, nose wrinkle, nasolabial furrow, cheek raiser, open lips, upper lip raise, lip corner puller, vertical mouth stretch, and horizontal mouth stretch [46]. The CFCS has been useful with acute short-duration procedural pain [47].

Poker Chip Tool
It is a tool that was developed for pre-schoolers to assess “pieces of hurt” [48]. The tool uses four poker chips, where one chip symbolizes “a little hurt” and four chips “the most hurt you could experience”. The tool is used to assess pain intensity. Health care professionals align the chips in front of the child on a flat surface, and explain, using simple terms, that the chips are “pieces of hurt”. The child is asked “how many pieces of hurt do you have right now?” [49] Although most studies focus on using it in children four to thirteen years old, adolescents have used it successfully as well [50].

Faces Pain Scale
It was developed by Wong and Baker and is recommended for children ages 3 and older [51]. The scale requires health care professionals to point to each face and describe the pain intensity associated with it, and then ask the child to choose the face that most accurately describes his or her pain level [51]. Most pain rating scales using faces that portray degrees of distress are divided into two categories: those starting with neutral face as the “no pain” indicator and those with a smiling face. Results showed that children exposed to smiling scale had considerably higher pain scores in the no pain categories and lower scores for positive pain than children who used the neutral faces scale [52]. A study by Chambers and colleagues indicated that children's pain ratings differ depending on the types of faces scale used, and that faces scales with smiling faces may confuse emotional states with pain ratings [52]. The revised pain scale (FPS-R) is a simplified 6 face adaption of Bieri’s validated faces pain scale. It does not contain smiling faces or tears thus avoiding the confounding of affect and pain intensity [45].

The OUCHER Scale
It was developed by Beyer in 1980 [53]. It is an ethnically based self-report scale, which has three versions: Caucasian, African-American, and Hispanic [54, 55]. Even though it covers a wide array of patients, it still has limits. For example, females are not represented, as well as other cultures. It is used for children older than 5 years [55]. The tool has two separate scales: the numeric scale (i.e., 0–100) and the photographic scale usually used for younger children. The photographic scale entails six different pictures of one child, portraying expressions of “no hurt” to “the biggest hurt you can ever have” [56]. Children are asked to choose the picture or number that closely corresponds to the amount of pain they feel [56].

2.4. School-Aged Children

Health care professionals depend more comfortably on self-reports from school-aged children. Although children at this age understand pain, their use of language to report it is different from adults. At roughly 7 to 8 years of age children, begin to understand the quality of pain [57]. Self-report visual analogue and numerical scales are effective in this age group. A few pain questionnaires have also proven effective for this age such as the pediatric pain questionnaire and the adolescent pediatric pain tool [58, 59]. A brief discussion of these tools is presented here.

Visual Analogue Scale (VAS)
It is a horizontal line, 100 mm in length, attached to word descriptions at each end, “not hurting” or “no pain” to “hurting a whole lot” or “severe pain”. The children are asked to mark on the line the point that they feel represents their pain at this moment [60]. A color analogue scale can also be used, where darker more intense colors (i.e., red) represent more pain [61].

Paediatric Pain Questionnaire
It is a self-report measure to assess children and adolescents coping abilities using 8 subscales “information seeking, problem solving, seeking social support, positive self-statements, behavioral distraction, cognitive distraction, externalizing and internalizing as well as three more complex scales (approach, distraction, and emotion-focused avoidance) [58]. It contains 39 items in total, with scores ranging from 1 (“never”) to 5 (“very often”). Children or adolescents are requested to state how often they “say, do, or think” certain items when they hurt or in pain. The questionnaire usually takes about 10–15 minutes to complete [62].

Adolescent Pediatric Pain Tool (APPT)
It is a valid all encompassing pain assessment tool used for individual pain assessments and measures intensity, location, and quality of pain in children older than 8 years of age [63]. The APPT is most useful with children and adolescents who are experiencing complex, difficult to manage pain [59]. It consists of a body map drawing to allow children to point to the location of pain on their body and a word graphic scale to measure pain intensity. The word graphic rating scale is a 67 word list describing the different dimension of pain and a horizontal line with words attached that range from “no,” “little,” “medium,” “large,” to “worst” possible pain [59, 64–66].

2.5. Adolescents

Adolescents tend to minimize or deny pain, especially in front of friends, so it is important to provide them with privacy and choice. For example, they may or may not choose to have parents present. They expect developmentally appropriate information about procedures and accompanying sensations. Some adolescents regress in behavior under stress [3]. They also need to feel able to accept or refuse strategies and medications to make procedures more tolerable. To assess pain and, specifically chronic pain, the adolescent pediatric pain tool (see above section) or the McGill pain questionnaire are helpful.

The McGill Pain Questionnaire (MPQ)
It was developed by Melzack in 1971 [67]. It is an assessment tool that combines a list of questions about the nature and frequency of pain with a body-map diagram to pinpoint its location [68]. The questionnaire uses word lists separated into 4 classes to assess the total pain experience. The categories are (1) sensory, which contains words describing pain in terms of time, space, pressure, heat, and brightness, (2) affective category which describes pain in terms of tension, fear, and autonomic properties, (3) evaluative, and (4) miscellaneous. After the patient is done rating their pain words, the administrator allocates a numerical score, called the “Pain Rating Index” [69]. Scores vary from 0–78 with the higher score indicating greater pain [68].

3. Minimizing Pain during Procedures: Nonpharmacologic Methods

Pain is one of the most frequent complaints presented in paediatric emergency settings. The emergency department itself is a very stressful place for children. Thus it is important for health care providers to follow a child centered or individual approach in their assessment and management of pain and painful procedures [70]. This approach promotes the right of the child to be fully involved in the procedure, to choose, associate, and communicate. It allows freedom for children to think, experience, explore, question, and search for answers, and allows them to feel proud for doing things for themselves. It is essential to focus on the child rather than the procedure and avoid statements such as “let’s just get it over with” [70]. The child and family should be active participants in the procedure. In fact, allowing parents or family members to act as positive assistants rather than negative restraints helps to reduce stress in both children and parents and minimizes the pain experience [70]. It is also essential to ensure that all procedures are truly necessary, and can be performed safely by experienced personnel. Ideally procedures should be done in a child-friendly environment, using appropriate pharmacologic and nonpharmacologic interventions with routine pain assessment and reassessment [70].

Distraction is the most frequent intervention used in the emergency department to guide children’s attention away from the painful stimuli and reduce pain and anxiety. It is most effective when adapted to the developmental level of the child [71]. Distraction techniques are often provided by nurses, parents or child life specialists. Current research has shown that distraction can lead to the reduction in procedure times, and the number of staff required for the procedure [72]. Distraction has also proven to be more economical than using certain analgesics [73]. Distraction is divided into two main categories: passive distraction, which calls for the child to remain quiet while the health care professional is actively distracting the child (i.e., by singing, talking, or reading a book) [74]. Active distraction, on the other hand, encourages the child’s participation in the activities during the procedures [74]. Interventions used to minimise pain are classified into three main categories (cognitive, behavioral, or combined) [75].

Cognitive Interventions
They are mostly used with older children to direct attention away from procedure-related pain (e.g., counting, listening to music, non procedure-related talk) [76]. The following are a few examples of cognitive interventions: (1) Imagery. The child is asked to imagine an enjoyable item or experience (e.g., playing on the beach) [77]. (2) Preparation/Education/Information. The procedure and feelings associated with the procedure are explained to child in an age appropriate manner. The child is provided with instructions about what he/she will need to do during the procedure to help them understand what to expect [78, 79]. (3) Coping statements. The child is taught to repeat a set of positive thoughts (e.g., “I can do this” or “this will be over soon”) [80]. (4) Parental training. The parents or family members are taught one of the above interventions to decrease their stress, as decreasing the parent's distress will often lead to a decrease in the child's distress [77]. (5) Video games and television. These may be used to distract children from the painful procedures [81].

Behavioral Interventions
They are behavioral methods to guide the child’s attention away from procedure-related pain. (e.g., videotapes, games, interactive books). A few examples are: (1) Breathing exercises. The child is taught to concentrate on deep breathing. To engage younger children, health care professionals can use party blowers, or blowing bubbles [82]. (2) Modeling positive coping behaviors. The child may watch another child or adult going through the procedure, and rehearse these behaviors [83]. (3) Desensitization. This is a step-by-step approach to coping with the painful stimuli. It involves slowly introducing the procedure and tasks involved, and effectively dealing with easier tasks before moving to the next one [77]. (4) Positive reinforcement. The child is rewarded with positive statements or concrete gifts, after the painful procedure (e.g., stickers, toys, games, small trophies) [80]. (5) Parent coaching. The parents are instructed to enthusiastically encourage the child to use these strategies [84].

Current studies are beginning to take into consideration children’s different responses to distraction interventions based on their developmental stage, maturity level, and age. Our goal in this section is to provide various forms of distraction that are proven effective with different age groups.

3.1. Neonates and Infants

When performing painful procedures on infants, it is important to take into consideration the context of the procedure (i.e., is the procedure really necessary, how many painful procedures has the infant had in the past, and what was their previous pain experience) [85]. The procedural environment should also be developmentally sensitive [86]. In fact, reducing noise and lighting, use of soothing smells and clustering procedures to avoid over handling, reduces pain reactions in infants [86].

Distraction techniques used with this age group are mostly passive. Cognitive strategies used to reduce pain perception in infants are either visual or auditory interventions. Visual aids can include pictures, cartoons, mobile phones, and mirrors [87]. Auditory aids include music, lullabies sung by parents or health care professionals [88]. Music is more frequently being used to improve painful outcomes in infants [89]. Studies suggest that music can significantly impact behavioral reactions to pain, but not physiological measures [89]. Behavioral strategies are more common for this age group, and involve either “direct or indirect” interventions that engage the caregivers in handling the infants [90]. The combination of different strategies to provoke different senses has been shown to be more effective [91]. Examples of behavioral strategies include the following. (1) Non-nutritive sucking, an indirect intervention involving insertion of a pacifier or a nonlactating nipple into the infant’s mouth to encourage sucking behaviors, was found to stimulate the orotactile and mechano receptors, and decrease cry durations and heart rate [92]. (2) Skin to skin contact with the mother (kangaroo care), where the infant is positioned on the mother’s exposed chest during, or after the painful procedure [93]. (3) Rocking and holding the infant, where the infant is carried by a parent or caregiver during (if possible) and after the painful procedure and gently rocked [94]. (4) Swaddling the infant is another similar calming technique where the infant is wrapped with its extremities close to their trunk to prevent him/her from moving around excessively [95].

3.2. Toddlers and Preschoolers

For young children, explaining the procedures with age appropriate information is useful, in addition to providing them with the opportunities to ask questions [70]. Examples for active distraction used with this age group include, allowing them to blow bubbles, providing toys with lots of colour or toys that light up. Initiating distracting conservations (e.g., how many brothers and sisters do you have? What did you do at your birthday party?) and deep breathing methods are also helpful for older children [74]. Passive distraction techniques include: having the parents or child life specialist read age appropriate books, sing songs, and practicing “blowing out birthday candles” with the child [74].

3.3. School-Aged Children

Older children have a better understanding of procedures and why they are being done, thus providing them with age appropriate information is also important [70]. Providing children with a choice (e.g., sit or lie down, choose which hand) helps them feel in control of the situation [70]. Asking parents about their child’s previous pain experiences and coping mechanisms helps health care professionals identify appropriate interventions to use with the child. Educating school-aged children about passive and active techniques available will help them cope with the distress and anxiety of the procedure [70]. Active techniques for this age group include blowing bubbles, singing songs, squeeze balls, relaxation breathing and playing with electronic devices [74]. Passive distraction can include watching videos, listening to music on headphones, reading a book to the child or telling them a story [74].

3.4. Adolescents

It is essential to always ensure a private setting for procedures with adolescents especially as they sometimes tend to deny pain in front of friends, and family. Giving them the power to choose the type of distraction, or whether they want friends and family present is helpful [70]. Striking conversations, using squeeze balls or having them play with electronic devices are examples of active techniques, while passive distractions include watching videos, training them to breathe deeply (in from the nose, count to 5 and out through the mouth), and listening to music [74].

4. Conclusion

Although there is an overwhelming amount of data regarding effective paediatric pain assessment and management, it is often not being effectively applied. Current studies demonstrate pain management in children remains undertreated. It is the responsibility of health care professionals to educate their peers and advocate for appropriate pain treatment in children. Infants and children present a unique challenge that necessitate consideration of their age, developmental level, cognitive and communication skills, previous pain experiences, and associated beliefs. There is a need for more research to illuminate optimal pain management and strategies that take these special needs into consideration, to improve the treatment of pain in children.

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Copyright

Copyright © 2010 Rasha Srouji et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


How Do Doctors Find the Cause of Pain?

If you have pain, your doctor has many ways to find out what’s causing it. They will ask about your symptoms and your medical history, including any illness, injury, or surgery.

Your doctor will also examine you and may order blood tests or X-rays. Among the tests that can help pinpoint the cause of your pain are:

  • CT scan: Computed tomography scans use X-rays and computers to produce an image of a cross-section of the body. During the test, you lie as still as possible on a table. It will move through a large, doughnut-shaped scanning device. Sometimes, your doctor may inject a solution into a vein before your scan. It can help make it easier to see what’s going on inside. Most CT scans take 15 minutes to an hour.
  • MRI:Magnetic resonance imaging can give your doctor clear pictures without X-rays. This test uses a large magnet, radio waves, and a computer to make images. An MRI can take 15 minutes to more than an hour, depending on the number of images made. For certain MRIs, you’ll need a shot of a contrast material to help make clearer images. Because an MRI uses magnets, some people, such as people who have pacemakers, shouldn’t have one.
  • Nerve blocks: These tests can treat and diagnose the cause of your pain. Your doctor injects something to numb pain (an anesthetic) into nerve locations. They may use an imaging test to find the best right place for the needle. Your response to the nerve block may help find out what’s causing your pain or where it’s coming from.
  • Discography: This test is for people who are considering surgery for their back pain. Doctors also use it when they want to do tests before deciding on a treatment. During this test, a dye is injected into the disk that’s thought to be causing the pain. The dye outlines damaged areas on X-rays.
  • Myelogram: This test is for back pain, too. During a myelogram, a dye is injected into your spinal canal. The test helps identify nerve compression caused by herniated disks or fractures.
  • EMG: An electromyogram allows doctors to check muscle activity. Your doctor puts fine needles into your muscles to measure their response to electrical signals.
  • Bone scans: These help diagnose and track infection, fracture, or other disorders in the bone. A doctor injects a small amount of radioactive material into your bloodstream. The material will collect in the bones, particularly in areas that aren't normal. A computer then can identify those specific areas.
  • Ultrasound imaging: Also called ultrasound scanning or sonography, this test uses high-frequency sound waves to get images of the inside of the body. The sound wave echoes are recorded and displayed as a real-time image.

Sources

National Institutes of Health.

Johns Hopkins Medicine: “Sympathetic Nerve Blocks for Pain.”

PubMed Journals: “The Impact of Discography on the Surgical Decision in Patients with Chronic Low Back Pain.”


AUTHOR CONTRIBUTIONS

Dr. Cook: manuscript concept and design. Dr. Dunn, Dr. Griffith, Dr. Morrison, Dr. Tanquary, Dr. Sabata, Dr. Victorson: domain conceptualization and critical review of the manuscript for important intellectual content. Dr. Carey: study supervision, domain conceptualization and critical review of the manuscript for important intellectual content, domain conceptualization, and critical review of the manuscript for important intellectual content. Dr. MacDermid, Dr. Dudgeon, Dr. Gershon: study supervision, domain conceptualization and critical review of the manuscript for important intellectual content.


Pain in Children: Assessment and Nonpharmacological Management

Pain perception in children is complex, and is often difficult to assess. In addition, pain management in children is not always optimized in various healthcare settings, including emergency departments. A review of pain assessment scales that can be used in children across all ages, and a discussion of the importance of pain in control and distraction techniques during painful procedures are presented. Age specific nonpharmacological interventions used to manage pain in children are most effective when adapted to the developmental level of the child. Distraction techniques are often provided by nurses, parents or child life specialists and help in pain alleviation during procedures.

1. Introduction

For pediatric patients presenting to the emergency department, medical procedures are often painful, unexpected, and heightened by situational stress and anxiety leading to an overall unpleasant experience. Although the principles of pain evaluation and management apply across the human lifespan, infants and children present unique challenges that necessitate consideration of the child’s age, developmental level, cognitive and communication skills, previous pain experiences, and associated beliefs [1]. According to the International Association for the Study of Pain, “Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage”. Perception of pain in pediatrics is complex, and entails physiological, psychological, behavioral, and developmental factors [1]. However, in spite of its frequency, pain in infants, children, and adolescent is often underestimated and under treated [2]. It has also been shown that infants and children, who experience pain in early life, show long-term changes in terms of pain perception and related behaviors [2]. Health care professionals in this setting have a responsibility to reduce pain and anxiety as much as possible while maintaining patient safety.

Pain in infants and children can be difficult to assess which has led to the creation of numerous age-specific pain management tools and scores. Health care workers need to be able to detect the symptoms and signs of pain in different age groups and determine whether these symptoms are caused by pain or other factors [1]. It is difficult for health care professionals to foresee which measurement systems apply to accurately measure pain in the pediatric population [1]. Health care professionals often prefer practical methods, which reliably track the child’s pain experience and pain control over time whereas researchers tend to focus on tools, which are meticulously proven for reliability with different observers. Thus a balance may be hard to achieve [1]. Barriers to pain management in children are numerous and include inaccuracies regarding pathophysiological mechanisms of pain with statements such as “children do not feel pain the way adults do” [3], fears regarding the use of pharmacological agents and deficits in knowledge of methods of pain assessment [3, 4]. These myths and other factors such as personal values and beliefs, prevent adequate identification and alleviation of pain for all children [2, 3].

Effective care in pediatrics requires special attention to the developmental stage of the child. Current research does not adequately discuss the effectiveness of certain tools and measurements used to assess pain in children at various ages [5]. The experience of pain and coping strategies from developmental perspective is also limited. In this paper, our aim is to address potential sources of pain measurement, and responses to pain control and distraction based on pediatric developmental stages. Pharmacological pain management will not be discussed, as it is beyond the intended scope of this article.

2. Pain Assessment Tools

Accurate pain measurements in children are difficult to achieve. Three main methods are currently used to measure pain intensity: self report, behavioral, and physiological measures. Self-report measures are optimal and the most valid [4]. Both verbal and nonverbal reports require a certain level of cognitive and language development for the child to understand and give reliable responses [4]. Children’s capability to describe pain increases with age and experience, and changes throughout their developmental stages [4]. Although, observed reports of pain and distress provide helpful information, particularly for younger children, they are reliant on the individuals completing the report [6]. Behavioral measures consist of assessment of crying, facial expressions, body postures, and movements. They are more frequently used with neonates, infants, and younger children where communication is difficult [7]. Physiological measures include assessment of heart rate, blood pressure, respiration, oxygen saturation, palmer sweating, and sometimes neuro-endocrine responses [8]. They are however generally used in combination with behavioral and self-report measures, as they are usually valid for short duration acute pain and differ with the general health and maturational age of the infant or child [8]. In addition, similar physiological responses also occur during stress which results in difficulty distinguishing stress versus pain responses. A summary of the following pain assessment tools by age can be found in Table 1.

2.1. Neonates and Infants

Despite early studies, current research supports that infants possess the anatomical and functional requirements to perceive pain [9]. Recent studies also demonstrate that infants elicit certain behavioral responses to pain perception [10]. Pain in infants, despite this data, remains under-treated and often mismanaged [11]. The most common pain measures used for infants are behavioral. These measures include crying, facial expressions, body posture, and movements. The quality of these behaviors depends on the infant’s gestational age, and maturity [12]. Preterm or acutely ill infants, for example, do not illicit similar responses to pain due to illness and lack of energy. In addition, interpretation of crying in infants is especially difficult as it may indicate general distress rather than pain. Cry characteristics are also not good indicators in preterm or acutely ill infants, as it is difficult for them to produce a robust cry [12].

Numerous scales are currently available to measure behavioral indicators in infants, the most common being the Neonatal Facial Coding System (NFCS) and the Neonatal Infant Pain Scale (NIPS). Other scales used with infants are composite measurement scales, meaning they use a combination of behavioral and physiological measures. Some scales also take into consideration gestational age and the general behavioral state of the infant [13]. Examples of these scales are The Premature Infant Pain Profile (PIPP), Crying Requires Increased Vital Signs Expression Sleeplessness (CRIES), and the Maximally Discriminate Facial Movement Coding System (MAX) [14–16].

Neonatal Facial Coding System (NFCS)
It is used to monitor facial actions in newborns. It was developed at the University of British Columbia, and the British Columbia children’s hospital [17]. The system looks at eight indicators to measure pain intensity: brow bulge, eye squeeze, nasolabial furrow, open lips, stretched mouth (horizontal or vertical), lip purse, tout tongue, and chin quiver [17]. The indicators are recorded on videotape, coded, and scored. It has been proven reliable for short duration, acute pain in infants and neonates [18]. Since some facial actions occur in nonpainful situations, while others (horizontal and vertical mouth stretch) are present in less than 50% of painful situations, NFCS is able to discriminate between degrees of distress, but not between pain-related and nonpain-related distress [19]. The system is also difficult to assess in intubated neonates [19].

Neonatal Infant Pain Scale (NIPS)
It was developed at the Children’s Hospital of Eastern Ontario. It is a behavioral assessment tool to measure pain [20]. The scale takes into account pain measurement before, during and after a painful procedure, scored in one-minute intervals. The indicators include: face, cry, breathing pattern, arms, legs, and state of arousal [20]. Results are obtained by summing up the scores for the six indicators (where 0 indicates no pain, and 2 indicates pain), with a maximum sore of 7 [20]. It is a good system to measure responses to acute painful stimuli. Although it has been fully validated, it is time consuming and hard to interpret in intubated infants.

The Premature Infant Pain Profile (PIPP)
It is a 7-indicator composite measure that was developed at the University of Toronto and McGill University to assess acute pain in preterm and term neonates. It has been validated in studies using synchronized videotaping of infants undergoing painful procedures [14, 21]. The indicators include (1) gestational age, (2) behavioral state before painful stimulus, (3) change in heart rate during stimulus, (4) change in oxygen saturation, (5) brow bulge during painful stimulus, (6) eye squeeze during stimulus, and (7) nasolabial furrow during painful stimulus [14]. Gestational age is taken into consideration. Scoring is initially done before the painful procedure. The infant is observed for 15 seconds and vital signs recorded. Infants are then observed for 30 seconds during the procedure where physiological and facial changes are recorded and scored. The score ranges from 0–21, with the higher score indicating more pain [14]. The PIPP is however burdensome and time consuming for clinical purposes, especially in the emergency department, and its use for intubated neonates remains questionable” [21].

Crying Requires Increased Vital Signs Expression Sleeplessness (CRIES)
It is an acronym of five physiological and behavioral variables proven to indicate neonatal pain. It is commonly used in neonates in the first month of life [15]. The scale was developed at the University of Missouri and may be recorded over time to monitor the infant’s recovery or response to different interventions [22]. CRIES looks at five parameters: (1) crying, where a high pitched cry is usually associated with pain, (2) increased oxygen requirements, as neonates in pain show decrease oxygen saturation, (3) facial expression where grimacing is the expression most associated with pain, (4) vitals signs, which are usually assessed last as to not awaken or disturb the child, and (5) sleeping patterns where increased sleeplessness is associated with pain [15]. Indicators are scored from 0–2 with the maximum possible score of 10, a higher score indicating a higher pain expression [15].

Maximally Discriminate Facial Movement Coding System (MAX)
It is used for infants to assess emotions associated with facial expression. It looks at brow, eye, and mouth movements [16, 23]. MAX provides a system for measuring emotional signals, and identifies nine fundamental emotions: interest, joy, surprise, sadness, anger, disgust, contempt, fear, and physical distress or pain. The scoring entails 68 MAX number codes, each representing a different facial expression. The description of the expression of each number code is based on the anatomically possible movements of the facial muscles and is a description of what the face looks like when the movements have taken place [16]. Critical studies argue that MAX only includes measurements that are said to correspond with emotions and does not differentiate between anatomically distinct facial movements (inner and outer brow raise) [24, 25].

2.2. Toddlers

In toddlers, verbal skills remain limited and quite inconsistent. Pain-related behaviors are still the main indicator for assessments in this age group. Nonverbal behaviors, such as facial expression, limb movement, grasping, holding, and crying, are considered more reliable and objective, measures of pain than self-reports [26]. Most children of this age however are capable of voluntarily producing displays of distress, with older children displaying fewer pain behaviors (e.g., they cry, moan, and groan less often). Most two-year-old children can report the incidence and location of pain, but do not have the adequate cognitive skills to describe its severity [27]. Three-year-old children, however, can start to differentiate the severity of pain, and are able to use a three-level pain intensity scale with simple terms like “no pain, little pain or a lot” [27]. Children in this age group are usually able to participate in simple dialogue and state whether they feel pain and “how bad it is” [27]. The following section describes common scales used for this age group.

The Children's Hospital of Eastern Ontario Pain Scales (CHEOPS)
It is one of the earliest tools used to assess and document pain behaviors in young children [28]. It used to assess the efficacy of interventions used in alleviating pain. It includes six categories of behavior: cry, facial, child verbal, torso, touch, and legs. Each is scored separately (ranging from 0–2 or 1–3) and calculated for a pain score ranging from 4–13 [28]. Its length and changeable scoring system among categories makes it complicated and impractical to use compared to other observational scales.

The Faces Legs Activity Cry Consolability Scale (FLACC)
It is a behavioral scale for measuring the intensity of postprocedural pain in young children [29]. It includes five indicators (face, legs, activity, cry, and consolability) with each item ranking on a three point scale (0–2) for severity by behavioral descriptions resulting in a total score between 0–10 [29]. FLACC is an easy and practical scale to use in evaluating and measuring pain especially in pre-verbal children from 2 months to 7 years. Numerous studies have proven its validity and reliability [30].

The COMFORT Scale
It is a behavioral scale used to measure distress in critically ill unconscious and ventilated infants, children, and adolescents [31, 32]. This scale is composed of 8 indicators: alertness, calmness/agitation, respiratory response, physical movement, blood pressure, heart rate, muscle tone, and facial tension. Each indicator is given a score between 1 and 5 depending on behaviors displayed by the child and the total score is gathered by adding all indicators (range from 8–40). Patients are monitored for two minutes. The COMFORT scale has been proven to be clinically useful to determine if a child is adequately sedated [32].

The Observational Scale of Behavioral Distress (OSBD)
It remains the most frequently used measurement in procedure-related distress studies [33]. It consists of 11 distress behaviors identified by specialists to be associated with paediatric procedure-related distress, anxiety, and pain. Scores are calculated from summing up all 11 distress behaviors. The behaviors are usually organized into categories of growing intensity, considering their level of interference with medical procedures (e.g., moaning, flinching, and disruption of medical materials) [34]. The validity and reliability of the OSBD has been widely reported [35, 36]. Limitations of the OSBD are noted, where the explanations of the different phases of the procedure: anticipatory (when the child is waiting for the procedure), procedural (distress while the procedure is taking place), and recovery (postprocedural distress) are interchangeable among studies [35, 36]. In instances where procedural phases are constant, differences arise in initiating the procedure (e.g., venipunctures) which are frequently independent of the child's behavior, and affect the duration of the procedure and the number of observation intervals. This ultimately increases or decreases the scores [37].

Observational Pain Scale (OPS)
It is intended to measure pain in children aged 1 to 4 years, and is used to assess pain of short or long duration [38]. The scale was primarily produced at the University of Amsterdam in the Netherlands. The scale measures 7 parameters: facial expression, cry, breathing, torso, arms and fingers, legs and toes, and states of arousal [38]. The OPS has a simple scoring system which makes it easy to use by all healthcare professionals to obtain valid and reliable results [39]. The indicators are rated from 0-1 with a maximum score of 7, where the higher score indicates greater discomfort [38].

The Toddler-Preschooler Postoperative Pain Scale (TPPPS)
It is used to assess pain in young children during and after a medical or surgical procedure. It is most commonly used for children aged 1–5 years [40]. In order to observe verbal, facial, and bodily movement, the child needs to be awake. This scale relies on behavioral observations, but also includes a self report element. The TPPPS includes seven indicators divided into three pain behavior groups: vocal pain expression, (verbal complaint, cry, moan) facial pain expression (open mouth, squinted eyes, brow bulging and furrowed forehead) and bodily pain expression (restlessness, rubbing touching painful area) [41]. It is a useful tool for evaluating the effectiveness of medication administration in children, but does not measure pain intensity [42]. If a behavior is present during a 5-minute observation period, a score if 1 is given whereas a score of 0 is given if the behavior was not present. The maximum score obtained is 7, which indicates a high pain intensity [40].

2.3. Preschoolers

By the age of four years, most children are usually able to use 4-5 item pain discrimination scales [43]. Their ability to recognize the influence of pain appears around the age of five years when they are able to rate the intensity of pain [44]. Facial expression scales are most commonly used with this age group to obtain self-reports of pain. These scales require children to point to the face that represents how they feel or the amount of pain they are experiencing [45]. The following section describes scales commonly used with this age group.

The Child Facial Coding System (CFCS)
It is adapted from the neonatal facial coding system and developed for use with preschool children (aged 2–5 years). It consists of 13 facial actions: brow lower, squint, eye squeeze, blink, flared nostril, nose wrinkle, nasolabial furrow, cheek raiser, open lips, upper lip raise, lip corner puller, vertical mouth stretch, and horizontal mouth stretch [46]. The CFCS has been useful with acute short-duration procedural pain [47].

Poker Chip Tool
It is a tool that was developed for pre-schoolers to assess “pieces of hurt” [48]. The tool uses four poker chips, where one chip symbolizes “a little hurt” and four chips “the most hurt you could experience”. The tool is used to assess pain intensity. Health care professionals align the chips in front of the child on a flat surface, and explain, using simple terms, that the chips are “pieces of hurt”. The child is asked “how many pieces of hurt do you have right now?” [49] Although most studies focus on using it in children four to thirteen years old, adolescents have used it successfully as well [50].

Faces Pain Scale
It was developed by Wong and Baker and is recommended for children ages 3 and older [51]. The scale requires health care professionals to point to each face and describe the pain intensity associated with it, and then ask the child to choose the face that most accurately describes his or her pain level [51]. Most pain rating scales using faces that portray degrees of distress are divided into two categories: those starting with neutral face as the “no pain” indicator and those with a smiling face. Results showed that children exposed to smiling scale had considerably higher pain scores in the no pain categories and lower scores for positive pain than children who used the neutral faces scale [52]. A study by Chambers and colleagues indicated that children's pain ratings differ depending on the types of faces scale used, and that faces scales with smiling faces may confuse emotional states with pain ratings [52]. The revised pain scale (FPS-R) is a simplified 6 face adaption of Bieri’s validated faces pain scale. It does not contain smiling faces or tears thus avoiding the confounding of affect and pain intensity [45].

The OUCHER Scale
It was developed by Beyer in 1980 [53]. It is an ethnically based self-report scale, which has three versions: Caucasian, African-American, and Hispanic [54, 55]. Even though it covers a wide array of patients, it still has limits. For example, females are not represented, as well as other cultures. It is used for children older than 5 years [55]. The tool has two separate scales: the numeric scale (i.e., 0–100) and the photographic scale usually used for younger children. The photographic scale entails six different pictures of one child, portraying expressions of “no hurt” to “the biggest hurt you can ever have” [56]. Children are asked to choose the picture or number that closely corresponds to the amount of pain they feel [56].

2.4. School-Aged Children

Health care professionals depend more comfortably on self-reports from school-aged children. Although children at this age understand pain, their use of language to report it is different from adults. At roughly 7 to 8 years of age children, begin to understand the quality of pain [57]. Self-report visual analogue and numerical scales are effective in this age group. A few pain questionnaires have also proven effective for this age such as the pediatric pain questionnaire and the adolescent pediatric pain tool [58, 59]. A brief discussion of these tools is presented here.

Visual Analogue Scale (VAS)
It is a horizontal line, 100 mm in length, attached to word descriptions at each end, “not hurting” or “no pain” to “hurting a whole lot” or “severe pain”. The children are asked to mark on the line the point that they feel represents their pain at this moment [60]. A color analogue scale can also be used, where darker more intense colors (i.e., red) represent more pain [61].

Paediatric Pain Questionnaire
It is a self-report measure to assess children and adolescents coping abilities using 8 subscales “information seeking, problem solving, seeking social support, positive self-statements, behavioral distraction, cognitive distraction, externalizing and internalizing as well as three more complex scales (approach, distraction, and emotion-focused avoidance) [58]. It contains 39 items in total, with scores ranging from 1 (“never”) to 5 (“very often”). Children or adolescents are requested to state how often they “say, do, or think” certain items when they hurt or in pain. The questionnaire usually takes about 10–15 minutes to complete [62].

Adolescent Pediatric Pain Tool (APPT)
It is a valid all encompassing pain assessment tool used for individual pain assessments and measures intensity, location, and quality of pain in children older than 8 years of age [63]. The APPT is most useful with children and adolescents who are experiencing complex, difficult to manage pain [59]. It consists of a body map drawing to allow children to point to the location of pain on their body and a word graphic scale to measure pain intensity. The word graphic rating scale is a 67 word list describing the different dimension of pain and a horizontal line with words attached that range from “no,” “little,” “medium,” “large,” to “worst” possible pain [59, 64–66].

2.5. Adolescents

Adolescents tend to minimize or deny pain, especially in front of friends, so it is important to provide them with privacy and choice. For example, they may or may not choose to have parents present. They expect developmentally appropriate information about procedures and accompanying sensations. Some adolescents regress in behavior under stress [3]. They also need to feel able to accept or refuse strategies and medications to make procedures more tolerable. To assess pain and, specifically chronic pain, the adolescent pediatric pain tool (see above section) or the McGill pain questionnaire are helpful.

The McGill Pain Questionnaire (MPQ)
It was developed by Melzack in 1971 [67]. It is an assessment tool that combines a list of questions about the nature and frequency of pain with a body-map diagram to pinpoint its location [68]. The questionnaire uses word lists separated into 4 classes to assess the total pain experience. The categories are (1) sensory, which contains words describing pain in terms of time, space, pressure, heat, and brightness, (2) affective category which describes pain in terms of tension, fear, and autonomic properties, (3) evaluative, and (4) miscellaneous. After the patient is done rating their pain words, the administrator allocates a numerical score, called the “Pain Rating Index” [69]. Scores vary from 0–78 with the higher score indicating greater pain [68].

3. Minimizing Pain during Procedures: Nonpharmacologic Methods

Pain is one of the most frequent complaints presented in paediatric emergency settings. The emergency department itself is a very stressful place for children. Thus it is important for health care providers to follow a child centered or individual approach in their assessment and management of pain and painful procedures [70]. This approach promotes the right of the child to be fully involved in the procedure, to choose, associate, and communicate. It allows freedom for children to think, experience, explore, question, and search for answers, and allows them to feel proud for doing things for themselves. It is essential to focus on the child rather than the procedure and avoid statements such as “let’s just get it over with” [70]. The child and family should be active participants in the procedure. In fact, allowing parents or family members to act as positive assistants rather than negative restraints helps to reduce stress in both children and parents and minimizes the pain experience [70]. It is also essential to ensure that all procedures are truly necessary, and can be performed safely by experienced personnel. Ideally procedures should be done in a child-friendly environment, using appropriate pharmacologic and nonpharmacologic interventions with routine pain assessment and reassessment [70].

Distraction is the most frequent intervention used in the emergency department to guide children’s attention away from the painful stimuli and reduce pain and anxiety. It is most effective when adapted to the developmental level of the child [71]. Distraction techniques are often provided by nurses, parents or child life specialists. Current research has shown that distraction can lead to the reduction in procedure times, and the number of staff required for the procedure [72]. Distraction has also proven to be more economical than using certain analgesics [73]. Distraction is divided into two main categories: passive distraction, which calls for the child to remain quiet while the health care professional is actively distracting the child (i.e., by singing, talking, or reading a book) [74]. Active distraction, on the other hand, encourages the child’s participation in the activities during the procedures [74]. Interventions used to minimise pain are classified into three main categories (cognitive, behavioral, or combined) [75].

Cognitive Interventions
They are mostly used with older children to direct attention away from procedure-related pain (e.g., counting, listening to music, non procedure-related talk) [76]. The following are a few examples of cognitive interventions: (1) Imagery. The child is asked to imagine an enjoyable item or experience (e.g., playing on the beach) [77]. (2) Preparation/Education/Information. The procedure and feelings associated with the procedure are explained to child in an age appropriate manner. The child is provided with instructions about what he/she will need to do during the procedure to help them understand what to expect [78, 79]. (3) Coping statements. The child is taught to repeat a set of positive thoughts (e.g., “I can do this” or “this will be over soon”) [80]. (4) Parental training. The parents or family members are taught one of the above interventions to decrease their stress, as decreasing the parent's distress will often lead to a decrease in the child's distress [77]. (5) Video games and television. These may be used to distract children from the painful procedures [81].

Behavioral Interventions
They are behavioral methods to guide the child’s attention away from procedure-related pain. (e.g., videotapes, games, interactive books). A few examples are: (1) Breathing exercises. The child is taught to concentrate on deep breathing. To engage younger children, health care professionals can use party blowers, or blowing bubbles [82]. (2) Modeling positive coping behaviors. The child may watch another child or adult going through the procedure, and rehearse these behaviors [83]. (3) Desensitization. This is a step-by-step approach to coping with the painful stimuli. It involves slowly introducing the procedure and tasks involved, and effectively dealing with easier tasks before moving to the next one [77]. (4) Positive reinforcement. The child is rewarded with positive statements or concrete gifts, after the painful procedure (e.g., stickers, toys, games, small trophies) [80]. (5) Parent coaching. The parents are instructed to enthusiastically encourage the child to use these strategies [84].

Current studies are beginning to take into consideration children’s different responses to distraction interventions based on their developmental stage, maturity level, and age. Our goal in this section is to provide various forms of distraction that are proven effective with different age groups.

3.1. Neonates and Infants

When performing painful procedures on infants, it is important to take into consideration the context of the procedure (i.e., is the procedure really necessary, how many painful procedures has the infant had in the past, and what was their previous pain experience) [85]. The procedural environment should also be developmentally sensitive [86]. In fact, reducing noise and lighting, use of soothing smells and clustering procedures to avoid over handling, reduces pain reactions in infants [86].

Distraction techniques used with this age group are mostly passive. Cognitive strategies used to reduce pain perception in infants are either visual or auditory interventions. Visual aids can include pictures, cartoons, mobile phones, and mirrors [87]. Auditory aids include music, lullabies sung by parents or health care professionals [88]. Music is more frequently being used to improve painful outcomes in infants [89]. Studies suggest that music can significantly impact behavioral reactions to pain, but not physiological measures [89]. Behavioral strategies are more common for this age group, and involve either “direct or indirect” interventions that engage the caregivers in handling the infants [90]. The combination of different strategies to provoke different senses has been shown to be more effective [91]. Examples of behavioral strategies include the following. (1) Non-nutritive sucking, an indirect intervention involving insertion of a pacifier or a nonlactating nipple into the infant’s mouth to encourage sucking behaviors, was found to stimulate the orotactile and mechano receptors, and decrease cry durations and heart rate [92]. (2) Skin to skin contact with the mother (kangaroo care), where the infant is positioned on the mother’s exposed chest during, or after the painful procedure [93]. (3) Rocking and holding the infant, where the infant is carried by a parent or caregiver during (if possible) and after the painful procedure and gently rocked [94]. (4) Swaddling the infant is another similar calming technique where the infant is wrapped with its extremities close to their trunk to prevent him/her from moving around excessively [95].

3.2. Toddlers and Preschoolers

For young children, explaining the procedures with age appropriate information is useful, in addition to providing them with the opportunities to ask questions [70]. Examples for active distraction used with this age group include, allowing them to blow bubbles, providing toys with lots of colour or toys that light up. Initiating distracting conservations (e.g., how many brothers and sisters do you have? What did you do at your birthday party?) and deep breathing methods are also helpful for older children [74]. Passive distraction techniques include: having the parents or child life specialist read age appropriate books, sing songs, and practicing “blowing out birthday candles” with the child [74].

3.3. School-Aged Children

Older children have a better understanding of procedures and why they are being done, thus providing them with age appropriate information is also important [70]. Providing children with a choice (e.g., sit or lie down, choose which hand) helps them feel in control of the situation [70]. Asking parents about their child’s previous pain experiences and coping mechanisms helps health care professionals identify appropriate interventions to use with the child. Educating school-aged children about passive and active techniques available will help them cope with the distress and anxiety of the procedure [70]. Active techniques for this age group include blowing bubbles, singing songs, squeeze balls, relaxation breathing and playing with electronic devices [74]. Passive distraction can include watching videos, listening to music on headphones, reading a book to the child or telling them a story [74].

3.4. Adolescents

It is essential to always ensure a private setting for procedures with adolescents especially as they sometimes tend to deny pain in front of friends, and family. Giving them the power to choose the type of distraction, or whether they want friends and family present is helpful [70]. Striking conversations, using squeeze balls or having them play with electronic devices are examples of active techniques, while passive distractions include watching videos, training them to breathe deeply (in from the nose, count to 5 and out through the mouth), and listening to music [74].

4. Conclusion

Although there is an overwhelming amount of data regarding effective paediatric pain assessment and management, it is often not being effectively applied. Current studies demonstrate pain management in children remains undertreated. It is the responsibility of health care professionals to educate their peers and advocate for appropriate pain treatment in children. Infants and children present a unique challenge that necessitate consideration of their age, developmental level, cognitive and communication skills, previous pain experiences, and associated beliefs. There is a need for more research to illuminate optimal pain management and strategies that take these special needs into consideration, to improve the treatment of pain in children.

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Copyright

Copyright © 2010 Rasha Srouji et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


Assessing Non-Verbal Signs

As mentioned earlier, it can be difficult to assess someone’s pain if they are unable to verbalize it and/or unable to point to the FACES scale. There are some signs and symptoms that a person may exhibit if they are in pain that can clue you in:

  • Facial grimacing or a frown
  • Writhing or constant shifting in bed
  • Moaning, groaning, or whimpering
  • Restlessness and agitation
  • Appearing uneasy and tense, perhaps drawing their legs up or kicking
  • Guarding the area of pain or withdrawing from touch to that area

The more symptoms a person has, and the more intense they appear to be, the more you will get a grasp of the degree of pain they are experiencing. You can then record their pain as "mild", "moderate", or "severe."


3. New developments in nonpharmacological management

Complexities of pain in older persons with dementia necessitate a comprehensive pain management approach that encompasses more than pharmacotherapy. For years, clinical practice guidelines have recommended incorporation of nonpharmacologic approaches as part of the pain management plan for older adults, 2 but recent concern related to opioid use for chronic pain has increased attention to the effective use of nondrug approaches. 65 Incorporation of nondrug techniques involves careful consideration of the unique patient circumstances, patient preferences, and evidence of effectiveness and guidance for selection of these interventions in the frail older person with dementia. Although evidence is growing, the majority of evidence for nondrug pain interventions has been conducted in cognitively intact older adults because those with dementia are typically excluded from most randomized control trials (RCTs). Evidence is accumulating on nondrug interventions to manage behavioral and psychological symptoms of dementia (BPSD), but few studies focus specifically on pain as the outcome of interest.

Exercise has been shown to be an effective nondrug intervention for pain in older adults thus, it is reasonable to assume that it may be beneficial for pain in those with dementia. 57 Choice of an exercise intervention, however, should take into consideration the individual's physical and cognitive status, health conditions, risk of falls, level of fitness, prior and current physical activity, support for implementation, and environmental factors. Approaches need to be tailored to the individuals understanding and abilities, capitalizing on significant other support/assistance with reasonable and achievable goals (Table ​ (Table2 2 ).

Table 2

Most promising nonpharmacologic interventions for use in dementia.

Psychological interventions have a strong evidence base in adult samples, and growing evidence in older adults 10 however, research is sparse on use in dementia. Impairments in memory, language, executive function, visuospatial skill, and other processes impact the ability to effectively engage in these pain interventions, such as cognitive-behavioral therapy, mindfulness approaches (including biofeedback and relaxation training), and self-regulatory approaches (including biofeedback, relaxation training, and hypnotherapy). It is likely that these interventions are not feasible in those with moderate and severe dementia.

Recent reviews of nonpharmacologic interventions for the treatment of BPSD, including agitation and disruptive behavior that have both been associated with pain, provide some guidance. In a review of systematic reviews evaluating RCTs, Dyer et al. 23 note that although quality of evidence for nonpharmacological interventions is low, lack of adverse events supports trialing techniques with potential benefit. Functional analysis-based interventions, such as behavior management and music therapy, demonstrated statistically significant improvements in BPSD. A second review of reviews conducted by Legere et al. 44 on nonpharmacological approaches for BPSD not limited to RCTs concluded that there continues to be sparse high-quality evidence, with the strongest support for music therapy.

Pieper et al. 51 found that behavioral interventions targeting pain, including music therapy, cognitive behavioral therapy, reflexology, Reiki, person-centered bathing or showering, and rocking chair therapy, were effective in reducing pain and behavioral symptoms in dementia. A recent integrative review examined the state of science on nonpharmacological intervention use for pain for older adults in long-term care facilities, many of which have dementia. 62 Exercise, massage, heat therapy, and relaxation/rest were identified as significant interventions for persistent noncancer pain. Finally, a recent review of RCTs focused on complementary and alternative interventions to treat pain and agitation in dementia found massage, touch, and human interaction and presence are effective in reducing pain and agitation. 6 Although evidence for efficacy is limited in this setting, incorporation of strategies that caregivers identify as potentially useful for the older person with dementia can be encouraged.

It is difficult to know whether any of the nonpharmacologic pain interventions are superior to another or when and how their use should be tailored to the individual's unique needs and characteristics. Studies are needed that use strong designs, include valid and reliable pain behavior outcomes, examine impact of dose of intervention, and establish feasibility, applicability, and cost-effectiveness for use in the long-term care setting.


Instruments for pain-intensity assessment

Visual Analogue Scale/Graphic Rating Scale

The Visual Analogue Scale (VAS) consists of a straight line with the endpoints defining extreme limits such as ‘no pain at all’ and ‘pain as bad as it could be’ (Fig.  1 ) [1]. The patient is asked to mark his pain level on the line between the two endpoints. The distance between ‘no pain at all’ and the mark then defines the subject’s pain. This tool was first used in psychology by Freyd in 1923 [24]. If descriptive terms like ‘mild’, ‘moderate’, ‘severe’ or a numerical scale is added to the VAS, one speaks of a Graphic Rating Scale (GRS) (Fig.  2 ) [1]. A line-length of 10 or 15਌m showed the smallest measurement error compared to 5- and 20-cm versions and seems to be most convenient for respondents [71].


How can botulinum toxin be used in chronic pain syndromes?

Onabotulinum toxin-A (Botox) was FDA approved in 1991 for therapeutic use and later for cosmetic use. Subsequently, new products containing botulinum for medical and cosmetic uses were approved (Dysport, Myobloc, Xeomin). In 2019, prabotulinum toxin-A (Jeuveau) was approved for cosmetic use only. 1 Botulinum toxin-A (BT) is FDA-approved for several medical indications listed in Table I and has been studied for other pain-related conditions.

Botulinum toxin is sourced from a bacterium called Clostridium botulinum . Its mechanism of action is essentially blocking neuromuscular transmission, which is achieved through binding and entering sites on nerve terminals on sympathetic or motor neurons and inhibiting acetylcholine release through cleaving SNAP-25. A protein, SNAP-25 is integral to acetylcholine docking and release from vesicles. After injection into a muscle, partial denervation occurs, reducing muscle movement in the local area. However, this can be reversed over time as the body may develop new axons leading to reinnervation of the muscle. 2

Researchers concluded that botulinum toxin may be an option for short-term pain relief in those with refractory joint pain. (Image: iStock)

Osteoarthritis

Knee OA

More than 30 million Americans are estimated to be affected by osteoarthritis (OA), close to half of whom have symptomatic knee OA. 3 Treatments for knee OA, as recommended by the American College of Rheumatology, include: acetaminophen, oral and topical NSAIDs, tramadol, and intra-articular injection of corticosteroids. 4 BT was studied in 121 patients with knee OA in a double-blind, randomized trial. This study used a one-time dose of an intra-articular injection of BT at 200 IU versus placebo. Biomarkers studied included pressure pain thresholds and wind-up pain. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were used in the analysis, as were average daily pain (ADP), patient global impression of change (GIC), the painDETECT questionnaire (PD-Q), and rescue medication to assess clinical improvement. At Week 8, results showed statistically significant improvement for all WOMAC outcomes and pain scores. For Weeks 9 and 10, ADP improved significantly, and by Week 12 GIC improved significantly. There were also significant reductions in the need for use of rescue medication at Weeks 9 and 10.

Although this research supported the possibility of BT as a treatment of nociceptive pain in knee OA, more studies are needed to assess longer durations of treatment. 5

Joint Pain

A 2018 meta-analysis evaluated use of intra-articular BT in patients with osteoarticular joint pain. Dosing in all studies was 100 units or 200 units of BT. Five of the six studies used a numeric rating scale (NRS) to measure pain (0 being no pain at all and 10 being maximal pain) and four of the five trials showed a positive effect on pain, irrespective of dose, at one or two months. One of the trials, however, found no significant difference in pain. The weighted mean difference in NRS between all five studies was −1.1, which was statistically significant. However, when evaluating the differences in dosing, high dosing (200 U) showed almost zero effect on pain scores while three out of the four studies with low dosing (100 U) showed significant results in regard to pain scores. Three trials re-evaluated the patients at six months to assess progress, and while their overall weighted mean NRS was lower, it was no longer statistically significant. Side effects associated with BT included flu-like symptoms, dry mouth, dizziness, and pain or swelling at the injection site. Researchers concluded that BT may be an option for short-term pain relief in those with refractory joint pain. 6

Myofascial Pain

Myofascial pain is a condition in which pain is activated by pressure on different points in the muscles. This type of pain can be attributed to extensive use and repetition. Physical therapy is often warranted as well as medications to control pain. 7 In 2014, a Cochrane review article evaluated BT and its use in myofascial pain syndromes from four randomized studies. Primary outcomes of the studies included pain intensity, frequency and duration of pain, relief from the pain, and pressure pain tolerance measured using visual analog scales (VAS) or categorical scales.

All studies included doses of BT that may be too low for pain relief, ranging from 5 to 50 units. However, in previous studies, higher doses (ie, up to 100 units) were associated with higher rates of adverse effects. Researchers concluded that the evidence was not sufficient to support the use of BT in patients with myofascial pain syndromes. 8

Pelvic Muscle Pain

However, BT has been studied in patients specifically with myofascial pelvic pain. In one retrospective case series 50 women treated with BT had statistically reduced pain scores after treatment (3.7 ± 4.0 vs 6.4 ± 1.8), as well as a significant decrease in patients with trigger points, 44% vs 100%. Authors of the study noted that patients who were likely to have no improvement were those who had chronic bowel disorders. 9

Peripheral Neuropathy

It is estimated that more than 20 million Americans have some form of peripheral neuropathy. 10 According to the American Academy of Neurology, recommended treatments include anticonvulsants, antidepressants, and opioids for painful diabetic neuropathy however, many of these therapies are limited by adverse effects. 11 Botulinum toxin could be an additional option for treatment in these patients that is much needed to avoid opioid use. According to a study from 2015, opioids were prescribed first-line most frequently for diabetic peripheral neuropathy. 12

Evidence suggests that BT injections may reduce pain intensity in patients with peripheral neuropathy. In a double-blind, randomized trial, the addition of BT statistically reduced intensity of pain over 24 weeks compared with placebo. Most patients who participated in this study had neuropathic pain stemming from post-traumatic events or post-surgical procedures. Dose per administration did not exceed 300 units, however it varied between patients based on the size of the painful area. Drug administration was repeated at 12 weeks. Mean pain scores ranged from 6.5 at baseline to 4.6 at the 24-week mark based on the 11-point pain scale (0 - 10). 13 A review was also conducted in 2018 that included 19 studies to evaluate the use of BT in central neuropathic pain. This included use in neuropathic pain after spinal cord injury, post-stroke shoulder pain, and multiple sclerosis specifically in detrusor overactivity and spasticity. Overall, they concluded that BT did have an effect on neuropathic pain and may be considered a treatment option. 14

Maxillofacial Pain

Use of BT for pain-related conditions in the maxillofacial region has also expanded. Chronic facial pain due to masseter muscle hypertrophy associated with teeth clenching/grinding (eg, bruxism) or other jaw disorders may benefit from treatment with BT. Pain and tenderness associated with temporomandibular disorders (TMD) may improve with BT as an adjunctive therapy to other strategies or after conservative treatments have failed. 15-17 However, not all studies of BT for TMD have shown benefit, and dosing has been inconsistent, ranging from 70 to 300 units. Most studies evaluated doses of 100 to 150 units. 18

Although BT may offer a safe, less expensive option to surgical intervention, it has been associated with facial paralysis and dysphagia when studied for TMD. 18 Use of BT may also improve quality of life in cancer and palliative care patients by reducing muscle spasticity and hypersecretions. 15 Assessments have shown BT to be relatively safe with only temporary adverse effects such as dysphagia, muscle weakness, speech/articulation difficulties, injection-site tenderness, and flu-like symptoms noted. 16 Inconsistent and/or one-time dosing, small sample sizes, and short duration of assessment limit current evidence.

Risk of bias due to study design and heterogeneity exists among studies. Well-designed, randomized clinical studies to overcome these limitations would help to further clarify the effectiveness of BT for many of these indications. 16,18,19

Other Types of Chronic Pain and Risks

Botulinum toxin has also been evaluated for use in chronic anal fissure. 20-22 Most studies assessing use of BT were not blinded. In addition, studies differed in dosing, site and number of injections which challenge the ability to establish recommendations for use.

Although BT has been shown to be helpful to treat pain in some populations it has not been well-studied across all populations. Botulinum toxin may cause fetal harm in pregnancy based on data gathered from animal studies. It is also unknown whether BT is present in breast milk so risk–benefit analysis should be considered. Pediatric patients have limited safety and efficacy data based on age and disease state it is being used to treat. Per the FDA labeling, efficacy and safety have not been proven in patients less than 18 years old for chronic migraine, detrusor overactivity, spasticity, and axillary hyperhidrosis. Patients under 16 do not have proven efficacy or safety for treatment of cervical dystonia, and those under 12 years of age are not supported for use in blepharospasm or strabismus. 2 Adverse effects of BT are specific to the indication for use, however a few of them include headache, flu-like symptoms, and pain at the injection site. 23

Additional research is essential to support adjunctive therapy or treatment with BT for various chronic pain conditions. Although studies may show benefit, it is important to consider that dosing and long-term efficacy have not been well-established for many of these conditions. •


What is a Pain Scale Chart?

Every person experiences pain differently. The same issue may seem like the worst physical pain ever to one person while someone else may only find themselves experiencing only minor pain. To get a better understanding of each individual’s pain, a simple yet effective solution was created - pain scales. These rating scales provide a way for people to convey to a medical professional what their pain level is. Everyone feels pain differently, so these pain charts can help doctors or nurses better understand someone’s present state and condition. Standard medical pain scales are numeric rating scales that range from 1-10 with each pain level being increasingly more painful.


3 RESULTS

Figure 2 gives an overview of the seven steps taken in the final round of the consensus process and their outcomes. It shows that the stepwise process of item selection was accompanied by a thorough discussion amongst the seven members of the formed expert panel (see the grey fields “expert discussions”).

3.1 Step 1: Clinical and experimental studies conducted to gather empirical evidence on the psychometric characteristics of each item of the PAIC research version

Thirteen studies conducted in eight countries tested psychometric properties of the 36 items of the PAIC research version (Table 1). Across the 13 studies, 587 persons with dementia, 27 individuals with intellectual disability, 12 Huntington's disease patients and 59 cognitively healthy controls were observed during rest and movement situations (clinical studies) or while receiving different intensities of experimental pressure pain, respectively. The persons with dementia were mostly at moderate (mostly in the experimental pain studies) to more advanced stages of the disease (clinical pain studies). Observations were mostly undertaken by healthcare professionals (nurses and physicians, N = 251) who did not receive any special training in how to assess pain using the PAIC research version.

3.2 Step 2: item difficulty

As can be seen in Table 1, the data of all 13 studies were used to compute “item difficulty” values. However, given that several studies (studies 5–10, 12–13) only focused on facial expressions, these studies could not be used to evaluate body movements or vocalizations.

The mean values of “item difficulty” are displayed in the left columns of Table 2 and values are given separately for each of the three categories of studies having been conducted. For our item selection, we wanted to exclude those items describing behaviour that is either hardly ever (<10%) or almost always (>90%) observed. Although there were some variations across studies, there were seven items detailing behaviour which was hardly ever observed across studies (percentage of occurrence was <10% in at least half of the studies). These items included “using offensive words” (<10% in six of six studies), “pacing,” “screaming” and “crying” (<10% in four of six studies), “pushing” and “rubbing” (<10% in three of six studies) and “teary eyes” (<10% in 6 of 13 studies). These seven items, which are shaded in grey in Table 2, were considered for exclusion and each item was thoroughly discussed in the expert panel. No item reached a percentage of occurrence >90% thus, no item was considered for exclusion based on “item difficulty” being too low. Based on an expert consensus, it was decided to nevertheless retain four of the items with too high item difficulty (see Figure 2), because it was argued that these items still are established indicators of pain in other contexts, despite being observed so infrequently in our studies, and it might produce a premature loss of pain-relevant information to already exclude them at the beginning of the step-wise decision process. Thus, step 2 resulted in the exclusion of only three items (see Figure 2).

3.3 Step 3: inter-rater reliability

As can be seen in Table 1, the data of seven studies could be used to compute “reliability” values. Given that step 2 led to the exclusion of three items, reliability was tested for 33 items (see Figure 2). The mean inter-rater reliability values across studies are displayed in the middle columns of Table 2. Poor reliability was defined as values <70% agreement or <0.70 for intraclass correlation (ICC), respectively. Overall, reliability values were quite good for all 33 PAIC items. As can be seen in Table 2, inter-rater reliability values were higher in the clinical studies compared to the experimental pain studies and somewhat lower for the facial expression items compared to the body movement and vocalization items. Based on the reliability outcomes, there were only two items (“seeming disinterested” and “looking sad” shaded grey in Table 2) that showed poor reliability values in more than half of the studies. The item “seeming disinterested” showed poor reliability in five of seven studies, and “looking sad” poor reliability in four of seven studies. These two items were considered for exclusion. Based on an expert consensus it was decided to exclude both items (see Figure 2).

3.4 Step 4: construct validity

As can be seen in Table 1, data from 10 studies were available for the “validity” analyses for the facial expression items. With regard to the “validity” analyses for the body movement and vocalization items, four studies were used. After the exclusion of five items in the preceding steps, validity analyses were run for the remaining 31 items (see Figure 2). For that purpose, we computed the number of studies that found a numerical increase, decrease, or no change for each PAIC item between rest versus movement or painful versus non-painful pressure stimulation, respectively. These numbers are combined across studies and are displayed in Table 2 (right columns). Across studies, there were seven items with scores that either remained unchanged or even decreased (rest vs. movement or non-painful vs. painful pressure stimulation) in more than half of the studies (these items are shaded in grey in Table 2). These items were “closing eyes,” “empty gaze,” “pale face,” “clenching hands,” “restlessness,” “screaming” and “gasping” (see Figure 2) and these items were considered for exclusion. After the expert panel discussed each item, consensus was reached to retain the item “restlessness” (see Figure 2), because it was argued that due to the clinical testing protocol, “restlessness” was more difficult to be observed in a movement situation and thus, the decrease in “restlessness” might be a methodological artefact. The other six items were excluded.

3.5 Step 5: content validity, usability and comprehensibility as well as knowledge from the literature

In step 5, the expert panel discussed each of the remaining 25 items by taking into consideration (a) the results of a content analysis that was conducted on the PAIC research version (van Dalen-Kok et al., 2018 ), (b) knowledge from the literature about the relevance of certain behaviours as pain indicators (e.g. studies on facial expressions of pain (Prkachin, 1992 ) or on the differentiation between pain and discomfort (van der Steen et al., 2015 )), as well as (c) evaluating the usability and comprehensibility of each item in different care situations (e.g. bedridden patients, palliative care settings). Based on this thorough and comprehensive discussion, 10 items were excluded (see Figure 2). In detail, four items were excluded because of low content validity for a pain indicator (“looking frightened,” “repeating words,” “crying” and “sighing”) two facial items were excluded because of low support from the literature, where these have never been reported as being pain related (“tightened lips” and “clenched teeth” e.g. Prkachin, 1992 ) and four items were excluded based on restricted usability and difficult comprehensibility (“pained expression” (not descriptive enough, low correlation with self-reported pain ratings), curling up” (can only be observed if patient is lying in bed), “limping” and “pacing” (can only be observed in those patients who can still walk, problems might also be due to other conditions (e.g. stroke) besides pain).

3.6 Step 6: feedback from invited “external” reviewers

The list of the remaining 15 items along with the description of the step-wise selection (steps 2–5) was sent to a group of “external” reviewers (N = 5) to gain feedback on the process. All external reviewers agreed that the process of item selection was well described, carefully conducted and methodologically sound. Furthermore, all reviewers agreed that the final number of 15 items is a satisfactory number, although fewer items would be preferable for day-to-day care practice. Overall, there were only two suggestions for more major revisions, namely to not eliminate the item “crying” and to add a new item “opening of the eyes.” Furthermore, two suggestions were made for minor revisions, namely to change the item “freezing” to “stiffening” and the item “opened mouth” to “opening of the mouth” (see Figure 2).

3.7 Step 7: Consensus on final item set

The suggested changes of the invited “external” reviewers were discussed within the expert panel. Consensus was reached that “crying” is not added, because it was observed so infrequently in our studies and might not have enough pain specificity. Furthermore, “opening of the eyes” was not be added, because this would be a completely new item that has never been included in other observational pain scales and has not been described within the literature on facial expressions of pain (e.g. Prkachin, 1992 ). As for the suggestions or minor revisions, consensus was reached to change the item “opened mouth” to “opening of the mouth” as to adjust it to the wording of the other facial expression items. Consensus was also reached to not change “freezing” to “stiffening” because “freezing” is a more common item in other observational pain scales and also performed well in the content analysis (van Dalen-Kok et al., 2018 ).

The final list of items is displayed in Figure 3, which shows the final scale with its 15 items, which we call PAIC15.