Pain behaviors: postsurgical responses of children and adolescents.

There is scant data identifying the range and variety of pain behaviors associated with ongoing, short-term acute pain of older children and adolescents. The purposes of this study were to identify and record pain behaviors manifested by children and adolescents during the first 3 days after surgery and examine the relationship between behaviors and self-report of pain intensity. Data were collected from 37 multi-ethnic children and adolescents using the Word Graphic Rating Scale for self-report of pain intensity and the Pediatric Pain Behavior List to record pain behaviors. The five most frequently observed behaviors were calm, maintaining one position, flexing limbs, eyes shut, and knees drawn up. All children reported pain on the first 2 days postsurgery. Many children who were lying in one position with a calm expression, at the same time, reported moderate to severe pain.

Word placement on the Word-Graphic Rating Scale by pediatric patients.

A descriptive study was undertaken to determine if children located at the descriptive words ("little pain", "medium pain," and "large pain") found on the Word-Graphic Rating Scale (WGRS) as they are placed on the original scale. The convenience sample consisted of 34 hospitalized children ages 8-15 years. There were 16 males and 18 females. Children did not place word descriptors equidistant on a 100 mm line. "Little pain" was placed closer to "no pain," while "medium pain" and "large pain" placement showed no statistical difference in simultaneous placement as compared to the WGRS.

A strategy to assess the temporal dimension of pain in children and adolescents.

Two formats to enable children and adolescents to report the changing intensity, duration, and pattern of their pain were developed and tested: (a) a dot matrix with intensity markers on the y-axis and time markers on the x-axis and (b) a list of words or word phrases describing the temporal dimension of pain. Analyses of the dot matrix markings revealed six patterns of pain: steady decrease, steady increase, ongoing sharp increases and decreases, stair-step increase and decrease, steady increase and decrease, and constant. The 12 words and phrases described how pain began as well as how the pattern of pain changed over time.

Postoperative analgesics for children and adolescents: prescription and administration.

Pain was measured and analgesic treatment examined in 131 children and adolescents, 8-17 years of age, for 5 days after surgery. Analgesic data were converted to 10 mg intramuscular morphine-equivalent doses (IMMSEQ) and were designated appropriate or inappropriate for body weight. Analgesic onset, peak, and duration were calculated in relation to administration routes and the time pain assessments were made. Children reported moderately severe pain in many body locations. Initially, all but two children were prescribed and ultimately all but one received analgesics. Prescribed and administered doses were frequently less than doses recommended for weight. Two-thirds of the children were beyond analgesic action when pain was assessed. Weak to moderately strong associations were noted between IMMSEQ doses and pain intensity scores on each of the 5 postoperative days. Unfortunately, findings indicate that children continue to be undertreated when they experience postoperative pain.

Assessment of postoperation pain in children and adolescents using the adolescent pediatric pain tool.

The location, intensity, and quality of pediatric postoperative pain were assessed in a convenience sample of 65 multiethnic children and adolescents, 8 to 17 years old. Pain was measured daily for 5 days during hospitalization using the Adolescent Pediatric Pain Tool (APPT). Mean pain intensity scores and mean number of pain descriptors (quality) decreased over time, but there was no significant change over time for the number of body segments marked (location). The findings provided valid and reliable estimates of adolescents' and children's self-reports of the location, intensity, and quality of postoperative pain.

The word-graphic rating scale as a measure of children's and adolescents' pain intensity.

A program of studies was designed to select and test a pain intensity scale for inclusion in a multidimensional pain assessment tool for children and adolescents. The focus was on determining each scale's validity, reliability, ease of use, preference, and the lack of age, gender, and ethnic biases. Five pain scales were evaluated in four separate studies: a word-graphic rating scale, a visual analogue scale, a graded-graphic rating scale, a magnitude estimation scale (0 to 10), and a color scale. Subjects (N = 1,223) were 8 to 17 years of age and, in three of the studies, were hospitalized and judged to be in pain. In Study 1, well children used the scales to assess pain in an analogue situation selecting the color scale easiest to use and best liked. Convergent validity for the five scales was supported. In Study 2, hospitalized children, who were experiencing pain, overwhelmingly selected the word-graphic rating scale as their choice. A pilot version of a multidimensional pain assessment tool incorporating the word-graphic rating scale was tested in Study 3 using a repeated measures design. The scale demonstrated sensitivity to changes in postoperative pain intensity over time. In Study 4, convergent validity of the five scales and test-retest reliability of the word-graphic rating scale were supported. The series of four studies provides strong evidence to support use of the word-graphic rating scale to measure pain intensity in pediatric populations.

Cancer pain intensity measurement: concurrent validity of three tools--finger dynamometer, pain intensity number scale, visual analogue scale.

Although the visual analogue scale (VAS) and number scales are known to be valid and sensitive measures of pain intensity, some older individuals are unable to use them. For individuals who lack the ability to use these scales, valid alternative measures of pain intensity would be useful for research and clinical practice. The purpose of this study was to examine the concurrent validity of a new measure of pain intensity, the Finger Dynamometer (FD), in a sample of 15 adults with advanced stage cancer pain. In a repeated measures correlational design each patient rated present pain intensity using the FD, a Pain Intensity Number Scale (PINS), and a VAS at four separate times. Data analyses using Kendall Correlational Coefficients indicated weak to moderate correlation between the FD and PINS (gamma = .47 to .68; p less than .01) and between the FD and VAS (gamma = .38 to .46; p less than .05) at each measurement time. Strong correlation was found between the VAS and the PINS (gamma = .77 to .89; p less than .001). Findings support the concurrent validity of the VAS and the PINS but indicate that further research is necessary to establish the psychometric properties of the FD as a measure of pain intensity in chronic pain models, such as cancer pain. Recommendations are made regarding important variables to be considered in further research with the FD.

Use of the McGill Pain Questionnaire to measure pain: a meta-analysis.

A meta-analysis of 51 studies was done to estimate normative mean McGill Pain Questionnaire (MPQ) scores and to assess pain quality and pain intensity as measured by the MPQ in 3,624 subjects with seven painful conditions. Across the painful conditions, all of the estimated normative mean scores were no more than 50% of the maximum score, suggesting that scores may be skewed to the left. Although the estimated normative mean scores were similar among the seven painful conditions, higher affective scores appeared to differentiate chronic painful conditions from acute painful conditions. Of the 78 MPQ words that describe pain quality, only 19 were selected by more than 20% of the subjects. Data reported in the majority of these studies were inadequate to test for differences in scores or word selection pattern by the seven painful conditions.

Pain location: validity and reliability of body outline markings by hospitalized children and adolescents.

Although pain location is an important assessment parameter, little research has addressed validity and reliability of a body outline in pediatric populations. In a descriptive study, validity and reliability of markings on a body outline were examined in a convenience sample of 8- to 17-year-old hospitalized children (n = 175). Children marked their pain location on a body outline. Each child then pointed to the pain location on his/her body as a nurse data collector, blind to the child's markings, recorded the location on a second body outline. Data were obtained to substantiate the pain location. Findings provide strong support for the validity and reliability of a body outline and for its inclusion in a multidimensional pediatric pain tool.

Assessing children's and adolescents' pain.

Problems related to the complex task of pain assessment in children and adolescents are identified. Solutions to the problems are presented by describing a variety of tools currently available to assess three distinct dimensions of pain: location, intensity, and quality. Characteristics and strengths of a variety of tools are discussed and examples of each are included. Presented are body outlines to report location, and a variety of tools appropriate for measuring intensity from young preschoolers to adolescents. Worldwide current work describing the development of word lists to describe childhood pain quality is summarized.

How adolescents describe pain.

This study assesses how adolescents describe the experience of pain. We queried a convenience sample of 156 adolescents, 13-17 years of age, in two schools and four hospitals. Adolescents answered questions on a questionnaire developed by the investigators. Findings suggest that adolescents can clearly describe pain, their feelings when in pain, and the strategies that help when they experience pain. Pain appears to be associated with mental anguish as well as trauma and pathology.

Efficacy of sucralfate in the prevention of recurrence of duodenal ulcers.

Eighty-four patients who were endoscopically confirmed to have healed duodenal ulcers were entered into this 1-year, double-blind, placebo-controlled trial of sucralfate, 1g twice daily, in the prevention of duodenal ulcer recurrence. Patients remained in the study until recurrence of ulceration was endoscopically confirmed. Sixty-one patients could be evaluated for efficacy of treatment. Within 6 months, 23 of 31 placebo patients (74%) and 6 of 30 sucralfate patients (20%) had ulcer recurrence. At 12 months, 25 of 31 placebo patients (80%) and 8 of 30 receiving sucralfate (27%) had ulcer recurrence. The lower rate of ulcer recurrence in patients receiving sucralfate was significant (p = 0.0001). Survival curves also showed that sucralfate was significantly more effective in preventing relapse (p = 0.0001). Three patients were judged as experiencing drug-related side effects, two of which were in the placebo group. The results indicate that sucralfate is significantly more effective than placebo in the prevention of recurrence of duodenal ulcer disease.

In vitro and In vivo evaluations of a tableted antacid and sucralfate, a new antiulcer agent.

Sucralfate is a nonsystemic drug used in the therapy of peptic ulcer disease. It is an aluminum salt of a sulfated disaccharide which adheres to ulcerated sites and forms a cytoprotective barrier to acid peptic digestion. The purposes of this study were to determine whether sucralfate had antacid activity in humans and to test the validity of the in vitro antacid qualifying test by comparing its results for tableted products with those of in vivo studies. In the in vitro antacid qualifying test Maalox #1 (4 tablets) passes and sucralfate (1 gm.) failed. These findings were consistent with the results of in vivo tests utilizing a telemetric device, the Heidelberg capsule and tube aspirations. We conclude that sucralfate does not possess antacid properties and that the results of the standard in vitro antacid qualifying test correlated well with those of in vitro studies.

Protection of gastric mucosa by sucralfate from aspirin-induced erosions.

The protective effect of sucralfate against aspirin caused damage to the gastric mucosa was studied in healthy male volunteers (age range 18 to 44 years) with no history of gastrointestinal disease. Each was randomly assigned to placebo or sucralfate. As determined by endoscopic studies, 8 of 12 subjects on sucralfate experienced complete protection; 3 were partially protected. The question was raised whether sucralfate might have inhibited the absorption of aspirin from the gastrointestinal tract, but measurement of salicylate levels showed no statistically significant difference between salicylate levels achieved after sucralfate and after placebo.