Pain during the first year after scoliosis surgery in adolescents, an exploratory, prospective cohort study.

Objective: Approximately 50% of adolescents who have undergone scoliosis surgery still experience severe pain one year postoperatively. We explored the postoperative pain trajectory and the potential value of preoperative Thermal Quantitative Sensory Testing (T-QST) as predictor of chronic postsurgical pain after scoliosis surgery. Design: Single-center prospective cohort study in adolescents undergoing scoliosis surgery. Outcomes: Prevalence of chronic postsurgical pain (CPSP) one year after scoliosis surgery and postsurgical pain course during this year. The need for rescue medication and the relationship between pre-operative T-QST, acute pain and CPSP. Results: Thirty-nine patients (mean age 13.9 years; SD 1.9 years) completed the study. One year postoperatively, ten patients (26%) self-reported pain [numeric rating scale (NRS) score ≥ 4]) when moving and two (5%) when in rest. Four of these patients (10.3%) experienced neuropathic pain. The pre-operative cold pain threshold was lower (p = 0.002) in patients with CPSP at 12 months. Preoperative cold and heat pain thresholds were correlated with the number of moderate or severe pain reports (NRS ≥ 4) in the first week postoperatively (r -.426; p = 0.009 and r.392; p = 0.016, respectively). Conclusions: One year after scoliosis surgery, a significant part of patients (26%) still reported pain, some with neuropathic characteristics. Better diagnosis and treatment is needed; our study suggests that T-QST could be further explored to better understand and treat children with this negative outcome.

Validation of the Rotterdam Elderly Pain Observation Scale in the Hospital Setting.

BACKGROUND: The Rotterdam Elderly Pain Observation Scale (REPOS) has been proven useful to assess pain in noncommunicative and cognitively impaired nursing home residents. We evaluated whether the REPOS is also reliable and valid for pain assessment in the hospital setting. METHODS: In this prospective multicenter observational study, surgical patients were observed perioperatively at bedside and internal medicine patients were filmed during a possible painful moment and at rest. Pain behavior was assessed from the video recordings with the REPOS and the Pain Assessment Checklist for seniors with Severe Dementia-Dutch language (PACSLAC-D). Longitudinal associations between REPOS score and numeric rating scale pain ratings from observers and nurses (NRSobs and NRSproxy ) corrected for patients' gender were assessed with linear mixed models. RESULTS: In total, 72 patients were included; 118 observations of surgical and 68 observations of internal medicine patients were analyzed. Interobserver reliability between the researcher and 2 other observers was good, with Cohen's kappa values of 0.71 (confidence interval [CI] 0.59 to 0.83) and 0.84 (CI 0.74 to 0.94), respectively. The intraobserver reliability of the principal investigator was good, with Cohen's kappa 0.82 (CI 0.67 to 0.91). Linear mixed modeling revealed correlation values between the REPOS and NRSobs of 0.67 and the REPOS and NRSproxy of 0.73. Optimal sensitivity (78%) and specificity (90%) for the detection of pain were found with a REPOS cutoff score of ≥3, using an NRS score of ≥4 as the reference value. CONCLUSIONS: The REPOS is reliable and valid for the assessment of postoperative and chronic pain in hospital patients who cannot self-report pain.

The Rotterdam Elderly Pain Observation Scale (REPOS) is reliable and valid for non-communicative end-of-life patients.

BACKGROUND: In palliative care, administration of opioids is often indispensable for pain treatment. Pain assessment may help recognize pain and guide treatment in non-communicative patients. In the Netherlands the Rotterdam Elderly Pain Observation Scale (REPOS) is recommended to this aim, but not yet validated. Therefore the objective of this study was to validate the REPOS in non-communicative or unconscious end-of-life patients. METHODS: In this observational study, the primary researcher applied the REPOS, while both the researcher and a nurse applied the Numeric Rating Scale (NRS). If possible, the patient in question applied the NRS as well. The NRS scores were compared with the REPOS scores to determine concurrent validity. REPOS scores obtained before and after a pain-reducing intervention were analysed to establish the scale's sensitivity to change. RESULTS: A total of 183 REPOS observations in 100 patients were analysed. Almost 90% of patients had an advanced malignancy; observations were done a median of 3 days (IQR 1 to 13) before death. Internal consistency of the REPOS was 0.73. The Pearson product moment correlation coefficient ranged from 0.64 to 0.80 between REPOS and NRS scores. REPOS scores declined with median 2 points (IQR 1 to 4) after a pain-reducing intervention (p < 0.001). Optimal sensitivity (0.81) and specificity (0.62) were found at cut-off score 3. CONCLUSIONS: This study demonstrates that the REPOS has promising psychometric properties for pain assessment in non-communicative end-of-life patients. Its application may be of additional value to relieve suffering, including pain, in palliative care.

Prevalence of pain in institutionalized adults with intellectual disabilities: a cross-sectional approach.

Information about pain prevalence in institutionalized individuals with intellectual disabilities is scarce, most likely because communication problems impede pain assessment. We aimed to inventory pain prevalence and actual pain management in intellectually disabled individuals living in a representative special care facility in the Netherlands. Caregivers rated the residents' present pain and overall pain during the preceding week on an 11-point numerical rating scale (NRS-11). In addition, behavioral pain assessment was performed with validated pain scales; the Rotterdam Elderly Pain Observation Scale (REPOS) or Checklist Pain Behavior (CPG). Ratings suggested that 47 of the 255 included residents (18%) suffered from pain either at present or during the preceding week, 14 of whom (30%) experienced pain on both occasions. Most of these 47 (85%) residents with pain had no analgesic prescription, not even in the case of severe pain (NRS 7 or higher). Ratings for nearly one out of every five residents suggested they suffered pain. This proportion is lower than in other studies and could imply that caregivers probably underestimate residents' prevalence of pain. Pain treatment might be inadequate in light of the low percentage of analgesic prescriptions. To prevent unnecessary suffering in institutes for residents with an intellectual disability (ID) we recommend use of a pain protocol including a validated pain measurement instrument.

Is pain assessment feasible as a performance indicator for Dutch nursing homes? A cross-sectional approach.

Quality of care gains transparency with the help of performance indicators. For Dutch nursing homes, the current set of performance indicators does not include pain. To determine the feasibility of pain assessment as performance indicator, information about pain prevalence and analgesic prescription in one nursing home was collected. Within the time span of 3 days, pain intensity was measured in 91% of the residents (201 out of 221), either with a numeric rating scale, a verbal rating scale, or the Rotterdam Elderly Pain Observation Scale (REPOS). Numerical rating was used for 72%, verbal rating for 3%, and REPOS observation for 25% of the residents. Pain was substantial in 65 residents (32%), who received the following analgesic prescription: World Health Organization (WHO) step 1, 45%; WHO step 3, 12%; and neuroactive agents, 5%. Thirty-eight percent of these residents were in pain and received no analgesics. Residents with substantial pain significantly more often received analgesics (p = .007). Results suggest that pain assessment is feasible in a nursing home and would stimulate staff attention to pain. Further investigation is necessary to find out if a pain algorithm is feasible and will lead to improved pain treatment.

The COMFORT behavior scale: is a shorter observation period feasible?.

OBJECTIVE: The COMFORT behavior scale has been validated for postoperative pain in 0- to 3-yr-old children. Scoring is preceded by a 2-min observation period, which nurses may consider too long. The objective of this study was to test the reliability of a 30-sec observation period. DESIGN: Observational study. SETTING: One Level III intensive care unit at a university children's hospital. PARTICIPANTS: Designated pain specialist and all nursing staff. INTERVENTIONS: None. MEASUREMENTS: The pain specialist and caregiver nurse each conducted a bedside COMFORT behavior scale assessment and assigned an additional pain rating on the 11-point Numerical Rating Scale. MAIN RESULTS: Total COMFORT behavior Scale score for the 2-min observation was 17 or higher in 19% of the patients and 11% for the 30-sec observation. The mean COMFORT behavior scale score for the 2-min observation was 13.5 (SD 3.8) and 12.7 (SD 3.7) for the 30-sec observation. The mean difference therefore was 0.8 (confidence interval 0.6-1.1, paired t test, p < .001). Sensitivity and positive predictive value for the 30-sec observation were 0.44 and 0.80, respectively. CONCLUSIONS: A 30-sec COMFORT behavior scale observation increases the risk of underscoring pain. Therefore, the 2-min observation period should be adhered to in the interest of the patients.

The COMFORT-behavior scale is useful to assess pain and distress in 0- to 3-year-old children with Down syndrome.

Many pediatric intensive care units use the COMFORT-Behavior scale (COMFORT-B) to assess pain in 0- to 3-year-old children. The objective of this study was to determine whether this scale is also valid for the assessment of pain in 0- to 3-year-old children with Down syndrome. These children often undergo cardiac or intestinal surgery early in life and therefore admission to a pediatric intensive care unit. Seventy-six patients with Down syndrome were included and 466 without Down syndrome. Pain was regularly assessed with the COMFORT-B scale and the pain Numeric Rating Scale (NRS). For either group, confirmatory factor analyses revealed a 1-factor model. Internal consistency between COMFORT-B items was good (Cronbach's α=0.84-0.87). Cutoff values for the COMFORT-B set at 17 or higher discriminated between pain (NRS pain of 4 or higher) and no pain (NRS pain below 4) in both groups. We concluded that the COMFORT-B scale is also valid for 0- to 3-year-old children with Down syndrome. This makes it even more useful in the pediatric intensive care unit setting, doing away with the need to apply another instrument for those children younger than 3.

Pain management in Dutch nursing homes leaves much to be desired.

This cross-sectional multicenter study describes several aspects of pain, pain intensity, and pain treatment in a Dutch nursing home population. A standardized pain questionnaire, including the Numeric Rating Scale (NRS), was used to measure aspects of pain and intensity of present pain, pain experienced in the previous week, and tolerable pain. The eligible sample comprised 320 residents (median age 79 years), of whom 233 residents completed the questionnaire. Sixty-six percent (n = 153) experienced (mostly chronic) pain, either in the previous week (median NRS 6) or at present (median NRS 5). Intolerable pain was recorded in 41% of 100 residents. The higher the pain scores, the more interference with activities of daily living was reported. Of the 153 residents with pain, about one-fourth did not receive any pain medication, and 65 (43%) received step 1, 13 (9%) step 2, and 16 (11%) step 3 analgesics. Most residents (60%) were satisfied with pain treatment, and 21% were not. Considering the high prevalences and intensities of pain, pain management in Dutch nursing homes leaves much to be desired. Apparently, residents do not seem to expect effective pain management. Awareness and knowledge about pain assessment and treatment, however, needs to be raised. Pain measurement tools and treatment protocols should be implemented in daily practice.

Pain prevalence and characteristics in three Dutch residential homes.

BACKGROUND: In Anglo-Saxon countries, high prevalence rates of pain have been reported for elderly living in nursing homes, residential homes and for community-dwelling elderly. No information on pain prevalence is available for elderly living in Dutch residential homes. METHODS: We performed an explorative study on pain prevalence, characteristics and treatment in three residential homes in Rotterdam, the Netherlands. Residents were interviewed using a standardized pain questionnaire. RESULTS: The overall prevalence of pain was 69%. In case of pain, it was chronic in 93% of residents. Present pain and mean pain during the preceding week were substantial (numeric rating scale 4) in 68% and 85% of residents, respectively. Of the residents with pain, 22% did not receive any analgesics and only 3% was prescribed a strong opioid. When analgesics were prescribed, they were given only 'as needed' in 31% of residents. In a majority of residents, pain interfered with daily living and mood. Almost 60% of the elderly was convinced that pain is a part of ageing, 70% indicated that they did not always report their pain to the caregivers. Thirty-seven percent was satisfied with the caregivers' and 39% with the doctors' attention towards pain. CONCLUSIONS: The pain prevalence rate in Dutch residential homes is similar to rates found in other Anglo-Saxon countries. Furthermore, they are also comparable to rates reported from European nursing homes. Pain treatment is insufficient and although pain interferes with daily activities and mood, elderly tend to accept pain as an unavoidable part of aging.