Exploration of a Multi-Parameter Technology for Pain Assessment in Postoperative Patients After Cardiac Surgery in the Intensive Care Unit: The Nociception Level Index (NOL)TM.

INTRODUCTION: The aim of this study was to explore the use of a multi-parameter technology, the Nociception Level (NOL) index (Medasense Biometrics Ltd, Ramat Gan, Israel), for pain assessment in postoperative awake patients after cardiac surgery during non-nociceptive and nociceptive procedures in the intensive care unit (ICU). MATERIALS AND METHODS: A prospective cohort repeated-measures design was used. Patients were included if they were in the ICU after undergoing cardiac surgery and if they could self-report their pain. A non-invasive probe was placed on the patient's finger for the continuous monitoring of the NOL index. Patients' self-reports of pain and anxiety (0-10 Numeric Rating Scale or NRS), and behavioral scores with the Critical-Care Pain Observation Tool (CPOT) were obtained before and during a non-nociceptive procedure (ie, non-invasive blood pressure [NIBP] using cuff inflation), and before, during and after a nociceptive procedure (ie, chest tube removal [CTR]) for a total of five time points. Non-parametric tests were used to compare scores at different time points, and receiver operating characteristic curve analysis was performed. RESULTS: Fifty-four patients were included in the analysis. The NOL index, pain and anxiety scores were significantly higher during CTR compared to rest and NIBP (p < 0.001). During CTR, the NOL was associated with self-reported pain intensity and unpleasantness but not with anxiety and CPOT scores. The NOL showed a modest performance in detecting pain (NRS ≥1 and ≥5) in this sample with sensitivity and specificity ranging from 61% to 85%. CONCLUSION: The NOL index was able to discriminate between a non-nociceptive and a nociceptive procedure and was associated with self-reported pain. Further validation testing of the NOL is necessary in a heterogeneous sample of ICU patients.

Validation of the Critical-Care Pain Observation Tool-Neuro in brain-injured adults in the intensive care unit: a prospective cohort study.

BACKGROUND: Pain assessment in brain-injured patients in the intensive care unit (ICU) is challenging and existing scales may not be representative of behavioral reactions expressed by this specific group. This study aimed to validate the French-Canadian and English revised versions of the Critical-Care Pain Observation Tool (CPOT-Neuro) for brain-injured ICU patients. METHODS: A prospective cohort study was conducted in three Canadian and one American sites. Patients with a traumatic or a non-traumatic brain injury were assessed with the CPOT-Neuro by trained raters (i.e., research staff and ICU nurses) before, during, and after nociceptive procedures (i.e., turning and other) and non-nociceptive procedures (i.e., non-invasive blood pressure, soft touch). Patients who were conscious and delirium-free were asked to provide their self-report of pain intensity (0-10). A first data set was completed for all participants (n = 226), and a second data set (n = 87) was obtained when a change in the level of consciousness (LOC) was observed after study enrollment. Three LOC groups were included: (a) unconscious (Glasgow Coma Scale or GCS 4-8); (b) altered LOC (GCS 9-12); and (c) conscious (GCS 13-15). RESULTS: Higher CPOT-Neuro scores were found during nociceptive procedures compared to rest and non-nociceptive procedures in both data sets (p < 0.001). CPOT-Neuro scores were not different across LOC groups. Moderate correlations between CPOT-Neuro and self-reported pain intensity scores were found at rest and during nociceptive procedures (Spearman rho > 0.40 and > 0.60, respectively). CPOT-Neuro cut-off scores ≥ 2 and ≥ 3 were found to adequately classify mild to severe self-reported pain ≥ 1 and moderate to severe self-reported pain ≥ 5, respectively. Interrater reliability of raters' CPOT-Neuro scores was supported with intraclass correlation coefficients > 0.69. CONCLUSIONS: The CPOT-Neuro was found to be valid in this multi-site sample of brain-injured ICU patients at various LOC. Implementation studies are necessary to evaluate the tool's performance in clinical practice.

Risk factors for severe opioid-induced respiratory depression in hospitalized adults: A case-control study.

Background: Opioids are commonly prescribed to hospitalized adults to promote adequate pain relief, yet they can cause potentially fatal respiratory depression. Aim: The aim of this study was to examine the risk factors for the development of severe opioid-induced respiratory depression (OIRD) in hospitalized adults to ensure adequate monitoring of high-risk patients. Methods: A retrospective case-control study was conducted using data from the medical records of a university-affiliated hospital in Canada. Cases were eligible if they were adults (≥18 years old) and received opioid analgesia within 24 h of naloxone administration for respiratory depression. Controls had the same eligibility criteria, except for respiratory depression and naloxone administration. The case-control ratio was 1:1, and they were matched based on sex, type of unit, opioid molecule and the presence/absence of medication errors. Results: A total of 133 cases and 133 controls were included. Following cumulative risk factor analysis, renal failure (odds ratio [OR] = 2.176, 95% confidence interval [CI], 1.021-4.640, P = 0.044), the first 24 h of opioid administration (OR = 1.899, 95% CI, 1.090-3.309, P = 0.024), concomitant central nervous system (CNS) depressants (OR = 1.785, 95% CI, 1.023-3.113, P = 0.041), and increasing age (OR = 1.019, 95% CI, 1.002-1.035, P = 0.028) were positively associated with severe OIRD. Conclusions: Some adult hospitalized patients were at higher risk of experiencing severe OIRD, such as those with renal failure, those in their first 24 h of opioid administration, those receiving CNS depressants in addition to opioids, and those with an advanced age. These results will assist with the screening of patients at higher risk for severe OIRD, which is key to implementing appropriate monitoring and enhancing the safety of opioid use in hospital settings.

Contexte: Les opioïdes sont couramment prescrits aux adultes hospitalisés pour favoriser un soulagement adéquat de la douleur, mais ils peuvent provoquer une dépression respiratoire potentiellement mortelle.Objectif: Examiner les facteurs de risque du développement d'une dépression respiratoire sévère induite par un opioïde chez les adultes hospitalisés afin d'assurer un suivi adéquat des patients à haut risque.Méthodes: Une étude rétrospective cas - témoins a été menée en utilisant les données des dossiers médicaux d'un hôpital universitaire au Canada. Les cas étaient admissibles s'ils étaient adultes (≥ 18 ans) et avaient reçu une analgésie opioïde dans les 24 heures suivant l'administration de naloxone pour une dépression respiratoire. Les critères d'admissibilité étaient les mêmes pour les témoins, à l'exception de la dépression respiratoire et de l'administration de naloxone. Le rapport cas/témoins était de 1:1 et ceux-ci étaient appariés en fonction du sexe, du type d'unité, de la molécule opioïde et de la présence ou absence d'erreurs de médication.Résultats: Un total de 133 cas et 133 témoins ont été inclus. Après analyse des facteurs de risque cumulés, l'insuffisance rénale (RC = 2,176, IC à 95 % : 1,021 - 4,640, p = 0,044), les premières 24 heures d'administration d'opioïdes (RC = 1,899, IC à 95 % : 1,090 -3, 309, p = .024), les dépresseurs du SNC concomitants (RC = 1,785, IC à 95 % : 1,023-3,113, p = 0,041) et l'augmentation de l'âge par âge avancé (RC = 1,019, IC à 95 % : 1,002 - 1,035, p = 0,028) ont été positivement associés à des dépressions respiratoires sévères induites par un opioïde.Conclusions: Certains patients adultes hospitalisés présentaient un risque plus élevé de souffrir d'une dépression respiratoire sévère induite par un opioïde, notamment les personnes souffrant d'insuffisance rénale, celles à qui un opoïde a été administré dans les dernières 24 heures, celles qui ont reçu ds dépresseurs du SNC en plus d'un opioïde et celles qui étaient plus âgées. Ces résultats permettront d'identifier les patients à haut risque de souffrir d'une dépression respiratoire sévère induite par un opioïde, ce qui est essentiel pour mettre en place un suivi approprié et améliorer la sécurité de l'utilisation des opioïdes en milieu hospitalier.

The Effect of Music on Pain in the Adult Intensive Care Unit: A Systematic Review of Randomized Controlled Trials.

CONTEXT: Multimodal analgesic approaches are recommended for intensive care unit (ICU) pain management. Although music is known to reduce pain in acute and chronic care settings, less is known about its effectiveness in the adult ICU. OBJECTIVES: Determine the effects of music interventions on pain in the adult ICU, compared with standard care or noise reduction. METHODS: This review was registered on PROSPERO (CRD42018106889). Databases were searched for randomized controlled trials of music interventions in the adult ICU, with the search terms ["music*" and ("critical care" or "intensive care")]. Pain scores (i.e., self-report rating scales or behavioral scores) were the main outcomes of this review. Data were analyzed using a DerSimonian-Laird random-effects method with standardized mean difference (SMD) of pain scores. Statistical heterogeneity was determined as I2 > 50% and explored via subgroup analyses and meta-regression. RESULTS: Eighteen randomized controlled trials with a total of 1173 participants (60% males; mean age 60 years) were identified. Ten of these studies were included in the meta-analysis based on risk of bias assessment (n = 706). Music was efficacious in reducing pain (SMD -0.63 [95% CI -1.02, -0.24; n = 10]; I2 = 87%). Music interventions of 20-30 minutes were associated with a larger decrease in pain scores (SMD -0.66 [95% CI -0.94, -0.37; n = 5]; I2 = 30%) compared with interventions of less than 20 minutes (SMD 0.10 [95% CI -0.10, 0.29; n = 4]; I2 = 0%). On a 0-10 scale, 20-30 minutes of music resulted in an average decrease in pain scores of 1.06 points (95% CI -1.56, -0.56). CONCLUSION: Music interventions of 20-30 minutes are efficacious to reduce pain in adult ICU patients able to self-report.

Vital signs fluctuations and their relationship with pain in the brain-injured adult critically ill - A repeated-measures descriptive-correlational study.

OBJECTIVES: To evaluate the use of vital signs for pain detection in brain-injured patients in the intensive care unit. DESIGN: A repeated-measures descriptive-correlational study. SETTING: Two neurological intensive care units in Montréal, Canada. A total of 101 brain-injured patients were included. MAIN OUTCOME MEASURES: This study examined the fluctuations in systolic and diastolic blood pressure, heart and respiratory rates, and oxygen saturation in brain-injured critically ill patients before, during, and 15 minutes after turning and soft touch using a data collection computer. When possible, patients' pain self-reports were obtained using a 0-10 Faces Pain Thermometer. RESULTS: The heart and respiratory rates were higher during turning than soft touch and higher during the procedure compared to prior (p < 0.05), but their fluctuation was modest. The systolic blood pressure increased during both turning and soft touch by 2 mmHg, but was 26.6 mmHg higher for those who reported pain versus no pain (Mann-Whitney = 25.00, p = 0.008, n = 28). A moderate correlation was observed between the systolic blood pressure (Spearman's rho = 0.617, p = 0.004, n = 24) and self-reported pain intensity during turning. No significant effects were observed for diastolic blood pressure and oxygen saturation. CONCLUSION: Only increases in systolic blood pressure were positively associated with pain in this sample and replication studies with larger samples is needed.

Family Members' Experiences with Observing Pain Behaviors Using the Critical-Care Pain Observation Tool.

BACKGROUND: Current guidelines support family members' participation in care, but little is known regarding their potential contribution to pain assessment using validated behavioral pain scales. AIMS: This study aimed to describe family members' observations of pain behaviors with the Critical-Care Pain Observation Tool and their evaluation of the tool and its use, and to understand their experience and perceptions of their potential role in pain management in the intensive care unit. DESIGN: A mixed methods cross-sectional explanatory design was used. SETTING: A medical-surgical intensive care unit in Canada. PARTICIPANTS/SUBJECTS: Family members were eligible if they had a loved one admitted in the intensive care unit who was unable to self-report. METHODS: Family members identified pain behaviors using the Critical-Care Pain Observation Tool after a brief training, completed a self-administered questionnaire, and participated in a follow-up individual interview regarding their experience and perceived potential role in pain management when their loved one is unable to self-report. RESULTS: Ten family members participated. A 15-minute training appeared sufficient for family members to be comfortable with observing pain behaviors included in the Critical-Care Pain Observation Tool. The tool allowed them to confirm their observations of pain behaviors, to focus more on the patient, and to advocate for better pain management. CONCLUSIONS: Future research is needed to explore the views of more family members and to compare their Critical-Care Pain Observation Tool scores to the ones of nurses' for interrater reliability testing.

Does Hand Massage Have Sustained Effects on Pain Intensity and Pain-Related Interference in the Cardiac Surgery Critically Ill? A Randomized Controlled Trial.

BACKGROUND: Despite the promising short-term pain relief effect of massage, little is known regarding its sustained effects on pain intensity and pain-related interference with functioning. AIMS: To evaluate the sustained effect of hand massage on the pain intensity and pain-related interference with functioning of cardiac surgery patients. DESIGN: A randomized controlled trial. SETTINGS: A medical-surgical intensive care unit in Canada. PARTICIPANTS/SUBJECTS: Adult patients undergoing cardiac surgery and at low risk for postoperative complications were eligible. METHODS: In the intensive care unit, patients were randomly assigned to either 20-minute hand massage, hand holding, or rest. Pain intensity and pain-related interference with functioning were assessed on the second postoperative day. RESULTS: A total of 60 patients were randomly allocated and 46 completed data collection on the second postoperative day. Although no significant differences were identified across groups, the hand massage group reported a maximum pain intensity (median 5.75, range: 2-10) that was lower than the hand-holding (median 6.50, range: 1-10) and standard care groups (median 6.25, range: 0-10). The hand massage group could reach 0 pain intensity throughout a 24-hour period (median 0, range: 0-7), contrary to the hand-holding (median 2, range: 0-5) and standard care groups (median 2, range: 0-4.5). A trend for statistical significance was noted for dichotomized ratings on pain interference with walking (p = .176) and sleep (p = .050). CONCLUSIONS: Hand massage could help patients experience longer periods without pain and lower levels of maximum pain intensity. When coupled with recovery activities, hand massage could reduce pain-related interference with functioning.

Validation of the Adolescent Pediatric Pain Tool for the Multidimensional Measurement of Pain in Children and Adolescents Diagnosed with Osteogenesis Imperfecta.

Background: The Adolescent Pediatric Pain Tool (APPT) is a self-reported, multidimensional assessment of pain location, intensity, and quality in children and adolescents. Yet, it has not been validated for use in children and adolescents with osteogenesis imperfecta (OI). Aims: This study aimed to validate and evaluate the feasibility of the APPT for pain assessment in children and adolescents with OI. Methods: A prospective observational study was conducted at a university-affiliated pediatric hospital in Canada. Thirty-three children and adolescents with OI participated by completing the APPT pre-bisphosphonate intravenous infusion and 1 week post-bisphosphonate intravenous infusion. Main outcomes were internal consistency, convergent and discriminative validity, and feasibility. Results: The Kuder-Richardson test of internal consistency was 0.863, 0.661, and 0.729 for the Sensory, Affective, and Evaluative subscales, respectively. For the entire pain quality scale, the Cronbach's alpha was 0.835. Regarding convergent validity, a moderate correlation was observed between the ratings on the pain intensity scale and the Faces Pain Scale-Revised (Spearman's rho = 0.711). Patients for whom pain was a problem reported higher pain intensity (Mann Whitney U = 41.50, P = 0.032) and more pain quality descriptors (Mann Whitney U = 45.50, P = 0.020) and painful body areas (Mann-Whitney U = 25.50, P = 0.001) than those for whom it was not (Mann-Whitney U, P < 0.05). In terms of feasibility, completing the tool may require a considerable time commitment and assistance from a clinician or parent, especially if the patient is experiencing pain and provides detailed pain location and quality information by completing the APPT. Conclusions: This study suggests that the APPT is valid for the multidimensional assessment of pain in children and adolescents with OI, but feasibility needs to be enhanced.

Contexte: L'outil d'évaluation de la douleur des adolescents en pédiatrie (APPT) est une évaluation multidimensionnelle auto-déclarée de l'emplacement, de l'intensité et de la qualité de la douleur chez les enfants et les adolescents. Toutefois, l'utilisation de cet outil auprès des enfants et des adolescents souffrant d'ostéogénèse imparfaite n'a pas encore été validée.But: Cette étude avait pour but de valider et d'évaluer la faisabilité de l'APPT pour l'évaluation de la douleur dans cette population.Méthodes: Une étude observationnelle prospective a été menée dans un centre hospitalier universitaire à vocation pédiatrique au Canada. Trente-trois enfants et adolescents atteints d'ostéogénèse imparfaite ont participé à cette étude en répondant à l'APPT avant l'infusion intraveineuse de bisphosphonate et une semaine après celle-ci. Les principaux résultats étaient la cohérence interne, la validation convergente et discriminante, et la faisabilité.Résultats: Le résultat du test de Kuder-Richardson pour mesurer la cohérence interne était de 0,863 pour le sensoriel, 0,661 pour l'affectif et 0,729 pour les sous-échelles d'évaluation. Pour l'échelle de qualité de la douleur au complet, l'indice alpha de Cronbach était de 0,835. En ce qui concerne la validation convergente, une corrélation modérée a été observée entre les scores obtenus à l'échelle d'intensité de la douleur et le FPS-R (Rho de Spearman= 0,711). Les patients pour lesquels la douleur était problématique ont fait état d'une intensité de la douleur plus élevée, ont eu recours à un plus grand nombre de descripteurs de la qualité de la douleur et ont identifié davantage de parties du corps douloureuses que ceux pour lesquels la douleur n'était pas problématique (Mann-Whitney U, p < 0,05). En ce qui concerne la faisabilité, le temps requis pour répondre au questionnaire peut être considérable et l'aide d'un clinicien ou d'un parent peut être nécessaire, particulièrement si le patient ressent de la douleur et donne de l'information détaillée sur la localisation et la qualité de la douleur en répondant à l'APPT.Conclusions: Selon cette étude, l'APPT est valide pour l'évaluation multidimensionnelle de la douleur chez les enfants et les adolescens souffrant d'oastéogénèse imparfaite, mais sa faisabilité doit être améliorée.

A Psychometric Analysis Update of Behavioral Pain Assessment Tools for Noncommunicative, Critically Ill Adults.

This is an updated, comprehensive review of the psychometric properties of behavioral pain assessment tools for use with noncommunicative, critically ill adults. Articles were searched in 5 health databases. A total of 106 articles were analyzed, including 54 recently published papers. Nine behavioral pain assessment tools developed for noncommunicative critically ill adults and 4 tools developed for other non-communicative populations were included. The scale development process, reliability, validity, feasibility, and clinical utility were analyzed using a 0 to 20 scoring system, and quality of evidence was also evaluated. The Behavioral Pain Scale, the Behavioral Pain Scale-Nonintubated, and the Critical-Care Pain Observation Tool remain the tools with the strongest psychometric properties, with validation testing having been conducted in multiple countries and various languages. Other tools may be good alternatives, but additional research on them is necessary.

Behaviors Indicative of Pain in Brain-Injured Adult Patients With Different Levels of Consciousness in the Intensive Care Unit.

CONTEXT: Many brain-injured patients are unable to self-report their pain during their hospitalization in the intensive care unit (ICU), and existing behavioral pain scales may not be well suited. OBJECTIVES: The objectives of this study were to describe and compare behaviors in brain-injured patients with different levels of consciousness during nociceptive and nonnociceptive care procedures in the ICU and to examine interrater agreement of individual behaviors as well as discriminative and criterion validation of putative pain behaviors. METHODS: Brain-injured ICU patients were observed using a 40-item behavioral checklist before and during soft touch (i.e., nonnociceptive procedure), turning, and other care procedures (nociceptive) by pairs of trained raters. When possible, patients self-reported their pain on a 0-10 visual thermometer. Patients were classified into unconscious (Glasgow Coma Scale, 3

Transition to a newly constructed single patient room adult intensive care unit - Clinicians' preparation and work experience.

PURPOSE: To describe how clinicians were prepared for the transition to a novel single patient room (SPR) intensive care unit (ICU) and their work experience during this transition. MATERIALS AND METHODS: In this qualitative descriptive study, four focus groups were conducted six months post-move with a multidisciplinary group of 29 clinicians at a hospital in Montreal, Canada. The interview guide was derived from a readiness for change conceptual framework. Audio recordings were transcribed verbatim and analyzed via thematic analysis. RESULTS: Clinicians described preparation strategies such as educational resources, managerial support and personal initiatives, with some variation across professions. Clinicians felt ready for the transition especially in their adaptation to the new physical environment, yet some challenges related to teamwork dynamics and bedside care persisted after the transition. CONCLUSIONS: The use of preparation strategies that are tailored to clinicians' roles helped build readiness for transition to a novel SPR ICU and facilitated the adaptation process. Challenges related to teamwork dynamics and practices in an isolating environment persisted beyond the adaptation period and must be addressed and overcome to better meet the needs and expectations of ICU clinicians.

Acceptability and feasibility of an interprofessional end-of-life/palliative care educational intervention in the intensive care unit: A mixed-methods study.

OBJECTIVES: This study aimed to describe a seven hour End-of-Life/Palliative Care educational intervention including online content related to symptom management, communication and decision-making capacity and an in-person group integration activity, from the perspective of the interprofessional team in terms of its acceptability and feasibility. RESEARCH DESIGN: A mixed-methods study design was used. SETTING AND SAMPLE: The study was conducted in a medical-surgical Intensive Care Unit in Montreal, Canada. The sample consisted of 27 clinicians of the Intensive Care Unit interprofessional team who completed the End-of-Life/Palliative Care educational intervention, and participated in focus groups and completed a self-administered questionnaire. MAIN OUTCOME MEASURES: The main outcomes were the acceptability and feasibility of the educational intervention. FINDINGS: The intervention was perceived to be appropriate and suitable in providing clinicians with knowledge and skills in symptom management and communication through self-reflection and self-evaluation, provision of assessment tools and promotion of interprofessional teamwork. The online format was more feasible, but the in-person group activity was key for the integration of knowledge and the promotion of interprofessional discussions. CONCLUSION: Findings suggest that an interprofessional educational intervention integrating on-line content with in-person training has the potential to support clinicians in providing quality End-of-Life/Palliative Care in the Intensive Care Unit.

Effects of Massage in Reducing the Pain and Anxiety of the Cardiac Surgery Critically Ill-a Randomized Controlled Trial.

Objective: To evaluate the effectiveness of hand massage on the pain and anxiety of the cardiac surgery critically ill. Design: A three-arm randomized controlled trial. Setting: This study was conducted in a medical-surgical intensive care unit in Canada. Subjects: Adult patients who underwent elective cardiac surgery, who were able to speak French/English and to self-report symptoms, without a high risk of postoperative complications were eligible. Methods: Patients were randomly allocated to standard care plus either two 20-minute hand massages (experimental), two 20-minute hand holdings (active control), or two 20-minute rest periods (passive control/standard care). Pain intensity, pain unpleasantness, anxiety, muscle tension, and vital signs were evaluated before, after, and 30 minutes later for each intervention. Results: From the 83 patients recruited, 60 were randomized (20 massage, 19 hand holding, 21 standard care). After controlling for baseline scores, the massage group reported significantly lower pain intensity, pain unpleasantness, and anxiety for the first data collection set compared with both hand holding and standard care (analysis of covariance, P < 0.02), with an average decrease of two points on a 0-10 scale. No statistically significant differences were noted between hand holding and standard care for any of the symptoms. Similar results were observed for the second data collection set (N = 43). Patients had decreased muscle tension post massage. Vital signs did not differ significantly between groups. Conclusions: Findings suggest that a 20-minute hand massage in addition to routine postoperative pain management can concomitantly reduce pain intensity, pain unpleasantness, and anxiety by two points on average on a 0-10 scale.

Pain and quality of life of children and adolescents with osteogenesis imperfecta over a bisphosphonate treatment cycle.

The objective was to describe the pain and quality of life among children and adolescents with any osteogenesis imperfecta (OI) type over one intravenous bisphosphonate treatment cycle from a child and parental perspective. A prospective, observational study was conducted, where children and adolescents evaluated their pain intensity, location, and quality, as well as quality of life before, 1 week after treatment, and 6 months later. Quality of life was also evaluated from the parental perspective at the same three time points. Thirty-three child/parent dyads participated. The results showed that pain intensity on the 0-10 self-report scale after the Zoledronate infusion (median = 0, range = 0-6) was not different from pre (median = 2, range = 0-10) and 6-months post-scores (median = 2, range = 0-8) (p = 0.170). Children and adolescents with OI reported experiencing pain mainly in the ankles and the anterior and posterior shoulders. They selected evaluative pain descriptors such as uncomfortable (n = 16, 48%) and annoying (n = 13, 39%). Children and adolescents' functioning and quality of life did not change significantly across the bisphosphonate treatment cycle (p = 0.326), parents perceived an improvement immediately after the treatment compared to before (p = 0.016). CONCLUSION: Children and adolescents with OI experience mild, yet complex pain localized across several body areas. There is little fluctuation in the pain intensity and functioning of children with OI undergoing bisphosphonate treatment. What is Known: • Acute and chronic musculoskeletal pain remains a major issue in OI. • Pain has a negative impact on quality of life. What is New: • New and unpublished methods and findings describing the pain and quality of life of children and adolescents with OI over one intravenous bisphosphonate treatment cycle from a child- and parental-proxy perspective. • Children and adolescents with OI experience pain intensity that is mild, yet complex in quality and localized across several body areas.

Family members' perceptions of pain behaviors and pain management of adult patients unable to self-report in the intensive care unit: A qualitative descriptive study.

BACKGROUND: Current guidelines suggest that family members be consulted in the pain assessment process of patients unable to self-report. However, little is known regarding family members' perceptions of their loved one's pain behaviors and pain management. AIMS: This qualitative descriptive study aimed to describe family members' perceptions of pain behaviors and pain management in critically ill hospitalized patients admitted to an intensive care unit and unable to self-report. METHODS: A qualitative descriptive design was used. This study was conducted in a medical-surgical intensive care unit in Canada. Family members of nonverbal adult patients participated in a semistructured interview regarding their perceptions of pain behaviors and pain management in the intensive care unit. RESULTS: Ten family members with a nonverbal loved one admitted to the intensive care unit participated. Family members agreed on the presence of pain in the intensive care unit and reported being proactive and applying nonpharmacological interventions to help palliate pain of their loved one. Although family members identified behavioral indicators such as grimace, limb movement, and verbal complaints to assess pain in their loved one, the majority were unsure of their ability to detect pain. CONCLUSIONS: Family members have intimate knowledge of their loved one and could be invited to share their perceptions of their loved one's pain when they feel confident to do so.

Contexte: Les lignes directrices actuelles suggèrent que les membres de la famille soient consultés lors du processus d'évaluation de la douleur des patients incapables de fournir une auto-évaluation. Toutefois, on sait peu de choses au sujet de perceptions des membres de la famille au sujet des comportements de leur proche relativement à la douleur et à la prise en charge de la douleur.But: Cette étude descriptive qualitative avait pour but de décrire la perception des membres de la famille des comportements relatifs à la douleur et à la prise en charge de la douleur chez des patients en état critique de santé admis dans une unité de soins intensifs et incapables de fournir une auto-évaluation.Méthodes: Un devis descriptif qualitatif a été utilisé. Cette étude a été menée dans une unité de soins intensifs médicale-chirurgicale au Canada. Les membres de la famille de patients adultes non verbaux ont participé à une entrevue semi-structurée concernant leur perception des comportements relatifs à la douleur et à la prise en charge de la douleur à l'unité des soins intensifs.Résultats: Dix membres de famille ayant un proche non verbal admis à l'unité des soins intensifs ont participé. Les membres de famille étaient d'accord pour dire que la douleur était présente dans l'unité des soins intensifs. Ils ont aussi dit être proactifs et appliquer des interventions non pharmacologiques pour aider à soulager la douleur de leur proche. Bien que les membres de la famille ont identifié des indicateurs comportementaux comme une grimace, le mouvement d'un membre ou des plaintes verbales pour évaluer la douleur de leur proche, la majorité d'entre eux n'étaient pas certains de leur capacité à détecter la douleur.Conclusions: Les membres de la famille ont une connaissance intime de leur proche et pourraient être invités à partager leur perception de la douleur ressentie par leur proche lorsqu'ils se sentent à l'aise de le faire.

Content validation of behaviours and autonomic responses for the assessment of pain in critically ill adults with a brain injury.

BACKGROUND: The evidence shows that brain-injured patients express behaviours that are related to their level of consciousness (LOC), and different from other patients in the intensive care unit (ICU). Therefore, existing behavioural scales should be revised to enhance their content and validity for use in these patients. OBJECTIVES: The aim was to evaluate the content relevance of behaviours and autonomic responses for pain assessment of brain-injured ICU patients from the perspective of critical care clinicians. METHODS: A total of 77 clinicians from four adult neuroscience ICUs (three from Canada and one from the United States) participated in this descriptive study. A physician/nurse ratio of 21% (13/61) was reached in this quota sample, and three physiotherapists also participated. They completed a content validation questionnaire of 19 items rated on clarity and relevance based on the patient's LOC. Item Content Validity Index (I-CVI), and modified kappa (κ*) were calculated. Values higher than 0.78 and 0.75 respectively were considered excellent. RESULTS: Regardless of the patient's LOC, brow lowering, grimacing, and trying to reach the pain site were rated as the most relevant behaviours by clinicians, with excellent values of I-CVI>0.78 and κ*>0.75. Eyes tightly closed, moaning and verbal complaints of pain also obtained excellent values in altered LOC and conscious patients. Eye weeping obtained excellent values only in conscious patients. Other items showed fair (0.40-0.59) to good (0.60-0.74) values, while blinking and coughing showed poor values (<0.40) at various LOC. CONCLUSIONS: Facial expressions, movements towards the pain site, and vocalisation of pain were the most relevant pain-related behaviours rated by critical care clinicians. The relevance of some behaviours (e.g., moaning and verbal complaints of pain) varied across LOCs, thereby calling forth adaptations of behavioural pain scales to allow for interpretation in the context of a patient's LOC and ability to express specific behaviours.

Tailored Web-Based Interventions for Pain: Systematic Review and Meta-Analysis.

BACKGROUND: Efforts have multiplied in the past decade to underline the importance of pain management. For both acute and chronic pain management, various barriers generate considerable treatment accessibility issues, thereby providing an opportunity for alternative intervention formats to be implemented. Several systematic reviews on Web-based interventions with a large emphasis on chronic pain and cognitive behavioral therapy have been recently conducted to explore the influence of these interventions on pain management However, to our knowledge, the specific contribution of tailored Web-based interventions for pain management has not been described and their effect on pain has not been evaluated. OBJECTIVE: The primary aim of this systematic review was to answer the following research question: What is the effect of tailored Web-based pain management interventions for adults on pain intensity compared with usual care, face-to-face interventions, and standardized Web-based interventions? A secondary aim was to examine the effects of these interventions on physical and psychological functions. METHODS: We conducted a systematic review of articles published from January 2000 to December 2015. We used the DerSimonian-Laird random effects models with 95% confidence intervals to calculate effect estimates for all analyses. We calculated standardized mean differences from extracted means and standard deviations, as outcome variables were measured on different continuous scales. We evaluated 5 different outcomes: pain intensity (primary outcome), pain-related disability, anxiety, depression, and pain catastrophizing. We assessed effects according to 3 time intervals: short term (<1 month), medium term (1-6 months), and long term (6-12 months). RESULTS: After full-text review, we excluded 31 articles, resulting in 17 eligible studies. Only 1 study concerned acute pain and was removed from the meta-analysis, resulting in 16 studies available for quantitative assessment. Compared with standard care or a waiting list, tailored Web-based intervention showed benefits immediately after, with small effect sizes (<0.40) for pain intensity (10 randomized controlled trials [RCTs], n=1310, P=.003) and pain-related disability (6 RCTs, n=953, P<.001). No other improvements were observed at follow-up in the medium and long terms. Compared with the active control group, no improvements were found for the primary outcome (pain intensity) or any of the outcomes except for a small effect size on pain catastrophizing (2 RCTs, n=333, P<.001) immediately after the intervention. CONCLUSIONS: Tailored Web-based interventions did not prove to be more efficacious than standardized Web-based interventions in terms of pain intensity, pain-related disability, anxiety, and depression. An interesting finding was that some efficacy was shown on pain catastrophizing compared with active control interventions. Considering the diversity of approaches used in tailored Web-based interventions for chronic pain management, their efficacy is yet to be explored. Moreover, their contribution to acute pain management is embryonic. TRIAL REGISTRATION: International prospective register of systematic reviews (PROSPERO): CRD42015027669; http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42015027669 (Archived by WebCite at http://www. webcitation.org/6uneWAuyR).

The Effect of Massage on Acute Postoperative Pain in Critically and Acutely Ill Adults Post-thoracic Surgery: Systematic Review and Meta-analysis of Randomized Controlled Trials.

Critical care practice guidelines identify a lack of clear evidence on the effectiveness of massage for pain control. To assess the effect of massage on acute pain in critically and acutely ill adults post-thoracic surgery. Medline, Embase, CINAHL, PsychInfo, Web of Science, Scopus and Cochrane Library databases were searched. Eligible studies were randomized controlled trials (RCTs) evaluating the effect of massage compared to attention control/sham massage or standard care alone on acute pain intensity post-thoracic surgery. Twelve RCTs were included. Of these, nine evaluated massage in addition to standard analgesia, including 2 that compared massage to attention control/sham massage in the intensive care unit (ICU), 6 that compared massage to standard analgesia alone early post-ICU discharge, and 1 that compared massage to both attention control and standard care in the ICU. Patients receiving massage with analgesia reported less pain (0-10 scale) compared to attention control/sham massage (3 RCTs; N = 462; mean difference -0.80, 95% confidence interval [CI] -1.25 to -0.35; p < 0.001; I2 = 13%) and standard care (7 RCTs; N = 1087; mean difference -0.85, 95% CI -1.28 to -0.42; p < 0.001; I2 = 70%). Massage, in addition to pharmacological analgesia, reduces acute post-cardiac surgery pain intensity.

The Effectiveness of Hand Massage on Pain in Critically Ill Patients After Cardiac Surgery: A Randomized Controlled Trial Protocol.

BACKGROUND: Postoperative pain is common in the intensive care unit despite the administration of analgesia. Some trials suggest that massage can be effective at reducing postoperative pain in acute care units; however, its effects on pain relief in the intensive care unit and when pain severity is highest remain unknown. OBJECTIVE: The objective is to evaluate the effectiveness of hand massage on the pain intensity (primary outcome), unpleasantness and interference, muscle tension, anxiety, and vital signs of critically ill patients after cardiac surgery. METHODS: A 3-arm randomized controlled trial will be conducted. A total of 79 patients who are 18 years or older, able to speak French or English and self-report symptoms, have undergone elective cardiac surgery, and do not have a high risk of postoperative complications and contraindications to hand massage will be recruited. They will be randomly allocated (1:1:1) to standard care plus either 3 20-minute hand massages (experimental), 3 20-minute hand holdings (active control), or 3 20-minute rest periods (passive control). Pain intensity, unpleasantness, anxiety, muscle tension, and vital signs will be evaluated before, immediately after, and 30 minutes later for each intervention administered within 24 hours postoperatively. Peer-reviewed competitive funding was received from the Quebec Nursing Intervention Research Network and McGill University in December 2015, and research ethics approval was obtained February 2016. RESULTS: Recruitment started in April 2016, and data collection is expected to be complete by January 2017. To date, 24 patients were randomized and had data collection done. CONCLUSIONS: This study will be one of the first randomized controlled trials to examine the effect of hand massage on the pain levels of critically ill patients after cardiac surgery and to provide empirical evidence for the use of massage among this population. CLINICALTRIAL: ClinicalTrials.gov NCT02679534; https://clinicaltrials.gov/ct2/show/NCT02679534 (Archived by WebCite at http://www.webcitation.org/6l8Ly5eHS).

Validation of the Critical-Care Pain Observation Tool in brain-injured critically ill adults.

OBJECTIVE: Pain is a common symptom in the intensive care unit (ICU). Brain-injured patients are often unable to reliably self-report their pain, calling forth the need to use behavioral scales such as the Critical-Care Pain Observation Tool (CPOT). This study aimed to test the reliability and validity of the CPOT use with brain-injured ICU adults. MATERIALS AND METHODS: Eight trained staff nurses and a medical student scored the CPOT before and during a nonpainful (ie, gentle touch) and at least 1 painful (eg, turning) procedure. Then, communicative patients self-reported their pain using yes/no and, when possible, on a 0 to 10 Faces Pain Thermometer. RESULTS: A total of 79 brain-injured ICU patients participated. The intraclass correlation coefficient between trained raters was 0.73 (95% confidence interval, 0.57-0.83) during turning. CPOT scores were significantly higher during turning compared with gentle touch (P< .001) and correlated significantly with self-reports of pain intensity during turning (0.64, P< .01). The receiver operating characteristics curve indicated a cutoff of 2 with a sensitivity of 0.90 and specificity of 0.67. CONCLUSIONS: Overall, the CPOT use was found to be reliable and valid in this patient group and is new evidence fulfilling an important gap highlighted in the Society of Critical Care Medicine practice guidelines.