Pain Measurement in Older Adults With Head and Neck Cancer and Communication Impairments

The Use and Perceptions of the Defense and Veterans Pain Rating Scale by Nursing Personnel

BACKGROUND

In 2010, the Office of the US Army Surgeon General recommended the Veterans Administration (VA) assess pain using the Defense and Veterans Pain Rating Scale (DVPRS). One item in the DVPRS is for measuring pain intensity. This item contains a combination of five response metrics: categories, faces, colors, numbers, and functional descriptors. A few studies have supported patients' and health care providers' preferences for the DVPRS and its psychometric properties. However, they also left uncertainties about its usability and validity.

AIMS

To advance our understanding of the DVPRS, this study examined the use and perceptions of the DVPRS' pain intensity item by nursing personnel during multi-modal care.

DESIGN

A cross-sectional survey design was used.

SETTING

VA Community Living Center.

PARTICIPANTS

Nursing personnel.

METHODS

Nursing personnel answered closed- and open-ended survey questions during a single session.

RESULTS

Nursing personnel reported sufficient training before implementing the measure and that patients primarily used the numeric metric. When patients used a non-numeric metric, the nursing personnel responded in variable ways. In addition, the nursing personnel interpreted the functional descriptors differently. The nursing personnel also noted the need to supplement the pain intensity item with patients' pain duration and pain location.

CONCLUSIONS

Results from this study inform the nursing community about the DVPRS' pain intensity item, which combines multiple response metrics. The results support the need for nursing units to generate and standardize procedures for using the item to measure multi-site pain and for interpreting and documenting patients' non-numeric responses. The effects of such procedures on the measure's usability and psychometric properties warrants additional investigation.

Numeric rating scale for pain should be used in an ordinal but not interval manner. A retrospective analysis of 346,892 patient reports of the quality improvement in postoperative pain treatment registry

ABSTRACT

To assess postoperative pain intensity in adults, the numeric rating scale (NRS) is used. This scale has shown acceptable psychometric features, although its scale properties need further examination. We aimed to evaluate scale properties of the NRS using an item response theory (IRT) approach. Data from an international postoperative pain registry (QUIPS) was analyzed retrospectively. Overall, 346,892 adult patients (age groups: 18-20 years: 1.6%, 21-30 years: 6.7%, 31-40 years: 8.3%, 41-50 years: 13.2%, 51-60 years: 17.1%, 61-70 years: 17.3%, 71-80 years: 16.4%, 81-90 years: 3.9%, >90: 0.2%) were included. Among the patients, 55.7% are female and 38% had preoperative pain. Three pain items (movement pain, worst pain, least pain) were analyzed using 4 different IRT models: partial credit model (PCM), generalized partial credit model (GPCM), rating scale model (RSM), and graded response model (GRM). Fit indices were compared to decide the best fitting model (lower fit indices indicate a better model fit). Subgroup analyses were done for sex and age groups. After collapsing the highest and the second highest response category, the GRM outperformed other models (lowest Bayesian information criterion) in all subgroups. Overlapping categories were found in category boundary curves for worst and minimum pain and particularly for higher pain ratings. Response category widths differed depending on pain intensity. For female, male, and age groups, similar results were obtained. Response categories on the NRS are ordered but have different widths. The interval scale properties of the NRS should be questioned. In dealing with missing linearity in pain intensity ratings using the NRS, IRT methods may be helpful.

Vascular outcomes of early deflation of radial artery band following coronary angiography: A controlled clinical trial

The present study aimed to investigate the effect of early deflation of the transradial (TR) band on the vascular outcomes of patients who have undergone coronary angiography through transradial access (TRA). The present controlled clinical trial included all patients who had undergone elective coronary angiography through TRA. The participants (n=70) met the inclusion criteria and were selected using convenient sampling. Then, they were randomly assigned to the intervention and control groups, using block randomization. Data collection tools included a questionnaire on demographic and related clinical data, including the history of diabetes, hypertension, hypercholesterolemia, heart failure and vascular disease, and the checklist of post-angiographic complications, including duration of the procedure, systolic and diastolic blood pressures measured before and after the procedure, and assessments of radial artery occlusion (RAO), hematoma and pain. The intervention group had their TR band on the artery for 1.5 hours after the procedure. Then, the cuff of the band was deflated at a speed of 5 cc every 15 minutes, using a syringe. However, the TR band was kept in place for 2 hours in the control group, followed by the deflation with the same speed. The pressure application time was recorded in both groups from the removal of sheaths until complete hemostasis. The patients with early deflation of the TR band experienced less pain compared to those with typical deflation (P=0.003). However, the variables of hematoma development (P=0.062) and RAO (P=0.371) were not significantly different between the patients with typical and early deflation of the TR band. The present study concluded that the patients with early deflation of the TR band experienced less pain compared to those with typical deflation. Therefore, deflating the TR band after cardiac angiography at 1,5 hours has similar efficacy and safety compare to 2 hours and associated with less reported pain score.

Palliative Care and End-of-Life Issues in Elderly Cancer Patients With Head and Neck Cancer

The number of elderly patients with incurable head and neck cancer will increase. They are in need of geriatric palliative care, that takes into account oncology, palliative care and geriatric medicine. In this review of the most recent and relevant literature and includes the expert opinion of the authors, several physical problems (e.g. pain, fatigue, malnutrition, and loco-regional problems) encountered by the elderly head and neck cancer patients are addressed. In addition end-of life issues in this patient population are discussed.

The CO2 waveguide laser with flexible fiber in transoral resection of oral and oropharyngeal cancers: a retrospective cohort study on postoperative and quality of life outcomes

The aim of this study was to evaluate the CO₂ waveguide laser (WG CO₂ laser) with flexible fiber (Lumenis Ltd., Yokneam, Israel) in the treatment of oral and oropharyngeal cancers, specifically focusing on postoperative outcomes, pain, and quality of life (QoL). Eighty-one patients, 43 women and 38 men, with oral or oropharyngeal cancer who consecutively underwent transoral resection by WG CO₂ laser from August 2015 to April 2020 were retrospectively enrolled. Resections were performed in super pulsed mode with a power setting ranging between 3 and 10 W. Data about frozen sections, reconstruction, complication rate, length of hospital stay, tracheostomy rate and time to decannulation, nasogastric feeding tube rate and time to oral feeding, pain, and QoL were reviewed. Continuous variables were presented as mean and standard deviation. Concordance between intraoperative frozen section examination and definitive histology was calculated using Cohen's K test of agreement. The mean length of hospital stay was 13 days. The feeding tube rate was 81%; the tracheostomy rate was 35%; the feeding tube was left in place for 8 days on average, and the time to decannulation was 9 days. The only complication was a postoperative bleeding in 4 patients. The median postoperative pain score measured by the Numeric Pain Rating Scale on postoperative days 1, 3, and 5 was 0 and there was a constant decrease in painkiller use over the days. The overall mean composite QoL score was 77 ± 14, with excellent results in saliva, taste, pain, and speech domains. Frozen section evaluation had a specificity of 99% and a negative predictive value of 98%. WG CO₂ laser is a good and safe tool for transoral tailored resection of oral and oropharyngeal cancers. It ensures a good overall QoL and guarantees fast recovery and a very low postoperative pain.

Intravenous fluids for pain management in head and neck cancer patients undergoing chemoradiation

Background

Pain due to oral mucositis affects the majority of patients receiving chemoradiation (CRT) for head and neck cancer (HNC), and often results in dehydration. Anecdotally, intravenous (IV) fluids administered during treatment for the resultant dehydration was found to alleviate this pain. The purpose of this retrospective study was to evaluate the effectiveness of IV fluids as a method pain management in this patient population.

Methods

Patients with oral mucositis pain, secondary to CRT for HNC, were given IV fluids according to standard clinic protocol. Patients were evaluated using orthostatic vital signs and prospectively surveyed pre- and post-IV fluid administration, which included the Visual Analog Scale (VAS) for pain. Difference in pain pre- and post-IV fluid administration was evaluated using a two-tailed paired Student’s t-test.

Results

Twenty-four patients with a total of 31 fluid administrations was available for analysis. Twenty-three patients were receiving or had recently completed CRT. One patient was receiving radiation alone. Six instances of fluid administration were excluded due to: refusal to complete the survey, concurrent pulmonary embolism, concurrent pain medication, and drug seeking behavior. Average pain score decreased from 6.5 [standard deviation (SD) 2.1] prior to IV fluids to 4.0 (SD 2.4) following fluid administration (P<0.001).

Conclusions

To our knowledge, this is the first report directly correlating IV fluid administration with pain relief, even in the absence of orthostasis. Our findings indicate that in patients undergoing CRT for HNC, the use of IV fluids alone was effective in acutely and significantly reducing pain secondary to oral mucositis.

Prevalência de discinese escapular e dor no ombro em surfistas amadores do Rio Grande do Sul: um estudo transversal

RESUMO O movimento de remada representa 51,4% do tempo total de prática do surfe, gerando alta demanda muscular do complexo do ombro. Apesar disso, há uma lacuna na literatura sobre a prevalência de dor e discinese escapular (DE) em surfistas. Este estudo teve o objetivo de avaliar a prevalência de dor no ombro em surfistas amadores do estado do Rio Grande do Sul, no Brasil. Trata-se de estudo observacional descritivo transversal. Foram incluídos 21 homens, com idade entre 18 e 42 anos, que praticassem surfe há no mínimo dois anos. Os desfechos avaliados foram DE estática, DE dinâmica, dor no ombro - através da escala numérica da dor -, comprimento do músculo peitoral menor, e escore no The Western Ontario Shoulder Instability Index. As variáveis contínuas foram apresentadas em média e desvio-padrão. As variáveis categóricas foram expressas em percentual. Associações dos dados foram testadas através do teste qui-quadrado e do teste de correlação de Pearson. A DE estava presente em 71,4% da amostra, tendo uma maior prevalência a discinesia do tipo I (57,1%), e 42,9% apresentaram dor no ombro durante o momento da avaliação. DE foi observada na maioria da população estudada, enquanto dor foi apresentada por pouco menos da metade dos participantes. Embora a DE seja um achado muito prevalente em surfistas amadores, não foi observada correlação com dor e redução da qualidade de vida.

Comparative evaluations of single-item pain-intensity measures in cancer patients: Numeric rating scale vs. verbal rating scale

AIMS AND OBJECTIVES

To evaluate the psychometric quality of two single-item pain-intensity measures: the Numeric Rating Scale (NRS) and the Verbal Rating Scale (VRS).

BACKGROUND

Measuring pain intensity is a vital step in initiating symptom management and evaluating the effectiveness of interventions with cancer patients. Single-item pain-intensity measures of the NRS and VRS format have been evaluated to be acceptable for use in clinical practice and research; however, evidence to choose one over the other, as a standardised pain-assessment format, is insufficient.

DESIGN

Descriptive correlational study. The study was guided and reported following the STROBE guideline.

METHODS

Data accrued at two time points during cancer treatment with a total of 249 patients treated in a Korean University Hospital. Two single-item measures were constructed to assess pain intensity over 1 week. The Brief Pain Inventory (BPI; pain intensity subscale and interference subscale) and the functional assessment of chronic illness therapy-fatigue were the criterion. Convergent and concurrent validity were tested with Pearson's correlations.

RESULTS

In the convergent-validity evaluation of the cross-sectional association with the BPI, the NRS showed a much higher level of association than the VRS (0.81 versus 0.61). In convergent validity with a longitudinal association with the BPI, the NRS score change had a much higher level of association (0.61 versus 0.37). In concurrent-validity evaluation, the NRS and VRS showed similar levels of associations with fatigue (-0.48 versus -0.49). Yet, the NRS showed statistically higher levels of correlation with functional limitations than the VRS (0.55 versus 0.42), comparable to the concurrent validity of the BPI.

CONCLUSION

The NRS showed higher validity than VRS when assessing overall pain intensity over the past week.

RELEVANCE TO CLINICAL NURSING

Pain assessment is a vital role of nurses in caring for patients with cancer. Current study findings support the use of the single-item NRS pain measure to assess global pain intensity over the past week.

Efficacy of Non-pharmacological Methods of Pain Management in Children Undergoing Venipuncture in a Pediatric Outpatient Clinic: A Randomized Controlled Trial of Audiovisual Distraction and External Cold and Vibration

PURPOSE

Venipuncture generates anxiety and pain in children. The primary aim of the study was to evaluate two non-pharmacological techniques, vibration combined with cryotherapeutic topical analgesia by means of the Buzzy® device and animated cartoons, in terms of pain and anxiety relief during venipuncture in children.

DESIGNS AND METHODS

150 children undergoing venipuncture were randomized into four groups: the 'no method' group, the Buzzy® device group, the animated cartoon group and the combination of Buzzy® and an animated cartoon group. Children's pain and anxiety levels along with parents' and nurses' anxiety levels were evaluated by means of validated grading scales.

RESULTS

Overall children's pain increased less in the non-pharmacological intervention groups as compared to the group without intervention. Notably, the difference was statistically significant in the animated cartoon group for children's perception of pain. Children's anxiety and parents' anxiety decreased more in non-pharmacological interventions groups as compared to the group without intervention.

CONCLUSIONS

The study showed the effectiveness of non-pharmacological methods of pain management during venipuncture. Notably, distraction with animated cartoons was superior in terms of children's perception of pain when compared to Buzzy®, and to the combination of cartoons and Buzzy®. Buzzy® was significantly effective at the secondary analysis for children younger than 9. Children's and parents' anxiety is decreased by non-pharmacological methods. Furthermore, nurses' involvement in pediatric care can be enhanced.

PRACTICE IMPLICATIONS

Non-pharmacological methods of pain management during venipuncture represent an easy way to achieve an increased level of compliance among children and parents.

The utility and validity of pain intensity rating scales for use in developing countries

Introduction:

Pain intensity is the domain most often assessed in pain research. Although the Numerical Rating Scale is recommended for use in western countries, the utility and validity of this scale, relative to others, has not been established in non–western developing countries, such as Nepal.

Objectives:

Here, we sought to (1) identify which of 4 commonly used pain scales is most preferred by Nepalese, (2) compare error rates, (3) determine whether preference and error rates are influenced by age or education level, and (4) evaluate construct validity of each scale using factor analysis.

Methods:

Two hundred two adults with musculoskeletal pain from Nepal rated their worst and average pain intensity using all 4 scales and selected their most preferred scale.

Results:

The results indicate that the Faces Pain Scale-Revised is the most preferred scale, followed by a Verbal Rating Scale. The Numerical Rating Scale and Visual Analogue Scale were both least preferred and had higher rates of incorrect responses, especially among the older participants. However, all the scales demonstrated adequate construct validity as measures of pain intensity among those participants who could accurately use all 4 scales.

Conclusion:

The findings indicate that the Faces Pain Scale-Revised should be the first choice for assessing pain intensity in Nepalese adults. Research is needed to determine whether these findings replicate in other non–western and developing countries, to identify the pain intensity measure that would be the best choice for use in cross-cultural pain research.

Pain assessment in the critically ill mechanically ventilated adult patients: Comparison between skin conductance algesimeter index and physiologic indicators

Background and Objectives:

Critically ill patients are unable to communicate effectively, so it is difficult to assess their pain and analgesic requirement. Skin conductance algesimeter (SCA) index is a device that primarily measures changes in skin conductance real time to assess pain.

Methods:

We planned this quantitative prospective observational study to assess pain in the critically ill mechanically ventilated patients in comparison to physiologic indicators such as blood pressure and heart rate. A repeated measures design was chosen, and a sample size of 180 was taken from 60 patients with sepsis, acute exacerbations of chronic obstructive pulmonary disease, community-acquired pneumonia, and postsurgical patients in the Intensive Care Unit (ICU). The two painful procedures chosen were tracheal suction and patient positioning. The data were collected at rest, at tracheal suctioning, 20 min later at positioning of the patient, and final reading 20 min later. Three testing periods, each including 4 assessments for a total of 12 pain assessments with sixty patients, were completed during each patient's ICU course. A total of six assessments were done with the patient at rest and three each with pain stimulus of tracheal suctioning and patient positioning.

Results:

There was a significant increase in both hemodynamic variables during painful procedures except for the heart rate during positioning. The correlation between the SCA index and Ramsay scale was negative and significant.

Conclusions:

This instrument might prove useful to measure pain in uncommunicative critically ill patients and to evaluate the effectiveness of analgesic treatment and adapt it.

Post-operative pain management in head and neck cancer patients: predictive factors and efficacy of therapy

There is increasing interest about all aspects of pain sensation for patients undergoing head and neck surgery, and efforts have been made to better assess, monitor and reduce the occurrence of pain. The aetiology of pain is considered to be "multifactorial", as it is defined by several features such as personal experience, quality perception, location, intensity and emotional impact. The aim of this paper is: (i) to evaluate the efficacy of analgesic treatment in patients with head and neck cancer treated by surgery, and (ii) to study the variables and predictive factors that can influence the occurrence of pain. A total of 164 patients, affected by head and neck cancer and surgically treated, between December 2009 and December 2013, were included in this study. Data collected include age, gender, assessment of anaesthetic risk, tumour localisation, pathological cancer stage, TNM stage, type of surgery performed, complexity and duration of surgery, post-operative complications, postoperative days of hospital stay and pain evaluation on days 0, 1, 3 and 5 post-surgery. We studied the appropriateness of analgesic therapy in terms of incidence and prevalence of post-operative pain; we also related pain to patient characteristics, disease and surgical treatment to determine possible predictive factors. The population studied received adequate pain control through analgesic therapy immediately post-surgery and in the following days. No associations between gender, age and post-operative pain were found, whereas pathological cancer stage, complexity of surgery and tumour site were significantly associated with the risk of post-operative pain. Adequate pain control is essential in oncological patients, and particularly in head and neck cancer patients as the prevalence of pain in this localisation is reported to be higher than in other anatomical sites. Improved comprehension of the biological and psychological factors that characterise pain perception will help to enhance its control in the future.

Effect of change in patient's bed angles on pain after coronary angiography according to vital signals

Background:

One of the most common and important diagnostic methods for the detection of heart diseases is coronary angiography. The aim of this study was to determine the optimum angle of the bed by using vital signals to optimize the patient's position after the angiography.

Materials and Methods:

This study was a randomized clinical trial (RCT) on participants after angiography who were divided into five groups. The first group was placed routinely in a supine position. In the other groups, all of the patients were placed in bed by angle 15°, 30°, 45°, and 60° upward. In each group, vital signals were measured that included blood pressure, percent of blood oxygen saturation, heart rate, respiratory rate, and temperature. All of measured data compared with the pain score has been achieved from numerical pain scale. The data were analyzed by descriptive statistics method, variance analysis, and post hoc tests in the Statistical Package for the Social Sciences (SPSS) software, version 16. Estimation of the relationship was done by MATLAB version 2011. The level of significance was considered to be 0.05.

Results:

In various groups, there was no significance difference in demographic variables such as gender, age, height, and weight. The mean of pain score, heart rate, systolic blood pressure, and respiratory rate changed significantly (P < 0.05) but the temperature variation, blood oxygen saturation, and diastolic blood pressure in subjects were not significant (P > 0.05). It showed linear changes between pain and systolic blood pressure, respiratory rate, and heart rate changes. A dramatic reduction was also seen in systolic blood pressure, respiratory rate, heart rate, and also pain at an angle of 45^°.

Conclusion:

This study showed that, 45^° was the best angle of the bed to optimize the patient's position after the procedure, based on his/her vital signs and pain score. Thus, in order to relive pain, this change in bed angle is advised to be planned by postangiography nurses in patients after coronary angiography.

Reliability of the surgical Pleth index for assessment of postoperative pain: a pilot study

BACKGROUND

Postoperative pain control is essential and may have a beneficial effect on postoperative outcome and morbidity. Analgesia quality is controlled using tools such as a Numerical Rating Scale (NRS). These tools require cooperation and often fail in the presence of reduced awareness. The Surgical Pleth index (SPI) has been introduced as a monitoring tool for intraoperative pain under general anaesthesia.

OBJECTIVE

We investigated the correlation between SPI and pain intensity, analgesic consumption and fitness for discharge in the postanaesthesia care unit.

DESIGN

An observational study.

SETTING

The central postanaesthesia care unit of our tertiary care hospital.

PATIENTS

Written informed consent was obtained from 100 patients scheduled for elective surgery under general anaesthesia. Patients below the age of 18 years and those with an abnormal cardiac rhythm were excluded from the study.

INTERVENTION

Patients were interviewed every 10 min for 2 h.

MAIN OUTCOME MEASURES

Pain intensity measured by NRS, discomfort and Aldrete and Post-Anaesthetic Discharge Scoring System (PADSS) scores were noted. SPI and total dose of opioids administered were recorded.

RESULTS

A total of 1300 pain measurements were recorded; 482 (37%) reflected no or mild pain (NRS 0 to 3), 532 (41%) moderate pain (NRS 4 to 6) and 286 (22%) severe pain (NRS 7 to 10). Both NRS (r = 0.62, P < 0.001) and SPI (r = 0.38, P < 0.001) correlated significantly with total opioid consumption. SPI showed a moderate correlation with NRS (r = 0.49, P < 0.001). Receiver operating characteristic analysis showed moderate sensitivity and specificity for discrimination between low and moderate pain (NRS ≤3) (sensitivity 67%, specificity 69% for SPI ≤45), and between moderate and severe pain (NRS >6) (sensitivity 72%, specificity 72% for SPI ≥57). SPI and NRS showed weak negative correlations with Aldrete and PADSS scores.

CONCLUSION

Sensitivity and specificity of SPI to discriminate between low, moderate and severe pain levels was moderate. Both NRS and SPI correlated significantly with total opioid consumption.

Toward a specific outcome instrument for spinal trauma: how to measure function and health

STUDY DESIGN

Validation study.

OBJECTIVE

To investigate the most valid, reliable, and comprehensible response scale for spinal trauma patients to compare their current level of function and health with their preinjury state.

SUMMARY OF BACKGROUND DATA

In the context of a main project of the AOSpine Knowledge Forum Trauma to develop a disease-specific outcome instrument for adult spinal trauma patients, the need to identify a response scale that uniquely reflects the degree to which a spine trauma patient has returned to his or her preinjury state is crucial.

METHODS

In the first phase, 3 different question formats and 3 different response formats were investigated in a questionnaire, which was administered twice. Based on the results of the first phase, in the second phase, a modified questionnaire was administered once to a second group of patients to investigate 5 different response formats: 0-10 Numeric Rating Scale-11, 0-100 Numeric Rating Scale-101, Visual Analogue Scale, Verbal Rating Scale, and Adjective Scale. All patients were interviewed in a semistructured fashion to identify their preferences. Multiple statistical analyses were performed: test-retest reliability, internal consistency, and discriminant validity.

RESULTS

Twenty eligible patients were enrolled in the first phase and 59 in the second phase. The initial phase revealed the highest preference for 1 specific question format (60.0% and 86.7% after the first and second administration of the questionnaire, respectively). The second phase showed the Verbal Rating Scale as the most preferred response format (35.6%). The semistructured interviews revealed that overall, a subgroup of patients preferred a verbal response format (42.4%), and another group of patients preferred a numerical response format (49.1%). The statistical analysis showed good to excellent psychometric properties for all formats.

CONCLUSION

The most preferred question and response formats were identified for use in a disease-specific outcome instrument for spinal trauma patients.

LEVEL OF EVIDENCE

3.

Preference for different anchor descriptors on visual analogue scales among Japanese patients with chronic pain

Context

Although many previous studies have examined the preference of patients for different pain measurement scales, preference for anchor descriptors has not been thoroughly discussed.

Objectives

To examine (1) the preferred end-phrases used in the VAS as anchor labels for Japanese patients with chronic pain, and (2) whether the preference differs according to factors such as age, sex, educational level, duration of pain, and pain intensity.

Methods

We performed an observational study in patients suffering from non-cancer chronic pain for more than 3 months at a pain center in Japan. The patients were asked to rate their pain intensity using four types of VAS that used the following different anchor descriptors: “worst pain” (“Worst”), “worst pain bearable” (“Bearable”), “worst pain imaginable” (“Imaginable”), and “worst pain you have ever experienced” (“Experienced”). They were also asked to rank the four scales according to ease of responding, and asked which descriptor best reflected their perceived pain.

Results

In total, 183 patients participated in the study. They consisted of 119 (65.0%) women and 64 (35.0%) men aged 18–84 years with the mean age of 56.9 years. “Experienced” was most preferred (69.8%), followed by “Bearable” (66.3%), “Worst” (48.8%), and “Imaginable” (16.9%). Factors such as age, sex, educational background, duration of pain, and pain intensity did not significantly affect the results. In 83.1% of patients, the preferred descriptor corresponded to the descriptor that best reflected patients' perceived pain.

Conclusion

The frequently used expression “worst pain imaginable” is considered to be difficult to understand for most patients. Widely preferred descriptors, such as “worst pain you have ever experienced” and “worst pain bearable”, should be used when evaluating perceived pain. The preference of anchor descriptors was not significantly affected by the factors such as age, sex, educational level, duration of pain, and pain intensity.

Assessment of postoperative pain intensity by using photoplethysmography

PURPOSE

Timely assessment of acute postoperative pain is very important for pain management. No objective and reliable method to assess postoperative pain intensity exists till now. The aim of the study was to investigate the feasibility of photoplethysmography (PPG) signals in postoperative pain assessment.

METHODS

Thirty patients scheduled for elective abdominal surgery under general anesthesia were examined. Finger PPG signals and visual analogue scale (VAS) score were acquired before and 5, 10, 20, and 30 min after sufentanil administration when the patients were awake and transferred to the post-anesthesia care unit (PACU). During each pain rating, the patient's blood pressure, heart rate, and pulse oxygen saturation were recorded. The amplitude of alternating current (AC) and direct current (DC) extracted from finger PPG signals were analyzed, and the ratio of AC and DC (AC/DC) was calculated. Receiver operating characteristic (ROC) curves were built to assess the performance of AC and AC/DC to detect patients with VAS >4 in the PACU.

RESULTS

After administration of sufentanil, VAS scores decreased significantly (p < 0.05), as did blood pressure and heart rate. Simultaneously, both values of AC and AC/DC increased significantly. The VAS score had significant correlations with AC (r = -0.477; p < 0.01), AC/DC (r = -0.738; p < 0.01) and heart rate (r = 0.280; p < 0.01). In contrast, no statistical correlations between VAS score and blood pressure were found. Further analysis found significant differences in both AC and AC/DC among different pain levels, but no obvious differences in blood pressures and heart rate. The area under the ROC curves were 0.754 for AC and 0.795 for AC/DC, respectively.

CONCLUSION

The finger PPG signal can be used in acute postoperative pain assessment. Both AC/DC and AC had significant correlations with the pain rating levels, while blood pressure and heart rate were unreliable in pain assessment.

The impact of loneliness on the relationship between depression and pain of Hong Kong Chinese terminally ill patients

BACKGROUND

Depression and pain often coexist in terminally ill patients, but few studies have examined their relationship among larger samples. Other psychosocial factors experienced by patients may become barriers to pain management and affect the relationship between depression and pain.

OBJECTIVE

This study aims to examine the relationship between depression and pain in terminally ill Chinese elders in Hong Kong and explore the moderating effect of psychosocial factors such as loneliness, communication, and being at ease interacting with others.

METHODS

A secondary data analysis was conducted on a large cohort of community-dwelling Chinese elders applying for long-term care service in Hong Kong between 2004 and 2009. A total of 312 elders who had a prognosis of less than 6 months were included.

RESULTS

Depression was associated positively and significantly with pain. However, loneliness moderated this relationship, and for participants who felt lonely, depression and pain were no longer significantly associated.

CONCLUSIONS

Findings support the positive relationship between depression and pain in terminally ill elders. Feeling lonely may affect the tendency to report pain. To ensure optimal pain management for patients in palliative and end-of-life care, assessment and intervention should focus on the impact of psychosocial factors such as loneliness, and how they may affect elders' reporting of pain.

Acute pain therapy in postanesthesia care unit directed by skin conductance: a randomized controlled trial

Background

After surgery, effective and well-directed acute pain therapy is a necessary and integral part of the overall treatment plan. Generally, the assessment of pain intensity depends on a patient’s self-evaluation using scoring systems such as numeric rating scales (NRS, 0 to 10). Recently, a “Pain Monitor” was commercially provided which is based on measurements of fluctuations of skin conductance (NFSC). In this randomized, controlled, single-blind trial, possible benefits of this certain device were studied.

Methods

Postoperative patients (n = 44) were randomly assigned to a test or a control group during their stay in the postanesthesia care unit (PACU). All patients were treated and monitored according to internal hospital standards. Whereas all patients systematically evaluated their pain each 15 min, test group patients were additionally addressed when NFSC exceeded a predefined level. In cases of NRS≥5 during a routine elevation or in between, pain relief was achieved by standard procedures irrespective of group allocation.

Results

During their stay in PACU, both test and control groups experienced a significant decrease in NRS as a consequence of pain therapy. No significant differences in mean NRS or in NFSC values were found between the test and control groups. No correlation was observed between NRS and NFSC.

Conclusion

Postoperative patients experience diverse stressors, such as anxiety, disorientation, shivering, sickness and pain. Although the application of continuous pain monitoring would be meaningful in this clinical setting, the tested device failed to distinguish pain from other stressors in postoperative adult patients.

Trial Registration

German Clinical Trials Register DRKS00000755.

New Concepts for Translational Head and Neck Oncology: Lessons from HPV-Related Oropharyngeal Squamous Cell Carcinomas

Human papillomavirus (HPV) infection is well established as an etiological agent responsible for a number of pathologies affecting the stratified epithelia of skin and anogenital sites. More recently, the infection by (mucosal) high-risk HPV types has also been found to be causally associated with squamous cell carcinoma in the head and neck region (HNSCC), especially in the oropharynx. Intriguingly, HPV-related oropharyngeal squamous cell carcinomas (OPSCC) represent a distinct clinical entity compared to HPV-negative tumors with particular regard to treatment–response and survival outcome. The association between HPV infection and OPSCC may therefore have important implications for the prevention and/or treatment of OPSCC. The improved survival of patients with HPV-related tumors also raises the question, as to whether a better understanding of the underlying differences may help to identify new therapeutic concepts that could be used in targeted therapy for HPV-negative and improved therapy for HPV-positive cancers. This review summarizes the most recent advances in our understanding of the molecular principles of HPV-related OPSCC, mainly based on functional genomic approaches, but also emphasizes the significant role played by the tumor microenvironment, especially the immune system, for improved clinical outcome and differential sensitivity of HPV-related tumors to current treatment options.

The utility of faces pain scale in a chronic musculoskeletal pain model

OBJECTIVES

The main aim of this study was to investigate the clinical utility and sensitivity to change of faces pain scale (FPS) in patients with shoulder pain, chosen as a chronic pain model. The secondary aim was to determine the association of FPS with psychologic status and quality of life of these patients.

METHODS

Thirty Turkish patients with chronic shoulder pain were included in the study. Pain intensity was evaluated by visual analog scale (VAS), which is a commonly used pain scale besides FPS. Depression and quality of life were screened by Beck Depression Inventory (BDI) and Short Form-36 (SF-36). All assessments were done before and after the physical therapy.

RESULTS

There was a statistically significant decrease in pain severity after the treatment as indicated by FPS and VAS (P=0.000). The standardized response mean (SRM) value of FPS of 2.35 was accepted as a good responsiveness. The FPS showed a strong correlation with VAS (r=0.62 and 0.73) both before and after the treatment. Also, moderate to strong correlations were detected between the FPS and physical functioning (PF), physical role (PR), bodily pain (BP), emotional role (ER), general health (GH), mental health (MH) subscales of SF-36 (r=-0.58-0.80), and BDI scores (r=0.39) before the treatment. However, there were moderate and weak correlations with FPS and PR and social functioning (SF) subscales of SF-36 only after the treatment (r=-0.52 and r=-0.39).

CONCLUSIONS

FPS is a satisfactory tool to assess pain in patients with chronic pain conditions and demonstrates sensitivity to detect changes after the treatment.

Studies comparing Numerical Rating Scales, Verbal Rating Scales, and Visual Analogue Scales for assessment of pain intensity in adults: a systematic literature review

CONTEXT

The use of unidimensional pain scales such as the Numerical Rating Scale (NRS), Verbal Rating Scale (VRS), or Visual Analogue Scale (VAS) is recommended for assessment of pain intensity (PI). A literature review of studies specifically comparing the NRS, VRS, and/or VAS for unidimensional self-report of PI was performed as part of the work of the European Palliative Care Research Collaborative on pain assessment.

OBJECTIVES

To investigate the use and performance of unidimensional pain scales, with specific emphasis on the NRSs.

METHODS

A systematic search was performed, including citations through April 2010. All abstracts were evaluated by two persons according to specified criteria.

RESULTS

Fifty-four of 239 papers were included. Postoperative PI was most frequently studied; six studies were in cancer. Eight versions of the NRS (NRS-6 to NRS-101) were used in 37 studies; a total of 41 NRSs were tested. Twenty-four different descriptors (15 for the NRSs) were used to anchor the extremes. When compared with the VAS and VRS, NRSs had better compliance in 15 of 19 studies reporting this, and were the recommended tool in 11 studies on the basis of higher compliance rates, better responsiveness and ease of use, and good applicability relative to VAS/VRS. Twenty-nine studies gave no preference. Many studies showed wide distributions of NRS scores within each category of the VRSs. Overall, NRS and VAS scores corresponded, with a few exceptions of systematically higher VAS scores.

CONCLUSION

NRSs are applicable for unidimensional assessment of PI in most settings. Whether the variability in anchors and response options directly influences the numerical scores needs to be empirically tested. This will aid in the work toward a consensus-based, standardized measure.

Pictograma de Fadiga: uma alternativa para avaliação da intensidade e impacto da fadiga

O objetivo foi validar o Fatigue Pictogram para uso no Brasil. Os dados foram coletados em quatro ambulatórios de oncologia de São Paulo (SP) e na Escola de Enfermagem da USP. A amostra de conveniência envolveu 584 pacientes com câncer, 184 acompanhantes e 189 estudantes de graduação enfermagem, que responderam ao Pictograma de Fadiga, ao Inventário de Depressão de Beck (IDB) e Escala de Karnofsky (KPS). Foram feitos testes de validade e confiabilidade. O Teste-reteste mostrou que o instrumento tem boa estabilidade. O primeiro item do Pictograma de Fadiga discriminou estudantes de cuidadores de pacientes, mas não pacientes de cuidadores. O segundo item discriminou todos os grupos. Observou-se adequada validade convergente (fadiga e depressão) e divergente (fadiga e Karnofsky). O Pictograma de Fadiga é válido, confiável e fácil de usar para avaliar fadiga em câncer, mas necessita ajustes para uso em pessoas saudáveis.

The assessment of postoperative pain by monitoring skin conductance: results of a prospective study

The number of fluctuations of skin conductance per second correlates with postoperative pain. The aim of this prospective study was to test the cut-off value for the number of fluctuations of skin conductance per second obtained from a previous study. Seventy-five patients were asked to quantify their level of pain on a numeric rating scale (0-10) in the recovery room. The number of fluctuations of skin conductance per second was recorded simultaneously. The number of fluctuations of skin conductance per second was different between patients with no (0.07), mild (0.16), moderate (0.28) and severe pain (0.33); p < 0.001. The tested cut-off value for the number of fluctuations of skin conductance per second (0.1) distinguished a numeric rating scale </= 3 from > 3 with 88.5% sensitivity and 67.7% specificity. The number of fluctuations of skin conductance per second may be a useful means of assessing postoperative pain.

Verbal numerical scales are as reliable and sensitive as visual analog scales for rating dyspnea in young and older subjects

This study compared the use of a simple verbal 0-10 numerical rating scale (verbal NRS) and a visual analog scale (VAS) for the rating of dyspnea during exercise in a group of young and older subjects. Twelve younger (32+/-9 yr) and 12 older (71+/-7 yr) subjects used either the verbal NRS or the VAS in a randomised fashion to rate dyspnea during 60 s of uphill treadmill walking (range 5.6-8.8 km h(-1)) performed at either a low (17% grade) or high workload (26% grade) and then during recovery. Rating scales were evaluated twice on separate days (day 1 and day 2) at each workload. While the verbal NRS scores proved to be reliable throughout exercise and recovery, VAS scores were significantly (p<0.05) lower on day 2 during the low workload test (younger group) and the high workload test (older group). Verbal NRS ratings were consistently greater than VAS ratings at both workloads (p<0.001) for both young and older groups. The intra-class correlation coefficients for rating peak dyspnea using either the VAS or verbal NRS were consistently lower for the older subjects (range: r=0.54-0.67) than the younger subjects (range: r=0.70-0.86). Overall, subjects preferred the verbal NRS to the VAS. These results suggest that the verbal NRS compares favourably with the VAS for rating dyspnea during exercise without mask or mouthpiece. However, when rating peak dyspnea both scales appear less reliable when used by the older compared to young subjects.

Monitoring of skin conductance to assess postoperative pain intensity

BACKGROUND

Pain is known to alter the electrogalvanic properties of the skin. The aim of this pilot study was to investigate the influence of postoperative pain on skin conductance (SC) readings.

METHODS

After obtaining ethical approval and written informed consent, 25 postoperative patients were asked to quantify their level of pain on a numeric rating scale (NRS, 0-10) at different time points in the recovery room. As a parameter of SC, the number of fluctuations within the mean SC per second (NFSC) was recorded. Simultaneously, the NRS was obtained from patients by a different observer who was blinded to the NFSC values.

RESULTS

Data from 110 readings of 25 patients (14 female, 11 male; 21-67 yr) were included. NFSC showed a significant correlation with the NRS (r=0.625; P<0.01), whereas heart rate and blood pressure showed no or very weak correlation with the NRS. NFSC was significantly different between patients with no (NRS=0), mild (NRS=1-3), moderate (NRS=4-5) and severe (NRS=6-10) pain (no: 0.047, mild: 0.089, moderate: 0.242, severe: 0.263; P<0.0001). Post hoc, a cut-off value for NFSC (0.1) was calculated above which a pain score >3 on the NRS was predicted with sensitivity of 89% and specificity of 74%.

CONCLUSIONS

The severity of postoperative pain significantly influences SC. Using cut-off values, NFSC may prove a useful tool for pain assessment in the postoperative period.