pain assessment

The aim of this study was to examine six different assessment tools for pain in children. The study sought to determine whether there were differences clinical usage among the various scales. Additionally, the study aimed to identify if any of the scales demonstrated superior sensitivity compared to the others.

Method and Materials: 

A narrative review of currently published studies was performed following standard guidelines. Online databases PUBMED and Google Scholar were searched for systematic reviews published before January 2024. The search terms initially included pain rating scales, pain measurement, pain intensity. Papers were examined for abstract relativity before being included. Ultimately, a total of 6 articles were selected for the final analysis.

The Wong-Baker Faces Pain Scale and Faces Pain Scale (FPS) were found to be the most frequently mentioned as sensitive, valid, and reliable tools in various clinical scenarios. In terms of clinical application, the Oucher Scale and Poker Chip Pain Scale have not been utilized for chronic pain assessment, whereas the other four measures have been employed in different contexts including acute, chronic, and post-operative pain.

All six assessed instruments yielded noteworthy favorable outcomes when assessing acute pain in children aged three and above. However, their sensitivity, validity,and reliability varied.

Temporomandibular disorders (TMDs) impair orofacial function and reduce functional capacity and have an impact on a person’s overall health and quality of life. For clinical and research purposes, it is encouraged to adopt the Diagnostic Criteria for Temporomandibular Diseases (DC/TMD) for an evidence-based assessment of abnormalities of the jaw joint. The purpose of this study was to identify the factors influencing the jaw’s functional restriction and to assess the association between pain, the Jaw Functional Limitation Scale (JFLS-8), and the Oral Behavioral Checklist (OBC) utilizing the DC/TMD.

A hundred and two patients with TMD were included in present study. TMD-Pain Screener and TMD-SymptomQuestionnaire from DC/TMD Axis-I were used. In order to determine parafunctional habits and function limitations, JFLS-8 and the OBC from the DC/TMD Axis-II assessment tools were utilized. Data analysis was performed using chi-square, the KruskalWallis test, and the Mann-Whitney U test. The Spearman and Pearson tests were used for correlation assessment.

Age, education level, occupation, marital status, and the onset time of jaw complaints of the 102 patients (64 female and 38 male) were not found to be associated with JFLS-8. Statistical significance was found between female gender and JFLS-8 (P<0.05). While there was no statistically significant relationship between joint closed locking and JFLS-8 evaluated with the TMD-Symptom Questionnaire, a significant relationship was found between open locking and JFLS-8 (P<0.001). There was a positive correlation between JFLS-8 and the TMD-Pain Questionnaire and also between JFLS-8 and the OBC (P<0.001, r=0.380; P=0.028, r=0.248).

DC/TMD is an important tool in the evaluation of jaw limitation. Female gender, presence of pain, and parafunctional habits are risk factors for functional limitation of the jaw.

Over the past few years, a growing body of evidence has allowed us to ascertain that the initiation of periodontitis stems from the existence of oral microbial biofilm and that this requires definitive treatment. Owing to its exceptional usability, affordability, and antibacterial activity, the “diode laser” (DL) has increasingly become a popular and important tool in a dentist’s armamentarium. However, there is a scarcity of scientific evidence on the utility and advantages of using “diode laser” in periodontal flap surgery. The study aimed to determine the efficacy of 940 nm diode laser exposure in combination with conventional periodontal flap surgery for the treatment of chronic periodontitis to evaluate postoperative discomfort and clinical parameters.

A total of 10 subjects (7 males and 3 females) with generalized chronic periodontitis were recruited and completed the study without any dropouts. For this split‑mouth study, 40 sample sites with pocket probing depth (PPD) 5–7 mm post periodontal Phase I therapy were selected. The quadrants were randomly allocated to Groups A, B, C, and D using the fish bowl lottery method. Kirkland flap surgery with laser and modified Widman flap (MWF) with laser were performed in Group A and C, respectively, while Kirkland flap surgery and MWF surgery were performed in Group B and Group D. Clinical parameters including visual analog scale (VAS) score and gingival inflammation were determined at 3rd and 7th day postoperatively while PPD, clinical attachment level (CAL), and sulcus bleeding index (SBI) were recorded at baseline and 6 months following treatment. Wilcoxon signed‑rank test and Kruskal–Wallis test were used for intra‑group and inter‑group comparison of parameters, respectively.

Statistically significant difference was attained with postoperative discomfort in laser‑assisted groups on 1st and 3rd day postoperatively (P < 0.001). There was no significant difference in the proportion of subjects with gingival inflammation. A statistically significant reduction in mean PPD at 6 months postoperatively was seen among all study groups (P < 0.05) but the inter‑group difference was not statistically significant. SBI score reduced significantly from baseline to 6 months follow‑up among all four groups (P < 0.05). However, we did not find the inter‑group difference to be statistically non‑significant.

Diode laser as an adjunct to the surgical procedure can demonstrate appreciable benefits by increasing the CAL and minimizing the postoperative pain and the probing pocket, but such additional effects were not observed with gingival inflammation.

This study aims to evaluate current pain assessment and management in critically ill patients and to describe (1) pain management episode, according to the behavioral pain scale (BPS), and (2) the effectiveness of analgesics, according to the recommendation of guidelines.

In this cross‑sectional study, a sample of 60 intubated critically ill patients was selected from the intensive care units (ICUs). A researcher evaluated the patient’ pain severity using the BPS tool in patients receiving analgesics according to nurses’ note. At each time of analgesic administration, the BPS score was recorded, and this process was repeated 72 h later. The appropriateness of pharmacological interventions was assessed according to the American College of Critical Care Medicine guideline.

The most prescribed analgesic was morphine sulfate (48.3%) followed by fentanyl (23.3%). 55% of analgesics on day 1 and 25% on day 3 were prescribed appropriately according to the guideline recommendation and BPS score. Morphine was the most effective drug (17 patients out of 29). Even though a BPS score was <5, 26 patients received analgesics.

Quality of pain assessment and management in our setting is inappropriate and inadequate, which leads to over‑ or under‑use of analgesics. The lack of an established pain protocol may contribute to this situation.

To monitor pain intensity, pain symptoms, and medication use in elderly with dementia.

Nursing home residents above 65 years of age, diagnosed with dementia, and showing pain symptoms were included in the study. The patients’ mental status was monitored through a mini‑mental state examination score and observations of pain symptoms using Part 1 of the Mobilization‑Observation‑Behaviour‑Intensity‑Dementia‑2 (MOBID‑2) pain scale. Community pharmacists reviewed the patients’ medication use, and the prescriptions were compared with guidelines for treatment of geriatric patients. Alterations to the patients’ medicine use were forwarded to the general practitioners.

Sixty‑one nursing home residents diagnosed with dementia were identified, 15 of these fulfilled the inclusion criteria, and 12 agreed to participate in the study. The mean age was 87 years of age (range: 77–96), and 42% of the residents were males. The patients’ overall pain intensity was 83% for observations on the numeric pain rating scale (NRS) >0 and 67% for NRS ≥3. Most painful were the situations in which the residents were to mobilize their legs, turn around to both sides of the bed, and when sitting on the bed. The medication reviews identified a total of 95 individual prescriptions, and 33% of these were for nervous system medications, followed by medicines for the treatment of alimentary tract and metabolism disorders (31% of total). Eleven prescriptions for pain medicine were identified; the majority of these were for paracetamol and opioids. Seventeen proposals to patients’ medication use were suggested, but the general practitioners accepted only 6% of these.

This study indicates that the MOBID‑2 pain scale in combination with medication reviews can be used as a tool for optimization of patients’ medication use. However, we recommend the conduction of a larger‑scale study in multiple settings, to validate our results and the generalizability of the findings.

This paper discusses some of the main methodological challenges involved in carrying out research on pain, especially pain experienced by people with multiple sclerosis (MS). It starts by arguing the most common challenges in pain related research methodology, which will form the framework of this article. Within this framework, the issues include pain definition, the self-reported nature of pain, the complex and multidimensional nature of pain, confounders, study design, and other methodological challenges faced by researchers in using assessment tools and scales. Presenting a universal framework for pain measurement, suggesting appropriate study design, and using comprehensive assessment and appropriate statistical method to analyze the collected data will be the main solutions for those challenges that are discussing at the end of this paper. Finally, paper will end with a conclusion of study's implications and significance.

Facial expression to pain is an important pain indicator; however, facial movements look unresponsive when perceiving mild pain. The present study investigates whether pain magnitude modulates the relationship between subjective pain rating and an observer’s evaluation of facial expression.
Twelve healthy volunteers were recruited to obtain 108 samples for pain rating with Visual Analogue Scale (VAS). Subjects underwent three different mechanical painful stimuli (monofilament forces of 100 g, 300 g, and 600 g) over three sessions and their facial expressions were videotaped throughout all sessions. Three observers independently evaluated facial expression of the subjects with a four-point categorical scale (no pain, mild pain, moderate pain, and severe pain). The correlations between subjective pain ratings and the evaluation of facial expression were analyzed in dichotomous group which was low pain ratings (VAS Subjective pain ratings was significantly correlated with the evaluation of facial expression in high pain ratings, however no correlation was found between them in mild pain ratings. In mild pain ratings, most of the subjects (78%) were rated as no pain by observers, despite the fact that subjects reported pain.
The results suggest that the evaluation of facial expression of pain was difficult for the observer to detect pain severity when the subjects feel mild pain.

Premature infants undergo several painful procedures in the neonatal intensive care units leading to many short-term and long-term detrimental effects on their health. Identifying pain in infants is complex because they are not able to express pain verbally. Hence, using a validated tool to assess pain in infants is essential to ensure effective control of pain.
The present study aimed to validate the Persian Premature Infant Pain Profile-revised (PIPP_R) in preterm and term infants hospitalized at neonatal intensive care units.
This methodological cross-sectional study recruited 145 infants in four gestational age groups Irrespective of gestational age, PIPP-R scores were significantly higher during painful procedures (9.59 ± 2.55) compared to non-painful procedures (3.34 ± 1.48). A comparison of pain scores among four infant groups showed a significant difference in pricking scores among the groups (P value The results showed that the Persian version of PIPP-R has a high construct validity and reliability and can be used as a valid tool to assess pain in preterm and term infants by physicians and nurses in clinical practices. The applicability of the tool by nurses must be assessed.

Application of a reliable and authentic behavioral tool for measuring patients’ pain, hospitalized in intensive care units who are not able to establish relationship, is needed severely. Therefore, this study is conducted with the aim of validating Critical Care Pain Observation Tool (CPOT) in patients hospitalized in surgical wards.
CPOT was first translated into Persian and was psychometrically measured in terms of content.
Then, this study was conducted as cross-sectional study on 60 patients who were hospitalized in surgical wards. The degree of pain was measured by the patients using a self-report pain tool (NRS) and with the help of two nurses using CPOT during two painful and nonpainful procedures. Eventually, diagnosed validity and reliability was studied.
It should be noted that the content validity of CPOT was approved by panel of specialists. In addition, validity of this tool was confirmed with high internal cluster correlation (nonpainful procedure (0.997) and painful procedure (0.726). The diagnostic validity was supported with the increased CPOT score during position change and its constancy during the measurement of blood pressure (P CPOT is a valid and reliable tool to study pain in patients hospitalized in intensive care units.

Osteoarthritis (OA) is one of the most common diseases of both bone and cartilage. Since calcitonin may have positive effect on both of them.
The current study aimed to evaluate the effect of weekly calcitonin injection on patients with knee osteoarthritis using Western Ontario and McMaster universities arthritis index (WOMAC) questionnaire.
The current prospective cross sectional study, randomly recruited 28 eligible female participants aged 55 - 70 from outpatients referred to rehabilitation clinics. These patients were in stages II and III based on Kellgren-Lawrence grading scale. Patients were requested to fill out the multidimensional WOMAC questionnaire on the day of enrollment into the study (baseline examination) and five weeks after completion of their treatment with calcitonin. Paired T-test was used to assess mean differences of the questionnaire.
Compared to baseline, significant improvement in WOMAC score was observed after five weeks of treatment. Pain, joint stiffness, functional activity and total score of WOMAC showed improvement of 80.6%, 25.3%, 41.9% and 47.91% respectively, which were statistically significant (P value The study results showed that calcitonin can provide proper outcomes such as increased locomotor activity. Although WOMAC parameters increased in all age groups, it had great effect just on 55 - 60 years age group. Therefore, improvement of quality of life and proper rehabilitation, which are the main factors in osteoarthritis patients, were almost achieved in this study.

Detecting pain is crucial in sedated and mechanically ventilated patients, as they are unable to communicate verbally..
This study aimed to compare Bispectral index (BIS) monitoring with the Critical-care pain observation tool (CPOT) and vital signs for pain assessment during painful procedures in intubated adult patients after cardiac surgery..
Seventy consecutive patients who underwent cardiac surgery (coronary artery bypass graft or valvular surgery) were enrolled in the study. Pain evaluations were performed early after the operation in the intubated and sedated patients by using BIS and CPOT, and also checking the vital signs. The pain assessments were done at three different times: 1) baseline (immediately before any painful procedure, including tracheal suctioning or changing the patient’s position), 2) during any painful procedure, and 3) five minutes after the procedure (recovery time)..
The mean values for CPOT, BIS, and mean arterial pressure (MAP) scores were significantly different at different times; they were increased during suctioning or changing position, and decreased five minutes after these procedures (CPOT: 3.98 ± 1.65 versus 1.31 ± 1.07, respectively (P ≤ 0.0001); BIS: 84.94 ± 10.52 versus 63.48 ± 12.17, respectively (P ≤ 0.0001); MAP: 92.88 ± 15.37 versus 89.77 ± 14.72, respectively (P = 0.003)). Change in heart rate (HR) was not significant over time (95.68 ± 16.78 versus 93.61 ± 16.56, respectively; P = 0.34). CPOT scores were significantly positively correlated with BIS at baseline, during painful stimulation, and at recovery time, but were not correlated with HR or MAP, except at baseline. BIS scores were significantly correlated with MAP but not with HR..
It appears that BIS monitoring can be used for pain assessment along with the CPOT tool in intubated patients, and it is much more sensitive than monitoring of hemodynamic changes. BIS monitoring can be used more efficiently in intubated patients under deep sedation in the ICU..

Pain scores are used for acute pain management. The assessment of pain by the patient as well as the caregiver can be influenced by a variety of factors. The numeric rating scale (NRS) is widely used due to its easy application. The NRS requires abstract thinking by a patient to assign a score to correctly reflect analgesic needs, and its interpretation is subject to bias.. The study was done to validate a 4-point objective pain score (OPS) for the evaluation of acute postoperative pain and its comparison with the NRS..Patient and A total of 1021 paired readings of the OPS and NRS of 93 patients who underwent laparotomy and used patient-controlled analgesia were evaluated. Acute pain service (APS) personnel recorded the OPS and NRS. Rescue analgesia was divided into two incremental levels (level 1-paracetamol 1 g for NRS 2 - 5 and OPS 3, Level 2-Fentanyl 25 mcg for NRS ≥ 6 and OPS 1 and 2). In cases of disagreement between the two scores, an independent consultant decided the rescue analgesia.. The NRS and OPS agreed across the range of pain. There were 25 disagreements in 8 patients. On 24 occasions, rescue analgesia was increased from level 1 to 2, and one occasion it was decreased from level 2 to 1. On all 25 occasions, the decision to supplement analgesia went in favor of the OPS over the NRS. Besides these 25 disagreements, there were 17 occasions in which observer bias was possible for level 2 rescue analgesia.. The OPS is a good stand-alone pain score and is better than the NRS for defining mild and moderate pain. It may even be used to supplement NRS when it is indicative of mild or moderate pain..

Critical-care patients are at higher risk of untreated pain, because they are often unable to communicate owing to altered mental status, tracheal intubation and sedation.. This study compared two pain assessment tools on tracheal intubated critically ill patients in a cardiac post-anesthesia care unit, who were unable to communicate verbally. The studied tools were “critical-care pain observation tool (CPOT)” and “facial expression (FE)”..Patients and This was a prospective study based on diagnostic test evaluation. A sample of 91 intubated patients was selected from cardiac post-anesthesia care unit. Collected data were demographic characteristics, vital signs, FE and CPOT tools’ scale. Pain was assessed with CPOT and FE scores five times. The first assessment was performed in at least 3 hours after admission of patients to ICU. Then, the pain intensity was reassessed every 30 minutes. In addition, blood pressure, heart rate, respiratory rate and oxygen saturation were measured simultaneously.. At the first period, the frequency of “severe” pain intensity using the CPOT was 58.2% and with the FE tool was 67% (P = 0.001). Both tools demonstrated reduction in severity of pain on second and third assessment times. Significantly increasing level of pain and blood pressure due to nursing painful procedures (endo-tracheal suctioning, changing patient’s position, etc.), were obtained by CPOT in fourth assessment. FE was not able to detect such important findings (κ = 0.249). In the fifth step, pain intensity was reduced. The most agreement between the two tools was observed when the reported pain was “severe” (κ = 0.787, P < 0.001) and “mild” (κ = 0.851, P < 0.001).. The sensitivity of CPOT was higher for detection and evaluation of pain in intubated postoperative patients compared with “Facial Expression”. Best agreement between these tools was observed in two extremes of pain intensity..