Discordance between patient self-reported visual analog scale pain scores and observed pain-related behavior in older children after surgery

Abstract

Study Objective: To assess the correlation in an older pediatric population between patient self-reported visual analog scale (VAS) pain scores and observational pain-related behavior scores. Design: Prospective, comparative study. Setting: Inpatient surgical units of a free-standing children's hospital. Patients: 30 ASA physical status I and II outpatients, 8 to 16 years of age, undergoing a variety of orthopedic, plastic, urologic, and general surgical procedures. Interventions: Each patient underwent a single assessment of pain intensity on the first postoperative day. Measurements and Main Results: Three health care providers (a clinical nurse specialist, a registered nurse with extensive pediatric experience, and a child life specialist) simultaneously generated an independent pain-related behavioral score (range of 0 = no pain to 100 = worst pain possible) based on their subjective perceptions of the patient's observed facial expression, activity level, and breathing pattern. The patient was then asked to provide a self-reported VAS pain score (range of 0 = “no pain” with a smiling face, to 100 = “worst pain ever” with a frowning face). A single set of such concurrent pain scores was obtained once from each study patient. The pain-related behavior scores displayed a satisfactory interrater reliability, with an observed interclass correlation coefficient (Cohen's kappa value) of 0.83. When compared with a patient's self-reported VAS score, the three pain-related behavioral scores generated by each health care provider for a given patient exhibited both variable and minimal correlation. Conclusions: A tenuous relationship may exist between an older child's own perception of pain intensity and his or her behavioral expression of that pain as interpreted by a health care provider.