Measurement properties of the Premature Infant Pain Profile-Revised applied at the bedside by physical therapists in the NICU.

Validity and Reliability of Pain and Behavioral Scales for Preterm Infants: A Systematic Review

Accurate assessments of pain in hospitalized preterm infants present a major challenge in improving the short- and long-term consequences associated with painful experiences. We evaluated the ability of the newborn infant parasympathetic evaluation (NIPE) index to detect acute procedural pain in preterm infants. Different painful and stressful interventions were prospectively observed in preterm infants born at 25 + 0 to 35 + 6 weeks gestation. Pain responses were measured using the composite Premature Infant Pain Profile Revised (PIPP-R) scale, the NIPE index, and skin conductance responses (SCR). Outcome measures were correlations between the NIPE index, the PIPP-R score, and the SCR. Sensitivity/specificity analyses tested the accuracy of the NIPE index and SCR. Two hundred and fifty-four procedures were recorded in 90 preterm infants. No significant correlation was found between PIPP-R and the NIPE index. PIPP-R and SCR were positively correlated (r = 0.27, P < 0.001), with stronger correlations for painful procedures (r = 0.68, P < 0.001) and especially for skin-breaking procedures (r = 0.82, P < 0.001). The NIPE index and SCR had high sensitivity and high negative predictive values to predict PIPP-R > 10, especially for skin-breaking painful procedures. We found no significant correlation between the NIPE index and PIPP-R during routine painful or stressful procedures in preterm infants. Exposure to repetitive pain can lead to neurodevelopmental sequelae. Behavior-based pain scales have limited clinical utility, especially for preterm infants. New devices for monitoring physiological responses to pain have not been validated sufficiently in preterm infants. This study found that the NIPE index was not significantly correlated to the validated PIPP-R scale during acute procedural pain. Secondary analysis of this study showed that NIPE index and SCRs may help to exclude severe pain in preterm infants. In clinical practice, measurements of physiological parameters should be combined with behavior-based scales for multidimensional pain assessments.

Electronic health (e-health) learning is a potential avenue to educate health professionals about accurately using infant pain assessment tools, although little is known about the impact of e-health interventions on clinical competence. To evaluate whether an e-health learning module for teaching the accurate use of the Premature Infant Pain Profile-Revised (PIPP-R) pain assessment tool results in immediate and sustained competency to assess infant pain. Neonatal intensive care unit (NICU) nurses who participated in a larger study across 2 tertiary NICUs in Canada examining the implementation and clinical utility of the PIPP-R e-learning module completed 2 follow-up evaluations at 1 week and 3 months. Participants were asked to view a video recording of an infant undergoing a painful procedure and to assess the infant's pain intensity response using the PIPP-R measure. Immediate and sustained competency was assessed via interrater consensus of participant-reported PIPP-R scores compared with those of an experienced trained coder. Of the 25 eligible nurses, 22 completed 1-week and 3-month follow-up evaluations. At the 1-week follow-up, 84% of nurses scored the video accurately compared with 50% at 3 months. Behavioral pain indicators were more likely to be scored incorrectly than physiological indicators. Follow-up training after completion of the initial e-learning module training may improve competency related to the clinical use of the PIPP-R tool to assess infant pain over time. Additional study regarding the need and timing of e-health training to optimize sustained competency in infant pain assessment is warranted.

Objective tools are needed to improve pain assessment in newborns. The aim of this study was to assess the correlation between the Newborn Infant Parasympathetic Evaluation (NIPE) index and two pain scales during a painful procedure in premature infants. Each baby born at least at 26weeks of gestational age (GA) undergoing a planned painful procedure in the Neonatal Intensive Care Unit (NICU) was eligible. NIPE index, heart rate variability (HRV) indices and Neonatal Acute Pain scale (DAN) were recorded across three periods: the first at rest 5min before the painful procedure (T1), the second during it (T2) and the third 3min after the end of it (T3). The Premature Infant Pain Profile-Revised (PIPP-R) pain scale was recorded at T2. Sixty-four recordings were performed in 29 preterm infants (mean GA=29.9±4.2weeks). Twenty-eight tachograms were coupled to NIPE for analysis. We did not find a correlation between the NIPE index and DAN and PIPP-R at the pain time T2. Between T1 and T2, heart rate was higher (159±16 vs. 169±12, p<0.001). Considering the linear HRV indices, we did not observe a modification in parasympathetic or sympathetic activity, while for the nonlinear HRV indices (H exponent, Approximate and conditional Entropy), a significant change towards a loss of physiological chaotic cardiac behaviour was detected. The NIPE index seems to be not reliable to assess acute pain in the preterm infant, but other HRV indices could be explored as additional tools next to pain scales in NICUs. The NIPE monitor was developed for objective pain assessment in neonates based on HFnu variations, but it does not seem reliable enough for assessing acute pain in real time in preterm neonates. Pain assessment in preterm babies still relies on pain scales.

Although most non-acute pain assessment tools are multi-dimensional (behavioral and physiological measures) in their approach, the outputs of such tools are considered unidimensional. This study aimed to explore and determine the behavioral and physiological pain structures of Premature Infant Pain Profile-Revised (PIPP-R) for neonates and its association with parental stress. This cross-sectional study was conducted in 2022-2023 in Isfahan, Iran. We recruited 400 pre-term infants, i.e. with gestational age (GA) of less than 37weeks who were admitted to the NICU of educational hospitals. PIPP-R and Parental Stressor Scale: Neonatal Intensive Care Unit (PSS: NICU) were used for data gathering. The latent structures of pain and its association with parental stress were explored using latent variable modeling approach. A two-factor model, i.e. behavioral and physiological pain factors, was extracted, explaining 65% of the total variance. The results of confirmatory factor analysis showed that the identified structures in the exploratory factor analysis could be nearly replicated (CFI = 0.99، TLI = 0.98, RMSEA = 0.001). Behavioral pain structure, independent from gestational age had a significant direct association with parental stress score (β = 0.005, SE = 0.002, p = 0.026). The PIPP-R assesses both behavioral and physiological pain factors. We also found that behavioral pain factor was associated with parental stress. These results may provide a potential clue for physicians, nurses, and parents to manage the pain in preterm infant. The PIPP-R scores in preterm infants consist of "Behavioral and Physiological" pain factors. Single dependence on behavioral indicators (such as facial expression) has some limitations. Multidimensional tools may be the optimal method in detecting pain in preterm infants. Parental stress can affect behavioral pain structure in preterm infants. Intensive care nurses play an effective role in reducing the parental stress and pain severity of these preterm infants by including the help of mothers in procedures and providing them with psychological support.

To compare and evaluate the reliability, validity, feasibility, clinical utility, and nurses' preference of the Premature Infant Pain Profile-Revised, the Neonatal Pain, Agitation, and Sedation Scale, and the Neonatal Infant Acute Pain Assessment Scale used for procedural pain in ventilated neonates. Procedural pain is a common phenomenon but is undermanaged and underassessed in hospitalised neonates. Information for clinician selecting pain measurements to improve neonatal care and outcomes is still limited. A prospective observational study was used. A total of 1,080 pain assessments were made at 90 neonates by two nurses independently, using three scales viewing three phases of videotaped painful (arterial blood sampling) and nonpainful procedures (diaper change). Internal consistency, inter-rater reliability, discriminant validity, concurrent validity and convergent validity of scales were analysed. Feasibility, clinical utility and nurses' preference of scales were also investigated. All three scales showed excellent inter-rater coefficients (from 0.991-0.992) and good internal consistency (0.733 for the Premature Infant Pain Profile-Revised, 0.837 for the Neonatal Pain, Agitation, and Sedation Scale and 0.836 for the Neonatal Infant Acute Pain Assessment Scale, respectively). Scores of painful and nonpainful procedures on the three scales changed significantly across the phases. There was a strong correlation between the three scales with adequate limits of agreement. The mean scores of the Neonatal Pain, Agitation, and Sedation Scale for feasibility and utility were significantly higher than those of the Neonatal Infant Acute Pain Assessment Scale, but not significantly higher than those of the Premature Infant Pain Profile-Revised. The Neonatal Pain, Agitation, and Sedation Scale was mostly preferred by 55.9% of the nurses, followed by the Neonatal Infant Acute Pain Assessment Scale (23.5%) and the Premature Infant Pain Profile-Revised (20.6%). The three scales are all reliable and valid, but the Neonatal Pain, Agitation, and Sedation Scale and the Neonatal Infant Acute Pain Assessment Scale perform better in reliability. The Neonatal Pain, Agitation, and Sedation Scale appears to be a better choice for frontier nurses to assess procedural pain in ventilated neonates based on its good feasibility, utility and nurses' preference. Choosing a valid, reliable, feasible and practical measurement is the key step for better management of procedural pain for ventilated newborns. Using the right and suitable tool is helpful to accurately identify pain, ultimately improve the neonatal care and outcomes.

Effects of white noise on procedural pain-related cortical response and pain score in neonates: A randomized controlled trial

Quantitative sensory testing protocols for perceptions of pleasantness and unpleasantness based on the German Research Network on Neuropathic Pain protocol were recently introduced. However, there are no reliability studies yet published. To evaluate the intra-examiner (test-retest) and inter-examiner reliability for orofacial pleasantness and unpleasantness quantitative sensory testing protocols. Sixteen healthy participants from Aarhus University (11 women and five men, mean age 24, range 21-26 years) contributed. Two examiners were trained in performing the entire quantitative sensory testing protocols for pleasantness and unpleasantness, which included the additional dynamic tactile stimulation test using a goat-hair brush. Each participant underwent examination of both protocols by each examiner (inter-examiner reliability) on day 1. They returned at least 8 days following the testing to be re-examined by one examiner (intra-examiner reliability). All testing was performed on the skin of the right mandibular mental region. The intraclass correlation (ICC) was used to determine reliability. For the protocol investigating pleasantness, the majority of parameters had good to excellent intra-examiner (11/14: Intraclass correlation 0.67-0.87) and inter-examiner (13/14: Intraclass correlation 0.62-0.96) reliabilities. Similarly, the protocol investigating unpleasantness had good to excellent intra-examiner (intraclass correlation 0.63-0.99) and inter-examiner (intraclass correlation 0.65-0.98) reliabilities for most (13/15) of the parameters. Intra and inter-examiner reliabilities in the majority of quantitative sensory testing parameters (apart from the summation ratio) investigating pleasantness and unpleasantness are acceptable when assessing somatosensory function of the orofacial region.Trial registration: NA.

Validation of the Premature Infant Pain Profile-Revised (PIPP-R)

The Reliability of Measuring Pain Distribution and Location Using Body Pain Diagrams in Patients With Acute Whiplash-Associated Disorders

The Indonesian version of the Premature Infant Pain Profile–Revised: Translation and adaptation of a neonatal pain assessment

ObjectiveClinicians are recommended to use the clinical reasoning framework developed by the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) to provide guidance regarding assessment of the cervical spine and potential for cervical artery dysfunction prior to manual therapy and exercise. However, the interexaminer agreement and reliability of this framework is unknown. This study aimed to estimate the interexaminer agreement and reliability of the IFOMPT framework among physical therapists in primary care.MethodsNinety-six patients who consulted a physical therapist for neck pain or headache were included in the study. Each patient was tested independently by 2 physical therapists, from a group of 17 physical therapists (10 pairs) across The Netherlands. Patients and examiners were blinded to the test results. The overall interexaminer agreement, specific agreement per risk category (high-, intermediate-, and low-risk), and interexaminer reliability (weighted κ) were calculated.ResultsOverall agreement was 71% (specific agreement in high-risk category = 63%; specific agreement in intermediate-risk category = 38%; specific agreement in low-risk category = 84%). Overall reliability was moderate (weighted κ = 0.39; 95% CI = 0.21–0.57) and varied considerably between pairs of physical therapists (κ = 0.14–1.00).ConclusionThe IFOMPT framework showed an insufficient interexaminer agreement and fair interexaminer reliability among physical therapists when screening the increased risks for vascular complications following manual therapy and exercise prior to treatment.ImpactThe IFOMPT framework contributes to the safety of manual therapy and exercise. It is widely adopted in clinical practice and educational programs, but the measurement properties are unknown. This project describes the agreement and reliability of the IFOMPT framework.

To develop and determine the reliability of a newly -designed resistance-enhanced dynamometer for muscle strength measurement, and to test the hypothesis that enhancing the examiner's resisting force improves the reliability of manual muscle strength measurements. An intra-examiner, inter-examiner, intra-session and inter-session reliability study. Twenty-five men (mean age 22.5 (standard deviation (SD) 1.7) years) were tested separately by 2 examiners using the resistance-enhanced dynamometer and a traditional hand-held dynamometer for an intra- and inter-examiner reliability study. Twenty-seven volunteers (mean age 22.1 (SD 0.8) years) were tested by a female examiner using the resistance-enhanced dynamometer for an intra- and inter-session reliability study. Maximum resisting forces for the knee flexors and extensors were measured using the resistance-enhanced dynamometer and the traditional hand-held dynamometer. The traditional hand-held dynamometer had good intra-examiner reliability (intra-class correlation coefficient (ICC) = 0.79-0.93) but poor inter-examiner reliability (ICC = 0.11-0.28). The resistance-enhanced dynamo meter had very good intra-examiner (ICC = 0.91-0.94), inter-examiner (ICC = 0.98), intra-session (ICC = 0.93-0.99) and inter-session (ICC = 0.91-0.92) reliability. The resistance-enhanced dynamometer also had better inter-examiner agreement (smallest real difference (SRD) 9-16% for resistance-enhanced dynamometer, 21-43% for traditional hand-held dynamometer). The resistance-enhanced dynamometer had very good reliability. Enhancing the examiner's resisting force appeared to improve the reliability of manual muscle strength measurements. The resistance-enhanced dynamometer is useful for muscle strength measurements in clinical practice.

Validating skin conductance for measuring acute pain in mechanically ventilated infants

Assessing pain in mechanically ventilated infants is challenging. The assessment of skin conductance (SC) is based on the sympathetic nervous system response to stress. This study purpose was to evaluate the validity of SC for assessing pain in mechanically ventilated infants. A prospective cross-sectional observational design was used to study SC and its relation to: the category of procedure (i.e., painful or non-painful); the phase of procedure (i.e., before, during and after), and referent pain measurements (i.e., Premature Infant Pain Profile-Revised (PIPP-R) and Neonatal Facial Coding System (NFCS)). Eligible infants were those up to 12months of age, in intensive care units, who were mechanically ventilated, and required painful and non-painful procedures. From October 2017 to November 2018, 130 eligible infants were identified, and 55 infants were studied. SC (number of waves per second) during painful procedures (median 0.27, interquartile range 0.2-0.4) was statistically significantly higher than those during non-painful procedures (0, 0-0.09). SC during painful procedures was statistically significantly higher than those before (0, 0-0.07) and after painful procedures (0, 0-0.07). SC showed moderate statistically significant positive correlations with PIPP-R (Spearman's rho=0.4-0.62) and the four-item NFCS (Spearman's rho=0.31-0.67) before, during and after painful or non-painful procedures respectively. SC had excellent performance (area under the receiver operator curve=0.979) with excellent sensitivity (92.31%), specificity (95.42%) and negative predictive value (99.21%) but only sufficient positive predictive value (66.67%) when used to discriminate moderate-to-severe pain. SC showed good validity for assessing pain in critically ill infants requiring mechanical ventilation. Pain assessment in mechanically ventilated infants is challenging. In this study, the validity of skin conductance (SC) for pain assessment is evaluated in the same population of infants during painful and nonpainful procedures. SC showed good validity for assessing acute pain in relation to category of procedure, phase of procedure, and referent pain measurements. SC is a promising method, especially with other pain assessment methods and other determinants of pain, in a multimodal pain assessment approach to understand the complexity of pain in mechanically ventilated infants.