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Detecting Pain in Traumatic Brain-injured Patients With Different Levels of Consciousness During Common Procedures in the ICU: Typical or Atypical Behaviors?

Arbour, Caroline RN, PhD*,†,‡,§; Choinière, Manon PhD; Topolovec-Vranic, Jane PhD; Loiselle, Carmen G. RN, PhD*,†,‡; Puntillo, Kathleen RN, PhD, FAAN, FCCM#; Gélinas, Céline RN, PhD*,†,‡,§

doi: 10.1097/AJP.0000000000000061
Original Articles

Purpose: Pain behaviors such as grimacing and muscle rigidity are recommended for pain assessment in nonverbal populations. However, these behaviors may not be appropriate for critically ill patients with a traumatic brain injury (TBI) depending on their level of consciousness (LOC). This study aimed to validate the use of behaviors for assessing pain of critically ill TBI adults with different LOC.

Methods: Using a repeated measure within subject design, participants (N=45) were observed for 1 minute before (baseline), during, and 15 minutes after 2 procedures: (1) noninvasive blood pressure: NIBP (non-nociceptive); and (2) turning (nociceptive). A behavioral checklist combining 50 items from existing pain assessment tools and video recording were used to describe participants’ behaviors. Intrarater and interrater agreements of observed behaviors were also examined.

Results: Overall, pain behaviors were observed more frequently during turning (median=4; T=−5.336; P≤0.001) than at baseline (median=1), or during noninvasive blood pressure (median=0). TBI patients’ pain behaviors were mostly “atypical” and included uncommon responses such as flushing, sudden eye opening, eye weeping, and flexion of limbs. These behaviors were observed in ≥25.0% of TBI participants during turning independent of their LOC, and in 22.2% to 66.7% of conscious participants who reported the presence of pain. Agreements were >92% among and between the 2 raters.

Conclusions: This study support previous findings that critically ill TBI patients could exhibit atypical behaviors when exposed to nociceptive procedures. As such, use of current recommended pain behaviors as part of standardized scales may not be optimal for assessing the analgesic needs of this vulnerable group.

*Ingram School of Nursing, McGill University

Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital, Montreal, Qc, Canada

Quebec Nursing Intervention Research Network (RRISIQ), Montreal, Qc, Canada

§The Alan Edwards Center for Research on Pain, McGill University

Centre de recherche de Centre hospitalier de l’Université de Montréal (CRCHUM), Université de Montréal, Montreal, Qc

Trauma and Neurosurgery Program, Keenan Research Center of the Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON, Canada

#Department of Physiological Nursing, School of Nursing, University of California San Francisco, San Francisco, CA

This study was initially funded by a pilot research grant from the Louise and Alan Edwards Foundation, and is part of a larger research program funded by the Canadian Institutes of Health Research (CIHR ♯258 867), Canada; and the Fonds de la Recherche du Québec-Santé (FRQ-S ♯25094), Montreal, Qc, Canada; held by the principal investigator (C.G.). Part of this study was also funded by a research grant from the Quebec Nursing Intervention Research Network (RRISIQ), Montreal, Qc, Canada; and 3 PhD studentship awards (C.A.) from the Louise and Alan Edwards, the FRQ-S, and by the Quebec Ministry of Education (FRESIQ-MELS program). The authors declare no conflict of interest.

Reprints: Céline Gélinas, RN, PhD, Ingram School of Nursing, McGill University, 3506 University Street, Montreal, Qc, Canada H3A 2A7 (e-mail:

Received May 13, 2013

Received in revised form December 18, 2013

Accepted November 29, 2013

© 2014 by Lippincott Williams & Wilkins