Learning Objective #1: identify behavioral pain tools for non-verbal patients available in the literature.

Learning Objective #2: describe psychometric properties of selected behavioral pain assessment tools.

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International experts agree that the gold standard for pain assessment is the patient's self-report of pain. However, challenges exist for clinicians when pain assessment is necessary for non-communicative patients. These challenges present themselves most notably in the critically ill adult population as well as in elderly patients with cognitive impairments; often resulting in undetected and undertreated pain. This presentation will examine the reported psychometric qualities of a variety of behavioral pain tools developed for nonverbal adults. The feasibility, appropriate setting, and clinical utility of existing pain scales will be discussed.

A bibliographic search was conducted for the period of 2000 to 2007 using the electronic databases from Cochrane Library, Ovid, CINAHL and PubMed. Nearly 18,000 hits were generated, yielding ten articles suitable for review after consideration of inclusion criteria. Articles were included if a pain observation tool was used in an empirical study and psychometric properties were reported in nonverbal adults. Non-English tools were excluded, as were tools targeting a pediatric population. 14 tools were included based on the aforementioned criteria. Most of the current behavioral assessment tools for non-communicative patients show only moderate psychometric scores. Cronbach alpha scores ranged from 0.24 to 0.88 and interrater reliability scores ranged from 0.41 to 0.98. Techniques to establish validity included factor analysis, content validity analysis and known-groups analysis. All of the reviewed scales lack a preponderance of evidence to establish convincing validity and reliability for broad adoption in clinical practice. Critical evaluation of selected tools is required preceding effective use by practitioners in specific settings.

Key recommendations from this presentation include 1) Behavioral pain assessment tools for the non-communicative population requires further development and 2) Clinical experts in specific populations should critically evaluate the described tools prior to implementing them in their own practice.