IDENTIFYING CHRONIC PAIN:
A PAIN ASSESSMENT TOOLBOX
Shauna Kingsnorth, PhD
ACKNOWLEDGEMENTS
Evidence to Care Team,
Pain Toolbox Working Group,
Holland Bloorview Kids Rehabilitation Hospital
Dr. Chantel Barney,
Gillette Children’s Specialty Healthcare
Disclosure Information |
AACPDM 70th Annual Meeting
September 20-24, 2016
Speaker Name: Dr. Shauna Kingsnorth
Disclosure of Relevant Financial Relationships
I have no financial relationships to disclose.
Disclosure of Off-Label and/or Investigative Uses:
I will not discuss off-label use and/or investigational use in my presentation.
• Largest children’s rehabilitation hospital in Canada
• Vision: Create a world of possibility for kids with disability
• Teaching hospital fully affiliated with the University of Toronto
• Onsite Bloorview Research Institute and Teaching & Learning Institute
• Knowledge translation hub: Evidence to Care
Holland Bloorview Kids Rehabilitation Hospital
PAIN LASTING LONGER THAN
3 MONTHS OR BEYOND THE
STATE OF NATURAL HEALING(NIH, 2011)
Chronic pain
GoalEnsure every child is
routinely asked about pain
in a consistent and
measurable way
HowDevelop and adopt a best
practice product for the
assessment of chronic pain
among children with
cerebral palsy
STRENGTHENING
SCREENING PRACTICES
www.hollandbloorview.ca/toolbox
TOOLBOX
OVERVIEW
1. How was it
developed?
2. What does it
contain?
3. How is it
used?
Development and adoption of a
best practice product
Phase 1
Gather Evidence
Phase 2
Develop a Product
Phase 3
Test
Product
Phase 4
Plan for Sustainability
Phase 5
Share with Others
Integrated knowledge translation activities
IDENTIFYING BEST PRACTICESPhase 1
Assess Barriers/Supports
to Knowledge Use
Adapt Knowledge to
Local Context
Monitor Knowledge
Use
Evaluate Outcomes
Sustain Knowledge Use
Select, Tailor, Implement
Interventions
Knowledge Inquiry
Knowledge Synthesis
Knowledge
Products/Tools
TA
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Identify Problem
Identify, Review, Select Knowledge
Reference: Adapted from Graham, 2006
Gathering evidence:
A multi-pronged approach
1. Evidence inventory of clinical practice
guidelines
2. Structured review of chronic pain and
cerebral palsy literature
3. Systematic review of pediatric chronic
pain assessment tools
Expert
review &
consensus
Evidence
inventory | key
recommendations• Goal was to
generate a
framework to build
the Toolbox around
• 3 guidelines
identified with the
RNAO selected
• Recommendations
specific to local
context extracted
Structured review | practice points
• Goal was to provide specific and
practical direction to operationalize
the CPG recommendations
• Content extracted from 3
guidelines and other seminal
papers
• Reviewed by clinical experts with
an ambulatory care lens
• Including OT, NP, & developmental
pediatrician perspectives
Systematic review | chronic pain tools
Objectives:
What pediatric chronic pain
assessment tools exist?
Which tools are valid and
reliable?
Which tools are applicable for
children with cerebral palsy?
14
Systematic review | chronic pain tools
15
• Consultation with Research Librarian and content experts
• Medline, EMBASE and CINAHL, and hand searches of prior
systematic reviews and key literature
• Inclusion criteria:
• children 1-18 years of age
• broad health conditions experiencing chronic pain
• standardized reliable and valid measures
• peer-reviewed published between 1980 and 2012
• developed in English
• multi-item addressing pain interference or experience NOT intensity
Quality & relevance | chronic pain tools
16
Psychometric rating Clinical utility Expert input
Pediatrics
October 2015
Volume 136, Issue 4
Open access
ASSEMBLING THE TOOLBOXPhase 2
www.hollandbloorview.ca/toolbox
Chronic Pain Assessment Toolbox for Children with Disabilities
Section 1
• Definition and experience
of chronic pain
• Assembly of the Toolbox,
including evidence
gathering and expert
consensus
• Summaries of included
tools
Section 2
• RNAO best practice guideline for the Assessment and Management of Pain (3rd edition)
• CP focused clinical practice pointsguide evidence-informed decision making when assessing chronic pain
Section 3
• 15 pediatric chronic
pain assessment tools:
7 chronic pain
interference and 8
chronic pain coping
• Detailed descriptions
are presented
alongside information
on availability and
accessibility
List of Tools
7 Chronic Pain Interference
• Bath Adolescent Pain Questionnaire
• Body Diagram
• Child Activity Limitations Inventory
• Non-Communicating Children’s Pain
Checklist – Revised
• Pediatric Pain Interference Scale
(PROMIS)
• Pediatric Pain Profile
• Varni-Thompson Pediatric Pain
Questionnaire
8 Chronic Pain Coping
• Child’s Self-Efficacy Scale for Pain
• Chronic Pain Acceptance
Questionnaire
• Graded Chronic Pain Scale
• Pain Anxiety Symptom Scale-20
• Pain Coping Questionnaire
• Pain Stages of Change Questionnaire
• Psychological Inflexibility in Pain Scale
• Waldron/Varni Pediatric Pain coping
Inventory
Section 4
• A step by step guide
built around the
Knowledge to Action
Cycle (Graham et al.,
2006)
• Includes templates and
resources
ADOPTING THE TOOLBOXPhases 3 and 4
Holland Bloorview
Kids Rehabilitation
Hospital, Toronto,
ON, Canada
Gillette Children’s
Speciality
Healthcare, St. Paul,
MN, USA
Assess Barriers/Supports
to Knowledge Use
Adapt Knowledge to
Local Context
Monitor Knowledge
Use
Evaluate Outcomes
Sustain Knowledge Use
Select, Tailor, Implement
Interventions
Knowledge Inquiry
Knowledge Synthesis
Knowledge
Products/Tools
TA
IL
OR
IN
G
KN
OW
LE
DG
E
TA
IL
OR
IN
G
KN
OW
LE
DG
E
Identify Problem
Identify, Review, Select Knowledge
Reference: Adapted from Graham, 2006
Across Hospitals
• Selected clinics based on:
• CP caseload
• Risk of chronic pain
• Feasibility
• Consensus building exercise to select tools to
meet clinical needs
• @HBKidsHospital 4 tools chosen among 3
clinics
• @GilletteChildrn 6 tools chosen among 3
clinicsD
riv
ing
to
olb
ox u
se
TOOL USAGETools chosen at Holland Bloorview
PROMIS
Patient Reporting Outcome Measurement
Reporting System
PPP
Pediatric Pain Profile
CALI
Child Activity Limitations Interview
Body Diagram
EVALUATIONPain assessments at Holland Bloorview
EVALUATIONTool usage at Holland Bloorview
EVALUATIONClinician Experience at Holland Bloorview
EVALUATIONPractice change at Holland Bloorview
• From baseline to implementation, centralized documentation dramatically increased by 56% (YR1)
• Documentation time is lengthy
Chronic Pain Assessment Screen
• Among children screened for pain, clinicians maintained high fidelity; 96% received a tool or strategy documented in the pain screen
Toolbox + tool usage
• Education campaign provided easy dissemination of knowledge pre-launch but less resource intensive approach needed long-term
• Reminders identified as a need to prompt pain assessment in future
Education + support
• Turnover/absence of super users impacts usage
• Original cohort are documenting at the same rate or have slightly increased their rate since launch
Staff
TOOL USAGECHOSEN TOOLS AT GILLETTE
– Intrathecal Baclofen Pump Management Clinics
• Paediatric Pain Profile
• PROMIS (child & parent report versions)
– Chronic Pain Physician Specialists
• Non-communicating Children’s Pain Checklist
• Pediatric Pain Questionnaire
• Paediatric Pain Profile
• Brief Pain Inventory
– Center for Gait and Motion Analysis
• Child Self Efficacy Scale (CSES) – pain coping
DATATOOL USAGE AT GILLETTE
BPI
NCCPC-R
PPQ
PROMIS
PPP
CSES
221221
221
4218
66
91
64
EVALUATION
What do you like? What don’t you like?
• Easy to administer
• Comprehensive
• Provides information on
comfort/spasticity even when
parents say pain is not an issue.
• Some behaviors measured are not
specific to pain
• Quick and easy to use
• Provides more information than a 0-
10 score
• Less involved children can give self-
report
• Some items are not applicable to
many of our patients
• Phrasing ‘when I had pain’ can be
confusing
• The breadth and depth of the
questions for non-verbal children• Nothing
• Simple and quick
• Provides a dimension of pain coping
that we don’t otherwise collect
• Not always relevant
• Psychometric properties relatively
undetermined
• No cut score
CSES (n=3)
NCCPC-R (n=1)
PROMIS (n=3)
PPP (n=6)
EVALUATIONHow is the information used in clinical practice?
• Characterizing pain, distress, and comfort
• Used in relation to changing baclofen dose
• Nice baseline for comparison over time/after intervention
• Interventions can be made using this information
• Used in relation to changing baclofen dose
• Compare scores over time
• Gives us some information on function
• It can expose the ways the child is impacted
• Gain better understanding of how the symptoms impact day-
to-day life
• Score is provided in pain section of dictation
• Information can prompt conversations about painCSES (n=3)
NCCPC-R (n=1)
PROMIS (n=3)
PPP (n=6)
Sustainability: Strategies in place
Reminders:
Visual prompts (posters) placed in clinic areas where clinicians see clients
Documentation screen: Finalized as of March 2016
Refined product informed by clinicians using the toolbox
Client and Family Resources:
Information cards placed in clinic waiting areas and are available on Hospital’s client and family resource page
Sustainability: Strategies in progress
3 modules developed: 1. Introduction to pain + toolbox; 2. Toolbox
development and implementation; 3. Case study
Internal role out: Part of new staff orientation; included in hospital’s e-learning
catalogue
External role out: Additional resource available for download
Exploring the inclusion of pain screen data in the
hospital score card
Toolbox update (2017/18):
Monitor literature on ‘updated/to watch’ tools specific for children with CP
SHARING THE TOOLBOXPhase 5
Pro
moting t
he t
oolb
ox
12 health-related conferences
3 provincial and national webinars
2 funded knowledge translation grants
1 peer-reviewed publication
External Push Activities
External Push Activities
http://www.todayskids.ca/good-advice/things-
know-chronic-pain/
External Push Activities
www.hollandbloorview.ca/toolbox
Photo by Hammonton Photography - Creative Commons Attribution-NonCommercial License https://www.flickr.com/photos/25880282@N04 Created with Haiku DeckPhoto by Hammonton Photography - Creative Commons Attribution-NonCommercial License https://www.flickr.com/photos/25880282@N04 Created with Haiku Deck
THANK YOUSHAUNA KINGSNORTH, PhD
Manager, Evidence to Care, Holland Bloorview Kids Rehabilitation Hospital
Clinical Study Investigator, Bloorview Research Institute
Assistant Professor, Department of Occupational Science & Occupational Therapy, Rehabilitation Sciences Institute, University of Toronto