scholarly journals ARE SELF-REPORTED PAIN SCALES IN PEDIATRICS VALID?

2019 ◽  
Vol 7 (3_suppl) ◽  
pp. 2325967119S0003 ◽  
Author(s):  
Meagan J. Sabatino ◽  
Chan-Hee Jo ◽  
Philip L. Wilson ◽  
Henry B. Ellis
Keyword(s):  
Knee Pain ◽  
Pain Assessment ◽  
Rating Scale ◽  
Assessment Tools ◽  
Assessment Instruments ◽  
Common Symptom ◽  
Significant Difference ◽  
Patient Reported ◽  
The Mean ◽  
Clinically Significant

Background: Pain is the most common symptom for presentation to an orthopaedic practice and orthopedists rank 4th among top prescribers of opiates. Pain acuity, etiology and severity have been published as guiding factors for pain assessment and management. In an attempt to address the underassessment and undertreatment of pain, pain was even considered the 5th vital sign for a period of time. Assessment of pain using validated severity assessment instruments including the Visual Analogue Scale and the Wong-Baker FACES® Scale, is common in orthopaedic practices. The purpose of this study is to evaluate the validity and sensitivity of self-reported pain assessment tools administered to pediatric and adolescent patients presenting with a primary complaint of knee pain. Methods: A retrospective review of 211 patients with a primary complaint of knee pain in a single practice over a nine-month period was completed. Medical records were reviewed for demographics, sport, laterality, symptoms, and factors described as influencing the pain. Prior to orthopaedic evaluation, patients were given an electronic tablet to complete patient reported outcomes measures and the visual analog scale (VAS). Patients were asked, electronically, “Do you have pain today?” and to verbally rate the pain using a Wong-Baker FACES® Pain Rating Scale (FACES). The FACES scale, typically a 0-5 rating, was normalized to a 0-10 scale for comparison to both the VAS and the pain component of the pedi-IKDC (Pain-pIKDC). A Pearson’s correlation was used to compare the VAS and the Pain-pIKDC with the FACES scores to determine validity. A paired t-test was used to identify differences between the three measures. Results: Of the 211 subjects, 112 were females and 99 were males, with a mean age of 13.9 years (range 7-18). 82% of patients reported presenting for pain due to a specific injury and not of spontaneous origin. The mean FACES score was 1.26 (normalized to 2.52) with a median score of 0. Compared to the FACES, the mean VAS was 4.22 (p<0.001) and Pain-pIKDC was 3.66 (p<0.001) noted to be both a statistically and clinically significant difference. When comparing the FACES to VAS, a weak correlation was noted (0.360, p<0.001). A stronger correlation was noted between the VAS and the Pain-pIKDC (0.752, p<0.001). 66.4% of patients reported no pain on the FACES but reported pain >1 on the Pedi-IKDC. 80.5% of patients reported no pain on FACES but pain of >1 on the VAS. Only 12.2% on VAS and 16.2% on Pain-pIKDC reported no pain . For both the VAS and Pain-pIKDC, the sensitivity of detecting “no pain” is low at 19.2% and 30.2% respectively. Conclusion: Though pain is widely accepted as an important factor for patient care management, clinicians should be aware that self-reported pain assessment tools in pediatrics and adolescents, without verbal confirmation, may inflate reported pain intensity and lead to possible overtreatment.

scholarly journals Memory Impairment in Patients With Schizophrenia and Bipolar Disorder With and Without Psychosis: A Comparative Study

2020 ◽  
Vol 6 (4) ◽  
pp. 214-221
Author(s):  
Robabeh Soleimani ◽  
◽  
Mohammadreza Akhzari ◽  
Fatemeh Eslamdoust-Siahestalkhi ◽  
◽  
...  
Keyword(s):  
Bipolar Disorder ◽  
Memory Impairment ◽  
Rating Scale ◽  
Memory Function ◽  
Cross Sectional Study ◽  
Common Symptom ◽  
Cross Sectional ◽  
Significant Difference ◽  
The Mean ◽  
Psychiatric Rating Scale

Background: Cognitive impairment is a common symptom in both Schizophrenia (SZ) and Bipolar Disorder (BD), and studies have demonstrated memory impairment in patients with these disorders. Objectives: To compare memory impairment in patients with SZ, BD with psychosis, and BD without psychosis. Materials & Methods: This study was a cross-sectional study conducted on 42 patients referred to Shafa Hospital in Rasht, Iran. Patients were examined in 3 groups of 14 people each (SZ, BD with psychosis, and BD without psychosis). The study tools included a demographic information questionnaire, a Brief Psychiatric Rating Scale (BPRS), and Wechsler’s Memory Scale (WMS) for adults. The obtained data were analyzed by SPSS version 21 using the 1 way analysis of variance (ANOVA). Results: The mean BPRS scores in patients with SZ (47.28) was higher than that in BD with psychosis (43.93) and BD without psychosis (23.14). ANOVA results showed a significant difference between patients with SZ and BD without psychosis (P=0.001), as well as BD with psychosis and BD without psychosis (P=0.001). Also, there was a statistically significant difference in the mean WMS scores between patients with SZ (62.07) and BD with psychosis (76.57) (P=0.009) and between SZ and BD without psychosis (73.5) (P=0.047). BPRS and WMS scores in SZ and BD without psychosis patients had a negative correlation. Conclusion: The results showed that SZ is associated with weaker memory than BD, and a history of psychosis does not have a significant effect on memory function in patients with BD.

scholarly journals Trajectories of fatigue in actively treated patients with established rheumatoid arthritis starting biologic DMARD therapy

RMD Open ◽  
2020 ◽  
Vol 6 (3) ◽  
pp. e001372
Author(s):  
Sella Aarrestad Provan ◽  
Brigitte Michelsen ◽  
Joseph Sexton ◽  
Tillmann Uhlig ◽  
Hilde Berner Hammer
Keyword(s):  
Rheumatoid Arthritis ◽  
Rating Scale ◽  
Numeric Rating Scale ◽  
Tender Joint Count ◽  
Tender Joint ◽  
Logistic Regression Models ◽  
Patient Reported ◽  
Biologic Dmard ◽  
Clinically Significant

ObjectivesTo define fatigue trajectories in patients with rheumatoid arthritis (RA) who initiate biological DMARD (bDMARD) treatment, and explore baseline predictors for a trajectory of continued fatigue.MethodsOne-hundred and eighty-four patients with RA initiating bDMARDs were assessed at 0, 1, 2, 3, 6 and 12 months. Swollen and tender joint counts, patient reported outcomes (PROMs), blood samples and ultrasound examinations were collected at each time point. Fatigue was assessed by the fatigue Numeric Rating Scale (0–10) from the Rheumatoid Arthritis Impact of Disease (RAID) questionnaire. Clinically significant fatigue was predefined as fatigue ≥4. Three trajectories of interest were defined according to level of RAID fatigue: no fatigue (≤3 at 5/6 visits), improved fatigue (≥4 at start, but ≤3 at follow-up) and continued fatigue (≥4 at 5/6 visits). Baseline variables were compared between groups by bivariate analyses, and logistic regression models were used to explore baseline predictors of continued vs improved fatigue.ResultsThe majority of patients starting bDMARD therapy followed one of three fatigue trajectories, (no fatigue; n=61, improved; n=33 and continued fatigue; n=53). Patients with continued fatigue were more likely to be anti–citrullinated protein antibody and/or rheumatoid factor positive and had higher baseline PROMs compared to the other groups, while there were no differences between the groups for variables of inflammation including. Patient global, tender joint count and anxiety were predictors for the continued fatigue trajectory.DiscussionA trajectory of continued fatigue was determined by PROMs and not by inflammatory RA disease activity.

No Difference in Outcomes Following Osteochondral Allograft with Fresh Precut Cores Compared to Hemi-Condylar Allografts

Cartilage ◽  
2021 ◽  
pp. 194760352110219
Author(s):  
Danielle H. Markus ◽  
Anna M. Blaeser ◽  
Eoghan T. Hurley ◽  
Brian J. Mannino ◽  
Kirk A. Campbell ◽  
...  
Keyword(s):  
Patient Reported Outcomes ◽  
Knee Injury ◽  
Lesion Size ◽  
Osteochondral Allograft ◽  
Osteochondral Lesions ◽  
Radiographic Outcomes ◽  
Significant Difference ◽  
Patient Reported ◽  
The Mean

Objective The purpose of the current study is to evaluate the clinical and radiographic outcomes at early to midterm follow-up between fresh precut cores versus hemi-condylar osteochondral allograft (OCAs) in the treatment of symptomatic osteochondral lesions. Design A retrospective review of patients who underwent an OCA was performed. Patient matching between those with OCA harvested from an allograft condyle/patella or a fresh precut allograft core was performed to generate 2 comparable groups. The cartilage at the graft site was assessed with use of a modified Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) scoring system and patient-reported outcomes were collected. Results Overall, 52 total patients who underwent OCA with either fresh precut OCA cores ( n = 26) and hemi-condylar OCA ( n = 26) were pair matched at a mean follow-up of 34.0 months (range 12 months to 99 months). The mean ages were 31.5 ± 10.7 for fresh precut cores and 30.9 ± 9.8 for hemi-condylar ( P = 0.673). Males accounted for 36.4% of the overall cohort, and the mean lesion size for fresh precut OCA core was 19.6 mm2 compared to 21.2 mm2 for whole condyle ( P = 0.178). There was no significant difference in patient-reported outcomes including Visual Analogue Scale, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, and Tegner ( P > 0.5 for each), or in MOCART score (69.2 vs. 68.3, P = 0.93). Conclusions This study found that there was no difference in patient-reported clinical outcomes or MOCART scores following OCA implantation using fresh precut OCA cores or size matched condylar grafts at early to midterm follow-up.

Differences in calculated percentage improvement versus patient-reported percentage improvement in pain scores: a review of spinal cord stimulation trials

2021 ◽  
pp. rapm-2020-102238
Author(s):  
Jonathan M Hagedorn ◽  
Timothy R Deer ◽  
Nicholas C Canzanello ◽  
Stephen M Covington ◽  
Darrell R Schroeder ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Spinal Cord Stimulation ◽  
Rating Scale ◽  
Numeric Rating Scale ◽  
Pain Scale ◽  
Concordance Correlation ◽  
Percentage Improvement ◽  
Patient Reported ◽  
The Mean ◽  
Numeric Rating

IntroductionSpinal cord stimulation is frequently used for the treatment of intractable chronic pain conditions. Trialing of the spinal cord stimulator device is recommended to assess the patient’s response to neurostimulation before permanent implantation. The trial response is often assessed by Numeric Rating Scale changes and patient-reported percentage pain improvement. Using number rating scale changes between prespinal and postspinal cord stimulation trial, a calculated percentage pain improvement can be obtained. The aim of this study was to assess the difference between calculated and patient-reported percentage improvement in pain scale during spinal cord stimulation trials.MethodsThis study was a retrospective single center review of all spinal cord stimulation trials from January 1 2017 to July 1 2019. A total of 174 patients were included. The paired t-test was used to compare numeric pain scores obtained prestimulation versus poststimulation. The mean difference between methods (patient-reported minus calculated) was compared with zero using the 1-sample t-test. Lin’s concordance correlation coefficient was computed with a 95% CI, calculated using Fisher z-transformation; and a bootstrapping approach was used to compare the concordance correlation coefficient between groups. In all cases, two-tailed tests were used with p<0.05 considered statistically significant.ResultsBased on prestimulation and poststimulation numeric rating scale scores, the mean±SD calculated percentage improvement in pain scale was 54±28. The mean±SD patient-reported percentage improvement in pain scale was 59±25. The overall 95% limits of agreement for the two methods are −30% to +41%. The overall concordance correlation coefficient was 0.76 (95% CI 0.69 to 0.81).ConclusionAlthough the two methods are highly correlated, there is substantial lack of agreement between patient-reported and calculated percentage improvement in pain scale, suggesting that these measures should not be used interchangeably for spinal cord stimulator trial outcome assessment. This emphasizes the need for improved metrics to better measure patient response to neuromodulation therapies. Additionally, patient-reported percentage improvement in pain was found to be higher than calculated percentage improvement in pain, potentially highlighting the multidimensional experience of pain and the unpredictability of solely using Numeric Rating Scale scores to assess patient outcomes.

scholarly journals Radiological Outcomes of Third Generation Minimally Invasive Chevron Akin Osteotomies (MICA) for Hallux Valgus

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0032
Author(s):  
Thomas L. Lewis ◽  
Robbie Ray; David Gordon
Keyword(s):  
Minimally Invasive ◽  
Hallux Valgus ◽  
Weight Bearing ◽  
Case Series ◽  
Deformity Correction ◽  
Third Generation ◽  
Radiographic Measurements ◽  
Significant Difference ◽  
Patient Reported ◽  
The Mean

Category: Bunion Introduction/Purpose: Minimally invasive surgery for hallux valgus has significantly increased in popularity recently due to smaller incisions, reduced soft tissue trauma, and the ability to achieve large deformity corrections compared to traditional treatments. This study aimed to investigate the radiological outcomes and degree of deformity correction of the intermetatarsal angle (IMA) and the hallux valgus angle (HVA) following third generation (using screw fixation) Minimally Invasive Chevron and Akin Osteotomies (MICA) for hallux valgus. Methods: A single surgeon case series of patients with hallux valgus underwent primary, third generation MICA for hallux valgus. Pre- and post-operative (6 weeks after surgery) radiological assessments of the IMA and HVA were based on weight-bearing dorso-plantar radiographs. Radiographic measurements were conducted by two foot & ankle fellowship trained consultant surgeons (RR, DG). Paired t-tests were used to determine the statistically significant difference between pre- and post-operative measurements. Results: Between January 2017 and December 2019, 401 MICAs were performed in 274 patients. Pre- and post-operative radiograph measurements were collected for 348 feet in 232 patients (219 female; 13 male). The mean age was 54.4 years (range 16.3-84.9, standard deviation (s.d.) 13.2). Mean pre-operative IMA was 15.3° (range 6.5°-27.0°, s.d. 3.4°) and HVA was 33.8° (range 9.3°-63.9°, s.d. 9.7°). Post-operatively, there was a statistically significant improvement in radiological deformity correction; mean IMA was 5.3° (range -1.2°-16.5°, s.d. 2.7°, p<0.001) and mean HVA was 8.8° (range -5.2°-24.0°, s.d. 4.5°, p<0.001). The mean post-operative reduction in IMA and HVA was 10.0° and 25.0° respectively. Conclusion: This is the largest case series demonstrating radiological outcomes following third generation Minimally Invasive Chevron and Akin Osteotomies (MICA) for hallux valgus to date. These data show that this is an effective approach at correcting both mild and severe hallux valgus deformities. Longer term radiological outcome studies are needed to investigate whether there is any change in radiological outcomes. Correlation with patient reported outcomes is planned.

Correction of mildly dysplastic hips with periacetabular osteotomy demonstrates promising outcomes, achievement of correction goals, and excellent five-year survivorship

2019 ◽  
Vol 101-B (6_Supple_B) ◽  
pp. 16-22 ◽  
Author(s):  
A. T. Livermore ◽  
L. A. Anderson ◽  
M. B. Anderson ◽  
J. A. Erickson ◽  
C. L. Peters
Keyword(s):  
Outcome Measures ◽  
Periacetabular Osteotomy ◽  
Severe Dysplasia ◽  
Free Survival ◽  
Mild Dysplasia ◽  
Significant Difference ◽  
Patient Reported ◽  
Radiological Measurements ◽  
The Mean

Aims The aim of this study was to compare patient-reported outcome measures (PROMs), radiological measurements, and total hip arthroplasty (THA)-free survival in patients who underwent periacetabular osteotomy (PAO) for mild, moderate, or severe developmental dysplasia of the hip. Patients and Methods We performed a retrospective study involving 336 patients (420 hips) who underwent PAO by a single surgeon at an academic centre. After exclusions, 124 patients (149 hips) were included. The preoperative lateral centre-edge angle (LCEA) was used to classify the severity of dysplasia: 18° to 25° was considered mild (n = 20), 10° to 17° moderate (n = 66), and < 10° severe (n = 63). There was no difference in patient characteristics between the groups (all, p > 0.05). Pre- and postoperative radiological measurements were made. The National Institute of Health’s Patient Reported Outcomes Measurement Information System (PROMIS) outcome measures (physical function computerized adaptive test (PF CAT), Global Physical and Mental Health Scores) were collected. Failure was defined as conversion to THA or PF CAT scores < 40, and was assessed with Kaplan–Meier analysis. The mean follow-up was five years (2 to 10) ending in either failure or the latest contact with the patient. Results There was no significant difference in PROMs for moderate (p = 0.167) or severe (p = 0.708) groups compared with the mild dysplasia group. The numerical pain scores were between 2 and 3 units in all groups at the final follow-up (all, p > 0.05). There was no significant difference (all, p > 0.05) in the proportion of patients achieving target correction for the LCEA between groups. The mean correction was 12° in the mild, 15° in the moderate (p = 0.135), and 23° in the severe group (p < 0.001). Failure-free survival at five years was 100% for mild, 79% for moderate, and 92% for severely dysplastic hips (p = 0.225). Conclusion Although requiring less correction than hips with moderate or severe dysplasia, we found PAO for mild dysplasia to be associated with promising PROMs, consistent with that of the general United States population, and excellent survivorship at five years. Future studies should compare these results with the outcome after arthroscopy of the hip in patients with mild dysplasia. Cite this article: Bone Joint J 2019;101-B(6 Supple B):16–22.

A Controlled Comparative Trial of a New Antidepressant, Ciclazindol

1979 ◽  
Vol 7 (1) ◽  
pp. 1-6 ◽  
Author(s):  
Sidney Levine
Keyword(s):  
Rating Scale ◽  
Comparative Trial ◽  
Poor Response ◽  
Endogenous Depression ◽  
Depressive Illness ◽  
Double Blind ◽  
Significant Difference ◽  
Severity Of Depression ◽  
The Mean ◽  
Rate Of Response

The author describes a controlled, double-blind, comparative trial of a new tetracyclic compound, ciclazindol (WY 23409), against amitriptyline in the treatment of thirty-five patients admitted to hospital with depressive illness. Each patient was randomly allocated to three weeks treatment with either 50 mg b.d. ciclazindol or 50 mg b.d. amitriptyline. In the event of a poor response the dose level was raised to 75 mg b.d. Separation of cases of endogenous depression and severity of depression were assessed by the Levine-Pilowsky Depression Questionnaire, a self-rating technique. Severity of depression was also assessed using the Hamilton Rating Scale. No significant difference was noted between the drugs in either the degree or the rate of response nor when the endogenous cases alone were studied. The interesting observation was made that only one-third of ciclazindol patients gained weight compared to almost three-quarters of the amitriptyline group and the mean weight gain of the latter was over double that of the ciclazindol group. The author concludes that ciclazindol offers promise and merits further study using higher dosage levels once its full safety trials have been completed.

scholarly journals Dentofacial Changes after Orthodontic Intervention with Eruption Guidance Appliance in the Early Mixed Dentition

2008 ◽  
Vol 78 (2) ◽  
pp. 324-331 ◽  
Author(s):  
Katri Keski-Nisula ◽  
Leo Keski-Nisula ◽  
Hannu Salo ◽  
Kati Voipio ◽  
Juha Varrela
Keyword(s):  
Treatment Group ◽  
Mixed Dentition ◽  
Class I ◽  
Control Group ◽  
Significant Shift ◽  
Facial Height ◽  
Significant Difference ◽  
The Mean ◽  
Maxillary Incisors ◽  
Clinically Significant

Abstract Objective: To evaluate skeletal and dentoalveolar changes induced by the eruption guidance appliance in the early mixed dentition. Materials and Methods: Pre- and posttreatment cephalometric radiographs of 115 consecutively treated children, 62 boys and 53 girls, were compared with those obtained from a control group of 104 children, 52 boys and 52 girls. Pretreatment radiographs were taken at the deciduous-mixed dentition interphase (T1) and after full eruption of all permanent incisors and first molars (T2). The mean age of the children in both groups was 5.1 years at T1 and 8.4 years at T2. Results: A significant difference between the groups at T2 was found in the mandibular length, midfacial length, and maxillomandibular differential. The increase in mandibular length was 11.1 mm in the treatment group and 7.2 mm in the control group. No differences were found in measurements of maxillary position or size. There was a significant shift toward a Class I relationship in the treatment group. Labial tipping and linear protrusion of the mandibular incisors was evident in the treatment group at T2. There was no effect on the inclination or position of the maxillary incisors. Conclusions: Occlusal correction was achieved mainly through changes in the dentoalveolar region of the mandible. In addition, the appliance enhanced condylar growth resulting in a clinically significant increase in mandibular length. No effect was observed on maxillary position, maxillary size, inclination or protrusion of the maxillary incisors, or facial height.

scholarly journals Computerized Adaptive Testing for Patient Reported Outcomes in Ankle Fracture Surgery

2018 ◽  
Vol 39 (10) ◽  
pp. 1192-1198 ◽  
Author(s):  
Elizabeth B. Gausden ◽  
Ashley Levack ◽  
Benedict U. Nwachukwu ◽  
Danielle Sin ◽  
David S. Wellman ◽  
...  
Keyword(s):  
Ankle Fracture ◽  
Patient Reported Outcomes ◽  
Computerized Adaptive Testing ◽  
Adaptive Testing ◽  
Ceiling Effect ◽  
Significant Difference ◽  
Patient Reported ◽  
Ceiling Effects ◽  
Clinically Significant ◽  
Fracture Surgery

Background: Advantages of using computerized adaptive testing (CAT) include decreased survey-burden, diminished floor and ceiling effect, and improved ability to detect the minimal clinical significant difference (MCID) among patients. The goal of this study was to compare the legacy patient-reported outcome measures (PROMs) to the Patient-Reported Outcomes Measurement Information System (PROMIS) scores in terms of ability to detect clinically significant changes in patients who have undergone surgery for ankle fractures. Methods: Patients who underwent osteosynthesis for an unstable ankle fracture between 2013-2016 and completed legacy outcome scores (Foot and Ankle Outcome Score [FAOS], Olerud and Molander Ankle Score [OMAS], and Weber Score) along with the PROMIS Physical Function (PF) and PROMIS Lower Extremity (LE) CATs postoperatively were included. Correlation between the scores at 3-month, 6-month, and 1-year intervals, as well as floor and ceiling effects, in addition to MCIDs were calculated for each instrument. A total of 132 patients were included in the study. Results: There was no observed floor or ceiling effect in either the PROMIS PF or the PROMIS LE scores. Clinically significant changes in the PROMIS LE score were detected in patients between 6-month and 12-month postoperative visits ( P = .0006), whereas the reported OMAS score and Weber scores did not identify a clinically significant difference between patients at their 6-month and 12-month visit. Conclusion: The results of this study indicate that the PROMIS LE was superior for evaluating patients following ankle fracture surgery in terms of lower floor and ceiling effects and greater ability to distinguish clinically significant changes in patients between time points following surgery. Level of Evidence: Level III, comparative study.

Observational Pain Assessment Instruments for Use With Nonverbal Patients at the End-of-life: A Systematic Review

2019 ◽  
Vol 34 (4) ◽  
pp. 255-266 ◽  
Author(s):  
Diane Tapp ◽  
Sara Chenacher ◽  
Ngangue Patrice Alain Gérard ◽  
Philippe Bérubé-Mercier ◽  
Celine Gelinas ◽  
...  
Keyword(s):  
Palliative Care ◽  
End Of Life ◽  
Pain Assessment ◽  
Reliability And Validity ◽  
Assessment Tools ◽  
Cochrane Library ◽  
Severe Illness ◽  
Assessment Instruments ◽  
Measurement Instruments ◽  
Health Measurement

Purpose: To review studies pertaining to the reliability and validity of observational pain assessment tools for use with nonverbal patients at the end-of-life, a field of research not documented by previous systematic reviews. Methods: Databases (PubMed, Embase, Epistemonikos, the Cochrane Library, and CINAHL) were systematically searched for studies from study inception to February 21, 2016 (update in May 9, 2018). Two independent reviewers screened study titles, abstracts, and full texts according to inclusion and exclusion criteria. Disagreements were resolved through consensus. Reviewers also extracted the psychometrics properties of studies of observational pain assessment instruments dedicated to a noncommunicative population in palliative care or at the end-of-life. A comprehensive quality assessment was conducted using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) to derive poor, fair, good or excellent ratings for the psychometric tests reported in each study. Results: Four studies linked to 4 different tools met the inclusion criteria. Study populations included dementia, palliative care and severe illness in the context of intensive care. All the studies included in this review obtained poor COSMIN ratings overall. Conclusions: At this point, it is impossible to recommend any of the tools evaluated given the low number and quality of the studies. Other analyses and studies need to be conducted to develop, adapt, or further validate observational pain instruments for the end-of-life population, regardless of the disease.

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