ABSTRACT
Objective: The objective of this review is to evaluate the measurement properties of multidimensional pain assessment tools for postoperative pain in adults.
Introduction: Effective postoperative pain management increases patient safety and satisfaction, and reduces healthcare costs. The most commonly used postoperative pain assessment tools only evaluate pain intensity, which is only one aspect of the sensory dimension of pain. Pain is a subjective phenomenon, and variability exists among patients. Efforts are underway to incorporate multidimensional assessment tools for postoperative pain assessment in clinical practice.
Inclusion criteria: Eligible studies will include postoperative patients aged 18 years and older from all surgical disciplines. Studies evaluating multidimensional assessment instruments for the measurement of postoperative pain during the first two weeks following surgery will be considered. Studies will include the following measurement properties of assessment tools as outcomes: reliability, validity and generalizability.
Methods: MEDLINE, CINAHL, Embase, PsycINFO and Cochrane Trials (CENTRAL) will be searched, as well as ClinicalTrials.gov and multiple gray literature sources. There will be no limitations on publication date. Titles and abstracts will be screened by independent reviewers for inclusion. The full text of selected papers will be retrieved and assessed against the inclusion criteria. Two independent reviewers will assess papers for methodological quality using the COSMIN checklist, and papers with poor scores on relevant items will be excluded. Data will be extracted by two independent reviewers using a standardized data extraction tool. Statistical pooling will be performed, if possible.
Article Content
Introduction
Pain is a common occurrence among patients in the postoperative period.1 While the prevalence rates of acute postoperative pain have not been accurately established, available data suggests that approximately 75%of postoperative patients experience moderate to severe pain, resulting in unnecessary suffering and discomfort.2 Pain in the postoperative period is mainly a result of tissue damage or nociceptive pain, which subsequently manifests as an undesirable emotional and sensory experience.2
Poorly managed postoperative pain can significantly delay ambulation which is associated with potentially life threatening risks such as venous thromboembolism, severe respiratory illness and long term chronic pain and disability.1 Healthcare services are also negatively impacted as persistent pain can increase the length of hospital stay, number of unanticipated hospital readmissions and need for outpatient chronic pain management services.3 Hence, effective postoperative pain management is imperative in increasing patient safety and satisfaction, and reducing costs to the healthcare services.1
The experience of postoperative pain is a complex multidimensional phenomenon which comprises a range of physiological, psychological, sensory, cognitive, behavioral and sociocultural dimensions.1,4 However, the most commonly used postoperative pain assessment tools are unidimensional and assess only pain intensity, which is just one aspect of the sensory dimension of pain.5 Examples of these unidimensional tools include versions of the Numerical Rating Scale (NRS) and the Visual Analog Scale (VAS).6-9 These tools rely on a score based on the patients' self-report of the existence of pain and its intensity. Yet, pain is a subjective phenomenon and a large amount of inter-individual variability exists in patients' pain experiences. For example, patients may experience severe pain in the absence of physiologic or behavioral signs.10 In addition, patients have also reported difficulties in describing the complex nature of their experience of pain by only a single numbered value or a point on a linear scale.3
As a result, evidence-based guidelines, expert consensus reports and position statements from health professional governing bodies have recommended comprehensive, multidimensional assessment as an integral component of effective pain management.11-13 Hence, efforts are being made to incorporate multidimensional assessment tools for postoperative pain assessment in clinical practice. The most frequently used multidimensional pain assessment tools are the McGill Pain Questionnaire (MPQ)4 and the Brief Pain Inventory (BPI).14,15 The MPQ is used to measure multidimensional aspects of pain including the physical and emotional characteristics of pain. The MPQ includes descriptive words to define pain, a diagram to indicate the exact location of the pain, a one to five score to represent overall present pain intensity (PPI) and a section that considers the individual context of the patient.4 The BPI is used to measure the complex pain experienced by patients with cancer. The BPI includes a sensory and reactive dimension, which measures both pain intensity and the interference of pain with activities of daily living.14
Other less commonly used multidimensional pain assessment tools include the Surgical Pain Scales (SPS),16 the Pain Assessment in Advanced Dementia scale (PAINAD) and the Checklist of Nonverbal Pain Indicators (CNPI).17,18 Despite the availability of several multidimensional tools, there is no evidence to inform the selection of the most reliable and valid tool that can be used to accurately assess pain in postoperative adult patients.
A preliminary search in MEDLINE, CINAHL, JBI Database of Systematic Reviews and Implementation Reports and the Cochrane Database of Systematic Reviews was performed to identify completed and in-progress systematic reviews on multidimensional postoperative pain assessment tools when used to assess postoperative pain in hospitalized adult patients. The search identified five existing, quantitative systematic reviews investigating the psychometric properties of pain assessment tools.19-23 However, there are a number of important limitations with the existing reviews. Three of the reviews focused only on the use of unidimensional pain assessment tools.19-21 The fourth review was limited to pain assessment tools used only in pediatric settings22 and the fifth review assessed multidimensional pain assessment tools only in elderly patients with dementia.23 While these reviews report important findings for pediatric patients and patients with dementia, they do not provide evidence on the most psychometrically reliable and valid multidimensional pain assessment tool for adult postoperative patients. Therefore, there is a need to appraise the best available evidence in relation to the measurement properties of multidimensional pain assessment tools when used to assess postoperative pain in hospitalized adult patients.
Review question/objective
The objective of this review is to evaluate the measurement properties (reliability, validity and generalizability) of multidimensional pain assessment tools that are used to assess postoperative pain in adults.
Inclusion criteria
Participants
The review will consider studies that include postoperative patients aged 18 years and over from all surgical disciplines.
Instrument(s) or construct
This review will consider multidimensional pain instruments used to measure postoperative pain during the first two weeks following surgery. The two-week time frame has been chosen as it is widely considered to be the period when patients experience the most severe postoperative pain.24
Outcomes
This review will consider studies that include the following measurement properties as outcomes:
* Reliability (internal consistency, test-retest reliability, inter-rater reliability and intra-rater reliability).
* Validity (content validity, face validity, construct validity, structural validity, cross-cultural validity, hypotheses testing, criterion validity, responsiveness, sensitivity to change).
* Generalizability (sample characteristics, setting(s), location, language, sampling methods, response rate).
As not every study will provide data for all the measurement properties, studies that report sufficient details pertaining to at least one outcome regarding reliability or validity will be considered.
Types of studies
This review will consider only instrument development or instrument evaluation studies. Other types of studies (in which needs assessment instruments are merely used) will be used to contact their authors in search for unpublished psychometric studies or testing of the instrument.
Methods
Search strategy
The search strategy will aim to find both published and unpublished studies. An initial limited search of MEDLINE and CINAHL has been undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the articles. This informed the development of a search strategy which will be tailored for each information source. A full search strategy for MEDLINE is detailed in Appendix I. The reference list of all studies selected for critical appraisal will be screened for additional studies. No limitations will be placed on publication date, and all databases will be searched from inception to the present so as to locate the best available evidence.
Information sources
The databases to be searched include: MEDLINE, CINAHL, Embase, PsycINFO and Cochrane Trials (CENTRAL). The trial register to be searched will be ClinicalTrials.gov. The search for unpublished studies will include: Google Scholar, Dissertation Abstracts International, ProQuest Dissertations and Theses, ProQuest ResearchGate (contact with relevant researchers), and MedNar. We will also identify relevant researchers during the literature research and contact them to obtain information about unpublished psychometric studies or instrument testing of relevant instrument.
Study selection
Following the search, all identified citations will be collated and uploaded into EndNote version X8 (Clarivate Analytics, PA, USA) and duplicates removed. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review. Studies that meet or could potentially meet the inclusion criteria will be retrieved in full and their details imported into JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI) (Joanna Briggs Institute, Adelaide, Australia). The full text of selected studies will be retrieved and assessed in detail against the inclusion criteria. Full text studies that do not meet the inclusion criteria will be excluded and reasons for exclusion will be provided in an appendix in the final systematic review report. Included studies will undergo a process of critical appraisal. The results of the search will be reported in full in the final report and presented in a PRISMA flow diagram. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.
Assessment of methodological quality
Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using the COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) checklist. The COSMIN checklist is a standardized tool that is recommended for use in systematic reviews of measurement properties.25 The checklist consists of a range of items that consider nine measurement properties, namely, internal consistency, reliability, measurement error, content validity, structural validity, hypotheses testing, cross-cultural validity, criterion validity and responsiveness. There are also four separate items for assessing the methodological quality of studies that have applied the classical test theory and the item response theory. Studies with poor scores in all relevant items will be excluded from the review. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.
Data extraction
Data will be extracted from papers by two reviewers independently using the standardized data extraction tools from JBI SUMARI and adapted to the specific elements of a psychometric review. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Authors of papers will be contacted to request missing or additional data, where required.
Data synthesis
The main aim of the data synthesis is to compare outcomes to provide recommendations on the most suitable instrument for research and clinical use. The pooled estimate and 95% confidence intervals for the measurement properties of indices used to measure multidimensional pain will, where possible, be calculated using standard statistical techniques and JBI SUMARI. Heterogeneity will be assessed statistically using the standard chi-square and also explored using subgroup analyses based on the different study designs included in this review. Where statistical pooling is not possible, the findings about reliability, validity and generalizability will be compared and presented in narrative form including tables and figures to aid data presentation. A content comparison will give an overview of the content of each instrument and the similarities and differences on an item level. To judge the measurement properties of the different instruments, the quality criteria from Terwee et al.26 will be used; these criteria enable evaluation of reliability, validity and generalizability in terms of positive rating, indeterminate rating, negative rating, absence of information, and questionable design or method. The results of this appraisal will be presented in a narrative form.
Appendix I: Search strategy for MEDLINE
References
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