Anaesthesiology Intensive Therapy

2017, vol. 49, no 1, 66–72

ISSN 1642–5758
10.5603/AIT.2017.0010
REVIEWS www.ait.viamedica.pl

Methods of pain assessment in adult intensive care unit

patients — Polish version of the CPOT (Critical Care Pain
Observation Tool) and BPS (Behavioral Pain Scale)
Katarzyna Kotfis1, Małgorzata Zegan-Barańska1, Łukasz Szydłowski1, Maciej Żukowski1, Eugene W. Ely2

1Department of Anaesthesiology, Intensive Care and Acute Poisonings, University Hospital no. 2,

Pomeranian Medical University in Szczecin, Poland

2Vanderbilt University School of Medicine, Medicine/Allergy, Pulmonary, and Critical Care, Veteran’s Affairs

Geriatric Research Education Clinical Center (GRECC) for Tennessee Valley, Nashville, Tennessee, USA

Abstract
Many patients treated in the intensive care unit (ICU) experience pain that is a source of suffering and leaves a long-
term imprint (chronic pain, post-traumatic stress disorder). Nearly 30% of patients experience pain at rest, while the
percentage increases to 50% during nursing procedures. Pain in ICU patients can be divided into four categories:
continuous ICU treatment-related pain/discomfort, acute illness-related pain, intermittent procedural pain and
pre-existing chronic pain present before ICU admission. As daily nursing procedures and interventions performed
in the ICU may be a potential source of pain, it is crucial to use simple pain monitoring tools. The assessment of pain
intensity in ICU patients remains an everyday challenge for clinicians, especially in sedated, intubated and mechani-
cally ventilated patients. Regular assessment of pain intensity leads to improved outcome and better quality of life of
patients in the ICU and after discharge from ICU. The gold standard in pain evaluation is patient self-reporting, which
is not always possible. Current research shows that the two tools best validated for patients unable to self-report
pain are the Behavioral Pain Scale (BPS) and the Critical Care Pain Observation Tool (CPOT). Although international
guidelines recommend the use of validated tools for pain evaluation, they underline the need for translation into
a given language. The authors of this publication obtained an official agreement from the authors of the two behav-
ioral scales — CPOT and BPS — for translation into Polish. Validation of these tools in the Polish population will aid
their wider use in pain assessment in ICUs in Poland.

Anaesthesiology Intensive Therapy 2017, vol. 49, no 1, 66–72

Key words: pain, assessment; behavioural scales, CPOT, BPS; critical care

The International Association for the Study of Pain (IASP) bated, mechanically ventilated or analgosedated. Additional
defines pain as “an unpleasant sensory and emotional ex- difficulties are co-existing neurological and mental disorders
perience associated with actual or potential tissue damage (e.g. aphasia, dementia, critical condition-related delirium,
or described in terms of such damage” [1]. The definition psychoses).
emphasises the subjective nature of pain and suggests that As daily nursing procedures and interventions in
its intensity can be assessed only by someone experiencing ICUs can be a potential source of pain, easy and simple
it. It is obvious that many patients treated in intensive care tools for pain assessment are required. The guidelines of
units (ICUs), particularly those intubated and mechanically management published by the international circle of ex-
ventilated, do not fit this definition as they cannot self-report perts recommend minimising pharmacological sedation
pain sensations or assess their intensity. The assessment and administering ventilation therapy without or with
of pain in ICU patients is a daily challenge for therapeutic minimal sedation, or only with analgesia. The Pain Agita-
teams, especially in patients who are endotracheally intu- tion Delirium Guidelines of the Society of Critical Care

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Medicine (PAD SCCM) of 2013, Delirium Agitation Seda- burns, neoplastic diseases or nursing-therapeutic interven-
tion (DAS) Guidelines of 2015 and early Comfort using tions [15–18]. Pain can be divided into 4 categories [4]:
Analgesia, minimal Sedatives and maximal Humane care I. Persistent pain associated with invasive procedures/
(eCASH concept) of 2016, clearly recommend providing /discomfort.
adequate analgesia first (before sedation) to humanise II. Acute pain related to an ongoing disease.
intensive care [2–4]. Moreover, the above guidelines III. Intermittent pain associated with ICU procedures.
highlight the role of pain, agitation and delirium moni- IV. Chronic pain occurring before ICU admission.
toring (called the ICU triad) in critically ill patients using The following procedures and interventions that can
dedicated scales validated for individual populations of potentially cause pain or discomfort include changes in posi-
patients [2]. tions, sucking of the oral cavity and bronchial tree, wound
The current clinical observations and results of pro- care, removal of drains or insertion of catheters, intravenous
spective observational studies indicate that the incidence accesses or intubation [18]. An additional issue is prolonged
of pain in patients subjected to endotracheal intubation acute pain, which substantially worsens the quality of life of
and mechanical ventilation is underestimated, hence left patients treated in ICUs and after discharge. The pain associ-
untreated or improperly treated. Considering the severity of ated with ICU procedures is still an essential issue in critically
conditions of ICU patients, as the issue of pain is not always ill patients [19]. It varies with age and gender, depends on
of utmost importance, not enough attention is paid to it. the level of pain before interventions and, most importantly,
The introduction of system solutions for pain assessment is treated only in 25% of patients; therefore, it requires spe-
improves the quality of care of critically ill patients, enables cial attention and pre-emptive treatment [19, 20].
them to inform one about their needs and improves prog-
nosis. However, prospective randomised studies are needed Consequences of pain in critically
to conclusively dispel doubts regarding the usefulness of ill patients
such scales in various clinical situations. The negative physiological and psychological conse-
quences associated with inadequate management of pain
Incidence of pain in ICU patients are long-term and extremely serious. It has been known for
The estimates of the World Health Organisation (WHO) years that the majority of patients identify the pain they ex-
demonstrate that almost 83% of the world population live perienced during ICU treatment as a source of sleep-related
in countries with poor or no access to pain management [5]. problems after discharge from the ICU [21]. The available
Pain experienced by ICU patients is common and well docu- study findings indicate that up to 82% of ICU-discharged
mented. During ICU treatment, up to 40–70% of patients patients remember the pain or discomfort associated with
experience pain (moderate to severe) [6, 7]. According to the presence of endotracheal tubes while 77% recollect con-
some authors, almost 30% of patients experience pain at tinuous moderate to severe pain [22]. According to Granja
rest and 50% during various nursing interventions [8]. The et al. [23], 17% of patients remember severe pain during ICU
majority of patients discharged from an ICU identify the treatment lasting up to 6 months after discharge while 18%
pain experienced as a huge source of stress [9–11]. Most have a  high risk of post-traumatic stress disorder (PTSD).
of them are not able to self-assess their pain (verbally) due Schelling et al. [24] have demonstrated that in a group of 80
to consciousness-related changes, mechanical ventilation, patients under long-term observation (4 years on average)
and high doses of sedatives or relaxants [12]. who underwent ICU treatment due to ARDS, the percent-
An overriding principle of effective pain management age of chronic pain and PTSD was higher (by 38% and 27%,
is proper identification of the problem. The inability to respectively); likewise, the quality of life in this group was
communicate verbally does not negate that a patient is lower (by 21%), as compared to the control group.
experiencing pain and is in need of proper analgesic treat- The pain-induced stress response can lead to disastrous
ment. Therefore, the role of clinicians is to assess reliably consequences [25], including increased concentrations of
the pain in patients with limited possibilities of communi- catecholamines, vasoconstriction, impaired tissue perfusion
cation by evaluating pain substitutes [13]. Identification, and decreased partial pressure of oxygen in the tissues [26].
measurement and proper pain management in critically The other disorders triggered by pain are hypermetabolism
ill patients is a priority and has been studied for the last leading to hyperglycaemia, lipolysis or protein catabolism,
20 years [14]. which results in impaired wound healing and increases the
risk of infections [26]. Pain leads to immune system disorders
Types of pain in critically ill patients by inhibiting the NK cell activity, decreasing the cytotoxic
The pain experienced by critically ill patients occurs at T lymphocyte count and reducing the phagocytic activity
rest, can be associated with surgical procedures, injuries, of neutrophils [27–29]. Finally, acute pain experienced by

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patients in various situations can be the essential risk factor ment of pain intensity, irrespective of the person engaged
of chronic pain, often neuropathic in nature. in the assessment. It is essential to use scales translated
from their original version, thus scales designated for indi-
Assessment of pain in critically ill patients vidual populations of patients. Although the exact process
Monitoring of pain in critically ill patients is rarely docu- of evaluation of the psychometric value of a test is complex
mented using validated tools. Observation of physiologi- and time-consuming, translations of the scales validated in
cal indices (heart rate, arterial pressure, respiration rate) is their original language of publication should precede their
misleading as they can depend on the underlying cause of implementation. The available study findings indicate that
exacerbation (e.g. sepsis, haemorrhage, hypoxia). Addition- the use of behavioural scales of pain assessment improves
ally, although it should be stressed that changes in basic nursing and therapeutic interventions in critically ill patients,
vital parameters can only suggest the presence of pain and introduces more effective protocols of pain management,
necessity to use a suitable tool for its identification, in the reduces the consumption of sedatives and shortens me-
majority of studies devoted to this issue, increased arterial chanical ventilation [35, 36].
pressure or tachycardia were not found to be associated The authors of the PAD SCCM guidelines of 2013 ana-
with the occurrence of pain. Heart rate and arterial pressure lysed six behavioural scales: BPS-non-intubated (BPS-NI),
may increase both during painful and painless procedures. CPOT, the Non-verbal Pain Scale (NVPS, NVPS-I, NVPS-R),
Moreover, these parameters are not correlated with the the Pain Behavioral Assessment Tool (PBAT) and the Pain as-
patient`s  assessment of pain and results of behavioural sessment, Intervention, and Notation (PAIN) algorithm [2]. In
tests [30–32]. Therefore, they should not be used as a basis the view of the authors, the most reliable and best validated
for the assessment of the occurrence and intensity of pain behavioural scales in patients who cannot self- report pain
in patients treated in ICUs. are the Behavioral Pain Scale (BPS) and Critical Care Pain Ob-
Regular assessment of pain intensity improves the pain servation Tool (CPOT) [2]. It was recommended to translate
management and quality of life of patients in ICUs and after them from French and English for their easier application;
discharge. The management of pain in dependent patients, hence the scales available in various languages [37, 38].
i.e. critically ill patients hospitalised in ICU, is based on reli- The observational studies have demonstrated that BPS
able and repeatable measurements of pain intensity and (3–12 total score) and CPOT (0–8 total score) have good
pain monitoring in time to evaluate the extent and level psychometric indices as for the inter-observer agreement
of interventions required for its treatment. The gold stand- of assessments in medical, surgical and trauma patients; yet
ard of management is the patient`s self-assessment; thus, without cerebral stroke [30, 31, 39–41]. A CPOT score of > 2
self-assessment should always be considered and patients indicates the presence of pain; the sensitivity of the test is
involved in determining the level of pain intensity. 86% while its specificity is 78% for the assessment of severe
The best tools to assess pain are those based on post-surgical pain [42, 43]. The cut-off value suggested for
patient`s  self-assessment, e.g. the visual analogue scale BPS is >5 [44, 45].
(VAS) or the numeric rating scale (NRS), which, however,
assume patient-caregiver cooperation. Additional difficul- Selected scales used to assess
ties are the effects of sedation, delirium, delirium treatment pain intensity in the ICU
and other factors affecting the central nervous system. It As both the CPOT and BPS require only short theoretical
is worth remembering that even the best tool may be un- and practical trainings, they can be easily used in clinical
suitable for certain groups of patients , e.g. 1) children , 2) practice. In Poland, various English-language scales are used,
patients who cannot communicate verbally, 3) those with including CPOT and BPS, which have not been translated or
dementia or 4) patients with mental illness. In many cases, validated in the Polish population.
as patients cannot self-assess pain due to the above factors,
some other tools have been designed which are based on Critical Care Pain Observation Tool (CPOT)
clinical observation of the patient`s  condition by nurses The CPOT was developed by Gelinas et al. [42] in French
and physicians. and shortly afterwards translated into and validated in other
According to Chanques et al. [33], who studied the group languages. The tool was designed to detect pain in critically
of 100 patients, the use of NRS was the most reliable tool for ill patients and includes 4 behavioural categories — facial
the assessment of pain intensity among five scales designed expressions, body movements, muscle tension, compliance
for this purpose. However, when the patient`s self-assess- with a  ventilator (for intubated patients) or verbalisation
ment is not possible, a validated, reliable and easy-to-use (for extubated patients). Each category is scored on a scale
tool should be applied [34]. The role of behavioural scales is of 0–2 (in total 0–8 points). According to the data reported
emphasised, which allow the routine and repeated assess- by Gelinas et al., [42], the cut-off point is 2–3, while a score

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Table 1. The Critical-Care Pain Observation Tool (CPOT)

Indicator Description Score

Facial expressions No muscle tension observed Relaxed, neutral 0
Presence of frowning, brow lowering, orbit tightening and levator Tense 1
contraction or any other change (e.g. opening eyes or tearing during
nociceptive procedures)
All previous facial movements plus eyelid tightly closed (the patient Grimacing 2
may present with mouth open or biting the endotracheal tube)
Body movements Does not move at all (doesn’t necessarily mean absence of pain) or Absence of movements or 0
normal position (movements not aimed toward the pain site or not normal position
made for the purpose of protection)
Slow, cautious movements, touching or rubbing the pain site, seeking Protection 1
attention through movements
Pulling tube, attempting to sit up, moving limbs/thrashing, not Restlessness/Agitation 2
following commands, striking at staff, trying to climb out of bed
Muscle tension No resistance to passive movements Relaxed 0
Evaluation by passive flexion and Resistance to passive movements Tense, rigid 1
extension of upper limbs when
patient is at rest or evaluation
when patient is being turned
Strong resistance to passive movements or incapacity to complete Very tense or rigid 2
them
Compliance with the ventilator Alarms not activated, easy ventilation Tolerating ventilator or 0
(intubated patients) movement
Coughing, alarms may be activated but stop spontaneously Coughing but tolerating 1
OR Asynchrony: blocking ventilation, alarms frequently activated Fighting ventilator 2
Vocalization (extubated patients) Talking in normal tone or no sound Talking in normal tone 0
or no sound
Sighing, moaning Sighing, moaning 1
Crying out, sobbing Crying out, sobbing 2
Total 0–8
Gélinas C, Fillion L, Puntillo KA, et al. Validation of the critical-care pain observation tool in adult patients. Am J Crit Care. 2006; 15(4): 420–427, indexed in Pubmed:
16823021. Table 1. Available at: http://ajcc.aacnjournals.org/content/15/4/420.short
CPOT Polish Translation: 16.10.2016, Katarzyna Kotfis MD, PhD

of > 2 indicates the occurrence of pain. The CPOT has good Behavioral Pain Scale (BPS)
psychometric properties (Cronbach`s α = 0.89) and moder- The BPS was developed by Paten et al. in order to as-
ate indices of inter-observer agreement (κ = 0.52–1; ICC = sess pain in unconscious mechanically ventilated patients.
0.80–0.93). The scale is a good tool in order to differentiate The scale is based on three types (ranges) of behaviour: 1)
between pain-related procedures (e.g. changes in body facial expressions, 2) movements of the upper extremities
position) and painless procedures (e.g. non-invasive arterial and 3) compliance with a ventilatory [46]. The details are
pressure measurement (P ≤ 0.001). [42] presented in Table 2.
Unfortunately, the CPOT has not been officially trans- The observer scores each range; the total score varies
lated into Polish. With the approval of the first author from 3 (no pain ) to 12. The available study findings dem-
of CPOT (Celine Gelinas), we translated the scale first onstrate that the BPS has good psychometric properties (
into Polish and then into English. Moreover, the trans- Cronbach`s α 0.64–0.79) and moderate/high indices of inter-
lation and the use of the scale in further publications observer agreement (κ = 0.67–0.89; [ICC] = 0.58–0.95) [39, 46].
was approved by the American Associated of Critical According to the international guidelines, both scales
Care Nurses. To date the scale has not been validated should be validated in specific clinical settings. Thanks to
in the Polish population. The data of the ongoing study this, intensive care teams (physicians, nurses, physiothera-
regarding the validation of POL-CPOT (ClinicalTrials.gov, pists) will be provided with reliable tools while early identifica-
NCT03024528) will be available in mid-2017. The details of tion of the problem will result in the quicker implementation
Original Critical-Care Pain Observation Tool are presented of treatment. The patient`s family is of extreme importance for
in Table 1 and Figure 1. assessment of pain in ICU patients; the family identifies the

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Figure 1. Facial expressions in Critical Care Pain Observation Tool (graphics by K. Kopczyński)

Table 2. Behavioral Pain Scale 2. The gold standard for the assessment of pain intensity
is the patient`s self-reporting using the VAS or NRS.
Item Description Score
3. In patients unable to self-report pain experiences, the
Facial expression Relaxed 1
behavioural scales (CPOT or BPS) are recommended;
Partially tightened (e.g., brow 2
lowering) currently available also in Polish.
4. It is necessary to evaluate the correlation between the
Fully tightened (e.g., eyelid 3
closing) pain reported by the patient and the assessment by the
Grimacing 4 experienced personnel in order to validate the CPOT and
Upper limb No movement 1 BPS in the Polish version.
movements
Partially bent 2 Acknowledgements:
Fully bent with finger flexion 3 1. Special thanks to Prof. C. Gelinas (CPOT) and Prof. J.F.
Permanently retracted 4 Payen (BPS) for their approval for the translation of
Compliance Tolerating movement 1 their scales into Polish. We would like to thank Joanna
with mechanical Stollings RN and Heather Hart RN from Vanderbilt Uni-
ventilation versity for their factual evaluation of the translations of
Coughing but tolerating 2 the pain scales.
ventilation for the most of
time
2. Source of funding: none
3. Conflicts of interest: none.
Fighting ventilator 3
Unable to control ventilation 4
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