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

skingsnorth@hollandbloorview.ca