Adequate pain assessment is a pre-requisite for appropriate pain management. If pain remains untreated in critically ill young children, it can have dramatic short- and long-term consequences on their health and development. Apart from humanitarian reasons, the assessment of pain has been recognised in some parts of the world as the fifth vital sign and thus should be part of standard practice of pain management. The evaluation of pain in preverbal children is, nevertheless, challenging for health professionals, as they cannot rely on self-report when making their assessment. Observational pain instruments have been developed to facilitate this task, but none of these existing instruments are appropriate for the postoperative critically ill young child. The aim of this research was to provide a clinically valid pain instrument for health professionals to use in practice for the evaluation of the pain and the effectiveness of pain treatment in critically ill young children. This thesis presents research that was conducted in three phases to (a) describe pain, (b) develop, and (c) test the pain instrument. Conceptualisation of pain and psychometric theory informed the conceptual framework for this study. An observational design was used in Phase One of the study to define pain behaviour in critically ill infants. Correlational design was used in Phase Two and Three to determine the association between the newly developed pain scale and other pain assessment instruments. Phase One of the study was conducted in the paediatric intensive care units of two tertiary referral hospitals. Eight hundred and three recorded segments were generated from recordings of five critically ill infants, aged between 0 and 9 months, who had undergone major surgery. / Results indicated significant physiological and behavioural changes in response to postoperative pain and when postoperative pain was exacerbated by painful procedures. Using the pain indicators observed in Phase One, in Phase Two the Multidimensional Assessment Pain Scale (MAPS) was developed and tested for reliability and validity in 43 postoperative preverbal children from the same settings. Internal consistency and interrater reliability were moderate and good, respectively. Concurrent and convergent validity was good. In Phase Three, the MAPS' response to analgesics and clinical utility was demonstrated in a convenience sample of 19 postoperative critically ill children aged between 0 and 3 1 months of age at a tertiary referral hospital in Western Australia. Development of a pain instrument is a complex and lengthy process. This study presents the preliminary psychometric properties that support the validity and clinical utility of the Multidimensional Assessment Pain Scale. The MAPS is a promising tool for assessing postoperative pain in critically ill young children, and its clinical validity will be strengthened with further testing and evaluation.

Acute and chronic pain conditions have a significant impact on the individual who is experiencing pain and resolution of pain continues to present a challenge to nurses and other health care professionals. It is widely accepted that pain education for nurses is necessary if nurses are to deliver effective, evidenced based pain care. Although it has been shown that participation in pain education improves nurses’ pain knowledge, very little is known about the way in which nurses use their improved pain knowledge in their practice or about the conditions that promote application of that pain knowledge. The aims of this study are (a) to explore the transfer of pain knowledge from a continuing education nursing course into practice, and (b) to investigate the impact that the nurses’ participation in action research has on their ability to improve aspects of their pain practice. Participants are 14 registered nurses who successfully completed two accredited pain course units as part of their BSc / BN degree in Nursing. The nurses formed two groups of inquiry, who used both their participation in the pain course and in action research to investigate and change aspects of pain assessment and management practices within their clinical areas. The inquiry groups were located in two different Health Board locations in Scotland. Following involvement in a pain course, the strategies used by the participating nurses to enhance their pain assessment and management practices are examined. Qualitative data was obtained through individual and group interviews, and analysis of significant incidents. An action research approach contributes to an understanding of conditions that promote application of pain knowledge into practice following participation in the course, and focuses on the possibilities for action and improvement of pain care. The findings from this study demonstrate how nurses develop a more patient-centred approach to pain care and become more accountable for their pain practice. The research also identifies a range of strategies used by nurses to improve collaborative working practices with their colleagues that help to reduce some of the obstacles to delivery of effective pain care. From the outcomes of the inquiry, it is evident that these nurses’ participation in action research has increased the possibilities of their involvement in pain practice interventions. Conditions are created through pain course participation and involvement in action research, which supports nurses’ transfer of pain knowledge into practice Additionally, findings demonstrate the potential action research has for identifying problems with pain care and its potential for helping to develop relevant and workable solutions for improving aspects of care. The findings from this study are significant because they inform teaching and learning approaches which can be used with pain education that helps to prepare nurses to deliver more effective pain care within their health care settings.

Breast cancer is the most common cancer among Canadian women. Chronic neuropathic pain post breast surgery (PPBS), also known as chronic post mastectomy/lumpectomy pain syndrome, is a poorly understood complication posing a significant clinical challenge with major negative impact on patients' quality of life. This study aims to: 1) provide a preliminary determination of the prevalence rate of women who suffer from PPBS; and 2) explore potential risk factors associated with women developing PPBS. This pilot study used a prospective, longitudinal, quantitative survey design, with a demographic questionnaire and the Brief Pain Inventory. Seventeen women were recruited at a breast health clinic in Western Canada; 23.5% developed PPBS. Younger age (≤50 years), more invasive surgery, acute post-operative pain, and less analgesic use at the acute post-operative period, were more commonly found in the women who developed PPBS. Future research is required to confirm the significance of these potential risk factors.

Breast cancer is the most common cancer among Canadian women. Chronic neuropathic pain post breast surgery (PPBS), also known as chronic post mastectomy/lumpectomy pain syndrome, is a poorly understood complication posing a significant clinical challenge with major negative impact on patients' quality of life. This study aims to: 1) provide a preliminary determination of the prevalence rate of women who suffer from PPBS; and 2) explore potential risk factors associated with women developing PPBS. This pilot study used a prospective, longitudinal, quantitative survey design, with a demographic questionnaire and the Brief Pain Inventory. Seventeen women were recruited at a breast health clinic in Western Canada; 23.5% developed PPBS. Younger age (≤50 years), more invasive surgery, acute post-operative pain, and less analgesic use at the acute post-operative period, were more commonly found in the women who developed PPBS. Future research is required to confirm the significance of these potential risk factors.

This investigation utilized a novel, self-help, multi-element psychological program to manage chronic low back pain. A literature review indicated that this disorder was costly and prevalent, yet a large percentage of chronic low back pain patients did not respond to traditional treatment. Recent research has demonstrated that numerous psychological difficulties have been associated with this disorder, including depression and anxiety. It was hypothesized that these psychological concomitants of chronic low back pain maintain and promote further pain, as part of a vicious cycle. Self-help treatment attempted to break this tension-pain-anxiety cycle using various stress reduction, and cognitive and behavioral management strategies.

This study was designed to investigate the experience of having arthritic pain from the children's perspective. Previous research on how Canadian children perceive and manage arthritic pain and how it affects their daily lives is nonexistent. Therefore the purpose of this qualitative descriptive study was to explore and describe the arthritic pain experience of school age children with juvenile rheumatoid arthritis (JRA) and to understand the impact/influence of various factors on the construction of that experience. Ten children, aged 10 to 13 years, with either early (at 2 to 4 years) or late (at 7 to 11 years) onset arthritis participated in this study. Descriptive data were obtained during two open-ended in depth interviews with the children in their homes. Using content analysis, data were analyzed for themes and their elements. An analytical framework of themes and their elements was developed that reflected the children's descriptions of and explanations for arthritic pain in the context of their day to day in the context of their day to day living with arthritis, both in the past and currently. The children perceived pain to be synonymous with arthritis and the mediating factor in how they functioned. They described arthritic pain in relation to distinguishing factors: intensity, duration, and frequency. Intermittent arthritic pain was attributed to cessation of medications, arthritis "flare-ups," inactivity, and activity. A current concern for most children was pain attributed to activity because it meant limitations in activities with peers. The children identified strategies they used to manage pain and cope with pain's unpredictability. The findings of this study were discussed in relation to selected research studies that either supported or refuted the findings of this study. Implications for nursing practice and research were addressed. / Applied Science, Faculty of / Nursing, School of / Graduate

The assessment of pain in children has been an enduring theme in the research literature over many decades, with particular focus on how pain can be adequately measured and the extent of under-measurement of pain (American Academy of Pediatrics 2001; Coyne, 2006; McCaffery & Beebe 1989; Subhashini et al., 2009). Definitions of pain, and hence development of pain measurement tools, are often criticised for not addressing the influence of culture and ethnicity on pain (Bates et al., 1993; McCaffery & Beebe 1989; Zinke, 2007), in children, the perception and expression of pain is also affected by cognitive development (Hallström and Elander, 2004). Whilst there has been an increase in the number of children living in the United Kingdom (UK) who do not speak English as their first language, it has been acknowledged that the measurement and management of pain by health service professionals relies predominantly on their experience with English speaking children (RCN, 2009). This study aimed primarily to examine how primary school age children in key stage 1 who speak English as a primary or additional language experience, express, and explain pain. This aim was addressed through three research questions: (1) how do primary school age children in key stage 1 talk about pain? (2) What are the similarities and differences in the language used to talk about pain by children with English as a primary and additional language? (3) Are there differences in the perceptions of pain by children of different age, gender, language background, and country of birth? A second aim was to examine whether language would affect actions taken by final year child health students and nurses working in Minor Injuries Units to manage pain in primary school age children. Study objectives were addressed using a two phase mixed methods design. The first aim was addressed using six focus group interviews with groups of primary school children (aged 4-7) (Phase 1). Two methods were used in the interviews: use of drawings from the Pediatric Pain Inventory (Lollar et al., 1982) to capture the language used by children to describe pain and observation of the children’s placing of pain drawings on red/amber/green paper to denote perceived severity of pain. Following data collection, the vocabulary of each child was assessed using a standardised lexical test (British Picture Vocabulary Score version II - BPVS II) (Dunn et al., 1997). To address the second aim, a factorial survey was conducted (Phase 2) with nurses working in Minor Injuries Units and child health nursing students to determine whether language has an impact on decisions made about the management of children in pain following a minor injury. Phase 1 findings demonstrated that children from English as an Additional Language (EAL) backgrounds used less elaborate language when talking about pain but tended to talk about the pictures prior to deciding where they should be placed. The children’s placement of pain drawings varied according to language background, gender, and age. The calculated language age of English lexical comprehension (BPVS II score) of monolingual children (M=69.85, SD=19.27) was significantly higher than EAL children (M=47.93, SD=14.32; t (32) = 3.60, p =0.001, two-tailed). However, when these differences were explored in terms of year group, the differences remain significant with foundation and year 2 but not with year 1. For the EAL children, there were also significant relationships between BPVS II score and length of stay in the UK (spearman’s rho 0.749, p = 0.33). The Phase 1 findings were used to construct vignettes, describing hypothetical care situations, for Phase 2. Multinomial logistic regression was used to analyse the impact of a child’s age, gender, language, parent’s language, injury mechanism, and reaction to pain on the way in which the child’s pain would be assessed and whether parents or an interpreter would be invited to assist in pain assessment. Findings demonstrated that observing the child’s behaviour is the most significant assessment process that is used to assess EAL children, rather than the Visual Analogue Scale (VAS), which was used with non-EAL children. This is significant as VAS is the mostly widely used tool to assess pain in health care settings. However, VAS is only effective if it can be understood by the child. Further, MIU nurses and child health students were more likely to involve parents who speak English well than those who speak English poorly but would ask for an interpreter if their involvement was necessary. In order for the respondents to explain their decisions, they were asked an open ended question for each vignette. They reported that language and age of children are the most common difficulties they faced during assessment of pain. Therefore, they suggested some solutions, like using an age appropriate tools for assessing younger children. Respondents also identified that using an interpreter is a time consuming process, which might delay the management of pain. In light of the growing numbers of EAL children in the UK; this research has application in a number of contexts. The variation in language would apply if children were reporting their own pain. However, the findings emphasise the need for sufficient time to be allocated to pain assessment to allow an individualised approach. Study findings suggest several factors that may be important in assessing pain in EAL children; these should be explored further in the context of clinicians’ assessment of pain. The implications of the study impact on policy, practice, education, and future research.

Dissertation submitted in partial compliance with the requirements for the Master’s degree in technology: Chiropractic, Durban University of Technology, Durban, South Africa, 2013. / Background: Forward head posture (FHP) is a common postural abnormality that is commonly associated with weak deep cervical flexor muscles (DCF). The craniovertebral (CV) angle lies between a horizontal line running through C7 spinous process and a line connecting the C7 spinous process to the tragus of the ear. The smaller the angle, the greater the forward head posture. Weak DCF musculature and FHP has been linked to cervical dysfunction in the short and long term such as cervicogenic headache and premature development of cervical regional degenerative joint disease. Improving isometric endurance and neuromotor control of the DCF muscles using craniocervical flexion exercise (CCFE) has been shown to be efficient in patients experiencing cervical dysfunction such as headache, although the relevance of CCFE has not been established in the asymptomatic group. Deficiency in the activity of these muscles can be accurately measured using craniocervical flexion testing (CCFT). There is a paucity of information regarding the definitive relationship between weakness of the DCF and FHP in asymptomatic participants. This research will help establish an efficient and safe prophylactic treatment protocol preventing long term sequela associated with FHP. Objectives: To determine the effect of CCFE on cervical posture by assessment of the CV angle in asymptomatic participants as well as to determine the effect of CCFE on cervical range of motion by assessment of flexion, extension, bilateral rotation and lateral flexion movements in asymptomatic participants whilst measuring the effect of CCFE on isometric endurance and neuromotor control of the DCF muscles assessed by the CCFT in asymptomatic participants. Method: This is a quantitative pre/post intervention study comparing the results of one group of 45 asymptomatic participants before and after the CCFE protocol has been allocated to them over a period of 3-5 weeks. Participants FHP was assessed by measuring the CV angle. This was done by marking the C7 spinous process and extending a horizontal line toward the shoulder. Then marking the tragus of the ipsilateral ear and measuring the angle using the smart tool angle finder (MD products). iv CCFT measurements were taken and the CCFE protocol allocated to those who qualified to take part in the study. Lastly, cervical range of motion was measured. This group received a home exercise protocol of 3 sets of 10 supine chin tucks daily with each repetition being held for 10 seconds. The technique was first ensured by the researcher prior to leaving the consultation rooms and an exercise diary was given to the participant until the 5th and final consultation to record the progress and efficiency of the home programme as well as any complaints regarding this. Result: The asymptomatic group included in the study improved in both the seated and standing CV angle measurements in that the CV was greater at the conclusion of the pre/post intervention (p=0.00000002) and (p=0.000003) respectively . Cervical range of motion showed improvement in some but not all ranges. Flexion showed a reduction in range of motion (p=0.0086) which was significant. Extension showed an improvement in range of motion (p=0.0000002) which was significant. Rotation toward the left (p=0.00003) and right (p=0.00063) showed an improvement in range of motion which was significant. Lateral flexion showed improvement which was not significant in both, left (p=0.0145) and right (p= 0.24985) ranges of motion. Neuromotor control showed 100 percent improvement in that all 45 of the participants were able to perform CCFT correctly through all five stages at conclusion of the study. Conclusion: Therefore it can be concluded that asymptomatic participants will benefit from CCFEs In terms of CV angle improvement, cervical range of motion as well as neuromotor control of the DCF muscles.

A dissertation presented to the Faculty of Health Sciences at the Durban University of Technology in partial compliance with the requirements for the Master’s Degree in Technology: Chiropractic, 2009 / Introduction: The aetiology of Temporomandibular Joint Dysfunction (TMJD) is not fully understood and the treatment of TMJD is controversial. Most treatment plans are based on postulated aetiology. Treatment plans currently range from pharmacological to surgical and occasionally physical therapy is also used for any myofascial component. Myofacial Trigger Points (MFTP’s) in the head and neck region have similar pain referral patterns as TMJD and there is overlap in aetiology and epidemiology. If correlation can be proved to exist between the severities of TMJD and MFTP’s then the treatment of MFTP’s can potentially decrease the severity of TMJD and then the more radical treatments can be avoided. Objectives: To determine whether TMJD was present and establish severity. To locate any MFTP’s in the Sternocleidomastiod (SCM), Temporalis, Masseter, Posterior Cervical (PC), Lateral and Medial Pterygoid muscles and determine their severity. Methods: A random sample of 25 participants were evaluated. A p value <0.05 was considered as statistically significant. Quantitative variables were summarized using median, inter-quartile range and range due to skewness of distribution, while categorical variables were described using frequency distributions and bar charts. Spearman’s nonparametric correlation analysis, and curve estimation were used to determine the existence of a relationship between TMJ severity and MFTP severity. A scatterplot was used to graphically assess the relationship. Conclusion: The results suggested that the participants were actually chronic neck pain suffers that developed TMJD over the long term as a result of chronic neck pain changing the kinematic biomechanics or as a result of a completely different and independent event as suggested by Foreman and Croft (1995).

Smärta är idag ett omfattande hälsoproblem. Idag finns det mycket kunskap omsmärta, effektiva smärtstillande läkemedel och metoder för smärtlindring inom hälsoochsjukvården. Trots detta får många patienter inte tillräcklig smärtbehandling. Föratt uppnå en optimal smärtbehandling är det viktig att sjuksköterskor genomför enadekvat smärtbedömning och har kunskap om de faktorer som påverkarsmärtbedömningen. I litteraturstudien granskades och analyserades totalt 10 artiklar,åtta kvantitativa, en kvalitativ och en med mixad metod. Resultatet visar att det finnsolika faktorer som påverkar smärtbedömningen. De faktorerna är: bedömning avsmärtintensitet, kunskap om riktlinjer, kunskapsnivå och erfarenhet, sociala faktoreroch dokumentation. Erfarna sjuksköterskor har högre tilltro till sina egna objektivabedömningar än till patienters subjektiva smärt-upplevelse vilket leder tillunderskattning av patientens smärta. Tillämpning av kliniska riktlinjer leder till attsjuksköterskor genomför en adekvat smärtbedömning. Patientens smärta kan påverkasnegativt av partners empati och socialt hot. Försening och otillräcklig dokumentationav smärtbedömning påverkar smärtlindringen vilket leder till onödig smärta ochlidande hos patienten. Brist i konsekvent användning av smärtskattningsskalor, ingaobserverade ändringar i de vitala parametrarna kopplade till smärta, tidsbrist ärytterligare faktorer som påverkar smärtbedömningen negativt. Framtida forskningbehövs för att identifiera faktorer som påverkar smärtbedömningen så attkompetensen hos hälso- och sjukvårdspersonalen ökar. / Pain is today an extensive health problem. A lot of knowledge exists today aboutpain, effective pain reducing medicines and methods to provide pain easement withinthe health and medical care. Despite those facts a lot of patients do not receiveadequate pain treatment. To achieve an optimal pain treatment is it important thatnurses performs an adequate pain assessment and has knowledge about the factorsthat influence the pain assessment. The study is a literature review that is based on tenarticles whereof eight are quantitative, one qualitative and one with mixed methods,those articles where studied and analyzed. The result shows that different factors thatinfluences the pain assessment exists. Those factors are: assessment of pain intensity,knowledge about guidelines, competence level and experience, social factors anddocumentation. Experienced nurses have higher belief on their own objectiveassessments than to the patient’s subjective pain experience, this leads to anunderestimation of the pain experienced by the patient. Application of clinicalguidelines leads to that nurse performs an adequate pain assessment. The patient’spain can be negatively impacted of their relatives’ empathy and by a social threat.Late or insufficient pain assessment documentation impacts the pain relief whichleads to unnecessary pain and suffering for the patients. Lack of a consequent use ofpain rating scales, no observed changes in the vital parameters related to pain and lackof time are additional factors that influences the pain assessment negative. Futureresearch is needed to identify factors that influence the pain assessment.