Aim: The overall aim of the thesis was to explore and describe registered nurses’ (RNs) and certified nursing assistants’ (CNAs) experiences of detection and assessment of pain in older people with cognitive impairment and dementia. A further aim was to evaluate the Abbey Pain Scale-SWE (APS-SWE) in dementia care practice. Methods: An exploratory and descriptive design was used in Study I. An exploratory and interpreting design was used in Study II and Study III. A prospective, descriptive, observational and instrumental design was used in Study IV. Focus group interviews (I) and individual interviews (II, III) were applied to explore and describe RNs’ and CNAs’ experiences of pain assessment in people living with dementia. Qualitative content analysis (I) and philosophical hermeneutics (II) were used to analyse qualitative data. Observation, instrument, and questionnaire were applied to evaluate reliability and face validity of the APS-SWE for pain assessment. Descriptive statistics and reliability analyses were used to analyse quantitative data (IV). Results: RNs in special housing accommodation settings experiences that pain assessment in people with dementia is challenging primarily due to their changed RN consultant role, which to a great extent is directed into administrative and consultative tasks rather than bedside care. This has led to decreased time in daily nursing care, preventing recognising symptoms of pain. This have also led to that RNs are dependent on information from CNAs who are the front-line staff providing daily care (I). CNAs’ perception of signs of pain in people with dementia emerges from being present in the care situation and alertness on physical and behavioural changes that could be due to pain, and from providing the care in a preventive, protective and supportive way to prevent painful situations occurring (II). RNs and CNAs working in home healthcare team use a variety of strategies to detect and assess pain. A trustful work relationship based on staff continuity and a good relation to the person in need of care facilitates pain assessment situations (III). Systematic observation of older people living in special housing accommodation during rest and mobility using the APS-SWE demonstrates that the scale has adequate internal consistency, reliability, and face validity for pain assessment (IV). Conclusions: This thesis found that the RNs’ and CNAs’ detections and assessments of pain rely on solid cooperation, staff continuity, and good knowledge of the person cared for. It was also revealed that there is a lack of using appropriate and assisting pain tools. The APS-SWE show adequate reliability and face validity and can serve as a useful pain tool to assist in detection and assessment of pain in older people who are limited in verbalising pain recognisable. Further evaluation of how the person-centred perspective is applied in pain assessment situations is needed in order to evaluate positive outcomes in people with dementia. Further psychometric evaluation of the APS-SWE in clinical dementia care practice is needed to strengthen validity and reliability. / <p>Study IV</p><p>Karlsson C, Ernsth Bravell M, Ek K, Johansson L &amp; Bergh I (2014): Reliability and face validity of the Abbey Pain Scale-SWE in Swedish dementia care practice. Submitted June, 2015.</p>

La douleur est une expérience multidimensionnelle comportant des aspects sensoriels, émotionnels et cognitifs. Théoriquement, des méthodes de mesures comportementales, physiologiques, neurophysiologiques et sensorielles peuvent quantifier la douleur. Peu d’études ont étudié la validation des mesures utilisées en médecine vétérinaire. La recherche combine les travaux de Maîtrise et de Doctorat, traite en partie de la validité de méthodes. Dans cet objectif, nos travaux de recherche étudiaient la validité de méthodes comportementales, physiologiques et neurophysiologiques usuelles pour la mesure de la douleur en comparant les expressions de douleur (vache et chien) chez des animaux contrôle par comparaison à des animaux sous analgésie préventive ou sous traitement curatif suivant une douleur induite par chirurgie (modèles de douleur viscérale bovine ou orthopédique canine) ou causée par une maladie naturelle (arthrose canine). Une première étude comparait les mesures de la douleur entre les vaches du groupe placebo et celles sous analgésie postopératoire sur une durée de 21 jours suivant l’induction d’une douleur viscérale chronique. Les vaches du groupe placebo ont présenté une plus forte sensibilité à la douleur et une diminution de la noradrénaline et de la transthyrétine mesurées dans le liquide cérébro-spinal, une diminution de l’activité motrice (AM) (moindre que dans les groupes avec analgésie), de l’agitation enregistrée par vidéo-analyse et une augmentation du stress selon la mesure de l’activité électrodermique (AED). Les méthodes d’intérêt identifiées étaient les marqueurs spinaux, la mesure de la sensibilisation, de comportements par vidéo-analyse et de l’AM par bio-télémétrie. En utilisant des méthodes semblables à celles précédemment décrites, deux études expérimentales de douleur orthopédique ont été réalisées afin de comparer les réponses à la douleur entre des chiens traités avec une analgésie préventive (opioïdes et anti-inflammatoires, étude #2) ou un biphosphonate (tiludronate, étude #3) par comparaison à des chiens contrôles. Seules les échelles de douleur étaient différentes entre les études de recherche. Pour l’étude #2, les ii chiens sous analgésie ont présenté de plus faibles scores de douleur mesurés avec l’échelle de douleur nommée 4A-VET et ceci simultanément à une faible réponse de l’AED une heure après la chirurgie de trochléoplastie. La fréquence du comportement spontané de ‘la marche avec plein appui de la patte opérée’ mesurée à l’aide de la vidéo-analyse augmentait chez les chiens sous analgésie préventive 24 heures après la chirurgie. L’étude #3 démontrait surtout l’apparition de sensibilisation centrale (à la fois par l’évaluation sensorielle quantitative et les marqueurs spinaux) chez les chiens contrôle, 56 jours après l’induction d’arthrose chirurgicale. Ainsi, les chiens traités avec le tiludronate ont présenté une différence sur la substance P et la transthyrétine cérébro-spinale, une diminution de la sensibilisation périphérique, plus d’appui de la patte opérée lors de la marche selon la mesure du pic de force verticale (PFV), une augmentation de la fréquence de ‘la marche avec plein appui de la patte opérée’. La sensibilisation centrale était associée à la diminution de PFV, et une augmentation de l’AED et du comportement spontané de ‘la marche avec plein appui de la patte opérée’. Pour l’étude #4, la validité et la sensibilité des méthodes ont été évaluées dans une condition d’arthrose naturelle chez des chiens traités avec une diète enrichie en moule verte, un produit ayant des effets anti-inflammatoires et chondroprotecteurs attendus. Les chiens traités présentaient une diminution des scores de douleur via l’échelle nommée CSOM, une augmentation de PFV et une augmentation de l’AM. Dans l’ensemble, les résultats confirment que la vidéo-analyse évaluait la douleur de façon objective et pour des modèles différents de douleur et les marqueurs spinaux sont prometteurs. Le PFV était spécifique de la douleur orthopédique. La sensibilisation était présente lors de douleur pathologique. L’AED n’est pas valide pour la mesure de la douleur. La baisse d’AM suggèrerait un comportement de douleur. Les études étaient exploratoires pour les échelles de douleur en raison de leur niveau (débutant) de développement et du manque d’informations sur les qualités métrologiques de ces mesures. / Pain is a multidimensional experience involving sensitive, emotional and cognitive components. Theoretically, there are multiple methods by which pain can be assessed including sensitive, behavioural, physiological, or neurophysiological measurements. However, little work has been done to validate these measurements in veterinary medicine. The presented research program including both Master and Doctorate works was intended to address partially this paucity of research. For this purpose, our work would validate some behavioural and physiological methods of pain assessment by contrasting pain expressions (cows and dogs) in painful animals (negative control) and animals treated with preventive analgesic or curative treatment following surgery-induced (bovine visceral and canine orthopaedic models) pain or natural occurring disease (osteoarthritis in dog). A pain study was first conducted to compare measurements of placebo treated-cows with postoperative analgesic treated-cows during 21 days following surgical induction of sustained visceral pain. Placebo treated-cows were found to have increased pain sensitization and decreased concentration of cerebrospinal fluid noradrenaline and transthyretin, less motor activity (but higher than in analgesic groups), more restlessness recorded with video-analysis and increased partially stress with measurement of electrodermal activity (EDA). This first study allowed a selection of methods of interest for pain evaluation including spinal biomarkers, measurement of sensitization, behavioural recording with video-analysis and motor activity with biotelemetry. Therefore, two canine pain experiments, with use of similar methods of pain assessment presented above, were performed to compare responses to pain between preventive analgesics treated-dogs (opioids and anti-inflammatory drug, study #2) or a bisphosphonate (tiludronate in study #3) with placebo-treated dogs. Only the pain scales were different among the projects. For project #2, analgesic treated-dogs were found to have lower pain scores measured with the so-called 4A-VET postoperative pain scale while simultaneously exhibiting reduction of EDA response up to 1 hour following trochleoplasty. In addition, the occurrence rate of the spontaneous behaviour ‘Walking with full weight bearing of the operated leg’ recorded with video-analysis, was higher in analgesic treated-dogs when compared with the placebotreated dogs at 24 hours post trochleoplasty. The pain study #3 was then conducted and demonstrated central sensitization (assessed with quantitative sensory testing and spinal biomarkers) in all control dogs at 56 days post induction of the canine osteoarthritis pain model. Nevertheless, tiludronate treated-dogs were found to have different spinal biomarkers (substance P and transthyretin), decreased peripheral sensitization, more peak vertical force (PVF), which is a kinetic gait parameter, and increased occurrence rate of ‘Walking with full weight bearing of the operated leg’. Interestingly, the central sensitization was associated negatively with PVF and positively with both EDA and ‘Walking with full weight bearing of the operated leg’. Finally, a fourth pain study was conducted to examine whether some of the methods performed validity and sensitivity in clinical condition with osteoarthritic dogs. For this purpose, osteoarthritic dogs were treated with a green-lipped mussel enriched-diet, having both anti-inflammatory and chondroprotective expected activities. The treated-dogs were found to have low pain scores measured with the pain scale for owner named CSOM, increased PVF and motor activity. Indeed, CSOM scores were associated with both PVF and motor activity. Taken together, the results suggest that video-analysis would assess pain expression through objective, predictive and unique evaluation whatever the species or the model, whereas spinal biomarkers are promising. The PVF changes were related to orthopaedic pain. Sensitization appeared to be common to the pathological pain pattern. The EDA was not validated for pain assessment in animals. Decreased motor activity is pain suggestive. Psychometric evaluation of the pain scales remained only exploratory at this (early) stage of development and knowledge of the present pain scales.

Made available in DSpace on 2016-06-02T20:18:18Z (GMT). No. of bitstreams: 1 TeseIAPW.pdf: 1512962 bytes, checksum: fa65d9db2288861ce39f29eb99b3533c (MD5) Previous issue date: 2004-12-02 / Work-related musculoskeletal disorders (WRMDs) are diseases that result in persistent pain, loss of functional capacity and associated work disability. This diagnostic is important because it is used to guide clinical and legal decisions. Their initial diagnosis is difficult because such diagnoses are based on complaints of pain and they often involve conflicting social and economic interests. Because of the complexity of such diagnoses, further studies are needed in order to analyze the association between subjective descriptions and objective findings. Therefore was made two research. The objective of the first research was to evaluate the impact of personal, clinical and occupational aspects on work ability of workers with and without WRMDs using an approved version of the Work Ability Index (WAI) and pain scale. This evaluated 127 workers of industrial production lines. A descriptive analysis was carried out using the Chi-square test and it was also performed a logistic regression analysis. A significant association was identified between the WAI and all personal, clinical and occupational aspects. Regression analysis showed that pain and sick leave together accounted for 59% of poor work ability. The objective of the second research was to evaluate the clinical and functional aspects of WRMDs, in relation to physical evaluation, perception of pain, self-reporting of symptoms and functional ability, among active workers at a single company with and without symptoms or evidence of this disorders. 134 female workers were physically evaluated by two trained physiotherapists. They filled out a questionnaire on discomfort due to pain, a pain scale, the Oswestry Disability Questionnaire (ODQ) and the Work Ability Index (WAI). The results were correlated and logistic regressions were run. According to the results symptom reports were explained by the results from the pain scale and the clinical findings and clinical findings by symptom reports and WAI. In two research the relationship between pain, symptom reports and clinical findings demonstrates that the patient s current state can be assessed not only by means of objective examinations, but also by means of instruments that take into account the patient s perception of his or her state. / Os distúrbios ostemusculares relacionados ao trabalho (DORT) podem resultar em dor crônica, diminuição da capacidade funcional e associada incapacidade para o trabalho.Seu diagnóstico é importante pois direciona as decisões clínicas e legais. No entanto, essas lesões apresentam desafios para seu diagnóstico e prognóstico, uma vez que envolvem indicadores subjetivos, porque há fatores de interesses sociais e econômicos envolvidos. Em função desta complexidade, mais estudos são necessários para analisar a associação entre relatos subjetivos e achados objetivos. Desta forma foram realizados dois estudos. O objetivo do primeiro foi avaliar o impacto de fatores pessoais, do trabalho e da lesão na capacidade funcional dos trabalhadores com e sem história de acometimento de lesões músculo-esqueléticas relacionadas ao trabalho, utilizando a aplicação autorizada do Índice de Capacidade para o Trabalho (WAI) e escala de dor. Este avaliou 127 trabalhadores de linhas de produção industrial. Os resultados foram analisados descritivamente, por meio do teste Qui-quadrado e pela análise de regressão logística. Todos os fatores pessoais, ocupacionais e clínicos analisados apresentaram relação significativa com a capacidade para o trabalho. A análise de regressão mostrou que dor e afastamento do trabalho explicaram juntas 59% da baixa capacidade para o trabalho. O objetivo do segundo estudo foi avaliar os aspectos clínicos e funcionais dos DORT, em relação a avaliação clínica, percepção da dor, auto-relato de sintomas e capacidade funcional através da avaliação de trabalhadores de uma mesma empresa, com sem sintomas de DORT. 134 mulheres foram fisicamente avaliadas por dois fisioterapeutas treinados e responderam a um questionário relacionado a sensação de dor ou desconforto, escala de dor, questionário de incapacidade de Oswestry (ODQ) e índice de capacidade para o trabalho (WAI). Os resultados foram correlacionados e a análise de logística foi aplicada. Os resultados indicaram que relatos de sintomas foram explicados pela escala de dor e exame clínico e o exame clínico foi explicado pelos relatos de sintomas e WAI. As associações entre dor, relatos de sintomas e exame clínico, demonstraram que o estado atual do paciente pode ser avaliado não somente por exames objetivos mas também por meio de instrumentos que levem em conta a percepção do próprio paciente sobre seu estado.

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