Research Reports - Indicators of pain in nonverbal patients with a traumatic brain injury

Pain Manag Nurs. 2014 Jun;15(2):506-18

Arbour C(1), Gélinas C(2)

The use of behavioral and physiologic indicators is recommended for pain
assessment in nonverbal patients. Traumatic brain injuries (TBI) can lead to
neurologic changes and affect the way patients respond to pain. As such, commonly
used indicators of pain may not apply to TBI patients. This study aimed to review
the literature about behavioral/physiologic indicators of pain in nonverbal TBI
patients. An integrative review method was used. Medline (from 1948 to June
2011), Cinahl, and Cochrane databases were searched using any combination of the
terms brain injury, behavioral indicators, behavioral scale, physiologic
indicators, pain, pain assessment, and pain measurement. All articles reporting
expert opinion or original data about the validity of behavioral and/or
physiologic indicators of pain in TBI patients were considered. For each article
included, the quality of findings/clinical recommendations was graded
independently by two raters using SORT taxonomy. Eight papers were reviewed.
Overall, TBI patients seemed to present a wider range of behavioral reactions to
pain than other adult populations. In addition to the commonly observed grimace,
agitation, and increased muscle tension, 14%-72% of TBI patients showed raising
eyebrows, opening eyes, weeping eyes, and absence of muscle tension when exposed
to pain. Those atypical reactions appeared to be present only in the acute phase
of TBIs recovery. Similarly to other populations, vital signs were identified as
potential indicators of pain in TBI patients. Further research studying TBI
patients and considering changes in level of consciousness, location/severity of
brain injury, and administration of analgesic/sedative is needed. Until then,
nurses should follow the current clinical recommendations.

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