Original Article|Articles in Press

Pain Behaviors Analyzed by Videorecording in Brain-Injured Patients Admitted to the Intensive Care Unit

Published:August 31, 2022DOI:



      To describe and classify pain behaviors (facial and body) in brain-injured patients with a low level of consciousness before, during, and after the performance of painful and non-painful care procedures.


      Facial behaviors and body movements in brain-injured patients were videotaped at rest, during the application of three care procedures (two painful and one non-painful), and 15 minutes after completion of these procedures. Each video recording was evaluated by expert evaluators blinded to each other. For each of the behaviors observed, all possible combinations between the three procedures and/or time were compared using the McNemar test. Effect size was measured by the difference in proportions using the Wilson score 95% confidence intervals.


      Twenty-seven patients were included. The mean (standard deviation) Glasgow Coma Score was 5.4 (1.9). A total of 33 behaviors (29 active, four neutral) were registered. Expression of behaviors was more common during the painful procedures compared with the other time points (non-painful procedures, baseline, and final evaluation). Inter-evaluator agreement was substantial (Kappa index >0.7) in more than 50% of the observed behaviors.


      In this study involving brain-injured patients with a low level of consciousness, facial, body, and ventilation-related behaviors were more common during painful procedures. Agreement between evaluators to detect the presence or absence of these behaviors was substantial. These findings underscore the need to develop pain assessment measures specific to this patient population.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Pain Management Nursing
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Arbour C.
        • Choiniere M.
        • Topolovec-Vranic J.
        • Loiselle C.G.
        • Puntillo K.
        • Gelinas C.
        Detecting pain in traumatic brain injured patients with different levels of consciousness during common procedures in the ICU: Typical or atypical behaviors?.
        Clinical Journal of Pain. 2014; 30: 960-969
        • Arias-Rivera S.
        • López-López C.
        • Frade-Mera M.J.
        • Via-Clavero G.
        • Rodríguez-Mondéjar J.J.
        • Sánchez-Sánchez M.M.
        • Acevedo-Nuevo M.
        • Dil-Castillejos D.
        • Robleda G.
        • Cachón-Pérez M.
        • Latorre-Marco I.
        • Equipo ASCyD
        Assessment of analgesia, sedation, physical restraint and delirium in patients admitted to Spanish intensive care units. Proyecto ASCyD.
        Enfermeria Intensiva. 2020; 31: 3-18
        • Baker S.P.
        • O'Neill B.
        • Haddon Jr, W.
        • Long W.B.
        The injury severity score: A method for describing patients with multiple injuries and evaluating emergency care.
        Journal of Trauma. 1974; 14: 187-196
        • Chatelle C.
        • De Val M.D.
        • Catano A.
        • Chaskis C.
        • Seeldrayers P.
        • Laureys S.
        • Biston P.
        • Schnakers C.
        Is the Nociception Coma Scale-Revised a useful clinical tool for managing pain in patients with disorders of consciousness?.
        Clinical Journal of Pain. 2016; 32: 321-326
        • Chatelle C.
        • Majerus S.
        • Whyte J.
        • Laureys S.
        • Schnakers C.
        A sensitive scale to assess nociceptive pain in patients with disorders of consciousness.
        Journal of Neurology, Neurosurgery, and Psychiatry. 2012; 83: 1233-1237
        • Dehghani H.
        • Tavangar H.
        • Ghandehari A.
        Validity and reliability of behavioral pain scale in patients with low level of consciousness due to head trauma hospitalized in intensive care unit.
        Archives of Trauma Research. 2014; 3: 18608
        • Devlin J.W.
        • Skrobik Y.
        • Gelinas C.
        • Needham D.M.
        • Slooter A.J.C.
        • Pandharipande P.P.
        • Watson P.L.
        • Weinhouse G.L.
        • Nunnally M.E.
        • Rochwerg B.
        • Balas M.D.
        • van den Boogaard M.
        • Bosma K.J.
        • Brummel N.E.
        • Chanques G.
        • Denehy L.
        • Drout X.
        • Fraser G.L.
        • Harris J.E.
        • Joffe A.M.
        • Kho M.
        • E
        • Kress J.P.
        • Lanphere J.A.
        • McKinley S.
        • Neufeld K.J.
        • Pisani M.A.
        • Payen J.F.
        • Pun B.T.
        • Puntillo K.A.
        • Riker R.R.
        • Robinson B.R.H.
        • Shehabi Y.
        • Szuita P.M.
        • Winkelman C.
        • Centofanti J.E.
        • Price C.
        • Nikayin S.
        • Misak C.J.
        • Flood P.D.
        • Kiedrowski K.
        • Alhazzani W
        Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU.
        Critical Care Medicine. 2018; 46: e825-e873
        • Echegaray-Benites C.
        • Kapoustina O.
        • Gelinas C.
        Validation of the use of the Critical-Care Pain Observation Tool (CPOT) with brain surgery patients in the neurosurgical intensive care unit.
        Intensive & Critical Care Nursing. 2014; 30: 257-265
        • Feeley K.
        • Gardner A.
        Sedation and analgesia management for mechanically ventilated adults: literature review, case study and recommendations for practice.
        Australian Critical Care: Official Journal of the Confederation of Australian Critical Care Nurses. 2006; 19: 73-77
        • Flexman A.M.
        • Ng J.L.
        • Gelb A.W.
        Acute and chronic pain following craniotomy.
        Current Opinion in Anaesthesiology. 2010; 23: 551-557
        • Gélinas C.
        Pain assessment in the critically ill adult: Recent evidence and new trends.
        Intensive and Critical Care Nursing. 2016; 34: 1-11
        • Gélinas C.
        • Boitor M.
        • Puntillo K.A.
        • Arbour C.
        • Topolovec-Vranic J.
        • Cusimano M.D.
        • Choinière M.
        • Streiner D.L.
        Behaviors indicative of pain in brain-injured adult patients with different levels of consciousness in the intensive care unit.
        Journal of Pain and Symptom Management. 2019; 57: 761-773
        • Gélinas C.
        • Puntillo K.A.
        • Boitor M.
        • Bérubé M.
        • Topolovec-Vranic J.
        • Ramelet A.S.
        • Joffee A.M.
        • Richard-Lalonde M.
        • Bernard F.
        • Streiner D.L.
        Content validation of behaviors and autonomic responses for the assessment of pain in critically ill adults with a brain injury.
        Australian Critical Care. 2018; 31: 145-151
        • Gottschalk A.
        • Yaster M.
        The perioperative management of pain from intracranial surgery.
        Neurocritical Care. 2009; 10: 387-402
        • Helmer L.M.L.
        • Weijenberg R.A.F.
        • de Vries R.
        • Achterberg W.P.
        • Lautenbacher S.
        • Sampson E.L.
        • Lobbezoo F.
        Crying out in pain—A systematic review into the validity of vocalization as an indicator for pain.
        European Journal of Pain. 2020; 24: 1703-1715
        • Irvine K.-A.
        • Clark J.D.
        Chronic pain after traumatic brain injury: Pathophysiology and pain mechanisms.
        Pain Medicine. 2018; 19: 1315-1333
        • Joffe A.M.
        • McNulty B.
        • Boitor M.
        • Marsh R.
        • Gélinas C.
        Validation of the Critical-Care Pain Observation Tool in brain-injured critically ill adults.
        Journal of Critical Care. 2016; 36: 76-80
        • Latorre-Marco I.
        • Acevedo-Nuevo M.
        • Solís-Muñoz M.
        • Hernández-Sánchez L.
        • López-López C.
        • Sánchez-Sánchez M.M.
        • Wojtysiak-Wojcicka M.
        • de Las Pozas-Abril J.
        • Robleda-Font G.
        • Frade-Mera M.
        • De Blas-García R.
        • Górgolas-Ortiz C.
        • De la Figuera-Bayón J.
        • Cavia-García C.
        Psychometric validation of the behavioral indicators of pain scale for the assessment of pain in mechanically ventilated and unable to self-report critical care patients.
        Medicina Intensiva. 2016; 40: 463-473
        • Le Gall J.R.
        • Lemeshow S.
        • Saulnier F
        A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study.
        JAMA. 1993; 270: 2957-2963
        • Lee K.
        • Oh H.
        • Suh Y.
        • Seo W.
        Patterns and clinical correlates of pain among brain injury patients in critical care assessed with the critical care pain observation tool.
        Pain Management Nursing. 2013; 14: 259-267
        • López-López C.
        • Arranz-Esteban A.
        • Arias-Rivera S.
        • Solís-Muñoz M.
        • Pérez-Pérez T.
        • Latorre-Marco I.
        Application of the Behavioral Indicators of Pain Scale in patients with traumatic brain injury.
        Journal of Advanced Nursing. 2020; 76: 1862-1870
        • López-López C.
        • Murillo-Pérez M.A.
        • Morales-Sánchez C.
        • Torrente-Vela S.
        • Orejana-Martín M.
        • García-Iglesias M.
        • Cuenca-Solanas M.
        • Alted-López E.
        Valoración del dolor en la aspiración de secrecciones traqueales en pacientes con traumatismo craneal mediante la Escala de Conductas Indicadoras de Dolor (ESCID).
        Enfermeria Intensiva. 2014; 25: 114-121
        • López-López C.
        • Pérez-Pérez T.
        • Beneit-Montesinos J.V.
        • García-Klepzig J.L.
        • Martinez-Ureta M.V.
        • Murillo-Pérez M.D.A.
        • Torrente-Vela S.A.
        • García-Iglesias M.
        Pain assessment in mechanically ventilated, noncommunicative severe trauma patients.
        Journal of Trauma Nursing. 2018; 25: 49-59
        • Newcombe R.G.
        Improved confidence intervals for the difference between binomial proportions based on paired data.
        Statistics in Medicine. 1998; 17: 2635-2650
        • Nampiaparampil D.E.
        Prevalence of chronic pain after traumatic brain injury: A systematic review.
        JAMA. 2008; 300: 711-719
        • Pardo C.
        • Muñoz T.
        • Chamorro C.
        • Analgesia and Sedation Work Group of SEMICYUC
        Monitorización del dolor. Recomendaciones del grupo de trabajo de analgesia y sedación de la SEMICYUC.
        Medicina Intensiva. 2006; 30: 379-385
        • Pasero C.
        Challenges in pain assessment.
        Journal of Perianesthesia Nursing. 2009; 24: 50-54
        • Poulsen I.
        • Brix P.
        • Andersen S.
        • Westergaard L.
        • Guldager R.
        Pain assessment scale for patients with disorders of consciousness: A preliminary validation study.
        Journal of Neuroscience Nursing. 2016; 48: 124-131
        • Puntillo K.
        • Gélinas C.
        • Chanques G.
        Next steps in ICU pain research.
        Intensive Care Medicine. 2017; 43: 1386-1388
        • Puntillo K.
        • Pasero C.
        • Li D.
        • Mularski R.A.
        • Grap M.J.
        • Erstad B.L.
        • Varkey B.
        • Gilbert H.C.
        • Medina J.
        • Sessler C.N.
        Evaluation of pain in ICU patients.
        Chest. 2009; 135: 1069-1074
        • Puntillo K.A.
        • Max A.
        • Timsit J.F.
        • Vignoud L.
        • Chanques G.
        • Robleda G.
        • Azoulay E
        Determinants of procedural pain intensity in the intensive care unit. The Europain® study.
        American Journal of Respiratory and Critical Care Medicine. 2014; 189: 39-47
        • Raja S.N.
        • Carr D.B.
        • Cohen M.
        • Finnerup N.B.
        • Flor H.
        • Gibson S.
        • Keefe F.J.
        • Mogil J.S.
        • Ringkamp M.
        • Sluka K.A.
        • Song X.J.
        • Stevens B.
        • Sullivan M.D.
        • Tutelman P.R.
        • Ushida T.
        • Vader K.
        The revised International Association for the Study of Pain definition of pain: Concepts, challenges, and compromises.
        Pain. 2020; 161: 1976-1982
        • Roulin M.J.
        • Ramelet A.S.
        Generating and selecting pain indicators for brain-injured critical care patients.
        Pain Management Nursing. 2015; 16: 221-232
        • Roulin M.J.
        • Ramelet A.S.
        Behavioral changes in brain-injured critical care adults with different levels of consciousness during nociceptive stimulation: An observational study.
        Intensive Care Medicine. 2014; 40: 1115-1123
        • Schnakers C.
        • Chatelle C.
        • Majerus S.
        • Gosseries O.
        • De Val M.
        • Laureys S.
        Assessment and detection of pain in noncommunicative severely brain-injured patients.
        Expert Review of Neurotherapeutics. 2010; 10: 1725-1731
        • Sessler C.N.
        • Gosnell M.S.
        • Grap M.J.
        • Brophy G.M.
        • O'Neal P.V
        • Keane K.A.
        • Tesoro E.P.
        • Elswick R.K
        The Richmond Agitation-Sedation Scale: Validity and reliability in adult intensive care unit patients.
        American Journal of Respiratory and Critical Care Medicine. 2002; 166: 1338-1344
        • Teasdale G.
        • Jennett B.
        Assessment of coma and impaired consciousness. A practical scale.
        Lancet. 1974; 2: 81-84