Assessing Pain Behaviors in Healthy Subjects Using the Critical-Care Pain Observation Tool (CPOT): A Pilot Study


      The Critical-Care Pain Observation Tool (CPOT) is a behavioral scale recommended by experts for pain assessment in critically ill patients unable to verbally communicate. The main goal of this study was to determine the relationship between self-reports of pain intensity and the CPOT score, and establish the sensibility and the specificity of the CPOT to different levels of pain intensity in healthy subjects. A total of 18 healthy subjects participated in the study (mean age = 37.8 years). All subjects underwent a 2 minutes noxious cold pressor test (CPT) at 7°C. Verbal pain ratings were obtained with a visual analog scale (0-100) while pain behaviors were videotaped. Afterwards, 2 independent evaluators quantified pain behaviors using the CPOT. Interrater reliability was supported with an ICC of 0.963 (95%CI [0.904-0.986]). A moderate positive correlation between the CPOT scores and self-reports of pain intensity during the CPT was found (r = 0.52, p = 0.028). Such result indicates that subjects reporting high level of pain showed a higher number or more intense pain behaviors. A cut-off score >2.5/8 on the CPOT led to a sensibility of 64% and a specificity of 86%. Results from this pilot study support that an increase of CPOT score is correlated with moderate to high levels of pain intensity and further support the clinical use of the CPOT.


      This article presents the psychometric properties of a behavioral pain scale called the CPOT which was developed to assess pain in critically ill adults unable to self-report. Our results in healthy subjects showed that the CPOT behavioral score is significantly correlated with the self-report of pain intensity and supports its clinical use.

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        • Gelinas C.
        • Fillion L.
        • Puntillo K.A.
        • Viens C.
        • Fortier M.
        Validation of the critical-care pain observation tool in adult patients.
        Am J Crit Care. 2006; 15: 420-427
        • Gelinas C.
        • Johnston C.
        Pain assessment in the critically ill ventilated adult: Validation of the Critical-Care Pain Observation Tool and physiologic indicators.
        Clin J Pain. 2007; 23: 497-505
        • Gelinas C.
        • Arbour C.
        Behavioral and physiologic indicators during a nociceptive procedure in conscious and unconscious mechanically ventilated adults: similar or different?.
        J Crit Care. 2009; 24 (628.e7-17)
        • Gelinas C.
        • Harel F.
        • Fillion L.
        • Puntillo K.A.
        • Johnston C.C.
        Sensitivity and specificity of the critical-care pain observation tool for the detection of pain in intubated adults after cardiac surgery.
        J Pain Symptom Manage. 2009; 37: 58-67
        • Granot M.
        • Weissman-Fogel I.
        • Crispel Y.
        • Pud D.
        • Granovsky Y.
        • Sprecher E.
        • Yarnitsky D.
        Determinants of endogenous analgesia magnitude in a diffuse noxious inhibitory control (DNIC) paradigm: Do conditioning stimulus painfulness, gender and personality variables matter?.
        Pain. 2008; 136: 142-149
        • Herr K.
        • Bjoro K.
        • Decker S.
        Tools for assessment of pain in nonverbal older adults with dementia: A state-of-the-science review.
        J Pain Symptom Manage. 2006; 31: 170-192
        • Herr K.
        • Coyne P.J.
        • Key T.
        • Manworren R.
        • McCaffery M.
        • Merkel S.
        • Pelosi-Kelly J.
        • Wild L.
        Pain assessment in the nonverbal patient: Position statement with clinical practice recommendations.
        Pain Manag Nurs. 2006; 7: 44-52
        • Jensen M.P.
        • Karoly P.
        • Braver S.
        The measurement of clinical pain intensity: A comparison of six methods.
        Pain. 1986; 27: 117-126
        • Julien N.
        • Goffaux P.
        • Arsenault P.
        • Marchand S.
        Widespread pain in fibromyalgia is related to a deficit of endogenous pain inhibition.
        Pain. 2005; 114: 295-302
        • Kunz M.
        • Mylius V.
        • Schepelmann K.
        • Lautenbacher S.
        On the relationship between self-report and facial expression of pain.
        J Pain. 2004; 5: 368-376
        • Kunz M.
        • Prkachin K.
        • Lautenbacher S.
        The smile of pain.
        Pain. 2009; 145: 273-275
        • Li D.
        • Puntillo K.
        • Miaskowski C.
        A review of objective pain measures for use with critical care adult patients unable to self-report.
        J Pain. 2008; 9: 2-10
        • Prkachin K.M.
        • Solomon P.E.
        The structure, reliability and validity of pain expression: Evidence from patients with shoulder pain.
        Pain. 2008; 139: 267-274
        • Puntillo K.A.
        • Morris A.B.
        • Thompson C.L.
        • Stanik-Hutt J.
        • White C.A.
        • Wild L.R.
        Pain behaviors observed during six common procedures: Results from Thunder Project II.
        Crit Care Med. 2004; 32: 421-427
        • Rainville P.
        • Feine J.S.
        • Bushnell M.C.
        • Duncan G.H.
        A psychophysical comparison of sensory and affective responses to four modalities of experimental pain.
        Somatosens Mot Res. 1992; 9: 265-277
        • Sessler C.N.
        • Grap M.J.
        • Ramsay M.A.
        Evaluating and monitoring analgesia and sedation in the intensive care unit.
        Crit Care. 2008; 12: S2
        • Tousignant-Laflamme Y.
        • Goffaux P.
        • Bourgault P.
        • Marchand S.
        Different autonomic responses to experimental pain in IBS patients and healthy controls.
        J Clin Gastroenterol. 2006; 40: 814-820
        • Tousignant-Laflamme Y.
        • Page S.
        • Goffaux P.
        • Marchand S.
        An experimental model to measure excitatory and inhibitory pain mechanisms in humans.
        Brain Res. 2008; 1230: 73-79
        • Tousignant-Laflamme Y.
        • Gelinas C.
        • Bourgault P.
        • Daigle K.
        • Marchand S.
        Assessing pain behaviors in healthy subjects using the Critical-Care Pain Observation Tool (CPOT): A pilot study.
        J Pain. 2009; 10: PS1