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Three Part Question

In [children] is the [Oucher better than CHEOPS] at [assessing pain]?

Clinical Scenario

A 3 year old child comes into casualty and you need to assess their pain. Would it be better to use the Oucher scale, a self report measure, or CHEOPS, a behavioural pain measure, as at this age using either seems equally valid.

Search Strategy

Medline 1966-06/03, Cinahl 1982- week 1 06/03 using the OVID interface.
{[oucher.mp. AND cheops.mp.] AND [pain.mp. OR exp pain/]} LIMIT to human AND English language)

Search Outcome

Altogether 12 papers were found. 3 of these addressed the subject indirectly, whilst testing efficacy of analgesia, they are reviewed below.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Beyer JE et al, 1990, USA	25 children aged 3-7 who were given morphine or methadone postoperatively had their pain levels assessed using the CHEOPS, Oucher and the analogue chromatic continuous scales (ACCS)	RCT to assess the effects of giving morphine or methadone post-operatively. All patients had their pain level assessed.	Looked at the postoperative pain scores 2 hourly for 36 hours and the correlation	The Oucher scale and the ACCS were strongly correlated. CHEOPS was only correlated with the Oucher 4/26 times and with ACCS 2/26 times	Sample size not justified, only 25 and at each time point not everyone was assessed, ranges from 6-25 Done postoperatively so may not be applicable generally Pre-op measurement was done 1 to 4 days before, not consistent might forget technique. Order was consistent with CHEOPS then Oucher and then ACCS to prevent the nurses being influenced by the self report scores
Sutters KA et al, 1995, Netherlands	87 children post-tonsillectomy. Children were given either im ketorolac or im saline. All children had their level of pain assessed using CHEOPS and the Oucher scale, if they were able	RCT for treatment group. All patients had their level of pain assessed	Changes in these scores over time	The Oucher proved statistically more sensitive to changes in pain levels over time	Does not include ages of children even though it states that the CHEOPS has thus been shown to be less reliable in older children Does not say why children couldn't complete the Oucher Does not say whether the 2 assessments were done by independent people
			CHEOPS score and Oucher scores post analgesia	Not all children could complete the Oucher scale post operatively
Jacobson SJ et al, 1997, England	56 children aged 5-17 One group received IV morphine plus placebo and the other oral morphine plus placebo Both groups were assessed for their pain using the CHEOPS, Oucher scale, Faces scale and a five point clinical assessment scale	RCT (with respect to allocation to morphine treatment group). All patients were pain scaled	Relation between the pain scales presented by use of a Pearson's correlation and linear regression coefficient	All pain scales correlated significantly	Little information about the pain scales Does not say if they used the Oucher picture or numerical scale Does not tell you if any were unable to use the Oucher scale There was a single investigator for assessing pain and this may have introduced bias Does not tell you the order of presentation of the pain scales and if this was random Uses the CHEOPS in an older age range than it was designed for

Comment(s)

The underlying question is whether pain behaviour tools (such as CHEOPS) or self report tools (such as Oucher) are more useable and valid in the assessment of pain in children capable of assessment by both methods. None of the papers addressed the question directly. There seems to be some disagreement as to whether the CHEOPS score correlates to the Oucher score or not. Jacobson et al states that they are correlated, but this may be unreliable as CHEOPS was used in an older age range than was intended. Sutters et al state that CHEOPS is less reliable in older children, though they do not support this with any evidence. The Beyer study uses the two scales in the correct age range but the study is small and conducted postoperatively and general applicability is therefore moot. Further studies using a larger sample of patients in a wide range of clinical situations are needed.

Clinical Bottom Line

There is no evidence to show whether Oucher or CHEOPS is better at assessing pain in children. Local policy should be followed.

References

1. Beyer JE, McGrath PJ, Berde CB. Discordance between self-report and behavioural pain measures in children aged 3-7 years after surgery. J of Pain and Symptom Management 1990;5(6):350-6.
2. Sutters KA, Levine JD, Dibble S, et al. Analgesic efficacy and safety of single dose intramuscular ketorolac for postoperative pain management in children following tonsillectomy. Pain 1995;61(1):145-53.
3. Jacobson SJ, Kopecky EA, Joshi P, et al. Randomised trial of oral morphine for painful episodes of sickle-cell disease in children. Lancet 1997;350(9088):1358-61.