Behavior Pain Assessment Tool Can Assess Perceived Pain

The Behavior Pain Assessment Tool can assess pain in critically ill adults and in patients who cannot self-report pain.

The Behavior Pain Assessment Tool (BPAT) is a brief, reliable, and valid tool for assessing pain in critically ill adults and in patients who cannot self-report pain, according to a study published in Pain.1

While many patients who are critically ill may have altered levels of consciousness or be mechanically ventilated, they can still perceive pain. Their clinical condition, however, often prevents them from talking to their healthcare providers about their pain. Vital signs, such as heart rate and blood pressure changes do not provide an adequate or reliable assessment of pain. Although pain assessment tools—such as the Behavioral Pain Scale and the Critical-Care Pain Observation Tool—have been validated for use in adult patients in the intensive care unit (ICU), these tools require interpretation of observed behaviors and training to ensure the reliability of the findings.1,2

In response to the complexity of validated pain assessment tools, researchers developed the BPAT, an 8-item tool that evaluates pain based on the presence of certain behaviors.1,3 In the current study, the researchers sought to validate the BPAT in the adult ICU population in a psychometric analysis of the Europain® study.

A total of 4812 procedures were performed in 3851 patients, over one-third of whom were mechanically ventilated or had a tracheotomy. The most common procedures consisted in turning the patient from supine to prone (or prone to supine) and endotracheal suctioning.

Each patient was assessed by 2 clinicians — primarily physicians and nurses — and patients who could communicate were asked to report their pain using numeric pain scales ranging from 0 to 10, with 10 indicating the highest level of intensity or distress.

Interrater reliability was moderate-to-excellent, with a concordance of more than 80%. Most behaviors (eg, grimace, moaning, or clenched fists) were more likely to be present during, rather than before, the procedure in patients who were less sedated.

BPAT scores had moderate positive correlations with pain distress and pain intensity scores. All 8 behaviors assessed showed significant associations with pain intensity and pain distress.

BPAT scores >3.5 indicated severe pain intensity and distress with a sensitivity and specificity that ranged from 61.8% to 75.1%.

Summary and Clinical Applicability

Managing pain in patients admitted to the ICU is challenging due to the inability of many patients to self-report pain. While validated pain assessment tools exist for use in this population, their administration is often complex. Researchers developed a brief, 8-item BPAT to address the need for a simple pain assessment tool in this population.

“The BPAT was found to be reliable and valid in this population and context. Its validation in heterogeneous patients in several ICUs from several countries provides a high degree of generalizability to our findings,” the researchers wrote.

“Implementation studies with the BPAT are needed to determine the effects of its use on ICU pain management practices and patient outcomes,” they added.


The BPAT does not include any items concerning patient compliance with the ventilator.

The reason for ICU admission for each patient was not known, so that it is unclear whether certain medical conditions affected the validity of the BPAT.

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  1. Gélinas C, Puntillo KA, Levin P, Azoulay E. The Behavior Pain Assessment Tool for critically ill adults: a validation study in 28 countries. [Published online March 24, 2017] Pain. doi: 10.1097/j.pain.0000000000000834
  2. Joffe AM, McNulty B, Boitor M, Marsh R, Gélinas C. Validation of the Critical-Care Pain Observation Tool in brain-injured critically ill adults. J Crit Care. 2016;36:76-80. doi: 10.1016/j.jcrc.2016.05.011
  3. Puntillo KA, Max A, Timsit JF, et al. Determinants of procedural pain intensity in the intensive care unit. The Europain® study. Am J Respir Crit Care Med. 2014;189(1):39-47. doi: 10.1164/rccm.201306-1174OC

This article originally appeared on Clinical Pain Advisor