A new assessment tool called the Behavior Pain Assessment Tool (BPAT) provides a way to measure pain in critically ill patients who may be unable to verbally communicate. Many ICU patients might be unable to communicate due to their level of consciousness, mechanical ventilation, sedation, or clinical condition.

“Since none of those conditions precludes the perception of pain, it is essential that clinicians have valid and reliable pain assessment methods,” said Céline Gélinas, RN, PhD, of McGill University, Montreal, and lead author of the recent study published in PAIN.

BPAT measures pain using 8 behavioral cues including facial expressions, verbal responses, and muscle responses. The assessment tool was evaluated during 4800 procedures in 3850 patients hospitalized in 192 ICUs and in 28 countries. Among patients assessed, approximately two-thirds could communicate their pain. In this group, pain was measured using both BPAT and a standard 10-point scale.

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BPAT scores corresponded to the pain ratings of patients who could communicate. Facial grimacing was the most frequent pain behavior observed. Among other pain behaviors were wincing, verbal complaints, and clenched fists. With a cutoff pain point of 3.5, BPAT was able to identify patients who were in need of opioid medications for pain management.

Researchers cautioned that BPAT could explain only one-third of the variation in pain scores and that more research is needed to identify pain behaviors. Nevertheless, the authors conclude that, “The BPAT was found to be reliable and valid for use in critically ill patients unable to self-report. Valid behavioral pain scales are necessary to ensure appropriate assessment of pain and to guide decisions for pain management in this vulnerable population.”


1. Gelinas 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