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Non-steroidal or opioid analgesia use for children with musculoskeletal injuries (the No OUCH study): statistical
Anna Heath1,2,3, Maryna Yaskina4, Gareth Hopkin5
1Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada. anna.heath@sickkids.ca.
Insights
This study analyzes pain management for pediatric limb injuries in the emergency department. It compares ibuprofen alone, with acetaminophen, or with hydromorphone to find the most effective pain relief.
Area of Science:
- Emergency medicine
- Pediatric pain management
- Musculoskeletal injuries
Background:
- Pediatric musculoskeletal injuries cause significant pain, often requiring emergency department (ED) care.
- Current ED pain management for children is frequently suboptimal despite research efforts.
- The No OUCH study addresses this by comparing different analgesic strategies in pediatric patients with acute limb injuries.
Purpose of the Study:
- To detail the statistical analysis plan for the No OUCH study, a randomized controlled trial.
- To evaluate the effectiveness of ibuprofen alone, ibuprofen with acetaminophen, and ibuprofen with hydromorphone for pediatric acute limb injury pain.
- To ensure unbiased analysis by pre-defining the statistical methods before trial outcomes are known.
Main Methods:
- Two complementary randomized, placebo-controlled trials involving pediatric patients (pain score ≥5/10).
- Caregiver choice determines randomization to a two-arm (ibuprofen vs. ibuprofen/acetaminophen) or three-arm (ibuprofen/acetaminophen vs. ibuprofen/hydromorphone) trial.
- Primary endpoint: self-reported pain at 60 minutes via verbal numerical rating scale (vNRS); safety outcomes include adverse events.
Main Results:
- The study's statistical analysis plan is detailed herein; results are pending.
- Primary effectiveness endpoint: pain reduction at 60 minutes using vNRS.
- Secondary endpoints include pain scores (Faces Pain Scale-Revised, visual analog scale), time to analgesia, rescue analgesic use, and safety assessments.
Conclusions:
- The No OUCH study will provide crucial data on the comparative effectiveness of non-opioid and opioid-containing analgesic regimens for pediatric acute limb injuries.
- Analysis according to this plan will minimize bias and data-driven results.
- Findings will inform optimal pain management strategies in the emergency department setting.
Background:
Pediatric musculoskeletal injuries cause moderate to severe pain, which should ideally be addressed upon arrival to the emergency department (ED). Despite extensive research in ED-based pediatric pain treatment, recent studies confirm that pain management in this setting remains suboptimal. The No OUCH study consist of two complementary, randomized, placebo-controlled trials that will run simultaneously for patients presenting to the ED with an acute limb injury and a self-reported pain score of at least 5/10, measured via a verbal numerical rating scale (vNRS). Caregiver/parent choice will determine whether patients are randomized to the two-arm or three-arm trial. In the two-arm trial, patients will be randomized to receive either ibuprofen alone or ibuprofen in combination with acetaminophen. In the three-arm trial, patients can also be randomized to a third arm where they would receive ibuprofen in combination with hydromorphone. This article details the statistical analysis plan for the No OUCH study and was submitted before the trial outcomes were available for analysis.
Methods/Design:
The primary endpoint of the No OUCH study is self-reported pain at 60 min, recorded using a vNRS. The principal safety outcome is the presence of any adverse event related to study drug administration. Secondary effectiveness endpoints include pain measurements using the Faces Pain Scale-Revised and the visual analog scale, time to effective analgesia, requirement of a rescue analgesic, missed fractures, and observed pain reduction using different definitions of successful analgesia. Secondary safety outcomes include sedation measured using the Ramsay Sedation Score and serious adverse events. Finally, the No OUCH study investigates the reasons given by the caregiver for selecting the two-arm (Non-Opioid) or three-arm (Opioid) trial, caregiver satisfaction, physician preferences for analgesics, and caregiver comfort with at-home pain management.
Discussion:
The No OUCH study will inform the relative effectiveness of acetaminophen and hydromorphone, in combination with ibuprofen, and ibuprofen alone as analgesic agents for patients presenting to the ED with an acute musculoskeletal injury. The data from these trials will be analyzed in accordance with this statistical analysis plan. This will reduce the risk of producing data-driven results and bias in our reported outcomes.
Trial Registration:
ClinicalTrials.gov NCT03767933 . Registered on December 7, 2018.
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