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PAIN ASSESSMENTPAIN ASSESSMENTAIM

Dr. Aashish Jain(PTAsst. Prof

MGPC

PAIN ASSESSMENTPAIN ASSESSMENTAND PAIN SCALESAND PAIN SCALES 1. Provide overview of Pain Assessment

2. Describe various methods of pain assessment3. Provide familiarity with various pain scales4. Facilitate the ability to choose appropriate

pain scales for different patient groups5. Assess treatment of pain

Definition of Pain

International Association for the Study of Pain• An unpleasant sensory and emotional

experience arising from actual or potential tissue damage or described in terms of such damage

• Sensory, emotional, cognitive, and behavioral components that are interrelated with environmental, developmental, socio-cultural, and contextual factors

Pain Assessment

• By its very definition, pain is an internal, subjective experience that cannot be directly observed by others or measured by the use of physiologic markers or bioassays.

• The assessment of pain, therefore, relies largely (and in many cases exclusively) upon the use of self-report.

Pain Assessment

• Though the self-report of pain or any other construct is subject to a number of biases, a good deal of effort has been invested in testing and refining self-report methodology within the field of human pain research.

Pain Assessment

• The Joint Commission in the United States has set standards for the assessment of pain in hospitalized patients.

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Pain Assessment• Pain assessment should be ongoing,

individualized, and documented. • Patients should be asked to describe their

pain in terms of the following characteristics: location, radiation, mode of onset, character, temporal pattern, exacerbating and relieving factors, and intensity.

Pain Assessment• Although pain cannot be considered vital,

nor is it a sign, the suggestion that it be routinely measured along with temperature, pulse, blood pressure, and respiratory rate is a powerful reminder to health care providers to attend to their patients' suffering.

Pain Assessment• Unfortunately, simple routine documentation of

pain levels has not been shown in and of itself to lead to any improvement in the quality of pain management. However, proper assessment is still a desirable goal before appropriate treatment.

Assessing Pain• Question the patient• Use pain rating scales• Evaluate behavior & physiologic signs• Secure family’s involvement

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desirable goal before appropriate treatment. • Secure family’s involvement• Take action and assess effectiveness

Assessing Pain• The single most reliable indicator of the

existence and intensity of pain is the patients self-report of pain. The patients' report of pain should be the primary source of information, since it is more accurate than the observations or others.

Assessing PainThe American Pain Society guidelines for the treatment

of acute and cancer pain suggest that each of the following assessment steps occur.

• The patient's self-reported pain is charted and displayed.

• The intensity of pain and discomfort are assessed and documented at regular intervals (i.e. prior to administration of medication and then after administration of medications)

• The degree of pain intensity is measured after allowing sufficient time to pass in order to ensure that a specific pain intervention treatment has occurred.

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Question The Patient SOCRATES• Obtain a detailed assessment of pain

– HPI, description of pain, experience with pain medications, use of non-pharmacologic techniques, family experience with pain

– Quality, location, duration, intensity, radiation, relieving & exacerbating factors, & associated symptoms

• Use appropriate pain scale– Cognitively impaired adults, Sedated patients Children

• Pain can be multi-dimensional and therefore, tools can be limited

• Directly ask patients and or family when appropriate

• Site - Where is the pain? • Onset - When did the pain start,

was it sudden or gradual? • Character - What is the pain like? • Radiation - Does the pain radiate anywhere? • Associations - Any other signs or symptoms

associated with the pain? • Time course - Does the pain follow any pattern? • Exacerbating/Relieving factors - Does anything

change the pain? • Severity - How bad is the pain?

Question the Patient

• May not be straight forward especially in– Cognitively impaired adults – The learning disabled – Sedated patients in an ICU or operating room

setting– Children

Use Pain Rating Scales

• Select a scale that is suitable for the patients abilities, age, and preferences

• Teach patient to use scale before pain is expected, such as preoperatively

• Use same scale with the patient each time pain is assessed

Types of Pain Rating Scales

• Single Dimensional Scales– Visual Analog Scale (VAS)– Numerical Rating Scale (NRS)– Verbal Descriptor Scale(s) (VDS)

Types of Pain Rating Scales

• Multidimensional Scales– McGill Pain Questionnaire– Short-Form McGill Pain Questionnaire– Brief Pain Inventory– Scales for Neuropathic Pain

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Visual Analog ScaleVisual Analog Scale

Visual Analog Scale• The VAS is most commonly a straight 100-mm line

without demarcations that has the words “no pain” at the left-most end and “worst pain imaginable”(or something similar) at the right-most end.

• Benefits of the VAS is that it has been validated and shown to be sensitive to changes in a patient's pain experience.

• It is quick to use and relatively easy to understand for most patients.

• It avoids the imprecise use of descriptive words to describe pain and allows a meaningful comparison of measurements over time.

Visual Analog Scale• Disadvantages of the VAS is that it attempts to

assign a single value to a complex, multidimensional experience.

• Some patients have trouble deciding how to represent their pain sensation. They often have no real concept of what “worst pain imaginable” actually means because every experience of pain is different.

• It has a false ceiling at the upper-most end. If a patient later time decides that the pain has become worse, the patient has no way to document this change if it was already at maximum.

Verbal Descriptive Scale• The verbal descriptor scale is a list of words, ordered in

terms of severity from least to most, that describe the amount of pain that a patient may be experiencing.

• Patients are asked to either circle or state the word that best describes their pain intensity at that moment in time.

• The benefits of VDS instruments are that they have been validated and are simple for patients to understand and quick to use.

• A disadvantage is that a VDS forces patients to select words that are not of their own choosing to describe their pain. – Changes in pain over time are difficult to interpret and probably have

different meanings to each individual.– This may especially be a problem with the VDS when only a limited number

of possible choices are offered to the patient (i.e. only four to six words).

Verbal Descriptive Scale Numerical Rating Pain Scale

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Numerical Rating Pain Scale Numerical Rating Pain Scale The Numerical Rating Pain Scale allows the • The numerical rating scale offers the individual in pain

to rate their pain score. • It is designed to be used by those over the age of 9. • In the numerical scale, the user has the option to

verbally rate their scale from 0 to 10 or to place a mark on a line indicating their level of pain. – 0 indicates the absence of pain, while 10 represents

the most intense pain possible.

• The Numerical Rating Pain Scale allows the healthcare provider to rate pain as mild, moderate or severe, which can indicate a potential disability level.

• Attempts have been made to define what is considered a meaningful change in the NRS. – At least a 30% reduction or an absolute

reduction in the value of at least 2 has been suggested as representing meaningful pain relief to patients

Numerical Rating Pain Scale • Disadvantages of the NRS and VNS are similar to

those of the VAS in that they attempt to assign a single number to the pain experience.

• They also have the same ceiling effect in that if a value of “10” is chosen and the pain worsens, the patient officially has no way to express this change.

• In practice, at least with the VNS, patients often rate their pain as some number higher than 10 (e.g., “15 out of 10”) in an attempt to express their extreme level of pain intensity.

• The Wong Baker Faces Pain Scale combines pictures and numbers to allow pain to be rated by the user.

• It can be used in children over the age of 3, and in adults.

• The faces range from a smiling face to a sad, crying face.

• A numerical rating is assigned to each face, of which there are 6 total.

Wong Baker Faces Pain Scale

0 2 4 6 8 10

Wong Baker Faces Pain Scale

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McGill Pain Questionnaire (MPQ)• The MPQ and its brief analog, the short-form MPQ , are

among the most widely used measures of pain. • In general, the MPQ is considered to be a

multidimensional measure of pain quality; however, it also yields numerical indices of several dimensions of the pain experience.

• Researchers have proposed three dimensions of the experience of pain: sensory-discriminative, affectivemotivational, and cognitive-evaluative. – The MPQ was created to assess these multiple aspects of pain.

McGill Pain Questionnaire• The McGill Pain Questionnaire consists of

groupings of words that describe pain. • The person rating their pain ranks the words in

each grouping. Some examples of the words used are tugging, sharp and wretched.

• Once the person has rated their pain words, the administrator assigns a numerical score, called the Pain Rating Index.

• Groups 1-10 = Somatic in nature• Groups 11-15 = Affective • Group 16 = Evaluative• Group 17-20 = Miscellaneous words that

are used in the scoring process.

McGill Pain Questionnaire

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McGill Pain Questionnaire• The benefits of the MPQ are that it is valid, reliable, and

Short-Form McGill Pain Questionnaire• The more frequently used short form of the MPQ • The benefits of the MPQ are that it is valid, reliable, and

consistent in its ability to assign seemingly appropriate descriptions to a given pain experience.

• The MPQ may be able to discriminate between different types of pain syndromes. Moreover, it has been shown to be sensitive to changes in the amount of pain experienced by patients in response to receiving various analgesic therapies in both the acute and chronic setting.

• One disadvantage of the MPQ is its length. The MPQ should take from 5 to 15 minutes to complete, which for some patients may be seen as more trouble than it is worth.

• In addition, this amount of time is prohibitive for use on a repeated basis over a short period (e.g., in a clinical acute pain setting).

• The more frequently used short form of the MPQ consists of 15 representative words that form the sensory (11 items) and affective (4 items) categories of the original MPQ.

• Each descriptor is ranked on a 0 (“none”) to 3(“severe”) intensity scale. The PPI, along with a VAS, are also included. The short form correlates highly with the original scale, can discriminate among different pain conditions, and may be easier than the original scale for geriatric patients to use.

Short-Form McGill Pain Questionnaire Special Populations

• Common populations that are challenging to assess pain– Children – Cognitively impaired adults – Adults whose cognition is temporarily impaired, by

medication or illness – The learning disabled – Sedated patients in an ICU or operating room setting

• Facial expressions (grimacing)– Less obvious: slight frown, rapid blinking, sad/frightened, any

distortion

• Vocalizations (crying, moaning, groaning) – Less obvious: grunting, chanting, calling out, noisy breathing, asking

for help

• Body movements (guarding)– Less obvious: rigid, tense posture, fidgeting, pacing, rocking, limping,

resistance to moving

Nonverbal Pain IndicatorsPhysiological Indications of

Acute Pain• Dilated pupils• Increased perspiration• Increased rate/ force of heart rate• Increased rate/depth of respirations• Increased blood pressure• Decreased urine output• Decreased peristalsis of GI tract

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• Increased basal metabolic rate

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Possible Physiologic Signs of PainPossible Physiologic Signs of

Pain• ↓ Pallor or flushing• Diaphoresis, palmar sweating• ↓O2 saturation• ↓ Vagal tone• EEG changes

Possible Signs of Pain in the Cognitively impaired

• Groaning, Crying • Changes in sleep/wake cycles• Changes in activity level• Agitation• Rigidity• Clenching of fists

Observe for Specific Behaviors that Indicate Local Body Pain

• Rolling head from side to side• Lying on side with legs flexed on

abdomen• Limping• Refusing to move a body part

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Multidimensional Model of Pain Multidimensional Model of Pain AssessmentAssessment Dolorimetery

• Dolorimetry has been defined as "the measurement of pain sensitivity or pain intensity.“

• A dolorimeter is an instrument used to measure pain threshold and pain tolerance.

• Introduced in 1940 by James D. Hardy of Cornell University• There are several kinds of dolorimeters that have been

developed. • Dolorimeters apply steady pressure, heat, or electrical stimulation

to some area, or move a joint or other body part and determine what level of heat or pressure or electric current or amount of movement produces a sensation of pain. movement produces a sensation of pain.

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Dolorimeters Pediatric Pain

• Barriers are often present and include:– Belief that children, especially infants, do not feel

pain the way adults do– Lack of routine pain assessment – Lack of knowledge in pain treatment– Belief that preventing pain in children takes too

much time and effort

Pediatric Pain• Well documented that children are often

undertreated for pain• Specifically in neonates:

– Studies show that neonates can experience pain by 26 weeks of gestation

• Mature afferent pain transmission

– Untreated pain in neonates lead to increased distress and altered pain response in the future

• Historically children and infants received less post-operative analgesia than adults

Assessment in Children, Neonates & Infants

• Challenging • Combines physiologic and behavioral

parameters• Many scales available

Possible Signs of Pain in Neonate: Behavioral Variables, cont.

Facial expression (most reliable sign):• Eyes tightly closed or opened• Mouth opened, squarish• Furrowing or bulging of brow• Quivering of chin• Deepened nasolabial fold

Facial Expression of Physical DistressFacial Expression of Physical Distress

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NASO-LABIAL FOLDdeepened

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Children with Cognitive Impairment Question

• Often unable to describe pain• Altered nervous system and experience pain

differently• Use behavioral observation scales • Can apply to intubated patients• Must use appropriate observational scales

• Which of the following is indicative of pain in a neonate receiving a circumcision?A. A Decrease in insulinB. Decrease in O2 SaturationC. Vigorous withdrawal to painD. Decrease in transcutaneous PCO2E. Bradycardia

Pediatric Pain Scales

• Neonates, infants, toddlers (<3 years)– Pain assessment it largely observational

• Cannot distinguish between pain, fear, anxiety, distress

– Examples of pain scales in this population: • CRIES, PIPP, FLACC, Comfort

Pediatric Pain Scales

• Toddlers to school age children (3 -8)– Self Report Scales

• Visual Analog (VAS): Age 5+• Faces/Oucher Scale/ Wong- Baker: Age 3+

– Observational Scales• FLACC: Age 2 mos- 7 years• CHEOPS scale age 1-7 years

• The COMFORT Scale is a behavioral, unobtrusive pain scale that may be used by a healthcare provider when a person cannot describe or rate their pain. – Unconscious and ventilated infants, children and adolescents.

• This scale has eight indicators (categories)• Validated for newborn to 3 years old

– Reported use of up to 17 years old

• The COMFORT Scale provides a pain rating between 9 and 45– 17-26 generally indicates adequate sedation and pain control.

COMFORT Observer Pain Scale

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CRIES Pain Scale

The CRIES Pain Scale is often used in the • The CRIES Pain Scale is often used in the neonatal healthcare setting.

• CRIES is an observer-rated pain assessment tool which is performed by a healthcare practitioner such as a nurse or physician.

• CRIES assesses crying, oxygenation, vital signs, facial expression and sleeplessness.

• The CRIES Pain Scale is generally used for neonates, from 32 weeks gestation to 6 months old.

CRIES Observer Pain Scale

FLACC Pain Scale

• FLACC stands for face, legs, activity, crying and consolability. • It is an observer rated pain scale, performed by a healthcare

practitioner such as a doctor or a nurse. • The FLACC pain scale was designed for neonates at 2 months,

may be useful up to 7 years of age. – However, some practitioners in adult settings may use the FLACC pain

scale for people who are unable to communicate their pain.

• FLACC provides a pain assessment scale between 0 and 10.

FLACC scale

Children's Hospital of Eastern Ontario Pain Scale (CHEOPS)

• The CHEOPS (Children's Hospital of Eastern Ontario Pain Scale) is a behavioral scale for evaluating postoperative pain in young children.

• Six items: Cry, Facial, Child Verbal, Torso, Touch, and Legs• It can be used to monitor the effectiveness of interventions for reducing

the pain and discomfort.• Patients:

– The initial study was done on children 1 to 5 years of age.– According to Furnish (2013) it is intended for ages 1-7. – It has been used in studies with adolescents but this may not be an

appropriate instrument for that age group.

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Oucher Scale

• Available in three ethnic versions• Suitable for a 3-7 years of age• Empowers the child to express pain

experience• May reflect mood instead of pain

White child, 3 yearWhite child, 3 year--old male old male Black child, 3 yearBlack child, 3 year--old male old male Hispanic chilHispanic child, 3 yeard, 3 year--old maleold male

Oucher Photographic / Numeric Pain Scale Oucher Photographic / Numeric Pain Scale

Premature Infant Pain Profile (PIPP)

• Developed at the Universities of Toronto and McGill in Canada.

• Used for infants less than 36 weeks gestation• Scores <6= minimum Pain, 6-12 = mild-moderate Pain, >12 =

moderate to severe pain• Scoring instructions:

– Score gestational age before examining infant.– Score the behavioral state before the potentially painful event by observing

the infant for 15 seconds . – Record the baseline heart rate and oxygen saturation. – Observe the infant for 30 seconds immediately following the painful event. – Score physiologic and facial changes seen during this time and record

immediately.

Neonatal Infant Pain Scale (NIPS)

• The Neonatal Infant Pain Scale (NIPS) is a behavioral scale and can be utilized with both full-term and pre-term infants. – From birth to one year of age

• The tool was adapted from the CHEOPS scale and uses the behaviors that nurses have described as being indicative of infant pain or distress.

Neonatal Infant Pain Scale (NIPS)

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Neonatal Infant Pain Scale (NIPS) N-PASS: Neonatal Pain, Agitation and Sedation Scale

• Total pain scores range from 0 -7. The suggested interventions based upon the infant's level of pain are listed below.

• The difficulty with any tool that is not self report is the ability to differentiate between pain and agitation, however, the non-pharmacological intervention may help differentiate between these two (i.e. changing the wet diaper, feeding the infant, repositioning, etc).

Children between 3Children between 3--8 years 8 years

Usually have a word for painUsually have a word for painCan articulate more detail about the Can articulate more detail about the

presence and location of pain; less presence and location of pain; less able to comment on quality or able to comment on quality or intensityintensity

Examples:Examples:Color scalesColor scalesFaces scalesFaces scales

Children older than 8 yearsChildren older than 8 years

Use the standard visual analog scaleUse the standard visual analog scaleSame used in adultsSame used in adults

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Question

• A pain physician is concerned that a patient's pain may be neuropathic in nature. An appropriate screening tool to assess for this is:A. Numeric Rating ScaleB. Visual Analog ScaleC. McGill Pain QuestionaireD. painDETECT

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Neuropathic Pain Scale

• The Neuropathic Pain Scale (NPS) has been described (Galer and Jensen, 1997) and attempted to discriminate between four diagnostic categories of neuropathic pain using single descriptors.

• Only post-herpetic neuralgia could be distinguished from the other diagnostic groups (reflex sympathetic dystrophy, diabetic neuropathy and peripheral nerve injury).

Neuropathic Pain Scale

Neuropathic Pain Scale The Leeds Assessment of Neuropathic Symptoms and Signs(LANSS) Pain Scale

painDETECT

• A new screening questionnaire to identify neuropathic components in patients with back pain.

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Pain Assessment tools for children and adults with intellectual disabilities

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Steps to take after treatment has started Secure Family’s Involvement• Secure Family’s Involvement• Observe for Improvement in Behavior

Following an Analgesic• Take action & assess effectiveness• Anticipate & Prevent Pain

• Take pain history before pain is expected, such as on admission to hospital or preoperatively

• Involve family in recording response to pain relief measures

Take action & assess effectiveness

• Anticipate & prevent pain• Adequately assess pain• Use multi-modal approach• Involve parents and family when available

• After intervention, assess a patients response to pain relief measures.

• Determine timing of assessment based on expected onset and peak effect of intervention

Take action & assess effectiveness

Anticipate & Prevent Pain

• Prepare patient and family on what to expect• Guide them on ways to minimize pain and

anxiety• Utilize quiet environment • Treat pain prophylactically when anticipated

Observe for Improvement in Behavior Following an Analgesic

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Observe for Improvement in Behavior Following an Analgesic Questions?

THANK YOU

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