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Peter Lascarides DO PGY4 PM&R SBUMC / VAMC / SCH

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1 Peter Lascarides DO PGY4 PM&R SBUMC / VAMC / SCH
PAIN ASSESSMENT AND PAIN SCALES Peter Lascarides DO PGY4 PM&R SBUMC / VAMC / SCH

2 AIM Provide overview of Pain Assessment
Describe various methods of pain assessment Provide familiarity with various pain scales Facilitate the ability to choose appropriate pain scales for different patient groups Assess treatment of pain

3 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

4 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.

5 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.

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

7 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.

8 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.

9 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.

10 Assessing Pain Question the patient Use pain rating scales
Evaluate behavior & physiologic signs Secure family’s involvement Take action and assess effectiveness

11 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.

12 Assessing Pain The 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.

13 Question The Patient 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

14 SOCRATES 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?

15 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 a variety of words to describe pain, such as owie, boo-boo, ouch, hurt, ow ow Know words in other languages Spanish: Ay ay, duele, lele, dolor

16 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

17 Types of Pain Rating Scales
Single Dimensional Scales Visual Analog Scale (VAS) Numerical Rating Scale (NRS) Verbal Descriptor Scale(s) (VDS)

18 Types of Pain Rating Scales
Multidimensional Scales McGill Pain Questionnaire Short-Form McGill Pain Questionnaire Brief Pain Inventory Scales for Neuropathic Pain

19 Visual Analog Scale

20 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.

21 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.

22 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).

23 Verbal Descriptive Scale

24 Numerical Rating Pain Scale

25 Numerical Rating Pain Scale
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.

26 Numerical Rating Pain Scale
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

27 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.

28 Wong Baker Faces Pain Scale
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.

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30 Wong Baker Faces Pain Scale

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32 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. 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.

33 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.

34 McGill Pain Questionnaire
Groups 1-10 = Somatic in nature Groups = Affective Group 16 = Evaluative Group = Miscellaneous words that are used in the scoring process.

35 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.

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37 McGill Pain Questionnaire
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). 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.

38 Short-Form McGill Pain Questionnaire
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. 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.

39 Short-Form McGill Pain Questionnaire
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.

40 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

41 Nonverbal Pain Indicators
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

42 Physiological 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 Increased basal metabolic rate

43 Possible Physiologic Signs of Pain
 Pallor or flushing Diaphoresis, palmar sweating  O2 saturation  Vagal tone EEG changes

44 Possible Physiologic Signs of Pain

45 Possible Signs of Pain in the Cognitively impaired
Groaning, Crying Changes in sleep/wake cycles Changes in activity level Agitation Rigidity Clenching of fists

46 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

47 Multidimensional Model of Pain Assessment
47

48 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.

49 Dolorimeters

50 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

51 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

52 Assessment in Children, Neonates & Infants
Challenging Combines physiologic and behavioral parameters Many scales available

53 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

54 Facial Expression of Physical Distress
NASO- LABIAL FOLD deepened 54

55 Children with Cognitive Impairment
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

56 Question Which of the following is indicative of pain in a neonate receiving a circumcision? A Decrease in insulin Decrease in O2 Saturation Vigorous withdrawal to pain Decrease in transcutaneous PCO2 Bradycardia Answer B

57 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

58 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

59 COMFORT Observer Pain Scale
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.

60 60

61 CRIES Pain Scale 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.

62 CRIES Observer Pain Scale
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63 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.

64 FLACC scale

65 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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67 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

68 Oucher Photographic / Numeric Pain Scale
White child, 3 year-old male Black child, 3 year-old male Hispanic child, 3 year-old male 68

69 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.

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71 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.

72 Neonatal Infant Pain Scale (NIPS)

73 Neonatal Infant Pain Scale (NIPS)
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).

74 N-PASS: Neonatal Pain, Agitation and Sedation Scale

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76 Children between 3-8 years
Usually have a word for pain Can articulate more detail about the presence and location of pain; less able to comment on quality or intensity Examples: Color scales Faces scales 76

77 Children older than 8 years
Use the standard visual analog scale Same used in adults 77

78 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: Numeric Rating Scale Visual Analog Scale McGill Pain Questionaire painDETECT

79 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).

80 Neuropathic Pain Scale

81 Neuropathic Pain Scale

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

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

84 Pain Assessment tools for children and adults with intellectual disabilities

85 Steps to take after treatment has started
Secure Family’s Involvement Observe for Improvement in Behavior Following an Analgesic Take action & assess effectiveness Anticipate & Prevent Pain

86 Secure Family’s Involvement
Take pain history before pain is expected, such as on admission to hospital or preoperatively Involve family in recording response to pain relief measures

87 Take action & assess effectiveness
Anticipate & prevent pain Adequately assess pain Use multi-modal approach Involve parents and family when available

88 Take action & assess effectiveness
After intervention, assess a patients response to pain relief measures. Determine timing of assessment based on expected onset and peak effect of intervention

89 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

90 Observe for Improvement in Behavior Following an Analgesic

91 Observe for Improvement in Behavior Following an Analgesic

92 Questions?

93 References International Association for the Study of Pain: Pain Definitions [cited 10 Sep 2011]. "Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage" Derived from Bonica JJ. The need of a taxonomy. Pain. 1979;6(3):247–8. doi: / (79) PMID Turk DC, Dworkin RH. What should be the core outcomes in chronic pain clinical trials?. Arthritis Res. Ther ;6(4):151–4. doi: /ar1196. PMID Hart RP, Wade JB, Martelli MF. Cognitive impairment in patients with chronic pain: the significance of stress. Curr Pain Headache Rep. 2003;7(2):116–26. doi: /s PMID Bruehl S, Burns JW, Chung OY, Chont M. Pain-related effects of trait anger expression: neural substrates and the role of endogenous opioid mechanisms. Neurosci Biobehav Rev. 2009;33(3):475–91. doi: /j.neubiorev PMID


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