Pain Assesment

Pain Assesment and Its Characteristic

dr.Nur Surya Wirawan M.kes Sp.An

Characteristic of host-Biological: genetic, sex, endogenous pain control

-Psychological: anxiety, depression, coping, behavior- Cognitive

Disease-History

- Present disease

Environment-Socialization – Lifestyle – Traumas

- Cultural: expectations, upbringing, roles

PAIN

Biopsychological factors that interact and modulate the experience of pain

(patient perception pain)

Pain expression

• Aching• Stabbing• Tender• Tiring• Numb• Dull• Crampy

• Throbbing• Gnawing• Burning• Penetrating• Miserable• Radiating• Deep

• Shooting• Sharp• Exhausting• Nagging• Unbearable• Squeezing• Pressure

Pain description• Location, transmition• Intensity • Quality• Onset, duration and rhythm• Patient expression• Aggravating or relieving factors• Impact of pain • Concomitant condition

Physiologic Consequences of Acute Pain

Bonica JJ. The Management of Pain. 2nd ed. Vol. 1; 1990.

Physiologic Consequences of Acute Pain

• General stress response/ neuro endocrine• Respiratory• Cardiovascular• Gastrointestinal/urinary• Musculoskeletal

Bonica JJ. The Management of Pain. 2nd ed. Vol. 1; 1990.

General Stress Response

Endocrine/Metabolic ACTH, cortisol, catecholamines,

interleukin-1 insulin

Water/Electrolyte Flux• H2O, Na+ retention

ACTH = adrenocorticotropic hormoneKehlet H. Reg Anesth.1996;21(6S):35–37.Cousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447–491.

Respiratory Effects

FRC = functional residual capacity; V/Q = ratio ventilation:perfusion of the lungCraig DB. Anesth Analg. 1981;60:46.Cousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447–491.

Mobility

Hypostatic pneumonia

Tidal volume

Vital capacity

FRC Alveolar ventilation

Atelectasis

V/Q inequality

Acute Pain

Respiratory Effects (Cont’d)

Cousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447–491.

Impaired ventilation

Muscle spasm

Muscle splinting

Cough suppression

Lobular collapse

Infection/pneumonia

Acute Pain

Hypoxemia

Cardiovascular Effects

MI = myocardial infarction; HR = heart rate; PVR = peripheral vascular resistance; BP = blood pressureCousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447–491.Bowler DB, et al. In: Cousins MJ, Phillips GD, eds. Acute Pain Management; 1986:187–236.

Sympatheticoveractivity

Coronaryvasoconstriction

Anxiety, pain Ischemia Angina MI

HR, PVR, BP, cardiac output

Ischemia

Acute Pain

Effects on Peripheral Circulation

Limb blood flow1

Venous emptying2

Venous thrombosis/embolism3

1. Cousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447–491.2. Modig J, et al. Acta Anaesth Scand. 1980;24:305–309.3. Modig J, et al. Anesth Analg. 1983;62:174–180.

Acute Pain

Gastrointestinal and Urinary Effects

UrinaryGastrointestinal

Sympatheticover activity Urinary

sphincter activity

Urinary retention

Intestinal secretions Smooth muscle

sphincter tone Intestinal motility

Cousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447–491.Nimmo WS. Br J Anaesth. 1984.56:29–37.

Acute Pain

Psychological Effects


Acute Pain

Anxiety

Depression

Sleep deprivation

Other Effects of Acute Pain

• Wound repair• Impaired immunocompetence• Hypercoagulable state

Drucker W, et al. J Trauma. 1996;40(3):S116–122.Cousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447–491.Jorgensen L, et al. Br J Anaesth. 1991;66:8–12.

Musculoskeletal Effects


Sensitivity of peripheral nociceptors

Musclespasm

Sympatheticoveractivity

Acute Pain

Musculoskeletal Effects (Cont’d)

Mobility

Impaired muscle metabolism

Muscle atrophy Delayed normal

muscle function

Reflex vasoconstriction


Acute Pain

Effects on Pain-Signaling Systems

Peripheral nociception Nerve excitability

Prolonged pain

Chronic pain Damaged spinal pain-signaling systems


Acute Pain

Hyperalgesia (1 + 2) Allodynia

Psychological effects of chronic pain

• Pain intensity, duration and frequency.• Mood, e.g. depression, anxiety, anger.• Personality.• Coping skills.• Patient belief of pain.• Physical function.• Family influence.• Use of medical service.

Characteristic of Peripheral Neuropathic Pain

• Caused by pathologic changes in peripheral nerves• Spontaneous pain• Burning, tingling, numbness• Allodynia, hyperalgesia

Rathmell JP. Katz JA. In: Benzon H, et al, eds. Essentials of Pain Medicine and Regional Anesthesia; 1999:288-294

Characteristics of Peripheral Neuropathic Pain

• Caused by pathologic changes in peripheral nerves:– Transection of peripheral nerve e.g., in amputation, phantom

pain, stump pain.

– Metabolic disease: diabetic polyneuropathy

– Compression of spinal root by a lumbar disk herniation: sciatica, LBP irradiating into leg

– Virus disease of sensory nerves to the skin: PHN

– Compression of trigeminal nerve by intracranial artery: trigeminal neuralgia

– Toxins: e.g. chemotherapeutic agents, alcohol

– Vascular disorders e.g. SLE, PAN

– Nutritional deficiencies: e.g. niacin, thyamine, pyridoxine

– Direct effects of cancer: e.g. metastasis, infiltrative

Characteristics of Peripheral Neuropathic Pain

• Caused by pathologic changes in central nerves:– Stroke

– Spinal cord lesions

– Multiple sclerosis

– Tumors

Wall PD, Melzack R (Eds). Textbook of pain. 4th Ed. 1999; Galer BS, Dworkin RH (Eds) A clinical guide to neuropathic pain. 2000:

Woolf CJ et al. Lancet. 1999;353:1959-1964.

• Burning pain, continuous• Convulsive Pain Attacks• Hyperalgesia (excessive sensation of noxious stimulus)• Allodynia (pain upon a touch stimulus)• Hypoesthesia (Numbness)• Paresthesia (non-natural sensations), dysesthesia (if near

painful)• False localization of a stimulus (e.g. referred pain)

Each diagnosis of neuropathic pain may have at least twoof these sensory qualities.

Neuropathic Pain –Characteristic Sensory Qualities

Rathmell JP. Katz JA. In: Benzon H, et al, eds. Essentials of Pain Medicine and Regional Anesthesia; 1999:288–294.Baron. Clin J Pain. 2000;16:S12-S20.

Mechanism

• Peripheral Mechanisms– Membrane hyperexcitability-Ectopic discharges– Peripheral sensitization

• Central Mechanisms– Membrane hyperexcitability-Ectopic discharges– Wind up– Central sensitization– Denervation supersensitvity– Loss of inhibitory controls

Attal N et al. Acta Neurol Scand. 1999;173:12-24. Woolf CJ et al. Lancet. 1999;353:1959-1964.

Diagnosis

History• Pain description/characteristic:

Primary or secondaryLocation and transitionOnset and related factorPain intensity and patternAggravating and relieving factorsAditional complain

• Functional and medical aspectsInfluence of pain on the daily activity and sleep pattern.Results of drug medications and pain management.History of drugs used.Family history.Psychosocial conditions.

• Factors related to successful pain management:Patients belief and expectancy.Coping style.Knowledge to pain management,ability to use assistive devices.Ability to assesses the pain

Physical examination

– Vital sign, height, weight– Mental status– Skin abnormality– Gait

– Behavior related to pain, face, the use of assistive device

– Complete physical examination.– Pain assessment

Neuropathic pain

Positive and negative sensory symptomsof neuropathic pain

Positive symptoms(due to excessive activity)

Dysesthesia

Sensory abnormalities and pain often co-existEach patient may have a combination of symptoms

that may change over time (even within a single etiology)

Paresthesia

Spontaneous pain

HyperalgesiaAllodynia Anesthesia

Negative symptoms(due to deficit of function)

Nervous system dysfunction or damage

Hypoesthesia

HypoalgesiaAnalgesia

“Numbness”

“Shooting” “

Listen to the patient describing their pain

Be alert for commonverbal descriptors of NeP

“Electric shock-like”

“Tingling”

“Shooting” “Burning”

“Numbness”

“Electric shock-like”

Locate: correlate the region of pain to the lesion/dysfunction in the nervous system

Carpal tunnel syndrome Diabetic peripheral neuropathyLumbar radiculopathy

Look for the presence of sensory and/orphysical abnormalities

• First, inspect the painful body area and compare it with the corresponding healthy area:– differences in color, texture, temperature, sweating

• Then, conduct simple bedside tests to confirm sensory abnormalities associated with neuropathic pain:– gauze– pinprick– pinch– etiology-specific tests

Applying the 3L approach to diagnosis differentiates neuropathic from nociceptive pain

Listen Locate LookNeuropathic pain(e.g. PHN, DPN, lumbar radiculopathy)

Common NePdescriptors:• shooting • electric

shock-like• burning• tingling• numbness

The painful region may not necessarily be the same as the site of injury. Pain occurs in the neurological territory of the affected structure (nerve, root, spinal cord, brain)

• Apply gauze, pinprick, pinch tests

• Conduct etiology-specific tests if appropriate, (e.g. straight-leg raise test for lumbar radiculopathy)

Nociceptive pain(e.g. burn, broken limb, osteoarthritis)

Common pain descriptors:• aching• throbbing• stiffness

Painful region is typically localized at the site of injury

Physical manipulation causes pain sensations insite of injury

YesNo

Confirmed NeP diagnosis – initiate treatment

Using the 3L approach to help make a differential diagnosis

Yes

NoCan you identify the

responsible nervous systemlesion/dysfunction?

Consider specialist referralif NeP is still suspected –

consider treatment in the interim period

Yes

No

Probablenociceptive pain

Can you detect sensoryabnormalities using

simple bedside tests?

Are verbal descriptorssuggestive of NeP?

Mixed pain

Pain component

• Nociceptive:– Underlying condition i.e. surgical wound,

limb pain after a fracture, pain of burns and bruises, osteoarthritis.

– Pain description: throbbing, aching, stiffness– Inflammatory mediators: PGs, cytokines,

acute phase reactants i.e. CRP.

Pain component

• Nociceptive: History

– Functional impact: effect of pain on sleep, ADL, self care, social or sexual function, mood, suicidal ideation.

– Attempted treatment: NeP usually resistant to NSAIDs / PCT.

– Alcohol / substance abuse

Pain component

• Neuropathic:History– Pain intensity: VAS-visual analogue scale– Sensory descriptor: pain qualities i.e. hot, burning,

sharp, stabbing, cold, allodynia or common non-painful sensation i.e. tingling, prickling, itching, numbness and pins and needles;

– Temporal variation: pain often gets worse towards the end of the day.

Pain component• Neuropathic:

Physical examination- Gross motor examination: motor weakness may occur

around the involved nerve, attempt to differentiate between true weakness and antalgic weakness.

- Deep tendon reflexes: diminished or absent.- Sensory examination: pin prick test etc.- Skin examination: alteration in temperature, colour,

sweating and hair growth suggestive of CRPS, residual dermatomal scars consistent with previous herpes infection.

Pain component

• Neuropathic:– Special test: CT and MRI scan,

electromyography and nerve conduction studies; three-phase nuclear medicine bone scan or biochemistry such as OGTT, and thyroid function.

Assessment of pain severity

Pain assessment

• One dimension instrumentsPain rating scale– Categorical

verbal rating scale (Likert scale)– Numerical

NRS, VAS, 11-point box scale

• Multi-dimensional instrument• Mechanical / mechanoelectric instruments

Frequency of Pain Assessment and Documentation

• Preoperatively• Routinely at regular intervals postoperatively• With each new report of pain• At suitable intervals after each analgesic

intervention

Carr DB, et al. AHCPR Pub. No. 92-0032. 1992.

Categorical pain scale

No pain mild

moderatesevere

Most pain

Likert scale

Numerical pain scale

0 1 2 3 4 5 6 7 8 9 10

No pain Very severe pain

109876543210

No pain Very severe pain

Visual Analogue Scale

No pain

Severe pain

No pain Severe painMild Moderate Severe

X


Visual analogue scale (vas)

VAS score Interpretation

< 4 Mild pain4 – 7 Moderate pain> 7 Severe pain


Face scale

Emotional gradation happy to depression

Pain Assesment

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