International Pain School Assessing pain taking a pain

International Pain School

Assessing pain & taking a pain history type in your name type in the name of your institution

Outline • Why is it important to assess pain? • Why should you use tools to evaluate pain? • What are the components of the pain assessment process? • How to optimize pain assessment • Pain assessment in children & in patients with impaired communication • Pain evaluation tools which are practical for low-resource settings • Conclusion: Pearls

Case • You are working in a small rural hospital when Parmanand, a 17 year old male, is admitted after a motorcycle accident. • He is awake, haemodynamically stable and seems to have fractured his left leg. He is groaning. The surgeon tries to carry out a physical examination, but Parmanand resists. • Do you need to assess Parmanand’s pain? • How would you do it? • How should you act once you have assessed Parmanand’s pain?

Why is it important to assess pain? • Assessment of pain is the first step in planning pain management. • Pain assessment should be repeated to evaluate the efficacy of pain management • Tailor the assessment tool to the patient’s age, condition, type of pain (acute vs chronic). • Evaluate the patient’s other symptoms, functional status and general clinical status in parallel with the pain assessment.

Timing of the pain assessment Pain assessment should occur at: • Each clinical encounter • Regular intervals after initiation of treatment, e. g. a suitable interval after pharmacologic or non-pharmacologic intervention [15– 30 minutes after parenteral drug therapy & 1 hour after oral administration] • Each new report of pain

Components of taking a pain history Ask about: • Location • Quality • Intensity of the pain • Duration • Alleviating and aggravating factors [e. g. , medicines/drugs, alcohol, herbals, movement, positioning] • Impact on patient’s life [e. g. , daily activities, work performance, social contacts] • Medication related side effects • Ask and assess for other symptoms [e. g. , nausea, vomiting, constipation, confusion, depression, dyspnoea].

How to assess a patient’s pain history: the ‘PQRST’ approach P: Provokes and Palliates • Does the pain radiate? If yes, where to? • What causes the pain? • Did it start elsewhere and now loclized to • What makes the pain better? • What makes the pain worse? one spot? S: Severity Q: Quality • How severe is the pain? • What does the pain feel like? • Sharp? Dull? Stabbing? Burning? T: Time Crushing? • When did the pain start? • Is it present all the time? R: Region and Radiation • Are you pain-free at night / day? • Where is the pain located? • Are you pain-free on movement? • Is it confined to one place? • How long does the pain last?

Factors influencing perception of pain • The patient is an expert about his/her body, his self-reported pain should be accepted as accurate. • In communicating patients, rely on the patient’s self report; it is affected by a variety of factors. • Factors influencing a person’s experience of pain: –positive vs. negative expectations –mood (sense of hopelessness vs. optimism) –culturally acceptable levels of ‘complaining’ –coping and adaptation abilities –meaning attached to the experience of pain

Communication between patient and caregiver: listen actively • Caregivers should not wait for the patient to report about pain, but actively and sensitively explore this with the patient. • Allow patients to describe their pain in their own words. • Consider, that patients may report their pain experience in socially acceptable words. • When patients feel uncomfortable describing their pain, health care providers can suggest a sample of relevant descriptors, they can be written on cards.

Communication of pain: locate the pain • Patients can be requested to indicate primary site/s of pain by shading relevant areas on a figure of a human body [front and back] OR pointing out on their own body. • This can indicate the direction of radiating or referred pain • Schematics such as these are used for assessing chronic pain conditions; not typically carried out in acute situations.

Communication of pain: locate the pain Eland Colour Scale A figurine adapted for children For instructions how to use http: //www. painresearch. utah. edu/cancerpain/attachb 6. html

Duration of pain assessment • Depends on the presenting problem/s and demands of clinic time.

Patients with communication barriers Patients with barriers to communication can affect the pain assessment. These include: • Pre-verbal children • Individuals of advanced age • Patients with dementia • Patients with emotional or cognitive dysfunction • Patient does not speak the same language as the care provider • Patients who are seriously ill

General approach to pain assessment • Allow sufficient time for the assessment. • Use interpreter if language of communication is second language. • Give the patient the opportunity to use a rating scale or other tool appropriate for that population.

General approach to pain assessment cont’d • Use pain indicators according to the following hierarchy of importance: • Patient self-report • Pathological conditions or procedures known to be painful • Pain-related behaviors (e. g. , grimacing, restlessness, vocalization) • Reports of pain by family members or caretakers • Physiological measures (vital signs) • Reliance on behavioral or objective indicators of pain (e. g. , vital signs) only when no suitable alternative exists

Assessment in situations of acute pain • Control of pain does not impede the accuracy of diagnosis. • Do not withhold pain management because of ongoing or planned diagnostic procedures. • A comfortable patient will tolerate diagnostic procedures better and will be more cooperative. • It is also a humane duty to ensure fast provision of pain relief.

Pain assessment in children • Children, even newborns, feel pain. • ‘QUESTT’ approach – Question the child if verbal, and the parent/guardian in both the verbal and non-verbal child – Use pain rating scales if appropriate – Evaluate behavior and physiological changes – Secure the parent’s involvement – Take the cause of pain into account – Take action and evaluate the results When possible: carry out the assessment in the presence of family/guardian

Pain assessment in children • Neonates: 0 -1 month • Behavioral observation, done accompanied by child’s family/guardian to discern between ‘normal’ and ‘abnormal’ behavior, is the only way of assessment at this age • Lack of behavioral responses [facial expressions e. g. crying, and discomforted movement] does not always mean absence of pain • Behavioral responses are not necessarily accurate indicators of the neonate’s level of pain

Pain assessment in children Infants: 1 month to 1 year Infants may exhibit the following when experiencing pain: • Body rigidity/thrashing • Facial expression of pain [brows lowered and drawn together, eyes tightly closed, mouth open and squared] • Loud and intense cries • Inconsolability, hypersensitivity / irritability • Draw knees to chest • Poor food intake, poor sleep

Pain assessment in children Toddlers: 1 -2 years Toddlers may exhibit the following when experiencing pain: • Verbal aggression, intense cries • Regressive behavior / withdrawal • Physical resistance, guard painful part of the body • Poor sleep • May require play and drawings to get an accurate assessment of their pain • Some may express their pain using simple language.

Assessing behavioral signs of pain FLACC Pain Scale (<2, 5 years)

Assessing behavioral signs of pain FLACC Pain Scale (<2, 5 years) How to Use the FLACC In patients who are awake: Observe for 1 to 5 minutes or longer. Observe legs and body uncovered. Reposition patient or observe activity. Assess body for tenseness and tone. Initiate consoling interventions if needed. In patients who are asleep: Observe for 5 minutes or longer. Observe body and legs uncovered. If possible, reposition the patient. Touch the body and assess for tenseness and tone

Assessing behavioral signs of pain FLACC Pain Scale (<2, 5 years) Interpreting the FLACC Score Each category is scored on a 0– 2 scale, which results in a total score of 0– 10. 0 -- Relaxed and comfortable 1– 3 -- Mild discomfort 4– 6 -- Moderate pain 7– 10 -- Severe discomfort or pain or both

Pain assessment in children Pre-school: 3 -5 years The pre-schooler may exhibit the following during pain: • may verbalize his/her pain • Thrash arms and legs, pushes stimuli away before they are applied • Be uncooperative, need physical restraint • Cling to their parent/guardian, need emotional support [e. g. hugs] • Poor sleep • Carry out the assessment using simple language and sympathetic demeanor

Self report OUCHER Scale (< 3 years) The OUCHER is a poster developed for children to help them communicate how much pain or hurt they feel. There are two scales on the OUCHER: a number scale for older children and a picture scale for younger children. For instructions how to use the scale: http: //www. oucher. org/the_scales. html It is possible to adapt the photos on the scale to different ethnicities (USA): • Caucasian • African American • Hispanic • Asian - Boy • Asian - Girl • First Nations (Canada- Boy • First Nations - Girl

Pain assessment in children School-age: 6 -12 years The school-age child may exhibit the following during pain: • Verbalize their pain • May even ask what causes their pain; may need age-sensitive explanations: ‘You have pain in your stomach because you have a lump there which is making it hurt. ’ • Influenced by cultural beliefs, experience pain-related nightmares • Stalling behaviors [e. g. ‘wait a minute’, ‘I’m not ready’] • Muscular rigidity [e. g. clenched fists, white knuckles, gritted teeth, contracted limbs, stiff body, closed eyes, wrinkled forehead] • Reservation in fear of consequences [e. g. injection] • All behaviors of pre-schoolers

Pain assessment in older children Age: > 6 years verbal rating scale • can also be used in adults unable to use numerical scales

Pain assessment in children Adolescents: 13 -18 years Adolescents may exhibit the following during pain: • Verbalize their pain • Peer pressure: deny pain in the presence of peers • Changes in sleep pattern or appetite • Health care provider - should avoid confrontation, engage conversation focused on the adolescent rather than the problem [informal questions about friends, school, hobbies, family, soccer …]

Pain assessment in adolescents and adults Numerical and verbal rating scales (>12 years) 0 – 3 OR no to mild pain = no change in therapy 4 – 7 OR moderate pain = initiate or change therapy 8 – 10 OR severe pain = emergency treatment How to use the scale? Example of what to say to a patient: ‘On a scale of 0 to 10, when ‘ 0’ represents NO PAIN and ’ 10’ represents the WORST PAIN IMAGINABLE, how much pain do you have now? ’

Pain assessment among the aged • The UN definition of ‘older people’ may not apply for sub-Saharan Africa where complex and multidimensional socio-cultural definitions exist [e. g. seniority status, number of grandchildren] • It is challenging to assess pain among geriatric patients with multi-morbidity, poli-pharmacy and dementia • Visual and hearing impairment may be obstacles • Use behavior-based proxies in non-communicative cases • In principle, for the geriatric patient: Ask for Pain

Pain evaluation tools practical for low-resource settings • One-dimensional tools can be practical because they: - take shorter time to administer - require lower levels of patient’s education - are validated in linguistically and culturally diverse settings • Examples include: African Palliative Outcome Scales (APOS), Numerical Rating Scale [NRS], Verbal Descriptor Scale [VDS], FLACC Behavioral Pain Scale, Wong-Baker FACES Pain Rating Scale, the Pain Thermometer

Example for Multidimensional Pain Evaluation APCA African Palliative Outcome Scale Rated using the hand scale: Clenched hand represents ‘no hurt’. Five extended digits represents ‘overwhelming/worst’ Each extended digit indicates increasing level of pain.

Pain assessment in Dementia Observational Scale: PAINAD Observe for 5 min Interpretation: moderate pain = 4 -6, severe pain = 7 -10

The Universal Pain Assessment Tool

Conclusion: Pearls I • Pain assessment should be part of the daily routine (“ 5 th vital sign”). • Tailor the assessment to the patient [e. g. age, cognitive ability, literacy level]. • Aim to use validated pain assessment tools – this helps to standardize the process of assessment. • Pain assessment is not an “academic exercise”: assessment should be used planning management of pain.

Conclusion: Pearls II • Once you have made an assessment, interpret it and carry out the relevant therapeutic intervention: • ≤ 3/0 -10 scale no change in therapy is typically necessary • ≥ 3/0 -10 scale typically analgesic therapy should be administered or current regimen changed • pain emergency, typically intensity of 9 -10/10 analgesic therapy should given immediately & intravenously, if appropriate.

Conclusion: Pearls III Interview the patient about which factors aggravate or relieve the pain. Can help to identify the etiology of pain, e. g. , • pain worst at early morning hours: inflammation? • pain constant and severe: chronic pain disease? • pain decreases with movement: osteoarthritis? • pain worse on coughing/sneezing: radicular pain? • pain is alleviated with a cool pack: inflammation? • pain is alleviated with heat: muscular pain?

Conclusion: Pearls IV • Pain descriptors help to differentiate the aetiology of the pain and point to a therapeutic strategy: • ‘burning’, ‘shooting’, ‘electrical’ -> think pain is of neuropathic origin. • ‘dull’, ‘aching’, drilling, etc -> think pain is of nociceptive origin.

Case study • You are working in a small rural hospital when Parmanand, a 17 year old male, is admitted after a motorcycle accident. • He is awake, haemodynamically stable and seems to have fractured his left leg. He is groaning. The surgeon tries to carry out a physical examination, but Parmanand resists. • Do you need to assess Parmanand’s pain? • How would you do it? • How should you act once you have assessed Parmanand’s pain?

Discussion of Case • Permanand seems to be in intense pain and so it is imperative to control his pain as quickly as possible. • Permanand is of an age that he can verbalize his pain, therefore, ask him to assess the intensity of his pain. • Use verbal descriptor scale or numerical pain scale. • If there is no acute volume loss, initiate analgesia before further diagnostic procedures • When the pain is severe, management should be intravenous and opioid based. • Using the body diagram in this acute situation is not necessary.

This talk was originally prepared by: Yohannes W Woldeamanuel, MD Ethiopia

International Pain School Talks in the International Pain School include the following: Physiology and pathophysiology of pain Nilesh Patel, Ph. D, Kenya Assessment of pain & taking a pain history Yohannes Woubished, M. D, Addis Ababa, Ethiopia Clinical pharmacology of analgesics and non-pharmacological treatments Ramani Vijayan, M. D. Kuala Lumpur, Malaysia Postoperative – low technology treatment methods Dominique Fletcher, M. D, Garches & Xavier Lassalle, RN, MSF, Paris, France Postoperative– high treatment technology methods Narinder Rawal, M. D. Ph. D, FRCA(Hon), Orebro, Sweden Cancer pain– low technology treatment methods Barbara Kleinmann, MD, Freiburg, Germany Cancer pain– high technology treatment methods Jamie Laubisch MD, Justin Baker MD, Doralina Anghelescu MD, Memphis, USA Palliative Care Jamie Laubisch MD, Justin Baker MD, Memphis, USA Neuropathic pain - low technology treatment methods Maija Haanpää, MD, Helsinki & Aki Hietaharju, Tampere, Finland Neuropathic pain – high technology treatment methods Maija Haanpää, M. D. , Helsinki & Aki Hietaharju, M. D. , Tampere, Finland Psychological aspects of managing pain Etleva Gjoni, Germany Special Management Challenges: Chronic pain, addiction and dependence, old age and dementia, obstetrics and lactation Debra Gordon, RN, DNP, FAAN, Seattle, USA

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