4. Components :
• Pain History
• Ruling out red flags
• Past history
• Personal history -sleep, bladder/ bowel habit
• Treatment history
• Family history.
5. A good history ???
• Time
• Chronological order
• Physician –Empathetic, no distraction
• Detailed history should be taken on the first visit.
• Pre-consultation questionnaire
7. cont..
• Quantity or severity of pain.
• Quality or nature of pain.
• Mode of onset and location.
• Duration or chronicity.
• Provocative and relieving factors.
• Special character.
• Timing of pain.
• Relation to posture.
• Associated complaints
9. A: Quantity or severity or intensity of pain
• Instruments for intensity assessment:
Unidimensional Multi dimensional
1.Verbal rating scales 1.Mc Gill pain questionnaire
2.Binary scale 2. Brief pain inventory
3.Numerical rating scale 3. West Haven –Yale multidimensional
4.Faces rating scale pain inventory
5.Visual analog scale 4. Medical outcome study 36 item
short form(SF-36)health survey
10. Unidimensional instruments:
1.Verbal rating scales(VRS)
Response is noted as None, mild ,moderate or severe
Advantage-short, easy to express and understand
especially in elderly
Disadvantage-lack of reproducibility
2. The binary scale
e.g. do you have a 60% reduction in your pain? “Yes/no”
Advantage-short, easy to express and understand.
Disadvantage-lack of reproducibility
11. 3.The numerical rating scale(NRS)-
• Most commonly used
• A reduction of 30% or 2 points and more from baseline-
positive response for Rx.
• Disadvantage –Digital scale reduces the capacity to detect
subtle changes
12. 4. The faces rating scale (Wong-Baker)
• Patient is asked to point at various facial expressions
ranging from a smiling face to an extremely unhappy face.
• Advantage :- when the communication with the patient is
difficult as with the pediatric and deaf and dumb patients
13.
14. 5. The visual analog scale (VAS)
10 cm horizontal line
• the distance from no pain to the patient mark indicates the severity
of pain numerically
• Advantage-simple, efficient , valid, and minimally intrusive
• Disadvantage-more time consuming than others & some difficulty
in understanding in elderly
15. Multi dimensional instruments:
1.The Mc Gill pain questionnaire(MPQ)- Melzack and Torgerson-1971
• Defines pain in 3 major dimensions by 20 set of descriptive words
divided as-
a. 10 sets describes sensory- discriminative (Nociceptive pathway)
b. 5 sets describe motivational –affective (reticular and limbic structure)
c. 1 set describe cognitive evaluative
d. 4 sets describe miscellaneous dimensions.
16.
17. Advantage- helps in diagnosis as choice of
descriptive words that characterize the pain
correlates well with pain syndromes.
Disadvantage – high level of anxiety and
psychological disturbances can obscure the
MPQ discriminative capacity.
18.
19. Short-Form MPQ
• 15 representative words = Sensory (11 items) and
Affective (4 items) categories of original MPQ
• Each descriptor is ranked on a 0(“none”) to
3(“severe”) intensity scale
20. Short-Form MPQ
• The PPI, along with a VAS, are also included
• The short form correlates highly with the original scale
• It can discriminate among different pain conditions
• May be easier than the original scale for geriatric patients
22. 2. Brief pain inventory(BPI):
Measures both the intensity of pain (sensory dimension) and
its interference with the patient life(reactive dimension)
• 7 items -: general activity, mood, walking ability, normal
work, relations with other people, sleep and enjoyment of
life
Advantage-
valid for cancer pain and various pain syndromes
shows good sensitivity to T/t.
helps in comparing international trials with different culture
and population
23. 3.Memorial Pain Assessment Card
• Pain assessment tool for cancer patients
• Consists of three separate visual analog scales
and assesses pain , pain relief and mood.
• Card includes a set of adjectives to describe
pain intensity
24. 4.West Haven-Yale multidimensional
pain inventory (WHYMPI)
composed of 52 items with 3 parts
• Part I: 20 questions; assess five pains domains
(interference, support, pain severity, self-control
and negative moods)
• Part II: Assess the spouse response to patient pain
behavior
• Part III: Participation in various life activities.
25. West Haven-Yale multidimensional
pain inventory (WHYMPI)
• Patient's response to question is noted on a 7-
point scale
• Advantages
a. Pain syndromes
b. Good sensitivity to treatment effects.
26. B:Assesment of Quality or nature of pain
• Important for diagnosing the nature or character of pain
whether it is nociceptive or neuropathic or a mixed nature.
Screening tools for Neuropathic pain:
1.Leeds assesment of neuropathic symptoms and signs:
It has two components in form of symptoms and signs
For Each item binary response is noted-yes/no
Scores ≥12/24 indicates pain is likely to be neuropathic
27. Use is limited- because of need for clinical
examination and pinprick testing
28. 2. Neuropathic pain questionnaire(NPQ)
• The NPQ is a self questionnaire consisting of 12
items :
10 related to sensations or sensory responses
2 related to affect
Each item is scored on a scale of 0(no pain ) to
100(worst possible pain)
29. NPQ Questionnaire:
A short form of NPQ has been described consisting
of 3 items: Numbness, tingling and pain increase in
response to touch.
30. 3.Douleur Neuropathique en 4(DN 4)
questions:
Consists of 7 items related to symptoms and 3
items related to physical examination
• Each item is scored 1(yes) or 0(no)
• sum of all ten items is taken as total score
• score of ≥ 4 as neuropathic pain
32. 4. Pain detect:
Patient based self report questionnaire consisting of 9 items:
7 sensory descriptions and
2 related to spatial(radiating) and temporal characteristics.
• Sensory descriptions are scored on a scale of 0 (no) to 5(very
strongly)
• Radiating pain as 1(yes) or 0(no)
Score ≥ 19 indicates neuropathic pain likely
≤ 12 unlikely neuropathic pain
Note –no clinical examination is needed.
34. 5. ID -Pain
• It is a self questionnaire consisting of 5 sensory
description and 1 item regarding pain located in the joints.
• Higher scores indicates neuropathic pain
ID –pain
- Pins and needles - Electric shocks
- Hot/ burning -Numb
- Is the pain made worse with touch of clothing or bed
sheets?
- Is the pain limited to your joints?(-1)
35.
36. C: Mode of onset and location
• Etiology of pain-eg. Sudden severe headache-sah
D: Chronicity (duration and frequency)
• e.g. in migraine the unilateral pain is frequently
throbbing and may exist for hours to days
E:Provocative and relieving factors
• E.g.- leg and back pain due to spinal stenosis
37. F: Special character
• e.g. – cluster headache- pain is deep , boring, wrenching,
and severe in intensity
G: Timing of pain
• Pain and stiffness felt in morning hours for> hours- d/t
inflammatory arthropathy
• < half hour – degenerative arthropathy
H: Relation to posture
Eg. Pain on sitting cross legged –Piriformis syndrome
38. Other :
• Past history-rash (phn)
• Personal history
• Family history
• Treatment history
40. Red flags
• Pain with major trauma
• Suspecting tumor
• Suspecting infection with fever, rigor, vomiting, etc.
• Motor weakness & Progressive sensory deficit
• Loss of bladder & bowel control
• Sudden onset pain which is progressing rapidly
41. Psychological assessment :
Patient in pain can have some psychological disorders like
anxiety or depression
• Tools available are:-
I. PHQ-9
II. Beck depression inventory(BDI)
III. Hamilton depression scale
IV. Hospital anxiety and depression scale(HADS)
V. Pain catastrophizing scale(PCS)
VI. The tampa scale of kinesophobia
Helps in assessing
personality disorder
42.
43. Becks depression inventory:
• 21 parameters and each are graded from 0 to
3 ,so total score of -63
• Results –
1-10-normal
11-16-mild mood disturbance
17-20-borderline
21-30-moderate depression
31-40-severe depression
>40-extreme depression
44.
45. Hamilton depression scale:-
17 parameters with score grade of 0 to 4
i.e. symptoms is absent ,mild , moderate, severe
Total score -54
Hospital anxiety and depression scale(HADS):-
14 parameters
• 2,4,6,8,11,12,14-anxiety
• 1,3,5,7,9,10,13-depression
Results –
0-7- non case
8-10-borderline case
11 or above -case
51. Facial appearance
• Anxious face
• Depressed face
• Moon face : Cushing's syndrome or long term steroid
therapy
• Face in myxedema: hypothyroidism
• Mask-like face: Parkinsonism
• Starring look: hyperthyroidism
66. 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
67. Pain assessment in children
• Neonates: 0-1 month
• Behavioral observation
• Lack of behavioral responses does not always
mean absence of pain
•not necessarily accurate indicators of the
neonate’s level of pain
68. Pain assessment in children
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
Infants: 1 month to 1 year
69. Pain assessment in children
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
Toddlers: 1-2 years
71. Assessing behavioral signs of pain
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
FLACC Pain Scale (<2,5 years)
72. Assessing behavioral signs of pain
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
FLACC Pain Scale (<2,5 years)
73. 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.
OUCHER Scale (< 3 years)
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
For instructions how to use the scale:
http://www.oucher.org/the_scales.html
History, clinical examination and investigations are the three keystone in making a clinical diagnosis.
helps in locating the pain generators and it avoids unnecessary investigations at the same time ,,History is also very important in ruling out the red flags
Greek philosopherSite - 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?
Pain is a subjective experience. Like many diseases such as hypertension or diabetes, there is no objective measurement for a patient's pain intensity. Unfortunately, we do not have a thermometer like device to measure pain so we need to rely on the patient's statement.
The variables to be measured are current pain intensity and
average pain intensity over a specified period of time, e.g. last 1 week or 4 weeks. It is the average pain intensity which is the usual target for pain treatment, both by the clinician and the patient.
For eg temperature can be measured using a thermometer , we don’t have a specific device for measuring pain
Unidimensional instruments measures only one dimension of pain – intensity while multidimensional instruments can measure nature and location in addition to intensity of pain.
Disadvantage-more time consuming and some difficulty in using and understanding this scale in elderly
Researchers have proposed three dimensions of the experience of pain: sensory, affective , evaluative
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.
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.
Maximum score is 27. Score 1-4/27 indicates minimal depression, 5-9/27 indicates mild depression, 10-14/ 27 indicates moderate depression, 15-19 /27 indicates moderately severe depression and 20-27 /27 indicates severe depression.
Wincing, sweating and guarding painful areas,,, Clutching of chest, pallor, diaphoresis, labored breathing
Put the right hand on the left hand. Then ask the patient to point to the ceiling with the left index finger.
a positive Babinski sign happens when the big toe bends up and back to the top of the foot and the other toes fan out.
