Making an accurate pain assessment

The importance of good history takingBy Joyce McSwan B.Pharm.MPS.Cert IV TAEClinical Director, GCPHN Persistent Pain Program 

Learning Objectives

1. Differentiate the pain measurement tools to assess and help manage patients with chronic pain 

2. Use appropriate communication techniques to conduct an effective pain assessment 

3. Identify red and yellow flags for early identification and intervention

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Pain Assessment = Effective management plan

• The patient’s self‐reporting is the most reliable, ‘gold standard’, indicator of the existence and intensity of pain1

“Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does” 2 (McCaffery, 1989)

• Pain assessment is based on a multidimensional, whole person (bio‐psycho‐social) observation of a patient’s experience of pain inclusive of their values and beliefs

1. Honorio T. Benzon, MD, Srinivasa N. Raja, MD, Robert E. Molloy, MD, Spencer S. Liu, MD, Scott M. Fishman, MD. Essentials of Pain Medicine. Third. USA: Elsevier Saunders; 2011. 28‐33.2. McCaffery M and Beebe A, Pain: Clinical manual for Nursing practice. C.V Mosby Company, St Louis, Missouri 1989

Pain Assessment is NOT….

• Relying on changes in vital signs

• Deciding a patient does not “look in pain”

• Knowing how much a procedure or disease “should hurt”

• Determined by radiological investigations alone (E.g. MRI, CTs, X‐Rays or Ultrasound)

• Assuming a sleeping patient does not have pain

• Assuming a patient will tell you they are in pain

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A fundamental ingredient to successful pain assessment

Language  ‐ verbal and non‐verbal

Positive reframes

Affirmations

Non‐judgmental reflections

Pain terminology Patient literacy

Cultural background

Use analogies

Building rapport Non‐interrogative

Empathethic

Active listening

Melzack, R. The McGill Pain Questionnaire, 2005 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc. 

Non‐Verbal 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

Keela A. Herr , Garrand L, Assessment and measurement of pain in older adults, Clin Geriatr Med. 2001 Aug; 17(3): 457‐vi

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Ways to measure pain

Self ReportSelf Report

BehaviourBehaviourPhysiologicalPhysiological

What the patient says

How the patient behaves

Clinical observations of how the patient functions

• Location of pain• Emotional and

psychological state• Memories of previous

pain• Upbringing• Expectations of and

attitudes towards pain• Beliefs and values• Age• Sex• Social and cultural

influences

Pain

Pic: Copyleft –Permission Granted to use

ACUTE SUBACUTE CHRONIC‐ MALADAPTIVE

Assessing with context 

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Assessing for better pain management

Acute or Chronic 

• Determined by length of time of experiencing pain• Determine intensity of pain and impact on function• Determine function impact on activities of daily living

Pain Diagnosis 

• Nociceptive• Neuropathic• Psychogenic – “Yellow Flags”• “Red Flags”

Impact on Quality of 

Life

• Sleep • Relationship• Independence• Enjoyment of life

Assessing different types of pain

Nociceptive 

Neuropathic

Visceral pain

Radicular pain

Central pain

Psychogenic pain

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Pain Measurement Tools 

• Unidimensional • Used in acute pain when the etiology is clear

• Used prior to trialling treatment 

• Good for baseline measure

• Only reports sensory experience of pain severity

• Multidimensional • Used in chronic/persistent, complex pain

• Used as an initial biopsychosocial assessment

• Assess pain severity and interference 

• Used for review and monitoring

Correll, Darin J. The Measurement of Pain: Objectifying the Subjective. Steven D. Waldman, MD, JD. Pain Management. 2nd. Philadelphia: Saunders Elsevier; 2011. 191‐201.

Examples of Unidimensional Pain Measurement Tools

Honorio T. Benzon, MD, Srinivasa N. Raja, MD, Robert E. Molloy, MD, Spencer S. Liu, MD, Scott M. Fishman, MD. Essentials of Pain Medicine. Third. USA: Elsevier Saunders; 2011. 28‐33.

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Examples of Multidimensional Pain Measurement Tools

Cleeland CS, Ryan KM. Pain assessment: global use of the Brief Pain Inventory. Ann Acad Med Singapore. 1994 Mar. 23(2):129‐38

Assessing neuropathic 

pain

Bouhassira D, Attal N, et al. Comparison of pain syndromes associated with nervous or somatic lesions and development of a new neuropathic pain diagnosis questionnaire (DN4©). Pain. 2005; 114(1‐2):29‐36. 

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Pain Assessment for the Elderly 

Abbey J, De Bellis A, Piller N, Esterman A, Giles L, Parker D, Lowcay B. Funded by the JH & JD Gunn Medical Research Foundation 1998–2002

Warden, V, Hurley AC, Volicer, V. (2003). Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) Scale. J Am Med Dir Assoc, 4:9‐15. Developed at the New England Geriatric Research Education & Clinical Center, Bedford VAMC, MA.

Mnemonics for pain assessment

P.Q.R.S.T

S.O.C.R.A.T.E.S1

C.O.L.D.E.R.R.A

1. Clayton, Holly A. (2000). "SOCRATES on Pain Assessment".MedSurg Nursing. Retrieved 2008‐03‐31.

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Mnemonics for pain assessment

P.Q.R.S.T

S.O.C.R.A.T.E.S1

C.O.L.D.E.R.R.A

1. Clayton, Holly A. (2000). "SOCRATES on Pain Assessment".MedSurg Nursing. Retrieved 2008‐03‐31.

Mnemonics for pain assessment

P.Q.R.S.T

S.O.C.R.A.T.E.S1

C.O.L.D.E.R.R.A

1. Clayton, Holly A. (2000). "SOCRATES on Pain Assessment".MedSurg Nursing. Retrieved 2008‐03‐31.

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Assessing Change in Pain Intensity

0 2 4 6 10831 7 95

No pain

Mild Moderate Severe Very severe

Worst possible

Helpful to determine treatment effect: • Score before treatment and score after treatment • Score before medication and score after medication

Before treatment

After treatment

Assessing Interference of Function

• The reality is that the pain will stay or it may go, but the bigger question is :

What can you still do even though the pain is around?

• Describing pain reduction as intensity reduction rather than completely FIXING the pain will enable the patient to concentrate on improving their quality of life despite pain.

• Assessing function interference will also provide information on the quality of life and ability to participate in activities of daily living

• Improving function capacity relies on understanding “Boom and bust or Pacing”

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• “Boom and bust”

• “Pacing”

Assessing Interference of Function

WIN

Boom and Bust Cycle 

Pacing

Indicators for RED flag

Possible fracture Possible tumour or infection Possible significant neurological deficit

From History

• Major trauma• Minor trauma in elderly or osteoporotic

Age >50 or <20 years• History of cancer• Constitutional symptoms (fever, chills, weight loss)• Recent bacterial infection• IV drug use• Immunosuppression• Pain worsening at night or when supine

• Severe or progressive sensory alteration or weakness• Bladder or bowel dysfunction

From Physical Examination

Evidence ofneurological deficit (in legs or perineum in the case of low back pain)

Red Flags (Low Back Pain) Ref: Pain Matters, Hunter New England, NSW Health, Medical Practice Guidelines, Hunter Integrated Pain Service Updated Nov 2005

If ONE or more areas are flagged REFER TO GP OR SPECIALIST

Low Back Pain: Rational use of opioids in chronic or recurrent non‐malignant pain. NSW Therapeutic Assessment Group: Prescribing guidelines for primary care clinicians. Published 1998. Revised 2002. (Sourced 24/2/14) http://www.ciap.health.nsw.gov.au/nswtag/documents/publications/guidelines/pain‐low‐back‐gp‐dec‐2002.pdf

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Headache Red Flags * SSNOOP Example

S Systemic Symptoms Fever, weight loss, after sickness, vomiting

S Secondary risk factors Underlying disease, e.g. HIV, systemic cancer, immunosuppression

N Neurologic symptoms or abnormal signs

Confusion, impaired alertness, consciousness, change in behaviour

O Onset Sudden, abrupt, split second (first, worst)

O Older or Younger New onset, progressive, middle-age >50 yo (giant cell arteritis)< 5 years old

P Previous headache history or Progression

Pattern change, first headache or different (change in attack frequency, severity or clinical featureFollowing traumaStarts after physical exertion, coughing, sneezing, sexual activity or bending over

Wolff's Headache and Other Head Pain, Eighth Edition

Psychosocial assessment

o Yellow Flag indicators – give indication of potential for progression to disability

oPsychosocial pain assessment form (PPAF): measures economic, social support, activities of daily living, emotional impact, and coping style

oPain self‐efficacy (PSEQ) – self‐confidence to participate in activities despite pain

oBeliefs (BPCQ) – measures  ‘locus of pain control’ or how much internal, external or chance factors influence pain control

Williams, David A. “The importance of psychological assessment in chronic pain” Current opinion in urology vol. 23,6 (2013): 554‐9.Otis‐Green, S. (2006). Psychosocial Pain Assessment Form. In Dow (Ed.), Nursing Care of Women with Cancer. St. Louis, MO: Elsevier Mosby, 556‐561.

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Assess for Yellow Flags

Reference: New Zealand acute low back pain guide: Incorporating the guide to assessing psychological yellow flags in acute low back pain. Accident Compensation Corporation (ACC)’ Wellington ,2004. (Sourced 24/2/14) http://www.acc.co.nz/PRD_EXT_CSMP/groups/external_ip/documents/internet/wcm002131.pdf

Once the clinical assessments are done….then what? 

What if….

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Assessing contributing factors

• Instead of waiting for pain to be “controlled” or for treatment options to be tried 

• We identified the factors contributing to the patient’s presenting problems

• Selectively prioritized based on assessment findings

• And targeted them

Steven J. Linton and Michael K. Nicholas, After assessment, then what?Integrating findings for successful caseformulation and treatment tailoring, Center for Health and Medical Psychology, Department of Behavioral, Social andLegal Sciences—Psychology, Örebro University; and Pain ManagementResearch Institute, University of Sydney

REDUCEDACTIVITY

UNHELPFULBELIEFS &THOUGHTS

REPEATEDTREATMENTFAILURES

LONG-TERMUSE OF ANALGESIC,SEDATIVE DRUGS

LOSS OF JOB, FINANCIALDIFFICULTIES, FAMILYSTRESS

CHRONICPAIN

PHYSICALDETERIORATION(eg. muscle wasting, wt gain, joint stiffness)

DEPRESSION,HELPLESSNESS,FRUSTRATIONANGERPOOR SLEEP

SIDE EFFECTS(eg. stomach problems, lethargy, constipation)

Instead of trying to ‘treat’ pain in isolation, what about tackling as many of these contributors as possible?

NEUROPATHIC orNEUROPLASTICMECHANISMS

NOCICEPTIVEMECHANISMS

EXCESSIVESUFFERING & DISABILITY

INPUT FROM: FAMILY; HEALTHCARE PROVIDER(S); INSURERS; EMPLOYER

M. Nicholas. 2012

Targeted medication, interventional techniques,desensitizing,distraction,hot packs, TENS

Set realistic goals & pace up activities, exercises – despite pain; diet plan

Education about pain & treatments + identify & challenge unhelpful beliefs

Schedule pleasant activities (not just chores), improve sleep habits, fears, anger

Rationalise & cease unhelpful drugs

Facilitate RTW planning/re-training family/relationship interventions

Negotiate with workplace, family, agree on management plan with all & HCPs

Maintenance plan – chronic pain will fluctuate, need to plan for these, and for dealing with other stressors

Integrating findings with a successful case formulation approach

Steven J. Linton and Michael K. Nicholas, After assessment, then 

what?Integrating findings for successful caseformulation and 

treatment tailoring, Center for Health and Medical Psychology, Department 

of Behavioral, Social andLegal Sciences—Psychology, Örebro 

University; and Pain ManagementResearch Institute, 

University of Sydney

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Case Study: Meet Peter

Neuropathic

Radicular pain

Nociceptive mechanical 

pain

Peter – 55yo, AccountantHx: T2DM, Hypertension, Obesity, Osteoarthritis, Hypercholesterolaemia, Depression, Insomnia

Meds: • Targin 20/10 TDS • Sertraline 100mg mane• Metformin 1000mg daily • Temazepam 10mg nocte• Nuromol – 1 TDS PRN

Pain Complaint: Burning feet and lower back pain with pain shooting up the leg– can’t walk more than 100 metres before needing to stop

TARGIN

Amitriptyline / Pregabalin

Topical diclofenac / Capsaicin

Change Sertraline to Duloxetine

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