Pain: Classification & Assessment Flashcards by J H

Pain

Define Pain -

Some findings -

“an unpleasant sensory and emotional experience associated with actual and potential tissue damage, or described in terms of such damage, or both.”

Pain is subjective
◦ Many clinicians define pain as “whatever the patient says it is.” –( Herndon et al., 2020)

Pain is a very common reason for seeking medical attention

Many healthcare providers do not receive adequate training in the treatment of pain

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What are the 4 Pain Classification?

Underlying cause (3 types)
Duration (acute or chronic)
Location (body region)
Intensity (mild, moderate, severe)

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Pain

What are the 3 Underlying Cause?

1. Somatic (Nociceptive Pain)
   • Fracture
   • Incisional injury
   • Thermal injury
   • Traumatic injury

2. Visceral (Nociceptive Pain)
    • Bowel obstruction
    • Constipation
    • Endometriosis
    • Metastatic organ involvement

3. Neuropathic Pain (Non‐Nociceptive)
    • Spinal stenosis
    • Diabetic neuropathy
    • Post herpetic neuralgia
    • Phantom limb pain

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Characteristics of Somatic Pain:

Involves activation of nociceptors in cutaneous or deep tissue
◦ Skin, bone, joint, muscle, or connective tissue
◦ e.g., broken bone, sprained ankle

Superficial
◦ Throbbing; aching; may be associated with
tenderness; localized
◦ e.g., superficial burns, cuts, bruises

Deep – structures of body wall
◦ Dull aching, can be localized, but may radiate to
adjacent area
◦ e.g., post‐operative pain, trauma (because of damage
to skeletal muscles)

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Characteristics of Visceral Pain:

Results from injury to sympathetically innervated organs

Five (5) key characteristics
1. Not evoked from all viscera / organs
◦ The kidneys, liver, and lungs are not sensitive to
pain; this is different mechanism
2. Not linked to injury
◦ e.g., a stretched bladder from urinary retention
may cause pain
3. Referred to body wall
4. Diffuse and poorly localized
5. Intense motor and autonomic reactions

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Characteristics of Neuropathic Pain:

Non‐nociceptive pain resulting from damage to or pathological changes in neurons

Characteristics
◦ Continuous or paroxysmal
◦ Burning, electric tingling, shooting, lack of sensation
◦ Persists beyond normal healing period

Responds poorly to traditional analgesia

Requires multidisciplinary approach

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Classification by Duration

Characteristics of Acute Pain:

Nociceptive ‐ Protective Mechanism
◦ Warns of danger
◦ Warns of disease
◦ Limits use of the painful area

Pain < 1 month duration
◦ Typically somatic and visceral in nature

Abates quickly when the underlying pathology stops
◦ e.g., surgery, acute illness, trauma, labour, and other
medical procedures
◦ Our goal is to recognize (and treat) this pain before it
becomes chronic

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Classification by Duration

Characteristics of Chronic Pain:

• > 6 months duration
• Little protective mechanism
• May be nociceptive, neuropathic or mixed
• Persists after pathology resolves
• Little chance of being pain free
- May result in changes to pain receptors

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Characteristics of Acute vs. Chronic Pain

Relief of Pain?

Acute Pain - Highly desirable

Chronic Pain - Highly desirable

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Characteristics of Acute vs. Chronic Pain

Dependence & tolerance to analgesics?

Acute Pain - Unusual

Chronic Pain - Common

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Characteristics of Acute vs. Chronic Pain

Psychological Component?

Acute Pain - Usually not present

Chronic Pain - Often a major problem

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Characteristics of Acute vs. Chronic Pain

Organic Cause?

Acute Pain - Common

Chronic Pain - May not be present

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Characteristics of Acute vs. Chronic Pain

Family/Environmental Issues?

Acute Pain - Small

Chronic Pain - Significant

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Characteristics of Acute vs. Chronic Pain

Insomnia?

Acute Pain - Unusual

Chronic Pain - Common component

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Characteristics of Acute vs. Chronic Pain

Treatment Goal?

Acute Pain - Cure or eliminate pain

Chronic Pain - Functionality

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Characteristics of Acute vs. Chronic Pain

Depression?

Acute Pain - Uncommon

Chronic Pain - Common

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Acute Pain – Presentation

General:

• Obvious distress (facial expressions, body
movements, vocalizations)
• Attention to factors that alter pain threshold

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Acute Pain – Presentation

Symptoms:

• Sharp, dull, tingling, shooting, radiating, fluctuating
intensity
• Occur in a timely relationship with noxious stimulus

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Acute Pain – Presentation

Signs:

• Hypertension, tachycardia, diaphoresis, mydriasis,
pallor (not diagnostic)
• Comorbid conditions not present
• Predictable response to treatment

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Acute Pain – Presentation

Lab & DI:

No specific findings to diagnose pain

* Role in determining & managing underlying pathology

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Chronic Pain – Presentation

General:

• Can appear to have no noticeable suffering
• Assess mental/emotional factors that alter the pain
threshold.
- Anxiety, depression, fatigue, anger, and fear are
noted to lower this threshold.
- Mood elevation, sympathy, distraction, and
understanding raise the pain threshold.

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Chronic Pain – Presentation

Symptoms:

• Sharp, dull, tingling, shooting, radiating, fluctuating
intensity, varying in location
• Occur in absence of a timely relationship with noxious
stimulus
• Over time, the pain stimulus may cause symptoms
that completely change (eg, sharp to dull, obvious to
vague).

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Chronic Pain – Presentation

Signs:

• Hypertension, tachycardia, diaphoresis, mydriasis,
pallor are SELDOM present
• Comorbid conditions are often present (e.g., insomnia,
depression, and anxiety).
• Unpredictable response to treatment

Chronic Pain – Presentation

Lab & DI:

• No specific findings to diagnose pain
• Pain is best diagnosed based on patient description
and history.

Classification by Duration List 2 other pains other than Acute or Chronic:

Subacute ◦ Pain lasting 4 or 7 to 12 weeks (i.e., > 1 month & < 6 months) ◦ Similar nociceptive mechanism Incidental Pain (a.k.a., breakthrough pain)

Pain Assessment List 4 ways to assess pain:

◦ Patient interview * Work through the PCP, SCHOLAR, PQRST * Medical & medication history (incl. pain treatment history) ◦ Use Pain Assessment Tools to quantify and or qualify pain ◦ Physical exam & diagnosis findings ◦ Behavioural observation

Barriers to Assessing Pain List 7 possible barriers to assessing pain:

Differing response or expectations Cognitive or communication barriers Cultural or social barriers ◦ Reluctance to report pain Co‐existing illness with medications Poor practitioner assessment techniques Practitioner limitations System barriers

Pain What is "S" in patient interview SCHOLAR?

Symptoms

Pain What is "C" in patient interview SCHOLAR?

Characteristics • Describe the pain • Sharp, dull, burning, stabbing, pressure, constant, intermittent

Pain What is "H" in patient interview SCHOLAR?

History • What has been done before? • Has this happened in the past?

Pain What is "O" in patient interview SCHOLAR?

Onset • When did it start? • What brought it on?

Pain What is "L" in patient interview SCHOLAR?

``` Location • Primary & secondary locations • Can you put your finger on it? Does it spread to other areas? • Do you have any other symptoms? ```

Pain What is "A" in patient interview SCHOLAR?

Aggravating Factors | • What makes it worse?

Pain What is "R" in patient interview SCHOLAR?

Relieving Factors | • What makes it better?

Pain What is "P" in patient interview PQRST?

Precipitating, provocation or palliating factors associated with pain • What brought it on? • What makes it worse/better?

Pain What is "Q" in patient interview PQRST?

Quality/quantity of the pain • Describe the pain • Sharp, dull, burning, stabbing, pressure, constant, intermittent

Pain What is "R" in patient interview PQRST?

Region where the pain is located or radiation of pain • Primary & secondary locations • Can you put your finger on it? Does it spread to other areas? • Do you have any other symptoms?

Pain What is "S" in patient interview PQRST?

Subjective description of severity of the pain • Numerical scale or other assessment tools • Impact on function

Pain What is "T" in patient interview PQRST?

Temporal (timing) or time‐related • When did it start? • When does it occur & how often?

Pain Behaviour in Children Infants:

Infants may present with increased fussiness & change in eating habits

Pain Behaviour in Children Preschoolers:

clingy, immobile, lose verbal & motor skills, lose sphincter control

Pain Behaviour in Children School age children:

Aggressive behaviour, shame, nightmares, withdrawal

Pain Behaviour in Children Adolescents:

Oppositional behaviour & depression (chronic pain)

Pain in Elderly What are some issues with pain in elderly? (4)

Assessments can be challenging Solicit information from caregivers and family members if poor historian (eg. Dementia) Pay attention to behavioural cues (eg. grimacing) More prone to adverse effects

Pain Assessment Tools Single Dimension Tools What are the 4 most commonly used Single Dimension Tools to assess pain?

1. Visual Analog Scale (VAS) 2. Verbal Numerical Scale 3. Verbal Rating Scale 4. Wong Baker Faces Pain Rating Scale

Pain Assessment Tools Single Dimension Tools Pros and cons of Single Dimension Tools in general:

Fast and easy to use, provide objective data but... oversimplify pain and have decreased reliability in certain populations

Pain Assessment Tools Single Dimension Tools Describe Visual Analog Scale (VAS) in terms of 1. Type of Patient 2. Type of pain 3. Advantages 4. Disadvantages

``` 1. Type of Patient Child ≥ 7 Adult 2. Type of pain Current 3. Advantages Simple, easily understood & reproducible 4. Disadvantages Mono‐dimensional, visual & motor coordination, limits of scale ```

Pain Assessment Tools Single Dimension Tools Describe Verbal Numerical Scale in terms of 1. Type of Patient 2. Type of pain 3. Advantages 4. Disadvantages

``` 1. Type of Patient Adult 2. Type of pain Current 3. Advantages As for VAS eliminates visual / motor coordination 4. Disadvantages Mono‐dimensional, limits of scale ```

Pain Assessment Tools Single Dimension Tools Describe Verbal Rating Scale in terms of 1. Type of Patient 2. Type of pain 3. Advantages 4. Disadvantages

``` 1. Type of Patient Adult 2. Type of pain Current 3. Advantages Qualifies pain, easy to administer 4. Disadvantages Limited categories, assumes equal distance between descriptors ```

Pain Assessment Tools ``` Asking patient how does your pain affect: ◦ your sleep? ◦ your physical functions? ◦ your ability to work? ◦ your mood? ◦ your family life? ◦ your social life? ◦ your sex life? ◦ Are you depressed? ``` is consider Single Dimensional Pain Assessment or Multi-Dimension Pain Assessment?

Multi-Dimension Pain Assessment

Pain Assessment Tools Multi-Dimension Tools What are the 4 most commonly used Multi-Dimension Tools to assess pain?

1. Pain Diary 2. Pain drawing 3. Brief Pain Inventory (BPI) 4. McGill Pain Questionnaire

Pain Assessment Tools Multi-Dimension Tools Describe Pain Diary in terms of 1. Type of Patient 2. Type of pain 3. Advantages 4. Disadvantages

``` 1. Type of Patient Adult 2. Type of pain Previous pain 3. Advantages Reliable, not subject to recall 4. Disadvantages Depended on accurate recording & verbal/motor skills ```

Pain Assessment Tools Multi-Dimension Tools Describe Pain Drawing in terms of 1. Type of Patient 2. Type of pain 3. Advantages 4. Disadvantages

``` 1. Type of Patient Child ≥ 8 Adult 2. Type of pain Current Pain 3. Advantages Used by non experts Reliability over time Discriminating 4. Disadvantages Do not measure intensity Not applicable to pain in discrete areas ```

Pain Assessment Tools Multi-Dimension Tools Describe Brief Pain Inventory (BPI) in terms of 1. Type of Patient 2. Type of pain 3. Advantages 4. Disadvantages

``` 1. Type of Patient Adult 2. Type of pain Cancer & non cancer pain 3. Advantages Reliable, valid, easy to administer 4. Disadvantages Does not address emotional significance or situational influence ```

Pain Assessment Tools Multi-Dimension Tools Describe McGill Pain Questionnaire in terms of 1. Type of Patient 2. Type of pain 3. Advantages 4. Disadvantages

``` 1. Type of Patient Adult 2. Type of pain Cancer & non cancer pain 3. Advantages Reliable, valid Widely applicable 4. Disadvantages Requires vocabulary & intellect ```

Pain What are the goals of therapy for pain? (5)

1. Recognize that the patient is experiencing pain 2. Identify and treat the cause of pain 3. Reduce or eliminate the pain 4. Minimize adverse effects 5. Prevent progression to chronic pain

Pain Non‐Pharmacological Management of Pain Therapy (7)

1. (P)RICE (cold < 48h) ◦ Most useful for MSK injury 2. Application of heat (> 48h post injury) 3. Acupuncture, Massage, Physiotherapy, Chiropractic 4. Exercise 5. Transcutaneous Electrical Nerve Stimulation (TENS) 6. Cognitive behavioural therapy 7. Biofeedback