Pain Assesment and Its Characteristic

dr.Nur Surya Wirawan M.kes Sp.An

Biopsychological factors that interact and modulate the experience of pain (patient perception pain)
Characteristic of host -Biological: genetic, sex, endogenous pain control -Psychological: anxiety, depression, coping, behavior - Cognitive

PAIN

Disease -History - Present disease

Environment -Socialization Lifestyle Traumas - Cultural: expectations, upbringing, roles

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 hormone Kehlet H. Reg Anesth.1996;21(6S):3537. Cousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447491.

Respiratory Effects
Acute Pain

Tidal volume

Vital capacity

FRC Atelectasis

Alveolar ventilation

Mobility

Hypostatic pneumonia V/Q inequality

FRC = functional residual capacity; V/Q = ratio ventilation:perfusion of the lung Craig DB. Anesth Analg. 1981;60:46. Cousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447491.

Respiratory Effects (Contd)

Acute Pain Muscle spasm Impaired ventilation

Muscle splinting

Cough suppression
Lobular collapse Hypoxemia

Infection/pneumonia
Cousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447491.

Cardiovascular Effects
Acute Pain

Coronary vasoconstriction
Anxiety, pain

Sympathetic overactivity
HR, PVR, BP, cardiac output Ischemia

Ischemia
Angina MI

MI = myocardial infarction; HR = heart rate; PVR = peripheral vascular resistance; BP = blood pressure Cousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447491. Bowler DB, et al. In: Cousins MJ, Phillips GD, eds. Acute Pain Management; 1986:187236.

Effects on Peripheral Circulation

Acute Pain

Limb blood flow1 Venous emptying2 Venous thrombosis/embolism3

1. Cousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447491. 2. Modig J, et al. Acta Anaesth Scand. 1980;24:305309. 3. Modig J, et al. Anesth Analg. 1983;62:174180.

Gastrointestinal and Urinary Effects

Gastrointestinal Intestinal secretions Smooth muscle sphincter tone Intestinal motility

Acute Pain

Urinary

Sympathetic over activity

Urinary sphincter activity Urinary retention

Cousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447491. Nimmo WS. Br J Anaesth. 1984.56:2937.

Psychological Effects
Acute Pain

Anxiety

Sleep deprivation Depressio n

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

Other Effects of Acute Pain

Wound repair Impaired immunocompetence Hypercoagulable state

Drucker W, et al. J Trauma. 1996;40(3):S116122. Cousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447491. Jorgensen L, et al. Br J Anaesth. 1991;66:812.

Musculoskeletal Effects

Acute Pain Muscle spasm

Sympathetic overactivity

Sensitivity of peripheral nociceptors

Cousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447491.

Musculoskeletal Effects (Contd)

Acute Pain

Mobility Reflex vasoconstriction

Impaired muscle
metabolism Muscle atrophy Delayed normal muscle function
Cousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447491.

Effects on Pain-Signaling Systems

Acute Pain
Peripheral nociception Nerve excitability Hyperalgesia (1 + 2) Prolonged pain Allodynia

Chronic pain Damaged spinal pain-signaling systems

Cousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447491.

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.

Neuropathic Pain Characteristic Sensory Qualities

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 two of these sensory qualities.
Rathmell JP. Katz JA. In: Benzon H, et al, eds. Essentials of Pain Medicine and Regional Anesthesia; 1999:288294. 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 secondary Location and transition Onset and related factor Pain intensity and pattern Aggravating and relieving factors Aditional complain

Functional and medical aspects

Influence 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 symptoms of neuropathic pain

Nervous system dysfunction or damage

Positive symptoms (due to excessive activity)

Negative symptoms (due to deficit of function) Hypoesthesia Anesthesia Hypoalgesia Analgesia

Spontaneous pain Allodynia Hyperalgesia Dysesthesia Paresthesia

Sensory abnormalities and pain often co-exist

Each patient may have a combination of symptoms that may change over time (even within a single etiology)

Listen to the patient describing their pain

Electric shock-like Electric shock-

like
Shooting Shooting
Burning

Tingling

Numbness

Be alert for common verbal descriptors of NeP

Locate: correlate the region of pain to the lesion/dysfunction in the nervous system
Lumbar radiculopathy Carpal tunnel syndrome Diabetic peripheral neuropathy

Look for the presence of sensory and/or physical 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
Neuropathic pain Common NeP (e.g. PHN, DPN, descriptors: lumbar radiculopathy) shooting electric shock-like burning tingling numbness

Locate

Look

The painful region Apply gauze, may not necessarily pinprick, pinch be the same as the tests site of injury. Pain Conduct occurs in the etiology-specific neurological tests if territory of the appropriate, affected structure (e.g. straight-leg (nerve, root, spinal raise test for cord, brain) lumbar radiculopathy) Painful region is typically localized at the site of injury Physical manipulation causes pain sensations in site of injury

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

Common pain descriptors: aching throbbing stiffness

Using the 3L approach to help make a differential diagnosis

Are verbal descriptors suggestive of NeP? Yes Can you detect sensory abnormalities using simple bedside tests?

No

Yes

Probable nociceptive pain

No

Can you identify the responsible nervous system lesion/dysfunction? No Yes

Consider specialist referral if NeP is still suspected consider treatment in the interim period

Confirmed NeP diagnosis initiate treatment

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 nonpainful 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 instruments
Pain 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

moderate mild severe

Most pain

Likert scale

Numerical pain scale

0 No pain

10
Very severe pain

0 No pain

10 Very severe pain

Visual Analogue Scale

No pain

Severe pain

No pain Mild Moderate Severe

Severe pain

Numerical pain scale

Visual analogue scale (vas)
VAS score <4 47 >7 Interpretation Mild pain Moderate pain Severe pain

Numerical pain scale

Face scale

Emotional gradation happy to depression