modul clinical characteristic of pain & pain assessment
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Pain Assesment and ItsCharacteristic
dr.Nur Surya Wirawan M.kes Sp.An
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Characteristic of host
-Biological: genetic, sex, endogenous pain control
-Psychological: anxiety, depression, coping, behavior
- Cognitive
Disease
-History
- Present disease
Environment
-SocializationLifestyleTraumas
- Cultural: expectations, upbringing, roles
PAIN
Biopsychological factors that interact and
modulate the experience of pain
(patient perception pain)
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Pain expression
Aching
Stabbing
Tender
Tiring
Numb
Dull
Crampy
Throbbing
Gnawing
Burning
Penetrating Miserable
Radiating
Deep
Shooting
Sharp
Exhausting
Nagging
Unbearable
Squeezing
Pressure
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Pain description
Location, transmition
Intensity
Quality
Onset, duration and rhythm
Patient expression
Aggravating or relieving factors
Impact of pain Concomitant condition
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Physiologic Consequences of Acute Pain
Bonica JJ. The Management of Pain. 2nd ed. Vol. 1; 1990.
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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.
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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.
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Respiratory Effects
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.
Mobility
Hypostatic pneumonia
Tidalvolume
Vitalcapacity
FRC Alveolarventilation
Atelectasis
V/Q inequality
AcutePain
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Respiratory Effects (Contd)
Cousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447491.
Impairedventilation
Musclespasm
Muscle splinting
Cough suppression
Lobular collapse
Infection/pneumonia
AcutePain
Hypoxemia
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Cardiovascular Effects
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.
Sympatheticoveractivity
Coronaryvasoconstriction
Anxiety, pain Ischemia
Angina
MI
HR, PVR, BP, cardiac
output
Ischemia
AcutePain
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Effects on Peripheral Circulation
Limb blood flow1
Venous emptying2
Venousthrombosis/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.
AcutePain
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Gastrointestinal and Urinary Effects
UrinaryGastrointestinal
Sympatheticover activity
Urinarysphincter
activity
Urinaryretention
Intestinalsecretions
Smooth musclesphincter tone
Intestinal motility
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.
AcutePain
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Psychological Effects
Cousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447491.
AcutePain
Anxiety
Depression
Sleepdeprivation
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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.
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Musculoskeletal Effects
Cousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447491.
Sensitivity of peripheralnociceptors
Musclespasm
Sympatheticoveractivity
AcutePain
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Musculoskeletal Effects (Contd)
Mobility
Impaired musclemetabolism
Muscle atrophy
Delayed normalmuscle function
Reflexvasoconstriction
Cousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447491.
AcutePain
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Effects on Pain-Signaling Systems
Peripheral nociception
Nerve excitability
Prolonged pain
Chronic pain Damaged spinalpain-signalingsystems
Cousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447491.
AcutePain
Hyperalgesia (1 + 2 )
Allodynia
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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.
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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 RegionalAnesthesia; 1999:288-294
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Characteristics of Peripheral
Neuropathic Pain
Caused by pathologic changes in peripheral nerves:
Transection of peripheral nerve e.g., in amputation, phantompain, 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
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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.
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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.
Neuropathic Pain
Characteristic Sensory Qualities
Rathmell JP. Katz JA. In: Benzon H, et al, eds.Essentials of Pain Medicine and Regional Anesthesia; 1999:288
294.Baron. Clin J Pain. 2000;16:S12-S20.
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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.
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Diagnosis
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History Pain description/characteristic:
Primary or secondaryLocation and transitionOnset and related factorPain intensity and patternAggravating and relieving factorsAditional complain
Functional and medical aspectsInfluence 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
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Physical examination
Vital sign, height, weight
Mental status
Skin abnormality
Gait
Behavior related to pain, face, the use of assistivedevice
Complete physical examination. Pain assessment
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Neuropathic pain
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Positive and negative sensory symptomsof neuropathic pain
Positive symptoms(due to excessive activity)
Dysesthesia
Sensory abnormalities and pain often co-existEach patient may have a combination of symptoms
that may change over time (even within a single etiology)
Paresthesia
Spontaneous pain
Hyperalgesia
Allodynia Anesthesia
Negative symptoms(due to deficit of function)
Nervous system dysfunction or damage
Hypoesthesia
Hypoalgesia
Analgesia
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Numbness
Shooting
Listen to the patient describing their pain
Be alert for common
verbal descriptors of NeP
Electric shock-
like
Tingling
ShootingBurning
Numbness
Electric shock-like
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Locate: correlate the region of pain to thelesion/dysfunction in the nervous system
Carpal tunnel syndrome Diabetic peripheral neuropathyLumbar radiculopathy
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Look for the presence of sensory and/orphysical 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
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Applying the 3L approach to diagnosisdifferentiates neuropathic from nociceptive pain
Listen Locate LookNeuropathic pain(e.g. PHN, DPN,lumbar radiculopathy)
Common NeP
descriptors:
shooting
electric
shock-like burning
tingling
numbness
The painful regionmay not necessarilybe the same as thesite of injury. Painoccurs in theneurologicalterritory of theaffected structure(nerve, root, spinalcord, brain)
Apply gauze,pinprick, pinchtests
Conduct
etiology-specifictests ifappropriate,(e.g. straight-legraise test forlumbarradiculopathy)
Nociceptive pain(e.g. burn, brokenlimb, osteoarthritis)
Common paindescriptors:
aching
throbbing
stiffness
Painful region istypically localizedat the site of injury
Physicalmanipulationcauses painsensations insite of injury
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YesNo
Confirmed NeP diagnosisinitiate treatment
Using the 3L approach to help make adifferential diagnosis
Yes
No
Can you identify theresponsible nervous system
lesion/dysfunction?
Consider specialist referralif NeP is still suspected
consider treatment inthe interim period
Yes
No
Probablenociceptive pain
Can you detect sensoryabnormalities using
simple bedside tests?
Are verbal descriptorssuggestive of NeP?
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Mixed pain
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Pain component
Nociceptive:
Underlying condition i.e. surgical wound,
limb pain after a fracture, pain of burns andbruises, osteoarthritis.
Pain description: throbbing, aching, stiffness
Inflammatory mediators: PGs, cytokines,acute phase reactants i.e. CRP.
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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
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Pain component
Neuropathic:
History
Pain intensity: VAS-visual analogue scale
Sensory descriptor: pain qualities i.e.hot, burning,
sharp, stabbing, cold, allodynia or common non-
painful sensation i.e. tingling, prickling, itching,
numbness andpins and needles;
Temporal variation: pain often gets worse towards
the end of the day.
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Pain component
Neuropathic:
Physical examination
- Gross motor examination: motor weakness may occur
around the involved nerve, attempt to differentiatebetween 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.
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Pain component
Neuropathic:
Special test: CT and MRI scan,
electromyography and nerve conductionstudies; three-phase nuclear medicine bone
scan or biochemistry such as OGTT, and
thyroid function.
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Assessment of pain severity
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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
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Frequency of Pain Assessmentand Documentation
Preoperatively
Routinely at regular intervals postoperatively With each new report of pain
At suitable intervals after each analgesicintervention
Carr DB, et al. AHCPR Pub. No. 92-0032. 1992.
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Categorical pain scale
No
pain mild
moderate
severe
Most pain
Likert scale
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Numerical pain scale
0 1 2 3 4 5 6 7 8 9 10
No pain Very severe pain
109876543210
No pain Very severe pain
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Visual Analogue Scale
No
pain
Severe
pain
No pain SeverepainMild Moderate Severe
X
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Numerical pain scale
Visual analogue scale (vas)
VAS score Interpretation
< 4 Mild pain
4 7 Moderate pain
> 7 Severe pain
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Numerical pain scale
Face scale
Emotional gradation happy to depression