pain assesment
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Pain Assesment and Its Characteristic
dr.Nur Surya Wirawan M.kes Sp.An
Characteristic of host-Biological: genetic, sex, endogenous pain control
-Psychological: anxiety, depression, coping, behavior- Cognitive
Disease-History
- Present disease
Environment-Socialization – Lifestyle – Traumas
- Cultural: expectations, upbringing, roles
PAIN
Biopsychological factors that interact and modulate the experience of pain
(patient perception pain)
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 hormoneKehlet H. Reg Anesth.1996;21(6S):35–37.Cousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447–491.
Respiratory Effects
FRC = functional residual capacity; V/Q = ratio ventilation:perfusion of the lungCraig DB. Anesth Analg. 1981;60:46.Cousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447–491.
Mobility
Hypostatic pneumonia
Tidal volume
Vital capacity
FRC Alveolar ventilation
Atelectasis
V/Q inequality
Acute Pain
Respiratory Effects (Cont’d)
Cousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447–491.
Impaired ventilation
Muscle spasm
Muscle splinting
Cough suppression
Lobular collapse
Infection/pneumonia
Acute Pain
Hypoxemia
Cardiovascular Effects
MI = myocardial infarction; HR = heart rate; PVR = peripheral vascular resistance; BP = blood pressureCousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447–491.Bowler DB, et al. In: Cousins MJ, Phillips GD, eds. Acute Pain Management; 1986:187–236.
Sympatheticoveractivity
Coronaryvasoconstriction
Anxiety, pain Ischemia Angina MI
HR, PVR, BP, cardiac output
Ischemia
Acute Pain
Effects on Peripheral Circulation
Limb blood flow1
Venous emptying2
Venous thrombosis/embolism3
1. Cousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447–491.2. Modig J, et al. Acta Anaesth Scand. 1980;24:305–309.3. Modig J, et al. Anesth Analg. 1983;62:174–180.
Acute Pain
Gastrointestinal and Urinary Effects
UrinaryGastrointestinal
Sympatheticover activity Urinary
sphincter activity
Urinary retention
Intestinal secretions Smooth muscle
sphincter tone Intestinal motility
Cousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447–491.Nimmo WS. Br J Anaesth. 1984.56:29–37.
Acute Pain
Psychological Effects
Cousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447–491.
Acute Pain
Anxiety
Depression
Sleep deprivation
Other Effects of Acute Pain
• Wound repair• Impaired immunocompetence• Hypercoagulable state
Drucker W, et al. J Trauma. 1996;40(3):S116–122.Cousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447–491.Jorgensen L, et al. Br J Anaesth. 1991;66:8–12.
Musculoskeletal Effects
Cousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447–491.
Sensitivity of peripheral nociceptors
Musclespasm
Sympatheticoveractivity
Acute Pain
Musculoskeletal Effects (Cont’d)
Mobility
Impaired muscle metabolism
Muscle atrophy Delayed normal
muscle function
Reflex vasoconstriction
Cousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447–491.
Acute Pain
Effects on Pain-Signaling Systems
Peripheral nociception Nerve excitability
Prolonged pain
Chronic pain Damaged spinal pain-signaling systems
Cousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447–491.
Acute Pain
Hyperalgesia (1 + 2) Allodynia
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.
• 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 twoof 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.
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 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
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 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
HyperalgesiaAllodynia Anesthesia
Negative symptoms(due to deficit of function)
Nervous system dysfunction or damage
Hypoesthesia
HypoalgesiaAnalgesia
“Numbness”
“Shooting” “
Listen to the patient describing their pain
Be alert for commonverbal descriptors of NeP
“Electric shock-like”
“Tingling”
“Shooting” “Burning”
“Numbness”
“Electric shock-like”
Locate: correlate the region of pain to the lesion/dysfunction in the nervous system
Carpal tunnel syndrome Diabetic peripheral neuropathyLumbar radiculopathy
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 differentiates neuropathic from nociceptive pain
Listen Locate LookNeuropathic pain(e.g. PHN, DPN, lumbar radiculopathy)
Common NePdescriptors:• shooting • electric
shock-like• burning• tingling• numbness
The painful region may not necessarily be the same as the site of injury. Pain occurs in the neurological territory of the affected structure (nerve, root, spinal cord, brain)
• Apply gauze, pinprick, pinch tests
• Conduct etiology-specific tests if appropriate, (e.g. straight-leg raise test for lumbar radiculopathy)
Nociceptive pain(e.g. burn, broken limb, osteoarthritis)
Common pain descriptors:• aching• throbbing• stiffness
Painful region is typically localized at the site of injury
Physical manipulation causes pain sensations insite of injury
YesNo
Confirmed NeP diagnosis – initiate treatment
Using the 3L approach to help make a differential diagnosis
Yes
NoCan you identify the
responsible nervous systemlesion/dysfunction?
Consider specialist referralif NeP is still suspected –
consider treatment in the interim period
Yes
No
Probablenociceptive pain
Can you detect sensoryabnormalities using
simple bedside tests?
Are verbal descriptorssuggestive of NeP?
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 non-painful 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 instrumentsPain 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 mild
moderatesevere
Most pain
Likert scale
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
Visual Analogue Scale
No pain
Severe pain
No pain Severe painMild Moderate Severe
X
Numerical pain scale
Visual analogue scale (vas)
VAS score Interpretation
< 4 Mild pain4 – 7 Moderate pain> 7 Severe pain
Numerical pain scale
Face scale
Emotional gradation happy to depression