Overview of Pain Assessment

The primary concern that brings people to a doctor’s office is usually pain. In the U.S., over 50 million people, which makes up 20% of all patients, experience chronic pain. Chronic pain is more common in older people. With the increasing misuse of opioids, it is crucial to treat patients’ pain effectively and sensibly.

When evaluating pain, doctors need to identify if it is acute (short-term) or chronic (long-lasting). If severe pain persists for longer than 3 months, it is typically considered chronic. Whether the pain is acute or chronic is an important distinction, as the nature of the pain pathways may change when pain becomes chronic. This could result in different characteristics, where the painful area becomes abnormally sensitive or experiences discomfort even with soft touch. Tissues might also become more tense and cold, and the pain may feel more dull and achy rather than sharp.

The way pain is evaluated can impact a patient’s long-term health. Considering that over 30% of patients report pain lasting longer than 6 months, healthcare providers should be equipped with various tools to accurately determine a patient’s pain to provide better treatment. Both adults and children can experience chronic pain, which can significantly impact daily functioning and quality of life.

Different types of pain like acute, chronic, and centralized, or nerve-related pain require different treatment approaches. For instance, 10% of the U.S. population reports nerve-related pain. This group may find more benefit from specific types of medications such as serotonin-norepinephrine reuptake inhibitors, like duloxetine, rather than common over-the-counter pain relievers like ibuprofen. Chronic pain is a major reason for disability and lost work hours in the U.S., resulting in significant economic loss. Therefore, using standardized methods to assess pain can help monitor a patient’s symptoms and recovery more objectively.

A critical part of evaluating pain is recognizing how associated medical conditions and social determinants of health affect pain. Mood disorders, for example, can worsen pain, but pain can improve with treatment of the mood disorder. Other factors affecting pain can include a history of opioid dependence, intravenous drug use, sexual abuse, trauma, old age, chronic diseases, and financial insecurity. Even cultural influences can affect a person’s experience of pain.

Anatomy and Physiology of Pain Assessment

Acute pain, or sudden pain, begins in the peripheral nervous system, which is the group of nerves that connect your nervous system to the rest of your body. These nerves send pain signals to your spinal cord and then to your brain. When these signals are strong enough, we feel pain. In addition to this, pain can also be caused by nerve problems or can become centralized.

After being in pain for a long time, usually 3 to 6 months, the pain can become centralized. This means that it takes less intense signals for someone to feel pain. This change can be problematic because pain is usually our body’s way of telling us something is wrong. But with centralized pain, we might feel pain from things that don’t usually cause pain (this is called allodynia), or we might feel more pain from minor injuries (this is called hyperalgesia). In other words, centralized pain doesn’t work the way pain is supposed to work.

Neuropathic pain, on the other hand, comes from problems with a part of our nervous system that helps us feel things on our skin and in our body like temperature or touch. This kind of pain can also be peripheral (coming from nerves outside the brain and spinal cord) or centralized. It’s possible to have both centralized and neuropathic pain, and they can both contribute to the development of long-term or chronic pain.

The way doctors help patients manage pain depends on what’s causing it. Sometimes, they can influence the chemicals in the brain that carry pain signals or ion channels that create electrical signals, which means they work on the level of your nerve cells. Pain can also be eased by medications that work on opioid receptors in the brain, which are specific areas in your brain where these medications can have their effect.

Why do People Need Pain Assessment

Pain is a personal experience and people feel and describe it differently. That’s why when doctors ask “how much pain are you in?”, the answers can really vary. For example, a patient dealing with a severe condition like pancreatitis (a painful inflammation of the pancreas) might say their pain is a 4 out of 10. Meanwhile, another patient with a wrist strain might say their pain is an 8 out of 10. Both patients are correct, because pain is a personal experience and can’t be objectively measured like your weight or blood pressure.

However, doctors have some objective ways to understand chronic (long-term) pain better. These methods aim to standardize how we discuss pain and its severity, with the ultimate goal being to better manage the pain and improve patient’s day-to-day lives and overall well-being.

A critical first step doctors take when assessing your pain is figuring out if it is nociceptive or neuropathic. Nociceptive pain is the body’s response to harmful or potentially harmful stimuli. If you describe your pain as sharp or throbbing, it’s likely nociceptive, which is often associated with acute or sudden injury. Neuropathic pain, on the other hand, is caused by damage to the nervous system itself. If you describe your pain as burning, shooting, a pins and needles sensation, or like an electric shock, doctors might conclude it is neuropathic. Understanding the type of pain is a first step towards effective treatment.

When a Person Should Avoid Pain Assessment

How a person’s individual life situation, like being pregnant, can impact decisions on how to treat their pain. For example, pregnancy is often linked with lower back pain, and it can make the selection of pain relief medicine more complicated. This can become particularly tricky when considering the use of strong painkillers, like opioids.

It’s important to remember that pain can’t just be measured with a number. Sometimes, healthcare professionals will ask a patient to rate their pain on a scale of 1 to 10. For example, a 1 out of 10 might feel like a small bruise, while a 10 out of 10 could feel like the pain of childbirth or passing a kidney stone. So, if someone says their pain is 9 out of 10, this doesn’t mean they should automatically be given strong painkillers like opioids. They might be better off with a less strong painkiller that can better treat the root cause of their pain.

Equipment used for Pain Assessment

A ‘body diagram map’ is a tool doctors use to understand where a patient is feeling pain in their body. If you’ve sprained your ankle, for example, your pain is in one specific location and a map might not be needed. But pain can sometimes be spread out in different places across your body, and then it gets complicated!

For instance, if you’re someone suffering from conditions like fibromyalgia (a disorder characterized by widespread musculoskeletal pain), centralized pain disorder (a condition where pain is felt in specific areas or all over the body), and rheumatoid arthritis (an inflammatory disorder affecting many joints, including those in the hands and feet), you might feel pain in many different places. This can make it hard for doctors to understand what’s hurting and why.

In such a case, a body diagram can be really helpful. A doctor will use it to make sense of where exactly you’re hurting, whether the pain is new or has been around for a while, and if it seems to be spreading from one place to another.

So, if you have multiple conditions, a doctor might want to know if you’re experiencing an increase in rheumatoid arthritis symptoms, or if the pain is due to knee osteoarthritis getting worse. Using the body diagram map, they can make sense of these different types of pain.

Doctors may also use a questionnaire specially designed for people with fibromyalgia to decipher new pain complaints. Advanced techniques like functional MRI (a procedure using MRI technology that measures brain activity by detecting changes associated with blood flow) and other imaging tests may also be used to better assess pain.[20][21]

Who is needed to perform Pain Assessment?

Your family doctor or specialist may need to look at your past medical records to understand your pain better. These records might include things like X-rays or MRI scans, mental health treatments like cognitive-behavioral therapies (a kind of therapy that helps you manage your problems by changing the way you think and behave), any operations you’ve had in the past, and the medicines you’ve taken before.

For instance, let’s say you have neuropathic pain due to diabetic peripheral neuropathy (a type of nerve damage that can occur with diabetes), and you’ve previously tried a drug called gabapentin but it didn’t work. Your doctor will want to know why it didn’t work. Was it because of side effects? Maybe gabapentin made you too sleepy, or it didn’t help with the pain as much as you would have liked. And before stopping a medicine, it’s important to consider the dose you were taking. If you were taking 300 mg of gabapentin twice a day, you were only taking a small part of the maximum dose. Gabapentin is usually considered to have failed in treating nerve pain only after reaching 1800 mg per day (provided it’s tolerable), not just 600 mg.

Besides medication, there are also non-drug treatments like virtual reality, acupuncture (a form of treatment that involves inserting very thin needles through a person’s skin at specific points on the body), physical therapy, and invasive treatments like neuromodulation (a treatment that uses electrical signals to balance the nerve activity in the body). It’s important for your doctor to gather these records and understand what worked and what didn’t in your previous treatments.

Preparing for Pain Assessment

The way a doctor interacts with their patients, how well they listen, and the care and understanding they show can make a big difference in the patient’s health outcomes. The bond between the doctor and the patient can deeply affect the patient’s level of pain. Research shows that when doctors are supportive and empathetic, patients tend to feel better and experience less pain.

How is Pain Assessment performed

Doctors use certain systems to understand and measure a patient’s pain. One of these methods involves the use of the acronyms “COLDERAS” and “OLDCARTS”, which help doctors to assess the type, timing, place, and duration of pain, as well as any additional symptoms or activities that make the pain better or worse.

Another measurement tool is called the Pain, Enjoyment, General Activity (PEG) score, which looks not only at the level of pain but also how much this pain affects a person’s daily activities and quality of life. For example, if a patient who had pain that was 7 out of 10 becomes 5 out of 10 after treatment, that might not seem like a big change. Still, if the person also says they’re enjoying life more and can do more activities, then the treatment has been very helpful. So, the PEG tool grades on a scale from 0 to 10 for each category, with higher scores indicating more severe pain and problems with daily activities.

The 4-item Patient Health Questionnaire (PHQ-4) is another tool used to screen for signs of depression and anxiety, which can often go hand in hand with chronic pain. If someone scores more than 5 on the PHQ-4, doctors will typically do more tests to further assess mental health. Another scale used is the Defense and Veterans Pain Rating Scale (DVRPS), which assesses not only the level of pain but also how it impacts sleep, mood, stress, and activities.

In children, doctors use a different approach since younger children may have trouble describing their pain. Sometimes they use visual aids, like pictures of faces showing different levels of distress. By the time they reach adolescence, most kids can rate their pain on a numerical scale like adults do. Additionally, there are tools like the Pediatric Pain Questionnaire or the Adolescent and Pediatric Pain Tool which ask the child to indicate on a drawing of a body where they feel the pain. These tools are usually best for kids around 10 years old.

For those too young or unable to communicate their pain, like infants or children with certain disabilities, doctors use observational tools. These look at things like facial expression, fussiness, and how easily they can be comforted. The Revised Face, Legs, Activity, Cry, Consolability (r-FLACC) scale is one such tool. Others might look for less typical behaviors, like grimacing, moaning, or aggressiveness.

In short, the methods of assessing pain can vary greatly depending on the patient’s age, ability to communicate, and specific symptoms. These tools help doctors understand a patient’s pain more accurately, paving the way for effective treatment.

Possible Complications of Pain Assessment

If your family has a history of issues such as mental health disorders, persistent pain, or drug abuse, you are likely to have a higher risk of suffering from chronic pain. It’s important not to overlook lifestyle factors like sleep, stress, exercise and diet. They all play an essential role in your recovery from injury.

If you think or worry excessively about your pain, this can actually make your pain even worse. This extreme focus on pain, known as “catastrophizing,” can result in a cycle of fear and anguish that intensifies the pain rather than reducing it.

Communities that don’t have a lot of resources or access to healthcare are more likely to suffer from issues like chronic pain, drug abuse, and dependence on opioids (a type of medication used for pain relief). It’s important to consider these factors when a healthcare professional analyses a patient’s pain. They should also keep in mind things like the patient’s financial situation and their cultural background. For example, more people use long-term opioids in certain parts of the world. How pain is assessed can vary depending on factors like the patient’s age, if they are a child or senior, or if they live with any disabilities.

If you start physical therapy for shoulder pain but stop attending after only two sessions, it’s not that the treatment has failed. It’s just that it hasn’t been fully carried out. This is why reviewing the effectiveness of therapy is so important. Deciding to stop therapy due to not wishing to attend more sessions is different from completing all sessions but still feeling pain. This could indicate that the initial assessment of your pain wasn’t accurate.

Remember, the way a healthcare professional assesses your pain based on mere observation, can often underestimate the intensity of pain you might be feeling on your own. It’s also worth noting that factors like hunger and stress can also affect how severe your pain feels.

What Else Should I Know About Pain Assessment?

If you’ve had surgery and are experiencing severe pain that lasts for several days, it might affect your quality of life in the long run more than the initial post-surgery discomfort. Part of understanding your pain involves figuring out what kind of pain you’re experiencing. Your doctor will pay close attention to how you describe your pain – whether it’s a burning or sharp sensation and whether it comes and goes or is constant. This can help your doctor understand what’s causing your pain.

Certain physical signs can also guide your doctor. If you’re experiencing allodynia (a condition where normal touch or pressure causes pain) or hyperalgesia (increased sensitivity to pain), it could suggest that your pain isn’t just a result of recent surgery, but rather a more centralized issue.

Your doctor should talk to you about what to expect from your pain treatment and educate you about your condition. Just know that certain types of surgery – like breast surgery – may have a higher risk of leading to long-term pain compared to others like knee replacement surgery.

Remember, assessing your pain isn’t a one-time event, but an ongoing process that helps your doctor refine their understanding of your condition, monitor the effectiveness of your treatments, and track changes in your pain over time. Having long-term (or chronic) pain doesn’t necessarily mean you have a chronic pain disorder. It’s important to understand that treatment may also involve addressing other health conditions you may be dealing with. This comprehensive approach can significantly improve your overall health results.

Frequently asked questions

1. How can we determine if my pain is acute or chronic? 2. What type of pain am I experiencing (nociceptive or neuropathic)? 3. Are there any specific tools or questionnaires that can help assess my pain? 4. How can my individual life situation or medical history impact the treatment options for my pain? 5. How will my pain be monitored and evaluated over time to ensure effective treatment?

Pain assessment can help determine the cause and severity of pain, which can guide treatment options and management strategies. It can help healthcare professionals understand the impact of pain on a person's daily life and overall well-being. By accurately assessing pain, healthcare providers can develop personalized treatment plans to alleviate pain and improve quality of life.

You would need pain assessment to accurately determine the severity and nature of your pain. Pain assessment helps healthcare professionals understand the level of pain you are experiencing and guide them in making appropriate decisions regarding pain management and treatment options. It allows for a more personalized and effective approach to pain relief, taking into consideration factors such as your individual circumstances, underlying causes of pain, and potential risks associated with certain medications.

One should not get a pain assessment if they are pregnant or if their pain can be better treated with a less strong painkiller that targets the root cause of their pain.

The text does not provide specific information about the recovery time for Pain Assessment.

To prepare for a pain assessment, the patient should be ready to describe their pain in detail, including the type of pain (nociceptive or neuropathic), the location, duration, and intensity. They should also be prepared to discuss any additional symptoms or activities that make the pain better or worse. It is important for the patient to provide a comprehensive medical history, including past treatments, medications, and any relevant medical records or imaging results.

The complications of pain assessment include the influence of family history and lifestyle factors on chronic pain, the exacerbation of pain through excessive focus and catastrophizing, the impact of limited resources and access to healthcare on pain management, the consideration of financial situation and cultural background in pain assessment, the variation in pain assessment based on age, disability, and other factors, the importance of reviewing the effectiveness of therapy, and the underestimation of pain intensity based on mere observation. Additionally, hunger and stress can also affect the perception of pain severity.

Symptoms that require Pain Assessment include sharp or throbbing pain, burning or shooting pain, a pins and needles sensation, or pain described as an electric shock. These symptoms may indicate nociceptive or neuropathic pain, which should be assessed by a doctor to determine the appropriate treatment.

The text does not specifically mention whether pain assessment is safe in pregnancy. However, it does mention that pregnancy can complicate the selection of pain relief medicine, particularly when considering the use of strong painkillers like opioids. It is important for healthcare professionals to consider a person's individual life situation, such as being pregnant, when making decisions about pain management.

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