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.


Mobility

Hypostatic pneumonia

Tidalvolume

Vitalcapacity

FRC Alveolarventilation

Atelectasis

V/Q inequality

AcutePain


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Respiratory Effects (Contd)


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


Nimmo WS. Br J Anaesth. 1984.56:2937.

AcutePain


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Psychological Effects


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


Sensitivity of peripheralnociceptors

Musclespasm

Sympatheticoveractivity

AcutePain


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Musculoskeletal Effects (Contd)

Mobility

Impaired musclemetabolism

Muscle atrophy

Delayed normalmuscle function

Reflexvasoconstriction


AcutePain


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Effects on Pain-Signaling Systems

Peripheral nociception

Nerve excitability

Prolonged pain

Chronic pain Damaged spinalpain-signalingsystems


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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Visual analogue scale (vas)

VAS score Interpretation

< 4 Mild pain

4 7 Moderate pain

> 7 Severe pain


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Face scale

Emotional gradation happy to depression

Modul Clinical Characteristic of Pain & Pain Assessment

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