Pain Measurement

by
Dr John Ajefolakemi
(Dept of Anaesthesia)
Table of content
• Introduction
• Why Pain Measurement
• Pain Rating Scales
• Conclusion
Introduction
• The International Association for the Study of Pain defines
pain as “an unpleasant sensory and emotional experience
associated with, or resemling that associated with, actual
or potential tissue damage, or described in terms of such
damage.

• Pain is a subjective feeling as such the response to pain

varies among different individuals as well as in the same
person at different times.
Why Pain Measurement?
• Inadequate pain control can quite disturbing leading to
adverse physical and psychological outcomes for patient
and their families.
• Also, Continous unrelieved pain can actvate the Putuitary-
Adrenal axis which can suppress immunity increasing risk
of post-op infection.
• Pain also have negative effect on the cardiovascular
system, increasing risk of adverse cardiac event.
Why Pain Measurement?

• Although pain is subjective,

it is important to have
validated scoring tools to
assess the severity of a
patient's pain and their
response to analgesia.
 “Patient satisfaction with care is
strongly tied to their experience with
pain control during hospitalization”
Tools for Pain Measurement

• Can be classify into:

a. Unidimensional tools
• Straightforward
• Useful for assessment of acute pain

b. Multidimensional Tools
• Complex and time consuming
• Useful for assessment of chronic pain or research
Visual Analog Scale
Visual Analog Scale
• Involve the use of a straight 10cm line without any
demarcation
• The start point has No pain and the other end WORST
Ever Pain
• Patient is require to mark a point on the line to represent
level of pain
• Advantage: It is simple and easy to understand
• Disadvantage: Difficulty deciding worst ever pain leading
to false ceiling of pain.
• No useful in the visually impaired patient
Verbal Descriptive Scale
Verbal Descriptive Scale
The scale uses a list of words, ordered in terms of
severity from least to most, that describe the patient
patient experience.
Patients are asked to either circle or state the word that
best describes their pain intensity at that moment in time.
Advantage:
VRS have been validated to be fast and simple for
patients to understand.
Disadvantage:
VRS forces patients to select words that are not of their
own choosing to describe their pain.
Changes in pain are difficult to interpret
Numerical Rating Pain Scale
Numerical Rating Scale
• It is an 11 point scoring sytem of 0 - 10
• The user has the option to verbally rate their scale from 0
to 10 or to place a mark on a line indicating their level of
pain.
• 0 - represent No Pain, while 10 - represents Worst Ever
Pain.
• It is designed to be used by those over the age of
9years.
• A meaningful change pain in the NRS: at least a 30%
reduction or an absolute reduction in the value of at least
2.
Pictorial Rating Scale
• Suitable in Patient with impaired communiation
• Example
 Wong-Baker Facial Pain Scale
 Revised Facial Pain Scale
 OUCHER Pain Scale
a. Wong Baker Faces Pain Scale

• Uses pictures and numbers to allow pain to be rated by

the user.
• The faces range from a smiling face to a sad, crying face.
• Useful in children above 3yrs and adults.
– Advantage: Available in several languages
b. Revised Face Pain Scale

• Uses pictures and numbers to allow pain to be

rated by the user.
• Unlike the Wong-Baker scale, the face don’t depict
smiles or tears. As such reduces potental for
confusion based on facia expression.
• Useful in children 8 -14 years.
c. OUCHER Pain Score
• It is a self reporting
photograph scale for pain
intensity.
• Useful in children age 3 -
12 years.
• May reflect mood instead
of pain
FLACC Pain Score
• FLACC stands for Face, Leg, Activity, Crying and
Consolability.
• The FLACC pain scale was developed to help medical
observers assess the level of pain in children who are too
young to cooperate verbally
• The overall score is interpreted as follow:
0 : Relaxed and Comfortable
1-3 : Mild Discomfort
4-6 : Moderate Discomfort
7-10: Severe discomfort
FLACC Pain Score
CRIES Scale
• CRIES scale is often use in the NICU to assess level of
pain in infant 6 month and younger.
• Assesment parameter include:
– Crying
– Oxygenation
– Vital signs
– Facial Expression
– Sleeplessness
CRIES Scale
0 : Relaxed and
Comfortable
1-3 : Mild Discomfort
4-6 : Moderate Discomfort
7-10: Severe discomfort
COMFORT Observer Pain Scale
The COMFORT Scale is a behavioral, unobtrusive pain scale
that may be used by a healthcare provider when a person
cannot describe or rate their pain.
Unconscious and ventilated infants, Children and Adolescents.
This scale has eight indicators (categories)
Validated for newborn to 3 years old
Reported use of up to 17 years old
The COMFORT Scale provides a pain rating between 9 and
45
17- 26 generally indicates adequate sedation and pain control.
COMFORT
Observer
Pain Scale
Children's Hospital of Eastern Ontario
Pain Scale (CHEOPS)
• The CHEOPS (Children's Hospital of Eastern Ontario
Pain Scale) is a behavioral scale for evaluating
postoperative pain in young children.
• Six items: Cry, Facial, Child Verbal, Torso, Touch, and
Legs
• It is intended for ages 1-7yrs. Although, it has been
used in studies with adolescents but this may not be
an appropriate instrument for that age group.
Neonatal Infant Pain Scale (NIPS)
• The Neonatal Infant Pain Scale (NIPS) is a behavioral
scale and can be utilized with both full-term and pre-term
infants.
• Use in children under age 1
• The tool was adapted from the CHEOPS scale and uses
the behaviors that nurses have described as being
indicative of infant pain or distress.
Neonatal Infant Pain Scale (NIPS)
Neonatal Infant Pain Scale (NIPS)
• Total pain scores range from 0-7.
• The difficulty with any tool includes it is not self report and
its inability to differentiate between pain and agitation.
Critical- Care Pain Oservation Tool (CPOT)
• Designed to assess pain in criticaly illed / sedated patient
in ICU
• Assess 5 parameters:
1. Facial expression
2. Body Movement
3. Compliance with the ventilator (Intubated Patient)
or Vocalization (extubated patient)
4. Muscle Tension
• Each Parameter is assign a score of 0-2
Directives of use of the CPOT
1. Observed Patient at rest for
one minute to obtain a baseline
value
2. Then observe during
nociceptive procedures (e.g.
turning, wound care) to detect any
changes in the patient’s behaviors
to pain.
3. Evaluated before and at the
peak effect of an analgesic agent
4. Attribute the highest score
observed during the observation
period.
5. Muscle tension should be
evaluated last, because the
stimulation of touch alone may
lead to behavioral reactions.
Mankoski Pain Scale
• The mankoski pain scale
uses numbers and
corresponding description
of pain
• The description are
detailed to ensure
imformation is well
understood by the patient.
McGill Pain Questionnaire (MPQ)
• The MPQ and the short-form MPQ, are among the most
widely used measures of pain.
• It is a multidimensional measure of pain quality; however,
it also yields numerical indices of several dimensions of the
pain experience.
• The MPQ has 20 groups of 78 words created to assess 3
aspects of pain:
– Groups 1-10: Sensory
– Groups 1-10: Affective and
– Group 16: Evaluative.
– Group 17-20: Miscellaneous words
McGill Pain Questionnaire
• The person rating their pain select word that best
describe their pain in each group leaving out groups
not applicable;
• Once the person has rated their pain words, the
administrator assigns a numerical score to each word,
which is sumed up to give the Pain Rating Index.
• Minium Pain Score: 0, Maximum pain score: 78.
• Pain intensity can also be assess using a 1- 5
Intensity Scale.
McGill Pain Questionnaire
• Benefit:
– It is valid, sensitive and consistent in its ability to assign
seemingly appropriate descriptions to a given pain
experience.
– The MPQ may be able to discriminate between different
types of pain syndromes.
• Limitations:
– It is lengthy, take from 5 to 15 minutes to complete. As such
makes it diffiult to use on a repeated basis over a short
period (e.g., in a clinical acute pain setting).
Short-Form McGill Pain Questionnaire
• Consists of 15 representative words that form
– The sensory category (1-11) and
– Affective category (12-15)
• Each descriptor is ranked on a 0 to 3 cirresponding
to No pain to severe pain.
• It also incorporate the PPI (present pain Index),
along with a VAS.
• It can discriminate among different pain conditions,
and may be easier than the original scale especially
in geriatric patients to use.
Short-Form
McGill Pain
Questionnaire
Brief Pain Inventary
• Short, self administer
questionaire that
asess severity of
pain and how it
interfere with daily
function
• Major use in Cancer
and AIDS patient
Neuropathic Pain Scale (NPS)
• Described by Galer and Jensen,
• It quantifies already diagnosed neuropathy pain
• It has not been validated to be able to differentiate
neuropathic from non neuropathic pain
Neuropathic Pain Scale
The Leeds Assessment of Neuropathic Symptoms and Signs
(LANSS) Pain Scale
Abbey Pain Scale
• Designed to assist in the assesment of pain in nonverbal
individual suffering end stage Dementia
• Scale of 6 Items, score 0 - 3
– Vocalisation (Groaning, crying,Whimpering)
– Facial Expression (Tense, frowning, frightening)
– Change in the body language (Fidgeting, rocking Guarding of
body part)
– behavioural changes (increased confusion, refusing to eat)
– Physiological Changes (Temp, Puse, BP, Flushing)
– Physical changes (skin Tear contracture, Pressure area)
PainDETECT
• A new screening
questionnaire to identify
neuropathic components
in patients with back pain.
Dolorimetery
• Dolorimetry can be defined as the measurement of
pain sensitivity or pain intensity.
• A dolorimeter is an instrument used to measure pain
threshold and pain tolerance.
• Dolorimeters apply steady pressure, heat, or
electrical stimulation to an area, or move a joint or
other body part and determine what level of heat or
pressure or electric current or amount of movement
is needed to produces a sensation of pain.
• There are several kinds of dolorimeters: Palpometer,
Laser Algometer,
Dolorimeter
 WHO Analgesic
Ladder
Guilding Principle
• By the Clock: Analgesic on a
regular schedule
• By the Mouth: Oral route is
Preferred or the least invasive
route
• By the Ladder: Appropriate to
pain severity
Summary
Paculiarity Appropriate Scale

NICU NIPS

Infants up to 1 year old Observational Scale e.g CRIES, FLACC,

Children aged >3 years Wong-Baker Pain Score,CHEOPS

Adults with dementia Abbey Pain Scale

Sedated patients in the ICU CPOT

Neuropathic Pain NPS, LANSS

Back Pain PainDIRECT

Conclusion
• The importance of pain measurement in routine patient
care can not be overemphasized.
• Proper pain assessment using apprioprate tool before
and after intervention is still a desirablse goal.
• Although pain is not a sign, it is often referred to as the
5th vital sign, this is to serve as a reminder to health care
providers to attend to their patients' suffering.
Question
• A pain physician is concerned that a patient's pain may be
neuropathic in nature. An appropriate screening tool to
assess for this is:
A. Numeric Rating Scale
B. Visual Analog Scale
C. McGill Pain Questionaire
D. painDETECT