Pain Assesment and Its

Characteristic
dr.Nur Surya Wirawan M.kes Sp.An

Biopsychological factors that interact and

modulate the experience of pain
(patient perception pain)
Characteristic of host
-Biological: genetic, sex, endogenous pain control
-Psychological: anxiety, depression, coping, behavior
- Cognitive

PAIN

Disease
-History
- Present disease

Environment
-Socialization Lifestyle Traumas
- Cultural: expectations, upbringing, roles

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 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.

Respiratory Effects
Acute
Pain

Tidal
volume

Vital
capacity

FRC

Alveolar
ventilation

Mobility

Atelectasis
Hypostatic pneumonia
V/Q inequality
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.

Respiratory Effects (Contd)

Acute
Pain
Muscle
spasm
Impaired
ventilation

Muscle splinting

Cough suppression
Lobular collapse

Hypoxemia

Infection/pneumonia
Cousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447491.

Cardiovascular Effects
Acute
Pain

Coronary
vasoconstriction
Anxiety, pain

Ischemia
Angina
MI

Sympathetic
overactivity
HR, PVR, BP, cardiac
output
Ischemia

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.

Effects on Peripheral Circulation

Acute
Pain
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;24:305309.
3. Modig J, et al. Anesth Analg. 1983;62:174180.

Gastrointestinal and Urinary Effects

Gastrointestinal
Intestinal
secretions
Smooth muscle
sphincter tone
Intestinal motility

Acute
Pain

Sympathetic
over activity

Urinary

Urinary
sphincter
activity
Urinary
retention

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.

Psychological Effects
Acute
Pain

Anxiety

Sleep
deprivation
Depressio
n
Cousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447
491.

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.

Musculoskeletal Effects

Acute
Pain
Muscle
spasm

Sympathetic
overactivity

Sensitivity of peripheral
nociceptors

Cousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447491.

Musculoskeletal Effects (Contd)

Acute
Pain

Mobility
Reflex
vasoconstriction

Impaired muscle
metabolism
Muscle atrophy
Delayed normal
muscle function
Cousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447491.

Effects on Pain-Signaling Systems

Acute
Pain
Peripheral nociception

Nerve excitability
Hyperalgesia (1 + 2)

Prolonged pain

Allodynia

Chronic pain Damaged spinal

pain-signaling
systems
Cousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447491.

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.

Neuropathic Pain
Characteristic Sensory Qualities
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.
Rathmell JP. Katz JA. In: Benzon H, et al, eds. Essentials of Pain Medicine and Regional Anesthesia; 1999:288294.
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 secondary
Location and transition
Onset and related factor
Pain intensity and pattern
Aggravating and relieving factors
Aditional complain

Functional and medical aspects

Influence 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 symptoms

of neuropathic pain
Nervous system dysfunction or damage

Positive symptoms
(due to excessive activity)
Spontaneous pain
Allodynia
Hyperalgesia
Dysesthesia
Paresthesia

Negative symptoms
(due to deficit of function)
Hypoesthesia
Anesthesia
Hypoalgesia
Analgesia

Sensory abnormalities and pain often co-exist

Each patient may have a combination of symptoms
that may change over time (even within a single etiology)

Listen to the patient describing their pain

Electric shock-like
shock-

like
Burning

Shooting
Shooting

Tingling

Numbness

Be alert for common

verbal descriptors of NeP

Locate: correlate the region of pain to the

lesion/dysfunction in the nervous system
Lumbar radiculopathy

Carpal tunnel syndrome

Diabetic peripheral neuropathy

Look for the presence of sensory and/or

physical 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

Look

Neuropathic pain
Common NeP
(e.g. PHN, DPN,
descriptors:
lumbar radiculopathy) shooting
electric
shock-like
burning
tingling
numbness

The painful region

Apply gauze,
may not necessarily
pinprick, pinch
be the same as the
tests
site of injury. Pain
Conduct
occurs in the
etiology-specific
neurological
tests if
territory of the
appropriate,
affected structure
(e.g. straight-leg
(nerve, root, spinal
raise test for
cord, brain)
lumbar
radiculopathy)

Nociceptive pain
(e.g. burn, broken
limb, osteoarthritis)

Painful region is
typically localized
at the site of injury

Common pain
descriptors:
aching
throbbing
stiffness

Physical
manipulation
causes pain
sensations in
site of injury

Using the 3L approach to help make a

differential diagnosis
Are verbal descriptors
suggestive of NeP?
Yes
Can you detect sensory
abnormalities using
simple bedside tests?

No

Probable
nociceptive pain

No

Yes

Can you identify the

responsible nervous system
lesion/dysfunction?
No

Consider specialist referral

if NeP is still suspected
consider treatment in
the interim period

Yes

Confirmed NeP diagnosis

initiate treatment

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 nonpainful 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 instruments
Pain 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

Most pain

moderate
mild

severe

Likert scale

Numerical pain scale

Very severe pain

No pain

0
No pain

10

10
Very severe pain

Visual Analogue Scale

No
pain

Severe
pain

No pain
Mild

Moderate

Severe

Severe
pain

Numerical pain scale

Visual analogue scale (vas)
VAS score
<4
47
>7

Interpretation
Mild pain
Moderate pain
Severe pain

Numerical pain scale

Face scale

Emotional gradation happy to depression