MURALIDHAR : EVALUATION OF- 339 PAIN Indian J. Anaesth.

2006; 50 (5) : 335

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EVALUATION OF PAIN
Dr. Muralidhar Joshi
Keywords : Evaluation, Pain. The person suffering from pain in his desperation to find a solution to his problem meets countless healthcare professionals.1 These patients often suffer from intractable, often multiple pain complaints which are usually inappropriate to existing somatogenic problem. Excessive preoccupation with the pain problem, an altered behavior pattern with some of the features of depression, anxiety and neurotism and in particular no realistic plans for the distant feature are some of the features of these patients. After having realized the profile of these patients, clinical history, evaluation and assessment importance need not be stressed. Medical & psychological evaluation/Assesment The patient reception should be warm and cordial. The atmosphere should be that of confidence building one. Always an open-ended question is better, something like tell me about your pain or what made you seek my help. Allow the patient to express his feelings; do not cut short the discussion abruptly. If you think, the discussion is taking you nowhere, politely divert attention to next topic. Clinical history the patients clinical history is evaluated on following lines. a) Presenting complaint this pertains to the immediate problem for which patient has sought the clinicians opinion. Best way to ask this complaint will be asking the patient as to what made him to come to you. History of present illness the onset of pain whether abrupt (vertebral fracture) or slow (migraine) gives a clue about the severity of pain and possible etiology. The duration of pain tells whether it is acute or chronic. Most often the acute pains are managed more conservatively (unless life threatening problem), chronic pains are evaluated more in depth. Next, the patient is asked about the character of pain. Usually the neuralgic pains are of either shooting or stabbing in nature, deafferentation pains are burning type. The malignancy pains are normally dull & boring type. considered. The radiating pain often gives an evidence for nerve root irritation as witnessed in the lumbar disc protrusion irritating the corresponding lumbar nerve root. One of the biggest problems in assessing pain is that it is subjective. Experience of pain not only varies from person to person but also from race to race. Tolerance to pain also depends on affluence of the person in the society and his or her sophistication/comfort level. Many scales and scores have been devised to assess pain like visual analogue scale (VAS), McGills questionnaire etc.1,2 By far the most popular scale is VAS. i) Pain as self-report on single dimension the VAS contains digits from 1 to 10. The person is asked to compare the severity of current pain when compared to worst pain he has ever faced in life (like labour pain, surgical pain, fracture pain). Having known the current pain at the beginning of the treatment, when patient comes for follow up, the pain relief can be assessed by asking him to compare his pre-treatment pain with post-treatment one. By far this is the easiest and simplest type (fig. 1).

b)

Fig. 1. Visual analogue scales i) Pain as self-report on multiple dimensions (McGills pain questionnaire) this scale assesses pain in a multimodal way. It measures the sensory, affective, evaluative and other miscellaneous aspects of pain, thus measuring pain multidimensionally. The questionnaire contains about 20 aspects. 1 to 10 represents sensory aspects of pain, 11 to 15 represent

The site of pain gives a possible clue for the source of pain. Referred pain possibility should always be
Director Pain Management Programme Kamineni Wockhardt Hospital 4-1-1227, Kingkoti, Abids, Hyderabad 500 001, Ap.

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affective aspect of pain, 16 represents evaluative aspect of pain, 17 to 20 other miscellaneous aspect of pain. Each subunit has 2 to 5 words under them, representing increasing degree of pain and numerical value. The sum of all points gives a rank value, which is called as pain rating index (PRI). The McGills pain questionnaire fulfills many aspects because of multidimensional approach.2 After assessing the severity of pain, next we need to know whether pain experienced is continuous, intermittent or occasional. The aggravating and relieving factors for the underlying problem have to be noted. Associated symptoms like bowel and bladder disturbances, numbness, weakness might signify serious problems. It is important to elicit the effect of pain on activities and sleep. Someone looking for workmans compensation will be always looking to take an off or leave at any given point of time. a) Past history patients with systemic illness like diabetes mellitus, acid peptic disease, ischaemic heart disease etc need to be managed differently. Some of the pains might be because of the disease per se and modifications of medications to be given need to be done. Previous exposures to surgery need to be noted. Past treatment for pain whether medications, physical therapies, interventions any other options considered to be recorded and the pain relieving efficacy of past treatment need to be elicited. Personal history details regarding occupation, whether fulltime, or part time, job satisfaction, work compensation and others very important. Habits like tobacco chewing, smoking, alcohol etc to be noted. Marital life, children, menstrual history, family disputes to be discussed. Review of systems any other relevant disturbances in systems either constitutional or systemic to be noted.

The systemic examination usually starts with the suspected affected system. The neurological examination is the commonly required evaluation. The evaluation involves higher motor function, cranial nerves examination, sensory & motor evaluation, reflexes, gait and certain specific tests. The specific tests involve trigger point detection, legraising tests for the backpain with radiculopathy, paraspinal tenderness for facetal problems, tinel test to pickup nerve compression etc. There are a group of functional patients who need to be examined for some nonorganic signs called as Waddells nonorganic signs.4,5 They are grouped into five categories; i) Tenderness- widespread superficial sensitivity to light touch over lumbar spine, bone tenderness over a large lumbar area. Simulation axial loading, during which light pressure is applied to the skull in the upright position, simulated rotation of lumbar spine with the shoulders. Distraction greater than 40 degree difference in sitting versus supine straight leg raising Regional disturbances motor: generalized giving way, sensory: nondermatomal loss of sensation to pinprick in lower extremities. Overreaction disproportionate pain response to testing.

ii)

iii) iv)

v)

b)

c)

Physical examination This part of evaluation should be like continuation of clinical history. By regularly following a protocol, it becomes a habit and physician can finish examination in 2 to 4 minutes.3 It is always better to undress the part to be examined and if necessary an examination gown can be provided. Physical examination consists of general physical examination and systemic examination. The general physical examination is done to record patients build, pallor, icterus, cyanosis, clubbing, oedema, lymphadenopathy and any rashes. The vitals should be recorded routinely.

Psychological evaluation The assessment of psychological influences is an important part of initial evaluation of the pain patient.6 The patients should be assessed for physical, psychological & environmental factors simultaneously. The goal of pain assessment is to determine the contribution of affective, cognitive & behavioral factors to the perception & report of pain. Some of the psychological symptoms observed might be secondary to pain complaint, while others may have been in existence before the pain occurred. Regardless of the chronological order, an adverse effect on the patients response to treatment is likely to be observed if the psychological factors are not identified & treated. Various objective psychological test measures are used to evaluate pain patients. Among them are;7,8 i) ii) iii) Minnesota Multiphasic Personality Inventory (MMPI) Symptom checklist 90 Million Behavioral Health Inventory

Brief inventories are also available for use in assessing their population. They include, but are not limited to,

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iv) v)

The Beck Depression Inventory The Spielberger State Trait Anxiety scale

ii)

i) Minnesota Multiphasic Personality Inventory (MMPI) The MMPI has been found useful in assessing emotional disorders that occur secondary to the pain complaint or preexisting personality factors that could potentially adversely affect patients response to treatment. ii) Symptom checklist 90 This is a 90-item problem checklist that allows the examinee to rate symptoms of physical & emotional distress on a 5-point scale To sum up, in assessing pain patients, it is important to integrate all data rather than rely on information from one source. Only then one can have a comprehensive psychological assessment of the patient. Pain measurement techniques should include subjective report of pain using both simple & complex measurement as well as relevant psycho physiological measures. Diagnostic imaging techniques Much of the progress in medical care is increasingly attributed to the imaging modalities.9 The commonly used imaging modalities for pain management and details are as follows: i) Plain radiography this is the most frequently requested radiological examination. Plain radiographs are helpful if an interface of a different density is between. It makes out differences in air, fat, soft tissue, calcific & metallic density (fig. 2.). The advantages are inexpensive, readily available, quickest investigation without prior preparation. The disadvantages are it is two dimensional and soft tissue densities cannot be differentiated. i) iii)

Ultrasonography (USG)this uses high frequency sound waves to produce sectional images of the body. USG is useful in evaluating the abdominal organs like liver, gall bladder, kidneys etc,. & its main advantage is portability. The disadvantages are it is an organ oriented imaging and operator dependance. The USG beam is scattered in the presence of air filled bowel loops and lesions behind the bone, which are highly calcified or mass lesions, are not imaged. Doppler evaluation it is used for detection of the blood flow, its direction and velocity. It is noninvasive, quick and simplest method to evaluate the venous and arterial system. Computed tomography (CT) this provides quick scanning which helps in very sick and restless or in a trauma patient (fig. 3). This provides excellent bony detail, superior detection of calcification and detects acute haemorrhage. The disadvantages are ionizing radiation, need of contrast in some patients, only axial plane of imaging (except brain and paranasal sinuses). Soft tissue contrast is inferior to MRI.

iv)

Fig. 3 : CT Neck of a patient with gloss pharyngeal neuralgia showing laryngeal tumour encroachment.

Magnetic resonance imaging (MRI) the MRI works on a large magnet and radiofrequency pulses and the effect of radiofrequency pulse on the hydrogen atoms present in the body. Its advantages are noninvasive, no use of radiation, multiplanar imaging, more information of tissue characterization etc (fig. 4) Its disadvantages are claustrophobia, implant compatibility, restless patient care, and patients on life support care, longer scan times etc. Nuclear medicine this involves performing scintigraphy using radioactive agent injected into vascular system. It has the ability to indicate functional status of the organ/part of body (fig. 5). The main disadvantage is its specificity to a particular organ imaging and cannot be used as a screening modality.

ii)

Fig. 2 : X-ray Lumbosacral spine in a patient of back pain showing Spina bifida.

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i)

The physiological changes are like an increase heart rate, respiratory rate, blood pressure and excessive palmar sweating. The behavioral changes include changes in facial expression, body movement and type of cry. Facial expressions associated with pain include eyebrow bulge, eye squeeze, nasolabial furrow, open lips, vertical or horizontal stretching of mouth, lip purse, taut tongue and chin quiver. The neonate will show diffuse body movements to noxious painful stimuli.

ii)

Fig. 4 : MRI of Lumbar spine in a backache patient showing disc bulge pressing on thecal sac.

iii)

Epiduroscopy this depicts colour visualization of the dura, blood vessels, fat, areolar tissues, and pathological changes in the epidural space1. Its limitations are minimally invasive, technical skill, availability of device and clinical utility.

Pain measurement in pre-school children when assessing pain in pre-school children apart from the physiological and behavioral changes, self-report is significant. The various self-report methods developed are happy-sad face scale, the Oucher scale, color analog scale, Poker chip tool, ladder scale, and linear analogue scale. i) Happy-sad face this scale shows a childs face in different moods, the child is asked to select the facial expression that best suites the pain expression. This assesses the affective and fear component of pain. The Oucher scale the oucher scale displays six photographs of a childs face showing increasing levels of discomfort. On the left is the vertical numerical scale for older children capable of counting till 100. The six photographs of a child on one side is used for children who have not yet learnt to count till 100. Children select the facial expression that best reflects their experience of hurt.

Apart from above mentioned diagnostic tools there are some more which are less often considered in pain management like arthrography, arteriography, myelography, PET scan, nerve conduction study etc. All these diagnostic modalities have helped a lot in finally deciding the course of treatment for the patient. Evaluation of pain in neonate & children This is an important aspect in pain evaluation, the paediatric age group patients may not be able to express pain with suitable words and it is much more difficult in preverbal age group.10 Pain measurement in neonates physiological systems are developed at approximately 26 weeks of gestation, for the foetus to perceive pain. Pain in neonates is mostly assessed in an indirect way such as observing physiological changes or behavioral responses of the neonate/ infant to pain.

ii)

Pain measurement in school aged children they are usually able to read and write and can comprehend what is explained to them. The commonly used methods to assess pain in this age group are: 6 point (0-5) numerical verbal pain score, 0 to 100 numerical scale, visual analog scale, modified McGill pain questionnaire. i) 6 point (0-5) numerical verbal pain score it has been used effectively with children over the age of 9 years to assess headache on a daily basis. 0 to 100 numerical scale in the Oucher scale to the left is the numerical scale for children who have learned to count till 100.

ii)

Fig. 5 : Nuclear Medicine scan in a patient of CRPS showing increased flow and pooling in left upper extremity with increased uptake in all joints more prominently in small joints of the hand.

Despite the availability of many scales and pictures, it is very well known that assessment of pain in children is rather difficult when compared to adults. Pain is fundamentally a subjective state with multidimensional experience. No single scale can sum up all features.

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Multidisciplinary pain assesment The multidisciplinary pain clinic offers multidisciplinary evaluation, treatment and rehabilitation, and a cohesive pain team approach.11 The members for this multidisciplinary approach depend on available resources (facilities & staff) and the needs of the surrounding patient population.12 Ideally the members should include pain physician, psychiatrist or psychologist, anaesthesiologist (if pain physician not one), oncologist, orthopaedician, neurosurgeon, neurologist, rheumatologist, radiologist, physiotherapist, social worker etc. As one can see it is not possible to make all these members in one single room and assess or evaluate the patient. Usually a protocol is followed in evaluation, varying from institution to institution. One of the ways of doing multidisciplinary pain assessment is mentioned below. All patients go through a pain physician. At the initial (screening) visit, a patients history is taken and a thorough clinical examination is carried out. A psychological interview and testing are usually performed at the same visit. A baseline measurement of the patients pain may be carried out, and a pain diary may be given to the patient to fill in. The patient will be assigned to one clinician depending on patients clinical presentation; he will be responsible for coordinating that patients care. The need for further evaluation is also determined and relevant laboratory and radiological assessments are done. Other assessments should include physiotherapy evaluation and family and vocational assessments. All these patients will go through an evaluation in which a problem-solving group attempts to identify the medical, behavioral, vocational, financial, social and other significant patient problems. Once the assessment has been completed, a decision is then made regarding the most likely diagnosis, and a treatment plan is formulated. Same thing is discussed with the patient, his or her family and significant others (employers), and specific goals are decided upon. The multidisciplinary approach towards patient evaluation and management is any day superior to unimodal approach (meta-analysis).13 The multidisciplinary approach has been found to produce improvements in illness-related behavior and psychological distress.14 Conclusions It is quite obvious after considering above-mentioned factors, how important is the proper assessment and

measurement of pain. The Pain physician should not only be a good clinician but also should be conversant with laboratory, imaging and other advanced modalities. The pain patient care with human touch goes miles and miles in building up the confidence of patient and his family. References
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