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Ch 5. Pain Assessment

Ch 5. Pain Assessment. R2 김용일. CHALLENGES OF PAIN MEASUREMENT. Pain Internal, subjective experience relies upon the use of self-report Measurement tools should be Vallid and reliable Ability to communicate Most self-report pain assessment tools Focus on pain intensity ratings

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Ch 5. Pain Assessment

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  1. Ch 5. Pain Assessment R2 김용일

  2. CHALLENGES OF PAIN MEASUREMENT • Pain • Internal, subjective experience • relies upon the use of self-report • Measurement tools should be • Vallid and reliable • Ability to communicate • Most self-report pain assessment tools • Focus on pain intensity ratings • Relatively brief and recent period of time

  3. TYPES OF SELF-REPORT PAIN SCALES

  4. Verbal rating scales (VRSs) • Strengths • Simplicity • Ease of administration and scoring • Easy to comprehend • High compliance rates • Good reliability • Weaknesses • Equal intervals between adjectives • Must be familiar with words • Must find accurately described one

  5. Numerical rating scales (NRSs) • Series of numbers (Ex. 0-10, 0-20, or 0-100) • Strenths • Good validity • Simple, easily understood • Easily administered and scored • Sensitivity to treatments • Weakness • Not have ratio qualities

  6. Visual analogue scales (VASs) • A line with verbal anchors at either end • Pt. places a mark at a point on the line corresponding to Pt’s rating of pain intensity • Strengths • Validity & sensitivity to treatment effects • Correlate with pain behaviors • Show ratio-level scoring properties • Limitations • Difficult to Pts with perceptual-motor problems • Generally scored using a ruler • Making scoring more time-consuming & additional bias or error • Higher non-completion rates • Among those of cognitive limitations and elderly samples

  7. McGill pain questionnaire (MPQ) • Most widely utilized measures of pain • Multidimensional measure of pain quqality • Sensory-discriminative : 10 sets • Affective-motivational : 5 sets • Cognitive-evaluative : 1 set • Miscellaneous : 4 sets • Present pain intensity VRS (“mild” to “excruciating”) • Short form of MPQ • Sensory (11 items), affective (4 items) • Highly correlates with original scale • Easier for geriatric patients to use • VAS included

  8. McGill pain questionnaire (MPQ)

  9. Pain relief • Designed to reduce pain • Post-treatment assessment of pain relief • VAS • VRS with gradations of relief • “none”, “slight”, “moderate”, “complete” • NRS : percentage of relief • Overreporting of relief • Memory for past pain greater than previous ratings

  10. BEHAVIORAL OBSERVATION • Pain behaviors • Although pain is private & subjective experience • May communicate their discomfort by vocalizations, facial expressions, body postures, actions • Valuable in • Establishing aPt’s level of physical functioning • Analyzing factors that may reinforce displays of pain • Assessing pain in nonverbal individuals • Lower correspondence between pain report & pain behavior in chronic pain than acute pain

  11. EXPERIMENTAL PAIN ASSESSMENT • Administraion of standardized noxious stimulation under controlled conditions • Thermal, mechanical, electrical, chemical, ischemic, etc • Typical parameters • Pain threshold, pain tolerance, ratings of suprethreshold noxious stimuli

  12. PSYCHOPHYSIOLOGICAL ASSESSMENT • Prerequisite for biofeedback • Elucidate the concomitants of pain • EMG • Record levels of local muscle tension • EEG • Assess brain responses to noxious stimulation • Heart rate & blood pressure

  13. SPECIAL POPULATIONSChildren • Behavioral pain rating scales for infants • Neonatal infant pain scale (NIPS) • Presence & intensity of six pain-related behaviors • Facial expressions, crying, breathing, arm movement, leg movement, arousal state • Direct questioning (e.g., “How is your pain today?”) • For among older children • Susceptible to bias • Faces scale & Oucher scale • Not require language, used for younger children • Pain thermometers • Vertical NRS superimposed on VAS shaped • Over 6 yrs, standard VAS is valid & reliable

  14. SPECIAL POPULATIONSThe elderly • Higher frequency of incomplete or non-scorable responses on VAS • Not on VRS or NRS • MPQ (long form) is inappropriate • Its complexity & time requirements • VRS is recommended in the elderly • Fewest failure responses

  15. BIASES IN PAIN MEASUREMENT • Inaccurate assessments of pain • Underestimation • Improper management • Unnecessary suffering • Delay in recovery • Overestimation • Over-treatment • Adverse iatrogenic consequences

  16. RECOMMENDATIONS • Single-item VAS, VRS, and NRS • All showed good validity & reliability • Elderly or cognitively compromised subjects • VRS or NRS is strongly preferable • Pain relief • Using sequential ratings • Changes from pre- to post-treatment • In infants • Coding of behavioral or facial responses • Slightly older children • Pictorial scale (Faces or Oucher scale) • 6 yr or older • Standard VAS

  17. RECOMMENDATIONS- continued • Healthcare professionals are not reliable judges of Pts’ report of pain • No matter how expert or experienced • Both inaccurate and systematically biased • In direction of underestimating Pts’ pain

  18. Ch6. Psychological evaluationand testing

  19. The experience of pain • Private, subjective phenomenon • No simple instrument, that can accurately assess an individual’s pain experience

  20. PSYCHOLOGICAL EVALUATION • Comprehensive evaluation of chronic pain • Assessment of psychological, social, behavioral factors • By combining interview techniques • At first, history of the pain complaint be taken • Intensity • Frequency • Affective & sensory quality of pain • Effecacy of previous treatment interventions

  21. PSYCHOLOGICAL EVALUATION- continued • Precipitants to pain exacerbation • Daily activities, disability, perceived interference • Evaluate familial/social factors • Identify any psychiatric disorders • High coprevalence of major depression • Anxiety disorders • Alcohol and substance abuse and dependence • Personality disorders • Any relevant family psychiatric history

  22. PSYCHOLOGICAL ASSESSMENT/TESTING

  23. Disability/ImpairmentBrief pain inventory (BPI) • Originally, measure pain severity & pain-related interference in cancer Pt • Extended to • Heterogeneous pain conditions • Osteoarthritis • Neuropathic pain (HIV/AIDS, cerebral palsy)

  24. Brief pain inventory (BPI)- continued • 11-point numeric rating scales in seven areas • General activity • Mood • Walking ability • Normal work including outside the home & housework • Relations with other people • Enjoyment of life • Sleep • Demonstrate efficacy of pain medication • Sensitive to change due to treatment

  25. Disability/ImpairmentPain disability index (PDI) • Measures perceived disability due to pain • Seven questions • Family/home • Recreation • Social activities • Occupation • Sexual behavior • self-care • Life support activities • Also sensitive to change following pain treatment

  26. Disability/ImpairmentSickness impact profile (SIP) • Complicated by length (136 items) and complex scoring algorithm • Seperated into 12 scales • Sleep and rest • Eating • Work • Home management • Recreation and pastimes • Ambulation • Mobility • Body care and movement • Social interaction • Alertness behavior • Emotional behavior • Communication

  27. Sickness impact profile (SIP)- continued • Each statement is weighted and percentage scores for three areas • Physical function • Personal care, mobility, walking • Psychosocial function • Emotions, cognitive function, social interactions, communication • Other function • Sleep/rest, household, work, recreation, eating

  28. Disability/ImpairmentRoland-Morris disability scale • Measure of function in back pain • 24 of original SIP items • By adding “because of my back pain” • Items include assessment of • Irritability, appetite, housework

  29. Negative affectBeck depression inventory (BDI) • 21-item, multiple choice of four statements • Measure symptoms of depression or distress • Alterations in mood • Negative self-concept • Self-devaluation • Self-blame • Self-punitive wishes • Vegetative symptoms • Alterations in activity level • May overestimate the degree of depression

  30. Negative affectCenter for epidemiological studies depression scale (CES-D) • Frequency with each 20 symptoms during past week on 4-point scale • Possibly overestimating prevalence and severity of depression • Overlap between somatic symptoms of depression & symptoms of chronic pain • Comparative analysis • CES-D : greater sensitivity • BDI : better specificity

  31. Coping • Many techniques to attempt to control or tolerate stressors • Coping strategies questionnaire • 50 items, 6 cognitive & 2 behavioral coping strategies • Diverting attention • Reinterpreting pain sensations • Coping self-statements • Ignoring pain sensations • Praying and hoping • Catastrophizing • Increasing behavioral activity • Increasing pain behaviors

  32. Coping-contineud • Pain catastrophizing scale • Measuring three dimensions of catastrophizing • Catastrophizing (e.g., “I feel I can’t stand it anymore”) • Maladaptive coping strategy • Chronic pain coping inventory • More behavioral measure of coping • Guarding, resting, asking for assistance, task persistence • Closely associated with measures of functioning • Relaxation, exercise/stretch, seeking social support, coping self-statements, medication use

  33. Multidimensional instruments • Multidimensional pain inventory (MPI) • Examines multiple pain domains • Pain severity • Interference of pain with daily activities • Work • Family relationships and social activities • Pain-specific support from spouse or partner • Perceived life control • Negative affect • Valuable in • Multiple dimensions of pain • Comprehensive focus on psychological, behavioral, social factors • Relative brevity • Sensitivity to treatment

  34. Multidimensional instruments- continued • Short form 36 health survey (SF-36) • Yields two major factors • Physical health • Mental health • Advantage • Comparable scores for different diagnostic groups

  35. Measures of psychopathology • Self-report instruments of psychopathology • Provide standardized, reliable, valid assessments • Minnesota multiphasic personality inventory (MMPI) • Evaluate psychological status • MMPI-2 • Ten clinical scales and three validity scales • Criticized due to • Length (566 items) • Frequeqncy of items relating to physical symptoms • Lack of predictive validity • Symptom checklist-90-revised (SCL-90-R) • Assesses 9 different types of psychological disturbance • Yields 3 global measures of distress • Briefer length, less Pt resistance (its focus on symptoms) • No predictive validity with regard to treatment outcome

  36. SPECIALIZED ASSESSMENTInvasive therapies • Psychological evaluation is recommended • Prior to pursuing invasive therapies • Screening for • Major psychopathology, retardation, dementia or delirium • Suggested in • Active psychosis, suicidality/homicidality, active alcohol or drug dependency • Screening for • Psychosocial factors that may impede optimal outcome • Help educate Pt as part of preparation for informed consent • Guide in identifying individual’s strengths and weaknesses

  37. SPECIALIZED ASSESSMENTChronic opioid therapy • When done prior to beginning therapy • Provides a baseline assessment of • Pain intensity, affective state, disability, quality of life • Potential behavioral and/or psychological contraindication for chronic opioid use • Current alcohol abuse or dependence • Illicit or prescription drug abuse or dependence • Severe major depression • Antisocial or borderline personality disorder • Three screening items • Pt believes he/she is addicted • Increases in opioid dose or frequency have occurred • Pt prefers one route of administration

  38. Chronic opioid therapy- continued • To avoid significant cognitive effects of opioid medications • Brief screening of intellectual functioning, memory, psychomotor speed • Attention prior to initiation of chronic opioids • Following titration to therapeutic doses • Baseline testing • When Pt has not taken any opioid therapy • Not taking other medications (e.g., benzodiazepines)  May impair cognitive functioning • Psychological evaluation may be helpful for Pt who exhibit problematic behavior while using chronic opioid therapy • Early prescription refills • Excessive telephone interactions with clinic staff

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