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Sunday, April 11, 2010

Acute Pain Management (3)

Pain Assessment

Pain History
The elements of a pain history provide information that can alert to the presence of a serious underlying condition. It is important to note that in the absence of a serious cause for the pain (e.g. fracture), it is not necessary to obtain a specific patho-anatomic diagnosis to manage acute musculoskeletal pain effectively.

The anatomical site where the person feels the pain may or may not be the site of origin as in the case of referred pain. The clinician should ask which part hurts the most and whether the pain started there or elsewhere.

The regions in which pain is felt should be described. Even a person who initially complains of ‘pain all over’ can usually describe distinct region(s) of pain (possibly large and overlapping). Having the patient draw their pain focus and radiation on a pain diagram clarifies its distribution and can act as a baseline from which to assess response to treatment and changes in pain patterns.



The quality of pain may be described in different ways. Somatic pain is usually deep, dull and aching. Radicular pain is mostly sharp and ‘electric’ or ‘shooting’. Neuropathic pain is often ‘burning’. Visceral pain is dull at first but sharp when lining tissues such as the peritoneum become involved.

By convention, pain present for less than three months is described as ‘acute’ pain. Chronic pain refers to pain present for greater than three months duration. Pain duration will affect pain management.

Temporal Factors
Pain may be constant or intermittent. If pain is constant the history should elicit whether its intensity varies. If pain is intermittent, the history should elicit its pattern in relation to time
of day, activity and duration.

The intensity of pain reflects the impact of the experience, not necessarily the degree of nociception. Even though pain is essentially subjective (Merskey and Bogduk 1994) it is important to assess the intensity of the pain. Simple tools can be used to assess pain at the initial and follow-up visits to evaluate progress. There is good correlation between the various types of
scales (Jensen at al. 1986). The Numerical Rating Scale is suitable for many clinical situations because it is simple to apply.

Aggravating and Relieving Factors
Aggravating factors include those that precipitate or worsenpain. Relieving factors are those that alleviate, reduce or abolish pain. People who say that nothing eases the pain can be asked about the posture in which they are least uncomfortable.

Impact on Activities of Daily Living and Sleep
The effects of pain on activities of daily living (ADL) determine
associated disabilities and handicaps (WHO 1986)
Identifying such effects gives the clinician an idea of the impact of pain on the patient’s lifestyle. The effect of pain on sleep should be specifically sought; sleep deprivation is a powerful amplifier of the pain experience.


Associated Symptoms
These include any symptom apparently associated with the painful condition, in contrast to symptoms associated with other conditions the person may also have.

Onset (Precipitating Event)
The first appearance of the pain and the circumstances in which it started should be assessed. The clinician should distinguish between an event that may have aggravated rather than
precipitated the pain.

Previous Similar Symptoms
Previous experience of similar symptoms suggests a recurrent condition.

Previous Action to Relieve Pain
All measures used for the condition before (and their effectiveness) should be noted. Unwanted effects associated with past treatment should also be recorded. Information on how each
intervention was applied can be helpful, as treatment ‘failures’ may be due to misapplication rather than to true failure of effect.

Current Action to Relieve Pain
All forms of treatment in current use should be noted. The clinician should ask about the use of physical interventions, including self-applied measures, all passive treatments, and all substances whether prescribed or otherwise that the person is taking or applying, with an appraisal of the helpfulness of each.

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