Includes Pain Scales- both uni dimensional & multidimensional scale,depression scales, History & examination of chronic pain patients.

1. Clinical evaluation of
patient with pain
complaint
Ravi shankar sharma
Moderator –Dr. Ajit

2. CONTENT
• History
• Physical examination
• Pain scoring
• Multidimensional assessment

4. Components :
• Pain History
• Ruling out red flags
• Past history
• Personal history -sleep, bladder/ bowel habit
• Treatment history
• Family history.

5. A good history ???
• Time
• Chronological order
• Physician –Empathetic, no distraction
• Detailed history should be taken on the first visit.
• Pre-consultation questionnaire

6. Pain history
S O C R A T E S

7. cont..
• Quantity or severity of pain.
• Quality or nature of pain.
• Mode of onset and location.
• Duration or chronicity.
• Provocative and relieving factors.
• Special character.
• Timing of pain.
• Relation to posture.
• Associated complaints

8. Quantity or Intensity of Pain

9. A: Quantity or severity or intensity of pain
• Instruments for intensity assessment:
Unidimensional Multi dimensional
1.Verbal rating scales 1.Mc Gill pain questionnaire
2.Binary scale 2. Brief pain inventory
3.Numerical rating scale 3. West Haven –Yale multidimensional
4.Faces rating scale pain inventory
5.Visual analog scale 4. Medical outcome study 36 item
short form(SF-36)health survey

10. Unidimensional instruments:
1.Verbal rating scales(VRS)
 Response is noted as None, mild ,moderate or severe
 Advantage-short, easy to express and understand
especially in elderly
 Disadvantage-lack of reproducibility
2. The binary scale
e.g. do you have a 60% reduction in your pain? “Yes/no”
 Advantage-short, easy to express and understand.
 Disadvantage-lack of reproducibility

11. 3.The numerical rating scale(NRS)-
• Most commonly used
• A reduction of 30% or 2 points and more from baseline-
positive response for Rx.
• Disadvantage –Digital scale reduces the capacity to detect
subtle changes

12. 4. The faces rating scale (Wong-Baker)
• Patient is asked to point at various facial expressions
ranging from a smiling face to an extremely unhappy face.
• Advantage :- when the communication with the patient is
difficult as with the pediatric and deaf and dumb patients

14. 5. The visual analog scale (VAS)
 10 cm horizontal line
• the distance from no pain to the patient mark indicates the severity
of pain numerically
• Advantage-simple, efficient , valid, and minimally intrusive
• Disadvantage-more time consuming than others & some difficulty
in understanding in elderly

15. Multi dimensional instruments:
1.The Mc Gill pain questionnaire(MPQ)- Melzack and Torgerson-1971
• Defines pain in 3 major dimensions by 20 set of descriptive words
divided as-
a. 10 sets describes sensory- discriminative (Nociceptive pathway)
b. 5 sets describe motivational –affective (reticular and limbic structure)
c. 1 set describe cognitive evaluative
d. 4 sets describe miscellaneous dimensions.

17. Advantage- helps in diagnosis as choice of
descriptive words that characterize the pain
correlates well with pain syndromes.
Disadvantage – high level of anxiety and
psychological disturbances can obscure the
MPQ discriminative capacity.

19. Short-Form MPQ
• 15 representative words = Sensory (11 items) and
Affective (4 items) categories of original MPQ
• Each descriptor is ranked on a 0(“none”) to
3(“severe”) intensity scale

20. Short-Form MPQ
• The PPI, along with a VAS, are also included
• The short form correlates highly with the original scale
• It can discriminate among different pain conditions
• May be easier than the original scale for geriatric patients

21. Short-Form McGill Pain Questionnaire

22. 2. Brief pain inventory(BPI):
Measures both the intensity of pain (sensory dimension) and
its interference with the patient life(reactive dimension)
• 7 items -: general activity, mood, walking ability, normal
work, relations with other people, sleep and enjoyment of
life
 Advantage-
 valid for cancer pain and various pain syndromes
 shows good sensitivity to T/t.
 helps in comparing international trials with different culture
and population

23. 3.Memorial Pain Assessment Card
• Pain assessment tool for cancer patients
• Consists of three separate visual analog scales
and assesses pain , pain relief and mood.
• Card includes a set of adjectives to describe
pain intensity

24. 4.West Haven-Yale multidimensional
pain inventory (WHYMPI)
composed of 52 items with 3 parts
• Part I: 20 questions; assess five pains domains
(interference, support, pain severity, self-control
and negative moods)
• Part II: Assess the spouse response to patient pain
behavior
• Part III: Participation in various life activities.

25. West Haven-Yale multidimensional
pain inventory (WHYMPI)
• Patient's response to question is noted on a 7-
point scale
• Advantages
a. Pain syndromes
b. Good sensitivity to treatment effects.

26. B:Assesment of Quality or nature of pain
• Important for diagnosing the nature or character of pain
whether it is nociceptive or neuropathic or a mixed nature.
Screening tools for Neuropathic pain:
1.Leeds assesment of neuropathic symptoms and signs:
 It has two components in form of symptoms and signs
 For Each item binary response is noted-yes/no
 Scores ≥12/24 indicates pain is likely to be neuropathic

27. Use is limited- because of need for clinical
examination and pinprick testing

28. 2. Neuropathic pain questionnaire(NPQ)
• The NPQ is a self questionnaire consisting of 12
items :
10 related to sensations or sensory responses
 2 related to affect
Each item is scored on a scale of 0(no pain ) to
100(worst possible pain)

29. NPQ Questionnaire:
A short form of NPQ has been described consisting
of 3 items: Numbness, tingling and pain increase in
response to touch.

30. 3.Douleur Neuropathique en 4(DN 4)
questions:
Consists of 7 items related to symptoms and 3
items related to physical examination
• Each item is scored 1(yes) or 0(no)
• sum of all ten items is taken as total score
• score of ≥ 4 as neuropathic pain

31. Douleur Neuropathique en 4(DN 4) questions

32. 4. Pain detect:
 Patient based self report questionnaire consisting of 9 items:
 7 sensory descriptions and
 2 related to spatial(radiating) and temporal characteristics.
• Sensory descriptions are scored on a scale of 0 (no) to 5(very
strongly)
• Radiating pain as 1(yes) or 0(no)
 Score ≥ 19 indicates neuropathic pain likely
≤ 12 unlikely neuropathic pain
Note –no clinical examination is needed.

33. Pain detect questionnaire:

34. 5. ID -Pain
• It is a self questionnaire consisting of 5 sensory
description and 1 item regarding pain located in the joints.
• Higher scores indicates neuropathic pain
ID –pain
- Pins and needles - Electric shocks
- Hot/ burning -Numb
- Is the pain made worse with touch of clothing or bed
sheets?
- Is the pain limited to your joints?(-1)

36. C: Mode of onset and location
• Etiology of pain-eg. Sudden severe headache-sah
D: Chronicity (duration and frequency)
• e.g. in migraine the unilateral pain is frequently
throbbing and may exist for hours to days
E:Provocative and relieving factors
• E.g.- leg and back pain due to spinal stenosis

37. F: Special character
• e.g. – cluster headache- pain is deep , boring, wrenching,
and severe in intensity
G: Timing of pain
• Pain and stiffness felt in morning hours for> hours- d/t
inflammatory arthropathy
• < half hour – degenerative arthropathy
H: Relation to posture
Eg. Pain on sitting cross legged –Piriformis syndrome

38. Other :
• Past history-rash (phn)
• Personal history
• Family history
• Treatment history

39. Pain Map

40. Red flags
• Pain with major trauma
• Suspecting tumor
• Suspecting infection with fever, rigor, vomiting, etc.
• Motor weakness & Progressive sensory deficit
• Loss of bladder & bowel control
• Sudden onset pain which is progressing rapidly

41. Psychological assessment :
 Patient in pain can have some psychological disorders like
anxiety or depression
• Tools available are:-
I. PHQ-9
II. Beck depression inventory(BDI)
III. Hamilton depression scale
IV. Hospital anxiety and depression scale(HADS)
V. Pain catastrophizing scale(PCS)
VI. The tampa scale of kinesophobia
Helps in assessing
personality disorder

43. Becks depression inventory:
• 21 parameters and each are graded from 0 to
3 ,so total score of -63
• Results –
1-10-normal
11-16-mild mood disturbance
17-20-borderline
21-30-moderate depression
31-40-severe depression
>40-extreme depression

45. Hamilton depression scale:-
17 parameters with score grade of 0 to 4
i.e. symptoms is absent ,mild , moderate, severe
Total score -54
Hospital anxiety and depression scale(HADS):-
 14 parameters
• 2,4,6,8,11,12,14-anxiety
• 1,3,5,7,9,10,13-depression
Results –
0-7- non case
8-10-borderline case
11 or above -case

46. Hamilton,s parameter:-

47. HADS parameters:-

48. Examination

49. Examination
GENERAL OBSERVATIONS
1. Signs of distress
2. Facial appearance
3. Posture and gait
4. Mental state
5. Built and nutrition
6. State of clothing

50. Signs of distress

51. Facial appearance
• Anxious face
• Depressed face
• Moon face : Cushing's syndrome or long term steroid
therapy
• Face in myxedema: hypothyroidism
• Mask-like face: Parkinsonism
• Starring look: hyperthyroidism

52. Posture
Leaning forward, stooped posture is the comfortable and
preferred for patient with lumbar canal stenosis.

53. Gait
Parkinsonism gait
Ataxic gait
Shuffling gait Antalgic gait

55. GENERAL EXAMINATION
• Height, Weight and BMI
• Vital Parameters-Pulse
Blood pressure
Respiratory rate
Temperature

56. Complete examination from head to toe
• Head
• Hair
• Eyes
• Oral cavity
• Ear ,nose, throat
• Skin
• Nail
• Clubbing
• Extremities
• Edema
• Fibromyalgia trigger points

57. Eyes
• Look for conjunctivitis,
uveitis, iridocyclitis
ankylosing spondylitis.

58. Skin

59. Extremity

60. Mental State Examination
• Orientation
• Calculations
• Memory
• Speech
• Comprehension

62. Reflexes

64. BICEPS REFLEX TRICEPS REFLEX
SUPINATOR REFLEX
ABDOMINAL REFLEX
REFLEXES

65. ANKLE REFLEX
BABINSKI REFLEX
KNEE REFLEX
REFLEXES

66. Pain assessment in children
• Children, even newborns, feel pain.
• ‘QUESTT’ approach
– Question the child if verbal, and the parent/guardian in both the
verbal and non-verbal child
– Use pain rating scales if appropriate
– Evaluate behavior and physiological changes
– Secure the parent’s involvement
– Take the cause of pain into account
– Take action and evaluate the results
When possible: carry out the assessment in the presence of family/guardian

67. Pain assessment in children
• Neonates: 0-1 month
• Behavioral observation
• Lack of behavioral responses does not always
mean absence of pain
•not necessarily accurate indicators of the
neonate’s level of pain

68. Pain assessment in children
Infants may exhibit the following when experiencing pain:
•Body rigidity/thrashing
•Facial expression of pain [brows lowered and drawn together, eyes
tightly closed, mouth open and squared]
•Loud and intense cries
•Inconsolability, hypersensitivity / irritability
•Draw knees to chest
Infants: 1 month to 1 year

69. Pain assessment in children
Toddlers may exhibit the following when experiencing pain:
• Verbal aggression, intense cries
• Regressive behavior / withdrawal
• Physical resistance, guard painful part of the body
• Poor sleep
Toddlers: 1-2 years

70. Assessing behavioral signs of pain
FLACC Pain Scale (<2,5 years)

71. Assessing behavioral signs of pain
How to Use the FLACC
In patients who are awake:
Observe for 1 to 5 minutes or longer. Observe legs and body uncovered.
Reposition patient or observe activity. Assess body for tenseness and
tone. Initiate consoling interventions if needed.
In patients who are asleep:
Observe for 5 minutes or longer. Observe body and legs uncovered. If
possible, reposition the patient. Touch the body and assess for tenseness
and tone
FLACC Pain Scale (<2,5 years)

72. Assessing behavioral signs of pain
Interpreting the FLACC Score
Each category is scored on a 0–2 scale, which results in a total score of
0–10.
0 -- Relaxed and comfortable
1–3 -- Mild discomfort
4–6 -- Moderate pain
7–10 -- Severe discomfort or pain or both
FLACC Pain Scale (<2,5 years)

73. The OUCHER is a poster developed
for children to help them
communicate how much pain or hurt
they feel.
There are two scales on the
OUCHER: a number scale for older
children and a picture scale for
younger children.
OUCHER Scale (< 3 years)
It is possible to adapt the photos on the
scale to different ethnicities (USA):
•Caucasian
•African American
•Hispanic
•Asian - Boy
•Asian - Girl
•First Nations (Canada- Boy
•First Nations - Girl
For instructions how to use the scale:
http://www.oucher.org/the_scales.html

74. The Universal Pain Assessment
Tool