GOOD USE OF THE DN4 QUESTIONNAIRE AND VAS IN PHLEBOLOGY

Dr Rodrigue DELEENS Centre d’Evaluation et de Traitement de la Douleur CHU Rouen I disclose the following financial relationships: none about this topic Which context? specificities • Acute – Predictable = anticipation – Nociceptive most often • – Repeated care – Chronic pathological context – Neuropathic or mixed pain Why?

The assessment of pain is everyone's business! (nurse, doctor, nursing auxiliary, physiotherapist, radio manipulator ...) It is a legal obligation, an ethical necessity and a team reflection!

Purpose of pain assessment: Characterize the pain: - To identify the painful patient circumstances of occurrence, history of pain, location, type of pain, quality, - To identify the factors (triggering, variations ...) periodicity, impact on quality of life and intensity … - To assess and adapt the treatment

- To improve the quality of care

- To improve communication between caregivers and the patient 2 methods of pain assessment = self-assessment or hetero-assessment

- Involvement of the patient in his care Self-assessment is, if possible, to be preferred In practice, assessment tools in phlebology To assess pain intensity

Quantifying pain at different times: during care, before and after; max / min / average, Allows to set up the adapted treatment and at the right moment (anticipation) TOOLS: VAS (Visual Analog Scale) or NPRS (Numeric Pain Rating Scale)

To detect neuropathic pain Chronic pain (7% of patients) Mixed pain during care! TOOL for screening: DN4

Self-assessment adult Visual Analogue Scale (VAS) - From 0 to 10 or 0 to 100. - The patient requires if EVA ≥ 4/10 (scale from 0 to 10 in cm) or EVA ≥40 / 100 (scale from 0 to 100 in mm). Numeric Pain Rating Scale (NPRS) - From 0 to 10 or 0 to 100. - The patient requires pain management if NPRS ≥ 4/10 (scale from 0 to 10 in cm) or NPRS ≥ 40/100 (scale from 0 to 100 in mm). Verbal Rating Scale (VRS) - Absent pain = 0; low pain = 1; moderate pain = 2; intense pain = 3; extremely intense pain = 4. - The patient requires pain management if VRS ≥ 2 (scale from 0 to 4).

HAS Liste d’échelles validées pour mesurer la douleur 20/02/2019 VAS Visual Analogue Scale • It is a one-dimensional scale of self-evaluation of the intensity of • Present the EVA strip horizontally, showing the unencrypted pain. side and explaining: For first-line use in communicating patients, from 5 years old (adults / children). "This is a scale to assess the intensity of your pain" or "This is a scale It is a simple, fast scale that allows for repeated and close that will help me understand how much you are hurting. We need measurements. your help to better treat your pain. It makes it possible to detect the patient's pain, to quantify it and to Move the cursor on the left part of the scale: "This part is the one follow its evolution. where you place the cursor if you have no pain". • Context: Move the cursor on the right side of the scale: "This part is where Check visual acuity (equipment if necessary). you place the cursor if your pain is the worst imaginable". Check understanding of the use of the scale. "I let you place the cursor at the level that corresponds to the pain In case of misunderstanding of the VAS, propose the Digital Scale, then you are feeling now." The patient moves the cursor himself. the Verbal Rating Scale. Locate the numerical value indicated on the back of the slider For children, do not hesitate to take a test by taking the example of a corresponding to the slider level. painful event that the child has already experienced. For transcribing on the integrated patient file, round up to the upper round if ≥ 0.5 and lower if <0.5.

If the patient score is equal to or greater than 4/10, the test is positive (82.9% sensitivity, 89.9% specificity)

Bouhassira D et al. Pain 2004 ; 108 (3) : 248‐57

Variation of VAS, clinically relevant?

Context -patients with a rheumatologic condition, pain that has been less than one month old, with intensity greater than or equal to 50 mm on the VAS -Fifty patients included (22 men and 28 women)

Objectif to study a clinically relevant variation of VAS felt by the patient and not to evaluate the efficacy of a therapeutic Variation of VAS, clinically relevant?

Methodology - VAS measurements on arrival and when relief considered "very good" or after max 7 days a verbal relief scale measuring the quality of the relief experienced by the patient, associated with a numerical score of 0 to 4: (0) no relief (1) insufficient relief (2) average relief (3) good relief (4)very good relief Results average value of the starting VAS: 77.7 ± 16.0 mm At the end of the study, the VAS value: mean 19.5 ± 20.1 mm Variation of VAS, clinically relevant?

At their inclusion: At the end of the study: 25 out of 49 patients rated their relief as zero (0), 26 out of 49 patient patients were getting good relief (3) with 13 out of 49 considered it insufficient (1), EVA -71.6 ± 12.7 mm 11 of 49 considered it medium (2) 15 out of 49 very good relief (4) with EVA -80.8 ± 21.2 mm Variation of VAS, clinically relevant?

YES!

The correlation tests performed between the relief scales and the VAS, led to the conclusion of a linear correlation between these two scales (r = 0.7 and p <0.001). To improve the pain of a class, it takes a 20 mm decrease of the VAS To improve it from two classes, a 40 mm decrease in VAS Take Home Messages - Pain assessment must take into account: - Its origin (nociceptive, neuropathic or mixed mechanisms) - Its temporality (acute pain or chronic pain) -Its repercussions (emotional, cognitive, behavioral ...)

- Assessment helps therapeutic adaptation and is renewed at each consultation or treatment

- Assessment tools do not replace the clinic THANK YOU FOR YOUR ATTENTION