Making an Accurate Pain Assessment the Importance of Good History Taking

Making an accurate pain assessment The importance of good history taking

By Joyce McSwan B.Pharm.MPS.Cert IV TAE Clinical Director, GCPHN Persistent Pain Program

Learning Objectives

1. Differentiate the pain measurement tools to assess and help manage patients with chronic pain 2. Use appropriate communication techniques to conduct an effective pain assessment 3. Identify red and yellow flags for early identification and intervention

2 Pain Assessment = Effective management plan

• The patient’s self‐reporting is the most reliable, ‘gold standard’, indicator of the existence and intensity of pain1 “Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does” 2 (McCaffery, 1989)

• Pain assessment is based on a multidimensional, whole person (bio‐ psycho‐social) observation of a patient’s experience of pain inclusive of their values and beliefs

1. Honorio T. Benzon, MD, Srinivasa N. Raja, MD, Robert E. Molloy, MD, Spencer S. Liu, MD, Scott M. Fishman, MD. Essentials of Pain Medicine. Third. USA: Elsevier Saunders; 2011. 28‐33. 2. McCaffery M and Beebe A, Pain: Clinical manual for Nursing practice. C.V Mosby Company, St Louis, Missouri 1989

Pain Assessment is NOT….

• Relying on changes in vital signs • Deciding a patient does not “look in pain” • Knowing how much a procedure or disease “should hurt” • Determined by radiological investigations alone (E.g. MRI, CTs, X‐Rays or Ultrasound) • Assuming a sleeping patient does not have pain • Assuming a patient will tell you they are in pain

4 A fundamental ingredient to successful pain assessment

Language ‐ verbal Positive reframes Affirmations and non‐verbal Non‐judgmental reflections

Patient literacy Pain terminology Cultural background Use analogies

Non‐interrogative Building rapport Empathethic Active listening

Melzack, R. The McGill Pain Questionnaire, 2005 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.

Non‐Verbal Pain Indicators

• Facial expressions (grimacing) ‐Less obvious: slight frown, rapid blinking, sad/frightened, any distortion • Vocalizations (crying, moaning, groaning) ‐Less obvious: grunting, chanting, calling out, noisy breathing, asking for help • Body movements (guarding) ‐Less obvious: rigid, tense posture, fidgeting, pacing, rocking, limping, resistance to moving

Keela A. Herr , Garrand L, Assessment and measurement of pain in older adults, Clin Geriatr Med. 2001 Aug; 17(3): 457‐vi

6 What the Ways to measure pain patient says

Self Report

Clinical observations of how the How the patient patient functions behaves

Physiological Behaviour

Assessing with context

• Location of pain • Emotional and psychological state • Memories of previous pain • Upbringing • Expectations of and attitudes towards pain • Beliefs and values Pain •Age •Sex • Social and cultural influences

ACUTE SUBACUTE CHRONIC‐ MALADAPTIVE

Pic: Copyleft –Permission Granted to use 8 Assessing for better pain management

Acute or • Determined by length of time of experiencing pain • Determine intensity of pain and impact on function Chronic • Determine function impact on activities of daily living

• Nociceptive Pain • Neuropathic Diagnosis • Psychogenic – “Yellow Flags” • “Red Flags”

Impact on • Sleep Quality of • Relationship • Independence Life • Enjoyment of life

Assessing different types of pain

Nociceptive

Psychogenic Neuropathic pain

Visceral Central pain pain

Radicular pain

10 Pain Measurement Tools

• Unidimensional • Used in acute pain when the etiology is clear • Used prior to trialling treatment • Good for baseline measure • Only reports sensory experience of pain severity • Multidimensional • Used in chronic/persistent, complex pain • Used as an initial biopsychosocial assessment • Assess pain severity and interference • Used for review and monitoring

Correll, Darin J. The Measurement of Pain: Objectifying the Subjective. Steven D. Waldman, MD, JD. Pain Management. 2nd. Philadelphia: Saunders Elsevier; 2011. 191‐201.

Examples of Unidimensional Pain Measurement Tools

Honorio T. Benzon, MD, Srinivasa N. Raja, MD, Robert E. Molloy, MD, Spencer S. Liu, MD, Scott M. Fishman, MD. Essentials of Pain Medicine. Third. USA: Elsevier Saunders; 2011. 28‐33.

12 Examples of Multidimensional Pain Measurement Tools

Cleeland CS, Ryan KM. Pain assessment: global use of the Brief Pain Inventory. Ann Acad Med Singapore. 1994 Mar. 23(2):129‐38 13

Assessing neuropathic pain

Bouhassira D, Attal N, et al. Comparison of pain syndromes associated with nervous or somatic lesions and development of a new neuropathic pain diagnosis questionnaire (DN4©). Pain. 2005; 114(1‐2):29‐36.

14 Pain Assessment for the Elderly

Warden, V, Hurley AC, Volicer, V. (2003). Development and psychometric evaluation of the Pain Abbey J, De Bellis A, Piller N, Esterman A, Giles L, Parker D, Lowcay B. Funded by the JH & JD Gunn Medical Assessment in Advanced Dementia (PAINAD) Scale. J Am Med Dir Assoc, 4:9‐15. Developed at the Research Foundation 1998–2002 New England Geriatric Research Education & Clinical Center, Bedford VAMC, MA. 15

Mnemonics for pain assessment

S.O.C.R.A.T.E.S1

P.Q.R.S.T

C.O.L.D.E.R.R.A

1. Clayton, Holly A. (2000). "SOCRATES on Pain Assessment". MedSurg Nursing. Retrieved 2008‐03‐31.

16 Mnemonics for pain assessment

S.O.C.R.A.T.E.S1

P.Q.R.S.T

C.O.L.D.E.R.R.A

1. Clayton, Holly A. (2000). "SOCRATES on Pain Assessment". MedSurg Nursing. Retrieved 2008‐03‐31.

Mnemonics for pain assessment

S.O.C.R.A.T.E.S1

P.Q.R.S.T

C.O.L.D.E.R.R.A

1. Clayton, Holly A. (2000). "SOCRATES on Pain Assessment". MedSurg Nursing. Retrieved 2008‐03‐31.

18 Assessing Change in Pain Intensity

After Before treatment treatment

0241 3 5 610798

No Mild Moderate Severe Very Worst pain severe possible

Helpful to determine treatment effect: • Score before treatment and score after treatment • Score before medication and score after medication

Assessing Interference of Function

• The reality is that the pain will stay or it may go, but the bigger question is : What can you still do even though the pain is around?

• Describing pain reduction as intensity reduction rather than completely FIXING the pain will enable the patient to concentrate on improving their quality of life despite pain.

• Assessing function interference will also provide information on the quality of life and ability to participate in activities of daily living

• Improving function capacity relies on understanding “Boom and bust or Pacing”

20 Assessing Interference of Function

• “Boom and bust” • “Pacing”

Boom and Bust Pacing Cycle WIN

Ref: Pain Matters, Hunter New England, Red Flags (Low Back Pain) NSW Health, Medical Practice Guidelines, Hunter Integrated Pain Service Updated Nov Indicators for RED flag 2005 Possible fracture Possible tumour or infection Possible significant neurological deficit From History • Major trauma Age >50 or <20 years • Severe or progressive sensory • Minor trauma in elderly or • History of cancer alteration or weakness osteoporotic • Constitutional symptoms (fever, • Bladder or bowel dysfunction chills, weight loss) • Recent bacterial infection • IV drug use • Immunosuppression • Pain worsening at night or when supine

From Physical Examination Evidence of neurological deficit (in legs or perineum in the case of low back pain) If ONE or more areas are flagged  REFER TO GP OR SPECIALIST

Low Back Pain: Rational use of opioids in chronic or recurrent non‐malignant pain. NSW Therapeutic Assessment Group: Prescribing guidelines for primary care clinicians. Published 1998. Revised 2002. (Sourced 24/2/14) http://www.ciap.health.nsw.gov.au/nswtag/documents/publications/guidelines/pain‐low‐back‐gp‐dec‐2002.pdf

22 Headache Red Flags *

SSNOOP Example

S Systemic Symptoms Fever, weight loss, after sickness, vomiting

S Secondary risk factors Underlying disease, e.g. HIV, systemic cancer, immunosuppression

N Neurologic symptoms Confusion, impaired alertness, consciousness, change or abnormal signs in behaviour

O Onset Sudden, abrupt, split second (first, worst)

O Older or Younger New onset, progressive, middle-age >50 yo (giant cell arteritis) < 5 years old P Previous headache Pattern change, first headache or different (change in history or Progression attack frequency, severity or clinical feature Following trauma Starts after physical exertion, coughing, sneezing, sexual activity or bending over

Wolff's Headache and Other Head Pain, Eighth Edition 23

Psychosocial assessment

o Yellow Flag indicators – give indication of potential for progression to disability

oPsychosocial pain assessment form (PPAF): measures economic, social support, activities of daily living, emotional impact, and coping style

oPain self‐efficacy (PSEQ) – self‐confidence to participate in activities despite pain

oBeliefs (BPCQ) – measures ‘locus of pain control’ or how much internal, external or chance factors influence pain control

Williams, David A. “The importance of psychological assessment in chronic pain” Current opinion in urology vol. 23,6 (2013): 554‐9. Otis‐Green, S. (2006). Psychosocial Pain Assessment Form. In Dow (Ed.), Nursing Care of Women with Cancer. St. Louis, MO: Elsevier Mosby, 556‐561.

24 Assess for Yellow Flags

Reference: New Zealand acute low back pain guide: Incorporating the guide to assessing psychological yellow flags in acute low back pain. Accident Compensation Corporation (ACC)’ Wellington ,2004. (Sourced 24/2/14) http://www.acc.co.nz/PRD_EXT_CSMP/groups/external_ip/documents/internet/wcm002131.pdf 25

Once the clinical assessments are done…. then what?

What if….

26 Assessing contributing factors

• Instead of waiting for pain to be “controlled” or for treatment options to be tried • We identified the factors contributing to the patient’s presenting problems • Selectively prioritized based on assessment findings • And targeted them

Steven J. Linton and Michael K. Nicholas, After assessment, then what?Integrating findings for successful caseformulation and treatment tailoring, Center for Health and Medical Psychology, Department of Behavioral, Social andLegal Sciences—Psychology, Örebro University; and Pain ManagementResearch Institute, University of Sydney

Integrating findings with a successful case formulation approach

Instead of trying to ‘treat’ pain in isolation, what about tackling as many of these contributors as possible?

REDUCEDSet realistic goals & ACTIVITYpace up activities, PHYSICAL NEUROPATHIC or exercises – despite DETERIORATION NEUROPLASTIC (eg. muscle wasting, MECHANISMS pain; diet plan wt gain, joint Targeted stiffness) medication, interventional EducationUNHELPFUL about Schedule pleasant painBELIEFS & & treatments techniques, THOUGHTS activities (not just desensitizing, + identify & chores), improve challenge distraction,CHRONIC sleep habits,DEPRESSION, fears, EXCESSIVE unhelpful beliefs hot packs, TENS anger HELPLESSNESS, SUFFERING PAIN REPEATED FRUSTRATION TREATMENT ANGER & DISABILITY FAILURES POOR SLEEP Maintenance Rationalise plan – chronic & cease pain will unhelpful LONG-TERM fluctuate, need NOCICEPTIVE drugs MECHANISMS USE OF ANALGESIC, to plan for these, SEDATIVE DRUGS SIDE EFFECTS Steven J. Linton and Michael K. (eg. stomach and for dealing Negotiate with Nicholas, After assessment, then problems, lethargy,with other workplace, family, constipation) what?Integrating findings for Facilitate RTW stressors successful caseformulation and agree on LOSS OF JOB, FINANCIALplanning/re-training treatment tailoring, Center for Health management DIFFICULTIES, FAMILY family/relationship and Medical Psychology, Department plan with all & STRESS interventions of Behavioral, Social andLegal HCPs INPUT FROM: FAMILY; HEALTHCARE PROVIDER(S); M. Nicholas. 2012 Sciences—Psychology, Örebro INSURERS; EMPLOYER University; and Pain ManagementResearch Institute, University of Sydney

28 Case Study: Meet Peter Peter – 55yo, Accountant Hx: T2DM, Hypertension, Obesity, Amitriptyline / Osteoarthritis, Hypercholesterolaemia, Pregabalin Depression, Insomnia Neuropathic Meds: Change Sertraline • Targin 20/10 TDS to Duloxetine • Sertraline 100mg mane Topical TARGIN diclofenac / • Metformin 1000mg daily Capsaicin • Temazepam 10mg nocte Nociceptive Radicular • Nuromol – 1 TDS PRN mechanical pain pain Pain Complaint: Burning feet and lower back pain with pain shooting up the leg– can’t walk more than 100 metres before needing to stop