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hello my name is caste bundle and I'm a.consultant in pain medicine here at jaws.where Chelsea Westminster Hospital in.London United Kingdom and I would like.to give you a quick introduction into.pain assessment tools pain is a.subjective experience and that's the.reason why you it cannot be objectively.measured hence pain can only be assessed.and this is important to remember at the.moment we are facing a dilemma and pain.medicine because the cause of pain is.frequently unknown we as clinicians are.aligned on unspecific symptoms to treat.our patients.this is aggravated by the situation.where a research is actually failing to.provide us with new therapies however.scientists and clinicians both think.that it is necessary to better.characterize painful conditions to.provide actually new solutions for its.treatment hence at the moment there is a.kind of new trend which basically can be.summarized under the headings of.phenotyping and biomarker research.what are biomarkers used for they should.be used ideally as diagnostic aids they.should help us to stratify patients to.best treatments and also they should.enable us to tell patients about the.prognosis of their disease biomarkers.can be classified in general into seven.groups naught to 6 and group 6 are.interestingly clinical scales and in.pain medicine at the moment we are using.Group naught and 6 for pain assessment.or as pain assessment tools two main.principles are applied to pain.assessment tools.the first one is patient self reporting.and the second one is reliant on.external observations and hence they are.called proxy assessments self reporting.tools are currently the preferred tools.for all cognitively and verbally.competent patients because they actually.allow or assure the sovereignty of.patients over their own private.experience and hence avoid the.interpretation by external parties there.are two different types unis and one.dimensional or one dimensional.assessment tools and multi-dimensional.assessment tools let us start with the.visual analog scale a classical visual.analog scale is a horizontal line which.is normally 10 cm centimeters long it is.anchored on the left hand side with no.pain and on the right hand side with.worst possible pain a patient is then.asked to mark the spot on the line which.they think or he or he thinks best.represents his or her pain a ruler can.then be applied to measure distance from.the no pain spot to the marked spot to.give a direct indication of pain.intensity verbal rating scales and it.should not be NRS it should be VRS in.this case as an operation actually.applies verbal descriptors of pain or.for pain normally it's no pain mild.moderate severe or very severe pain but.it can also include more or less verbal.descriptors a patient is asked to mark.the word which he or she thinks best.represents his or her pain intensity and.this is a direct indicator than for his.or her pain experience however the.criticism people have or the issue.people have with visual analogue scales.is that they require translation of a.sensory experience into a spot on a line.further it requires patience to have an.intact motor and coordination systems.system and as you can imagine if you.think about your elderly patient that.might actually be a problem.further in the classical way people.think about visual analogue scales as.continuous scales or even ratio scales.however this might not be the case also.verbal rating scales are categorical.data and sometimes you read actually.papers where verbal rating scales have.been analyzed with parametric tests.although this is a slightly different.story here I'm basically drifting up.into off into statistics however this is.not accurate because categorical data.should always be analyzed with.nonparametric tests also there is more.and more evidence to suggest that.patients actually prefer verbal rating.scales over visual analogue scales or in.other words all data at present suggests.that visual analogue scales are the.least preferred ones in daily clinical.practice by patients another thing to.consider is if it do or if you employ.verbal rating scales you have to be.careful that actually the scale is.validated for your patient cohort what.I'm trying to say is basically that the.meaning of words might be different from.depending on the patient's background so.just be careful with the wording you are.using for your verbal rating scales.numeric rating scales are many ways.similar to the visual analog scale.however in contrast to the visual analog.scale it they can exist in many.different forms and I will explain to.you the two forms we are currently using.in our clinical practice the first one.is the 11-point numeric rating scale.which you might have come across in your.clinical practice as you can see it.again it is a straight line but in.contrast to the visual analogue scales.scale it is subdivided into equal.intervals also it is marked on the or.anchored on the left hand side with no.pain and on the.inside with worst possible pain again a.patient is asked to mark this spot on.the line which he or she thinks best.represents his or her pain but as you.can see you don't need an ruler or.anything like this to basically measure.the pain but instead the number is used.as a direct indicator for the patient's.pain intensity we are also using a.five-point numeric rating scale which is.actually from Nord which equals no pain.to four worst pain worst possible pain.but I know that other hospitals for.example using a four-point numeric.rating scale which ranges from nought to.three and again the patient is asked to.mark this spot or the number which he or.she thinks best represents his or her or.his pain the thing is again if you look.at the literature and this is a slight.excursion to statistics again a lot of.people believe that numeric rating.scales are actually continuous data.which is not true as a matter of fact.the short of the the the scale the more.likely it is that it these gates.represent ordinal data also although you.might think that the interval between.each mark is identical this is by far.this is so far not really established by.research also as I said to you before.some patient actually prefer numeric.rating scales over visual analogue.scales or verbal rating scales however.there is evidence in elderly populations.that they might prefer verbal.descriptors over any form of numeric.rating scales or visual analogue scales.and similar to what I said about the.visual analogue scales the numeric.rating scales also require the patient.to translate a sensory experience into a.number on the line and we have now.evidence to suggest.that this translation is not always.accurate and doesn't always work as we.think it works finally for our younger.patients meaning the children you've got.pictorial rating scales the one you.probably have seen in many textbooks are.the faces pain scale in this case is a.revised pain scale because it contains.six pictures of faces the original one.contained seven and again the child is.being asked to basically indicate or.point on the face which he or she might.think best represents her pain or.discomfort level and then there is the.wrong Baker faces pain scale which I.prefer because it's basically comic or.it contains comic representations of.faces and to some extent I've got an.affinity for that so I like them better.and it's the same principle so basically.the patient has to indicate which face.best represents his or her pain however.there is research out there which.suggests that actually children don't.choose these faces because they best.represent their pain they this all these.researchers that actually suggest that.they sympathize with the faces and hence.these gates become a measure of effect.rather than pain and also another thing.is in another unsolved problem and pain.research or in clinical pain even is.when should we be using the faces pain.scale on other words when is a patient.or a child able to self-report now I.come to the multi-dimensional pain.assessment tools and there are three.different types the first one or the.first type judges the impact of pain the.second one assesses the quality of pain.and the third one are pure screening.tools or.coming back to our biomarker story they.are group north biomarkers and they are.used for phenotyping of pain.most of these multi-dimensional.assessment tools are based on.questionnaires however sometimes these.questionnaires are going in conjunction.with rating scales sometimes even they.are required or clinicians who apply.them are required to do specific.clinical examinations in conjunction.with these multi-dimensional assessment.tools multi-dimensional assessment tools.as the name implies assess multiple.aspects of pain such as sensation mood.pain intensity I will quickly run with.you through some of the commonly used.multi-dimensional assessment tools for.the assessment of the impact of pain in.our Hospital we are using the brief pain.inventory for the assessment of the.quality of pain people use the Megillah.pain questionnaire as a matter of fact.the McGill pain questionnaire is.probably at the moment of to all of us.the the best known pain assessment tool.then there is a short form of the McGill.pain questionnaire and also there's a.neuropathic pain scale as well as a pain.quality assessment scale as screening.towards especially to distinguish.neuropathic pain from let's say.inflammatory pain there's the leads.assessment of neuropathic symptoms and.signs or lens there's new neuropathic.pain questionnaire and there's the.neuropathic pain diagnostic.questionnaire let me just introduce you.to the McGill pain question and I think.you probably all have heard about it it.is basically an a4 form which contains.in total 78 descriptors of pain and.these 78 descriptors are organized into.22 groups.the first 10 groups are concerned with a.sensory quality of pain and I've.indicated this with this line group 11.to 20 are assessing effective evaluative.and miscellaneous components of pain.shown here group 22 21 and 22 are.concerned with pain intensity and as you.can say per definition this is probably.more a verbal rating scale or verbal.descriptive scale of pain and the images.on these on the form on the Miguel.questionnaire are used for the patient.to indicate where the pain is actually.located however although the Miguel.creme pain questionnaire is quite well.known there's some shortcoming in.Cummings with this scale or with.multi-dimensional assessment tools.altogether the shortcomings are are they.of value and day to day practice and.this has actually been questioned in.recent research so at the moment people.really think they're more the remit of.research rather than a clinical work.because there's a question whether they.are sensitive enough for the detection.of any treatment effect which is.important for the clinician and also as.you can imagine going through 78.descriptors of pain this is actually a.lengthy process and it might not be.applicable or not be as good in daily.clinical practice because it's just too.long now we are coming to the proxy or.observational assessment tools but.before I do that I have to go back to.the self reporting tools because the.self reporting tools are reliant or rely.on intact higher cognitive function.which is memory language the concept of.numbers and the concept of proportions.however proxy assessments don't need us.because as the name name implies it is.someone else who does the assessment for.the patient.there's a problem of course with that.because this actually requires.subjective skills of the observer and.this is basically how well can you.observe oshi and also it kind of goes.into the remedy of clinical judgment and.as we all know clinical judgment is also.a function of clinical experience or.maybe even training so proxy assessments.or the aim of proxy assessments is.actually to make assessments or to.standardized assessments to make them.widely applicable let us first discuss.the situation in children whenever I do.my ward rounds I'm frequently faced with.a situation where trainees or students.tell me that why would i assess pain in.children because children can't feel.pain anyway and I'm always a little bit.shocked about this statement because.this actually should be or this kind of.statement it should have been abandoned.many years ago because now we know.actually that children of all ages do.experience pain and hence we have an.obligation to not only treat pain but.also to assess pain and this the more.because we know that untreated pain in.children has a negative impact on the.further development so what type of.treatment or of assessment tools should.we be using now there's a rule of thumb.saying that actually children from about.four years onwards should be using or.should be ready to to use self reporting.scales like the one Baker scale or the.faces pain scale however younger.children need to be assessed with proxy.tools and these tools make use of.behavioral cues like crying breathing or.movements I don't want to bore you with.the presentation of too many proxy.assessment tools for children but it's.probably worth looking at the most.commonly used ones one which is.neonatal infant pain scale or nips it is.kind of validated for children of less.than one year old and as you can see it.makes use of the facial expression of.the child of the crying behavior.breathing pattern of arms movements of.our movements leg movements and the.state of arousal and as you can see the.each component can be scored and at the.moment we think that the score of.greater than 3 indicates pain and/or not.only indicates pain but pain that should.be treated let us now discuss the.situation in our demented patients.dementia is regarded as the prototypical.cognitive impairment and people believe.or still believe that if a patient is.demented we can't use self-reporting.tools to assess their pain however there.is evidence to suggest that this is not.true as a matter of fact now there's.good evidence to suggest that mild to.moderate dementia can be assessed with.self reporting tools however the ideal.assessment tools or tool in severe.dementia should incorporate multiple.aspects of pain such as sensation.behavior and emotions however.unfortunately the currently used.assessment tools are not very well.validated at present and they also only.cover some aspects of pain currently.used tools in dementia pain assessment.tools in advanced dementia or pain aide.pain assessment checklist for seniors.with limited ability to communicate or.pack slack and finally the dolo plus.scale or assessment tool to give you an.idea of how we assessing pain in the.demented patient or to be more precise.in the severely demented patient I'm.giving you the example of the pecs lack.assessment tool.similar to what we've seen in our.children on the pain assessment tools.for children.it relies on patience facial expression.body movements social personal.personality and mood symptoms as well as.other symptoms now the observer simply.has to mark whether a symptom is present.and or not.so hence with this assessment tool we.are dealing with binary data and the.maximum score a patient can achieve is.60 however one of the biggest drawbacks.with this assessment tool is that we.don't know which score truly reflects.pain and more importantly which score.reflects pain that needs to be treated.as a matter of urgently urgency now.let's carry on to look at patients in.the critical care environment there is a.special challenge to the pain assessment.in critical care because as we all know.patient in severe pain in critical care.might experience in adverse outcome.because of the activated simple.sympathetic nervous system this might.actually aggravate their disease process.also pain and on intensive care is.difficult to recognize because of the.underlying medical condition of.treatments we have given for example.beta blockers or some practical mimetics.and also self-report is usually not.possible in inpatients on intensive care.hence we are reliant on proxy.assessments and again similar to what we.said about the children's or the.demented patients these assessment tool.towards rely on behavioral cues and.physiological signs such as heart rate.and blood pressure.there are many proxy assessment tools.available at the moment for critical.care patients they might be.uni-dimensional.multi-dimensional and I quickly I'm.quickly running you through some of the.uni dimensional tools the first one is.the behavioral pain rating scale or B.RPS there's the behavioral pain scale or.bps the pain behavior assessment tool B.pad and the critical care pain.observation to a support as.multi-dimensional assessment tools we.know the pain assessment and.intervention notation or pain algorithm.and the non verbal pain scale and bps.however most tools at the moment are not.readily readily or adequately validated.let me now quickly go over a commonly.used assessment tool in critical care.which is the critical care pain.observation tool or C pot and similar to.what I already discussed with you when.we looked at the pain assessment tools.proxy assessment tools in children and.the demented patients also the critical.care proxy assessment tool is reliant on.behavior cues like facial expression.body movements muscle tension and what I.found interesting as well as the.compliance with a ventilator or.vocalization if the patient is already.extubated now similar to all the other.towards the observer now is asked to.rate the symptoms and with this support.assessment tool the patient can actually.or the highest score the patient can be.given is an 8 so the range of scores is.from naught to 8 however similar to what.I said with the other assessment tools.at present we don't know what score.represents a treatable pain now I've.come to the end of my talk about pain.assessment tools and let me quickly.summarize what we have discussed this.afternoon.pain assessment tools are biomarkers and.there are a plethora of tools out there.which are ready to be used.however this in itself tells you a story.because at present there is no ideal.pain as.tool out there however you as a clinical.clinician or maybe clinical scientist.should know about the strengths and.weaknesses of the currently available.tools to make best use of them in your.practice thank you very much for your.intention.

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