You are on page 1of 93



Peter Lascarides DO
1. Provide overview of Pain Assessment
2. Describe various methods of pain assessment
3. Provide familiarity with various pain scales
4. Facilitate the ability to choose appropriate
pain scales for different patient groups
5. Assess treatment of pain
Definition of Pain
International Association for the Study of Pain
• An unpleasant sensory and emotional
experience arising from actual or potential
tissue damage or described in terms of such
• Sensory, emotional, cognitive, and behavioral
components that are interrelated with
environmental, developmental, socio-cultural,
and contextual factors
Pain Assessment
• By its very definition, pain is an internal,
subjective experience that cannot be directly
observed by others or measured by the use of
physiologic markers or bioassays.
• The assessment of pain, therefore, relies
largely (and in many cases exclusively) upon
the use of self-report.
Pain Assessment
• Though the self-report of pain or any other
construct is subject to a number of biases, a
good deal of effort has been invested in
testing and refining self-report methodology
within the field of human pain research.
Pain Assessment
• The Joint Commission in the United States has
set standards for the assessment of pain in
hospitalized patients.
Pain Assessment
• Pain assessment should be ongoing,
individualized, and documented.
• Patients should be asked to describe their
pain in terms of the following characteristics:
location, radiation, mode of onset, character,
temporal pattern, exacerbating and relieving
factors, and intensity.
Pain Assessment
• Although pain cannot be considered vital,
nor is it a sign, the suggestion that it be
routinely measured along with temperature,
pulse, blood pressure, and respiratory rate is
a powerful reminder to health care providers
to attend to their patients' suffering.
Pain Assessment
• Unfortunately, simple routine documentation of
pain levels has not been shown in and of itself to
lead to any improvement in the quality of pain
management. However, proper assessment is still a
desirable goal before appropriate treatment.
Assessing Pain
• Question the patient
• Use pain rating scales
• Evaluate behavior & physiologic signs
• Secure family’s involvement
• Take action and assess effectiveness
Assessing Pain
• The single most reliable indicator of the
existence and intensity of pain is the patients
self-report of pain. The patients' report of pain
should be the primary source of information,
since it is more accurate than the observations
or others.
Assessing Pain
The American Pain Society guidelines for the treatment
of acute and cancer pain suggest that each of the
following assessment steps occur.
• The patient's self-reported pain is charted and
• The intensity of pain and discomfort are assessed and
documented at regular intervals (i.e. prior to
administration of medication and then after
administration of medications)
• The degree of pain intensity is measured after allowing
sufficient time to pass in order to ensure that a specific
pain intervention treatment has occurred.
Question The Patient
• Obtain a detailed assessment of pain
– HPI, description of pain, experience with pain medications, use
of non-pharmacologic techniques, family experience with pain
– Quality, location, duration, intensity, radiation, relieving &
exacerbating factors, & associated symptoms
• Use appropriate pain scale
– Cognitively impaired adults, Sedated patients Children
• Pain can be multi-dimensional and therefore, tools can be limited
• Directly ask patients and or family when appropriate
• Site - Where is the pain?
• Onset - When did the pain start,
was it sudden or gradual?
• Character - What is the pain like?
• Radiation - Does the pain radiate anywhere?
• Associations - Any other signs or symptoms
associated with the pain?
• Time course - Does the pain follow any pattern?
• Exacerbating/Relieving factors - Does anything
change the pain?
• Severity - How bad is the pain?
Question the Patient
• May not be straight forward especially in
– Cognitively impaired adults
– The learning disabled
– Sedated patients in an ICU or operating room
– Children
Use Pain Rating Scales
• Select a scale that is suitable for the patients
abilities, age, and preferences
• Teach patient to use scale before pain is
expected, such as preoperatively
• Use same scale with the patient each time pain
is assessed
Types of Pain Rating Scales

• Single Dimensional Scales

– Visual Analog Scale (VAS)
– Numerical Rating Scale (NRS)
– Verbal Descriptor Scale(s) (VDS)
Types of Pain Rating Scales

• Multidimensional Scales
– McGill Pain Questionnaire
– Short-Form McGill Pain Questionnaire
– Brief Pain Inventory
– Scales for Neuropathic Pain
Visual Analog Scale
Visual Analog Scale
• The VAS is most commonly a straight 100-mm line
without demarcations that has the words “no pain” at
the left-most end and “worst pain imaginable”(or
something similar) at the right-most end.
• Benefits of the VAS is that it has been validated and
shown to be sensitive to changes in a patient's pain
• It is quick to use and relatively easy to understand for
most patients.
• It avoids the imprecise use of descriptive words to
describe pain and allows a meaningful comparison of
measurements over time.
Visual Analog Scale
• Disadvantages of the VAS is that it attempts to
assign a single value to a complex,
multidimensional experience.
• Some patients have trouble deciding how to
represent their pain sensation. They often have no
real concept of what “worst pain imaginable”
actually means because every experience of pain is
• It has a false ceiling at the upper-most end. If a
patient later time decides that the pain has become
worse, the patient has no way to document this
change if it was already at maximum.
Verbal Descriptive Scale
• The verbal descriptor scale is a list of words, ordered in
terms of severity from least to most, that describe the
amount of pain that a patient may be experiencing.
• Patients are asked to either circle or state the word that best
describes their pain intensity at that moment in time.
• The benefits of VDS instruments are that they have been
validated and are simple for patients to understand and
quick to use.
• A disadvantage is that a VDS forces patients to select words
that are not of their own choosing to describe their pain.
– Changes in pain over time are difficult to interpret and probably have
different meanings to each individual.
– This may especially be a problem with the VDS when only a limited number
of possible choices are offered to the patient (i.e. only four to six words).
Verbal Descriptive Scale
Numerical Rating Pain Scale
Numerical Rating Pain Scale
• The numerical rating scale offers the individual in pain
to rate their pain score.
• It is designed to be used by those over the age of 9.
• In the numerical scale, the user has the option to
verbally rate their scale from 0 to 10 or to place a mark
on a line indicating their level of pain.
– 0 indicates the absence of pain, while 10 represents
the most intense pain possible.
Numerical Rating Pain Scale
• The Numerical Rating Pain Scale allows the
healthcare provider to rate pain as mild,
moderate or severe, which can indicate a
potential disability level.
• Attempts have been made to define what is
considered a meaningful change in the NRS.
– At least a 30% reduction or an absolute
reduction in the value of at least 2 has been
suggested as representing meaningful pain relief
to patients
Numerical Rating Pain Scale
• Disadvantages of the NRS and VNS are similar to
those of the VAS in that they attempt to assign a
single number to the pain experience.
• They also have the same ceiling effect in that if a
value of “10” is chosen and the pain worsens, the
patient officially has no way to express this change.
• In practice, at least with the VNS, patients often
rate their pain as some number higher than 10
(e.g., “15 out of 10”) in an attempt to express their
extreme level of pain intensity.
Wong Baker Faces Pain Scale
• The Wong Baker Faces Pain Scale
combines pictures and numbers to allow
pain to be rated by the user.
• It can be used in children over the age of
3, and in adults.
• The faces range from a smiling face to a
sad, crying face.
• A numerical rating is assigned to each
face, of which there are 6 total.
Wong Baker Faces Pain Scale

0 2 4 6 8 10
McGill Pain Questionnaire (MPQ)
• The MPQ and its brief analog, the short-form MPQ, are
among the most widely used measures of pain.
• In general, the MPQ is considered to be a
multidimensional measure of pain quality; however, it
also yields numerical indices of several dimensions of the
pain experience.
• Researchers have proposed three dimensions of the
experience of pain: sensory-discriminative,
affectivemotivational, and cognitive-evaluative.
– The MPQ was created to assess these multiple aspects of pain.
McGill Pain Questionnaire
• The McGill Pain Questionnaire consists of
groupings of words that describe pain.
• The person rating their pain ranks the words in
each grouping. Some examples of the words
used are tugging, sharp and wretched.
• Once the person has rated their pain words, the
administrator assigns a numerical score, called
the Pain Rating Index.
McGill Pain Questionnaire
• Groups 1-10 = Somatic in nature
• Groups 11-15 = Affective
• Group 16 = Evaluative
• Group 17-20 = Miscellaneous words that
are used in the scoring process.
McGill Pain Questionnaire
• The benefits of the MPQ are that it is valid, reliable, and
consistent in its ability to assign seemingly appropriate
descriptions to a given pain experience.
• The MPQ may be able to discriminate between different
types of pain syndromes. Moreover, it has been shown to be
sensitive to changes in the amount of pain experienced by
patients in response to receiving various analgesic therapies
in both the acute and chronic setting.
• One disadvantage of the MPQ is its length. The MPQ should
take from 5 to 15 minutes to complete, which for some
patients may be seen as more trouble than it is worth.
• In addition, this amount of time is prohibitive for use on a
repeated basis over a short period (e.g., in a clinical acute
pain setting).
Short-Form McGill Pain Questionnaire
• The more frequently used short form of the MPQ
consists of 15 representative words that form the
sensory (11 items) and affective (4 items) categories
of the original MPQ.
• Each descriptor is ranked on a 0 (“none”) to
3(“severe”) intensity scale. The PPI, along with a
VAS, are also included. The short form correlates
highly with the original scale, can discriminate
among different pain conditions, and may be easier
than the original scale for geriatric patients to use.
Short-Form McGill Pain Questionnaire
Special Populations
• Common populations that are challenging to
assess pain
– Children
– Cognitively impaired adults
– Adults whose cognition is temporarily impaired, by
medication or illness
– The learning disabled
– Sedated patients in an ICU or operating room setting
Nonverbal Pain Indicators
• Facial expressions (grimacing)
– Less obvious: slight frown, rapid blinking, sad/frightened, any
• 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
Physiological Indications of
Acute Pain
• Dilated pupils
• Increased perspiration
• Increased rate/ force of heart rate
• Increased rate/depth of respirations
• Increased blood pressure
• Decreased urine output
• Decreased peristalsis of GI tract
• Increased basal metabolic rate
Possible Physiologic Signs of Pain

•  Pallor or flushing
• Diaphoresis, palmar sweating
•  O2 saturation
•  Vagal tone
• EEG changes
Possible Physiologic Signs of
Possible Signs of Pain in
the Cognitively impaired

• Groaning, Crying
• Changes in sleep/wake cycles
• Changes in activity level
• Agitation
• Rigidity
• Clenching of fists
Observe for Specific Behaviors that
Indicate Local Body Pain
• Rolling head from side to side
• Lying on side with legs flexed on
• Limping
• Refusing to move a body part
Multidimensional Model of Pain
• Dolorimetry has been defined as "the measurement of pain
sensitivity or pain intensity.“
• A dolorimeter is an instrument used to measure pain threshold
and pain tolerance.
• Introduced in 1940 by James D. Hardy of Cornell University
• There are several kinds of dolorimeters that have been
• Dolorimeters apply steady pressure, heat, or electrical stimulation
to some area, or move a joint or other body part and determine
what level of heat or pressure or electric current or amount of
movement produces a sensation of pain.
Pediatric Pain
• Barriers are often present and include:
– Belief that children, especially infants, do not feel
pain the way adults do
– Lack of routine pain assessment
– Lack of knowledge in pain treatment
– Belief that preventing pain in children takes too
much time and effort
Pediatric Pain
• Well documented that children are often
undertreated for pain
• Specifically in neonates:
– Studies show that neonates can experience pain by 26 weeks of
• Mature afferent pain transmission
– Untreated pain in neonates lead to increased distress and
altered pain response in the future
• Historically children and infants received less post-
operative analgesia than adults
Assessment in Children,
Neonates & Infants
• Challenging
• Combines physiologic and behavioral
• Many scales available
Possible Signs of Pain in Neonate:
Behavioral Variables, cont.
Facial expression (most reliable sign):
• Eyes tightly closed or opened
• Mouth opened, squarish
• Furrowing or bulging of brow
• Quivering of chin
• Deepened nasolabial fold
Facial Expression of Physical Distress

Children with Cognitive Impairment
• Often unable to describe pain
• Altered nervous system and experience pain
• Use behavioral observation scales
• Can apply to intubated patients
• Must use appropriate observational scales
• Which of the following is indicative of pain in a
neonate receiving a circumcision?
A. A Decrease in insulin
B. Decrease in O2 Saturation
C. Vigorous withdrawal to pain
D. Decrease in transcutaneous PCO2
E. Bradycardia
Pediatric Pain Scales
• Neonates, infants, toddlers (<3 years)
– Pain assessment it largely observational
• Cannot distinguish between pain, fear, anxiety, distress
– Examples of pain scales in this population:
Pediatric Pain Scales
• Toddlers to school age children (3-8)
– Self Report Scales
• Visual Analog (VAS): Age 5+
• Faces/Oucher Scale/ Wong- Baker: Age 3+
– Observational Scales
• FLACC: Age 2 mos- 7 years
• CHEOPS scale age 1-7 years
COMFORT Observer Pain Scale
• The COMFORT Scale is a behavioral, unobtrusive pain scale
that may be used by a healthcare provider when a person
cannot describe or rate their pain.
– Unconscious and ventilated infants, children and adolescents.
• This scale has eight indicators (categories)
• Validated for newborn to 3 years old
– Reported use of up to 17 years old
• The COMFORT Scale provides a pain rating between 9 and 45
– 17-26 generally indicates adequate sedation and pain control.
CRIES Pain Scale
• The CRIES Pain Scale is often used in the
neonatal healthcare setting.
• CRIES is an observer-rated pain assessment
tool which is performed by a healthcare
practitioner such as a nurse or physician.
• CRIES assesses crying, oxygenation, vital signs,
facial expression and sleeplessness.
• The CRIES Pain Scale is generally used for
neonates, from 32 weeks gestation to 6
months old.
CRIES Observer Pain Scale
FLACC Pain Scale
• FLACC stands for face, legs, activity, crying and consolability.
• It is an observer rated pain scale, performed by a healthcare
practitioner such as a doctor or a nurse.
• The FLACC pain scale was designed for neonates at 2 months,
may be useful up to 7 years of age.
– However, some practitioners in adult settings may use the FLACC pain
scale for people who are unable to communicate their pain.
• FLACC provides a pain assessment scale between 0 and 10.
FLACC scale
Children's Hospital of Eastern
Ontario Pain Scale (CHEOPS)
• The CHEOPS (Children's Hospital of Eastern Ontario Pain Scale) is a
behavioral scale for evaluating postoperative pain in young children.
• Six items: Cry, Facial, Child Verbal, Torso, Touch, and Legs
• It can be used to monitor the effectiveness of interventions for reducing
the pain and discomfort.
• Patients:
– The initial study was done on children 1 to 5 years of age.
– According to Furnish (2013) it is intended for ages 1-7.
– It has been used in studies with adolescents but this may not be an
appropriate instrument for that age group.
Oucher Scale
• Available in three ethnic versions
• Suitable for a 3-7 years of age
• Empowers the child to express pain
• May reflect mood instead of pain
Oucher Photographic / Numeric Pain Scale

White child, 3 year-old male Black child, 3 year-old male Hispanic child, 3 year-old male
Premature Infant Pain Profile (PIPP)
• Developed at the Universities of Toronto and McGill in
• Used for infants less than 36 weeks gestation
• Scores <6= minimum Pain, 6-12 = mild-moderate Pain, >12 =
moderate to severe pain
• Scoring instructions:
– Score gestational age before examining infant.
– Score the behavioral state before the potentially painful event by observing
the infant for 15 seconds .
– Record the baseline heart rate and oxygen saturation.
– Observe the infant for 30 seconds immediately following the painful event.
– Score physiologic and facial changes seen during this time and record
Neonatal Infant Pain Scale (NIPS)
• The Neonatal Infant Pain Scale (NIPS) is a behavioral scale and
can be utilized with both full-term and pre-term infants.
– From birth to one year of age
• The tool was adapted from the CHEOPS scale and uses the
behaviors that nurses have described as being indicative of
infant pain or distress.
Neonatal Infant Pain Scale (NIPS)
Neonatal Infant Pain Scale (NIPS)
• Total pain scores range from 0-7. The suggested interventions
based upon the infant's level of pain are listed below.
• The difficulty with any tool that is not self report is the ability
to differentiate between pain and agitation, however, the
non-pharmacological intervention may help differentiate
between these two (i.e. changing the wet diaper, feeding the
infant, repositioning, etc).
N-PASS: Neonatal Pain, Agitation and Sedation Scale
Children between 3-8 years
Usually have a word for pain
Can articulate more detail about the
presence and location of pain; less
able to comment on quality or
Color scales
Faces scales
Children older than 8 years
Use the standard visual analog scale
Same used in adults
• A pain physician is concerned that a patient's
pain may be neuropathic in nature. An
appropriate screening tool to assess for this is:
A. Numeric Rating Scale
B. Visual Analog Scale
C. McGill Pain Questionaire
Neuropathic Pain Scale
• The Neuropathic Pain Scale (NPS) has been
described (Galer and Jensen, 1997) and
attempted to discriminate between four
diagnostic categories of neuropathic pain
using single descriptors.
• Only post-herpetic neuralgia could be
distinguished from the other diagnostic
groups (reflex sympathetic dystrophy, diabetic
neuropathy and peripheral nerve injury).
Neuropathic Pain Scale
Neuropathic Pain Scale
The Leeds Assessment of Neuropathic Symptoms and Signs
(LANSS) Pain Scale
• A new screening
questionnaire to
identify neuropathic
components in patients
with back pain.
Pain Assessment tools for children and adults
with intellectual disabilities
Steps to take after treatment has started

• Secure Family’s Involvement

• Observe for Improvement in Behavior
Following an Analgesic
• Take action & assess effectiveness
• Anticipate & Prevent Pain
Secure Family’s Involvement
• Take pain history before pain is expected,
such as on admission to hospital or
• Involve family in recording response to pain
relief measures
Take action & assess effectiveness

• Anticipate & prevent pain

• Adequately assess pain
• Use multi-modal approach
• Involve parents and family when available
Take action & assess effectiveness
• After intervention, assess a patients
response to pain relief measures.
• Determine timing of assessment based on
expected onset and peak effect of
Anticipate & Prevent Pain
• Prepare patient and family on what to expect
• Guide them on ways to minimize pain and
• Utilize quiet environment
• Treat pain prophylactically when anticipated
Observe for Improvement in Behavior
Following an Analgesic
Observe for Improvement in Behavior
Following an Analgesic
• International Association for the Study of Pain: Pain Definitions [cited 10 Sep 2011]. "Pain is an
unpleasant sensory and emotional experience associated with actual or potential tissue damage,
or described in terms of such damage" Derived from Bonica JJ. The need of a taxonomy. Pain.
1979;6(3):247–8. doi:10.1016/0304-3959(79)90046-0. PMID 460931.
• Turk DC, Dworkin RH. What should be the core outcomes in chronic pain clinical trials?. Arthritis
Res. Ther.. 2004;6(4):151–4. doi:10.1186/ar1196. PMID 15225358.
• Hart RP, Wade JB, Martelli MF. Cognitive impairment in patients with chronic pain: the
significance of stress. Curr Pain Headache Rep. 2003;7(2):116–26. doi:10.1007/s11916-003-0021-
5. PMID 12628053.
• Bruehl S, Burns JW, Chung OY, Chont M. Pain-related effects of trait anger expression: neural
substrates and the role of endogenous opioid mechanisms. Neurosci Biobehav Rev.
2009;33(3):475–91. doi:10.1016/j.neubiorev.2008.12.003. PMID 19146872