PAIN ASSESSMENT
A precise and systematic assessment of pain is important for making an accurate diagnosis and for the development of an effective treatment plan. Pain is a multidimensional phenomenon that produces strong emotional reactions that can affect an individual’s function, quality of life, emotional state, social and vocational status, and general well-being. Therefore, it is recommended that pain be assessed using a multidimensional approach and that these various impacts be addressed and included in the diagnostic formulation.
A comprehensive pain assessment includes a history of the pain, behavioral observations, past medical history, medications, family history, a physical examination, and if necessary, diagnostic testing.
Pain History
A pain assessment begins with the history of the problem and can be obtained from written documents and from interviews with the person in pain as well as family members and other caregivers. Pain is a subjective symptom, and pain assessment is, therefore, based on the patient’s own perception of pain and its severity.
Because pain is subjective, a self-report is considered the “gold standard,” or the best, most accurate measure of a person’s pain. One method to obtain a complete pain history is the PQRST assessment (see box).
PQRST PAIN ASSESSMENT
Provocation/Palliation (P)
- What were you doing when the pain started?
- What caused the pain?
- What seems to trigger it (e.g., stress, position, certain activities)?
- What relieves it (e.g., medications, massage, heat/cold, changing position, being active, resting)?
- What aggravates it (e.g., movement, bending, lying down, walking, standing)?
Quality/Quantity (Q)
- What does the pain feel like (e.g., sharp, dull, stabbing, burning, crushing, throbbing, nauseating, shooting, twisting, stretching)?
Region/Radiation (R)
- Where is the pain located?
- Does the pain radiate, and if so, where?
- Does the pain feel like it travels/moves around?
- Did it start somewhere else and is now localized to another spot?
- Is it accompanied by other signs and symptoms?
Severity Scale (S)
- How severe is the pain on a scale of 0–10, with 0 as no pain and 10 as the worst pain ever?
- Does the pain interfere with activities?
- How bad is the pain at its worst?
- Does it force you to sit down, lie down, slow down?
- How long does an episode last?
Timing (T)
- When or at what time did the pain begin?
- How long did it last?
- How often does it occur (e.g., hourly, daily, weekly, monthly)?
- Is the pain sudden or gradual in onset?
- When do you usually experience it (e.g., daytime, night, early morning)?
- Are you ever awakened by it?
- Does it ever occur before, during, or after meals?
- Does it occur seasonally?
(Crozer Health, 2022)
Behavioral Observations
Most people who are experiencing pain usually show it either by verbal complaint or nonverbal behaviors or indicators. It is important, however, to remember that people in pain may or may not display behaviors that are considered an indication of “being in pain,” and making judgments about their honesty is inappropriate. Nonverbal indicators of pain may include:
- Facial expressions
- Vocalizations
- Body movements
- Activity/routine changes
- Alterations in social interactions
- Protective movements
- Mental status changes
- Physiological changes
(Toney-Butler, 2019; Victoria Department of Health, 2021)
History
Relevant past medical and surgical history may help determine the etiology of pain (e.g., diabetes, history of cancer, rheumatic disease) and may reveal conditions that affect the choice of therapy. This includes:
- Prior medical illness (e.g., renal or hepatic insufficiency/disease, which affects choice of analgesic and dosing)
- Prior psychiatric illnesses (e.g., depression or anxiety)
- Prior surgeries, scarring, repeated surgeries (may increase sensitivity to pain)
- Past injuries and accidents
- Coexisting acute or chronic illnesses
- Chemical dependence
- Prior problems with pain and treatment outcomes
- Investigations conducted (e.g., medical imaging)
A complete list of current medications (past and present) and usage, including over-the-counter medications and alternative, herbal, and natural products, is obtained, as well as the patient’s report of their effectiveness. Evaluation of physiologic tolerance (diminished response) related to chronic use of some medications and use of alcohol and illicit drugs is also included.
Family history is important, as it may give a clue to any predisposition to pain-causing illnesses and conditions that may involve the connective tissues (e.g., kyphoscoliosis), metabolism (e.g., sickle cell disease), and neurologic system (e.g., familial amyloid neuropathy). Other types of disorders that may cluster in families include fibromyalgia, persistent back pain, irritable bowel syndrome, and some types of arthritis (CASN/AFPC, 2021).
Review of Systems
The review of systems may suggest conditions that are associated with nociplastic sensory hypersensitivity (pain with no clear evidence as to source), and may support a syndromic pain diagnosis such as chronic fatigue, headache, or widespread conditions such as fibromyalgia (Tauben & Stacey, 2022).
The psychosocial history is an important aspect to a review of systems, because what first appears to be a simple problem can become much more complex due to the influence of psychological and social factors. A psychosocial history includes:
- Psychological history: emotional state, personality, self-esteem
- History of mental illness and past traumatic experiences
- Family systems
- Social history: economic factors, education, social class, culture/ethnicity
(Caring to the End, 2022)
Functional Assessment
Components of a functional assessment include:
- Ability to complete activities of daily living
- Mood/mental health
- Mobility
- Work ability
- Sleep
- Relations with other people
(CASN/AFPC, 2021)
Physical Examination
A systematic, targeted, pain-focused physical examination is most fruitful when the pain history interview and behavioral observations are conducted at the same time. Because pain may be referred from some other area of the body, the examination should include a full visual scan from head to toe, including:
- Mental status examination
- Vital signs
- General inspection
- Auscultation of lungs, heart, and bowel sounds
- Palpation to demarcate the painful area, trigger points, or changes in sensory or pain processing
- Musculoskeletal examination
- Neurological examination
- Abdominal, pelvic, or rectal exam
(Anesthesia Key, 2019; Tauben & Stacey, 2022)
Diagnostic Testing
Although there are no diagnostic tests available as yet to determine how much pain a person is experiencing, and no test that can measure the intensity or location of pain, there are a number of tests that can be done to determine the cause or source of pain.
LABORATORY TESTS
Routine blood studies are not indicated, but directed testing should be ordered when specific causes of pain are suggested by the patient’s history or physical examination. These may include:
- Complete blood count
- Comprehensive metabolic panel
- Erythrocyte sedimentation rate (ESR)
- C-reactive protein
- Vitamin B12, B6, and folate levels
- Fasting blood sugar
- Hemoglobin S
- HIV antibodies
- HSV antibodies
- Lyme antibody
- Rheumatologic tests
- HLA-B27 antigen
(Nnanna, 2021; Asher, 2022)
IMAGING AND ELECTRODIAGNOSTIC TESTING
- Plain X-ray films
- Ultrasound
- Myelograms
- Computerized tomography
- Discogram
- Magnetic resonance imaging (MRI)
- 18-FDG PET and MRI (a newer PET/MRI method)
- Functional MRI
- Bone scans
- Electromyography (EMG)
- Nerve conduction studies (NCS)
- Diagnostic nerve block
- Somatosensory evoked potential (SSEP)
- Electroencephalography (EEG) and magnetoencephalography (MEG)
(Agranoff, 2020; Wheeler, 2021; O’Connor, 2020)
Psychological Examination
A psychological assessment is intended to identify emotional reactions, maladaptive thinking and behavior, and social problems that can contribute to pain and disability. A psychological assessment includes a semistructured clinical interview and self-report instrument to assess differences in the domains of pain experience, functional impairment, and pain-related disability.
PAIN AND RISK FOR SUICIDE
Chronic pain is prevalent in people who die by suicide. Chronic, nonmalignant pain, independent of other factors such as sociodemographic and physical and mental health status, doubles the risk of suicide. Risk factors for suicidal ideation and behavior in those with chronic pain include:
- Multiple pain conditions
- Severe pain
- More frequent episodes of intermittent pain (e.g., migraines)
- Longer duration of pain
- Sleep onset insomnia
Psychological processes relevant to patients with chronic pain who may be at risk for suicide include helplessness and hopelessness, a desire to escape the pain, and problem-solving deficit. Evaluation should include patient and family past histories of suicidal ideation and behavior (Schreiber & Culpepper, 2022).