Pain -Measurement. Dr Thiru Thirukkumaran

Transcription

1 Pain -Measurement Dr Thiru Thirukkumaran Palliative Care Physician (CMO), Northwest Palliative Care Services, Burnie, Tasmania. Senior Lecturer in Palliative Medicine Rural Clinical School - Burnie, University of Tasmania.

2 Outline What is Pain? Pain Prevalence : - Why does pain measurement matter? Pain experience : - What are we trying to measure? How to measure?

3 What is Pain?

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5 How do we define pain?

6 Definition of Pain by International Association for the study of Pain (1979) An unpleasant sensory & emotional experience associated with actual or potential tissue damage or described in terms of such damage

7 Pain - more than a physical Phenomenon! Subjective Individual response Always unpleasant A sensation in part of the body Also has an emotional component

8 The Pain Pathway

9 What are the common types of physical pain you know of?

10 Common Types of physical pain Bone Pain Muscular-skeletal pain Smooth muscle colic Nerve Pain Liver capsular Pain ICP Pain Infection e.g.: Cellulites Odynophagia ( Painful dysphagia) Ischemic pain

11 Concept of Total Pain The experience of pain is influenced by physical, emotional, social, & spiritual factors. The concept of total pain acknowledges the importance of all of these dimensions of a person s suffering & good pain relief is unlikely without attention to all of these areas.

12 Extent of Nociceptive insult Attitudes Beliefs Previous Pain Experiences Individual Pain Experience Current emotional status Cognitive Understanding Cultural factors Individual coping Strategies

13 Gate Control Theory of Pain - 1 The Gate control theory was 1 st proposed in 1965 by psychologist Ronald Melzack & anatomist Patrick Wall. They suggested that there is a gating system in the central nervous system that opens & closes to let pain messages through to the brain or block them. According to the gate control theory of pain, our thoughts, beliefs & emotions may affect how much pain we feel from a given physical stimuli.

14 Examples for Gate Control Theory Many athletes do not experience pain during the intense activity of the game. After the game, when they turn their attention to their injuries, the pain suddenly appears to come from nowhere. Many pain sufferers find that their pain is worst when they feel depressed and hopeless-feelings that may open the pain gate-and that it s not so bothersome when they are focused on doing something that demands attention or is enjoyable. Although the physical cause of pain may be identical, the perception of pain is dramatically different.

15 Pain Prevalence : Why does pain measurement matter? Patients at all stages 53% Patients with advanced / metastatic / terminal disease -64% 1/3 of the patients with pain graded their pain as moderate to severe Van den Beuken van Everdingen. Prevalence of pain in patients with cancer: A systematic review of the past 40 yrs. Annals of Oncology 2007; 18(9):

16 Symptom Prevalence JPSM 2006 Symptom Cancer AIDS Heart Disease COPD Renal Disease Pain % (n = 10,379) % (n = 942) % (n = 882) % (n = 372) % (n = 370) Nausea 6 68 % (n = 9140) % (n = 689) % (n = 146) % (n = 362) Depression 3 77 % (n = 4378) % (n = 942) 9 36 % (n = 80) % (n = 150) 5 60 % (n 956)

17 Pain Experience: What are we trying to measure?

18 Pain intensity Pain affect (Mental / Emotional status triggered by pain experience) Pain quality Pain location

19 Process of Pain Assessment Identify your individual patient s pain Patient should be the prime assessor of his / her pain A detailed history Physical Examination Psychosocial / Cultural / Spiritual assessment MDT input Regular re-assessment

20 Quantitative Assessment Although pain is subjective, the ability to quantify the intensity of pain is essential to monitor a patient s responsiveness to analgesia To assist in a quantitative assessment, the patient must be introduced to the idea of a pain assessment tool. This then reduces bias. (Patient should be the prime assessor of his / her pain)

21 Pain Assessment Most commonly used uni-dimensional Scales ( Balancing the simplicity & Sensitivity) Visual Analogue Scale (VAS) Numeric Rating Scale ( NRS) Verbal Descriptor Scale ( VDS) not at all / little / Quit a bit / very much Faces Pain Scale (FPS) Pain Thermometer Multi-dimensional Scales Brief Pain inventory McGill Pain Questionnaire Memorial Pain Assessment Card

22 Pain Assessment in Cognitively impaired Patients or Non-verbal assessments Facial Expressions Body Language/ Movements Protective mechanisms Vocalisations Mental status changes Changes in activity, patterns, routines & etc

23 Barriers to optimal pain Assessment & Management Health Care Professional Barriers (Doctor: How do I answer if patient ask difficult Questions? I m not comfortable to say that you are going to die ) Health Care System Barriers (Not bother to send corresponding letters or recent Investigations by Hospital colleagues / GPs, but they what Palliative care assessment & advice..) Patient / Family / Social Barriers ( Please not to tell father he has cancer ) Mgt? Good communications & Negotiations

24 Pain Assessment Pain can be well palliated For successful pain relieve, accurate & continuous pain assessment is an absolute.

25 Aim of Pain Control:- Ensure that the optimal well being & quality of life have been achieved How? Detailed history Proper physical examination Multidisciplinary team Approach Appropriate investigations Comprehensive, Accurate & Systematic pain assessment Using tools Implementation of management plan Re-assessment

26 Take home message The patient should be the prime assessor of his / her pain Patient centred approach Multi-professional input Remember Total Pain Comprehensive, Accurate & Systematic pain assessment / Using tools Re-assessment

27 Pain relief & Terminal care For adequate Pain Relief Need proper assessment! Thank you