Pain Assessment - Science topic

Shalaleh Karkon

sorry: Scales EVA

I disagree to the statement that shooting in the head can be considered as a good method for people who want to have euthanasias, because of two main reason.

First of all, the ball of the gun must pass throw skin so it surly makes pain.

secondly, methods to exam the mentioned hypothesis face a lot of limitation.

Because of the mentioned reasons, I stand behind of my opinion.

The pain VAS is available in the public domain at no cost. [Burckhardt CS, Jones KD. Adult measures of pain: The McGill Pain Questionnaire (MPQ), Rheumatoid Arthritis Pain Scale (RAPS), Short-Form McGill Pain Questionnaire (SF-MPQ), Verbal Descriptive Scale (VDS), Visual Analog Scale (VAS), and West Haven-Yale Multidisciplinary Pain Inventory (WHYMPI). Arthritis Rheum 2003; 49: S96–104.] [Hawker, G. A., Mian, S., Kendzerska, T. and French, M. Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care Res, 2011; 63: S240–S252. doi:10.1002/acr.20543]

Tony -You are 100% right. Dennis is a good guy and a careful researcher. However, our group at Johns Hopkins Hospital, which consisted of MDs, including the chairman of neurosurgery, the president of the American Pain Society, the President of the American Academy of Pain Management, and the assistant dean of the medical school, took a more medical approach. We found that 40%-80% of chronic pain patients are misdiagnosed, and have psychological problems as the results of chronic pain and from not being believed, when the doctor couldn't find anything wrong with the patient. The real failure lay with physicians not taking a careful history, and ordering the wrong tests. MRIs miss disc pathology detected by provocative discograms 78% of the time. CT miss pathology detected by 3D-CT 56% of the time. There are more errors which I can share. When properly diagnosed, and correctly tested and treated, we were able to reduce narcotic use 89% of the time, reduce doctor visits 45% of the time, and increase return to work rates, sustained for more than 1 year, to a level 6 X higher than reported by others. So the Pain Validity Test predicted with 95% accuracy who would have abnormal medical testing, and the Diagnostic Paradigm gave correct diagnoses with a 96% correlation with Johns Hopkins doctors diagnosed. We had cost savings of $20,000 to $175,000 for long term case, and an over 54% cost savings on workers' compensation case. All real statistics.-all published. Email me if you would like reprints. DocNelse@aol.com

I think yes, you could start using oxytocin in the incision points.The recovery will be fast and better.

Please let me know if the following references/sites are useful to you:

Central Sensitization: A Generator of Pain Hypersensitivity by Central ...

by A Latremoliere - ‎2009 - ‎Cited by 1508 - ‎Related articles

Recruiting these subthreshold inputs to the output of a neuron markedly alters its .... Interestingly, nociceptor afferents innervating muscles or joints produce a ...

1.  Muscle Pain: Understanding the Mechanisms

Siegfried Mense, ‎Robert D. Gerwin - 2010 - ‎Medical

The strong sensitizing action of NGF-induced subthreshold potentials at the spinal level ... Nociceptive afferent fibers from muscle and other tissues possess ...

2.  Neurosurgery: The Essential Guide to the Oral and Clinical ...

Vivian A. Elwell, ‎Ramez Kirollos, ‎Syed Al-Haddad - 2014 - ‎Medical

Increased responsiveness of nociceptive neurons in the central nervous system to their normal or subthreshold afferent input. Increased responsiveness and ...

3.  Pain Medicine: An Essential Review - Page 433 - Google Books Result

R. Jason Yong, ‎Michael Nguyen, ‎Ehren Nelson - 2017 - ‎Medical

Nociceptive Neuron A central or peripheral neuron of the somatosensory nervous ... in the central nervous system to their normal or subthreshold afferent input.

Dennis

Dennis Mazur

I think there is a little misunderstanding about hot plate.

I suppose you have a hot plate with magnetic stirrer, which is usual lab equipment for heating and mixing solutions:

You cannot use this hot plate for measuring analgesia in rodents!

We published a paper in which we show an absolute ODI-value corresponding to patient acceptabel symptomen state (PASS) for the official ODI v.2.1a. An ODI <=22 equals PASS and seems corresponding to 'normal', healthy populations as well. I suggest to use ODI <=22 as a lower limit. Furthermore, it is known that a minimal clinical important difference is at least 10 points or 30% of the baseline value (Ostelo et al. 2008) and literature shows that an ODI >= 41 corresponds to longstanding chronicLBP. Hopefully, this information is of use.

I'd echo Chris' suggestion.  On reviewing the guidelines for use of the tool, I found the following:

"Q3: Please provide guidance on scoring when there is missing data.

A: It is not possible to provide a truly valid estimate of the score for any domain(e.g.

satisfaction, function, etc) that is missing responses. However, to satisfy the criteria for unidimensionality of each subscale on the instrument, we selected individual items that were themselves strongly correlated which gives robustness to the final estimates of function, satisfaction and expectation In practice, we recommend that clinicians or research investigators: (a) contact the patient and ask them to answer the missing items, or (b) to enter dummy values equal to the average of all of the other items in the same domain. This practice is limited to instances where fewer than 50% of responses are missing, preferably less than 25%." (page 5)

Best wishes,

Rich

you can use oswestry disability index and nordic musculoskeletel questionnaire 

Because pain sensitivity is dependent on both genetics and experience, individuals who have more frequent painful procedure pain will have a higher sensitivity.  So if an ethnic group generally finds itself on the lower economic rungs of the societal ladder, that ethnic group may have more pain sensitivity due  to the lower quality techniques and procedure pain control it experiences during inoculations, blood draws and emergency room visits.   In the United States, the Center for Disease Control recommends 25 different inoculations by age 3.  Kids that come from families under financial stress, transportation issues with parents working two jobs and cannot always make medical appointments reliably are likely to see their children receive 4 or 5 vaccinations at one appointment.  After the first injection, the child's attention is turned to the procedure and this increases their pain perception for the next 3 or 4 injections.  These kids experience long term sensitization and classical fear conditioning.  They are highly sensitized.  40 years ago clinicians would come back to the US after donating services in developing countries and they would report how stoic and compliant the children were.  They would say "American kids are such crybabies".   Now, these "developing" countries have developed western style medicine in the form of abundant inoculations and the clinicians returning from them have no idea what I am talking about when I tell that story.  They would say, "No.  Those kids had a lot of anxiety."  Moral of the story here is that an ethnic group will have high or low sensitivity to pain depending on if it has access to western style medicine.  When it does have access, the quality of that access will matter too.  So an ethnic group in one country may have high sensitivity while in another it may be low.  my hunch is that this effect will be a confounding factor that will limit your ability to make broad conclusions about any ethnic group's sensitivity to pain unless you are a brilliant epidemiologist who can control for these factors.  No matter what, you have asked a good question and I would be interested in any new light that you could shed on the matter.  Good luck! 

It depend on the pain. In case of the arthritic pain use computerized analysis of audible and ultrasonic vocalizations (J Neurosci Methods 2005, 141(2):261-9). Otherwise refer to M.Barrot’s review (Neuroscience 2012, 211: 39-50).

With my pleasure

I have now an patient with an toral feotal attitude . The only respons is the push away othese that gives an decrease on tone in the whole body, She is lying on an firm matras with het best side to the wall.

When she lioes in this orthese she looks angry and push with there feet the orthesis away but when this movement occur the re face is ligthing and the tone decrease and here cognition is increase. No medication was given 

In this case there was the feeling of instabvility and that is no poain but fear !! 

I use a mobicool C40 'frost-box' and a simple submersion pump (Reich, 10 L/min, 0.5 bar) running of a 12v battery. All of which are relatively inexpensive (less than £200 in total) and can be purchased online or in shops which sell camping equipment.

...you will need to keep the water in circulation during CPTesting ... this is important!

The mobicool box is thermostate controlled and with a bit of fiddling, you can get it just right where it keeps the water at 0-2 Celsius. You will need a regular thermometer to confirm the temperature. Also, until you get the thermostat setting right -- do not leave the thermometer in the water overnight as you are likely to find a block of ice in there on the first few attempts, and you don't want a cracked thermometer.

For easy cleaning, I keep the water in a plastic contained inside the mobicool box.

I place a neodynium magnet on the outside of the plastic contained to hold the submersible pump in place near the bottom (on the inside) of the plastic container ... otherwise it will start moving about once it is turned on and it will eventually get close to the surface and spray water all over the place.

I have cut a small groove in the upper edge of the mobicool box to pass the flex/wire for the pump into the box and still allow it to close and seal completely. This helps keep the temperature just right.

For VAS scale: below is a link to an online VAScale I have made, which is simple to use -- it samples the VAS score every second and can be controlled with a regular computer mouse, albeit I use a trackball mouse instead. After use it reports the time, max-score, time-to-max-score and raw data. I'd like som feedback if you find it useful: http://smerteforskning.dk/tools/freeVAS/scale.php

I have found that participants who will not tolerate CPT normally quite within 60 seconds. Most who can tolerate it for 1+ minute will tolerate it for as long as you care to keep testing.

Hi Roman,

We always use Zoletil mix with Rompun (4:1) to anesthetize mice. The concentration are 20-40 mg/kg and 5-10 mg/kg, respectively. If you concerned the overdose you give to mice. I suggest that you could mix Z & R with the same volume of PBS (1:1) before injection and give about 20-40 ul to mice (IM). It's very workable for us, hope you too.

Good Luck~

Dear Eleonora Mess,

Thanks you very much

May you give me a feedback about publication in this link:

Or

Or

we have developed a software, which can average and overlay pain drawings, which then present as contour lines of different intensity of color (I attached a paper showing). If you are only interested in mean and SD I suggest a "primitive" solution: Copy the drawing on standard paper, cut out the marked area and weigh the paper on a fine balance, and then compare to a standard area (e.g. the complete body representation of your scheme). The ration gives you the precentage of full body area). Than calculate your numbers as usual. By the way, our software does something very similar, it scans at 600 dpi resolution and identifies the marked area in numbers of pixels. Xaver's [Hi, and kind regards across the river ;-))] comment points to a similar technique. A paper attached to demonstrate

I wish to add the older adults would not like to be regarded as people who are always complaining by the younger adults. They do not want to be disturbing their families and other health care team such as the nurses.

Wasana, not clear exactly what you are asking here.  Pain is extremely complex, and a physiological process strongly influenced by perceptual processes, particularly so in chronic pain. The meaning of acute pain is injury avoidance or damage notification; that of chronic pain is much more ambiguous. Pain comprises several components, not only nociception (physical sensation). Cognitive, motivational, emotional and communicative elements make up the "pie" of pain.  Numerous studies show that expectations and anxiety, mood and other psychological dimensions all modify both degree of reported pain and amount of self-medicaltion with different analgesics. People who are anxious and depressed report more pain, irrespective of the level of nociception. Phantom limb pain illustrates that pain is a central process as much as it is due to peripheral release of inflammatory agents at the injury site.  Changes to the local biochemical environment occur but cognitive and emotional changes interact to confer different meanings on the nociception.  So chronic pain from disc herniation can be as severe as that from cancer, sometimes worse, but the meaning of the two are completely different and this affects the resultant experience of suffering.  All of this needs disentangling.  Good pain control requires good psychological skill as well as pharmacological knowledge.

Dear Laura, 

if you contact the authors -they are here on RG-  you could get an answer: 

Hi Mateus ! Thanks for this very interesting review 

Hi Peter,

Very informative..... Thanks a lot.

Warm regards,

Physical exercises are necessary for the Rheumatoid patients as the joints remain flexible and soft tissues mobile. Despite this it will be better to do them when the inflammation is better (so better not during acute inflammatory phases where the patient will be benefitted by rest). Medication has to be monitored and controlled by having regular follow up reviews and the regime has to be changed accordingly.

Hi Gloria,

I enjoy using West Haven Yale Multidimensional Pain Inventory (WHYMPI) for measuring pain with my patients.  It classifies the pain intensity in a number of ways as well as pain affect and pain coping.  It is very commonly used in research and is also very useful clinically.  Its very useful for screening functional vs dysfunctional coping styles for referrals to psychological consults.  

I am very happy to answer your question about hypnotic assessment as well.  Many people assume that whatever method that they like to practice with patients is the best method to use with every patient.  This is a terrible assumption as we know from research that people vary wildly in terms of their experience of their mind body relationship.  About a good 15% of the population has a fairly impoverished experience of their mind/body relationship (classified as low hypnotizables) and it would be best to use biofeedback with them to begin clinical work.  These patients would also do poorly with medium level techniques like mindfulness meditation which requires a certain level of absorption potential.  

I recommend that you use the phenomenology of consciousness inventory to get a good picture of your patients' hypnotic (mind/body) abilities.  For example, that instrument can reveal that a patient is good with imagery although their sense of an altered state of consciousness is fairly impoverished.  Here is a paper that I wrote outlining my strategy to assessment in mind body medicine with hypnosis, biofeedback, meditation, and other methods such as yoga.  No one method is really good for every patient.  Assessment is necessary to figure out the right plan for each patient at their stage of development of their mind/body relationship.

https://www.researchgate.net/publication/242455517_SPECIAL_TOPICS_Best_of_Both_Worlds_How_to_Integrate_Hypnosis_and_Biofeedback_with_Empathy_and_Hypnotic_Assessment_Procedures  

Excellent question!!  An article from one of the journals from AACN (Critical Care Nurse. 2013;33[3]:68-79), Stites, M, revealed that CPOT had a higher and more consistent inter rater reliability than the BPS, however dementia or chronic illness may effect the scoring.  The assessment of pain needs to be an effective culmination of the observational behavior of the patient, the self-report of the pain, the physical findings of the patient, as well as the situational background causing the patient's pain.  My suggestion is to start w/ this study and take note of all of the studies that are sited in this article--you will find that it is comprehensive.

I assume you have made sure the hot plate is actually at 45 degrees and that there isnt an issue with the kit. 

There an numerous factors what can affect pain behaviour:

Firstly, have you changed supplier or have the supplier started sending you rats from a different colony? Are you certian they are sending SD rats? Has the constituents of the diet changed? (Seltzer et al saw a significant reduction in neuropathic pain behaviour when soy protein was added to their rat chow without them knowing). Have you changed experimenters, if not have you changed after shave or shampoo? Have there been any changed in animal care staff? Are there any works in the facility or in the surrounding buildings? Stress induced hyperalgesia is as real a problem as stress induced analgesia. The list could go on!

Another point is that over the years I've seen dramatic alteration of pain behaviour over the course of a year with a marked reduction over winter months. I've never had the resource to look into this effect methodically but I'm certain its not an artifact. 

Hello,

I tried to look for, but I found only a manual about COMFORT Pain Scale

Ages Birth - Adult

I hope will be usefull.

Thanks Paritosh,

Now that the 6 weeks is up. The pain of falling from the double decker bus has taken its toll. The patient is given morphine every 2 hrs because the ssp pain is excruciating. Is it safe now to do another arthroscopy for SAD and remove the oedema as the MRI indicated the latter has spread to the deltoid region even with new ssp tendonis is found?

FYI passive ROM indicated the oedema is present and precluding the patient from performing active ROM. Tq.

I Think that the pain could have origin by a compartimental sindrome or periostytis inserzionale of the tibial muscles 

Hourly and again if there is a status change. I can look around for a source. Hth!

I reckon that would depend on how long your experiment would be. If you need to measure only three time points after a treatment it would be ok to test them twice (morning and evening) on the first day and then 24 hrs later. However, if you are planning a longer experiment I would not recommend a daily testing schedule. Repeated testing (considering the long acclimatization time and testing time in mice) will cause stress and thus weight loss over time, which of course would be an animal welfare concern.

Hello David! I have another suggestion: the pain trajectory. This simple approach describes the pain of your patients with a regression line. 

Thank you! Anyone use any kind of objective analysis method?

Thank you both so much! This was hugely helpful.

Thank you

ethovision is very good software but we use panlab harvard apparatuse and it's very simple to use. don't worry about the video formats because you can converte all formats to each other by converter softwares without loosing quality. 

Pain is subjective and there is no fail safe method of assessing pain in patients. But additional parameters might be helpful. VAS alone does have it's limitations. The use of pain diagram, healthy related quality of life, and emotional aspects of the pain need to be assessed for better results I believe.

My thesis was on TMJ disorders. I used the pain scale (Numerical Rating Scale - NRS) which was part of the then RDC/TMD (it has now been revised into the new CDC/TMD) which includes screeners and pain diagrams.I also used Jaw function Limitation Scale along with Mandibular Function assessment.

You can consider a similar multiple assessment approach for more relevant answers.

http://www.ncbi.nlm.nih.gov/pubmed/21621130 This article might be helpful as well

And if you haven't read the discussion on similar topic already in researchgate. please do so here at: https://www.researchgate.net/post/Are_VAS_scales_appropriate_for_pain_measurement

Regards,

Dr. Akilesh R

India

We want to know if there is some kind of cut-off score that correlates with a minimal clinical improvement/deterioration. For instance a patient scores 74/78 on intake, during the intervention he scored a 62/78. How can this be interpreted? Can one say that he actually has a 'better' quality of life? 

Well I have a very simple answer. They sit for hours on persian toilet, As you know this is very difficult and may impose lots of physical stress on thigh and back.

Best.

I'm sure that chronic-pain scales are useful to score pain in order to modulate analgesics. While acute-pain scales have scarce utility. Thus, I suggest not to score acute pain but just to detect it (pain we provoke - at any score level - is always a failure). Detecting pain is easy: you just have to know if you are activating parts of the body with nociceptors and then to assess if a sudden reaction (crying or increase in heart rate) appears.

Thank you very much.

Quizás puedas dividir la muestra y homogeneizar una parte en algún medio sin rojo fenol para la medición de NO?

As Mr. Enrique has suggested, severety of post operative pain can vary with the type of surgery (caesarean to open chest surgery, amputation or tumour removal. The mechanism of pain varies, the mode should vary and as Mr Borja suggested, multimodal and rotatory schedule with multiple agents suits peri and immediate post op. pain management (to manage inflammation, release of endotheins by tumour cells leading to pain, neuropathic pain etc.). As you suggested, the least invasive mode is intramuscular or oral, which works well with caesarean patients, and good old practice of acupuncture. This case needs a meta analysis on the use of oral or intramuscular route.

Sorry if this question was misleading. Pain scales were developed to determine if we have adequate analgesia on-board; i.e. are we sufficiently preventing pain. Since dogs can't talk, like infants, pain scales based on their behavior have been developed. The Glasgow pain scale, or a modification of that scale, is the most extensively used. It does not however, include that the cessation of a normal behavior may occur with pain. For example, if a dog is wagging its tail and it stops, this may indicate discomfort. This question was intended for veterinarians working in the field of analgesia and pain management in animals. We are working towards more comprehensive and objective ways to ensure that animals DON'T suffer.

@Bronnie

We are not in disagreement at all I think. I have never disputed, nor am I reluctant to integrate the psychosocial with the biological aspects of pain when discussing the theoretical aspects of pain. It is just that you and I probably see, in the main, the opposite ends of the spectrum While most of my patients have a "bio" component that predominates in terms of treatment needs and the psychosocial is along for the ride, I suspect you see the other end where the "bio" is so buried in the psychosocial dimension that the bio seems incapable of being teased out from the complexity of the florid chronic pain patient. I do see these patients too but less frequently. Even the most obvious 'bio' case - like a fracture or a wound carries with it the learned experiences and responses to past instances of pain woven into a behaviour pattern. This is why one patient with bones sticking out of the leg will grit his teeth and make humorous comments to the ambulance officers about how he will have to put off the Tongariro traverse until next month, while another will scream and cry, wail and moan as if he will be crippled and in pain forever. The injury is the same but the responses are different. The treatment - at least initially is not that different though - provide relief from nociceptive input, reduce the fracture, stabilize it and let nature do the physical healing. However, the different responses are cues to how pain relief and rehab should proceed. They are cues only however. I have seen the former patient become disabled and chronically painful because of poor management and interaction with the health care system despite the initial rather positive response type. Conversely I have seen the latter case calm down rapidly once pain is under control and proceed through rehab without a hitch despite the initial 'yellow flag' type of behavour initially.

My point here is that the clinician must be responsive to what is needed when it is needed, and not doctrinaire in either direction about what approach or mixtures of approach are needed, for it can and does change from patient to patient, and for any given patient throughout the process of acute presentation to rehabilitation.

Again, I reiterate, I have no quibble with your statement "..that psychological and social factors are present in all experiences of pain." Absolutely correct - we are not insects but perceptual / cognitive / emotional entities, enormously complex and individually unique. Nociception is a primitive sensory level data input and pain is the experience of, and the behaviour in response to, that sensory input. I think pain arising completely de novo is rather rare is it not?