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Recognition and Assessment of Pain

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(from talks by Dr. Hobbs, Pain specialist and Professor Flecknell, expert in comparative biology)

Having looked at a broad outline of the purpose and nature of pain, it is now important to be able to recognise pain and assess its severity.

Two speakers addressed this. I will also make reference again to Professor Fitzgerald's talk on newborn babies.

Professor Flecknell spoke about recognising pain in animals. Later in the conference, his colleague, Professor Andrea Norton, summed up the situation by stating that " effective pain management relies on the recognition of pain." This holds as true for humans as it does for animals.

As might be expected, it can be extremely difficult to assess pain in animals (or indeed new-born babies)

Professor Flecknell stressed that one must look not only for abnormal behaviours, but also for a lack of normal behaviour. Signs which are pain-specific should be assessed.

As with humans, there may be a huge variation between individuals and also in each individual according to the emotional state.

Professor Fitzgerald also spoke about this in the neonate, citing 4 basic states of arousal: deeply asleep, lightly asleep, lightly awake, alert and very awake. In the deeply asleep state, the nervous system seems to have "shut down" somewhat, whereas in the fully awake state it can be difficult to measure baselines.

This is of relevance even in adult humans as it indicates that the "context" of pain may affect the level of pain perceived. It could be viewed as a complex situation, involving as it does, thinking as well as emotional factors.

However, Dr. Hobbs insisted that pain intensity is a simple concept and that the patient's self-reporting of the pain should be the "gold standard" in assessing pain. (Other clinicians, however, tend to be more skeptical about the reliability of the patient's report)

Professor Morton, who had spoken earlier about our changing attitudes towards animals' response to pain, suggested that it is better to look at tolerance of pain (the level the patient can tolerate) rather than pain threshold (level at which pain is first felt.) Some dog breeds such as the pit bull can be very tolerant of pain, although this can vary even within a litter.

It seems clear that we need to find some reproducible measures of pain.
Dr. Hobbs finds rating scales to be very useful clinically. They can be either a very simple scale such as rating the pain as:


Or Numerical rating  0-10 (No pain-Worst pain): useful retrospectively and  clinically.

Or the Visual Analogue Scale which is a 10cm  line along which the patient marks the intensity of his/her pain.

no                                                                 unbearable
pain                         patient's                           pain

This is the method of choice for children over 7 and adults, as well as being a valuable research tool.

Dr. Hobbs stressed that it is vital to assess pain both at rest and on movement, thereby linking pain assessment to action.

It is important to score the worst pain, the degree of pain relief from current medication and the level of mobility and function. He believes that self-report of disability is reliable and valid.

Activities of Daily Living (ADL) should be assessed, (such as ability to dress, shop, cook etc.)

It may be useful to use body charts or dermatome maps (show areas supplied by different spinal nerves) to illustrate the sites of pain. Diaries may also be helpful.

A short form of the McGill questionnaire may elicit the language of pain the individual is accustomed to using.

Other rating scales include the Sickness Impact Profile, the Oswestry Low Back Pain disability and the Brief Pain Inventory. The latter assesses intensity, relief, activity, mood, work, sleep and enjoyment.

Alongside the patient's story, it is important for a clinician to assess behaviour- the verbal and non-verbal communication of pain, distress and suffering.

"Pain behaviour" is often seen as abnormal. In fact, it is initially protective, though it may become maladaptive over time.

Dr. Hobbs stressed that proper assessment of pain enhances a humanitarian outcome, with better response to analgesia, better function and chance of rehabilitation if possible.

He concluded by stating that inadequate assessment leads to inadequate treatment and he advocated a multidisciplinary approach.