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Dr. Nurver Turfaner, M.D., PhD,
Assoc. Prof.
Istanbul University
Cerrahpasa Medical Faculty
Department of Family Medicine
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Pain: the 5th vital sign (pulse, blood
pressure, temperature, respiration)
an unpleasant sensory and
emotional experience associated
with actual or potential tissue
damage or described in terms of
such damage
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Age
Anxiety
Culture
Fear
Gender
Observational learning (family
history of pain/previous experience
of pain
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Personality:
Introvert: greater sensitivity, fewer
complaints
Extrovert: High pain tolerance
Psychological factors
Religion
Response of healthcare staff
Sleep deprivation
Society
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Clinician influenced
Insufficient knowledge
Lack of pain training in medical school
Lack of pain-assessment skills
Rigidity or timidity in prescribing
practices
Overestimation of risks involved in the
therapy
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Patient influenced
Reluctance to report pain
Reluctance to take opioid drugs
Poor adherence to management plan
Healthcare system influenced
Low priority given to symptom control
Unavailability or bureaucracy in opioid
analgesic administration
Inaccesibility of specialised care
To make a working diagnosis define the
extent of injury or disease
• To determine the type of pain
• To establish co-existing medical,
emotional and psychological factors
influencing pain
(soldiers and sportsmen can sustain severe
physical trauma without initially feeling pain)
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To determine a pain management
strategy on the basis of information
obtained
To evaluate response to therapy
To compare and monitor progress of
individual patients
To validate effectiveness of new
treatments for clinical and research
purposes
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First- hand history from the patient
Pain description: a verbal picture of pain
Primary or secondary complaint
Location and radiation
Specific site of pain
Mode of onset
Intensity and severity
Character
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Temporal features
Exacerbating and relieving factors
Associated symptoms
How pain has changed since onset
Treatments so far
Medical aspects
Functional status
Psychological assessment
Factors relevant to treatment
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Inspection: Attention to symmetry and
cutaneous landmarks
Skin colour, rashes, scars, abnormal hair
growth, pseudomotor dysfunction, oedema,
muscular atrophy, hypertrophy or
fasciculations, spinal curvatures, limb lengths
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Palpation: Perform in a systematic and
comprehensive manner from the least painful
to the most painful area helps differentiate
normal tissues and painful region
Elicits gross sensory changes: allodynia,
dysaesthesia,paraesthesia, hyper/hypoalgesia,
hyperpathia, hypoaesthesia and analgesia
dolorosa
Elicits painful muscle bands or nodules,
(tender/trigger points), neuromas in scars,
peripheral pulsations and temperature
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Percussion: can indicate nerve entrapment
or presence of a neuroma (Tinel’s sign).
Percussion of bony structures may indicate
fracture, dislocation, inflammation, infection
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Range of motion: for articulated areas,
active and passive range of motion, all
movements possible for that particular joint
and their effect on pain in degrees
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Motor examination: Muscle bulk, tone,
isolated muscle power, involuntary movements
should be assessed and correlated with
myotomal innervations
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Sensory examination: response to light
touch, light pressure, pinprick or cold and
vibration
Match any sensory changes to dermatomal
and peripheral cutaneous nerve maps to
assess the anatomical significance
Reflexes: tendon reflexes are increased in
upper motor neurone lesions and decreased
in lower motor neurone lesions and
muscular diseases
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Provocative tests: concordant vs nonconcordant pain
Phalen’s sign: carpal-tunnel’s syndrome
Patrick/Faber (Flexion ABduction External
Rotation): for hip pathologies
Sciatic and femoral nerve stretching tests
Straight leg raising test
Lasegue’s test: differentiate hamstring tightness
and spondylolisthesis
Crossed SLR
Bowstring test
Valsalva manoeuvre
Investigations
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radiological examinations;
Plain X-rays
MRI
fMRI
CT
SPECT scan
Others: thermography, diagnostic nerve blocks,
measurement of autonomic variables
These investigations are helpful to rule out
rather than diagnose the cause of pain
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Repetition of investigations will have
potentially negative effects on the
patient’s expectations of management
and be an unnecessary expense
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The multidimensional nature of pain offers many
potential ‘targets’ for measurement.
Pain is a subjective, personal experience, the
logical and true assessments of a patient’s pain
must be the patient’s own report. The self-report is
the gold standard of pain measurement.
Self report measurement tools: unidimensional
(e.g. categorical scales, numerical rating scales
(NRS), visual analogue scales (VAS), picture
scales or pain drawings
Multidimensional: e.g. McGill pain questionnaire
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Categorical scales/verbal rating scales
Are you in Pain?-yes/no
none, mild, moderate,severe, excruciating
Pain relief: none, slightly, moderate, good,
complete
0,1,2,3,4
Advantages: quick, simple,suitable for the
elderly,older children,visually impaired,
sensitive to ethnic and gender differences
Disadvantages: subject to bias
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Visual analogue scales: 10 cm straight line,
scoring by measuring the distance in mm from
left to right
no pain
No pain relief
worst pain
imaginable
complete
pain relief
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Advantages: quick, simple, avoidance of
imprecise, descriptive terms, suitable for
children over 5 years, parametric statistical
tests can be applied
Disadvantages:more demanding, requires
greater cognitive skills
(concentration,language), may not be easy to
measure extremes, can be influenced by
medication, sleep disturbance, it measures
relief better
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Classical Pain: three dimensions
sensory-discriminative
Motivational-affective
Cognitive-evaluative
Long-form McGill questionnaire
Short form of McGill pain questionnaire
Brief pain inventory
Health-related quality of life measures
Hospital anxiety and depression scale
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Post-operative Pain
Assessment of pain in children:
Physiological: heart rate, blood pressure,
respiratory rate, palmar sweating,
transcutaneous oxygen, serum catecholamine,
glucagon and cortisol
Behavioural: crying, grimacing, irritability
Self-report measures: faces
scale,VAS,CHEOPS,FLACC(face-legs-activitycry-consolability)
Pain in the elderly: be aware of dementia,
confusion and cognitive deficit,deafness
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Pain assessment is multidimensional
including biological, psychological and
social elements
A thorough history is required along with
what the pain means to the patient
Patient expectations must be assessed
before a management plan is produced
Many scoring systems exist for scoring
pain and are validated in a variety of
clinical and research settings
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Patient self-reports of pain and direct
involvement in assessment is the gold
standard. Observational reporting and
proxy reporting are less reliable
Pain should be considered as the 5th vital
sign with documentation showing the
intensity, action taken and response to
intervention
Many pain scales are (e.g.
VAS,VSR,NRS) easy to use in the clinical
setting
Acute Pain
Chronic pain
<3 months duration
months duration
Protective, preventing further damage
normal functioning
Useful
Not useful
e.g. broken limb, appendicitis
>3
Prevents
e.g. post-
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Belief that pain and activity are harmful
Sickness behaviors such as extended rest
Social withdrawal
Emotional problems such as low or negative
mood, depression, anxiety or stress
Problems and/or dissatisfaction at work
Problems with claims or compensation or time
off work
Overprotective family; lack of support
Inappropriate expectations of treatment
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Nociceptive
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Visceral
Non-nociceptive
Somatic
Neuropathic Idiopathic
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is presumed to be maintained by
continual tissue injury
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Somatic pain: Arises in tissues such as
joints, bones and muscles and is well
localised.
e.g:arthritic pain
described as aching, stabbing or
throbbing
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Visceral pain: Arises from viscera in the
thorax, abdomen or pelvis.
tends to be rather diffuse and poorly
defined and may be described as deep,
dull or colicky
referred to other locations
e.g: chronic refractory angina
associated with motor reflexes such as
muscle spasms and with autonomic
reflexes such as nausea and vomiting
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Neuropathic pain: is due to injury to the
nociceptive pathway, either peripherally or
centrally
e.g: post-herpetic neuralgia is peripheral
e.g: post-stroke pain is central
described as burning or ‘electric shock-like’
clinical features: allodynia, hyperalgesia and
hyperpathia
Idiopathic pain: No identifiable organic cause
e.g: atypical facial pain
Thoughts
Physical sensation
Behaviours
Feelings
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Analgesics
Adjunct analgesics
Neurostimulation techniques
Topical treatments
Injections
Neurolytic therapies
Improving and optimising the patient’s
level of functioning: improving sleep,
graded exercise programme, treatment of
anxiety and depression
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The clinician has to understand the sensory
and emotional components of chronic pain
The clinician has to be aware of treatments
available for pain
Most importantly, the clinician has to
understand the patient
Psychosocial factors are more important
than medical factors in the development of
disability
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Being off work with chronic pain for more than
6 months means the chance of returning to
work is only 50%, after 1 year off work it is
only 10%
The emotional aspects must not be
underestimated as there is wide variation in
the reported severity of pain experienced by
individuals in association with comparable
noxious stimuli
Improvements in how a patient manages their
chronic pain can be very rewarding for the
healthcare professionals involved
Strong opioids (eg.
morphine ±nonopioids ±adjuvants
Pain controlled
Weak
opioids(eg.Codeine) ±
Non-opioids ±Adjuvants
Pain
persisting
or
increasing
Non-opioids (e.g
paracetamol,NSA
IDS) ±Adjuvants
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Route
Comments
Oral: Ideal for chronic use, dependent on
patient’s ability to swallow, gastric
emptying,food and pH, opioids have low oral
bioavailability
Intramuscular: Pain and tissue irritation on
injection, unreliable plasma concentration
especially in low perfusion, unsuitable for long
term use
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Intravenous
rapid action, can be titrated to effect
High bioavailability,
not dependent on patients characteristics
unsuitable for long term use
Subcutaneous
absorption is variable
and dependent on tissue perfusion
used for long term opioid administration
especially in malignancy related pain
Transmucosal sublingual, buccal, and gingival
modes of administration
Offers rapid onset and patient comfort,
oral transmucosalfentanyl citrate-for
breakthrough cancer pain
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Rectal: Unreliable absorption and mucosal irritation
Transdermal: Improved patient compliance, long
duration of action and steady plasma concentrations,
slow onset makes it less useful for acute pain, Fentanyl
and buprenorphine patches are popular in chronic pain
management
Topical: Topical NSAIDS are effective in acute pain
Intraarticular: Not popular, intra-articular morphine
provides good analgesia following arthroscopies;
steroid injections are used in treating arthritis
Inhalational: Limited use, inhaled entonox (50%
nitrous oxide+50% oxygen) is used for labour
analgesia and change of dressing in burns
Class
Complications
NSAIDS
Gastrointestinal
ulceration/bleeding, impaired platelet function,
fluid retention, reduction in renal blood flow,
bronchospasm, Reye’s syndrome and
anaphlaxis
Opioids
Respiratory depression, nausea
and vomiting, constipation, euphoria/dysphoria
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First session:
Introduction to drugs
Types of medicines
Benefits, uses, side-effects and problems.
Second session:
Tolerance
Addiction and dependence
Physical and psychological dependence
Withdrawal: problems and benefits
Monitoring medicines
When to use painkillers
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Non-steroidal anti-inflammatory drugs
(NSAIDS)
Opioids and opioid-containing medicines
including co-compounds
Paracetamol
Tranquillisers (benzodiazepines)
Anti-depressants (tricyclic antidepressants,
newer antidepressants, selective serotonin
uptake inhibitors (SSRIs)
Anticonvulsants
Others
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Choose to reduce or withdraw from one drug at
a time
Choose the easiest one first (probably the
opioid)
Start by stabilising level of medication usage
Change from pain-contingent to timecontingent medication
Keep timing of medication the same (do not
extend time between medication)
Reduce the amount taken by a small amount
(half a tablet) at a time
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General guidelines for teaching relaxation
exercises:
Adress posture and find a comfortable position
Begin with abdominal breathing
Wear loose, comfortable clothing
Importance of scheduling,space and time (aim
to be undisturbed for 30’ min)
Anticipate ‘unsuccessful sessions and don’t
lose confidence or become dishearted
Develop a relaxed approach rather than simply
applying a technique
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normal relaxation:15-30 min, once a day
Brief relaxation: 5-10 min, several times a
day, in any position
Mini relaxation: few seconds to few
minutes, anytime, often,identify ‘trouble
spots’ for muscular tension
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Avoid stimulants such as caffeine,smoking,
alcohol and proprietary painkilling or cold
remedies, which contain stimulants
particularly late in the day
Avoid excessive intake of liquid for some
hours before sleep
Timetable analgesic medication
appropriately
Stay in bed only when asleep and restrict
the time in bed if not sleeping
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Get up and go to another room and read
or perform routine tasks until feeling
sleepy then return to bed
Only use the bed for sleep (or physical
intimacy)
THANK YOU
FOR YOUR
ATTENTION