Pain intensity and severe pain in young immigrant patients with long-standing back pain

The aim of this study was to explore if self-rated pain intensity and severe pain differed significantly between immigrants from different regions, and if other socio-economic, or clinical, characteristics could predict severe pain. A total of 129 men and 217 women at a primary health centre in Stockholm, Sweden, 27–45 years, on long-term sick leave, were recruited in consecutive order and grouped into a Turkish (n = 122), Southern European (n = 52), Middle East (n = 69) and one Mixed (n = 173) group of immigrants. All were employed in service jobs. Somatic status, depression and level of psychosocial stressors, including pain anxiety, were established by standardized procedures. All reported long-standing disabling back pain. Patients rated intensity of pain “right now” on a 0–100 mm visual analogue scale (VAS) as a last part of the consultation with two doctors. Severe pain was defined as VAS 75–100. Median values (md) with inter-quartile ranges (IQR) were calculated for interval and ordinal data. Non-parametric statistics were used to calculate significant differences between groups. Crude and age-standardized odds ratios (OR) with 95% confidence intervals (95% CI) as rating severe pain were calculated by binary and forward conditional logistic regression. Men and women were analyzed separately. Women had more tender points, (P < 0.001), and reported pain anxiety more often (P < 0.01). Frequency of depression did not differ between the immigrant groups. The VAS-values varied, but not significantly, between the immigrant groups of men and women. Men had lower VAS values than women (md 50, IQR 36–69 vs. md 72, IQR 51–85), (P < 0.001). Women had a three-fold risk to rate severe pain (OR 2.9, 95% CI 1.8–4.7). By sex, no immigrant group had significantly elevated OR to rate severe pain. Being 40–45 year old doubled the OR as rating severe pain. Men with depression, or little education, had high risks as rating severe pain (age-standardized ORs 4.1; 95% CI 1.7–10.0 and 2.7; 95% CI 1.1–6.8, respectively), and so had depressed women (age-standardized OR 1.9; 95% CI 1.1–3.4). Women with pain anxiety had a doubled, not statistically significant, elevated risk (age-standardized OR 2.0, 95% CI 0.95–4.3). The groups did not differ significantly in pain intensity or severe pain. Severe pain was predicted by depressed mood and probably linked to gender, age and sick roles.     

Evaluation and assessment of cancer pain and cancer pain treatment

Evaluation and assessment are the first steps of any strategy for the management of cancer pain, and are fundamental for any clinical research project in this field. Different clinical systems for evaluation and classification of cancer pain syndromes are available and their clinical usefulness should be tested. The measurement of pain intensity is necessary to document and assess the outcome of established and new treatments. Visual analogue scales, verbal and numerical rating scales and some multidimensional tools such as the Brief Pain Inventory and the McGill Pain Questionnaire are helpful in the assessment of cancer pain provided the limitations of their validity are considered. Specific questions arise when these tools are used in long-term repeated assessments of cancer patients. Assessment and measuring techniques deserve more investigations to optimize standard valid procedures and to enable us to exchange clinical information and produce comparable data in research.     

Pain intensity, pain interference and characteristics of spinal cord injury

STUDY DESIGN: Postal survey. OBJECTIVES: To examine if the intensity of pain in persons with spinal cord injury (SCI) varied as a function of pain site, and to identify the patient and SCI characteristics associated with pain location, pain intensity and pain interference in a sample of persons with SCI. SETTING: Community sample, United States. METHODS: A postal survey including measures of pain intensity, pain interference, other pain, demographic and medical characteristics was completed by 238 adults with SCI. RESULTS: Average pain intensity was moderate and pain was common across the body. Demographic and medical variables, including SCI level, were generally not associated with pain prevalence, intensity and interference. However, persons with higher level injuries were more likely to report upper extremity pain than persons with paraplegic injuries. The lower body was the location of the highest pain ratings. CONCLUSION: Persons with SCI tend to experience high pain intensity over multiple body locations. Lower body pain was as common as upper extremity pain, but tended to be more intense.     

Low back pain: critical assessment of various scales

To study the various pain assessment tools based on their psychometric properties and ease of use. Published articles on psychometric properties of pain tools were accessed and data collected for low back pain (LBP)-specific tools, generic tools, neuropathic LBP tools, tools for cognitively impaired patients, and tools for acute LBP. Among the LBP-specific tools, Roland Morris Disability Questionnaire (RMDQ) and Oswestry Disability Index (ODI) have good construct validity and reliability, and responsiveness over short intervals. Quebec Back Pain Disability Scale (QBPDS) gauges only disability and sleep. Among the generic tools, McGill Pain Questionnaire (MPQ), West Haven-Yale Multidimensional Pain Inventory (MPI), and Brief Pain Inventory (BPI) show good responsiveness, but BPI is the only tool validated for LBP. Neuropathic Pain Scale (NPS) and Short Form-MPQ-2 (SF-MPQ-2) are both reliable tools for neuropathic LBP. For cognitively impaired patients, Pain Assessment in Advanced Dementia (PAINAD), Abbey Pain Scale (APS), and Doloplus-2 are all reliable tools, but PAINAD has good construct validity. For acute pain, Clinically Aligned Pain Assessment (CAPA) is reliable and responsive, but presently, unidimensional tools and SF-MPQ-2 are the tools most preferred. Based on psychometric properties and ease of use, the best tools for LBP seem to be RMDQ/ODI (among LBP-specific tools), BPI (among generic tools), SF-MPQ-2/NPS (for neuropathic LBP), PAINAD (for cognitively impaired patients), and unidimensional tools and SF-MPQ-2 (for acute pain). Overall, BPI seems to be a tool that can be relied upon the most. These slides can be retrieved under Electronic Supplementary Material.     

中文版多维疼痛评估工具的比较分析

随着疼痛定义的更新,应用多维疼痛评估工具对慢性疼痛患者开展评估的重要性日益凸显。分析4种经过汉化及信效度测定的多维疼痛评估工具的异同点,在我国的应用现状及其在临床应用中的注意事项,以期为医护人员合理选用疼痛评估工具提供参考。     

Pain and pain generation in pancreatic cancer

Background  Pain can be a frequent symptom during the natural history of a patient with pancreatic cancer. An increase in incidence with disease progression and the presence of unbearable pain may preclude a curative resection. Materials and methods  Even in those patients with resectable pancreatic cancer, the presence of pain has an impact on prognosis. To date, we do not really know why some patients develop pain. Results  Perineural cancer cell invasion is one of the most intriguing characteristics of this neoplasia and may in some cases explain the pain sensation. In addition, so-called “neurogenic inflammation” might also play a role in pain generation in pancreatic cancer, just like in chronic pancreatitis. Conclusion  In conclusion, understanding the mechanisms of pain in pancreatic cancer could help patients because what counts is not only 5-year survival but also median survival with good quality of life.     

Pain measurement scales: a comparison of the visual analogue and faces rating scales in measuring pressure ulcer pain.

OBJECTIVE: Although different pain scales often have been used interchangeably, it is not known whether interchanging them is appropriate. The purpose of this report was twofold: to better understand the statistical properties of the Faces Rating Scale (FRS) so it can be used appropriately in clinical settings and to describe the mathematical relationship between the Visual Analogue Scale (VAS) and the FRS when they are used to quantify pressure ulcer pain in hospitalized elderly patients. DESIGN: Secondary data analyses were performed as part of a cross-sectional study. SETTING AND SUBJECTS: A quality assurance program was undertaken to evaluate pressure ulcer pain perceived by elderly hospitalized patients. All patients without aphasia participated. INSTRUMENTS: The VAS used was a 0 to 100 mm horizontal line demonstrated to have ratio scale properties with high validity and reproducibility, and the FRS used was 6 faces ordered horizontally from smiling to crying, labeled 0 to 5 beneath each face, respectively. METHODS: Nonlinear least squares regression with a Gauss-Newton iterative procedure was used. RESULTS: Among models with cubic, quadratic, and linear terms, only the quadratic term was significant (P <.05). With use of the equation derived, VAS = 3.33*(FRS)(2), the resulting reliability coefficient was r = 0.92. CONCLUSIONS: The nonlinear relationship indicated high reliability between VAS and FRS for pain assessment in populations with diminished verbal and abstract thinking abilities. For readers who would like to translate results from one scale to another, a quadratic equation is provided.     

The evaluation of change in pain intensity: a comparison of the P4 and single-item numeric pain rating scales

STUDY DESIGN: Prospective observation study. OBJECTIVES: To compare the test-retest reliability and longitudinal validity (sensitivity to change) of 2 single-item numeric pain rating scales (NPRSs) with a 4-item pain intensity measure (P4). BACKGROUND: Pain is a frequent outcome measure for patients seen in physical therapy; however, the error associated with efficient pain measures, such as the single-item NPRS, is greater than for self-report measures of functional status. Initial evaluation of the P4 suggests that it is more reliable and sensitive to change than the NPRS. METHODS AND MEASURES: Two single-item NPRSs and the P4 were administered on 3 occasions--initial visit (n = 220), within 72 hours of baseline (n = 213), and 12 days following baseline assessment (n = 183)--to patients with musculoskeletal problems receiving physical therapy. Reliability was assessed using a type 2,1 intraclass correlation coefficient. Longitudinal validity was assessed by correlating the measures' change scores with a retrospective rating of change that included patients' and clinicians' perspectives. RESULTS: The test-retest reliability and longitudinal validity of the P4 were significantly greater (P1<.05) than both single-item NPRSs. Minimal detectable change of the P4 at the 90% confidence level was estimated to be a change of 22% of the scale range (9 points) compared to 27.3% (3 points) and 31.8% (3.5 points) for the 2-day NPRS and 24-hour NPRS, respectively. CONCLUSIONS: The findings of this study suggest the P4 is more adept at assessing change in pain intensity than popular versions of single-item NPRSs.     

4种疼痛评估量表在房颤射频消融术患者中的应用比较

目的 比较4种疼痛评估量表在房颤患者射频消融术中的应用效果。方法 选取160例接受射频消融术的房颤患者为研究对象,术中分别采用数字评定量表、视觉模拟评分、Wong-Baker面部表情疼痛量表、词语描述量表评估疼痛,比较不同疼痛评估量表在患者首选率、作答时间及效标效度方面的差异。结果 4种疼痛评估量表在患者首选率、作答时间方面差异具有统计学意义(均P<0.05),Wong-Baker面部表情疼痛量表及词语描述量表患者首选率较高,而作答时间最短。不同性别、年龄及文化程度患者对4种疼痛量表首选率比较,差异无统计学意义(均P>0.05)。消融术中不同时间点词语描述量表、Wong-Baker面部表情疼痛量表、视觉模拟评分分别与数字评定量表(作为效标)评分存在高度相关(r=0.774～0.886,均P<0.05)。结论 4种疼痛评估量表在房颤射频消融术中具有较好的疼痛评估作用,且Wong-Baker面部表情疼痛量表、词语描述量表的临床应用效果最佳。     

慢性疼痛患者疼痛程度及应对策略的调查

目的了解慢性疼痛患者的疼痛程度及应对策略,并探讨两者之间的相关性。方法采用随机抽样方法抽取武汉市11所三级甲等医院住院的慢性疼痛患者270例,采用数字疼痛强度量表及自行设计的慢性疼痛应对策略问卷进行调查。结果患者近1周的疼痛评分为0～10(6.39±2.49);近1周无疼痛1例(0.37%),轻度疼痛44例(16.30%),中度疼痛122例(45.18%),重度疼痛68例(25.18%),剧烈疼痛35例(12.96%)。其应对策略各维度中,积极心态评分(2.99±1.10)、忽视疼痛(2.61±1.11)、分散注意力(3.21±1.06)、行动解决(2.77±0.73)、寻求帮助(2.99±0.86)、消极心态(2.57±1.01)、限定活动(4.12±1.01)。患者疼痛强度与应对策略中的忽视疼痛呈负相关(r=-0.208,P<0.01)。结论慢性疼痛患者的疼痛程度多处于中重度,其疼痛程度与应对策略相关。医护人员应重视和规范慢性疼痛的管理,采取相应措施提高患者应对策略,以减轻其疼痛程度。     

Pain assessment

The accurate assessment of acute and chronic pain is challenging. Assessment should be approached by taking a relevant history, examining the patient and ordering suitable investigations if necessary. Pain scales facilitate the initial assessment of the patient and provide a measurement of the success or otherwise of pain-relieving interventions. A comprehensive pain history should investigate both the pain (site, character, context and treatment history) and the patient (including psychosocial yellow and red flag markers of life-threatening pathology, anxiety and depression). The aims of examination and investigation are to document baseline signs and look for potential underlying causes of the pain. Investigations can include blood tests, anatomical investigations or functional investigations.     

Comparative validity of the sickness impact profile and shorter scales for functional assessment in low-back pain

Several scales exist for measuring functional status in patients with low-back pain (LBP). There are few comparative data, however, to suggest which scales may perform best. We compared the Sickness Impact Profile (SIP), its major subscales, and a short index derived from the SIP (a slight modification of an index proposed by Roland) with regard to reliability, validity, and sensitivity to change. Walk-in patients with mechanical LBP (n = 136) completed the entire SIP at an index visit and again 3 weeks later. The examination of individual items allowed scoring for the derivative scales. The modified Roland Scale appeared to have reliability, validity, and sensitivity that were at least as good as the overall SIP or its major subscales. Although the Roland Scale did not measure psychosocial function well, this aspect of functioning changed less over time than physical function.     

Pain perception and assessment

Our inability to measure pain effectively is a major barrier to progress in pain research and advancement in clinical interventions for pain. Historically, the mind-body dichotomy has constrained our thinking about pain and its quantification. One line of work has pursued pain as the sensory end product of nociception: pain is the realization of signals of tissue injury arriving at the cortex. At the other extreme, some clinicians contend that pain is 'what the patient says it is'. In other words, it is a purely mental and entirely subjective phenomenon. Research on functional brain imaging, psychophysiological research and recent neurophysiological research on animal models provide confluent evidence that both of these positions are misleading oversimplifications. Pain is the emergent product of massive, parallel, distributed processing in the brain that engages structures involved in emotion and cognition as well as in sensation. To advance pain measurement, our research team has examined Sokolov's defense response in human subjects experiencing repeated, brief painful electrical shocks delivered to a fingertip through a tiny electrode. Sokolov proposed that threatening events elicit a hypothalamically-orchestrated pattern of arousal that prepares the organism to cope with threat. Measures of sympathetic nervous system arousal and brain evoked potentials in our subjects reveal a stable pattern of this sort when we subject the data to structural equation modeling. When subjects undergo equally intense shocks delivered through a large electrode, they experience a strong vibration-like, unpleasant sensation that causes discomfort but not nociception. The non-painful shock elicits broad levels of arousal equal to those obtained with painful shocks in subjects, but structural equation modeling demonstrates that such arousal does not conform to the defense response pattern. Moreover, multivariate measures of sympathetic arousal and evoked potentials can discriminate painful from non-painful stimuli more accurately than can subjective pain reports. These observations suggest that pain may have a unique psychophysiological signature. More importantly, perhaps, this approach suggests that the combination of psychophysiological research and multivariate statistics provides an avenue for advancing pain research outside of the mind-body dichotomy.     

Pain intensity after laseruvulopalatoplasty and tonsillectomy.

OBJECTIVE: The first objective of this study was to evaluate pain intensity and opioid consumption during the first 24 hours after uvulopalatoplasty and tonsillectomy in the hospital, and the second was to evaluate pain intensity and its progression during the first 2 weeks after surgery at home. STUDY DESIGN AND SETTINGS: In a prospective parallel group study, 51 patients with uvulopalatoplasty or tonsillectomy were studied. Ketoprofen, a nonsteroidal antiinflammatory drug, and fentanyl citrate, an opioid, were used as analgesics. RESULTS: Despite ketoprofen infusion and free access to a patient-controlled pump with fentanyl citrate for rescue analgesia, inadequate pain relief was common both after uvulopalatoplasty (35%) and after tonsillectomy (28%) during the first 24 hours after surgery. The consumption of fentanyl citrate was similar after both operations. At home, pain intensity was highest in the mornings during the first 5 days, and 10 patients had some pain still after 2 weeks. Also at home, high pain scores were reported commonly in both groups. CONCLUSION: Significant pain after uvulopalatoplasty and tonsillectomy lasted for several days. Ketoprofen in the commercial capsule form proved to be too short acting for overnight pain relief. SIGNIFICANCE: Pain treatment in patients with uvulopalatoplasty and tonsillectomy should be improved to allow patients a peaceful recovery after surgery.     

Measuring pain phenomena after spinal cord injury: Development and psychometric properties of the SCI-QOL Pain Interference and Pain Behavior assessment tools

Objective: To develop modern patient-reported outcome measures that assess pain interference and pain behavior after spinal cord injury (SCI).

Design: Grounded-theory based qualitative item development; large-scale item calibration field-testing; confirmatory factor analyses; graded response model item response theory analyses; statistical linking techniques to transform scores to the Patient Reported Outcome Measurement Information System (PROMIS) metric.

Setting: Five SCI Model Systems centers and one Department of Veterans Affairs medical center in the United States.

Participants: Adults with traumatic SCI.

Interventions: N/A.

Outcome Measures: Spinal Cord Injury - Quality of Life (SCI-QOL) Pain Interference item bank, SCI-QOL Pain Interference short form, and SCI-QOL Pain Behavior scale.

Results: Seven hundred fifty-seven individuals with traumatic SCI completed 58 items addressing various aspects of pain. Items were then separated by whether they assessed pain interference or pain behavior, and poorly functioning items were removed. Confirmatory factor analyses confirmed that each set of items was unidimensional, and item response theory analyses were used to estimate slopes and thresholds for the items. Ultimately, 7 items (4 from PROMIS) comprised the Pain Behavior scale and 25 items (18 from PROMIS) comprised the Pain Interference item bank. Ten of these 25 items were selected to form the Pain Interference short form.

Conclusions: The SCI-QOL Pain Interference item bank and the SCI-QOL Pain Behavior scale demonstrated robust psychometric properties. The Pain Interference item bank is available as a computer adaptive test or short form for research and clinical applications, and scores are transformed to the PROMIS metric.     

Visual analog scales for interpretation of back and leg pain intensity in patients operated for degenerative lumbar spine disorders.

STUDY DESIGN: A prospective observational study of visual analog scale (VAS) scores for pain in patients operated at one institution within the framework of a national registry. OBJECTIVE: To describe the use of recording VAS for pain intensity in patients operated on for lumbar spine problems. SUMMARY OF BACKGROUND DATA: There is no consensus regarding pain outcomes assessment in spine patients. Pain intensity, recorded on a VAS, is one of the most used measures. Still, many aspects of its interpretation are still debated or unclear. METHODS: A total of 755 consecutive patients, mean age 50 years (range, 15-86 years), operated from 1993 to 1998 were included in the study; there were 420 males and 335 females. Diagnoses included herniated nucleus pulposus (45%), central stenosis (19%), lateral stenosis (14%), isthmic spondylolisthesis (9%), and degenerative disc disease (9%). Local pain, radiating pain, analgesic intake, and walking ability were recorded before surgery and at 4 and 12 months after surgery. The patients' opinions regarding the change in pain and satisfaction with the result were assessed separately. Correlation among variables reflecting perceived pain was sought. RESULTS: Preoperative VAS mean values for local and radiating pain were significantly different in the five diagnostic groups. Significant but moderate correlation between different types of pain outcomes and with patient satisfaction was present in all cases. CONCLUSIONS: Measuring pain intensity with VAS is a useful tool in describing spine patients. In the search for a standard in the evaluation of pain as an outcome, the differences between the various methods should be taken into account.     

Improvement in physician pain perception with using pain scales

Background and aims

Acute pain is the most common reason for visits to the emergency department (ED). The underuse of analgesics occurs in a large proportion of ED patients. The physician’s accurate assessment of patients’ pain is a key element to improved pain management. The purpose of this study was to assess if physicians’ perception of pain can improve with looking at the pain score of the patient marked on VAS.

Study design

This was a single-center, cross-sectional prospective observational study, that took place in an academic ED.

Methods

All adult ED patients presenting with a painful condition were enrolled to the study. In the first phase of the study, the physician rated his/her opinion about the patient’s pain on a 100 mm VAS, in a blinded fashion to the patient’s pain score. In the second phase, the physician rated his/her opinion after looking at the pain scale marked by patient.

Results

587 patients (295, in first and 292, in second phase) were enrolled. The groups were not statistically different for demographic data. The physician’s perception of pain was lower than the patient’s pain score at both phases of the study. Insight of the patient’s pain score on VAS increased the physician’s pain perception significantly (p?=?0.03). During the second phase, physicians ordered significantly more analgesic medications to the patients (p?=?0.03).

Conclusion

The physicians’ perception of the patients’ pain differs significantly from the pain that the patient is experiencing. VAS helps to bring the physicians impression of pain perception to the level of pain that the patient is actually experiencing and resulted in ordering more analgesics to the patients. Implementation of a pain assessment tool can raise the physician’s perception of the pain and may improve pain management practices and patient satisfaction.