Pain assessment is a process in which pain is evaluated to determine its symptoms, severity and possible causes.
A pain assessment usually consists of two primary parts – questions posed by a physician or other healthcare professional and a physical examination.
During the discussion, a patient may be asked to describe the pain according to its onset date, character, severity, location and factors that improve or worsen the pain. Tools such as a diagram, pain scale or questionnaire may be used to quantify the pain, though pain perception is very subjective and varies from individual to individual.
During a physical exam, the healthcare professional will visually inspect the area of pain. The examiner may assess joints and muscles for strength and range of motion.
There are numerous diagnostic tests that a physician may order to help identify the cause of pain, including x-rays, electrodiagnostics, MRI or sensory testing.
After a pain assessment, healthcare professionals may make a diagnosis and recommend treatments including lifestyle changes, medications, interventions such as physical therapy or manipulation therapy, modalities such as heat therapy or electrical therapy, or surgery.
About pain assessment
A pain assessment is a process in which healthcare professionals evaluate pain to determine its possible causes. A pain assessment may be completed by many professionals, including:
Physicians
Physician assistants
Nurse practitioners
Nurses
Physical therapists
Occupational therapists
Chiropractors
Acupuncturists
A pain assessment is usually composed of two main parts – questions or discussion of the pain and a physical examination. The assessment often includes evaluation of physical, mental and emotional factors possibly associated with the pain. A review of the patient’s medical history generally precedes the assessment.
The questions of an assessment focus on obtaining as much information as possible from the patient regarding his or her pain. The patient may be asked to describe the pain according to:
Date of onset
Location and symptoms
Type and severity
Conditions that make pain worse or better
Changes over time
Past treatments and response
Possible causes
The examiner may use a diagram to help the patient indicate the location of the pain. Tools such as a pain scale using numbers may be used to help quantify the pain.
In the physical examination, the healthcare professional will assess the primary site of the pain as well as other areas. In addition to a general examination of the body and its functions, the examination may include a more detailed inspection of:
Limbs, joints and muscles for movement problems
Body mechanics, posture and ergonomics
Skin for bruising, lesions or infection
Nerve responses
Sensitivity to pressure
If the cause of pain cannot be determined by a physical examination alone, numerous diagnostic tests ranging from blood tests to MRI (magnetic resonance imaging) are available to help physicians pinpoint the cause of pain. Identifying its source can help physicians determine the most effective treatment method.
In some instances, the cause of pain may be difficult to identify. In some cases, the pain may be acute (sudden), whereas in other cases it may be chronic (long-term). Obtaining accurate information during assessment is an important step in determining the potential causes of pain and identifying the best possible treatments.
Pain is often the result of an injury, condition or disease. Some pain, especially when it occurs suddenly, may indicate a medical emergency. Patients should seek medical treatment immediately if pain is:
Severe, sudden and sharp
Accompanied by fever
Accompanied by vomiting blood or bloody diarrhea
Accompanied by joint swelling or limited range of motion
Accompanied by numbness or tingling in any extremity
It is especially important to seek immediate help if the pain is a possible sign of an emergency such as a heart attack, stroke or ruptured aneurysm - for example, chest pain that spreads through the upper body, blinding headache or sudden and severe back pain.
Before the pain assessment
Before a pain assessment, a patient may be asked to change into a gown that will allow the physician or other practitioner to visually examine areas experiencing pain. The practitioner will review the patient’s medical history, focusing on any conditions that could contribute to the complaint of pain and other symptoms.
It is important for the patient to provide as detailed a history as possible because it can help identify possible causes and contributing factors. The history may include information about past:
Illnesses, diseases and injuries
Diagnostic tests
Treatments, including medications, therapy and surgery
Emotional or psychological issues
Experiences with pain
A detailed family history will be obtained as well to evaluate any genetic or hereditary components that may be considered a factor in the patient’s pain.
During the pain assessment
The first part of the pain assessment consists of detailed questions regarding the nature of the pain. The questions are designed to help the examiner gain information and assess the patient’s condition. The most common questions address:
Date of onset of pain. When the pain was first noticed and what factors preceded the onset.
Character and severity of pain. Some common words used to describe pain include aching, burning, sore, pounding, sharp, pulsing and dull.
Location of pain. Sometimes pain is localized to one part of the body, but sometimes a patient experiences pain in multiple locations.
Radiation of pain. Sometimes pain radiates, such as from the back to the leg or toes.
Changes in daily activities that have resulted from pain. Many patients suffer sleep disturbances. Others experience changes in mood or appetite.
Other symptoms experienced in addition to pain. Pain can be accompanied by other symptoms including fatigue, balance problems, or motor difficulties such as gait disturbances or tremors.
Factors that alleviate or worsen pain. A certain physical activity may trigger pain.
Past experiences of pain. Some patients experience chronic (long-term) pain. Others experience acute pain, which is sudden or short-term.
Treatments received for pain (if any). A physician may ask whether a patient has tried remedies such as medications, relaxation, meditation, heat therapy, cold therapy, water therapy or exercise.
Physicians may use a pain diagram or pain scale to evaluate pain. A pain diagram is a picture of the human body. Patients mark the area(s) where pain is being experienced and describe the nature of the pain (e.g., shooting or throbbing).
Pain scales help quantify pain experienced. For example, the visual analog scale (VAS) asks patients to rate pain based on a scale of 1 to 10. The McGill Pain Questionnaire provides information about the quality of pain experienced. The Health Assessment Questionnaire (HAQ) has been validated in patients with rheumatic conditions including rheumatoid arthritis, osteoarthritis, juvenile rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, lupus and fibromyalgia.
When a specific condition is suspected, patients may be asked to complete specialized forms, such as the Migraine Disability Assessment (MIDAS) Test for migraines or the American Urological Association’s BPH Symptom Index Questionnaire for benign prostatic hyperplasia.
An overall physical examination may be completed for a general health assessment. During the physical exam, the patient’s temperature, blood pressure, pulse, height and weight may be recorded.
A more detailed examination will then focus on the specific areas of complaint. Depending on the location and type of pain, the physician or other practitioner may examine:
Joints for range of motion, by having the patient briefly perform functional movements such as reaching over the head and touching the floor, or by using a protractor-like device called a goniometer
Muscles for strength and flexibility with techniques such as manual muscle testing (MMT), which involves placing body parts in various positions and applying resistance
Hand and finger strength with a dynamometer (grip meter) and pinch meter
Skin for signs of ulcers or infection
Response to pressure or movement
A sensory examination may also be performed. This usually entails the use of light touch, pinprick or vibration to determine the level of pain being experienced.
After the pain assessment
After the initial pain assessment, a number of diagnostic tests may be performed to help a physician identify the cause of pain when the results of a physical examination are inconclusive.
Common tests include blood tests and urine tests. Many other tests can be grouped into one of three categories:
Radiologic evaluation. Use of devices that create images of the body using radiology.
Electrodiagnostic testing. Tests that measure the electrical activity of nerves and muscles.
Quantitative sensory testing. Method used to assess damage to the small nerve endings that detect changes in temperature and the large nerve endings that detect vibration.
Radiologic imaging tests may include:
X-ray. Low doses of electromagnetic radiation create an image of a body part, organ or bodily system on film or fluorescent screens. This is an inexpensive and widely available test that can detect fractures, bone damage and other conditions.
MRI (magnetic resonance imaging). Powerful magnets produce images on a computer screen and film. This test provides more detailed images than an x-ray and can detect damage to soft tissue. MRI may be used when more detailed information is necessary.
CAT scan (computed axial tomography). Multiple x-rays are taken from different angles around the patient. As with an MRI, a contrast medium may be injected to highlight structures. This test provides more sophisticated images than an x-ray and can provide more detailed information about bone fractures, internal organs and other medical conditions.
Arthrography. Injection of a contrast medium enhances an x-ray of a joint.
Bone scans and other radionuclide imaging. These tests introduce tiny amounts of radioactive materials called tracers into the body. The tracer is either injected or swallowed. Once in the body, it travels through the bloodstream to the targeted area. The test is not painful, and can detect cancer, infection or other disorders.
Myelography. This imaging test uses x-rays and fluoroscopy to provide pictures of the cavity within the bones of the spine (spinal column). This test may detect blockage of the spinal column caused by a tumor, infection, herniated disc or arthritis.
Discography. An x-ray is taken after injection of a contrast agent into an intervertebral disc. The contrast agent enhances the definition of the tissue on the image and can detect damage of a disc.
Arteriography. An x-ray is taken after injection of a contrast agent into the arteries. The test causes some discomfort but can detect blocked arteries.
Electrodiagnostic testing may include:
Nerve conduction studies (NCS). These evaluate for damage to muscles or nerves. The test involves the use of a computer to monitor the muscle and nerve functioning. A small electrode is placed on the skin over the muscles or nerves being tested. Using a stimulator, a small electrical current is sent to the nerves being tested, which causes them to become active. Nerve activity is picked up the computer and analyzed by a physician. The electrical current produces only a small shock and does not damage the body.
Repetitive nerve stimulation (RNS). This test evaluates muscle and nerve activity. It is conducted in a similar fashion to the nerve conduction study. The muscle or nerve being tested is stimulated numerous times to monitor activity.
Needle electromyography. Needle electrodes are used to evaluate the electrical activity of muscle fibers. This test can identify muscle or nerve damage that may be causing pain.
Quantitative sensory testing (QST) may include:
Mechanical nonpainful sensation. An instrument that measures nerve sensation evaluates individual nerve fibers. The instrument stimulates the nerve but does not cause pain. Nerve reactions are measured.
Mechanical painful sensation. An instrument that causes pressure or a pinching sensation evaluates individual nerve fibers. This test involves creating a small amount of pain and measuring nerve reactions.
Thermal sensation. This evaluates the response of individual nerve fibers to heat and cold.
Current perception threshold (CPT). An instrument that emits a small vibration evaluates nerve fibers. Unlike the other tests that measure anatomical reactions to stimulus, CPT measures the patient’s perception of the stimulus.
The discomfort associated with electrodiagnostic and sensory testing varies among individuals. Some individuals experience more pain with the testing because of their condition prior to the testing. Other individuals experience little discomfort during the tests.
Spinal tap (lumbar puncture). Analysis of cerebrospinal fluid drawn with a needle can help diagnose conditions such as meningitis and encephalitis.
Biopsy. Analysis of a tissue sample can diagnose or rule out cancer.
Interventional procedures. For example, facet joint (zygapophyseal) injection and selective nerve root injection are also sometimes used to make a diagnosis.
Patients’ abilities and limitations may also be further assessed in a functional capacity evaluation (FCE), offered in occupational therapy or physical therapy.
Pain is complex process that involves biological, psychological and social factors. For this reason, a psychological evaluation is often a part of assessment. This may include questions designed to assess a patient’s mood, pain-coping strategies, areas of disability and social environment. Some lifestyle aspects that a physician may ask about include:
Work and finances
Personal relationships
Recreational pursuits
Daily activities
Sleep patterns
Appetite
Sex drive
Ability to concentrate
Energy level
Presence of suicidal or other thoughts
Treatments that may follow pain assessment
There are a number of injuries, diseases or conditions that may be diagnosed during assessment. Examples of conditions that may lead to chronic pain:
Arthritis. A group of conditions, the most common of which is osteoarthritis, that cause joint pain.
Back pain. The many sources of long-term back pain include pinched nerves, ruptured discs and degenerative disc disease.
Fibromyalgia. A chronic illness characterized by musculoskeletal aches, pain and stiffness, soft tissue tenderness, general fatigue and sleep disturbances.
Chronic fatigue syndrome. A debilitating disorder marked by pain and profound fatigue.
Complex regional pain syndrome. Pain that occurs after an injury to an arm or leg, and is much worse than expected for the injury.
Lupus. An inflammatory autoimmune disease that can affect many parts of the body, including the skin, joints and kidneys.
Carpal tunnel syndrome. A condition that occurs when the median nerve, which runs from the forearm into the hand, becomes pressed or squeezed at the wrist.
There are a number of conditions that may cause acute pain as well. Many of these conditions can be linked to a recent injury, surgery or diagnosed illness. They may be easier to treat because the cause of the pain can be identified.
Conditions that cause pain may be treated in a variety of ways, including:
Medications, such as anti-inflammatory drugs or other analgesics
Lifestyle changes, such as exercise or diet
Physical therapy or occupational therapy
Massage therapy or other types of manipulation therapy
Modalities, such as thermotherapy, cryotherapy, hydrotherapy, therapeutic ultrasound or electrical therapy
Alternative remedies, such as acupuncture or acupressure
Injections, such as a nerve block or epidural injection
Surgery, such as arthroplasty (joint replacement), carpal tunnel release or spine surgery
Issues with pain relief
According to the American Pain Foundation, more than 50 million Americans experience chronic pain that interferes with daily activities. But most pain is either untreated, undertreated or treated improperly.
Some patients, particularly men and elders, do not report pain for a variety of reasons. Some fear their complaints will not be taken seriously or caregivers will lose respect for them. Others underreport pain because they believe adequate remedies to treat pain are not available or they will become addicted to pain medications.
Tolerance and addiction can occur with certain medications, including some painkillers. Tolerance occurs when the body becomes accustomed to medication and a higher dose is required to treat a similar amount of pain. Addiction is the overwhelming urge to use a drug even when pain relief is no longer needed. Physicians sometimes do not treat pain sufficiently because they fear patients will become addicted. However, addiction is rare when opioids are taken under close supervision of a physician for acute pain or cancer pain.
There are a number of ways that patients can address this issue, including:
Appropriate healthcare provider. Patients should make sure healthcare providers are trained and committed to the assessment and treatment of pain.
Clear descriptions of pain. Patients should accurately describe the location, severity and type of pain to physicians. This may ensure that pain is accurately assessed and treated.
Accurate diagnosis. Determining the correct underlying condition or disease causing pain can lead to a more effective treatment plan.
Advocacy. Patients should understand that pain cannot be ignored. It needs to be assessed and treated. They should never allow a physician to determine that pain is “just in the head.”
Commitment. Patients should attend all scheduled appointments with their healthcare provider and adhere to pain management plans.
Information. Patients should conduct research about their conditions and pain management options to ensure the best treatment.
Questions for your doctor on pain assessment
Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about pain assessment:
Will a pain assessment reveal the cause of my pain?
Do I need to bring my medical history or any other records, or do anything else to prepare for my pain assessment? Do I need to wear certain clothes?
What tests are available to help determine the cause of my pain?
Will nerve conduction studies or other assessments cause me pain or discomfort?
What can sensory testing reveal about my condition?
Will any of my tests require hospitalization?
After the cause of my pain is determined, what treatments are available?
What happens if I am experiencing pain but damage cannot be detected on an x-ray, MRI or other imaging test?
What happens if the cause of my pain cannot be determined?
Who is qualified to conduct my pain assessment?
Can a pain assessment help monitor my condition over time?
![Electrodiagnostics assess muscle function (e.g., electromyography [EMG], nerve conduction study).](http://images.healthcentersonline.com/pain/images/article/electrothumb.jpg)
