Pain is such sign/symptom that any patient can describe it as high or low although he/she have no pain.
I know there are many pain provocation MSK tests but patient can also express it as false.
Is there any tool to assess pain severity, which patient exactly have, not that patient describe?
No, not at all, according to the IAPS itself pain IS ALWAYS A SUBJECTIVE SENSATION AND PERCEPTION (in fact, as it says in its famous definition / conceptualization of pain).
Completing what has been said, the Three-dimensional model of Pain or "of the Key", establishes that it combines three Dimensions. The sensory discriminative, the affective motivational and the cognitive evaluative; having recently joined a fourth: La Social. Thus, to eliminate the substantial weight of the subjective would be to reduce pain to a mere mechanical / sensory reductionist experience and we know that -p.ej.- the experience of pain, ALWAYS SUBJECTIVE, does not depend on the degree, extension and intensity of the tissue injury, if there is one, since it is widely proven that pain can be perceived without any tissue injury or being minimal, in the same way that, like Bonica et al. tested, there may be a large tissue injury and pain may be perceived, as evidenced by evaluating combatants in the battle of Anzio, who were going to be evacuated to the US at a 2nd level, according to the established triage, and -even without morphines- no they expressed pain at the flattering expectations of being repatriated and leaving the war; this, a mere sensory mechanistic explanation cannot explain it.
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No, there is not a reliable tool. Physiology is insufficient. People who have lived with pain a long time have often learned to mask it. Subjective measures are the gold standard, and the benchmark from which improvement or worsening can be measured.
Other critical measures in assessing progress are changes in functionality and mood, as well as reduction in medication.
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What type of pain are you thinking about, neuropathic or somatic?
My colleague Shaun Kilminster devised The Short Pain Inventory that asked the patient to rate pain and moods that he recognised as in the constellation of mood changes caused by chronic pain. The questionnaire was on 1 side of A4 paper just like the well-known Spielberger for assessing anxiety, so it is very practical. Shaun found that anger, fatigue and depression (AFD) were raised in those who had long-term marked to severe pain from arthritis. The interesting finding was that some people rated their AFD lowly while they rated pain highly ( eg: 7 or 8 out of 10 on a Likert scale) , so they were reporting high pain levels with low mood disturbance. At the other end of the stoic scale some patients rated one or more in AFD high while reporting low pain levels. They were the real stoics. For clinical trials it is important to realise that the first group give large placebo effects, bigger than the stoic group can report even if they have taken the active analgesic, so it is wise to stratify your patients to ensure that you allocate even numbers of both those 2 groups to your medicines under test. If you do not you risk concluding that your analgesic is no better than placebo.
Shaun is on Research Gate.
His paper in osteoarthritis of the knees is:
Comparison of diclofenac spray and gel on knee joints of patients with osteoarthritic pain
SG Kilminster, GP Mould (1999) - Clinical drug investigation, 18, 345-354
Abstract
Objective: To compare a new diclofenac spray with the reference gel preparation in patients with osteoarthritic knee pain.
Design: Patients were monitored for at least 1 week for consistent pain. They then underwent 1 week of active treatment, a 1-week washout and then crossed over onto the alternative treatment in a counterbalanced trial.
Setting: Patients were screened and reviewed on a hospital outpatient basis. Treatments and pain measures were administered at home. Patients: Forty-three patients with osteoarthritic knee pain were randomised and 39 completed both treatments. At entry (n = 43), the mean (± SD) age was 58.6 ± 12.8 years and the mean bodyweight was 76.7 ± 17.1kg.
Interventions: Patients applied 17.5 to 35mg of diclofenac from a metered dose (3.5mg) spray or 20 to 40mg of diclofenac as a 1% gel, three times daily.
Outcome Measures: Pain was measured daily on a simple 5-point Likert scale and recorded in a study diary card. Global pain was assessed with the Short Pain Inventory© (SPI) on days 4 and 7 of each treatment.
Results: Pain ratings by diary card and the SPI showed significantly improved analgesia and pain-induced mood changes equally with both preparations compared with a washout period with no drug treatment. The spray showed significantly faster onset of action than the gel on the SPI. 39 of 40 patients on both active treatments reported no gastrointestinal irritation. Subscales of the SPI also showed highly significantly improved pain-induced mood disturbance.
Conclusions: Diclofenac gel and spray significantly improved osteoarthitic knee pain. Patient well-being was also significantly improved on the SPI. The spray showed significantly faster onset of action than the gel on the SPI.
The universal scale for assessing pain is the NRS scale, which has an 11-point scale
0-no pain
10-the strongest pain imaginable.
The patient does not describe the nature of the pain, but its intensity.
It can be used to assess the intensity of any pain.
To diagnose neuropathic pain, I recommend the DN4 scale.
@Kluczna : but as i said in my question, patient may describe as high or low but in reality he/she have no pain. (False)
Agnieszka. Perhaps I should have added that if there are no mood disturbances as shown by a questionnaire, then one can assume the pain is minor if not false, as you put it. There are other validated mood questionnaires than the Short Pain Inventory that I think you can find by Googling, but they have been developed by American Universities so they charge a fee.
@Kluczna: I am not talking about any specific patient. Im talking generally as many patients speaks lie that they have high pain but in reality he/she have no pain.
There family also telling that he/she have nothing but dont know why she/he complaining pain.
The dolorimeter is used to apply pressure, heat and a small electric stimulus to measure pain sensation. This exclusively applies to pain threshold but does not measure how an individual describe pain felt
For use in clinical trials pressure and electric current are flawed as threshold pain measurements because they change with repeated measurements, the tissues becoming more sensitive, as you might expect with repeated pressure on the tibia for example. The Laser heat threshold model has been made to work well with variances over time down to levels that match a good assay, such as 3 to 4% coefficients of variation. That was achieved by a meticulous technique that included: blackening the skin of the inner surface of the forearm to minimise differences in heat absorption, taking the average of six readings, using different points each time, spreading the 6 readings along the forearm to avoid different sensitivities near hand and elbow, escalating beam power at different rates to avoid anticipation. The volunteer had complete control because just letting go a button stopped the beam instantly, so they were not anxious about the pain. It was truly remarkable that we found so little difference between individuals for what is thought to be a purely subjective phenomenon. Anxiety has a huge and variable effect on pain sensation.
See: Sutton JA et al . A new laser pain threshold model detects a faster onset of action from a liquid formulation of 1 g paracetamol than an equivalent tablet formulation. Br J Clin Pharmacol, 53, 43-47
Any pain of the different origin is subjective sensation and depends on pain experience of patients... culture...social factors..et al
Its unlikely to get an objective tool to assess a subjective sensation like pain.. May be in future we will be equipped with brain mapping to scale the location and severity of pain with ease ...
Dear Dr Muhammad Waqas . Yes there are different tools that can be used such as :
- Numerical Rating Scale (NRS)
- Visual Analog Scale (VAS)
- Defense and Veterans Pain Rating Scale (DVPRS)
- Adult Non-Verbal Pain Scale (NVPS)
- Pain Assessment in Advanced Dementia Scale (PAINAD)
- Behavioral Pain Scale (BPS)
- Critical-Care Observation Tool (CPOT).
- See the link: https://pami.emergency.med.jax.ufl.edu/resources/provider-resources/pain-assessment-scales/
Kindly see also the following useful link: https://journals.rcni.com/nursing-standard/evidence-and-practice/use-of-pain-scales-and-observational-pain-assessment-tools-in-hospital-settings-ns.2019.e11308
Also check please the following very good RG link:
Article Assessment of patients with chronic pain
The following link is very useful too: https://www.practicalpainmanagement.com/resources/diagnostic-tests/guide-chronic-pain-assessment-tools
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