The DFNS approach obtains 13 different measures in response to thermal and mechanical stimuli, which reflect both gain of function (e.g., allodynia, hyperalgesia) and loss of function (e.g., insensitivity to cold or vibration) changes. The DFNS protocol has been shown to have excellent inter-rater and test-retest reliability, and they have reported reference values from a group of pain-free controls (Terkelsen& Birklein, 2022). Using this QST protocol, these investigators have identified multiple somatosensory profiles within major neuropathic pain diagnostic groups, suggesting that different mechanisms may be at play for patients with the same neuropathic pain diagnoses and that these subgroups respond differently to a treatment. Using the DFNS QST methodology, a previous double- blind randomized clinical trial in patients with peripheral neuropathic pain found that the sodium channel blocker oxcarbazepine showed substantially greater efficacy in patients who showed sensory gain (i.e., hyperalgesia) compared to those who showed a sensory loss. Importantly, these phenotype groups did not differ in their responses to placebo. QST has been increasingly studied in non-neuropathic pain conditions. In this context, the general goal is to characterize pain modulatory function more globally in contrast to the greater focus on peripheral afferent function in assessing neuropathic pain. The most frequently used The COMFORT pain scale for infants and small children The COMFORT pain scale for infants and children directly measures distress in unconscious and ventilated infants, children, and adolescents. It relies on nine indicators: alertness; calmness or agitation; respiratory distress; crying; physical movement; muscle tone; facial tension; arterial pressure; and heart rate. Each indicator is scored between 1 and 5 based upon the behaviors exhibited by the patient, who is observed unobtrusively for about 2 min. The sum of scores can range between 9 and 45. A score of 17–26 generally indicates adequate sedation and pain control (Sarkaria & Gruszfeld, 2022). The Morbid-2 Pain Scale for assessment of pain in persons with dementia and nursing homes The Mobilization-Observation-Behavior-Intensity-Dementia -2 (MOBID-2) pain scale assessment is a staff-administered behavioral pain assessment tool for older persons with Assessment of pain and cancer pain in palliative care In 1986, the WHO published the first version of a pain assessment protocol for the assessment of pain and cancer pain in palliative care. This publication set the pace for a major improvement in the management of cancer-related pain and discomforts globally. However, recent studies document that relief of cancer pain is far from satisfactory, even in the most developed parts of the world. The WHO estimates that the majority of the 4–5 million terminal cancer patients and 1–2 million end-stage HIV/AIDS patients globally suffer from unnecessary severe pain because essential analgesic drugs are not available, something the WHO and the International Narcotic Control Board (INCB)
measure of pain facilitation is a temporal summation, which refers to a transient form of central sensitization manifested by increased pain evoked by rapid repetitive stimulation at a fixed stimulus intensity. Pain inhibition is most commonly assessed via conditioned pain modulation (CPM), which refers to the decrease in pain evoked by one stimulus (the test stimulus) produced by the contemporaneous application of a second pain stimulus at a different body site (the conditioning stimulus) (Wilson et al., 2022). Considerable evidence demonstrates that individuals with chronic pain often exhibit a pain modulatory imbalance, characterized by increased pain facilitation and diminished pain inhibition. This pattern has been observed for multiple pain conditions, including FM, temporomandibular disorders, irritable bowel syndrome, and osteoarthritis. Neuropathic pain screening The self-complete Leeds Assessment of Neuropathic Symptoms and Signs and the neuropathic pain scale screen for and evaluate neuropathic pain conditions. The pain quality assessment scale (PQAS) is a more generic instrument that will differentiate between more nociceptive and more neuropathic pain conditions. Complex chronic pain conditions may have components of nociceptive, inflammatory, and neuropathic pain mechanisms. Treatments may have different effects on the different pain mechanisms. dementia. It is based on patients’ behavior in connection with standardized active, guided movements of different body parts and pain behavior related to internal organs, the head, and skin. It is documented to be reliable, but validity is difficult to document because pain scores are indirectly observed and inferred by proxies (nurses or doctors). The same is true for other scales in persons not able to express their subjective experiences, such as the Checklist of Nonverbal Pain Indicators. The CRIES Pain Scale The CRIES Pain Scale is validated for neonates from 32 weeks of gestational age to 6 months. Each of the five categories is scored from 0 to 2: crying; requires O2 for saturation below 95%; increased vital signs (arterial pressure and heart rate); expression—facial; and sleepless. Face-Legs-Activity-Cry-Consolability Tool (FLACC) The Face, Legs, Activity, Cry and Consolability (FLACC) scale, designed to assess postoperative pain in young children, is one of the most commonly used scales. The FLACC scale scores pain intensity by rating 5 behaviors on a 0 to 2 scale; face, legs, activity, consolability, and cry resulting in a maximum score of 10. Developed in 1997 as a more practical alternative to existing pain measurement scales, FLACC was comprised exclusively of behavioral items and was originally designed and validated for use in infants and children aged 2 months to 7 years to measure postoperative pain. are now trying to change through the Access to Controlled Medications Program (ACMP) in collaboration with the International Association for the Study of Pain (IASP) and others. Adequate and systematic assessment of cancer pain is also prerequisite for improving pain treatment in cancer patients. The BPI was originally designed to assess cancer-related pain and is now the most commonly used cancer pain assessment instrument (see previous discussion). In palliative care, pain is the most important of several symptoms assessed in outcome measures. The Edmonton Symptom Assessment System assesses nine items—pain,
Tools for pain assessment in patients with dementia and communication problems Patients with dementia and communication problems find it difficult to accurately report their subjective pain experience, so proxy measurements of pain must be used, such as pain behaviors and reactions that may indicate that the person is suffering painful experiences. Besides communication difficulties caused by language problems, patients of extremes of age and critically ill patients in the intensive care setting are common assessment problems. The following pain assessment tools are recommended for wide adoption in these patients.
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Book Code: PYCA2725
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