Comprehensive Pain Assessment
Pain is a universal human experience. Millions of people experience pain from surgery, injury and disease. A certain percentage experiences chronic pain that has no known cause. Since assessing pain is the first step toward effective pain management, doctors need to have organized methods of evaluating pain in all of their patients, even those who are too young to have mastered spoken language; are uncommunicative; are speakers of other languages; or are cognitively or hearing-impaired.
The doctor’s attitude is important in pain assessment and treatment. Empathic listening goes a long way toward relieving patient anxiety, providing patient support, validating the patient’s personal experience, and finding appropriate pain treatments.
Types Of Pain
Pain is generally divided into two categories: acute and chronic. Acute pain lasts for hours, days or weeks; chronic pain, which may vary in intensity over time, persists for months, years or, even, a lifetime. Acute pain is typically associated with inflammation, injury, infection, surgery or short-lived disease. Blockages, such as kidney stones or gallstones, can also cause acute pain.
Chronic pain, on the other hand, accompanies diseases/conditions such as cancer, rheumatoid arthritis, osteoarthritis, HIV/AIDS, fibromyalgia and diabetes. It can also be the result of an injury that has not healed properly, nerve impingement (often a cause of back pain), unsuccessful surgery or phantom-limb syndrome. It has been estimated that nearly 10 percent of the population of the United States lives with moderate-to-severe nonmalignant chronic pain.
It is possible, of course, for acute pain to become a chronic problem, or for chronic pain to increase in intensity and become acute.
The WILDA® Pain Assessment Guide
The WILDA® Pain Assessment Guide is a condensed approach to assessing pain. It attempts to quantify the subjective pain experience. There are five elements to the WILDA approach.
The patient is asked to describe the pain in words, so that the doctor understands the nature of the pain, and can better address it. The following types of pain are differentiated in the WILDA guide:
- Neuropathic, described as burning, shooting, radiating, tingling or electric
- Somatic (orthopedic), described as aching, throbbing or dull
- Visceral (abdominal/bowel), described as pressure, cramping or bloating
- The medication administered to relieve pain depends on the patient’s description, and the pain’s known, or suspected, source.
Patients are asked to rate their pain on a scale from 0 to 10, with 0 representing a total absence of pain and 10 representing the worst pain possible. The scale is used to rate pain in the present, and after medication or other intervention. It helps the doctor to determine whether pain is improving or worsening, or remaining at a constant level.
The Wong/Baker faces rating scale pairs each number on the pain scale with a facial expression. The scale is used for pediatric patients, elderly patients who are cognitively or verbally impaired, and patients who do not speak the language.
The majority of patients experience pain at two or more sites, so it is important for the clinician to understand which pain site the patient is describing.
The duration of the pain over a period of time is significant. It is also important that the patient reports any flareups during a period of persistent pain.
Aggravating Or Alleviating Factors
The doctor can discover a great deal about the source of pain from understanding factors that make the pain worse or better. Emotions, as well as physical acts or medications, may affect the intensity of pain.
In addition to medication, the following may be helpful in reducing pain:
- Relaxation or visualization techniques
- Applications of heat or cold
- Injected corticosteroids
- Nerve-deadening agents
Factors that exacerbate pain include the following:
- Particular movements
- Cold or heat
- Blood draws
- Depression, fear and anxiety
Factors that aggravate or alleviate pain are individualized, and can vary for the same patient. Physical therapy or exercise can either improve the patient’s condition or worsen it, depending upon the specific circumstance.
Once pain has been assessed, many types of medications are available to treat it, including non-steroidal anti-inflammatory drugs (NSAIDs), opioids, antidepressants, anticonvulsants, benzodiazepines, bone-seeking radio pharmaceuticals, muscle relaxants and bisphosphonates. There may be times, however, when alleviating pain requires other types of medical treatment, possibly even surgery.
Nerve Conduction Study
Nerve conduction study (NCS), also known as a nerve conduction velocity (NCV) test, enables the diagnosis of possible nerve damage by measuring the speed with which an electrical impulse travels through a nerve. This test, often performed in conjunction with electromyography (EMG), allows the doctor to differentiate nervous system issues from musculoskeletal ones, and is invaluable in helping to establish the source of nerve damage, information that can be vital to effective treatment. Nerve conduction studies may be used to diagnose specific causes of nerve damages, including: substance abuse, nerve compression or various types of neuropathy.
Candidates For An NCS
Nerve conduction studies may be administered to patients with symptoms such of chronic pain, numbness or tingling in various parts of the body. Physicians may recommend an NSC study to either rule out or confirm a diagnosis of one of the following conditions:
- Myasthenia gravis
- Amyotrophic lateral sclerosis (Lou Gehrig’s disease)
- Alcoholic or diabetic neuropathy
- Traumatic nerve injury
- Guillain-Barre syndrome
- Certain hereditary diseases
- Spinal nerve compression
It is important that the doctor administering the NCS be aware of any medications the patient is taking and of any underlying medical conditions. The patient’s temperature needs to be taken because a low body temperature will result in slower nerve conduction.
The NCS Study Procedure
During the outpatient NCS study, the nerves presumed to be affected are targeted. Electrodes are placed at various points on the skin, their adherence aided by a sticky gel. Each electrode is placed at a precise distance from its partner, a recording electrode.
As the nerve is stimulated by a mild, brief electrical charge, the exact time the impulse takes to reach the receptive device is recorded. This response time is displayed on a monitor for the doctor to observe and evaluate. Patients usually experience some discomfort from the mild shocks administered during the NCS study, but this is short-lived. After the procedure, patients may experience some muscle soreness.
Risks Of An NCS
The NCS is noninvasive and ordinarily results in no side effects. While patients experience various degrees of discomfort during the test itself, the electrical voltage employed during the test is very low and not damaging. Some patients with sensitive skin may have some irritation from the gel used to attach the electrodes. Typically, patients can resume normal, but not strenuous, activities immediately following the test. Some patients with sensitive skin may have some local irritation from the gel used to attach the electrodes. Individual patients with underlying medical conditions may be given specific recommendations after the examination.
Arthrography is an X-ray that examines and diagnoses abnormalities in the joints.
This procedure uses fluoroscopy, a technique that injects iodine into the joint space in order to make the joint structures stand out in the image and easier to assess. People with unexplained joint pain may benefit from an arthrogram, which is most effective in detecting tears or lesions in joint structures.
This type of procedure can be used to identify problems within the: