Startseite Medizin Patients’ subjective acute pain rating scales (VAS, NRS) are fine; more elaborate evaluations needed for chronic pain, especially in the elderly and demented patients
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Patients’ subjective acute pain rating scales (VAS, NRS) are fine; more elaborate evaluations needed for chronic pain, especially in the elderly and demented patients

  • Harald Breivik EMAIL logo
Veröffentlicht/Copyright: 1. April 2017
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Scandinavian Journal of Pain
Aus der Zeitschrift Scandinavian Journal of Pain Band 15 Heft 1

In this issue of the Scandinavian Journal of Pain, Pardis Zalmay and Amanda C de C Williams publish an interesting study on how a group of lay persons understand the commonly used pain intensity scales [1]. This group of medical students early in their clinical training, most likely are a more interested and better informed group of persons than the general public, illustrate that our pain-intensity scales can be misunderstood and misinterpreted.

Ever since Michael Bond and Issy Pilowsky in 1966 [2] were the first to use and publish the VAS – the Visual Analogue Scale for assessing subjectively experienced pain intensity, this instrument has been ubiquitously used and misused. The expressions “doing VAS” – “VASing” being synonymous with doing a pain-assessment, at least in the Nordic countries.

1 The NRS is equally sensitive but more practical in use than the VAS

Many mix VAS with NRS – the Numeric Rating Scale. The latter can be used without pen and paper, without sharp vision, and without ability to move the indicator on a paper, plastic, or electronic VAS-scale. It is so much easier to ask the patient: “.. .how bad is your pain right now – on a scale from 0 to 10, where 0 is no pain and 10 is unbearable pain, the worst pain imaginable?”

Children from around 9 to 10 years can understand and respond appropriately. Elderly patients and patients soon after waking up from anaesthesia and surgery usually understand and respond reliably [3,4]. The NRS is equally sensitive to changes in pain intensity as the VAS [4,5] and NRS and VAS scales are more sensitive to changes than VRS – verbal rating scales using verbal descriptions like mild, moderate, severe, and excruciating pain [4]. The NRS is preferred because it is so much easier to understand and use [1]. But I observe again and again that even well informed nurses and physicians use the verbal NRS-scale, but report that they are using a VAS-scale for pain assessment.

2 What does VAS = 100 and NRS = 10 mean?

The upper end of these scales is often defined as “the worst pain imaginable”. But this must vary a lot from patient to patient because most of us will relate this “worst pain imaginable” to episodes of severe acute pain that we may have experienced before [1]. For women who have children, they will relate this to the pain during delivery of a baby. For others this “worst pain imaginable” may relate to pain after an accident, tooth-ache, low-back pain, headache, etc. This must vary a lot. In the clinic I try to explain NRS = 10 as pain that is so severe that if effective relief is not provided soon, acute pain with intensity NRS = 10 will cause the patients to seriously consider suicide.

3 Remembering what pain was like yesterday is unreliable

Our memory of pain is unreliable and depends on a number of confounders: Has pain relief been effective? Nausea, lack of sleep, meaning of the pain – is it related to cancer, to an episode of serious, even life-threatening medical event? Did treatment relieve the pain well, but left the patient with nausea, even vomiting severely?

Our memory-functions may not serve us reliably if we are asked to estimate “average” pain during the last 24 h? Or even worse – ask the patient to estimate average pain during a whole week [6].

4 Suffering from chronic pain and its consequences

The subjective experience of acute and short-lasting pain can be well characterized by the intensity of pain assessed with a VAS or NRS score. However, patients suffering from pain that goes on for month after month have difficulties expressing the degree of suffering from the pain condition with a simple pain intensity-scale: “my pain is at least 15, or even 20 at times” is a not unusual response from a patient who suffers from the many consequences of “chronic” pain: anxiety and fear of what the future will bring, depression, worries about work, worries about economy and family relations, disappointments from lack of relief by multiple failed therapies [7]. More in-depth evaluations are needed, observing the many negative bio-psycho-social aspects of chronic pain conditions [8].

5 When communication is difficult

When the patients have difficulties expressing their suffering from pain conditions, the challenge becomes more difficult, e.g. in small children and in the elderly patients [9].

The most neglected patients with chronic pain are the elderly, frail (mostly women) with increasing degrees of dementia. And because their expressions of pain and other burdensome symptoms are limited, treatment becomes difficult.

Bettina Husebø and her co-workers at the University of Bergen, Norway developed an evaluation instrument based on observing the patients with dementia during nursing care: the MOBID-2, the Mobilization-Observation-Behaviour-Intensity-Dementia Pain Scale that has proved to be useful and highly reliable and sensitive in documenting changes with effective treatment [10,11].

DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2016.12.007.

Oslo University Hospital, Department of Pain Management and Research, Pbox 4956 Nydalen, 0424 Oslo, Norway. Fax: +47 23073690.

  1. Conflict of interest: None declared.

References

[1] Zalmay P, Williams ACDC. How do medical students use and understand pain rating scales? Scand J Pain 2017;15:68–72.Suche in Google Scholar

[2] Bond MR, Pilowsky I. Subjective assessment of pain and its relationship to the administration of analgesics in patients with advanced cancer. J Psychosom Res 1966;10:203–8.Suche in Google Scholar

[3] Breivik H, Borchgrevink PC, Allen SM, Rosseland LA, Romundstad L, Breivik-Hals EK, Kvarstein G, Stubhaug A. Assessment of pain. Br J Anaesth 2008;101:17–24.Suche in Google Scholar

[4] Breivik EK, Bjornsson GA, Skovlund E. A comparison of pain rating scales by sampling from clinical trial data. Clin J Pain 2000;16:22–8.Suche in Google Scholar

[5] Skovlund E, Breivik H. Analysis of pain-intensity measurements. Scand J Pain 2016;13:123–4.Suche in Google Scholar

[6] Broderick JE, Stone AA, Calvanese P, Schwartz JE, Turk DC. Recalled pain ratings: a complex and poorly defined task. J Pain 2006;7:142–9.Suche in Google Scholar

[7] Williams ACDC, Davies HTO, Chadury Y. Simple pain rating scales hide complex idiosyncratic meanings. Pain 2000;85:457–63.Suche in Google Scholar

[8] Hadjistavropoulos T, Craig KD, Duck S, Cano AM, Goubert L, Jackson P, Mogil J, Rainville P, Sullivan M, de C Williams AC, Vervoort T, Dever Fitzgerald T. A biopsychosocial formulation of pain communication. Psychol Bull 2011;137:910–39.Suche in Google Scholar

[9] Hadjistavropoulos T, Breau LM, Craig KD. Assessment of pain in adults and children with limited ability to communicate. In: Turk DC, Melzack R, editors. Handbook of pain assessment. 3rd ed. New York: Guilford Press; 2011. p. 260–80.Suche in Google Scholar

[10] Husebo BS, Strand LI, Moe-Nilssen R, Husebo SB, Ljunggren AE. Pain in older persons with severe dementia. Psychometric properties of the Mobilization-Observation-Behaviour-Intensity-Dementia (MOBID-2) Pain Scale in a clinical setting. Scand J Caring Sci 2010;24:380–91.Suche in Google Scholar

[11] Sandvik R, Selbaek G, Seifert R, Aarsland D, Ballard C, Corbett C, Husebo BS. Impact of a stepwise protocol for treating pain on pain intensity in nursing home patients with dementia: a cluster randomized trial. Eur J Pain 2014;18:1490–500.Suche in Google Scholar
Published Online: 2017-04-01
Published in Print: 2017-04-01

© 2017 Scandinavian Association for the Study of Pain

Artikel in diesem Heft

  2. Scandinavian Journal of Pain
  3. Editorial comment
  4. Cardiovascular risk reduction as a population strategy for preventing pain?
  5. Observational study
  6. Diabetes mellitus and hyperlipidaemia as risk factors for frequent pain in the back, neck and/or shoulders/arms among adults in Stockholm 2006 to 2010 – Results from the Stockholm Public Health Cohort
  7. Editorial comment
  8. Exercising non-painful muscles can induce hypoalgesia in individuals with chronic pain
  9. Clinical pain research
  10. Exercise induced hypoalgesia is elicited by isometric, but not aerobic exercise in individuals with chronic whiplash associated disorders
  11. Editorial comment
  12. Education of nurses and medical doctors is a sine qua non for improving pain management of hospitalized patients, but not enough
  13. Observational study
  14. Acute pain in the emergency department: Effect of an educational intervention
  15. Editorial comment
  16. Home training in sensorimotor discrimination reduces pain in complex regional pain syndrome (CRPS)
  17. Original experimental
  18. Pain reduction due to novel sensory-motor training in Complex Regional Pain Syndrome I – A pilot study
  19. Editorial comment
  20. How can pain management be improved in hospitalized patients?
  21. Original experimental
  22. Pain and pain management in hospitalized patients before and after an intervention
  23. Editorial comment
  24. Is musculoskeletal pain associated with work engagement?
  25. Clinical pain research
  26. Relationship of musculoskeletal pain and well-being at work – Does pain matter?
  27. Editorial comment
  28. Preoperative quantitative sensory testing (QST) predicting postoperative pain: Image or mirage?
  29. Systematic review
  30. Are preoperative experimental pain assessments correlated with clinical pain outcomes after surgery? A systematic review
  31. Editorial comment
  32. A possible biomarker of low back pain: 18F-FDeoxyGlucose uptake in PETscan and CT of the spinal cord
  33. Observational study
  34. Detection of nociceptive-related metabolic activity in the spinal cord of low back pain patients using 18F-FDG PET/CT
  35. Editorial comment
  36. Patients’ subjective acute pain rating scales (VAS, NRS) are fine; more elaborate evaluations needed for chronic pain, especially in the elderly and demented patients
  37. Clinical pain research
  38. How do medical students use and understand pain rating scales?
  39. Editorial comment
  40. Opioids and the gut; not only constipation and laxatives
  41. Observational study
  42. Healthcare resource use and costs of opioid-induced constipation among non-cancer and cancer patients on opioid therapy: A nationwide register-based cohort study in Denmark
  43. Editorial comment
  44. Relief of phantom limb pain using mirror therapy: A bit more optimism from retrospective analysis of two studies
  45. Clinical pain research
  46. Trajectory of phantom limb pain relief using mirror therapy: Retrospective analysis of two studies
  47. Editorial comment
  48. Qualitative pain research emphasizes that patients need true information and physicians and nurses need more knowledge of complex regional pain syndrome (CRPS)
  49. Clinical pain research
  50. Adolescents’ experience of complex persistent pain
  51. Editorial comment
  52. New knowledge reduces risk of damage to spinal cord from spinal haematoma after epidural- or spinal-analgesia and from spinal cord stimulator leads
  53. Review
  54. Neuraxial blocks and spinal haematoma: Review of 166 case reports published 1994–2015. Part 1: Demographics and risk-factors
  55. Review
  56. Neuraxial blocks and spinal haematoma: Review of 166 cases published 1994 – 2015. Part 2: diagnosis, treatment, and outcome
  57. Editorial comment
  58. CNS–mechanisms contribute to chronification of pain
  59. Topical review
  60. A neurobiologist’s attempt to understand persistent pain
  61. Editorial Comment
  62. The triumvirate of co-morbid chronic pain, depression, and cognitive impairment: Attacking this “chicken-and-egg” in novel ways
  63. Observational study
  64. Pain and major depressive disorder: Associations with cognitive impairment as measured by the THINC-integrated tool (THINC-it)
https://doi.org/10.1016/j.sjpain.2017.01.001

Artikel in diesem Heft

  2. Scandinavian Journal of Pain
  3. Editorial comment
  4. Cardiovascular risk reduction as a population strategy for preventing pain?
  5. Observational study
  6. Diabetes mellitus and hyperlipidaemia as risk factors for frequent pain in the back, neck and/or shoulders/arms among adults in Stockholm 2006 to 2010 – Results from the Stockholm Public Health Cohort
  7. Editorial comment
  8. Exercising non-painful muscles can induce hypoalgesia in individuals with chronic pain
  9. Clinical pain research
  10. Exercise induced hypoalgesia is elicited by isometric, but not aerobic exercise in individuals with chronic whiplash associated disorders
  11. Editorial comment
  12. Education of nurses and medical doctors is a sine qua non for improving pain management of hospitalized patients, but not enough
  13. Observational study
  14. Acute pain in the emergency department: Effect of an educational intervention
  15. Editorial comment
  16. Home training in sensorimotor discrimination reduces pain in complex regional pain syndrome (CRPS)
  17. Original experimental
  18. Pain reduction due to novel sensory-motor training in Complex Regional Pain Syndrome I – A pilot study
  19. Editorial comment
  20. How can pain management be improved in hospitalized patients?
  21. Original experimental
  22. Pain and pain management in hospitalized patients before and after an intervention
  23. Editorial comment
  24. Is musculoskeletal pain associated with work engagement?
  25. Clinical pain research
  26. Relationship of musculoskeletal pain and well-being at work – Does pain matter?
  27. Editorial comment
  28. Preoperative quantitative sensory testing (QST) predicting postoperative pain: Image or mirage?
  29. Systematic review
  30. Are preoperative experimental pain assessments correlated with clinical pain outcomes after surgery? A systematic review
  31. Editorial comment
  32. A possible biomarker of low back pain: 18F-FDeoxyGlucose uptake in PETscan and CT of the spinal cord
  33. Observational study
  34. Detection of nociceptive-related metabolic activity in the spinal cord of low back pain patients using 18F-FDG PET/CT
  35. Editorial comment
  36. Patients’ subjective acute pain rating scales (VAS, NRS) are fine; more elaborate evaluations needed for chronic pain, especially in the elderly and demented patients
  37. Clinical pain research
  38. How do medical students use and understand pain rating scales?
  39. Editorial comment
  40. Opioids and the gut; not only constipation and laxatives
  41. Observational study
  42. Healthcare resource use and costs of opioid-induced constipation among non-cancer and cancer patients on opioid therapy: A nationwide register-based cohort study in Denmark
  43. Editorial comment
  44. Relief of phantom limb pain using mirror therapy: A bit more optimism from retrospective analysis of two studies
  45. Clinical pain research
  46. Trajectory of phantom limb pain relief using mirror therapy: Retrospective analysis of two studies
  47. Editorial comment
  48. Qualitative pain research emphasizes that patients need true information and physicians and nurses need more knowledge of complex regional pain syndrome (CRPS)
  49. Clinical pain research
  50. Adolescents’ experience of complex persistent pain
  51. Editorial comment
  52. New knowledge reduces risk of damage to spinal cord from spinal haematoma after epidural- or spinal-analgesia and from spinal cord stimulator leads
  53. Review
  54. Neuraxial blocks and spinal haematoma: Review of 166 case reports published 1994–2015. Part 1: Demographics and risk-factors
  55. Review
  56. Neuraxial blocks and spinal haematoma: Review of 166 cases published 1994 – 2015. Part 2: diagnosis, treatment, and outcome
  57. Editorial comment
  58. CNS–mechanisms contribute to chronification of pain
  59. Topical review
  60. A neurobiologist’s attempt to understand persistent pain
  61. Editorial Comment
  62. The triumvirate of co-morbid chronic pain, depression, and cognitive impairment: Attacking this “chicken-and-egg” in novel ways
  63. Observational study
  64. Pain and major depressive disorder: Associations with cognitive impairment as measured by the THINC-integrated tool (THINC-it)
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