Pain assessment: differences in quality and intensity of the words pain, ache and hurt

A study was undertaken to investigate if the concepts pain, ache and hurt differ from each other in intensity and quality and to identify discriminating semantic correlates for each of these concepts. Forty-one nurses with different backgrounds in nursing and 12 patients with chronic pain syndrome were included in the study. The methods used were a questionnaire, the visual analogue scale (VAS), and the McGill Pain Questionnaire (MPQ). There was a statistically significant difference in the intensity of the words pain, ache and hurt on both the VAS and the MPQ. Pain was shown to have the highest intensity, followed by ache with hurt having the lowest. Semantic correlates consisting of sensory and affective words which best discriminate between the concepts pain, ache and hurt were identified. Semantic correlates for pain were: cutting, crushing, tearing, sharp, dreadful, killing, torturing and suffocating: for ache were: aching, pulling, gnawing, irritating, annoying, troublesome, exhausting, unbearable and terrifying; for hurt were: pricking, pinching, stinging, sore, fearful, unhappy.     

Worst experiences of pain and conceptions of worst pain imaginable among nursing students

Title. Worst experiences of pain and conceptions of worst pain imaginable among nursing students Aim. This paper is a report of a study to explore nursing students’ own worst experiences of pain as well as their conceptions of the worst pain imaginable. Background. Pain is a personal experience, often assessed using a visual analogue scale. The endpoints of this scale are labelled with the extremes for pain experience (e.g. no pain to worst pain imaginable). People may understand the meaning of ‘no pain’, but it is unclear what meaning they assign to ‘worst pain imaginable’. This indicates that a rating along the Visual Analogue Scale‐line is dependent on the individual’s previous experiences. Methods. Data were collected during the autumn of 2002. In total, 549 nursing students completed a questionnaire focusing on two main questions: ‘What is the worst experience of hurt, ache or pain you have had?’ and ‘What is the worst pain imaginable for you?’ Content analysis was used for data analysis. Results. The students’ worst experience of pain was mostly related to acute or traumatic painful conditions, pain associated with female physiology, inflicted pain, psychological suffering and chronic painful conditions. The worst pain imaginable was described as condition‐related pain, overwhelming pain, experiences of losses, deliberately inflicted pain, psychological suffering and as vicarious pain. Conclusion. The findings imply that nursing students, when they are imagining pain, include dimensions such as hope of relief, grief, control over the situation, powerlessness and empathy for and suffer with other people’s pain. Further research is needed to explore why professional experience as a nurse diminishes the ability to imagine patients’ pain.     

Ratings of pain and activity limitation on the visual analogue scale and global impression of change in multimodal rehabilitation of back pain – analyses at group and individual level

Purpose: To evaluate changes in pain intensity and activity limitation, at group and individual levels, and their associations with the global impression of change after multimodal rehabilitation in patients with back pain.

Method: Patients with long-term back pain (n?=?282) participated in a 4-week programme with a follow-up after 6 months. Visual analogue scales (VAS) were used to rate pain intensity and activity limitation. Global impression of change (GIC) was rated on a 7-category scale. The sign test, the Svensson method and the Spearman rank correlation were used for analyses.

Results: Significantly lower ratings in pain and activity limitation at follow-up were found at group level. However, a large individual variability was found by the Svensson method. The correlations between GIC and changes in pain and activity limitation were r_s??=_? 0.49 and r_s =?_?0.50, respectively. A rated GIC of at least “much better” on group level showed changes of ≥20?mm on the VAS.

Conclusions: At group level, lower VAS ratings were found in patients with back pain. However, a large individual variability in pain and activity limitation was also found resulting in low to moderate associations between GIC and the change in VAS ratings. The large individual variability might be due to the impreciseness in the ratings on the VAS. We have presented a critical discussion of statistical methods in connection with the VAS.

• Implications for Rehabilitation

• The use of VAS as a rating instrument may be questioned, especially for perceived pain intensity which is a too complex experience to be rated on a line without any visible categories.

• Single ratings of pain intensity should preferably be complemented with the ratings of activity limitation in patients with long-term back pain.

• Global impression of change is a suggested inclusive rating after rehabilitation.

• The improvement desired by the patient should preferably be determined before rehabilitation.

     

Student nurses'' assessment of children in pain

A self-administered questionnaire was developed to ascertain the criteria that student nurses used to assess children in pain. The sample consisted of 17 second-year registered general nurse students who had just completed their paediatric secondment. The questionnaire required the students to provide their own definition of pain, to rate the pain of four hypothetical children, giving reasons for their ratings and provide data about their assessment of a child they had cared for. Definitions of pain concentrated mainly on the physical effects of pain on patients. The students attributed a wide range of pain ratings to the hypothetical children, though the reasons for reaching these differing conclusions were often based on similar statements. There was limited reference to either personal episodes of pain or previous nursing experience. In their own assessment of children in pain the students appeared to use all the acknowledged criteria. The use of physiological signs was in some circumstances possibly inappropriate.     

Reliability of rating low back pain with a visual analogue scale and a semantic differential scale

Pain rating scales, such as the Visual Analogue Scale (VAS) and the Verbal Rating Scale (VRS) are important tools for assessing patients’ symptom status. For a non-English speaking patient, VRS could pose a problem as a result of language barrier. The objective of this study was to determine the intra-class and inter-class correlations of VAS and a Semantic Differential Scale (SDS) in patients with low back pain. 25 patients with chronic low back pain were purposively selected for the study. Two testers (1 and 2) independently rated the pain experienced by the patients when asked to bend forward and hold on when pain was either exacerbated or aggravated. Finger-to-floor distance (FFD) was taken, as a measure of flexion of the spine, for each patient. Pain was rated using VAS and SDS. Our results showed strong intra-tester correlations between VAS and SDS of each tester (p < .05), and strong inter-tester correlations for VAS and for SDS (p < .05). The result of using two-way ANOVA showed that there was no significant difference in pain ratings with VAS by tester-1, VAS by tester-2, SDS by tester-1, and SDS by tester-2. F-ratio was not significant (p > .05). There was no significant difference between FFDs by the two testers (p > .05). Our results suggest that the two scales are reliable and valid for clinical rating of low back pain. Further studies with larger samples and using other movements of the spine are suggested.     

A comparison of patient and proxy symptom assessments in advanced cancer patients

The purpose of this study was to compare patient and proxy (physician and nurse) assessments of symptoms in advanced cancer patients. The sample consisted of 49 patients with advanced cancer admitted to an acute palliative care unit. Three independent assessments were completed for each patient on two occasions within 11 days of admission. On each occasion, symptoms were rated independently by the patient and two proxies (treating physician and nurse), using the Edmonton Symptom Assessment System (ESAS). The ESAS is a nine-item visual analogue scale (VAS) for assessing pain, activity, nausea, depression, anxiety, drowsiness, appetite, well-being and shortness of breath. Symptom ratings were compared using a repeated-measures ANOVA procedure and correlations. Average physician ratings were generally lower than average patient ratings for both occasions. Average nurse ratings agreed more closely with patient ratings, with a trend towards lower ratings on occasion 1 and higher ratings on occasion 2. There was a significant rater (person rating the effects) effect (P < 0.01) for three of the nine symptoms: physicians rated drowsiness, shortness of breath and pain significantly lower than patients. For drowsiness and shortness of breath, these differences were clinically relevant, representing a difference of more than 12 mm on a 100-mm VAS. The accuracy of assessments amongst those rating the symptoms did not improve over time. Proxy assessments of symptom intensity, particularly by physicians, were significantly lower than patient assessments for three of the nine symptoms. Further research regarding the reliability of patient and proxy assessments is needed to assess and manage symptoms in advanced cancer effectively.     

Health related quality of life and quantitative pain measurement in females with chronic non-malignant pain.

The aim of the present study was to assess, compare, and correlate the pain response to an experimental pain stimulus (hyperalgesia to pressure pain threshold (PPT) measured from different body sites), the pain intensity (VAS) of the habitual pain, and quality of life parameters (SF-36) in groups of females with chronic non-malignant pain syndromes. Forty female pain patients with fibromyalgia/whiplash (n = 10), endometriosis (n = 10), low back pain (n = 10), or rheumatoid arthritis (n = 10), as well as 41 age-matched healthy female controls participated in the study. The fibromyalgia/whiplash patients scored significantly higher (p < 0.04) VAS ratings (median rating = 7.0) than the endometriosis (6.0), low back pain (6.0), and rheumatoid arthritis (3.5) patients. All fours patient groups had significantly lower PPTs at all sites as compared with controls. The fibromyalgia/whiplash patients experienced the highest influence of pain on their overall health status, particularly vitality, social function, emotional problems, and mental health. A significant negative correlation was found between VAS rating and quality of life (p < 0.04). Significant correlation (p < 0.05) was found between pressure hyperalgesia measured at lowest PPT sites and the impairment of SF-36 physical function as well as mental health parameters. This study demonstrates significant generalised pressure hyperalgesia in four groups of chronic pain patients, correlations between degree of pressure hyperalgesia and impairment of some quality of life parameters, and increased pain intensity of the ongoing pain is associated with decreased quality of life.     

Factors Affecting Pain Scores during Female Urethral Catheterization

OBJECTIVES: To compare pain and discomfort ratings of female patients undergoing urethral catheterization randomized to topical application of plain lubricant versus lidocaine gel prior to the procedure. METHODS: This was a prospective, randomized, double-blind study involving female patients requiring urethral catheterization at an urban university-based academic emergency department. A staff nurse blinded to the lubricant type injected 5 mL of sterile surgical lubricant or 2% lidocaine gel into the urinary meatus. After 1 minute, an 8-F (for specimen collection) or a 16-F (for continuous collection) catheter was inserted into the urethra. Each patient rated the pain of the procedure on a validated 0- to 100-mm visual analog scale. The Mann-Whitney U test was used to analyze associations between pain ratings, lubricant type, and catheter size. Logistic regression was used to identify the contribution of lubricant type, catheter size, age category, difficulty of insertion, preprocedural pain, and diagnosis of urinary tract infection to procedural pain rating. RESULTS: One hundred women were randomized to plain lubricant (n = 50) or lidocaine (n = 50). The overall mean ( +/- SD) pain score was 23.5 +/- 27.2 mm. No significant differences in pain ratings were found based on catheter size or lubricant type. Younger women, aged 18-59 years, experienced higher pain ratings than women aged 60-101 (mean pain difference 14.4 mm; 95% CI = 4.3 to 24.5; p < 0.006). Multiple logistic regression identified preprocedural pain as the only predictor of higher pain rating after catheterization (OR 1.02; 95% CI = 1.002 to 1.039, p = 0.03). CONCLUSIONS: Catheter size and lubricant type did not affect the severity of pain after urethral catheterization in women.     

Nurses' assessment of pain in hospitalised patients.

This study compared the incidence of pain reported by hospitalised patients with that recorded by nurses, correlated patients' and nurses' ratings of pain intensity and explored the relative importance nurses placed on various criteria in pain assessment. Patients (n = 115) in a university teaching hospital rated pain intensity on a visual analogue scale (VAS) and indicated its source and duration. Nurses (n = 115) caring for them rated their pain intensity on a VAS and ranked the importance of 12 factors in their assessments. Seventy-two patients (63%) reported pain and 97 nurses (84%) indicated that their patients had pain (X2 = 13.94, p less than 0.001). Patients' and nurses' VAS ratings were poorly correlated (rs = 0.35, p less than 0.001). The highest ranked factors in nurses' assessments were: what the patient said; the patient's report of the severity of pain; the patient's facial expression and the patient's posture. It was concluded that the prevalence of pain was high and that nurses' judgements were poor.     

Children's pain at home following (adeno) tonsillectomy.

The aim of this study was to evaluate the prevalence and severity of children's pain at home following (adeno)tonsillectomies. The subjects were parents of 161 children (86 boys, 75 girls) undergoing myringotomies, adenoidectomies and (adeno)tonsillectomies. The mean age of the children was 5.5 years (SD=2.4; range 1-14). Parents were asked to assess the child's average pain on the day of operation and 7 days after the operation, using a 100 mm Visual Analogue Scale (VAS). Parents from (adeno)tonsillectomy patients were also interviewed by phone on day 7.The mean VAS pain intensity scores by period (day of operation until 7th day after operation) differed between the myringotomy (3.2), adenoidectomy (10.6), and (adeno)tonsillectomy (22.1) group (F(2,133)=31.65; p<0.001). The VAS ratings were highest for the tonsillectomy group (p<0.001). There was a trend that pain intensity scores for adenoidectomies were significantly higher than scores for myringotomies (p=0.07). In the interviews, 81% of the parents stated that their child suffered pain at home. However, this was not necessarily a reason to administer an analgesic. Furthermore, parents reported pain-related problems like problems regarding eating, fluid intake, vomiting and sleep disturbance. Finally, 67% of the children at home recalled severe pain experience in the hospital.It was concluded that especially following (adeno)tonsillectomies children suffer clinically significant pain at home and that the management of pain and related problems needs to be clearly improved.     

The Short-Term Effects of Acupuncture on Myofascial Pain Patients After Clenching

Aim: Short‐term pain reduction from acupuncture in chronic myofascial pain subjects was evaluated using an 11‐point (0 to 10) numeric rating scale, visual analog scale (VAS), and pain rating of mechanical pressure on the masseter muscle. Methods: A single‐blind, randomized, controlled, clinical trial with an independent observer was performed. Fifteen chronic myofascial pain subjects over the age of 18 were randomly assigned into groups: nine subjects received real acupuncture; six subjects received sham acupuncture. Each subject clenched his/her teeth for 2 minutes. Acupuncture or sham acupuncture was administered at the Hegu Large Intestine 4 acupoint. Sham acupuncture was conducted by lightly pricking the skin with a shortened, blunted acupuncture needle through a foam pad, without penetrating the skin. The foam pad visually conceals the needle's point of the entry, so that the subject cannot discern which technique is being used. The subjects rated their general pain on a numeric rating scale. A mechanical pain stimulus was applied with an algometer and the subject rated his/her pain on a VAS. Statistical analysis was performed using the repeated measures anova , paired t‐tests, and Fisher's exact test as appropriate. Results: There was a statistically significant difference in pain tolerance with acupuncture (P = 0.027). There was statistically significant reduction in face pain (P = 0.003), neck pain (P = 0.011), and headache (P = 0.015) with perception of real acupuncture. Conclusion: Pain tolerance in the masticatory muscles increased significantly more with acupuncture than sham acupuncture.     

Is Homatropine 5% effective in reducing pain associated with corneal abrasion when compared with placebo? A randomized controlled trial

Objective: To compare the change in visual analogue scale (VAS) pain ratings over 24 h following mechanical corneal abrasion between patients receiving sixth hourly drops of either 5% homatropine or placebo. Methods: A triple blind randomized controlled trial was conducted on a convenience sample of eligible consenting adults who were randomized to receive either sixth hourly 5% homatropine (active) or 0.5% hypromellose (placebo) eye drops. VAS pain ratings were performed at 0, 6, 12, 18 and 24 h whereas the study drug was instilled at 0, 6, 12 and 18 h. The primary outcome was attainment of a clinically significant reduction in pain on the VAS (>20 mm decrease) from enrolment to each time point. Results: There were no significant differences in baseline variables or VAS pain ratings at any time point between those in the homatropine (n= 20) and placebo (n= 20) groups. The percentages of patients reporting a >20 mm VAS decrease at 12 h were 50% (95% CI –27.2–72.8) and 60% (95% CI –36.1–80.9) for the homatropine and placebo groups, respectively. Conclusion: We found no significant difference in pain score reductions between the two groups but some level of therapeutic benefit is not excluded.     

Children's ratings of postoperative pain compared to ratings by nurses and physicians.

Children's ratings of their postoperative pain were compared to nurses' and physicians' ratings of the children's postoperative pain. Children and adolescents were able to rate their pain using a visual analogue scale (VAS). Although there were differences between groups on their mean pain ratings, the ratings of the nurses and physicians correlated significantly with the children's pain ratings. Also, the correlation between nurses and physicians was highly significant, indicating that the use of a VAS may help nurses and physicians explore the cues used to estimate children's pain. This dialogue may enhance communication and collaboration between professionals about pain management strategies specific to each child's pain experience.