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sensory examination (Cruccu et al, 2004; Bouhassira et al, 2005) and allow evaluation of response
to treatment (Bouhassira et al, 2004).
Global scales are designed to measure the effectiveness of overall treatment (see
Section 2.3.1). They are more suited to outcome evaluation at the end of treatment than to
modifying treatment in the acute stage (Moore et al, 2003). Questions such as ‘How effective do
you think the treatment was?’ recognise that unimodal measures of pain intensity cannot
adequately represent all aspects of pain perception.
Satisfaction is often used as a global indicator of outcome, however patients may report high
levels of satisfaction even if they have moderate to severe acute pain (Svensson et al, 2001
Level IV). Satisfaction may also be influenced by preoperative expectations of pain,
effectiveness of pain relief, the patient–provider relationship (eg communication by medical
and nursing staff), interference with function due to pain and number of opioid‐related side
effects (Svensson et al, 2001 Level IV; Carlson et al, 2003 Level IV; Jensen et al, 2004 Level IV).
Although complete absence of pain is not required for patients to report high levels of
satisfaction, moderate pain (VAS greater than 50, scale 0 to 100) has been associated with
dissatisfaction (Jensen et al, 2005 Level III‐2).
2.2.4 Patients with special needs CHAPTER 2
Validated tools are available for measuring pain in neonates, infants and children, but must be
both age and developmentally appropriate (see Section 10.3). These include behavioural
assessments, pictorial scales (eg faces) and response to treatment. Adult patients who have
difficulty communicating their pain (eg patients with cognitive impairment or who are critically
unwell in the emergency department or intensive care) require special attention as do patients
whose language or cultural background differs significantly from that of their health care team
(see Sections 9.8, 9.9, 11.2.3, 11.3 and 11.4). Communication aids and behavioural scales such
as the modified Faces, Legs, Activity, Cry and Consolability (FLACC) scale (Erdek & Pronovost,
2004) can be particularly useful in these situations (see Section 11.2.3).
Key messages
1. Regular assessment of pain leads to improved acute pain management (U) (Level III‐3).
2. There is good correlation between the visual analogue and numerical rating scales (U)
(Level III‐2).
The following tick boxes represent conclusions based on clinical experience and expert
opinion.
Self‐reporting of pain should be used whenever appropriate as pain is by definition a
subjective experience (U).
The pain measurement tool chosen should be appropriate to the individual patient;
developmental, cognitive, emotional, language and cultural factors should be
considered (U).
Scoring should incorporate different components of pain including the functional capacity
of the patient. In the postoperative patient this should include static (rest) and dynamic (eg
pain on sitting, coughing) pain (U).
Uncontrolled or unexpected pain requires a reassessment of the diagnosis and
consideration of alternative causes for the pain (eg new surgical/ medical diagnosis,
neuropathic pain) (U).
Acute pain management: scientific evidence 39
