Page 83 Guide to Pain Management in Low-Resource Settings

Pain History and Pain Assessment 71

to age-specifi c pension benefi ts arising from the formal Scale, the Depressivity Scale; the University of Ala-
employment sector, but in regions such as sub-Saharan bama in Birmingham (UAB) Pain Behavior Scale, the
Africa such a chronological defi nition is problematic, Neonatal/Infant Pain Scale, and the Children’s Hospi-
often replaced by more complex, multidimensional tal Eastern Ontario Pain Scale.) Importantly, it is es-
sociocultural defi nitions, such as the person’s senior- sential that the health care provider selects the most
ity status within their community and the number of appropriate tool (depending on the aims of the pain
grandchildren they have.) assessment, and on the practicality, applicability, and
Consequently, the principal rule, especially for acceptability of the instrument to particular patient
the geriatric patient, is to ask for pain. Among those populations) and uses it consistently over time.
who have suffi cient cognitive functioning to express Th e most commonly used tools for assessing
themselves, the health care provider can increase the pain in cognitively unimpaired adults and the elderly
text size of word descriptors for the visually impaired, are the visual analogue scale (VAS), the numerical rat-
include relatives in the pain assessment process where ing scale (NRS), the verbal descriptor scale (VDS). A
it is considered appropriate and helpful, and avoid tool that has been evaluated in a low-resource setting,
“mental overload” (i.e., discussing multiple topics and the APCA (African Palliative Care Association)’s Af-
providing insuffi cient explanatory guidance in the rican Palliative Outcome Scale (POS). One tool used
pain assessment). among cognitively impaired adults is the Pain Assess-
In noncommunicative patients, however, assess- ment in Advanced Dementia (PAINAD) Scale. Th e
ments of the extent of presenting pain will be primar- most commonly used tools for assessing children’s pain,
ily based on behaviorally based proxies (e.g., facial im- in addition to the VAS, NRS, and VDS (for some chil-
pression, daily activity, emotional reactions, the eff ect of dren aged over seven years old), include the FLACC
consolation, and vegetative reactions) rather than rely- (i.e. Face, Legs, Activity, Cry, and Consolability) Behav-
ing upon any scale whose use is premised on communi- ioral Pain Scale, the Touch Visual Pain (TVP) Scale, the
cation (see Chapter 27 on Pain in Old Age and Demen- Wong-Baker FACES Pain Rating Scale, and the Pain
tia for additional information). Th ermometer. Th ese tools, and how they are used, are
described below, along with an outline of the compara-
How do you measure a patient’s pain? tive advantages and disadvantages of each.

A number of unidimensional and multidimension- Adult pain tools
al tools exist that to varying degrees lend themselves
to everyday use. One-dimensional assessment tools i) Visual analogue scale (VAS)
simplify the pain experience by focusing on one par- Th e VAS pain rating scale uses a 10-cm-long horizon-
ticular aspect or dimension, and in a challenging low- tal line, anchored by the verbal descriptors “No pain”
resource, nonresearch, clinical setting they take less and “Worst pain imaginable,” on which patients make
time to administer and require less patient cognitive a mark to indicate what they feel best represents their
functionality than do multidimensional instruments. perception of the intensity of their current pain (Fig. 1).
Often these tools have been validated in linguistically
and culturally diverse settings. Additionally, they are
not usually used in isolation (e.g., a body diagram may No Worst
be used in conjunction with a scale indicating the se- pain pain
imaginable
verity of the pain experienced). (Examples of multidi-
mensional tools not discussed in this chapter, which
Fig. 1. Visual analogue scale.
could be used for clinical and research purposes, in-
clude the McGill Pain Questionnaire (short- and long-
ii) Numerical rating scale
form); the Brief Pain Inventory; the Dartmouth Pain
Questionnaire; the West Haven-Yale Multidimensional Using this scale, the health care provider asks patients
Pain Inventory; the Minnesota Multiphasic Personal- to rate their pain intensity on a numerical scale that
ity Inventory; the State-Trait Anxiety Inventory; the usually ranges from 0 (indicating “No pain”) to 10 (indi-
Beck Depression Inventory, the Self-Rating Depression cating the “Worst pain imaginable”).