Effective pain management requires careful assessment and regular review of pain. Pain is a subjective symptom, and pain assessment tools are therefore based on the patient’s own perception of their pain and its severity. [1] Pain assessment involves both an initial, detailed evaluation of each type of pain, and then a regular reassessment of severity and response to treatment.

What is known
A large number of pain assessment tools exist, and their content varies. A systematic review of available pain assessment tools suggests that none adequately address all of the domains which are significant for palliative care patients. [2]

What it means in practice

• Whilst there is no single pain assessment tool in use at present which is regarded as ideal, there is expert consensus that for palliative care patients, the five most important aspects of the pain experience which should be addressed by a pain assessment tool are:
  • Pain intensity
  • Temporal pattern
  • Treatment and exacerbating / relieving factors
  • Pain location
  • Pain interference. 
• Other dimensions that are important are pain quality, affective aspects of pain, the duration of pain, pain beliefs and pain history. [2]
• For ongoing monitoring of pain intensity, a simple visual analogue scale or numerical rating scale is appropriate. [2, 3]
• It is particularly challenging to assess pain in infants and children, or patients who are unable to communicate effectively. Communication problems are common in palliative care, and may be due to cognitive problems, language differences, physical problems, delirium, reduced conscious state, or at end-of-life. In general, patients’ ability to use assessment tools may diminish as their illness progresses. [3]
• When a patient’s communication is impaired, pain assessment tools that rely on observing pain behaviours may improve the assessment of pain. Developing these tools is methodologically very challenging, and a recent systematic review suggests that all the available tools require further validation. [4] However, the Abbey pain assessment tool is in widespread clinical use in Australia, and it is recommended as current best practice for patients with severe cognitive impairment. [5]
• Cultural and linguistic differences also create significant barriers to pain assessment. [6] Using a pain assessment tool in the patient’s own language has the potential to improve at least one element of this complex situation.

Finding out more
Guidelines

• Pain in Residential Aged Care Facilities: Management Strategies Australian Pain Society
  NB: The Appendices contain a comprehensive set of validated pain assessment tools that are very useful in a range of palliative care settings.

Link to prescribing information
NB Prescribing information may not yet have been updated to include the most recent evidence

• Online Palliative Medicine Handbook
  Click on “Notes on Prescribing”
  This prescribing information is from the UK and some medications may not be available in Australia
• Therapeutic Guidelines for Palliative Care
  An Australian source of prescribing information not available directly online through CareSearch, but can be accessed online in most hospitals, or purchased.

Overview articles

• Pain in elderly people with severe dementia: A systematic review of behavioural pain assessment tools [4]
• Pain measurement in children.[7]

Related CareSearch pages
Assessment tools (GP Resources)
Health service issues in pain management
Opioid analgesics
Adjuvants and radiotherapy
Non-pharmacological approaches to pain management

References

1. Noble B, Clark D, Meldrum M, ten Have H, Seymour J, Winslow M, et al. The measurement of pain, 1945-2000. Journal of Pain and Symptom Management. 2005 JaN;29(1):14-21. 
2. Holen JC, Hjermstad MJ, Loge JH, Fayers PM, Caraceni A, De Conno F, et al. Pain assessment tools: is the content appropriate for use in palliative care? Journal of Pain & Symptom Management. 2006 Dec;32(6):567-80. 
3. Jensen M. The validity and reliability of pain measures in adults with cancer. Journal of Pain. 2003 Feb;4(1):2-21.  
4. Zwakhalen SM, Hamers JP, Abu-Saad HH, Berger MP. Pain in elderly people with severe dementia: A systematic review of behavioural pain assessment tools. BMC Geriatrics. 2006 Jan 27;6:3. 
5. Australian Pain Society. Pain in Residential Aged Care Facilities: Management Strategies. North Sydney; Australian Pain Society: 2005. 
6. Cintron A, Morrison RS. Pain and ethnicity in the United States: A systematic review. Journal of Palliative Medicine. 2006 Dec;9(6):1454-73.  
7. McGrath, J., J. Unruh, and G. Finley, Pain measurement in children IASP Pain: Clinical Updates, 1995. III(2).

This page was created on 23 May 2008 and will be reviewed in May 2010