Effective pain management requires careful assessment and regular review of pain. Pain is a subjective symptom. Pain assessment tools are therefore based on the patient’s own perception of their pain and its severity. [1-2] Pain assessment involves initial, detailed evaluation of each type of pain, and regular reassessment of severity and response to treatment. 
What is known
A large number of pain assessment tools exist, and their content varies. No generally accepted pain classification yet exists on which to base such tools.  A systematic review of available pain assessment tools suggests that none adequately address all of the domains which are significant for palliative care patients. [4-5] Tools to assess patients’ pain communication and their adherence to pain medication regimes have also been found to be lacking. 
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.  Depression and cognitive symptoms should be also assessed, as these impact on the manifestation of pain and on its treatment. 
- For ongoing monitoring of pain intensity, a simple visual analogue scale or numerical rating scale is appropriate. [4, 8]
- Families and caregivers should be provided with a written pain management plan, which is updated upon reassessment of the pain. 
- It is hard to assess pain in infants and children, or patients who are unable to communicate effectively, but wherever possible a validated assessment tool should be used.  Communication problems are common in palliative care, and may be due to cognitive problems including dementia, language differences, physical problems, delirium, reduced conscious state, or the end-of-life. In general, patients’ ability to use assessment tools may diminish as their illness progresses. 
- 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.  Using an appropriate, validated pain assessment tool such as PAINAD or the Abbey pain scale is recommended as current best practice for patients with severe cognitive impairment.  Pain tools for use in sedated critically ill adults have also been reviewed, and the Behavioural Pain Scale is able to be recommended for use in this population. 
- Cultural and linguistic differences also create significant barriers to pain assessment.  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
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- Noble B, Clark D, Meldrum M, ten Have H, Seymour J, Winslow M, et al. The measurement of pain, 1945-2000. J Pain Symptom Manage. 2005 Jan;29(1):14-21.
- Green E, Zwaal C, Beals C, Fitzgerald B, Harle I, Jones J, et al. Cancer-related pain management: a report of evidence-based recommendations to guide practice. Clin J Pain. 2010 Jul-Aug;26(6):449-62.
- Knudsen AK, Aass N, Fainsinger R, Caraceni A, Klepstad P, Jordhøy M, et al. Classification of pain in cancer patients--a systematic literature review. Palliat Med. 2009 Jun;23(4):295-308. Epub 2009 Mar 13.
- 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? J Pain Symptom Manage. 2006 Dec;32(6):567-80.
- Hjermstad MJ, Gibbins J, Haugen DF, Caraceni A, Loge JH, Kaasa S, et al. Pain assessment tools in palliative care: an urgent need for consensus. Palliat Med. 2008 Dec;22(8):895-903. Epub 2008 Sep 17.
- Jacobsen R, Møldrup C, Christrup L, Sjøgren P. Patient-related barriers to cancer pain management: a systematic exploratory review. Scand J Caring Sci. 2009 Mar;23(1):190-208. Epub 2008 Sep 10.
- Spoletini I, Caltagirone C, Ceci M, Gianni W, Spalletta G. Management of pain in cancer patients with depression and cognitive deterioration. Surg Oncol. 2010 Sep;19(3):160-6. Epub 2009 Dec 6.
- Jensen MP. The validity and reliability of pain measures in adults with cancer. J Pain. 2003 Feb;4(1):2-21.
- McAuliffe L, Nay R, O'Donnell M, Fetherstonhaugh D. Pain assessment in older people with dementia: literature review. J Adv Nurs. 2009 Jan;65(1):2-10. Epub 2008 Nov 11.
- 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 Geriatr. 2006 Jan 27;6:3.
- Australian Pain Society. Pain in residential aged care facilities: management strategies. North Sydney: Australian Pain Society; 2005.
- Cade CH. Clinical tools for the assessment of pain in sedated critically ill adults. Nurs Crit Care. 2008 Nov-Dec;13(6):288-97.
- Cintron A, Morrison RS. Pain and ethnicity in the United States: A systematic review. J Palliat Med. 2006 Dec;9(6):1454-73.
Last updated 5 May 2012