What is the recommended approach for grading and managing pain?

Pain Grading and Management

Pain assessment should begin with patient self-report using a 0-10 numerical rating scale to quantify current pain, worst pain in the past 24 hours, and usual pain, followed by a comprehensive biopsychosocial evaluation that extends beyond simple intensity scoring to include functional impact, pain characteristics, and patient-centered goals. 1

Initial Pain Assessment Framework

Pain Intensity Quantification

• Use a 0-10 numerical rating scale as the primary tool for quantifying pain intensity, asking specifically about current pain, worst pain in past 24 hours, and usual pain 1, 2
• For comprehensive assessment, also document worst pain in the past week, pain at rest, and pain with movement 1
• The numerical rating scale is more powerful in detecting changes in pain intensity than verbal categorical scales 2
• For patients unable to use numerical scales (cognitive impairment, language barriers, children), employ the Faces Pain Rating Scale or behavioral observation tools 1

Comprehensive Pain Characterization

Beyond intensity scoring, systematically evaluate:

• Pain characteristics: severity, type (nociceptive vs neuropathic), spread, quality (sharp, burning, aching, shooting), location, and radiation pattern 1
• Temporal factors: onset, duration, course, and factors that exacerbate or relieve pain 1
• Functional impact: what specific activities the patient cannot currently perform, rather than focusing solely on pain scores 1, 3
• Previous treatments: all prior pain therapies and their perceived efficacy, including over-the-counter and homeopathic remedies 1

Biopsychosocial Assessment Components

Physical/Biological Factors

• Underlying pathology: Differentiate between localized and generalized pain; assess current inflammation and joint damage as pain sources 1
• Physical disability: Evaluate physical activity, mobility, activities of daily living, social participation, general fitness (aerobic capacity, muscle strength, endurance), pain-related fear and avoidance of activities 1
• Sleep disturbance: Quantity and quality of sleep, whether patient feels refreshed on waking, sleep hygiene habits 1
• Obesity: Document presence as a contributing factor 1

Psychological Factors

• Beliefs and emotions: Psychological response to pain, psychological vulnerability factors, distress, psychiatric comorbidity 1
• Catastrophizing cognitions: Rumination, magnification, helplessness, fear of movement-related pain, pain self-efficacy 1
• Patient's understanding: Ideas and concerns regarding cause of pain, perceived control over pain episodes 1

Social Factors

• Social influences: How family members and significant others react to patient's pain or disability; work status; family and friends support; economic problems; housing 1
• Cultural and linguistic considerations: Be aware of impact that cultural and linguistic diversity may have during assessment 1

Stepped-Care Management Approach

Step 1: Education and Self-Management (All Patients)

• Provide educational materials (brochures, online resources) with encouragement to stay active and sleep hygiene guidelines 1
• Deliver psychoeducation by the health professional 1, 3
• Offer self-management interventions through online or face-to-face programs 1, 3

Step 2: Specialist Interventions (If Indicated)

Physical interventions:

• Physical activity and exercise show the most uniformly positive effects on pain across systematic reviews 3
• Refer to physiotherapist for individually tailored graded physical exercise or strength training if patient cannot initiate activity independently 1
• Orthotics and assistive devices (splints, braces, insoles, canes) for pain during activities of daily living that impedes functioning 1

Psychological/social interventions:

• Cognitive behavioral therapy is recommended as first-line non-pharmacological intervention for chronic non-malignant pain 3
• Refer to psychologist, social worker, or CBT program if psychological factors interfere with effective pain management 1

Sleep interventions:

• Provide education about good sleep hygiene practices 1
• Refer to specialized sleep clinic if sleep remains severely disturbed 1

Weight management:

• Explain that obesity contributes to pain and disability 1
• Refer to dietitian, psychologist, community lifestyle services, or bariatric clinic 1

Pharmacological management:

• Acetaminophen is the safest first-line option for musculoskeletal pain, up to 3 grams daily 3
• Gabapentin is first-line for neuropathic pain, titrating to 2400 mg daily in divided doses 3
• Avoid NSAIDs in patients with cirrhosis, kidney disease, or cardiovascular disease 3

Step 3: Multidisciplinary Treatment

• Consider multidisciplinary intervention if more than one treatment option is indicated (e.g., psychological distress combined with sedentary lifestyle) and monotherapy has failed 1

Monitoring and Reassessment

The "Four A's" Framework

Monitor treatment effectiveness using 1:

• Analgesia: Pain relief achieved
• Activities of daily living: Psychosocial functioning improvements
• Adverse effects: Treatment-related side effects
• Aberrant drug taking: Addiction-related outcomes

Monitoring Schedule

• Stable patients on strong opioids: Minimum six-monthly monitoring 1
• High-risk patients: Review within 6 months once management plan is agreed 1
• No improvement: Specialist assessment within 8-12 weeks if no sign of improvement 1
• Focus on functional goals: Assess achieving functional goals, decreasing pain severity, improving quality of life, and identifying adverse events 3

Special Populations

Nonverbal Patients

• Use behavioral observation as valid approach when self-report unavailable 1
• Combine direct observation, family/caregiver input, and evaluation of response to interventions 1
• For advanced dementia: Use validated tools like Pain Assessment in Advanced Dementia Scale (PAINAD) 1
• For intubated/unconscious patients: Use Behavioral Pain Scale (BPS) or Critical-Care Pain Observation Tool (CPOT) 1

Procedure-Related Pain

• Pretreat all procedures expected to cause discomfort with analgesic intervention 1
• Use multimodal approach including local anesthetics, physical approaches, and additional analgesics available for immediate titration 1

Critical Pitfalls to Avoid

• Never rely solely on pain intensity scores: Pain is multidimensional and requires assessment of functional impact and patient goals 1, 3
• Expect analgesic failure: Patient response is individualistic; only small cohorts respond to each analgesic, requiring trials with close monitoring and willingness to stop ineffective treatments 1
• Avoid undertreating high-risk patients: Early identification of patients at high risk for chronic disability allows more intensive management and reduces long-term disability 3
• Don't ignore underlying treatable causes: Providing only opioids for conditions like impending spinal cord compression without addressing the underlying pathology is inappropriate 1