Signs of pain in nonverbal patients

To map international experience in measuring pain a literature study was conducted using the Medline and Psychlit databases. We restrict ourselves to the review articles cited in Current contens and textbooks on pain in children published since 1986 to 1994. Publications in Dutch scientific journals on pain and its measurement in children were also examined

Pain and pain assessment in children

Definition of pain, types of pain and perception of pain. The most commonly used is the definition of the International Association for the Study of Pain (IAIB): "Pain is an unpleasant sensory and emotional experience accompanied by actual or potential tissue damage, or a condition whose verbal description corresponds to such damage"
Distinguish between acute, chronic and recurrent pain. Acute pain is caused by tissue damage, such as injury, illness, or invasive medical intervention. This pain is most common in children. Pain is termed chronic if it lasts longer than would be expected based on normal healing time. The scientific literature indicates periods from 3 to 6 months. In children, chronic pain is most often of an organic nature, such as pain due to cancer or arthritis. Recurrent pain is referred to as 3 or more episodes of acute pain within 3 months. These episodes may be due to diseases such as arthritis, but they may also be headache or abdominal pain without a detectable nociceptive (pain receptor) substrate. In this case, pain is associated with a stressful situation and is often observed in children whose parents have a history of such pain in their anamnesis
Melzack and Wall introduced "gate control theory", expanding the concept of pain from a purely sensory to a multidimensional phenomenon. At the physiological level, this theory shows, in particular, how emotions can influence the experience of pain. According to this theory, nociceptive information can be inhibited during transmission from peripheral nerve fibers to nerve fibers in the spinal cord. The authors describe this mechanism as a gate. When the gate is open, nociceptive information reaches the brain. When the gate is partially or completely closed, less information comes to the brain or it does not come at all. Peripheral processes (for example, when rubbing an injured part of the body) and central processes (for example, with an increased level of fear) can affect the transmission of pain information and cause a decrease or increase in pain

Rice 1. Egg Loesor;
The 4 circles represent a variable effect on the experience of pain. (Published with permission.)
Based on this theory, Melzack developed the first multidimensional pain assessment system, the McGill Pain Questionnaire. The multidimensional nature of pain can also be found in the oft-cited Loeser model. The "Egg of Loeser" consists of 4 circles that reflect the exchange interactions between nociception (an organic component of pain), sensation (registration by the central nervous system), experience (suffering from pain) and pain behavior. As the duration of pain increases, the components of experience and behavior increasingly influence how a person feels pain (Fig. 1)
Cognitive development and choosing the right way to assess the degree of pain
The choice of how to assess the degree of pain in addition to the type of pain is determined by the age and development of the child, clinical circumstances and cultural background. The subjective nature of pain makes it difficult to measure. This is especially true for those who find it difficult to put their pain into words. As a result, the treatment of pain in newborns until the early 1980s was rarely adequately performed, since it was assumed that due to the immature nervous system, they practically did not feel pain. The experiments of Anand et al., as well as Anand and Hickey, have changed these ideas. They showed that preterm infants after surgery with conventional minimal anesthesia developed significantly greater stress responses (defined as an increase in the concentration of catecholamines, growth hormone, glucagon, corticosteroids), had more postoperative complications, and had higher mortality than in the neonatal group. who received full anesthesia (fentanyl)

Table 1. adapted for Holland

"Scale Comfort", with the help of which the intensity of some reactions of the body

Clead state
Deep sleep
Light sleep
Clead and defeat
Status of increased readiness
Calm/excited
Calm
Slightly scared
Scared
Very scared
Panic
Blood pressure
Below baseline
All the time at baseline
Infrequent (1 to 3 times) increases of 15% or more over baseline
Frequent (more than 3 times) increases of 15% or more over baseline
Constantly increased by 15% or more from baseline

Better observational techniques have shown that newborns are sensitive to pain on a behavioral and emotional level and that their responses to noxious stimuli are influenced by biological and environmental factors. Preterm infants appear to be even more sensitive to pain stimuli than term infants. Based on these findings, McGrath and Unruh conclude that neonatal immaturity is not about the inability to experience pain, but the inability to communicate it. Under these conditions, cognitive (mental) development probably plays the most important role. Therefore, in young children, methods based on non-verbal behavioral research, in particular on the study of emotions, are often used. The facial expression study conducted by Ekman and Friesen was decisive.

Figure 2. Newborn facial expression: reaction to a heel prick.

Available non-verbal measures of pain in the absence of a "gold standard" are being explored by comparing results with other measures (eg physiological) and with expected changes in pain experience under anesthesia and over time after the intervention. In this way, their "constructive consistency" can be established, in other words, whether they measure what they are supposed to measure
A child in the period from birth to 3 years is in the phase of sensory-motor development; he thinks, so to speak, with his body. Therefore, behavioral observation is recommended as a method for assessing the degree of pain. The movement, position of the body, facial expression and the nature of the crying of the child are recorded (Fig. 2). Observation of behavior can be done directly or later using videotape. In the first case, this is usually done by specially trained nursing staff. At the same time, they check in advance whether their consistency in the estimates is acceptable (for example, weighted k _ 70; kappa is a statistical variable for measuring consistency between observers, taking into account the measure of random consistency)

Figure 3. Oucher scale. To assess the degree of pain, the child can choose one of the photographs of children's faces with and without increasing expression of pain.
(Copyright owned by Judith E. Beyer, R.N.,
Ph.D., University of Colorado Health Sciences Center School of Nursing, Denver, Colo, USA.)

Based on the Eastern Ontario Children's Hospital Pain Scale (OECH) for preterm (less than 37 weeks) and term newborns (from 37 weeks to 6 weeks after birth), the Neonatal Pediatric Pain Scale (NIPS) has been developed to record acute pain (from a needle) and pain-induced distress. To assess postoperative pain in Dutch children, Boelen van der Loo modified the FWDBVO. Facial observation forms the basis of the "Neonatal Facial Coding System" (NFCS) developed by Grunau and Craig to measure acute pain in newborns
In addition, in this age group, the degree of pain is judged on the basis of physiological changes, such as accelerated heart rate and high blood pressure, slow breathing, sweating of the palms and increased levels of catecholamines. Physiological measurements, however, require complex equipment, so they are used only when the child is already connected to this equipment, perhaps when used in an intensive care unit, for example. Optimal measurement of pain in this age group is possible using a combination of behavioral and physiological measurements. An example of such a combined method is the "Comfort Scale", which records the intensity of 8 reactions, such as alertness, calmness/arousal, body movements, muscle (face) tension, blood pressure, respiration and heartbeat. This scale has been developed for Holland and, together with other different methods of assessing the degree of pain, is currently being investigated in the intensive care unit of the Department of Pediatric Surgery of the Academic Hospital Rotterdam - Children's Hospital Sofia in cooperation with the Department of Pediatric Surgery of the Academic Medical Center in Amsterdam (Table 1; H. Koot message 1994 g.)
The cognitive level of children aged 3-7 years is such that they themselves can indicate pain. Their increased focus on the sensory leads to the fact that various sensory stimuli, for example, during a puncture of a vein, they experience more than older children. These irritants can be, for example, the smell of a disinfectant, a bright white coat and the intonation of the voice of a doctor giving an injection, the feel of a rubber glove on his hand, etc. Children of this age are often asked to express pain intensity in terms of color or drawing (projective methods) using, for example, the "Eland color tool" or the "Poker chip scale"
In this age group, the Oucher scale is also often used to measure pain intensity, and the child can choose from various photographs of baby faces (Fig. 3)
If the child is about 7 years old, more abstract intensity scales can be used to record pain
Pain intensity can , for example, expressed through words (verbal rating scale - VVO) or by crossing out numbers from 0 (no pain) to 10 (terrible pain; numerical rating scale - NVR). The downside of the SVO is that the interpretation of words can be different. The problems with the use of the SNR are that some people have a strong preference for one or another number. In addition, students tend to rate high numbers as "good" and low numbers as "bad". Another disadvantage is the low sensitivity. Therefore, the child is also sometimes asked to self-rate the pain from 0 (no pain) to, for example, 100 (unbearable pain; 101-item NNR). More sensitive than most verbal and numerical scales is the visual analog scale (VAS). It is a horizontal line 10 cm long, on which the child himself can indicate the intensity of pain with a dash, the assessment varies from "no pain" to "the worst pain imaginable. " VAS-type scales allow very accurate and reliable registration of both acute and chronic and recurrent pain. Additional advantages are that the scale is a sliding continuity and the sums constitute a scale of proportions so that they can be tested by parametric statistical methods
Subjective assessment of pain in this age group is often combined with standardized behavioral assessment methods; an example is the Behavioral Distress Observation Scale (BEDS), which monitors socially desirable responses. SNPD allows accurate and reliable recording of both pain and fear during bone marrow puncture
Children 7-12 years old have concrete-operational thinking. The ability to think abstractly in this age category increases, but, mainly in younger children, is still strongly associated with concrete ideas. In older children, the experience of pain, in addition to sensual ones, is often also associated with mental associations. Pain, for example, is not only "stabbing", but also something that "loses the good mood". Older children are also more likely to associate pain with loss of control over their own actions (eg, inability to participate in sports and school activities). In this age group, methods are used that, in addition to sensory, allow for an affective and evaluative assessment of pain, such as the McGill Pain Questionnaire adapted by Huijer Abu-Saad for Dutch children. The Varni/Thompson Pediatric Pain Inventory (VAP) is used to assess chronic and recurrent pain in children with rheumatoid arthritis. In addition to the quality and intensity of pain, PHB also registers the pain history of parents and the child and environmental factors
And in this age group, behavior is an important additional measure of pain assessment, as in the Procedural Behavioral Rating Scale-r (PPS-r) used for bone marrow and spinal canal punctures. abstract thinking. He is able to think about such negative consequences of pain in the near and distant future as disability. In this age group, self-report methods are mainly used. For chronic or recurrent pain, VAS is an important part of the questionnaires. In addition, a child suffering from such pain can use a pain diary, in which, in addition to the intensity of pain, he can also record other, probably important information, such as the use of medications, the time of the onset of pain and his activities before it began, indicate what interference this causes him pain. Diaries are currently mainly used in the Netherlands and abroad in the study of pain in young patients with migraine
In this age group, it is also possible to use self-report methods that aim to assess such aspects of quality of life as functioning at school, activity at home, hobbies and social life. The scale for assessing the quality of life for patients with headache aged 12 to 17 years was developed by Langeveld et al. Table 2 provides an overview of methods for assessing the degree of pain

Lack of methods for assessing pain in children

Due to the large number of available methods, it may seem that further development of methods for assessing pain is futile. It is not right. For many patients, the available pain assessment methods are not suitable because they cannot adequately express the pain. This applies primarily to pain in newborns (especially premature ones) with congenital abnormalities, in which the degree of pain cannot yet be correctly assessed. In addition, their movements are often constrained by the abundance of modern life-sustaining medical equipment. It remains to be seen whether existing behavioral pain assessment methods are suitable for them or whether new tools need to be developed. This is also true for pain in a mentally or physically disabled child and for children from different ethnic groups
Most methods have been developed to assess acute pain. The question is whether they are also valid for recording long-term or chronic pain when some signs, in particular movement, are less pronounced
A large number of methods have been developed to assess the quality of life in adults, while there are still few available methods for recording the quality of life in children. There is a great need for methods to record the impact of recurrent and chronic pain, for example, on social functioning, school achievement, and the overall well-being of a child in pain

Conclusion

Over the past 10 years, there has been increasing attention in the Netherlands both to assessing the degree of pain in children and to managing it. Pain assessment methods developed in the US and UK are usually adapted for the Dutch population. Currently, integrated projects are being carried out in various institutions in the Netherlands, the aim of which is to develop methods for measuring the degree of pain in children from 0 to 3 years. The development of methods for recording the quality of life of a child with chronic pain has also begun. When applying existing methods and developing new ones, it is necessary to remember all the time that many methods can be implemented within the framework of research, but they often require too much time and labor, and this makes their routine use in clinical practice impossible. When developing new methods, it is necessary to take into account the fact that pain assessment takes place in everyday life: at home, at school and in the hospital

Literature:

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19. Grunau RVE, Craig KD. Facial activity as a measure of neonatal pain expression. In: Tyler DC, Krane EJ, editors. Advances in pain research and therapy. New York: Raven Press, 1990:147-56
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Table 2. Different ways of assessing the degree of pain in children (according to McGrath et al.)

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How to measure your own and others' pain. Scales and methods of pain relief

Pain is the most common symptom that occurs in any pathology: infections, coronary heart disease, rheumatoid arthritis and other diseases. The issue of anesthesia is especially acute in metastatic cancer. We tell you how to measure pain and learn how to manage it.

Illustration: Katya October

Types of pain

Pain evolutionarily helps us survive, respond in time to a cut, sprain, burn or injury. Pain can also be a sign of illness. If something hurts for a long time, we don’t know the cause of the pain and we can’t focus on daily activities - we understand that we need to go to a therapist or a neurologist.

At the appointment, the doctor usually asks to describe the pain and its nature, to tell in what situations and for how long it has been manifested, to show the location of the pain. Interestingly, the description of pain often depends on the field of activity of a person and his communication skills. The neurosurgeon of the Three Sisters clinic Mikhail Zonov says: “If there is a teacher, writer, artist or philosopher at the reception, then the pain in the description acquires a bright emotional coloring: “it looks like an iron burn”, “tingles”, “shoots”, “whines”, "It's like goosebumps." It is more difficult to understand what a person means when he says: “It hurts, that’s all.”

Pain can be neuropathic (caused by disturbances in the structure and function of nerves), nociceptive (occurs when peripheral pain receptors located in organs are irritated) and psychogenic (provoked by emotional factors). If the pain occurs suddenly and unexpectedly, it is called acute. If it bothers you for several weeks or months - chronic. A patient may have several types of pain at the same time.

People with chronic pain may be encouraged to keep a diary. In it, the patient records the time of occurrence of pain, his feelings, as well as the intake of painkillers. Some experts believe that the diary helps to reduce psycho-emotional perception, to understand the duration of the prescribed drug, others believe that this fixes the patient on his own world of pain.

In the treatment of pain, doctors use different methods: drug therapy (painkillers, antidepressants, muscle relaxants), targeted therapy (blockades), neuromodulation (using electrical or chemical effects on the nerve), surgery. In addition, to relieve pain, the doctor may recommend sports, massage, meditation.

Neurosurgeon Mikhail Zonov says that psychogenic pain is often found in patients: “In addition to pain, people usually experience difficulty in breathing, spasms, discomfort in the chest, a sensation of a lump in the throat. One of the indicators of psychogenic pain is if the patient says that pain from the neck radiates to the arms, legs and lower back at the same time. Patients with psychogenic pain syndrome need the help of a psychologist or psychotherapist. But often because people have preconceptions about psychotherapy, they end up on the operating table or receive months of treatment that doesn't work for them."

Not all people can report their pain, and this does not mean that they do not experience it. Perhaps an older person is embarrassed to talk about pain, because he is used to the fact that pain "must be endured." A person with progressive dementia who has lost the ability to communicate with others cannot communicate his feelings. The child may not talk about the pain, because he is afraid of the consequences (go to the hospital, doctors, injections).

It is important that loved ones pay attention to the well-being of their relatives and be able to recognize pain. The longer a person suffers pain, the more difficult it is to treat.

Illustration: Katya October

Pain scales

For adults

Feeling pain is always subjective. People in the same circumstances experience pain differently, not just because people have different pain thresholds. The sensation of pain is influenced by: accompanying emotional and mental disorders, social factors, traditions, habits, access to medical care. Medical anthropologists talk about a different "culture of pain" - someone is ready to endure pain at all costs, someone turns to doctors immediately after discomfort has arisen.

Special scales are used to assess pain. They can be used by doctors, nurses, patients themselves and their loved ones. Scales are selected depending on the age of the patient, his condition and cognitive characteristics. The most popular in the world is the visual analogue scale (VAS), which is a line of 10 segments, where zero means no pain, and 10 means unbearable pain. It is suitable for children who understand the meaning of numbers and adults.

Various scales are used for patients in the intensive care unit, including intubated patients (Behavioral Pain Scale). There are scales that are created for people with various complications and diseases. For people with dementia, the Doloplus 2 scale is used. When assessing pain, you need to pay attention to the position in which the person is at rest, whether sleep is disturbed, whether he allows hygiene procedures, and other indicators.

The Abbey scale is suitable for assessing pain in severe non-verbal patients. It should be used when a person is in motion, for example, during coups, eating or hygiene procedures. The following parameters are important: emitted sounds (crying, moaning, whimpering), facial expressions (tense, frowning), non-verbal signs (fidgeting, detachment), behavior (refusal to eat), physiological changes (sweating, pale skin, fever), physical changes (pressure sores, contractures, arthritis).

Neurosurgeon Mikhail Zonov: “The way a person evaluates his pain is influenced by his experience of experiencing pain in the past. I have had patients who, when they were clearly in severe pain, called 4-5 on the VAS scale. In the conversation, it turned out that these people treated their teeth without anesthesia. And there are patients who, it would seem, not with the most significant pain, called 5 out of 10 according to VAS. It may have been the worst pain of their lives."

Illustration: Katya October

For children

In children, it is difficult to assess the level of pain, especially up to three years. Instead of the word “pain”, the child can name words-definitions close to him, for example, “bo-bo”, and if you ask the child to point to the place of pain, most likely he will point to the stomach, even if his head or throat hurts. Children over 8 years of age are able to describe pain based on their experience, adolescents are able to talk in detail about the causes of pain and talk in detail about pain sensations.

NIPS - Neonatal Infant Pain Scale is used to assess pain in children under one year old. When using it, parents or medical workers are guided by the child's facial expression, crying, breathing, the position of the arms and legs, the state of consciousness. But the result on the scale will be only approximate.

Pediatric scales for older children are numerous. Here are some of them:

• Wong-Baker scale, where the child needs to choose a smiley face that is close to his condition. A sad emoticon hurts, a cheerful one does not hurt;
• Oucher Scale with photographs of children with and without increasing pain;
• Hand scale: if the child does not have pain, he should show his fist, if it hurts a little - one finger, and if the pain is severe - fully open his palm;
• Touch Visual Pain Scale for HIV-infected non-verbal children with multiple organ involvement;
• Eland body tool. The child determines the intensity of pain with the help of color: severe pain - red, moderate pain - orange, weak pain - yellow. The scale allows you to determine the location of pain.

It is important to understand that there are no ideal scales. Parents should pay attention to the behavior of the child: did the child eat today, did he refuse to drink, does he want to play or talk, does he cry, how natural is the position in which he is.

Pain is not a necessary companion of the disease

The issue of pain and pain relief is especially common in people with cancer. If at the initial stage of the disease, when the tumor is small and does not cause irritation of the receptors, there may be no pain, then with progression, severe pain may appear suddenly.

Pain may be associated with the formation of a tumor, its germination in the surrounding tissues, with damage to organs and nerves. In addition, pain may occur after surgery or be a reaction to chemotherapy. For a patient with oncology, the doctor should prescribe pain relief therapy according to an increasing scheme - from a weak analgesic to a strong one, depending on whether the prescribed drug worked or not. At the first stage of anesthesia are paracetamol and ibuprofen, at the second - tramadol, at the top - morphine and fentanyl.

Many myths are associated with the prescription of narcotic painkillers: “This is how you can become addicted”, “Pain is an obligatory part of the disease, you have to endure it” and even “Hair will fall out!”. Firstly, addiction can be avoided by proper selection of the drug and dosage, as well as gradual withdrawal if necessary. If a person has not abused drugs during their lifetime, then the risk of developing opioid dependence from treatment is minimal.

Secondly, pain cannot be (and almost impossible in oncology) tolerable, it worsens the work of the heart and digestive system, increases blood pressure and depresses the psycho-emotional state. A person in severe pain can only lie down and suffer from their sensations. Thirdly, hair loss in people with cancer is not associated with taking painkillers, but with receiving chemotherapy, and this is reversible.

If the patient follows the recommendations of doctors, he can lead an active life and not concentrate on the disease. Perhaps every evidence-based oncologist has a story about how he persuaded a patient to start taking morphine for a long time, the patient refused until the condition became very serious. And when he agreed, he cheered up, began to communicate with loved ones again, felt a return to life.

Text: Diana Karliner. The material was published in the fifth issue of the Three Sisters magazine.

The Three Sisters Clinic treats acute and chronic pain. We can arrange a consultation with our neurologist or neurosurgeon, perform pain relief procedures on an outpatient basis or offer a comprehensive pain management program that includes not only pain relief, but also physical therapy, massage, aqua therapy.