Basics of Pain Control

Lydia Melek, Hany A.K. Dawood

Oral and Maxillofacial Surgery Department
Faculty of Dentistry - Alexandria University
Alexandria - Egypt
2020

About this article

One of the most important aspects of dental practice is the alleviation and control of pain. This article is a literature review
about the basics of pain control, added to them our own comments, explanations and drawings. It aims to helping dental
students understand the types of sensations, nerve impulses, pain pathway, pain mechanism, and the basic methods of
pain control to manage pain situations in the dental practice.
For more information about pain and anatomy subjects, refer to the Websites Section.1

Innervation
Innervation of the body
u Somatic Innervation
N Sensory
G General sensations
ê of condition (touch, pressure, pain, temperature)
ê of position and movements “Proprioception”
G Special Senses (vision, hearing, smell, taste, touch)
N Motor
G Voluntary
G Involuntary
u Autonomic Innervation
N Sympathetic
N Parasympathetic

Anaesthesia vs. Analgesia

an aesthe s ia an alge s ia
no sensation a case (state) of no pain a case (state) of

Nerve Impulses
The unit structure of the Nervous System is the nerve cell “The Neuron”. The Sensory Nerve Cell consists of a body 2 ,
peripheral nerve fibre (which terminates in nerve endings), and central nerve fibre which synapses3 with the next
neuron. The terminal nerve endings contain sensory receptors, which respond to sensory stimuli.4

Figure 1: The Neuron and The Nerve Trunk

1 In the PDF viewer, use the Bookmarks tab when you need them to go to a certain location.
2 The cell bodies of the first order sensory neurons are located in either the Trigeminal ganglia for the oro-maxillofacial region;
or the Dorsal Root Ganglia (alongside the spinal cord) for the rest of the body.
3 Synapse comes from “syn-haptein”; syn (together), haptein (to clasp).
4 Increasing stimulus intensity will result in more frequent nerve impulses to the brain, and increase in the number of nerve fibres stimulated;
thus increasing the intensity of the sensation.

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The resting nerve fibre is in a Polarized State5 . When stimulated, it becomes depolarized “Reversed Polarized State”.
This depolarization generates electric nerve impulses “action potentials” , which propagate (travel) through the nerve
fibre.6 When the nerve impulses reach the end of the axon of the pre-synaptic neuron, they cause the release of
neurotransmitters, which provoke new action potentials on the post-synaptic neuron.
The depolarized nerve fibre does not respond to any stimulation until it becomes repolarized and returns to the resting
condition again7 . The depolarization process takes 0.3 milliseconds, and the repolarization process 0.7 milliseconds.
So, each individual nerve fibre is in either a polarized or a depolarized state. This is The All or None Rule.
Nerves are collections of peripheral nerve fibres, having definite names, as the Trigeminal nerve, Mandibular nerve,
Lingual nerve, ...etc.

Figure 2: Polarized (Resting) (non-conducting) State

Figure 3: Depolarized (Reversed Polarized) (conducting) (Action Potential) State

Pain Definition
Pain is defined by the International Association for the Study of Pain as:
“An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or
described in terms of such damage.” Clinically, pain is “what the patient states it is”; it is then up to the clinician to
determine exactly what the patient means.

Pain is considered now as a part of the body’s defence system8 ; which triggers mental and physical behaviours to end
the painful experience.

Pain Pathway
For the pain signals (impulses) to reach the Pain Centre in the brain, they travel through 3 neurons.
• Pain stimuli, as from a carious lower tooth, will initiate pain impulses, which pass through the Inferior Alveolar Nerve
to the Mandibular Nerve to reach the Sensory Cell Bodies in the Trigeminal Ganglion.
• Then they are transmitted through the Descending Tract of the Sensory Root of the Trigeminal Nerve9 to the
Sensory Nucleus of the Trigeminal Nerve in the Medulla.10
• These impulses cross the midline11 , and pass through the Spino-Thalamic Tract, to reach the Pain Centre in the
Thalamus, where Pain Perception mechanism terminates.
• From the Thalamus, these impulses pass to the Cortex, from which Pain Reaction starts.

5 The outside of the nerve fibre is positively charged, while the inside is negatively charged.
6 A local analgesic agent prevents the propagation of the nerve impulses through the nerve fibres.
7 The sodium and potassium ions that do cross the cell membrane are pumped out again by the continual action of the sodium-potassium pump.
8 The defence system of the body includes: The intact skin, ciliated epithelium in the respiratory tract, secretions (gastric, tears, saliva),
immune system (WBCs, antibodies), reflexes (coughing, sneezing), vision, hearing.
9 The Ascending Tract carries the touch and pressure sensations (and ends in the Sensory Nucleus of the Trigeminal Nerve in the Pons),
while the Descending Tract carries the pain and temperature signals.
10 The Sensory cell bodies of Proprioception are located in the (Mesencephalic Nucleus of the Trigeminal Nerve) in the Midbrain.
11 at the level of the second cervical segment

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 Figure 4: Pain Pathway

Types of Pain
Sharp vs. Dull Pain
The feeling of sharp or dull pain depends mainly on the intensity of the noxious stimulus. This might be modulated by
many factors as the person‘s mood and previous pain experience.

Acute vs. Chronic Pain

Acute12 pain is associated with trauma or disease. It usually has a well-defined location, character and timing. It is
accompanied by symptoms of autonomic hyperactivity (as tachycardia, hypertension and sweating).
Chronic13 pain is usually regarded as pain lasting more than 6 months. It is due to a disease (as arthritis, diabetes, TMJ
dysfunction due to malocclusion), accident, surgery or infection that damage a nerve. Once damaged, the nerve may
send pain messages that are unwarranted (unprovoked). For example, diabetes can damage the small nerves in hands
and feet, leaving a painful burning sensation in fingers and toes.

Chronic pain may not be clearly associated with trauma or disease; or may persist after the initial injury has healed. Its
localization, character and timing are more vague than with acute pain. As the autonomic nervous system adapts, the
signs of autonomic hyperactivity associated with acute pain disappear. Some forms of pain regarded as being chronic
may consist of intermittent attacks of acute pain followed by relatively long pain-free periods.

Chronic pain might be associated with depression or anxiety, sleep deprivation, loss of appetite; with physical, psycho-
logical, social and functional deterioration, which contribute towards exacerbation of the pain. Early treatment of pain is
important, as unrelieved pain can have profound psychological effects on the patient. Acute pain that is poorly managed
can degenerate into chronic pain, which is much more difficult to treat. It is important to assess and treat the mental and
emotional aspects of the pain as well as its physical aspects.

12 Acute comes from a Latin word meaning “sharp, pointed, needle”.

13 Chronic comes from the Greek word chronos for “time”.

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Referred Pain
Pain arising from an area but “felt” in another area is called referred pain. Pain from one side of the body can always be
referred to a region from this ipsilateral side; and not to the opposite (contralateral) side.
This phenomenon results
• either from the close proximity of the nerve fibres to each other, which allows nerve impulses from one pathway to
pass to the other
• or when some nerve fibres synapse on the same secondary neurons which receive pain impulses from other fibres.

Descriptive Types of Pain

Pain might be described as: throbbing, shooting, stabbing (lancinating), burning, vague. For more information, refer to
[Appendix A]

Physiologic Types of Pain

Pain is not a simple phenomenon. It is a complex of biological, psychological, and sociological phenomena.
Pain has physical and/or psychological components.

l Organic Pain (due to a physical cause)

ä Nociceptive Pain: which is the pain caused by the activation of nociceptors in response to damaging or
potentially damaging (noxious) stimuli.
Tissue damage produces acidic medium, and releases chemical pain mediators (as Serotonin, Histamine,
Prostaglandins, Substance P); which are released also by trauma, infection, and allergic reactions.
The pain mediators induce inflammatory responses, and also sensitize (excite) nociceptors (increase their
sensitivity) so that they respond to low intensity or innocuous stimuli (touching the inflamed tissue produces
“tenderness”).
Nociceptive pain usually responds to treatment with conventional analgesics.

ä Neuropathic (Neurogenic) Pain: which is the pain initiated or caused by a primary lesion or dysfunction of
the nervous system.14 It is a clinical description not a diagnosis.

Neuropathic pain can be difficult to treat. It is associated with disturbance of sleep and mood, and it responds
poorly to conventional analgesics.

Neuropathic pain may result from:

• injury (trauma or surgery), or dysfunction of peripheral nerves or the central nervous system.
• CNS infection (as herpes zoster) (post-herpetic neuralgia)
• Trigeminal neuralgia15
• endocrine disturbances (as diabetes “diabetic neuropathy”)
• demyelination (as Multiple Sclerosis)
• Phantom Limb Phenomenon; which is a burning or shooting pain suffered by a person in a missing limb
following amputation.
This phenomenon occurs because the remaining parts of the nerve trunks, that connected the now absent
limb to the brain, still exist from the amputation site till the cell bodies in the dorsal root ganglia. They are
still capable of being excited. The brain continues to interpret stimuli from these fibres as arriving from
what it had previously learned was the “now absent” limb.
l Psychogenic Pain (due to a psychological cause)
The patient feels pain; but the cause is emotional rather than physical. Every possible reason must be ruled out,
including referring the patient to a Pain Clinic (with specialists in all medical fields), to diagnose the pain (by a
psychotherapist) as psychogenic.

14 This requires a demonstrable lesion or a disease that satisfies established neurological diagnostic criteria.
The clinical signs of neuropathic pain can vary greatly. It might be described as burning, tingling, shooting, stabbing or lancinating pain.
15 A non-noxious stimulus (as touch or a cold air draft) in the nerve distribution can elicit pain, which is often severe.

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Pain Mechanism
Pain is an Experience which depends on:
è Stimulus
à nature
à intensity
à frequency (duration)
è Location
Sensitivity differs in different areas of the body. Pain from cornea is not as from skin of feet. This is due to the
presence of
• different number of nerve fibres per unit surface area
• different number of nociceptors in the terminal nerve endings.
Not all tissues are sensitive to the same type of injury. Some tissues do not give rise to pain, no matter how they are
stimulated. For example, brain has no nociceptors, so intra-cranial operations can be done under local analgesia,
and the patient is conscious.
è Emotional Status (stress, apprehension, anxiety, fear, depression)
è Physical Status (fatigue, environment)
è Age and previous experience
è Motivation
è Gender
è Race

The Pain Mechanism involves 4 stages:

q Reception of stimuli and initiation of impulses in the peripheral nerve endings sensory receptors (nociceptors)
q Conduction of impulses through the nervous system
• electric impulses within the nerve fibres
• neurotransmitters in Synapses
q Perception (Recognition) and Modulation of pain through the release of neurotransmitters, which enhance or
inhibit pain impulses transmission.
• Excitatory neurotransmitters are produced in vesicles near the pre-synaptic neurons membrane. When stim-
ulated, they pass through the synaptic cleft to bind to post-synaptic receptors, exciting them, causing depo-
larization of the post-synaptic neuron.16 Pain inhibitors, as Endorphins and Enkephalins, block the release of
these neurotransmitters.
• Inhibitory neurotransmitters, as Dopamine and GABA17 , bind to the receptors in the post-synaptic neuron,
making its membrane more permeable to chloride ions (hyper-polarized); which make it less likely to depolar-
ize and generate action potentials.
q Reaction to the pain, which differs in different situations in the same person, and from individual to another.

Theories of Pain Mechanism

m Pattern (Intensity) (Quantitative) Theory (1800s)
m Stimulus-specific Theory (Von Frey 1894)
m Gate Control Theory (Melzack and Wall 1965)18
m Neuromatrix Theory (Melzack 2001)
16 Some neurotransmitters are broken down once they reach the post-synaptic neuron to prevent further excitatory or inhibitory signal transduction.
Others might diffuse away from their targeted synaptic junctions and are eliminated via the kidneys, or destroyed in the liver.
17 Gamma-Amino Butyric Acid
18 Ronald Melzack: a Canadian psychologist, Department of Psychology, McGill University, Montreal, Canada.
Patrick Wall: a British physiologist, Department of Biology, Massachusetts Institute of Technology, USA.

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Pattern (intensity) (quantitative) Theory
All sensations are transmitted through the same nerves, which have non-specific receptors. All afferent nerve fibre
endings (apart from those that innervate hair cells) are activated by all various stimuli. Pain is felt merely when they are
conducting far more impulses than usual; i.e. pain results from their excessive stimulation (too much pressure, heat, or
damage to the tissues).

Stimulus-specific Theory
This theory proposes that the peripheral nerve endings contain specific receptors that generate pain impulses, which
are carried out to a pain center in the Thalamus. In other words, the nerve endings of each specific peripheral nerve
fibre contain specialized stimulus-specific receptors, mechano-receptors, thermo-receptors, or nociceptors; which are
excited by a certain form of energy, mechanical, thermal or chemical, respectively; and transmit a specific sensation.
Nociceptors are also sensitive to extreme thermal or mechanical energy.

The first-order afferent nerve fibres are classified in terms of their structure, diameter, and conduction velocity (in
metre/second).

Gate Control Theory

Pain is not simply a direct response to a stimulus. There is a Gate Control System; and pain signals must pass through
“nerve gates” that open to allow them to get through, or close to prevent them from reaching the higher levels of the brain.
The Gate Control System is controlled through 2 mechanisms.
q It is possible for central nervous system activities (as attention, knowledge, expectations, beliefs, emotions, anxiety,
suggestions, and memories of prior experience) to exert control over the sensory input (Pain Perception).
The brain filters, selects and modulates sensory inputs. The nerve gates (located where the first and second order
neurons synapse) are sites at which dynamic activities (inhibition, excitation and modulation) occur.
Stimulation of the brain activates descending efferent fibres from Midbrain and Hypothalamus to release
Endorphins and Enkephalins, which suppress the incoming afferent nociceptive information (pain signals), by
shutting off the gates, at the earliest synaptic levels of the somesthetic system.
q Stimulation of the faster larger diameter non-nociceptive nerve fibres (A-alpha and A-beta), transmitting tactile
sensations “touch and pressure”, crowd out the slower small diameter nerve fibres (A-delta and C) transmit-
ting pain signals;19 because like a road or a highway, the CNS tracks have limited capacity to transmit nerve
signals, and can handle only a limited number of them at one time. So, pain relief can be achieved when an injured
area is stimulated by rubbing, applying pressure, massage, TENS, and acupuncture.

Neuromatrix Theory
Pain is a multi-dimensional experience produced by characteristic “neurosignature patterns” of nerve impulses gen-
erated by a widely distributed network of neurons (neuromatrix) in the brain. The neurosignature for pain experience
is genetically determined by the synaptic architecture of the neuromatrix. It is adjusted (continually modified) by psy-
chological and sensory experiences, which only trigger and do not produce the neurosignature itself.
Injury does not only produce pain, it also leads to stress, which the body attempts to deal with. Physical injury and psy-
chological stress may produce lesions of muscles (myopathy, weakness, fatigue), bones (decalcification), and nerves
(neural degeneration), and suppress the immune system (autoimmune diseases as multiple sclerosis, rheumatoid arthri-
tis). These cumulative destructive effects change the neurosignature patterns and give rise to chronic pain.

19 They also stimulate the release of Endorphins to close the gate for them.

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Methods of Pain Control
Pain could be controlled through the following methods:
è Removal of the cause (surgical methods)
Every effort should be made to diagnose the painful situation. Effective pain relief is achieved by treating the cause
not only the symptoms.
è Blocking the pathway of pain impulses (using local analgesics)
è Raising the pain threshold (using general analgesics)
(pre-emptive, post-traumatic, implantation of spinal cord pumps)
è Using psycho-somatic methods, and physical rehabilitative interventions
à gaining the patient‘s confidence, explanation of procedures
à control of environment
à rest and support of the injured part
à relaxation, music, therapeutic exercises, and psychological, behavioural and cognitive recreational activities
à physical modalities “physiotherapy” as the application of: pressure, massage, heat, cold, ultrasound, and
nervous system stimulation techniques (as acupuncture and electricity)
à Therapeutic heat application
The physiological effects of heat are:
ß Relief of pain (analgesia) (stimulate thermo-receptors in A-delta fibres “afferent gate control”)
ß Mental and body relaxation (efferent gate control)
ß Reduction of muscle spasm, and increase flexibility of collagenous tissues
ß Increase in blood flow by vasodilatation, which accelerates healing and wash out accumulated metabo-
lites (including those that contribute to nociception). Heat is contraindicated for acute injuries, since
there will be an increased potential for oedema formation due to the increase in capillary permeability.
Methods of heat application
ß Hot packs, hot water bottles, hydrotherapy, heating pads, moist compresses, hot mouth wash
ß Ultrasound (high-frequency acoustic vibration converted to heat) “has deep heating effects on joints,
muscles, and bone”.
ß Shortwave (high-frequency electric currents converted to heat)
ß Microwave (electromagnetic radiation), Infra-red heating lamps
à Therapeutic cold application
Application of cold is the immediate treatment of choice to relieve pain after acute injuries (post-operative
and post-traumatic).
The physiological effects of cold application are:
ß Relief of pain (analgesia) (stimulate thermo-receptors in A-delta fibres “afferent gate control”)
ß Activates Brain Stem mechanisms to exert descending inhibitory influences that block pain signals
(efferent gate control).
ß Decrease of the inflammatory response and associated swelling (oedema), so decreasing the pro-
duction of pain mediators.
ß Reduction of local metabolic activity of underlying tissues, slowing nerve conduction, and reduction
of muscle spasm, by its direct effect on muscle spindle activity.
Methods of cold application
ß Cold packs
ß Ice massage
ß Vapo-coolant Sprays (Ethyl chloride, Fluoromethane) “for treatment of myofascial trigger points”
à Electro-analgesic Therapy (electrical stimulation for pain control “afferent and efferent gate control”)
ß Transcutaneous Electrical Nerve Stimulation (TENS), Transcutaneous Acupoint Electrical Stimulation
(TAES), Percutaneous Neuromodulation Therapy (PNT), H-Wave Therapy (HWT), and Piezo Electric
Current Therapy (PECT) “used to relieve pain through the delivery of electrical energy across the
surface of the skin”.
ß Electrogalvanic stimulation (EGS)
ß Electrical muscle stimulation (EMS)
ß Spinal Cord Stimulation (SCS) “produces an electric field over the spinal cord to control neuropathic
and some chronic pain syndromes”.
è Cortical depression (decreasing pain reaction) (using general anaesthetics, sedatives)

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Recommended Regimen for Pain Control
è Pre-emptive vs. Post-operative Analgesia
Treatments to control post-surgical pain are often best started before injury activates peripheral nociceptors and
triggers central sensitization.
The hypothesis of pre-emptive analgesia proposes that: Analgesia administered before the initiation of painful
stimuli will prevent or reduce the “memory” of pain, and subsequently the analgesic requirements; in comparison
to the identical analgesic intervention administered after the painful stimuli begin.
è Combination of Agents vs. Single Agent
It is more effective for pain control to give a combination of analgesic agents than to give a single one.
A combination will use lower doses of each of the combined agents, rather than using a high dose of a single
agent. This decreases the side effects of the agents used in small doses, and benefits from the synergy effect
between them.
è Regular Intervals intake vs. “When Needed” intake of Analgesics
It is more efficient to adopt the regimen of giving the analgesic medication at regular time intervals (every 4-6
hours), rather than using the “when needed” regimen and adjusting the dose according to the intensity of the pain.
This avoids the periods of “feeling pain”, thus eliminating the whole pain experience.

Agents used for Pain Control

è Non-opioid Analgesics (Paracetamol, NSAIDs)

à They affect the Thalamus (raise pain threshold and inhibit pain perception), without depressing the Cortex
(pain reaction) (not sedatives).
à They have no addiction potentiality.20
è Paracetamol “Acetaminophen”
à It is the first choice of analgesics for mild to moderate pain, taking in consideration the age and general
condition of the patient, with the fewest side effects. It does not develop tolerance. It does not produce
gastrointestinal upset. Very few patients are allergic to it.
à Unlike aspirin and NSAIDs, it does not have an anti-inflammatory effect.
è Non-steroidal Anti-inflammatory Drugs “NSAIDs” (Aspirin “Salicylates”, Ibuprofen, Voltaren)
à They have anti-inflammatory, analgesic, anti-rheumatic and anti-pyretic effects.
à They have a variety of side effects as gastrointestinal disturbances, and inhibition of platelet aggregation
(impaired coagulation, increasing surgical bleeding).
à In general, it is recommended that patients avoid taking over-the-counter NSAIDs for more than 10 days.

è Opioid Analgesics (Narcotics) (Morphine, Codeine, Tramadol)

à They affect the Thalamus, and depress the Cortex (pain reaction). So they produce analgesia and sedation.
à They have addicting potentiality.
à They have a significant number of side effects and complications, including sedation, dizziness, nausea, vom-
iting, constipation, hypotension, physical dependence, tolerance, respiratory depression, and hyperalgesia.
à They are mainly used for chronic severe painful conditions.
è Sedatives and Hypnotics (N2 O & O2 , Barbiturates)
à They depress the Cortex (pain reaction).
à Barbiturates are used as sedatives, hypnotics or general anaesthetics, according to the dose.
à They have no analgesic effect, but they potentiate analgesics.
à At low blood level, the patient is calm and cooperative (sedated) (Hypothalamus depression).
As blood level increases, they cause drowsiness. Then the patient becomes uncooperative and over-reactive
to stimulation (especially pain), due to loss of self control and over-emotion (can’t follow commands as open
your mouth).
Then they cause hypnosis, unconsciousness, and subsequently medullary, respiratory and cardiovascular
depression.
20 Addiction is a “psychological dependence”.
Physical dependence is the development of an altered physiological state that is revealed by an opioid withdrawal syndrome
involving autonomic and somatic hyperactivity.
Pharmacologic tolerance is the reduced effectiveness (potency) of a given dose of medication over time, leading to ever-increasing
dose requirements and decreasing effectiveness over time.

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 è Tranquillizers (Valium “Benzodiazepine”)
à They are not analgesics. They reduce anxiety and apprehension (used for premedication).

è Anti-convulsants (Neuroleptics) (Carbamazepine)

à The first-line medications for neuropathic pain (as Trigeminal neuralgia)
è Anti-depressants (Amitriptyline “tricyclic agent”)

à They alter emotional response with significant sedation (used for the treatment of neuropathic pain, depressive
illnesses).
è General Anaesthetics
à They are mainly used for:
• major surgery
• mentally compromised patients
• uncontrollable apprehensive patients/children

Pain Glossary
Allodynia Pain in response to a stimulus which does not normally provoke pain. (non-nociceptive stimulus, as touch,
light pressure, moderate cold or warmth, vibration).21
Anaesthesia Absence of all sensory modalities.
Analgesia Absence of pain in response to stimulation that would normally be painful.
Hyperaesthesia increased sensitivity to stimulation, excluding the special senses.
Hyperaesthesia to painful stimulus is hyperalgesia
Hyperaesthesia to touch is allodynia
Hyperalgesia An increased response to a stimulus which is normally painful. (increased pain sensitivity)
Neuralgia Pain in the distribution of a nerve or nerves.
Neuritis Inflammation of a nerve or nerves. (it is a special case of neuropathy)
Neuropathy A disturbance of function or pathological change in a nerve.
Nociceptor A sensory receptor of the peripheral nervous system that is capable of transducing22 and encoding noxious
stimuli.
Pain-Chronic Pain that persists beyond the anticipated ‘expected’ time of tissue healing.
Pain Perception It is a physio-anatomical process by which pain is received and transmitted by neural structures from
the end organs (pain receptors) through conductive and perceptive mechanisms.
Pain Reaction The patients‘ manifestation of their perception of an unpleasant experience.
Pain Threshold The minimum intensity of a stimulus that is perceived as painful.
The point at which a person becomes aware of “can recognize” pain.
Pain Tolerance Level The maximum intensity of a stimulus that evokes pain, and that a subject is willing to tolerate in
a given situation.
The greatest level of pain which a subject can tolerate.
Paraesthesia Abnormal sensation, whether spontaneous or evoked. (as pricking, tingling)
Stimulus Any physical energy (mechanical, thermal or chemical) that excites a receptor.
Noxious “Nociceptive” Stimulus A stimulus which is actually or potentially damaging to normal tissues.
Touching the skin with a needle is not damaging, so this is felt as touch. Piercing the skin with the needle is
damaging (noxious), so this is felt as pain.

21 Allodynia (other pain) involves a change in the quality of a sensation, whether tactile, thermal, or of any other sort.
22 Transduce: change or convert stimulus energy (mechanical, thermal or chemical) into electric signals (action potentials)

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Pain Assessment Tools
Pain is now considered to be the fifth vital sign, along with body temperature[O] , heart rate[P] , blood pressure[N] , and
respiratory rate[Q] . They are used to measure the basic functions of the body, to help assess the general physical health
of a person, and to detect or monitor medical problems. Valid and reliable assessment of pain is essential for the proper
diagnosis and management of the patient‘s complaint and condition. An inadequate pain assessment is one of the
most problematic barriers in achieving pain control. Inadequate pain control can lead to both physical and psycholog-
ical problems for the patients and their families. The initial patient assessment should include the patient interview,
comprehensive medical history (including pain history, medication and treatments review), physical assessment, and
psychosocial aspects of the patient and family environment.

Pain is a complex human experience with sensory (physical), functional (ability to work), emotional, cognitive, be-
havioural, social, and spiritual components. Because pain is a subjective, private personal experience, it is very difficult
to know precisely what someone else’s pain feels like; especially in persons who cannot describe or rate their pain, with
whom we cannot communicate well as: children, patients suffering cognitive impairment “learning disabled, mentally
compromised” or dementia, adults whose cognition is temporarily impaired by medication or illness, or sedated patients
in an ICU.

Pain assessment should include its location, onset, duration, description (type), intensity (severity), alleviating and re-
lieving factors, side effects (nausea, vomiting, inability to eat, ...etc.), and effect on the quality of life. Other factors should
also be considered as the patient‘s knowledge, education, skill level, readiness and willingness to learn, ability to adhere
to the treatment plan, and the patient‘s expectations and goal for both functionality and pain management.

Uni-dimensional pain intensity scales do not measure the other aspects or characteristics of pain. There are many
multi-dimensional tools proposed to assess pain, among other symptoms and body functions. Not all of these tools
can be used in all situations, or for all patients (according to age, mental/cognitive condition, ...etc.). The proper tool has
to be chosen for any specific condition, and it should be carefully explained to the patient. Some of the commonly used
tools in clinical and research settings are included in this article. Refer to [Appendix B] for explanation of the terms used.

Three main methods are currently used to measure pain:

1- Self-reporting measures: What a person is saying, using age-appropriate numeric, pictorial, or verbal scales. Both
verbal and non-verbal reports require a certain level of cognitive and language development for the person to understand
and give reliable responses.
2- Behavioural measures (observer-reporting): Assessment of what a person is doing (behaviour) using motor or be-
havioural responses, facial expressions, crying, sleep patterns, body postures, decreased activity, or eating.
3- Physiologic measures (observer-reporting): Assessment of bio-signals (changes associated with stress response) as
heart rate, blood pressure, respiration, Oxygen saturation, skin conductance, pallor, flushing or cyanosis, palm sweating,
muscle tension, and neuro-endocrine responses. They are generally used in combination with behavioural and self-
report measures, as they are usually valid for short-duration acute pain; and differ with the general health and age. In
addition, similar physiologic responses also occur during stress, which results in difficulty distinguishing stress versus
pain responses.

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The Numerical Pain Rating Scale
The Numerical Rating Scale (NRS) is a unidimensional 11-point measure of pain intensity in adults. It is easy to ad-
minister and has good sensitivity. The patient is asked to choose a number from 0 to 10, that best reflects the level of
pain intensity. The scale meanings should be thoroughly explained to the patient. The Mankoski Scale is one of the
explanations of the NRS.
Mankoski Numerical Pain Rating Scale
0- No Pain
Feeling perfectly normal.
Mild Pain

Annoying pain, but does not interfere with most daily activities.
The patient is able to adapt to the pain psychologically and with medication or devices as cushions.
1- Very Mild Pain
Very mild annoyance, like a mosquito bite or a poison ivy itch. Barely noticeable pain, with no limitations on daily activities.
No medication is needed.
2- Discomforting Pain
Mild annoying pain, like lightly pinching the fold of skin between the thumb and first finger with the other hand, using the
fingernails. No limitations on daily activities. Possible occasional twinges (sudden, sharp localized pain). No medication.
3- Tolerable Pain
Very noticeable and distracting pain; like an accidental cut, a blow to the nose causing a bloody nose, or a doctor giving an
injection. Most of the time the patient does not notice the pain, and will adapt and get used to it. Mild restrictions on daily
activities. “Over the counter” pain medication (as Aspirin, Acetaminophen, Ibuprofen) are effective.
Moderate Pain

Pain interferes significantly with many daily activities.

The Patient is unable to adapt to pain. It requires lifestyle changes, but patient remains independent.
4- Distressing Pain
Frequent pain, like an average toothache, initial pain from a bee sting, or minor trauma such as hitting the toe against a hard
surface. The patient notices the pain all the time; but if he is deeply involved in work or an activity, he can ignore it; but it is
still distracting. OTC analgesics are only effective for 3-4 hours. This pain level can be simulated by pinching the fold of skin
between the thumb and first finger with the other hand, using the fingernails, and squeezing real hard.
5- Very Distressing Pain
Continuous pain, such as a sprained ankle when standing on it wrong, or mild back pain. The patients notice the pain all
the time, and cannot ignore it for more than a few minutes; and they are so preoccupied with managing it, that their normal
lifestyle is limited. OTC analgesics may be effective for 3-4 hours. The patients can still manage to work or participate in
some social activities, but with effort. Temporary personality disorders (aggression, withdrawal, resisting care) are frequent.
6- Intense Pain
Strong pain that cannot be ignored for any length of time. It partially dominates the patient‘ senses, causing him to think
somewhat unclearly. It significantly interferes with normal daily activities, frequently causes confinement to bed or the house.
The patient can still concentrate, go to work and participate in social activities, but with difficulty. Opioid analgesics (as
Codeine) every 3-4 hours might be effective. Pain is comparable to a bad non-migraine headache, or back pain.
Severe Pain

The patient is disabled, unable to sleep or perform normal daily activities, or function independently.
7- Very Intense Pain
Severe pain that completely dominates the patients‘ senses and significantly limits their ability to concentrate, sleep, perform
normal daily activities, or maintain social relationships; but they can still function with great effort. The patients are effectively
disabled and cannot live alone. Stronger opioid analgesics are only partially effective. Pain is comparable to an average
migraine headache.
8- Utterly Horrible Pain[U]
Very severe pain that causes severe limitation of the patient‘s physical activities, and he can no longer think clearly at all.
The patient can only read and converse[D] with great effort. Nausea and dizziness set in as factors of pain. The patient has
often undergone severe personality change if the pain has been present for a long time. Suicide is frequently considered
deeply and sometimes tried. Pain is comparable to childbirth or a real bad migraine headache.
9- Excruciating Unbearable Pain
The patient cannot tolerate the pain, or even converse. He is crying out and/or moaning uncontrollably, with complete
limitation of daily activities requiring interventions or assistance by others. He demands strong pain killers or surgery, no
matter what the side effects or risk. There is no more joy in life whatsoever.
10- Unimaginable Unspeakable Pain
The pain is so intense that the patient is completely bedridden, severely confused, and will become unconscious shortly. It
requires emergency room treatment, generally with opioid injections. It is caused by severe accidents, as crushed hand.

Basics of Pain Control - 2020 11 / 22

Hochman Numerical Pain Rating Scale
The Hochman Scale is an another explanation of the NRS. As the Mankoski Scale, it uses descriptions of the patient‘s
pain and functionality at various levels, as well as the predicted efficacy of various medications at those levels.
Hochman Numerical Pain Rating Scale
0- No Pain.
1- Occasional pain effectively managed by Acetylsalicylic acid, Acetaminophen, Ibuprofen, one tablet, 3 times a day or less; or
by opioids. No limitation on activities of daily living.
2- Frequent pain, managed only by 1 or more tablets of Aspirin, Acetaminophen, Ibuprofen, every 4 hours; or by opioids. Slight
impairment of activities of daily living.
3- Frequent pain, not effectively managed by NSAIDs, requiring an opioid medication. Mild restriction on activities of daily living.
4- Frequent pain, moderately affecting activities of daily living; but still controlled by opioids.
5- Frequent or almost constant pain. Contained by opioids, but causing significant limitations on activities of daily living. Occa-
sionally causing the patient to be house or bed confined.
6- Constant pain, moderately contained by opioids; but with frequent limitations of activities of daily living. Frequently causing
the patient to be house or bed confined.
7- Constant pain, only partially contained by opioids at the doses prescribed; with continuous limitation of activities of daily living.
8- Constant pain, frequently disabling, making most activities of daily living difficult if at all possible.
9- Constant pain, un-contained by prescribed medications and doses; completely disabling of activities of daily living. Requiring
interventions or assistance by others. Preventing any form of employment and fully qualifying the patient for Social Security
Disability.
10- Intolerable pain requiring emergency room treatment, generally with opioid injections.

The Visual Analogue Pain Rating Scale

The Visual Analogue Pain Rating Scale (VAS) is a unidimensional measure of pain intensity in adults. It is presented as
a 10-cm-long horizontal line, anchored by verbal descriptors (words), usually ‘no pain’ (at one end) and ‘worst imaginable
pain’ (at the opposite end). It might have specific points along the line that are labeled with intensity-denoting adjectives
or numbers; such a scale is called Graphic Rating Scale (GRS).
The patient is asked to place a mark on the line to indicate the pain intensity level. A millimetre ruler is used to measure
the distance from the zero anchor to the patient‘s mark, to provide 101 levels of pain intensity; no pain (0-4 mm), mild
pain (5-44 mm), moderate pain (45-74 mm), and severe pain (75-100 mm).
The VAS is administered on paper23 or electronically. Mechanical VAS usually looks like a ruler with a red line on a slide
that can be moved by the patient on one side of the ruler, and scored by the nurse on the other side.
Patients with cognitive impairment cannot use it; since it requires the patient to have the ability to make a mark along the
line or move the slide on a ruler.

0 cm 10 cm
no pain worst possible pain

Figure 5: The Visual Analogue Pain Rating Scale and Ruler

23 caution is required when photocopying the scale as this can lead to significant change in its length

Basics of Pain Control - 2020 12 / 22

The OPQRSTUV Pain Assessment Tool
The OPQRSTUV Symptom Assessment Acronym[A] is a tool used to identify the symptoms in the event of an acute
illness.
OPQRSTUV Symptom Assessment Tool
O - Onset/Duration
When did it start? Is it present all the time or does it come and go (intermittent)? How long does it last? How often does it
occur? Is it worse at any particular time? What is its timing onset (sudden, gradual, or part of an ongoing chronic problem)?
P - Provoking/Palliative Factors
What causes it? What makes it better? What makes it worse? Aggravating and Relieving Factors (movement, rest, pressure,
other external factors).
Q - Quality
What does it feel like? Can you describe it (sharp, dull, crushing, burning, throbbing, shooting, stabbing “lancinating”, vague)?
R - Region/Radiation
Where did it start and where is its location now? Is it confined to one place? Does it spread or move to any other area? If so,
where to?
S - Severity
What is the intensity of this symptom (On a scale of 0 to 10 24 with 0 being none and 10 being worst possible)? Right now? At
best? At worst? On average? How bothered are you by this symptom? Are there any other symptom(s) that accompany this
symptom?
T - Treatment
What medications or treatments are you currently using? How effective are these? Do you have any side effects from the med-
ication/treatment? What medications/treatments have you used in the past? History including dosage, frequency, regularity.
U - Understanding/Impact on You
What do you believe is causing this symptom? How is this symptom affecting you and/or your family?
V - Values
What is your goal for this symptom? What is your comfort goal or acceptable level for this symptom (On a scale of 0 to 10 with
0 being none and 10 being worst possible)? Are there any other views/feelings/symptoms that are important to you or your
family? Patient beliefs about the meaning of pain, effectiveness of its treatments and consequences of drug therapies. Is there
anything else you would like to say about this symptom that has not been discussed or asked? Presence of clinically significant
psychological disorder e.g. anxiety and/or depression.

Wong-Baker Faces Pain Rating Scale

The Wong-Baker Facial Grimace Scale employs photographs or drawings that illustrate facial expressions or persons
experiencing different levels of pain severity. It is used for children who do not have verbal skills to express their pain
level. Six faces, numbered 0 to 5, are used.

Figure 6: Wong-Baker Faces Pain Rating Scale

Wong-Baker Faces Pain Rating Scale

Face 0- A happy face
No pain. Normal activity.
Face 1- A still smiling face
A very little (annoying) pain (hurts a little bit, can be ignored). Still normal activity.
Face 2- Not smiling face
Mild pain (hurts a little more). Neutral expression, able to play and talk normally. Can do most activities.
Face 3- Starting to frown face, pursed lips
Moderate (distressing) pain (hurts even more). Protective of affected area, limited movements, quite complaining of pain.
Unable to do some activities.
Face 4- Definitely frowning face
Severe pain (hurts a lot). No movements, especially of the affected part, looks frightened. Unable to do most activities.
Face 5- Crying face
Intolerable worst possible pain. Restless, unsettled, complains about lots of pain, cries inconsolably. Unable to do any activities.

24 Use the age-appropriate tool to determine the numeric score for the pain.

Basics of Pain Control - 2020 13 / 22

The Verbal Pain Rating Scale
The Verbal Rating (Descriptor) Scale (VRS) (VDS) is the least sensitive unidimensional pain measurement scale. It
lacks any written patient derived assessment. It comprises a list of adjectives, scored from 0 to 5, used to describe pain
intensity. Patients are asked to select the phrase that best describes the level of pain.
The most common 6 phrases used are: no pain, mild pain, moderate (discomforting[E] ) pain, severe (distressing[F] ) pain,
very severe (horrible) pain, and worst possible (excruciating[G] ) pain.

The McGill Pain Questionnaire

The McGill Pain Questionnaire (McGill Pain Index) (MPQ) is a multidimensional pain questionnaire for rating pain in
adults. The patients are presented with a list of 78 words (descriptors)25 , grouped into 20 categories (subclasses), to
respond to the question “What does your pain feel like?”. The patients are asked to select up to 3 words in groups 1-10;
2 words in groups 11-15; one word in group 16; and one word in groups 17-20 that most convey their pain response
(but not to select more than one word in each group). At the end they should have up to 7 words that will help describe
both the quality and the intensity of pain. The MPQ is scored by first counting the number of words selected, to obtain a
Number of Words Chosen (NWC) score. Then the rank values of the words chosen are summed to give a total Pain
Rating Index (PRI) score.

The (PRI) is based on the position (or rank order) of each adjective in a group. The first word in each group is given a
value of 1, the next one is given a value of 2, and so on. The rank values of the words are summed within each group,
to obtain a separate score for each dimension; as well as an overall value.
PRI-Sensory (PRI-S, score 0-42); PRI-Affective (PRI-A, score 0-14); PRI-Evaluative (PRI-E, score 0-5); PRI-Miscellaneous
(PRI-M, score 0-17); and PRI-Total (PRI-T, score 0-78).

The 20 categories form 4 major classes of descriptors which measure the 3 dimensions (qualities) of pain experience.
The sensory (subjective) (physical) (discriminative) dimension “42 items” (Groups 1–10) describes the sensory
qualities of pain “intensity, quality, nature, pattern”.
The affective (emotional) (psychological) (motivational) dimension “14 items” (Groups 11–15) describes the affec-
tive qualities of pain (including emotional aspects) in terms of tension, fear, depression, anxiety and autonomic properties
associated with the pain experience.
The evaluative (cognitive) dimension “5 items” (Group 16) is a 6-point Present Pain Intensity (PPI) scale which mea-
sures the magnitude (strength) of pain. It describes a summary of the overall pain intensity as : 0 (No Pain), 1 (Mild), 2
(Discomforting), 3 (Distressing), 4 (Horrible), 5 (Excruciating).
The miscellaneous category “17 items” (Groups 17–20) determines the properties of pain (sensory qualities).

The MPQ also includes 3 other measures:

1- Pain Location (sensory dimension). A drawing of the human body with both anterior and posterior sides, on which
patients indicate the areas that have pain. The number of pain sites is summed as an indicator of the sensory pain
dimension.
2- Pain Temporal Pattern (duration/timing) (sensory dimension). Patients respond to the question, “How does your
pain change with time?” by selecting from 9 words, categorized into 3 main pain patterns: continuous, intermittent, and
transient: 1-[continuous, steady, constant], 2-[rhythmic, periodic, intermittent], 3-[brief, momentary, transient].
3- Alleviating and Aggravating Factors (behavioural dimension). Patients respond to two open-ended questions,
“What kinds of things decrease your pain?” and “What kinds of things increase your pain?” (as: taking analgesic medi-
cations, movement, fatigue, tension, eating, heat, cold, weather change, pressure, sleep or rest, lying down, distraction
“TV, reading,...etc.”, music therapy).

A limitation of the MPQ is the rich vocabulary required for completion. Also, gender and ethnic differences may affect
the selection of pain descriptors. However, the interviewer can facilitate MPQ completion by providing the patients with
clear definitions of words during administration.

A simpler version is the Short-Form McGill Questionnaire (SF-MPQ), which consists of 15 words (11 words describe the
sensory component, and 4 words describe the affective component). Each word has 4 intensity scores: 0 (not marked),
1 (mild), 2 (moderate), and 3 (severe). The patients are asked to check the column that indicates the level of pain for
each word, or to leave blank if it does not apply to them.

The SF-MPQ also includes a pain map to locate pain, 1 item for PPI, and 1 item for a 10-cm visual analog scale (VAS)
for average pain. The PRI score range is from 0 to 45 (6-15 are termed mild, 16-25 moderate, and above 25 severe).
The PPI score range is 0 to 5; and the VAS index range is 0 to 10.
25 Pain descriptors were derived from recording the words used by chronic pain patients to describe their pain.
They were rank ordered by intensity by groups of physicians, patients, and students.

Basics of Pain Control - 2020 14 / 22

 The McGill Pain Questionnaire
Group 1 (Temporal): Flickering, Quivering, Pulsing, Throbbing, Beating, Pounding
Group 2 (Spatial): Jumping, Flashing, Shooting
Group 3 (Punctate Pressure): Pricking, Boring, Drilling, Stabbing, Lancinating
Group 4 (Incisive Pressure): Sharp, Cutting, Lacerating
Group 5 (Constrictive Pressure): Pinching, Pressing, Gnawing, Cramping, Crushing
Group 6 (Traction Pressure): Tugging, Pulling, Wrenching
Group 7 (Thermal): Hot, Burning, Scalding, Searing
Group 8 (Brightness): Tingling, Itching, Smarting, Stinging
Group 9 (Dullness): Dull, Sore, Hurting, Aching, Heavy
Group 10 (Sensory Miscellaneous): Tender, Taut, Rasping, Splitting
Group 11 (Tension): Tiring, Exhausting
Group 12 (Autonomic): Sickening, Suffocating
Group 13 (Fear): Fearful, Frightful, Terrifying
Group 14 (Punishment): Punishing, Grueling, Cruel, Vicious, Killing
Group 15 (Affective-Evaluative-Sensory Miscellaneous): Wretched, Blinding
Group 16 (Evaluative): Annoying, Troublesome, Miserable, Intense, Unbearable
Group 17 (Sensory Miscellaneous): Spreading, Radiating, Penetrating, Piercing
Group 18 (Sensory Miscellaneous): Tight, Numb, Drawing, Squeezing, Tearing
Group 19 (Sensory): Cool, Cold, Freezing
Group 20 (Affective-Evaluative Miscellaneous): Nagging, Nauseating, Agonizing, Dreadful, Torturing

McGill Pain Questionnaire Short Form

Mild Moderate Severe
1 Throbbing
2 Shooting
3 Stabbing
4 Sharp
5 Cramping
6 Gnawing
7 Hot-burning
8 Aching
9 Heavy
10 Tender
11 Splitting
12 Tiring-Exhausting
13 Sickening
14 Fearful
15 Cruel-Punishing

Figure 7: The McGill Pain Questionnaire and The Short-Form McGill Pain Questionnaire

Basics of Pain Control - 2020 15 / 22

The Brief Pain Inventory
The Brief Pain Inventory (BPI) is an interview (or even administered over the telephone) or self-report questionnaire,
used to to follow chronic pain patients receiving long term treatment with medications or interventions.

The BPI assesses 4 components: the severity of pain (sensory dimension), its location (on a body diagram), pain
medications and amount of pain relief in the past 24 hours or the past week, and how pain affects (interferes with) (its
impact on) the ability to function in daily life (reactive dimension).

Chronic pain usually varies throughout the day and night, and therefore the BPI asks the patient to rate their present
pain intensity ‘pain now’, and pain ‘at its worst’, ‘least’, and ‘average’ over the last 24 hours or previous week.

It measures pain-related functional impairment in 7 domains (aspects of life): Each one is scored from 0 (“no interfer-
ence”) to 10 (“interferes completely”). The overall BPI interference score is the mean of the 7 item scores:
(1) general activity
(2) mood (emotion)
(3) walking ability
(4) normal work
(5) relations with other people (social activity)
(6) sleep
(7) enjoyment of life

The BPI is available in two formats: The BPI short form, which is used for clinical trials; and is the version used for the
foreign-language translations; and the BPI long form, which contains additional descriptive items that may be clinically
useful. To download and get a permission to use The BPI, including the Arabic Language translation, go to “Choose
an Assessment Tool”, check the radio button of “Brief Pain Inventory”, click on “Continue” at the end of the page on the
website of The University of Texas, MD Anderson Cancer Center, Symptom Assessment Tools Order Form
(http://www3.mdanderson.org/depts/symptomresearch/)

Figure 8: The Brief Pain Inventory-Short Form

Basics of Pain Control - 2020 16 / 22

The FLACC Pain Assessment Tool
The FLACC Behavioural Pain Scale is used for patients who are unable to self-report pain. Each item is scored
from 0 to 2, which results in a total score between 0 and 10.
Scores are grouped as: 0 (Relaxed and comfortable); 1-3 (Mild discomfort); 4-6 (Moderate pain); 7-10 (Severe pain).

The FLACC Pain Assessment Tool

Facial Expression
0- Smiling, or no particular expression, has a relaxed face, eye contact and interest in surroundings.
1- Occasional facial grimace[I] or frown[H] , withdrawn, disinterested, has a worried look with mouth pursed.
2- Frequent to constant frown, quivering chin[R] , clenched jaw.
Leg Movement
0- Normal position or relaxed.
1- Uneasy, restless, tense, intermittent flexion/extension of limbs.
2- Kicking, or legs drawn up, pulled tight, exaggerated flexion/extension of limbs, tremors.
Activity
0- Lying quietly, normal position/activities, moves easily and freely.
1- Squirming[T] , shifting back and forth, tense.
2- Arched back, fixed position, rigid or jerking[L] , rubbing body part.
Cry
0- No cry (awake or asleep).
1- Moans[M] or whimpers[V] , occasional complaints.
2- Crying steadily, screams or sobs[S] , frequent complaints.
Consolability
0- Content[C] , relaxed, calm.
1- Reassured by occasional touching, hugging or being talked to, distractable.
2- Difficulty to console[B] .

The Functional Pain Scale

A simplified Behavioural Functional Pain Rating Scale (BRS) (FPS) assesses the impact of pain on daily activities.
0- No pain.
1- Tolerable pain, that can easily be ignored, does not prevent any activities.
2- Tolerable pain, cannot be ignored, and prevents some everyday activities.
3- Intolerable pain, cannot be ignored, interferes with concentration, but can use telephone, watch TV, or read.
4- Intolerable pain interferes with most tasks (as using a telephone, watching TV, reading), except taking care of basic
needs such as going to the toilet and eating.
5- Intolerable pain, unable to verbally communicate, rest or bed rest is required.

The Functional Activity Score

The patients are asked to perform an activity related to their painful area (for example, deep breathe and cough for
thoracic injury; or move affected leg for lower limb pain); and they are observed during the activity and scored A, B or C.
A- No limitation: means the patient‘s activity is unrestricted by pain.
B- Mild limitation: means the patient‘s activity is mildly to moderately restricted by pain.
C- Severe limitation: means the patient‘s ability to perform the activity is severely limited by pain.

The Quality of Life Scale

The American Chronic Pain Association (ACPA) Quality of Life Scale is a “Measure Of Function For People With Pain”.
This scale evaluates the ability to function, and the impact of pain on the basic activities of daily life (such as eating,
grooming, dressing, bathing, and transferring), rather than pain alone.
0- Non-functioning: Stay in bed all day. Feel hopeless and helpless about life.
1- Stay in bed at least half the day. Have no contact with outside world.
2- Get out of bed but don‘t get dressed. Stay at home all day.
3- Get dressed in the morning. Minimal activities at home. Contact with friends via phone, email.
4- Do simple routine or minor duties or tasks around the house. Minimal activities outside of home two days a week.
5- Struggle but fulfill daily home responsibilities. No outside activity. Not able to work/volunteer.
6- Work/volunteer limited hours. Take part in limited social activities on weekends.
7- Work/volunteer for a few hours daily. Can be active at least 5 hours a day. Can make plans to do simple activities on
weekends.
8- Work/volunteer for at least 6 hours daily. Have energy to make plans for one evening social activity during the week.
Active on weekends.
9- Work/volunteer/be active 8 hours daily. Take part in family life. Outside social activities limited.
10- Normal Quality of Life: Go to work/volunteer each day. Normal daily activities each day. Have a social life outside of
work. Take an active part in family life.

Basics of Pain Control - 2020 17 / 22

The Comfort Pain Scale
The Comfort Behavioural Pain Scale is used for persons who cannot describe or rate their pain. It measures distress by
relying on 9 indicators: alertness, calmness or agitation, respiratory distress, crying, physical movement, muscle tone,
facial tension, arterial pressure, and heart rate. Each indicator is scored between 1 and 5 based upon the behaviours
exhibited by the patient, who is observed for about 2 minutes. The sum of scores can range between 9 and 45. A score
of 17-26 generally indicates adequate sedation and pain control.
Comfort Pain Scale
Alertness
1- Deeply asleep
2- Lightly asleep
3- Drowsy
4- Fully awake and alert
5- Hyper alert
Calmness
1- Calm
2- Slightly anxious
3- Anxious
4- Very anxious
5- Panicky
Respiratory Distress
1- No coughing and no spontaneous respiration
2- Spontaneous respiration with little or no response to ventilation
3- Occasional cough or resistance to ventilation
4- Actively breathes against ventilator or coughs regularly
5- Fights ventilator, coughing or choking
Crying
1- Quiet breathing, no crying
2- Sobbing or gasping
3- Moaning
4- Crying
5- Screaming
Physical Movement
1- No movement
2- Occasional, slight movements
3- Frequent, slight movements
4- Vigorous movements
5- Vigorous movements including torso and head
Muscle Tone
1- Muscles totally relaxed; no muscle tone
2- Reduced muscle tone
3- Normal muscle tone
4- Increased muscle tone and flexion of fingers and toes
5- Extreme muscle rigidity and flexion of fingers and toes
Facial Tension
1- Facial muscles totally relaxed
2- Facial muscle tone normal; no facial muscle tension evident
3- Tension evident in some facial muscles
4- Tension evident throughout facial muscles
5- Facial muscles contorted and grimacing
Blood Pressure (MAP) Baseline
1- Blood pressure below baseline
2- Blood pressure consistently at baseline
3- Infrequent elevations of 15% or more above baseline (1-3 during 2 minutes observation)
4- Frequent elevations of 15% or more above baseline (more than 3 during 2 minutes observation)
5- Sustained elevations of 15% or more
Heart Rate Baseline
1- Heart rate below baseline
2- Heart rate consistently at baseline
3- Infrequent elevations of 15% or more above baseline (1-3 during 2 minutes observation)
4- Frequent elevations of 15% or more above baseline (more than 3 during 2 minutes observation)
5- Sustained elevations of 15% or more

Basics of Pain Control - 2020 18 / 22

PAINAD Assessment Tool
The PAINAD Behavioural Pain Assessment Tool is used for patients with Advanced Dementia26 , who are cognitively
impaired, non-communicative, and unable to use self-report methods to describe pain. It records behavioural indicators
of pain during activity. It is a 5-item observational tool, each scored 0 to 2, with total scores ranging from 0 to 10:
0 (No Pain), 1-3 (Mild), 4-6 (Moderate), 7-10 (Severe).
PAINAD Pain Assessment Tool
Breathing
0- Normal breathing27 .
1- Occasional labored breathing28 . Short period of hyperventilation29 .
2- Noisy labored breathing30 . Long period of hyperventilation31 . Cheyne-Stokes respirations32 .
Negative Vocalization
0- None33 .
1- Occasional moan or groan[J] . Low level speech with a negative or disapproving quality34 .
2- Repeated troubled calling out35 . Loud moaning or groaning. Crying.
Facial Expression
0- Smiling36 or inexpressive37 .
1- Sad38 . Frightened39 . Frown.
2- Facial grimace.
Body Language
0- Relaxed40 .
1- Tense41 . Distressed pacing42 . Fidgeting43 . Grunts[K] .
2- Rigid44 . Fists clenched45 . Knees pulled up46 . Pulling or pushing away47 . Striking out48 .
Consolability
0- No need to console[B] .
1- Distracted or reassured by voice or touch49 .
2- Unable to console, distract or reassure50 .

The Abbey Pain Scale

The Abbey Pain Scale is a brief assessment scale for people with dementia. The scale consists of 6 items, scored as:
0 (Absent), 1 (Mild), 2 (Moderate), 3 (severe); with total score: No pain (0-2), Mild (3-7), Moderate (8-13), Severe (14+).
1- Vocalization: as Whimpering, groaning, crying.
2- Facial expression: as looking tense, frowning, grimacing, looking frightened.
3- Change in body language: as fidgeting, rocking, guarding body part, withdrawn.
4- Behavioural change: as increased confusion, refusing to eat, alteration in usual patterns.
5- Physiological change: as temperature, pulse or blood pressure outside normal limits, perspiring, flushing or pallor.
6- Physical changes: as skin tears, pressure areas, arthritis, contractures, previous injuries.

26 Dementia is a broad category of brain diseases that cause progressive global deterioration of cognitive functioning. It is characterized by a long

term and gradual memory loss, personality changes and loss of other functions such as judgement, abstract thinking and language skills.
27 Normal breathing is characterized by effortless, quiet, rhythmic (smooth) respirations.
28 Occasional labored breathing: episodic bursts of harsh, difficult or wearing respirations.
29 Short period of hyperventilation: intervals of rapid, deep breaths lasting a short period of time.
30 Noisy labored breathing: sounds on inspiration or expiration. They may be loud, gurgling, wheezing. They appear strenuous or wearing.
31 Long period of hyperventilation: an excessive rate and depth of respirations lasting a considerable time.
32 Cheyne-Stokes respirations: Progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in a temporary

stop in breathing (apnea). The pattern repeats, with each cycle usually taking 30 seconds to 2 minutes.
33 None is characterized by speech or vocalization that has a neutral or pleasant quality.
34 Low level speech with negative or disapproving quality: muttering, whining, or swearing in a low volume. Complaining, sarcastic or caustic.
35 Repeated troubled calling out: phrases or words being used over and over in a tone that suggests anxiety, uneasiness, or distress.
36 Smiling: upturned corners of the mouth with a look of pleasure or contentment.
37 Inexpressive: neutral, at ease, relaxed.
38 Sad: an unhappy, lonesome, sorrowful, or dejected look. There may be tears in the eyes.
39 Frightened: a look of fear, alarm or heightened anxiety. Eyes appear wide open.
40 Relaxed: a calm, restful appearance. The person seems to be taking it easy.
41 Tense: a strained, apprehensive or worried appearance. The jaw may be clenched.
42 Distressed pacing: activity that seems unsettled. May appear fearful, worried, or disturbed. Pacing may be faster or slower than usual.
43 Fidgeting: Moving about restlessly as a result of nervousness, agitation, boredom or a combination of these.
44 Rigid: stiffening of the body. The arms and/or legs are tight and inflexible. The trunk may appear straight and unyielding.
45 Fists clenched : tightly closed hands. They may be opened and closed repeatedly or held tightly shut.
46 Knees pulled up: flexing the legs and drawing the knees up toward the chest. An overall troubled appearance.
47 Pulling or pushing away: Resists attempts of others to help. Tries to escape by yanking or wrenching free or shoving helpers away.
48 Striking out: hitting, kicking, grabbing, punching, biting, or other form of personal assault.
49 Distracted or reassured by voice or touch: Behaviour suggestive of distress stops when the person is spoken to or touched.
50 Unable to console, distract or reassure: the inability to sooth the person or stop a behaviour with words or actions. No amount of comforting,

verbal or physical, will alleviate the behaviour suggestive of distress.

Basics of Pain Control - 2020 19 / 22

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Websites for further reading

Click on the following links to visit them. In different sites, use the search box.
è International Association for the Study of Pain (http://www.iasp-pain.org)
à IASP Terminology (https://www.iasp-pain.org/terminology)
è European Journal of Pain (http://www.europeanjournalpain.com)
è Practical Pain Management Journal (http://www.ppmjournal.com)
è PainEDU (https://www.painedu.org)
è The American Academy of Pain Medicine (http://www.painmed.org)
è American Academy of Pain Management (http://www.aapainmanage.org)
è The American Chronic Pain Association (https://www.theacpa.org/)
è Medical News Today (http://www.medicalnewstoday.com)
à Pain/Anesthetics (https://www.medicalnewstoday.com/categories/pain)
è The Australian Pain Society (http://www.apsoc.org.au)
è The British Pain Society (http://www.britishpainsociety.org)
è The Canadian Pain Society (http://www.canadianpainsociety.ca)
è Wikipedia Encyclopedia Basic knowledge for different subjects (http://en.wikipedia.org)
è Gray‘s Anatomy of the Human Body (http://www.bartleby.com/107)
è Human Anatomy Online (http://ect.downstate.edu/courseware/haonline/index.htm)
è Loyola University, Stritch School of Medicine/Structure of the Human Body (Go to: Educational Resources)
à Learn Them (http://www.stritch.luc.edu/lumen/meded/grossanatomy/learnem/learnit2.htm)

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Appendix A: Some Descriptive Types of Pain Go Back

[a] Beating/Rhythmic/Pulsating/Throbbing: Beats rapidly or violently, as the heart, in a rhythmic contraction and ex-
pansion (in a uniform or regular repeated pattern).
[b] Cramping/Pinching: Feeling of becoming hard or tight. Compressing feeling.
[c] Dull “Blunt”: Having a very little intensity.
[d] Flashing/Flickering Pain: Sudden, intermittent, and severe brief episodes of pain moving unsteadily back and forth.
[e] Gnawing Pain: A sensation of dull, constant pain or suffering.
[f] Itching: An irritating sensation that makes one wants to scratch to relieve the feeling.
[g] Lacerating: Tearing or cutting.
[h] Nagging: To be a constant source of anxiety or annoyance. To keep in a state of troubled awareness or anxiety.
[i] Shooting: Hitting, striking. Coming into contact forcefully.
[j] Stabbing/Pricking: Feeling as if pierced (punctured) with a sharp point as a needle.
[k] Stinging/Tingling: A sensation of being tapped or poked lightly with many sharp-pointed objects “needles” (slight
prickles “piercing or pricking”).
[l] Tender: Sensitive or slightly painful as a result of pressure or contact that is not sufficient to cause discomfort.
[m] Torturing/Agonizing/Excruciating: To cause intense suffering or extreme unbearable pain.

Timing of Pain
[a] Brief/Momentary/Transient: Remaining for a brief time (short duration).
[b] Continuous/Constant/Steady: Happening all the time without stopping or interruption.
[c] Intermittent/Periodic: Having repeated cycles. Occurring occasionally, or at regular/irregular intervals.

Appendix B: Some terms used in the Pain Assessment Tools Section Go Back

[A] An acronym is an abbreviation formed from the first letter or first few letters of each word in a phrase; as LASER.
[B] Console: Psychological comfort, a sense of well being, content.
[C] Content: A state of satisfaction.
[D] Conversation: Social communication/interaction for interchange of information, ideas and feelings by means of
speech or sign language.
[E] Discomforting: Something that disturbs one‘s comfort (Comfort: A condition or feeling of pleasurable physical ease
or relief. A condition of well-being, contentment, and security). An annoyance. Causing worry or anxiety.
[F] Distressing: To cause strain, anxiety, or suffering.
[G] Excruciating: Very severe. Causing great mental or physical pain.
[H] Frown: A facial expression with the eyebrows brought together, forehead wrinkled, and corners of mouth turned
downward.
[I] Grimace: A facial expression, usually of disapproval or pain, with a distorted, distressed look. The eyebrows and
area around the mouth are wrinkled, eyes may be squeezed shut.
[J] Groan: To make a deep inarticulate involuntary sounds, often abruptly beginning and ending sound.
[K] Grunt: To produce deep throat sound.
[L] Jerking: To give a sudden quick motion, thrust, push, pull, or twist.
[M] Moaning: Producing a long, low sound; as aaaaah.
[N] Normal blood pressure for a healthy adult is 120/80 mm Hg.
[O] Normal body temperature for a healthy adult is 36.5–37.2 degrees Celsius (97.8–99 degrees Fahrenheit).
[P] Normal heart rate for a healthy adult ranges from 60 to 100 beats per minute.
[Q] Normal respiration rate for a healthy adult at rest ranges from 12 to 20 breaths per minute.
[R] Quivering: Shaking with a slight but rapid motion, twitching, tremor.
[S] Sob: To cry with a convulsive catching of the breath.
[T] Squirming: Twisting the body from side to side, as a result of nervousness or discomfort.
[U] Utterly Horrible: Causing absolute extreme fear.
[V] Whimper: To cry or make a series of low, faint sounds softly or intermittently.

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