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Pain Assessment, Management and Patient Centered Care

Pain is believed to be a physiological phenomenon that informs people on the harmful effects that damage the body or pose a potential danger to it. Pain is the subjective awareness that is a result of transduction, transmission, and modulation of sensory stimulation refracted through the ‘filter’ of the genetic characteristics of and individual and previous personal experience. This perception undergoes further changes under the influence of the physiological state of a person, his or her ideas, expectations, mood at a given moment, and the sociocultural environment of its own neuro-matrix of the organism. Therefore, the measures that need to be taken for pain assessment and management are extremely necessary as they help denote the diagnosis and stimulate the improvement of the patient’s health.

The quantitative assessment of pain is vital for the adequate assessment of the severity of the condition, clarifying the amount of analgesic therapy, analyzing the effectiveness of treatment, and determining the degree of disability and the quality of patient’s life. Objectivization of pain is one of the most intractable problems in the practice of physicians of various specialties (de Vries, Sloot & Achterberg, 2017). One of the most important reasons for the ineffective treatment of pain is insufficient use of methods for measuring and assessing. The judgment about the intensity of pain is the most significant indicator at all stages of pain-relieving activities (von Baeyer & Pasero, 2017). The study of such a subjective symptom as pain cannot have an unambiguous interpretation by different people. Pain assessment and its management is a complex set of problems (de Vries, et al., 2017). Nowadays, a variety of questionnaires, scales and tables have been proposed for the analysis of pain sensations. Some of them are characterized with obvious simplicity while others, on the contrary, are too extensive and inconvenient, which makes it very difficult to use them in everyday clinical practice (von Baeyer & Pasero, 2017). The most reliable and generally accepted tools for assessing the quality and the quantity of pain in the world practice are scales or questionnaires filled by the patients themselves (von Baeyer & Pasero, 2017). Individual perception of pain is influenced by demographic factors, ethnic characteristics, gender, and age, as well as the emotional and physical state of the patient. In addition, the emergence of pain is closely related to social and psychological factors.

 

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The difficulties that arise when patients are trying to describe their condition complicate the diagnosis. These patients are subjected to numerous additional medical diagnostic tests. Objectivization of subjective sensations invariably encounters a number of obstacles. The main one is the contradictory nature of the opinions expressed about similar events (de Vries, et al. 2017). Social and biological factors are closely intertwined throughout the life of an individual, which forms a different approach to assessing of the condition, including the evaluation of pain (von Baeyer & Pasero, 2017). In practice, the foregoing is expressed in the existence of dissimilarities in the assessment of pain determined by the medical staff and described by the patient himself or herself (de Vries, et al., 2017). The lack of clear criteria and methods for pain sensation and measurement leads to frequent diagnostic, expert and deontological errors.

When assessing the pain, it is not enough to limit oneself to determining indirect signs of the intensity of pain on the part of physiological indicators or behavioral reactions of the patient. It is necessary to have information about the qualitative characteristics of pain and its effect on the main aspects of the patient’s life (von Baeyer & Pasero, 2017). The use of special pain assessment questionnaires allows quickly obtaining comprehensive information about the patient’s condition and also provides a focused and structured dialogue between the patient and the doctor (de Vries, et al., 2017). The choice of a tool for assessing pain is based on its suitability for a particular application. However, some of the existing questionnaires are inconvenient or difficult to understand by patients and not suitable for routine clinical practice (von Baeyer & Pasero, 2017). Other questionnaires have a pronounced ethnolinguistic specificity that makes it troublesome to translate them into other languages.

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A verbal rating scale is another way of assessing the options and the intensity of pain. This scale looks like a list of words from which the patient chooses those that most accurately reflect him or her pain. Patients also usually use a variety of descriptions to explain the degree of discomfort. Therefore, a verbal rating scale is equally needed both for employees of medical institutions and patients (von Baeyer & Pasero, 2017). A verbal rating scale, like a linear digital scale, facilitates the assessment of the degree of pain. In the literature, different types of verbal rating scale are described, varying from 4 up to 15 included points (de Vries, et al., 2017). Words are usually arranged in series according to the degree of the severity of the pain and are successively numbered from lesser gravity to greater (von Baeyer & Pasero, 2017). The use of a verbal rating scale has several advantages. It is easy to apply by just putting marks and adequately reflects the patient's condition and the effectiveness of the therapy (von Baeyer & Pasero, 2017). The data of the verbal scale are well-combined with the results of other measurements of pain intensity but poorly reflect the personal factors affecting pain. This scale reflects well the changes that have been made (von Baeyer & Pasero, 2017). Pain remains an individual sensation; therefore, verbal rating best identify the diverse nature of pain. Currently, a verbal rating scale is the most popular method for measuring pain. Unfortunately, this method has drawbacks (de Vries, et al., 2017). Most often, it is planned in the calculation of the increase in the strength of pain (von Baeyer & Pasero, 2017). Such an arrangement is explained by the fact that the scale was developed for persons subjected to pain in the conditions of the experiment and not for patients with spontaneously arising pains.

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To assess the pain sensitivity of patients and control the effectiveness of analgesia, clinical studies also use electrophysiological methods. The most common approach was the registration of a nociceptive withdrawal reflex or RIII-reflex (von Baeyer & Pasero, 2017). Nociceptive flexor reflexes are mainly associated with the activation of A-delta fibers. According to the classification of sensory nerve fibers, as stated by Lloyd-Hunt, these fibers belong to group III, hence the nociceptive flexor reflex is also called the RIII-reflex (von Baeyer & Pasero, 2017). Nociceptive flexor reflex allows objectively quantifying the pain threshold, determining the state of nociceptive and antinociceptive systems, and also examining the role and the influence of various neurotransmitters and medications involved in pain control (Finkelman & Kenner, 2016). Currently, there are and continue to appear new methods of instrumental and projection evaluation of painful sensations, the total number of which exceeds a hundred. A rather large number of approaches for assessing pain sensations have been developed, among which methods based on the presentation of intensifying pain stimuli are followed by fixation of the reaction with the help of biochemical analysis of blood plasma, saliva and other liquids (de Vries, et al., 2017). Recently, the methods of functional magnetic resonance and functional mapping of neuronal activity of brain structures in acute and chronic pain, such as positron emission tomography and have been increasingly introduced into clinical practice (von Baeyer & Pasero, 2017). These methods are based on recording in the brain structures of a local hemodynamic reaction, which has a positive correlation with the electrical activity of neurons (Finkelman & Kenner, 2016). With their help, it is possible to visualize the change in the activity of neurons in response to the effects, which enables studying the neurophysiological and neuropsychological mechanisms of pain.

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Chronic pain has a noteworthy effect on physical, emotional and intellectual functions. Assessment of such a kind of pain is more multifaceted and significant than assessing severe pain and requires an inspection of its history, physical inspection and specific diagnostic tests. A general medical history is important in the study of chronic pain. It is often possible to identify co-morbidities that contribute to the overall painful complex (von Baeyer & Pasero, 2017). Specific anamnesis should determine localization, intensity, dynamic and possible pathophysiological and etiological characteristics of pain.

In the world practice, methods of subjective and objective assessment of pain and determining the effectiveness of anesthesia are constantly being developed. Adequate assessment using carefully designed, tested and approved methods suitable for a particular patient is obligatory for the successful management ofpatients (Finkelman & Kenner, 2016). In many studies, it has been shown that an inadequate assessment of pain can lead to the administration of inadequate anesthesia (Finkelman & Kenner, 2016). Only regular and routine assessment of pain along with evaluation of other physiological parameters can provide sufficient information for a doctor treating a patient with a pain syndrome and, thus, allow the selection of adequate analgesia and the optimization of treatment.

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The effectiveness of anesthesia in a patient with a high level of personal anxiety is determined by descriptors: ‘it is very painful, the intervention is impossible’ and ‘it is painful, but the intervention is done’ (Finkelman & Kenner, 2016). As studies have shown, the simultaneous determination of the patient's psychoemotional state before the intervention and the degree of painfulness of the intervention allows more objective reflection of the clinical effectiveness of the anesthesia performed. Using this scale allows receiving the results of the effectiveness of anesthesia in percent, without the transfer of points in numbers. The proposed method can be used in studying new methods of local anesthesia.

Conclusion

The proper quantitative evaluation of the severity of the pain syndrome is the first step in a complex of pain management measures, which affects the effectiveness of anesthesia and the adequacy of the selected treatment. The use of modern methods for assessing pain should be routine practice in the daily work of the pain management service. Pain is the spiteful sensory and the emotional practice associated with true or potential tissue injury or described in terms of such harm. Determination of presence, localization, intensity of subjective pain sensations and clinical evaluation of the effectiveness of analgesia are of great importance; therefore, various methods of pain scales were developed (visual analogue scales, questionnaires and others). In clinical practice and in the conduct of scientific researches, it is crucial to evaluate various types of pain with conventional and easily accessible methods. Acute pain is short-lived, easily identifiable in terms of the cause of occurrence and stops with elimination of the cause. Chronic pain lasts more than three months, does not depend on its cause, and is difficult to treat.

 

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