Tools
Pain Assessment
Introduction
Pain management clinicians across specialties recognize the impossibility of directly measuring pain or suffering in another person. However, this limitation does not eliminate the need for objective measures or their approximations. Pain is the most common complaint in primary care. More than 50 million individuals in the United States (US)—approximately 20% of the population—experience chronic pain, with prevalence increasing significantly among older adults.[1][2] Amid rising opioid use disorder, logical and adequate pain treatment remains critical. This reality underscores the importance of adjunctive agents defined by the World Health Organization that may reduce opioid reliance and the need to measure pain alongside the effects of these therapies.[3]
Pain assessment requires distinguishing acute from chronic pain; severe pain persisting beyond 3 months generally qualifies as chronic. This distinction proves essential, as chronic pain often reflects central nervous system dysfunction rather than peripheral nociception. Maladaptive changes such as hyperalgesia and allodynia become more common. Affected tissues develop a hypertonic, ropy, and cold texture, with pain sensations shifting from sharp to dull and achy.
How pain is assessed significantly influences patients’ long-term morbidity and mortality. Over 30% of patients report pain lasting longer than 6 months, highlighting the need for clinicians to employ multiple tools to characterize pain and improve symptom management accurately. Approximately 8% of adults and 6% of children experience chronic pain that substantially limits function and quality of life, with an overall 20.9% of adults in the US affected to some degree.[4][5]
Effective treatments differ among acute, chronic, centralized, and neuropathic pain types. Neuropathic pain affects roughly 10% of the US population and may respond better to serotonin-norepinephrine reuptake inhibitors, such as duloxetine, than to nonsteroidal anti-inflammatory drugs like ibuprofen in acute injuries.[6][7] Chronic pain ranks among the leading causes of disability and lost productivity in the US, resulting in billions of dollars in economic losses. Standardized pain assessment tools offer an objective means of monitoring symptoms and recovery over time.
An important aspect of pain assessment involves recognizing the impact of comorbidities and psychosocial factors that influence pain perception. Mood disorders exacerbate pain, and their treatment often leads to improvement in symptoms. A patient’s history of opioid dependence, intravenous drug use, sexual abuse, trauma, advanced age, chronic illness, and economic disparity also contributes to pain experiences. Cultural factors further influence the expression and response to pain.[8][9][10] Ultimately, integrating standardized testing, physical examination, psychological factors, including thought and mood disorders and their impact on perception, secondary gain, abuse history, and the emotional dimensions of pain and treatment response exemplifies how medicine combines art with science.
The Numeric Rating Scale (NRS) is a simple and widely used tool for quantifying pain intensity, where patients rate their pain from 0 (no pain) to 10 (worst possible pain). Despite its popularity, the NRS remains a crude and generic measure, lacking consistency and objective verification. This scale proves useful in certain contexts, such as assessing pain before and after sublingual nitroglycerin administration for cardiac angina, or evaluating simple fractures in older patients, where a pain rating of 4 may correlate with respiratory suppression.
However, the NRS has limitations. For example, patients with myofascial pain or uncertain diagnoses who report extreme pain (eg, 10/10) despite stable vital signs and evidence of analgesic administration may raise concerns for drug-seeking behavior. In cases involving an “aggressive escort” or a quiet patient, clinicians should note the language used, avoid assumptions, and maintain vigilance. Oral medications should be administered under supervision to prevent “sharing” or diversion, as “pocketing” pills for later use or trafficking is common. The presence of an escort dominating communication warrants careful assessment for potential abuse or trafficking.
The Visual Analogue Scale functions similarly to the NRS but may incorporate pictorial elements to assist patients who do not share the clinician’s language. This scale consists of a line with endpoints labeled “no pain” and “worst possible pain,” where patients mark their pain level. The score corresponds to the distance from “no pain” to the mark. The VAS shares the same limitations as the NRS.
The Wong-Baker FACES Pain Rating Scale is designed for pediatric individuals who may be nonverbal in acute settings and can also be adapted for use with adults who have communication difficulties. (Source: Wong Baker FACES History, 2016) The Nonverbal Pain Scale is particularly useful in intensive care units to assess pain in nonverbal adults, such as intubated but not fully sedated patients.
The Behavioral Pain Scale offers an observational method for assessing pain in patients who are sedated or unconscious.[11] This tool evaluates facial expressions, upper limb movements, and compliance with mechanical ventilation. Effective use requires considerable experience and interpretation within the clinical context, including the interpretation of vital signs. For example, tachycardia may indicate distress or resolution, depending on the patient’s medication, such as β-blockers or calcium channel blockers, which are commonly used among patients in the intensive care unit, regardless of ventilation status.
The Short Form Health Survey 36 consists of 36 questions assessing multiple health domains, including physical functioning, role limitations, bodily pain, general health, vitality, social functioning, emotional role, and mental health. Although not solely a pain assessment tool, it serves as an objective measure of quality of life in patients with chronic pain. This tool may be used to guide chronic treatment decisions. Opinions vary regarding its utility across different populations.[12] The common “squeeze my hand where it hurts most” technique is the worst tool.
The McGill Pain Questionnaire (MPQ) is a self-reported instrument designed to assess both the quality and intensity of pain.[13] This questionnaire presents 78 descriptors divided into sensory, affective, and evaluative categories, allowing patients to select words that best characterize their pain experience. The MPQ provides a quantitative measure useful for tracking pain over time and evaluating treatment effectiveness. The value of the MPQ lies in differentiating emotional-somatic descriptors such as “agonizing,” “dreadful,” and “torture” from sensory terms like “sharp,” “dull,” “throbbing,” or “constant.”
Anatomy and Physiology
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Anatomy and Physiology
Acute pain is primarily nociceptive, originating in the peripheral nervous system where pain receptors synapse in the dorsal horn of the spinal cord and transmit signals via the spinothalamic tract to the thalamus. When pain signals reach the central nervous system, action potentials are generated, and once a threshold is reached, pain perception occurs. Pain may also be neuropathic or centralized.
Pain becomes centralized when acute pain persists beyond 3 to 6 months, lowering the threshold for pain perception. Reduced thresholds pose challenges, as pain normally serves as an adaptive response to harmful stimuli. A lowered threshold results in pain triggered by non-painful stimuli (allodynia) or an exaggerated response to mildly painful stimuli (hyperalgesia). Centralized pain represents a maladaptive state.
Neuropathic pain results from dysfunction in the somatosensory pathways rather than the spinothalamic tract.[14] Centralized and neuropathic pain often coexist but are not mutually exclusive. Neuropathic pain may arise from peripheral or central origins. Both centralized and neuropathic pain represent functional gains and contribute to the development of chronic pain.[15][16][17] Pain treatment depends on its underlying pathophysiology. Some pain types respond to modulation of neurotransmitters or ion channels, while others are more responsive to opioid receptor-targeted therapies.
Indications
Pain is inherently subjective, making the biopsychosocial elements gathered during history-taking critical. For example, a stoic patient with acute pancreatitis may rate pain as 4 out of 10, while a more expressive patient with a wrist strain might report an 8 out of 10. Both ratings reflect valid subjective experiences.[18] Objective pain measures, particularly for chronic pain, provide a standardized framework for patients and clinicians, aiming to improve pain control and outcomes such as function and quality of life. A key initial step in pain assessment involves distinguishing nociceptive from neuropathic pain. Sharp or throbbing sensations typically indicate acute nociceptive pain, whereas burning, shooting, pins-and-needles, or electric shock–like qualities suggest a neuropathic origin.[19][20][21]
Contraindications
Pain assessment in patients is contraindicated. Various aspects of a patient’s life influence treatment decisions. For example, pregnancy often involves low back pain and complicates medication choices for chronic pain, especially opioid use.[22] Focusing solely on a numerical pain score proves inadequate. Patients often require prompting to explain their rating. A 1/10 typically reflects a minor bump or bruise, while 10/10 represents the worst pain experienced, comparable to childbirth or passing a kidney stone.[23] A complaint of 9/10 pain does not automatically justify opioid analgesia.[24] Less potent analgesics targeting the underlying cause may prove more appropriate.
Equipment
A body diagram map helps assess the location of a patient’s pain. In cases such as an ankle sprain—a solitary, acute injury—body diagrams may not prove necessary. Localized pain differs from widespread pain; however, patients with multiple comorbid pain disorders—such as fibromyalgia, centralized pain syndrome, and rheumatoid arthritis—present challenges in distinguishing pain locations and patterns of radiation. Despite this difficulty, body diagrams remain essential for guiding therapy. For patients with widespread pain, these maps assist in differentiating new complaints from chronic pain. For example, distinguishing a rheumatoid arthritis flare from reactivated knee osteoarthritis pain depends on careful mapping. Visceral and referred pain, particularly cardiac pain, vary widely in perception across demographics and sexual differences.[25]
A "fibromyalgia survey" can aid in differentiating new pain complaints from symptoms related to comorbid fibromyalgia versus conditions such as pancreatitis, lymphangitis, esophageal noncardiac chest pain, or depression-related pain flares. Clinicians must recognize that measuring pain and making a diagnosis are separate processes. Further, language barriers may complicate assessment; clinicians should understand the distinction between a translator and an interpreter.[26]
Personnel
Clinicians from any specialty, as well as physical therapists, occupational therapists, dentists, and respiratory therapists, can use various pain assessment tools. Primary care clinicians and specialists often need to review patients’ previous pain records comprehensively. These records typically include imaging, mental health therapies such as cognitive-behavioral therapy, surgical history, and prior medications.
For instance, if a patient with neuropathic pain due to diabetic peripheral neuropathy failed gabapentin therapy, the reason for failure must be documented. Nonpharmacological therapies also play a role. Obtaining records enables the identification of both successful and unsuccessful treatments. A translator or interpreter may be necessary, and many pain assessment tools can be converted online into multiple languages using search engines, translators, or artificial intelligence.
Preparation
The way a clinician approaches the patient, their receptiveness, and the empathy demonstrated significantly influence patient outcomes. The clinician–patient relationship has a lasting effect on pain improvement. Study results show that clinical support and empathy enhance both pain control and patient well-being.[27][28] Written pain assessments should be provided on a clipboard with a simple writing tool in a quiet space, ideally not the waiting room. The form must be legible, clear, and presented in the patient’s native language. Computer screens and tablets offer alternatives.
However, many older patients may prefer written forms over digital interfaces. Print size should accommodate individuals with visual impairments or those who wear corrective lenses. For illiterate individuals, trained staff, such as state-tested nursing assistants, medical assistants, or secretaries, can assist by explaining, “We are going over a pain questionnaire. I will ask questions, and you tell me the answers while I write them down.”
Technique or Treatment
Multiple acronyms guide pain history taking. Two commonly used examples include COLDERAS and OLDCARTS, which summarize character, onset, location, duration, exacerbating symptoms, relieving symptoms, radiation, associated symptoms, and severity. A multidimensional assessment provides more insight than a simple sensory-focused approach. Several tools enable a more comprehensive evaluation of pain, each with distinct strengths. Tool selection depends on clinical relevance, care setting (inpatient vs outpatient), and the chronicity or severity of pain.
The Pain, Enjoyment, General Activity (PEG) tool supports multidimensional assessment and emphasizes function and quality of life.[29] A patient with chronic pain reporting daily 7/10 pain may undergo treatment, both pharmacologic and nonpharmacologic, that reduces their pain to 5/10. The numerical change may appear small, but improvements in enjoyment, daily function, and life satisfaction suggest substantial progress. PEG assigns scores from 0 to 10 in each domain. Higher scores indicate worse function and less-controlled pain. This tool offers a quick, structured, and repeatable measure for tracking a patient’s pain and response to treatment over time.[30] Clinicians can apply PEG across care settings.
The 4-item Patient Health Questionnaire (PHQ-4) combines elements of the PHQ-9 and Generalized Anxiety Disorder (GAD)-7, screening for depression and anxiety, respectively.[31] All chronic pain evaluations should include PHQ-4. Scores above 5 warrant full assessment with the GAD-7, PHQ-9, and Primary Care Posttraumatic Stress Disorder Screen.[32] The Defense and Veterans Pain Rating Scale measures pain intensity (rated 0 to 10) and the impact of pain on sleep, mood, stress, and activity.[33]
In children, behavioral observation and self-report tools are used to assess pain.[34] Age-based scales are applied, often in conjunction with visual analog tools, such as facial expression charts, which are particularly useful with younger children. By adolescence, most can use a numerical scale like adults.[35] The Pediatric Pain Questionnaire and the Adolescent and Pediatric Pain Tool assess pain location; children draw on a body map to identify painful areas.[36] These tools are best suited for children aged 10 and older.
Observational pain assessment tools are suitable for patients who are unable to self-report their pain. Clinicians assess facial expressions, fussiness, distractibility, consolability, verbal responsiveness, and motor control. In infants and young children, the revised Face, Legs, Activity, Cry, Consolability tool provides a standardized approach to pain assessment.[37][38] Additional validated tools include the Neonatal Assessment of Pain Inventory, the Postoperative Pain Score, and the Pain Recovery Scale.[39][40][41][42]
In geriatric individuals, the Geriatric Pain Measure provides a 24-item questionnaire that addresses pain intensity, functional status, mood, and health service utilization over the preceding week. This tool helps uncover unmet needs, particularly in older adults with socioeconomic or functional comorbidities. Cognitive decline from dementia complicates pain assessment in older adults. Tools such as the Pain Assessment in Advanced Dementia, the Pain Assessment Checklist for Seniors with Limited Ability to Communicate, and the DOLOPLUS2 support pain recognition and management in these patients. While imperfect, current literature supports at least moderate utility for these instruments in dementia-related care.[43] Additionally, physiologic indicators can contribute to pain assessment. Examples include heart rate variability, oxygen saturation, and skin perfusion. These indicators vary in sensitivity and specificity. None should be used in isolation. A holistic approach, incorporating multiple data points and tools, provides more accurate assessments.[44]
Nonverbal children with neurologic impairment present a unique challenge. Caregivers play a critical role in identifying behavioral changes. Signs to monitor include grimacing, moaning, increased muscle tone, crying, arching, and atypical behaviors such as aggression. Validated tools for this population include the Face, Legs, Activity, Cry, Consolability tool, and the Individualized Numeric Rating Scale. These tools incorporate patient-specific behaviors that reflect pain in atypical presentations.[45]
Clinical Pearl
In cases involving patients who are intubated, semiconscious, or alert, where identifying the region of pain is critical to diagnosis, such as differentiating renal, visceral, or cardiac origins, a simple body diagram divided into 4 quadrants can assist with localization. The clinician can instruct, “Squeeze my hand when I point to the area that hurts most.” To verify understanding, a preliminary cue can be given: “Squeeze my hand when I say the number four.” Then state, “Three, nine, one, eight, four.” A correct response confirms comprehension. Acknowledgment helps build confidence: “Good, we’re on the same page.”
Alternative methods include blinking or indicating laterality, whether right or left, through hand squeezing. Once the general area is identified, such as the abdomen, a more detailed diagram can be used. The abdomen may be subdivided into 4 quadrants. The clinician can then point to each area sequentially, waiting for the patient to respond with a hand squeeze corresponding to the painful quadrant. No formal name exists for this method, but it remains a practical clinical technique. Pain descriptors may also guide this assessment. Patients can be instructed to squeeze upon hearing a word that best describes their pain, for example, burning, hot, dull, sharp, pounding, throbbing, stabbing, or aching.
Complications
A family history of mental health disorders, chronic pain, or substance use increases the risk of developing chronic pain.[46][47][48] Sleep hygiene, stress management, exercise, and diet have a significant influence on injury recovery but are often overlooked in pain management. Catastrophizing about pain can indicate severe and debilitating symptoms. The associated fear can become all-consuming, and paradoxically, this hyperfocus often intensifies the subjective experience of pain rather than alleviating it.[49]
Underserved communities face higher risks of chronic pain, substance use, and opioid dependence. Assessing pain requires awareness of practice location, as limited access to care and socioeconomic factors contribute to these disparities. Local culture and geography influence the prevalence of chronic opioid use. Pain assessment approaches must adapt for adults, children, individuals with disabilities, and people of advanced age.[50][51][52]
Failure to complete physical therapy after attending only 2 sessions for shoulder pain does not constitute treatment failure; rather, it reflects noncompliance. Assessing therapy effectiveness requires distinguishing between patients who discontinue treatment prematurely and those who complete all sessions but continue to experience persistent pain. Premature discontinuation often results from inadequate pain assessment. Observational assessments tend to underestimate pain compared to self-reported scores.[53] Additionally, factors such as hunger and stress can also influence the severity of pain.[54]
Clinical Significance
The long-term impact of 2 to 3 days of acute postoperative nociceptive pain is minimal compared to the enduring effects of centralized pain on a patient’s quality of life. A crucial part of the pain assessment involves categorizing the type of pain experienced. The way patients describe their pain is highly informative. Clinicians must ask whether the pain is burning or sharp, and whether it is constant or intermittent, as these descriptors provide valuable clues to understanding the nature of the pain. Examination findings can also help differentiate between different types of pain. For instance, symptoms such as allodynia or hyperalgesia suggest a centralized pain process rather than acute nociceptive pain.[55][56]
Clinicians must set clear therapy expectations and educate patients about their pain. Certain surgical procedures increase the risk of developing chronic pain. For example, breast surgery is associated with a higher likelihood of chronic pain than knee replacement.[57][58] Pain assessment is an ongoing process and should be conducted at every patient encounter. This practice helps refine the differential diagnosis and monitor the effectiveness of therapy, as well as changes in pain over time. Although chronic pain disorder serves as an appropriate diagnosis in certain cases, it does not apply universally to all patients with prolonged pain.[59] Addressing comorbid health conditions remains essential in managing all pain complaints.
Enhancing Healthcare Team Outcomes
Pain management plays a central role in many patient encounters and requires a structured approach to accurately identify and treat the underlying condition. Efficient and clear communication among healthcare professionals is crucial for developing a thorough diagnostic assessment and treatment plan. Numerous well-studied and validated tools exist to help the healthcare team understand the nature of a patient’s pain. Regular use of these tools helps gauge patient progress and guides care toward addressing the specific physiological causes of pain, which often present in recognizable patterns.
An interprofessional team providing a holistic, integrated approach to pain management can optimize patient outcomes. Identifying any specific underlying cause of pain remains a priority. The primary care clinician plays a crucial role in managing both acute and chronic pain, as well as associated comorbidities. Specialists, such as neurologists, pain medicine clinicians, and orthopedic surgeons, often collaborate as part of a comprehensive pain assessment and management team.
Palliative care and supportive medicine specialists, physical therapists, occupational therapists, and cognitive-behavioral therapists also play integral roles in pain assessment. Pain assessment tools apply across inpatient and outpatient settings and support management of diverse scenarios, including postoperative pain, palliative pain, acute injury, and chronic pain disorders. Effective pain management in both acute and chronic contexts leads to improved patient outcomes. Optimizing care requires integrating nonpharmacological, pharmacological, and interventional treatment approaches tailored to each patient.
Nursing and allied health staff provide essential support in evaluating patients' conditions at each encounter. In the inpatient setting, nurses interact with patients regularly, enabling early recognition of pain patterns and minimizing delays in care. This ongoing information guides clinical pain management and facilitates the development of personalized treatment plans that address individual patient needs. Collaboration, shared decision-making, and clear communication are essential for achieving successful outcomes. Interprofessional care should follow an integrated pathway combined with evidence-based planning and evaluation of all joint activities. Early identification of complications is associated with an improved prognosis. Thorough assessment and treatment of acute pain remain critical to preventing progression to chronic pain.
Nursing, Allied Health, and Interprofessional Team Interventions
Depending on the patient’s age and comorbidities, relevant questionnaires should be administered at the start of each visit. Consistent use of these tools allows providers to monitor changes in pain and related factors over time effectively.
Nursing, Allied Health, and Interprofessional Team Monitoring
Various pain assessment tools should be used at each visit to monitor changes in pain and evaluate treatment responses over time. Regular assessments enable timely adjustments to pain management plans, improving patient outcomes.
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