Pain Assessment

Why ask about pain? 

• Pain is a common feature for children and young people with musculoskeletal conditions and can have a significant, long-term impact on function and quality of life.
• Pain does not necessarily correlate with disease activity, it is important to ask explicitly about pain rather than make inferences from the clinical examination.
• Untreated pain in children and young people can impact on the developing central nervous system leading to pain pathology such as altered nociceptor processing, central sensitisation or amplified pain.
• Ongoing pain can also have a long term impact on behaviours and/or beliefs about pain into adulthood.
• Doing your own pain assessment is beneficial, even if there are reports from other healthcare professionals in the patient case notes.
• Not talking about pain does not mean that pain is not there. 
• Asking about pain at every assessment allows evaluation of previous pain management and identification of any new and/or evolving pain.

What to ask about pain?

• Pain assessment is a multi-dimensional observational assessment of a child/young person’s experience of pain and should consider the type, significance and context of pain.
• Pain is subjective. Always ask the child/young person directly about their pain when possible; proxies such as parent or caregiver can provide useful additional information but ideally are not the primary source.
• Include objective clinical assessments to identify or rule out likely causes/contributors to pain such as active inflammation or joint damage.
• When talking to a child/young person about their pain consider their cognitive ability, environment, anxiety and cause. Encourage the child/young person to feel confident talking about their pain. 
• Ask the child to explain/give a narrative about their pain. Give consistent, short time frames (e.g., over the last week) and use consistent wording and tools.
• Ask about the impact on overall quality of life including physical and cognitive function, participation, sleep, fatigue, mental health.
• Ask about pain features to identify the type(s) of pain experienced - e.g., acute versus chronic, inflammatory versus biomechanical, neuropathic.
• Pain scales are useful tools as part of a broader assessment to start a conversation about pain. They should be appropriate to the age and developmental level of the child/young person. Pain scores can be compared over time to evaluate management.
• Ask the child a few unrelated questions to pain to gauge their developmental level; think about whether they have the skills to be able to reliably rate pain easily or whether they might need to be asked more questions to verify their answer.
• Encourage the child to talk about pain and put them at ease about the consequences of sharing pain experiences. Children can be scared to report pain if they feel it is going to lead to more painful procedures. A suggestion; “This will help me understand your condition better, so I can work out what is needed to help you”.
• Ask about pain at every appointment with the child/young person. 

How to ask about pain?

• SOCRATES is a useful basic checklist for a pain history.  
• Pain Assessment Tools.
• Multi-dimensional tools can provide useful information intensity, location, qualities (e.g., throbbing, aching), emotion, frequency and pain interference or impact. They also can make the young person feel heard (and understood) and also result in better pain management.
• There are basic uni-dimensional tools that are useful to start a conversation about pain; e.g., the visual analogue scale (aged 7 and above) or a faces pain scale (aged 4 and above).
• It may be easier to present a body image or mannikin if pain is in more than one area. Younger children may need assistance to identifying left and right sides of the body.
• Look out for both paper-based and electronic versions of tools; use them regularly with patients who will get used to seeing and rating their pain on the same tools.
• Use consistent time-frames for referencing pain e.g., if you ask a young person about their pain in the past few weeks, use this reference point at each visit. Use short time-frames. The shorter the time period, the better, such as last week or last few days. Use consistent anchor points for pain assessments and try to avoid phrases like ‘worst imaginable pain’ which can be interpreted very differently between children and young people. Anchors such as ‘a lot of pain’ or ‘severe pain’ are better.
• Ask the young person to keep some reports about how their pain is at home e.g., in a diary. If they do not have any pain, reporting that they had ‘pain free days’ can be very helpful.
• Sometimes the clinical environment or the young person’s perceptions about the person asking about pain (e.g., a consultation to be followed by a painful procedure such as blood taking may impact on their willingness to honestly report pain). 

What to do about pain reported?

• Pain management starts with a pain assessment.
• Management of pain will involve the multidisciplinary team. Optimal disease control with medicines is an important aspect of pain management due to infllammatory disease. 
• There are many non-pharmacological strategies which play a significant role in pain management, and developing self-management skills.