Pain assessment

 Why ask about pain? 

• Children and young people often present because of pain symptoms rather than other red flags for musculoskeletal conditions (such as swelling and stiffness).
• Pain can continue even when disease activity appears to be well managed; it is important to ask explicitly about pain, rather than make inferences from the clinical examination.
• Not talking about pain does not mean that pain is not there.
• Make sure to give the impression that you have the time to listen, even when you are busy.
• Doing your own pain assessment is beneficial, even if there are reports from other healthcare professionals in the patient case notes. 

What to ask about pain?

• Always ask the child/young person about their pain directly; Proxies such as a parent or caregiver can be helpful but a proxy report only is of limited value.
• 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.
• Multi-dimensional assessment requires attention to intensity, location, qualities (e.g., throbbing, aching), emotion, frequency and pain interference or impact.
• A multi-dimensional pain assessment can be very useful and can make the young person feel heard (and understood) and also result in better pain management.
• Ask about pain at rest and provoked pain during activities and explore this. Consider mechanical or inflammatory features.
• 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?

• There are basic 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).
• Never ask for a pain score without having a narrative with the child about their score.
• 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., “This Dr is scary”) might affect the pain report that is given. 

What to do about pain reported?

• Pain management starts with a conversation about pain and it's assessment. 
• Pain can be thought of as ‘danger signalling’; it is helpful to let the young person know whether you think that they should try to ignore the pain signals or whether it should be acted upon. e.g., “This sort of feeling that you are describing is just due to X  - it will not cause long-term damage if you try to ignore it” or” If you have not done this sort of activity for a while you may feel a bit achy afterwards, it is nothing to worry about”.
• Give explanations for pain that match developmental level and involve parents where appropriate.
• Suggest specific pain relief strategies. There are many non-pharmacological options such relaxation techniques, distraction, positive imagery, coping skills or using specific techniques such as rubbing and heat or ice packs. Education about theory of pain and biological processes underpinning pain can also be useful.
• You may also suggest that they discuss with a carer or other health professionals if you think analgesic medication is warranted. There is a lack of good quality research evidence supporting effectiveness of medications in those with chronic pain; the usefulness of non-pharmacological options should not be overlooked.
• Significant emotional and intellectual changes occur during childhood and adolescence; there is need to rethink the approach to pain sometimes, even with individuals you have met often. 

PMM gratefully acknowledges the contribution of Dr Rebecca Lee, Manchester University, UK