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Patients should be asked to describe their pain in terms of the following characteristics: location, radiation, mode of onset, character, temporal pattern, exacerbating and relieving factors, and intensity. The Joint Commission updated the assessment of pain to include focusing on how it affects patients’ function.

What are the types of characteristics of pain?

INSTRUCTION 1. Please read and listen to the text 2. Learn the new words 3. Do exercises 4.1. and 4.2.4. If necessary, revise the material Please read and listen to the text and learn the words in blue The most common subjective symptoms The most common subjective symptoms known only to the patient by his sensations are chill, malaise, lassitude, weakness and prostration.

One of the main subjective symptoms is pain which may be either mild and slight or bad, severe and even violent or excruciating. The pain may be of a stabbing, cutting, stinging, burning, boring, splitting, colicky, crushing, gnawing, nagging, gripping, scalding, shooting, or throbbing character. It may be dull or sharp, localized or general, persistent, recurrent or chronic.

Often it is radiating. Cramping is a type of pain that comes and goes (intermittent) or that changes in position or severity. Many women have cramping pain with their menstrual periods. Some other subjective symptoms are discomfort, restlessness and fatigue.

A patient may suffer from insomnia, somnolence and dizziness. Indigestion is often accompanied by nausea, anorexia and heartburn. Heart diseases are often characterized by palpitation, shortness of breath or dyspnoea and respiratory distress. Irritation of the skin causes itching. The most common objective symptoms The most common objective symptoms are fever, anemia, and sweating.

An upper respiratory infection is usually characterized by hoarseness, a sore throat, running nose, running eyes and sneezing. Most lung diseases are characterized by cough. Cough may be either productive with expectoration or dry and hacking. Gastrointestinal symptoms may be vomiting, diarrhea, constipation, regurgitation and salivation, while jaundice appears in hepatic diseases.

What is the defining characteristic of pain?

Faculty credentials/disclosure: – Regina Fink, RN, PhD, AOCN, is a research nurse scientist at the University of Colorado Hospital in Denver. Dr. Fink has held positions as oncology and pain clinical nurse specialist. She is co–principal investigator of a National Institutes of Health grant on palliative care and is on the speakers bureaus of Purdue Pharmaceuticals, Anestra Corporation, and Roxane Laboratories.

Before beginning this activity, please read the instructions for CME on p.321. This page also provides important information on method of physician participation, estimated time to complete the educational activity, medium used for instruction, date of release, and expiration. The quiz, evaluation form, and certification appear on pp.321–323 as well,

According to the International Association for the Study of Pain, pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage ( 1 ). Clinically, pain is whatever the person says he or she is experiencing whenever he or she says it occurs ( 2 ).

Pain is commonly categorized along a continuum of duration. Acute pain usually lasts hours, days, or weeks and is associated with tissue damage, inflammation, a surgical procedure, or a brief disease process. Acute pain serves as a warning that something is wrong. Chronic pain, in contrast, worsens and intensifies over time and persists for months, years, or a lifetime.

It accompanies disease processes such as cancer, HIV/AIDS, arthritis, fibromyalgia, and diabetes. Chronic pain can also accompany an injury that has not resolved over time, such as reflex sympathetic dystrophy, low back pain, or phantom limb pain. In the USA, 23.3 million surgical procedures are performed each year, and most, if not all, result in some form of pain ( 3 – 6 ).

Pain in persons with cancer also remains a significant problem, with studies suggesting that as many as 30% to 40% of cancer patients at diagnosis and 70% to 80% of cancer patients undergoing therapy or in the end stages of life have unrelieved pain ( 7 – 12 ). The Mayday Fund survey noted that pain is a part of life for many Americans, with 46% of respondents reporting pain at some time in their lives ( 13 ).

It has been estimated that 9% of the US adult population suffers from moderate to severe chronic nonmalignant pain ( 14 ). Despite the existence of evidence-based guidelines, acute pain is not adequately addressed by health care professionals ( 15 ). Suboptimal pain management is not the result of lack of scientific information, considering the explosion of research on pain assessment and treatment.

• Yet reports documenting the inability of health care professionals to use this information continue to appear in the literature.
• Studies have found that two of the chief barriers for health care professionals are poor pain assessment and lack of knowledge about pain ( 15, 16 ).
• Additionally, clinicians’ personal belief systems, attitudes, and fears can directly influence the manner in which they and their patients respond to the varied dimensions ofpain management.

Recognition of the widespread inadequacy of pain management has prompted efforts to correct the problems by a wide variety of organizations, including the Agency for Health Care Policy and Research, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the American Pain Soci-ety, and the Oncology Nursing Society.

The development of practice guidelines and standards reflects the national trend in health care to assess quality of care in high-incidence patients by moni-toring selected patient outcomes, as well as the assessment and management of pain. JCAHO surveyors routinely inquire about pain assessment and management practices and quality assurance activitiesin both inpatient and outpatient care areas.

Assessment of the patient experiencing pain is the cornerstone to optimal pain management. However, the quality and utility of any assessment tool is only as good as the clinician’s ability to thoroughly focus on the patient. This means listening empathically, believing and legitimizing the patient’s pain, and understanding, to the best of his or her capability, what the patient may be experiencing.

A health care professional’s empathic understanding of the patient’s pain experience and accompanying symptoms confirms that there is genuine interest in the patient as a person. This can influence a positive pain management outcome. After the assessment, quality pain management depends on clinicians’ earnest efforts to ensure that patients have access to the best level of pain relief that can be safely provided.

Clinicians most successful at this task are those who are knowledgeable, experienced, empathic, and available to respond to patient needs quickly.

What are subjective characteristics of pain?

Discussion: – MAP is expected to help clinicians validate pain reports as important and legitimate, regardless of other findings, and help our field develop more comprehensive, valid, and compassionate approaches to assessing pain. Key Words: pain assessment, qualitative methods, mixed-methods, patient communication, narrative medicine, medical ethics, brain imaging, definition of pain, compassionate care, mechanism-based management Pain is an enigmatic phenomenon that is challenging to treat and study.

1. One challenging attribute is its subjective nature.
2. Pain is defined as a subjective experience, 1 which means that it cannot be directly observed by those who are not experiencing it.
3. Yet, clinicians and researchers rely upon observations and measures to assess and infer the pain experienced by other people.

This raises the fundamental question of how the inherent subjectivity of pain can and should be addressed and integrated within its assessment. Current frameworks for guiding pain assessment do not adequately tackle this problem. For instance, biopsychosocial frameworks encourage a multidimensional approach to pain assessment.

However, they do not specify the different ways through which this assessment can be conducted. They also do not delineate how different forms of assessment relate to the subjective experience of pain. Different approaches to assessment include observing direct expressions of pain, such as the words and behaviors used by the person in pain.

They also include administering quantitative measures of pain, such as self-report questionnaires as well as physiological and psychophysical measures. The overwhelming emphasis in the pain literature is on quantitative methodologies. As a result, pain assessment strategies are typically focused on aspects of pain most readily communicated through numbers, such as pain intensity ratings or pain threshold levels.

Although quantitative pain measures are vital to understanding and targeting mechanisms and benchmarking management, they often overlook important attributes of the subjective experience, such as personal context and meaning, which can profoundly shape the experience of pain. Current models do not adequately emphasize what aspects of the pain experience can be uniquely accessed through more qualitative forms of assessment, such as talking, observing, and listening.

Previous reports show that patients with pain often do not feel listened to or understood by their health care providers.2 – 6 These findings highlight the need for assessment models that specifically emphasize how to address subjectivity related to pain.

1. Current models of pain assessment also fail to provide adequate guidance on what forms of assessment should be prioritized to best align with our conceptualization of pain as a subjective experience.
2. This creates ambiguity in what should be regarded as a root proxy for the pain experience.
3. Specifying an observable, root proxy for pain is an essential step in establishing a conceptual bridge between the nonobservable experience of pain and our assessment methodology.

Recent debate on how to best integrate physiological measures of brain activity within pain assessment illustrates the ambiguity in this area. On the one side, there have been calls for using measures of brain activity as objective biomarkers of the pain experience, 7 – 9 whereas on the other, self-report is prioritized as the best root proxy for pain.10, 11 Ambiguity in this area raises important challenges for people assessing pain.

For instance, when faced with discrepancies across different forms of assessment, clinicians report uncertainty in trying to decide which of their assessment findings should be relied upon as indicators for the nonobservable pain experience.12 – 16 Although there is preliminary consensus among leaders in brain imaging research that self-reports of pain should be prioritized over physiological measures, 17 there is still a lack of clarity in what this means for clinical practice and research.

For instance, what do we mean by self-reports of pain? If the intention is to support patient autonomy, should self-report measures be regarded on equal footing with direct narrative reports of pain? Also, from a research perspective, how should objective measures of pain be best anchored to more subjective forms of assessments? Assessment frameworks are needed to help inform decision-making around these questions.

1. Polarities of opinion in what should be regarded as a root proxy for pain emphasize the potentially competing pillars of what we value in pain assessment.
2. Objective measures of pain are valued, in part, for their usefulness in guiding mechanism-based management.7 – 9 Self-report is valued, in part, for its ability to support patient autonomy and to provide compassion-based care.10, 11, 18 Failure to support both of these pillars is associated with important risks.

For instance, failure to identify underlying pain mechanisms can result in, at best, a waste of time for the patient and clinician and, at worst, iatrogenesis by providing a rationale for potentially harmful treatments. Similarly, failure to validate pain reports and show compassion can increase patient distress, degrade therapeutic alliance, and undermine hope for improvement.5, 16, 19, 20 Current models of assessment do not provide adequate guidance on how to navigate these competing values.

Without guidance in this area, there is increased potential for conflating the validation of a pain experience with the identification of its underlying mechanisms. For instance, pain reports that can be linked to specific mechanisms may be validated as legitimate, while reports without clear links may be dismissed as spurious.

Not delineating these aspects of assessment raises the risk that people living with pain continue to feel stigmatized and alienated when certain findings from their assessment are used to invalidate their reports of pain.2 – 6, 20, 21 Assessment frameworks are needed to help establish criteria for both legitimizing pain and supporting the principles of mechanism-based management.

1. This paper introduces the multimodal assessment model of pain (MAP; Table ​ 1 and Fig.
2. ​ 1 ), a novel framework that aims to address these gaps by: (1) specifying a root proxy for the subjective pain experience; (2) characterizing how different assessment methodologies relate to pain subjectivity; and (3) offering frameworks to further integrate the subjective pain experience within pain research and practice.

The first sections of this paper aim to delineate MAP’s nomenclature, postulates, and applications to clinical practice and research. This is followed by a general discussion of how MAP relates to the broader literature and implications for future work.

What are the characteristics of pain physiology?

Figure 7-3 – The relation of discharge frequency in primary afferent nociceptors to subjective pain intensity in human subjects. Top left: The skin of human subjects was subjected to brief, calibrated temperature increases. Subjects began to identify the temperature (more.) Monitoring activity in identified primary afferent nociceptors is a potential tool for the evaluation of certain types of clinical pain.

1. In fact, this method has been used clinically to demonstrate pain-producing neural activity arising from a damaged nerve (Nystrom and Hagbarth, 1981).
2. At present, this method should be considered just a research tool; however, it is technically feasible and is of great potential value for evaluating pain patients.

It raises the possibility of actually demonstrating nociceptor activity coming from a painful area. This method could be an advance over other correlative techniques for assessing pain because it measures the presumed noxious input, that is, the neural activity that ordinarily causes pain.

1. Most of the other measures assess responses that could be, but are not necessarily, caused by noxious stimuli.
2. It is important to point out that (1) there can be pain without activity in primary afferent nociceptors, and (2) there can be activity in primary afferent nociceptors without pain.
3. These phenomena occur when there has been damage to the central or peripheral nervous systems.

In addition, the modulating system can suppress central transmission of activity elicited by nociceptor input. Thus, there is a variable relation between nociceptor input and perceived pain intensity. For this reason the method of recording primary afferent nociceptors could be used to confirm the presence of an input, but it could not be used to prove that pain was not present.

Besides these theoretical limitations of trying to assess subjective pain intensity by recording primary afferent nociceptors, there are important practical problems in measuring either pain-producing substances or primary afferent nociceptor activity. One is that the largest group of patients disabled by pain localize it to musculoskeletal structures in the lower back.

Because the nerves innervating these structures are not near the skin, they are difficult to find. Another problem is that pain arising from deep structures is often felt at sites distant from where the tissue damage occurs. In contrast to the pain produced by skin damage, which is sharp or burning and well localized to the site of injury, the pain that arises from deep tissue injury is generally aching, dull, and poorly localized (Lewis, 1942).

When the damage to deep tissues is severe or long lasting, the sensation it produces may be misperceived as arising from a site that is distant from the actual site of damage (Head, 1893; Kellgren, 1938; Lewis, 1942; Sinclair et al., 1948). This phenomenon, known as referred pain, helps to explain the frequent discrepancy between physical findings and patient complaints.

The mechanism of referred pain is unknown for any particular case. Referred pain can be a major source of confusion in the examination of patients complaining primarily of pain. The fact that pain is referred from visceral internal organs to somatic body structures is well known and commonly used by physicians.

For example, the pain of a heart attack is not always localized to the heart but commonly is felt diffusely in the chest, the left arm, and sometimes in the upper abdomen. Less widely recognized is the fact that irritable spots, such as myofascial trigger points, in skeletal muscles also cause feelings of pain in locations distant from the irritable spot.

This was demonstrated experimentally in muscle and fascia by Kellgren in the late 1930s (Kellgren, 1938). Specific patterns of pain referred from particular muscles have been described clinically (Travell and Rinzler, 1952; Travell and Simons, 1983). (See Chapter 10 and Appendix.) At least four physiological mechanisms have been proposed to explain referred pain: (1) activity in sympathetic nerves, (2) peripheral branching of primary afferent nociceptors, (3) convergence projection, and (4) convergence facilitation.

• The latter two involve primarily central nervous system mechanisms.1.
• Sympathetic nerves may cause referred pain by releasing substances that sensitize primary afferent nerve endings in the region of referred pain (Procacci and Zoppi, 1981), or possibly by restricting the flow of blood in the vessels that nourish the sensory nerve fiber itself.2.

Peripheral branching of a nerve to separate parts of the body causes the brain to misinterpret messages originating from nerve endings in one part of the body as coming from the nerve branch supplying the other part of the body.3. According to the convergence-projection hypothesis, a single nerve cell in the spinal cord receives nociceptive input both from the internal organs and from nociceptors coming from the skin and muscles.

The brain has no way of distinguishing whether the excitation arose from the somatic structures or from the visceral organs. It is proposed that the brain interprets any such messages as coming from skin and muscle nerves rather than from an internal organ. The convergence of visceral and somatic sensory inputs onto pain projection neurons in the spinal cord has been demonstrated (Milne et al., 1981; Foreman et al., 1979).4.

According to the convergence-facilitation hypothesis, the background (resting) activity of pain projection neurons in the spinal cord that receive input from one somatic region is amplified (facilitated) in the spinal cord by activity arising in nociceptors originating in another region of the body.

• In this model, nociceptors producing the background activity originate in the region of perceived pain and tenderness; the nerve activity producing the facilitation originates elsewhere, for example, at a myofascial trigger point.
• This convergence-facilitation mechanism is of clinical interest because one would expect that blocking sensory input in the reference zone with cold or a local anesthetic should provide temporary pain relief.

One would not expect such relief according to the convergence-projection theory. Clinical experiments have demonstrated both kinds of responses. This phenomenon of referred pain can present a serious problem to both patients and physicians when it goes unrecognized.

What are subjective characteristics of pain?

Discussion: – MAP is expected to help clinicians validate pain reports as important and legitimate, regardless of other findings, and help our field develop more comprehensive, valid, and compassionate approaches to assessing pain. Key Words: pain assessment, qualitative methods, mixed-methods, patient communication, narrative medicine, medical ethics, brain imaging, definition of pain, compassionate care, mechanism-based management Pain is an enigmatic phenomenon that is challenging to treat and study.

• One challenging attribute is its subjective nature.
• Pain is defined as a subjective experience, 1 which means that it cannot be directly observed by those who are not experiencing it.
• Yet, clinicians and researchers rely upon observations and measures to assess and infer the pain experienced by other people.

This raises the fundamental question of how the inherent subjectivity of pain can and should be addressed and integrated within its assessment. Current frameworks for guiding pain assessment do not adequately tackle this problem. For instance, biopsychosocial frameworks encourage a multidimensional approach to pain assessment.

However, they do not specify the different ways through which this assessment can be conducted. They also do not delineate how different forms of assessment relate to the subjective experience of pain. Different approaches to assessment include observing direct expressions of pain, such as the words and behaviors used by the person in pain.

They also include administering quantitative measures of pain, such as self-report questionnaires as well as physiological and psychophysical measures. The overwhelming emphasis in the pain literature is on quantitative methodologies. As a result, pain assessment strategies are typically focused on aspects of pain most readily communicated through numbers, such as pain intensity ratings or pain threshold levels.

• Although quantitative pain measures are vital to understanding and targeting mechanisms and benchmarking management, they often overlook important attributes of the subjective experience, such as personal context and meaning, which can profoundly shape the experience of pain.
• Current models do not adequately emphasize what aspects of the pain experience can be uniquely accessed through more qualitative forms of assessment, such as talking, observing, and listening.

Previous reports show that patients with pain often do not feel listened to or understood by their health care providers.2 – 6 These findings highlight the need for assessment models that specifically emphasize how to address subjectivity related to pain.

Current models of pain assessment also fail to provide adequate guidance on what forms of assessment should be prioritized to best align with our conceptualization of pain as a subjective experience. This creates ambiguity in what should be regarded as a root proxy for the pain experience. Specifying an observable, root proxy for pain is an essential step in establishing a conceptual bridge between the nonobservable experience of pain and our assessment methodology.

Recent debate on how to best integrate physiological measures of brain activity within pain assessment illustrates the ambiguity in this area. On the one side, there have been calls for using measures of brain activity as objective biomarkers of the pain experience, 7 – 9 whereas on the other, self-report is prioritized as the best root proxy for pain.10, 11 Ambiguity in this area raises important challenges for people assessing pain.

For instance, when faced with discrepancies across different forms of assessment, clinicians report uncertainty in trying to decide which of their assessment findings should be relied upon as indicators for the nonobservable pain experience.12 – 16 Although there is preliminary consensus among leaders in brain imaging research that self-reports of pain should be prioritized over physiological measures, 17 there is still a lack of clarity in what this means for clinical practice and research.

For instance, what do we mean by self-reports of pain? If the intention is to support patient autonomy, should self-report measures be regarded on equal footing with direct narrative reports of pain? Also, from a research perspective, how should objective measures of pain be best anchored to more subjective forms of assessments? Assessment frameworks are needed to help inform decision-making around these questions.

Polarities of opinion in what should be regarded as a root proxy for pain emphasize the potentially competing pillars of what we value in pain assessment. Objective measures of pain are valued, in part, for their usefulness in guiding mechanism-based management.7 – 9 Self-report is valued, in part, for its ability to support patient autonomy and to provide compassion-based care.10, 11, 18 Failure to support both of these pillars is associated with important risks.

For instance, failure to identify underlying pain mechanisms can result in, at best, a waste of time for the patient and clinician and, at worst, iatrogenesis by providing a rationale for potentially harmful treatments. Similarly, failure to validate pain reports and show compassion can increase patient distress, degrade therapeutic alliance, and undermine hope for improvement.5, 16, 19, 20 Current models of assessment do not provide adequate guidance on how to navigate these competing values.

1. Without guidance in this area, there is increased potential for conflating the validation of a pain experience with the identification of its underlying mechanisms.
2. For instance, pain reports that can be linked to specific mechanisms may be validated as legitimate, while reports without clear links may be dismissed as spurious.

Not delineating these aspects of assessment raises the risk that people living with pain continue to feel stigmatized and alienated when certain findings from their assessment are used to invalidate their reports of pain.2 – 6, 20, 21 Assessment frameworks are needed to help establish criteria for both legitimizing pain and supporting the principles of mechanism-based management.

This paper introduces the multimodal assessment model of pain (MAP; Table ​ 1 and Fig. ​ 1 ), a novel framework that aims to address these gaps by: (1) specifying a root proxy for the subjective pain experience; (2) characterizing how different assessment methodologies relate to pain subjectivity; and (3) offering frameworks to further integrate the subjective pain experience within pain research and practice.

The first sections of this paper aim to delineate MAP’s nomenclature, postulates, and applications to clinical practice and research. This is followed by a general discussion of how MAP relates to the broader literature and implications for future work.