7th January 2024

Approach to assessment of pain

General principles

Pain management depends on identifying the underlying cause of the pain. Taking a good pain history is vital. The SOCRATES mnemonic can be a useful starting point for this:

• Site
• Onset
• Character
• Radiation
• Associated symptoms
• Timing and duration
• Exacerbating/alleviating factors
• Severity

A structured pain assessment tool captures many aspects of a person’s pain. There are validated tools which can help to track the patient’s pain over a disease course and also in response to interventions. These have been adapted for both children and adults in a number of languages. The Brief Pain Inventory (BPI) is one such validated tool. Patients outline the pain treatment they have received but also answer questions on a ten-point scale detailing the impact of the pain on activity, mood, work, relations with others, sleep, and enjoyment of life.

Examination of the patient is helpful. As discussed previously, hepatomegaly may point to a liver capsular pain, or sensory loss may suggest a neuropathic pain.

Reversible causes

Based on history and examination, investigations can be undertaken. This may seem counterintuitive. Often, patients are labelled ‘palliative’ or ‘TLC’ and deemed not for further investigation. However, many pains, even in patients with advanced disease, are the result of reversible pathology. Investigating and treating these can have a significant pain control function. For instance, a malignant pleural effusion can cause chest pain. This would be reversible with a pleural drain and pleurodesis. Performing a Chest X-ray could facilitate this. Alternatively, an X-ray may reveal a treatable pneumonia, and a course of antibiotics may give pain relief. More complex investigations, such as an MRI Spine for Metastatic Spinal Cord Compression, would also fall under this bracket, and treatment for the underlying disease – such as radiotherapy – may also be considered.

References

• The Brief Pain Inventory (BPI) [Internet]. [Cited 14/2/2022]. Available at: https://www.mdanderson.org/research/departments-labs-institutes/departments-divisions/symptom-research/symptom-assessment-tools/brief-pain-inventory.html