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Investigations and pain management guidelines

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Tools, techniques and guidelines for acurate diagnosis in pain management

Healthcare professionals must be able to describe a patient’s symptoms, aided by the use of diagnostic tools and techniques (where appropriate or possible), with the aim of making an accurate diagnosis.

There are numerous definitions of pain that may assist healthcare professionals in reaching a diagnosis of the cause of a patient’s pain (see assessment article from this series).

The diagnosis of acute pain and interventions are usually simple, but this is not usually the case with chronic pain, as the processes of investigation, diagnosis and management are often complex and lengthy.

Investigations and diagnosis of the underlying cause of pain are components of the pain assessment process. There is no single ‘test’ for pain but numerous measures can be used. Table 1 lists some commonly used examples.

Table 1. Investigations used to diagnose the cause of pain

Biomedical

 

 

 

 

 

 

 

 

  • Medical history, history of pain and clinical examination (See assessment section)
  • Pain assessment tools
  • Clinical tests (including those to identify an underlying disease process, for example, radiography)
  • Physiological and biochemical measures including, heart rate, blood pressure, respiratory rate, arterial blood gases, catecholamine, cortisol, antidiuretic hormone levels.
  • Quantitative sensory testing (QST) for neuropathic pain.
  • This involves cutaneous stimulation tests for changes in tactile, vibratory, pressure and temperature sensations and pressure algometry to assess deeper muscle sensation.
  • Neurophysiological measures: including neurography to identify a peripheral nerve lesion and thermography to detect abnormalities in heat and cold perception
  • Intravenous drug challenges of analgesia may be used in combination with QST to provide more information about underlying pathophysiology
  • Nerve blocks
  • Changes in associated symptoms, for example, nausea or numbness as a result of pain management
Psychosocial
  • Emotion, for example, depression, anxiety, anger
  • Coping skills checklists can be used to assess a patients coping style as this may influence management strategies
Behaviour and activity
  • Observation of the patient, for example, physical performance
  • Has the patient consulted a doctor?
  • Quality of life measures
  • Measurement of satisfaction with pain management
  • Effects of pain on social function, for example, employment

Investigation and management

The use of strategies and techniques to investigate and diagnose pain are often guided by clinical practice guidelines (Box 1) and the expert opinion of the clinical teams.

There is no single evidence-based document for the management of pain, and it is not included in the Essence of Care.

However, there are many published audits, recommendations and clinical practice guidelines specifically about pain and many others that encompass pain as a component of a specific disease/problem, for example, sickle cell disease.

 

Box 1. Clinicalpractice guidelines for pain management

Clinical Resource Efficiency Support Team. (2008)Guideline for the Management of Neuropathic Pain
European Association of Urology. (2008)Guidelines on Chronic Pelvic Pain
Association of Paediatric Anaesthetists of Great Britain and Ireland. (2008)Good Practice in Postoperative and Procedural Pain
Royal College of Physicians, British Geriatrics Society, The British Pain Society. (2007).The Assessment of Pain in Older People
European Association of Urology. (2007)Guidelines on pain management
British Pain Society: (2007)Recommended Guidlines for Pain Management Programmes for Adults
Royal College of Nursing. (2007)Clinical Practice Guidelines: The recognition and Assessment of Acute Pain in Children
The Royal College of Anaesthetists, The Association of Anaesthetists of Great Britain and Ireland (2006)An Guide For Departments of Anaesthesia, Critical Care and
Pain Management.

NHS Quality Improvement Scotland. (2006)Best Practice Statement. Management of Chronic Pain in Adults
Australian and New Zealand College of Anaesthetists and faculty of Pain Medicine. (2005)Acute Pain Management: Scientific Evidence
Royal College of Anaesthetists. (2004)Good Practice in the Management of Continuous Epidural Analgesia in the Hospital Setting
Tissue Viability Nurse Association. (2004)Best Practice Statement. Minimising trauma and pain in wound management
British Association for Emergency Medicine (2004)Guideline for the Management of Pain in Adults
British Association for Emergency Medicine (2004)Guideline for the Management of Pain in Children
NHS Quality Improvement Scotland. (2004)Best Practice Statement. Postoperative Pain Management
NHS Quality Improvement Scotland. (2004)Best Practice Statement. The Management of Pain in Patients with Cancer
The Royal College of Anaesthetists, The Pain Society. (2003)Pain Management Services. Good Practice
British Committee for the Standards in Haematology (2003)Guidelines for the Management of Acute Painful Crisis in Sickle Cell Disease
British Society for Rheumatology. (2001)Guidelines on Epidural Steroids for Spinal Pain
Royal College of Paediatrics and Child Health. (2001)Recognition And Assessment Of Acute Pain in Children
Scottish Intercollegiate Guidelines Network. (2000)Control of Pain in Patients with Cancer
Clinical Standards Advisory Group (CSAG) (1999)Services for Patients with Pain
International Association for the Study of Pain. (1992) Task force on Acute Pain, Management of Acute Pain: A Practical Guide (restricted access to document www.iasp -pain.org/

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