Anesthesiology, Article

A systematic review of the pain scales in adults: Which to use?

a b s t r a c t

Objective: The study analysed the Visual analogue scale (VAS), the Verbal rating scale and the numerical rating scale (NRS) to determine: 1. Were the compliance and usability different among scales? 2. Were any of the scales superior over the other(s) for clinical use?

Methods: A systematic review of currently published studies was performed following standard guidelines. On- line database searches were performed for clinical trials published before November 2017, on the comparison of the pain scores in adults and preferences of the specific patient groups. A literature search via electronic data- bases was carried out for the last fifteen years on English Language papers. The search terms initially included pain rating scales, Pain measurement, pain intensity, VAS, VRS, and NRS. Papers were examined for methodolog- ical soundness before being included. Data were independently extracted by two blinded reviewers. Studies were also assessed for bias using the Cochrane criteria.

Results: The initial data search yielded 872 potentially relevant studies; of these, 853 were excluded for some rea- son. The main reason for exclusion (33.7%) was that irrelevance to comparison of pain scales and scores, followed by pediatric studies (32.1%). Finally, 19 underwent full-text review, and were analysed for the study purposes. Studies were of moderate (n = 12, 63%) to low (n = 7, 37%) quality.

Conclusions: All three scales are valid, reliable and appropriate for use in clinical practice, although the VAS is more difficulties than the others. For general purposes the NRS has good sensitivity and generates data that can be analysed for audit purposes.

(C) 2018

Pain in the emergency department

Acute pain is one of the most common chief complaints reported by most patients admitted to the ED, while its perception and expression have great variations between countries [1]. The definition of pain by In- ternational Association for the Study of Pain (IASP) as ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage’ is accepted world- wide [2].

Subjective and multidimensional nature of the pain experience render pain assessment really challenging. In the Joint Commission on Accredita- tion of Healthcare organizations (JCAHO) guidelines, implementation of this standard in clinical practice comprised the addition of pain as the “fifth” vital sign to be noted in the context of initial assessment; the use of pain intensity ratings; and posting of a statement on pain management in all patient care areas. Supplemented with regular pain reassessments, the schedule of pain reassessment should be driven by patients’ pain se- verity [3].

* Corresponding author at: Dept. of Emergency Medicine, Univ. of Health Sciences, Istanbul Education and Research Hospital, PK 34098, Fatih, Istanbul, Turkey.

E-mail address: [email protected] (O. Karcioglu).

Pain estimations need to be elicited and recorded to highlight both the presence of pain and the efficacy of pain treatment. The patients’ perception of pain should be documented during the initial assessment of a patient. Current evidence provides a general recommendation that pain needs to be evaluated and managed within 20-25 min of initial healthcare provider assessment in the ED [4]. Pain treatment should be targeted to a goal of reducing the pain score (e.g., by 50%, below 4/ 10, or referred to as mild/moderate or severe) rather than a specific an- algesic dose [5].

Pain scores and documentation of pain

The patient’s self-report is the most accurate and reliable evidence of the existence of pain and its intensity, and this holds true for patients of all ages, regardless of communication or cognitive deficits [6].

In the absence of objective measures, the clinician must depend on

the patient to supply key information on the localization, quality and se- verity of the pain. Although physicians commonly question the reported severity and rely on their own estimates, the value of the patients’ de- scription of the location and nature of the discomfort has been proved on the theoretical basis and routine practice [7].

https://doi.org/10.1016/j.ajem.2018.01.008

0735-6757/(C) 2018

Pain scores have gained acceptance as the most accurate and reliable measure of assessing a patient’s pain and response to pain treatment [5]. Scales devised to estimate and/or express the patient’s pain can be eval- uated in two groups: Unidimensional and multidimensional measures. It should be noted that unidimensional scales measure only intensity, they cannot be viewed as a comprehensive pain assessment. Compre- hensive pain assessment is expected to encompass both the unidimen- sional measurement of pain intensity and the multidimensional evaluation of the pain perception. The unidimensional pain intensity scales commonly used bedsides are:

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