Measurement and control of pain. Visual analog scale - a method for assessing the intensity of pain: an abbreviation, application in medical practice

The simplest and most common way is to record the intensity of pain using rating scales.

There is a numerical rank scale (NRS), consisting of a sequential series of numbers from 1 to 5 or up to 10.

The patient must select a number that reflects the intensity of the pain experienced.

The Verbal Rank Scale (VRS) contains a set of pain descriptor words that reflect the degree of pain increase, sequentially numbered from lesser severity to greater: none (0), mild pain (\), moderate pain (2), severe pain (3), very severe pain (4), unbearable (unbearable) pain (5). The Visual Analogue Scale (VAS) is a straight line 100 mm long, with or without millimeter divisions. The starting point of the line means the absence of pain, the end point means unbearable pain.

The patient is required to mark the level of pain with a dot on the proposed straight line. For patients who have difficulty abstracting and representing pain as a number or a point on a straight line, a facial pain scale can be used. Variants of the listed scales most commonly used in clinical practice shown in Figure 1.

Rice. 1. Scales for assessing pain

Pain is assessed uniquely - by intensity, as a simple sensation that differs only quantitatively, while it has qualitative differences. Analogue, numerical and verbal scales give a single, generalized assessment, which reflects the almost completely unexplored process of integrating multidimensional pain experience.

For multidimensional pain assessment R.Melzack and W.S.Torgerson (1971) proposed a questionnaire called "McGill Pain Questionnaire" (McGill Pain Questionnaire). Also known is the method of multidimensional semantic description of pain, which is based on the extended McGill questionnaire (Melzack R., 1975).

The expanded questionnaire contains 78 words-descriptors of pain, introduced into 20 subclasses (subscales) according to the principle of semantic meaning and forming three main classes (scales): sensory, affective and evaluative.

Survey results can serve as a criterion mental state sick. Numerous studies have verified the adequacy of the method for assessing pain, anesthesia and diagnosis, and now it has become standard method examinations abroad.

Similar work has been done in our country. V.V. Kuzmenko, V.A. Fokin, E.R. Mattis and co-authors (1986), taking the McGill questionnaire as a basis, developed an original questionnaire in Russian and proposed a methodology for analyzing its results. In this questionnaire, each subclass consists of words that are similar in their semantic meaning, but differ in the intensity of the pain they convey (Table 3).

Table 3. McGill pain questionnaire

Subclasses form three main classes (scales): sensory, affective and evaluative (evaluative). Sensory scale descriptors (subclasses 1-13) characterize pain in terms of mechanical or thermal impact, changes in spatial or temporal parameters. The affective scale (14-19 subclasses) reflects the emotional side of pain in terms of tension, fear, anger, or autonomic manifestations.

The evaluation scale (subclass 20) consists of five words expressing the patient's subjective assessment of pain intensity and is a variant of the verbal rating scale. When filling out the questionnaire, the patient chooses words that correspond to his feelings in this moment, in any of the 20 subclasses (not necessarily each, but only one word per subclass).

Each selected word has a numerical indicator corresponding to the ordinal number of the word in the subclass. The calculation is reduced to the definition of two indicators: the index of the number of selected descriptors (NDI), which is the number (sum) of the selected words, and the rank index of pain (RIB), which is the sum serial numbers descriptors in subclasses. Both indicators are calculated for the sensory and affective scales separately and together (total index).

According to the International Association for the Study of Pain, “Pain Threshold (PT) is the minimum sensation of pain that can be perceived”. An informative characteristic is also the level of pain tolerance (pain tolerance threshold - PPB), defined as " highest level pain to bear."

Method name quantitative research pain sensitivity is formed from the name of the algogenic stimulus used in it: mechanoalgometry, thermal algometry, electroalgometry.

Most often, pressure is used as a mechanical effect, and then the method is called tensoalgometry (dolorimetry). In tensoalgometry, PB is expressed in units of pressure force per unit area (kg / cm2). Depending on the localization of measurements, interchangeable nozzles are used: in the area of ​​the head and distal extremities with a diameter of 1.5 mm, and in the area of ​​massive skeletal muscles - 5 mm.

Tensoalgometry is carried out by a smooth or stepwise increase in pressure on the tested area of ​​the body. Pain sensation occurs at the moment when the pressure force reaches values ​​sufficient to excite Ab-mechanoreceptors and C-polymodal nociceptors.

The definition of PB and PB can provide important clinical information. A decrease in PB indicates the presence of allodynia, and a decrease in PB is a sign of hyperesthesia (hyperalgesia). Peripheral sensitization of nociceptors is accompanied by both allodynia and hyperalgesia, while central sensitization is manifested predominantly by hyperalgesia without concomitant allodynia.

R.G. Esin, O.R. Esin, G.D. Akhmadeeva, G.V. Salikhova

For diagnostics pain syndrome in cancer patients, for ethical reasons, it is customary to use only non-invasive methods. In the beginning, it is necessary to study the history of pain (prescription, intensity, localization, type, factors that increase or decrease pain; time of onset of pain during the day, previously used analgesics and their doses and effectiveness). In the future, it should be clinical examination patient in order to assess the nature and prevalence oncological process; study physical, neurological and mental status patient. It is necessary to familiarize yourself with the data of clinical and laboratory research methods (clinical and biochemical analysis blood, urinalysis), which is important for choosing the safest for this patient a complex of analgesics and adjuvant agents (BP, heart rate, ECG, ultrasound, radiography, etc.).

Assessment of the intensity of chronic pain syndrome is carried out using the scale of verbal (verbal) assessments (VVR), visual analogue scale (VAS), pain questionnaires (McGill Pain Questionaire and others). The simplest and most convenient for clinical use is 5-point SVO, which is filled in by the doctor according to the patient:

0 points - no pain

1 point - mild pain,

2 points - moderate pain,

3 points - severe pain,

4 points - unbearable, the most severe pain.

Often used visual analog scale (VAS) of pain intensity from 0 to 100%, which is offered to the patient, and he himself notes on it the degree of his pain.

These scales make it possible to quantify the dynamics of chronic pain syndrome during treatment.

Assessment of the quality of life of an oncological patient can be fairly objectively carried out according to 5-point physical activity scale:

• 1 point - normal physical activity,
• 2 points - slightly reduced, the patient is able to visit a doctor on his own,
• 3 points - moderately reduced (bed rest less than 50% of the daytime,
• 4 points - significantly reduced (bed rest more than 50% of the daytime),
• 5 points - minimum (complete bed rest).

For rate general condition oncological patient is used Karnofsky quality of life scale, where the dynamics of the degree of activity of the patient is measured as a percentage:

For a more detailed assessment, the whole set of criteria recommended by the International Association for the Study of Pain(IASP, 1994), which includes the following parameters:

• general physical state
• functional activity
• social activity,
• self-care ability
• communication, family behavior
• spirituality
• treatment satisfaction
• future plans
• sexual functions
• professional activity

For assessment of tolerability of analgesic therapy take into account the appearance of a side effect caused by a particular drug (drowsiness, dry mouth, dizziness, headache etc.) and the degree of its severity on a 3-point scale:

0 - no side effects,

1 - weakly expressed,

2 - moderately expressed,

3 - strongly pronounced.

It should be remembered that patients with advanced forms of tumors may present with symptoms similar to side effect many analgesics (nausea, dry mouth, dizziness, weakness), so it is important to start assessing the baseline status before starting analgesic therapy or its correction.

For an in-depth assessment of pain in special scientific research apply neurophysiological methods(registration of evoked potentials, nociceptive flexor reflex, study of the dynamics of a conditionally negative wave, sensory, electroencephalography), the plasma level of stress factors (cortisol, growth hormone, glucose, beta-endorphin, etc.). Recently, it has become possible to objectify the level of pain according to activity data. various departments brain with the help positron emission tomography. But the use of these methods in their daily practice is limited due to their invasiveness and high cost.

Of academic interest is opiate addiction test with naloxone, which is carried out in specialized clinics with the consent of the patient with long-term (over a month) therapy with opioid analgesics. In normal practice, it is not used, since it can lead to the elimination of analgesia and the development of an acute withdrawal syndrome.

Based on the diagnostic data, the cause, type, intensity of chronic pain syndrome, pain localization, associated complications and possible mental disorders. At subsequent stages of observation and therapy, it is necessary to re-evaluate the effectiveness of pain relief. At the same time, the maximum individualization of the pain syndrome is achieved, possible side effects used analgesics and the dynamics of the patient's condition.

verbal rating scale

The verbal rating scale allows you to assess the intensity of pain severity through a qualitative verbal assessment. Pain intensity is described in specific terms ranging from 0 (no pain) to 4 (worst pain). From the proposed verbal characteristics, patients choose the one that best reflects the experiences they experience. pain.

One of the characteristics of verbal rating scales is that the verbal characteristics of the pain description can be presented to patients in an arbitrary order. This encourages the patient to choose exactly the gradation of pain that is based on the semantic content.

Verbal descriptive pain rating scale

Verbal Descriptor Scale (Gaston-Johansson F., Albert M., Fagan E. et al., 1990)

When using a verbal descriptive scale with a patient, it is necessary to find out if he is experiencing any pain right now. If there is no pain, then his condition is estimated at 0 points. If there is pain, you need to ask: “Would you say that the pain has increased, is the pain unimaginable, or is this the most severe pain you have ever experienced?” If so, the highest score of 10 points is recorded. If there is neither the first nor the second option, then further it is necessary to clarify: “Can you say that your pain is weak, moderate (moderate, tolerable, not strong), strong (sharp) or very (especially, excessively) strong (acute) ".

Thus, six options for assessing pain are possible:

• 0 - no pain;
• 2 - mild pain;
• 4 - moderate pain;
• 6 - severe pain;
• 8 - very severe pain;
• 10 - unbearable pain.

If the patient experiences pain that cannot be characterized by the proposed characteristics, for example, between moderate (4 points) and severe pain(6 points), then the pain is evaluated by an odd number that is between these values ​​(5 points).

The verbal descriptive pain rating scale can also be used in children over seven years of age who are able to understand and use it. This scale can be useful for assessing both chronic and acute pain.

The scale is equally reliable as for younger children school age, and older age groups. In addition, this scale is also effective in various ethnic and cultural groups, as well as in adults with minor violations cognitive abilities.

Faces Pain Scale (Bien, D. et al., 1990)

The Facial Pain Scale was created in 1990 by Bieri D. et al. (1990).

The authors developed a scale with the aim of optimizing the assessment of the intensity of pain by the child, using the change in facial expression depending on the degree of pain experienced. The scale is represented by pictures of seven faces, with the first face having a neutral expression. The next six faces depict growing pain. The child must choose the face that, in his opinion, best demonstrates the level of pain that he is experiencing.

The Facial Pain Scale has several features compared to other facial pain rating scales. First, it is more of a proportional scale than an ordinal scale. In addition, the advantage of the scale is that it is easier for children to relate their own pain to the drawing of the face presented on the scale than to the photograph of the face. The simplicity and ease of use of the scale make it possible to clinical application. The scale has not been validated for use with preschool children.

The Faces Pain Scale-Revised (FPS-R)

(Von Baeyer C. L. et al., 2001)

Carl von Baeyer with students from the University of Saskatch-ewan (Canada), in collaboration with the Pain Research Unit, modified the facial pain scale, which was called the modified facial pain scale. Instead of seven faces, the authors left six faces in their version of the scale, while maintaining a neutral facial expression. Each of the images presented in the scale received a digital score in the range from 0 to 10 points.

Instructions for using the scale:

“Look closely at this picture, where faces are drawn that show how much pain you can have. This face (show leftmost) shows a person who is not hurt at all. These faces (show each face from left to right) show people whose pain is increasing, increasing. The face on the right shows a person who is in unbearable pain. Now show me a face indicating how much pain you are in at the moment.”

Visual analog scale (VAS)

Visual Analogue Scale (VAS) (Huskisson E. C., 1974)

This method of subjective pain assessment consists in asking the patient to mark a point on a 10 cm long non-graded line that corresponds to the severity of pain. The left border of the line corresponds to the definition of "no pain", the right one - "the worst pain imaginable." As a rule, a paper, cardboard or plastic ruler 10 cm long is used.

FROM reverse side the rulers are marked with centimeter divisions, according to which the doctor (and in foreign clinics this is the duty of the nursing staff) notes the value obtained and enters it on the observation sheet. The undoubted advantages of this scale include its simplicity and convenience.

Also, in order to assess the intensity of pain, a modified visual analogue scale can also be used, in which the intensity of pain is also determined by different shades of colors.

The disadvantage of VAS is its one-dimensionality, i.e., according to this scale, the patient notes only the intensity of pain. The emotional component of the pain syndrome introduces significant errors in the VAS.

In a dynamic assessment, a change in pain intensity is considered objective and significant if the current VAS value differs from the previous one by more than 13 mm.

Numerical Pain Scale (PNS)

Numeric Pain Scale (NPS) (McCaffery M., Beebe A., 1993)

According to the above principle, another scale is built - a numerical scale of pain. The ten-centimeter segment is broken with marks corresponding to centimeters. According to it, it is easier for the patient, unlike VAS, to evaluate pain in digital terms, he determines its intensity on the scale much faster. However, it turned out that during repeated tests, the patient, remembering the numerical value of the previous measurement, subconsciously reproduces an unrealistic intensity.

pain, but tends to stay in the area of ​​the previously named values. Even with a feeling of relief, the patient tries to recognize a higher intensity, so as not to provoke the doctor to reduce the dose of opioids, etc., the so-called symptom of fear of repeated pain. Hence the desire of clinicians to move away from digital values ​​and replace them with verbal characteristics of pain intensity.

Bloechle et al.

Pain scale of Bloechle et al. (Bloechle C., Izbicki J. R. et al., 1995)

The scale was developed to assess the intensity of pain in patients with chronic pancreatitis. It includes four criteria:

1. The frequency of attacks of pain.
2. Pain intensity (pain score on a VAS scale from 0 to 100).
3. The need for analgesics to eliminate pain (the maximum severity is the need for morphine).
4. Lack of performance.

NB!: The scale does not include such characteristics as the duration of the pain attack.

When more than one analgesic is used, the need for analgesics to relieve pain is equal to 100 (maximum score).

In the presence of continuous pain, it is also estimated at 100 points.

The assessment on the scale is made by summing up the assessments for all four criteria. The pain index is calculated by the formula:

Overall score on a scale / 4.

The minimum score on the scale is 0, and the maximum is 100 points.

The higher the score, the more intense the pain and its impact on the patient.

Observation Based ICU Pain Rating Scale

Critical Care Pain Observation Tool (CPOT) (Gelinas C., Fortier M. et al., 2004)

The CPOT scale can be used to assess pain in adult ICU patients. It includes four features, which are presented below:

1. Facial expression.
2. motor reactions.
3. Tension of the muscles of the upper limbs.
4. Speech reactions (in non-intubated) or ventilator resistance (in intubated) patients.

To assess the severity of the pain syndrome, as well as the effectiveness of its elimination, the so-called ranking scales. The visual analogue scale (VAS) is a segment of a straight line 10 cm long, the beginning and end of which reflect the absence of pain and the extreme limit of its sensation (Fig. 2.15).

The patient was asked to mark a straight line segment, the size of which approximately corresponded to the intensity of pain experienced by him. Having measured the marked area, the conditional pain intensity was determined in points (corresponding to the length in cm). The verbal rank scale is the same VAS, but with pain scores arranged along a straight line: mild, moderate, severe, etc. Numeric evaluation scale represents the same segment of a straight line with numbers from 0 to 10 printed on it. Pain assessments obtained using horizontal scales are considered the most objective. They correlate well with the assessment of pain sensations and more accurately reflect their dynamics.

Qualitative characteristics of the pain syndrome were obtained using the McGill pain questionnaire (183). This test includes 102 pain parameters, divided into three main groups. The first group (88 descriptive expressions) is associated with the nature of pain sensations, the second (5 descriptive expressions) with pain intensity, and the third (9 indicators) with pain duration. The parameters of the first group are divided into 4 classes and 20 subclasses. The first class is the parameters of sensory characteristics (pain "throbbing, shooting, burning", etc.).

Rice. 2.15. Visual scales for subjective pain assessment

The second class - parameters of affective characteristics (pain "tiring, terrifying, exhausting", etc.), the third class - evaluating parameters (pain "causing irritation, suffering, unbearable", etc.), the fourth - mixed sensory-affective parameters (pain "obtrusive, excruciating, tormenting", etc.). Each indicator in the subclass is located according to its ranking value and has a weighted mathematical expression (first = 1, second = 2, etc.). In the subsequent analysis, the number and rank position of the selected parameters for each class were taken into account.

A quantitative assessment of pain sensations was carried out using a dolorimeter (Kreimer A. Ya., 1966). The principle of operation of the dolorimeter is based on measuring the pressure at which pain occurs at the point under study. The pressure measurement is recorded using a rubber-tipped rod connected to a spring mechanism. A scale is applied on the flat surface of the rod, graduated in 30 divisions in increments of 0.3 kg/cm. The amount of displacement of the rod is recorded using a fixing ring.

Algesimetry data are expressed in absolute units - kg/cm. The degree of soreness of 9.2 ± 0.4 kg/cm2 or more, determined in 30 patients, was taken as the norm. healthy people. For standardization of indicators, the coefficient of soreness (CB), which shows the ratio of normal algesimetric indicators to the corresponding indicators at the studied points. Normally, it is equal to one relative unit. The test was also used during treatment to determine the effectiveness of the chosen treatment method.

The described approach made it possible to carry out an objective differential diagnosis and based on the results complex diagnostics an individual scheme of treatment and rehabilitation in the postoperative period was selected.

Everyone have a good day. We are with you in recent times very often we talk about remission, a decrease in the activity of the disease, about activity in general, activity indices, and so on.

Today and tomorrow we will talk about how to measure this activity and how to interpret the result. Let's look at an example, if you are interested in other activity indices, just let us know.

So, today we will analyze the pain scale, which is often used by rheumatologists and which is used to calculate disease activity indices. Pain assessment scales are designed to determine the intensity of the pain syndrome (for any disease). These scales allow you to evaluate the subjective pain experienced by the patient pain at the time of the study. The Visual Analogue Scale (VAS) was introduced by Huskisson in 1974.

This method of subjective pain assessment consists in asking the patient to mark a point on a 10 cm long non-graded line that corresponds to the severity of pain. The left border of the line corresponds to the definition of "no pain at all", the right - "the most intense pain that you can imagine." As a rule, a paper, cardboard or plastic ruler 10 cm long is used. outpatient card. Also, in order to assess the intensity of pain, a modified visual analogue scale can also be used, in which the intensity of pain is also determined by different shades of colors.

The undoubted advantages of this scale include its simplicity and convenience, the ability to control the effectiveness of therapy.

With a dynamic assessment, an objective and significant difference in the VAS value from the previous one is more than 13 mm.

• The disadvantage of VAS is its one-dimensionality, i.e., according to this scale, the patient notes only the intensity of pain.
• The emotional component of the pain syndrome introduces significant errors in the VAS.
• The subjectivity of VAS is also its main disadvantage. The patient, pursuing his goals, may deliberately underestimate or overestimate the values. When? For example, a patient does not want to offend (strain, disturb) his doctor, and even if there is no result and the pain syndrome remains at the same level, he underestimates the value. Yes, there are some) Or the patient wants to get a disability, wants to become a candidate for expensive treatment and so on, and specifically puts the score significantly higher than the previous result. Well, do not forget that we are all different: someone will endure walking and even smile, and someone with the same pain will not even be able to get out of bed.

Plus, the doctor also needs to be attentive and actively communicate (no, do not push!!!) with the patient. For example, offer him options for comparison. Let's say a woman enters the office quite cheerfully, but on a scale she gives 10 out of 10, all this is accompanied by a story about how terrible she feels. You ask: “Did you give birth? Does it hurt as well?" “Oh, no, doctor, what are you, when I gave birth, I thought that I would die.” After that, the value decreases to 5. That is why VAS is only one of the tools for calculating the activity index by the doctor himself, who already uses objective methods assessment of the patient's condition. Here you can remember Dr. House and his iron "Everyone lies", but we are well-mannered people and we will not be so categorical😄

In conclusion, I want to say only one thing: please be honest with your doctor. If you feel better - talk about it, if it gets worse - again, tell the doctor about it. Don't fake or hide anything on purpose. If the doctor does not hear you, does not want to hear, it means that he is simply not your doctor. Tomorrow we will discuss DAS-28 and what is considered remission.