MOOCS Entendendo Dor Crônica para Viver Melhor - 04 - Quais são as características da dor?

Hello, in today's video we will talk about some characteristics of pain. So, the objective of this lesson is to better understand the characteristics of pain. And why would this be important?

Understanding the characteristics of pain is important both for people that feel pain and for health professionals that treat these people. First because pain is an individual, personal characteristic, sensation, it’s a personal experience and, sometimes, it’s very difficult to convey to others what you are feeling. So, when you comprehend the characteristics of pain, you are able to better understand your pain and, this way, communicate better with others, and you can also understand how your pain may be different from that of other people.

For health workers, understanding the characteristics of someone's pain allows for a more individualized treatment. Did you know there are 10 characteristics of pain? It’s called the decalogue of pain.

So, when a health professional evaluates an individual's pain, they need to explore its 10 characteristics. These characteristics are: pain location; irradiation; quality; pain intensity; duration; pain evolution; aggravating factors, which increase pain; mitigating factors, which improve pain; there are also parallel manifestations, those that happen alongside pain; and the link between pain and organic functions, the relation of the pain location and the functioning of organs in that region. Let's start with the perception of pain location.

So, when a health professional is investigating characteristics of pain, they will, in general, ask the person in pain where the pain is and, through mimic gestures, the patient says "I feel pain right here, it's quite light" and we deem this pain to be superficial. Some patients, for example, express where their pain is by pressing or by saying that the pain is deep inside there, so we consider it to be deeper. Therefore, pain location is related to the way the patient demonstrates or speaks about their pain, and it may be superficial or deep.

Considering its location, pain can also be classified as condensed, this is easily noticed when the patient points to either an exact or a diffused pain location, for example, a patient says they feel pain, but when placing the pain in their body, they go over a large region, such as "I feel this pain that starts in my shoulder and goes all the way to my head", which is a diffused pain. So, by assessing pain location we can comprehend if it’s superficial or deep, or if the pain is condensed or diffused. We can also evaluate if the pain irradiates or if it has a reference standard.

But what is irradiate pain? This type of pain follows the nerves pathway. So, our nerves leave the spinal cord, innervates our arms, trunk, lower body.

If there is some kind of compression, such as herniated disk in the lower back, which compresses nerve roots, the person may feel pain not only the back, but in the entire path of that nerve root. It’s very common for patients to come to us with pain in the lower back that irradiates to the lower limbs, they say "the pain stretches from the back to the thighs" or "the pain starts in the back and goes all the way to my feet". These standards tell us that the pain irradiates, that is, it follows the nerve path.

Reference standard pain are a bit different, this type of pain occurs beyond the original pain location. I will give you an example of how patients express the pain in question. A patient, for example, feels tension in the upper part of the shoulder, a trigger point, they press it and feel pain.

But they also say that, when pressing hard, aside from feeling pain in the shoulder, they feel it in the neck as well. It is very common to have pain reference standards, they are not related to nerves or innervation, but to a bigger pain location. It’s also very important to understand two other characteristics: pain quality and intensity.

And it’s very difficult for patients to express the amount of pain they feel. For some people, the pain may be very intense but they can still maintain their usual activities, for others, the pain may be so intense that they cannot perform their activities. But, first, I would like to say that pain cannot be measured mathematically, that is, it’is not an exact measure.

So, when using strategies to assess pain, we are trying to help someone in pain to better explain the impact pain has on their lives, that's it. To evaluate pain intensity, we may use some scales, which I will show you now, that helps to make this information more objective. We can use, for example, a scale with faces, and these scales will suggest if the patient's pain is light, and so the face has a more mild facial expression, or if they feel a very intense pain, with a more serious expression.

We may use numeric scales, when we ask patients, for example, how would you rate your pain from 0 to 10. And, to help the patient even more, there are scales for functional debilitating pain. What does that mean?

These are scales that, in addition to having a numeric scale, from 0 to 10, 0 meaning no pain and 10 the most intense pain, they have the characteristics of activities patients may have stopped doing as it causes pain. For example, the patient reports moderate pain that interferes but doesn't prevents them from doing certain things. So these tools help us to evaluate pain intensity in a more objective way.

Another important characteristic to evaluate is pain quality. In general, when assessing quality, we may ask what the pain is like and the person may use words, adjectives to name the pain, so we use a list of words and the person chooses which words are more strongly associated with what they feel. The patient may say that the pain feels like stabbing, piercing, the pain is warm, cold, it is squeezing or throbbing.

These words give us an idea of a person's pain quality. The next characteristic we should investigate is pain duration, and we ask an individual in pain, how long they have been feeling pain. And, through their response, considering pain duration, we can classify it into either acute or chronic pain.

Chronic pain is the type of pain that lasts for over six months, but it’s important to evaluate the characteristics of acute pain. Acute pain is, in general, related to an injury and, when an injury heals, then it’s self-limited, when the injury goes away, it stops. As for chronic pain, it’s more diffused, its intensity can be light, moderate or intense.

It’s not specifically related to tissue injury, it lasts for over six months and it becomes an illness by itself. Another characteristic is pain evolution. When we investigate that, when we try to understand that, we may ask the patient when the pain started, if it began all of a sudden or if it was slow, how the pain developed across time.

So we often ask: did the pain change places? Is it increasing or decreasing? Has it occurred before?

Have you tried some kind of treatment that improved or didn't improve this pain? This way we are able to better understand the life period in which this pain developed. We classify pain evolution into 3 situations pain may be consistent, persistent, it has a present stimulus; periodic pain, for example, is related to a period, I'm going to share a simple example.

A person says they work the whole day and, at night, they feel pain in their legs. So this is the evolution of periodic pain, every night, after a work overload, they feel pain in their legs; and there is also another classification, that is episodic pain, which is related to an event that caused pain. Someone may say: every time I wash the dishes I feel back pain, so this pain is caused by an episode, and here, in the example I gave, the episode is washing the dishes.

It's also important to know the aggravating factors and mitigating factors of pain. And all these factors are quite personal because what may help with someone's pain, may not help someone else, so, you need to ask yourself what improves your pain and what make your pain worse, and understand the individual characterization of these factors. For example, some patients say that resting helps to soothe the pain, others say that staying active improves pain, some say that a good night of sleep will improve the pain, other say that the pain increases after a night of sleep.

So, it's important to investigate these factors to better characterize what influences people's pain. Another important characteristic that should be evaluated is the connection between pain and the function of the organs in the area where the person feels pain. I will give an example for the chest area, this region of the upper body.

Some kinds of pain felt in the chest stem from, for example, the skeletal muscle systems, pain in the articulation between the ribs and sternum. It's an inflammatory pain, but if a patient points out pain in this region, I need to know if there are other problems in the chest organs. Which organs are in this region?

The heart, the lungs and the esophagus, for example. How can I do that? By asking questions to better understand the pain and to differentiate cardiac pain, pulmonary pain, oesophageal reflux pain from Costochondritis pain.

At last, we should investigate all manifestations simultaneous to pain. What does this mean? When people feel pain, they often feel other symptoms too, this may help us to understand or to make a different diagnosis for other diseases.

I'm going to give a simple example. Any regular person that feels a lot of pain, very intense pain, can have other reactions, such as cold and sweaty palms, pale skin, higher blood pressure. These are expected outcomes of very intense pain.

So, when I know this is happening, I feel a bit more safe. If there are symptoms that can differentiate diseases, then we can truly understand what the patient has. Another example: there's a type of headache called migraine and there's tension headache.

But how can I differentiate migraine and tension headache if they are both headaches? We need to investigate simultaneous symptoms. A very simple example is that patients with migraine report having visual phenomena, they see lights, there's a phenomenon called aura, very distinctive for this diagnosis.

So, if a patient experiences visual phenomena, aside from headache, and we are aligned to a comprehensive evaluation, we can diagnose headache with these simultaneous manifestations as migraine. We have reached the end of our content on characteristics of pain. I hope you keep watching our videos and understanding a bit more about your pain in order for you to communicate better with health workers and realize how important it's to individualise your pain and seek adequate treatment for it.

Continue watching the next videos. Thank you so much! [Thank you!