CAPSTONE 2018, CARLA DIANA
TANGIBLE PAIN SCALES
AISHWARYA JANWADKAR
UNDERSTANDING PAIN Pain is one of the most misunderstood, under-diagnosed, and under-treated medical problems
25.3 million
Americans suffer from daily pain
Total Health Care Spending, 2012
$2.82 trillion
Physician Visits
$49 billion
https://www.nih.gov/news-events/news-releases/nih-analysis-shows-americans-are-pain
ACUTE PAIN [NOCICEPTIVE PAIN] Short term less than 3 to 6 months
Cause generally known
Acute pain is provoked by a specific disease or injury, serves a useful biologic purpose, is associated with skeletal muscle spasm and sympathetic nervous system activation, and is self-limited. An example of acute pain is when you stub your toe or touch a hot stove.
76.2 million
suffered from pain that lasts longer than 24 hours https://report.nih.gov/nihfactsheets/ViewFactSheet.aspx?csid=57
CHRONIC PAIN [NEUROPATHIC PAIN]
Long term
Cause often unknown
Chronic pain, in contrast, may be considered a disease state. It is pain that outlasts the normal time of healing, if associated with a disease or injury. Chronic pain may arise from psychological states, serves no biologic purpose, and has no recognizable end-point. An example of chronic pain is back pain that lasts longer than 4 weeks.
100 million
Americans suffer from chronic pain http://www.painmed.org/patientcenter/facts_on_pain.aspx
PAIN IN CHILDREN Each year, 1.5 million children have surgery, and many receive inadequate pain relief.
34%
40%
complain of abdominal pain lasting two weeks or longer
of children and adolescents complain of pain that occurs at least once weekly
20%
suffer headaches
In 20% of cases, the pain becomes chronic. Failure to intervene early in children’s pain leads to impairment in functioning and disruption in families. Unaddressed pain heightens anxiety and fear, which, in turn, increases perception of pain. To accurately assess pain in children, the medical care-giver must tailor assessment strategies to the child’s developmental level. Children are particularly responsive to strategies that involve their imaginations and senses of play. Approaches as simple as play therapy could be used.
Pain in Children: Neglected, Unaddressed and Mismanaged, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3140088/
PAIN TREATMENT PHYSICAL THERAPY OPIOIDS
Pain is often alleviated with opioids and physical therapy.
2.1 million
259 million
people misused opioid prescription
prescriptions
16,000 deaths
In the late 1990s, pharmaceutical companies reassured the medical community that patients would not become addicted to opioid pain relievers and healthcare providers began to prescribe them at greater rates. Increased prescription of opioid medications led to widespread misuse of both prescription and nonprescription opioids before it became clear that these medications could indeed be highly addictive. All too often, the treatment of pain is delayed, inaccessible or inadequate. Patients, health-care providers and our society need to overcome misperceptions and biases about pain. - Philip Pizzo, MD, Dean of the Stanford School of Medicine
https://www.cdc.gov/drugoverdose/data/index.html
PAIN ASSESSMENT Starting at about age three or four, children are asked to self report their pain. The ideal pain assessment tool would have the following attributes but when you consider these attributes and measure them against the tools available you realise that no one tool has all attributes: • Sensitive and free from bias • Immediate information about accuracy and reliability • Distinguishes between pain, unpleasantness and emotion
NUMERIC RATING SCALE (NRS) A NRS involves asking the patient to rate his or her pain from 0 to 10 (11 point scale) or from 0 to 100 (101 point scale) with the understanding that 0 is equal to no pain and 10 or 100 is equal to worst possible pain. This does not require the patient to write or use a ruler and he or she provides a verbal response which the healthcare provider can then document.
FACES PAIN SCALE (FPS-R)
Face Scales employ photographs or drawings that illustrate facial expressions or persons experiencing different levels of pain severity. Patients are asked to indicate which one of the illustrations best represents their pain experience. Each face has a number representing the rank order of the pain illustrated and the number of the picture chosen by the patient represents that patient’s pain intensity score.
COLOR ANALOGUE SCALE (CAS) The color analog scale (CAS) has been shown to be a valid pain measurement tool for use in children aged 5 years and older, but its reliability has not been established. The CAS resembles a ruler, with one side showing a wedge-shaped figure filled with color that gradually progresses from white to red as the figure widens and the other side showing corresponding numerical ratings from 1 to 10.
MAJOR PROBELMS
VISUAL SCALES
VERBAL COMMUNICATION
ONLY MEASURES INTENSITY OF PAIN
Most of these scales are meant for verbal communication and are visual only. Patients can have all kinds of communication barriers, from emotional and cognitive impairments to cultural or educational differences that make these scales difficult to grasp. Patients might speak a different language or have a breathing tube, both of which hinder their ability to communicate verbally. Some times children also misreport their pain, for example. They might give doctors a low pain score in order to avoid an injection or other uncomfortable procedure, even if they are truly hurting.
SOLUTION
CATEGORICAL AS S E S S M E N T
CONTINUOUS ASSESSMENT
TACTILE
The current pain scales only measure the quantity/intensity of pain. Tangible pain Scales consist of two different scales; one that measures the category of pain and other that measures the intensity of pain. These scales are tactile and interactive to enhance non verbal communication.
https://eagereyes.org/basics/data-continuous-vs-categorical
PROCESS
Tangible Pain Scales (TPS) are tactile tools that enhance non-verbal doctor/patient communication and help children self-report their pain adequately.
CATEGORICAL ASSESSMENT It can be surprisingly difficult to describe how pain feels. Each of us experiences our pain differently, making it highly subjective and that makes it a challenge for a doctor to evaluate. “It is relative,” says Micke Brown, RN, director of advocacy at the Baltimore-based American Pain Foundation and past president of the American Society for Pain Management Nursing. She remembers one patient who had suffered chronic pain for years: “She said that she would measure her pain at a 6. She would compare it to breaking a bone, which for me would maybe be a 10.”
Children espesically 3 to 4 year olds dont understand the concept of pain. Some of them might not know the words that are used to commonly describe pain. Categorical pain assessment tools help identify the character of the pain such as sharp or dull pain, soreness/tender pain, stabbing/throbbing pain, etc through tactile and visual objects.
sharp pain at point sharp pain all over
sore / tender
stabbing
Dull
tingly
CONTINUOUS ASSESSMENT Pain needs to be quantified to be treated effectively. However, children don’t need 10 options on a pain scale. Research by Dr. Carl Von Bayer shows that scales with fewer response options are much efficient especially with 3-4 year olds. The Continuous Assessment tools help describe the intensity of the pain. They are inspired by the Goldilocks principle. The Goldilocks principle is named by analogy to the children’s story, The Three Bears, in which a little girl named Goldilocks tastes three different bowls of porridge, and she finds that she prefers porridge which is neither too hot nor too cold, but has just the right temperature. Since the children’s story is well known across cultures, the concept of “just the right amount” is easily understood and is easily applied to a wide range of disciplines, including developmental psychology, biology, astronomy, economics and engineering. Hence the scale consists of three objects varying in size and roundness that describe the intensity of pain from low, medium to high.
https://bodyinmind.org/children-reporting-pain/
low
medium
high
TESTING + VALIDATION
Gabby, age 8, using one of the categorical tools to communicate where she felt stabbing stomach ache.
Pediatrician and researcher Dr.Daniel Tsze giving his expert feedback on the tools.
MATERIALS Materials like metal, wood, ceramics, glass, and plastics are used in many medical device applications. Plastics have a wide range of desirable attributes that lend themselves to increased use in the design and development of many medical device applications. Complex shapes, multiple functionalities, and the use of a minimal number of parts (part reduction) in the device or product all make the use of plastics very attractive to designers. Such designs were not possible with materials like wood, metals, ceramics, and glass. Unique processing methods, assembly options, and design styles can reduce manufacturing costs and increase speed and part throughput significantly.
Plastics
Low cost Easy to sanitize Strong and Lightweight
Metals
Ceramics
Glass
PROPERTY
PLASTICS
METAL
CERAMICS
GLASS
Flexibility
Excellent
Poor
Poor
Poor
Clarity
Good
Poor
Poor
Excellent
Design Versatility
Excellent
Poor
Poor
Poor
Barrier Properties
Good
Excellent
Poor
Excellent
Toughness
Excellent
Good
Good
Poor
Strength
Poor
Excellent
Good
Good
Chemical Resistance
Good
Poor
Excellent
Excellent
Sealability
Excellent
Poor
Poor
Poor
Performance
Excellent
Poor
Good
Poor
Weigth/volume ratio
Excellent
Poor
Poor
Poor
Perforance/weight ratio Excellent
Poor
Poor
Good
Performance ratio/cost
Poor
Poor
Poor
Excellent
Plastics have superior design flexibility compared to metals, ceramics, and glass. They can be processed into innumerable shapes, sizes, thicknesses, and colors, and their properties can be tailored to meet a wide spectrum of physical, mechanical, chemical, and biocompatibility requirements. Additives and fillers can be used to render plastics flexible or rigid, insulating or conductive, hydrophilic or hydrophobic, transparent or opaque, and chemically resistant and sterilization resistant. They are lightweight compared to metals, ceramics, and glass and can have an excellent balance of strength, stiffness, toughness, ductility, and impact resistance. Many applications are using plastic to replace either metal or glass to reduce costs, leverage design flexibility, and still maintain performance. Plastics in Medical Devices: Properties, Requirements, and Applications by Vinny R. Sastri
DISINFECTION & STERILIZATION Noncritical items are those that come in contact with intact skin but not mucous membranes. Intact skin acts as an effective barrier to most microorganisms; therefore, the sterility of items coming in contact with intact skin is “not critical.� In this guideline, noncritical items are divided into noncritical patient care items and noncritical environmental surfaces. In contrast to critical and some semicritical items, most noncritical reusable items may be decontaminated where they are used and do not need to be transported to a central processing area. Virtually no risk has been documented for transmission of infectious agents to patients through noncritical items. Most Environmental Protection Agency (EPA)-registered disinfectants have a 10-minute label claim.
Critical Items
Semicritical Items
Noncritical Items
come in contact with blood or sterile tissue
come in contact with mucus membranes
come in contact with unbroken skin
https://www.cdc.gov/infectioncontrol/guidelines/disinfection/rational-approach.html
COST ANALYSIS Out of pocket health approaches 358.8 billion
Other conventional care $255.1 billion
Reimbursed $2.46 trillion
Physician Visits $49.6 billion Complementary practitioner visits $14.7 billion
Prescription Drugs $54.1billion Natural Products $12.8 billion self care purchases $2.7 billion
Physical Pain costs trillions of dollars to Americans every year due to lack of adequate treatment and assessment. Tangible Pain Scales contributes to the medical industry by providing adequate assessment of pain which in as a result will help provide accurate treatment, therefore saving millions of dollars in healthcare.
NEXT STEPS • Apply for an IRB certificate in order to beable to test ethically. • Developing the categorical and continuous sclales through testing in ER with children from ages 3-8 years old. • Proposing a research Paper in collaboration with Dr.Daniel Tsze to conclude results from the testing.
Tangible Pain Scales (TPS) is a work in progess. A major success for this project will be when children from various cultures, race and educational backgrounds can easily graspthe concept of TPS and self-report their pain adequately. In order to do so, I need to collect statistics on the success and failures of different object to realize what works and what doesn’t.
WWW.AISHWARYAJ.COM
© AISHWARYA JANWADKAR
TANGIBLE PAIN SCALES Pain is one of the most misunderstood, under-diagnosed, and under-treated medical problems. Tangible Pain Scales are tactile tools that enhance non-verbal doctor/patient communication and help children self-report their pain adequately. They consist of two scales : A continuous scale that measures the intensity of the pain and a categorical scale that measures the character of the pain.
25.3 million
Americans suffer from daily pain
40%
of children complain of pain that occurs at least once weekly
2.1 million
people have misused opioid prescriptions
CONTINUOUS ASSESSMENT Pain needs to be quantified to be treated effectively. Research shows that scales with fewer response options are more efficient especially with 3-4 year olds.
The Goldilocks Principle
CATEGORICAL ASSESSMENT Each of us experiences our pain differently, making it highly subjective. Categorical pain assessment tools help identify the character of the pain such as sharp or dull pain, soreness, stabbing pain, etc through tactile and visual objects.