Assessing Pain in in Post Operative Breast Cancer Patients

Assessing Pain in in Post Operative Breast Cancer Patients Comparison between Brief  Pain  Inventory (BPI) and Numerical Rating Scale (NRS) for post-operative pain assessment in Saudi Arabian  breast cancer patients. Questions Does  BPI assess  post-operative breast cancer pain  more  accurately than NRS? Summary: Effective pain assessment is one of the  fundamental  criteria  of the  management of  pain. It involves  the  evaluation of pain intensity, location of the pain and response to treatment. There are  a  number  of multi and one-dimensional assessment tools  that  have already been established to assess cancer pain. Among these  are the  Brief Pain Inventory (BPI) and  the  Numerical Rating Scale (NRS), Breast cancer is  a growing public  concern in Saudi Arabia  as rates continue to escalate, with patients  also  suffering multiple problems after surgery. Therefore, my research aim is to  conduct a  comparative study  of tools  used to  assess post-operative breast cancer pain  in  Saudi Arabian  patients  and determine which is the most effective. In this process I will use questionnaires for both nurses and patients to collect data,  followed by statistical analysis and  a  comparative  study between  the  BPI and NRS. Research Hypothesis: BPI assesses  post-operative breast cancer pain  in Saudi Arabian  patients  more  accurately than NRS.   Null hypothesis: There is no significant difference between BPI and NRS  as tools for  assessing post-operative breast cancer pain  in  Saudi Arabian  patients Background: Pain is defined as  Ã¢â‚¬Ëœthe normal, predicted physiological response to an adverse chemical, thermal or mechanical stimulus related with surgery, trauma or acute illness’ (Carr and Goudas, 1999).  Pain assessment is a crucial component for the effective management of post-operative pain in relation to breast cancer. The patient’s report is the main  resource  of information  regarding the  characterisation and evaluation of pain; as such, assessment is  the ‘dynamic method of explanation of the syndrome of the pain, patho-physiology and  the basis for  designing a protocol for its management’  (Yomiya, 2011). A recent survey  questioned almost 900 physicians  897 and found  that  76% reported substandard  pain assessment  procedures  as the single most important barrier  to  suitable  pain management (Roenn  et al, 1993). Breast cancer is characterized by  a  lump or thickening in  the  breast, discharge or bleeding,  a  change in colour of  the  areola, redness or pitting of skin  and a  marble like area under  the  skin (WebMD, 2014[A1]). Breast cancer  has a high prevalence rate globally and is the second most diagnosed cancer in women. Approximately  1.7 million cases were reported in 2012  alone  (WCRFI, 2014). In 2014,  just over  15,000  women  have  already  been  diagnosed with breast cancer: this figure is predicted to rise to around 17,200 in 2020 Breast cancer  has also been identified  as one of the major cancer related problems in Saudi Arabia, with 6,922 women were  assessed[A2]  for breast cancer between 2001-2008 (Alghamdi,  2013[A3]). D  Pain assessment tools Polit  et al  (2006) conducted  a systematic review of the evidence base  and  recorded a total of  80 different assessment tools that  contained  at least one pain item. The  tools were then  categorised into pain tools  (n=48)  and general symptoms tools  (n=32) . They were then  separated into uni-dimensional  tools  (which measure the pain intensity)  and multi-dimensional tools  (include more than one pain dimension). 33%  of all pain tools  (n=16) were uni-dimensional, and  50% of all  general symptom tools  (n=16)were uni-dimensional. 58% of the uni-dimensional tools  employed  single  item scales such as  the  Visual  Analogue  Scale (VAS), Verbal Rating Scales (VRS)  and NRS (Numerical  Rating  Scale). The most common dimension  included  was pain intensity, present in 60% of  tools. In  the assessed tools, 60% assessed pain  in a  multi-dimensional  format. Among  pain tools,  67% were found   to be  multi-dimensional  compared with 50% of the general symptom tools.  38% of all multi-dimensional tools were two-dimensional.  The most  commonly used  dimension was  Ã¢â‚¬Ëœintensity’,  present  in 75% of  all  multi-dimensional tools. Other common  dimensions  include  interference, location  and beliefs. All the dimensions were specifically targeted by two particular tools which were disease-specific tools and tools that measure pains affect, beliefs, and coping-related  issues[A4]. Multidimensional Pain assessment tools: F  The  adequate measurement of pain  requires  more than one tool. Melzack and Casey (1968)  highlight that  pain assessment  Ã¢â‚¬Ëœshould include three dimensions which are sensory-discriminative, motivational-affective and cognitive-evaluative’.  This builds on the  earlier  proposal of  Beecher (1959)  who considered that all tools should include the  two dimensions  of  pain and reaction to pain. Cleeland (1989)  considered that  the  two dimensions  should be classified  as sensory and reactive. Sensory dimensions  should record  the intensity or severity  of pain  and the reactive dimensions should include accurate measures of interference  in the  daily function  of the patient.   Multi-dimensional pain assessments generally consist of  six  dimensions: physiologic, sensory, affective, cognitive, behavioural and sociocultural (McGuire, 1992). Cleeland (1989)  interviewed patients and  found  that  seven items could effectively measure the intensity and effects of the pain in daily activities: these  comprise  of  general activity, walking, work, mood, enjoyment of life, relations with others and sleep. These elements were later subdivided  into two groups: ‘REM’  (relations with others, enjoyment of life and mood) and  Ã¢â‚¬ËœWAW’  (walking, general activity and work). Later, Cleeland  et al  (1996) developed  the  Brief  Pain  Inventory (BPI) in both  its  short and long form.  It was designed  to capture two  categories  of interference such as  activity and affect on  emotions.  The  BPI provides  a relatively  quick and easy method  of measuring  the  intensity  of pa in  and the  level of  interference  in the  daily activities of the  sufferer. With the BPI  tool, patients are graded  on  a 0-10 and it  was  specifically  designed  for the  assessment of  cancer related pain. Patients  are  asked  about the intensity of the pain that they are experiencing at present, as well as the pain intensity over  the last 24 hours as  the  worst, least  or  average  pain (also  on a scale of 0-10). Each  scale is bound  by the words ‘no pain’  (0) and  Ã¢â‚¬Ëœpain as bad as you can imagine’  (10). Patients are also  requested  to rate the degree to which pain interferes  with their  daily activities within the seven  domains  on a scale of 0-10.  that comprise general activity, walking, mood, sleep, work, relations with other persons, and enjoyment of life using similar scales of 0 to  10[A5]. These scales are only confined by the words ‘does not interfere’ and ‘interferes  completely[A6]’ (Tan  et al, 2004).  Validation of BPI across the world among the different language people has already been justified.  [A7]Additionally, the localization of the pain in the body  could be  [A8]assessed and details of current medication are assessed (Caraceni  et al, 1996). Uni-dimensional pain assessment tool:   Previous studies  have  shown  that  the  Numerical  Rating  Scale (NRS) had the power to assess pain intensity for patients  experiencing chronic pain and was also an effective assessment tool for patients with cancer related pain. The  NRS consists of a numerical scale range between 0-100 where 0 was considered as one extreme point represented no pain and 100 was considered other extreme point which represented bad/ worse pain  (Jensen et al, 1986). Turk  et al  (1993) developed  an  11 point  NRS (scale 0-10) where 0 equalled  no pain and 10  equalled  worst pain. Though cancer pain differs from acute, postoperative and chronic  pain experiences, the most common feature is its subjective nature. [A9]  In this regard a consensus meeting on cancer pain assessment and classification was held in Italy in 2009  with the  recommendation that  pain intensity should be measured  on a  scale  of  0-10 with  Ã¢â‚¬Ëœno pain’à ‚  and  Ã¢â‚¬Ëœpain as bad as you can  imagine[A10]’  (Hjermstad  et al.,  2011). Krebs  et al.  (2007) categorised NRS scores as mild (1–3), moderate (4–6), or severe (7–10). A rating of  4 or 5  is  the most commonly recommended lower limit  for moderate pain and 7 or 8 for severe pain. Aimed at moderate pain assessment,  For the purpose of clinical and administrative use the  recommendation for moderate pain assessment on the scale is a score of 4. Importance of post- operative pain assessment: Post-operative pains  is  very common after surgery  and  the  use of  medication  often  depends  on the intensity of pain  that the patient is experiencing  (Chung  et al, 1997). Insufficient assessment of post-operative pain  can have a  Ã¢â‚¬Ëœsignificant detrimental  effect on raised levels of anxiety, sleep disturbance, restlessness, irritability, aggression, distress and suffering’  (Carr  et al,  2005). Additional  physiological  effects can include  increased  blood pressure, vomiting and paralytic ileus, increased adrenaline production, sleep vein thrombosis and pulmonary embolus (Macintyre and Ready, 2002). Effective post-operative pain assessment ensures better pain management  and can significantly reduce the risk of the symptoms listed above, giving minimal distress or suffering  to patients  and reducing  potential complications (Machintosh, 2007). References: Alghamdi IG, Hussain II, Alhamdi MS, El-Sheemy MA (2013) Arabia: an observational descriptive epidemiological analysis of data from Saudi Cancer Registry 2001-2008. Dovepress. Breast cancer: Targets and therapy; 5: 103-109. Caraceni A, Mendoza TR, Mencaglia E (1996) A validation study of an Italian version of the Brief Pain Inventory (Breve Questionario per la Valutazione del Dolore). Pain; 65: 87-92. Carr D and Goudas L. C. (1999) Acute pain. Lancet 353, 2051-2058. Carr EC, Thomas NV, Wilson-Barnet J (2005) Patient experiences of anxiety, depression and acute pain after surgery: a longitudinal perspective. International Journal of Nursing Studies. 42(5): 521-530. Chung F, Ritchie E, Su J (1997) Postoperative pain in ambulatory surgery. Anaesthesia and Analgesia 85: 808-816.   Cleeland CS (1989) Measurement of pain by subjective report. Issues in pain measurement. New York: Raven Press; pp. 391-403. Cleeland CS, Nakamura Y, Mendoza TR, Edwards KR, Douglas J, Serlin RC (1996) Dimensions of the impact of cancer pain in a four country sample: new information from multidimensional scaling. Pain 67 (2-3): 267-273. Hjermstad MJ, Fayers PM, Haugen DF, Caraceni A, Hanks GW, Loge JH, Fainsinger R, Aass N, Kaasa S (2011) Studies comparing numerical rating scale, verbal rating scale and visual analogue scales for assessment of pain intensity in adults: a systematic literature review. Journal of pain and symptom management. 41 (6): 1073-1093. Jensen MP, Karoly P, Braver S (1986) The measurement of clinical pain intensity: a comparison of six methods. Pain 27: 117-126. Krebs EE, Carey TS, Weinberger M (2007) Accuracy of the pain numeric rating scale as a screening test in primary care. Journal of general medicine. 22(10): 1453-1458. Machintosh C (2007) Assessment and management of patients with post-operative pain. Nursing Standard. 22 (5): 49-55. Macintyre PE, Ready LB (2002) Acute pain management. Second edition, WB Saunders, Edinburgh. McGuire DB (1992) Comprehensive and multidimensional assessment and measurement of pain. Journal of pain and symptom management; 7(5): 312-319. Melzack R and Casey KL (1968) Sensory, motivational and central control determinants of pain: a new conceptual model. In: Kenshalo DR, editor. The skin senses proceedings. Springfield IL: Thomas; pp. 423-439. National Breast Cancer Foundation (NBCF): 2014;  http://www.nbcf.org.au/Research/About-Breast-Cancer.aspx Polit JCHC, Hjermstad MJ, Loge JH, Fayers PM, Caraceni A, Conno FD, Forbes K, Furst CJ, Radbruch L, Kaasa S (2006) Pain assessment tools: Is the content appropriate for use in palliative care? Journal of pain and symptom management, 32 (6): 567-580. Roenn JHV, Cleeland CS, Gonin R, Hatfield AK, Pandya KJ (1993) Physician attitudes and practice in cancer pain management. A survey from the Eastern Cooperative Oncology Group. Annals of Internal Medicine, 119(2): 121-126. Tan G, Jensen MP, Thornby JI, Shanti BF (2004) Validation of the brief pain inventory for chronic non-malignant pain. The Journal of Pain. 5(2): 133-137. Turk DC, Rudy TE, Sorkin BA (1993) Neglected topics in chronic pain treatment outcome studies: determination of success. Pain (53):3–16. WebMD (2014)  http://www.webmd.com/breast-cancer/guide/overview-breast-cancer. World cancer research fund international (WCRFI): 2014;  http://www.wcrf.org/cancer_statistics/data_specific_cancers/breast_cancer_statistics.php. Youmiya K (2011) Cancer pain assessment. The Japanese Journal of Anesthesiology. 60(9): 1046-1052. [A1]I would consider using a more reputable source for describing medical symptoms themselves (Grey’s Anatomy, WHO guidelines etc) [A2]and treated? [A3]Is it worth commenting that breast cancer reporting rates in SA might be different from actual prevalence? Lack of awareness regarding certain cancers often results in late diagnosis or misdiagnosis. [A4]This sentence is unclear. I am assuming that you are stating that all dimensions are present in two particular tools? [A5]I’ve deleted this as you have highlighted the same domains in the previous paragraph and the reader will already be familiar with this term. [A6]Sentence shows up on copyscape / turnitin but it’s fine as a directly referenced quote. [A7]Is this sentence stating that the BPIs valid internationally because it has been adjusted culturally / linguistically for all groups? [A8]Are you making a suggestion that it could be assessed, or stating that sometimes people do assess localised pain in the body? [A9]Deleted as the next sentence deals with this already. [A10]Again shows up in turnitin: any quotes must be in inverted commas so that tutors / markers will not downgrade or suspect plagiarism.