1 Pain Assessment and Treatment Goals

Pain mechanisms

Pain can involve different mechanisms, and more than one mechanism may contribute to a person’s pain. Distinguishing among mechanisms helps describe the pain experience without assuming that one explanation accounts for every symptom.

• Nociceptive pain is associated with actual or threatened damage to non-neural tissue. For example, a sprained ankle may hurt when weight is placed on swollen tissue.

• Neuropathic pain is caused by a lesion or disease of the somatosensory nervous system. Burning and tingling in the feet associated with diabetic nerve damage is an example.

• Nociplastic pain arises from altered nociception when there is no clear evidence that tissue damage or a nerve lesion or disease fully explains the pain. Widespread pain and tenderness not fully explained by tissue damage or a nerve lesion is an example.

Assess pain and its effects

A patient-centered assessment describes the person’s pain experience and how it affects their life, rather than recording intensity alone. Ask about location, quality, timing, aggravating and relieving factors, and severity. Also ask how pain affects sleep, activity, mood, and other tasks that matter to the person.

The patient’s own account is central: take a Self-report of pain seriously. Observed behavior can add information, especially when communication is limited, but a calm appearance alone does not disprove reported pain. Consider the patient’s communication needs and priorities; when the patient can communicate, do not rely on another person’s estimate or use the same description for everyone with the same diagnosis.

For example, a patient who reports pain of $\frac{8}{10}$ after surgery may identify coughing and walking to the bathroom as their main priorities. Ask how pain affects those goals and daily activities, then agree on a realistic treatment goal rather than choosing treatment before finding out what matters to the patient.

Measure pain and interference

A numeric rating can track pain intensity, but it is only one part of assessment and does not describe the whole outcome. The PEG captures average pain, interference with enjoyment of life, and interference with general activity.

For example, a patient’s ratings for the past week are $\frac{6}{10}$ for average pain, $\frac{7}{10}$ for interference with enjoyment of life, and $\frac{5}{10}$ for interference with general activity. The mean PEG score is:

The mean summarizes the three ratings; the individual ratings still show which aspects of pain and interference were reported.

Set patient-centered goals

Ask what the patient wants to be able to do, then agree on a realistic treatment goal together. Pain relief matters, but goals can also address function and quality of life. Goals should reflect the patient’s priorities rather than focus only on lowering a pain score to zero.

A Functional goal can be specific and tied to an activity that matters to the individual. For example, the patient might aim to walk to the mailbox and back once daily. Progress could be measured by whether the patient completes the activity and how often.

Reassess treatment and progress

After starting treatment, reassess at a clinically appropriate time based on the intervention and situation, including the expected response. Compare findings with the baseline using comparable measures of pain and function, revisit progress toward the patient’s goals, and check for relevant unwanted effects. Document the findings and use them to inform the next step.

Do not judge success by pain intensity alone. If a patient’s pain remains $\frac{6}{10}$ but they can now sleep through most of the night and prepare breakfast, consider both the unchanged pain rating and the functional improvements. Ask whether the patient considers the plan helpful and whether further goals remain. Evaluate benefits, risks, and the patient’s preferences rather than relying only on whether the patient is pain-free.