To assess the severity of pain syndrome, as well as the effectiveness of its elimination, the so-called ranking scales. Visually analogue scale(VAS) is a straight line segment 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 value of which approximately corresponded to the intensity of the pain he experienced. After measuring the marked area, the conditional pain intensity was determined in points (corresponding to the length in cm). The verbal ranking scale is the same as VAS, but with pain ratings located along a straight line: weak, moderate, strong, etc. The numerical rating scale is the same 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.

We obtained qualitative characteristics of the pain syndrome using the McGill pain questionnaire (183). This test includes 102 pain parameters, distributed into three main groups. The first group (88 descriptive expressions) is associated with the nature of pain, the second (5 descriptive expressions) with the intensity of pain, and the third (9 indicators) with the duration of pain. The parameters of the first group are distributed into 4 classes and 20 subclasses. The first class is the parameters of sensory characteristics (pain “pulsating, 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 - evaluative parameters (pain "irritating, suffering, unbearable", etc.), the fourth - mixed sensory-affective parameters (pain “annoying, 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.). Subsequent analysis took into account the number and rank position of selected parameters for each class.

Quantitative assessment of pain was carried out using a dolorimeter (Kreimer A. Ya., 1966). The operating principle of the dolorimeter is based on measuring the pressure at which pain occurs at the point being examined. The pressure measurement is recorded using a rod with a rubber tip connected to a spring mechanism. On the flat surface of the rod there is a scale, graduated into 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 pain of 9.2±0.4 kg/cm or more, determined in 30 practically healthy people, was taken as the norm. To standardize the indicators, the pain coefficient (KB), which shows the ratio of normal algesimetric indicators to the corresponding indicators at the points under study. Normally it is equal to one relative unit. The test was also used during the treatment process to determine the effectiveness of the chosen treatment method.

The described approach allowed us to carry out objective differential diagnostics and, based on the results of complex diagnostics, an individual treatment and rehabilitation regimen in the postoperative period was selected.

... objectification of pain is one of the intractable problems in the clinical practice of doctors of various specialties.

Currently, to assess the presence, degree, and location of pain in the clinic, (1) psychological, (2) psychophysiological and (3) neurophysiological methods. Most of them are based on a subjective assessment of their feelings by the patient himself.

The simplest ways to quantify pain are the ranking scale (Bonica J.J., 1990).

Numerical ranking scale consists of a sequential series of numbers from 0 to 10. Patients are asked to rate their pain sensations with numbers from 0 (no pain) to 10 (maximum possible pain). Patients can easily learn to use this scale. The scale is simple, visual and easy to fill out and can be used quite often during treatment. This allows you to obtain information about the dynamics of pain: by comparing previous and subsequent indicators of pain, you can judge the effectiveness of the treatment.

Verbal ranking scale consists of a set of words characterizing the intensity of pain. The words are lined up in a row, reflecting the degree of increase in pain, and are numbered sequentially from less severe to greater. The most commonly used series of descriptors is: no pain (0), mild pain (1), moderate pain (2), severe pain (3), very severe (4) and intolerable (unbearable) pain (5). The patient chooses the word that most closely matches his feelings. The scale is easy to use, adequately reflects the patient's pain intensity and can be used to monitor the effectiveness of pain relief. The verbal rating scale data compares well with the results of pain intensity measurements using other scales.

Visual analogue scale(VAS) is a straight line 10 cm long, the beginning of which corresponds to the absence of pain - “no pain.” The end point on the scale reflects excruciating, unbearable pain – “unbearable pain.” The line can be either horizontal or vertical. The patient is asked to make a mark on this line that corresponds to the intensity of the pain he is experiencing at the moment. The distance between the beginning of the line (“no pain”) and the mark made by the patient is measured in centimeters and rounded to the nearest whole. Each centimeter on the visual analogue scale corresponds to 1 point. As a rule, all patients, including children over 5 years of age, easily learn the visual analogue scale and use it correctly.

The visual analog scale is a fairly sensitive method for quantifying pain, and data obtained using the VAS correlates well with other methods of measuring pain intensity.

McGill Pain Questionnaire(McGill Pain Questionnaire). Pain is a complex, multidimensional feeling, which simultaneously reflects the intensity of pain, its sensory and emotional components, therefore, when using one-dimensional ranking scales, the doctor evaluates pain only quantitatively, without taking into account the qualitative features of pain. In the early 70s of the 20th century, R. Melzack developed the McGill Pain Questionnaire, in which all words (descriptors) describing the qualitative characteristics of pain are divided into 20 subclasses (Melzack R., 1975). The McGill Pain Questionnaire has been translated into many languages ​​and has proven highly effective in multidimensional pain assessment.

In our country, there are several versions of the questionnaire in Russian, but the most successful is the version prepared by employees of the Russian State Medical University, Moscow State University. M.V. Lomonosov and CITO named after. N.N. Priorov (Kuzmenko V.V. et al., 1986), which is given below.

MCGILL PAIN QUESTIONNAIRE

Please read all the definition words and mark only those that most accurately describe your pain. You can mark only one word in any of the 20 columns (rows), but not necessarily in each column (row).

What words can you use to describe your pain? (sensory scale)

(1) 1. pulsating, 2. grasping, 3. jerking, 4. constricting, 5. pounding, 6. gouging.
(2) similar to: 1. electric discharge, 2. electric shock, 3. shot.
(3) 1. piercing, 2. biting, 3 drilling, 4. drilling, 5. piercing.
(4) 1. sharp, 2. cutting, 3. striping.
(5) 1. pressing, 2. squeezing, 3. pinching, 4. squeezing, 5. crushing.
(6) 1. pulling, 2. twisting, 3. tearing out.
(7) 1. hot, 2. burning, 3. scalding, 4. scorching.
(8) 1. itchy, 2. pinching, 3. corrosive, 4. stinging.
(9) 1. dull, 2. aching, 3. brainy, 4. aching, 5. splitting.
(10) 1. bursting, 2. stretching, 3. tearing, 4. tearing.
(11) 1. diffuse, 2. spreading, 3. penetrating, 4. penetrating.
(12) 1. scratching, 2. sore, 3. tearing, 4. sawing, 5. gnawing.
(13) 1. mute, 2. cramping, 3. chilling.

What feeling does pain cause, what effect does it have on the psyche? (affective scale)

(14) 1. tires, 2. exhausts.
(15) causes a feeling of: 1. nausea, 2. suffocation.
(16) causes feelings of: 1. anxiety, 2. fear, 3. horror.
(17) 1. depresses, 2. irritates, 3. angers, 4. enrages, 5. despairs.
(18) 1. weakens, 2. blinds.
(19) 1. pain-interference, 2. pain-annoyance, 3. pain-suffering, 4. pain-torture, 5. pain-torture.

How do you rate your pain? (evaluative scale)

(20) 1. weak, 2. moderate, 3. strong, 4. strongest, 5. unbearable.

Each subclass consisted of words that were similar in their semantic meaning, but differed in the intensity of the pain sensation they conveyed. The subclasses formed three main classes: a sensory scale, an affective scale and an evaluative (evaluative) scale. Descriptors of the sensory scale (subclasses 1–13) characterize pain in terms of mechanical or thermal effects, 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 vegetative manifestations. The evaluative scale (20th subclass) consists of 5 words expressing the patient’s subjective assessment of the intensity of pain.

When filling out the questionnaire, the patient selects words that correspond to his feelings at the moment in any of 20 subclasses (not necessarily in each, but only one word in a subclass). Each selected word has a numerical indicator corresponding to the ordinal number of the word in the subclass. The calculation comes down to determining two indicators: (1) index of the number of selected descriptors, which is the sum of the selected words, and (2) pain rank index– the sum of the ordinal numbers of descriptors in subclasses. Both measures can be scored for the sensory and affective scales separately or together. The evaluative scale is essentially a verbal ranking scale in which the selected word corresponds to a certain rank. The obtained data is entered into a table and can be presented in the form of a diagram.

McGill Questionnaire allows you to characterize in dynamics not only the intensity of pain, but also its sensory and emotional components, which can be used in the differential diagnosis of diseases.

Age factor in assessing pain in children. Children aged 8 years and older can use the same visual analogue scales as adults to assess pain severity - this scale is plotted on a ruler, which should be positioned horizontally.

For children from 3 to 8 years old, when self-assessing the severity of pain, you can use either facial scales (faces in photographs or drawings are lined up in a row, in which the facial expressions of distress gradually intensify) or scales with a color analogy (rulers with increasing brightness of red color, indicating the severity of pain) . Reported high degree similarities in pain severity parameters obtained using the photographic portrait scale and the color analogy scale in children aged 3 to 7 years after surgery.

The use of child behavior scales is the main method for assessing pain in newborns, infants and children aged 1 to 4 years, as well as in children with developmental disorders. In such scales, pain is assessed by facial expression, motor responses of the limbs and trunk, verbal responses, or a combination of behavioral and autonomic changes. In some of these techniques, the term “distress” reflects not only pain, but also fear and anxiety. Behavioral scales may underestimate the severity of long-term pain when compared with self-report measures.

During surgery and in critical care settings, it is prudent to document physiological responses to pain, although these responses may be nonspecific. For example, tachycardia can be caused not only by pain, but also by hypovolemia or hypoxemia. Hence, ( !!! ) it can be difficult to assess the severity of pain in newborns, infants and children aged 1 to 4 years, as well as in children with significant developmental disorders. If the clinical picture does not allow definite conclusions to be drawn, stress-levelling measures should be resorted to, which include creating comfort, nutrition and analgesia, and the effect can be used to judge the cause of distress.

Quantitative assessment of pain sensitivity refers to integrative indicators that reflect the general state of the body and its response to physiological or psycho-emotional stress, therefore measuring pain thresholds is very useful method in a comprehensive examination of patients. The threshold of pain sensitivity is taken to be the minimum value of the stimulus that is perceived by the test subject as a painful sensation.

Pain threshold determined using instrumental methods, in which various mechanical, thermal or electrical stimuli are used as stimuli (Vasilenko A.M., 1997). The threshold of pain sensitivity is expressed in (1) units of stimulus strength when using methods with increasing intensity, or in (2) units of time when a stimulus is applied with constant force. For example, when measuring pain sensitivity using a strain gauge, which provides a gradual increase in pressure on the skin, the pain threshold is expressed in units of the ratio of pressure force to tip area (kg/cm2). In thermoalgometry with a constant thermode temperature, the threshold of pain sensitivity is expressed in seconds - the time from the beginning of exposure to the onset of pain.

Using methods for quantitative assessment of pain sensitivity, it is possible to (1) detect areas of hyperalgesia in pathologies of internal organs, (2) trigger points in myofascial pain syndromes, (3) monitor the effectiveness of analgesics, and in some cases (for example, with psychogenic pain syndromes) ( 4) determine therapeutic tactics.

Electrophysiological methods. Electrophysiological methods are also used in clinical studies to assess patients' pain sensitivity and monitor the effectiveness of pain relief. The most widely used method for recording the nociceptive withdrawal reflex, or RIII reflex.

Nociceptive withdrawal reflex(NRO), or nociceptive flexor reflex, is a typical defensive reflex. This type of protective reflexes, which occur in both animals and humans in response to painful stimulation, was first described by Sherrington in 1910 and has been used clinically since 1960 to objectify pain (Kugekberg E. et al., 1960). Most often, NRO is recorded in response to electrical stimulation of n. suralis or plantar surface of the foot (Vein A.M., 2001; Skljarevski V., Ramadan N.M., 2002). At the same time, NPO can be recorded during painful stimulation of the fingers (Gnezdilova A.V. et al., 1998) and even with heterosegmental stimulation (Syrovegina A.V. et al., 2000).

When recording NPO, two components are distinguished in EMG activity – RII and RIII responses. The RII response has a latent period of 40–60 ms and its appearance is associated with the activation of thick low-threshold Aβ fibers, while the RIII response occurs with a latent period of 90–130 ms at an intensity of stimulation exceeding the excitation threshold of thin Aδ fibers. It is believed that the NPO is polysynaptic, the reflex arc of which closes at the level of the spinal cord.

However, there is evidence indicating the possibility of involvement of supraspinal structures in the mechanisms of occurrence of NRA. Direct confirmation of this is studies that compared the characteristics of changes in NPO in intact and spinal rats (Gozariu M. et al., 1997; Weng H.R., Schouenborg J., 2000). In the first study, the authors found that in intact rats, the preservation of supraspinal pain control mechanisms counteracts the development of an increase in NPO amplitude under conditions of prolonged painful stimulation, in contrast to spinal animals. The second paper provides evidence of an increase in NPO inhibitory reactions to heterotopic nociceptive stimuli under conditions of spinalization of animals.

Understanding the fact that supraspinal structures of the brain are involved in the formation of NPO not only expands the diagnostic capabilities of the method, but also allows its use in the clinic for an objective assessment of the severity of pain not only during homotopic stimulation, but also during heterosegmental pain stimulation.

Method of exteroceptive suppression of voluntary muscle activity in m. masseter. To study the mechanisms of development of headaches and facial pain, the clinic also uses the method of exteroceptive suppression of voluntary muscle activity in the m. masseter (Vein A.M. et al., 1999; Andersen O.K. et al., 1998; Godaux E., Desmendt J.E., 1975; Hansen P.O. et al., 1999). This method is essentially a variation of the nociceptive withdrawal reflex.

It has been established that perioral electrical stimulation causes two successive periods of inhibition in the tonic EMG activity of the masticatory muscles, designated ES1 and ES2 (exteroceptive suppression). The early period of inhibition (ES1) occurs with a latency of 10–15 ms, the late period (ES2) has a latency period of 25–55 ms. The degree of exteroceptive suppression in the masticatory muscles is enhanced by homotopic nociceptive activity in trigeminal afferents, which is used clinically to quantify pain in patients with headaches and facial pain.

The exact mechanisms of development of ES1 and ES2 are unknown. ES1 is thought to be associated with oligosynaptic activation by trigeminal afferents of interneurons of the trigeminal complex nuclei, exerting an inhibitory effect on motoneurons of the masticatory muscles, while ES2 is mediated by a polysynaptic reflex arc involving neurons of the medullary part of the spinal trigeminal nucleus (Ongerboer de Visser et al., 1990). . At the same time, there is evidence that ES2 can be recorded during heterotopic pain stimulation, and electrical stimulation of the fingers reduces ES2 in the masticatory muscles (Kukushkin M.L. et al., 2003). This suggests that the mechanisms of ES2 development are more complex and are realized with the participation of supraspinal centers through the spinocorticospinal recurrent loop.

Method for recording somatosensory evoked potentials. Over the past two decades, somatosensory evoked potentials (SSEPs) have been widely used to measure clinical and experimental pain in humans. There is extensive research material on this issue, summarized in a number of review articles (Zenkov L.R., Ronkin M.A., 1991; Bromm B., 1985; Chen A.C.N., 1993). It is believed that the early SSEP components (N65-P120) reflect the intensity of the physical stimulus used to evoke pain, while the amplitude of the late SSEP components (N140-P300) correlates with the subjective perception of pain.

The idea that the amplitude of late SSEP components may reflect the subjective perception of pain was formed on the basis of studies that showed a positive relationship between a decrease in the amplitude of the N140-P300 SSEP components and the administration of various analgesics. At the same time, the variability of the amplitude of late SSEP components is well known, which depends on a number of psychological factors, such as attention, memory, emotional state (Kostandov E.A., Zakharova N.N., 1992), which can largely change without only analgesics, but also the research procedure itself. In addition, recent publications on this problem (Syrovegin A.V. et al., 2000; Zaslansky R. et al., 1996) indicate a low connection between subjective pain perception and the amplitude of late SSEP components.

!!! The most reliable among electrophysiological methods for monitoring the magnitude of subjective pain sensation remains the nociceptive withdrawal reflex (NRE).

Functional mapping of neuronal activity of brain structures. Recently, methods of functional mapping of neuronal activity of brain structures in acute and chronic pain have been increasingly introduced into clinical practice (Coghill R.C., et al., 2000; Rainville P. et al., 2000). The most famous of them are: (1) positron emission tomography and method (2) functional magnetic resonance. All functional mapping methods are based on recording a local hemodynamic reaction in brain structures, which has a positive correlation with the electrical activity of neuron populations.

Using functional mapping methods, it is possible to visualize in three-dimensional spatial coordinates (millimeters in humans and micrometers in animals) changes in neuronal activity in response to presented nociceptive (painful) influences, which makes it possible to study the neuro-physiological and neuro-psychological mechanisms of pain.

Literature: 1. Guide for doctors “General pathology of pain” M.L. Kukushkin, N.K. Khitrov; Moscow, “Medicine”; 2004. 2. “The Use of Analgesics in the Treatment of Pain in Children” Editor Elester J. Wood, Charles Verde, Javil F. Sethna (Children's Hospital Boston, Harvard Medical School, Boston, USA, 2002).

For ethical reasons, it is customary to use only non-invasive methods to diagnose pain in cancer patients. At the beginning, it is necessary to study the history of pain (duration, intensity, localization, type, factors that increase or decrease pain; time of pain occurrence during the day, previously used analgesics and their doses and effectiveness). In the future, a clinical examination of the patient should be carried out to assess the nature and extent of the oncological process; examine the physical, neurological and mental status of the patient. It is necessary to familiarize yourself with the data of clinical and laboratory research methods (clinical and biochemical blood tests, urine tests), which is important for choosing the safest combination of analgesics and adjuvant agents for a given patient (blood pressure, heart rate, ECG, ultrasound, radiography, etc.).

The intensity of chronic pain syndrome is assessed using a verbal (verbal) rating scale (VRS), a visual analogue scale (VAS), and pain questionnaires. (McGill Pain Questionaire, etc.). The simplest and most convenient for clinical use is 5-point ShVO, which is filled out 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, 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 oncology patient can be fairly objectively carried out using 5-point physical activity scale:

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

To assess the general condition of a cancer patient, it is used Karnofsky quality of life scale, where the dynamics of the patient’s degree of activity is measured as a percentage:

A: Normal activity and performance. No special assistance is required.	100% Normal. No complaints. No signs of illness.
	90% Normal activity, minor signs and symptoms of illness.
	80% Normal activity, some signs and symptoms of illness.
IN: The patient is unable to work, but can live at home and care for himself, some assistance is required.	70% The patient takes care of himself, but cannot carry out normal activities.
	60% The patient takes care of himself in most cases. Sometimes you need help.
	50% Significant and frequent medical care is required.
WITH: The patient cannot care for himself. Inpatient care required. The disease can progress quickly.	40% Disability. Special help and support is required.
	30% Severe disability. Hospitalization is indicated, although there is no threat to life.
	20% Hospitalization and active supportive care are necessary.
	10% Fatal processes progress rapidly.
	0% Death

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

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

For assessing tolerability of analgesic therapy take into account the occurrence 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 expressed.

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

For in-depth assessment of pain, special scientific studies use neurophysiological methods(registration of evoked potentials, nociceptive flexor reflex, study of the dynamics of a conditioned negative wave, sensometry, electroencephalography), the plasma level of stress factors (cortisol, somatotropic hormone, glucose, beta-endorphin, etc.) is determined. Recently, it has become possible to objectify the level of pain according to the activity of various parts of the brain using positron emission tomography. But the use of these methods in daily practice is limited due to their invasiveness and high cost.

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

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

Visual Analog Scale (VAS)

The visual analogue scale (VAS) was originally created for use in medicine - on it the patient had to assess the intensity of pain currently experienced. Using the VAS method, on a straight line 10 cm long, the patient notes the intensity of pain. The beginning of the line on the left corresponds to the absence of pain, the end of the segment on the right corresponds to unbearable pain. For convenience of quantitative processing, divisions are applied on the segment every centimeter. The line can be either horizontal or vertical.

The use of VAS is quite common in the medical field because it has the following advantages:

1) the method allows you to determine the actual intensity of pain;

2) most patients, even children (aged 5 years and older), easily understand and correctly use the VAS;

3) the use of VAS allows you to study the distribution of ratings;

4) research results are reproducible over time;

5) more adequate assessment of the treatment effect compared to verbal description of pain. The VAS has been used successfully in many studies to examine the effectiveness of therapy.

However, VAS also has certain disadvantages compared to other methods. First, patients can mark the scale quite arbitrarily. Often such marks do not reflect reality and do not correspond to verbal assessments of pain given by the patients themselves. Secondly, the distance to the mark made must be measured, which requires time and accuracy, and errors in measurement are also possible. Third, the VAS is difficult to explain to older patients who do not understand the connection between the line and the position of their mark on it. Finally, photocopying sometimes results in line distortion, which affects the measurement. Therefore, VAS is not considered the optimal method for measuring pain intensity in adults and elderly patients, but is recommended as successful in children.

As already mentioned, in the medical field, the use of VAS in various studies is much more common than in any other field. In particular, this applies to psychology.

The visual analogue scale was first described in 1921 by Hayes & Patterson. . Only since 1969 has it become the subject of serious study, after the publication of Aitken’s work, which is still relevant today, due to the small number of works devoted to VAS.

Aitken used this scale in his study to assess the feelings of patients with depressive disorder. He believed that a digital system was being imposed on the observer when an analogue system would have been more appropriate.

If different people use the same word, this does not mean that they experience the same emotions - this also applies to the location of the marks on the scale. An emotion experienced twice as intense cannot be correlated with a value multiplied by two. There is a tendency to limit the divisions into categories, since only the most basic ones are usually used. This makes such scales ineffective in studying specific associations to given concepts, for example, the physical magnitude of a stimulus. These scales are unable to mark shades of feelings.

Aitken was convinced that analogies should be visual and not simply phrases, otherwise extreme ratings (eg 0 or 5) would occur too often (Yerkes & Urban 1906).

In his study, patients were asked to mark the intensity of their condition on a visual analogue scale every day for several weeks. In this situation, the scale was indeed very suitable for measuring changes and assessing their importance. However, Dr. Raymond Levy (Department of Psychiatry, Middlesex Hospital Medical School, London) believed that he had underestimated all the difficulties encountered when working with such scales. He suspected that such scales were especially effective in assessing patients with mild symptoms who knew exactly what the doctor meant, who began to use the same terminology. Patients suffering from both moderate and more severe forms of depression experienced difficulties when working with these scales.

Dr. J.P. Watson (Maudsley Hospital, London) believed that the problems of defining the terms and scales that Dr Aitken presented were no different from the problems of using any rating scale. He wondered whether Dr Aitken had evidence that patients were deliberately giving results that they knew were wrong.

Dr Aitken noted that Dr Levy's point was important and he agreed with Dr Watson that it applies to all types of self-assessment. In his experience, patients today use words like "depression" without thinking, but there is no doubt that their words may mean something very different from what psychiatrists meant when they used them. Clarification of the exact nature of the symptom is required, as given in the clinical assessment of all symptoms. Analog scales can accurately determine what patients want to communicate, but not what the doctor intended.

This study explains in some detail why the VAS may be better, more convenient, more reliable, and more valid than measures with scores or limited divisions. Obviously, people suffering from depression fall into different categories, and the use of a “digital system” can distort the results from the point of view of the fact that the patient simply does not try to think about the intensity of his experiences and chooses one of the extreme values. The use of similar scales, but only with a description of the condition, again gives rise to the feeling that they are choosing for the patient without obtaining a truly reliable result. However, this is only one study in which the subject is a psychological state that is quite complex to be able to clearly select the best measurement system for it.

In general, there are not many studies that compare Likert scales and visual analogue scales. For example, in a study conducted by Torrance, Feeny, and Furlong, the VAS was shown to have greater reliability than the Likert scale. . Another study by Flynn comparing a 5-point Likert scale and 65mm. Using the VAS as an example to measure coping, it is shown that subjects, when answering the same question, show more good results when working with a Likert scale, compared to a VAS.

Jennifer A. Cowley and Heather Youngblood, in their study in which they compared differences in responses on visual analog, numerical, and mixed scales, report that they found it emotionally more difficult to use analog scales than numerical ones because the divisions were left blank , did not contain explanations.

Scales in which each division contained a detailed textual explanation showed more reliable results than those in which some divisions contained gaps. Also, the advantage of using numerical data, for example, when working with variational analysis, is that in this case it is possible to evaluate certain variable interactions, which is impossible when working with nonparametric data.

However, some researchers may prefer analog scales because, unlike numerical scales, they can use efficient parametric statistical analyses.

Also in this study, mixed scales were used - analogue scales with the addition of various divisions: digital or with selective text explanations. At the same time, the opportunity to put your rating at any point on the scale was preserved.

The mixed scales here showed much higher mean scores than the analog scales. Also, the responses collected from the numerical and mixed scales did not differ much from each other, while the responses from the analog and numerical scales diverged greatly.

Thus, we can conclude that the VAS, like the Likert scale, have their own sets of pros and cons. However, the first study, like the last, raised the main question that may subsequently resolve the problem of choosing a measuring instrument - can we measure characteristics such as depression, anxiety, or any other continuous condition with ordinal scales? In this case, we should use a nonparametric scale, because when using an ordinal scale, we risk getting a rough result that is far from the true attitude of the subject, as well as losing a significant amount of data.

It is possible that the solution to this issue will also be the idea of ​​​​using mixed scales. Given that numeric and mixed produce higher average grades in many studies, researchers may wonder whether this depends on the fact that the person marks without reference to or in accordance with the numeric and text divisions. While this issue is not yet resolved, researchers can use mixed scales to make it easier for subjects to complete the questionnaire, ensuring the reliability of the results of parametric analysis using analogue data.

8371 0

Pain is a subjective phenomenon and therefore difficult to assess objectively.

A comprehensive pain assessment, including both subjective and objective data, is essential to determine the extent of intervention required.

It is known that methods of evidence-based medicine, in particular, analytical meta-analyses of randomized trials, make it possible to obtain integrated assessments of the effectiveness of diagnostic programs used in various clinics.

However, in practice it turns out that, despite the abundance of developed tests, firstly, there is still no unified diagnostic method that would allow one to obtain a starting point when conducting an exhaustive analysis; secondly, it is extremely difficult to compare the methodology for diagnosing pain in various clinical conditions (diagnosis of postoperative pain and cancer pain, etc.); thirdly, it is necessary to distinguish and consider two completely independent programs for assessing acute and chronic pain; fourthly, it is not possible to track the dynamics of revision of diagnostic tests during repeated clinical trials of drugs used in pain relief; and, finally, in order to converge data on the use of various testing methods, the introduction of an additional generalizing value is required.

However, the minimum amount of basic diagnostic testing is sufficiently standardized and can be used to assess all types of pain, regardless of the cause. It includes several sections according to the multifactorial conceptual model of pain.

First, you need to pay special attention to the patient's description of pain. This can provide important information regarding the causes of its occurrence and intensity, and lead to the recognition of its source. A good example is the "hot, burning sensation" described by patients with herpetic neuralgia. Nerve or neuropathic pain is usually described as "searing, stinging, scalding, scorching."

It is difficult for the patient to find the right words and expressions and to describe his feelings. He tries to create in the doctor a certain emotional state, similar to the one he is experiencing, to achieve empathy. Patients should be allowed to be as specific as possible in describing their sensations, while being respectful and sensitive to the description of the nature and location of the pain.

In order to facilitate communication between the doctor and the patient, objectify the patient’s experiences, differential diagnostic and therapeutic comparison of data, questionnaires were created, consisting of sets of standard verbal descriptors, the most common for all patients.

The standard examination method abroad is the McGill Pain Questionnaire (MPQ), which uses verbal characteristics of sensory, affective, and motor-motivational components of pain, ranked according to five intensity categories (Table 3).

Table 3. Survey questionnaire: What words can you use to describe your pain?

First class - descriptors of sensory characteristics
shimmering fluttering pulsating vibrating knocking tingling		jumping flashing shooting					piercing boring drilling piercing jerking
sharp cutting tearing		pinching pressing gnawing convulsive crushing					pulling tugging twisting
hot burning scorching	tingling itchy raw stinging			muffled brainy aching cruel dull				superficial contractive tearing splitting
Second class - descriptors of affective characteristics
tiring exhausting			nauseating suffocating			terrifying, terrifying nightmare
oppressive, tormenting, ferocious, evil, killing									defiant blinding despair
Third class - general descriptive evaluative descriptors
irritating, disturbing, causing suffering strong, intolerable
Fourth class - mixed sensory-affective diverse deserts
spilled radiant piercing spilling		twisting constraining pulling squeezing tearing			cool, cold, icy				pain-interference pain-annoyance pain-suffering pain-torment pain-torture

In the final version, it contains 102 words - pain descriptors, distributed into three groups. The first group is associated with the nature of the sensations, the second with the intensity and the third with the duration of pain. The expressions included in the first group are combined into four main classes and distributed into 20 subclasses (the principle of semantic meaning).

In each subclass, descriptors are arranged in increasing intensity. The patient is asked to describe the pain by selecting one or another descriptor from any of 20 subscales, but only one from each subscale. Data processing comes down to obtaining two main indicators: the number of selected words and the pain rank index.

The total number of selected descriptors is the first indicator - the index of the number of selected words. The pain rank index is the sum of the ranks of the descriptors. Rank is the ordinal number of the descriptor in a given subscale from top to bottom.

The most important thing is that each type of pain is characterized by a certain set of sensory descriptors, which makes it possible to differentiate the organic nature of the pain. At the same time, descriptors of affective characteristics more fully illustrate the psychological state of patients.

The results of a survey of patients showed that in emotionally labile individuals with more pronounced symptoms of depression and anxiety, all indicators in the affective class were higher than in those examined with a normal psyche; in women it is higher than in men, in patients with chronic pain it is higher than with acute pain. Computer processing of data obtained as a result of testing makes it possible to make an accurate diagnosis in 77% of cases. However, after adding additional information in the form of determining the location of pain and the gender of the patients, the accuracy of the diagnosis increases to 100%.

Assessment of pain intensity

There are several methods for assessing the intensity of pain, presented in table. 4.

Table 4. Methods for grading pain intensity

Way	Gradations of pain	When to use
Five-digit general scale	0 = no pain 1 = weak (slightly) 2 = moderate (painful) 3 = severe (very painful) 4 = unbearable (cannot be tolerated)	During assessment (examination) under normal conditions
Verbal quantitative scale	0................... 5................. 10 no pain unbearable (What number corresponds to your pain?)	During assessment (examination) under normal conditions
Visual analogue scale (10 cm line, sliding ruler)	1...................1 no pain unbearable (Mark on the line how severe your pain is)	During assessment (examination) under normal conditions Can be used in children over 6 years of age
Behavioral and psychological parameters (indirect signs of pain; should be taken into account with caution as they are not specific)		When assessing unconscious, autistic, critically ill patients
Assessment of the patient's vital functions by a doctor	Can the patient independently perform basic functions (for example, voluntary deep breathing, coughing, active joint movements, walking) Yes/No	Correlate with subjective assessments obtained from the patient himself. Should be used in all categories of patients

The intensity and severity of pain is determined using one of the available standardized scales that can facilitate the assessment of the sensations described by the patient and determine the effect of the treatment (Fig. 2).

Rice. 2. Simple, 10-point and analog pain intensity scales

The severity of pain is also assessed by its impact on the patient's consciousness, habits and daily life activities, including sleep, appetite, nutrition (eating), mobility, career and sexual activity.

The prevalence of pain is assessed by the presence of redness, swelling, increased skin temperature or vice versa, cooling of the skin, as well as changes in function (skin sensitivity and mobility). To assess the extent of pain, conventional examination methods are used, such as visual inspection, palpation, percussion, auscultation, sensometry, dolorimetry, reflexometry, passive and active joint movement, etc. It is necessary to ask the patient to demonstrate movements or positions that increase or decrease pain.

During the examination, it is necessary to clarify the duration of the pain, its constancy or frequency, occurrence at a certain time of the day, year, connection with food intake, etc.

It is also necessary to ask the patient about the presence of symptoms accompanying pain, such as dizziness, increased sensitivity to light, disorientation in space and time, fainting, nausea, profuse sweating, paleness or flushing, incontinence, weakness, weight loss, swelling, redness or fever . It is also necessary to determine the presence of comorbidities or other health problems that may alter the patient's experience of pain.

Since pain is a subjective phenomenon, upon examination by a doctor, objective signs can be identified, such as an increase or decrease in cardiac activity, blood pressure and/or respiration, changes in pupil size, reflexes, impairment of certain types of sensitivity, biochemical changes in the blood, endocrine changes, electrophysiological indicators or a change in the state of consciousness, the presence of a state of passion. Their presence may be important in assessing pain, but their absence may not indicate the absence of pain.

We should not forget about instrumental diagnostic methods that allow us to clarify the cause and localization of pain (ultrasound, CT, MRI, X-ray studies, rheovasography, electromyography, electroencephalography, etc.)

It should be remembered that pain itself may be the primary barrier to pain assessment, creating such discomfort for the patient that he is unable to concentrate and answer questions. Other barriers may be embarrassment, the physical and emotional state of the patient, time, cultural, linguistic or tribal characteristics.

G.I. Lysenko, V.I. Tkachenko