They found that classifying mild pain as , moderate pain as , and severe pain as was most consistent with the pattern of nonlinear. Objectives: The 0–10 Numeric Rating Scale (NRS) is often used in pain management. The aims of our study were to determine the cut-off. Cutpoints have generally been found to be between 1 and for mild pain; ranging between to for moderate pain and ranging from to 10 for severe.
In some locations pain is only experienced during a short period of time, while pain in other sites may be persistent pain of either neuropathic or musculoskeletal origins, or some combination of the two. In clinical research and in many clinical settings, pain intensity is commonly measured with numerical rating scales NRS , where patients rate their pain intensity from 0 to 10 or 0 to 3.
However, treatment guidelines e. Despite the development of category-based treatment guidelines, there is no clearly defined mechanism for classifying pain intensity into these categories, which can make it difficult to determine when patients are experiencing the level of pain specified in treatment guidelines. This important gap has inspired a number of studies to gain an understanding of how NRS pain ratings relate to categorical pain ratings, and cutoffs for classifying pain intensity into discrete categories for a number of populations have been identified 7 - However, the extent to which existing cutoffs are valid for classifying pain intensity in persons with MS is not known.
In a seminal study, Serlin and colleagues 13 evaluated NRS pain intensity ratings with respect to the interference of pain with daily activities among persons with cancer.
They found that classifying mild pain as , moderate pain as , and severe pain as was most consistent with the pattern of nonlinear associations between worst pain intensity ratings and pain interference in their sample. This study has been subsequently replicated in samples of individuals with a variety of pain conditions and diagnoses. Patient groups that have yielded the same cutoffs as those found by Serlin and colleagues include those with post-operative pain 8 and low back pain However, a number of studies have found variations in cutoffs, primarily surrounding whether 4 should be classified as mild or moderate and 7 should be classified as moderate or severe.
For example, relative to the study by Serlin and colleagues, a study of patients with diabetic peripheral neuropathy found a lower cutoff between mild and moderate pain i. Beyond these between-group differences, additional studies have shown differences based on the type of pain measured.
Cutoffs have been found to vary between general , , , phantom limb , , , and back pain , , 7. Thus, despite some consistencies across populations for some intensity ratings, research shows that the best classification scheme varies to some extent as a function of patient population and type of pain measured. It is unclear, however, which scheme is most useful for persons with MS and chronic pain. As research on pain cutoffs has evolved, Anderson 17 recommended that researchers consider cutoffs for both average pain and worst pain, given 1 the variability of pain for many patients and 2 that cutoffs may vary as a function of the pain intensity domain being considered.
Using average pain is likely to adequately measure pain severity among persons who experience stable pain, but asking patients to rate worst pain in addition to average pain could provide additional critical information in individuals whose pain is highly variable. However, thus far, results are mixed: Cutoffs have not varied for average vs. The principle aim of the study was to identify the optimal classification scheme for average and worst pain for individuals with MS, using the method described by Serlin and colleagues Secondary aims included determining if the schemes would be the same for measures of average and worst pain intensity, and assessing how the optimal classification scheme for individuals with MS relates to those identified in other patient populations 7 - Participants included in the present study participated in a multi-phase postal survey study of pain in persons with MS.
All study procedures were approved by the University of Washington Human Subjects Review Committee, and written informed consent was obtained from each participant.
The subset of participants considered for the present study came from two waves of recruitment and survey completion, as both groups completed the relevant measures, were recruited through a similar method, and were independent samples with no repeat participants. Previous publications have reported on data from this same study 1 , 18 , 19 , but neither of the previous papers addressed the questions that were the focus of the current paper.
Participant recruitment is depicted in Figure 1. In the first wave, surveys were mailed to participants from September to October We excluded 18 participants who could not be reached survey was returned to sender or participant was deceased , leaving participants who we presume received surveys. A total of individuals In the second wave, surveys were mailed to individuals from April to June In this sample, 47 participants could not be contacted, resulting in a presumed sample of participants.
A total of surveys were returned Of this sample, participants were experiencing pain. In sum, there were usable surveys, with Participants in the present study were participants who affirmed that they were currently experiencing pain.
Participants were then asked to consider their pain over the past week and provide 0 no pain to 10 pain as bad as it could be NRS ratings for the average pain and worst pain. The NRS has been validated extensively, with a large body of research supports the reliability and validity of this measurement approach This version of the BPI has evolved from the original 7-item measure 21 , 22 and is a valid and reliable measure of pain interference in persons with MS Participants were asked to provide 0 does not interfere to 10 completely interferes ratings of the extent to which their pain interferes with general activity, mood, mobility, normal work, relations with other people, sleep, enjoyment of life, self-care, recreational activities, social activities, communication with others, and learning new information or skills.
We employed the statistical method detailed below, which was the same method that was used by Serlin and colleagues 13 and replicated in subsequent research 7 - In addition, we examined cutoffs for both average and worst pain, as recommended by Anderson To determine the boundaries for mild, moderate, and severe pain among persons with MS, we tested five classification schemes each for average and worst intensity.
Four of the classification schemes were used with both average and worst pain, and were selected based upon the existing literature 7 - 16 ; one additional classification scheme was chosen each for average and worst pain based upon apparent nonlinear increases in BPI score during visual inspection of the data that is presented in Figure 2. Average pain interference level at each level of pain intensity for both average and worst pain.
We named the classification schemes based on the upper values of the mild and moderate categories. The four schemes identified in the literature 7 - 16 were: We conducted ten five for the five average pain classification schemes and five for the five worst pain classification schemes analyses of variance ANOVA to identify the best classification scheme for mild, moderate, and severe pain, with pain classification group as the independent variable and pain interference BPI as the dependent variable.
A significant F value was indicative of significant differences between the three pain severity groups on pain interference. Consistent with the method suggested by Serlin et al.
The mean age was Participants were primarily females The majority of participants in both samples had completed at least some college education Table 1 reports descriptive statistics for the participants who returned surveys, demonstrating that the participants with pain were of similar characteristics to participants without pain, and that the two groups of participants with pain were also similar to each other, with the following statistically significant exceptions: Demographic data for each sample of pain patients, all pain patients combined, and all non-pain patients combined.
The means and standard deviation for pain interference at each pain intensity rating for both average and worst pain are reported in Table 2 and displayed in Figure 1. Assessment of the classification schemes revealed that the optimal scheme for average pain intensity differs from the optimal scheme for worst pain intensity in our sample.
In this scheme Comparison of classification systems for mild, moderate and severe pain intensity based on interference with activity. Values in table are F scores. These findings for persons with MS indicate interesting similarities and differences relative to the findings of previous studies of pain cutoffs in non-MS populations. Importantly, the present results were consistent with all of the previous studies in the identification of a non-linear association between average pain intensity and pain interference 7 - It has previously been suggested that average pain should be used for patients with consistent pain over time, whereas worst pain should be used for pain with greater variability 7 , 11 , 17 ; MS pain does not typically include extreme variability, as evidenced by modest differences between average and worst pain ratings Before considering reasons why persons with MS might differ from other populations in pain classification scheme, it is important to recognize that the differences in classification could be due to characteristics of the sample, and not the disease.
Similar to many of the previous studies with the lowest classification schemes CP 3,6 7 , 12 , 14 , our sample was a community sample and not necessarily patients who were actively seeking treatment for pain.
This contrasts to other studies of clinical outpatients 9 , 13 , 15 , patients on disability claims 10 , and post-surgical inpatients 8 that had higher cutpoints. Thus, it is possible that pain begins to impact functioning at lower levels of intensity in individuals in the community who experience lower average levels of severity or chronicity relative to individuals with more experience with pain i.
Thus, it is not known at this point if sample demographics contribute to differences in cutpoints. It remains possible that at least some of the differences we identified could be related to MS-specific causes. Persons with MS and pain commonly experience pain in more than one location, with the average person reporting pain in 6. Previous studies of non-MS populations have suggested that the number of pain sites, referred to as pain extent, is associated with pain interference and psychological suffering Therefore, one might hypothesize that one of the reasons pain cutoffs are lower among persons with MS is that at least some of the pain interference could be attributed to pain extent, and not solely to pain intensity; future research should examine this possibility.
Another unique aspect of MS that makes the current sample distinct from other pain populations examining cutoffs is that it is a progressive demyelinating condition which typically results in multiple neurologic symptoms.
It could also reflect a difficulty differentiating pain-related interference from interference due to non-pain aspects of MS. Ultimately, the use of cutoffs is intended to guide clinical decision-making. This has been particularly true when the optimal classification scheme differs only slightly from the most common classification scheme Update to the text to reflect the European Medicines Agency EMA warning, which now restricts the use of codeine in children and adolescents.
Update to the text to reflect recent advice from the MHRA regarding diclofenac. Update to the text to reflect new guidance issued by the National Institute for Health and Care Excellence for feverish illness in children.
The QIPP options for local implementation have been added to this topic. More exact paracetamol dosing for children has been introduced by the Medicines and Healthcare products Regulatory Agency. Text and prescriptions have been updated to reflect the revised dosing. Issued in July Text updated to include more detailed advice about the use of paracetamol in pregnancy. Issued in June Prescriptions for analgesics added.
Issued in February The evidence-base has been reviewed in detail, and recommendations are clearly justified. To support primary healthcare professionals to provide information on the prescribing of appropriate analgesics for mild-to-moderate pain. CKS found no trial-based evidence or expert opinion on offering advice to people taking paracetamol. These recommendations are based on what CKS considers to be good clinical practice. CKS found no trial-based evidence or expert opinion on giving advice to people taking aspirin.
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Moderate pain levels interfere with many daily activities. These pain levels usually require some lifestyle changes but you can remain independent, however . Other than medicines, how else can I manage mild to moderate pain? The following may help you manage your pain: • Application of heat/cold packs to the site. If these first-line agents are not sufficient for mild to moderate pain, medications that target separate pathways simultaneously, such as an.