- Email: [email protected]
Pain Assessment Tools for Adults
CHAPTER 222 PAIN ASSESSMENT TOOLS FOR ADULTS
300 msec and positive polarity. The P300 response latency may be abnormally prolonged or reduced in amplitude in disorders that impair cognition, such as dementias, autism, schizophrenia, and Huntington’s chorea.
Summary EMG and EP testing are essential tools in the diagnosis of neuromuscular disorders. They provide reliable and reproducible information on function of the nervous system that would not be obtainable through other means. They provide an extension of the clinical examination and are complementary to laboratory, radiologic, and other evaluations. Development of new techniques and improvements in old ones continue to expand the clinical utility of these tests. For example, the addition of transcranial magnetic stimulation has allowed evaluation of central motor pathways that had not been possible with EMG or other EP testing. Further refinements in cognitive
CHAPTER
375
EP testing may allow greater understanding of the nature and complexity of cognitive processing. The clinical neurophysiology laboratory is an increasingly important part of the total clinical milieu. With this thought in mind, the prudent practitioner will find greater utility and put more reliance on these tests for evaluation of patients, now and in the future.
SUGGESTED READINGS Campbell W (ed): DeJong’s The Neurological Examination, ed 6. Philadelphia, Lippincott Williams and Wilkins, 2005. Goetz CG (ed): Textbook of Clinical Neurology, ed 2. Philadelphia, Saunders, 2003. Waldman HJ: Evoked potential testing. In Waldman SD (ed): Pain Management. Philadelphia, Saunders, 2007. Waldman SD: Parsonage-Turner syndrome. Atlas of Uncommon Pain Syndromes, ed 2. Philadelphia, Saunders, 2008. Waldman SD: Trigeminal neuralgia. In: Atlas of Common Pain Syndromes, ed 2. Philadelphia, Saunders, 2008.
222
Pain Assessment Tools for Adults The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has stated that the assessment of pain is a required part of patient care and went on to say that pain should be considered the fifth vital sign. As has been aptly pointed out by many, pain is neither vital nor is it a sign. Having said that, there are few who would not agree that the ongoing assessment of a patient’s pain is a worthwhile endeavor. However, given that pain is a subjective response that is registered as a conscious experience unique to the patient, objectification presents a variety of problems. A complete solution for these problems awaits discovery of a method to objectively measure pain the way we objectively measure a patient’s blood pressure or pulse, however, several assessment tools have been developed to allow the clinician to try to quantify the patient’s subjective pain experience.
Single-Dimension Pain Assessment Tools VISUAL ANALOG SCALE The most commonly used pain assessment tool is the visual analog scale (VAS), which is unidimensional measurement
tool that allows the patient to assign a number to their subjective pain experience (Fig. 222-1). The typical VAS is composed of a 10-cm straight line with the left end of the line labeled ‘‘no pain’’ and the right end of the line labeled ‘‘worst pain imaginable.’’ The patient is then instructed to mark where on the VAS he or she believes the pain being experienced at that point in time is located. The distance from the left end of the line is then measured, and a numerical value from 1 to 10 or 1 to 100 is assigned. Research has shown the VAS to be a sensitive measure of variations in the patient’s pain in response to treatment and procedures and reproducible over time for the individual patient. Shortcomings of the VAS include the fact that the VAS attempts to assign a single unidimensional value to the complex multidimensional pain experience. Furthermore, if the patient has to decide if the pain he or she is having is the worst pain imaginable, even the patient may have no concept of what the worst pain imaginable is like. If the patient decides that the current pain they are experiencing is in fact the worst pain imaginable and at a later point in time they perceive their pain as worse than the previous pain that they described as the worst pain imaginable, there is no mechanism for the patient to document the change.
376
SECTION 4 DIAGNOSTIC TESTING
NUMERICAL PAIN INTENSITY SCALE Like the VAS, the Numerical Pain Intensity Scale (NPIS) assigns a value of ‘‘no pain’’ on the left end of the scale and a value of ‘‘worst pain imaginable’’ to the right end of the scale (Fig. 222-2). Instead of a simple line without gradations or numbers as is found on the VAS, numbers from 0 to 10 are spaced evenly along the line from left to right. The patient is shown the NPIS and asked to circle a number that corresponds to the level of pain that he or she is currently having. The NPIS has the advantage that it requires no measurements and is self-scoring, making it easier to use than the VAS. Like the VAS, the NPIS suffers from the same unidimensional measurement limitation of the patient’s complex multidimensional pain experience. Patients may also tend to assign the pain level they are experiencing a number off the scale (e.g., ‘‘my pain is a 100!’’).
pain is located. The second part of the MPQ is a VDS that allows the patient to record the intensity level of his or her current pain experience. The third part of the MPQ is a pain verbal descriptor inventory consisting of 72 descriptive adjectives. The patient is asked to review this list of pain descriptors and circle the ones that serve to best describe his or her current pain experience. Each part or dimension of the MPQ is individually scored and a cumulative total score is also recorded. Although the length of time required for the patient to correctly complete the MPQ is a major limitation to this multidimensional pain assessment tool, extensive clinic experience with the MPQ has shown that it is a reliable and valid way to quantify an individual patient’s conscious pain experience. The MPQ may also aid the clinician in identifying the specific type of pain syndrome, such as neuropathic, that the patient suffers from.
VERBAL DESCRIPTOR SCALE The verbal descriptor scale (VDS) is another unidimensional pain assessment tool that uses descriptive words rather than numbers to allow the patient to assign a value to his or her current pain experience (Fig. 222-3). Like the NPIS, the VDS is self-scoring, making it easy to use at the bedside. Like all of the unidimensional pain assessment tools, it fails to measure the multidimensional aspects of the patient’s pain experience. Another disadvantage of the VDS is that it forces the patient to use someone else’s words to describe his or her pain, which may lead to misinterpretation.
Multidimensional Pain Assessment Tools As mentioned, pain is a complex, subjective, multidimensional conscious experience that is unique to the individual patient. Multidimensional pain assessment tools attempt to overcome some of the shortcomings of unidimensional pain assessment tools by attempting to measure the various dimensions that make up the pain experience. Examples of multidimensional pain assessment tools include the various forms of the McGill Pain Questionnaire, the Brief Pain Inventory, the Memorial Pain Assessment Card, and the Multidimensional Affect and Pain Survey.
BRIEF PAIN INVENTORY Like the MPQ, the Brief Pain Inventory (BPI) uses an anatomic drawing of the human form on which the patient marks where his or her pain is located (Fig. 222-5). The BPI also includes a number of questions about their pain treatment in the past 24 hours as well as 11 different numerical pain intensity scales that ask the patient to rank various aspects of his or her current pain experience and the effect that pain is having on the patient’s activities of daily living. While a valid and reliable multidimensional pain assessment tool, the BPI is reasonably time consuming for the patient to fill out, which may limit its utility in many clinical settings.
MULTIDIMENSIONAL AFFECT AND PAIN SURVEY Like the MPQ and the BPI, the Multidimensional Affect and Pain Survey (MAPS) suffers from the disadvantage of complexity and the length of time it takes to administer this pain assessment tool. The MAPS is made up of an extensive list of descriptor adjectives that encompass the pain and emotional experience. This descriptor list is subdivided into clusters, with the patient required to answer a question about each descriptor to further refine the assessment.
MCGILL PAIN QUESTIONAIRE
MEMORIAL PAIN ASSESSMENT CARD
The McGill Pain Questionnaire (MPQ) is a three-part pain assessment tool that measures several dimensions of the patient’s pain experience (Fig. 222-4). The first part consists of an anatomic drawing of the human form on which the patient marks where his or her
Designed in part to address the time-consuming nature of the MPI and the BPI, the Memorial Pain Assessment Card (MPAC) is a multidimensional pain assessment tool that is very quick to administer (Fig. 222-6). Designed initially for use in the assessment of very ill inpatients
CHAPTER 222 PAIN ASSESSMENT TOOLS FOR ADULTS
suffering from pain of malignant origin, the MPAC is now used in a variety of pain settings. Its ease of use makes it ideally suited in clinical situations such as acute pain management, where frequent repeated assessments are desirable.
SUGGESTED READING Correll DJ: The measurement of pain: Objectifying the subjective. In Waldman SD (ed): Pain Management. Philadelphia, Saunders, 2007.
How severe is your pain?
No pain
Worst pain imaginable
FIGURE 222–1 Example of a visual analog scale for the assessment of pain.
0−10 Numeric Pain Intensity Scale1
0 No pain
1
2
3
4
5 6 Moderate pain
7
8
9
10 Worst pain imaginable!
1If used as a graphic rating scale, a 10 cm baseline is recommended.
FIGURE 222–2 Example of a numerical pain intensity scale for the assessment of pain.
Simple Descriptive Pain Intensity Scale1
No pain
Mild pain
Moderate pain
377
Severe pain
Very severe pain
Worst possible pain
1If used as a graphic rating scale, a 10 cm baseline is recommended.
FIGURE 222–3 Example of a verbal descriptor scale for the assessment of pain.
378
SECTION 4 DIAGNOSTIC TESTING McGill Pain Questionnaire
Patient’s Name
PRI: S
Date
A
E
(1-10)
1 FLICKERING QUIVERING PULSING THROBBING BEATING POUNDING 2 JUMPING FLASHING SHOOTING 3 PRICKING BORING DRILLING STABBING LANCINATING 4 SHARP CUTTING LACERATING 5 PINCHING PRESSING GNAWING CRAMPING CRUSHING 6 TUGGING PULLING WRENCHING 7 HOT BURNING SCALDING SEARING 8 TINGLING ITCHY SMARTING STINGING 9 DULL SORE HURTING ACHING HEAVY 10 TENDER TAUT RASPING SPLITTING
(11-15)
11 TIRING EXHAUSTING
Time
M (16)
PRI(T) (17-20)
BRIEF MOMENTARY TRANSIENT
am/pm
PPI (1-20)
RHYTHMIC PERIODIC INTERMITTENT
CONTINUOUS STEADY CONSTANT
12 SICKENING SUFFOCATING 13 FEARFUL FRIGHTFUL TERRIFYING 14 PUNISHING GRUELLING CRUEL VICIOUS KILLING 15 WRETCHED BLINDING 16 ANNOYING TROUBLESOME MISERABLE INTENSE UNBEARABLE 17 SPREADING RADIATING PENETRATING PIERCING 18 TIGHT NUMB DRAWING SQUEEZING TEARING
E = EXTERNAL I = INTERNAL
19 COOL COLD FREEZING 20 NAGGING NAUSEATING AGONIZING DREADFUL TORTURING
COMMENTS:
PPI 0 1 2 3 4 5
NO PAIN MILD DISCOMFORTING DISTRESSING HORRIBLE EXCRUCIATING
FIGURE 222–4 The McGill Pain Questionnaire. (From Melzack R: The McGill Pain Questionnaire: Major properties and scoring methods. Pain 1975; 1:277-299.)
CHAPTER 222 PAIN ASSESSMENT TOOLS FOR ADULTS
379
FIGURE 222–5 The Brief Pain Inventory multidimensional pain assessment tool. (From Cleeland CS, Ryan KM: Pain assessment: Global use of the Brief Pain Inventory. Ann Acad Med Singapore 1994; 23:129-138.)
380
SECTION 4 DIAGNOSTIC TESTING
FIGURE 222–6 The Memorial Pain Assessment Card. (From Fishman B, Pasternak S, Wallenstein SL, et al: The Memorial Pain Assessment Card. A valid instrument for the evaluation of cancer pain. Cancer 1987; 60:1151-1158.)
CHAPTER
223
Pain Assessment Tools for Children and the Elderly The assessment of pain in children and the elderly is a difficult but necessary part of the care of these special patient populations. In both of these patient populations, problems in the patient’s ability to comprehend and verbalize their pain symptomatology make many of the traditional pain assessment tools used in adults less useful. In very young children, infants, and those elderly patients with diminished mental capacity, the available pain assessment tools are based primarily on the observations of the clinician rather than on input from the patient. Examples of such observational pain assessment tools include the COMFORT Scale and a tool specially designed to assess neonatal pain called CRIES (Figs. 223-1 and 223-2).
For children more than 3 years of age, some degree of patient self-assessment is actually possible using a specially designed numerical pain intensity scale known as the Wong-Baker Faces Scale (Fig. 223-3). This pain assessment tool uses a 6-point scale with corresponding line drawings of faces that exhibit emotions from smiling to crying. Some experts have criticized this pain assessment tool because it may confuse the child into thinking that even though the pain is severe, they may not choose the corresponding face that is crying because the child in pain is not actually crying at the time of the assessment. Other pain assessment tools that have been validated for use in children over 3 years of age include the Faces Pain
300 msec and positive polarity. The P300 response latency may be abnormally prolonged or reduced in amplitude in disorders that impair cognition, such as dementias, autism, schizophrenia, and Huntington’s chorea.
Summary EMG and EP testing are essential tools in the diagnosis of neuromuscular disorders. They provide reliable and reproducible information on function of the nervous system that would not be obtainable through other means. They provide an extension of the clinical examination and are complementary to laboratory, radiologic, and other evaluations. Development of new techniques and improvements in old ones continue to expand the clinical utility of these tests. For example, the addition of transcranial magnetic stimulation has allowed evaluation of central motor pathways that had not been possible with EMG or other EP testing. Further refinements in cognitive
CHAPTER
375
EP testing may allow greater understanding of the nature and complexity of cognitive processing. The clinical neurophysiology laboratory is an increasingly important part of the total clinical milieu. With this thought in mind, the prudent practitioner will find greater utility and put more reliance on these tests for evaluation of patients, now and in the future.
SUGGESTED READINGS Campbell W (ed): DeJong’s The Neurological Examination, ed 6. Philadelphia, Lippincott Williams and Wilkins, 2005. Goetz CG (ed): Textbook of Clinical Neurology, ed 2. Philadelphia, Saunders, 2003. Waldman HJ: Evoked potential testing. In Waldman SD (ed): Pain Management. Philadelphia, Saunders, 2007. Waldman SD: Parsonage-Turner syndrome. Atlas of Uncommon Pain Syndromes, ed 2. Philadelphia, Saunders, 2008. Waldman SD: Trigeminal neuralgia. In: Atlas of Common Pain Syndromes, ed 2. Philadelphia, Saunders, 2008.
222
Pain Assessment Tools for Adults The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has stated that the assessment of pain is a required part of patient care and went on to say that pain should be considered the fifth vital sign. As has been aptly pointed out by many, pain is neither vital nor is it a sign. Having said that, there are few who would not agree that the ongoing assessment of a patient’s pain is a worthwhile endeavor. However, given that pain is a subjective response that is registered as a conscious experience unique to the patient, objectification presents a variety of problems. A complete solution for these problems awaits discovery of a method to objectively measure pain the way we objectively measure a patient’s blood pressure or pulse, however, several assessment tools have been developed to allow the clinician to try to quantify the patient’s subjective pain experience.
Single-Dimension Pain Assessment Tools VISUAL ANALOG SCALE The most commonly used pain assessment tool is the visual analog scale (VAS), which is unidimensional measurement
tool that allows the patient to assign a number to their subjective pain experience (Fig. 222-1). The typical VAS is composed of a 10-cm straight line with the left end of the line labeled ‘‘no pain’’ and the right end of the line labeled ‘‘worst pain imaginable.’’ The patient is then instructed to mark where on the VAS he or she believes the pain being experienced at that point in time is located. The distance from the left end of the line is then measured, and a numerical value from 1 to 10 or 1 to 100 is assigned. Research has shown the VAS to be a sensitive measure of variations in the patient’s pain in response to treatment and procedures and reproducible over time for the individual patient. Shortcomings of the VAS include the fact that the VAS attempts to assign a single unidimensional value to the complex multidimensional pain experience. Furthermore, if the patient has to decide if the pain he or she is having is the worst pain imaginable, even the patient may have no concept of what the worst pain imaginable is like. If the patient decides that the current pain they are experiencing is in fact the worst pain imaginable and at a later point in time they perceive their pain as worse than the previous pain that they described as the worst pain imaginable, there is no mechanism for the patient to document the change.
376
SECTION 4 DIAGNOSTIC TESTING
NUMERICAL PAIN INTENSITY SCALE Like the VAS, the Numerical Pain Intensity Scale (NPIS) assigns a value of ‘‘no pain’’ on the left end of the scale and a value of ‘‘worst pain imaginable’’ to the right end of the scale (Fig. 222-2). Instead of a simple line without gradations or numbers as is found on the VAS, numbers from 0 to 10 are spaced evenly along the line from left to right. The patient is shown the NPIS and asked to circle a number that corresponds to the level of pain that he or she is currently having. The NPIS has the advantage that it requires no measurements and is self-scoring, making it easier to use than the VAS. Like the VAS, the NPIS suffers from the same unidimensional measurement limitation of the patient’s complex multidimensional pain experience. Patients may also tend to assign the pain level they are experiencing a number off the scale (e.g., ‘‘my pain is a 100!’’).
pain is located. The second part of the MPQ is a VDS that allows the patient to record the intensity level of his or her current pain experience. The third part of the MPQ is a pain verbal descriptor inventory consisting of 72 descriptive adjectives. The patient is asked to review this list of pain descriptors and circle the ones that serve to best describe his or her current pain experience. Each part or dimension of the MPQ is individually scored and a cumulative total score is also recorded. Although the length of time required for the patient to correctly complete the MPQ is a major limitation to this multidimensional pain assessment tool, extensive clinic experience with the MPQ has shown that it is a reliable and valid way to quantify an individual patient’s conscious pain experience. The MPQ may also aid the clinician in identifying the specific type of pain syndrome, such as neuropathic, that the patient suffers from.
VERBAL DESCRIPTOR SCALE The verbal descriptor scale (VDS) is another unidimensional pain assessment tool that uses descriptive words rather than numbers to allow the patient to assign a value to his or her current pain experience (Fig. 222-3). Like the NPIS, the VDS is self-scoring, making it easy to use at the bedside. Like all of the unidimensional pain assessment tools, it fails to measure the multidimensional aspects of the patient’s pain experience. Another disadvantage of the VDS is that it forces the patient to use someone else’s words to describe his or her pain, which may lead to misinterpretation.
Multidimensional Pain Assessment Tools As mentioned, pain is a complex, subjective, multidimensional conscious experience that is unique to the individual patient. Multidimensional pain assessment tools attempt to overcome some of the shortcomings of unidimensional pain assessment tools by attempting to measure the various dimensions that make up the pain experience. Examples of multidimensional pain assessment tools include the various forms of the McGill Pain Questionnaire, the Brief Pain Inventory, the Memorial Pain Assessment Card, and the Multidimensional Affect and Pain Survey.
BRIEF PAIN INVENTORY Like the MPQ, the Brief Pain Inventory (BPI) uses an anatomic drawing of the human form on which the patient marks where his or her pain is located (Fig. 222-5). The BPI also includes a number of questions about their pain treatment in the past 24 hours as well as 11 different numerical pain intensity scales that ask the patient to rank various aspects of his or her current pain experience and the effect that pain is having on the patient’s activities of daily living. While a valid and reliable multidimensional pain assessment tool, the BPI is reasonably time consuming for the patient to fill out, which may limit its utility in many clinical settings.
MULTIDIMENSIONAL AFFECT AND PAIN SURVEY Like the MPQ and the BPI, the Multidimensional Affect and Pain Survey (MAPS) suffers from the disadvantage of complexity and the length of time it takes to administer this pain assessment tool. The MAPS is made up of an extensive list of descriptor adjectives that encompass the pain and emotional experience. This descriptor list is subdivided into clusters, with the patient required to answer a question about each descriptor to further refine the assessment.
MCGILL PAIN QUESTIONAIRE
MEMORIAL PAIN ASSESSMENT CARD
The McGill Pain Questionnaire (MPQ) is a three-part pain assessment tool that measures several dimensions of the patient’s pain experience (Fig. 222-4). The first part consists of an anatomic drawing of the human form on which the patient marks where his or her
Designed in part to address the time-consuming nature of the MPI and the BPI, the Memorial Pain Assessment Card (MPAC) is a multidimensional pain assessment tool that is very quick to administer (Fig. 222-6). Designed initially for use in the assessment of very ill inpatients
CHAPTER 222 PAIN ASSESSMENT TOOLS FOR ADULTS
suffering from pain of malignant origin, the MPAC is now used in a variety of pain settings. Its ease of use makes it ideally suited in clinical situations such as acute pain management, where frequent repeated assessments are desirable.
SUGGESTED READING Correll DJ: The measurement of pain: Objectifying the subjective. In Waldman SD (ed): Pain Management. Philadelphia, Saunders, 2007.
How severe is your pain?
No pain
Worst pain imaginable
FIGURE 222–1 Example of a visual analog scale for the assessment of pain.
0−10 Numeric Pain Intensity Scale1
0 No pain
1
2
3
4
5 6 Moderate pain
7
8
9
10 Worst pain imaginable!
1If used as a graphic rating scale, a 10 cm baseline is recommended.
FIGURE 222–2 Example of a numerical pain intensity scale for the assessment of pain.
Simple Descriptive Pain Intensity Scale1
No pain
Mild pain
Moderate pain
377
Severe pain
Very severe pain
Worst possible pain
1If used as a graphic rating scale, a 10 cm baseline is recommended.
FIGURE 222–3 Example of a verbal descriptor scale for the assessment of pain.
378
SECTION 4 DIAGNOSTIC TESTING McGill Pain Questionnaire
Patient’s Name
PRI: S
Date
A
E
(1-10)
1 FLICKERING QUIVERING PULSING THROBBING BEATING POUNDING 2 JUMPING FLASHING SHOOTING 3 PRICKING BORING DRILLING STABBING LANCINATING 4 SHARP CUTTING LACERATING 5 PINCHING PRESSING GNAWING CRAMPING CRUSHING 6 TUGGING PULLING WRENCHING 7 HOT BURNING SCALDING SEARING 8 TINGLING ITCHY SMARTING STINGING 9 DULL SORE HURTING ACHING HEAVY 10 TENDER TAUT RASPING SPLITTING
(11-15)
11 TIRING EXHAUSTING
Time
M (16)
PRI(T) (17-20)
BRIEF MOMENTARY TRANSIENT
am/pm
PPI (1-20)
RHYTHMIC PERIODIC INTERMITTENT
CONTINUOUS STEADY CONSTANT
12 SICKENING SUFFOCATING 13 FEARFUL FRIGHTFUL TERRIFYING 14 PUNISHING GRUELLING CRUEL VICIOUS KILLING 15 WRETCHED BLINDING 16 ANNOYING TROUBLESOME MISERABLE INTENSE UNBEARABLE 17 SPREADING RADIATING PENETRATING PIERCING 18 TIGHT NUMB DRAWING SQUEEZING TEARING
E = EXTERNAL I = INTERNAL
19 COOL COLD FREEZING 20 NAGGING NAUSEATING AGONIZING DREADFUL TORTURING
COMMENTS:
PPI 0 1 2 3 4 5
NO PAIN MILD DISCOMFORTING DISTRESSING HORRIBLE EXCRUCIATING
FIGURE 222–4 The McGill Pain Questionnaire. (From Melzack R: The McGill Pain Questionnaire: Major properties and scoring methods. Pain 1975; 1:277-299.)
CHAPTER 222 PAIN ASSESSMENT TOOLS FOR ADULTS
379
FIGURE 222–5 The Brief Pain Inventory multidimensional pain assessment tool. (From Cleeland CS, Ryan KM: Pain assessment: Global use of the Brief Pain Inventory. Ann Acad Med Singapore 1994; 23:129-138.)
380
SECTION 4 DIAGNOSTIC TESTING
FIGURE 222–6 The Memorial Pain Assessment Card. (From Fishman B, Pasternak S, Wallenstein SL, et al: The Memorial Pain Assessment Card. A valid instrument for the evaluation of cancer pain. Cancer 1987; 60:1151-1158.)
CHAPTER
223
Pain Assessment Tools for Children and the Elderly The assessment of pain in children and the elderly is a difficult but necessary part of the care of these special patient populations. In both of these patient populations, problems in the patient’s ability to comprehend and verbalize their pain symptomatology make many of the traditional pain assessment tools used in adults less useful. In very young children, infants, and those elderly patients with diminished mental capacity, the available pain assessment tools are based primarily on the observations of the clinician rather than on input from the patient. Examples of such observational pain assessment tools include the COMFORT Scale and a tool specially designed to assess neonatal pain called CRIES (Figs. 223-1 and 223-2).
For children more than 3 years of age, some degree of patient self-assessment is actually possible using a specially designed numerical pain intensity scale known as the Wong-Baker Faces Scale (Fig. 223-3). This pain assessment tool uses a 6-point scale with corresponding line drawings of faces that exhibit emotions from smiling to crying. Some experts have criticized this pain assessment tool because it may confuse the child into thinking that even though the pain is severe, they may not choose the corresponding face that is crying because the child in pain is not actually crying at the time of the assessment. Other pain assessment tools that have been validated for use in children over 3 years of age include the Faces Pain