GUIDELINE ATTACHMENTS

Attachment A.

Contents

Tables of Scientific Evidence

A1. Scientific evidence for pain reduction in adults

A2. Scientific evidence for pain reduction in children

Explanation of Table of Evidence

The following tables summarize the scientific evidence for interventions to manage pain. The evidence is classified by type and strength. The type of evidence for recommendations isordinally ranked in categories from I to V. I is evidence from metaanalysis of multiple, well-designed controlled studies. II through V are evidence obtained from experimental studies (II) through case reports and clinical examples (V). Evidence is further subdivided according to whether the studies were conducted on patients with cancer or on other clinical populations. The column in the table labeled "Type of Evidence" summarizes the types of evidence that support interventions discussed in the guideline. The strength and consistency of evidence are described in the text.

Briefly, the strength and consistency of evidence for recommendations summarize the evidence and note whether the evidence is generally consistent or inconsistent. Strength of evidence ranges from A, which is the strongest evidence, to D, which indicates that there is little or no evidence or evidence of type V only. The strength of recommendation is summarized in the column of the tabled labeled "Strength and Consistency of Evidence."

When the strength of evidence is A or B, the panel's recommendations are based primarily on the evidence. When the strength of recommendation is C or D, the panel used the available empirical evidence but based their recommendations primarily on expert judgment. The term "panel consensus" is used when the recommendation is a statement of panel opinion regarding desirable practice and there is evidence that the practice is not commonly being followed.

Two tables are provided. Table A1 summarizes the scientific evidence for the management of pain in adult populations. Table A2 summarizes the scientific evidence for the management of pain in children and adolescents.

A1. Scientific evidence for pain reduction in adults

A2. Scientific evidence for pain reduction in children

Type of evidence
       I. Meta-analysis of multiple, well-designed controlled studies.
             A.  Studies of patients with cancer.
             B.  Studies of other clinical populations.
      II. At least one well-designed experimental study.
             A.  Studies of patients with cancer.
             B.  Studies of other clinical populations.
     III. Well-designed, quasiexperimental studies such as nonrandom-
          ized controlled, single group pre-post, cohort, time series,
          or matched case-controlled studies.
             A.  Studies of patients with cancer.
             B.  Studies of other clinical populations.
      IV. Well-designed nonexperimental studies, such as
comparative
          and correlational descriptive and case studies.
             A.  Studies of patients with cancer.
             B.  Studies of other clinical populations.
       V. Case reports and clinical examples.
             A.  Studies of patients with cancer.
             B.  Studies of other clinical populations.
Strength and consistency of evidence
 A.  There is evidence of type I or consistent findings from multiple
     studies of types II, III, or IV.
 B.  There is evidence of types II, III, or IV, and findings are gen-
     erally consistent.
 C.  There is evidence of types II, III, or IV, but findings are incon-
     sistent.
 D.  There is little or no evidence, or there is type V evidence only.

Panel Consensus -- Practice recommended on the basis of opinion of experts in pain management.

Attachment B.

[Contents]

Pain Assessment Instruments for Adults

B1. Brief Pain Inventory (Short Form)

B2. Initial Pain Assessment Tool

B3. Pain Distress Scales

B4. The Memorial Pain Assessment Card

Pain Assessment Instruments for Children

B5. Pain Experience History

B6. Eland Color Scale Figures

B7. Poker Chip Tool Instructions Sheet

B8. Word-Graphic Rating Scale

B9. Pain Affect Faces Scale

Instruments for Pain Management Documentation

B10. Pain Management Log

B11. Flowsheet for Pain Management Documentation

B1. Brief Pain Inventory (Short Form)

B2. Initial Pain Assessment Tool

B3. Pain Distress Scales

B4. Memorial Pain Assessment Card

B5. Pain Experience History

B6. Eland Color Scale: Directions for Use

After discussing with the child several things that have hurt the child in the past:

1. Present eight crayons or markers to the child. Suggested colors are yellow, orange, red, green, blue, purple, brown, and black.
2. Ask the following questions, and after the child has answered, mark the appropriate square on the tool (e.g., severe pain, worst hurt), and put that color away from the others. For convenience, the word hurt is used here, but whatever term the child uses should be substituted. Ask the child these questions:
   • "Of these colors, which color is most like the worst hurt you have ever had, (using whatever example the child has given) or the worst hurt anybody could ever have?" Which phrase is chosen will depend on the child's experience and what the child is able to understand. Some children may be able to imagine much worse pain than they have ever had, while other children can only understand what they have experienced. Of course, some children may have experienced the worst pain they can imagine.
   • "Which color is almost as much hurt as the worst hurt (or, use example given above, if any), but not quite as bad?"
   • "Which color is like something that hurts just a little?"
   • "Which color is like no hurt at all?"
3. Show the four colors (marked boxes, crayons, or markers) to the child in the order he has chosen them, from the color chosen for the worst hurt to the color chosen for no hurt.
4. Ask the child to color the body outlines where he hurts, using the colors he has chosen to show how much it hurts.
5. When the child finishes, ask the child if this is a picture of how he hurts now or how he hurt earlier. Be specific about what earlier means by relating the time to an event, e.g., at lunch or in the playroom.

B7. Poker Chip Tool Instruction Sheet1

English Instructions:

1. Say to the child:"I want to talk with you about the hurt you may be having right now."
2. Align the chips horizontally in front of the child on the bedside table, a clipboard, or other firm surface.
3. Tell the child,"These are pieces of hurt." Beginning at the chip nearest the child's left side and ending at the one nearest the right side, point to the chips and say,"This (first chip) is a little bit of hurt and this (fourth chip) is the most hurt you could ever have."

   For a young child or for any child who may not fully comprehend the instructions, clarify by saying, "That means this (one)is just a little hurt, this (two)is a little more hurt, this (three) is more yet, and this (four) is the most hurt you could ever have."

   • Do not give children an option for zero hurt. Research with the Poker Chip Tool has verified that children without pain will so indicate by responses such as, "I don't have any."
4. Ask the child, "How many pieces of hurt do you have right now?"
   • After initial use of the Poker Chip Tool, some children internalize the concept "pieces of hurt". If a child gives a response such as "I have one right now", before you ask or before you lay out the poker chips, proceed with instruction # 5.
5. Record the number of chips on the Pain Flow Sheet.
6. Clarify the child's answer by words such as, "Oh, you have a little hurt? Tell me about the hurt."

Spanish Instructions:2

1. Tell the parent:"Estas fichas de poker son una manera de medir dolor. Usamos cuatro fichas rojas."
2. Say to the child: "Las fichas son como pedazos de dolor: una ficha (pedazo) es un poquito de dolor, mientras cuatro fichas (pedazos) significa el dolor máximo que tu puedes sentir. ?Cuántos pedazos de dolor tienes?"

[1] Developed in 1975 by Nancy O. Hester, University of Colorado Health Sciences Center, Denver, CO.

[2] Spanish instructions by Jordan-Marsh, M., Hall, D., Yoder, L., Watson, R., McFarlane-Sosa, G., & Garcia, M. (1990). The Harbor-UCLA Medical Center Humor Project for Children. Los Angeles: Harbor-UCLA Medical Center.

B8. Word-Graphic Rating Scale

"This is a line with words to describe how much pain you may have. This side of the line means no pain and over here the line means worst possible pain." (Point with your finger where "no pain" is, and run your finger along the line to "worst possible pain," as you say it.) "If you have no pain, you would mark like this." (Show example.) "If you have some pain, you would mark somewhere along the line, depending on how much pain you have." (Show example.) "The more pain you have, the closer to worst pain you would mark. The worst pain possible is marked like this." (Show example.)

"Show me how much pain you have right now by marking with a straight, up and down line anywhere along the line to show how much pain you have right now."

 |___________________________________________________________________|
No            Little            Medium              Large           Worst
pain          pain              pain                pain          possible
                                                                    pain

B9. Pain Affect Faces Scale

Children are presented with one of three different randomly ordered face sheets. They select the face that best represents how they feel in relation to their pain conditions from "the happiest feeling possible" to the "saddest feeling possible." This figure is actually the scoring card used to quantify children's responses. The numbers represent the magnitude of pain affect (between 0 and 1) shown in each face, based on previous research on children.

B10. Pain Management Log

B11. Flowsheet for Pain Management Documentation

Attachment C.

[Contents]

Sample relaxation exercises

Exercise 1.

Slow rhythmic breathing for relaxation

Exercise 2.

Simple touch, massage, or warmth for relaxation

Exercise 3.

Peaceful past experience

Exercise 4.

Actively listening to recorded music

Exercise 1: Slow rhythmic breathing for relaxation

1. Breathe in slowly and deeply.
2. As you breathe out slowly, feel yourself beginning to relax; feel the tension leaving your body.
3. Now breathe in and out slowly and regularly, at whatever rate is comfortable for you. You may wish to try abdominal breathing.
4. To help you focus on your breathing and breathe slowly and rhythmically: (a) breathe in as you say silently to yourself, "in, two, three"; (b) breathe out as you say silently to yourself, "out, two, three." or Each time you breathe out, say silently to yourself a word such as "peace" or "relax."
5. Do steps 1 through 4 only once or repeat steps 3 and 4 for up to 20 minutes.
6. End with a slow deep breath. As you breathe out say to yourself "I feel alert and relaxed."

Exercise 2. Simple touch, massage, or warmth for relaxation

Touch and massage are age-old methods of helping others relax. Some examples are:

1. Brief touch or massage, e.g., handholding or briefly touching or rubbing a person's shoulder.
2. Warm foot soak in a basin of warm water, or wrap the feet in a warm, wet towel.
3. Massage (3 to 10 minutes) may consist of whole body or be restricted to back, feet, or hands. If the patient is modest or cannot move or turn easily in bed, consider massage of the hands and feet.
   • Use a warm lubricant, e.g., a small bowl of hand lotion may be warmed in the microwave oven, or a bottle of lotion may be warmed by placing it in a sink of hot water for about 10 minutes.
   • Massage for relaxation is usually done with smooth, long, slow strokes. (Rapid strokes, circular movements, and squeezing of tissues tend to stimulate circulation and increase arousal.) However, try several degrees of pressure along with different types of massage, e.g., kneading, stroking, and circling. Determine which is preferred.

Especially for the elderly person, a back rub that effectively produces relaxation may consist of no more than 3 minutes of slow, rhythmic stroking (about 60 strokes per minute) on both sides of the spinous process from the crown of the head to the lower back. Continuous hand contact is maintained by starting one hand down the back as the other hand stops at the lower back and is raised. Set aside a regular time for the massage. This gives the patient something to look forward to and depend on.

Exercise 3. Peaceful past experiences

Something may have happened to you a while ago that brought you peace and comfort. You may be able to draw on that past experience to bring you peace or comfort now. Think about these questions:

1. Can you remember any situation, even when you were a child, when you felt calm, peaceful, secure, hopeful, or comfortable?
2. Have you ever daydreamed about something peaceful? What were you thinking of?
3. Do you get a dreamy feeling when you listen to music? Do you have any favorite music?
4. Do you have any favorite poetry that you find uplifting or reassuring?
5. Have you ever been religiously active? Do you have favorite readings, hymns, or prayers? Even if you haven't heard or thought of them for many years, childhood religious experiences may still be very soothing.

Exercise 4. Active listening to recorded music

1. Obtain the following:

   A cassette player or tape recorder. (Small, battery-operated ones are more convenient.)

   Earphone or headset. (This is a more demanding stimulus than a speaker a few feet away, and it avoids disturbing others.)

   Cassette of music you like. (Most people prefer fast, lively music, but some select relaxing music. Other options are comedy routines, sporting events, old radio shows, or stories.)

2. Mark time to the music, e.g., tap out the rhythm with your finger or nod your head. This helps you concentrate on the music rather than your discomfort.
3. Keep your eyes open and focus steadily on one stationary spot or object. If you wish to close your eyes, picture something about the music.
4. Listen to the music at a comfortable volume. If the discomfort increases, try increasing the volume; decrease the volume when the discomfort decreases.
5. If this is not effective enough, try adding or changing one or more of the following: massage your body in rhythm to the music; try other music; mark time to the music in more than one manner, e.g., tap your foot and finger at the same time.