Complexities of Pain Assessment

Original Editor - Rachel Vennard

Top Contributors - Rachel Vennard, Lauren Lopez, Jo Etherton, Kim Jackson and Claire Knott  


Louis Gifford (MappSc. BSc. FCSP.), an internationally renowned expert and published author in pain treatment and management, describes the complexities of pain assessment in the following words:

‘It is my opinion that a clinician unacquainted with the complexity of the pain experience will regard painful conditions as either psychological or pathological; a more informed clinician will unconsciously ascribe a percentage to each area; but an enlightened clinician will see pain as a dynamic interaction between a multitude of influences and manage it accordingly and appropriately.’[1]

His words demonstrate not only that pain itself is a complex sensation but also that a clinician’s effective interpretation of a patient’s pain requires experience, knowledge and awareness. A person’s experience of pain is highly personal and pain itself may present in a variety of different ways. The English language has a multitude of words to describe the sensation of pain; The Oxford Dictionary lists 9 synonyms under the definition of pain, ranging from ‘discomfort’ to ‘torture’ [2]. Although pain is a physical sensation, it is also affected by factors such as psychology, social issues, environmental issues, feelings and behaviours[3]. In short, the assessment of pain should be approached in a holistic manner, looking at the patient as an individual, appreciating the context of their experience and the difficulties the patient may have in expressing their pain.

As highlighted in the quote by Louis Gifford above, improved knowledge and awareness of the influences on a patient’s pain, perception and expression will vastly improve a clinician’s approach to the patient in pain. This concept forms the focus of this article, which does not look in detail at the specific tools available to assess pain but instead seeks to highlight and analyse the barriers to successful understanding. For a more specific look at Pain Assessment tools refer to the Physiopedia 'Pain Assessment' page.

Barriers to Pain Assessment

When identifying barriers to pain assessment it becomes clear that communication is a key aspect. Subjective history is an important aspect of the assessment of pain, as ‘pain is by definition a subjective experience’[4]. When barriers to communication occur this aspect of assessment can be affected, which may impact on the outcome of the patient’s assessment and treatment. Issues of communication can stem from the patient or the therapist, and the overall connection between the two can influence the effectiveness of assessment. The varying causes of limitations to communication are discussed later in this article under the subheadings below:

- Dementia
- Learning Difficulties
- Paediatrics
- Intensive Care – intubated / sedated patients

There are a variety of reasons why a person’s communication may be affected, but when assessing a patient with an inhibited ability to communicate it is important to be aware that alternative methods of assessment can be used. Physiotherapists can utilise a number of approaches to overcome communication barriers such as active listening, being patient centred and individual with their approach, and questionnaires or validated assessment tools[5].

Table 1: Examples of non-Verbal Cues that may be observed during the assessment of pain in a patient with limited communication[6][7]
Physical Facial expression
Opening Mouth
Autonomic Sweating
General increase in muscle tone
Increased Heart Rate
Increased Blood Pressure
Behavioural Aggression
General change in behaviour from baseline
Changes in sleep
Changes in appetite
Altered interaction with environment / other people


Pain Assessment Considerations with More Complex Patients


Dementia is a barrier that can affect a patient’s communication, cognition and emotional experience[8]. The Alzheimer’s society states that in 2015 dementia will affect 850,000 people in the UK[9]. When assessing patients with dementia therapists must be aware that the patient may not be capable of directly communicating exactly where the pain is, or even whether they are in pain at all[10]. Horgas, A.L. (2012) suggested that, due to the limitations in communication with some dementia patients, it would be beneficial to liaise closely with family and regular care-givers who may be able to identify indicators of pain that may not be recognised by a new assessor.

Although assessing pain in patients with dementia can be challenging, there is evidence to suggest that patients with mild to moderate dementia can effectively self-report pain levels when appropriate assessment tools are chosen[11][12]. When dementia progresses to the point that a patient cannot verbally communicate, or cognition prevents effective expression then measures with more behavioural and physical observations become more relevant[12].

Learning Difficulties

When assessing patients with more severe learning difficulties, the importance of carers recognising and interpreting non-verbal cues has been identified. The ability to identify distress in the non-verbally communicative patient is a challenge but it can be completed by carers with no previous experience of the patient using more structured assessment tools such as the DisDAT tool[13]. As with dementia patients, those with learning difficulties may have similar issues with communication and expression with regards to pain. This area, as yet, is relatively under researched; Quinn, B.L. et al, 2014[14] suggested that a systematic review of current research revealed the need to look in more depth at current pain assessment methods and practices with regards to patients with learning difficulties.


When working with children there may be communication difficulties in younger children with a lack of effective verbal expression, or indeed those with learning difficulties as previously discussed. However, even if communication seems intact, when treating children the influence of the parents / family must be considered. Parental anxiety and catastrophizing when their child has chronic musculoskeletal pain has been shown to significantly correlate with the child’s pain intensity, protective parenting responses and subsequent disability[15]. Furthermore, it has been demonstrated that adolescents (between the ages of 12 and 17) undergoing cancer treatment report their main barrier to reporting pain and using analgesia is a fear that it may lead to restrictions in social activities[16].

Intubated / Sedated Patients on Intensive Care

Pain relief is an ethical and professional responsibility of those directly involved in patient care. Patients that are critically ill are at risk of inhibited communication with regards to expressing pain due to intubation, sedation, use of opioids, or delirium caused by acute infection[17]. It is important to remember that when a patient is intubated, sedatives and paralyzing agents are used to calm the patient but these do not provide pain relief – rather they inhibit a patient’s ability to express any pain they may feel. When looking at pain levels and appropriate treatment in those patients incapable of communicating effectively it has been suggested that we first acknowledge the patient’s previous use of analgesia and any pre-existing conditions (such as arthritis or lower back pain for example) that may be aggravated by prolonged bed rest and reduced mobility[18].

When assessing patients that lack the ability to express we must rely on alternative methods of pain analysis as referenced in the table earlier (Table 1). For intubated patients in particular it may be useful to some degree to rely on physiological signs of pain, but this must be used with caution as these signs (such as increased heart rate) are not pain specific and may be due to alternative medical issues[19].

Assessor Related Barriers to Pain Assessment

Limitations of the Assessor

When assessing pain it has been suggested that the experience, education and, on occasion, physician indifference all play a factor[20]. A study by Tzu-Ying Wu (2015)[21], which questioned a total of 810 nurses working in a variety of hospital settings, concluded that knowledge of pain assessment / management of critically ill patients was improved in relation to the amount of training, education and experience the assessor had. The presence of pain management guidelines within clinical areas also improved the knowledge of those questioned within the study. When assessing pain there may also be personal factors at play in terms of patient rapport and inability of the assessor to empathise with the patient[22]. A study by Modanloo, M. et al (2011)[23] found that patient’s pain reports were overall significantly higher than their nurse’s perception and analysis of the patient’s pain, suggesting that pain assessment may differ dependant on the perception of the assessor.

Healthcare System Barriers

Within individual healthcare systems there is variability in terms of pain assessment and a variety of tools used to assess pain in different aspects of healthcare. It is important for trusts to keep up to date with current evidence and to use validated assessment tools where possible in order to optimise pain assessment and management. It has been demonstrated that the introduction of validated pain assessment tools in accident and emergency not only prompts the assessment of patients pain but also promotes more effective subsequent management of any pain identified[24].

An additional barrier that may affect pain assessment is the lack of accountability with regards to pain assessment; it is ethical to ensure a patient’s pain is under control but staff may not understand or acknowledge the importance of pain assessment as part of a patient’s overall treatment and management[22]. A recent ‘systematic review of systematic reviews’[25] looking at pain assessment tools in dementia patients concluded that, although there are a variety of pain assessment tools available, there is currently limited evidence to reliably validate and recommend the use of any one in particular.

Patient Related Barriers to Pain Assessment

Patient Beliefs / Cultural Barriers

Unfortunately, there is evidence to suggest that race / ethnicity can affect the way patients report pain and also the way in which assessors interpret a patient’s pain. In a study by Staton et al (2007)[26] it was found that clinician’s generally under-rated their patient’s pain, regardless of race, in agreement with Modanloo M. et al (2011)[23]. However, physicians were twice as likely to under-estimate a patient with black ethnicity’s pain in comparison to those patients of white ethnicity. Ultimately this study was unable to conclude the reasons behind this difference in pain assessment – further research has been suggested to combat this disparity in pain assessment.

Research suggests that a person’s personality traits may have an influence on their perception of pain [27][28]. A study by Wranker et al (2015)[28] demonstrated that, in the elderly population, neuroticism and insomnia are both significantly related to a patient’s experience of pain. The assessment and management of pain is also affected by the patient’s beliefs associated with pain. For example, Cogan et al (2014)[29] discovered that post cardiac surgery patients reported holding beliefs such as ‘good patients do not speak of their pain’ and ‘pain medication should be saved in case their pain worsens’. These beliefs may lead to patients deliberately underreporting their pain and subsequently receiving inadequate pain relief as a result. Interestingly, a study by Darlow et al (2011)[30] concluded that healthcare practitioner’s beliefs about pain are strongly linked to their patients, which suggests that healthcare practitioners may project their beliefs onto the patient during the assessment and treatment process.

Psychosocial Factors

Pain can be influenced by a wide variety of psychosocial factors including depression, psychological vulnerability, stress and late return to work[31]. When looking at predictors of post op pain research suggests that pain catastrophizing has been shown to be a unique predictor of post-surgical pain severity (along with pre-operative pain levels)[32]. A study by Saatsamoinen, P. et al (2008)[33] investigating the effect of psychosocial risk factors of pain in relation to employment concluded that work placed bullying was directly associated with the development of acute pain. In addition, it was noted that the risks factors linked to chronic pain included high job strain, and family to work conflicts[33].


References will automatically be added here, see adding references tutorial.

  1. Gifford L. Topical Issues in Pain 4: Placebo and non-placebo pain management, muscles and pain. Author House 2013; Page 194.
  2. Oxford Dictionaries. Oxford University Press 2015: [Online – Accessed May 2015]
  3. Main CJ. Sullivan MJL. Watson PJ. Pain Management: Practical applications of the bio-psychosocial perspective in clinical and occupational settings. Churchill Livingstone Elsevier 2008: Chapters 2,3,4: 29-73.
  4. ANZCA - Australian and New Zealand College of Anaesthetists and Faculty of Pain Management. Acute pain management: Scientific evidence. Third Edition 2010; Page xx.
  5. Lowe R. Thomas E. Etherton J. Walker W. Jackson D. Physiopaedia. Pain Assessment: [Online – accessed June 2015]
  6. Zwakhalen SM. Hamers JP. Abu-Saad HH. Berger MP. Pain in elderly people with severe dementia: A systematic review of behavioural pain assessment tools. BMC Geriatrics 2006: 6:3.
  7. Fink R. Pain Assessment: The cornerstone to optimal pain management. Baylor University Medical Centre Proceedings 2000; 13(3): 236-239.
  8. NHS Choices.[ Online – Accessed June 2015]
  9. Alzheimer’s Society Alzheimer’s Society: [Online – Accessed May 2015]
  10. Horgas AL. Assessing pain with older adults with dementia; Try This – Best practices in nursing care to older patients: Issue D2. New York University College of Nursing 2012. [Editor Greenberg, S.A.].
  11. Chibnall JT. Tait RC. Pain assessment in cognitively impaired and unimpaired older adults: A comparison of four scales. Pain 2001; 92(1-2):173-186.
  12. 12.0 12.1 AGS Panel on Persistent Pain in Older Persons. The management of persistent pain in older persons. American Geriatrics Society 2002; 50:S205-S224.
  13. Regnard C. Reynolds J. Watson B. Matthews D. Gibson L. Clarke C. Understanding distress in people with severe communication difficulties: Developing and assessing the Disability Distress Assessment Tool (DisDAT); Journal of Intellectual Disability Research 2007: 51(4):277-292.
  14. Quinn BL. Seibold E. Hayman L. Pain Assessment in Children with Special Needs: A Review of the Literature; Exceptional Children 2014: [Online – Accessed May 2015]
  15. Guite JW. Logan DE. McCue R. Sherry D. Rose J. Parental beliefs and worries regarding adolescent chronic pain. The Clinical Journal of Pain 2011; 25(3):223-232.
  16. Ameringer S. Barriers to pain management among adolescents with cancer. Pain Management Nursing 2010; 11(4): 224-233.
  17. Alderson SM. McKechnie SR. Unrecognised, undertreated pain in ICU: Cause, effects, and how to do better. Open Journal of Nursing 2013; 3(1):108-113.
  18. Sessler CN. Varney K. Patient Focused Sedation and Analgesia in the ICU. Chest 2008; 133(2):522-65.
  19. AACN - American Association of Critical Care Nurses. AACN Practice Alert; assessing pain in the critically ill adult 2013; Page 3.
  20. Elcigil A. RN, PhD. Maltepe H. RN, MSc. Esrefgil G. RN. Mutafoglu K. MD. Nurse’s perceived barriers to assessment and management of pain in a University Hospital. Journal of Paediatric Oncology/Haematology 2011; 33: S33-S38.
  21. Tzu-Ying Wu,MPH, MS, BS, RN. Nurse’s Knowledge and Associated Factors Related to Critically Ill Patients’ Pain Assessment/Management. Sigma Theta Tau International: 43rd Biennial Convention 2015.
  22. 22.0 22.1 Paice JA. Physical aspects of care: Pain and gastrointestinal symptoms; Oxford University Press. 2014 Chapter 1: Pain Assessment. Page 3.
  23. 23.0 23.1 Modanloo M. Abdollahi H. Behnampour N. Agreement of pain assessment between nurses and patients in the Emergency Department. Golestan University of Medical Sciences 2011: 15(1): 457
  24. Kage A. Mohammed A. Assessment and management of pain in children in A&E: Are we doing it the right way? Critical Care 2007; 11(2): 428.
  25. Litchner V. Dowding D. Esterhuizen P. Closs J. Long AF. Corbett A. Briggs M. Pain assessment for people with dementia: A systematic review of systematic reviews of pain assessment tools. BMC Geriatrics 2014; 14:138.
  26. Staton LJ. Panda M. Chen I. Genao I. Kurz J. Pasanen M. Mechaber AJ. Menon M. O’Rorke J. Wood J. Rosenberg E. Faeslis C. Carey T. Calleson D. Cykert S. When race matters: disagreement in pain perception between patients and their physicians in primary care. J Natl Med Assoc 2007: 99: 532–538.
  27. Krok JL. Baker TA. The influence of personality on reported pain and self-efficacy for pain management in older cancer patients. Journal of Health Psychology 2014; 19(10):1261-1270
  28. 28.0 28.1 Wranker AS. Rennemark M. Elmstahl S. Berglund J. The influence of personality traits on the perception of pain in older adults – Findings on the Swedish International Study on Aging and Care – Blekinge Study. Scandinavian Association for the Study of Pain 2015; 7: 3-8.
  29. Cogan J. Ouimette M.F. Vargas-Schaffer G.Yegin Z. Deschamps A. Denault A. Pain attitudes and beliefs regarding pain medication after cardiac surgery: Barriers to adequate pain management. Pain Management Nursing 2014; 15(3):574-579.
  30. Darlow B. Fullen BM. Dean S. Hurley DA. Baxter GD. Dowell A. The association between health care professional attitudes and beliefs and the attitudes and beliefs, clinical management and outcomes of patients with low back pain: A systematic review. European Journal of Pain 2011; 16(1):3-17.
  31. Hinrichs-Rocker A. Schulz K. Jarvinen I. Lefering R. Simanski C. Neugebauer E.A.M. Psychosocial predictors and correlates for chronic post-surgical pain (CPSP) – A Systematic Review. European Journal of Pain 2012; 13(7):719-730.
  32. Sullivan M. Tanzer M. Stanish W. Fallaha M. Keefe F.J. Simmonds M. Dunbar M. Psychological determinants of problematic outcomes following Total Knee Arthroscopy. Pain 2009: 143(1-2):123-129.
  33. 33.0 33.1 Saatsamoinen P. Laaksonen M. Leino,-Arjas P. Lahelma E. Psychosocial risk factors of pain among employees. European Journal of Pain 2008: 13(1): 102-108.