Epidemiology Shingles

Most current estimates of the epidemiology and burden of herpes zoster and PHN come from studies in Europe and the USA. The reported incidence of herpes zoster in these regions varies from 1.3 to 4.8/1000 patients/year, and this rate increases sharply with age, with a 2- to 4-fold increase in those aged >60 years.

The incidence rate of herpes zoster ranges from 1.2 to 3.4 per 1,000 person-years among healthy individuals, increasing to 3.9–11.8 per 1,000 person‐years among those older than 65 years.Similar incidence rates have been observed worldwide. Herpes zoster develops in an estimated 500,000 Americans each year.

United States

A study of patients in a large health maintenance organization (HMO) in the United States revealed 1075 cases from 1990-1992.¹ The following characteristics were noted:

• Incidence was 215 cases per 100,000 people per year.
• Older patients were more at risk (1424 cases per 100,000 people per year for age >75 y).
• Fewer than 5% of cases were in children and younger adolescents.
• Three of 4 patients with recurrent zoster were HIV positive.

Over 90 percent of adults in the United States have serologic evidence of varicella–zoster virus infection and are at risk for herpes zoster.² The annualized incidence of herpes zoster is about 1.5 to 3.0 cases per 1000 persons.^3,4 An incidence of 2.0 cases per 1000 persons would translate into more than 500,000 cases annually in the United States. Increasing age is a key risk factor for the development of herpes zoster; the incidence of shingles among persons older than 75 years of age exceeds 10 cases per 1000 person-years.³ The lifetime risk of herpes zoster is estimated to be 10 to 20 percent.⁴

Resource on Pain Treatment

http://www.painfoundation.org/learn/publications/files/TreatmentOptions2006.pdf

Complementary Treatment for Shingles *addition*

THE ORTHODOX APPROACH

If the complaint is caught early enough and treatment starts within say 24 hours of the rash appearing, antiviral drugs will reduce the duration of the illness and lessen the risk of post-herpetic neuralgia. Strong pain-killers may also be prescribed. If shingles affects the forehead, the physician will examine your eyes to make sure that the cornea has not been harmed (sight can be damaged if treatment comes too late), and special eye drops will be prescribed to protect the eyesight. It is wise to wear loose fitting clothing so that the blisters are not rubbed and irritated. Cool baths may help relieve the pain.

ACUPUNCTURE

According to the theory of ancient Chinese medicine, shingles is caused by overheating along with viruses and toxins in the body. As one acupuncturist explains, “The principle of treatment is to tackle the overheating, to get through the blockages and to balance the body”.

He estimates that it normally takes about two weeks to clear up shingles. “Acupuncture alone is excellent for shingles and for the accompanying pain”, he says.

HYPNOTHERAPY

Post shingles pain can linger for a long time, often causing depression, and hypnotherapy can be most effective in dealing with this attendant aspect of the disease. When the patient is in a hypnotic state, visualization techniques can be used so that he or she sees the virus being expelled from the body and sees him/herself being well again.

HOMEOPATHY

One homeopath reports that “most cases of shingles show good improvement” using homeopathic remedies. He estimates that three to four consultations are usually adequate to produce results. The best known homeopathic remedies for shingles are Bellis per. and Hedera helix (ivy). Other commonly used remedies include Rhus tox. for the blistered, itchy skin, Apis mel if the skin burns or stings, and Mezereum for extreme pain and itching.

NATUROPATHY

There are dietary factors that are known to help or hinder the development of this painful disease. Specifically, there are two amino acids, lysine and arginine, which have an antagonistic effect on each other – arginine promotes herpes and lysine suppresses it. Therefore, foods rich in arginine and low in lysine are to be avoided. These include peanuts and other nuts, chocolate, various seeds (sunflower, poppy, and sesame), cereal grains (bread, breakfast cereals), raisins, gelatin and carob. Instead, choose foods which have a higher ratio of lysine to arginine, such as eggs, beans, fish, chicken, meat, potatoes, milk, and brewers’ yeast. One naturopath recommends that you drink red bush (Rooibosch) tea, which contains a bioflavonoid called quercetin that is useful in combating the herpes virus. In addition, aloe vera and liquorice can be taken internally and/or applied topically to help the rash.

Finally, for local, topical application, he recommends two treatments. Firstly, propolis, which has a “tremendous anti-viral effect”; and secondly lithium, an element found to inhibit herpes. It can be used in the form of an ointment containing lithium succinate with Vitamin E and zinc. “When applied to the blistered area four times daily, it can reduce the duration of the pain and discomfort considerably, easily by half”, he says.

SUPPORTIVE TREATMENTS

When combined with other remedies, the following therapies can be highly beneficial: the therapeutic properties of a Moor therapy drink or body treatment; the ancient Chinese exercise of Chi Kung, which balances the body’s energies and brings a sense of well-being; and the powerful effects of healing energy.

Anatomy - CNS

CENTRAL NERVOUS SYSTEM (CNS)

SOMATIC PART of CNS
- Carry conscious sensation from peripheral à CNS
- Innervates voluntary muscles
- Dermatomytome (from somites) : skeletal muscles + dermis
o Migrate to
§ ANTERIOR : Hypaxial muscles (limbs & trunk)
§ POSTERIOR : Epaxial muscles (intrinsic back muscles & dermis)
- Developing nerve cells in anterior neural tube (form CNS) à differentiating dermatomytome [ MOTOR neurons]
- Developing nerve cells in the neural crest (form PNS) à a) Medial process à posterior of NT
- à b) Lateral process à differentiating dermatomytomes [ SENSORY neurons]
Organized segmentally along the NT and form parts of all spinal nerves & some cranial nerves


- Sensory infos à POSTERIOR spinal cord Motor infos àAnterior spinal cord
- Peripheral à CNS Somatic Sensory Afferents/ General Somatic Afferents (GPAs)
· Modalities include pain, touch, temperature & proprioception
- CNS à Peripheral Somatic Motor Efferents/ General Somatic Efferents (GSEs)

Dermatomes (sensory)
- Specific somite develops à dermis at a precise location à associated somatic sensory fibres enter à POSTERIOR spinal cord at a specific level becomes à ONE specific spinal nerve
- Thus, EACH spinal nerve carries somatic sensory infos from a specific area of skin on the surface of the body
Area of skin supplied by a SINGLE spinal cord level/spinal nerve

- Dermatome is usually overlap
o Autonomous Region: Overlap of dermatomes is least likely
§ TESTING TOUCH in conscious patient à localize lesions to a specific spinal nerve
Mytomes (motor)
- Specific somite develops à skeletal muscle at a precise location à associated somatic motor fibres ­+ somatic sensory nerves from the SAME level = SPINAL NERVE
Portion of skeletal muscle innervated by a SINGLE spinal cord level/ spinal nerve

- More difficult to test than dermatomes as each skeletal muscle is usually innervated by > 1 spinal nerve
- However, TESTING MOVEMENT at successive joints à localize lesions to specific spinal nerve, e.g. a) shoulder joint (C5 & C6) b) elbow (C6 & C7) c) hand (C8 & T1)

IMPORTANT CLINICAL USE
Fundamental to carry out neurological examination

Risk Factors of Shingles

An Overview of Shingles Risk Factors
Shingles is a condition caused by the varicella-zoster virus, which is the same virus that causes chickenpox. After you recover from chickenpox (or have the chickenpox vaccine), the virus does not leave your body, but continues to live in some nerve cells. For reasons that aren't totally understood, the virus can become active instead of remaining inactive. When it is activated, it produces shingles.
Anyone with the varicella-zoster virus in his or her body can be at risk for getting shingles. Right now there is no way of knowing who will get shingles disease. But, there are things that make you more likely to get shingles. These "shingles risk factors" include:

• Advanced age
• Problems with the immune system
• Chickenpox during pregnancy.

Advanced Age
About 25 percent of all adults, mostly otherwise healthy, will get shingles during their lifetime, usually after age 40. The incidence increases with age. For example, shingles is 10 times more likely to occur in adults over 60 than in children under 10.

Immune System Problems
Your immune system is the part of your body that fights off infections. Age can affect your immune system. So can an HIV infection (or AIDS), cancer, cancer drugs, radiation treatments, or an organ transplant. Even stress or a cold can weaken your immune system for a short time and put you at risk for shingles.

Chickenpox During Pregnancy
Youngsters whose mothers had chickenpox late in pregnancy -- 5 to 21 days before giving birth -- or who had chickenpox in infancy have an increased risk of pediatric shingles. Sometimes these children are born with chickenpox or develop a typical case within a few days.
What Are the Causes of Shingles?
There is only one cause of shingles (also known as herpes zoster) -- a reinfection with the varicella-zoster virus. The varicella-zoster virus that causes shingles is the same virus that causes chickenpox. The infection with this virus just tends to occur during different decades of a person's life.

The Varicella-Zoster Virus - - The "Cause of Shingles"
Varicella-zoster is part of the herpesvirus family. This group of viruses includes the herpes simplex virus (HSV) that causes cold sores, fever blisters, genital herpes (a sexually transmitted disease), and the Epstein-Barr virus involved in infectious mononucleosis.

As early as 1909, a German scientist suspected that the viruses causing chickenpox and shingles were one and the same. In the 1920s and 1930s, the case was strengthened. As part of an experiment, children were inoculated with fluid from the lesions of people with shingles. Within two weeks, about half the children came down with chickenpox. Finally, in 1958, detailed analyses of the viruses taken from people with either chickenpox or shingles confirmed that the viruses were identical.

So how does the same virus that causes chickenpox also cause shingles? To understand this, it may be helpful to understand the "reactivation" of the varicella-zoster virus.

Reactivation of the Shingles Virus Causes Shingles
After an attack of chickenpox, the varicella-zoster virus moves up into the nerves, where it settles down in an inactive form (known as a latent form). It "lies down" inside specific nerve cells (neurons) that relay information to the brain about what your body is sensing -- such as whether your skin feels hot or cold, whether you've been touched, or whether you're feeling feel pain. These nerve cells lie in clusters (ganglia) adjacent to the spinal cord and brain, and are one type of sensory neuron.

As we get older, it is possible for the varicella-zoster virus to "come alive." When this happens, the shingle virus "reactivates" and then moves down the nerves to cause symptoms of shingles. Research scientists are still trying to understand why this happens and why it happens in some people and not in others.

Although shingles is most common in people over age 50, if you have had chickenpox or the chickenpox vaccine, you are at risk for developing shingles. This disease is also more common in people with weakened immune systems from HIV infection, chemotherapy or radiation treatment, transplant operations, and stress.

Prognosis + Complications of Herpes Zoster

PROGNOSIS

• most healthy people who receive treatment soon after the outbreak of blisters, the lesions heal, the pain subsides within 3 to 5 weeks
  
• The blisters often leave no scars.
  
• a serious threat in immunocompromised individuals
  

COMPLICATIONS

Herpes Zoster Opthalmicus

• Occurs when one of the nerves that go into the eye (known as the ophthalmic nerve) is involved with the shingles infection.
  
• Most common problem is known as anterior uveitis, which is inflammation that normally includes the iris
  
• may cause
  
  • Redness of the eye
    
  • Pain
    
  • Blurred vision.
    
• Up to 70% people with this complication will develop some sort of temporary or permanent eye problem.
  
• May also lead to temporary or permanent blindness.
  

Ramsay Hunt Syndrome

• Occurs when herpes zoster causes facial paralysis and rash on the ear (herpes zoster oticus) or in the mouth.
  
• Symptoms
  
  • Severe ear pain
    
  • Hearing loss
    
    • Varies from partial to total
      
    • May be permanent
      
  • Ringing in the ear
    
  • Loss of taste
    
  • Nausea
    
  • Vomiting
    
  • Dizziness
    
    • May last for a few days or even for weeks
      
    • Usually resolves
      
• May also cause a mild inflammation in the brain
  

Bell's palsy

• Partial paralysis of the face.
  
• May suggest a reactivation of herpes zoster, even if no rash appears.
  

Postherpetic Neuralgia

• Most common severe complication (10%-70%)
  
• Risk factor:
  
  • Age
    
  • Gender
    
  • Severe/ complicated shingles
    
• Pain that persists for longer than a month, sometimes years after the onset of herpes (commonly resolves within 3 months)
  
• Mechanism :
  
  
  • Occurs from damage to the nerve fibers, caused by the varicella zoster virus
    
  • The herpes zoster virus appears to produce persistent inflammation in the spinal cord that causes long-term damage, including nerve scarring.
    
  • Nerves that are injured in the initial attack may regrow abnormally and provoke an exaggerated response in the brain that signals intense sensitivity or pain.
    
• Skin is so sensitive that clothing or even a passing breeze cannot be tolerated on the affected area.
  
• The pain is described as agonizing, excruciating, and burning.
  
• last longer
  
• Difficult to treat
  
• Can result in an inability to perform daily tasks of living. This can lead to loss of independence and, ultimately, depression and isolation.
  

Sacral Zoster

• When the shingles virus affects the nerves that control bladder function
  
• Symptoms can include
  
  • Being unable to urinate
    
  • Feeling the urge to urinate but not being able to
    
  • Having a dribbling urinary stream.
    

Secondary Infection In The Blisters

• If the blistered area is not kept clean and free from irritation
  
• May become infected with Streptococcus A or Staphylococcus bacteria
  
• If the infection is severe, scarring can occur.
  

Disseminated Herpes Zoster

• Spreads to other organs
  
• Can be life-threatening, particularly if it affects the lungs
  
• Immunocompromised person are at greatest danger, with risk of 5 - 25%.
  
• Very rare in people with healthy immune systems.
  

Encephalitis / Meningitis

• A rare complication
  
• Generally mild
  
• Resolves in short period
  
• Can be severe and even life-threatening in immunocompromised person
  

Imminent acute retinal necrosis syndrome

• A devastating infection in the retina
  
• Visual changes develop within weeks or months after the herpes zoster outbreak has resolved
  
• Usually follows a herpes outbreak in the face
  
• Can also occur after an outbreak in any part of the body
  
• Symptoms
  
  • Conjunctivitis
    
  • Inflammation of the cornea
    
  • Pain
    

Treatment of Postherpetic Neuralgia

Treatment of Postherpetic Neuralgia

Analgesics
Capsaicin, an extract from hot chili peppers, is currently the only drug labeled by the U.S. Food and Drug Administration for the treatment of postherpetic neuralgia.19 Trials have shown this drug to be more efficacious than placebo but not necessarily more so than other conventional treatments.20

Substance P, a neuropeptide released from pain fibers in response to trauma, is also released when capsaicin is applied to the skin, producing a burning sensation. Analgesia occurs when substance P is depleted from the nerve fibers. To achieve this response, capsaicin cream must be applied to the affected area three to five times daily. Patients must be counseled about the need to apply capsaicin regularly for continued benefit. They also need to be counseled that their pain will likely increase during the first few days to a week after capsaicin therapy is initiated. Patients should wash their hands thoroughly after applying capsaicin cream in order to prevent inadvertent contact with other areas.

Patches containing lidocaine have also been used to treat postherpetic neuralgia. One study found that compared with no treatment, lidocaine patches reduced pain intensity, with minimal systemic absorption. Although lidocaine was efficacious in relieving pain, the effect was temporary, lasting only four to 12 hours with each application.21

Over-the-counter analgesics such as acetaminophen (e.g., Tylenol) and nonsteroidal anti-inflammatory drugs have not been shown to be highly effective in the treatment of postherpetic neuralgia. However, these agents are often useful for potentiating the pain-relieving effects of narcotics in patients with severe pain. Because of the addictive properties of narcotics, their chronic use is discouraged except in the rare patient who does not adequately respond to other modalities.
Tricyclic antidepressants or anticonvulsant medications given in low dosages can be effective adjuncts in controlling the pain of postherpetic neuralgia.

Tricyclic Antidepressants
Tricyclic antidepressants can be effective adjuncts in reducing the neuropathic pain of postherpetic neuralgia. These agents most likely lessen pain by inhibiting the reuptake of serotonin and norepinephrine neurotransmitters.22

Tricyclic antidepressants commonly used in the treatment of postherpetic neuralgia include amitriptyline (Elavil), nortriptyline (Pamelor), imipramine (Tofranil) and desipramine (Norpramin). These drugs are best tolerated when they are started in a low dosage and given at bedtime. The dosage is increased every two to four weeks to achieve an effective dose.

The tricyclic antidepressants share common side effects, such as sedation, dry mouth, postural hypotension, blurred vision and urinary retention. Nortriptyline and amitriptyline appear to have equal efficacy; however, nortriptyline tends to produce fewer anticholinergic effects and is therefore better tolerated. Treatment with tricyclic antidepressants can occasionally lead to cardiac conduction abnormalities or liver toxicity. The potential for these problems should be considered in elderly patients and patients with cardiac or liver disease.

Because tricyclic antidepressants do not act quickly, a clinical trial of at least three months is required to judge a patient's response. The onset of pain relief using tricyclic antidepressants may be enhanced by beginning treatment early in the course of herpes zoster infection in conjunction with antiviral medications.20

Anticonvulsants
Phenytoin (Dilantin), carbamazepine (Tegretol) and gabapentin (Neurontin) are often used to control neuropathic pain. A recent double-blind, placebo-controlled study showed gabapentin to be effective in treating the pain of postherpetic neuralgia, as well as the often associated sleep disturbance.23

The anticonvulsants appear to be equally effective, and drug selection often involves trial and error. Lack of response to one of these medications does not necessarily portend a poor response to another. The dosages required for analgesia are often lower than those used in the treatment of epilepsy.

Anticonvulsants are associated with a variety of side effects, including sedation, memory disturbances, electrolyte abnormalities, liver toxicity and thrombocytopenia. Side effects may be reduced or eliminated by initiating treatment in a low dosage, which can then be slowly titrated upward.

There are no specific contraindications to using anticonvulsants in combination with antidepressants or analgesics. However, the risk of side effects increases when multiple medications are used.

Effective treatment of postherpetic neuralgia often requires multiple treatment approaches. In addition to medications, modalities to consider include transcutaneous electric nerve stimulation (TENS), biofeedback and nerve blocks.

Corticosteroids
Orally administered corticosteroids are commonly used in the treatment of herpes zoster, even though clinical trials have shown variable results. Prednisone used in conjunction with acyclovir has been shown to reduce the pain associated with herpes zoster.15 The likely mechanism involves decreasing the degree of neuritis caused by active infection and, possibly, decreasing residual damage to affected nerves.

Some studies designed to evaluate the effectiveness of prednisone therapy in preventing postherpetic neuralgia have shown decreased pain at three and 12 months.16,17 Other studies have demonstrated no benefit.15,18

If the use of orally administered prednisone is not contraindicated, adjunctive treatment with this agent is justified on the basis of its effects in reducing pain, despite questionable evidence for its benefits in decreasing the incidence of postherpetic neuralgia. Given the theoretic risk of immunosuppression with corticosteroids, some investigators believe that these agents should be used only in patients more than 50 years of age because they are at greater risk of developing postherpetic neuralgia.15 The recommended dosage for prednisone is given in Table 1.

Analgesics
The pain associated with herpes zoster ranges from mild to excruciating. Patients with mild to moderate pain may respond to over-the-counter analgesics. Patients with more severe pain may require the addition of a narcotic medication. When analgesics are used, with or without a narcotic, a regular dosing schedule results in better pain control and less anxiety than "as-needed" dosing.

Lotions containing calamine (e.g., Caladryl) may be used on open lesions to reduce pain and pruritus. Once the lesions have crusted over, capsaicin cream (Zostrix) may be applied. Topically administered lidocaine (Xylocaine) and nerve blocks have also been reported to be effective in reducing pain.

What is Pain and Types of Pain

The English word 'pain' probably comes from Old French (peine), Latin (poena - meaning punishment pain), or Ancient Greek (poine - a word more related to penalty), or a combination of all three.

In medicine pain relates to a sensation that hurts. If you feel pain it hurts, you feel discomfort, distress and perhaps agony, depending on the severity of it. Pain can be steady and constant, in which case it may be an ache. It might be a throbbing pain - a pulsating pain. The pain could have a pinching sensation, or a stabbing one.

Only the person who is experiencing the pain can describe it properly. Pain is a very individual experience.
Types of pain
Acute pain - this can be intense and short-lived, in which case we call it acute pain. Acute pain may be an indication of an injury. When the injury heals the pain usually goes away.

Chronic pain - this sensation lasts much longer than acute pain. Chronic pain can be mild or intense (severe).

How do we classify pain?

Pain can be nociceptive, non-nociveptive, somatic, visceral, neuropathic, or sympathetic. Look at the table below.

Pain
Nociceptive Nociceptive
1)Somatic 2)Visceral 1)Neuropathic 2)Sympathetic


Nociceptive Pain - specific pain receptors are stimulated. These receptors sense temperature (hot/cold), vibration, stretch, and chemicals released from damaged cells.

Somatic Pain - a type of nociceptive pain. Pain felt on the skin, muscle, joints, bones and ligaments is called somatic pain. The term musculo-skeletal pain means somatic pain. The pain receptors are sensitive to temperature (hot/cold), vibration, and stretch (in the muscles). They are also sensitive to inflammation, as would happen if you cut yourself, sprain something that causes tissue damage. Pain as a result of lack of oxygen, as in ischemic muscle cramps, are a type of nociceptive pain. Somatic pain is generally sharp and well localized - if you touch it or move the affected area the pain will worsen.

Visceral Pain - a type of nociceptive pain. It is felt in the internal organs and main body cavities. The cavities are divided into the thorax (lungs and heart), abdomen (bowels, spleen, liver and kidneys), and the pelvis (ovaries, bladder, and the womb). The pain receptors - nociceptors - sense inflammation, stretch and ischemia (oxygen starvation).

Visceral pain is more difficult to localize than somatic pain. The sensation is more likely to be a vague deep ache. Colicky and cramping sensations are generally types of visceral pain. Visceral pain commonly refers to some type of back pain - pelvic pain generally refers to the lower back, abdominal pain to the mid-back, and thoracic pain to the upper back (see below for the meaning of referred pain).

Nerve Pain or Neuropathic Pain

Nerve pain is also known as neuropathic pain. It is a type of non-nociceptive pain. It comes from within the nervous system itself. People often refer to it as pinched nerve, or trapped nerve. The pain can originate from the nerves between the tissues and the spinal cord (peripheral nervous system) and the nerves between the spinal cord and the brain (central nervous system, or CNS).

Neuropathic pain can be caused by nerve degeneration, as might be the case in a stroke, multiple-sclerosis, or oxygen starvation. It could be due to a trapped nerve, meaning there is pressure on the nerve. A torn or slipped disc will cause nerve inflammation, which will trigger neuropathic pain. Nerve infection, such as shingles, can also cause neuropathic pain.

Pain that comes from the nervous system is called non-nociceptive because there are no specific pain receptors. Nociceptive in this text means responding to pain. When a nerve is injured it becomes unstable and its signaling system becomes muddled and haphazard. The brain interprets these abnormal signals as pain. This randomness can also cause other sensations, such as numbness, pins and needles, tingling, and hypersensitivity to temperature, vibration and touch. The pain can sometimes be unpredictable because of this.

Sympathetic Pain

The sympathetic nervous system controls our blood flow to our skin and muscles, perspiration (sweating) by the skin, and how quickly the peripheral nervous system works.

Sympathetic pain occurs generally after a fracture or a soft tissue injury of the limbs. This pain is non-nociceptive - there are no specific pain receptors. As with neuropathic pain, the nerve is injured, becomes unstable and fires off random, chaotic, abnormal signals to the brain, which interprets them as pain.

Generally with this kind of pain the skin and the area around the injury become extremely sensitive. The pain often becomes so intense that the sufferer daren't use the affected arm or leg. Lack of limb use after a time can cause other problems, such as muscle wasting, osteoporosis, and stiffness in the joints.
What is referred pain?
Also known as reflective pain. When pain is felt either next to, or at a distance from the origin of an injury it is called referred pain. For example, when a person has a heart attack, even though the affected area is the heart, the pain is sometimes felt around the shoulders, back and neck, rather than in the chest. We have known about referred pain for centuries, but we still do not know its origins and what causes it.
How do you measure pain?
It is virtually impossible to measure a person's pain objectively. Most experts say that the best way to find out how much pain a person is enduring is by a subjective pain report. A comprehensive assessment of pain should include:
The identification of all the pains. This must include the most important ones.
The site, quality, and radiation of pain
What factors aggravate and relieve the pain

When the pain occurs throughout the day

What impact the pain has on the person's function

What impact the pain has on the person's mood

The sufferers' understanding of their pain
There are many different methods for measuring pain and its severity. Health care professionals say it is important to stick to whatever system or tool you chose for a specific patient all the way through. If a patient is unable to report his pain, such as an infant, or a person with dementia, there are a number of observational pain measures a doctor can use.

Here is a list of some pain measures used today:

Numerical Rating Scales

The patient is given a form which asks him to tick from 0 to 10 what his level of pain is. 0 is no pain, 5 is moderate pain, and 10 is the worst pain imaginable.

Please rate the pain you have right now
0 2 3 4 5 6 7 8 9 10
No pain Moderate pain Worst pain imaginable


The Numerical Rating Scales are useful if you want to measure any changes in pain, as well as gauging the patient's response to pain treatment. If the patient has dyslexia, autism, or is very elderly and has dementia this may not be the best tool (see the ones below).

Verbal Descriptor Scale

This type of scale exists in many different forms. The patient is asked questions and responds verbally choosing from such terms as mild, moderate, severe, no pain, mild pain, discomforting, distressing, horrible, and excruciating.

Elderly patients with cognitive impairment, very young children, and people who respond better to verbal stimuli tend to have better completion rates with this type of scale, compared to the written numerical scale. Children respond even better to the faces scale (description below).

Faces Scale

The patient sees a series of faces. The first one is calm and happy, the second less so, etc., and the final one has an expression of extreme pain. This scale is used mainly for children, but can also be used with elderly patients with cognitive impairment. Patients with autism may respond better to this type of approach - people with autism tend to respond to visual stimuli well.

Brief Pain Inventory

This is a much more comprehensive written questionnaire. Not only does it gauge current level of pain, but also records the peaks and troughs of pain during previous days, how pain has affected mood, activity, sleep patterns, and how the pain may have affected the patient's interpersonal relationship. The questionnaire also has diagrams which the patient shades - the shaded parts being where the pain is located and where it is most severe.

McGill Pain Questionnaire

This questionnaire measures the intensity (severity) of the pain, the quality of the pain, mood, and understanding of the pain. It is also known as the McGill Pain Index. It is a scale of rating pain developed at McGill University by Melzack and Torgerson (1971).

Look at the 20 groups below.
Circle one word in each group that best describes your pain.
Circle only three words from Groups 1 to 10 that best describe your pain response.
Choose just two words in Groups 11 to 15 that best describe your pain.
Just pick the one in Group 16.
Finally, choose just one word from Groups 17-20.
You should now have seven words. Those seven words should be taken to your doctor. They will help describe both the quality and intensity of your pain.

Group 1 - Flickering, Pulsing, Quivering, Throbbing, Beating, Pounding
Group 2 - Jumping, Flashing, Shooting
Group 3 - Pricking, Boring, Drilling, Stabbing
Group 4 - Sharp, Gritting, Lacerating
Group 5 - Pinching, Pressing, Gnawing, Cramping, Crushing
Group 6 - Tugging, Pulling, Wrenching
Group 7 - Hot, Burning, Scalding, Searing
Group 8 - Tingling, Itching, Smarting, Stinging
Group 9 - Dull, Sore, Hurting, Aching, Heavy
Group 10 - Tender, Taunt, Rasping, Splitting
Group 11 - Tiring, Exhausting
Group 12 - Sickening, Suffocating
Group 13 - Fearful, Frightful, Terrifying
Group 14 - Punishing, Grueling, Cruel, Vicious, Killing
Group 15 - Wretched, Binding
Group 16 - Annoying, Troublesome, Miserable, Intense, Unbearable
Group 17 - Spreading, Radiating, Penetrating, Piercing
Group 18 - Tight, Numb, Squeezing, Drawing, Tearing
Group 19 - Cool, Cold, Freezing
Group 20 - Nagging, Nauseating, Agonizing, Dreadful, Torturing

Measuring pain when the patient is cognitively impaired

In this case doctors say that the patient's subjective pain report is the most effective and accurate way of evaluating pain. If the severely cognitively impaired patient is observed carefully it is possible to pick out clues as to the presence of pain, e.g. restlessness, crying, moaning, groaning, grimacing, resistance to care, reduced social interactions, increased wandering, not eating, and sleeping problem