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Assessing Pain in in Post Operative Breast Cancer Patients

Comparison between Brief Pain Inventory (BPI) and Numerical Rating Scale (NRS) for post-operative pain assessment in Saudi Arabian breast cancer patients.


Does BPI assess post-operative breast cancer pain more accurately than NRS?


Effective pain assessment is one of the fundamental criteria of the management of pain. It involves the evaluation of pain intensity, location of the pain and response to treatment. There are a number of multi and one-dimensional assessment tools that have already been established to assess cancer pain. Among these are the Brief Pain Inventory (BPI) and the Numerical Rating Scale (NRS), Breast cancer is a growing public concern in Saudi Arabia as rates continue to escalate, with patients also suffering multiple problems after surgery. Therefore, my research aim is to conduct a comparative study of tools used to assess post-operative breast cancer pain in Saudi Arabian patients and determine which is the most effective. In this process I will use questionnaires for both nurses and patients to collect data, followed by statistical analysis and a comparative study between the BPI and NRS.

Research Hypothesis:

BPI assesses post-operative breast cancer pain in Saudi Arabian patients more accurately than NRS.

Null hypothesis:

There is no significant difference between BPI and NRS as tools for assessing post-operative breast cancer pain in Saudi Arabian patients


Pain is defined as ‘the normal, predicted physiological response to an adverse chemical, thermal or mechanical stimulus related with surgery, trauma or acute illness’ (Carr and Goudas, 1999). Pain assessment is a crucial component for the effective management of post-operative pain in relation to breast cancer. The patient’s report is the main resource of information regarding the characterisation and evaluation of pain; as such, assessment is the ‘dynamic method of explanation of the syndrome of the pain, patho-physiology and the basis for designing a protocol for its management’ (Yomiya, 2011). A recent survey questioned almost 900 physicians 897 and found that 76% reported substandard pain assessment procedures as the single most important barrier to suitable pain management (Roenn et al, 1993).

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Breast cancer is characterized by a lump or thickening in the breast, discharge or bleeding, a change in colour of the areola, redness or pitting of skin and a marble like area under the skin (WebMD, 2014[A1]). Breast cancer has a high prevalence rate globally and is the second most diagnosed cancer in women. Approximately 1.7 million cases were reported in 2012 alone (WCRFI, 2014). In 2014, just over 15,000 women have already been diagnosed with breast cancer: this figure is predicted to rise to around 17,200 in 2020 Breast cancer has also been identified as one of the major cancer related problems in Saudi Arabia, with 6,922 women were assessed[A2] for breast cancer between 2001-2008 (Alghamdi, 2013[A3]).

D Pain assessment tools

Polit et al (2006) conducted a systematic review of the evidence base and recorded a total of 80 different assessment tools that contained at least one pain item. The tools were then categorised into pain tools (n=48) and general symptoms tools (n=32) . They were then separated into uni-dimensional tools (which measure the pain intensity) and multi-dimensional tools (include more than one pain dimension). 33% of all pain tools (n=16) were uni-dimensional, and 50% of all general symptom tools (n=16)were uni-dimensional. 58% of the uni-dimensional tools employed single item scales such as the Visual Analogue Scale (VAS), Verbal Rating Scales (VRS) and NRS (Numerical Rating Scale). The most common dimension included was pain intensity, present in 60% of tools. In the assessed tools, 60% assessed pain in a multi-dimensional format. Among pain tools, 67% were found to be multi-dimensional compared with 50% of the general symptom tools. 38% of all multi-dimensional tools were two-dimensional. The most commonly used dimension was ‘intensity’, present in 75% of all multi-dimensional tools. Other common dimensions include interference, location and beliefs. All the dimensions were specifically targeted by two particular tools which were disease-specific tools and tools that measure pains affect, beliefs, and coping-related issues[A4].

Multidimensional Pain assessment tools:

F The adequate measurement of pain requires more than one tool. Melzack and Casey (1968) highlight that pain assessment ‘should include three dimensions which are sensory-discriminative, motivational-affective and cognitive-evaluative’. This builds on the earlier proposal of Beecher (1959) who considered that all tools should include the two dimensions of pain and reaction to pain. Cleeland (1989) considered that the two dimensions should be classified as sensory and reactive. Sensory dimensions should record the intensity or severity of pain and the reactive dimensions should include accurate measures of interference in the daily function of the patient.

Multi-dimensional pain assessments generally consist of six dimensions: physiologic, sensory, affective, cognitive, behavioural and sociocultural (McGuire, 1992). Cleeland (1989) interviewed patients and found that seven items could effectively measure the intensity and effects of the pain in daily activities: these comprise of general activity, walking, work, mood, enjoyment of life, relations with others and sleep. These elements were later subdivided into two groups: ‘REM’ (relations with others, enjoyment of life and mood) and ‘WAW’ (walking, general activity and work). Later, Cleeland et al (1996) developed the Brief Pain Inventory (BPI) in both its short and long form. It was designed to capture two categories of interference such as activity and affect on emotions. The BPI provides a relatively quick and easy method of measuring the intensity of pain and the level of interference in the daily activities of the sufferer.

With the BPI tool, patients are graded on a 0-10 and it was specifically designed for the assessment of cancer related pain. Patients are asked about the intensity of the pain that they are experiencing at present, as well as the pain intensity over the last 24 hours as the worst, least or average pain (also on a scale of 0-10). Each scale is bound by the words ‘no pain’ (0) and ‘pain as bad as you can imagine’ (10). Patients are also requested to rate the degree to which pain interferes with their daily activities within the seven domains on a scale of 0-10. that comprise general activity, walking, mood, sleep, work, relations with other persons, and enjoyment of life using similar scales of 0 to 10[A5]. These scales are only confined by the words ‘does not interfere’ and ‘interferes completely[A6]’ (Tan et al, 2004). Validation of BPI across the world among the different language people has already been justified. [A7]Additionally, the localization of the pain in the body could be [A8]assessed and details of current medication are assessed (Caraceni et al, 1996).

Uni-dimensional pain assessment tool:

Previous studies have shown that the Numerical Rating Scale (NRS) had the power to assess pain intensity for patients experiencing chronic pain and was also an effective assessment tool for patients with cancer related pain. The NRS consists of a numerical scale range between 0-100 where 0 was considered as one extreme point represented no pain and 100 was considered other extreme point which represented bad/ worse pain (Jensen et al, 1986). Turk et al (1993) developed an 11 point NRS (scale 0-10) where 0 equalled no pain and 10 equalled worst pain. Though cancer pain differs from acute, postoperative and chronic pain experiences, the most common feature is its subjective nature. [A9] In this regard a consensus meeting on cancer pain assessment and classification was held in Italy in 2009 with the recommendation that pain intensity should be measured on a scale of 0-10 with ‘no pain’ and ‘pain as bad as you can imagine[A10]’ (Hjermstad et al., 2011). Krebs et al. (2007) categorised NRS scores as mild (1–3), moderate (4–6), or severe (7–10). A rating of 4 or 5 is the most commonly recommended lower limit for moderate pain and 7 or 8 for severe pain. Aimed at moderate pain assessment, For the purpose of clinical and administrative use the recommendation for moderate pain assessment on the scale is a score of 4.

Importance of post- operative pain assessment:

Post-operative pains is very common after surgery and the use of medication often depends on the intensity of pain that the patient is experiencing (Chung et al, 1997). Insufficient assessment of post-operative pain can have a ‘significant detrimental effect on raised levels of anxiety, sleep disturbance, restlessness, irritability, aggression, distress and suffering’ (Carr et al, 2005). Additional physiological effects can include increased blood pressure, vomiting and paralytic ileus, increased adrenaline production, sleep vein thrombosis and pulmonary embolus (Macintyre and Ready, 2002). Effective post-operative pain assessment ensures better pain management and can significantly reduce the risk of the symptoms listed above, giving minimal distress or suffering to patients and reducing potential complications (Machintosh, 2007).



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Carr EC, Thomas NV, Wilson-Barnet J (2005) Patient experiences of anxiety, depression and acute pain after surgery: a longitudinal perspective. International Journal of Nursing Studies. 42(5): 521-530.

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[A1]I would consider using a more reputable source for describing medical symptoms themselves (Grey’s Anatomy, WHO guidelines etc)

[A2]and treated?

[A3]Is it worth commenting that breast cancer reporting rates in SA might be different from actual prevalence? Lack of awareness regarding certain cancers often results in late diagnosis or misdiagnosis.

[A4]This sentence is unclear. I am assuming that you are stating that all dimensions are present in two particular tools?

[A5]I’ve deleted this as you have highlighted the same domains in the previous paragraph and the reader will already be familiar with this term.

[A6]Sentence shows up on copyscape / turnitin but it’s fine as a directly referenced quote.

[A7]Is this sentence stating that the BPIs valid internationally because it has been adjusted culturally / linguistically for all groups?

[A8]Are you making a suggestion that it could be assessed, or stating that sometimes people do assess localised pain in the body?

[A9]Deleted as the next sentence deals with this already.

[A10]Again shows up in turnitin: any quotes must be in inverted commas so that tutors / markers will not downgrade or suspect plagiarism.

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