Running head POSTOPERATIVE PAIN .docx

Running head: POSTOPERATIVE PAIN
1
POSTOPERATIVE PAIN
3
Postoperative Pain after Reconstructive Surgery
Carla S. Garcia
Nicole Wertheim College of Nursing and Health Sciences
Author Note
Carla S. Garcia, Nicole Wertheim College of Nursing and
Health Sciences, Florida International University
Correspondence concerning this article should be addressed
to Carla Garcia, Nicole Wertheim College of Nursing and
Health Sciences, Florida International University, Miami, FL
33199. Contact: [email protected]
Abstract
Postoperative pain is common for most patients who have
undergone reconstructive surgery after a burn. The American
Society of Pain (ASP) has devised methods of dealing with
postoperative pain since most patients report the incident and
only half of them were reported to have recovered from it. The
use of local anesthetic-based peripheral regional analgesic
technique is an efficient way of reducing postoperative pain, as
well as the multi-modal approach for pain management, which
has been used for patients after a forty-eight-hour post operative
period. The American Society of Regional Anesthesia (ASRA)
has approved these methods, and through research, has prepared
organizational plans that assist surgical and outpatients with

postoperative pain management. Measures such as preoperative
education, preoperative pain management and pharmacological
and non-pharmacological modalities have been recommended.
Evidence shows that multi-modal methods of dealing with
postoperative pain have been used for most of the cases. This
paper will explore the evidence of postoperative pain
management after burn reconstruction surgery and include the
comparison between the uses of local anesthetic to the use of
multi-modal methods in dealing with postoperative pain. In
adition, the paper will look at the use of these postoperative
methods both in the United States of America (USA) and other
countries, and how these methods impact patient outcome.
Keywords: Evidence-Based, Research, Nursing Research,
Postoperative, Patient Response.
Significance and Background
Burn reconstruction is a common experience for patients both in
the USA and other countries in the world. Postoperative pain is
expected after a burn reconstruction, hence the incorporation of
methods such as the use of local anesthesia and multi-modal
techniques in dealing with pain are recommended. The inquiry
is whether the use of local anesthetics is more effective than the
multi-modal method in dealing with postoperative pain in adult
patients recovering from reconstructive surgery within a forthy-
eight-hour time frame.
During a study composed of members of the ASP with help from
the American Society of Anesthesiologists (ASA), they
assembled in a meeting where members with expertise in
anesthesia or pain medicine were put in a research panel
(Fuzaylov & Kelly, 2015). The panel’s objective was to review
the evidence presented to them and recommend on ways of
managing postoperative pain. The target audience of the study
were clinicians who managed chronic pain, acute surgical pain,
dental pain, and traumatic pain. Over 858 studies were included

in the research making it a very effective research (Fuzaylov &
Kelly, 2015).
Purpose
The pain experienced after the surgical procedure can be
managed in different ways. One way is through the
subcutaneous infusion of local anesthetics. Skin burns are
accompanied by a burning sensation that can be very irritating
to the victim. This method of subcutaneous infusion of local
anesthetic admission reduces that unpleasant burning feeling.
For adolescents, the anaesthetic is administered in different
dosage for those of 13-18 years, adults 19-44 years and adults
between 45-64 years to both male and female (Poulsen, 2019).
The anesthetic is administered in small amounts over the course
of healing and the use of multi-modal techniques is not
required.
Most countries especially the developing ones do not have
adequate clinical equipment to perform multi-modal methods of
dealing with postoperative pain. In some countries, skin
reconstruction procedures are not available to burn victims,
thus, most people are forced to remain with healing scars. The
lack of resources has been the down side of many countries
without the necessary equipment (Poulsen, 2019). Victims are
left with no choice but to receive local anesthesia and wait for
the pruritic burns to resolve in time.
The administration of local anesthesia is introduced depending
on the patients consent. A multi-modal approach of dealing with
postoperative pain is widely practiced in the USA since most
clinicians are assigned to the task of reducing pain after surgery
(Poulsen, 2019). Therapeutic exercise and constant skin
stretches are recommended by the ASP in the postoperative
period for pain control.
Study #1: Nursing Research Study in the USA

The APS and the ASA have joined hands to handle the research
being done in the USA (Poulsen, 2019). Preoperative education
and preoperative pain management planning has been one key
recommendation of these societies. Clinicians are advised to
brief the family and the patient on the surgical procedure to be
performed and how the postoperative pain experience will be
managed. The method of checking is based on tracking patient’s
response to postoperative pain treatment and change the
treatment plan if the need arises (Poulsen, 2019). Cognitive
behavioral modalities are recommended by the societies in order
to access the patient’s response to surgery and ascertain whether
they are still in their right set of mind. The panel neither
recommends nor stops the use of other therapeutic method to
control pain such as acupuncture and massage therapy (Poulsen,
2019). The choice is left entirely to the clinician assigned the
task of managing the patient’s postoperative pain.
The use of systematic pharmacological therapies have also been
recommended by the societies. The use of oral methods over the
intravenous administration of opioids for patients after surgery
are highly recommended to those who can receive the drugs
orally (Chou & Gordon, 2016). The intramuscular route should
be avoided at all costs since patients are not very stable after
surgery and the injection can become lethal to them, especially
within burn victims. The use of gabapentin and pregabalin is
recommended among multi-modal analgesia.
For adults, intravenous ketamine should be used as a form of
multi-modal analgesia but it is not a strict recommendation
since research evidence was based on moderate quality evidence
(Poulsen, 2019). Therefore, in the USA, nursing research has
been spearheaded by medical societies that have made it easier
to be able to apply both the local anesthetic methods and the
multi-modal technics in an effective manner. Medical societies
have shaped down the nursing sector and all clinicians are

subjected to a study session where they learn how to manage
postoperative pain. In addition, specific clinicians in health
centers are given the task of evaluating the outcomes.
Study #2: Nursing Research Study Non-USA
The nursing research modality in foreign countries is totally
different from that of the USA. The differences are brought
about by different government policies that are used to control
the medical space. The policies in different countries enable the
study to be carried out in a very fast and effective manner.
While some other counties lack the necessary resources in order
to make the research a success (Cooney, 2016). Time has shown
that research needs to be taken seriously with the result being
studied on a daily basis and ensuring that patients are the sole
beneficiaries of the programs.
For example, in a study of burned victims conducted in Ukraine,
the results obtained were different since clinic resources were
limited and patients were numerous. Therefore, clinicians had to
administer small dosages of medicication to a total of 109
patients present and then observe the results. A group of 64
patients received the standard postoperative drug of metamizole
1g or ketorolac 3%-30mg by the nursing staff (Chou & Gordon,
2016). The other 45 patients received a different type of dosage
and then the researchers had to wait and observe the patients.
From the presented case, it is clear that the hospital in which
the study was being performed had inadequate resources; Thus,
researchers were forced to maintain spare supplies for future
use to avoid depletion (Fuzaylov & Kelly, 2015). Organizational
structure, policies and procedures have been laid down by
societies on the placement of surgery platforms for safe and
effective delivery of postoperative pain control (Chou &
Gordon, 2016). For example, surgical rooms should be full of
clinicians that have specialized in pain management. Facilities
in which neuraxial analgesia and continuous peripheral blocks

are conducted have procedures for safe delivery and trained
individuals to manage those procedures.
Study #3: Postoperative pain management: clinical practice
guidelines. Journal of Paranesthesia Nursing.
Postoperative pain has been reported by patients with 80% of
them reporting on acute pain and 75% of them reporting on
moderate pain (Cooney, 2016). Lack of proper pain control can
lead to decreased function, impaired recovery and reduced
quality of life. Many organizations have published guidelines on
how to use methods to control patient’s postoperative pain.
These organizations comprise of American Society of Pain
Management, American Society of Perinesthesia and the ASA.
The ASA published its first guideline in 2012 (Cooney, 2016).
In addition, the APS in parftenrship with the ASA and the
ASRA published other effective methods of dealing with
postoperative pain. The guidelines in these publications
included the preoperative education, planning for preoperative
pain management, organizational policies and procedures of
dealing with postoperative pain and the transition to outpatient
care.
A study was carried out to determine the nursing practice
implications of care to patients with postoperative pain. The
study was composed of 23 multi-disciplinary experts that came
from different departments including: surgery, gynecology,
primary care, physical therapy, nursing, anesthesia, hospital
medicine and psychology (Cooney, 2016). The panel chosen to
carry out the study was tasked with reviewing the evidence
based on postoperative pain management. The panel was in
charge of formulating conclusions and giving recommendations
for effective, safe and evidence-based postoperative pain
management for patients. The study was composed of over 107
systematic reviews and 858 primary studies that were evidence-
based on the final report (Cooney, 2016). Reviewers from the
Oregon Health Sciences ranked the strengths of the reports

using the methods from the grading recommendation assessment
and they found that using both the pharmacological methods and
multi-modal methods all worked in reducing postoperative pain.
Therefore, the combination of these methods was found to be
the best way of treating the post-surgical pain.
Study #4: Music as a Postoperative Pain Management
Intervention
The most common reported effect after surgical intervention is
pain, and opioid therapy has been used to treat it. The use of
opioids has been extensive because of its immediate effects in
the central nervous system, ease of administration and multiple
delivery forms. Nevertheless, it has been reported by the US
Department of Health and Human Services that opioid’s side
effects are detrimental (Poulsen, 2019). These side effects
include opioid use disorder and even opioid related deaths;
Hence, causing the medical community to reconsider the
approach to pain management. Between the years 2016 and
2017, the United States Drug Enforcement Agency started
restricting companies on producing opioid drugs. While in 2018
the commission from the organization of drug enforcement
raised new standards which focused on improving pain
management and implemented measures to improve opioid
safety (Poulsen, 2019). In the new standards established, multi-
modal therapies have been proposed. Citation here?
Ironically, one of the non-pharmacological methods for pain
control, is the therapeutic use of music to reduce post-operative
pain. Music has been discovered to reduce post-surgical pain in
recent years. It is also a good method for nurses and patients
since it requires no provider orders. A study utilized Positron
Emission Tomography (PET) scan and functional magnetic
resonance imaging (fMRI) to reveal that music arouses the
caudate and nucleus acumens parts of the brain (Poulsen, 2019).
These regions of the brain are responsible for the release of
dopamine, inducing an euphoric state, producing pleasure that
significantly reduces pain. Further research on a number of
patients gave positive results that made music an alternative

method of reducing postoperative pain.(source?) Therefore,
music can be used as a multi-modal method of reducing post-
surgical pain and can also be used in preoperative nursing
practice.
Conclusion
Neither the local anesthetic analgesic techniques nor the multi-
modal techniques can be dismissed. Both techniques target the
same issue from different approaches to relieve postoperative
pain. Pain manifests differently from person to person, and
recovery is based on the person’s overall health, age, and
comorbidities. For instance, a person who smokes chronicly, or
has a long standing use of ilicit drugs may have more difficulty
recovering after surgery as opposed to a person who has
maintained a healthy life style and has no significant
comorbidities.
The comparison between the local anesthetic-based peripheral
regional analgesic techniques, with the use of a multi-modal
approach for pain management alone differs in countries
depending on the resources available (Cooney, 2016). The USA
has shown to be better equipped with societies such as the APS
managing the nursing sector and making sure that the required
research is conducted properly.
Postoperative pain has been reported to persist for years in
some patients. The nursing research team and any governmental
policy that is aimed at helping research through funding, should
prioritize this matter and establish evidence based guidelines,
and create innovative methods to help patients who are
experiencing postoperative surgical pain. A relief to the
suffering of this patients should be provided, and the most
accurate results come from research. Based on the presented
review of studies, the use of local anesthetic-based peripheral
regional analgesic techniques, and the use of multi-modal
approaches should both be considered to provide fast and
effective pain relief in recovering surgical patients.

References
Chou, R., Gordon, D. B. (2016). Management of Postoperative
Pain: a clinical practice guideline from the American pain
society, the American Society of Regional Anesthesia and Pain
Medicine, and the American Society of Anesthesiologists'
committee on regional anesthesia, executive committee, and
administrative council. The Journal of Pain.
Cooney, M. F. (2016). Postoperative pain management: clinical
practice guidelines. Journal of Perianesthesia Nursing.
Fuzaylov, G., Kelly, T. L. (2015). Post-operative pain control
for burn reconstructive surgery in a resource-restricted country
with subcutaneous infusion of local anesthetics through a soaker
catheter to the surgical site: Preliminary results. Burns.
Poulsen, M. J. (2019). Music as a Postoperative Pain
Management Intervention. Journal of PeriAnesthesia Nursing.
Running head: POSTOPERATIVE PAIN
1
POSTOPERATIVE PAIN
3
Postoperative Pain
Name
Institution
Abstract
Postoperative pain is common for most of patients who have
undergone reconstructive surgery after a burn. The American
Society of Pain (ASP) has devised methods of dealing with this
problem since most patients report the incident and only half of
them were reported to have recovered from post-operative pain.

The problem is a real challenge for the medical professionals
and the medical society’s device ways of dealing with the issue
on every occasion. The use of local anesthetic-based peripheral
regional analgesic technique is one way of dealing with the pain
and the multi-modal approach for pain management is another
technique that has been used for patients after a forty eight hour
period post operation. The techniques are also different in the
USA and other countries. The American society of regional
anesthesia (ASRA) has approved these methods and through
research has come up with the organizational plans that assist
outpatients with postoperative pain management. Measures such
as preoperative education, preoperative pain management and
pharmacological and non-pharmacological modalities have been
recommended. Evidence shows that multi-modal methods of
dealing with postoperative pain have been used for most of the
cases. This paper will explore the evidence of postoperative
pain management after burn reconstruction surgery and include
the comparison between the uses of local anesthetic to the use
of multi-modal methods in dealing with postoperative pain. In
adition, the paper will look at the use of these postoperative
methods both in the USA and other countries and how these
methods impact patient outcome.
Keywords: Evidence-Based, Research, Nursing Research,
Postoperative, Patient Response.
Significance and background
Burn reconstruction is a common experience for patients both in
the USA and other countries in the world. Postoperative pain is
expected after a burn reconstruction hence the incorporation of
methods such as the use of local anesthesia and multi-modal
techniques in dealing with pain is recommended. The
interrogant is whether the use of local anesthetic is more
effective than the multi-modal method in dealing with
postoperative pain in adult patients recovering from

reconstructive surgery within a forthy eight hour time frame.
A research done on the same was composed of members of the
American Society of Pain (ASP) with the help from the
American Society of Anesthesiologists (ASA). They assembled
in a meeting where the members with expertise in anesthesia or
pain medicine were put in a research panel (Fuzaylov & Kelly,
2015). The panel’s objective was to review the evidence
presented to them and recommend on ways of managing
postoperative pain. The target audience of the study were
clinicians who managed chronic pain, acute surgical pain,
dental pain, and even traumatic pain (Fuzaylov & Kelly, 2015).
Over 858 studies were included in the research making it a very
effective research. Therefore, post operative pain mangement
has been reviewed by the nursing department over time making
it easier to compare the different postoperative pain techniques
and delivering a good report on the same.
Purpose
Postoperative pain can be a problem for burn victims especially
the ones who have already been on the surgical table. Over the
years, burns were observed as a deformation of the skin but
today with technology advancement, it has become easier to
reconstruct and reverse the burn process. The pain experienced
after the surgical procedure can be managed in different ways.
One way is through the subcutaneous infusion of local
anesthetics. The infusion is done using a sacker that penetrates
the skin to the lower layer and the drug is given at that juncture.
Skin burns are accompanied by a burning sensation that can be
very irritating to the victim. This method of anesthetic
admission reduces that unpleasant burning feeling.
Local anasthetics have been used in other countries to treat the
burn reconstructed patient and it usually works differently
depending on the age of the patient. For adolescents, the
anaesthetic is administered in different dosage for those of 13-
18 years, adults 19-44 years and adults between 45-64 years to

both male and female (Poulsen, 2019). The anesthetic is
administered in small amounts over the course of the healing
and no use of multi-modal techniques is required.
Most countries especially the developing ones do not have
adequate clinical equipment to perform multi-modal methods of
dealing with postoperative pain. In some countries, skin
reconstruction procedures are not available to burn victims,
thus, most people are forced to remain with healing scars. The
lack of resources has been the down side of many countries
without the necessary equipment (Poulsen, 2019). Victims are
left with no choice but to receive local anesthesia and wait for
the pruritic burns to resolve in time.
In the United States, the methods for treating postoperative pain
are different since the American Society of pain (ASP)
establishes guidelines concerning this issue. Continuous use of
the infusion of local anesthetics is done in order to provide
analgesia following a skin harvest from the thigh which is used
in the burn reconstruction process. The administration of local
anesthesia is introduced depending on the patients consent. A
multi-modal approach of dealing with postoperative pain is
widely practiced in the USA since most clinicians are assigned
to the task of reducing pain after surgery (Poulsen, 2019).
Therapeutic exercise and constant skin stretches are
recommended by the ASP in the postoperative period for pain
control. Therefore, there is an obvious difference between the
practices in the USA and other countries on how they handle
burn victims.
Study #1: Nursing research Study in the USA
Research is the key to many issues affecting the nursing field
and postoperative pain for burn victims is one area that can be
used for research. The American Pain Society (APS) and the
American Society of Anesthesiologists (ASA) have joined hands

and handle the research being done in the USA (Poulsen, 2019).
Preoperative education and preoperative pain management
planning has been one key recommendation of these societies.
Clinicians are advised to brief the family and the patient on the
surgical procedure to be performed and how the postoperative
pain experience will be managed. Medication is administered to
provide pain relief and to make sure it is reduced as much as
possible.
The method of checking is based on tracking patient’s response
to postoperative pain treatment and change the treatment plan if
the need arises (Poulsen, 2019). General principles regarding
the use of multi-modal therapies is recommended and the
clinicians are advised to use nonpharmacological
interventions for the treatment of postoperative pain. Cognitive
behavioral modalities are recommended by the societies in order
to access the patient’s response to surgery and ascertain whether
they are still in their right set of mind. The panel neither
recommends nor stops the use of other therapeutic method to
control pain such as acupuncture and massage therapy (Poulsen,
2019). The choice is left entirely to the clinician assigned the
task of managing the patient’s postoperative pain.
The use of systematic pharmacological therapies have also been
recommended by the societies. The use of oral methods over the
intravenous administration of opioids for patients after surgery
are highly recommended to those who can receive the drugs
orally. The intramuscular route should be avoided at all costs
since patients are not very stable after surgery and the injection
can become lethal to them, especially within burn victims. The
use of gabapentin and pregabalin is recommended among multi-
modal analgesia.
For adults, intravenous ketamine should be used as a form of
multi-modal analgesia but it is not a strict recommendation
since research evidence was based on moderate quality evidence

(Poulsen, 2019). Therefore, in the USA, nursing research has
been spearheaded by medical societies that have made it easier
to be able to apply both the local anesthetic methods and the
multi-modal technics in an effective manner. Medical societies
have shaped down the nursing sector and all clinicians are
subjected to a study session where they learn how to manage
postoperative pain. In addition, specific clinicians in health
centers are given the task of evaluating the outcomes.
Study #2: Nursing Research Study Non-USA
The nursing research modality in foreign countries is totally
different from that of the USA. The differences are brought
about by different government policies that are used to control
the medical space. The policies in different countries enable the
study to be carried out in a very fast and effective manner.
While some other counties lack the necessary resources in order
to make the research a success (Cooney, 2016). Time has shown
that research needs to be taken seriously with the result being
studied on a daily basis and ensuring that patients are the sole
beneficiaries of the programs.
For example, in a study of burned victims conducted in Ukraine,
the results obtained were different since clinic resources were
limited and patients were numerous. Therefore, clinicians had to
administer small dosages of medicication to a total of 109
patients present and then observe the results. A group of 64
patients received the standard postoperative drug of metamizole
1g or ketorolac 3%-30mg by the nursing staff (Chou & Gordon,
2016). The other 45 patients received a different type of dosage
and then the researchers had to wait and observe the patients.
From the presented case, it is clear that the hospital in which
the study was being performed had inadequate resources; Thus,
researchers were forced to maintain spare supplies for future
use to avoid depletion. Hence, there is a clear cut difference
between researchers in international communities in countries

that have underfunded medical budgets, or in countries where
there is scarcely any tools for research. Burn patients in such
countries face many difficulties in utilizing what is available to
them. Nevertheless, some countries do have the resources, for
instance England, wich is part of the European nations,
competing with the USA in terms of delivering research
including nursing professionals. Life has never been easy for
such counties since they have societies that keep pushing the
delivery of better health care to its people.
Organizational structure, policies and procedures have been laid
down by societies on the placement of surgery platforms for
safe and effective delivery of postoperative pain control (Chou
& Gordon, 2016). For example, surgical rooms should be full of
clinicians that have specialized in pain management. Facilities
in which neuraxial analgesia and continuous peripheral blocks
are conducted have procedures for safe delivery and trained
individuals to manage those procedures.
In England, clinicians consider the surgical local anesthetic
based on topical pharmacological therapies due to their location
and constant weather change in the region. Therefore, pain
reduction after an operation also considers the weather at the
time and prevent any medication that can endanger the patient.
Therefore, the difference is there for cases in and out of the
USA. Though the approach and goals are the same, the
execution of duties change depending on the region. Countries
that are able to compete with the USA have been reviewing
their nursing profession and making sure their research is as
good as any other. Hence, research in the nursing sector is
beneficial to many postoperative cases and the morale for
research should be encouraged.
Conclusion
Neither the local anesthetic analgesic techniques nor the multi-

modal techniques can be dismissed. Both techniques target the
same issue from different approaches to relieve postoperative
pain. Over the years, patients have required innovative methods
of controlling pain. Pain manifests differently from person to
person, and recovery is based on the person’s overall health,
age, and comorbidities. For instance, a person who smokes
chronicly, or has a long standing use of ilicit drugs may have
more difficulty recovering after surgery as opposed to a person
who has maintained a healthy life style and has no significant
comorbidities.
The comparison between the local anesthetic-based peripheral
regional analgesic techniques, with the use of a multi-modal
approach for pain management alone differs in countries
depending on the resources available. For multi-modal
approaches a country needs to provide the necessary resources
in order for them to be applied. For local aesthetics to be used
the process needs to be funded. The USA has shown to be better
equipped with societies such as the APS managing the nursing
sector and making sure that the required research is conducted
properly.
Changes that relate to these question of comparison include the
research process. The research is sometime equipped with
moderately researched evidence. At least, the conserved parties
should try and have very strong recommended research as the
only option when it comes with dealing with postoperative pain.
Therefore, the research should be define and there should not be
any second guessing on the final recommendations of the
research.
Another factor, would be to provide the guidelines of the
practice to nurses or other clinicians and make sure they follow
those steps for the safety of the patient. In addition, there
should be a clear understanding of which multi-modal therapies
to use and the medical societies should not be skeptical with use
of therapies such as acupuncture.

Postoperative pain has been reported to persist for years in
some patients. The nursing research team and any governmental
policy that is aimed at helping research through funding, should
prioritize this matter and establish evidence based guidelines,
and create innovative methods to help patients who are
experiencing postoperative surgical pain. A relief to the
suffering of this patients should be provided, and the most
accurate results come from research. Based on the presented
review of studies, the use of local anesthetic-based peripheral
regional analgesic techniques, and the use of multi-modal
approaches should both be considered to provide fast and
effective pain relief in recovering surgical patients.
References
Chou, R., Gordon, D. B. (2016). Management of Postoperative
Pain: a clinical practice guideline from the American pain
society, the American Society of Regional Anesthesia and Pain
Medicine, and the American Society of Anesthesiologists'
committee on regional anesthesia, executive committee, and
administrative council. The Journal of Pain.
Cooney, M. F. (2016). Postoperative pain management: clinical
practice guidelines. Journal of Perianesthesia Nursing.
Fuzaylov, G., Kelly, T. L. (2015). Post-operative pain control
for burn reconstructive surgery in a resource-restricted country
with subcutaneous infusion of local anesthetics through a soaker
catheter to the surgical site: Preliminary results. Burns.
Poulsen, M. J. (2019). Music as a Postoperative Pain
Management Intervention. Journal of PeriAnesthesia Nursing.
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International Journal of Nursing Studies 49 (2012) 65–71
A R
Artic
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Rece
Acce
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Guid
Pain
Post
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Tel.:
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002
doi:
stoperative pain assessment based on numeric ratings is not the
same
r patients and professionals: A cross-sectional study
queline F.M. van Dijk a,*, Albert J.M. van Wijck a, Teus H.
Kappen a, Linda M. Peelen a,b,
r J. Kalkman a, Marieke J. Schuurmans c
iversity Medical Centre Utrecht, Department of Perioperative
Care and Emergency Medicine, The Netherlands
iversity Medical Centre Utrecht, Julius Centre for Health
Sciences and Primary Care, The Netherlands
iversity Medical Centre Utrecht, Department of Nursing
Science, The Netherlands
What is already known about the topic?
ain assessment is the foundation of pain management
hen a patient is experiencing postoperative pain. A
frequent and thorough assessment of patients’ pain by
registered nurses provides information to achieve
optimal pain relief.
� Clinical guidelines are developed for postoperative pain
management based on the patient’s pain score. In these
guidelines different cut-off points are used to treat the

pain.
What this paper adds
� Patients and professionals do interpret the numeric
rating scores for postoperative pain differently.
T I C L E I N F O
le history:
ived 27 December 2010
ived in revised form 7 July 2011
pted 16 July 2011
ords:
lgesics
eline
measurement
operative pain
A B S T R A C T
Background: Numeric pain scores have become important in
clinical practice to assess
postoperative pain and to help develop guidelines for treating
pain. Professionals need the
patients’ pain scores to administer analgesic medication.

However, do professionals
interpret the pain scores in line with the actual perception of
pain by the patients?
Objective: The study aim was to assess which Numerical Rating
Scale (NRS) pain score was
considered bearable on a Verbal Rating Scale (VRS) by patients
and professionals.
Methods: This prospective study examined the relationship
between the Numerical Rating
Scale and a Verbal Rating Scale. The patients (n = 10,434) rated
their pain the day after
surgery on the 11-point NRS (0 = no pain and 10 = worst
imaginable pain) and a VRS
comprising five descriptors: ‘‘no pain’’; ‘‘little pain’’; ‘‘painful
but bearable’’; ‘‘considerable
pain’’; and ‘‘terrible pain’’. The first three categories together
(‘‘no pain’’, ‘‘little pain’’ and
‘‘painful but bearable’’) were considered ‘‘bearable’’ and the
last two categories (‘‘considerable
pain’’ and ‘‘terrible pain’’) were deemed as ‘‘unbearable’’ pain.
The professionals (n = 303)
were asked to relate the numbers of the NRS to the words of the
VRS.
Results: Most patients considered NRS 4–6 as ‘‘bearable’’ pain.

Among professionals,
anesthesiologists, Post Anaesthesia Care nurses, and ward
nurses interpreted NRS scores in
the same way as the patients. Only the Acute Pain Nurses
interpreted the scores
differently; they considered NRS of 5 and higher to be not
bearable.
Conclusions: Some care providers and patients differ in their
interpretation of the
postoperative NRS scores. A risk of overtreatment might arise
when health care providers
rigidly follow guidelines that prescribe strong analgesics for
pain scores above 3 or 4
without probing the patient’s preference for pharmacological
treatment.
� 2011 Elsevier Ltd. All rights reserved.
Corresponding author at: University Medical Centre Utrecht,
Pain
ic L02.502, Department of Perioperative Care and Emergency
icine, P.O. Box 85500, 3508 GA Utrecht, The Netherlands.
+31 88 75 56163; fax: +31 88 75 55511.
E-mail address: [email protected]
queline F.M. van Dijk).

Contents lists available at ScienceDirect
International Journal of Nursing Studies
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0-7489/$ – see front matter � 2011 Elsevier Ltd. All rights
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10.1016/j.ijnurstu.2011.07.009
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J.F.M. van Dijk et al. / International Journal of Nursing Studies
49 (2012) 65–7166
� The findings suggest a potential risk of overtreatment if
the pain is assessed by the Numeric Rating Scale (NRS)
only.
1. Introduction
According to the American Pain Society guidelines (APS,
1995) for pain management, postoperative pain should be
assessed regularly and documented carefully. The inten-
sity of pain should be evaluated and recorded at intervals
depending on the severity of pain and the clinical situation.
Pain assessment and management is a significant part of
nursing care and the pain is mostly assessed through
verbal communication with the patient. The Numeric
Rating Scale (NRS) is frequently used for this purpose: the
patient is asked to score the pain on an 11 point scale,
where 0 indicates no pain and 10 indicates the worst
imaginable pain. The NRS is considered a valid and reliable

pain assessment tool (Breivik et al., 2000; DeLoach et al.,
1998; Good et al., 2001).
The patient’s NRS score is a leading indicator in the
postoperative pain treatment. Many guidelines for pain
management recommend prescription of analgesics on the
basis of the patients’ NRS pain score (APS, 1995; Gordon
et al., 2005; VMS, 2009). However, the NRS threshold for
prescribing analgesics varies: some guidelines for acute
and cancer pain chose an NRS cut-off >4 (APS, 1995;
Gordon et al., 2005) while at least in one other, also for
acute and cancer pain, an NRS cut-off >3 is the criterion for
administering analgesics (VMS, 2009). Furthermore, in
clinical practice not all patients with an NRS pain score
above the treatment threshold are willing to accept the
analgesic treatment offered mostly because they still
consider the pain as ‘‘bearable’’. This suggests that
professionals and patients might perceive the necessity
for pain treatment differently. If so, health care providers
who strictly follow current guidelines could be at risk of
overtreating some patients.
The aim of the study was to investigate how post-
operative NRS pain scores of the patients relate to the
presence of ‘‘bearable’’ versus ‘‘unbearable’’ pain. In a
prospective study, the postoperative NRS pain scores were
compared with the same patients’ adjectival descriptions
of pain on a Verbal Rating Scale (VRS). The agreement
between patients and professionals on the relationship
between the NRS and VRS was then studied on the basis of
comparisons between the two scales. We hypothesized
that patients and professionals might differ in their
interpretation of NRS scores.
2. Methods

2.1. Study design
We describe a cross-sectional study of a large sample of
patients admitted for elective surgery. The current study
was part of a large cluster-randomized study, implement-
ing a prediction rule for improving the treatment of
postoperative nausea and vomiting. In this study, 23,000
in- and out-patients participated. The study was approved
by the institutional Ethics Committee of the University
Medical Centre in Utrecht. It was not necessary to obtain
informed consent from the patients because pain mea-
surement is part of clinical care. Informed and voluntary
consent of the health care professionals was assumed by
return of a completed questionnaire.
2.2. Subjects
Between March 16th, 2006 and December 21st, 2007, all
adult patients scheduled for elective surgery at the
University Medical Centre of Utrecht were recruited. The
following patients were excluded: those who were trans-
ferred directly to an intensive care unit; who needed
postoperative ventilatory support; who had complications
followed by a second operation; who did not understand the
verbal questions of the research nurse; or who underwent
ambulatory surgery. All patients received a written bro-
chure preoperatively giving information about postopera-
tive pain measurement and treatment, in accordance with
the protocol of the hospital’s Acute Pain Service.
Furthermore, we conducted a national survey in which
303 professionals participated: anesthesiologists, Acute
Pain Nurses, nurses working on the Post Anaesthesia Care
Unit (PACU), student PACU-nurses and ward nurses. The
health professionals were a convenience sample. During

one week in May, 2008 the PACU nurses and nurses on the
surgical wards of the UMC Utrecht were visited and invited
to participate in the study. In addition, the nurses in
training in the UMC Utrecht for PACU-nurse and working
in different hospitals in the Netherlands were invited to
participate. The anesthesiologists were randomly selected
from a national anaesthesia congress. The Acute Pain
Nurses, registered as members of the Dutch association for
pain nurses in 2008, were approached by email. All health
professionals were personally informed and invited to
participate by the pain nurse who was not involved in
patient care.
2.3. Data collection
Trained research nurses who were not involved in the
postoperative care asked the patients about their pain at
rest on the day after surgery. The 11 point NRS was used,
where 0 indicates no pain and 10 the worst pain
imaginable. The VRS used in this study gives five
expressions on a scale of increasing burden: ‘‘no pain’’
(VRS 0), ‘‘little pain’’ (VRS 1), ‘‘painful but bearable’’ (VRS
2),
‘‘considerable pain’’ (VRS 3) and ‘‘terrible pain’’ (VRS 4). The
first three categories together (‘‘no pain’’, ‘‘little pain’’ and
‘painful but bearable’) were considered ‘bearable’ and the
last two categories together (‘considerable pain’ and
‘terrible pain’) were deemed as ‘unbearable’ pain. Further-
more, information concerning gender, age, surgical pro-
cedure and type of anaesthesia was gathered. The
professionals were invited to relate the NRS to the VRS;
they received a hand-delivered questionnaire with the five
descriptions constituting the aforementioned VRS and
were asked to relate the numbers 0–10 of the NRS to these
words. The questionnaires were hand-collected when once
completed. No demographic data from the health profes-

sionals were collected.
2.4.
com
exp
foll
tive
Cor
Spe
for
Wh
Sen
‘un
VRS
we
(RO
NR
val
exa
pat
bet
did
ana
ver
con
tha
3. R
3.1.
in
elig

und
inc
obt
one
ma
sco
unc
Tab
Dem
Ag
Ge
Ty
Ty
ENT
Valu
49 (2012) 65–71 67
Statistical analyses
Data were analyzed using descriptive statistics on
plete cases. Results for continuous variables were
ressed as mean (SD) or as median for variables
owing normal and non-normal distributions, respec-
ly. Categorical data were expressed as frequencies.
relations between NRS and VRS were calculated by the
arman rank correlation coefficient. Statistical testing

non-normally distributed variables used the Mann–
itney test, and for categorical values the x2 test.
sitivity and specificity of the NRS in detecting
bearable’ pain were calculated using cut-off points
�2 (bearable pain) and VRS >2 (unbearable pain) and
re represented by a Receiver Operator Characteristic
C) curve. To analyze the relationship between VRS and
S scores, we used the modal score (the most frequent
ue) of the numbers of the NRS per VRS category and
mined whether this relationship differed between
ients and professionals. To be able to detect differences
ween males and females and different age groups we
subgroup analyses for gender and age. Statistical
lyses were performed using SPSS Statistical Software,
sion 15.0 (SPSS Inc., Chicago, IL). The results were
sidered statistically significant if the p-values were less
n 0.05.
esults
Patients
The demographic and perioperative data are presented
Table 1. Data from 10,576 surgical inpatients were
ible for the current study; the other 12,424 patients
erwent ambulatory surgery or did not meet the
lusion criteria. An NRS and VRS pain score pair was
ained 24 h after surgery from 10,434 patients. Data on
or both scales were incomplete for 142 patients,
inly because they were too sick to determine the pain
re; failed to understand; were confused; or were
ooperative.

Fig. 1 shows the distribution of the NRS scores of actual
pain at rest 24 h after the operation. The median NRS score
was 2. Twenty-four percent of the patients scored an NRS
>4; this is the threshold value for pain treatment
according to various guidelines (APS, 1995; Gordon
et al., 2005). In general, women reported higher pain
scores than men (median 3 versus 2, respectively;
p < 0.001). Older patients (aged 65 and older) reported
lower pain scores than younger patients (median 2 versus
3; p < 0.001) (Table 2).
Fig. 2 shows the distribution of the VRS scores of actual
pain at rest 24 h after surgery. Both the median and the
mode of the VRS scores were 1 (little pain). In total, 22.7% of
the patients reported ‘no pain’ (VRS 0), 38.9% reported ‘little
pain’ (VRS 1), 29.4% reported ‘painful but bearable’ (VRS 2),
8.3% reported ‘considerable pain’ (VRS 3) and 0.7% reported
‘terrible pain’ (VRS 4). Women consistently reported more
severe pain scores than men (p < 0.001). Older patients
reported less severe pain scores than younger patients
(p < 0.001) (Table 3).
3.2. Professionals
One hundred and forty anesthesiologists participated
(response rate 100%), along with 50 Acute Pain Nurses
(response rate 94%); 33 PACU nurses (response rate 100%);
16 nurses in training for PACU-nurse (response rate 100%);
and 67 nurses on the ward (response rate 100%).
le 1
ographic and perioperative data (n = 10,434 patients).
e, mean � SD (range) 52 � 17 (18–98)

nder, n (%)
Female 5348 (51)
Male 5086 (49)
pe of surgery, n (%)
General 2097 (20)
ENT/faciomaxillary 1988 (19)
Orthopedic 1058 (10)
Neurosurgery 974 (9)
Urology 965 (9)
Gynecologic 868 (8)
Plastic surgery 838 (8)
Vascular surgery 676 (6)
Eye surgery 593 (6)
Cardiothoracic 226 (2)
Other 151 (1)
pe of anaesthesia, n (%)
General 9182 (88)
Locoregional 1252 (12)

NRS
109876543210
Pe
rc
en
t
20%
15%
10%
5%
0%
Fig. 1. Pain scores on the Numeric Rating Scale 24 h after
surgery in
percentages.
Table 2
Differences in NRS pain scores.
Median pain score p-Value
Gender (n)
Male (5086) 2 <0.001a
Female (5348) 3

Age (n)
�65 years (7760) 2 <0.001a
<65 years (2674) 3
: ear, nose and throat surgery.
es are numbers (%). a Mann–Whitney test.
49 (2012) 65–7168
3.3. The relation of the NRS to the VRS
The VRS and NRS scores of the patients were
significantly correlated (Spearman correlation coefficient
r = 0.84, p < 0.001). Twenty-four percent of the post-
operative patients reported an NRS pain score >4, while
9% reported ‘considerable’ or ‘terrible pain’ on the VRS. The
patients associated NRS 0 with VRS ‘no pain’; NRS 1–3 with
VRS ‘little pain’; NRS 4–5 with VRS ‘painful but bearable’;
NRS 6–8 with VRS ‘considerable pain’; and NRS 9–10 with
VRS ‘terrible pain’.
As different guidelines show various NRS cut-off points
to determine the need for treatment with analgesics, the
sensitivity and specificity of the NRS scores and VRS
‘bearable’ and ‘unbearable’ were calculated for different
NRS cut-off points. Fig. 3 shows an ROC curve depicting the
sensitivity and 1 � specificity for these cut-off points.
Using an NRS cut-off point of 4, 17% of the patients
considered NRS >4 to be ‘bearable’ pain (1 � specificity)
and 5% considered it as ‘unbearable’ pain (1 � sensitivity).
So using an NRS cut-off value >4 for analgesic adminis-
tration, 17% of the patients would be incorrectly classified

as having unbearable pain, possibly resulting in over-
treatment, while 5% would be undertreated. With a cut-off
point of NRS >3, 30% of the patients would be overtreated
and 3% would be undertreated.
Fig. 4 shows the distribution of the relationship
between the NRS and VRS according to the patients and
the professionals. The PACU and ward nurses interpreted
the NRS and VRS scores in the same way: NRS 0 equated
with VRS ‘no pain’; NRS 1-3 with VRS ‘little pain’; NRS 4–5
with VRS ‘painful but bearable’; NRS 6–8 with VRS
‘considerable pain’; and NRS 9–10 with VRS ‘terrible pain’.
The anesthesiologists interpreted NRS 1 as ‘no pain’ but
their other ratings were identical to those of the PACU and
ward nurses. The Acute Pain Nurses interpreted the scores
differently: NRS 1–2 ‘little pain’; 3–4 ‘painful but bearable’;
5–7 ‘considerable pain’; and 8–10 ‘terrible pain’. The
distribution of the NRS scores over the VRS categories
given by the Acute Pain Nurse was shifted to the left in
comparison with those of the other professionals and
patients, because they assigned lower NRS scores to the
VRS categories.
4. Discussion
The present study distinguishes ‘bearable’ from
‘unbearable’ postoperative pain and analyzes the relation-
ship between NRS and VRS scores as assessed by post-
operative patients and professionals. We found that most
patients (65%) with NRS 4–6 considered their pain
bearable. Among the professionals, the anesthesiologists,
PACU and ward nurses interpreted the NRS scores in the
same way as the patients. Only the Acute Pain Nurses
interpreted the scores differently.

In previous studies, different descriptions of pain have
frequently been used: no; mild; moderate; and severe
pain. In a recent study on pain after orthopedic surgery, the
patients related NRS 1–3 to mild; 4–5 to moderate; and 6–
10 to severe pain (Dihle et al., 2006). After coronary artery
bypass grafting, NRS 1–3 was related to mild; 4–6 to
moderate; and 7–10 to severe pain (Mendoza et al., 2004).
These studies show that in postoperative pain the upper
boundary for mild pain is NRS 3 and for moderate pain NRS
5 or 6. These results are comparable to the findings of the
VRS
terrible painconsiderable
pain
pain but
bearable
little painno pain
Pe
rc
en
t
40%
30%
20%
10%
0%

Fig. 2. Pain scores on the Verbal Rating Scale 24 h after surgery
in
percentages.
1 - Specificity
1,00,80,60,40,20,0
Se
ns
iti
vi
ty
1,0
0,8
0,6
0,4
0,2
0,0
NRS 4
NRS 5
NRS 6
NRS 3

NRS 2
NRS 7
Fig. 3. ROC curve of bearable pain (VRS �2) and unbearable
pain (VRS >2)
with the different NRS cut-off points for 10,434 patients.
Table 3
Differences in VRS pain scores.
Considerable and terrible pain p-Value
Gender (n)
Male (5086) 7.6% <0.001a
Female (5348) 10.3%
Age (n)
�65 years (7760) 8.0% <0.001a
<65 years (2674) 9.4%
a Chi-square test.
cur
the
dist
pre
pat
gui
Dol

sev
(Jam
200
wh
Fig.
prof
Care
VRS
49 (2012) 65–71 69
rent study. However, instead of moderate pain we used
term ‘painful but bearable’. For severe pain we
inguished ‘considerable’ and ‘terrible pain’. Several
vious studies have demonstrated that postoperative
ients suffer moderate to severe pain despite the use of
delines (Apfelbaum et al., 2003; Chung and Lui, 2003;
in et al., 2002) and that nurses often underestimate the
erity of postoperative pain of the patients in their care
ison et al., 1997; Taylor et al., 2003; Zelman et al.,
3). It is, however, uncertain to what extent the patients
o indicate ‘moderate’ pain really suffer. In the current
study most patients with NRS 4–6 considered their pain as
bearable. This relates with other studies where the patients
were satisfied with their postoperative pain relief although
they still had moderate pain (Apfelbaum et al., 2003;
Jamison et al., 1997; Hawkins, 1997). It is possible that
most patients experienced moderate but ‘bearable’ pain
and that the nurses did not underestimate the patients’

pain.
Most patients with NRS 4–6 considered their pain
bearable. Possible reasons are that patients do not under-
stand the NRS pain scores or refuse pain therapy because of
side effects or fear for addiction (Wilder-Smith and
Schuler, 1992). It is unknown why some patients bear
acute pain to some degree and why others do not. Nurses
should not only ask the patient about the pain score and
follow the guidelines rigidly but also communicate with
the patient about the pain and pain therapy (McDonald
et al., 2000). The numerical pain ratings are only one
dimension of the patient’s subjective experience of pain
(Hanks, 2008) and adequate pain relief cannot be reliably
achieved using opioid analgesics without a high risk of
adverse effects (White and Kehlet, 2007).
The results of the current study indicate that the
patients and the professionals have a different view of the
range of numerical ratings that indicate ‘bearable’ or
‘unbearable’ pain.
In particular, Acute Pain Nurses tended to over-
estimate the severity of pain as perceived by the patient
when interpreting NRS scores. Of all health care
professionals, the nurses operate most closely to the
patient in postoperative care and they can make
independent medication decisions for pain relief. The
results of this study suggest that the PACU and ward
nurses were best informed about what the patients
consider as ‘bearable’ pain. In contrast, the Acute Pain
Nurses evaluated the pain scores differently from the
patients; they more often overestimate the intensity of
pain. In most hospitals the Acute Pain Nurse is the
coordinator of the Acute Pain Service and responsible for
the in-service education of health care professionals.

Although he/she often daily checks up on the patients
with Patient Controlled Analgesia or epidural analgesia,
the Acute Pain Nurse is not as close to the patient as the
ward and PACU nurses are. Another possible explanation
of the observed differences is that the Acute Pain Nurses
are typically aware of the results of several former
studies which have repeatedly demonstrated under-
assessment and undertreatment of postoperative pain
(Idvall et al., 2005; Sloman et al., 2005; Zalon, 1993).
What does ‘moderate’ pain or an NRS 5 or 6 mean for the
patient in order to decide on the need for opioid
administration? In the present study, many patients
who reported an NRS of 5 or 6 considered their condition
to be ‘painful but bearable’. A patient who indicates that his/
her pain is ‘bearable’ might not necessarily want to receive
additional analgesic medication, even though all guide-
lines suggest starting treatment on the basis of these NRS
scores. Although we did not ask the patient if he/she would
need treatment for his pain, and we did not measure the
administered amount of analgesics, the data imply a
potential risk of overtreatment when health care providers
4. The relations made of the NRS with the VRS by patients and
essionals: Anesthesiologists, Acute Pain Nurses, Post
Anaesthesia
Unit nurses and ward nurses. Spearman correlation coefficient
NRS–
r = 0.84, p < 0.001.

49 (2012) 65–7170
follow the postoperative pain guidelines to the letter.
Because a number of studies have demonstrated poor
control of the postoperative pain (Apfelbaum et al., 2003;
Chung and Lui, 2003; Dolin et al., 2002) the Joint
Commission on Accreditation of Health Care Organizations
defined new standards for pain management in their
standards manual (Philips, 2000). In addition, the Amer-
ican Pain Society and the Dutch VMS recently provided
recommendations for improving the quality of acute and
cancer pain management (Gordon et al., 2005; VMS, 2009).
In these recommendations increasing emphasis is placed
on reducing the patients’ pain scores, which entails
increased analgesic usage. Decreasing the intensity of
pain is a laudable objective and one of the pillars of health
care. In postoperative pain management, both under-
treatment and overtreatment are undesirable. Unrelieved
pain has adverse psychological and physiological con-
sequences e.g., more complications and prolonged hospital
stay (Watt-Watson et al., 1999). On the other hand,
improved pain control should not jeopardize patient safety
(Taylor et al., 2003). Unnecessary use of analgesics,
especially opioids, increases the patient’s discomfort
because of the side effects, such as nausea, vomiting and
pruritus. Unnecessary opioid administration also increases
the probability of sedation and potentially dangerous
respiratory depression (Cashman and Dolin, 2004; Taylor
et al., 2005). An increase of opioid oversedation is reported
after the implementation of the new standards of the Joint
Commission (Vila et al., 2005). Therefore, to balance the
risks of overtreatment and undertreatment in this range of
numerical pain scores, the health care provider might
simply add the following question: ‘‘would you like to have
an analgesic?’’ In addition, the patients’ level of conscious-
ness should be assessed when patients receive (additional)
opioids.

4.1. Limitations
The present study is subject to a number of limitations.
We measured the postoperative pain scores of the patient
in rest. These pain scores can be different of the pain scores
at movement. Nevertheless, the purpose of the study was
to examine what numeric ratings were bearable to the
patient. The health care professionals participated in this
study were a convenience sample and no demographic
data were collected. Regarding their level of experience,
however, given the fact that all professionals working in
the shift in which the data were collected participated, the
sample was representative. Another potential source of
error is the order in which the two pain scores were asked.
All patients first indicated the severity of their pain on the
VRS and then on the NRS. We chose this order because we
anticipated that patients might try to ‘convert back’ to an
adjective in the VRS once they had given an NRS score
(which requires mental conversion from a subjective
feeling to a number). Although in theory it can make a
difference whether NRS or VRS is asked first, a recent study
reported that error rates were not related to the order of
presentation of the scales (Gagliese et al., 2005).
The data we used for this study were part of a larger
treatment of postoperative nausea and vomiting (PONV).
We are aware of the relationship between PONV and pain.
In the larger study, the anesthesiologists were more
focused on PONV and possibly prescribed less analgesia.
However, we assume that there was no interference from
the PONV study, because we studied two scales for
expressing the severity of pain, and not the severity of
the pain itself. This assumption was verified by repeating
our analyses with data from the control group of the PONV

study only; this yielded similar results.
5. Conclusions
By combining data from a large sample of surgical
patients with a national survey of health care workers, a
lack of agreement is found between the patients and the
Acute Pain Nurses on what constitutes ‘bearable’ pain in
relation to the reported NRS scores. The Acute Pain Nurses
tended to overestimate the severity of pain when the
patients reported intermediate NRS scores, whereas most
patients considered NRS 4–6 to be ‘bearable’ pain. These
findings suggest a potential risk of overtreatment, if the
pain is assessed by the NRS only and treatment decisions
are based solely on a patient’s NRS response. Specifically
asking a patient whether the pain is bearable and he/she
would like to receive additional analgesics might circum-
vent this problem.
Conflict of interest. None of the authors has any potential
conflicting interest in this study.
Funding. This study is supported by ZonMW (Clinical Trial nr.
NCT00293618), the Netherlands Organization for Health
Research and Development. The study is supported by the
Division of Perioperative Care and Emergency Medicine,
University Medical Centre Utrecht, The Netherlands.
Ethical approval. The study was approved by the institutional
Ethics Committee of the University Medical Centre in

Utrecht.
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Postoperative pain assessment based on numeric ratings is not
the same for patients and professionals: A cross-sectional
studyIntroductionMethodsStudy designSubjectsData
collectionStatistical analysesResultsPatientsProfessionalsThe
relation of the NRS to the
VRSDiscussionLimitationsConclusionsReferences
PAIN MANAGEMENT
Postoperative Pain Management: Clinical
Practice Guidelines
Maureen F. Cooney, DNP, FNP-BC
OVER THE PAST 2 decades, there has been an
increased emphasis on the need for effective
management of acute pain. The focus on pain man-
agement was sharpened when the Joint Commis-
sion on Accreditation of Healthcare Organizations

integrated the requirement for pain assessment
and management into their standards in 2000.
1
Acute postoperative pain, however, continues to
be inadequately controlled. Among patients who
have had surgical procedures, 80% experience
postoperative pain and 75% or more of them report
pain that is at a moderate, severe, or extreme level.
2
Inadequately treated acute pain is associated with
the risk for the development of persistent postsur-
gical pain.
3,4
Poor pain control has significant
physiological consequences that can ultimately
result in impaired recovery, decreased function,
and reduced quality of life.
2,5
In recent years, the number and types of pharma-
cologic, interventional, and nonpharmacological

options to treat acute postoperative pain have
expanded. Many professional organizations,
including the American Society of PeriAnesthesia
Nurses and American Society for Pain Management
Nursing have published guidelines and other doc-
uments related to the management of acute pain.
The American Society of Anesthesiologists (ASA)
published guidelines for perioperative pain man-
agement in 2012.
6
In 2016, the American Pain So-
ciety (APS), with input from the ASA, and review
and approval by the American Society of Regional
Anesthesia and Pain Medicine, published guide-
lines for the management of postoperative pain.
Maureen F. Cooney, DNP, FNP-BC, is a Nurse Practitioner,
Pain Management, Westchester Medical Center, Valhalla, NY.
Conflict of interest: None to report.
Address correspondence to Maureen F. Cooney, Westchester
Medical Center, Pain Management, Rm 2108 Macy Pavilion,
100 Woods Rd, Valhalla, NY 10595; e-mail address:

[email protected]
� 2016 by American Society of PeriAnesthesia Nurses
1089-9472/$36.00
http://dx.doi.org/10.1016/j.jopan.2016.08.001
Journal of PeriAnesthesia Nursing, Vol 31, No 5 (October),
2016: pp 445-451
These guidelines are somewhat unique because,
in addition to recommendations for pharmacolog-
ical and nonpharmacological pain interventions,
they include recommendations for preoperative
education, perioperative pain management plan-
ning, organizational policies and procedures, and
transition to outpatient care.
7
This article summa-
rizes the development of the guidelines and high-
lights key recommendations with nursing
practice implications for the care of patients with
acute postsurgical pain.
Methodology for Guideline Development
AguidelinepanelwasselectedbytheAPS,withinput

from the ASA, and consisted of 23 multidisciplinary
experts representing specialists from fields that
included anesthesia, pain management, surgery, hos-
pital medicine, nursing, obstetrics and gynecology,
psychology, primary care, and physical therapy.
The panel was charged with the tasks of reviewing
the evidence related to postoperative pain manage-
ment and formulating recommendations for
evidence-based, effective, safer postsurgical pain
management for adults and children.
7
The Oregon
Evidence-Based Practice Center conducted an evi-
dence review that included literature searches
through December 2015.
7,8
Upon completion of
the literature search, there were 107 systematic
reviews and an additional 858 primary studies in
the final evidence report.
8

The quality of randomized
trials was assessed using criteria adapted by the Co-
chrane Back Review Group.
7,8
Two reviewers
from the Oregon Health Sciences Evidence center
independently reviewed and ranked the strength
(strong or weak) and quality of the evidence (high,
moderate, or low) using methods adapted from
the Grading of Recommendations Assessment,
Development, and Evaluation Working Group
and the Agency for Healthcare Research and
Quality (AHRQ) Methods Guide for Effectiveness
and Comparative Effectiveness Reviews.
7,8
A
strong recommendation indicates the reviewers’
assessment that the potential benefits of following
the recommendation clearly outweigh potential
445

Delta:1_given name
mailto:[email protected]
http://dx.doi.org/10.1016/j.jopan.2016.08.001
http://crossmark.crossref.org/dialog/?doi=10.1016/j.jopan.2016.
08.001&domain=pdf
446 MAUREEN F. COONEY
harms and burdens. A weak recommendation
indicates the reviewers’ assessment that benefits of
following the recommendation outweigh the
potential harms and burdens, but the benefits to
harms or burdens balance is smaller or evidence is
weaker.
7
The grade of the quality of evidence
(high, moderate, low) reflects the confidence level
ofthereviewersthattheevidencereflectsthetrueef-
fect and the likelihood that further research would
change the confidence in the estimate of effect.
8
The grading of evidence and recommendations is
further detailed in the published guidelines.
Following the evidence review, the guideline panel

drafted recommendations and engaged in a multi-
stage Delphi process to rank and revise the series
of the draft recommendation statements.
7
Unani-
mous or near-unanimous consensus was achieved
for all recommendations.
7
Subsequently, 20 external
peer reviewers provided additional comments on
the draft guidelines, which underwent an additional
revision and panel approval process.
7
The finalized
guidelines were approved by the APS Board of Direc-
tors; the ASA’s Committee on Regional Anesthesia,
Executive Committee, and Administrative Council;
and the American Society of Regional Anesthesia
Board of Directors in 2015 and published in early
2016.
7
Key Recommendations

Preoperative Education and Perioperative
Pain Management Planning
The panel recommends:
1. Clinicians should provide patient- and
family-centered, individually tailored edu-
cation to the patient (and/or responsible
caregiver), including information on treat-
ment options for management of postoper-
ative pain, and document the plan and
goals for postoperative pain management
(strong recommendation, low-quality evi-
dence).
2. Parents (or other adult caregivers) of chil-
dren who undergo surgery receive instruc-
tion in developmentally appropriate
methods for assessing pain and counseling
on appropriate administration of analgesics
and modalities (strong recommendation,
low-quality evidence).
3. Clinicians conduct a preoperative evaluation

including assessment of medical and psychi-
atric comorbidities, concomitant medica-
tions, history of chronic pain, substance
abuse, and previous postoperative treatment
regimes and responses, to guide the periop-
erative pain management plan (strong
recommendation, low-quality evidence).
4. Clinicians adjust the pain management plan
on the basis of adequacy of pain relief and
presence of adverse events (strong recom-
mendation, low-quality evidence).
Methods of Assessment
5. Clinicians use a validated pain assessment
tool to track responses to postoperative
pain treatments and adjust treatment plans
accordingly (strong recommendation, low-
quality evidence).
General Principles Regarding the Use of
Multimodal Therapies

6. Clinicians offer multimodal analgesia or the
use of a variety of analgesic medications
and techniques combined with nonpharma-
cological interventions for the treatment of
postoperative pain in children and adults
(strong recommendation, high-quality evi-
dence).
Use of Physical Modalities
7. Clinicians consider transcutaneous electri-
cal nerve stimulation (TENS) as an adjunct
to other postoperative pain treatments
(weak recommendation, moderate-quality
evidence).
The panel:
8. Neither recommends nor discourages
acupuncture, massage, or cold therapy as ad-
juncts to other postoperative pain treat-
ments (insufficient evidence).

PAIN MANAGEMENT 447
Use of Cognitive Behavioral Modalities
9. Clinicians consider the use of cognitive
behavioral modalities in adults as part of a
multimodal approach (weak recommenda-
tion, moderate-quality evidence).
Use of Systemic Pharmacological Therapies
10. Oral over intravenous (IV) administration
of opioids for postoperative analgesia in pa-
tients who can use the oral route (strong
recommendation, moderate-quality evi-
dence).
11. Clinicians avoid using the intramuscular
route for the administration of analgesics
for management of postoperative pain
(strong recommendation, moderate-
quality evidence).

12. IV patient-controlled analgesia (PCA) use
for postoperative systemic analgesia when
the parenteral route is needed (strong
dence).
13. Against routine use of basal infusion of
opioids with IV PCA in opioid-na€ıve
adults (strong recommendation, moderate-
quality evidence).
14. Clinicians provide appropriate monitoring
of sedation, respiratory status, and other
adverse events in patients who receive sys-
temic opioids for postoperative analgesia
dence).
15. Clinicians provide adults and children with
acetaminophen and/or nonsteroidal anti-
inflammatory drugs (NSAIDs) as part of
multimodal analgesia for management of

postoperative pain in patients without con-
traindications (strong recommendation,
high-quality evidence).
16. Clinicians consider giving a preoperative
dose of oral celecoxib in adult patients
without contraindications (strong recom-
mendation, moderate-quality evidence).
17. Clinicians consider use of gabapentin
or pregabalin as a component of multi-
modal analgesia (strong recommendation,
moderate-quality evidence).
18. Clinicians consider IV ketamine as a
component of multimodal analgesia in
adults (weak recommendation, moderate-
quality evidence).
19. Clinicians consider IV lidocaine infusions
in adults who undergo open and laparo-
scopic abdominal surgery who do not
have contraindications (weak recommen-
dation, moderate-quality evidence).

Use of Local and/or Topical
Pharmacological Therapies
20. Clinicians consider surgical site-specific
local anesthetic infiltration for surgical pro-
cedures with evidence indicating efficacy
(weak recommendation, moderate-quality
evidence).
21. Clinicians use topical local anesthetics in
combination with nerve blocks before
circumcision (strong recommendation,
The panel does not recommend:
22. Intrapleural analgesia with local anes-
thetics for pain control after thoracic sur-
gery (strong recommendation, moderate-
quality evidence).
Use of Peripheral Regional Anesthesia
23. Clinicians consider surgical site-specific pe-
ripheral regional anesthetic techniques in

adults and children for procedures with ev-
idence indicating efficacy (strong recom-
mendation, high-quality evidence).
24. Clinicians use continuous, local anesthetic-
based peripheral regional analgesic tech-
niques when the need for analgesia is
likely to exceed the duration of effect of a
single injection (strong recommendation,
25. Clinicians consider the addition of cloni-
dine as an adjuvant for prolongation of anal-
gesia with a single-injection peripheral
neural blockade (weak recommendation,
Use of Neuraxial Therapies
26. Clinicians offer neuraxial analgesia for ma-

jor thoracic and abdominal procedures,
particularly in patients at risk for cardiac
complications, pulmonary complications,
or prolonged ileus (strong recommenda-
tion, high-quality evidence).
27. Clinicians avoid the neuraxial administra-
tion of magnesium, benzodiazepines,
neostigmine, tramadol, and ketamine in
the treatment of postoperative pain (strong
dence).
28. Clinicians provide appropriate monitoring
of patients who have received neuraxial in-
terventions for perioperative analgesia
dence).
Organizational Structure, Policies, and
Procedures
29. Facilities in which surgery is performed

have an organizational structure in place
to develop and refine policies and proced-
ures for safe and effective delivery of
postoperative pain control (strong recom-
mendation, low-quality evidence).
30. Facilities in which surgery is performed
provide clinicians with access to consulta-
tion with a pain specialist for patients
with inadequately controlled postopera-
tive pain or at risk of inadequately
controlled postoperative pain (eg, opioid
tolerant, history of substance abuse)
dence).
31. Facilities in which neuraxial analgesia and
continuous peripheral blocks are per-
formed have policies and procedures to
support their safe delivery and trained in-
dividuals to manage these procedures

dence).
Transitioning to Outpatient Care
32. Clinicians provide education to all patients
(adults and children) and primary care-
givers on the pain treatment plan including
tapering of analgesics after hospital
discharge (strong recommendation, low-
quality evidence).
Perianesthesia Nursing
Recommendations
Awareness of the content in the APS Guidelines in
the Management of Postoperative Pain
7
is impor-
tant for nurses working in perianesthesia settings.
A complete review of the article, along with a
focused examination of recommendations specific
to their roles, will provide valuable information.
Recommendations related to preoperative educa-
tion, pain assessment, multimodal therapies, use

of physical and cognitive behavioral modalities,
use of systemic, local, and/or topical pharmacolog-
ical therapies, use of peripheral regional anes-
thesia and neuraxial therapies, and outpatient
care transitions have particular applicability to
the nurse in a direct care provider role. Some
specific content applicable to the practice of the
perianesthesia nurse is addressed in the following
paragraphs.
The guideline development panel members
recommend preoperative education and perioper-
ative pain management planning, and cite studies
which show that educational programs individu-
ally designed for surgical patients with specific
medical, developmental, psychological, or social
needs have been found to reduce opioid consump-
tion, preoperative anxiety, requests for sedating
medications, and postoperative lengths of stay.
7

There is no strong evidence to support the use of
one educational intervention over another or the
timing and content of interventions. However, it
is recommended that content includes specific in-
formation related to analgesic use before surgery
(continuation, discontinuation, or changes) to
avoid withdrawal syndrome (such as is possible
with opioids, benzodiazepines, gabapentin, and
baclofen), prevent surgical complications (eg,
aspirin and hemorrhage), and improve postopera-
tive pain control (eg, routine use of nonopioid
PAIN MANAGEMENT 449
analgesics).
7
Preoperative education related to the
use of pain assessment tools, realistic pain goals,
and how and when to report pain is advised. It is
important to address specific pain-related expecta-
tions and misconceptions, and inform patients
about the effects and possible adverse effects of

postoperative pain interventions. If patients will
be using postoperative devices and modalities
(eg, IV PCA), they/significant others should be in-
structed in the use of the modalities preopera-
tively. The pain management plan should be
developed preoperatively through shared
decision-making with the patient/parent/signifi-
cant other, based on an assessment of the individ-
ual patient’s history, condition, needs, and risks.
The panel identifies the importance of an assess-
ment of substance use and abuse (opioids, benzo-
diazepines, cocaine, alcohol and other substances
that may affect pain management) to guide devel-
opment of the postoperative pain management
plan. The role of the perianesthesia nurse in assess-
ing pain and patient responses to analgesic inter-
ventions is critical in assuring the re-evaluation
and adjustment of the pain management plan.
The panel emphasizes the importance of the use of

validated instruments to assess pain.
7
Patient self-
report, not behaviors or vital signs, is the primary
basis of pain assessment. Behaviors and the input
from caregivers are used to assess pain when the
patient cannot self-report. Pain should be assessed
during rest and activity. There are no clear recom-
mendations as to the optimal timing and frequency
of assessment, but after analgesic administration,
reassessment should occur by the time the medica-
tion reaches peak effect (15 to 30 minutes after
parenteral analgesics and 1 to 2 hours after oral
agents).
7
The use of multimodal analgesia, including phar-
macological and nonpharmacological interven-
tions, is recommended in the management of
postoperative pain. It is noted that a number of
different combinations of pharmacological and

nonpharmacological approaches are possible and
may vary depending on the type of surgery, patient
condition, and preferences.
7
Within the guide-
lines, there are some specific recommendations
for the particular multimodal approach based on
the type of surgical procedure. The use of TENS,
inexpensive, small, portable devices that deliver
a small low-voltage electrical impulse through
electrodes on the skin has been shown to reduce
pain through the descending inhibitory pain path-
ways which activate opioid receptors.
7
The panel
cites studies that have demonstrated reductions
in postoperative analgesic requirements. In most
cases, TENS electrodes were applied near the sur-
gical incision. There is insufficient evidence to
recommend the use of acupuncture. Other phys-
ical modalities such as acupressure, massage,
cold therapy, immobilization, and bracing are

generally safe, but there is a lack of evidence to
recommend their use. As components of a multi-
modal plan, cognitive behavioral therapies such
as hypnosis, guided imagery, music, and relaxation
methods have shown some positive effects on
postoperative pain, anxiety, or analgesic use, but
few studies of these modalities have been conduct-
ed with children.
7
Multimodal pharmacological approaches are rec-
ommended. Oral opioids, when possible, are
preferred over IV administration as there is no
strong evidence to show that IV therapy provides
superior relief of pain.
7
The use of short-acting opi-
oids, administered around the clock in the immedi-
ate postoperative period, is recommended.
7
Except if used preoperatively, long-acting opioids
should not be used for postoperative pain manage-

ment. Intramuscular injections should be avoided
as they do not provide reliable effects and show
no superiority over other routes.
7
The guidelines
support the use of IV PCA, without the use of a
basal infusion, when IV opioids are needed as IV
PCA has been shown to provide greater effective-
ness and patient satisfaction.
7
To reduce the risk
of opioid-related adverse events, the panel re-
commends close monitoring of sedation level
and respiratory status, especially in the hours
immediately after surgery or with dose changes.
7
There is no clear recommendation for the use of
pulse oximetry, capnography, or other monitoring
methods due to a lack of evidence.
7
Identification
of patients at increased risk for opioid-related

adverse events is advised, and interventions to
minimize risks, including dose adjustments, are
recommended.
7
Nonopioids are recommended as components of a
multimodal analgesic plan.
7
The panel cites evi-
dence that shows that acetaminophen and NSAIDs
reduce pain and opioid requirements in postsur-
gical patients. NSAIDs are associated with risks,
including gastrointestinal bleeding, anastomotic
leakage in colorectal surgery, and cardiovascular
events and renal dysfunction, which must be
considered and may contraindicate their use in
some postsurgical patients.
7
NSAIDs and cele-
coxib are contraindicated for perioperative pain

management in patients undergoing coronary ar-
tery bypass grafting.
7
Perianesthesia nurses may
be aware of the reluctance of some orthopaedic
surgeons to use NSAIDs for their patients due to
concerns of bone nonunion after certain surgical
procedures, but the panel notes that there is insuf-
ficient evidence to recommend against the use of
NSAIDs for orthopaedic fractures and spinal fusion
and identifies the need for informed decision-
making and consideration of alternatives by the
surgeon and the patient.
7
Celecoxib, in doses of
200 to 400 mg administered 30 to 60 minutes pre-
operatively to adults is recommended for postsur-
gical pain and opioid requirement reducing
benefits.
7
The panel cites evidence that doses of
gabapentin (600 or 1,200 mg) or pregabalin (150

or 300 mg) administered 1 to 2 hours preopera-
tively to adults are effective components of a multi-
modal plan, and postoperative dosing has shown
effectiveness in some trials.
7
Additional multimodal pharmacological interven-
tions that perianesthesia nurses may be less
familiar with are also recommended in the guide-
lines. Although the panel is unable to identify suf-
ficient evidence for optimal dosing of IV ketamine,
it recommends a preoperative bolus of 0.5 mg/kg
followed by an infusion of 10 mcg/kg/minute intra-
operatively, and a lower dosage postoperative infu-
sion as a multimodal analgesic component for
adult surgical patients to reduce postoperative
pain, analgesic use, and possibly the risk of persis-
tent postsurgical pain.
7
Evidence is cited to sup-
port the use of IV lidocaine infusions in adults

undergoing open and laparoscopic abdominal sur-
geries as this intervention is associated with
shorter duration of ileus and improved analgesia.
7
The panel recommends an initial bolus dose of
1.5 mg/kg followed by an infusion of 2 mg/kg/
hour during surgery; insufficient evidence is cited
to recommend postoperative use.
7
Site-specific peripheral regional local anesthetic in-
jections, and in some cases, continuous infusions
are supported in the guidelines. Neuraxial
(epidural or spinal) analgesia is recommended for
the management of major thoracic, abdominal, ce-
sarean section, hip, and lower extremity sur-
geries.
7
The neuraxial approach may reduce risks
of postoperative mortality, venous thromboembo-
lism, myocardial, infarction, pneumonia, respira-
tory depression, and may decrease duration of an
ileus.

7
The panel notes that epidural analgesia
has the advantage over spinal analgesia as an
epidural can be used as a continuous infusion
with or without PCA and can be used to deliver
local anesthetics. Epidural clonidine is sometimes
used with local anesthetics to improve postopera-
tive pain, but evidence is lacking and it may be
associated with increased hypotension.
7
Perianes-
thesia nurses need to be competent in the assess-
ment of patients who have received peripheral
regional anesthesia and neuraxial anesthetics/anal-
gesics and must be aware of the signs, symptoms,
and emergency management of any complications,
including local anesthetic toxicity. Some orthopae-
dic surgeries are associated with an increased risk
for compartment syndrome, and signs and symp-
toms may be diminished or masked with regional

and neuraxial techniques. When opioids are used
in spinal or epidural analgesia, patients must be
monitored for opioid-related adverse outcomes.
In addition, patients who have received neuraxial
analgesia are at risk for spinal cord compression.
Perianesthesia nurses must be educated about
these potential complications and prepared to
implement appropriate emergency measures.
Perianesthesia nurses have significant roles in
assuring appropriate transitions of patient care.
The panel recommends that all patients and/or
caregivers receive a coordinated approach to
discharge planning and discharge teaching from
all involved disciplines (surgeons, nurses, thera-
pists, pharmacists). It is necessary to provide in-
structions in the safe and appropriate use of
pain medications and side effect management.
Discharge teaching should include warnings about
the life-threatening risks of concomitant use of

alcohol and other central nervous system depres-
sants when opioids are used. Teaching should also
include an individualized plan for opioid weaning
and discontinuation and safe storage and disposal
of opioids and other medications.
7
Clear evidence
to guide the method for postsurgical opioid wean-
ing is not available, but the panel notes that severe
postoperative pain usually diminishes rapidly in the
first few days after surgery. For minor surgeries,
PAIN MANAGEMENT 451
pain may be controlled with nonopioid analgesics
or a very limited opioid supply after discharge. In
patients with more involved surgeries, a longer
course of postoperative analgesics, including opi-
oids, may be needed. If used for more than 1 to
2 weeks, a gradual opioid reduction is suggested
to prevent withdrawal, with dose reductions by
20% to 25% of the discharge dose every 1 to 2 days.

7
Conclusion
The above statements constitute key recommen-
dations contained in the APS Postoperative Pain
Guidelines. In addition, the guidelines include
elaboration on each of the recommendations, a
list of interventions for the management of postop-
erative pain in patients receiving long-term opioid
therapy, a table of options for components of a
multimodal analgesic surgery-specific approach,
and a summary table of interventions for manage-
ment of postoperative pain. Perianesthesia nurses
may find it helpful to review the guidelines to
inform various aspects of their clinical practice.
It is important to note that clinical practice guide-
lines are general statements that do not dictate
practice, but provide guidance for practice based
on the evidence available at the time they are writ-
ten. They do not apply to all patients, as individual

patients and clinical scenarios may not be appro-
priate for implementation of the recommenda-
tions, but require patient-specific approaches
based on assessment and consideration of individ-
ual patient needs and resources. In examining each
recommendation, it is important to note that
despite a comprehensive review of the literature,
only 4 of the 32 recommendations have a high-
quality evidence rating.
7,8
High-quality evidence was only found to support
the use of multimodal analgesia, including the
use of acetaminophen and NSAIDs, site-specific
peripheral regional anesthetic techniques, and
neuraxial analgesia with opioids and local anes-
thetics for thoracic and abdominal procedures.
7,8
Although there are 28 other recommendations,
they are rated with moderate- or low-quality evi-
dence because the panel identified significant

research gaps in the evidence review.
7,8
However, despite the lack of high-quality evi-
dence, these recommendations reflect the panel’s
near-unanimous consensus on all the recommen-
dations.
7
The task of developing evidence-based
guidelines presents challenges; There are limita-
tions in the ability to gather and synthesize all
high-quality studies that are available related to
an area as broad as postoperative pain, and even
as available evidence is analyzed and recommen-
dations are developed, additional studies are
completed and newer evidence surfaces.
8
This
further highlights the necessity of individualizing
patient care and using informed clinical judgment
over strict adherence to recommendations con-
tained in the guidelines. It also demonstrates the
significant need for additional research to address

the gaps in evidence related to the management
of postoperative pain.
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http://refhub.elsevier.com/S1089-9472(16)30282-
9/sref8Postoperative Pain Management: Clinical Practice
GuidelinesMethodology for Guideline DevelopmentKey
RecommendationsPreoperative Education and Perioperative
Pain Management PlanningMethods of AssessmentGeneral
Principles Regarding the Use of Multimodal TherapiesUse of
Physical ModalitiesUse of Cognitive Behavioral ModalitiesUse
of Systemic Pharmacological TherapiesUse of Local and/or
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stoperative pain assessment based on numeric ratings is not the
same
r patients and professionals: A cross-sectional study
queline F.M. van Dijk a,*, Albert J.M. van Wijck a, Teus H.
Kappen a, Linda M. Peelen a,b,
r J. Kalkman a, Marieke J. Schuurmans c
iversity Medical Centre Utrecht, Department of Perioperative

Care and Emergency Medicine, The Netherlands
iversity Medical Centre Utrecht, Julius Centre for Health
Sciences and Primary Care, The Netherlands
iversity Medical Centre Utrecht, Department of Nursing
Science, The Netherlands
What is already known about the topic?
ain assessment is the foundation of pain management
hen a patient is experiencing postoperative pain. A
frequent and thorough assessment of patients’ pain by
registered nurses provides information to achieve
optimal pain relief.
� Clinical guidelines are developed for postoperative pain
management based on the patient’s pain score. In these
guidelines different cut-off points are used to treat the
pain.
What this paper adds
� Patients and professionals do interpret the numeric
rating scores for postoperative pain differently.
T I C L E I N F O
le history:
ived 27 December 2010
ived in revised form 7 July 2011
pted 16 July 2011

ords:
lgesics
eline
measurement
operative pain
A B S T R A C T
Background: Numeric pain scores have become important in
clinical practice to assess
postoperative pain and to help develop guidelines for treating
pain. Professionals need the
patients’ pain scores to administer analgesic medication.
However, do professionals
interpret the pain scores in line with the actual perception of
pain by the patients?
Objective: The study aim was to assess which Numerical Rating
Scale (NRS) pain score was
considered bearable on a Verbal Rating Scale (VRS) by patients
and professionals.
Methods: This prospective study examined the relationship
between the Numerical Rating
Scale and a Verbal Rating Scale. The patients (n = 10,434) rated
their pain the day after

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