BACKGROUND and AIMS. Patellofemoral pain syndrome (PFPS) is complex and challenging musculoskeletal disorder. Maltracking of the patella is considered to be one of the primary causative factors. Vastus Medialis Oblique (VMO) and Vastus Lateralis (VL) muscle imbalance in terms of EMG magnitude and timed onset is implicated in either initiating or perpetuating the patellofemoral pain (Cowan et al, 2002, Witvrouw et al, 1996). Many physiotherapeutic treatments are aimed at addressing this muscle imbalance despite a lack of evidence confirming or refuting it exists and it's association with pain and function. The ultimate aim of the study was therefore to establish if it is appropriate to continue treating muscle imbalance in patients with clinically defined PFPS. OBJECTIVES. The overall objectives of the study were to establish: 1. If VMO-VL muscle imbalance exists in PFPS patients and if so is it specific to this condition or does a similar VMO-VL muscle imbalance exists in a healthy population? 2. If muscle imbalance does exist is it related to clinical symptoms used as indications of pain syndrome in clinical practice? 3. Is muscle imbalance associated with lower limb muscle physiology i.e. lower limb and quadriceps muscle strength in both fresh and fatigued states. METHODS. The study employed a cross-sectional design. 63 patients with patellofemoral pain syndrome (PFPS) and 63 age/sex matched healthy subjects were recruited and VMO & VL normalised EMG RMS amplitude and time onset differences were assessed during functional and experimental tasks. Additionally, correlations with pain level, functional status, muscular flexibility and biomechanical characteristics of the lower limb were explored. RESULTS. The results revealed that the VMO-VL activation patterns are task specific and most significantly related to functional stepping down task at a fast speed of execution (p=0.000). This interesting link between the type of muscle contraction, the speed of execution and the recruitment pattern of the VMO-VL was also confirmed by the non-functional isokinetic eccentric contraction (p=0.000). Additionally, it is the timing of the VMO-VL activation rather the intensity that is important. Also, a correlation appears to exist between activation pattern and duration of symptoms and knee functional performance (p=0.03) but not with the level of pain. CONCLUSION. The findings of the study suggest that the VMO-VL muscle imbalance does exist in a clinically defined PFPS population. Unlike previous studies however, this thesis suggests that specificity of the functional activities and speed of execution have a significant role to play in the muscular performance and it could be argued that this translates to a role in PFPS. It would therefore seem appropriate to continue addressing and treating this complex and challenging issue with physiotherapeutic interventions but this may need to be targeted to interventions that are tailored to addressing issues in relation to stepping down and at fast speed.

This research project addressed pain at parturition in pigs using three different approaches. Firstly, a survey study explored UK pig farmer and veterinarian attitudes to pain and the use of pain relief in order to understand the commercial context behind decisions relating to pain and its management. Secondly, an observational study was conducted to investigate the use of behaviour to assess pain associated with the process of giving birth (or farrowing) in pigs. A final experimental study was used to investigate the administration of a pain relief drug post-farrowing to improve pig welfare and increase productivity. In a questionnaire to farmers and veterinarians, individuals were asked to identify the anti-inflammatory drugs they used or prescribed and how often for selected conditions in pigs. They were also asked to rate the painfulness of different conditions and indicate their level of agreement with statements about pain and the use of pain relief. Results showed anti-inflammatories were widely used, with high agreement that pigs recovered better when given these drugs. Farmers and vets gave similar scores for painful conditions but females and younger respondents scored higher for specific conditions. The results suggest that potential barriers to the increased use of pain relief include a lack of up to date knowledge and communication between farmers and vets about pain and how best to treat it. A preliminary investigation was conducted to identify novel behavioural measures to assess pain in sows over the periparturient period. A set of spontaneous putative pain behaviours were characterised and quantified, using observations of sows before, during and after farrowing. These potential behavioural pain indicators were rare or absent before farrowing and the highest levels were seen during farrowing. For the post-farrowing observations, levels were highest for the immediate post-farrowing period and remained higher than pre-farrowing values up to 24 hours after the last piglet was born. Positive correlations between behavioural variables measured during and after farrowing indicate the individual consistency in the expression of these behaviours. Putative pain behaviours, along with other measures of welfare and productivity were then used to test the benefits of administering the non-steroidal anti-inflammatory drug ketoprofen, compared with a saline placebo, 1.5 hours post farrowing in primiparous and multiparous sows. No clear treatment differences were observed for the sow welfare measures, including the putative behavioural indicators of pain. For primiparous sows treated with ketoprofen, fewer piglets died, but this could be due to an unexpected treatment difference in piglet birth weight, which is strongly linked with piglet mortality. Further research is needed to validate the spontaneous behaviours used in this study as indicators of pain in periparturient sows.

This study sought to provide a description of the psychosocial profile of persons with complex regional pain syndrome (CRPS). CRPS is an excruciatingly painful and debilitating condition that is poorly understood by medical professionals. Its profound impact on an individual's quality of life prompts a closer examination of the psychosocial profile of individuals suffering from CRPS. The extant literature examining psychological variables associated with CRPS is inconclusive with regard to the role that these factors play in the course of the syndrome. It has been shown, however, that CRPS patients suffer tremendous physical discomfort and this is often reflected in increased emotional distress. The present study assesses level of pain, anxiety, depression, disability, intrusive thoughts, quality of life, and demographic variables utilizing a national sample obtained from an online survey distributed to members of an organization that provides resources to CRPS patients. Descriptive data are presented for all data gathered and specific correlates of quality of life were examined. Results of the study demonstrated that this sample endorsed high levels of anxiety and depression and reported low levels of both physical and mental quality of life. When compared to normative data, this sample endorsed more pain and anxiety than other pain populations and also endorsed lower mental and physical quality of life than other pain conditions. The psychosocial profile of individuals with CRPS type I did not vary significantly from individuals with type II. Intrusive thoughts were uniquely predictive of disability, physical quality of life, and mental quality of life after controlling for age, gender, and pain level. The role of intrusive thoughts in predicting disability and quality of life suggests a potential mechanism by which clinicians can target psychotherapeutic treatment. Understanding the psychosocial profile and psychological sequelae of this disorder will help both physicians and psychologists understand the impact of CRPS on patients and provide a pathway for improved comprehensive interdisciplinary treatments.

Cognitive-behavioural based models of chronic pain contend that appraisals of harm affect the individual�s response to pain. It has been suggested that fear of pain and/or anxiety sensitivity predispose individuals to chronicity. However, other factors such as pain self-efficacy are believed to mediate between experience of pain and disability. According to this view, pain is maintained through hypervigilance towards painful sensations and subsequent avoidance. Four studies were conducted in order to evaluate the structure of fear-avoidance models of chronic pain, and also, to examine the role of hypervigilance as an underlying mechanism in maintenance of pain. In study one, using a sample of 207 consecutive patients, two models were tested. First, fear of movement model as proposed by Vlaeyen et al. (1995a) was examined. It was found that negative affectivity has direct effects on the fear and avoidance of pain, which in turn, contributes to disability. In total, fear/avoidance accounted for a significant amount of the variance of disability. In addition, severity of pain was found to increase pain disability, while itself is influenced still by negative affectivity. These findings supported the model of fear of pain as described by Vlaeyen et al. (1995a). Further, we found that self-efficacy may mediate the impact of fear of pain on disability and reduces the perceived physical disability. At the same time, self-efficacy was shown to have direct reductive impact on disability. However, both studies indicated that people who are fearful in response to pain are more likely to develop disability, although self-efficacy may play a moderating role. In the studies one, two, and three, the role of hypervigilance in over attending to pain was investigated. In study one a large sample of 168 chronic pain patients were studied. Questionnaires measuring different aspects of pain and a computerised version of the Dot-Probe Task were administered. Four types of words related to different dimensions of pain and matched neutral words were used as stimuli. Reaction times in response to the stimuli were recorded. A factorial design 3x4x2x2 and ANOVAs were employed to analyse the data. Chronic pain patients showed a cognitive bias to sensory pain words relative to affective, disability, and threat-related words. However, contrary to expectations, those high in fear of pain responded more slowly to stimuli than those less fearful of pain. These results suggest that patients with chronic pain problems selectively attend to sensory aspects of pain. However, selective attention appears to depend upon the nature of pain stimuli. For those who are highly fearful of pain they may not only selectively attend to pain-related information but also have difficulty disengaging from those stimuli. In study two, 35 chronic pain patients were compared with the same number matched healthy subjects. Both groups completed measures of fear of pain, anxiety sensitivity, depression and anxiety, in addition to dot probe task. Results indicated that both groups show similar attentional bias to sensory words in comparison with other word types. However, the level of this biasness was higher for chronic pain patients. Lack of significant differences between patients and controls is discussed in the context of possible evolutionary value of sensitivity to pain as an adaptive reaction in healthy controls, and contrary, as a maladaptive response to pain in chronic pain patients. The results of the previous research suggest that chronic pain patients demonstrate cognitive biases towards pain-related information and that such biases predict patient functioning. The forth study examined the degree to which a successful cognitive-behavioural program was able to modify the observed attentional bias towards sensory pain words. Forty-two patients with chronic pain conditions for more than three months were recruited prior to commencing a cognitive-behavioural pain management program. Participants were assessed before the program, after the program and at one-month follow-up. Results confirmed that chronic pain patients exhibited biased attention towards sensory pain-related words at pre-treatment. These biases were still evident at post-treatment, but were no longer statistically significant at follow up. Multiple regression analyses indicated that the changes in attentional bias towards sensory words between post-treatment and follow-up were predicted by pre- to post- treatment changes in fear of movement (Tampa Scale for Kinesiophobia) but not other relevant variables, such as fear of pain or anxiety sensitivity. These results demonstrate that successful cognitive-behavioural treatments can reduce selective attention, thought to be indicative of hypervigilance towards pain. Moreover, these biases appear to be changed by reducing the fear associated with movement. Theoretically, these results provide support for the fear of (re)injury model of pain. Clinically, this study supports the contention that fear of (re)injury and movement is an appropriate target of pain management and that reducing these fears causes patients to attend less to pain-related stimuli.

Neuropathic pain is defined as "pain initiated or caused by a primary lesion or dysfunction in the nervous system". In contrast to physiological pain that warns of noxious stimuli likely to result in tissue damage, neuropathic pain serves no protective function. Examples of neuropathic pain states include postherpetic neuralgia (shingles) and phantom limb / stump pain. This pain state also exists in the orofacial region, with the possibility of several variants including atypical odontalgia and burning mouth syndrome. There is a paucity of information on the prevalence of neuropathic pain in the orofacial region. One study assessed patients following endodontic treatment and found that approximately 3 to 6percent of patients reported persistent pain. Patients predisposed to the condition atypical odontalgia (phantom tooth pain) include those suffering from recurrent cluster or migraine headaches. Biochemical and neurobiological processes leading to a neuropathic pain state are complex and involve peripheral sensitisation, and neuronal plasticity of the central and peripheral nervous systems. Subsequent associated pathophysiology includes regional muscle spasm, sympathetic hyperfunction, and centralisation of pain. The relevant clinical features of neuropathic pain are: (i) precipitating factors such as trauma or disease (infection), (ii) pain that is frequently described as having burning, paroxysmal, and lancinating or sharp qualities, and (iii) physical examination may indicate hyperalgesia, allodynia and sympathetic hyperfunction. The typical patient complains of persistent, severe pain, yet there are no clearly identifiable clinical or radiographic abnormalities. Often, due to the chronicity of the problem, afflicted patients exhibit significant distress and are poor pain historians, thus complicating the clinician's task of obtaining a detailed and relevant clinical and psychosocial history. An appropriate analgetic blockade test for intraoral sites of neuropathic pain is mucosal application of topical anaesthetics. Other, more specific, tests include placebo controlled lignocaine infusions for assessing neuropathic pain, and placebo controlled phentolamine infusions for sympathetically maintained pain. The treatment and management of neuropathic pain is multidisciplinary. Medication rationalisation utilises first-line antineuropathic drugs including tricyclic antidepressants, and possibly an anticonvulsant. Topical applications of capsaicin to the gingivae and oral mucosa are a simple and effective treatment. Neuropathic pain responds poorly to opioid medication. Psychological assessment is often crucial in developing strategies for pain management. Psychological variables include distress, depression, expectations of treatment, motivation to improve, and background environmental factors. To enable a greater understanding of neuropathic pain, thereby leading to improved treatments, high-performance liquid chromatography-mass spectrometry is one analytical technique that has the potential to contribute to our knowledge base. This technique allows drugs and endogenous substances to be assayed from one sample in a relatively short time. The technique can identify, confirm, and measure the concentrations of multiple analytes from a single sample.

This thesis was initiated by an awareness of the impact of low back pain in Western society in general and Australian society in particular. The studies and experiments in this thesis contribute towards an understanding of chiropractic as a professional entity in Victoria and the nature of its clinical practice. The issue of male adolescent LBP has been explored and in addition to an epidemiological description of this clinical entity, its anthropometric dimensions have been documented. The qualitative review of the literature provides ample justification for the management of patients with LBP by chiropractors, using manual or manipulative techniques. The observational study of the Victorian context in which chiropractors are educated, registered, and entitled to practice, demonstrates that Victorian chiropractors are appropriate providers of manipulative health care. They perform the role of primary contact, primary health care providers with diagnostic, treatment and management skills focussed mainly on musculoskeletal conditions, but with a small proportion of practice based in the health or preventive context, and are well placed to provide the manual and manipulative services required in the management of LBP patients. The profession is shown to have strategies in place to ensure continued legal and community acceptance. The strategies include those at entry level to the profession, such as the legislative provisions of government and the competencies required for registration as instilled during the professional education process, and those which are more of the nature to maintain the integrity of professional practice, such as the " standards of practice" concept. These are important characteristics given it is shown that the Victorian chiropractic profession is not homogenous with respect to educational standards, has a disparate gender balance, the presence of a few non-registered 'chiropractors', and a disparity in utilisation patterns with a significant tail to the right. However the chiropractic profession is shown to hold a position of strength and leadership in the Australian context with respect to the provision of manipulative health care. Indeed, it could be said that chiropractors are at the leading edge of the quality process with respect to the provision of manipulative health care in Australia. The description of chiropractic practice shows a patient base of all ages, including adolescents, presenting with a range of possible diagnoses, often funded by a third party, and with a high proportion of return visits suggestive of patient compliance and satisfaction. It is convincingly demonstrated that persons with work-related LBP attend to chiropractors in Victoria and are effectively managed with the aim being the restoration of optimal spinal function and, in the case of work-injured patients, an early return to work. This thesis includes utilisation data which suggest only a minority of Victorian chiropractors practice outside the responsible parameters described above. The case-mix data and patient profiles presented in this thesis are congruent and complement each other, suggesting a high level of patient satisfaction indicated by the high proportion of return visits by regular patients and a faster, return-to-work by work-injured claimants. The point and sample prevalence of LBP in a population of suburban male adolescents is described and shown to be similar to those found in comparable Western societies. The data for a sample of traditional Australian male adolescents describes the LBP experience for the first time in such a population and emphasises the wide variance between societies which is now being identified in the literature. The LBP experience of a typical suburban Australian male adolescent is identified and described in terms of chronicity, frequency and episode duration. Typically the male adolescent with LBP has a chronic (> 90 d) problem with frequent episodes of pain (from 2 or 3 times a month to 2 or 3 times week) which last a few hours. The pain is a little limiting but allows the performance of the Activities of Daily Living. While some limitation of general sporting activity due to pain is experienced, school attendance is generally not compromised. A particular clinical instrument, the Metrecom computerised electro-goniometer, is studied and found to be appropriate for use in gathering anthropometric dimensions to test hypotheses relating to an association between anthropometric dimensions and LBP in a male adolescent population. The applied level of uncertainty of the instrument is within acceptable limits for these dimensions. The anthropometric study tests the broad null hypothesis that the mean of specific anthropometric dimensions would be equal among samples of male adolescents drawn from the Australian population. The actual groups are a Melbourne 'Pain' group, a Melbourne 'No Pain' group, and a 'Traditional No Pain' group. The pain group reported either current LBP or a positive history of LBP, while the 'no pain' groups denied either current or historical LBP. The alternate hypothesis will be shown to be proven for the dimensions 'sitting height', 'upper body' length, 'pelvic height', and the ratio of the 'upper:lower' body segment in a population of male adolescents with idiopathic or mechanical LBP. This thesis meets its objectives of describing the chiropractic profession and its practise in the Victorian context, demonstrates the prevalence of LBP in a male adolescent population, and identifies particular anthropometric dimensions associated with those who report a LBP experience. The fact that a number of anthropometric dimensions are detectable in adolescence may allow the development of appropriate screening programs which in turn may lead to the design and introduction of suitable prophylactic interventional programs for persons found to be potentially prone to idiopathic or mechanical LBP, at the least reducing the severity and at most reducing the onset of this expensive problem in adulthood. The ratio of the upper body segment to the lower body segment would appear to be most appropriate indicator; it is robust in that it is a prime dimension, easily accessible, and with a low level of measurement uncertainty. Most importantly it would appear to hold validity throughout adolescence as it does not have a linear relationship with age.

<p>Syftet med denna studie var att belysa metoder som vårdpersonal kan använda sig av för att bedöma smärta hos personer med demens och vilka konsekvenser som detta medför. En litteraturstudie gjordes där 16 vetenskapliga artiklar analyserades. Resultatet visade att det finns smärtbedömningsinstrument tillgängliga som kan identifiera smärta hos personer med demens som inte själva verbalt kan beskriva sin smärta. Instrumenten innehöll beskrivningar av beteenden som kunde vara tecken på smärta. En del instrument innehöll förslag till interventioner som kunde utföras och utvärderas. Konsekvenser av användandet av ett smärtbedömningsinstrument visade signifikant minskade smärtbeteenden och ökade farmakologiska och ickefarmakologiska åtgärder.</p><p>Sammanfattningsvis finns det smärtbedömningsverktyg tillgängliga för att identifiera smärta hos personer med demens.</p> / <p>The aim of this study was to illuminate methods healthcare workers can utilize assessing pain among persons with dementia and what consequences it would bring. A literature review was made by analyzing sixteen scientific articles. The result showed that there are pain assessment tools available to identify pain among persons with dementia, who cannot verbally describe their pain. The instruments contained descriptions of behaviours that could be signs of pain. Some of the instruments contained suggestions of interventions that could be performed and evaluated. Consequences of using a pain assessment tool showed significant decrease in discomfort and increased pharmacological and non-pharmacological interventions. In conclusion there are pain assessment tools available to identify pain among persons with dementia.</p>

<p><strong>Introduktion:</strong> Smärta, smärtskattning samt smärtbehandling är centrala begrepp inom hematologin. Intresset att genomföra en studie huruvida kvalitetsmål för smärtbehandling som finns utarbetade på Akademiska sjukhuset (AS) i Uppsala följs, väcktes med anledning av detta. <strong>Syfte:</strong> Författarna valde i denna uppsats att undersöka om gällande kvalitetsmål för smärtbehandling uppnås på hematologen på AS för patienter med maligna blodsjukdomar. De mål som undersöks är dokumentation, kunskap hos behandlande personal på avdelningen, smärtskattning samt smärtbehandling.<strong>Metod:</strong> Studien är en journal- och enkätstudie med deskriptiv design. 30 journalers dokumentation på inneliggande patienter från november 2008 har granskats under en period med fokus på smärta. Utöver journalgranskning har en enkätstudie med smärtrelaterade frågor gjorts bland läkare och sjuksköterskor på avdelningen. <strong>Resultat:</strong> Resultatet från studien påvisar en del brister i smärtskattning, i dokumentation samt kännedom av sjukhusets kvalitetsmål för smärtbehandling. Dock tror sig både sjuksköterskor och läkare att de har den kunskap som krävs för en god vård.<strong>Slutsats: </strong>Om sjukhusövergripande kvalitetsmål för smärtbehandling implementeras på rätt sätt är de till hjälp i vården. Väl utförd smärtskattning, bra dokumentation och tydlig utvärdering hjälper vårdpersonalen att få inblick i patientens smärtstatus.</p> / <p><strong>Introduction:</strong> Pain, pain estimation and pain treatment is central concepts within hematology. The interest to conduct a study whether quality of Pain Medicine, which is prepared in the Academic hospital (AS) in Uppsala are followed, brought with it. <strong>Aim:</strong> The authors chose in this paper to examine whether the existing quality of Pain Medicine achieved in the Department of Hematology at AS in patients with malignant blood diseases. The targets under investigation are the documentation, knowledge of the treating staff, pain estimation and Pain Medicine.<strong>Methods:</strong> The study is a record and a survey-study with descriptive design. 30 journals documentation of indwelling patients from November 2008 have been reviewed in a period with a focus on pain. In addition to record review, a survey of pain-related issues among doctors and nurses in the department has also been done.<strong>Results:</strong> Showing some weaknesses in the painfully estimation, in documentation and knowledge of hospital quality of Pain Medicine. However, both nurses and doctors believe they have the knowledge required for good health care.<strong>Conclusion:</strong> If the hospital overall quality objectives for Pain Medicine is implemented correctly, they are helpful in care. Well done pain estimation, good documentation and clear evaluation helps the nursing staff to gain insight into the patient's pain status.</p>

Syftet med denna studie var att belysa metoder som vårdpersonal kan använda sig av för att bedöma smärta hos personer med demens och vilka konsekvenser som detta medför. En litteraturstudie gjordes där 16 vetenskapliga artiklar analyserades. Resultatet visade att det finns smärtbedömningsinstrument tillgängliga som kan identifiera smärta hos personer med demens som inte själva verbalt kan beskriva sin smärta. Instrumenten innehöll beskrivningar av beteenden som kunde vara tecken på smärta. En del instrument innehöll förslag till interventioner som kunde utföras och utvärderas. Konsekvenser av användandet av ett smärtbedömningsinstrument visade signifikant minskade smärtbeteenden och ökade farmakologiska och ickefarmakologiska åtgärder. Sammanfattningsvis finns det smärtbedömningsverktyg tillgängliga för att identifiera smärta hos personer med demens. / The aim of this study was to illuminate methods healthcare workers can utilize assessing pain among persons with dementia and what consequences it would bring. A literature review was made by analyzing sixteen scientific articles. The result showed that there are pain assessment tools available to identify pain among persons with dementia, who cannot verbally describe their pain. The instruments contained descriptions of behaviours that could be signs of pain. Some of the instruments contained suggestions of interventions that could be performed and evaluated. Consequences of using a pain assessment tool showed significant decrease in discomfort and increased pharmacological and non-pharmacological interventions. In conclusion there are pain assessment tools available to identify pain among persons with dementia.

Introduktion: Smärta, smärtskattning samt smärtbehandling är centrala begrepp inom hematologin. Intresset att genomföra en studie huruvida kvalitetsmål för smärtbehandling som finns utarbetade på Akademiska sjukhuset (AS) i Uppsala följs, väcktes med anledning av detta. Syfte: Författarna valde i denna uppsats att undersöka om gällande kvalitetsmål för smärtbehandling uppnås på hematologen på AS för patienter med maligna blodsjukdomar. De mål som undersöks är dokumentation, kunskap hos behandlande personal på avdelningen, smärtskattning samt smärtbehandling.Metod: Studien är en journal- och enkätstudie med deskriptiv design. 30 journalers dokumentation på inneliggande patienter från november 2008 har granskats under en period med fokus på smärta. Utöver journalgranskning har en enkätstudie med smärtrelaterade frågor gjorts bland läkare och sjuksköterskor på avdelningen. Resultat: Resultatet från studien påvisar en del brister i smärtskattning, i dokumentation samt kännedom av sjukhusets kvalitetsmål för smärtbehandling. Dock tror sig både sjuksköterskor och läkare att de har den kunskap som krävs för en god vård.Slutsats: Om sjukhusövergripande kvalitetsmål för smärtbehandling implementeras på rätt sätt är de till hjälp i vården. Väl utförd smärtskattning, bra dokumentation och tydlig utvärdering hjälper vårdpersonalen att få inblick i patientens smärtstatus. / Introduction: Pain, pain estimation and pain treatment is central concepts within hematology. The interest to conduct a study whether quality of Pain Medicine, which is prepared in the Academic hospital (AS) in Uppsala are followed, brought with it. Aim: The authors chose in this paper to examine whether the existing quality of Pain Medicine achieved in the Department of Hematology at AS in patients with malignant blood diseases. The targets under investigation are the documentation, knowledge of the treating staff, pain estimation and Pain Medicine.Methods: The study is a record and a survey-study with descriptive design. 30 journals documentation of indwelling patients from November 2008 have been reviewed in a period with a focus on pain. In addition to record review, a survey of pain-related issues among doctors and nurses in the department has also been done.Results: Showing some weaknesses in the painfully estimation, in documentation and knowledge of hospital quality of Pain Medicine. However, both nurses and doctors believe they have the knowledge required for good health care.Conclusion: If the hospital overall quality objectives for Pain Medicine is implemented correctly, they are helpful in care. Well done pain estimation, good documentation and clear evaluation helps the nursing staff to gain insight into the patient's pain status.