The available evidence is limited about effective clinical practices and interventions that inform effective pain management.

Some tools include verbal reporting tools, numerical description tools, picture-based tools and behavioural and psychological observation tools. However, picture-based tools such as Wong-Baker Faces are not always accessible for people with a learning disability due to the reliance on abstract conceptions and can be difficult to understand.

For people with a learning disability, responses such as laughing and crying can be difficult to interpret. It is important to establish how the person typically presents when in pain. They may also experience altered observational and psychological responses to pain. Pain is more likely to be identified if expected, for example, procedural pain such as blood being taken, but pain is often missed in other contexts.

Some assessment tools may be more appropriate for use in hospitals, while others will work better in community or residential settings. In hospice or community/care home settings, there may be a greater scope to use more complex behavioural observation tools that require considerable time to populate and use.

A combination of tools may also be appropriate; it is important to use the tool that works for your setting and your patients.

The Abbey Pain Scale (PDF) is a recognised tool for cognitively impaired elderly people with dementia to help identify and treat pain. Although not validated for people with learning disabilities, it has been proven to be useful.

The disadvantages of this tool are that depression, fatigue and agitation could be mistaken for pain. As a result, sensitivity is essential for accurately interpreting behavioural and non-verbal indicators of changes in activity, behaviour and mental health presentation.

The advantages include is its brevity—comprising just six questions that capture both acute and chronic pain. It covers observations of vocalisation, facial expression, changes in body language, and behavioural, physiological and physical changes.

The scale also provides a measure that can serve as a baseline for subsequent assessments to identify changes in pain and presentation. Additionally, when used alongside a person-centred approach, it can be very effective.

The DisDAT has been developed for people with severe or profound learning disabilities. It covers seven categories, which include:

• facial signs
• body observations (skin appearance)
• vocal sounds
• speech
• habits and mannerisms
• body posture and body observations at baseline, repeated to measure any changes (Weir and Koritsas 2021).

This tool is best used when completed in advance, the person is in a stable condition and baseline data can be collated. However, providing descriptions of signs and behaviours observed remains open to interpretation and depends on the person who is assessing.

Although the tool provides informal caregivers, family carers and professionals with confidence to identify possible causes of distress and monitor the effects of agreed pharmacological and therapeutic interventions, it is found to be a lengthy assessment.

All of the tools below are suitable for use in acute hospital or residential settings.

Although not fully validated, the Pain Picture Tool has been found to be useful. Where pain may be indicated, further detailed exploration of the person’s presentation, diagnoses and current and historical health needs, including prescribed medication, will take place.

This information will then inform the initial plan of care and agreed actions can be taken forward.

The Pain Picture tool has several pain indicators that are colour-coded (red/amber/green) to highlight the severity of pain. It can be used when working with wider professionals and health services to raise awareness of physical and mental pain.

The Iowa Pain Thermometer (IPT) is a tool developed for research that can also be used in clinical and residential settings. The tool is a pictorial thermometer with a numerical scale running along the side; the higher the number, the greater the pain intensity.

While the scale values may differ, what truly matters is the individual's placement of their pain on the pictorial thermometer. For care providers, using a consistent thermometer is essential to ensure continuity and reliable interpretation over time.

Caution is needed when using this tool, as it demands conceptual thinking and cognitive ability, which may make it unsuitable for some people with a learning disability.

This tool, developed by Gregory et al. (2017), is useful for assessing pain in people with learning disabilities. The Bolton Pain Assessment Tool (BPAT) combines elements from other tools and prompts to elicit carers' opinions.

BPAT was well-received and used across clinical and residential settings. It is recognised as being easy and quick to use, and even though family involvement is limited, it is still relevant.