What should I include in my pain assessment?

With such a wide array of factors influencing a person’s pain experience, it can be difficult to decide exactly what to include in a pain assessment.

We do know that the model we use to view pain will influence the factors that are included – and although the internationally accepted model of pain is a biopsychosocial one, there are any number of versions of this model that can be adopted.

Within each domain of the biopsychosocial model the research over the past few years has exploded, meaning there are more and more factors than can be considered – and these need to be organised in a systematic way so that we can make sense of them, make good clinical decisions about interventions and then work with the person who has the pain so they can understand them and contribute.

There are a couple of fundamental things we should always have as guiding principles:

  1. No single element in the biopsychosocial model of pain is more (or less) important than any other
  2. All three domains must be assessed to fully understand the ‘four p’s’ of a pain presentation:
    1. Predisposing factors
    2. Precipitating factors
    3. Perpetuating factors
    4. Protective factors
  3. The fundamental questions to be answered through assessment are
    1. ‘What brought this person to this place with this problem today?’
    2. ‘What can be done to reduce distress and disability?’
  4. Simply asking the person with pain provides some good information, but on its own is probably inadequate.  Interviews need to be supplemented with:
    1. History – from relevant documentation (from the referrer, other health care notes, previous consultations within your facility)
    2. Observation – structured or unstructured observation from the moment the person enters your clinic, to the time they leave
    3. Clinical examination or testing – including functional performance as well as pen and paper questionnaires
    4. Other people – particularly partners or other family members
  5. Assessment only begins the process of developing a working set of hypotheses about what might be ‘true’ for this person at this time for these problems

A couple of models that can be helpful:

This one is from Robert Gatchel (Gatchel, 2004).

, American Psychologist, 59, 792–805.

Another model I like is by Tim Sharp, published in 2000, which is somewhat less complicated than Gatchel’s one, but still has a whole lot of arrows!  Dr Sharp now runs a successful consulting practice listed in my blogroll, worth a look!

Of course, no matter what model you use, under each ‘heading’ you will need to continue to update relevant research into specific factors to include (eg ‘appraisals’ would now routinely include catastrophising and pain-related anxiety, while ‘motor behaviours’ would include avoidance, safety behaviours, as well as task persistence).  And after deciding what to include, it will be just as important to determine the best way to access the information – through questionnaire, observation, history, testing or interview.

Finally, it will be important to work out a structured way to put the information collected together so it can be readily understood and used as the basis for hypothesis testing.

I’m not sure I’ve got a handle on this part yet – but I’m keen to hear what you use, or how you think this part can be structured.  I think we’ll have to draw on research from small group/teamwork literature into decision-making, and on human cognition and information processing to inform us on the best way to integrate such complex information without jumping to conclusions.

Isn’t it great the way that answering one question leads to a whole lot of new bits of research?  Can ya tell how much I love questions?!

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Gatchel, R. (2004). American Psychologist, 59, 792-805

Sharp, T. (2000). Chronic pain: A reformulation of the cognitive-behavioural model.  Behaviour Research and Therapy, 39, 787–800

Gatchel, R. J.(2004), American Psychologist, 59, 792–805

A couple of interesting pain sites

It’s been a while since I linked to pain websites, so I did a little trawl through the web pages to find these ones.

The NPEC (National Pain Education Council) has some FREE resources – notably some pdf documents on Patient forms, several pain assessment tools, two functional assessment tools, and two quality of life measures. Worth a look – and if you go to the home page, and are prepared to log in, there are some CME activities, and it’s FREE!

If you’ve ever struggled to find a pain assessment, Hardin Library at the University of Iowa describes some search strategies that can be used in common databases – and a bunch of web-based health assessment resources – so it’s a great place to go to refine your search techniques. You will need to have a way to obtain the commercial assessments, but for many pain assessments, you can find the original research article and either contact the researcher direct, or find out the place to buy the assessment if that’s necessary.

For the ACC (in New Zealand) ‘Pain Assessment Compendium’, you can go to the ACC ‘Provider publications order form’ and fill out the blanks to obtain a CD of the compendium. This provides you with a large number of psychometrically valid assessments – but be warned, they are not outcome measures, and as normal with pain measures, the normative data is North American or British, and won’t directly translate to New Zealand populations.

Chirogeek, despite the name, has some very useful resources online. Head to this page for links to four measures often used in musculoskeletal pain assessment: the Oswestry Disability Index, Roland-Morris Disability Questionnaire, Stanford Score, and the Neck Disability Index.

The final website I want to include today is the PROQOLID, or the Patient-Reported Outcome and Quality of Life Instruments Database. This lists a range of Quality of Life measures across various disabilities and describes the author, purpose, population, and other details to help you decide whether it would be helpful in your population. Details of the questionnaires are restricted to subscribers, but the summary alone is helpful – and you can always search for the original or for publishers with the name and author listed.

I hope this has been helpful – let me know what you think! And remember it’s lonely out here in cyberland – comments are always welcome and I DO respond! and you can subscribe using the RSS feed and/or bookmarking. I post most days except the weekend – so there’s usually something new to read!

The impact of pain management on quality of life

What exactly is quality of life? And what is pain management? This article, presented at a 2002 Roundtable on ‘The role of coxibs in successful pain management’ is written by a medical researcher, which should give you a bit of a clue about how pain management is defined for the purpose of this paper (i.e. pain control). Much of the discussion about quality of life measures, however, is useful, and the article itself is reasonably short – and it talks the language of doctors, which I thought gives an interesting slant.

Firstly, the point is made that quality of life involves assessment over multiple dimensions, with the World Health Organisation’s ‘Domains and factors of quality of life’ being used as an example of the domains that can be considered. For those who haven’t reviewed this recently, there are six domains:
1. Physical
2. Psychological
3. Level of independence
4. Social relationships
5. Environmental health
6. Spirituality
and a final ‘general’ facet that evaluates ‘overall perceptions of health and quality of life’.  This link to WHOQOL leads directly to the Seattle Quality of Life Group website.

The point is made that pain affects cognitive, motivational, affective, behavioural and physical components, and quality of life has a similarly all-encompassing nature. Katz points out that ‘quality of life … can be defined as an individual’s ability to perform a range of roles in society and to reach an acceptable level of satisfaction from functionoing in those roles’, but at the same time recognising that quality of life research is relatively new, and the effects of pain on quality of life is only just beginning to be investigated.

When we’re choosing any assessment tool, there are some practical things to consider – quite apart from the psychometric properties of the instruments we may think of. Katz nicely identifies some considerations:
1. Which is more applicable – a disease-specific or generic instrument? He identifies that there are both advantages in specific measures (for example, able to detect more subtle change) as well as disadvantages (difficulty comparing across patient groups). The SF-36 (Medical Outcomes Study Short Form 36) is suggested as a general health status measure that combines the ‘best’ of both worlds.
2. What dimensions of quality of life need to be measured? Katz acknowledges that quality of life measures are multi-dimensional since ‘an instrument that does not include several dimensions will make it impossible to determine the nature of a score change’. The areas of physical, psychological, social, somatic, and spiritual are thought to be important, and again the SF-36 is identified as a key contender because of the breadth of dimensions included.
3. How much responder burden is acceptable? This refers to the amount of work needed to complete the questionnaires – an important consideration when we recognise that many people don’t like paperwork, or have relatively low reading levels.
4. What administrative issues need to be considered? Ahhh, now that’s an excellent point! A very comprehensive database that I know of has been abandoned from time to time because of difficulty obtaining clerical time to score and enter questionnaires, and in the mists of time, some of the original scoring ‘rules’ have been lost… Questionnaires used in pain outcome measurement need to be applied at least twice, more appropriately three or four times – and ‘compliance’ or the number of people who complete all of the measures all of the time reduces over time…
5. Has the instrument been validated, and is it reliable? Well, this goes without saying… and should be a ‘given’ for people working in the area of pain management.

There are a number of issues that this paper does not cover well.
Firstly, there is an assumption that if quality of life is reduced when pain is experienced, an individual’s quality of life should improve simply by reducing pain intensity. While this intuitively makes sense, it assumes that pain intensity alone is responsible for loss of quality of life. Reports of pain intensity are influenced by things like psychological distress, fear of injury, fear of being out of control, low mood, health anxiety and so on (e.g. Severeijns, Vlaeyen, van den Hout & Weber, 2001). When analgesia is used, while it may reduce pain intensity it may not address underlying issues such as low mood, health anxiety, and most especially fear of injury. The latter is one reason some patients tell me they don’t want to take medication, because it ‘masks’ pain!

Katz suggests that ‘analgesic agents should be compared … incorporating the use of symptom distress scales, which may be the most sensitive way of discriminating among analgesics in effects of quality of life’. I suggest that distress scales may not be the most appropriate measure of effectiveness in quality of life, and in fact changes across several domains such as Physical, Psychological, Level of Independence, and Social Relationships should be observed before an intervention should be considered ‘successful’.

Another issue is that although Katz indicates that taking repeated measures is important, he makes little mention of the need for longer-term followup. At least part of the initial response from any intervention is likely to be due to the ‘meaning response’, or expectancies or placebo response that people have simply from having been given a treatment. As a result, it’s important to measure changes in quality of life (and any other outcome measure) some months or even years later after the treatment is first initiated. The risk otherwise is that an initial lifting of mood, sense of hope, even physiological changes secondary to placebo can subside over time – and in the end, it’s the effects that are sustained that are important.

However, it’s difficult to argue with Katz on this: quality of life measures should be included as a key variable in future pharmacological research. Personally, I think it should be included as an outcome measurement of any pain management intervention.

For further information on a broader range of outcome measures that are being considered for pain management, this article by Dworkin and colleagues provides some insights into the areas that the IMMPACT group recommend: (1) pain; (2) physical functioning; (3) emotional functioning; (4) participant ratings of improvement and satisfaction with treatment; (5) symptoms and adverse events; and (6) participant disposition.  Worth a read – and they’re continuing to publish more on this area.

Katz, N. (2002). The Impact of Pain Management
on Quality of Life. Journal of Pain and Symptom Management, 24(1S), S38-S47.

Severeijns, R., Vlaeyen, JWS., van den Hout MA., & Weber, JWA., (2001)Pain catastrophizing predicts pain intensity, disability, and psychological distress independent of the level of physical impairment. The Clinical journal of pain vol. 17, no2, pp. 165-172

Self regulation readings

Self regulation is a concept we often use in pain management and in other areas of therapy where setting and achieving goals is a key aspect.

This post by Dale Schunk provides an excellent overview of some of the main areas in the approach, and includes a definition I particularly like Self-regulation, or systematic efforts to direct thoughts, feelings, and actions, toward the attainment of one’s goals (Zimmerman, 2000)

Albert Bandura is a well-known Canadian scholar who researches self efficacy and social cognitive theory. His theory of self efficacy and motivation is drawn on as a contributor to the self regulation construct. For more on his life, go to this site , and if you’re interested in Self efficacy in more detail, that site also has a good number of resources. I particularly liked this post on Ability vs Capability.

Self determination theory is a macro-theory of human motivation concerned with the development and functioning of personality within social contexts. The theory focuses on the degree to which human behaviors are volitional or self-determined – that is, the degree to which people endorse their actions at the highest level of reflection and engage in the actions with a full sense of choice.
Once you get past some of the psychobabble, this site has some great resources including validated questionnaires on self-regulation for healthcare, academic and exercise that have been developed for research.

When we develop new habits, we need to use self-regulation to become aware of how we are currently functioning, what we want to do that is new, and then monitor what we do and how close we get to our new behaviour. Senia Maymin’s post provides a good review of some of Baumeister’s theory, and encourages us to recognise that by developing self regulation and mastery in one area, we strengthen our ability to self regulate in all areas! So setting goals and achieving them in one area makes it easier to apply that same discipline elsewhere in life. Good to know!

Finally for today, Hall and Fong’s paper Temporal self-regulation theory: A model for individual health behavior from Health Psychology Review Volume 1, Issue 1 March 2007 , pages 6 – 52, provides a description of a model that frames behaviours depending upon the timescale being considered at the moment of choice – this, it is argued, can explain why so many people ‘know what to do’ that is best for health in the long term, but actually do things that are self-defeating, and have a short-term positive payoff.

I hope you enjoy this quick swing through some brief readings in self-regulation. There will be more as time goes on, so don’t forget to come on back and check in again to see what I’ve included in this roundup. If you haven’t already, remember you can subscribe to my blog using the RSS reader at the top of the page, or you can bookmark. And don’t forget to comment – I am always happy to read that someone’s reading this blog!!

Chronic Pain Assessment and Measurement

Ask anyone who has worked in chronic pain management for a while about assessment tools or measurement and you’ll see the eyes roll – how many assessment questionnaires do we need???

Firstly I want to clarify what I mean by assessment, and the difference between that and measurement.

Measurement is all about quantifying something – how much, how often, is there more of [x] than [y]? did [a] have an effect on [b]?

The problem in pain is that because pain is an individual, subjective, personal experience we can’t directly measure it. We have to extrapolate from something observable to something that can’t be seen. This means we are really measuring correlates of the pain experience rather than pain itself.

Pain assessment, on the other hand, is about learning more about the qualitative experience of pain.

In pain assessment, I am forming a ’rounded’ picture of the individual and the factors that may be associated with the experience, and hoping to answer the question I have of ‘why did this person present to me in this way on this occasion?’ I collect information over a range of domains including biophysical, psychological and social – and rely on other members of the team to help complete the picture through their assessments (I focus on psychosocial and functional).

What difference does it make?

  • Pain measurement is really helpful when trying to quantify improvement, difficulties, or to establish whether this person is more or less severely affected by their pain. Measurement is important when trying to determine whether an intervention has achieved anything (eg outcome measurement), or whether to provide a person with a certain type of treatment (eg will this person respond to anti-depressant medication?). Measurement on its own, however, won’t make any difference to your rapport, empathy or quality of your intervention. It won’t necessarily help you to understand where this person is coming from nor to prioritise your interventions.
  • Pain assessment should directly help you establish the beginning of a case formulation, or working hypotheses, about the factors that may be influencing this person’s presentation – and in doing so, should help you develop some understanding of how the problems have arisen, how they are affecting the individual, how they are being maintained, and what intervention priorities you may have.

What tools can you use for pain measurement and assessment?

Hmmmm! well there are literally 100’s of pen and paper and other measurement instruments in pain…where to start? Before I answer this, there are quite a few questions to ask yourself…

  • If you’re assessing an individual, you may not want to use any formal measurement tools – quite simply psychometric tests can’t provide you with anything more than what your patient/client is prepared to tell you. They are not X-rays of the mind! They simply organise information, may be a little more efficient at times than interview, and they should (if well-developed) be reliable (measure the same thing the same way each time they’re used), be valid (measure what they say they’re going to measure), and help you compare this person with other people who have taken the same questionnaire (provided the original group with whom you are comparing this person is somewhat similar to your client/person!).

In choosing questionnaires or measurement instruments, it’s important to ask yourself – what do I really want to find out? Why might I use a pen and paper tool when I could ask the question? What is the burden on the patient/client to fill out this questionnaire? Can I interpret it? What does it mean if I do interpret it? What does a certain score actually mean? Can it predict anything? I can use it as an outcome measure? How do I report the findings?

    Behavioural measures are not nearly as readily available, nor used, as pen and paper questionnaires. This is partly because they are time-consuming to do properly, and often involve recording the person using video or photographs, then reviewing and scoring. Training to complete behavioural measures accurately is essential to ensure inter-rater reliability (like calibrating any other measurement instrument!). The predictive validity of behavioural measures such as Functional Capacity Evaluations or Assessments has not been well-established, and it’s important to recognise that these measures are only an indication of what this person is prepared to do on this day, not ‘lie detectors’! There is no way to determine whether someone is ‘malingering’ or ‘faking’ or ‘symptom magnifying’ – and health providers should not allow themselves to try to make this type of determination, it probably belongs with investigators rather than in health.

    A great reference for assessments that may be used in pain, and including a wealth of information on concepts such as validity, reliability and so on is the Handbook of Pain Assessment (2nd Ed, 2001) Edited by DC Turk and R Melzack, published by The Guilford Press.
    This mighty tome contains 100’s of full versions of many of the assessment tools that have been used in pain and pain management. More importantly is the reference to the original articles for these tools. To be really ethical about using psychometric assessments and measures, it’s vital to read the original research, and subsequent published literature about the properties and normative data associated with the measure.

    I’ll write more about assessment and case formulation soon – keep coming back for more, or if you don’t want to miss, you can subscribe using the RSS feed above. If there is a specific assessment or measurement tool you’d like to learn more about, put it in the comments and I’ll do my best!