5ch. Pain Assessment

5ch. Pain Assessment 경희의료원 마취통증의학과 R2 전주연

Type of self-Report Pain Scales Verbal Rating Scale(VRSs) Numerical Rating Scale(NRSs) Visual Analogue Scale(VASs) McGill Pain Questionnaire(MPQ) Pain Relief • Behavioral Observation • Experimental Pain Assessment • Psychophysiological Assessment • Special Population • Biases in pain measurement

Type of self-Report Pain scales • Verbal Rating Scale(VRSs) • series of adjectives, ordered from least intense(or unpleasant) to most intense(or unpleasant) • Strengths 1)simplicity, ease of administration and scoring 2) easy to comprehension : compliance rate 높다. (within certain populatin such as elderly) 3) good reliability

Verbal Rating Scale(VRSs ) • Weaknesses 1) Equal intervals between adjectives from None to mild equal from moderate to severe (often violated) Difficulties in both interpretation and analysis of VRS-derived data 2) A patient must both be familiar with all of the words used on the scale and must be able to find one that accurately describes his or her pain.

Numerical Rating Scales(NRSs) • NRS consists of a series of numbers with verbal anchors representing the entire possible range of pain intensity • from 0 to 10, from 0 to 20, or from 0 to 100. ( 0 represent “no pain” 10,20,100 represents the opposite end of the pain continuum.)

Numerical Rating Scales(NRSs) • validity; they correlate positively with other measures of pain and sensitivity to treatments that are expected to affect pain. • verbally or in a written format, is simple and easily understood, and is easily administered and scored • Weakness : it does not have ratio qualities

Visual analogue Scales(VASs) • consists of a line, often 10cm long with verbal anchors at either end(“no pain” on the far left and “the most intense pain imaginable” on the far right) • Recent versions include the mechanical VAS, which uses a sliding • marker superimposed on a horizontal VAS drawn on a ruler and • is easily scored from the back, which includes numbers for each • marker placement.

Visual analogue Scales(VASs) • Validity 1) sensitive to treatment effects. 2) correlate with pain behaviors and do show ratio-level scoring properties • limitation 1) perceptual-motor problems환자에게 적용 어려움. 2) Using ruler : making scoring more time- consuming and adding additional possible sources of bias or error. 3) Relative to other rating scales, use of a VAS produces higher non-completion rates. (cognitive limitations and among elderly )

McGill Pain Questionnaire(MPQ) • MPQ, or its brief analogue the short-form MPQ, are among the most widely utilized measures of pain. • MPQ is considered to be a multidimensional measure of pain quality. • three dimension : sensory-discriminative, affective-motivational, and cognitive-evaluative • It consists of 20sets of verbal descriptors : divided into sensory(10sets), affective(5sets), evaluative(1set) and miscellaneous(4sets)

McGill Pain Questionnaire(MPQ) • Short form of the MPQ(more frequently use) • 15 representive words form the sensory(11items) and affective(4 items). Each descriptor is ranked on a 0(“none”) to 3(“Severe”) intensity scale. The VRS, along with VAS, is also included.

Pain relief • Studies of interventions designed to reduce pain often include a post-treatment assessment of pain relief • VAS, VRS with gradation of relief (eg, none, slight, moderate, complete) • NRS assessing the percentage of relief. • Overreporting of relief : 90% of patients reported some degree of relief on a VAS. (due to in part to a memory for past pain as being substantially greater than previous ratings)

Behavioral observation • Peaple in pain may communicate their discomfort by vocalization, body postures, and actions. • Numerous pain behavior coding systems. For example, OA pain behavior coding system assesses the position, movement, and specific pain behavior. • Assessment of pain behaviors can be valuable in establishing a patient’s level of physical functioning, in analyzing the factors that may reinforce displays of pain, or in assessing pain in nonverbal indivisuals. • Chronic pain – acute pain에 비해 pain report and pain behavior사이에 연관성이 더 떨어진다.

Experimental pain assessment • Noxious stimulation의 administration • Noxious stimulation induce Pain(thermal, mechanical, electrical, chemical, ischemic,etc); typical parameters that are measured include pain threshold, pain tolerance, and rating of suprathreshold noxious stimuli using an NRS,a VAS, or a VRS. • Quantitative sensory testing – subtype patients with chronic pain. , to identify mechanisms of chronic pain, and to predict prospectively postoperative pain

Psychophysiological assessment • 1) They are a prerequisite for performing biofeedback or related procedures in which patients are taught to bring physiological processes under some degree of voluntary control. • 2) psychophysiological measures can help to elucidate some of the concomitants of pain not easily measured by self-report.

Psychophysiological assessment • EMG Often used to record local muscle tension in the context of musculoskeletal pain synd, such as low back pain or tension headache. • EEG Assess brain responses to noxious stimulation. EEG-measured cortical responses are eahanced in patients with chronic pain relative to healthy control. • BP and HR are frequently assessed in the context of experimental pain administration. ( but, resting BP and pain response are inversely correlated, no consistent relationship between cardiovascular reactivity and pain responses.

Special population • Children ( cannot reliably provide information about their pain.) • Behavioral pain rating scales for infant : NIPS(Neonatal Infact Pain Scale) Facial expression, crying, breathing, arm movement, leg movement, and arousal state. • Older children : Direct questioning (“How is your pain?”) • Standardized pain assessment scale 1) Faces scale and the Oucher scale – not require language and are used for younger children 2) Pain thermometer – consisting of a vertical NRS superimposed on a VAS shaped to resemble thermometer • 6세 이상 어린이 – standard VAS is a valid and reliable measure

Special population • The elderly • Increasing age is associated with a higher frequency of incomplete or non scorable responses on a VAS, but not on a VRS or NRS. • In addition, MPQ is inappropriate for use in elderly due to its complexity and time requirement. • Collectively, recent finding suggest that a VRS produces the fewest “failure” responses among samples of cognitively intact and cognitively impaired elderly subject.

Biases in pain measurement • Inaccurate assessment • Underestimation of pain-improper treatment, Unnecessary suffering, delay in recovery • Overestimatioin of pain-over-treatment and adverse iatrogenic consequences.

Summary and recommendation • private and subjective experience, a wide array of valid and reliable measurement tools is available. • At least one self-report measure, and it is often beneficial to use either multiple measures or a multidimensional measure of pain. • Assessment of pain in vitally important to both clinicians and researchers. Self-report is the most direct manner of assessing pain. • Measures should be selected with as complete a knowledge as possible of their properties, strengths, and limitations.

6ch. Psychological Evaluation and Testing

Psychological evauation • Psychological assessment/testing Disability/Impairment Negative affect Coping Multidimensional instrument Measures of psychopathology • Specialized assessment Invasive Therapies Chronic opioid therapy

Psychological evaluation • Include an examination of psychological aspects of the pain experience and more comprehensive psychiatric interview to diagnosis current or past psychiatric disorders, particularly depression. • This assessment will focus upon the intensity, frequency, and affective and sensory quality of pain, as well as the efficacy of previous treatment intervention. • Because of the high coprevalence of chronic pain and major depression, all depressive symptom be carefully assessed. And practitioners assess symptom of anxiety, alcohol and substance abuse and dependence, personality disorders, and any relevant family psychiatric history.

Psychological assessment/testing • Disability/Impairment • Brief Pain Inventory(BPI): measure pain severity and pain-related interference in patient with cancer in many different countries.(recently non-cancer patient) • the pain interference scale uses 11point numeric rating scale(0=no,10=interference completely) • Pain related interference in seven area: general activity, mood, walking ability, normal work including outside the home and housework, relations with other people, enjoyment of life, and sleep.(from “the past week” to “the past 24 hours”) • The BPI has been used to demonstrate the efficacy of pain medication in a variety of chronic painful conditions and appears to be sensitive to change due to treatment.

Disability/Impairment • Pain disability index(PDI) 7 question : family/home, recreation, social activities, occupation, sexual behavior, self-care, and life support activities.(0~10) Sensitive to change following pain treatment – improvement in each area of role functioning, except life-support activitites. • Sickness Impact Profile(SIP):136items separated into 12scales: sleep, rest, eating, work, home management, recreation, pastimes,ambulation, mobility, body care and movement, social interaction, alertness behavior, emotional behavior and communication. • Roland-Morris Disability Scale(24 of the original SIP items) Developed as a measure of function in back pain. Assessment of irritability, appetitie and housework

Negative affect • Often result from chronic pain and unduly influence its experience • Beck Depression Inventory(BDI) 1) 21item, multiple choice measure that requires indivisuals to endorse one of a series of four statements which best describes his or her subjective experience. 2)Alteration in mood, a negative self-concept associated with self-devaluation and self-blame, self- punitive wishes, vegetative symptoms, and alterations in activity level. 3)장점 : Brief and easy to score and interpret 4)단점 : Overestimate the degree of depression among chronic pain patients (∵focus on a number of somatic and vegetative symptoms.)

Negative affect • Center for Epidemiological Studies Depression Scale 1)Report the frequency with which they have experienced each of 20 symptoms during the past week on a 4 point scale. 2)장점 : Brief and excellent psychometric properties 3)단점 : Overestimating the prevalence and severity of depression. • CES-D; greater sensitivity, BDI; better specificity

Coping • Definition: encompasses the many techniques that people utilize to attempt to control or tolerate stressors, including the experience of pain • Coping Strategies Questionnare 50 item measure assessing 6 cognitive and 2 behavioral coping strategies including (1) diverting attention, (2) reinterpreting pain sensation,(3) coping self-statements,(4)ignoring pain sensation (5)praying and hoping (6) catastrophizing,(“I feel I can’t stand it anymore.”) (7) increasing behavioral activity, and (8) increasing pain behaviors. • Chronic pain Coping Inventory 65-item scale has subscales including guarding, resting ,asking for assistance, relaxation, task persistence, exercise/stretch, seeking social support, coping self-statement, and medication use

Multidimensional instruments • Multidimensional Pain Inventory(MPI) 1) 56item measure is comprised of three sections and examines multiple pain domains including pain severity; interference of pain with daily activities; work;family relationship and social activities;pain-specific support form spouse; perceived life control; and negative affect 2) Valuable in its ability to assess multiple dimension of pain, its comprehensive focus on psychological, behavioral,and social factor, its relative brevity, and its demonstrated sensitivity to treatment. • Short Form 36 Health Survey(SF-36) 1)36 item self-report measure of health-related quality of life yielding 8 subscales 2) Although not specific to pain, an advantage of the SF-36 is the opportunity to compare scores for different diagnostic groups.

Measures of Psychopathology • Minnesota Multiphasic Personality Inventory (MMPI)-2 1)Ten clinical scale which assess psychopathology and three validity scales. 2)Weakness : Its length(566items), frequency of items relating to physical symptoms, and lack of predictive validity among populations with chronic pain • Symptom Checklist 90-Revised(SCL-90-R) 9 different types of psychological disturbance and yields 3 global measures of distress.

Specialized Assessment • Invasive Therapies 1) Psychological evaluation is often recommended prior to pursuing invasive therapies. 2) Screening for major psychopathology, retardation, dementia or delirium. 3) Psychosis, suicidality/homocidality, or active alcohol or drug dependency. 4) Help educate the patient as part of preparation for informed consent, and guide both the patient and physician in identifying the indivisual’s strengths and weakness. 5) Psychological testing, a psychiatric interview, and an educational component.

Specialized Assessment • Chronic opioid therapy 1) Prior to beginning therapy, this evaluation provides a baseline assessment of the patient’s pain intensity, affective state, disability, and quality of life. 2) Contraindication for chronic opioid use current alcohol abuse or dependence, illicit or prescription drug abuse or dependence, severe major depression, or antisocial or borderline PD. 3) Psychological evaluation may be helpful for patient who exhibit problematic behavior while using chronic opioid therapy.

Summary • Assessment of chronic pain requires careful multidisplinary assessment to arrive at an optimally helpful treatment plan. • Psychological assessment and clinical interviewing can be helpful adjuncts to physicians’ evaluation.

5ch. Pain Assessment