Measuring Clinical Outcomes of Chronic Pain Patients
Pain is a multidimensional subjective experience 1 and has profound effects on the health and quality of life. 2 Since pain is very subjective, there is no direct measurement tool to assess the intensity and distress of pain.
It is essential for physicians treating chronic pain to assess pain using indirect markers. A simple effective tool would help to optimize clinical practice and treatment outcomes for patients. 3 Such a tool should be sensitive, reliable and valid, as well as easy to use in a clinical setting for patients and health professionals alike.
The effects of chronic or intractable pain may include poor sleep, restricted mobility, decreased activity, poor mood, greater use of medications and more health practitioner visits. 4 The authors have devised a simple bed-side tool to aid physicians in assessing outcomes of chronic pain treatment by taking into account the dimensions described above. This tool, with the acronym SPAASMS (S- Score for pain, P- Physical activity levels, A- Additional pain medication, A- Additional Physician/ER Visits, S- Sleep, M- Mood, S- Side effects), allows quick, simple scoring across these dimensions (see Table 1).
SPASSMS Measurement Domains Score For Pain
The visual analog pain scale (VAS) is commonly used to assess the subjective intensity of pain (where 0 is no pain and 10 is agonizing pain).
Physical Activity Levels
Physical activity levels are considered an important factor in pain assessment and could indicate functional outcomes such as improved activities of daily living (ADL) like household chores, walking, working or travel. 5-8 In 1985, Linton found that physical activity and pain levels could be correlated only when based on overall physical functioning. 7 A recent study found that more than two-thirds (68%) of the persistent pain patients considered improvement in daily activities as necessary for a successful outcome. 8
The results of a Finnish study indicated that daily or continuous pain of high intensity resulted in increased frequency of analgesic medication use. 9 Historically, successful pain management has been indicated by decreased frequency of medication use. 10 We postulate that decreased frequency of medication—especially short acting opioids—would follow decreased pain intensity and decreased frequency of pain flares as a result of successful pain management.
Additional Physician/ER Visits
A study in the UK concluded that medically unexplained abdominal pain, chest pain, headache, and back pain accounted for a significant proportion of consultations in secondary health care facilities. 11 We considered that a patients’ frequency of physician and/or ER visits for pain relief should also be one of the factors used in assessing effectiveness of pain management for chronic pain.
Studies have demonstrated an inverse relationship between sleep quality and pain, 12-13 Insomnia has been found to increase the severity of pain. 14 Another study confirmed that, in comparison to healthy controls, subjects suffering fatigue and pain experience poor sleep. For improvement in chronic pain to be inferred, sleep issues need to be measured and reduced. Whether they are a cause or consequence of the pain condition, sleep disorders need to be treated concomitantly with pain. 15
Mood is defined as a state of mind or emotion. A World Health Organization study showed that 22% of primary care patients are suffering from constant debilitating pain and are four times more likely to present with a depression or anxiety mood disorder than patients without chronic pain. 16 Patten et al, in a large scale study in Canada, showed that long-term pain increases the risk of major depression. 17
Opioid use results in a range of adverse, unpleasant side effects of which nausea, constipation, vomiting, drowsiness and cognitive impairment of varying degrees have been reported by patients. 18 The use of other synthetic and semi-synthetic opioids like transdermal fentanyl and buprenorphine for treatment of chronic pain has added to the list of unwanted side-effects including local irritation, rashes and skin eruptions. 19-20
A study was designed to test the feasibility of using SPAASMS scoring to include the common dimensions of chronic pain in the assessment of patients to indicate treatment efficacy and outcomes over time.
The SPAASMS score was designed to measure the direct and indirect markers of chronic pain across the seven domains previously mentioned. For simplicity and ease of administration, each component was self-reported by patients with intensity of pain rated on a VAS 0 to 10 (where 0 is no pain and 10 is excruciating pain) and the remaining components rated on a scale of 0 to 3, depending on the severity of symptoms. SPAASMS was recorded and scored to a maximum of 25 at the initial
baseline assessment before starting the treatment (since it excluded the side effects of medication component). A test-retest was performed to confirm consistency and repeatability of the patients’ self-reporting of baseline data (see Figure 1). Subsequent SPAASMS scoring was to a maximum of 28 to include the side effects component (see Table1).
Comparison to Other Validated Tools
A study was conducted to test how the SPAASMS scale would perform in comparison to other validated tools—Depression, Anxiety, and Stress Scales (DASS21), 21 Pain Disability Index (PDI), 22 and VAS—in reporting treatment efficacy for chronic pain patients. DASS21 is an internationally–validated tool to assess depression, anxiety and stress symptoms. PDI is a measure for disability and VAS is the familiar visual analog scale for pain reporting. Concurrent validity was assessed via the correlation between SPAASMS, VAS, DASS21 and PDI measured at three-month intervals over a period of nine months.
Twenty-five adult patients (16 male and 9 female) with a mean age 47.96 years (± standard deviation of 13.27) who were being treated for chronic pain (mean duration 13.52 years ± SD of 12.87) were recruited at the Townsville Hospital Pain Management Clinic in Townsville, Australia (see Table 2). Their progress on treatment was studied using the SPAASMS scale. For uniformity, patients recruited met the following criteria: