Moving Beyond Pain Scales: Building Better Assessment Tools for Today’s Pain Practitioner
Pain reduction has been one of the primary goals of pain treatment for decades.1-3 Traditionally, reduction in pain was measured by asking patients to rate their pain on a 0 to 10 visual analog scale (VAS) or numeric pain scale (NPS). A 2-point change in the patient’s pain rating (before and after therapy) was considered a successful treatment.
More recently, physicians have added improvement in function as a goal of therapy.1-3 Although not clearly defined, the term function tends to include whether the patient was able to complete activities of daily living. Another popular assessment tool that incorporates elements of both these tools has been the 5-A assessment system: (1) analgesia; (2) activity; (3) adverse events; (4) aberrant behavior; and (5) affect (Table 1).2-4
However, advances in pain management have expanded our understanding of chronic pain management and central sensitization, resulting in the need for new tools to assess control of the autonomic nervous system, normalization of the endocrine system, and elimination of excess neuroinflammation. Also, there are new assessments of pain reduction in addition to the pain score, and the term “function” has heretofore been poorly defined.
This article summarizes some of the new goals and assessments to assist practitioners in selection of pharmacologic and nonpharmacologic measures. This article also highlights some of the refinements in assessing pain reduction and improvement in functions. It is emphasized that the goals and assessment of treatment success are paramount, regardless of any specific treatment agent or measure.1,5 Also, it seems important to identify and clarify new goals and assessments, as pain management is maturing into a fixture in every community.
Better Than a Pain Score
The 0 to 10 VAS and NPS have proved invaluable in many settings, such as emergency rooms, and at the initial evaluation of a chronic pain patient. Unfortunately, the 0-10 pain score has not proved to be a reliable indicator of pain relief and control in the chronic pain patient who is in medical management. The patient naturally wants a zero score, and patients tend to always report a high pain score even when they have clearly improved and lowered their pain threshold.
I highly recommend assessments related to pain lessening or reduction in addition to the pain score (see Table 2). My favored assessment tool is asking about the attainment of pain-free hours. Equally important is a reduction of pain flares, including their severity and frequency. For example, typical questions would be “Has a pain flare(s) been severe enough to seek help in an emergency room or hospital?” and “Is the time between flares lengthening?”
The importance of reducing these pain flare episodes is multifactorial. Sleep time episodes increase in length when baseline pain is reduced. Poorly controlled baseline pain as well as pain flares may incapacitate patients so they spend the better part of a day in bed or on the couch. Chronic pain patients clearly understand the meaning of bed- and couch-bound days.
Function: Goals and Assessments
While the goal of improved function is found in every guideline of pain treatment, it is poorly defined and conceptualized. For example, the first two points in the new Centers for Disease Control and Prevention (CDC) guidelines mentions “function.” The first recommendation states: “consider adding opioid therapy if expected benefits for both pain and function are anticipated to outweigh risks to the patient.” In the second recommendation, these statements are made: “Before starting opioid therapy for chronic pain, providers should establish treatment goals with all patients, including realistic goals for pain and function,” and “Providers should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.”
Despite improvement in “function” now included in our national guidelines, the term is not defined. For example, there can be patient improvement or deterioration in physical, mental, social, or vocational function. It can also refer to “activity function” in that a common goal of treatment is to function well enough to carry out activities of daily living, which I define here as the ability to provide one’s own sanitation, hygiene, meals, finances, transportation, and socialization.
Since “function” has essentially not been defined by any consensus in pain management, practitioners should set specific functional goals for individual patients related to physical, mental, social, or vocational activities. There are some scales, such as the “Pain, Enjoyment, and General Activity Scale,” which are short and givegood information. Many practitioners, including this author, make their own scales to assess various functions.
Since there is no universal consensus on what the term “function” means, here are some of my observations and assessments:
- Severe chronic pain, particularly if the pain is constant and centralized, will depress and immobilize a patient. Patients may socially withdraw, become quite reclusive, and spend many days in bed or on the couch.
- Pain practitioners can assess activity and function quite well by simply asking verbal or written questions that inquire about activities of daily living, such as hygiene, nutrition, socializing, housekeeping, reading, sexual activity, and exercise.
- Patients may, unfortunately, want to put a good face on their activities of daily living to compliment or assuage the practitioner.
- It is recommended that functions and activities of daily living be specific and even quantitated. For example, a patient may report that her or she is doing “just fine,” but he or she is spending half of their days in bed and rarely leaves his or her house to socialize. Many also fail to eat or sleep at normal times.
- An accurate assessment of general functions and activities of daily living may often best be accomplished by interview of family members.
When pain is out of control, patients’ eating habits become atrocious. The patient may seldom eat, and when eating does occur, the meal will usually consist mainly of carbohydrates (sugars and starches). A regular eating habit of three meals a day with some protein intake is a good indicator of effective pain control.