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11 Articles in this Series
Introduction
A PAINWeek 2019 preview with EVP Debra Weiner
Comparing Marijuana and Hemp
Fibromyalgia: What’s New in Diagnosis and Pain Management
Life Hacks to Teach Patients with Chronic Pain
Managing Pain (and Function) in Osteoarthritis: Are Patients and Physicians on the Same Page?
Marijuana: How to Proceed When Controlled Substances are Involved
Menopause Comes with More than Mood Swings - It Deserves its Place Among Chronic Pain Conditions
More APPs Are Coming to the Forefront of Pain Care
Motivational Interviewing and Its Extension into Pain Management
Revisiting Documentation
Side Chat: Modern Analgesic Trials

Managing Pain (and Function) in Osteoarthritis: Are Patients and Physicians on the Same Page?

Reported by Sunali Wadehra, MD, with Tina Doshi, MD and Srinivas Nalamachu, MD      

Patients and physicians show concordance across multiple clinical measures of osteoarthritis, including pain intensity, functional impairment, and disease severity, according to the results of a new study.  The strongest correlation between patient and physician perspectives was seen in assessments of pain intensity, whereas the weakest correlation was seen in measures of functional impairment.  A team of research scientists from Eli Lilly and Co. and Pfizer Inc. presented these findings at the 2019 PAINWeek conference held in Las Vegas. 

Osteoarthritis (OA) is a common and chronic condition characterized by joint damage that may accumulate over time.  Symptoms may increase disability among patients and reduce their quality of life.  However, disease progression does not always correlate to symptoms.  Furthermore, patients’ perspectives of their disease may not necessarily align with clinical assessments conducted by their physicians.  Accordingly, this study - which included real-world data from 866 OA patients and their HCPs - was designed to evaluate whether various clinical measures associated with OA correlated between patients and physicians.1

“These results suggest that better measurement and monitoring, and more focus on function in doctor-patient discussions may improve the management of patients with osteoarthritis,” a spokesperson from Pfizer/Lilly Alliance told PPM

iStock Photo

Rating Methods

The key measures used for analysis were pain, disease severity, and functional impairment. Subjects (n-866) were participants in the OA Adelphi Disease Specific Program during the months of February to May 2017. Both patients and physicians rated pain intensity using a numeric rating scale (NRS) ranging from 0 (no pain) to 10 (worst possible pain).   Patients reported their physical functioning using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC NRS 3.1), which assigns numerical ratings ranging from 0 (fully functional) to 10 (completely impaired) over a range of daily tasks.  Physicians also used a numerical rating scale, but they applied the ratings to patients’ overall function rather than assigning ratings per various daily activities.  Both patients and physicians rated the presenting OA disease severity as mild, moderate, or severe, with physicians also providing information on what factors influenced their rating.

Patients and Physicians Showed Some Agreement

Approximately “three-quarters of patients and physicians (74%) were in agreement on their assessment of disease severity; more than two-thirds (68%) on their overall assessment of pain; and nearly two-thirds (61%) on functional impairment,” said the spokesperson. 

Specifically, patients and physicians rated disease severity as mild (43.2% and 38.0%), moderate (44.9% and 48.1%), or severe (11.9% and 13.8%), respectively, positively correlated by 0.68.  Pain intensity averaged an NRS of 4.2 (2.5) by patients and 4.1 (2.3) by physicians, with a positive correlation of 0.73.  Functional impairment averaged an NRS of 3.3 (2.4) by patients and 3.9 (2.6) by physicians, positively correlated by 0.54.1

For outside perspective PPM spoke to editorial board advisor Tina Doshi, MD, who serves as an assistant professor of anesthesiology and critical care medicine at the John Hopkins University School of Medicine, in Baltimore. “Physicians’ and patients’ ratings of pain intensity on a numeric rating scale were fairly concordant—hardly surprising since both groups were provided with the same scale. By contrast, functional impairment was not as well correlated, suggesting physicians are less able to gauge patient function accurately,” noted Dr. Doshi. “These findings could be explained by the fact that physicians used a 0 - 10 scale to rate patient functional impairment, while patients used the more formal WOMAC index to assess physical functioning,” she continued. “As a result, physicians need to think carefully about what questions and questionnaires we pose to our patients, what information we use to form our own medical opinions, and ultimately how both perspectives influence our medical decision-making.”

Shifting from Ratings to Function  

Current standards of care for pain management require regular pain assessments.  Several well-validated pain intensity scales are readily available for use by clinicians, including the NRS applied to the study presented, as well as other commonly used metrics like the visual analog scale, verbal rating scale, or Wong-Baker FACES scale.

Srinivas R. Nalamachu, MD, founder and medical director of the Mid America PolyClinic in Overland Park, Kansas, and also a PPM editorial advisor, said he has observed this approach first-hand in the clinical setting.  “We often ask patients, ‘how is your pain?’” he said.  “But it is very subjective.  The question of whether assessment of pain should also include discussion of functional impairment is a longstanding topic in the pain management space,” he continued.  “A comprehensive scale about function and overall quality of life would give us much more credibility.”

Dr. Doshi agreed: “Assessing both pain intensity and functional impairment are important to getting a full picture about a patient’s experience and understanding both aspects can guide us toward the best treatment recommendations for the patient.”

One such scale that has been introduced to the pain management space is the Indiana PolyClinic Combined Pain Scale (IPCPS), which combines function, depression, and anxiety into its metrics.  It incorporates a modified version of a questionnaire called the Functional Independence Measure (FIM), comprised of 18 questions covering motor and cognitive functions.  However, further information is required to validate this scale so that it meets the same standards of more established options.2 

Dr. Nalamachu noted that having more comprehensive scales that incorporate domains such as function are not only useful in clinical settings, but could aid in research on best practices for care of patients suffering from pain. 

“[I]t’s important for HCPs to understand the unmet needs of osteoarthritis patients, and the impact it can have on their lives. Beyond living with daily pain, OA places a significant burden on patients – it can limit their ability to function, which can force compromises in everyday life and cause feelings of isolation, frustration and anxiety,” concluded the company spokesperson.

 

 

Sources

Robinson RL et al. Measuring the Severity of Osteoarthritis: Do patients and physicians agree? Presented at PAINWeek, September 2019. 

Arbuck DM and Fleming A. Pain Assessment: Review of Current Tools. Practical Pain Management. April 29, 2019. Available at https://www.practicalpainmanagement.com/resource-centers/opioid-prescribing-monitoring/pain-assessment-review-current-tools.  Accessed November 3, 2019.   

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