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12 Articles in Volume 11, Issue #1
Simultaneous Use of Stimulants 
and Opioids
Therapy for Management of Childbirth Perineal Tears and Post-Partum Pain
Measuring Clinical Outcomes of Chronic Pain Patients
Real-Time Functional Magnetic Resonance Imaging in Pain Management
A Non-Surgical Treatment for Carpal Tunnel Syndrome
Fibromyalgia, Chronic Widespread Pain, and the Fallacy of Pain from Nowhere
Sonoanatomy and Injection Technique of the Iliolumbar Ligament
Back Surgery That Does Not Relieve Pain
The Immune System and Headache
Diversity in Pharmacologic Treatment of Pain
Memantine for Migraine and Tension-Type Headache Prophylaxis
Pain Management in Inflammatory Arthritis

Measuring Clinical Outcomes of Chronic Pain Patients

A new simplified, easy-to-use, self-reporting score card, SPAASMS, measures changes in activity/mobility, pain medication levels, physician/ER visits, sleep quality, mood, and medication side-effects.
Editor’s note: To date, the only wide-scale assessment tool for treatment of chronic pain has been the 1 to 10 scale with 1 being no pain and 10 being the worst. While this evaluation, now known as the fifth vital sign, is important, it only measures treatment progress at one point in time. In order to better evaluate treatment progress, the authors developed a short questionnaire that succinctly and quickly measures progress in activity and mobility, need for additional pain medications, sleep, need for additional visits, and mood. We present their questionnaire as an effort to have other practitioners adopt it or create a similar assessment tool.

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

Additional Medication 


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.


Sleep


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


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

Side Effects


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


Study Design


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

Figure 1. Scatter plot (with line of equality) for test–retest results of 20 patients to confirm repeatability and consistency of patient self-reporting.

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.


Methods

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:


  • opioid naïve,

  • had chronic pain for more than one year,

  • experienced pain for the greater part of the day or night,

  • deemed appropriate for treatment with transdermal patches.


The patients were titrated to optimal doses of medications and followed up every three months by the same clinician who evaluated the patients’ progress independently over the nine months. During the course of treatment, the patients were asked to keep a record of any additional medicines or doctor visits/emergency room visits that they made for break-through pain and also record any changes in daily activities. The patients were monitored monthly for nine months by a telephone interviewer using a predetermined, structured questionnaire. Patients completed the VAS, DASS21 and PDI questionnaires every three months for comparison with SPAASMS. The final scores of SPAASMS were recorded and the results were collated. 



Results

Figure 2a. SPAASMS score was lower than VAS throughout the study.

The comparison of SPAASMS percentile scores with the intensity of pain using a VAS score showed a similar trend (see Figure 2a). Initial percentile scores for SPAASMS and VAS were almost identical. However, with initiation of treatment, SPAASMS percentile scores were persistently lower with differences at six months being statistically significant (P <0.05). 


Figure 2b. No statistically significant difference between SPAASMS and PDI scores for physical dysfunction were detected throughout the study.

R-square for the correlation between SPAASMS and PDI was 0.84 (P =0.085). We assume that SPAASMS reflected a greater response to treatment as it included other components of chronic pain assessment. In Figure 2b, PDI and SPAASMS percentile scores both showed a decrease. However, the SPAASMS percentile score was lower than PDI and may suggest a better reflection of the treatment response. Physical disability as reflected by the multidimensional PDI may not be directly related to chronic pain intensity. However, global physical activity levels as reflected by improved ADL are related to pain intensity. 7 Functional improvement in disability may not immediately follow an improvement in nociception due to other factors such as de-conditioning, wasting of muscles or depression. 23

Figure 2c. DASS21 scores were lower than SPAASMS for the duration of the study.

The SPAASMS scale indicated a general tendency in improvement that was maximal at the end of third month as compared to DASS21 (see Figure 2c). However, DASS21 seemed to be a more sensitive indicator for mood since it has components to measure different aspects of psychological distress of depression—including anxiety and stress. No significant difference between SPAASMS and VPD—the combined VAS, PDI, and DASS21 scores—was found (see Figure 3). During the initial three months, SPAASMS and VPD scores declined progressively signifying a successful response to treatment. All these changes were more marked in the SPAASMS score than the combined VPD score.


Figure 3. The SPAASMS score was compared with a combined score, VPD, that combined VAS, PDI, and DASS21 (n=24). To normalize values for comparison to SPAASMS, the combined VPD was calculated out of a maximum of 16 as follows: 10 for VAS, 3 each for PDI and DASS21 in percents. All data were represented as a mean score ± standard error.

Conclusion 


The study demonstrated that the SPAASMS score card—having the advantages of being a simple, time efficient, clinical assessment tool—was comparable in accuracy to other validated tools and one which patients found simple to use. The score card could be reported by phone or during consultation. Further, the patient could be shown objective progress regarding treatment response over a period of time.


The sub-scale scores (domain level), indicated specific symptoms of chronic pain, to which the patient had not responded. Further assistance could then be provided, addressing the particular need. Possibly this was an important advantage of the tool. 


We propose that the SPAASMS score card be used as a reliable clinical tool for a rapid measurement of chronic pain symptoms. Patients’ satisfaction was not factored in this scoring. Further refinement of the structure and component of SPAASMS may be considered in the future.

Last updated on: March 7, 2011
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