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Better Approach to Pain Assessment Places Emphasizes on Function

January 18, 2018
A clinically aligned pain assessment tool employs a multidimensional approach that focuses on improving pain based on function rather than a single pain number.

With Cary Reid, MD, PhD, and Debra Topham, PhD, JD, RN

Since pain is a multidimensional, complex experience, a new clinical tool is being proposed to fill just such as need—one that addresses the desire to improve overall function if treatment is to be successful.1,2

That's the bottom line of our opinion piece in Pain Management Nursing,1said corresponding author, Cary Reid, MD, PhD, director of the Translational Research Institute on Pain in Later Life at Weill Cornell Medical Center in New York City.

CAPA tool assures better pain care than relying on a numerical measure of pain.

"What we advocate for is a move away from asking people to rate their pain on a 0 to 10 scale," he told Practical Pain Management, “the focus must be on the impact of that pain on a person's function. If the patient has a pain score of 8, but he is getting through a work day and going out to dinner, I am less bothered by that because it is not having a significantly adverse impact on his function."

On the other hand, he said, there may be people who are greatly impaired and unable to go about their activities of daily living despite the report of a pain severity score of just 2 or 3.

Dr. Reid presents a review of the policies and position statement that have been implemented in the past few decades, such as looking at ''pain as the fifth vital sign" and discussing why these approaches have not led to consistently improved pain management.

Beyond a Number, Using Function to Assess Pain

Dr. Reid applauded another report that also appeared in the same issue of Pain Management Nursing,2 in which researchers from the University of Minnesota Medical Center in Minneapolis reported success with a multidimensional pain assessment approach that goes beyond simply asking a patient about pain intensity—the CAPA tool for “clinically aligned pain assessment”.

The tool includes five questions centered on:

  • Comfort
  • Change in pain
  • Pain control
  • Physical Functioning
  • Sleep

For instance, when asked about function, answers can range from cannot do anything due to pain to can do everything they need to do. The tool not only measures intensity but looks at the effect on function and on sleep, as well as how well treatment is working.

CAPA is meant to trigger a conversation—without putting numbers on everything.

While many pain specialists already may have begun to move beyond assessing pain in a one-dimensional manner, this information may be especially valuable for physicians who have not found an acceptable approach or may find this new tool useful in their practice, Dr. Reid said.

Moving Away from Pain as the Fifth Vital Sign  

Pain specialists and primary care physicians alike likely well aware of how prevalent a challenge treating pain has become. In the US, about 20% of women and nearly 17% of men have pain most days or daily,3 according to data from the 2010-2011 National Health Interview.

Well-meaning guidelines have failed to help clinicians assess pain with sufficient effectiveness, Dr. Reid said. As long ago as 1995, experts were urging physicians to look at pain as ''the fifth vital sign."  Soon after, the Veterans Health Administration introduced a national strategy to improve pain treatment, including pain screening using the one-dimensional numeric rating scale (NRS).4

“However, it is important to recognize that measuring pain in that way has not improved outcomes,” Dr. Reid said, “Another initiative designed to improve pain outcomes was a method of embedding pain-focused questions in the patient satisfaction survey—another fail.

 In 2010, the Affordable Care Act linked Medicare reimbursement for hospitals to patient satisfaction rating. In 2012, the Centers for Medicare and Medicaid Services followed suit and implemented a survey that asked patients about the care they received from their providers and how well their pain was managed.5

As a result, Dr. Reid said, “the satisfaction surveys about pain became intertwined with financial incentives for hospitals,” and that may have produced pressure on providers to prescribe opioids, although research is mixed on that.1

Fast forward to 2016, when the American Medical Association voted to stop treating pain as the fifth vital sign, citing the likelihood that the initiative, along with other factors, has contributed to the driving up the reliance on opioids to reduce pain in across all settings.

Evolving Pain Assessment Solutions

That best way to assure that pain is properly addressed is by involving an interprofessional team that approaches the assessment of pain using a multidimensional approach, said Dr. Reid. Among the tools he discussed in his report, one of the most promising is the CAPA (clinically-aligned pain assessment) tool.1 Employing the CAPA tool requires a conversation between the patient and the healthcare provider, with an emphasis on how the pain is affecting daily functioning.

A team from the University of Minnesota Medical Center in Minneapolis reports on its experience with CAPA in a separate article,2 appearing in Pain Management Nursing.

"CAPA is really focused on [the patient’s] function," said Debra Topham, PhD, JD, RN, director of regulatory and compliance at the medical center and a coauthor. “What's vital,” she told Practical Pain Management, “ is the social interaction between the person using the tool and the patient.”

Given the Joint Commission requirements on pain assessment and management, which took effect on January 1, the tool will be a valuable addition for all health care providers to consider using with their patients, Dr. Topham predicted.

Originally, she said, ''the University of Utah initiated the CAPA tool through their anesthesia program," then university officials gave her team permission to use and modify it.

Topham's team rolled out the CAPA tool throughout the hospital, except for pediatrics. About 90% of the evaluations were completed by the end of the first quarter in 2014.2

Dr. Topham used a case history to illustrate the value of using the CAPA tool:  One woman who presented with chronic pain gave a rating of 10 out of 10 to describe her pain using the numerical scale. However, the patient continued to knit (one of her favorite pastimes). When the staff inquired about her ability to knit while she was in such pain, she explained that knitting was a kind of a meditation for her—a way to relieve the pain.

After CAPA was put into play at their center, Dr. Topham said, their Press Ganey score trended upward. When the staff of one medical-surgical unit within the medical center was surveyed, 80% of the 21 respondents said communication had improved after the CAPA tool was used in place of the numeric pain scale; 66% of clinicians indicated a preference for it over the NRS.2

The CAPA did not take much more time than the numerical scale,2 according to staff members at the University of Minnesota Medical Center.

Most importantly, “we found that implementing the CAPA tool changes the culture of an [institution/practice] by broadening the understanding of pain assessment beyond that of a simple pain intensity score," Dr. Topham said.

Last updated on: December 21, 2020
Continue Reading:
Numbers Don't Tell the Whole Story: Experts Say Better Pain Assessment Measures Needed

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