ASSESSMENT_OF_PAIN

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quantitative assessment of the patient’s pain needs
to be routinely made by the manual therapist. The
extent of such assessment will depend upon the
assessments is the often pragmatic nature of clinical
practice. As a clinician, one needs an assessment that
is do-able, economic and does not o€end the patient.
Manual Therapy (1999) 4(4), 216–220
# 1999 Harcourt Publishers Ltd
type of patient being seen by the therapist. What
constitutes an adequate pain assessment will be
context-specific. In some cases, a purely biomedical
approach to pain assessment may be insucient
(Vlaeyen et al., 1995).
In this paper, a model for pain assessment, which
may provide a useful heuristic for clinicians, is
presented. Examples of possible assessments for each
level of the model are then presented within the
context of reliability, validity and clinical utility
parameters. Finally, the timing of di€erent levels of
pain assessment will be briefly considered.
COMPONENTS OF THE PAIN ASSESSMENT
For therapists hoping to begin assessing pain in a
more systematic fashion in their practice, the
Against such a backdrop, the author would argue
that the three essential components of pain assess-
ment are (a) a description of the pain; (b) a record of
responses to the pain; and (c) a gauge of the impact
which the pain has had on the patient’s life. Each of
these three dimensions has a range of sub-categories
which can be assessed, and for each sub-category
there are usually a number of assessment tools or
styles of assessment available. It is useful for the
therapist to be aware of the sub-categories and some
available assessment tools.
Assessments to describe pain
Assessments which describe pain are usually self-
report in style, with questionnaires, rating scales,
visual analogue scales, and drawings being used in
this context. Pain can be described in terms of its
intensity (i.e. how much pain), its quality (e.g. if it is
Review article
Assessment of pain perception in clinica
J. Strong
Department of Occupational Therapy, University of Qu
SUMMARY. With pain a frequent precipitant in individ
to adequately assess pain. At one level, pain forms an im
that a simple, reliable and quantitative pain measure be
another level, when the therapist is presented with clients
distribution, history or features, it is advisable to go be
Publishers Ltd.
INTRODUCTION
Pain features significantly in most cases seen by the
manual therapist. Manual therapists are not alone
in this territory; pain is considered ‘the primary
symptom that instigates people to seek medical
treatment’ (Turk & Melzack 1992, p3).
Given the prominence of pain, it is agreed that
Jenny Strong, Bocc Thy, Mocc Thy, PhD, Professor and Head,
Department of Occupational Therapy, University of Queensland,
Qld 4072, Australia.
21
practice
ensland, Australia
als seeking manual therapy, it is important for therapists
ortant part of the diagnostic assessment. It is suggested
used in patients who present with routine problems. At
n whom pain does not make sense in terms of its pattern,
ond a simple pain intensity measure. # 1999 Harcourt
seemingly exponential development of di€erent pain
assessments makes choosing a pain assessment a
daunting task. Each new journal issue makes mention
of a new pain measurement tool, be it the Multi-
perspective Multidimensional Pain Assessment Pro-
tocol (Rucker et al., 1996) or the Pain Management
Inventory (Davies & Atwood, 1996), or others.
Added to the plethora of literature on pain
burning, aching, dull, sharp, etc.), and its location on
the body.
6
Assessment of pain perception in clinical practice 217
In gathering a description of the pain from a
patient, several purposes are served. A baseline
description of the pain allows for comparison of
changes. Ideally, pain should be monitored for some
time before treatment commences, during treatment,
and at the end of treatment. The brief scales, such
as the numerical rating scale, have been used daily
for up to 2 weeks in chronic pain programmes and
the results were averaged to increase the reliability of
the assessment. Although this amount of assessment
will provide a baseline to truly compare to changes
following intervention, it is rather more than is
achievable or desirable in most clinical contexts.
There is considerable evidence that self-report of pain
intensity in both reliable and valid.
The numerical rating scale is the most popular, but
visual analogue and verbal rating scales are also well
used. In a study to examine the validity of a number
of commonly used measures of pain intensity, the 11-
point box scale emerged as the most valid compared
to a linear model of pain (Jensen et al. 1989). The box
scale was also accurate to score. Strong et al. (1991)
also found the box scale to be one of two preferred
pain intensity measures for use with patients with
chronic low back pain, along with the visual analogue
scale in a horizontal orientation.
The visual analogue scale (VAS) consists of a 10
cm line with ‘anchor’s’ at each end. The line may be
horizontal or vertical. The author’s own experience
cautions against the use of a vertical VAS since a
number of back pain patients interpreted the line to
be of their spine and then went on to locate their pain
on the line rather than indicate its intensity. The
patient is asked to mark the line at a point
corresponding to the severity of his/her pain. End
point descriptors are ‘none’ and ‘severe’ or similar
phrases. Visual analogue scales have been said to be
sensitive, simple, reproducible, and universal (i.e.
they can be understood in many situations where
there are cultural or language di€erences to the
assessor) (Ohnhaus & Adler 1975).
The pain drawing is another simple way to gain a
graphic representation of where the patient feels their
pain (Margolis et al. 1986). While this may sound like
a straightforward procedure, two important aspects
of the pain drawing may di€er widely from setting to
setting; the instructions on how to complete the pain
drawing, and the scoring (if any) and interpretation
of the pain drawing. Perhaps the simplest procedure
for completing the pain drawing is to ask patients to
shade in, on front and back view full body outlines,
where their pain is (Margolis et al. 1986). Other
systems ask patients to mark on diagrams where
they feel di€erent types of sensations using di€erent
symbols (Ransford et al. 1976). With respect to
scoring a pain drawing, Margolis et al. (1986; 1988)
have utilized a system based upon the total body area
in pain. Meanwhile, Ransford et al. (1976) developed
# 1999 Harcourt Publishers Ltd
a detailed scoring system to screen for psychological
problems. Various methods of scoring or rating pain
drawings in order to suggest levels of psychological
distress have been attempted (Parker et al. 1995). A
review of the Ransford et al. (1976) paper is
suggested, not so that manual therapists score up
their patients’ pain drawings, but so that they are
aware of possible markers of problems. Indeed, this
author finds a pain drawing to be a useful tool to
assist in clinical reasoning.
The McGill Pain Questionnaire (MPQ) (Melzack
1975) contains a unique pain description method,
whereby patients are asked to indicate, from 20
groups of adjectives, descriptors of their present pain.
Patients are restricted to utilizing only one word
from each descriptor group. These adjectives tap the
sensory, a€ective and evaluative dimensions of a
person’s pain. The MPQ is probably the most widely-
reported pain assessment tool. While many research-
ers have utilized the MPQ in a highly quantitative
way (see for example, Lowe et al. 1991), its primary
value to the author as a clinician is to identify
qualitative features of a person’s pain experience, and
to detect less than dramatic, moresubtle clinical
changes. From the words chosen, the therapist can
form an idea of unexpected features of a person’s
pain. For example, if a patient endorsed the adjective
‘cold’ as a descriptor of their low back pain, this
would be unusual. Jerome et al. (1988) also suggest
that attention be given to the specific words chosen
by the patients on the MPQ rather than concentrat-
ing on the total scores obtained.
A comprehensive assessment of the patient’s pain
description, using several methods, may allow the
patient to feel they have fully communicated the way
their pain feels to them. This can be valuable in the
establishment of a therapeutic relationship with the
patient. However, comprehensive assessment may not
be suitable in some clinical situations. It is suggested,
however, that a minimum pain description, using the
box scale or a horizontal VAS, be gathered. Where
time permits, the McGill Pain Questionnaire adjec-
tives should also be administered.
Assessments to measure responses to pain
A person’s response to pain is a very personal thing,
based on their physiology, their personality, their
previous life experiences, and on family and cultural
factors which impinge on all aspects of their life. How
someone responds to pain is often demonstrated by
behavioural and psychological reactions or changes,
and it is these features which therapists need to
understand. Therefore aspects such as depression and
illness behaviour are valuable components of a
comprehensive pain assessment.
There is some evidence that a person’s fears or
beliefs about the source of their pain or possibility of
Manual Therapy (1999) 4(4), 216–220
218 Manual Therapy
reinjury can influence their responses to treatment
and their course of recovery (Dworkin et al. 1996;
Vlaeyen et al. 1995; Zusman 1997) Fear-avoidance
beliefs probably arise from the patient’s perspective,
and to understand what influences their behaviour,
some of these attitudes and beliefs need to be
evaluated (Strong et al. 1992).
The Survey of Pain Attitudes (Revised) (SOPAR),
assesses seven beliefs which possibly influence long-
term adjustment for people with chronic pain. It
consists of 35 items. The subscales of the SOPAR
measure the extent to which patients believe they can
control their pain; they are disabled by their pain;
they are damaging themselves and should avoid
exercise; their emotions a€ect their pain experience;
medications are appropriate; others, especially family,
should be solicitous; and there is a medical cure for
their problem (Jensen et al. 1987; Jensen & Karoly
1991). Another tool, the Pain Beliefs and Perceptions
Inventory (PBPI), examines patient’s beliefs in the
stability of pain over time, to what extent they see
pain as a mystery, and how much they are to blame
for their pain (Williams & Thorn 1989). This
inventory contains 16 items. Both these assessment
tools have strengths, however, the psychometric
properties of the SOPAR have been found to be
stronger, and to possibly be of use with a broader
range of patients than the PBPI (Strong et al. 1992).
The SOPAR does take longer to administer with
patients. More recent work with the PBPI has
supported the existence of four, rather than three,
scales across a number of patient groups (Herda et al.
1994; Williams et al. 1994; Morley & Wilkinson 1995)
Utilizing the four-scaled version of the PBPI may
provide a simple, yet clinically useful, gauge of the
patient’s beliefs about: pain as mystery, self-blame,
pain permanence and pain constancy (Williams et al.
1994). A scoring key and some normative data are
contained as appendices in the Williams et al. (1994)
article.
Picking up on a particular maladaptive belief seen
in many patients, it may be useful to particularly
measure fear of movement and reinjury beliefs held
by patients. Vlaeyen et al. (1995) used a translated
version of the Tampa Scale for Kinesiophobia in their
work. This is a 17 item questionnaire that is
contained in the article appendix. An alternative
measure is the Fear-Avoidance Beliefs Questionnaire,
which has the subscales of Fear-Avoidance Beliefs
of Physical Activity, and Fear-Avoidance Beliefs of
Work (Waddell et al. 1993).
Clinical observation of responses to pain are also
valid methods of assessment. These are taken while
the patient is involved in assessment or treatment
activities. Such behaviours as grimacing, bracing and
total body sti€ness are noted. All formal assessment
is supplemented by clinical observation and to a
certain extent interpretation is based on experience.
Manual Therapy (1999) 4(4), 216–220
The aim is to establish a realistic level of distress,
which may not be simply related to the number of
obvious pain behaviours. Clients with chronic pain
may, unintentionally, use a lot of learned pain
behaviours to signal their pain. However, the distress
may actually be psychological at the predicament in
which they find themselves, rather than a direct
function of presently experienced pain.
Assessment to measure the impact of pain
The third level of pain evaluation commonly carried
out is to measure functional status, level of activity,
outcome, disability, and other similar constructs. A
number of authors have recently given attention to
this level of pain measurement (e.g. C de C Williams
1995; Liebenson & Yeomans 1997).
This dimension of pain has been measured in a
variety of ways, ranging from self-report measures
to activity diaries, to automated measurement of
activity, though to detailed functional capacity
evaluations. Once again, the extent to which this
dimension is tapped by the manual therapist will be
context-specific.
One of the most frequently utilized measures of this
dimension is to obtain the patient’s self-report via a
reliable and valid questionnaire. There are numerous
scales of this nature available (Strong et al. 1994), but
perhaps the most widely known measures are the
Oswestry Low Back Pain Disability Questionnaire
(OLBPDQ) (Fairbank et al. 1980), the Pain Disability
Index (PDI) (Pollard 1985; Tait et al. 1987; 1990),
and the Sickness Impact Profile (SIP) (Bergner et al.
1976; 1981).
The Oswestry LBPDQ is one of the most
frequently used measures to ascertain how pain is
a€ecting a patient’s lifestyle (Strong et al. 1994). It
consists of nine functional categories and a pain
intensity scale. A possible score out of 50 is obtained,
and this is converted to a percentage (Fairbank
et al. 1980). Strong et al. (1994) found the OLBPDQ
to have reasonable internal consistency, and con-
current validity. A recent review has shown it to have
good face validity, and some evidence of factorial
and criterion-related validity, and some sensitivity to
change (Fisher & Johnston 1997). These features, and
the fact that it is brief to administer, make it a very
useable assessment for low back pain patients.
However, it is limited to back pain conditions.
The Pain Disability Index (PDI) (Pollard 1985;
Tait et al. 1987; 1990) is a self-report measure which
asks the client to state how much the pain prevents
them doing, or doing as well as previously, in seven
areas of functioning. As such, it evaluates the
di€erence between the person’s capacity and the
environmental demands as used to define disability.
It assesses voluntary (work, social) activities and
obligatory (self-care) activities. The PDI is a valid
# 1999 Harcourt Publishers Ltd
Assessment of pain perception in clinical practice 219
and reliable tool, with a high internal consistency and
valid factor structure (Jerome & Gross 1991; Gron-
blad et al. 1993; 1994; Strong et al. 1994). It can be
used with all types of pain, and is quick to administer.
The Sickness Impact Profiles (SIP) is a question-
naire with 136 items to be self-completed or
administered by interview, which was designed to
provide a measure of health status that isbehaviou-
rally based (Bergner et al. 1981; 1976). It was
developed for use with various populations, not only
those with chronic pain, and has been able to show
change in health status over time and between
groups. There have been some recent developments
in the selection of items for specific use with low back
pain patients, and has thus created a shorter
questionnaire for this population alone (Stratford
et al. 1993).
There is considerable evidence that a daily activity
diary is both reliable and valid when assessing daily
activity patterns (e.g. uptime/downtime, pill taking,
mood, pain) for chronic pain patients in their home
environment (Follick et al. 1984). Patient report was
compared to spouse report to establish this evidence.
However, when self-report of uptime (i.e. time spent
upright and moving rather than resting) is compared
to that of an automated measuring device, there is
significant under-reporting of uptime by clients
(White & Strong 1992). Keeping a diary of activity
is useful if a structured recording system is used, and
if clients are instructed to make entries relatively
frequently throughout the day. Memory factors may
impinge on accuracy. Some clinicians feel that such a
focus upon activities and pain is not particularly
helpful. It is, however, a frequently utilized practice
in many chronic pain facilities.
THE TIMING OF PAIN ASSESSMENT
The underlying tenant of this paper is that some sort
of formal pain assessment needs to be made when an
individual with pain presents for treatment. The
extent of this assessment will depend upon possibly
overlapping contextual factors such as the duration
of the patient’s pain (do the symptoms fit into an
understandable picture?), the forum in which the
patient is seen (private practice, hospital outpatient
pain clinic or vocational rehabilitation facility?), and
the precipitating features of pain (sports injury, just
begun, work injury or motor vehicle accident?). It is
suggested that, at the very least, all patients with pain
be assessed on a simple and reliable measure of pain
intensity such as the box scale or visual analogue
scale (in a horizontal orientation). Such a measure
should be used pre-treatment and post-treatment to
give an accurate numeric measure of treatment
ecacy. Other pain description measures such as
the McGill Pain Questionnaire adjectives, and a pain
# 1999 Harcourt Publishers Ltd
drawing might be considered if time permits with all
cases. However, with patients in whom the pain
seems to be complex or dicult to localize or
understand, the use of a pain intensity measure alone
becomes inadequate. At this level, a more thorough
assessment is necessary. The therapist should con-
sider using a measure of the patient’s responses
to pain, and a measure of the impact the pain has on
the patient’s life. The need for a multidisciplinary
approach should also be considered.
CONCLUSION
This paper has pointed out that while there is a
plethora of pain assessments available to the thera-
pist, pain assessment can be considered under the
categories of description of pain, responses to the
pain and impact of the pain on a person’s life. A
number of assessments available for each of these
three dimensions were then described. Of course, this
description was far from exhaustive; further coverage
can be gained from reading Deyo (1988), Williams
(1988), Millard (1991), C de C Williams (1995) and
Liebenson and Yeomans (1997).
Acknowledgement
I would like to acknowledge the assistance of Jennifer Sturgess
MOccThy, in the preparation of this paper.
References
Bergner M, Bobbitt RA, Pollard WE, Martin DP, Gilson BS 1976
The Sickness Impact Profile: validation of a health status
measure. Medical Care 14: 57–67
Bergner M, Bobbitt RA, Carter WB, Gilson BS 1981 The Sickness
Impact Profile: development and final revision of a health status
measure. Medical Care 19: 787–805
C de C Williams A 1995 Pain measurement in chronic pain
management. Pain Reviews 2: 39–63
Davis GC, Atwood JR 1996 The development of the Pain
Management Inventory for patients with arthritis. Journal of
Advanced Nursing 24: 236–243
Deyo RA 1988 Measuring the functional status of patients with
low Back pain. Archives of Physical Medicine and
Rehabilitation 69: 1044–1053
Dworkin RH, Cooper EM, Siegfried RN 1996 Chronic Pain and
Disease Conviction: Illness Behaviour Questionnaire (IBQ).
The Clinical Journal of Pain 12: 111–117
Fairbank J, Couper J, Davies JB, O’Brien JP 1980 The Oswestry
Low Back Pain Disability Questionnaire. Physiotherapy 66:
271–273
Fisher K, Johnston M 1997 Validation of the Oswestry Low Back
Pain Disability Questionnaire, its sensitivity as a measure of
change following treatment and its relationship with other
aspects of the chronic pain experience. Physiotherapy Theory
and Practice 13: 67–80
Follick MJ, Ahern DK, Laser-Wolston N 1984 Evaluation of a
daily activity diary for chronic pain patients. Pain 19: 373–382
Follick MJ, Ahern DK, Laser-Wolston N, Adams AE, Molloy AJ
1985 Chronic pain; electromechanical recording device for
measuring patient’s activity. Archives of Physical Medicine and
Rehabilitation 66: 75–79
Gronblad M, Hupli M, Wennerstrand P, Jarvinen E, Lukinmaa A,
Kouri JP, Karaharju E 1993 Intercorrelation and test-retest
Manual Therapy (1999) 4(4), 216–220
reliability of the Pain Disability Index (PDI) and the Oswestry
Disability Questionnaire (ODQ) and their correlation with pain
intensity in low back pain patients. Clinical Journal of Pain 9:
189–195
Gronblad M, Jarvinen E, Hurri H, Hupli M, Karaharju EO 1994
Relationship of the Pain Disability Index (PDI) and the
Oswestry Disability Questionnaire (ODQ) with three dynamic
physical tests in a group of patients with chronic low-back and
leg pain. The Clinical Journal of Pain 10: 197–203
Herda CA, Siegeris K, Basler H-D 1994 The Pain Beliefs and
Perceptions Inventory: further evidence for a 4-factor structure.
Pain 57: 85–90
Jensen MP, Karoly P 1991 Control beliefs, coping e€orts, and
adjustment to chronic pain. Journal of Consulting and Clinical
Psychology 59: 431–438
Jensen MP, Karoly P, Huger R 1987 The development and
preliminary validation of an instrument to assess patients’
attitudes towards pain. Journal of Psychosomatic Research
31: 393–400
Jensen MP, Karoly P, O’Riordan EF, Bland F, Burns RS 1989 The
subjective experience of acute pain. An assessment of the utility
of 10 indices. The Clinical Journal of Pain 5: 153–159
Jerome A, Gross RT 1991 Pain Disability Index construct and
discriminant validity. Archives of Physical Medicine and
Rehabilitation 72: 920–922
Jerome A, Holroyd KA, Theofanous AG, Pingel JD, Lake AE,
Saper JR 1988 Cluster headache pain vs. other vascular
headache pain: di€erences revealed with two approaches to the
Parker H, Wood RLR, Main CJ 1995 The use of the pain drawing
as a screening measure to predict psychological distress in
chronic low back pain. Spine 20: 236–243
Pollard CA 1985 Preliminary validity study of the Pain Disability
Index. Perceptual Motor Skills 59: 974
Ransford AO, Cairns D, Mooney V 1976 The Pain Drawing
as an aid to the psychologic evaluation of patients with low-
back pain. Spine 1: 127–134
Rucker KS, Metzler HM, Kregel J 1996 Standardization of chronic
pain assessment: a multiperspective approach. The Clinical
Journal of Pain 12: 94–110
Stratford P, Solomon P, Binkley J, Finch E, Gill C 1993 Sensitivity
of Sickness Impact Profile items to measure change over time in
a low-back pain patient group. Spine 18: 1723–1727
Strong J, Ashton R, Chant D 1991 Pain intensity measurement in
chronic low back pain. The Clinical Journal of Pain 7: 209–218
Strong J, Ashton R, Chant D 1992 The measurement of attitudes
towards and beliefs about pain. Pain 48: 227–236
Strong J, Ashton R, Large RG 1994 Function and the patientwith chronic low back pain. The Clinical Journal of Pain 10:
191–196
Tait RC, Chibnall JT, Krause S 1990 The Pain Disability Index.
Pain 40: 171–182
Tait RC, Pollard CA, Margolis RB, Duckro PN, Krause SJ 1987
The Pain Disability Index: psychometric properties and validity
data. Archives of Physical Medicine and Rehabilitation 68:
438–441
Turk DC, Melzack R 1992 (eds) Handbook of Pain Assessment.
New York, Guilford Press
220 Manual Therapy
McGill Pain Questionnaire. Pain 34: 35–42
Liebenson C, Yeomans S 1997 Outcomes assessment in
musculoskeletal medicine. Manual Therapy 2: 67–74
Lowe NK, Walker SN, MacCallum RC 1991 Confirming the
theoretical structure of the McGill Pain Questionnaire in acute
clinical pain. Pain 46: 57–62
Margolis RB, Tait RC, Krause SJ 1986 A rating system for use
with patient pain drawings. Pain 24: 57–65
Margolis RB, Chibnall JT, Tait RC 1988 Test-retest reliability of
the pain drawing instrument. Pain 33: 49–51
Melzack R 1975 The McGill Pain Questionnaire: major properties
and scoring methods. Pain 1: 227–279
Millard RW 1991 A critical review of questionnaires for assessing
pain-related disability. Journal of Occupational Rehabilitation
1: 289–302
Morley S, Wilkinson L 1995 The pain beliefs and perceptions
inventory; a British replication. Pain 61: 427–433
Ohnhaus EE, Adler R 1975 Methodological problems in the
measurement of pain: a comparison between the verbal rating
scale and the visual analogue scale. Pain 1: 379–384
Manual Therapy (1999) 4(4), 216–220
Vlaeyen JWS, Kole-Snijders AMK, Boeren RGB, van Eek H 1995
Fear of movement/(re) injury in chronic low back pain and its
relation to behavioral performance. Pain 62: 363–372
Waddell G, Newton M, Henderson I, Somerville D, Main C 1993
A Fear-Avoidance Beliefs questionnaire (FABQ) and the role
of fear-avoidance beliefs in chronic low back pain and
disability. Pain 52: 157–168
White J, Strong J 1992 Measurement of activity levels in patients
with chronic low back pain. Occupational Therapy Journal of
Research 12: 217–228
Williams RC 1988 Toward a set of reliable and valid measures
for chronic pain assessment and outcome research. Pain 32:
239–251
Williams A, Thorn BE 1989 An empirical assessment of pain
beliefs. Pain 36: 351–358
Williams DA, Robinson ME, Geisser ME 1994 Pain beliefs:
assessment and utility. Pain 59: 71–78
Zusman M 1997 Instigators of activity intolerance. Manual
Therapy 2: 75–86
# 1999 Harcourt Publishers Ltd
	INTRODUCTION
	COMPONENTS OF THE PAIN ASSESSMENT
	THE TIMING OF PAIN ASSESSMENT
	CONCLUSION
	Acknowledgement
	References