ASSESSING PEOPLE’S PAIN

Assessing people's pain is a complex task that involves a combination of subjective and
objective measures. Pain is a personal and subjective experience, and individuals may perceive
and express their pain differently. Healthcare professionals use various tools and methods to
assess and understand a person's pain.

We'll categorize methods of measurement to structure our conversation. self-report techniques,

behavioral assessment methodologies, and psychophysiological assessments into three
categories.
SELF-REPORT METHODS
An obvious approach to measure people’s pain is to ask them to describe the discomfort,
either in their own words or by filling out a rating scale or questionnaire.
When attending to a patient experiencing acute pain, medical professionals inquire about the
location, nature, intensity, and frequency of the pain. Medical and psychological practitioners
frequently use this type of inquiry within the framework of a clinical interview with patients who
have chronic pain.
Interview Methods in Assessing Pain
To treat chronic pain effectively, professionals need more information than a description of the
pain. Interviews with the patient and key others, such as family members and coworkers,
provide a rich source of background information in the early phases of treatment (Chapman,
1991; Karoly, 1985; Turk, Monarch, & Williams, 2004). These discussions ordinarily focus on
such issues as:
• The history of the pain problem, including when it started, how it progressed, and what
approaches have been used for controlling it.
• The patient’s emotional adjustment, currently and before the pain syndrome began.
• The patient’s lifestyle before the pain condition began: recreational interests, exercise patterns,
diet, and so on.
• The pain syndrome’s impact on the patient’s current lifestyle, interpersonal relations, and
work.
• The social context of pain episodes, such as happenings in the family before an attack and how
family members respond when the pain occurs.
• Factors that seem to trigger attacks or make them worse.
• How the patient typically tries to cope with the pain. The information obtained in these
interviews can also be supplemented by having the patient and key others fill out
questionnaires.
Pain Rating Scales and Diaries
A direct, simple, and commonly used way to assess pain is to have individuals rate some
aspect of their discomfort on a scale (Jensen & Karoly, 2001; Mann & Carr, 2006).
This method is often utilized to assess the severity of pain; the following slide shows three
distinct scales that may be used to rate pain. One kind uses a visual analog scale, in which
participants mark a point on a line with labels only at one end to indicate how much pain they
are experiencing. This kind of scale is incredibly user-friendly and suitable for usage with kids as
young as five years old (Karoly, 1985). Using the box scale, participants select a number from a
range of numbers that indicate their intensity of discomfort within a certain range. Using a
verbal rating scale, participants select a word or phrase from a list of options to express their
level of pain.
PPT SHOWING ILLUSTRATIONS
visual analog scale— ‘‘Mark a point on the line to show how strong your pain is’’;
box scale— ‘‘Rate the level of your pain by circling one number on the scale, where 0 means ‘no
pain’ and 10 means ‘worst pain possible’’;
verbal rating scale— ‘‘Circle the one phrase that best describes your pain.’’
The labels and number of choices on a scale can be different from those shown here.
People can rate their discomfort often since rating scales are so quick and simple to use.
Individual evaluations are not as indicative of the person's overall discomfort as they are when
these ratings are averaged across time (Jensen & McFarland, 1993).
Repeated ratings can also show how pain varies over time, for example, when participating in
daily activities or conducting an experiment. For a period of, say, two weeks, patients might
assess their level of discomfort throughout each waking hour. They could also note when they
take pain medicine.
Pain Questionnaires
Pain is only partly described by the intensity of the discomfort people feel—the experience of
pain has many qualities and dimensions.
Melzack's experiences with pain patients helped him to understand the complex nature of pain.
In an interview, he explained how conversations with a woman who had agony in her phantom
limbs led him to this understanding. She would describe excruciating aches that seemed like
someone had driven a hot poker into her ankle and toes. Her legs would hurt so much that she
would cry out. There were no legs, of course. That, however, made me understand how
completely subjective pain is and how unlikely it is for any objective bodily metric to adequately
express it. I started to jot down the terms she used to express her suffering. I soon discovered
that the words she used to describe the sensory aspect of her pain—"shooting, scalding,
splitting, cramping"—were very different from those describing the emotional motivational
component of her pain—"exhausting, sickening, terrifying, punishing." Later, I discovered there
was also an evaluative component, such as "it's unbearable" or "it's annoying." I also took note
of the words other patients used, but I wasn't sure what to do with them.
Through research in which participants categorized over 100 pain-related terms into
independent categories, Melzack came to the conclusion that pain has three major dimensions:
affective (emotional-motivational), sensory, and evaluative.
SENSORY dimension included a subclass with the words; words relating to temperature.
 hot
 Burning
 Scalding
 searing
AFFECTIVE dimension included a subclass of three words relating to fear:
 fearful
 frightful
 terrifying
McGill University professor Melzack (1975) created a device to assess pain by calculating the
amount of suffering conveyed in each phrase. The McGill Pain Questionnaire (MPQ), which you
completed in the Assess Yourself exercise, is the name of this exam.

FIGURE 11-6. A pain diary. The chronic pain patient keeps a daily record of important
information about pain episodes.

BEHAVIORAL ASSESSMENT APPROACHES

Because people tend to exhibit pain behaviors when they are in discomfort, it should be
possible to assess their pain by observing their behavior.
When a person has severe pain as opposed to moderate pain, headaches as opposed to low back
pain, or recurring chronic pain as opposed to intractable pain, they are likely to exhibit distinct
types and patterns of behavior. Psychologists have devised protocols to evaluate pain behavior in
two contexts: routine activities and formal clinical settings.
Assessing Pain Behavior in Structured Clinical Sessions
One approach of this kind has been developed into a pain assessment instrument—the UAB
Pain Behavior Scale—for use by nurses during their standard routines, such as in early morning
rounds (Richards et al., 1982).

The UAB Pain Behavior Scale typically involves the observation and rating of various pain-related
behaviors during a specific period. These behaviors may include facial expressions, body
movements, verbalizations, and other actions that indicate the presence and intensity of pain.
The scale is often used in clinical settings to complement self-report measures, especially in cases
where patients may have difficulty communicating their pain verbally. The nurse has the patient
perform several activities and rates each of 10 behaviors, such as the patient’s mobility and use
of medication, on a 3-point scale: ‘‘none,’’ ‘‘occasional,’’ and ‘‘frequent.’’ These ratings are
converted into numerical values and summed for a total score.

Structured clinical sessions have been used in assessing discomfort in individuals with a variety
of pain conditions, including arthritis and low back pain (Keefe, Williams, & Smith, 2001;
Ohlund et al., 1994).
Patients are required to complete a series of standard tasks throughout each session. According
to Kleinke and Spangler's 1988 study, individuals suffering from low back pain were required to
walk, pick up an object from the floor, take off their shoes while seated, and engage in various
activities such sit-ups, trunk rotations, and toe touching. Sighing, cautious movement, touching
the painful location, and grimacing were among the pain behaviors for which the patients were
recorded and scored by skilled assessors. This makes it simple and reliable to measure pain
behaviors, and the results have a strong correlation with patients' self-ratings of their own pain.
Assessing Pain Behavior in Everyday Activities
Assessing pain behavior in everyday activities involves observing an individual's actions and
expressions during routine tasks to understand how pain may be affecting their functioning.
This observational approach can provide valuable insights into the impact of pain on a
person's daily life.
The ideal persons to perform these routine assessments of pain behavior are typically family
members or important individuals in the patient's life. Naturally, in addition to being educated to
make meticulous observations and maintain reliable records, these individuals must be eager to
assist. Scientist Wilbert Fordyce (1976) developed a protocol in which the assessor—let's say the
client's spouse—makes a list of five to ten actions that often indicate discomfort in the patient.
Next, the spouse receives training on how to recognize these behaviors, note how long the
patient displays them, and observe how others—including the assessor—respond to the client's
pain behavior. This process is helpful in evaluating the patient's pain experiences as well as how
they affect their lives and the social environment that could encourage pain behaviors. In
addition to this process, the assessor can document the date, time, and location of the patient's
acute pain episodes in a pain journal, noting whether the incident happened in bed at home or in
the car (Turk, Meichenbaum, & Genest, 1983). These extra processes yield more information that
may be useful in managing interpersonal problems that impact pain perception.

PSYCHOPHYSIOLOGICAL MEASURES

Psychophysiology is the study of mental or emotional processes as reflected by changes they

produce in physiological activity (Lykken, 2004).
Another approach for assessing pain involves taking measurements of physiological activity,
since pain has both sensory and emotional components that can produce changes in bodily
functions.
PSYCHOPHYSIOLOGICAL MEASURES
Electromyograph (EMG) - to measure the electrical activity in muscles, which reflects their
tension. Because muscle tension is associated with various pain states, such as headaches and
low back pain.
It is reasonable to anticipate that EMG recordings of tense muscles under physical or
psychological stress would be higher in pain sufferers than in pain-free controls, and this is
indeed the case (Flor, 2001). However, there is seldom a consistent change when the muscles are
not used. Does the EMG signal the severity of pain? Indeed, but only in cases when evaluations
are conducted over a lengthy period of time (Flor, 2001). The association between pain levels and
EMG is unreliable when examined for short periods of time.
Autonomic Activity – it measures people’s pain such as of heart rate and skin conductance, but
these measures do not seem to be very useful.
This is due to the fact that variations in autonomic activity are frequently seen in the absence of
pain perception, such as during stressful situations, and are more closely correlated with
people's assessments of their level of pain than with the intensity of the pain stimuli. Autonomic
activity is also inconsistently linked to chronic pain. Because of this, it is frequently challenging to
interpret changes in autonomic activity as indicative of pain.
Electroencephalograph (EEG) - When a person’s sensory system detects a stimulus, such as a
clicking sound from earphones, the signal to the brain produces a change in EEG voltage.
EEG recordings of stimuli cause electrical alterations known as evoked potentials, which appear
as abrupt spikes or surges on the graph. The amplitudes of the surges rise with the severity of
the stimuli, diminish when individuals take analgesics, and correspond with people's subjective
judgments of pain. Pain stimuli induce evoked potentials that vary in magnitude (Chapman et al.,
1985; Flor, 2001).
Although psychophysiological tests offer impartial evaluations of the physiological alterations
brought on by pain, other elements like stress, nutrition, and attention may also have an impact
on these changes. Measures of muscular tension, autonomic activity, and evoked potential are
probably best applied as adjuncts to behavioral assessment techniques and self-report in
therapeutic settings (Chapman et al., 1985).