___________________________________________________ Pain Assessment and Management, 2nd Edition
STANDARDIZED ASSESSMENTS Some assessments have evidence to support their validity and reliability. The McGill Pain Questionnaire consists of group- ings of words that describe pain (e.g., sharp, sore, throbbing; Kremer & Atkinson, 1981). This questionnaire has been found to be a valid and reliable tool with evidence of moderate qual- ity (Marin, 2021). This tool has four subscales, which address the following features of pain: sensory, effective, evaluative, and miscellaneous. The Pain Behavior Checklist (PBCL) is used with adults who experience chronic pain. It is a self-report checklist that addresses four dimensions: ambulation, affective distress, facial/audible expressions, and seeking help. Individuals are asked to identify the frequency of specific responses of pain. This assessment has been validated with the McGill Pain Questionnaire (Haynes et al., 2014). The Pain Assessment Screening Tool and Outcomes Registry (PASTOR) has recently been validated within the military health system (Cook et al., 2017). The PASTOR is a com- bination of the Defense and Veterans Pain Rating Scale (DVPRS) along with several component measures of the Patient-Reported Outcomes Measurement Information System (PROMIS) from the National Institutes of Health (Cook et al., 2017). Areas addressed include general activity, mood, stress, sleep, anxiety, depression, fatigue, sleep, anger, interference, physical function, and social roles (Cook et al., 2017). Recently, military providers were surveyed for their recommendations for tools to evaluate pain (Mathew et al., 2023). The PASTOR was the assessment most recommended. The Checklist of Nonverbal Pain Indicators (CNPI; Table 4 ) is an observational tool employed for those who are unable to use other pain intensity instruments. Smith and Harvey (2022) found strong and moderate evidence to support using this evaluation with individuals living with dementia. Ersek et at. (2010) found that it has a marked floor effect when used at rest. The authors concluded that the CNPI should be used for observation of pain levels either during or immediately after treatment of a nonverbal client (Ersek et al., 2010). A zero signifies that the behavior was not observed and a 1 means the behavior was seen. Simply by observing a client’s face, leg movements, restlessness, cry, vocal complaints, and consola- bility, the clinician can ascertain in both adults and children whether the individual is feeling pain. ASSESSMENTS VALIDATED FOR USE WITH CLIENTS WITH PAIN There are several standardized assessments that have been spe- cifically validated for use with clients who experience pain. The Canadian Occupational Performance Measure (COPM; Law et al., 2019) is a standardized outcome measure that has been studied for use with clients who experience pain (Carpenter et al., 2001). “The COPM is an individualized measure designed to detect change in a client’s self-perception of occupational
performance over time” (Law et al., 2019, p. 1). The Functional Disability Inventory (FDI) (Walker & Greene, 1991) has been used to assess children and youth with chronic pain (Kashikar- Zuck et al., 2011; Solé et al., 2019; Stahlschmidt et al., 2018). According to Walker and Greene (1991), the FDI is used to assess activity limitations in children and adolescents with a variety of conditions. The Patient-Specific Functional Scale (PSFS; Stratford et al., 1995) has been found to be an easy to use, responsive, and reliable tool to assess musculoskeletal conditions (Pathak et al., 2022). Some caution should be taken, as the construct validity of this assessment is lacking as deter- mined in this systematic review by Pathak et al. (2022). The PSFS assesses an individual’s functional ability to complete specific activities. NONSTANDARDIZED ASSESSMENTS There is some objective evidence that may suggest when pain is being experienced. The sympathetic nervous system, with its fight-or-flight reaction, becomes involved when there is pain. Pain causes increased production of epinephrine, which results in increased heart rate (tachycardia), increased respiratory rate (tachypnea), and increased blood pressure caused by periph- eral vasoconstriction (McGuire, 2006). Pain may also cause nausea, vomiting, perspiration, or pallor; occasionally, clients may faint. Because the client is not necessarily in a position to fight or escape, differences in these measurements may be used, cautiously, to gauge the degree of pain and whether it is increasing or decreasing. More recent findings indicate that heart rate variability is not a suitable marker for chronic pain (Moens et al., 2023). Luebke et al. (2023) found that these physiological indicators are able to distinguish between no and severe pain, but because the differences in responses to pain were small, it was difficult to differentiate between the lower levels of pain. These authors report the differences in the physiological responses to pain is small. However, these measurements must not be the only method of pain evaluation (McCaffery & Robinson, 2002). Indicators called pain behaviors should be observed in conjunc- tion with other assessments. Communicative pain behaviors include facial (grimacing, winces, wrinkled forehead, or clenched teeth) and verbal expressions (crying, gasping, grunting, moaning, and sighing) along with protective pain behaviors, which include guarding, holding, touching, or rubbing (Morrison et al., 2020, Pu et al., 2024). Significant associations between pain catastrophizing and physical intol- erance to stimuli have been found with both types of pain behaviors (Meints et al., 2019). Pain catastrophizing is an exaggerated negative estimate, magnification of the symptoms related to pain, and rumination and feelings of helplessness (Simic et al., 2024). Most rehabilitation professionals become keen observers and constantly ask a client during treatment if they are comfortable. In addition, pediatric practitioners may consider using the face scale shown in Figure 3 with children during and after treatment so that they may indicate the level of pain they felt.
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