Standardized assessments Some assessments have evidence to support the validity and reliability. The McGill Pain Questionnaire, consists of groupings of words that describe pain (e.g., sharp, sore, throbbing). This questionnaire has been found to be a “valid and reliable tool that evaluates both the quality and quantity of pain through use of unique pain descriptors” and can “evaluate the efficacy of different pain therapies” (Hawker, Mian, Kendzerska, & French, 2011, p. S243). 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 for specific responses of pain. This assessment has been validated with the McGill Pain Questionnaire (Haynes, Anderson, Brown, & Jackel, 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 combination of the
Defense and Veterans Pain Rating Scale (DVPRS) and several component measures of the Patient-Reported Outcomes Measurement Information System (PROMIS) by 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). The Checklist of Nonverbal Pain Indicators (Table 4; CNPI) is an observational tool employed for those unable to use other pain intensity instruments. While this tool does have support for validity and reliability, Ersek, Herr, Neradilek, Buck, and Black (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 consolability, the clinician can ascertain in both adults and children whether the individual is feeling pain.
Table 4: Checklist of Nonverbal Pain Indicators (CNPI)
With Movement
At Rest
Vocal complaints – nonverbal (expression of pain demonstrated by moans, groans, grunts, cries, gasps, sighs). Facial grimaces and winces – furrowed brow, narrowed eyes, tightened lips, dropped jaw, clenched teeth, distorted expression. Bracing – clutching or holding onto siderails, bed, tray table, or affected area during movement. Restlessness – constant or intermittent shifting of position, rocking, intermittent or constant hand motions, inability to keep still. Rubbing – massaging affected area.
Vocal complaints – verbal (expression of pain using words, e.g., “ouch” or “that hurts”; cursing during movement, or exclamations of protest, e.g., “stop” or “that’s enough”). TOTAL SCORE Instructions: 1. Write a 0 if the behavior was not observed. 2. Write a 1 if the behavior was observed even briefly during activity or rest. 3. Results in a total score between 0 and 5. 4. The interdisciplinary team in collaboration with the patient (if appropriate) can determine appropriate interventions in response to CNPI scores. Note . From Feldt, K.S. The checklist of nonverbal pain indicators (CNPI). (2000). Pain Management Nursing, 1 (1), 13-21. Reprinted with permission. 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 peripheral 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 can be used, cautiously, to gauge the degree of pain and whether it is increasing or decreasing. However, these measurements must not be the only method of pain evaluation (McCaffery & Robinson, 2002). Indicators called pain behaviors should be observed in conjunction with other assessments. Communicative pain behaviors include facial and verbal expressions (grimacing, grunting, words used, and sighing), and protective pain behaviors, which include guarding, holding, touching, or
rubbing (Leung, 2012). Significant associations between pain catastrophizing and physical intolerance to stimuli have been found with both types of pain behaviors (Leung, 2012). Pain catastrophizing is a concept that describes an “exaggerated negative cognitive response to actual or anticipated pain experience” (Engel-Yeger & Dunn, 2011, p. e1). Pain catastrophizing involves: ● Magnification : “ I wonder whether something serious may happen .” ● Rumination : “ I cannot stop thinking about how much it hurts .” ● Helplessness : “ There is nothing I can do to reduce the intensity of pain ” (Sullivan, Bishop, & Pivic, 1995). Most rehabilitation professionals become keen observers and constantly ask a client during treatment if he or she is comfortable. In addition, pediatric practitioners may consider using the face scale shown in Figure 3 with children after treatment so that they may indicate the level of pain they felt during their treatment.
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