Kl’oiF” 7Jvo. 534Y I992

312 Journalof Painand &mptomMayyment

Special Article

Comprehensive and Multidimensional Assessment and Measurement of Pain Deborah B. McGuire, PhD

lTze3ohm Hophks Unhxity &hool of .hhsing, Baltimore,Malyiand

Abstract Currentthemies ofpain and clinical experience s&bort a multidimensionaljameworkfor the experience ofpain that has imp&tionsfor assessment and management in any setting. Six major dimensions haue been r&nu>d: pt&iologic, sensoty aflectioe, cognitive, behavioral, and sociocultural. Any clinical assessmentprocess must address reksvantdimensions of pain in the @en setting. In acute care settings, fw example, clinCns mayfocus on physiologic and sensory dimensions, whereas in chronic care settings, the affectioe, cognitive,and behaoioral dimensions might assumepriori& Kin&s tools are auaikrblefw multidimensional assessment of pain, spanning the dimensions of the experiencejom physioologicto sociocultural. The clinician in any setting must use appropriate tools that provide use&l information. Guia!elineshe&l in a selection process include sdentiiation of relevant dimer&ms of pain, we ofpain, patient pqtudationand setting,psrchomelr; properties of the tool, and issues of time, clinical rehvance, andfasibili~. Men a car&l selectionprocess occurs, the resultingdata shoukd simultreous~ meet clinicians’ needsfor information as well as pmoide thefoundation for initiation of multidLu@‘nary interventions.J Pain Symptom Manage 1992;7:312-319.

Pain assessment, pain measurement, experience of pain, multiple dimensions ofpain

Introduction Pain assessment in the clinical setting is an essential activity that must occur prior to initiation of therapy and throughout treatment.‘-3 Many clinicians, however, feel less than optimally prepared for this process, and the literature is replete with documentation of poor

Adclrcss npn’ntrequestito.-Deborah B. McGuire, PhD, The Johns Hopkins University School of Nursing, 600 North Wolfe Street, Houck 316, Baltimore, Maryland 21287. E5i.spaper was presentedinpart as an irwrbdpresentation at the Inkmaliwral Hospice Insthte, hnth Annual @npo&m, W~hitgton,Oc, 3u& 1991. Q U.S. Cancer Pain Relief’Committee, 1992 Published by Ekevier, New York, New York

assessment practicesP* Tlxs, assessment is one of the ongoing, unresolvelrl issues in pain management. The purpose of this paptla is to discuss, from a broad perspective, the coqxehensive and multidimensional assessmen~t ai pain in the clinical setting. The difference. ktween measurement and assessment are clarrfkd, and a multidimensional conceptualizations rf pain is presented, with examples from diffkent disease states. The goals and process of assessment are explained, and the roles of health-care providers in this process are delineated. Finally assessment tools are briefly reviewed and Iconsiderations in selecting tools are discussed.

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Measurement and assessment are two different processes. A look at formal dictionary definitions is useful in clarifying some of the differences. Qne definition of measurement is cc . . . to ascertain the quantity, mass, extent, or degree of in terms of a standard unit or fixed amount usualiy by means of an instrument or container marked off in units. . . .‘rg The emphasis here is on the quantity, extent, and degree of some entity, using a standard unit or tool. Another important point is the comparison to a standard of some kind. In relation to pain, Donovanlo noted that measurement is used, particularly in laboratory research, to quanG$ pain in an objective, bias-free manner. Syrjala” described measurement as a means to quanti@ pain. Assessment is “ . . . to analyze critically and judge definitively the nature, significance, status, or merit . . . .“g This process involves an analysis of and judgment about the nature, significance, and other properties of an entity. When the word assessment is applied to pain, it involves an overall appraisal of the experience of pain. Rather than rigorous evaluation in a bias-free manner, it connotes a more generalized judgment that is made for clinical purposes. In the clinical setting, assessment of pain can be put into a broader framework of surveillance (IV. Hester, personal communication, 1990). Surveillance, according to Dougherty and Molenr2 is “. . . the application of behavioral and cognitive processes in the systematic collection of information used to make judgments and predictions. . . .” This notion, although originally described for critical care patients, is equally applicable to patients with pain, or those for whom pain is a potential problem. It implies a state of constant watchfulness to anticipate, or predict, so that early interventions may be initiated. The collection of data allows decisions about primary interventions, both nursing and other. A framework of surveillance helps the clinician determine when to intervene, with what, and why. It thus helps establish objectives and priorities and allows planning and structure in the delivery of care. Ultimately, diagnosis and treatment are enhanced because more accurate predictions are made.

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During the past several decades, and particularly following the introduction and refinement Of the Gate Control Theory of Pain,13-15 a conceptualization of pain as a multidimensional, subjective, and uniqttely personal experience has emerged. Ahles and colleague@ developed the notion of a five-dimensional model for cancer pain, which they substantiated with research findings. A sixth dimension has been proposed as well. ’ 7 These six dimensio~hysiologic, sensory, affective, cognitive, behavioral, and sociocultural-are applicable not only to individuals with cancer-related pain, but also to individuals with pain caused by other conditions. Components of the dimensions are shown in Table 1. They occur together in any individual, may overlap, and are often interrelated in ways that clinicians and researchers are only beginning to understand. Each dimension is described briefly below. The physiologic dimension is concerned primarily with the organic etiology of the paini Other components include location, onset, duration, and type of pain. In cancer pain, for example, the etiology may be tumor, treatment, something else, or a combination of these, and it may be acute and/or chronic.‘* The pain may be visceral, somatic, neuropathic, or some combination of these. lg The sensory dimension is related to how the pain actually feels to the individual who has it. I6 Components such as intensity, quality, and pattern comprise this dimension. Various studies have found that pain in different disease conditions or speciIic syndromes of pain is characterized by specific patterns and qualitative sensations.20~2’ For example, cancer-related pain due to tumor is often described as constant or continuous.22~2s Its qualitative characteristics may vary depending on location and syndrome (somatic is often sharp and stabbing, whereas visceral pain is dull and aching, and neuropathic pain is burning and/or paroxysma.l).‘gs24 For the individual experiencing pain, many feelings are engendered. This aspect of pain is the affective dimension, which is related to how the pain makes the sufferer feel. Pain has effects on and is related to one’s mood, outlook, sense of w&b&g, and other emotional states. Affective factors often associated with pain include depres-

314

Tile 1 Multiple Dimensions of the Pain Experience Physiologic dimension Location Onset Duration Etiology Syndrome Sensory dimension Intensity 22 A&&e dimension Mood state Anxiety Depression Well-being Cognitive dimension Meaning of pain View of self Coping skills and strategies Previous treatment At&u&s and belie& Factors inlluencing pain Behavioral dimension Communication Interpersonal interaction Physical activity Pain behaviors Medications Interventions Sleep Socioculhual dimension Ethnocultural background Family and social life Work and home responsibilities Recreation and leisure Environmental factors Attitudes and beliefs Social intluences

sion, anxiety, and fear. 16125 Whether pain exacerbates some of these factors or is exacerbated by their presence, or both, is not clear, but their interrelationships are acknowledged and have been substantiated by research.16126 The fourth dimension of the pain experience is the cognitive dimension, which is concerned with the meaning of pain and other related thought processes. l6 This dimension also includes conscious thoughts, feelings, opinions, and experiences such as those shown in Table 1. The component of the meaning of pain has been most carefully investigated in patients with cancer-related pain. Individuals with such pain often associate it with progression of their cancer. 16a26

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The presence of pain causes or contributes to a number of behaviors that may be termed pain-related and comprise the behavioral dimension of pain. Some behaviors (see Table 1) are often undertaken to decrease the severity of Pain, 26-29although others are actually indicators of ,the presence of pain.3a-33 Many such behaviors will increase as the severity of pain increases and decrease when it lessens. Finally, the sociocultural dimension of pain is comprised of a broad range of ethnocultural, demographic, spiritual, social, and other factors related to an individual’s perception of and response to pain. 34-3pThese factors are still not well understood but are acknowledged to have a powerful influence on the experience of pain. Their impact is manifested not only in the individual who has pain, but in those who are involved in the experience as supporters (e.g., family or friends) or caregivers (e.g., nurses or physicians). Attitudes and beliefs about pain are critical to its acknowledgment as a legitimate situation requiring action.1*38-40 In summary, it is important to reiterate that these six dimensions cannot be easily separated. The human being, as an integrated organism constantly adapting to the environment,4’ also experiences and responds to pain in an integrated way. Some dimensions are more relevant than others in certain pain situations (see Table 2). In chronic rheumatic pain, for example, the affective dimension was found to distinguish this type of pain from acute postoperative pain, and sensory aspects were different as welL30 Pain in the postanesthesia unit is obviously very different, and recent research on its assessment indicates that the behavioral component, manifested by restlessness, muscle tension, frowning/ grimacing, and vocalization is paramount.s* Pain in newborns is different &I, with the behavioral dimension assuming primary importance (crying, fussiness, grimacing) and the physiologic dimension (increased heart and respiratory rates, diaphoresis) being manifested as well.3’*33Finally, pain in the hospice setting is receiving increasing attention from researchers,42-50 whose coIlective work has also supported the six dimensions of the pain experience (see Table 3). Thus, the relevance of the different dimensions changes according to the etiology of pain, whether it is acute or chronic, and by disease state as well.

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Table2 Pain in rheumatoid arthritis~ Sensory dimension-rheumatic pain and acute postoperative pain condnuous, steady, constant; postoperative pain more intense Aarective dimension-distinguished rheumatic pain Cognitive dimension--focus on pain, no effects on self-esteem, distraction, religious faith Behavioral dimension-rest/fatigue, physical activity, heat Sociocultura+takkg with others about pain Assessment of pain in postanesthesia recovery unitb Behavioral indicators--restlessness, muscle tension, liowning/gGmacing, vocalizations Sensory indicator-pain intensity (self-report) Different indicators at different points in recovery time Assessment of pain in newborn9 Behavioral indicato&ssiness, crying, grimacing selected %ually” or “always” Physiologic indicators-increased heart rate/respiration rate and diaphoresis ‘kually” Behavioral indicatotx-tkial expression, facial color, limb movement, torso activity, breathing, cry, state (alert, asleep) Sensory indicatorslevel of pain was indicated by severity of behavior aSe.e reference 30. Bee reference32. c&e references31 and 33.

The

goals of assessment are

to assist in

establishing a baseline, selecting interventions, and evaluating the individual’s reponse to treatment. The impact of assessment is important, as particular outcomes can be anticipated when a systematic process is used. Benefits of assessment for patients include the facts that pain is identified, recognized

as legitimate, quantified l-llie 3

Dimensions

of Pain in Hospice

Physiologic Site of disease Extent of disease Duration of pain

Sensory Intensity

Aikctive Depression Anxiety Distress

Cognitive Meaning of pain Value of s&e&g Other symptoms Coping sttategies

Mood

zEy

Confusion Adjustment Behavioral Medications Elimination Nutrition Functional status Interventions Cnmmnnic2tinn

Socioculhxal Adjustment coping Support Spiritual Caring &&on&+ Time and plans

and described, documented and followed, and used to evaluate interventions. Additionally, the patient becomes an active participant in his or her care, and as a result becomes more comfortable and functional. These positive outcomes are important to all patients in pain, but perhaps most especially those who are at the end of Me. The impact of assessment on care providers can be extremely positive as well, including, similarly, the identification and recognition of pain as a problem, its quantification and documentation, and its use as an indicator of therapeutic success. Appropriate assessment of pain allows caregivers to be more my cognizant of pain status, more responsible and accountable for the management of pain, more collegial in managing it, and finally, less frustrated and impotent in their attempts to relieve pain. All clinicians involved in the care of patients with pain have an essential role to play in the assessment process. Foley51 described the physician’s role as including (1) obtaining the medical history, (2) assessing psychosocial status, (3) performing medical and neurologic exams, (4) ordering appropriate diagnostic tests, (5) determining extent of disease, (6) selecting methods of pain control, and (7) evaluating response to treatment. The nurse’s role in assessing pain, while described initially some years ago,52 has recently been formally integrated into a description of the nurse’s scope of practice in the Oncology

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Nursing Society position paper on cancer pain.3 This description includes (1) describing the phenomenon, (2) identifying aggravating and relieving factors, (3) determining the meaning of pain to the indivihl, (4) determining its cause, (5) determining definitions of optimal pain relief, (6) deriving nursing diagnoses, (7) assisting in selecting interventions, and (8) evaluating efficacy of interventions. Additionally, the position paper delineates a scope of nursing practice in relation to patients in pain that emphasizes the need to coordinate care and communication for those with pain. There is obvious overlap in the roles nurses and physicians play in assessing pain, but they have different and unique functions as well. Nurses may focus more on the identification of a patient’s definition of optimal relief, psychosocial and physical problems that are amenable to nursing interventions, and an evaluation of the individual’s overall response to treatment. Physicians, on the other hand, may focus on diagnosing and treating the cause of the pain as well as an evaluation of overall response. The overlapping and complementary aspects of caregivers’ roles in assessing pain point clearly to the need for a multidisciplinary, collaborative approach to assessment and management of pain. Lastly, other individuals have an important role to play in assessing pain. Parents ofa patient, family members, friends, or others who are around the individual for any time will certainly have observations or other information to contribute to the assessment of pain. In many instances, particularly in the home-care setting, family members are /he assessors of pain. Although they have their own stresses and burdens,*+* the information they provide is essential to caregivers who are assisting in the management of pain.

Toolsfor AssessingPain How does one assess this multidimensional experience of pain? Like a diner reading a menu in a restaurant and choosing an entree, selection of a tool is simply a matter of picking a variation on a theme. The theme is multidimensionality and the variation is the spec@% assessment needs of a given patient and health-care provider. There are two major approaches to assessing pain. First is the unidimensional approach which is

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T&L?4 Examples of Tools for Assessing Sin Uxh_Iimcnsional

assessmenta

Body diagrams Visual analogue scales Grq hit rating scales Verbal descriptor scales Behavioral rating scales Multidimensional assessment Pain Assessment Tool and Flow Sheetb Brief Pain InventoryC McGill Pain Questionnaire (short and long)d Memorial Pain Assessment Can3 Pain/Comfort Journal’ Body Charts %%ee references IO, 11, and 53-55. bSee reference 60. %ee reference 56. ‘JSeereferences 21 and 58. %Seereference 57. ‘See reference 59. Gee reference 61.

adopted if the clinician wishes to assess components of only a single dimension such as pain location or intensity or relief. Tools can be used to assess components of the physiologic (location), sensory (intensity), affective (distress), cognitive (perceived relief), and behavioral (specific pain-related behaviors) dimensions. Table 4 shows some examples of comman imtruments. Although detailed description and discussion of these tools is beyond the scope of this paper, they are reviewed in several chapters on assessing and measuring pain.10vi’15’55 The second approach ts a&&g pain is the moultidimensional method, ZI which hvo or mJre dimensions of the experience arc assessed simultaneously, either with the same or combined tools. Many tools have been developed by psychologists, nurses, physicians, and others to assess various dimensions of pain. Some of them, also highlighted in Table 4, are familiar and have good reliability and validity.2’J6+J Several others are les; well known, but offer excellent possibilities for baseline and ongoing assessment of pain.5g6’ The tools shown in Table 4 also offer ample opportunity for the documentation of assessment data in ways that can be made readily available to clinicians involved in patient care. Documentation of assessment data is key to adequate management of pain. l The selection of specific tools for specific settings is a careful process with components that are delineated below.

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In the selection of an assessment tool, the foremost need is to decide which dimensions of pain are of most interest. Determination of those that predominate in particular painful situations is helpful. Additionally, consideration of the therapeutic approach to pain is helpful. For example, if the clinician is using interventions to decrease perception or sensation of pain (e.g., pharmacologic agents), assessment tools that address primarily the sensory and behavioral dimensions of pain are appropriate. If interventions to diminish the suffering component of pain are used (e.g., distraction, hypnosis), then tools addressing the affective, cognitive, and sociocultural dimensions may be more appropriate. Finally, if the cause of the pain is being treated (e.g., antineoplastic drugs), assessment should focus primarily on the physiologic dimension. The use of multidimensional tools gives more comprehensive information. With any tool, adequate psychometric properties such as reliability and validity are important, as are previous use in similar types of patients and “goodness of fit” with the current patient population. Other important areas of consideration are shown in Table 5. Subjectivity versus objectivity zb1e 5 in Selecting Pain Assesmmnt Teals

Considerations

Subjectivityversusobjectivity Behavioralobservation Self-report Cognitivelyimpaired Intact cognition Acutelyill Able to report Excruciating pain willing tD report Evaluation of behaviors Quality of pain Quantilication Multipledimensions Patient population/setting Clinicalfactors Demographics Diagnosis Age Type of pain Education Acuity of illness Culture Phase of illness Language Other symptoms Communication Therapies Preference Time/feasibility/relevance Time required for completion Format or layout/amount of writing Overlap with existingdocumentation Relevance of parameters to setting Relevance of parameters to clinician Comfort and preference Responsibiity and accountability

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is a major concern. Although self-report is clearly preferable, certain conditions must be present to facilitate its use. There are situations in which behavioral observations may be necessary or even preferable. Characteristics of the patient population and setting will have a strong impact on decisions about which tools to use. Both demographic and clinical factors should be considered. Finally, issues related to time, feasibility, and relevance in the specific clinical setting are of paramount importance.

Clearly, assessment is the key to relief of pain. A systematic process, with appropriate tools and documentation procedures, enhances the clinician’s ability to carefully evaluate pain through the collection of subjective and objective data. Such evaluation, when performed initially and throughout treatment, enables clinicians to achieve the goals of pain relief and patients to achieve the goals of increased comfort and improved functioning.

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