Standardized psychometric assessments

Many standardized questionnaires have been developed for the assessment of patients with chronic pain. They can be valuable for identifying mechanisms that contribute to pain, planning treatment, and monitoring changes during and after treatment. The evaluation of pain and associated beliefs and behaviours require measures developed specifically for this purpose, and these are described below.

Other assessments, for example of mood, illness behaviour, and social dysfunction, have been developed within the field of pain research. Some measures are rather idiosyncratic, with uncertain psychometric properties, aimed at restricted diagnostic groups and clinical settings. This undermines the need to use consistent methods that allow comparison of different groups of patients, with physical, mental, and mixed disorders, at different places and times.

Pain

The severity of pain can be assessed using visual analogue scales and numeric analogue scales. These scales have anchor points ranging from 'no pain' to 'the worst possible pain'.

The quality of pain can be assessed with verbal descriptor scales, of which the best known is the McGill Pain Questionnaire ( MPQ). Factor analysis has resulted in the description of several scales claimed to represent different qualities or 'dimensions' of pain. The two that have best survived the test of time are an 'affective' dimension (represented by words such as exhausting, terrifying, vicious), and a 'sensory' dimension (e.g. stabbing, crushing, burning). These have been found consistently when the MPQ has been administered in different languages and in different cultural groups. Ratings on both the affective and sensory scales are positively correlated with pain severity and mood ratings and, in the presence of mental disorders, contribute little to diagnosis.

The topographical distribution of pain can be assessed by using outline drawings of the body (front, back, and sometimes sides), which the patient is asked to shade to indicate the distribution of pain. These can help to identify pain that does not conform to physiological distributions and also widespread pain. Measures of pain intensity, quality, and distribution can be used together to capture the rather elusive and entirely subjective experience of pain.

Pain behaviours

Although the experience of pain is entirely personal, it may be communicated to others by a range of verbal and non-verbal behaviours, which in some cases may be maladaptive, and which in turn influence the responses of others. Standardized structured assessments are available to measure a range of well-defined behaviours/5) These may include complaints of pain, requests for medication, groaning, facial expression, mobility, time spent resting, and postures such as guarding and bracing. Such behaviours have been shown to fluctuate in response to changes in the environment, including different attitudes and responses of observers, and may improve dramatically when patients are admitted to an inpatient treatment programme.

Pain beliefs

The belief that chronic as well as acute pain signals an underlying physical disease, which requires and should respond to physical intervention, contributes to the widespread dissatisfaction often expressed by patients and their doctors. Inappropriate beliefs contribute to the development and maintenance of chronic pain and non-adherence to treatment and must therefore be assessed. Beliefs that are relevant to pain assessment fall into three groups: (6)

1. beliefs about the nature of reality—for example 'life should be pain-free';

2. beliefs in response to challenging circumstances, such as pain—including locus of control, attributional style, cognitive errors, and coping strategies;

3. specific ideas about the cause of a pain, appropriate management, and outcome.

The questionnaire assessment of pain-related beliefs has assumed increasing importance in the field of pain research in recent years, (6) with the recognition that pain beliefs interact with pain, cognitions, behaviours, and affects, and contribute to the prediction of outcome.

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