To summarize our previous lecture 📘, the process by which people perceive pain 🤕 involves a complex chain 🔗 of physiological 🧬 and neuro-chemical events ⚡. These events can be affected by psychosocial processes 🧠, such as people's beliefs 💭 about whether a drug 💊 will reduce their discomfort 📉.
Pain 🤕 also affects and can be influenced by people's learning 📚, cognition 🧠, social experiences 👥 and emotion 😢. Although people can indicate through their behavior 🧍♂️ that they are feeling pain 🤕, the pain they perceive is actually a private 🔒 and subjective experience 💭.
How can researchers 👨🔬 and clinicians 🧑⚕️ who work with patients who have painful symptoms 🤕 assess the level and type of pain these individuals perceive? We will be answering this question ❓ in this lecture.
Assessing People's Pain 📊🤕
Researchers 👨🔬 and clinicians 🧑⚕️ have developed a variety of techniques 🛠️ for assessing people's pain 🤕. Although virtually all these methods can be applied both in research 🔬 and in treating pain patients 🏥, some techniques are used more often in research 📊, whereas others are used mostly to supplement a detailed medical history 📋 in clinical practice 🏥. In either setting, it is advisable to use two or more different measurement techniques 🔄 to enhance the accuracy 🎯 of the assessment. We will organize our discussion of techniques for measuring people's pain 🤕 by classifying them into three groups 3️⃣: self-report methods 📝, behavioral assessment approaches 🧍♂️, and psycho-physiological measures 📊.
1. Self-Report Methods 📝💬
Perhaps the most obvious approach to measuring people's pain 🤕 is to ask them to describe their discomfort 😣, either in their own words 💬 or by filling out a rating scale 📊 or questionnaire 📋. In treating a patient's pain 🏥, health care workers 🧑⚕️ ask where the pain is 📍, what it feels like 💭, how strong it is 📏, and when it tends to occur ⏰. With chronic pain patients ⏳, medical 🧑⚕️ and psychological professionals 👨🔬 often incorporate this kind of questioning within the structure of a clinical interview 💬.
A. Interview Methods in Assessing Pain 💬🤕
To treat chronic pain ⏳ effectively 💪, professionals 🧑⚕️ need more information 📚 than just 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 🏥. 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 🌍—recreational interests 🎾, exercise patterns 🏃♂️, diet 🥗, and so on—before the pain condition 🤕 began.
- 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 📋.
B. Pain Rating Scales 📊📏
One of the most direct, simple, and commonly used ways to assess pain 🤕 is to have individuals rate some aspect of their discomfort 😣 on a scale 📏. This approach is used very often to measure how strong 💪 the pain is. Because rating scales 📊 are so easy and quick ⚡ to use, people can rate their pain frequently 🔄. Averaging these ratings across time ⏳ gives a more accurate picture 🖼️ of the pain the person generally experiences than individual ratings do. Repeated ratings 🔄 can also reveal how the pain changed over time ⏳, such as during everyday activities 📅 or during the course of an experiment 🔬. One use of repeated ratings 🔄 is in showing the ebbs and flows 🌊 of pain intensity 📊 that patients often experience.
For instance, one patient's wife 👩 believed that her husband 👨 was experiencing incapacitating and severe pain 😖 every waking hour ⏰ of his life. This belief 💭 contributed to her preventing him from participating in any but the simplest chores 🏠 around the house. Their social life 👥 had deteriorated 📉, and the couple had grown increasingly depressed 😞 over the course of 4 years ⏳. Upon hearing that her husband experienced only moderate pain 😣 most of the time ⏰, that he indeed felt capable 💪 of various tasks 📋, and that he actually resented 😠 his wife's efforts at pampering 🤗 him, she was helped to alter her behavior 🔄.
Repeated ratings 🔄 during each day 📅 may also reveal patterns 📊 in the timing ⏰ of severe pain 😖. Is the pain most severe in the evening 🌙, or on certain days 📅? If so, are there some aspects of the environment 🌍 that may be responsible and perhaps changeable 🔄?
C. Pain Diaries 📓✍️
Pain ratings 📊 can also be used in a pain diary 📓, which is a detailed record 📝 of a person's pain experiences 🤕. The pain diary a patient keeps 📓 would include pain ratings 📏 and information about the time ⏰ and circumstances 🌍 of pain episodes 💥, any medications 💊 taken, and comments 💬 about each episode.
D. Pain Questionnaires 📋📝
Pain 🤕 is only partly described by the intensity 📏 of the discomfort people feel 😣—the experience of pain has many qualities 🎨 and dimensions 📊. Ronald Melzack 👨🔬 began to recognize the multidimensional nature 🌐 of pain through his interactions 💬 with pain patients 🤕. He described in an interview how this realization 💡 emerged from talks 💬 he had with a woman 👩 who suffered from phantom limb pain 🦾. She would describe burning pains 🔥 that were like a red-hot poker 🔥 being shoved through her toes 🦶 and her ankle. She would cry out 😭 from the pain in her legs 🦵. Of course, there were no legs ❌. Well, that made me realize the utter subjectivity 💭 of pain—no objective physical measure 📊 is very likely to capture that.... I began to write down ✍️ the words she used to describe her pain 🤕. I realized that the words describing the emotional-motivational component 😢 of her pain—"exhausting 😫, sickening 🤢, terrifying 😱, punishing"—were very different from those for the sensory component 👁️—"shooting ⚡, scalding 🔥, splitting, cramping 😣." Later I came to see there was also an evaluative component 💭 such as "it's unbearable" or "it's annoying 😤". I wrote down ✍️ the words other patients 🤕 used, too, but I didn't know what to do with them.
Melzack 👨🔬 determined that pain 🤕 involves three broad dimensions 3️⃣—affective (emotional-motivational) 😢, sensory 👁️ and evaluative 💭—by conducting a study 🔬 in which subjects sorted over 100 pain-related words 💬 into separate groups 📋 of their own making.
Melzack's research 📊 also indicated that each of the three dimensions 3️⃣ consisted of sub-classes. For instance, the sensory dimension 👁️ included a sub-class with the words "hot 🔥," "burning 🔥," "scalding 🌡️" and "searing 🔥"—words relating to temperature 🌡️. Notice that these four words connote increasingly hot temperatures 📈, with searing being the hottest 🔥. Similarly, the affective dimension 😢 included a subclass of three words relating to fear 😱: "fearful 😟," "frightful 😰," "terrifying 😱." Then, by determining the degree of pain 📏 reflected by each word 💬, Melzack 👨🔬 (1975)—a professor at McGill University 🏫—was able to construct an instrument 📋 to measure pain 🤕. This test is called the McGill Pain Questionnaire (MPQ) 📋.
2. 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 👀. A person is likely to show different types and patterns of behavior 🔄 if the pain is intense 😖 as compared to moderate 😣; if it involves a headache 🤕 as opposed to low back pain 🦴; and if chronic pain ⏳ is recurrent 🔄 than if it is intractable. Psychologists 👨🔬 have developed procedures for assessing pain behavior 🧍♂️ in two types of situations 2️⃣: in everyday activities 🌍 and in structured clinical sessions 🏥.
A. Assessing Pain Behavior in Structured Clinical Sessions 🏥📋
Procedures are available whereby health care workers 🧑⚕️ can assess the pain behavior 🧍♂️ of patients 🤕 in structured sessions that are usually conducted in hospital settings 🏥. They are structured 📋 by the specific pain behaviors 🧍♂️ to be assessed and the tasks 📝 the patient is asked to perform. 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 ☀️. 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 0️⃣," "occasional 1️⃣," and "frequent 2️⃣." These ratings are converted into numerical values 🔢 and summed for a total score 📊.
Some studies using structured clinical sessions 🏥 have focused on assessing discomfort 😣 in individuals suffering from low back pain 🦴. Each investigation had patients perform a standard set of activities 📋. In one study 🔬, for example, the people were asked to walk 🚶♂️, pick up an object 📦 on the floor, remove their shoes 👞 while sitting, and perform several exercises 🏃♂️, such as trunk rotations 🔄, toe touching 🦶, and sit-ups 💪. Patients in each investigation were videotaped 📹, and trained assessors 👨🔬 rated their performance for several pain behaviors 🧍♂️, such as guarded movement 🛡️, rubbing the pain area 🤲, grimacing 😖, and sighing 😮💨. These studies have shown that pain behaviors can be assessed easily ✅ and reliably 🎯 and that behavioral assessments 📊 correlate well 🔗 with patients' self-ratings 📝 of pain 🤕.
B. Assessing Pain Behavior in Everyday Activities 🌍📅
How does the pain patient 🤕 behave in everyday activities 📅 especially at home 🏠? Does the person spend much time in bed 🛏️, complain of discomfort 😣 a lot 💬, seek help frequently 🙏 in moving 🚶♂️, or walk with a limp 🦵 most of the time ⏰? How much of these behaviors 🧍♂️ do the person exhibit? Behavioral assessments 📊 of everyday activities like these can be made.
Family members 👨👩👧 or key others 👥 in the patient's life are usually the best people to make these everyday assessments 📊 of pain behavior 🧍♂️. These people must, of course, be willing to help 🤝 and be trained 📚 to make careful observations 👀 and keep accurate records 📓.
Researcher Wilbert Fordyce 👨🔬 (1976) has recommended a procedure whereby the assessor 👥—say, the client's spouse 👫—compiles a list 📝 of five to ten behaviors 🔟 that generally signal when the patient is in pain 🤕. Then the spouse is trained 📚 to watch for these behaviors 👀, to keep track of the amount of time ⏰ the patient exhibits them, and to monitor how people 👥, including the assessor, react to the client's pain behavior 🧍♂️. This procedure is useful not only in assessing the patient's pain experiences 🤕 but in determining their impact ⚡ on his or her life 🌍 and the social context 👥 that may maintain pain behaviors 🔄.
These supplemental procedures 📋 provide additional data 📊 that can be of value in dealing with interpersonal issues 👥 that influence the pain experience 🤕.
3. Psychophysiological Measures 📊🧬
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 🧍♂️. Psychophysiology is the study of mental 🧠 or emotional 😢 processes as reflected by changes they produce in physiological activity 🧬.
A. Electromyograph (EMG) ⚡💪
One psychophysiological measure 📊 researchers 👨🔬 have used for assessing pain 🤕 uses an apparatus called an Electromyograph (EMG) ⚡ to measure the electrical activity ⚡ in muscles 💪, which reflects their tension 😤. The findings of various researches 📚 suggest that differences between pain patients 🤕 and controls may exist when the subjects' muscles 💪 are active 🏃♂️. And headache patients 🤕 show different EMG patterns 📊 when they have headaches than when they do not ❌.
B. Autonomic Activity ❤️📊
Researchers 👨🔬 have also attempted to assess peoples' pain 🤕 with measures of autonomic activity 🧬, such as of heart rate ❤️ and skin conductance 👤.
Although some measures of autonomic activity 🧬 may be useful in assessing the emotional component 😢 of pain 🤕, they are not likely to be very useful ❌ because changes in autonomic activity 🧬 also occur in the absence of the sensation of pain 🤕.
C. Electroencephalograph (EEG) 🧠⚡
The last psychophysiological measure 📊 of pain 🤕 we will consider involves the electrical activity ⚡ of the brain 🧠, as measured by an 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 ⚡. Electrical changes produced by stimuli are called evoked potentials ⚡ and show up in EEG recordings 📊 as sharp surges 📈 or peaks in the graph 📊. Pain stimuli 🤕 produce evoked potentials ⚡ that vary in magnitude 📏—the amplitudes of the surges increase 📈 with the intensity of the stimuli 💥, decrease 📉 when subjects take analgesics 💊, and correlate 🔗 with people's subjective reports 📝 of pain 🤕.
Even though psychophysiological measures 📊 provide objective assessments 🎯 of bodily changes 🧬 that occur in response to pain 🤕, these changes may also be affected by other factors ⚠️, such as attention 👀, diet 🥗, and stress 😰. In clinical situations 🏥, measures of muscle tension 💪, autonomic activity 🧬, and evoked potential ⚡ are probably best used as supplements 📊 to self-report 📝 and behavioral assessment approaches 🧍♂️.
Assessing Pain in Children 👶🤕
When a patient has symptoms that include pain 🤕, the physician 🧑⚕️ usually needs to know its location 📍, intensity 📏, quality 🎨, duration ⏰, and temporal patterning ⏳. This information helps in making an accurate diagnosis 🔍. Although children's 👶 ability to provide this information is limited 📉, especially if they are young 👶, researchers 👨🔬 have developed measures that use self-report 📝, behavioral 🧍♂️, and physiological methods 📊. Effectively interviewing children 💬 requires considerable skill 🎯 in developing rapport 🤝 with them, asking the right questions ❓ in ways they can understand 🧠, and knowing what their answers mean 💭.
What kinds of self-report methods 📝 are available to assess children's pain 👶? One approach uses rating scales 📊 to describe the intensity 📏 of their pain 🤕. Another approach uses questionnaires 📋. These instruments assess the pain itself 🤕 and its psychosocial effects 😢, such as how the child 👶 and family 👨👩👧 reacted to the pain. Adults 🧑 may help the children fill out portions of the questionnaires 📋 when they lack needed language skills 💬.
Behavioral 🧍♂️ and physiological assessment approaches 📊 also provide valuable ways to measure children's pain 👶, especially in early childhood 👶. The most obvious behavioral approach 🧍♂️ simply involves having the child 👶 or parents 👨👩👧 report the child's pain behaviors in pain diaries 📓. Other behavioral assessments 📊 can use structured clinical sessions 🏥 in which health care workers 🧑⚕️ rate or record 📹 the occurrence of pain behavior 🧍♂️. Methods for physiological assessment 📊 are like those we considered earlier.
Children's pain experiences 👶 are affected by a variety of psychosocial factors 🧠, particularly the social environment 👥 in which pain 🤕 occurs. Parents 👨👩👧 serve as models 🎭 and agents of reinforcement 👍 for the pain behavior 🧍♂️ of their children 👶. But little is known about the personality 🧠 and family characteristics 👨👩👧 of children that may contribute to the intensity 📏 and frequency 🔄 of their pain 🤕. Most studies on pain 🤕 have focused on adult subjects 🧑, not on children 👶, and the studies conducted with children have generally produced unclear results ❓ because they were often poorly designed 📋 and carried out. Now that researchers 👨🔬 have methods to assess children's pain 👶, they can do the kind of high-quality research 📚 that is needed.