Pain Assessment Instruments for Use in the Emergency Department

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Barriers to assessment

Pain is inherently subjective and inevitably complex. Our patients experience pain and suffering as individuals; we assess it only indirectly. Our clinical and research task is to use a commonly understood vocabulary and classification system in assessing pain, so that our findings can be communicated consistently. Only by quantifying the pain experience in meaningful ways can we move beyond myth and idiosyncratic opinions toward a more scientific approach to questions regarding the pain

Reliability and validity

As the author discusses specific measurement instruments, he will refer often to validity and reliability. Validity asks the question: “Does this instrument measure what it is supposed to measure?” Common aspects of validity that can be assessed include content validity, criterion validity, or predictive validity. In judging content validity, we question how relevant specific questions are to the aims of the instrument. This is often done informally by asking experts their opinions of the

Pain intensity

We will consider four single-item instruments used to rate pain intensity: the numerical rating scale (NRS), visual analog scale (VAS), graphical rating scale (GRS), and verbal rating scale (VRS). The integration of pain intensity as a “vital sign” within health care institutions has been promoted with some success by the Joint Commission on the Accreditation of Health Care Organizations (JCAHO), and in most US emergency departments today, a single-item rating of pain intensity (usually some

The numerical rating scale

A typical NRS consists of a range of numbers, from which one is selected by the patient as most representative of their level of pain intensity (Fig. 2). Although the range of numbers used is usually 0 to 10, other ranges may be used, such as 0 to 20, or 0 to 100. Patients are told that zero represents “no pain” and that the highest number represents some maximal measure of pain. The verbal descriptor for this extreme state may vary; however, phrases such as “pain as intense as you can imagine”

The visual analog scale

The VAS typically consists of a 100-mm line, oriented horizontally and bounded at each end by verbal descriptors of pain intensity severity (Fig. 3). The descriptor “no pain” is situated to the left of the line, and a phrase describing an upper pain intensity limit, such as “worst pain possible” or “pain as bad as it could be,” appears to the right of the line. Patients are asked to place a mark at the point on the line that best represents their pain intensity level. The distance from the left

Visual analog scale versus numerical rating scale

Given the similar psychometric properties of the VAS and NRS, which instrument is preferred? As mentioned above, the VAS has been used more frequently in the past; however, patients appear to prefer the NRS, and comprehension of the VAS is problematic in the elderly population and in those with cognitive impairments. Patients unable to complete the VAS were found to be older than those able to complete the measure (73 versus 54 years) [6]. Other investigators have found that patients prefer the

Picture scales

These instruments include a series of facial images or illustrations of facial expressions meant to represent various pain states [14]. They are presented to the patient, who is asked to choose the facial expression that best matches his or her pain intensity. Each image is assigned a number, which becomes the patient's pain intensity score (Fig. 4).

Picture scales demonstrate both criterion and predictive validity, and may be particularly useful for populations with limited literacy, including

Verbal rating scales

Verbal rating scales (VRS) consist of a number of adjectives or phrases describing increasing pain intensities (Fig. 5). Patients are told to choose the adjective or phrase that best describes their pain intensity. The pain intensity score is the number assigned to the descriptor chosen by the patient. The number of descriptors used has ranged from four (none, mild, moderate, severe) [7] to 15 [19]. The four-descriptor scale is widely used in clinical settings, is easy to administer, and has

Temporal characteristics

Pain in the emergent setting tends to be severe; thus measures of time to pain relief are of particular importance. These measures are relatively underused in pain research, and are a promising area of investigation for emergency medicine pain researchers. For emergency medical in general, and pain management in particular, minutes count.

One method of assessing this temporal quality of pain experience uses a “double stopwatch” technique [21], [22], [23], [24], [25], [26]. Patients are given two

Pain-related physical function—the Brief Pain Inventory

Pain is a multidimensional experience. The impact of pain on the patient's function and mood is particularly important to understand and has relevance to multiple stakeholders, including his or her family, social contacts, and employer, and workmen's' compensation entities. Although measures of physical function are commonly incorporated into studies of chronic pain, the author was unable to identify emergency medicine studies assessing the impact of pain on function. Given that emergency

Summary

Each patient's pain experience is uniquely his or her own. Standardized pain assessment methodologies and procedures provide a window to this experience and constitute a necessary first step to our understanding of pain, in both clinical and research settings. All too often, emergency department pain assessment is cursory—performed more to satisfy regulatory requirements than to guide our therapies or evaluate our practices. This article provides information on a number of assessment techniques

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References (42)

  • A. Saxena et al.

    The assessment of cancer pain in north India: the validation of the Hindi Brief Pain Inventory—BPI-H

    J Pain Symptom Manage

    (1999)
  • X.S. Wang et al.

    The Chinese version of the Brief Pain Inventory (BPI-C): its development and use in a study of cancer pain

    Pain

    (1996)
  • E.J. Tyler et al.

    The reliability and validity of pain interference measures in persons with cerebral palsy

    Arch Phys Med Rehabil

    (2002)
  • M.P. Jensen et al.

    Cognitions, coping and social environment predict adjustment to phantom limb pain

    Pain

    (2002)
  • R.C. Serlin et al.

    When is cancer pain mild, moderate or severe? Grading pain severity by its interference with function

    Pain

    (1995)
  • V.T. Chang et al.

    Longitudinal documentation of cancer pain management outcomes. A pilot study at a VA medical center

    J Pain Symptom Manage

    (2002)
  • S. Evans et al.

    Randomized trial of cognitive behavior therapy versus supportive psychotherapy for HIV-related peripheral neuropathic pain

    Psychosomatics

    (2003)
  • C.R. Chapman

    Measurement of pain: problems and issues

  • P.E. Bijur et al.

    Validation of a verbally administered numerical rating scale of acute pain for use in the emergency department

    Acad Emerg Med

    (2003)
  • M.P. Jensen et al.

    The subjective experience of acute pain. An assessment of the utility of 10 indices

    Clin J Pain

    (1989)
  • A.J. Singer et al.

    Ability of patients to accurately recall the severity of acute painful events

    Acad Emerg Med

    (2001)
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    This work is supported, in part, though a generous grant from The Mayday Fund, New York, New York.

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