Clinical Oncology 23 (2011) 381e386 Contents lists available at ScienceDirect

Clinical Oncology
journal homepage: www.elsevier.com/locate/clon

Overview

The Measurement of Pain

C.L. Frampton *, P. Hughes-Webb y
* Churchill y

Hospital, Oxford, UK John Radcliffe Hospital, Oxford, UK

Received 1 February 2010; received in revised form 16 February 2011; accepted 11 April 2011

Abstract
Pain has been studied in depth for decades, yet the pain associated with cancer is still frequently under treated. The measurement of pain in patients with terminal cancer is imperative, because failure to carry it out is recognised as an important reason for inadequate treatment. Although pain is characterised as a symptom, it is a subjective personal experience or a perception. This perception is inuenced by both nociceptive transmission and central nervous system modulation; and psychological, social and other environmental factors. It is a complex issue most simply described by the phrase Pain is whatever the experiencing person says it is, existing whenever he says it does. With such complex interplays between pathophysiological and biopsychosocial factors, it is unsurprising that an objective assessment of pain remains elusive. Despite this, many subjective measures of pain have been developed that produce consistent and reliable results when used properly and appropriately. 2011 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
Key words: Biopsychosocial factors; measurement of pain; noiciceptive transmission; pathophysiological

Statement of Search Strategies Used and Sources of Information

We searched MEDLINE, EMBASE, CINAHL, PubMed, Bondolier, Cochrane Library, AMED, British Nursing Index, ZETOC and PsychINFO for English-language papers for all years. The key words and medical subject headings used were: pain measurement, or pain assessment alone and combined with palliative care, validity, cognitively impaired and elderly. The Oxford textbook of palliative medicine, third edition and Principles and practices of pain medicine, second edition were also examined. This was not a systematic review. If you cannot measure it you cannot control it John Grebe[from R. Boundy and J.L. Amos (eds) A history of the Dow chemical physics laboratory: the freedom to be creative. New York: Marcel Dekker, 1990: 53]

Pain Measurement Tools

There is a large number of validated pain measurement tools used for the research and treatment of patients with chronic non-cancer pain and some have been used for cancer pain [1]. The type of tool that is used depends on what factor of the pain experience is being evaluated, for example; pain intensity, pain relief, pain interference, pain quality, pain site, affect/unpleasantness and the temporal aspects of pain. Pain intensity is recognised as one of the most relevant clinical dimensions of the pain experience [2,3]. To measure pain intensity in a reliable and valid way, patients rate and record their pain on different types of unidimensional scale. However, as the perception of pain is inuenced by functional and other biopsychosocial factors, multidimensional pain measurement tools and healthrelated quality of life (HRQOL) questionnaires are also used to assess, not only pain intensity, but the effect of pain on patients lives.

Author for correspondence: C.L. Frampton, Oxford Pain Relief Unit, Churchill Hospital, Old Road, Headington, Oxford OX3 7LJ, UK. Tel: 44-07771553406. E-mail address: claireframpton@hotmail.com (C.L. Frampton).

Unidimensional Pain Scales

The three most commonly used methods to assess pain intensity (and pain relief) are the categorical verbal rating

0936-6555/$36.00 2011 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.clon.2011.04.008

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scales (VRS), visual analogue scales (VAS) and numerical rating scales (NRS). They are all well validated in the cancer pain population [4]. Verbal Rating Scales VRS have been used since the 1940s [5] and consist of lists of descriptors that represent varying degrees of pain intensity. The least intense descriptor is usually given a score of 0, the next 1 and so on. The patient picks the most appropriate descriptor from the list. For analysis purposes, the patients intensity score is the number associated with the chosen descriptor. The four-point VRS is most widely used clinically and the ve-point scale is commonly used for treatment outcome studies. The main advantage of the VRS is that they are relatively quick and simple to use. However, there are disadvantages; they are language dependent, the intervals between the categories may not be equal and having a nite number of discrete terms may force patients to pigeon hole their pain into a category that does not describe their pain satisfactorily. Using scales with larger numbers of descriptors increases the sensitivity of the tool [6]. A further VRS has been developed for pain relief often using a ve-word scale. Visual Analogue Scale The VAS consists of a line, usually 100 mm, anchored by two descriptors of extremes of pain: no pain on the extreme left and the worst imaginable pain on the extreme right. The patient marks a point on the line that best represents their perceived pain intensity at a specied point in time or within a well-dened interval (e.g. the past 24 h). The scale is scored by measuring the distance from the no pain end to their mark. VAS are easy to use and score, more independent of language and provide more points to choose from. They are more sensitive and precise than descriptive scales and have consistently shown sensitivity to changes in cancer pain associated with treatment or time [7]. Problems with the scale include: conceptual difculty for patients to understand the worst imaginable pain and difculty of use in the elderly, the unwell and disabled as more concentration and co-ordination are required. Bruera et al. [8] found that 16% of 101 palliative care patients were unable to complete a VAS for pain intensity and this number increased to 84% with disease progression. The validity of VAS depends on the administration method and the instructions given to patients [9]. VAS can also be used to assess other dimensions of pain, such as pain relief, pain frequency, efcacy of treatment, anxiety and emotional responses. Numeric Rating Scales The NRS consists of a numerical scale; from 0 to 100 (101-point scale), 0 to 10 (11-point scale) or 1 to 10 (10point scale), with 0 or 1 no pain and 100 or 10 worst pain. Patients are asked to write down, circle or state the number that best represents their perceived pain intensity.

Like the VAS and VRS, NRS can also be used to measure pain relief by asking patients to compare pain before and after treatment. NRS are considered both valid and sensitive, with a signicant correlation to other measures of pain intensity [10]. Evidence suggests that NRS are easier to use, associated with better compliance than the VAS [4] and generally preferred for the assessment of pain intensity [11]. Farrar et al. [12] looked at the clinical importance of changes in chronic pain intensity measured on an 11-point NRS by relating the changes to global assessments of change in multiple studies of chronic pain. They showed that a reduction of about two points or a reduction of about 30% in the pain intensity NRS represented a clinically important difference and the relationship was consistent regardless of baseline pain. Pain Intensity Versus Pain Relief Pain relief scales are perceived to be more appropriate than pain intensity scales, as all patients have the same baseline (zero pain relief), whereas with pain intensity scales patients start from different baseline pain intensities. There is also some evidence to suggest that pain relief scales are more sensitive than intensity scales [13,14]. However, pain relief scales rely upon the patient being able to recall their level of pain before intervention, and thus have less validity in the chronic or palliative setting [15]. Current evidence does not support the use of one scale over another. However, using a VRS may decrease the chance patients will confuse relief ratings with pain intensity ratings [7].

Multidimensional Scales
Pain intensity, pain relief and psychological distress are independent subjective judgements that interact in complex ways to determine the perception and experience of cancer pain. Multidimensional pain measurement tools can be used to assess the wider pain experience. Brief Pain Inventory The Brief Pain Inventory was originally developed for use in patients with cancer [16] and it is the most frequently used multidimensional pain measurement tool in cancer research [17]. This measurement tool consists of: a gure representing the body to identify the site of pain, four 11-point pain intensity NRS (current pain, worst pain in previous 24 h, least pain in previous 24 h and average pain) with the composite giving a single pain intensity score, a percentage scale quantifying pain relief from treatments and seven 11-point NRS that rate the extent to which pain interferes with function, mood and enjoyment in life, with the composite giving a single pain interference score. For pain intensity each NRS is sensitive, so theoretically the use of a multiple-item scale should be reliable and sensitive for detecting changes in pain associated with time or treatment [7]. However, for the pain interference items, recent publications have questioned their validity [18]. The form takes

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about 10 min to complete and it is valid in multiple languages. A shortened form is available, the Brief Pain Inventory-Short Form [17], which takes about 5 min to complete. The McGill Pain Questionnaire The McGill Pain Questionnaire (MPQ) provides estimates of the sensory, affective and evaluative dimensions of pain [19], and is often considered to be the gold standard of the pain measurement tools. The perception of pain has many different qualities in addition to pain intensity. The MPQ attempts to evaluate these different qualities. Measuring the qualitative and affective components of pain may be more useful in cancer pain, which is more likely to be multifactorial. The questionnaire consists of: a body drawing for identifying the site of pain, a ve-point pain intensity VRS and a list of 78 pain adjectives divided into 20 subclasses that reect different dimensions of the pain experience (sensory, affective and evaluative) [19]. Each word is assigned a value according to its position in its subclass. Patients indicate the words that best describe their pain. The questionnaire generates three major scores. The rst is the Pain Rating Index, which is the sum of the scale values of all the words chosen. The second is a rank score, which is the sum of all the rank values within each group of words for either the whole questionnaire or each dimension. The third is the total number of words chosen. Current evidence supports the validity of the MPQ scales to measure pain, including qualitative and affective components (in particular pain-related distress), as well as its reliability in patients with cancer (i.e. patients with cancer are generally consistent with the MPQ words they use to describe their pain) [7]. The MPQ does not measure pain interference. In terms of utility, the MPQ is time consuming to administer, 5e20 min, and often requires supervision. This may make it unusable for very sick and debilitated patients. The questionnaire is available in several languages as well as extended (McGill Comprehensive Pain Questionnaire) and shortened versions (Short Form-MPQ). The Short Form-MPQ is mainly used in the research setting [20]. It consists of only 15 descriptors from the sensory (n 11) and affective (n 4) categories, making it less of a burden to administer. The 15 descriptors are scored using a four-point VRS (0e3 scale) allowing for analysis of each pain descriptor. The Short FormMPQ correlates highly with the MPQ [4]. The Memorial Pain Assessment Card The Memorial Pain Assessment Card is a simple, short, easy to administer and readily understood assessment tool that can be used to obtain important subjective information from medically ill patients without contributing signicantly to their distress [21]. It is a validated tool that consists of three VAS to measure pain intensity, pain relief and mood, and a set of eight pain severity descriptors to further characterise pain intensity, all printed on one card. The mood scale correlates with measures of overall psychological distress, depression and anxiety, and is considered to be

a valid measure of global psychological distress [22]. The Memorial Pain Assessment Card has been used in the clinical evaluation of patients, and as an outcome measure in analgesic trials. It is currently available in English.

Assessment of Neuropathic Pain

Cancer pain is often complex, with patients having multiple pain at different sites each with a different character and quality (nociceptive or neuropathic). Multiple pains must be evaluated separately as some pain therapies may be found to affect some types of pain better than others. Therefore, it may be benecial to be able to distinguish between these different types of pain and in particular identify neuropathic pain from non-neuropathic pain. There are a number of different neuropathic pain screening tools that may be helpful, for example: the Leeds Assessment of Neuropathic Symptoms and Signs scale (LANSS), the Neuropathic Pain Questionnaire (NPQ) and the Douleur Neuropathique en 4 questions (DN4). The LANSS is a seven-item pain scale consisting of grouped sensory descriptors and a sensory examination, with a simple scoring system [23]. The prototype LANSS was initially validated in a sample of 60 patients and the nal seven-item scale was validated in another 40 patients. It has subsequently been validated in a number of other studies [24]. The LANSS scale is both sensitive (85%) and specic (80%), with a predictive value of 82% [25]. The NPQ consists of 12 items to help differentiate neuropathic pain from non-neuropathic pain [26]. It has 66.6% sensitivity, 74.4% specicity and 71.4% accuracy [27]. A Short Form-NPQ is a three-item questionnaire and it has similar sensitivity, specicity and accuracy [28]. The DN4 was developed by the French Neuropathic Pain Group. It is a 10-item questionnaire consisting of sensory descriptors and signs. The DN4 shows 83% sensitivity and 90% sensitivity. It is being translated into other languages [29]. Such questionnaires may be of help in screening patients for neuropathic pain, particularly by non-specialists.

Assessment of Breakthrough Pain

The temporal pattern of pain (variability, frequency, duration and pattern over time) is consistently rated as highly relevant in the assessment of cancer pain by experts in the eld of palliative care [11,30]. This is unsurprising given the high prevalence of breakthrough pain in both cancer and palliative care patients. Despite this, there is little research into the temporal aspects of cancer pain and few specic validated breakthrough pain assessment tools. The Breakthrough Pain Questionnaire [31] and the Alberta Breakthrough Pain Assessment Tool [32] both require further investigation for clinical validation.

Health-Related Quality of Life Instruments

The World Health Organization denes palliative care as: The active total care of patients whose disease is not

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responsive to curative treatment. Control of pain, of other symptoms and of psychological, social and spiritual problems, is paramount. The goal of palliative care is achievement of best quality of life for patients and their families. [27]. HRQOL instruments evaluate the overall health of an individual with an emphasis on physical functioning, mental health, social functioning and health-related concepts, including pain, fatigue and perceived well-being [33]. Several HRQOL instruments have been developed and internationally validated during the last decade [34]. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) is one of the most widely used HRQOL instruments used in both the oncology and palliative care settings [35]. It has been extensively validated in multiple languages [36]. The main disadvantage of the EORTC QLQ-C30 when used in palliative care is its length: it contains 30 items. A shortened version, the EORTC QLQ-C15, was developed specically for use in palliative care. Researchers identied and included 15 of the most important and relevant items to palliative care from the original questionnaire [34]. Using a multidimensional HRQOL questionnaire may give a more comprehensive overview of a patients symptom experience and more accurately assess the effect of pain on function.

seniors [28,42]. Examples of observational tools used clinically are, DOLOPLUS-2, Non-Communicating Patients Pain Assessment Instrument and Pain Assessment Checklist for Seniors with Limited Ability to Communicate. However, most studies have failed to show validity and reliability in the assessment of pain in the cognitively impaired [43]. Despite the lack of evidence, early recognition of pain in this population is essential. Observational measurement tools can be used to screen for the presence of pain and then incorporated with regular proxy pain assessments to guide treatments and therapies.

Pain Measurement Tools in Palliative and Advanced Cancer Care Research

In 2002, an expert working group, under the auspices of the Steering Committee of the Research Network of the European Association of Palliative Care, made a number of recommendations on the use of pain measurement tools in palliative care research, based on a literature review and expert opinion [4]. The group made the following recommendations for the selection of pain measurement tools for specic types of study: (1) Prevalence/severity and trajectory studies in adult patients: (a) Adult patients with no cognitive impairmentdthe Brief Pain Inventory-Short Form. (b) Adult patients with cognitive impairmentdthe fourpoint pain intensity VRS. (c) Adult patients unable to communicatedobserver rating using the four-point VRS. (2) Pain syndrome characterisation in: (a) Adult patients with no cognitive impairmentdco-administration of the Brief Pain InventoryShort Form and the short form of the MPQ. (b) Adult patients with cognitive impairmentdthese patients should be excluded. (3) Pharmacokinetic/pharmacodynamic studies in: (a) Adult patients with no cognitive impairmentdpain intensity and pain relief measured using an 11-point NRS. (b) Adult patients with cognitive impairmentdthese patients should be excluded. (4) Phase I, II and III analgesic studies in: (a) Adult patients with no cognitive impairmentdthe Brief Pain Inventory-Short Form to measure longterm changes in pain and pain interference with function, and an 11-point NRS to measure short-term changes in pain. For multiple dose phase II and III studies, inclusion of measures of adverse effects and a quality of life measure such as the EORTC QLQ-C30. In addition, for phase III studies, inclusion of a measure of satisfaction. (b) Adult patients with cognitive impairmentdthese patients should be excluded. The purpose of the recommendations was to achieve standardisation of outcomes and presentation of data in

Pain Measurement in Patients with Cognitive Impairment

Although self-report is the gold standard for pain assessment tools, other measures, such as observational and proxy reports, are necessary for patients with cognitive impairment, for example: reduced level of consciousness and delirium. Most research regarding pain measurement tools for use in the cognitively impaired has been carried out using elderly patients with dementia. Most studies have shown that observer and patient assessments are not highly correlated, and that the accuracy of a clinicians assessment cannot be assumed [37,38]. Physicians tend to underestimate and caregivers tend to overestimate patient cancer pain, whereas nurses (perhaps because of their more frequent contact with patients during treatment) are more often (but not always) more accurate than both physicians and caregivers when rating patient cancer pain [7]. The end result is that proxy ratings may provide some indication of patients cancer pain, but cannot be assumed to be accurate and therefore must be interpreted cautiously. A variety of different observational measurement tools for the assessment of pain in the cognitively impaired are currently used clinically and in research. Such tools make use of a number of potential behavioural indicators that suggest the possible presence of pain: facial expressions, verbalisations/vocalisations, body movements, changes in interpersonal interactions, changes in activity patterns of routines and changes in mental status. However, research has not established the sensitivity of such indicators [39]. Observational tools primarily suited to research include the Facial Action Coding System [40] and the Pain Behaviour Measurement [41], which has shown validity among

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studies of pain in palliative care, which will include patients with advanced cancer. Standardisation would enable comparison between studies and increase validity of the comparisons [4]. However, new pain measurement tools for advanced cancer continue to be developed, mainly driven by specic research interests, and as such, are not adding to a consensus base for an optimal pain measurement tool [11]. Pain Measurement in Clinical Practice In clinical practice, cancer pain is still not routinely measured [44] and as it stands there is no universally accepted pain measurement tool [11]. Cancer pain can be transient or chronic, or both, and may be related to the disease or the treatment. Like any clinical assessment, the evaluation of cancer pain should begin with a thorough history and examination with the assessment of pain with a suitable pain measurement tool. The choice of pain measurement tool used depends on the objective. When the objective is to measure the state of the pain at a given time, then pain intensity scales should be used. Both current and typical pain can be rated. Current pain assessments tend to be more popular as they are independent of memory, which may be a signicant factor in the advanced cancer population. As cancer pain is multifactorial, ideally a multidimensional pain management tool, such as the MPQ or Short Form-MPQ, should be administered. If neuropathic pain is suspected, this can also be assessed using the LANSS or NPQ or a similar neuropathic pain screening tool. In subsequent assessments, when the objective is to measure the clinical response of pain to treatment, both pain intensity and pain relief scales should be administered. The pain measurement tools used at the initial assessment should be used for subsequent assessments. For inpatients, routine use of pain charts will improve quality of care [45]. The Multidimensional Continuous Pain Assessment Chart for cancer patients is one example of a pain chart currently being used in clinical practice. It integrates pain intensity VAS, treatment techniques, regular medication and rescue doses, co-analgesics, pain categories and parameters relating to quality of life [46]. It is done at the bedside and takes only a few minutes to complete. Most probably the fact of a pain chart is more important than the form it takes. In North America, pain is recorded as the fth vital sign, alongside blood pressure, heart rate, temperature and respiratory rate, for all patients. For outpatients, pain diaries can be used. Pain diaries can provide information on the temporal aspects as well as the severity of pain. The diaries can be completed at the end of the day or at set times over the day. Patients can record information on function, mood and sleep, as well as analgesia consumption. In a study by de Witt et al. [47], 86% of 156 cancer patients were able to complete 11-point NRS pain diaries for 2 months. They found a strong association between average pain intensity ratings at 2 weekly interviews with actual diary averages. With adequate

instruction, pain diaries have been shown to be very accurate [48]. Diaries have been used successfully in analgesic studies.

Conclusion
Pain is common in cancer care and the assessment and measurement of pain is the essential rst step in the successful management of pain. There are a number of pain measurement tools used in the research and clinical management of pain in cancer care patients, but there is no gold standard tool. Ideally, such a tool would be valid and reliable, multidimensional but short and easy to use, and appropriate for both clinical practice and research. The use of pain measurement tools should be part of normal everyday clinical practice. The implementation of such tools in cancer care should ensure patients are receiving the quality of service they expect and clinicians think they are providing.

Conict of Interest
The authors declare that they have no Conict of Interest.

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