Assessment of pain in rheumatic diseases T. Sokka Tuulikki Sokka, MD, PhD, Research ABSTRACT ture or myocardial infarction can pro- Assistant Professor, Vanderbilt University, Pain is the most prominent symptom in vide clinical information concerning Nashville, and Consultant Rheumatologist, people with musculoskeletal disorders, pain, and changes can be observed over Jyväskylä Central Hospital, Jyväskylä, and the most common motivation for the next few hours and days without the Finland. patients seeking medical help. Howev - apparent need for quantitative data. Reprinted and modified from Best Pract er, pain generally is not recorded quan - Pain and other symptoms are regarded Res Clin Rheumatol, vol. 17, Sokka T: "Assessment of pain in patients with titatively in routine medical care. Over as “subjective,” based on data obtained rheumatic diseases", pp. 17: 427-49, the last three decades, self-report ques - from the patient, and are viewed by the copyright 2003, with permission from t i o n n a i res have been developed in clinician largely as preliminary to criti- Elsevier. which a patient may record quantita - cal “objective” data obtained from the Please address correspondence and tively a pain score at baseline and over physical examination, laboratory tests, reprint requests to: Tuulikki Sokka, MD, time to determine whether their condi - or imaging procedures. This view is PhD, Vanderbilt University / Rheumato- tion has improved, remains unchanged, consistent with what has been termed logy, 203 Oxford House, Nashville, TN or has worsened. The most robust quan - the traditional “biomedical model” 37232-4500, USA. titative pain measure appears to be a (12), which has been applied so suc- E-mail: [email protected] simple 10 cm visual analog scale (VAS ) , cessfully in acute medical care during Clin Exp Rheumatol 2005; 23 (Suppl. 39): which can be completed by the patient the 20 th century that it is often applied S77-S84. and scored by a health professional in to chronic diseases as well. © Copyright CLINICALAND EXPERIMENTAL less than 10 seconds. Quantitative data At this time, chronic diseases are the RHEUMATOLOGY 2005. concerning pain cannot be obtained most important problem in medical Key words: Pain, assessment of pain, from any source other than the patient. care. In the management of chronic dis- rheumatoid arthritis, osteoarthritis, Quantitative assessment of pain at ea c h eases, the “biomedical model” is not as fibromyalgia, MDHAQ. visit in routine rheumatology care , useful as in acute diseases in guiding along with the assessment of functional diagnosis and management and has d i s a b i l i t y, global status, and other substantial limitations. For example, patient variables, using a patient self- the most effective predictors of mortal- re p o rt questionnaire might lead to ity in patients with rheumatoid arthritis improved patient care. (RA) include data from a patient ques- tionnaire concerning the patient’s phys- Introduction ical function and level of formal educa- Pain is the most prominent symptom in tion, rather than data from a physical the majority of people with arthritis (2- examination, laboratory tests or radio- 5), a common reason for primary care graph (13-16). In the management of consultation (6-8), and a major source chronic rheumatic diseases, it is virtu- of health care costs (9). Musculoskele- ally impossible to assess pain over long tal pain appears to be much more com- periods without quantitative data to mon now than 40 years ago (10). None- estimate whether or not a patient’s con- theless, quantitative information con- dition is improved, unchanged or worse cerning pain, which is required to over months to years. assess and document possible improve- A clinical science of pain assessment ment, stabilization, or worsening of using patient self-report questionnaires pain over time, is generally not record- has been developed over the last few ed in routine medical care. In a survey decades to facilitate qualitative and of U.S. emergency department visits in quantitative assessment of pain status 1999, 52% included no recorded infor- at any given time (17-27). Despite lim- mation concerning the presenting level itations which are intrinsic in any sci- of pain (11). entific measurement, pain question- In acute medical situations, the primary naires have proven valuable in the stu- setting for most medical education and dy of the mechanisms underlying the training, the quantitative assessment causes and control of pain. and recording of pain levels may ap- In this essay, we review patient self- pear unnecessary.A patient with a frac- report questionnaires as quantitative S-77 Assessment of pain in rheumatic diseases / T. Sokka measures of pain. We summarize the log scale, but that generally self-report- derivations of the HAQ have been dev- results generated using these question- ing is adequate thereafter. eloped, including a modified HAQ (M- naires in RA, osteoarthritis (OA), and The standard visual analog scale is a 10 HAQ) (36), a multidimensional HAQ fibromyalgia (FM). We also summarize cm scale with a border on each side. To (MDHAQ) (37), and the HAQII (38). data which reveal significant associa- the left of the “0” mark appears the The HAQ and its derivative versions tions between pain scores and the phys- indication “No pain at all”, and to the are discussed in greater detail in other ical examination, and radiographic and right of the “10” mark “Pain as bad as it chapters in this supplement. laboratory data. Such associations ap- could be”. There are occasional distor- pear weaker, however, than the associa- tions through photocopying and print- The Arthritis Impact Measurement tions of pain scores with measures of ing, but adjustments can be made so Scales (AIMS) functional and psychological status. that the total score is 10. The Arthritis Impact Measurement Huskisson and colleagues also pointed Scales (AIMS) was developed by Assessment of pain using patient out that an alternative descriptive pain Meenan and colleagues (22) to assess questionnaires relief scale – based on the indications the physical, emotional and social well- The Minnesota Multiphasic Person- “complete”, “moderate”, “slight” and being of individuals with arthritis, with ality Inventory and the McGill Pain “no pain” relief – was possible, but scores for 9 categories: mobility, physi- Questionnaire much less sensitive than the visual ana- cal activity, social activity, social role, The Minnesota Multiphasic Personality log scale. A number of studies have activities of daily living, pain, dexteri- Inventory (MMPI) (28) is an early established that data from self-report ty, anxiety, and depression. Each score patient self-report questionnaire. A l- visual analog scales are reproducible is based on 4 to 6 items with response though not strictly a pain questionnaire, (34, 35). In one study (35) an absolute alternatives on Likert-format scales. the MMPI represents one of the first visual analog scale was found to be The AIMS pain category includes 4 widely used patient questionnaires more reproducible than a comparative questions: “During the past month, which gained acceptance over the last visual analog scale. how often have you had severe pain half-century. With the development of optical scan- from your arthritis ?”; “During the past The McGill Pain Questionnaire (17, ning technology for the automated month, how would you describe the 18) constituted a major advance in clin- computer entry of scores, visual analog arthritis pain you usually have ? ” ; ical research on pain. The question- scales have been presented in a format “During the past month, how long has naire is complex and completion re- of 21 small boxes or circles for patients your morning stiffness usually lasted quires 15-20 minutes, even in its short to assess their pain from 0-10 (or 100). from the time you wake up ?” “During form (29). Therefore, it is not easily Although formal direct comparative the past month, how often have you administered in a non-research clinical studies have not been performed to had pain in two or more joints at the setting, and simpler measures – such as analyze the results of automated optical same time ?” a visual analog pain scale – have scanning, they appear to have criterion The AIMS index has excellent psycho- become more widely accepted for use validity. The visual analog pain scale metric validity and greater reliability in clinical research, clinical trials, and has proven a great advance in the as- than the HAQ and its derivatives, and clinical care. sessment of pain. has been used in clinical trials to docu- ment the sensitivity of patient question- Visual analog pain scales The Health Assessment Questionnaire naires to changes in clinical status. A visual analog pain scale was initially (HAQ) and its derivatives: The Modi- However, the HAQ and its derivatives used in psychology by Freyd and oth- fied Health Assessment Questionnaire are more easily completed by patients ers since the early 1900s. Huskisson (MHAQ), Multi-Dimensional Health and more easily scored by health pro- and colleagues developed the use of a Assessment Questionnaire (MDHAQ), fessionals in clinical trials and in rou- pain VAS in rheumatology through a and Health Assessment Questionnaire tine care, and used considerably more series of investigations in the late (HAQ-II) widely than the AIMS. 1970s (19, 20, 30-33), pointing out that The HAQ was developed in the 1970s “only the patient can measure [pain] by Fries and associates and published The Western Ontario McMaster severity” (30). These investigators des- in Arthritis and Rheumatism in 1980 (WOMAC) cribed a variety of visual analog scales, (21). This questionnaire provided a The Western Ontario McMaster (WO- including vertical and horizontal scales, milestone in the development of a meth- MAC) questionnaire was developed, and scales with equally spaced lines odology based on patient self-reporting based on a survey of 100 patients with with the indications of mild, moderate to obtain information concerning func- primary OAof the hip or knee, initially and severe pain.