Case 68: Pain Assessment: Most Prominent Measures/Tests in the Research Literature, 2006-2018

Pain Assessment: Most Prominent Measures/Tests in the Research Literature,2006-2018

Chris Piotrowski

        The issue of pain measurement and assessment has attracted intense clinical and research attention, particularly over the past three decades. Hence, pain assessment has become a) a central feature in the study of pain across a myriad of health care disciplines (i.e., medicine, rehabilitation, psychology, nursing, social work, quality of life, and public health), b) a major component of comprehensive pain management, and c) a burgeoning area of applied research. Given the vast landscape of this literature: Where is the practicing mental health clinician to turn in identifying the major pain assessment instruments reported in the recent scholarly literature? T o that end, the aim of the current study is to identify the most prominent methods (i.e., measures, scales, inventories, tests) in research, reported in studies with a focus on pain or pain states, 2006-2018. Hence, an extension of a similar study design reported by Piotrowski (2007). Based on a bibliometric examination of the literature, including assessment measures noted in major texts on pain, nearly 200 assessment instruments were identified and determined to be the most visible scales/tests related to the issue of pain. Next, the author conducted an online search in the ProQuest database (restricted to years 2006-2018). Using a Boolean logic search strategy on these instruments, individual searches produced the total number of scholarly articles for each assessment method that was noted in the Abstract of primary articles. This procedure identified 130 measures that were the focus of study in at least 5 articles. Of these, 49 tests appeared in study abstracts more than 100 times. Noteworthy, several of these ‘popular’ tests were measures of psychopathology, outside the specific domain of Pain, such as the Beck Depression Inventory, the STAI, and the MMPI series. Moreover, many of the most popular scales reflect general health assessment and quality of life issues. In addition, the assessment of functional disability was well represented in the top ranked scales/measures (e.g., Oswestry Disability Index, the DASH Questionnaire). Other prominent assessment methods were, the Visual Analogue Scale, the Health Assessment Questionnaire, the Numerical Rating Scale, Brief Pain Inventory, the McGill Pain Questionnaire, the Hospital Anxiety & Depression Scale, the SF-36 Health Survey, the Pittsburgh Sleep Quality Index, and the PROMIS. These findings should provide a seminal template for mapping the extant scholarship regarding preferred methods or assessment techniques used in research on pain. Furthermore, the current analysis points to the vast array of measures and scales on which research findings in pain scholarship are based, which prompts the problematic concern regarding the lack of investigatory cohesion in this rapidly expanding literature and fragmentation of research streams across this multidisciplinary field.

        Historically, the myriad of pain conditions and the deleterious experience of chronic pain have continued to inflict an onerous impact on the human condition, designating ‘pain’ as a major public health problem and vital-sign metric (Gaskin & Richard, 2012; Melzack, 1983; Turk & Gatchel, 2018). More recently, the Biopsychosocial paradigm, reflected in the modern era of clinical practice and research scholarship in the healthcare field (Castelnuovo, 2017; Porter-Moffitt et al., 2006), has been well-incorporated in the study of pain (Deer & Ray, 2015; Eisenberger, 2012; Flor & Turk, 2011; Gatchel et al., 2007; Gatchel& Turk, 1999; Hickling et al., 1995;

Huzmeli & Melek, 2017; Riva et al., 2011). Accordingly, the extant literature on various pain states is voluminous and growing at an exponential rate (Gatchel, 2005; Jensen & Turk, 2014).

        In mental health practice, complaints regarding pain or experience of chronic pain are a ubiquitous symptom presented to the clinician (Fillingim et al., 2016; Gaskin & Richard, 2012; Jensen & Turk, 2014; Lee et al., 2017; Wallace et al., 2018). Thus, it follows that the study of pain, particularly the area of pain assessment, has been and continues to be a prominent topic of scholarly investigation in the mental health field, exemplified by well-cited textbooks (Gatchel & Weisberg, 2000; Keller & Butcher 1991; Turk & Gatchel, 2002; Turk & Melzack, 2011).

Evaluation and Assessment of Pain:

        Within this clinical domain, comprehensive evaluation of the ‘patient-in-pain’ is considered a critical, central component in the treatment of the myriad of pain conditions (Epker, 2013; Gatchel et al., 2017; Mikail et al., 1993; Ruben et al., 2018). Based on the voluminous body of extant research, the issue of pain measurement and assessment has attracted intense investigatory attention from both clinicians and scholars (Bruns & Disorbio, 2015; Kovatch et al., 2017; Turk & Okifuji, 2002). Moreover, co-morbidity factors play a significant role in the study of pain (Reist et al., 2017; Turk & Gatchel, 2018). Hence, pain assessment has become a) a central feature in the study of pain across a multitude of clinical health care disciplines (Medicine, rehabilitation, psychology, nursing, quality of life, and public health), b) a major component of chronic pain management, and

1. c) a burgeoning area of clinical and applied research.

Interestingly, there have been limited reviews of the literature regarding the clinical usage of specific pain measures and scales, beyond confirmation on the popularity of the MMPI (all revisions) in the assessment protocol used with pain patients in professional practice (see Andrasik et al., 1989; Piotrowski, 2018; Piotrowski & Lubin, 1990; Porter-Moffitt et al., 2006). In fact, in a seminal study, Piotrowski (1998) reported on the top-ranked tests used by clinicians in the pain field, i.e., the MMPI (all versions), the Beck Depression Inventory, McGill Pain Questionnaire, SCL-90, the Multidimensional Pain Inventory, and the Millon MCMI.

From an evaluation perspective, the pain experience is usually conceptualized along several domains: nociception, neuropathic, psychological factors, personality strengths, emotion  regulation,  pain  beliefs,  coping

resources, functional capacity, social/ interpersonal milieu. Yet, practicing clinicians, with limited exposure (due to lack of training and hands-on experience) with the copious array of pain assessment instruments usually rely on pain measures like the McGill Pain Questionnaire and/or broadband mental health tests of psychopathology (see Piotrowski, 2018, 1998).

Rationale for the Current Study:

        In a recent review, based on the extant body of literature on pain studies, Piotrowski (2017) found that projective techniques have garnered limited clinical interest in this area. In an earlier bibliometric study, the most noted assessment instruments on the topic of pain were: the McGill Pain Questionnaire, Beck

Depression Inventory, the Multidimensional Pain Inventory, the Coping Strategies Questionnaire, and the Low Back Pain Questionnaire (Piotrowski, 2007). Thus, an updated analysis of the pain literature is urgently needed.

        The salient issue is: Where is the practicing mental health clinician to turn in identifying the major pain assessment instruments available and discussed in the recent scholarly literature? Moreover, having an awareness of the most prominent measures in the study of pain should facilitate professional communication in consultancy with specialists or multidisciplinary pain treatment teams (Gatchel et al., 2014; Townsend et al., 2006). To that end, the aim of the current study is to identify the most prominent methods (i.e., measures, scales, inventories, tests) in the research literature, reported in studies with a focus on pain or pain states, 2006-2018. Hence, an extension of a similar study design reported by Piotrowski (2007, 2019).

Method:

        The design followed the parameters of a bibliometric ‘Content Analysis’ of the literature (see Krippendorff, 2004), which has been recently applied in the study of pain states (Piotrowski, 2014). The initial challenge was to obtain a listing of the major evaluation measures, tests, and scales in the field of pain assessment. To that end, researchers have utilized systematic reviews of the extant literature to identify key instruments with high visibility in research studies (e.g., Zijlema et al., 2013). For the current analysis, a 3-prong procedure was applied: 1) scanning test coverage in several recent textbooks on the topic of pain and mental health assessment (e.g., Marchand et al., 2014; Sajatovic, 2012),

        2) identifying listings of top tests noted in review articles on the measurement of pain states (i.e., Banerjee et al., 2017; Epker, 2013; Piotrowski, 2007) and quality of life (e.g., Hall et al., 2011), and 3) scanning the results of a bibliometric search (see De Bellis, 2009) of the recent mental health literature on the topic of pain (PsycINFO database; a menu tab displays the most frequently cited assessment instruments across specific ‘pain’ domains). This systematic approach yielded nearly 200 assessment instruments determined to be the most visible scales/tests discussed in the literature regarding the topic of Pain.

        Next, the author conducted an online search in the ProQuest database, restricted to years 2006-2018. This repository of extensive literature indexes scholarly studies across the medical, health, psychological, and social sciences, containing over 125 billion digital pages. In order to determine which measures were the main focus of study, the search option ABSTRACT was used in order to identify which scales/tests were specifically noted by investigators. Using Boolean logic (name of test/questionnaire/scale/measure/ inventory + pain) on each of the instruments, individual searches produced the total number of scholarly articles where the test was noted in the Abstract. A running frequency tabulation was maintained during all online searches which identified the 130 measures/scales that appeared in at least 5 articles. This scoring template then illustrated the ranking of individual assessment techniques, based on frequency distribution.

Findings:

         First, the most striking observation of the data analysis is the vast scope, comprehensive nature, and impressive number of measures which serve as part of the methodology across the research spectrum in the pain literature. In and of itself, this finding may have both positive and negative implications. One possibility is that such a voluminous foundation of measurement techniques and methods may reflect the robustness of the burgeoning literature of a multidisciplinary field; on the other hand, the vast array of distinct methods and assessment tools may be an indicator of disparate investigatory interests and research designs which, to some extent, contribute to a lack of conceptual cohesion and clinical consensus regarding both research focus and relevance of research findings. Thus, advances in scholarship in the study of pain may be stymied or side-tracked by fragmentation in investigatory streams, leading to an opaque sense of direction for future research.

        Table 1 displays, in rank order, the most mentioned or cited scales/measures used in studies on the evaluation of pain across a myriad of pain states and conditions since 2006. While this listing is rather exhaustive (encompassing 130 assessment tools), a select 49 appeared in study abstracts more than 100 times. Moreover, several of these ‘popular’ tests were measures of psychopathology, outside the specific domain of ‘Pain’, such as the Beck Depression Inventory, the Geriatric Depression Scale, the State-Trait Anxiety Inventory, and the MMPI series (Banks & Kerns, 1996; Lee et al., 2017; Piotrowski, 2018). Apparently, researchers who are involved in the study of pain have a strong clinical interest in mental health comorbidity factors, particularly levels of depression and anxiety, and related general psychological indices of pain patients (see Bair et al., 2003; Morgan, 2009; Okifuji & Turk, 2014 for discussion). Furthermore, many of the most prominent scales, noted in Table 1, reflect general health assessment and quality of life issues. In addition, the assessment on the extent of functional disability is well represented in the top ranked scales/measures (e.g., Oswestry Disability Index, the DASH Questionnaire).

        The issue of chronic pain has been a major area of research concentration (e.g., Alschuler & Otis, 2014; Dansie & Turk, 2013; Dysvik et al., 2013), exemplified by the vast number of measures with the specific aim to evaluate patients experiencing and coping with longterm pain. In this regard, prior research studies suggest that common psychological features, evident in chronic pain sufferers, support the characterization of the ‘pain personality’ in the clinical evaluation of these patients (Doherty et al., 2017; Kennedy et al., 2011; Naylor et al., 2017; Zhang, 2002). Moreover, in the aggregate, Quality-of-Life issues appear to be a major emerging assessment area in the study of chronic pain populations (Dezutter et al., 2013; Dusova & Cseszarova, 2008; Trost et al., 2015), evident by the proliferation of Quality-of-Life scales noted in the current analysis.

Conclusion:

        Table 1 should be relied upon as a handy clinical assessment reference guide in the treatment of pain patients. While this list of measures appears rather extensive, new assessment tools in the area of pain assessment continue to be introduced in the literature (e.g., Meyer et al. 2016). Thus, staying abreast of the emerging literature in the study of pain will surely be challenging. The current content analysis exercise provided the opportunity to deduce several key developments regarding recent investigatory research streams in pain scholarship:

*Despite the popularity of tests of psychopathology such as the MMPI and Millon inventories (Frauenhoffer et al., 1998), these broadband measures seem to be used selectively in pain-related research. Perhaps, as health care providers become more familiar with the efficacy of these robust instruments in pain-related conditions, there

use may increase in the future (see Gatchel et al., 2006; Haggard et al., 2008; Marek & Ben Porath,  2017;  Tarescavage  et  al.,  2015;

Vendrig, 2000).

*With the aging U.S. population, there should be more research attention devoted to the study of pain, particularly chronic pain states, in the elderly; such robust investigatory emphasis has been quite evident over the past decade (Buffum et al., 2007; Gagliese, 2009; Jacobs et al., 2006; Kang & Demiris, 2016; Molton & Terrill, 2014; Sofaer-Bennett et al., 2007; Tse et al., 2013; Yohannes & Caton, 2010). In this regard, ‘Collateral’ assessment of family and other caretakers of long-term pain patients will be a critical factor in mental health evaluations (see Leonard et al., 2006).

*Whereas the issue of suicidal ideation has been discussed in the extant literature with regard to chronic pain patients (Edwards et al., 2006; Reist et al., 2017), few measures that tap suicide potential or cognitions in pain populations were evident in the current analysis.

*Interestingly, there is a dearth of research focus on racial and ethnic factors in pain assessment (Tait & Chibnall, 2014).

*While the study of pain states in children has been a bourgeoning area of research (e.g., Azize et al., 2014; Gorodzinsky et al., 2011; Lollar et al., 1982; McGrath et al., 2013; Stefanatou & Bowler, 1997), the availability and range of assessment measures specifically designed for this unique clinical population (including adolescent-age patients) are somewhat limited.

*The recent emphasis on patient-reported outcomes in mental health assessment (i.e., PROMIS) has application in the comprehensive assessment of pain patients (Holmes et al., 2017).

*The role of the health provider in the pain assessment process has been a neglected area of research (see Ruben et al., 2018).

Future Research:

        This study, by design, was limited to published journal articles in the database ProQuest. Although journal coverage was multidisciplinary, further research efforts should concentrate on scholarly literature files and repositories such as MEDLINE and related health care databases. In addition, bibliometric  studies  on  pain  assessment

regarding specific clinical conditions or specialty-area journals (e.g.cancer, headache, musculoskeletal, orofacial, fibromyalgia) should not only be informative, but also introduce a template for mapping the extant scholarship on pain assessment while providing directions for future research on these clinical conditions.

Table 1. Measures in Abstract of Scholarly Articles on Pain in ProQuest Database (2006-2018)

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