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excruciating). The Faces Pain Scale (FPS) for Adults and Children16 and the Wong-Baker Faces Rating Scale (for children)30-31 are categorical scales with visual descriptors. The FPS consists of eight images of faces with various expressions (e.g., smiling, frowning, grimacing). The patient selects the face that is consistent with his or her current level of pain. 2. Multidimensional Tools Although not used as often as they should be, multidimensional tools provide important information about the pain’s characteristics and effects on the patient’s daily life.12,22 These tools are designed for patient self-report, but a clinician may assist the patient. Examples of multidimensional tools include (see Table 18): ■ Initial Pain Assessment Tool: This tool, which was developed for use in the initial patient evaluation, elicits information about characteristics of the pain, the patient’s manner of expressing pain, and the effects of the pain on the patient’s life (e.g., daily activities, sleep, appetite, relationships, emotions).7 It includes a diagram for indicating pain location(s), a scale for the patient to rate pain intensity, and a space for documenting additional comments and management plans. ■ Brief Pain Inventory (BPI): This tool is quick and easy to use and quantifies both pain intensity and associated disability.12,34-35 It consists of a series of questions that address aspects of the pain experienced over the preceding 24 hours (e.g., pain location and intensity, impact on the patient’s life, type and effectiveness of any treatments). The BPI generally takes about 5 to15 minutes to complete and is useful for a variety of patient populations.36-37 ■ McGill Pain Questionnaire (MPQ): The MPQ is one of the most extensively tested multidimensional scales in use.32 This tool assesses pain in three dimensions (i.e., sensory, affective, and evaluative) based on words that patients select to describe their pain. The MPQ can be combined with other tools to improve diagnostic accuracy.12 A briefer form of the MPQ, the short-form McGill Pain Questionnaire, is also available.39 A number of other multidimensional tools for pain assessment exist.12 Some are designed to measure chronic pain in general, while others are specific to particular pain syndromes. In addition, some quality of life instruments (e.g., Medical Outcome Study Short-Form 36 Health Survey Instrument) assess pain. 26 Pain: Current Understanding of Assessment, Management, and Treatments Section II: Assessment of Pain Table 14. Additional Aspects of the Patient History in Patients With Chronic Noncancer Pain • Pain treatment history: full review of results from past work-ups and treatments as well as patient’s utilization of health care resources (e.g., office visits). • Comprehensive psychosocial evaluation focused on: 1) patient responses to chronic pain (e.g., coping skills, avoidance of stressors, presence of chronic pain syndrome); 2) what the pain means to the patient; 3) evidence of family, legal, or vocational issues; and 4) expectations of family members, employers, attorneys, or social agencies (e.g., Social Security Administration). This evaluation may involve interviewing family members, too. • Psychiatric interview to: 1) identify any psychological symptoms (e.g., depression, anxiety, anger), coexisting psychiatric disorders, or psychological traits; 2) evaluate suicide risk in patients with clinical signs of depression (e.g., sleep or appetite disturbances, hopelessness); and 3) identify history of events (e.g., severe or extreme trauma) that may lead to somatization or pain. • Psychometric tests,a when appropriate, to provide information about the pain, associated problems, and any coexisting psychopathology. • Assessment of function and any disability to determine the patient’s ability to perform daily activities (e.g., household chores, work tasks, leisure interests) and function autonomously, as well as the presence and levels of disability. Questionnaires such as the Pain Disability Index can be used to assess levels of disability, when appropriate. More formal evaluation of disability may be needed in some cases (e.g., application for disability benefits). • Review of results with patient and family: This is the first step in the treatment of chronic noncancer pain, providing an opportunity to establish the rehabilitative focus of pain management and set realistic treatment goals. Sources: References 8 and 18. aPsychometric tests include pain-related instruments (e.g., McGill Questionnaire, Multidimensional Pain Inventory, Beck Depression Inventory) and personality assessment instruments (e.g., Minnesota Multiphasic Personality Inventory-2, Coping Strategies Questionnaire). National Pharmaceutical Council 27 Section II: Assessment of Pain Table 15. Physical Examination of a Patient With Pain Region Rationale, Methods, and Potential findings General Observe and/or identify: • Patient’s general appearance and vital signs • Evidence of overt abnormalities (e.g., weight loss, muscle atrophy, deformities, trophic changes) • Any subjective manifestations of pain (e.g., grimacing, splinting) Site of pain Inspect the pain site(s) for abnormal appearance or color of overlying skin or visible muscle spasm Palpate the site(s) to assess for tenderness and correlate tenderness with any associated subjective or objective findings Use percussion (or jarring) to elicit, reproduce, or evaluate the pain and any
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