From OT Europe

Expert interview: A paradigm shift in pain measurement from pain intensity to mobility measurement for better pain outcomes

EFORT

Professor Winfried Meissner is the Head of the Pain Unit, Department of Anesthesiology and Intensive Care at Jena University Hospital in Jena, Germany. We caught up with Prof. Meissner following a presentation on improving outcomes through pain management he gave at a meeting of German traumatologists.

This article is part of our continuing series to raise awareness of the unmet needs in postoperative pain management (POPM) and to develop solutions that improve POPM across Europe. The opinions expressed in this interview are meant as an informal conversation to facilitate dialogue.

To further discuss the opinions expressed in this article, engage on Twitter, Facebook and LinkedIn #painmanagement #changepain #POPM

Key tools

The first element to understanding patient pain that Prof. Meissner points out is it is extremely important to measure pain with some parameter or another. Currently, this is still not being done as a matter of course and on a regular basis throughout Europe, where estimates show that only between one-fourth and two-thirds of patients are regularly being assessed on pain parameters. While this is a good start, pain assessment must be made much more of a priority to provide better long-term outcomes for patients and the management of postoperative pain.

Traditionally, pain measurement tools that Prof. Meissner sees used include the numeric rating scale (NRS), the visual analog scale and the verbal rating scale (VRS). These tools are a quick, uncomplicated, and efficient, nonintrusive method of measuring pain intensity and are, therefore, simple to implement and understand and they help address patients’ pain management needs.

As an overview of these measurement tools, the NRS for pain focuses on measuring pain intensity in adults and is most commonly used in the form of an 11-point numeric scale where 0 represents one end of the pain spectrum – “no pain” – and 10 represents the opposite end of that spectrum – “the worst pain imaginable.” Benefits of the NRS are that it is a quick assessment (takes generally less than 1 minute to administer) and can be performed verbally, either in person or by phone. It can also be conducted as a written self-assessment by the patient. This flexibility in assessment and scoring allows the test to be conducted in a broad cross-section of patients (including the elderly or immobile patients), which gives it in some respects an advantage over a VAS assessment.

The pain VAS also measures pain intensity but focuses on a visual unit of measurement to avoid groupings of scores around common numeric valuations. The VAS can be conducted with paper and pencil where a line of 0 mm represents “no pain” and one of, for example, 10 cm would be “worst pain imaginable”. While the necessity of visual representation of pain intensity limits this assessment to pencil and paper (i.e., no possibility to conduct the assessment by telephone), it does benefit by having flexibility in the descriptors that may be used to better understand the intensity of pain and to weed out common clusters around sometimes biased numerical representations of pain intensity. Also, this assessment can be limited in that it requires the patient to have the motor capacity to be able to create the mark for the measurement of the pain intensity score.

Finally, Prof. Meissner mentions the VRS as a common-practice pain assessment tool. The VRS provides the patient with a number of adjectives to which the patient may assign their description of their current pain intensity, thus allowing the polar ends of the pain spectrum provided in the other common tests – “no pain” at one end and “extremely intense pain” at the other – but also with a variety of gradations of intensity from which the health care provider may have a deeper understanding of the pain intensity being described beyond numeric or visual representations of pain. As with the other tests, the VRS is also easy to administer and score but given the subjectivity of verbal representations of pain, the interval between, for example, “no pain” and “mild pain” might differ substantially from the range between “moderate pain” and “severe pain” (an issue much better managed in the numeric or visual representations of pain intensity.

Are the right tools?

Prof. Meissner notes that despite all the benefits that practitioners face in using some measurement of understanding of a patient’s pain, each of the commonly used assessment tools currently measures only pain intensity. Too often, so-called “cut-off” values (e.g., NRS > 4) are used to indicate the need for treatment/intervention, which can lead to overtreatment. Cut-off values work well on averages and in large-scale studies but are much more variable in individual applications.

Moreover, there is no clear consensus on the value of such cut-offs, which might vary from patient-to-patient, surgery-to-surgery, etc. These pain measures are not particularly standardized either. For example, when assessing pain either numerically or visually, is the representation of pain measured as the maximum pain, resting pain, current pain or is it an average of pain over the last 24 hours? The validity of the various tools currently being used depends massively on the individual parameters of the assessment, such as the staff–patient relationship and other variables that will differ from patient to patient and procedure to procedure.

“We learn more and more that these might not be the right measurements to assess in all cases,” Prof. Meissner said. “We are working right now on some research projects where we have come to understand that in some cases it is much more important to obtain an understanding of the functional interference of pain.”

Prof. Meissner refers to this as a “paradigm shift” from intensity-focused pain measurement to patient mobility-focused and functionality-focused assessments. For example, there is a heavy focus, especially in US-based practices, on pain as the “fifth vital sign,” which brings intense focus to pain within the patient, in general, as a key factor that should be assessed at all times for better patient outcomes. However, many health care providers are discovering that the heavy and near-exclusive focus on pain intensity could have better outcomes if assessments of pain as it relates to function were also incorporated into common pain assessment tools. Focusing on pain intensity may lead to overtreatment when reduction of pain intensity is not calculated alongside other factors such as pain treatment side effects (e.g., nausea in opioid treatment, muscle weakness in regional analgesics). Having a broader toolkit for pain assessment, including the functional implications of pain, may provide patients with better overall postoperative pain management outcomes.

What is the best pain scale or measurement tool guide treatments for better outcomes for postoperative pain?

Prof. Meissner wishes he had the “top secret formula” that was the end-all solution to providing the best outcomes. The truth is that the combination of assessments is as variable as each patient encountered. There are various research projects that Prof. Meissner and his colleagues are working on that expand upon the emerging focus on patient mobility and functionality. In a recent workshop, Prof. Meissner refers to a nurse who mentioned the pain assessment he regularly provided to patients was asking a simple question:

“If you were at home, would you do something right now to address your pain?”

Questions like these focus on the “acceptability” of pain to the individual patient. In such a case, on a traditional NRS scale, the patient may have indicated the pain as an 8/10 or a “severe pain” on a VAS scale, either of which might be considered a high threshold requiring immediate treatment with an aggressive option. Focusing on acceptability, however, the patient may indicate that such “severe pain” was still manageable with peripheral or maybe even no support and that pain was not impacting the patients’ everyday function. This further depth in understanding the patient self-assessment based on acceptability helps prevent unnecessary intervention. With such measures, treatment is provided only in situations where functionality is compromised as a result of pain. Other useful questions for assessing the impact of pain on functionality might include:

  • Is pain preventing you from taking a deep breath?
  • Is it possible to cough?
  • How has your pain impacted your sleep?

The goal, therefore, is not to provide a “pain free” hospital or even a “pain free” patient, but rather to acknowledge the pain that exists and to address pain only when it falls outside of patient-centric measurements of pain “acceptability.”

Prof. Meissner and other researchers are currently working on standardizing assessment tools that follow patient-centric questions like these and better measure the functional interference and the consequences of pain over mere pain intensity. Prof. Meissner makes sure to impress that the measurement of pain in general is already an important start to better managing patient outcomes, especially with understanding the effects of pain and patient susceptibility to postoperative pain chronification. As previously mentioned, there is still vast room for improvement when only between one-fourth and two-thirds of patients across Europe are regularly being assessed on pain parameters. Moving these assessments to a broader focus on patient functionality only improves the toolkit for physicians looking to address pain early and often for better long-term patient outcomes.

Interim tools

While future research is ongoing to provide uniform assessment techniques that address patient functionality in response to pain, Prof. Meissner noted several best practices he has seen in taking a global view of pain management through pain measurement.

First, he advocates multi-modal analgesia where a mix between opiate administration and regional analgesia plays an important role in reducing long-term dependence and giving a broader focus for better outcomes. There is a clear trend also towards using regional anesthesia as peripherally as possible. Specifically, Local Infiltration Analgesia is gaining increasing attention and seems to be effective in knee surgery, although less so in hip replacement surgery. The use of wound infiltration in almost every surgery is becoming common practice as well.

Referring to EFORT’s previous interview with Dr. Christian Simanski, Prof. Meissner reiterates the importance of bottom–up multi-disciplinary development of scoring tools for the impact of pain on patient mobility. It is known, for example, that preoperative chronic pain, preoperative opioid treatment and some psychosocial risk factors, such as catastrophizing, are risk factors for severe acute as well as chronic postsurgical pain. Other risk factors as well are still under debate.

Communicating clearly with standardized methods to assess these risk factors could better inform the postoperative treatment team to better understand how, when, or whether to provide additional treatments such as intravenous ketamine, lidocaine or other approaches during the postoperative phase of pain management, all of which may have significant impact on any patient’s treatment regime and personalized outcomes.

Whether or not it is possible to simplify such measures into one score is still a matter up for debate and requiring further research, but teams are recognizing the importance of this paradigm shift in pain management and working on finding the right solutions. As an interim solution, Prof. Meissner also points to assessment tools available from the web-based information system “PAIN OUT,” funded by the European Commission’s Seventh Framework Programme.

Key focuses of future research

With key risk factors of poorly addressed early pain management, including a delay in patient mobilization, an increase in the length of stay and the need for rehabilitation, and complications, like thrombosis, an added focus on and continued attention to preventing chronic postsurgical pain is essential. Severe chronic postsurgical pain develops — depending on individual risk factors and the type of surgery — in 2% to 20% of patients. Given these risks and the direct impact on patient outcomes and health care expenditures, Prof. Meissner points to the following next steps in research:

  • Identifying meaningful patient-reported outcomes (PROs) that are valid and accepted by a wide cross-section of health care providers and authorities;
  • Studying clearly if PROs in fact mirror functional interference; and
  • Implementing PROs as a core pillar among a key set of quality indicators for patient outcomes.
EFORT

Professor Winfried Meissner is the Head of the Pain Unit, Department of Anesthesiology and Intensive Care at Jena University Hospital in Jena, Germany. We caught up with Prof. Meissner following a presentation on improving outcomes through pain management he gave at a meeting of German traumatologists.

This article is part of our continuing series to raise awareness of the unmet needs in postoperative pain management (POPM) and to develop solutions that improve POPM across Europe. The opinions expressed in this interview are meant as an informal conversation to facilitate dialogue.

To further discuss the opinions expressed in this article, engage on Twitter, Facebook and LinkedIn #painmanagement #changepain #POPM

Key tools

The first element to understanding patient pain that Prof. Meissner points out is it is extremely important to measure pain with some parameter or another. Currently, this is still not being done as a matter of course and on a regular basis throughout Europe, where estimates show that only between one-fourth and two-thirds of patients are regularly being assessed on pain parameters. While this is a good start, pain assessment must be made much more of a priority to provide better long-term outcomes for patients and the management of postoperative pain.

Traditionally, pain measurement tools that Prof. Meissner sees used include the numeric rating scale (NRS), the visual analog scale and the verbal rating scale (VRS). These tools are a quick, uncomplicated, and efficient, nonintrusive method of measuring pain intensity and are, therefore, simple to implement and understand and they help address patients’ pain management needs.

As an overview of these measurement tools, the NRS for pain focuses on measuring pain intensity in adults and is most commonly used in the form of an 11-point numeric scale where 0 represents one end of the pain spectrum – “no pain” – and 10 represents the opposite end of that spectrum – “the worst pain imaginable.” Benefits of the NRS are that it is a quick assessment (takes generally less than 1 minute to administer) and can be performed verbally, either in person or by phone. It can also be conducted as a written self-assessment by the patient. This flexibility in assessment and scoring allows the test to be conducted in a broad cross-section of patients (including the elderly or immobile patients), which gives it in some respects an advantage over a VAS assessment.

The pain VAS also measures pain intensity but focuses on a visual unit of measurement to avoid groupings of scores around common numeric valuations. The VAS can be conducted with paper and pencil where a line of 0 mm represents “no pain” and one of, for example, 10 cm would be “worst pain imaginable”. While the necessity of visual representation of pain intensity limits this assessment to pencil and paper (i.e., no possibility to conduct the assessment by telephone), it does benefit by having flexibility in the descriptors that may be used to better understand the intensity of pain and to weed out common clusters around sometimes biased numerical representations of pain intensity. Also, this assessment can be limited in that it requires the patient to have the motor capacity to be able to create the mark for the measurement of the pain intensity score.

PAGE BREAK

Finally, Prof. Meissner mentions the VRS as a common-practice pain assessment tool. The VRS provides the patient with a number of adjectives to which the patient may assign their description of their current pain intensity, thus allowing the polar ends of the pain spectrum provided in the other common tests – “no pain” at one end and “extremely intense pain” at the other – but also with a variety of gradations of intensity from which the health care provider may have a deeper understanding of the pain intensity being described beyond numeric or visual representations of pain. As with the other tests, the VRS is also easy to administer and score but given the subjectivity of verbal representations of pain, the interval between, for example, “no pain” and “mild pain” might differ substantially from the range between “moderate pain” and “severe pain” (an issue much better managed in the numeric or visual representations of pain intensity.

Are the right tools?

Prof. Meissner notes that despite all the benefits that practitioners face in using some measurement of understanding of a patient’s pain, each of the commonly used assessment tools currently measures only pain intensity. Too often, so-called “cut-off” values (e.g., NRS > 4) are used to indicate the need for treatment/intervention, which can lead to overtreatment. Cut-off values work well on averages and in large-scale studies but are much more variable in individual applications.

Moreover, there is no clear consensus on the value of such cut-offs, which might vary from patient-to-patient, surgery-to-surgery, etc. These pain measures are not particularly standardized either. For example, when assessing pain either numerically or visually, is the representation of pain measured as the maximum pain, resting pain, current pain or is it an average of pain over the last 24 hours? The validity of the various tools currently being used depends massively on the individual parameters of the assessment, such as the staff–patient relationship and other variables that will differ from patient to patient and procedure to procedure.

“We learn more and more that these might not be the right measurements to assess in all cases,” Prof. Meissner said. “We are working right now on some research projects where we have come to understand that in some cases it is much more important to obtain an understanding of the functional interference of pain.”

Prof. Meissner refers to this as a “paradigm shift” from intensity-focused pain measurement to patient mobility-focused and functionality-focused assessments. For example, there is a heavy focus, especially in US-based practices, on pain as the “fifth vital sign,” which brings intense focus to pain within the patient, in general, as a key factor that should be assessed at all times for better patient outcomes. However, many health care providers are discovering that the heavy and near-exclusive focus on pain intensity could have better outcomes if assessments of pain as it relates to function were also incorporated into common pain assessment tools. Focusing on pain intensity may lead to overtreatment when reduction of pain intensity is not calculated alongside other factors such as pain treatment side effects (e.g., nausea in opioid treatment, muscle weakness in regional analgesics). Having a broader toolkit for pain assessment, including the functional implications of pain, may provide patients with better overall postoperative pain management outcomes.

PAGE BREAK

What is the best pain scale or measurement tool guide treatments for better outcomes for postoperative pain?

Prof. Meissner wishes he had the “top secret formula” that was the end-all solution to providing the best outcomes. The truth is that the combination of assessments is as variable as each patient encountered. There are various research projects that Prof. Meissner and his colleagues are working on that expand upon the emerging focus on patient mobility and functionality. In a recent workshop, Prof. Meissner refers to a nurse who mentioned the pain assessment he regularly provided to patients was asking a simple question:

“If you were at home, would you do something right now to address your pain?”

Questions like these focus on the “acceptability” of pain to the individual patient. In such a case, on a traditional NRS scale, the patient may have indicated the pain as an 8/10 or a “severe pain” on a VAS scale, either of which might be considered a high threshold requiring immediate treatment with an aggressive option. Focusing on acceptability, however, the patient may indicate that such “severe pain” was still manageable with peripheral or maybe even no support and that pain was not impacting the patients’ everyday function. This further depth in understanding the patient self-assessment based on acceptability helps prevent unnecessary intervention. With such measures, treatment is provided only in situations where functionality is compromised as a result of pain. Other useful questions for assessing the impact of pain on functionality might include:

  • Is pain preventing you from taking a deep breath?
  • Is it possible to cough?
  • How has your pain impacted your sleep?

The goal, therefore, is not to provide a “pain free” hospital or even a “pain free” patient, but rather to acknowledge the pain that exists and to address pain only when it falls outside of patient-centric measurements of pain “acceptability.”

Prof. Meissner and other researchers are currently working on standardizing assessment tools that follow patient-centric questions like these and better measure the functional interference and the consequences of pain over mere pain intensity. Prof. Meissner makes sure to impress that the measurement of pain in general is already an important start to better managing patient outcomes, especially with understanding the effects of pain and patient susceptibility to postoperative pain chronification. As previously mentioned, there is still vast room for improvement when only between one-fourth and two-thirds of patients across Europe are regularly being assessed on pain parameters. Moving these assessments to a broader focus on patient functionality only improves the toolkit for physicians looking to address pain early and often for better long-term patient outcomes.

PAGE BREAK

Interim tools

While future research is ongoing to provide uniform assessment techniques that address patient functionality in response to pain, Prof. Meissner noted several best practices he has seen in taking a global view of pain management through pain measurement.

First, he advocates multi-modal analgesia where a mix between opiate administration and regional analgesia plays an important role in reducing long-term dependence and giving a broader focus for better outcomes. There is a clear trend also towards using regional anesthesia as peripherally as possible. Specifically, Local Infiltration Analgesia is gaining increasing attention and seems to be effective in knee surgery, although less so in hip replacement surgery. The use of wound infiltration in almost every surgery is becoming common practice as well.

Referring to EFORT’s previous interview with Dr. Christian Simanski, Prof. Meissner reiterates the importance of bottom–up multi-disciplinary development of scoring tools for the impact of pain on patient mobility. It is known, for example, that preoperative chronic pain, preoperative opioid treatment and some psychosocial risk factors, such as catastrophizing, are risk factors for severe acute as well as chronic postsurgical pain. Other risk factors as well are still under debate.

Communicating clearly with standardized methods to assess these risk factors could better inform the postoperative treatment team to better understand how, when, or whether to provide additional treatments such as intravenous ketamine, lidocaine or other approaches during the postoperative phase of pain management, all of which may have significant impact on any patient’s treatment regime and personalized outcomes.

Whether or not it is possible to simplify such measures into one score is still a matter up for debate and requiring further research, but teams are recognizing the importance of this paradigm shift in pain management and working on finding the right solutions. As an interim solution, Prof. Meissner also points to assessment tools available from the web-based information system “PAIN OUT,” funded by the European Commission’s Seventh Framework Programme.

Key focuses of future research

With key risk factors of poorly addressed early pain management, including a delay in patient mobilization, an increase in the length of stay and the need for rehabilitation, and complications, like thrombosis, an added focus on and continued attention to preventing chronic postsurgical pain is essential. Severe chronic postsurgical pain develops — depending on individual risk factors and the type of surgery — in 2% to 20% of patients. Given these risks and the direct impact on patient outcomes and health care expenditures, Prof. Meissner points to the following next steps in research:

  • Identifying meaningful patient-reported outcomes (PROs) that are valid and accepted by a wide cross-section of health care providers and authorities;
  • Studying clearly if PROs in fact mirror functional interference; and
  • Implementing PROs as a core pillar among a key set of quality indicators for patient outcomes.