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November 1, 2013 Volume 77, Number 11
Committee News: Finding New Ways to Measure Pain Gregory K. Applegate, D.O.
Committee on Regional Anesthesia

Chester “Trip” Buckenmaier III, M.D.



The U.S. military and Veterans Health Administration (VHA) have developed a common language Department of Defense (DoD) and VHA pain assessment tool with measure-ment enhancements, including visual cues and common language for patient-reported pain outcomes. The Defense and Veterans Pain Rating Scale (DVPRS) was published in May 2010 after the creation of the Army Pain Management Task Force (TF), which was chartered by Lieutenant General (Ret.) Eric B. Schoomaker in August 2009. The recent conflicts in Iraq and Afghanistan have introduced a new influx of DoD and VHA patients with acute and chronic pain. The TF, a tri-service and VHA effort, was looking for a novel way to assess pain in response to the military’s concerns about difficulties and inconsistences in using and interpreting traditional pain measuring tools in practice. The ability to apply a set of standard pain questions across the entire military health system was viewed as a substantial improvement for the integration of pain outcomes data to drive clinical decisions and resource allocation. Currently, validation studies are under way to test the DVPRS in multiple clinical settings and with diverse patient populations. The initial validation study was published in January 2013.1

 

The DVPRS (v2.0) combines the traditional 11-point, 0-10 Numeric Rating Scale (NRS), and “traffic light” color codes to define categories for mild, moderate and severe pain (Figure 1). The color coding feature was developed for use across transitions of care and has specific importance to pain management practices by field medics and health care professionals in austere combat environments who need to focus on “red” (need to treat), “yellow” (consider supplement) and “green” (good to go). In an effort to facilitate patient safety and quality of care, “traffic light” colors were initially introduced in the Transforming Care at the Bedside initiative, which was developed by the Robert Wood Johnson Foundation and Institute for Health Care Improvement.2 The unique feature of the DVPRS v2.0 also incorporates 11-word descriptors of functional impact aligned with ratings of pain from 0-10 (Figure 1). This feature is designed for use across all transitions in care from combat support hospitals to all other military medical facility practice settings.

 

Figure 1: Defense and Veterans Pain Rating Scale

 

The DoD/VA Pain Supplemental Questions (Figure 2, page 46) permit the assessment of the biophysical impact of pain. On a scale from 0 to 10, patients are asked to report the number that describes how their pain has contributed or interfered with their usual activity, sleep, mood or stress. While patient clinical scenarios may vary, these additional questions provide opportunities for all health care professionals to screen patients for potential problems associated with pain and to assess ongoing responses to pain therapies and other interventions. The integration of measurement enhancements to the DVPRS emphasizes the military’s commitment to evaluating multiple dimensions of pain using a standardized approach and a common language for reporting and communicating pain and related outcomes, and evaluating care across the federal health care system.

 

Figure 2

Figure 2: DoD/VA Pain Supplemental Questions

 

The 11-word descriptors give patients an alternative way to communicate their pain levels in relation to their daily activities. For example, a patient recovering from a total knee arthroplasty on postoperative day one might describe his or her pain as 9 out of 10. This same patient may also be seen enjoying a meal or text messaging a friend, which seems inconsistent with a “9” on the pain scale. The DVPRS word descriptors ground the subjective nature of pain in functional language that should facilitate a more consistent conversation between provider and patient when it comes to pain management and goals of therapy. The DVPRS attempts to re-orient the patient from an “isolated number” toward a scale based on how a number influences function. The patient recovering from total knee arthroplasty may report pain, but he or she may forget to realize that a recent surgery has improved his or her ambulation, knee range of motion and overall physical activity. Perhaps most important, this new focus on achieving maximal function will overshadow the desire to achieve zero pain, a desirable but rarely achieved goal.

 

The VHA launched the “Pain as the Fifth Vital Sign” initiative in 1999, which requires an NRS with every encounter. In 2001, The Joint Commission initiated “Pain: The Fifth Vital Sign” to identify that pain was undertreated in U.S. hospitals. Although patients have been selecting subjective pain numbers to describe their pain for over a decade, the VHA demonstrated that the fifth vital sign does not improve the quality of pain management.3

 

The current 0-10 NRS and Visual Analogue Scale (VAS) present two controversies. The first issue involves patients who report their pain as 10/10 and appear to have no problem with higher-level thinking or activities of daily living. These patients experience chronic pain and have learned to be functional when they report their pain as 10. Unfortunately, the meaning of 10/10 pain is a very individualized concept. We are well aware that no pain measure should negate the subjective nature of pain or limit expressions of patients’ perceived levels of pain. However, the underlying concept of “do no harm” requires that physicians safely prescribe pain medications such as opioid analgesics without causing respiratory depression or contributing to misuse or abuse. Conversely, underestimation of pain by military service members can lead to failure to aggressively treat pain and more seriously persistent chronic pain states. Pain assessment is not just about a number and requires a more comprehensive interpretation of outcomes beyond this number. The DVPRS attempts to introduce a new framework to guide patient and health care and provide discussions about pain and its impact on function and biopsychosocial aspects of life.

 

Unidimensional pain scales such as the NRS and VAS often fall short of capturing additional dimensions of pain, and more comprehensive scales can pose limitations for use in routine clinical practice. The addition of the four supplemental questions that complement the NRS is designed to further characterize the impact of pain on usual activity, sleep, mood or stress. The ability to screen for potentially important aspects of the pain experience and track these other outcomes have important implications for designing and re-designing plans of care. For example, a treatment plan may not necessarily improve a patient’s pain score on the DVPRS, but the patient might reveal significant improvements in the areas of sleep and general activity from the supplemental questions. While the DVPRS certainly is not a panacea for the pain discussion, it does provide a basic, standardized foundation and greater refinement of the pain question to serve as a starting point for further discussion.

 

We believe that the new scale will benefit patients, physicians and other health care professionals in the treatment of acute and chronic pain. The DVPRS v2.0 grounds the existing 11-point scale with “functional language” that corresponds to perceptions of daily activities. In addition, the supplemental questions enhance the DVPRS, which becomes a more sensitive tool for evaluating the success of treatment plans.

 

The tool has tremendous potential for widespread integration in electronic health records across military and VHA health care systems to ensure a uniform data capture of pain outcomes. The task force will continue to study and validate the DVPRS in a variety of patient populations. Perhaps more important, the DVPRS represents a reorientation of military medical thinking that now emphasizes pain management directed toward achieving maximum function and participation in rehabilitation for military and VHA patients.

 

The authors attest: The views expressed herein are those of the authors and do not reflect the official policy of the Department of the Army, Department of Defense or the U.S. government.



Gregory K. Applegate, D.O. is a staff anesthesiologist, University Hospitals Case Medical Center, Cleveland, and Assistant Professor, Case Western Reserve University School of Medicine.

 

Chester “Trip” Buckenmaier III, M.D. is COL, MC, USA; Program Director, Defense and Veterans Center for Integrative Pain Management; Associate Professor of Anesthesiology, Uniformed Services University of the Health Sciences, Rockville, Maryland.



References:

1. Buckenmaier CC 3rd, Galloway KT, Polomano RC, McDuffie M, Kwon N, Gallagher RM. Preliminary validation of the Defense and Veterans Pain Rating Scale (DVPRS) in a military population. Pain Med. 2013;14(1):110-123.

2. Brown MH. Transforming Care at the Bedside: An RWJF national program. Princeton, NJ: Robert Wood Johnson Foundation; July 11, 2011. http://www.rwjf.org/content/dam/farm/reports/program_results_reports/2011/rwjf70624. Accessed September 16, 2013.

3. Mularski RA, White-Chu F, Overbay D, Miller L, Asch SM, Ganzini L. Measuring pain as the 5th vital sign does not improve the quality of pain management. J Gen Intern Med. 2006;21(6):607-612.

 


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