CLEVELAND, OhioWhen cancer is diagnosed, most patients fear
pain more than any other symptom, Victoria Lipnickey, PA-C, said at a
symposium on palliative medicine, sponsored by the Cleveland Clinic
Accurately assessing pain is very important, said Ms. Lipnickey, of
the Cleveland Clinics Harry R. Horvitz Center for Palliative
Medicine. A complete pain evaluation must identify the location of
the pain, time of onset, duration, its quality (throbbing or
lancinating, for instance), and alleviating and exacerbating
features. The characteristics of pain must be discussed every
time pain is discussed, as these qualities often change as the cancer
progresses, she said.
An assessment of pain should include subjective features. The
clinician should always ask how the pain affects the patients
quality of life. This is likely to be a very important issue
for the patient, Ms. Lipnickey said.
Pain assessment tools record the patients own report of pain.
These tools measure only a single dimension of pain: intensity.
However, they can be used to provide an ongoing assessment of pain as
well as measure the alleviating effects of treatment.
The advantage of the single-dimension scales is their ease of use for
both the patient and clinician. These scales are pocket-sized, easy
to understand, inexpensive, and readily available.
The disadvantage is that there is a risk of oversimplifying the
patients experience of pain, Ms. Lipnickey said. The
patient may feel that you care more about the number than the
pains effect on the patients life, she said.
Pain assessment scales include the verbal rating scale, visual analog
scale, numerical rating scale, behavior rating scale, picture scale,
box scale, and descriptor differential scale.
Numerical Rating Scale
With the numerical rating scale, the patient rates pain on a scale
from 0 to 10 (or 100), with 0 representing no pain and the highest
number representing the worst imaginable pain.
The advantage of the numerical rating scale is that it has been
proved to have high consistency, even with different clinicians
administering the scale, Ms. Lipnickey said. It is a useful way to
measure past episodes of pain, such as incident pain or pain that was
felt prior to taking medication.
Its disadvantages are that few validation studies have been conducted
using it, and those only with chronic pain. No validation studies
have been conducted with cancer pain.
The verbal rating scale asks patients to select descriptive
adjectives for their pain. Typically there are three to six
adjectives on the list, ranging from no pain to
The advantages of the verbal scale are that it is easy to use and
evidence exists for its validity. However, one disadvantage is that
the patient needs to read the entire list of adjectives before making
a judgment. It is also difficult to make comparisons if a different
rating scale is used on subsequent visits. For patients with limited
vocabulary or limited vision, the usefulness of the visual rating
scale is sharply curtailed, and it becomes less reliable, Ms.
With the visual analog scale, patients are shown a 10 cm line with
ends labeled as extremes of pain. The patients are asked to mark a
point on the line that corresponds with their sensation of pain. The
clinician scores the scale by measuring the distance from no
pain to the patients mark.
The visual analog scale is easy to administer, and good evidence
exists for its validity. It is more difficult for patients to
understand and use than the other scales, however, and there is a
greater chance for error when the clinician scores the result, Ms.
Lipnickey said. Also, use of this scale is difficult for the
sight-impaired and physically challenged.
Behavior Rating Scale
The behavior rating scale asks patients to rate the intensity of
their pain and to describe how pain interferes with the performance
of everyday tasks. This discussion of the effect of pain on their
lives may make this scale more meaningful to patients, she said.
The drawbacks of the behavior rating scale, however, are that some
patients may confuse pain intensity with pain interference. If they
suffer from depression, for instance, that may affect how they score
the behavior rating scale.
The picture scale displays five line drawings of facial expressions
registering different levels of pain intensity. The faces may be
cartoon-like (for young patients) or may show the face of an older
man (for adult patients).
The advantage of the picture scale is that it is easy to administer
and score. It is useful when working with children or adults with
cognitive impairment. It may also be recommended when a language
barrier exists between clinician and patient, Ms. Lipnickey said.
The disadvantage of the picture scale is that it is not widely used.
Limited evidence exists for its validity, and no evidence exists
regarding compliance rates. Also, the scale does not take into
account cultural and ethnic differences in facial expressions.
The box scale is a combination of the numerical rating scale and the
visual analog scale. Numbers ranging from 0 (no pain) to 10 (pain as
bad as it could be) are displayed inside boxes, and patients are
asked to put an x in the box that corresponds with their
level of pain.
For some reason, the box scale is easier for older patients to use,
Ms. Lipnickey said. It is easy to administer and score; preliminary
evidence supports validity; and when used with patients consistently,
it has high compliance rates.
One of the disadvantages of this scale is the limited number of
response categories. It is not widely used, and, as with the visual
analog scale, its usefulness with sight-impaired or physically
challenged patients is limited.
Descriptor Differential Scale
The descriptor differential scale is a list of 12 adjectives of pain
intensity. The patient rates pain intensity in each of the 12
categories according to a 10-point scale.
The advantages of this scale are that it has high internal
consistency and high re-test stability. The disadvantages are that it
is time consuming, difficult to complete, and not yet evaluated for
treatment sensitivity. It is a very cumbersome scale and can be
overwhelming for the patient, Ms. Lipnickey said.