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6/01 c:/CIRCIDateDue.p65-p.15

CHRONIC PAIN:

Development of an Assessment Tool for Primary Care

By
Miriam A. Hock

Submitted to
Michigan State University
College of Nursing
in partial fulfillment of the requirements
for the degree of
Master of Science in Nursing

1997

ABSTRACT

Chronic Pain: Development of an Assessment Tool for Primary Care
by
Miriam A. Hock

Chronic pain is a major cause of physical and psychological disability,
with multidimensional implications: injured self-esteem, unemployment,
inability to perform simple daily activities, sexual dysfunction, and social
isolation from family and friends.

A variety of tools have been used in the assessment of chronic pain.
Many of these tools were developed in pain treatment programs to furnish a
basis for treatment and to measure treatment outcomes. Many are impracti-
cal for use in a primary care setting.

It is the objective of this project to develop a clinically useful assess-
ment tool that can be used by primary health care providers in the assess-
ment of patients who suffer from chronic pain, whether the cause of the pain

is known or not.

ACKNOWLEDGEMENTS

The writing of a scholarly project is labor intensive; also I have found
it to be a communal endeavor. Sustaining me during this time was a large
circle of friends. The members of the Olivet Congregational Church where
my husband is minister graciously accepted a reduction of my usual parish
activities. My co-workers at the Veterans Affairs Medical Center in Battle
Creek encouraged me when my motivation declined and were cooperative
with the flexible scheduling required to permit me to finish my work; in
particular I wish to thank Julie Hoffman, Library Assistant at the VAMC,
whose assistance in literature search was invaluable. My classmates in the
graduate nursing program at Michigan State University affirmed my early
work on chronic pain; that affirmation encouraged me to stay with the sub-
ject

My scholarly project committee comprising Linda Beth 'Iiedje, Louise
Selanders, Brigid Warren and Celia Wills, gave excellent direction to the
project and were both intellectually challenging and warmly affirming as it
took shape. Linda Beth Tiedje, committee chair, deserves particular thanks;
she spent hours critiquing multiple incarnations of this work as it progressed.

This project could not have been completed without the love and
support of my family. My husband, Clark, provided a haven where my
studies could be uninterrupted and gently prodded me when my confidence
flagged. Our four children and three grandchildren endured too much sepa-

ration; for their understanding and patience, I am forever grateful.

TABLE OF CONTENTS

Introduction ................................................................................................... 5
Background Issues Related to Chronic Pain ........................................ 6
Conceptual Framework ................................................................................. 10
Conceptual Definitions ....................................................................... 10
Conceptual Framework ...................................................................... 12
Theoretical Framework ...................................................................... 13
Literature Review ......................................................................................... 18
Treatment literature ........................................................................... 19
Depression .......................................................................................... 21
Attitudes ............................................................................................. 22
Ability to Function ............................................................................. 23
Assessment of Pain ............................................................................. 24
Coping Strategies ............................................................................... 26
Assessment as Treatment ................................................................... 26
Critique of Literature .......................................................................... 27
Review and Synthesis ................................................................................... 28
Project Development .................................................................................... 32
Approach and Procedures ................................................................... 32
Pilot of Assessment Tool .................................................................... 36
Target Group ....................................................................................... 37
Evaluation ........................................................................................... 37
Implications for Advanced Nursing Practice and Primary Care ........ 39
List of References ......................................................................................... 42

Appendices ................................................................................................... 48

INTRODUCTION

Chronic pain is a major cause of psychological and physical disability,
with multidimensional implications: injured self-esteem, unemployment,
inability to perform simple daily activities, sexual dysfunction, and social
isolation from family and friends (Mayer et al., 1987; Potter & Perry, 1989;
Bowman, 1994). In many patients, chronic pain is inadequately relieved
(Bonica, 1991 ). Some estimate that chronic back problems disable 1% of
the total population (Mayer et al., 1987).

Given the complex causes and effects of chronic pain, it is under-
standable that a variety of tools have been used in its assessment (Basler,
1993; Geisser, Robinson, Keefe, & Weiner, 1994; Goldberg & Maciewicz,
1994; Jensen, Turner, & Romano, 1994; Mayer et al., 1987; Pilowsky,
Spence, Rounsefell, Forsten, & Soda, 1995; Subramanian, 1994). The tools
used address the many faces of the chronic pain syndrome: pain intensity,
depression, body symptoms associated with pain, coping strategies, attitudes
about pain, and physical functioning.

Primary health care providers are the gatekeepers for medical care
(Mezey & McGiven, 1993) and chronic pain patients will likely seek pain
management from these providers (Hitchcock, Ferrell, & McCaffery, 1994).
It is therefore necessary that primary health care providers be able to assess
and treat chronic pain sufferers.

The objective of this project is to develop a clinically useful tool that
can be used by primary health care providers in the assessment of patients
who suffer from chronic pain. The tool is intended for assessing the impact

of chronic pain more than its etiology.

Background Issues Related to Chronic Pain
Attitudes/Behaviors of Patients and Health Care Providers

People with chronic pain come repeatedly for care and are often frus-
trated that the cause and scope of their pain are not fully understood. In one
survey, the average person with pain had sought treatment from ten different
health care providers and had visited a health care provider on the average of
ten times during the previous year. In this study, internists and general prac-
titioners were frequently sought to provide pain management (Hitchcock et
al., 1994).

Health care providers are often frustrated by chronic pain patients,
feeling puzzled and helpless that their efforts do little to make the patient
better. In the survey conducted by Hitchcock et a1. (1994), 41% of respon-
dents reported that their physicians refused to prescribe enough medication
to relieve their pain. Among the reasons given for this refusal were the
physician’s belief that patients should not take medications on a long-term
basis, the belief that the patient’s report of pain was not severe enough to
prescribe medication, or that the patient should be able to “handle” even
severe pain without using any medication.

The average health care provider in primary care may have neither the
time nor the resources to use multiple assessment tools. However, primary
health care providers are the ones who have an ongoing relationship with
chronic pain patients. It is, therefore, all the more necessary that primary
health care providers be able to assess and treat chronic pain sufferers. One

of the unfortunate results of chronic pain is that the patient may have been

referred to one specialist after another in the hope that a “cure” will be
found. When this expectation is not realized the chronic pain patient has
another reason to be discouraged. This lack of “curing” may lead to further
psychological and psychosocial disability. An important part of a health
professional’s commitment is the obligation to manage pain and relieve a
patient’s suffering (AHCPR Publication No. 92-0032, 1992). As
gatekeepers to medi cal care, primary health care providers are in a unique
position to insure that barriers to care are minimized and/or eliminated. The
primary health care provider needs a simple and usable assessment tool so
that he/she may have some confidence that the patient with chronic pain has
been adequately assessed. Comprehensive and appropriate ongoing treat-
ment that alleviates lifestyle pain-induced problems as well as treatment of

pain causes and symptoms can then be initiated.

Communication Issues

The issue of communication difficulties between patient and health
care provider in the area of chronic pain is well-supported by the literature.
In long-term care facilities, one-fourth of patients who complain of pain are
thought by nurses to be exaggerating the severity of that pain (Ryan,
Vortherms & Ward, 1994). Patients report satisfaction with pain manage-
ment even when their pain is not relieved; their satisfaction is hi ghly related
to psychosocial aspects of care such as communication (Ward & Gordon,
1994). Health care providers sometimes see chronic pain patients as malin-

gerers, seeking care when it is not really needed. This compounds the pa-

8
tients’ problems, making them feel that they must be “bad” patients. “What-

ever pain achieves, it achieves in part through its unsharability, and it en-
sures this unsharability through its resistance to language” (Scarry, 1985, p.
4). This “loss of language” is two sided. The patient perceives her/himself
as inhabiting an autistic realm, bereft of words with sufficient currency to
articulate her/his presenting symptoms. On the other hand, the health care
provider functions in the “realistic” world structured by medical/scientific
definitions, social expectations, and cultural norms. For the person in pain,
“having pain” is a vibrant example of certainty; while for the person “hear-
ing about pain,” the reath of pain is elusive and can easily be doubted
(Scarry, 1985).

Pain is a subjective experience and is entirely real to the person in
pain. “Pain is whatever the experiencing person says it is and exists when-
ever he says it does” (McCaffrey, 1972, p. 8). If the patient’s perceptions are
not included in the assessment of pain, the health care provider must depend
on physiological responses (heart rate, blood pressure and respiratory rate)
and behavioral responses (grimacing, groaning, guarding, etc.) (AHCPR
Publication No. 92-0032, 1992). When physiological responses are within
normal limits and/or behavioral responses are absent, the health care pro-
vider may doubt the presence of pain. As a result, patients’ pain is often
poorly predicted by healthcare professionals (Voigt, Paice, & Pouliot, 1995).

In treating the chronic pain patient, the success of the health care
provider’s work will frequently depend on the acuity with which he/she can

hear the description of pain, coax it into clarity, and interpret it. Alterna-

tively, the doubt of the health care provider may amplify the suffering of the
person with chronic pain (Scarry, 1985).

Models/Standards for Providing Care

It is important for health care providers to be aware of the manner in
which they relate to their clients from initial assessment through treatment.
Health care providers usually provide care in one of two major roles, either
as caretaker or consultant (Texidor, 1991). In the caretaker role, health care
providers are willing to take ownership of the patient’s problem and are in
control of the outcome of treatment. This approach does not support the
patient’s participation in treatment. Alternately, when the health care pro-
vider acts as consultant, the client is encouraged to share ownership of the
health care issue at hand. This approach to treatment is especially appr0pri-
ate for chronic pain patients where personal involvement, self-care, self-
responsibility, and decision making have the potential to produce lifestyle
changes that may have a positive effect on the chronic pain patient’s quality
of life (Texidor, 1991).

While the Agency for Health Care Policy and Research has not pub-
lished a clinical practice guideline specifically focused on the management
of chronic pain, the published guidelines on the management of cancer pain
can serve as a helpful guide for health care providers working with chronic
pain patients. The cancer pain guidelines recommend that (1) formal means
should be developed for evaluating pain management and for obtaining

patient feedback on the adequacy of pain control, (2) the quality of pain

9

10
management should be evaluated at points of transition in provision of ser-

vices, (3) each practice setting should designate who will be responsible for
pain management, and (4) standard procedures should be developed defining
acceptable levels of patient monitoring and the responsibilities of care pro-
viders in the administration of specialized forms of analgesia (AHCPR
Publication No. 94-0592, 1994).

CONCEPTUAL FRAMEWORK
Conceptual Definitions

Pain is defined as an unpleasant sensory and emotional experience
that is associated with tissue damage, either actual or potential (AHCPR
Publication No. 94—0592, 1994). Acute pain is defined as pain that has a
rapid onset, varies in intensity, lasts for a brief time (or up to six months),
and is self-limiting (Potter & Perry, 1989). With acute pain, both the patient
and the provider know that relief of pain is in sight. The time-limited nature
of acute pain has implications for its management. The prevention and
control of acute pain is aggressive and primarily pharmacological (AHCPR
Publication No. 92-0032, 1992).

Chronic pain is defined as pain which persists for more than six
months and results in the need for long-term treatment (Potter & Perry,
1989). The management of chronic pain uses a variety of modalities, includ-
ing, but not limited to, cognitive-behavioral strategies (Mobily, Herr, &
Kelley, 1993), group treatment (Basler, 1993), multidisciplinary treatment
(Jensen et al., 1994) and psychotherapeutic approaches (Miller, 1993).

11
Chronic pain is often treated pharmacologically (Bowman, 1994; Ryan et al.,

1994). Some patients have had surgery or other treatments to relieve their
chronic pain (Mayer etal., 1987; Miller & Kraus, 1990). Chronic pain
impacts individuals’ ability to conduct regular daily activities such as work-
ing at a job, keeping house, taking care of children, attending school, doing
volunteer work, or taking part in community activities (Basler, 1993;
Follick, Smith, & Ahern, 1985). Depression frequently accompanies chronic
pain (Hitchcock etal., 1994; Geisser et al., 1994). Chronic pain requires
coping skills on the part of both the patient and the provider that go beyond
measures used with acute pain (Basler, 1993; Bowman, 1994; Mayer et al.,
1987; Miller & Kraus, 1990; Smoller & Schulrnan, 1982). Patients report
that they must accept the pain, learn to live with it, and center their life
around it (Bowman, 1994). The continuous presence of chronic pain affects
psychological well-being, leading to depression, anxiety, and impaired
memory (Hitchcock et al., 1994). Constant pain also affects the nervous
system’s perception of pain. It is believed that the tissues themselves retain
a memory of the pain, increasing its perception (Bonica, 1991). These fac-
tors must be understood by the health care provider when treating the
chronic pain patient.

Persons suffering from chronic pain are likely to seek care from pri-
mary care providers (Hitchcock et al., 1994). Primary care providers are
those health professionals who bear the responsibility for providing primary
health care (Starfield, 1992). Primary care is defined as the point of entry
into the health care system and has the locus of responsibility for organizing

the care of patients and p0pulations over time (Starfield, 1992).

12
In summary, while pain is defined as an unpleasant sensory and emo-

tional experience that is associated with tissue damage, either actual or
potential (AHCPR Publication No. 94-0592, 1994), chronic pain must be
differentiated from acute pain. Acute pain is time- and self-limited and is
frequently managed by aggressive pharmacological therapy (AHCPR Publi-
cation No. 92-0032, 1992). Chronic pain is an entirely different concept and
is defined as pain that continues over a long period of time, affecting quality
of life. Treatment approaches range from non-pharmacological means such
as physical therapy, exercise, stress management and biofeedback to the

combined use of these methods with medications (Hitchcock et al., 1994)

Conceptual Framework

The complex issues surrounding the assessment and treatment of
chronic pain point toward the need to see the patient suffering from chronic
pain in a holistic way, with his/her own unique personality, coping strategies,
and psycho-social history and environment. The mind is not separable from
the body; hence quality health care requires a humanistic respect for the
functional unity of the human being (Watson, 1985). Watson’s (1985) con-
ceptual framework identifies the strain between considering the person as a
m and the traditional divisions of the natural, basic, and biomedical
sciences with a sum-of-parts focus. While careful to acknowledge the legiti-
mate role of the traditional sciences in the study of human beings, Watson
asserts that to use only this approach requires making certain assumptions

about human life and human caring that are nonhuman in character. For

l3
example, to see the human being as separable, with divisions of mind, body,

and spirit, denies the unity in which every person lives. Yet, traditionally,
health care providers treat people as divisible. The proliferation of special-
ties (psychiatry, intemal medicine, podiatry, urology, dermatology, cardiol-
ogy, obstetrics and gynecology, etc.) illustrate the way the human being is
viewed as divisible. Watson sees nursing as a human science, combining
and integrating traditional science with beauty, art, ethics and the aesthetics
of the human-to-human care process. As a human science, nursing views
human life as a gift to be cherished—a process of wonder, awe, and mystery
(Watson, 1985).

The issue can be focused sharply in the following way. The philo-
sophical basis of nursing is to heal and care. The philosophical basis of
medicine is to cure. For patients suffering with chronic pain, cure is remote,
elusive, and perhaps impossible. Healing and care can provide hope, under-

standing and the potential for improved quality of life.

Theoretical Framework

Chronic pain impacts every aspect of the chronic pain sufferer’s life—
work, relationships, leisure time, self-esteem, and ability to perform daily
activities. Therefore, Watson’s holistic approach is particularly well-suited
to the care of patients who suffer with chronic pain. The interaction of the
primary health care provider with the chronic pain patient is appropriately

illustrated in Watson’s schematic model (See Figure 1).

14

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For Watson, the main focus of nursing is care. A liberal arts education

provides the nurse/health care provider with a humanistic perspective and a

scientific knowledge base. These are required for successful application of

her seven assumptions about the science of caring:

1.

Caring can be effectively demonstrated and practiced
only interpersonally.

Caring consists of carative factors that result in the satis-
faction of certain human needs.

Effective caring promotes health and individual or family
growth.

Caring responses accept a person not only as he or she is
now but as what he or she may become.

A caring environment is one that offers the development
of potential while allowing the person to choose the best
action for himself or herself at a given point in time.
Caring is more “healthogenic” than is curing. The prac-
tice of caring integrates biophysical knowledge with
knowledge of human behavior to generate or promote
health and to provide ministrations to those who are ill.
A science of caring is therefore complementary to the
science of curing.

The practice of caring is central to nursing (Talento,

1989,p.294)

16
Watson’s seven carative factors are particularly well-suited to the care

of patients with chronic pain because of the emphasis on human interaction
between patient and health care provider. Working effectively with a person
who endures chronic pain requires the health care provider to interact with
the person, going beyond a curing emphasis (#1, #2, and #3). A health care
provider can assist the patient by helping him/her to accept life with chronic
pain and the limitations that pain imposes (Bowman, 1994), and by under-
standing the experience of chronic pain (Bonica, 1991). This is acutely
important for persons with chronic pain because they frequently become
isolated from family and friends. For chronic pain sufferers to become
motivated to look at pain in a different way requires the health care provider
to accept these persons not only as they are now but as what they may be-
come (#4). Chronic pain sufferers may need assistance in seeing that they
need not be victims of their pain. Chronic pain sufferers must also believe
that they have choices about what treatments may be most effective for them
(#5). In order for chronic pain sufferers to interrupt the chronic pain phe-
nomenon, they need to believe that they can reestablish control over their
lives by the choices they make regarding treatment. When persons hear that
there is probably no cure for their pain, they may accept this fact more
readily if care is not withdrawn (#6). Patients with chronic pain need to
know that they are not “bad” patients when their pain is not cured; they need
ongoing care and empathy from their health care providers (#7).

The interaction of the health care provider with the chronic pain pa-

tient is shown in Figure 2. Chronic pain is a factor in the phenomenal field

17

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18
of the patient. The health care provider’s ability to care, and conduct assess-

ment in a supportive manner are part of the health care provider’s phenom-
ena] field. The two interact in the actual caring occasion. The assessment of

chronic pain will be emphasized in this project.

LITERATURE REVIEW

The literature on chronic pain is highly varied. It includes global
reviews (Miller & Kraus, 1990; Texidor, 1991; Turk, Rudy, & Sorkin, 1993),
phenomenological studies on the experience of chronic pain (Bowman,
1994; Hitchcock et al., 1994), the challenges surrounding diagnosis
(Hockberger, 1990), and pain concepts and theory (Bonica, 1991; Ferrell,
Rhiner, Cohen, & Grant, 1991). Also included are the impact of pain man-
agement on quality improvement in health care settings (Ferrell, Whedon, &
Rollins, 1995; Ward & Gordon, 1994), the assessment of pain and disability
(Follick et al., 1985; Voigt et al., 1995), and attitudes toward pharmacologic
management of pain (McCaffery & Ferrell, 1996; Ryan et al.,1994; Ward &
Gatwood, 1994). The literature further includes approaches for the treatment
of chronic pain. The literature review that follows will include treatment
literature (from the perspective of chronic pain assessment); depression;

attitudes; ability to function; assessment of pain; and coping strategies.

19
Treatment Literature

Assessment of the patient is a common feature in all treatment studies.
Since the focus of this project is the assessment of chronic pain, it is appro-
priate to review the literature that includes the use of assessment tools, even
where the tools have been used in treatment studies. Assessment in the
treatment literature is often used as a means to measure treatment outcomes.
The assessment of patients to determine outcomes of treatment has a differ-
ent focus and may be done at different times than assessment to determine
patient needs. Patients who are participants in pain treatment programs have
been evaluated and determined to be appropriate candidates for pain treat-
ment. This is very different from initial pain assessment to determine the
needs of a patient, such as would be done in a primary care setting.

The focus of this project is the assessment of a patient with chronic
pain who presents for care in a primary care setting. This assessment should
enable the health care provider to determine the needs of the chronic pain
patient. Even though assessment in a primary care setting has a different
purpose (to determine needs) than assessment of treatment outcomes, the
tools that have been used to measure treatment outcomes can guide the
development of an initial assessment tool for use in primary care. Therefore
the literature reviewed will highlight material in which assessment measures
are used, for both the initial assessment of pain and for the outcomes of
treatment.

The complexity of the response to chronic pain is reflected in the use

of a number of assessment tools. These tools have addressed various aspects

20
of the response to chronic pain: 1) depression (Basler, 1993; Geisser et al.,

1994; Goldberg & Maciewicz, 1994; Jensen et al., 1994; Mayer et al., 1987;
Pilowsky et al., 1995; and Subramanian, 1994); 2) the impact of attitudes on
the perception of pain (Geisser et al., 1994; Jensen etal., 1994; Pilowsky et
al., 1995); 3) the ability to function when experiencing pain (Basler, 1993;
Goldberg & Maciewicz, 1994; Jensen et al., 1994; Mayer et al., 1987; and
Subramanian, 1994); 4) coping strategies used with chronic pain (Basler,
1993; Geisser et al., 1994; and Jensen et al., 1994); and 5) assessment of the
pain itself (Basler, 1993; Geisser et al., 1994; Goldberg & Maciewicz, 1994;
Jensen et al., 1994; Mayer et al., 1987; Pilowsky et al., 1995; and
Subramanian, 1994).

The Sickness Impact Profile is a global assessment tool that has been
widely used in the assessment of chronic pain patients (for example, by
Follick et al., 1985; Jensen et al., 1994; Pilowsky et al., 1995; Subramanian,
1994). It is a l36-item behaviorally based measure of health status, and
covers categories of activity involved in normal living: ambulation, mobil-
ity, body care and movement, communication, alertness, emotional behavior,
sleep and rest, work, recreation and pastimes, home management, and eat-
ing. It is a self-report measure of illness-related dysfunction (Follick et al.,
1985). This tool gives a wealth of information but has a heavy respondent
burden, requiring an average of 40 to 60 minutes for completion (Gerety et

al., 1994).

21
Depression

The Beck Depression Inventory is frequently used to assess depres-
sion in patients who suffer from chronic pain (Geisser et al., 1994; Goldberg
& Maciewicz, 1994; Jensen et al., 1994; and Mayer et al., 1987) . It is a 21-
item multiple-choice self-report inventory. It measures both the cognitive
affective components and the neuro-vegetative signs of depression (Beck,
1972).

In long-term follow-up of a treatment program for the management of
chronic pain, Subramanian (1994) used the Profile of Mood States to assess
depression. This profile is a 65-item, 5-point rating scale that assesses six
transient aspects of affect and mood: tension—anxiety, depression-dejection,
anger-hostility, vigor-activity, fatigue-inertia and confusion-bewilderment.

The Von Zerssen Depression Scale is a 16-item scale that assesses the
frequency with which depressive symptoms occur, including the report of
general dysphoric mood, behavior, and suicidal ideation on a four-point
scale ranging from ‘not at all true’ to ‘absolutely true.’ It was used in the
assessment of patients who suffer from low back pain, tension headache,
rheumatoid arthritis, and ankylosing spondylitis (Basler, 1993).

Other questionnaires used to measure the affective state of chronic
pain patients include the lung Depression Questionnaire, the Levine-
Pilowsky Depression Questionnaire, and the Spielberger State-Trait Anxiety
Inventory (Pilowsky et al., 1995).

22
Attitudes

Catastrophizing is one of the many attitudes seen in chronic pain
patients. Geisser et a1. (1994) conducted a study to determine whether
catastrophizing is related to McGill Pain Questionnaire scores when control-
ling for depression using the Beck Depression Inventory. Catastrophizing is
a measure of a person’s judgment about his/her inability to persist in coping
efforts, excessive worry about the future, and a tendency to view pain and
the individual’s life situation as overwhelming. Results suggest that
catastrophizing may increase pain perception and decrease the efficacy of
treatment.

The Survey of Pain Attitudes (Jensen, Karoly, & Huger, 1987; Jensen
& Karoly, 1989) was developed to assess seven beliefs hypothesized to be
important in adjustment to chronic pain: pain control (belief in one’s control
over pain), disability (belief in oneself as disabled by pain), harm (belief that
pain is a signal of damage and that activity should be avoided), emotion
(belief that emotions influence pain), medical cure (belief in a medical cure
for pain), solicitude (belief that others should be solicitous in response to
pain behaviors), and medication (belief in the appropriateness of medica-
tions for the treatment of chronic pain). Changes in pain-related attitudes
were found to be associated with improvement in depressive symptoms and
in physical functioning, as well as with decreased number of pain-related
physician visits (Jensen et al., 1994).

Pilowsky etal., (1995) measured illness-related attitudes and beliefs

of chronic pain patients through the use of the Illness Behaviour Assessment

23
Schedule and the Illness Behaviour Questionnaire. The patients were treated

using cognitive-behavioural therapy with amitriptyline (Elavil). This study
suggests that non-specific factors (being accepted, respected, and receiving

psychological support) are helpful in pain management.

Ability to Function

The Goldberg Scale of Vocational Development was designed to
measure specific problems of motivation and work disability encountered by
people with disabilities; it is not limited to persons with chronic pain
(Goldberg, 1992). It measures specific problems of motivation and work
disability and is a two-hour clinical interview synthesizing educational and
vocational history, work values, interests, motivation to work, realistic as-
sessment of pain disability, and optimistic/pessimistic outlook towards the
future. Its first use with a chronic pain population was in a study of 21
patients in an inpatient pain program (Goldberg & Maciewicz, 1994). Moti-
vation as measured by the Goldberg Scale was found to be a significant
factor in the reduction of pain complaints and in decreased depression.

A checklist of bodily symptoms containing 57 items (nausea, tired-
ness, trembling, exhaustion, etc.) was developed by Brahler and Scheer
(1983). It was used by Basler (1993) to assess patients’ ability to function.
Chronic pain patients rated the extent to which they suffer from these debili-
tating symptoms using a scale between 1 (not at all) and 5 (extremely). The
use of cognitive-behavioural treatment in this study resulted in an improve-

ment of physical complaints.

24
The Physical Dysfunction scale of the Sickness Impact Profile was

used to assess physical ability to function in a multidisciplinary treatment
program for chronic pain patients (Jensen et al., 1994). The study suggests
that coping strategies taught in this treatment program did not have a signifi-
cant impact on physical functioning at three and six month follow-up.

Mayer et a1. (1987) assessed patients with chronic low back pain using
a variety of physical function tests. Included were spinal range of motion,
dynamic trunk strength, static lifting, lifting under workload, cardiovascular
fitness/muscular endurance measures, and a global effort rating. Following
the functional restoration program examined in the study, 87% of the treat-
ment group were working as compared with 41% of the comparison group
(who were denied treatment by the insurance carrier).

The Pain Disability Index measures household responsibilities, social
activities, occupational activities, sexual behaviour, recreational activities,
self-care and life support activities. It is a good indicator of the disabling
effects of chronic pain on normal life activities as an index of the ability to
function (Goldberg & Maciewicz, 1994). Younger people were found to
have higher pain disability scores before treatment; correlation between age
and Pain Disability Index was not significant at follow-up. The study which

included 21 patients did not define the age of “younger people.”

Assessment of Pain
The McGill Pain Questionnaire is a descriptive measure of pain using

twenty groups of single-word pain descriptors. The patient chooses a word

25
most consistent with his/her subjective pain experience; the words in each

group increase in rank order intensity (Melzack, 1975). The questionnaire
has repeatedly been used in assessing both acute and chronic pain intensity
(for example, Geisser et al., 1994; Paice et al., 1995; and Pilowsky et
al.,1995). It is useful in assessing patient’s pain over time for comparison
purposes; for example, when changing treatment strategies.

Patients sometimes are instructed to keep a pain diary in the assess-
ment of their pain (Basler, 1993; Smoller & Schulman, 1982). A pain diary
may also take the shape of a visual analogue scale (Pilowsky et al.,1995).
Mayer et a1. (1987) used pain drawing and the Million Analog Scale to
assess pain. Severity of pain is often measured by a numerical scale that
rates pain intensity on a scale from 0=n0 pain to 10=pain as bad as it can
be (AHCPR Publication No. 92-0032, 1992; Subramanian, 1994). It must
be remembered that these scales should not be used for comparing pain
among individuals. Because pain is a subjective experience, each person’s
pain intensity rating is uniquely his/her own. However, these tools are use-
ful in assessing individual patient’s pain over time. If a health care provider
relies only on the patient’s report of pain “today,” significant information
may not be available as the patient may not accurately remember what the
pain was like a week or a month ago. Keeping a pain diary or recording pain
on a scale provides objective, within-subject information about a subjective

experience.

26
Coping Strategies

The Coping Strategy Questionnaire (Rosenstiel & Keefe, 1983) mea-
sures six cognitive coping responses to pain (diverting attention, coping self-
statements, praying and hoping, reinterpreting pain sensations,
catastrophizing, and ignoring pain) and a behavioral response (increased
behavioral activities). In one study, changes in pain-related beliefs (mea-
sured by the Survey of Pain Attitudes referred to above) and cognitive cop-
ing strategies were associated with improvement in depressive symptoms

and physical functioning (Jensen et al., 1994).

Assessment as Treatment

Interpersonal support leads to patients developing a sense of being
accepted and respected. Many patients arriving at pain clinics report that
previous experiences with health care providers have not generated such
feelings (Pilowsky et al., 1995). Support of this kind must begin with as-
sessment.

Patients report satisfaction with care when they are evaluated
nonjudgmentally and receive support and empathy for their problems
(Hockberger, 1990), even though their pain is not relieved (Ward & Gordon,
1994; Ferrell et al., 1995). How we treat the pain is less important than how
we make patients feel about their care. Patients leave health care sites with a
positive view of the encounter if providers take time to examine, listen to,
and talk with patients. Primary care providers must provide support and
empathy from initial assessment through treatment if they expect their pa-

tients to be satisfied with care.

27
Critique of Literature

Of the treatment studies here reviewed, five had fewer than 100 sub-
jects (Goldberg & Maciewicz, 1994; Jensen et al., 1994; Geisser et al., 1994;
Pilowsky etal., 1995; Subramanian, 1994). The other two studies had 176
subjects (Basler, 1993) and 188 subjects (Mayer etal., 1987).

Only three of the studies mentioned the race of subjects (Geisser etal.,
1994; Jensen et al., 1994; Subramanian, 1994). These were characterized as
89% white, 91% Caucasian, or “almost all” Caucasian.

One study (Pilowsky et al.,1995) made no mention of gender. Other
studies included both men and women in varying percentages (Basler, 1993;
Geisser et al., 1994; Goldberg & Maciewicz, 1994; Jensen et al., 1994;
Mayer et al., 1987; Subramanian, 1994). It can be concluded that chronic
pain affects both men and women.

Some studies refer to the age of subjects (Goldberg & Maciewicz,
1994; Geisser et al., 1994; Jensen et al., 1994; Subramanian, 1994). Others
include age as one aspect of the demographic profile of participants
(Pilowsky et al., 1995; Subramanian, 1994). One study had a range of 21 to
76 years (Geisser et al., 1994); another had a range of 21 to 64 years (Jensen
et al., 1994); and a third included clients ranging in age from 38 to 82 years
(Subramanian, 1994).

Only three of the studies reviewed included the duration of chronic
pain as a characteristic of participants. In Basler’s (1993) study, the duration
of pain was more than 10 years. Average duration of pain was 3.9 years in
the study done by Geisser et a1. (1994). In another study the duration of pain

was 2 to 34 years (Subramanian, 1994).

28
In summary, it may be concluded that these studies may not be gener-

alizable to the total population of chronic pain patients because samples are
small in size, and do not include multiple ethnic groups. Chronic pain ap-
pears to afflict adult patients regardless of age. The literature suggests that
chronic pain afflicts men and women about equally.

Most studies used multiple assessment measures; the areas most fre-
quently assessed are depression, the pain itself, and the impact of chronic
pain on daily living. Given the multidimensional response to chronic pain,
the assessment measures used are appropriately distributed to evaluate the

variety of responses to chronic pain.

Review and Synthesis

The focus of this project is the assessment of chronic pain. If Watson
is correct that every interaction between the patient and health care provider
has the potential to be therapeutic, then assessment is part of therapy. As-
sessment and treatment can not be divorced. This idea is validated by sev-
eral writers in current literature (Bowman, 1994; Hockberger, 1990;
Pilowsky et al., 1995; Texidor, 1991). It has been shown in our literature
review that assessment measures are commonly used by researchers pre- and
post-treatment, both to furnish a baseline for treatment and to measure out-
comes of therapy. Assessment when used by primary health care providers
may also be part of the therapy process itself.

The assessment tool envisioned in this project has a different purpose

than merely measuring outcomes of treatment. Assessment is a repetitive

29
problem—solving process. The guidelines for the management of cancer pain

(AHCPR Publication No. 94-0592, 1994) suggest that pain be assessed at
regular intervals and with each new report of pain. The approach used with
cancer patients may also be appropriate for chronic pain patients. A clinical
guideline for the management of pain is outlined as follows: A) Ask about
pain regularly and assess it systematically; B) Believe the patient’s (or
family’s) report of pain and what relieves it; Q) Choose appropriate pain
control options; Q) Deliver interventions in a timely, coordinated and logi-

cal manner; E) Empower patients and their families and enable them to
control their options as much as possible (AHCPR Publication No. 94-0592,
1994).

The primary care provider must regularly assess the pain of persons
who suffer from chronic pain, and provide treatment options and coping
strategies that are appropriate to the patient. An ongoing and empathetic
relationship with the patient that involves him/her in the treatment plan is
essential. Primary care providers are familiar with the necessity of continu-
ous monitoring of their diabetic and hypertensive patients’ response to treat-
ment. Medications or dosages are frequently changed. The patient’s partici-
pation in treatment is essential for success because changes in behavior are
usually required. Health care providers must be equally flexible and creative
when assessing and treating the patient with chronic pain (Meinhart &
McCaffery, 1983).

The foregoing literature review illustrates the multitude and variety of

measures that may be used to assess the patient with chronic pain. In sum-

30
mary, it is instructive to note that all use a depression inventory or some

measure of mood states. Three used the McGill Pain Questionnaire and the
Sickness Impact Profile. Most use a pain rating index. There is frequent use
of some measure of coping strategies.

Given the complexity of factors that contribute to the chronic pain
syndrome and the frustration that many chronic pain patients experience
when their pain is not relieved, it is not surprising that the assessment of
chronic pain patients may be overwhelming to the primary health care pro-
vider. Clearly both the patient and the health care provider need to have
confidence that chronic pain can be assessed and treated.

Based on the literature review, the three most important categories to
be included in a chronic pain assessment are: l) coping strategies; 2) the
degree to which chronic pain has impacted daily living activities, work and
relationships; and 3) the presence/absence of depression. Assessment of
coping strategies can give the health care provider important insight regard-
ing the patient (Bowman, 1994; Geisser et al., 1994; Jensen et al., 1994;
Miller, 1993; Subramanian, 1994; Texidor, 1991). The patient’s use of cop-
ing strategies that he/she has developed independently may indicate the
individual’s ability to be involved in his/her care. For example, a previous
study has shown that when patients catastrophize, their perception of pain
increases and treatment has lower efficacy (Geisser et al., 1994). Chronic
pain impacts daily living, work and relationships (Bowman, 1994; Geisser
et al., 1994; Goldberg & Maciewicz, 1994; Mayer etal., 1987; Smoller &
Schulman, 1982; Jensen et al., 1994). Therefore, these issues must be as-

31

sessed. Depression must be assessed, since it is almost axiomatic that de-
pression is associated with chronic pain (Geisser et al., 1994; Miller, 1993;
Pilowsky et al., 1995; Texidor, 1991).

It is important for the health care provider to acquire knowledge about
three additional factors when assessing a patient presenting with chronic
pain: 1) use of medication; 2) history of previous treatment(s); 3) the
patient’s perception of the effectiveness of these treatments. The patient’s
use of medication must be assessed because pain relievers are the first line of
treatment in patients suffering from pain. The health care provider needs to
know what medications have been tried and the level of relief that the patient
has experienced (Bowman, 1994; Miller & Kraus, 1990; Smoller &
Schulman, 1982). Previous treatment and the patient’s perception of effec-
tiveness must be addressed because most chronic pain patients have been
seen by a variety of health care providers. Frequently their experiences have
not been positive (Texidor, 1991; Pilowsky et al., 1995; Miller, 1993).

The assessment itself M be accomplished in a face-to-face en-
counter with the patient, in keeping with Watson’s model of the human-to-
human care process outlined in the conceptual framework above. If this
method is found to be impossible in the clinical setting, the purpose may be
accomplished by the use of a carefully crafted questionnaire that the patient
can fill out and mail in or bring back on a follow-up visit. It must, however,
be short enough that the health care provider can assist the patient in answer-
ing the questions if responding to a written questionnaire is difficult. Diffi-
culties could include, but are not limited to, vision or literacy problems and

the pain itself.

32
PROJECT DEVELOPMENT

Approach and Procedures

It was the goal of the writer to develop a clinically useful assessment
tool that could be used by primary health care providers in assessing patients
with chronic pain in a primary care site. It must be short enough to be prac-
tical for use in a primary care setting where the provider must see a new
patient every 20 to 30 minutes. It included: (Table 1) the patient’s use of
medication (Hock, 1996); (Table 2) a history of previous treatment(s) (Hock,
1996); (Table 3) the patient’s perception of the effectiveness of these treat-
ments (Hock, 1996); (Table 4) current coping strategies (Hock, 1996); (Table
5) the degree to which chronic pain has impacted daily living activities,
work and relationships (Sherboume, Stewart, & Wells, 1992); and (Table 6)
the presence/absence of depression, using the CESD-10 scale, (Andresen,
Carter, Malmgren, & Patrick, 1994). (See Appendix A for actual tool.)

It seemed desirable to pilot the tool with a cohort of patients to deter-
mine usefulness. Therefore, permission was sought and granted from the
University Committee on Research Involving Human Subjects at Michigan

State University (See Appendix B).

33
Table 1.

Ptien’ 3 fm ic 'on

 

Do you take medication for your pain? (please circle) Yes No

 

 

 

 

 

 

If yes, Name Dosage
Name Dosage
Name Dosage
Name Dosage

 

 

Which medication works best for you?

 

Note, Questions developed for this study. (Hock,l996).

Table 2.

Hit frv' n

 

Have you had surgery related to your pain? (please circle) Yes No
If yes, describe the surgery.
Have you had other treatments for your pain? (please circle) Yes No

If yes, describe the treatments.

 

Note, Questions developed for this study. (Hock,l996).

34
Table 3.

Patients pereeptien ef treatment effeetiveness

 

Explain how the surgery has helped/changed your pain.

Explain how the treatments have helped/changed your pain.

 

Nete, Questions developed for this study. (Hock,l996).

Table 4.

rrn in ei

 

In addition to medications and treatment, what else do you do to help you

cope with your pain?

 

Mtg Question developed for this study. (Hock,l996).

Table 5.

fh' 'nn ' 'v'n rknrlti shi

 

The following questions are about your regular daily activities such as
working at a job, keeping house, taking care of children, attending school,
doing volunteer work, or taking part in community activities.

During the past 4 weeks, have you had any of the following problems

with your work or other regular daily activities as a result of chronic pain?

35
Circle Yes or N o for each question.

Yes No a. Took frequent rests when doing work or other activities

Yes No b. Cut down the amount of time you spend on work or other
activities

Yes No c. Accomplished less than you would like

Yes No (1. Didn’t do work or other activities as carefully as usual

Yes No e. Were limited in the kind of work or other activities

Yes No f. Had difficulty performing the work or other activities (for
example, it took extra effort)

Yes No g. Required special assistance (the assistance of others or special

devices) to perform these activities

Yes No h. Acted irritable toward people (for example, snapped at them,

gave sharp answers, criticized easily)?

 

Nete, (Sherboume et al., 1992)

Table 6.

Prn n ri

 

Please rate how often you have felt this way during the past week, by
circling the appropriate number on the left-hand side of each statement:
0 = Rarely or None of the Time (less than 1 day)
l = Some or a Little of the Time (1-2 days)
2 = Occasionally or a Moderate Amount of Time (3-4 days)
3 = Most or All of the Time (5-7 days)

36

During the past week:

0 1 2 3 1. I was bothered by things that usually don’t bother me.
0 1 2 3 2. I had trouble keeping my mind on what I was doing.
0 1 2 3 3. I felt depressed.

0 l 2 3 4. I felt that everything I did was an effort.

0 1 2 3 5. Ifelt hopeful about the future.

0 l 2 3 6. I felt fearful.

0 l 2 3 7. My sleep was restless.

0 1 2 3 8. I was happy.

0 1 2 3 9. I felt lonely.

0 l 2 3 10. Icould not get “going.”

 

Me, CESD-10 scale, (Andresen et al., 1994).

Pilot of Assessment Tool

The purpose of the assessment tool was explained in a face-to-face
interview. The consent of the patient to participate was secured (Appendix C).

The tool was piloted with five individuals known to suffer from
chronic pain. Included were the following persons: (1) an 87 year-old
woman with an 18-year history of osteoporosis, (2) a 56 year-old woman
with bone spurs on the walking surface of the right heel complicated by
nerve damage secondary to a severe laceration of the heel of the right foot
more than two years ago, (3) a woman in her early fifties with chronic low

back pain for 4 to 5 years, (4) a woman in her early sixties with chronic low

37
back pain for many years and back surgery 29 months ago, and (5) a 40

year-old woman with severe low back pain secondary to an on-the-job in-
jury, requiring a variety of treatments, none of which has been effective to

date in controlling the pain.

Target Group

The convenience sample of five individuals who suffer from chronic
pain was chosen from co-workers and acquaintances of the writer. The
initial plan to include patients from the family practice clinics where the
writer is currently engaged in clinical practice was impossible to implement
because of scheduling difficulties and the limited time that the writer was at
those clinics.

The target group included only females. Three are health care work-
ers. One is retired living with her spouse on an above-average income. One
is a single parent supporting a middle school age child on the salary of a
staff nurse. One is a single health care professional who owns her own

home. Two are married and working full-time at middle-income jobs.

Evaluation

Prior to administration, three primary health care physicians were
asked to review the tool and evaluate its potential usefulness. One indicated
that he thought it had usability but gave no feedback about possible im-
provements. A second did not respond. The third filled it out as a question-
naire and indicated that it was clear but gave no feedback about its clinical

usefulness.

38

The five interviews were conducted in face-to-face encounters. Pri-
vacy was assured by conducting the interview either in the individual’s or
the interviewer’s home or in a room to which the door was closed. Each
interview required from fifteen to twenty minutes to complete, considerably
less than the forty-five minutes originally targeted.

All participants stated that the assessment content was clear and read-
able. Participants gave helpful feedback about possible improvements. One
suggested that the patient’s perspective about what should be done to relieve
the pain should be included (she volunteered the opinion that losing weight
would undoubtedly relieve some of her pain); this individual also thought
that factors precipitating pain should be addressed. Another thought that the
frequency, duration and intensity of the pain should have been an element in
the assessment; this was clearly an omission that should have been included.
Two individuals believed that the degree to which chronic pain had changed
the person’s life should have been assessed; this would seem to be a difficult
item to quantify. While conducting the interviews, the writer became aware
that the time-frames stated in the daily activities and depression sections of
the questionnaire were somewhat constricting, particularly with individuals
who had been coping with chronic pain over many years. The time frames
could be adapted according to the experiences of individual patients. The
date of surgery (if applicable) could also be included.

While the group with whom the tool was piloted was very small and
lacked diversity, it is believed that the tool has usefulness. It could be im-

proved by incorporating an assessment of the pain itself without sacrificing

39
the advantage of its short administration time, an essential characteristic for

usefulness in a primary care site.

The studies in the literature review did not include multiple ethnic
groups. The assessment tool developed in this project could overcome this
shortcoming by including a question that would capture the awareness that
cultural groups differ in their response to pain. This inclusion would make
the assessment tool more useful in primary care settings where a variety of
cultural groups seek healthcare. (See Appendix D for a revision of the as-

sessment tool.)

Implications for Advanced Nursing Practice and Primary Care

Chronic pain is a troublesome problem both for patients and for health
care providers. As noted earlier in this paper, chronic pain sufferers fre-
quently feel that their pain is not understood, and often find that their pain
impacts negatively on their work, life, and relationships. Health care provid-
ers are hard-pressed to remain empathetic and caring in the face of a prob-
lem that is resistant to “cure.”

Healthcare providers must be educated about the complex nature of
chronic pain and the need to remain empathetic toward those who suffer
with it. Advanced practice nurses are uniquely qualified to provide
empathetic and flexible care to these individuals because the philosophical
basis of their training focuses on healing and care. The patient suffering
from chronic pain needs assurance that the pain is “not in my head” (Bow-

man, 1994). Chronic pain sufferers may need assistance in finding ways to

40
regain control of their lives. Advanced practice nurses, trained to see indi-

viduals in a holistic manner and with information about adjunctive therapies,
are well-qualified to suggest alternative treatments (such as massage, heat,
rest, and flexible activity scheduling). Both health care providers and pa-
tients need education about the impact of attitudes on the ability to cope with
chronic pain.

The primary health care provider, whether an advanced practice nurse
or other professional, is in a unique position to make a significant and posi-
tive impact on the chronic pain sufferer. Beginning with initial assessment
and continuing through ongoing contacts with these patients, the attitude of
the provider is critical (Hockberger, 1990; Pilowsky et al., 1995). Therapeu-
tic effects can be achieved by remaining respectful toward the patient (Bow-
man, 1994), acting as a consultant to the patient (Texidor, 1991), assisting
the patient in taking control of their pain management (Subramanian, 1994),
maintaining an empathetic and caring attitude (Ferrell et al., 1995), and not
abandoning the patient (Watson, 1985).

A health care provider desiring to relieve suffering could use the
assessment tool developed for this project as a worthwhile first step in work-
ing with a chronic pain patient. The writer found the interview process
productive; those interviewed seemed comfortable and were forthcoming
with information. The assessment tool should become part of the patient’s
medical record.

The need to document ongoing problem-solving and reassessment

could be accomplished by the use of a pain flowsheet placed in the patient’s

4]
record. (See Appendix E for a possible format for such a pain flowsheet; not

all aspects of the flowsheet would need to be documented at every pain-
related visit.) Outcomes of treatment could be documented by periodic chart
reviews to ascertain whether the number of pain-related visits to the health

care provider becomes less over time.

42
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48
APPENDIX A

Chronic Pain: An Assessment Tool for Primary Care

1. Do you take medication for your pain? (please circle) Yes No

 

 

 

 

 

 

2. Ifyes, Name Dosage
Name Dosage
Name Dosage
Name Dosage

 

 

3. Which medication works best for you?
4. Have you had surgery related to your pain? (please circle) Yes No
5. If yes, describe the surgery.

6. Explain how the surgery has helped/changed your pain.

7. Have you had other treatments for your pain? (please circle) Yes No

8. If yes, describe the treatments.

9. Explain how the treatments have helped/changed your pain.

10. In addition to medications and treatment, what else do you do to help

you cope with your pain?

49

The following questions are about your regular daily activities such as

working at a job, keeping house, taking care of children, attending school,

doing volunteer work, or taking part in community activities.

During the past 4 weeks, have you had any of the following problems

with your work or other regular daily activities as a result of chronic pain?

Circle Yes or No for each question.

Yes
Yes

Yes

Yes

Yes

Yes

Yes

Yes

No
No

No

No

No

No

No

No

a. Took frequent rests when doing work or other activities

b. Cut down the amount of time you spend on work or other
activities

c. Accomplished less than you would like

(1. Didn’t do work or other activities as carefully as usual

e. Were limited in the kind of work or other activities

f. Had difficulty performing the work or other activities (for
example, it took extra effort)

g. Required special assistance (the assistance of others or special
devices) to perform these activities

h. Acted irritable toward people (for example, snapped at them,

gave sharp answers, criticized easily)?

50

Please rate how often you have felt this way during the past week, by

circling the appropriate number on the left-hand side of each statement:

0 = Rarely or None of the Time (less than 1 day)

l = Some or a Little of the Time (1-2 days)

2 = Occasionally or a Moderate Amount of Time (3-4 days)
3 = Most or All of the Time (5-7 days)

During the past week:

0 1 2 3 1. I was bothered by things that usually don’t bother me.
0 l 2 3 2. I had trouble keeping my mind on what I was doing.
0 1 2 3 3. I felt depressed.

0 l 2 3 4. I felt that everything I did was an effort.

0 1 2 3 5. I felt hopeful about the future.

0 l 2 3 6. I felt fearful.

0 1 2 3 7. My sleep was restless.

0 l 2 3 8. I was happy.

0 l 2 3 9. I felt lonely.

0 l 2 3 10. Icould not get “going.”

Are the items in this questionnaire clear? Yes No

Have you any suggestions that might improve this assessment tool? Please

state your suggestions. Thank you very much for your participation.

 

OFFICE OF
RESEARCH
AND
GRADUATE
STUDIES

University Committee on
Research Involving
Human Subjects
(UCRIHS)

Michigan State University
246 Administralion Building
East Lansing. Michigan
48824-1046

517/355-2180
FAX: 517/432-1171

lne Michigan Slate UniveISIIy
10f A IS Insult/Irona/ DIVBISIIy
Excellence m Aaron

MSU IS an affirmative-action,

    
  

MICHIGAN STATE 51

 

UNIVERSITY APPENDIXB
February 13, 1997 UCRH‘IS Approval
TO: Linda Beth Tiedje . .
A-230 Life Sciences Building
RE: IRB#: 97-046
TITLE: CHRONIC PAIN: DEVELOPMENT OF AN ASSESSMENT TOOL
REVISION REQUESTED: N/A
CATEGORY: l-C
APPROVAL DATE: 02/12/97

The University
review of this
rights and welf

Committee on Research Involving Human Subjects'IUCRIHS)
project is complete.. I am pleased to adVise that the
are of the human subjects appear to be adequately

protected and methods to obtain informed consent are appropriate.

herefore, the
above.

RENEWAL UCRI
the

cont

form (enclosed with t

proj

UCRIHS approved this project and any reVisions listed

HS approval is valid for one calendar year, beginning with

approval date shown above. Investigators planning to

inue a preject beyond one year must use the green renewal
e original approval letter or when a

ect is renewed) to seek u date certification. There is a

maXimum of four such expedite renewals possible. Investigators
wishing to continue a prOJect beyond that time need to submit it
o

agai

REVISIONS: UCRI
subj
the

revise an approved protocol at an

n r complete reView.

HS must review any changes in probedures involving human
ects, rior to initiation of t e change. If this is done at
time o renewal, please use the green renewal form. To
other time during the year,

send your written request to the UCRIHS Chair, requesting revised
approval and referencing the project's IRB # and title. Include
in your request a description of the change and any revised
instruments, consent forms or advertisements that are applicable.

PROBLEMS/

CHANGES: Should either of the followin arise during the course of the
work, investigators must noti UCRIHS promptly: (I) roblems
(unexpected Side effects, comp aints, etc.) involving uman

subj

ects or (2) changes in the research environment or new

information indicating greater risk to the human sub'ects than
eXisted when the protocol was preViously reviewed an approved.

If we can be of
at (517)355-218

Sincerely,

avid E. Wr'
UCRIHS Chai

DEW:bed

cozvyfiidam Hock

 
   

any future help, please do not hesitate to contact us
0 or FAX (517)4 2-1171.

52
APPENDIX C

PARTICIPANT INFORMED CONSENT

CHRONIC PAIN:
Development of an Assessment Tool for Primary Care

College of Nursing
Michigan State University

I understand that I am being asked to participate in the devel-
opment of a chronic pain assessment. I also understand that this
assessment uses an interview format and will take approximately
forty-five minutes to complete. I further understand that my par-
ticipation is completely voluntary and that I may refuse to partici-
pate. If there are particular questions that I do not wish to answer, I
may refuse to do so. Should I choose not to participate, it will have
no negative impact on the care that I receive from my primary phy-
srcran.

I understand that my responses will be kept completely confi-
dential and that my identity will not be disclosed in any report of
this project. By request, and within these restrictions, a report will
be made available to participants.

If I have any concerns or questions regarding my participation
in this project, I understand that I may contact Miriam Hock at
(616) 749-9396, and she will try to answer my concerns or ques-
tions to my satisfaction.

Participant’s Name (please print)

 

Participant’s Signature

 

 

Signature of interviewer

Date

 

53

APPENDIX D
Chronic Pain: An Assessment Tool for Primary Care

1. In your family of origin, how did you react to pain? What was done

when people were in pain?

1. Do you take medication for your pain? (please circle) Yes No

 

 

 

 

 

 

2. Ifyes, Name Dosage
Name Dosage
Name Dosage
Name Dosage

 

 

3. Which medication works best for you?
4. Have you had surgery related to your pain? (please circle) Yes No
5. If yes, give the date and describe the surgery.

6. Explain how the surgery has helped/changed your pain.

7. Have you had other treatments for your pain? (please circle) Yes No

8. If yes, describe the treatments.

9. Explain how the treatments have helped/changed your pain.

10. In addition to medications and treatment, what else do you do to help

you cope with your pain?

54

11. On a scale of 0 to 10, with 0 = no pain and 10 = the worst pain you can

imagine, how would you rate your pain today?

12. How frequently do you have pain?

13. How long does the pain usually last?

The following questions are about your regular daily activities such as

working at a job, keeping house, taking care of children, attending school,

doing volunteer work, or taking part in community activities.

During the past 4 weeks, have you had any of the following problems

with your work or other regular daily activities as a result of chronic pain?

Circle Yes or No for each question.

Yes
Yes

Yes

Yes

Yes

Yes

Yes

Yes

No
No

No

No

No

No

No

No

a. Took frequent rests when doing work or other activities

b. Cut down the amount of time you spend on work or other
activities

c. Accomplished less than you would like

(1. Didn’t do work or other activities as carefully as usual

e. Were limited in the kind of work or other activities

f. Had difficulty performing the work or other activities (for
example, it took extra effort)

g. Required special assistance (the assistance of others or special

devices) to perform these activities

h. Acted irritable toward people (for example, snapped at them,

gave sharp answers, criticized easily)?

55

Please rate how often you have felt this way during the past week, by

circling the appropriate number on the left-hand side of each statement:

0 = Rarely or None of the Time (less than 1 day)
1 = Some or a Little of the Time (1-2 days)
2 = Occasionally or a Moderate Amount of Time (3-4 days)

3 = Most or All of the Time (5-7 days)

During the past week:

123
123
23
23
23
23
23
23
23
23

¢¢¢¢°¢¢¢¢¢
HHHHHHHH

l.

PWNQWPP’N

i—A
.9

I was bothered by things that usually don’t bother me.
I had trouble keeping my mind on what I was doing.

I felt depressed.

I felt that everything I did was an effort.

I felt hopeful about the future.

I felt fearful.

My sleep was restless.

I was happy.

I felt lonely.

I could not get “going.”

Appendix E
Pain Flowsheet

Use of medications:

56

 

 

 

 

 

 

 

 

 

 

 

 

 

Medication Dosage Frequency Efficacy (1-5*)
Coping Strategies:

Strategy Frequency Efficacy (1-5*)
Pain Diary?

Date Yes No Date Yes No Date Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

* (1=no relief; 5=highly effective)

 

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