Moving beyond pain scores: Multidimensional pain assessment is essential for adequate pain management after surgery.

Regina L M Van Boekel,Kris C P Vissers,Jos G C Lerou,Monique A H Steegers,Ewald Bronkhorst,Rob Van Der Sande,André Mouraux

doi:10.1371/journal.pone.0177345

Abstract

BackgroundClinical experience teaches us that patients are willing to accept postoperative pain, despite high pain intensity scores. Nevertheless, relationships between pain scores and other methods of pain assessment, e.g. acceptability of pain or its interference with physical functioning, are not fully established. Our aims were to examine these relationships.MethodsA cross-sectional study was conducted on patients who underwent major surgery between January 2008 and August 2013. Using logistic regression, we quantified the relationships between movement-evoked pain scores on the numerical rating scale (NRS-MEP) and three dichotomous dependent variables: patient’s opinion on acceptability of pain (PO: acceptable or unacceptable pain); nurses’ observation of patient’s performance of necessary activities to expedite recovery (NO: good or bad performance); a compound measure judging the presence of the clinically desirable situation of acceptable pain associated with good patients’ performance (PONO: present or not). Using Receiver Operating Characteristics (ROC) analysis, NRS cut-off points were determined such that they best discriminate between patients having one versus the other outcome for PO, NO and PONO.Results15,394 assessments were obtained in 9,082 patients in the first three postoperative days. Nine percent of the patients had unacceptable pain while having an NRS-MEP of 0–4. An estimated 47% (95%CI = 45%-49%) of patients with an NRS-MEP of 7 described their pain as acceptable on day one. Moreover, 33% (31%-35%) performed all required physical activities, and 22% (21%-24%) combined acceptable pain with appropriate movement. NRS cut-off points for PO, NO and PONO were five, four and four, respectively, but had insufficient discriminatory power.ConclusionsOur results suggest pain management should be guided by the many dimensions of the patient’s pain experience, not solely by NRS cut-off points. Future research should evaluate the impact of such multidimensional pain assessment on patients’ functional outcome.

Highlights

Many patients experience acute postoperative pain after major as well as minor surgery [1, 2]
We quantified the relationships between movement-evoked pain scores on the numerical rating scale (NRS-MEP) and three dichotomous dependent variables: patient’s opinion on acceptability of pain (PO: acceptable or unacceptable pain); nurses’ observation of patient’s performance of necessary activities to expedite recovery (NO: good or bad performance); a compound measure judging the presence of the clinically desirable situation of acceptable pain associated with good patients’ performance (PONO: present or not)
Using Receiver Operating Characteristics (ROC) analysis, NRS cut-off points were determined such that they best discriminate between patients having one versus the other outcome for PO, NO and PONO

Summary

Introduction

Many patients experience acute postoperative pain after major as well as minor surgery [1, 2]. As pain is a complex and subjective experience, in the postoperative period, various methods exist to evaluate key aspects of acute pain after surgery. Most of these assessment methods rely on the perception of pain and pain- related phenomena by either the patient or a professional caregiver [3, 4]. Clinical experience teaches us that patients are willing to accept postoperative pain, despite high pain intensity scores. Relationships between pain scores and other methods of pain assessment, e.g. acceptability of pain or its interference with physical functioning, are not fully established.

Objectives

Methods

Findings

Conclusion