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Quantitative pain assessment for routine care of rheumatoid arthritis patients using a pain scale based on activities of daily living and a visual analog pain scale.

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QUANTITATIVE PAIN ASSESSMENT FOR ROUTINE
CARE OF RHEUMATOID ARTHRITIS PATIENTS,
USING A PAIN SCALE BASED ON ACTIVITIES OF
DAILY LIVING AND A VISUAL ANALOG PAIN SCALE
LEIGH F. CALLAHAN, RAYE H. BROOKS, JANE A. SUMMEY, and THEODORE PINCUS
Pain was assessed quantitatively as a component
of routine visits of 385 outpatients with rheumatoid
arthritis, using a pain scale based on activities of daily
living (ADL) and a visual analog scale. The ADL pain
scale met psychometric criteria for validity and reliability. Scores on the 2 pain scales were correlated significantly with one another and with other measures of
disease status, including joint count, grip strength,
walking time, button test, morning stiffness, erythrocyte
sedimentation rate, global self-assessment, ADL difficulty, and ADL dissatisfaction scales. Correlations of
ADL pain scale scores with other measures were higher
than were correlations of visual analog scale scores with
other measures, in both unadjusted and adjusted analyses. Significantly more patients completed the ADL
pain scale without assistance than the number of those
who completed the visual analog pain scale. The ADL
pain scale was more sensitive to problems in ADL than
were the ADL scales for difficulty and dissatisfaction.
The ADL and visual analog pain scales appear to
Presented in part at the southeastern Regional Meeting of
the American Rheumatism Association, Savannah, GA, December
1985, and at the 50th Annual Meeting of the Arthritis Health
Professions Association, New Orleans, LA, June 1986.
From the Division of Rheumatology and Immunology,
Department of Medicine, Vanderbilt University School of Medicine,
Nashville, Tennessee.
Supported in part by the Jack C. Massey Foundation, the
Maury County Lupus Fund, and the Robert Wood Johnson Foundation.
Leigh F. Callahan, BS; Raye H. Brooks, BS; Jane A.
Summey, MS; Theodore Pincus, MD.
Address reprint requests to Leigh F. Callahan, BS, Division
of Rheumatology and Immunology, B-3219 Medical Center North,
Depari ment of Medicine, Vanderbilt University, Nashville, TN
31232.
Submitted for publication November 5, 1986; accepted in
revised form January 9, 1987.
Arthritis and Rheumatism, Vol. 30, No. 6 (June 1987)
provide useful data for quantitative assessment of pain
in the routine care of rheumatoid arthritis patients.
Pain is a most important indicator of clinical
status in rheumatoid arthritis (RA) (1-8). Inquiry about
pain is included in every encounter of RA patients with
a health professional; however, the patient’s response
to such inquiry is generally regarded as “subjective”
(9). Systematic assessment of pain, therefore, is generally not pursued in routine clinical practice, despite
recognition that pain may be considerably more significant in the status of an RA patient than data derived from many, if not most, routinely studied
“objective” sources, including radiographic and laboratory tests (10).
In recent years, efforts to assess pain quantitatively for comparisons of different patients, and for
comparisons of the same patient from one visit to the
next, have led to development of a number of formal
pain questionnaires (1-8,ll). In these questionnaires,
patients may report pain intensity, severity, relief, or
descriptors in various numerical, as well as visual
analog, scales. Most of these scales were developed
for use in research settings, however, and have not
been applied in routine clinical care.
We have sought to quantitate the clinical status
of RA patients under routine care in our clinic using
traditional articular and radiographic measures (12), as
well as questionnaires, to assess difficulty, dissatisfaction, and change in capacity to perform activities of
daily living (ADL) (13). Initial efforts to assess pain,
using available scales, during routine care in our clinic,
yielded suboptimum results. For example, many patients were unable to use the descriptors in the McGill
PAIN ASSESSMENT FOR CARE IN RA
631
How Often is It PAINFUL For You To:
Never
a. Dress yourself. including tying shoelaces and
doing buttons?
Sometimes
Most
The Time
Always
-
b. Get in and out of bed?
c. Lift a full cup or glass to your mouth?
d. Walk outdoors on flat ground?
8.
Wash and dry your entire body?
1. Bend down to pick up clothing from the floor?
Q.
Turn regular faucets on and off?
h. Get in and out of a car?
How Much Pain Have You Had Because Of Your Condition IN THE PAST WEEK?
Place a mark on the line below to indicate how severe your pain has been:
NO
PAIN
PAIN AS BAD AS
IT COULD BE
Figure 1. A pain scale based on activities of daily living and a visual analog pain scale in format for use in routine clinical settings.
Pain Questionnaire (1 1). The visual analog pain scale
(2) found in the Stanford Health Assessment Questionnaire (14) was found to be the most useful available
measure for routine clinical use, but some patients
could not complete this scale without assistance. We
therefore developed a brief pain scale for regular use,
based on the frequency of pain in the same 8 activities
of daily living used to assess difficulty, dissatisfaction,
and change in status (13). In this report, we analyze
the sensitivity and utility of the ADL pain scale and a
visual analog pain scale in RA patients who were seen
in their usual clinical outpatient settings.
PATIENTS AND METHODS
Patients. The study population included 385 patients
who had been seen during 1982-1985 at the Division of
Rheumatology and Immunology Clinic of Vanderbilt University, the Nashville Veterans Administration Hospital Clinic,
or in the offices of 4 rheumatologists in private practice in
Nashville, Drs. Joseph H. Huston, J. Thomas John, John S.
Johnson, and John S. Sergent. All patients seen at Vanderbilt (n = 224) met the American Rheumatism Association
(ARA) criteria for definite
(15). The other 161 patients
were diagnosed by their rheumatologists as having RA; 30 of
these patients have been reviewed subsequently for other
studies, and all met the ARA criteria for definite RA. The
mean age of these patients was 56.1 years, and the mean
duration of disease was 11.0 years. The study population
was 90% white, 56% female, 71% married, 15% full-time
employed, and 57% high school graduates.
Questionnairefor routine use in outpatient settings. At
the time the patient registered for a visit, the receptionist
presented a 4-page questionnaire, the Activities and Lifestyle Index. The entire questionnaire required about 10-15
minutes for completion, and was usually completed before
the patient was seen by a physician. The first 2 pages of this
questionnaire contained an ADL difficulty scale (13), an
ADL dissatisfaction scale (13), the ADL pain scale described
in this report, a visual analog pain scale (2,6,14), a global
self-rating of functional status, and a Rheumatology Attitudes Index that is based on the Arthritis Helplessness Index
(16). The following 2 pages of the questionnaire included a
review of demographic variables and disease features.
ADL pain scale. The ADL pain scale (Figure 1)
includes the same 8 ADL included in the difficulty and
dissatisfaction scales (13). The patient was asked: “How
often is it painful for you to . . .” for each of the 8 ADL.
Four response options were presented and were scored as
follows: never = 1, sometimes = 2, most of the time = 3, and
always = 4. The total ADL pain score was the mean score
for the 8 responses. The 4 responses of 1-4 in this scale and
other ADL scales of are regarded as analogous to those for
functional class (17).
CALLAHAN ET AL
632.
Visual analog pain scale. The visual analog pain scale,
shown in Figure 1, is a standard 10-cm horizontal scale
(2,6,14). The patient indicates the severity of pain by placing
a mark between terminal points designated “No pain” and
“Pain as bad as it could be.” The visual analog scale is
scored from 0 (no pain) to 10 (pain as bad as it could be).
Comparisons with other measures of disease status were
performed using the scoring from 0-10, as well as converting
the scoring to a 1 4 scale for comparison with the ADL pain,
difficulty, and dissatisfaction scales, as follows:
Converted score
Visual analog pain scale score x 3
=
10
+ l
ADL difficulty and ADL dissatisfaction scales. The
ADL difficulty scale and ADL dissatisfaction scale used
were those described previously (13). In the studies reported
here, the ADL change in status scale, which is not highly
correlated with other measures of disease status (13), was
replaced by the ADL pain scale.
The degree of difficulty in the same 8 ADL included
in the ADL pain scale (Figure 1) was assessed by the
patient’s responses to the question: “Are you able to . . .”
Patients rated their capacities according to a 4-point scale:
without any difficulty = 1, with some difficulty = 2, with
much difficulty = 3, and unable to do = 4.The total difficulty
score was expressed as the mean score for the 8 responses,
which ranged from 1-4 (13).
Dissatisfaction with the patient’s capacity to perform
the same 8 ADL was assessed by the patient’s response to
the question, “How satisfied are you with your ability
to . . .” The response options were modified from the initial
report (13) to include 4 options, as in the ADL difficulty and
ADL pain scales: very satisfied = 1, somewhat satisfied = 2,
somewhat dissatisfied = 3, and very dissatisfied = 4. The
total dissatisfaction score was the mean score for the 8
activities, with a range of 1 4 , similar to the other scales.
Other components of the assessment questionnaire.
Patients were asked to indicate a global assessment of their
overall functional status by selecting 1 of 4 responses to the
question: “Which of the following best describes you today?” The responses and ratings were: I can do everything
I want to do = 1; 1 can do most of the things I want to do =
2; I can d o some, but not all, of the things I want to do and
have many limitations = 3; I can do hardly any of the things
I want to d o = 4.
The Rheumatology Attitudes Index, consisting of 15
belief statements modified from the “Arthritis Helplessness
Index” (16), was developed to measure the patient’s perceived “learned helplessness” (see ref. 16), and was administered to all patients (18). The mean score of the patient’s
responses to the 15 statements was determined for the total
score, with a range of 1-4.
Other measures of disease status. Joint counts were
made by assessments of swelling and pain on motion in 66
joints (19,20): temporomandibular (n = 2), sternoclavicular
(n = 2), acromioclavicular (n = 2), shoulder (n = 2), elbow
(n = 2), wrist (n = 2), metacarpophalangeal (n = lo),
proximal interphalangeal of fingers (n = lo), distal interphalangeal (n = 8), knee (n = 2), ankle (n = 2), tarsus (n =
2), metatarsophalangeal (n = lo), and proximal interphalan-
geal of toes (n = 10). Morning stiffness was assessed as the
number of minutes from awakening to time of optimum
status for that day. The erythrocyte sedimentation rate was
determined using the Westergren method (21).
Three performance measures of functional capacity-grip strength, walking time, and the button test-were
obtained (22). To measure grip strength, a blood pressure
cuff was inflated to 30 mm Hg, and the patient was asked to
squeeze as hard as possible (23). The score recorded was the
mean mm Hg of 3 measurements of both hands, i.e., 6
measurements. To measure walking time, the patient was
asked to walk at a normal pace for 25 feet. The score was
recorded in seconds (24). A standard board (JA Preston,
Clifton, NJ) was used to perform the button test. The patient
was asked to unbutton 5 buttons and then rebutton them as
quickly as possible. The score was recorded in seconds, and
the mean for both hands was recorded (25).
Statistical methods. The data were analyzed using the
CLINFO (Bolt, Beranek and Newman, Boston, MA) and
Statistical Package for the Social Sciences-X (SPSS-X) (26)
software packages. The ADL pain scale was evaluated for
internal consistency using Cronbach’s a test. Test-retest
reliability of the scale and items was evaluated using Pearson
product moment correlation coefficients of the 2 administrations of the questionnaire. Pearson product moment correlation coefficients of ADL pain scale and visual analog pain
scale scores were computed. Correlations were computed
for the visual analog pain scale scores and ADL pain scale
scores with values for other disease status measures. Firstorder partial correlations of each pain scale score with
values for other disease measures were also computed,
controlling for the second pain scale score. These partial
correlation analyses allowed adjustment for the influence of
1 of the 2 pain scale scores on the correlation between the
other pain scale score and another disease measure, which
may occur as a result of the correlation between the 2 pain
scale scores. Scores on the ADL pain scale, visual analog
pain scale, ADL difficulty scale, and ADL dissatisfaction
scale were compared using cross-tabulations to analyze the
sensitivity and completion rates.
Table 1. Mean scores, test-retest correlations, and item-scale
reliability on a pain scale based on activities of daily living (ADL)
ADL pain
scale item*
a
b
C
d
e
f
g
h
Total scale
Reliability?
Mean
score
(n = 385)
Test-retest
(n = 133)
Item-scale
(n = 330)
2.49
2.33
2.09
2.40
2.45
2.40
2.39
2.44
2.37
0.70
0.65
0.73
0.69
0.73
0.77
0.73
0.74
0.81
0.85
0.74
0.83
0.75
0.82
0.79
0.73
0.81
* See Figure 1.
t All correlations were statistically significant ( P < 0.001).
633
PAIN ASSESSMENT FOR CARE IN RA
Table 2. Correlations of activities of daily living (ADL) pain scale scores and visual analog pain
scale scores with other measures of clinical status in rheumatoid arthritis patients*
Measure
ADL pain scale
Visual analog pain scale
Demographic
Formal educational level
Age
Disease
Duration of disease
Erythrocyte sedimentation rate
Joint count, swelling
Joint count, pain on motion
Morning stiffness
Functional performance
Walking time
Grip strength total
Button test
Self-report
ADL difficulty
ADL dissatisfaction
Global assessment
Rheumatology Attitudes Index
ADL
pain scale
Visual
analog
pain scale
ADL pain scale
controlled for
visual analog
scalet
Visual analog
scale controlled
for ADL pain
scalet
NA
0.54t
0.54t
NA
NA
NA
NA
NA
-0.158
-0.04
-0.130
-0.20t
0.09
-0.149
-0.06
0.148
0.148
0.23t
0.38t
0.52.t
0.30t
0.178
0.24t
0.33t
0.34.t
0.24t
0.05
0.129
0.26.t
0.42$
0.2111
0.129
0.149
0.169
0.09
0.09
0.26.t
-0.42t
0.29.t
0.24$
-0.29t
0.21.t
0.168
-0.33t
0.22.t
0.129
-0.08
0.06
0.74.t
0.70t
0.64t
0.37t
0.55.t
0.63.t
0.58t
0.26.t
0.29.t
0.28t
0.21.t
0.55$
0.53.t
0.36t
0.5ot
0.22.t
* See Patients and Methods for description of scales and Rheumatology Attitudes Index. NA = not
applicable.
t Correlations reported are first-order partial correlations, controlling for the ADL pain scale or the
visual analog pain scale.
t P 5 0.001.
9 P 5 0.05.
n P 5 0.01.
RESULTS
Reliability and validity of the ADL pain scale.
The internal consistency of the ADL pain scale was
analyzed in 330 completed questionnaires. Cronbach’s
a was 0.94, and item-scale reliability was 20.73 for all
8 items (Table I). Test-retest reliability was determined in 133 patients who completed the scale twice
within a 2-week period. Correlations between the 2
scales were highly significant for the total score (r =
0.81, P < 0.001), as well as 8 individual items (r =
0.65-0.77, P < 0.001 for each item). The ADL pain
scale showed high levels of internal consistency and
test-retest reliability.
As shown in Table 2, ADL pain scale scores
were correlated significantly with visual analog pain
scale scores (r = 0.54, P < 0.001). The visual analog
scale is a validated measure for assessing pain (6), and
the correlation between the 2 scale scores indicates
that both scales appear to detect similar information,
although these scores are not entirely predictable at
this level of correlation. The construct validity of the
ADL pain scale is demonstrated by its correlation with
the visual analog pain scale and by associations of this
scale with various disease status measures presented
below.
Correlations of ADL pain scale scores and visual
analog pain scale scores with other measures of disease
status. There were significant correlations between
ADL pain scale scores and all other measures of
disease status studied, except age (Table 2). The
highest correlations (r = 0.64-0.74) were those of the
ADL pain scale scores and other self-report measures,
i.e., the ADL difficulty, dissatisfaction, and global
self-assessment. Correlations between the ADL pain
scale scores and the Rheumatology Attitudes Index
and the non-self-report measures, i.e., walking time,
grip strength, button test, number of swollen joints or
joints with pain on motion, erythrocyte sedimentation
rate, and morning stiffness, were lower (r = 0.23-0.52)
but were statistically significant. Correlations of ADL
pain scale scores with formal educational level and
duration of disease were quite low (r = 0.14-0.20),
though marginally statistically significant (Table 2).
CALLAHAN ET AL
634
Table 3. Scores on activities of daily living (ADL) pain scale, visual analog pain scale, ADL
difficulty scale, and ADL dissatisfaction scale in 385 patients with rheumatoid arthritis*
Range of scores
Scale
1.o
1.01-2.0
2.01-3.0
3.014.0
Missing
ADL pain
ADL difficulty
ADL dissatisfaction
Visual analog pain
18 (4.7)
32 (8.3)
38 (9.9)
23 (6.0)
128 (33.2)
180 (46.8)
120 (31.2)
62 (16.1)
129 (33.5)
110 (28.6)
106 (27.5)
118 (30.6)
69 (17.9)
24 (6.2)
69 (17.9)
64 (16.6)
41 (10.6)
39 (10.1)
52 (13.5)
118 (30.6)
* Values are no.of patients (%). Visual analog scale ranges from 0-10, and scores were mathematically
converted to a 1 4 range scale for comparison with other scales (see Patients and Methods for details).
Significant correlations between visual analog
pain scale scores and values for other measures of
disease status were also seen. In general, the levels of
these correlations were lower than those of ADL pain
scale scores and these measures, for all variables other
than the relatively small differences for duration of
disease and erythrocyte sedimentation rate (Table 2).
The correlations of ADL pain scale scores and
visual analog pain scale scores with other measures of
disease status were analyzed using partial correlation
analyses (Table 2). Most correlations of ADL pain
scale scores with other disease status measures remained significant and were not greatly reduced when
controlled for visual analog scale scores. In contrast,
most correlations of visual analog scale scores with
other measures were greatly reduced or were not
significant when controlled for ADL pain scale scores.
Therefore, the correlation between visual analog pain
scale scores and other measures can be explained
largely by correlations with ADL pain scale scores.
The ADL pain scale score contributes more incremental information if the visual analog pain scale score is
known than vice versa.
Analyses of ADL pain scale, visual analog pain
scale, ADL difficulty scale, and ADL dissatisfaction
scale for capacity to detect problems in ADL and rates of
completion in outpatient clinical settings. The correlations observed do not address 2 important concerns in
the use of questionnaires to monitor patient status: the
capacity to detect the patient’s perception of a problem in ADL, and the rate of completion by patients in
clinical settings.
The number of patients reporting no problem in
the scales (scores of 1.O on the ADL scales or 0 on the
visual analog pain scale, converted to 1 mathematically for ease of comparison; see Patients and Methods) was computed. Of 385 patients in the study, 18
(4.75%)reported no pain on the ADL pain scale, 23
(6.0%) indicated no pain on the visual analog pain
scale, 32 (8.3%) reported no “difficulty” on the ADL
difficulty scale, and 38 (9.9%) reported no “dissatisfaction” on the ADL dissatisfaction scale (Table 3). Of
the 32 patients reporting no “difficulty” on the ADL
difficulty scale, 19 (59.4%) reported the presence of
“pain” (scores z 1.1 on the ADL pain scale) (Table 4).
Of the 38 patients reporting no “dissatisfaction” on
the ADL dissatisfaction scale, 23 (60.5%) reported
some frequency of pain. In contrast, of 18 patients
reporting no pain, only 5 (27.8%) reported any degree
of difficulty, and only 2 (11.1%) reported any degree of
dissatisfaction on these ADL scales. Findings were
similar when the visual analog pain scales were compared with the ADL difficulty and ADL dissatisfaction
scales. The ADL and visual analog pain scales, therefore, appear to detect perceived problems in ADL that
are not detected in the ADL difficulty and ADL
dissatisfaction scales, i.e., patients appear to be more
likely to report perceived pain in the absence of
perceived difficulty or dissatisfaction than vice versa.
Table 4. Sensitivity of activities of daily living (ADL) pain scale,
visual analog pain scale, ADL difficulty scale, and ADL
dissatisfaction scale to problems in rheumatoid arthritis
ADL pain
scale score*
Visual analog
pain scale score?
Score
1.0
>1.0
0
>o. 1
ADL difficulty scale*
1.o
13
5
19
3 16
11
11
14
230
1.5
2
23
291
12
20
213
9
3
12
237
>1.0
ADL dissatisfaction
scale*
1.o
>1.0
Visual analog pain
scale?
0
>o. 1
10
* Score of 1.O indicates absence of pain, difficulty, or dissatisfaction;
score > 1.O indicates presence of pain, difficulty, or dissatisfaction.
t Score of 0 indicates absence of pain, score >O. 1indicates presence
of pain.
635
PAIN ASSESSMENT FOR CARE IN RA
Analysis of completion rates in this outpatient
setting indicated that 344 of the 385 patients (89.4%)
completed the ADL pain scale, while 267 (69.4%)
completed the visual analog scale, without instruction
from a health professional (Table 3). Overall, 74
(19.2%) patients completed the ADL pain scale but not
the visual analog scale, while only 3 (0.8%) showed the
reciprocal pattern ( P < 0.05 by chi-square analysis).
Completion rates for the ADL difficulty and dissatisfaction scales were similar to those seen for the ADL
pain scale (Table 2). Therefore, significantly more
patients completed the ADL pain scale, as well as the
ADL difficulty and dissatisfaction scales, than the
visual analog scale. It should be noted that more than
10% of patients did not complete any ADL self-report
scale.
DISCUSSION
These studies suggest that the ADL pain scale
and visual analog pain scales may provide a useful
approach to quantitative assessment of pain in RA
patients in routine outpatient settings. Completion of
the scales requires less than 5 minutes. Previous
studies indicate that self-report questionnaires provide
valid and reliable information regarding patient status
(1-8, I 1,14,16). The correlations of the ADL and visual
analog pain scales with other measures of disease
status in these RA patients (Table 2) indicate their
construct validity. More patients completed the ADL
pain scale than completed the visual analog scale
(Table 3). The ADL pain scale shows capacity to
detect problems in ADL that are not detected by
the ADL difficulty and ADL dissatisfaction scales
(Table 4).
In view af the availability of many welldescribed pain scales and the excellent studies which
have used these scales (1-8,1 I), the development of a
new ADL pain scale may initially appear to be unnecessary; however, our goal was to monitor patient
status routinely, from one visit to the next, and existing scales were not designed to meet that goal. Therefore. we develoned the ADL Dain scale.
Our results indicate several potential advantages in using the ADL pain scale to characterize
patient status: (a) Scores on the ADL pain scale were
generally more highly correlated with other disease
measures than were scores on the visual analog pain
scale. (b) Most patients in ambulatory outpatient settings completed the ADL pain scale without assistance
from a health care professional, whereas the completion rate for the visual analog pain scale was signifi-
cantly lower. (c) The ADL pain scale showed a greater
capacity to detect a problem in ADL than did the ADL
difficulty and ADL dissatisfaction scales.
It should be noted that approximately 10% of
the patients did not complete the ADL pain scale or
any other self-report scale. Others have noted that a
significant number of patients in outpatient settings do
not complete self-report questionnaires (Goeppinger J,
Wegener S, Brunner C: personal communication).
These findings should be considered in efforts to
introduce more widespread use of questionnaires into
clinical trials and routine rheumatology practice.
When a self-report scale is not completed, we have a
health care professional query patients; this results in
completion rates that approach 100%. The most common reason that patients do not complete self-report
questionnaires is illiteracy o r poor literacy which,
unfortunately, is more widespread than is generally
recognized. The visual analog pain scale is the only
valid self-report for illiterate patients, although the
need for an observer to explain its use may somewhat
compromise its validity.
It appears that none of the presently available
pain scales have found acceptance in rheumatology
practice, despite recognition that pain is usually the
primary reason patients visit a rheumatologist. Further
studies using the approach reported here may contribute to improved quantitative assessment of RA in
research studies and clinical practice.
ACKNOWLEDGMENTS
We thank Drs. Alan N . Baer, Howard A. Fuchs,
Joseph H. Huston, J. Thomas John, John S. Johnson, and
John S. Sergent, for their cooperation in encouraging their
patients to participate in these studies. We thank Carolyn
Burnette, Lou Condrey Douglas, Mary Ellis, Ginnie Farley ,
and Beverly Jo Johnson for meticulous data collection and
entry, and Joan Koehler and Marilyn Welch-Fava for expert
secretarial assistance.
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