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Introduction
e management of persistent pain and its associated distress
remains an enormous problem in global terms. In developed
countries, the cost of disability programmes for people with
pain are staggeringly high, whether viewed from a medical,
occupational or psychosocial perspective [20, 49]. is
chapter discusses the principles underlying the assessment
of pain, provides a practical approach for assessing people
presenting with pain and briefly outlines a number of novel
pain investigative approaches.
What is pain?
Although this is a basic question and one that has been addressed
previously in this book, how we define pain fundamentally
influences our approach to the evaluation of pain. It is therefore
worth reiterating the definition of pain as put forward by the
International Association for the Study of Pain: “Pain is an
unpleasant sensory and emotional experience associated with
actual or potential tissue damage, or described in terms of such
damage” [39]. Contained within this definition is the concept
that pain is not only a sensory experience but is a complex
interaction involving emotional and behavioural factors.
Types of pain
Pain is often categorised as acute, persistent (chronic) and
cancer-related. Persistent pain, the focus of this chapter, has
been defined in a number of ways. Some prefer the definition:
pain continuing beyond the time of normal healing [2]. However,
determining the expected time for healing can be difficult,
leading others to use a timeframe of 3 months, beyond which
pain is considered persistent. Although common aspects are
present across all types of pain, each type varies to some degree
in its assessment requirements.
The Clinical Evaluation of Pain
4
Paul J. WRIGLEY, Philip J. SIDDALL
INTRODUCTION
What is pain?
Types of pain
P
ain is a subjective experience
Multidimensional assessment
The setting for evaluation
Aims of patient evaluation
A CLINICAL APPROACH TO
ASSESSMENT
Pain contributors
P
ain associated consequences
Functional assessment
HISTORY TAKING
Establishing rapport
Details of pain history
PHYSICAL EXAMINATION
General physical examination
Examination of pain beha
viours
Examination of the painful region
Musculoskeletal examination
Neurological examination
INVESTIGATIONS
Clinical neurophysiology
Quantitati
v
e sensory testing
Thermography
Brain imaging
Response to intervention
ASSESSMENT OF SPECIAL
POPULA
TIONS
CONCLUSION
REFERENCES
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32 Paul J. WRIGLEY, Philip J. SIDDALL
In most acute pain situations, it is appropriate to
focus on identifying the source of pain in order
to enable treatments to resolve the underlying
pathology, or at least relieve the pain. A person
with persistent pain, however, may have already
undergone multiple investigations and treatments
without benefit and may have no identifiable
pathology to explain their pain. In this case, it
is important that the patient be assisted to move
from an “acute, curative approach” to a “long-
term, management” approach. In addition to the
challenges posed by acute and persistent pain, the
person with cancer-related pain may have end of
life or existential issues to be addressed.
Pain is a subjective experience
…the investigator who would study pain is at the mercy
of the patient, upon whose ability and willingness to
communicate he is dependent [35]
A central factor impeding progress in pain research
and treatment is the inherent subjectivity of pain.
People commonly express difficulty describing
their pain. A common vocabulary for pain does not
exist, and as a result individuals with objectively
similar conditions often describe vastly different
experiences [52].
e subjective nature of the pain experience has
been highlighted widely in the pain literature [8,
39, 51]. Despite this, much work has been done
attempting to objectify pain assessment. To date,
the relationships between pathology, measurement
of physical indices, behavioural observation and
reports of pain seem to be only weakly correlated
[52].
Assessment of the pain experience (hereafter
referred to as pain) is therefore largely dependent
on patient self-report [31]. Among clinicians,
there exists a certain uneasiness when it comes
to subjective ratings of pain. e uneasiness
rests with perceived discrepancies between verbal
reports of pain and what is felt to be “true” pain
by the observer. ese discrepancies are often
due to differences in the way the assessor and
the patient view the meaning of the report. It is
important to realise that a simple pain intensity
measure cannot reflect a person’s pain experience,
which is influenced by many factors (see below).
Determining whether a pain report is “true” or
accurate is less important than determining the
factors contributing to the pain and the effect of
the pain on the person.
Multidimensional assessment
Given the number of factors affecting the perception
of pain, assessment is best performed using a
multidimensional model [31, 47]. Each dimension
or component does not always co-occur in the same
way in all individuals, and is a dynamic process.
For humans, the sensory experience of pain contains
at least two distinct elements, the generation of a
nociceptive or neuropathic sensory trace associated
with tissue pathology, and the perception of this
trace by the central nervous system (see Chapter 1)
[36]. Numerous factors including past experiences,
culture, and environmental and genetic factors
influence both the perception and expression
of pain (see Chapter 2) [11, 40]. erefore, in
evaluating pain, it is important to consider the
contribution of biological, psychological and
environmental contributors. is interaction
of biological, psychological and environmental
influences underlies the biopsychosocial model
of assessment and treatment of disease, and will
be the approach taken throughout this chapter.
ere is also increasing recognition of the role
of spiritual factors in the experience of pain and
a comprehensive evaluation of pain will include
the interaction of biological (body), psychological
(mind) and spiritual (spirit) aspects with the
person’s environment (social/physical) as part of
the overall assessment.
A careful assessment of the patient’s biopsychosocial-
spiritual system allows the clinician to formulate a
rational assessment of the causal links involved in
the pain problem. A prioritised problem list and
goal-orientated management plan can then be
formulated and has been shown to result in better
long-term outcomes than unimodal treatment
approaches [21]. While the biopsychosocial
approach to pain assessment was recommended
over 25 years ago [38], it has taken some time to
understand the way each element interacts. In
recent years, substantial progress has been made,
though ongoing refinement continues [19, 21,
24, 54]. A detailed discussion of how these broad
elements interact is beyond the scope of this
chapter. A pragmatic approach, suitable for use in
the busy clinical setting, is however provided in the
next section.
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The Clinical Evaluation of Pain 33
The setting for evaluation
It is difficult for the sole health practitioner, in a
limited period of time, to assess adequately the
complicated multidimensional problems presented
by a person with persistent pain. is means that,
ideally, evaluation is undertaken in the context of
a multidisciplinary setting. Such a setting provides
the opportunity for a range of health professionals
to collaborate in the formulation of an assessment
and treatment plan. Typically, such a team comprises
experts able to identify pain pathophysiology as well
as psychological and environmental factors that may
be impacting on the person’s pain perception and
behaviour. In a multidisciplinary setting, greater
attention to detail can be achieved and members of
the team are able to pay particular attention to their
area of expertise. e benefits of multidisciplinary
treatment are not limited to improvements in pain,
mood and function, but have been shown to extend
to variables such as return to work and use of the
health care system [13, 18, 50].
Although the management of persistent pain
ideally occurs in a multidisciplinary setting, this
is not always possible. Geographical and financial
constraints can mean that these resources are not
available. Sole practitioners are often required
to assess not only biological factors, but also the
elements usually assessed by therapists in other
settings. In the absence of a pain assessment
team, referral to individual professionals may be
an alternative. is of course extends the time
required to complete an assessment and poses
additional communication difficulties in obtaining
management consensus.
Aims of patient evaluation
1. Develop rapport
2. Diagnose treatable medical conditions
3. Assess the contribution of non-biological
factors to the pain experience
4. To develop a treatment approach most likely
to reduce pain and/or the impact of pain on
function.
In clinical practice, the primary aim of evaluation is
to determine a diagnostic formulation that provides
direction for treatment.
1
However, an evaluation
first allows the development of rapport and trust
with the patient. Much of the success of treatment
and acceptance of the clinician’s diagnosis and
plan for treatment depends on the confidence and
relationship established during assessment. is
is particularly important where no underlying
treatable cause is found to explain the pain, and
psychological strategies are suggested to assist in
the ongoing management of the problem.
An assessment also allows the identification of
readily treatable contributors to the pain. It is
not uncommon for people with persistent pain
to have new symptoms that are not followed
up as aggressively or even disregarded because
it is assumed that they are part of a persistent
benign condition or even of psychological origin.
erefore, the clinician involved in evaluating
people with persistent pain must retain a high
index of suspicion and avoid dismissing symptoms
that may suggest an alternative diagnosis.
In addition, a multidimensional assessment can
identify important psychological, spiritual and
environmental influences on the pain experience.
Finally, an assessment needs to identify the impact
of the pain on the person. is requires a careful
assessment of associated problems and the effect of
pain on function (described in more detail below).
In addition to biomedical treatments aimed at
reducing pain, efforts need to be directed towards
reducing the way the pain impacts on the person’s
life, i.e. pain management.
Once treatment is commenced, ongoing evaluation
is important to determine the effectiveness of the
treatment. Evaluation may be conducted informally
or may be carried out within a rigid protocol
such as those used in clinical trials. Obviously,
the evaluation requirements of these particular
situations are different. is chapter will focus
primarily on evaluation in the clinical setting but
some of the methods and tools described will be
applicable to a more formal evaluation.
Traditionally, assessment begins by taking a history
and performing a physical examination. ese
initial steps are followed, where necessary, by the
1. e term diagnostic formulation refers to an outline of potential contributing factors arising from the biological, psychological,
environmental and spiritual domains. It is a multidimensional assessment rather than a biomedical assessment, which is commonly
implied by the term provisional diagnosis.
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34 Paul J. WRIGLEY, Philip J. SIDDALL
performance of further diagnostic procedures
that can help to add further information
and clarify the diagnosis. Often a provisional
diagnostic formulation is proposed following the
initial assessment and then modified as further
information is obtained. is approach will be
used in this chapter as a framework for examining
the specific issues that may need to be considered
in the evaluation of the person with persistent
pain.
Table 4.01 Summary of a pain assessment
(a)
(b)
1. Assessment of pain contributors and associated consequences
Pain contributors Pain associated consequences
Biological
Underlying treatable conditions
Nociception or neuropathy
e.g. nausea, fatigue
Psychological
Affective disorders
Behavioural responses
Cognitions
e.g. anxiety, fear avoidance of
pain
Social
Family, work, litigation and
physical environment
e.g. social isolation
Spiritual
Life view and approach e.g. loss of faith
2. Functional assessment (Effect of consequences on life roles)
Self-maintenance
PADLs and DADLs
Rest
e.g. sleep, relaxation
Leisure
e.g. hobbies or interests
Productivity
e.g. paid and unpaid employment
(a) Performance of a pain history, pain-focused examination and appropriate investigations allows the
clinician/assessment team to (b) identifiy pain contributors, determine the presence of pain associated
consequences and gauge the effect of pain on function. Assessment findings need to be constantly
under review as new information is obtained. PADLs = personal activities of daily living; DADLs =
domestic activities of daily living.
History Examination Investigation
Pain assessment
Review / Collaborative information
TEAM meeting
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The Clinical Evaluation of Pain 35
A Clinical Approach to
Assessment
In the clinical setting, it is useful to have a relatively
simple overall structure to guide an assessment.
For most patients presenting with persistent pain,
simple curative treatments are usually not available.
Even when a proposed pain “generator” can be
removed, this does not necessarily guarantee return
to premorbid functioning. With this in mind,
assessment needs to allow the development of a
reasonable long-term management plan.
Assessment may involve the use of standardised
questionnaires or rely on the clinician’s judgement.
e relative benefit of these two approaches has
been long debated [53]. While we will focus in this
chapter on clinical judgement, the two approaches
need not be considered mutually exclusive. A
detailed account of available assessment tools has
already been outlined in Chapter 3. We would
suggest a pain assessment first attempts to identify
pain contributors and associated consequences, and
then assesses the effect of pain on function (Table
4.01).
Pain contributors
As suggested by others, pain is a dynamic response
rather than a simple sensory phenomenon [19]. In
Table 4.02 Diagnostic grid of pain contributors
Predisposing Precipitating Perpetuating
Biological
(Nociception
and
neuropathy)
Adversive:
• genetic
• physical
developmental factors
Physical stressors:
• trauma
• inflammation
• neuropathy
Poorly controlled:
• pathology (e.g. diabetes)
• complications from
therapies
Psychological
Maladaptive:
• attitudes
• cognitive abilities
• coping style
• risk taking behaviour
Psychological stressors:
e.g. near death experience
Unhelpful:
• cognitions, e.g.
catastrophising, fear of pain
• behaviours
(a) excesses, e.g. medication
overuse, reliance on health
providers
(b) deficits, e.g activity-
avoidance, poor pacing
• coping style, e.g. passive
approach
• self-efficacy, i.e. low
• learning — consequences of
and linked associations with
behaviour
Social/
environmental
Inadequate:
• social support network
• institutional support
• workplace design
(ergonomics)
Adversive external
stressors:
• social network
• occupational
• medical system
Inadequate or inappropriate
response by:
• social support network
• occupational network
• medical system
Spiritual
• Poor sense of control
or responsibility for
major life events
• Fatalistic perspective
• View of God as
punishing or cruel
• Failed requests to a god
figure to resolve or heal
illness
• Life crisis which
challenges meaning
and purpose
• A sense of persecution or
punishment
• Loss of hope, despair
This table presents a diagnostic grid which can be used to analyse the factors contributing to a person’s persistent pain
problem. Examples are given to illustrate each section of the grid. This list is not meant to be exhaustive.
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36 Paul J. WRIGLEY, Philip J. SIDDALL
order to develop a management plan it is important
to identify the factors contributing to the person’s
pain. ese contributing factors may predispose,
precipitate, or perpetuate a person’s pain. It may
also be possible to identify factors that protect a
person and assist them in managing persistent pain.
In order to organise the large amounts of potential
information using this approach, it is suggested a
diagnostic grid be employed (Table 4.02). Similar
diagnostic grids have been proposed [21].
Biological pain contributors (nociception
and neuropathy)
From a biomedical point of view, pain can be
broadly divided into two main categories based on
the structures affected: nociceptive or neuropathic.
Nociceptive pain is defined as pain due to
activation of primary afferent nociceptive nerve
endings by damaging or potentially damaging
stimuli. is includes pain arising from pathology
in somatic and visceral structures which may
resolve (e.g. acute pain following a fractured bone)
or be ongoing (e.g. persistent pain associated with
degenerative arthritis). In practice, nociceptive pain
is almost invariably accompanied by inflammation.
erefore this type of pain is also often referred to
as inflammatory pain. Neuropathic pain has been
defined as pain initiated or caused by a primary
lesion or dysfunction of the nervous system [39].
Nociceptive and neuropathic pains differ in their
underlying mechanisms, pain characteristics and
response to treatment. Despite emerging evidence
suggesting overlap between nociceptive and
neuropathic mechanisms, these categories remain
useful clinically (Table 4.03).
While significant debate continues [30], pain
occurring in a region of sensory disturbance which
is described as burning, pressure, squeezing or
electric shock-like is typically considered to be
neuropathic in origin [3, 4]. Neuropathic pain can
occur in the absence of stimulation (spontaneous
pain) or can be evoked. Evoked pain occurs when
normally non-painful stimuli such as brushing,
light touch and innocuous cold are perceived as
painful (allodynia). In contrast, nociceptive pain is
typically described as dull, tiring and heavy [4].
Biological factors that may predispose an individual
to developing pain may be genetic or related to
persistent or past aversive stimuli/trauma (e.g.
premature birth with extended neonatal intensive
care [16]). Biological pain-perpetuating factors may
occur in a number of circumstances including poor
disease control, e.g. poor blood sugar control in
diabetic peripheral neuropathic pain, or from further
damaging stimuli secondary to treatment measures
themselves, e.g. scarring following surgery.
Psychological pain contributors
e clinician involved in the management of pain
needs to be familiar with not only the physical
changes that may give rise to the generation of
signals in pain pathways but also the emotional,
cognitive and environmental influences that may
modify the transmission and processing of these
signals and thereby impact on the perception and
expression of pain.
Various psychological models have been proposed to
explain chronic pain which influence the approach
to evaluation. e Psychoanalytic model views pain
to be a result of underlying unconscious conflicts,
whereas the Family Systems model proposes that
pain is the response to distressed family dynamics.
In contrast, the Operant Behavioural model
emphasises the importance of consequences in
determining how an individual behaves when they
are in pain and the Respondent model emphasises the
reinforcement of pain by conditioned associations
with other stimuli. In addition to these models,
there is the Social Modelling theory where learning
is said to occur through a process of observation;
the Cognitive model, which emphasises the way
in which cognitions affect behaviour and mood;
and the Cognitive-Behavioural theory, which
Table 4.03 Verbal descriptors typical of nociceptive
and neuropathic pain
Category Structures
affected
Typical
descriptors
(from [3,4])
Nociceptive
Somatic and
visceral
dull
tiring
heavy
Neuropathic
Peripheral and
central nervous
system
burning
pressure
squeezing
electric shock
tingling
pricking
itching
cold
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The Clinical Evaluation of Pain 37
acknowledges the importance of reinforcement
contingencies but also accepts the influence of
cognitive factors.
ere is little evidence that psychological factors
commonly result in pain in the absence of biological
precipitating factors. e psychoanalytic model
of emotional conflict giving rise to bodily pain
has not been readily substantiated [22]. Evidence
for psychological factors sustaining pain and its
associated distress and disability is more substantial
[19, 23, 50]. ere is increasing evidence that
psychosocial variables are especially important
in the transition from acute to chronic disability
[37]. Psychological factors include mood, attitudes,
cognitions, coping style and risk-taking behaviour.
Social factors are discussed in the next section.
Psychological contributors are commonly assessed
by using both a structured interview (Table 4.04)
and a variety of self-report instruments. Self-report
instruments may assist in the assessment of affective
distress, psychiatric morbidity and functional
disability. e goal of a psychological assessment
is to identify the psychological factors that affect
pain perception, behaviour and function. is
information can then be used to develop specific
treatment strategies to assist in achieving optimum
patient improvement [5].
Social pain contributors
Relationships occurring within family and work play
an important role in managing the stress associated
with ongoing pain. A strong social support network
and supportive workplace usually facilitates
recovery. e presence of dismissive relationships,
however, can encourage exaggerated pain behaviours
while overly protective relationships may prolong
disability by discouraging functional recovery.
A common impediment to functional recovery
is delayed financial compensation [26]. Lack of
social compensation (e.g. requiring an apology for
a perceived error) from family, friends or treating
practitioners may also slow recovery. In addition,
the physical at-work or home environment may
predispose an individual to injury (e.g. poor
ergonomics) or prevent their return to normal
activities (e.g. absence of appropriate access for
people requiring wheelchairs to facilitate mobility).
Spiritual contributors
Although some link spirituality to religious beliefs,
the concept needs to be viewed in a much broader
context. Spirituality encompasses a person’s core
beliefs (whether framed in religious terms or not)
that bring meaning and purpose to their actions,
relationships and view of self [9]. A person’s
belief structure may therefore profoundly affect
behaviours and cognitions in the presence of the
challenge of persisting pain [44]. Spiritual beliefs
surrounding the meaning and purpose of life
can provide a helpful or unhelpful influence on
self-management, e.g. belief in evil spirits and
the presence of a curse may result in a person
relinquishing hope for improvement and remove a
sense of control [7].
ere is increasing recognition that a person’s
spirituality can have a direct contribution to pain and
disability and should be part of patient assessment
[7, 44]. Some would consider assessment of
spirituality part of a broad psychological assessment
of beliefs. However, the person conducting the
assessment must feel comfortable exploring
spiritual issues and be familiar with the evidence
describing the contribution of spiritual factors to
pain and disability. At times, it may be helpful to
have a separate assessment with a person who has
appropriate expertise and skills in this area.
Pain associated consequences
While the word consequence implies aetiology, its
use here is not meant to imply a direct causal link
with pain, but to highlight important disturbances
associated with the presence of ongoing pain. Once
Table 4.04 Aims of a structured interview assessing
psychological contributors to pain (based on [42])
Interview aims to determine
• Description of current pain problem
• Impact of pain on the patient’s life (behavioural
deficits and excesses — pain behaviours)
• Mood disturbance (and relationship to pain)
• Pain cognitions (responses to pain, beliefs
about the cause/treatment/outcome)
• Pain coping strategies (active/passive)
• Patterns of medication use (as required/time-
based)
• Reinforcement contingencies surrounding pain
behaviour (significant others, litigation)
• Other stressors present (financial,
compensation process, family, losses)
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38 Paul J. WRIGLEY, Philip J. SIDDALL
again, it is helpful to consider consequences in a
biopsychosocial-spiritual framework.
An enormous range of associated biological
consequences are possible. ey can be subjective
(self-reported), e.g. nausea, palpitations and fatigue,
or objective (measured or observed) such as weight
loss, oedema or raised blood pressure. Any bodily
system may be involved; however, appropriate
history taking usually allows targeted questioning.
e psychological consequences of longstanding
pain (see Chapter 2) are frequently associated
with, rather than caused by pain and can include
alterations in mood and cognitions. Psychological
consequences tend to be more dependent on a
combination of factors rather than purely the
presence of pain (Table 4.06) [41] including the
ability to:
• Solve problems
• Change unhelpful ways of thinking
• Improve interaction with other people
• Develop a graded activity programme
• Employ behavioural strategies such as pacing
and relaxation
• Develop strategies for medication reduction
and improvement in sleep.
Associated social consequences relate to either
relational or physical environmental interactions.
Important relationships within the family,
community or work may change in the presence
of ongoing pain. Litigation or other compensation
issues may perpetuate a person’s pain associated
disability. Other social consequences, such as loss
of paid or unpaid employment, may occur resulting
in emotional and financial difficulties. In addition,
the ability of a person to carry out life roles may
be affected. is is discussed in more detail under
functional assessment.
As mentioned above, a person’s spirituality can
directly impact on pain and disability. As might
be expected, pain can also have an impact upon a
person’s spirituality. On a religious level, persistent
pain can make a person question their fundamental
beliefs in the nature and even the existence of a
supernatural being. On a broader level, persistent
pain and disability can influence a person’s view
of self, meaning and purpose and give rise to a
spiritual crisis that is marked by guilt, sense of
failure, abandonment and despair. Most people
see the impact of pain in negative terms. However,
if a person can draw on positive spiritual beliefs
regarding suffering, life purpose and divine support
there is an opportunity for growth on a spiritual
level. In this circumstance, a person can emerge
with a new direction, purpose and meaning that
is more robust and outward looking than prior to
their pain experience [7].
Functional assessment
It is also crucial to assess functional outcomes as
part of an overall patient assessment. Indeed, a
global need for this approach has been prompted
by the recognition that traditional diagnostic data
on morbidity and disease do not adequately capture
the health outcomes of individuals and populations
[48]. e enormous burden imposed on society
by health outcomes linked to health conditions
has recently been recognised by the World Health
Organization as an area of priority [48].
Table 4.05 Psychosocial factors associated with an
increased risk of chronic disability (based on [41])
Attitudes and beliefs about pain
• Fear that pain means physical damage
resulting in avoidance of activity and physical
deconditioning
• Belief that all pain must be abolished prior to
return to work
• Catastrophic thoughts about the cause and
potential effects of pain
• Belief pain is uncontrollable
• Expectation of increased pain with increased
activity
Behaviours
• Use of excessive rest/decreased normal
activities
• Poor compliance with physical activity
• Poor pacing skills
• Excessive reliance on passive strategies (e.g.
massage, medication taking)
Mood/emotions
• Depressed mood (this may lead to exaggerated
negative appraisal of events)
• Feelings of uselessness
Compensation issues
• Lack of financial incentive to return to work
• Disputes over eligibility for financial support
• Desire for social compensation from family/
friends/treating practitioners
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The Clinical Evaluation of Pain 39
Assessment of function or a person’s ability to carry
out a “life role” is a complicated process, and a
wide variety of approaches have been developed. A
unique vocabulary exists in the literature dealing
with functional assessment and rehabilitation. e
most recent international guidelines, produced
by the World Health Organization, called the
International Classification of Functioning,
Disability and Health (ICF) were first published in
1999 [57]. While a detailed description is beyond
the scope of this text, this model views functioning
at three levels namely: the body (bodily function
and structure), the whole person (activities) and the
whole person in a social context (participation). A
formal functional assessment is best performed by
health professionals specifically trained in this area.
e health professionals most commonly skilled
in functional assessment include occupational
therapists, physiotherapists, clinical psychologists
and medical rehabilitation specialists.
Functional measures
While there are a wide variety of outcome measures
available, there is general agreement that some
measure of physical and emotional function
needs to accompany pain measurement when
assessing a person with persistent pain. ere have
been a number of groups working to standardise
functional/outcome measures for use in chronic
pain clinical practice and research. A consensus
statement regarding core outcome measures in
clinical trials was recently published (2005) [14].
Measures may be generic or be adapted to specific
pain populations, i.e. condition-specific (e.g. spinal
cord injury, paediatric pain and pain in the older
person). ey may involve the administration of
questionnaires (self-report) or involve standardised
observational measures as undertaken in a Physical
Functional Capacity evaluation [1]. ere are a
range of generic measures that assess global changes
in disability/activity including the Sickness Impact
Profile (a multidimensional self-report measure)
and the Functional Independence Measure (FIM,
an observational or self-report measure for physical
and cognitive ability). Several condition-specific
disability/activity measures are also available
including the Roland and Morris Disability
Survey and Oswestry Low-Back Pain Disability
Questionnaire, commonly used in spinal pain [1].
In spinal cord injury, a new functional measure
based on the FIM has been developed, called the
Spinal Cord Independence Measure (SCIM) [6].
e validity and reliability of the SCIM have been
confirmed [27, 28] and the measure is now in its
third version, i.e. SCIM III.
Eect on physical function
e impact of pain on various aspects of daily
living may be assessed using tools that provide
information on pain intensity as well as function.
ese include the Brief Pain Inventory (BPI) and
the Multidimensional Pain Inventory (MPI) [33].
A recent consensus statement (IMMPACT) [14]
has recommended physical functioning be assessed
by either the MPI or BPI interference scales.
Assessment of mood
Measures commonly used to assess mood in people
with chronic pain include the Beck Depression
Inventory (BDI) and the Center for Epidemiologic
Studies-Depression scale (CES-D) [5]. e
measures suggested in the IMMPACT paper are
either the BDI or the Profile of Mood States.
General measures of participation
e Medical Outcomes Study 36-Item Short-
Form Health Survey (SF-36) has been used widely
to assess levels of participation in a more general
social context. It is an eight-scale health survey
encompassing physical and mental health. Its use
is intended for clinical practice, research, health
policy evaluations and general population surveys
[1].
To make individual test results useful, the clinician
needs to be able to compare the assessment results
with normative data obtained from a population
sample with similar demographics. Of most benefit
is normative data collected from individuals at the
same clinic attended by the patient. is enables
comparison of the results obtained from an
individual with the average patient seen in your
clinic or setting.
A brief functional assessment in the clinical
setting
A simplified clinical approach to functional
assessment is also possible. e information
required for this can be taken from the history
and examination and involves a basic appraisal of
a person’s ability to carry out their nominated life
roles. Life roles are established through personal
need and/or choice and are modified over time
based on ability, experience, circumstance and
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