PERSPECTIVES

J Oral Maxillofac Surg

Assessing Pain Using Patient-Reported

Pain management is an essential goal in surgical care, Though pain is a dynamic experience, relying on the
requiring reliable, pragmatic, and simple methods to individual’s memory to recall and report the nature of
assess pain. However, pain assessment is challenging pain from the past (recall bias) can skew the reporting
since pain is multidimensional and subjective in mea- accuracy. Ecological Momentary Assessment (EMA)
surement and reporting. Increasing pain intensity is is a method that can minimize recall bias, where indi-
distressing and a common reason for surgical consulta- viduals record the pain intensity close to the time of
tion. Hence, pain intensity is the most common dimen- occurrence, providing a momentary and near real-
sion of pain, assessed and managed. This article time assessment of the pain using any validated assess-
discusses practical patient-provider and participant- ment tool. The frequency of assessments should be
researcher perspectives in pain assessment. Structures balanced to avoid the psychological impact of
innervated by the trigeminal system experience the repeated pain assessments.
most prevalent and debilitating pain conditions from Worse experiences or those associated with another
different etiologies. Orofacial pain can be odonto- intense emotional response may be better remem-
genic, temporomandibular joint, postoperative, bered and recalled. Any associated bad experience
neuralgic/neuropathic, myofascial, or soft-tissue may bias the pain reporting towards more severe,
origin, highlighting the importance of accurate pain even if the actual pain intensity may be lower, leading
assessment. to reporting bias. We can provide better patient care
Visual analog scale (VAS), verbal rating scale (VRS), by identifying and handling these factors empa-
and numerical rating scale (NRS) are 3 widely used thetically.
simple, validated, and practical methods of pain assess- VAS, VRS, and NRS, though self-reported, require
ment1 (see Table 1). All 3 scales are reliable, valid, and clear explanations and some assistance initially. For
have good concordance in orofacial settings,2 with a example, marking the pain characteristic on a line in
high correlation between VAS and NRS (>85%).3 Peo- VAS is difficult. The individuals struggle to convert
ple prefer using words (VRS) more than numbers the subjective pain experience into an objective mea-
(NRS), and show a low preference for marking on a sure using a verbal anchor (VRS), a numerical rating
line (VAS). We must choose measurement tools based (NRS), or by making a mark on a line (VAS). Familiarity
on our preferences, needs, and context. For instance, improves reporting; hence, the first 2 or 3 pain assess-
we can use VAS where we need better precision and in ments may be unreliable. In research settings, stan-
adults, especially for repeated follow-ups. In people dardized instructions in a neutral language and tone
with poor health literacy, physical or cognitive impair- with training and piloting of the assessor and the as-
ment, and situations where compliance, time, or us- sessed are essential for accuracy. The native script
ability matters more than precision, we can use reading direction (vertically vs horizontally oriented
VRS’s or NRS.1 script) may affect the accuracy of the reporting. For

Associate Professor and Officer in-Charge, Department of Conflict of Interest Disclosures: None to declare.
Dentistry, Jawaharlal Institute of Postgraduate Medical Education Received October 28 2023
and Research (JIPMER), Karaikal Campus, Puducherry, India. Accepted November 7 2023
Address correspondence and reprint requests to Dr Akilesh Ó 2023 American Association of Oral and Maxillofacial Surgeons
Ramasamy: Department of Dentistry, Jawaharlal Institute of 0278-2391/23/01250-8
Postgraduate Medical Education and Research (JIPMER), Karaikal https://doi.org/10.1016/j.joms.2023.11.007
Campus, Puducherry, India 609602; e-mail: [email protected]

139
140 ASSESSING PAIN USING PATIENT-REPORTED MEASURES

Table 1. COMPARISON OF THE 3 COMMON DIFFERENT UNIDIMENSIONAL PAIN ASSESSMENT TOOLS

Component Visual Analog Scale Verbal Rating Scale Numerical Rating Scale

Brief Description A straight unmarked line Uses 4 or 5 adjectives A straight line with
of length 100 mm with describing the pain markings (11, 21 or
anchors at 2 extremes experience 101 markings)
Dimensions Unidimensional Unidimensional Unidimensional
Subjective/Objective Subjective Subjective Subjective
Mode of administration digital, paper digital, paper, verbal digital, paper, verbal
Statistical properties Interval or ratio scale Categorical ordinal scale Interval scale with 11
with 4 or 5 categories points (0-10), 21
points (0-20) or 101
points (0-100)
Statistical Properties Can provide data for Can provide data for Can provide data for
parametric analysis, if nonparametric parametric analysis, if
data are normally analysis only data are normally
distributed distributed
In young individuals Younger children may Useful May be useful
(8-17 yr) find it difficult, but may
be useful in
adolescents
In older Adults May have difficulty May be useful May be useful
In people with cognitive Not suitable Suitable 11-point scale may be
impairment suitable

Akilesh Ramasamy. Assessing Pain Using Patient-Reported Measures. J Oral Maxillofac Surg 2024.

example, someone who uses Chinese scripts naturally validated well before with due consideration for tech-
reads scripts from top to bottom, and hence, a verti- nological barriers.
cally oriented tool may be more accurate in this group. Humans are usually better at making comparisons
A mixed methods approach (using a validated tool than at making absolute judgments. Hence, repeated
and a specific focused interview) may improve the reli- measures in the same patient are more reliable than
ability and provide contextual information. In the point assessments. Proper orientation and guidance
mixed methods approach, there are concerns about in marking may help them report their experience bet-
circularity introduced by asking the individual about ter. Patients may over-report the pain, assuming re-
the measure which they reported themselves. Howev- porting a high score will get them better treatment.
er, this concern is less relevant in pain assessment Individuals may under-report pain intensity for fear
since pain is an individual’s subjective experience. of being branded as a problem patient. The patient
Genetics, age, race, previous experiences, trauma must understand that honest and accurate reporting
stress, societal discrimination and inequities, life of pain will help the clinician to provide appropriate
events, comorbidities, ongoing pain, recent physical treatment, avoiding over-treatments and unnecessary
or psychosocial factors, and pre-existing paresthesia tests. Only basic language comprehension is sufficient
is a nonexhaustive list of factors that modify the way for using the tools for reporting pain intensity, but fa-
pain intensity is perceived and reported.4 The assessor miliarity and understanding of the measure facilitate
must use simple instructions framed in a familiar accurate reporting. In my clinical and mentoring expe-
language in a culturally and linguistically appro- rience, I have observed that individuals, both the
priate tone. assessor and the assessed, when using the tool for
Digital data collection tools are now the standard, the first time, found VAS confusing. The same may
simplifying data collection and enabling piping data be relevant for VRS and NRS as well, though to a lesser
directly into the analysis workflow, saving time and extent due to their simplicity.
minimizing transcription errors. However, digital tools When using these tools, the instructions are pro-
may have inherent biases and other sources of error. vided, such as ‘‘make a mark on the line .’’ or ‘‘which
For example, in a smaller screen space, they are scaled of the following words precisely describe the intensity
to smaller lengths, though they occupy the whole of the pain you experience(d).’’ These messages appear
screen width. They may have a different user interface simple but ambiguous. The patient may be over-
than pen-paper and hence different psychometric whelmed with questions such as What mark? How to
properties and usability. So, the digital tool has to be make the mark? Vertical or X or dot or other? Is the
AKILESH RAMASAMY 141

pain moderate or severe? or with how to express ‘‘pain same interval of pain worsening (say, a 3-point in-
is better than last time when I marked 6, but it is not as crease in pain in NRS) may impair function at a
bad as 7, and there is no 6.5 on this scale!’’ different scale than the improvement obtained for
For example, in our controlled trial in an outpatient the same magnitude of pain relief (say a 3-point
setting, we assessed pain intensity using VAS, and decrease in NRS).
among the 180 participants, around 20(10%) individ- In oral and maxillofacial surgical settings, VAS,
uals made invalid markings. If this can occur in a NRS, and VRS are all validated, and their successful
controlled research setting, the invalid or inaccurate use depends on contextual and consistent imple-
reporting will be higher in real-world settings and mentation. We must interpret the reports consid-
more so in inpatient and acute care settings. So, I rein- ering the limitations of the tools and possible
force the importance of simple, easily understandable biases. The overall trial-reported mean pain relief
instructions and prior training with the measurement or worsening of pain is unsuitable for setting individ-
tools before deployment. ual treatment goals in clinical settings. Here, the
Both VRS and NRS are straightforward but less pre- goals must be patient-centric patient-specific, and
cise than VAS. Numerical ratings and verbal ratings aim for functional improvement. When multiple as-
are suitable for remote use and verbal administration. sessors are part of a large trial, all must receive
In perioperative and intensive care settings, cognitive proper training to use the tools in a uniformly,
impairment makes reporting inconsistent and inaccu- consistent manner and high levels of inter-rater
rate.5 For individuals with physical or visual impair- and intrarater reliability. Understanding these con-
ments, VAS is challenging to use. In these cerns and choosing appropriate tools as per the re-
individuals, we can administer VRS or NRS verbally quirements is the key to the successful use of
or use some innovative VAS variants. However, we patient-reported pain assessment tools in practice.
must design these innovative tools using a participa-
tory approach with continuous evaluation in real-
world settings. Responsiveness to NRS and VRS may
be better among older individuals because of
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