专家视点：疼痛量表的选择

圣迭戈——梅奥医院神经介入外科的Jeffrey A. Stone博士在美国神经介入外科学会(SNIS)年会上称，在用于评估急性疼痛的众多量表中，最常用的3个是数字评估量表(NRS)、主诉评估量表(VRS)和视觉模拟量表(VAS)。
Stone博士介绍说，上述量表的可靠性均已得到验证。由于NRS和VRS使用方便，所以得到多数患者的偏爱。此外，患者还可通过电话或电子日记完成这2个量表的评估。


Jeffrey A. Stone博士

NRS通常采用0~10个数字对疼痛程度进行分级，0为无疼痛，1~3为轻度疼痛，4~6为中度疼痛，7~10为重度疼痛。但Stone博士说：“如果患者告诉你是5/10，则难以判定，尤其是对于老年患者。”VRS将疼痛程度从无疼痛至严重疼痛分为4级，相对更为简单，且与NRS的相关性良好。应用VAS要求患者在长度为100 mm的垂直直线上标记其疼痛程度。“我较多使用该量表，但有些麻烦，尤其是在随访的时候。”

了解疼痛程度的背景资料时，需要考虑的因素包括镇痛药物的使用和其他疼痛治疗措施。这些药物可能是其他医生为处置患者睡眠或焦虑、预防活动量增大引起的疼痛或治疗其他无关疼痛而开具的，其他治疗措施包括针灸和按摩治疗等。此外，参加临床试验安慰剂组的患者通常比治疗组患者希望得到更多的镇痛药物治疗。

有关疼痛的其他不同特点还包括疼痛感觉和疼痛情绪。疼痛感觉是指疼痛性质和时间特征，前者如灼痛、跳痛、锐痛和钝痛等，后者包括不同时间疼痛程度的变化、有意义疼痛缓解起效时间、疼痛缓解持续时间、疼痛发作频率、持续时间以及程度等。疼痛情绪是指疼痛导致的精神痛苦。

疼痛感觉和疼痛情绪总体评估工具包括修订的McGill疼痛问卷(MPQ)，即简化MPQ，以及由Wisconsin简明疼痛问卷修订而来的简明疼痛评估量表(BPI)。简化MPQ包括15项有关感觉和情绪的描述，而BPI则偏重于疼痛时间特征的评估，常与简化MPQ配合使用。

另外两个重要疼痛结局分别为生理功能和情绪功能。有效性结局评估方法包括Oswestry功能障碍指数(ODI)、SF-36量表、Roland-Morris腰痛失能问卷(RMQ)和疼痛障碍指数(PDI)。ODI包括10个问题，除考察疼痛程度外，还涉及诸如提物、行走能力、社交生活、性行为以及睡眠周期等其他方面内容，这是一种考察患者综合疼痛失能非常准确的方法，已用于多项临床试验。患者完成SF-36量表需要回答有关功能健康和幸福评分的8个问题以及基于心理感受的身心健康总结性问题，稍显繁琐。RMQ由24个是与非问题组成，旨在评估患者自我感知的失能程度，而包括7个问题的PDI则用于评估疼痛对身体和社会心理角色表现的影响程度。

Stone博士指出，NRS、VRS和 VAS可用于住院患者，而ODI和RMQ等结局评估方法涉及性生活和活动水平等许多功能问题，对住院患者或许不太适用。

Stone博士声称无相关利益冲突披露。

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By: DOUG BRUNK, Internal Medicine News Digital Network

SAN DIEGO – Of the many scales at a clinician’s disposal to measure acute pain, the three most commonly used are the Numerical Rating Scale, the Verbal Rating Scale, and the Visual Analog Scale, Dr. Jeffrey A. Stone said at the annual meeting of the Society of Neurointerventional Surgery.

"All of these scales have been shown to be statistically reliable and valid," said Dr. Stone, associate professor of neurointerventional surgery in the radiology department at the Mayo Clinic, Jacksonville, Fla. In his clinical experience, most patients prefer the Numerical Rating Scale (NRS) and the Verbal Rating Scale (VRS) because they are easy to use. "The other advantage is that these can be conducted by telephone or electronic diaries," he said.
 
The NRS is a familiar and commonly used 0-10 scale, where 0 = no pain, 1-3 = mild pain, 4-6 = moderate pain, and 7-10 = severe pain. "If patients tell you, ‘I’m a 5 out of 10,’ that can be difficult to gauge, particularly in the elderly," Dr. Stone said. "The VRS, a four-scale system ranging from no pain up to severe pain, is somewhat simpler and correlates well with the NRS."

With the Visual Analog Scale, patients are asked to make a vertical slash on a 100-mm line to denote their level of pain. "I use this scale a lot, but it can be cumbersome, particularly with follow-up," he said.

Factors to consider in the backdrop of pain intensity include rescue analgesics, which may be prescribed by other physicians for sleep or anxiety, or may be used to prevent pain from increased activity or to treat unrelated pain. "Another factor is concomitant pain treatments, such as acupuncture and chiropractic treatments," Dr. Stone said. "In addition, patients enrolled in the placebo group of a clinical trial are generally expected to have more pain medication use compared with those in an efficacious treatment group."

Other distinct components of pain include pain sensation and pain affect. Pain sensation "is the quality of the pain, such as burning, throbbing, or sharp pain versus dull pain," Dr. Stone said. "There are also temporal aspects to pain, such as variability of intensity over time; time to onset of meaningful pain relief; durability of pain relief; and the frequency, duration, and intensity of pain episodes. Pain affect is the mental distress caused by the pain."

Global pain assessments for pain sensation and pain affect include a modification of the McGill Pain Questionnaire (MPQ), known as the short-form MPQ, and the Brief Pain Inventory (BPI), which was adapted from the Wisconsin Brief Pain Questionnaire. The short-form MPQ contains 15 sensory and affective descriptors, while the BPI "does a much better job measuring the temporal aspect of pain and is often used in conjunction with the short-form MPQ," Dr. Stone said.

Two other core pain outcome domains are physical function and emotional function. Effective outcome measures for these domains include the Oswestry Disability Index (ODI), the Short Form-36 (SF-36), the Roland-Morris Disability Questionnaire (RMQ) and the Pain Disability Index (PDI).

The ODI, a 10-item questionnaire, "has been used in many pain trials," he said. "It looks at pain intensity but also other things such as lifting, the ability to walk, social life, sexual activity, and sleep cycle. It is a very accurate way to look at a patient’s global disability from pain."

He described the SF-36 as "a little bit more cumbersome for patients to complete" in measuring physical and emotional function. This tool provides an eight-scale profile of functional health and well-being scores, as well as a psychometric-based physical and mental health summary.

The 24-item RMQ consists of yes/no questions intended to measure self-perceived disability, while the 7-question PDI measures pain interference in physical and psychosocial role performance.

In a later interview, Dr. Stone said that the NRS, VRS, and VAS instruments can be used in hospitalized patients. Outcome measures such as the ODI and the RMQ "would not be very useful, as they ask many functional questions such as sex life [and] activity level, which would not be applicable to a hospitalized patient."

Dr. Stone said that he had no relevant financial disclosures to make.