The research literature (Flor, Fyrich, & Turk, 1992; Turk & Okifuji, 1998) and various organizations (American Society of Anesthesiologists, 1997; Commission on the Accreditation of Rehabilitation Facilities, 1999) support the use of an interdisciplinary rehabilitative approach to the management of chronic pain. This includes a process in which health care professionals from diverse treatment approaches collaborate to diagnose and treat patients suffering from debilitating pain. The Rehabilitation Accreditation Commission defines a chronic pain management program as a program that “provides coordinated, interdisciplinary team services to reduce pain, improve functioning, and decrease the dependence on the health care system of persons with chronic pain syndrome” (Commission of the Accreditation of Rehabilitation Facilities, 1998; 1999). Team members may include physicians (neurologists, psychiatrists, rheumatologists, anesthesiologists), nurses, pharmacists, case managers, social workers, physical therapists, vocational counselors, psychologists, and related professions (International Association for the Study of Pain, 2009; Stanos, 2012; Stanos & Houle, 2006).
In many developed countries, a variety of pain treatment facilities exist for the management of chronic pain. The International Association for the Study of Pain (2009) has outlined and defined the characteristics of these facilities as follows: multidisciplinary pain center (largest and most complex of the
pain treatment facilities, usually attached to medical school or teaching hospital, has a wide range of health care specialists and researchers); multidisciplinary pain clinic (similar to multidisciplinary pain center; however, does not include research and teaching activities); and pain clinic (distinguished from above centers by the absence of interdisciplinary assessment and management of chronic pain). Information is not currently available on the percentage of pain centers or clinics that employ music therapists or refer chronic pain patients to music therapy to address the physical, emotional, or spiritual needs of those living with chronic pain.
Assessment
The American Pain Society (2006) recommends a six-step assessment of pain. The first step is the initial pain evaluation. This step focuses on the physical aspects of pain, including the location, quality, and severity of the pain, as well as the triggers and fluctuations in the pain experience. The second step focuses on assessing the physical and psychosocial impact of pain. Specific areas include general activity level, sleeping patterns, mood, and relationship patterns. The third step gathers pain-related history. This includes any comorbidities, as well as pain treatment history. The fourth step focuses on a physical examination. The fifth step focuses on treatment goals. This includes having the patient state what level of pain relief is acceptable to them. This is particularly important if complete resolution of pain is not achievable. The sixth step focuses on treatment follow-up. This step determines the effectiveness of the pain management plan, including patient adherence to the plan as well as perceived problems with the plan.
Several tools are available to assess and evaluate pain intensity. Self-report measures are the most reliable way to assess pain intensity in cognitively intact adults (Wells, Pasero, & McCaffery, 2008). In the clinical setting, this is most often done by using the zero to 10 numerical rating scale or the zero to 5 Wong-Baker FACES scale (McCaffery & Pasero, 1999). The numerical rating scale consists of a straight horizontal line numbered at equal intervals from zero to 10, with anchor words of “no pain” for zero, “moderate pain” for 5, and “worst pain” for 10. The FACES scale consists of six faces showing progressive pain intensities, beginning with a smiling face and ending with a crying face.
Although not as widely used, multidimensional self-report assessment tools can provide information on pain characteristics and effects on a patient’s daily life (Chapman & Syrjala, 2001). The Brief Pain Inventory consists of a series of questions addressing the pain experience over a 24-hour period. It has been found useful in quantifying pain intensity and associated disability in a wide range of populations (Breitbart et al., 1997; Chapman & Syrjala, 2001; Cleeland, 1985). The McGill Pain Questionnaire assesses sensory, affective, and evaluative components of the pain experience. The self- report questionnaire was designed to provide quantitative measures of clinical pain that can be treated statistically (Melzack, 1975).
In addition to self-report measures, physiological and behavioral responses to perceived pain should be assessed (Carr et al., 1992). Physiological responses include increases in respiratory rate, heart rate, and blood pressure. Behavioral responses include splinting, grimacing, moaning or grunting, distorted posture, and reluctance to move. A lack of physiological responses or an absence of pain-related behavior(s) should not be used as an indicator of the absence of pain (Wells, Pasero, & McCaffery, 2008).
When the patient is unable to self-report pain, other less reliable measures must be used to identify the existence and probable intensity of pain. These include the following: conditions or procedures that are likely to cause pain, including surgery and wound care; nonverbal indicators of pain, including affect, muscle tension, and motor agitation/excessive motor movement; and consultation with family members to determine any pre-existing conditions associated with pain or behaviors indicative of pain (McCaffery & Pasero, 1999; Pasero & McCaffery, 2005).
Behavioral assessment tools are helpful in identifying the existence of pain and evaluating interventions. One example of such a scale is the Behavioral Pain Scale, developed for use with critically ill ICU patients (Payen et al., 2001). The Behavioral Pain Scale evaluates and scores the categories of behavior: facial expressions, with scores ranging from 1 for relaxed to 4 for grimacing; upper-limb movement, with scores ranging from 1 for no movement to 4 for permanently retracted; and ventilator compliance, with scores ranging from 1 for tolerating ventilator to 4 for unable to control ventilation. It is important to note that this scale is not a pain intensity score, but it is useful in determining the effectiveness of interventions to address the probable presence of pain.
Clinicians, including music therapists, need to remember that all pain assessment tools should be appropriate to the given patient. Special consideration should be given to the cultural, educational, and developmental age of the patient. Research indicates underreporting of pain secondary to fear, cultural beliefs, cognitive impairments, stoicism, and fear of addiction or side effects of treatment (Berry & Dahl, 1998; McCaffery & Pasero, 1999).