The Multimodal Assessment Model of Pain

Abstract

Objectives: Pain assessment is enigmatic. Although clinicians and researchers must rely upon observations to evaluate pain, the personal experience of pain is fundamentally unobservable. This raises the question of how the inherent subjectivity of pain can and should be integrated within assessment. Current models fail to tackle key facets of this problem, such as what essential aspects of pain are overlooked when we only rely on numeric forms of assessment, and what types of assessment need to be prioritized to ensure alignment with our conceptualization of pain as a subjective experience. We present the multimodal assessment model of pain (MAP) as offering practical frameworks for navigating these challenges. Methods: This is a narrative review. Results: MAP delineates qualitative (words, behaviors) and quantitative (self-reported measures, non–self-reported measures) assessment and regards the qualitative pain narrative as the best available root proxy for inferring pain in others. MAP offers frameworks to better address pain subjectivity by: (1) delineating separate criteria for identifying versus assessing pain. Pain is identified through narrative reports, while comprehensive assessment is used to infer why pain is reported; (2) integrating compassion-based and mechanism-based management by both validating pain reports and assessing underlying processes; (3) conceptualizing comprehensive pain assessment as both multidimensional and multimodal (listening/observing and measuring); and (4) describing how qualitative data help validate and contextualize quantitative pain measures. Discussion: MAP is expected to help clinicians validate pain reports as important and legitimate, regardless of other findings, and help our field develop more comprehensive, valid, and compassionate approaches to assessing pain.

Language-Related Disparities in Pain Management in the Post-Anesthesia Care Unit for Children Undergoing Laparoscopic Appendectomy

“…Optimal treatment of pain requires balancing both objective and subjective assessments of pain and can prevent long-lasting complications in a post-surgical population. Overreliance on objective pain scales, without incorporation of clinicians’ and patients’ subjective assessments, can increase patient anxiety and diminish the therapeutic alliance among patients, family members, and their healthcare providers [ 21 ]. However, overreliance on subjective assessments can introduce conscious or unconscious bias into a clinician’s assessment, as has been documented in studies investigating racial [ 22 ] and gender-based [ 23 ] prejudice in the treatment of pain.…”

What narrative devices do people with systemic sclerosis use to describe the experience of pain from digital ulcers: a multicentre focus group study at UK scleroderma centres

“…The participants' pain narratives exhibit a diverse use of language; both elements of Wideman's 35 pain expression (pain narrative and pain behaviour) are evident in the transcripts. Rather than being observed, 'pain behaviour' was described by participants (such as rocking backwards and forwards).…”

“…The Multimodal Assessment Model of Pain (MAP) distinguishes between qualitative (words and behaviours) and quantitative (self and non-self-reported measures) assessments of pain 'and regards the qualitative pain narrative as the best available root proxy for inferring pain in others'. 35 Wideman et al describe 'pain expression' as 'the broad collection of qualitative words and behaviours that communicate pain'. They divide pain expression into two components: 'pain narrative', comprising words used to describe pain; and 'pain behaviour', which comprises nonverbal and para-verbal pain-related behaviours.…”

“…They divide pain expression into two components: 'pain narrative', comprising words used to describe pain; and 'pain behaviour', which comprises nonverbal and para-verbal pain-related behaviours. 35 Bostick et al 36 found that the 'pain narrative' is important for capturing the experience of women who live with chronic pain conditions and suggest that it should be included alongside quantitative pain assessment measures. Pain is an important symptom of many health conditions, and some conditions have bespoke measurement scales to capture the severity and impact of pain such as WOMAC for osteoarthritis pain.…”

A Deep Brain Stimulation Trial Period for Treating Chronic Pain

“…Individual patents also differ in their adeptness of communicating pain through numeric ratings, free speech dialog, pain maps [ 73 ], or standardized surveys. Different methods of collecting information about pain symptoms also tap into different aspects of the pain experience [ 74 ], such as quantitative pain measures (e.g., numerical rating), pain experience (e.g., unpleasant sensory or emotional experience), and pain expression (e.g., qualitative words, pain narrative, and behavior to communicate pain, pain behavior). We found that a combination of metrics was the most useful, with short versions administered more frequently and long versions administered about three times per day.…”