Journal of Pain and Symptom Management

Impact of Pain and Symptom Burden on the Health-Related Quality of Life of Hemodialysis Patients

Sara N. Davison, Gian S. Jhangri — 2010-03-01

Abstract: Context: Dialysis patients experience tremendous symptom burden and substantial impaired health-related quality of life (HRQL).Objectives: We determined the association between symptom burden and HRQL in 591 hemodialysis patients.Methods: Patients completed the modified Edmonton Symptom Assessment System and the Kidney Dialysis Quality of Life Short Form at baseline and after six months.Results: There were no demographic, serological, or dialysis-related predictors for either HRQL or symptom burden. Pain, tiredness, lack of well-being, and depression were the only independent predictors of mental HRQL, accounting for 42.5% of the variation in the baseline mental health composite (MHC). Pain, fatigue, lack of well-being, and shortness of breath were the only independent predictors of physical HRQL, accounting for 38.5% of the variation in the baseline physical health composite (PHC). After follow-up, only changes in depression, anxiety, tiredness, and lack of appetite were independently associated with a change in MHC score, accounting for 48.7% of the variability. Only changes in pain, tiredness, and lack of appetite were independently associated with a change in PHC, accounting for 44.6% of the variability in the final multivariate regression model. No change in biochemical parameters predicted a change in either the MHC or the PHC.Conclusion: Symptom burden in end-stage renal disease was substantial and had a tremendous negative impact on all aspects of hemodialysis patients' HRQL. These patients, therefore, would likely benefit from the institution of programs to reduce symptom burden.

Reducing Patient Barriers to Pain and Fatigue Management

2010-03-01

Abstract: Context: Pain and fatigue are recognized as critical symptoms that impact the quality of life of cancer patients. The barriers to pain and fatigue relief have been classified into three categories: patient, professional, and system barriers.Objectives: The overall objective of this trial as to test the effects of the “Passport to Comfort” intervention on reducing barriers to pain and fatigue management for ambulatory care cancer patients.Methods: This quasi-experimental, comparative study uses a Phase 1 control group of usual care followed sequentially by a Phase 2 intervention group in which educational and system-change efforts were directed toward improved pain and fatigue management. A sample of 187 cancer patients with breast, lung, colon, or prostate cancers, and a pain and/or fatigue rating of 4 or more (moderate to severe), were recruited. Patients in the intervention group received four educational sessions on pain/fatigue assessment and management, whereas patients in the control group received usual care. Pain and fatigue barriers and patient knowledge were measured at baseline, one month, and three months post-accrual.Results: Patients in the intervention group experienced significant improvements in pain and fatigue measures immediately postintervention, and these improvements were sustained over time.Conclusion: The “Passport to Comfort” intervention was effective in reducing patient barriers to pain and fatigue management as well as in increasing patient knowledge regarding pain and fatigue. This intervention demonstrates innovation by translating the evidence-based guidelines for pain and fatigue as developed by the National Comprehensive Cancer Network into practice.

Got Volunteers? Association of Hospice Use of Volunteers With Bereaved Family Members' Overall Rating of the Quality of End-of-Life Care

2010-03-01

Abstract: Context: Volunteers are a key component of hospice, and they are required by Medicare conditions of participation in the United States. Yet, little is known about the impact of volunteers in hospice.Objectives: The goal of this study was to characterize whether bereaved family members in hospice programs with increased use of volunteer hours per patient day report higher overall satisfaction with hospice services.Methods: A secondary analysis of the 2006 Family Evaluation of Hospice Care data repository with hospice organization data regarding the number of volunteer hours in direct patient care and the total number of patient days served. A multivariate model examined the association of institutional rate of bereaved family members stating end-of-life care was excellent with that of hospices' rate of volunteer hours per patient day, controlling for other organizational characteristics.Results: Three hundred five hospice programs (67% freestanding and 20.7% for profit) submitted 57,353 surveys in 2006 (54.2% female decedents and 47.4% with cancer). Hospice programs reported on average 0.71 hours per patient week (25th percentile: 0.245 hours per patient week; 75th percentile: 0.91 volunteer hours per patient week; and 99th percentile: 3.3 hours per patient week). Those hospice programs in the highest quartile of volunteer usage had higher overall satisfaction compared with those in the lowest-quartile usage of volunteers (75.8% reported excellent overall quality of care compared with 67.8% reporting excellent in the lowest quartile. After adjustment for hospice program characteristics, hospice programs in the highest quartile had highest overall rating of the quality of care (coefficient=0.06, 95% confidence interval=0.04, 0.09).Conclusion: In this cross-sectional study, hospice programs with higher use of volunteers per patient day were associated with bereaved family member reports that the hospice program quality of care was excellent.

Families' Perceptions of Veterans' Distress Due to Post-Traumatic Stress Disorder-Related Symptoms at the End of Life

2010-01-18

Abstract: Objectives: To define the frequency of post-traumatic stress disorder (PTSD)-related symptoms among veterans who are near the end of life and to describe the impact that these symptoms have on patients and their families.Methods: Patients had received inpatient or outpatient care from a participating VA facility in the last month of life, and one family member per patient was selected using predefined eligibility criteria. Family members then completed a telephone survey, The Family Assessment of Treatment at End-of-Life, which assessed their perceptions of the quality of the care that the patients and they themselves received during the patients' last month of life.Results: Seventeen percent of patients (89 of 524) were reported to have had PTSD-related symptoms in the last month of life. PTSD-related symptoms caused discomfort less often than pain did (mean frequency score 1.79 vs. 1.93; Wilcoxon sign rank test, P<0.001) but more often than dyspnea did (mean severity score 1.79 vs. 1.73; Wilcoxon sign rank test, P<0.001). Family members of patients with PTSD-related symptoms reported less satisfaction overall with the care the patient received (mean score 48 vs. 62; rank sum test, P<0.001). Patients who received a palliative care consult (n=49) had lower ratings of discomfort attributed to PTSD-related symptoms (mean 1.55 vs. 2.07; rank sum test, P=0.007).Conclusion: PTSD-related symptoms may be common and severe among veterans near the end of life and may have a negative effect on families' perceptions of the quality of care that the veteran received.

A Comparison of Two Spirituality Instruments and Their Relationship With Depression and Quality of Life in Chronic Heart Failure

2010-03-01

Abstract: Spirituality is a multifaceted construct related to health outcomes that remains ill defined and difficult to measure. Spirituality in patients with advanced chronic illnesses, such as chronic heart failure, has received limited attention. We compared two widely used spirituality instruments, the Functional Assessment of Chronic Illness Therapy—Spiritual Well-Being (FACIT-Sp) and the Ironson-Woods Spirituality/Religiousness Index (IW), to better understand what they measure in 60 outpatients with chronic heart failure. We examined how these instruments related to each other and to measures of depression and quality of life using correlations and principal component analyses. The FACIT-Sp measured aspects of spirituality related to feelings of peace and coping, whereas the IW measured beliefs, coping, and relational aspects of spirituality. Only the FACIT-Sp Meaning/Peace subscale consistently correlated with depression (r=−0.50, P<0.0001) and quality of life (r=0.41, P=0.001). Three items from the depression measure loaded onto the same factor as the FACIT-Sp Meaning/Peace subscale (r=0.43, −0.43, and 0.71), whereas the remaining 12 items formed a separate factor (Cronbach's alpha=0.82) when combined with the spirituality instruments in a principal component analysis. The results demonstrate several clinically useful constructs of spirituality in patients with heart failure and suggest that psychological and spiritual well-being, despite some overlap, remain distinct phenomena.

Provider Communication and Patient Understanding of Life-Limiting Illness and Their Relationship to Patient Communication of Treatment Preferences

2010-02-22

Abstract: Medical decision making in the context of serious illness ideally involves a patient who understands his or her condition and prognosis and can effectively formulate and communicate his or her care preferences. To understand the relationships among these care processes, we analyzed baseline interview data from veterans enrolled in a randomized controlled trial of a palliative care intervention. Participants were 400 inpatient veterans admitted with a physician-estimated risk of one-year mortality more than 25%; 260 (65%) had cancer as the primary diagnosis. Patients who believed that they had a life-limiting illness (89% of sample) reported that their provider had communicated this to them more frequently than those who did not share that belief (78% vs. 22%, P<0.001). Over half (53%) of the participants reported discussing their care preferences with their providers and 66% reported such discussions with their family; 35% had a living will. In multivariate analysis, greater functional impairment was associated with patients having discussed their care preferences with providers (P<0.05), whereas patient understanding of prognosis (P<0.05), better quality of life (P<0.01), and not being African American (P<0.05) were associated with patients having discussed their care preferences with family; higher education (P<0.001), and not being African American (P<0.01) were associated with having a living will. Patients with poor understanding of prognosis are less likely to discuss care preferences with family members, suggesting the importance of provider communication with patients regarding prognosis. Because functional decline may prompt physicians to discuss prognosis with patients, patients with relatively preserved function may particularly need such communication.

Prevalence, Severity, and Correlates of Sleep-Wake Disturbances in Long-Term Breast Cancer Survivors

2010-01-18

Abstract: Context: Current evidence shows that sleep-wake disturbances are a persistent problem linked to poor quality of life in women surviving breast cancer. Information regarding correlates of sleep-wake disturbances in long-term survivors is sparse.Objectives: The objective of this study was to refine knowledge regarding prevalence, severity, and correlates of sleep-wake disturbances in long-term breast cancer survivors (BCS) compared with age-matched women without breast cancer (WWC).Methods: The cross-sectional convenience sample included 246 BCS and 246 WWC who completed a quality-of-life study and were matched within ±5 years of age.Results: BCS were a mean of 5.6 years beyond completion of cancer treatment (range = 5.6–10.0 years). Based on Pittsburgh Sleep Quality Index (PSQI) scores, BCS had significantly more prevalent sleep-wake disturbances (65%) compared with WWC (55%) (P < 0.05). BCS also had significantly higher PSQI global scores indicating poorer sleep quality compared with WWC (P < 0.05). Significant correlates of prevalence of poor sleep for BCS included hot flashes, poor physical functioning, depressive symptoms, and distress, and for WWC, these included hot flashes, poor physical functioning, and depressive symptoms. Significant correlates (P < 0.05) of severity of poor sleep for BCS included presence of noncancer comorbidities, hot flashes, depressive symptoms, and residual effects of cancer treatment. For WWC, these included hot flashes, poor physical functioning, depressive symptoms, and impact of a life event.Conclusion: Knowledge of prevalence, severity, and correlates of sleep-wake disturbances provides useful information to health care providers during clinical evaluations for treatment of sleep-wake disturbances in BCS.

Lack of Benefit From Paracetamol (Acetaminophen) for Palliative Cancer Patients Requiring High-Dose Strong Opioids: A Randomized, Double-Blind, Placebo-Controlled, Crossover Trial

Fiona J. Israel, Greg Parker, Margaret Charles, Liz Reymond — 2010-01-18

Abstract: Context: The adjunctive use of paracetamol (acetaminophen) with strong opioids has become entrenched practice in palliative care pain management, despite little evidence to support its use.Objective: The study aim was to investigate potential analgesic benefits of 4g of paracetamol daily for palliative cancer patients requiring high-dose opioids.Methods: Thirty-one patients, using at least 200mg of oral morphine equivalent daily, were recruited to a prospective, double-blinded, randomized, crossover trial. Patients received usual medications plus 4g of paracetamol or placebo for five days each in random order. Primary outcome, effect on pain, was assessed using daily diaries, including a numerical rating scale (NRS) from zero (no pain) to 10 (unbearable) and recording numbers of breakthrough analgesics. Secondary outcomes—nausea, vomiting, cognitive impairment, constipation, and overall well-being—were assessed using the NRS. Data from the last four days of each treatment were analyzed. Patients also indicated in which part of the study their pain was better controlled.Results: Twenty-two patients, requiring a median dose of 255mg of oral morphine equivalent daily, completed the trial. There were no significant order or treatment-by-order interaction effects for any variable; paired t-tests were conducted to investigate change in mean levels on outcome variables with placebo vs. paracetamol. For none of the variables was there a statistically significant difference when assessed with placebo compared with paracetamol. No change approached clinically significant levels, with a mean difference in rated pain of 0.16, and mean difference of 0.42 for a number of breakthrough medications. Fifteen patients were undecided whether paracetamol improved pain.Conclusions: These data do not support the common practice of adding regular paracetamol daily as an adjunct to high-dose opioids for pain control in cancer patients receiving palliative care.

The Experience of Breathlessness: The Social Course of Chronic Obstructive Pulmonary Disease

Marjolein Gysels, Irene J. Higginson — 2010-03-01

Abstract: Context: There is a trend toward extending palliative care to nonmalignant diseases. There is no evidence that chronic obstructive pulmonary disease (COPD) requires its own model.Objectives: The aim of this study was to investigate how the experience of breathlessness in COPD influences patients' attitudes toward the end of life and their quality of life.Methods: Eighteen patients were purposively sampled. Data were collected through in-depth interviews and participant observation during outpatient consultations. Narrative methods were used to analyze the data.Results: Treatment-seeking in COPD deviated from prototypical trajectories. Contact with health care was postponed to crisis point. Treatment did not follow diagnosis because of how the diagnosis was given. Help was sought when the symptom had acquired meaning in a person's life. The future did not feature in the interviews.Conclusion: Good communication practices are fundamental in the care for COPD patients. Particularly, diagnosis and prognosis need to be rethought in a model to suit the condition of COPD.

Single- vs. Multiple-Item Instruments in the Assessment of Quality of Life in Patients with Advanced Cancer

2010-03-01

Abstract: Although multidimensional instruments are usually used to measure quality of life in advanced cancer patients, recent research suggests that single-item assessments can provide a reliable measure. Using the Functional Assessment of Cancer Therapy-General (FACT-G) instrument as a gold standard, we assessed the performance of the Edmonton Symptom Assessment System “feeling of well-being” (ESAS WB) item. We reviewed the data from 213 patients enrolled in six clinical trials. We determined the association between baseline ESAS WB and FACT-G total and subscale domain scores (Physical Well-being [PWB], Social/Family Well-being [SWB], Emotional Well-being [EWB], and Functional Well-being [FWB]. We also calculated the association between baseline (T1) and second (T2) observations of ESAS WB and of FACT-G total score. In addition, we predicted the change in FACT-G predicted by the ESAS WB score using regression analysis. Mean age was 60 (SD 12) years and 48% were female. The Spearman correlation coefficient of ESAS WB and FACT-G was −0.48 (P<0.0001). Correlations with FACT-G subscale domains were also highly significant, except for the SWB domain (P=0.08). The Pearson correlation coefficient for T1–T2 in ESAS WB and FACT-G for 146 patients was −0.36 (P<0.0001). The change in ESAS WB corresponding to FACT-G published minimally important difference was −0.24 for 3, −1.55 for 5, and −2.87 for 7, respectively. These results suggest that the single-item measure ESAS WB best reflects the total score on the FACT-G and PWB, EWB, and FWB domains but not on the SWB domain.

Psychometric and Clinical Assessment of the 10-Item Reduced Version of the Fatigue Scale—Child Instrument

2010-03-01

Abstract: Fatigue is one of the most debilitating conditions associated with cancer and anticancer therapy. The lack of reliable and valid self-report instruments has prevented accurate assessment of fatigue in pediatric oncology patients. The purpose of this study was to identify the most sensitive and specific score, that is, the “cut score,” on the Fatigue Scale-Child (FS-C) to identify those children with high cancer-related fatigue in need of clinical intervention. We first used Rasch methods to identify the items on the FS-C that distinguished children with high cancer-related fatigue from other children; our findings indicated that the FS-C needed to be reduced from 14 items to 10 items. We then assessed the 10-item FS-C for its psychometric properties and applied the receiver operating characteristics curve analysis to the FS-C responses from 221 children (aged 7–12 years) receiving anticancer treatment. The cut score identified with 75% sensitivity and 73.5% specificity was 12; 73 (33%) patients scored 12 or higher. Findings from this validated instrument provide a needed guide for clinicians to interpret fatigue scores and provide clinical interventions for this debilitating condition to their pediatric patients with cancer.

Parent Pain Responses as Predictors of Daily Activities and Mood in Children with Juvenile Idiopathic Arthritis: The Utility of Electronic Diaries

2010-03-01

Abstract: The present study used electronic diaries to examine how parent responses to their child's pain predict daily adjustment of children with juvenile idiopathic arthritis (JIA). Nine school-aged children with JIA along with one of their parents completed thrice-daily assessments of pain-related variables, activity participation, and mood using handheld computers (Palm® pilots) for 14 days, yielding a potential of 42 child and parent assessments for each dyad. Children provided information on current pain level, mood, and participation in social, physical, and school activities. Parents independently rated their own mood as well as their behavioral responses to their child's pain at the same time points using a separate handheld computer. Results of multilevel modeling analyses demonstrated that use of “protective” pain responses by parents significantly predicted decreases in child activity and positive mood, with an even stronger inverse relationship between protective pain response and positive mood observed in children with higher than average disease severity. Protective pain responses were not found to be significantly predictive of daily negative mood in children. The use of “distracting” responses by parents significantly predicted less child activity restrictions but only in children having higher disease severity. There also was an unexpected trend in which parent use of more distracting pain responses tended to be associated with lower child positive mood. These preliminary findings suggest the importance of the parent in influencing adjustment in children with JIA and lend support to the incorporation of parents into comprehensive pain management approaches. The potential benefits of using electronic daily diaries as a strategy to examine pain and adjustment in children with JIA pain are discussed.

Factors Associated with Congruence Between Preferred and Actual Place of Death

Christina L. Bell, Emese Somogyi-Zalud, Kamal H. Masaki — 2010-01-29

Abstract: Congruence between preferred and actual place of death may be an essential component in terminal care. Most patients prefer a home death, but many patients do not die in their preferred location. Specialized (physician, hospice, and palliative) home care visits may increase home deaths, but factors associated with congruence have not been systematically reviewed. This study sought to review the extent of congruence reported in the literature and examine factors that may influence congruence. In July 2009, a comprehensive literature search was performed using MEDLINE, PsychInfo, CINAHL, and Web of Science. Reference lists, related articles, and the past five years of six palliative care journals were also searched. Overall congruence rates (percentage of met preferences for all locations of death) were calculated for each study using reported data to allow cross-study comparison. Eighteen articles described 30%–91% congruence. Eight specialized home care studies reported 59%–91% congruence. A physician-led home care program reported 91% congruence. Of the 10 studies without specialized home care for all patients, seven reported 56%–71% congruence and most reported unique care programs. Of the remaining three studies without specialized home care for all patients, two reported 43%–46% congruence among hospital inpatients, and one elicited patient preference “if everything were possible,” with 30% congruence. Physician support, hospice enrollment, and family support improved congruence in multiple studies. Research in this important area must consider potential sources of bias, the method of eliciting patient preference, and the absence of a single ideal place of death.

Dying Tax Free: The Modern Advance Directive and Patients' Financial Values

Timothy W. Kirk, George R. Luck — 2010-03-01

Abstract: Advance directives are often used to help patients articulate their end-of-life treatment preferences and guide proxy decision makers in making health care decisions when patients cannot. This case study and commentary puts forth a situation in which a palliative care consultation team encountered a patient with an advance directive that instructed her proxy decision maker to consider estate tax implications when making end-of-life decisions. Following presentation of the case, the authors focus on two ethical issues: 1) the appropriateness of considering patients' financial goals and values in medical decision making and 2) whether certain kinds of patient values should be considered more or less relevant than others as reasons for expressed treatment preferences. Clinicians are encouraged to accept a wide range of patient values as relevant to the clinical decision-making process and to balance the influence of those values with more traditional notions of clinical harm and benefit.

Fundamental Facets of Pediatric Hospice Care

Chris Feudtner — 2010-02-12

If one of the surest signs of a maturing discipline within medicine is the growth in the number of textbooks devoted to the topic, then pediatric palliative and hospice care is blossoming. Among several fine textbooks that are either already available or in the works, in the vanguard stands Hospice Care for Children, which was first published in 1993 and now appears in a revised and updated third edition.

A Singular Source of Contemporary Information on Pain Management

Gregg Figg, John C. Rowlingson — 2010-02-12

The fourth edition of Raj's Practical Management of Pain continues to upgrade and expand what is widely regarded as a definitive standard for textbooks in the field of pain management. As the specialty itself rapidly changes, it becomes more difficult to consolidate the plethora of evolving knowledge into an easily accessible reference. Yet, this new textbook seems to have met that challenge. Intended initially in 1986 by Raj to be “a resource for a pain trainee who had one year to learn everything about pain management,” the scope of this new text has been broadened by the inclusion of input from a multidisciplinary group of distinguished experts. The stated goal of this edition is to serve “pain clinicians looking for application in their daily practice, pain researchers seeking adequate background on relevant topics, fellows reviewing for the pain boards, and residents who want a complete discussion of the breadth of the field.” This text achieves these lofty goals in admirable fashion.

Every Patient Tells a Story

Martin Chasen — 2010-02-08

In today's health care system, enormous attention is given to the biomedical model of approaching the health aspects of the patients. The correct diagnosis is the key to prescribing the correct treatment, which aims to alleviate the patient's suffering. Targeted questioning, which leads to categorization of symptoms into specific syndromes provides the bulk of knowledge, which then allows for further clinical examination to verify our clinical suspicions.

Psychosocial Issues in Palliative Care: A Message for Us All

Carolyn Hullick — 2010-03-01

As an Australian emergency physician interested in geriatric care and certainly not someone who considers myself an expert in palliative care, this book not only gives an excellent overview of psychosocial issues in palliative care but also has applicability to a broader health care audience. Understanding psychosocial issues and tools for intervention in patient care is not generally given a high priority in formal medical education. Yet, with increasing clinical experience, I have come to recognize the importance of addressing patient comfort, in the broad sense. Palliative care has embraced this holistic approach as defined by its World Health Organization definition, “an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual.” Other disciplines are beginning to recognize the importance and leadership that palliative care has shown for addressing suffering, for treating physical, psychosocial, and spiritual pain to deliver better health care and quality of life for patients, and for acknowledging their caregivers in holistic, patient-centered care in the context of their families.

Proceedings of the 12th World Congress on Pain: An Informative Compilation

Judith A. Paice — 2010-02-12

The 12th World Congress on Pain, the biennial meeting of the International Association for the Study of Pain (IASP), was held in Glasgow in August 2008. This was an extraordinary meeting that addressed the most timely topics, delivered by esteemed clinicians, scientists, and others interested in pain. This book superbly translates the plenary sessions delivered by these experts into an interesting compilation that will be appreciated by all, regardless of whether they attended the meeting or not. In particular, this book provides an excellent primer for those wishing to update their knowledge of a broad array of pain-related topics, from the basic sciences to psychology to methodology issues in pain research and quality improvement.

Prognostication Remains More an Art Than a Science

Larry D. Cripe — 2010-02-08

Prognosis in Advanced Cancer is a multiauthored volume, edited by Drs. Paul Glare and Nicholas Christakis, divided into three sections. The first section, “The Science of Prognostication,” consists of eight chapters that serve as part critique of the current prognostic activities of physicians and part primer to improve prognostication. The goal of the first section is a renaissance in the science of prognostication. The second and third sections are entitled “Prognostication in Specific Cancers” and “Prognosis in Palliative Care” and consist of 12 and 14 chapters, respectively. The apparent purpose of these chapters is to provide a brief summary of selected information about survival based on the specific type of cancer or a sentinel finding, such as spinal cord compression or hypercalcemia. The goals of the latter two sections are to provide information that may be useful in prognostication in specific situations. The overall goal of the book is “…to help physicians and other clinicians to improve their skills of prognostication near the end of life in patient [sic] with cancer…” And therein lies the potential relevance of this volume to the readership of this journal. However, I believe that the relevance of this volume is seriously diminished by several shortcomings. Thus, having completed my review of the book, I suspect I will neither consult it again nor recommend it to colleagues or students.

A Sourcebook for Pain-Related Research

Frederick Burgess — 2010-02-05

Although pain is the primary reason most patients will seek the assistance of a physician, the concept of pain as a sensation and as a disease remains confused in the minds of most patients and clinicians. Pain as a distinct disease state, maldynia, has been difficult to define and study. The uniquely subjective nature of pain, the highly variable individual response to pain, and the associated physical and emotional impact of pain on patients' lives creates a formidable challenge for the health care provider. As noted by the authors in Chapter 1, patients with pain have begun to exert greater autonomy in controlling and directing their care, in contrast to other more conventional disease-centered models, reflecting in part the difficulties encountered in measuring such a personal experience. This frequently leaves the health care provider in an uncomfortable and pressured position of trying to balance the risks and benefits of various treatment options without a clear set of objectively measurable parameters to guide therapy. As in other disease models, health care providers continue to seek reliable outcome measures to ensure that optimal care is being provided. Unfortunately, this has led to the propagation of a myriad of pain-related outcome measures, which are often population and diagnosis specific, with individual strengths and weaknesses, depending on the targeted physical, functional, or psychological measure. As a clinician and researcher, it is often difficult to sort out which tools are most appropriate for a given circumstance.

PC-FACS

2010-03-01