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Studies Comparing Numerical Rating Scales, Verbal Rating Scales, and Visual Analogue Scales for Assessment of Pain Intensity in Adults: A Systematic Literature Review

CONTEXT The use of unidimensional pain scales such as the Numerical Rating Scale (NRS), Verbal Rating Scale (VRS), or Visual Analogue Scale (VAS) is recommended for assessment of pain intensity (PI). A literature review of studies specifically comparing the NRS, VRS, and/or VAS for unidimensional self-report of PI was performed as part of the work of the European Palliative Care Research Collaborative on pain assessment. OBJECTIVES To investigate the use and performance of unidimensional pain scales, with specific emphasis on the NRSs. METHODS A systematic search was performed, including citations through April 2010. All abstracts were evaluated by two persons according to specified criteria. RESULTS Fifty-four of 239 papers were included. Postoperative PI was most frequently studied; six studies were in cancer. Eight versions of the NRS (NRS-6 to NRS-101) were used in 37 studies; a total of 41 NRSs were tested. Twenty-four different descriptors (15 for the NRSs) were used to anchor the extremes. When compared with the VAS and VRS, NRSs had better compliance in 15 of 19 studies reporting this, and were the recommended tool in 11 studies on the basis of higher compliance rates, better responsiveness and ease of use, and good applicability relative to VAS/VRS. Twenty-nine studies gave no preference. Many studies showed wide distributions of NRS scores within each category of the VRSs. Overall, NRS and VAS scores corresponded, with a few exceptions of systematically higher VAS scores. CONCLUSION NRSs are applicable for unidimensional assessment of PI in most settings. Whether the variability in anchors and response options directly influences the numerical scores needs to be empirically tested. This will aid in the work toward a consensus-based, standardized measure.

Short Form 36 (SF-36) health survey: Normative data from the general Norwegian population

Anchoring health-related quality of life (HRQOL) measures in population norms makes clinical interpretations more meaningful and is in accordance with practice in other fields of medicine. In this paper norms for the Short Form 36 (SF-36) are presented in a random sample, representative of the general Norwegian population. In addition, sociodemographic variables affecting the scale scores are explored and discussed. The response rate was 67%, being lowest among subjects aged 70 years or over. Data-completeness strongly declined with increasing age. Physical health scales were also strongly affected by age. In all scales, with the exception of general health perceptions, women reported having poorer health than men. Marital status affected the four mental health scales. Educational status affected all the scales, but the effect was smallest in the mental scales. These norms can be employed for comparison in case-control studies, or to interpret HRQOL changes in prospective studies. Differences in social status should be given special attention. Caution should be exercised when assessing subjective health or employing the norms among subjects aged 70 years or over.

Fatigue in the general Norwegian population: Normative data and associations

Population norms for interpretation of fatigue measurements have been lacking, and the sociodemographic associations of fatigue are poorly documented. A random sample of 3500 Norwegians, aged 19-80 years, was therefore investigated. A mailed questionnaire included the fatigue questionnaire (11 items) in which the sum score of the responses (each scored 0, 1, 2, 3) is designated as total fatigue (TF). Sixty-seven percent of those receiving the questionnaire responded. Women (TF mean=12.6) were more fatigued than men (TF mean=11.9), and 11.4% reported substantial fatigue lasting 6 months or longer. TF and age were weakly correlated (men: r=0.17; women: r=0.09). No firm associations between fatigue and social variables were found. Disabled and subjects reporting health problems were more fatigued than subjects at work or in good health. Fatigue is highly prevalent in somatic and psychiatric disorders, but is often neglected. This national representative sample provides age- and gender-specific norms that will allow for comparisons and interpretations of fatigue scores in future studies.

Translation and performance of the Norwegian SF-36 Health survey in patients with rheumatoid arthritis. I. Data quality, scaling assumptions, reliability, and construct validity

The SF-36 was translated into Norwegian following the procedures developed by the International Quality of Life Assessment (IQOLA) Project. To test for the appropriateness of the Norwegian Version 1.1 of the SF-36 in patients with rheumatoid arthritis (RA), 1552 RA patients were mailed the form. Psychometric methods used in previous U.S. and Swedish studies were replicated. The response rate was 66%. The sample (mean age 62 years, mean disease duration 13 years) was over-represented by females (79%). Totally, 74% of the questionnaires were complete. Missing value rates per item ranged from 0.4% to 9.0% (mean 4.2%). In the Role-Emotional scale, all three items had missing value rates above average and higher than reported in the U.S. and Swedish studies. Tests of scaling assumptions confirmed the hypothesized structure of the questionnaire, but results were suboptimal in the General Health scale. In all scales the Cronbachs alphas exceeded the 0.70 standard for group comparisons. In the Physical Functioning scale, Cronbachs alpha exceeded the 0.90 standard for individual comparisons. There was good evidence for the construct validity of the questionnaire. Generally, the Norwegian SF-36 version 1.1 distributed to RA patients held the psychometric properties found in other countries and in normal populations. The translations of items in the General Health and Role-Emotional scales were reassessed. Minor deficiencies were detected and changed (SF-36 Norwegian Version 1.2).

Pain in Parkinson's disease: Prevalence and characteristics

Abstract Parkinson’s disease is a chronic, progressive, incurable neurodegenerative disease. As the disease progresses, motor disturbances and non‐motor symptoms represent considerable illness burdens. Symptom relief is the goal for the treatment. Pain is frequently observed in patients with Parkinson’s disease, but its prevalence, characteristics and associations with Parkinson’s disease are poorly documented. These were investigated in 176 home‐living PD patients. They underwent a neurological examination and a structured interview for registration of pain characteristics in addition to responding to standardised questionnaires. Pain was reported by 146 (83%) patients. Compared to the general population, the Parkinson’s disease patients experienced significantly more pain as measured by SF‐36 Bodily Pain Scale. The average pain during the last 24 h measured by the Brief Pain Inventory was 2.85. Fifty‐three percent of the patients reported one, 24% reported two and 5% reported three pain types. Musculoskeletal pain was reported by 70%, dystonic pain by 40%, radicular‐neuropathic pain by 20% and central neuropathic pain by 10%. Thirty‐four percent were on analgesic medication. Pain was not associated with age, disease duration or severity of the disease; female gender was the only significant predictor of pain. Pain is frequent and disabling, independent of demographic and clinical variables except for female gender, and is significantly more common in Parkinson’s patients compared to the general population. A minority of the Parkinson’s disease patients with pain received analgesic medication. The findings call for improved attention to assessment and treatment of pain in the follow‐up of Parkinson’s disease patients.

The Norwegian brief pain inventory questionnaire: translation and validation in cancer pain patients.

The European Association of Palliative Care recommends the Brief Pain Inventory questionnaire (BPI) as a pain assessment tool in clinical studies. After translation into Norwegian, we administered the BPI to 300 hospitalized cancer patients. Cronbachs alphas were computed to assess reliability, and factor analysis was utilized to ascertain construct validity. The BPI interference and pain severity scales were validated against items on pain intensity and pain influence on daily function in the European Organization for Research and Therapy of Cancer (EORTC) QLQ-C30 questionnaire. In total, 235 patients (78%) were able to complete the BPI questionnaire, but 82 (35%) of these questionnaires had one or more missing items. Cronbachs alphas were 0.87 for the pain severity and 0.92 for the interference scales. A factor analysis identified three factors; pain intensity, interference with physical function, and interference with psychological functions/sleep. These three factors explained 82% of the variance. The correlation between BPI pain severity index and the EORTC QLQ-C30 item on pain intensity was 0.70 (P < 0.001). The correlation between BPI interference index and the EORTC QLQ-C30 item on pain influence on daily living was 0.62 (P < 0.001). We conclude that BPI has satisfactory psychometric properties, but is not completed by a significant proportion of patients. Further research is needed to establish pain assessment tools for patients unable to answer a comprehensive pain questionnaire, to establish routines for analysis of missing values, and to investigate if pain interference items also reflect disease-related impairment.

Hodgkin's Disease Survivors More Fatigued Than the General Population

PURPOSE To estimate the level of fatigue and frequency of fatigue cases among Hodgkins disease survivors (HDS) and compare them with normative data from the general population. PATIENTS AND METHODS A cross-sectional follow-up study was done of 557 HDS (age range, 19 to 74 years) treated at the Norwegian Radium Hospital from 1971 to 1991. The sample was approached by mail, and their data were compared with normative data from 2,214 controls (age range, 19 to 74 years) representative of the general Norwegian population. Of the 557 HDS, 459 (82%) responded. The mean age (+/- SD) at the time of study was 44+/-12 years, and the mean observation time was 12+/-6 years. The Fatigue Questionnaire (11 items) measures physical and mental fatigue. Two systems of scoring were used, dichotomized (0, 0, 1, and 1) and Likert (0, 1, 2, and 3). Total fatigue (TF) constitutes the sum of all the Likert scores. Caseness was defined as a total dichotomized score of > or =4 and fatigue that lasted 6 months or longer. RESULTS The HDS had significantly higher levels of TF than the controls (14.3 v 12.2) (P < .001). Fatigue among the HDS equaled that of the controls in poorest health. More HDS (61%) than controls (31%) reported fatigue symptoms lasting 6 months or longer (P < .001). Fatigue cases were more frequent among HDS (men, 24%; women, 27%) than among the controls (men, 9%; women, 12%) (P < .001). Disease stage/substage IB/IIB predicted fatigue caseness (P = .03). No significant associations were found between treatment characteristics and fatigue. CONCLUSION Hodgkins disease survivors are considerably more fatigued than the general population and report fatigue of a substantially longer duration.

Fatigue in palliative care patients — an EAPC approach:

Fatigue is one of the most frequent symptoms in palliative care patients, reported in .80% of cancer patients and in up to 99% of patients following radio- or chemotherapy. Fatigue also plays a major role in palliative care for noncancer patients, with large percentages of patients with HIV, multiple sclerosis, chronic obstructive pulmonary disease or heart failure reporting fatigue.This paper presents the position of an expert working group of the European Association for Palliative Care (EAPC), evaluating the available evidence on diagnosis and treatment of fatigue in palliative care patients and providing the basis for future discussions. As the expert group feels that culture and language influence the approach to fatigue in different European countries, a focus was on cultural issues in the assessment and treatment of fatigue in palliative care. As a working definition, fatigue was defined as a subjective feeling of tiredness, weakness or lack of energy. Qualitative differences between fatigue in cancer patients and in healthy controls have been proposed, but these differences seem to be only an expression of the overwhelming intensity of cancer-related fatigue. The pathophysiology of fatigue in palliative care patients is not fully understood. For a systematic approach, primary fatigue, most probably related to high load of proinflammatory cytokines and secondary fatigue from concurrent syndromes and comorbidities may be differentiated. Fatigue is generally recognized as a multidimensional construct, with a physical and cognitive dimension acknowledged by all authors. As fatigue is an inherent word only in the English and French language, but not in other European languages, screening for fatigue should include questions on weakness as a paraphrase for the physical dimension and on tiredness as a paraphrase for the cognitive dimension. Treatment of fatigue should include causal interventions for secondary fatigue and symptomatic treatment with pharmacological and nonpharmacological interventions. Strong evidence has been accumulated that aerobic exercise will reduce fatigue levels in cancer survivors and patients receiving cancer treatment. In the final stage of life, fatigue may provide protection and shielding from suffering for the patient and thus treatment may be detrimental. Identification of the time point, where treatment of fatigue is no longer indicated is important to alleviate distress at the end of life. Palliative Medicine 2008; 22: 13—22.

Quality of life in palliative care: principles and practice

In healthcare, most researchers and clinicians agree that quality of life (QOL) is related to symptoms, functioning, psychological and social wellbeing, and probably to a lesser extent to meaning and fulfilment. This multidimensional health-oriented concept has been named health-related quality of life (HRQOL). However, during end-of-life care spirituality and existential issues become more prominent, as well as family members’ perception of quality of care. Outcome measures in palliative care require constructs that reflect the specific goals of palliative care, such as improving QOL before death, symptom control, family support and satisfaction, as well as patients’ perceptions of ‘purpose’ and ‘meaning of life’. It is generally recommended that internationally developed and validated patient-rated multidimensional questionnaires should be used when assessing HRQOL in research. However, ‘multidimensionality’, with often more than 10 possible outcomes, is a threat both to statistical analysis and clinical interpretation of data. Preferentially, a more limited number of outcomes based upon the research question(s) should be defined prior to data collection in the study protocol. The researcher needs to carefully evaluate the content of the questionnaire, in addition to other properties, such as the validity and reliability, before the final decision is made with regards to which instrument to use in a given study.

Fatigue, Anxiety, and Depression in Long-Term Survivors of Testicular Cancer

PURPOSE To investigate the prevalence of chronic fatigue (CF), the levels of anxiety and depression, and the correlation between these conditions in long-term survivors of testicular cancer (TCSs). Occurrence of CF in TCSs is compared with findings in male survivors of Hodgkins disease (HDSs) and in males from the general population (GenPop). METHODS TCSs, HDSs, and two cohorts of the GenPop completed the Fatigue Questionnaire (FQ) and the Hospital Anxiety and Depression Scale (HADS) as part of a questionnaire survey. Cases of CF were identified according to published cut-offs, and the levels of anxiety (HADS-A) and depression (HADS-D) were calculated. RESULTS Among 791 TCSs, 16% displayed CF (HDSs, 24%; GenPop, 10%). In the age group younger than 30 years, the prevalence of CF was higher in TCSs than in the GenPop (P <.01). In TCSs, age, anxiety, depression, and comorbidity were independent predictors of CF. The mean HADS-A score in TCSs was significantly above the comparable figure of the GenPop and similar to that of HDSs. The mean HADS-D score in TCSs was below that of the GenPop. The highest and lowest mean scores of HADS-A and HADS-D were observed in the youngest TCSs. CONCLUSION The prevalence of CF is less in TCSs than in HDSs but exceeds that of the GenPop. Together with comorbidity and age, anxiety and depression predict CF in TCSs, warranting psychiatric intervention for cases of CF among TCSs. Anxiety is a larger problem in TCSs than depression, particularly among the youngest TCSs.