手术疼痛强度的评估
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摘要
目的：评价四种常用疼痛量表在我国患者手术后疼痛强度评估中应用的心理测量学特性及使用情况，为选用适合患者的疼痛强度评估工具提供客观依据。
对象：2002年9月至2003年1月广州市某三级甲等医院的173名择期手术的患者，年龄18～78岁，平均45.3±15.0岁。
方法：采用四种量表——直观模拟量表(VAS)、数字评定量表(NRS)、词语描述量表(VDS)和修订版面部表情疼痛量表(FPS-R)，术前评估患者记忆中最深刻的一次疼痛强度以及术后预期的疼痛强度。手术当天(day 0)至手术后第6天(day 6)的18：00～21：00依次用上述量表评估手术切口的当前疼痛强度、回顾一天以来的最重疼痛、最轻疼痛和通常疼痛强度。在day 6还评估手术7天以来的回顾性疼痛强度，了解患者的疼痛缓解情况及首选疼痛评估工具。
结果：四种量表有较好的信度与效度，组内相关系数均在0.83以上，各次评分间的所有相关系数均有统计学意义，但FPS-R与VDS间的相关性似乎最弱。当前和通常疼痛强度间的相关性较强，而最重与最轻疼痛强度间相关性较弱。四种量表对止痛干预均敏感。随着术后天数的延长，每种工具的评分显著下降，但day 0至day 3内，以及day0至day 2与day 4至day 6之间的评分有显著性差异。FPS-R的评分较其它量表略高，测量当前、最轻及通常疼痛时最敏感，而VAS较不敏感。测量最重疼痛时，VDS最敏感而NRS较不敏感。另外，首次使用量表评估回忆性疼痛时，错误应答率依次为VAS 12.3％、NRS 4.9％、FPS-R 2.5％、VDS0.8％；再次使用工具评估预期术后疼痛及实际的手术疼痛时各量
表的错误率均较低。工具首选率依次为FPS一R 48.1%、NRS 24.4%、
VDS 23.1%和VAS 3.8%。
结论:结果证实手术后疼痛的持续评估及有效处理非常重要，支
持四种疼痛量表均可用于我国成人主诉疼痛强度，但FPS一R在信
度、效度、错误率和首选率方面都是最合适的量表。合并FPS一R、
NRS和VDS三种量表设计而成的简易疼痛评估尺将是十分适合
临床使用的工具。
Objectives: The purposes of the study were to determine the psychometric properties and usability of four commonly used pain scales for the assessment of postoperative pain intensity in Chinese patients, and to provide reliable data for the selection of the right tools to assess pain intensity.
Subjects: From Sep 2002 to Jan 2003, one hundred and seventy-three patients undergoing scheduled surgery in a general hospital in Guangzhou participated in the study (age range 18-78 years, mean age 45.3 ?15.0 years).
Methods: Patients were tested preoperatively with four scales (Visual Analog Scale, VAS; Numeric Rating Scale, NRS; Verbal Descriptor Scale, VDS; and Faces Pain Scale Revised, FPS-R) to rate their remembered pain and expected postoperative pain. After operation, patients were interviewed in the evening (18:00 to 21:00) from the operative day (day 0) to the 6th postoperative day (day 6) to record their current pain intensity scores and retrospective ratings of worst, least and average pain levels on that day. On day 6, retrospective ratings over the 7 days were also obtained and the situation of pain relief and tool preference were investigated. Results: All the four scales showed good reliability and validity with the ICCs above 0.83, the correlation between ratings of each scales was statistically significant, but the correlation between the FPS-R and VDS appeared least significant. The correlation between current and average pain was stronger than that between the worst
and the least pain. All the four scales were sensitive for testing the efficacy of analgesic interventions. Although there was a significant decrease in scores with time on all scales, differences in scores were significant within day 3, between day 0 to day 2 and day 4 to day 6. FPS-R had higher pain scores, being the most sensitive scale for assessing current, least and average pain, while VAS was the least sensitive. When measuring the worst pain, YDS was the most sensitive and NRS the least sensitive. In addition, the error rate for the first time use of the scales to assess remembered pain was VAS 12.3%, NRS 4.9%, FPS-R 2.5% and YDS 0.8%, respectively. When used to assess the expected postoperative pain and actual postoperative pain, the error rates for each tool remained rather low. The tool preference was FPS-R 48.1%, NRS 24.4%, YDS 23.1% and VAS 3.8%, respectively.
Conclusions: The findings confirm the importance of ongoing assessment and effective management of postoperative pain and that all the four scales can be used for Chinese adults to report pain intensity, but FPS-R emerges as the best scale with respect to reliability, validity, error and preference rate. A mini pain assessment ruler that incorporates a FPS-R, NRS and YDS would be the most appropriate tool for clinical use.
对象：2002年9月至2003年1月广州市某三级甲等医院的173名择期手术的患者，年龄18～78岁，平均45.3±15.0岁。
方法：采用四种量表——直观模拟量表(VAS)、数字评定量表(NRS)、词语描述量表(VDS)和修订版面部表情疼痛量表(FPS-R)，术前评估患者记忆中最深刻的一次疼痛强度以及术后预期的疼痛强度。手术当天(day 0)至手术后第6天(day 6)的18：00～21：00依次用上述量表评估手术切口的当前疼痛强度、回顾一天以来的最重疼痛、最轻疼痛和通常疼痛强度。在day 6还评估手术7天以来的回顾性疼痛强度，了解患者的疼痛缓解情况及首选疼痛评估工具。
结果：四种量表有较好的信度与效度，组内相关系数均在0.83以上，各次评分间的所有相关系数均有统计学意义，但FPS-R与VDS间的相关性似乎最弱。当前和通常疼痛强度间的相关性较强，而最重与最轻疼痛强度间相关性较弱。四种量表对止痛干预均敏感。随着术后天数的延长，每种工具的评分显著下降，但day 0至day 3内，以及day0至day 2与day 4至day 6之间的评分有显著性差异。FPS-R的评分较其它量表略高，测量当前、最轻及通常疼痛时最敏感，而VAS较不敏感。测量最重疼痛时，VDS最敏感而NRS较不敏感。另外，首次使用量表评估回忆性疼痛时，错误应答率依次为VAS 12.3％、NRS 4.9％、FPS-R 2.5％、VDS0.8％；再次使用工具评估预期术后疼痛及实际的手术疼痛时各量
表的错误率均较低。工具首选率依次为FPS一R 48.1%、NRS 24.4%、
VDS 23.1%和VAS 3.8%。
结论:结果证实手术后疼痛的持续评估及有效处理非常重要，支
持四种疼痛量表均可用于我国成人主诉疼痛强度，但FPS一R在信
度、效度、错误率和首选率方面都是最合适的量表。合并FPS一R、
NRS和VDS三种量表设计而成的简易疼痛评估尺将是十分适合
临床使用的工具。
Objectives: The purposes of the study were to determine the psychometric properties and usability of four commonly used pain scales for the assessment of postoperative pain intensity in Chinese patients, and to provide reliable data for the selection of the right tools to assess pain intensity.
Subjects: From Sep 2002 to Jan 2003, one hundred and seventy-three patients undergoing scheduled surgery in a general hospital in Guangzhou participated in the study (age range 18-78 years, mean age 45.3 ?15.0 years).
Methods: Patients were tested preoperatively with four scales (Visual Analog Scale, VAS; Numeric Rating Scale, NRS; Verbal Descriptor Scale, VDS; and Faces Pain Scale Revised, FPS-R) to rate their remembered pain and expected postoperative pain. After operation, patients were interviewed in the evening (18:00 to 21:00) from the operative day (day 0) to the 6th postoperative day (day 6) to record their current pain intensity scores and retrospective ratings of worst, least and average pain levels on that day. On day 6, retrospective ratings over the 7 days were also obtained and the situation of pain relief and tool preference were investigated. Results: All the four scales showed good reliability and validity with the ICCs above 0.83, the correlation between ratings of each scales was statistically significant, but the correlation between the FPS-R and VDS appeared least significant. The correlation between current and average pain was stronger than that between the worst
and the least pain. All the four scales were sensitive for testing the efficacy of analgesic interventions. Although there was a significant decrease in scores with time on all scales, differences in scores were significant within day 3, between day 0 to day 2 and day 4 to day 6. FPS-R had higher pain scores, being the most sensitive scale for assessing current, least and average pain, while VAS was the least sensitive. When measuring the worst pain, YDS was the most sensitive and NRS the least sensitive. In addition, the error rate for the first time use of the scales to assess remembered pain was VAS 12.3%, NRS 4.9%, FPS-R 2.5% and YDS 0.8%, respectively. When used to assess the expected postoperative pain and actual postoperative pain, the error rates for each tool remained rather low. The tool preference was FPS-R 48.1%, NRS 24.4%, YDS 23.1% and VAS 3.8%, respectively.
Conclusions: The findings confirm the importance of ongoing assessment and effective management of postoperative pain and that all the four scales can be used for Chinese adults to report pain intensity, but FPS-R emerges as the best scale with respect to reliability, validity, error and preference rate. A mini pain assessment ruler that incorporates a FPS-R, NRS and YDS would be the most appropriate tool for clinical use.
引文
1 American Pain Society. Pain: the fifth vital sign. http://www.ampainsoc.org/advocacy/fifth.html995-l 1-11．
2 McCaffery M, Pasero CL. Pain ratings: the fifth vital sign [J]. Am JNurs, 1997,97(2) : 15-16．
3 Merboth MK, Barnason S. Managing pain: the fifth vital sign. Nurs Clin North Am, 2000,35(2) : 375-383．
4 Acute Pain Management Guideline Panel: Acute pain management in adults: operative or medical procedures and trauma. AHCPR Pub. No.92-0019, Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S.Department of Health and Human Services, 1992．
5 Clark FM, Szokol J, Kyu Koh E, et al. Pain control and postoperative outcome. Anesthesiology 2002, 97(4) : 1026．
6 Jamison RN, Ross MJ, Hoopman P, et al. Assessment of postoperative pain management: patient satisfaction and perceived helpfulness. Clin J Pain, 1997, 13(3) : 229-236．
7 Cohen FL. Postsurgical pain relief: patients' status and nurses' medication choices. Pain, 1980, 9(2) : 265-274．
8 Melzack R, Abbott FV, Zackon W, et al. Pain on a surgical ward: a survey of the duration and intensity of pain and the effectiveness of medication. Pain, 1987, 29(1) : 67-72．
9 Owen H, McMillan V, Rogowski D. Postoperative pain therapy: a survey of patients' expectations and their experiences. Pain, 1990, 41(3) : 303-307．
10 Zalon ML. Nurses' assessment of postoperative patients' pain. Pain, 1993, 54(3) : 329-334．
11 Carroll KC, Atkins PJ, Herold GR, et al. Pain assessment and management in critically ill postoperative and trauma patients: a multisite study. Am J Crit Care, 1999, 8(2) : 105-117．
12 Gillies ML, Smith LN, Parry-Jones WL. Postoperative pain assessment and management in adolescents. Pain, 1999,79(2-3) : 207-215．
13 Allcock N. Factors affecting the assessment of postoperative pain: a literature review. J Adv Nurs, 1996, 24(6) : 1144-1151．
14 Sjostrom B, Dahlgren LO, Haljamae H. Strategies in postoperative pain assessment: validation study. Intensive Crit Care Nurs, 1999,15(5) : 247-258．
15 Dahl JL. Effective pain management in terminal care. Clin Geriatr Med, 1996,12(2) : 279-300．
16 AGS Panel on Chronic Pain in Older Persons: The management of chronic pain in older persons. J Am Geriatr Soc, 1998, 46(5) : 635-651．
17 McCaffery M, Pasero C. Assessment: underlying complexities, misconceptions, and practical tools. In: McCaffery M, Pasero C. Pain: clinical manual. 2nd ed. St.Louis: Mosby, 1999． 35-102．
18 Hicks CL, von Baeyer CL, Spafford P, et al. The Faces Pain Scale-Revised: toward a common metric in pediatric pain measurement. Pain, 2001,93 (2) : 173-183．
19 Dalton JA, McNaull F. A call for standardizing the clinical rating of pain intensity using a 0 to 10 rating scale. Cancer Nurs. 1998, 21(1) : 46-49．
20 Briggs M, Closs JS. A descriptive study of the use of visual analogue scales and verbal rating scales for the assessment of postoperative pain in orthopedic patients. J Pain Symptom Manage, 1999, 18(6) : 438-446．
21 Jensen M, Chen C, Brugger A. Postsurgical pain outcome assessment. Pain, 2002, 99: 101-109.
22 Mom T, Bazin JE, Commun F, et al. Assessment of postoperative pain after laryngeal surgery for cancer. Arch Otolaryngol Head Neck Surg, 1998, 124(7): 794-798.
23 Gagliese L, Katz J. Age differences in postoperative pain are scale dependent: a comparison of measures of pain intensity and quality in younger and older surgical patients. Pain, 2003, 103(1-2): 11-20.
24 Aun C, Lam YM, Collett B. Evaluation of the use of visual analogue scale in Chinese patients. Pain, 1986, 25(2): 215-221.
25 赵继军，陆小英，赵存凤，等．数字疼痛量表和描述疼痛量表的相关性研究和改进[J]．现代护理，2002，8(9)：660-661．
26 陆宇晗．临床应用疼痛评估标尺的效果观察．实用护理杂志，1999，15(11)：36．
27 李漓，刘雪琴．护士疼痛知识掌握情况的调查．护理研究，2003，17(6)：633-635．
28 WANG X, Li T, Yu S, et al. China. Status of pain and palliative care. J Pain Symptom Manage 2002, 24(2): 177-179.
29 Huskisson EC. Measurement of pain. Lancet, 1974, 2(7889): 1127-1131.
30 Carlsson AM. Assessment of chronic pain. Ⅰ. Aspects of the reliability and validity of the visual analogue scale. Pain, 1983, 16(1): 87-101.
31 Hawksley H. Pain assessment using a visual analogue scale. Prof Nurse, 2000, 15(9): 593-597.
32 Jensen MP, Karoly P, Braver S. The measurement of clinical pain intensity: a comparison of six methods. Pain, 1986, 27(1): 117-126.
33 Hartrick CT. A four-category verbal rating scale (VRS-4) , an 11-point numeric rating scale (NRS-11) , and a 100-mm visual analog scale (VAS) were compared in the assessment of acute pain after oral surgery. Clin J Pain, 2001, 17(1) : 104-105．
34 Price DD, McGrath PA, Rafii A, et al. The validation of visual analogue scales as ratio scale measures for chronic and experimental pain. Pain, 1983,17(1) : 45-56．
35 Paice JA, Cohen FL. Validity of a verbally administered numeric rating scale to measure cancer pain intensity. Cancer Nurs, 1997, 20(2) : 88-93．
36 Bieri D, Reeve RA, Champion GD, et al. The Faces Pain Scale for the self-assessment of the severity of pain experienced by children: development, initial validation, and preliminary investigation for ratio scale properties. Pain, 1990, 41 (2) : 139-150．
37 McCaffery M. Choosing a faces pain scale. Nursing, 2002, 32(5) : 68．
38 Wong D, Baker C. Pain in children: comparison of assessment scales. Pediatr Nurs, 1988, 14(1) : 9-17．
39 Herr K, Mobily P, Richardson G, et al. Pain intensity assessment: use of experimental pain to compare psychometric properties and usability of selected scales in adult and older populations [abstract]. Annual Meeting of the American Society for Pain Management in Nursing, Orlando, FL, 1998．
40 Herr KA, Mobily PR, Kohout FJ, et al. Evaluation of the Faces Pain Scale for use with the elderly. Clin J Pain, 1998,14(1) : 29-38．
41 陈平雁，黄浙明．SPSS10． 0统计软件应用教程．北京：人民军 医出版社，2002． 139-148．
42 Jensen MP, Turner JA, Romano JM, et al. Comparative reliability and validity of chronic pain intensity measures. Pain, 1999, 83(2) : 157-162．
43 Liu WH, Aitkenhead AR. Comparison of contemporaneous and retrospective assessment of postoperative pain using the visual analogue scale. Br J Anaesth. 1991, 67(6) : 768-771．
44 Babul N, Darke AC, Johnson DH, et al. Using memory for pain in analgesic research. Ann Pharmacother, 1993, 27(1) : 9-12．
45 McCaffery M, Pasero C. Using the 0-10 pain rating scale. Am J Nurs, 2001, 101(10) : 81-82．
46 陆小英，赵存凤，张婷婷，等．“长海痛尺”在疼痛评估中的应用． 解放军护理杂志，2003，20(4) ：6-7．
47 Slaughter A, Pasero C, Manworren R. Pain control-unacceptable pain levels: approaches to prompting pain relief. Am J Nurs, 2002, 102(5) : 75-77．
48 Twycross R, et al. A survey of pain in patients with advanced cancer. J Pain Symptom Manage 1996, 12(5) : 273-282．
2 McCaffery M, Pasero CL. Pain ratings: the fifth vital sign [J]. Am JNurs, 1997,97(2) : 15-16．
3 Merboth MK, Barnason S. Managing pain: the fifth vital sign. Nurs Clin North Am, 2000,35(2) : 375-383．
4 Acute Pain Management Guideline Panel: Acute pain management in adults: operative or medical procedures and trauma. AHCPR Pub. No.92-0019, Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S.Department of Health and Human Services, 1992．
5 Clark FM, Szokol J, Kyu Koh E, et al. Pain control and postoperative outcome. Anesthesiology 2002, 97(4) : 1026．
6 Jamison RN, Ross MJ, Hoopman P, et al. Assessment of postoperative pain management: patient satisfaction and perceived helpfulness. Clin J Pain, 1997, 13(3) : 229-236．
7 Cohen FL. Postsurgical pain relief: patients' status and nurses' medication choices. Pain, 1980, 9(2) : 265-274．
8 Melzack R, Abbott FV, Zackon W, et al. Pain on a surgical ward: a survey of the duration and intensity of pain and the effectiveness of medication. Pain, 1987, 29(1) : 67-72．
9 Owen H, McMillan V, Rogowski D. Postoperative pain therapy: a survey of patients' expectations and their experiences. Pain, 1990, 41(3) : 303-307．
10 Zalon ML. Nurses' assessment of postoperative patients' pain. Pain, 1993, 54(3) : 329-334．
11 Carroll KC, Atkins PJ, Herold GR, et al. Pain assessment and management in critically ill postoperative and trauma patients: a multisite study. Am J Crit Care, 1999, 8(2) : 105-117．
12 Gillies ML, Smith LN, Parry-Jones WL. Postoperative pain assessment and management in adolescents. Pain, 1999,79(2-3) : 207-215．
13 Allcock N. Factors affecting the assessment of postoperative pain: a literature review. J Adv Nurs, 1996, 24(6) : 1144-1151．
14 Sjostrom B, Dahlgren LO, Haljamae H. Strategies in postoperative pain assessment: validation study. Intensive Crit Care Nurs, 1999,15(5) : 247-258．
15 Dahl JL. Effective pain management in terminal care. Clin Geriatr Med, 1996,12(2) : 279-300．
16 AGS Panel on Chronic Pain in Older Persons: The management of chronic pain in older persons. J Am Geriatr Soc, 1998, 46(5) : 635-651．
17 McCaffery M, Pasero C. Assessment: underlying complexities, misconceptions, and practical tools. In: McCaffery M, Pasero C. Pain: clinical manual. 2nd ed. St.Louis: Mosby, 1999． 35-102．
18 Hicks CL, von Baeyer CL, Spafford P, et al. The Faces Pain Scale-Revised: toward a common metric in pediatric pain measurement. Pain, 2001,93 (2) : 173-183．
19 Dalton JA, McNaull F. A call for standardizing the clinical rating of pain intensity using a 0 to 10 rating scale. Cancer Nurs. 1998, 21(1) : 46-49．
20 Briggs M, Closs JS. A descriptive study of the use of visual analogue scales and verbal rating scales for the assessment of postoperative pain in orthopedic patients. J Pain Symptom Manage, 1999, 18(6) : 438-446．
21 Jensen M, Chen C, Brugger A. Postsurgical pain outcome assessment. Pain, 2002, 99: 101-109.
22 Mom T, Bazin JE, Commun F, et al. Assessment of postoperative pain after laryngeal surgery for cancer. Arch Otolaryngol Head Neck Surg, 1998, 124(7): 794-798.
23 Gagliese L, Katz J. Age differences in postoperative pain are scale dependent: a comparison of measures of pain intensity and quality in younger and older surgical patients. Pain, 2003, 103(1-2): 11-20.
24 Aun C, Lam YM, Collett B. Evaluation of the use of visual analogue scale in Chinese patients. Pain, 1986, 25(2): 215-221.
25 赵继军，陆小英，赵存凤，等．数字疼痛量表和描述疼痛量表的相关性研究和改进[J]．现代护理，2002，8(9)：660-661．
26 陆宇晗．临床应用疼痛评估标尺的效果观察．实用护理杂志，1999，15(11)：36．
27 李漓，刘雪琴．护士疼痛知识掌握情况的调查．护理研究，2003，17(6)：633-635．
28 WANG X, Li T, Yu S, et al. China. Status of pain and palliative care. J Pain Symptom Manage 2002, 24(2): 177-179.
29 Huskisson EC. Measurement of pain. Lancet, 1974, 2(7889): 1127-1131.
30 Carlsson AM. Assessment of chronic pain. Ⅰ. Aspects of the reliability and validity of the visual analogue scale. Pain, 1983, 16(1): 87-101.
31 Hawksley H. Pain assessment using a visual analogue scale. Prof Nurse, 2000, 15(9): 593-597.
32 Jensen MP, Karoly P, Braver S. The measurement of clinical pain intensity: a comparison of six methods. Pain, 1986, 27(1): 117-126.
33 Hartrick CT. A four-category verbal rating scale (VRS-4) , an 11-point numeric rating scale (NRS-11) , and a 100-mm visual analog scale (VAS) were compared in the assessment of acute pain after oral surgery. Clin J Pain, 2001, 17(1) : 104-105．
34 Price DD, McGrath PA, Rafii A, et al. The validation of visual analogue scales as ratio scale measures for chronic and experimental pain. Pain, 1983,17(1) : 45-56．
35 Paice JA, Cohen FL. Validity of a verbally administered numeric rating scale to measure cancer pain intensity. Cancer Nurs, 1997, 20(2) : 88-93．
36 Bieri D, Reeve RA, Champion GD, et al. The Faces Pain Scale for the self-assessment of the severity of pain experienced by children: development, initial validation, and preliminary investigation for ratio scale properties. Pain, 1990, 41 (2) : 139-150．
37 McCaffery M. Choosing a faces pain scale. Nursing, 2002, 32(5) : 68．
38 Wong D, Baker C. Pain in children: comparison of assessment scales. Pediatr Nurs, 1988, 14(1) : 9-17．
39 Herr K, Mobily P, Richardson G, et al. Pain intensity assessment: use of experimental pain to compare psychometric properties and usability of selected scales in adult and older populations [abstract]. Annual Meeting of the American Society for Pain Management in Nursing, Orlando, FL, 1998．
40 Herr KA, Mobily PR, Kohout FJ, et al. Evaluation of the Faces Pain Scale for use with the elderly. Clin J Pain, 1998,14(1) : 29-38．
41 陈平雁，黄浙明．SPSS10． 0统计软件应用教程．北京：人民军 医出版社，2002． 139-148．
42 Jensen MP, Turner JA, Romano JM, et al. Comparative reliability and validity of chronic pain intensity measures. Pain, 1999, 83(2) : 157-162．
43 Liu WH, Aitkenhead AR. Comparison of contemporaneous and retrospective assessment of postoperative pain using the visual analogue scale. Br J Anaesth. 1991, 67(6) : 768-771．
44 Babul N, Darke AC, Johnson DH, et al. Using memory for pain in analgesic research. Ann Pharmacother, 1993, 27(1) : 9-12．
45 McCaffery M, Pasero C. Using the 0-10 pain rating scale. Am J Nurs, 2001, 101(10) : 81-82．
46 陆小英，赵存凤，张婷婷，等．“长海痛尺”在疼痛评估中的应用． 解放军护理杂志，2003，20(4) ：6-7．
47 Slaughter A, Pasero C, Manworren R. Pain control-unacceptable pain levels: approaches to prompting pain relief. Am J Nurs, 2002, 102(5) : 75-77．
48 Twycross R, et al. A survey of pain in patients with advanced cancer. J Pain Symptom Manage 1996, 12(5) : 273-282．