Highlights
- •Multiple indices characterizing patterns of pain intensity were derived from EMA.
- •How the EMA pain indices relate to patient functioning was examined in 10 studies.
- •Several indices uniquely contributed to functioning outcomes above average pain.
- •Alternative EMA pain indices can enhance understanding of patient functioning.
Abstract
Pain intensity is a complex and dynamic experience. A focus on assessing patients’
average pain levels may miss important aspects of pain that impact functioning in daily life.
In this second of 3 articles investigating alternative indices of pain intensity derived
from Ecological Momentary Assessments (EMA), we examine the indices’ associations
with physical and psychosocial functioning. EMA data from 10 studies (2,660 patients)
were reanalyzed to construct indices of Average Pain, Maximum Pain, Minimum Pain,
Pain Variability, Time in High Pain, Time in Low Pain, Pain after Wake-up. Three sets
of individual patient data meta-analyses examined 1) the test-retest reliability of
the pain indices, 2) their convergent validity in relation to physical functioning,
fatigue, depression, mental health, and social functioning, and 3) the incremental
validity of alternative indices above Average Pain. Reliabilities approaching or exceeding
a level of .7 were observed for all indices, and most correlated significantly with
all functioning domains, with small to medium effect sizes. Controlling for Average
Pain, Maximum Pain and Pain Variability uniquely predicted all functioning measures,
and Time in High Pain predicted physical and social functioning. We suggest that alternative
pain indices can provide new perspectives for understanding functioning in chronic
pain.
Perspective
Alternative summary measures of pain intensity derived from EMA have the potential
to help better understand patients’ pain experience. Utilizing EMA for the assessment
of Maximum Pain, Pain Variability, and Time in High Pain may provide an enhanced window
into the relationships between pain and patients’ physical and psychosocial functioning.
Key Words
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References
- Individual differences in the day-to-day experience of chronic pain: A prospective daily study of rheumatoid arthritis patients.Health Psychol. 1991; 10: 419-426
- The value of measuring variability in osteoarthritis pain.J Rheumatol. 2007; 34: 2132-2133
- An effect size for regression predictors in meta-analysis.J Educ Behav Stat. 2012; 37: 278-297
- Novel metrics in the longitudinal evaluation of pain data in sickle cell disease.Clin J Pain. 2017; 33: 517-527
- An inventory for measuring depression.Arch Gen Psychiatry. 1961; 4: 561-571
- Rhythmic variations in pain, stiffness, and manual dexterity in hand osteoarthritis.Ann Rheum Dis. 2002; 61: 1075-1080
- Cut-off points for mild, moderate, and severe pain on the visual analogue scale for pain in patients with chronic musculoskeletal pain.PAIN. 2014; 155: 2545-2550
- The accuracy of pain and fatigue items across different reporting periods.Pain. 2008; 139: 146-157
- The patient-reported outcomes measurement information system (PROMIS) developed and tested its first wave of adult self-reported health outcome item banks: 2005–2008.J Clin Epidemiol. 2010; 63: 1179-1194
- Which pain intensity scale from the Brief Pain Inventory correlates most highly with functional interference scores in patients experiencing taxane-induced arthralgia and myalgia?.Support Care Cancer. 2016; 24: 2979-2988
- Milnacipran for the treatment of fibromyalgia in adults: A 15-week, multicenter, randomized, double-blind, placebo-controlled, multiple-dose clinical trial.Clin Ther. 2008; 30: 1988-2004
- Trends in ambulatory self-report: The role of momentary experience in psychosomatic medicine.Psychosom Med. 2012; 74: 327-337
- Reliabilities of intraindividual variability indicators with autocorrelated longitudinal data: Implications for longitudinal study designs.Multivar Behav Res. 2018; 53: 502-520
- Core outcome measures for chronic pain clinical trials: IMMPACT recommendations.Pain. 2005; 113: 9-19
- Patient phenotyping in clinical trials of chronic pain treatments: IMMPACT recommendations.Pain. 2016; 157: 1851-1871
- A Monte Carlo simulation study of the reliability of intraindividual variability.Psychol Aging. 2012; 27: 560-576
- The clinical importance of changes in the 0 to 10 numeric rating scale for worst, least, and average pain intensity: Analyses of data from clinical trials of duloxetine in pain disorders.J Pain. 2010; 11: 109-118
- Effect of variability in the 7-day baseline pain diary on the assay sensitivity of neuropathic pain randomized clinical trials: An ACTTION study.Pain. 2014; 155: 1622-1631
- Associations between psychosocial factors and pain intensity, physical functioning, and psychological functioning in patients with chronic pain: A cross-cultural comparison.Clin J Pain. 2014; 30: 713-723
- Assessment of chronic pain: Domains, methods, and mechanisms.J Pain. 2016; 17: T10-T20
- Nonlinear oscillations in pain prediction accuracy: A dynamical systems approach to understanding daily pain prediction.Nonlinear Dyn Psychol Life Sci. 2010; 14: 27-46
- Peripheral and electrocortical responses to painful and non-painful stimulation in chronic pain patients, tension headache patients and healthy controls.Neurosci Lett. 2004; 361: 147-150
- Worst, average or current pain in the brief pain inventory: Which should be used to calculate the response to palliative radiotherapy in patients with bone metastases?.Clin Oncol. 2007; 19: 523-527
- Characterization and consequences of pain variability in individuals with fibromyalgia.Arthritis Rheum. 2005; 52: 3670-3674
- Measuring inconsistency in meta-analyses.BMJ. 2003; 327: 557-560
- More powerful procedures for multiple significance testing.Stat Med. 1990; 9: 811-818
- One day at a time: The impact of daily satisfaction with spouse responses on pain, negative affect and catastrophizing among individuals with rheumatoid arthritis.Pain. 2007; 131: 202-213
- Do depression and pain intensity interfere with physical activity in daily life in patients with chronic low back pain?.Pain. 2010; 150: 161-166
- The Hartung-Knapp-Sidik-Jonkman method for random effects meta-analysis is straightforward and considerably outperforms the standard derSimonian-laird method.BMC Med Res Methodol. 2014; 14: 25
- The measurement of clinical pain intensity: A comparison of six methods.Pain. 1986; 27: 117-126
- Increasing the reliability and validity of pain intensity measurement in chronic pain patients.Pain. 1993; 55: 195-203
- The West Haven-Yale Multidimensional Pain Inventory (WHYMPI).Pain. 1985; 23: 345-356
- Improved tests for a random effects meta‐regression with a single covariate.Stat Med. 2003; 22: 2693-2710
- Assessment of pain: A community-based diary survey in the USA.Lancet. 2008; 371: 1519-1525
- Testing the null hypothesis of stationarity against the alternative of a unit root.J Econometrics. 1992; 54: 159-178
- Momentary pain and coping in temporomandibular disorder pain: Exploring mechanisms of cognitive behavioral treatment for chronic pain.PAIN. 2009; 145: 160-168
- Ecological momentary assessment methodology in chronic pain research: A systematic review.J Pain. 2018; 19: 699-716
- The efficacy and safety of milnacipran for treatment of fibromyalgia. A randomized, double-blind, placebo-controlled trial.J Rheumatol. 2009; 36: 398-409
- Sidelining the mean: The relative variability index as a generic mean-corrected variability measure for bounded variables.Psychol Methods. 2018; 23: 690-707
- Investigating intraindividual pain variability: Methods, applications, issues, and directions.Pain. 2019; 160: 2415-2429
Muthén LK, Muthén BO: Mplus User's Guide. Los Angeles, CA, Muthén & Muthén, 1998-2017.
- What affects the completion of ecological momentary assessments in chronic pain research? An individual patient data meta-analysis.J Med Internet Res. 2019; 21: e11398
- Electronic diary assessment of pain, disability and psychological adaptation in patients differing in duration of pain.PAIN. 2000; 84: 181-192
- The CES-D scale: A self-report depression scale for research in the general population.Appl Psychol Meas. 1977; 1: 385-401
- Time-structured and net intraindividual variability: Tools for examining the development of dynamic characteristics and processes.Psychol Aging. 2009; 24: 778-791
- Using the delta method for approximate interval estimation of parameter functions in SEM.Struct Equation Model. 2004; 11: 621-637
- Introduction to Psychometric Theory.Taylor & Francis, New York, NY2011
- Patients' memories of painful medical treatments: Real-time and retrospective evaluations of two minimally invasive procedures.Pain. 1996; 66: 3-8
- Memories of colonoscopy: A randomized trial.Pain. 2003; 104: 187-194
- Meta-analysis of individual participant data: rationale, conduct, and reporting.BMJ. 2010; 340: c221
- Confidence intervals for the overall effect size in random-effects meta-analysis.Psychol Methods. 2008; 13: 31-48
- Individual differences in the day-to-day variability of pain, fatigue, and well-being in patients with rheumatic disease: Associations with psychological variables.Pain. 2012; 153: 813-822
- Temporal dynamics of pain: An application of regime-switching models to ecological momentary assessments in patients with rheumatic diseases.Pain. 2018; 159: 1346-1358
- Distinguishing between frequency and intensity of health-related symptoms from diary assessments.J Psychosom Res. 2014; 77: 205-212
- Ambulatory and diary methods can facilitate the measurement of patient-reported outcomes.Qual Life Res. 2016; 25: 497-506
- The analysis of real-time momentary data: A practical guide.in: Stone AA Shiffman S Atienza A Nebeling L The Science of Real-Time Data Capture: Self-Report in Health Research. Oxford University Press, Oxford, England2007: 76-113
- When is cancer pain mild, moderate or severe? Grading pain severity by its interference with function.Pain. 1995; 61: 277-284
- Habituation and sensitization to heat and cold pain in women with fibromyalgia and healthy controls.Pain. 2008; 140: 420-428
- A comparison of the assay sensitivity of average and worst pain intensity in pharmacologic trials: An ACTTION systematic review and meta-analysis.J Pain. 2018; 19: 953-960
- Examining the effects of perceived social support on momentary mood and symptom reports in asthma and arthritis patients.Psychol Health. 2014; 29: 813-831
Stone AA, Broderick JE, Goldman RE, Junghaenel DU, Bolton A, May M, Schneider S: Indices of pain intensity derived from ecological momentary assessments: Rationale and stakeholder interviews. J Pain, (under review). DOI: https://doi.org/10.1016/j.jpain.2020.08.003
- The experience of rheumatoid arthritis pain and fatigue: Examining momentary reports and correlates over one week.Arthritis Rheum. 1997; 10: 185-193
- Expanding options for developing outcome measures from momentary assessment data.Psychosom Med. 2012; 74: 387-397
- Validity of average, minimum, and maximum end-of-day recall assessments of pain and fatigue.Contemp Clin Trials. 2010; 31: 483-490
- Intensive momentary reporting of pain with an electronic diary: Reactivity, compliance, and patient satisfaction.Pain. 2003; 104: 343-351
- Variability of momentary pain predicts recall of weekly pain: A consequence of the peak (or salience) memory heuristic.Pers Soc Psychol Bull. 2005; 31: 1340-1346
- Variability of momentary pain predicts recall of weekly pain: A consequence of the peak (or salience) memory heuristic.Pers Soc Psychol Bull. 2005; 31: 1340-1346
- Patient non-compliance with paper diaries.BMJ. 2002; 324: 1193-1194
- Relations between adaptive and maladaptive pain cognitions and within-day pain exacerbations in individuals with fibromyalgia.J Behav Med. 2017; 40: 458-467
- Acceptance of the unpleasant reality of chronic pain: Effects upon attention to pain and engagement with daily activities.Pain. 2004; 112: 282-288
- Bias and efficiency of meta-analytic variance estimators in the random-effects model.J Educ Behav Stat. 2005; 30: 261-293
- Conducting meta-analyses in R with the metafor package.J Stat Software. 2010; 36: 1-48
- Outlier and influence diagnostics for meta‐analysis.Res Synthesis Methods. 2010; 1: 112-125
- Investigating inter-individual differences in short-term intra-individual variability.Psychol Methods. 2012; 17: 567-581
- Quality of life differs among headache diagnoses: Analysis of SF-36 survey in 901 headache patients.Pain. 2001; 89: 285-292
- The MOS 36-item short-form health survey (SF-36): I. Conceptual framework and item selection.Med Care. 1992; 30: 473-483
- Pain variability and its predictors in older adults: Depression, cognition, functional status, health, and pain.J Aging Health. 2013; 25: 1329-1339
- Development of a metric for a day of manageable pain control: Derivation of pain severity cut-points for low back pain and osteoarthritis.Pain. 2003; 106: 35-42
- The hospital anxiety and depression scale.Acta Psychiatr Scand. 1983; 67: 361-370
Article info
Publication history
Published online: October 23, 2020
Footnotes
This work was supported by a grant from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (R01 AR066200; A.A.S. and S.S., principal investigators).
A.A.S. is a Senior Scientist with the Gallup Organization and a consultant with IQVIA and Adelphi Values, Inc.
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© 2020 by United States Association for the Study of Pain, Inc.
