Saturday, February 10, 2018

The Pain Scale in Your Chart Note, using a Validated Tool: Focus on the Defense and Veterans Pain Rating Scale (DVPRS)

November 2017
Keywords:  documentation standards, pain scale, validated measurement tools for clinical work, SOAP note, metrics, clinical outcome measures, tracking outcomes, measuring change, visual analog scale (VAS), Defense and Veterans Pain Rating Scale (DVPRS), pain management

Topics:  documentation standards, SOAP note, clinical care, metrics, using validated tools, the Pain Scale in clinical use

update April 2018:  This information is now available as a mini-course, How to Use a Validated Pain Scale in Your Chart Note, in our online school.  100% of proceeds from the course go toward the Hospital-practice Handbook Project.

What this is: A discussion about using the Pain Scale
1.       what Pain Scale we use in clinical practice
2.       how to use one that is a validated tool, and
3.       why it matters. 

Focus today is on the Defense and Veterans Pain Rating Scale (DVPRS)

What is a pain scale?
The pain scale is what we clinicians use when we say to a patient: “how do rate your pain, on a scale of 1-10, 10 being high?”
However, what is less commonly discussed, is that this scale is not arbitrary.  It is a scale that has been validated through research.
There are two main pain scales that are free for clinical use in the U.S. that have been validated: 
1.       The Visual Analog Scale (VAS) and
2.       The Defense and Veterans Pain Rating Scale (DVPRS)

What does it matter if a scale has been validated through research studies? 
When a tool is validated through research it means that it has been tested thoroughly and often.  Its results are repeatable and can be consistently used to measure change.

Why does that matter?
If you are using a tool in clinical practice, you need it to be consistent so that, when change occurs, you can measure that change.
For example, you measure a child’s growth with a height chart.  Four cm on a height chart is a consistent measurement.  Johnny and Maggie both had growth spurts in the past 6 weeks.  Using the height chart, you determine how much they changed height.  Maggie grew 4 cm in 6 weeks and Johnny grew less, just 2 cm in 6 weeks.

A validated tool ensures the accuracy of its use within one patient (Maggie 6 weeks ago vs. today) and accuracy of its use to measure change across the population (in the 6-week time Maggie is growing faster than Johnny).

When you (practitioner) use a subjective tool, like a Pain Scale, you must apply it in a consistent way.  This means:

  • Ask the question the same way
  • Explain it the same way to each patient

“Given the opioid crisis and [EAMP]’s ability to treat pain, we as a profession need to consistently document patient pain levels.  And, of course, this is what L&I as well as most health insurance plans will pay for!” --Lisa Taylor-Swanson, Advisor, WEAMA L&I Committee
Using a Pain Scale in Clinical Practice, the L&I Acupuncture Pilot Project
The Washington East Asian Medicine Association (WEAMA) L&I Committee (and myself, as a former member of the committee) strongly recommend practitioners in the WA State L&I Acupuncture Pilot to use the DVPRS as their pain scale.  
·        It is a validated tool.  It has been validated in the military and veteran population, which is a similar population to the “working age” population of civilians in the workers’ comp system
·         It is free to use
·         It’s user-friendly
·        On the back of the scale are some simple biopsychosocial measures of health that pain affects:  activity, mood, sleep, and stress

Does WA L&I Require me to do this? [updated July 2019]
No.  However, it is: 

  • a biopsychosocial measure 
  • a tool validated by research
  • a patient-centered metric
  • it helps you measure subjective functional change 
  • and it fits well into L&I's "Healthy Worker 2020" goals. 

And using validated metrics as part of your clinical practice is just a usual part of professional practice standards. 

Why use this Pain Scale Tool?
  • Patients are coming in with a symptom of "pain", you measure pain.
  • Since you are already measuring it, use a validated tool.
  • Using a validated tool in your chart note template makes it consistent for your use and measurement.
  • When all practitioners in a program or clinic use the same tool and are using it in the same way, the tool becomes as consistent as that ruler when measuring change.
    • So, if someday in the future, say 2-5 years from now, your clinic or program does a retrospective data pull, looking at metrics collected in your chart notes, the validated tools you and your colleagues used would be useful data points for measuring change. 

How do I use the DVPRS as my pain scale in clinical work?
See this 4-minute video overview of what the DVPRS pain scale is and how to use it.
When you ask your patient, “How is your pain today?”, have a copy of the DVPRS nearby.  You can have a copy of it on your computer or printed and laminated as a visual tool in your treatment room—whichever helps you in your quest to use it consistently with every patient and every treatment.
  1. So, go here to print a copy of the DVPRS for yourself and your treatment space:  The DVPRS tool, both sides, with concise instructions  
    • I like to print it in color on paper with the visual scale on one side and the biopsychosocial quick questions on the back side and then laminate the double-sided tool.
    • If you want to print just one side at a time, without instructions, here is the front side and the back side.
  2. When you ask, “how is your pain today?”, 
    • hand the DVPRS visual tool to your patient to review and give you a descriptive answer.
    • The back side, the 4 questions (activity, sleep, mood, and stress) are there to prompt the practitioner to ask how the pain affects those aspects of life.

Why use both DVPRS and MEQ as metrics when you treat a Chronic Pain Condition?  
Applicable settings:  private practice, return-to-work clinic models, pain management

Disability questionnaires (like the ODI) and chronic pain scales (like a GCPS) can be challenged [by researchers, policy-makers, program directors, program-funders] as influenced by patient perception or by practitioner bias.  Bias or perception can be mitigated, however, when you have another tool (DVPRS pain scale) that can be compared to them.

For example, you have treated Ann who has mechanical low back pain with a course of acupuncture at 2 tx/week for 8 weeks and you measured, at specific points in treatment (initial, mid-tx re-evaluation, and discharge/re-evaluation), not just her pain level (DVPRS), but also her MEQ (during medication review), range of motion of the low back, and a functional questionnaire (ODI).  At the initial visit, her pain level was 8/10, MEQ was 70, ODI was 85% and she was not able to work due to the pain.  At the discharge visit, her pain level was 3/10 with no flare-ups for the past 2 weeks, MEQ is 0, ROM has improved 30%, and ODI is 20% and she will be starting work tomorrow.

This combination of metrics shows:
  1. her pain decreased
  2. her function has improved, and
  3. she is no longer dependent on opioid-based medications for pain relief or basic function
Because of this combination, she is already going back to full-time work, the same type of work, the same job, and able to operate machinery again.

So, because you used this combination of metrics, you are able to demonstrate to both the referring provider (or program director, department head, etc) that your clinical work has been clinically significant (30% or greater change in numbers) and it has been cost-effective. This patient, who is returning to her same job with no restrictions and good functional recovery, now has no or minimal long-term disability risks.

Review:  Using this combination of metrics, DVPRS + MEQ, is essential to be able to measure-ably demonstrate your patient care is clinically significant and cost-effective.

copyright Megan Kingsley Gale
Do not reproduce without author's written permission

Thank you
Thank you to Dr. Fujio McPherson and Dr. Lisa Taylor-Swanson for their help and support on this article.

The Short Course on Using the Pain Scale for Practitioners
Want to learn more about how to use this Pain Scale as a metric in your clinic's patient outcome measures toolkit?  Take our new mini-course, "How to use a validated pain scale in your Chart note".  It contains this post as a download-able pdf, some simple templates you may use for recording this tool in your chart note, as well as videos that walk you through how to use it, and information to dive deeper into related resources.

100% of the proceeds from this course go towards supporting the Hospital-practice Handbook Project.  Take the course and build the project with us!


Research, DVPRS validation study
Rosemary C. Polomano, Kevin T. Galloway, Michael L. Kent, Hisani Brandon-Edwards, Kyung “Nancy” Kwon, Carlos Morales, Chester ‘Trip’ Buckenmaier; Psychometric Testing of the Defense and Veterans Pain Rating Scale (DVPRS): A New Pain Scale for Military Population, Pain Medicine, Volume 17, Issue 8, 1 August 2016, Pages 1505–1519,

Research paper citation on history and usefulness of the older pain scales:  Visual Analog Scale (VAS), Graphic Rating Scale (GRS), and Numeric Rating Scale (NRS)

Haefeli, M, and Elfering, A. (2006). Pain assessment.  European Spine Journal, 15 (Suppl 1), S17-S24.

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