Pain, 14 (1982) 393-398

Elsevier Biomedical Press

393

Assessing Pain Behavior: The UAB Pain Behavior Scale

J. Scott Richards ‘3*, Cecilio Nepomuceno *, Maxine Riles * and Zehra Suer **

* Department of Rehabilitation Medicine, University of Alabama in Birmingham, Research and Training

Center-19, I71 7 Sixth Avenue South, Birmingham, Ala. 35233, and ** 1715. D Vestwood Court,

Birmingham, Ala. 35216 (U.S.A.)

(Received 20 January 1982, accepted 17 May 1982)

Summary

Review of the chronic pain literature reveals that there have been few systematic attempts to devise rating scales which reliably and/or validly quantify pain behav-

ior. The UAB Pain Behavior Scale was designed so that it could be administered rapidly by a variety of pain team personnel without sacrificing interrater reliability.

The scale is described along with initial reliability and validity data. A summary of

its use with chronic pain patients is presented.

The quantitative assessment of pain, an essentially subjective experience, is an elusive and complex undertaking. However, measuring the manifestations of pain, in

particular pain behavior, has proven a more feasible task. Behavioral approaches to the treatment of chronic pain have utilized operant techniques successfully to modify

and extinguish pain behavior [ 11. In such programs, however, pain behavior per se is

not typically systematically measured, but competing, mutually exclusive ‘well’

behaviors are measured instead such as walking, exercising, interacting socially and decreasing medication intake [l]. Others have attempted to measure pain behavior either directly [6] or indirectly through such measures as drug intake [2] or self-re- port [5]. Still others have focused on pain language as the major pain behavior to be monitored [4]. Quantification of pain behavior typically has taken the form of frequency estimates [7] or rating scales which have combined a number of pain behaviors [3]. To date, however, no scale has been published which is detailed, reliable and/or sensitive to small changes in observable pain behavior. The purpose

’ Please send requests for reprints to first author.

0304-3959/82/0000-0000/$02.75 0 1982 Elsevier Biomedical Press

lY4

of this paper is to describe such a rating instrument. the UAB Pain Behavior Scale, which is used in :tn operant-based inpatient treatment program for chronic pain

patients.

Rationale

In the operant treatment of pain it is clear that one is interested not only in reinforcing well behavior, but extinguishing pain behavior as well. These processes may not necessarily be mutually exclusive (e.g., the patient who increases his walking

substantially without ‘giving up’ his limp or cane). Pain behavior is often described

clinically, and there is probably close agreement between different pain centers and treatment staff of these centers as to what constitutes pain behavior. But validated

methods for the quantification of pain behavior. an important measure of treatment outcome, are lacking.

Recognizing the need for such a scale, its development was guided by several practical considerations: (1) given time constraints of hospital personnel, it should be able to be scored quickly, (2) it should be able to be used accurately by a variety of pain team personnel. (3) interrater reliability must be high, and (4) it must be a

valid measure of pain behavior.

Content

The UAB Pain Behavior Scale with criteria for scoring is presented in Fig. 1. The scale consists of 10 target behaviors, each of which contributes equally to the total

score, hence a range of possible scores from 0 to 10. This set of 10 target pain

behaviors has been culled from a larger list and represents what to the authors were among the most salient. reliably measurable and frequently observed pain behaviors in a chronic pain population.

Verbal and non-verbal vocal complaints are treated as separate behaviors, the latter consisting of moans, groans, gasps and/or similar vocal but non-verbai pain complaints. Ratings are based on frequency estimates for both of these variables: none (0), occasional (l/2) and frequent (1). Downtime is defined as amount of time per day spent reclining or lying down because of pain between the hours of 8 a.m. and 8 p.m. Patients are asked to learn to make the distinction between downtime for

pain and downtime for other reasons (e.g., boredom, fatigue, etc.). Sixty minutes or greater downtime per day is given the maximum score for this variable. This is

admittedly an arbitrary cut-off point which reflects the realities of our program: it is

difficult for patients active in the program to greatly exceed 60 min downtime per day. The Fourth category, facial grimaces, is again judged on frequency. Standing posture and mobility, the fifth and sixth categories, are judged on the basis of distorted posture and limping and/or labored walking, respectively. Body language. the seventh category, refers specifically to how often the patient clutches or rubs the site of his/her pain. The eighth category reflects the use of visible supportive

Patient ___

Room x_

Rater _“.

1. vocal Complaints: Verbal

2. Vocal Complsints: Non-Verbal

(moans. groans, gasps, etc.)

3. DUWl-time:

{Time spent tying down per day because of pain : 8 a.m.4 p.m.)

4. Facial Grimaces: ~--

Mild andfor infrequent

Severe and/or frequent

5. Standinq Pasture:

6. Mobility: __x-

7.

6.

9.

IO.

Body LJngwg --

(cfutctiing. rubbing site of pain)

usuf! ortivq equipment: !Ii. //%$I : Iii/,

Itches, cane, leaning on None 0’0 0 0 0~0~0~0~0 OiO/O/O

/i/I/ I! I!

Use of visib

(braces. crt furniture, TENS, etc.) Do not scora if equipment prescribed.

Stationa_ry movement;

Occasional shifts of position

Constant movement, position shifts

gIjaI None

Non-oorcotic analgesic and/or psychogenic medications as prescribed.

Demands far increased dosrge or frequency. rndlor rWCotiC$, aodlor medication abuse.

TOTAL

THE UA8 PAIN f3EHAVIOR SCALE W-lf3

DATE

None

Occasional

Frequent

None

Occasional

Frequent

None

O-60 min

>&I min

None

Occasional

Dependent; constant use

Sits or stands still

Fig. 1‘ The UAB Pain Behavior Scale (O-IO>.

eyuipment. An invisible brace. for exampfe. a.-ould not be scored ;rs ;I pawn behavior in this category, the rationale being that an\: supportive e~uip~l~~~~t which is nctt

visible cannot therefore signal others in the ~~~~~~~~n~~~tlt as to the patient’s condi- tion. Visible braces, canes, crutches, ieaning on furniture or people, 311 act 3s

potential visual flags for others in the patient’s environment and thereftrrcr make the ‘pull’ to reinforce the pain role that much stronger. Use of these supportive devices is not counted as pain behavior, however, if they are physician-prescrihedl, The ninth

category, stationary movement. measures how often a patient shifts position while

sitting or standing. The tenth category reflects pain medication behavior. One-half

point is given if the patient is taking non-narcotic analgesics and/or psychogenic medications (typically anti-anxiety or anti-depressant medications) a> prescribed.

Demands for increased or more frequent dosages. medication abuse (e.g., suspected

supplementing with alcohol and/or patient’s own medication source] and/or the use of narcotics (even if prescribed) earn a full point.

Procedures

The UAB Pain Behavior Scale as we have used it is administered in a standar- dized fashion. Fain behavior is assessed during early morning pain team rounds by a trained staff nurse. She observes the behaviors emitted by the patient as he/she interacts with the pain team. The patient is greeted by the pain team leader, activity levels and downtime from the previous day are recorded, and goals for the present

day established. Patients are observed when asked to walk a short distance and stand momentarily. They are also observed as they move from a sitting to a standing position. and vice versa. Questions or concerns raised by the patient are addressed.

The total process typically takes 5 min per patient. which provides sufficient time and behavioral sampling for the entire rating to be completed.

The UAB Pain Behavior Scale can be rapidly scored and has been used accurately

in our setting by pain team staff representing a number of disciplines: psychology, nursing, social work, medicine, occupational and physical therapies. Minimal train- ing is needed to achieve an adequate level of accuracy.

Interrater reliability estimates of the total scores &tween 3 trained raters (psy-

chologist, nurse, medical student) were quite satisfactory: 0.94. 0.96 and 0.94, for an average interrater reliability of 0.95 (P < 0.01). Initial inter-rater reliabilities were

lower (0.7-0.8) but reliability increased substantially over a short time as consensual definitions of the various pain categories were developed, e.g., how much of a limp constitutes a ‘mild limp.

Test-retest refiabihty was determined by recording the total pain behavior scale

397

score for 50 patients on 2 consecutive days and correlating those data across

patients. The test-retest reliability coefficient was 0.89 (P < 0.01, 48 df), suggesting a high degree of stability for pain scale scores across short time intervals in which one would not a priori expect large changes in pain behavior.

In a second sample of 70 patients who completed a 2 week inpatient operant-based pain treatment program, pain behavior scores ranged the full length of the scale from 0 to 10. Average pain behavior in this program, which is designed to reduce

pain behavior, was 5.4 at admission and 3.2 at discharge (f test, P < 0.05. 69 df). As was stated earlier, there are no other well-validated scales for assessing pain

behavior, hence assessing validity of the present scale by correlating it with similar measures was not possible. Instead, the scale was compared to two related sets of

measures: self-report measures of pain and well behaviors.

The two self-report measures chosen were the McGill Pain Questionnaire [4] and the O-10 analog scale [8] used by patients in the UAB pain program. For the McGill Questionnaire, the total number of pain descriptors endorsed by the patient at admission was selected as the variable for analysis. The correlation between the McGill and UAB Pain Behavior Scale scores at admission was 0.17 (not significant).

The correlation between patient self-reports of pain (O-10) and the UAB Pain

Behavior Scale was 0.16 (not significant) at admission and 0.55 at discharge (P < 0.05, 68 df). These data suggest that the relationship between observable

manifestations of pain (behavior) and self-report of pain (subjective experience) is

not generally a close one, although a closer correlation may be approximated toward discharge. These data appear to reflect what is often seen clinically with chronic pain

patients: a marked discrepancy between what they report (experience) and what they ‘show,’ the former being affected by such factors as anxiety, depression, the need to impress treating staff with the gravity of their complaints, etc. The opposite pattern is also seen, but less frequently: the stoical refusal to display any behavioral evidence of subjectively experienced pain. In both cases the result is a low correlation between subjective reports and visible manifestations of pain.

The relationship between well behavior and pain behavior would seem a priori to

be an inverse one, although as mentioned earlier, the extent to which they in fact are mutually exclusive can be questioned. In a random sample of pain patients, daily measures of the ‘well behaviors’: walking, biking, sitting and standing were corre- lated with pain behavior as assessed by the UAB Pain Behavior Scale. Correlations

were respectively - 0.30; - 0.10; -0.29; and -0.38; all coefficients (except the second) reaching statistical significance (P < 0.05, 48 df). The correlations are negative as expected, supporting the assumption that pain and well behaviors are inversely related. The fact that the correlations are not higher than they are,

however, underscores the point that they are not mirror images. Patients do show increases in well behavior in operant-based treatment programs, but this may not necessarily be accompanied by equivalent decreases in pain behavior (e.g., the patient who becomes much more mobile but continues to seek medication and complain of pain). This further underscores the need for multiple outcome measures

in pain control programs: e.g., self-report. well behavior. and pain brhavlor as the\e measures do not appear to be highly correlated with each other and are apparentl? tapping different dimensions of the pain experience.

Discussion

The UAB Pain Behavior Scale is a quick. reliable. simple but valid method for quantifying pain behavior. The categories of pain behavior chosen are not sacred,

and some of the cut-off points were arbitrarily chosen and clearly reflect the needs of our program. Other cut-off points and/or behavioral categories could be sub-

stituted as program needs or patient populations dictate. As the scale presently

exists. all categories of pain behavior are equally weighted in their contribution to

the total score. although future research may suggest a differential weighting 01 behavioral categories on the basis of salience for the observer and/or resistance to

extinction. It might also be possible to use the scale to characterize different types of pain in terms of the various behavioral categories. A person with a migraine headache and a person with chronic low back pain could both have identical pain behavior scores for example. but the specific pain behaviors they manifest would

clearly be different.

The UAB Pain Behavior Scale has proven helpful in our center for staff training. teaching new pain team staff to become acutely a\vare of pain bcha\ior. This ia ;I

necessary step in the training of any staff in an operant-based program. Such persons must first be aware of what pain behavior consists before being in a position

to bc non-reinforcing of it. Finally. the UAB Pain Behavior Scale has proven helpful as one of several measures we use to evaluate treatment outcome. We present it as a working tool in the hope that it will prove useful in identical or modified form to others in similar behaviorally oriented pain trsatment programs.

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