Measuring Chronic Pain: Methods, Implications, and Purposes

Marlena Norwood
I BACKGROUND
Due to its impact on the individual and society, chronic pain is a significant public health issue
(Loeser, 1991). In order to effectively address the issue, chronic pain must be measured. According to
current measures, chronic pain is very prevalent throughout the globe, and especially in the United States
(IHME, 2013). But how accurate are these measures? How can pain measurements be obtained?
In seminar, Dr. Sullivan discussed the transformation of how pain has been viewed in society.
First, pain was thought of as having a what element, a how element, and a why element (Sullivan,
2014). Next, with influence from Descartes, pain was reduced to the what element and the how
element: the social context of the why, was removed (Sullivan, 2014). Lastly, and reflecting modern day
perceptions of pain, we are left with only the what element: modern biomedicine asks us what hurts
rather than how and why it hurts (Sullivan, 2014; Loeser, 1991).
A parallel from Dr. Sullivans continuum can be made to a continuum of measurements of pain.
Following Loesers Onion, pain can be conceptualized as beginning as nociception, perceived as
pain/suffering, and manifested in observable pain behaviors (Loeser, 1991). Pain can, and has been
attempted to be, measured at each of these stages. The parallel is made that as one moves from
measures of nociception to measures of pain behaviors, pain moves from objective to subjective,
becoming more situated in its social and environmental context.
In, What is Chronic Pain?, Dr. Loeser outlines this continuum from nociception to pain behaviors,
and he discusses difficulties in measuring chronic pain. This ensuing analysis further explores claims made
by Loeser in What Is Chronic Pain?, and introduces many additional points of consideration in measuring
chronic pain. I explain various ways that pain can be measured at each stage of the continuum of
objective to subjective, from nociception to pain/suffering to pain behaviors, and the implications
associated with each of the conceptual ways of viewing each stage as an accurate measurement of pain.
Each type of pain measurement may measure one or both of two things: (1) pain severity (acute and
chronic measures included), and (2) overall prevalence of chronic pain. I discuss in-depth the advantages
and disadvantages of surveys that capture both measurements at the level of pain/suffering and at the
level of pain behaviors. I conclude by considering how measures of chronic pain should differ based on
the intended use of the measurement: (1) for health care systems planning, (2) for descriptive
epidemiology, and (3) for inferential epidemiology.
II NOCICEPTION
Medical advances have perpetuated the notion that pain can be completely objectified: if I
experience identical environmental stimulus as you, we will feel the same amount of pain (Loeser, 2014).
This theory has been manifested in measuring pain at the moment of encounter between stimulus and
pain receptor (Loeser, 1991).

Von Frey, Hargreaves, and CatWalk

Von Frey filaments are synthetic fibers used to examine pain thresholds in animals and humans.
They are used commonly in pain research and they are constantly being improved upon (Fruhstorfer,
Gross, and Selbmann, 2001). The Hargreaves method similarly objectifies pain measures, but this time
through the use of heat stimuli (Banik and Kabadi, 2013). Paw withdrawal threshold temperatures can
be assessed to determine how much heat stimuli it takes for nociception (Banik and Kabadi, 2013, 41-42).
CatWalk automated gait analysis measures pain by using a computerized method for assessing different
gaits in animals with a chronic constriction injury (Vrinten and Hamers, 2003).
There are many problems with these measurements of pain. First, they strip pain of its subjective
context, assuming the biomedical model of pain rather than the biopsychosocial. Second, chronic pain is
not caused by tissue damage, which is the basis of von Frey filaments, the Hargreaves method, and
CatWalk automated gait analysis (Loeser, 1991). Additionally, acute pain caused by tissue damage is not
generalizable to chronic pain. If a threshold is determined by the Hargreaves method on a human for
how much stimulus produces nociception, it is not generalizable to chronic pain because of a
fundamental flaw: the human being experimented on knows that they can stop the pain at any point
whereas someone with chronic pain sees no immediate end in sight (Sullivan, 2014). Lastly, all of these
measures are primarily tested on animal models. Although animals may offer some insight into pain
measurements, animal models are not always generalizable to humans.
The fMRI
Functional magnetic resonance imaging also attempts to objectify pain, but this time through
analyzing the brain. In a recent study published in the New England Journal of Medicine, researchers used
fMRIs experimentally to determine neurologic signatures for painful heat stimuli (Wagner et al, 2013).
The end goal of experimental fMRIs is that once a neurologic signature is determined for a certain
threshold of pain, the fMRI could be used in the clinical setting to replace, or supplement patient selfreports of acute or chronic pain (Sullivan, 2014).
Wagner et al argue that the fMRI is a valuable tool in assessing pain because self-reports of pain
are an imperfect measure of subjective experience (Wagner et al, 2013, 1389). Dr. Sullivan argues the
opposite: that since pain is a subjective experience, subjective self-reports are immensely more accurate
than any type of pain objectification (Sullivan, 2014). Brains do not contain or feel pain, people do
(Sullivan, 2014). In the same way, bodies do not feel pain, only people do. Thus, when someone has some
kind of injury or impairment, it is not guaranteed that they will have pain associated with that injury or
impairment. Dr. Sullivan claims that large numbers of people with bulging disks, that normally cause
severe back pain, do not have back pain (Sullivan, 2014). Pain cannot be separated from the whole
person; therefore, any measure that attempts to objectify pain at the basis of nociception, the brain, or
the body, are inherently flawed.
III PAIN AND SUFFERING
It is difficult to parse apart pain and suffering in Loesers Onion as separate entities, so for the
purposes of measurement, they are lumped together. If measuring pain at the level of nociception, the
brain, and the body is inherently flawed because pain is a subjective experience, then we must use

measures that attempt to capture the subjective experience of pain such as patient self-reports and
observational pain scales. If an individual receives a stimulus identical to another person, they will
perceive that pain in different ways because of their environmental context (Loeser, 2014). For example,
it has often been observed that soldiers in battle who lose limbs do not feel pain because they are so
excited to be leaving the battlefield and going home (Loeser, 2014; Loeser, 1991). Although pain and
suffering cannot be measured, they can be inferred from one person to another (Loeser, 1991).
Factors Involved in the Subjectivity of Pain Experience
Social-ecological factors greatly influence the perception of pain (Loeser, 2014). Subsets of the
population differ in prevalence of chronic pain: there is disparity in the prevalence of chronic pain
between different racial and ethnic groups (Mossey, 2011) and risk factors, such as intimate partner
violence, causing certain individuals to be at a higher risk of developing chronic pain (Wong and Mellor,
2014). But more importantly, social-ecological factors must be preserved in pain measurements because
they influence an individuals perception of their pain. Prior attitudes towards and beliefs about pain
influence pain perceptions (Miro, Huguet, and Jensen, 2014). In a study of veterans, those with substance
abuse issues and/or post-traumatic stress disorder perceive[d] a higher level of pain than veteran
counterparts with chronic pain who did not have substance abuse issues or PTSD (Randleman, Douglas,
DeLane, and Palmer, 2014, 79).
As demonstrated, peoples past and current socio-environmental contexts influence their
perception of pain: the subjectivity of pain therefore must be preserved rather than using one of the
objective measures previously discussed. Self-report scales offer a way of measuring pain that preserves
the subjectivity of the human pain experience. Though factors such as recall bias make self-reported pain
measures less than ideal (Loeser, 1991), they provide valuable measures that preserve the subjectivity of
pain.
Self-Report Pain Scales
There are a variety of self-report pain scales, and the majority of the published literature focuses
on that of children, including word-graphic rating scales, Faces Pain Scale-Revised, and the Color Analog
Scale (Tsze, von Baeyer, Bulloch and Dayan, 2013; Telser et al, 1991). These scales focus on pain intensity
associated with an acute condition (Tsze, von Baeyer, Bulloch and Dayan, 2013). However, the reliability
of pain scales such as these in children relies on the developmental stage of the child, since children at
different developmental stages use different vocabulary to describe their pain (Tsze, von Baeyer, Bulloch
and Dayan, 2013; Stanford, Chambers, and Craig, 2005).
Literature on childrens chronic pain indicates a big difference in reporting of pain between
ethnicities. It is important when assessing pain in children of different ethnicities to acknowledge that
there are cultural differences in the communication and perception of pain (Fortier, Anderson, and Kain,
2009). For example, Latino children with chronic pain may be less likely to report their pain than nonLatino children (Fortier, Anderson, and Kain, 2009).
Often times when the patient is unable to self-report, observational pain scales are used.
However, in a review of the reliability and validity of twenty observational pain scales for children aged 318, none were recommended for chronic pain patients because of the tendency for chronic pain patients
observable behaviors to habituate or dissipate as time passes, despite continued self-reported pain

(von Baeyer and Spagrud, 2006, 146). I will return to self-reported pain measurements and implications in
section V when considering surveys and questionnaires.
IV PAIN BEHAVIORS
Observational pain scales hint at the idea of measuring pain via pain behaviors: anything a
person does or does not do that you and I would interpret as likely to be due to tissue damage, such as
moaning, grimacing, talking about pain, limping, lying down, refusing to work, going to doctors, etc.
(Loeser, 1991, 217). Pain behaviors are all real and they are all quantifiable, which makes them ideal
candidates for measurement purposes (Loeser, 1991, 217). The measurement of pain behaviors moves
farthest in the direction of subjectivity because it takes into even greater consideration the
environmental influences on an individual. Pain behaviors can be used to measure the intensity of chronic
pain, such as most of the measurements described earlier, but they can also be used to attempt to
measure the prevalence of chronic pain in populations.
Three potential ways to measure pain behaviors are through: (1) chronic pain diagnoses records,
(2) opioid/other pain medication prescription/consumption, and (3) claims for disability. These measures
together, in theory, address both the severity and prevalence of chronic pain, and they are potentially all
available from medical records. Clinics have information about diagnoses of chronic pain that address the
prevalence of chronic pain and they have information about pain medication prescriptions such as
opioids that could potentially address both the severity and prevalence of chronic pain. Likewise,
physicians may have access to claims for disability, since those claims need to be substantiated by
medical diagnoses (U.S. Social Security Administration, 2014).
There are a few problems with these measures. First, although clinics may have information
about diagnoses for disease: (1) depending on a physicians specialty, they may be more apt to diagnose
chronic pain as something else related to their own field (Loeser, 1991; Loeser, 2014), (2) case definitions
of chronic pain often vary (Huser et al, 2014; Kurita et al, 2012), and (3) using diagnoses to estimate the
prevalence of chronic pain does not account for individuals with chronic pain that do not seek treatment
(Loeser, 1991).
Second, although many people may use opioids to manage chronic pain, opioid consumption may
not be an accurate measure for severity or prevalence of chronic pain. For example, in a study comparing
chronic pain prevalence and opioid consumption in two subsets of a Danish population, the researchers
found an inverse relationship: one subset had the higher chronic pain prevalence and the other subset
had the higher opioid consumption (Kurita et al, 2012). This may be due to differential access to pain
management resources, barriers to health care, and overall attitudes of health care providers (Kurita et
al, 2012).
Lastly, disability claims are subject to the same faults as diagnoses for disease, namely that case
definitions of chronic pain, and physician specialties, vary. Measures that take into account disability have
another problem: disability depends on the environment (Loeser, 2014; Loeser, 1991). Impairment is
something that is objective - if someone loses a limb they have impairment because they have a loss of
psychological, physiological, or anatomic structure or function (Loeser, 1991, 217). But the extent to
which someone that loses that limb is disabled depends entirely on their environment: do they need that
limb to carry out basic tasks, or does that persons everyday home and work life remain unaffected by the

loss of that limb (Loeser, 2014)? Thus, depending on someones work environment, and socio-ecological
environment, disability for the same impairment of chronic pain, and thus disability claims, will vary
drastically.
Although they may paint some of the picture of prevalence and intensity of chronic pain, presentday health records of diagnoses, opioid prescription/consumption, and claims for disability, are an
imperfect data source.
V SURVEYS AND QUESTIONNAIRES
A common method to measure pain is the use of surveys or questionnaires. Surveys do not fit
into the category of only self-reported pain/suffering because they can contain measurements of both
pain/suffering and self-reported pain behaviors. In a cross-sectional survey in a German population,
researchers were able to obtain many common measurements to assess both prevalence and severity of
chronic pain (Huser et al, 2014). The survey included information on chronic pain symptoms, stages of
chronic pain (or severity of pain), and utilization of health care services (Huser et al, 2014). It also
included days of work missed, disability, doctor visits, and days spent in the hospital (Huser et al, 2014).
Survey/Questionnaire Wording Discrepancies
This survey is important, not only for identifying the prevalence of chronic pain in the target
population, but also for assessing the validity of surveys as a measure of chronic pain. The researchers
notice that there is considerable discrepancy from study to study regarding the prevalence of chronic
pain in the same location (Huser et al, 2014). In analyzing these studies, they found that the prevalence
of chronic pain was determined by the way that questions about chronic pain were phrased (Huser et al,
2014). For example, Canadian surveys asked the question, Are you usually free of pain or discomfort?
whereas the German survey asked more specifically about pain within the last seven days and if the
symptoms had persisted for at least three months (Huser et al, 2014).
Because of this observed difference, the researchers call for a standardization of survey questions
for chronic pain in order to have data consistency (Huser et al, 2014). The researchers recommended
the survey they used, the Short Form Health Survey to be considered as the standardized measure, and
that measures must include the severity of chronic pain, measured through the stages of chronic pain
questions in the survey (Huser et al, 2014).
Survey/Questionnaire Characteristics
Standardized survey instruments are incredibly important, not only because the wording of
questions can influence responses, but also because the placement of questions and the length of the
whole survey can influence responses (Hanlon, 2014). In a survey of household expenditures, researchers
from the University of Washington Institute for Health Metrics and Evaluation (IHME) noticed that two
separate surveys in the Philippines in 2003 estimated two very different shares of household health
expenditure: 1.3% versus 7.7%, health expenditure questions being only one component of the survey of
total household expenditures (Lavado, Brooks, and Hanlon, 2013, 519).
The researchers found that certain survey characteristics would influence the share of household
health expenditure reported by survey respondents. For example, a one unit increase in the number of

health questions was correlated with a 1% increase in household health expenditure share (Lavado,
Brooks, and Hanlon 2013, 521). The more specific and prevalent the questions on health expenditure
were, the more survey respondents reported spending on health. Conversely, if the whole survey was
longer in general, the respondents reported less household health expenditure (Lavado, Brooks, and
Hanlon, 2013). This may be due to the fact that people are less likely to report accurately and less likely to
finish when filling out very lengthy surveys (Hanlon, 2014).
Although the study is an example of health expenditure, there are clear parallels to surveys about
chronic pain. The surveys being analyzed by the IHME had multiple components - they were not strictly
surveys of household health expenditure. The same is often true of surveys that measure pain. The Short
Form Health Survey (SF-8) discussed earlier, was a general health survey that contained chronic pain
questions, not strictly a survey about chronic pain. Depending on the length of the survey, people may
not accurately report their chronic pain measures. If there are many, highly specific questions targeted at
different types and elements of chronic pain, people may be more likely to report that they have chronic
pain, compared to if the survey only has one question asking Do you have chronic pain? It is therefore
crucial to have a gold standard survey instrument to control for differences in wording of questions, and
differences in survey characteristics.
Consideration of Subjectivity
Although surveys provide a platform to gather a large volume of data, they present an additional
issue for consideration: the extent to which a survey preserves subjectivity. Surveys to some extent
preserve the subjectivity of the human pain experience because they do not attempt to measure pain
through a method that does not consider the whole person, such as through fMRIs. However, surveys
that ask for multiple-choice answers force people to reduce their experience to categories.
This phenomenon is seen in poverty studies, deemed the econometric imaginary (Lawson,
2014). The econometric imaginary occurs when economists, statisticians, and policy-makers turn to
numbers as a way of knowing poverty. Measures such as the Safe Harbors Homeless Management
Information System in King County do just this, asking patrons of shelters to categorize their complex
socio-economic situations into categories by prompting them to check boxes such as literally homeless
(Sparks, 2010). By stripping away someones complex socio-economic situation into categories, a persons
human experience is objectified.
Just as econometrics has a tendency to objectify subjective experiences, so do surveys on chronic
pain. Although they preserve the subjectivity of the pain by allowing individuals to self-report, the surveys
do not capture the full human pain experience. This sentiment was expressed by elderly German women
participating in a randomized controlled trial on chronic neck pain, who were being asked to convey their
complex, subjective human pain experience through quantitative and categorical questionnaires
(Holmberg et al, 2014). Researchers interviewed the subset of 20 women pulled from the RCT in order to
understand their experiences conveying their pain experience on surveys (Holmberg et al, 2014).
The researchers found that often times, the women complained about the difficulties of
expressing complex experiences in the standardised terms the questionnaire asked of them (Holmberg
et al, 2014, 3). The women used strategies to modify their responses in order to better portray their
experiences, such as skipping questions, adding questions, adding notes, and only addressing part of a
question (Holmberg et al, 2014).

Although their strategies may have helped them to better express their full experience of pain,
the strategies are detrimental for data collection and measurement because of missing data and modified
or added variables. Because of this, the researchers recommend that for clinical trials, it may be helpful to
add qualitative interviews to obtain those notes, additional variables and specifications that cannot be
expressed on questionnaires (Holmberg et al, 2014).
The findings of this study nested within the larger RCT suggest that surveys and questionnaires
that are quantitative and categorical rather than qualitative restrict patient responses, therefore not
capturing the full subjectivity of the human pain experience, and can thus result in faulty and unreliable
data. Purely qualitative surveys may suffice for small sample sizes, but when measuring chronic pain on a
global scale, they are surely inefficient for data analysis because of the manpower it would take to
understand and code all of the responses. Instead, I argue that any survey to measure the prevalence
and/or the intensity of chronic pain needs to include both quantitative/categorical measures and
qualitative measures. In this way, the survey measures are still efficient, but they include space for
subjectivity in responses to both pain/suffering and pain behaviors.
VI STANDARDIZED MEASUREMENT
Given all of these types of measurements from objective to subjective, and the considerations
and implications they pose, is it possible standardize a chronic pain measurement of prevalence and/or
intensity? Should a measurement contain both of those components? How objective or subjective should
the measurements be? These questions warrant consideration of the purpose and end goal of the
measurement. I see three purposes for which measurements of chronic pain are needed: (1) for health
care systems planning for chronic pain, (2) for health care prioritization of chronic pain through
descriptive epidemiology, and (3) for determining etiology and risk factors of the severity of chronic pain
through inferential epidemiology.
Health Care Systems Planning
In planning health care systems, it is important to know how many physicians will be required,
number of beds needed, volume of pharmaceuticals that are likely to be requested, and what services
should be offered. In planning health care systems for pain, such as in pain clinics, it is crucial to know
these measures specifically for chronic pain: how many patients the clinic will see, how many patients are
likely to request opioids and other pain medications, and what types of treatment should be offered.
Knowledge of pain and suffering through surveys is not quite relevant to health systems planning
because it does not indicate how many people will actually use the services available. Plenty of people in
a community could have chronic pain, but they may not seek treatment, and their pain may not disable
them as it may disable others based on their environment (Loeser, 1991). Thus, the measurements
discussed in the pain behaviors section would inform a pain clinic more accurately. By collecting
measurements from clinics in the surrounding area of chronic pain diagnoses, opioid prescriptions and
consumption, and disability claims, a pain clinic would have a good idea of the number of physicians, the
volume of opioids, and the types of services needed.
However, these measures would not provide perfect information to a fledgling pain clinic
because with increased availability of services directed specifically towards pain, more people may use

the services over time. To supplement this information, a sample of the targeted population should be
surveyed with questions asking about not only presence and severity of chronic pain, but questions also
to assess the likeliness that they would actually demand services if a pain clinic was opened. It would be
necessary to track these measures within the new pain clinic over time. Then, statistical models could be
employed to analyze the growth rate of the pain clinic and predict the volume of services that are likely to
be demanded in the future.
Prioritizing Health: Descriptive Epidemiology
A major reason to measure health is to determine the prevalence of disease. This is descriptive
epidemiology: using measures such as incidence and prevalence to determine the extent of disease in a
population. These measures can be used for a variety of purposes, and one of the most important is
prioritizing health issues. In a perfect world, a government would have the resources to address all health
issues effectively and simultaneously. But instead, we live in a world with finite resources where some
health issues must be prioritized over other health issues. This is where descriptive epidemiology comes
into play.
Health issues must be prioritized by severity and by prevalence. The University of Washington
Institute for Health Metrics and Evaluation (IHME) employed a unit of measurement in their Global
Burden of Disease (GBD) 2010 study that targets both of these factors for prioritization: disability
adjusted life years (DALYs) (IHME, 2013). DALYs are the combination of years of potential life lost (YLLs)
and years lived with disability (YLDs). DALYs take into consideration the current prevalence of a disease,
and then weight that disease with the relative measure of disability that the specific disease causes on a
scale of 0-1 (Vos et al, 2012). DALYs also consider the years lost to disease in the calculation of YLLs: for
example, if a child from Ghana died from AIDS at age 7, they would have more years of potential life lost
than if an adult from the same location died from the same disease at age 40.
YLLs can be obtained through mortality data. YLDs are trickier because of the consideration of
disability weights. The current prevalence of disease was determined by methods ranging from disease
registries and hospital discharge data to interviews and questionnaires (Salomon et al, 2012). Disability
weights were determined by asking people of diverse communities and experts in the field how much
they felt that a certain disease caused disability (Salomon et al, 2012). The disability weights determined
for various stages of chronic neck and lower back pain varied from 0.101-0.366 (Salomon et al, 2012,
Table 2).
By using descriptive epidemiology methods, such as that employed by the IHME in the GBD 2010
study, diseases can be prioritized based on their prevalence and severity. Chronic pain is an important
disease to consider in prioritization because of its ubiquity and its associated disability. Measures
obtained for the purposes of descriptive epidemiology of chronic pain should be similar to that of the
measures used in GBD 2010: self-report surveys, hospital days, interviews, etc.
Etiology of Disease: Inferential Epidemiology
Inferential epidemiology uses measures such as relative risks and odds ratios to infer the etiology
of and risk factors for disease. The basis of inferential epidemiology is comparison: comparisons across
racial and ethnic groups, sexes, time periods, places, etc. Measures used in inferential epidemiology
should be similar to the measures used in descriptive epidemiology: health reports data, surveys and

questionnaires, interviews, etc. However, the crucial part about inferential epidemiology is that
measurements must be standardized across populations in order to make meaningful comparisons.
There are many ways in which some of the standard measurements used for descriptive
epidemiology need to be closely examined from a data integrity perspective to be used in inferential
epidemiology. The first was discussed previously: the use of surveys and questionnaires. It is clear that
differential wording of questions and survey characteristics results in different chronic pain estimates for
the same population. Consider two surveys: survey one consistently estimates a higher prevalence of
chronic pain than survey two when they are given in the same population, due to characteristic
differences between the surveys. Consider two populations: both have the same true prevalence of
chronic pain. If survey one is used in population one and survey two is used in population two, the
estimate of the prevalence of chronic pain in population one will be higher than in population two. Since
the purpose of the measurements in this case is inferential epidemiology to determine environmental
risk factors for or causes of chronic pain the researchers may erroneously conclude with these
estimates that a characteristic present in population one that is absent from population two predisposes
individuals to chronic pain. Using unstandardized surveys in different populations to collect measures of
chronic pain threatens the validity of the data and may result in erroneous inferences because of
characteristic differences between the surveys.
The previous issue addresses problems associated with estimating the prevalence of chronic pain.
This next issue pertains to measures of disability attributed to chronic pain, such as the YLD component of
DALYs, in attempt to measure chronic pains severity. If two different cultures, subgroups,
races/ethnicities, etc. have the same true prevalence of chronic pain, but one reports higher disability,
not because of the severity of their chronic pain, but because of their living and working environments,
that may lead researchers to draw erroneous conclusions about the environmental etiology of and/or risk
factors for more severe chronic pain.
At this time, I want to emphasize that when I say determining etiology of and/or risk factors for
severe chronic pain, I am looking beyond a physically disabling environment. It is clear that a risk factor
for disabling chronic pain would be an environment in which someone is disabled by his or her chronic
pain (Loeser, 1991). I want to look beyond that at what other factors influence the development,
perpetuation, and severity of chronic pain, controlling for a disabling environment. An example of this
type of risk factor was mentioned earlier in the study of PTSD and substance abuse, in which chronic pain
patients with PTSD and/or substance abuse perceived their chronic pain as more severe than those
without PTSD and substance abuse (Randleman et al, 2014).
In the case of DALYs, prior to GBD 2010, literature recommended that disability weights be
assigned differentially based on culture, since disability varies greatly, precisely because of environmental
living and working conditions aforementioned (Salomon, 2012). The GBD 2010 study noted this concern
when considering disability weights. A previous GBD study in 1990 did not distinguish between health loss
and welfare loss due to disease (Salomon et al, 2012). Welfare loss has to do with the relative disability
brought on by disease when taking into consideration social and environmental context (Salomon et al,
2012). Based on how the IHME describes health loss and welfare loss, it seems as though health loss is
most similar to Loesers definition of impairment and welfare loss is most similar to Loesers definition of
disability (Loeser, 1991). In the GBD 2010 study, IHME narrowed their survey and interview questions
about the disability associated with disease to only questions associated with health loss instead of

welfare loss because disability weights in terms of welfare loss varied from culture to culture whereas
disability weights in terms of health loss, including chronic pain, remained constant (Salomon et al, 2012).
Using health loss instead of welfare loss makes a lot of sense for inferential epidemiology because
it controls for different social environments: the data will be more reliable when deriving etiology of and
risk factors for increased severity of chronic pain. I have argued previously that it is important to preserve
the maximum amount of subjectivity in measures of chronic pain as possible - and measures of welfare
loss due to disability certainly preserve that subjectivity since it is so influenced by environmental context.
However, for the purposes of inferential epidemiology to determine etiology of and/or risk factors for
severity of chronic pain, it may be necessary for the measures to sacrifice a bit of subjectivity in order to
preserve data reliability.
Lastly, although an important factor of measuring chronic pain for all of the discussed purposes health care systems planning, health prioritization, and determination of etiology/risk factors - is to
preserve subjectivity, the use of an objective measure such as fMRIs might be interesting, especially in
inferential epidemiology. Although fMRIs should in no way replace subjective measures of the human
pain experience, comparing fMRI results between populations may yield interesting results and should be
researched further.
VII CONCLUDING THOUGHTS
I analyzed the advantages and disadvantages of pain measurements on the continuum of
objective to subjective, from nociception to pain behaviors, along with the advantages and disadvantages
of surveys to capture measures that satisfy multiple stages of the continuum. I discussed how these
measurements measure prevalence and/or severity. I discussed how different combinations of these
measures might be employed to satisfy the different purposes of health care systems planning,
prioritizing health, and inferring etiology of disease.
The conclusion of my research on chronic pain measurements is three-fold: (1) preferred
measurements will vary widely based on the intended purpose of those measurements, (2)
standardization of surveys is incredibly important, especially when comparing populations, and (3) since
pain is an inherently subjective and complex human experience, it is necessary to maintain as much
subjectivity and complexity as possible in the measurements, except in the context of disability weights
with inferring etiology of and risk factors for the severity of chronic pain.

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