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      The Multimodal Assessment Model of Pain : A Novel Framework for Further Integrating the Subjective Pain Experience Within Research and Practice

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          Abstract

          Objectives:

          Pain assessment is enigmatic. Although clinicians and researchers must rely upon observations to evaluate pain, the personal experience of pain is fundamentally unobservable. This raises the question of how the inherent subjectivity of pain can and should be integrated within assessment. Current models fail to tackle key facets of this problem, such as what essential aspects of pain are overlooked when we only rely on numeric forms of assessment, and what types of assessment need to be prioritized to ensure alignment with our conceptualization of pain as a subjective experience. We present the multimodal assessment model of pain (MAP) as offering practical frameworks for navigating these challenges.

          Methods:

          This is a narrative review.

          Results:

          MAP delineates qualitative (words, behaviors) and quantitative (self-reported measures, non–self-reported measures) assessment and regards the qualitative pain narrative as the best available root proxy for inferring pain in others. MAP offers frameworks to better address pain subjectivity by: (1) delineating separate criteria for identifying versus assessing pain. Pain is identified through narrative reports, while comprehensive assessment is used to infer why pain is reported; (2) integrating compassion-based and mechanism-based management by both validating pain reports and assessing underlying processes; (3) conceptualizing comprehensive pain assessment as both multidimensional and multimodal (listening/observing and measuring); and (4) describing how qualitative data help validate and contextualize quantitative pain measures.

          Discussion:

          MAP is expected to help clinicians validate pain reports as important and legitimate, regardless of other findings, and help our field develop more comprehensive, valid, and compassionate approaches to assessing pain.

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          Most cited references 82

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          Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research.

           N Mays,  C Pope (1995)
          Qualitative research methods have a long history in the social sciences and deserve to be an essential component in health and health services research. Qualitative and quantitative approaches to research tend to be portrayed as antithetical; the aim of this series of papers is to show the value of a range of qualitative techniques and how they can complement quantitative research.
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            Rigour and qualitative research.

             C Pope,  N Mays (1995)
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              1987 Volvo award in clinical sciences. A new clinical model for the treatment of low-back pain.

              Because there is increasing concern about low-back disability and its current medical management, this analysis attempts to construct a new theoretic framework for treatment. Observations of natural history and epidemiology suggest that low-back pain should be a benign, self-limiting condition, that low back-disability as opposed to pain is a relatively recent Western epidemic, and that the role of medicine in that epidemic must be critically examined. The traditional medical model of disease is contrasted with a biopsychosocial model of illness to analyze success and failure in low-back disorders. Studies of the mathematical relationship between the elements of illness in chronic low-back pain suggest that the biopsychosocial concept can be used as an operational model that explains many clinical observations. This model is used to compare rest and active rehabilitation for low-back pain. Rest is the commonest treatment prescribed after analgesics but is based on a doubtful rationale, and there is little evidence of any lasting benefit. There is, however, little doubt about the harmful effects--especially of prolonged bed rest. Conversely, there is no evidence that activity is harmful and, contrary to common belief, it does not necessarily make the pain worse. Experimental studies clearly show that controlled exercises not only restore function, reduce distress and illness behavior, and promote return to work, but actually reduce pain. Clinical studies confirm the value of active rehabilitation in practice. To achieve the goal of treating patients rather than spines, we must approach low-back disability as an illness rather than low-back pain as a purely physical disease. We must distinguish pain as a purely the symptoms and signs of distress and illness behavior from those of physical disease, and nominal from substantive diagnoses. Management must change from a negative philosophy of rest for pain to more active restoration of function. Only a new model and understanding of illness by physicians and patients alike makes real change possible.
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                Author and article information

                Journal
                Clin J Pain
                Clin J Pain
                AJP
                The Clinical Journal of Pain
                Lippincott Williams & Wilkins
                0749-8047
                1536-5409
                March 2019
                16 November 2018
                : 35
                : 3
                : 212-221
                Affiliations
                [* ]School of Physical and Occupational Therapy
                [§ ]Faculty of Dentistry, McGill University, Montreal, PQ
                []School of Public Health and Health Systems, University of Waterloo and Faculty of law, Civil Law Section, University of Ottawa, Ottawa
                []School of Physical Therapy, The University of Western Ontario, London, ON, Canada
                []Department of Anaesthesia, Harvard School of Medicine, Boston, MA
                []Department of Neural and Pain Sciences, School of Dentistry, and Center to Advance Chronic Pain Research, University of Maryland, Baltimore, MD
                Author notes
                Reprints: Timothy H. Wideman, PhD, School of Physical and Occupational Therapy, McGill University, Hosmer House, Room 303B, 3630 Promenade Sir-William-Osler, Montreal, PQ, Canada, H3G 1Y5 (e-mail: timothy.wideman@ 123456mcgill.ca ).
                Article
                00002
                10.1097/AJP.0000000000000670
                6382036
                30444733
                Copyright © 2018 The Author(s). Published by Wolters Kluwer Health, Inc.

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0/

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