Pain evaluation typically relies upon the use of self-report instruments. The validity of these tools is questionable in many older adults, however, particularly those with
cognitive impairment. Rating of
pain behavior (e.g. grimacing, sighing) by an objective observer represents an alternative
pain assessment strategy which has been validated in subjects of heterogeneous ages. The purpose of this study was to examine, in a group of community-dwelling elderly with
low back pain and lumbosacral
osteoarthritis, the concurrent validity of observational
pain behavior rating techniques as compared with self-report instruments and the degree to which
pain and
pain behavior relate to disability. Thirty-nine cognitively intact subjects, age > 65 years, without depression, other sources of
pain, or other known spinal pathology underwent the following measures: (1)
pain self-report using the verbal 0-10 scale, vertical verbal descriptor scale,
Arthritis Impact Measurement Scales and McGill
Pain Questionnaire; (2)
pain behavior was sampled during two protocols, one, identical to that used by Keefe and Block (Behav. Ther., 13 (1982) 363-375), that required subjects to sit, stand, walk, and recline for 1-2 minute periods (which we have labelled the traditional protocol), and a second, more demanding protocol that was designed to simulate
activities of daily living that place a premium on axial movement (the '
ADL' protocol); (3) disability was assessed using the Roland questionnaire, a 6 month global disability question and the Jette Functional Status Index; and (4) radiographic evaluation of the lumbosacral
spine; osteoarthritis was quantitated using a previously validated scoring system. Interrelationships among
pain,
pain behavior and disability measures were tested using canonical correlations. Self-reported
pain was associated with
pain behavior frequency; the association was stronger when the
ADL protocol was used, as compared with the traditional protocol. The association between
pain and disability was modestly strong with both self-report instruments and
pain behavior observation when the
ADL protocol was used, but not when the traditional protocol was used. Our findings suggest that
pain behavior observation is a valid assessment tool in the elderly. In addition, it seems that observation of elders during performance of
activities of daily living may be a more sensitive and valid way of assessing
pain behavior than observing
pain behavior during sitting, walking, standing, or reclining.