Sample Report

Pain Profile Assessment

Case Report for James David Case Number
Requested by: Aetna Med. Clinic

Introduction

This individual was referred for a Pain Profile Assessment to evaluate the level of emotional components significantly impacting his symptoms and evaluate anxiety factors associated with the pain. An evaluation form was completed by the individual. The following report is a summary of the scoring analysis with norms and interpretation of results based on an objective computerized scoring model.

Pain Profile Assessments

PAIN PROFILE assessment reports are based on theoretical inferences and probabilistic data from primary and actuarial research on norms of individuals in varying stages of treatment for injuries or medical conditions. This report is designed to alert practitioners of any emotional discomfort or psychological characteristics associated with the dynamics of pain. Rather than suggesting treatment therapies, it should be viewed as only one facet of a comprehensive assessment and evaluated in conjunction with additional clinical data (e.g. information from other diagnostic tests, and practitioners interviews).

Please note that the information and statements contained in this report highlight the individuals perceptions of and response to their present pain experience. This report is a summary of the individual's input and comments, and defines subjective data as evaluated by objective qualification with interpretations based on the individuals response. To optimize clinical utility, this report targets psychological characteristics and dynamics of pain, rather than suggesting treatment therapies. The referring practitioner utilizing these results should keep this focus in mind.

Based on theoretical inferences and probabilistic data from actuarial research this report should not be judged definitive. The referring results are not derived exclusively from data related strictly to physical pathology, but represents and addresses the individuals point of view. Please note that the information and statements contained in this report are intended to highlight the individual’s perceptions of, and response to their present pain experience caused by injury or medical condition.

This is a summary of the individual’s input and comments providing insights and interpretations based on that individuals input. This report defines subjective data as evaluated by objective qualification. Results are not derived exclusively from data related strictly to physical pathology but considers and address the individual’s point of view. It is a individuals right to maximum care and the doctors responsibility to determine effective treatment.

Patient Information

Report Date: 03/17/2009
Name: James David
Sex: Male
SSN: 123301231

Date of Birth: 03/18/1950
Address: 123 main
City: anytown
State: CA
Zip: 96963
Home Phone: 714 555 1212
Occupation: blocker on a rolling mill

Insurance Information

Work Related: No
Policy Holder Name: N/A
Policy Number: N/A
Insurance Company: N/A
Address: N/A
City: N/A
State: N/A
Zip: N/A
Date: N/A

This individual has given authorization for release of any information requested/required by his insurance company with respect to any insurance claims.

The purpose of this Pain Assessment is to evaluate the level of components significantly impacting his symptoms and evaluate anxiety factors associated with the pain he is currently experiencing. The evaluation form was completed by James David on 03/13/2009. The following report is based on the individuals perceptions of his current pain.

Cause Of Injury Or Pain

James David has given the following reasons as to the cause of injury or pain and has given a brief comment or explanation of any details related:

Cause of injury: Injured at Work
Comment/Explanation: fell off the loading dock while unloading equipment

Pain Assessment

The following, regarding James David's pain cycle, is information provided by him when filling out the Pain Assessment Questionaire.

Length of time in Pain: 15 Days
Hospitalized with this pain: No Date: N/A
Ever had back, neck or knee surgery: No If yes enter date: N/A
Other Practitioners seen for this Pain: None
Diagnostic Tests undergone for this pain:

Type: X-Rays
Date: 03/04/2009

Medications being taken at this time: None
Is this a workman's compensation case: No Start Date: N/A
Working Now: No Start Date: N/A

Where Is Your Pain Drawing

Pain Location

The following symbols indicate the type of pain the individual is experiencing and the place on the body where this pain is being experienced.

BURNING PAIN: " X "      NUMBNESS: " O "
PINS & NEEDLES: " = "      STABBING: " / "      ACHE: " + "

This individual has selected the following numbers and pain experience:

Your Pain Word Descriptors

This individual has selected the following descriptor words to describe their pain:

Throbbing: to pulsate or pound with abnormal force or rapidity, to beat or vibrate rhythmically
Definition: This individual has selected Throbbing from the Major Class Sensory with the Sub Classification of Temporal with a general description of: temporary, short-term, transitory, fleeting, momentary passing sensation lasting a short time.

This individual's experience of this pain is temporary and transitory sensations that momentarily suspend continuity, passing in a short time.

Stabbing: to thrust or give a wound with or as if with a pointed weapon
Definition: This individual has selected Stabbing from the Major Class Sensory with the Sub Classification of Punctuate Pressure with a general description of: pointed or sharp, (implies insistence) but in a particular interval of time that is limited, but crucial, or transitional intervals.

This individual's experience of this pain is intensely insistent, sharply pointed with acute severity, but limited to crucial intervals which elicit strong emotional responses often provoking anger.

Crushing: to feel weighted down, extreme pressure, subdued or brought low in condition or status
Definition: This individual has selected Crushing from the Major Class Sensory with the Sub Classification of Constrictive with a general description of: squeezes, pushing – implies coercion.

This individual's experience of this pain makes the individual feel severely impaired in spirit and effectiveness, imposed on or consumed by the weight of the unknown, implying coercion - it controls, restricts, limits.

Lacerating: to tear or rend roughly: wound jaggedly, to cause sharp mental or emotional pain, distress
Definition: This individual has selected Lacerating from the Major Class Sensory with the Sub Classification of Incisive with a general description of: acute, distinct sharpness causing mental pain.

This individual's experience of this pain reveals that the individual feels episodes of acutely distinct sharpness in strong, harsh sensations causing mental pains and which seems to overwhelm other senses.

Piercing: penetrating
Definition: This individual has selected Piercing from the Major Class Sensory with the Sub Classification of Spatial Punctuate with a general description of: directed sharpness.

This individual's experience of this pain relates to a sense of loss of control as directed sharpness in random intervals causes mental distress, leaves individual unsure what to believe but aware that another state of affairs is possible - this may be a transitional phase (consider with other factors to see if this reflects a good or poor attitude).

Splitting: to divide or break down, separation
Definition: This individual has selected Splitting from the Major Class Sensory with the Sub Classification of Constrictive with a general description of: sliding, abrasive cramping, disagreeable conflicting feelings.

This individuals experience with this pain is represented as abrasive, disagreeable, conflicting feelings, as if compelled to resistance, cramped by restrictions and sense of loss of control.

Agonizing: extremely painful causing physical or psychological pain
Definition: This individual has selected Agonizing from the Major Class Sensory with the Sub Classification of Evaluative I with a general description of: subjective judgment, feeling subjected to distress and suffering, associated with fear.

This individual's experience with this type of pain is subjected to distress and suffering, with persistent discomfort from stressful physical sensations associated with fear.

He states that the pain cycle is continuous, brief and momentary.

Pain Intensity Ratings

This individual has selected the following pain intensity ratings for the following categories.

What Makes My Pain Worse

This individual has stated that the following items/activities make his pain worse:

• During Exercise
• Weather

Weather: when it's raining and cold

Other: None

Comments on what makes his pain worse: None

What Reduces My Pain

This individual has stated that the following items/activities reduce his pain:

• Lying Down
• Aspirin / Tylenol

He is taking the following pain pills: None

He states that nothing reduces him pain at this time: None

He has given the following comments on what makes his pain decrease: None

Check List of Present and Past Health Problems

This individual has stated that the following current and past symptoms are experiences that may or may not be related to his current pain experience.

Present Symptoms:

• Ulcers
• Low Stamina
• Loss of Taste
• Headaches
• Nervous

Past Symptoms:

• Ears Buzzing
• Fever
• Irritability
• Face Flushed
• Cold Hand

Because Of My Pain

This individual has stated the following in regards to his activities and interaction with friends and family.

I always keep regular health habits.
I sometimes keep hobbies and habits I enjoy.
I frequently go out with friends and family.
I always remember appointments.
My friends and family sometimes pay attention to me.
I sometimes keep a regular exercise routine.
I hardly ever have problems with sleeping.

Additional comments: None

Word Graph Comparative Scoring

The graph shows this individuals rank against norm tables based on his ranking.

Factors = Projection (P)   Fear (F)  Organic (O)  Real (R)

FACTOR VALUE

                                                P Factor = 0                          O Factor = 1

                                                F Factor = 4                          R Factor = 0

CATEGORY
1 - 13 = Sensory       14 - 15 = Evaluative       16 - 20 = Affective      
(Numbers above Correspond to Descriptions in Category Glossary)

This individual has chosen the following descriptor words from his Pain Assessment Questionnaire:

Throbbing: This word is from the Temporal and is scored high and is identified with the Sensory Category. The Sensory Category equals physical sensations, physical and perceptive senses, involved perception or awareness of emotions, feelings, senses and tactile response. Sensory components of pain denote how clearly defined the strength of the pain is as a stimulus, how intense it feels, and how much it disturbs a person.

Stabbing: This word is from the Punctuate Pressure and is scored high and is identified with the Sensory Category. The Sensory Category equals physical sensations, physical and perceptive senses, involved perception or awareness of emotions, feelings, senses and tactile response. Sensory components of pain denote how clearly defined the strength of the pain is as a stimulus, how intense it feels, and how much it disturbs a person.

Crushing: This word is from the Constrictive and is scored high and is identified with the Sensory Category. The Sensory Category equals physical sensations, physical and perceptive senses, involved perception or awareness of emotions, feelings, senses and tactile response. Sensory components of pain denote how clearly defined the strength of the pain is as a stimulus, how intense it feels, and how much it disturbs a person.

Lacerating: This word is from the Incisive and is scored high and is identified with the Sensory Category. The Sensory Category equals physical sensations, physical and perceptive senses, involved perception or awareness of emotions, feelings, senses and tactile response. Sensory components of pain denote how clearly defined the strength of the pain is as a stimulus, how intense it feels, and how much it disturbs a person.

Piercing: This word is from the Spatial Punctuate and is scored high and is identified with the Sensory Category. The Sensory Category equals physical sensations, physical and perceptive senses, involved perception or awareness of emotions, feelings, senses and tactile response. Sensory components of pain denote how clearly defined the strength of the pain is as a stimulus, how intense it feels, and how much it disturbs a person.

Splitting: This word is from the Constrictive and is scored high and is identified with the Sensory Category. The Sensory Category equals physical sensations, physical and perceptive senses, involved perception or awareness of emotions, feelings, senses and tactile response. Sensory components of pain denote how clearly defined the strength of the pain is as a stimulus, how intense it feels, and how much it disturbs a person.

Agonizing: This word is from the Evaluative I and is scored high and is identified with the Evaluative Category. The Evaluative Category equals an individuals' self-judgment, often from belief system or childhood training bothered by the possibility and/or existence of problems. Evaluative components describe the subjective judgment, or degree to which the pain "imposes" by the individuals personal, subjective assessment.

Whether these scores are within range of normal or low, and especially if they are showing high, consider Factor scores. If Factors Organic and Real rate 2 or more, it reflects legitimate Organic causes to their pain and their reaction to it. The Projection and Fear factors show the reactive aspects of their pain and have been incorporated into comparisons considered with Category Scoring. Basically, higher sensory levels with high Organic and Real factors should reflect higher than "norms" in all other categories. If scores are high only in Affective categories with high Projection and Fear factors, individual needs to be considered for pain management therapies in conjunction with other treatment.

FACTORS PROVIDE MOST IMPORTANT SCORES AND REVEALING ASPECTS OF AN INDIVIDUALS PAIN EXPERIENCE

As individuals choose words which best describe their pain from 85 words grouped on the pain word list, they may also be adding points to their Factor Scores. There are 47 words integrated into the word list groups. Associated word selections are totaled up and put through statistical formulations to produce an individual Factor Score and Factors Value.

FACTOR VALUE and category FACTOR Scores: "Trail Markers"
Total possible words in each Factor's category.

                                                Fear  22                                 Organic  6

                                                Projection  7                        Real  8

• Each Factor score provides crucial insight into the focus of the pain experience for an individual. Your communication is enhanced when you understand the individuals "pain" environment.
• The four Factors show predominate emotional stressors that trigger the Pain Behavior Cycle. These are indicators of the primary motivations or consideration and perspective a individual attaches to the pain experience. It may be considered the posture they have assumed or the context in which pain is perceived.
• By understanding the significance of an individuals' pain patterns, it is easier to induce the appropriate stimulus to break the Pain Behavior Cycle, reduce the physical tension or sources of stressful anxiety for the individual and facilitate their recovery.

This individual has scored 4 in the Fear Category.

Scores over 2 in the Fear Category shows a predominate focus of behavior. Fear of pain can inhibit a individuals' participation or confidence in treatment and is often disabling due to inability to manage emotions relating to pain itself, oftentimes relating to potential losses that they fear...it's life-style threatening. Addressing the issues they are "afraid" of (which may just be, they are afraid !!) Encouraging them to find "do-able" challenges, a little one every day, can pull some individuals out of this by helping them focus on what they can do.

This individual has scored 0 in the Projection Category.

Scores over 2 in Projection Category shows a predominate focus of behavior. Projection factors relate to the imagination or memory of pain, an inability to overcome the anguish of "hurting". This usually inhibits participation in general life activities, a result of their imagining any activity may exacerbate the injury. High scores here may exhibit irritability, agitation, almost as if "beside their self"

This individual has scored 1 in the Organic Category.

Organic factors are usually verifiable by other diagnostics, therefore dealt with more openly...frequently reflect more in form of mental distress than emotional. With scores over 2, pain is wearing heavily, may be producing nervousness.

This individual has scored 0 in the Real Category.

Real factors often arise from a genuine physical problem even if not verified by diagnostics ...most likely organically based as with soft tissue damage so it won't tip scales with emotional disturbance but may heighten anger, anxiety or stress. Momentary or intermittent physical sensations might mentally engage a individual short term, however prescribing specified activities with, or to, a measurable goal is effective.

Review Analysis Criteria

In reviewing the individual's report, consider all of the following:

Are responses appropriate and common based on the general picture of the individual demographics - time in pain, working or not, sex, age, diagnostic test results, use of meds, etc. Is this a verifiable, genuine or "real" response to their pain that is common and appropriate for the nature of the complaint?

1. Look at categories individual chooses to describe their experience-Sensory, Evaluative, Affective
2. Are responses consistent for the length of time in pain (acute stage or becoming chronic)
3. Is injury related to work or auto accident-could symptoms be exaggerated by shock or trauma
4. Check the Pain Drawing to see the kind of pain and the locations. Does it follow typical patterns for the nature of the injury, does it correspond to what is typical for the length of time in pain?
5. Note Pain Intensity-consistent with other response? Pain Now, Least Pain, Pain Symbols , etc
6. Consider the pattern of the pain changing through the day - morning, afternoon, evening levels (Mornings higher but decreasing through the day - may mean movement loosens muscles and alleviates tenseness. Morning levels low but increasing through the day, may mean muscles swelling and tensing from use or individual tensing from projected fears of possible pain

Is the pattern presented consistent with the nature of their complaint?.

7. How has the individual responded to rating previous "other pains" - high or low tolerance?
8. Using overall picture of the individuals responses--consistencies and discrepancies--determine if individual is reporting accurately, being honest with themselves about this pain, or do they exhibit exaggerated symptoms (does not mean that they are exaggerating)--are they in control of the pain and its effects or does it control them?
9. Review self-rating from the individuals responses to: "Because of this Pain" (efficacy statements) and note any diminished participation in general activities and whether they are heading towards possible depression and isolation, detachment or withdrawal. Are they still participating at a normal level based on their injury and length of time in pain, maintaining significant aspects of social interaction, part Danard-Lily, Corporation participating in customary and consequential manners?

Consider the potential of emotional rewards to be gained by the individuals' pain behavior and the effect or influence this has on the individual's treatment response.

When comparing Graph Category placements with your findings and opinion, determine the extent to which a individual believes it is "real" and is their experience appropriate or inhibited?

Check each score within the various Factors and Total Factor Value. Total Value Score of 2 or under is generally acceptable as demonstration of pain management It is still important to note scores in each Factor, as anything over 2 will play a role in individuals treatment outcome.

Individuals' raw scores are analyzed in comparison with potentials for various categories and classifications. This raw data on each individual is weighted according to the rating of various critical factors, including age, sex, acute or chronic condition, and the pain quotient of the individual. The data undergoes statistical analysis to produce the individuals’ individualized graph charted in correlation to "norms".

Pain Assessment Report

This report is simply designed to be used much in the same manner a practitioner utilizes an x-ray or specimen report. The scores and interpretation evaluate individual input, with nothing added or removed. Use of the data is at the sole discretion of a practitioner or insurance provider, whether used strictly to document an individuals’ current status or to validate a course of treatment. Pain Assessment Reports are meant to provide extensive supplementary diagnostic information on specific aspects of a individual’s condition but no inference of recommendations to any individual, medical facility, legal firm, insurance provider or any other entity is intended, suggested or implied.

In Summary

In summary, all items marked on the Pain Assessment Symptom Inventory Form are scored in several ways and used to calculate individual pain descriptors, factor value, sensory, evaluative and affective ratings in their experience of the pain thereby allowing projective interpretation. Each item scored is assigned scale values, rank values and categories which are rated by three classifications, Sensory with items that reflect physical sensations, Evaluative as the items denote judgments or evaluations made in response to the pain, and Affective as these items imply impact reactions as the pain affects life at a deeper subconscious level, out of reach of normal reasoning faculties.

Each method sets different aspects of the various components in a perspective that offers critical insights and definition to the nature of the individuals’ pain experience, providing particularly accurate status reports or "trail markers" of an individuals pain behavior cycle. All responses are scored based on a statistical comparison of other answers for rank within an "appropriate" range based on each individuals present pain. In other words, the type of injury, length of time in pain, age, other treatments, etc. all contribute to final scores to determine a individuals ability to manage their pain and determine how (or possibly when) they will respond to treatment.