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

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.

FIGURE 1

The MAP. A, MAP components are shown from a third-person perspective. This 3-dimensional view emphasizes the nonobservable nature of the pain experience and the relative breadth and scope of the different model components. B, MAP components are depicted in 2-dimensional cross-section and are oriented to both first-person and third-person perspectives. This view emphasizes how pain experience is a function of the whole person, who is influenced by environmental and contextual factors, and how this person relates to different assessment methodologies used in research and practice settings. In both images, the size and shape of MAP components reflect their capacity to address subjectivity related to pain; components with greater breadth and volume have greater potential to address pain-related subjectivity. The textured surface of pain expression represents the idiosyncratic collection of words and behaviors that any particular individual may use to express pain. This is in contrast to the smooth surface of pain measures, which require expressions of pain to be translated into standardized metrics. Cone size represents the relative ability of different pain measures to quantify different aspects of pain expression; measures with relatively larger cones indicate that they address a broader scope of pain expression. Gradients are used to depict the intimate link between the pain narrative and pain behavior, as well as the measures that bridge traditional classification as either self-report or non–self-report (eg, psychophysical measures). MAP indicates multimodal assessment model of pain.