A Paradigm Shift for Movement-based Pain Assessment in Older Adults: Practice, Policy and Regulatory Drivers

Abstract

The profession of nursing has been on the frontline of pain assessment and management in older adults for several decades. Self-report has traditionally been the most reliable pain assessment method, and it remains a priority best practice in identifying the presence and intensity of pain. While advances in technology, biomarkers, and facial cue recognition now complement self-report, it is still important to maximize self-report of pain and to gather understanding of the total pain experience directly from patients. Practices in pain assessment in older adults have evolved over the past 25 years, and current research and quality improvement studies seek not only to detect the presence of pain but also to determine the best protocol for assessment and most important pain characteristics to assess. Increasing data are now supporting two emerging practices (1) consistently assessing the impact of pain on function and (2) measuring pain during movement-based activities rather than at rest. Thus, the purpose of this article is to discuss the shifting paradigm toward movement-based pain assessment in older adults, as well as the practice, policy, and regulatory drivers that support this practice change.

Introduction

Overview of Pain in Older Adults

Pain is a significant problem in one of the fastest growing demographics worldwide - individuals over the age of 65 (i.e., older adults). In the United Sates, the number of adults ages 65 and older is projected to reach 78 million by 2035 (United States Census Bureau, 2018). If current trends persist, over half of this population will have pain (Patel, Guralnik, Dansie, & Turk, 2013), particularly persistent pain associated with musculoskeletal conditions and multimorbidity (i.e., presence of two or more chronic conditions that exponentially increases health complexity and poor health outcomes) (Nakad et al., 2020). Pain is also prevalent worldwide. About 30% of Canadian older adults report pain (Reitsma, Tranmer, Buchanan, & Vandenkerkhof, 2011). Among European countries, rates of chronic pain vary from about 19% of older adults in Switzerland to 46% of older adults in France. Other countries report similar prevalence rates; 32% in Iran (Roghani, Delbari, Asadi-Lari, Rashedi, & Lokk, 2019) and 41% in China (Si et al., 2019). Given these data and the negative consequences of under-recognized and undertreated pain in older adults (Horgas, 2017) and the importance of a biopsychosocial model of pain (Miaskowski et al., 2019), accurate and meaningful assessment of pain is essential to assure pain is recognized, appropriately evaluated and treatment planning initiated. It is important that the assessment of pain in this population be guided by current research and subsequent best practice recommendations. Further, it is important that the evidence-base be continuously reviewed in order to align pain assessment practices with most current research. In fact, the groundbreaking Relieving Pain in America report from the Institute of Medicine (2011; now National Academies of Sciences, Engineering, and Medicine) boldly called for a transformation in the care of people with pain, expanding assessment to identify the contextual factors that impact pain severity. Thus, the purpose of this article is to discuss the shifting paradigm toward movement-based pain assessment in older adults.

Current Paradigm in Pain Assessment among Older Adults

Over the past three decades, significant advances have been made to recognize and address the problem of pain in older adults. In 2001, the Joint Commission on Accreditation of Healthcare Organizations initially endorsed the concept of pain as the “5^th vital sign” in their guidance for pain assessment and management and mandated that pain be routinely assessed and documented among hospitalized patients. This requirement highlighted the importance of pain across the lifespan, but called particular attention to the challenges associated with assessing and managing pain among older adults, particularly those with cognitive impairment who were unable to verbally express pain. In addition to establishing pain severity scales reliable and valid for older adults (Ware et al., 2015; Kang & Demiris, 2018), this led to the development of over 20 pain assessment tools for older adults with dementia (Lichtner et al., 2014; Chow et al., 2016). In recent years, the legitimacy of the pain as the “5^th vital sign” and the potential negative impact on emphasizing a “number” to describe and measure pain have been questioned (Scher, Meador, Van Cleave, & Reid, 2018). Indeed, the Joint Commission no longer uses or supports this analogy to signify the importance of performing good and regular pain assessment.

Pain assessment is the first step in the pain management process, and relies primarily on patient self-report (when possible) to guide treatment and evaluate pain management outcomes. A number of clinical guidelines by leading professional organizations such as the American Geriatrics Society (2002; 2009), British Geriatrics Society/British Pain Society/Royal College of Nursing (Schofield et al., 2018), and the American Society for Pain Management Nursing (Herr et al., 2019) provide in-depth review of pain assessment tools and best-practices for pain assessment in older adults. These guidelines review the primary multi-dimensional pain tools and disease-specific measures, such as those designed to assess pain associated with cancer or osteoarthritis. These tools were not developed specifically for use with older adults, although they are relevant to this population. In general, these measures assess pain itself (e.g., presence, location, intensity) and the impact of pain on everyday functioning (e.g., sleep, movement, relationships) (e.g., Brief Pain Inventory-Short Form [BPI-SF], Roland Morris Disability Questionnaire).

In clinical settings, pain presence and intensity is typically assessed with either of the following two questions: (1) “Are you currently experiencing any pain? [yes/no]” and (2) “On a scale of 0 to 10, how much pain are you experiencing?” With this in mind, Booker and Herr (2016) offer that nurses should explicitly ask about pain and not about “comfort” or how the individual “is doing.” Scales such as the Iowa Pain Thermometer-Revised (0-10; Ware et al., 2015) and the verbal descriptor scale (VDS) which measure pain intensity using word anchors (e.g., no pain to worst pain imaginable) are recommended for use among older adults (Herr, Spratt, Mobily, & Richardson, 2004). However, these scales only assess the presence and intensity of pain, and not the multidimensional aspects of pain. In contrast, Resnick and colleagues (2019) reported that in a sample of older adults in assisted living, self-reported pain on the VDS was associated with function. While, numerical rating scale (NRS) scores have often been used as cut-off points to guide initiation of treatment in patients, measuring clinically significant reductions in pain, and as a metric of the quality of pain management, pain experts warn against dosing opioid medications solely based on pain intensity; instead providers must consider other factors in totality, such as function, comorbidities, and drug-drug interactions (Pasero, Quinlan-Colwell, Rae, Broglio, & Drew, 2016). It is information on severity, as well as the impact that level of pain has on older adult’s function and quality of life, that is key. Many providers and organizations conduct a comprehensive assessment that includes all the characteristics of pain (not just severity) as well as its impact, but without a policy, it has not been a consistent common practice across settings and with the older adult population. For this reason, it is important to consider the limitations of measuring pain intensity solely and discuss emerging evidence that may improve the specificity of pain assessment.

Limitations of Current Paradigm

The NRS as a unidimensional measure of pain is insufficient in characterizing the dynamic, multidimensional experience of pain or in evaluating changes in pain, even at the bedside (Gordon, 2015). Inconsistent practices in pain assessment lead to under-reporting from older adults, and a 0-10 pain score simplifies an extremely complex experience that may contribute to underestimation of pain. Further, this simple assessment of intensity may not best reflect patients’ goals for pain relief, control, and pain acceptability nor sufficiently guide thoughtful decision-making about the treatment plan, necessitating broader assessment (Gordon, 2015). The Joint Commission also now recognizes that the unidimensional assessment using the NRS is inadequate alone and it is more important to assess “how pain affects function and the ability to make progress towards treatment goals” (The Joint Commission, 2018, p. 5). These limitations give rise to two emerging pain practices that we recommend be codified in organizational policies and procedures to improve pain care of older adults and all patients: (1) assessing the impact of pain on function (i.e., pain interference) and (2) measuring pain during movement-based activities to understand the dynamic triggers and changes of pain (See Box 1 for conceptual definitions).

Box 1. Definitions.

Movement- the act of using the body to change a position through active or passive (i.e., assisted) range of motion of musculature or joints.

Function- physical abilities that allow individuals to perform basic and instrumental activities of daily living independently or with assistance.

Pain interference- the extent to which persistent pain limits or interferes with daily or overall function as well as physical, cognitive, emotional, and social/recreational activities (Amtmann et al., 2010)

*Note: Movement and function are defined here as separate concepts. For example, measuring pain during flexion (i.e., movement) of the knee, may not provide representative information about a person’s ability to be functional or function within their environment. Thus, the importance of assessing the impact of pain on function via pain interference and measuring pain during movement to understand the dynamic triggers and changes of pain.

Emerging Evidence to Inform Pain Assessment

Pain and Function

The National Pain Strategy and Federal Pain Research Strategy (Interagency Pain Research Coordinating Committee, 2016; 2017) have put forth recommendations to characterize chronic pain more accurately. Hence, the new concept of high-impact chronic pain (i.e., pain that has lasted for 3 months or longer and accompanied by at least one major life activity restriction; Dahlhamer et al., 2018) is the latest driver for assessment of function with pain. The impact of pain on function can be measured by the concept of pain interference, which is defined as the extent to which pain limits performance of and engagement in activity, work, mood, and social interactions (Wilson, 2014). Currently, Patient-Reported Outcomes Measurement Information System (PROMIS®) tools endorsed by the National Institutes of Health include pain intensity and pain interference, signaling the importance of assessing multiple qualities of pain.

Enhanced physical function and pain tolerability and reduced disability are important goals for patients with acute and chronic pain, but especially older adults with chronic pain. In terms of healthcare policy, improvement or decline in pain intensity and physical function are the primary metrics designated by health insurance payers to approve or deny pain-relieving procedures and devices, rehabilitative therapy, and pharmacological treatments (Karayannis et al., 2017). Indeed the Centers for Medicare and Medicaid Services state that pain assessments should determine the mechanisms of pain by identifying factors including but not limited to pain location, intensity, onset, duration and functional ability (Centers for Medicare Services, 2019; World Health Organization, 2019). In addition, new diagnostic codes for chronic pain are also driving changes in pain assessment, emphasizing the comprehensive nature of chronic pain (i.e., etiology, temporal factors, pain severity/intensity, and functional properties). Particularly, the International Code of Functioning-11 (ICD-11) chronic primary pain code is delineated “as pain in one or more anatomical regions that persists or recurs for longer than 3 months and is associated with significant emotional distress or functional disability (interference with activities of daily life and participation in social roles)” (Treede et al., 2019, p. 21). Regulatory changes in diagnostic criteria strengthens the argument to ensure routine integration of function in pain assessment. Moreover, assessing pain during function and managing therewith may improve patients’ satisfaction with pain care, particularly if they feel nurses and providers are invested in knowing and treating more than the intensity of pain.

New research and quality improvement studies have found promising preliminary evidence that suggest that incorporating functional assessment has positive outcomes. Specifically, use of the Clinically Aligned Pain Assessment (CAPA) (Topham & Drew, 2017) and the Functional Pain Scale are two tools that may improve pain reporting and management (Arnstein et al., 2019). CAPA is a multidimensional, conversational tool where providers talk with patients about pain and how it impacts five key areas: comfort, change in pain, pain control, physical functioning, and sleep without placing emphasis on numeric evaluations of such areas (Topham & Drew, 2017; Twining & Padula, 2019). Pilot evidence indicated that patients find CAPA easy to use, are satisfied with this approach, and reported that it facilitated greater comfort levels (Twining & Padula, 2019; Mclain, Nelson, & Waldo, 2019), but more research on its effect on pain outcomes particularly in older adults is warranted.

The Functional Pain Scale (FPS) was developed specifically to measure pain intensity in relation to its tolerability and interference with function (Gloth, Scheve, Stober, Chow, & Prosser, 2001; Arnstein, Gentile, & Wilson, 2019). In fact, the current second edition of the Pain Management Nursing Scope and Standards of Practice lists the FPS as a valid pain assessment tool to use across adult patient populations, clinical settings, and pain conditions (American Nurses Association, 2016). Arnstein and colleagues (2019) found preliminary evidence for reliability and validity of the FPS, but noted several methodological limitations (e.g., missing data) and a need for additional validation research. Nonetheless, the FPS is a promising tool to capture the broader biopsychosocial experience of pain and function in older adults. For many of the reasons cited earlier, primarily the lack of tools to evaluate pain-related function, the Functional Pain Assessment tool is a new acute care measure with preliminary reliability for use with in-patient adult populations (Halm et al., 2019). The Defense and Veteran’s Pain Rating Scale (DVPRS) is another scale that provides patients with more inclusive options for describing and reporting pain, including how pain severity incrementally impacts activity levels (Buckenmaier et al., 2013). In a study with older African Americans with chronic joint pain, participants overwhelmingly preferred the DVRS to the NRS 3:1 (Author blinded) because it was more comprehensive and allowed participants to conceptualize and describe the effect of pain intensity on activity levels. Other brief tools that can be used in practice with older adults are the Pain, Enjoyment, General Activity (PEG) and the BPI-SF (Booker & Herr, 2016). The BPI-SF has been tested and used in older adults with different pain problems (Schofield & Abdulla, 2018; Mendoza, Mayne, Rublee, & Cleeland, 2006). .The PEG is actually a subset of 3 items from the BPI-SF that are strongly associated with the longer BPI, making it a clinically useful short tool (Krebs et al., 2009). These tools bring us closer to understanding the absolute importance of function and pain intensity as simultaneous assessment measures. Changing policy to require assessment of impact of pain on function is an important practice change. In addition to assessing the effect of pain on physical function, research evidence is starting to suggest the value of assessing pain during movement using validated tools that incorporate a multimodal perspective.

Pain at Rest vs. Movement

There are multiple relationships between pain and movement, wherein a change in one can inversely as well as paradoxically impact the other (Corbett et al., 2019). For example, increases in pain will decrease movement, while increases in regular movement (e.g., exercise) can either reduce pain or increase pain (Booker, Herr, & Fillingim, 2019; Hodges & Smeets, 2015). Advances in pain science have increased our understanding of chronic pain mechanisms resulting in a need for new tools and methods to assess pain to better guide the type of multimodal treatment utilized. Given the dynamic and biopsychosocial nature of the pain experience, current trends in research-based practice include assessing pain using less static measures and more dynamic and ecologically valid measures and techniques (Corbett et al., 2019). Static measures (e.g., pain intensity assessment at rest) overgeneralize the pain experience and fail to address the variability in pain that is experienced between periods of rest and with movement. Thus, emerging recommendations suggest assessing pain at rest and during/with movement (Corbett et al., 2019; van Boekel et al., 2017) and evaluating its subjective (e.g., selfreport) and objective (e.g., ambulation time and length; ability to complete activities of daily living [ADLs] or physical therapy) effect on overall daily function (Ersek et al., 2019; Breivik et al., 2008). Indeed, it is typically during movement-based activities (e.g., ADLs) that pain response behaviors in older adults are observed, signifying the important relationship between pain and movement.

There is emerging evidence that pain with movement and pain at rest may be fundamentally different. Rest pain may be more tolerable than movement pain because it does not interfere with function and mobility. Nevertheless, assessing pain during movement is a more precise measurement which can be helpful in gleaning the acute and long-term impact of pain intensity and interference on function and determining the best management approach that optimizes function and mobility. Further, the biological and psychological mechanisms underlying movement and resting pain may differ (Corbett et al., 2019; Booker et al., 2019). Several authors reported that pain sensitivity predicted pain with movement but not resting pain (Rakel et al., 2012; Wan et al., 2018) and that neuroplastic changes in central pain processing may contribute to movement-evoked pain in older adults (Simon, Bishop, Riley, Fillingim, & George, 2015). In a nurse-led study of knee arthroplasty pain, the investigators found that movement pain was highly associated with resting pain and was additive to resting pain (Rakel et al., 2012). However, pain is often assessed during periods of inactivity or after activity, but rarely during activity. It could be argued, however, that assessing and treating pain during movement may be less accurate, given that once movement and activity reduces or ceases, pain is likely to decrease or even resolve. Yet, the opposite could also be argued that pain during rest is less accurate because pain and its intensification may be triggered or exacerbated by movement, thus the true extent of pain may be underestimated. Clinical experience has shown us that older adults are more likely to report or exhibit signs of pain during movement-based functional and performance activities, as this is typically related to pain of musculoskeletal origin. Although there may be potential clinical utility in skipping assessment of pain at rest and doing all evaluations during movement, this could be problematic in identifying pain and its impact when the etiology relates to other conditions that are not impacted by movement.

Towards a New Paradigm: Movement-Based Pain Assessment

Given the clinical importance of measuring function and pain during movement, we offer that clinical practice recommendations, as well as policy directives, move in the direction of implementing movement-based pain assessment. What is movement-based assessment? It is the assessment of pain intensity and interference on function during movement or physical activities in patients, as opposed to at rest or after movement. Such activities could include walking/ambulation, turning in bed, deep breathing and coughing, or basic ADLs. Rather than asking patients about pain at rest or to recall how much pain they experienced with moving (post-movement), movement-based assessment is an “in-the-moment” assessment that captures a phenomenon called movement-evoked pain (MEP)— pain that is triggered or exacerbated by active or passive human movement. As described by Corbett and colleagues (2019, p.757), “the call to use movement-evoked pain measures arises from a recent transformation in our understanding of pain,” yet clinical practice has been slow to adopt this pain assessment approach. Booker and colleagues asserted that MEP should be considered a patient-reported outcome measure (PROM) (Booker et al., 2019), especially since some studies conclude that MEP may be a more sensitive predictor of disability (Mankovsky-Arnold, Wideman, Larivière, & Sullivan, 2014), post-operative recovery (Rakel et al., 2012), and conversion of acute to chronic pain. As such, adopting MEP as a PROM is a potential policy-related recommendation relevant to the PROMIS® initiative and tools and to the National Institute of Nursing’s list of common data elements (CDEs; pain is a CDE) to facilitate measurement of common concepts to improve data quality and use across clinical and research purposes (Redeker et al., 2015).

Some contend that acute pain can be reliably assessed at rest and during movement with one-dimensional tools such as the NRS (Breivik et al., 2008). Given that the NRS remains the most common pain scale used in acute, long-term, and primary care settings, van Boekel and colleagues (2017) recently tested a new variation, the Numeric Rating Scale-Movement-Evoked Pain (NRS-MEP) on pain acceptability and functionality. They concluded that the numeric ratings of intensity do not sufficiently reflect how tolerable or acceptable pain is to patients or how well a patient moves and functions. Thus, the authors recommended that multidimensional assessment be considered, which could include function-oriented tools such as the FPS or CAPA as described earlier. Attending to these aspects may improve patient satisfaction with pain. Measurement of MEP may be especially important for patients where movement, mobility, and physical function are important recovery outcomes such as in post-operative patients, those with neurological, orthopedic and musculoskeletal conditions, or undergoing physical and occupational therapy.

While it is beyond the scope of this paper to discuss current and emerging approaches to pain assessment in older adults with cognitive impairment, we acknowledge that males and females across the cognitive spectrum perceive and self-report pain differently (Romano et al., 2019). There is limited evidence on factors that impact pain experience and report in persons with cognitive impairment, such as sex and race, but research is beginning to contribute understanding of relevant factors, including pain with movement and pain interference. There is a growing body of work that individuals with cognitive impairment may be less able to verbally report pain intensity and pain interference (Herr et al., 2019). Recent work offers that racially diverse persons with dementia still report and experience pain interference but that caregiver proxy reports of pain interference are needed to inform the assessment (Amspoker et al., 2020). Instead, cognitively impaired older adults may demonstrate significant or subtle changes in movement and behavior as a means for communicating pain. It is important to note that most pain behavior tools examine the characteristics of body movements rather than assessment during movement-based activities to determine pain. The newly-updated Hierarchy of Pain Assessment for patients unable to self-report briefly mentions that the key to using behavioral pain assessment tools is to focus on the older adult’s behavior during movement or a painful procedure (Herr et al., 2019). Among cognitively-impaired nursing home residents, Horgas and colleagues used an activity-based protocol (e.g., sitting, standing, walking in place, lying down, and transferring between these positions) to elicit measurable behavioral indicators of pain. This protocol highlighted significant differences between self-reported pain intensity and behavioral indicators of pain at rest vs. during activities (Horgas, Elliott, & Marsiske, 2009). Other authors have subsequently supported these findings by suggesting that assessments with behavioral pain assessment tools should compare ratings between rest and movement (Ersek et al., 2019). Expanding the current paradigm towards a movement-based Hierarchy of Pain Assessment may hold promise in better detecting pain vs. other symptoms such as stiffness. Existing behavioral pain scales, such as the Pain Assessment Checklist for Seniors with Limited Ability to Communicate-II (PACSLAC-II), use a movement exacerbated standardized pain protocol (Kunz et al., 2020; Chan, Hadjistavropoulos, Williams, & Lints-Martindale, 2017). Other pain behavior tools that support use during movement and/or rest include: the Pain Assessment in Impaired Cognition (PAIC15) scale (Kunz et al., 2020), Checklist of Nonverbal Pain Indicators (CNPI; Feldt, 2000), Pain Intensity Measure for Persons with Dementia (PIMD; Ersek et al., 2019), Mobilization-Observation-Behavior-Intensity-Dementia-2 (MOBID-2; Husebo, Ostelo, & Strand, 2014; Herr, Sefcik, et al., 2019), and the DOLOPLUS-2 (Holen et al., 2005; Pickering et al., 2010). Measuring pain intensity intentionally during movement is still relatively new, especially in cognitively impaired older adults, but this is the goal of the PIMD scale. Despite evidence-based recommendations to assess movement-based pain, this approach has not been widely adopted in clinical settings. There are practice, policy, and regulatory issues that must be addressed to advance more precise and patient-oriented pain assessment.

The Way Forward

For too long, pain intensity has been the focus of relief, but patients are more often concerned about how pain limits their functional ability and mobility. Understanding what’s important or matters to the patient in terms of pain relief cannot be overstated. Developing a measurable comfort-function-mood goal to reduce pain during movement is more realistic than reducing general or rest pain, because the pain can be anticipated and treated with targeted, preemptive pharmacologic medications and non-drug therapies. Measuring progress toward goals of improving functional ability can only be done by (1) assessing baseline function, (2) understanding how pain interferes with function and movement, and (3) using an assessment tool that allows patients to communicate the most relevant aspects of their pain experience.

Factors of interest to organizations, including reimbursement and readmission, can be considered by answering questions such as the following: Should MEP be an outcome for readiness to discharge from hospital? Physical therapy? Ability to go home and care for self (ADLs, etc.)? How should nurses work with other healthcare team members, such as physical therapists, physicians, and nursing assistants/patient care technicians to implement and evaluate movement-based pain assessments?

Future directions for enhancing pain assessment and quality of care are numerous and exciting. Research is needed to increase the evidence base to support policy and practice changes. Example of future research include:

• Validating movement-related pain, particularly in acute pain, and determining its pain character signature- nociceptive, neuropathic, or nociplastic. Also associating movement-evoked pain with functional outcomes.

• Defining the most relevant movement behaviors (e.g., turning, walking, etc.) for observation of pain behaviors and/or gaining self-report of pain. This would standardize assessment during movement, reduce HCP burden in implementing this assessment, and be most clinically useful and feasible.

• Developing activity-based bedside pain protocols (incorporating quantitative sensory testing), such as The Functional Activity Score (FAS) which involves a patient completing a task relevant to the site of pain and the observer (e.g., nurse) objectively rates the impact of pain on task performance ability (Schug et al., 2015; Tong et al., 2018).

We contend, however, that patient self-report should remain the priority assessment technique—just expanding the “what” of that self-report to include information on movement-based pain impact. In those unable to self-report, refining existing approaches, such as the Hierarchy of Pain Assessment, and pain behavior tools to use a movement protocol such as that described by Husebo et al. (2007) and Horgas et al. (2009) can move pain assessment practices for older adults to obtain more consistent relevant information to support tailored pain management treatment. Another regulatory issue to consider amending is to have the Joint Commission and the Centers for Medicare and Medicaid Services require pain assessment and management documented in the Minimum Data Set (MDS) 3.0 and the related survey requirements to include movement-based pain assessment along with current assessment of function.

We also need to raise awareness of issues related to assessment of movement-evoked pain that need to be considered. One is that this approach temporarily stimulates or increases pain. Is this acceptable as standard of practice? Does increasing pain to assess pain violate ethical principles for nurses to reduce suffering? or Is the positive outcome gained by identifying underlying pain to achieve a treatment plan for ongoing pain reduction acceptable? We argue that this is similar to many procedures we engage in that cause pain but are necessary as part of medical care to achieve positive outcomes and the practice is justified. Second, consistent implementation of the practice of movement-based pain assessment will require development of organization policies and procedures to support the practice, as well as education of providers and those who assess pain in older adults. Changing pain assessment practices is often a challenge and senior leadership support is essential.

Conclusion

Pain management necessitates a systematic and thorough assessment. Pain assessment is fundamental to determining the presence, intensity, characteristics, location and functional impact of pain. The approaches discussed are leading the way in improving providers’ assessment of pain, and in some settings, these approaches are already implemented. Nonetheless, we foresee major changes in the movement to strengthen the evidence and impact policies that codify this approach as standard of care expected in all settings where older adults are cared for, but also in all patient populations. This article is intended to ignite that transformation in how pain is perceived, assessed, and subsequently managed.

Key Practice Points:

• It is imperative to maximize self-report of pain and to gather understanding of the total pain experience directly from patients.

• Two emerging self-report practices are the routine (1) assessment of the impact of pain on function and (2) measurement of pain during movement-based activities.

• Movement-based pain assessment is the assessment of pain intensity and interference on function during movement or physical activities in patients.

• Consistent implementation of the practice of movement-based pain assessment will require development of regulatory and organizational policies and procedures to support the nursing and healthcare practices.