Assessing persistent cancer pain: a comparison of current pain ratings and pain recalled from the past week

Recent guidelines developed by the U.S. Food and Drug Administration for the use of patient-reported outcomes discuss the rating of pain and other symptoms at their current level of severity versus rating these symptoms using a recall period, such as the past 24 hours or past week. To explore whether the overall experience of cancer patients is better represented by ratings of current pain or pain recalled from the past week, we conducted a secondary analysis of Eastern Cooperative Oncology Group data from 1147 patients with cancer who had reported having persistent pain during the past week. Patients used the Brief Pain Inventory (BPI) to rate their current pain along with their pain at its worst, least, and average during the past week. T-tests were used to compare ratings of current pain and pain recalled from the past week. Linear regressions described the extent to which the various pain ratings contributed to overall pain interference, also derived from the BPI. Overall, patients rated their current pain as less severe than their worst or average pain recalled from the past week. Worst pain recalled from the past week contributed most to ratings of pain interference. These findings indicate that ratings of recalled worst pain, rather than ratings of current pain, might better reflect the overall experience of pain and its impact on function in cancer patients with persistent pain. Our results provide information that might guide the choice of recall period for cancer clinical trials with pain as a self-reported outcome.     

Validity of 24-h recall ratings of pain severity: biasing effects of "Peak" and "End" pain

Despite the frequent use of pain recall ratings in clinical research, there remains doubt about the ability of individuals to accurately recall their pain. In particular, previous research indicates the possibility that the most pain experienced during a recall period and the most recent pain experienced (known as peak and end effects, respectively) might bias recall ratings. The current study used data from a published clinical trial to determine the relative validity of a 24-h recall rating of average post-operative pain and the nature and extent of any biasing influence of peak and end effects on nine separate 24-h recall ratings. The results supported a statistically significant but small biasing influence of both peak and end pain. Also, the influence of peak pain was stronger than that of end pain. However, the biasing impact of both peak and end pain together was very small, suggesting that 24-h recall ratings are adequately valid indicants of average pain for patients participating in post-surgery clinical pain trials.     

Can End-of-Day Reports Replace Momentary Assessment of Pain and Fatigue?

This study evaluated the ability of end-of-day (EOD) ratings to accurately reflect momentary (EMA) ratings on 10 widely used pain and fatigue items. Rheumatology patients (n = 105) completed ≥5 randomly scheduled EMA assessments of each item per day as well as EOD ratings. Correlations were high between EOD and EMA ratings of the 5 pain items (r = .90 to .92) and somewhat lower for the 5 fatigue/energy items (r = .71 to .86). To examine the ability of EOD ratings to represent 1 week of EMA ratings, 7 EOD ratings were averaged and correlated with EMA (r ≥ .95 for pain items, r = .88 to .95 for fatigue/energy items). Further, averaging only 3 to 5 EOD ratings achieved very high correlations with 1 week of EMA ratings. Within-subject correlations of EOD with mean daily EMA across 7 days confirmed patients' ability to provide daily ratings that accurately reflect their day-to-day variation in symptom levels. These EOD results were compared to traditional recall ratings collected in the same protocol. It was concluded (1) that EOD ratings were a better representation of EMA than were recall ratings, and (2) that EOD ratings across a reporting period can replace EMA for studies targeting average levels of pain or fatigue.PerspectiveThis study in chronic pain patients demonstrated that end-of-day ratings of pain are highly accurate representations of average levels of pain experience across a day; ratings of fatigue were somewhat less accurate, though still at a level that would be valid.     

Accuracy of recall of usual pain intensity in back pain patients

Pain intensity ratings of 'usual' pain, or pain 'on average', are gaining in popularity since they are arguably a more realistic measure of a patient's pain status than the single snapshot of 'current' pain. An alternative to the 'actual average' of ratings obtained from multiple measures is the single rating of patients' recall of their 'usual' pain over a period of time, usually 1 week. The use of such a scale relies on the assumption that patients can accurately recall their 'usual' pain. Although accuracy of memory for pain has been investigated, most studies have failed to use appropriate statistical analyses for accuracy (validity). In this study, 200 back pain patients completed four daily recordings of pain intensity over 7 days. These were averaged to compute 'actual average' pain intensity. The next day, patients estimated their pain over the week at its 'least', 'worst' and 'on average' ('usual') as well as recording their 'current' pain intensity. Using the Intra-class Correlation Coefficient (ICC) to compute accuracy, the single rating asking patients to estimate their pain 'on average' over the week was found to be an accurate measure of 'actual average' pain intensity (ICC=0.82) and more accurate than 'current' pain (ICC=0.66). Although some composite measures of single ratings gave more accurate estimates of 'actual average' pain, this was not considered sufficient advantage to advocate their use. The results of this study propose the single rating of pain 'on average' as a valid and practical measure of a patient's pain intensity over a period of 1 week.     

Comparison of Pain Measures Among Patients With Osteoarthritis

This study compared recalled average pain, assessed at the end of the day, with the average of real-time pain ratings recorded throughout the day among patients with osteoarthritis (OA). Participants (N = 157) with hand, hip, or knee OA completed electronic pain diaries on 1 weekend day and 1 weekday. Diaries included at least 7 pain ratings per day, immediately after waking and every 2 hours following, using a visual analog scale (VAS) scored as 1 to 100 (scores not seen by participants). At the end of each diary day, participants rated their average pain that day on the same VAS. Pearson correlations examined associations between recalled average pain and the average of real-time pain ratings that day. Mixed models, including interaction terms, examined whether associations between recalled and actual average pain ratings differed according to the following patient characteristics: joint site, age, race, gender, study enrollment site, and pain catastrophizing. Correlations between recalled and actual average pain ratings were r = .88 for weekdays and r = .86 for weekends (P < .0001). In mixed models, there were no significant interaction terms for any patient characteristics. In summary, patients with OA accurately recalled their average pain over a 1-day period, and this did not differ according to any patient characteristics examined.PerspectiveThis study showed that patients with OA accurately recalled their average pain over a single-day period, and this did not differ according to patient characteristics. Results of this study indicate that end-of-day recall is a practical and valid method for assessing patients' average pain during a day.     

The Clinical Importance of Changes in the 0 to 10 Numeric Rating Scale for Worst,Least, and Average Pain Intensity: Analyses of Data from Clinical Trials of Duloxetine in Pain Disorders

Data on 1,700 patients pooled from 5 randomized, placebo-controlled duloxetine studies (3 in diabetic peripheral neuropathic pain and 2 in fibromyalgia) were analyzed to determine clinically important differences (CIDs) in the 0 to 10 Numeric Rating Scale-Pain Intensity (NRS-PI) for patient-reported “worst” and “least” pain intensity while validating the previously published level for “average” pain. The correspondence between the baseline-to-endpoint raw and percentage change in the NRS-PI for the worst, least, and average pain were compared to patients' perceived improvements at endpoint as measured by the 7-point Patient Global Impression of Improvement (PGI-I) scales. Stratification by baseline pain separated the raw but not the percent change scores. The PGI-I category of “much better” or above was our a priori definition of a CID. Cutoff points for the NRS-PI change scores were determined using a receiver operator curve analysis. A consistent relationship between the worst and average NRS-PI percent change and the PGI-I was demonstrated regardless of the study, pain type, age, sex, or treatment group with a reduction of approximately 34%. The least pain item CID was slightly higher at 41%. Raw change CID cutoff points were approximately –2, –2.5 and –3 for least, average, and worst pain respectively.PerspectiveWe determined an anchor-based value for the change in the worst, least, and average pain intensity items of the Brief Pain Inventory that best represents a clinically important difference. Our findings support a standard definition of a clinically important difference in clinical trials of chronic-pain therapies.     

Intense Pain Soon After Wrist Fracture Strongly Predicts Who Will Develop Complex Regional Pain Syndrome: Prospective Cohort Study

Complex regional pain syndrome (CRPS) is a distressing and difficult-to-treat complication of wrist fracture. Estimates of the incidence of CRPS after wrist fracture vary greatly. It is not currently possible to identify who will go on to develop CRPS after wrist fracture. In this prospective cohort study, a nearly consecutive sample of 1,549 patients presenting with wrist fracture to 1 of 3 hospital-based fracture clinics and managed nonsurgically was assessed within 1 week of fracture and followed up 4 months later. Established criteria were used to diagnose CRPS. The incidence of CRPS in the 4 months after wrist fracture was 3.8% (95% confidence interval = 2.9–4.8%). A prediction model based on 4 clinical assessments (pain, reaction time, dysynchiria, and swelling) discriminated well between patients who would and would not subsequently develop CRPS (c index .99). A simple assessment of pain intensity (0–10 numerical rating scale) provided nearly the same level of discrimination (c index .98). One in 26 patients develops CRPS within 4 months of nonsurgically managed wrist fracture. A pain score of ≥5 in the first week after fracture should be considered a “red flag” for CRPS.PerspectiveThis study shows that excessive baseline pain in the week after wrist fracture greatly elevates the risk of developing CRPS. Clinicians can consider a rating of greater than 5/10 to the question “What is your average pain over the last 2 days?” to be a “red flag” for CRPS.     

Validity of average,minimum, and maximum end-of-day recall assessments of pain and fatigue

End-of-day (EOD) diary assessments of symptoms have the potential to reduce recall bias associated with longer recall periods, and therefore be useful for generating accurate patient reported outcomes (PROs). In this report we examine the relative validity of diary questions about the experience of daily pain and fatigue, including several questions about experience for the entire day and questions about minimum and maximum daily levels, with previously collected data [1]. Validity estimates are based on comparisons of EOD reports with momentary recordings of pain and fatigue from the same days. One hundred and six participants with rheumatologic diseases yielded 2852 days for analysis. Differences in levels as assessed by EOD and momentary reports were small (just a few points), although in many instances were significantly different. Correlational analyses indicated that “how much,” “how intense,” and “on average” EOD questions were more strongly associated with momentary reports (rs = 0.85–0.90 for pain and 0.81–0.83 for fatigue) than were minimum and maximum questions (rs = 0.73–0.80 for pain and 0.67–0.75 for fatigue). Overall, the pain measures had higher EOD-momentary correspondence than the fatigue measures. Analyses of difference scores between EOD and momentary reports confirmed the better correspondence of the average questions compared with minimum and maximum questions. There was little evidence of individual differences in level and correspondence analyses. The implication of these results is that over-the-day diary measures may yield superior PROs than those based on minimum or maximum daily levels.     

A Trial of Scrambler Therapy in the Treatment of Cancer Pain Syndromes and Chronic Chemotherapy-Induced Peripheral Neuropathy

ABSTRACT

Neuropathic pain is common among cancer patients and often difficult to treat. This study used Scrambler therapy, a patient-specific electrocutaneous nerve stimulation device, to treat cancer patients with pain. Patients received Scrambler therapy for 10 sessions (one daily) over a two-week period. The primary outcome was changed in pain numerical rating scale (NRS) at one month; secondary outcomes were changes in the Brief Pain Inventory and European Organization for Treatment and Cancer QLC-CIPN-20(EORTC CIPN-20), over time. Thirty-nine patients, mean age 56.5 yr, 16 men and 23 women, were treated over an 18-month period for an average of 9.3 days each. The “now” pain scores reduced from 6.6 before treatment to 4.5 at 14 days, 4.6, 4.8, and 4.6 at 1, 2, and 3 months, respectively (?p < 0.001). Clinically important and statistically significant improvements were seen in average, least, and worst pain; BPI interference with life scores, and motor and sensory scales on the EORTC CIPN-20. No adverse effects were observed. In this single arm trial, Scrambler therapy appeared to relieve cancer-associated chronic neuropathic pain both acutely and chronically, and provided sustained improvements in many indicators of quality of life.     

Psychometric Evaluation of the MOBID Dementia Pain Scale in U.S. Nursing Homes

PurposeThe Mobilization-Observation-Behavior-Intensity-Dementia (MOBID) Pain Scale is an observational tool in which raters estimate pain intensity on a 0-10 scale following five standardized movements. The tool has been shown to be valid and reliable in northern European samples and could be useful in the United States (US) for research and clinical purposes. The goal of this study was to examine the validity and reliability of the MOBID among English-speaking nursing home residents in the US.DesignCross-sectional study.SettingsSixteen nursing homes in Pennsylvania, New Jersey, Georgia and Alabama.ParticipantsOne hundred thirty-eight older adults with dementia and moderate to severe cognitive impairment.MethodsValidity was evaluated using Spearman correlations between the MOBID overall pain intensity score and 1) an expert clinician’s pain intensity rating (ECPIR), 2) nursing staff surrogate pain intensity ratings, and 3) known correlates of pain. We assessed internal consistency by Cronbach’s alpha.ResultsMOBID overall scores were significantly associated with expert clinician’s rating of current and worst pain in the past week (rho = 0.54, and 0.57; p < .001, respectively). Statistically significant associations also were found between the MOBID overall score and nursing staff current and worst pain intensity ratings as well as the Cornell Scale for Depression in Dementia (rho = 0.29; p < .001). Internal consistency was acceptable (α = 0.83).Conclusions and Clinical ImplicationsResult of this study support the use of the MOBID in English-speaking staff and residents in the US. Findings also suggest that the tool can be completed by trained, nonclinical staff.     

Core Aspects of Satisfaction with Pain Management: Cancer Patients' Perspectives

ContextThe coexistence of high levels of satisfaction and high levels of pain has been perplexing.ObjectivesThe aims of this study were to 1) describe patient expectations related to the experience of cancer-related pain, 2) explore the cognitive processes and meaning that underlie patient judgments about satisfaction and dissatisfaction with pain management, and 3) explore the discrepancies between ratings of high satisfaction with pain management with high pain intensity.MethodsThe sample included 33 patients: 18 with advanced cancer and 15 experiencing pain after a surgery for a cancer diagnosis. All patients had experienced “worst pain” of at least moderate intensity and were interviewed using standard pain measures from the American Pain Society Patient Outcome Questionnaire and open-ended questions about the underlying meaning of their answers. We systematically analyzed the transcribed qualitative data using NVivo software.ResultsFifty-five percent of patients were females and were aged 25–78 years. Most (75%) were satisfied or very satisfied with their overall pain management. Key findings indicate that for some, the worst pain rating was often brief, even momentary. Most patients expected pain relief. Four key themes were important to the quality of pain management: being treated right, having a safety net, being in a partnership with their health care team, and having pain treatment that was efficacious. Key aspects of the patient-provider relationship that mattered were how the nurses and doctors behaved toward them and how quickly they responded to reports of pain. For some, an important factor was whether they had control of the amount of pain they experienced.ConclusionThe findings inform measurement of patient satisfaction with the quality of pain management.     

Ratings of pain and activity limitation on the visual analogue scale and global impression of change in multimodal rehabilitation of back pain – analyses at group and individual level

Purpose: To evaluate changes in pain intensity and activity limitation, at group and individual levels, and their associations with the global impression of change after multimodal rehabilitation in patients with back pain.

Method: Patients with long-term back pain (n?=?282) participated in a 4-week programme with a follow-up after 6 months. Visual analogue scales (VAS) were used to rate pain intensity and activity limitation. Global impression of change (GIC) was rated on a 7-category scale. The sign test, the Svensson method and the Spearman rank correlation were used for analyses.

Results: Significantly lower ratings in pain and activity limitation at follow-up were found at group level. However, a large individual variability was found by the Svensson method. The correlations between GIC and changes in pain and activity limitation were r_s??=_? 0.49 and r_s =?_?0.50, respectively. A rated GIC of at least “much better” on group level showed changes of ≥20?mm on the VAS.

Conclusions: At group level, lower VAS ratings were found in patients with back pain. However, a large individual variability in pain and activity limitation was also found resulting in low to moderate associations between GIC and the change in VAS ratings. The large individual variability might be due to the impreciseness in the ratings on the VAS. We have presented a critical discussion of statistical methods in connection with the VAS.

• Implications for Rehabilitation

• The use of VAS as a rating instrument may be questioned, especially for perceived pain intensity which is a too complex experience to be rated on a line without any visible categories.

• Single ratings of pain intensity should preferably be complemented with the ratings of activity limitation in patients with long-term back pain.

• Global impression of change is a suggested inclusive rating after rehabilitation.

• The improvement desired by the patient should preferably be determined before rehabilitation.

     

Results of a randomized controlled pilot study of a self-management intervention for cancer pain

Purpose of the researchThis paper reports findings from a randomized controlled pilot study evaluating the PRO-SELF^© Plus Pain Control Program, a U.S.-developed cancer pain self-management intervention, regarding feasibility and effect sizes in a German patient sample.Methods and sampleThirty-nine German oncology outpatients were randomized to intervention (n = 19) and control (n = 20) groups. The intervention group received the PRO-SELF^© Plus Pain Control Program in 6 visits and 4 phone calls a 10-week period. The control group received standard education and care. The intervention employed three key strategies: information provision, skills building, and nurse coaching. Primary outcomes were changes in average and worst pain intensity. Secondary outcomes included changes in pain-related knowledge, opioid intake, and self-efficacy. Data were collected at enrollment, then at 6, 10, 14, and 22 weeks.Key resultsThe group-by-time effect showed a statistically significant increase in knowledge (week 10: p = 0.04; week 22: p < 0.01). Despite slight reductions in average and worst pain, no statistically significant changes were found for pain, opioid intake, or self-efficacy.ConclusionsThis study is the first to evaluate and demonstrate the feasibility of a U.S.-developed cancer pain self-management intervention in a German patient population. Pain self-management related knowledge improved significantly and effect sizes for pain reduction were determined. Findings from this pilot RCT provide the basis for planning a larger RCT.Clinical trial registration number: NCT00920504.     

The Effect of Neuroticism on the Recall of Persistent Low-Back Pain and Perceived Activity Interference

The assessment of persistent pain often relies on recalling and then summarizing the entire pain experience using a single rating. Newer methodologies, such as the Original Pain Recall Assessment, ask people to recall the pain they experienced over a specific period of time by tracing a single line in a graph to represent their pain levels. One advantage of this approach is that one can compare recalled levels of pain with actual daily diary pain ratings. This methodology was used to investigate the effects of neuroticism on the recall of levels and patterns of persistent pain. The study involved 70 participants who completed a measure of neuroticism, depressive symptoms, and up to 15 daily diaries that asked for ratings of pain intensity, pain unpleasantness, and activity interference due to pain. Following completion of the daily diary period, the participants were asked to recall the entire diary period using the Original Pain Recall Assessment methodology. The analyses revealed that higher levels of neuroticism were related to significantly better recall of the variability of pain unpleasantness over time. Furthermore, individuals who reported higher levels of depressive symptoms were less accurate in the recall of pain in general.PerspectiveMemory for pain is crucial in the assessment of pain, with little research devoted to the study of this topic. The current study demonstrates that people higher on neuroticism had better recall of pain unpleasantness, and people with higher levels of depressive symptoms had poorer recall of pain in general.     

Symptomatic Magnetic Resonance Imaging–Confirmed Lumbar Disk Herniation Patients: A Comparative Effectiveness Prospective Observational Study of 2 Age- and Sex-Matched Cohorts Treated With Either High-Velocity,Low-Amplitude Spinal Manipulative Therapy or Imaging-Guided Lumbar Nerve Root Injections

ObjectivesThe purpose of this study was to compare self-reported pain and “improvement” of patients with symptomatic, magnetic resonance imaging–confirmed, lumbar disk herniations treated with either high-velocity, low-amplitude spinal manipulative therapy (SMT) or nerve root injections (NRI).MethodsThis prospective cohort comparative effectiveness study included 102 age- and sex-matched patients treated with either NRI or SMT. Numerical rating scale (NRS) pain data were collected before treatment. One month after treatment, current NRS pain levels and overall improvement assessed using the Patient Global Impression of Change scale were recorded. The proportion of patients, “improved” or “worse,” was calculated for each treatment. Comparison of pretreatment and 1-month NRS scores used the paired t test. Numerical rating scale and NRS change scores for the 2 groups were compared using the unpaired t test. The groups were also compared for “improvement” using the χ² test. Odds ratios with 95% confidence intervals were calculated. Average direct procedure costs for each treatment were calculated.ResultsNo significant differences for self-reported pain or improvement were found between the 2 groups. “Improvement” was reported in 76.5% of SMT patients and in 62.7% of the NRI group. Both groups reported significantly reduced NRS scores at 1 month (P = .0001). Average cost for treatment with SMT was Swiss Francs 533.77 (US $558.75) and Swiss Francs 697 (US $729.61) for NRI.ConclusionsMost SMT and NRI patients with radicular low back pain and magnetic resonance imaging–confirmed disk herniation matching symptomatic presentation reported significant and clinically relevant reduction in self-reported pain level and increased global perception of improvement. There were no significant differences in outcomes between NRI and SMT. When considering direct procedure costs, the average cost of SMT was slightly less expensive.     

A structured protocol of evidence-based conservative care compared with usual care for acute nonspecific low back pain: a randomized clinical trial

Parkin-Smith GF, Norman IJ, Briggs E, Angier E, Wood TG, Brantingham JW. A structured protocol of evidence-based conservative care compared with usual care for acute nonspecific low back pain: a randomized clinical trial.ObjectiveTo compare a protocol of evidence-based conservative care with usual care for acute nonspecific low back pain (LBP) of less than 6 weeks' duration.DesignParallel-group randomized trial.SettingThree practices in the United Kingdom.ParticipantsConvenience sample of 149 eligible patients were invited to participate in the study, with 118 volunteers being consented and randomly allocated to a treatment group.InterventionsThe experimental group received evidence-based treatments for acute nonspecific LBP as prescribed in a structured protocol of care developed for this study. The control group received usual conservative care. Participants in both groups could receive up to 7 treatments over a 4-week period.Main Outcome MeasuresOswestry Low Back Disability Index (ODI), visual analog scale (VAS), and Patient Satisfaction Questionnaire, alongside estimation of clinically meaningful outcomes.ResultsTotal dropout rate was 14% (n=16), with 13% of data missing. Missing data were replaced using a multiple imputation method. Participants in both groups received an average of 6 treatments. There was no statistically significant difference in disability (ODI) scores at the end of week 4 (P=.33), but there was for pain (VAS) scores (P<.001). Interestingly, there were statistically significant differences between the 2 groups for both disability and pain measures at the midpoint of the treatment period (P<.001). Patient satisfaction with care was equally high (85%) in both groups. Minimally clinically important differences in scores and number needed to treat scores (NNT<6) indicated that the experimental treatment (protocol of care) offered a clinically meaningful benefit over the control treatment (usual care), particularly at the midpoint of the treatment period.ConclusionsOverall, the 2 treatment groups were similar based on primary or secondary outcome measure scores for the full treatment period (4 weeks, with up to 7 treatments). However, there were statistically significant and clinically meaningful differences in both disability and pain scores at week 2 (midpoint) with 4 treatments, suggesting that the protocol of care had a more rapid effect than usual care.     

Assessor status influences pain recall.

Anecdotal clinical reports suggest that patients report differing levels of pain, depending on the status within the medical hierarchy of the individual gathering the pain rating. This observation has clinical relevance, given the practice of delegating the assessment of pain to lower status clinic staff members. In this study, both pain and mood were assessed in 70 patients diagnosed with low back pain at pretreatment, immediately after epidural lumbar injection, and again 2 weeks later by phone. At the 2-week follow-up, patients were also asked to recall the postprocedural rating that they had given immediately after the injection. This rating was obtained by either the treating physician or by a research assistant who was present at the time of injection, on a randomly determined basis. Current ratings of pain and mood did not differ for either group before the epidural injection, after the epidural injection, or at the 2-week follow-up. Two-week recall of postprocedural pain did, however, differ depending on assessor status. Those called by the physician provided recalled pain ratings that closely matched the ratings provided immediately after the procedure. Those called by the research assistant provided ratings that were 86% higher (that is, worse) than their original ratings. This status-driven bias in recalled postprocedural pain reporting is discussed in the context of social demands inherent in the physician-patient relationship, with implications for assessing treatment effectiveness in clinical practice and research. PERSPECTIVE: Accurate assessment of patients' pain is critical to effective pain management and treatment planning. This study found evidence of a status-based bias in which physicians elicited lower ratings of previously experienced pain associated with treatment procedures than did staff members of lower status.     

Comparison of daily and weekly retrospectively reported pain intensity in patients with localized and generalized musculoskeletal pain

The purpose of the study was to compare daily and weekly recalled pain intensity over time and their correspondence with real-time pain intensity in patients with localized (LP) and generalized (GP) musculoskeletal pain. Daily recalled pain, averaged over seven consecutive days, and weekly recalled pain at day 8 were recorded on 100 mm visual analogue scales monthly over 4 months for 40 LP and 50 GP patients. Multiple real-time pain ratings on numerical rating scales (0–10) were averaged over the week for 23 LP and 33 GP patients in Month 4. Reliability was assessed using the intraclass correlation coefficients (ICC) and the standard deviations of the repeated measurements.Daily pain ratings were lower than weekly ratings across the 4-month period. Reliability was lower for weekly than for daily recalled pain in the GP group, and lower than in the LP group. These results were independent of the magnitude of pain intensity. No difference was found between daily recalled and real-time ratings. The ICC was higher between daily and real-time ratings than between weekly and real-time ratings in Month 4. Weekly ratings were higher than real-time ratings in the GP group, and the overestimation increased with increasing pain intensity.The results of the present study indicated that reliability was improved by using ratings of daily recalled pain averaged over a week rather than single ratings of weekly recalled pain in subjects with localized or generalized pain. Weekly recalled pain was overestimated in subjects exhibiting generalized pain and high pain intensity.