Pain, 11 (1981) 247--253 Elsevier/North-Holland Biomedical Press

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A PAIN VOCABULARY IN FINNISH -- THE FINNISH PAIN QUESTIONNAIRE *

HEIKKI KETOVUORI and P.J. PONTINEN **

Acupuncture Research Project, University of Kuopio, P.O. Box 13~, SF-70101 Kuopio 10 (Finland)

(Received 15 april 1980, accepted 11 March 1981)

SUMMARY

Words related to pain were collected by asking 59 students and 18 patients to create a list by free association. Each subject was then given a dictionary- derived Finnish version of the McGfll Pain Questionnarie (MPQ) with the words arranged in alphabetical order and was asked to place his own words among the dictionary-derived words which appeared most appropriate. Simultaneously, each word was allocated on a visual analogue scale (VAS) in order of increasing intensity. A vocabulary using the MPQ groups was then collated using the words for which at least one-half of the subjects agreed as to classification. The words in each group were presented in alphabetical order. The list was then given #~o 76 university students whose job was to decide if in fact each wo~d did belong to the class assigned. Following this, the words were arranged on a V AS scale in intensity order. The words mm- mean differences were then compared using a t-test. Those words were chosen for the pain vocabulary which reflected a statistically significant intensity change and were most often to be found in the word-list. The same method is applicable irrespective of language. Words are replaceable by numerical values so that follow-up and renewed investigations become statistically com- parable.

INTRODUCTION

Pain is extremely difficult to quantify and qualify objectively. Unless one can do so, however, insurmountable difficulties present themselves when

* Presented at the Scandinavian Chapter Meeting of IASP 27--28 September in Tampere, Finland. ** Correspondence to: Ass. Prof. P.J. PSntinen, Pain Clinic, Palom~/entie 34, SF-33230 Tampere 23, Finland.

0304-3959/81/0000--0000/$02.50 © 1981 Elsevier/North-Holland BiomediceA Press

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seeking to prognose and diagnose pain, and to compare the relative efficacy of various pain-relieving methods.

The hIcGill Pain Questionnarie (MPQ) appears to have eliminated these difficulties in English-speaking countries [ 7,8 ]. This article describes its mod- ification for use in Finland and proposes a method for use in other languages.

Till now, the evaluation of pain has been partly based on verbal rating scales, since they alone can enable us to differentiate its quality and a l s o - to some degree at l e a s t - its quantity [ 1,3 ]. A common word usage has been found to exist which transcends differences in the patients' sex, regional and social derivations [ 6,10 ].

A rough estimate of pain intensity by relating the verbal evaluations to a Visual Analogue Scale (VAS), but though patients can describe their pains and understand the verbal rating scales they are often unable to imagine their pain as a point on a straight line [2,10,12]. For this reason it is essential first to develop graded verbal scales for each of the many facets of pain. The MPQ is claimed to provide valuable diagnostic aid and it is already widely used in English-speaking countries in seeking to measure the quality of pain for both experimental and clinical research. It includes ranking values for pain words in qualitatively different subgroups [8]. Dubuisson and Melzack [6] have co:ucluded there are appreciable and quantifiable differences in verbal reac- tions to various types of pain; patients with the same disease or pain syn- drome tend to use remarkably similar words to communicate what they feel.

Melzack and Torgerson's work, based on Dallenbach's vocabulary and clas- sification [ 4], produced the MPQ by categorizing the descriptors chosen into 3 main classes. These were (1)words describing sensory qualities in terms of time, space, pressure, temperature and other properties; (2) words to describe affective qualities in terms of tension, fear and autonomic properties; (3) evaluative words. A high level of agreement emerges when these are classed and subclassed to portray any particular dimension of pain. The MPQ, how- ever, encounters a semantic problem [5]. Its validity disappears when the descriptors are translated into Finnish, for no dictionary contains satisfac- torily meaningful category/intensity equivalents. The purpose of this study is to create a Finnish Pain Questionnaire (FPQ).

METHODS

To compile the Finnish Pain Vocabulary, 77 p e o p l e - 45 senior high school students from East Finland, 14 university students and 18 patients from West F i n l a n d - were asked to list words related to pain. Each was asked to include the maximum possible number of words related to all aspec.ts and dimensions of pain. The same individuals were also given a MPQ Finn'tcized by means of a dictionary. In this, the words were listed alphabet- ically, but though they were classified as in the original, the classifications' names were omitted so that the assessment would reflect a homogeneity deri'ved from words' significant content not the desire to allocate them according to pre~letermined class-groups.

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When the 77 had listed their c.wn words, they were asked to allocate them on a content basis at the most appropriate place in the Finnicized MPQ. Each word in the total list was then allocated on a VAS according to its rela- tive intensity on a 10 cm long straight line who~e were marked "no pain" and "unbearable pain".

Results o f word collation and preliminary test The questionnaire elicited 253 pain-related words of which 146 "appeared

at least twice though only 39 appeared in at least 10% of the lists. At this stage only the words' mean ranking values on the VAS scale were noted so as to observe if sufficient similarity existed for a viable intensity grading. Simul- taneously, answers from the 3 groups were compared: 60% were in full agreement on type classification whilst even more agreed on intensity grad- ing.

The formulation of a final pain vocabulary On the basis of the preliminary test, a new list was made of words used by

at least two of the test group. The words in alphabetical sequence were then assigned to those categories where at least half of the testees considered they should be placed.

Now subgroups were each given their English name and its Finnish transla- tion and 76 university students were given this list and were asked to decide whether each word's meaning justified its position within the named group in which it appeared. "Punishment" as a group term was discarded, since most of those asked had assigned words so described to the evaluative cate- gory. At this stage, testees were asked to asign each word's relative position on the V AS scale.

For those words which at least half regarded as belonging to the correct category, a millimeter value wits assigned on the VAS scale. This value represented .the word's intensity. From these mm-values, each word's mean value and position were aUocated so that the intensities of the words could be compared by t-tests.

A final pain vocabulary was formed by using those words most frequently listed in the preliminary test but only the ones which indicated an intensity change of at least 5% level of significance within each group. Thus when con- sidering any pain phenomenon, the shift from one word to the following one, whatever the group indicated, represents a statistically measurable and significant change.

RESULTS

The same factors were encountered when forming the FPQ as in devel- oping the MPQ. Different people class the words into type groups with remarkable uniformity. People with widely different I)ackgrounds show equally great uniformity when constructing an intensity scale.

By using the VAS method, one can form a measuring system which uses a

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TABLE I

The McGill Pain Questionnaire (Melzack and Perry [8 ])

Classes subclasses

Pain descriptors

Rank order

i ,

The Finnish Pain Questionnaire

Pain Mean values descriptors in VAS _+ S.D.

Sensory temporal

Spatial

Punctate pressure

Incisive pressure

Constrictive pressure

Traction pressure

Thermal

Brightness

Dullness

flickering quivering pulsing throbbing beating pounding

jumping flashing shooting

pricking boring drilling stabbing lancinating

sharp cutting lacerating

pinching pressing gnawing cramping crushing

tugging pulling wrenching

hot burning scalding searing

tingling itchy smarting stinging

dull sore hurting

A aaltofleva 32.5 23.0 kohtauksittainen 49.5 24.0 jatkuva 73.4 23.6 B tykytt~vii 40.2 24.6 jumputtava 59.1 19.7 jyskytt~/v~i 75.7 18.2

pinnallinen 19.1 12.0 to~spuoleinen 45.0 19.3 s//teilev~ 55.5 21.8 syv~i 72.9 16.6

pisfiiv/i 44.6 24.5 l~ivist~iv~i 63.4 22.9 l~ipitunkeva 72.1 21.8

ter~/vii 43.4 23.3 vihlova 55.1 23.1 viilt~/v~i 63.1 22.4 repiv~i 78.7 15.4

vySm~iinen 27.1 16.7 puristava 4 5.6 21.3 kouristava 62.9 16.6 tukahdutta'~a 73.4 18.7 musertava 82.3 14.0

nykivii 30.0 20.8 tempova 52.2 20.7 riuhtova 73.0 18.1

kuumottava 23.0 18.4 paah tara 44.1 23.7 polttava 63.5 18.3 tulinen 72.4 16.9

A kutiseva 22.5 17.4 syyhy~iv~i 37.0 20.3 kirvelev~i 62.2 21.2 B hell~/ 25.7 17.7 aristava 34.2 20.9 kihelmSiv~i 44.1 23.9

hiipiv~i 17.6 16.5 painava 32.7 15.0 turruttava 56.1 24.9

TABLE I (continued)

The McGiil Pain Questionn~!r-, (Melzack and Perry [8]

Classes subclasses

Affective tension

Autonomic

Fear

Punishment

Evaluative

The Finnish Pain Questionnaire

Pain descriptors

Rank order

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Affective -- evaluative -- (miscellaneous)

Supplementary sensory

Spatial presst~re

Pressure-dullness

Thermal

Affective

aching heavy

tiring exhausting

sickening suffocating

fearful frightful terrifying

punishing gruelling cruel vicious killing

annoying troublesome miserable intense unbearable

sensory wretched blinding

spreading radiating piercing tight numb drawing squeezing tearing cool cold freezing

nagging nauseating agonizing dreadful torturing

j~iyt~/v~/ 6 5.1 22.3

~sytt~v~i 38.6" 21.5 ahdistava 57.6 25.4 tuskaUinen 73.1 19.3

n~r//s~v~ 24.1 15.9 kuvottava 48.3 20.0 tainnuttava 76.2 21.3

pelottava 29.5 21.7 kauhea 50.0 23.8 karmiva 70.9 19.7

liev~i 9.1 7.9 kiu sallinen 27.0 12,9 kova 57.5 17.4 siet~im~it~n 7 9.7 11.5 tappava 93.1 5,9

viile~i 19.1 16.5 kylm~/ 40.9 16.3 hyyt~/v~/ 68.4 18.3

Pain Mean values descriptors in VAS _+ S.D.

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ratio graduated scale in place of a mere sequence scale. This permits the use of many-faceted statistical methods. In compiling the Pain Vocabulary, each group contains statistically significant increases in intensity when moving from one descriptor to the next. Moreover it is possible to get intensity com- parisons between the groups on the basis of the ratio-graduated scale ob- tained.

Fifty-six words chosen on the basis of t-test and word frequency form the final definitive FPQ. In the FPQ groups, A and B appear in the sensory- temporal division. A and B here represent different aspects of the temporal feature clearly forming distinct subgroup differences. Moreover, they differ in relation to degree of intensity. The same is present in the brightness divi- sion which also has A and B groups. The punishment division has been eliminated from the FPQ for the translated MPQ words were almost assigned to the evaluative division.

The FPQ has absorbed the extra miscellaneous groups found in the MPQ into its original divisions except for words relating to temperature which have been divided into words indicating warmth or coldness.

DISCUSSION

In the Ehglish-speaking world, the MPQ is invaluable in examining pain in patients, in portraying manifestations of the pain and in following treatment (in follow-up studies). But when attempting to adjust the MPQ for use in non-English speaking areas, its value is greatly diminished since both attri- bute meanings and intensity scales defy translation. The purpose of this paper is to develop an effective substitute for MPQ in Finnish and also to examine the possibilities of eliminating the semantic barrier altogether, in order to develop a universally acceptable pain measuring system. The essen- tial factor is that concepts of pain develop by very similar processes which transcend all barriers, be local, national, class, ace or sex. Thus it is reasonable to suppose that world-wide concepts are reasonably uniform for type and intensity classifica:tion [ 11]. Melzack and Torgerson have demonstrated this to be valid when e~amining subjects of widely different types both scholasti- cally and culturally as well as from differing speech pattern areas [ 9 ]. Similar observations have been tested and found valid in Finland. One feature may well indicate a superior refinement of this system relative to MPQ. When investigating the "temporal" and "brightness" categories two distinctly dif- ferent subgroups manifested themselves which represent different aspects of the properties associated with the properties of these sensory classes. This fact was either unnoticed or ignored when compiling the MPQ. But if one con- siders these aspects as they would be worded in Finnish, they are of such significance medically that they should be included. Another very significant factor is associated with the "punishment" category. An overwhelming majority of the testees associated this word with intensity of pain; the idea of retribution for some real or imagined sin was absent. Why? Is it that the Finnish cultural milieu is unable to associate pain with punishment or merely

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that the words given just did not connect with the emotions characterized by it? What are the notations of the pain words in different languages [5]? When defining the scale of word intensity, the VAS method shows to advan- tage for, with its help, a higher degree of definition grading is obtained than using a system based solely on rank order. The ratio-graduated scale adopted for this vocabulary, unlike the former order scale, makes it possible to use all statistical methods.

Finnish pain words are many but, as always, people's active vocabulary is very restricted. One increases a patients discomfort by vaguely seeking to elicit an enlightening description of his pain so one must provide a stan- dardized vocabulary. This allows the patient to draw on his immensely larger passive vocabulary so that he can give a far richer description of his pain. But are the word/pain associations reliable or misleading? Research as to the reliability of the words given is at present under way.

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