PEG Tool for Improving Persistent Pain Management

I recently saw a woman for a colleague who had been one of my patients in the remote past.  Since that time, her persistent low back pain despite multiple prior back surgeries has persisted and been complicated by depression, malnutrition, frailty, polypharmacy, and recent functional decline requiring SNF care.  Fortunately for her, my colleague had begun deprescribing medicines which were potentially more burdensome than beneficial.  Though this patient didn’t recognize it, her husband said her appetite had greatly improved.  When I saw her I observed she was easily moving about the facility in her wheelchair.  When I asked if her pain was keeping her from getting about the facility, she confirmed my observation that this was a good day.  

When I inquired about her quality of life, she said it was poor, but couldn’t recall how pain prevented her from activities she might enjoy.  In fact, she said her poor quality of life (QOL) was likely due more to being institutionalized and being bored, at least in that moment.  With this information, I encouraged the facility activities director to further customize this resident’s activity program.  I also advised this resident and her husband to be open to further deprescribing since her appetite had already improved, she was functioning better, and modifications of our activity program might improve her quality of life and overall perception of pain even further.  

You may have noticed that I didn’t ask this patient about her persistently high pain score, because a focus on that area of pain management typically results in higher doses of pain medications, regardless of their adverse impact on health, function, and QOL.  Instead, I focused on how her pain affected her ability to function or prevented her from participating in important activities.  This much more targeted approach helps our team refine its pain management approach so that as a team, we provide care that matters to this patient and minimize the burden of medication side effects that may compromise QOL or function.   For the patient and family, it sets realistic expectations that pain is likely to persist, but we can work together as a team to reduce its adverse impact on what’s important to her.  In fact, this should always be our goal in managing persistent pain.  

The PEG (Pain/Enjoyment/General Activity) tool is a tool that is evidence-based, has been around for over 20 years, and broadens the monitoring of the effectiveness of a facility’s pain management program, by including the resident’s perspective on pain and how it adversely effects their enjoyment of life and general activity.  These are important domains that open up non-pharmacologic strategies to manage persistent pain, may reduce the burden of traditional pain medications, and affirm the overall effectiveness of the pain management program better than our traditional pain scales.  

This tool is a composite of 3 questions:

  1. What number best describes your pain on the average in the past week? (1-10)
  2. What number best describes how, during the past week, pain has interfered with your enjoyment of life? (1-10)
  3. What number best describes how, during the past week, pain has interfered with your general activity? (1-10)

The PEG score for that week is the total # divided by 3, which gives a 1-10 value that can be tracked over time.  A digital version of this pain tool is available at:  Microsoft Word - PEG Pain Screening Tool.docx (

I hope this tool and above approach helps your facility to better serve your patients with significant persistent pain problems.

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