What is the PEG (Pain, Enjoyment of life, General activity) tool?

The PEG Pain Assessment Tool

The PEG is an ultra-brief, 3-item pain assessment tool that measures average Pain intensity (P), interference with Enjoyment of life (E), and interference with General activity (G) over the past week using three 0-10 visual analog scales. 1

Tool Structure and Administration

The PEG consists of three questions, each scored on a 0-10 scale:

• P (Pain intensity): "What number best describes your pain on average in the past week?" (0 = no pain, 10 = worst imaginable pain) 1, 2
• E (Enjoyment of life): "What number best describes how, during the past week, pain has interfered with your enjoyment of life?" (0 = does not interfere, 10 = completely interferes) 1, 2
• G (General activity): "What number best describes how, during the past week, pain has interfered with your general activity?" (0 = does not interfere, 10 = completely interferes) 1, 2

The total PEG score is calculated by averaging the three item scores, yielding a composite score from 0-10. 2

Clinical Utility and Validation

The PEG demonstrates excellent reliability (Cronbach's alpha 0.73-0.89) and strong construct validity (r = 0.60-0.95) when compared to the more comprehensive Brief Pain Inventory (BPI). 2

• The tool is sensitive to change and can differentiate between patients with and without pain improvement over time 2
• A 1-2 point change represents the minimally important difference (MID), with 1 point being the lower bound and 2 points the upper bound for clinically meaningful improvement 3
• A 30% improvement in PEG scores indicates clinically meaningful benefit 1

Recommended Clinical Applications

The CDC and HIVMA/IDSA guidelines recommend the PEG for tracking treatment outcomes in chronic pain management, particularly in busy clinical settings where the BPI may be too time-consuming. 1

• Use the PEG at baseline before initiating opioid therapy to establish treatment goals 1
• Reassess with the PEG at 1-4 weeks after treatment initiation, then at least every 3 months during ongoing therapy 4
• Patients without pain relief at 1 month are unlikely to experience benefit at 6 months, making this a critical decision point 4

Advantages Over Other Pain Measures

The PEG's brevity makes it practical for primary care implementation, where comprehensive tools like the BPI (which takes significantly longer) or McGill Pain Questionnaire are often impractical. 1

• The PEG captures both pain intensity and functional interference in just three items 2
• It has been validated in Spanish (PEG-S) with similar psychometric properties (Cronbach's alpha 0.82, convergent validity r = 0.68-0.79) 5
• Implementation studies show 94.5% completion rates when systematically integrated into primary care workflows 6

Interpretation Guidelines

A PEG score ≥7 indicates severe pain with significant interference in activities of daily living and warrants immediate attention. 6

• The PEG correlates strongly with global physical health measures (r = 0.74), allowing estimation of overall functional status 7
• Function encompasses emotional and social dimensions, not just physical activity, and mood has important interactions with pain perception 1

Common Implementation Pitfalls

Challenges include lengthy administration time in some settings, patient comprehension difficulties with interference questions, and the need for clear explanation that function can improve even when pain persists. 6

• Clinicians should emphasize that complete pain relief is unrealistic, but functional improvement is achievable 1
• The tool should be used alongside assessment of patient-centered functional goals (returning to work, family activities, social engagement) rather than as the sole outcome measure 1