What’s your pain level?
We’ve all been asked the same question “What’s your pain level?” to which we are expected to give an arbitrary numerical response between 0 meaning no pain, and 10 being the worst imaginable pain. But pain is relative to the patient as well as that specific experience. So how did we end up with such a generic universal pain scale?
A brief history of the pain scale.
My research on this topic lead me to many discoveries. From the history of the study of pain to horrific tales of women in labor being burned in order to compare the pain to contractions! One thing became very clear: pain itself is a universal human experience, but we still have so much to learn in regards to how it affects individuals and how different people experience it differently. Another thing I came to realize is that the study of how to measure pain is a fairly new concept. As Stephen McMahon, a professor of physiology at King’s College London states, “From medieval time onwards, people were much more interested in causing pain than in measuring it…I think it’s quite a modern endeavor, trying to evaluate [pain].”
I’m sure we’ve all seen the 10-point smiley face scale in a hospital or doctor’s office at one time or another. It’s called the Wong-Baker pain scale and was instituted in 1983 for use in patients ages 3 and up. And people who suffer from chronic pain can immediately tell you this scale is, for practical purposes, useless. Studies have even found that when using face scales (FPS) patients often underrate their pain. So why is it still the standard 40 years later when every field of medicine has advanced so much over that time period? The simplest answer is: I don’t know. After hours of research, fascinating though it was, I couldn’t find a clear-cut reason why this antiquated assessment scale is still the go-to method, especially since there are so many different pain scales out there. So instead of arguing for or against this outdated scale, I’m going to focus on what we know about pain now and how it affects our nervous system and ability to heal. I’ll show you different pain scales that you can advocate for and implement in your own life. And I’ll share with you the pros and cons of each in my opinion and let you decide what works best for you.
Let’s talk about the nervous system. Please do not mistake me for a medical professional. But as someone who suffers from chronic illness and pain, this is a subject on which I’m well versed. I’ve had many conversations with various medical professionals and everyone I’ve talked to agrees that the Wong-Baker scale doesn’t work for chronic pain or illness sufferers. So in this article, I’d like to talk briefly about why that is.
There are three divisions of the nervous system: the sympathetic, the parasympathetic, and the enteric. They each serve different functions and today we’re going to take a closer look at the first two. What’s the difference between the sympathetic and parasympathetic divisions? The simplest answer as it pertains to this article is that the sympathetic division sends out adrenaline and is related to the fight or flight response, while the parasympathetic division calms those reactions and handles healing and relaxation within the body.
For example: when someone first experiences an injury, the sympathetic nervous system is activated and adrenaline surges through the person’s body as they begin to feel pain. This adrenaline serves the purpose of allowing the person to continue functioning until they can get to a doctor or address the injury. On the other hand, mindfulness and meditation have been known to activate the parasympathetic nervous system. Through deep breathing and body awareness, the adrenaline can be turned off and relaxation and healing can begin. This is part of why doctors will advise “taking it easy” during the recovery period after an injury.
Why is this relevant? For starters, if your body has activated the sympathetic nervous system, it can’t at the same time have the parasympathetic nervous system active. Which means that the part of the nervous system that handles relaxation and healing is shut off. In other words, once the pain is high enough, if left untreated, the body creates a vicious cycle of pain and inflammation that is very difficult to break. This is one of the main reasons why pain management is so important. It’s not just about the patient’s comfort level. Prolonged elevated pain can create further negative symptoms, complications, and prevent healing.
Knowing this, I’m going to walk you through some of the different pain scales available. A quick google image search can show you there are many different ones, but which one works best for you and your needs? Which one should you talk with your medical providers about implementing in your care plan?
How to narrow down your options.
Different pain scales are designed for different purposes. Some are meant to be quantitative answering the question “How much pain” and others are designed to be qualitative answering the question “How does it feel”. By first determining which question you want to answer, you can greatly narrow down which pain scale works best for you. Then there’s the different types to consider. There are numerical rating scales (NRS), visual analogue scales (VAS), categorical scales, and ones that are a mixture of the three. The Wong-Baker scale is an example of a VAS scale and an NRS scale.
Starting with the pain assessment chart that the United States Department of Defense created. It’s known as the Defense and Veterans Pain Rating Scale (DVPRS) and is similar to the Wong-Baker scale with a few key differences. While it too has facial depictions, they are accompanied by a color coding system, practical word descriptors, and 4 supplemental questions. This means it encompasses the 3 main types of pain scale but still only answers the quantitative question. The benefits of the descriptors and supplemental questions are that they remove some of the subjectivity inherent in the Wong-Baker scale and allow medical professionals to better assess the needs of their patients. In a study done, over 70% of participants found the DVPRS to be superior to other pain scales. There was also a study done in a cancer center where 78% of nursing staff preferred the DVPRS over other pain assessment scales.
The 4 supplemental questions attached to the DVPRS qualify it as a Likert scale. Likert scales are questionnaire-based assessments where a series of questions is asked, and the surveyor must answer based upon how much they agree or disagree with the statements made within the questionnaire. These types of surveys are known to have greater validity and are now the gold standard. They offer greater data for trackable analytics and can give increased insights into what subject matter is being surveyed.
While we’re on the subject of Likert scales and data analytics, let’s briefly touch on the Brief Pain Inventory sheet. This questionnaire is categorical and answers qualitative and quantitative questions and can be used to track pain over a period of time allowing for analytics to play a part in tracking progression or regression of pain.
Tracking data overtime is referred to as data analytics and can be applied to just about anything, but tracking the progression of symptoms such as pain can be extremely valuable. Take, for example, NeuroSpice. An app designed to gather and collate data in order to bridge the communication gap between people and their doctors. While it doesn’t at this time include a pain scale, it does allow users to gain new insight into their lifestyle through the use of data analytics over time.
Both of these questionnaires that we have discussed thus far have great benefits for the patients and their health care providers, but they also have a glaringly obvious flaw: they are entirely subjective to the experiences of the patient. There are several situations where subjectivity cannot be the order of the day. Many instances require objective evidence. Take, for example, non-verbal patients such as small children, people in the ICU, or patients that are confused or disoriented. These patients may not be able to articulate how they are feeling, but that doesn’t mean they aren’t experiencing pain. Other people have a high pain tolerance and so would subjectively underrate their pain. Is there a scale out there that can help with these needs for objectivity? Absolutely! The FLACC scale is one such scale. It stands for Face, Legs, Activity, Cry, and Consolability. It is often used for very small children and infants. Based on visible, objective symptoms a provider can give points in each category that can add up to a total on the scale of 0 to 10.
Next is the CRIES scale, which stands for Crying, Requires oxygen, Increased vital signs, Expression, and Sleeplessness. This scale has similarities in application to FLACC but is more in depth in regards to the physiological symptoms associated with pain and the necessary steps taken to alleviate the additional symptoms that arose due to the pain. As you can see, this scale also has columns for 0 to 2 points in each category adding up to a potential total of 10 on the scale. The way it’s set up also allows the medical professional to record data over time. The is a great tool to show the progression or regression of pain as well as keeping different medical professionals handling the patients care on the same page.
While these objective scales are great for instances of non-verbal communication and physiological evidence, they aren’t comprehensive enough to stand on their own in most instances where pain is concerned. Though objective and subjective scales serve a purpose, the ideal pain scale would encompass both, allowing for patients to express subjectively the severity of their pain while also allowing medical professionals a way to objectively measure the patient’s pain response. With a scale like that, patients and doctors can work together to manage and alleviate pain.
I wish I could have found a pain scale that perfectly marries subjective and objective data and allows for long term tracking like what’s available within the NeuroSpice app where task and care tracking are concerned and included it in this article. As of right now, I’m not sure there is one. But if any of you know of one, or create one, drop a comment below with a link to the pain scale you prefer. In the meantime, I hope I’ve given you some food for thought and enough information to get you started on your own pain assessment scale preference journey. Don’t forget to include your care providers in your journey as they may have tips on what scales will and won’t work for you and for what reason. And remember, we’re all in this together and are here to support each other as we take steps to live better.
