Using a 0-10 Pain Scale Effectively

Ok, so this thread is pushing some buttons.  I have been meaning to write something about this because acupuncture school does such a shitty job of teaching us to evaluate pain and the 0-10 scale can be tricky to understand.

I know we all have good intentions here and I'm not judging anyone... So please bear with me...  Im going to be directive here based on my experience as a nurse, my nursing education, and providing palliative care

--puts on nurses cap--

Practitioners of all types have an inclination to move against a purely subjective measurement tool but this is really a disservice to the patient.  We need to listen to their experience and trust what they are saying to us.

The 0-10 point scale is indeed subjective.  That is good because pain is also subjective.  There are a few common misunderstandings about the 0-10 scale that I would like to address. 

The first mistake people make when using the 0-10 pain scale is thinking that two people with the same pain level will look the same.  Forget about trying to compare one persons 7/10 to another persons 7/10.  That is impossible and irrelevant.  Two people who rate their pain 7/10 can and will be having different experiences of that pain.  That is normal because we are talking about two unique people in unique situations with unique histories. 

From the wikipedia pain page

A person's self-report is the most reliable measure of pain, with health care professionals tending to underestimate severity.[58] A definition of pain widely employed in nursing, emphasizing its subjective nature and the importance of believing patient reports, was introduced by Margo McCaffery in 1968: "Pain is whatever the experiencing person says it is, existing whenever he says it does".[59] To assess intensity, the patient may be asked to locate their pain on a scale of 0 to 10, with 0 being no pain at all, and 10 the worst pain they have ever felt. Quality can be established by having the patient complete the McGill Pain Questionnaire indicating which words best describe their pain.[6]

The second mistake is to give an imaginary example of 10/10 pain or ask for the patient to imagine "the worst pain possible".  Forget about imaginary pain.  The problem with this is that it is disconnected to the person's reality.  Not many people actually know what it feels like to get hit by a bus or get torn apart by grizzly bears.  The "worst pain imaginable" is kind of a mind fuck.  How do you know what something is like that you have never experienced?  Its like me asking you to imagine what it is like to live on Mars.  Talk about inaccurate!  It is best to stick with what the patient knows from their own life.

A good way to clearly ask for a pain rating is: "What is your pain on a scale of 0-10 with 0 being no pain and 10 being the worst pain you have ever experienced."

The third mistake is the idea that you can look at a person and get a good idea of what their pain is.  The problem with judging pain based on activity or expression is that many people with chronic pain have learned to cope with it.  That does not mean their pain is not 10/10.  It is.  It has just been 10/10 for such a long time and life goes on.

A lot of patients (especially women) have had the experience of health care providers not believing that they are in pain or that they somehow deserve to be in pain (often because of lifestyle choices but sex, race, class, and physical ability play into this big time).  Many of them have been labeled "drug seeking".  If you are going to earn these peoples trust and really be of service to them you need to start with taking their subjective experience seriously and let them take some power back.  Their pain is exactly what they say it is and no one deserves to be in pain.

It sounds like we are doing a good job at is getting the other information about our patients pain.  Quality is important: tight, aching, dull, sharp, burning, stabbing, pulling and so on.  Another thing to look at is does it interfere with their daily activities like working, dressing, cooking, cleaning, and bathing.  Are they on medication and is it effective?  Does activity help?  What time of the day is it the worst?  Does hot or cold help it?  All this extra information can be helpful with forming a treatment plan.

Please remember that the subjective number they give you is real and take it seriously.  You just need to know what it is that you are really asking and to communicate that clearly.

This story was posted on May 18 2013 by Nic.

Comments

  • May 18 2013 at 6:01 PM
    Fiona writes:

    This is an excellent explanation of the pain scale. I’ll be taking into acu student-clinic and my practice with me. As a manual therapist I see people all the time who have had their pain diminished by their caregivers.

      0 likes
  • May 18 2013 at 6:18 PM
    Lisafer writes:

    Thank you, Nick. This is going straight to the POCA Tech curriculum.

      5 likes
    • Fiona
    • emily
    • Lisa B.
    • kevingermain
    • Nora
  • May 20 2013 at 11:39 PM
    acupunkgirl writes:

    Thanks for your article, Nick.  Very helpful.

    Honorably mention from elsewhere on the web:

    http://hyperboleandahalf.blogspot.com/2010/02/boyfriend-doesnt-have-ebola-probably.html

    The link above is called:  “A Better Pain Scale”.  I will admit to having printed out the cartoonist’s graphics to show to patients (and make them laugh).

      3 likes
  • June 12 2013 at 8:38 PM
    mhurley writes:

    This is great Nick.  Thank you!  I am still an Intern at my school and I have been tending toward asking my patients this based on 10 being the worst pain imaginable.  I will be more objective in the future and probably using the exact question you put in this post.

      0 likes
  • June 20 2013 at 1:51 PM
    jokerpoker writes:

    Great posting.  I see examples of all three mistakes with patients everyday.  Thank you!

      0 likes

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