A hand holding a dart ready to be thrown at the Wong-Baker pain scale. There are 6 bullseyes on the target mimicking the pain scale.

What Is Your Pain Number?

Mine is six (6). The number refers to the pain level scale. I get so tired of being asked this question at the doctor’s office. The medical assistant always asks, "Today what is your level of pain on a one to ten scale?" What does that even mean?  Well let’s see today, okay I am out of bed (more 1 than 10), I walked in here (more 1 then 10), I cannot seem to stand up straight (more 10 than 1), I was able to drive but the mirrors are so difficult (more 10 than 1).

Pain scales for chronic pain are meaningless

There is no way I can assess all of those components and arrive at a number. So I choose 6. It is my automatic response. My rheumatologist said the other day, "You seem to be stable. You have been 6 for quite some time." Sure stable, but what is stable on such an arbitrary scale? Should I vary my response, like being 7 tomorrow and 6.25 the day after? It is so meaningless that maybe I should run a 9 once or twice then get radical and say 1.23456 the next day.

Research studies on measuring and assessing pain

Surely there must be some research about this? Well, it turns out there is some research about it. Not surprisingly, most of it centers on prescribing opioids. One concise and impactful paper that is easily obtained is a 2018 study titled “Pain Measurement in Research and Practice.”

This study found that in VA clinical care settings “Although numerous pain measures have been used in clinical research, there has been insufficient evidence to recommend one measure over another.”1 This rationale being that no matter which of the various pain measures the authors looked at, no one measure appeared to be best.

The need for more comprehensive pain measures

The assessment of pain scores was also the subject of an easily accessible 2008 paper titled “Assessment of Pain.” In it, the authors write “A comprehensive assessment of any chronic complex pain condition requires documenting (i) pain history, (ii) physical examination, and (iii) specific diagnostic tests.”2 

This seems to indicate that the simple pain score of 1-10 is likely not in itself an adequate way to measure and treat pain. While the authors acknowledge that the pain score may be a part of pain assessment, they propose that more comprehensive measures are available and should be used if for nothing else at least for establishing a baseline pain score.

Measuring chronic pain should be a process

All of this literature about the validity of different pain management scores helps me understand why I have been seeing new pain scores being used in my doctors’ office of late. In the past year, I have filled out at least five different pain measures. Each is aimed at obtaining the same information using a different technique. 

But in the end, I am a 6. I have been for years and will be for years to come most likely. How can I be so callous about such an important topic? There is a great opinion piece titled “Acute Pain Assessment Tools: Let Us Move beyond Simple Pain Ratings” which summarizes my feelings exactly. The author writes: “Pain assessment should be considered a process, rather than a tool. New methods such as the CAPA (Clinically Aligned Pain Assessment)* that help translate the patient experience into more than a number would be useful.”3

Single measures for chronic pain is misleading

The source of cynicism is that a number, a smiley face, or a scale is just too easy and misleading. Pain is a multidimensional outcome of a number of processes that may be psychological, physical, or even relational. 

The need for new dynamic pain measures

In my opinion, it is almost impossible to adequately assess what pain is related to and how it is impacting our bodies. Some pain assessments seem to be better than others at getting at the root of the issue. But in the end, pain is about perception, human experience, and physical hurt. For that reason, I will be at a 6 on the pain level scale for the foreseeable future. 

I hope someday a better measure will be developed or used by my doctors. But given the constraints of the reimbursement system where doctors are paid for the number of visits and not the time spent per visit, it seems unlikely that a better measure is on the horizon.

*Description added for clarity

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